Musculoskeletal "don't touch" lesions: pictorial essay

Focal bone lesions are not uncommon findings in the daily practice of radiology. Therefore, it is essential to differentiate between lesions with aggressive, malignant potential that require action and those that have no clinical significance, many of which are variants or benign lesions, sometimes self-limited and related to reactive processes. In some cases, a diagnostic error can have catastrophic results. For example, a biopsy performed in a patient with myositis ossificans can lead to an incorrect diagnosis of sarcomatous lesions and consequently to mutilating surgical procedures. The present study reviews the main radiological aspects of the lesions that are most commonly seen in daily practice and have the potential to be confused with aggressive, malignant bone processes. We also illustrate these entities by presenting cases seen at our institution.

Keywords:
Bone diseases; Muscular diseases; Diagnostic imaging; Myositis ossificans; Bone neoplasms

Authorship

Eduardo Kaiser Ururahy Nunes Fonseca Correspondence: Dr. Eduardo Kaiser Ururahy Nunes Fonseca. Hospital Israelita Albert Einstein - Departamento de Imagem. Avenida Albert Einstein, 627, Jardim Leonor. São Paulo, SP, Brazil, 05652-901. Email: edukaiser.unf@gmail.com.

Hospital Israelita Albert Einstein - Departamento de Imagem, São Paulo, SP, Brazil.Hospital Israelita Albert EinsteinBrazilSão Paulo, SP, BrazilHospital Israelita Albert Einstein - Departamento de Imagem, São Paulo, SP, Brazil.

https://orcid.org/0000-0002-0233-0041

Adham do Amaral e Castro

https://orcid.org/0000-0003-0649-3662

Rafael Seiji Kubo

https://orcid.org/0000-0001-8815-3586

Frederico Celestino Miranda

https://orcid.org/0000-0001-8822-5295

Atul Kumar Taneja

https://orcid.org/0000-0002-4655-2033

Durval do Carmo Barros Santos

https://orcid.org/0000-0002-5210-3605

Laércio Alberto Rosemberg

https://orcid.org/0000-0003-4395-1159

Correspondence: Dr. Eduardo Kaiser Ururahy Nunes Fonseca. Hospital Israelita Albert Einstein - Departamento de Imagem. Avenida Albert Einstein, 627, Jardim Leonor. São Paulo, SP, Brazil, 05652-901. Email: edukaiser.unf@gmail.com.

SCIMAGO INSTITUTIONS RANKINGS

Figures

Figures (13)

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Figure 1
A 4-year-old female with spontaneous knee pain. Note, as an incidental finding on an X-ray of the left knee (A), as well as in T2-weighted and T1-weighted MRI sequences of the same knee (B and C, respectively), a typical cortical desmoid (arrows) in the distal femoral metaphysis, located in the posterior cortex.

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Figure 2
A 73-year-old male with knee pain. Anteroposterior X-ray of the left knee showing arthrosis, with subchondral cysts (arrows).

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Figure 3
A 38-year-old female with chest wall pain. An MRI scan shows edema and enhancement of the periarticular bone (arrow) in the first left costochondral junction (in the sternal notch and in the first rib), extending to the adjacent soft tissue between the left sternoclavicular joint and the second left costochondral junction, suggesting local inflammatory changes (costochondritis), with no signs of associated fractures or collections.

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Figure 4
A 61-year-old female with a 10-day history of constant pain, unrelated to trauma. CT showing a small bone island (arrow) in the transition between the body and the wing of the right iliac bone.

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Figure 5
A 28-year-old asymptomatic female reporting disproportionality between the size of the bones on the right side of her body and that of those on the left side (the former being larger than the latter), with an incidental finding of fibrous dysplasia on CT. Note the areas of ground-glass attenuation (arrow).

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Figure 6
A 12-year-old male with a one-week history of pain in the medial region of the left knee. He reported no history of trauma, although he did report being a runner and playing soccer on a regular basis. A well-defined, lobulated bone lesion (arrow) with sclerotic margins in the posteromedial metadiaphyseal subcortical bone of the proximal tibia, with cortical sharpness, with no ruptures.

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Figure 7
A 12-year-old male with a two-day history of right shoulder pain and no history of trauma. An X-ray of the shoulder shows a lytic lesion without aggressive features in the proximal metadiaphyseal region of the humerus, presenting a transverse fracture line with mild medial impaction and signs of developing consolidation, in addition to a dislodged bone fragment within the lesion. The radiographic appearance suggests a simple bone cyst (dashed ellipse).

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Figure 8
A 2-year-old male examined five days after a fall. An MRI scan shows a multilocular cystic expansile osteolytic lesion (dashed ellipse), observed as an incidental finding, in the lateral third of the clavicle, resulting in cortical thinning and narrowing, with a fluidfluid level. The lesion had no softtissue or solid components.

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Figure 9
A 14-year-old male with a six-month history of meningitis, which was still under treatment, and a more recent history of pain in the left hip. MRI shows osteonecrosis of the left femoral head, accompanied by marked edema extending to the proximal metaphysis, without joint collapse or fracture of the loading area. Note the small focus of bone infarction, with a geographic pattern (arrow), in the major trochanter of the left femur.

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Figure 10
10. A 46-year-old female with a history of L5-S1 disc herniation, with a synovial cyst (arrow), identified as an incidental finding on X-ray (A) and MRI (B), in the right femoral neck.

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Figure 11
A 26-year-old female with a two-week history of left knee pain and no history of trauma. X-ray of the lower limbs, obtained to investigate asymmetry, revealed an additional finding of textural alteration with linear bone sclerosis (arrows) in the distal and posterior contour of the right femur, characteristic of melorheostosis.

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Figure 12
A 22-year-old male with left shoulder pain after trauma. MRI of the left axillary region (A) showing a tumor (arrow) involving neural vessels and bundles. Ultrasound (B) showing an infiltrative muscle lesion (arrow), with peripheral calcification in the pectoral/left axillary region and no detectable vascularization on the Doppler flow study. Positron emission tomography (C) and CT (D) showing an infiltrative lesion (arrow) in the left retrosternal/axillary region, with a marked increase in glycolytic activity. The imaging aspect, together with the clinical history, was definitive of myositis ossificans.

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Figure 13
A 27-year-old male examined one hour after a bicycle accident. Note the image suggestive of a humeral cyst (dashed circle) on the X-ray (A), an incidental finding that was not confirmed in complementary views or in MRI study (B), indicating that it was a humeral pseudocyst.

Figure 1 A 4-year-old female with spontaneous knee pain. Note, as an incidental finding on an X-ray of the left knee (A), as well as in T2-weighted and T1-weighted MRI sequences of the same knee (B and C, respectively), a typical cortical desmoid (arrows) in the distal femoral metaphysis, located in the posterior cortex.

Figure 2 A 73-year-old male with knee pain. Anteroposterior X-ray of the left knee showing arthrosis, with subchondral cysts (arrows).

Figure 3 A 38-year-old female with chest wall pain. An MRI scan shows edema and enhancement of the periarticular bone (arrow) in the first left costochondral junction (in the sternal notch and in the first rib), extending to the adjacent soft tissue between the left sternoclavicular joint and the second left costochondral junction, suggesting local inflammatory changes (costochondritis), with no signs of associated fractures or collections.

Figure 4 A 61-year-old female with a 10-day history of constant pain, unrelated to trauma. CT showing a small bone island (arrow) in the transition between the body and the wing of the right iliac bone.

Figure 5 A 28-year-old asymptomatic female reporting disproportionality between the size of the bones on the right side of her body and that of those on the left side (the former being larger than the latter), with an incidental finding of fibrous dysplasia on CT. Note the areas of ground-glass attenuation (arrow).

Figure 6 A 12-year-old male with a one-week history of pain in the medial region of the left knee. He reported no history of trauma, although he did report being a runner and playing soccer on a regular basis. A well-defined, lobulated bone lesion (arrow) with sclerotic margins in the posteromedial metadiaphyseal subcortical bone of the proximal tibia, with cortical sharpness, with no ruptures.

Figure 7 A 12-year-old male with a two-day history of right shoulder pain and no history of trauma. An X-ray of the shoulder shows a lytic lesion without aggressive features in the proximal metadiaphyseal region of the humerus, presenting a transverse fracture line with mild medial impaction and signs of developing consolidation, in addition to a dislodged bone fragment within the lesion. The radiographic appearance suggests a simple bone cyst (dashed ellipse).

Figure 8 A 2-year-old male examined five days after a fall. An MRI scan shows a multilocular cystic expansile osteolytic lesion (dashed ellipse), observed as an incidental finding, in the lateral third of the clavicle, resulting in cortical thinning and narrowing, with a fluidfluid level. The lesion had no softtissue or solid components.

Figure 9 A 14-year-old male with a six-month history of meningitis, which was still under treatment, and a more recent history of pain in the left hip. MRI shows osteonecrosis of the left femoral head, accompanied by marked edema extending to the proximal metaphysis, without joint collapse or fracture of the loading area. Note the small focus of bone infarction, with a geographic pattern (arrow), in the major trochanter of the left femur.

Figure 10 10. A 46-year-old female with a history of L5-S1 disc herniation, with a synovial cyst (arrow), identified as an incidental finding on X-ray (A) and MRI (B), in the right femoral neck.

Figure 11 A 26-year-old female with a two-week history of left knee pain and no history of trauma. X-ray of the lower limbs, obtained to investigate asymmetry, revealed an additional finding of textural alteration with linear bone sclerosis (arrows) in the distal and posterior contour of the right femur, characteristic of melorheostosis.

Figure 12 A 22-year-old male with left shoulder pain after trauma. MRI of the left axillary region (A) showing a tumor (arrow) involving neural vessels and bundles. Ultrasound (B) showing an infiltrative muscle lesion (arrow), with peripheral calcification in the pectoral/left axillary region and no detectable vascularization on the Doppler flow study. Positron emission tomography (C) and CT (D) showing an infiltrative lesion (arrow) in the left retrosternal/axillary region, with a marked increase in glycolytic activity. The imaging aspect, together with the clinical history, was definitive of myositis ossificans.

Figure 13 A 27-year-old male examined one hour after a bicycle accident. Note the image suggestive of a humeral cyst (dashed circle) on the X-ray (A), an incidental finding that was not confirmed in complementary views or in MRI study (B), indicating that it was a humeral pseudocyst.

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Musculoskeletal "don't touch" lesions: pictorial essay

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[1] Correspondence: Dr. Eduardo Kaiser Ururahy Nunes Fonseca. Hospital Israelita Albert Einstein - Departamento de Imagem. Avenida Albert Einstein, 627, Jardim Leonor. São Paulo, SP, Brazil, 05652-901. Email: edukaiser.unf@gmail.com.