ORTHOPEDICS AND
TRAUMATOLOGY
IMAGING
MUSCULOSKELETAL IMAGING
Technology
Advances in Imaging
MSK IMAGING – IMAGING
MODALITIES
• Plain Radiographs (X-ray )
• Nuclear Scintigraphy
• Ultrasound (US)
• Computed Tomography
• Magnetic Resonance Imaging
PLAIN RADIOGRAPHS
• Radiation sent through pt to film
• First line study for most medical issues
• Excellent for fractures/bony detail
• Very limited for soft tissues (ligaments,
tendons, muscles)
• Only a screening tool in the spine
PLAIN RADIOGRAPHS
• Widely available
• Reproducible
• Patient friendly
• ‘Inexpensive’
• Usually the indicated primary imaging modality
PLAIN RADIOGRAPHS
Common Views:
•Anteroposterior (AP)
•Lateral (R and L)
•Oblique (R and L)
All x-rays should have an
adequate number of views.
◦ Minimum of 2 views—AP and
lateral
◦ 3 views preferred
◦ Some bones require 4 views
Pelvic bones
AP Ankle xray Oblique
Lateral View
A lateral view of
the ankle is
provided in this
image. All bone
and joint
markings are
within normal
limits.
There is no
evidence of
fracture or
dislocation and
soft tissue planes
are
ABC’S OF VIEWING FILMS
A: ALIGNMENT
1. Assess the size of the bones:
gigantism,
dwarfism, etc
2. Assess the number of bones
3. Assess each bone for normal shape
and
contour; irregularities can be from
trauma, congenital, developmental
or
pathological
4. Assess joint position: trauma,
inflammatory
or degenerative disease
PLAIN RADIOGRAPHS -
OBVIOUS
PLAIN RADIOGRAPHS – 2
VIEWS
PLAIN RADIOGRAPHS – 2
VIEWS
Posterior
Dislocation
PLAIN RADIOGRAPHS – EXTRA
VIEWS
Radial Head
Fx
PLAIN RADIOGRAPHS – EXTRA
VIEWS
Scaphoid Fx
B. BONE DENSITY
1. Assess general bone density
*contrast between soft tissues and
bone
*contrast between cortical margin and
the
cancellous bone and medullary cavity
*loss of contrast means loss of bone
density
ie: osteoporosis
*labeled as osteopenia,
demineralization or
rarefaction
Originally coined for the changes of senile osteoporosis,
biconcave deformities of the vertebral bodies ("fish
vertebrae") are characteristic of disorders in which there
is diffuse weakening of the bone. The name is derived
from the actual appearance of a fish vertebrae which
normally has depressions in the superior and inferior
surfaces of each vertebral body. This sign is typically
used for osteopenia.
C. CARTILAGE SPACES
1. Assess joint space width
2. Assess subchondral bone
3. Assess the epiphysis and
growth
plates
D.SOFT TISSUES
1. Assess the gross size of the musculature
2. Assess outline of joint capsules: normally
indistinct; become obvious during
episodes
of increased joint volume from infection,
hemorrhage or inflammation
3. Assess the periosteum: normally
indistinct;
NUCLEAR SCINTIGRAPHY
• Most common = Bone Scan
• Very sensitive for skeletal pathology
• Mildly sensitive for soft tissue pathology
• Usually nonspecific as an isolated test
• Mostly patient friendly; no significant
environmental exposure
• Small-moderate expense
NUCLEAR SCINTIGRAPHY
• Excellent for specific pathologies
• Osteomyelitis
• Metastases – Not Multiple myeloma
• Occult fracture
• Reasonably reassuring
• Normal is usually normal
NUCLEAR SCINTIGRAPHY –
BONE SCAN
• IV injection radioisotope (Tc-99m) bound to
phosphate +/- dynamic imaging
• Approx 3 hour delay
• Delayed static imaging with a superficial
detector
NUCLEAR SCINTIGRAPHY –
BONE SCAN
Osteomyeliti
s
NUCLEAR SCINTIGRAPHY
2nd MT stress
fracture
ULTRASOUND
• Not available at all institutions
• Reproducible in trained hands
• Excellent for superficial soft tissue elements
including tendons and muscle
• Patient friendly
• Small to moderate expense
• No radiation
ULTRASOUND
• Routine exam room equipped with adequate
imaging devices
• Superficial gel (standard or aseptic) application
with touch with transducer
• Usually static exam of architecture +/-
vascularity assessment
• Potential for dynamic imaging
Ultrasound of a Shoulder
ULTRASOUND – ACHILLES
TENDON
Intrasubstance
tear
ULTRASOUND – PATELLAR
TENDON
Proximal patellar
tendonitis –
Jumper’s Knee
COMPUTED TOMOGRAPHY (CT)
• Widely available
• Reproducible, although variety of techniques
• Excellent bone assessment
• Occasionally useful for soft tissue
assessment
• Patient friendly
• Moderate expense
• Interventional options
COMPUTED TOMOGRAPHY (CT)
• Fancy X-ray
• Excellent for bony structural anatomy in the
setting of complicated fracture
• High radiation Dose
COMPUTED TOMOGRAPHY
• Usually supine axial exam, with some
alternative positioning options
• Can develop reformatted images after exam for
alternative views
• Imaging time in seconds, rarely minutes
• Usually without IV or oral contrast
CT - FRACTURES
Scaphoid
fracture
CT - DISLOCATION
Lis Franc Fx/Dislocation
CT- acetabular fracture
CT –posterior dislocation of hip
3D CT RECONSTRUCTION
TIBIAL PLATE FRACTURE
3D CT Reconstruction
CT – BONY ANOMALIES
Midsubtalar
coalition
MAGNETIC RESONANCE
IMAGING
• Widely available, but non-standardized imaging
techniques
• Reproducible
• Excellent for soft tissue pathology
• Good-excellent for bone pathology
• NOT patient friendly
• Large expense
MRI – ABSOLUTE
CONTRAINDICATIONS
• Cardiac Pacemakers
• Electronic stimulators
• Metallic foreign bodies in the orbit
• Body habitus beyond limits of physical unit
• Huge listing maintained in MRI facility
MRI - RELATIVE
CONTRAINDICATIONS
• Penile prostheses
• IUD’s
• Cardiac valves
• Berry aneurysm clips
• Retained bullet fragments
• Claustrophobia
• Huge listing in MRI facility
MRI
• Usually performed with patient
supine
• Multiplanar imaging obtained
without changing position
• One exam = one body part
• Average exam time 45 minutes;
most patients can’t last >2 hours
• Strict guidelines for sedation
• Optional contrast – Rad usually
decides for body imaging
MRI – TRAUMA
Osteochondritis
dissecans
MRI – TRAUMA
Femoral Neck
Fracture
MRI - TRAUMA
Tear vastus medialis
MRI – INTERNAL
DERANGEMENT
MRI – INTERNAL
DERANGEMENT
Supraspinatus tear= Full thickness, Full width
Coronal PD Coronal
T2
MRI – INTERNAL
DERANGEMENT
Sagittal Sagittal FT, FW Supra
NL
MRI – INTERNAL
DERANGEMENT
Sagittal, Meniscus Posterior Horn Tear
NL
MRI – INTERNAL
DERANGEMENT
Bucket handle meniscal tear
MRI – INTERNAL
DERANGEMENT
Sagittal – Intact
ACL
Torn
ACL
THANK YOU
