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© 4 June 2014

Musculoskeletal Specialty Review

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Slide 2

Musculoskeletal Specialty Review:

Christopher Cerniglia, DO, MEngChief, Division of Musculoskeletal ImagingDepartment of RadiologyUMass Memorial Medical CenterProgram Director, Musculoskeletal FellowshipAssociate Director, Radiology Residency ProgramUniversity of Massachusetts Medical School

Trauma & Tumors

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Slide 3 Outline

• Cases

• Trauma

• Tumors

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Slide 4

4 June 2014

CASES

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Slide 5 Case 1

• Hx: Trauma

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Slide 6 Case 1

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Slide 7 Question 1

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Slide 8 Case 2

• Pain s/p trauma

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Slide 9 Case 2

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Slide 10 Question 2

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Slide 11 Case 3

• Hx: Clip injury while playing football

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Slide 12 Case 3

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Slide 13 Question 3

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Slide 14 Case 4

• Palpable Mass x 1 month

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Slide 15 Case 4

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Slide 16 Question 4

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Slide 17 Case 5

• Slowly Enlarging Palpable Mass

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Slide 18 Case 5

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Slide 19 Question 5

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Slide 20 Case 6

• Medial Volar Hand Mass

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Slide 21 Case 6

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Slide 22 Question 6

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Slide 23 Case 7

• 51 year old female with several week history of knee pain.

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Slide 24 Case 7

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Slide 25 Question 7

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Slide 26 Case 8

• 40 year old with right thigh pain

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Slide 27 Case 8

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Slide 28 Question 8

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Slide 29 Trauma & Sports Injuries

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Slide 30 TRAUMA

• Axial Trauma

– Spine

– Pelvis

• Appendicular Trauma

– Upper Extremity

– Lower Extremity

• Sequela & Complications

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Slide 31 TRAUMA

• Axial Trauma

– Spine

– Pelvis

• Appendicular Trauma

– Upper Extremity

– Lower Extremity

• Sequela & Complications

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Slide 32 SPINE

• Mechanism of injury – Flexion – Extension – Axial load/burst – Distraction – Translation

• Fracture/ligament injury patterns • Column concept/stability

– Cervical – Thoracic – Lumbar – Sacrum/coccyx

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Slide 33

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Slide 34 MECHANISM OF INJURY

• Flexion/Extension

– E.g. Teardrop Fx

• Axial Load/Distraction

– E.g. Compression Fx

• Rotation

• Translation

• MIXED

– E.g. Hangman (Distraction/Extension)

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Slide 35 FLEXION

• Hyperflexion Sprain (Ant Subluxation)

• Anterior Wedge Fx

• Clay Shoveler’s Fx

• B/L Interfacetal Dislocation

• Flexion Teardrop Fx

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Slide 36 Anterior Wedge Fx

• Loss of height of anterior vertebral body

• Buckled anterior cortex

• Anterior superior Fx of VB• C/W Burst NO Vertical Fx Component

NO Post cortical Involvement

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Slide 37

7/1/2014 37

Seatbelt Fracture

• Secondary to hyperflexion at the waist :– Anterior

compression of the vertebral body

– Distraction of posterior elements and ligaments

• Usually involves T12, L1, or L2

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Slide 38

7/1/2014 38

Bilateral Locked Facets

• There is hyperflexion, the spinous process is distracted, facets override, and the spine recoils

• 50% vertebral body displacement anteriorly

Unstable

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Slide 39 Flexion Teardrop• Teardrop fragment

anterior vertebral body avulsion fracture

• All ligaments are disrupted

• Posterior subluxation of vertebral body into the spinal canal often leads to Spinal cord compression

• Spinous Process Fx

Image: c/o Spencer B. Gay, MD Univ of Virginia Health System

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Slide 40 EXTENSION

• C1 anterior arch Avulsion Fx

• C1 posterior arch Fx

• Extension Teardrop Fx

• Laminar Fx

• Hangman’s Fx

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Slide 41 ANSWER 1

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Slide 42 Hangman’s Fracture

• Extension & Distraction of C2 from MVA/Hanging

• B/L C2 pars (common) or pedicle fx

• Anterior sublux of C2 can occur

• Ant Inf corner Fx C2 can occur (ALLig)

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Slide 43 AXIAL LOAD

• Jefferson Fx

• Compression Fx

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Slide 44 Jefferson’s Fx

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Slide 45

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Slide 46 Jefferson Fx

• Fracture of C1 vertebra• Axial loading with neck extended• Transverse ligament integrety

determines stability• Open mouth view- lateral masses

of C1 align with lateral masses of C2

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Slide 47 MIXED/OTHER

• Unilateral Facet

• Odontoid Fracture

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Slide 48 Unilateral Facet

• MIXED Severe flexion associated with rotation

• Results in:

– Rupture of Facet joint ligaments

– Facet joint dislocation

• 25 % anterior vertebral body displacement

• “Bow tie” appearance on lateral radiograph

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Slide 49 Unilateral Facet

• MIXED Severe flexion associated with rotation

• Results in:– Rupture of Facet

joint ligaments – Facet joint

dislocation

• 25 % anterior vertebral body displacement

• “Bow tie” appearance on lateral radiograph

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Slide 50 Unilateral Facet

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Slide 51 Odontoid Fx

• Type 1

– Fx upper dens

– Rare

• Type 2

– Fx at base of dens

• Type 3

– Base and body of C2

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Slide 52 DISH/AS

• Be careful with ankylotic and fused spine

• Significant Injury with Minor Trauma

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Slide 53

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Slide 54 TRAUMA

• Axial Trauma

– Spine

– Pelvis

• Appendicular Trauma

– Upper Extremity

– Lower Extremity

• Sequela & Complications

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Slide 55 Sacral Insufficiency Fracture

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Slide 56 Pelvic Fx

• Stable– Single break of ring

• Unilateral Pubic Rami (PR)

– Peripheral Fx• Avulsions

– ASIS, AIIS, IT, Pubus

• Unstable– 2 breaks in ring– Malgaigne: SI & Ipsilateral

PR– Bucket: SI & Contralateral

PR– Straddle: B/L Opterator

Rings– Dislocation: SI and

symphysis

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Slide 57 TRAUMA

• Axial Trauma

– Spine

– Pelvis

• Appendicular Trauma

– Upper Extremity

– Lower Extremity

• Sequela & Complications

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Slide 58 Upper Extremity Trauma

• Clavicle & AC joint

• Shoulder & GH joint

• Elbow

• Forearm

• Wrist

• Hand

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Slide 59 Clavicle and AC joint

• Grades of acromioclavicular joint separation

• Clavicle fracture

• Sternoclavicular fracture / dislocation

• Post-traumatic osteolysis

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Slide 60 AC Separation

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Slide 61 Clavicle Fracture

• Nonunion and malunion greatest at central 1/3 of clavicle

• Allman Classification

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Slide 62 SC Fracture/Dislocations

• Direct Impact

• Anterior MC

• Posterior LC

– Risk for vascular injury

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Slide 63 Post Traumatic Osteolysis

• Common repetitive trauma/overuse

• Weightlifters

• DDX:– B/L:

Hyperparathyroidism/RA/Scleroderma

– U/L: Infection/Tumor/Surgery

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Slide 64 Upper Extremity Trauma

• Clavicle & AC joint

• Shoulder & GH joint

• Elbow

• Forearm

• Wrist

• Hand

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Slide 65 Shoulder

• Anatomic vs. surgical neck humerusfracture

• Greater tuberosity humerus fracture • Scapular fracture

– Body – Glenoid

• Dislocations – Anterior

• (a) Hill Sachs fracture • (b) Bankart fracture • (c) Recurrence

– Posterior • (a) Reverse Bankart• (b) Neurovascular injuries

– Other• Inferior• scapulothoracic dissociation*

• Rotator cuff tear • Labral injury

– Patterns of instability – SLAP tear

• Proximal biceps tear or dislocation • Impingement syndrome

– Anterior – Posterior – Coracoid

• Adhesive capsulitis

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Slide 66

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Slide 67 Greater Tuberosity Fx

• Post dislocation

• Avulsion fractures of RTC

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Slide 68 Anterior Dislocation

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Slide 69 Anterior Dislocation

Hill-Sachs Deformity Bankart Lesion

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Slide 70 Anterior Dislocation

• Indirect force from

– abduction,

– external rotation and

– extension

• Best demonstrated on AP internal rotation view

• Recurrence is common after first dislocation

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Slide 71 Posterior Dislocation

• Direct or Indirect force a/w seizures or electrical shock

• Fixed Internal Rotation

• No overlap of humerus

• + Rim Sign

• +/- Trough Sign

• +/- Reverse Bankart

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Slide 72 Inferior Dislocation

• Luxatio Erecta

• Risk of injury to:

– Ax artery

– Brachial Plexus

– Rotator Cuff

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Slide 73 Pseudo-dislocation

• Inferior and lateral displacement of humeral head due to hemarthrosis

• Often occurs in fractures of the humeral head or neck

• NOT a true dislocation

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Slide 74 RTC

• SS, IS, TM = GT

• SubS = LT

• AH interval <6mm Chronic RCT

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Slide 75

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Slide 76 FT Supraspinatus Ter

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Slide 77 FT Tear Junctional Fibers SS-IS

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Slide 78 Labral Injuries

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Slide 79 Labral Injuries

SLAP

• Type I Fraying

• Type II Tear SL

• Type III bucket handle of SL

• Type IV Tear SL w/biceps involvment

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Slide 80 Prox Biceps Tear/Dislocation

• A/W Labral tear

• Often degenerative in etiology c/w distal biceps often traumatic

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Slide 81 Impingement

• Suprascapular Notch

• Spinoglenoid Notch

• Quadrilateral Space Syndrome

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Slide 82 Quadrilateral Space Syndrome

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Slide 83 Adhesive Capsulitis

• Acute/Subacute phase

PD FSE w/wo FS

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Slide 84 Adhesive Capsulitis

• Chronic phase

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Slide 85 Upper Extremity Trauma

• Clavicle & AC joint

• Shoulder & GH joint

• Elbow

• Forearm

• Wrist

• Hand

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Slide 86 Elbow

• Radial head fracture

• Fracture/dislocation

• Humeral condyle fractures

• Extensor tendinosis (tennis elbow/lateral epicondylitis)

• Flexor tendinosis (pitcher’s elbow/medial epicondylitis)

• Ulnar collateral ligament tear

• Radial collateral ligament tear

• Biceps avulsion

• Triceps avulsion

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Slide 87 Radial Head/Neck Fx

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Slide 88 Posterior Elbow Dislocation

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Slide 89 Lateral Epicondylitis

• Tennis Elbow• Degeneration and Tearing of CET

(ECU, EDC, and ECRB)• Overuse injury

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Slide 90 RCL tear

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Slide 91 RCL Tear

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Slide 92 UCL tear

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Slide 93 Biceps Tendon Tear

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Slide 94

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Slide 95 Post Tendon Repair

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Slide 96 Upper Extremity Trauma

• Clavicle & AC joint

• Shoulder & GH joint

• Elbow

• Forearm

• Wrist

• Hand

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Slide 97 Forearm

• Galeazzi fracture/dislocation

• Monteggia fracture/dislocation

• Isolated ulna (nightstick) fracture

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Slide 98 Galeazzi fracture-dislocation

Fx RADIUS with Dislocation at DRUJ.Galeazzi fractures have a peak incidence of 9-12 years of age.

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Slide 99 Monteggia fracture-dislocation

• Fracture of the ulna diaphysis & dislocation of radial head

• Detect Ulnar Fx -> Look to radial head – can miss disloc

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Slide 100 Night Stick Fracture

Isolated ulnar shaft fracture

Most commonly a/wself defense against blunt trauma

Force is to the medial forearm as the arm is used to shield head and body

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Slide 101 Essex-Lopresti Fracture

• Comminuted fracture of the radial head

• Dislocation of the DRUJ

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Slide 102 Buckle and Greenstick Fractures

• Distal radius Buckle (Torus) fractures very common injuries in children.

• Quick to heal

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Slide 103 Forearm

• Galeazzi fracture/dislocation

• Monteggia fracture/dislocation

• Isolated ulna (nightstick) fracture

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Slide 104 Upper Extremity Trauma

• Clavicle & AC joint

• Shoulder & GH joint

• Elbow

• Forearm

• Wrist

• Hand

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Slide 105 Wrist

• Colles fracture • Smith fracture• Radial styloid fracture • Isolated carpal bone fracture

– Scaphoid fracture • Significance of blood supply • Osteonecrosis• Non-union

– Triquetral fracture – Hamate fracture – Other

• Complex carpal bone injuries – Perilunate dislocation – Lunate dislocation

• Ligament tears – Interosseous ligaments – Triangular fibrocartilage

complex – Extrinsic ligaments

• Chronic carpal instability – Dorsal intercalated segment

instability – Volar intercalated segment

instability – Scapholunate advanced

collapse

• Distal radioulnar joint injury • Carpal tunnel syndrome • Ulnar impaction syndrome

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Slide 106 Colles Fracture

• MC Fx distal radius.• Transverse Fx of

distal radial metaphysis

• Dorsal angulationand displacementof the distal fragment.

• Typically produced by a fall on an outstretched hand, with the wrist dorsiflexed.

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Slide 107 Smith Fracture

• Reverse Colles fracture with fracture of the metaphysis and volarangulation of the distal fracture fragment.

• Younger patients results from extensive traumatic forces on the volar flexed wrist.

• Volar comminution is common.

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Slide 108 Smith Fracture

• Type 1: Horizontal Fx line

• Type 2: Oblique Fx line

• Type 3: Intra-articularoblique (Reverse Bartons)

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Slide 109 Chauffeur Fracture

• Chauffeur aka Hutchinson or Backfire fracture consists of an oblique, intraarticular fracture of the distal radius involving the radial styloid. Displaced fracture fragments indicates disruption of intercarpal ligaments.

•

• The name originates from documented injuries while cranking backfiring automobile starters in the early 20th century. This fracture is classically a shearing force transmitted through the scaphoid or scapholunateinterval.

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Slide 110 Chauffeur Fracture

Intra-articular fracture of the distal radius involving the radial styloid.

Displaced fracture fragments indicates disruption of intercarpal ligaments

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Slide 111 Scaphoid Fracture

• Most common carpal fracture

• At risk of AVN, especially at proximal pole

• 65%: waist

• 15%: proximal pole

• 10%: distal body

• 8%: volar tuberosity

• 2%: through the distalarticular surface

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Slide 112 Scaphoid Fracture

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Slide 113 Lunate Fracture

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Slide 114 Triquetral Fracture

• Common at dorsal surface

• Avulsions from ligamentousattachments

• Dorsal avulsion best detected on a lateral projection

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Slide 115 Hamate Fractures

BODY HOOK

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Slide 116 Hamate Hook Fracture

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Slide 117 Other Carpal Fracture

• Capitate fx = rare; high suspicion

• Trapezoid are rare due to stabilization from its articulations, and may be associated with a dislocation of the second metacarpal.

• Pisiform (sesamoid bone) within FCU tendon and injury often occurs in the setting of direct trauma. – vertical,

– transverse

– or a compressive

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Slide 118 Pisiform Fracture

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Slide 119 Answer 2

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Slide 120 Carpal Arcs

Arc 1

Arc 2

Arc 3

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Slide 121

• Perilunate dislocation (lesser arc injury) is a pure ligamentous disruption around the lunate.

• Perilunate dislocation with associated fracture of one or more bones around the lunate (scaphoid, trapezium, capitate, hamate, or triquetrum) is called a greater arc injury.

• Perilunate injuries result from high-energy wrist hyperextension, typically falls from a height, motor vehicle collisions, or sports-related injuries.

Perilunate injury: Greater and Lesser Arcs

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Slide 122 Perilunate injury: Greater and Lesser Arcs

• Lesser Arc injuries (ligamentous)

– Scapholunate

– Perilunate

– Midcarpal

– Lunate

• Greater Arc injuries (ligamentous with adjacent fractures)

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Slide 123 Lesser Arc InjuryStage I: Scapholunate Dissociation

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Slide 124 Lesser Arc Injury Stage II: Perilunate

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Normal Comparison

Stage 2 lesser arc with associated fractures/greater arc disrpution

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Slide 125 Trans Styloid Perilunate Dislocation

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Slide 126 Lesser Arc Injury Stage III: Midcarpal

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Slide 127 Lesser Arc Injury Stage IV: Lunate

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Slide 128 Stage IV: Trans-ScaphoidLunate Dislocation

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Slide 129 SLAC Wrist

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Slide 130 SLAC: Watson Classification

• Stage I Arthritis between scaphoidand radial styloid

• Stage II Arthritis between scaphoidand entire scaphoidfacet of the radius

• Stage III Arthritis between capitateand lunate

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Slide 131 Wrist

• Colles fracture • Smith fracture• Radial styloid fracture • Isolated carpal bone fracture

– Scaphoid fracture • Significance of blood supply • Osteonecrosis• Non-union

– Triquetral fracture – Hamate fracture – Other

• Complex carpal bone injuries – Perilunate dislocation – Lunate dislocation

• Ligament tears – Interosseous ligaments – Triangular fibrocartilage

complex – Extrinsic ligaments

• Chronic carpal instability – Dorsal intercalated segment

instability – Volar intercalated segment

instability – Scapholunate advanced

collapse

• Distal radioulnar joint injury • Carpal tunnel syndrome • Ulnar impaction syndrome

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Slide 132 Upper Extremity Trauma

• Clavicle & AC joint

• Shoulder & GH joint

• Elbow

• Forearm

• Wrist

• Hand

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Slide 133 Hand

• Phalanx fracture / dislocation – Intra vs. extra articular– Volar plate fracture – Tuft fracture

• Metacarpal fracture – Bennett vs. Rolando fracture – Boxer fracture

• Carpometacarpal dislocation • Tendon injuries • Pulley injuries • Capsular and collateral ligament injuries

– Gamekeeper (skier) thumb – Metacarpophalangeal joint

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Slide 134

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Slide 135 TRAUMA

• Axial Trauma

– Spine

– Pelvis

• Appendicular Trauma

– Upper Extremity

– Lower Extremity

• Sequela & Complications

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Slide 136 Lower Extremity Trauma

• Hip

• Femur

• Knee

• Ankle

• Foot

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Slide 137 Hip & Femur

• Acetabular fracture - fracture patterns

• Hip dislocation - risk of osteonecrosis

• Femoral neck fracture

• Intertrochanteric fracture

• Femoral head fracture

• Labral injury

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Slide 138 Lower Extremity Trauma

• Hip

• Femur

• Knee

• Ankle

• Foot

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Slide 139 Patellar Fx post Dislocation

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Slide 140 Patellar Dislocation

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Slide 141 Discoid LM

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Slide 142 Bucket Handle

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Slide 143 Radial Tear

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Slide 144 Horizontal Oblique Tear

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Slide 145 Parrot-beak

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Slide 146 IT Band Syndrome

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Slide 147 Displaced Meniscal Fragments

• Anterior Flipped LM

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Slide 148 Answer 3

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Slide 149 ACL

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Slide 150 Knee

• Femoral condyle fracture • Tibial plateau fracture • Knee dislocation • Patella fracture • Patella dislocation • Meniscal injury

– Bucket handle tear – Parrot-beak tear – Horizontal oblique tear – Horizontal cleavage tear – Vertical longitudinal tear – Radial tear – Complex tear – Root tear – Meniscocapsular separation – Fraying and degeneration – Displaced fragments – Meniscal cyst

• Ligament injury – Anterior cruciate– Posterior cruciate– Medial collateral – Lateral collateral

• Extensor mechanism injury – Quadriceps tear – Patellar tendon (ligament) tear – Retinaculum injury

• Posterolateral corner injury – Popliteus muscle/tendon – Arcuate ligament* – Popliteofibular ligament* – Fabellofibular ligament*

• Articular cartilage injury • Overuse injuries

– Plica syndrome – Iliotibial band friction syndrome – Pes anserine bursitis

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Slide 151 Lower Extremity Trauma

• Hip

• Femur

• Knee

• Ankle

• Foot

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Slide 152 Ankle Foot

• Mechanisms of injury • Pilon fracture • Tilleaux fracture • Maisonneuve fracture • Ligament injury

– Anterior talofibular ligament – Deltoid ligament – Syndesmotic/anterior

tibiofibular ligament

• Talar fracture – Dome fracture – Neck fracture – Lateral process fracture

• Calcaneal fracture - anterior process fracture

• Fifth metatarsal base fracture

• Metatarsal fracture • Lisfranc fracture/dislocation • Phalanx fracture • Cuboid fracture • Navicular fracture

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Slide 153 Lisfranc

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Slide 154 TRAUMA

• Axial Trauma

– Spine

– Pelvis

• Appendicular Trauma

– Upper Extremity

– Lower Extremity

• Complications

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Slide 155 FRACTURE COMPLICATIONS

IMMEDIATE• Hemorrhage/Epidural

Hematoma• Fat Embolism• Acute Ischemia• Spinal Cord Injury

DELAYED• Malunion• Nonunion • Premature physeal

closure • Osteonecrosis

– Femoral head – Scaphoid proximal pole – Talar dome

• Infection • Arthritis

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Slide 156

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Slide 157 AVN scaphoid

• Post fracture

• AVN of scaphoid without prior fx:

– Preiser Dz

• DDx fx nonunion without avn

• Typically prox pole waist fxand nonunion

• T1C+ indicates viable marrow

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Slide 158 Osteonecrosis

• Femoral Head

• Scaphoid

• Talar dome

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Slide 159

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Slide 160 OTHER TRAUMA

• Stress injuries (bone and soft tissue) – Mechanisms

– Pathophysiology

– Epidemiology

– Imaging diagnosis

– Implications for treatment

• Repetitive trauma– Tendinosis

– Enthesophytes

– Other

• Soft tissue injuries – Grades of muscle tear

– Grades of ligament tear

– Myositis ossificans

• Thermal trauma – Burns

– Cold injury

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Slide 161 Answer 4

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Slide 162

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Slide 163

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Slide 164 Tenosynovitis 2nd EC

• EXTENSOR CARPI RADIALIS LONGUS AND BREVISTENOSYNOVITIS

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Slide 165

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Slide 166 BREAK

• End Part 1: Trauma• Begin Part 2: Tumor after the break

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Slide 167

• Insert Picture

Tumors

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Slide 168 Answer 5

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Slide 169

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Slide 170 Answer 6

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Slide 171 Answer 7

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Slide 172 Answer 8

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Slide 173 EG

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Slide 174 BONE

• Clinical: Age & Symptoms

• Tumor Location

• Tumor Matrix

• Tumor Aggressiveness

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Slide 175 PEARLS: AGE

• AGE < 30

– Infection

– EG

– ABC

– NOF

– Chondroblastoma

– UBC

• AGE > 40

– Mets

– Myeloma

– Infection

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Slide 176 PEARLS: Symptoms

• PAINLESS

– FD

– Enchondroma

– NOF

– UBC

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Slide 177 PEARLS: Location

• Epiphysis

– Infection

– GCT

– Chondroblastoma

– Infection

– Geode

– Mets/Infiltrative

– CCC

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Slide 178 PEARLS: Symptoms

• PAINLESS

– FD

– Enchondroma

– NOF

– UBC

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Slide 179 Lodwick

Classification

RADIOGRAPHS

• IA Geographic

– Well defined

– Sclerotic Rim

– Intact Cortex

• IB Geographic

– Well defined

– Non-sclerotic rim

– Thinning of Cortex

• IC Geographic

– Ill defined

– Non-sclerotic rim

– Penetration /Destruction of Cortex

• II Moth-eaten

– Lamellar/Onion-skin Rxn.

• III Moth-eaten and permeative

– Destruction

– Radial/Spicular rxn

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Slide 180 Lodwick

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Slide 181 CT/MRI - Bone

• CT:

– Matrix characterization

• MRI:

– Assessing the response to treatment

– Postchemotherapeutic MRI signal–intensity changes

– Detecting recurrence

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Slide 182 PEARLS: Multiple Osseous Lesions

• METS

• Myloma

• EG

• FD

• Enchondromas

• Brown Tumers

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Slide 183 Bone: BENIGN

• Cartilaginous

– Enchondroma

• Multiple (Ollier disease)

• Maffucci syndrome

– Osteochondroma - Multiple hereditary exostoses

– Chondromyxoid Fibroma

– Chondroblastoma

– Chondroma - Periosteal (surface, juxtacortical)

• Fibrous

– Fibroxanthoma (non-ossifying fibroma)

• Fibrous cortical defect

• Benign fibrous histiocytoma

– Fibrous dysplasia - McCune-Albright

– Chondromyxoid fibroma

– Desmoplastic fibroma

– Osteofibrous dysplasia (ossifying fibroma)*

• Osteogenic

– Enostosis (bone island) - Multiple

– Osteoma - Multiple

– Osteoid osteoma

– Osteoblastoma

• Lipoid

– Lipoma

– Liposclerosing myxofibrous tumor (LSMFT)*

• Vascular

– Hemangioma - Multiple (Osler-Weber- Rendu)

– Hemophilic pseudotumor

– Lymphangioma

– Glomus tumor

– Hemangiopericytoma*

– Gorham disease*

• Other

– Unicameral bone cyst (simple bone cyst)

– Aneurysmal bone cyst

• (a) Primary

• (b) Secondary

– Giant cell tumor of bone

– Langerhans cell histiocytosis (eosinophilicgranuloma)

– Chordoma

– Intraosseous ganglion

– Reactive lesions

• Giant cell reparative granuloma

• Bizarre parosteal osseous proliferation (BPOP)*

• Epidermoid inclusion cyst

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Slide 184 Enchondroma

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Slide 185 MHE

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Slide 186 Periosteal Chondroma

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Slide 187 Periosteal Chondroma

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Slide 188 Periosteal Chondroma

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Slide 189

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Slide 190

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Slide 191

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Slide 192 Osteoid Osteoma

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Slide 193 Surface Osteoma

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Slide 194

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Slide 195

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Slide 196

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Slide 197

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Slide 198 EG

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Slide 199 Bone: BENIGN

• Cartilaginous

– Enchondroma

• Multiple (Ollier disease)

• Maffucci syndrome

– Osteochondroma - Multiple hereditary exostoses

– Chondromyxoid Fibroma

– Chondroblastoma

– Chondroma - Periosteal (surface, juxtacortical)

• Fibrous

– Fibroxanthoma (non-ossifying fibroma)

• Fibrous cortical defect

• Benign fibrous histiocytoma

– Fibrous dysplasia - McCune-Albright

– Chondromyxoid fibroma

– Desmoplastic fibroma

– Osteofibrous dysplasia (ossifying fibroma)*

• Osteogenic

– Enostosis (bone island) - Multiple

– Osteoma - Multiple

– Osteoid osteoma

– Osteoblastoma

• Lipoid

– Lipoma

– Liposclerosing myxofibrous tumor (LSMFT)*

• Vascular

– Hemangioma - Multiple (Osler-Weber- Rendu)

– Hemophilic pseudotumor

– Lymphangioma

– Glomus tumor

– Hemangiopericytoma*

– Gorham disease*

• Other

– Unicameral bone cyst (simple bone cyst)

– Aneurysmal bone cyst

• (a) Primary

• (b) Secondary

– Giant cell tumor of bone

– Langerhans cell histiocytosis (eosinophilicgranuloma)

– Chordoma

– Intraosseous ganglion

– Reactive lesions

• Giant cell reparative granuloma

• Bizarre parosteal osseous proliferation (BPOP)*

• Epidermoid inclusion cyst

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Slide 200 Bone: MALIGNANT

• Cartilaginous - Chondrosarcoma– Central – Peripheral – Dedifferentiated – Mesenchymal– Clear cell

• Fibrous – Fibrosarcoma– Malignant fibrous histiocytoma

• Osteogenic - Osteosarcoma– Conventional – Surface

• Periosteal• Parosteal• High grade surface

– Telangiectatic– Low grade central

• Vascular – Angiosarcoma– Hemangioendothelioma

• Other – Chordoma– Multiple myeloma (plasmacytoma) – Ewing sarcoma – Primitive neuroectodermal tumor

(PNET) – Adamantinoma– Lymphoma – Leukemia

• chloroma

SECONDARY• Radiation• Pagets• Metastatic

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Slide 201

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Slide 202

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Slide 203 Bone: MALIGNANT

PRIMARY• Cartilaginous - Chondrosarcoma

– Central – Peripheral – Dedifferentiated – Mesenchymal– Clear cell

• Fibrous – Fibrosarcoma– Malignant fibrous histiocytoma

• Osteogenic - Osteosarcoma– Conventional – Surface

• Periosteal• Parosteal• High grade surface

– Telangiectatic– Low grade central

• Vascular – Angiosarcoma– Hemangioendothelioma

• Other – Chordoma– Multiple myeloma (plasmacytoma) – Ewing sarcoma – Primitive neuroectodermal tumor

(PNET) – Adamantinoma– Lymphoma – Leukemia

• Chloroma

SECONDARY• Radiation• Pagets• Metastatic

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Slide 204 SOFT TISSUE

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Slide 205 Soft Tissue: BENIGN

• Fibrous – Fibroma– Fibromatosis– Desmoid– Elastofibroma

• Neural – Neurofibroma– Schwannoma– Neurofibromatosis – Neuroma– Lipomatosis of nerve (fibrolipomatous

hamartoma) – Post-resection neuroma– Morton neuroma

• Cartilaginous - soft tissue chondroma• Vascular

– Hemangioma– Hemangioendothelioma– Glomus tumor – Vascular malformations – Lymphangioma

• Lipoid – Lipoma– Angiolipoma– Hibernoma– Lipoblastoma

• Muscle – Rhabdomyoma– Leiomyoma

• Dermal/subcutaneous – Sebaceous cyst – Dermatofibroma– Granuloma annulare– Granular cell tumor*

• Other – Myxoma– Giant cell tumor of tendon sheath – Pigmented villonodular synovitis– Ganglion

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Slide 206 Desmoid Tumor

• Plantar Fibromatosis

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Slide 207 Elastofibroma

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Slide 208

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Slide 209 Neuroma

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Slide 210 Atypical Lipoma

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Slide 211 Epidermal Cyst

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Slide 212

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Slide 213

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Slide 214

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Slide 215 Soft Tissue: BENIGN

• Fibrous – Fibroma– Fibromatosis– Desmoid– Elastofibroma

• Neural – Neurofibroma– Schwannoma– Neurofibromatosis – Neuroma– Lipomatosis of nerve (fibrolipomatous

hamartoma) – Post-resection neuroma– Morton neuroma

• Cartilaginous - soft tissue chondroma• Vascular

– Hemangioma– Hemangioendothelioma– Glomus tumor – Vascular malformations – Lymphangioma

• Lipoid – Lipoma– Angiolipoma– Hibernoma– Lipoblastoma

• Muscle – Rhabdomyoma– Leiomyoma

• Dermal/subcutaneous – Sebaceous cyst / Epidermoid cyst– Dermatofibroma– Granuloma annulare– Granular cell tumor*

• Other – Myxoma– Giant cell tumor of tendon sheath – Pigmented villonodular synovitis– Ganglion

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Slide 216 Soft Tissue: MALIGNANT

PRIMARY• Fibrosarcoma• Malignant fibrous histiocytoma

(high-grade undifferentiated pleomorphic sarcoma)

• Synovial sarcoma • Rhabdomyosarcoma• Malignant peripheral nerve

sheath tumor • Liposarcoma

– (a) Myxoid– (b) Well-differentiated – (c) Dedifferentiated

• Melanoma

SECONDARY• Metastasis • Leukemia • Lymphoma • Soft tissue extension of bone

lesion

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Slide 217 High Grade Sarcoma

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Slide 218 Synovial Sarcoma

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Slide 219

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Slide 220 Lymphoma

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Slide 221 Soft Tissue: MALIGNANT

• Fibrosarcoma• Malignant fibrous histiocytoma (high-

grade undifferentiated pleomorphicsarcoma)

• Synovial sarcoma • Rhabdomyosarcoma• Malignant peripheral nerve sheath tumor • Epithelioid sarcoma* • Liposarcoma

– (a) Myxoid– (b) Well-differentiated – (c) Dedifferentiated

• Dermatofibrosarcoma protuberans* • Alveolar soft part sarcoma* • Myxofibrosarcoma* • Soft tissue osteosarcoma* • Kaposi sarcoma* • Melanoma

• Metastasis • Leukemia • Lymphoma • Soft t

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Slide 222

Thank You

Contact/Questions:

Christopher.Cerniglia@umassmed.edu

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