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RADIOLOGIE RADIOLOGIE OSTEO-ARTICULARAOSTEO-ARTICULARA
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Generalitati• Numarul total al oaselor care alcatuiesc scheletul omului este de 223,
din care 95 sunt oase perechi iar 33 oase neperechi.• Luandu-se insa in consideratie raporturile care exista intre cele trei
dimensiuni ale lor (lungime,latime,grosime), oasele pot fi impartite in trei grupe: oase lungi, oase late, oase scurte.
• Suprafetele sau fatetele articulare sunt portiuni de pe suprafata oaselor care servesc pentru articularea cu alte oase.
• Cand fetele articulare se prezinta ca o scobitura sferica, ea se numeste cavitate glenoida, cand are forma de scripete poarta numele de trohlee iar cand apare ca o formatiune proeminenta, se numeste cap sau condil.
• Apofizele, spinele, tuberculii sunt proeminente osoase de forme diferite ce constituie suport pentru inserţiile ligamento-tendinoase.
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STRUCTURA OASELOROasele sunt alcatuite din tesut osos compact si tesut osos spongios, la care se adauga si alte varietati de tesut conjunctiv, cu dispunere diferentiata in functie de forma lor.
Oasele lungi:• Diafiza:
– canalul medular ce conţine maduva osoasa,– endostul este o membrana conjunctiva care captuseste la interior masa osoasa atat
a diafizei, cat si a epifizelor,– masa osoasa propriu-zisa circumscrie canalul medular si este alcatuita din tesut
osos compact haversian si interhaversian,– periostul, membrana vasculo-conjunctiva cu proprietati osteogene, inveleste la
periferie intregul os, cu exceptia capetelor articulare, care sunt acoperite de cartilaje.
• Epifiza:– masa osoasa din structura epifizei este formata indeosebi din tesut osos spongios,
tesutul osos compact formand doar un strat foarte subtire pe suprafata epifizei.– periostul si endostul au urmatoarele particularitati: periostul lipseste de pe
suprafetele articulare ale epifizelor fiind inlocuit cu cartilaj hialin iar endostul captuseste trabeculele care delimiteaza areolele,
– trabeculele osoase au orientare caracteristica pentru fiecare epifiza, orientare determinata de directia fortelor mecanice care se exercita asupra epifizei.
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STRUCTURA OASELOR
Oasele scurte• In structura oaselor scurte intra periostul si masa osoasa:
– Masa osoasa - formata indeosebi din tesut osos spongios asezat in partea interna si dintr-un strat subtire de tesut osos compact asezat la periferie.
– Ca si la oasele lungi, periostul este inlocuit la nivelul suprafetelor articulare cu cartilaj hialin.
Oasele late• In structura oaselor late intra: periostul,masa osoasa, endostul si maduva
osoasa. • Caracteristica structurala: tesutul osos spongios este situat intre doua straturi
de tesut osos compact invelit de periost. Aceste straturi de tesut osos haversian poarta numele de table (tabla interna si tabla externa). Areolele tesutului spongios sunt captusite de emdost si gazduiesc maduva osoasa hematogena.
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METODE IMAGISTICE• RADIOGRAFIA STANDARD/DIGITALA
• cel puţin două incidenţe perpendiculare. • trebuie să cuprindă cel puţin o articulaţie a osului examinat- astfel se pot stabili modificări de poziţie în ax ale osului.• în regiunile simetrice - examinări bilaterale.
• TOMOGRAFIA COMPUTERIZATA •evidenţierea unor detalii de structură ale osului, •rapoartele anatomice a regiunii explorate•extensia de vecinătate a procesului patologic;•reconstrucţii 3D,•manevre intervenţionale ( puncţii) în scop diagnostic şi terapeutic.
• ULTRASONOGRAFIA => P. MOI ARTICULARE • IRM
• neiradiantă, • evidenţierea tuturor structurilor anatomice, • studiul atât secţional în mai multe planuri.
• SCINTIGRAMA OSOASA• diagnosticul incipient al tumorilor maligne, în bilanţul lezional al metastazelor osoase şi în diagnosticul distrofiilor osoase.
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ANATOMIEANATOMIE
RADIOLOGICARADIOLOGICA:
STRUCTURA
HAVERSIANA
NORMALA
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CT-VERTEBRO
DISCALA
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CT RECON.3 DCT RECON.3 D
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IRMN:IRMN:STUDIUL ARTICULATIEI COXO-FEMURALESTUDIUL ARTICULATIEI COXO-FEMURALE
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IRMN:STUDIUL COL.VERTEBRALE & CANAL RAHIDIANIRMN:STUDIUL COL.VERTEBRALE & CANAL RAHIDIAN
T 1 T 2
SAGITAL
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IRMN:PUMN CORONAL(A):PUMN CORONAL(A)
GENUNCHI SAGITAL(B)GENUNCHI SAGITAL(B)
A B
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SEMEIOLOGIE SEMEIOLOGIE RADIOLOGICA OSOASARADIOLOGICA OSOASA
I.MODIFICARI STRUCTURALEI.MODIFICARI STRUCTURALE
1.REZORBTIA:1.REZORBTIA: - -osteoporozaosteoporoza
-osteoliza-osteoliza
-osteonecroza-osteonecroza
2.OSTEOCONDENSAREA(OSTEOSCLEROZE):2.OSTEOCONDENSAREA(OSTEOSCLEROZE):
-periostoza-periostoza
-endostoza-endostoza
-spongioscleroza-spongioscleroza
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OSTEOPOROZA:STUDIU COMPARATIV PE RADIOGRAFIE STANDARD.
NORMAL
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SEMEIOLOGIE RADIOLOGICA:OSTEOPOROZA
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OSTEOLIZA
CIRCUMSCRISA DE
LIZEREU DE SCLEROZA:
CHIST OSOS
ESENTIAL
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SEMIOLOGIE RADIOLOGICA:
OSTEOLIZA
VERTEBRALA
(metastaze osoase)
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NECROZA ASEPTICA A CALCANEULUI-EVOLUTIE
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SEMEIOLOGIE OSOASA
II.II.MODIFICARI DE ORGANOGENEZAMODIFICARI DE ORGANOGENEZA::
-hiperostoza-hipostoza-hiperostoza-hipostoza
-oedostoza-oedostoza
-scoliostoza-scoliostoza
-hiperplazie-hipoplazie-hiperplazie-hipoplazie
-aplazie-agenezie-aplazie-agenezie
DISTROFIIDISTROFII
DISPLAZIIDISPLAZII
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SEMEIOLOGIE RADIOLOGICA:osteoporoza,osteocondensare,scoliostoza,oedostoza
RAHITISM FLORID PSEUDARTROZA
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SEMEIOLOGIE:
SCOLIOSTOZA,
OSTEOPOROZA,
OSTEOSCLEROZA
(remaniere complexa)
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PATOLOGIE OSOASAPATOLOGIE OSOASA
•TRAUMATISME: fracturi, luxatii, entorse;
•BOLI INFLAMATORII: osteite, osteomielite;
•TUMORI: benigne, potential maligne, maligne: primitive, meta
•NECROZE ASEPTICE
•DISPLAZII;DISTROFII
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PATOLOGIE INFLAMATORIE PATOLOGIE INFLAMATORIE OSTEO-ARTICULARAOSTEO-ARTICULARA
AFECTIUNI ARTICULARE ACUTE:
-nesupurate => RAA
-supurate => artrite (stafilo/streptococ);
AFECTIUNI ARTICULARE CRONICE:
-nesupurate: PR, SA, artroze, metabolice, neuropatice;
-supurate: tbc.
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OSTEOMIELITA
•ETIOLOGIE:ETIOLOGIE:stafilococ auriu,streptococ;stafilococ auriu,streptococ;
•MECANISM:-MECANISM:-embol microbian=>art.nutritiva;embol microbian=>art.nutritiva;
-contiguitate (fracturi deschise,artrite etc);-contiguitate (fracturi deschise,artrite etc);
•SEDIU: SEDIU: -os lung=>metafize (debut);-os lung=>metafize (debut);
-extenzie diafizara, epifizara, articulara;-extenzie diafizara, epifizara, articulara;
-monostica, monotopa: tibie, femur cca 75%-monostica, monotopa: tibie, femur cca 75%
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OSTEOMIELITAOSTEOMIELITA
ASPECTE RADIOLOGICEASPECTE RADIOLOGICE
•DEBUT:DEBUT:osteoporoza localizata metafizar;dg.dificil=>IRMN,osteoporoza localizata metafizar;dg.dificil=>IRMN,
scintigrafie polinucleare marcate Ga-67;scintigrafie polinucleare marcate Ga-67;
STARESTARE::-osteoliza “patata”;-osteoliza “patata”;
-tumefactie de parti moi;-tumefactie de parti moi;
-necroza septica=>halou + sechestre;-necroza septica=>halou + sechestre;
-periostita=>mansoane,grosiera,extenzie diafizara;-periostita=>mansoane,grosiera,extenzie diafizara;
-abces subperiostal-abces subperiostal
-fistulizare in partile moi periosoase-fistulizare in partile moi periosoase
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OSTEOMIELITA ACUTA:DEBUT=>STARE
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OSTEOMIELITA:
EXTENZIA
DIAFIZO-METAFIZARA
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CT,RECONSTRUCTIE 3 D:CT,RECONSTRUCTIE 3 D:
OSTEOMIELITAOSTEOMIELITA
SECHESTRU
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OSTEOMIELITA
EVOLUTIE:-VINDECARE=>cicatrici fibroscleroase,geode;
-reactivare==>CRONICIZARE:domina reactia
endosteala/periosteala; focare osteolitice mici, sechestre mici;
COMPLICATII:-artrita supurata=>anchiloze ;
-fracturi=>scurtari de os;
-tulb.de crestere (adolescent):scoliostoza,hiper-plazii unilaterale de membru;
-septico-pioemie:abcese viscerale secundare;
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Osteomielita
cronica,in puseu
de acutizare:
microgeode,
micro-sechestre
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OSTEOMIELITA CRONICA;DEFORMARI
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OSTEITA/MIELITA POST -INTERV.CHIRURGICALA(fractura)
Reactie
periostala osteoliza
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OSTEOMIELITA
FFORME PARTICULARE
ABCES OSOS CENTRALABCES OSOS CENTRAL(BRODIE):
-SEDIU:tibie,metafiza superioara;
-ASPECT Rx:-geoda ovala,inel scleroza;fara sechestre/r.periost.
-EVOLUTIE:cronica,cu pusee de acutizare;
PANARITIU OSOS(osteita/mielita=>contiguitate de la p.moi;
-SEDIU:-falange terminale
-ASPECT RX:-liza osoasa din afara spre canal med.; -fara reactie periostala.
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PANARITIU OSOS:EVOLUTIE NEFAVORABILA
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Artrite cronice nesupurate
1.SPONDILITA ANKILOZANTA(B.STRUMPEL-BECHTEREV)
DEBUT:sacro-iliac,periferic(genunchi),vertebral(C7-T1)
APECTE RX:DEBUT-ingustare,stergere,largire spatiu art.;-condensarea osului subchondral;-osteoporoza;
STARE -osificari ligamentare;-sindesmofite(ligam.perivertebrale anrtero-laterale);
TERMINAL(IV):-osificarea ap.ligamentar=>ANKILOZARE==> “bat de bambus”,”sina de tramvai”;-cifoza dorso-lombara larga=> “pozitia schiorului”;
-artrite/artroze/ankiloze a articulatiilor mari:coxo-fem.,genunchi.
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SPONDILITA ANKILOZANTA:SPONDILITA ANKILOZANTA:MODIFICARI SACROILIACE
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SPONDILITA ANKILOZANTA:SINDESMOFITE CERVICALE
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Spondilita anchilopoetica-coloana de bambus sindesmofite
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Artrite cronice nesupurate2.POLIARTRITA REUMATOIDA.CLINIC:- b.artritica cu teste inflam.pozitive;etiol.incerta=> componenta autoimuna probabila.sediu la debut:artic.miciDEBUT:-osteoporoza; largirea sp. art.-chisturi, microgeode subchondrale epifizare;EVOLUTIE:- subluxatii falangiene, deviatii cubitale “in grifa”,
ghiara;
-ankiloza fibroasa/punti osoase inter- falangiene; osteoscleroza sec.
-extenzie la alte articulatii: picior, vertebrale, coxo-fem.; genunchi etc.
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POLIARTRITA
REUMATOIDA:
DEBUT/STARE
POLIARTRITA REUMATOIDA:
PERIOADA DE STARE
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POLIARTRITA REUMATIDA:
STADIU AVANSAT
POLIARTRITA REUMATIDA:
STADIU AVANSAT-GRIFA CUBITALA
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TUMORI OSOASEBENIGNE : BENIGNE : MALIGNE PRIMARE:MALIGNE PRIMARE:
OSTEOM OSTEOM OSTEOSARCOMOSTEOSARCOM
FIBROM FIBROM FIBROSARCOM FIBROSARCOM
HEMANGIOM HEMANGIOM ANGIOSARCOMANGIOSARCOM
CONDROM CONDROM CONDROSARCOMCONDROSARCOMT.MIELOPLAXE T.MIELOPLAXE SARCOM MEDULARSARCOM MEDULAR -EWING;-EWING; -JAKSON-PARKER-JAKSON-PARKER
MIELOMMIELOM
MALIGNE SECUNDARE: MALIGNE SECUNDARE:
metastaze,leucemii,limfoamemetastaze,leucemii,limfoame
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OSTEOMTESUT OSOS ADULT, SUPER-COMPACT; BENIGN;TESUT OSOS ADULT, SUPER-COMPACT; BENIGN;
CLINIC: lent evolutiv; NU METASTAZEAZACLINIC: lent evolutiv; NU METASTAZEAZASEDIU: SEDIU: sinus frontal;oase cranienesinus frontal;oase cranieneASPECT RX: ASPECT RX: osteocondensat, compact, intens opac, omogen, osteocondensat, compact, intens opac, omogen, oval/rotund, contur policiclic;oval/rotund, contur policiclic;
VARIANTAVARIANTA: focar osteolitic 4-10 mm : focar osteolitic 4-10 mm ((NIDUS)((NIDUS), cu, cusechestru mic central; hiperostoza /scleroza in jur, bombeazasechestru mic central; hiperostoza /scleroza in jur, bombeazasubperiostal, in partile moisubperiostal, in partile moi
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OSTEOM DE SINUS FRONTAL
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FIBROM
TESUT CONJUNCTIV NEOSIFICAT-INTRAOSOS
SEDIU: metafiza/diafiza oaselor lungi;
mandibula
ASPECT RX:
- zona osteolitica,cu inel net de
- scleroza in jur;
- contur ciclic;
- osul adiacent nemodificat;
- fara reactie periosteala
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OSTEOFIBROM
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OSTEOCONDROM
TESUT CARTILAGINOS NEOSIFICAT
SEDIU:OASE TUBULARE=FALANGE,METACARPIENE;
TIPURI: CENTRAL = ENCONDROM;
PERIFERIC = ECCONDROM;
ASPECTE RX:
-lacuna osteolitica ovalara, net delimitata, cu inel fin de
sleroza periferica;
- absenta reactiei periostale
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CONDROAME MULTIPLE-BOALA OLLIER
ECCONDROM
ENCONDROM
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EncondromEncondrom
radiografieradiografie IRM,T 1/T 2,CORONALAIRM,T 1/T 2,CORONALA
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T1T1
T2T2
Osteocondrom
radiografie IRM,SECT.AXIALA
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TUMORA CU MIELOPLAXE(CELULE GIGANTE)
SEDIU: epifiza oase lungi (tibia,femur), os plat;
ASPECTE RX:
- zona osteolitica net conturata, cu septuri fine si aspect multiloculat(“bule de sapun”),
- corticala subtiata dar vizibila,aspect de os “suflat”.
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TUMORA
CU
MIELOPLAXE
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TUMORA
CU
MIELOPLAXE
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OSTEOSARCOMT osteocitara agresiva,metastazanta
TIPURI: osteolitic, osteoplastic, mixt
T.OSTEOLITICA:
ASPECT RX: lacuna osteolitica METAFIZARA periferica sau centrala, cu contur neregulat, ce asociaza reactia periostala limitata + decolarea periostului /distructie periostala (pinten sarcomatos CODMANN);
T.OSTEOPLASTIC:
ASPECT RX: osteoliza + reactie periostala exuberanta, cu aspect radiar (“spiculi perpendiculari / diafiza”,in perie”); respecta epifiza.
EVOLUTIE: - METASTAZEAZA RAPID (pulmon, creier, ficat); - fracturi patologice; invazia articulatiei vecine.
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OSTEOSARCOM:
TIPURI SI VARIANTERADIOLOGICE
OSTEOLITICCENTRAL PERIFERIC,RADIAR
OSTEOCONDENSANT
OSTEOLITICPERIFERIC
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PINTENCODMANN
OSTEOSARCOM
TIP OSTEOLITIC,
VARIANTA PERIFERICA
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OSTEOSARCOM EXTINS LOCO-REGIONAL(fractura)
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OSTEOSARCOM
OSTEOPLASTIC:
DEBUT
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OSTEOSARCOM:CT EVALUEAZA EXTENZIA
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OSTEOSARCOM OSTEOPLASTIC
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OSTEOSARCOM:
PERIFERIC
TIP RADIAR
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SARCOM PAROSTAL
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CONDROSARCOM
TESUT CARTILAGINOS (..CONDROM..?);
SEDIU: metafize, bazin, coaste;ASPECT RX: - osteoliza + calcificari amorfe in masa tumorala + invazie de parti moi.
FIBROSARCOM OSOSTESUT CONJUNCTIV; dg f. dificil;
TIP CENTRAL = osteoliza os lung;
TIP PERIFERIC = sarcom periostal (parostal)
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CondrosarcomCondrosarcom
Osificare enchondralăOsificare enchondrală
Scintigrafie Tc.99 pirofosfat
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CondrosarcomCondrosarcom
RADIOGRAFIERADIOGRAFIE
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CondrosarcomCondrosarcom
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SARCOM EWINGSARCOM MEDULOGEN; RETICULOSARCOM INFANTIL
SEDIU: metafizo-diafizar,tibie,femur,coaste;
ASPECT RX: - osteoliza central-medulara;
- uzura a compactei din interior;
- reactie periostala “in foi de bulb de ceapa” (mansoane fine, concentrice);
-”suflare”, ”in butoi”, a diafizei (OEDOSTOZA)
EVOLUTIE: - metastazeaza in acelasi os si in alte oase , dar si in viscere.
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SARCOM EWING:SARCOM EWING:
SCHITASCHITA
Reactie periostala”foi ceapa”
osteolizaosteoliza
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SARCOM EWING
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SARCOM EWING:RADIO.DIGITALA & CT
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MIELOM MULTIPLU (PLASMOCITOM)
Este cea mai frecventa tum. maligna primara
ORIGINE: - cel. plasmocitare medulare (monoclonala)
SEDIU: - maduva hematogena=>adulttip multiplu => b. Rustitki-Khaler;
tip solitar => plasmocitom (rara);
ASPECT RX: - zone osteolitice izolate si confluente ce pot asocia tasari vertebrale, aspect suflat al oaselor lungi si osteoza difuza.
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MIELOM MULTIPLUMIELOM MULTIPLU
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MIELOM MULTIPLU
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TUMORI MALIGNE SECUNDARE
Cancer declarat/operat sau ocult (cauta sin, prostata, pulmon, tiroida, rinichi etc).
TIPURI: osteolitice, osteoplastice, mixte.
OSTEOLITICE: - osteoliza progresiva pe c. vert., bazin, coaste: zone transparente, lacunare, fara delimitare, fara r.periostala; fracturi secundare=>paraplegii,pareze etc.
OSTEOCONDENSANTE: - zone dense, patate,confluente; sediu pe bazin, vertebre;
- sunt rare = cancerul prostatei, vezicii, sanului.
MIXTE: - alternanta liza/condensare pe aceleasi sedii topogr.
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METASTAZE OSOASE:A)OSTEOLITICE;B)OSTEOPLASTICE
A B
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METASTAZE OSTEOLITICE
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METASTAZE OSOASE OSTEOPLASTICE:pete de ceara(Reboul)
CANCER MAMAR T-4
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TUMORI MALIGNE SECUNDARE
II.LEUCEMII;LIMFOAMEII.LEUCEMII;LIMFOAME
1)OSTEOPOROZA DIFUZA=>LEUCEMIA ACUTA(copil)
2)OSTEOSCLEROZA DIFUZA=>LEUCEMII CR.(adult)
3)LEZ.OSTEOLITICE VERTEBRALE=>INVAZIE DE LA
GANGLIONII RETROPERITONEALI =>ADENOPATIILE
DIN LIMFOAME MALIGTNE:VERTEBRA”DE IVORIU”
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NECROZE ASEPTICEMECANISM:-tulburarile vascularizatiei locale; -post-traumatice; -embolii gazoase (boala de cheson).1)OSTEONECROZA CAPULUI FEMURAL=boala LEGG- CALVE-PERTHES): -distructie progresiva a capului fem.; spatiu articular pastrat; evolutie spre anchiloza; subluxatie, coxartroza;2)OSTEONECROZA TIBIALA ANTERIOARA = boala OSGOOD SCHLATTER-LANELONG): -decolare si osteo sinteza (realipire) sau detasare de fragment.3)VERTEBRALA = cifoscolioza juvenila (b.SCHEUERMANN)=vertebre tasate, cuneiforme, scolioza, cifoza, hernii nucleu pulpos intraspongios (noduli SCHMORL);evolutie=>spondilartroza precoce
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NECROZAASEPTICA A
NUCLEULUI DE CRESTERE A
CAPULUI FEMURAL
FRAGMENTARE
PULVERIZARE
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NECROZA ASEPTICA A CAPULUI FEMURAL
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NECROZA ASEPTICA A CAPULUI FEMURAL:DEBUT
Forma adultului
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COMPUTER-COMPUTER-
TOMOGRAFIETOMOGRAFIE
NECROZA
ASEPTICA
CAP FEMURAL
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NECROZA ASEPTICA NECROZA ASEPTICA A CAPULUIA CAPULUI
FEMURAL;SECHELEFEMURAL;SECHELE:
SUBLUXATIESUBLUXATIE
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NECROZA ASP\EPTICA A CRESTEI TIBIALE ANTERIOARENECROZA ASP\EPTICA A CRESTEI TIBIALE ANTERIOARE (OSGOOD-SCHLATTER-LANELONG)(OSGOOD-SCHLATTER-LANELONG)
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NECROZANECROZA
ASEPTICA A ASEPTICA A
SCAFOIDULUISCAFOIDULUI
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NECROZA ASEPTICANECROZA ASEPTICA
A CAPULUIA CAPULUI
CELUI DE-AL 2-LEACELUI DE-AL 2-LEA
METACARPIANMETACARPIAN
(KOHLER II)
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ARTROZA DEFORMANTA
B.DEGENERATIVA-primitiva=>virsta 2-a-3-a..;-secundara:=> post-traumatica,necrotica,post-inflamatorie,metabolica etc.
ASPECTE RX:-ingustarea interliniului;scleroza subchondrala; modificari epifizare:”slefuire”,dezrotunjire”;osteofitoza margin,: productii osoase spiculare pe insertii ligamentare,tendinoase=> “ciocuri de papagal”;-osificari capsulare;fen de vacuum articular (vid-CT,IRMN=fen descris de DITTMAR -FERGUSON:degene- rescenta cartilagiului=>grasime,aer ?!)
SEDII PREFERENTIALE:-coloana vertebrala(spondiloza defor)
--sold(coxartroza);genunchi(gonartroza)
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ARTROZA DE GENUNCHIARTROZA DE GENUNCHI
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COXARTROZA IN STADIU AVANSAT(ANKILOZA)
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SPONDILOZA
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IRM:fisura complexa menisc internIRM:fisura complexa menisc intern
T2 EGT2 EGSagitalSagital
T2 fat satT2 fat satcoronalcoronal
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IRM,T2: fisura de menisc IRM,T2: fisura de menisc orizontalaorizontala
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Ruptura lig.X anterior
T1 SAGITAL
T2-SAGITAL
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Mielopatie cervicartrozicăMielopatie cervicartrozică
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