“Don’t touch” lesions new version dr ahmed esawy CALCANEAL PSEUDOCYST INTRAOSSEOUS LIPOMA BIPARTITE PATELLA MYOSITIS OSSIFICANS AVULSION INJURY CORTICAL DESMIOD GEODES DORSAL DEFECT OF THE PATELLA PSEUDOCYST OF THE HUMURUS OS ODONTOIDEUM NON OSSIFYING FIBROMA BONE ISLANDS UNICAMERAL BONY CYST EARLY BONE INFARCT MELORHEOSTOSIS HYPERTROPHIC PULMONARY OSTEOARTHROPATHY ACHONDROPLASIA AVASCULAR NECROSIS HURLER SYNDROME TRANSIENT OSTEOPOROSIS OF THE HIP DIAPHYSEAL ACLASIA MULTIPLE HEREDITARY EXOSTOSIS OSTEOID OSTEOMA OSTEPATHIA STRIATA OSTEOPIKILOSIS SARCIOD OS STYLOIDEUM OS TRIGONUM

1. Dr Ahmed Esawy

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3. Dr Ahmed Esawy

4. “Don’t Touch” Lesions
 Auntminnie diagnosis that do not need a biopsy
– more importantly you the radiologist can
prevent any further painful or costly work-up.
 Three categories :
 Posttraumatic
 Normal variants
 Benign lesions
Dr Ahmed Esawy

5. Calcaneal
pseudocyst
Dr Ahmed Esawy

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11. Conclusion
normal variants are common
but maintain high degree of
suspicion of pathology
Dr Ahmed Esawy

12. Myositis Ossificans
Findings: Circumferential calcification with a lucent center.
Best seen on CT
Sometimes associated with periosteal reaction.
Biopsy should be avoided since aggressive histologic appearance can mimic a sarcoma which then
can lead to unfortunate radical surgery! Dr Ahmed Esawy

13. Avusion Injury
Common in characteristic locations at ligament and tendon insertion sites.
Biopsy can be misleading because healing avulsion may mimic malignant histology.
Even further imaging like MRI can lead one towards biopsy.
Rather good clinical correlation and at the most follow up films in several weeks are a better
option. Dr Ahmed Esawy

14. Cortical desmoid
Dr Ahmed Esawy

15. Well Healed Cortical Desmoid
Dr Ahmed Esawy

16. Geodes
 Young soccer player with painful hip.
Dr Ahmed Esawy

17. Fracture
 Fracture mimiking osteosarcoma
Dr Ahmed Esawy

18. Pseudodislocation of the Humerus
Fracture with hemarthrosis causing distension of the joint and inferior subluxation of the
humerus.
AP view can mimic a posterior dislocation.
Get axillary or scapular Y view to asses for dislocation.Dr Ahmed Esawy

19. Dorsal Defect of the Patella
Normal variant
Dr Ahmed Esawy

20. Pseudocyst of the Humerus
Normal variant
Hyperemia and disuse caused by rotator cuff problems may increase the lucency in this region.
Very characteristic location for pseudocyst. However, chondroblastoma, infection ,or even
metastasis is still possible in this location Dr Ahmed Esawy

21. Os Odontoideum
Normal variant which demonstrates unfused dens to the body of C2.
Although this still may cause instability especially in the setting of acute trauma, if well corticated
then you can assume that there is no ACUTE fracture.
Additional finding of densely corticated anterior arch of C1 presumably due to compesnatory
hypertrophy.
Dr Ahmed Esawy

22. Os Odontoideum
Dr Ahmed Esawy

23. Os Odontoideum
Dr Ahmed Esawy

24. Non ossifying fibroma
Similar to fibrous cortical defect except for the larger size (greater than 2 cm)
Lytic lesion in the cortex of the metaphysis.
Well-defined with scalloped borders.
Always in younger patients (less than 30 years)
Involute as patient grows
Clinically asymptomatic and never leads to malignant degneration – no biopsy neededDr Ahmed Esawy

25. Healing NOF
Cortically based lytic lesion with sclerotic margins indicating healing and involution.
May have increased radiotracer activity on bone scan.
Again, clinically patient is asymptomatic.
NO BIOPSY !
Dr Ahmed Esawy

26. Bone Islands
Always asymptomatic.
Can it be metastatic disease? (especially when as large as the one we just looked at?)
Two distinguishing characteristic
A. Oblong in shape with long axis is along the axis of stress.
B. Margins show bony trabeculae extending from the lesion into normal bone in a spiculated
fashion.
Dr Ahmed Esawy

27. Bone Island
Spiculated appearance of bony trabeculae
Extending from the bone island
Dr Ahmed Esawy

28. Unicameral bone cyst
 Characteristic location – anteroinferior portion
of the calcaneus
 Only differential is psedocyst of the calcaneus.
Dr Ahmed Esawy

29. Dr Ahmed Esawy

30. Unicameral bone cyst
Dr Ahmed Esawy

31. Early Bone Infarct
Mixed lytic-sclerotic pattern which can resemble a permeative process.
Consider the diagnosis for patients with sickle cell anemia or systemic lupus erythematosus.
MRI can be helpful to avoid biopsy due to the characteristic serpiginous pattern
Dr Ahmed Esawy

32. MRI of Bone Infarction
Dr Ahmed Esawy

33. Bone Infarction
Dr Ahmed Esawy

34. Sorry, not bone infarct!!
Enchondroma
Bone Infart!
Dr Ahmed Esawy

35. Dr Ahmed Esawy

36. Miscellaneous
non-touch Bone Lesions
 Achondroplasia
 Avascular necrosis
 Hypertrophic pulmonary osteoarthropathy
 Melorheostosis
 Mucopolysaccharidoses
 Multiple Hereditary Exostosis
 Osteoid Osteoma
 Osteopathia Striata
 Osteopoikilosis
 Pachydermoperiostosis
 Sarcoidosis
 Transient Osteoporosis of the hip
Dr Ahmed Esawy

37. Melorheostosis
Thickened cortical new bone that accumulates near the ends of long bones, usually only on
one side of the bone
“Dripping candle wax”
Can be symptomatic
Dr Ahmed Esawy

38. Hypertrophic pulmonary osteoarthropathy
Manifested by clubbing of the fingers and periostitis
May or may not be associated with bone pain.
Associated with lung cancer, bronchiectasis, GI
disorders, and liver disease.
The actual mechanism of formation of periostitis
secondary to a distant malignancy or other process is
unknown.
Differential diagnosis for periostitis in a long bone
without an underlying bony abnormality would
include :
venous stasis
thyroid acropachy
Pachydermoperiostosis
trauma
Dr Ahmed Esawy

39. Achondroplasia
The most common cause of dwarfism is achondroplasia
Congenital, hereditary disease of failure of endochondral bone formation.
Characteristic finding is that the spine typically has narrowing of the interpedicular
distances in a caudal direction
Achondroplasia causes rhizomelic dwarfism
Dr Ahmed Esawy

40. Achondroplasia
 Narrowed AP canal.
 Scalloped posterior vertebra
Dr Ahmed Esawy

41. Patient on steroids AVN
Lack of blood supply with subsequent bone death
and ensuing bony collapse in an articular surface
Etiology of AVN most commonly includes trauma,
steroids, aspirin, collagen vascular diseases,
alcoholism, and idiopathic causes
Dr Ahmed Esawy

42. Avascular Necrosis
Dr Ahmed Esawy

43. Avascular Necrosis
Early
Late
Dr Ahmed Esawy

44. Hurler Syndrome
central anterior projection or “beak” off the vertebral body, as viewed on a lateral plain film
Dr Ahmed Esawy

45. Morquio
Dr Ahmed Esawy

46. Hurler
 Notch at base of 5th MCB
Dr Ahmed Esawy

47. Transient Osteoporosis of the Hip
7 month later
Dr Ahmed Esawy

48. Multiple Hereditary Exostosis
diaphyseal aclasia
Dr Ahmed Esawy

49. Multiple Hereditary Exostosis
Dr Ahmed Esawy

50. Osteoid Osteoma
Dr Ahmed Esawy

51. Osteoid Osteoma
Dr Ahmed Esawy

52. Osteopathia Striata
Also known as Voorhoeve disease
This disorder is manifested by multiple 2- to 3-mm-thick linear bands of sclerotic bone aligned
parallel to the long axis of a bone
It usually affects multiple long bones and is asymptomatic; hence, it is usually an incidental finding.Dr Ahmed Esawy

53. Osteopoikilosis
Clue: Patient is asymptomatic
Osteopoikilosis is an hereditary, asymptomatic disorder that is usually an incidental finding of
multiple small (3 to 10 mm) sclerotic bony densities affecting primarily the ends of long bones and
the pelvis
It has no clinical significance other than that it can be confused for diffuse osteoblastic metastases.
Dr Ahmed Esawy

54. Sarcoid
When sarcoid affects the musculoskeletal system is involved, the hands are most often affected,
with the spine and long bones only infrequently involved.
Sarcoid causes a characteristic lacelike pattern of bony destruction in the hands.
Multiple phalanges are typically affected in either one or both hands.
Auntminnie diagnosis. Dr Ahmed Esawy

55. Hyoid bone:
 The hyoid bone is considered a lingual bone
 The hyoid bone consists of a central body and paired lateral
greater and lesser horns
 The line of fusion of the body and greater horns of the hyoid
bone should not be mistaken for a fracture
Dr Ahmed Esawy

56.  Normal lucency (white arrowhead) between the
body and greater cornus of the hyoid bone is
seen. Large arrow, omohyoid muscle; small arrow
platysma muscle. Dr Ahmed Esawy

57. GOODBYE AND GOOD
IMAGING!
Dr Ahmed Esawy

58. Accessory bones of the foot
 21 accessory bones of the foot have been discovered (includes the sesamoid
bones)
 25% of the feet of adults and 22% of the feet of children under 16 years of
age have roentgenographic evidence of one or more accessory bones.
 Os trigonum – lokal pain (simptomatic treatment, excission)
 Accessory Navicular bone – local tenderness from pressure of the shoe (
excision of bone and fixation of the posterior tibial tendon)
os tibiale
externum
os
peroneum
Accessory
Navicular
Os
Trigonum
Os
vesalinum
Dr Ahmed Esawy

59. Os Styloideum (Carpal Boss)
Dr Ahmed Esawy

60. os trigonum
Dr Ahmed Esawy

61. Os calcaneus secundarius
Dr Ahmed Esawy

62. Accessory Navicular (Os Tibiale
Externum, Os Naviculare
Secundarium)
Dr Ahmed Esawy

63.  type II accessory navicular (arrow) articulating with the medial aspect
of the navicular bone, with irregular articulating surfaces and
osteophytes
Dr Ahmed Esawy

64.  lateral radiographs show fragmentation/fracture of an os peroneum (arrows)
and a transverse fracture of the fifth metatarsal base (arrowheads).
 The os peroneum is an oval or round ossicle located within the substance of
the distal peroneus longus tendon near the cuboid.
Dr Ahmed Esawy

65. Os Intermetatarseum
 os intermetatarseum situated between the first and second
metatarsal bases (arrow). Dr Ahmed Esawy

66. Hallux Sesamoids
 transverse fracture through the central portion of the tibial hallux
sesamoid bone, with mild distraction of the 2 fragments (arrows).Dr Ahmed Esawy

67. Hallux Sesamoids
Dr Ahmed Esawy

68. CHRONIC HINDFOOT PAIN
 SUSPECT:
 Calcaneus stress fx
 Talar neck stress fx
 Subtalar arthritis
 Painful os trigonum
 Haglund’s deformity
 Tarsal coalition (Calcaneonavicular
coalition seen on foot oblique),
Obtain foot 3-v as well
 Calcaneus 2-v
 Lateral, Harris-Beath
 ACR: 9
Dr Ahmed Esawy

69. Incidental
finding on
knee xray
Fabella = posterior sesmoids or
little confused knee caps
Dr Ahmed Esawy

70. Os Acromiale
Dr Ahmed Esawy

71. Os Subfibulare: Case report of a
painful fibular accessory ossicle
 The AP and Oblique radiograph showing a large accessory ossicle or os subfibulare to the
tip of the lateral malleolus. The accessory ossicle is at the anterior medial portion of the
malleolus giving it a bifid appearance.
Dr Ahmed Esawy

72.  CT images show a fibular ossicle or os subfibulare at the
distal end of the fibular with pseudo-arthrosis.
Dr Ahmed Esawy

73.  3-dimensional CT reveals a large accessory ossicle or
os subfibulare to the tip of the lateral malleolus with
pseudo-arthrosis of the fragment
Dr Ahmed Esawy

74.  Illustration of lateral foot shows os peroneum (white
arrow) and peroneus longus tendon (black arrows.)
Dr Ahmed Esawy

75. fracture of os peroneum and full-thickness tear of peroneus longus tendon .Dr Ahmed Esawy

76. os peroneum fracture and full-thickness peroneus longus tendon tear .(
Dr Ahmed Esawy

77. fracture of os peroneum and full-thickness peroneus longus tendon tear .(
Dr Ahmed Esawy

78. Unipartite os peroneum
Dr Ahmed Esawy

79. Bipartite os peroneum .
Dr Ahmed Esawy

80.  We have reviewed a spectrum of pathology
involving accessory ossicles and sesamoid bones.
These normal anatomic variations may, in fact,
represent the source of patient symptomatology.
The identification of key imaging characteristics
can help determine whether or not to attribute
clinical symptoms to these structures
Dr Ahmed Esawy