Imaging techniques of bone consist of

• Plain bone radiograph

The plain radiograph remains a very important investigation in many
types of bone disease. It is helpful to understand the anatomical terms
used to describe a normal long bone The radiological responses of
bone to pathological process are limited; thus, similar x-ray signs occur
in widely different conditions. It should be noted that it takes time
for the various signs to develop. For example, in adults, it takes several
weeks for a periosteal reaction to be visible after trauma and, in a
child with osteomyelitis, the clinical features are present from 7 to 10
days before the first sign is visible on the radiograph. In general, the
signs take longer to develop in adults than they do in children
 Radiographic signs of bone disease

• Decrease in bone density

• Increase in bone density
• Periosteal reaction
• Cortical thickening
• Alteration in trabecular pattern
• Alteration in the shape of a bone
• Alteration in bone age
 Decrease in bone density
A decrease in bone density may be focal or
generalized. Focal reduction in density is usually
referred to as a ‘lytic area’ or an area of ‘bone
destruction’. Generalized decrease in bone
density is best referred to as ‘osteopenia’ until a
specific diagnosis such as osteomalacia or
osteoporosis can be made.
 Increase in bone density
An increase in bone density (sclerosis) may also be focal or
generalized.

Periosteal reaction
The periosteum is not normally visible on a radiograph. The term
‘periosteal reaction’ refers to excess bone produced by the periosteum,
which occurs in response to such conditions as neoplasm, inflammation
or trauma. Several patterns of periosteal reaction are seen, but they do
not correlate with specific diagnoses. At the edge of a very active
periosteal reaction there may be a cuff of new bone known as a
Codman’s triangle Although often seen in highly malignant primary
bone tumours, e.g. osteosarcoma, a Codman’s triangle is also found in
other aggressive conditions.
 Cortical thickening
Cortical thickening also involves the laying down of new
bone by the periosteum but here the process is
very slow. The result is that the new bone, although it may
be thick and irregular, shows the same homogeneous
density as does the normal cortex. There are no separate
lines or spicules of calcification as seen in a periosteal reaction. The causes include
chronic osteomyelitis, healed
trauma, response to chronic stress or benign neoplasm. The
feature common to all these conditions is that the process
is either very slowly progressive or has healed.

Alteration in trabecular pattern

Alteration in trabecular pattern is a complex response usually involving a reduction in
the number of trabeculae with an alteration in the remaining trabeculae, e.g. in
osteoporosis and Paget’s disease. In osteoporosis, the cortex is thin and the trabeculae
that remain are more prominent than usual, whereas in Paget’s disease the trabeculae
are thickened and trabeculation is seen in the normal compact bone of the cortex .
 Alteration in shape of bone
Alteration in the shape of a bone is another complex
response with many causes. Many cases are congenital in
origin; some are acquired, e.g. acromegaly and expanding
bone tumours.
Alteration in bone age
Alteration in bone age. The time of appearance of the
various epiphyseal centres and their time of fusion depends
on the age of the child. For the measurement of ‘bone age’,
a film of one hand and wrist is taken and compared with
a set of standard films, which provides an indication of
skeletal maturity.
 Ultrasound in musculoskeletal disease
Ultrasound cannot evaluate bone pathology but does have a
complementary imaging role in the following:
• in detecting tenosynovitis, tendon tears and rupture.
• in the diagnosis of osteomyelitis

Radionuclide bone imaging

Technetium-99m (99mTc) labelled phosphate complexes given
as an intravenous injection are the agents used for bone
scintigraphy. They are taken up selectively by the bones and
are also excreted in the urine. These agents may be
concentrated by certain soft tissue tumours, by soft tissue
calcifications and by sites of tissue damage.
 CT scan
• Plain radiographs are usually very informative, however CT is needed
in selected cases, particularly in the detection of subtle fractures or in
complex fractures
Indications

• Demonstration of abnormalities in the spine, pelvis and hips where

plain films are frequently difficult to interpret
• Three-dimensional reconstructions can be made of fractures, which
are particularly useful in showing the fractures and position of the
fragments and for planning corrective surgery
• Demonstration of the extent and characterization of bone tumours in
selected cases to complement MRI
• As a guide for bone biopsy
 Magnetic resonance imaging in bone
disease
Magnetic resonance imaging (MRI) has come to play a
vitally important role in musculoskeletal
disorders .Calcified tissues such as bone produce no
signal with MRI, but MRI can demonstrate the bone
marrow, making it possible to see the extent of
disease such as metastases, other tumours and
infections, even in areas where bone destruction is not
yet evident on plain films or CT. MRI is also particularly
good for showing soft tissue
abnormalities.
Major indications for musculoskeletal MRI
• Demonstration of disc herniation and spinal cord or nerve
root compression
• Diagnosis of bone metastases
• To show the extent of primary bone tumours
• Demonstration of myeloma and lymphoma
• To image soft tissue masses
• Diagnosis of osteomyelitis and to show any soft tissue
abscess
• Diagnosis of avascular necrosis and other joint pathologies
• To image both acute and chronic injury to joint cartilages,
ligaments and other intra-articular soft tissues
 Generalized decrease in bone density
(osteopenia)
The radiographic density of bone is dependent on the
amount of calcium present in the bones. Calcium content
may be reduced due to a disorder of calcium metabolism,
as in osteomalacia or hyperparathyroidism, or to a reduction in protein matrix, as in
osteoporosis. The radiological diagnosis of decreased bone density is often difficult, especially
as the appearances of the bones are markedly affected by radiographic exposure factors
The main causes of generalized decrease in bone density
The main causes of generalized decrease in bone density
are:
• osteoporosis
• osteomalacia
• hyperparathyroidism
• multiple myeloma, which may cause generalized loss of
bone density, with or without focal bone destruction.Each of these conditions may have other
radiological features that enable the diagnosis to be made, but when they are lacking, as they
frequently are in osteoporosis and osteomalacia, it becomes very difficult to distinguish
between them radiologically.
 Osteoporosis
Osteoporosis is the consequence of a deficiency of protein matrex (osteoid).
The remaining bone is normally mineralized and appears normal
histologically, but because the matrix is reduced in quantity there is
necessarily a reduction in calcium content. Osteoporosis predisposes to
fractures, particularly of the vertebral bodies and hips. Postmenopausal and
senile osteoporosis are the commonest forms: up to 50% of women over 60
years of age have osteoporosis.

Causes of osteoporosis

Idiopathic:
– juvenile
– postmenopausal
– senile
• Cushing’s syndrome
• Steroid therapy
• Disuse
 Screening for osteoporosis
Because osteoporosis is such a prevalent
problem and, once established, is difficult to
treat, attempts have been made to develop
screening tests for the at-risk population in
order to institute preventative treatment. Bone
mass is usually measured by dual-energy x-ray
absorption, often abbreviated to DEXA.
 Rickets and osteomalacia
In these conditions there is poor mineralization of osteoid. If this
occurs before epiphyseal closure, the condition is known as rickets;
in adults the condition is known as osteomalacia.
Causes of rickets and osteomalacia
• Decreased production of endogenous vitamin D:
– dietary deficiency
– lack of exposure to sunlight
• Impaired absorption of calcium or vitamin D:
– malabsorption
• Renal disease, causing vitamin D-resistant rickets, despite
normal amounts of vitamin D in diet:
– tubular defects: hypophosphataemia, Fanconi’s syndrome
and renal tubular acidosis
– chronic renal failure: impaired ability to activate vitamin D
 Hyperparathyroidism
Excess parathyroid hormone secretion mobilizes
calcium from the bones, resulting in a decrease
in bone density. Hyperparathyroidism may be
primary, from hyperplasia or a tumour of the
parathyroid glands, or secondary, due to chronic
renal failure .Many patients with primary
hyperparathyroidism present with renal stones
and only a small minority have
radiological bone changes
 Generalized increase in bone density
Several conditions can cause a generalized increase in bone
density, including:
• Sclerotic metastases are by far the commonest cause,
particularly from prostatic or breast carcinoma. These may affect
the skeleton diffusely • Osteopetrosis (marble bone disease). In
this congenital disorder of bone formation the bones are densely
sclerotic. The bones are brittle and may fracture readily, but if
fractured they heal easily.
• Myelosclerosis is a form of myelofibrosis in which, in addition
to the replacement of bone marrow by fibrous tissue, the
process extends to lay down extratrabecular bone, usually in a
rather patchy fashion The spleen is invariably enlarged because it
becomes the site of haemopoiesis. It may reach a very large size
and forms an important sign on abdominal radiographs
 Alteration of trabecular pattern and change in
shape
Pagets disease
The incidence of Paget’s disease varies greatly from country to
country, being common in the UK but rare in the USA and Asia.
It is usually a chance finding in an elderly patient. One or more
bones may be affected, the usual sites being the pelvis, spine,
skull and long bones. Bone softening causes bowing and
deformity of the bones and pathological fractures may occur.

Hemolytic anaemia
There are several types of haemolytic anaemia, but
radiological changes are seen in two main types: thalassaemia
and sickle cell disease. Both show changes of marrow
hyperplasia, but sickle cell anaemia may also show evidence of
bone infarction and infection.
 Changes in bone shape
Bone dysplasias
Bone dysplasias are congenital disorders
resulting in abnormalities in the size and shape
of the bones. There are a large number of
different dysplasias; many of them are
hereditary and all of them are rare.