Musculoskeltal xray
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Transcript of Musculoskeltal xray
How to read How to read musculo-skeletal x raysmusculo-skeletal x rays
Dr.Mahesh kumar MSDr.Mahesh kumar MSDept. of OrthopedicsDept. of Orthopedics
General Hospital General Hospital TrivandrumTrivandrum
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Rule 1Rule 1
CommonCommonthings -firstthings -first
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When you see a black bird in trivandrum
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Do not say it is a penguin
Say it is a crow
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Appearances can be deceptive-
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Reading an x rayReading an x ray It is not getting the It is not getting the “appearance”“appearance” It is not commenting It is not commenting “oh! I have seen it “oh! I have seen it
before”before” And not distracted by the And not distracted by the “obvious”-“obvious”- it may it may
not be the causative pathologynot be the causative pathology We should have a We should have a systematic approachsystematic approach
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ABC’s of bone RadiologyABC’s of bone Radiology
Look for Look for Alignment Alignment Bones Bones
Abnormal lucency Abnormal lucency Abnormal sclerosis Abnormal sclerosis Periosteal reaction Periosteal reaction Abnormal contour Abnormal contour
Cartilage Cartilage Soft TissueSoft Tissue
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AlignmentAlignment Subluxation Subluxation
A displacement of a bone in relation to the apposing A displacement of a bone in relation to the apposing bone at the joint, resulting in a partial loss of bone at the joint, resulting in a partial loss of continuity of the joint surfaces. continuity of the joint surfaces.
Dislocation Dislocation A displacement of a bone in relation to the apposing A displacement of a bone in relation to the apposing
bone at the joint, resulting in a complete loss of bone at the joint, resulting in a complete loss of continuity of the joint surfaces. continuity of the joint surfaces.
Diastasis Diastasis A displacement of a bone in relation to the apposing A displacement of a bone in relation to the apposing
bone in a slightly movable (e.g. sacroiliac) or bone in a slightly movable (e.g. sacroiliac) or synarthrodial joint (cranial sutures).synarthrodial joint (cranial sutures).
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dislocation1010www.similima.comwww.similima.com
subluxation 1111www.similima.comwww.similima.com
Decreased Opacity (Lucency)Decreased Opacity (Lucency)Lucency comes in several flavors. Depending on the exact Lucency comes in several flavors. Depending on the exact
morphology and distribution of the lucency, our morphology and distribution of the lucency, our differential diagnosis may vary widely. differential diagnosis may vary widely.
Lucent lineLucent line fracturefracture
Focal lucencyFocal lucency tumortumor infectioninfection
Diffuse lucencyDiffuse lucency drugsdrugs endocrine / metabolicendocrine / metabolic tumortumor
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Lucent lineLucent line
A A linear lucencylinear lucency is the classic is the classic sign of a fracture. If a fracture sign of a fracture. If a fracture is displaced enough, it is easyis displaced enough, it is easy
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Focal lucencyFocal lucency With focal lucencies, bone tumors and osteomyelitis are two of the With focal lucencies, bone tumors and osteomyelitis are two of the
top entities on the differential diagnosis.top entities on the differential diagnosis. In the rest of the world, a handful of benign tumors are seen In the rest of the world, a handful of benign tumors are seen
occasionally, and theoccasionally, and the only malignant tumors commonly seen only malignant tumors commonly seen are metastases and multiple myeloma. are metastases and multiple myeloma.
In practice, the In practice, the patient’s historypatient’s history is often key in is often key in distinguishing tumor and infection, as they sometimes distinguishing tumor and infection, as they sometimes appear quite similar on radiographs.appear quite similar on radiographs.
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focal lucenciesfocal lucencies
focal lucencies, bone tumors focal lucencies, bone tumors and osteomyelitis are two of and osteomyelitis are two of the top entities on the the top entities on the differential diagnosis.differential diagnosis.
only malignant tumors only malignant tumors commonly seen are commonly seen are metastases and multiple metastases and multiple myelomamyeloma
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Differential Diagnosis of Solitary Lucent Bone LesionsDifferential Diagnosis of Solitary Lucent Bone Lesions
Fibrous Dysplasia Fibrous Dysplasia Osteoblastoma Osteoblastoma Giant Cell Tumor Giant Cell Tumor Metastasis / Myeloma Metastasis / Myeloma Aneurysmal Bone Cyst Aneurysmal Bone Cyst Chondroblastoma / Chondromyxoid Fibroma Chondroblastoma / Chondromyxoid Fibroma Hyperparathyroidism (brown tumors) / Hemangioma Hyperparathyroidism (brown tumors) / Hemangioma Infection Infection Non-ossifying Fibroma Non-ossifying Fibroma Eosinophilic Granuloma / Enchondroma Eosinophilic Granuloma / Enchondroma Solitary Bone CystSolitary Bone Cyst
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Look forLook for Age of the patientAge of the patient Size of the lesionSize of the lesion Margins of the lesionMargins of the lesion Matrix- the “inside” of the lesionMatrix- the “inside” of the lesion Location in the boneLocation in the bone Periosteal reaction - present or not?Periosteal reaction - present or not? multiplicitymultiplicity
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Age and lucent bone lesionsAge and lucent bone lesions 11
neuroblastomaneuroblastoma 1 - 101 - 10
Ewing's of tubular bonesEwing's of tubular bones 10 - 3010 - 30
osteosarcoma, Ewing's of flat bonesosteosarcoma, Ewing's of flat bones 30 - 4030 - 40
reticulum cell sarcoma (Primary histiocytic lymphoma), reticulum cell sarcoma (Primary histiocytic lymphoma), fibrosarcoma, parosteal osteosarcoma, malignant giant cell fibrosarcoma, parosteal osteosarcoma, malignant giant cell tumor, lymphomatumor, lymphoma
40 +40 + metastatic carcinoma, multiple myeloma, chondrosarcomametastatic carcinoma, multiple myeloma, chondrosarcoma
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Normal bone
geographic
Moth eaten
permeative
TYPES OF LESIONS
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locationlocation
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MultiplicityMultiplicityDifferential Diagnosis of Multiple Lucent Bone LesionsDifferential Diagnosis of Multiple Lucent Bone Lesions
Fibrous Dysplasia Fibrous Dysplasia
Metastasis / Myeloma Metastasis / Myeloma
Hyperparathyroidism (brown tumors) / Hemangioma Hyperparathyroidism (brown tumors) / Hemangioma
Infection Infection
Eosinophilic Granuloma / EnchondromaEosinophilic Granuloma / Enchondroma
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Some tips Some tips
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a a long lesion in a long bonelong lesion in a long bone, , think of think of
fibrous dysplasiafibrous dysplasia. .
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Simple cyst, Simple cyst, enchondroma, enchondroma,
and fibrous dysplasiaand fibrous dysplasia can mimic each other and can be can mimic each other and can be
hard to distinguish. hard to distinguish.
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Giant cell tumorsGiant cell tumors nearly alwaysnearly always
occur near a joint surfaceoccur near a joint surface. .
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Lucent lesions of the sternumLucent lesions of the sternum should be consideredshould be considered
malignantmalignant until proven otherwise until proven otherwise
(Helms CA, 1983(Helms CA, 1983).).
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Certain bones in the body are Certain bones in the body are "epiphyseal equivalents""epiphyseal equivalents". .
lucent lesions in these areas, lucent lesions in these areas, the classic epiphyseal entities such as the classic epiphyseal entities such as chondroblastoma, chondroblastoma, giant cell tumors and aneurysmal bone cysts. giant cell tumors and aneurysmal bone cysts.
They are They are patella, patella, calcaneus, calcaneus, most apophyses. most apophyses.
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Diffuse lucencyDiffuse lucency Diffuse lucency usually Diffuse lucency usually
bespeaks some bespeaks some global global processprocess capable of capable of affecting the entire affecting the entire skeleton.skeleton.
A metabolic bone A metabolic bone disorder such as disorder such as osteoporosisosteoporosis
multiple myelomamultiple myeloma
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extensive myelomatosis
rheumatoid arthritis treated with steroids
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Increased Opacity (Sclerosis)Increased Opacity (Sclerosis)Causes of Increased OpacityCauses of Increased Opacity
Bone impaction or rotationBone impaction or rotation fracturefracture
Bone production(reactive sclerosisBone production(reactive sclerosis)) fracturefracture calluscallus tumortumor tumor bone formation or tumor bone formation or
periosteal reactionperiosteal reaction infectioninfection periosteal reactionperiosteal reaction osteoarthritisosteoarthritis subchondral sclerosis or subchondral sclerosis or
osteophytosisosteophytosis Congenital Congenital
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Generic Differential Diagnosis of Sclerotic Bone Lesions Generic Differential Diagnosis of Sclerotic Bone Lesions
Vascular Vascular hemangiomas hemangiomas infarct infarct Infection Infection
chronic osteomyelitis chronic osteomyelitis Neoplasm Neoplasm
primaryprimary osteoma osteoma osteosarcoma osteosarcoma
metastatic metastatic prostate prostate breast breast otherother
Drugs Drugs Vitamin D Vitamin D fluoride fluoride
Inflammatory/Idiopathic Inflammatory/Idiopathic Congenital Congenital
bone islands bone islands osteopoikilosis osteopoikilosis osteopetrosis osteopetrosis pyknodysostosis pyknodysostosis
Autoimmune Autoimmune Trauma Trauma fracture (stress) fracture (stress) Endocrine/MetabolicEndocrine/Metabolic
hyperparathyroidism hyperparathyroidism Paget's diseasePaget's disease 3434www.similima.comwww.similima.com
Bone impaction or rotationBone impaction or rotation Although the classic Although the classic
sign of a fracture is a sign of a fracture is a lucent line, some lucent line, some fractures present fractures present otherwise.otherwise.
In cancellous bones
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Fracture callusFracture callus Some fractures are so Some fractures are so
subtle that you may subtle that you may miss them altogether miss them altogether at first, and only at first, and only diagnose them once diagnose them once they have started to they have started to heal due to the heal due to the formation of fracture formation of fracture callus.callus.
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Reactive sclerosis due to tumorReactive sclerosis due to tumor diffusely sclerotic diffusely sclerotic
metastsis are seen in a metastsis are seen in a very slow process very slow process (prostatic carcinoma) (prostatic carcinoma)
or a patient with diffusely or a patient with diffusely lytic mets who has been lytic mets who has been successfully treated (with successfully treated (with resultant healing and resultant healing and sclerosis of these sclerosis of these metastatic depositsmetastatic deposits).).
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Bone island
pagets
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melhorrostesisosteoma
Bone island
osteopoikilocytosis
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Periosteal reaction Periosteal reaction Depends on whether the lesion is Depends on whether the lesion is
slow growing or rapidly growingslow growing or rapidly growing
Slow growing-Slow growing- periosteum is able to periosteum is able to produce bone at the same rate as tumor produce bone at the same rate as tumor grows- so grows- so solid periosteal reactionsolid periosteal reaction
Rapidly growingRapidly growing lesion -the perisoteum lesion -the perisoteum cannot cope up- hence cannot cope up- hence interrupted patterninterrupted pattern
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Periosteum produces bone when stimulatedPeriosteum produces bone when stimulatedType of periosteal reaction Type of periosteal reaction depends on the depends on the
processprocess than the periosteum than the periosteum
Slow growing- Slow growing- solid periosteal reactionsolid periosteal reaction Faster growing Faster growing layered or lamellar typelayered or lamellar type Rapid, steady growth -Rapid, steady growth -sun burst, sun burst,
codeman’s trianglecodeman’s triangle Mixed patternsMixed patterns
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Solid Lamellar sunburst Codeman’s triangle
Mixed type
Types of periosteal
reaction
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causescauses Solid Periosteal ReactionSolid Periosteal Reaction
infection infection benign neoplasms benign neoplasms
osteoid osteoma osteoid osteoma eosinophilic granuloma eosinophilic granuloma
hypertrophic pulmonary osteoarthropathy hypertrophic pulmonary osteoarthropathy deep venous thrombosis (lower extremity) deep venous thrombosis (lower extremity)
Aggressive Periosteal ReactionAggressive Periosteal Reaction osteomyelitis osteomyelitis malignant neoplasms malignant neoplasms
osteosarcoma osteosarcoma chondrosarcoma chondrosarcoma fibrosarcoma fibrosarcoma lymphoma lymphoma leukemia leukemia
metastasismetastasis 4444www.similima.comwww.similima.com
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Causes of Solid Periosteal Causes of Solid Periosteal ReactionReaction
OsteomyelitisOsteomyelitis Benign neoplasmsBenign neoplasms
osteoid osteomaosteoid osteoma Eosinophilic granulomaEosinophilic granuloma Hypertrophic Hypertrophic
osteoarthropathyosteoarthropathy Deep venous thrombosis Deep venous thrombosis
(lower extremity)(lower extremity) Trauma (healing fracture)Trauma (healing fracture)
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Causes of Aggressive (Interrupted) Causes of Aggressive (Interrupted) Periosteal ReactionPeriosteal Reaction
OsteomyelitisOsteomyelitis Malignant neoplasmsMalignant neoplasms
osteosarcoma osteosarcoma chondrosarcoma chondrosarcoma fibrosarcoma fibrosarcoma lymphoma lymphoma leukemia leukemia metastasis metastasis
TraumaTrauma
osteogenic sarcoma.
"sunburst".
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Abnormal Contour, Size and ShapeAbnormal Contour, Size and Shape
FocalFocalfracturefracturesurgerysurgeryinfectioninfectiontumortumor
DiffuseDiffusedysplasiadysplasiametabolicmetabolic
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multiple hereditary exostoses,
Paget’s disease,
Paget’s disease,
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CartilageCartilage
decreased joint space decreased joint space
increased joint space increased joint space
chondrocalcinosischondrocalcinosis
we can’t really see we can’t really see cartilage on plain cartilage on plain radiographs, but we can radiographs, but we can still use these films to still use these films to infer a few rough ideas infer a few rough ideas about how the cartilage is about how the cartilage is doing. Hyaline articular doing. Hyaline articular cartilage is what cartilage is what separates the bones in a separates the bones in a synovial joint. This space synovial joint. This space taken up by the cartilage taken up by the cartilage is termed the is termed the "joint "joint space"space" on a plain on a plain radiograph.radiograph.
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Marked joint space Marked joint space narrowing is noted in the narrowing is noted in the superior weight-bearing superior weight-bearing portion of the joint space portion of the joint space in this patient with in this patient with osteoarthritis. osteoarthritis. Subchondral sclerosis Subchondral sclerosis and marked and marked osteophytosis are also osteophytosis are also noted.noted.
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Chondrocalcinosis Chondrocalcinosis (arrows) is noted in (arrows) is noted in the hyaline articular the hyaline articular cartilage and menisci cartilage and menisci of this patient with of this patient with calcium calcium pyrophosphate pyrophosphate deposition (CPPD) deposition (CPPD) diseasedisease
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Soft TissueSoft Tissue
When looking at the soft tissues, one can When looking at the soft tissues, one can occasionally see a variety of useful occasionally see a variety of useful findings on plain films, such as: findings on plain films, such as:
swelling swelling gas gas calcification calcification massmass
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DystrophicDystrophic small to large amorphous Ca++ in the small to large amorphous Ca++ in the damaged tissuedamaged tissue -- may progress to -- may progress to ossification (formation of cortex and medullary ossification (formation of cortex and medullary space are then seen)space are then seen)
CPPDCPPD chondrocalcinosis; occasionally chondrocalcinosis; occasionally associated with calcifications in the associated with calcifications in the soft tissues of the spinesoft tissues of the spine
Metastatic calcificationMetastatic calcification finely speckled Ca++ throughout soft finely speckled Ca++ throughout soft tissuestissues
Tumoral calcinosisTumoral calcinosis big globs of Ca++, usually near a big globs of Ca++, usually near a jointjoint
Metastatic osteosarcomaMetastatic osteosarcoma amorphous, fluffy, confluent amorphous, fluffy, confluent collection of Ca++collection of Ca++
Primary soft tissue Primary soft tissue osteosarcomaosteosarcoma
amorphous, fluffy, confluent amorphous, fluffy, confluent collection of Ca++collection of Ca++
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cysticercosis5959www.similima.comwww.similima.com
scleroderma
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dermatomyositis
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Heterotrophic ossification
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SLE
Metasataic calcifications in soft tissues
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chondrocalcinosis6464www.similima.comwww.similima.com
Tumoral calcinosis
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Calcific tendinitis
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