Bones & Joints

Ian Bickle
Radiology for Finals
Nottingham

(special thanks to Dr A Raghavan)

 Main Themes

 Systemic bone diseases

 Fractures

The KEY pathologies

 The Aim of the Film
 Powers of observation

 Completeness of Search

 Descriptive abilities

ALL FEATURES OF A GOOD JUNIOR DOCTOR

 Key Points

Have a system of approach

Stick to it

Don’t forget the soft tissues

 Viewing Bones
 Typically 2 views

 Essential for Fractures (90 degrees)

 Compare & Contrast

 Check bone outline and density

 Don’t
overcomplicate the
simple
 Anatomy of the Hand & Wrist
Carpal Bones:

 Proximal Row:
tp
Scaphoid (a),
c t Lunate (l),
h
p
tq Triquetrum (tq),
l Pisiform (p)

 Distal Row:
Trapezium (t),
Trapezoid (tp),
Capitate (c),
Hamate (h)
 Anatomy of the Pelvis & Hip
a  A = sacral ala

 B = left sacroiliac joint

b  C = iliopectineal line
d
e c  D = ilium

 E = ischial spine

 F = pubic symphysis

 G = inferior pubic ramus

g

f h  H = obdurator foramen
 Anatomy of Knee

femur

patella
Medial
condyle
fibula
Intercondylar
eminence Tibial
tuberosity tibia
Anatomy of lumbar spine

1 = vertebral body

2, 3 = intervertebral disc space

4 = pedicle

5 = lamina

6 = spinous process
Anatomy of lumbar spine

1 = vertebral body

2 = intervertebral disc space

3 = lamina

4 = spinous process
 Normal Anatomy
cortex
diaphysis metaphysis

epiphysis physis medullary

space

physeal scar

Childhood Adult
Systemic Bone Diseases
 Common Pathologies
 Osteoarthritis  Paget’s disease

 Rheumatoid disease  Osteoporosis

 Gout  Ankylosing Spondylitis

 Psoriatic Arthropathy  Multiple myeloma

 Common Pathologies
 HPOA  Bone Metastases

 Osteomyelitis  Sclerotic Eg, Prostate

 Hyperparathyrodism  Lucent (Lytic) eg. Lung

 Osteosarcoma  Pathological fracture

 Charcot’s joint
 Osteoarthritis
Key Features

 Loss of joint space

 Difference in hips 

 Subchondral bone cysts

 Subchondral sclerosis

 Osteophyte formation
 OA Features

Sub-chondral sclerosis 
 Reduced joint space
Sub-chondral cyst
Rheumatoid Arthritis

Erosions 

 Erosive arthropathy
 Spares DIP joints
 Periarticular osteopenia
 Soft tissue swelling
 Gout

 Erosions – ‘punched out’

(away from joint)
Erosion 

Soft tissue  Soft tissue swelling

 Gouty tophi
 Psoriatic Arthropathy

 Erosive arthropathy

 DIP typically

 Sarcoiliac joints
(may be involved)

DIP’s only
Pencil and cup deformity
 Paget’s Disease (of bone)

Key Features

 Sclerotic Bone

 Sclerotic bone
 Coarse trabecular pattern

 Expanded Bone

 Pathological #
1% osteosarcoma
 Osteoporosis

Key Features

Wedge #   Normal biochemical tests

 Plain x-ray not sensitive

 DEXA scan best test

 Sequelae on x-ray – wedge #

 Ankylosing Spondylitis

Spine and SI joints

 Bamboo Spine
 Sacroilitis
 Syndesmophye
formation
 Calcification of anterior
longitudinal spinous
ligament
 Apophyseal joint fusion
Multiple Myeloma

multiple lytic bone lesions

 Metastases
Lytic:
Sclerotic:

 Lytic Met
 Sclerotic Met

 Bowel
 Bronchus
 Breast
 Kidney  Prostate
 HPOA

Unusual but important

diagnosis

 Bronchial carcinoma
Periosteal reaction 
 Suppurative lung disease
 Osteomyelitis
Key Features:

 Peri-osteal reaction

 Osteopenia

 Bony destruction

 Pathological #
Both sides of the joint
 Hyperparathyroidism

Key Features:
Scalloping 
 Sub-periosteal bone
resorption – typically
middle phalanx of hand

 Osteopenia
 Charcot’s Joint

 Disorganized and disrupted joint

 Sclerosis
 Destruction of joint
 Fragmentation

 Think Diabetics
 Osteosarcoma
 Typically at the knee
 Soft tissue mass
 Frequently young patient

 Periosteal reaction

 Soft tissue mass

periosteal  Destructive lesion

reaction
 Codman Triangle

periosteal reaction
Codman
Triangle
advancing tumor margin
destroys periosteal new
bone before it ossifies

tumor
Fractures
 Fractures: Features to Describe
 Bone

 Place of Bone

 Nature of Fracture

 Special Features of
Fracture Management Implications
 Fracture Features
 Black (lucent) line  Always look for another
abnormality
 White if overlapping
fragments  Another #

 Associated soft tissue  A dislocation

abnormalities
 An underlying cause
 Displacement &
Angulation
 Fresh & Former

 callus

Fracture 
 Systemic Disease with Bone/Joint
Involvement
 Best Exam Cases

 Great test of knowledge

 Test lateral thinking

BE THE BEST – think for the test

 Rheumatoid Disease
Erosive Arthropathy & Pulmonary Fibrosis
Bronchial CA & HPOA
Paget’s Disease  Osteosarcoma