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General Approach to Musculoskeletal Imaging A Alignment B Bone C Cartilage D Disc S Soft tissue
Geographic
Large, well-defined or ill-defined hole
Motheaten
Small, countable holes
Permeative
Tiny, uncountable holes
benign
malignant
Lamellated/ Onion-skin Sunburst/sunray Hair-on-end Codmans triangle
Solid type
Slowing-growing process
Interrupted type
Rapid-growing process
benign
malignant
VITAMIN C+D
Specific DDx
Demographics
Age
20-40 SpA RA CNTD Septic Male SpA Gout 2OA HOA >40 OA / DISH Gout/CPPD HOA
Septic
Sex
CNTD Spondyloarthropathies DISH Tumors : osteosarcoma, MM, metastasis Rheum.manifestations in systemic dis.
Radiographic Hallmarks
Osteophytes ( OA ) Erosion ( RA ) Punch-out Metabolic ( Gout ) Inflammation Degenerative
Pattern Approach
Radiographic Reading
Describe type of X-rays Joint space Joint surface Subchondral bone ABCDS Adjacent bone Alignment Periosteal reaction ( if present ) Soft tissue Always specify which one / side is/are abnormal
Case Approach
1.Radiographic Reading 2.Most likely diagnosis
Osteoarthritis
Characteristic : Non-uniform joint space narrowing Irregular joint surface Subchondral sclerosis / cyst Osteophytes Deformity
Common location : Knee, DIP, PIP, 1st CMC, 1st MTP Spine : lower C, lower L
Septic arthritis
Soft tissue swelling with joint effusion Localized osteopenia Diffuse joint space loss Marginal or central erosion May occur with periosteal reaction
Chronic granulomatous disease ( TB ) Characterized by extensive osseous destruction with minimal reactive sclerosis
TB arthritis
Phemisters triad :
Pyogenic +
+ Late + + + +
+ Early + + + -
Osteoblastic Metstasis
5 Bees Lick Pollen
Brain ( medulloblastoma ) Bronchus Breast Bowel ( espeically carcinoid ) Bladder Lymphoma Prostate
Neuropathic Joint
Hypertrophic : 5Ds ( 6Ds ) Atrophic Density Resorbed articular surface Debris Tapered bone end Dislocation Disorganization Destruction ( Distension )
Spine T
LE
L H K A F S E W
++ + +++ + + +++ ++ +
+ +++ ++
+++ ++
++
Case 5 : 15 yo boy fever, weight loss, painful progressive swelling of Rt.thigh 5 mths
Osteosarcoma
Location :
Femur ( 40% ) > tibia, humerus
Codmans triangle
Characteristics : Typical mixed osteolysis + sclerosis Poorly-dened, intramedullary, metaphyseal lesion cortex and
extended through or
triangle
Osteoarthritis : Spine
Common location C5, C6 L4, L5 Osteophytes Sclerosis Intervertebral disc Loss of disc height Vaccum phenomenon
Vacuum phenomenon
Chondrocalcinosis
Chondrocalcinosis
WHIP A DOG Wilsons disease Hemophilia / hemochromatosis Hyperparathyroidism / hypothyroidism Hypomagnesemia / Hypophosphatasia Idiopathic Pseudogout Amyloidosis DM Ochronosis
Case 8 : 45 yo female symmetrical pain in both hands, knees & feet with severe deformity
RA :
Bilateral Symmetry Uniform joint space narrowing : PIP, MCP, wrist Marginal erosion Juxtaarticular osteopenia Deformity : ulnar deviation, Boutoniere, swan-neck
Atlanto-axial Subluxation
Common :
Case 9 : 43 yo healthy athlete man painful Rt.knee with vigorous exercise 3 mths
Characteristic :
Overhanging
RA
Symmetry
Fusiform Rare
Case 11: 54 yo lady finger pain with activity & intermittent swelling
Erosive OA
Gull-wing appearance
Case 12 : 28 yo man prolonged fever with back pain at mid-thoracic region 3 mths
Tuberbulous Spondylitis
Most common site of skeletal tuberculosis Common site : T12-L1 Radiographic findings : Discovertebral lesion Vertebral end plate + disc involvement
May occur with paraspinal abscess
Case 13 : 52 yo man swollen, painful both legs with chronic cough & weight loss 4 mths
Case 14 : 47 yo lady Rt.sided chest pain & back pain with weight loss 3 mths
CA Metastasis
Spinal Metastasis
Location
Lumbar / Thoracic vertebra Vertebral body, pedicle
Sign
Altered bone density Decreased : motheaten, permeative Increased : localized, ivory vertebra Cortical destruction Disc space preserved Pathologic collapse Decreased posterior vertebral height Endplate disruption
Bumpy spinal contour
Radiolucent area beneath the deposited
( halo space between the ossication
and the anterior aspect of spine )
bone
Sausage-shaped swelling Less / lack of osteopenia More BONY ankylosis Evidence of enthesitis : Achilles & plantar fascia
Crescent Sign