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CHAPTER13•CongenitalFoot,Ankle,andLowerExtremityConditions
TylerA.GonzalezandRaymondHsu
CHAPTER14•EndocrineDisordersPresentingintheLowerExtremity
DanielGuss
CHAPTER15•DermatologicManifestationsofSystemicDiseaseintheLowerExtremity
SharonR.Barlizo,ThomasM.Delauro,andMarkLebwohl
CHAPTER16•LaboratoryEvaluationofSystemicRheumaticDiseasesintheLower Extremity
BellaMehtaandStevenK.Magid
CHAPTER17•MetabolicBoneDiseaseManifestationsintheFoot
PanagiotaAndreopoulou
CHAPTER18•Gastrointestinal/HepaticDiseaseManifestationsintheLowerExtremity
BrianP.BosworthandYecheskelSchneider
CHAPTER19•AcuteEmergenciesRelatedtoSystemicDiseaseandHowTheyPresentin theLowerExtremity
EdwardAmoresandRahulSharma
CHAPTER20•FootUlcersAssociatedwithHematologicDisorders
LeonardA.Levy
CHAPTER21•LowerExtremityManifestationsofSpineDisease
SravishtIyerandToddJ.Albert
CHAPTER22•LowerExtremityTendinopathyintheSettingofSystemicDisease
AndrewJ.Rosenbaum,JasonP.Tartaglione,MostafaAbousayed,MaxwellC.Alley,andJoshuaS.Dines
CHAPTER23•PedalandLowerExtremityManifestationsofHIV
KhurramH.Khan,GeorgeS.AbdelmessiehandRihamM.Wahba
CHAPTER24•FootComplicationsofObesity
LouisJ.Aronne,AnthonyCasper,RekhaKumar,LeonIgel,andAlpanaShukla
CHAPTER25•LowerExtremitySignsandSymptomsofMultipleSclerosis
MaryAnnPicone,HunterVincent,KarenBlitz-Shabbir,CloverYounWest,andJemimaAkinsanya
Index
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SystemicDisease
Manifestationsin theFoot,Ankle,and
LowerExtremity
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T
he foot and ankle are constantly being stepped on and stressed by both normal and extraordinaryforces.Feetaretakenforgranted,untiltheyarehurt,limitambulation,make
wearing shoes difficult, cause gait disturbances, or some other malady forces the foot and/or ankle to take on a new level of importance. Most of the time, foot conditions are localizedtoa bunion,flat foot, or Achilles tendon injurythat canbe treated withorthotics, change of footwear, exercises, local injection, or a combination of these therapies and/or surgery.Onotheroccasions,footand/oranklepainandabnormalitiesofthelowerextremity mayresultfromanunderlyingsystemiccondition.Whenreviewingimagingexaminations,for example, radiographs (X-ray), magnetic resonance imaging (MRI), ultrasound, or computerized tomography (CT) examinations of the lower extremity, possible underlying systemic conditions must be considered. Familiarity with systemic conditions that can be identified on an imaging examination facilitates early diagnosis and intervention. These conditions fall into the classic categories of arthritis, infection, tumor, vascular, developmental,metabolic,andother.Inthischapter,theimagingfindingsofvarioussystemic conditionsthatcanpresentwithchangesinthelowerextremityareorganizedalphabetically.
FIBROUSDYSPLASIA
Fibrousdysplasiaisasporadicbonediseaseinwhichbenignfibro-osseouslesionsdevelop during skeletal formation.1 Occasionally, fibrous dysplasia can arise as a component of McCune–Albright syndrome or Mazabraud syndrome.2 Lesions can occur anywhere on the skeleton, with thecraniofacialbones, ribs,andlongbonesmostcommonlyinvolved.1In the lowerextremity,thefemurandtibiaaremostoftenaffected.1Fibrousdysplasiaoccursinboth
monostotic andpolyostotic forms, with theformer accounting for approximately80% ofall cases.2 Often asymptomatic, fibrous dysplasia is diagnosed incidentally on radiographs obtainedforunrelatedreasons.1Insuchcases,notreatmentisneeded.1Thepolyostoticformis
morelikelyto producesymptoms includingpain,limp,anddeformity, andlargelesions are prone to pathologic fracture.1 Rarely, fibrous dysplasia is complicated by malignant
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degeneration,particularlyinpreviouslyirradiatedareas.
1
FIGURE1-1.Radiographicpatternoffibrousdysplasia.FrontalX-rayofthelowerextremities(A)andleftfemur
(B)demonstratesexpansilelesionswithcharacteristicgroundglassmatrix,thincortices,andbowingdeformities.
Notatypically,polyostoticfibrousdysplasiaaffectsonesidemorethantheother.
Fibrous dysplasia demonstrates a characteristic radiographic appearance of
intramedullary, well-defined, and expansile lesions with a radiolucent “ground glass” matrix.
1,2
Shepherd’scrookdeformityoftheproximalfemurisalateralbowingdeformityand
coxa vara.2 Saber shin deformity is an anterior bowing deformity of the tibia commonly associatedwithfibrousdysplasia(Fig.1-1).
GOUT
Gout, aninflammatory arthritis, is a crystal arthropathy characterizedby hyperuricemia and subsequentdepositionofmonosodiumurate(MSU)crystalsinjointsandsofttissues.3Goutis acommon andpotentiallydebilitatingcondition,disproportionatelyaffectingmen.3 Affected
individuals experience recurrent acute inflammatory flares as well as chronic destructive changessecondarytoMSUcrystaldeposition.Goutcaninvolveanyjointbutmostfrequently
affects the feet, demonstrating a predilectionfor the 1st metatarsophalangeal (MTP) joint.
4
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Gout can be associated with metabolic syndromes, myocardial infarction, and diabetes mellitus.
Radiographs of involved joints may reveal marginal “punched out” erosions, sclerotic
margins,andoverhangingedges,withrelativepreservationofthejointspace;however,X-ray changestypicallyoccurlateinthecourseofthedisease.
3,4
Radiographsmayalsodemonstrate
macroscopicdepositionsofMSU crystals,ortophi,whichareahallmark featureofchronic gout.4Tophimaybeperiarticularorintra-articular;CTisparticularlyusefulindetectingintra­articular depositions.4 Tophi display intermediate or low signal on T1-weighted MRI sequences, with variable appearance on T2-weighted sequences.3 Postcontrast sequences
generally demonstrate enhancement, and there is often associated synovial thickening and adjacent marrow edema.
3,4
 MRI can also reveal erosions before they become visible on
radiographs(Fig.1-2).
4
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FIGURE1-2.RadiographicandMRpatternsofgout.AandB:Frontalandobliqueradiographsofthefootin
differentpatientswithgout.A:FrontalX-rayofthefootdemonstratesmedialsofttissueprominenceofgoutytophus adjacenttothemetatarsalheadofthegreattoewithoutunderlyingboneorjointabnormalities.B:ObliqueX-rayview demonstratesclassic“overhangingedge”ofgoutatthemedialandlateralaspectsofthemetatarsalheadofthe greattoe.CtoE:MRdemonstrationofgout.C:CoronalfastspinechoMRimageofthe1stMTPjointdemonstrates theheterogeneouslyhyperintensesofttissuemassofgoutytophusmedialtothe1stMTPjoint.D:Coronalfastspin echoprotondensity-weightedimagedemonstratesaheterogeneousexpansilehyperintensemassofgoutytyphus circumferentiallyaboutthe3rdPIPjoint.E:Axialfastspinechoprotondensity-weightedimagethroughtheforefoot demonstratesfocalheterogeneouslyhyperintensesofttissuetophuswithintheplantarmarginsofboththe1stand 3rdMTPjoints.Thesofttissuetophusaboutthe3rdMTPjointextendsdorsally.
HYPERTROPHICPULMONARYOSTEOARTHROPATHY
Hypertrophic pulmonaryosteoarthropathy(HPO)orPierreMarie–Bambergersyndrome isa
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syndrome of unknown etiology characterized by the triad of periosteal bone deposition, clubbingofthedigits,andarthralgia,whichoccursinassociationwithpulmonarypathology.
5,6
HPO can develop in many chronic pulmonary conditions, but in the majority of cases is associatedwithprimarylungmalignancies.5Rarely,patientswithextrathoracicdiseasessuch as inflammatory bowel disease can develop HPO.5 Patients typically present with pain,
tenderness,and swelling.Radiographsdemonstrate generalizedperiostealreactionalong the diaphyses and metaphyses of long bones sparing the epiphyses.6 MRI can be helpful in demonstratingadjacentsofttissueswellingandmuscularedema(Fig.1-3).
6
INFARCTANDOSTEONECROSIS
Osteonecrosisandboneinfarctdefinebonedeath.Osteonecrosisistypicallyusedtodescribe ischemicbonedeathinasubchondrallocation,andboneinfarctisusedwhenthelesionisnot in a subchondral location. Systemic causes of bone death are corticosteroids, sickle cell
anemia, collagenvascular disease, alcoholism, andidiopathic.7 Themost common cause of osteonecrosis in a subchondral location istrauma thatpresents as mixedlytic andsclerotic areas on radiographs and that can progress to microfractures in articular collapse if left
untreated.
8
FIGURE1-3.RadiographicpresentationofHPO.A:X-rayoftherightankledemonstratesthickperiosteal
reactionatthedistalaspectofthelongbone,sparingtheepiphysis(arrow)withoutunderlyingbonepathology. Posteroanterior(PA)radiographofthechest(B)inthesamepatientdemonstratesalarge,leftupperlobelesion.
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Infarctsinthelowerextremityoccurprimarilyinthemedullarycavityofthelongbones.
8
On radiographs,infarctspresentasan elongatedserpiginous rimofsclerosis witha central lucency. MRI is the most sensitive test for suspected bone infarct and demonstrates
characteristicfindings.7The lesionscontainacenterofdevitalizedmarrow surroundedbya rimofgranulationtissueandsclerosis,whichgivestheselesions a centralhigh signalfrom adipose marrow with a surrounding ring of hyperintense inner granulation tissue and hypointenseouterringofsclerosisandisclassicallyreferredtoasthe“double-line”sign(Fig.
1-4).
MAFFUCCISYNDROME
Maffucci syndrome is a nonhereditary and rare dyschondroplasia of unknown origin characterized by multiple enchondromas combined with soft tissue venous malformations.
9
Enchondromasarebenigncartilaginouslesionswithinthemetadiaphysisoftubularbonesthat typically present as osteolytic expansile lesions with central stippled calcifications
characteristicofachondroidmatrix(Fig.1-5).
10
MELORHEOSTOSIS
Melorheostosisisanuncommonsclerosingbonedysplasia ofunknownetiology.
11,12
 Patients
areusuallyasymptomaticbutcanpresentwithlimbstiffnessorpain.11Thetypicalappearance onradiographsisofflowinghyperostosisalongtheoutercorticalsurfaceofthelongbonesof the lower extremity, which usually has an undulating appearance, referred to as “dripping
candlewaxsign”(Fig.1-6).
11
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FIGURE1-4.X-rayandMRfindingsofboneinfarct.A:LateralX-rayoftheankledemonstratesaclassicbone
infarctwithanirregularserpiginouselongatedlucencyinthedistaltibiawithoutperiostealorendostealreaction (arrow).Sagittalinversionrecovery(B)andprotondensity-weightedimages(C)demonstratethecharacteristic
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heterogeneouslyhyperintenseserpiginouspatternofboneinfarctonMRI.
METASTATICDISEASE
Boneisacommonsiteofmetastaticinvolvementinmalignancy.13Manyprimarymalignancies can metastasize to the skeleton; however, breast, prostate, and lung carcinoma are most
frequentlyassociatedwithosseousinvolvement.13Lessfrequently,kidneyandthyroidcancers metastasizetothebone.Metastaticlesionscanbepainfulandmayleadtopathologicfractureif
extensive cortical destruction is present.14 The axial skeleton and proximal long bones are disproportionatelyaffectedinmetastaticdisease,inpartbecauseofthehigherrelativecontent
ofvascularizedredmarrow.
14
The radiographic appearance ofosseousmetastases dependson the primarymalignancy andtheboneresponseelicitedbythemetastaticdeposit.13Breastandlungcarcinomatypically producemixedlyticandblastic lesions.13Lyticlesions are characterizedby excessive bone
resorption andare often seenwith thyroid andrenal carcinoma, whereas blastic (sclerotic) lesions,characterizedbyexcessiveboneformation,areoftenseenwithprostatecarcinoma.
13
Radiographic features associated with osseous metastases include poorly defined margins, endostealscalloping,corticaldestruction,andperiostealreaction.Anextraosseoussofttissue
componentmayoccasionallybeassociated(Fig.1-7).
14
FIGURE1-5.RadiographicmanifestationsofMaffuccisyndromeintwoseparatepatients.A:Standing
anteroposterior(AP)examinationofthelowerextremitiesdemonstratesnumerousdeformingenchondromas throughouttherightlowerextremityinvolvingthetibia,fibula,femur,andthepelvis.Asymmetricdistributionis
common,withupto50%oflesionsbeingunilateral.9B:Lateralviewoftherighttibiaandfibulademonstratessoft tissuecalcificationsrepresentativeofvenousmalformationanteriortothekneeandtibia.C:APofthefoot demonstratesclassiccalcifiedvenousmalformationsinthesofttissuesandscallopingofthemetatarsals.The enchondromasarelessevidentinthefootofthispatient.
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