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Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. Radiology has expanded rapidly in recent years, and as such this 7th edition is the biggest revision this book has had in its long history.
Nearly every section in every chapter has undergone major changes, with the addition of a new Nuclear Medicine chapter to reflect its importance in modern medical imaging. Part 2 has been restructured to focus on multisystem disorders which cannot be fully covered in individual chapters—many of these are a favourite of the long cases in the FRCR Part 2B exam.
Important discriminating features have been added to nearly every differential to aid the reader in developing a strategy for reaching a diagnosis. Diagnoses are still listed in the approximate order of commonness, but note that this order is less clear-cut for rarer diagnoses due to less reliable epidemiological data.
Also, the presence or absence of discriminating features has significant impact on the relative likelihood of the differentials. These are far less important than learning the discriminating features. Finally, the top differentials in each list which are considered most important for radiology trainees to learn are underlined. The number of diagnoses underlined varies from list to list—some of the more important lists have all of their differentials underlined, whereas other lists which are aimed at specialists may have no underlined differentials at all.
Special thanks go to Sami Khan for his additional invaluable assistance in the planning stage of the project and for helping me find contributors for various chapters, as well as Stuart Taylor and the publishing team at Elsevier for giving me the opportunity to take on this project in the first place.
The culture of excellent radiology education and support in our department makes it a wonderful place to train and work, and has quite literally made me the radiologist I am today. Metastases—prostate and breast most common. Heterogeneous; generally not diffuse. Sickle cell disease—medullary sclerosis and bone infarcts. Growth arrest of long bones. H-shaped vertebrae. Myelofibrosis—older patients. Diffuse medullary sclerosis, loss of corticomedullary differentiation.
No heterogeneity. Less common 4. Rugger jersey spine. Osteopetrosis—thickened cortices with reduced marrow space. Pathological transverse fractures. Multiple bones rather than generalized. Systemic mastocytosis—lytic, sclerotic or mixed. Usually diffuse affecting spine and epiphyses of long bones. Rare 8. Fluorosis—diffuse osteosclerosis, particularly ribs and spine, with entheseal ossification.
Pyknodysostosis—narrow medullary cavities with multiple long bone fractures. Dense metaphyseal bands and skull vault thickening. Progressive diaphyseal dysplasia Camurati-Engelmann disease —young patients.
Fusiform enlargement and sclerosis of long bones sparing the epiphyses. Myeloma—rare osteosclerosing form. Bone island enostosis —ovoid with long axis parallel to long axis of bone and a feathered border. Enchondroma—confluent punctate or nodular calcification, denser centrally than peripherally. Enchondromas in the large long bones are often more calcified than those in the fingers. Metastasis—prostate, breast, mucinous adenocarcinoma of GI tract, carcinoid, lymphoma, TCC in adults.
Medulloblastoma and neuroblastoma in children. Callus—usually associated with a fusiform swelling in long bones. Bone infarct—usually a central metadiaphyseal lucency with thin serpentine calcified margins. Less common 6. Osteoma—arises from membranous bone: skull and paranasal sinuses. Ivory osteomas contain no trabeculae. Mature osteomas have visible marrow.
If multiple consider Gardner syndrome. A regional cluster of lytic lesions is suggestive Nonspecific. Bold text represents key features. Note that items in the table have been loosely grouped together based on their features, but there is some overlap between the categories. If seen in children, suspect underlying sickle cell or Gaucher disease.
Termed avascular necrosis when located in the epiphysis. Bone infarcts can transform into various sarcomas. The clear cell variant of chondrosarcoma arises in epiphyses and can mimic chondroblastoma though usually in an older age group.
Chondrosarcomas can also arise from an existing enchondroma or osteochondroma. In flat bones haemangiomas are often expansile with a sunburst periosteal reaction. In long bones the trabecular coarsening often creates a honeycomb appearance. Also beware the telangiectatic variant mimics ABC. Nonossifying fibroma—young patients, eccentric metaphyseal location. ABCs are more eccentric and expansile.
Fibrous dysplasia—variable appearance, typically diaphyseal. Chondroblastoma—epiphyseal location, young patients. Discrete lucency with surrounding ill-defined sclerosis.
Healing metastases or primary malignant bone lesions—sclerotic rim indicates a good response to treatment. Osteoblastoma—large lucent nidus with a sclerotic margin. Most common in spine. Intraosseous lipoma—typically in calcaneus or intertrochanteric region of femur. Thin sclerotic margin. Focus of central calcification is pathognomonic but not always present. Liposclerosing myxofibrous tumour—characteristic location: intertrochanteric region of femur. Usually a thick sclerotic margin.
Heterotopic ossification and myositis ossificans—well-defined with dense ossification in the periphery and less density centrally. May mimic surface osteosarcoma in the early stage; follow up can help differentiate by showing maturation of ossification.
Surface osteosarcoma—three types: a Parosteal—low grade, arises from outer periosteum, usually metaphyseal. Mature osteoid matrix within the mass which is more dense centrally in contrast to myositis ossificans. Broad-based with cortical erosion and spiculated periosteal reaction.
Less organized osteoid matrix. Usually diaphyseal. The underlying cortex is mildly scalloped. Cortical desmoid—characteristic location: distal posteromedial femoral metaphyseal cortex at muscle insertion site. Well-defined scalloping of cortical surface, typically small. Parosteal lipoma—juxtacortical radiolucent mass with an associated irregular bony excrescence arising perpendicularly from the periosteum.
Mimics an osteochondroma but does not show medullary continuity with the underlying bone. Overgrowth of nearby bones is usually also seen. Osteoma—usually located within the paranasal sinuses but can arise from the surface of the skull, mandible or long bones in Gardner syndrome.
Small, well-defined, uniformly dense osseous nodule on the cortical surface; typically sessile in the long bones with no periosteal reaction. Can be multiple and lobulated, mimicking melorheostosis, but no endosteal involvement or sclerotomal distribution. Can progress to osteomyelitis. Subperiosteal haemorrhage—e. Periarticular lesions—e. These can scallop the cortex. Other rare lesions not specific to this site—e. Multiple myeloma—numerous punched-out lytic lesions.
Bone sarcomas—e. Ewing sarcoma, osteosarcoma, chondrosarcoma. Bone lymphoma—subtle ill-defined bone destruction, usually with a large soft tissue mass.
Langerhans cell histiocytosis—young adults only. Osteoporosis—extensive cortical tunnelling can mimic an aggressive process. Most common 1. Disuse—typically distal foot and ankle, hand and wrist. Complex regional pain syndrome—typically unilateral upper limb. Triple phase uptake on bone scintigraphy. Inflammatory arthropathy. Septic arthritis. Less common 5. Transient osteoporosis of the hip. Regional migratory osteoporosis. Haemophilic arthropathy.
Soft tissue arteriovenous malformation. Diffuse infiltrative bone disease—multiple myeloma in adults, leukaemia in children. Also defined by the WHO as 2. Radiographic findings 1. Increased radiolucency of bone—can be affected by radiographic factors. Cortical thinning—most commonly endosteal resorption in the elderly. Pencil-line cortex, vertebral picture framing. Prominent secondary trabeculae—caused by preferential resorption of primary trabeculae. Vertebral fractures—anterior wedge or biconcave vertebral compression.
Insufficiency fractures—sacrum, pubis, femoral neck, tibial plateau, ankle and foot. Causes Primary 1. Juvenile—rare self-limiting condition occurring in children of 8—12 years. Spontaneous improvement is seen. Secondary 1. Deficiency states—e. Chronic and systemic disease—e. Vitamin D deficiency—either low dietary intake, poor sunlight exposure or malabsorption. Other causes 2. Renal disease. Hepatic disease—parenchymal failure or chronic cholestasis.
Anticonvulsants—phenytoin and phenobarbital. Tumour-associated—paraneoplastic phenomenon, usually due to a benign phosphaturic mesenchymal tumour which may be small and hard to find; PET-CT can aid localization. Metaphyseal chondrodysplasia Schmid type —metaphyseal cupping and irregularity, bowed long bones, short-limbed dwarfism.
Bronchiectasis—frequently due to cystic fibrosis. Lung metastases. Other pleuropulmonary causes—e. Cyanotic congenital heart disease—produces clubbing but only rarely a periosteal reaction. Cirrhosis and hepatobiliary malignancies. Other malignancies—lymphoma, nasopharyngeal carcinoma, RCC, breast phyllodes tumour, thymic carcinoma, melanoma. Hypertrophic fracture nonunion. Neuropathic arthropathy—including congenital insensitivity to pain.
Accompanied by joint destruction, fragmentation, sclerosis and osteophyte formation. Osteogenesis imperfecta. Paralysis—more common in lower extremities. Renal osteodystrophy. Multiple myeloma. Children 8. Nonaccidental injury. Fractures—especially femoral neck, talus and scaphoid.
Haemoglobinopathies—especially sickle cell anaemia. Radiotherapy—localized to the treatment field, e. Metabolic and endocrine—e. Connective tissue diseases—e. SLE, rheumatoid arthritis, scleroderma. Haemopoietic disorders—e. Thrombotic and embolic—including vasculitis, fat embolism and dysbaric osteonecrosis.
Normal variant. Chronic rotator cuff tear—results in elevation of humeral head and impingement of medial metaphysis on glenoid, causing mechanical erosion. Hyperparathyroidism—subperiosteal resorption. Rheumatoid arthritis. Lysosomal storage disorders—e. Gaucher disease, Hurler syndrome, Niemann-Pick disease. Posttraumatic osteolysis.
Rheumatoid arthritis—typically bilateral and symmetrical. Malignancy—metastasis, myeloma. Septic arthritis—erosion involves both sides of joint. Cleidocranial dysplasia. Pyknodysostosis—hypoplastic clavicles also associated with hypoplastic mandibles, acroosteolysis and osteosclerosis.
Scleroderma—juxtaarticular soft tissue calcification highly suggestive. Secondary The term secondary Madelung is often applied to similar bowing deformities of the distal radius that do not always include a long ulna. Causes include: 1. Growth arrest following radial growth plate injury or infection. Multiple hereditary exostoses. Turner syndrome. Leri-Weill dyschondrosteosis. More common in Afro-Caribbeans. Lunate-triquetral—most common site. Syndrome-related Tend to exhibit massive carpal fusion affecting bones in different rows proximal and distal.
Acrocephalosyndactyly Apert syndrome —craniosynostosis, syndactyly. Arthrogryposis multiplex congenita—multiple congenital contractures. Diastrophic dwarfism—short-limbed dwarfism.
Ellis-van Creveld syndrome—short-limbed dwarfism, polydactyly. Hand-foot-genital syndrome—scaphoid-trapezium coalition. Nievergelt syndrome—mesomelic dwarfism, club foot, metatarsal synostoses.
Oto-palato-digital syndrome—deformed carpals, ear and palatal anomalies. Holt-Oram syndrome—radial ray anomalies and cardiac malformations. Turner syndrome—Madelung deformity and lunate-triquetral coalition may be seen.
Symphalangism—interphalangeal joint fusions and carpal coalitions. Acquired 1. Inflammatory arthritides—especially juvenile idiopathic arthritis and rheumatoid arthritis. Pyogenic arthritis. Chronic tuberculous arthritis. Posttraumatic—iatrogenic, fracture, growth plate injury, thermal or electrical. Pseudo and pseudopseudohypoparathyroidism—4th and 5th metacarpals.
The metacarpal index aids diagnosis and is estimated by measuring the lengths of the 2nd to 5th metacarpals and dividing by their breadths at the exact midpoints. These four figures are then added together and divided by 4. NB: this is a poor discriminator between Marfan syndrome and constitutional tall stature.
Normal range 5. Arachnodactyly range 8. Marfan syndrome—although arachnodactyly is not necessary for the diagnosis. Harry Potter. Popular Features. The first section presents lists of differential diagnoses, supplemented by notes on useful facts and discriminating factors. These assist with the systematic assessment of radiographs and images from other modalities. The second section offers detailed summaries of the characteristic radiological appearance of a wide range of clinical conditions.
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