DOI: 10.1148/rg.231015088
Cortical Lesions of the Tibia: Characteristic Appearances at Conventional Radiography1
Scott M. Levine, MD,
Robert E. Lambiase, MD and
Catherine N. Petchprapa, MD
1 From the Department of Diagnostic Imaging, Brown University Medical School, Rhode Island Hospital, 593 Eddy St, Providence, RI 02903 (S.M.L., R.E.L.); and the Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Boston, Mass (C.N.P.). Recipient of a Certificate of Merit award for an education exhibit at the 2000 RSNA scientific assembly. Received April 18, 2001; revision requested July 26; final revision received May 15, 2002; accepted May 17. Address correspondence to R.E.L. (e-mail: rlambiase@lifespan.org).
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Figure 1. Nonossifying fibroma in a 25-year-old man with knee pain after minor trauma. Radiograph shows an eccentric, well-defined, lytic lesion with a bubbly appearance in the metadiaphysis, an appearance consistent with nonossifying fibroma.
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Figure 2. Multiple nonossifying fibromas in a 14-year-old boy with pain in the left lower extremity after minor trauma. Radiograph shows eccentric, mildly expansile, bubbly lesions within the proximal and distal tibial metadiaphyses. In cases such as this, distinction from fibrous dysplasia can be difficult with radiography. The eccentric, cortical nature of each individual lesion should suggest the proper diagnosis. In this case, biopsy was performed both proximally and distally due to the presence of pain.
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Figure 3a. Fibrous dysplasia in a 44-year-old woman with ankle discomfort. Anteroposterior (a) and lateral (b) radiographs show a typical ground-glass matrix, which is due to lack of normal cortical and trabecular organization.
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Figure 3b. Fibrous dysplasia in a 44-year-old woman with ankle discomfort. Anteroposterior (a) and lateral (b) radiographs show a typical ground-glass matrix, which is due to lack of normal cortical and trabecular organization.
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Figure 4a. Osteofibrous dysplasia in a 4-year-old child. (a) Lateral radiograph of the right tibia shows a midtibial lesion with bowing. Note the intracortical osteolysis (white arrow) and adjacent sclerotic band (black arrow), which are characteristic of osteofibrous dysplasia. (b) Follow-up radiograph obtained 18 months later shows regression of the lesion without progression to pseudoarthrosis. Such healing is more common in osteofibrous dysplasia than in those lesions associated with neurofibromatosis.
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Figure 4b. Osteofibrous dysplasia in a 4-year-old child. (a) Lateral radiograph of the right tibia shows a midtibial lesion with bowing. Note the intracortical osteolysis (white arrow) and adjacent sclerotic band (black arrow), which are characteristic of osteofibrous dysplasia. (b) Follow-up radiograph obtained 18 months later shows regression of the lesion without progression to pseudoarthrosis. Such healing is more common in osteofibrous dysplasia than in those lesions associated with neurofibromatosis.
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Figure 5. Aneurysmal bone cyst in a 13-year-old girl with a painful, expanding mass around the knee. Anteroposterior radiograph shows an osteolytic, expansile lesion in the proximal tibial metaphysis. Although aneurysmal bone cysts are typically eccentric in location, they can appear to be medullary based when very large.
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Figure 6. Aneurysmal bone cyst in a 14-year-old boy with pain in the right midtibia. Radiograph shows an expansile lytic lesion that is more characteristically eccentric. Even with rapid expansion, a shell of cortical bone surrounding the lesion is usually discernible.
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Figure 7a. Giant cell tumor in a 28-year-old man with pain in the right knee. Anteroposterior (a) and lateral (b) radiographs show a lytic lesion (arrows) that extends from the subchondral epiphysis into the metaphysis. Such a location is typical of giant cell tumor, which has a predilection for subchondral bone. The age of onset, an epiphyseal epicenter, and minimal expansion often allow differentiation of this tumor from aneurysmal bone cyst with radiography.
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Figure 7b. Giant cell tumor in a 28-year-old man with pain in the right knee. Anteroposterior (a) and lateral (b) radiographs show a lytic lesion (arrows) that extends from the subchondral epiphysis into the metaphysis. Such a location is typical of giant cell tumor, which has a predilection for subchondral bone. The age of onset, an epiphyseal epicenter, and minimal expansion often allow differentiation of this tumor from aneurysmal bone cyst with radiography.
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Figure 8a. Eosinophilic granuloma in a 16-year-old boy with pain in the right calf. Oblique (a) and anteroposterior (b) radiographs show a central osseous area of increased opacity (arrow) surrounded by lysis, the so-called button sequestrum. This finding is rarely seen in the long bones, being more typical in skull lesions of eosinophilic granuloma. Also note the subtle periostitis on the anteroposterior radiograph (b).
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Figure 8b. Eosinophilic granuloma in a 16-year-old boy with pain in the right calf. Oblique (a) and anteroposterior (b) radiographs show a central osseous area of increased opacity (arrow) surrounded by lysis, the so-called button sequestrum. This finding is rarely seen in the long bones, being more typical in skull lesions of eosinophilic granuloma. Also note the subtle periostitis on the anteroposterior radiograph (b).
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Figure 9a. Ewing sarcoma in a 17-year-old girl with discomfort in the right calf. Anteroposterior (a) and lateral (b) radiographs show subtle infiltrative osteolysis, cortical "tunneling," and linear periostitis, all of which indicate a biologically aggressive process.
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Figure 9b. Ewing sarcoma in a 17-year-old girl with discomfort in the right calf. Anteroposterior (a) and lateral (b) radiographs show subtle infiltrative osteolysis, cortical "tunneling," and linear periostitis, all of which indicate a biologically aggressive process.
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Figure 10. Pseudoarthrosis of the tibia in a 7-year-old boy with neurofibromatosis who presented with leg swelling and deformity. Radiograph shows tibial pseudoarthrosis and a nonhealed fracture of the distal fibula.
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Figure 11. Cystic lesions in a patient with neurofibromatosis. Radiograph shows multiple well-defined, slightly expansile areas of lucency around the knee. Their origin is controversial, although the radiographic appearance is consistent with multiple nonossifying fibromas.
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Figure 12. Adamantinoma in a 19-year-old woman with calf pain. Lateral radiograph of the right tibia shows an appearance that is not readily distinguishable from that of fibrous dysplasia. Satellite lesions are not uncommon with adamantinoma.
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Figure 13a. Adamantinoma in a 29-year-old man with pain. Anteroposterior (a) and lateral (b) radiographs of the left tibia show a well-defined, slightly expansile intracortical area of lucency in the anterior middiaphysis. The location is typical of adamantinoma.
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Figure 13b. Adamantinoma in a 29-year-old man with pain. Anteroposterior (a) and lateral (b) radiographs of the left tibia show a well-defined, slightly expansile intracortical area of lucency in the anterior middiaphysis. The location is typical of adamantinoma.
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Figure 14. Adamantinoma in a 21-year-old woman with pain. Radiograph of the left tibia shows mixed sclerosis and lysis in the middiaphysis. Radiographic distinction between fibrous dysplasia and adamantinoma can be difficult. Note the minimal expansion and the endosteal scalloping.
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Figure 15. Osteoblastoma in an 11-year-old boy with pain after mild trauma. Anteroposterior radiograph of the left tibia shows a well-defined cortical area of lucency with surrounding sclerosis in the proximal diaphysis. The appearance is not unlike that of a large osteoid osteoma. The radiographic appearances of osteoblastomas can be quite variable, and the diagnosis is usually based on biopsy results.
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Figure 16a. Chondromyxoid fibroma in a 16-year-old boy with pain and swelling. Anteroposterior (a) and lateral (b) radiographs of the left tibia show a mildly expansile eccentric focus of osteolysis in the proximal metaphysis. The lesion is oriented along the long axis of the bone.
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Figure 16b. Chondromyxoid fibroma in a 16-year-old boy with pain and swelling. Anteroposterior (a) and lateral (b) radiographs of the left tibia show a mildly expansile eccentric focus of osteolysis in the proximal metaphysis. The lesion is oriented along the long axis of the bone.
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Figure 17. Hemangioendothelioma in a 32-year-old man infected with human immunodeficiency virus who presented with lower extremity pain. Radiograph shows multiple tibial lesions.
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Figure 18. Metastatic renal cell carcinoma in a 70-year-old man with calf pain 1 year after nephrectomy for renal cell carcinoma. Anteroposterior radiograph of the right tibia shows an expansile cortical lesion. A single osteolytic skeletal metastatic focus is common in renal cell carcinoma; however, an expansile cortical lesion is unusual.
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Figure 19a. (a) Hemangioma in a 40-year-old woman who experienced minor trauma. Radiograph shows an eccentric focus of osteolysis in the middiaphysis with a coarse trabecular appearance. Latticelike trabeculae, which are commonly seen in the skull, can suggest the diagnosis of hemangioma. (b) Hemangioma in a 55-year-old woman with calf pain. Anteroposterior radiograph of the left tibia shows a small focus of osteolysis (arrow) in the medial diaphyseal cortex. Intracortical hemangiomas are quite rare and mimic osteoid osteoma, stress fracture, and intracortical abscess, as well as the very rare intracortical osteogenic sarcoma.
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Figure 19b. (a) Hemangioma in a 40-year-old woman who experienced minor trauma. Radiograph shows an eccentric focus of osteolysis in the middiaphysis with a coarse trabecular appearance. Latticelike trabeculae, which are commonly seen in the skull, can suggest the diagnosis of hemangioma. (b) Hemangioma in a 55-year-old woman with calf pain. Anteroposterior radiograph of the left tibia shows a small focus of osteolysis (arrow) in the medial diaphyseal cortex. Intracortical hemangiomas are quite rare and mimic osteoid osteoma, stress fracture, and intracortical abscess, as well as the very rare intracortical osteogenic sarcoma.
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Figure 20. Hemangiopericytoma in a 40-year-old man with calf pain and swelling. Anteroposterior radiograph of the left proximal calf shows a mass centered in the soft tissues with scattered calcifications within the matrix. Hemangiopericytomas typically arise from the soft tissues and result in extrinsic bone destruction.
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Figure 21. Osteochondroma in a 24-year-old man with pain and a hard mass. Anteroposterior radiograph of the distal left tibia shows an eccentric lesion contiguous to the underlying cortical and trabecular bone, an appearance characteristic of osteochondroma.
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Figure 22. Stress fracture in a 25-year-old female long-distance runner with midtibial pain. Radiograph shows cortical sclerosis with an incomplete fracture (arrow) of the anterolateral cortex of the tibial middiaphysis.
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Figure 23. Insufficiency fracture in a 55-year-old woman with renal failure and secondary hyperparathyroidism who presented with discomfort in the left lower calf. Radiograph of the distal diaphysis of the tibia shows a sclerotic line (arrow) and a mature callus at the site of an insufficiency fracture. Note the radiopaque cement from fixation of a previous fracture in the more proximal tibial diaphysis.
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Figure 24. Osteoid osteoma in a 19-year-old man with severe midtibial pain. Lateral radiograph of the right tibia shows an osteolytic focus (arrow) with surrounding cortical thickening that involves the anterior cortex of the middiaphysis. Note the similarity in radiographic appearance to that of intracortical hemangioma (Fig 19b).
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Figure 25. Periosteal osteogenic sarcoma in a 28-year-old woman with lower calf pain. Radiograph shows cortical destruction (arrows) in the posterior cortex of the tibial diaphysis with surrounding new bone formation. The appearance is typical of a periosteal osteogenic sarcoma.
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Figure 26a. Diaphyseal dysplasia in a 55-year-old woman with bilateral knee pain. Anteroposterior (a) and lateral (b) radiographs of the left tibia and fibula show extensive sclerosis with near obliteration of the medullary spaces of both the tibia and fibula but with sparing of the metaphyses and epiphyses. Such a circumferential pattern of sclerosis in a symmetric distribution is not seen in melorheostosis. The findings are characteristic of diaphyseal dysplasia. There was similar symmetric involvement of all the long bones.
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Figure 26b. Diaphyseal dysplasia in a 55-year-old woman with bilateral knee pain. Anteroposterior (a) and lateral (b) radiographs of the left tibia and fibula show extensive sclerosis with near obliteration of the medullary spaces of both the tibia and fibula but with sparing of the metaphyses and epiphyses. Such a circumferential pattern of sclerosis in a symmetric distribution is not seen in melorheostosis. The findings are characteristic of diaphyseal dysplasia. There was similar symmetric involvement of all the long bones.
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Figure 27a. Venous stasis in a 22-year-old woman with swelling of the left lower leg. (a) Radiograph shows mature periostitis involving the medial cortex of the tibial diaphysis (arrowhead). Also noted is a phlebolith (arrow). (b) Oblique venogram shows a large venous varix close to the affected area of tibial cortex.
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Figure 27b. Venous stasis in a 22-year-old woman with swelling of the left lower leg. (a) Radiograph shows mature periostitis involving the medial cortex of the tibial diaphysis (arrowhead). Also noted is a phlebolith (arrow). (b) Oblique venogram shows a large venous varix close to the affected area of tibial cortex.
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Figure 28. Cellulitis of the right lower extremity in a 45-year-old man. Anteroposterior radiograph shows laminar periostitis (arrows). Radionuclide studies failed to demonstrate underlying osteomyelitis.
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Figure 29. Chronic osteomyelitis in a 62-year-old man with a draining sinus. Radiograph shows sclerosis and lysis involving the middle of the right tibia. According to the patient’s history, the infection had been present for at least 15 years.
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Figure 30a. Osteopathia striatum in a 28-year-old man after minor trauma. Anteroposterior (a) and lateral (b) radiographs show linear bands that extend to the joint space, findings consistent with osteopathia striatum. The femur was also affected.
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Figure 30b. Osteopathia striatum in a 28-year-old man after minor trauma. Anteroposterior (a) and lateral (b) radiographs show linear bands that extend to the joint space, findings consistent with osteopathia striatum. The femur was also affected.
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Figure 31. Melorheostosis in an 11-year-old boy with discomfort in and swelling of the right lower extremity. Radiograph obtained with a long leg cassette shows cortical hyperostosis that involves the femur and tibia, a finding typical of melorheostosis.
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Copyright © 2003 by the Radiological Society of North America.
