Differential Diagnoses in
Musculoskeletal Disease
© William Herring, MD, FACR
An Incomplete List
I see a disclaimer in yourfuture*
*Thesedifferentials arenot intended tobe all inclusive.
Consult atextbook for all-inclusivedifferentials.
They aredesigned as anaid toremembering afew of the mostimportantcauses for eachof the findingsshown.
How to Use This Presentation
●First, a case isshown as anunknown
●Try to guesswhatdifferential thecaseexemplifies
How to Use This Presentation
●The next slideshows thename of thedifferential; inthis case it isankylosis ofthe SI joints
The number in the corner indicates the number of answers in the differential
5
How to Use This Presentation
●The nextmouse clickwill revealthedifferentialitself
5
How to Use This Presentation
●The lastslidereveals theetiology oftheoriginalcase
Begin with next case…
Diffuse Increase in Bone Density
1.1° malignancy – none
2.2° malignancy - metastases
3.Non-malignant disease - Paget’s Disease
4.Myelosclerosis, e.g. Sickle Cell Anemia
5.Fluorosis
6.Mastocytosis
7.Osteopetrosis
8.Hypervitaminosis D
8
Osteopetrosis
Diffuse Decrease in Bone Density
1.Osteoporosis
a. Multiple myeloma
b. Steroid administration
2.Osteomalacia
3.Hyperparathyroidism
4.Immobilization
5.Osteogenesis imperfecta
5+
Osteogenesis imperfecta
© R3, 2000
Focal Sclerotic Lesion(s)
A. Primary malignancy
1. Osteosarcoma
B. Secondary malignancy
1. Metastases
2. Lymphoma
C. Non-malignant
1. Paget’s Disease
2. Bone island(s)
3. Healed fracture(s)
4. Bone infarct(s)5. Osteoid osteoma
8
Mets from prostate ca
© R3, 2000
Focal lytic lesion
A. 1° malignancy
1. Myeloma
B. 2° malignancy
1. Metastases
C. Non-malignant
1. Eosinophilic granuloma
2. Brown tumors
4+
Mets from renal cell ca
Cell typeproducing thisfinding
Round Cell Lesions
1.Lymphoma and leukemia
2.Ewing’s sarcoma
3.Multiple myeloma
4.Osteomyelitis
5.Neuroblastoma
5
Leukemia
Expansile Lesion
1.1° malignancy – Plasmacytoma
2.2° malignancy - Mets
3.Non-malignant – Aneurysmal bone cyst
4.GCT
5.Fibrous dysplasia
6.Brown tumor
7.Enchondroma
7
Renal cell carcinoma
Location
© R3, 2000
Expansile Lesion of Rib
1.1° malignancy – Plasmacytoma
2.Chondrosarcoma
3.2° malignancy – Mets
4.Non-malignant – Fibrous dysplasia
5.Enchondroma
6.Eosinophilic granuloma
7.Neurofibromatosis
7
Fibrous dysplasia
© R3, 2000
Blowout Lesion
1.Metastases, esp. kidney, thyroid, lung
2.Giant Cell Tumor
3.Plasmacytoma
4.Chondrosarcoma
4
Renal cell ca
© R3, 2000
Soap-bubbly Lesion
1.1° Malignancy - Plasmacytoma
1.Chondrosarcoma
2.2° Malignancy - Mets
3.Non-malignant - Fibrous dysplasia
4.GCT
5.ABC
6.Chondromyxoid fibroma
7.Enchondroma
8.EG
8+
Plasmacytoma
© R3, 2000
Lesions with AssociatedSoft Tissue Masses
1.Multiple myeloma
2.Metastases
3.Osteomyelitis
4.Primary malignancies of bone
1.Osteosarcoma
2.Chondrosarcoma
3.Fibrosarcoma
4.Ewing’s sarcoma
4+
Lung ca
Sclerotic Cortical lesions
1.Osteoid osteoma
2.Brodie’s abscess
3.Healing stress fracture
3
Osteoid osteoma
© R3, 2000
Short Thumb
1.Myositis ossificans progressiva
2.Fanconi’s syndrome
3.Holt-Oram Syndrome
3
Fanconi’s Syndrome
© R3, 2000
© R3, 2000
Short 4th Metacarpal
1.Turner’s syndrome
2.Pseudohypoparathyroidism*
3.Pseudopseudohypoparathyroidism
3
*Short, obese, retarded, abnormal dentition, corneal opacities,hypocalcemia, hypophosphatemia
Pseudohypoparathyroidism
© R3, 2000
© R3, 2000
ClinodactylyInward curvature of 5th finger
1.Down’s syndrome
2.Cornelia de Lange syndrome*
3.Carpenter’s syndrome**
3
*Retarded, hirsutism, feeble cry, arched palate, small nose, brachycepalicskull** Acrocephalopolysyndactyly = retardation, hypogonadism, PDA, poly-syndactyly
Otopalatodigital syndrome
© R3, 2000
© R3, 2000
Polydactyly
1.Isolated anomaly
2.Ellis-Van Creveld syndrome*
3.Carpenter’s syndrome**
3
*Chondroectodermal dysplasia = pointy teeth, brittle nails, scant hair,accelerated maturation, Wormian bones, shortening of all bones
** Acrocephalopolysyndactyly = retardation, hypogonadism, PDA, poly-syndactyly
Isolated anomaly
© R3, 2000
© R3, 2000
SyndactylyOsseous c or s soft tissue fusion
1.Apert’s syndrome*
2.Carpenter’s syndrome
3.Down’s syndrome
3
*Hypertelorism, exopthalmus, underdeveloped sinuses, pseudarthroses,high palate
Carpenter’s Syndrome
© R3, 2000
Erosion - Distal Clavicle
1.Rheumatoid Arthritis
2.Hyperparathyroidism
3.Scleroderma
4.Cleidocranial dysplasia
4
Hyperparathyroidism
Protrusio Acetabuli
1.Paget’s disease
2.RA
3.Osteomalacia
4.Osteoporosis
5.Mucopolysaccharidosis
5
Paget’s Disease
Acro-osteolysis
1.Thermal injury, burns, frostbite
2.Scleroderma
3.Hyperparathyroidism
4.Psoriasis
5.Raynaud’s disease
6.PVC worker
6
Scleroderma
Avascular Necrosis
1.Idiopathic (Legg-Calve-Perthe’s Disease)
2.Steroid administration
3.Sickle cell anemia
4.Arteritis - collagen-vascular disease
5.Trauma
6.Gaucher’s
7.Pancreatitis
8.Fat embolism
8
Legg-Calve-Perthe’s Disease
Hypertrophic Osteoarthropathy
1.Carcinoma of the lung
2.Mesothelioma
3.Chronic lung infection (TB)
4.Chronic liver disease, e.g. cirrhosis
5.Ulcerative colitis
5
HPO 2° Lung Cancer
Location of lesion
© R3, 2000
Lesions That Affect The Spine
1.Osteoblastoma
2.Chordoma
3.Aneurysmal bone cysts
4.Metastases
4
Osteoblastoma
© R3, 2000
Location
© R3, 2000
Lesions That Affect The Pelvis
1.Chondrosarcoma
2.Plasmacytoma
3.Chordoma
3
Chondrosarcoma
© R3, 2000
Posterior Scalloping
1.Neurofibromatosis
2.Achondroplasia
3.Spinal cord tumor (ependymoma)
3
Neurofibromatosis
© R3, 2000
Anterior Scalloping
1.Aortic aneurysm
2.TB
3.Neurofibroma
3
Aortic aneurysm
© R3, 2000
© R3, 2000
Lucent Metaphyseal Bands
1.Normal
2.Leukemia
3.Neuroblastoma
4.TORCH infection
4
Scurvy
© R3, 2000
Dense Metaphyseal Bands
1.Normal
2.Lead poisoning
3.Treated leukemia
4.Healing rickets
4
Lead poisoning
Bone Within a Bone
1.Osteopetrosis
2.Paget’s disease
3.Thorotrast
3
Thorotrast
© R3, 2000
Chondrocalcinosis
1.Pseudogout
2.Gout
3.DJD
4.Hyperparathyroidism
5.Hemochromatosis
6.Wilson’s Disease
6
Pseudogout
© R3, 2000
Ankylosis of SI Joints
1.Ankylosing spondylitis
2.Psoriasis
3.Reiter’s syndrome
4.Inflammatory bowel disease
5.TB
Ankylosing spondylitis
Intramedullary Calcification
1.Enchondroma
2.Bone infarct
3.Chondrosarcoma
3
Enchondroma
Ribs
© R3, 2000
Thinned Ribs (Ribbon-Ribs)
1.Neurofibromatosis
2.Osteogenesis imperfecta
3.Trisomy 18
4.Gorham’s Disease
4
Osteogenesis imperfecta
© R3, 2000
© R3, 2000
Wide Ribs
1.Achondroplasia
2.Fibrous dysplasia
3.Rickets (rosary)
4.Marrow packing disorders
1.Thalassemia
2.Mucopolysaccharidosis, esp. Hunter’sand Hurler’s
3.Gaucher’s disease
4
Rickets
© R3, 2000
Location
© ACR, 1995
Lytic Lesion - Finger
1.Enchondroma
2.Epidermoid inclusion cyst
3.Glomus tumor
4.ABC
5.GCT
6.Met from lung, hepatoma
6
Epidermoid Inclusion Cyst
© ACR, 1995
Wormian Bones
1.Normal
2.Hypothyroidism
3.Down’s Syndrome
4.Cleidocranial dysostosis
5.Osteogenesis imperfecta
5
Normal
The End