Biomedical subjects
Publications and source records attributed to D Resnick.
Three cases are presented in which unusual healing patterns of pubic features simulated malignant processes. Consideration of trauma as an etiologic factor in such cases may obviate the need for extensive clinical and histologic evaluation.
This report describes 2 patients in whom focal areas of decreased 99mTc sulfur colloid marrow activity were associated with callus formation and healing rib fractures in one case and rib fractures with bony bridging in the second. Since bone marrow scans are occasionally used to select appropriate sites for marrow biopsy in patients with suspected metastatic disease, radiographic correlation of "cold" lesions on marrow scans is recommended prior to biopsy to exclude fracture with callus formation as a benign cause of the abnormality.
A comprehensive anatomic, pathologic and radiographic study of the adult hip was undertaken to define bony landmarks which, when altered, are reliable indicators of disease. Methodology included radiography of cadaveric specimens and analysis of over 300 anteroposterior (AP) radiographs of "normal" adult hips. This information was applied to clinical situations with the following conclusions: (a) The diagnosis of protrusio acetabuli is warranted if the acetabular line projects medial to the ilioischial line by 3 mm or more in men and by 6 mm or more in women. (b) In acetabular trauma, an AP and two oblique radiographs (30 degrees anterior oblique and 30--45 degrees posterior oblique) are required for complete evaluation. (c) Characteristic alterations in the joint space allow accurate diagnosis of disease.
A comprehensive anatomic, pathologic, and radiographic study was undertaken to define reliable soft-tissue landmarks about the hip. Methodology included an analysis of 300 "normal" adult hip radiographs, tissue maceration, cadaveric intra-articular injection studies and review of selected clinical cases. Results, when applied to clinical situations, indicate: (a) The iliopsoas and "capsular" fat planes are poor indicators of small to moderate amounts of intra-articular fluid in the adult. (b) The "capsular" fat plane is not associated with the joint capsule, but in fact is a fat plane between two muscle bundles anterior to the articulation. (c) Distinct soft-tissue planes are available for dissemination of fluid from the hip joint. These include the iliopsoas bursa, which may distend in association with articular disease, and the fat plane of the obturator externus muscle.
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An anatomic-pathologic-radiographic study of the proximal tibiofibular joint was undertaken. This synovial articulation between the proximal tibia and fibula may communicate with the knee joint in 10% of adults. Radiography of the normal proximal tibiofibular articulation outlines a consistent relationship between the proximal portions of the tibia and fibula. Disruption of this normal relationship is indicative of anterolateral or posteromedial subluxation or dislocation. Articular disorders of this joint include reheumatoid arthritis and septic arthritis. In the latter, initial alterations of the knee joint may subsequently extend to involve the proximal tibiofibular joint, illustrating the potential communication between these two articulations.
Selective involvement of the first carpometacarpal joint is described in four women with scleroderma. Radiographic abnormalities at this site included osseous erosion, radial subluxation of the metacarpal base, and (in two patients) intraarticular calcification. Perlarticular osseous erosions were noted at adjacent locations in three patients. The cause of this distinctive wrist finding in scleroderma is unknown, but its similarity to alterations in other connective tissue diseases suggests that muscular and tendon imbalance may be important in producing bone erosion and subluxation at this articulation.
99mTc pyrophosphate radionuclide scans of the axial and appendicular skeletons in 23 patients with rheumatoid arthritis and 15 patients with systemic arthritic conditions were compared to clinical and radiographic examinations. The nuclear scan was the most sensitive indicator of active disease and correlated extremely well with the other methods. A pattern of abnormal radionuclide activity in rheumatoid arthritis consisting of a symmetric peripheral joint process can be distinguished from that of the rheumatoid variants which tend to have more central skeletal involvement and asymmetric peripheral articular involvement. The nuclear scan is less specific than the radiograph in its ability to distinguish among the clinical entities. However, documentation of scintigraphic activity often antedated radiographic or clinical abnormalities.
Diffuse idiopathic skeletal hyperostosis (DISH) is a common ossifying diathesis in middle-aged and elderly patients characterized by bone proliferation along the anterior aspect of the spine and at extraspinal sites of ligament and tendon attachment to bone. Four patients with DISH revealed extensive calcification and ossification of the posterior longitudinal ligament in the cervical spine. Review of cervical spine radiographs in 74 additional patients with DISH demonstrated bony hyperostosis of the posterior aspect of the vertebrae in 41%, posterior spinal osteophytosis in 34%, and posterior longitudinal ligament calcification and ossification in 50%. These ligamentous findings, which have previously been described almost exclusively in Japanese people, appear to be an additional skeletal manifestation of DISH.
The radiographic manifestations of rheumatic disease are varied. Proper interpretation of the observed roentgen abnormalities requires knowledge of the underlying pathogenesis and characteristic distribution of the disease. With this knowledge the physician may provide accurate and early diagnosis in many patients with arthritis.
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The terms erosive or inflammatory osteoarthritis refer to an inflammatory condition of the interphalangeal joints of the hand. In this report, observations of 15 patients with erosive osteoarthritis are described. The principal clinical features are symmetrical synovitis of the interphalangeal joints of the hand, the knees, and the first carpometacarpal, interphalangeal, and metacarpophalangeal joints. The principal roentgenographic features are productive and destructive osseous changes. These changes, found particularly at the interphalangeal joints of the hand, consist of both central and peripheral articular erosions and cysts associated with adjacent osteophyte formation. Serologic abnormalities commonly found in rheumatoid arthritis are rarely encountered. In two thirds of the patients, the synovial fluid is noninflammatory; in the remainder, it is mildly to severely inflammatory. The injection of intra-articular corticosteroids predictably results in decreased synovitis but does not seem to affect the subsequent development of erosions.
A new pattern of osteolysis accompanied by detritic synovitis occurred in a 71-year-old woman. The patient had a severe, destructive, and multilating arthropathy of her hands, with distal phalangeal deformity. Radiographs outlined bone resorption of the appendicular and axial skeleton, with involvement of phalanges, metacarpals, metatarsals, clavicles, long bones, and spine. There was no notable occupational history nor laboratory evidence of hyperparathyroidism. Pathological evaluation revealed synovial ulceration and necrosis, and necrotic bone embedded with fibrotic synovium. This patient's abnormalities appear to represent a new pattern of osteolysis that can be distinguished from other disorders.
This report by no means includes all nontraumatic conditions that may produce symptoms and signs that require emergency treatment. Rather, it indicates some of the more common problems that may present in this fashion. This report also serves to remind us that we, as radiologists, do have an important role in the diagnosis and proper treatment of emergency room patients, and that such a role requires our close cooperation with the referring physicians. As we survey radiographs taken on these patients, we must remember to ask ourselves important questions: Are the films adequate? Is the abnormality the cause of the patient's symptoms?
A variety of disease processes may involve the axial skeleton, producing acute symptoms and signs. This discussion summarizes some of the important diseases that become apparent in this fashion. Roentgen manifestations of these disorders include abnormalities of vertebral body shap or density, loss of intervertebral disc space, formation of a paraspinal mass, abnormal curvature and subluxation, disc calcification, and pedicle destruction. Attention to these radiographic manifestations provides important clues to the underlying disease process.
Ossifying fibromas involving the tibia were seen in two patients. In both patients, the radiographic appearance of the lesions suggested fibrous dysplasia, but histopathologic evaluation demonstrated findings similar to ossifying fibroma of the mandible and facial bones. Radiologic and pathologic recognition of this entity is necessary for proper treatment.
The roentgen appearance and pathogenesis of carpal instability are described in an evaluation of patients and cadavers with rheumatoid arthritis and calcium pyrophosphate deposition disease. Dorsiflexion (16%) and palmar flexion (8%) instability occurs in rheumatoid arthritis, particularly in patients with moderate to advanced disease. Navicular-lunate dissociation frequently accompanies dorsiflexion instability and results from involvement of the interosseous ligament between the two bones by rheumatoid pannus. Carpal instability and navicular-lunate dissociation also accompany pyrophosphate arthropathy, resulting from calcific deposition and cystic degeneration of ligamentous structures.
Clinical, radiographic and pathologic abnormalities in calcium pyrophosphate dihydrate deposition disease (CPPD) (pseudogout) are outlined in an investigation of 85 patients with definite or probable disease and available cadaveric and human surgical material. Pyrophosphate arthropathy produced distinctive roentgenographic abnormalities with were most frequent in the knee, wrist and metacarpophalangeal joints. Although the alterations superficially resembled osteoarthritis, they were frequently more severe and progressive with extensive fragmentation of bone, causing intra-articular osseous bodies. Pyrophosphate arthropathy occurred in unusual locations, such as the radiocarpal compartment of the wrist, elbow, and patellofemoral compartment of the knee. These characteristics allow the radiologist to suggest a probable diagnosis of CPPD even in the absence of articular calcification.