UNC MSK Course Day 5 Lab XR UNKNOWNS (for self study)

2. UNC MSK Course Day 5 Lab XR UNKNOWNS (for self study)

3. UNC MSK Course Day 5 Lab XR Location of lesion in bone Epiphyseal Metaphyseal Diaphyseal

4. UNC MSK Course Day 5 Lab XR • Location of lesion in bone • Epiphyseal • Giant cell tumor (adults) • Chondroblastoma (children) • Metaphyseal • All others not listed above or below • Diaphyseal • Osteomyeliltis • Ewing’s Sarcoma • Fibrous Dysplasia • Paget’s disease (actually throughout bone)

5. UNC MSK Course Day 5 Lab XR • Location in bone • Central • Unicameral bone cyst • Enchondroma • Peripheral • Non-ossifying fibroma • Osteoid osteoma • Expanding the bone • Aneursymal bone cyst (not taught in MSK) • Pagets • Outside the bone • Osteochondroma • Osteosarcoma

6. UNC MSK Course Day 5 Lab XR Location in body (can occur elsewhere but have a predilection for) Hand/foot Proximal humerus At rapidly growing physes of long bones

7. UNC MSK Course Day 5 Lab XR • Location in body (can occur elsewhere but have a predilection for) • Hand/foot • Enchondroma • Proximal humerus • Unicameral bone cyst • At rapidly growing physes of long bones (near knee, far from elbow) • Osteosarcoma

8. UNC MSK Course Day 5 Lab XR Location in body (can occur elsewhere but have a predilection for) Where there is red marrow Central skeleton

9. UNC MSK Course Day 5 Lab XR • Location in body (can occur elsewhere but have a predilection for) • Where there is red marrow (central bones including proximal femur and humerus) • Metastases • Multiple myeloma (later in disease, the destruction of the centrally located hematogenous marrow causes marrow metaplasia from fatty back to hematogenous in the long bones and subsequent spread of myeloma to limbs) • Central skeleton • Chondrosarcoma (as opposed to enchondroma, so that a cartilage lesion in the pelvis is much more likely to be malignant than one in the finger)

10. UNC MSK Course Day 5 Lab XR • Patient age (most can occur at other ages but more common at age listed • Child • Adolescent

11. UNC MSK Course Day 5 Lab XR • Patient age (most can occur at other ages but more common at age listed • Child • Rhabdosaroma • Unicameral (solitary) cyst • Osteomyelitis (hematogenous) • Adolescent • Osteosarcoma • Chondroblastoma • Osteochondroma (discovered in adolescence or as young adult) • Non-ossifying fibroma

12. UNC MSK Course Day 5 Lab XR • Patient age (most can occur at other ages but more common at age listed • Young adult • Middle age to elderly

13. UNC MSK Course Day 5 Lab XR • Patient age (most can occur at other ages but more common at age listed • Young adult • Giant cell tumor • Ewing’s sarcoma • Osteoid osteoma • Middle age to elderly • Metastases • Multiple myeloma • Chondrosarcoma • Paget’s disease • Malignant fibrous histiocytoma

14. UNC MSK Course Day 5 Lab XR • Lesion descriptors on XR • “reactive rim of sclerotic bone” - • “bone destruction with no reactive rim” – • “mottled and moth eaten” – • “punched out holes in bone” – • “marrow cavity continues into lesion” – • “onion skinning” – • “Codman’s triangle” – • “ground glass appearance” –

15. UNC MSK Course Day 5 Lab XR • Lesion descriptors on XR • “reactive rim of sclerotic bone” - benign • “bone destruction with no reactive rim” – malignant • “mottled and moth eaten” – osteomyelitis • “punched out holes in bone” – myeloma • “marrow cavity continues into lesion” – osteochondroma • “onion skinning” – layered new bone caused by peeling up of the periosteum due to rapid tumor growth (common in Ewing’s but can occur in other malignancies). • “Codman’s triangle” – new bone triangle that occurs at the corner of where the periosteum is stripped as above (common in osteosarcoma but can occur in other malignancies). • “ground glass appearance” –the lesions in fibrous dysplasia.

16. UNC MSK Course Day 5 Lab XR • Lesion descriptors on XR • “lucent nidus with reactive rim of sclerotic bone” - • “central in bone” – • “peripheral or cortical” – • “respects the disc space” - • “destroying the disc space” – • “sunburst” – • “Calcification” –

17. UNC MSK Course Day 5 Lab XR • Lesion descriptors on XR • “lucent nidus with reactive rim of sclerotic bone” - osteoid osteoma • “central in bone” – unicameral bone cyst and enchondroma • “peripheral or cortical” – osteoid osteoma and non-ossifying fibroma • “respects the disc space” (destroys bone but not the IVD) – malignancy (avoids the disc as it is avascular). • “destroying the disc space” – infection (prefers the disc because it is avascular). • “sunburst” – exploding rays of new bone outside the original bone, common to osteosarcoma. • “Calcification” – enchondroma, can be told from ossification because there are no trabeculae (a speckled, “snowflake” appearance is common)

18. UNC MSK Course Day 5 Lab XR • Lesion descriptors on XR • “hypertrabeculation” - • “blastic” – • “lytic” – • “bone within a bone” – • “sequestrum” – • “involucrum” –

19. UNC MSK Course Day 5 Lab XR • Lesion descriptors on XR • “hypertrabeculation” - Paget’s disease • “blastic” – the lesion is making new bone, common to osteosarcoma, prostatic metastases and occasionally breast metastatses. • “lytic” – the lesion is destroying bone, common in malignancy and infection • “bone within a bone” – appearance of one vertebra inside another common in Paget’s disease of the spine • “sequestrum” – a fragment of dead bone walled off inside an infection • “involucrum” – new bone formed around a sequestrum.

20. Age 50 Pathology?

21. Age 50 • Pathology? • Benign appearing (sclerotic rims) • Metaphyseal • Calcified • Central

22. Age 50 • Pathology? • Benign appearing (sclerotic rims) • Metaphyseal • Calcified • Central • Enchondroma

23. Age 25 Pathology?

24. Age 25 Pathology? “bone destruction with no reactive rim” “onion skinning” “Codman’s triangle”

25. Age 25 Pathology? Diaphyseal “bone destruction with no reactive rim” “onion skinning” “Codman’s triangle” Ewing’s Sarcoma (Differential should include infection)

26. Age 50 Pathology?

27. Age 50 Pathology? “punched out holes in bone” Proximal humerus

28. Age 50 Pathology? “punched out holes in bone” Proximal humerus Multiple Myeloma

29. Age 25 Pathology?

30. Age 25 Pathology? “diaphyseal lesion” “reactive rim of sclerotic bone” “ground glass appearance”

31. Age 25 Pathology? Diaphyseal “reactive rim of sclerotic bone” “ground glass appearance” Fibrous dysplasia

32. Age 30 Pathology?

33. Age 30 Pathology? epiphyseal “Sclerotic rim”

34. Age 30 Pathology? Lesion in epiphysis Sclerotic rim Giant Cell Tumor

35. Age 60 Pathology?

36. Age 60 Pathology? “respects the disc space”

37. Age 60 Pathology? “respects the disc space” (cancer) Multiple myeloma (differential would include severe osteoporosis and metastatic disease)

38. Age 20 Pathology?

39. Age 20 Pathology? Eccentric Reactive rim sclerotic bone Shortly after physeal closure

40. Age 20 Pathology? Eccentric Reactive rim sclerotic bone Shortly after physeal closure Non-ossifying fibroma

41. Age 25 Pathology?

42. Age 25 Pathology? Old fracture present “sequestrum” “involucrum”

43. Age 25 Pathology? Old fracture present “sequestrum” “involucrum” Post traumatic osteomylitis

44. Age 16 Pathology?

45. Age 16 Pathology? “marrow cavity continues into lesion” Outside the bone Discovered during growth spurt. Stalk pointing away from growth plate.

46. Age 16 Pathology? “marrow cavity continues into lesion” Outside the bone Discovered during growth spurt. Stalk pointing away from growth plate. Osteochondroma

47. Age 17 Pathology?

48. Age 17 Pathology? “sunburst” “blastic” Outside the bone

49. Age 17 Pathology? “sunburst” “blastic” Outside the bone Osteosarcoma

50. Age 45 Pathology?