PRESENTASI RADIOLOGI

Dita Ayu Pertiwi

FAA 114 016
 CONTENT
• Osteoarthritis (OA)
• Rheumathoid Arthritis (RA)
• Gout Arthritis (GA)
• Spondilitis TB
• Metastasis Pada Tulang
• Tumor Tulang  Jinak dan Ganas
Osteoarthritis
Osteoarthritis OA is a degenerative disease of diarthrodial
(synovial) joints, characterized by :
• Breakdown of articular cartilage
• and proliferative changes of surrounding bones

• Osteoarthritis(OA) is the most common joint disease (Esp. Weight

Bearring Joint)
• Radiological evidence of OA can be found in over 90 % of the population
• Knee OA is very common and is the most common joint disease in the
elderly. In the community, it is estimated to affect ~12.5% of patients >45
years. The medial femorotibial joint compartment is more commonly
affected and often more severe compared to the lateral.
 Limited Function
• OA may cause functional loss Primary OA
• Activites of daily living • Age
• Most important cause of disability in old age • Sex
• Major indication for joint replacement surgery • Obesity
• Genetics
• Trauma (daily)
Secondrary OA
Risk Factor • Trauma
• OA Primer  Etiologi Unknown • Previous joint disorders;
• Congenital hip dislocation
• OA Sekunder  Etiologi Known • Infection: Septic arthritis
• Inflammatory: RA
• Metabolic: Gout
• Hematologic: Hemophilia
• Endocrine: DM
 Patofisiologi

Gangguan metabolisme kartilago Rusaknya membran proteoglikan

krn etio beragam Replikasi kondrosit n produksi matrix baru
Sintesis NEW DNA dan kolagen Imbalance sintesis n degradasi
(lebih tinggi degradasi)Penumpukan produk hasil
degradasiINFLAMASIpeningkatan aktivitas fibrinogen dan
pnurunan aktivitas fibrinolisisakumulasi thrombus dan lipid
Iskemik n nekrosisBone destruction
<30 menit
Kriteria Diagnosis American College of Rheumatology (ACR)
 RADIOLOGIC FINDINGS OF OA
The hallmarks of knee osteoarthritis are the same for most other joints :
• Joint space narrowing
• usually asymmetric, typically of the medial tibiofemoral compartment, and/or
patellofemoral compartment
• <3 mm on weight-bearing knee radiographs is considered a finding of absolute joint
space narrowing with a normal joint space >5 mm
• weight-bearing radiographs will demonstrate more joint space narrowing than non-
weight-bearing radiographs, hence affecting the radiographic severity
• Subchondral Sclerosis
• Marginal Osteophytes
• Subchondral Cysts (Geodes)
• Altered Shape Of The Femoral Condyles And Tibial Plateau
 Grading
The Kellgren and Lawrence system
Ahlbäck system: • grade 0: no radiographic features of OA are
• grade 1: joint space narrowing present
(less than 3 mm) • grade 1: doubtful joint space narrowing
• grade 2: joint space obliteration (JSN) and possible osteophytic lipping
• grade 2: definite osteophytes and possible
• grade 3: minor bone attrition (0-
5 mm) JSN on anteroposterior weight-bearing
radiograph
• grade 4: moderate bone attrition • grade 3: multiple osteophytes, definite
(5-10 mm) JSN, sclerosis, possible bony deformity
• grade 5: severe bone attrition • grade 4: large osteophytes, marked JSN,
(more than 10 mm) severe sclerosis and definite bony
deformity
 OA OF HIP JOINT
• More common in males over 40 years of age
• Joint stiffness
• Pain of hip, gluteal and groin areas radiating
to the knee (N obturatorius)
• Mechanical pain
• Limited walking function
Physical examination:
• Antalgic limping
• Limitation of ROM (first internal
rotation)
• Painful ROM
• Trendelenburg test positivity
• Leg length discrepancy
Laboratory analysis within normal limits
 OA of the Hip Grading
Conventional radiograph grading
grade 0: normal
grade 1: possible joint space narrowing and subtle osteophytes
grade 2: definite joint space narrowing, defined osteophytes and some sclerosis, especially in the
acetabular region
grade 3: marked joint space narrowing, small osteophytes, some sclerosis and cyst formation and
deformity of femoral head and acetabulum
grade 4: gross loss of joint space with above features plus large osteophytes and increased
deformity of the femoral head and acetabulum
X-RAY OF HIP OA
The hallmark of osteoarthritis in the spine, as is the case elsewhere, is the presence of osteophytes.
Traction osteophytes project obliquely or horizontally from the endplates, which is helpful in
distinguishing them from syndesmophytes of ankylosing spondylitis.
Treatment
Non-operative management involves simple analgesia and weight
loss. However, patients will often eventually require joint
replacement. Total joint replacement is effective. Unicompartmental
joint replacement may be considered in some institutions for cases
where the disease is predominantly isolated to a single joint
compartment.
If the 2nd Etiology find and treat the etiology 1st
DAFTAR PUSTAKA
• https://radiopaedia.org/articles/osteoarthritis-of-the-knee
• Kapita Selekta Jilid II
• Buku Ajar Ilmu Penyakit Dalam Jilid II
• https://radiopaedia.org/articles/ahlback-classification-of-
osteoarthritis-of-the-knee-joint
• https://radiopaedia.org/articles/osteoarthritis-of-the-vertebral-
column
• https://radiopaedia.org/articles/osteoarthritis-of-the-hip-grading-1
Rheumathoid Arthritis
 DEFINISI
Penyakit inflamasi kronis sistemik yang ditandai dengan pembengkkan
dan nyeri pada persendian serta destruksi membrane synovial
persendian.
Faktor risiko Etiologi
• PR > Laki- laki 2-3: 1
• UNKNOWN.
• Usia : 20-45 tahun
• Riwayat keluarga • Diduga karena predisposisi genetik (HLA-DR4 dan HLA-DR1
• Merokok sehingga terjdi reaksi imunonologis di membrane
sinovium)Aktivasi mekanisme inflamasi
• Infeksi
• Autoimun
Patofisiologi
Migrasi sel inflamasi yang dipicu o/ aktivasi sel endotel vaskular
peningkatan ekspressi molekul adhesiproliferasi sel leukosit di
kompartemen synovial joint  Aktivasi sel2 imunitas Pelepasan
mediator inflamasi di kompartemen joint
has a maximal score of 10 and requires a score of >6 for a diagnosis of RA to be made if <6 Suspect
 Kriteria Diagnostik American Rheumatism Association (ARA)

Ditemukan setidaknya 1 sampai 4 dialami minimal 6 minggu.

1. Kaku pada pagi hari di persendian atau sekitarnya sekurang2nya
1 jam
2. Timbul arthritis pada 3 daerah persendian atau lebih secara
bersamaan
3. Terdapat arthritis pada minima 1 persendian tangan
4. Artritis yang simetris
5. Terdapat nodul rheumatoid (nodul subkutan pada penonjolan
tulang/ permukaan ekstensor
6. RF Positif
 GEJALA KLINIS
Gejala Konstitusional Gejala Artikular Gejala Ekstraartikular
• Manifestasi reversibel
• Penurunan BB • Sistem KV : Perikarditis,
1. Kekakuan sendi pada pagi hari >2jam kardiomiopati
• Malaise 2. Terdapat tanda sinovitis
• Demam • Manifestasi Irreversibel • Kulit : Nodul
1. Vertebrae servikalis : kekakuan seluruh segmen leher Rheumathoid
• Kakeksia
2. Gelang bahu : frozen shoulder syndrome
3. Siku : sinovitis artikulasio cubiti
4. Tangan : swan neck deformities, Boutonniere.
5. Panggul : Keterbatasan ROM
6. Lutut : Baker cyst
 Radiographic Finding
The radiographic hallmarks of rheumatoid arthritis are:
• soft tissue swelling
• fusiform and periarticular; it represents a combination of joint effusion
(Subchondral Cyst Form), oedema and tenosynovitis
• this can be an early/only radiographic finding
• osteoporosis: initially juxta-articular, and later
generalised; compounded by corticosteroid therapy and disuse
• joint space narrowing: symmetrical or concentric
• marginal erosions: due to erosion by pannus of the bony “bare areas”
Radiologi
 Gambaran klinis dan radiologis

Gambar 1.a Peradangan dan pembengkakan jaringan ikat sendi jari-jari tangan
Gambar 1.b Pembengkakan jaringan lunak dan fusi dari sendi interfalang proksimal. Pada
jari ke 2 dan ke 3, dikutip dari ACR Clinical Slide Collection on the Rheumatic disease.5

36
C. Swelling dan erosi pada sendi MTP 5.
D. Nodul subkutaneus multipel pada tangan
DAFTAR PUSTAKA
• https://www.rheumatology.org/Portals/0/Files/2010_revised_criteria
_classification_ra.pdf
• Kapita Selekta Jilid II
Gout Arthritis
• Gout is a crystal arthropathy due to deposition of monosodium urate crystals in and
around the joints.
• Disebut arthritis gout bila serangan inflamasi terjadi pada articular dan periartikular
seperti bursa dan tendon.
• Hiperurisemia (L >7,0 g/dl P >6,0 g/dl)

ETIOLOGI
undersecretion by kidneys:
• chronic kidney disease
• hypertension
• hyperparathyroidism
• alcoholism
• drugs (e.g. furosemide, thiazide diuretics, ethambutol, pyrazinamide, aspirin)
• lead poisoning (saturnine gout)
• obesity
overproduction:
• myeloproliferative disorders
• haemolysis
• extreme exercise
• Lesch-Nyhan syndrome
 Kriteria Diagnosis American Rheumathology
• Ditemukan Kristal monosodium urat pada cairan sendi
• Terdapat Topus berisi Kristal monosodium urat
• Ditemukan 6 dari 12 fenomena klinis ,laboratorium,maupun
radiologi
 PATOFISIOLOGI
Aktivasi sel
fagosit
Peningkatan monosodium Aktivasi sel
Kristal endotel
urat/hiperurisemia
Interaksi
membrane lipid

• Vasodilatasi dan peningkatan

aliran darah
Serangan GOUT
• PH • Peningkatan permeabilitas
• SUHU pembuluh darah
• Peningkatan UA pada Protein
Plasma
 Stadium
Here are five recognised stages of gout:
• asymptomatic hyperuricaemia
• acute gouty arthritis
• intercritical gout (between acute attacks)
• chronic tophaceous gout
• gouty nephropathy
Radiology Finding
Most radiographic findings include the skeletal system.
Joints
• joint effusion (earliest sign)
• preservation of joint space until late stages of the disease
• an absence of periarticular osteopenia
• eccentric erosions
• the typical appearance is the presence of well-defined “punched-out”
erosions with sclerotic margins in a marginal and juxta-articular
distribution, with overhanging edges (see case 12), also known as rat
bite erosions
Bone
• punched-out lytic bone lesions
• overhanging sclerotic margins
• osteonecrosis
• mineralisation is normal
Surrounding soft tissues
• tophi: pathognomonic
• olecranon and prepatellar bursitis
• periarticular soft tissue swelling due to crystal deposition in tophi around the
joints is common (the soft tissue swelling may be hyperdense due to the
crystals, and the tophi can calcify)
 juxta-articular erosive changes around the
first metatarsophalangeal (MTP) joint with overhanging edges and
associated with a moderate soft tissue swelling. However, the joint
space is maintained.
Px Tn. S di A
Gambaran Swelling + Bone
erosion (Lusen)  Gout
Complication
Daftar Pustaka
• https://radiopaedia.org/articles/gout
• https://radiopaedia.org/search?utf8=%E2%9C%93&q=Gout+Arthtritis
&scope=all
TUMOR TULANG
 Normal Anatomy
• Parts of a long bones: diaphysis (shaft), physis (growth plate), epiphysis (ends
of bone, partially covered by articular cartilage), metaphysis (junction of
diaphysis and epiphysis, most common site of primary bone tumors)
• Cross section: periosteum, cortex (composed of cortical bone or compact
bone), medullary space (composed of cancellous or spongy bone)
 TUMOR
TERDIRI DARI :
i. BENIGNA
ii. MALIGNA : # PRIMER.

# SEKUNDER---METASTASE
 The most reliable indicator in determining whether
ABC = Aneurysmal bone cyst these lesions are benign or malignant is the zone of
CMF = Chondromyxoid fibroma transition between the lesion and the adjacent normal
EG = Eosinophilic Granuloma bone.
GCT = Giant cell tumour
FD = Fibrous dysplasia
HPT = Hyperparathyroidism with Brown tumor
NOF = Non Ossifying Fibroma
SBC = Simple Bone Cyst
PERBEDAAN RADIOLOGIS JINAK DAN GANAS

NO TUMOR JINAK GANAS

1. BATAS TEGAS TDK TEGAS

2. TUMBUH LAMBAT CEPAT

3. TEPI SKLEROTIK IRREGULER

4. SIFAT EKSPONSIF INFILTRATIF

5. Rx perios (-) (+)

teal

6. Metastase (-) (+)

TUMOR GANAS PRIMER SEKUNDER

1.FOKUS SOLITER MULTIPLE

2.USIA MUDA TUA

3.Rx periost (+) (-)

4.Soft tissue
Swelling (+) (-)
 three bone lesions with a narrow zone of transition.
Based on the morphology and the age of the patients, Infections and eosinophilic granuloma are exceptional
these lesions are benign. because they are benign lesions which may seem malignant
due to their aggressive biologic behavior.
 OSTEOSARKOM Sarkoma Ewing Infeksi
Aggressive Periosteal Reaction

irregular cortical
destruction in an
osteosarcoma (left)
and cortical
destruction with
aggressive
periosteal reaction
Beningn Periosteal Reaction in Ewing's sarcoma
thick, wavy and uniform callus formation resulting from
OSTEOSARKOM Sarkoma Ewing
chronic irritation.
 Balooning

Chondromyxoid fibroma Giant cell tumor

destruction of endosteal cortical bone and the addition of

new bone on the outside occur at the same rate, resulting
in expansion
BENIGN BONE TUMOR
Osteoma
Osteoid Osteoma
Tampak lesi lusen sirkuler kecil (nidus) di
bawah kortek desertai lesi sklerotik tebal
disekelilingnya (reaksi peritoneal)
Osteoblastoma
Osteokondroma
Aneurisma Bone Cyst
MALIGNANT BONE TUMOR
OSTEOSARKOMA
CHONDROSARKOMA
OSTEOCLASTOMA (GIANT CELL TUMOR)
SARKOMA EWING
METASTASE PADA TULANG
METASTASE PADA TULANG
SERING : PELVIS, COLLUM VERTEBRALIS,COSTA, FEMUR PROXIMAL,
HUMERUS PROXIMAL, TENGKORAK.

RADIOLOGIS : - OSTEOBLASTIK
- OSTEOLITIK
- CAMPURAN

TUMOR YANG SERING METASTASE :

- CA MAMMAE
- CA PROSTAT
- CA PARU
- CA GINJAL
PENILAIAN TUMOR TULANG YANG PERLU DIPERHATIKAN :

 UMUR
 LESI
 BAGIAN TULANG YANG KENA
 KELAINAN (destruksi, rx periosteal, tulang baru, jaringan
sekitarnya).
BATAS LESI (tegas, tidak tegas)
TUMOR JINAK
1.OSTEOMA
• PENOJOLAN TULANG YANG
NORMAL
• BATAS TEGAS
• PADAT,
OSTEOSKLEROTIK,HOMOGEN
• BULAT OVAL
• DIAMETER <2.5 cm.
• PERDILEKSI: KALVARIUM,
MANDIBULA, MAKSILA, TLG
FRONTAL
2. OSTEOCHONDROMA
MENGENAI TULANG PANJANG
BANYAK DIJUMPAI
BIASANYA BERTANGKAI
SOLITER, KADANG MULTIPEL.
LOKASI SEKITAR LUTUT-------
METAFISIS
KHAS : PENONJOLAN TULANG
DGN UJUNG TAK TERATUR, DAN
MENJAUHI SENDI.
UMUR 2- 60 TH, SERING PADA
10-20 TH.
3. ANEURYSMAL BONE CYST
@UMUR 5 – 20 TH
@PEREMPUAN LEBIH BANYAK
@RADIOLOGI :
*SOFT TISSUE MASS
*OSTEOLITIK IRREGULER
*KORTEX MENIPIS DAN
MENGGEMBUNG KELUAR
* BATAS LESI TAK TEGAS DAN SERING
DISERTAi SKLEROTIK
@LOKASI : TULANG PANJANG PADA
METAFISIS
4. OSTEOKLASTOMA
UMUR 20-40 TH (GIANT
CELL TUMOR)

PREDILEKSI : TULANG PANJANG

PADA UJUNG TULANG
(SUBARTIKULER)-----SENDI LUTUT
RADIOLOGIS :
-LESI EKSENTRIS
-KORTEX TIPIS
-OSTEOLITIK +
-SOFT TISSUE MASS +
-RX PERIOST +
DD/: ANEURYSMA BONE CYST
 TUMOR GANAS
1.OSTEOSARCOMA
UMUR 10-25 THN
PREDILEKSI : FEMUR DISTAL, TIBIA
PROKSIMAL, HUMERUS PROXIMAL,
PELVIS.
LOKASI: METAFISIS.
RADIOLOGIS :
• SUN RAY APP---RX PERIOSTEAL.
• SOFT TISSUE SWELLING.
• DESTRUKSI TULANG ---OSTEOLITIK,
OSTEOBLASTIK, CAMPURAN.
 SEGITIGA CODMAN
2. SARCOMA EWING

=ENDOTEHELIAL
MYLOMA
=HEMANGIOMA
ENDOTHELIOMA
USIA MUDA
PREDILEKSI : TULANG
PANJANG, IGA, PELVIS.
LOKASI : DIAFISIS.
SIFAT RADIOSENSITIF
SPONDILITIS TB
KOLUMNA VERTEBRALIS
NORMAL :
• CERVIKAL ----------- LORDOSIS
• TORAKAL ----------- KIFOSIS.
• LUMBAL ----------- LORDOSIS.
• SAKRAL -------- --- KIFOSIS.
• COCCYGEUS-------- KIFOSIS
 1.SPONDILITIS
SPESIFIK DAN NON SPESIFIK(BANAL)

TBC PIOGENIK
1. RESPON < OSTEOBLASTIK > OSTEOBLASTIK.
TULANG

2. DESTRUKSI + + PADA + PADA ARCUS.

CORPUS
3. GIBBUS (+) (-)
4. DISKUS SEMPIT N/ SEMPIT
5.ABSES PARA ++ -
VERTEBRAE
6.PERJALANAN LAMBAT CEPAT
PENYAKIT
2. FRAKTUR KOMPRESI
JARANG LEBIH DARI SATU
VERTEBRAE
DISCUS INTAK
KORPUS WEDGING---
PEMIPIHAN
ABSES PARAVERTEBRAE (-).
SEMUA BAGIAN KOLUMNA
VERTEBRALIS DAPAT
TERKENA
3. SPONDILOLISTHESIS
PERGESERAN CORPUS
VERTEBRAE KE POSTERIOR
DIBANDING CORPUS
DIATASNYA.
HANYA DAPAT DITEGAKKAN
SECARA RADIOLOGIK
JELAS PADA FOTO LATERAL