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 THIRD EDITION

Davis | Blankenbaker | Bernard

ii
 THIRD EDITION

Kirkland W. Davis, MD, FACR

Professor of Radiology
Musculoskeletal Imaging and Intervention
Department of Radiology
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin

Donna G. Blankenbaker, MD, FACR

Professor of Radiology
Musculoskeletal Imaging and Intervention
Department of Radiology
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin

Stephanie A. Bernard, MD
Musculoskeletal Radiologist
Brooke Army Medical Center
Fort Sam Houston, Texas

iii
 Elsevier
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

DIAGNOSTIC IMAGING: MUSCULOSKELETAL NON-TRAUMATIC DISEASE, THIRD EDITION ISBN: 978-0-323-83473-5

Inkling: 978-0-323-83475-9
Copyright © 2022 by Elsevier. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical,
including photocopying, recording, or any information storage and retrieval system, without permission in writing from
the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our
arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be
found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as
may be noted herein).

Notices

Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds or experiments described herein.
Because of rapid advances in the medical sciences, in particular, independent verification of
diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is
assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or
property as a matter of products liability, negligence or otherwise, or from any use or operation of
any methods, products, instructions, or ideas contained in the material herein.

Previous edition copyrighted 2016.

Library of Congress Control Number: 2022931352

Printed in Canada by Friesens, Altona, Manitoba, Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

iv
 Dedications
To my beautiful wife, Jenni. Thank you for all your love, support,
and forbearance always, and especially during a lengthy book project
during a global pandemic.
I couldn’t do any of this without you.

KWD

I write this in loving memory of my father and dedicate this to my

mother, Aunt Eunice, colleagues, and mentors who have encouraged me
to work hard and follow my dreams.

DGB

To my family and mentors, who have made it possible for me

to explore such a wonderful specialty:
thank you for the years of love, support, and guidance.

SAB

v
 Contributing Authors
Behrang Amini, MD, PhD Lauren M. Ladd, MD
Associate Professor Assistant Professor of Clinical Radiology
The University of Texas MD Anderson Cancer Center Department of Radiology & Imaging Sciences
Houston, Texas Indiana University School of Medicine
Indianapolis, Indiana
Nathan D. Cecava, MD
Assistant Professor Jonelle M. Petscavage-Thomas,
Department of Radiology MD, MPH
Uniformed Services University of the Health Sciences Professor of Radiology
Division of Musculoskeletal Imaging Penn State Health Milton S. Hershey Medical Center
San Antonio Military Medical Center Hershey, Pennsylvania
Joint Base San Antonio, Texas
Eric Walker, MD, MHA, FACR, FACHE
Nancy A. Chauvin, MD Professor of Radiology
Professor of Radiology and Pediatrics Penn State Health Milton S. Hershey Medical Center
Penn State College of Medicine Hershey, Pennsylvania
Penn State Health Milton S. Hershey Medical Center Adjunct Assistant Professor of Radiology
Hershey, Pennsylvania Uniformed Services University of the Health Sciences
Bethesda, Maryland
Derik L. Davis, MD
Associate Professor Kristopher Joseph de Ga, MD
Department of Diagnostic Radiology Resident Physician
and Nuclear Medicine Department of Radiology
Musculoskeletal Radiology Section UC Davis Health
University of Maryland School of Medicine Sacramento, California
Baltimore, Maryland
Dylan A. Noblett, MD
Eva M. Escobedo, MD Resident Physician
Clinical Professor Department of Radiology
Department of Radiology UC Davis Health
UC Davis Medical Center Sacramento, California
Sacramento, California
Stephen Vong, MD
Kara G. Gill, MD Resident Physician
Department of Radiology
Associate Professor of Radiology,
UC Davis Health
Surgery, and Pediatrics
Sacramento, California
University of Wisconsin School of Medicine
and Public Health
Madison, Wisconsin

Brady K. Huang, MD
Clinical Professor
Department of Radiology
Division of Musculoskeletal Imaging
UC San Diego Medical Center
San Diego, California
vi
Additional Contributing Authors
Julia R. Crim, MD
Chris Hanrahan, MD, PhD
B. J. Manaster, MD, PhD, FACR
Sandra Moore, MD
Cheryl A. Petersilge, MD, MBA
Catherine C. Roberts, MD

vii
 Preface
Welcome to the third edition of Diagnostic Imaging: Musculoskeletal Non-Traumatic Disease.
This book partners with the third edition of Diagnostic Imaging: Musculoskeletal Trauma,
published last year, to provide updated comprehensive information covering imaging
of all human musculoskeletal conditions.

We have retained the standard Diagnostic Imaging format, with clear organization and text
presented in easy-to-digest bullets. History and clinical presentation, which are essential
elements in the diagnosis of musculoskeletal conditions, are important portions of each
chapter, as are alternative diagnostic considerations and brief reviews of differentiating
features. Standard treatment options and diagnostic clues to remember round out
the chapters. As always, the first page of each chapter is a Key Facts section that provides a
quick overview of the most important points on the topic.

Our understanding of many musculoskeletal conditions continues to evolve. For instance,

advances in genetics have refined classification and treatment of many musculoskeletal
neoplasms as well as metabolic, systemic, and congenital conditions. Similarly, knowledge
of nutritional aberrations and medication effects on the musculoskeletal system,
advanced imaging and treatment of arthritis, and the treatment of musculoskeletal
conditions with surgical implants continue to improve every year. As such, we chose to build
on the excellent foundation provided by Dr. Manaster and her expert author team
from the first two editions by recruiting a completely new team of experts in bone
and soft tissue neoplasms, arthritis, marrow disease, metabolic bone disease, systemic
disease affecting the musculoskeletal system, musculoskeletal infections, orthopedic
implants, nutritional and medication effects on the musculoskeletal system, and congenital
and developmental aberrations of the musculoskeletal system and skeletal dysplasias.

This new team combined extensive review of the current literature with their own
expertise in these topics to provide a major revision to the textbook. The text
in all chapters has been updated, with substantial changes in the vast majority. Over
2,000 new images have been added to this edition, providing copious up-to-date
examples of important pathology and conditions, while retaining the best images from
the second edition. Numerous new ultrasound images are included, along with examples of
advanced MR techniques and PET/CT and PET/MR tools where appropriate.

We encourage the reader to utilize the digital-only portion of the textbook; many
chapters hold additional text that may be helpful, such as additional clinical presentation
information and classification systems. More importantly, there are additional imaging
examples of the conditions that may help enhance and round out the reader’s understanding
of the topic and its varied presentations.

Our team believes the two musculoskeletal Diagnostic Imaging texts provide
comprehensive information radiologists and other musculoskeletal providers need
to understand and diagnose musculoskeletal conditions, presented in a readable
format not matched by other textbooks. We hope and expect this text to be interesting
and valuable to your learning and practice and that you will enjoy reading it.

viii
Kirkland W. Davis, MD, FACR
Professor of Radiology
Musculoskeletal Imaging and Intervention
Department of Radiology
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin

Donna G. Blankenbaker, MD, FACR

Professor of Radiology
Musculoskeletal Imaging and Intervention
Department of Radiology
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin

Stephanie A. Bernard, MD
Musculoskeletal Radiologist
Brooke Army Medical Center
Fort Sam Houston, Texas

ix
x
Acknowledgments
LEAD EDITOR
Kathryn Watkins, BA

LEAD ILLUSTRATOR
Lane R. Bennion, MS

TEXT EDITORS
Arthur G. Gelsinger, MA
Rebecca L. Bluth, BA
Nina Themann, BA
Terry W. Ferrell, MS
Megg Morin, BA
Shannon Kelly, MA

ILLUSTRATIONS
Richard Coombs, MS
Laura C. Wissler, MA

IMAGE EDITORS
Jeffrey J. Marmorstone, BS
Lisa A. M. Steadman, BS

ILLUSTRATION SUPPORT
Eric Walker, MD, MHA, FACR, FACHE

ART DIRECTION AND DESIGN

Cindy Lin, BFA

PRODUCTION EDITORS
Emily C. Fassett, BA
John Pecorelli, BS

xi
xii
 Sections
SECTION 1: Arthritis

SECTION 2: Bone Tumors and Tumor-Like Conditions

SECTION 3: Soft Tissue Tumors

SECTION 4: Congenital and Developmental Abnormalities

SECTION 5: Dysplasias

SECTION 6: Systemic Diseases With Musculoskeletal

Involvement

SECTION 7: Orthopedic Implants or Arthrodesis

SECTION 8: Infection

SECTION 9: Bone Marrow

SECTION 10: Metabolic Bone Disease

SECTION 11: Drug-Induced and Nutritional Musculoskeletal

Conditions

xiii
 TABLE OF CONTENTS

SECTION 1: ARTHRITIS MIXED EROSIVE AND PRODUCTIVE

INTRODUCTION AND OVERVIEW 86 Ankylosing Spondylitis
Eva M. Escobedo, MD and B. J. Manaster, MD, PhD, FACR
4 Introduction to Arthritis 92 Inflammatory Bowel Disease Arthritis
Eva M. Escobedo, MD and B. J. Manaster, MD, PhD, FACR Eva M. Escobedo, MD and B. J. Manaster, MD, PhD, FACR
98 Psoriatic Arthritis
EROSIVE Eva M. Escobedo, MD and B. J. Manaster, MD, PhD, FACR
10 Rheumatoid Arthritis of Axial Skeleton 104 Chronic Reactive Arthritis
Eva M. Escobedo, MD, Stephanie A. Bernard, MD, and B. J. Eva M. Escobedo, MD and B. J. Manaster, MD, PhD, FACR
Manaster, MD, PhD, FACR
16 Rheumatoid Arthritis of Shoulder and Elbow DUE TO BIOCHEMICAL DISORDERS OR
Eva M. Escobedo, MD and B. J. Manaster, MD, PhD, FACR DEPOSITIONAL DISEASE
22 Rheumatoid Arthritis of Wrist and Hand 110 Gout
Eva M. Escobedo, MD and B. J. Manaster, MD, PhD, FACR Eva M. Escobedo, MD and B. J. Manaster, MD, PhD, FACR
28 Rheumatoid Arthritis of Hip 116 Pyrophosphate Arthropathy
Eva M. Escobedo, MD and B. J. Manaster, MD, PhD, FACR Stephanie A. Bernard, MD, Kirkland W. Davis, MD, FACR,
32 Rheumatoid Arthritis of Knee and B. J. Manaster, MD, PhD, FACR
Eva M. Escobedo, MD, Stephanie A. Bernard, MD, and B. J. 122 Hydroxyapatite Deposition Disease
Manaster, MD, PhD, FACR Eva M. Escobedo, MD and B. J. Manaster, MD, PhD, FACR
36 Rheumatoid Arthritis of Ankle and Foot 128 Amyloid Deposition
Eva M. Escobedo, MD and B. J. Manaster, MD, PhD, FACR Eva M. Escobedo, MD, Dylan A. Noblett, MD, and B. J.
40 Felty Syndrome Manaster, MD, PhD, FACR
Eva M. Escobedo, MD and B. J. Manaster, MD, PhD, FACR 134 Hemochromatosis
42 Juvenile Idiopathic Arthritis Eva M. Escobedo, MD, Stephen Vong, MD, and B. J.
Stephanie A. Bernard, MD and B. J. Manaster, MD, PhD, Manaster, MD, PhD, FACR
FACR 135 Ochronosis
48 Adult Still Disease Derik L. Davis, MD and B. J. Manaster, MD, PhD, FACR
Eva M. Escobedo, MD and B. J. Manaster, MD, PhD, FACR 136 Wilson Disease
Derik L. Davis, MD and B. J. Manaster, MD, PhD, FACR
PRODUCTIVE 137 Oxalosis
50 Osteoarthritis of Axial Skeleton Derik L. Davis, MD and B. J. Manaster, MD, PhD, FACR
Eva M. Escobedo, MD, Kristopher Joseph de Ga, MD, and
B. J. Manaster, MD, PhD, FACR MISCELLANEOUS JOINT DISORDERS
54 DISH 138 Tenosynovial Giant Cell Tumor, Intraarticular
Eva M. Escobedo, MD and B. J. Manaster, MD, PhD, FACR Derik L. Davis, MD and B. J. Manaster, MD, PhD, FACR
60 OPLL 144 Intraarticular Chondroma
Eva M. Escobedo, MD and B. J. Manaster, MD, PhD, FACR Derik L. Davis, MD, B. J. Manaster, MD, PhD, FACR, and
64 Rapidly Progressive Osteoarthritis Eric Walker, MD, MHA, FACR, FACHE
Derik L. Davis, MD 148 Multicentric Reticulohistiocytosis
66 Osteoarthritis of Shoulder and Elbow Derik L. Davis, MD, Stephanie A. Bernard, MD, and B. J.
Eva M. Escobedo, MD and B. J. Manaster, MD, PhD, FACR Manaster, MD, PhD, FACR
70 Osteoarthritis of Wrist and Hand 149 Synovial Vascular Malformation
Eva M. Escobedo, MD and B. J. Manaster, MD, PhD, FACR Derik L. Davis, MD and B. J. Manaster, MD, PhD, FACR
74 Osteoarthritis of Hip 150 Synovial Chondromatosis
Eva M. Escobedo, MD and B. J. Manaster, MD, PhD, FACR Derik L. Davis, MD and B. J. Manaster, MD, PhD, FACR
80 Osteoarthritis of Knee 156 Neuropathic (Charcot) Arthropathy
Eva M. Escobedo, MD and B. J. Manaster, MD, PhD, FACR Derik L. Davis, MD and B. J. Manaster, MD, PhD, FACR
162 Hypertrophic Osteoarthropathy
Derik L. Davis, MD and B. J. Manaster, MD, PhD, FACR

xiv
 TABLE OF CONTENTS
168 Complex Regional Pain Syndrome 256 Multiple Hereditary Exostoses
Derik L. Davis, MD and B. J. Manaster, MD, PhD, FACR Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD,
FACR
SECTION 2: BONE TUMORS AND TUMOR- 262 Chondroblastoma
LIKE CONDITIONS Behrang Amini, MD, PhD, Stephanie A. Bernard, MD, and
B. J. Manaster, MD, PhD, FACR
INTRODUCTION AND OVERVIEW 266 Chondromyxoid Fibroma
176 Bone Tumors: Diagnosis, Staging, and Biopsy Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD,
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, FACR
FACR 270 Periosteal Chondroma
184 Staging of Primary Malignant Bone Tumors Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD,
Behrang Amini, MD, PhD FACR
186 Bone Tumors: Treatment Options and Follow-Up 276 Chondrosarcoma
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, Behrang Amini, MD, PhD
FACR 282 Dedifferentiated Chondrosarcoma
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD,
BONE-FORMING TUMORS FACR
192 Enostosis (Bone Island) 284 Periosteal Chondrosarcoma
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD,
FACR FACR
196 Osteoma 286 Clear Cell Chondrosarcoma
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD,
FACR FACR
202 Osteoid Osteoma
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, MARROW TUMORS
FACR 288 Plasmacytoma
208 Osteoblastoma Behrang Amini, MD, PhD, B. J. Manaster, MD, PhD, FACR,
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, and Chris Hanrahan, MD, PhD
FACR 294 Multiple Myeloma
214 Conventional Osteosarcoma Behrang Amini, MD, PhD
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, 300 POEMS
FACR Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD,
220 Parosteal Osteosarcoma FACR
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, 302 Ewing Sarcoma
FACR Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD,
226 Periosteal Osteosarcoma FACR
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, 308 Leukemia: Bone Changes
FACR Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD,
230 Telangiectatic Osteosarcoma FACR
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, 312 Lymphoma of Bone
FACR Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD,
234 Low-Grade Central Osteosarcoma FACR
Behrang Amini, MD, PhD 318 Metastases of Bone Marrow
238 High-Grade Surface Osteosarcoma Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD,
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, FACR
FACR
240 Secondary Osteosarcoma OTHER BONE TUMORS
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, 324 Desmoplastic Fibroma
FACR Behrang Amini, MD, PhD, Stephanie A. Bernard, MD, and
B. J. Manaster, MD, PhD, FACR
CARTILAGE-FORMING TUMORS 328 Undifferentiated Pleomorphic Sarcoma of Bone
244 Enchondroma Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD,
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, FACR
FACR 332 Fibrosarcoma of Bone
250 Osteochondroma Behrang Amini, MD, PhD and Eric Walker, MD, MHA,
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, FACR, FACHE
FACR

xv
 TABLE OF CONTENTS
334 Lipoma of Bone
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD,
SECTION 3: SOFT TISSUE TUMORS
FACR INTRODUCTION AND OVERVIEW
338 Giant Cell Tumor of Bone
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, 416 Introduction to Soft Tissue Tumors
FACR Stephanie A. Bernard, MD, Catherine C. Roberts, MD, and
344 Aneurysmal Bone Cyst Eric Walker, MD, MHA, FACR, FACHE
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, 424 Staging of Soft Tissue Tumors
FACR Stephanie A. Bernard, MD
350 Adamantinoma ADIPOCYTIC TUMORS
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD,
FACR BENIGN ADIPOCYTIC TUMORS
354 Hemangioma of Bone
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, 426 Lipoma of Soft Tissue
FACR Eric Walker, MD, MHA, FACR, FACHE, Stephanie A.
360 Epithelioid Hemangioma Bernard, MD, and Catherine C. Roberts, MD
Behrang Amini, MD, PhD 432 Lipomatosis
362 Epithelioid Hemangioendothelioma of Bone Eric Walker, MD, MHA, FACR, FACHE and Catherine C.
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, Roberts, MD
FACR 438 Lipomatosis of Nerve
364 Angiosarcoma of Bone Eric Walker, MD, MHA, FACR, FACHE and Catherine C.
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, Roberts, MD
FACR 442 Macrodystrophia Lipomatosa
368 Chordoma Eric Walker, MD, MHA, FACR, FACHE and Catherine C.
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, Roberts, MD
FACR 446 Lipoma Arborescens
372 Fibrous Dysplasia Eric Walker, MD, MHA, FACR, FACHE, Catherine C.
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, Roberts, MD, and B. J. Manaster, MD, PhD, FACR
FACR 450 Lipoblastoma/Lipoblastomatosis
Eric Walker, MD, MHA, FACR, FACHE and Catherine C.
TUMOR-LIKE CONDITIONS Roberts, MD
378 Paget Disease 452 Hibernoma
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, Eric Walker, MD, MHA, FACR, FACHE and Catherine C.
FACR Roberts, MD
384 Langerhans Cell Histiocytosis 456 Parosteal Lipoma
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, Eric Walker, MD, MHA, FACR, FACHE, Catherine C.
FACR Roberts, MD, and B. J. Manaster, MD, PhD, FACR
390 Osteofibrous Dysplasia INTERMEDIATE ADIPOCYTIC TUMORS
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD,
FACR 460 Atypical Lipomatous Tumor/Well-Differentiated
396 Simple Bone Cyst Liposarcoma
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD, Eric Walker, MD, MHA, FACR, FACHE and Catherine C.
FACR Roberts, MD
402 Nonossifying Fibroma MALIGNANT ADIPOCYTIC TUMORS
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD,
FACR 464 Myxoid Liposarcoma
406 Trevor Fairbank Disease Eric Walker, MD, MHA, FACR, FACHE and Catherine C.
Behrang Amini, MD, PhD, B. J. Manaster, MD, PhD, FACR, Roberts, MD
and Eric Walker, MD, MHA, FACR, FACHE 468 Pleomorphic Liposarcoma
Eric Walker, MD, MHA, FACR, FACHE and Catherine C.
RADIATION-INDUCED ABNORMALITIES Roberts, MD
469 Dedifferentiated Liposarcoma
408 Radiation-Induced Complications of Skeleton
Eric Walker, MD, MHA, FACR, FACHE and Catherine C.
Behrang Amini, MD, PhD and B. J. Manaster, MD, PhD,
Roberts, MD
FACR

xvi
 TABLE OF CONTENTS
FIBROBLASTIC/MYOFIBROBLASTIC TUMORS MALIGNANT FIBROUS TUMORS
516 Fibrosarcoma of Soft Tissue
BENIGN FIBROUS TUMORS Eric Walker, MD, MHA, FACR, FACHE and Catherine C.
470 Nodular and Proliferative Fasciitis Roberts, MD
Eric Walker, MD, MHA, FACR, FACHE and Catherine C. 520 Myxofibrosarcoma
Roberts, MD Eric Walker, MD, MHA, FACR, FACHE and Catherine C.
471 Bizarre Parosteal Osteochondromatous Roberts, MD
Proliferation 524 Low-Grade Fibromyxoid Sarcoma
Eric Walker, MD, MHA, FACR, FACHE and Catherine C. Eric Walker, MD, MHA, FACR, FACHE and Catherine C.
Roberts, MD Roberts, MD
472 Elastofibroma 526 Sclerosing Epithelioid Fibrosarcoma
Eric Walker, MD, MHA, FACR, FACHE, Stephanie A. Eric Walker, MD, MHA, FACR, FACHE, Stephanie A.
Bernard, MD, and Catherine C. Roberts, MD Bernard, MD, and Catherine C. Roberts, MD
476 Fibrous Hamartoma of Infancy 530 Dermatofibrosarcoma Protuberans
Eric Walker, MD, MHA, FACR, FACHE and Catherine C. Eric Walker, MD, MHA, FACR, FACHE, Catherine C.
Roberts, MD Roberts, MD, and Stephanie A. Bernard, MD
477 Myofibroma/Myofibromatosis SO-CALLED FIBROHISTIOCYTIC TUMORS
Eric Walker, MD, MHA, FACR, FACHE and Catherine C.
Roberts, MD BENIGN FIBROHISTIOCYTIC TUMORS
478 Fibromatosis Colli
Eric Walker, MD, MHA, FACR, FACHE and Catherine C. 534 Tenosynovial Giant Cell Tumor, Extraarticular
Roberts, MD Eric Walker, MD, MHA, FACR, FACHE, Stephanie A.
479 Juvenile Hyaline Fibromatosis Bernard, MD, and Catherine C. Roberts, MD
Eric Walker, MD, MHA, FACR, FACHE, Behrang Amini, MD, 540 Deep Benign Fibrous Histiocytoma
PhD, and Lauren M. Ladd, MD Eric Walker, MD, MHA, FACR, FACHE and Catherine C.
480 Fibroma of Tendon Sheath Roberts, MD
Eric Walker, MD, MHA, FACR, FACHE and Catherine C.
Roberts, MD SMOOTH MUSCLE TUMORS
484 Desmoplastic Fibroblastoma
Eric Walker, MD, MHA, FACR, FACHE and Catherine C. SMOOTH MUSCLE TUMORS, BENIGN
Roberts, MD 542 Leiomyoma: Superficial and Deep
486 Calcifying Aponeurotic Fibroma Eric Walker, MD, MHA, FACR, FACHE and Catherine C.
Eric Walker, MD, MHA, FACR, FACHE, Catherine C. Roberts, MD
Roberts, MD, and Behrang Amini, MD, PhD
488 Myositis Ossificans/Heterotopic Ossification SMOOTH MUSCLE TUMORS, MALIGNANT
Stephanie A. Bernard, MD and B. J. Manaster, MD, PhD, 546 Leiomyosarcoma
FACR Eric Walker, MD, MHA, FACR, FACHE, Catherine C.
Roberts, MD, and B. J. Manaster, MD, PhD, FACR
INTERMEDIATE (LOCALLY AGGRESSIVE)
FIBROUS TUMORS PERICYTIC (PERIVASCULAR) TUMORS
494 Superficial Fibromatoses 552 Glomus Tumor
Eric Walker, MD, MHA, FACR, FACHE, Kirkland W. Davis, Eric Walker, MD, MHA, FACR, FACHE, Catherine C.
MD, FACR, and Catherine C. Roberts, MD Roberts, MD, and Stephanie A. Bernard, MD
498 Desmoid-Type Fibromatosis 556 Angioleiomyoma
Eric Walker, MD, MHA, FACR, FACHE, Stephanie A. Eric Walker, MD, MHA, FACR, FACHE, Catherine C.
Bernard, MD, and Catherine C. Roberts, MD Roberts, MD, and Stephanie A. Bernard, MD
INTERMEDIATE (RARELY METASTASIZING) SKELETAL MUSCLE TUMORS
FIBROHISTIOCYTIC TUMORS
504 Solitary Fibrous Tumor SKELETAL MUSCLE TUMORS, BENIGN
Stephanie A. Bernard, MD and Catherine C. Roberts, MD 558 Rhabdomyoma
510 Inflammatory Myofibroblastic Tumor Eric Walker, MD, MHA, FACR, FACHE and Catherine C.
Eric Walker, MD, MHA, FACR, FACHE, Behrang Amini, MD, Roberts, MD
PhD, and Kara G. Gill, MD
514 Infantile Fibrosarcoma
Eric Walker, MD, MHA, FACR, FACHE and Catherine C.
Roberts, MD

xvii
 TABLE OF CONTENTS
SKELETAL MUSCLE TUMORS, MALIGNANT INTERMEDIATE TUMORS (RARELY
560 Rhabdomyosarcoma METASTASIZING) OF UNCERTAIN
Eric Walker, MD, MHA, FACR, FACHE and Catherine C. DIFFERENTIATION
Roberts, MD 612 Angiomatoid Fibrous Histiocytoma
Stephanie A. Bernard, MD
VASCULAR AND LYMPHATIC TUMORS 614 Ossifying Fibromyxoid Tumor
Stephanie A. Bernard, MD, Catherine C. Roberts, MD, and
BENIGN VASCULAR TUMORS Behrang Amini, MD, PhD
566 Vascular Malformations MALIGNANT TUMORS OF UNCERTAIN
Stephanie A. Bernard, MD
DIFFERENTIATION
572 Hemangioma
Stephanie A. Bernard, MD 616 Undifferentiated Pleomorphic Sarcoma
576 Angiomatosis Eric Walker, MD, MHA, FACR, FACHE, Catherine C.
Stephanie A. Bernard, MD and Catherine C. Roberts, MD Roberts, MD, and B. J. Manaster, MD, PhD, FACR
578 Klippel-Trenaunay Syndrome 620 Synovial Sarcoma
Stephanie A. Bernard, MD and Catherine C. Roberts, MD Stephanie A. Bernard, MD, Catherine C. Roberts, MD, and
582 Lymphatic Malformations B. J. Manaster, MD, PhD, FACR
Stephanie A. Bernard, MD and Catherine C. Roberts, MD 626 Epithelioid Sarcoma
Stephanie A. Bernard, MD, Catherine C. Roberts, MD, and
INTERMEDIATE (RARELY METASTASIZING) Eric Walker, MD, MHA, FACR, FACHE
VASCULAR TUMORS 630 Clear Cell Sarcoma
586 Kaposi Sarcoma Stephanie A. Bernard, MD
Stephanie A. Bernard, MD, Catherine C. Roberts, MD, and 632 Extraskeletal Myxoid Chondrosarcoma
Behrang Amini, MD, PhD Stephanie A. Bernard, MD, Catherine C. Roberts, MD, and
590 Hemangioendothelioma of Soft Tissue B. J. Manaster, MD, PhD, FACR
Stephanie A. Bernard, MD and Catherine C. Roberts, MD 636 Extraskeletal Ewing Sarcoma
Stephanie A. Bernard, MD and Catherine C. Roberts, MD
MALIGNANT VASCULAR TUMORS
592 Angiosarcoma of Soft Tissue PERIPHERAL NERVE SHEATH TUMORS
Stephanie A. Bernard, MD and B. J. Manaster, MD, PhD,
FACR NONNEOPLASTIC
638 Morton Neuroma
CHONDROOSSEOUS TUMORS Stephanie A. Bernard, MD, Catherine C. Roberts, MD, and
596 Chondroma of Soft Tissue Eric Walker, MD, MHA, FACR, FACHE
Eric Walker, MD, MHA, FACR, FACHE and Catherine C. 642 Traumatic Neuroma
Roberts, MD Stephanie A. Bernard, MD and Catherine C. Roberts, MD
598 Extraskeletal Mesenchymal Chondrosarcoma
Eric Walker, MD, MHA, FACR, FACHE and Catherine C.
NEUROFIBROMA
Roberts, MD 644 Neurofibroma
600 Extraskeletal Osteosarcoma Stephanie A. Bernard, MD, Catherine C. Roberts, MD, and
Eric Walker, MD, MHA, FACR, FACHE, Catherine C. B. J. Manaster, MD, PhD, FACR
Roberts, MD, and Stephanie A. Bernard, MD
SCHWANNOMA
TUMORS OF UNCERTAIN DIFFERENTIATION 650 Schwannoma
Stephanie A. Bernard, MD, Catherine C. Roberts, MD, and
BENIGN TUMORS OF UNCERTAIN B. J. Manaster, MD, PhD, FACR
DIFFERENTIATION
MALIGNANT PERIPHERAL NERVE SHEATH
604 Phosphaturic Mesenchymal Tumor TUMOR
Stephanie A. Bernard, MD
606 Myxoma 656 Malignant Peripheral Nerve Sheath Tumor
Stephanie A. Bernard, MD and B. J. Manaster, MD, PhD, Stephanie A. Bernard, MD and Catherine C. Roberts, MD
FACR
SKIN AND SUBCUTANEOUS LESIONS
660 Epidermoid/Epidermal Inclusion Cyst
Stephanie A. Bernard, MD, Catherine C. Roberts, MD, and
Kirkland W. Davis, MD, FACR
662 Rheumatoid Nodule
Stephanie A. Bernard, MD and Catherine C. Roberts, MD

xviii
 TABLE OF CONTENTS
666 Metastases of Soft Tissue 745 Sinding-Larsen-Johansson Disease
Stephanie A. Bernard, MD and Catherine C. Roberts, MD Kara G. Gill, MD and B. J. Manaster, MD, PhD, FACR
670 Melanoma 746 Blount Disease
Stephanie A. Bernard, MD and Catherine C. Roberts, MD Kara G. Gill, MD and B. J. Manaster, MD, PhD, FACR
748 Pes Planus (Flatfoot)
SOFT TISSUE TUMOR MIMICS Kara G. Gill, MD and B. J. Manaster, MD, PhD, FACR
676 Soft Tissue Tumor Mimics: Infection/Inflammation 754 Clubfoot (Talipes Equinovarus)
Stephanie A. Bernard, MD and Catherine C. Roberts, MD Kara G. Gill, MD and B. J. Manaster, MD, PhD, FACR
680 Soft Tissue Tumor Mimics: Vascular 758 Congenital Vertical Talus (Rocker-Bottom Foot)
Stephanie A. Bernard, MD B. J. Manaster, MD, PhD, FACR and Kara G. Gill, MD
684 Soft Tissue Tumor Mimics: Crystal Disease 759 Pes Cavus
Stephanie A. Bernard, MD and Catherine C. Roberts, MD Kara G. Gill, MD and B. J. Manaster, MD, PhD, FACR
688 Soft Tissue Tumor Mimics: Other 760 Tarsal Coalition
Stephanie A. Bernard, MD and Catherine C. Roberts, MD Kara G. Gill, MD, B. J. Manaster, MD, PhD, FACR, and
694 Xanthoma Stephanie A. Bernard, MD
Stephanie A. Bernard, MD and Catherine C. Roberts, MD
SECTION 5: DYSPLASIAS
SECTION 4: CONGENITAL AND
DEVELOPMENTAL ABNORMALITIES SKELETAL DYSPLASIA

GENERAL SHORT LIMB LENGTH

700 Arthrogryposis 768 Introduction to Skeletal Dysplasias
Kara G. Gill, MD and B. J. Manaster, MD, PhD, FACR Cheryl A. Petersilge, MD, MBA and Nancy A. Chauvin, MD
701 Amniotic Band Syndrome 772 Achondroplasia
Kara G. Gill, MD and B. J. Manaster, MD, PhD, FACR Nancy A. Chauvin, MD and Cheryl A. Petersilge, MD, MBA
702 Cerebral Palsy 776 Pseudoachondroplasia
B. J. Manaster, MD, PhD, FACR and Kara G. Gill, MD Cheryl A. Petersilge, MD, MBA and Nancy A. Chauvin, MD
703 Down Syndrome (Trisomy 21) 777 Achondrogenesis
Kara G. Gill, MD and B. J. Manaster, MD, PhD, FACR Nancy A. Chauvin, MD and Cheryl A. Petersilge, MD, MBA
704 Fibrodysplasia Ossificans Progressiva 778 Thanatophoric Dysplasia
Kara G. Gill, MD and B. J. Manaster, MD, PhD, FACR Nancy A. Chauvin, MD and Cheryl A. Petersilge, MD, MBA
705 Muscular Dystrophy 780 Asphyxiating Thoracic Dystrophy of Jeune
B. J. Manaster, MD, PhD, FACR and Kara G. Gill, MD Cheryl A. Petersilge, MD, MBA and Nancy A. Chauvin, MD
706 Neurofibromatosis 781 Chondroectodermal Dysplasia (Ellis-van Creveld)
Kara G. Gill, MD and B. J. Manaster, MD, PhD, FACR Nancy A. Chauvin, MD and Cheryl A. Petersilge, MD, MBA
712 Osteogenesis Imperfecta 782 Spondyloepiphyseal Dysplasia
Kara G. Gill, MD and B. J. Manaster, MD, PhD, FACR Nancy A. Chauvin, MD and Cheryl A. Petersilge, MD, MBA
718 Turner Syndrome 786 Multiple Epiphyseal Dysplasia
Kara G. Gill, MD and B. J. Manaster, MD, PhD, FACR Cheryl A. Petersilge, MD, MBA and Nancy A. Chauvin, MD

UPPER EXTREMITY NORMAL LIMB LENGTH

719 Glenoid Hypoplasia 790 Ollier Disease
Kara G. Gill, MD and B. J. Manaster, MD, PhD, FACR Cheryl A. Petersilge, MD, MBA and Nancy A. Chauvin, MD
720 Madelung Deformity 794 Maffucci Syndrome
B. J. Manaster, MD, PhD, FACR and Kara G. Gill, MD Cheryl A. Petersilge, MD, MBA and Nancy A. Chauvin, MD
724 Ulnar Variance 795 Chondrodysplasia Punctata
Kara G. Gill, MD and B. J. Manaster, MD, PhD, FACR Nancy A. Chauvin, MD and Cheryl A. Petersilge, MD, MBA
796 Cleidocranial Dysplasia
LOWER EXTREMITY Nancy A. Chauvin, MD and Cheryl A. Petersilge, MD, MBA
797 Caffey Disease
728 Developmental Dysplasia of Hip
Nancy A. Chauvin, MD and Cheryl A. Petersilge, MD, MBA
Kara G. Gill, MD and B. J. Manaster, MD, PhD, FACR
798 Fong Disease (Nail Patella Syndrome)
734 Slipped Capital Femoral Epiphysis
Cheryl A. Petersilge, MD, MBA and Nancy A. Chauvin, MD
Kara G. Gill, MD and B. J. Manaster, MD, PhD, FACR
740 Proximal Femoral Focal Deficiency SCLEROSING DYSPLASIAS
B. J. Manaster, MD, PhD, FACR and Kara G. Gill, MD
744 Osgood-Schlatter Disease 800 Melorheostosis
B. J. Manaster, MD, PhD, FACR and Kara G. Gill, MD Cheryl A. Petersilge, MD, MBA and Nancy A. Chauvin, MD
804 Progressive Diaphyseal Dysplasia
Cheryl A. Petersilge, MD, MBA and Nancy A. Chauvin, MD

xix
Another random document with
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For the English giant had done well. Like a great and redoubtable
captain—and some there were to believe that this product of a
barbarous land was the first of his age—he had seized the hour
when panic had descended upon the Castilian host. When they were
as sheep without a shepherd, owing to their belief that the Prince of
Darkness had spirited away the father of the flock, he had fallen
upon them under the cover of night. He had dealt with them
ruthlessly, killing many, despoiling their treasuries, abusing their
arms, pursuing them off the plains full many a league, and dispersing
a proud army to the four winds of God.
All this had the Englishman performed under the cover of night, at
the instance of no more than two hundred well-mounted men. So
had their fears at the mysterious loss of their king wrought upon the
soldiers of the army of Castile that they had fled hot-foot in all
directions before the onfall of Sir Richard Pendragon. For they were
fain to believe that the Prince of Darkness had returned to claim
them as well as their royal master.
In the very act of pursuit the Englishman had indulged his masterful
skill to the full. He had singled out those of our foes it would profit
him best to destroy. He had cut down all of the King’s captains and
ministers he could come at, overriding them full many a league, yet
sparing nine of the foremost in order that their presence in captivity
might pleasure our mistress and promote the terms of the peace.
In this also Sir Richard Pendragon had counted well. The presence
of these nine noble Castilians with halters about their necks gave
credence to the wonderful story that he had to tell. When his great
exploit had been unfolded in its fulness, it appeared that the power of
Castile was broken. And when madam understood so much, and
further, that her great captain had not only delivered her of famine
and the sword, but had also returned with great loot of treasure, she
said with a proud yet gentle instancy that her good Sirrah Red
Dragon might command her anything.
Now, in the fire of that imperious yet chaste and lovely glance the
Count of Nullepart and myself read the invitation for which our veins
were hungry. Yet I think it must be allowed to the Count of Nullepart
that he had the gift of prophecy. For as the Countess Sylvia again
extended her slender fingers that were all lily-white daintiness, the
English barbarian robber, as he bore them to his bearded chops in
his bloodstained gripe, caused the very roof to re-echo with his
laughter.
“By my good mother’s soul!” he roared, “if it were not that old honest
Dickon durst not marry out of the English nobility, sweet madam and
ladyship, you might easily have the best husband in Spain.”
Again the eyes of the Countess Sylvia sparkled like the beautiful
Tagus.
“What words are these, Sirrah Red Dragon?” said she with a proud
instancy. “Do you reject the gracious dignity of a woman’s heart? Is
it, Sirrah Red Dragon, that you disdain the royal gratitude of an
hundred descents?”
“It is that I neither disdain nor reject them, madam,” said the English
giant, speaking as though his soul was an empire, yet with a
whimsical humour in his great red eyes. “But this old jack bully must
reck his rede, as we English say. He can never marry, good madam
and ladyship, although there is the blood of kings under his doublet.
He must reck his rede. He is the offspring of fantasy; he was born in
a mild and sweet season under the bright moon. He is of the seed of
Merlin; the sap of Arthur is in his bones; and although he had a good
mother, and he is the natural son of Henry Plantagenet, yet from his
natal hour a bend sinister hath twisted his sweet soul. Therefore he
can wed no woman, dear little Spanish butterfly, for, let me whisper it
in thy pretty ears, that good Dickon, honest fellow, is none other than
the veritable Solpesius Mus, the Captain-General of the Jogalones.”
Having thus spoke our mistress in this strange mad wise, the English
giant, for all the world as though his soul was a wide dominion, bent
to her his grinning visage and bussed her soundly upon the lips in
the presence of the whole company. No sooner had she suffered this
bold caress than she withdrew her face swiftly, as though it had been
stung by the venom of bees. Her cheek was like a crimson flower
and her eyes brimmed with their passionate tears.
“Sirrah giant,” said this delectable thing, as if she too had a wide
dominion in her soul, “I would have the whole of thee, the whole of
thy great capacity and thy wide-wingèd fantasy, or I would have thee
not at all.”
“Alack, alack!” said the Englishman with a whimsical sigh, “that poor
Dickon, old honest fellow, should be none other than the veritable
Solpesius Mus, the Captain-General of the Jogalones!”
And in my ears came the soft enchanting laughter of the worshipful
Count of Nullepart.
 CHAPTER XXXVII
OF THE RIGOURS TO BE SUFFERED BY THE
INFAMOUS KING

The proud tears were still in the eyes of our mistress, when she
looked all about her swiftly with the features of a hawk. In ringing
tones she cried, “Bring forth the spawn of darkness. We will now
arrange his fate.”
When the Count of Nullepart and myself made to obey this
command, as you will believe, gentle reader, we had grave concern
lest madam should observe the presence of the captive’s ears. And
such was her present humour that I think we did well to have
apprehension of the penalty that might overtake us. Greatly doubtful,
we led forth the Castilian from his durance and brought him into the
room.
The King of Castile entered the presence of his victorious
adversaries with a calm and noble smile. Yet no sooner did his gaze
fall upon the grey-bearded noblemen with halters about their necks
than his eyes drooped, and a great anguish seemed to cloud them.
The relentless eyes of madam were fixed upon her foe.
“Dost thou see them, bloody-minded one?” said she. “These old
bears shall have the fangs drawn out of their chaps so that they shall
bite no more.”
Then, like a veritable sovereign princess, she turned to Sir Richard
Pendragon, to whom all the success of her arms was due.
“Avise us, Sirrah Red Dragon. Avise us in what manner we shall cast
out these several parcels of beastliness that encumber the earth.”
“By our lady!” said the English giant, rubbing the palm of one hand
slowly round that of the other, “if that is not my honest gossip, John
Castilian, I am a poor mad soul! English Richard gives a greeting to
you, John Castilian, a greeting to your most excellent King’s
majesty.”
Upon this speaking, Sir Richard Pendragon was like to crack his
head on the ground with his lowly obeisance.
Although the King of Castile seemed all broken by the disaster that
had overtaken his arms, upon hearing the voice of Sir Richard
Pendragon he looked up and received his mockery with an
unflinching glance.
“Foreign robber,” he said simply, “you have borne yourself as a true
captain. I make you my service. And as the life of myself and the
lives of my honourable friends are forfeit to your cunning I hope that
they may profit you.”
These words, spoken only as a King could deliver them, brought a
sort of whimsical pity to the mocking face of the English barbarian.
“Dost thou remember, John Castilian,” he said, with that softness
which the Count of Nullepart and I knew was wont to accompany his
most ferocious designs, “that summer’s morning a twelvemonth
since, when thou flungest one of a gentle and kindly nurture, a good
mother’s son, into the deepest dungeon of your Spanish palace, and
chained him by the leg, with foul straws for his pillow, and with lean
rats and large beetles for his only familiar company?”
“Yes, foreign robber, I remember it to my sorrow,” said the King of
Castile coldly. “And had I broke you upon the wheel and thrown your
corpse to the dogs a day before my reckoning, I should not now be
mourning for not having done so.”
“John Castilian,” said the Englishman, “you speak in the wise of an
unfortunate famous ancestor of mine own. He was called Sir
Procrastinatus, owing to the unlucky habit of his mind that he
continually put off till the morrow that which he should have done the
day; a habit that in the process of nature grew upon the unlucky
wight in such a measure that upon the last day of his life he failed to
die until after his friends had buried him. Can it be, John Castilian,
that yourself is a victim to a like preoccupancy? For I understand
from madam’s gracious ladyship that your trench hath been dug the
last three days in the kitchen midden.”
“No, no, Sirrah Red Dragon, that is not so,” said madam ruthlessly.
“The spawn of darkness is entitled to no burial. We will hang it upon
a fork on the outer barbican to poison the crows and the vultures and
the unclean fowls of the air.”
“A thousand pardons, ladyship,” said Sir Richard Pendragon. “It
appears I am the victim of a misinformation.”
“Do you avise us, Sirrah Red Dragon, so that the bloody-minded
prince shall begin his dying immediately. But we would have him
take not less than one-and-twenty days to the consummation of it,
for we would have him drain the dregs of the cup he hath prepared
for others.”
It was here, however, that Sir Richard Pendragon began to stroke his
beard. Mad he was, and whimsical, yet beyond all things he had a
mind for affairs. Therefore he was fain to speak aside with the Count
of Nullepart and myself.
“By my troth,” he said, “it would be a happy deliverance of a bad man
if John Castilian was hung on the gate with a spike through his neck.
But grievously do I doubt me of the wisdom of the policy. We are but
three hundred men-at-arms, and Castile is a broad dominion. If we
put out the life of this prince, the queen-mother will gather new
forces and come again to the gate. And honest Dickon is fain to
observe that the old bitch wolf will be found with a longer tooth than
the whelp.”
That this was the voice of wisdom we had no thought to deny.
Therefore it behoved us to spread the light of statecraft before our
mistress. Yet, as you will readily believe, such a task was no light
one. Still, accomplished it must be, although he who would turn a
woman aside from her vengeance may be said to take his life in his
hand.
Sir Richard Pendragon, however, was the last man in the world to
blench before the face of danger. And so, with a most humble civility
that rendered the sinister laughter of his eyes the more formidable,
he addressed the Countess Sylvia.
“Madam,” said he, “was old honest Dickon dreaming o’ nights when
he heard the grace of your ladyship’s nobility declare that he might
command her anything?”
The fair damask cheek of our mistress grew again like that of a
carnation; again were her eyes filled with proud shining.
“You heard aright, Sirrah Red Dragon,” she said softly. “It is my
desire that you command me anything.”
“Then old honest Dickon, a good fellow, kisses your small feet and
makes you a leg, peerless rose of the south, and he asks for the life
of John Castilian.”
The bosom of our mistress heaved rebelliously. Tears of mortified
caprice crept into her eyes. With contempt and bitterness she cast a
glance at the King, who stood in mournful converse with his
ministers. She then confronted her great captain.
“Sirrah Red Dragon,” she said in accents that were choked by a rage
of tears, “do you take the life of the spawn of darkness. Use it as you
will, sirrah. It was you that gave it to me; it is meet that you should
receive it back again. I do not ask upon what pretext you would hold
it; but—but, sirrah,” and her whole form quivered strangely, “I do ask
—I do ask, sirrah, is this the whole of your good pleasure?”
Yet no sooner had she spoke those last unlucky words, and, as it
were, laid bare her proud bosom, than she averted her beautiful
cheeks that were like a scarlet rose, and in the sudden wild rage of
her own weakness, that she whom kings must woo in vain had come
herself to woo, she hid her eyes.
“Nay, by the soul of a nice mother,” said Sir Richard Pendragon, “this
is but a moiety of what her good son would ask you. Having received
the life of John Castilian, he would ask your permission, madam, that
in some sort he may punish him, for you need not to be told that his
crimes are many and abominable.”
“As you say, Sirrah Red Dragon, his crimes are many and
abominable,” said the Countess Sylvia. “I would indeed have you
punish him. I would have you punish him with all possible rigour.”
Speaking thus, she gazed at the unfortunate prince with a power of
resentment that he, who was true to his degree, met with a calm
indifferency.
“All possible rigour,” said Sir Richard Pendragon softly, “is indeed the
best part of the design of your old honest servant. And to that end,
madam, I would ask to deliver John Castilian to you again in order
that you may bestow this dreadful rigor upon him.”
“It is well, Sirrah Red Dragon,” said his mistress. “In this you are
wise. We shall know in what sort to visit the spawn of darkness and
bloody-minded prince.”
“And yet, madam,” said Sir Richard Pendragon, “by the grace of your
ladyship is it not left to old honest Dickon to nominate the weapons
of your severity?”
“Pray do so, Sirrah Red Dragon,” said madam with a courteous
indulgence. “But perhaps you will not omit to weigh the efficacy upon
delicate flesh of hot sharp-pointed nails? And also of hard pieces of
rock upon the sensitive limb bones?”
“Nay, madam,” said Sir Richard Pendragon, “a good mother’s son
forgets not the efficacy of these honest things; yet, under the favour
of your ladyship, if he is minded to speak out of his ripe observation,
this elderly seeker after virtue would venture to recommend an even
more dreadful rigour, a rigour even more salutary.”
“By every manner of means, Sirrah Red Dragon, I would have you
recommend it.”
As the Countess Sylvia spoke she fixed another remorseless glance
upon the unhappy prince.
“That which one who is old, madam,” said the English giant in his
softest voice, “and one who hath been accustomed all his years to
grope for the light of the truth is fain to recommend to the grace of
your ladyship, is the most excessive rigour known to mankind; a
greater rigour which contains all the lesser rigours within itself; a
rigour which poor unlucky manhood, be it that of prince or of
peasant, is wont to regard with the same abhorrence as a sea-coal
fire is regarded by a gib cat with a singed tail. The barbarous and
excessive rigour to which your old honest servant refers, madam, is
that which is profanely called holy matrimony. English Dickon humbly
submits, madam, that you should receive John Castilian in the bonds
of wedlock, and so visit the royal rascal according to his merit.”
Upon the enunciation of this project, which had only been possible to
one of Sir Richard Pendragon’s surpassing boldness, the Count of
Nullepart and myself had a lively fear that madam would drive her
poinard into the heart of her over-presumptuous captain. For when
he spoke in this wise her slender fingers trembled on the jewelled hilt
of her dagger, and she cried out with flaming eyes,—
“Wed the spawn of darkness, sirrah! Wed the bloody-minded prince!”
“Even so, madam,” said the English giant, withdrawing a pace from
her striking hand. “Under your gracious favour, that is the rigour that
is humbly proposed by one who hath grown old in the love of virtue.”
As the Englishman spoke, a change was wrought in the demeanour
of the Countess Sylvia. Like a very woman or a small child, or
perchance like them both (for the worshipful Count of Nullepart
assures me that they are one and the same), she peered into the
eyes of her captain. And the manner of this action, which was one of
a furtive modesty, seemed to imply that she dared hardly to look lest
she should discover that which she feared to see.
“Wed the spawn of darkness!” she breathed softly. “I—I, Sirrah Red
Dragon—I wed the froward prince!”
She continued to repeat these words in a low voice. Yet ever and
anon she peered upwards to the red and hungry eyes of her great
captain, that were full of a sombre and whimsical phantasy. And to
the worshipful Count of Nullepart and to myself, who hung upon
each phase of that which was toward, it seemed to us both, in the
curious anguish of our hearts, that the lifeblood of the little Countess
Sylvia ebbed away from her even as she gazed.
 CHAPTER XXXVIII
THE LAST

I know not how long it was before the eyes of our mistress recoiled
from that humorous front with which her great captain met the whole
assembly. With her, I fear it must have been an age. Yet at last her
gaze, that was now hapless, faltered altogether, and, like a proud-
wingèd bird with its plumage torn, it fell to earth.
At the same instant this delectable form was shaken bitterly. And
then our mistress looked up, and with eyes that shone no more like
the Tagus, and with cheeks ashen white instead of the rosy carmine
of a fair flower, she said with a most beautiful gentleness,—
“An it please you, Sirrah Red Dragon, I—I will wed the froward
prince.”
Without permitting her unhappiness to stray away to him to whom
this resolve was published, she summoned to her side the royal
captive with an air that was ineffable.
The King, who was only too well acquainted with all that had passed,
for it was of the highest significance to Castile and to himself, came
forward at his youthful cousin’s behest.
“Froward prince,” said the Countess Sylvia, speaking with a sweet
broken gentleness which yet seemed to proclaim a wide dominion of
the soul, “your crime is forgot. The halters are taken from the throats
of your ministers. Your treasuries are given back to you; and with
them is given my good pleasure.”
With a cheek the colour of snow, our mistress held forth her slender
jewelled fingers to him of Castile. Yet at first the King made no sign,
perhaps for bewilderment or perhaps for shame. And then, slowly
and modestly, with a humility in all his gestures, with a pure and
noble fire in his eyes, he knelt before her and bowed his head.
THE END
 TRANSCRIBER’S NOTES:
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