Musculoskeletal
Dr KAMBALE LUSSY
TUTOR: Prof Alina
TOLEDO
Application of imaging tools in the
musculoskeletal system
• Trauma.
• Joint disease.
• Infections
• Metabolic diseases.
• Bone tumours
• Non accidental trauma
The tools or imaging
investigation
• Plain x rays.
• Conventional tomography
• CT
• Angiography
• Radionuclide scan.
• Ultrasonography.
• MRI
1. Radiographs
Radiographs are indicated in all fractures and
dislocations.
2. Multidetector CT is used for further delineation of
complex fractures.
CT may also be used to diagnose complications of
fractures such as non union.
3. Bone scintigraphy
Bone scintigraphy is highly sensitive and therefore able to
demonstrate pathologies such as subtle undisplaced
fractures.
4. US
Musculoskeletal US (MSUS) is used to assess the soft
tissues of the musculoskeletal system, i.e. tendons,
ligaments and muscles. MSUS is able to diagnose
muscle and tendon tears.
Limitations of MSUS include inability to visualize bone
pathology and most internal joint derangements.
6. MRI
MRI is able to visualize all of the different tissues of the
musculoskeletal system including cortical and
medullary bone, hyaline and fibrocartilage, tendon,
ligament and muscle.
Conventional x-rays (plain X-rays)
There are 6 principles densities recognised on plain X-rays:
•air/gas = black (e.g. lung, bowel, stomach)
•fat = dark grey (e.g. subcutaneous tissue layer,
retroperitoneal fat)
•soft tissues/water = light grey (e.g. solid organs,
heart ,muscle, bladder)
•Calcification = off-off white
•bone = off white
•contrast material/metal = bright white
The formula
Remember ABCDES of the skeletal system.
•Anatomy and Alignment.
•Bone density.
•Cartilage.
•Displacement/dislocation.
•Erosions.
•Soft tissues.
Trauma.
• Skeletal trauma is one of the most
important aspects of orthopedic
radiology being by far the commonest
problem presented to the
musculoskeletal radiologist.
Imaging is complementary.
• Presence and severity of a fracture may be
apparent clinically.
• Confirmation and determination of extent of
injury are best documented at imaging.
• Imaging has a role in unsuspected or
doubtful injuries.
What is a fracture?
• A fracture is a discontinuity in a bone or cartilage
resulting from mechanical forces which exceed the
bone’s ability to withstand them.
• This may either be complete or incomplete.
• When a loading force is applied to bone it initially
deforms elastically so that removal of the load
reverses the insult.
• When the loading force exceeds the elasticity of
bone a plastic fracture results.
Femoral fracture
Fractures can also occur :
• Insufficiency fractures. The entire skeleton may be weak
due to metabolic / Genetic
•Fatigue fractures. The protrated chronic application of
abnormal stresses : e;g running
•Stress fractures
•Pathological fractures. The bone may have a lesion that
focally weakens. E.g metastasis
Describing a fracture
Check the :
•Who ?
•What ?
•Why ?
•When ?
• and where ?
Where is the fracture
The next thing to describe is the bone that is involved and
what part of the bone is affected:
•diaphysis: the shaft of the bone
•metaphysis: the widening portion adjacent to the growth
plate
•epiphysis: the end of the bone adjacent to the joint
•In some cases, you will use the anatomical name for a part of
the bone, e.g. the metacarpals have a base, shaft, neck, and
head
Complete fracture
Incomplete fracture: often for children
Fracture Deformity : the deformity of the distal fragment
in relation to the proximal fragment.
Transverse fracture of the mid-to-distal third of the right
tibia.
No significant angulation, but ventral (80%) and lateral
(10%) translation
Supracondylar fracture distal humerus.
The distal fragment is displaced posteriorly (arrow).
Terry Thomas sign.
Dancers fracture.
Bowing fracture.
Boxer fracture
Bucket-handle fracture
Burst fracture
Butterfly fragment
Chauffeur fracture
Chisel fracture
Big boys.
Multimodality imaging.
Other terms describing fractures
• A torus or buckle fracture is the term applied
to a fracture of the cortex on the compressive
side of the bone with an intact cortex on the
tension side.
• A green stick fracture has a cortical disruption
only on the compressive side without cortical
interruption on the tension side.
Soft tissue abnormalities
• The majority of fractures are readily identified.
• On occasion they may be difficult or
impossible to visualize on initial radiographs.
• Clues may be in the soft tissue.
• Fractures around a joint may be associated
with an effusion or hemarthrosis as long as
the joint capsule remains intact.
• Knee joint may show lipohemarthrosis.
Joint injuries
• Dislocations occur when there is complete
loss of normal articular contact between
the bones comprising the joint.
• Diastasis refers to the separation of fibrous
joints e.g. symphysis pubis or sacroiliac
joint.
• Major ligamentous injuries are easily
missed on x-ray.
Bone tumours
• Radiology is essential for full evaluation of a
bone tumour.
• Definitive diagnosis is established by
histopathologist.
• This is not always possible.
• Also pathology findings should not be
considered in isolation.
• Team work vital between clinician ,
radiologist and pathologist.
General principles for bone tumours.
• Age at presentation has a heavy bearing on
likely diagnosis.
• The majority of bone tumours show a peak
incidence confined to one or more decades.
• Metastases are the most common malignant
tumours of bone in patients over the age of 45
years.
• Primary malignant bone tumours are rare
under the age of 5 years.
Rate of growth of bone tumours
• The radiologist achieves a better
assessment of the rate of growth than the
histopathologist.
• Grades provided by Lodwick.
• May be geographical, Moth eaten or
permeative .
• Regular or scalloped margins suggest a
benign cause.
CT scan and MRI
• Major role in staging of tumours.
• CT has replaced linear tomography in the
determination of tumour extent.
• CT defines tumour matrix and calcification
well.
• The expectation that MRI would be
invaluable for distinguishing different types
of bone tumours has not been realized.
Simple bone cyst
Chrondromyxoid fibroma
Hemangioma
Lymphoma of bone
Osteosarcoma
Parosteal osteosarcoma
Prostatic metastases to lumbar
spine
BREAST METASTASIS
BONE TUMOURS: Detection
Scint
CT
Rt Osteoid Osteoma
presenting complaint = painful adolescent scoliosis
BONE TUMOURS 66yrs
Peak Age Incidence
6yrs
Histiocytosis
Myeloma
Bone sepsis/osteomyelitis.
Micro-organisms may infect any of
the tissues of the musculoskeletal
system where they cause similar
symptom complexes of pain loss of
function variably accompanied by
fever systemic illness
Imaging in
osteomyelitis
•Early diagnosis greatly improves
outlook.
•Must use available tools optimally.
•often xrays are all you have.
Why is imaging vital?
• The symptoms and signs of skeletal infections are varied
and often non specific.
• They mimic many other conditions most significantly
degenerative disease.
• Thus imaging has a crucial role in the detection,
discrimination and follow-up of infections of bone, joint
and soft tissues.
What is the role of radionuclide
radiology in chronic osteomyelitis?
•99mTcMDP has high sensitivity but
low specificity.
•111 In labelled wbc have high
specificity but low sensitivity.
•Should they be combined?
Others.
•The menu is wide.
•So must your
appetite be.
Osteopetrosis
Psoriatic spondylitis;Floating
syndesmophytes
Rotator cuff tear.
Scaphoid fracture.
And back to earth
