Tuesday, June 23, 2009

Sclerotic Bone Lesion

SCLEROTIC BONE LESION

By Dr. KM Liau

Generally bone sclerosis signifies a slow-growing process. Bone reacts to disorder in two ways -- either by removing some of itself or by creating more of itself. If the disorder is rapidly progressive, there may only be time for retreat, hence bone resorption will occur giving rise to lytic lesion . If the process is slower growing, then the bone may have time to defend itself by forming a sclerotic border around the offender.

UNIVERSAL DIFFERENTIAL DIAGNOSIS

Mnemonic = VINDICATE

1. Vascular - hemangiomas, infarct(sickle cell).

2. Infection - Chronic osteomyelitis

3. Neoplasm

---A) Primary - Osteoma, Osteosarcoma

---B) Metastatic - Prostate, Breast

4. Drugs - Vitamin D, fluoride

5. Inflammatory/Idiopathic

6. Congenital - Osteopoikilosis, Osteopetrosis

7. Autoimmune

8. Trauma - Stress fracture

9. Endocrine/metabloic - Hyperparathyroidism, Paget's disease

HEMANGIOMA

Hemangiomas are benign lesions characterized by vascular spaces lined with endothelial cells.

Approximately 50% of osseous hemangiomas are found in the vertebral bodies (thoracic especially) and 20% in the calvarium.

The remaining lesions are found in the tibia, femur and humerus.

HEMANGIOMA ANGIOGRAM

Hemangioma Link List

Hemangioma
Learn more about hemangioma here.
Hemangioma 2
Learn more & more about hemangioma.

SICKLE CELL

Musculoskeletal Manifestations

* Infarction
* Marrow Hyperplasia
* Spontaneous Fracture
* Growth Disturbance
* Osteomyelitis
* Arthritis (septic-reactive)
* Dactylitis

X ray finding:
* Thinning of cortex
* Dense amorphous chalky zones ( Infarcts )

SICKLE ANAEMIA WITH AVN OF HEAD OF FEMUR

40 year old lady with left hip pain - Mechanical pain.

Patchy sclerosis is particularly marked over the proximal femoral metaphyses and diaphyses.

There is a bone-within a bone appearance, particularly in the diaphysis of the left femur that implies an intermittent process.

The head of the left femur is flattened and broadened.

The curvatures of both surfaces of the left hip no longer correspond as the centre of the neck of left femur has migrated upwards and outwards.

The right hip joint surfaces are congruent, despite the sclerosis of that femoral head.

There is osteophytic lipping at the margins of the acetabulum on both sides.

Diagnosis: AVN of Left Head of Femur Ficat Stage 4

Sickle Cell Link List

AVN Hip
Click here for large picture of Hip AVN
AVN in sickle cell disease
AVASCULAR NECROSIS OF THE HIP IN SICKLE CELL DISEASE

CHRONIC OSTEOMYELITIS

Skeletal manifestations include unifocal or multifocal bone lesions, which are lytic and destructive in the early phase, and sclerotic and reactive in the late phase, occurring in any bone.

The metaphyseal area of long bones, the clavicle, and the shoulder girdle are common locations.

Chronic Osteomyelitis Link List

Chronic Recurrent Multifocal Osteomyelitis
Chronic Recurrent Multifocal Osteomyelitis
Hyperbaric Oxygen Therapy
Hyperbaric Oxygen Therapy and Chronic Osteomyelitis

OSTEOID OSTEOMA

Osteoid Osteoma is a benign bone lesion with a nidus of less than 2 cm surrounded by a zone of reactive bone.

Osteoid osteoma has a distinct clinical picture of dull pain that is worse at night and disappears within 20 to 30 minutes of treatment with non-steroidal anti-inflammatory medication.

4 diagnostic features include

(1) a sharp round or oval lesion
(2) less than 2 cm in diameter,
(3) has a homogeneous dense center
(4) a 1-2 mm peripheral radiolucent zone.

Osteoid Osteoma Link List

Osteoid osteoma
Learn more about osteoid osteoma

OSTEOSARCOMA

Features of osteosarcoma:

1. Osteoblastic (bone forming)

(note a rare variant which is osteolytic and
resemble aneurysmal bone cyst - telangiectatic
osteosarcoma)

2. Sun ray spicules (Radial ossification) and Codmans triangle (lifting of periosteum)

3. Wide zone of transition.

4. Cortical breach common

5. Adjacent soft tissue mass

6. Joint space rarely involved

New Link List

Osteosarcoma
Learn more about osteosarcoma

PROSTATE METASTASIS

In male patient always think of prostate metastasis whenever you see blastic lesion in the vertebra.

Always do a per rectal examination (or be prepared to get screwed!!!)

BREAST METASTASIS

In female patients, always think of breast cancer.

They can present either as lytic or blastic lesion.

The picture shows blastic lesion over L1, L2, L3 vertebrae.

New Link List

Breast canser metastasis
Case study on breast cancer metastasis

FLUOROSIS

Recent immigrant from India with a stiff back and bad teeth.

There is a widespread patchy increase in bone density with ossification of capular ligament insertions of hip and intervertebral joints and particularly of the sacro-iliac joints.

New Link List

Fluorosis large picture
Click here to see large picture

OSTEOPETROSIS

Rare hereditary disorder

Defective osteoclast function with failure of proper reabsorption produces sclerotic bone

Structurally weak bone.

X-ray findings:

Diffuse osteosclerosis

Cortical thickening with medullary encroachment

Erlenmeyer flask deformity = clublike long bones due to lack of tubulization + flaring of ends

Bone-within-bone appearance

"Sandwich" vertebrae=alternating sclerotic + radiolucent transverse metaphyseal lines (phalanges, iliac bones) indicate fluctuating course of disease

Longitudinal metaphyseal striations

Osteopetrosis - Spine

Osteopetrosis Spine
Click here for large photo.

STRESS FRACTURE

Commonly occur among athletes who has undergone continuous vigorous training.

Note the fine lucent line involving 1 cortex only and mild periosteal reaction.

Abscence of lytic or blastic lesion and normal medullary canal rules out other pathologies.

Stress Fracture Link List

Stress fracture
Learn more about stress fracture at wikepidia.
Common Stress Fracture
Learn more about common stress farcture at Journal of American Academy of Family Physician.

SECONDARY HYPERPARATHYROIDISM

Soft tissue calcification are common

Calcified deposits around joints may mimic tumoral calcinosis (Picture)

NOTe: Brown tumors due to primary hyperparathyroidism are LYTIC and they are less common.

Hyperparathyroidism Link List

Wikipedia
Learn more about secondary hyperparathyroidism at Wikipedia.

PAGET'S DISEASE

This is a disease more common in the Western countries.

Very rare in Malaysia.

Imaging Findings:

* Classical triad of:
o Thickening of the cortex
o Accentuation of the trabecular pattern
o Increased size of bone

Associated neoplasia (0.7-20%)

* Sarcomatous transformation into osteosarcoma (22-90%)

* Fibrosarcoma /malignant fibrous histiocytoma (29-51%)

* Chondrosarcoma (1-15%)

Paget Link List

Paget Disease
Learn more about Paget Disease here.

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