UST Medicine & Surgery Mitz

Radiology 3C ‘09

Musculoskeletal Radiology Skeletal Scintigraphy - normal

September 27, 2007
Dark areas à normal concentration of
Tc will be seen
Essence:
“Imaging modality approach” – makes use of several modalities à MULTI-
Pathologic à ↑ activity:
MODALITY APPROACH
à either ↑ turnover or ↑ destruction
à see Tc in those areas, abnormal
Main objective: To have a clear/specific choice that can image certain
conc
musculoskeletal disease that could yield to a single dx or a significant ddx
Example of a bone scan in w/c the
3 aspects isotopes have preponderance to areas
1. Imaging Modality of the bone w/ increase activity such
- Plain x-ray as the ends, since that’s where active
- Nuclear imaging bone growth occurs.
- CT
- MRI
Computed Tomography
2. Clinical background – Hx & PE of px, particularly of musculoskeletal Axial images
that is of concern Visualized cortex,
marrow, soft
3. Laboratory data – to r/o or r/i certain disease tissues, vessels
Sensitive for bone
destruction
Modalities Preop evaluation
Staging
X Plain radiograph – makes use of a plain film
▪ PA view X makes use of x-ray à topographic x-ray that is manipulated by computer
▪ Lateral Oblique X can be viewed on axial, coronal, or sagittal sections
▪ The more views, the better
X Conventional CT ü show the same images
X Helical CT ü have time in reformatting the images so
X Multislice CT you can see cross sections of different
views

The advantage of CT:

X Aside from axial, you will have an excellent visualization of bone itself,
as well as cortex and marrow, and surrounding soft tissues, especially
during times when contemplating limb salvaging, etc.
cortex X Usually used for staging, esp for bone & soft tissue tumors

medulla MRI
Superior images
A normal image of knee joint Multiplanar
Useful in joints, tumors,
This is a plain x-ray, one can note: infection, bone infarcts,
Cortex ischemic necrosis
- composed of the compact bone Exquisite marrow
- seen in the periphery and usually seen as a very dense or white visualization
area, or strip in the periphery, esp noted from the metaphysic to
the shaft of the bone
Medulla § High field magnet coupled w/ radiofrequency
- composed of cancellous bone/ bone marrow § Show excellently the soft tissues as well as bone marrow
- contains the loose layer of the bone § Bone is not paramagnetic à no signal on MRI, appear as black
- contains the bone marrow § Signal → produced by bone marrow
Articular ends – near joint
§ Any problem in bone itself à show changes in bone marrow
Epiphysis, metaphysic complex – usually seen near the joint
§ That’s why in MR, if there is any changes in bone marrow, you can readily
Physis
diagnosed that there is a bone problem even if it doesn’t have any signal
Soft tissues – surrounding soft tx, impt to interpret as a whole the
on MR
bones and the joint that is being examined
§ Mainstay: evaluation of the joint (any joint in the human body) à better
The cartilaginous plate or growth plate is the one producing osteophytes w/c evaluated by MR
is received by the metaphysis for promoting bone growth and lengthening § Joint pathology à MRI is
Later on, as the individual approaches adulthood, the physis will ultimately the imaging modality of
fuse w/ the metaphysis and disappear. choice! (esp in sports injury,
post traumatic injury)
ü Although plain film or
Skeletal Scintigraphy (“Nuclear Imaging” in plain simple terms) CT can be used to
image joints
Tc99m / IV – radioisotope usually used ü May skip other imaging
- Purpose: settle on the areas of the bone that has ↑ activity modalities
Increased bone turnover / destruction – manifest as ↑ activity
Normal growth plates

*Any pathology may be detected by technetium scan Ultrasound

Tumors Visualize soft tissue & bony cortex
Infection Adjunctive procedure
Fractures Useful in evaluating tendons, joints, soft tissues
Arthritis Narrow FOV (Field of View), segmental visualization or organ of
Periostitis interest
Operator dependent
Very sensitive / less specific – still search for a cause

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UST Medicine & Surgery Mitz
Radiology 3C ‘09

▫ Occult
œa fracture that is not seen on plain radiograph
œPx has pain despite no fracture on plain film
œw/ symptom but no finding
œnext choice to dx à bone scintigraphy or nuclear imaging

Knee joint with prosthesis

« use sound wave → doesn’t penetrate the bone, doesn’t image the
bone
« sound wave doesn’t penetrate through bone & prosthesis
« just shows the prosthesis at the area of examination
« Limited by size of the probe (only about 3-4 inches) à size of the
image is limited (Narrow FOV)
« For large/small tendon esp. digits, joints, soft tissue ¯ Occult fracture
N – uniform ABN -
on the carpal bone
uptake of Tc Concentrated
Contents:
☼ Trauma Tc uptake
☼ Tumors ▫ Bone bruise
☼ Infections
œintracanalicular injury in the intracanalicular haversian
☼ Joint Disorders portion of the cortex
œUsually reflected in Bone marrow as a low intensity focus
Traumatic bone injuries œIf there is a low signal area, coupled with hx of fracture in
♦ Fractures that area, consider a bone bruise
- General rule, plain radiograph is always indicated even at the
œUsually dx by MR
slightest doubt of fracture or trauma œCan’t be dx by CT or plain film
- any discontinuity or deformity of the bone
- especially in resilient bones of pediatric patients, in trauma, it will
not literally break, but will be deformed…so it is still a fracture

♦ Types of Fracture
▫ Complete
© Transverse
low intensity focus BM
© Oblique
© Spiral

▫ Comminuted
œmore than 2 fragments
œbased on shape of 3rd fragment
ü Butterfly – triangular
ü Segmental – rectangular
Oblique fracture
w/ angulation

▫ Incomplete
© Greenstick – break on one side of cortex
œDistal fracture of tibia
deformities © Buckle (torus) – secondary to twisting or buckling œComminuted butterfly
© Plastic – bending
injury

▫ Avulsion / chip fracture

greenstick œusually occurs in areas of the bones that are sites of either
fracture (ulna) muscular or tendon attachment
œjust a small fracture
œbut may affect function of muscle or tendon (moderately or
severely)

at the area of the greater tuberosity of the

humerus

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UST Medicine & Surgery Mitz
Radiology 3C ‘09

▫ Epiphyseal fractures ,Non union (or non-healing of the fracture)

♥ Classify by Salter-Harris classification (1960) - Factors
♥ Pedia – epiphyseal line seen ü ↑ Age à less calcium à more osteoporotic bone
♥ Normal ? ü Infection
ü Vascular injury
ü Improper fixation
- Salient features (X-ray Findings)
ü No callus bridging across fracture line
ü Motion in stress radiographs
ü Or formation of a pseudojoint (pseudoarthrosis)

Bone tumors

Main goal: identify whether

Type I limited to the entire epiphyseal line
• Primary - relatively rare as compared to metastatic tumors
• Metastatic – malignant
Type II Epiphyseal line + portion of metaphysis (most common)
- several organs gives metastatic process e.g. breast thyroid lung
Type III Epiphyseal line + portion of epiphysis
kidney prostate
Type IV Epiphyseal line + epiphysis-metaphysic complex DDx – may mimic bone tumors, always think of these 3
Type V Modification of type 1 where injury is limited to one side of • Infection
epiphyseal line, sparing the other side
• Metabolic
• Dysplastic
Type I / V – significant if it involves a functioning joint – ex. ankle joint
The injured portion of bone will not continue growing → affect joint function
Benign Malignant
Cortex Intact Disrupted
▫ Pathologic
♥ usually secondary through an existing bone pathology Borders Well defined Poorly defined
- Bone tumor Soft tissues No involvement With involvement
- Malignancy
- Osteomyelitis ¤ Classification - based on cell origin, e.g. osteoid, cartilaginous, fibrous,
- Multiple Myeloma myelogenous, metastatic, cystic
♥ existing bone pathology produces weakening of the cortex,
producing injury ~Cartilaginous – usually occur near the joint
▫ Stress • Osteochondroma
♥ usually subjected to chronic stress - benign
ü Calcaneus - coat hanger deformity
ü Ribs - characterized by a cartilaginous cap → not usually
ü Hips seen in plain x ray but can be defined by CT
♥ To demonstrate it → skeletal scintigraphy – note ↑activity - usually grows near the joint → bec of the muscular
in that area and tendon pull direction
- Exostosis near the joint – in the metaphysic
- Cortex is intact
• Chondrosarcoma
- malignant
- disrupted cortex
- ill defined borders
- soft tissue involucrum

~Osseous
• Osteoma
- usually seen in the sinuses particularly frontal sinus
- appears as sharply marginate lobulated dense mass
Dense area at hips - often times may block ostium passages of the
sinuses → produce sinusitis
Healing • Osteosarcoma
"also monitored by plain film - calcifications extend in soft tissues, and margins of
"Gauged by: evident visualization of CALLUS formation lesions are very much irregular, some soft of ill
"Callus formation: defined lesions
,Occurs in two stages - char as sunburst periosteal reaction w/ dense
ü 1st stage – not visualized radiographically osteoed poorly defined cortical destruction and
ü 2nd stage – after 2-3 weeks from the time of injury, expansion
visualized radiographically, so follow up is done @ 2-3 - MRI show evidence of marrow replacement indicative
weeks after injury of tumor infiltration
,If radiograph is done early, no evidence of callous formation - dense osteoid gives typical low signal
"Types - medullary cortices destroyed
,Union When you do limb salvaging procedures, CT or MRI done, take note that
- Clinical – precedes radiographic evidence bone marrow, reflects lesion in bone→ the lesion extend well beyond the
- Radiographic – appear 2/n 2 wks plain field... in this case, beyond the midshaft of the femur (middle image)

ü produce bridging
of fractured
fragments

ü Signs of bone
remodelling

- noted if there's bridging of callus bet fractured fragments

- And disappearance of fracture line indicating endosteal T2 shows high signal intensity mass bowing the quadriceps muscle
callus Low signal intensity in the soft tissue mass also represents osteoid

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UST Medicine & Surgery Mitz
Radiology 3C ‘09

~Cystic
• Simple bone cyst
- benign
- small, rounded, well defined, dark area on the bone
itself
• Giant Cell Tumor
- premalignant (only about 2-3% go to malignancy)
- expansile with septations
- In the metaphysic of bone
- Althought the margins are not that irregular, but you
see some sort of cortical break, but it is still a benign
lesion

~Myelogenous – tumors originating from bone marrow

• Multiple myeloma – classic
- presentation: punch out lytic lesions on the skull and
long bones æAcute osteomyelitis
- always malignant Ÿ Latent period = 10 to 12 days (will not be seen on film)
- Lesions may coalesce when numerous Ÿ On this period, the best modality of choice would be
- in contrast to histiocytosis x LS disease in w/c lesions nuclear medicine
don’t coalesce Ÿ Beyond latent period → plain film → see bone destruction
- whenever you tend to place MM in ddx, r/i or r/o MM Ÿ (in latent period) Pain, soft tissue swelling, etc
by doing skull xray
- almost always à skull is involved æChronic osteomyelitis
Ÿ Thickened cortex
Ÿ Wavy outline
Ÿ Obliterated medullary portion
Ÿ Attempt of bone to seal of infection:
ü Sequestrum – dark areas surrounding bone
ü Involucrum

Joint abnormalities
Periarticular bony structures – bone surrounding the joint space
Joint space
Soft tissues
~Metastastic
- common site: vertebra (pedicles) X Radiographic signs of Joint disease
- can either be lytic or blastic Abnormality in apposing bony margins
ü lytic – bone destruction Changes in width of joint space – most important
ü blastic – bone formation • Narrowed – cartilage is destroyed
- do also scintigraphy, in which conc of Tc can be seen with • Widened – ↑ amount of synovial fluid in the joint space
↑ or ↓ bone destruction etc Subluxation
- in a single px, consider 4 organs: Periarticular swelling – of soft tissues
ü breast
ü prostate Infectious arthritis
ü lung X Acute
ü renal X Chronic
ü thyroid X 2° to S. aureus or TB

Infections

…Osteomyelitis
áStaph aureus
~Routes
Hematogenous
Implantation
Secondary normal joint widened joint (↑ synovial fluid in area)
~There is a difference in vascular supply in children & adults
áEarly lesions in pedia, start in metaphysis
áEarly lesions in adult, start in epiphysis
§ Bec. Of the vascular supply narrowed
§ You should not consider infection if epiphysis is clear joint →
(adult) & vice versa expect
cartilaginous
destruction
already

Tuberculous arthritis
X Hallmark: RAT BITE DEFORMITY on the sides
X Or the periarticular bony structures
X Pott’s disease → usually affect BODY of the vertebra

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UST Medicine & Surgery Mitz
Radiology 3C ‘09

TB spondylitis Degenerative joint disease

X blood supply from the spine emanates from end plates ü Affects distal joint
X Spare disse space ü Weight bearing joint
X That’s why there is… …secondary to wear and tear of joint (chronic)
ü Destruction …Not inflammatory
ü Anterior wedging …In contrast to RA, the joint space is ASSYMETRICALLY narrowed
ü Gibbus deformity
X Rarely, TB will first involve entire vertebral body Neuropathic arthropathies
X Almost always affect the intervertebral disc § Hallmark: Fragmented, disorganized joints (compared to other side)
X paravertebral abscess form †Leprosy
†Tabes dorsalis
†Diabetes

Metabolic
§ Gout → 1st MTP
ü Uric acid crystal deposits
ü Pseudoarthropathy
- Findings of bone will be seen after a long period of clinical
symptoms, about 6 years or more, before there could be abn
findings in bone
- Px w/ ssx of gout for 2 years → no expected findings on x-ray
- If joint space is intact → No cartilaginous destruction
- Erosions on sides / periarticular margins
- Classic finding of uric acid deposition in the tissues

Rheumatoid arthritis
X Affects proximal joints of hand
X Symmetrical – bilateral
X Proximal Interphalangeal joints & carpal bones
X Salient findings:
ü Osteoporosis of periarticular bony structures
ü Producing early synovial fluid tension and erosion L → 1st metatarsointerphalangeal joint
R → Ultrasound showing calcification of uric acid crystal deposits

Ann Mitzel Mata

Fred Monteverde
Cecil Ong

Erosion on radial side

because of small joint capsule
on radial side producing
tension & fluid

X Can affect other portions:

ü Hip joints – symmetrically narrowed
ü Atlanto-axial joint – sublax

Rheumatoid variants
X Ankylosing spondylitis
- Maybe RF (-)
- Usually male in predominance
- About 25-30 younger age group
- Start centrally à that’s why central type of RA
- Usually affects spine and sacroiliac joint
- Bamboo spine deformity
- Calcification of anterior and posterior spinal ligaments

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