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MUSCULOSKELETAL

RADIOLOGY

dr. Yanto Budiman, SpRad., M.Kes


Bagian Radiologi FKUAJ/RSAJ
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Technical consideration
 Plain Film Radiography
 Tomography
 Contrast Examination
 Radionuclide Imaging
 Computed Tomography
 Magnetic Resonance Imaging

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Diagnostic Imaging in
Musculoskeletal Radiology
 Conventional “plain” xray is used initially
in almost all circumstances for evaluation of
musculoskeletal complaints
 CT aids in assessment of bone tumors,
evaluation of certain fractures, better
assessment of spinal column

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Diagnostic Imaging in
Musculoskeletal Radiology
 MRI
 Bone is not adequately vizualized because there
are no signals from bone cortex but bone marrow
in cancellous bone produces very clear images
 Assists in the investigation of bone tumors, soft
tissue masses, spinal column (discs, cartilage,
cord)
 Used now instead of arthography to evaluate joint,
ligament, meniscus
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MRI Cervical Spine

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MRI

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MRI

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Anterior Cruciate Ligament

MRI normal ACL MRI ACL tear


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Ultrasound & Nuclear
 Assessment of soft tissue lesions, abscesses,
masses, joint effusions, congenital hip
dislocations in infants
 Nuclear Medicine Role: Bone Scan
 Used for detecting areas of abnormal
metabolic activity within the bone (ex.
Infection, inflammation, metastatic disease,
rapid turnover of bone)
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Sonography: Ganglion of Dorsal
Aspect of Wrist

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Nuclear Scintigraphy
 Most common = Bone Scan
 Very sensitive for skeletal pathology
 Mildly sensitive for soft tissue pathology
 Usually nonspecific as an isolated test
 Small-moderate expense

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Nuclear scintigraphy – Bone
Scan
 IV injection radioisotope (Tc-99m) bound
to phosphate +/- dynamic imaging
 Approx 3 hour delay
 Delayed static imaging with a superficial
detector

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Bone Scan-metastase

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Bone Anatomy
 Type of connective tissue
 Covered with 2 layers of periosteum
 Cortical bone- dense, compact
 Cancellous bone-spongy, porous, loosely
knit
 Medullary canal- open canal running
through center of shaft on long bones

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Radiologic Predictor Variables
 Preliminary Analysis
 Clinical data

 Number of lesions

 Symetri of lesions

 Determination of Systems Involved

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Radiologic Predictor Variables
 Analysis of The Lesions
 Skeletal Location

 Position Within Bone

 Shape

 Size

 Margination

 Cortical Integrity

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Radiologic Predictor Variables
 Behavior of Lesions
 Osteolytic Lesions

 Osteoblastic Lesions

 Mixed Lesions

 Matrix
 Periosteal Response
 Solid Respons

 Laminated Respons

 Spiculated Respons

 Codmans’ Triangle 19
Radiologic Predictor Variables
 Soft Tissue Changes
 Supplementary Analysis
 Other imaging Procedures

 Laboratory Examination

 Biopsy

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The Categorical approach to
bone disease
 Congenital
 Arthritis
 Trauma
 Blood
 Infection
 Tumor
 Endocrine,Nutritional,Metabolic
 Soft Tissue
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*TRAUMA*

Fracture and Dislocation


The radiographs should be made
 Include at least one joint
 Preferably two joints
 Two position AP – LAT

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Why to get 2 views?
The radial head must be
aligned with the capitellum on
all views. Simple ulna fracture on
anteroposterior view; radial
head appears in place
Dislocated radial head is observed
on the lateral radiograph.

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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
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Fractures
Four major parameters for describing :
 Number of fragments
 Direction of the fracture line
 Relationship of the fragments to each other
(displacement, angulation, shortening,rotation)
 Communication of the frature with the
outside atmosphere

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Stable vs. Unstable
 Stable Fracture
A stable fracture is a broken bone which is
generally transverse, oblique, greenstick or a
hairline fracture which is somewhat secure.

Unstable Fracture
An unstable fracture is generally a broken bone
which is comminuted, oblique or a spiral fracture
requiring external or internal fixation.
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Complete Fracture
 Complete Bone Fracture
 This is where the bone has been completely
fractured through it's own width. This is
opposite from a hairline fracture or
incomplete bone fracture where there is
only a "crack" and not a complete break

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Incomplete Fracture
 Common in children
 Hairline fracture

 Greenstick fracture

 Buckle fracture

 Bowing/plastic fracture

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Greenstick Fracture
 Greenstick Fracture
 A "greenstick" fracture
usually occurs in children,
whose still soft bones
splinter without breaking
in two. Sudden force
causes only the outer side
of the bent bone to break.
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Buckle #

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Hairline Fracture

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Impacted Fracture
 Impacted Fracture
Type of fracture where the ends of the broken
bones are wedged together

Displaced,
greenstick,
and impacted
fractures

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Compression Fracture

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Avulsion Fractures
Small fragments of bone detach from where
tendons or ligaments attach to bones;
usually affect hand, foot, ankle, knee,
shoulder

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Calcaneal Tuberosity
Avulsion Fracture

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Avulsion fracture of the head of left humerous

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Pathologic Fracture
 An underlying disorder (such as infection, a
noncancerous bone tumor, cancer) weakens
a bone, leading to a fracture

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Pathologic fracture
X-ray with multiple osteolytic lesions in the
forearm caused by multiple myeloma with
pathologic fracture of the ulna
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Scaphoid Fracture
 Navicular bone fracture
 Caused by fall on an out stretched hand
 Not always picked up on initial xray
 Easier to see on follow-up xray
 SX: pain in the wrist and tenderness to area
just below the thumb, wrist swelling PAIN
IN ANATOMICAL SNUFF BOX
 Many times interpreted as a wrist sprain
because of initial negative xray
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Scaphoid Fracture

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Plain Radiographs – Extra views
Scaphoid Fx

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CT Image of Scaphoid Fracture

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Colles Fracture-aka Distal Radius
Fracture
 Fracture of the distal radius, dorsal
displacement of distal fragment + volar
silver fork deformity
 Fall on outstretched hand
 More common in elderly

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Salter Harris Fractures
 Salter-Harris fractures are injuries through
the physis. Therefore, by definition, they
must occur before the physis closes.
Typically, physis closure occurs during the
teenage years.
 5 Types

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Salter Harris
 Salter-Harris classification
 I : epiphyseal plate
 II : epiphyseal plate &
metaphysis (most common)
 III : epiphyseal plate &
epiphysis
 IV : epiphyseal plate,
metaphysis & epiphysis
 V : crush fracture epiphyseal
plate

Type IV 48
Sometimes difficult to diagnose
 (AP) plain radiograph of the
knee in a child with persistent
knee pain after trauma. The
radiographic findings appear
normal.
 Lateral view
Shows only joint
effusion

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Persistant knee pain- follow-up MRI ordered several weeks
later to assess ligament injury

shows an unexpected finding of a


Salter-Harris type III fracture.
Physis and epiphysis

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Subluxation
 Incomplete or partial dislocation of a joint
 Caused by some trauma (fall on
outstretched arm, direct blow, etc)

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Dislocation
 Is an injury in which a bone is displaced from its
proper position.
 May cause ligament or nerve damage
 Dislocations are usually caused by a sudden
impact to the joint. This usually occurs following
a blow, fall, or other trauma

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Dislocation
Signs/Symptoms
 A dislocated joint may be:
 Visibly out-of-place, discolored, or
misshapen
 Limited in movement
 Swollen or bruised
 Intensely painful, especially if you try to
use the joint or bear weight on it
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Shoulder Dislocation
AP view of a patient with an anterior
dislocation of the right shoulder

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ANTERIOR KNEE DISLOCATION

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TRAUMA
Fracture Healing
 Main steps in fracture healing
 Formation of hematoma
 Organization of hematoma
 Formation of fibrous callus
 Replacement of fibrous callus by
primary bony callus
 Absorption primary bony callus
Transformation to secondary bony callus
 Remodeling 56
TRAUMA
Complication of Fractures
 Immediate complication
 Arterial injury

 Compartement syndrome

 Gas gangrene

 Fat embolism syndrome

 Thromboembolism

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TRAUMA
 Intermediate complication
 Osteomyelitis

 Myositis ossificans

 Synostosis

 Delayed union

 Delayed complication
 Osteonecrosis

 Osteoporosis

 Non union – Mal union


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Myositis Ossificans

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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

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INFECTION
 Etiology
 Staphylococcus aureus causes 90%

 Pathway for the spread

 Hematogenous

 Contigunous

 Direct Implantation

 Postoperative

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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.

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INFECTION
 Bone changes :
 Moth-eaten bone destruction

Usually metaphyseal in origin


 Periosteal new bone formation

Solid – Laminated – Codman’s Triangle


 Sequestrum

 Involucrum

 Joint space destruction (ankylosis)

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0steomyelitis
extensive
osteolytic
destructyion

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Osteomyelitis-
sequestration
of bone within
area of
destruction

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INFECTION
Septic Arthritis
 General consideration
 Single joint involvement

 Most common route is hematogenous

or direct traumatic implantation


 Etiology
 Most frequently is Staphylococcus Aureus

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INFECTION
 Radiologic Features
 The knee and hip are the most common

sites
 Joint effusion leads to distorsion of the

fat folds
 Rapid loss of joint space

 Bony ankylosis

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Elbow septic
arthritis

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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

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INFECTION

 Etiology
 Mycobacterium tuberculosis

 Two mode of spread

 Inhalation

 Ingestion

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INFECTION

 Radiologic Features
 Spinal tuberculosis is most common at L-I

 Early sign for spine are :

 Lytic endplate destruction

 loss of disc height

 Paraspinal swelling

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Spinal tuberculosis
 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 72
Tuberculosis

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Tuberculosis

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Spondilitis TB, paravertebra abses

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TUMORS AND TUMORLIKE
PROCESSES
METASTATIC BONE TUMORS
PRIMARY MALIGNANT BONE TUMORS
 Multiple myeloma
 Osteosarcoma
 Ewing’s Sarcoma
PRIMARY QUASIMALIGNANT BONE
TUMOR
 Giant Cell Tumor
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TUMORS

PRIMARY BENIGN BONE TUMORS


 Osteochondroma
 Osteoma
 Bone island
 Osteoid osteoma
 Simple bone cyst
 Aneurysmal bone cyst

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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


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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


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Metastatic

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TUMORS
Primary Malignant Bone Tumors
 Multiple Myeloma
 Bone scan are cold

 Gross Osteoporosis may be the only early

sign
 Punched out lesions

Preservation of pedicles

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Multiple Myeloma

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Multiple Myeloma

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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 84
Osteosarcoma

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Osteosarcoma

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TUMORS
 Ewing’s Sarcoma
 Most cases occur in the 5 – 15 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

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Ewing’s Sarcoma

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Ewing’s Sarcoma

“onion-skin”
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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 Bubble appearance


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Giant Cell Tumor

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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
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Osteochondroma

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TUMOR

 Osteoma
 A rise in membranous bones

 Sinuses – frontal, ethmoid

Mandible
Skull bones
 Homogenously opaque

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Osteoma

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TUMOR
 Osteoid osteoma
 Consists a nidus, that usually 1 cm or less

 Target calsification

 Most common location is in the cortex

 Radiolucent nidus surrounded by perifocal

reactive sclerosis

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Osteoid Osteoma

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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”

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Aneurysmal Bone Cyst

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Aneurysmal Bone Cyst

100
Location

Rad Clin N Am,


Dec 1981 101
Types of
Periosteal
Reaction

Rad Clin N
Am,
Dec 1981 102
Periosteal Reaction

 Thick, uninterrupted
 long standing process, often non-
aggressive
 stress fracture

 chronic infection

 osteoid osteoma

 Spiculated, lamellated
 aggressive process

 tumor likely 103


Codman Triangle

periosteal reaction
Codman
Triangle
advancing tumor margin
destroys periosteal new
bone before it ossifies

tumor

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ARTHRITIC DISORDERS
Degenerative Disorders
 Degenerative Joint Disease

 etc

Inflamatory Disorders
 Rheumatoid Arthritis

 etc

Metabolic Disorders
 Gout

 etc
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Spondylosis

Note severely decreased


height of several disc spaces
(white arrow) and anterior
osteophytes (bone spur, open
arrow). Also, sclerosis (3
arrowheads) of posterior
facet joints, consistent with
osteroarthritis (x-ray)

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Osteoarthrosis

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Rheumatoid Arthritis

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Gout

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