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2. CT SCAN
Defined the presence and extent of fractures or dislocations
Useful for some bone tumors. Bone tumors can be seen in CT
scan
3. NUCLEAR MEDICINE
Can look at the entire body at one time
For demonstration of metastatic processes because it
demonstrates metabolic reaction of the bone
Conventional projections:
o PA Projection
o Lateral Projection
Additional projections:
o Towne’s projection – to demonstrate the occipital
bone
If you need to get for example the occipital
bone, the trauma is in the occipital bone patient
hit his head backwards or fell from the bed and
then the patient hit his head then you request for
town’s view. So you request AP Lateral +
Towne’s view.
How does jug handle view look like (encircled). It looks like the handle
of a jug, so you could see the zygomatic arches. If you want to see the
zygmatic arches don’t request for water’s, what you have to request is
This is the Water’s view. Water’s view looks like a balloon, but it is the SMV or jug handle view.
more circular and you see very clearly the maxillary sinuses in
this image and also the nasal septum. To demonstrate the B. SPINE
maxillary bone and maxillary sinuses. When you take the x-ray of the spine from the cervical up to
the lumbar vertebra you always ask for AP and lateral views
Let’s go to the other bones of the skull: and then additional oblique views. The oblique view is
Mastoid important so you could see the intervertebral foramina if
o When you take the mastoid sinuses we need 2 view for there is narrowing or forminal narrowing.
that: Towne’s view and Schuller’s view. AP and Lateral view
o Towne’s view – frontal view of mastoid bones Oblique view – to demonstrate the intervertebral foramina
o Schuller’s view – lateral view of mastoid bones SCOTTY DOG
Mandible D. SHOULDER/CLAVICLE/PELVIS
o When you request for mandible you request for mandible You request only AP, why because if you take lateral view
AP Oblique (APO) will you see the shoulder? No because it’s on top of each
o AP view other. Also the pelvis, if you request for lateral view of the
o Panoramic view pelvis would you see the entire pelvis? No also.
AP
E. EXTREMITIES
Always AP and Lateral view
AP Lateral except for hand and feet
- Why? Because if you take an x-ray of the hand AP and
Lateral the bones are on top of each other, so how do you
see the lateral view of these bones? You take an oblique
view. Also the foot AP then oblique view. Because if you
don’t take the oblique view an take the lateral view for the
hands and the feet you will not see the bones because
they’re on top of each other.
G. PATELLA
Sunrise view
In effect, if you see a Scotty dog the normal you would see like this
(left photo), if you have fracture or spondylolysis you would see the
fracture there (middle photo), in spondylolisthesis (right photo) is
when there is subluxation of the bone, it will separate.
This is the sunrise view. Like the sun, you could see the patella and its
entirety. You would also know if there’s dislocations, for example the
patella is located here or there and you would also see fractures in
that patella.
SCOTTY DOG
Transverse Nose
process
Pedicle Eye
Pars Neck
interarticularis
Superior articular Ear
process
Inferior articular Front
facet leg
Now we have the water’s view. If you look at this one, I just want to
show you how sinusitis looks like. When you look at this, this is the
frontal sinuses. His is clear and aerated and then you have the left
maxillary sinus its clear and aerated. What about your right maxillary
sinus, it’s white. So if this is opaque it means that there is water in the
maxillary sinus. So that is an example of a maxillary sinusitis.
This is maxillary sinuses (orange circle) and that is the ethmoid sinuses
This is another example of mastoiditis. Where in you see the mastoid
(yellow circle). If you look at this CT scan image, you could see that
air cells on the left which is normal, while the mastoid sinus in the
there is water inside the sinuses (left sinuses). So this is ethmoid and
right is abnormal and you see here a cholesteatoma.
maxillary sinusitis
III. OSTEOMYELITS
refers to bone infection by infecting organism: bacteria,
mycobacterium, pathogenic fungi
may remain localized or spread to involved marrow, cortex,
periosteum and soft tissues
When you say osteomyelitis, that is bone infection. The most
common cause is always a bacteria, mycobacterium or
pathogenic fungi.
A. ROUTES OF INFECTION
1. HEMATOGENOUS
Via the blood stream
Bacteria from distant focus like the upper respiratory tract,
Let’s go to mastoiditis. This is a CT scan image, you can see that there urinary tract can enter the blood vessels and reach the bone
is normal aeration of the left mastoid, but in the right mastoid it is 2. DIRECT EXTENSION
already sclerotic, it is white so once the air echoes disappears from the From adjacent soft tissue infection like furuncle, carbuncles
mastoid, that’s mastoiditis. and abscesses that get deeper reaching the bone
3. DIRECT INOCULATION
Can happen in cases of open fracture, penetrating wounds
or even surgery
3. CHRONIC OSTEOMYELITS
Symptoms longer than 1 month
Another example because of an old fracture the patient developed
Mixed lytic and sclerotic appearance with periosteal bone
osteomyelitis. You always see this by history.
reaction and thickening
You see 2 important things: the involucrum and the
sequestrum
Involucurm – enveloping immature periosteal bone
Sequestrum – dead bone separated from viable bone by
granulation tissue
So how do you differentiate one from another? When you
say sequestrum it’s like sequestered, the dead bone is
sequestered an is surrounded by an area of lucency.
You see this bone here (right photo) this is known as the sequestrum
and the luscent area surrounding the sequestrum is the involucrum
(left photo). This sequestrum is a dead bone and the involucrum that
surrounds the dead bone. When they do this, you have to operate on
the patient and remove this one, drain the abscess out and put
antibiotic beads
This is an example of chronic osteomyelitis because of a fracture. And
definitely this patient has a draining sinus, may abscess na lumalabas
sa leg.
2. Location- there are some lesions that occur in 1 part of the bone
and never occur in other parts of the bone. So by location you know
what type of tumor that is.
3. Specific bone – there are tumors that attack only a specific bone.
For example they only attack the tibia. For example osteosarcoma
attacks the long bones. There are tumors that only attack the rib or
only the spine.
4. Internal Margins
Zone of Transition – aggressiveness depends on the zone
of transition, presence or absence of sclerotic margins
- If there’s presence of sclerotic margins it is probably less
aggressive, but if sclerotic margins are not seen then it’s
more aggressive. Zone of transition is the transition between
the normal bone and the abnormal bone. If the zone of
transition is not clear, it means that tumor is probably very
aggressive.
This is the antibiotic beads, it looks like a rosary. You put it inside for IV. BENIGN AND MALIGNANT BONE TUMORS
osteomyelitis because even if you drink lots of antibiotics you might A. BENIGN
not get well with cloxacillin or coamoxiclav. You have to put the 1. BENIGN CARTILAGENOUS BONE TUMORS
antibiotic inside. -arises from the cartilage
A. Enchondroma
COMPARISSON OF ACUTE TO SUBACUTE OSTEOMYELITIS B. Osteochondroma
(ROCKWOOD) C. Chondroblastoma
PRESENTATION SUBACUTE ACUTE D. Chondromyxoid Fibroma
Pain Mild Severe 2. BENIGN OSSEOUS TUMORS
-arises from bone or osseous structures
Fever Few patients Majority
A. Osteoma
Loss of function Minimal Marked B. Enostosis
Prior antibiotics Often (30-40% Occasional C. Osteoid Osteoma
D. Osteoblastoma
Elevated WBC Few Majority 3. BENIGN FIBROUS TUMORS
-occurs in the fibers
ESR Majority Majority A. Non Ossifying Fibroma
Blood culture Few positive 50% positive B. Benign Cortical Defect
Bone culture 60% positive 85% positive 4. CYSTIC TUMORS
Initial x-ray study Frequently Often normal A. Unicameral Bone Cyst (Solitary)
abnormal B. Giant Cell Tumor (Osteioclastoma)
Site Any location (may Usually metaphysis C. Epidermoid Cyst(Cholesteatoma)
cross physis) D. Epidermoid Inclusion Cyst
Early stages, limited to soft tissue changes E. Hemangioma of the Bone
Bone haziness and mottling of metaphysis F. Teratoma
Sequestrum and involucrum: hallmark of chronic B. MALIGNANT
1. Primary
DIAGNOSTIC CRITERIA FOR BONE TUMORS o Osteosarcoma
1. Age – excellent indicator for type of tumor o Ewing’s Sarcoma
- There are bone tumors that only occur in children and there are bone 2. Metastatic
tumors that only occur in adults. So age is important. When you look 3. Multiple Myeloma
at x-rays kasi they all look the same, they all look like lytic lesions and
you wouldn’t know what bone tumor it is, but the age will give you an V. BENIGN BONE TUMORS
idea what that bone tumor is. A. BENIGN CARTILAGENOUS
1. ENCHONDROMA – Hand
Specific for the hands and feet, but more common in the
hand. More common in the metatarsals, metacarpals and the
pahalanges.
2. OSTEOCHONDROMA
Tumor arising from the cortex and pointing away from the
nearest joint
3. CHONDROBALSTOMA
Common in the epiphysis
Stippled chondroid calcification
4. CHONDROMYXOID FIBROMA
Metaphysis and eccentric in location
Osteochondroma, arises from the cortex and pointing away from the
joint. It is not a spur, it is an osteochondroma and it looks like a
cauliflower. There are some osteochondromas that grow so big that it
really looks like a cauliflower.
So this is your hand, you see a lytic lesion of your hand and it is
located in your proximal phalanx of the 2nd digit. It’s an Enchondroma
Another is the middle phalanx of the 5th digit. An enchondroma. If you Chondroblastoma, you see stippled calcifications. Stippled, so may mga
see multiple enchondromas, kahit 2 it is already considered multiple, dots siya. Common in the epiphysis, but in this picture you see the
that’s ollier’s disease. Syempre pag 1, that’s solitary enchondroma. If epiphysis and part of the metaphysis.
you have ollier’s disease and you see the skin have multiple
hemangiomas, that is maffucci’s syndrome.
This is a CT image where in you see an osteoma there inside the sinus.
2. BONE ISLAND
A sclerotic tumor. It not lytic, it’s white.
Ovoid nodules of sclerotic regions
3. OSTEOID OSTEOMA
<1.5cm
Feature: pain at night relieved by aspirin
History of bone pain at night. In the morning she’s okay, but
at night it’s so painful and you give aspirin or celecoxib or
6. TERATOMA
Common in the sacrococcygeal area
This is the unicameral bone cyst and if you see this structure there,
that is the fallen fragment sign (arrow) of a bone cyst. Fallen fragment
sign is seen in pathologic fractures.
You see this usually in the long bones. You see a lucent area there,
looks like a bone cyst, but the symptoms of the patient is that the
patient has pain at night then you took an x-ray and that’s what you
see, you know that that’s an osteoid osteoma. If it’s bigger than that
>1.5 cm then that is osteoblastoma.
This is the ewing’s tumor where you see the onion skinning, parang
periosteal elevation.