IMAGISTICA

SISTEM MUSCULOSCHELETAL

CURS 9
 MSK Imaging – Imaging
Modalities
 Plain Radiographs
 Nuclear Scintigraphy
 Ultrasound
 Computed Tomography
 Magnetic Resonance Imaging
 Plain Radiographs
 Widely available
 Reproducible
 Patient friendly
 ‘Inexpensive’
 Usually the indicated primary imaging
modality
 Common indications
A bone x-ray is used to:
 diagnose fractured bones or joint dislocation.
 demonstrate proper alignment and stabilization of bony fragments
following treatment of a fracture. guide orthopedic surgery, such as spine
repair/fusion, joint replacement and fracture reductions.
 look for injury, infection, arthritis, abnormal bone growths and bony
changes seen in metabolic conditions.
 assist in the detection and diagnosis of bone cancer. locate foreign objects
in soft tissues around or in bones.

Rule of Two
 Two views - AP and Lateral
 Two joints – joint above and below
 Two occasions – repeat x- rays
 Two limbs – Compare
 ABCs APPROACH
A
◦ Assess adequacy of x-ray which includes proper number of views
and penetration
◦ Assess alignment of x-rays
B
◦ Examine bones throughout their entire length for for lesions
and/or distortions
C
◦ Examine cartilages (joint spaces) for widening
S
◦ Assess soft tissues for swelling/effusions
 TRAUMATIC BONE PATHOLOGY
THE LANGUAGE OF FRACTURES
 Things you must describe (clinical and x-ray):
 Open vs Closed fracture

 Anatomic location of fracture

 Fracture line

 Relationship of fracture fragments

 Neurovascular status

FRACTURE LINES
 FRACTURE LINES

Transverse fracture Oblique fracture Spiral fracture

Comminution fracture

Greenstick fracture
are incomplete fractures of long bones and
are usually seen in young children, more
commonly less than 10 years of age. They
are commonly mid-diaphyseal, affecting
the forearm and lower leg.
Fracture at the junction
of the middle and distal
third of tibia and fibula
with bayonet apposition
There is also anterior
and later displacement of
distal fragment with
respect to the proximal
fragment.
Fracture at the middle
third of tibia and fibula
with apex anterior
angulation
There is anterior
displacement of the distal
facture fragment of tibia
with respect to the
proximal fragment.
The aposition of fracture
fragments of fibula is
normal.
 Healing of fracture

Healing of fracture begins with the immediate hemorrhage in and around it. This
is followed by ingrowth of granulation tissue, the formation of an osseous and
sometimes cartilaginous matrix, decalcification and resorption of the devitalized
bone in the opposing ends of the fragments, progressive calcification of the
osseous and cartilaginous matrix (callus formation) and finally, shaping of the
shaft at the junction of the fragments.

Factors that have influence on

the healing of fracture include
age, fracture type, nutrition,
treatment, etc.
Callus usually cannot be
detected earlier than the 3rd
week after fracture in older
children or adults but becomes
visible during the 2nd week in
the new born.
Formation of calli around the fracture
at distal third of radius
Bony union of the fracture at
proximal humerus
Disappearance of fracture line,
anatomical apposition, normal
alignment, slight irregularity of
humerus at the fracture site.
 Bone infection pathology
Acute Pyogenic osteomyelitis
Etiology
 Infecting organism: Staphylococcus aureus

 RouteS of contamination

 Hematogenous seeding

 Direct contamination

penetrating trauma, post surgical

 Contiguous spread

soft tissue infection, septic arthritis

Location
 Metaphysis
Age:
 Children most commonly affected
Clinical presentation
 Pain, fever
 Restricted motion + point tenderness
 Soft tissue swelling + erythema + sinus tract
 Prognosis good if treated early
 Osseous destruction will reoccur if untreated
 Develop into chronic infection

Radiographic findings
 Soft tissue swelling
 Bone changes delayed 10-14 days after onset of fever
 Focal lucency to frank destruction of bone
 Periosteal new bone formation
 Sequestrum
 Osteosclerosis
 1 2

Soft tissue swelling without Focal bone destruction

visibe bone destruction with
increase in diameter
 5
3

Bone destruction Osteosclerosis, without soft tissue

and osteosclerosis swelling
Acute osteomyelitis
Bone destruction
sequestrum periosteal new bone
formation
 Chronic pyogenic osteomyelitis
Clinical presentation
 Mild fever
 Focal pain
 Sinus tract discharging pus due to the
existence of pus cavity or sequestrum

Radiographic findings
 Bone destruction with surrounding sclerosis

 Periosteal new bone formation

 Thickening of cortex and deformation of bone

 Sequestrum

 Soft tissue atrophy ， formation of sinus tract

Chronic osteomyelitis of tibia
Chronic osteomyelits of
Radiographs show sclerosis, widening fibula with sequestrum
and deformation of tibia with
narrowing of medullary cavity.
 Tuberculosis of bone
Etiology
 Mycobacterium tuberculosis
 Hematogenous dissemination of pulmonary TB
Location
 Long bone
 Short bone
 Spine
Clinical presentation
 Depend on the stage and location of the disease
 Acute symptoms rare
 Swelling, pain, weakness, draining sinus

Tuberculosis of Spine
 Involvement of vertebral body more common than posterior
appendages
 Bone destruction
 Collapse and deformity of vertebral body
 Scoliosis, kyphosis
 Narrowing or disappearance of intervetebral space
 Paravertebral abscess, calcification
Destruction , collapse
and fusion of T8,9
vertebral body ,
disappearance of T8/9
intervertebral space
and formation of
paravertebral abscess.
Soft tissue
abnormality
Destruction of vertebral body with paravertebral abscess and calcifications
 Tuberculosis of spine with paravertebral abscess

T1 after SDC inject

T1 before inject
contrast

T2 before inject SDC

 Comparison of pyogenic osteomyelitis and tuberculosis of long bone

Pyogenic osteomyelitis Tuberculosis

Progression Acute and rapid Slow

Extensive, may involve Focal, may invade joint,

Extent
whole diaphysis seldom extend to diaphysis

Involvement of epiphysis Uncommon Common

Destruction and osteoprosis,

Osseous changes Destruction and sclerosis
sclerosis uncommon

Periosteal reaction Common, various pattern Uncommon

Sequestrum Common, large Uncommon, small

 Normal X-ray appearance of
joints

Joint
capsule Bone
end
Joint space
Articular
cartilage

 The articular cartilages, synovium, synovial fluid and joint capsule are
undifferentiated from other soft tissues in a radiogram because of similar densities.
 The thickness of the cartilages may be indicated by the width of the joint space.
  Joint space of children is wider than that of adults
because of incompletely ossified epiphyseal cartilage.

Elbow joint of adult Elbow joint of adolescent Elbow joint of child

 Basic X-ray features of joint diseases
1. Swelling of joint
 Etiology: effusion of joint or congestion, edema, hemorrhage or inflammation of joint
capsule and the adjacent soft tissue.
 Radiological appearance: increased density, widening of joint space and displacement
of fat pad.
Osteoporosis and swelling of knee joint
Dislocation of joint
 Dislocation is a complete
loss of contact between two
bone surfaces in a joint that
normally articulate. This
abnormality is severe than a
subluxation, in which loss of
contact is partial.
 Usually the joint capsule
and ligaments tear when a
joint becomes dislocated,
and often the nerves are
injured as well.
 Traumatic, pathologic,
recurrent and congenital
dislocations constitute the
variety of dislocation.

Posterior and lateral displacement of the radius and ulna with respect to
humerus
 Congenital hip dislocation

Radiograph of pelvis demonstrates an superiorly dislocated

femoral head as well as the shallow acetabulum on the right side.
 Destruction of joint
 Definition: the invasion and replacement of articular cartilage and subchondral
bone by pathological tissue
 Radiological appearance: narrowing of joint space , destruction of bone in
affected areas, subluxation and deformity of joint.
 Etiology: pyogenic, tuberculous, rheumatoid arthritis, etc

Osteoarthritis
of hip joint

Radiograph of pelvis
shows joint space
narrowing, subchondral
sclerosis, osteophyte and
lucency of subchondral
cyst.
 Pyogenic arthritis
Etiology
 Infecting organism: Location:
staphylococcus aureus  Weight-bearing joint: hip,

 Route of contamination knee

 Hematogenous seeding Age:
synovium, bone marrow  Childhood
joint Clinical presentation
 Direct contamination  Acute onset and rapid

penetrating trauma, post progression

surgical  Pain, fever
 Contiguous spread  Restricted motion +

soft tissue infection, tenderness

osteomyelitis
 Tuberculous arthritis
Etiology Clinical presentation
 Mycobacterium tuberculosis
 Swelling
 Hematogenous seeding to
 Mild pain
synovial membrane
 Spread from adjacent  Restriction of motion
tuberculosis of bone
 Atrophy of muscle in the
Location
 Knee and hip joint later stage
Age Radiographic findings
 Childhood  Bone destruction (marginal erosion )

 Swelling of joint

 Gradual narrowing of joint space

 Osteoporosis

 Atrophy of muscle

 Cold abscess, sinus tract

 Fibrous ankylosis
 Tuberculosis of knee joint

Radiographs show marginal erosion, narrowing of joint

space, swelling of joint and osteoporosis
 Comparison of tuberculous and pyogenic arthritis

Tuberculous
Pyogenic arthritis
arthritis

Osteoprosis + ±
Osteosclerosis ± +
Bone destruction margin weight-bearing area

Joint space loss late early

Ankylosis fibrous bony

Progression slow acute and rapid
BONE TUMORS
 Osteosarcoma
 Definition

 Malignant tumor with ability to produce osteoid or immature

bone directly from neoplastic cells
 Demographics
 Age: second and third decades of life (children and
adolescents)
 Gender: M:F=2:1

 Skeletal location
 Metaphysis of long tubular bone
 Femur(40%), tibia(16%), and humerus(15%)
 Clinical presentation
 Soft tissue mass, pain, swelling, warmth, and restriction of
motion
 Pathological fracture
 Increased serum alkaline phosphatase
 Early metastasis: lungs , bones and other sites

 Radiographic findings
The pattern of osseous involvement depends to a large extent on the
amount of immature bone produced by the tumor. A mixed pattern
consisting of both osteolysis and osteosclerosis is most typical, with
purely osteolytic or osteosclerotic lesions being encountered less
frequently.
Osteosarcoma of the femur (osteosclerotic pattern) with multiple
pulmonary metastases
Osteosarcoma on the
lower third of femur
(osteolytic pattern)

Radiograph shows bone

destruction in the distal
metaphysis and
diaphysis of the femur,
with soft tissue mass
and Codman triangle.
 Giant cell tumor of bone
Definitions
Locally aggressive
neoplasm composed of
osteoclast like giant
cells, usually involving
the end of mature long
bone

GCT of radius
 Simple bone cyst
Definition: Fluid containing lesion of bone, lined by
mesenchymal cells
Etiology: tumor like lesion of unknown etiology,
attributed to local disturbance of bone growth
Location
 Metaphysis, migration to diaphysis with growth
 Humerus and femur

Demographics
 Age: children and adolescents
 Gender: M:F=2-3:1
Clinical presentation
 Most
lesions
asymptomatic
 Pain,
swelling, stiffness at
closed joint
 66% of cysts present with
pathologic fractures
 Inactive,latent after
skeletal maturity
 Spontaneous Simple bone
regression in
cyst at upper
some cases third of
humerus
with
pathological
fracture
 Skeletal Metastasis

 Spread of malignant tumors to osseous structures (usually through

haematogenous dissemination)
 Primary lesions : carcinoma of breast, lung, prostate, thyroid,
kidney, neuroblastoma etc

 Age: middle-aged and elderly patients children younger than 5

neuroblastoma)
 Skeletal location
 Spine, pelvis, ribs, skull, femur and humerus, etc
 Involvement of bones distal to knee and elbow rare
 Clinical presentations ：
 Pain, pathological fracture, etc.
 Radiographic findings

 Osteolytic pattern: multiple

poorly defined or well defined
osteolytic bone destruction,
perhaps with soft tissue mass
or pathological fracture,
usually without periosteal
reaction; destruction of pedicle
and vertebral body with intact
intervertebral space.

Radiograph shows osteolytic

bone destruction at upper third
of humerus, lateral end of
clavicle with formation of soft
tissue mass.
 Osteoblastic
pattern: multiple
round or patchy
radiodense lesion,
or diffuse
increased density
 Mixed pattern ：
osteolytic +
osteoblastic

Osteoblastic
metastasis Diffuse increased density in
vertebral body of L2, L4, L5
, sacrum and ilium.
Ewing's sarcoma
Key facts
Most common presentation: ill-defined
osteolytic lesion with multiple small
holes in the diaphysis of a long bone in
a child with a large soft tissue mass.
Presentation with pain, mass, fever,
anemia and leukocytosis. Most common
location: femur, iliac bone, fibula, rib,
tibia.
Differential diagnosis: Osteosarcoma,
lymphoma, infection and EG.
Frequently aggressive type of periosteal
reaction, but never a benign type.

On the left a patient with a Ewing's

sarcoma in the femur.
Notice the ill-defined osteolysis.
There is an aggressive periosteal
reaction.
Multiple Myeloma

Multiple myeloma - lytic bone lesion,

whether well-defined or ill-defined in
age > 40.
The most common location is in the
axial skeleton (spine, skull, pelvis
and ribs) and in the diaphysis of long
bones (femur and humerus).
Most common presentation: multiple
lytic 'punched out' lesions.
Multiple myeloma doe not show any
uptake on bone scan.

Discriminator:
Must be over age 40.
 Osteoid osteoma

key facts:
Small osteolytic lesion (up to 1.5 cm) with or without central calcification.
Surrounded by a prominent zone of reactive sclerosis due to a periosteal and endosteal reaction, which
may obscure the central nidus. In juxta-articular localisation, the reactive sclerosis may be absent.

Localisation: femur, tibia, hands and feet, spine (arch).

Axial imaging for differentiation from Brodie abscess, osteoblastoma, stress fracture
Here the reactive sclerosis is the most obvious finding on the X-ray. There is reactive sclerosis with a
nidus that is barely visible on the radiograph (blue arrow), but clearly visible on the CT (red arrows).
CT scan is usually very helpful in detecting the nidus and differentiating osteoid osteoma from other
sclerotic lesions like osteoblastoma, osteomyelitis, arthritis, stress fracture and enostosis.
MRI also may detect the nidus, combined with abundant bone marrow and soft tissue edema.
 Metabolic Bone Diseases
 Mineralization; osteomalacia/rickets
 Bone turnover; pagets; primary
hyperparthyroidism; secondary
hyperparathyroidism
 Low Bone content; osteoporosis/
generalized and localized;
 High bone content; osteopetrosis
 Rickets / Osteomalacia
Decalcification and softening of the bone

Caused mainly by: vitamin D deficiency

**Vitamin D is required for the absorption of calcium from
the intestine and calcium is responsible for mineralization of
bone

Etiology
 Lack of exposure to sun light
 GI malabsorption, extensive burns, chronic diarrhea,
pregnancy, drugs such as Dilantin.
Rickets
Disease of growing bones of children(in it epiphyseal plate not closed )in which defective
mineralization occurs in both bone and cartilage of epiphyseal growth plate.

RICKETS
Thickening and widening of
physes,
Cupping of metaphysis,
Wide metaphysis, Bowing
of diaphysis, Blurred
trabeculae
XRAY FINDINGS:

Loosers zones -
incomplete stress
fracture with healing
lacking calcium, on
compression side of
long bones.
Codfish vertebrae due to
pressure of discs
Trefoil pelvis, due to
indentation of
acetabulae stress
fractures
Osteomalacia
Disorder of mature bones in adult (after epiphyseal plate closure )in which
mineralization of new osteoid bone is inadequate or delayed
 Paget’s Disease
Excessive bone resorption followed by replacement of normal
marrow by vascular, fibrous connective tissue.
Most often affect the pelvis, long bones, spine, ribs, sternum, and
cranium
Paget disease is a chronic
disorder of unknown origin with
increased breakdown of bone and
formation of disorganized new
bone.
The most common appearance is
the mixed lytic-sclerotic.
In this case we see the
pathognomonic triad of bone
expansion, cortical thickening
and trabecular bone thickening in
the mixed lytic and sclerotic
phase of Paget's disease of right
hemipelvis.
Secondary hyperparathyoidism
 Osteoporosis
Chronic, progressive metabolic bone disease
characterized by
 Porous bone
 Structural deterioration of bone tissue

 Increased bone fragility

Increased Osteodensity

• Osteopetrosis (Marble Bone

Disease)

Autosomal recessive osteopetrosis

Increased Osteodensity

• Osteopoikilosis (Spoted Bone Disease)