introduction to skeletal imaging
DESCRIPTION
Introduction to Skeletal ImagingTRANSCRIPT
INTRODUCTION TO SKELETAL IMAGING
Muhammad Bin Zulfiqar
PGR II SIMS/SHL
New Radiology Department
Overview of Skeletal system•Total bones 206•Skull bones 22 •Ear bones 6 •Throat Bone 1 •Thorax 25•Vertebral column 24•Shoulder girdle 4 •Upper limb 60•Pelvis 4
•Lower Limb 60
Imaging Modalities for Skeletal System •Plain Radiographs(main focus)•Nuclear Scintigraphy•Contrast Examination•Ultrasound•Computed Tomography•Magnetic Resonance Imaging
Major Diseases of Bone
Trauma Congenital Infections Tumors Metabolic, Endocrine, Nutritional Bone Dysplasia Inflammatory Diseases(R.A.) Associated soft tissues abnormalities
Skeletal Anatomy and Physiology
Skeletal Development Intramembranous Ossification Enchondral Ossification
Bone Structure Epiphysis – ZPC – Metaphysis
– Diaphysis Cortex – Medulla – Periosteum
– Endosteum
Bone Metabolism Bone mineral - Hormones
Anatomy
Anatomy
Anatomy
Approach to skeletal imaging
Preliminary Analysis
• Clinical data
• Number of lesions
• Symmetry of lesions
• Determination of Systems Involved
Analysis of The Lesions
Skeletal Location
Position Within Bone
Site of Origin
Shape
Size
Margination
Cortical Integrity
Analysis of The Lesions
Behavior of Lesions• Osteolytic Lesions• Osteoblastic Lesions• Mixed Lesions
Matrix Periosteal Response• Solid Response• Laminated Response• Spiculated Response• Codmans’ Triangle
Radiologic Predictor Variables Supplementary Analysis
Other imaging Procedures Laboratory Examination Biopsy
Soft Tissue Changes
TRAUMA
Fracture and Dislocation
The radiographs should be made Include at least one joint Preferably two joints Two position AP – LAT
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
TRAUMATypes 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
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 segment
TRAUMA Incomplete Fracture
Broken only one side of the bone Greenstick (Hickory Stick) fracture Torus (Buckling) fracture
Fracture Orientation Oblique fracture
Commonly occurs in the shaft of long
tubular bone 45° to the long axis of the bone
Fractur
Fracture
TRAUMA
Spiral fracture Torsion, coupled with axial compression
and angulation Transverse fracture
Run at a right angle to the lonh axis Uncommon through healthy bone Pathologic fracture
Fracture
TRAUMA
Spatial Relationships of Fracture Alignment
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
Fracture
TRAUMA
Rotation Twisting forces on a fractured bone along
its longitudinal axis
Traumatic Articular Lesions Subluxation Dislocation Diastasis
Epiphyseal Fractures Salter-Harris Classification
Salter - Harris
Dislocation
TRAUMAFracture 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
TRAUMA
Complication of Fractures Immediate complication
Arterial injury Compartment syndrome Gas gangrene Fat embolism syndrome Thromboembolism
TRAUMA Intermediate complication
Osteomyelitis Myositis ossificans Synostosis Delayed union
Delayed complication Osteonecrosis Osteoporosis Non union – Mal union
Myositis Ossificans
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
INFECTION
Etiology Staphylococcus aureus causes 90% Pathway for the spread
Hematogenous Contiguous Direct Implantation Postoperative
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.
INFECTION Bone changes :
Moth-eaten bone destruction
Usually metaphyseal in origin Periosteal new bone formation
Solid – Laminated – Codman’s Triangle Sequestrum Involucrum Joint space destruction (ankylosis)
0steomyelitis
Osteomyelitis
INFECTION
Septic Arthritis General consideration
Single joint involvement in the rule Most common route is hematogenous
or direct traumatic implantation Etiology
Most frequently is Staphylococcus Aureus
INFECTION
Radiologic Features The knee and hip are the most common
sites Joint effusion leads to distortion of the
fat folds Positive Walden storm's sign Rapid loss of joint space Bony ankylosis
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
INFECTION
Etiology Mycobacterium tuberculosis Two mode of spread
Inhalation Ingestion
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
INFECTIONAdvanced sign for spinal involvement are:
Vertebral body collapse Gibbus formation and obliteration of the
disc Tubercular arthritis is common in the hip and
knee Uniform joint space narrowing, early destruction
of the subchondral cortex, “moth-eaten” bone
destruction and juxtaarticular osteoporosis are
the cardinal sign of tubercular arthritis
Tuberculosis
Tuberculosis
TUMORS AND TUMORLIKEPROCESSES
METASTATIC BONE TUMORS
PRIMARY MALIGNANT BONE TUMORS Multiple myeloma Osteosarcoma Ewing’s Sarcoma
PRIMARY QUASIMALIGNANT BONE TUMOR Giant Cell Tumor
TUMORS
PRIMARY BENIGN BONE TUMORS Osteochondroma Osteoma Bone island Osteoid osteoma Simple bone cyst Aneurysmal bone cyst
TUMORS
Metastatic Bone Tumors General Consideration
The most common malignant tumors CNS tumors and basal cell Ca rarely Life threatening complication
Incidence 70% are metastatic, 30% are primary In females 70% from breast Ca
In males 60% from prostate Ca
TUMORS Radiologic Features
Technetium bone scan 80% of all metastases 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 response is rare
Metastatic
TUMORSPrimary 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
Multiple Myeloma
Multiple Myeloma
TUMORS Osteosarcoma
75% of cases occurs in the 10 to 25 age Metaphysis of the distal femur, proximal
humerus are the most common sites Permeative or ivory medullary 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
Osteosarcoma
Osteosarcoma
TUMORS Ewing’s 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
Ewing’s Sarcoma
TUMORSPrimary 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, eccentric Soap Bubble appearance
Giant Cell Tumor
TUMORPrimary 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
Osteochondroma
TUMOR
Osteoma A rise in membranous bones Sinuses – frontal, ethmoid
Mandible
Skull bones Homogenously opaque
Osteoma
TUMOR
Bone Island Epiphyseal, metaphyseal Medullary Round – oval : Long axis oriented
Smooth or radiating border
Opaque
Normal adjacent cortex
May change size
TUMOR
Osteoid osteoma Consists a nidus, that usually 1 cm or less Target calcification Most common location is in the cortex Radiolucent nidus surrounded by perifocal
reactive sclerosis
Osteoid Osteoma
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”
Aneurysmal Bone Cyst
Aneurysmal Bone Cyst
ARTHRITIC DISORDERS
Degenerative Disorders Degenerative Joint Disease etc
Inflammatory Disorders Rheumatoid Arthritis etc
Metabolic Disorders Gout etc
ARTHRITIC Degenerative Joint Disease
Osteoarthritis – Osteoarthrosis Asymmetric distribution Non uniform loss of the joint space Osteophytes Subchondral sclerosis Subchondral cyst Loose bodies Subluxation
Osteoarthrosis
ARTHRITIC Rheumatoid Arthritis
Generalized Connective tissue disorder Highest incidence among the 40 – 50 year Symmetric peripheral joint pain and swelling Early : - Soft tissue swelling
Marginal erosions
Osteoporosis - Periostitis
Loss of joint space
Late : - Ankylosis
Deformities
Rheumatoid Arthritis
Rheumatoid Arthritis
ARTHRITISGout
Disorder of purin metabolism Deposits 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
Gout
QUESTIONS
THANK YOU