MUSCULOSKELETALRADIOLOGY Roentgenographic of bone give information 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. 3. Radiologic anatomy A.Metaphyseal& a. epiphyseal (direct supply for meta/epiphyse) A. Periosteal (branch from nutricia artery which through the Harvers&Volkman system)

Book of Meschan I : 1. Articular cartilage 2. Subarticular of epiphyse 3. Epiphysis 4. Epiphyseal line 5. Metaphysis 6. Diaphysis 1. 2. 3. 4. 5. 6. 7. 8. Development anomaly/Congenital Infection Trauma & fracture Deficiency Bone disease Bone Dysplasia Bone tumors Avascular necrosis/Aseptic necrosis Degenerative disc disease/Metabolic

Disorder of bone and joint

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. e.

Congenital Pseudoarthrosis Tibia & Fibula: mid/lower third and commonly lesion in fibula 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 - commonly in children - metaphyseal (distal femur, proximal tibia , proximal and distal humerus ,radius, ulna and collumna vertebrae ) Radiology: - Lytic lesion - Periosteal reaction - Soft tissue swelling Chronic inadequacy therapy 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 - Superior/inferior adjacent vertebral disc - Destruction with lytic lesion in anterior column, disc damage very fast narrowing disc - involvement multiple contiguous column.vertb - wedge gibbus - Spider leg app - chronic Calcification in abses - Osteosclerotic (-) Central Type - Abcess /cold abcess in the central of collumn vertebra. - destruction of disc slowly - if extend to the periphery the process is same with marginal Anterior type - process under periosteum - extend below the Lig. Longitudinale anterior - Disc destruction slowly

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 discontinuity of bone, cartilage or both of them with soft tissue damage Fracture open or close Fracture Complication 1. Osteomyelitis 2. Non Union (neoarthrosis) 3. Bone artrophy 4. Bone formation in muscle myositis 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.

Fracture

Frakturtranseversa Distal Radius fracture

Fraktur oblique

Frakturkominutif

Frakturkompresi 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. 2.

Severe trauma Fr. 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 T,V,Y shape fr., Impacted fr., Longitudinal fr.

Other

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X-Ray evaluation

1. 2. 3. 4. 5. 6.

Diagnostic immediately after trauma Post reposition 1-2 weeks to follow up the position of the bone fracture(changing position or no) 6-8 minggu callus formation Every changing position/traction Before go out from hospital

4.DEFICIENCY BONE DISEASES Rickets (Hypovitaminosis D) Bone disease deficiency vit D with kidney and mineral absorption disorder Roentgenographic feature : 1. chondrocostal junction enlargement (rachitis rosary) 2. Cupping of metaphysis (muscle &ligamentum traction) 3. Bowing long bone 4. Commonly Greenstick fr. 5. SubperiostealCalsification 6. Irregularity of ossisilii 7. Metaphyseal line irreguler& frayed 8. skull : Fontanella + suture (still open) 9. Osteoporosis Scurvy (hypovitaminosis C) 1. Caused of deficiency Vit C make the failure of intracellular forming include bone, catilage&endothel forming 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 sign marginal spur formation 6. Wimbergers sign marginal ring calcification of central ossification in epiphysis 7. Subperiosteal hematoma calcification 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 bones unilateral) 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 tabula external (tabula internal not frequent), sclerotic of skull base, sphenoid crypt & facial bone ( thickness & sclerotic of facial bone & skull base, obliteration of sinus maxillaries)

consisted of 2 type congenital (since born) &tarda (the symptoms seen in childhood) Rontgen : 1. Osteoporotic (ground glass appearance) 2. Multiple fracture 3. Bowing of inferior extremity 4. Vertebra biconcave 5. Bone deossification + diameter of bone become wider 6.skull: - thin tabula + warmian bone 7. Protrusioacetabuli

All long bone (extremity) short But Corpus Vertebra still normal Roentgen : 1. Shortened of long bone &symetries (mycromelia) 2. The Proximal bone shorter than distal 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 the foramen intervertebrale more wide, diameter AP of pedicle become shorter 6. Head bigger (brachycephaly) 7. Fibula head longer than tibia (same as ulna and radius) 8. Pelvic bone champagne shape (acetabular angle leveling off)

Ireguler circumscribed destruction of bone with thick sclerotic margin

7. BONE TUMOR May 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. 2. 3. 4. 5. 6. 7. 8.

Age How long the pain & the swelling and the growth of the tumor (slowly or fast) Size of the tumor Number of lesion (mono/polystotic) Location (what part of the bone) Density : osteolitic, osteosclerotic& mixed Structure of tumor : the margin, the type of destruction (central/marginal), type of periosteal reaction, continuity of the cortex Bone shape : bowing, fracture 2. 3. 4. 5. 6. 7. 8. 9. 5 - 20 years 10 - 25 years 20 - 40 years 20 - 70 years 30 - 45 years 30 - 50 years 30 - 60 years 30 - 70 years : Ewing tumor : osteosarcoma : giant cell tumor : lipoma : fibrosarkoma : periosteal sarcoma : chondrosarcoma : hemangioma : metastasis, Multiple

10. 40 - 80 years Myeloma

There are 3 principal point in bone lesion assessment : * infection or neoplasm * benign or malignant * primary or secondary

From skeletal tissue a. Benign: bone island, osteoma, osteoid osteoma, osteoblastoma

Cartilage

Classification of Bone tumor Fibrous a. Benign: Fibroma, Brown Tumor

a. Benign :Chondroma,Chondroblastoma, Chondromyxoid Fibroma

Giant Cell (Giant Cell Tumor) a. Benign: GCT, ABC {Aneurysma Bone Cyst} b. Malignant: Giant Cell Tumor Maligna

b. Malignant: b. Malignant b. Malignant Fibrosarcoma Osteosarcoma, periosteal (Chondrosarcoma) sarcoma From other tissue in the bone: From the joint Sinovioma 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

Unknown : a. Benign Bone Cyst b. Malignant Tumor : Solitary : Ewing

Benign Tumor 1. Bone Island ( Enostosis )

Malignant Tumor 1. Osteosarcoma

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Ro : - Soliter/ Multiple - always in Medulla - density Homogen - margin may Irreguler . Spiculated into medulla

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 & invasion to soft tissue Soft tissue swelling Codman Triangle

Sclerotic bone island in the distal femur & proximal portion of tibia

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 year Often in medulla Metaphysis, 80% knee Ro : 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 / 3 Predilection : 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 femur Ro : o Local cortex destruction, ill-definedtransition between normal tissue & lesion cannot be differentiated o Central tumor irregular calcification o Endosteal erosion, scallopingpop-corn

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- Diameter 2.5 Cm o

appearance Periosteal reaction Lamellar

Benign osteoblastoma (Giant osteoid osteoma) 4. Osteochondroma - outgrowth of bone , from cortex diaphysis of long bone - point away from nearest joint Ro : - Pedunculated type (outgrowth of bone from cortex trabecula penetrate into medulla through the defect of the cortex ) - Calcification - size 8-10 cm point away from joint - Pelvic & scapula irregular & high density Cauliflower app. chondrosarcoma 4. Ewing Tumor from medula age 5 20 years Sites : long bone Ro : Lamellar periosteal reaction(Onion Skin app.) Codman triangle Sometime sclerotic (longitudinal band) Bone destruction Soft tissue swelling

Ewing tumor

osteochondroma 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 of juxtacapsular

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calcification Angiography hypervascular, 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 at arcusneuralis, rarely at corpus. - Commonly multiple vertebrae Ro : 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 with osteoclastoma. Sometime scalloped atauirreguler, sclerotic margin Angiography similar with Osteoclastoma DD : Osteoclastoma /Giant Cell Tumor

6. MM (Multiple Myeloma) Primary Malignant tumor of bone marrow Ro : Osteoporosis cortical thinning Osteolytic Punch out lesion multiple, rounded, welldefined, intact, varying in size Inner cortex scalloping Sometime expansive with soap bubble app. DD : metastasis

Aneurysm bone cyst 7. Metastasis May osteolytic, osteoblastic, ill-defined Irregular margin& sometime with sclerotic margin sites 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 vascularity make the cell dead osteonecrosis
Commonly no infection Early stage Late stage Ro : Big joint (microfracture of the early stage no damage cortex hip & shoulder, of bone follow by trabecula medium diffuse compression &colaps that make osteoporosis, normal density joint more horizontal with in the avascular area subarticular growth and in same time the trabecula depressed into smaller space. Sites of osteochondritis 1. Corpus vertebra Calve Disease 2. Vertebral epiphysis Scheuermann disease 3. CapitulumHumerusPanners Disease 4. LunatumKienboeck disease 5. Proximal phalanges Thiemans disease 6. Caput metacarpal Dietrich disease 7. Caput femoris Calve Leg Perthes 8. Distal collumfemorisCoxavara 9. Tibia/apophysis tibia Osgood Schlatter 10. Condylus medial tibia Blounts disease 11. Calcaneus apophysis Sever disease 12. Naviculare Alban Kochler 13. Caput metatarsal Freiberg Kochler

Infarction of metaphysis
&subarticular infarction lucent in the central

Bone within Bone linear

density in the bone & parallel with cortex

Abnormality of epiphysis Cone epiphysis premature

fusion

Osteoporosis Systemic skeletal diseases decrease of 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 Analysis 9. Compton Scattering 10. Radioisotop 11. Magnetic Resonance Imaging (MRI)

8. DEGENERATIVE JOINT DISEASES A. SPONDYLOSIS / SPONDYLOARTHROSIS Osteo Arthritis of Spine Rontgen : - Spur formation / osteophyte Anterior, 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 joint space Irreguler of joint (the margin) Herbedens Nodes at dorsal facies of distal phalanges (base) spur-formation Subchondral cyst like defect Ro (Knee) : Spur at posterior aspect of patella Spur formation : condylus tibiaproximal, femur distal,eminentiaintercondyloid ea tibia Narrowing of joint space medial aspect (DD.Rheumatoid:all joint)

C. PSORIATIC ARTHRITIS

Predominant destruction distal interphalangeal joint (as Osteoartritis) - Ankylosing at interphalangeal joint DD. - Rheumatoid at interphalangeal joint - Joint space more wide surface is clearly - Destruction arthritis at interphalangeal joint of feet thumb - Mild osteoporosis - Foot more shown psoriatic arthritis - Bone mineralization is normal

D. ANKYLOSING SPONDYLITIS

Marie strumpells/von Bechterews/rhematoid Spondylitis, female =male commonly 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 joint metacarpophalangeal 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: Fracture Infection Tumor : primary and secondary Sinus paranasalis Congenital Sign of Intracranial pressure increasing : Suture more wide Impressionesdigitatae Destruction of sella

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