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SKELETAL RADIOLOGY

dr. H.Undang Ruhimat,SpRad





Principles of Radiologic Interpretation
Technical Consideration
Skeletal Anatomy and Physiology
The Categorical approach to bone disease
Radiologic predictor variables
Medicolegal implication


Technical consideration
Plain Film Radiography
Tomography
Contrast Examination
Radionuclide Imaging
Computed Tomography
Magnetic Resonance Imaging
Skeletal Anatomy and Physiology
Skeletal Development
Intramembranous Ossification
Enchondral Ossification
Bone Structure
Epiphyse Physis ZPC Metaphysis
Diaphysis
Cortex Medulla Periosteum
Endosteum
Bone Metabolism
Bone mineral - Hormones

Anatomy
Anatomy
Anatomy
The Categorical approach to
bone disease

Congenital
Arthritis
Trauma
Blood
I nfection
Tumor
Endocrine,Nutritional,Metabolic
Soft Tissue


Radiologic Predictor Variables
Preliminary Analysis
Clinical data
Number of lesions
Symetri of lesions
Determination of Systems Involved

Radiologic Predictor Variables
Analysis of The Lesions
Skeletal Location
Position Within Bone
Site of Origin
Shape
Size
Margination
Cortical Integrity
Radiologic Predictor Variables
Behavior of Lesions
Osteolytic Lesions
Osteoblastic Lesions
Mixed Lesions
Matrix
Periosteal Response
Solid Respons
Laminated Respons
Spiculated Respons
Codmans Triangle
Radiologic Predictor Variables
Soft Tissue Changes
Supplementary Analysis
Other imaging Procedures
Laboratory Examination
Biopsy
TRAUMA
Fracture and Dislocation
The radiographs should be made
Include at least one joint
Preferably two joints
Two position AP LAT


TRAUMA
Time intervals between Radiographic Study
Initial Diagnostic study
Post reduction and post immobilization
One or Two weeks later, if position has
changed
After approximately six eight weeks for
Primary callus
After each plaster cast or traction change
Before final discharge of patient


TRAUMA
Types of Fracture
Closed fracture
Does not break the skin or communicate
with the outside environment
Simple fracture
Open fractur
Penetrates the skin over fracture site
Compound fracture

TRAUMA
Comminuted fracture
Two or more bony fragments have separated
Non Comminuted fracture
Penetrates completely through the bone
Avulsion fracture
Tearing away of a portion of the bone
Impaction fracture
Bone is driven into its adjacent segmen


TRAUMA
Incomplete Fracture
Broken only one side of the bone
Greenstick (Hickory Stick) fracture
Torus (Buckling) fracture

Fracture Orientation
Oblique fractur
Commonly occurs in the shaft of long
tubular bone
45 to the long axis of the bone
Fractur
Fracture
TRAUMA
Spiral fractur
Torsion, coupled with axial compression
and angulation
Transverse fractur
Run at a right angle to the lonh axis
Uncommon through healthy bone
Pathologic fractur
Fracture
TRAUMA
Spatial Relationships of Fracture
Aligment
Position of the distal fragment in relation
to the proximal fragment
Apposition
Closeness of the bony contact at the
fracture site
If the ends are pulled referred to as
Distraction
Fracture
TRAUMA
Rotation
Twisting forces on a fractured bone along
its longitudinal axis
Traumatic Articular Lesions
Subluxation
Dislocation
Diastasis
Epiphyseal Fractures
Salter-Harris Classification

Salter - Harris
Dislocation
TRAUMA
Fracture Healing
Main steps in fracture healing
Formation of hematoma
Organization of hematoma
Formation of fibrous callus
Replacement of fibrous callus by
primary bany callus
Absorption primary bany callus
Transformation to secondary bony callus
Remodeling

TRAUMA
Complication of Fractures
Immediate complication
Arterial injury
Compartement syndrome
Gas gangrene
Fat embolism syndrome
Thromboembolism
TRAUMA
Intermediate complication
Osteomyelitis
Myositis ossificans
Synostosis
Delayed union

Delayed complication
Osteonecrosis
Osteoporosis
Non union Mal union
Myositis Ossificans
INFECTION
Suppurative Osteomyelitis

General Consideration
Systemic or Local infections
Immunosuppresed patients, alcoholics,
newborns, and drug addicts are predisposed
Antibiotics have significatly reduced the
sepsis-related mortality
INFECTION
Etiology
Staphylococcus aureus causes 90%
Pathway for the spread
Hematogenous
Contigunous
Direct Implantation
Postoperative
INFECTION
Radiologic Features
Bone scan are the earliest means of
diagnosis
Radiographic latent period for plain film
10 days for extremities
21 days for spine
Soft tissue alteration : elevated fat planes,
obliterated fat planes, increased density.
INFECTION
Bone changes :
Moth-eaten bone destruction
Usually metaphyseal in origin
Periosteal new bone formation
Solid Laminated Codmans Triangle
Sequestrum
Involucrum
Joint space destruction (ankylosis)

0steomyelitis
Osteomyelitis
INFECTION
Septic Arthritis
General consideration
Single joint involvment in the rule
Most common rute is hematogenous
or direct traumatic implantation
Etiology
Most frequently is Staphylococcus Aureus
INFECTION
Radiologic Features
The knee and hip are the most common
sites
Joint effusion leads to distrorsion of the
fat folds
Positive Waldenstorms sign
Rapid loss of joint space
Bony ankylosis
INFECTION
Nonsuppurative osteomyelitis
(tuberculosis)
General Consideration
Found in patients such as prepubertal
children, debilitated geriatric, silicosis,
AIDS sufferers, Lymphoma patients,
Alcoholics, corticosteroid and drug abusers
INFECTION
Etiology
Mycobacterium tuberculosis
Two mode of spread
Inhalation
Ingestion
INFECTION
Radiologic Features
Spinal tuberculosis is most common at L-I
Early sign for spine are :
Lytic endplate destruction
loss of disc height
Anterior gouge defect
Paraspinal swelling

INFECTION
Advanced sign for spinal involvement are:
Vertebral body collaps
Gibbus formation and obliteration of the
disc
Tubercular arthritis is common in the hip and
knee
Uniform joint space narowing, early destruction
of the subchondral cortex, moth-eaten bone
destruction and juxtaarticular osteoporosis are
the cardinal sign of tubercular arthritis
Tuberculosis
Tuberculosis
TUMORS AND TUMORLIKE
PROCESSES
METASTATIC BONE TUMORS
PRIMARY MALIGNANT BONE TUMORS
Multiple myeloma
Osteosarcoma
Ewings Sarcoma
PRIMARY QUASIMALIGNANT BONE
TUMOR
Giant Cell Tumor

TUMORS
PRIMARY BENIGN BONE TUMORS
Osteochondroma
Osteoma
Bone island
Osteoid osteoma
Simple bone cyst
Aneurysmal bone cyst
TUMORS
Metastatic Bone Tumors
General Consideration
The most common malignant tumors
CNS tumors and basal cell Ca rarely
Life threatening complication
Insidence
70% are metastatic, 30% are primary
In females 70% from breast Ca
In males 60% from prostate Ca
TUMORS
Radiologic Features
Technetium bone scan
80% of all metastase are located in the
central or axial skeleton
- Spine and Pelvis being a most common
Alteration in bone density and architecture
75% osteolytic, moth eaten or permeative
15% osteoblastic
Periosteal respose is rare
Metastatic
TUMORS
Primary Malignant Bone Tumors
Multiple Myeloma
Bone scan are cold
Gross Osteoporosis may be the only early
sign
Punched out lesions
Vertebra plana or wrinkled vertebra
Preservation of pedicles
Multiple Myeloma
Multiple Myeloma
TUMORS
Osteosarcoma
75% of cases occurs in the 10 to 25 age
Metaphyses of the distal femur, proximal
humerus are the most common sites
Permeative or ivory medulary lesion in
metaphysis of a long tubular bone
A sunburst or sunray periosteal response
Cortical disruption with soft tissue mass
formation
Sclerotic Lytic Mixed lesion
Osteosarcoma
Osteosarcoma
TUMORS
Ewings Sarcoma
Most cases occur in the 10 25 age range
May mimic infection
Diaphyseal permeative lesion
Femur, tibia and fibula
Onion skin periosteal response
Most common primary malignant bone
tumor to metastasize to bone
Ewings Sarcoma
TUMORS
Primary quasimalignant bone tumor
Giant cell Tumor
Osteoclastoma
20-40 years is the usual age range
Distal femur, proximal tibia
distal radius, proximal humerus
Metaphysis and extend to subarticular
Radiolucent, excentric
Soap Buble appearance

Giant Cell Tumor
TUMOR
Primary Benign Bone Tumors
Osteochondroma
Painless and hard mass near a joint
Humerus, tibia, femur, ribs
Two types : - sessile
- pedunculated
Coat hanger exostose cauliflower mass
The cortex and spongiosa blend
imperceptibly
Osteochondroma
TUMOR
Osteoma
A rise in membranous bones
Sinuses frontal, ethmoid
Mandible
Skull bones
Homogenously opaque
Osteoma

TUMOR
Bone Island
Epiphyseal, metaphyseal
Medulary
Round oval : Long axis oriented
Smooth or radiating border
Opaque
Normal adjecent cortex
May change size
TUMOR
Osteoid osteoma
Consists a nidus, thst usually 1 cm or less
Target calsification
Most common location is in the cortex
Radiolucent nidus surrounded by perifocal
reactive sclerosis
Osteoid Osteoma
TUMOR
Simple Bone Cyst
Expansile radiolucent
Proximal humerus, femur, calcaneus
No periosteal reaction
Pathologic fracture
Aneurysmal Bone Cyst
Some lesion may reach 8 10 cm
Cortical ballooning blown out app
Aneurysmal Bone Cyst
Aneurysmal Bone Cyst
ARTHRITIC DISORDERS
Degenerative Disorders
Degenerative Joint Disease
etc
Inflamatory Disorders
Rheumatoid Arthritis
etc
Metabolic Disorders
Gout
etc
ARTHRITIC
Degenerative Joint Disease
Osteoarthritis Osteoarthrosis
Asimetric distribution
Non uniform loss of the joint space
Osteophytes
Subchondral sclerosis
Subchondral cyst
Loose bodies
Subluxation

Osteoarthrosis
ARTHRITIC
Rheumatoid Arthritis
Generalized Connective tissue disorder
Higest insidence among the 40 50 year
Symetric peripheral joint pain and swelling
Early : - Soft tissue swelling
Marginal erosions
Osteoporosis - Periostitis
Loss of joint space
Late : - Ankylosis
Deformities
Rheumatoid Arthritis
Rheumatoid Arthritis
ARTHRITIC
Gout
Disorder of purin metabolism
Deposite of Sodium monourate crystals
into cartilage, synovium, periarticular
and subcutaneous tissues
Dense soft tissue Tophi, preservation
of joint space, Bone erosions (marginal
periarticular) overhanging margin sign
Metatarsophalangeal joint

Gout
Osteoporosis
Diagnosis Radiologi

Primer
Type I : Post menopouse osteoclast mediated
radius dan vertebra
Type II: Senile osteoporosis osteoblast mediated
proksimal femur
Compotition mineral

Normal > 833 mg / cm
2
Osteopeni 833 648 mg / cm
2
Osteoporosis < 648 mg / cm
2
Established osteoporosis
Diagnosa Radiologi
Peningkatan radiolusensi
Penurunan kandungan mineral <30-50%
Penipisan korteks
Gambaran trabekula menonjol
Perubahan bentuk
Radiografi Konvensional
Vertebra
Penurunan densitas
Perubahan trabekula
trabekula vertikal
Wash out
Penipisan korteks
Perubahan bentuk
Femur
Penurunan densitas kolum femoris
trochanter mayor
Perubahan trabekula

1.Principal Compressive group 2.Secondary Compressive Group
Wards triangle
3. Tensile Group
CT Scanogram
Penipisan korteks

Pelebaran diameter intrameduler
CT Scanogram
Densitometri
Penurunan kandungan mineral
umur 30-35 th
Penurunan 3-5% / dekade
Menopause > 2% / tahun

Dexa
Dua panjang gelombang Energi
Antero-posterior

BMC: Bone mineral content (gram)
BMD: Bone mineral density (gram/cm2)
T. Score
Normal : > -1
Osteopeni: -1 2,5
Osteoporosis: < -2.5
QUS
Dua buah transduser 0,1 1 MHz
Transmitter & Receiver

BUA (Boardband Ultrasound
Attenuation)Bone Mass
SOS (Speed of Sound) Internal Arsitektur
dari trabekulaelastisitas


Kesimpulan.
USG Skrining massal
DEXA Gold standard
Konvensional radiografi