Introduction to skeletal imaging ii

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Information about Introduction to skeletal imaging ii

Published on March 20, 2014

Author: muhammadbinzulfiqar5



Skeletal Imaging

INTRODUCTION TO SKELETAL IMAGING Muhammad Bin Zulfiqar PGR II SIMS/SHL New Radiology Department

Overview of Skeletal system •Total bones 206 •Skull bones 22 •Ear bones 6 •Throat Bone 1 •Thorax 25 •Vertebral column 24 •Shoulder girdle 4 •Upper limb 60 •Pelvis 4 •Lower Limb 60

Imaging Modalities for Skeletal System •Plain Radiographs(main focus) •Nuclear Scintigraphy •Contrast Examination •Ultrasound •Computed Tomography •Magnetic Resonance Imaging

Major Diseases of Bone  Trauma  Congenital  Infections  Tumors  Metabolic, Endocrine, Nutritional  Bone Dysplasia  Inflammatory Diseases(R.A.)  Associated soft tissues abnormalities

Skeletal Anatomy and Physiology Skeletal Development  Intramembranous Ossification  Enchondral Ossification Bone Structure  Epiphysis – ZPC – Metaphysis – Diaphysis  Cortex – Medulla – Periosteum – Endosteum Bone Metabolism  Bone mineral - Hormones




Approach to skeletal imaging Preliminary Analysis • Clinical data • Number of lesions • Symmetry of lesions • Determination of Systems Involved

Analysis of The Lesions Skeletal Location Position Within Bone Site of Origin Shape Size Margination Cortical Integrity

Analysis of The Lesions Behavior of Lesions • Osteolytic Lesions • Osteoblastic Lesions • Mixed Lesions  Matrix  Periosteal Response • Solid Response • Laminated Response • Spiculated Response • Codmans’Triangle

Radiologic Predictor Variables  Supplementary Analysis  Other imaging Procedures  Laboratory Examination  Biopsy  Soft Tissue Changes

TRAUMA Fracture and Dislocation The radiographs should be made  Include at least one joint  Preferably two joints  Two position AP – LAT

TRAUMA Time intervals between Radiographic Study  Initial Diagnostic study  Post reduction and post immobilization  One or Two weeks later, if position has changed  After approximately six eight weeks for Primary callus  After each plaster cast or traction change  Before final discharge of patient

TRAUMA Types of Fracture  Closed fracture  Does not break the skin or communicate with the outside environment  Simple fracture  Open fractur  Penetrates the skin over fracture site  Compound fracture

TRAUMA Comminuted fracture  Two or more bony fragments have separated  Non Comminuted fracture  Penetrates completely through the bone  Avulsion fracture  Tearing away of a portion of the bone  Impaction fracture  Bone is driven into its adjacent segment

TRAUMA  Incomplete Fracture  Broken only one side of the bone  Greenstick (Hickory Stick) fracture  Torus (Buckling) fracture Fracture Orientation  Oblique fracture  Commonly occurs in the shaft of long tubular bone  45° to the long axis of the bone



TRAUMA  Spiral fracture  Torsion, coupled with axial compression and angulation  Transverse fracture  Run at a right angle to the lonh axis  Uncommon through healthy bone  Pathologic fracture


TRAUMA Spatial Relationships of Fracture  Alignment  Position of the distal fragment in relation to the proximal fragment  Apposition  Closeness of the bony contact at the fracture site  If the ends are pulled referred to as Distraction


TRAUMA  Rotation  Twisting forces on a fractured bone along its longitudinal axis Traumatic Articular Lesions  Subluxation  Dislocation  Diastasis Epiphyseal Fractures  Salter-Harris Classification

Salter - Harris


TRAUMA Fracture Healing  Main steps in fracture healing  Formation of hematoma  Organization of hematoma  Formation of fibrous callus  Replacement of fibrous callus by primary bany callus  Absorption primary bany callus Transformation to secondary bony callus  Remodeling

TRAUMA Complication of Fractures  Immediate complication  Arterial injury  Compartment syndrome  Gas gangrene  Fat embolism syndrome  Thromboembolism

TRAUMA  Intermediate complication  Osteomyelitis  Myositis ossificans  Synostosis  Delayed union  Delayed complication  Osteonecrosis  Osteoporosis  Non union – Mal union

Myositis Ossificans

INFECTION Suppurative Osteomyelitis  General Consideration  Systemic or Local infections  Immunosuppresed patients, alcoholics, newborns, and drug addicts are predisposed  Antibiotics have significatly reduced the sepsis-related mortality

INFECTION  Etiology  Staphylococcus aureus causes 90%  Pathway for the spread  Hematogenous  Contiguous  Direct Implantation  Postoperative

INFECTION  Radiologic Features  Bone scan are the earliest means of diagnosis  Radiographic latent period for plain film  10 days for extremities  21 days for spine  Soft tissue alteration : elevated fat planes, obliterated fat planes, increased density.

INFECTION  Bone changes :  Moth-eaten bone destruction Usually metaphyseal in origin  Periosteal new bone formation Solid – Laminated – Codman’s Triangle  Sequestrum  Involucrum  Joint space destruction (ankylosis)



INFECTION Septic Arthritis  General consideration  Single joint involvement in the rule  Most common route is hematogenous or direct traumatic implantation  Etiology  Most frequently is Staphylococcus Aureus

INFECTION  Radiologic Features  The knee and hip are the most common sites  Joint effusion leads to distortion of the fat folds  Positive Walden storm's sign  Rapid loss of joint space  Bony ankylosis

INFECTION Nonsuppurative osteomyelitis (tuberculosis)  General Consideration  Found in patients such as prepubertal children, debilitated geriatric, silicosis, AIDS sufferers, Lymphoma patients, Alcoholics, corticosteroid and drug abusers

INFECTION  Etiology  Mycobacterium tuberculosis  Two mode of spread  Inhalation  Ingestion

INFECTION  Radiologic Features  Spinal tuberculosis is most common at L-I  Early sign for spine are :  Lytic endplate destruction  loss of disc height  Anterior “ gouge defect “  Paraspinal swelling

INFECTION Advanced sign for spinal involvement are:  Vertebral body collapse  Gibbus formation and obliteration of the disc  Tubercular arthritis is common in the hip and knee  Uniform joint space narrowing, early destruction of the subchondral cortex, “moth-eaten” bone destruction and juxtaarticular osteoporosis are the cardinal sign of tubercular arthritis




TUMORS PRIMARY BENIGN BONE TUMORS  Osteochondroma  Osteoma  Bone island  Osteoid osteoma  Simple bone cyst  Aneurysmal bone cyst

TUMORS Metastatic Bone Tumors  General Consideration  The most common malignant tumors  CNS tumors and basal cell Ca rarely  Life threatening complication  Incidence  70% are metastatic, 30% are primary  In females 70% from breast Ca In males 60% from prostate Ca

TUMORS  Radiologic Features  Technetium bone scan  80% of all metastases are located in the central or axial skeleton - Spine and Pelvis being a most common  Alteration in bone density and architecture  75% osteolytic, moth eaten or permeative  15% osteoblastic  Periosteal response is rare


TUMORS Primary Malignant Bone Tumors  Multiple Myeloma  Bone scan are cold  Gross Osteoporosis may be the only early sign  Punched out lesions  Vertebra plana or wrinkled vertebra  Preservation of pedicles

Multiple Myeloma

Multiple Myeloma

TUMORS  Osteosarcoma  75% of cases occurs in the 10 to 25 age  Metaphysis of the distal femur, proximal humerus are the most common sites  Permeative or ivory medullary lesion in metaphysis of a long tubular bone  A sunburst or sunray periosteal response  Cortical disruption with soft tissue mass formation  Sclerotic – Lytic – Mixed lesion



TUMORS  Ewing’s Sarcoma  Most cases occur in the 10 – 25 age range  May mimic infection  Diaphyseal permeative lesion  Femur, tibia and fibula  Onion skin periosteal response  Most common primary malignant bone tumor to metastasize to bone

Ewing’s Sarcoma

TUMORS Primary quasimalignant bone tumor  Giant cell Tumor  Osteoclastoma  20-40 years is the usual age range  Distal femur, proximal tibia distal radius, proximal humerus  Metaphysis and extend to subarticular  Radiolucent, eccentric  Soap Bubble appearance

Giant Cell Tumor

TUMOR Primary Benign Bone Tumors  Osteochondroma  Painless and hard mass near a joint  Humerus, tibia, femur, ribs  Two types : - sessile - pedunculated  Coat hanger exostose – cauliflower mass  The cortex and spongiosa blend imperceptibly


TUMOR  Osteoma  A rise in membranous bones  Sinuses – frontal, ethmoid Mandible Skull bones  Homogenously opaque

Osteoma 

TUMOR  Bone Island  Epiphyseal, metaphyseal  Medullary  Round – oval : Long axis oriented Smooth or radiating border Opaque Normal adjacent cortex May change size

TUMOR  Osteoid osteoma  Consists a nidus, that usually 1 cm or less  Target calcification  Most common location is in the cortex  Radiolucent nidus surrounded by perifocal reactive sclerosis

Osteoid Osteoma

TUMOR  Simple Bone Cyst  Expansile radiolucent  Proximal humerus, femur, calcaneus  No periosteal reaction  Pathologic fracture  Aneurysmal Bone Cyst  Some lesion may reach 8 – 10 cm  Cortical ballooning “ blown out app”

Aneurysmal Bone Cyst

Aneurysmal Bone Cyst

ARTHRITIC DISORDERS Degenerative Disorders  Degenerative Joint Disease  etc Inflammatory Disorders  Rheumatoid Arthritis  etc Metabolic Disorders  Gout  etc

ARTHRITIC  Degenerative Joint Disease Osteoarthritis – Osteoarthrosis  Asymmetric distribution  Non uniform loss of the joint space  Osteophytes  Subchondral sclerosis  Subchondral cyst  Loose bodies  Subluxation


ARTHRITIC  Rheumatoid Arthritis  Generalized Connective tissue disorder  Highest incidence among the 40 – 50 year  Symmetric peripheral joint pain and swelling  Early : - Soft tissue swelling Marginal erosions Osteoporosis - Periostitis Loss of joint space Late : - Ankylosis Deformities

Rheumatoid Arthritis

Rheumatoid Arthritis

ARTHRITIS Gout  Disorder of purin metabolism  Deposits of Sodium monourate crystals into cartilage, synovium, periarticular and subcutaneous tissues  Dense soft tissue Tophi, preservation of joint space, Bone erosions (marginal periarticular) “overhanging margin sign”  Metatarsophalangeal joint




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