SKELETAL RADIOLOGY dr. H.Undang Ruhimat,SpRad

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SKELETAL RADIOLOGY
dr. H.Undang Ruhimat,SpRad
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Principles of Radiologic Interpretation

• Technical Consideration
• Skeletal Anatomy and Physiology
• The Categorical approach to bone disease
• Radiologic predictor variables
• Medicolegal implication

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Technical consideration

• Plain Film Radiography
• Tomography
• Contrast Examination
• Radionuclide Imaging
• Computed Tomography
• Magnetic Resonance Imaging

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Skeletal Anatomy and Physiology

• Skeletal Development
• Intramembranous Ossification
• Enchondral Ossification
• Bone Structure
• Epiphyse Physis ZPC Metaphysis
• Diaphysis
• Cortex Medulla Periosteum
• Endosteum
• Bone Metabolism
• Bone mineral - Hormones

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Anatomy
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Anatomy
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Anatomy
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The Categorical approach to bone disease

• Congenital
• Arthritis
• Trauma
• Blood
• Infection
• Tumor
• Endocrine,Nutritional,Metabolic
• Soft Tissue

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Radiologic Predictor Variables

• Preliminary Analysis
• Clinical data
• Number of lesions
• Symetri of lesions
• Determination of Systems Involved

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Radiologic Predictor Variables

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

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Radiologic Predictor Variables

• Behavior of Lesions
• Osteolytic Lesions
• Osteoblastic Lesions
• Mixed Lesions
• Matrix
• Periosteal Response
• Solid Respons
• Laminated Respons
• Spiculated Respons
• Codmans Triangle

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Radiologic Predictor Variables

• Soft Tissue Changes
• Supplementary Analysis
• Other imaging Procedures
• Laboratory Examination
• Biopsy

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TRAUMA

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

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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

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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

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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 segmen

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TRAUMA

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

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Fractur
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Fracture
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TRAUMA

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

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Fracture
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TRAUMA

• Spatial Relationships of Fracture
• Aligment
• 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

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Fracture
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TRAUMA

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

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Salter - Harris
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Dislocation
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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

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TRAUMA

• Complication of Fractures
• Immediate complication
• Arterial injury
• Compartement syndrome
• Gas gangrene
• Fat embolism syndrome
• Thromboembolism

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TRAUMA

• Intermediate complication
• Osteomyelitis
• Myositis ossificans
• Synostosis
• Delayed union
• Delayed complication
• Osteonecrosis
• Osteoporosis
• Non union Mal union

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Myositis Ossificans
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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

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INFECTION

• Etiology
• Staphylococcus aureus causes 90
• Pathway for the spread
• Hematogenous
• Contigunous
• Direct Implantation
• Postoperative

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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.

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INFECTION

• Bone changes
• Moth-eaten bone destruction
• Usually metaphyseal in origin
• Periosteal new bone formation
• Solid Laminated Codmans Triangle
• Sequestrum
• Involucrum
• Joint space destruction (ankylosis)

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• 0steomyelitis

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Osteomyelitis
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INFECTION

• Septic Arthritis
• General consideration
• Single joint involvment in the rule
• Most common rute is hematogenous
• or direct traumatic implantation
• Etiology
• Most frequently is Staphylococcus Aureus

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INFECTION

• Radiologic Features
• The knee and hip are the most common
• sites
• Joint effusion leads to distrorsion of the
• fat folds
• Positive Waldenstorms sign
• Rapid loss of joint space
• Bony ankylosis

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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

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INFECTION

• Etiology
• Mycobacterium tuberculosis
• Two mode of spread
• Inhalation
• Ingestion

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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

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INFECTION

• Advanced sign for spinal involvement are
• Vertebral body collaps
• Gibbus formation and obliteration of the
• disc
• Tubercular arthritis is common in the hip and
• knee
• Uniform joint space narowing, early destruction
• of the subchondral cortex, moth-eaten bone
• destruction and juxtaarticular osteoporosis
  are
• the cardinal sign of tubercular arthritis

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Tuberculosis
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Tuberculosis
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TUMORS AND TUMORLIKEPROCESSES

• METASTATIC BONE TUMORS
• PRIMARY MALIGNANT BONE TUMORS
• Multiple myeloma
• Osteosarcoma
• Ewings Sarcoma
• PRIMARY QUASIMALIGNANT BONE TUMOR
• Giant Cell Tumor

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TUMORS

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

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TUMORS

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

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TUMORS

• Radiologic Features
• Technetium bone scan
• 80 of all metastase 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 respose is rare

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Metastatic
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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

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Multiple Myeloma
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Multiple Myeloma
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TUMORS

• Osteosarcoma
• 75 of cases occurs in the 10 to 25 age
• Metaphyses of the distal femur, proximal
• humerus are the most common sites
• Permeative or ivory medulary 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

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Osteosarcoma
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Osteosarcoma
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TUMORS

• Ewings 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

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Ewings Sarcoma
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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, excentric
• Soap Buble appearance

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Giant Cell Tumor
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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

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Osteochondroma
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TUMOR

• Osteoma
• A rise in membranous bones
• Sinuses frontal, ethmoid
• Mandible
• Skull bones
• Homogenously opaque

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Osteoma

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TUMOR

• Bone Island
• Epiphyseal, metaphyseal
• Medulary
• Round oval Long axis oriented
• Smooth or radiating
  border
• Opaque
• Normal adjecent
  cortex
• May change size

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TUMOR

• Osteoid osteoma
• Consists a nidus, thst usually 1 cm or less
• Target calsification
• Most common location is in the cortex
• Radiolucent nidus surrounded by perifocal
• reactive sclerosis

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Osteoid Osteoma
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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

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Aneurysmal Bone Cyst
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Aneurysmal Bone Cyst
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ARTHRITIC DISORDERS

• Degenerative Disorders
• Degenerative Joint Disease
• etc
• Inflamatory Disorders
• Rheumatoid Arthritis
• etc
• Metabolic Disorders
• Gout
• etc

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ARTHRITIC

• Degenerative Joint Disease
• Osteoarthritis Osteoarthrosis
• Asimetric distribution
• Non uniform loss of the joint space
• Osteophytes
• Subchondral sclerosis
• Subchondral cyst
• Loose bodies
• Subluxation

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Osteoarthrosis
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ARTHRITIC

• Rheumatoid Arthritis
• Generalized Connective tissue disorder
• Higest insidence among the 40 50 year
• Symetric peripheral joint pain and swelling
• Early - Soft tissue swelling
• Marginal erosions
• Osteoporosis - Periostitis
• Loss of joint space
• Late - Ankylosis
• Deformities

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Rheumatoid Arthritis
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Rheumatoid Arthritis
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ARTHRITIC

• Gout
• Disorder of purin metabolism
• Deposite 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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Gout
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OsteoporosisDiagnosis Radiologi
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Primer

• Type I Post menopouse osteoclast mediated
• ? radius dan vertebra
• Type II Senile osteoporosis osteoblast
  mediated
• ? proksimal femur

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Compotition mineral

• Normal ? gt 833 mg / cm2
• Osteopeni ? 833 648 mg / cm2
• Osteoporosis ? lt 648 mg / cm2
• Established osteoporosis

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Diagnosa Radiologi
Radiografi Konvensional

• Peningkatan radiolusensi
• Penurunan kandungan mineral? lt30-50
• Penipisan korteks
• Gambaran trabekula menonjol
• Perubahan bentuk

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Vertebra

• Penurunan densitas
• Perubahan trabekula
• ? trabekula vertikal
• ? Wash out
• Penipisan korteks
• Perubahan bentuk

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Femur

• Penurunan densitas ? kolum femoris
• trochanter mayor
• Perubahan trabekula

1.Principal Compressive group
2.Secondary Compressive Group
Wards triangle
3. Tensile Group
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CT Scanogram

• Penipisan korteks

Pelebaran diameter intrameduler
CT Scanogram
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Densitometri

• Penurunan kandungan mineral
• ?umur 30-35 th
• Penurunan ? 3-5 / dekade
• Menopause ? gt 2 / tahun

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Dexa

• Dua panjang gelombang ? Energi
• Antero-posterior

BMC Bone mineral content (gram)
BMD Bone mineral density (gram/cm2)
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T. Score

• Normal gt -1
• Osteopeni -1 2,5
• Osteoporosis lt -2.5

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QUS

• Dua buah transduser ? 0,1 1 MHz
• Transmitter Receiver
• BUA (Boardband Ultrasound Attenuation)?Bone Mass
• SOS (Speed of Sound)? Internal Arsitektur dari
  trabekula?elastisitas

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Kesimpulan.

• USG Skrining massal
• DEXA Gold standard
• Konvensional radiografi