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结核常发生在骺板软骨，向骨骺和干骺端侵犯并累及关节，病变范围较小，约13cm，边缘模糊不清，硬化边出现在静止期，钙化呈斑点状，骨膜反应少见。 短管骨结核的病理基础主要是肉芽肿，常在骨干中部呈囊状膨胀性破坏，髓腔增宽，皮质变薄，伴有不同程度骨膜反应，骨外形呈梭形。双手双足可同时发病，软组织增厚，较少累及末节指(趾)骨，有自愈倾向 。骨髓炎局部软组织不像Ewing肉瘤那么硬，压痛明显。骨髓炎多起自干骺端向骨干蔓延，骨膜反应广泛，常超出骨破坏区,何谓骨纤杭章禄,骨纤维异常增殖症（fibrous dysplasia of bone）又称骨纤维结构不良，简称骨纤。曹来宾教授等认为是同一疾病，没有必要将骨纤维结构不良（ossifying fibrousma或osteofibrous dysplasia）鉴别开来。而Kempson-Campanacci及徐万鹏、段承祥教授等应将骨纤维结构不良【应是“骨纤维发育不良”】又称骨化性纤维瘤鉴别开来.后者在光镜下：见未成熟的骨小梁周围有骨母细胞或纤维母细胞镶边和骨小梁周围有板层骨。而骨纤在病理上骨小梁周边无骨母细胞，而且纤维细胞排列成车轮状。鉴别的目的为了治疗。手术与不手术. 骨纤手术后增加恶变率。 【见后病例】骨化性纤维瘤也可自愈。,致密性骨发育异常 （Pycnodysostosis） 又译为致密性成骨不全症：特点是全身性骨骼发生均匀性致密性骨硬化，伴有颅、锁骨发育不全，与石骨症不同点是囟门未闭，有缝间骨，2/3病例肩峰端发育不全，下颌角消失，末节指（趾）骨发育不全或缺如，骨质硬化但髓腔存在，矮小，髋外翻等。,骨内骨增生症（Endosteal hyperostosis）:分为常染色体隐性遗传性疾病(Van Buchem)和常染色体显性遗传性骨硬化症（Worth病）。后者更少见，亦较轻。两者的病理上均为骨内膜 成熟的板状新生骨形成，髓腔变窄。颅骨、颅底骨 、下颌骨，肋骨、四肢骨及骨盆骨、脊柱均可见骨内膜增生，髓腔变窄或消失，但骨外径不加大，骨骺不累及。,郁万江,在骶骨部位各种干细胞及破骨细胞生长活跃, 成为骨源性肿瘤的好发部位。同时骶骨作为脊柱的一部分,发育过程中包绕脊索，因此它也是脊索瘤及神经源性肿瘤的好发部位。据Smith统计, 骶骨原发性肿瘤中，脊索瘤发病率居首位，50；巨细胞瘤次之，神经源性肿瘤居第三位。,病理分型：普通型脊索瘤，软骨样脊索瘤和低分化型脊索瘤。普通型脊索瘤生长缓慢、质地软、血供丰富局部有出血；低分化型脊索瘤为双向分化的肿瘤、生长较快，瘤组织内即有典型的脊索瘤结构同时也有肉瘤样的结构骶骨脊索瘤：脊索瘤是骶骨中最常见的肿瘤，多位于下位骶骨的中线部位，向前发展趋势明显。贾雨辰等报告的21例脊索瘤中位于骶骨下部中线者18例。Smith等报告60例无1例发生于12骶椎，都起源于35骶椎或尾椎。肿块内多有钙化（半数以上）,骶骨骨巨细胞瘤由于膨胀性生长，且横向生长大于纵向生长，故往往累及双侧耳状关节面。多位于骶骨翼偏侧生长，向耳状关节面下方呈偏心性膨胀。常跨越骶髂关节侵犯髂骨。部分骨巨细胞瘤周围可出现硬化边。可有明显的骨嵴形成骨巨细胞瘤和软骨母细胞瘤可合并ABC。,软骨肉瘤：与恶性骨肉瘤相比，在脊柱上发生的软骨肉瘤则更常见。MR与透明软骨信号相似，增强扫描呈花边状强化，颇俱诊断价值。滑膜肉瘤：严格说来本不属于骶骨肿瘤，位于骶周区域的滑膜肉瘤与骶骨原发肿瘤常混易淆，可见软组织肿块内不规则多形性钙化，而骶骨破坏不显著，这是滑膜肉瘤的特征。,郁万江,骶骨原始神经外胚层肿瘤：最近陆续有不少报道，而且以中轴骨周围居多。（1）软组织肿块 大软组织肿块是pPNET的重要表现，软组织肿块呈浸润性的生长，病灶内无成骨及钙化征象，与正常组织分界不清楚，并侵犯周围的神经血管间隙。病灶密度通常不均匀，多见坏死或出血，但坏死均为小灶性，未见有大块坏死出现，是本病软组织肿块的特点之一。CT及MRI增强扫描呈明显的不均匀强化，反映了肿瘤实质部分血供丰富。笔者认为浸润性迅速生长并明显强化的软组织肿块，无成骨及钙化为脊柱外pPNET软组织肿块的特征之一。（2）骨质改变 本组6例发生于骨的病变均为溶骨性骨质破坏，均未见到骨膜反应及钙化或瘤骨的形成，与转移瘤、骨髓瘤和淋巴瘤极其相似。但pPNET弥漫性骨质破坏者具有沿硬膜外间隙跨节段浸润的特点，在其他恶性肿瘤中很少出现，为脊柱弥漫性pPNET的重要特征，既往文献未见报道。至于脊柱上这些病灶都是原发的，还是部分病灶是转移的还不能确定，需进一步研究。笔者的资料表明：MR显示的病变范围明显大于X线和CT所显示的范围，说明MRI反映pPNET骨髓浸润情况有明显的优势，对X线和CT发现骨骼有侵犯的病例应常规行MRI检查。自己补：好发年龄平均15岁。青少年恶性肿瘤的第 2位。,骨淋巴瘤-郁万江,年龄：多见于40-70岁，发病高峰50岁左右部位：大多数位于富含红骨髓的长管骨和扁骨。骨原发性淋巴瘤最常发生的部位是股骨，约占20%25%，其次是骨盆，其他部位依次为肱骨、胫骨、脊椎、颅骨和肋骨。继发性淋巴瘤好发于中轴骨，最常见于脊椎和骨盆影像：1、原发性好发于四肢长骨，多为单发，骨质破坏更明显，软组织肿块更大，一般病程较长。2、继发性好发于红骨髓丰富的中轴骨，以多发常见，骨破坏较轻，可仅表现为骨髓浸润，而骨皮质完整，病程发展较快。3、软组织肿块“围骨生长”。4、一般无坏死及囊变。5、核医学和MR异常，平片正常占5%。6、无大块骨质破坏占80%,Fifty-year-old woman with knee pain,继发性淋巴瘤：与原发性淋巴瘤相似，有不同程度的骨质破坏，软组织肿块、骨膜反应等。特点： 中轴骨多见，70%，脊柱、骨盆、颅骨。多发骨病，往往同时侵犯骨盆、脊柱和股骨 骨硬化比例提高，硬化型和混合型比例较原发性淋巴瘤升高。 象牙椎是HL的典型表现，多见于结节硬化型和淋巴细胞为主型骨髓浸润性病变压脂序列十分必要！,斜坡区肿块T2WI常呈明显高信号-脊索瘤【本人】脊索瘤其中一种类型：T2常呈明显高信号，T1散在斑点高信号、增强呈黑白杂乱无章征。其他类型较少特征性表现？【见上海市一病例】,脊椎附件：转移瘤最早期受累，而骨髓瘤晚期才受累。The small round cell tumors are some of the most frequently occurring primary bone tumors with the Ewings sarcoma variety being the most common. Included in this group of round cell tumors are: Ewings sarcoma; primitive neuroectodermal tumors, lymphoma, embryonal rhabdomyosarcoma and metastatic neuroblastoma.There are innumerable lytic bony lesions. Yes, the findings could represent metastatic adenocarcinoma (lung, kidney, etc), but the absence of metastases to lungs or mediastinum mitigates in favor of myeloma.,股骨头无菌坏死分期,0期：无症状、无X线片和MRI异常，组织学上可见坏死期：有或无症状，X线片正常，MRI异常，组织学上可见骨坏死期：有症状，X线片可见骨小梁改变，但无软骨下骨折（半月征），关节间隙正常。MRI可能典型表现期：有症状，X线片和MRI均见不同的骨小梁改变和软骨下骨折，股骨头外形尚保持正常，关节间隙正常a期：半月征累及关节面下小于15%b期：半月板累及关节面下的15-30%c期：半月征累及关节面大于30%期：有症状，股骨头外形改变，关节间隙正常或狭窄a期：塌陷股骨头范围小于15%b期：塌陷股骨头范围15-30%c期：塌陷股骨头范围大于30% ARCO（国际骨循环和骨坏死联合会）分期法,Enchondroma of the distal femur. (A) Anteroposterior radiograph of the right knee in a patient who recently fell shows a poorly marginated area of calcification overlying the distal femur. A chondroid lesion is suspected. (B) Coronal T1-weighted MR image shows a lobulated, and very hypointense, well-defined lesion that is centrally located within the distal femur. (C) Coronal fat-suppressed T2-weighted MR image shows the same lesion to be predominantly hyperintense with low signal intensity fibrovascular septae interspersed within it. A rounded focus of very low signal superiorly within the lesion corresponds to a focus of calcification. There is no endosteal scalloping, cortical breaththrough, or associated soft-tissue mass to suggest a malignancy or a chondrosarcoma.,Hemophilic arthropathy. (A) Anteroposterior radiograph of the left knee demonstrates erosive changes of the articular surfaces, diffuse osteopenia, and severe loss of joint space.(B) Coronal T1-weighted MR image confirms the erosive changes and narrowed joint space, but also shows theperiarticular marrow edema and the extent of intraosseous involvement.(C) Coronal fat-suppressed T2-weighted MR image shows an irregular area of very low signal (arrow) corresponding to hemosiderin deposition resulting from repetitive hemarthroses.,Pigmented villonodular synovitis (PVNS). (A) Lateral radiograph shows a density within the suprapatellar bursa, which was thought to represent a small knee effusion. (B) Sagittal T1-weighted MR image demonstrates a heterogeneous but largely intermediate to low signal intensity mass within the suprapatellar bursa. This mass contains several linear and oblong foci ofdecreased signal. (C) Sagittal T2- weighted MR image shows a heterogeneous mass with high signal similar to that of the marrow or subcutaneous fat. Interspersed within the mass are very low signal foci , which are indicative of PVNS (the synovial biopsy was confirmatory). Note that there are no osseous erosions.,TIC曲线：早期快速明显强化更提示恶性,Myxoid chondrosarcoma of bone in a 50-year-old woman注意软骨基质钙化与骨碎片的鉴别,恶变征象,particularly pain related to the lesion, depth of scalloping greater than two-thirds of cortical thickness, cortical destruction and soft-tissue mass (at CT or MR imaging), periosteal reaction (at radiography), and greater uptake than the anterior iliac crest at bone scintigraphy-strongly suggest the diagnosis of chondrosarcoma. chondrosarcomas grow with lobular type architecture, and these hyaline cartilage nodules demonstrate high water content and peripheral enchondral ossificationTIC：软骨肉瘤呈早期快速明显强化,Osteoarthritis (a.k.a. degenerative joint disease)rheumatoid arthritis and calcium pyrophosphate dihydrate (CPPD) deposition disease.,typical distribution of arthritis in the hands,joint compartments of the wrist - CMC (first carpometacarpal腕掌), CCMC (common carpometacarpal), ST (scaphotrapezial舟大小多角骨), MC (midcarpal), RC (radiocarpal), and DRUJ (distal radioulnar joint),typical distribution of arthritis in the wrists,typical distribution of arthritis in the knees,typical distribution of arthritis in the hip,CPPD 二水焦磷酸钙盐（calcium pyrophosphate dihydrate deposition diseaes,）。CPPD结晶是最常见的钙结晶体，并且已确知能引起假性痛风。CPPD沉着性疾病的临床表现与急性痛风相似；发作时炎症反应极其强烈，起病十分突然，并且可分为单关节型或多关节型。与痛风不同的是本病的发作最常见于膝关节，其次是腕关节。,Calcium pyrophosphate dihydrate deposition: advanced degenerative changes seen at the radiocarpal and distal radioulnar joints, with scapholunate separation and a large degenerative geode within the adjacent radial metaphysis. Note the calcification within the TFCC secondary to CPPD.,Meniscal chondrocalcinosis secondary to CPPD. Degenerative changes seenwithin the medial tibiofemoral compartment, with prominent associated degenerative cysts,男 42岁，今年三月份右小腿紧缩感，右膝关节隐痛，七月份发现右膝关节肿胀，并触及软组织肿块，肿块并进行性增大，右侧腹股沟可触及肿大的淋巴结。最近感觉发热，T:38C左右，尤其在夜间明显,右股骨下端恶性B细胞型淋巴瘤,Multiple epiphyseal（骨骺） dysplasia: irregular mottled calcification of the right femoral epiphysis, with further irregularity of the left.,Metaphyseal （干骺端） chondrodysplasia: shortened and bowed radius, with an irregular widened cupped metaphysis and widened epiphysis.,HPOA: periosteal new bone formation along the distal radius and ulna (arrowheads).Hypertrophic pulmonaryosteoarthropathy（HPOA）,Irritable hip / transient synovitis,Age range: 9 months to 18 years with a peak at 5 years.平片正常， Occasionally a hip effusion,Psoriatic dactylitis牛皮癣性指炎: soft-tissue swelling of entire digit giving the appearance of a sausage digit腊肠指.,Osteomalacia (frontal and lateral views of the right hip)- Renal osteodystrophy. Pseudofracture (Looser zone) of the proximal femoral metaphysis,休门氏病Scheuermanns disease; plain X-ray and corresponding sagittal T2 MRI. Mild wedging of lower thoracic vertebral bodies, resulting in an increased kyphosis.Associated end plate irregularity and end plate depression Schmorls nodes(arrows).,Characteristics Wedging of three adjacent vertebra (5 degrees). Most common cause of structural kyphosis in thoracic and thoracolumbar spine. Unknown aetiology but strong family history. Usually seen in children/adolescents. M F. Associated with spondylolysis and scoliosis.Clinical features Non-reversible hyperkyphosis in thoraco-lumbar spine with pain atthe apex of the deformity. Hyperlordotic lumbar spine to compensate associated with lumbar pain. Tight hamstrings. Poor posture generally. Back pain usually resolves as skeleton stops growing.Radiological features Wedging of three adjacent vertebra (5 degrees). Anteroposterior vertebral body diameter is increased. Disc space may be mildly narrowed. Vertebral body endplate depression (Schmorls node) in up to 30%. Thoracic kyphosis (normally 258408) 458. Thoracolumbar kyphosis 308 as there is straightening of the normalthoracolumbar spine58._x0002_ Thoracolumbar kyphosis 308 as there is straightening of the normalthoracolumbar spine,腱鞘囊肿,表面由扁平梭形细胞覆盖 含有粘蛋白或液体 和关节相通？ 来自于关节囊 韧带 腱鞘 粘液囊 软骨下骨质,关节内腱鞘囊肿：交叉韧带尤如一塞条,T1w,FE,PD,T2w,粘液性囊肿,后交叉韧带粘液囊肿,腱鞘囊肿,Gadolinium,髌前骨膜腱鞘囊肿,骨内腱鞘囊肿,神经内腱鞘囊肿,囊肿液 产生于滑膜关节神经外的或神经内的腱鞘囊肿腘窝有报道神经内的较常见小腿胫神经亦受累,T1w,T2w fs,神经内腱鞘囊肿,Tibial intraneural ganglion cysts, Spinner et al Skel radiol ,2007 36:281-292 (3 cases),神经内囊肿 来自于胫神经上胫腓关节分支的神经外膜，囊肿沿阻力最小的路径进入关节囊,神经纤维瘤病I型,满足以下7条中的2条或2条以上 1. 皮肤6个以上奶油咖啡斑：青春前期：5mm；青春后期：15mm 2.腋窝或腹股沟多发性雀斑3. 虹膜多发Lisch结节4. 视神经胶质瘤 5. 多发神经纤维瘤或单发丛状神经纤维瘤 6. 特异性骨改变，如蝶骨翼发育不良、长骨骨皮质变薄、假关节等 7. 一级家族史,腋窝或腹股沟褐色雀斑,NF2,1） 双侧听神经瘤；2） 有NF2家族史（一级亲属中有NF2患者），患单侧听神经瘤；3） 有NF2家族史（一级亲属中有NF2患者），患者有以下病变中的2种：神经纤维瘤、脑膜瘤、胶质瘤、雪旺氏细胞瘤、青少年晶状体后囊浑浊斑。上述标准符合1项即可诊断NF2。,多发性骨髓瘤与溶骨型转移瘤鉴别陈英,MM仅见破骨细胞增多，呈典型膨胀性骨破坏骨破坏如穿凿样，边界清晰、锐利破坏数量较多，范围较广，大小相近本-周蛋白阳性,骨巨细胞瘤,实际上，许多研究均显示,骨巨细胞瘤的大小、部位、 X线表现、病理性骨折的有无、肿瘤的组织学分级均和肿瘤是否复发、是否具有侵袭性、是否会出现远处转移无关。目前趋向认为,骨巨细胞瘤局部多少有侵袭性,具有潜在的恶性倾向,属于“交界性肿瘤”范畴。年龄：一般在20-40岁之间， 10岁以下， 50岁以上罕见典型部位：是长骨的骨骺及干骺端区域，其原发部位几乎都发生在骨骺，随病灶扩大逐渐侵及干骺端，如病灶局限于干骺端而不破坏骨骺，骨巨细胞瘤诊断几乎不能成立。约84-99的GCT病灶累及到关节面下1 cm。脊柱的巨细胞瘤少见，骶椎是脊柱巨细胞瘤的好发部位T1WI 和T2WI均为低信号区为含铁血黄素沉着所致,刘尚礼等的骨巨细胞瘤X线分度,I度 : 肿瘤境界清楚， 无软组织肿块和骨膜反应。度:肿瘤境界部分清晰， 部分模糊，有向外侵袭的表现。有时可出现软组织肿块， 境界却清晰可辨。度：肿瘤境界几乎完全模糊等恶性征象,鉴别：动脉瘤样骨囊肿,多发生于年轻人。原发性的动脉瘤样骨囊肿很少侵犯关节端，动脉瘤样骨囊肿膨胀较巨细胞瘤明显，多纵向生长，并自皮质缺损处向骨外膜下延伸【有吗？】，晚期可形成粗大的纵行骨嵴或间隔。巨细胞瘤和动脉瘤样骨囊肿，两者在CT或MRI检查时均可显示病灶中的液面形成，但更多见于动脉瘤样骨囊肿。应注意动脉瘤样骨囊肿有时可与其他病变共存，其中也包括巨细胞瘤。,骨巨细胞瘤的液液平面,当肿瘤内出血时， T2WI上常出现液液平面液-液平缺乏特异性， 需要和动脉瘤样骨囊肿、单纯性骨囊肿合并出血，软骨母细胞瘤合并动脉瘤样骨囊肿、毛细血管扩张型骨肉瘤鉴别,骨嵴与侵袭性：骨嵴的发现对诊断骨巨细胞瘤意义很大，骨嵴在CT上显示清楚， MRI表现为在肿瘤内或边缘条状或短刺状低信号。无骨嵴形成说明肿瘤生长速度快，有一定的侵袭性多量含铁血黄素沉着表示肿瘤分化程度较高,髌骨肿瘤及瘤样病变-林祺,髌骨肿瘤，以软骨母细胞瘤多见，骨巨细胞次之。【髌骨类似骨骺】Singh等总结了欧洲4个骨肿瘤中心的59例髌骨病变，其中46%是非肿瘤，39%是良性肿瘤，15%是恶性肿瘤。最常见是骨巨细胞瘤良性，包括软骨母细胞瘤、巨细胞瘤、纤维结构不良、动脉瘤样骨囊肿和痛风国内文献报道发病率占据前几位者依次为骨巨细胞瘤、软骨母细胞瘤、骨母细胞瘤和骨软骨瘤。恶性肿瘤主要为转移瘤和骨肉瘤。,腱鞘囊肿：多见于腕关节背侧及指间关节掌侧PVNS绒毛结节表面血管增生，强化明显，其底部血管少【底部指哪？】，纤维化和玻璃样变多，强化较弱，这在鉴别诊断上有意义血友病关节炎仅见于男性颅骨神经纤维瘤起源于板障或外板；表皮样囊肿起源于板障， 加减内外板；组织细胞增生症起源于板障。先天性皮肤窦道及先天性颅顶小孔起源于三层板。新生儿颅骨缺失起源于三层板或内板。儿童顶骨变薄起源于板障或外板。桥小脑角、鞍旁及头顶：表皮样囊肿和皮样囊肿蝶骨、颞骨及筛骨：巨细胞性肉芽肿,颅骨生长迅速的肿块：促结缔组织增生性纤维瘤、巨细胞修复性肉芽肿女性：骨瘤、软骨瘤、巨细胞性肉芽肿、骨化性纤维瘤。男性：骨样骨瘤、成骨细胞瘤、嗜酸性肉芽肿、Paget病、血管瘤郎格罕细胞增生产生前列腺素，引起骨质吸收。颅骨巨细胞瘤少见，发生于颞骨或蝶骨，颅底及颌面部骨巨细胞的很少皂泡样改变。 Kashiwagi等认为颞骨骨巨细胞瘤多在板障内扩散，呈膨胀性生长，表现为反应性骨质增生改变，而蝶骨骨巨细胞瘤则表现为完全的溶骨性改变，且没有不规则形状。“osteofibrous dysplasia ”骨化纤维发育不良，是另一疾病，只发生婴幼儿胫骨【也可其他年龄，见随后图】,Young adult with leg pain,The alternative name for ossifying fibroma is osteo-fibrous dysplasia,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 steofibrous dysplasia than in those lesions associated with neurofibromatosis.OFD is a self-limited disease which has a similar radiologic appearance to adamantinoma,(12) Adamantinoma in a 19-year-old woman with calf pain. Lateral radiograph of the right tibiashows an appearance that is not readily distinguishable from that of fibrous dysplasia. Satellite lesions are not uncommon with adamantinoma. (13) 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. (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,造釉细胞瘤,女 41岁，患者一年前无明显诱因触及右胫骨前面中段肿物，质硬无压痛。右胫骨中段前侧骨皮质破坏，略有膨胀，病灶内有小分隔,造釉细胞瘤,巨细胞修复性肉芽肿Giant cell reparative granuloma,少见的骨内修复性病变，大量增生的成纤维细胞，胶原纤维化，基质细胞间有分布小型多核巨细胞。预后好 好发于儿童及青少年， 女性多见 上、下颌骨 X线及CT：具有局部侵袭性。溶骨性病灶，无硬化边，境界清楚，无骨膜反应。 MR:T1加权、T2加权均为低信号。,洋葱皮样改变Onion-skinning见于尤文氏瘤、嗜酸性肉芽肿等骨样组织是指尚未钙化的新生骨，主要由I型胶原、酸性粘多糖和非胶原性蛋白质构成，HE为均匀红染的细胞外基质，呈分带状结构 编织骨是一种不成熟骨，指骨基质中的胶原纤维粗大，排列紊乱，呈编织状。可出现在纤维结构不良或骨折后骨痂 板层骨是由编织骨经过改建形成的成熟骨，骨胶原纤维变细，呈有规则的同心圆结构不管影像学具有什么样表现，如果组织学表现是骨肉瘤就可诊断为骨肉瘤【骨肉瘤病理很准确】。在其他一些病例，像低恶性级别软骨性肿瘤，如果影像学不支持，就不能诊断。,F，30岁，骨血管瘤,骨血管瘤是一种呈瘤样增生的血管组织，掺杂于骨小梁之间，不易将其单独分离。,骨瘤（松质型）,骨转移瘤与骨髓瘤的区别,病变分布的区别：转移瘤椎体受累呈跳跃分布，且同一病例的多个椎体呈不同表现，原发病灶不同，脊柱转移部位也相应不同，如甲状腺癌易转移到颈椎，肺癌易转移到胸椎，前列腺癌及子宫附件肿瘤易转移到腰骶椎等，此与椎体供血及静脉引流有关。MR上的晕征转移瘤多见。转移瘤使椎体变形多于骨髓瘤，椎旁软组织肿块常以破坏椎体为中心发展，而骨髓瘤软组织肿块多围绕椎管发展，累及硬膜外间隙，硬膜囊狭窄呈“围管性”的特点。骨髓瘤MRI类似淋巴瘤信号也较均匀,骨样骨瘤的瘤巢有强化,要注意瘤巢周围可有炎性水肿但缺乏特异性，MRI上可出现似恶性肿瘤征象。而皮质脓肿或肉芽肿可见死骨，其周围炎性反应骨比骨样骨瘤范围广而不规整Ewing肉瘤:局部炎性表现为慢性进行性，软组织较硬。病变多起自骨干，以骨破坏为主，骨膜反应较局限，层状骨膜反应模糊、破坏，可出现针状瘤骨。硬化型Ewing肉瘤此征象常见,骨骺或/和干骺结核与软骨母细胞瘤鉴别:,1、结核常发生在骺板软骨，向骨骺和干骺端侵犯并累及关节，病变范围较小，约13cm，边缘模糊不清，硬化边出现在静止期，钙化呈斑点状，骨膜反应少见。 （病灶常跨越骺线）2、软骨母细胞瘤病灶范围较大，约14cm，多位于骨骺或干骺端的一侧（也可跨骺线），钙化多呈小环状，边缘见分叶或硬化，骨膜反应较明显。,短管状骨结核与内生软骨瘤鉴别,1.短管骨结核的病理基础主要是肉芽肿，常在骨干中部呈囊状膨胀性破坏，髓腔增宽，皮质变薄，伴有不同程度骨膜反应，骨外形呈梭形。双手双足可同时发病，软组织增厚，较少累及末节指(趾)骨，有自愈倾向 。2、内生软骨瘤常具有单侧手足骨发病倾向，病变广泛，可累及末节指(趾)骨【为膜内成骨，末端一般不累及】，其形态可多种多样，有的病变可突出骨皮质向骨外生长，表现为皮质旁型或骨膜下型软骨瘤的本质表现，病灶大小不等的钙化灶是软骨瘤的特点，如软骨瘤被溶解破坏，出现环状钙化的瘤软骨，这是软骨瘤恶变为软骨肉瘤的征象,嗜酸性肉芽肿发生在椎体，常为单椎体呈扁平椎，不累及椎板等附件，少有软组织肿块，青少年多见，与骨髓瘤和转移瘤不同。,3月肱骨小头滑车外?,5岁桡头6岁内上来,9岁鹰嘴滑内都存在,11肱骨外上也出台（此例13岁还未出台）,15、16干骺闭合成一块，上限加2，减1减2为女孩。,关 节 结 核,好发年龄 骨型 多见于10岁以下儿童 滑膜型 青壮年多好发部位 髋关节、膝关节；占75%以上。儿童骨骺出现早、大、早闭合?骨关节TB：儿童及青少年多见，30岁以下占84.2%,红黄骨髓转换,黄骨髓红髓化： 生理性：应激、嗜烟、嗜酒、高原生活及 部分运动员； 病理性：贫血、中轴骨广泛肿瘤浸润红骨髓黄髓化 未治疗的再生障碍性贫血，放化疗后患者。,骨髓梗死T2WI上可在高信号环外周见与之平行的低信号，即“双线征”，病理上为富血供肉芽组织周边伴有骨质硬化。骺板纤维桥和骨桥表现为横跨骺板连接干骺端和骨骺的低信号影。多发性内生软骨瘤，【可】偏心性膨胀性生长小儿外伤观察骺板情况3D_VIBE,85,骨梗死,男，40岁，右膝关节痛半年,骨囊肿,一般将骨囊肿分为两期，一为活动期，一为潜伏期，前者为囊肿紧邻骨骺板，说明病变有活动性，具潜在生长能力，后者为囊肿离开骨骺板，移向骨干，说明病变稳定，有重建机制。【上海市一病例：27岁，紧邻骺板，为ABC】典型的活动性骨囊肿征象为1、囊肿为邻近骨骺板的干骺部中心性病变，但不能超越骨骺板。股骨上段病变可邻近大粗隆骨骺；2、其长轴与骨干方向一致，显示为基底部在骨骺板侧的截头圆椎体；3、其横径往往不能大于骺板潜在的骨囊肿表现为骨干部单房性卵圆形透亮区，但因于囊肿壁上存在着骨嵴，而可能显示为多房性投影。,肿瘤对骨的破坏,良、恶性骨肿瘤所发生的骨破坏大致分三类：1.囊状破坏；2.囊状扩张性破坏；3.骨的弥漫性浸润性破坏。如硬化边内缘清楚，外缘模糊，多为慢性感染，也见于关节软骨囊性变，偶见于嗜酸性肉芽肿。病理见针状瘤骨并非骨膜反应，是肿瘤血管的生长部分与骨干相垂直，在其周围直接成骨，多见于骨肉瘤。针状瘤骨和絮状瘤骨均为膜内化骨，恶性度高。,瘤软骨,软骨类肿瘤或肿瘤内存在很多软骨团时，多数都可以见到环形钙化。它真实反映了瘤软骨的存在，是诊断肿瘤中软骨成分的非常可靠的依据。 环状钙化是异常增生的软骨基质钙化，是环绕在软骨内成骨的的外层的肥大软骨细胞基质钙化带环状钙化表现为环状或半环状，可大可小，小者只有1mm，大者可在23cm，可彼此相连，重叠交错，也可彼此不连，分散存在。它不同于结核干酪样坏死的无结构的钙化斑点，也与瘤骨不同，其成片或团分布，其密度高低总是均匀一致的。 可根据钙化环多少，密度，边缘等可区分为良恶性，以及良性肿瘤是否恶变有一定帮助。,颅底骨折：干眼症、反复鼻出血和运动血管性鼻炎需要注意翼管和蝶腭孔-附一方哲明自己：骨软骨瘤的软骨帽T2WI信号高于关节面软骨的原因，可能关节面软骨退变脱水。陈自谦：软组织淋巴瘤常有“四不像”特点,即不像炎症、不像肿瘤样病变、不像良性肿瘤及不像恶性肿瘤，此时应考虑淋巴瘤可能,Chrondroblastoma in a 16-year-old girl. (A) An anteroposterior radiograph of the distal femur showing a grade IA lytic lesion containing possible chondroid matrix. (B) An axial CT image of the same lesion readily shows the coarse dot-like, popcorn-like mineralization of chondroid matrix.,Axial non-contrast CT photographed in bone windows of a 94-year-old woman demonstrates the marked calvarial expansion and focal patchy areas of sclerosis(cotton-wool appearance) typical of Pagets disease.,钮扣样死骨：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 eosinophilicgranuloma. Also note the subtle periostitis on the anteroposterior radiograph (b),骨嗜酸性肉芽肿：钮扣征。但应注意亦可见于TB、转移瘤、放射性骨坏死,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（格子样）trabeculae, which are commonly seen in the skull, can suggest the diagnosis of hemangioma,良性纤维组织细胞瘤,又称黄色瘤或纤维黄色瘤，极少见，肿瘤起源于间充质细胞，主要成分是组织细胞和纤维母细胞。 临床表现：多见于成人【但有报道10-15岁，3-20岁多见】，以长管状骨多见。持续的局部严重疼痛，轻度肿胀。X线表现位于长骨骨干或干骺端，呈偏心性溶骨性破坏。皮质骨膨胀变薄，周围有明显的粗糙不规则的硬化，无骨膜反应。发生在扁平骨者，硬化骨呈环状。类似于组织细胞纤维瘤和骨巨细胞瘤MRI：T2WI瘤灶多区域信号低【见上海市一病例50岁】鉴别：非骨化性纤维瘤：多为儿童及青年，无明显症状，多因病理骨折才就诊，几乎均发生在干骺端，两者病理表现相似，主要根据临床及X线鉴别。,M 55y。左股骨下端疼痛十余天,M,55Y,右髋痛，跛行，术前股骨头坏死，术中转移瘤，PATH纤维组织细胞瘤,History:Male teenager with pain,Fibroxanthoma（纤维黄色瘤=良性纤维组织细胞瘤） with pathologic fracture【与非骨化性纤维瘤鉴别：有无疼痛是要点，影像呈NOF伴明显疼痛的，应考虑纤维黄色瘤】,Fibroxanthomas are eccentric intramedullary lesions extending to the cortex with a classic superficial scalloping contour, never abutting the physis（生长板）Histologically they are benign, and contain spindle shaped fibroblasts oriented in a cartwheel pattern with scattered giant cells, foam cells, and collagen. By definition, these lesions measure greater than 3 cm. When less than 3 cm, the lesion is called a fibrous cortical defect (FCD). Although histologically identical, FCD lesions are more likely to remain asymptomatic and resolve spontaneously. Most commonly occurs between age 10 -15, age range 3 -20. Male to female ratio 2:1. 90 % involve long tubular bones. Common sites include the distal femur (38%) and proximal or distal tibial metaphysis (43%). Multiple fibroxanthomas / FCD lesions with caf?au lait spots are suggestive of a rare disorder called Jaffe-Campanacci syndrome. Closed reduction is usually sufficient for pathologic fracture management, as callous will partially replace the lesion and provide stability. Curettage with bone graft provides better prophylaxis against future fracture.,成纤维细胞性纤维瘤Desmoplastic fibroma,又称骨韧带样纤维瘤，罕见的良性骨肿瘤 易复发 病理：轻度异型的梭形细胞及其产生的大量胶原构成 好发于青少年 无性别差异 最易累及颌骨，可侵犯全身任何骨 X线及CT： 膨胀性 溶骨性病变 不强化【？指CT】 边界清晰 内常见分隔，呈皂泡样 无骨膜反应 MRI：T1WI等低信号和T2WI混杂高低信号。而软 组织韧带样纤维瘤T2高信号，不均匀轻度（中度？指MR）强化，边缘不清【见上海市一病例】。,Osteolytic, expansile lesion with apparent septations (pseudo-trabeculae) in the tibial diaphysis. Theanterior margins are well defined. However, the cortex appears disrupted along the posterior and lateralaspect.There is periosteal thickening and irregularity posteriorly. Suggestion of soft-tissue mass associated with the bone lesion.Pseudo-trabeculae are a classic feature of desmoplastic fibroma(Desmoid Tumor of Bone),假性骨小梁是韧带样纤维瘤的典型征象,Desmoplastic fibroma (DF) is a very rare, locally aggressive, benign neoplasm of bone. Histologically,Fibromatosis纤维瘤病： The mass is predominantly dark on both T1 and T2 sequences. It enhances heterogeneously after administration of Gadolinium,SAPHO综合征(synovitis-acne-pustulosis-hyperostosis-osteomyelitis syndrome)被定义为由滑膜炎、痤疮、脓疱病、骨肥厚、骨髓炎组成的联合征。,诊 断 标 准,内生软骨瘤也可偏心Enchondroma of the proximal phalanx in a 57-year old woman. The pathognomonic findings of a lytic geographic lesion with expansion and chondroid matrix (arrows) are seen on this radiograph of the proximal phalanx of the index finger.,
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