Marcel E. Durieux, MD, PhD

• Professor
• Departments of Anesthesiology and Neurological Surgery
• University of Virginia
• Charlottesville, Virginia

Phase: Extracapsular spread of infection from a suppurative lymph node rupture results in abscess formation blood pressure medication every other day 0.25 mg digoxin amex. Can also result from ventral spread of diskitis/osteomyelitis and prevertebral infection or from accidental or iatrogenic pharyngeal perforation pulse pressure 19 cheap digoxin 0.25 mg visa. Lipomas of the retropharyngeal space are rare and do not cause symptoms until they reach a large size and have a significant mass effect on the pharynx (obstructive sleep apnea) arrhythmia hypothyroidism order digoxin 0.25mg line. Such fatty tumors also carry the rare possibility of being liposarcomas (inhomogeneous mass with soft tissue and fatty components and contrast enhancement) heart attack 85 blockage order digoxin, which further warrants their excision blood pressure lowering discount 0.25mg digoxin with mastercard. Also seen is an irregular blood pressure medication olmetec order digoxin toronto, ill-defined, low-density fluid collection (open arrow) after medial rupture in to the retropharyngeal space, as well as additional bilateral reactive nodes (N). Necrosis appears as central low density with a variably thick, irregular enhancing wall. Later extranodal progression may cause the lymphomatous tissue to fill the entire retropharyngeal space. At the level of the nasopharynx, an ill-defined soft tissue mass of the posterior wall may be seen with extrapharyngeal tumor spread in to the soft tissues of the retropharyngeal space in a nonnodal pattern of retropharyngeal space involvement. Associated malignant lymphadenopathy in the suprahyoid retropharyngeal space may be present. Metastatic involvement of lateral and medial retropharyngeal lymph nodes is most commonly seen with a nasopharyngeal primary squamous cell carcinoma, but also with an oropharyngeal, nasal cavity, and hypopharynx carcinoma. In addition, the retropharyngeal lymph nodes may be involved by thyroid carcinoma, malignant melanoma, and breast carcinoma. The most common malignant processes involving the suprahyoid retropharyngeal space are direct contiguous extension from nasopharyngeal, posterior oropharyngeal wall, or tonsillar carcinoma. Nasopharyngeal lymphoma, rhabdomyosarcomas, or minor salivary gland malignancies may also involve the retropharyngeal space by direct extension from the nasopharynx (visceral space) or involvement of the retropharyngeal lymph nodes. Contiguous tumor extension Trauma Emphysema Interstitial radiolucent gaseous collections in the retropharyngeal space and in several other spaces, including subcutaneous tissues. Extensive soft tissue emphysema may extend downward, giving rise to pneumomediastinum. Tense fluid collection distending the retropharyngeal space in a nonnodal pattern of retropharyngeal space involvement producing pharyngeal airway narrowing. In the subacute stage, the hematoma may be either isodense or slightly hypodense, with patchy or inhomogeneous appearance. When completely liquefied, the hematoma again has a homogeneous density that is lower than muscle and may be surrounded by a pseudocapsule, which enhances after contrast administration. Gas in the retropharyngeal space secondary to laryngeal trauma and accidental (foreign body, fish bones, and gunshots) or iatrogenic pharyngeal perforation (endoscopy, intubation, and assisted ventilation) is well known. Hematomas in the retropharyngeal space are unusual and are most often related to blunt head and neck trauma. Nontraumatic causes of retropharyngeal hematoma include anticoagulant therapy and complications of aneurysms, tumors, and infection. Absent ipsilateral internal jugular vein and sternocleidomastoid muscle from radical neck dissection, or an ipsilateral jugular foramen mass are findings of underlying cause. Asymmetry of the levator scapulae muscles is an unusual cause of a palpable posterior triangle mass. Damage to the spinal accessory nerve secondary to radical neck dissection or, less commonly, an ipsilateral jugular foramen mass (paraganglioma, schwannoma, meningioma, or metastasis) leads to denervation atrophy of the trapezius muscle with compensatory hypertrophy of the levator scapulae muscle. In case of levator scapulae muscle atrophy secondary to cervical spondylosis with spinal nerve compression of the C3, C4, and C5 roots, the normal-sized contralateral levator scapulae muscle may present as a palpable mass. A normal variant not to be mistaken for an abnormality (lymphadenopathy or unenhanced vessel). Levator claviculae muscle Uni- or bilaterally, the levator claviculae muscles arise from the anterior portion of the transverse processes of the upper cervical vertebrae (most likely above the C3 level), then head inferiorly and laterally, coursing lateral to the scalene muscles, anterior to the levator scapulae muscle, and medial to the sternocleidomastoid muscle, and insert in the lateral third of the clavicle, blending with the trapezius. At the beginning, they extend in a horizontal direction; in the more advanced phase, they become hooked and grow vertically. Sometimes osteophytes develop on both sites of a disc space and grow until they fuse together to form a "bridge" osteophyte. Vertebral body osteophyte Spondylosis deformans of the cervical spine is the most typical consequence of age- or load-related degeneration of the vertebral body. Osteophytes can be distinguished from syndesmophytes of ankylosing spondylitis, paravertebral ossification of psoriasis and reactive arthritis, and bulky anterior-flowing ossification of the anterior longitudinal ligament of diffuse idiopathic skeletal hyperostosis. Hypertrophic degenerative facet may be perceived as a cervical mass on physical examination. Facet degenerative arthropathy Osseous facet overgrowth ("mushroom cap" facet appearance) and bone excrescences impinging on neural foramina and the spinal canal in conjunction with articular joint space narrowing with sclerosis and intra-articular gas (vacuum phenomenon). Enhancing inflammatory soft tissue changes surrounding the facet joint are common. Congenital/developmental lesions Venous vascular malformation (cavernous hemangioma) Lobulated soft tissue mass, isodense to muscle, containing rounded calcifications (phleboliths). These are usually infiltrative transspatial lesions and may extend in to the perivertebral space as part of multiple space involvement. Comment Lymphatic malformations represent a spectrum of congenital low-flow vascular malformations, differentiated by size of dilated lymphatic channels. May be sporadic or part of congenital syndromes (Turner, Noonan, and fetal alcohol syndrome). In the oral cavity, lymphatic malformations can occur in the tongue, floor of the mouth, cheek, and lips. The paraspinal soft tissue component with soft tissue swelling, cellulitis with diffusely enhancing soft tissue edema, and abscess formation tend to involve the entire prevertebral space. Gas within both bone and adjacent soft tissue is a reliable indicator of infection. The prevertebral space infection may secondarily involve the retropharyngeal space and carotid space. Phlegmon of the perivertebral space may present as focal or diffuse muscle enlargement and obliteration of soft tissues, fascial planes and skin, due to diffuse soft tissue edema, with enhancement. Often associated with abscess formation: peripherally enhancing, low-density liquefied collection, with or without gas. Vertebral osteomyelitis is usually caused by hematogenous spread to the vertebral body, whereas infection of the intervertebral disc is due to osteomyelitis of the adjacent vertebral body that secondarily invades the disc or to direct contamination of the disc during surgical spine procedures or penetrating trauma. Soft tissue infection Soft tissue infection of the prevertebral and/or paraspinal portion of the perivertebral space from direct extension from adjacent infection (spondylodiscitis and septic facet arthritis), hematogenous spread from distant sites, or transcutaneous direct inoculation of deep tissue. Calcific tendinitis of the longus colli muscle is characterized by the deposition of calcium hydroxyapatite in to the longus colli tendon. Patients (third to sixth decade) often complain of odynophagy, neck pain, paraspinal muscle spasm, and mild fever for 2 to 7 days. Longus colli tendinitis Focal soft tissue thickening with calcification in the prevertebral area anterior to C1 and C2. It is associated with a retropharyngeal space edema, extending as a uniform low-density fluid collection in the retropharyngeal space down to C5, without significant mass effect, without wall enhancement, or surrounding cellulitis. However, if the dissection occurs in the subadventitial layer, considerable wall expansion may occur without causing relevant vessel narrowing. A thin rim of contrast enhancement can sometimes be seen surrounding the mural hematoma (possibly resulting from enhancement of the vasa vasorum). Dissection of the vertebral artery is an often overlooked cause of stroke in young adults (45 y). Vertebral artery dissections are caused by a primary intramural hematoma (due to ruptured vasa vasorum) or by penetration of blood in to the arterial wall through a primary intimal tear. Nontraumatic dissection can be either spontaneous or in association with an underlying vasculopathy. Dissections may cause headache or neck/suboccipital pain, accompanied or followed by ischemic symptoms, originating in the vertebrobasilary territory (either from flow reduction or thromboembolic complications). Rarer clinical manifestations include cervical spine cord ischemia and cervical root impairment. Large tumors may undergo cystic degeneration and therefore present with central unenhancing and peripheral enhancing areas. Sporadic neurofibromas may present as solitary or multiple ovoid or fusiform heterogeneous low-density masses with well-circumscribed margins. Tumors of neurogenic origin are some of the more frequently seen benign neoplasms of the perivertebral space. This consists mainly of anterior displacement and effacement of the longus muscle at suprahyoid levels and of the anterior scalene muscle at infrahyoid levels. Neurofibroma Aggressive fibromatosis (extra-abdominal desmoid fibromatosis, juvenile fibromatosis) Benign soft tissue tumor of fibroblastic origin arising from aponeurotic neck structures. Other benign mesenchymal tumors of the perivertebral space are relatively rare and include (myo)fibroblastic tumors, fibrohistiocytic tumors, rhabdomyoma, mesenchymoma, or myxoma. Clinically, these present as a mass of increasing size, associated with discomfort or pain. Comment Only 2% to 3% of osteochondromas (sporadic, hereditary multiple exostosis) occur in the spine: cervical (50%, C2 predilection) thoracic lumbar sacrum. Primary lesions are usually observed in the first, second, and third decades of life, with slight female predominance; 20% occur in the spine. Lytic, expansile lesion centered in the vertebral body, with heterogeneous contrast enhancement; may contain fluid attenuation regions due to necrosis or focal aneurysmal bone cyst component. The expansile, lytic lesion with thin, sclerotic margins may contain partially calcified matrix. Giant cell tumor In spine, peak incidence in second and third decades of life, with female preponderance. Can undergo sarcomatous transformation (spontaneously or in response to radiation therapy). Histologically identical to osteoid osteoma but larger and occurs typically in the spine. Osteoblastoma Malignant neoplasms Vertebral body metastases Focal, multifocal, or diffuse involvement of the cervical spine with osteolytic, osteoblastic, or mixed-type lesions. Associated cortical bone destruction and contiguous enhancing soft tissue extension in to the perivertebral space are common. Bone expansion is virtually limited to lytic metastases from carcinomas of the kidney, thyroid, and lung and osteoblastic metastases from prostatic carcinoma that may mimic Paget disease. Metastatic disease to the vertebral body with extraosseous tumor extension through cortical perforations is the most common malignant lesion of the perivertebral space. Most common symptoms are spine pain, focal tenderness, soft tissue mass, and neurologic compromise from cord compression. Mild/moderate contrast enhancement with inhomogeneous necrotic areas is characteristic. Anteroinferiorly expanding tumor of the clivus may invade or displace the nasopharyngeal perivertebral space and nasopharynx. Lytic, permeative bone destruction with enhancing poorly defined soft tissue mass involving adjacent structures (epidural, paraspinal muscles) is characteristic. Solitary, large, expansile, osteolytic lesion with scalloped, poorly marginated, nonsclerotic margins, associated with soft tissue masses, with mild/moderate homogeneous contrast enhancement. The vertebral body is more frequently involved by plasmocytoma, but the disease may also affect the posterior elements. No tumoral calcifications, but peripherally displaced osseous fragments may be seen. Primary sclerotic form is extremely rare, but sclerosis may occur after proper treatment. Epidural extension and/or variable degrees of pathologic fractures (vertebra plana) may cause spinal cord compression. Common spine presentations are multiple or diffuse lytic lesions, sometimes associated with irregular dense hypertrophy of the remaining vertical trabeculae or diffuse osteopenia. Vertebral destruction and pathologic fractures with variable spinal canal narrowing are common. Most common presenting symptom is pain, most often in patients between the ages of 40 and 70 y. Plasmocytoma Solitary intra- or extramedullary tumor of plasma cells, with no evidence of multiple myeloma elsewhere. Cervical spine plasmocytomas occur in patients older than 40 y, with male predominance; can be asymptomatic or present with local neck pain, low levels of serum/urine monoclonal proteins, and neurologic compromise from cord compression. Multiple myeloma Most common primary tumor of bone with multifocal malignant proliferation of monoclonal plasma cells within bone marrow. Occur in 40- to 80-y-old patients (M:F 3:2), more common in African Americans than Caucasians or Asians. Several different primary neoplasms can arise in the soft tissues of the perivertebral space: malignant fibrous histiocytoma, fibrosarcoma, neurofibrosarcoma, hemangiopericytoma, synovial sarcoma, and rhabdomyosarcoma. Metastatic disease within the muscles of the perivertebral space is rare and is seen most frequently with advanced disease. The center of a mass in the paraspinal portion is within the paraspinal musculature or posterior vertebral body elements, and the mass displaces the paraspinal musculature and posterior cervical space fat away from the spine. Comment Late cases of pharyngeal squamous cell carcinoma, particularly those arising in the posterior pharyngeal wall, may rarely invade the perivertebral space. Unlike hematoma, muscle hemorrhage has little mass effect, with preservation of fascial planes. Hematomas are a common finding after sport and other injuries associated with cervical spine and muscle injury. Hematomas can be seen in the muscle, in the intermuscular fat planes, or within the subcutaneous tissues.

This allows interventionists to tackle cases that were not previously considered feasible and hence improves the success rates appreciably low blood pressure chart nhs buy digoxin in united states online. A graduated wire approach is usually followed blood pressure top number discount 0.25mg digoxin mastercard, starting with a softer wire and progressing to stiffer ones as needed arrhythmia caffeine order digoxin 0.25mg amex. Having the balloon or the microcatheter close to the tip of the wire increases its stiffness significantly blood pressure medication metoprolol buy digoxin online now. Experienced operators may prefer going directly to stiffer specialty wires to reduce the risk of creating a false channel with softer wires heart attack enrique lyrics purchase 0.25mg digoxin with mastercard. Provide further stiffness to the wire by advancing the shaft of the catheter closer to the wire tip arrhythmia in 5 year old cheap digoxin 0.25 mg free shipping. Frequently, distal segments are diffusely diseased, and multiple and/or long stents are required. Commonly, distal vessels appear small due to underfilling and impaired endothelial function. Retrograde filling from left to right collaterals reached the distal segment of the artery (not shown). In such cases, the wire should be left in place for two purposes: to plug the entrance to the false channel, and, with angiography in multiple projections, to guide the entrance of a second wire. Therefore, the second wire almost always needs to be on the inside of the first one. If the second wire again passes in to a false channel, it can be left in place and the first one pulled back and used for another attempt, hence the name see-saw technique. Other operators prefer to leave both wires in place and try to cross with a third wire. Before injecting, it is important to ensure the lumen is cleared of air by giving it time to "bleed back," aspirating gently using a small syringe and filling the catheter hub with saline as a small contrast syringe is connected. Immediately after the contrast injection, the lumen must be cleared by a saline injection to avoid crystallization of contrast molecules, which can impair advancing the wire back in the distal lumen. The balloon is in the true lumen, as evidenced by brisk flow and washout of contrast, in addition to visualization of small branches distally (B, arrow). Defining the actual size, degree of tortuosity, and continuity of the collateral with the recipient vessel are all critical steps in planning the procedure. These vessels are thin walled and more prone to dissection and rupture, thus wiring should be done meticulously and with patience. A soft wire is advanced in to the collateral through a balloon catheter or a microcatheter. Septal perforators tend to spasm over the wire and frequently require very gentle balloon inflations (1. A septal dilator catheter is now available and may obviate the need for this step. Subintimal Tracking and Reentry Techniques this group of techniques can be performed antegrade or retrograde. They are generally reserved for cases that are not amenable to the techniques described earlier. The incidence of major adverse events has significantly dropped over the last few decades. Attention must be paid to delayed tamponade, diagnosed hours after the procedure, which is a typical presentation for wire perforations. Operators should be restrained when using contrast during wiring and in cases in which dual injections are needed. Success rates have improved significantly, but vast experience is needed to achieve these improved outcomes. Nonetheless, the potential for complications exists, particularly with more aggressive and complex techniques. Prior to attempting these procedures, operators and patients need to have a comprehensive discussion about risks versus benefits. Improvement in survival following successful percutaneous coronary intervention of coronary chronic total occlusions: variability by target vessel. A comparison of the transradial and the transfemoral approach in chronic total occlusion percutaneous coronary intervention. Retrograde percutaneous recanalization of chronic total occlusion of the coronary arteries: procedural outcomes and predictors of success in contemporary practice. Trends in outcomes after percutaneous coronary intervention for chronic total occlusions: a 25-year experience from the Mayo Clinic. Procedural and in-hospital outcomes after percutaneous coronary intervention for chronic total occlusions of coronary arteries 2002 to 2008: impact of novel guidewire techniques. Procedural outcomes and long-term survival among patients undergoing percutaneous coronary intervention of a chronic total occlusion in native coronary arteries: a 20-year experience. Higher frequency of stent malapposition and asymmetry may account for higher acute and subacute stent thrombosis rates. Patient Management Approach to the Patient the first step in approaching the patient with coronary calcification is identification. Once identified, the next step is to ascertain whether the calcification will interfere with the delivery and performance of interventional equipment. In general, larger guiding catheters and "extra backup" shapes that offer greater support are preferred (Table 7e. However, in cases of vessel tortuosity and/or angulated lesions, it may be difficult to cross a heavily calcified lesion with a supportive wire. In these cases, crossing a lesion with a light support or hydrophilic-coated wire and exchanging for the more supportive wire with an exchange catheter or an over-the-wire balloon system may be advantageous. If it still proves difficult to advance equipment past a calcified lesion, advancing a second guidewire (a "buddy wire") to assist has been established as a useful technique to deliver equipment. Rarely, medium-support wires in the setting of calcification combined with tortuosity may paradoxically hinder delivery of equipment. In these cases, reverting back to light support wires can occasionally lead to success not achievable with more supportive wires. However, noncompliant balloons may not initially cross a calcified stenosis, and initial dilation with an undersized (0. In choosing a stent, the ability to cross a lesion is an important consideration and, in general, those stents with more compliant delivery systems are more deliverable. Yet stent apposition and symmetry are important in reducing acute and subacute complications, and a less compliant stent delivery system may be advantageous in the setting of vessel calcification. This led to a proliferation of technologies aimed at increasing luminal diameter prior to stent insertion (Table 7e. Once the plaque is "scored" in this fashion, the hoop stress of balloon inflation is decreased, which leads to more consistent expansion of balloons and subsequent stents. The cutting balloon uses lower balloon inflation pressures to achieve a larger lumen gain, which may reduce the incidence of major dissection. It increases the relative contribution of plaque compression to vessel dilation in overall vessel expansion, which may be of particular advantage in the setting of circumferential calcification that significantly inhibits vessel expansion. By inflating the balloon against these wires, points of highly focal longitudinal stress are introduced at low inflation pressures. Initial studies suggested improved stent expansion, but the balloon is no longer available for use in the United States. A well thought-out strategy with regard to equipment and approach is highly recommended. Heavily calcified coronary lesions preclude strut apposition despite high pressure balloon dilatation and rotational atherectomy: in vivo demonstration with optical coherence tomography. Coronary plaque morphology affects stent deployment: assessment by intracoronary ultrasound. The dilemma of diagnosing coronary calcification: angiography versus intravascular ultrasound. Drug-eluting stents versus bare metal stents following rotational atherectomy for heavily calcified coronary lesions: late angiographic and clinical follow-up results. Mechanisms of acute lumen gain following cutting balloon angioplasty in calcified and noncalcified lesions: an intravascular ultrasound study. Nonrandomized comparison of coronary stenting under intravascular ultrasound guidance of direct stenting without predilatation versus conventional predilitation with a semi-compliant balloon versus predilation with a new scoring balloon. Optimizing plaque modification in complex lesions utilizing the AngioSculpt device: acute and long term results from a large two-center registry. Unfortunately, exaggerated plaque shift caused by stenting the main branch may compromise side branches. In cases in which both the main vessel and the side branch are stented, reported incidences of major adverse events range up to 9%. This technique is associated with a 98% angiographic success rate in both branches. Planning and Risk Assessment To determine the technique most likely to be effective for a particular type of bifurcation lesion, various classification schemes have been developed that are based on angiographic morphology. Generally, one should attempt to preserve any at-risk side branch of greater than 2. The anatomic descriptive classification systems provide useful information regarding the short- and long-term risk of failure. It may be wisest to adopt a combination of simple schemes that includes the useful subscripts describing angulation, calcification, or left main coronary artery involvement. The choice of guide is determined by the angulation proximal to the lesion, the angulation of the lesion, and the severity of calcification. Generally, once you have determined the minimum guide support that you suspect will be successful, step it up one notch. If final dilation with a kissing balloon is anticipated, ensure that the inner lumen (7 or 8 Fr) will accommodate two balloons. Guiding-catheter choice may be the key to success, and in a bifurcation case, it is a choice that you cannot take back. If the main branch is the principal target, any floppy-tipped wire is appropriate. Techniques For almost all bifurcation lesions with a significant side branch, both vessels should be wired. When it is likely that the bifurcation lesion endangers the side branch, or if there is ostial or more extensive side-branch disease (Medina 1. The initial plan is to implant the main-branch stent so as to leave the sidebranch wire "jailed. After the wire is successfully placed in the side branch, the jailed wire may be removed. After predilation through the stent struts, final kissing-balloon postdilation is performed. In the event that residual stenosis of greater 75% remains in the side branch, a second stent may be deployed (T-technique) in the nonstented side branch. Avoid excessively stretching the proximal left main artery when both balloons are inflated simultaneously (Table 7f. If significant extra-ostial disease is present within the side branch, or if occlusive or near-occlusive dissection of the side branch results from predilation, the side branch should be stented first, and only secondary attention should be paid to the distal main branch. Alternative Techniques In the "classical crush" technique, a stent is positioned in the side branch with about one-third of its length protruding in to the main branch. Another stent is positioned in the main branch (covering the proximal and distal segments of the lesion and the ostium of the side branch). The side-branch stent is deployed, and if there is no downstream dissection, the side-branch balloon and wire are removed. The main-branch stent is then deployed, crushing the portion of the side-branch stent lying in the main branch. In the "mini-crush" technique, the side-branch stent is slightly retracted in to the main vessel, and a balloon is used to crush the side-branch stent rather than the main-branch stent. This procedure is followed by the jailed wire technique, then kissing-balloon angioplasty. If the side branch is to be stented first, then a floppy-tipped wire is used there, and the hydrophilic wire is used in the main branch. Recrossing in to a vessel through the side struts is more easily accomplished with a hydrophilic wire. With respect to stent choices, stent designs differ in the maximum diameter that can be achieved by side-strut dilation. Therefore, the size of the side branch (or main branch) should be the most important determinant of stent choice. Wire all side-branches t2 mm in diameter, crossing the most difficult part of the lesion first. Plan on provisional side-branch treatment if possible and provisional side-branch stenting if side-branch treatment is necessary. A planned, modified Y-technique (stenting the distal main branch and side branch only) may be considered if the proximal main segment is completely normal. For bifurcation lesions with involvement of the side-branch ostium, predilate both the side-branch and the main branch. For provisional side-branch treatment, decide whether to predilate the side branch after the main branch is predilated. Stent the main branch first unless there is potential abrupt closure of the side branch or the angle of the side branch remains t90 degrees after wiring and sidebranch stent treatment is deemed necessary. Obtain side-branch wire access via stent side struts, using the original side-branch wire as a guide. End with kissing-balloon postdilation, alternately using high-pressure inflation in either branch, ending with the main branch.

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Histiocytic lymphoma (large B-cell lymphoma) frequently has a mixed osteolytic-osteoblastic appearance and may resemble Paget disease without bony expansion blood pressure chart history cheap 0.25mg digoxin amex. Diffuse sclerosis of a vertebral body ("ivory" vertebra) is not an unusual manifestation arrhythmia forum order digoxin 0.25 mg on line. Osteolytic lesions tend to be poorly defined and are associated with periostitis in one third of the cases blood pressure medication valsartan purchase on line digoxin. Burkitt lymphoma presents as expansile osteolytic lesions associated with a soft tissue mass hypertension pamphlet order online digoxin. Involvement of the facial bones (especially the maxilla) is most characteristic in children in tropical Africa hypertension of the lungs buy digoxin 0.25 mg. Discrete or poorly defined osteolytic lesions may be associated in the appendicular skeleton blood pressure medication hydrochlorothiazide buy generic digoxin 0.25mg online. Leukemias are classified based on cell maturity (acute with immature or blastic cells versus chronic with mature cells), cell morphology (myeloid versus lymphoid) or cell origin (thymus derived T cells versus blood marrow derived B cells). Skeletal abnormalities are similar for all forms of leukemias, but are most common in acute childhood leukemias, where they occur in over 50% of cases, and least common in chronic leukemias. Leukemia Diffuse osteopenia with medullary widening and cortical thinning in tubular bones and vertebral compressions are the most common presentation. Radiolucent and/or radiodense metaphyseal bands, as well as periosteal new bone formation, are particularly common in children. Complications may include intra-articular and subperiosteal hemorrhages, septic arthritis, osteomyelitis, osteonecrosis, and secondary gout. Granulocytic sarcomas (chloromas) present as single or multiple, often expansile lytic lesions in the skull, spine, ribs, sternum, and long tubular bones, usually in acute myelogenic leukemia. Osseous manifestations vary from a chest wall soft tissue mass (arrows) secondary to a completely destroyed rib (a), to a solitary osteolytic humeral head lesion (b), to a mixed osteolytic and osteoblastic lesion in the femoral neck (c), and diffuse osteoblastic manifestations (d). A coarse trabecular pattern that can mimic a hemangioma is seen in this vertebral body. Relatively well-defined radiolucent areas with endosteal scalloping with or without slight bone expansion and varying degrees of periosteal new bone formation and sclerosis are typical in the long bones. More aggressive lesions with cortical violation and interrupted laminated periosteal reaction may mimic acute osteomyelitis or Ewing sarcoma. Well-defined lytic lesions with or without sclerotic borders may be found in the skull and pelvis. Larger osteolytic areas in the skull typically depict beveled edges caused by the uneven destruction of the inner and outer tables. In the mandible, radiolucent lesions about the teeth may lead to the "floating teeth" appearance. In the spine, a collapsed vertebral body (vertebra plana) with intact intervertebral spaces or, less frequently, a lytic and occasionally slightly expansile lesion involving the vertebral body and/or the posterior elements may be found. Osteolytic lesions of variable size with endosteal scalloping simulating multiple myeloma preferentially located in the proximal humerus or proximal femur is the most common presentation. Subchondral amyloid deposition may result in avascular necrosis caused by perivascular amyloid deposition with subsequent vascular occlusion. Subchondral cyst formation and erosions in the hand and wrist (especially carpal bones) associated with periarticular or diffuse osteoporosis may simulate rheumatoid arthritis, although extensive nodular soft tissue masses, well-defined cystic lesions with or without surrounding sclerosis and preservation of the joint space are more characteristic for amyloidosis. Single or multiple, occasionally expansile, well- to poorly defined osteolytic lesions of the axial and appendicular skeleton. Brown tumors may undergo necrosis and liquefaction, producing cysts, or with proper treatment (removal of the parathyroid adenoma) become increasingly sclerotic. Central (intraosseous) or eccentric (subperiosteal), well-demarcated osteolytic lesion, often associated with cortical violation, a solid or interrupted periosteal reaction, and a large soft tissue mass is a common presentation. Minimal to massive calcification within the lesion is occasionally also encountered. One or more cystic lesions often with partial calcification may be found in the subchondral and deeper osseous areas simulating enchondromas. Eosinophilic granuloma is both the most common and most benign variant, representing about 70% of cases. Spontaneous healing of a solitary lesion occurs, typically progressing from the periphery toward its center, and eventually resulting in its disappearance or transformation in to a sclerotic focus. Bone lesions are less common but may include multiple widespread lytic lesions in the skull ("raindrop" pattern). Hepatosplenomegaly, lymphadenopathy, and nonitching eczematous skin lesions are commonly associated. Secondary amyloidosis is associated with chronic renal disease, rheumatoid arthritis, lupus erythematosus, ulcerative colitis, chronic suppurative disease, and lymphoproliferative disorders. Other manifestations of hyperparathyroidism are usually also apparent and include osteopenia, subperiosteal, endosteal, and subchondral bone resorption, intracortical tunneling, chondrocalcinosis, and paraarticular calcifications and vascular calcifications. Lesions are late sequelae of intramedullary or periosteal hemorrhage/hematoma occurring in 2% of hemophiliacs. Hemophilic arthropathy, including dense joint effusions and joint contractures, avascular necrosis, especially of the femoral head and talus, spontaneous fractures, and soft tissue hematomas, may also be evident. Intraosseous urate deposition with subsequent calcifications usually originates from the adjacent joint, penetrates the cartilaginous surface, and extends in to the spongiosa. An eccentric lesion is seen in the midshaft of the femur with cortical destruction, soft tissue extension, and periosteal reaction. Diffuse lytic and sclerotic involvement of the vault and base of the skull is seen. Vertebral manifestations include a poorly defined osteolytic lesion (a), a well-demarcated osteolytic lesion with a sclerotic border (b), and a vertebra plana (c). Expansile lesion with central calcification is seen in the left ilium of a patient with von Willebrand disease. In the diametaphyses, they include serpiginous peripheral rim of calcification or sclerosis surrounding an oblong area of bone rarefaction. Intramedullary calcifications are often the only finding and are typically shell-like and peripheral, whereas the calcifications in chondroid matrix tumors tend to be punctate, ringlike or irregular and central and are surrounded by a rim of noncalcified, radiolucent tumor matrix. Solid periosteal reactions and cortical thickening may be associated with both conditions, but in the case of chondroid matrix tumor suggest a low-grade chondrosarcoma rather than enchondroma. Typical findings of osteonecrosis in the epiphyses (avascular necrosis) include curvilinear subchondral sclerosis, subchondral cyst(s) with sclerotic rim, arclike subchondral radiolucency (crescent sign), subchondral fragmentation, and eventually collapse of the articular surface, with considerable sclerosis and secondary degenerative changes in the affected joint. Comments Osteonecrosis can be divided in to bone infarction, occurring more frequently in the metadiaphyseal regions of long bones. Osteonecrosis may be idiopathic (25%) or associated with hematological and reticuloendothelial diseases. Round to ovoid radiolucent lesions within the cortex of long tubular bones are characteristic as opposed to endosteal scalloping caused by tumor recurrence. Bony changes are dose-dependent, with a minimal dose of 3000 cGy required, and occur at the earliest 1 y after irradiation, at a time, when a nuclear medicine scan no longer depicts an increased uptake. Demonstration of a fracture line in an area of localized elliptical cortical thickening of a long tubular bone (as opposed to a round or ovoid intracortical abscess or a nidus) is diagnostic. Intra-articular/periarticular soft tissue mass and joint effusion with often slightly increased attenuation values due to varying degrees of hemosiderin deposition are characteristic. Subchondral pressure erosions with or without sclerotic margins may be found in "tight" joints, such as hip, ankle, and wrist. A hemorrhagic (chocolate brown) joint effusion in the absence of trauma is characteristic. Differential diagnosis: synovial (osteo)chondromatosis in which calcified/ossified loose bodies are characteristic. Symmetric bilateral fracture lines (arrows) with considerable adjacent sclerosis are seen in the sacrum. A soft tissue mass (arrows) is seen in the intercondylic area causing an erosion with sclerotic margin in the medial femoral condyle. Progression of the disease to the Haversian and Volkmann canals results in cortical fissuring with subsequent destruction and subperiosteal abscess formation. A periosteal reaction (laminated or, less commonly, spiculated) is a characteristic finding at this stage. After 1 month, a sequestrum (detached necrotic cortical bone) presenting as a radiodense bony spicule surrounded by granulation tissue and newly formed cortical bone (involucrum) may be evident. Osteomyelitis from a contiguous soft tissue infection typically presents as focal osteoporosis due to edema with subsequent cortical erosion. Usually solitary, lytic, and often elongated lesion with sclerotic border typically in the metaphyses of long bones. In the diaphysis, the abscesses may be found in central, subcortical, or cortical locations. In the cortex, the abscess is surrounded by periosteal new bone formation, simulating an osteoid osteoma or a stress fracture. Thick, irregular sclerotic bone with radiolucencies and extensive periosteal new bone formation is characteristic. Signs of remaining activity or reactivation include a change from the previous exam, poorly defined areas of osteolysis, laminated periosteal reaction, poorly defined bony excrescences, and demonstration of a sequestrum, sinus tract, or soft tissue abscess. In the latter location, osteoid osteoma, stress fracture, and Ribbing disease (hereditary multiple diaphyseal sclerosis with typically asymmetric distribution) must be considered in the differential diagnosis. Occurs by hematogenous route, spread from contiguous infection, or direct implantation (punctures, penetrating injury, and postoperative infection). Pyogenic osteomyelitis in children is most often caused by Staphylococcus aureus, Streptococci, Escherichia coli, and Haemophilus influenzae. Compared with pyogenic osteomyelitis, osteoporosis is more pronounced, whereas new bone formation is less extensive. Tuberculous dactylitis (spina ventosa) refers to cystic expansion of the short tubular bones of the hands and feet of young children with varying degrees of periostitis. Cystic tuberculosis presents as one or multiple welldefined osteolytic foci without sclerosis, preferentially in the peripheral skeleton. Solitary or multiple osteolytic lesions with discrete margins, mild surrounding sclerosis, and little or no periosteal reaction are a common presentation. Subacute pyogenic osteomyelitis (smoldering indolent infection), usually of staphylococcal origin, is common in children, in whom the lesion is typically located in the proximal or distal tibia metaphysis and sometimes connected to the growth plate by a tortuous channel. Histologically, a central purulent or mucoid fluid collection is surrounded by inflammatory granulation tissue and spongy bone eburnation. Thickened sclerotic long bones caused by endosteal and periosteal new bone formation and ill-defined lytic lesions (gumma formation) are characteristic. Epidermoid carcinoma occurs in 1% of osteomyelitis at the site of a chronically draining sinus and is evident as an enlarging soft tissue mass eroding the osteomyelitic bone. Destructive lesion is seen in the mandible with a thin, laminated periosteal reaction (arrow). Destructive lesion with scattered areas of gas collection is seen in the lumbar vertebral body. Osteolytic lesions in the right acetabular roof are associated with three large abscesses in the surrounding soft tissues. Preferential locations are the hip and shoulder regions, although any bone can be affected. In the pelvis, a rapidly destructive arthropathy of the hip presenting with destruction of primarily the femoral head and to a lesser degree the acetabulum must be differentiated. Solitary or multiple soft tissue masses with erosions of the adjacent bone or osteolytic lesions. Comments Occurs sporadically at any age, without gender predilection, but is usually diagnosed before the age of 40 y. Histologically, a nonmalignant proliferation of angiomatous and fibrous tissue is evident. Other osteolysis syndromes diagnosed in infancy or childhood include acro-osteolysis of Hajdu and Cheney, Joseph, or Shinz, carpal-tarsal osteolysis (hereditary or associated with nephropathy), Farber disease (elbows, wrists, knees, and ankles), and Winchester syndrome (carpal and tarsal areas and elbows). Involvement of the adjacent bone is not uncommon in infantile forms of the disease. Rare hereditary disorder of adipose tissue affecting primarily the bones and brain. Presents commonly in the second or third decade of life with painful bones and joints and subsequently with presenile dementia. Common disorder of middle-aged and elderly patients that is often diagnosed as an incidental finding on radiographs obtained for unrelated purposes. The disease is present in 10% of patients over the age of 80 y and rare in patients under 40. Laboratory findings include elevated alkaline phosphatase and hydroxyproline levels in the serum and abnormally high hydroxyproline urine levels. Neoplastic involvement in Paget disease includes sarcomatous degeneration, giant cell tumor, aneurysmal bone cyst, and superimposition of metastases, multiple myeloma, and lymphoma.

Femur shaft fractures are best classified by location (proximal blood pressure 40 buy discount digoxin, middle blood pressure guidelines 2015 cheap 0.25mg digoxin amex, and distal third or junction between these regions) and fracture morphology blood pressure 50 over 70 buy line digoxin, including degree and type of comminution heart attack 8 months pregnant order 0.25mg digoxin with mastercard. A subcapital fracture with superior displacement (foreshortening) of the femoral shaft is evident blood pressure normal ki dua order digoxin online pills. Complications include vascular injuries blood pressure chart 5 year old buy 0.25 mg digoxin amex, infection, painful internal fixation devices. Loose intra-articular bodies may be the sequelae of osteochondral and meniscal fractures. Patellar fractures are classified for a treatment-directed approach as either nondisplaced or displaced. A displaced fracture is defined by fracture fragment separation of 4 mm or more or an articular incongruity of 2 mm or more. Descriptive terms such as transverse, vertical, stellate (comminuted), marginal (medial or lateral side), proximal or. The classification is based on the angle the fracture forms with the horizontal plane. As the fracture progresses from type 1 to type 3, the obliquity of the fracture line increases, resulting in increased shearing forces at the fracture site with corresponding increased risk of nonunion. Displacement is graded according to the alignment and angulation of the compressive trabeculae in the femoral neck fracture. Garden 4 is a fracture with cephalad displacement (foreshortening) of the femur shaft. The compressive trabeculae (blue) between femoral head and neck at the fracture site form a valgus angle in Garden 1 and a varus angle in Garden 2 and 3. A fracture extending from the greater to the lesser trochanter with complete separation of the latter is seen. Two-part fractures involving either the greater or lesser trochanter are always stable. Type 1 fractures (most common) occur at the level of the lesser trochanter; type 2, up to 2. Type 2: Two-part: transverse, oblique, or spiral fracture with or without extension in to the lesser trochanter. Type 3: Three-part: oblique or spiral fracture with either detached lesser trochanter or butterfly fragment posterior. Type 4: Oblique or spiral fracture with detached lesser trochanter and butterfly fragment posterior. A comminuted distal femoral metaphysis fracture with extension in to the knee is seen. Pelvis and Lower Extremity distal pole, and osteochondral can be used to further describe patellar fractures. Bipartite and, rarely, multipartite patella with the fragments representing accessory ossification center(s) with a smoothly rounded margin are characteristically located in the superolateral aspect of the patella and must be differentiated. Type 1 (split fracture) is a pure cleavage fracture of the lateral tibial plateau. Type 2 (splitdepression) is a cleavage fracture of the lateral tibial plateau in which the remaining articular surface is depressed in to the metaphysis. Type 3 (depression) is a central depression fracture of the lateral tibial plateau. Type 4 involves the medial tibial plateau either as a split (4A), depression (4B), or split-depression (4C) fracture. Type 5 is a bicondylar fracture in which the fracture line often forms an inverted Y with intact junction between metaphysis and diaphysis. Type 6 is a tibial plateau fracture in which there is complete dissociation between the metaphysis and the diaphysis. These fractures may have varying degrees of comminution of one or both tibial condyles and the articular surface. Late complications include painful hardware (up to 50%), malunion, and posttraumatic osteoarthritis. This fracture is frequently associated with tears of the anterior cruciate ligament and lateral meniscus secondary to varus stress with internal rotation of the flexed knee. The Segond fracture has to be differentiated from an avulsion of the Gerdy tubercle (insertion of the iliotibial tract) that is located anterior and slightly more distal to the former. A reverse Segond-type fracture consists of an avulsion fracture of the medial aspect of the proximal tibia at the insertion of the medial collateral ligament associated with tears of the posterior cruciate ligament and medial meniscus secondary to valgus stress and external rotation of the flexed knee. Knee dislocation is a relatively rare injury that, besides extensive ligamentous damage and avulsions, is also frequently associated with a neurovascular insult (popliteal artery, peroneal nerve). In order of decreasing frequency anterior, posterior, medial, and lateral dislocations are differentiated. Spontaneous reduction is not uncommon, resulting in underdiagnosis of this injury. Disruption of all four major ligaments of the knee (both cruciate and collateral ligaments) is highly suggestive that a dislocation has occurred. Patellar dislocation is usually lateral, but it may be transient (spontaneous reduction of a traumatic dislocation). Type 2: Split-depression fracture (combined cleavage and compression fracture) of lateral plateau. Type 6: Plateau fracture with complete dissociation between metaphysis and diaphysis. Predisposing factors include a patella alta, deficient height of the lateral femoral condyle, shallowness of the patellofemoral groove, and genu valgum or recurvatum. Proximal tibiofibular joint dislocation occurs anteriorly or, less frequently, posteriorly. More typically, an apparently isolated fibular fracture is actually a component of an ankle injury. Because of the subcutaneous location of the anteromedial surface of the tibia, an open (compound) fracture is not uncommon, resulting in a relatively high incidence of infection with nonunion. In type A fractures, spiral (A1), oblique (A2), and transverse (A3) fractures are differentiated. In type B fractures, an intact spiral wedge or butterfly fragment (B1), an intact nonspiral wedge in which the butterfly fragment is separated from the tibial shaft by oblique (not spiral) fracture lines (B2), and a fractured wedge (B3) are discerned. Furthermore, for both type A and B fractures, it must be assessed if the fibula is intact or if the tibia and fibula fractures are at the same or a different level. Compartment syndrome occurs in about 4% of all tibial shaft fractures, but it is most common in male patients under 35 y of age. The syndrome may affect all four compartments of the lower leg, but it is always present in the anterior compartment. In the ankle, axial-loading injuries resulting in tibial plafond (pilon) fractures and rotational ankle injuries resulting in malleolar fractures are differentiated. It has to be kept in mind, however, that axial load and rotational forces may coexist in an ankle injury, resulting in a more complex fracture pattern. Classifying these fractures by description, the displacement of the talus and articular fragments should be noted. The talus is frequently proximally displaced, but it may translate in any direction. The degree of comminution of both the articular surface and the metaphyseal area of the distal tibia must be assessed. The presence or absence of an associated fibula fracture and, if present, its location and degree of comminution also need to be evaluated. Type 1 is a nondisplaced cleavage fracture, type 2 a minimally comminuted and displaced fracture with articular incongruity but without depression of any articular fracture fragment, and type 3 a highly comminuted and displaced fracture. Rotational ankle fractures can be classified by location as unimalleolar, bimalleolar, trimalleolar, or complex (comminuted intra-articular fracture of the distal tibia associated with a distal fibular fracture, indistinguishable from a pilon fracture). Rotational injuries of the ankle are commonly caused by supination (inversion, adduction) or pronation (eversion, abduction) of the foot and may be associated with external (lateral) rotation of the foot. Rotational ankle fractures can be classified by either anatomical location or injury mechanism. The Weber classification is based on the level of the fibular fracture: type A fracture is at or below the level of the ankle joint line, type B fracture originates at the level of the joint line or slightly above it and progresses superiorly, and type C fracture is located 2 cm or higher above the ankle joint line. Sagittal (a) and axial (b) views of a distal tibial fracture extending in to the tibial plafond. Type 3: Highly comminuted and displaced fracture commonly with impacted articular fracture fragments. The classification is based on the anatomical location of the fracture line in the fibula. Type A: Fracture originates at or below the ankle joint line and corresponds to supination or pronation injuries of the ankle without external rotation. Type B: Fracture originates at the joint line and progresses superiorly and posteriorly. Transverse (avulsion fracture of the lateral malleolus and oblique (talar impaction) fracture of the medial malleolus, both originating at or below the joint line. Transverse (avulsion) fracture of the medial malleolus and oblique (talar impaction) fracture of the lateral malleolus, both originating at or below the joint line. Fractures of the medial and posterior malleolus and the anterior tibial (Chaput) tubercle may be associated. Fracture of the medial malleolus associated with a transverse supramalleolar (2 cm or higher above the joint line) fibula fracture. Fractures of the posterior malleolus and anterior tibial (Chaput) tubercle may be associated. Note that instead of a malleolar fracture, the corresponding medial (deltoid) or lateral collateral ligament may be torn. Widening of the mortise (injury to the tibiofibular syndesmosis consisting of the anterior and posterior tibiofibular ligaments, inferior transverse ligament [immediately distal to the latter], and interosseous membrane) can be diagnosed when the distal tibiofibular joint measures 4 mm in width or when there is a joint incongruity. With conventional radiography, there is no longer an overlap between the distal tibia and fibula on the mortise view in this condition. Type 3: Talar neck fracture with dislocation of the ankle and the talocalcaneal joint. Type 4: Talar neck fracture with dislocation of the ankle, talocalcaneal, and talonavicular joint. These fibular shaft fractures associated with ankle injuries are often better known by their eponym. A Maisonneuve fracture is a pronation external rotation type injury consisting of a proximal fibula fracture, disruption of the tibiofibular syndesmosis distal to this fracture, and a medial malleolar fracture or a torn medial collateral (deltoid) ligament. A Dupuytren fracture consists of a distal fibula fracture 2 to 7 cm above the ankle joint line associated with disruption of the distal tibiofibular syndesmosis and the medial collateral (deltoid) ligament. Avulsion fractures predominate in the talus and occur in the superior aspect of the head and neck and in the lateral, medial, and posterior aspects of the body. Major talar fractures may involve the head, neck, body, and the lateral or posterior process. Of these, talar neck fractures are the most common and typically depict a vertical fracture course. The modified Hawkins classification differentiates four types of talar neck fractures. Type 2 refers to a talar neck fracture with associated dislocation of the subtalar joint. Type 3 is a talar neck fracture with dislocation of both the ankle and subtalar joint. Type 4 is also associated with subluxation or dislocation in the talonavicular joint. Osteonecrosis of the proximal fracture fragment is a common complication of talar neck fracture. It is relatively rare in Hawkins type 1 fractures but may reach close to 100% in type 4 fractures. The appearance of a linear subchondral lucent area (Hawkins sign) in the talar dome after 1 to 3 months relates to hyperemia and continuity of blood supply and should not be misinterpreted as a crescent sign of osteonecrosis. At this stage, osteonecrosis manifests itself as relatively increased density in the proximal talar fragment when compared with the distal one. The lateral talar process is a large, broad-based, wedge-shaped prominence of the talar body and includes two articular surfaces. A comminuted fracture of the talus with numerous loose fragments and displacement of the rotated talar body posteriorly is seen. Differentiation of an os trigonum from a posterior process fracture may be difficult at times, particularly when the former is diseased. Differentiation of an osteochondral fracture from osteochondritis dissecans is not always possible based on imaging examinations alone. A subtalar (peritalar) dislocation has to be differentiated from a total talar dislocation. A subtalar dislocation involves simultaneous dislocations of the talocalcaneal and talonavicular joint. Up to 85% of dislocations are medial, in which the calcaneus and the rest of the foot are displaced medially. The navicular is located medial and sometimes dorsal to the head and neck of the talus. Lateral subtalar dislocations are second in frequency, followed by anterior and posterior subtalar dislocations. In the total talar dislocation, the ankle is, besides the talocalcaneal and talonavicular joint, also completely dislocated (not only subluxed), resulting in a "floating talus.