Musculoskeletal Radiology

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Musculoskeletal Radiology

• Department of Radiology
• Peking University First Hospital
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?.the anatomic features evaluation with
Radiological methods

• contrast in density materials
• Between bone and soft tissue good with x-ray
• Between compact bone and cancellous bone good
  with x-ray
• X-ray can be used to differentiate the difference
  of density
• contrast in soft tissue
• Between muscle and vessels poor with x-ray, good
  at MR
• Between muscle and cartilage poor with x-ray,
  good at MR
• MR play an important role in soft tissue

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• With x-ray CT and x-ray radiography
• Spatial resolution x-ray film gtgt CT
• Contrast resolution CT gtgt x-ray film
• Overlap of structure
• not at CT
• with some tissue at x-ray film
• Easy to identify the calcification small
  ossification

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• high soft tissue contrast in MR imaging
• Identify bone marrow diseases
• Muscle and vessels involvement
• Cartilage change
• Tendon and ligament injury
• Sensitive to edema
• Not sensitive to small calcification
• The modalities of choice adopt ones good points
  and avoid his short-comings
• Anyway, X-ray radiography is basic examination.

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HR with small FOV and thin slices
FOV 10 ép 2mm 512x256
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?. Bone and Joints Normal appearance of
Radiology
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(?). The skeletonhistology Radiological
appearance

• 1. Three functions of bone
• the structural support of the body
• to protect the bone marrow
• a source of calcium ions
• 2. Macroscopic organization of bone
• compact bone
• about 70 of bone
• very dense few visible spaces
• Cortex is made up of compact bone.
• The cortex provides most of the structural
  strength of the skeletal frame.

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• cancellous bone also spongy bone
• inside the cortices and forms an interconnecting
  network of plates or bars called trabeculae.
• The trabeculae are continuous with the inner
  surface of the cortex, and
• the spaces between trabeculae are filled with
  hematopoietic or fatty bone marrow.

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• Cancellous bone two important features.
• First, cancellous bone assists the cortex in
  structural support
• Second, more metabolically active
• The proportion of compact and spongy bone varies
  in different portions of any particular bone.

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High Resolution Wrist Joint 24lp/cm
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Bone Structure
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• 3. The growth of the bone
• Ossification
• Intramembranous Ossification
• Endochondral Ossification
• Centers of ossification
• Epiphyseal plate (?hóu?)
• Modeling

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• 4. the factors influence the bone growth
• Calcium-phosphorus metabolism
• Incretion
• Vitamin

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• 5. Normal appearances
• The diaphysis the midportion of a long bone is a
  cylindrical rod composed mainly of compact bone.
• The medullary canal the area between the
  cortices contains marrow and a few spicules of
  cancellous bone.
• The epiphysis the end of a long bone is called.
  This segment consists of abundant cancellous bone
  and a thin shell of cortical bone. Because the
  epiphysis often articulates with another bone, it
  is usually covered by articular cartilage.

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• The metaphysis between the epiphysis and the
  diaphysis. This segment also contains abundant
  cancellous bone, which is surrounded by cortex.
  The metaphysis is the zone where a bone narrows
  from the wide epiphysis to the narrower
  diaphysis.
• The cartilaginous epiphyseal plate (the physis )
  in growing children, the epiphysis is separated
  from the metaphysis by the physis.

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epiphysis
the cartilaginous epiphyseal plate (the physis
)
metaphysis
diaphysis
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normal long bone of child
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Normal appearance

• Tuber-like bone
• Major large articulation
• spine

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6. Bone development bone age

• X-ray characters in premature bone
• diaphysis(??)
• Metaphysis(???)
• Epiphysis(?)
• epiphyseal plate(??)

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Bone age using the bone feature of x-ray
appearances to judge the patients age
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(?). The jointshistology Radiological
appearance

• 327 joints in the human body.
• vary greatly in size and complexity.
• the largest joint the knee
• the smallest one the tiny ossicles of the middle
  ear.
• the knee is far more complex than the simple
  ball-and-socket structure of the hip joint.

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• different degrees of motion.
• syndesmoses, the bone thin connective tissue
  ligamentbone (the cranial sutures) almost no
  movement.
• synchondroses, the bonecartilage bone slight
  motion The joints between the vertebral bodies,
  the intervertebral discs.
• diarthrodial joints, the bones move freely
  relative to one another. most joints in the body.

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• Diarthrodial joints
• articular cartilage
• synovial membrane
• articular fluid
• supporting tissues
• joint capsule
• various ligaments
• tendons

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• Fibrocartilage
• Function stabilize the joint or facilitates
  motion
• Location labra of the glenoid, acetabulum, the
  menisci of the knee, the annulus fibrosus of the
  intervertebral discs, the terminal portion of a
  tendon or ligament, at its insertion into bone
• Radiological appearance
• X-ray slightly higher density than that of the
  muscle
• MR low signal intensity on both T1WI T2WI

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• Hyaline cartilage
• Function provides a smooth, slippery surface
  absorbs mechanical shock and spreads forces
  evenly onto the supporting bone underneath
• Component chondrocytes abundant extracellular
  matrix
• Radiological appearances
• almost can not be identified on x-ray or CT
  imaging
• MR slightly high signal intensity

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• Synovial membrane
• Function secrete some of the components of the
  synovial fluid
• composed of loose fibrovascular tissue fat
  the synovial lining cells
• Too thin to be identified on radiological exam.
  except at villous fronds
• Synovial fluid
• Function lubricates the articular cartilage
• thick, viscous liquid water solutes from the
  blood hyaluronic acid, glycoprotein, and
  lubricin from synovial membrane
• Radiological appearance like water in the body

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Normal knee joint (adult vs child)
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A 3D T1
B FSE T2
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?. Muscular-skeleton systembasic abnormality
Radiological appearances
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(?). The basic appearances of bone lesions

• 1.osteoporosisdecreasing both the calcium salt
  and collagen tissue , and the ratio between them
  is normal

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osteoporosis
normal
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Right hip transient osteoporosis left normal
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Osteoporosis Hyperparathyroidism
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• 2. osteomalaciadecreasing calcium salt and with
  normal collagen tissue

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Osteomalacia, incomplete fracture
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• 3. Destruction of bonenormal bone structure was
  replaced by pathologic tissue

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bone destruction (fibrosarcoma
)
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• 4 . Hyperosteosis osteosclerosisincreasing the
  calcium salts in local bone

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CT
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• 5 . periosteal reactionwhen he periosteum is
  stimulated appropriately, the reactive bone
  formation occur. Usually reminder having lesion.

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"sunburst" or "hair-on-end"
solid
lamellated
lamellated

• periosteal reaction type

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complex pattern
a Codman's triangle

• periosteal reaction type

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• 6.osteal chondral calcification

Benign solitary sessile osteochondroma of the
fibula
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Bone infarction
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• 7. Osteonecrosis bespeaks bone death. Synonyms
  include aseptic necrosis, bone necrosis,
  avascular necrosis, and ischemic necrosis.

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osteonecrosis
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• multiple segmental areas of osteonecrosis in
  the distal femur in this patient with Gaucher's
  syndrome

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• 8.mineral aggregation or deposition
  lead(?)?phosphorus(?)?bismuth(?)et al deposit in
  the bone when the fluorin combined with calcium
  in the bone, is called skeletal fluorosis.

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plumbism (Chronic lead poisoning)
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• 9. deformation of bone

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Fibrous dysplasia of bone
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10. Reaction of soft-tissue

• Edema
• Swelling
• Gas in the tissue
• Atrophy of muscle
• Deposit of calcium salts (myositis ossificans)

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(?). The basic appearances of joints lesions
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• The swelling of joint
• Reason joint effusion, hemorrhage, inflammatory
  reaction,or soft tissue bruise
• Radiological appearance high density on X-ray,
  CT around articuli, with or without articular
  space enlargement
• Often in septic, collagen/collagen-like disease,
  biochemical, degenerative, traumatic arthritis

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• 2. The bone destruction of joint
• Bone destruction underneath joint surface or
  margin, invading or replacing by inflammatory
  tissue or tumor

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• 3. The degenerative change
• Decreased chondroitin sulfate with age creates
  unsupported collagen fibrils followed by
  cartilage degeneration
• Radiological Appearance joint space narrowing,
  sclerosis, subchondral cyst formation,
  osteophytosis at articular margin
• Most of aged people, major large joint knee,
  spine

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• 4. The ankylosis
• Fixation and immobility of a joint
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• 5. The dislocation of articulation
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?. Bone and joint injury
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(?). Basic appearances of bone trauma

• 1. Fracture
• OPEN VERSUS CLOSED
• Communication of the fracture site with the
  external environment or not
• INCOMPLETE VERSUS COMPLETE
• Incomplete fractures in all age groups but most
  commonly in children, three types buckle, or
  torus, fracture greenstick fracture plastic
  fracture
• Complete fractures transverse fracture An
  oblique fracture, Spiral fractures

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• COMMINUTION
• more than two fragments Segmental and butterfly
  fractures
• POSITION
• Accurate description of the site of the fracture
  is required.
• intra- or extra-articular fracture
• APPOSITION
• Anatomical Apposition
• Complete and normal apposition is termed
  anatomical

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• Displacement
• the fragments in partial apposition
• Lack of Apposition
• complete loss of contact of the bone ends
• ALIGNMENT
• refers to the relationship of the long axes of
  the fracture fragments
• ROTATION
• comparison of the direction of the joints
  proximal and distal to the fracture

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• ADDITIONAL DEFINITIONS
• chip fracture
• avulsion fracture
• Dislocation in joint injuries
• Diastasis pubic symphysis, sacroiliac joint, or
  distal tibiofibular joint
• Stress fractures abnormal stress, is placed on
  normal bone
• Pathologic fractures normal stress is placed on
  abnormal bone

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• Childhood fractures unique in three major ways
• more porous in children than in adults, often
  resulting in incomplete fractures.
• greater potential for remodeling malaligned
  fractures than do adults
• attributable to the epiphyseal plate, the weakest
  and therefore one of the most easily fractured
  sites in the long bone
• The complication of premature epiphyseal plate
  closure must be recognized early, since it can
  cause significant deformity.

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• 2. Periosteal reaction
• 3. Soft-tissue swelling
• 4. Complication of fracture

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• 5. The role of Planar tomography, CT, and MRI

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(?). Basic appearances of joint trauma

• 1. Dislocation
• 2. Cartilage injuriescartilage fracture, defect
• 3. Tendon ligamental injuriespartial tear
  complete tear

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Helical CT of a comminuted intraarticular distal
radial fracture.
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CT
X-ray plain
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a 76-year-old man with a hyperflexion injury to
the cervical spine with quadriparesis Conventiona
l lateral radiograph and MR images
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32-year-old, hit by a truck 10 months.
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PCL complete tear
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Dislocation of joint

• traumatic
• Non-traumatic
• Congenital dislocation of hip joint

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Osteomyelitis in a patient who had undergone
below-knee amputation.
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Soft-tissue abscesses in a 33-year-old woman with
SLE.
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Pain in both legs in a 32-year-old woman.
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(?). Soft tissue injuries

• 1.Muscle tendons injury and tear
• 2. Haemorrhage in musculus
• 3. Contusion (bruise)

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(?). Musculoskeletal injuriesmodalities of choice

• First choice x-ray radiography detection and
  diagnosis most of injuries
• CT skull, spine injury with CNS trauma
• MR joints, tendon and lig. soft-tissue injury
  injuries

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The advantage of x-ray radiography

• Cheap
• convenience
• Clearly demonstrate bone structure
• Diagnostic experience for over 100 years
• Possibility in clarify the nature of disease

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The limitation of x-ray radiography

• Early diagnosis micro-fracture
• Overlapping structure skull base
• Differential diagnosis

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?. The intervertebral disks degeneration

• And so from hour to hour We ripe and ripe, And
  then from hour to hour We rot and rot.
• 
  -Shakespeare-
• disc bulging

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disc bulging
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• discal herniation
• Herniation of an intervertebral disk represents a
  focal protrusion of disk material beyond the
  margin of the disk.
• Free fragment herniation
• Free fragment herniation is a term indicating
  separation of the focal herniation from the
  remainder of the disk, with penetration of the
  separated fragment through the fibers of the
  posterior longitudinal ligament.

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discal herniation
Free fragment herniation
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Thanks for your attention!