Bubbly or lytic lesions (FEGNOMASHIC): fibrous dysplasia (no

periosteal reaction, mention adamantinoma if in tibia or jaw; pelvis,

proximal femur, ribs, skull, long lesion in long bone, expansile
medullary lytic lesion, ground glass, well-defined sclerotic margin,
bowing deformities, base of skull sclerotic, hot on bone scan,
cherubism in mandible and maxilla, craniofacial in facial and frontal
bones, pseudoarthrosis of tibia, Mccune Albright is polyostotic FD
with café-au-lait spots with precocious puberty), enchondroma (must
have calcifications except in phalanges, no periostitis; tubular bones,
chondroid calcifications, endosteal scalloping, pain is malignant,
Ollier’s enchondromatosis, Mafucci’s enchondromatosis with multiple
ST hemangiomas), EG (age<30; lytic lesion can look aggressive,
skull lesion beveled-edge appearance, sequestrum, floating tooth,
vertebra plana, lung dz, pituitary, RES), GCT (epiphyses must be
closed, must be epiphyseal and abut the articular surface in long
bones, eccentric, well-defined but nonsclerotic border except in flat
bones; long tubular bone > spine or sacrum, 50% at knee), NOF
(age<30, no periostitis, cortically based; metaphysis), osteoblastoma
(mention with ABC even if age>30, especially in posterior elements
of spine), mets (age>40; renal and thyroid), myeloma (age>40;
plasmacytoma in ilium and sacrum, cold on bone scan; vertebral
bodies destroyed before pedicles, axial skeleton, long bones,
punched-out lytic lesions, generalized osteopenia, skeletal survey
more sensitive), ABC (age<30, expansile, eccentric, pain, fluid-fluid
levels on MR; posterior elements of spine, metaphysis of long
bones, pelvis), SBC (age<30, central, no periostitis; proximal
humerus, proximal femur, calcaneus, fallen fragment sign), HPT
(brown tumor, must have other evidence of HPT), infection (always
mention), chondroblastoma (age<30, epiphyseal), chondromyxoid
fibroma (mention with NOF, no calcified matrix)
Automatics (must mention in every case): age<30 – infection, EG;
age>40 – infection, mets, myeloma
Multiple lytic lesions (FEEMHI): fibrous dysplasia, enchondromas,
EG, mets, myeloma, HPT, infection
Rib lesions (FAME): fibrous dysplasia, ABC, mets, myeloma,
enchondroma, EG
Lytic epiphyseal lesion (also apophyseal, carpal and tarsal bones,
patella): chondroblastoma, infection, EG, GCT, geode; age>40 –
add mets and myeloma and remove chondroblastoma
Lytic lesion in posterior elements of spine (OAT): osteoblastoma,
ABC, TB
Exclude these lytic lesions if age>30 (CANES): chondroblastoma,
ABC, NOF, EG, SBC
Lesions that have no pain or periostitis (FENS): fibrous dysplasia,
enchondroma, NOF, SBC
Bony sequestrum (FILE): fibrosarcoma, infection, lymphoma, EG,
osteoid osteoma (mimic)
Geodes (CARD): CPPD, AVN, RA, DJD, trauma
Sclerotic lesion age 20-40: chondroblastoma, ABC, NOF, EG, SBC,
fibrous dysplasia, infection, HPT (healing brown tumor), osteoid
osteoma, giant bone island; age>40 - mets
Endosteal scalloping: fibrous dysplasia, enchondroma, cartilaginous
tumor
Wide zone of transition (permeative): mets + myeloma, reticulum
cell sarcoma, Ewing’s sarcoma, infection, EG
Malignant bone tumors: age<30 – Ewing’s sarcoma (diaphysis long
bones > flat bones, aggressive, ST mass typical, medullary location),
osteosarcoma (poorly defined intramedullary metaphyseal mass
lesion extends through cortex, osteoid or chondroid matrix,
aggressive periosteal reaction with Codman triangle or sunburst
pattern, telangiectatic form purely lytic and simulates ABC, parosteal
form is low-grade and seen in posterior distal femur with more
mature ossification centrally), mets in children (neuroblastoma,
leukemia/lymphoma, Wilm’s); age>40 – mets + myeloma,
chondrosarcoma (pain, long bones, pelvis, ribs, clivus, most
metaphyseal); age 30-40 – GCT (if lung mets or recurrence),
parosteal osteosarcoma (densest calcification is central), fibrosarcoma
(almost always lytic), malignant fibrous histiocytoma (mention with
fibrosarcoma, aggressive, large soft tissue mass), reticulum cell
sarcoma (primary lymphoma of bone, looks like Ewing’s sarcoma,
often asx)
Permeative lesion in child: Ewing’s sarcoma, infection, EG
Permeative lesion in older pt: infection, mets, myeloma, malignant
fibrous histiocytoma, reticulum cell sarcoma
Soft tissue tumors: MFH, liposarcoma (may or may not have fat),
synovial sarcoma (usu extraarticular), synovial osteochondromatosis
(multiple Ca loose bodies, jt effusion, erosions, destruction; knee,
++

hip, elbow; mimics PVNS if not Ca ), pigmented villonodular

++

synovitis (hemosiderin deposits lining synovium, erosions, jt

destruction, no joint space narrowing), hemangiomas (phleboliths,
cortical holes, striated vertebral body)
Malignant transformation of bony lesions: fibrous dysplasia –
fibrosarcoma, OSA, MFH; Paget’s – OSA; osteomyelitis with draining
sinus – SCC; radiation – OSA, chondrosarcoma, MFH; bone infarct –
fibrosarcoma, MFH; Ollier’s – chondrosarcoma; Maffucci’s –
chondrosarcoma; osteochondroma - chondrosarcoma
Cortical holes (pseudopermeative lesion): osteoporosis (metacarpal
cortex less then ¼ to 1/3 of metacarpal), radiation, hemangiomas
Focal cortical thickening: stress fracture, infection, osteoid osteoma
Mets to bone: PBKTL; P – mostly blastic, B – mixed, K – purely
lytic, TL – mostly lytic
Hallmarks of DJD: joint space narrowing (asymmetric), subchondral
sclerosis, osteophytes, subchondral cysts, lack of osteoporosis or
erosions
Joints that exhibit erosions with OA: TMJ, SI, AC, pubic
symphysis
Hallmarks of RA: soft tissue swelling, periarticular and diffuse
osteoporosis, joint space narrowing, marginal erosions (including
ulnar styloid and triquetrum, proximal distribution (hands), bilaterally
symmetric, subchondral cysts, ulnar deviation, carpal instability,
rotator cuff tear, distal clavicle resorption, axial migration, protrusio
acetabuli, A-a subluxation, may see rice bodies in synovial
inflammation; secondary DJD – severe JSN out of proportion to
sclerosis and osteophytes
Hallmarks of HLA-B27 spondyloarthropathies: bony ankylosis,
proliferative new bone formation, predominantly axial (spinal)
involvement, syndesmophytes
Sacroiliac joint involvement: AS (bamboo spine, Andersen lesion
and pseudoarthrosis), IBD (like AS), psoriasis (distal predominance,
sausage digit, pencil-in-cup, acroosteolysis, proliferative erosions,
STS, periostitis, bony ankylosis, arthritis mutilans deformities, heel
spur with fuzzy margins), Reiter’s syndrome (like psoriasis but
feet>hands, IP joint great toe), DJD, infection, gout, HPT; bilateral +
symmetric SI jt + marginal symmetric syndesmophytes – usually AS
or IBD; unilateral or asymmetric SI jt – exclude AS and IBD and
consider psoriasis and Reiter’s
Large joint involvement: DJD (superolateral migration in hips,
medial compartment of knee most affected), RA (axial migration in
hips), CPPD, AS (resembles RA), PVNS, synovial
osteochondromatosis, infection (Staph aureus most common,
Salmonella in SCD, joint effusion, joint destruction, crosses disc
space in spine, periosteal reaction, bone destruction, Brodie’s
abscess is well-defined lytic lesion with thick sclerotic border,
sequestrum), amyloidosis (nodular synovitis with erosions resembling
RA), ochronosis (DSN with vacuum, disc calcifications, generalized
osteoporosis, secondary OA)
Arthropathy distribution in hands and wrists: distal – psoriasis,
Reiter’s syndrome, osteoarthritis; proximal – RA, CPPD
Bilateral symmetry of arthropathy: primary OA (middle-aged
women in hands only, 1 CMC, gull-wing erosive pattern), RA,
st
multicentric reticulohistiocytosis (multiple erosions predominantly in
phalanges without osteoporosis)
Monoarticular arthritis: CHRIST – crystal arthropathies, hemophilia,
RA, infection, synovial (synovial osteochondromatosis, PVNS), trauma
Normal mineralization: DJD, CPPD, gout, multicentric
reticulohistiocytosis, PVNS, synovial osteochondromatosis
Hallmarks of gout: well-defined erosions often with sclerotic borders
or overhanging edges, soft tissue nodules that calcify in presence of
renal failure, random distribution in hands without marked
osteoporosis, podagra (1 MTP jt), often have chondrocalcinosis,
st

preserved joint space, olecranon/prepatellar bursitis

Hallmarks of CPPD: pain, cartilage calcification (knee, triangular
fibrocartilage of wrist, pubic symphysis), joint destruction from
secondary DJD (shoulder, elbow, radiocarpal jt, patellofemoral jt),
subchondral cysts, can present as pseudogout
CPPD-associated disorders: primary HPT, gout, hemochromatosis
(DJD 2 -4 MCP jts with squaring of metacarpal heads with
nd th

drooping osteophytes, generalized osteoporosis)

Hallmarks of collagen vascular diseases: osteoporosis and soft
tissue wasting in the hands, erosions generally not present; SLE -
ulnar deviation of phalanges, nonerosive, resembles Jaccoud’s
arthropathy; scleroderma - ST calcifications, acroosteolysis, severe
resorption of 1 CMC with radial subluxation of 1 metacarpal;
st st

dermatomyositis - widespread ST calcifications, radial subluxation of

IP joint of thumb
Charcot joint: joint destruction, dislocation, heterotopic new bone;
causes – DM, spinal cord injury, alcohol abuse,
myelomeningocele/syringomyelia
Epiphyseal enlargement and gracile diaphyses: hemophilia
(hemarthrosis, secondary OA, widened intercondylar notch, enlarged
trochlear notch, subchondral cysts; pseudotumor – large ST mass
with adjacent bone destruction, hematoma, Ca common), JRA
++

(diffuse ankylosis of posterior articular joints, periosteal new bone

formation, STS, short metacarpals), paralysis
Hallmarks of AVN: increased bone density at otherwise nl jt; joint
effusion, patchy or mottled density, subchondral lucency, articular
surface collapse and joint fragmentation, low signal serpiginous
border on MR; causes – trauma, steroids, sickle cell anemia, renal
disease, collagen vascular diseases, alcoholism, idiopathic; OCD at
lateral aspect of medial femoral condyle, talus, capitellum; SONK in
elderly at weight bearing medial femoral condyle
Hallmarks of osteomalacia: osteopenia, Looser’s fxs (femur, pelvis,
scapula), epiphyseal flaring and irregularity, bending of long bones
Hallmarks of HPT: subperiosteal resorption in radial aspect of
middle phalanges, medial aspect of proximal tibia, SI jts, distal
clavicle resorption, rugger jersey spine, brown tumors, sclerosis, salt
and pepper skull, ST calcifications, chondrocalcinosis
Dense bones: renal osteodystrophy (2 HPT, osteomalacia), sickle
o

cell disease (bone infarcts, dactylitis, H shaped or fish vertebrae,

AVN hip, hair on end skull, osteomyelitis, spleen autoinfarction,
cholelithiasis, papillary necrosis), myelofibrosis (splenomegaly and
extramedullary hematopoeisis), osteopetrosis (“bone in bone,
sandwich vertebrae”, erlenmeyer flask, dense base of skull),
pyknodysostosis (distal phalanges pointed and dense, tufts absent,
widened sutures, straight angle mandible), mastocytosis (thickened
SB folds with nodules), mets (breast and prostate), Paget’s disease
(bony enlargement, commonly in pelvis with thickened iliopectineal
line, lytic phase with flame-shaped or blade of grass leading edge
that always starts at end of bone except in tibia, cotton wool skull,
2 OSA, thickened trabeculae, protrusio acetabuli, picture frame
o

vertebral body, ivory vertebral body, osteoporosis circumscripta,

diploic widening, bowing of bones), athletes, fluorosis (ligamentous
calcification, sacrotuberous ligament) – 3MsPROOF
Periostitis without underlying bony lesion: trauma, HPO (painful
periostitis of long tubular bones; causes - lung cancer, benign
fibrous tumor of pleura, mets, mesothelioma, chronic pulmonary
infection), venous stasis (lower extremities), thyroid acropachy
(occurs post thyroidectomy, metacarpals and phalanges, esp ulnar
aspect of 5 metacarpal), pachydermoperiostosis (like HPO but rarely
th

painful)
Periosteal reaction in children: scurvy (dense metaphyseal lines),
Caffey’s (tibia, ulna, mandible), trauma, hypervitaminosis, leukemia,
lymphoma, neuroblastoma, infection, physiologic, prostaglandins -
SCALP
Don’t Touch” lesions: posttraumatic lesions – myositis ossificans
(peripheral circumferential calcification with lucent center), avulsion
injury (cortical irregularity and periostitis at ligament or tendon
insertion site, lesser trochanter avulsion suggests mets), cortical
desmoid (posteromedial epicondyle of femur), geodes, discogenic
vertebral sclerosis (variant of Schmorl’s node), fracture (if not
immobilized), pseudodislocation of humerus (inferior subluxation from
fracture and hemarthrosis); normal variants – dorsal defect of patella
(lytic defect upper outer quadrant), pseudocyst of humerus (lytic area
at greater tuberosity), os odontoideum (smooth well-corticated inferior
border of dens and hypertrophied densely corticated anterior arch of
C1); benign lesions – NOF, bone islands (asymptomatic, usually
oblong with long axis in axis of stress, trabeculae extend into nl
bone spiculated), SBC (do not prophylactically curettage if in
calcaneus), pseudocyst of calcaneus, bone infarct (dense serpiginous
border), Pitt’s pit (lytic lesion at lateral aspect of femoral neck);
osteoma (facial bones, skull, Gardner’s)
Miscellaneous bone lesions: achondroplasia (shortened long bones
with narrowing of interpedicular distance in caudal direction, posterior
vertebral body scalloping), melorrheostosis (thickened cortical new
bone like “dripping candle wax”, follows sclerotome),
mucopolysaccharidoses (flattened vertebral bodies with anterior beak,
flared iliac wings and broad femoral necks, pointed proximal 5
th

metacarpal base with notch appearance to ulnar aspect, posterior

vertebral body scalloping), multiple hereditary exostosis
(osteochondromas, metaphyseal, lesion grows away from joint,
undertubulation, knees, proximal femur, axial more prone to
degeneration), osteoid osteoma (pain, age<30, lucent nidus
surrounded by reactive sclerosis in cortex of long bone, can be on
concave side of painful scoliosis, “double density” sign on bone
scan), osteopathia striata (multiple 2-3mm thick linear bands of
sclerotic bone aligned parallel to long axis of bone, asymptomatic),
osteopoikilosis (hereditary, asymptomatic, multiple small sclerotic
densities on ends of long bones and pelvis), sarcoid (“lace-like”
pattern of bony destruction in hands), SCFE (overweight teenage
boys, line through lateral femoral neck does not intersect with
portion of epiphysis, can be complication of hypothyroidism), DISH
(flowing anterior osteophytes at least 4 contiguous vertebral bodies
without DSN or sclerosis), reflex sympathetic dystrophy (=Sudeck’s
atrophy, severe patchy osteoporosis and STS following minor
trauma), acromegaly (skull thickening, enlarged sinuses and sella
turcica, hypertrophied terminal tufts with spade appearance, posterior
vertebral body scalloping, elongated and widened vertebral bodies,
heel pad thickening), transient osteoporosis of the hip (pain, self-
limited, low T1 signal, hot on bone scan), tarsal coalition (talar beak,
sclerosis of middle facet of subtalar joint), intraosseous lipoma (asx,
proximal femur, fibula, calcaneus, may have central calcified nidus);
OPLL (C-spine); Poland’s syndrome (absence of pectoral muscles
and syndactyly); congenital rubella (“celery-stalk” metaphysis)
Dense base of skull: fibrous dysplasia, Engelmann’s disease (kids,
cortical thickening midshaft of long bones involving both periosteal
and endosteal surfaces), Von Buchem’s disease (adults), Paget’s
disease, meningioma, pyknodysostosis, osteopetrosis
Lytic skull lesion: SCD, HPT, Paget’s, FD, TS, infection, mets,
myeloma, EG, epidermoid, hemangioma
Wormian bones: pyknodysostosis, OI, cleidocranial dysplasia
(absent distal clavicles, supernumerary teeth), hypothyroidism,
pachydermoperiostosis, Down’s – PORKCHOPS
Atlanto-axial subluxation: RA, trauma, Down’s, Morquio’s, POOF
High-riding shoulder: RA, CPPD, torn rotator cuff
Distal clavicle resorption: RA, HPT, osteomyelitis, weightlifting,
trauma, scleroderma
Inferior rib resorption: vascular impression (coarctation), HPT, NF
Madelung’s deformity: Hurler’s, infection, trauma,
dyschondrosteosis, osteochondromatosis, chromosomal anomalies
(Turner’s) – HITDOC
Radial hypoplasia: VACTERL, Holt-Oram syndrome,
thrombocytopenia-absent radius syndrome
Ulnar variance: negative – Kienbock’s; positive – TFCC tear, ulnar
impingement syndrome
Distal tuft resorption: scleroderma, psoriasis, Raynaud’s, vascular
disease, frostbite, electrical burns, tabes dorsalis, HPT,
pyknodysostosis – PINCH; band-like – polyvinyl chloride, Hajdu-
Cheney syndrome
Lytic finger: enchondroma, glomus tumor (pain, terminal phalanx),
epidermoid inclusion cyst, mets, infection, sarcoid, erosive
arthropathy
Polydactyly: familial, chondroectodermal dysplasia, trisomy 13,
Meckel-Gruber
Short 4 metacarpal: idiopathic, pseudohypoparathyroid
th

(brachydactyly), pseudopseudohypoparathyroid, Turner’s, basal cell

nevus syndrome (mandibular cysts, dural calcifications)
Sclerotic vertebral body: LIMMP – lymphoma, infection, mets,
myeloma, Paget’s
Vertebral body lesion: Paget’s, osteoporosis, HPT, LIMP, myeloma,
hemangioma, SCD, HLA-B27, EG, GCT, osteoblastoma, ABC, TB,
osteoid osteoma
Platyspondyly: diffuse - dwarf, OI, Morquio’s, epiphyseal dysplasia,
Cushing’s; solitary or multifocal – EG, infection, trauma, mets,
myeloma, lymphoma, leukemia, SCD, osteonecrosis (with vacuum
disc phenomenon)
Anterior vertebral body beaking: Morquio’s (middle), others
(inferior) – Hurler, achondroplasia, Downs
Posterior vertebral scalloping: dural ectasia (NF, Marfan’s, Ehlers-
Danlos), syrinx, spinal canal tumor, congenital (achondroplasia,
mucopolysaccharidoses, OI), acromegaly
Posterior spinal fusion: Klippel-Feil, surgical fusion, JRA, HLA-B27
Fused vertebrae: isolated, trauma, Klippel-Feil
Lytic ilium: FD, ABC, SBC, hemophilia, mets, plasmacytoma,
Ewing’s sarcoma, chondrosarcoma, lymphoma
Lytic sacrum: met, chordoma (sacrum, clivus, vertebral bodies,
expansile lytic lesion with large ST component and variable
calcifications), plasmacytoma, chondrosarcoma, GCT
Widened pubic symphysis: bladder exstrophy, infection, mets,
trauma, pregnancy
Widened teardrop in hip: infection, trauma, pigmented villonodular
synovitis (erosions, preserved joint space), synovial
osteochondromatosis (multiple calcified loose bodies in jt, mimics
PVNS if noncalcified), AVN
Protrusio acetabuli: RA, trauma, Paget’s, osteomalacia, AS, IBD –
PROT A
Femoral head AVN: alcohol, SCD, exogenous steroids or radiation,
pancreatitis, pregnancy, trauma, infection, Caisson, LCP, epiphyseal
dysplasia, Gaucher’s (hepatosplenomegaly, osteopenia, AVN,
Erlenmeyer flask) – ASEPTIC LEG
Medial tibial spur: osteochrondroma, Blount’s disease, trauma
Dense metaphyseal lines: growth recovery lines, lead, healing
rickets, scurvy
Erlenmeyer flask: craniometaphyseal dysplasia, hemoglobinopathies
including SCD and thalassemia (marrow hyperplasia, hair-on-end
skull, Erlenmeyer flask, extramedullary hematopoeisis), osteopetrosis,
Niemann-Pick, Gaucher’s - CHONG
Gracile bones: NF, immobilization, muscular dystrophy, JRA, OI,
dysplasias – NIMROD
Bowed bones: rickets, NF, OI, FD
Soft bone: Paget’s, osteogenesis imperfecta, osteomalacia, fibrous
dysplasia
Osteopenia: steroids, osteoporosis, osteomalacia, multiple myeloma
Epiphysis: chondroblastoma, GCT (after physis closure), EG,
chondrosarcoma
Metaphysis: osteosarcoma, parosteal sarcoma, chondrosarcoma,
fibrosarcoma, NOF, GCT (before physis closure), SBC, ABC,
osteochondroma
Diaphysis: myeloma, Ewing’s, reticulum cell sarcoma
Metadiaphyseal: fibrosarcoma, fibrous dysplasia, enchondroma,
osteoid osteoma, chondromyxoid fibroma
Soft tissue mass: MFH, lipoma, liposarcoma, hemangioma, synovial
sarcoma, nerve sheath tumor, mets, hematoma, abscess,
rhabdosarcoma, leiomyosarcoma, myositis ossificans, aneurysm
Soft tissue calcification: tumoral calcinosis, synovial
osteochondromatosis, ST tumor, scleroderma, dermatomyositis,
myositis ossificans progressiva, HPT, metastatic calcifications, CPPD,
calcium hydroxyapatite deposition, hematoma, vascular
Tendon rupture: steroids, RA, DM, HPT, gout
Heel pad thickening: >25mm, myxedema, acromegaly, dilantin,
callus, obesity, peripheral edema - MADCOP
Periprosthetic lucency: loosening, particle disease, infection
Massive osteolysis: palmar fibromatosis (Dupuytren’s contracture),
Gorham’s disease (regional lysis by angiomatous tissue, tapering of
remaining bone, ST atrophy), mets, aggressive primary bone or ST
tumor, infection