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Musculosceletal Imaging

for Medical Student

Herman Pieter L. W
Radiologist

Departement of Radiology Medical Faculty


NUSA CENDANA UNIVERSITY
Goals of this lecture:
To be able to choose appropriate imaging
modalities for various MSK pathology
To be able to detect pathology, diagnose
fractures, detect joint abnormalities,
recognize the systematic approach of
diagnosing bone tumors
MSK Imaging Imaging Modalities
Plain Radiographs
Ultrasound
Computed Tomography
Magnetic Resonance Imaging
Nuclear Scintigraphy
BMD-DEXA
Plain
Radiograph

ULTRASOUND

MRI Scintigraphy

CT Scan
Plain Film
Primary imaging modality of
bone and joint imaging,
particularly in trauma
Advantages
fast
inexpensive
readily available
good for assessing bones and
joints
Plain Film
Primary imaging modality of
bone and joint imaging,
particularly in trauma

Disadvantages
uses ionising radiation (x rays)
limited information regarding
soft tissues
How to Interpret MSK images?
What is this???? What??????
ABC-s
Evaluasi sistematik

a.Alignment
b.Bone
c.Cartilage
d.Soft tissue
ABC-s
Evaluasi sistematik

a.Alignment
b.Bone
c.Cartilage
d.Soft tissue
Plain x-ray Orthogonal Views (AP-Lat) for
fractures
Mal - alignment ; joint dislocation
Spondylolisthesis
AC joint dislocation
Sacro-coccygeal angulation- post trauma
Scoliosis: Neutral + lateral bendings
ABC-s
Evaluasi sistematik

a.Alignment
b.Bone
c.Cartilage
d.Soft tissue
BONE

Bentuk
Cortex
Medula
Trauma/
FRAKTUR
Fraktur
Tipe Fraktur
Arah garis fraktur
Fraktur inkomplet dan
epiphysiolysis
Patah Tulang pada lempeng tulang yang
masih tumbuh: Epiphysiolysis
Klasifikasi menurut Salter & Harris

S A L T R
slipped above lower through ruined
Trauma
lempeng
pertumbuhan
Pathologic Fracture
Plain films post ORIF (open reduction
internal fixation)
After 2 months
Pins and wires Dislocated pins
OSTEOMYELITIS
Soft tissue mass above the right knee Osteomyelitis
TUMOR
Despite all of the imaging advances: CT,
MRI, Scintigraphy .

Radiograph remains the


most reliable predictor
of the histologic nature
of a given lesion
Informations needed to formulate diagosis
or differential diagnosis of bone tumor
Age
Growth Rate/ Activity
Periosteal reaction
Location
Matrix calcification
Soft tissue Component
Size of the lesion
Growth Rate/ Activity:
Based on 3 types of destruction:
Geographic
moth-eaten
permeative

Lodwick et al. Radiology 134:577-583,1980


Geographic
Geographic
Moth eaten
Permeative

Batas air dalam


sponge sulit
ditentukan
Margin + Transition Zone Aggressiveness

More Agressive / Malignant

Geographic Moth-eaten Permeative


Informations needed to formulate diagosis
or differential diagnosis of bone tumor
Age
Growth Rate/ Activity
Periosteal reaction
Location
Matrix calcification
Soft tissue Component
Size of the lesion
Periosteal recation

MORE AGRESSIVE/ Malignant

Interupted Interupted Uninterupted


Informations needed to formulate diagosis
or differential diagnosis of bone tumor
Age
Growth Rate/ Activity
Periosteal reaction
Location
Matrix calcification
Soft tissue Component
Size of the lesion
Location

Osteosarcoma

Parosteal sarcoma

Osteochondroma
Typical Locations of Bone Lesions
Informations needed to formulate diagosis
or differential diagnosis of bone tumor

Age
Growth Rate/ Activity
Periosteal reaction
Location
Matrix calcification
Soft tissue Component
Size of the lesion
The form of calcification determine the
tissue origin of the Tumor

Punctate
chondoid/ Flocculent
chondroblastic Comma shaped
Ring like

Fluffy
osteoid/ Amorphous
osteoblastic Cloudlike
Calcification Matrix

ChondroblasticEnchondroma
Informations needed to formulate diagosis
or differential diagnosis of bone tumor
Age
Growth Rate/ Activity
Periosteal reaction
Location
Matrix calcification
Soft tissue Component
Size of the lesion
CT Large soft tissue mass malignant transformation
from (benign) Osteochondroma to Chrondrosarcoma
Informations needed to formulate diagosis
or differential diagnosis of bone tumor

Age
Growth Rate/ Activity
Periosteal reaction
Location
Matrix calcification
Soft tissue Component
Size of the lesion
Size and Diagnosis

1,5 cm < Osteoid Nidus > 1,5 cm :


Steoma Osteobastoma

< 3 cm Well defined lytic >3 cm


Fibrous Cortical Lesion Nonossifying Fibroma/
defect/ In the cortex of long Fibroxantoma
Fibroxantoma bone

1-2 cm Chondral 4-5 cm


Enchondroma Lesion Low Grade
Chondrosarcoma
ABC-s
Evaluasi sistematik

a.Alignment
b.Bone
c.Cartilage
d.Soft tissue
Catrilage: Joint narrowing
Catrilage: Joint narrowing + osteophyte / lipping
Example of applying ABCs

(A)Spndylolisthesis
(B)Spondylolysis
(C)Severe DDD-
degenerative disc
disease
ABC-s
Evaluasi sistematik

a.Alignment
b.Bone
c.Cartilage
d.Soft tissue
Swelling after DPT injection
Ultrasound
Relatively inexpensive
Sound waves reflecting from soft tissue interfaces
No ionizing radiation
MSK applications
tendon injuries especially rotator cuff
soft tissue masses
US guided biopsy
ROTATOR CUFF TEAR
The majority of cuff
tears: in supraspinatus
tendon.
Supraspinatus
(longitudinal)

GT
Normal Achilles

Calcaneus
Computed Tomography (CT)
x ray tube rotated around the patient

cross sectional imaging capability

reformatting in other planes and 3D

best for bony cortex and calcification

good at evaluation of comminuted fractures to


complex structures
Pelvis, calcaneus, wrist
Calcaneal fracture
coronal and sagittal reformatting
Computed Tomography (CT)
disadvantages

radiation dose to patient

metal artefact

poor soft tissue characterization


Magnetic Resonance Imaging

Non-standardized imaging techniques


Excellent for soft tissue pathology
Good-excellent for bone pathology
NOT patient friendly
Large expense
MRI Absolute Contraindications

Aneurysmal clip.
Pace maker.
Stress Fx.
MRI for Stress Fx.
Nuclear Medicine
entire skeleton at once
bone scan is an indicator of bone turn over
very sensitive, not specific
fracture
tumour
arthritis
infection
metabolic bone disease
Normal plain film

Bone scan multiple


bony metastases
Imaging
Plain radiographs are usually the starting
point
Secondary imaging techniques have
specific advantages and disadvantages
When in doubt, ask a Radiologist
Communication

between
referring
physicians and
Radiologist is
most important