Imaging

Plain film radiography

The radiographic image are produced by the
accentuation of x- rays as they pass through
intervening tissues before striking plate or film.
The more dense and impermeable the tissues, the
greater the accentuation and therefore the more
blank. Or white.
Metal implant appears intensely white , bone less so
and soft tissues in varying shades of grey.
Cartilage appears as a dark area between the adjacent
bone ends
One bone overlying another produces superimposed
images .
Any abnormality seen in the resulting combined
image could be in either bone , so it is important to
obtain several image from different projections in
order to separate the anatomical outlines.
A convenient sequence for examination is
1. Patient
2. Soft tissues
3. Bone
4. Joint
5. Cartilage
6. Diagnostic associations
patient
Name
Age
Sex
Clinical details

Similarly, when requesting an x-ray examination ,

give the radiologist enough information to indicate
your line of thinking.
The soft tissues
Shape
Muscle planes are often visible and may reveal
wasting or swelling .
Bulging outlines around the hip may suggest a joint
effusion .
Soft tissue swelling around interphalengeal joints
may be the sign of rheumatiod arthritis.
Density
Increased density in the soft tissues follows
calcification in a tendon , blood vessel, a haematoma ,
or an abscess .
The radiographic density of a metallic foreign body is
usually unmistakable.
Decreased density of soft tissues is due either to fat or
to gas
The bones
Shape
Look at overall shape and how they fit together.
Identify the anatomical structures and study each
carefully.
for the spine, look at the overall vertebral alignment,
then at the disc spaces, and then at each vertebra
separately, moving from the body to the pedicles, the
facet joints and finally to the spinous appendages.
For pelvis, see if the shape is symmetrical with the
bones in their normal positions, then look at the
sacrum, the two innominate bones , the pubic rami
and the ischial tuberosities , then the femoral heads
and the upper ends of the femora.
Always comparing both sides
The bone may be bent as in Paget’s disease.
A localized deformity or swelling may be due to
bulging from within or to excessive new bone
formation.
Examine the periosteal surface , the cortex , and the
endosteum .
Density
Note whether the density is increased( sclerosis) or
decreased( osteoporosis or abnormal bone tissues)
The trabecular structure is usually visible .
 Is it regular?
 Is it disarranged ?
 Or absent
Focal defects with sharp margins are usually benign.
Defect with fuzzy margins may signify infection or a
malignant lesion.
Moth eaten appearance indicates malignant.
The site of lesion is important.
Bone cyst occur in the metaphysis
Giant cell tumor always at the very ends of the bone
The joint
Shape
General orientation of the joint and the congruity of
the bone ends.
Look for narrowing or asymmetry of the joint ‘ space”
which could signify loss of articular cartilage
thickness( athritis)
Interruption of the subarticular bone plates indicate
joint destruction.
Bony outgrowth from the joint margins are typical of
osteoarthritis
Density
Lines of increased density within the articular space
may be due to calcification of the cartilage or menisci(
chondrocalcinosis)
Diagnostic associations
Narrowing of the joint space+ subarticular cysts +
osteophytes= osteoarthritis
Narrowing of joint space + osteoporosis +
periarticular erosion = inflammatory arthritis
Bone destruction+periosteal bone formation=
infection or malignancy until proven otherwise
X-rays using contrast media
Iodine – based liquids is commonly used and is
injected into sinuses, joint cavities, or the spinal
theca.
Air or gas can be injected to produce ‘ negative
image’ outlining the joint cavity.
Oily iodides are non-miscible and do not penetrate
well into all the nooks and crannies.
Metrizamide is a non ionic iodide , is the least toxic
and least irritant.
Sinography
The simplest form.
The medium is injected into an open sinus.
The film shows the track and whether or not it leads
to the underlying bone or joint.
Arthrography
Intra-articular loose bodies will produce filling
defects in the opaque contrast medium .
In children’s hips, arthrography is useful in outlining
the cartilaginous and femoral head.
Arthrography may show up torn flaps of cartilage in
avascular necrosis.
In the ankle or wrist , extrusion of injected contrast
medium may disclose tears in the capsular structures.
Myelography
Used to diagnose disc prolapse and spinal canal
lesions.
Replaced by CT or MRI.
However , it is indicated for cervical root lesions.
The oily media are no longer used.
Metrizamide is used .
A bulging disc, an intrathecal tumour produce
distortion of opaque column in the myelogram.
Tomography
It provides an image focused on a selected plane and
may show changes that are obsecured by the
overlapping image in conventional x-ray.
Useful for detecting changes in the spine.
Computed tomography( CT )
Useful for showing detailed fracture patterns, for
displaying the shape of the spinal canal and for
mapping the spread of tumours into soft tissues.
The computed data can be reconstructed as a 3D
image.
Disadvantage= high radiation exposure.
Radionuclide scanning
99m technetium diphosphate is injected
intravenously and its presence is recorded with
gamma camera or rectilinear scanner.
Increased uptake during blood phase signifies a
hyperemia.
Activity during bone phase suggests new bone
formation.
Useful to diagnose stress fractures , bone infection,
and bone tumours.
MRI
Bone tumor can be displayed in their transverse and
longitudinal extent ,and extraosseous can be assessed.
It is useful is diagnosing bone ischemia , and
necrosis , the investigation of backache and spinal
disorder, and the elucidation of cartilage and
ligament injuries.
Also useful to diagnose rotator cuff tears and labral
injuries in the shoulder and ligament injuries around
the ankle.
Diagnostic ultrasound
High frequency sound waves generated by transducer, can
penetrate soft tissue and some reflected back to the
transducer where they are registered as electrical signal
and displayed as images on a screen .
Real time display gives a dynamic images which is more
useful than usual static images on transparent plates.
It is simple and portable.
Useful in identifying hidden ‘cystic lesion ‘ such as
hematoma, abscess and popliteal cyst.
Also useful in screening newborn babies for
developmental dysplasia of hip.
electrophysiological
Motor nerve conduction
The time interval between stimulation of a motor
nerve and muscle contraction can be measured
accurately .
If the test is repeated at two points a fixed distance
apart along the nerve, the conduction velocity can be
determined.
Normal values are 40-60 m/s
Conduction velocity is reduced in peripheral nerve
damage or compression.
The site of lesion can be established by taking
measurements in different segments of the nerve.
If the nerve is divided , there is no response to
stimulation of the nerve and an abnormal response to
galvanic stimulation of the muscle- reaction of
degeneration.
Electromyography
An electrode is used to record motor unit activity at
rest and during attempts to contract the muscle.
Normally there is no electrical activity at rest, but on
voluntary contraction , characteristic oscilloscopic
patterns appear.
Changes in these patterns can be identify certain
neuropathic and myopathic disorder.
After nerve injury, there will be denervation potentials
and recovery equally typical re-nervation potential.
Biochemical tests
Non specific blood tests
Hypochromic anemia
Usual in rheumatoid arthritis(RA)

Leucocytosis
Associated with infection.
Mild leucocytosis is common in RA and during attack
of gout.
The erythrocyte sedimentation rate(ESR)
Increased in acute and chronic inflammatory
disorders and tissue injury.
ESR is affected by presence of monoclonal
immunoglobulin.
High ESR is mandatory in diagnosis of myelomatosis.
C-reactive protein (CRP)
Increased in chronic inflammatory arthritis.
Used to monitor the progress and activity of
rheumatoid arthritis.

Plasma gamma-globulin
Helpful is assessment of rheumatoid disorders , and
in the diagnosis of myelomatosis.
Rheumatoid factor tests
Rheumatoid factor is an autoantibody which is often
present in patients with RA
It is not diagnostic and some patient will remain
seronegative.
It is absent in patients with ankylosing spondylitis ,
reiter’s disease or psoariatic arthritis.
Tissue typing
HLA antigens can be detected in WBC and they are
used to characterize individual tissue type.
Seronegative spondarthritides are associated with
HLA-B27 on chromosome 6.
This is used as confirmatory test in patient having
ankylosing spondyarthritis or Reiter’s disease.
Biochemical tests for metabolic
bone diseases
Serum calcium and phosphate
Should be measured in the fasting state and it is the
ionized calcium fraction that is important.

Serum alkaline phosphatase concentration

Index of osteoblastic activity.
It is raised in osteomalacia , and high bone turn over (
hyperparathyroidism , Paget’s disease , bone
metastases)
Parathyroid hormone activity
Can be estimated from serum assays of the COOH
terminal fragment.
But in renal failure, it is unreliable because there is
reduced clearance of COOH fragment

Vitamin D activity
Assess by measuring the serum 25-HCC
concentration.
Urinary calcium and phosphate
Significant alterations are found in
hyperparathyroidism and malabsorption disorder.

Urinary hydroxyproline excretion

It is a measure of bone resorption.
Increased in high-turnover conditions like Paget’s
disease.
Excretion of pyridinium compounds and telopeptides
Sensitive index of bone resorption .
Useful in monitoring the progress of osteoporosis and
hyperparathyroidism.
rehabilitation
rehabilitation is recognized as an important part of
the acute-care program.
It involves correcting limb deformities, increasing
muscle strength, maximizing motor control, training
individuals to make the most effective use of residual
function, and providing adaptive equipment.
Management of Common
Problems in Rehabilitation
Inadequate nutrition
 decubitus ulcers
 urinary tract infections
 impaired bladder control
 spasticity
 contractures
acquired musculoskeletal deformities
 muscle weakness
 physiologic deconditioning
Inadequate Nutrition
In trauma patients, the nutritional requirements are
markedly increased from the normal maintenance
requirement of 30 kcal/kg/day.
Most trauma patients have been receiving
intravenous fluids with minimal nutritional benefit
and so arrive at the rehabilitation center in various
degrees of malnutrition.
Physically handicapped people expend much of their
energy performing simple activities of daily living
(ADLs) and may also have difficulty in obtaining and
preparing adequate amounts of food.
Decubitus Ulcers (Pressure Sores)
The combination of poor nutritional status, lack of
sensation at pressure points of the body, and
decreased ability to move can cause decubitus ulcers.
The ulcer is a potential source of sepsis in an already
compromised individual and often requires that a flap
graft be rotated to cover the defect.
After a sacral flap is rotated, the patient must remain
in a prone position until the graft heals.
The clinical rule of protecting the patient's skin is to
change position every 2 hours. No cushion can
completely prevent decubitus ulcers.
Urinary Tract Infections and
Impaired Bladder Control
In an acutely ill or multiply injured patient, an
indwelling catheter may be necessary for medical
reasons but should be removed as soon as possible.
In male patients, incontinence can be managed with a
carefully applied condom catheter.
Restoring bladder function to achieve adequate reflex
voiding or a balanced bladder may require the use of
an intermittent catheterization program.
Muscle Weakness and Physiologic
Deconditioning
A physical conditioning program can increase the aerobic
capacity by improving cardiac output, increasing
hemoglobin levels, enhancing the capacity of cells to
extract oxygen from the blood, and increasing the muscle
mass by hypertrophy.
Prolonged immobilization of extremities, bed rest, and
inactivity lead to pronounced muscle wasting and
physiologic deconditioning in a short period of time.
Because disabled patients generally expend more energy
than normal individuals in performing the routine ADLs,
they must be mobilized as quickly as possible to prevent
unnecessary physiologic decline.
Spasticity
Spasticity must be managed aggressively to prevent
permanent deformities and joint contractures.
Spasmolytic Drugs
Drugs can be of some assistance in controlling
spasticity associated with upper motor neuron
diseases. Drugs are used when spasticity affects
multiple large muscle groups in the body and when
the spasticity is not severe.
 Baclofen (Lioresal)
 Dantrolene (Dantrium)
Casts
Casting temporarily reduces muscle tone and is
frequently used to correct a contracture.

If a cast must be used for a prolonged period, the

patient should be placed on anticoagulant therapy to
prevent deep venous thrombosis.
Splints
Anterior and posterior clamshell splints can be used
to control joint position and still allow for active and
passive range of motion (ROM) of the joints in
therapy.
Joint Contractures
Inactivity and uncontrolled spasticity often lead to joint
contractures which are difficult to correct and greatly
extend the needed rehabilitation program.
To prevent contractures, exercises to maintain ROM must
be performed several times daily. The patient, family
members, therapists, and nursing personnel should all
participate in this task.
In general, if a contracture is present for less than 3
months, it may be amenable to nonsurgical methods of
correction such as serial casting or electrical stimulation of
the antagonist muscles.
When the desired limb position is obtained, a holding cast
is used to maintain the position for an additional week.
Use of Orthoses
Orthotic (brace) prescription plays a vital role in
rehabilitation.
A temporary orthosis may be used in an early stage of
illness until a definitive, custom-fitted orthosis is
fabricated.
Definitive orthoses for the lower extremity are the below-
knee ankle-foot orthosis (AFO) and the above-knee knee-
ankle-foot orthosis (KAFO).
The bichannel adjustable ankle-locking (BiCAAL) type of
AFO is commonly applied as the first orthosis following
stroke, head trauma, spinal injury, or other condition that
causes extensive muscle imbalance about the foot and
ankle.
Ankle-Foot Orthosis
The primary requirement for orthotic support is that
all joints must be passively capable of being
positioned in adequate alignment. An orthosis cannot
correct a fixed bony deformity or fixed joint
contracture.