BASIC PRINCIPLE OF X-RAY IN MUSCULOSKELETAL

INTERESTING CASES FOR RHEUMATOLOGY AND ORTHOPEDIC IN

MUSCULOSKELETAL X-RAY
PIT NASIONAL PEROSI, PALEMBANG 6-7 DESEMBER 2019

dr. Muhammad Iqbal Sp.Rad

Divisi radiologi musculoskeletal FK UNSRI/RSMH
 KUMPULAN CASE
(NGETIK SEMENTARA)
 Iqbal_kando

Iqbal_kando

Iqbal_kando

Perempuan, 68 tahun
Aspergilloma (panah orange) dengan TB paru (panah ungu)
Recommended terminology for describing bone anatomy in adults and children
 M

GP

E
 SYSTEMATIC APPROACH
ABC-s

Alignment
Bone
Cartilage
Soft tissue
 SYSTEMATIC APPROACH
ABC-s

Alignment
Bone
Cartilage
Soft tissue
 ALIGNMENT

 Alignment : Anatomic relationship between bones on

x-ray

 Normal x-rays should have normal alignment

 Fracture, dislocation, and listhesis may affect the

alignment on the x-ray
DISLOCATION
MTP III JOINT DISLOCATION NORMAL ANATOMY
ELBOW DISLOCATION
LISTHESIS
 Listhesis

 The slippage of one vertebra relative to the one below

Anterolisthesis
 Listhesis

Retrolisthesis
 Spondylolisthesis grading system – Meyerding classification

Grade I : 0-25%
Grade II : 26-50%
Grade III : 51-75%
Grade IV : 76-100%
Grade V (spondyloptosis) : >100%
L4 - 5 Anterolisthesis - grade II
L2 - 3 Retrolisthesis - grade II
 SYSTEMATIC APPROACH
ABC-s

Alignment
Bone
Cartilage
Soft tissue
FRAKTUR
Bone terminology diagram
Lateral

AP

Displaced transverse diaphyseal fracture of the right tibia

Spiral fractures : looks like corkscrew
Oblique fracture of the tibial shaft with posterior displacement
More than two bone fragments in distal femoral shaft fracture Comminuted fracture
Longitudinal fractures – proximal phalanx
 A fracture of the distal diaphysis of the radius.
 Evaluating the films for displacement of the distal fragment
 The lateral view shows dorsal shift
 The ‘AP’ view shows lateral shift and lateral angulation.
Non-ossifying fibroma (Panah Biru) - pathological fracture (panah hijau)
M/8 YO/Rickets with pathological fracture of the femur shaft
FRACTURE HEALING STAGES
 Fracture healing of cortical bone without fixation in an adult.
A: Acute fracture of the humeral shaft. B: At 6 weeks, calcified callus is visible and the fracture lines are
becoming obscured. C: At 12 weeks, the fracture has almost completely healed.
 M/4 YO/History of fall
Greenstick fracture with callus formation
BONE TUMORS
Bone tumors
Primary malignant bone tumors
Primary bone sarcomas
Benign bone tumors
 Evaluation team of bone tumors

Patient history
Physical examination
Clinician Clinical
Laboratory value
Coordinate the patient’s overall
care

Radiologist Imaging Imaging studies

Image-guided biopsy

Pathologist Histology Tissue analysis

(Lesion identification)
 Age

Clinical factors
Gender

Radiological analysis Location

of bone tumor
Biological activity
(Pattern of destruction)

Periosteal & endosteal

Radiographic factors reaction

Opacity of the lesion &

Matrix mineralization

Size & number

Soft tissue component

 Prof. Enneking:
“Tell me the age – I’ll tell you the pathology”

Courtesy : dr. Paulus Rahardjo Sp.Rad (K)

Gender predilection of bone tumors
Predilection for specific locations within a bone
 Biological activity
(Pattern of destruction)
Geographic

Courtesy : dr. Paulus Rahardjo Sp.Rad (K)

Moth eaten

Courtesy : dr. Paulus Rahardjo Sp.Rad (K)

Permeative

Courtesy : dr. Paulus Rahardjo Sp.Rad (K)

Periosteal reaction
Sun burst Codman Triangle
Opacity of the lesion
&
Matrix mineralization
Differential diagnoses according to the opacity of the lesion
Lusent lesion. Aneurysmal bone cyst (ABC) in proximal phalang (arrow)
Sclerotic lesion. Carcinoid metastasis seen as a focal sclerotic lesion in the proximal tibial metaphysis (arrow)
 Mixed lucent and sclerotic lesion.
 Fibrous dysplasia seen as a mixed lucent and sclerotic lesion in the proxi­mal humeral metadiaphysis (arrow)
 Calcification of Tumor Matrix

•Punctate
chondroid/ •Flocculent
chondroblastic •Comma shaped
•Ring like

Calcification = mineralization=“matrix”
Courtesy : dr. Paulus Rahardjo Sp.Rad (K), Dr. dr. Rosy Setiawati Sp.Rad (K)
Calcification of Tumor Matrix

•Fluffy
osteoid/ •Amorphous
osteoblastic •Cloudlike

Calcification = mineralization=matrix
Courtesy : dr. Paulus Rahardjo Sp.Rad (K), Dr. dr. Rosy Setiawati Sp.Rad (K)
Soft tissue component
 > 5 cm : Probably malignant

Soft tissue component

< 5 cm : Probably benign

Single or multiple
Multiple sclerotic lesions
Multiple lytic lesions
Skeletal survey in multiple myeloma
Multiple lytic lesions (arrows)
Size
 NOF/Non-Ossifying Fibroma (>2 cm)
VS
FCD/Fibrous Cortical Defect (<2 cm)

Size

Osteoblastoma (>2 cm)

VS
Osteoid osteoma nidus (<2 cm)
 SYSTEMATIC APPROACH
ABC-s

Alignment
Bone
Cartilage
Soft tissue
Arthritis
 Courtesy : dr. Paulus Rahardjo Sp.Rad (K)

osteopenia
osteopenia
Osteoarthritis (OA)
 Asymetrical joint space narrowing

Subchondral bone sclerosis

The radiographic hallmarks of OA, Osteophyte

regardless of location in the body

Subchondral cystic change

Lack of periarticular osteopenia

Cartilage : Joint narrowing + osteophyte /
“lipping”

Courtesy : dr. Paulus Rahardjo Sp.Rad (K)

Features of OA with marginal osteophytes (purple) and supero‐lateral joint space narrowing (green). The adjacent
subchondral bone of the acetabulum shows areas of increased density (sclerosis) relative to normal bone and rounded areas of
reduced density due to the presence of a subchondral cyst (blue).
The Osteoarthritis (OA) of the first carpometacarpal joint. Typical OA changes with prominent osteophytes
(purple), joint space narrowing (green) and minor subchondral sclerosis (yellow) on both sides of the thumb
carpometacarpal joint.
Rheumatoid Arthritis (RA)
 Marginal erosions

Soft tissue swelling

Symetric joint space narrowing

The radiographic hallmarks of RA

Periarticular osteopenia

Joint subluxations
Rheumatoid arthritis. There are extensive erosions (orange) visible particularly in the metacarpal heads of the thumb, index
and middle fingers on the right and middle finger on the left, together with scaphoid bone in the left wrist and ulnar styloid on
the right seen en face. There is severe joint space narrowing in the right first and second MCP joints (green).
Erosions (Panah biru)
Normal (panah merah)
GOUT
 Crystal arthropathy due to deposition of monosodium
urate crystals in and around the joints.

1st MTP joint (great toe) is most commonly involved

Typically > 40 YO

GOUT
Younger and middle young adults = M (20) : 1 (F)
Elderly : more equal gender distribution

Radiographic hallmarks are sharply

marginated erosions with overhanging
margins, associated with soft-tissue gouty
tophi.
Gout affecting left great toe. There is soft tissue swelling (yellow) and severe erosive changes (purple) which are
characteristically wide based and ‘punched out’, located just away from the interphalangeal joint margin.
Tophaceous gout great toe. There is a destructive arthropathy affecting the great toe MTP and interphalangeal (IP) joints, with
severe erosive damage shown as loss of clarity of bone margins (orange), marked joint space loss (green), soft tissue swelling
and tophaceous deposits in the soft tissues with punctate calcification (pink) adjacent to the IP joint.
Gout. There are characteristic erosions with "overhanging" edges seen in gout (white arrows).
These have been characterized as appearing like "rat-bites.”
The first metatarsophalangeal and interphalangeal joints in gout.
(A) AP radiograph show bone erosion (*) with overhanging edges (orange arrow) and sclerotic borders (black arrow) on the medial aspect of
the first proximal phalanx. The joint space is preserved.
(B) AP radiograph shows tophi (blue arrows) and bone erosion (*) with sclerotic borders (black arrow) on the medial aspect of the first
proximal phalanx. The mineralization and joint space are maintained.
(C) AP radiograph shows tophi (blue arrows) and erosions (*) with overhanging edges (orange arrow) and sclerotic borders (black arrow) on
the medial aspect of the first proximal and distal phalanges. The joint spaces are preserved.
PSORIATIC ARTHRITIS
Predominant DIP finger joints involvement (Figure 1) Knees and small peripheral joints (Figure 2)
Symmetrical polyarthritis (like RA) (Figure 3) Spine and sacroiliac joints (Figure 4)
Arthritis with destruction and osteolysis of the fingers
Psoriatic arthritis finger DIP joints. A combination of erosions (orange) and new bone formation (purple) affecting the DIP
joints of left thumb and middle finger and right thumb and all fingers, at different stages of severity.
Psoriatic arthritis feet. Severe psoriatic arthropathy and deformity of the distal toes with erosions, osteolysis
and some new bone formation and ‘pencil in cup’ deformities at a number of MTP and IP joints (yellow).
OSTEOPOROSIS
 Systemic skeletal disease with loss of bone mass and
density leading to reduced bone strength and increased
risk of fragility or insufficiency fractures

Distal radius, neck of the humerus, neck of femur,

vertebral body, pubic ramus and sacral ala

Osteoporosis Most common metabolic bone disease

Primer : - Post menopause (type 1)

- Senile (type 2)
- Idopathic juvenile osteoporosis

Sekunder (Type 3) : - Endocrine

- Chronic illness
- Inflammation, etc
Osteoporosis plain radiography :

 Decreased bone density (lucent)

 Loss of cortical bone and trabecular bone

 Compression fractures and vertebra plana

Saville index
a b

Conventional radiographs of the hand in a healthy woman (a) and in a patient suffering from
osteoporosis (b).
Scurvy. Lateral radiograph of both lower legs shows diffuse osteoporosis of the bone
Osteoporosis. – AP Knee
Genant semiquantitative method for diagnosing osteoporotic vertebral
fractures
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