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dr.

Zulfan O Siregar, SpOT


What is musculoskeletal Imaging?

 Musculoskeletal imaging is the subspecialty of


radiology concerned with the diagnostic evaluation of
the musculoskeletal system
Why do Clinicians
need to view diagnostic images?
 A more comprehensive evaluation is obtained. The
success of rehabilitation depends on the
effectiveness of the clinician’s evaluation
 The information the clinician seeks is often of a
different nature than the information the physician
seeks and of a different nature than may be
described in the radiologist’s report.
Rule of Two
 2 view (The Perception of a Third Dimension )
 2 joints distal dan proximal
 2 sides (pediatric) utk lihat lempeng epifisis
 2 times (before and after treatment, perjalanan
penyakit infeksi dan tumor)
Pre-Reading Musculoskeletal
Radiograph
 1: Identity of the foto (Name, Age of patients,
Registration Number, Date )
 2: Foto Marker (L or R)
 3: What type of view
The ABCs of Radiologic Analysis
 ALIGNMENT
 BONE DENSITY
 CARTILAGE
 SOFT TISSUE
Alignment
 A : Alignment
1. General Skeletal Architecture
2. General Contour of Bone
3. Alignment of Bones Relative to Adjacent Bones
Bone Density
 B: Bone Density
1. General Bone Density
2. Textural Abnormalities
3. Local Density Changes
Cartilage Spaces
 C: Cartilage Spaces
1. Joint Space Width
2. Subchondral Bone
3. Epiphyseal Plates
Soft Tissues
 S: Soft Tissues
1. Muscles
2. Fat Pads and Fat Lines
3. Joint Capsules
4. Periosteum
5. Miscellaneous Soft Tissue Findings
Radiological Examination in Trauma
 INGAT  anggaplah ada fraktur servikal pada setiap
pasien multi trauma, terlebih bila ada gangguan
kesadaran, atau perlukaan diatas klavikula.
Radiological Examination in Trauma
TRAUMA SERIES
Cervical Lateral
Thorax AP
Pelvis AP
Cervical Lateral
The important observations are:
 Line 1: The anterior borders of the vertebral bodies
 Line 2: The posterior borders of the vertebral bodies
 Line 3: The spinolaminar line is the junction of the
 The retropharyngeal space is the distance from the
posterior pharyngeal wall to the anteroinferior aspect of C2
(Normal 6 mm or less)
 The retrotracheal space is the distance from the
posterior wall of the trachea to the anteroinferior aspect of
C6 (Normal measures 22 mm in adults and
 14 mm in children)
 Aligment :
 Anteior body line is in one line
 Posterior body line is in one line.
 Spinolaminal line is in one line
 Proc. Spinosus line is in one line.
 Bone :
 Tidak tampak garis fraktur.
 Connective tissue:
 C2 : 0,41 cm
 C6 : 1,02 cm
 Discuss :
 Tidak ada widening dan narrowing.
 Enviroment :
 Tampak loss of lordotic
Thoraks AP
Apakah ada fraktur pada gambar
ini?
 Closed fracture lateral right clavicle.
 Closed fracture right posterior ribs 3, 4, 5, and 6
Pelvis AP
6 radiographic lines:
 1. Iliopectineal (ant. column)
 2. Ilioischial (post. column)
 3. Radiographic “teardrop”
 4. Acetabular roof (“dome”)
 5. Ant. acetabulum rim/wall
 6. Post. acetabulum rim/wall
 7. Sacro Iiac joint
 8. Pubic Sympisis
 9. Shenton line
Mnemonic: OLD ACID
 O: Open vs. closed
 L: Location
 D: Degree (complete vs. incomplete)

 A: Articular extension
 C: Comminution / Pattern
 I: Intrinsic bone quality
 D: Displacement, angulation, rotation
O: Open vs. Closed
 Open fracture
 AKA: “Compound fracture”
 A fracture in which bone
penetrates through skin;
 “Open to air”
 Some define this as a fracture
with any open wound or soft
tissue laceration near the bony
fracture
 Closed fracture
 Fracture with intact overlying
skin
L: Location
Epiphysis  Which bone?
Physis  Thirds (long bones)
 Proximal, middle, distal third
Metaphysis
 Anatomic orientation
 E.g. proximal, distal, medial,
Diaphysis lateral, anterior, posterior
(Shaft)  Anatomic landmarks
 E.g. head, neck, body / shaft,
base, condyle
 Segment (long bones)
 Epiphysis, physis, metaphysis,
diaphysis

Articular
Surface
D: Degree of Fracture
 Complete
 Complete cortical
circumference involved
 Fragments are completely
separated
 Incomplete
 Not fractured all the way
through
 “Only one cortex” involved
 e.g “Greenstick fracture”
A: Articular Extension / Involvement
 Intra-articular
fractures
 “Involves the
articular surface”
 Dislocation
 Loss of joint surface /
articular congruity
 Fracture-dislocation
C: Comminution / Pattern
 Transverse (Simple)
 Oblique (Simple)
 Spiral (Simple)
 Linear / longitudinal
 Segmental
 Comminuted
 Compression / impacted
 “Buckle / Torus”
 Distraction / avulsion
C: Comminution / Pattern
 Transverse (Simple)
C: Comminution / Pattern
 Oblique (Simple)
 Spiral (Simple)
 Oblique in 2+ views
C: Comminution / Pattern
 Linear / longitudinal / split
C: Comminution / Pattern
 Segmental
 Bone broken in 2+ separate places; Fx
lines do not connect
C: Comminution / Pattern
 Comminuted
 Broken, splintered, or crushed into >3 pieces
C: Comminution / Pattern
 Compression
 Impacted
 (e.g. “Buckle / Torus”)
C: Comminution / Pattern
 “Buckle / Torus”
C: Comminution / Pattern
 Distracted
 Avulsion
I: Intrinsic Bone Quality
Normal Osteopenia
I: Intrinsic Bone Quality
Normal Osteopetrosis
– Incr’d density
D: Displacement, Angulation, Rotation
Displacement
– Extent to which Fx
fragments are not axially
aligned
– Fragments shifted in
various directions relative
to each other
– Convention: describe
displacement of distal
fragment relative to
proximal
Oblique tibial shaft Fx b/w
distal & middle thirds; laterally
displaced
D: Displacement, Angulation, Rotation
Angulation
– Extent to which Fx
fragments are not
anatomically aligned
– Convention: describe
angulation as the direction
the apex is pointing
relative to anatomical long
axis of the bone (e.g. apex
medial, apex valgus)
Tibial shaft fracture prox &
middle thirds, angulated to
lateral
D: Displacement, Angulation, Rotation
Angulation

Valgus No angulation Varus


D: Displacement, Angulation, Rotation

Rotation
– Extent to which Fxracture
fragments are rotated relative to
each other
– Convention: describe which
direction the distal fragment is
rotated relative to the proximal
portion of the bone
D: Displacement, Angulation, Rotation
Rotation

Normal PA view of hip PA view of rotated hip Fx


- Greater trochanter in profile Greater trochanter perpendicular to film
Salter-Harris Fractures
Other signs of fractures

Periosteal reaction
Callus /Osteosclerosis
Other signs of fractures
 Fat pad sign / “Sail sign”