Corso di Radiologia - FisiokinesiterapiaBlount’disease • The patient is a 14 + 6 year old black male with a one year history of progressively worsening left knee pain. He states

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Corso di RadiologiaCorso di Radiologia

Struttura del corsoStruttura del corso

1.1. Concetti generaliConcetti generali

2.2. Cranio, colonna cervicaleCranio, colonna cervicale

3.3. Colonna dorsale e lombareColonna dorsale e lombare

4.4. Rachide sacrale, bacino, anca, femore, ginocchio, Rachide sacrale, bacino, anca, femore, ginocchio, tibia e tibia e perone, caviglia, piedeperone, caviglia, piede

5.5. Coste,sterno, articolazioni sternoCoste,sterno, articolazioni sterno--clavicolariclavicolari

6.6. Spalla, omero, gomito, radio e ulna, polso e manoSpalla, omero, gomito, radio e ulna, polso e mano

Tibia Tibia -- peroneperone

Frattura Frattura diafisariadiafisaria

Distacco epifisarioDistacco epifisario

•• A 14 A 14 yearyear old old HispanicHispanic male male presentedpresented toto anan outsideoutsideinstitutioninstitution after after sustainingsustaining a a hyperextensionhyperextension injuryinjury toto hishisrightright kneeknee duringduring a soccer a soccer collisioncollision. . HeHe hadhad the the immediate immediate onsetonset of of painpain and and notednoted swellingswelling of the of the kneekneeduringduring the first the first hourhour after after injuryinjury. . HeHe waswas unableunable toto bear bear weightweight; ; flexionflexion and and extensionextensionof the of the kneeknee exacerbatedexacerbated the the painpain. . HeHe hadhad no no previousprevioushistoryhistory of of injuryinjury toto hishis rightrightlowerlower extremityextremity..

Post Post TraumaticTraumatic Tibia Valga Tibia Valga •• A A threethree yearyear old old whitewhite

male male sustainedsustained a a fracturefracture of the of the leftleftproximalproximal tibia tibia whilewhilejumpingjumping off a off a chairchair. The . The minimallyminimally displaceddisplacedfracturefracture waswas locatedlocated in in the the proximalproximal. Treatment . Treatment consistedconsisted of a long of a long leglegcast cast forfor sixsix weeksweeks. . UponUponremovalremoval of the cast a of the cast a slightslight valgusvalgus deformitydeformitywaswas notednoted. .

•• 10 10 MonthsMonths post post FractureFracture, , RightRight 88°° LeftLeft1919°° MechanicalMechanical axisaxis

Post Post TraumaticTraumatic Tibia ValgaTibia Valga

•• 16 16 MonthsMonths post post FractureFracture, ,

•• RightRight 88°° LeftLeft 2626°°MechanicalMechanical axisaxis, ,

•• LeftLeft 3434°° FemoralFemoralTibialTibial AngleAngle


•• HeHe waswas treatedtreated withwith varusvarus producingproducingclosingclosing wedgewedge osteotomyosteotomy of the of the proximalproximal tibia tibia withwith neutralneutral alignmentalignment


•• 3 3 MonthsMonths post post SurgerySurgery

•• LeftLeft 66°° MechanicalMechanicalaxisaxis


•• 9 9 MonthsMonths post post SurgerySurgery

•• LeftLeft 1010°° MechanicalMechanicalaxisaxis

BlountBlount’’diseasedisease

DefinitionDefinition: : GrowthGrowth disorderdisorder of the of the medialmedial aspectaspect of the of the

proximalproximal tibialtibial physisphysis, , withwith abruptabrupt medialmedialangulationangulation of the of the proximalproximal tibia tibia distaldistal toto the the epiphysisepiphysis, , leadingleading toto varusvarus angulationangulation of the of the proximalproximal tibia and tibia and medialmedial rotation of the tibia. rotation of the tibia.


•• The The patientpatient isis a 14 + 6 a 14 + 6 yearyear old black male old black male withwith a one a one yearyear historyhistoryof of progressivelyprogressively worseningworsening leftleft kneeknee painpain. . HeHe statesstates thatthat the the painpainbeganbegan in in bothboth kneesknees and and waswas intermittentintermittent, , TylenolTylenol helpedhelped alleviate alleviate the the painpain. Over the . Over the pastpast 6 6 monthsmonths the the painpain isis more more isolatedisolated toto the the leftleft kneeknee and and hashas becomebecome constantconstant in nature. in nature. WithinWithin the the lastlast 2 2 weeksweeks the the constantconstant painpain hashas becomebecome bad bad enoughenough toto limitlimit hishisactivitiesactivities. . HeHe isis unableunable toto attendattend schoolschool or or walkwalk more more thanthan severalseveralhundredhundred feetfeet becausebecause of the of the painpain. The . The painpain isis nownow affectingaffecting hishissleepsleep. . HeHe doesdoes getget some some reliefrelief withwith restrest and and elevationelevation of the of the kneeknee. . The The painpain alsoalso limits limits hishis motionmotion in in thatthat kneeknee. . HeHe deniesdenies anyany trauma trauma toto the the kneeknee and and hashas no no otherother medicalmedical problemsproblems. . HeHe isis notnot takingtakinganyany medicationsmedications. . ThereThere isis no family no family historyhistory of of legleg deformitiesdeformities. .


•• AP/AP/LateralLateral of of leftleft kneekneefromfrom SeptemberSeptember of 1995 of 1995 demonstratedemonstrate a a mildmild varusvarusdeformitydeformity withwith ananestimatedestimatedmetaphysealmetaphyseal//diaphysealdiaphysealangle of 8angle of 8oo. . ThereThere isis alsoalsoevidenceevidence of of wideningwidening of of the the medialmedial 1/3 of the 1/3 of the proximalproximal tibialtibial physisphysis

BlountBlount’’diseasedisease•• The AP of the The AP of the leftleft kneeknee in in

MayMay of 1996 of 1996 showsshowsworseningworsening of the of the varusvarusdeformitydeformity withwith a a metaphysealmetaphyseal//diaphysealdiaphysealangle of 14angle of 14oo. . ThereThere isisincreasedincreased wideningwidening of the of the medialmedial proximalproximal tibialtibial physisphysiswithwith evidenceevidence of of sclerosissclerosis. .

•• The The scanogramscanogramdemonstrateddemonstrated a 4 cm a 4 cm legleglengthlength discrepancydiscrepancy, , withwith the the leftleft shortershorter thanthan the the rightright . . ThereThere isis no no abnormalityabnormality in in the the hiphip or or femurfemur. .


•• HypoplasyHypoplasy of the of the platesplates internintern tibiaetibiaewithwith deformationdeformationen"en"bayonetbayonet " " kneesknees..

•• boy : 10 boy : 10 yearsyears•• HistoryHistory : :

deformationdeformation willwill vara vara some of the some of the twotwokneesknees in a 10 in a 10 yearyear old old childchild. .

CYST ANEURYSMAL CYST ANEURYSMAL DIAPHYSAIREDIAPHYSAIRE

•• boy : 8 boy : 8 yearsyears•• HistoryHistory ::8 8 yearyear old old

childchild hospitalizedhospitalized forfora a painfulpainful tumourtumour on on the the levellevel of the of the internalinternal face of the face of the tibia D. tibia D.

•• 7.1.82: Osteolytic gap 7.1.82: Osteolytic gap of the tibia Dof the tibia D


•• 22.3.83 Repeat after 22.3.83 Repeat after surgicalsurgical fillingfilling the 8.1.82 the 8.1.82 of the of the cavitycavity byby a a iliaciliacgraftgraft. . OsteolytiqueOsteolytiquecloisonneecloisonnee imageimage, , limitedlimitedwellwell byby a a periosteumperiosteumossificationossification and and withoutwithoutextensionextension toto the soft the soft partsparts..


•• 17.1.84: One 17.1.84: One yearyearafter the after the lastlastinterventionintervention, the , the stereotypesstereotypes do do notnotshow a show a signsign of of repetitionrepetition. The . The osseousosseous graftgraft isisincorporatingincorporating itselfitselfcompletelycompletely in the in the tibia.tibia.

CHONDROSARCOMACHONDROSARCOMA

•• 23 23 yearyear old old youngyoung man; man; painpain of the of the kneeknee. .

•• DiagnosisDiagnosis : : chondrosarcomachondrosarcoma of of higherhigher partpart of tibiaof tibia

•• HeterogeneousHeterogeneouscondensationcondensation, , osteosclerosisosteosclerosis and and invasioninvasion of the soft of the soft partspartsof the of the higherhigher end of the end of the tibia.tibia.

TibioTibio--tarsicatarsica

Pilone tibialePilone tibiale

Pilone tibialePilone tibiale

Frattura lussazioneFrattura lussazione

••

Terzo malleolo?Terzo malleolo?

Distacco epifisarioDistacco epifisario

GANGLIAL CYSTGANGLIAL CYST•• YoungYoung adultadult presentingpresenting

himselfhimself toto the the urgenciesurgencies forfor a a benignbenigndistorsiondistorsion of of ankleankle G. G.

•• DiagnosisDiagnosis : : CYST CYST JUXTAJUXTA--articulararticular OF OF ankleankle

•• HighlightedHighlighted of a of a polycyclicpolycyclic geode geode ovalovalringedringed condensationcondensation, , at the at the basesbases internalinternalmalleolusmalleolus and and withwithsome some millimilli metersmeters of a of a normalnormal line line tibiotibio--tarsictarsicspacespace

GANGLIAL CYSTGANGLIAL CYST

•• Of Of profileprofile, the gap , the gap ringedringed of a little more of a little more thanthan 1 cm 1 cm heightheight isisratherrather posteriorposterior


•• The The tomographytomographyconfirmsconfirms the the aspectaspect of of the the cysticcystic lesionlesion and and showsshows a a communicationcommunication withwiththe the articulararticular line line space (space (arrowarrow).).


•• A A arthrographyarthrography showsshowsthatthat the the articulararticularcartilagecartilage isis respectedrespectedoveralloverall


•• At the end of the At the end of the examinationexamination after after mobilizationmobilization one one obtainsobtains a discrete a discrete passagepassage of of productproduct of of contrastcontrast in the in the cysticcysticcavitycavity

OS UNDER INTERNAL OS UNDER INTERNAL MALLEOLAIREMALLEOLAIRE

•• 9 9 yearsyears•• HistoryHistory : : radiographedradiographed

followingfollowing a a traumatismtraumatismwithwith woundwound of of ankleankle leftleft. .

•• PresencePresence of a of a smallsmallosseousosseous formationformation toto the the lowerlower partpart of the of the malleolusmalleolus internalinternal and and independentindependent of of thisthis one. one. No No otherother abnormalabnormalimageimage..

DISTORSION, LAXITY LIGAMENT DISTORSION, LAXITY LIGAMENT

•• 22 22 yearsyears HistoryHistory : : ACCIDENT OF ACCIDENT OF FOOTBALL GOING BACK TO TWO FOOTBALL GOING BACK TO TWO MONTHSMONTHS

POSTPOST--TRAUMATIC DYSPLASIA WITH TOTAL TRAUMATIC DYSPLASIA WITH TOTAL ANKYLOSIS OF ANKYLOSIS OF tarsustarsus posteriorposterior

•• 51 51 yearsyears•• HistoryHistory :: ImportantImportant

modificationmodification of of ankleanklerightright, , sincesince a a traumatismtraumatism goinggoingback back toto 20 20 yearsyears..

POSTPOST--TRAUMATIC DYSPLASIA WITH TOTAL TRAUMATIC DYSPLASIA WITH TOTAL ANKYLOSIS OF ANKYLOSIS OF tarsustarsus posteriorposterior

•• RADIOGRAPH ANKLE RADIOGRAPH ANKLE OF PROFILEOF PROFILE

NEURILEMMOMA DEVELOPS WITH THE NEURILEMMOMA DEVELOPS WITH THE DEPENS OF NERVE TIBIAL POSTERIORDEPENS OF NERVE TIBIAL POSTERIOR

•• 70 70 yearyear old woman, old woman, presentingpresenting sincesince severalseveralmonthsmonths a a retroretro--mallmallééolaireolairetumefactiontumefaction internalinternal leftleft, , firmfirm and sensitive and sensitive toto the the pressurepressure, regular, , regular, nonpulsatilenonpulsatile. The . The clinicalclinicalexaminationexamination of of ankleankle and and standard standard radiographiesradiographies are are normalnormal. .

•• The scanner The scanner waswas the the keykeyexaminationexamination in the case in the case presentpresent. . WeWe willwill seesee twotwocutscuts of scanner of scanner initiallyinitiallypassingpassing byby ankleankle and and perpendicularperpendicular toto the the largelargeaxisaxis of the of the legleg..


•• Mass Mass ovaloval, regular, , regular, of 25 mm of 25 mm homogeneoushomogeneousdensity density closeclose toto thatthatof the of the musclemusclebehind of the behind of the posteriorposterior malleolusmalleolusof the tibia. of the tibia.

•• ContoursContours NetsNets and and absenceabsence of of calcificationcalcification


•• BeforeBefore injectioninjection of of contrastcontrast


•• EvenEven cut in cut in osseousosseous window window toto show show thatthat therethere isisnotnot osseousosseous erosionerosion comparedcompared toto the mass, the mass, whichwhichhashas a connection a connection withwith angle acute angle acute toto the the articulararticularline spaceline space


•• WeWe willwill seesee a cut a cut nownowpassingpassing byby the mass the mass butbut directeddirected accordingaccordingtoto a plan a plan perpendicularperpendicular toto the the largelarge axisaxis of the of the footfoot..


•• One One seessees wellwell on on thisthis cut cut thatthat the mass the mass isis at the at the input of the input of the channelchannelcalcancalcanééenen internintern whichwhichcontainscontains the the tendonstendons of of legleg posteriorposterior, of the , of the flexorflexorcommuncommun runrun, , flexorflexor cleancleanand the package and the package posteriorposterior vasculovasculo--highlyhighly--strungstrung personperson tibialtibial..


•• WeWe hesitatedhesitated betweenbetweenseveralseveral diagnosesdiagnoses and and itit isis the the biopsybiopsy withwiththe the trutru--cutcut whichwhichcarriedcarried the the diagnosisdiagnosisof of thisthis mass of soft mass of soft partsparts..

PIEDEPIEDE

ANATOMIAANATOMIA

ANATOMIAANATOMIA

TRAUMATRAUMA

•• 10 10 yearyear old boy, old boy, painspainswithwith the the functioningfunctioning on on the the levellevel of the of the externalexternaledgeedge of the of the leftleft footfoot, , sincesince 3 3 daysdays. . AfterAfter--effecteffectof of clubclub--footfoot varusvarus equine equine leftleft. .

•• DiagnosisDiagnosis : : FRACTURE EFFORT OF the FRACTURE EFFORT OF the

5th METATARSIEN 5th METATARSIEN

TRAUMATRAUMA

•• FOOT OF PROFILE OF FOOT OF PROFILE OF the LEFT the LEFT DIMENSION:DIMENSION:persistenpersistencece of a of a hollowhollow footfoot, , afterafter--effecteffect of the of the clubclub--footfoot varusvarusequine. The equine. The fracturefractureof the 5th of the 5th metatarsalmetatarsalappearsappears veryvery wellwell. .

TRAUMA 2TRAUMA 2

•• RefusalRefusal of the of the functioningfunctioning or or leftleft boiteryboitery in a 21 in a 21 monthmonth old old childchild. No . No conceptconcept of of traumatismtraumatism. Excel . Excel generalgeneralstate, state, notnot of of feverfever. light . light swellingswelling of the of the externalexternal edgeedgeof the of the footfoot comparedcompared toto the the 5th 5th metatarsalmetatarsal. .

•• NormalNormal aspectaspect of the of the skeletonskeletonof of beforebefore footfoot on on thisthisradiographradiograph of face of face takentaken a few a few daysdays after the after the beginningbeginning of the of the disordersdisorders. The . The stereotypestereotype of of unrolledunrolled profileprofile waswas alsoalsonormalnormal

TRAUMA 2TRAUMA 2

•• radiographradiograph in the in the samesame incidenceincidence twotwoweeksweeks laterlater: one : one guessesguesses a a veryvery fine fine featurefeature of of fracturefracturebarringbarring obliquementleobliquementlemetatarsalmetatarsal withwith smallsmallperiosteumperiosteum reactionreactioncorrespondcorrespond withwith one one calcal periosteumperiosteum . .

Trauma 3Trauma 3

Trauma 3Trauma 3

LisfrancLisfranc

LisfrancLisfranc

FRACTURE COMMINUTIVE OF CALCANEUM FRACTURE COMMINUTIVE OF CALCANEUM ASSOCIATE A AN ARTICULAR FRACTURE OF THE ASSOCIATE A AN ARTICULAR FRACTURE OF THE TALUSTALUS

•• FallFall withwith functionalfunctionalimpotenceimpotence of the of the footfootG at a 24 G at a 24 yearyear old old man. man.

•• RADIO OF ANKLE G RADIO OF ANKLE G OF PROFILE OF PROFILE comminutivecomminutive::FractureFractureof the of the osos calciscalcis


•• CUT SAGITTAL CUT SAGITTAL tomographictomographic OF THE OF THE LEFT ARREARAGE LEFT ARREARAGE FOOT: multiple FOOT: multiple solutionssolutions of of continuitycontinuityon the on the levellevel of the of the ososcalciscalcis withwith insulatedinsulatedintermediate intermediate fragmentsfragments. The . The talustalusappearsappears intactintact..


•• CUT LONGITUDINAL CT CUT LONGITUDINAL CT WITHOUT PRODUCT OF WITHOUT PRODUCT OF CONTRAST IN OSSEOUS CONTRAST IN OSSEOUS window: multiple window: multiple osseousosseousfragmentsfragments on the on the levellevel of of the the osos calciscalcis withwithdisplacementdisplacement in inside of in inside of the the smallsmall apophysisapophysis of of the the osos calciscalcis and the and the articulararticular facetfacetastragalienneastragalienne formerformer..


•• CUT TRANSVERSE CT CUT TRANSVERSE CT WITHOUT INJECTION OF WITHOUT INJECTION OF PRODUCT OF CONTRAST PRODUCT OF CONTRAST IN OSSEOUS window:A IN OSSEOUS window:A side of the side of the fracturesfractures of of the the osos calciscalcis , , itit existsexists a a fracturefracture of the of the talustalus withwithdepressiondepression of the of the internalinternalpartpart of the of the articulararticular facetfacetcalcaneennecalcaneenne posteriorposterior..

DISEASE OF KOHLERDISEASE OF KOHLER

•• 6 6 yearsyears•• HistoryHistory : : PainPain withwith

the the functioningfunctioning•• FOOT PROFILE: FOOT PROFILE:

flatnessflatness of the of the scaphoidscaphoid bone bone tarsientarsienwithwithosteocondensationosteocondensation of of the the edgesedges..


•• FOOT DEROULE one FOOT DEROULE one yearyear afterwardsafterwards: : scaphoidscaphoid bone bone alwaysalwaysflattenedflattened, , irregularirregular, , osteoosteo condensedcondensed..


•• FOOT DEROULE: FOOT DEROULE: persistencepersistence of a of a discrete discrete flatnessflatness of of the the scaphoidscaphoid bone of bone of whichwhich the the osseousosseousstructurestructure isis becomebecomeagainagain normalnormal..

PSEUDO CYST OF THE CALCANEUM PSEUDO CYST OF THE CALCANEUM

•• 14 14 yearyear old girl. old girl. TraumatismTraumatism of of ankleanklerightright..

•• Radio of Radio of ankleankle: : presencepresenceof a of a lacunarlacunar imageimage of the of the osos calciscalcis , in , in triangletriangle at at base base plantarplantar, , limitedlimited wellwell, , withoutwithout peripheralperipheralcondensationcondensation nornor corticalcorticallysislysis

OSTEOARTHRITIS OSTEOARTHRITIS ASTRAGALOASTRAGALO--CALCANEAR CALCANEAR

•• PainPain of of ankleankle, , mechanicalmechanical; 36 ; 36 yearyearold man. old man.

•• CT CT crossescrosses frontalfrontal of of the the jointsjoints underunder--astragaliennesastragaliennes: on the : on the rightright, , osteophytoseosteophytoseand and pinchingpinching of the of the line spaceline space

OSTEOARTHRITIS OSTEOARTHRITIS ASTRAGALOASTRAGALO--CALCANEARCALCANEAR

•• FormerFormer frontalfrontal cut cut showingshowing the the bilateralbilateralaspectaspect..

OSTEOARTHRITIS OSTEOARTHRITIS ASTRAGALOASTRAGALO--CALCANEARCALCANEAR

•• SagittalSagittal rebuildingrebuildingpassingpassing byby the the sustentaculum tali: sustentaculum tali: pinchingpinching of the line of the line space space astragaloastragalo--calcancalcanééenen internintern..

Osteomielite calcagnoOsteomielite calcagno

•• InflammatoryInflammatory and and painfulpainful tumefactiontumefaction of of the the rightright heelheel. 15 . 15 yearyearold old youngyoung man.man.

•• CT OF OSSEOUS CT OF OSSEOUS HEELS window: HEELS window: IrregularIrregular lysislysis of the of the partpart internsinterns osos calciscalcisrightright..

Osteomielite calcagnoOsteomielite calcagno

•• CT OF SOFT HEELS CT OF SOFT HEELS window LEFT window LEFT INJECTION I V: INJECTION I V: TumefactionTumefaction of the of the soft soft partsparts

Alluce valgoAlluce valgo

•• HereHere twotwo feetfeet of the of the patientpatient;;makemake a note a note the the halluxhallux valgusvalgus etl'etl'wideningwidening of of beforebeforefootfoot..


TWO FEET OF FACE: TWO FEET OF FACE: halluxhalluxvalgusvalgus bilateralbilateral withwithafterafter--effectseffects of of bilateralbilateralsurgicalsurgical operationoperation. . SubuxationsSubuxations of the IPP of of the IPP of the 5the 5èè mymy fingersfingers. . AbsenceAbsence of of erosionerosion and and articulararticular pinchingpinching..


•• RADIOGRAPH BEFORE FEET OF FACE:RADIOGRAPH BEFORE FEET OF FACE:HalluxHallux valgusvalgusbilateralbilateral the, the, prevailprevail one on a side, one on a side, withwith increaseincrease in the in the angle angle betweenbetween the first the first metatarsalmetatarsal and the and the secondsecondmetatarsalmetatarsal

AlgodistrofiaAlgodistrofia•• 40 40 yearyear old man. old man. PainsPains

and and impotanceimpotancefonctionnellefonctionnelle of the of the leftleftlowerlower limblimb. .

•• DiagnosisDiagnosis : : algodystrophyalgodystrophy OF THE OF THE LEFT FOOT LEFT FOOT

•• Diffuse Diffuse demineralizationdemineralizationof of allall the the skeletalskeletalelementselements of of ankleankle and and the the leftleft footfoot. Compare . Compare withwith the the normalnormal aspectaspectof the of the rightright footfoot. . PersistencePersistence of the of the visibilityvisibility of the line of the line spacesspaces whichwhich are are normalnormal

Piede diabeticoPiede diabetico

•• 62 62 yearsyears diabeticdiabetic, obese woman, , obese woman, hospitalizedhospitalized forforplantarplantar evilevil. .

•• DiagnosisDiagnosis : : OSTEOOSTEO--arthropathyarthropathy diabeticdiabetic (ANKLE (ANKLE LEFT).LEFT).

•• ANKLE LEFT: ANKLE LEFT: OsteoarthropathyOsteoarthropathy of of beforebefore footfoot. . DisappearanceDisappearance of of the line the line spacesspaces

•• TOMOGRAPHY OF ANKLE LEFT TOMOGRAPHY OF ANKLE LEFT showingshowing the the destructiondestruction of the line of the line spacesspaces tibiotibio--ppééronronééoo--astragalienastragalien and and astragaloastragalo--calcancalcanééenen..

•• DisappearanceDisappearance of the of the condensedcondensed and and fuzzyfuzzyosseousosseous structurestructure. . DestructionDestruction of the of the articulationarticulation of of ankleankle leftleft..

•• Total Total destructiondestruction of the of the jointsjoints deladela ankleankleand and deformationdeformation..

Documents

Corso di Radiologia - FisiokinesiterapiaBlount’disease • The patient is a 14 + 6 year old black male with a one year history of progressively worsening left knee pain. He states