Musculoskeltal xray
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Musculoskeltal xray






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Musculoskeltal xray Musculoskeltal xray Presentation Transcript

  • How to readmusculo-skeletal x rays Dr.Mahesh kumar MS Dept. of Orthopedics General Hospital Trivandrum 1
  • Rule 1 Commonthings -first 2
  • When you see a blackbird in trivandrum 3
  • Do not say it is a penguin Say it is a crow 4
  • Appearances can be deceptive- 5 do not go by appearances
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  • Reading an x ray It is not getting the “appearance” It is not commenting “oh! I have seen it before” And not distracted by the “obvious”- it may not be the causative pathology We should have a systematic approach 7
  • ABC’s of bone RadiologyLook for Alignment Bones  Abnormal lucency  Abnormal sclerosis  Periosteal reaction  Abnormal contour Cartilage Soft Tissue 8
  • Alignment Subluxation  A displacement of a bone in relation to the apposing bone at the joint, resulting in a partial loss of continuity of the joint surfaces. Dislocation  A displacement of a bone in relation to the apposing bone at the joint, resulting in a complete loss of continuity of the joint surfaces. Diastasis  A displacement of a bone in relation to the apposing bone in a slightly movable (e.g. sacroiliac) or synarthrodial joint (cranial sutures). 9
  • dislocation 10
  • 11subluxation
  • Decreased Opacity (Lucency)Lucency comes in several flavors. Depending on the exact morphology and distribution of the lucency, our differential diagnosis may vary widely. Lucent line  fracture Focal lucency  tumor  infection Diffuse lucency  drugs  endocrine / metabolic  tumor 12
  • Lucent line  A linear lucency is the classic sign of a fracture. If a fracture is displaced enough, it is easy 13
  • Focal lucency With focal lucencies, bone tumors and osteomyelitis are two of the top entities on the differential diagnosis. In the rest of the world, a handful of benign tumors are seen occasionally, and the only malignant tumors commonly seen are metastases and multiple myeloma. In practice, the patient’s history is often key in distinguishing tumor and infection, as they sometimes appear quite similar on radiographs. 14
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  • focal lucencies  focal lucencies, bone tumors and osteomyelitis are two of the top entities on the differential diagnosis.  only malignant tumors commonly seen are metastases and multiple myeloma 17
  • Differential Diagnosis of Solitary Lucent Bone Lesions Fibrous Dysplasia Osteoblastoma Giant Cell Tumor Metastasis / Myeloma Aneurysmal Bone Cyst Chondroblastoma / Chondromyxoid Fibroma Hyperparathyroidism (brown tumors) / Hemangioma Infection Non-ossifying Fibroma Eosinophilic Granuloma / Enchondroma Solitary Bone Cyst 18
  • Look for Age of the patient Size of the lesion Margins of the lesion Matrix- the “inside” of the lesion Location in the bone Periosteal reaction - present or not? multiplicity 19
  • Age and lucent bone lesions 1  neuroblastoma 1 - 10  Ewings of tubular bones 10 - 30  osteosarcoma, Ewings of flat bones 30 - 40  reticulum cell sarcoma (Primary histiocytic lymphoma), fibrosarcoma, parosteal osteosarcoma, malignant giant cell tumor, lymphoma 40 +  metastatic carcinoma, multiple myeloma, chondrosarcoma 20
  • geographic Normal boneMoth eaten TYPES OF LESIONS permeative 21
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  • Multiplicity Differential Diagnosis of Multiple Lucent Bone Lesions Fibrous Dysplasia Metastasis / Myeloma Hyperparathyroidism (brown tumors) / Hemangioma Infection Eosinophilic Granuloma / Enchondroma 23
  • Some tips 24
  • a long lesion in a long bone, think of fibrous dysplasia. 25
  •  Simple cyst,  enchondroma,  and fibrous dysplasiacan mimic each other and can be hard to distinguish. 26
  • Giant cell tumors nearly alwaysoccur near a joint surface. 27
  • Lucent lesions of the sternum should be considered malignant until proven otherwise (Helms CA, 1983). 28
  •  Certain bones in the body are "epiphyseal equivalents". lucent lesions in these areas, the classic epiphyseal entities such as chondroblastoma, giant cell tumors and aneurysmal bone cysts. They are  patella,  calcaneus,  most apophyses. 29
  • Diffuse lucency  Diffuse lucency usually bespeaks some global process capable of affecting the entire skeleton.  A metabolic bone disorder such as osteoporosis  multiple myeloma 30
  • extensivemyelomatosis rheumatoid arthritis treated with steroids 31
  • ? 32
  • Increased Opacity (Sclerosis) Causes of Increased Opacity Bone impaction or rotation  fracture Bone production(reactive sclerosis)  fracture callus  tumor tumor bone formation or periosteal reaction  infection periosteal reaction  osteoarthritis subchondral sclerosis or osteophytosis  Congenital 33
  • Generic Differential Diagnosis of Sclerotic Bone Lesions  Drugs Vascular  Vitamin D  hemangiomas  fluoride  infarct  Inflammatory/Idiopathic  Infection  Congenital chronic osteomyelitis  bone islands Neoplasm  osteopoikilosis  primary  osteopetrosis  osteoma  pyknodysostosis  osteosarcoma  Autoimmune  metastatic  prostate  Trauma  breast  fracture (stress)  other  Endocrine/Metabolic  hyperparathyroidism 34  Pagets disease
  • Bone impaction or rotation  Although the classic sign of a fracture is a lucent line, some fractures present otherwise. In cancellous bones 35
  • Fracture callus  Some fractures are so subtle that you may miss them altogether at first, and only diagnose them once they have started to heal due to the formation of fracture callus. 36
  • Reactive sclerosis due to tumor  diffusely sclerotic metastsis are seen in a very slow process (prostatic carcinoma)  or a patient with diffusely lytic mets who has been successfully treated (with resultant healing and sclerosis of these metastatic deposits). 37
  • pagetsBone island 38
  • osteopoikilocytosismelhorrostesis osteoma Bone island 39
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  • Periosteal reaction Depends on whether the lesion is slow growing or rapidly growing Slow growing- periosteum is able to produce bone at the same rate as tumor grows- so solid periosteal reaction Rapidly growing lesion -the perisoteum cannot cope up- hence interrupted pattern 41
  • Periosteum produces bone when stimulatedType of periosteal reaction depends on the process than the periosteum Slow growing- solid periosteal reaction Faster growing layered or lamellar type Rapid, steady growth -sun burst, codeman’s triangle Mixed patterns 42
  • Solid Lamellar sunburst Codeman’s triangle Types of periosteal reaction Mixed type 43
  • causes Solid Periosteal Reaction  infection  benign neoplasms  osteoid osteoma  eosinophilic granuloma  hypertrophic pulmonary osteoarthropathy  deep venous thrombosis (lower extremity) Aggressive Periosteal Reaction  osteomyelitis  malignant neoplasms  osteosarcoma  chondrosarcoma  fibrosarcoma  lymphoma  leukemia  metastasis 44
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  • Causes of Solid Periosteal Reaction Osteomyelitis Benign neoplasms osteoid osteoma Eosinophilic granuloma Hypertrophic osteoarthropathy Deep venous thrombosis (lower extremity) Trauma (healing fracture) 46
  • Causes of Aggressive (Interrupted) Periosteal Reaction"sunburst".  Osteomyelitis  Malignant neoplasms  osteosarcoma  chondrosarcoma  fibrosarcoma  lymphoma  leukemia  metastasis  Trauma osteogenic sarcoma. 47
  • Abnormal Contour, Size and Shape  Focal fracture surgery infection tumor  Diffuse dysplasia metabolic 48
  • multiple hereditary exostoses, Paget’s disease, 49 Paget’s disease,
  • Cartilage  we can’t really see cartilage on plain radiographs, but we can still use these films to infer a few rough ideas decreased joint space about how the cartilage is doing. Hyaline articular cartilage is what increased joint space separates the bones in a synovial joint. This space taken up by the cartilage chondrocalcinosis is termed the "joint space" on a plain radiograph. 50
  • Marked joint space narrowing is noted in the superior weight-bearing portion of the joint space in this patient with osteoarthritis. Subchondral sclerosis and marked osteophytosis are also 51
  •  Chondrocalcinosis (arrows) is noted in the hyaline articular cartilage and menisci of this patient with calcium pyrophosphate deposition (CPPD) disease 52
  • Soft TissueWhen looking at the soft tissues, one can occasionally see a variety of useful findings on plain films, such as: swelling gas calcification mass 53
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  • small to large amorphous Ca++ in theDystrophic damaged tissue -- may progress to ossification (formation of cortex and medullary space are then seen)CPPD chondrocalcinosis; occasionally associated with calcifications in the soft tissues of the spineMetastatic calcification finely speckled Ca++ throughout soft tissuesTumoral calcinosis big globs of Ca++, usually near a jointMetastatic osteosarcoma amorphous, fluffy, confluent collection of Ca++Primary soft tissue amorphous, fluffy, confluent collection of Ca++osteosarcoma 56
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  • 59cysticercosis
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  • dermatomyositis 61
  • Heterotrophic ossification 62
  • ? SLE Metasataic calcifications in soft 63
  • 64chondrocalcinosis
  • Tumoralcalcinosis 65
  • Calcific tendinitis 66
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  • Thank you 68