MUSCULOSKELETAL

IMAGING
Dr. Jaya Selvi Nagendran
Department of Diagnostic Imaging
Penang General Hospital

OUTLINE
Imaging Modalities & Indications
Approach in Interpretation of Plain

Radiograph
Trauma imaging/Fracture
When to order what ?

IMAGING MODALITIES
1.
2.
3.
4.

Plain Radiographs
CT
MRI
Nuclear Medicine Bone Scan

1.Plain Radiography
Still commonest imaging modalities for
musculoskeletal imaging.
To evaluate
1. Trauma
2. Bone tumor
3. Alignment (scoliosis)
4. Arthritis

2. Computed Tomography
To evaluate:
1. Complex fractures (e.g. acetabulum,
wrist, facial bones)
2. Spine trauma/fracture
3. To guide biopsy

CT Acetabular & Pelvic Fracture

CT Facial Bone Fractures

3D Reconstruction

Cervical Spine Imaging

CT vs. Radiograph
Cervical radiography has been the
standard initial screening examination
In the past decade, helical CT has
begun replacing radiography as the
method of choice for cervical trauma
screening.

CT Cervical Spine
Advantages of CT Cervical Spine
1. Easy to perform
2. Speed of study
3. Greater sensitivity to detect fracture
(close to 100%; cf 38-65% for
radiograph).

Cervical Spine Imaging Radiograph

Cervical Spine Imaging - CT

3. MRI
To evaluate
1. Tendons, ligament, cartilage & soft
tissue abnormalities.
2. Staging of bone & soft tissue tumor
3. Spinal Infection/Trauma
4. Occult fracture

MRI Knee Coronal & Sagittal T1W

MCL tear & Bone Contusion

Giant Cell Tumour

Tuberculous Spondylitis

4. Radionuclide Bone Scan

To evaluate:
1. Bone metastasis.
2. Osteomyelitis.
3. Occult & stress fracture.

Radionuclide Bone Scan

Approach In Interpretation Of
Plain Radiographs
Imaging of extremities:
Bone, Joint or Soft Tissue?

BONE DISEASE - Diffuse or

Focal?
Diffuse: Congenital
Metabolic
Hematological
Focal: Tumor
Infection

Diffuse or Focal?

Focal Bone Lesion

Benign or Malignant?
Most important clinical question.
1. Zone of transition border between
2.
3.
4.
5.

normal & abnormal bone.

Sclerotic margin.
Cortical destruction.
Periosteal reaction.
Soft tissue mass.

Bone Lesion Zone of Transition

- Benign/non-aggressive lesion narrow
zone of transition sharp border.
- Malignant/aggressive lesion wide zone of
transition ill-defined border.

Small zone of transition

A small zone of
transition results in a
sharp, well-defined
border and is a sign
of slow growth.

Wide zone of transition

An ill-defined border
with a broad zone of
transition is a sign of
aggressive growth.
It is a feature of
malignant /infective
bone lesions.

Bone Lesion Sclerotic Margin

-Well-defined sclerotic margin typically benign.

Chondromyxoid fibroma
A benign, well-defined,
expansile lesion with
regular destruction of
cortical bone and a
peripheral layer of new
bone.

Giant cell tumor

A locally aggressive lesion with

cortical destruction,
expansion
Wide zone of transition
-which is a sign of
aggressive behaviour.

Bone Lesion Cortical Destruction

Benign lesion may cause thinning of

cortex.
Malignant lesion frank destruction.

Bone Lesion Periosteal Reaction

Slow growing benign lesion typically thick,

uniform, or wavy.
Malignant lesion typically more amorphous,
irregular lamellated (onion-skin) or sunburst
type.

Bone Lesion - Location

Border :
geographical,
moth eaten or
permeative?

Case 1

Non-ossifying fibroma
Lytic, cortical-based lesion in
metaphysis or metadiaphysis,
with geographic (well defined),
sclerotic border.
Smaller lesion < 2 cm fibrous
cortical defect.
Asymptomatic, incidental
finding.
Routinely heal with sclerosis &
eventually disappear.

Osteosarcoma
Border: lytic

expansile pattern
Cortical destruction
Sunburst periosteal
rx.
Location:
metaphysis
Case 2

Ewing Sarcoma

Case 3

Border:
Permeative
pattern
Onion-skin
appearance
periosteal rx.
Location:
diaphysis

13 y.o, pain & swelling in left wrist and ankle

Case 4

Osteomyelitis
irregular patchy bone destruction in the
metaphysis of left tibia.
diaphyseal sub-periosteal bone
destruction.
elevated and irritated the tibial
periosteum, giving an onion skin
appearance.
Diagnosis: Osteomyelitis
Diff Diagnosis: Leukemia. Osteosarcoma
(less likely).

Case 5

Multiple Myeloma
Most common primary malignant bone

tumour in adult.
Overall most common malignant bone
tumour = metastases!

TRAUMA & FRACTURE

Fracture is a clinical, not a radiographic

diagnosis.
Other bones may also fracture.
Associated soft tissue injury tendon,
ligament, neurovascular structures)
may be of greater consequences than
fracture itself.

TYPES OF FRACTURE

Closed fractures

Open fractures

TYPES OF FRACTURE

Oblique

Comminuted

Spiral

Transverse

DIAGNOSIS OF FRACTURES
3 Radiographic Signs:

Identification of fracture line

Alteration in skeletal alignment or
contour
Indirect Sign - Adjacent soft tissue
changes

Basic principles in trauma imaging

1.
2.
3.
4.
5.

Correlate
Two views
Include proximal and distal joints.
Look at the whole picture
Know what is normal.

Basic principles in trauma imaging

1. Always correlate with

NATURE OF TRAUMA

SITE OF IMPACT

SITE OF WOUND / TENDERNESS.

Basic principles in trauma imaging

Basic principles in trauma imaging

2. Two views of any bone or joint

should be obtained

Basic principles in trauma imaging

3. The joints
above and
below a
long bone
should be
included
on the
radiograph

Basic principles in trauma imaging

4. Look
at the
whole
picture

FRACTURE DIAGNOSIS- APPROACH

Systematic approach

Mnemonics: ABCS
-Adequacy : Positioning & exposure
2 views , 2 joints
- Alignment : anatomical relationship between
all bones are normal
- Bones
: # line, disruption of cortex
- Cartilage : Joint space
- Soft tissue changes : swelling, joint effusion,
distortion of fat planes.

PEDIATRIC FRACTURES

GREEN STICK

TORUS

PLASTIC
BOWING

HELPFUL LINES
AND TIPS

Elbow Radiograph
Lateral view with elbow flexed to 90
Soft tissue sign - Fat pad sign.
2 Helpful Features:
- Anterior humeral line
- Radiocapitellar line

The fat pad sign.

Anterior and posterior fat pads are elevated, sometimes called the sailboat sign.
A fracture of the radial head usually elevates the anterior fat pad only.
Whereas a supracondylar fracture of the humerus will almost certainly elevate both fat pads.

 ANTERIOR HUMERAL
LINE a line traced along
the anterior cortex of the
humerus, approximately
one third of the capitellum
lies anterior to this line.
RADIOCAPITELLAR
LINE A line drawn along
the centre of the shaft of
the proximal radius should
pass through the
capitellum. If this line does
not pass through the
capitellum then a
dislocation of the radial
head is probable.

Case 6

L
Case
7

Radial head fracture

Elbow dislocation

Wrist AP view

She Looks Too Pretty, Try To Catch Her

Scaphoid, Lunate,Triquetrum,
Pisiform,
Trapezium,
Trapezoid, Capitate, Hamate

Wrist AP

Joint spaces between the

intercarpal joints are
normally of uniform width,
each about 1- 2 mm.
3 parallel curvilinear arcs
outline the carpal bones :
Arc I outline the proximal
articular surface of scaphoid,
lunate & triquetrum
Arc II outlines the distal
concavities of the same bone

GILULA ARCS helpful for

detecting occult carpal
mal-alignment

Arc III outlines the proximal

convexity of the capitate and
hamate

Wrist lateral
The longitudinal
axis of the radius,
lunate, capitate &
3 rd metacarpal
bone form a
straight line

3rd metacarpal

capitate
lunate

radius

LUNATE DISLOCATION

LL
R

AP view demonstrates
abnormal configuration of the lunate
(asterisk), which resembles a
piece of pie.

The lateral view demonstrates

volar dislocation of the lunate (asterisk),
with the capitate aligned with the
radius).

PERILUNATE
DISLOCATION
C

L
R

L
normal relationship of the lunate
relative to the radius.
dorsal displacement of the capitate
AP view crowding of the carpals.
The perilunate dislocation results from a backwards fall on an
extended hand which disrupts the scaphoid ligaments.

SCAPHOID FRACTURE
- most common
fractured carpal bone:
~60-90%.
- if missed fracture
avascular necrosis of
proximal pole.
- anatomical snuff box
tenderness.
- ask for scaphoid
view.

Knee Cross Table Lateral View

Fat-fluid level in suprapatellar

recess.
Indicating intra-articular fracture.

LIPOHAEMARTHROSIS

LIPOHAEMARTHROSIS
SHOWING LAYERING
1. RBC
2. serum
3. Fat

QUIZ

Fracture clavicle

QUIZ

Shoulder anterior
dislocation

Anterior dislocation humerus

anterior, medial, inferior head
lies inferior to the coracoid
process.

QUIZ

Fracture midshaft of proximal phalanx right ring finger

QUIZ

Scaphoid fracture

QUIZ

Scaphoid fracture : Avascular necrosis of proximal

fragment ( blood supply derived from distal part )

QUIZ

ENOSTOSIS - Bone island

QUIZ

Aneurysmal Bone Cyst

GIANT CELL TUMOUR

QUIZ

Expansile, solitary lytic bone lesion

(soap bubble appearance).
Aggressive lesion.

QUIZ

QUIZ

QUIZ

OSTEOMYELITIS - acute

Rarefaction of radial shaft with significant periosteal new

bone formation and linear cortical sequestration bone in
bone appearance.

QUIZ

OSTEOMYELITIS - chronic

Radiograph of forearm showing marked irregular

sclerosis of radial shaft, destruction of proximal end
and sequestration in proximal and distal shaft.

QUIZ

QUIZ

FUTURE OF RADIOLOGY???

TREAT THE PATIENT, NOT THE FILM

THANK
YOU