Catatan Radiologi Muskuloskeletal

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MUSCULOSKELETALRADIOLOGY

Roentgenographic

of bone giveinformation about

1. Bone & soft tissue lesions

2. Fracture/ pathologic fracture

3. The origin of the lesion dan the type of the tumor (benign/malignant)

4. Guiding biopsy

5. Follow Up

Composition of

bone 25% of water, 30% organic, 45% nonorganic (radioopaque density) :

Caphosphat 85% and Cacarbonat 15%

Blood supply of bone :

1. A.Nutricia (fossa a.nutricia bone x-ray)

2. A.Metaphyseal& a. epiphyseal (direct supply for meta/epiphyse)

3. A. Periosteal (branch from nutricia artery which through the Harvers&Volkmansystem)

Radiologicanatomy

Book of Meschan I :1. Articular cartilage

2. Subarticular of epiphyse3. Epiphysis

4. Epiphyseal line5. Metaphysis

6. Diaphysis

Disorder of boneand joint

1. Development anomaly/Congenital2. Infection

3. Trauma & fracture4. Deficiency Bone disease

5. Bone Dysplasia

6. Bone tumors7. Avascular necrosis/Aseptic necrosis

8. Degenerative disc disease/Metabolic

1. Development Anomaly/Congenital

1.1 Arthrogryposis Multiple Congenital failure of muscle growth

1.2 Upper extremities : a. Bone absent : hemipelya distal and Phacomelya proximal

b. Synostosis Radius & Ulna

c. Hand:Brachyphalangea (short hand), Brachydactili (short metacarpal), Long

tubular bone , and Polydactyli

1.3 Pelvis : - Nargle& Robert pelvis :Absent of one sacral wing and Robert = Nagle bilateral

- Iliac Horns Dorsal Protrusion of Processus from iliac wing

1.4 Lower extremities : a. Congenital dislocation of the coxae (Hip)

b. Congenital Coxavara : bowing femur, bilateral shortening

c. Patella bipartite & multipartite

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d. Congenital Pseudoarthrosis Tibia & Fibula: mid/lower third and commonlylesion in fibula

e. Leg & ankle: Pesequinovarus and Ball &sochet ankle foot

1.5. Columnavertebralis : Coronal clefts vertebraspina bifida, Hemivertebra, Sacralization, Lumbarization,

and Scoliosis.

2.INFECTION

2.1. OSTEOMYELITIS

a. Pyogenic / suppurative: Staphylococcus, Pneumococcus, Streptococcus, Salmonella

Mechanism of contamination: - Hematogenous from focus infection(throat & skin)

- External contamination (open fracture/bone operation)

b. Spesific/ non suppurative: TBC, virus, dan fungi, and slowly than pyogenic

Acute Chronic

- commonly in children

- metaphyseal (distal femur, proximal tibia , proximaland distal humerus ,radius, ulna and collumna vertebrae )

inadequacy therapy

Radiology:- Lytic lesion

- Periosteal reaction- Soft tissue swelling

Radiology :- Generally Osteosclerosis

- Increased in bone diameter- Irreguler contour with thickening cortex

- Lytic lesion can occur- Occationallysequestrum formation

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2.2.TUBERCULOUS SPONDYLITIS

Marginal type Central Type Anterior type

- Superior/inferior adjacent

vertebral disc

- Destruction with lytic lesion in

anterior column, disc damage very

fast narrowing disc

- involvement multiple contiguous

column.vertb

- wedgegibbus

- Spider leg app

- chronic Calcification in abses

- Osteosclerotic (-)

- Abcess /cold abcess in the central

of collumn vertebra.

- destruction of disc slowly

- if extend to the periphery theprocess is same with

marginal

- process under periosteum

- extend below the Lig.Longitudinale anterior

- Disc destructionslowly

2.3. LONG BONE TBC

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Radiology :

- especially in metaphysis

- lytic lesion is dominant

- sometimes minimal surrounding sclerotic

- minimal/no periosteal reaction

- minimal soft tissue swelling

Primary bone

Secondaryhematogen

3. TRAUMA & FRACTURE

Trauma Minimal : Hematoma sometimes not seen in bone x-ray,

Severe ; subluxation, dislocation with fracture

External : accident, fall

Internal : strong and sudden muscle contraction, for example : epilepsy, tetanus &

electric shock

Fracture discontinuity of bone, cartilage or both of them with soft tissue damage

Fracture open or close

Fracture Complication

1. Osteomyelitis2. Non Union (neoarthrosis)3. Bone artrophy

4. Bone formation in musclemyositis ossificans

5. Severe deformity

Fracture type :

Transversal fr Oblique/spiral/screw fr.

Comminuted fr more than 2 fragment Avulsion fr.

Green stick fr. (children)

Compression fr. vertebrae

Impression fr. skull Linier fr.

FrakturtranseversaFraktur

oblique

Frakturkominutif

Frakturkompresi

Distal

Radius

fracture

a.Colles Fracture: Distal radius fr. (until 2 cm ) with posterior angulation, posterior dislocation

& deviation of distal fragmen to radial.

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b. Smith Fracture: Distal radius fr. with dislocation of fragmen distal to volar.

Fracture

and

dislocation

radius and

ulna

a. Monteggiafraktur: proximal ulna

fr.with caput radii dislocation

b. Galeazzifraktur: distal radius fr.with distal

dislocation of radioulna joint.

Pathologic

Fracture

1. Severe trauma Fr.2. Spontaneous Fr./pathologic Fr. : Bone tumor ( primary, secondary) and Infection

( osteomyelitis)

3. Stress Fr. minimal and continous for examples

March fr. metacarpal

Tibia fr. Ballet dancer

Fibula fr. long distance runner

Other T,V,Y shape fr., Impacted fr., Longitudinal fr.

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X-Rayevaluation

1. Diagnostic immediately after trauma2. Post reposition

3. 1-2 weeksto follow up the position of the bone fracture(changing position or no)

4. 6-8 minggu callus formation5. Every changing position/traction6. Before go out from hospital

4.DEFICIENCY BONE DISEASES

Rickets (Hypovitaminosis D) Scurvy (hypovitaminosis C)

Bone disease deficiency vit D with kidney andmineral absorption disorder

Roentgenographic feature :

1. chondrocostal junction enlargement(rachitis rosary)

2. Cupping of metaphysis (muscle &ligamentumtraction)

3. Bowing long bone4. Commonly Greenstick fr.

5. SubperiostealCalsification6. Irregularity of ossisilii

7. Metaphyseal lineirreguler& frayed

8. skull : Fontanella + suture (still open)9. Osteoporosis

1. Caused of deficiency Vit C make the failure of

intracellular forming include bone, catilage&endothelforming

2. The bone forming is persued but the reabsorption

still happen osteoporosis

Rontgen :

1. General Osteoporosis

2. Ground Glass Appearance

3. Cortex thin

4. Metaphysealwide (cupping)

5. Pelkens signmarginal spur formation

6. Wimbergers sign marginal ring calcification ofcentral ossification in epiphysis

7. Subperiosteal hematomacalcification

subperiosteal bone

5.BONE DYSPLASIA

Bone forming disturb or intrinsic bone modelling

Fibrous dysplasia OsteogenesisImperfecta Achondroplasia

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Divided into 2 : monostotic (femur,tibia, costae,& facial bone)

danpolyostotic (many bonesunilateral)

Rontgen :

1. Ground glass app

2. Cortex intact & wide

3. Endosteal cortex thin &scalloping

4. Diaphysis wide & expansive

5. Sometimes sclerotic is dominant

6. Skull : marginal sclerotic, wide

diploe, uppermost of tabulaexternal (tabula internal not

frequent), sclerotic of skull base,sphenoid crypt & facial bone

( thickness & sclerotic of facialbone & skull base, obliteration of

sinus maxillaries)

Ireguler circumscribed destruction

of bone with thick sclerotic margin

consisted of 2 type

congenital (since born) &tarda

(the symptoms seen inchildhood)

Rontgen :

1. Osteoporotic (ground glassappearance)2. Multiple fracture

3. Bowing of inferior extremity

4. Vertebra biconcave

5. Bone deossification +

diameter of bone become wider6.skull: - thin tabula + warmian

bone7. Protrusioacetabuli

All long bone (extremity) short

But Corpus Vertebra still normal

Roentgen :

1. Shortened of long bone &symetries

(mycromelia)

2. The Proximal bone shorter thandistal bone (rhizomelia)humerus

shorter than radius, femur shorter than

tibia

3. Metaphysis wide & cupping (in

the distal long bone)4. The finger bone short & more wide .

For example 3rd finger & 4th finger are

same (trident hand)5. Column Vertebrae : wedge (vertebra

lumbal), posterior margin of column

vertebrae become concave so that theforamen intervertebrale more wide,

diameter AP of pedicle become shorter

6. Head bigger (brachycephaly)

7. Fibula head longer than tibia (sameas ulna and radius)

8. Pelvic bone champagne shape(acetabular angle leveling off)

7. BONE TUMORMay benign or malignant and may primary or secondary (metastasis) :

To differentiate the tumor is malignant or not 1. 0 - 5 years : neuroblastoma

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1. Age

2. How long the pain & the swelling and the

growth of the tumor (slowly or fast)

3. Size of the tumor

4. Number of lesion (mono/polystotic)5. Location (what part of the bone)

6. Density : osteolitic, osteosclerotic& mixed7. Structure of tumor : the margin, the type of

destruction (central/marginal), type ofperiosteal reaction, continuity of the cortex

8. Bone shape : bowing, fracture

2. 5 - 20 years : Ewing tumor

3. 10 - 25 years : osteosarcoma

4. 20 - 40 years : giant cell tumor

5. 20 - 70 years : lipoma

6. 30 - 45 years : fibrosarkoma

7. 30 - 50 years : periosteal sarcoma

8. 30 - 60 years : chondrosarcoma

9. 30 - 70 years : hemangioma

10. 40 - 80 years : metastasis, Multiple

Myeloma

There are 3 principal point in bone lesion

assessment : * infection or neoplasm

* benign or malignant

* primary or secondary

Classification of Bone tumor

From skeletal tissue Cartilage Fibrous Giant Cell (Giant Cell

Tumor)

a. Benign: bone island,

osteoma, osteoidosteoma, osteoblastoma

b. Malignant

Osteosarcoma, periostealsarcoma

a. Benign

:Chondroma,Chondroblastoma,Chondromyxoid Fibroma

b. Malignant

(Chondrosarcoma)

a. Benign: Fibroma,

Brown Tumor

b. Malignant:Fibrosarcoma

a. Benign: GCT, ABC

{Aneurysma BoneCyst}

b. Malignant: Giant

Cell Tumor Maligna

From other tissue in the bone:

1. Vessels : Hemangioma,

Glomustumor, Hemangiosarcoma

2. Nerve : Neurofibroma,

Neuroblastoma,Neurofibrosarcoma

3. Fat : Lipoma, Liposarcoma

4. Notochord : Chordoma

5. Epithel : Dermoid, Adamantinoma

6. Lymphoid/Hemopoetic ;Lymphoma, Leukemia,Plasmocytoma,

Multiple Myelom

From the jointSinovioma Unknown :

a. Benign : SolitaryBone Cyst

b. Malignant : Ewing

Tumor

Benign Tumor Malignant Tumor1. Bone Island ( Enostosis ) 1. Osteosarcoma

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Ro : - Soliter/ Multiple- always in Medulla

- densityHomogen

- marginmay Irreguler .

Spiculated into medulla

Sclerotic bone island in the distal femur & proximal

portion of tibia

according to position (central,peripheral)according to lesion (osteolytic,osteosclerotic,mixed)

Male > female

Ro :

Sites : distal femur, rarely in tibia, sternum,

costae, skull Position of lesion : metaphysis / diaphysis

50% sclerotic, may osteolytic, mixed (irregular

margin )

Periosteal reaction sunburst/Sun Ray app.

Other Typically : cortex destruction & invasionto soft tissue

Soft tissue swelling

Codman Triangle

2. Osteoma :

Ro : - Sites : Skull, Sinus Paranasalis- Size 2.5 Cm

- High density, welldefined margin &homogen

2. Fibrosarcoma

5 % skeletal tumor

Low grade pain

1 yearOften in medulla Metaphysis, 80% kneeRo :

Typically osteolytic

In medulla (irregular radiolucent area)

Expansion of cortex

Soft tissue swelling (caused of expansion to soft

tissue)

Periosteal reaction No/rarely

Periosteal fibrosarcoma of forearm involving the ulna

3. Osteoid Osteoma

Male : Female = 3 : 1

Decade 2 / 3Predilection : Diaphysis of long bone (50% proximal

femur), Tibia, Skull rarely

Ro : - Radiolucent area, Oval/rounded sclerotic

margin- High density

3. Chondrosarcoma

Age : 30 70 thn

Sites : Pelvis, costae, proximal femurRo :

o Local cortex destruction, ill-definedtransition

between normal tissue & lesion cannot be

differentiated

o Central tumor irregular calcificationo Endosteal erosion, scallopingpop-corn

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- Diameter 2.5 Cm

Benign osteoblastoma (Giant osteoid osteoma)

appearance

o Periosteal reaction Lamellar

chondrosarcoma

4. Osteochondroma

- outgrowth of bone , from cortex diaphysis of long

bone- point away from nearest joint

Ro :

- Pedunculated type (outgrowth of bone from cortextrabecula penetrate into medulla through the defectof the cortex )

- Calcification

- size 8-10 cm point away from joint

- Pelvic & scapula irregular & high density

Cauliflower app.

osteochondroma

4. Ewing Tumorfrom medula

age 5 20 yearsSites : long bone

Ro :

Lamellar periosteal reaction(Onion Skin app.)

Codman triangle Sometime sclerotic (longitudinal band)

Bone destruction

Soft tissue swelling

Ewing tumor

5. Giant Cell Tumor (Osteoclastoma)

Age 20 40 years

Rarely before maturity of bone

Sometimes multifocal in hand SoliterSites : knee, distal radius, sacrum,

pelvis & vertebrae.Ro :

Radiolucent zone, typically in the cortex below

the joint

Eccentric in the tip of long bone

No calcification/occification except after

pathologic fracture

Typical finding : trabeculationlikeSoap

Bubble App40% of cases

Osteolitic margin

ill defined, no bone reaction

Cortical thinning & expansion

Lesion may expansion to soft tissue, no

5. Sinovioma

70% inferior extremity knee

Age < 30 years

Very malignant immediately metastasis(lymphogen)

Ro :

Soft tissue mass around the joint

Many calcification

Irregular bone destruction near the joint

Thickening of sinovial& erosion ofjuxtacapsular

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calcification

Angiographyhypervascular, with many

vessels & shunting arteriovenous

DD : Aneurysmal Bone Cyst,

Chondroblastoma, Fibrous Dysplasia

Aneurysmal Bone Cyst

- Ethiology unknown

- Sometimes found after fracture

- Affect to children, sites long bone

- in vertebrae age 10-20 years, especially atarcusneuralis, rarely at corpus.

- Commonly multiple vertebraeRo :

reabsorption bone area with bone expansion

Size varying 2-20 cm

Cortex thin & expansion

Endosteal margin is well-defined with cortex

Soap Bubble Appearance

Transition zone between lesion & medulla,

sometime with sclerotic. Similar withosteoclastoma. Sometime scalloped

atauirreguler, sclerotic margin Angiography similar with Osteoclastoma

DD : Osteoclastoma /Giant Cell Tumor

Aneurysm bone cyst

6. MM (Multiple Myeloma)

Primary Malignant tumor of bone marrowRo :

Osteoporosis cortical thinning

Osteolytic Punch out lesionmultiple, rounded, well-

defined, intact, varying in size

Inner cortex scalloping

Sometime expansive with soap bubble app.DD : metastasis

7. Metastasis

May osteolytic, osteoblastic, ill-defined

Irregular margin& sometime with sclerotic marginsites of metastasis :

vertebrae

costae & sternum

skull & pelvic

other bone

8. Avasculer necrotic of bone ( osteochondritis, osteochondrosis,bone infarction)

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abnormality of bone which one of the bone loss of vascularitymake the cell dead osteonecrosis

Commonly no infection

Early stage Late stage Sites of osteochondritis

Ro :

early stage no damageof bone

medium diffuse

osteoporosis, normal densityin the avascular area

Big joint (microfracture of thecortex hip & shoulder,

follow by trabecula

compression &colaps that make

joint more horizontal with

subarticular growth and in same

time the trabecula depressed

into smaller space.

Infarction of metaphysis

&subarticular infarction

lucent in the central

Bone within Bonelineardensity in the bone & parallel

with cortex

Abnormality of epiphysis

Cone epiphysis premature

fusion

1. Corpus vertebra Calve Disease

2. Vertebral epiphysisScheuermanndisease

3. CapitulumHumerusPannersDisease

4. LunatumKienboeck disease

5. Proximal phalangesThiemansdisease

6. Caput metacarpal Dietrich disease

7. Caput femoris Calve Leg Perthes

8. Distal collumfemorisCoxavara

9. Tibia/apophysis tibia OsgoodSchlatter

10. Condylus medial tibia Blountsdisease

11. Calcaneus apophysis Sever disease

12.Naviculare Alban Kochler

13. Caput metatarsal Freiberg Kochler

OsteoporosisSystemic skeletal diseases decreaseof bone mass & microstructures caused bone weaker& easier to get fracture

Radiologic of osteoporosis

1. Conventional Radiology

- Vertebrae x-ray 4 grading

- Femur x-ray used index Singh- Metacarpal

2. Photodensitometry/Radiography Densitometry

3. Single Photon Absorptiometry (SPA)4. Quantitative Computed Tomography (QCT)

5. Peripheral Quantitative Computed Tomography(PQCT)

6. Dual Energy X-Ray Absorptiometry (DXA)7. Sonodensitometry.

8. Neutron Activation Analysis9. Compton Scattering

10. Radioisotop11. Magnetic Resonance Imaging (MRI)

8. DEGENERATIVE JOINT DISEASES

A. SPONDYLOSIS /

SPONDYLOARTHROSIS

Osteo Arthritis of Spine

Rontgen :

- Spur formation / osteophyteAnterior, Posterior, and Lateral

- bridging bamboo spine

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- Marginal sclerosis of corpus vertebra

- Spur may in-growth (foramen Intervertebralis usually cervical (C5,C6,C7)neurologic sign

B. OSTEOARTHRITIS

(OA)- Osteoarthrosisdegeneratif joint disease

- Predilection from the knee

- Female > male

Rontgen (finger) most find at

interphalangeal joint

Always narrowing of jointspace

Irreguler of joint (the

margin)

Herbedens Nodes at dorsalfacies of distal phalanges

(base) spur-formation

Subchondral cyst like defect

Ro (Knee) :

Spur at posterior aspect of

patella

Spur formation : condylus

tibiaproximal, femurdistal,eminentiaintercondyloid

ea tibia

Narrowing of joint spacemedial aspect

(DD.Rheumatoid:all joint)

C. PSORIATIC

ARTHRITIS- Predominant destruction distal interphalangeal joint (as Osteoartritis)- Ankylosing at interphalangeal joint

DD.- Rheumatoidat interphalangeal joint

- Joint space more widesurface is clearly- Destruction arthritis at interphalangeal joint of feet thumb

- Mild osteoporosis

- Footmore shown psoriatic arthritis- Bone mineralization is normal

D. ANKYLOSING

SPONDYLITIS

Marie strumpells/von Bechterews/rhematoid

Spondylitis, female =malecommonly youth

Rontgen :

Sacro-iIiac Joint (SI joint) blur wider narrowing

sclerosing/ankylosing (bilateral)

Always start at SI Joint

Squaring anterior corpus vertebrae

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Generalize osteoporosis

Calcification of ligament+ paraspinal soft tissue

Bamboo-spine

Disc destruction

Syndesmophyte formation

E. RHEUMATOID

ARTHRITIS

- Female > male- Multiples &Symmetris

- Mostly : proximal interphalangeal joint, metacarpophalangealjoint,wrist joint(radiocarpal), not all joint can affect

Rontgen :

Periarticular soft tissue swelling fusiform (spindle shaped)

Periarticular Osteoporosis cartilage destruction

Marginal erotionjuxta articular arthritis mutilans

Ankylosing + subluxatio

Ulnar deviation of finger caused of subluxatio ( flexy- extension swan neck Appearance )

Rheumatoid arthritis with scleroderma

F. GOUT Male > female, > 40 years

Rontgen :

Radiologic change after multiple attack

Commonly only one jointmetacarpophalangeal joint ( but other

joint in hand & leg can be attacked)

Deposite of Na-Uric not radiopaque (not seen ,just periarticular&joint swelling)

Osteolyticjuxta articular small/big with well-defined

Subarticuler cystic area sclerotic margin Over hanging

edge,D0,3-3 cm PUNCHED OUT

If there are depositesCa in tophy the tophy is seen Narrowing joint space

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Decrease of Osteoporosis

SKULL X-RAY

Information /abnormality: Sign of Intracranial pressure increasing :

Fracture

Infection

Tumor : primary and secondary

Sinus paranasalis

Congenital

Suture more wide

Impressionesdigitatae

Destruction of sella

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Catatan Radiologi Muskuloskeletal

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