Muculoskeletal Pediatic Imaging..pptx

1. Musculo-skeletal pediatric Imaging.
Dr/ ABD ALLAH NAZEER. MD.

2. DEVELOPMENTAL DISORDERS OF THE KNEE JOINT:
1. CONGENITAL ABSENCE OF CRUCIATE LIGAMENTS.
This is a very infrequent finding. They are usually
associated with other malformations, such as
longitudinal limb deficiencies. MRI usually shows an
abnormal morphology of the tibial spines, dysplastic
femoral condyles, and absence of cruciate ligaments,
with hypertrophy of Humphrey's meniscofemoral
ligament.

3. Patient with longitudinal
fibular deficiency (fibular
hemimelia) (A), absence
of both cruciate ligaments
(C, D) and hypoplasia of
femoral condyles (B).
Radiograph at one year
of age (A). Axial proton-
density–weighted FS (B)
Sagittal proton-density–
weighted (C) and coronal
FSE T1-weighted(D) at 5
years of age.

4. 2. DISCOID MENISCUS:
Dysplastic and enlarged meniscus, with loss of
the normal semilunar morphology. It is usually
more frequent on the external side. It may be
identified in the MRI sagittal sequences, in which
continuity of the anterior and posterior horn will
be seen in three or more cuts. Signs of mucinous
degeneration use to be found and there is a
greater probability of tears.

5. External discoid
meniscus with marked
degenerative changes
and complex tear in the
body and anterior horn.
A)Sagittal FSE T1-
weighted, B)Sagittal FS
proton-density–
weighted, C) Coronal
proton-density–
weighted, D) coronal
STIR MR images.

6. 3. BLOUNT DISEASE:
Blount disease refers to a local disturbance
of growth of the medial aspect of the
proximal tibial metaphysis and/or epiphysis
that results in tibia vara. The medial
epiphysis is wedge-shaped and the adjacent
metaphysis is fragmented and depressed,
with physis bone bars.

7. Blount disease. (A) PA
radiograph, (B) Coronal
T2*-weighted gradient-
echo and (C) Coronal FSE
T1-weighted MR images.
Inclination and medial
fragmentation of the
epiphysis, with the
formation of bony bridges
and metaphyseal
widening (arrows).

8. Advanced
Blount disease.
Coronal CT(A),
T1-weighted(B)
and T2*-
weighted
gradient-echo
MR image(C).

9. 4. VASCULAR MALFORMATIONS:
Vascular malformations can seen intraarticular
location. These malformations are present at birth
and grow with the child. Main symptoms are pain,
swelling, and spontaneous hemarthroses. The intra-
articular lesions can be low-flow or high-flow vascular
malformations. Synovial venous malformations are
the most frequent in the knee. They are usually
visualized in MRI as a lobulated multiloculated mass,
with venous lakes separated by septa.

10. Venous malformation in
the internal articular
recess that infiltrates the
anterior margin of the
right femoral condyle, the
vastus medialis, and the
patellar retinaculum. A)
Sagittal STIR, B) Axial FSE
T2-weighted, (C and D)
Coronal and axial
contrast-enhanced fat-
suppressed T1-weighted,
(E) Dynamic angio-MRI.

11. INFECTIOUS DISEASES:
Osteomyelitis is a bone infection that frequently affects the growing
skeleton, with half of the cases occurring in children under the age of 5.
It is usually secondary to bacterial hematogenous spread.
It usually affects the metaphysis of the tubular bones. Osteomyelitis is
classically divided into acute, subacute and chronic, depending on the
clinical features, the duration of the disease and imaging findings.
1. ACUTE OSTEOMYELITIS:
The x-ray imaging is usually normal during the first days. MRI shows the
edema in the BM and adjacent soft tissues. It is common the appearance
of intraosseous and subperiosteal abscesses, which can cross the cortical
bone, with purulent material that may drain to soft tissue.

12. Coronal and axial
Contrast-enhanced
fat-suppressed T1-
weighted MRI. Tibial
acute osteomyelitis
with an extensive
area of ischemia.
Myositis signs with
small intramuscular
abscesses (red
arrows) and
subperiosteal
abscess (blue
arrow).

13. Sagittal and axial
contrast-
enhanced fat-
suppressed T1-
weighted MRI.
Femoral acute
osteomyelitis with
septic arthritis,
soft tissues
edema and small
posterior
subperiosteal
collection
(arrow).

14. 2. SUBACUTE OSTEOMYELITIS:
It is characterized by the appearance of the
Brodie's abscess. In the radiography, it will be
visualized as a well-circumscribed lytic lesion
with sclerotic borders. MRI shows a center of
necrosis, surrounded by a ring of granulation
tissue that has an intermediate intensity in T1-
weighted MRI image ("the penumbra sign").

15. Subacute OM in a 10-months-
old boy. On the radiography, we
can see a lytic lesion with
sclerotic margins and periosteal
reaction (arrow) in femoral
metaphysis (A, B). MRI with a
metaphyseal abscess that
crosses the physis to the
epiphyseal cartilage. There is
also an extension of the process
towards the subperiosteal
space. Joint effusion. Coronal
FSE T1-weighted(C), coronal
STIR(D), sagittal FS T2-weighted
(E) and coronal Contrast-
enhanced fat-suppressed T1-
weighted MR images (F)

16. 3. CHRONIC OSTEOMYELITIS:
It is characteristic the appearance of
fragments of necrotic bone (sequestrum),
surrounded by purulent tissue and reactive
bone sclerosis (involucrum). A defect in the
cortical bone can also develop, allowing
drainage of the purulent material into
adjacent soft tissue or skin (sinus tract).

17. Chronic osteomyelitis in
an 8-years-old child.
Initial PA radiograph of
the tibia and fibula. CT
after sequestrectomy,
cement placement, and
fasciocutaneous graft.
Extensive metaphyseal-
diaphyseal involvement
of the right tibia and
fibula. Sequestrum
(radiograph) and
reactive bone sclerosis
(involucrum).

18. INFLAMMATORY DISEASE:
1. PIGMENTED VILLONODULAR SYNOVITIS.
Benign proliferative disease of unknown etiology.
The knee is the most involved joint. It is rare in
the pediatric age. MRI demonstrates a lobulated
mass (synovial proliferation). Lesions tend to
bleed, causing hemosiderin deposition and
therefore a low-intensity signal in all sequences.

19. 14 years old boy with
pigmented
villonodular synovitis.
Ultrasound (A), MRI
axial FSE T2-weighted
(B), sagittal Contrast-
enhanced fat-
suppressed T1-
weighted(C), sagittal
T2*-weighted
gradient-echo(D).

20. 2. JUVENILE INFLAMMATORY ARTHRITIS:
Chronic rheumatological disease, more
frequent in children under 16 years.
The most frequent form of presentation
in the oligoarticular, with greater
involvement of the knee.

21. 10-year-old boy with an
oligoarticular form of
JIA. Sagittal contrast-
enhanced fat-
suppressed T1-weighted
MRI and CT. Joint
effusion with thickening
and synovial uptake.
Inflammatory changes
in Hoffa´s fat-pad.
Erosion in the
posteromedial margin
of the internal tibial
plateau.

22. 2-year-old girl with an
oligoarticular form of
juvenile inflammatory
arthritis. Joint effusion
with marked thickening
and diffuse
enhancement of the
synovium. A)
Ultrasound, B) Axial T2-
weighted, C) Axial FS
T2-weighted and D)
Axial contrast-
enhanced fat-
suppressed T1-
weighted MR images.

23. 3. LIPOMA ARBORESCENS:
Infrequent benign synovial lesion of unknown
etiology, characterized by a massive infiltration of
the synovium by mature adipocytes without atypia.
The most frequent form is the monoarticular
involvement of the knee. MRI is characterized by the
presence of joint effusion (with frequent synovial
contrast-enhancement) and multiple synovial
proliferation of adipose tissue ("rice grains").

24. 12-year-old girl with a
arborescent lipoma.
Synovial fatty tissue
proliferation. A) Axial
T2-weighted, B) Axial
Contrast-enhanced
fat-suppressed T1-
weighted, C) Coronal
T1-weighted and D)
Coronal FS proton-
density–weighted MR
images, E)
Ultrasound.

25. NEOPLASTIC PATHOLOGY:
1. FIBROUS CORTICAL DEFECT (FCD) &
NONOSSIFYING FIBROMA (NOF).
It is a frequent benign neoplasm. It is
usually found in metaphysis. It appears
as a lytic lesion with well-defined sclerotic
borders. As the lesion matures, sclerosis
increases.

26. NOF in the
proximal diaphysis
of the fibula. PA
and lateral knee
radiograph (A, B).
Coronal FSE T1-
weighted and
coronal STIR.

27. 2. OSTEOCHONDROMA.
This is the second most frequent benign
pediatric tumor. They usually appear in the
metaphysis of long bones, especially the
distal femur and proximal tibia. It is an
extension of bone that shows continuity with
the periosteum, cortex, and bone marrow of
the native bone.

28. Osteochondroma.
Coronal T1-
weighted and
axial T2-weighted
MR images.

29. 3. CHONDROBLASTOMA.
It is a rare benign tumor of immature cartilage, with
a peak incidence between 10 and 20 years. It has a
predilection for the epiphysis of the femur and tibia.
X-ray is shown as a radiolucent lesion with sclerotic
borders and a chondroid matrix inside. MRI shows
a heterogeneous lobular pattern, with a low-
intermediate signal intensity in T1-weighted
sequences and variable in T2-weighted sequences,
with a peripheral hypointense ring.

30. Chondroblastoma in
the epiphysis of the
internal femoral
condyle. PA and
lateral radiograph
(A, B), Coronal CT
(C), Sagittal T1-
weighted (D), axial
T2-weighted (E) and
coronal STIR MR
images(F).

31. MALIGNANT TUMOURS:
1. OSTEOSARCOMA.
Osteosarcoma is the most common primary malignant tumor
of the knee. They usually appear in the metaphysis of long
bones (most frequent in the femur) and it may extend to the
epiphysis. The x-ray will show a lesion with aggressive
features, permeative appearance, with cortical destruction,
soft tissue mass and aggressive periosteal reaction. In MRI
it usually appears hypointense in T1-weighted sequences
and hyperintense in T2-weighted sequences with foci of low
intensity in all sequences, secondary to its osteoid matrix.

32. Lateral knee radiograph (A),
coronal (B) and axial CT (C y D)
show an osteosarcoma located
in the distal metaphysis of the
femur with large soft tissue
mass and aggressive
periosteal reaction. Axial FS
T2-weighted MRI(E): The soft
tissue mass has a cystic
component with fluid levels
that suggest intralesional
bleeding. Coronal contrast-
enhanced fat-suppressed T1-
weighted (F), the lesion
extends upwards to proximal
metadiaphyseal junction.

33. 2. EWING SARCOMA.
It is the second primary malignant
tumor of childhood. Imaging typically
demonstrates an aggressive lesion,
similar to osteosarcoma. In contrast,
it usually associates an important
non-calcified soft tissue mass.

34. Ewing's sarcoma
in the fibula. X-ray
(A), CT (B), MRI
sagittal STIR (C),
coronal T1 FS with
contrast (D) and
coronal T1 (E).

38. Transient synovitis. The left hip shows a joint effusion (arrow) in the anterior recess which
causes separation of the layers of the capsule which are now easily recognized

39. Perthes disease with flattened and sclerotic femoral epiphysis.
Subchondral fracture, best appreciated on the frog-leg lateral view.
MRI will show edema in the femoral head with loss
of high bone marrow signal on T1-weighted images.

40. Advanced Perthes disease with collapse and sclerosis of the femoral head and metaphyseal lucency.
Progression to fragmentation and development of a short, broad collum. Developing coxa magna deformity.

41. Multiple epiphyseal dysplasia: Multiple epiphyseal dysplasia can
mimic Perthes disease as it may manifest primarily in the hips.

42. Slipped Capital Femoral Epiphysis:
Slipped Capital Femoral Epiphysis (SCFE) is an idiopathic
Salter-Harris type I fracture of the proximal femoral epiphysis.
It occurs more commonly in boys and in obese children. The
typical age at presentation is between 12-15 years.
SCFE may occur bilaterally in up to one third of cases.
The epiphysis slips posteriorly, and to a lesser extent medially.
It is therefore best appreciated on the frog-leg lateral view.
Avascular necrosis of the femoral epiphysis is a potential
complication.

43. Slipped epiphysis in a
thirteen-year old boy.
AP radiograph shows a
slightly widened
epiphysis, but this can
easily be overlooked.
The frog-leg lateral
view shows a medio-
posterior slippage of
the left femoral
epiphysis.

44. Juvenile Idiopathic Arthritis:
Juvenile Idiopathic Arthritis (JIA) is a clinical diagnosis and is
currently divided into six different subtypes. In most cases, less
than 4 joints are involved. Large joints are mainly affected,
including the hips. JIA begins with a tenosynovitis and only later
shows bone edema, periostitis, osteoporosis and growth
disturbances.
X-rays are usually negative early on in the disease.
Typical findings in later stages of the disease may be a slightly
larger epiphysis, or accelerated bone maturation.
MRI will also demonstrate the joint effusion and synovial
thickening, but can also show damage to the bone and cartilage.

45. JIA: Effusion of
the right hip in
JIA. The synovium
is thickened and
loads Gadolinium
contrast (right).
Images courtesy
of Dr LS Ording
Muller.

46. Osteomyelitis:
Osteomyelitis is a relatively common severe
condition in children, occurring most
frequently in children under the age of five
years.
At this young age, the presentation can be
rather non-specific, and infants may present
only with a fever and failure to thrive.

47. 5 week old, sick infant with severe osteomyelitis of the left hip. MRI with Gadolinium
contrast shows extensive soft tissue involvement and periosteal reaction.

48. Septic arthritis:
Septic arthritis is a surgical emergency.
The inflammation of a joint in septic arthritis is bacterial and,
as in osteomyelitis, is usually caused by Staphylococcus aureus.
Septic arthritis can have a rapidly deteriorating course with
destruction of the joint.
The synovium may be thickened, but this is a non-specific
finding also found in other inflammatory pathology such as JIA.
The clinical profile, presence of a joint effusion are suggestive
of septic arthritis. Subsequent aspiration of pus confirms the
diagnosis.

49. Five-year old boy
with a limp and
fever at
presentation.
Ultrasound was
difficult because the
boy was unable to
stretch his leg, but
the left hip clearly
shows an effusion
and synovial
thickening. Pus was
evacuated in the
operating theater.

50. Avulsion injuries:
Avulsion injuries of the pelvis are a frequent
cause of hip pain in adolescents involved in sports.
Because at this age the tendons are generally
stronger than the apophyses, strong muscle
contraction can result in apophyseal avulsion
fractures. Avulsion injuries can be acute or
chronic.

52. Typical avulsion injury of the anterior inferior iliac
spine at the insertion of the rectus femoris tendon.

53. Typical avulsion injury of the right ischial aphophysis.

54. Bone tumors and tumor-like lesions:
There are many bone tumors and tumor-like lesions
that may cause pain in the hip or upper leg.
Osteoid osteoma is a benign tumor characterized
by an extensive bony reaction and severe bone pain,
occurring mainly at night.
X-ray imaging shows a small oval lytic lesion which
may be obscured by the dense, bony reaction
surrounding it. MRI shows the nidus.

55. Osteoid osteoma.

56. Eosinophilic
granuloma.

57. MRI findings of elbow joint.
1) Diagnostic pitfalls of MRI of the elbow joint
(a) Pseudo defect of the capitellum.
The capitellum is an anterior protuberance arising from the distal
humerus, that has a smooth and round articular surface. There is a
non-articular, bony groove at the junction of the capitellum and the
lateral epicondyle of the distal humerus. The capitellar overhanging
edge with the groove beneath appears as a defect or notch on
sagittal or coronal MR images, which is shown more apparently
on the more posterior and lateral sections of the elbow joint.

58. Coronal (left) and
sagittal (right) T2
weighted images in
a 16-year-old
healthy boy show
pseudo defect of
the capitellum (red
arrows). It should
not be mistaken for
osteochondritis
dissecans.

59. (b) Pseudodefect of the trochlear groove
and transverse trochlear ridge.
The trochlear groove is a large depression in the
proximal ulna, articulating with the trochlea of the
humerus. There may be a small cortical notch at the
junction of the olecranon and coronoid process of
the trochlear groove. Pseudodefect of the trochlear
groove corresponds to the medial and lateral edges
of the waist of the trochlear groove.

60. Sagittal T2-
weighted images in
a 13-year-old boy
(left) and a 18-year-
old male (right)
show variable-sized
notch's at the
midportion of the
trochlear groove
(red arrows).

61. (c) Synovial plicae/folds.
Synovial plicae are prominent folds of synovial
membrane, those are remnants of the normal
embryonic development of the articular
synovial membrane. The synovial plicae appear
to originate from the synovium adjacent to the
posterior fat pad of the elbow joint. Normal
synovial plicae are 2mm or less in thickness.

62. Coronal T2-
weighted image
in a 15-year-old
boy shows a
plica/fold of
synovium
laterally (red
arrows).

63. Six ossification centers
about the elbow appear
radiographically, the
capitellum is the first of
them. The medial
epicondyle is the second
ossification center to
appear at age 4, which
slowly develops and is
the last center to fuse
with the humeral shaft,
as late as 15 to 16 years
of age.

64. Coronal T2-weighted
image in a 13-year-old
boy shows that the
ossification center of
the medial epicondyle
has not fused with the
shaft of the humerus
yet (red arrow),
though other
ossification centers
have already fused.

65. Sagittal T2-weighted image
in a 14-year-old boy shows
unfused ossification center of
the olecranon. The growth
plate is seen as a
hypointense band between
the epiphysis and metaphysis
(red arrow), which should
not be mistaken for
olecranon fracture.

66. 2) MRI of the elbow injuries in young athlete.
(a) Osteochondritis dissecans of the capitellum.
Repeated microtrauma from compressive forces between
the radial head and capitellum may turn to develop a focal
avascular necrosis and osteochondritis dissecans of the
capitellum. MR imaging is a very useful tool for the detection
and staging of osteochondritis dissecans's, especially for the
evaluation of chondral injury. Unstable lesions are
characterized by fluid signal intensity around the
osteochondral fragment on T2-weighted images.

67. T2-weighted sagittal image
in a 14-year-old baseball
player shows hypointense
at the anterior aspect of the
capitellum. However,
hyaline cartilage covering
the lesion remains intact
(red arrow). This lesion is
considered to be stable
lesion.

68. T2-weighted sagittal
image in a 14-year-old
boy shows a linear fluid
signal intensity (arrow)
and several subchondral
cystic changes at the
anterior aspect of the
capitellum. This lesion is
considered to be unstable.

69. T2-weighted sagittal image
in a 14-year-old baseball
pitcher shows a bony
defect at the anterior
aspect of the capitellum
and a loosened and
displaced fragment of bone
(red arrow). This lesion in
considered to be unstable
lesion.

70. Coronal T1-weighted image
in a 10-year-old boy (left)
shows slight dilatation of
growth plate (blue arrows)
and a decrease in signal
intensity of the epiphysis
(red arrow) of the medial
epicondyle. Coronal STIR
(right) shows linear
hyperintense at the growth
plate (blue arrows) and a
patchy hyperintense at the
epiphysis (red arrow) of the
medial epicondyle.

71. Fat-suppressed T2-
weighted sagittal
image in a 21-year-
old baseball pitcher
shows hyperintense
at the olecranon,
suggesting stress
fracture (red arrow).

72. T2-weighted
sagittal image in
a 18-year-old
rugby player
shows complete
disruption of the
brachialis muscle.

73. Sagittal T2*-weighted
images in a 13-year-
old boy with severe
elbow deformity and
pain show a flatten
articular surface with
a remarkable
proliferation of the
synovium and multiple
tiny loose bodies
around the elbow
joint.

74. Madelung deformity refers to bowing of the radial shaft with increased
interosseous space and dorsal subluxation of the distal radioulnar joint.
This deformity is due to premature closure or defective development of
the ulnar third of the distal physis of the radius.
Madelung deformity can be bilateral in 50-66% of patients. It often
occurs as a rare congenital deformity and does not usually manifest
until 10-14 years of age. It may also be seen as an acquired consequence
of trauma to the growth plate, e.g. Salter-Harris fracture (type V). The
congenital form has autosomal dominant inheritance with variable
penetrance.
wrist joint.

75. Madelung deformity
with:
elongated & dorsally
subluxated ulna
triangularization of
the lunate
absent sigmoid notch
of the distal radius
volar tilt of the distal
radius.

76. Madelung deformity. Coronal T1WI of the wrist. a The Vickers ligament (arrowhead) extends from the radial notch to
the volar lunate. b The RTL (arrow) arises from the radial notch two slices dorsal to Vickers ligament in the coronal plane

77. Carpal coalition refers to the abnormal union of two or more carpal
bones, and is usually congenital, due to failure of separation of the
involved bones during development. The most commonly involved
bones are the lunate and triquetrum, although many combinations
of united bones have been reported.
Types
The two most common types of congenital carpal coalition are:
lunotriquetral coalition: much more common than all other types
combined
capitohamate coalition
Less common
hamate-pisiform coalition

78. Lunotriquetral coalition (complète osseous fusion).

79. Massive carpal
and
carpometacarpal
Coalition.

80. Juvenile idiopathic arthritis (JIA), also known as juvenile rheumatoid arthritis,
is the most common chronic arthritic disease of childhood and corresponds
to a group of different subtypes.
There are several subtypes of juvenile idiopathic arthritis:
oligoarticular JIA
affected ≤4 joints in the first six months of illness
peak age: 1-6 years
mainly affects medium and large joints
polyarticular JIA (pJIA)
≥5 joints are affected
peak age: 1-4 years; 7-10 years
mainly affects small and medium joints
systemic onset JIA (Still disease, not to be confused with adult onset Still
disease)
arthritis may present weeks to months after the onset of systemic symptoms

81. Severe erosion and joint space
reduction noted in bilateral 2nd
metacarpophalangeal joints,
right 2nd and 3rd and left 2nd,
3rd and 5th proximal
interphalangeal joints.
Fusiform soft tissue swelling is
noted over the affected joints.
Periarticular osteoporosis is
noted.
Subluxation of 1st
metacarpophalangeal joint is
noted. Ulnar deviation of right
little finger is noted.
Severe destruction and fusion of
right sided carpal bones noted.
Destruction of the distal
epiphysis of right radius and ulna
noted.

82. 8-year-old girl with systemic juvenile idiopathic arthritis and active joint inflammation of wrist without
tenosynovitis. A, STIR coronal images in posterior (A) and anterior (B) views show effusions within
radiocarpal (arrowhead, A), intercarpal (arrow, A), and first carpometacarpal (arrow, B) joints.

83. MRI in a 13-year-old girl with JIA. Examples of signal suggestive of diffuse BMO in most of the
carpal bones as evident in coronal 3D T1-weighted turbo spin-echo sequence (a), coronal fat-
saturated T2-weighed turbo spin-echo (b) and coronal, contrast-enhanced fat-saturated T1-
weighted 3D gradient-echo (c) Collapse

86. Ankle joint.
Tarsal coalition is a rare congenital abnormality
due to failure of mesenchymal separation of two
or more tarsal bones. The connection between
the tarsal bones may be osseous (synostosis),
fibrous (syndesmosis), or cartilaginous
(synchondrosis).

87. Bony bridging bar suggesting calcaneonavicular coalition Sagittal STIR image of the same
patient showing bone marrow oedema around the bony calcaneonavicular coallition.

88. Pes planus and C sign in bilateral talocalcaneal coalition.

89. Sagittal STIR image of the same patient confirming the diagnosis of talocalcaneal
coalition and showing bone marrow oedema around the coalition of the left foot.

90. The accessory
navicular bone is the
most common
accessory ossicle in
the foot. It is
positioned medial and
dorsal to the
navicular bone. The
posterior tibial
tendon inserts on this
ossicle in the majority
of cases. Three types
of accessory navicular
have been described

91. The os trigonum
is a commonly
found accessory
ossicle located
near the lateral
tubercle of the
posterior
process of the
talus.

92. Two radiographs of
the same patient
(20 years), showing
juxtaarticular
osteopenia (blue),
joint space
narrowing, erosions
(green), periosteal
new bone formation
(red) and ankylosis
(yellow).

93. The oblique and AP
radiographs of the
same patient depicted
deformity and sclerosis
of the navicular, which
adopted the classic
“comma-shaped
deformity” due to the
collapse of the lateral
part of the bone. The
findings were
confirmed in Computed
Tomography
(arrowhead).

94. Septic arthritis. Lateral radiograph demonstrates evidence of a tibiotalar joint effusion with a large erosion showing
marginal indistinct sclerosis at the talar neck. Corresponding sagittal fat-suppressed enhanced T1-weighted MRI
depicts a joint effusion with diffuse increased signal intensity within talus and navicular. There is a focal area of
higher signal intensity with a low-intensity margin within the talar neck with loss of adjacent anterior cortex.

95. Soft-tissue hemangioma. Standard
radiography of the ankle (A) shows
a soft-tissue mass lesion at the
posterior aspect of the distal tibia
with internal phleboliths. Sagittal
T2- weighted fat saturated image
(B) shows a large soft-tissue mass
with hyperintense aspect at the
posterior aspect of the distal tibia.
Note the extension of the lesion
superficially and deeply to the
plantar aponeurosis. B

96. Vascular malformation. a Axial T1W and (b) proton density with fat suppression (PDFS) images of
the ankle demonstrating a low flow vascular malformation overlying the lateral aspect of the
calcaneus with delayed multinodular enhancement (arrows) on the post contrast T1FS image (c)

97. Rhabdomyosarcoma. Short axis
T1 image (a) of the foot of a 14-
year-old girl demonstrating a
hyperintense mass in the first
web-space with avid
enhancement on postcontrast
T1FS imaging (b)

98. Shoulder joint.
Sprengel deformity, or congenital elevation of the scapula.
The radiographic classification:
grade I: superomedial angle lower than T2 but above T4
transverse process
grade II: superomedial angle located between C5 and T2
transverse process
grade III: superomedial angle above C5 transverse process,

99. Sprengel shoulder
(elevated
scapula) with large
omovertebral
bone (osseous bar
connects the
elevated scapula to
cervical spine).

100. Septic arthritis.

101. Septic arthritis of the shoulder.

102. A) Radiographs showed
large focal area of
nodular calcification
around the
glenohumeral joint.
The joint structures
were intact. B)
Magnetic resonance
imaging revealed
multiple centers of
nodular calcification
and similar findings
within the biceps
tendon sheath.

104. Intra-muscular
hemangioma
of the shoulder
joint,

105. Preoperative magnetic resonance
imaging. (A) T1-weighted coronal
image; relatively low-signal
intensity mass with heterogeneous
signal in subscapularis recess.
(B) T2-weighted coronal image; the
lesion is defined and lobulated with
high-signal intensity. Calcification is
demonstrated as foci of signal void
(arrows). T2-weighted sagittal
image with fat suppression showed
high signal intensity in mass ruling-
out fatty component (C), T1-
weighted axial image with
fat suppression after contrast-
enhancing (D)

106. Aneurysmal bone cyst after pathologic fracture. Frontal radiograph shows large expansile
lesion (arrows) in acromion. Sagittal oblique fat-suppressed T2-weighted MR image shows
well-defined lesion (arrowhead) with large cystic component. Axial spin-echo T1-weighted
MR image shows homogeneous high signal intensity in cystic portion of lesion
(arrowheads), consistent with degraded blood products.

107. chondrosarcoma in preexisting osteochondroma. Frontal
radiograph obtained 1 year after resection shows lesion
recurrence in glenoid. Axial CT scan shows large cartilage
component surrounding bony glenoid (arrowheads) with
cortical destruction. Axial fat-saturated T2-weighted MR image
shows high-signal-intensity cartilage component (arrowheads).

108. Ewing's sarcoma of scapula. Frontal radiograph of 17-year-old boy with palpable
mass shows lytic lesion (arrows) in superior rim of scapular body. Axial CT scan of
patient in A shows destructive lesion with large soft-tissue mass (arrowheads).

109. Primary malignant fibrous histiocytoma of scapula. Frontal radiograph shows lytic lesion (arrowhead)
in body of scapula. Sagittal oblique spin-echo T1-weighted MR image shows lesion (arrowheads) that
is isointense to muscle with cortical destruction. Sagittal oblique fat-saturated T2-weighted MR image
shows heterogeneous high signal intensity with soft-tissue extension (arrows).

110. Thank You.