RADIOLOGY: Musculoskeletal o Marrow

o Soft tissue
A. Imaging Modality o Vessels
B. Cinical Background  Sensitive for bone
C. Laboratory Data destruction (useful in
ABC correlation for a close salvaging procedures)
differential diagnosis.  Pre-operative evauation
 Staging
IMAGING MODALITIES
 Advantages
A. Plain Radiograph
o delineate bone in
 Cortex
x.s.
 Medulla o multiplanar, 3D/4D
 Articular ends
 Apiphysis D. MRI
 Physis  superior images
 Soft tissue  multiplanar
 useful in joints, tumors,
 Mostly seen: bone and soft infection, bone infarcts,
tissues ischemic necrosis
 Cannot delineate from one  doesn’t show bone but
another: cartilage, SHOWS bone marrow
ligament, fascia,  exquisite marrow
periosteum visualization
 any problems in the bone
 Epiphysis- growth is reflected in the bone
 Cortex- cancerous bone marrow
bone marrow  also good visualization
o soft tissues
B. Skeletal Scintigraph o cartilage
 Tc99m/IV o meniscus
 ↑ bone marrow o ligaments
turnover/destruction
 especially/very useful in
 N growth plates sports injury
 Diagnosis of
o Tumors E. Ultrasound
o Infection  visualize soft tissue &
o Fractures bone content
o Arthritis  cannot penetrate bone
o Periostitis itself (sound wave)
 Very sensitive/less specific  adjunctive procedure
(Difficult to differentiate  useful in evaluating
but one knows there is an o tendons
abnormality present.) o joints
 Abnormal= abnormal o soft tissue
concentration of  narrow FOV (field of view),
technetium (e.g. in segmental visualization of
diaphysis) organ of interest
 Gamma camera – detect  operator-dependent
technetium

C. CT
 Axial images (x.s.)
 Visualized
o Cortex
CONTENTS F. Avulsion/Chip
 Trauma • Ends of long bones
 Tumors • Injury limited to
 Infections small joints
 Joint Disorders especially processes
of bones
TRAUMATIC BONE INJURIES • Processes may
Fractures contain tendon
 any bone deformity 2º to insertion thus, there
trauma usually (even if may be abN function
cortical area is unaffected, of muscle tendons
fracture is still considered) involved
 general rule, plain • Tendons in areas
radiograph is always prone to chip
indicative even at the fracture
slightest doubt G. Epiphyseal
 1st screening procedure of • N
choice ormal
 Types
A. Complete (into 2
fragments)
• Transverse • Type I. growth plate
• Oblique
• Spinal
B. Incomplete (usually
in resilient bones;
esp. in pediatrics) • Type II. GP +
• Greenstick metaphysis
• Buckle (Torus)
• Plastic
C. Occult
• Type III. GP + part
• Visible in plain film
epiphysis
• For Dx, bone
scintigraphy is best
D. Bone Bruise
• Intracanalicular • Type IV.
fractures GP + epiphysis &
• Cortex – intact metaphysis
Beneath – injured
• MRI only
• Main abN - ↓ signal
of N hyperintense
signal of bone Pathologic
marrow (it is usually • Occurs in areas of bones
hyperintense) that are diseased
• Bone bruise = • May be precipitated by
hypointense slight trauma
E. Comminuted Stress
• Butterfly • Usually 2º to areas of bones
chronically subjected to
stress
• Segmental • Commonly present as just
sudden pain
Healing
Union Myelogenous
• clinical Multiple Myeloma –
• radiographic punched-out deformity feature
Advantage: if acute, monitor in bone (scapula &pelvis)
bone progression into callus
formation Metastatic
Non-Union • Breast
• usually infection, vascular • Prostate
injusry, improper fixation • Lung
X-ray findings • Renal
• (-) callus bridging across • Thyroid
functional line, motion in • Epiphysis-metaphysis
stress in radiographs complex *
• Spine: pedicles *
BONE TUMORS * ↑ blood vessels,
• Primary hematogenous spread
• Metastatic • Metastasis almost always
• DOX start from spine then, to
• Infection pelvis
• Metal
• Dye INFECTIONS
Osteomyelitis (Staph aureus)
Benign vs. Malignant Routes
Benign Malignan • Hematogenous
t • Implantation
Cortex Intact Disrupted • Secondary
Border Well- Poorly
s defined defined Blood Supply
Soft No With Child – epiphysis/metaphysis
Tissue involveme involveme Adult – distal portion (epiphyseal
nt nt lines fused)

Classification: Examples Changes are Commonly Seen

Cartilaginous Child - metaphysis
Osteochondroma – well- Adult - epiphysis
defined margins, intact cortex
Chondrosarcoma – Acute Osteomyelitis
indeterminate margins, • Latent period – 10-12
calcification in soft tissue, days; not in early stage
disrupted cortex • Role of Nuclear Medicine
Osseous • MRI: bone, bone marrow
Osteoma – well-defined
(bright), fluid (dark)
margin, no discontinuity in
• Ultrasound: difficult; fluid
cortex
accumulation
Osteosarcoma – disupted
cortex, calcification
Chronic Osteomyelitis
∗ MRI/CT determine extent of
• Thickened cortex
surgery
Cystic • Warm outline
Simple Bone Cyst • Obliterated medullary
Giant Cell Tumor portion
- Borderline • ↓ sequestrum involucrum
- Benign but tendency to
be JOINT ABNORMALITIES
Malignant
 • Periarticular Bony
Structure Degenerative Joint Disease
• Joint Space • Pathophysiology: wear-
• Soft Tissue and-tear (aging)
• Asymmetric
Radiograph Sign of Joint • Distal joints
Disease • Weight-bearing joints
• abN in apposing bony
margins Neuropathic Arthopathies
• changes in width joint • Feature: fragmented,
space (cartilage disorganized joints
destruction) – • Secondary
narrow/widened • Examples
• subluxation o Diabetes – most
• periarticular swelling common
o Leprosy
Gout o Tabes dorsalis
• N joint space
• No narrowing/widening Metabolic
Gout
Infectious Arthritis • Uric acid crystal deposits
• Acute - soft tissue • Pseudoarthropathy
swelling; more • Classic = 1st MTP joint,
pronounced foot
• Chronic – contiguous with • Ultrasound: tophaceous
structures deposits

TB Arthritis
• Classic Psalm 52:8
o (+) erosions on side But I am an olive tree
o black bite deformity flourishing in the house of
pattern God;
I trust in God’s unfailing love
TB Spondylitis/Pott’s forever and ever.
Disease
• maximal vascular supply
thus, disease of vertebrae
• usually involves
intervertebral disc
• gibbus
• soft tissue abscess in
intervertebral disc and
vertebral body –
PARAVERTEBRAL SOFT
TISSUE ABSCESS

Rheumatoid Arthritis
Ankylosing Sponydlitis
• central type RA
• axial: spine, hips,
sacroiliac
• calcification is paraspinal –
BAMBOO SPINE
DEFORMITY