#1 Flashcards
(305 cards)
1
Q
What is the most common site of shaft fracture of humerus?
A
Surgical Neck
2
Q
What is visible on film, radiographic joint space, or anatomic joint space?
A
Radiographic Joint space
3
Q
Does the certified radiology technologist have any liability for diagnostic interpretation? - What reliability do they carry?
A
no - Carry liability for production of any technical component
4
Q
Who carries the liability for diagnostic interpretation when providing that service?
A
General Practitioner
5
Q
What is the primary responsibility of the radiologist?
A
Image Interpretation (highest level of service)
6
Q
Who had the greatest and least % of correct films read in regards to the list in class?
A
Chiropractic Radiologist = 71.9% Medical Student = 5.74%
7
Q
If a general practitioner uses a radiologist and gets a report, who has the liability?
A
Radiologist
8
Q
Human skeleton has how many bones?
A
206
9
Q
Axial skeleton =
A
74 bones
10
Q
Appendicular Skeleton =
A
126 Bones
11
Q
Chiropractic students had what % of results when correctly identifying pathology?
A
20.45%
12
Q
90% of bone metastisis is where?
A
The Axial Skeleton
13
Q
Ectodermally derived malignant tumors are…?
A
Carcinoma
14
Q
What are the precursors of all structures and organs?
A
Mesoderm
15
Q
Malignant tumors that are mesodermal are?
A
Sarcoma
16
Q
What is the primary center for ossification?
A
Diaphysis
17
Q
What is the secondary ossification center?
A
Metaphysis
18
Q
What is a separate structure in kids, but not in adults?
A
Epiphysis
19
Q
Aka, “growth plate”
A
Physis
20
Q
What part of the bone is a protuberance and functions as an attachment site?
A
Apophysis
21
Q
What is the point where tendon/ligament attaches to bone?
A
Ethesis
22
Q
What are the only tubular bones to have 1 ossification center?
A
- Metatarsals (distal)
- Metacarpals (distal)
- Phalanges (proximal)
23
Q
Describe the cortex…
A
- Major storehouse of CALCIUM
- Major STRENGTH area of bone
- DENSITY & THICKNESS
24
Q
Thickness of the cortex is _______ proportional to the diameter of the bone?
A
INVERSELY
* Cortex is thickest at the narrowest, or center of diaphysis
25
What is the bone described as when the cortex begins to thin?
Osteopenic
26
Red and Yellow bone marrow reside where?
Medullary cavity
27
What are the main sites for Red Bone Marrow in adults?
* **Sternum**
* **Facial Bones**
* **Ribs**
28
Bone is the \_\_#\_\_\_\_ location for metastatic spread?
3
29
Metastatic cancer spreads to what top 3 regions?
1. ***_LUNG_***
2. Brain/Liver
3. **BONE**
30
Over 2/3 of bone metastisis in women come from?
BREASTS
31
Who is more likely to have bone cancer?
Adults or Children
CHILDREN
- This is due to the amount of RBM (greater % in kids vs. adults)
32
What type of bone has marrow in it, and is known as "spongy bone?"
Trabecular
33
Can you see periosteum on radiograph?
NO
34
The periosteum has 2 layers, what are they, and what do they do?
**_OUTER LAYER:_** Fibrous (insertion layer for tendons & ligaments)
**_INNER LAYER_**: Cambium - Labile (Physiologically active)
* Important indicator of ***_BONE DISEASE_***
35
How many layers thick is the endosteum?
1
36
What is at the corticomedullary Junction?
Endosteum
37
What is significant in adults in regard to the endosteum?
Atrophies a lot in adults
38
What part of the bone has the function of osteoblastic/clastic function?
ENDOSTEUM
39
What is "Direct ossification," and a conversion of mesenchymal tissue into bone without a cartilagenous precursor?
Intramembranous Ossification
40
Longitudinal bone growth comes from where?
Physis
41
What is the precursor to appositional bone growth (growth in diameter)?
Intramembraneous Ossification WITHOUT a cartilagenous precursor
42
Describe Endochondral Ossification with Cartilage
**Longitudinal** Bone growth\*\*
Mesenchymal cells differentiate into **_cartilage_** (later replaced with bone); PHYSIS
43
What is the MAIN difference between Intramembraneous Ossification and Endochondral Ossification?
* **Intramembraneous** is mesenchymal tissue into bone
* **Endochondral** is mesenchymal ---\> Differentiated cell -----\> BONE
44
What are the 2 major way we grow bone?
1. **PERIOSTEAL**: Blastic/Productive
2. **ENDOSTEAL**: Clastic/Destructive
45
What is "endochondral bone growth" associated with?
Physis
46
Physis =
**HYPERTROPHIC ZONE & METAPHYSIS\*\*\*\***
47
As the cells move down from the resting layer to the proliferating zone, what happens?
They get larger due to more oxygen availability
\*\*Once they reach the zone degeneration zone they began to die (Lack of OXYGEN)
48
The reserve/resting zone has what type of blood supply?
**_Excellent_**
* Will start growing & make more "blue stuff" = Extra Cartilage Matrix
* As they grow and get larger = *Proliferating* Layer
49
The Maturation & Degenerative Zone =
Columnar Layer
50
Where do cells start to line up in vertical columns?
**_Maturation Zone_**
* _No blood vessels (avascular)_
* Lack of **O2**
* Cells die
* Need them to die to utilize cells surface area
51
What are the key features of the primary spongiosa?
* Deminished thickness of mineralized matrix
* Once it's gone, becomes secondary spongiosa
* **CLOSED** cappilary loops
* **_Vasculature_** - Bring calcium & Phosphorus in Blood (hydroxyapatite)
* *Oozes* into matrix and mineralizes
52
How does bone grow occur?
* Bone growth upward meets higher zones --\> End of Growth
Rate is influenced genetically, hormonally, and nutritionally
53
In a pediatric patient, the metaphysis _____ ?
Consists of primary and secondary spongiosa
54
Cell zone of provisional calcification =
ZONE OF PROVISIONAL ***_MINERALIZATION_***
- Takes calcium and phosphorus to produce this layer
55
What allows bone to grow transversely?
Periochondral/Fibrous ring of La Croix
\* Supports & at outter peripheral rim of physis
56
What does the ossification Groove of Ranvier do?
Support and at the outer peripheral rim of physis - Provides cells for growth in **width/diameter**
57
What is the physis function?
Endochondral ossification largely avascular, longitudinal bone growth
58
What do osteoblasts produce?
Osteoids, which are then mineralized to give it rigidity by interacting calcium phosphate appetite
59
What is the whole point of old cells dying?
We need the SURFACE AREA that it was taking up
\*\* The whole point is to build the matrix (scaffold) and to die for new cells to take its place
60
Achondroplasia
Genetic mutation (midgets)
- Literally means, "No cartilage growth"
61
What is categorized as slow endochondral bone formation, and affects (extremity growth)?
Achondroplasia
"hypo" - actually
62
What is termed as, "greater shortening proximally of (Humerus & Femur)?
Rhizomelia
63
Where would Someone with Achondroplasia have a great level of stenosis?
_L5_
- Due to: **DJD**, or buckling of **ligamentum flava**
64
Is appositional growth affected in achondroplasia?
NO
65
Hydrocephalus may result from what disease?
* Achondroplasia*
- This RESTRICTS the **_Foramen Magnum_**
66
Periosteal bone will have what type of growth in Achondroplasia?
NORMAL
67
What type of bone growth does Achondroplasia slow down?
_Enchondral_ bone formation (length), but doesn't impact Periosteal bone growth (Width) and ONLY in **APPENDICULAR** **SKELETON**, not axial
\* Bones appear _FAT_
68
Define ; Tubulation
Formation of tubular bone
69
Why does the lumbar spine possibly lead to central canal stenosis in achondroplasia?
Pedicles are not long enough
70
3 most common signs of Achondroplasia:
* **L5** has the worst pedicle stenosis
* **_Horizontal Sacrum_** is common
* Increased Lordosis
71
Marfan's Syndrome
Accelerates rate of **_longitudinal bone growth_**
72
What disease creates bones to look "overtubulated"
Marfan's
73
What does Arachondactyly mean?
What disease is associated with it?
Long skinny fingers/toes
- **_Marfan's_**
74
What type of problems will people with Marfan's sydrome suffer with?
_***\*Dissecting Aneurysm (Exsanguination)***_
* Weaken medial layer, weakens intima, lots of blood goes on mediastinum
**kills 1/3**
* **Occular Issues**
75
Gigantism accelerates what?
**BOTH** endochondral and periosteal bone formation
(PROPORTIONAL GROWTH)
76
What is a common problem with Gigantism?
**_Pituitary tumor (adenoma) making too much HGH_**
- As adults, the periosteal can still grow so bones get **THICKER**, but not longer
- Joint cartilage also proliferates (Secondary DJD)
77
Osteopetrosis
**GENETIC**
* Alber-Schomberg's Disease
* Marble Bone
* Chalk Bone
78
What are people with osteopetrosis prone to?
**Anemia**: Medullary cavity filled w/ Mineralized matrix. Hematopoetic tissue crowded out
**Fracture**: Bones become sclerotic, but BRITTLE, decreased blastic activity
79
What is impacted by osteopetrosis?
Transition from primary to secondary spongiosa (problem converting from primary --\> secondary)
80
What is osteosclerosis defined as?
Increasing bone density
81
Osteopetrosis makes bone ____ ?
Really sclerotic
82
What does Osteopetrosis Tarda result in?
**Mild** form can be turned on, and then off genetically (stop and go process)
_**\*Erlenmeyer Flask Deformity**_
83
What does the appearance of Osteopetrosis create?
**_Bone in bone_** appearance (stop and go sequence)
* Cortex of bone has mostly taken over the bone's ability to function (becomes **anemic**)
* Osteoclast are unable to resorb bone and therefore primitive calcified cartilage is ALL OVER
84
Osteopetrosis Congenita is what type of form?
HYPERACTIVE, and happens all over
- Can't grow enough marrow to keep up
85
What is the problem with Rickets/Pediatric Osteomalacia?
**_Deficiency_** of Calcium, Vit D, or Phosphorus
- One of the MAIN **_osteopenic_** Bone diseases
86
What is the area of bone that is affected by Rickets/Pediatric Osteomalacia?
**_Zone of Provisional Mineralization (ZPM)_** is the area in dispute
* Can't mineralize matrix (osteocytes) = No "scaffold" = **STOPS LONGITUDINAL GROWTH**
87
What does Ricket's present?
* Bowing* deformity
- Bone is **_soft_**
- Doesn't have enough calcium or phosphorus
88
Long term rickets =
Dwarfism Disorder
89
What is the weakest layer of growth plate?
**_Columnar Zone_** because cells are big, there's lots of space, getting ready to die, and they're lined up in a column
90
What area of bone would kids be vulnerable to side loading?
**Columnar Zone** (Marginal & Degenerative)
- TRAUMA
**Resting/ Reserve layer** vulnerable to AXIAL load injuries (compression)
- Once crushed, bone growth PERMANENTLY stops
91
What is the least and most common Salter Harris Fracture type?
**_MOST COMMON_**: Type 2
* Through physis and apophysis
**_LEAST COMMON_**: Type 5
* growth plate crushed
92
Where does the type 1 Salter Harris Fracture usually occur?
Proximal Femur
## Footnote
- Separates epiphysis from metaphysis through the **COLUMNAR LAYER**
93
What is common with Salter Harris Fracture (Type 1)?
Slipped Capital Femoral Epiphysis (***_SCFE_***)
- Common injury to **HIP** of children
94
What are the details of Salter Harris Fracture type 2?
\*\*\*\* MOST COMMON \*\*\*\*\*
* ***_Thurston-Hollan Fragment_***
* Side loaded injury
* MOST COMMON SITES: **Distal Radius & Tibia, Fibula Ulna**
95
Salter Harris Type 3 fracture:
Creates a **_separate_** epiphyseal piece
(side load trauma)
\*\* Happens with **VERTICAL** impact
96
Type 4 Salter Harris Fracture:
**Straight Vertical Trauma**
* Combined 2 or 3
* MOST COMMON SITE: Fracture through tibia (lateral epicondyle most common in children \<10)
* Kid jumps out of Tree
97
Type 5 Salter Harris Fracture:
Crushes the **_PHYSIS_** (extreme pain)
\*\*\*\* Can prematurely **STOP** longitudinal bone growth if damage to the resting/reserve layer
- Very ***UNCOMMON***, and if it happens, child needs to be followed for 1-2 years to monitor progress (premature fuses)
98
What is the weakest and most vulnerable layer to fracture in bone?
Columnar (maturation & degeneration)
99
What layer (if damaged) causes growth to stop?
Resting and Reserve Layer
100
Main points of Cortical bone anatomy:
- Cortex is DENSE, STRONG, THICK, POREOUS, and made up of cylindrical bone units
- **_Haversion systems/osteons_** containing a central neurovascular bundle and interconnected with Volkmann Canals as well as interstitial lamellar bone
101
What does each osteon have?
**Concentric lamellae** of bone (holds everything together) with collagen fibers and hydroxyapatite crystals having a unique orientation in each layer (or ring)
102
What is contained within each lamellar layer?
**_Osteocytes_** (mature bone cells) each in its own lacuna, which are interconnected and to the central canal by **CANALICULI**
103
How do corticol and trabecular bone differ?
By **_POROSITY_** **_ONLY_**
Corticol is dense, and trabecular is porous (same type of bone other than that)
104
What is the main funciton of Periosteum?
_**MAKING NEW BONE\*\*\*\***_
105
Is the periosteum pain sensitive?
yes
106
What builds bone in children?
**Subperiosteal Outer Circumferential Lamellae**
107
Are the periosteum or endosteum ever seen radiographically?
oh hell NO
108
Describe the Periosteum....
a **_2 cell layer thick_**, very vascular and pain potential membrane
109
What is the outer fibrous layer of the periosteum used for?
Insertion of ligaments and tendons by way of **_Sharpey_** **_Fibers_** (enthuses) and
Inner *cambium* layer with **OSTEOBLASTIC** and osteoclastic potential
110
How does periosteum grow?
Via Intramembraneous Ossification (found on external cortical surface)
\* Increases in thickness as we get older
111
The endosteum has what type of properties?
A single layer at trabecular and INNER CORTICAL MARGINS, also have both properties
* Predominantly found on the _internal cortical surface_
* Has **clastic** and **blastic** properties
112
What is the Dominant job of the Endosteum? \*\*
***_OSTEOCLASTIC_***\*\*\*
Eat away at cortex on inside as periosteum expands externally
(They **CANNOT** work at the same rate)
* _**THE ENDOSTEUM HEALS FRACTURES \*\*\***_
113
Endosteum vs Periosteum (work rate):
Endosteal layer is slightly slower, so bones are not the same width as when they're born. A lot of the endosteum disappears in the adult. Function of both is in _balance_, but the activity **FAVORS** the periosteum in ***_IMMATURE_*** skeleton
114
What happens in the first year of life in regards to bone vascularity?
Epiphyseal and Metaphyseal vessels separate after first year, and some anastamose in infants
\* After the first year, **_physis_** is a vascular barrier
115
Metaphysis is _________ area in pediatrics?
_***MOST RICHLY VASCULARIZED\*\*\*\****_
116
Infant, Child, and Adult Vascularity (picture & explanation):
* **Infant Vascularity (A)**: Rich metaphysis vascularity, no connection to epiphysis
* **Child Vasculartiy (B)**: Rich metaphysis vascularity connects with and helps epiphysis
* **Adult Vascularity (C)**: Epiphysis and metaphysis _connect again after growth plate is closed_
117
Cortex has what type of vascularity?
Unique **_DUAL_** from medullary and periosteal vessels
118
What happens during a bone infection?
All the exudate (pus) takes up space where marrow could be, this will compress blood vessels causing some bone death, causing cut off of medullary supply from cortex. Once it seeps through to the cortex, this will push the periosteum from the bone. This will then rip and tear periosteal blood vessels, thus cutting blood supply and killing the bone.
119
What is the process of Infection in children?
Exudate (pus) in bone compresses the blood vessels and causes PARTIAL bone death. Medullary blood supply is cut off from the cortex, and it seeps through the cortex, the periosteum is then pushed away from the cortex. Periosteal blood vessels tear, and blood supply is cut off = **_BONE DEATH_**
120
Mylitis =
Only Marrow Infection
121
Osteomylitis highlights =
* **_Blood born_** infection bone and marrow
* Typically spreads from one site to another to the bone
* Most likely to end up in the **METAPHYSIS** due to the large amount of vascularization
* Infections destroy by pressure or lytic reactions
* In a 5 month old, it can **_cross from Metaphysis to the Epiphysis_**
122
What destroys a joint very fast?
**_INFECTION (2-3 weeks)_**
123
Describe "Thomas Smith Arthritis"
Osteomyelitis
- Goes straight from Metaphysis --\> Joint capsule (avoids physis)
124
How does the cortex have vascularity?
From periosteum vessels through channels, and from nutrient vessels
125
Define Septic Arthritis
6 month old with infection in metaphysis --\> destroys epiphysis up to subchondral bone --\> eats through cartilage into joint --\> now child has SEPTIC ARTHRITIS (acute osteomylitis in infants)
\*\* Destroys joint in child in weeks what it takes 25 years to happen in adults
126
Where is the most common site for infection in adults?
Metaphysis (most vascularity is there)
\*\* after 2 years old, there's no vessels in epiphysis
127
Acute osteomyelitis is common where in infants?
Nutrient metaphyseal capillaries perforate the epiphyseal growth plate, particulary in the hip, shoulder, and knee
128
When will infection spread in infants?
Within the 1st year, it is going to spread into the epiphysis from the metaphysis
\*\* Most likely happen in the metaphysis
* **_Staph (pus forming) and tubercle bacillis (TB) cause most bone infection_**
129
What causes most bone infection?
Staph (pus forming) and tubercle bacillis (TB) cause most bone infection
130
What are the patterns of bone destruction?
**_Radioluscency_**
1. Periosteal Reactions
2. Trabecular Bone changes
3. Shape Changes
4. Bone Density Alterations
5. Soft Tissues
131
What are the bone lesions?
* **_OSTEOLYTIC_**: Destroyed, radioluscent (osteoclastic activity), bone being taken away or being replaced with cancer
* **_OSTEOBLASTIC_**: Pathological Process, osteosclerotic (bright white) = more bone produced
* **_COMBINATION_**/**_MIXED_**: Combined radioluscent and osteosclerotic. Have both clastic and blastic activity
* *_Example_*, Avascular necrosis, mixed metastisis, Pagets
132
WHat is pictured?
Avascular Necrosis
133
Ultimately, bones change ____ ?
Shape, Density, or BOTH
134
What are the main destroyers of bone?
Infection and Tumor
135
WHat is pictured? Describe it
Bone and mesoderm derived tumor
OSTEOSARCOMA
136
Primary bone malignancies are _____ ?
Sarcoma
137
For plain film radiology, must lose minimum of _____ of bone to see actual bone loss ?
**_30_**% \*\*\*
138
Describe a "Geographic Lesion"
Area lesion/ Takes up space
* _ONE_ hole
* *Benign*
* **SLOW** growing
* ***_Zone of transition is most important_***
139
Permeative is the _____ ?
Most aggressive lesion (many holes)
140
Authors vary on lower limit of size, but a general consensus of ____ seems to be a good standard size for Geographic lesions
larger than 1 cm
141
Less than 1 cm =
punched out
142
What is the most important indicator in describing a geographic bone lesion?
Margin (zone of transition)
"edge" of lesion
143
How are geographic lesions defined?
Subdivided in accordance to their margin:
* **1A**
* **1B**
* **1C**
144
Describe 1A Geographic Lesion:
Well defined with **sclerosis** in margin (least aggressive)
* ***_Short transitional zone_***
* Has a thin rim of bone (looks **white**) around margin (sometimes thin rim, sometimes thick rim)
145
Describe 1B Geographic lesion:
Slowest growing of sclerotic lesions. Well-defined, but **_NO_** **_SCLEROSIS_** in margin
- Short transitional Change
146
Describe 1C bone lesion:
Geographic destruction with *ill-defined* margin. Wider or Longer transitional zone (**_MOST_** **_AGGRESSIVE_**)
\*\* Less distinct where change happens
147
What does the border or lesion margin indicate?
The general GROWTH RATE
148
Slow growing benign =
Well defined and a narrow zone of transition often with thin or thick reactive osteosclerosis at the margin 1A
149
More Agressive Lesions =
Tend to have fainter borders and somewhat wider transitional zone at the margin, may still be benign but more aggressive
\* Eg. **_OSTEOMYELITIS_**
150
What bone lesion is OFTEN MALIGNANT?
1C (zone of transition is hard to define)
\* This is a great indicator for aggressiveness
151
Identify
Margin 1 A on top and 1B on the bottom
152
Geographic lesions may also have little compartments, this would be known as?
Soap Bubble Lesion
153
When examining the X ray, what are the most important factors?
* **AGE**
* **LOCATION**
* **APPEARANCE**
* **SYMPTOMS**
## Footnote
**_ALAS\*\*\*_**
154
Geographic lesions may be what in regards to location?
Centric or Eccentric
155
Expanison lesions:
Giant cell tumor, may be **expansile** (blown out lesions) or non expansile
156
"Epithelial tissue" (malignant)
Carcinoma
157
(slightly) expansive lesion
1A, short transitional zone with defined margin
158
* **1A**, not purely radiolucent (has peaks and valleys/ridging inside)
- Little bit of **expansion**
- **_Speckled_** calcification (snowflake) : Internal matrix not fully radiolucent
\*\* Possibly an **_endochondroma_**
159
* _Eccentric_ (off centered)
* **Slightly expansile, radiolucent, short tranzitional zone, well defined, and benign**
* A little "scalloped"
* Cortical destruction
* **_Geographic_**, probably benign, slow growing
160
What is traumatic determinism?
Patient has a trauma and finds something more sinister on the film (disease in bone)
161
What does "Curitage" mean?
Scrape out
162
Some lesions may be GROSSLY expansile... what is an example?
Blow out lesion
163
**_Soap Bubble_** Geographic Lesion
* Giant cell tumor (ages 20-40)
* Started in metaphysis
* "Blow out lesion"
* Geographic
164
Giant cell tumor occurs in what ages?
20-40
165
An osteosclerotic lesion is NOT ....
a GEOGRAPHIC lesion
166
Expansile or non expansile determien
Geographic lesions
167
A larger zone on a geographic lesion would most likely indicate what?
A benign tumor
168
Geographic Lesions, name the whole list
* uni or multi compartmental (soap bubble), can sometimes cause ridges on cortex
* Centric or Eccentric
* Expansile vs Non expansile
* Well defined or poorly defined (transitional zone)
* 1A, 1B, 1C
* Thin/Thick Osteosclerotic Margin
* Large: Benign
* Internal Matrix (stuff inside; internal composition) - radiolucent, speckled calcification, isodense (fibrodysplasia) with medullary cavity
* Isodense: Internal matrix has same desnsity as medullary cavity
* Tumors: Malignant or Benign
* Tumor Like Lesions: (can be dangerous) - full of plasma fluid (as opposed to cells)
* Osteomyelitis: Bone infection - no respect for anything (joints) unlike tumors, DONT stop at subchondral bone, would continue to joints.
169
How can you tell the difference between Osteomyelitis and a tumor?
Osteomyelitis has no respect for joints unlike tumors, it does NOT stop at subchondral bone, it will continue to the joints
170
**_Punched Out lesions_**
* Well defined with NO sclerotic margin 1B
171
What usually occur in flat bone, especially in cranial vault, and are usually part of Myelomatosis?
Punched out Lesions
172
What does Monoclonalgamopathy produce?
Immunoglobulin w/ no antigenic stiumulus
\*\* Skull is a common place for punched out lesions
173
Give a few characteristics of Moth Eaten
Small much more numerous holes (few mm in size)
* ***_Ragged_*** border/wide zone of transition (cant tell where it ends)
* _RAPID_ GROWTH
* Larger holes than permeative
* Holes in the **Haversion Canals**
174
What 2 diseases are associated with "moth eaten" appearance?
**Osteomyelitis** : Common cause of mothy osteomyelysis
or Malignant: **Osteosarcoma**
* Metastisis doesn't involve periosteum
175
If we can see the moth eaten appearance, where is it in the bone?
Cortex
176
What is the MOST COMMON primary bone malignancy? \*\*\*
MULTIPLE MYELOMA \*\*\*\*
test
177
What are the list of causes of Moth Eaten Osteolysis?
1. Multiple Myeloma
2. Mets (very common cause)
3. Ewings Sarcoma
4. Lymphoma
5. Osteomyelitis
178
Does Mets start in the bone?
no
179
Does lymphoma start in the bone, or does it normally spread there?
Normally spreads there
180
Describe Ewing's Sarcoma:
**Primary** bone malignancy, classified as a ***round*** cell malignancy
- _4th_ MOST COMMON Primary bone malignancy
- Primarily in **_CHILDREN_**
181
Left side
(right side is permeative)
182
Permeative Osteolysis characteristics:
* **Ill**-**defined**
* "worm holes"
* _WIDE_ zone of transition
* Margins are ***_fine_*** vs ragged
* Almost always, **_MALIGNANT_**
183
What implies aggressive malginancy?
Permeative Bone
184
What is something special about permeative pattern in the diaphysis?
This is the worst possible sign one can see, mostly malignant in bone tumors
185
Permeative Lesions are normally associated with what?
* Lymphoma
* Ewing's Sarcoma
* Myeloma
* Osteomyelitis
* NEUROBLASTOMA (Mets)
186
Where does neuroblastoma come from?
(mets) comes from Sympathetic Tissue (from adrenals) Happen in children under 5
* Strong tendency to metastasize to bone
* Can also be moth eaten
187
What is the only moth eaten look that is not malignant? \*\*\*
test
OSTEOMYELITIS
188
Geographic lesions in bone cannot ______ ?
Kill within months, it takes many months to years
189
What is a periosteal reaction?
Stimulus for *new bone pathologically*
- **Extension** of _blood, pus, or tumor cells_.
- Periosteum being **_stimulated_** when it shouldn't (lift/push periosteum away from bone)
190
When do you see a periosteal reaction?
It has a 10-21 day latent period for Identification
- If there is a trauma or infection, this could take a couple weeks to see
191
What are some irritants that can give a periosteum reaction?
Hyperemia, inflammation, and edema (irritate bone)
192
what are the 3 patterns of new bone formation?
1. Solid
2. Laminated/Onion Skin
3. Spiculated
\* These are productive patterns that periosteum is **_PRODUCING BONE_**
193
Can periosteum act pathologically?
YES
194
What is another aggressiveness indicator?
Periosteal Reaction
1. Solid = Most **Benign** (Codman's)
2. Laminated/Onion Skin
3. **Spiculated (hair on end) = _MOST AGGRESSIVE_**
195
Describe a single layer periosteal reaction:
**_SINGLE_** layer periosteal new bone\*\*
* Runs longitudinally **parallel** to bone
* Typically Benign
* Can be *Localized* or ***_DIFFUSE_***
\*CAN respond to insult, irritation, etc.
196
Describe Lamellated Periosteal Reaction:
**Onion Layers (mult. Solids)**
* Essentially a few "Solid" periosteal reactions on top of eachother
197
Describe a Spiculated Periosteal Reaction:
Going perpendicular to the bone, looks like rays of sunlight
198
Explain what happens during Codman's Periosteal Reaction:
Happens at peripheral margin of pathology (not really a separate type, but happens with the other types)
199
Describe what Osteoid Osteoma is and what can it cause?
Very _LOCALIZED_ solid periosteal reaction
\*\*\*\* Benign bone NEOPLASM
* Very **dense** and looks like area of cortical thickening
* Very **_COMMON_**; classic bone forming bone tumor
200
Can Infection cause a periosteal raection?
***_YES_***
201
Describe Eosinophilic Granuloma and what it can do:
* Granulation tissue is stimulated by **_chronic_** **_inflammation_**, only; Associated with eosinophilium
\* Cause of **_COMPRESSION_** fractures in the spine
1. (CAN CAUSE PERIOSTEAL REACTIONS)
202
What is Granulomous?
**_Chronic inflammatory_**
## Footnote
- Produce Granulation tissue
- Response of host being chronically inflamed
203
Describe Hypertrophic Osteoarthropathy and what it can do:
It is "ALL OVER"
* TOO MUCH growth of bones and joints
* Primary and Secondary
SECONDARY: COMMON\*, diffuse, secondary--\> lung cancer
_\*\*\* CAN CAUSE PERIOSTEAL REACTION_
204
Describes Varicosities in the lower extremities:
Accumulate in the bone leading to BONE PAIN in varicose veins (predominantly: _**Tibia, Fibula, and Metatarsals\*\*)**_
* Blood pools under periosteum due to poor venous drainage
* Bone expresses venous disorder
\*\*\*\*\* CAN CAUSE PERIOSTEAL REACTIONS\*\*\*\*
205
Describe Fracture Healing:
**_Callous_** ***_Formation_*** helps produce a new collar of new bone
* **Periosteum** contributes to fracture, builds shell around fracture site
* Can be runner with fatigue stress fracture or trauma
_**\*\*\*\* CAN CAUSE PERIOSTEAL REACTION \*\*\*\*\***_
206
What are the 2 types of Solid Periosteal Reactions?
1. **_LOCALIZED_**: Direct Stimulus from an underlying bone lesion (intrinsic); mc *fracture healing, infection and benign bone neoplasm*
2. **_WIDE_** **_SPREAD_**: Systemic diseases and the periosteum is reacting; mc Hypertrophic osteoarthropathy
207
Pic on the RIGHT: Looks like area of cortical thickening; solid periosteal reaction is less dense MOST OF THE TIME (not in this picture).
It is hard to see tumor in growht, but patient would have "Point Pain" at growth site
**_NO_** **_TRAUMA_** HISTORY
208
Describe some key features of primary hypertrophic osteoarthropathy/pachydermoperiostitis:
Skin thickening and PERIOSTEUM
* 3-5% are primary; rest are secondary
* Digital CLUBBING (soft tissue thickening on tips of fingers)
* Progressive for 10 years and then regresses
* \*\*\* **Radiographically diffuse widespread symmetrical periostitis involving diaphyses and metaphyses**
209
Describe the key points of Secondary Hypertrophic Osteoarthropathy:
Diffuse, solid periostitis in an adult perineoplastic syndrome
\*\* **Mesothelioma, Hodgkin's, Cystic Fibrosis, Pulmonary Metastasis, Cyanotic Heart Disease, Chron's**
* A TUMOR producing hormones (cushings disease)
* Up to 12% of patients with bronchosarcoma (lung cancer) maybe first symptom
* Patient with Lung Cancer (no symptoms)
210
Describe the key points of Thyroid Acropachy:
Usually seen after treatment for **hyperthyroidism** when patients are **euthyroid** or **hypothyroid**
**_Findings_**: Exopthalmos digital clubbing, pretibial myxedema and periostitis similar to secondary HOA
211
Describe Venous Stasis:
Lower extremity almost exclusively, associated with varicosities which
**_May Contain_**: phleboliths, periostitis involving distal tibia, fibula, and possibly metatarsals
212
Infantile Cortical Hyperostosis (Caffey's Disease):
Uncommon disorder of infancy middle of 1st year
* Abrupt onset with fever hyperirritability and soft tissue swelling especially over **mandible**
* Children with **_BONE PAIN_**
* MANDIBLE, CLAVICLE, RIBS, PERIOSTITIS (can be extreme enlarged bone.
213
Describe Hypervitaminosis A:
Can occur in both children and adults, vomitting, headache, drowsiness and irritability
* Periostitis, involving tubular bone: ulna and metatarsals, clavicle, tibia, and fibula
214
Describe Scurvy
Periostitis may occur in children related to subperiosteal bleeding related to capillary fragility associated with Hypovitaminosis C
215
Describe Battered Children
Multiple areas of solid periosteal new bone associated with multiple fractures at different stages of healing
216
Describe Acromegaly
Excessive growth hormone production can stimulate solid periosteal new bone formation
217
Describe Leukemia:
Multiple areas of bone destruction associated with adjacent periostitis
218
What is a laminated Periosteal Reaction?
**_AKA: Lamellated, layered, onion skin_**
* Alternating layers of parallel/solid bone separated by thin radiolucent layer (multiple layers)
* WIll NEVER form full cortex
219
What is the most common disease associated with a "Laminated Periosteal Reaction?"
\*\*\*test\*\*\*
EWINGS SARCOMA\*\*\*\*
Most Common: Eosinophilic granuloma, Osteomyelitis, Leukemia - Most common under 30
* _***FIRST DECADE OF LIFE\*\*\*\*\****_
* Usually localized, intrinsic
* Most likely will be found in _**DIAPHYSIS\*\***_
220
What is the TOP 5 Primary Malignant bone cancer?
**M.O.C.E.F.**
1. Multiple Myeloma
2. Osteosarcoma
3. Condrosarcoma
4. Ewings
5. Fibrosarcoma
\*\*\*\* ALL ***_ORIGINATE_*** IN BONE = **_PRIMARY_** \*\*\*\*\*\*\*
221
What is the most aggressive periosteal reaction?
Spiculated
**_AKA_**: Perpendicular, brushed whiskers, hair on end, and sunburst
* Sunburst is characteristic of osteosarcoma
222
How does the spiculated periosteal reaction occur?
Growth is so quick that periosteum being lifted so fast (**5**-**6** weeks) doesn't have time to fill in, so it leaves traces (hairs)
\*\* Rapidly Growing Lesions
223
What are the main characteristics of Spiculated Periosteal Reaction?
Fine, linear spicules oriented perpendicular to cortex
* All outgrowth happening under the periosteum
224
Spiculated happens faster than solid periosteal layer?
t/f
TRUE
225
What is the most common disease to have spiculated Reaction?
**_Osteosarcoma_**,
can be leukemia, but it can also be Solid, Lammelated, or Spiculated
226
Ewing's is from what type of cells?
ROUND
227
Osteomyolitis can induce what type of periosteal reaction?
ANY of them
228
What are the big malignant neoplasms?
* Ewings
* Osteosarcoma
* Chondrosarcoma
* Fibrosarcoma
* Non-Hodgkin's Lymphoma
* Leukemia
229
Where does Codman's Triangle/Cuff occur? What are the key features of it?
Occurs at PERIPHERY of fast growing lesions
* Typically with an **_AGGRESSIVE REACTION_**
* Can be **SOLID** or **LAYERED**/**LAMELLATED**
* _USUALLY at edge of SPICULATED LESION_
\*\*\*\* Commonly MALIGNANT, but can be with any type \*\*\*
230
Left: Spiculated and moth eaten
Right: Spiculated
231
What is the summary features of PERIOSTEAL REACTIONS? \*\*\* know this next picture and you'll be good
232
Less trabecular bone =
Thinning (osteoperosis is a classic example)
233
Accentuated Trabecular Bone =
Can happen because of production of more trabeculation or by compressing into smaller spaces
234
Describe what happens during Padget's disease...
Osteoclasts are thinned out by osteoclasts, but when they rebuild, it is too thick
This creates a thick cortex, and weaker bone (poor quality osteoids)
- Hemolytic Anemia then follows
235
With loss of trabeculation or osteoperosis, what happens to bone?
THINNER CORTEX, greater potential for fracture
30-50% less seen on film
\*\*\*\* **OSTEOPENIA**: soft bone, looks like soft tissue on film
236
Coarsend/Prominent Trabeculation:
Over production of trabecular bone, or by squeezing and compression
\* Can happen locally or widespread depending on unerlying pathology
\*Can do this by compressing or squeezing bone, locally, widespread, or diffuse
237
What are some diseases that have a coarsened/prominent trabeculation look?
Hemolytic Anemias (sickle cell), Paget's disease (overproducing trabecular bone will be very thick looking)
**\*\* _HEMANGIOMA_ \*\*\***
**Most common benign bone tumor**
238
What's the most common benign bone tumor?
**HEMANGIOMA**
239
In the case of a coarsened/prominent trabeculation, if there is hemolytic anemia, what will occur?
**_Increase_** in red marrow volume (in diaphysis of tubular bones)
RBC production **increases** in medullary (small cavity), this will compress trebeculation, creating bigger gaps between them, thus....more **_TRABECULATION_** grows in gaps
240
What is the single sentence summary of Paget's Disease?
***_Overproduce_*** trabeculae and makes them thicker (2 mm)
241
What is Hemangioma? (one sentence)
Benign vascular tumor --\> Compresses trabecular bone
242
*_**Corduroy Cloth Appearance\*\***_*
* Regional Squeezing
* Trabeculae are thicker going verticle
* Vessels are grossly EXPANDED, compresses trabeculae
* Sometimes it will be in **_PEDICLES_** and not verticle
* **LOCALIZED**
_**\*\* HEMANGIOMA**_
243
In flat bone, what would the appearance of hemangioma be called/look like?
Hub and Spoke
244
**_Paget's Disease (Osteitis Deformans)_**
* _REGIONAL_ overproduction
* Makes bone **_SOFTER_**\*\*\*\* despite THICKER looking trabecular (check out left acetabulum)
* _NO pain_ with PAGET'S
* Femur tends to **bow** LATERALLY (Saber shin deformity)
245
How common is Paget's?
Single digit (common)
246
How does the trabeculation increase in paget's?
Via **_overproduction_**, NOT be squeezing
247
Can Paget's lead to DJD?
YES
248
***_COARSE TRABECULATION_***
(**NOT**\*\*\* spiculation \*\*)
* **Thalassemia Skull:** Course trabeculation by compression, again, NOT spiculation (dont confuse the 2)
* "Hair on End Appearance"
* Stops at **_EOP_** because of the red marrow above (no hematopoietic potential), and the yellow marrow below EOP
* Expands medullary cavities, facial bones, and destroys sinuses
249
What is Coarse Trabeculation derived from?
Hemolytic Anemia
250
Describe the cortex of Coarse Trabeculation...
Actual Cortex is very thin, and is at edge of "hair"; skull **EXPANDS**!
* Increase in pressure pushes out cortex
* *_**DERIVED FROM HEMOLYTIC ANEMIA\*\*\*\***_*
251
How can bone bend?
Softening disease,
- **_Paget's,_**
**_- Polyostic fibrous dysplasia,_**
**_- Osteomalacia_**
\*\*\*\* test \*\*\*\*
252
***_BRACHYDACTYLY_***
* Short fingers, short toes
* Patients with sickle cell are prone to microvascular occlusion; cut off blood flow to bone = **Avascular** **Necrosis** --\> Leads to stunded bone growth
253
Shape change = **_POLYDACTYLY_**
\*\*\*\* **_Ellis van Crevald Syndrome_**: Patient will have an extra digit off the hand and or foot, usually symmetrical and will have a seperatie bone off the base of 5th metacarpal/metatarsal
254
**_SHEPHERD'S CROOK DEFORMITY_**
* Bone softening disease (osteomalacia, rickets)
* _**Femoral neck angle \> 90\*\*\*\***_
255
**_ERLENMYER FLASK DEFORMITY_**
* _Typically seen in big tubular bones_
* Many Pathologies
* EXPANISON of proximal and distal diaphysis
* **\*\*\* ONLY IN BIG TUBULAR BONES** (short ones become rectangles)
256
**_MADELUNG'S DEFORMITY_**
* **__**Have a hard time picking up things (ROM changed)
* Impacts **_ossification_** center at distal radiusarticular surfaces
\*\* **Caused** **by**: Many things, but commonly Salter Hairris Fracture Type 5 in a peds patient, if it happens via TRAUMA
257
When madelung's deformity is idiopathic, what happens?
It happens in teenage girls
258
Madelung's can be .....
genetic or acquired
259
What will Madelung's create? How does it happen?
with **_FOOSH_** injury that damages growth plate in peds patient
* Sometimes ***_idiopathic_*** in teenage girls, dwarfism, Turner's children
* Will affect grip strength and creates a **_V shape_**
* PAINFUL
260
Bones can either be what?
Increase in density (Osteoblastic, **OSTEOSCLEROSIS**)
Decrease in density (Osteoclastic, **OSTEOPENIA**)
Localized/Regional or Widespread/diffuse/Global
* Global Osteopenia
* Osteopenia around joint
\*\*\* Bone density changes are extremly common\*\*
261
Describe Osteosclerosis/Hyperostosis:
Increase of amount of bone matrix in given volume of bone
X RAY APPEARANCE: Bone density increased
* **_Cortex Thickens = Periosteal growing_**
* This causes patient to become anemic because there isn't enough marrow to produce RBC
* Bone Marrow Cavity Narrowing = Endostosis growing and trabecular thickening
262
What is the Etiology of Osteosclerosis/Hyperostosis?
- Inflammation or Granuloma (chronic)
- Trauma & Fracture Healing
- Tumor or Tumor Like Lesion
263
***_Osteoperosis (Osteosclerotic)_***
* **Cannot transition from primary --\> Secondary Spongiosa**
* Diffuse Osteosclerosis (Dramatic increase in density)
* Not really common
264
***_OSTEOPOIKILOSIS_***
* Regional (periarticular) Osteosclerosis
* No increase in bone density in ilium
* Generally an accidental finding-patient has no complaint
* _**HAS PATTERN, and AROUND JOINTS\*\***_
* Not really around extremities, just joints
AKA: **"Patchy Osteosclerosis" "Bone Islands"**
**\* NO SIGNS OR SYMPTOMS \***
265
**_IVORY VERTEBRA_**
* Multifocal Osteoblastic metastasis (Not around Joint)
* Probably PROSTATE/BREAST cancer spread to bone via bloodstream --\> Bone marrow
* Stimulate OSTEOBLASTS
* Very random; NO uniform distribution on both sides
* FOCAL AND RANDOM
266
Define Osteoperosis:
The bone matrix or osteoid specific **_deficiency_**
Both of the organic material & calcium are decreased, but the ratio them is still normal
267
What is the X ray appearance of Osteoperosis (Osteopenia)?
Bone Density is decreased local/general
* The cortex becomes **thinner**, the trabeculae become **thin** and **decreased** number. Bone begins to look as _gray_ as soft tissue
* PATHOLOGICAL fracture
268
What is the etiology of Osteoperosis/osteopenia?
- Common in **elderly** and **immobilization**
**_Pathology_**: Hormonal (PTH, etc) / Vitamin deficiency
269
What do we look at with Osteoperosis/Osteopenia?
* Soft tissue first
* Should look GRAY
* If there is thin cortex: They will have loss in strength
270
***_REGIONAL/LOCALIZED OSTEOPENIA_***
* Very PAINFUL (usually follow trauma) - FOOSH
* Crps/smps/rsds/Sudeck's atrophy
* Rhuematoid can cause this
* Para-articular Osteopenia (sympathetic nerve pain)
\* Bone density on right significantly decreased
\* Rheumatoid Arthritis can also do this, but it would be bilateral (80% of the time)
271
DIFFUSE OSTEOPENIA
* childhood osteomalacia/rickets ( lose zone of provisional mineralization) mostly from **renal disease**
- Soft tissue looks gray: (GOOD)
- Bone tissue looks ***_gray_***: (BAD); should look white
-Cortex too _thin_
272
**_Combination of osteosclerosis intermixed with areas of radiolucency_**
- Have both osteoclastic and osteoblastic activity going on at the same time
- Osteoclasts tend to win out leading to decrease in bone density
273
Avascular necrosis is most common where?
Femoral Head
274
When chondrocytes die, this causes what to happen?
Cartilage Degeneration (DJD)
275
\* Small and large patchy bone destruction area as well as increased density area in pelvis, lumbosacral vertebrae and bilateral femur.
276
Very **COMMON**
\*\* AVASCULAR NECROSIS \*\*\*
* ***_Density_*** change coming from repair
* Use **_osteoclast_** to remove dead bone (radiolucency)
* Use **_Osteoblasts_** to build new bone (radiodense/radiopaque)
* Osteoclastic Activity usually higher than osteoblastic activity
So if patient walks, femoral head will suffer (femoral head changing shape) = **_DJD_**
277
What is common cause of mixed density change in the femoral head?
Avascular Necrosis
278
\*\* MIXED DENSITY change on CT scan
279
What can plain film reveal about soft tissue?
Abnormalities
280
Soft tissue masses may be _________ ?
Tumor associated, soft tissue swelling around the joints, traumatic hematoma, infectious abscess, calcification, or ossification of soft tissue
281
What is the "GOLD STANDARD" for soft tissue?
MRI
282
Fat is not as _____ as muscle is?
DENSE
283
Soft tissue enlargement of the knee
* ***_Peripheral Chondrosarcoma_*** - Originated from **_benign OSTEOSARCOMA_**
284
What is related to peripheral chondrosarcoma?
Soft tissue enlargement and speckled calcification (malignancy)
285
Soft tissue swelling/enlargement - Heel pad calcanealapophysis fracture
* Not abnormal for calcaneous to be osteosclerotic
_**\*\*\* SALTER HARRIS 3 FRACTURE \*\*\*\***_ (pictured)
286
**_Calcinosis Cutis_**
* Progressive Systemic Sclerosis (Scleroderma) --\> soft tissue calcification
**\*\*\* When patient has _Rheumatoid_ type _autoimmune_ _condition_ - lupus, scleroderma, dermatomyositis, polymyositis**
287
Define Calcinosis Cutis.....
Calcification around joints
288
Sclerosis in soft tissue =
Scarring
289
**Calcinosis Universalis** - Dermatomyositis
\* **_AUTOIMMUNE DISEASE_**
\* MUSCLE FASCIA INFLAMMATION
* Weakness and fatigue, muscle fascia _CALCIFIES_
290
WHat is calcinosis?
Soft tissue calcification relatable to autoimmune disease
291
Describe the soft tissue calcification (Metastatic)?
Elevated serum Calcium (Hypercalcemia)
* HPT : Hyperparathyroidism
* Hypervitaminosis D 40,000 - 50,000 IU for months
* Milk Alkali Syndrome \> 1 gallon a day
292
Describe soft tissue calcification (Calcinosis)?
Cutis (just in skin)
* _Circumscripta_ (local, but deeper than skiin around joints), universalis (very wide spread; Extensive calcification)
* Normal serum calcium but they have an **AUTOIMMUNE** disease (rheumatoid)
293
What is the most common Soft tissue calcifciation?
_**Dystrophic\*\***_
* _Scar Tissue_
* _NORMAL_ serum calcium, but **DONT** have autoimmune disease
* Happens a lot in chest
294
Post tramautic myositis ossificans
Impact sports, car accident, falling
* Happens in large muscle groups
* LARGE BLOOD CLOT IN SOFT TISSUE \*\*\*\*
* Can scar, dystrophically calcify bone
\* May even develop corticol bone
295
**_Hetertopic Ossificans_**
* Quadriplegia\*\*\**
* P*atients with total hip arthroplasties can get this (due to trauma and manipulation of soft tissue)
\*\* Soft tissue ossifies, but no macrotraumatic event
296
Fibrodysplasia Ossificans Progressive "Munchmeyer's Disease"
* Most don't live beyond mid-30's
* **_Ossification of SKELETAL MUSCLE ONLY_**
* Turns skeletal muscle into bone (muscle ossifying)
* Inability to breathe
297
Most benign tumors happen when?
Before age 30
298
Radionuclide bone scan =
WHOLE BODY
299
is MRI full body?
no, its REGIONAL
300
CT will find ______ of spinal trauma?
100%
301
Nucelar Medicine has great ____ but lousy \_\_\_\_\_
Great sensitivity
Lousy Specificity
302
What does Diagnostic Nuclear Medicine measure?
What the patient is emitting = Endoradiology
303
What is a synonymous term for nm scan?
Scintigraphy
304
What is Methyline Dipohsphate used as?
As a carrier for radioactive substance (Tc-99m) into bloodstream
305
Technetium 99m MDP (methylenediposphonate) most widely used for ---
bone
