Slide 1. Slide 2. Slide 3. Musculoskeletal Specialty Review. Outline. Musculoskeletal Specialty Review: Trauma & Tumors. Cases. Trauma.

Transcription

1 Slide 1 Musculoskeletal Specialty Review 4 June 2014 Slide 2 Musculoskeletal Specialty Review: Trauma & Tumors Christopher Cerniglia, DO, MEng Chief, Division of Musculoskeletal Imaging Department of Radiology UMass Memorial Medical Center Program Director, Musculoskeletal Fellowship Associate Director, Radiology Residency Program University of Massachusetts Medical School Slide 3 Cases Trauma Tumors Outline

2 Slide 4 CASES 4 June 2014 Slide 5 Case 1 Hx: Trauma Slide 6 Case 1

3 Slide 7 Question 1 Slide 8 Pain s/p trauma Case 2 Slide 9 Case 2

4 Slide 10 Question 2 Slide 11 Case 3 Hx: Clip injury while playing football Slide 12 Case 3

5 Slide 13 Question 3 Slide 14 Case 4 Palpable Mass x 1 month Slide 15 Case 4

6 Slide 16 Question 4 Slide 17 Case 5 Slowly Enlarging Palpable Mass Slide 18 Case 5

7 Slide 19 Question 5 Slide 20 Case 6 Medial Volar Hand Mass Slide 21 Case 6

8 Slide 22 Question 6 Slide 23 Case 7 51 year old female with several week history of knee pain. Slide 24 Case 7

9 Slide 25 Question 7 Slide 26 Case 8 40 year old with right thigh pain Slide 27 Case 8

10 Slide 28 Question 8 Slide 29 Trauma & Sports Injuries Slide 30 TRAUMA Axial Trauma Spine Pelvis Appendicular Trauma Upper Extremity Lower Extremity Sequela & Complications

11 Slide 31 TRAUMA Axial Trauma Spine Pelvis Appendicular Trauma Upper Extremity Lower Extremity Sequela & Complications Slide 32 SPINE Mechanism of injury Flexion Extension Axial load/burst Distraction Translation Fracture/ligament injury patterns Column concept/stability Cervical Thoracic Lumbar Sacrum/coccyx Slide 33

12 Slide 34 MECHANISM OF INJURY Flexion/Extension E.g. Teardrop Fx Axial Load/Distraction E.g. Compression Fx Rotation Translation MIXED E.g. Hangman (Distraction/Extension) Slide 35 FLEXION Hyperflexion Sprain (Ant Subluxation) Anterior Wedge Fx Clay Shoveler s Fx B/L Interfacetal Dislocation Flexion Teardrop Fx Slide 36 Anterior Wedge Fx Loss of height of anterior vertebral body Buckled anterior cortex Anterior superior Fx of VB C/W Burst NO Vertical Fx Component NO Post cortical Involvement

13 Slide 37 Secondary to hyperflexion at the waist : Anterior compression of the vertebral body Distraction of posterior elements and ligaments Usually involves T12, L1, or L2 Seatbelt Fracture 7/1/ Slide 38 Bilateral Locked Facets There is hyperflexion, the spinous process is distracted, facets override, and the spine recoils 50% vertebral body displacement anteriorly Unstable 7/1/ Slide 39 Teardrop fragment anterior vertebral body avulsion fracture All ligaments are disrupted Flexion Teardrop Posterior subluxation of vertebral body into the spinal canal often leads to Spinal cord compression Spinous Process Fx Image: c/o Spencer B. Gay, MD Univ of Virginia Health System

14 Slide 40 EXTENSION C1 anterior arch Avulsion Fx C1 posterior arch Fx Extension Teardrop Fx Laminar Fx Hangman s Fx Slide 41 ANSWER 1 Slide 42 Extension & Distraction of C2 from MVA/Hanging B/L C2 pars (common) or pedicle fx Anterior sublux of C2 can occur Ant Inf corner Fx C2 can occur (ALLig) Hangman s Fracture

15 Slide 43 Jefferson Fx Compression Fx AXIAL LOAD Slide 44 Jefferson s Fx Slide 45

16 Slide 46 Jefferson Fx Fracture of C1 vertebra Axial loading with neck extended Transverse ligament integrety determines stability Open mouth view- lateral masses of C1 align with lateral masses of C2 Slide 47 Unilateral Facet Odontoid Fracture MIXED/OTHER Slide 48 Unilateral Facet MIXED Severe flexion associated with rotation Results in: Rupture of Facet joint ligaments Facet joint dislocation 25 % anterior vertebral body displacement Bow tie appearance on lateral radiograph

17 Slide 49 Unilateral Facet MIXED Severe flexion associated with rotation Results in: Rupture of Facet joint ligaments Facet joint dislocation 25 % anterior vertebral body displacement Bow tie appearance on lateral radiograph Slide 50 Unilateral Facet Slide 51 Type 1 Fx upper dens Rare Type 2 Fx at base of dens Odontoid Fx Type 3 Base and body of C2

18 Slide 52 DISH/AS Be careful with ankylotic and fused spine Significant Injury with Minor Trauma Slide 53 Slide 54 TRAUMA Axial Trauma Spine Pelvis Appendicular Trauma Upper Extremity Lower Extremity Sequela & Complications

19 Slide 55 Sacral Insufficiency Fracture Slide 56 Stable Single break of ring Unilateral Pubic Rami (PR) Peripheral Fx Avulsions ASIS, AIIS, IT, Pubus Unstable 2 breaks in ring Malgaigne: SI & Ipsilateral PR Bucket: SI & Contralateral PR Straddle: B/L Opterator Rings Dislocation: SI and symphysis Pelvic Fx Slide 57 TRAUMA Axial Trauma Spine Pelvis Appendicular Trauma Upper Extremity Lower Extremity Sequela & Complications

20 Slide 58 Upper Extremity Trauma Clavicle & AC joint Shoulder & GH joint Elbow Forearm Wrist Hand Slide 59 Clavicle and AC joint Grades of acromioclavicular joint separation Clavicle fracture Sternoclavicular fracture / dislocation Post-traumatic osteolysis Slide 60 AC Separation

21 Slide 61 Clavicle Fracture Nonunion and malunion greatest at central 1/3 of clavicle Allman Classification Slide 62 SC Fracture/Dislocations Direct Impact Anterior MC Posterior LC Risk for vascular injury Slide 63 Post Traumatic Osteolysis Common repetitive trauma/overuse Weightlifters DDX: B/L: Hyperparathyroidism/ RA/Scleroderma U/L: Infection/Tumor/Surg ery

22 Slide 64 Upper Extremity Trauma Clavicle & AC joint Shoulder & GH joint Elbow Forearm Wrist Hand Slide 65 Shoulder Anatomic vs. surgical neck humerus fracture Greater tuberosity humerus fracture Scapular fracture Body Glenoid Dislocations Anterior (a) Hill Sachs fracture (b) Bankart fracture (c) Recurrence Posterior (a) Reverse Bankart (b) Neurovascular injuries Other Inferior scapulothoracic dissociation* Rotator cuff tear Labral injury Patterns of instability SLAP tear Proximal biceps tear or dislocation Impingement syndrome Anterior Posterior Coracoid Adhesive capsulitis Slide 66

23 Slide 67 Greater Tuberosity Fx Post dislocation Avulsion fractures of RTC Slide 68 Anterior Dislocation Slide 69 Anterior Dislocation Hill-Sachs Deformity Bankart Lesion

24 Slide 70 Anterior Dislocation Indirect force from abduction, external rotation and extension Best demonstrated on AP internal rotation view Recurrence is common after first dislocation Slide 71 Posterior Dislocation Direct or Indirect force a/w seizures or electrical shock Fixed Internal Rotation No overlap of humerus + Rim Sign +/- Trough Sign +/- Reverse Bankart Slide 72 Inferior Dislocation Luxatio Erecta Risk of injury to: Ax artery Brachial Plexus Rotator Cuff

25 Slide 73 Pseudo-dislocation Inferior and lateral displacement of humeral head due to hemarthrosis Often occurs in fractures of the humeral head or neck NOT a true dislocation Slide 74 RTC SS, IS, TM = GT SubS = LT AH interval <6mm Chronic RCT Slide 75

26 Slide 76 FT Supraspinatus Ter Slide 77 FT Tear Junctional Fibers SS-IS Slide 78 Labral Injuries

27 Slide 79 Labral Injuries SLAP Type I Fraying Type II Tear SL Type III bucket handle of SL Type IV Tear SL w/biceps involvment Slide 80 Prox Biceps Tear/Dislocation A/W Labral tear Often degenerative in etiology c/w distal biceps often traumatic Slide 81 Impingement Suprascapular Notch Spinoglenoid Notch Quadrilateral Space Syndrome

28 Slide 82 Quadrilateral Space Syndrome Slide 83 Adhesive Capsulitis Acute/Subacute phase PD FSE w/wo FS Slide 84 Chronic phase Adhesive Capsulitis

29 Slide 85 Upper Extremity Trauma Clavicle & AC joint Shoulder & GH joint Elbow Forearm Wrist Hand Slide 86 Elbow Radial head fracture Fracture/dislocation Humeral condyle fractures Extensor tendinosis (tennis elbow/lateral epicondylitis) Flexor tendinosis (pitcher s elbow/medial epicondylitis) Ulnar collateral ligament tear Radial collateral ligament tear Biceps avulsion Triceps avulsion Slide 87 Radial Head/Neck Fx

30 Slide 88 Posterior Elbow Dislocation Slide 89 Lateral Epicondylitis Tennis Elbow Degeneration and Tearing of CET (ECU, EDC, and ECRB) Overuse injury Slide 90 RCL tear

31 Slide 91 RCL Tear Slide 92 UCL tear Slide 93 Biceps Tendon Tear

32 Slide 94 Slide 95 Post Tendon Repair Slide 96 Upper Extremity Trauma Clavicle & AC joint Shoulder & GH joint Elbow Forearm Wrist Hand

33 Slide 97 Forearm Galeazzi fracture/dislocation Monteggia fracture/dislocation Isolated ulna (nightstick) fracture Slide 98 Galeazzi fracture-dislocation Fx RADIUS with Dislocation at DRUJ. Galeazzi fractures have a peak incidence of 9-12 years of age. Slide 99 Monteggia fracture-dislocation Fracture of the ulna diaphysis & dislocation of radial head Detect Ulnar Fx -> Look to radial head can miss disloc

34 Slide 100 Isolated ulnar shaft fracture Most commonly a/w self defense against blunt trauma Force is to the medial forearm as the arm is used to shield head and body Night Stick Fracture Slide 101 Essex-Lopresti Fracture Comminuted fracture of the radial head Dislocation of the DRUJ Slide 102 Buckle and Greenstick Fractures Distal radius Buckle (Torus) fractures very common injuries in children. Quick to heal

35 Slide 103 Forearm Galeazzi fracture/dislocation Monteggia fracture/dislocation Isolated ulna (nightstick) fracture Slide 104 Upper Extremity Trauma Clavicle & AC joint Shoulder & GH joint Elbow Forearm Wrist Hand Slide 105 Wrist Colles fracture Smith fracture Radial styloid fracture Isolated carpal bone fracture Scaphoid fracture Significance of blood supply Osteonecrosis Non-union Triquetral fracture Hamate fracture Other Complex carpal bone injuries Perilunate dislocation Lunate dislocation Ligament tears Interosseous ligaments Triangular fibrocartilage complex Extrinsic ligaments Chronic carpal instability Dorsal intercalated segment instability Volar intercalated segment instability Scapholunate advanced collapse Distal radioulnar joint injury Carpal tunnel syndrome Ulnar impaction syndrome

36 Slide 106 Colles Fracture MC Fx distal radius. Transverse Fx of distal radial metaphysis Dorsal angulation and displacement of the distal fragment. Typically produced by a fall on an outstretched hand, with the wrist dorsiflexed. Slide 107 Smith Fracture Reverse Colles fracture with fracture of the metaphysis and volar angulation of the distal fracture fragment. Younger patients results from extensive traumatic forces on the volar flexed wrist. Volar comminution is common. Slide 108 Smith Fracture Type 1: Horizontal Fx line Type 2: Oblique Fx line Type 3: Intra-articular oblique (Reverse Bartons)

37 Slide 109 Chauffeur Fracture Chauffeur aka Hutchinson or Backfire fracture consists of an oblique, intraarticular fracture of the distal radius involving the radial styloid. Displaced fracture fragments indicates disruption of intercarpal ligaments. The name originates from documented injuries while cranking backfiring automobile starters in the early 20th century. This fracture is classically a shearing force transmitted through the scaphoid or scapholunate interval. Slide 110 Chauffeur Fracture Intra-articular fracture of the distal radius involving the radial styloid. Displaced fracture fragments indicates disruption of intercarpal ligaments Slide 111 Scaphoid Fracture Most common carpal fracture At risk of AVN, especially at proximal pole 65%: waist 15%: proximal pole 10%: distal body 8%: volar tuberosity 2%: through the distal articular surface

38 Slide 112 Scaphoid Fracture Slide 113 Lunate Fracture Slide 114 Common at dorsal surface Avulsions from ligamentous attachments Triquetral Fracture Dorsal avulsion best detected on a lateral projection

39 Slide 115 Hamate Fractures BODY HOOK Slide 116 Hamate Hook Fracture Slide 117 Other Carpal Fracture Capitate fx = rare; high suspicion Trapezoid are rare due to stabilization from its articulations, and may be associated with a dislocation of the second metacarpal. Pisiform (sesamoid bone) within FCU tendon and injury often occurs in the setting of direct trauma. vertical, transverse or a compressive

40 Slide 118 Pisiform Fracture Slide 119 Answer 2 Slide 120 Carpal Arcs Arc 3 Arc 2 Arc 1

41 Slide 121 Perilunate injury: Greater and Lesser Arcs Perilunate dislocation (lesser arc injury) is a pure ligamentous disruption around the lunate. Perilunate dislocation with associated fracture of one or more bones around the lunate (scaphoid, trapezium, capitate, hamate, or triquetrum) is called a greater arc injury. Perilunate injuries result from high-energy wrist hyperextension, typically falls from a height, motor vehicle collisions, or sports-related injuries. Slide 122 Perilunate injury: Greater and Lesser Arcs Lesser Arc injuries (ligamentous) Scapholunate Perilunate Midcarpal Lunate Greater Arc injuries (ligamentous with adjacent fractures) Slide 123 Lesser Arc Injury Stage I: Scapholunate Dissociation

42 Slide 124 Lesser Arc Injury Stage II: Perilunate Stage 2 lesser arc with associated fractures/greater arc disrpution Normal Comparison Slide 125 Trans Styloid Perilunate Dislocation Slide 126 Lesser Arc Injury Stage III: Midcarpal

43 Slide 127 Lesser Arc Injury Stage IV: Lunate Slide 128 Stage IV: Trans-Scaphoid Lunate Dislocation Slide 129 SLAC Wrist

44 Slide 130 SLAC: Watson Classification Stage I Arthritis between scaphoid and radial styloid Stage II Arthritis between scaphoid and entire scaphoid facet of the radius Stage III Arthritis between capitate and lunate Slide 131 Wrist Colles fracture Smith fracture Radial styloid fracture Isolated carpal bone fracture Scaphoid fracture Significance of blood supply Osteonecrosis Non-union Triquetral fracture Hamate fracture Other Complex carpal bone injuries Perilunate dislocation Lunate dislocation Ligament tears Interosseous ligaments Triangular fibrocartilage complex Extrinsic ligaments Chronic carpal instability Dorsal intercalated segment instability Volar intercalated segment instability Scapholunate advanced collapse Distal radioulnar joint injury Carpal tunnel syndrome Ulnar impaction syndrome Slide 132 Upper Extremity Trauma Clavicle & AC joint Shoulder & GH joint Elbow Forearm Wrist Hand

45 Slide 133 Hand Phalanx fracture / dislocation Intra vs. extra articular Volar plate fracture Tuft fracture Metacarpal fracture Bennett vs. Rolando fracture Boxer fracture Carpometacarpal dislocation Tendon injuries Pulley injuries Capsular and collateral ligament injuries Gamekeeper (skier) thumb Metacarpophalangeal joint Slide 134 Slide 135 TRAUMA Axial Trauma Spine Pelvis Appendicular Trauma Upper Extremity Lower Extremity Sequela & Complications

46 Slide 136 Hip Femur Knee Ankle Foot Lower Extremity Trauma Slide 137 Hip & Femur Acetabular fracture - fracture patterns Hip dislocation - risk of osteonecrosis Femoral neck fracture Intertrochanteric fracture Femoral head fracture Labral injury Slide 138 Hip Femur Knee Ankle Foot Lower Extremity Trauma

47 Slide 139 Patellar Fx post Dislocation Slide 140 Patellar Dislocation Slide 141 Discoid LM

48 Slide 142 Bucket Handle Slide 143 Radial Tear Slide 144 Horizontal Oblique Tear

49 Slide 145 Parrot-beak Slide 146 IT Band Syndrome Slide 147 Displaced Meniscal Fragments Anterior Flipped LM

50 Slide 148 Answer 3 Slide 149 ACL Slide 150 Knee Femoral condyle fracture Tibial plateau fracture Knee dislocation Patella fracture Patella dislocation Meniscal injury Bucket handle tear Parrot-beak tear Horizontal oblique tear Horizontal cleavage tear Vertical longitudinal tear Radial tear Complex tear Root tear Meniscocapsular separation Fraying and degeneration Displaced fragments Meniscal cyst Ligament injury Anterior cruciate Posterior cruciate Medial collateral Lateral collateral Extensor mechanism injury Quadriceps tear Patellar tendon (ligament) tear Retinaculum injury Posterolateral corner injury Popliteus muscle/tendon Arcuate ligament* Popliteofibular ligament* Fabellofibular ligament* Articular cartilage injury Overuse injuries Plica syndrome Iliotibial band friction syndrome Pes anserine bursitis

51 Slide 151 Hip Femur Knee Ankle Foot Lower Extremity Trauma Slide 152 Ankle Foot Mechanisms of injury Pilon fracture Tilleaux fracture Maisonneuve fracture Ligament injury Anterior talofibular ligament Deltoid ligament Syndesmotic/anterior tibiofibular ligament Talar fracture Dome fracture Neck fracture Lateral process fracture Calcaneal fracture - anterior process fracture Fifth metatarsal base fracture Metatarsal fracture Lisfranc fracture/dislocation Phalanx fracture Cuboid fracture Navicular fracture Slide 153 Lisfranc

52 Slide 154 Axial Trauma Spine Pelvis Appendicular Trauma Upper Extremity Lower Extremity Complications TRAUMA Slide 155 FRACTURE COMPLICATIONS IMMEDIATE Hemorrhage/Epidural Hematoma Fat Embolism Acute Ischemia Spinal Cord Injury DELAYED Malunion Nonunion Premature physeal closure Osteonecrosis Femoral head Scaphoid proximal pole Talar dome Infection Arthritis Slide 156

53 Slide 157 AVN scaphoid Post fracture AVN of scaphoid without prior fx: Preiser Dz DDx fx nonunion without avn Typically prox pole waist fx and nonunion T1C+ indicates viable marrow Slide 158 Femoral Head Scaphoid Talar dome Osteonecrosis Slide 159

54 Slide 160 OTHER TRAUMA Stress injuries (bone and soft tissue) Mechanisms Pathophysiology Epidemiology Imaging diagnosis Implications for treatment Repetitive trauma Tendinosis Enthesophytes Other Soft tissue injuries Grades of muscle tear Grades of ligament tear Myositis ossificans Thermal trauma Burns Cold injury Slide 161 Answer 4 Slide 162

55 Slide 163 Slide 164 Tenosynovitis 2 nd EC EXTENSOR CARPI RADIALIS LONGUS AND BREVIS TENOSYNOVITIS Slide 165

56 Slide 166 BREAK End Part 1: Trauma Begin Part 2: Tumor after the break Slide 167 Tumors Insert Picture Slide 168 Answer 5

57 Slide 169 Slide 170 Answer 6 Slide 171 Answer 7

58 Slide 172 Answer 8 Slide 173 EG Slide 174 BONE Clinical: Age & Symptoms Tumor Location Tumor Matrix Tumor Aggressiveness

59 Slide 175 PEARLS: AGE AGE < 30 Infection EG ABC NOF Chondroblastoma UBC AGE > 40 Mets Myeloma Infection Slide 176 PAINLESS FD Enchondroma NOF UBC PEARLS: Symptoms Slide 177 Epiphysis Infection GCT Chondroblastoma Infection Geode Mets/Infiltrative CCC PEARLS: Location

60 Slide 178 PAINLESS FD Enchondroma NOF UBC PEARLS: Symptoms Slide 179 RADIOGRAPHS IA Geographic Well defined Sclerotic Rim Intact Cortex IB Geographic Well defined Non-sclerotic rim Thinning of Cortex IC Geographic Ill defined Non-sclerotic rim Penetration /Destruction of Cortex II Moth-eaten Lamellar/Onion-skin Rxn. III Moth-eaten and permeative Destruction Radial/Spicular rxn Lodwick Classification Slide 180 Lodwick

61 Slide 181 CT/MRI - Bone CT: Matrix characterization MRI: Assessing the response to treatment Postchemotherapeutic MRI signal intensity changes Detecting recurrence Slide 182 PEARLS: Multiple Osseous Lesions METS Myloma EG FD Enchondromas Brown Tumers Slide 183 Bone: BENIGN Cartilaginous Enchondroma Multiple (Ollier disease) Maffucci syndrome Osteochondroma - Multiple hereditary exostoses Chondromyxoid Fibroma Chondroblastoma Chondroma - Periosteal (surface, juxtacortical) Fibrous Fibroxanthoma (non-ossifying fibroma) Fibrous cortical defect Benign fibrous histiocytoma Fibrous dysplasia - McCune-Albright Chondromyxoid fibroma Desmoplastic fibroma Osteofibrous dysplasia (ossifying fibroma)* Osteogenic Enostosis (bone island) - Multiple Osteoma - Multiple Osteoid osteoma Osteoblastoma Lipoid Lipoma Liposclerosing myxofibrous tumor (LSMFT)* Vascular Hemangioma - Multiple (Osler-Weber- Rendu) Hemophilic pseudotumor Lymphangioma Glomus tumor Hemangiopericytoma* Gorham disease* Other Unicameral bone cyst (simple bone cyst) Aneurysmal bone cyst (a) Primary (b) Secondary Giant cell tumor of bone Langerhans cell histiocytosis (eosinophilic granuloma) Chordoma Intraosseous ganglion Reactive lesions Giant cell reparative granuloma Bizarre parosteal osseous proliferation (BPOP)* Epidermoid inclusion cyst

62 Slide 184 Enchondroma Slide 185 MHE Slide 186 Periosteal Chondroma

63 Slide 187 Periosteal Chondroma Slide 188 Periosteal Chondroma Slide 189

64 Slide 190 Slide 191 Slide 192 Osteoid Osteoma

65 Slide 193 Surface Osteoma Slide 194 Slide 195

66 Slide 196 Slide 197 Slide 198 EG

67 Slide 199 Bone: BENIGN Cartilaginous Enchondroma Multiple (Ollier disease) Maffucci syndrome Osteochondroma - Multiple hereditary exostoses Chondromyxoid Fibroma Chondroblastoma Chondroma - Periosteal (surface, juxtacortical) Fibrous Fibroxanthoma (non-ossifying fibroma) Fibrous cortical defect Benign fibrous histiocytoma Fibrous dysplasia - McCune-Albright Chondromyxoid fibroma Desmoplastic fibroma Osteofibrous dysplasia (ossifying fibroma)* Osteogenic Enostosis (bone island) - Multiple Osteoma - Multiple Osteoid osteoma Osteoblastoma Lipoid Lipoma Liposclerosing myxofibrous tumor (LSMFT)* Vascular Hemangioma - Multiple (Osler-Weber- Rendu) Hemophilic pseudotumor Lymphangioma Glomus tumor Hemangiopericytoma* Gorham disease* Other Unicameral bone cyst (simple bone cyst) Aneurysmal bone cyst (a) Primary (b) Secondary Giant cell tumor of bone Langerhans cell histiocytosis (eosinophilic granuloma) Chordoma Intraosseous ganglion Reactive lesions Giant cell reparative granuloma Bizarre parosteal osseous proliferation (BPOP)* Epidermoid inclusion cyst Slide 200 Bone: MALIGNANT Cartilaginous - Chondrosarcoma Central Peripheral Dedifferentiated Mesenchymal Clear cell Fibrous Fibrosarcoma Malignant fibrous histiocytoma Osteogenic - Osteosarcoma Conventional Surface Periosteal Parosteal High grade surface Telangiectatic Low grade central Vascular Angiosarcoma Hemangioendothelioma Other Chordoma Multiple myeloma (plasmacytoma) Ewing sarcoma Primitive neuroectodermal tumor (PNET) Adamantinoma Lymphoma Leukemia chloroma SECONDARY Radiation Pagets Metastatic Slide 201

68 Slide 202 Slide 203 Bone: MALIGNANT PRIMARY Cartilaginous - Chondrosarcoma Central Peripheral Dedifferentiated Mesenchymal Clear cell Fibrous Fibrosarcoma Malignant fibrous histiocytoma Osteogenic - Osteosarcoma Conventional Surface Periosteal Parosteal High grade surface Telangiectatic Low grade central Vascular Angiosarcoma Hemangioendothelioma Other Chordoma Multiple myeloma (plasmacytoma) Ewing sarcoma Primitive neuroectodermal tumor (PNET) Adamantinoma Lymphoma Leukemia Chloroma SECONDARY Radiation Pagets Metastatic Slide 204 SOFT TISSUE

69 Slide 205 Soft Tissue: BENIGN Fibrous Fibroma Fibromatosis Desmoid Elastofibroma Neural Neurofibroma Schwannoma Neurofibromatosis Neuroma Lipomatosis of nerve (fibrolipomatous hamartoma) Post-resection neuroma Morton neuroma Cartilaginous - soft tissue chondroma Vascular Hemangioma Hemangioendothelioma Glomus tumor Vascular malformations Lymphangioma Lipoid Lipoma Angiolipoma Hibernoma Lipoblastoma Muscle Rhabdomyoma Leiomyoma Dermal/subcutaneous Sebaceous cyst Dermatofibroma Granuloma annulare Granular cell tumor* Other Myxoma Giant cell tumor of tendon sheath Pigmented villonodular synovitis Ganglion Slide 206 Desmoid Tumor Plantar Fibromatosis Slide 207 Elastofibroma

70 Slide 208 Slide 209 Neuroma Slide 210 Atypical Lipoma

71 Slide 211 Epidermal Cyst Slide 212 Slide 213

72 Slide 214 Slide 215 Soft Tissue: BENIGN Fibrous Fibroma Fibromatosis Desmoid Elastofibroma Neural Neurofibroma Schwannoma Neurofibromatosis Neuroma Lipomatosis of nerve (fibrolipomatous hamartoma) Post-resection neuroma Morton neuroma Cartilaginous - soft tissue chondroma Vascular Hemangioma Hemangioendothelioma Glomus tumor Vascular malformations Lymphangioma Lipoid Lipoma Angiolipoma Hibernoma Lipoblastoma Muscle Rhabdomyoma Leiomyoma Dermal/subcutaneous Sebaceous cyst / Epidermoid cyst Dermatofibroma Granuloma annulare Granular cell tumor* Other Myxoma Giant cell tumor of tendon sheath Pigmented villonodular synovitis Ganglion Slide 216 Soft Tissue: MALIGNANT PRIMARY Fibrosarcoma Malignant fibrous histiocytoma (high-grade undifferentiated pleomorphic sarcoma) Synovial sarcoma Rhabdomyosarcoma Malignant peripheral nerve sheath tumor Liposarcoma (a) Myxoid (b) Well-differentiated (c) Dedifferentiated Melanoma SECONDARY Metastasis Leukemia Lymphoma Soft tissue extension of bone lesion

73 Slide 217 High Grade Sarcoma Slide 218 Synovial Sarcoma Slide 219

74 Slide 220 Lymphoma Slide 221 Soft Tissue: MALIGNANT Fibrosarcoma Malignant fibrous histiocytoma (highgrade undifferentiated pleomorphic sarcoma) Synovial sarcoma Rhabdomyosarcoma Malignant peripheral nerve sheath tumor Epithelioid sarcoma* Liposarcoma (a) Myxoid (b) Well-differentiated (c) Dedifferentiated Dermatofibrosarcoma protuberans* Alveolar soft part sarcoma* Myxofibrosarcoma* Soft tissue osteosarcoma* Kaposi sarcoma* Melanoma Metastasis Leukemia Lymphoma Soft t Slide 222 Thank You Contact/Questions: Christopher.Cerniglia@umassmed.edu