Avascular necrosis and MSX bone lesions new presentation.pptx

avascular necrosis and MSX bone lesion

1. AVASCULAR NECROSIS AND MISCELLANEOUS BONE LESIONS: Dr MUHAMMAD SALMAN Resident radiology CMH Peshawar

2. Osteo n ecros i s ( Avasc u l ar Necros i s ) O s teo n ecrosis (avascular n ecrosis, isc h e m ic n ecrosis, aseptic n ecrosis) T wo mec h a n isms l n terru p tion of arter i al supply In tra I extraosseous ve n ous i n sufficie n cy

3. l schaemia r Death of haemopoietic tissue -(6-12 ) hrs ) r Death of Bone C e lls ( Osteoclast, Osteoblast & Osteocytes ) (12- 48 h rs) Marrow Fat (2-5 days)

4. 4 Z O NES I N A VN A-ART I CU L AR CAR T I LAGE B - ZO N E O F I S C H E M I A C - R EPARA T I VE ZONE D - N O R M AL BO N E

5. V a sc u l ar i n s uf f i c i ency to b one i s of 3 ty p es l nterru p t i on to the flow of b l oo d - tear i ng of blood vessels - Trauma * Em b o l i or s l udg i ng - b y r b c ag g regates in f at emboli i n gas b u b b les in vasculitis in - SCD -Pancreatitis -Ca i sson's disease - collagen d isor d er 3 . l ntr a osseous com p ress ion of vesse l s Gauc h er's D iasease.

6. R a d iology Ch a n g es S tage I : cli n ical sym p toms of AVN but n o radiograp h ic fi n di n gs S tage II : osteoporosis, cystic areas a n d osteosclerosis S tage III : tra n sluce n t su b cortical fracture li n e ( crescent sig n ) , flattenin g of femoral head S tage I V : l oss of bo n e co ntour with seco n dary osteoart h ritis

7. R a d iology- se q ue n ti a l Ch a n g es Crescent S i gn O steo p oros i s Scleros i s Cyst i c changes Loss of s p her i cal we i ght b ear i ng d ome P a rt i a l coll a pse of he a d Secon d a ry O steoarthr i t i s

8. Crescent sign

9. Sc l eros i s Sc l erosis/s u bchond r a l cysts s u bchondr a l cysts

10. BONE SCAN Bone scintigraphy quite sensitive (~85%) and is the second option after MRI. early disease: cold area likely representing the vascular interruption late disease: "doughnut sign": a cold spot with surrounding high uptake ring (surrounding hyperaemia and adjacent synovitis)

11. • MRI most sens i t i ve techn i que f or early d i a g nosi s C a n di a g n ose A VN a s e arly a s 48 h o u rs

12. M R I F i n d i n gs C l a s s i c Fi n di n g : Focal lesion in the anteriosuperior portion of femoral head- well demarcated but inhomogeneous T 1 i m a g e s s e r pigineous zone of low signal intensity around the avascular area T 2 i m a g e s d o u b le lin e sign = > c l a ss ic sign o f A V N, made of two concentric high and low signal bands

13. • MRI - F i ndi n g s Bone Marrow ede m a Doub l e L i n e - He a d i n He a d s i gn Cresce n t s i gn Co l l a p se Joint ef f usion Involvement of a c e ta bul um Status of other h i p

14. MRI T1 Low sig n a l from i schem i c m a rrow S i ng l e b a nd like area of l ow s i gn a l i ntens i ty. 1 00 ° / o sen s it i v i ty 9 8 ° / o s pec i f i c i ty

15. Do u b l e L ine sign - T2 Image I A second h i gh s i gn a l i ntens i ty seen w i th i n the line seen on T1 i m a ges. Represent hy p er vascu l ar gr a nu l a tion t i ssue •

16. St a ge 2

17. St a ge 3 Mo d erate sym ptoms. Loss of sh a p e Crescent s i gn S u b chon d ral coll a pse 5 7

18. St a ge 4 S evere symptoms . • Joint sp ace narrowing. OA changes in acetabulum. 5 8

19. - M i tc h e l l c l a ss i f i cat i on : *C l a ss A (early d i sease) : sig n al i nte n sity a n alogous to fat (h i gh on T1 a nd i n termediate on T 2) *C l a ss B : sig n al i nte n sity a n alogous to blood ( h igh on T1 a nd T 2) *C l a ss C : sig n al i nte n sity a n alogous to fluid (low on T1 a n d h igh on T2 ) *C l a ss D ( late disease) : signal i nte n sity a n alogous to fibrous t i ssue (low on T1 a n d T 2)

20. Coronal T1 of the p e l v i s i n a pa t i ent w i th b i l at e r al ava s cu l a r n e c r o s i s of t h e f e mo r al he a d s hows i ncr e as e d s i gn a l w i th i n t h e s up e r i or a s pect of the femor al h e ad, r e p r e s ent i ng fat, surrou n ded b y a li n e of d ecres e d s i gna l , r e p r es e nt i ng s c l e r ot i c r eact i ve m a r g i n , th i s i s an M RI c l ass A ( fat l i k e )

21. Patient 39 years old with use o f h i gh dose o f corticostero i ds, Cor T 1 and T2 o f t h e pelvis shows a s tage B (b l ood - l ike) at the l evel o f r i ght femoral head with i ncreased s i gnal on T 1 W and T2 W ; AVN stage C ( f l ui d - l i ke) i n l eft femoral hea d , w i th decreased si g nal i n tensity on T 1 W and i ncreased s i gnal on T2

22. Cor T1 and T 2 i n a patient with AVN on the left fe m oral head with d ecresed si gnal i n tensity on T 1 and T 2 , represent i ng a stage D ( f i bro u s - l i ke)

23. ( i i ) L ow e r L i m b : 1 - L e gg - Ca l ve - P e r t h e s (Ost e onecros i s of fem o ral h e ad) I nc i d e nce Rad i o g rap h i c F eatures

24. a ) I n c i d e n ce : - Oste o n ecros i s of f e moral h e ad -Sc h ool a g e (5-8 years)

25. - E a r l y s i gns : Asy m m e t r i cal f e m oral e p i p h ys e al s i ze (smaller o n affected s i d e ) Ap p are n t i n cr e ased d e ns i ty of t h e f e moral h e ad e p i p h ys i s W i d e n i n g of the m e di al jo i nt s p ace 4 B l u r r i n g of t h e p hys e al p l ate

26. - Late s i gns : T h e fem o ral h e ad b e g i ns to fragm e nt w i th s u b c h o n dral l uc e n cy (cr e sc e n t s i gn) F e m o ral h e ad defo r mity w i th wide n i ng a n d f latt e n i n g 3 O st e o a rt h r i t i s

27. b ) Ra d i o g ra p h i c F eat u res : - P lain film stag i ng system ( F icat ) : * S tage I : cli n ical sym p toms of AVN but n o radiograp h ic fi n di n gs * S tage II : osteoporosis, cystic areas a n d osteosclerosis * S tage III : tra n sluce n t su b cortical fracture li n e ( crescent sig n ) , flat tenin g of femoral head * S tage I V : l oss of bo n e co ntour with seco n dary osteoart h ritis

28. Stage I I

29. AP radi o grap h ic view of the pelvis shows flatten i ng of the o uter portion o f the r i ght fe m oral head f r om a v ascu l ar n ecrosis , with a d jacent j o int space narrow i ng, j u xta-art i cular scle r osi s , and osteophytes representi n g degenerative jo i nt d isease (stage IV )

30. B i lat e ral P e rthes

31. Bilate ral AVN, (a) T 1 , (b) T2

32. The Catterall classification for  Legg- Calvé - Perthes disease   is based on radiographic appearances and is as follows: Group I: involvement of the anterior epiphysis only Group II: involvement of the anterior epiphysis with a clear sequestrum Group III: only a small part of the epiphysis is not involved Group IV: total head involvement

33. Ost e on e cros i s in br i ef : K i e n b ock d i sease : l u nate P re i s e r's D isease : scap h o i d L e g g -Ca l ve- P er t h e s : fem o ral h e ad 4 Ko h l e r's D i s e ase : nav i cu l ar b o ne 5 F r i e b e r g ' s D isease : metatarsal h e ad 6 Kum m e l 's D i s e ase : verte b ral body

34. U p per L i m b : 1 - K i e n b o ck d i sea se (Ost e o necros i s of the l u nate) : Sc l e rot i c l u nate on p l a i n rad i o g ra p hy Sc l e ro s is ( l ow T 1 a n d T2 )

35. T1 T2

36. 2 - P r e i ser's D i s e ase : (Ost e o n e cros i s of the s ca p h oi d) :

37. N o rmal navicular bo n e 2 - Ko h l e r ' s D i se a se (Oste o necros i s of t h e n av i cular b o n e )

38. 3- F r i e b e rg ' s Dis e ase ( Osteonecro s is o f the Metat a rsal head) : - O ste o necrosis of the d i stal end of the 2nd (75 % ) or 3rd (2 5 ° / o ) metatarsal - B i l ateral in 10 ° / o of pa t ients -Ear l y : *Flatten i ng a nd cyst i c l e sions of the affected metat a rsal head *W i de n i ng o f t h e metatarsophalangeal (MTP) joi n t -Late : *Sclero s is and flatt e n ing o f the bone - M RI : as befo re

39. ( i i i ) S p i n e : K u m m e l 's D i se a se (Oste o n ecros i s of the verte b ral body) : -Collapse of affe cted verte b rae

40. Oste o c h o n d r o s i s - A b n ormal bo n e a n d cartilage at t h e e n d of bo n e -T h e term is a catc h -all term referri n g to a spectrum of diseases : a ) Ab n or m al e n d oc h o n d ral oss i f i cat i on s e co n dary to r e peated stress w i thou t osteo n e cros i s : 1- S c h euerman n ' s disease : spi n e 2- O sgood-Sc h latter disease : ti b ial tubercle 3- B lou n t ' s disease : ti b i al epip h ysis

41. 1 - S che u erma n n D isease (Juve n ile Kyp h osis) ( Vertebral apop h yses) : -Common co n dition resulting in kyp h osis of t h e t h oracic or t h oracolumbar spi n e - D iag n ostic c r iteria : *T h oracic spi n e kyp h osis > 40 deg (normal 25-40 deg) or *T h oracolumbar spi n e kyp h os i s > 30 deg *At least 3 adjace n t vertebrae demo n strati n g wedg i n g of > 5 de g rees

42. - P l a i n R a d i o gr a phy : * P ro g res s ive na r ro w i ng of di s k s p aces *W e d g i n g of t h e ante r i o r p or t i on of v e rte b ral b odi e s * I r r e gular i ty of e ndp l at e s *C h a n g es s e en i n >3 verte b ral bod i es *Mu l t i p le Sc h m o r l ' s n odes

43. We dge shaped vert e brae

44. 2- O sgood- S c h latter Disease ( Ti b ial tubercle ) : - S eco n dary to repeated trauma to deep fibers of patellar te n don -Male : female 5 : 1 -2 5 % are b ilateral - I rregu l ar ti b ial t u berosity -T h icken i n g of patellar tendo n , soft t i ssue swelli n g arou n d patellar ligame n t

45. 3- B lo u n t's D isease : (Co n gen i tal t i b i a vara) , ( P roximal medial t i b ial epip hysis) Blount disease  refers to a local disturbance of growth of the medial aspect of the proximal tibial  metaphysis  and/or  epiphysis  that results in  tibia vara . The condition is commonly bilateral. Age of presentation 1-12 years

46. Osteochondritis Dissecans develops in joints, most often in children and adolescents   It is a  joint  disorder primarily of the subchondral bone in which cracks form in the  articular cartilage  and the underlying  subchondral bone .  OCD usually causes pain during and after sports. In later stages of the disorder there will be  swelling  of the affected joint which catches and locks during movement