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Self Assessment in

Musculoskeletal Pathology


Karen Sakthivel-Wainford

Self Assessment in Musculoskeletal Pathology X-rays

Karen Sakthivel-Wainford

ISBN: 978-1-905539-61-1

First published 2011

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without either the prior permission of the publishers or a licence permitting restricted copying in the United Kingdom issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London, W1T 4LP. Permissions may be sought directly from M&K Publishing, phone: 01768 773030, fax: 01768 781099 or email:

Any person who does any unauthorised act in relation to this publication may be liable to criminal prosecution and civil claims for damages.

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library


Clinical practice and medical knowledge constantly evolve. Standard safety precautions must be followed, but, as knowledge is broadened by research, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers must check the most current product information provided by the manufacturer of each drug to be administered and verify the dosages and correct administration, as well as contraindications. It is the responsibility of the practitioner, utilising the experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. Any brands mentioned in this book are as examples only and are not endorsed by the publisher. Neither the publisher nor the authors assume any liability for any injury and/or damage to persons or property arising from this publication.

To contact M&K Publishing write to:

M&K Update Ltd · The Old Bakery · St. John’s Street

Keswick · Cumbria CA12 5AS

Tel: 01768 773030 · Fax: 01768 781099

Designed and typeset by Mary Blood

Printed in England by Ferguson Print, Keswick.


List of figures

List of tables



1 Arthritis

Karen Sakthivel-Wainford

2 Osteoporosis

Paul Atkinson

3 Bone Tumours

Katy Johnson

4 Avascular Necrosis and the Osteochondroses

Karen Sakthivel-Wainford

5 Arthropathies

6 Tumours

7 Metabolic Bone Disease

8 Miscellaneous Cases

9 Mixed Cases

Reading list/bibliography


List of figures

1.1 Diarthrodial joint

1.2 A schematic representation of the sequential changes of osteoarthritis

1.3 Venn diagram of classic RA

1.4 Routes of invasion of infection into a joint

2.1 Macroscopic view of normal trabecular bone on the left and osteoporotic bone on the right

2.2 Examples of DXA results

2.3 Hand

2.4 Spine

2.5 Shoulder

2.6 Wrist

2.7 Hip

3.1 Interrupted periosteal reactions in the form of (a) sunburst pattern, (b) lamellated, or ‘onion skin’, pattern and (c) a Codman’s triangle

4.1 Example of osteochondritis dissecans

4.2 Kienböck’s disease

4.3 Köhler’s disease

4.4 Stage 2 of Legg-Calvé-Perthes disease

4.5 Stage 4 of Legg-Calvé-Perthes disease

4.6 Panner’s disease

4.7 Freiberg’s disease

4.8 Scheuermann’s disease

5.1 Heberden’s and Bouchard’s nodes

5.2 Patellar ‘tooth’ sign

5.3 Muscles of the rotator cuff

5.4 Rheumatoid Arthritis of the shoulder joint

5.5 Hip migration in osteoarthritis and rheumatoid arthritis

5.6 Osteoarthritis of the femoral head

5.7 Grading of spondylolisthesis

5.8 The Scottie dog as described by Lachepele, as viewed on oblique lumbar vertebra radiographs

5.9 Spinous process sign

7.1 Rickets – radiographic appearances

8.1 Pathogenesis of long bone osteomyelitis

8.2 Common sites of apophyseal avulsion and muscle attachment

8.3 Progression of spinal infection

9.1 Cysticercosis cycle of infection

List of tables

1.1 Pathology-related radiographic changes in RA

1.2 Comparison of RA and OA

6.1 Classic osteogenic sarcoma

7.1 Skeletal radiographic appearances of primary and secondary hyperparathyroidism

8.1 Some causes of periosteal reaction in infants

8.2 Common sites of osteochondritis dissecans of the knee

Other Health and Social Care books from M&K include:

Self-assessment in Axial Musculoskeletal Trauma X-rays

ISBN: 978-1-905539-47-5

Self-assessment in Paediatric Musculoskeletal Trauma X-rays

ISBN: 978-1-905539-34-5

Self-assessment in Limb X-ray Interpretation

ISBN: 978-1-905539-13-0

CT Anatomy for Radiotherapy

ISBN: 978-1-905539-54-3

A Guide to Research for Podiatrists

ISBN: 978-1-905539-41-3

Research Issues in Health and Social Care

ISBN: 978-1-905539-20-8

A Pre-Reader for the Foundation Degree in Health and Social Care

ISBN: 978-1-905539-68-0


To the Radiology Departments of Leeds General Infirmary and Wharfedale General

Hospital for their continued support and use of the radiographs in this book.

To Paul Atkinson for his excellent chapter on osteoporosis and DXA Scanners.

To Katy Johnson for again contributing to this book with her chapter on tumours.

To my husband, Sakthivel Perumal for his continued support and technical computer expertise, for when everything breaks down!

In memory of my parents who are at peace and together again.


Today many radiographers are trained to report on trauma radiographs. Universities are also training student radiographers to comment on trauma radiographs. It is useful, in some cases essential, that whilst we review the trauma radiograph we also recognise and note any appropriate pathology. For instance a patient attends Accident and Emergency (A&E) with pain in their knee for several weeks following trauma; the radiographs show no fracture but some signs of a malignant bony tumour, which on further investigation is an osteosarcoma. It is imperative that the trauma reporting Radiographer Practitioner recognises these signs and seeks advice to allow correct management of the patient. Also some Radiographer Practitioners are expanding their reporting roles into reporting GP patients, myeloma skeletal surveys, bone scans etc. Other professions, such as extended role nurses and physiotherapists, may be reviewing radiographs in clinic and looking at other pathologies, for example, arthropathies or metabolic diseases.

This book, like others in the series, is intended to accompany a reporting course and to be used alongside further research and reading. This book is relevant to all the above professions, but also to any profession that routinely reviews radiographs and has an interest in musculoskeletal pathology. For the more we educate ourselves in our varied professions, the better; not only does it make our job more interesting, provide essential continued professional development (CPD), but also improves the quality of care we provide for our patients.

As with the other books in the series, this book starts with several chapters by different authors followed by a series of cases. The first chapter gives some key points on reviewing some of the many arthropathies. The second is written by Paul Atkinson, an experienced Advanced Reporting Radiographer within the Leeds Trust and a teaching colleague of mine for many years. He discusses the pathogenesis of osteoporosis and the reporting of DXA scans. DXA scans are reported by Radiographer Practitioners at Wharfedale General Hospital.

Next Katy Johnson, a Reporting Radiographer working at Leeds General Infirmary, contributes some helpful pointers for reviewing tumours. There is then a chapter outlining avascular necrosis and the osteochondroses.

Following these chapters are 100 cases. I have tried to find as many different pathologies as possible, so there is a wide range which would under normal circumstances take several years in practice to come across. As with the previous books each case has been anonymised, which may have resulted in side markers being removed. Each case will have some appropriate clinical history or details with it but it may not be the original. For each case you will be asked to write a comment/report which may be descriptive in nature but also may include a diagnosis or a list of differentials. Sometimes additional questions maybe asked. The book is intended to resemble sitting in on a reporting/ teaching session with a Radiologist or Reporting Radiographer.

The cases are divided into 25 arthropathies, 25 tumours, 15 metabolic disease processes, 15 miscellaneous cases which do not quite fit into any other of the categories, and finally 20 mixed cases.

At the end of the book is a reading list and bibliography. Musculoskeletal pathology is a difficult and challenging subject; there is always lots more to learn. I hope you find this book useful and that it helps you to recognise some of the pathologies you may encounter when you are reporting, and also when to ask for another opinion or help!



Karen Sakthivel-Wainford


Arthritis is a collection of diseases that affect the true or diarthrodial joint (see Figure 1.1). A diarthrodial joint consists of cartilage covering the articular ends of the bones forming the joints, the articular capsule which is reinforced by ligamentous structures and the joint space which is lined with synovial membrane and filled with synovial fluid.

Figure 1.1 Diarthrodial joint

The abnormality of the joint in arthritis usually consists of destruction of the articular cartilage which appears on the radiograph as a narrowing of the joint space; narrowing of the joint is the cardinal sign of arthritis. However in some arthritic processes the joint space may become expanded instead, for example in the early stages of some arthrides, when there is joint effusion and ligament laxity.

However this does not help in distinguishing one arthropathy from another radiographically. The rest of this chapter will give brief descriptions of some of the most common arthropathies, but mainly will attempt to give some guidance in distinguishing one arthropathy from another.

In order to focus our minds when looking at arthrides, Debbie Forrester (Forrester and Brown, 1998) suggests the following ABCS search pattern:

Alignment (is there subluxation or dislocation?)

Bone mineralisation (is sclerosis or osteopenia present?)