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N. Diana Yulisa, Marcel Prasetyo

Radiology DepartmentFaculty of Medicine, University of IndonesiaDr. Cipto Mangunkusumo General Hospital

Jakarta

Imaging Imaging of the of the

Musculoskeletal SystemMusculoskeletal System

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Introduction

• Radiology : key to the diagnosis!

• Understand the basis to determine the most effective radiological technique.

• Each bone to be examined in its entirely.

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• Plain film : most effective modality.

• Views and techniques that best demonstrate the abnormality

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• Correlation to clinical history, age and sex

• If definitive diagnosis cannot be established DD/

• Monitor progress of treatment and possible complications

• Other imaging modalities : compliment!

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6AP projection

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Lateral projection

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How to analyze a plain film?

• Position and alignment of joints

• Cortex, medulla, bone contour and structure

• Articular ends

• Adjacent soft tissue

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Other modalities

• Ultrasound• CT scan• MRI• Nuclear medicine/bone scan

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Ultrasound

• Interaction of sound waves with tissue interfaces in the body

• Noninvasive• Dynamic study real

time• Cost-effective• Operator dependent

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Musculoskeletal US

• Infant CDH, spina bifida• Soft tissue muscles, joint• Dynamic study combined with plain

radiography first line imaging modality in musculoskeletal imaging and sports medicine.

• Bone fracture, destruction• Biopsy guidance

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CT scan• Using X-ray source,

detectors and computer data-processing system.

• Multi slice• Complimentary to

plain film

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Computed Tomography (CT scan)

• Trauma small bony fragments, cartilage damage, 3D reconstruction

• Soft tissue tumors visualization of adjacent soft-tissue structures and medullary cavity

• Contrast media determine the vascular structures

• Biopsy guidance

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Magnetic Resonance Imaging(MRI)

• Re-emission of an absorbed radio frequency with the patient in a strong magnetic field

• The system: magnet, radio-frequency coils, a computer display unit

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• detection and evaluation of the joints, bone tumors, infection, bone infarct, and ischemic necrosis

• Visualize bone marrow exquisitely• Visualize abnormalities within bone and

their relationship to the surrounding tissue

• Vascular structures : clearly demonstrated

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Scintigraphy

• Radiopharmaceuticals and gamma camera

• Functional imaging• Using radioisotope

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Bone scintigraphy• Valuable adjunct to standard film

radiography• Radionuclides are taken up in areas of

increased bone turnover• Normal uptake vs abnormal uptake• Whole body scanning• More sensitive than anatomic imaging

screening• Less specific

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Five major groups of disorders

• Trauma• Infections• Tumors• Degenerative diseases• Congenital disorders

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Trauma

• Fractures and dislocation : most common

• Plain film radiography 1. Diagnosis and evaluation 2. Monitori results of treatment 3. Look for possible complications!

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• Two views : AP and lateral projection.

• Additional oblique projection : joint

• Radiography of the long bone : both joints included

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• CT scan : detection of fractures in complicated structures

• MRI : soft tissue involvement

• Bone scan screening for subtle/occult fracture and monitor fracture healing

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Infections

• Involving bones : osteomyelitis

• Involving joints : infectious arthritis

• Involving soft tissue : cellulitis

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Acute osteomyelitis

• Latent period of 10 to 12 days between onset of clinical symptoms and definite radiographic changes

• Early osteomyelitis bone scan• Leucocyte-labelled radioisotope : locate

infection site• Early bone marrow changes MR

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Plain radiograph:• Less sensitive• Poorly defined destruction area and a fine,

granular or slightly mottled appearance.• Periosteal reaction : new-bone formation • Late stage : prominent destruction &

periosteal reaction

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Subacute and chronic osteomyelitis

• Bone abscess Brodie’s • Involucrum and sequestrum • Thickened & deformed bone with

sclerotic cortex and wavy outer margin• MRI is very useful in the evaluation of

chronic osteomyelitis

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Tuberculosis

• Usually as hematogenous spread from lung or genitourinary tract

• In children, predilection site is metaphyseal segment of long bone; in adults, the joints are more often affected

• Radiographic findings are progressive destructive of medullary region with abscess formation and minimal periosteal new-bone formation

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Tumors/Neoplasms

• Benign

• Malignant primary secondary metastatic

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Diagnostic criteria Plain film radiograph:• Age• Location• Type of bone destruction• Lesion margins• Matrix calcification• Periosteal new-bone formation • Soft tissue involvement• Single or multiple lesion(s)

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Bone Metastasis

• Bone scan or SPECT-CT can be used for screening

• Plain radiography to confirm may be needed, CT/MRI in negative or equivocal result

• Symptom (+) plain radiography• Follow up by bone scan or MRI if needed

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Conventional radiographs of vertebral metastases, compare to normal vertebra (right).

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Female with breast carcinoma : Detection of metastases using

SPECT

http://www.fsnm.org/assets/images

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Bone scan vs PET ScanOehr P, Biersack HJ, Coleman RE.

PET and PET-CT in oncology.Berlin : Springer-Verlag, 2004.

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Male, 32 yrs old, with non-Hodgkin lymphoma. CT Images showed multiple vertebral destruction due to metastases.

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67Courtesy of PT Siemens Indonesia

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Arthritis

• Abnormality of joints due to degenerative, inflammatory infectious or metabolic process

• Including : connective tissue arthropathies, (SLE, scleroderma)

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• Plain radiography: AP and lateral positions Special projection if needed• A weight-bearing view, particularly for joint

space under the weight of the body• Scintigraphy is commonly used for evaluating

the distribution in different joints• MRI provides excellent contrast between soft

tissue and bone the best modality to shows the joint abnormality

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Congenital Disorders

• Complete failure of a bone form• Faulty formation of bones• Manifest as decreased number of bones

(agenesis and aplasia), supernumerary bones (polydactyly), bone fusion (syndactyly and synostosis) disturbance in bone growth (hypoplasia, atrophy, hipertrphy, giagantism), etc

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• Radiologic examination: Most cases can be diagnosed by plain

radiography Essential for the accurate diagnosis

(some cases w/o symptom), monitoring progress treatment

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Metabolic Disorders

• Plain radiograph shows increased radiodensity (sclerosis) or radiolucency (osteopenia)

• Need proper setting of kilovoltage and mA to give good photo

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Summary

• Plain film radiography is the key to the diagnosis many skeletal disorders

• Have to be familiar with the views• Other imaging modalities serve as

complimentary study • Clinical-radiological-pathological meeting

plays an important role

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References1. Greenspan A. Orthopedic imaging. Philadelphia : Lippincott Williams &

Wilkins, 2004.2. Juhl JH, Crummy AB. Paul & Juhl’s essentials of radiologic imaging.

Philadelphia : JB Lippincott Co., 1987.3. Berquist TH. MRI of the musculoskeletal system. Ed 5. Philadelphia :

Lippincott Williams & Wilkins, 2006.4. Burgener FA, Kormano M. Bone & joint disorders, conventional

radiologic differential diagnosis. New York : Thieme Medical Publishers Inc., 1997.