Principles of Radiologic Interpretation Technical Consideration Skeletal Anatomy and Physiology The Categorical approach to bone disease Radiologic predictor variables Medicolegal implication
Technical consideration Plain Film Radiography Tomography Contrast Examination Radionuclide Imaging Computed Tomography Magnetic Resonance Imaging Skeletal Anatomy and Physiology Skeletal Development Intramembranous Ossification Enchondral Ossification Bone Structure Epiphyse Physis ZPC Metaphysis Diaphysis Cortex Medulla Periosteum Endosteum Bone Metabolism Bone mineral - Hormones
Anatomy Anatomy Anatomy The Categorical approach to bone disease
Congenital Arthritis Trauma Blood I nfection Tumor Endocrine,Nutritional,Metabolic Soft Tissue
Radiologic Predictor Variables Preliminary Analysis Clinical data Number of lesions Symetri of lesions Determination of Systems Involved
Radiologic Predictor Variables Analysis of The Lesions Skeletal Location Position Within Bone Site of Origin Shape Size Margination Cortical Integrity Radiologic Predictor Variables Behavior of Lesions Osteolytic Lesions Osteoblastic Lesions Mixed Lesions Matrix Periosteal Response Solid Respons Laminated Respons Spiculated Respons Codmans Triangle Radiologic Predictor Variables Soft Tissue Changes Supplementary Analysis Other imaging Procedures Laboratory Examination Biopsy TRAUMA Fracture and Dislocation The radiographs should be made Include at least one joint Preferably two joints Two position AP LAT
TRAUMA Time intervals between Radiographic Study Initial Diagnostic study Post reduction and post immobilization One or Two weeks later, if position has changed After approximately six eight weeks for Primary callus After each plaster cast or traction change Before final discharge of patient
TRAUMA Types of Fracture Closed fracture Does not break the skin or communicate with the outside environment Simple fracture Open fractur Penetrates the skin over fracture site Compound fracture
TRAUMA Comminuted fracture Two or more bony fragments have separated Non Comminuted fracture Penetrates completely through the bone Avulsion fracture Tearing away of a portion of the bone Impaction fracture Bone is driven into its adjacent segmen
TRAUMA Incomplete Fracture Broken only one side of the bone Greenstick (Hickory Stick) fracture Torus (Buckling) fracture
Fracture Orientation Oblique fractur Commonly occurs in the shaft of long tubular bone 45 to the long axis of the bone Fractur Fracture TRAUMA Spiral fractur Torsion, coupled with axial compression and angulation Transverse fractur Run at a right angle to the lonh axis Uncommon through healthy bone Pathologic fractur Fracture TRAUMA Spatial Relationships of Fracture Aligment Position of the distal fragment in relation to the proximal fragment Apposition Closeness of the bony contact at the fracture site If the ends are pulled referred to as Distraction Fracture TRAUMA Rotation Twisting forces on a fractured bone along its longitudinal axis Traumatic Articular Lesions Subluxation Dislocation Diastasis Epiphyseal Fractures Salter-Harris Classification
Salter - Harris Dislocation TRAUMA Fracture Healing Main steps in fracture healing Formation of hematoma Organization of hematoma Formation of fibrous callus Replacement of fibrous callus by primary bany callus Absorption primary bany callus Transformation to secondary bony callus Remodeling
TRAUMA Complication of Fractures Immediate complication Arterial injury Compartement syndrome Gas gangrene Fat embolism syndrome Thromboembolism TRAUMA Intermediate complication Osteomyelitis Myositis ossificans Synostosis Delayed union
Delayed complication Osteonecrosis Osteoporosis Non union Mal union Myositis Ossificans INFECTION Suppurative Osteomyelitis
General Consideration Systemic or Local infections Immunosuppresed patients, alcoholics, newborns, and drug addicts are predisposed Antibiotics have significatly reduced the sepsis-related mortality INFECTION Etiology Staphylococcus aureus causes 90% Pathway for the spread Hematogenous Contigunous Direct Implantation Postoperative INFECTION Radiologic Features Bone scan are the earliest means of diagnosis Radiographic latent period for plain film 10 days for extremities 21 days for spine Soft tissue alteration : elevated fat planes, obliterated fat planes, increased density. INFECTION Bone changes : Moth-eaten bone destruction Usually metaphyseal in origin Periosteal new bone formation Solid Laminated Codmans Triangle Sequestrum Involucrum Joint space destruction (ankylosis)
0steomyelitis Osteomyelitis INFECTION Septic Arthritis General consideration Single joint involvment in the rule Most common rute is hematogenous or direct traumatic implantation Etiology Most frequently is Staphylococcus Aureus INFECTION Radiologic Features The knee and hip are the most common sites Joint effusion leads to distrorsion of the fat folds Positive Waldenstorms sign Rapid loss of joint space Bony ankylosis INFECTION Nonsuppurative osteomyelitis (tuberculosis) General Consideration Found in patients such as prepubertal children, debilitated geriatric, silicosis, AIDS sufferers, Lymphoma patients, Alcoholics, corticosteroid and drug abusers INFECTION Etiology Mycobacterium tuberculosis Two mode of spread Inhalation Ingestion INFECTION Radiologic Features Spinal tuberculosis is most common at L-I Early sign for spine are : Lytic endplate destruction loss of disc height Anterior gouge defect Paraspinal swelling
INFECTION Advanced sign for spinal involvement are: Vertebral body collaps Gibbus formation and obliteration of the disc Tubercular arthritis is common in the hip and knee Uniform joint space narowing, early destruction of the subchondral cortex, moth-eaten bone destruction and juxtaarticular osteoporosis are the cardinal sign of tubercular arthritis Tuberculosis Tuberculosis TUMORS AND TUMORLIKE PROCESSES METASTATIC BONE TUMORS PRIMARY MALIGNANT BONE TUMORS Multiple myeloma Osteosarcoma Ewings Sarcoma PRIMARY QUASIMALIGNANT BONE TUMOR Giant Cell Tumor
TUMORS PRIMARY BENIGN BONE TUMORS Osteochondroma Osteoma Bone island Osteoid osteoma Simple bone cyst Aneurysmal bone cyst TUMORS Metastatic Bone Tumors General Consideration The most common malignant tumors CNS tumors and basal cell Ca rarely Life threatening complication Insidence 70% are metastatic, 30% are primary In females 70% from breast Ca In males 60% from prostate Ca TUMORS Radiologic Features Technetium bone scan 80% of all metastase are located in the central or axial skeleton - Spine and Pelvis being a most common Alteration in bone density and architecture 75% osteolytic, moth eaten or permeative 15% osteoblastic Periosteal respose is rare Metastatic TUMORS Primary Malignant Bone Tumors Multiple Myeloma Bone scan are cold Gross Osteoporosis may be the only early sign Punched out lesions Vertebra plana or wrinkled vertebra Preservation of pedicles Multiple Myeloma Multiple Myeloma TUMORS Osteosarcoma 75% of cases occurs in the 10 to 25 age Metaphyses of the distal femur, proximal humerus are the most common sites Permeative or ivory medulary lesion in metaphysis of a long tubular bone A sunburst or sunray periosteal response Cortical disruption with soft tissue mass formation Sclerotic Lytic Mixed lesion Osteosarcoma Osteosarcoma TUMORS Ewings Sarcoma Most cases occur in the 10 25 age range May mimic infection Diaphyseal permeative lesion Femur, tibia and fibula Onion skin periosteal response Most common primary malignant bone tumor to metastasize to bone Ewings Sarcoma TUMORS Primary quasimalignant bone tumor Giant cell Tumor Osteoclastoma 20-40 years is the usual age range Distal femur, proximal tibia distal radius, proximal humerus Metaphysis and extend to subarticular Radiolucent, excentric Soap Buble appearance
Giant Cell Tumor TUMOR Primary Benign Bone Tumors Osteochondroma Painless and hard mass near a joint Humerus, tibia, femur, ribs Two types : - sessile - pedunculated Coat hanger exostose cauliflower mass The cortex and spongiosa blend imperceptibly Osteochondroma TUMOR Osteoma A rise in membranous bones Sinuses frontal, ethmoid Mandible Skull bones Homogenously opaque Osteoma
TUMOR Bone Island Epiphyseal, metaphyseal Medulary Round oval : Long axis oriented Smooth or radiating border Opaque Normal adjecent cortex May change size TUMOR Osteoid osteoma Consists a nidus, thst usually 1 cm or less Target calsification Most common location is in the cortex Radiolucent nidus surrounded by perifocal reactive sclerosis Osteoid Osteoma TUMOR Simple Bone Cyst Expansile radiolucent Proximal humerus, femur, calcaneus No periosteal reaction Pathologic fracture Aneurysmal Bone Cyst Some lesion may reach 8 10 cm Cortical ballooning blown out app Aneurysmal Bone Cyst Aneurysmal Bone Cyst ARTHRITIC DISORDERS Degenerative Disorders Degenerative Joint Disease etc Inflamatory Disorders Rheumatoid Arthritis etc Metabolic Disorders Gout etc ARTHRITIC Degenerative Joint Disease Osteoarthritis Osteoarthrosis Asimetric distribution Non uniform loss of the joint space Osteophytes Subchondral sclerosis Subchondral cyst Loose bodies Subluxation
Osteoarthrosis ARTHRITIC Rheumatoid Arthritis Generalized Connective tissue disorder Higest insidence among the 40 50 year Symetric peripheral joint pain and swelling Early : - Soft tissue swelling Marginal erosions Osteoporosis - Periostitis Loss of joint space Late : - Ankylosis Deformities Rheumatoid Arthritis Rheumatoid Arthritis ARTHRITIC Gout Disorder of purin metabolism Deposite of Sodium monourate crystals into cartilage, synovium, periarticular and subcutaneous tissues Dense soft tissue Tophi, preservation of joint space, Bone erosions (marginal periarticular) overhanging margin sign Metatarsophalangeal joint
Gout Osteoporosis Diagnosis Radiologi
Primer Type I : Post menopouse osteoclast mediated radius dan vertebra Type II: Senile osteoporosis osteoblast mediated proksimal femur Compotition mineral
Normal > 833 mg / cm 2 Osteopeni 833 648 mg / cm 2 Osteoporosis < 648 mg / cm 2 Established osteoporosis Diagnosa Radiologi Peningkatan radiolusensi Penurunan kandungan mineral <30-50% Penipisan korteks Gambaran trabekula menonjol Perubahan bentuk Radiografi Konvensional Vertebra Penurunan densitas Perubahan trabekula trabekula vertikal Wash out Penipisan korteks Perubahan bentuk Femur Penurunan densitas kolum femoris trochanter mayor Perubahan trabekula
1.Principal Compressive group 2.Secondary Compressive Group Wards triangle 3. Tensile Group CT Scanogram Penipisan korteks
Pelebaran diameter intrameduler CT Scanogram Densitometri Penurunan kandungan mineral umur 30-35 th Penurunan 3-5% / dekade Menopause > 2% / tahun
Dexa Dua panjang gelombang Energi Antero-posterior
BMC: Bone mineral content (gram) BMD: Bone mineral density (gram/cm2) T. Score Normal : > -1 Osteopeni: -1 2,5 Osteoporosis: < -2.5 QUS Dua buah transduser 0,1 1 MHz Transmitter & Receiver
BUA (Boardband Ultrasound Attenuation)Bone Mass SOS (Speed of Sound) Internal Arsitektur dari trabekulaelastisitas
Kesimpulan. USG Skrining massal DEXA Gold standard Konvensional radiografi