How to readmusculo-skeletal x rays    Dr.Mahesh kumar MS     Dept. of Orthopedics      General Hospital         Trivandrum...
Rule 1 Commonthings -first      www.similima.com   2
When you see a blackbird in trivandrum        www.similima.com   3
Do not say it is a penguin                              Say it is a crow           www.similima.com                      4
Appearances can be deceptive-          www.similima.com      5  do not go by appearances
www.similima.com   6
Reading an x ray It is not getting the “appearance” It is not commenting “oh! I have seen it  before” And not distracte...
ABC’s of bone RadiologyLook for Alignment Bones       Abnormal lucency       Abnormal sclerosis       Periosteal reac...
Alignment   Subluxation       A displacement of a bone in relation to the apposing        bone at the joint, resulting i...
dislocation              www.similima.com   10
www.similima.com   11subluxation
Decreased Opacity (Lucency)Lucency comes in several flavors. Depending on the exact  morphology and distribution of the lu...
Lucent line                 A linear lucency is the classic                  sign of a fracture. If a fracture           ...
Focal lucency   With focal lucencies, bone tumors and osteomyelitis are two of the    top entities on the differential di...
www.similima.com   15
www.similima.com   16
focal lucencies                  focal lucencies, bone tumors                   and osteomyelitis are two of             ...
Differential Diagnosis of Solitary Lucent Bone Lesions   Fibrous Dysplasia   Osteoblastoma   Giant Cell Tumor   Metast...
Look for Age of the patient Size of the lesion Margins of the lesion Matrix- the “inside” of the lesion Location in t...
Age and lucent bone lesions   1       neuroblastoma   1 - 10       Ewings of tubular bones   10 - 30       osteosarc...
geographic                                    Normal boneMoth eaten                                TYPES OF               ...
locationwww.similima.com              22
Multiplicity    Differential Diagnosis of Multiple Lucent Bone Lesions   Fibrous Dysplasia   Metastasis / Myeloma   Hyp...
Some tips  www.similima.com   24
a long lesion in a long bone,           think of     fibrous dysplasia.            www.similima.com    25
 Simple   cyst,         enchondroma,     and fibrous dysplasiacan mimic each other and can be       hard to distinguish...
Giant cell tumors      nearly alwaysoccur near a joint surface.           www.similima.com   27
Lucent lesions of the sternum   should be considered          malignant   until proven otherwise         (Helms CA, 1983)....
   Certain bones in the body are    "epiphyseal equivalents".    lucent lesions in these areas,    the classic epiphysea...
Diffuse lucency                           Diffuse lucency usually                            bespeaks some global        ...
extensivemyelomatosis                             rheumatoid arthritis                             treated with steroids  ...
?    www.similima.com   32
Increased Opacity (Sclerosis)           Causes of Increased Opacity   Bone impaction or rotation       fracture   Bone ...
Generic Differential Diagnosis of Sclerotic Bone Lesions                                           Drugs    Vascular    ...
Bone impaction or rotation                        Although the classic                         sign of a fracture is a   ...
Fracture callus                   Some fractures are so                    subtle that you may                    miss th...
Reactive sclerosis due to tumor                           diffusely sclerotic                            metastsis are se...
pagetsBone island              www.similima.com            38
osteopoikilocytosismelhorrostesis                 osteoma                                                 Bone island     ...
www.similima.com   40
Periosteal reaction   Depends on whether the lesion is    slow growing or rapidly growing   Slow growing- periosteum is ...
Periosteum produces bone when stimulatedType of periosteal reaction depends on the process than the periosteum Slow growi...
Solid              Lamellar             sunburst              Codeman’s                                                   ...
causes    Solid Periosteal Reaction       infection       benign neoplasms            osteoid osteoma            eosi...
www.similima.com   45
Causes of Solid Periosteal                   Reaction   Osteomyelitis   Benign neoplasms    osteoid osteoma   Eosinophi...
Causes of Aggressive (Interrupted)      Periosteal Reaction"sunburst".                          Osteomyelitis            ...
Abnormal Contour, Size and Shape                           Focal                                fracture                 ...
multiple hereditary exostoses,                                                 Paget’s disease,                           ...
Cartilage                                          we can’t really see                                           cartilag...
Marked joint space               narrowing is noted in the               superior weight-bearing               portion of ...
   Chondrocalcinosis    (arrows) is noted in    the hyaline articular    cartilage and menisci    of this patient with   ...
Soft TissueWhen looking at the soft tissues, one can  occasionally see a variety of useful  findings on plain films, such ...
www.similima.com   54
www.similima.com   55
small to large amorphous Ca++ in theDystrophic                      damaged tissue -- may progress to                     ...
www.similima.com   57
www.similima.com   58
www.similima.com   59cysticercosis
sclerodermawww.similima.com                 60
dermatomyositis                  www.similima.com   61
Heterotrophic ossification                             www.similima.com   62
?                   SLE                   Metasataic                   calcifications in                   soft tissueswww...
www.similima.com   64chondrocalcinosis
Tumoralcalcinosis             www.similima.com   65
Calcific tendinitis                      www.similima.com   66
www.similima.com   67
Thank you   www.similima.com   68
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Musculoskeltal xray

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Musculoskeltal xray

  1. 1. How to readmusculo-skeletal x rays Dr.Mahesh kumar MS Dept. of Orthopedics General Hospital Trivandrum www.similima.com 1
  2. 2. Rule 1 Commonthings -first www.similima.com 2
  3. 3. When you see a blackbird in trivandrum www.similima.com 3
  4. 4. Do not say it is a penguin Say it is a crow www.similima.com 4
  5. 5. Appearances can be deceptive- www.similima.com 5 do not go by appearances
  6. 6. www.similima.com 6
  7. 7. 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 www.similima.com 7
  8. 8. ABC’s of bone RadiologyLook for Alignment Bones  Abnormal lucency  Abnormal sclerosis  Periosteal reaction  Abnormal contour Cartilage Soft Tissue www.similima.com 8
  9. 9. 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). www.similima.com 9
  10. 10. dislocation www.similima.com 10
  11. 11. www.similima.com 11subluxation
  12. 12. 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 www.similima.com 12
  13. 13. Lucent line  A linear lucency is the classic sign of a fracture. If a fracture is displaced enough, it is easy www.similima.com 13
  14. 14. 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. www.similima.com 14
  15. 15. www.similima.com 15
  16. 16. www.similima.com 16
  17. 17. 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 www.similima.com 17
  18. 18. 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 www.similima.com 18
  19. 19. 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 www.similima.com 19
  20. 20. 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 www.similima.com 20
  21. 21. geographic Normal boneMoth eaten TYPES OF LESIONS permeative www.similima.com 21
  22. 22. locationwww.similima.com 22
  23. 23. Multiplicity Differential Diagnosis of Multiple Lucent Bone Lesions Fibrous Dysplasia Metastasis / Myeloma Hyperparathyroidism (brown tumors) / Hemangioma Infection Eosinophilic Granuloma / Enchondroma www.similima.com 23
  24. 24. Some tips www.similima.com 24
  25. 25. a long lesion in a long bone, think of fibrous dysplasia. www.similima.com 25
  26. 26.  Simple cyst,  enchondroma,  and fibrous dysplasiacan mimic each other and can be hard to distinguish. www.similima.com 26
  27. 27. Giant cell tumors nearly alwaysoccur near a joint surface. www.similima.com 27
  28. 28. Lucent lesions of the sternum should be considered malignant until proven otherwise (Helms CA, 1983). www.similima.com 28
  29. 29.  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. www.similima.com 29
  30. 30. Diffuse lucency  Diffuse lucency usually bespeaks some global process capable of affecting the entire skeleton.  A metabolic bone disorder such as osteoporosis  multiple myeloma www.similima.com 30
  31. 31. extensivemyelomatosis rheumatoid arthritis treated with steroids www.similima.com 31
  32. 32. ? www.similima.com 32
  33. 33. 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 www.similima.com 33
  34. 34. 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 www.similima.com 34  Pagets disease
  35. 35. Bone impaction or rotation  Although the classic sign of a fracture is a lucent line, some fractures present otherwise. In cancellous bones www.similima.com 35
  36. 36. 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. www.similima.com 36
  37. 37. 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). www.similima.com 37
  38. 38. pagetsBone island www.similima.com 38
  39. 39. osteopoikilocytosismelhorrostesis osteoma Bone island www.similima.com 39
  40. 40. www.similima.com 40
  41. 41. 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 www.similima.com 41
  42. 42. 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 www.similima.com 42
  43. 43. Solid Lamellar sunburst Codeman’s triangle Types of periosteal reaction Mixed type www.similima.com 43
  44. 44. 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 www.similima.com 44
  45. 45. www.similima.com 45
  46. 46. Causes of Solid Periosteal Reaction Osteomyelitis Benign neoplasms osteoid osteoma Eosinophilic granuloma Hypertrophic osteoarthropathy Deep venous thrombosis (lower extremity) Trauma (healing fracture) www.similima.com 46
  47. 47. Causes of Aggressive (Interrupted) Periosteal Reaction"sunburst".  Osteomyelitis  Malignant neoplasms  osteosarcoma  chondrosarcoma  fibrosarcoma  lymphoma  leukemia  metastasis  Trauma osteogenic sarcoma. www.similima.com 47
  48. 48. Abnormal Contour, Size and Shape  Focal fracture surgery infection tumor  Diffuse dysplasia metabolic www.similima.com 48
  49. 49. multiple hereditary exostoses, Paget’s disease, www.similima.com 49 Paget’s disease,
  50. 50. 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. www.similima.com 50
  51. 51. 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 noted.www.similima.com 51
  52. 52.  Chondrocalcinosis (arrows) is noted in the hyaline articular cartilage and menisci of this patient with calcium pyrophosphate deposition (CPPD) disease www.similima.com 52
  53. 53. 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 www.similima.com 53
  54. 54. www.similima.com 54
  55. 55. www.similima.com 55
  56. 56. 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 www.similima.com 56
  57. 57. www.similima.com 57
  58. 58. www.similima.com 58
  59. 59. www.similima.com 59cysticercosis
  60. 60. sclerodermawww.similima.com 60
  61. 61. dermatomyositis www.similima.com 61
  62. 62. Heterotrophic ossification www.similima.com 62
  63. 63. ? SLE Metasataic calcifications in soft tissueswww.similima.com 63
  64. 64. www.similima.com 64chondrocalcinosis
  65. 65. Tumoralcalcinosis www.similima.com 65
  66. 66. Calcific tendinitis www.similima.com 66
  67. 67. www.similima.com 67
  68. 68. Thank you www.similima.com 68

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