Tulang

Pendahuluan
Pemeriksaan Rongen” Tulang memberi informasi :
1. Lesil tulang & jaringan Lunak sekitarnya
2. Adanya fraktur/ancaman fraktur patologis

3. Asal/Sifat suatu lesi(jinak/ganas)

4. Sebagai guide untuk biopsi
5. Follow Up perjalanan penyakit
 Anatomi Tulang Panjang

• Struktur tulang
keras (Kalsifikasi)
& elastitas (serabut
organik)
• Bentuk Tubuler
• Panjang > Lebar
 Gambar 2 . A.
Skema tulang
system haversian

.
Struktur tulang kompak
Mikroskopis
arsitektur
tulang
Arteri nutrisi tulang

Suplai darah kaya

(10-20% CO)
1. a. Nutrisi diafisis
2. a. metafisis dan
epifisis
3. a. Periosteal
•Neonatus : P. d penetrasi plate
epifisis

•Anak : bbrp P. D
menembus plate epifise  mll
periosteum, .P. D metafisis berakhir
di sinusoid dg aliran lambat

•Dewasa : Plate epifise telah

menyatu  P.D metafisis&Epifise
menyatu
KELAINAN TULANG DAN SENDI
1. Anomali perkembangan / kongenital

2. Infeksi

3. Trauma & Fraktur

4. Penyakit defisiensi tulang

5. Penyakit displasia tulang

6. Tumor tulang

7. Osteochondritis/Aseptik nekrosis

8. Penyakit2 degeneratif sendi

 Positioning
• Routine
– PA / AP
– Lateral
• Additional
– Oblique (RAO/LAO)
– Tangential
 Specific
• Skull :
– Waters and Caldwel : Paranasalis Sinus
– Schuller and Stenver : Mastoid
– Eisler : Mandible
– Rheese : Opticum Foramen
– Towne : Canalis Acusticus Interna
– Basis Cranii : Fossa Cranii

• Patella : Sunrise (Mountain View)

Tulang
panjang
Seri foto tangan yang normal
Anatomi sendi siku
normal
Foto lateral Elbow
 Skull Radiogram
• Shape and size
• Outline
• Density
• Lines
• Calsification
• Sella tursica
• Specific positioning
 Columna Vertebrae
• Alignment
• Besar, bentuk dan struktur trabekula
• Curvature
• Densitas , discus dan foramen
intervertebralis,
• Pedicle
 Joint
1. Bone
– Size
– Shape
– Trabecular structure
– Integrity and alignment
2. Joint Space
3. Dataran sendi
4. Soft tissue
 Mengenali FRAKTUR
• Fracture
• Dislocation
• Subluxation
 Fracture
• A disruption in all or
part of the cortex of a
bone
• All = complete
• Part = incomplete =
children
 Dislocation
• The bony
components of a joint
no longer are in
contact with each
other
• There is complete
disruption of the joint
 SUBLUXATION
• he bony components
of a joint are partially
in contact with each
other
• There is partial
disruption of the joint
 Incomplete fracture

Green Stick #  # mengenai 1

Torus – buckling of the cortex
cortex
 How Fractures Are Described
• By the direction of the fracture line
• By the relationship of the fragments
• By the number of fragments
• By communication with the atmosphere
• By the direction of the
fracture line
– Transverse
– Diagonal or oblique
– Longitudinal
– Spiral
• By the direction of the
fracture line
– Transverse
• By the direction of the
fracture line
– Diagonal or oblique
• By the direction of the
fracture line
– Longitudinal – along
the long axis of the
bone
• By the direction of the
fracture line
– Spiral – a twisting
fracture caused by a
torque injury such as
planting the foot in a
hole while running
• By the relationship of one fracture
fragment to another
– Displacement
– Angulation
– Shortening
– Rotation
• Most fractures display more than one
of these abnormalities of position
 Displacement
• The amount of off-set
of the distal fracture
fragment relative to
the proximal
• There is lateral
displacement of the
distal femoral fracture
fragment in this case

Lateral Medial
ANGULATION
 SHORTENING
• Overlapping of the
ends of the fracture
fragments
• Shortening is usually
described by the
number of
centimeters of overlap
 ROTATION
• Almost always
involves long bones
(humerus and femur)
• Knee joint is in AP
position (points
forward) but ankle
points lateral, in this
case
By the number of
fracture
fragments:
1

●Two fragments 1
2
: Simple 3

● More than two

fragments : 2
4
Comminuted

Simple Comminuted
• By the relationship of
the fracture to the
atmosphere
– Closed
– Open or compound
– Best evaluated
clinically

Open or compound fracture of the tibia

communicates with outside air
 Salter-Harris Classification
• Type I – Epiphyseal plate alone
• Type II – Epiphyseal plate and metaphysis
• Type III – Epiphyseal plate and epiphysis
• Type IV – Epiphyseal plate, metaphysis and
epiphysis
• Type V – crush fracture of epiphyseal plate
 Common Fracture Eponyms
• Colle’s fracture
• Smith’s fracture
• Jones’ fracture
• Boxer’s fracture
 A. B.

CD,SV
Fraktur Galleazzi Fraktur Monteggia
GRUM
Jones’ fracture – fx base 5th metatarsal
• Boxer’s fracture – fx
head 5th metacarpal
with palmar
angulation
• Most often the result
of punching a person
or wall
 Easily Missed Fractures
• Scaphoid fractures
• Buckle fractures of
radius/ulna
• Radial head fracture
• Supracondylar
fractures in children
• Posterior dislocation
of the shoulder
• Hip fractures
• Scaphoid fractures –
common
• Pain in anatomical
snuff box
• Fall on outstretched
hand
• Can lead to avascular
necrosis
• Radial head fracture
• Common
• May require multiple
views to see it
 • Supracondylar
fractures in children

Supracondylar fractures can be difficult – especially in children (this is an adult)

• Buckle fractures of
radius/ulna
• Children
• Look for angulation of
cortex
• Heal quickly
• Posterior dislocation
of the shoulder
• Humeral head looks
like “lightbulb”
• Usually need another
view like axillary or Y
view
• Hip fractures
• May be very subtle
and require bone
scan or MRI for
diagnosis
• In this case, white
zone of sclerosis is an
impacted subcapital
fracture
Anatomi dari panggul dan sendi panggul

Foto AP dari panggul normal

Foto AP dari panggul yang memperlihatkan beberapa garis
anatomis yang penting pada panggul
 Set into place

Set into place

Posterior dislocation of right hip
 Normal Knee Anatomy

AP View Lateral View

Oblique view AP view
Sunrise view
Anatomi pergelangan kaki/Ankle

Foto Lateral dari

Ankle normal
Foto AP dari Ankle Normal Foto posisi Mortise dari Ankle
Normal
Look at the radiographs below. The labels show the fracture component, but also note
the dislocation. The medial border of the second metatarsal is not aligned with the
medial border of the second cuneiform. The dislocation is the main radiographic feature
of a Lisfranc injury.
 Metatarsal Fracture
•It is important to remember that a fracture may only be visible on one view.
Therefore, a careful look at each metatarsal in each view is necessary.
 Fracture Healing
• Indistinctness of
fracture line
• Bony callous production
• Bridging of fracture
– Obliteration of fracture
line
• Remodeling of bone
Normal joint
 1º Degenerative Arthritis
• X-ray Findings
– Narrowing of joint space
– Subchondral sclerosis
– Marginal osteophyte formation
– Subchondral cysts
 1. Osteoartritis of knees affects medial, weight-
bearing surface

2. Osteoartritis
of hips affects superior,
weight-bearing surface
 2º Degenerative Arthritis
Causes

• Trauma
• Infection
• Avascular necrosis
• CPPD
• RA
• Hemophilia
Septic artritis
 • Bilaretal, symmetrical
• Radiocarpal jct commonly
narrowed,
Rheumatoid artritis • Periarticullar demineralizasion
• Erotion Metacarpal,carpal
 Bilateral, simetris
Psoriasis artritis of hands
Bengkak jaringan lunak
Erosi tulang, t u : distal phalang
 Osteomielitis Kronis

• Pada seluruh Tibia

dan distal fibula
kanan

• Tampak sequester
( Tanda Panah )
Ankylosing
Spondilits
 HLA-B27 positive
 B/L SI arthritis
 Squaring of
vertebral bodies
 Bamboo-spine
from continuous
syndesmophytes
 Peripheral large
joint erosive
arthritis
Bone tumor
Dapat benigna/maligna serta bisa primer/
Sekunder (metastase) :
Untuk membedakan maligna atau tidak :
1. Umur penderita
2. Lamanya gejala2 nyeri & pembengkakan serta
kecepatan pembesaran
3. Besar kecilnya tumor
4. Jumlah lesi (mono/polistatik)
5. Lokalisasi dalam tulang
6. Densitas : osteolitik, osteosklerotik &
campuran
7. Struktur tumor : tepinya, destruksi: sentral/
tepi, bentuk reaksi periosteal, kontinuitas cortex
8. Bentuk tulang keseluruhan : bengkok, ada
fraktur
1. 0 - 5 thn : neuroblastoma
2. 5 - 20 thn : ewing tumor
3. 10 - 25 thn : osteosarcoma
4. 20 - 40 thn : giant cell tumor
5. 20 - 70 thn : lipoma
6. 30 - 45 thn : fibrosarkoma
7. 30 - 50 thn : periosteal sarcoma
8. 30 - 60 thn : chondrosarcoma
9. 30 - 70 thn : hemangioma
10. 40 - 80 thn : metastase, Multipel Mieloma
3 Hal penting lesi pada tulang
* infeksi/neoplasma
* benigna/maligna
*primer/sekunder
Klasifikasi tumor tulang :
A. Dari jaringan Skeletal
1. Jaringan tulang:
a. Jinak: bone island, osteoma, osteoid
osteoma, osteoblastoma
b. Ganas ; Osteosarkoma, periosteal sarcoma
2. Kartilago :
a. Jinak :Khondroma,Khondroblastoma,
Khondromixoid Fibroma
b. Ganas ( Khondrosarcoma )
3. Jaringan Fibrosa :
a. Jinak : Fibrosa, Brown Tumor
b. Ganas : Fibrosarkoma
4. Giant Cell ( Giant Cell Tumor )
a. Jinak: GCT,ABC {Aneurysma Bone Cyste}
b. Ganas : Giant Cell Tumor Maligna
Klasifikasi Tumor Tulang :
B. Dari Jaringan Lain Dalam Tulang :
1. Pembuluh Darah : Hemangioma,Glomus
Tumor,Hemagio Sarcoma
2. Saraf : Neurofibroma,Neuroblastoma,
Neurofibrosarcoma
3. Lemak : Lipoma,Liposarcoma
4. Natokord : Chordoma
5. Epitel : Dermoid, Adamantinoma
6. Limfoid/Hemopoetik ; Limfoma, Leukimia,
Plasmositoma,Multipel Mieloma
Clues Bone tumor by
Appearance
of Lesion
 Patterns of Destruction

Geographic Moth-eaten Permeative

Less malignant More malignant

 Periosteal Reactions

l
Benign
n
None
n
Solid
l
More aggressive or malignant
n
Lamellated or onion-skinning
n
Sunburst
n
Codman’s triangle
Periosteal Reactions
l
Benign
n
None
n
Solid
l
Aggressive/malignant
n
Onion-skinning
n
Sunburst
n
Codman’s triangle

Non-ossifying fibroma
Periosteal Reactions
l
Benign
n
None
n
Solid
l
Aggressive/malignant
n
Onion-skinning
n
Sunburst
n
Codman’s triangle

Chronic osteomyelitis
Periosteal Reactions
l
Benign
n
None
n
Solid
l
Aggressive/malignant
n
Onion-skinning
n
Sunburst
n
Codman’s triangle

Ewing’s sarcoma
Periosteal Reactions
l
Benign
n
None
n
Solid
l
Aggressive/malignant
n
Onion-skinning
n
Sunburst
n
Codman’s triangle

Osteosarcoma
Periosteal Reactions
l
Benign
n
None
n
Solid
l
Aggressive/malignant
n
Onion-skinning
n
Sunburst
n
Codman’s triangle

Ewing’s-Codman’s
triangle
 Periosteal Reactions

Solid Lamellated Sunburst Codman’s

Less malignant More malignant

Expansile lesions

l
Multiple myeloma
l
Mets
l
Aneurysmal bone cyst
l
Fibrous dysplasia
l
Brown tumor
l
Enchondroma
l
Lymphoma
•
Multiple Myeloma
Expansile lesions

l
Multiple myeloma
l
Mets
l
Aneurysmal bone cyst
l
Fibrous dysplasia
l
Brown tumor
l
Enchondroma
l
Lymphoma
•
Renal Cell Carcinoma
Expansile lesions

l
Multiple myeloma
l
Mets
l
Aneurysmal bone cyst
l
Fibrous dysplasia
l
Brown tumor
l
Enchondroma
l
Lymphoma
•
Aneurysmal Bone Cyst
Expansile lesions

l
Multiple myeloma
l
Mets
l
Aneurysmal bone cyst
l
Fibrous dysplasia
l
Brown tumor
l
Enchondroma
l
Lymphoma
•
Fibrous Dysplasia
Expansile lesions

l
Multiple myeloma
l
Mets
l
Aneurysmal bone cyst
l
Fibrous dysplasia
l
Brown tumor
l
Enchondroma
l
Lymphoma
•
Brown Tumor
Expansile lesions

l
Multiple myeloma
l
Mets
l
Aneurysmal bone cyst
l
Fibrous dysplasia
l
Brown tumor
l
Enchondroma
l
Lymphoma
•
Enchondroma
Expansile lesions

l
Multiple myeloma
l
Mets
l
Aneurysmal bone cyst
l
Fibrous dysplasia
l
Brown tumor
l
Enchondroma
l
Lymphoma
• Lymphoma
Clues Bone tumor by
Location
of Lesion
 In the Transverse Plane
l
Central
n
Enchondroma
l
Eccentric
n
GCT, osteosarcoma, chondromyxoid fibroma
l
Cortical
n
Non-ossifying fibroma, osteoid osteoma
l
Parosteal
n
Parosteal osteosarcoma, osteochondroma
 Osteosarcoma

Parosteal sarcoma
Osteochondroma

In The Transverse Plane

 In the Longitudinal Plane

l
Epiphyseal
n
GCT, chondroblastoma
l
Metaphyseal
n
Osteomyelitis, osteo- and chondrosarcoma
l
Diaphyseal
n
Round cell lesions, ABC, enchondroma
 Tumor Types
Characteristic Locations

l
Simple bone cyst
n
Proximal humerus
l
Chondroblastoma
n
Epiphyses
l
Giant Cell tumor
n
Epiphyses
Characteristic locations

l
Simple bone cyst
n
Proximal humerus
l
Chondroblastoma
n
Epiphyses
l
Giant Cell tumor
n
Epiphyses
Characteristic locations

l
Simple bone cyst
n
Proximal humerus
l
Chondroblastoma
n
Epiphyses
l
Giant Cell tumor
n
Epiphyses

Chondroblastoma
Characteristic locations

l
Simple bone cyst
n
Proximal humerus
l
Chondroblastoma
n
Epiphyses
l
Giant Cell tumor
n
Epiphyses

Giant Cell Tumor

 Tumor Types
Characteristic Locations

l
Adamantinoma
n
Tibia
l
Chordoma
n
Sacrum, clivus
l
Osteoblastoma
n
Spine, posterior
Characteristic locations

l
Adamantinoma
n
Tibia
l
Chordoma
n
Sacrum, clivus
l
Osteoblastoma
n
Spine, posterior

Adamantinoma
Characteristic locations

l
Adamantinoma
n
Tibia
l
Chordoma
n
Sacrum, clivus
l
Osteoblastoma
n
Spine, posterior

Chordoma
Characteristic locations

l
Adamantinoma
n
Tibia
l
Chordoma
n
Sacrum, clivus
l
Osteoblastoma
n
Spine, posterior

Osteoblastoma
 Tumor Types
Characteristic Locations

l
Parosteal sarcoma
n
Distal femur
l
Periosteal sarcoma
n
Tibia
Characteristic locations

l
Parosteal sarcoma
n
Distal femur
l
Periosteal sarcoma
n
Tibia

Parosteal sarcoma
Characteristic locations

l
Parosteal sarcoma
n
Distal femur
l
Periosteal sarcoma
n
Tibia
Lytic Lesions in Adults

l
Metastatic lesions
n
Lung
n
Renal
n
Thyroid
l
Multiple myeloma
l
Primary bone tumor
Lytic Lesions in Adults

l
Mets
l
Myeloma
l
Primary bone
tumor

Met from Thyroid Carcinoma

Lytic Lesions in Adults

l
Mets
l
Myeloma
l
Primary bone
tumor

Multiple myeloma
Lytic Lesions in Adults

l
Mets
l
Myeloma
l
Primary bone
tumor

Chondrosarcoma
Blastic Lesions in Children

l
Medulloblastoma
l
Lymphoma
Blastic Lesions in Children

l
Medulloblastoma
l
Lymphoma

Medulloblastoma
Blastic Lesions in Children

l
Medulloblastoma
l
Lymphoma

Lymphoma
Blastic Lesions in Adults

l
Metastatic disease
n
Breast – female
n
Prostate – male
l
Lymphoma
l
Paget’s disease
l
Etcetera-mastocytosis, fluorosis
Blastic Lesions in Adults

l
Mets
l
Lymphoma
l
Paget’s

Prostate Mets
Blastic Lesions in Adults

l
Mets
l
Lymphoma
l
Paget’s

Breast Mets
Blastic Lesions in Adults

l
Mets
l
Lymphoma
l
Paget’s

Lymphoma
Blastic Lesions in Adults

l
Mets
l
Lymphoma
l
Paget’s

Paget’s of Spine
Other Clues
 Benign Lesions
Without Sclerotic Boarders

l
Giant Cell tumor
l
Brown tumor
l
Osteolytic phase of Paget’s Disease
l
Benign Lesions without Sclerotic
Borders

l
Giant cell tumor
l
Brown tumor
l
Osteolytic Paget’s

Giant Cell Tumor

Benign Lesions without Sclerotic
Borders

l
Giant cell tumor
l
Brown tumor
l
Osteolytic Paget’s

Osteolytic Paget’s
 Soft Tissue Extension

l
Usually implies malignancy
n
More likely to form discrete soft tissue mass
l
Benign conditions with soft tissue
extension
n
Osteomyelitis
s
Usually infiltration of fat
Osteosarcoma
 Multiple Lesions

l
More often benign
l
Malignancies with multiple lesions
n
Metastatic disease
n
Multiple myeloma
n
Lymphoma
n
Ewing’s sarcoma (rarely)
n
Osteosarcoma (rarely)
Multiple lesions

l
Metastatic
l
Multiple myeloma
l
Lymphoma
l

Mets from Ca of Prostate

Multiple lesions

l
Metastatic
l
Multiple myeloma
l
Lymphoma
l

Multiple Myeloma
Multiple lesions

l
Metastatic
l
Multiple myeloma
l
Lymphoma
l

Lymphoma
Multiple lesions

l
Metastatic
l
Multiple myeloma
l
Lymphoma
l
Osteosarcomatosis
l

Osteosarcomatosis
Example 1
Example 1

AGE adult
Location metaphysis
Margins 1B
Periosteal Reaction none
Matrix none
Other fx
DX ABC
Aneurysmal Bone Cyst
Etiologi tidak diketahui
Kadang2 terjadi sesudah fraktur
Terjadi pd anak2 dengan predileksi pada
tulang panjang
Pada vertebra  umur 10-20 thn, terutama
pada arcus neuralis, jarang pada corpus,
kebanyakan beberapa vertebra kena.
Ro :
• Area reabsorbsi tulang yang khas dengan ekspansi
tulang
• Ukuran lesi bervariasi 2-20 cm
• Cortex menipis & ekspansi
• Tepi endosteal berbatas tegas dengan cortex
• “Soap Bubble Appearance”
• Terdapat zona transisi antara lesi dengan medulla,
kadang2 dengan sedikit sklerosis. Sering mirip
dengan osteoclastoma. Kadang2 tepi scalloped atau
irreguler, tepi sklerotik
• Angiografi  mirip Osteoclastoma
DD : Osteoclastoma /Giant Cell Tumor
Aneurysmal bone cyst
2.Giant Cell Tumor (Osteoclastoma)
Usia 20 – 40 thn
Amat jarang terjadi sebelum maturitas tulang
Kadang2 multifokal pada tangan.
Lesi soliter, predileksi di lutut, ujung distal radius, kadang-kadang pada
sacrum, pelvis & vertebra.
Ro :
 Zone radiolusen, khas terletak tepat pada cortex dibawah sendi
 Letak eksentris pada ujung tulang panjang
 Tidak ada kalsifikasi / occifikasi kecuali setelah terjadi fraktur
patologis
 Gambaran khas : trabekulasi,berbentuk “Soap Bubble App”→40%
kasus
Tepi Osteolitik
Batas lesi tidak tegas, reaksi tulang
negatif
Cortex menipis dan ekspansi
Lesi dapat ekspansi ke jaringan lunak,
tanpa kalsifikasi
Angiografi  hypervascular, dengan
banyak pembuluh darah & shunting
arteriovenosa
DD : Aneurysmal Bone cyst,
chondroblastoma,Fibrous Dysplasia
Example 3.

AGE 12
Location diaphysis
Margins 3
Periosteal Reaction lamellated
Matrix none
Other
DX Ewing
Example 3,

“onion-skin”
3. Ewing Tumor
Asal dari medula
Umur 5 – 20 thn
Predileksi : tulang2 panjang
Ro :
– Reaksi periosteal berlapis-lapis (Onion Skin
Appearance)
– Segitiga Codman
– Sklerotik kadang2 & sebagai garis longitudinal
– Destruksi tulang
– Soft tissue swelling
 4.

AGE 20
Location metaphysis
Margins 3
Periosteal Reaction irregular
Matrix bone
Other
DX osteosarcoma
Tumor ganas
Osteosarcoma
menurut letak (sentral,perifer)
menurut lesi (osteolitik,osteosklerotik, campuran)
Pria > wanita
Umur predileksi 10-25 th
Ro :
• Predileksi : distal femur, jarang tibia, sternum, costa,
kepala
• Letak lesi : metafise / diafise
• 50% sklerotik, dapat osteolitik, campuran (tepi tidak
teratur)
• Reaksi periosteal  gambaran “sunburst”/”Sun
Ray”
• Khas lain : destruksi cortex & invasi ke jaringan
lunak
• Soft tissue swelling
• Codman Triangle
4.

AGE 56
Location metaphyseal
Margins 1A
Periosteal Reaction none
Matrix chondroid
Other
DX enchondroma
Osteochondroma
-Pertumbuhan keluar dari tulang
berasal dari cortex
diafise tulang panjang
-menjauhi sendi

Ro :
- Tipe pedunculated (khas tonjolan
tulang dari
cortex dengan gambaran dari
trabekula lesi masuk dalam medulla
melalui defek dari cortex )
- Kalsifikasi dalam lesi
- Ukuran ± 8-10 cm  arah menjauhi
sendi
- Pada pelvis dan scapula  gambaran
irreguler dengan densitas tinggi 
memberi gambaran Bunga Kol
Example 5

AGE 66
Location diaphyseal
Margins 1A
Periosteal Reaction minimal, thick
Matrix none
Other 2nd lesion
DX wait…..
Example 5

AGE 66
Location diaphyseal
Margins 2
Periosteal Reaction none
Matrix none
Other
DX wait…..
 AGE 66
Example 5 Location flat bone
Margins 1B
Periosteal Reaction none
Matrix none
Other multiple
DX myeloma
MM (Multiple Mieloma)

Tumor primer ganas sumsum tulang

Ro :
 Osteoporosis  cortex menipis
 Osteolitik
 Punch out lesion  multiple, bulat,
tegas, intak,
ukuran bervariasi
 Tepi dlm kortex  scalloping
 Kadang2 lesi ekspansif & memberi
gbr “soap bubble” DD : metastasis
Benign vs. Malignant
 Summary
• Radiographs are essential
• Aggressiveness of process dictates the
response of the bone
• Most helpful information in analysis
– Age
– Location
– Margins
The End