Table Of ContentI
II
III
Bone and Joint Disorders
Differential Diagnosis in Conventional Radiology
Francis A. Burgener, M.D. Martti Kormano, M.D. Tomi Pudas, M.D.
Professor of Radiology Formerly Professor and Chairman Department of Radiology
University of Rochester Department of Radiology University of Turku
Medical Center University of Turku Turku, Finland
Rochester, N.Y., U.S.A. Turku, Finland
2nd revised edition
1108 illustrations
Thieme
Stuttgart · New York
IV
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V
Preface
Conventional radiography remains the backbone of went a major overhaul by the inclusion of specific fracture
musculoskeletalradiologydespitetheadventofnewerand sites.Intheremainingchaptersofthebookthetextwasup-
moreexcitingimagingtechniquessuchascomputedtomo- dated, many illustrations replaced, and large numbers of
graphy, magnetic resonance imaging, and, most recently, newillustrationsadded.
positronemissiontomography.Incontrasttomanyofthese A changing of the guard has also taken place. Since Dr.
newer methods, conventional radiography is practiced not Martti Kormano‘s professional endeavors do no longer in-
onlybyradiologistsbutalsobyalargenumberofclinicians cludeclinicalradiology,hefeltnolongerupthetasktoup-
and surgeons. With each examination, one is confronted datehisoriginalcontributionstothetext.Hewashowever
withradiologicfindingsthatrequireinterpretationinorder very fortunate to find in Dr. Tomi Pudas a very talented
toarriveatageneraldiagnosticimpressionandareasonable young radiologist to take over the revision of the chapters
differential diagnosis. To assist the film reader in attaining originallypreparedbyhim.
thisgoal,thisbookisbaseduponradiographicfindingsun- Ihopethisneweditionwillbeaswellreceivedasitspred-
like most other textbooks in radiology that are disease ecessors in the past that were translated into five foreign
oriented.Sincemanydiseasespresentradiographicallyina languages. The concept of an imaging pattern approach in
variety of manifestations, some overlap in the text is un- tabularformratherthanadiseaseorientedtextwasintro-
avoidable.Tominimizerepetitionthedifferentialdiagnosis ducedin1985withouroriginaleditionDifferentialDiagnosis
of a radiographic finding is presented in tabular form in Conventional Radiology and has since been adopted by
whenever feasible. Most tables do not only list the various manyauthors.Ifeelcomplimentedbytheoldcliché,“imita-
diseases that my present radiologically in a a specific pat- tionisthesincerestformofflattery.“
tern,butalsodescribeinsuccinctformothercharacteristi- Thisbookismeantforphysicianswithsomeexperiencein
callyassociatedradiographicfindingsandpertinentclinical musculoskeletalradiologywhowishtostrengthentheirdi-
data.Radiographicillustrationsanddrawingsareincludedto agnostic acumen. It is a comprehensive outline of radio-
demonstrate visually the radiographic features under dis- graphicfindingsanditshouldbeparticularityusefultoradi-
cussion. ology residents preparing for their specialist examination,
The transition from film to digital radiography had the especially since the exposure to conventional radiography
greatestimpactonconventionalradiologysincethepublica- during their training continuously decreased in the past in
tionofthelastedition.Thischange,however,didnotaffect favorofnewerimagingmodalities.Anyphysicianinvolvedin
thewayradiologicdiagnosesareascertained.Sincethepub- theinterpretationofconventionalboneradiographicexami-
licationofthelasteditionthenameofafewdisordershas nationsshouldfindthisbookhelpfulindirectproportionto
changed(e.g.,histiocytosisXtoLangerhanscellhistiocyto- hisorhercuriosity.
sis) and a few disease are newly recognized (e.g., Itismyhopethatthisneweditionwillbeaswellreceived
femoroacetabular impingement). These facts were taken asthepreviousonesbymedicalstudents,residents,radiolo-
into account in the new edition. The chapters “Localized gists, and physicians involved in the interpretation of con-
BoneLesions“and“JointDiseases“werecompletelyrewrit- ventionalboneradiographs.
ten and newly illustrated, since I took them over from Dr.
Kormano. The chapter “Trauma and Fractures“ also under FrancisA.Burgener,M.D.
VI
Acknowledgements
Itisimpossibletothankindividuallyallthosewhohelpedto I wish to express also many thanks to Jeanette Griebel,
preparethethirdeditionofthistextbook.Iwishtoacknowl- IonaMackey,andMarcellaMaierfortheirassistanceinpre-
edgethestaffofourpublisherThieme,inparticularDr.Clif- paringthereferencesandtoShirleyCappielloforhergeneral
fordBergmanandMr.GertA.Krüger. assistance. Last, but not least, I am most grateful to Alyce
IamdeeplyindebtedtoDr.GertrudGollman,Steinacham NorderwholefttheUniversityandmeafter30yearsforthe
Attersee,Austria,whotranslatedthelasteditionofthistext richness of the industry. She is the only person capable of
into German and suggested many alterations and correc- deciphering my longhand and, as in the past, did a superb
tions,whichhavebeenincorporatedintothisnewedition. job in typing, editing, and proofreading the manuscript of
My gratitude goes to all the radiologists whose coopera- theneweditionofthistext.Despiteherheavyworkloadas
tion made available illustrative cases to compliment the executive assistant in her new endeavor. Alyce was kind
originalcollectionortoreplaceolderillustrations.Iamin- enoughtoperformthistaskinhersparetime,forwhichIam
debtedtoDrs.StevenP.Meyers,JohnnyU.V.Monu,andGwy greatlyappreciative.
Suk Seo, all staff members of the University of Rochester FinallyIappreciatethesupportofmywifeTherese,who
RadiologyDepartment,andtotheformerresidentsDrs.John has generously given her precious family time for the pre-
M. Fitzgerald and Wael E. A. Saad for providing selected parationofthisbook.
cases. FrancisA.Burgener,M.D.
I would like to express my deepest gratitude to honorary radiology.ThemanyfascinatingdiscussionsIhavehadwith
professor Martti Kormano who invited me to carry on his Drs. Seppo Kortelainen and Teemu Paavilainen brought me
workinthisnewedition.Icontinuetoadmirethemassive muchdelight,onnon-radiologicaltopicsasmuchasonpro-
workthatheandDr.Burgeneroriginallyputintotheproject fessionalsubjects.
intheearlynineteen-eighties.Thehundredsofhourswhich Ialsoexpresssincerethankstothestaffofthepublishers,
Dr. Kormano and I have spent together editing this edition Thieme, especially to Dr. Clifford Bergman and Mr. Gert
havebeenagreatpleasure.Itwasafascinatingtimeinmy Krüger. Finally, much gratitude is due to Mr. Markku
life. Livanaien for his valuable assistance with technical ques-
IespeciallywanttothankDrs.KimmoMattilaandSeppo tions,andtoMs.PirjoHelankoforallherhelpwithgeneral
Koskinen for introducing me to musculoskeletal radiology, matters.Manyotherindividualshelpedinvariouswayswith
and for their extraordinary teaching and support. Many thisproject,andthoughIcannotnamethemall,Iamgrateful
thanks also belong to Drs. Erkki Svedström, Risto Elo, and fortheircontributions.
PeterB.Deanforencouragingmeonmywayinthefieldof TomiPudas,M.D.
VII
Contents
1 Osteopenia........................... 3 10 Nasal Fossa and Paranasal Sinuses ........ 237
FrancisA.Burgener FrancisA.Burgener
2 Osteosclerosis ........................ 15 11 Jaws and Teeth ....................... 245
FrancisA.Burgener FrancisA.Burgener
3 Periosteal Reactions ................... 41 12 Spine and Pelvis ....................... 255
FrancisA.Burgener MarttiKormanoandTomiPudas
4 Trauma and Fractures .................. 53 13 Clavicles, Ribs, and Sternum............. 305
FrancisA.Burgener MarttiKormanoandTomiPudas
5 Localized Bone Lesions ................. 75 14 Extremities ........................... 313
FrancisA.Burgener FrancisA.Burgener,MarttiKormano,
andTomiPudas
6 Joint Diseases......................... 129
FrancisA.Burgener 15 Hands and Feet ....................... 353
MarttiKormanoandTomiPudas
7 Joint and Soft-Tissue Calcification ........ 189
MarttiKormanoandTomiPudas References ............................... 392
8 Skull ................................ 203 Index ................................... 393
FrancisA.Burgener
9 Orbits ............................... 233
FrancisA.Burgener
VIII
Abbreviations
ABC aneurysmalbonecyst IP interphalangeal(joint)
AC acromioclavicular(joint) IV intravenous
ACTH adrenocorticotropichormone L left
AIDS acquiredimmunedeficienclysyndrome LCH Langerhanscellhistiocytosis
ALL acutelymphoblasticleukemia LE lupuserythematosus
AML acutemyeloblasticleukemia M male
ANCA antineutrophilcytoplasmoticautoantibodies MAI Mycobacteriumaviumintracellulare
ANT anterior MCP metacarpophalangeal(joint)
AP anteroposterior MFH malignantfibroushistiocytoma
AV arteriovenous MPS mucopolysaccharidosis
AVF arteriovenousfistula MR magneticresonance
AVM arteriovenousmalformation MRI magneticresonanceimaging
AVN avascularnecrosis MS multiplesclerosis
Bx biopsy MTP metatarsophalangeal(joint)
Ca calcium NHL non-Hodgkinlymphoma
CLL chroniclymphaticleukemia NUC nuclearmedicine
CNS centralnervoussystem PA posteroanterior
CPP calciumpyrophosphatedihydratecrystals PATH pathology
CPPD calciumpyrophosphatedihydratedeposition PET positronemissiontomography
disease PIP proximalinterphalangeal(joint)
CRMO chronicrecurrentmultifocalosteomyelitis PNET primitiveneuroectodermaltumor
CT computedtomography PVNS pigmentedvillonodularsynovitis
D disease RA rheumatoidarthritis
DD differentialdiagnosis RBC redbloodcell
DDH developmentdysplasiaofthehip RES reticuloendothelialsystem
DIP distalinterphalangeal(joint) RSD reflexsympatheticdystrophy
DISH diffuseidiopathicskeletalhyperostosis SC sternoclavicular(joint)
DISI dorsalintercalatedsegmentalinstability SI sacroiliac(joint)
EAC externalauditorycanal SLAC scapholunateadvancedcollapse
EG eosinophilicgranuloma SLE systemiclupuserythematosus
F female STT scaphotrapeziotrapezoidal
HAD calciumhydroxyapatitecrystals TB tuberculosis
HADD calciumhydroxyapatitecrystaldepositiondisease TFC triangularfibrocartilage
Hb hemoglobin TFCC triangularfibrocartilagecomplex
HD Hodgkindisease TMJ temporomandibularjoint
HIV humanimmunodeficiencyvirus TNM tumor-node-metastasis
Hx history VISI volarintercalatedsegmentalinstability
IAC internalauditorycanal WBC whitebloodcells
IM intramuscular
1
