musculoskeltal xray

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  • 1. How to readmusculo-skeletal x raysDr.Mahesh kumar MS Dept. of OrthopedicsGeneral Hospital Trivandrum 1

2. Rule 1 Commonthings 2 3. When you see a blackbird in 3 4. Do not say it is a penguinSay it is a crow www.similima.com4 5. Appearances can be deceptive-www.similima.com5do not go by appearances 6. 6 7. Reading an x ray It is not getting the appearance It is not commenting oh! I have seen itbefore And not distracted by the obvious- it maynot be the causative pathology We should have a systematic approach 7 8. ABCs of bone RadiologyLook for Alignment Bones Abnormal lucency Abnormal sclerosis Periosteal reaction Abnormal contour Cartilage Soft 8 9. Alignment Subluxation A displacement of a bone in relation to the apposingbone at the joint, resulting in a partial loss ofcontinuity of the joint surfaces. Dislocation A displacement of a bone in relation to the apposingbone at the joint, resulting in a complete loss ofcontinuity of the joint surfaces. Diastasis A displacement of a bone in relation to the apposingbone in a slightly movable (e.g. sacroiliac) orsynarthrodial joint (cranial sutures) 9 10. 10 11. 11subluxation 12. Decreased Opacity (Lucency)Lucency comes in several flavors. Depending on the exactmorphology and distribution of the lucency, ourdifferential diagnosis may vary widely. Lucent line fracture Focal lucency tumor infection Diffuse lucency drugs endocrine / metabolic 12 13. Lucent line A linear lucency is the classicsign of a fracture. If a fractureis displaced enough, it is easy 13 14. Focal lucency With focal lucencies, bone tumors and osteomyelitis are two of thetop entities on the differential diagnosis.In the rest of the world, a handful of benign tumors are seenoccasionally, and the only malignant tumors commonly seenare metastases and multiple myeloma. In practice, the patients history is often key indistinguishing tumor and infection, as they sometimesappear quite similar on radiographs. www.similima.com14 15. 15 16. 16 17. focal lucenciesfocal lucencies, bone tumors and osteomyelitis are two of the top entities on the differential diagnosis.only malignant tumors commonly seen are metastases and multiple myelomawww.similima.com17 18. Differential Diagnosis of Solitary Lucent Bone Lesions Fibrous Dysplasia Osteoblastoma Giant Cell Tumor Metastasis / Myeloma Aneurysmal Bone Cyst Chondroblastoma / Chondromyxoid Fibroma Hyperparathyroidism (brown tumors) / Hemangioma Infection Non-ossifying Fibroma Eosinophilic Granuloma / Enchondroma Solitary Bone Cyst www.similima.com18 19. Look for Age of the patient Size of the lesion Margins of the lesion Matrix- the inside of the lesion Location in the bone Periosteal reaction - present or not? multiplicitywww.similima.com19 20. Age and lucent bone lesions 1 neuroblastoma 1 - 10 Ewings of tubular bones 10 - 30 osteosarcoma, Ewings of flat bones 30 - 40 reticulum cell sarcoma (Primary histiocytic lymphoma),fibrosarcoma, parosteal osteosarcoma, malignant giant celltumor, lymphoma 40 + metastatic carcinoma, multiple myeloma, 20 21. geographicNormal boneMoth eatenTYPES OFLESIONS permeative 21 22. locationwww.similima.com22 23. MultiplicityDifferential Diagnosis of Multiple Lucent Bone Lesions Fibrous Dysplasia Metastasis / Myeloma Hyperparathyroidism (brown tumors) / Hemangioma Infection Eosinophilic Granuloma / Enchondroma www.similima.com23 24. Some 24 25. a long lesion in a long bone, think of fibrous dysplasia.www.similima.com25 26. Simple cyst, enchondroma, and fibrous dysplasiacan mimic each other and can be hard to distinguish. 26 27. Giant cell tumorsnearly alwaysoccur near a joint surface. 27 28. Lucent lesions of the sternum should be consideredmalignant until proven otherwise (Helms CA, 1983). 28 29. Certain bones in the body are"epiphyseal equivalents".lucent lesions in these areas,the classic epiphyseal entities such as chondroblastoma,giant cell tumors and aneurysmal bone cysts. They are patella, calcaneus, most apophyses. www.similima.com29 30. Diffuse lucency Diffuse lucency usuallybespeaks some globalprocess capable ofaffecting the entireskeleton. A metabolic bonedisorder such asosteoporosismultiple myeloma 30 31. extensivemyelomatosis rheumatoid arthritis treated with steroids www.similima.com31 32. ? 32 33. Increased Opacity (Sclerosis) Causes of Increased Opacity Bone impaction or rotation fracture Bone production(reactive sclerosis) fracture callus tumortumor bone formation or periosteal reaction infectionperiosteal reaction osteoarthritis subchondral sclerosis or osteophytosis Congenital 33 34. Generic Differential Diagnosis of Sclerotic Bone Lesions DrugsVascular Vitamin D hemangiomas fluoride infarct Inflammatory/Idiopathic Infection Congenitalchronic osteomyelitis bone islandsNeoplasm osteopoikilosis primary osteopetrosis osteoma pyknodysostosis osteosarcoma Autoimmune metastatic prostate Trauma breast fracture (stress) otherEndocrine/Metabolic hyperparathyroidism 34 Pagets disease 35. Bone impaction or rotationAlthough the classic sign of a fracture is a lucent line, some fractures present otherwise. In cancellous 35 36. Fracture callus Some fractures are sosubtle that you maymiss them altogetherat first, and onlydiagnose them oncethey have started toheal due to theformation of fracturecallus. 36 37. Reactive sclerosis due to tumor diffusely scleroticmetastsis are seen in avery slow process(prostatic carcinoma) or a patient with diffuselylytic mets who has beensuccessfully treated (withresultant healing andsclerosis of thesemetastatic deposits). 37 38. pagetsBone islandwww.similima.com38 39. osteopoikilocytosismelhorrostesis osteoma Bone island www.similima.com39 40. 40 41. Periosteal reaction Depends on whether the lesion isslow growing or rapidly growing Slow growing- periosteum is able toproduce bone at the same rate as tumorgrows- so solid periosteal reaction Rapidly growing lesion -the perisoteumcannot cope up- hence interrupted pattern www.similima.com41 42. Periosteum produces bone when stimulatedType of periosteal reaction depends on the process than the periosteum Slow growing- solid periosteal reaction Faster growing layered or lamellar type Rapid, steady growth -sun burst,codemans triangle Mixed patterns 42 43. SolidLamellar sunburstCodemans triangleTypes of periostealreaction Mixed typewww.similima.com43 44. causesSolid Periosteal Reaction infection benign neoplasms osteoid osteoma eosinophilic granuloma hypertrophic pulmonary osteoarthropathy deep venous thrombosis (lower extremity) Aggressive Periosteal Reaction osteomyelitis malignant neoplasms osteosarcoma chondrosarcoma fibrosarcoma lymphoma leukemia 44 45. 45 46. Causes of Solid Periosteal Reaction Osteomyelitis Benign neoplasmsosteoid osteoma Eosinophilic granuloma Hypertrophicosteoarthropathy Deep venous thrombosis(lower extremity) Trauma (healing fracture) 46 47. Causes of Aggressive (Interrupted)Periosteal Reaction"sunburst".Osteomyelitis Malignant neoplasms osteosarcoma chondrosarcoma fibrosarcoma lymphoma leukemia metastasis Trauma osteogenic sarcoma. www.similima.com47 48. Abnormal Contour, Size and Shape Focalfracturesurgeryinfectiontumor Diffusedysplasiametabolic 48 49. multiple hereditary exostoses, Pagets disease,www.similima.com49Pagets disease, 50. Cartilagewe cant really see cartilage on plain radiographs, but we can still use these films to infer a few rough ideas decreased joint spaceabout how the cartilage is doing. Hyaline articular cartilage is what increased joint spaceseparates the bones in a synovial joint. This space taken up by the cartilage chondrocalcinosisis termed the "joint space" on a plain radiograph.www.similima.com50 51. Marked joint space narrowing is noted in the superior weight-bearing portion of the joint space in this patient with osteoarthritis. Subchondral sclerosis and marked osteophytosis are also noted.www.similima.com51 52. Chondrocalcinosis(arrows) is noted inthe hyaline articularcartilage and menisciof this patient withcalciumpyrophosphatedeposition (CPPD)disease 52 53. Soft TissueWhen looking at the soft tissues, one canoccasionally see a variety of usefulfindings on plain films, such as: swelling gas calcification mass 53 54. 54 55. 55 56. small to large amorphous Ca++ in theDystrophicdamaged tissue -- may progress toossification (formation of cortex and medullaryspace are then seen)CPPDchondrocalcinosis; occasionallyassociated with calcifications in thesoft tissues of the spineMetastatic calcificationfinely speckled Ca++ throughout softtissuesTumoral calcinosisbig globs of Ca++, usually near ajointMetastatic osteosarcoma amorphous, fluffy, confluentcollection of Ca++Primary soft tissue amorphous, fluffy, confluentcollection of Ca++osteosarcoma www.similima.com56 57. 57 58. 58 59. 59cysticercosis 60. 60 61. 61 62. Heterotrophic ossification 62 63. ? SLE Metasataic calcifications in soft 63 64. 64chondrocalcinosis 65. Tumoralcalcinosis