Midwest Podiatry Conference Surgical Review Course Medical Imaging Daniel P.

Evans, DPM, FACPR

1. Medical Imaging A. Plain Film Radiographs Primary Podiatric Imaging Modality

B. Static Biomechanical Assessment C. Five Step Approach to Evaluation Film Quality Soft Tissue Bones and Bone Density Joints and Joint Spaces Biomechanical Assessment

D. Radiographic Evaluation of Arthritic Processes Degenerative Joint Disease Gouty Arthritis Rheumatoid Arthritis Psoriatic Arthritis E. Radiographic Evaluation of Infection Plain Film Analysis Nuclear Imaging C.T. Assessment MRI Assessment

F. Radiographic Evaluation of Neoplastic Processes Benign vs. Malignant Rate of Growth Evaluation of Tumor Matrix 2. Preparation for the Oral Exam

3. Questions and Answers

THE FIVE STEP APPROACH TO THE ANALYSIS OF PEDAL RADIOGRAPHS SCHOLL COLLEGE OF PODIATRIC MEDICINE DEPARTMENT OF RADIOLOGY
I. QUALITY II. SOFT TISSUE III. BONE AND BONE DENSITY IV. JOINTS AND JOTNT SPACES V. BIOMECHAMCAL EVALUATION I. QUALITY: Analysis of positioning and technical factors for the production of diagnostic film. Assess exposure factors - over, underexposure. Soft tissue technique Magnification Technique II. SOFT TISSUE: Evaluation of soft tissue contour and density A. Lesional Density: Air Fat Water Intermediate (pathological) Calcification Ossification Metallic Density B. Ossification vs. Calcification: Presence of absence of organized trabecular patterns and/or a cortical rim. C. Edema: Obstructive Inflammatory Traumatic D. Gas Abscess vs. Emphysema: (Self contained vs. Evidence of Malignant spread or deep facial involvement) E. Vascular Calcification: Phleboliths Varicose Veins Monckebergs Medial Calcinosis ASO Thrombophlebitis Venous Thrombosis

Hemosiderin Deposits F. Soft Tissue Calcification 1. Metastatic Calcification: Disturbance in calcium or phosphorus metabolism. (Hyperparathyroidism, Vitaminosis D, Renalosteodystrophy, Sarcoidosis, Metastatic CA) 2. Calcinosis: The deposition of calcium in skin and soft tissue in the presence of normal metabolism. 3. Dystrophic Calcification: Related to calcium deposits in damaged or devitalized tissue in the absence of a generalized metabolic derangement. G. Myositis Ossificans 1. Progressive Myositis Ossificans: Genetic dysplasia, progressive, may be fatal. 2. Myositis Ossificans Associated with Neurological Disorders. Rapid ossification developing below the level of the neurological lesion. No periosteal reaction. 3. Myositis Ossificans Post-Traumatica: Direct injury or repetitive trauma. Soil tissue mass consolidates and organizes into osseous mass. May mimic a tumor. H. Foreign Body Analysis: 1. Soft tissue technique 2. Tunnel Analysis (to minimize light effect and cone-in on affected area). 3. Needle Isolation of Foreign Body 4. Advanced Imaging Modalities: (Ultrasound, Xerography, C.T., M.R.I.) III. BONE AND BONE DENSITY A. Evaluation of Bone Density 1. Rule of Thirds 2. Rule of Halves 3. Calcaneal Index B. Systematic Evaluation of Radiographs. C. Risk Factors Associated with Osteoporosis: Body Size Estrogen Deficiency Age Cigarette Smoking Sex ETOH Intake Race Coexistent disease Diet Medication Activity Level D. Osteomalacia: Accumulation of high amounts of uncalcified osteoid.

E. Reflex Sympathetic Dystrophy 1. Stage One: Hyperasthesia, Edema, Hyperhydrosis. 2. Stage Two: Spotty Osteoporosis (Severe and Diffuse) 3. Stage Three: Marked Deossification, Joints may Ankylose.

F. Hyperparathyroidism 1. Primary, Secondary, Tertiary 2. Subperiosteal Bone Resorption 3. Brown Tumors G. Renal Osteodystrophy 1. Associated with chronic renal failure. 2. Bone resorption in 61% of the patients. H. Pagets Disease 1. Stages: Lytic Combined Sclerotic Malignant Degeneration 2. Involvement: Monostotic or Polyostolic. I. Avascular Necrosis: 1. Stages: Avascular Revascularization Bony Heating Residual Deformity J. Charcot Joint 1. German vs. French Theory 2. Hypertrophic and Atrophic 3. Atrophic: (NWBing Jts.) Licked Candy Stick Appearance 4. Hypertrophic: Six Ds: Radiographic Appearance: Destruction Density Increase Distention Debris Dislocation Disorganization 5. Stages: 1. Destructive 2. Coalescence 3. Reconstruction

IV. JOINTS AND JOINT SPACES A. Joint Status: 1. Congruent 2. Deviated 3. Dislocated 4. Distended 5. Diminished 6. Absent B. Coalitions: 1. Plain Film Analysis A. Joint Space Narrowing B. Angulation C. Adaptive Changes at Surrounding Joints D. Ball and Socket Ankle Joint E. Halo Effect 2. C.T. / M.R.I. Analysis A. Planar analysis of deformity. B. Assessment of tissue type of coalition (fibrous, cartilaginous, osseous), V. BIOMECHANICAL EVALUATION: (Proper positioning and tube angulation critical) A. Pre-Op Evaluation: IM Met. Protrusion Distance Hallux Abductus Met. Primus Elevatus Hallux Interphalangeus Joint Status PASA/DASA Sesamoid Position Metatarsus Adductus Bone Density Total Adductory Angle

REVIEW OF ARTHRITIC PROCESSES I. Rheumatoid Arthritis A. Early R.A.: May initially see joint space widening during the inflammatory process. Narrowing of the joint spaces, particularly T-N jt. Formation of pseudocysts in subchondral bone. Subluxations- metatarsal phalangeal, interphalangeal joints. B. Late R. A.: Fibular deviation of pedal digits, ulner deviation of hand digits. Flexion and extension contractures. Marked destruction and narrowing of joint spaces, Peri-articular osteopenia. Boney fusion and ankylosis.

II. Degenerative Joint Disease A. Mechanical wear and tear. Inflammatory Component. B. Radiographic Findings: (Hallux Limitus- classical example) Asymmetrical Joint Space Loss Osteophytes, Joint Mice Subchondral Cysts, Subchondral Sclerosis Eburnation Ill. Gouty Arthritis A. Primary Gout: Inborn error of Metabolism B. Secondary Gout: Medication or Disorder C. Hyperuricemia- Hallmark -Excessive Production of Purines -Diminished Excretion -Males> Females -4th-5th decade for male/ Postmenopausal for females. D. Radiographic Findings: Often no findings for up to 10 years. Marked Soft Tissue Inflammation. Joint Preservation Despite Severe Erosions. Extra-Articular Erosions (Martels Sign) Asymmetric, Polyarticular (1st MPJ)

IV. Psoriatic Arthritis A. Predilections:

Males > Females 2 - 6 % of patients with Psoriasis Can mimic RA Tends to effect distal joints. B. Radiographic Findings 1. Soft Tissue: Fusiform Sausage Toe 2. Osseous: Osteoporosis is not characteristic (unlike RA). Bone Erosion - esp. IPJ of Hallux and DIPJs of Digits Tuftal Erosion - Acro-osteolysis Bone Proliferation (Diagnostic Sign) Periosteal Whiskering Ivory Phalanx Deformity : Main-en-Lorgnette

V. Reiters Syndrome A. Feet Affected 80% Ankles, MPJs, Calcaneus B. Classic Triad: Urethritis Conjunctivitis Arthritis (May also have: Balanitis, Keratoderma Blennorhagicum) C. Heel Pain May be bilateral May be initial symptom Mild to incapacitating - Can last for years D. Radiographic Findings: (Non-Specific) Soft Tissue Swelling - sausage toe. Osteoporosis: Juxta-articular Joint space narrowing: Symmetrical, Small Joints. Bone Erosion: IPJ, MPJ Bone Proliferation: Phalanges, Metatarsals, Enthesis.

VI. D.I. S.H. (Disseminated Idiopathic Skeletal Hyperostosis) A. Incidence: Males > Females Elderly (over 50) Morning Stiffness and Back Pain 20 % have concurrent Diabetes Feet affected 70 % of the time. B. Radiographic Findings: Calcaneal Hyperostosis: Plantar Aponeurosis, Achilles Tendon Talar Beaking Fifth Metatarsal Base Distal Tuftal Enlargement

RADIOGRAPHIC EVALUATION OF INFECTIOUS PROCESSES I. Plain Film Analysis: A. Radiographic findings will lag clinical findings (7-10 days). B. Soft Tissue: Earliest findings - increase in density, loss of tissue planes. Soft tissue emphysema - air or gas in the soft tissue. C. Osseous: 1. Periosteal Activity 2. Cortical Disruption 3. Loss of Trabecular Patterns 4. Sclerosing Osteitis of Garre II. Nuclear Imaging: A. Uptake is dependent on intact vascular supply and rate of boney turnover. B. Isotopes: Technetium-99, Gallium-67, Indium-III, Ceretec (Tc labeled WBC S) C. Phases: Blood Flow - (Vascular Angiogram, immediate post injection) Blood Pool - (Highlights soft tissue involvement) Bone Imaging - (3-4 hours post injection, highlights bone turnover) Delayed Bone Imaging - 24 hours post inj. allows for S.T. clearance. D. Sequencing of Scans: Technetium prior to Gallium due to long half-life of Ga. III. C.T. Evaluation of infection: A. May overestimate the extent of soft tissue infection. B. Assists in evaluation of deep compartment involvement. C. Identifies cortical thickening, extent of cortical disruption. D. Assists in determining extent of infectious process. IV. M.R.I. Evaluation of Infection: A. Decrease in marrow signal intensity on T-l weighted image. B. Increase in marrow signal intensity on T-2 weighted image. C. M.R.I. does not distinguish between a septic and inflamed joint. D. Cortical evaluation difficult with M.R.I. E. STIR Image for assessment of inflammatory response, bone marrow edema.

RADIOGRAPHIC EVALUATION OF NEOPLASTIC LESIONS I. Evaluation of Lesion: A. Initial Plain Film Analysis B. C.T., M.R.I., Nuclear Imaging for further evaluation. II. Benignity vs. Malignancy A. Evaluate lesion examining borders, aggressiveness, cortical thinning, periosteal reaction, and associated soft tissue mass. B. Assess rate of growth of lesion. 1. Permeative - mets., primary malignancies. 2. Moth eaten 3. Geographic - most commonly associated with benign tumors and cysts. III. Evaluate as to Location of Lesion A. Metaphyseal B. Diaphyseal C. Epiphyseal IV. Evaluation of Lesions based on Tissue Matrix A. Cartilaginous B. Osseous C. Fibro-osseous V. Cartilaginous Lesions A. Enchondroma 1. Benign cartilaginous lesion. 2. Location- medullary space of small tubular bones. Lesion may have punctate calcifications, may be expansile with cortical thinning and possible fracture. 3. Olliers Disease - Multiple enchondromatosis. 4. Maffuccis Syndrome - Mult. Ench. with soft tissue hemangiomas. B. Chondroblastoma 1. Location - epiphysis. Lytic lesion. 2. Symptoms - may exhibit joint pain due to location. 3. Males:Females 2:1 Teens to late 20s. C. Osteochondroma 1. Benign lesion composed of bone and cartilage. Lesion has cortical surface which is continuous with the surrounding bone. Generally project away from the nearest joint. 2. May be stalked, pedunculated, or plateau in shape. D. Chondrosarcoma 1. Malignant neoplasm of cartilaginous origin. 2. May be primary or arise from an existing lesion.

3. Radiographic Findings: Often large, lucent lesions with punctate calcifications. May exhibit assoc. S.T. mass as well as cortical disruption, periosteal rxn. VI. Osseous Lesions A. Osteoid Osteoma 1. Highly symptomatic lesion - esp. at night. Pain relieved by ASA. 2. Males: Females 2:1 3. Radiographic Appearance: Lesion <1cm. Central nidus of osteoid surrounded by reactive sclerosis which may extend far beyond the lesion B. Osteoblastoma 1. Often referred to in literature as Giant Osteoid Osteoma. 2. Radiographic Appearance: Large geographic lesion with lucent matrix. Rarely have surrounding sclerosis. C. Osteosarcoma 1. Age: 10-25 2. Location: Distal Femur, Proximal Tibia, Pelvis. (Metaphyseal region). 3. Radiographic Appearance: Marked lysis and destruction of bone, with cortical loss, periosteal activity. May have assoc. large S.T. mass. VII. Fibrous Lesions A. Non-ossifying Fibromas & Benign Cortical Defects 1. Benign fibrous lesions. 2. Very Common - est. 30 - 40 % of all children have at least one. Spontaneously involute and regress. 3. NOFs - Located eccentrically in the medullary space. BFCJYs - Arise in the cortex. May appear Flame-like. B. Fibrous Dysplasia 1. Benign fibro-osseous lesion. 2. Radiographic Appearance: Ground Glass. Medullary, geographic. 3. Allbrights Syndrome A. Endocrine dysfunction - precocious puberty. B. Cafe au lait spots. C. Fibrosarcoma 1. Fibrous Malignant Lesion 2. 3rd - 6th decade. 3. Radiographic Appearance: lytic destructive lesion without internal matrix density changes. Found in metaphysis of long bones. VIII. Other Neoplastic Lesions A. Unicameral Bone Cyst 1. Benign cyst like lesion - common in calcaneus. 2. Males: Females 2; 1 Asymptomatic, however may fracture. 3. Radiographic Appearance: Geographic, lytic lesion which may have thin sclerotic rim. 4. Fallen fragment or Fallen leaf sign.- Amorphous, dense area located

within cyst. May appear as a true fracture fragment or as a precipitant or agglutination type of phenomena. B. Aneurysmal Bone Cyst 1. Benign cyst like lesion. 2. More aggressive in appearance. Aspiration- blood or blood tinged serous fluid. 3. Radiographic Appearance: Lytic expansile lesion. Cortises may thin or bulge as cyst develops. Often loculated or compartmentalized. May fx. C. Giant Cell Tumor 1. Locally aggressive lesion. 2. Potential for malignant degeneration. 3. Location: Metaphyseal or epiphyseal. May give joint symptomatology. 4. Radiographic Appearance: Aggressive lytic lesion. May have cortical disruption, soft tissue mass. IX. Primary or Metastatic A. Look for Evidence of Other Lesions 1. Chest X-Ray 2. Bone Scan 3. Nuclear Imaging 4. C.T. 5. M.R.I. B. Multiple sites of involvement C. Similar Lesions of Differing Sizes D. Presentation: Male Lytic Lung Kidney Bladder Colon Blastic Prostate Breast GI Tract Mixed Lung

Female Breast Lung Kidney Uterus-Cervix Breast GI Tract Breast Uterus-Cervix

Midwest Podiatry Conference Surgical Board Review Course Mock Examination Questions Dr. Daniel P. Evans Medical Imaging 1. You are examining the radiographs of a 24 year old white female with a chief complaint of pain in her right ankle. Radiographs are obtained and a lesion is noted in the distal fibula. The lesion is oval, measuring 2cm x 1cm with a thin sclerotic rim surrounding the lesion. There is no evidence of cortical disruption or periosteal activity. The lesion has a matrix with punctuate areas of marked increase in density surrounded by areas of marked radiolucency. The lesion appears to be centered within the distal epiphyseal region. Which of the following is the most likely diagnosis for the lesion described above? A. Enchondroma B. Osteoid osteoma C. Chondroblastoma D. Osteosarcoma E. Chondrosarcoma (For questions 2,3.) A fifty-nine year old white male presents to your office complaining of a painful left heel. Radiographs are obtained and the following is noted: a well defined circumscribed lesion within the left calcaneus. The lesion is located inferior to the sustentaculum tali and measures 3cm x 2cm. The lesion is lucent, without evidence of trabecular patterns. In the center of the lesion there is noted to be a focal area of increased density which is consistent with bone. 2. Which of the following diagnosis would be least likely to be consistent with the above presentation? A. Unicameral bone cyst B. Aneurysmal bone cyst C. Intraosseus lipoma D. Fibrous dysplasia E. lntraosseous ganglion 3. You decide to order an MRI to further evaluate the above patients lesion. When assessing the MRI you note a marked increase in signal intensity on a T-l weighted image as well as a marked decrease in signal intensity on a T-2 weighted image. Which of the above diagnosis is most consistent with these findings?

4. A 60 year old Hispanic male presents to your office for evaluation. He complains of arthritis in my right foot. Physical examination of the involved extremity shows intact pedal pulses. Mild forefoot edema is noted. The right hallux is markedly edematous. Radiographs demonstrate the following: an increase in soft tissue density involving the right hallux with evidence of cystic changes and bone destruction affecting the interphalangeal joint of the right hallux. A mild amount of periosteal activity is noted at the interphalangeal joint area. Also noted is resorption of the distal tuftal region of the distal phalanges of the hallux, second and third digits. Taking into account the above information, which of the following is the most likely diagnosis which would account for these findings? A. Rheumatoid arthritis B. Gouty arthritis C. Ankylosing spondylitis D. Osteoarthritis E. Psoriatic arthritis

ANSWERS: 1. 2. 3. 4. C D C E