Generalised Increased Bone Density (Adult)
- MYELOPROLIFERATIVE: myelofibrosis
- METABOLIC: renal osteodystrophy
- NEOPLASTIC (probably multifocal rather than generalised):
- Osteoblastic metastases (commonly breast and prostate)
- Lymphoma
- Mastocytosis - IDIOPATHIC: Paget’s Disease
Solitary sclerotic bone lesion
- DEVELOPMENTAL: Fibrous dysplasia, enostosis (bone island)
- NEOPLASTIC:
- Metastasis (prostate/breast)
- Lymphoma
- Osteoma/osteoid osteoma/osteoblastoma
- Healed/healing benign or malignant bone lesion: lytic mets treated with chemoRT, fibrous cortical defect, eosinophilic granuloma, brown tumor
- Primary bone sarcoma - VASCULAR: bone infarct
- TRAUMATIC: callus (esp around stress fracture site)
- INFECTIVE: sclerosing osteomyelitis
- IDIOPATHIC: Paget’s disease
Multiple sclerotic bone lesions
- DEVELOPMENTAL
- Fibrous dysplasia
- Osteopoikilosis
– Osteopathia striata (Voorhoeve’s disease)
– Tuberous sclerosis - NEOPLASTIC:
- Sclerotic metastases
- Lymphoma
- Mastocytosis
- Multiple healed/healing benign/malignant lesions
- Multiple myeloma (sclerosis in 3%)
- Osteomata (e.g. Gardner’s syndrome)
- Multifocal osteosarcoma - IDIOPATHIC: Paget’s disease
- VASCULAR: bone infarcts
- TRAUMATIC: callus
Bone sclerosis with periosteal reaction
- TRAUMATIC: healing fracture with callus
- NEOPLASTIC:
- metastasis
- osteoid osteoma/osteoblastoma
- osteosarcoma
- Ewing’s sarcoma
- Chondrosarcoma - INFECTIVE:
- chronic osteomyelitis (sclerosing osteomyelitis of Garre, Brodie’s abscess)
- Syphillis - DEVELOPMENTAL/IDIOPATHIC:
- Caffey’s disease (idiopathic cortical hyperostosis)- massive periosteal new bone along diaphyses. tender and painful soft tissue swelling, erythema, fever, and irritability.
- Melorhosteosis (molten wax of burning candle)
Coarse trabecular pattern
- Paget’s disease
- Osteoporosis
- Osteomalacia
- Hemoglobinopathies- especially thalassemia
- Hemangioma - esp in vertebral body
- Gaucher’s disease
Coarse trabecular pattern
- Paget’s disease
- Osteoporosis
- Osteomalacia
- Hemoglobinopathies- especially thalassemia
- Hemangioma - esp in vertebral body
- Gaucher’s disease
Skeletal metastases by their common radiological appearance
MIXED/SCLEROTIC:
- breast
- prostate
- carcinoid
- cervical
- testis
- gastric
LYTIC, EXPANSILE:
- Renal cell carcinoma
- Thyroid
- Pheochromocytoma
- Melanoma
LYTIC:
- SCC
- lung
- rectal, colon (occ sclerotic)
- uterus, ovary
- Wilm’s tumor
- bladder (occ sclerotic)
- neuroblastoma (occ sclerotic)
Sites of origin of primary bone neoplasm
Non-aggressive lucent lesion in the medulla (well-defined, marginal sclerosis, no expansion)
- Geode – a subarticular cyst. Other signs of arthritis.
- Healing benign or malignant bone lesion – e.g. metastasis, eosinophilic granuloma or brown tumour.
- Brodie’s abscess.
- Benign bone neoplasms:
(a) Simple bone cyst.
(b) Enchondroma.
(c) Chondroblastoma. - Fibrous dysplasia.
Indeterminate lucent lesion in the medulla (well-defined, NO marginal sclerosis, no expansion).
- Metastasis – especially from breast, lung, kidney or thyroid.
- Multiple myeloma. (look for multiplicity)
- Eosinophilic granuloma.
- Brown tumour of hyperparathyroidism.
- Benign bone neoplasms
(a) Enchondroma.
(b) Chondroblastoma.
Aggressive lucent lesion in the medulla (ill-defined)
- Metastasis.
- Multiple myeloma.
- Osteomyelitis.
- Lymphoma of bone.
- Long bone sarcomas
(a) Osteosarcoma.
(b) Ewing’s sarcoma.
(c) Central chondrosarcoma.
(d) Fibrosarcoma and malignant fibrous histiocytoma.
LUCENT BONE LESION IN THE MEDULLA
– WELL-DEFINED, ECCENTRIC
EXPANSION
- Giant cell tumour*.
- Aneurysmal bone cyst*.
- Enchondroma*.
- Non-ossifying fibroma (fibrous cortical defect)*.
- Chondromyxoid fibroma*.
LUCENT BONE LESION – GROSSLY
EXPANSILE
Malignant bone neoplasms:
1. Metastases – renal cell carcinoma and thyroid; less commonly melanoma, bronchus, breast and phaeochromocytoma.
2. Plasmacytoma
3. Central chondrosarcoma/lymphoma of bone/fibrosarcoma:
– when slow growing may have this appearance.
4. Telangiectatic osteosarcoma
Benign bone neoplasms:
1. Aneurysmal bone cyst
2. Giant cell tumour
3. Enchondroma
Non-neoplastic:
1. Fibrous dysplasia
2. Haemophilic pseudotumour (see Haemophilia) – especially in the iliac wing and lower limb bones. Soft-tissue swelling.
± Haemophilic arthropathy.
3. Brown tumour of hyperparathyroidism*.
4. Hydatid.
‘MOTH-EATEN BONE’ IN AN ADULT
Neoplastic:
1. Metastases.
2. Multiple myeloma.
3. Leukaemia – consider when there is involvement of an entire bone
4. Long-bone sarcomas:
(a) Ewing’s sarcoma.
(b) Lymphoma of bone.
(c) Osteosarcoma.
(d) Chondrosarcoma.
(e) Fibrosarcoma and malignant fibrous histiocytoma.
5. Langerhans’ cell histiocytosis.
Infective:
Acute osteomyelitis.
Osteomalacia and rickets
Vitamin D deficiency
1. Dietary.
2. Malabsorption.
Renal Disease
1. Glomerular disease (renal osteodystrophy*).
2. Tubular disease
(a) Renal tubular acidosis.
(i) Primary – sporadic or hereditary.
(ii) Secondary.
– Inborn errors of metabolism, e.g. cystinosis,
galactosaemia, Wilson’s disease, tyrosinosis, hereditary
fructose intolerance.
– Poisoning, e.g. lead, cadmium, beryllium.
– Drugs, e.g. amphotericin B, lithium salts, outdated
tetracycline, ifosfamide.
– Renal transplantation.
(b) Fanconi syndrome – osteomalacia or rickets, growth
retardation, RTA, glycosuria, phosphaturia, aminoaciduria and proteinuria.
(c) Vitamin D-resistant rickets (familial hypophosphataemia,
X-linked hypophosphataemia)
Hepatic disease:
1. Parenchymal failure.
2. Obstructive jaundice – especially biliary atresia.
If the patient is less than 6 months of age then consider:
1. Biliary atresia.
2. Metabolic bone disease of prematurity – combined dietary deficiency and hepatic hydroxylation of vitamin D.
3. Hypophosphatasia.
4. Vitamin D-dependent rickets.
PERIOSTEAL REACTIONS – BILATERALLY
SYMMETRICAL IN ADULTS
- Hypertrophic osteoarthropathy (HOA) – this condition can be caused by the conditions in 1.27.
- Pachydermoperiostosis.
- Vascular insufficiency (venous, lymphatic or arterial).
- Thyroid acropachy.
- Fluorosis.
- Diffuse idiopathic skeletal hyperostosis (DISH; Forestier disease).
HYPERTROPHIC OSTEOARTHROPATHY
Pulmonary:
1. Carcinoma of bronchus.
2. Lymphoma.
3. Abscess.
4. Bronchiectasis – frequently due to cystic fibrosis.
5. Metastases.
Pleural:
1. Pleural fibroma – has the highest incidence of accompanying HOA, although it is itself a rare cause.
2. Mesothelioma.
Gastrointestinal
1. Ulcerative colitis.
2. Crohn’s disease.
3. Dysentery – amoebic or bacillary.
4. Lymphoma*.
5. Whipple’s disease.
6. Coeliac disease.
7. Cirrhosis – especially primary biliary cirrhosis.
8. Nasopharyngeal carcinomas (Schmincke’s tumour).
Avascular necrosis (Toxic, traumatic, metabolic/endocrine, inflammatory/infective, Hb disorders)
Toxic:
1. Steroids – probably does not occur with less than 2 years of treatment.
2. Alcohol – possibly because of fat emboli in chronic alcoholic pancreatitis.
3. Immunosuppressives, Anti-inflammatory drugs
Traumatic:
1. Idiopathic – e.g. Perthes’ disease
2. Fractures – especially femoral neck, talus and scaphoid.
3. Radiotherapy.
4. Fat embolism.
Inflammatory:
1. RA (probably vasculitis)
2. SLE (probably vasculitis)
3. Scleroderma
4. Infection: pyogenic arthritis
Metabolic and endocrine:
1. Pregnancy.
2. Diabetes.
3. Cushing’s syndrome.
4. Hyperlipidaemias.
5. Gout.
Haemopoietic disorders:
1. Haemoglobinopathies – especially sickle-cell anaemia.
2. Polycythaemia rubra vera.
3. Gaucher’s disease.
4. Haemophilia
Erosion/absent outer end of clavicle
- Rheumatoid arthritis*.
- Post-traumatic osteolysis.
- Multiple myeloma*.
- Metastasis.
- Hyperparathyroidism*.
- Cleidocranial dysplasia*.
- Pyknodysostosis.
Focal rib lesion (SOLITARY OR
MULTIPLE)
NEOPLASTIC:
Secondary more common than primary. Primary malignant more common than benign.
- Metastases:
(a) Adult male – bronchus, kidney or prostate most commonly.
(b) Adult female – breast. - Primary malignant
(a) Multiple myeloma/plasmacytoma.
(b) Chondrosarcoma.
(c) Askin tumour – uncommon tumour of an intercostal nerve causing rib destruction. - Benign
(a) Osteochondroma.
(b) Enchondroma.
(c) Langerhans’ cell histiocytosis*.
NON-NEOPLASTIC:
1. Healed rib fracture.
2. Fibrous dysplasia.
3. Paget’s disease.
4. Brown tumour of hyperparathyroidism.
5. Osteomyelitis – bacterial, tuberculous or fungal.
Inferior rib notching
ARTERIAL:
- coarctation of the aorta: Bilateral 4th to 8th ribs conventionally. Unilateral and right-sided if coarc is prox. to left subclavian artery. Unilateral and left-sided if coarc associated with anomalous right subclavian artery distal to coarc.
- Subclavian obstruction (unilateral rib notching of 1-4th ribs on operated side of Blalock operation for TOF repair)
VENOUS:
- SVCO
NEUROGENIC:
- neurofibromatosis (ribbon ribs may be a feature)
Superior rib notching
Connective tissue diseases:
1. Rheumatoid arthritis.
2. Systemic lupus erythematosus.
3. Scleroderma*.
4. Sjögren’s syndrome.
Metabolic:
Hyperparathyroidism*.
Miscellaneous
1. Neurofibromatosis.
2. Restrictive lung disease.
3. Poliomyelitis.
4. Marfan’s syndrome.
5. Osteogenesis imperfecta*.
Wide/thick ribs
- Chronic anaemias (extramedullary hematopoiesis)
- Fibrous dysplasia
- Paget’s disease
- Healed fractures with callus
- Achondroplasia
- Mucopolysaccharidoses
Madelung deformity. It comprises: (a) short distal radius, which shows a dorsal and ulnar curve;
(b) triangular shape of the distal radial epiphysis;
(c) premature fusion of the ulnar side of the distal
radial epiphysis;
(d) dorsal subluxation of the distal ulna;
(e) enlarged and distorted ulnar head; and
(f) wedging of the triangular-shaped carpus between the distal radius and ulna.
- Isolated – bilateral > unilateral. Asymmetrical. Predominantly adolescent or young adult women.
- Dyschondrosteosis (Leri–Weil disease) – bilateral with mesomelic limb shortening. AD. Predominantly men.
- Diaphyseal aclasis.
- Turner’s syndrome*.
- Post-traumatic.
- Postinfective.
