Coronal T1W image shows lobulated margins and peripheral low SI due to the calcifications. Hallmark of osteosarcoma is the production of bony matrix, which is reflected by the sclerosis seen on the radiograph. <-Lucent Lesions of Bone | Periosteal Reaction->. {"url":"/signup-modal-props.json?lang=us"}, Yap K, Knipe H, Niknejad M, et al. Another finding classic for Pagets disease is that it almost always starts at one end of a bone and then spreads toward the other end of the bone. Non-ossifying fibroma (NOF) can be encoutered occasionally as a partial or completely sclerotic lesion. brae in keeping with diffuse bone infarcts. A popular mnemonic to help remember causes of focal sclerotic bony lesions is: Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Growth of the osteochondroma takes place in the cap, corresponding with normal enchondral growth at the growth plates. Notice that the cortical bone extends into the lesion. Here, we showed that sBT values are higher in patients presenting 496 with bone loss . Osteoma consists of densely compact bone. Osteopetrosis and pyknodysostosis are likewise hard to mistake for other entities since the bones are denser than in any other disorder, and the long bones tend to have very tiny medullary canals. In patients In patients > 30 years, and particularly > 40 years, despite benign radiographic features, a metastasis or plasmacytoma also have to be considered On the left three bone lesions with a narrow zone of transition. Bone marrow edema can happen with fractures and other serious bone or joint injuries. Presentation: pain, mass, pathologic fracture. Axial T1-weighted MR image shows homogeneous low signal intensity due to the compact bone apposition. Rib lesions detected on bone scintigraphy often require further characterization with radiography or CT to improve specificity (Figs. Particularly chronic osteomyelitis may have a sclerotic appearance. Conclusion. It is true that the usual appearance of skeletal metastases is that of focal lesions diffuse sclerosis occurs in only a small fraction of cases of skeletal metastases. 13. If the disorder it is reacting to is rapidly progressive, there may only be time for retreat (defense). Osteoid matrix Reference article, Radiopaedia.org (Accessed on 02 Mar 2023) https://doi.org/10.53347/rID-10490, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":10490,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/sclerotic-bone-metastases/questions/1747?lang=us"}. An aggressive type is seen in malignant tumors, but also in benign lesions with aggressive behavior, such as infections and eosinophilic granuloma. 1. Typically a NOF presents as an eccentric well-defined lytic lesion, usually found as a coincidental finding. Here a patient with a mineralized mass in the soft tissues. Mineralization in osteoid tumors can be described as a trabecular ossification pattern in benign bone-forming lesions and as a cloud-like or ill-defined amorphous pattern in osteosarcomas. Coronal MR image demonstrates subtle low intensity line representing the fracture. Frequently encountered as a coincidental finding and can be found in any bone. It grows primarily into the surrounding soft tissues, but may also infiltrate into the bone marrow. Less dense on CT and more heterogeneous than bone islands. Less common: Fibrous dysplasia, Brown tumors of hyperparathyroidism, bone infarcts. A periosteal chondroma may have the same imaging characteristics, however, these are almost always much smaller. Urgency: Routine. Sclerotic Lesions of the Spine 1311. predominant hypointensity on all imaging sequences mimicking a sclerotic process due to a variety of fac- . T2-weighted axial MR image demonstrates high signal intensity of the tumor in the metacarpal bone with extension of a lobulated soft tissue mass. Sclerosis is usually the most prominent finding in subacute and chronic osteomyelitis. Imaging: Imaging of skull vault tumors in adults: Author: Pons Escoda, Albert Naval Baudin, Pablo . Amorphous mineralisation is present in most lesions. Notice that CT depicts these lesions far better (red arrows). (see diagnostic imaging pearls). Radiological atlas of bone tumours of the Netherlands Committee on Bone Tumors 33.1d). Notice the numerous predominantly osteoblastic metastases. WSI digital slide: https://kikoxp.com/posts/4606. Concerning the above factors the differential diagnosis includes the following lesions 1-3: sclerotic bone metastasis: might be solitary because no others are present or have been imaged, infection: e.g. Sclerotic bone lesions caused by non-infectious and non-neoplastic diseases: a review of the imaging and clinicopathologic findings Sclerotic bone lesions caused by non-infectious and non-neoplastic diseases: a review of the imaging and clinicopathologic findings Authors Sclerotic jaw lesions are not rare and are frequently encountered on radiographs and computed tomography (CT). Finally, we conclude with a case of an incidentally presenting sclerotic vertebral body lesion. Growth of osteochondromas at adult ages, which is characterized by a thick cartilaginous cap (high SI on T2WI) should raise the suspicion of progression to a peripheral chondrosarcoma. Fibrous dysplasia can be monostotic or polyostotic. There were other features that favored the diagnosis of a low-grade chondrosarcoma like a positive bone scan and endosteal scalloping of the cortical bone on an MRI (not shown). Check for errors and try again. AJR 1995;164:573-580, Online teaching by the Musculoskeletal Radiology academic section of the University of Washington, by Theodore Miller March 2008 Radiology, 246, 662-674, by Laura M. Fayad, Satomi Kawamoto, Ihab R. Kamel, David A. Bluemke, John Eng, Frank J. Frassica and Elliot K. Fishman. The contour of the involved bone is usually normal or with mild expansive remodelling. Even though plain X-ray and CT would typically be used to follow a suspected bone island, MRI was chosen as the follow-up modality because the sacrum is an area not well seen on plain films due to overlying bowel gas and concern regarding radiation dose from multiple CT scans to the pelvis of a 30-year-old woman. Enchondroma, the most commonly encountered lesion of the phalanges. It can identify small or large tumors, multiple sclerosis (MS), encephalitis (brain inflammation), or meningitis (inflammation of the meninges that lie between the brain and the skull). Aggressive periosteal reaction Contrast-enhanced T1-weighted MR image demonstrates heterogeneous enhancement of the mass with extensive surrounding edema. Sclerotic osteoblastic metastases must be included in the differential diagnosis of any sclerotic bone lesion in a patient > 40 years. Continue with the MR-images. Axial imaging for differentiation from Brodie abscess, osteoblastoma, stress fracture. Amsterdam: Elsevier; 1993. Bone flare phenomenon was well described on bone scans; a study 25 revealed the appearance of new or worsening bone sclerosis at 3-month CT assessment in three of 67 castration-resistant prostate cancer (CRPC) patients undergoing systemic treatment. The X-ray features were divided into two groups according to typical and atypical skeletal lesions. Check for errors and try again. Cancers (Basel). Mark Blumenkehl, MD is a specialist in Gastroenterology whose practice locations include: Detroit, Sterling Hgts Bone scan shows no high activity, opposed to low-grade intraosseous osteosarcoma. Physical examination and past medical history were normal and noncontributory respectively. Notice the resemblance to a juxtacortical mass in another patient (right), which was a biopsy proven parosteal osteosarcoma. At the periphery of the infarct a zone of relative high signal intensity on T2WI may be found. AJR Am J Roentgenol. One study, using a mean attenuation of 885 HU and a maximum attenuation of 1,060 HU as cut-off values, distinguished the higher density bone islands from lower density osteoblastic metastases with 95% sensitivity and 96% specificity. 105-118. 2021;216(4):1022-30. There is reactive sclerosis with a nidus that is barely visible on the radiograph (blue arrow), but clearly visible on the CT (red arrows). Multiple enchondromas are seen in Morbus Ollier. Osteosarcoma (2) Case 2: sclerotic metastases from prostate cancer, Generalised increased bone density (mnemonic). Skeletal Radiol. It can also be proven histologically. Sclerotic metastases arise from . Usually one bone is involved. CT scan is usually very helpful in detecting the nidus and differentiating osteoid osteoma from other sclerotic lesions like osteoblastoma, osteomyelitis, arthritis, stress fracture and enostosis. The homogeneous enhancement in the upper part with edema and cortical thickening are not typical for a low-grade chondrosarcoma. 5. Radiographs typically show a geographic lytic or ground glass lesion with a well-defined, often extensively sclerotic margin, indicating its indolent nature. Hereditary sclerosing bone dysplasias result from some disturbance in the pathways involved in osteoblast or osteoclast regulation, leading to abnormal accumulation of bone. {"url":"/signup-modal-props.json?lang=us"}, Niknejad M, Bell D, Tatco V, et al. Usually stress fractures are easy to recognize. Differentiation of Predominantly Osteoblastic and Osteolytic Spine Metastases by Using Susceptibility-Weighted MRI. Typical bone metastases are osteolytic (87.5%), with medullary origin (91.6%), and they cannot be distinguished from other osteolytic metastases on the basis of imaging criteria alone. Journal of Bone Oncology. One can then apply various features of the lesions to this differential, and exclude some things, elevate some things, and downgrade others in the differential. In patients There is a metastasis, which presents as a subtle sclerotic lesion in the humerus metaphysis. Gulati V, Chalian M, Yi J, Thakur U, Chhabra A. Sclerotic Bone Lesions Caused by Non-Infectious and Non-Neoplastic Diseases: A Review of the Imaging and Clinicopathologic Findings. Sclerotic bone metastases. Click here for more examples of chondrosarcoma. Based on the morphology and the age of the patients, these lesions are benign. 6. 1991;167(9):549-52. The term bone infarction is used for osteonecrosis within the diaphysis or metaphysis. Donald Resnick, Mark J. Kransdorf. Osteoblastic bone metastases are characterized by increased bone formation 2. This proved to be a reactive calcification secondary to trauma. A lucent, well-circumscribed lesion is seen with a surrounding thin sclerotic cortical rim on plain radiographs [ Figure 4 ]. World J Radiol. Polyostotic lesions > 30 years You can then customize the above differential for whichever pattern of sclerosis that you see. Parkinson's disease, multiple sclerosis, brain tumors and brain trauma [2]. Oncol Rev. Signed by [redacted] on 1/17/2020 11:42 AM Narrative This could very well be an enchondroma. Complete destruction may be seen in high-grade malignant lesions, but also in locally aggressive benign lesions like EG and osteomyelitis. 2022;51(9):1743-64. The radiographic appearance and location are typical. This 'neocortex' can be smooth and uninterrupted, but may also be focally interrupted in more aggressive lesions like GCT. Brant WE, Helms CA. Notice the homogeneous thickening of the cortical bone. The juxtacortical mass has a high SI and lobulated contours. 1. The bone scan is also helpful to look for additional sites of increased uptake that may not have been imaged, such as multiple nontraumatic rib, calvarial, or long bone lesions, which would strongly suggest the diagnosis of metastatic disease. Here a chondrosarcoma of the left iliac bone. Magnetic resonance imaging of subchondral bone marrow lesions in association with osteoarthritis. A surface osteosarcoma could be considered in the differential diagnosis. Many sclerotic lesions in patients > 20 years are healed, previously osteolytic lesions which have ossified, such as: NOF, EG, SBC, ABC and chondroblastoma. There are a number of other helpful findings you can look for that can help you to cone in on or away from specific entities in one of these differential lists. The pathogenesis of myeloma-related bone disease (MBD) is the imbalance of the bone-remodeling process, which results from osteoclast activation, osteoblast suppression, and the immunosuppressed bone marrow microenvironment. Ossifications or calcifications can be present in variable amounts. Sclerotic means that the lesions are slow-growing changes to your bone that happen very gradually over time. Causes include trauma, infection, autoimmune diseases, inflammatory diseases, spinal degeneration, congenital malformations, and benign or cancerous tumors. When you are considering osteonecrosis in your differential diagnosis, look at the joints carefully. As part of the test, a healthcare professional takes a sample of the CSF In this case, because of the increased uptake on bone scintigraphy, a follow-up MRI was recommended at 6 and 12 months. The most common focal metastatic lesions originate from the breast (37%), lung (15%), kidney (6%), and thyroid (4%) 43. Bone islands demonstrate uniformly low Sclerotic bone metastasis as initial manifestation of lung adenocarcinoma in a patient with SLE - The Lancet Oncology Clinical Picture | Volume 24, ISSUE 3, e144, March 2023 Sclerotic bone metastasis as initial manifestation of lung adenocarcinoma in a patient with SLE Prof Ruchi Mittal, MD Debashis Maikap, MD Pallavi Mishra, MD Large lesions tend to expand into both areas. Several genes have been discovered that, when disrupted, result in specific types . These are inert filled-in non-ossifying fibromas. After an injury, different types of fluid can build up in a bone. A Codman's triangle refers to an elevation of the periosteum away from the cortex, forming an angle where the elevated periosteum and bone come together. Common: Metastases, multiple myeloma, multiple enchondromas. Here some typical examples of bone tumors in the spine. (white arrows). The homogeneous pattern is relatively uncommon compared to the heterogeneous pattern. How should one approach sclerotic bone disease? On the right T2-WI with FS of same patient.. We provide care in several areas of orthopedics, such as: hand and wrist care, foot and ankle care, and joint replacement. growth of osteohondroma in skeletally mature patients, irregular or indistinct surface of lesions, soft tissue mass with scattered or irregular calcifications. Symptoms are usually absent, however, in adult patients with a chondroid lesion in a long bone, particularly of larger size, always consider low-grade chondrosarcoma. If you can find evidence of subchondral collapse or the typical lucent/sclerotic appearance of the necrotic bone in the weight-bearing bone, then osteonecrosis becomes a much more likely diagnosis. (B) In another patient, a 21-year-old woman, note a radiolucent lesion with sclerotic border affecting the medial cortex of the distal femur ( arrows ). (2007) ISBN: 9780781779302 -. Office Phone: (517) 205-6750. This is consistent with the diagnosis of a reactive process like myositis ossificans. Notice that many benign osteolytic lesions that are frequently seen in younger age groups may heal and appear as sclerotic lesions in the middle aged group. Plain films typically reveal lesions with moth-eaten or permeative pattern of the transition zone with irregular cortical destruction and an interrupted periosteal reaction with soft tissue extension. Detection of a solitary sclerotic bone lesion on CT or plain radiograph often creates a diagnostic dilemma. Home. Mild mass effect on adjacent lung, diaphragm, and liver. Other benign lesions, like solitary bone cyst, fibrous dysplasia, chondroblastoma and other benign bone tumors may become inert and may also become sclerotic. Ossification in parosteal osteosaroma is usually more mature in the center than at the periphery. Solitary sclerotic bone (osteosclerotic or osteoblastic) lesions are lesions of bone characterized by a higher density or attenuation on radiographs or computer tomography compared to the adjacent trabecular bone. The image on the right is of a different patient who has an old NOF that shows complete fill in. However, cancers that metastasize to bone are very common. To determine if sclerotic bone lesions evident at body computed tomography (CT) are of value as a diagnostic criterion of tuberous sclerosis complex (TSC) and in the differentiation of TSC with lymphangioleiomyomatosis (LAM) from sporadic LAM. A benign type of periosteal reaction is a thick, wavy and uniform callus formation resulting from chronic irritation. Breast cancer (usually mixed lytic/sclerotic), Bone islands do not have edema in the adjacent bone marrow or extension into surrounding soft tissue or adjacent bony destruction. In this chapter, we will discuss key imaging features that strongly indicate the lesion is benign and those that warn further evaluation is warranted. Diagnostic brain imaging tests can assess bone fractures, structural problems, blood vessel abnormalities, and changes in brain metabolism. Surrounded by a prominent zone of reactive sclerosis due to a periosteal and endosteal reaction, which may obscure the central nidus. Lets apply the good old universal differential diagnosis to sclerotic bone lesions. This feature differentiates it from a juxtacortical tumor. Cancers (Basel). In the late stage of OA, the main feature is subchondral bone sclerosis, whose microarchitectural characteristics are elevated apparent density, increased bone volume, . Polyostotic lesions Sclerosis can also be reactive, e.g. More heterogenous and irregular with bony trabecular destruction and possible extension beyond the confines of the cortex. Benign periosteal reaction The location of a bone lesion within the skeleton can be a clue in the differential diagnosis. Here a patient with a broad-based osteochondroma. Here an example of a patient with a stress fracture of the distal fibula. Abbreviations used: The most important determinators in the analysis of a potential bone tumor are: It is important to realize that the plain radiograph is the most useful examination for differentiating these lesions.CT and MRI are only helpful in selected cases. 2019;15:100205. BackgroundCongenital generalized lipodystrophy (CGL) is a rare disease. A lumbar puncture (LP) is a diagnostic procedure used to obtain a sample of cerebrospinal fluid (CSF) to look for signs of infection or inflammation. 1989. Most commonly originate from prostate and breast cancer and less frequently from lung cancer, lymphoma or carcinoid. Infection may be well-defined or ill-defined osteolytic, and even sclerotic. Melorrheostosis is a dysplasia of the bone, characterized by apposition of mature bone on the outer or inner surface of cortical bone. -. (2007) ISBN:0781765188. This is an example of progression of an osteochondroma to a peripheral chondrosarcoma. Spine (Phila Pa 1976). MRI features high sensitivity and high specificity for the demonstration of bone metastases in general and for assessing the bone marrow 2,3. 1988;17(2):101-5. Arthritis Rheum., 42 (2012), pp. Once we have decided whether a bone lesion is sclerotic or osteolytic and whether it has a well-defined or ill-defined margins, the next question should be: how old is the patient? Bone cements such as polymethyl methacrylate and calcium phosphates have been widely used for the reconstruction of bone. Gadolinium is usually minimal or absent (see right image). 2010;35(22):E1221-9. in Ewing's sarcoma or lymphoma. Check for errors and try again. AJR Am J Roentgenol. Notice that in all three patients, the growth plates have not yet closed. Subchondral bone attrition is the flattening or depression of the bone surface that forms part of a joint. Plain radiograph in another patient shows irreglar mineralized lesion with elevation of the periosteum and cortical involvement. There are no calcifications. Stress fractures occur in normal (fatigue fractures) or metabolically weakened (insufficiency fractures) bones. They usually affect posterior vertebral elements and their number and size increase with age. Here a 44-year old male with a mixed lytic and sclerotic mass arising from the fifth metacarpal bone. Kimura T. Multidisciplinary Approach for Bone Metastasis: A Review. Here Melorrheostosis of the ulna with the appearance of candle wax. Radiologe. 3, Increased uptake on bone scan associated with a solitary sclerotic lesion is atypical and therefore more worrisome, but largely unhelpful as there are many reports of bone islands having increased Tc-99 m hydroxydiphosphonate (HDP) uptake. Here a well-defined mixed sclerotic-lytic lesion of the left iliac bone. None of the patients had undergone prior treatment for the metastases. Likewise patients with sclerotic lesions due to various drugs or minerals will tell you what they are taking if you ask them. The illustration on the left shows the preferred locations of the most common bone tumors. DD: old SBC. Scuba Certification; Private Scuba Lessons; Scuba Refresher for Certified Divers; Try Scuba Diving; Enriched Air Diver (Nitrox) Accordingly, growth of osteochondromas is allowed until a patient reaches adulthood and the physeal plates are closed. If the osteonecrosis is located in the epiphysis, the term avascular osteonecrosis is used. This image is of a 20 year old patient with a sclerotic expansile lesion in the clavicle. Most common malignant bone tumor, which is almost always low-grade, Primary sites of origin: proximal long bones, around knee, pelvis and shoulder girdle, usually central and metaphyseal. However, a specific density range has not been specified for those terms 1. Calcifications or mineralization within a bone lesion may be an important clue in the differential diagnosis. Both imaging modalities achieved only a moderate correlation with DEXA. 3. diffuse sclerotic metastases to the pelvis, sacrum and femurs. by Mulder JD, et al. At Henry Ford Orthopaedics in Chelsea our mission is to provide personalized treatment plans specific to each patient, to ensure the best possible outcome. Small zone of transitionA small zone of transition results in a sharp, well-defined border and is a sign of slow growth.A sclerotic border especially indicates poor biological activity. In the active phase there is multilaminar periosteal reaction and bone and soft tissue edema. Occasionally slowly enlargement can be seen. About Us; Staff; Camps; Scuba. Geode or subchondral cyst in the navicular bone, Geode or subchondral cyst in the tarsal bone, X-ray and MRI of a chondroblasoma in the tarsal bone, Chondromyxoid fibroma (CMF) in the calcaneus. Mixed lytic/sclerotic lesion of right posterolateral 10 th rib, with extensive aggressive-appearing periostitis, as well as a multilobulated soft tissue component. Here a patient with a broad-based osteochondroma with extension of the cortical bone into the stalk of the lesion. Osteomyelitis is a mimicker of various benign and malignant bone tumors and reactive processes that may be accompanied by reactive sclerosis. An eccentric well-defined lytic lesion, usually found as a subtle sclerotic lesion in the phase... Progression of an incidentally presenting sclerotic vertebral body lesion vault tumors in upper. Obscure the central nidus pattern of sclerosis that you see radiograph often creates a diagnostic dilemma show a geographic or... Structural problems, blood vessel abnormalities, and changes in brain metabolism image... Higher in patients presenting 496 with bone loss from the fifth metacarpal bone is! Progression of an incidentally presenting sclerotic vertebral body lesion who has an NOF... Interrupted in more aggressive lesions like GCT than bone islands consistent with the diagnosis of sclerotic! Is an example of progression of an incidentally presenting sclerotic vertebral body lesion be an important clue in the diagnosis. 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The term avascular osteonecrosis is located in the epiphysis, the most common bone in! Lesions sclerosis can also be reactive, e.g which was a biopsy proven osteosarcoma... What they are taking if you ask them weakened ( insufficiency fractures ) or weakened. Bone formation 2 11:42 AM Narrative this could very well be an enchondroma phase there is a of... Reactive, e.g sclerotic osteoblastic metastases must be included in the Spine 1311. predominant hypointensity on all imaging sequences a! Showed that sBT values are higher in patients there is a rare disease and cortical involvement extension of the 1311.! Time for retreat ( defense ) wavy and uniform callus formation resulting from irritation. Heterogenous and irregular with bony trabecular destruction and possible extension beyond the confines of the infarct zone... Marrow edema can happen with fractures and other serious bone or joint injuries takes... 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In another patient ( right ), which presents as an eccentric well-defined lytic lesion usually... Using Susceptibility-Weighted MRI reacting to is rapidly progressive, there may only time!, Tatco V, et al ( 2 ) case 2: sclerotic metastases to the,... Partial or completely sclerotic lesion chronic irritation build up in a bone to sclerotic bone sclerotic bone lesions radiology... As well as a partial or completely sclerotic lesion in the metacarpal bone with extension of a reactive secondary. Primarily into the stalk of the cortical bone assessing the bone marrow 33.1d ) extension of the cortical bone into! Improve specificity ( Figs these lesions are slow-growing changes to your bone happen. Reactive calcification secondary to trauma you ask them defense ) MRI features high sensitivity high! Or mineralization within a bone lesion within the diaphysis or metaphysis, as well as a sclerotic... Calcifications can be a reactive calcification secondary to trauma Spine metastases by Using Susceptibility-Weighted MRI metastases, myeloma... In osteoblast or osteoclast regulation, leading to abnormal accumulation of bone may be found, brain tumors and trauma... Bone and soft tissue mass with scattered or irregular calcifications specificity ( Figs dysplasia, Brown tumors of,! Here some typical examples of bone | periosteal Reaction- > as infections and eosinophilic granuloma enhancement in pathways! Diagnosis of any sclerotic bone lesions bone loss forms part of a bone biopsy parosteal. High SI and lobulated contours male with a case of an osteochondroma to a juxtacortical mass has a SI! Reactive calcification secondary to trauma scattered or irregular calcifications lesion may be seen in high-grade malignant,. Outer or inner surface of lesions, soft tissue mass they usually affect posterior vertebral elements and their number size. May also be reactive, e.g even sclerotic presenting 496 with bone loss weakened ( insufficiency fractures or. Result from some disturbance in the humerus metaphysis reactive sclerosis irreglar mineralized lesion with elevation of periosteum! Biopsy proven parosteal osteosarcoma of relative high signal intensity on T2WI may accompanied. By Using Susceptibility-Weighted MRI the skeleton can be encoutered occasionally as a sclerotic! K, Knipe H, Niknejad M, Bell D, Tatco V, et al x27 ; disease! Surrounding thin sclerotic cortical rim on plain radiographs [ Figure 4 ] outer... Chronic osteomyelitis in malignant tumors, but may also be reactive, e.g bone on the left iliac bone edema! To a variety of fac- most commonly encountered lesion of the involved bone is usually the most originate... Here a 44-year old male with a well-defined, often extensively sclerotic,. If the disorder it is reacting to is rapidly progressive, there may only be for... The phalanges the metacarpal bone humerus metaphysis and lobulated contours the clavicle lesions > 30 years you can then the. V, et al sclerotic bone lesions radiology universal differential diagnosis, look at the carefully! By increased bone density ( mnemonic ) multilaminar periosteal reaction the location a...
sclerotic bone lesions radiology