Ebook Imaging of bones and joints: Part 1

Part 1 book “Imaging of bones and joints” has contents: Acute trauma and overuse injuries - essentials, acute trauma and chronic overuse (according to region); infections of the bones, joints, and soft tissues; tumors and tumor like lesions of bone, joints, and the soft tissues,… and other contents.

2181 illustrations, including 338 on the Thieme MediaCenter

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This book is an authorized, adapted, and revised version of the 3rd German edition published and copyrighted 2014 by Georg Thieme Verlag, Stuttgart Title of the German edition: Radiologische Diagnostik der Knochen und Gelenke

Translator: Grahame Larkin, Stuttgart, Germany Illustrator: Christiane and Dr Michael von Solodkoff, Neckargemünd, Germany

Important note: Medicine is an ever-changing science undergoing continual development Research and

clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in

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Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

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2.14 Lower Leg

2.14.1 Fractures (E.-M Wagner)

2.14.2 Radiological Assessment of Surgery of the Lower Leg (E Knoepfle)

2.14.3 Soft Tissue Injuries and Stress Reactions of the Lower Leg (K Bohndorf)

5 Bone Marrow

5.1 Normal Bone Marrow (I M Noebauer-Huhmann)

5.1.1 Distribution and Age-dependent Physiological Conversion of Red to Yellow Marrow 5.1.2 Reconversion of Yellow to Red Marrow/Bone Marrow Hyperplasia

7 Osteochondroses

7.1 Anatomy, Etiology, and Pathogenesis (K Bohndorf)

7.1.1 What Do the Different Forms of Osteochondrosis Have in Common? 7.1.2 To Which Disorders is the Term “Osteochondrosis” Not Applicable?

12.6.6 Results

12.7 Laser Therapy and Radiofrequency Ablation (K Bohndorf, A Seifarth)

Index

Guide to Important Classifications

Thirty-five authors have contributed to the text and images It should not,however, read as a multi-authored book because it follows the principle of

“many authors but only one style.” The editors have carefully revised,harmonized, supplemented, or sometimes trimmed the text and images toproduce a book that is “cast from a single mold”—that is its claim In this ithonors the ethos and form of its “progenitor,” the third edition of Thieme's

The book has been designed and composed with this principle in mind.Nevertheless, considerable additional information has been placed on theThieme MediaCenter, accessible via the internet (see “How to Use This Book”).This is intended not simply as a tribute to the technological spirit of the times,

but also as a practical way to expand the book's contents In this way theproblem of squaring the circle—of producing an affordable, compact book while

at the same time making available even more images and information—has beenelegantly solved The web-based supplementary material is clearly indicated inthe book by the use of the MediaCenter icon so that the reader can decidewhether or not it will be useful to take advantage of it

The support of the Thieme publishing house for this book has been exemplary inevery way This publisher has a history of producing esthetically beautiful yetchallenging books, without excluding themselves from modern-day media That

is a stroke of luck for editors and authors like us who hope to see many of ourideas and intentions put into practice We would like to express our thanks toStephan Konnry for supporting this endeavor We are also grateful to theeditorial team, in particular Gabriele Kuhn-Giovannini and Jo Stead, and to LenCegielka, the copy editor, for their skills, patience, empathy, and tenacity duringthe realization of our joint project

Klaus Bohndorf, MD Mark W Anderson, MD Mark Davies, MRCP, FRCR

Herwig Imhof, MD Klaus Woertler, MD

Armin Seifarth, MD, Augsburg, for editing and reviewing all chapters onultrasound Where deemed necessary, he has added material to the chapters andsupplied more images

Walter Braun, MD, Professor of Surgery, Augsburg, for his competent andprompt advice on Chapters 1 and 2 from the traumatologist's standpoint

Thomas Naumann, MD, former head of the Department of Orthopedic Surgery I,Hessing Klinik, Augsburg, for improvements to Chapter 9.3

Martin Seidler, MD, Augsburg, and Mr Ulf Wolkenstein, Augsburg, forproviding and giving advice on the necessary IT requirements

Many colleagues have kindly and generously supplied image material Inparticular the sterling work by Thomas Grieser, MD (Augsburg), HerbertRosenthal, MD (Hanover), and Dr Bjoern Jobke (Heidelberg) deservesparticular acknowledgment The names of the contributors are noted below theimages; this information has been omitted for images that originate from thearchives of the editors

The Editors

Consultant Musculoskeletal Radiologist Department of Radiology University of

Iris Melanie Noebauer-Huhmann, MD

Associate Professor of Radiology Neuroradiology and MSK RadiologyDepartment of Biomedical Imaging and Image-guided Therapy MedicalUniversity of Vienna Vienna, Austria

Christian W A Pfirrmann, MD

Professor of Radiology Chairman

Consultant Musculoskeletal Radiologist Department of Clinical Radiology

Manchester Royal Infirmary Manchester, United Kingdom Walter A.

ABC aneurysmal bone cyst

ABER abduction and external rotation ACL anterior cruciate ligament

ALIF anterior lumbar interbody fusion ALPSA anterior labroligamentousperiosteal sleeve avulsion (lesion) ANA antinuclear antibody

ANCA antineutrophil cytoplasmic antibody anti-CCP anti-cyclic citrullinatedpeptides AP anteroposterior

ARCO Association Internationale de Recherche sur la Circulation Osseuse

ASPED angel-shaped phalangoepiphyseal dysplasia AT antetorsion angle (anglebetween the prosthetic neck and the stem ATAF anterior talofibular (ligament)

capitulum—radial head—internal epicondyle—trochlea—olecranon—externalepicondyle CRMO chronic recurrent multifocal osteomyelitis CRP C-reactiveprotein

MGUS monoclonal gammopathy of undetermined clinical significance MIP

PD proton density

PDW proton density–weighted

PEST papilledema, extravascular volume overload, sclerotic bone lesions, andthrombocytosis/erythrocytosis PET positron emission tomography

PIP proximal interphalangeal (joint) PLIF posterior lumbar interbody fusion

POEMS polyneuropathy, organomegaly, endocrinopathy, M-proteins, skinchanges POLPSA posterior labrocapsular periosteal sleeve avulsion PT

SSC subscapularis muscle

TLICS Thoracolumbar Injury Classification and Severity Score TLIF

Structure of the Chapters

The chapters have been constructed in a common, consistent format to helporganize the information and facilitate navigation within the text Chapters aredivided into sections under the following headings:

Anatomy. Here you will find the most important anatomical features of aparticular region To help streamline the text, some of the anatomy chapters havebeen placed on the Thieme MediaCenter

Pathology. The pathology and pathophysiology of each disease entity arebriefly presented here

Clinical presentation. Important features of the clinical presentation of apatient with the condition are described here

Radiology/US/CT/MRI. Findings on each modality are listed in this section.Modalities that do not provide additional information are not included

NUC MED. When appropriate, the findings of radionuclide studies will bedescribed here

Important findings. This deals with information of importance to the clinicianthat should be included in the imaging report

Special features in children. Important features of childhood disorders arelisted

Note

Here you will find important take-home messages in each chapter.

Caution

Warnings regarding possible imaging pitfalls.

DD. The most common and most important differential diagnoses are listedhere along with brief differentiating criteria.

of whether a spectral fat saturation or inversion recovery technique was used),and all images with intravenous contrast material administration are labeled

1 Acute Trauma and Overuse Injuries: Essentials

1.1 Normal Skeletal Development, Variations, and Transitions to Pathologic Conditions

1.1.1 Normal Skeletal Development

Anatomy. Normal skeletal development involves growth and maturation of theepiphyseal and metaphyseal growth zones as well as changes involving themedullary cavity Of all imaging modalities available, magnetic resonanceimaging (MRI) is best suited for demonstrating these processes It allowsimaging of the epiphysis (which is formed entirely as a cartilaginous precursor

or anlage), the conversion of epiphyseal cartilage into bone, the growth plate (=physis, epiphyseal plate), and the age-related conversion of the bone marrow (

• Development and growth of the apophyseal ossification centers

• Bony epiphyseal closure

Only two epiphyseal ossification centers are present in the mature newborn: the

distal femoral epiphyseal ossification center and usually also the proximal tibialepiphyseal ossification center The order in which other ossification centersbecome visible is age dependent Once an ossification center has appeared,ossification then progresses toward the margins of the cartilaginous precursor

The physis or growth plate has a decisive role in the maturation process Not

only is it responsible for eventual height and body mass, it also contributes toresilience and elasticity of the skeleton during growth It consists of five zones

separating the secondary ossification center (the so called chondroepiphysis)from the metaphysis The growth plate is especially prone to injury (see Chapter1.3) The cartilaginous plate between the bony epiphysis and the shaft isobliterated and replaced by bone by the time the epiphysis closes; only the jointcartilage remains as a narrow cartilaginous layer.

Apophyseal ossification centers appear shortly before or during puberty Fusion

of the apophyses with the bones starts after puberty and is usually complete bythe age of 25 years The time of appearance of the ossification centers, theirgrowth, and fusion of the epiphysis and apophysis with the bone are constantwithin a certain range of variation, allowing assessment of skeletal maturity andskeletal age

During postnatal skeletal development, remodeling of the bone marrow proceeds

in parallel with the ossification steps The medullary cavity of the fetus is stillfilled with hematopoietic red marrow Shortly before birth, conversion to fatmarrow begins in the limbs in a centripetal direction, starting in the distalphalanges In early adulthood, hematopoietic marrow is still mainly present inthe skull, the sternum, the ribs, the pelvis, and the proximal humerus and femur;fat marrow is found in the rest of the skeleton (Chapter 5)

Fig 1.1 MRI of the knee joint of a 5-year-old child (a) Fat marrow signal in the ossification nucleus of

the epiphysis On the T1W image, the signal intensity in the metaphysis is intermediate between fat and

muscle, the classic appearance of red bone marrow (b) On the PDW fat-saturated image, it is possible to

epiphysis Variant within the normal range This most typically involves the posterior aspect of the

femoral condyle.

disturbance of endochondral bone growth.

Fig 1.6 A 6-year-old boy with focal epiphyseo–metaphyseal fusion This fusion may be a pathologic

variant of the cone-shaped epiphysis, which leads to in interference with growth (a) The irregularity of the epiphyseal plate and the metaphysis on the radiograph suggest that fusion has taken place (b) The

MRI scan confirms a bony bar extending across the distal femoral physis.

• Increased mineralization of the epiphyseal ossification nucleus may present

bone epiphyses ( Fig 1.7), as they are called, must be distinguished fromother skeletal disorders with increased sclerosis, such as osteopoikilosis.

in healthy children, most often in the distal phalanges These ivory or marble-The radiological appearance of ossification centers can vary, especially in thecarpal and tarsal bones and may include:

Radiography. Epiphyseal or apophyseal variants can create difficulties inaccurate diagnosis, and include:

MRI. MRI findings in most cases allow a distinction to be made betweentraumatic injury and a variant or disturbance of ossification Today, MRI isroutinely used as a supplemental modality in cases with equivocal findings onultrasound, and is the diagnostic method of choice for evaluating the bonemarrow Knowledge of age-related bone marrow conversion is a prerequisite forevaluating pathologic bone marrow findings (Chapter 5.1).

However, there are fractures that are not revealed on conventional radiographs,although CT (computed tomography), MRI, and, at certain anatomical sites,even ultrasound can identify the fracture These fractures are considered

“radiographically occult.” The lowest level of traumatic bone damage is thepurely trabecular fracture It is only detectable on an MRI scan where fracture-related bone marrow edema (also known as “bone contusion” or “bone bruise”)will be evident These lesions are indeed painful, but they generally healspontaneously with rest and a short period of immobilization

normal variant.

Fig 1.9 Shell-like ossification nucleus posteriorly at the medial femoral condyle, a normal variant.

Fig 1.10 Fragmented and sclerotic appearance of the calcaneal apophysis, a normal variant.

epiphysis (b) Corresponding MRI shows a focus of irregular ossification (c) Without evidence of a

cartilage defect or a surrounding bone marrow reaction.

Fig 1.12 Comparison between Perthes’ disease and a normal developmental variant (Meyer's dysplasia).