WESTERN DIAGNOSTIC STUDIES
CLASS # 12: MUSCULOSKELETAL SYSTEM
RADIOLOGIC STUDIES OF THE SKELETAL SYSTEM
A. X-rays ("plain films")
1. X-rays are produced mechanically by making electrons strike a target, causing the electrons to give up their
energy as x-rays.
2. Best used to visualize bony structures. Soft tissues show up as shadows, so gives little distinct information
about soft tissue structures.
3. Bone is the most resistant tissue to the effects of radiation. The testes, ovaries, bone marrow and mucosal
lining of the intestinal tract are the most sensitive.
B. CT and MRI (see previous lectures). Can visualize muscle and bone.
C. Bone densitometry (dual-energy x-ray absorptiometry = DEXA scan)
1. Used to determine bone mineral content, and therefore density, for purposes of diagnosing osteoporosis
and osteopenia
2. Can theoretically be done of any bone, but the sites commonly studied are the lumbar spine (representative of
cancellous bone), hip (mixed cancellous and cortical bone) and radius (representative of cortical bone).
3. Bone density is evaluated in relative terms, as the standard deviation from the mean. The "T-score" is usually
used, comparing the patient's bone density to that of young, healthy adults.
4. T score of 0 = average. A positive T score implies above average density. A negative T score implies below
average density.
5. By World Health Organization standards:
a. Normal bone density is a T score above -1.0
b. Osteopenia is defined as T score between -1.0 and -2.5
c. Osteoporosis is defined as T score below -2.5
6. Bone Mineral Density (BMD) testing is recommended for:
a. All women over the age of 65
b. Any post-menopausal woman who has one or more additional risk factors, such as body weight less than 120 pounds,
first-degree relatives who have osteoporosis, Caucasian, early menopause (natural or surgical), aromatase inhibitor
use, >1.6” loss of height
c. Men or women with history of osteoporosis, long-term steroid use, hyperparathyroidism, chronic inflammatory
disease (such as RA, ulcerative colitis, Crohn’s disease)
7. Follow-up studies done every two years, unless extenuating risks, as in #6c above
8. Issues falsely elevating DEXA results:
a. Previous fractures, surgery or arthritic changes in the area of study
b. Surgically implanted metallic clips/ fixation devices or overlying metallic jewelry
c. Calcifications in nearby arteries
d. Barium studies of the bowel less than 10 days prior
D. Bone scan
1. Patient is given an intravenous injection of radioactive technetium-99, which has a high affinity for bone and emits
gamma rays. The Tc-99 is excreted spontaneously over the next 6-24 hours. (No need to isolate the patient)
2. Areas of increased uptake indicate processes such as primary bone or metastatic cancers, fractures, arthritis,
osteomyelitis, bony disorders such as Paget’s disease
3. Used to assist in the diagnosis and extent of the above disorders. Routinely used in cancer patients to assist staging
and response of metastatic lesions to therapy.
OTHER TESTS RELATIVE TO MUSCULOSKELETAL SYSTEM
A. Electromyography (EMG)
1. Used to help determine the etiology of either focal or diffuse muscular weakness or atrophy. (Muscular vs. neurologic
etiology)
2. A thin needle-like electrode is inserted into a muscle and records electrical activity and spontaneous movements, like
fasciculations. Sometimes nerve conduction studies are performed at the same time.
B. Arthrocentesis
1. To assist with diagnosis of joint pathology, using sterile technique, fluid is drawn from a synovial joint.
2. Synovial fluid is examined microscopically for uric acid crystals, RBC, WBC + differential, and gram stain for bacteria.
Chemical tests are done for glucose (decreased in inflammation), protein and LDH (both elevated in infection), and
complement for autoimmune diseases (SLE, RA). Fluid is cultured for bacteria, fungi and sometimes TB
3. Joint infection is a medical emergency, requiring IV antibiotics and sometimes surgical debridement
4. Arthrocentesis is performed by orthopedists and rheumatologists.
C. Vitamin D levels
1. Vitamin D is a fat-soluble vitamin which plays a vital role in several stages of bone formation and maintenance.
Deficiency contributes to osteoporosis.
2. The major circulating form, 25-hydroxy Vitamin D, is the test of choice. Target levels: 30-100 ng/mL
3. Consider checking levels in cases of osteoporosis / osteopenia, age >70, people with dark skin tones, little sun
exposure, liver or renal disease, fat malabsorption
4. Lots more about Vit D in Western Nutrition class!
