David Sutton Chapter 36

DAVID SUTTON PICTURES

DR. Muhammad Bin Zulfiqar PGR-FCPS III SIMS/SHL

• Fig. 36.1 Irregular periosteal new bone is demonstrated in a patient with varicose veins.

Fig. 36.2 Polyarteritis nodosa. An exuberant periostitis is seen along bothtibia and fibula-much more florid than that seen in hypertrophicosteoarthropathy.

• Fig. 36.3 Thyroid acropachy. Marked cortical thickening is demonstrated at the midshafts of the tubular bones of the hands (see Ch. 42).

Fig. 36.4 Osteomyelitis. The three ages of infection and how changeinvolves the joint.

• Fig. 36.5 (A) Early metaphyseal infection. There is very minimal focal destruction at the distal radial metaphysis. (B) With progressive bone destruction, metaphyseal abnormality is now very evident.

• Fig. 36.6 Advanced osteomyelitis involving the whole of the right tibia and lower end of fibula. Note sequestrum in tibia arrow) and further sequestrum being extruded from the fibula (arrow).

• Fig. 36.7 Chronic osteomyelitis. (A) The preliminary radiograph shows a deformed right femur. There is cortical thickening with evidence of intramedullary cavitation and angulation. Linear calcified densities in the soft tissues may represent extruded sequestra. (B) Coronal fat-suppression MR image shows muscle wasting; the deformity of the bone is again demonstrated. There is extensive increase in signal within the medulla, indicating a fluid collection. A band of high signal can be seen extending from the medulla superiorly, through the cortex laterally and into the adjacent soft tissues. There is an effusion in the knee joint and oedema of the subcutaneous soft tissues. (C) The sinogram shows contrast medium in the same distribution as the fluid in B.

• Fig. 36.8 Osteomyelitis of femur and septic arthritis of the hip in neonate. Note dislocation of hip, involucrum, cloaca and sequestrum.

• Fig. 36.9 Chronic osteomyelitis.(A) The plain film shows mottled medullary destruction and a smooth periosteal reaction. (B) The radionuclide bone scan shows gross increase in uptake locally.

• Fig. 36.9 Chronic osteomyelitis: (C) On CT scanning, gross periosteal reaction is demonstrated, causing considerable enlargement and sclerosis of bone.(D) The MR scan shows the grossly altered signal in the affected femoral neck and greater trochanter, with replacement of the normal bright marrow signal on the T 1 – weighted image. Cortical changes are demonstrated and a periostitis is seen.

Fig. 36.10 Early osteomyelitis. (A) There is a barely discernible radiolucency affecting the distal shaft of the femur, but an early periostitis is demonstrated medially and laterally. (B) The radioisotope bone scan shows the extent of the pathological change.

• Fig. 36.11 Chronic osteomyelitis. The CT scan shows the left side to be normal, while on the right there is extreme cortical thickening and marrow oedema of the tibia.

• Fig: 13.6 osteomyelitis of the clavicle with an involucrum and sequestrum, demonstrated at CT.

• Fig. 36.13 Garre's type of osteomyelitis.

• Fig. 36.14 Brodie's abscess demonstrated at MR. On this fat-suppression image, the localized abscess is demonstrated as an area of extremely high signal.

• Fig. 36,15 ' Tunnelling' in osteomyelitis. (A) A finger-like process of osteomyelitic bone destruction extends from the main focus. This is tunnelling, which usually indicates the presence of chronic infection. (B) In another patient, the sagittal fat-suppression MR sequence shows a vertically orientated and fluid-filled cavity in the proximal tibia. It is well defined and has all the features of a chronic infective lesion. (C) The chronically thickened cortex together with the central fluid-filled cavity lying within the medulla are demonstrated on this axial fat-suppression MR image.

• Fig. 36.16 Brodie's abscess. The plain film was not helpful. (A) The radioisotope bone scan confirms the presence of a focal lesion in the upper cervical spine.

• Fig. 36.16 Brodie's abscess. (B) The CT scan shows an appearance which could represent either an osteoid osteoma or a Brodie's abscess, that is, an area of osteolysis with central sclerosis and surrounding it a well-demarcated zone of reactive sclerosis. (C) Changes at MR mirror those seen at CT in the lateral mass of C2.

• Fig. 36.17 Multiple areas of bone destruction and reactive sclerosis (arrow) are seen in a patient with chronic osteomyelitis.

• Fig. 36.18 Bone destruction, sequestrum formation and periostitis follow implantation of oral organisms after a bite.

• Fig. 36.19 Infective discitis. (A) The initial film shows early bone destruction beneath the end-plates around a narrowed disc. (B) The later film shows progressive destruction of disc and bone with surrounding reactive sclerosis.

• Fig. 36.20 Infective discitis. The sagittal T,-weighted MR sequence shows vertebrodiscal destruction at [3/4 and replacement of marrow-fat signal by soft tissue. There is also expansion of the vertebrodiscal mass posteriorly into the canal.

• Fig. 36.21 End-plate destruction with distal loss and a kyphosis is associated with facet subluxation and a large anterior soft-tissue mass (arrow).

• Fig. 36.22 Infective discitis with progressive healing and reactive sclerotic change: (A) September; (B) October; (C) subsequent January.

• Fig. 36.23 Diabetic ulcer. Gas is seen in the defect adjacent to the fifth metatarsal head.

The phalanges are subluxed and there is reactive periostitis around the proximal shaft of the little toe.

• Fig. 36.24 Chronic granulomatous disease. (A) There is a localised metaphyseal defect surrounded by sclerosis. These features are characteristic of chronic infection in a child. (B) The MR scan confirms the presence of localized metaphyseal abnormality with replacement of the local fat. There is a mixture of destruction of bone, oedema and reactive new bone formation at the margin of the lesion.

• Fig. 36.24 Chronic granulomatous disease. (C) Same patient. The radioisotope bone scan shows increase in uptake in the proximal tibial metaphysic of the left knee. (D) Coronal T, and STIR sequences confirm the presence of change, not merely in the metaphysis but also in the epiphysis. Fluid replaces fat on both sequences. (Courtesy of Dr R. Phillips.)

• Fig. 36.25 Gross reactive sclerosis with new bone formation at multiple sites is found in chronic granulomatous disease.

• Fig. 36.26 (A-C) Pyogenic arthritis of the hip-rapid progression of the lesion during a period of one month.

• Fig. 36.27 Septic dislocation of the right hip.

Fig. 36.28 Infective sacroiliitis. (A) There is resorption of bone and sclerosis around the left sacroiliac joint.

• Fig. 36.28 Infective sacroiliitis. The radioisotope bone scan (B) shows the increase in uptake, and the CT scan (C) shows the widened joint with areas of irregular bone destruction and soft-tissue swelling. (Courtesy of ProfessorH. Carty.)

• Fig. 36.29 Tuberculosis of femur-large metaphyseal focus.

• Fig. 36.30 Tuberculous focus in greate trochanter. This type is less common than a surface erosion.

Fig. 36.31 Tuberculous discitis. (A) The changes on the plain film are really quite similar to those that would be seen with a simple infection. There is distal destruction associated with irregularity of the overlying end-plates and some reactive new bone formation. There is perhaps a suggestion on the plain film that a soft-tissue mass is demonstrated anterior to the vertebral bodies. (B) The MR T,-weighted axial image shows the end-plate defect seen so well on the plain film but, in addition, psoas abscesses with central necrosis are demonstrated.

• Fig. 36.32 (A) The plain film shows features which are typical for spinal tuberculous disease. There is an extensive paraspinal soft-tissue mass. Detail in the underlying spine is poor but there is early crowding of ribs posteriorly, indicating early vertebral collapse. (B) Coronal MR image of the thoracic spine demonstrates destruction of the intervertebral disc at the point where the paraspinal widening is maximal and this change is associated with alteration of signal from the vertebrae. (C) The sagittal fat-suppression image shows increase in signal in adjacent vertebral bodies together with anterior and posterior soft-tissue masses, the latter indenting the spinal canal and compressing the adjacent cord.

• Fig. 36.33 Tuberculous spondylitis has healed with calcifying psoas abscesses and angular kyphos.

• Fig. 36.34 (A, B) Anterior subperiosteal type of Pott's disease.

• Fig. 36.35 Spinal osteomyelitis in a Saudi Arabian patient showing vertebra plana with preservation of the disc and end-plates.

• 36.36 A large abscess displaces the right ureter medially and destroys the right transverse process and adjacent part of the body of L5. Two and a half pints of tuberculous pus were removed at operation.

• Fig. 36.37 Typical spina ventosa of the proximal phalanx of the forefinger. (Courtesy of Dr D. J. Mitchell.)

• Fig. 36.38 Tuberculosis of the skull vault. The fairly well defined lytic lesion was a solitary finding but these changes are often multiple. Note the gross tunnelling

• Fig. 36.39 Synovial tuberculosis of left knee-note synovial effusion, osteoporosis, blurring of trabeculae and accelerated maturation of bone ends (normal right knee for comparison).

• Fig. 36.40 Tuberculous erosions of margins of medial tibial condyle and lateral femoral condyle (arrows).

• Fig. 36.41 Tuberculous arthritis. (A) The plain film shows destruction of the articular surfaces on both sides of the hip joint, with narrowing of the joint space and subarticular cyst formation. (B) At arthrography the presence of an irregular and shrunken synovial capsule is demonstrated. Defects are shown in the acetabulum and on the femoral head. Infection has resulted in a restrictive capsulitis and destruction of cartilage and bone.

• Fig. 36.44 Old tuberculosis of the carpus. No doubt this occurred relatively early on in life as the metacarpals are shortened. The carpal bones are fused following widespread osteoarticular destruction. The tuberculous origin of the lesion is shown by soft-tissue and bone calcification on the lateral view.

• Fig. 36.45 Tuberculous sacroiliac joint-extensive destructive lesion.

• Fig. 36.46 Congenital syphilis some increased density with subjacent translucent zones at lower ends of femora. Metaphyseal fractures are shown.

• Fig. 36.47 Gamma of the lower femoral shaft. Note bone destruction and periosteal reaction.

• Fig. 36.48 Syphilitic osteomyelitis of the humerus. (Courtesy of Dr W. Fowler.)

• Fig: 36.49 Gummatous osteomyelitis of the skull

• Fig. 36.50 Sarcoid-foot showing typical pseudocysts and absorption of tufts of distal phalanges.

• Fig. 36.51 Sarcoid. (A) Multiple foci of sclerosis are a recognised, if uncommon, feature of sarcoid. (B) Sclerotic change in sarcoidosis demonstrated at CT scanning.

• Fig. 36.52 Brucellosis. Vertebro-distal destruction with florid new bone formation are characteristic features of this disease.

• Fig. 36.53 Hydatid disease. (A) Bone destruction with the formation of large cysts around both sides of the hip joint are a classical feature of osseous hydrated. Sequestra can be seen.

• Fig. 36.53 Hydatid disease. At CT scanning (B) and MRI (C), the cystic nature of the lesions is demonstrated, together with destruction of the hip joint from both sides.

• Fig. 36.54 This patient had never been outside England but had hydatid disease of the spine. Note the large paraspinal soft-tissue mass.

• Fig. 36.55 Yaws-moderately early stage, showing destructive areas and much periosteal new bone formation. The appearances of the small destructive foci in yaws have been likened to the effects of a borer beetle. (Courtesy of Dr A. G. Davies.

Fig. 36.56 Leprosy. Some small 'cysts' are seen, e.g. in the head of the proximal phalanx of the fifth finger-this condition is sometimes called ' osteitis multiplex cystica leprosa'. The end-results of lepra granulomas are seen in the heads of the proximal phalanges of the third and fourth fingers. (Courtesy of Dr. D. E. Paterson.)

• Fig. 36.57 Leprosy. 'Cup and pencil' or 'licked candy stick' appearances demonstrated associated with thickening and irregularity of the soft tissues presumably the result of chronic infection in the soft tissues.

• Fig. 36.58 Tropical ulcer. (A) Extensive osteomyelitis is seen in the underlying tibia. (B) Osteoma-like lesion on the front of the tibial shaft-a late sequelea of tropical ulcer.

• Fig. 36.59 Mycetoma (Madura foot)-diffuse infiltrating destruction affecting the whole tarsus and proximal ends of the metatarsals.

• Fig. 36.60 Ainhum, showing progression of the lesion in an African Immigrant. (B) was taken 2 years after A.