MUSCULOSKELETAL RADIOLOGY

CASE BASED APPROACH

Thariqah Salamah
Musculoskeletal Division, Department of Radiology
Faculty of Medicine Universitas Indonesia
Dr Cipto Mangunkusumo General Hospital
Radiology Unit Universitas Indonesia Hospital
Algorithm
 Comparison of Relevant Modalities
Radiography CT US MR
Magnetic field &
Source Planar X-ray Rotating X-ray Ultrasound
Radiogrequency

X-ray penetration X-ray penetration

Ultrasound reflection on Excitation of hydrogen
Mechanism through biological through biological
tissue interface proton to induce signals
material material

Role Initial/Primary Secondary Secondary Secondary

Cost Low High Relatively low High

Radiation Relatively low Relatively high None None

Better cost Highly accurate Easy to perform

Superior for soft tissue,
Advantage effectiveness Superior on cortical & Superior on joint & soft
joint & bone marrow
Widely available complex bones tissue
Poor resolution on deep Longer time exam,
Limitation 70% sensitivity Higher radiation dose structures claustrophobia,
Operator dependency pacemaker
TRAUMA
Fracture of Long Bone

• Type of fracture line

• Location
• Alignment of fragments
(displacement, angulation,
shortening, distraction)
• Associated abnormalities
REMEMBER
• 2 joints
• 2 perpendicular views
AP LAT
Pediatric
Incomplete Fracture
• Torus
• Greenstick
Bowing fracture
Angulated longitudinal force greater
than mechanical stength of bone 🡪
plastic deformation
microfractures along the concave
border of the bowed bone
absence of visible cortical injury
Torus fracture

Bulging of the cortex.

Result from trabecular compression from an axial loading force along the long axis
of the bone.
Greenstick Fracture
• Fracture of convex survace
• Concave surface of the bent bone
remains intact.
• Angulated longitudinal force
applied down the bone (e.g. an
indirect trauma following a fall on
an outstretched arm), or after a
force applied perpendicular to the
bone (e.g. a direct blow).
• Middiaphyseal predilection
Pediatric complete fracture

Growth plate
involvement
 Physeal Plate
Fracture
Salter-Harris

• Type I & II: heal

• Type III: degenerative changes, asymmetrical growth plate fusion
• Type IV & V: early growth plate fusion, deformity & shortening
• Fracture line involving
attachment site of
ligament
• Next imaging study?
MRI for soft tissue evaluation
• Look for sign of
instability in
vertebral fracture
Three collum theory by Dennis
• Spinal stability is dependent on at
least two intact columns.
When two of the three columns are
disrupted, it will allow abnormal
segmental motion, i.e. instability.
• Criteria to predict soft-tissue injury
from bony injury are:
▪ Angulation greater than 20
degrees.
▪ Translation of 3.5 mm or more.

http://www.radiologyassistant.nl/en/p4906c8352d8d2/spine-thoracolumbar-injury.html
Instability criteria on lateral radiograph
• Greater than 50% loss of vertebral body height,
• Greater than 20° angulation of the thoracolumbar junction,
• Neurologic injury
• Canal narrowing of greater than 30%.
• CT scan for
fracture line
delineation and
alignment of
fragments in
complex bone
fracture
• MRI for neural
involvement
• Bone marrow
edema
Trauma Complication

Avascular
necrosis due
to neglected
scaphoid
fracture
INFECTION
Chronic Osteomyelitis

Sequestrum with
surrounding lytic
lesion
Involucrum and
solid periosteal
reaction
MRI with Gadolinium contrast for chronic
osteomyelitis

Extent of bone
marrow involvement
Extent of soft tissue
involvement
Abscess formation
ARTHRITIS
Osteoarthritis
Osteophyte
Non uniform joint space narrowing
Articular loose body
Rheumatoid arthritis
• Erosion
• Uniform joint space
narrowing
• Soft tissue edema
• Ulnar deviation
METABOLIC BONE DISEASE
METABOLIC BONE DISEASE
• Diverse group of diseases that diffusely affect the mass or structure of
bones by external process
• Can be caused by genetic disorders, nutritional deficiencies, acquired
conditions
• General radiologic appearance: increased or decreased bone density
• Can caused deformity because of remodelling or severely weakened
bone
Renal Osteodistrophy
• Complex findings of osteomalacia and secondary
hyperparathyroidism
• Diffuse osteosclerosis probably due to anabolic effect of parathyroid
hormone
• Soft tissue deposits of calcium hydroxyapatite, calcium pyrophospate
dihydrate, calcium oxalate around large joint
Salt and pepper skull
Cortical Resorbtion
Subarticular/Subligamentous/Subtendinous
Resorbtion
Soft Tissue Calcification
Brown Tumor
• Lytic lesion
• Parathyroid hormone
driven osteoclast
activation
• Might be associated
with large soft tissue
component
SKELETAL DYSPLASIA
ACR SPR
PRACTICE
GUIDELINES
Cranium

• Sutures
• Wormian bones
• Sella Turcica
• Craniofacial proportions
• Calvarial/skull base
thickening
Spine
• Alignment
• Vertebral shape
• Fusion/segmentation anomalies
• Interpediculate distance narrowing in lower lumbar spine
Vertebral body shape

• Platyspondyly
• Posterior scalloping
• Anterior beaking
• Wedging
• Clefting
Segmentation anomalies
Interpediculate distance
Pelvis
• Sciatic notches
• Acetabular roof
• Iliac wings
• Pubic bone
ossification
Extremities
• Focal or Generalized
• Epiphysis, Metaphysis, Diaphysis
• Small epiphyseal ossification center
• Metaphyseal flaring, marginal irregularity
• Disproportionate shortening (rhizomelia, mesomelia, acromelia)
• Micromelia
• Polydactyly, duplications, hypoplasia
MUSCULOSKELETAL TUMOR
AP LAT
Well Differentiated
Liposarcoma

RadioGraphics 2005; 25:1371-1395

• Radiography as a first line imaging. Differentiating bone and soft
tissue tumor
• MRI for evaluation of tumor component and local staging (soft tissue
extension, intramedullary extension, joint involvement, neurovascular
involvement)
• Bone scintigraphy for assessing bone metastasis
CT guided biopsy in suspected metastatic
bone disease, unknown primary
Final diagnosis:
Multiple myeloma
ESSR Consensus on Bone Tumors &
Tumor Mimickers
ESSR Guidelines on Adult Soft Tissue
Tumors
Soft tissue sarcoma, agressive & non agressive but
needed further management bone tumors should be
managed by multidisciplinary sarcoma team
(Orthopedic tumor surgeon, MSK radiologist,
oncologist, MSK pathologist, radiotherapist, specialized
physiotherapist)
Take Home Messages
• Radiography is the primary imaging modality for MSK cases
• Use other imaging modalities as indicated (e.g: MRI for joint and soft
tissue extension of lesion, CT for complex bone fracture)
• Do history taking and physical examination before ordering radiology
examination
• Have a sufficient knowledge on indication and positioning
THANK YOU