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Hndaw Pblshn CopoatonRadoloy Rsach and PactcVolm 2013, Atcl ID 370169, 10 pashttp://dx.do.o/10.1155/2013/370169

Review ArticleRadiographically Occult and Subtle Fractures:

A Pictorial Review

Mohamed Jarraya,1 Daichi Hayashi,1 Frank W. Roemer,1,2 Michel D. Crema,1,3 Luis Diaz,4

Jane Conlin,1,5 Monica D. Marra,1 Nabil Jomaah,6 and Ali Guermazi1

1 Department o Radiology, Musculoskeletal Section, Boston University School o Medicine, 820 Harrison Avenue, FGH Building,3rd Floor, Boston, MA 02118, USA

2 Department o Radiology, University o Erlangen, 91054 Erlangen, Germany3 Department o Radiology, Hospital do Coracao sp (HCor) and eleimagem, 04004-030 Sao Paulo, SP, Brazil4 Department o Radiology, VA Boston Healthcare System, Boston, MA 02130, USA5 Department o Radiology, Seattle Cancer Care Alliance, University o Washington, Seattle, WA 98109, USA6Department o Radiology, Aspetar, Qatar Orthopaedic and Sports Medicine Hospital, P.O. Box 29222, Doha, Qatar

Cospondnc shold b addssd to Mohamd Jaaya; [email protected]

Rcvd 24 Dcmb 2012; Accptd 20 Fbay 2013

Acadmc Edto: Andas H. Mahnkn

Copyht 2013 Mohamd Jaaya t al. Ts s an opn accss atcl dstbtd nd th Catv Commons AttbtonLcns, whch pmts nstctd s, dstbton, and podcton n any mdm, povdd th onal wok s poplyctd.

Radoaphcally occlt and sbtl acts a a danostc challn. Ty may b dvdd nto (1) hh ny tama act,(2) at act om cyclcal and sstand mchancal stss, and (3) nsfcncy act occn n waknd bon(.., n ostopooss and postadothapy). Indpndntly o th cas, th ntal adoaphc xamnaton can b natv thbcas th ndns sm nomal o a too sbtl. Ealy dtcton o ths acts s ccal to xplan th patnts symptomsand pvnt th complcatons. Advancd man tools sch as comptd tomoaphy, mantc sonanc man, andscntaphy a hhly valabl n ths contxt. O am s to as th awanss o adolosts and clncans n ths cass bypsntn llstatv cass and a dscsson o th lvant ltat.

1. Introduction

Radoaphcally occlt and sbtl acts a a com-mon danostc challn n daly pactc. Indd, ac-

ts psnt p to 80% o th mssd danoss n thmncy dpatmnt [1]. Fal to conz th sbtlsns o ossos njy s on o th asons bhnd thsmajo danostc challn [2]. Whl occlt acts psntno adoaphc ndns, adoaphcally sbtl actsa asly ovlookd on ntal adoaphs. In both cass,a natv adoaphc danoss wth pomnnt clncalsspcon o ossos njy wll pompt advancd manxamnaton sch as comptd tomoaphy (C), mantcsonanc man (MRI), ltasond, and ncla mdcnto conm o xcld th clncally sspctd danoss. Tbdn ntald n mssn ths acts nclds polondpan wth a loss o ncton, anddsablty. Ealy dtcton, on

th oth hand, nabls mo ctv tatmnt, a shothosptalzaton pod ncssay, and dcasd mdcalcosts n th lon n. It wll also pvnt nhnt complca-tons sch as nonnon, malnon, pmat ostoathts,

and avascla ostoncoss (as n scaphod act) [3].Occlt and sbtl acts may b dvdd nto: (1) actsassocatd wth hh ny tama; (2) at act sc-onday to pttv and nsal stss bn appld to bonwth nomal lastc sstanc; and (3) nsfcncy actsltn om nomal o mnmal stss on a bon wthdcasd lastc sstanc [4]. T tm stss act smo nal and ncompasss both o th latt two ntts[5]. Pdatc and mcotabcla actsknown as bonbss and contsonsa otsd th scop o ths pap.O am s to as th awanss o both clncans andadolosts to ths common poblm by llstatn vaoscass o adoaphcally occlt and sbtl acts.

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2 Radoloy Rsach and Pactc

(a) (b) (c)

Figure 1: A 56-ya-old woman psntn wth l kn pan a a all. (a) Intal antoposto adoaph was consdd nomal,howv, sbtl cotcal dspton o th anto m o th mdal tbal plata, mdal to th tbal spn, s notd (aow). (b) Coonal1-whtd MRI conms th cotcal dspton (aow) and shows xtnsv act thoh th poxmal tba. (c) Coonal potondnsty-whtd ma wth at sataton shows xtnsv dma n th sbchondal bon. Not also hypsnal adjacnt to th mdalcollatal lamnt cospondn to a ad I span (aowhads).

(a) (b)

Figure 2: Posto actabla act n a 49-ya-old womanpsntn wth hp pan a a al l. (a) Antoposto adoapho th l hp shows a adolcnt ln thoh th postoactabla wall (aows). (b) Axal C conms th actablaact (aow).

2. Imaging Tools

Tanks to apd tchnolocal advancmnt, nw and mofcnt man hadwa s constantly lasd o allman modalts ncldn C, MRI, ncla mdcn,and ltasond. Nonthlss, not vy dpatmnt canaod all nw tchnolos, and adolosts somtms havto ac th challn o povdn th hhst danostcpomanc wth basc man tools. Ts can only bachvd by nsn hh qalty o xamnaton wth thavalabl man tools.

2.1. Conventional Radiographs. Radoaphy s th st stpodtcton o acts.T dtcton o sbtl sns o ac-t qs a hh standad o th acqston tchnqand a thooh and systmatc ntptaton o adoaphcmas. Coct danoss pmaly ls on th adsxpnc. Awanss o nomal anatomc ats s ccalo th ntpt to b abl to dtct sbtl sns oact. Fat pads shold b cally xamnd o convxty,whch mpls jont son (.., n th hp and lbow

jonts). Howv, th adoaphc tchnq (postonn n

patcla) mst b optmalo ths valaton to b vald [6].Ossos lns shold b chckd o ntty (.., actablam n th hp). abcla anlaton, mpacton lns, andsclotc bands also sst act n ossos stctswth a sncant popoton o cancllos bon sch aspoxmal m [6].

T nal l s to pom two othoonal vws, btmo spcc vws shold b addd th s any sspcono act. Moov, on shold b awa o th commonlyncontd lsons and th locatons. In wst tama, onstanc, th ntpt shold pay clos attnton to thscaphod and tqtm, whch a th two most commonlynjd capal bons [3]. T mchansm o tama may

also b hlpl to locat th potntal act. A all onan otsttchd hand ssts scaphod act. Althohth classcal psntaton conssts o a adolcnt ln andcotcal dspton, th adoaphc sns wll dpnd ponth tm lapsd btwn th st clncal symptoms and thtm o adoaphc xamnaton, th locaton o th actwthn th bon, and th ato o cotcal to cancllosbon. Patcla attnton shold b pad whn analysnth sbchondal plat, whch may b dsptd o domd.In mtaphysal aas, dlayd sns o act ncld aband o scloss ppndcla to th tabcla, whldaphysal acts may psnt as postal thcknn[7].

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Radoloy Rsach and Pactc 3

(a) (b) (c)

Figure 3: A 26-ya-old man psntn wth wst pan a bn assaltd. (a) Intal antoposto adoaph shows a sbtl lnalcncy wthn th scaphod xtndn to th scaphocaptat atcla sac that was ovlookd (aow). (b) Intal scaphod vw wasnatv. (c) Followp antoposto adoaphs, 12 days lat, shows obvos scaphod act (aows).

(a) (b)

Figure 4: Dosal tqtal act o th l wst n a 30-ya-old man a a tama. Antoposto adoaph shows a nomalappaanc. (b) Latal adoaph o th sam wst dmonstats a chp act o th dosal aspct o th tqtm (aow).

Dtal adoaphy known as tomosynthss has bnshown to b spo to convntonal adoaphs n thdtcton o occlt act o th scaphod [8]. omosynth-ss has th ablty to dmonstat cotcal, as wll as mod-atly dsplacd tabcla acts. Ts, th pomanc otomosynthss n dtctn adoaphcally occlt actss consdd as compaabl to C.

2.2. Computedomography. Mltdtctocomptd tomo-aphy (MDC) s a hhly valabl man tool o th

danoss o occlt acts. C has sval advantasncldn shot acqston tm (compad to MRI), thablty to acq volmtc andsotopc ma data sts, thoppotnty to constct mltplana omatons n anyabtay plan, and xcllntspatal solton [9]. Moov,th ma qalty o mltplana constcton may bncasd by dcn slc thcknss and acqston ptch.In nal, bony stcts a bst dmonstatd by sn asmall ocal spot andsn a bon alothm.C contbtsmch to th danoss o occlt acts by dpctn sbtlact lns, dpssd, o dstactd atcla sacs andby assssn bon loss [9]. It also dtcts lat bony chanssch as ncasd mdllay dnsty, ndostal scloss,

sclotc lns n tabcla bon, and postal thcknn.Moov, C ads n xcldn oth dntal danoss,spcally n cas o solatdbon maow dma, by conm-n th nomal appaanc o th mann tabcla andxcldn spac-occpyn lsons sch as malnancy andostomylts [10].

Nwst naton o C, sch as ddcatd con-bamC (CBC) systm o mscloskltal xtmts, may bbncal n vaos condtons, sch as athts and occltacts [11]. Althoh ddcatd CBC o mscloskltalxtmts s stll a matt o sach, t has bn shown tob o potntal bnt as an adjnct o C and MRI. It osthpossblty o volmtc man, whch may b hlpl ncas o sspctd occlt acts [8]. It also povds hhspatal solton anda potntally dcd dos compad toC [11].

2.3. Magnetic Resonance Imaging. T danostc po-manc o MRI n th dtcton o occlt acts has bnshown to b compaabl [12], o btt [1317] than MDC.Indd, whl th spccty o both C and MRI o th da-noss o act can b as hh as 100% [ 18], th snstvtywas potd to b hh o MRI [1316]. T spoty

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Figure 5: amatc act o th at tbosty n a 51-ya-old man psntn wth l shold pan a a all on c. Intaladoaphs w nomal. Coonal nvson covy MRI shows aact ln (aow) thoh th at tbosty sondd by

a bon maow dma pattn.

o MRI ov any oth man modalty ncldn MDCo th dtcton o occlt hp acts s now consd[1315]. Fo nstanc, an occlt nttochantc xtnsono a at tochant act can b most ctvlyappcatd on MRI [19]. Moov, MRI s xtmly hlpln dtctn assocatd so tss abnomalts, spcallylamntos lsons [20]. MRI s now consdd as thstandad n ths contxt [21]. Howv, bcas o ts latvnavalablty n mncy sttns and hh costs, MRI mayonly b pomd n hh sk patnts wth natv X-ays. Fo xampl, whn a hp occlt act s sspctd,patnts wth dcd basln moblty and pan on axalcompsson a consdd at sk and, tho, sholdb xamnd by MRI [22]. MRI sns o occlt actsa vdnt sval wks bo adoaphc sns appa[15, 16]. In th hp, a lmtd and cost ctv MR potocol,wth only 1 whtd () coonal mas, may nabl alabl danoss o xclson o occlt act n vylttl tm, o xampl, 7 mnts [23]. ypcally, a lnahypontnsty s obsvd on 1 W mas. MRI s also hhlysnstv to maow abnomalts sondn th actln, whch appa as hypontnsty on 1 W mas andhypntnsty on d-snstv sqncs [24]. Sch snalchans a thoht to b a combnaton o bon maow

dma, ntaossos hamoha, and/o anlaton tss[20] and hlp to dnty vn ndsplacd acts [25].Howv, n th absnc o a hstoy o tama and lnahypontnstson 1 W mas, solatdbon maow dmamay psnt oth patholos sch as ostod ostoma andsclosn ostomylts [26].

Althoh 1.5 and 3 MR s consdd as th cntold standad o th dtcton o adoaphcally occltacts, lta-hh ld MR povd hh snal-to-nosato and, tho, s xpctd to b spo to 1.5 and3 [27]. Ulta-hh ld MR sms to b pomsn n thdanoss o a vaty o mscloskltal condtons ncldntama, bt t s not sd n daly otn yt.

2.4. Nuclear Medicine. T most tadtonal mthod s bonscntaphy. Althoh scntaphy s hhly snstv oth dtcton o occlt act, ts lack o spccty lmtsts danostc tlty. Howv, whn MRI s not avalabl,scntaphy may b o val, spcally n th absnc otama hstoy, o xampl, o dtcton o nsfcncy

and at acts. Whl adoaphy may show onlylat sns o bon acton (sch as postal thcknnand band o scloss), scntaphc xamnaton allows oal dtcton o bony chans. Radn Flon-182-doxy-D-lcos (FDG) poston msson tomoaphy(PE), t s ctcal to b awa that occlt acts may bsponsbl o makd mtabolc ptak, and, ths, psnta potntal als postv o mtastatc dsas [28]. Intatdhybd snl-photon msson comptzd tomoaphy(SPEC)/C combns th dtcton o abnomal bonmtabolsm wth SPEC, to th pcs anatomcal dtalpovdd by hh solton C. Fo nstanc, SPEC/Cmay b ntstn n th dtcton o adoaphc occltacts o th wst [29] and oth spot-latd njs[30].

2.5. Ultrasonography. Hh qncy ltasond has bnshown to b o val, patclaly n th pdatc poplaton[31, 32]. In ths cas, and n an mncy sttn, lta-sonoaphy can b mo accssbl and lss tm consmnthan adoaphs and has hh spccty and snstvty nth valaton o sspctd lon bon acts [32]. Ttlty o ltasonoaphy has also bn shown o adlts wthsspcon o wst tama [33] o at/stss act [34].Rcntly, t has bn sstd that thaptc ltasondmayb bncal as a pmayvalaton o bon stssnjy

[35]; howv, ts bnt sms to b mo vdnt n slctdhh sk patnts ath than nal poplaton [36].

3. High Energy Trauma Fractures

Occlt ossos njs may slt om a dct blow toth bon by compssv ocs o adjacnt bons aanston anoth o by tacton ocs dn an avlson njy.Lsons n th tbal plata, hp, ankl, and wst a onmssd [37]. In a tbal plata act, any dspton oth posto and anto cotcal ms o th plata sholdb soht. Impacton o sbchondal bon wll appa asan ncasd scloss o th sbchondal bon (F 1).

In th hp, posto actabla acts also psnt sbtladoaphc ndns. T actabla lns shold thn bcally xamnd kpn n mnd that th posto m,whch s had to s on X-ays, s mo qntly actdthan th anto m (F 2). In th wst, dtcton ocapal bon acts s on challnn, wth p to 18%o scaphod acts adoaphcally occlt [38]. Capalacts, spcally th scaphod, a assocatd wth thsk o avascla ncoss [38]. In appantly nomal wstadoaphs om symptomatc patnts, th s hstoyo a all on an otsttchd hand wth pan n th anatomcsnox, sstn scaphod njy, th ntal xamnatonwth postoanto, latal, and ponaton oblq vws

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(a) (b)

Figure 6: Sbtl anto tala act n a 39-ya-old man psntn wth ankl pan a a all. (a) Antoposto adoaph shows asbtloblq adolcnt ln thoh thtals(wht aows). (b) Sattal C omaton conms thpsnco an antotalaactwth cotcal ost (black aow).

(a) (b)

Figure 7: Fat act o th tals n a 25-ya-old mal basktball play wth ht hnd oot and ankl pan, wthot hstoy o tama,and a nomal ntal adoaph (not shown). (a) On-month ollowp latal adoaph shows nomal appaanc. (b) Sattal 1-whtd

MRI shows an la act ln (aow) wthn an ll-dnd aa o hypontnsty cospondn to bon maow dma.

mst b complmntd by oth spcc vws sch asspnaton oblq and th scaphod vw [3]. A calxamnaton o cotcs o vdnc o dscontnty o ostand cancllos bon o lcncy s ncssay (F 3).

qtal act sally occs on th dosal aspctby mpnmnt om th lna stylod o avlson o stonlamntos attachmnt [3]. T dosal avlson act ochp act appas as a small bony amnt on th dosalaspct o th tqtm and s bst dtctd on th latal

vw [3] (F 4). Whn adoaphy s natv n patntswth hh sspcon o a act, both MRI and MDC wll

b o val [39]. Howv, t has bn shown that MRI sspo o dtctn tabcla acts n capal bons[16].

T at tbosty o th hms s also an lls-tatv locaton o occlt acts. T ossos njy mayollow szs, lnohmal dslocaton, ocd abdcton,o dct mpacton. Ty a commonly dscovd on MRIn symptomatc patnts wth sspcon o otato c ta.Coonal mas a bst std o dtcton. Ty appa ascscntc oblq lns sondd by a bon maow dmapattn (F 5). T otato c mst b nspctd sncassocatd lamntos lsons a common. In th ankl,mallol and tasal bons shold b chckd cally o any

cotcal dsptons and adolcnt lns that may val aact. Awanss o th xact locaton o th pan wll hlpdct th attnton o th ntpt whn sachn o vysbtl sns o act (F 6).

Avlson acts, whch consst o a dtachd bonamnt sltn om a lamnt o tndon plln awayom th bon, may also psnt wth sbtl adoaphcsns. ny ossos amnts na th psmd attachmntst o a lamnt sst ths danoss. Common sts ath latal tbal plata (th Sond act), th spnaltbosty o th tba sltn om anto ccat la-

mnt avlson, and th schal tbosty.

4. Fatigue Fractures

Fat acts occ whn halthy bon s xposd topatd stss. T bon s a lvn tss, wth th capac-ty to pa tsl; at acts occ whn pttvnjs xcd th pa capacty o th bon [14]. Tstyp o act dos not occ as a snl vnt bt athncmntally as a sqnc o cllla vnts that bn wthncasd ostoclastc actvty [14, 40]. Mcoacts occlat anda accompand by bon maow dma, whch can

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(a) (b) (c)

Figure 8: Poxmal daphysal at act o th tba n a 20-ya-old man wth a hstoy o la jon. (a) Latal adoaph showsno obvos act lns bta sbtl localzd mdal tbal cotx postal acton (aows). (b) Sattal omattd C ma acqd 1-month a th adoaph shows a lna hypoattnaton n th tbal cotx (aowhad), as wll as obvos postal thcknn (aows).(c) Sattal 2-whtd at-satatd maacqd th sam day shows an aao hypntnsty spadn ov th poxmal tba(aows),whch s consstnt wth th psnc o poxmal tbal act.

(a) (b)

Figure 9: Poxmal mtaphysal at act o th tba n a 27-ya-old cnt mal mltay ct. (a) Antoposto adoaph swthn nomal lmts. (b) Coonal 1-whtd MR ma shows a makd lna hypoattnaton alon th mdal tbal mtaphyss (aow)sondd by ds hypontnsty n kpn wth posttamatc dma.

b dtctd on MRI. Ts sta appas on MRI as an solatdbon maow dma pattn wthot a act ln and scalld stss acton. Tn, postal nw bon oms andmay b vsbl on adoaphy. Fll cotcal acts occ th pttv stss contns. Only tmly dtcton andappopat manamnt can ntpt ths sqnc.

Fat acts a mo qnt n womn whchmay b d to th latvly small bons o womn. Mo-ov, pnancy s a wll-conzd sk acto o moalnck at act. Whl bla and mtatasal actshav a low sk o complcatons, oth sts ncldn thmoal nck, mdanto tba, navcla, tala, and othntaatcla acts a pon to complcatons sch as

dlayd non, nonnon, and dsplacmnt [14]. T sto th nsfcncy act may b spcc to th actvty:o xampl, by and basktball plays a mo ponto navcla acts, whl ymnasts hav a hh sko tala acts (F 7). Lon dstanc nns a atncasd sk o plvc, tbal (Fs 8 and 9), and blaacts [14]. In th mltay, calcans (F 10) andmtatasals a th most commonly ctd njs, spcallyn nw cts [15]. Bllad plays a at sk o pp lmbacts (F 11).

Radoaphc xamnaton sally shows dlayd snso act p to 2 to 3 months a ntal njy. In abony on wth a hh popoton o cancllos bon (..,

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(a) (b)

Figure 10: Calcanal at act n a 30-ya-old mal nn. Radoaphs w nomal (not shown). (a) Sattal 1-whtd and (b)shot ta nvson covy mas show a lna hypontnsty (aows) o calcanal tbosty wthn ds bon maow dma, whchappas as an ll-dnd aa o hypntnsty on a d snstv pls sqnc (aowhads).

(a) (b) (c)

Figure 11: Stss act o th htads n a 40-ya-old man, a smpossonal blladplay, wth no hstoy o tama andcomplanno pan o th ht oam o on month. (a) Antoposto adoaph shows mdal adal cotx postal acton (aow) bt noact ln s sn. (b) Coonal omattd C dpcts monocotcal act ln thoh th postal thcknn (aowhads). (c)Coonal 2-whtd at-sppssd MRI shows ntamdllay hypntnsty wthn th bon maow (aow) cospondn to bonmaow dma.

moal nck), a at act appas as an ll-dndtansvs sclotc band (n contact o clos to th mdalcotx), wth a postal thcknn appan at a latsta. In cas o contnd stss, a act ln thoh ththcknd cotx and a on o scloss may b obsvd[6]. MRI s o at val o aly danoss and dsplaynbon maow dma, whl scntaphy s sl o shownncasd mtabolc actvty wthn th bon. Howv, MRIs pd snc scntaphy lacks spccty. In cas osolatd bon maow dma n MRI wthot a act ln,th danoss o at act may b mo complcatd,and oth condtons sch as tansnt dma and ostod

ostoma nd to b xcldd [14]. Addtonal man by Cs waantd n sch cass.

5. Insufficiency Fractures

Insfcncy acts occ n waknd bons. Althohostopooss s a classc cas, oth condtons sltn nbon dmnalzaton a wll-conzd sk actos. Tsncld pvos adaton thapy and chmothapy, sp-cally n a contxt o ynacoloc malnancy, chonc nalal, chonc hmatolocal dsass, and cotcostod

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Figure 12: Rht sacal ala nsfcncy act n a 29-ya-old woman wth a 9-ya hstoy o cotcostod thapy o systmclps ythmatos. Convntonal adoaphs showd nomal appaanc (not shown). Coonal nvson covy MRI shows an aa ohypntnsty n th ht sacal ala (wht aows), cntd on a lna hypontnsty cospondn to th act ln (black aowhad).

(a) (b)

Figure 13: Patal ossos avlson o th ltal mscls at th at tochant n a 59-ya-old man who psntd wth th ht hppan wthot a hstoy o tama. Lanstn vw and antoposto and adoaphs (not shown) dd not show an obvos act ln odspton o bony contos n th actablm o th ht moal nck. (a) Coonal 1-whtd MRI dsplays an ncomplt act lnxtndn patally om th at tochant (aow). (b) Coonal shot ta nvson covy MRI shows htonos hypntnstyn th sam on (aow) as wll as hypntnsty wthn th lts mds and mnms mscls (aowhads) consstnt wth tssdma and hmatoma.

thapy [24]. In lon bons, chonc jont dsass sch ashmatod athts a assocatd wth anla domtyand xon contacton, ncasn th stss on th bonaond th jonts [41] and, tho, th sk o nsfcncyact. Plvc, sacal, and poxmal moal acts a

o ncasn sncanc spcally wth th an o thpoplaton [42].

T sacm s sally maskd by ovlappn bowl asn convntonal adoaphs, and th sbtl adoaphcndns a sally nondanostc and vn msladn. Tchaactstc H pattn has bn colatd wth bom-chancal modls o patnt actvts. T vtcal paasattalplans cospond to th on o maxmal stss dnwalkn, whl th hozontal act dvlops lat, sc-onday to th loss o latal sppot by paasattal acts[43]. MRI s th pmay man tchnq n ths cas,wth th most common MRI pattn shown bon maow

dma and a act ln [18] (F 12). Coonal vws aqt contbtv n sacal acts, allown th dtctono th hozontal componnt, spcally wth d-snstvsqncs. Althoh th sacm s th most commonlynvolvd, plvc nsfcncy acts a on mltpl, and

oth typcal locatons shold b mntond.Poxmal moal acts sally occ n ostopootc

patnts, and th sns ncld sbtl nck anlaton,tabcla anlaton, and sbcaptal mpacton ln. A o-llatal vw mayb hlpl that tochant s shotnoh. Howv, postonn can b dfclt bcas o hppan. In patnts wth ston sspcon o poxmal moalact and natv adoaphs, MRI lmtd to coonal 1W mas and scntaphy can b hhly valabl (Fs13 and 14). Sch an opton, wth lmtd xamnaton tm, scost-ctv and allows labl xclson o conmaton oth danoss, pvntn an nncssay stay at th hosptal

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(a) (b)

Figure 14: Sbcaptal nsfcncy act n a 55-ya-old man wth a l hp pan wthot a hstoy o tama. Antoposto andLanstn vw adoaphs cntd on th l hp do not show an obvos act ln, bt mld actabla ostophytoss was notdconsstnt wth hp ostoathts (not shown). (a) Coonal 1-whtd MRI shows a lna low-snal band thoh th moal nckcospondn to a act ln (aowhads). (b) Bon scntaphy shows ocal ptak (aow) cospondn to th act.

o dlayd tatmnt [23, 25]. Moov, MRI hlps to dtctso tss abnomalts whch a mo qntly sn nmoal, actabla, and pbc njs than sacal lsons.Concomtant acts a also qntly sn n typcalplvc sts [18].

6. Conclusion

Radoaphcally occlt and sbtl acts a on achallnn danostc poblm n daly clncal pactc.Radolosts shold b awa o th dnt statons andmchansms o ths njs as wll as th sbtl ado-aphc sns that can b ncontd n ach staton. Tknowld o nomal mas and th consdaton o thclncal contxt a o at val n mpovn th dtctono ths acts th on convntonal adoaphs o wthmo advancd man tools.

Disclosure

A. Gmaz cvd consltn s om Gnzym, Nova-ts, AstaZnca, Mck Sono, and Styk. H s th Ps-dnt o Boston Iman Co Lab (BICL), LLC. F. Rom sth CMO o BICL and cvd consltn s om MckSono and th Natonal Insttt o Halth. M. Cma andM. Maa a shaholds o BICL. Oth athos dcladnothn to dsclos.

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