Radiography of bones: It's not just black and white (Proceedings)
The evaluation of the musculoskeletal system is difficult due to the numerous soft tissues as well as the bone structures involved. Rapid assessment of the bone structure is routinely performed using radiographs; however, the subtlety of disease and joint compared to bone pathology can be confusing. The purpose of this lecture is to cover the identification of aggressive compared to non-aggressive bone lesions as well as erosive compared to non-erosive joint pathology.
When evaluating the skeletal system, the first thing to determine is if the lesion is aggressive or non-aggressive. A non-aggressive lesion diagnoses include callous, malunion fractures, bone cysts, osteomas, osteochondritis dessicans, panosteitis, fragmented medial coronoid process, osteoarthritis or metabolic disorders. Aggressive lesions are due to neoplasia or osteomyelitis.
When deciding about aggressive lesions, there are 6 radiographic signs that are used: bone lysis, periosteal reaction, rate of progression, zone of transition, cortical lysis. Bone lysis has three different appearances, geographic (focal) moth-eaten and permeative. The difference between the degree of lysis is mainly on the rate of progression. It requires approximately 50% of the bone per unit area to be destroyed before it is visible on radiographs. This is because the bone is a three dimensional object viewed from two dimensions. Because of this, bone is superimposed on itself, making subtle lesions hard to detect. The more lysis that is present, the easier it is to see on radiographs. Also, by the time lysis is seen on a radiograph, the lesion is quite severe.Periosteal reaction can either be smooth (continuous) or interrupted. The easiest way to determine this is if you could trace the outline of the periosteal reaction with a pencil and never have to lift the pencil from the radiograph. Smooth periosteal reactions are generally associated with trauma whereas interrupted periosteal reactions are due to an aggressive process.
Rate of progression is probably the most overlooked method to assess an aggressive lesion. By the time a questionable aggressive lesion is seen on a radiograph, the lysis is quite substantial. Therefore, the rate of progression in 2-4 weeks will also be dramatic. If a question exists between an aggressive and non-aggressive lesions, supportive medical management for 2-4 weeks then repeat radiographs to look for progression can aid in determining if the lesion is aggressive.
Zone of transition is a more nebulous sign, but the idea is that if a clear-cut demarcation between normal and abnormal bone is seen, then the lesion is more likely non-aggressive. If there is a long zone of transition, the difference between normal and abnormal bone is blurred and the lesion is more likely to be aggressive. In addition, cortical lysis as opposed to overall bone lysis can be used to determine aggressive bone lesions. If the cortex is thin, but no lysis is present, then it is more likely that the lesion is non-aggressive.
After determining these radiographic signs, the next clue is based on the location of the lesion. If the lesion is generalize in that it effects all bones equally, then the primary differential diagnosis is a metabolic or nutritional abnormality. If only one bone is involved, this is a focal or monostotic lesion and a primary bone tumor or soft tissue tumor with secondary bone involvement is considered most likely. If multiple bones in the same region (locally extensive), different bones that are not in close proximity or multiple areas in the same bone are involved, this generally indicates a hematogenous spread disease as bacterial osteomyelitis or metastatic neoplasia. A soft tissue tumor with secondary bone involvement is possible with locally extensive lesions, such as aggressive lesions that cross a joint.