Radiology and Musculoskeletal Disease

Question One

Describe the fracture on the following slide in terms below:

• Views
• Type of bone
• Adult
• Pediatric
• Osteoporotic
• Location of fracture
• Fracture plane
• Joint involvement
• Dislocation
• Angulation
• Translation
• Rotation
• Varus/valgus
• Underlying pathology

Question Two

Put the 4 following images below or order of their healing and give the phase of healing.

• Inflammatory
• Reparative (soft callus)
• Hard callus
• Remodeling

Case One

11 year old presents with left wrist pain for one month. Outside radiographs obtained.

Case One - Question One

Given the lesion of the distal radius, would you put this lesion in aggressive or nonaggressive category and what are some of the reasons you used to make your decision.

These images will be used for the next 4 questions

Case One - Question Two

How is the tissue sample obtained? What procedure does the surgeon do?

1. Core needle biopsy
2. Curettage
3. Resection
4. Needle aspiration

Case One - Question Three

What is the type of involvement seen in the first micrograph?

1. Within marrow
2. Within cortical bone
3. Within blood vessels
4. In the periosteum

Case One - Question Four

What is the predominant cell type present in the marrow spaces?

1. Macrophages
2. Osteoclast
3. Neutrophil
4. Osteoblast

Case One - Question Five

How would you characterize the cancellous bone?

1. Too thick
2. Normal
3. Necrotic
4. Irregular shape

Case One - Question Six

What is the nature of the lesion shown in the gross photograph? Is it from the same case?

Case Two

22 year old man presents with leg pain to an outside institution. Two view knee radiographs were obtained.

Case Two - Question One

Where is the lesion? Is the lesion aggressive appearing?

1. Femoral Diaphysis
2. Femoral Epiphysis
3. Tibial Diaphysis
4. Tibial Epiphysis

A few days later he had minor trauma and developed severe left lower extremity pain.

Case Two - Question Two

What would you call this fracture?

1. Insufficiency fracture
2. Pathological fracture
3. Stress fracture
4. Compound fracture

Further workup included whole body bone scan, CT chest and MRI of the left femur. Based on initial tests the patient was worked up for a bone malignancy and received neoadjuvant chemotherapy. Prior to surgical resection he underwent a repeat MRI.

Case Two - Question Three

Which features in the above images make the lesion aggressive?

1. Size
2. Extent
3. Soft tissue component
4. Respect for bony confines
5. Involvement of neurovascular structures

Case Two - Question Four

What is the behavior of the tumor in the micrograph below?

1. Permative
2. Breaking through the cortex
3. Sclerosing
4. Lytic

Case Two - Question Five

What is the cellular composition of the tumor seen at higher power in the micrograph below?

1. Biphasic (two cell types)
2. Polymorphic (many different cell types)
3. Pleomorphic (single cell type many forms)
4. Rich in osteoclasts

Case Two - Question Six

Does this gross picture correlate with the imaging? Does this gross picture correlate with the micrographs you just saw? If not, what would you do?

Case Two - Question Seven

How do these two micrographs link the gross to the first micrographs? What histological elements do you see that establish the link?

Case Two - Question Eight

What is the element demonstrated by the slide below?

1. A lake of blood
2. Necrosis
3. Osteoid formation by tumor cells
4. Bone resporption

Case Three

49 yo presents with knee pain and swelling and sensation of an anterior mass. This is worsened by deep flexion and kneeling. No rest pain.

Case Three - Question One

Based on the X-ray and MRI images, where would you place the lesion? Discuss what possible entities could create the imaging appearance.

1. Extraarticular
2. Intraarticular
3. Femoral
4. Tibial

Case Three - Question Two

The gross specimen below shows which of the following?

1. Multiple inflammatory lesions
2. A fragmented tumor
3. An articular surface
4. Necrotic bone

Case Three - Question Three

Which tissue types do you see in the images below?

1. Bone marrow
2. Adipose tissue
3. FIbrocartilage
4. Hyaline cartilage
5. Synovial membrane

Case Three - Question Four

Based on the images above, how do these nodules get into the joint space? What effect do they produce?

Question Three

Establishing the location of a lesion/process is key in forming a differential diagnosis. Given what you know about positions of processes on a 2 dimensional picture, try and determine where the lesion is located on these views of the knee.

1. Cortical
2. Medullary
3. Surface of bone/periosteum
4. Extra-osseous

Question Four

Which case below would you describe as a fracture associated with osteoporosis?