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With this caveat in mind, in this article the authors present the incidental osseous lesions that they have encountered most frequently in their personal and consultative experience during MR imaging of the knee. This article is intended not as a complete review of the imaging findings associated with these lesions but as a summary, highlighting the MR imaging features that are most useful in suggesting a specific diagnosis. Radiographs Despite advances in MR imaging, the radiograph remains invaluable in evaluating bone lesions and in many cases is the most diagnostic study. Therefore, the authors strongly recommend radiographic correlation of incidentally identified lesions. Radiographs accurately predict the biologic activity of a lesion, which is reflected in the This article was originally published in Magnetic Resonance Imaging Clinics of North America , February All rights reserved.
Intraosseous ganglion Intraosseous ganglia are solitary, unilocular or multilocular lesions found at or near the ends of long bones in the subchondral region . Typically occurring in middle-aged adults who present with mild, localized pain, the lesion is similar to a soft tissue ganglion [35,36].
The pathogenesis of intraosseous ganglia is unclear, and there is debate as to whether this entity may be differentiated from degenerative subchondral or posttraumatic cysts. Although they are not histologically unique, intraosseous ganglia are characterized by fibroblastic proliferation and mucoid degeneration.
Those who use this designation typically reserve it for intraosseous lesions resembling subchondral cysts in patients who have little or no degenerative arthritis in the adjacent articulation. Summary Incidental osseous lesions are commonly identified in patients undergoing MR imaging of the knee. Although a wide spectrum of lesions may be seen, the most common lesions may often be successfully diagnosed on the basis of their MR imaging findings and correlating radiographs.
References  Unni KK. Philadelphia: Lippincott-Raven; The origins of osteochondromas and enchondromas. A histopathologic study. Clin Orthop Relat Res ;— Incidental enchondromas of the knee [abstract]. Skeletal Radiol ; Hyaline cartilage—origin bone and soft tissue neoplasms: MR appearance and histologic correlation.
Radiology ;— J Comput Assist Tomogr ;—6. From the archives of the AFIP: imaging of primary chondrosarcoma: radiologic—pathologic correlation. Radiographics ;— Benign bone tumors and tumor-like lesions: value of cross-sectional imaging.
Eur Radiol ;— The formation of osteochondroma by epiphyseal cartilage transplantation. Radiation-induced osteochondromas. Radiology ;—7. Tumor and tumor-like lesions of bone: imaging of specific lesions.
In: Resnick D, editor. Diagnosis of bone and joint disorders. Philadelphia: W. Saunders; MR imaging of solitary osteochondromas: report of eight cases. Benign exostoses and exostotic chondrosarcomas: evaluation of cartilage thickness by CT.
Radiology ;—9. On fibrous defects in cortical walls of growing tubular bones. Adv Pediatr ;— MR appearance of fibroxanthoma. J Comput Assist Tomogr ;—5. Fibrous metaphyseal defects—determination of their origin and natural history using a radiomorphological study. Skeletal Radiol ;— Nonossifying fibroma: characteristics at MR imaging with pathologic correlation. Radiology ; — The prevalence and diagnostic significance of fluid—fluid levels in focal lesions of bone.
Skeletal Radiol ; —6. Benign fibrous histiocytoma of bone. WHO classification of tumors. Pathology and genetics: tumors of soft tissue and bone. Osseous lipoma: CT appearance. Intraosseous lipomas.
A clinicopathologic study of 66 cases. Intraosseous lipoma: report of 35 new cases and a review of the literature. Skeletal Radiol ; — MR findings of calcaneal intraosseous lipoma with hemorrhage.
Deposition of intraosseous fat in a degenerating simple bone cyst. Skeletal Radiol ;—8. Bone tumors: clinical, radiologic and pathologic correlations. Skeletal benign bone-forming lesions. Eur J Radiol ;S91—7. Bone island enostosis : clinical significance and radiologic and pathologic correlations. Degenerative disease of extraspinal locations. Saunders Company; The pathological significance of intra-articular pressure. Edinburgh Med J ;— The cysts of osteoarthritis of the hip: a radiologic and pathologic study.
J Bone Joint Surg Br ;— Subchondral cysts geodes in arthritic disorders: pathologic and radiographic appearance of the hip joint. Magnetic resonance imaging of bone destruction in rheumatoid arthritis: comparison with radiography. Neoplastic and tumorlike lesions detected on MR imaging of the knee in patients with suspected internal derangement: part 1, intraosseous entities. Juxtaarticular bone cysts intra-osseous ganglia : a clinicopathological study of eighty-eight cases.
Intraosseous ganglia of the wrist. Intra-osseous ganglion. Displaced fractures can be diagnosed easily on radiographs; however, multiple, subtle osseous or osteochondral lesions may not be defined radiographically. In addition, subtle findings on MR images, such as bone bruises, can be useful for evaluating the mechanism and extent of bone and soft-tissue involvement .
MR imaging is also a valuable technique for the detection and follow-up evaluation of children with physeal injuries [5,6]. Table 1 summarizes osseous and osteochondral injuries about the knee, and optimal imaging approaches.
Bone bruise or marrow edema pattern Bone bruises or marrow edema may be identified with numerous conditions, including trauma, Myotendinous injuries Quadriceps injuries Patellar tendon injuries Patellar retinacular tears Gastrocnemius, soleus, and plantaris injuries Popliteus muscle injuries Iliotibial band syndrome Other myotendinous injuries References infection, and osteoporosis [4,7—9].
Bone bruises related to trauma may be caused by a direct blow, articular compression forces, or avulsion injuries . The extent of marrow edema tends to be more dramatic with compression or direct trauma, compared with avulsion injuries . Typically, bone bruises are not visible on radiographs. Specific edema patterns are also useful in predicting the mechanism of injury and the associated ligament, tendon, or meniscal involvement .
Five classic patterns have been described. Patients who have pivot shift injuries typically have bone contusions involving the posterior lateral tibial plateau and midlateral femoral condyle. The posterior margin of the medial tibial plateau may be involved as well.
The switch to smaller molecules such as peptides looks far more promising see Chaps. Positron imaging will be discussed interspersed with single photon imaging for neurologic, cardiac and oncologic applications Chaps.
Three chapters deal exclusively with positron imaging Chaps. In Chap. Neuro-receptors and their potential in neuro-degenerative disease as well as applications in psychiatric illness will be discussed.
The use of emission tomography allows assessment of cerebral blood flow, glucose utilization, oxygen metabolism, rate of incorporation of amino acids into proteins, and rate of transport of substrates into the brain. Measurement of the rate of neurotransmitter storage, release, and binding to specific receptors is possible, but is not used in clinical practice yet. This possibility has raised high expectations among clinical neurologists and psychiatrists for future developments.
Dysfunctional myocardium in patients with poor left ventricular function can be caused by several mechanisms. Distinction of viable myocardium from scar tissue is crucial to determine whether revascularization is a therapeutic option. The available clinical evidence to assess myocardial viability prior to coronary revascularization is presented.
Various techniques are highlighted indicating that viability assessment will lead to the correct use of resources, with the potential of decreasing health care costs. Pulmonary embolism is a common clinical entity, and the imaging diagnosis remains a topic of fierce debate. The emphasis on evidence-based medicine and outcome significantly affects our thinking about diagnosis and treatment.
Introduction Studies of the urinary tract are directed to quantification of renal flow and function. Various tracers are discussed and compared, a detailed analysis is given of how they affect the measured parameters. The addition of pharmacological augmentation became popular for several existing tests of the GI and the GU tract.
These topics are dealt with in Chap. Hepatobiliary imaging and augmentation are now incorporated in a new Chap. Specific applications for pediatric NM are given in Chap. Bone scintigraphy has been around for a long time.
It remains an exclusively sensitive procedure for evaluating a variety of skeletal disorders. Main referrals are detection of metastases, trauma, and orthopedic problems. Sports injuries also appear a major indication for performing bone scans. Some 40 years ago 18F-fluoride was introduced as a bone imaging agent. This radiopharmaceutical has been revived since PET systems have become commonplace in the NM clinic. The PET technique allows for true regional quantification of bone blood flow Chap.
Wolfgang Becker, who wrote the previous chapter on infection and inflammation, passed away unexpectedly. The group of Nijmegen, Netherlands has prepared the text of Chap. In order to localize an infectious process, we need procedures with high sensitivity for all body regions.
The studies available and their clinical effectiveness are discussed. A typical diagnostic dilemma, posed daily, is the differential diagnosis of inflammation versus infection, e. A variety of tracers and clinical conditions are presented, as well as interpretation and reporting of the image findings. The field of receptor imaging came back in vogue in the s with the introduction of new peptides. Receptors are proteins, which bind specific ligands, and subsequently respond with a well-defined event.
Recognition of tumor-specific properties can be used to detect cancers, and peptide receptors appear highly expressed on tumor cells. Chapter 10 illustrates that peptides have proven effective in clinical practice. In the field of oncology, the s showed an emerging role for the glucose analog FDG Ffluorodeoxy-D-glucose , which is the most frequently used PET radiopharmaceutical.
High rates of glycolysis are found in many malignant tumor cells with increased membrane transporters. The uptake of FDG varies greatly for different tumor 3 types. Increased FDG uptake is not specific for neoplasms and many inflammatory processes have increased uptake. An overview for the common cancers in the Western world is given in Chap. The pioneering work of the Zurich group is well known and they present their experience in lung, and head and neck cancer in Chap.
Pediatric nuclear medicine has special needs, because of the size and age of the patients. A selection of topics is presented in Chap. The potential variety of radiopharmaceuticals which may be developed is unlimited, keeping nuclear medicine in the forefront of clinical imaging.
Chapter 15 provides an overview of the developments and trends for the near future. The technological improvements of the standard gamma camera include higher spatial resolution, better uniformity, higher count rate performance, and multi-detector geometry.
New hybrid devices were manufactured for both single photon and coincidence imaging, bringing the advantages of PET to the general nuclear medicine clinic. These hybrid devices have been discontinued, and the new trend is merging of standard imaging equipment, e.
Combining both imaging modalities in one system, which appeared promising in the previous version of the book, has become reality. CT not only provides images of diagnostic quality, but is also used for attenuation correction, greatly reducing acquisition time. Clinical applications of dual modality imaging are discussed in Chaps. Chapter 16 provides a text on instrumentation and data acquisition.
Computer speed tends to double per year, an exponential growth curve that will continue up to the limit set by physics. New reconstruction techniques will be discussed and compared, leading to improved image quality.
Iterative reconstruction techniques, and correction for attenuation and scatter are the standard 4 in tomographic NM imaging. The effects on quantification of tracer distribution will be touched upon. In addition, simple and handy techniques for image enhancement are presented Chap. The C. Schiepers advances in molecular biology have made it possible to image specific molecular processes, and by inference the expression of gene s controlling these processes may be visualized.
All will want to update their library with this newest edition of Orthopedic Imaging: A Practical Approach. It is a great honor and privilege to review this book written by my respected friends, Adam and Javier.
They are at the top of their field and a true dream team. Lynne S. Its underlying concept is threefold: to provide a basic understanding of the currently available imaging modalities used to diagnose many commonly encountered disorders of bones and joints, to help in the choice of the most effective radiologic technique with a view to minimizing the cost of examination as well as the exposure of patients to radiation, and to emphasize the need for providing the orthopedic surgeon with the information required to choose the right therapy.
It does not attempt to compete in size and scope with other books on the same subject. Many uncommon entities have been excluded, as have the exact instructions for performing procedures. Likewise, the nature of the volume does not allow inclusion of every detail of a given disorder or full discussion of controversial aspects. As its subtitle states, Orthopedic Radiology strives to provide its primary audience, medical students and residents in radiology and orthopedics, with a practical approach to its subject.
Numerous original schematic diagrams and tables have been developed, detailing, for example, classifications of fractures, the morphologic features of arthritic and neoplastic disorders, and the positioning of patients for the various standard and special radiographic projections, as well as the most effective radiologic techniques for demonstrating abnormalities.
Radiographic reproductions, many of which are accompanied by explanatory, labeled line drawings, have been specially prepared to provide high-quality examples of the classic presentations of a wide spectrum of orthopedic disorders. Moreover, most figure captions are written in a case-study format, which, combined with a system of diagnostic notations explained in Chapter 1 following each legend, is meant to impart an appreciation of the process of radiologic investigations.
Although its aim is to teach, Orthopedic Radiology should also serve as a convenient reference for physicians interested in bone and joint disorders and those customarily employing radiologic studies in their everyday practice. The introduction of new imaging modalities and the improvement of existing ones have expanded the armamentarium of the radiologist but, at the same time, created some confusion in the 5 Orthopedic Imaging A Practical Approach 6th proper use of these techniques.
Concerns about the increasing use of imaging techniques that involve ionizing radiation radiography, fluoroscopy, arthrography, scintigraphy, and computed tomography [CT] have grown during the past decade. These concerns have led to a shift toward the increased use of ultrasonography and magnetic resonance imaging MRI. The task of the sixth edition of Orthopedic Imaging: A Practical Approach is not only to familiarize the reader with a variety of new imaging modalities but also to present the constructive and beneficial, as well as negative, aspects of these techniques.
The goal is to help the radiologist choose the proper sequence of radiologic examinations with the purpose of decreasing the cost and time needed to arrive at the correct diagnosis and to carry out the proper evaluation of a given disorder.
This new edition has many changes, additions, and improvements. Beltran, a pioneer of musculoskeletal MRI, is the author and coauthor of many books in this field, including the classic book MRI: Musculoskeletal System.
Because advances in MRI have considerable impact on musculoskeletal imaging and because MRI has become a primary diagnostic tool in orthopedic imaging, the addition of such an expert as Dr. Beltran has strengthened the sections devoted to this subject and guaranteed inclusion of the most up-to-date information. The overall design of this book, incorporating full color, has been retained; however, a new interior design has been created.
The singlevolume format, despite an increase in size, has been preserved. Practical Points have again been provided at the end of each chapter as a quick review of pertinent information. New references have been added to each chapter. Technically suboptimal figures have been deleted and replaced with better quality images. Some outdated material has also been deleted, and discussion of a variety of conditions has been updated. In particular, new information on cytogenetic and molecular genetics of a variety of tumors and other diseases has been added.
Almost every chapter contains new sections and new illustrations. Examples include new material on sports injuries, knee joint dislocations, injuries of the posterolateral corner of the knee, and imaging of the postoperative shoulder and knee; new views on so-called spontaneous osteonecrosis of the knee and osteochondritis dissecans of the talus; current views on cartilage imaging; classification of fractures of the sacrum; new trends in applying dual-energy CT to the diagnosis of tophaceous gout; imaging evaluation of compressive and entrapment neuropathies of the upper and lower extremities; imaging of parasitic infections; and many more.
Advances in the latest therapeutic approaches to many conditions have also been included. Nevertheless, although the authors recognize the value of more advanced imaging techniques, as in the previous editions, they emphasize the mastery of conventional radiography as the basic tool of every radiologist. This book has been written primarily for the radiologists and orthopedic surgeons, although it may also be of use for the physical therapists, rheumatologists, and other physicians interested in application of imaging techniques to the musculoskeletal system.
Dinkel, Product Development Editor for many editorial advices, enduring and attentive review of the manuscript, and meaningful suggestions. We are indebted to Dr. Luis Beltran and Dr. Frank Seidelmann and Dr. Peter Franklin from Radisphere for allowing an access to their immense case resources. Joseph Surace and Tennyson Maliro, for their help in finding good imaging examples of common and less common disease entities in the radiology files.
We also would like to thank Dr. Salvador Beltran from Barcelona, Spain, for creating such beautiful and informative schematics; Julie A. Ostoich-Prather, Senior Photographer from the Department of Radiology, University of California, Davis Medical Center, for help in creating some digital illustrations; and Hue To from the same institution for her invaluable secretarial assistance.
We are grateful to Lynne S. Again, we are indebted to all authors who have given permission to reproduce selective illustrations from their books and publications. As with the previous editions, this project could not have been successfully completed without the prudent and dutiful efforts of the many individuals acknowledged here.
These new technologic developments have also brought disadvantages. They have contributed to a dramatic increase in the cost of medical care and have often led clinicians, trying to keep up with new imaging modalities, to order too many frequently unnecessary radiologic examinations. This situation has served to emphasize the crucial importance of the role of the orthopedic radiologist and the place of conventional radiography.
The radiologist must not only comply with prerequisites for various examinations but also, more importantly, screen them to choose only those procedures that will lead to the 7 Orthopedic Imaging A Practical Approach 6th correct diagnosis and proper evaluation of a given disorder. To perform examinations in the proper sequence and to know what should be performed next in the radiologic investigation.
To demonstrate the determining imaging features of a known disorder, the distribution of a lesion in the skeleton, and its location in the bone.
To monitor the progress of therapy and possible complications. To be aware of what specific information is important to the orthopedic surgeon. To recognize the limits of noninvasive radiologic investigation and to know when to proceed with invasive techniques. To assume a more active role in therapeutic management, such as performing an embolization procedure, delivering chemotherapeutic material by means of selective catheterization, or performing usually CT-guided radiofrequency thermal ablation of osseous lesions such as osteoid osteoma.
The radiologic diagnosis of many bone and joint disorders cannot be made solely on the basis of particular recognizable radiographic patterns. Clinical data, such as the patient's age, gender, symptoms, history, and laboratory findings, are also important to the radiologist in correctly interpreting an imaging study. Occasionally, clinical information is so typical of a certain disorder that it alone may suffice as the basis for diagnosis.
Bone pain in a young person that is characteristically most severe at night and is promptly relieved by salicylates, for example, is so highly suggestive of osteoid osteoma that often the radiologist's only task is finding the lesion.
However, in many cases, clinical data do not suffice and may even be misleading. When presented with a patient, the cause of whose symptom is unknown Fig. This approach is essential not only to maintain cost-effectiveness but also to decrease the amount of radiation to which a patient is exposed. Proceeding first with conventional technique also has a firm basis in the chemistry and physiology of bone.
The calcium apatite crystal, one of the mineral constituents of bone, is an intrinsic contrast agent that gives skeletal radiology a great advantage over other radiologic subspecialties and makes information on bone production and destruction readily available through conventional radiography. Simple observation of changes in the shape or density of normal bone, for example in the vertebrae, can be a deciding factor in arriving at a specific diagnosis Figs.
To aid the radiologist in the analysis of radiographic patterns and signs, some of which may be pathognomonic and others nonspecific, a number of options within the confines of conventional radiography are available. Certain ways of positioning the patient when radiographs are obtained allow the radiologist the opportunity to evaluate otherwise hidden anatomic sites and to more suitably demonstrate a particular abnormality.
The froglateral projection of the hip, for example, is better than the anteroposterior view for imaging the signs of suspected osteonecrosis ON of the femoral head by more readily demonstrating the crescent sign, the early radiographic feature of this condition see Figs.
The frog-lateral view is also extremely helpful in the early diagnosis of slipped femoral capital epiphysis see Fig. Likewise, the application of P.
Fractures of complex structures such as the elbow, wrist, ankle, and foot are not always demonstrated on the standard projections. Because of the overlap of bones on the lateral view of the elbow, for example, detecting a nondisplaced or minimally displaced fracture of the radial head occasionally requires a special degree angle view called the radial head-capitellum view that projects the radial head free of adjacent structures, making an otherwise obscure lesion evident see Figs.
Stress radiographic views are similarly useful, particularly in evaluating tears of various ligaments of the knee and ankle joints see Figs. A,B The patient's history and the results of the clinical examination, supplied to the radiologist by the referring physician, are not sufficient to form a diagnosis? On the basis of conventional radiographic studies, a the diagnosis is established Dx , or b the studies may suggest the differential possibilities DDx.
In the latter case, ancillary imaging techniques, such as arthrography, scintigraphy, CT, or MRI, among others, are called on to confirm or exclude one of the options. An accurate diagnosis depends on the radiologist's acute observations and careful analysis, in light of clinical information, of the radiographic findings regarding the size, shape, configuration, and density of a lesion; its location within the bone; and its distribution in the skeletal system.
Until the conventional approach with its range of options fails to provide the radiographic findings necessary for correct diagnosis and precise evaluation of an abnormality, the radiologist need not turn to more costly procedures. Knowing the proper sequence of procedures in radiologic investigation depends, to a great extent, on the pertinent clinical information provided by the referring physician.
The choice of modality or modalities for imaging a lesion or investigating a pathologic process is dictated by the clinical presentation as well as by the equipment availability, physician expertise, cost, and individual patient restrictions.
Knowing where to begin and what to do next, as rudimentary as it may sound, is of paramount importance in reaching a precise diagnosis by the shortest possible route, with the least expense and detriment to the patient. It is instead more sensible to perform a skeletal scintigraphy and, afterward, to order radiographs of only those areas that show increased uptake of radiopharmaceutical.
A simple radionuclide bone scan rather than a broad-ranging bone survey is also a reasonable starting point for investigating other possible sites of involvement when a lesion is detected in a single bone and is suspected of representing part of a multifocal or systemic disorder, such as Langerhans cell histiocytosis, enchondromatosis, polyostotic fibrous dysplasia, polyostotic Paget disease, or metastatic disease.
Similarly, if a patient is suspected of having osteoid osteoma around the hip joint and standard radiography has not demonstrated the nidus, a radionuclide bone scan should be performed next to determine the site of the lesion.
This should be followed up by CT for more precise localization of a nidus in the bone. However, if the routine examination demonstrates the nidus, scintigraphy can be omitted from the sequence of examination. At this point, only CT scan is required to determine the lesion's exact location in the bone and to obtain specific measurements of the nidus Fig.
If ON of the femoral head is suspected and the radiographs are normal, MRI should be ordered as the next diagnostic procedure, because it is a more sensitive modality than CT, or scintigraphy. If the clinician suspects a gouty arthritis and the conventional radiographs are equivocal, the best action is to proceed directly to DECT because this modality may identify outright the presence of monosodium urate crystals and confirm or exclude gout in clinically challenging cases see Figs.
However, the choice of proper action is not always so clear. For instance, if the patient complains of wrist pain after fall on the outstretched hand, and there is significant tenderness on the P.
The radiologist may suggest to immobilize the wrist in the thumb spica splint and repeat the radiographs in 14 days from the time of injury, or conversely, to take a more direct approach although more costly and proceed with MRI examination see Fig. The text that follows presents many similar situations in which the proper sequence of imaging modalities may dramatically shorten the diagnostic investigation.
A,B From the information supplied by the referring physician, the radiologist may suspect the diagnosis Dx? The studies may also show inconclusive evidence of the original suspected diagnosis, in which case ancillary imaging modalities, such as scintigraphy, CT, or MRI, among others, are used.
Observation of changes in the shape and contour of a vertebral body on conventional radiographs may disclose critical information leading to a correct diagnosis. Changes in the density and texture of a vertebral body on conventional radiographs may offer useful data for arriving at a diagnosis.
Reaching a correct diagnosis does not end the process of radiologic investigation because the course of treatment often depends on the identification of distinguishing features of a particular disorder Fig. For example, the diagnosis of Ewing sarcoma by conventional radiography is only the beginning of a radiologic workup of the patient.
The crucial features of this tumor must be identified, such as intraosseous and softtissue extension by CT or MRI and the vascularity of the lesion by conventional arteriography or MRA.
Similarly, a diagnosis of osteosarcoma must be followed by determination of the exact extent of the lesion in the bone and the status of bone marrow in the vicinity of the tumor. This can be accomplished by precise measurement of bone marrow density using Hounsfield numbers during CT examination see Fig.
Diagnosing Paget disease may be an important achievement in the investigation of an unknown disorder, but even more important is the further search for an answer to a crucial question: Is there any sign of malignant transformation? The best example of this is, again, the precise localization of the nidus of osteoid osteoma because incomplete resection of this lesion invariably results in recurrence. Determining the distribution of a lesion in the skeleton is helpful in planning the treatment of various arthritides and the management of a patient with metastatic disease.
Scintigraphy is an invaluable technique in this respect. Many of the most important questions put to the radiologist by the orthopedic surgeon concern monitoring the progress of treatment and the appearance of possible complications. At the stage when the diagnosis is already established, the fate of the lesion, and consequently the patient, must be established. Comparison of earlier radiographic examinations with present findings plays a crucial role at this stage because it may disclose the dynamics of specific conditions see Fig.
Likewise, in monitoring the progress of healing fractures, study of the diagnostic sequence of radiographs complemented by CT should decide questionable cases. Ancillary imaging techniques such as scintigraphy, CT, PET-CT, and MRI play an essential role in evaluating one of the most serious complications of benign tumors and tumor-like lesions—malignant transformation that may occur in enchondroma, osteochondroma, fibrous dysplasia, or Paget disease.
Its value for the evaluation of the musculoskeletal system is still to be determined, but early clinical experience indicates very promising results and great potential for clinical imaging see Fig. Providing the orthopedic surgeon with specific information is also an important function of the radiologist at the time when a diagnosis is being established.
If, for example, osteochondritis dissecans is diagnosed, the decision on the choice of therapy requires information on the status of the articular cartilage covering the lesion. If the cartilage is intact, conservative treatment should be contemplated; if it is damaged, surgical intervention is the more likely course of treatment.
Similarly, in contributing to the plan of treatment of anterior dislocation in the shoulder joint, P. These features must be confirmed or excluded by arthrography combined with tomography arthrotomography , CT computed arthrotomography , or MRI Fig.
A,B A diagnosis is suspected Dx? The radiologist suggests the proper sequence of imaging modalities, eliminating various disorders in the process and narrowing the differential possibilities to arrive at one correct diagnosis Dx! An accurate localization Dx diagnosis Dxi are also provided. This situation is best illustrated in the case of tumors and tumor-like bone lesions. Many tumor-like lesions have distinctive radiographic presentations that lead to unquestionable diagnoses on conventional studies.
In such cases, invasive procedures such as biopsy are not indicated. This is particularly true of a group of definitely benign conditions commonly called don't touch lesions see Fig. The name don't touch speaks for itself. Conditions such as a bone island enostosis , posttraumatic juxtacortical myositis ossificans, and a periosteal desmoid are unquestionably benign lesions whose 15 Orthopedic Imaging A Practical Approach 6th determining features can, with certainty, be demonstrated with the appropriate noninvasive techniques without the need for histopathologic confirmation.
Obtaining a biopsy of such lesions may in fact lead to mistakes in diagnosis and treatment. The histologic appearance of a periosteal desmoid, for example, may exhibit aggressive features resembling a malignant tumor; in inexperienced hands, this can lead to inappropriate treatment. However, there are times when the radiologist faces the situation in which a battery of conventional and advanced noninvasive techniques has yielded equivocal information.
Fluoroscopyguided or P. Occasionally, the radiologist may also assume a more active role in therapeutic management by performing an embolization procedure under image intensification or with CT guidance, or performing radiofrequency thermal ablation of bone lesion. This more interventional role for the radiologist may shorten the length of a patient's hospitalization and be more cost-effective. Information hidden in the radiologic image, whether it is conventional radiography, scintigraphy, ultrasonography, CT, MRI, or other modality, can be effectively extracted by knowing the sensitivity of applied technique, spatial resolution, contrast resolution, and distortion among other factors.
But at the same time, radiologist should never forget the drawbacks of some techniques, such as radiation exposure to the patient or high cost of imaging procedures Fig. Choosing logical diagnostic imaging pathway would not only benefit the patient but also will reduce the cost of radiologic studies and cost of treatment Fig. Therefore, it is mandatory for musculoskeletal radiologist to develop a strategic course of action in pursuing his or her goal to make the correct diagnosis.
Radiologist must take into consideration the effectiveness of imaging modalities, their safety, required time to complete the examination, as well as the cost of investigation Fig. The effectiveness will depend upon the use of imaging techniques in proper sequence, and knowledge of which of these techniques is better to demonstrate the lesion, its localization and distribution in the skeleton, and which is the best to monitor the progress of treatment or emergence of possible complications Fig.
The diagnosis is known Dx. The clinician is interested in demonstrating 1 the crucial features of the lesion Dx , that is, its character, extent, stage, and other pertinent data; 2 the location of the lesion in the bone Dx 18 Orthopedic Imaging A Practical Approach 6th distribution of the lesion in the skeleton Dx of any complications Dxc. A,B The diagnosis is known Dx.
The radiologist should be aware of the specific information i , for example, regarding the features i1? The information may also concern the distribution of a lesion and its localization, the progress of treatment, or the emergence of complications.
Application of the best radiologic modality for demonstrating the required information is one of the radiologist's primary functions. The modalities may vary depending on the specific information needed.
A,B The diagnosis is unknown?