catatan radiologi muskuloskeletal
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MUSCULOSKELETALRADIOLOGY
Roentgenographic
of bone giveinformation about
1. Bone & soft tissue lesions
2. Fracture/ pathologic fracture
3. The origin of the lesion dan the type of the tumor (benign/malignant)
4. Guiding biopsy
5. Follow Up
Composition of
bone 25% of water, 30% organic, 45% nonorganic (radioopaque density) :
Caphosphat 85% and Cacarbonat 15%
Blood supply of bone :
1. A.Nutricia (fossa a.nutricia bone x-ray)
2. A.Metaphyseal& a. epiphyseal (direct supply for meta/epiphyse)
3. A. Periosteal (branch from nutricia artery which through the Harvers&Volkmansystem)
Radiologicanatomy
Book of Meschan I :1. Articular cartilage
2. Subarticular of epiphyse3. Epiphysis
4. Epiphyseal line5. Metaphysis
6. Diaphysis
Disorder of boneand joint
1. Development anomaly/Congenital2. Infection
3. Trauma & fracture4. Deficiency Bone disease
5. Bone Dysplasia
6. Bone tumors7. Avascular necrosis/Aseptic necrosis
8. Degenerative disc disease/Metabolic
1. Development Anomaly/Congenital
1.1 Arthrogryposis Multiple Congenital failure of muscle growth
1.2 Upper extremities : a. Bone absent : hemipelya distal and Phacomelya proximal
b. Synostosis Radius & Ulna
c. Hand:Brachyphalangea (short hand), Brachydactili (short metacarpal), Long
tubular bone , and Polydactyli
1.3 Pelvis : - Nargle& Robert pelvis :Absent of one sacral wing and Robert = Nagle bilateral
- Iliac Horns Dorsal Protrusion of Processus from iliac wing
1.4 Lower extremities : a. Congenital dislocation of the coxae (Hip)
b. Congenital Coxavara : bowing femur, bilateral shortening
c. Patella bipartite & multipartite
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d. Congenital Pseudoarthrosis Tibia & Fibula: mid/lower third and commonlylesion in fibula
e. Leg & ankle: Pesequinovarus and Ball &sochet ankle foot
1.5. Columnavertebralis : Coronal clefts vertebraspina bifida, Hemivertebra, Sacralization, Lumbarization,
and Scoliosis.
2.INFECTION
2.1. OSTEOMYELITIS
a. Pyogenic / suppurative: Staphylococcus, Pneumococcus, Streptococcus, Salmonella
Mechanism of contamination: - Hematogenous from focus infection(throat & skin)
- External contamination (open fracture/bone operation)
b. Spesific/ non suppurative: TBC, virus, dan fungi, and slowly than pyogenic
Acute Chronic
- commonly in children
- metaphyseal (distal femur, proximal tibia , proximaland distal humerus ,radius, ulna and collumna vertebrae )
inadequacy therapy
Radiology:- Lytic lesion
- Periosteal reaction- Soft tissue swelling
Radiology :- Generally Osteosclerosis
- Increased in bone diameter- Irreguler contour with thickening cortex
- Lytic lesion can occur- Occationallysequestrum formation
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2.2.TUBERCULOUS SPONDYLITIS
Marginal type Central Type Anterior type
- Superior/inferior adjacent
vertebral disc
- Destruction with lytic lesion in
anterior column, disc damage very
fast narrowing disc
- involvement multiple contiguous
column.vertb
- wedgegibbus
- Spider leg app
- chronic Calcification in abses
- Osteosclerotic (-)
- Abcess /cold abcess in the central
of collumn vertebra.
- destruction of disc slowly
- if extend to the periphery theprocess is same with
marginal
- process under periosteum
- extend below the Lig.Longitudinale anterior
- Disc destructionslowly
2.3. LONG BONE TBC
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Radiology :
- especially in metaphysis
- lytic lesion is dominant
- sometimes minimal surrounding sclerotic
- minimal/no periosteal reaction
- minimal soft tissue swelling
Primary bone
Secondaryhematogen
3. TRAUMA & FRACTURE
Trauma Minimal : Hematoma sometimes not seen in bone x-ray,
Severe ; subluxation, dislocation with fracture
External : accident, fall
Internal : strong and sudden muscle contraction, for example : epilepsy, tetanus &
electric shock
Fracture discontinuity of bone, cartilage or both of them with soft tissue damage
Fracture open or close
Fracture Complication
1. Osteomyelitis2. Non Union (neoarthrosis)3. Bone artrophy
4. Bone formation in musclemyositis ossificans
5. Severe deformity
Fracture type :
Transversal fr Oblique/spiral/screw fr.
Comminuted fr more than 2 fragment Avulsion fr.
Green stick fr. (children)
Compression fr. vertebrae
Impression fr. skull Linier fr.
FrakturtranseversaFraktur
oblique
Frakturkominutif
Frakturkompresi
Distal
Radius
fracture
a.Colles Fracture: Distal radius fr. (until 2 cm ) with posterior angulation, posterior dislocation
& deviation of distal fragmen to radial.
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b. Smith Fracture: Distal radius fr. with dislocation of fragmen distal to volar.
Fracture
and
dislocation
radius and
ulna
a. Monteggiafraktur: proximal ulna
fr.with caput radii dislocation
b. Galeazzifraktur: distal radius fr.with distal
dislocation of radioulna joint.
Pathologic
Fracture
1. Severe trauma Fr.2. Spontaneous Fr./pathologic Fr. : Bone tumor ( primary, secondary) and Infection
( osteomyelitis)
3. Stress Fr. minimal and continous for examples
March fr. metacarpal
Tibia fr. Ballet dancer
Fibula fr. long distance runner
Other T,V,Y shape fr., Impacted fr., Longitudinal fr.
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X-Rayevaluation
1. Diagnostic immediately after trauma2. Post reposition
3. 1-2 weeksto follow up the position of the bone fracture(changing position or no)
4. 6-8 minggu callus formation5. Every changing position/traction6. Before go out from hospital
4.DEFICIENCY BONE DISEASES
Rickets (Hypovitaminosis D) Scurvy (hypovitaminosis C)
Bone disease deficiency vit D with kidney andmineral absorption disorder
Roentgenographic feature :
1. chondrocostal junction enlargement(rachitis rosary)
2. Cupping of metaphysis (muscle &ligamentumtraction)
3. Bowing long bone4. Commonly Greenstick fr.
5. SubperiostealCalsification6. Irregularity of ossisilii
7. Metaphyseal lineirreguler& frayed
8. skull : Fontanella + suture (still open)9. Osteoporosis
1. Caused of deficiency Vit C make the failure of
intracellular forming include bone, catilage&endothelforming
2. The bone forming is persued but the reabsorption
still happen osteoporosis
Rontgen :
1. General Osteoporosis
2. Ground Glass Appearance
3. Cortex thin
4. Metaphysealwide (cupping)
5. Pelkens signmarginal spur formation
6. Wimbergers sign marginal ring calcification ofcentral ossification in epiphysis
7. Subperiosteal hematomacalcification
subperiosteal bone
5.BONE DYSPLASIA
Bone forming disturb or intrinsic bone modelling
Fibrous dysplasia OsteogenesisImperfecta Achondroplasia
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Divided into 2 : monostotic (femur,tibia, costae,& facial bone)
danpolyostotic (many bonesunilateral)
Rontgen :
1. Ground glass app
2. Cortex intact & wide
3. Endosteal cortex thin &scalloping
4. Diaphysis wide & expansive
5. Sometimes sclerotic is dominant
6. Skull : marginal sclerotic, wide
diploe, uppermost of tabulaexternal (tabula internal not
frequent), sclerotic of skull base,sphenoid crypt & facial bone
( thickness & sclerotic of facialbone & skull base, obliteration of
sinus maxillaries)
Ireguler circumscribed destruction
of bone with thick sclerotic margin
consisted of 2 type
congenital (since born) &tarda
(the symptoms seen inchildhood)
Rontgen :
1. Osteoporotic (ground glassappearance)2. Multiple fracture
3. Bowing of inferior extremity
4. Vertebra biconcave
5. Bone deossification +
diameter of bone become wider6.skull: - thin tabula + warmian
bone7. Protrusioacetabuli
All long bone (extremity) short
But Corpus Vertebra still normal
Roentgen :
1. Shortened of long bone &symetries
(mycromelia)
2. The Proximal bone shorter thandistal bone (rhizomelia)humerus
shorter than radius, femur shorter than
tibia
3. Metaphysis wide & cupping (in
the distal long bone)4. The finger bone short & more wide .
For example 3rd finger & 4th finger are
same (trident hand)5. Column Vertebrae : wedge (vertebra
lumbal), posterior margin of column
vertebrae become concave so that theforamen intervertebrale more wide,
diameter AP of pedicle become shorter
6. Head bigger (brachycephaly)
7. Fibula head longer than tibia (sameas ulna and radius)
8. Pelvic bone champagne shape(acetabular angle leveling off)
7. BONE TUMORMay benign or malignant and may primary or secondary (metastasis) :
To differentiate the tumor is malignant or not 1. 0 - 5 years : neuroblastoma
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1. Age
2. How long the pain & the swelling and the
growth of the tumor (slowly or fast)
3. Size of the tumor
4. Number of lesion (mono/polystotic)5. Location (what part of the bone)
6. Density : osteolitic, osteosclerotic& mixed7. Structure of tumor : the margin, the type of
destruction (central/marginal), type ofperiosteal reaction, continuity of the cortex
8. Bone shape : bowing, fracture
2. 5 - 20 years : Ewing tumor
3. 10 - 25 years : osteosarcoma
4. 20 - 40 years : giant cell tumor
5. 20 - 70 years : lipoma
6. 30 - 45 years : fibrosarkoma
7. 30 - 50 years : periosteal sarcoma
8. 30 - 60 years : chondrosarcoma
9. 30 - 70 years : hemangioma
10. 40 - 80 years : metastasis, Multiple
Myeloma
There are 3 principal point in bone lesion
assessment : * infection or neoplasm
* benign or malignant
* primary or secondary
Classification of Bone tumor
From skeletal tissue Cartilage Fibrous Giant Cell (Giant Cell
Tumor)
a. Benign: bone island,
osteoma, osteoidosteoma, osteoblastoma
b. Malignant
Osteosarcoma, periostealsarcoma
a. Benign
:Chondroma,Chondroblastoma,Chondromyxoid Fibroma
b. Malignant
(Chondrosarcoma)
a. Benign: Fibroma,
Brown Tumor
b. Malignant:Fibrosarcoma
a. Benign: GCT, ABC
{Aneurysma BoneCyst}
b. Malignant: Giant
Cell Tumor Maligna
From other tissue in the bone:
1. Vessels : Hemangioma,
Glomustumor, Hemangiosarcoma
2. Nerve : Neurofibroma,
Neuroblastoma,Neurofibrosarcoma
3. Fat : Lipoma, Liposarcoma
4. Notochord : Chordoma
5. Epithel : Dermoid, Adamantinoma
6. Lymphoid/Hemopoetic ;Lymphoma, Leukemia,Plasmocytoma,
Multiple Myelom
From the jointSinovioma Unknown :
a. Benign : SolitaryBone Cyst
b. Malignant : Ewing
Tumor
Benign Tumor Malignant Tumor1. Bone Island ( Enostosis ) 1. Osteosarcoma
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Ro : - Soliter/ Multiple- always in Medulla
- densityHomogen
- marginmay Irreguler .
Spiculated into medulla
Sclerotic bone island in the distal femur & proximal
portion of tibia
according to position (central,peripheral)according to lesion (osteolytic,osteosclerotic,mixed)
Male > female
Ro :
Sites : distal femur, rarely in tibia, sternum,
costae, skull Position of lesion : metaphysis / diaphysis
50% sclerotic, may osteolytic, mixed (irregular
margin )
Periosteal reaction sunburst/Sun Ray app.
Other Typically : cortex destruction & invasionto soft tissue
Soft tissue swelling
Codman Triangle
2. Osteoma :
Ro : - Sites : Skull, Sinus Paranasalis- Size 2.5 Cm
- High density, welldefined margin &homogen
2. Fibrosarcoma
5 % skeletal tumor
Low grade pain
1 yearOften in medulla Metaphysis, 80% kneeRo :
Typically osteolytic
In medulla (irregular radiolucent area)
Expansion of cortex
Soft tissue swelling (caused of expansion to soft
tissue)
Periosteal reaction No/rarely
Periosteal fibrosarcoma of forearm involving the ulna
3. Osteoid Osteoma
Male : Female = 3 : 1
Decade 2 / 3Predilection : Diaphysis of long bone (50% proximal
femur), Tibia, Skull rarely
Ro : - Radiolucent area, Oval/rounded sclerotic
margin- High density
3. Chondrosarcoma
Age : 30 70 thn
Sites : Pelvis, costae, proximal femurRo :
o Local cortex destruction, ill-definedtransition
between normal tissue & lesion cannot be
differentiated
o Central tumor irregular calcificationo Endosteal erosion, scallopingpop-corn
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- Diameter 2.5 Cm
Benign osteoblastoma (Giant osteoid osteoma)
appearance
o Periosteal reaction Lamellar
chondrosarcoma
4. Osteochondroma
- outgrowth of bone , from cortex diaphysis of long
bone- point away from nearest joint
Ro :
- Pedunculated type (outgrowth of bone from cortextrabecula penetrate into medulla through the defectof the cortex )
- Calcification
- size 8-10 cm point away from joint
- Pelvic & scapula irregular & high density
Cauliflower app.
osteochondroma
4. Ewing Tumorfrom medula
age 5 20 yearsSites : long bone
Ro :
Lamellar periosteal reaction(Onion Skin app.)
Codman triangle Sometime sclerotic (longitudinal band)
Bone destruction
Soft tissue swelling
Ewing tumor
5. Giant Cell Tumor (Osteoclastoma)
Age 20 40 years
Rarely before maturity of bone
Sometimes multifocal in hand SoliterSites : knee, distal radius, sacrum,
pelvis & vertebrae.Ro :
Radiolucent zone, typically in the cortex below
the joint
Eccentric in the tip of long bone
No calcification/occification except after
pathologic fracture
Typical finding : trabeculationlikeSoap
Bubble App40% of cases
Osteolitic margin
ill defined, no bone reaction
Cortical thinning & expansion
Lesion may expansion to soft tissue, no
5. Sinovioma
70% inferior extremity knee
Age < 30 years
Very malignant immediately metastasis(lymphogen)
Ro :
Soft tissue mass around the joint
Many calcification
Irregular bone destruction near the joint
Thickening of sinovial& erosion ofjuxtacapsular
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calcification
Angiographyhypervascular, with many
vessels & shunting arteriovenous
DD : Aneurysmal Bone Cyst,
Chondroblastoma, Fibrous Dysplasia
Aneurysmal Bone Cyst
- Ethiology unknown
- Sometimes found after fracture
- Affect to children, sites long bone
- in vertebrae age 10-20 years, especially atarcusneuralis, rarely at corpus.
- Commonly multiple vertebraeRo :
reabsorption bone area with bone expansion
Size varying 2-20 cm
Cortex thin & expansion
Endosteal margin is well-defined with cortex
Soap Bubble Appearance
Transition zone between lesion & medulla,
sometime with sclerotic. Similar withosteoclastoma. Sometime scalloped
atauirreguler, sclerotic margin Angiography similar with Osteoclastoma
DD : Osteoclastoma /Giant Cell Tumor
Aneurysm bone cyst
6. MM (Multiple Myeloma)
Primary Malignant tumor of bone marrowRo :
Osteoporosis cortical thinning
Osteolytic Punch out lesionmultiple, rounded, well-
defined, intact, varying in size
Inner cortex scalloping
Sometime expansive with soap bubble app.DD : metastasis
7. Metastasis
May osteolytic, osteoblastic, ill-defined
Irregular margin& sometime with sclerotic marginsites of metastasis :
vertebrae
costae & sternum
skull & pelvic
other bone
8. Avasculer necrotic of bone ( osteochondritis, osteochondrosis,bone infarction)
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abnormality of bone which one of the bone loss of vascularitymake the cell dead osteonecrosis
Commonly no infection
Early stage Late stage Sites of osteochondritis
Ro :
early stage no damageof bone
medium diffuse
osteoporosis, normal densityin the avascular area
Big joint (microfracture of thecortex hip & shoulder,
follow by trabecula
compression &colaps that make
joint more horizontal with
subarticular growth and in same
time the trabecula depressed
into smaller space.
Infarction of metaphysis
&subarticular infarction
lucent in the central
Bone within Bonelineardensity in the bone & parallel
with cortex
Abnormality of epiphysis
Cone epiphysis premature
fusion
1. Corpus vertebra Calve Disease
2. Vertebral epiphysisScheuermanndisease
3. CapitulumHumerusPannersDisease
4. LunatumKienboeck disease
5. Proximal phalangesThiemansdisease
6. Caput metacarpal Dietrich disease
7. Caput femoris Calve Leg Perthes
8. Distal collumfemorisCoxavara
9. Tibia/apophysis tibia OsgoodSchlatter
10. Condylus medial tibia Blountsdisease
11. Calcaneus apophysis Sever disease
12.Naviculare Alban Kochler
13. Caput metatarsal Freiberg Kochler
OsteoporosisSystemic skeletal diseases decreaseof bone mass & microstructures caused bone weaker& easier to get fracture
Radiologic of osteoporosis
1. Conventional Radiology
- Vertebrae x-ray 4 grading
- Femur x-ray used index Singh- Metacarpal
2. Photodensitometry/Radiography Densitometry
3. Single Photon Absorptiometry (SPA)4. Quantitative Computed Tomography (QCT)
5. Peripheral Quantitative Computed Tomography(PQCT)
6. Dual Energy X-Ray Absorptiometry (DXA)7. Sonodensitometry.
8. Neutron Activation Analysis9. Compton Scattering
10. Radioisotop11. Magnetic Resonance Imaging (MRI)
8. DEGENERATIVE JOINT DISEASES
A. SPONDYLOSIS /
SPONDYLOARTHROSIS
Osteo Arthritis of Spine
Rontgen :
- Spur formation / osteophyteAnterior, Posterior, and Lateral
- bridging bamboo spine
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- Marginal sclerosis of corpus vertebra
- Spur may in-growth (foramen Intervertebralis usually cervical (C5,C6,C7)neurologic sign
B. OSTEOARTHRITIS
(OA)- Osteoarthrosisdegeneratif joint disease
- Predilection from the knee
- Female > male
Rontgen (finger) most find at
interphalangeal joint
Always narrowing of jointspace
Irreguler of joint (the
margin)
Herbedens Nodes at dorsalfacies of distal phalanges
(base) spur-formation
Subchondral cyst like defect
Ro (Knee) :
Spur at posterior aspect of
patella
Spur formation : condylus
tibiaproximal, femurdistal,eminentiaintercondyloid
ea tibia
Narrowing of joint spacemedial aspect
(DD.Rheumatoid:all joint)
C. PSORIATIC
ARTHRITIS- Predominant destruction distal interphalangeal joint (as Osteoartritis)- Ankylosing at interphalangeal joint
DD.- Rheumatoidat interphalangeal joint
- Joint space more widesurface is clearly- Destruction arthritis at interphalangeal joint of feet thumb
- Mild osteoporosis
- Footmore shown psoriatic arthritis- Bone mineralization is normal
D. ANKYLOSING
SPONDYLITIS
Marie strumpells/von Bechterews/rhematoid
Spondylitis, female =malecommonly youth
Rontgen :
Sacro-iIiac Joint (SI joint) blur wider narrowing
sclerosing/ankylosing (bilateral)
Always start at SI Joint
Squaring anterior corpus vertebrae
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Generalize osteoporosis
Calcification of ligament+ paraspinal soft tissue
Bamboo-spine
Disc destruction
Syndesmophyte formation
E. RHEUMATOID
ARTHRITIS
- Female > male- Multiples &Symmetris
- Mostly : proximal interphalangeal joint, metacarpophalangealjoint,wrist joint(radiocarpal), not all joint can affect
Rontgen :
Periarticular soft tissue swelling fusiform (spindle shaped)
Periarticular Osteoporosis cartilage destruction
Marginal erotionjuxta articular arthritis mutilans
Ankylosing + subluxatio
Ulnar deviation of finger caused of subluxatio ( flexy- extension swan neck Appearance )
Rheumatoid arthritis with scleroderma
F. GOUT Male > female, > 40 years
Rontgen :
Radiologic change after multiple attack
Commonly only one jointmetacarpophalangeal joint ( but other
joint in hand & leg can be attacked)
Deposite of Na-Uric not radiopaque (not seen ,just periarticular&joint swelling)
Osteolyticjuxta articular small/big with well-defined
Subarticuler cystic area sclerotic margin Over hanging
edge,D0,3-3 cm PUNCHED OUT
If there are depositesCa in tophy the tophy is seen Narrowing joint space
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Decrease of Osteoporosis
SKULL X-RAY
Information /abnormality: Sign of Intracranial pressure increasing :
Fracture
Infection
Tumor : primary and secondary
Sinus paranasalis
Congenital
Suture more wide
Impressionesdigitatae
Destruction of sella
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