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RADIOLOGY

o Water’s projection – demonstrate the maxillary


bone
F.09 Bone Radiology  If you hit your maxilla, you don’t ask for AP and
Dr. Galang | December 4, 2018 Lateral or the orbit, you do not see the orbit
usually in AP Lateral because when they take the
examination you are in supine position, so the
I. IMAGING CONSIDERATIONS orbits are far away from the detector. So you
want to see the orbits very clearly as well as the
1. MRI
maxillary bone then you request for water’s
 Provides soft tissue detail
view.
 For evaluation of joints particularly the knee and the
shoulder
 In bone radiology we use MRI just to check for presence of
infections and evaluation of joints especially the shoulder,
ankle and the joints

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

4. BONE MINERAL DENSITOMETRY


 They use this to check your T-score or the DEXA, -1 is
normal. -2 to 2.49-osteopenia. -2.5 osteoporosis Here in this slide you see the Caldwell’s projection. Where in you
 DEXA (Double Energy X-ray Absorptiometry) see the frontal bone (star) very clearly. You also see the presence of
 Shows bone density by evaluating the bone mass of 
 the your frontal sinuses (encircled) and also the ethmoid sinuses can
distal radius, femoral neck and lumbar spine also be seen in this xray.
 T-Score: 

Normal: > -1.0
Osteopenia: -1.0 ~ -2.49
Osteoporosis: < -2.5 

 Just put your hand there and the densitometer will check your
hand and then it’s like an x-ray of the hand and then it will give
you a score. And the corresponding score will tell you your
sickness.
 Don’t say that you are always okay because you don’t feel any
pain because when you do this test you might find that there is
something wrong with you.

II. RADIOGRAPHY OF THE BONES


 Projections – images obtained

A. SKULL X RAY This is the lateral view of the x-ray


 For the skull x-ray, the usual request is like this you write
there: skull x-ray AP Lateral. So it’s standard view. They will
take an AP and lateral view for skull x-ray

 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.

o Caldwell’s projection – to demonstrate the frontal


bone
 If you have trauma to the frontal bone, you can
ask for AP Lateral + Caldwell’s view. So
Caldwell’s view is the radiographic examination of This is the Towne’s projection. Looks like an inflated balloon, where
the frontal bone and the frontal sinuses. in you see the occipital bone

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RADIOLOGY
This is the lateral view of the soft tissue nasal bone. So you see here
the image of the nasal bone very clearly and you would see if there is
a fracture in the nasal bone. This is different because from other
xrays, this one is a high MA technique, so it’s technical. High MA
technique so that we want to demonstrate the soft tissues. Just like
the breast that is a high MA technique that’s why we see the soft
tissues. If we use another high KV technique low MA we see the bone,
but if we want to see the soft tissue it is high MA low KV, so baliktad.

 Zygomatic bone/ Base of the skull


o The zygomatic bone is demonstrated by the
submenovertical view
o Submentovertical (SMV) aka jug handle view
o Jug Handle View

This is another Caldwell’s projection

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

 Nasal bone C. RIBS


o STN – soft tissue lateral of the nasal bone or soft tissue  For the ribs you request for chest bucky and not chest x-ray
nasal bone  Chest Bucky

 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.

F. HAND AND FEET


 AP and Oblique
 Lateral view is only taken for localization of foreign bodies

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RADIOLOGY
 Lateral view is only taken because you want to see for
example foreign bodies, for example there’s a pellet gun,
you shot someone and you want to know whether the pellet
is in the anterior portion of the hand of the posterior portion
of the hand, so you only take the lateral view because you
want to see the location of a foreign body. That’s the only
reason why you take the lateral view beforehand.

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.

So this is an example of spondylolisthesis, how do I know that? This is


dislocation of the bone. How? You look at the bones, you count it
5,4,3,2,1. Look at the alignment, and then there the alignment is not
straight. So that is dislocation, that’s spondylolisthesis. So when you
see this one, remember me (dra. Galang). Sana maalala niyo ko pag
nakita niyo to. So patient complains of low back pain, then you have
an x-ray the lateral view you see this one. You just always have to look
at the alignment of the bone.
This is the oblique view of the lumbar spine. For lumbar spine we take
the oblique view and this is known as the SCOTTY DOG, where you
see the dog. The Scotty dog is important because we would want to
see the following:

 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.

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RADIOLOGY

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

B. TYPES ACCORDING TO DURATION


1. ACUTE OSTEOMYELITIS
 Most common, especially in children
 In x-rays you don’t see anything in acute osteomyelitis, but
in subacute and chronic osteomyelitis you will already see
some changes in the bone.
2. SUBACUTE OSTEOMYELITIS
 Without an acute disease, insidious onset
 Radiographic Findings: Brodie’s Abscess
 You already see bone changes.

So here is another example. Where is the mastoiditis, Right or left?


Left, but what is this yellow circle. That thing is what you call a
cholesteatoma, how do you know that the patient has cholesteatoma.
You just ask do you have history of ear discharge. And if the patient
says yes and is painful here and always with headache, you do the CT
scan and you see this a sclerotic area and there’s lucency inside, so
cholesteatoma looks like that. Lucency with area of sclerosis. When
you look at this it should always be air that you see inside, but if it’s
not air and something else is inside then that’s something else. There is a lytic lesion in this bone that is surrounded by a thin rim of
sclerosis. This is what you see in subacute osteomyelitis.

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RADIOLOGY

Another example of subacute osteomyelitis where in you see area of


lucency surrounded by sclerosis. By history you would know because
the patient is complaining of pain and then they have draining sinuses
there or the leg is so swollen. You will not have this symptom if it’s not
swollen. So you would have the x-ray done and you would see this one
and then the patient has fever and then what do you think of?
Probably osteomyelitis.

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.

Another example of chronic osteomyelitis, where there is periosteal


reaction already. And you have this lytic lesions inside the bone.

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RADIOLOGY
 Examples
o Metastatic Neuroblastoma - Most common
malignant tumor encountered before the age of
1, never occur in adults

o Ewings Tumor – Most common between age 1-


20 
 years old (common in flat bones)

o Osteosarcoma and Ewings - Most common


between age 10-30 years old in flat bones.
How do you differentiate one from another? By
radiographic findings already

o Metastatic Carcinoma, Multiple Myeloma and


Chondrosarcoma - After 40 years of age

**age is an important indicator for the type of tumor

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

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RADIOLOGY
-there are only 4 benign cartilagenous tumors.

1. ENCHONDROMA – Hand
 Specific for the hands and feet, but more common in the
hand. More common in the metatarsals, metacarpals and the
pahalanges.

 Ollier’s disease – multiple enchondroma


 Maffucci’s syndrome – enchondroma with hemangiomas

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

This is an osteochondroma also that affected this bone. So what bone


is that? That is the fibula.

Another example of enchondroma that you see in the metacarpal.

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.

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RADIOLOGY
any medications for pain or pain relievers, the pain would go
away.

4. OSTEOBLASTOMA (GIANT OSTEOID OSTEOMA)


 >1.5cm
 Also has the same symptoms with osteoid osteoma (pain at
night relieved by medications) size lang ang difference.

This is also chondroblastoma

This is a CT image where in you see an osteoma there inside the sinus.

Chondromyxoid fibroma, that is located in the metaphysis and


eccentric in location and not central.

This is another example of chondromyxoid fibroma

B. BENIGN OSSEOUS TUMORS


1. OSTEOMA So here where is the osteoma? It is in the frontal sinus.
 What’s nice with osteoma is that you only see this in the
sinuses and the most common affectation is the frontal and
ethmoid sinuses.
 Related to,the Gardner’s syndrome
 Frontal and ethmoid sinus
 If multiple osteomas are seen, check the colon for possibility
of Gardner’s syndrome, but if you only have 1 osteoma you
don’t need to look at the colon.

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

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RADIOLOGY
This is a blastic type of tumor which is round seen in the flat bones.  Fallen fragment sign – cyst associated with pathologic
This is known as the bone island. fracture, common in the unicameral bone cyst.

2. GIANT CELL TUMOR (OSTEIOCLASTOMA)


FEATURES:
 Eccentric in location
 Abuts articular surface
 Epiphyses
**Even if it is benign it can become malignant. Sometimes they
amputate patients with GCT

**IN CONTRAST WITH CHONDROMYXOID FIBROMA WHICH IS


LOCATED ECCENTRIC AND IN THE METAPHYSIS
3. EPIDERMOID CYST (CHOLESTEATOMA)

 Seen in the cranial bone


 Aka cholesteatoma

4. EPIDERMOID INCLUSION CYST


Another bone island.  Located only in the Terminal phalanx

5. HEMANGIOMA OF THE BONE


 Skull bony mass protruding in the outer table
 Occur in the skull, but sometimes it does not affect the
bone.

6. TERATOMA
 Common in the sacrococcygeal area

This is the osteoid osteoma. Pain at night relieved by aspirin. Osteoid


osteoma is a lytic bone lesion. It is not blastic. The one we saw a while
ago is a blastic type of bone lesion because it’s white. In osteoid
osteoma it is lytic.

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.

C. BENIGN FIBROUS TUMORS


-most common is that it is superficial in nature and can be seen in CT
scan only.
1. NON OSSIFYING FIBROMA
2. BENIGN CORTICAL DEFECT
So what is this? It is located on the epiphysis, eccentric and abuts the
D. CYSTIC TUMORS articular surface, it is GCT (Giant cell Tumor)
1. UNICAMERAL BONE CYST (SOLITARY)
OR THE SIMPLE BONE CYT

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RADIOLOGY
This is the sun burst appearance that we see on osteosarcoma. Most
of the time in osteosarcoma, the leg is swelling it is also big. When you
take an x-ray you will see this sun burst tumor. It is not hiding, when
you see the patient, you would see that the leg is so big and when you
take the x-ray, you will see this sun burst tumor. This is common in
children. Unfortunately this osteosarcomas are very aggressive in 3
months to 6 months time you can die.

This is the Codman’s triangle (yellow arrow) of osteosarcoma. Or


This is the epidermoid cyst or the cholesteatoma, but it periosteal elevation, that’s the Codman’s triangle.
occurred on the cranial bone not on the mastoid.
B. EWING’S TUMOR
 Primary malignant tumor arising from the red bone marrow
 5-25 y/o
 Males > females
 Affects the femur at the diaphysis
 X-ray:
o Involves a considerable length of the shaft
o Permeative, poorly marginated, destructive lesion
that perforates the cortex
o Fine hair on end spiculations, onionskin
periosteal reaction
What is this? On the terminal phalanx, known as the epidermal
o What you need to remember in ewing’s tumor is
inclusion cyst.
the onion skinning of ewing’s tumor.
VI. MALIGNANT BONE TUMORS
A. PRIMARY
1. OSTEOSARCOMA
 Most common primary malignant tumor
 Common in males than females
 10-25 years old
 Seen in the end of the femur and the proximal end of the
tibia and the humerus
 Pain and local swelling
 X-ray:
o There is bone destruction and osteoid production
o Tumor disrupts the cortex and extends to the soft
tissue
o Codman’s triangle is present
o Sun burst appearance of the lesion with
coarseradiating spiculations
o Tendency to metastasize to the lungs

This is the ewing’s tumor where you see the onion skinning, parang
periosteal elevation.

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RADIOLOGY

Punched-out lesions in multiple myeloma. This is the most painful type


of bone lesion.

VII. LYTIC BONE LESIONS


FOGMACHINES
 Fibrous Dysplasia
 Osteoblastoma, Osteoid Osteoma
Onion skinning on CT scan. There is soft tissue involvement, yung
 Giant Cell Tumor
nakabuldge (small arrow on the right of image A).  Metastasis / Myeloma
 Aneurysmal Bone Cyst
B. METASTATIC  Chondroblastoma / Chondromyxoid Fibroma
1. METASTATIC BONE TUMORS  Hyperparathyroidism (brown tumors) / Hemangioma
 Arises from breast and prostate
 Lesions are usually blastic  Infection
 Most common sites are the axial skeleton namely spine.  Non-ossifying Fibroma
Pelvis, ribs and skull  Eosinophilic Granuloma / Enchondroma
 The prostate because of proximity, the most common  Solitary Bone Cyst
affected bone is the lumbar spine and pelvic bone. Syempre
pag breast by proximity, the most common affected bone is
VIII. SUMMARY
the ribs.
 2 Primary bone tumors occurring in the Epiphysis
1. Chondroblastoma
2. METASTATIC NEUROBLASTOMA
2. Giant cell tumor
 Arises from the adrenal gland
 Paraspinal mass lesions
 Most common primary malignant tumor in children
 Skull – cranial sutures are widened with permeative
1. Ewing’s sarcoma
destruction of the skull, widened with lytic lesions of the
2. Osteosarcoma
skull
 Long bones – permeative and moth eaten appearance
 Most common primary malignant tumor in adult
1. Multiple Myeloma
C. MULTIPLE MYELOMA
 Myelopoetic lesion of the bone
 Always show punched out lesions
 It is the most common primary tumor arising in the bone
 Abnormal gamma globulin, abnormal protein (Bence Jones
protein)
 X-ray:
o Multiple, round, punch out lesions

- exam 100 points


10 doc leung
10 me
30 leung
50 galang
10 breast
10 OB
10 gyne
20 bone

This is the common punched-out lesions of the bone.

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