Radioanatomy of the Extremities

&
Some of the MSK Pathologies
Enrico, MD / Radiologist
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Modalities in MSK
Radioanatomy of the Limb
Some of the MSK Pathologies
Radiological examinations
• Plain radiography (basic imaging)
• CT
• Ultrasound
• MRI
• Arthrography
• Nuclear medicine
Modalities in MSK
Radioanatomy of the Limb
Some of the MSK Pathologies
SHOULDER JOINT SERIES
HUMERUS

AP
HUMERUS

Lateral
ELBOW JOINT SERIES
ANTEBRACHII SERIES
WRIST JOINT SERIES
MANUS SERIES
FEMUR SERIES
 GENU JOINT SERIES

Sunrise

AP Lateral
CRURIS SERIES
ANKLE JOINT SERIES
PEDIS SERIES
Modalities in MSK
Radioanatomy of the Limb
Some of the MSK Pathologies
Trauma
Infections, inflammations, & necrosis
Endocrine & metabolic diseases
Congenital & developmental disorders
Bone tumors, tumor-like, & soft tissue tumors
Arthritides & degenerative processes
Radiology evaluation
• Diagnosing & evaluating fracture / dislocation
• Monitoring follow up treatment & complications
• Minimum of 2 views & 2 joints
• Some subtle, nondisplaced, & hairline fractures may not be obvious
• Children  comparison with normal side & involvement of the
growth plate (physis)
Shoulder dislocation
• = Glenohumeral joint dislocation
• Separation of the humerus from
the glenoid of the scapula at the
glenohumeral joint

The humeral head is dislocated anteriorly & inferiorly

with the anteroinferior margin of the glenoid
 Proximal humeral fractures

There is a fracture through the surgical neck of the humerus. The

Plate & screw ORIF performed
shaft of the humerus appears displaced anteriorly & superiorly
 3D CT

Marked comminution of the surgical neck extending into the greater & lesser tuberosities
with gross avulsion of the humeral head & displacement anteriorly
Distal humeral fractures

Comminuted fracture in the distal right humerus

Elbow dislocation
• The most common large joint
dislocation in children
• Second most common large joint
dislocation in adults

Posterior elbow dislocation with radial neck fracture

Monteggia fracture-dislocations
• Fracture of the ulnar shaft with concomitant dislocation of the radial
head (proximal radioulnar dislocation)
• Mostly in children

Monteggia fracture dislocation

A displaced & overlapped fracture of the ulnar shaft is present. Additionally the radial head is dislocated anteriorly
Galeazzi fracture-dislocations
• Fracture of the distal shaft of
radius with dislocation of distal
radioulnar joint & an intact ulna
• Galeazzi-equivalent fracture
• Distal radial fracture with a distal
ulnar physeal fracture
Open transverse fracture at the junction of the distal & middle third of
the radial diaphysis with volar dislocation of the distal radio-ulnar joint
Colles fractures
• Very common extra-articular • RÖ:
fractures of the distal radius • Dinner fork deformity
• Fracture of the distal radial • Associated ulnar styloid
fracture (50%)
metaphyseal region with dorsal
angulation & impaction, but
without the involvement of the
articular surface
Transverse extra-articular distal radius fracture with
dorsal angulation consistent with a Colles fracture
Transverse extra-articular fracture with dorsal angulation. Ulnar styloid fracture.
Extra-articular transverse fracture through distal radius with dorsal angulation
Smith fractures
• = Reverse Colles fracture
• Fractures of the extra-articular
distal radius with associated
volar angulation of the distal
fracture fragment(s)
There are fractures of the right distal radius & ulna with significant
shortening & volar angulation of the distal fracture fragments
 3D CT

Impacted extra-articular distal radial shaft fracture is noted with volar angulation of the distal fragment
Carpal bone fractures
• Scaphoid fractures account for
70-80% of all carpal bone
fractures

Scaphoid fracture - proximal pole

Metacarpal fractures
• Fractures of the metacarpal
bones
• 10% of all fractures
• 40% of all hand fractures

• Boxer fractures
• Most common type of metacarpal
fracture
• Transverse fractures of the 5th
metacarpal neck
• Minimally comminuted
Comminuted fracture through the neck of the fifth metacarpal bone, with palmar angulation
Fifth metacarpal neck fracture with palmar angulation of the distal fracture fragment.
No evidence of intra-articular extension of the fracture.
Neck of femur fractures
There is a transcervical (bordering on basicervical) fracture of the right femoral neck with resultant coxa vara deformity.
 MRI

Displaced impacted subcapital right neck of femur fracture.

Stranding within adjacent soft tissues consistent with soft tissue injury.
Patellar fracture

The radiograph shows a transverse & displaced fracture of the patella

Crural fractures

There is comminuted tibial shaft fracture with displaced butterfly fragment.

Transverse fracture is present at the proximal fibular diaphysis.
3D CT
 Ankle fractures

Views of the ankle demonstrate a horizontal fracture through the lateral malleolus, below the level of the ankle joint.
Calcaneal fractures
• Most common tarsal fracture

Calcaneal fracture
Anterior cruciate ligament tears
• Most common knee ligament injury
• RÖ:
• Fiber discontinuity
• Increased signal on MRI
• Swelling
 MRI

Abnormal increased signal in the ACL in keeping with sprain

Normal MRI knee for reference
(partial thickness tear)
Achilles tendon tears
• The most common ankle tendon injuries
• RÖ:
• Fiber discontinuity
• Chaging of signal intensity:
• Increased signal on MRI
• Hipoechoic on US
• Swelling
 Lateral radiograph of ankle shows calcaneal enthesophytes. Thickening of
soft tissue shadow of Achilles tendon with loss of margin definition is seen.
Normal ankle Kager's fat pad is effaced.
 USG

Normal Achilles tendon USG shows complete tear with defect.

Proximal stump shows thick & swollen tendon.
 MRI

Disruption of Achilles tendon. The proximal stump has

Normal Achilles tendon
been retracted towards the muscle belly.
Trauma
Infections, inflammations, & necrosis
Endocrine & metabolic diseases
Congenital & developmental disorders
Bone tumors, tumor-like, & soft tissue tumors
Arthritides & degenerative processes
Osteomyelitis
• Inflammation of bone, due to • RÖ:
infection: • Regional osteopenia
• Haematogenous spread • Focal bony lysis or cortical loss
• Direct extension from trauma &/or • Periosteal reaction
ulcers (especially in the feet of • Chronic:
diabetic patients) • Sequestrum
• Involucrum
• Cloaca
 6 months later 4 years later
12 year old with osteomyelitis of the distal radius,
with followup x-rays at 1 month, 6 months & 4 years demonstrating complete resolution.
Evidence of destruction of the 5th metatarsal head, cortical disruption & periosteal reaction. Further area of cortical bone
loss & focal osteopenia with the 5th proximal phalanx base. Findings in keeping with osteomyelitis/ septic arthritis.
 MRI

MRI confirm intra-medullary collection with surrounding reactive inflammatory muscle swelling
Elderly diabetic with a foot ulcer over the 5th metatarsal head -
osteomyelitis?

Tc99m MDP SPECT/CT

Soft tissue swelling & subtle soft tissue gas over the 5th Focus of intense isotope accumulation superimposed over the 5th
metatarsal head. No overt bone erosion thus bone scan has metatarsal head. In the context of clinical sepsis & given the presence
been very helpful in diagnosis. of adjacent subcutaneous gas, findings indicate osteomyelitis.
Osteomyelitis in nuclear medicine
 MRI

The case clearly illustrates the pathology & complications of chronic osteomyelitis
with formation of sequestrum, involucrum & cloaca
Calcific tendinitis
X-RAY CT

• Deposition of calcium
hydroxyapatite within tendons
(usually of the rotator cuff)

Calcific tendinitis

USG MRI
Tenosynovitis
• Inflammation of the synovial
membrane surrounding a
tendon
• RÖ:
• Ultrasound:
• Increased fluid content within
tendon sheath
• Thickening of the synovial sheath
• Doppler: with or without increased
vascularity
• MRI:
• Increased fluid within tendon sheath
 USG

Global thickening with effusion is noted at sheath of extensor carpi ulnaris ( ECU ) tendon.
Local hypervascularity also is present.
 MRI

Fluid is seen surrounding the tendon of flexor hallucis longus

Osteonecrosis (avascular necrosis)
• Ischemic death of the • RÖ:
constituents of bone • Mixed osteopenia &/or sclerosis
&/or subchondral cysts,
• Location: hip is more common
• Cortical collapse
than other sites
• Secondary degenerative change
• Etiology:
• Traumatic
• Non-traumatic:
• Chronic corticosteroid therapy
• Alcoholism
• Smoking
Advanced degenerative changes are seen at right hip joint accompanied by a widening of the acetabulum, loss of
volume of the femoral head & flattening of the remnant proximal femur. Superolateral subluxation also is evident.
Trauma
Infections, inflammations, & necrosis
Endocrine & metabolic diseases
Congenital & developmental disorders
Bone tumors, tumor-like, & soft tissue tumors
Arthritides & degenerative processes
Osteogenesis imperfecta
• Congenital, non-sex-linked,
genetic disorders of collagen
type I production, involving
connective tissues & bones
• Osteoporosis - fragile bones
• Blue sclera
• Dental fragility
• Hearing loss
• RÖ:
• Severe osteoporosis
• Cortical thinning
• Deformed, gracile (over-tubulated)
bones
• Hyperplastic callus formation
 Multiple fractures at various stages of healing; many with malunion, angulation & bridging callus:
multiple ribs bilaterally, left humerus, radii & ulnae, femora (segmental fractures in both), & fibulae
Osteopaenic, gracile bones
Rickets
• = Rachitis
• Deficient mineralization of the
growth plate in the pediatric
population:
• Premature infants
• Unbalanced infant nutrition (Vit D
deficiency)
• Maternal vitamin D deficiency
• Lack of sun exposure
• RÖ: growth plate widening &
abnormal configuration of the
metaphysis
Fraying, splaying & cupping of the distal radial & ulnar metaphyses. Widening of the physes.
These findings are consistent with rickets.
Cupping & flaring of bilateral distal metaphysis of radius & ulna with growth plate widening: characteristic of rickets
Trauma
Infections, inflammations, & necrosis
Endocrine & metabolic diseases
Congenital & developmental disorders
Bone tumors, tumor-like, & soft tissue tumors
Arthritides & degenerative processes
Genu varum (bow legs)
• Varus angular deformity of the
knee joint
• Leg is bowing outwards at the
knee, while the lower leg is angled
medially

Marked leg bowing

Genu valgum (knock-knee)
• Valgus deformity of the knee
• Lower leg is bending outwards in
relation to the axis of the femur

Knock-knee
Syndactyly
• Congenital fusion of two or more digits

Complete fusion of the soft tissues of the 2nd & 3rd rays. The 2nd ray has no middle phalanx.
The 3rd ray has three phalanges. The left 5th ray also only has 2 phalanges.
Ossification is slightly delayed on the side with syndactyly & the hand is slightly smaller.
Polydactyly
• There are more than the usual number of digits (five) in a hand or
foot

The thumb has an additional three phalanx digit

This child has polydactyly arising medial to it consistent with polydactyly
Trauma
Infections, inflammations, & necrosis
Endocrine & metabolic diseases
Congenital & developmental disorders
Bone tumors, tumor-like, & soft tissue tumors
Arthritides & degenerative processes
Giant cell tumor
• Benign primary bone tumor
• RÖ:
• Closed growth plate
• Abuts articular surface
• Well-defined with non-sclerotic margin
• Eccentric
 CT

Lucent lesion located eccentrically within the

distal lateral femur, abutting the articular surface Expansile lesion in a sub-articular location in the distal radius
 Giant cell tumor

X-RAY CT MRI Nuclear medicine

Osteosarcoma
• Malignant primary bone tumor
• Second most common primary
bone tumor after multiple
myeloma
• RÖ:
• Medullary & cortical bone
destruction
• Permeative or moth-eaten
appearance
• Wide zone of transition
• Aggressive periosteal reaction:
• Sunburst type
• Codman triangle
• Lamellated (onion skin) reaction: less
seen
Radiographs showing sclerotic lesion involving dia-metaphyseal region of
the tibia with a wide zone of transition, periosteal elevation (Codman’s
Triangle) & characteristic " Sunburst " type of periosteal reaction

An ill-defined sclerotic area affecting the metaphysis of distal

fibula with an aggressive periosteal reaction (sunburst type).
It is associated with a moderately large soft tissue swelling.
Ewing sarcoma
• Second most common malignant
primary bone tumors of
childhood after osteosarcoma
• RÖ:
• Permeative (76%), sclerosis (40%)
• Lamellated (onion skin) periosteal
reaction (57%)
• Occasionally: Codman triangles,
spiculated (sunburst), thick
periosteal reaction
Ill-defined lucency in the distal femur is noted, with a wide
zone of transition & onion-skin periosteal reaction

X-ray of the humerus demonstrates destruction of the bone with cortical

erosions & poor transition to normal bone. In this case, there are
perpendicular spiculations producing a sunburst appearance in the center
of the tumor. Laminated appearance occurs towards the edge of the
tumor (not prominent in this case) producing an onion-skin appearance.
Skeletal metastases (bone metastases)
• Malignant secondary bone
tumor
• RÖ:
• Lytic metastases
• Sclerotic metastases
• Mixed lytic & sclerotic metastases
Osteolytic metastatic lesion
A lytic lesion with slightly irregular margins are noted in
the proximal femoral shaft
 CT

Extensive sclerotic skeletal metastases throughout the pelvis & femora There are mixed lytic & sclerotic
vertebral metastatic lesions throughout
visualized spine
Lipoma
• Benign soft tissue tumors
• Most common soft tissue tumor
• RÖ:
• USG:
• Variably echogenic masses
• Well demarcated
• CT & MRI:
• Fat attenuation mass
• Circumscribed
 USG

There is a well-defined, encapsulated mass with

A homogeneous soft tissue lucency over echopattern identical to fat at the site of swelling pointed
the 2nd & 3rd metacarpal bones by the patient
 CT

CECT neck reveals a purely fatty lesion at the inferior portion of the right parotid & shows intimate relation
to the anterior surface of the right sternocleidomastoid muscle. No enhancing soft tissue component is seen.
 MRI

T1W1 T2W1 STIR

Left submandibular region oval shaped well defined mass. It exhibits high signal in T1, T2 & suppressed in STIR images.
No bony or soft tissue infiltration.
Soft-tissue sarcoma
• Malignant soft tissue tumors of
mesenchymal origin

• Liposarcoma
• Second most common type of
soft-tissue sarcoma
• RÖ:
• Fat signal with thick septa
• Enhancement or evidence of local
invasion
 MRI

Sagittal T1 C+

The tumor is well encapsulated & contains

homogeneous fat tissue. There is enhancement.
There is a large, predominantly fatty mass in the posteromedial aspect of the left thigh which is heterogeneous
in appearance with multiple septations that are thickened & enhanced

CT
Trauma
Infections, inflammations, & necrosis
Endocrine & metabolic diseases
Congenital & developmental disorders
Bone tumors, tumor-like, & soft tissue tumors
Arthritides & degenerative processes
Gout
• Crystal arthropathy due to
deposition of monosodium urate
crystals in & around the joints
• Location:
• Most common: 1st MTP joint
(podagra)
• Hands & feet
• RÖ:
• Rat bite erosions:
• “Punched-out” erosions
• Sclerotic margins
• Overhanging edges
• Tophus (pathognomonic)
Juxta-articular erosions with overhanging margins involving the
metatarsophalangeal joint of both big toes, with associated soft
tissue swelling & relative sparing of the joint space.
There are several well-circumscribed punched-out bony erosions with sclerotic margins, especially at first
MTP joints, bilaterally. Juxta-articular soft tissue densities & swelling are also visible.
Rheumatoid arthritis
• Chronic multi-system disease • RÖ:
with predominant • Erosions
musculoskeletal manifestations • Soft tissue swelling
• Attacks: • Osteoporosis
• Synovial tissues • Joint space narrowing
• Synovial joints
• Tendons
• Bursae
Typical changes of rheumatoid arthritis of the hands with
prominent metacarpophalangeal osteopenia, erosions very
marked within the carpus & radiocarpal/ulnocarpal joints.
Advanced features of rheumatoid arthritis, with erosive subluxation most marked of the
MCP joints with ulnar deviation. Prominent degenerative change is also seen at the ulnar-
carpal articulation. Note also osteopaenia particularly of the MCP regions.
Septic arthritis
• Destructive arthropathy caused
by an intra-articular infection
• Location:
• Large joints with abundant blood
supply to the metaphyses
• Shoulder, hip, & knee
• RÖ:
• Destruction of the subchondral
bone on both sides of a joint
• Juxta-articular osteoporosis due to
hyperemia
• Narrowing of the joint space due
to cartilage destruction in the
acute phase
There is a complete loss of the right superior femora acetabular joint space, with mild destruction of the superior
aspect of the femoral head & adjacent acetabulum. The medial FAJ space is mildly widened
Osteoarthritis
• Most common form of arthritis
• Most common joint disease in
the elderly
• RÖ:
• Subchondral sclerosis
• Marginal osteophytes
• Subchondral cysts
• Joint space narrowing (usually
asymmetric)
 AP projection of both the knees reveals severe loss of joint space in both (medial > lateral)
compartments associated with osteophytes , subchondral sclerosis & an obvious varus deformity.
There are narrowing of the medial compartment of the tibiofemoral & of the patellofemoral compartment,
prominent subchondral sclerosis & prominent osteophyte formation. Similar findings are also noted in the
articulation between the tibia & proximal fibula.
Thank You