Dr Ravi Ramakantan took a fantastic film reading session with some classic radiographs on display for description and learning. We lay down the descriptions for everyone to learn from.

Case 1:

These are frontal and lateral radiographs of the upper humerus and shoulder of an immature skeleton. (How do we tell which is lateral view if the lower humerus is not covered? Usually, the greater tuberosity is seen better on frontal view rather than lateral. The xrays here are actually only partly frontal and lateral; they are more orthogonal of sorts so to speak).

Soft tissues are normal. Fat planes are normal (notice the maintained deltoid fat plane on the lateral aspect). There is a proximal humeral metadiaphseal permeative lesion with a wide zone of transition with mixed areas of sclerosis and lysis. There is dense lamellated periosteal reaction. No perpendicular (sunburst) periosteal reaction. This is a benign aggressive lesion, consistent with chronic osteomyelitis. (Note that the patient often may have prior xrays to compare with as well).

Case 2:

This is a frontal view of the wrist joint of a mature skeleton. (There is a cast present, indicating that the patient presented with fracture). There is mild soft tissue swelling. The fat planes are difficult to appreciate due to the overlying cast. There is a well defined osteolytic eccentric subarticular lesion in the distal radius with a narrow zone of transition. No periosteal reaction. Findings are consistent with giant cell tumor of the bone.

Case 3:

This is a frontal view of bilateral wrists of an immature skeleton. (Remember, bilateral views indicate a congenital or metabolic etiology; infection or neoplasm usually requires a unilateral bone x-ray).

Soft tissues and fat planes are normal. There is osteopenia with coarse trabecular pattern. The epiphyseal plate is widened (this is because the provisional zone of calcification is widened and not seen, as there is no calcium deposition happening). There is symmetric widening and fraying (brush border appearance) of the distal metaphysis of the radius and ulna. Radiological findings are consistent with rickets.

Note: You may be asked what is the bone age if the viva is going well; the distal epiphysis of the ulna is not yet present-it should appear at 5-6 years. 4 carpals are present, indicating an age of at least around 4 years. Exact bone age estimation can be done using the Greulich and Pyle atlas. Bone age may be delayed in rickets.

To read more on metabolic bone disease, read more at our blog on Dr Ravi Ramakantan’s classic talk on this topic.

– Akshay Baheti, Tata Memorial Hospital