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Symptomatic Accessory Ossicles: A Pictorial Review
Poster No.:
C-1827
Congress:
ECR 2016
Type:
Educational Exhibit
Authors:
J. Saraiva, C. Bilreiro, L. Silva, C. Carneiro, B. M. Q. Santos, M. O.
E. Castro; Portimão/PT
Keywords:
MR, CT, Conventional radiography, Musculoskeletal system,
Musculoskeletal bone, Normal variants, Education and training
DOI:
10.1594/ecr2016/C-1827
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Learning objectives
To learn how accessory ossicles can become symptomatic and what are their spectrum
of appearances and clinical manifestations.
Background
Accessory ossicles are generally regarded as clinically insignificant anatomic variations,
when in fact they can become symptomatic.
They can suffer traumatic events (e.g. acute fractures, stress fractures, pseudarthrosis).
Neoplastic and osteoarthritic disorders are also reported, as well as inflammatory and
degenerative conditions.
Findings and procedure details
This presentation reviews the reported symptomatic accessory ossicles and suggests
guidelines on their imaging diagnosis while attempting to provide some clinical-radiological correlation.
We provide our own examples of the more commonly symptomatic ossicles:
1. os odontoideum;
2. Accessory Navicular;
3. os acromiale;
4. os subfibulare;
5. os trigonum;
6. Carpal Boss;
7. os calcaneus secundarius;
8. os peroneum;
9. os intermetatarseum.
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Fig. 1: Locations of the more common symptomatic ossicles: 1. os odontoideum; 2.
Accessory Navicular; 3. os acromiale; 4. os subfibulare; 5. os trigonum; 6. Carpal Boss;
7. os calcaneus secundarius; 8. os peroneum; 9. os intermetatarseum.
References: Imagiologia / Radiologia, Unidade Hospitalar de Portimão, Centro
Hospitalar do Algarve - Portimão/PT
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1. Os Odontoideum
Location
Unfused dens axis fragment, adjacent to
C2 vertebral body.
General Incidence
Symptoms
Atlantoaxial instability (anterior or posterior
atlantoaxial subluxation) is common.
May lead to substantial spinal canal
narrowing and spinal cord compression at
the level of C1.
Causes / Risk Factors
Imaging
MRI narrowing...
Differential Diagnosis
Assymptomatic os odontoideum : well
corticated convex of upper margin of
atlas body(arrowhead). Hypertrophic and
rounded anterior atlas arch(arrow).
-Type 2 odontoid Fracture: flattened,
sharp, uncorticated upper margin of
atlas body(arrowhead). Normal half moonshaped anterior atlas arch.
Notes
Fig. 12: os odontoideum
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2. Accessory navicular
Location
Adjacent to the medial side of the navicular
bone.
General Incidence
~10% (range 4-21%) of the population
Symptoms
medial side foot pain (os naviculare
syndrome)
Pain is worsened by walking, running and
other weight-bearing activities. If large, it
can protrude outwards and cause friction
against footwear.
Imaging
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A medial navicular eminence is best
visualised on the lateral-oblique view.
Symptomatic accessory navicular bones
can appear bright on bone scan and bone
marrow oedema is best seen on MRI.
Notes
Acute pain can be managed
with corticosteroid injection and
immobilisation. In refractory cases
surgical management can be an option.
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Fig. 7: Accessory navicular
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3. Os Acromiale
Location
Unfused accessory center of ossification of
the acromion of the scapula
General Incidence
1 - 15%
Symptoms
Shoulder pain
It may cause shoulder impingement,
rotator cuff tear or degenerative AC joint
disease
Imaging
On conventional radiography is best seen
on axillary views. On MRI it can easily be
mistaken for the normal acromioclavicular
joint.
•
normal AC joint
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•
•
degenerative ossification
acromion fracture
Notes
Fig. 18: os acromiale
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4. Os Subfibulare
Location
Ajacent to the tip of the lateral malleolus of
the ankle
General Incidence
very rare
Symptoms
Can cause painful syndromes or
degenerative change in response to
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overuse and trauma. The ossicle itself may
fracture.
There are two hypotheses:
1.
2.
It's an unfused accessory
ossification center.
It's an avulsion fracture
attributable to pull of the
anterior talofibular ligament.
Imaging
Avulsion fracture of the lateral malleolus
Notes
5. Os Trigonum
Location
Posterior to the talus
General Incidence
~7 %
Symptoms
Posterior
syndrome
It origins on a failure of fusion of the
lateral tubercle of the talus
Imaging
Best characterized on MRI, signal
characteristics of the affected region
include:
ankle
impingement
(PAI)
T1: low signal in areas of bony bruising
T2/STIR: high signal posterior to ankle in
areas of bone bruising
PD/PD fat saturated: high signal posterior
to the ankle
•
•
avulsion fracture of lateral
tubercle of talus (Shepherd
fracture)
fracture of Stieda process
Notes
Page 14 of 45
Fig. 15: os trigonum
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Fig. 14
6. Carpal Boss
Location
•
•
os styloideum is located
dorsally between the trapezoid,
capitate and 2nd and 3rd
metacarpal base.
os trapezium secundarium is
located between the trapezium
and the base of the first
metacarpal, developing as an
appendage to the tubercle of
the trapezium.
General Incidence
~2.0 % (os styloideum)
Symptoms
Degenerative joint disease
Imaging
Notes
Page 17 of 45
Fig. 3: os trapezoideum secundarium
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Fig. 4: os styloideum
7. Os Calcaneus secundarius
Location
anterior calcaneal process
General Incidence
5%
Symptoms
ankle pain
Imaging
bifurcated ligament avulsion fracture of
the anterior calcaneal process.
Notes
Page 20 of 45
Fig. 16: os calcaneus secundarius
8. Os Peroneum
Location
lateral plantar aspect of the cuboid
General Incidence
very common, seen in up to 26% of feet
Symptoms
Os peroneum syndrome includes fracture,
peroneus longus tenosynovitis and
peroneus longus tendon tear.
Imaging
•
•
•
os vesalianum
apophysis of the 5th
metatarsal
avulsion fracture (pseudoJones fracture)
Notes
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9. Os Intermetatarseum
Location
Typically
positioned
dorsally
between
the bases
of
the
first and
second
metatarsals
but
has
been
reported to
occur near
the
metatarsal
heads or
between
the fourth
and fifth
metatarsal
bases.
General
~4%
Incidence (range
1-7%)
Symptoms dorsal
midfoot
pain
Causes /
Risk
Factors
Imaging
It can have
a variety of
shapes:
•
•
•
•
round
oval
beanshaped
linear
Page 22 of 45
•
resemble
a
rudimentary
metatarsal
Differential
Diagnosis
Notes
It can be
classified
into three
basic
types:
•
•
free
standing:
it
is
a
completely
independent
ossicle,
and
it
does
not
show
any
osseous
or
articular
connection
with
any
structure
articulating:
it
may
form
a
synovial
joint
with
first
or
second
metatarsal
Page 23 of 45
•
or
the
medial
cuneiform
fused:
it
forms
a
spur
that
is
seen
as
a
bony
projection
in
the
first
and
second
intermetatarsal
space
Page 24 of 45
Fig. 5: os intermetatarseum
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Images for this section:
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© Imagiologia / Radiologia, Unidade Hospitalar de Portimão, Centro Hospitalar do
Algarve - Portimão/PT
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Fig. 4: os styloideum
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Fig. 1: Locations of the more common symptomatic ossicles: 1. os odontoideum; 2.
Accessory Navicular; 3. os acromiale; 4. os subfibulare; 5. os trigonum; 6. Carpal Boss;
7. os calcaneus secundarius; 8. os peroneum; 9. os intermetatarseum.
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Fig. 14
Fig. 15: os trigonum
Fig. 16: os calcaneus secundarius
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Conclusion
Normal anatomic variations are frequently overlooked as a minor finding, sometimes
not being reported when identified, when in fact they can be the source of a patient's
symptomatology.
Learning the key imaging characteristics of these pathologies is essential for determining
whether or not to attribute clinical symptoms to the accessory ossicles.
Personal information
•
J. Saraiva
1
•
C. Bilreiro
1
•
L. Silva
•
C. Carneiro
•
B.M.Q. Santos
1
•
M.O.E. Castro
1
1
1
All authors declare to have no conflits of interest on this publication.
1
Serviço de Radiologia, Centro Hospitalar do Algarve, Unidade Hospitalar de Portimão,
Sítio do Poço Seco, 8500 Portimão - PORTUGAL
References
1.
2.
3.
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ossicles and sesamoid bones of the ankle and foot: imaging findings, clinical
significance and differential diagnosis.Eur Radiol 2003; 13:L164-L177
Miller TT. Painful accessory bones of the foot. Semin Musculoskelet Radiol.
2002; 6(2) :153-161.
Jack P. Lawson. Clincial Significance of Radologic Anatomic variants of the
Skeletons. AJR 1994;163:249-255
Page 44 of 45
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Radiology 1985; 156:29-31.
Wendy R. K Smoker. Craniovertebral Junction: Normal Anatomy,
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V. J. Sammarco. Os Acromiale: Frequency, Anatomy, and Clinical
Implications. J. Bone and Joint Surg 2000;82-A(3) :394-400
7. H. Chang, J.B. Park, K.W. Kim, W.S. Choi, Retro-Dental Reactive
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Instability Secondary to Os Odontoideum. Spine 2000;25:2777-2783
Ogden JA, Ganey TM, Hill JD, Jaakkola JI. Sever's injury: a stress fracture
of the immature calcaneal metaphysis. J. Pediatr. Orthop. 2004; 24:488-92.
Atsushi Hirano Toru Fukubayashi, Tomoo Ishii, Naoyuki Ochiai. Magnetic
resonance imaging of Osgood-Schlatter disease: the course of the disease.
Skeletal Radiol 2002; 31:334-342
J. Arnaiz1, T. Piedra, E. M. de Lucas, A. M. Arnaiz, M. Pelaz at al. Imaging
Findings of Lower Limb Apophysitis. AJR 2011; 196:W316-W325
Louis DS, Calhoun TP, Garr SM, et al. Congenital bipartite scaphoid-fact or
fiction? J Bone J Surg 1976;58A:1108-12
Eoin C. K., Adam Z., Imran O., Stephanie F., Mark S., Stephen E. MRI
findings in bipartite patella. Skeletal Radiol 2007; 36:209 214
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73:687-695
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