Clinical Skills MSK

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Clinical SkillsMSK
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Objectives

• By the end of the session, the student will have
• 1. Been exposed to some common imaging modalities
  used to evaluate the musculoskeletal system
• 2. Been exposed to the imaging of some common
  musculoskeletal pathologies
• 3. Practiced an approach to description and
  analysis of images of the musculoskeletal system

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Plan

• Goal
• To form an approach to MSK radiology
• Organization
• Basic anatomy
• Approach to MSK radiology
• Pathology
• Plain films to review

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Types of bones

• Long bones
• Femur, tibia, humerus, phalanges, vertebrae
• Flat bones
• Skull, pelvis, scapula
• Sesamoid bones
• Patella

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Anatomy

• Long bones
• Diaphysis shaft
• Epiphysis ends
• Metaphysis Region joining diaphysis and
  epiphysis
• Articular cartilage thin layer hyaline cartilage
• Periosteum
• Fibrous dense connective tissue
• Osteogenic Inner layer with elastic fibers,
  cells, vessels
• Medullary or marrow cavity

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Types of Joints

• Functional classification
• Synarthrosis immovable joint
• Sutures, teeth, epiphysis
• Amphiarthrosis slightly movable joint
• Distal articulation of tibia and fibula, between
  intervertebral discs and vertebral bodies
• Diarthrosis freely movable joint
• Aka synovial joints

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Approach to Radiology

• Basic concepts
• X-rays-produced by bombarding tungsten with an
  electron beam.
• When X-rays hit photographic film
• a photochemical process takes place in which
  metallic silver is precipitated rendering the
  film black when developed.
• As the x-rays project through an object (ex. a
  hand), the various parts of an object will absorb
  part or all of the x-rays so that more or less of
  the x-rays will the photographic film

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Radiology concepts
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Approach to Radiology

• Air black
• Fat dark gray
• Soft tissues gray
• Bones white (has Ca which absorbs more than
  soft tissues)
• Metal Every metal absorbs X-rays depending on
  thickness and atomic number

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Terms in Radiology

• Radioopaque more dense
• Radiolucent more transparent
• Factors affecting appearance
• Density/Composition
• Thickness
• Summation of all X-ray shadows
• Technical factors kilovoltage, time of exposure

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MSK Radiology

• Approach ABCs
• Alignment
• Bones
• Density
• Cortical continuity
• Cartilage
• Soft tissues

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Alignment

• With most joints, two surfaces will be congruent
  (similarly shaped) and should line up with one
  another
• Ball (convex) in cup (concave)
• Subluxation displacement causing partial loss of
  continuity of joint surfaces
• Displacement displacement causing complete loss
  of continuity of joint surfaces

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Bone

• Abnormal opacity
• Decreased (lucency)
• Lucent line
• Classical sign of fracture

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Types of fractures

• Alignment
• Angulated or straight
• Open vs Closed
• Open Skin is open
• Closed no opening in skin

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Bone

• Focal lucency
• Bone tumors
• Benign
• Malignant
• Osteomyelitis
• Pt Hx is key
• Multiple myeloma patient with several lytic
  lesions of the ulna.

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Osteomyelitis

• Earliest finding Osteopenia
• Osseous destruction followed by pathologic
  fracture
• May spread to adj joint
• Evidence of destruction on both sides of the
  joint is strong evidence of septic joint
• AP view of a great toe with marked osteomyelitis,
  a septic joint and a pathologic fracture of the
  toe.

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Bone

• Diffuse lucency
• Osteoporosis
• This patient has diffuse osteopenia due to
  osteoporosis, and has developed an insufficiency
  fracture in his T6 vertebral body.
• Multiple myeloma

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Bone

• Increased Opacity (Sclerosis)
• bone impaction or rotation
• fracture
• bone production (reactive sclerosis)
• fracture --gt callus
• tumor --gt tumor bone formation or periosteal
  reaction
• infection --gt periosteal reaction
• osteoarthritis --gt subchondral sclerosis or
  osteophytosis

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Cartilage

• Hyaline articular cartilage separates bones in a
  joint space
• Radiographic findings
• decreased joint space
• Arthritis
• increased joint space
• Chondrocalcinosis
• Deposition of CPPD crystals in hyaline articular
  cartilage of fibrocartilage

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Arthritis

• Osteoarthritis
• Degenerative alterations in a synovial joint.
  This is the most common articular affliction
  there is.
• Findings
• Osteophytes
• Asymmetric joint space narrowing
• DIP, PIP

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Arthritis

• Rheumatoid arthritis
• An inflammatory arthropathy of unknown etiology,
  characterized by synovial inflammation, pannus
  formation and erosion formation.
• Findings
• Erosions
• Symmetric joint space narrowing
• MCP, PIP

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Chondrocalcinosis

• CPPD (95)
• calcium pyrophosphate deposition (CPPD) disease

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Soft tissue

• swelling
• localization
• gas
• Penetrating injuries, post surgery or infections
• calcification
• Usually implies some tissue damage with
  dystrophic calcification
• mass hematoma, tumor or abscess (MRI)

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Differential Diagnosis

• VINDICATE" for Musculoskeletal Disease
• Vascular osteonecrosis
• Infection
• osteomyelitis
• abscess
• Neoplasm
• mets
• myeloma
• benign
• Drugs
• steroids --gt osteonecrosis
• Inflammatory
• Congenital

• Autoimmune
• rheumatoid arthritis
• ankylosing spondylitis
• Trauma
• fracture
• dislocation
• Endocrine / metabolic
• Paget's
• hyperparathyroidism
• gout

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Normal Anatomy Shoulder
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Normal Anatomy shoulder
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Normal Anatomy Hand
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Normal Anatomy Hand
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Normal Anatomy Pelvis
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Normal Anatomy Pelvis
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Normal Anatomy Ankle
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Normal Anatomy Ankle
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Normal Anatomy Knee
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Normal Anatomy Knee
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C-Spine

• Anterior vertebral line
• Posterior vertebral line
• Posterior border of facets
• Laminar fusion line
• Spinous process line
• Soft tissue Up to C4 ½ vert body
• Beyond C4 1 vert body
• McGregor line (Hard palate to base of skull
  lt4.5mm)

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C-Spine