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MUSCULOSCELETAL

RADIOLOGY
Dr.Sri Asriyani,SpRad
Dr. Muh. Ilyas, Sp.Rad
DEPARTEMENT OF RADIOLOGY
MEDICAL FACULTY OF HASASUDDIN UNIVERSITY

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Introduction
Roentgenographic of bone give information about :
1.

Bone & soft tissue lesions

2.

Fracture/ patologic fracture

3.

The origin of the lesion dan the type of the


tumor ( benign/malignant)

4.

Guiding biopsy

5.

Follow Up
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Today the radiologic modality are very


sophisticated, for example :
X-ray
CT Scan
MRI
Skintigraphy
USG
Angiography
Although modality progress in radiology is
very fast, The convetional radiology is still
very important
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Composition of bone :
25% of water
30% organic
45% nonorganic (radioopaque density) :

Ca phosphat 85%
Ca carbonat 15%
Blood suplay of bone :
1. A.Nutricia (fossa a.nutricia bone x-ray)
2. A.metaphyseal & a. epiphyseal (direct suplay for
meta/epiphyse)
3. A. Periosteal (branch from nutricia artery which through
the Harvers & Volkman system)
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RADIOLOGIC ANATOMY
Book of Meschan I :
1.

Articular cartilage

2.

Subarticular of epiphyse

3.

Epiphysis

4.

Epiphyseal line

5.

Metaphysis

6.

Diaphysis
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4.
3.
2.
1.

5.
6.
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DISORDER OF BONE AND JOINT


1.

Development anomaly/Congenital

2.

Infection

3.

Trauma & fracture

4.

Deficiency Bone disease

5.

Bone Dysplasia

6.

Bone tumors

7.

Avascular necrosis/Aseptic necrosis

8.

Degenerative disc disease/Metabolic

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1. Development Anomaly/Congenital
1.

2.

Arthrogriposis Multiple Congenital failure of


muscle growth

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

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b. Synostosis Radius & Ulna


c. Hand:
Brachyphalangea ( short hand)
Brachydactili (short metacarpal )
Long Tubular bone
Polydactyli

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3.

Pelvis :

Nargle & Robert pelvis :


a. Absent of one sacral wing
b. Robert = Nagle bilateral

Iliac Horns Dorsal Protrusion of


Processus from iliac wing

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4. Lower extremities :

Congenital dislocation of the coxae (Hip)

Congenital Coxa vara kongenital:


bowing femur, bilateral shortening

Patella bipartite & multipartite

Congenital Pseudoarthrosis Tibia & Fibula


a. mid/lower third
b. commonly lesion in fibula

Leg & ankle :


- Pes equino varus
- Ball & sochet ankle foot
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5. Columna vertebralis :
- Coronal clefts vertebra spina bifida
- Hemivertebra
- Sacralisation
- Lumbalisation
- Scoliosis

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2.INFECTION OSTEOMYELITIS
a. Pyogenic / suppurative
* Stafilokokus * Pneumokokus
* Streptokokus
* Salmonella
Mechanisme of contamination
- Hematogenous from focus infection(throat & skin)
- External contamination
(open fracture/bone operation)
b. Spesifik/ non suppurative
- TBC, virus, dan fungi
- slowly than pyogenic
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OSTEOMYELITIS
a. Acute:
- commonly in children
- metaphyseal (distal femur, proximal tibia ,
proximal dan distal humerus ,radius, ulna and
collumna vertebrae )
Radiology :
- Lytic lesion
- Periosteal reaction
- Soft tissue swelling

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b. Chronic :
inadequacy therapy

Radiology :

Generally Osteosclerosis

Increased in bone diameter

Irreguler contour with thickening cortex

Lytic lesion can occur

Occationally sequestrum formation

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Acute osteomyelitis
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TUBERCULOUS SPONDYLITIS
Common site in column vertebrae :
A.
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 Calsification in abses
- Osteosclerotic (-)
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B. Central Type
- Abcess /cold abcess in the central of
collumn vertb.
- destruction of disc slowly
- if extend to the periphery the process is
same with marginal
C. Anterior type
- process under periosteum
- extend below the Lig.Longitudinale anterior
- Disc destruction slowly

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LONG BONE TBC


Radiology :
- especially in metaphysis
- lytic lesion is dominant
- sometimes minimal surrounding sclerotic
- minimal/no periosteal reaction
- minimal soft tissue swelling
Primary bone
Secondary hematogen
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Tuberculosis of the knee


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Tuberculosis of right hip


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3. TRAUMA & FRACTURE


a. Trauma

Minimal : Hematoma sometimes not seen in bone


x-ray
Severe ; sublucsation, dislocation with fracture

External : accident, fall

Internal : strong and sudden muscle contraction, for


example : epilepsi, tetanus & electric shock
b. Fracture
- discontinuity of bone, cartilage or both of them with
soft tissue damage
- Fracture open or close
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X-Ray evaluation :
1.

Diagnostic immediately after trauma

2.

Post reposition

3.

1-2 weeks to follow up the position of the bone


fracture(changing position or no)

4.

6-8 minggu callus formation

5.

Every changing potition/traction

6.

Before go out from hospital

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Fracture Complication
1.

Osteomyelitis

2.

Non Union (neoarthrosis)

3.

Bone artrophy

4.

5.

Bone formation in muscle myositis


ossificans
Severe deformity

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Fracture type :

Transversal fr
Oblique/spiral/screw fr.
Comminuted fr more than 2 fragment
Avultion fr.
Green stick fr. (children)
Compression fr. vertebrae
Impression fr. skull
Linier fr.

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Fr.transversal

Fr.oblik

Fr. kominutif
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Compression fracture.
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Distal Radius fracture


a.Colles Fracture
Distal radius fr. (until 1 mm ) with posterior
angulation, posterior dislocation & deviation
of distal fragmen to radial.
b. Smith Fracture
Distal radius fr. with dislocation of fragmen
distal to volar.

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Fr.Colles

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Fraktur radius dan ulna


a. Monteggia fr.
proximal ulna fr.with caput radii dislocation
b. Galeazzi fr.
distal radius fr.with distal dislocation of ulna

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Fr. Galeazzi

Fr. Monteggia
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Fr. Galeazzi
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Fr. Monteggia
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Patologic Fracture
1.

Severe trauma Fr.

Spontaneous Fr./patologic Fr.


- Bone tumor ( primary, secondary)
- Infection ( osteomyelitis)
3. Stress Fr.
minimal and contimous for examples
March fr. metacarpal
Tibia fr. Ballet dancer
Fibula fr. long distance runner
2.

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

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4.DEFICIENCY BONE DISEASES


A. Rickets (Hypovitaminosis D)
Bone disease deficiency vit D with kidney and mineral
absorbtion disorder

Roentgenographic feature :
1. chondrocostal junction enlargement
(rachitis rosary)
2. Cupping metaphisis (muscle &ligamentum traction)
3. Bowing long bone
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4. Commonly Greenstick fr.


5. Subperiosteal Calsification
6. Irregularity of ossis ilii
7. Metaphyseal line irreguler & frayed
8. skull : Fontanella + suture (still open)
9. Osteoporostic

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Rickets
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B. Scurvy (hypovitaminosis C)

1.

Caused of deficiency Vit C make the failure of


intracellular forming include bone,catilage &
endotel forming

2.

The bone forming is persued but the


reabsorbtion still happen osteoporosis

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3.

Rontgen :
1. General Osteoporosis
2. Ground Glass Appearance
3. Cortex thin
4. Metafiseal wide (cupping)
5. Pelkens sign marginal spur formation
6. Wimbergers sign marginal ring
calcification of central ossification in epifiseal
7. Subperiosteal hematoma calcification
subperiosteal bone
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Femur & tibia around


the knee in scurvy
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Scurvy
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5.BONE DYSPLASIA
Bone forming disturb or intrinsic bone modelling
A.Fibrous dysplasia
divided into 2 : monostatic (femur, tibia, costae,&
facial bone) dan Polystatic (many bone
unilateral)
Rontgen :
1.

Ground glass app

2.

Cortex intact & wide

3.

Endosteal cortex thin & scalloping


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4.

Diafise 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)

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Fibrous dysplasia:
Ireguler circumscribed destruction of
bone with thick sclerotic margin
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B. Osteogenesis Imperfecta :
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.
Protrusio acetabuli
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C. Achondroplasia
All long bone (extremity) short
But Corpus Vertebra still normal Roentgen :
1.

2.

3.

Shortened of long bone & symetries


(mycromelia)
The Proximal bone shorter than distal bone
(rhizomelia) humerus shorter than radius,
femur shorter than tibia
Metafise wide & cupping (in the distal long
bone)
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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 (branchycephaly)
7. Fibula head longer than tibia (same as ulna and
radius)
8. Pelvic bone champagne shape (acetabular
angle leveling off)
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Achondroplasia

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6. BONE TUMOR
May benign or malignant and may primer or
secondary (metastasis) :
To differentiated the tumor is malignant or not
1.

Age

2.

How long the pain & the swelling and the growth
of the tumor (slowly or fast)

3.

Size of the tumor


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4. Number of lesion (mono/polystatic)


5. Location (what part of the bone)
6. Density : osteolitic, osteosclerotic & mixed
7. Structure of tumor : the margin, the type of
destruction (central/marginal),type of
periosteal reaction, continuity of the cortex
8. Bone shape : bowing, fracture

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0 - 5 years
: neuroblastoma
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
: metastase, Multipel Mieloma
There are 3 principal point in bone lesion assessment :
* infection or neoplasma
* benign or malignant
*primer or secondary
1.

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Clasification of Bone tumor :


A. From skeletal tissue
1. Skeletal tissue:

a. Benign: bone island, osteoma, osteoid


osteoma, osteoblastoma
b. Malignant ; Osteosarkoma, periosteal
sarcoma
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2. Cartilage :
a. Benign

:Chondroma,Chondroblastoma,
Chondromixoid Fybroma

b. Malignant ( Chondrosarcoma )
3. Fibrous :
a. Benign : Fibrosa, Brown Tumor
b. malignant : Fibrosarkoma
4. Giant Cell ( Giant Cell Tumor )
a. Benign : GCT,ABC {Aneurysma Bone Cyste}
b. Malignant

: Giant Cell Tumor Maligna

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6. BONE TUMOR
B. From other tissue in the bone:
1. Vessels : Hemangioma, Glomus
Tumor, Hemagiosarcoma
2. Nerve : Neurofibroma, Neuroblastoma,
Neurofibrosarcoma
3. Fat : Lipoma, Liposarcoma
4. Natokord : Chordoma
5. Epitel : Dermoid, Adamantinoma
6. Limfoid/Hemopoetik ; Limfoma, Leukimia,
Plasmositoma,Multipel Mieloma
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C. From the joint Sinovioma


D. Unknown :
a. Benign

: Solitary Bone Cyst

b. Malignant : Ewing Tumor

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Benign Tumor :
1. Bone Island ( Enostosis )
Ro : - Soliter/ Multiple
- always in Medulla
- density Homogen
- margin may Irreguler .
Spiculated into meduller

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Sclerotic bone island in the distal


femur & proximal portion of tibia

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2. Osteoma :
Ro : - Sites : Skull, Sinus Paranasalis
- size 2.5 Cm
- high density ,good defined margin
& homogen

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3. Osteoid Osteoma
Man : Woman = 3 : 1
Decade 2 / 3
Predilection :
Diafise of long bone (50% proximal Femur )
Tibia
Skull rarely
Ro : - Radiolucent area, Oval/rounded sclerotic
margin
- High density
- Diameter 2.5 Cm
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Benign osteoblastoma (Giant osteoid osteoma)


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4. Osteochondroma
- outgrowth of bone , from cortex diafise long
bone
- point away from nearest joint
Ro :
- Pedunculated type (outgrowth of bone from
cortex trabecula penetrate into medulla
trough the defect of the cortex )
- Calcification
- size 8-10 cm point away from joint
- Pelvic & scapula irregular & high density
Cauliflower app.
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Giant Cell Tumor (Osteoclastoma)


Age 20 40 years
Rarely before maturity of bone
Sometimes multifocal in hand
Soliter
Sites : 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 patologic fracture

Typical finding : trabeculation likeSoap Bubble App40%


of cases

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Osteolitic margin

ill defined, no bone reaction

Cortical thinning & expansion

Lesion may expansion to soft tissue, no calcification

Angiography hypervascular, with many vessels &


shunting arteriovenosa

DD : Aneurysmal Bone cyst,


chondroblastoma,Fibrous Dysplasia

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Giant cell tumor of bone


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Aneurysmal Bone Cyst


Etiology unknown
Sometimes find after fracture
affect to children, sites long bone
in vertebrae age 10-20 years,
especially at arcus neuralis, rarely at
corpus. Commonly multiple vertebrae

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Ro :
reabsorbsion bone area with bone expansion
Size varying 2-20 cm
Cortex thin & expansion
Tepi endosteal margin is good defined with cortex
Soap Bubble Appearance
Trantition zone between lesion & medulla,
sometime with sclerotic. Similar with
osteoclastoma. Sometime scalloped atau irreguler,
sclerotic margin
Angiography similar with Osteoclastoma
DD : Osteoclastoma /Giant Cell Tumor
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Aneurysmal bone cyst

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Aneurysmal bone cyst involving


the distal metaphysis & epiphysis
of femur
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Malignant Tumor
Osteosarcoma
according to position (central,peripheral)
according to lesion (osteolytic,osteosclerotic,
mixed)
Man > woman

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Ro :
Sites : distal femur, rarely in tibia, sternum, costae,
skull
Position of lesion : metafise / dyafise
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
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Osteosarcoma of lytic type involving the distal femur


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2. Fibrosarcoma
5 % skeletal tumor
Low grade pain 1 year
Often in medulla
Metafise
80% knee

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Ro :

Typically osteolytic

In medulla (irregular radiolucent area)

Expansion of cortex

Soft tissue swelling (caused of expansion to soft


tissue)

Periosteal reaction No/rarely

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Periosteal fibrosarcoma of forearm involving the ulna


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3. Chondrosarcoma
Age : 30 70 thn
Sites : Pelvis, costae, proximal femur
Ro :
Local cortex destruction, ill defined
transition between normal tissue & lesion
cannot be differentiated
Central tumor irregular calcification
Endosteal erosion, scalloping
pop-corn appearance
Periosteal reaction Lamellar
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Chondrosarkoma
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4. Ewing Tumor
from medula
age 5 20 years
Sites : long bone
Ro :
Lamelar Periosteal reaction(Onion Skin app.)
Codman Triangle
Sometime Sclerotic (longitudinal band)
Bone destruction
Soft tissue swelling

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Ewings tumor

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5. Sinovioma
70% inferior extremity knee
Age < 30 years
Very malignat immediately metastasis to lymphe
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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6. MM (Multiple Mieloma)
Primary Malignant tumor of bone marrow
Ro :
Osteoporosis cortical thinning menipis
Osteolytic
Punch out lesion multiple, rounded,good
defined, intact, varying
Inner cortex scalloping
Sometime expansive with soap bubble app.
DD : metastasis
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7. Metastasis
May osteolytic, osteoblastic
ill defined
Irregular margin & sometime with sklerotic margin
sites of metastasis :
vertebrae
costae & sternum
skull & pelvic
other bone

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7. AVASKULER NECROTIC OF BONE

( OSTEOCHONDRITIS, OSTEOCHONDROSIS,BONE INFARCTION)

abnormality of bone which one of the bone loss


of vascularity make the sel dead
osteonecrosis
Commonly no infection
Ro :
early stage no damage of bone
medium difuse osteoporosis, normal
density in the avascular area
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Late stage :
a.

Big joint (microfracture of the cortex


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.

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a.

Infark metafise & subarticular

infarct

lucent in the central


b.

Bone within Bone linier density in


the bone & paralel with cortex

c.

Abnormality of epifiseal Cone


epiphyse premature fusion

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SITES OF OSTEOCHONDRITIS
1. Corpus verteba Calve Disease
2. Vertebral epiphyse Scheuermann disease
3. Capitulum Humerus Panners Disease
4. Lunatum Kienboeck disease
5. Proxphlanges (jari) thiemmanns disease
6. Caput metacarpal dietrich disease
7. Caput femoris calve leg perthes

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1. Distal collum femoris coxa vara


2. Tibia/apophysis tibia osgood schlatter
3. Condylus medial tibia blounts disease
4. Colcaneus apophysis sever disease
5. Naviculare alban kochler
6. Caput metatarsal Freiberg Kochler

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Osteoporoses

Defenition
Systemic skeletal diseases decrease of
bone mass & microstructure caused bone
more weak & more easier to have fracture

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Radiologic of osteoporosis

1. Conventional Radiology
- Vertebrae x-ray 4 grading
- Femur x-ray used index Singh
- Metacarpal
2. Fotodensitometri/Radiografi Densitometri
3. Single Photon Absorptiometry (SPA)
4. Quantitative Computed Tomography (QCT)
5. Pheripheral Quantitative Computed Tomography (POCT)
6. Dual Energy X-Ray Absorptiometry (DXA)
7. Sonodensitometri
8. Neutron Activation Analisys
9. Compton Scattering
10. Radioisotop
11. Magnetic Resonance Imaging (MRI)
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8. DEGENERATIVE JOINT DISEASES


A. SPONDYLOSIS / SPONDYLOARTHROSIS
Osteo Arthritis of Spine
Rontgen :
- Spur formation / osteophyte
> Anterior
> Posterior
> Lateral
- bridging bamboo spine
- Marginal sclerosis of corpus vertebra
- Spur may in-growth (foramen Intervertebralis
usually cervical (C5,C6,C7) neurologic sign
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B. OSTEOARTHRITIS (OA)
- Osteoarthrosis degeneratif joint disease
- Predilection from the knee
- Woman > man
Rontgen (finger) most find at interphalangeal joint

Always narrowing of joint space

Irreguler of joint (the margin)

Herbendens Nodes at dorsal facies of distal phalangs


(base) spurformation
Subchondral cyst like defect

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Ro (Knee) :

Spur at posterior aspect of patella


Spur formation : condylus tibia proximal,femur
distal, eminentia intercondyloidea tibia
Narrowing of joint space medial aspect
(DD.Rheumatoid :all joint)

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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 artriris at interphalangeal joint of feet thumb
Mild osteoporosis
Foot more shown psoriatic arthritis
Bone mineralisation is normal

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PSORIATIC ARTHRITIS
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D. ANKYLOSING SPONDYLITIS
Marie strumpells/von bechterews/rhematoid
spondylitis woman = man commolly youth
Rontgen :
Sacro-iIiac Joint (SI joint) blur wider narrowing
sklerosing/ankylosing (bilateral)
Always start at SI Joint
Squaring anterior corpus vertebrae
Generalize osteoporosis

Calcification of ligament+ paraspinal soft tissue


Bamboospine
Disc destruction
Syndesmophyte formation
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E. RHEUMATOID ARTHRITIS
- Woman > man
- Multiple & Symetris
- Mostly : proksimal interphalangeal
joint, metacarpophalangeal joint,wrist joint
(radiocarpal), not all joint can affect
Rontgen :

Periarticular soft tissue swelling fusiform


(spindle sharped)
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Periarticular
destruction

Osteoporosis

cartilage

Marginal erotion juxta articular arthritis


mutilans
Ankylosing + subluxatio
Ulnar deviation of finger caused of subluxatio
( flexi extensi swan neck Appearance )

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RHEUMATOID ARTHRITIS WITH SCLERODERMA


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F. GOUT
Man > woman
> 40 years
Rontgen :
Radiologic change after multiple attack
Commonly only one joint metacarphalangeal
joint ( but other joint in hand & leg can be
attacked)
Deposite of Na. urat not radiopact (not seen
,just periarticular & joint swelling)

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Osteolytic juxta articular small/big with good


defined

Subarticuler cystic area sclerotic margin Over


hanging edge,D0,3-3 cm PUNCHED OUT

If there are deposite ca in tophy the tophy is


seen

Narrowing joint space

Decrease of Osteoporosis

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SKULL- X RAY
Information /abnormality :
Fracture
Infection
Tumor : - primery
- secondaryr
Sinus paranasalis
Kongenital
Sign of Intracranial pressure increasing :
Suture more wide
Impressiones digitatae
Destruction of sella
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