Diagnostic Imaging of Musculoskeletal Diseases: A Systematic Approach · Akbar Bonakdarpour, MD William R. · Reinus, MD Jasvir S. Khurana, MD Editors Diagnostic Imaging of Musculoskeletal Diseases A Systematic Approach 1 3 Editors AkbarBonakdarpour WilliamR.Reinus DepartmentofRadiology DepartmentofRadiology TempleUniversityHospital TempleUniversityHospital 3401N.BroadStreet 3401N.BroadStreet Philadelphia,PA19140-5189 Philadelphia,PA19140-5189 USA USA [email protected] [email protected] JasvirS.Khurana,MD DepartmentofPathology TempleUniversityHospital 3401N.BroadSt. Philadelphia,PA19140-5189 USA [email protected] ISBN978-1-58829-947-5 e-ISBN978-1-59745-355-4 DOI10.1007/978-1-59745-355-4 SpringerNewYorkDordrechtHeidelbergLondon LibraryofCongressControlNumber:2009935060 ©SpringerScience+BusinessMedia,LLC2010 Allrightsreserved.Thisworkmaynotbetranslatedorcopiedinwholeorinpartwithoutthewrittenpermissionofthe publisher(SpringerScience+BusinessMedia,LLC,233SpringStreet,NewYork,NY10013,USA),exceptforbrief excerptsinconnectionwithreviewsorscholarlyanalysis.Useinconnectionwithanyformofinformationstorageand retrieval,electronicadaptation,computersoftware,orbysimilarordissimilarmethodologynowknownorhereafter developedisforbidden. Theuseinthispublicationoftradenames,trademarks,servicemarks,andsimilarterms,eveniftheyarenotidentified assuch,isnottobetakenasanexpressionofopinionastowhetherornottheyaresubjecttoproprietaryrights. Whiletheadviceandinformationinthisbookarebelievedtobetrueandaccurateatthedateofgoingtopress,neither theauthorsnortheeditorsnorthepublishercanacceptanylegalresponsibilityforanyerrorsoromissionsthatmay bemade.Thepublishermakesnowarranty,expressorimplied,withrespecttothematerialcontainedherein. Printedonacid-freepaper SpringerispartofSpringerScience+BusinessMedia(www.springer.com) Preface We dedicate this text to Drs. Ernest E. Aegerter, a pathologist, and John A. Kirkpatrick Jr., a radiologist. They were among the principal founders of the field of skeletal pathology and radiology.Duringtheirtime,theirresidentsandcolleaguesknewthemasgreateducatorswith a dedication and a passion for their work. Their textbook, Orthopedic Diseases, published initiallyin1958wasamongthefirstinterdisciplinaryworksdevotedtothisfield.Dr.Aegerter andDr.Kirkpatrickilluminatedmanyaspectsofthefieldofradiology.Today,withtheadvent ofnewtechnologies,thisfieldhasgrowntoincludenotonlydiseasesthataffecttheskeleton but also those that affect muscles, ligaments, tendons, and also the cartilaginous structures withinjoints. Withthistext we intend to carryon Dr. Aegerter and Dr. Kirkpatrick’s tradition. We have recruited only well-known musculoskeletal radiologists and pathologists to participate in the writingofthisbook.Eachauthorhasbeencarefullyselectedforhisexpertiseonthetopicabout which he’s been asked to contribute. Each author is known as an experienced and seasoned teacher.Eachauthorhasmadeamarkonthefield. With this talent we aim to lay the foundation of a useful and worthy teaching text. Our goal is to create a textbook that is at once readable by the radiology resident experiencing musculoskeletalradiologyforthefirsttimeandthoroughenoughtobeusedbythepracticing radiologist.Wedonotintend,however,topresentanexhaustivereferencework.Weleavethat tasktootherauthors. Instead we aim to provide a text that not only conveys important information about com- monandsomelesscommonmusculoskeletaldiseases,butmoreimportantlyprovidesapracti- calandsystematicapproachtoanalyzingdiseasesofbones,muscles,tendons,ligaments,and joints.Wewillprovidewitheachcategoryameansbywhichtoconceptualizeandanalyzehow pathologychangestheirappearanceonmedicalimages. To meet these goals we have organized this text according to major categories of disease: trauma,infection,tumorsandtumor-likeconditions,metabolicdiseases,endocrinedisorders, dysplastic diseases, and arthritis. Where disease categories overlap, e.g., intraosseous tophus orbrowntumorofbone,wediscussthosepointsundereachappropriateheading.Wherethere isdebateastotheetiologyofadisease,wealsodiscusstheseissuesguidingthereader,tothe bestofourability,towhatcurrentthinkinghastosayaboutthatdisease. Wealsoincludeachapterthatexaminesbasicinterventionaltechniquesthatapplytomus- culoskeletal imaging. Again, the idea is not to provide an exhaustive reference on any one technique, but instead to give the reader a primer on these techniques and their indications withguidanceforfindingfurtherinformation. Finally,inrecognitionoftheimportanceoforthopedicprocedures,weincludeinformation ontheuse,imagingappearance,andpathologyaffectingprosthesesandfixationdevices.This informationisessentialtothepracticeofmodernradiology. Wehopethatthereaderwillbothenjoyreadingthistextandfindtheexperienceprofitable to their knowledge base, both in fact and in concept. We look forward to receiving readers’ impressions,criticisms,andsuggestionstoimprovethistextinfutureeditions. v vi Preface ErnestE.Aegerter JohnA.Kirkpatrick AkbarBonakdarpour Philadelphia,PA WilliamR.Reinus JasvirS.Khurana Contents 1 BoneStructureandFunction . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 FayezF.SafadiandJasvirS.Khurana 2 SystematicApproachtoMetabolicDiseasesofBone . . . . . . . . . . . . . . 15 AkbarBonakdarpour 3 SystematicApproachtoRadiologyofEndocrineDisordersAffecting theMusculoskeletalSystem . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 AkbarBonakdarpourandColleenVeloski 4 CirculatoryDiseasesofBoneandAdjacentSoftTissues . . . . . . . . . . . . 99 WilfredC.G.PehandSeoung-OhYang 5 ImagingApproachtoMusculoskeletalTrauma . . . . . . . . . . . . . . . . . 125 WilliamR.Reinus 6 ImagingandUnderstandingFractureFixation . . . . . . . . . . . . . . . . . 203 BahmanRafiee 7 SystematicApproachtoTumorsandFocalLesionsofBone . . . . . . . . . . 241 ShigeruEharaandJasvirS.Khurana 8 Systematic Approach to Tumors and Tumor-Like Conditions ofSoftTissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313 TheodoreT.Miller,CarolynM.Sofka,PaulZhang, andJasvirS.Khurana 9 ImagingApproachtoHemoglobinopathies . . . . . . . . . . . . . . . . . . . . 351 AvneeshChhabraandWilliamR.Reinus 10 ImagingApproachtoMusculoskeletalInfections . . . . . . . . . . . . . . . . 363 WilliamR.Reinus 11 SystematicApproachtoArthropathies . . . . . . . . . . . . . . . . . . . . . . 407 WilliamR.Reinus 12 ImagingofProstheses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497 SayedAliandWilliamR.Reinus 13 Systematic Approach to Skeletal Dysplasias with Emphasis onNon-lethalDisorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 527 AkbarBonakdarpour 14 InterventionalProceduresinMusculoskeletalRadiology . . . . . . . . . . . . 599 JamshidTehranzadeh,ScottSeibert,andAfshinGangi SubjectIndex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 635 vii Contributors SayedAli,MD Assistant Professor, Department of Radiology, Temple University School ofMedicine,Philadelphia,PA,USA,[email protected] ∗ AkbarBonakdarpour,MD,MS(Radiology),FACR W.EdwardChamberlainProfessorof Radiology,EmeritusProfessorofRadiologyandFormerChiefofMusculoskeletalRadiology, FormerProfessorofOrthopedicSurgery,TempleUniversitySchoolofMedicine,Philadelphia, PA,USA,[email protected] AvneeshChhabra,MD Assistant Professor, Department of Radiology, Johns Hopkins SchoolofMedicine,Baltimore,MD,USA,[email protected] ∗ ShigeruEhara,MD ProfessorandChair,DepartmentofRadiologyIwateMedicalUniver- sitySchoolofMedicine,Morioka,Japan,[email protected] AfshinGangi,MD,PhD Professor of Radiology, University Hospital of Strasbourg, Stras- bourg,France ∗ JasvirS.Khurana,MD Associate Professor, Department of Pathology, Temple University SchoolofMedicine,Philadelphia,PA,USA,[email protected] ∗ TheodoreT.Miller,MD,FACR ProfessorofRadiology,WeillMedicalCollegeofCornell University,NewYork;AttendingRadiologist,DepartmentofRadiologyandImaging,Hospital forSpecialSurgery,NewYork,USA,[email protected] ∗ WilfredC.G.Peh, MBBS, MHSM, MD, FRCPG, FRCPE, FRCR Clinical Professor, NationalUniversityofSingapore,Singapore,RepublicofSingapore;SeniorConsultantRadi- ologist,AlexandraHospital,Singapore,RepublicofSingapore,[email protected];wil- [email protected] BahmanRafiee,MD Assistant Professor, Musculoskeletal Division, Department of Radiol- ogy,UniversityofPittsburgh,Pittsburgh,PA,USA,rafi[email protected];rafi[email protected] ∗ WilliamR.Reinus,MDMBAFACR ViceChairmanandProfessor,DepartmentofRadio- logy; Chief, Musculoskeletal Radiology Temple University, Temple University School of Medicine,Philadelphia,PA,USA,[email protected] FayezF.Safadi,PhD AssociateProfessor,DepartmentofAnatomyandCellBiology,Temple UniversitySchoolofMedicine,Philadelphia,PA;AdjunctAssociateProfessor,Departmentof Cell and Developmental Biology, Weill Cornell Medical College in Qatar, Education City, Doha,Qatar,[email protected] ScottSeibert,MD St. Mary’s Medical Center, San Francisco Orthopaedic Residency Pro- gram,SanFrancisco,CA,scottyfi[email protected] ix x Contributors ∗ CarolynM.Sofka,MD Associate Professor of Radiology, Weill Medical College of Cor- nell University, New York; Associate Attending Radiologist, Department of Radiology and Imaging,HospitalforSpecialSurgery,NewYork,USA ∗ JamshidTehranzadeh,MD VALongBeachHealthCareSystem,DMMHealthCareGroup #05/114,5901E.7thStreetLongBeach,CA90822USA,[email protected] ColleenVeloski,MD Assistant Professor, Department of Endocrinology and Metabolism, TempleUniversitySchoolofMedicine,Philadelphia,PA,USA,[email protected] Seoung-OhYang,MD,PhD Professor, Department of Radiology, Eulji University School ofMedicine,Daejeon,SouthKorea,[email protected] PaulZhang,MD AssociateProfessorofPathology,HospitaloftheUniversityofPennsylva- nia,Philadelphia,PA,USA ∗DenotesmemberoftheInternationalSkeletalSociety Chapter1 Bone Structure and Function FayezF.SafadiandJasvirS.Khurana Abstract This chapter discusses the normal structure and Introduction function of the skeleton and the various ways it is regu- lated. The skeleton is both an organ and a type of con- TheSkeleton nective tissue. Knowledge of its various identifiable parts greatly facilitates an understanding of skeletal function and alsothediseaseprocessesthatcanoccur.Normally,themajor Apart from functioning as a major endocrine, hematopoi- skeletal processes of resorption and formation are tightly etic, and reticuloendothelial organ, the skeleton serves as coupled. This feature plays a role in the normal function the body’s structural support and locomotion system. It has of skeletal renewal. Disturbances of the remodeling cycle mechanisms to grow and change in shape and size to suit can be seen in a number of generalized skeletal disorders varying stressors including the ability to resist mechanical including metabolic bone disease and conditions such as forces. It is also a major organ in the homeostasis of cal- Paget disease. This chapter discusses the macroscopic and cium/phosphate balance and in the detoxification of heavy microscopic anatomy of the skeleton as well as its bio- metals. chemical makeup. It introduces the emerging information Bone tissue is continuously formed and remodeled about the molecular control of bone cells and the skeletal throughout life. This is necessary since otherwise it would processes. fatiguewiththedailyrepetitivestressandtorsionofmotion andweightbearing. Keywords Remodeling • Coupling • Formation • Resorp- Initially, the bone achieves its increase in size and shape tion • Mineralization • Cortical • Trabecular • Epiph- throughgrowth(increaseinsize)andmodeling.Inlatechild- ysis • Metaphysis • Diaphysis • Periosteum • Endosteum • hoodandadulthoodthereiscontinuousrenewaloftheskele- Woven • Lamellar • Osteoblasts • Osteoclasts • Receptor ton, by a process termed remodeling. Both modeling and activator of nuclear factor kappa B (RANK) • Transform- remodeling require two separate processes, namely bone ing growth factor-beta (TGF-β) • Bone morphogenetic pro- resorptionandboneformation,tooccurincoordinationand teins (BMPs) • Platelet-derived growth factors (PDGFs) • simultaneously to be effective. This phenomenon is known Insulin-like growth factors (IGFs) • Calcium hydroxyap- as“coupling.” atite • Collagen • Alkaline phosphatase • Glycosaminogly- cans • Proteoglycans • Non-collagenous proteins • Osteo- BoneFormationandDegradation pontin • Osteocalcin • Vitamin D • Vitamin A • Estrogen • Androgen•Parathyroidhormone•Wolff’slaw The major functions of bone cells include matrix forma- tion(osteogenesis),mineralization,anddegradation(resorp- tion). Because formation and resorption are antagonistic processes that proceed simultaneously, bone metabolism must be tightly regulated at all times. During the first two decades of life when the skeleton is growing, there is a net increase in bone mass such that bone formation exceeds its degradation. Once the skeleton has reached maturity, the F.F.Safadi((cid:2)) skeleton maintains a constant balance between formation DepartmentofAnatomyandCellBiology,TempleUniversitySchool and resorption to ensure that there is no net gain or loss of ofMedicine,Philadelphia,PA19140,USA e-mail:[email protected];[email protected] bone; this regulated balance is called coupling. Uncoupling A.Bonakdarpouretal.(eds.),DiagnosticImagingofMusculoskeletalDiseases:ASystematicApproach, 1 DOI10.1007/978-1-59745-355-4_1,©SpringerScience+BusinessMedia,LLC2010