Introduction to skeletal imaging

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Introduction to Skeletal Imaging

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Introduction to skeletal imaging

  1. 1. INTRODUCTION TO SKELETAL IMAGING Muhammad Bin Zulfiqar PGR II SIMS/SHL New Radiology Department
  2. 2. Overview of Skeletal system •Total bones •Skull bones •Ear bones •Throat Bone •Thorax •Vertebral column •Shoulder girdle •Upper limb •Pelvis •Lower Limb 206 22 6 1 25 24 4 60 4 60
  3. 3. Imaging Modalities for Skeletal System •Plain Radiographs(main focus) •Nuclear Scintigraphy •Contrast Examination •Ultrasound •Computed Tomography •Magnetic Resonance Imaging
  4. 4. Major Diseases of Bone         Trauma Congenital Infections Tumors Metabolic, Endocrine, Nutritional Bone Dysplasia Inflammatory Diseases(R.A.) Associated soft tissues abnormalities
  5. 5. 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
  6. 6. Anatomy
  7. 7. Anatomy
  8. 8. Anatomy
  9. 9. Approach to skeletal imaging Preliminary Analysis • Clinical data • Number of lesions • Symmetry of lesions • Determination of Systems Involved
  10. 10. Analysis of The Lesions Skeletal Location Position Within Bone Site of Origin Shape Size Margination Cortical Integrity
  11. 11. Analysis of The Lesions Behavior of Lesions • Osteolytic Lesions • Osteoblastic Lesions • Mixed Lesions  Matrix  Periosteal Response • Solid Response • Laminated Response • Spiculated Response • Codmans’ Triangle
  12. 12. Radiologic Predictor Variables Supplementary Analysis  Other imaging Procedures  Laboratory Examination  Biopsy  Soft Tissue Changes 
  13. 13. TRAUMA Fracture and Dislocation The radiographs should be made  Include at least one joint  Preferably two joints  Two position AP – LAT
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. Fractur
  19. 19. Fracture
  20. 20. 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 
  21. 21. Fracture
  22. 22. 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
  23. 23. Fracture
  24. 24. TRAUMA Rotation  Twisting forces on a fractured bone along its longitudinal axis Traumatic Articular Lesions  Subluxation  Dislocation  Diastasis Epiphyseal Fractures  Salter-Harris Classification 
  25. 25. Salter - Harris
  26. 26. Dislocation
  27. 27. 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
  28. 28. TRAUMA Complication of Fractures  Immediate complication  Arterial injury  Compartment syndrome  Gas gangrene  Fat embolism syndrome  Thromboembolism
  29. 29. TRAUMA  Intermediate complication  Osteomyelitis  Myositis ossificans  Synostosis  Delayed union  Delayed complication  Osteonecrosis  Osteoporosis  Non union – Mal union
  30. 30. Myositis Ossificans
  31. 31. 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
  32. 32. INFECTION  Etiology  Staphylococcus aureus causes 90%  Pathway for the spread  Hematogenous  Contiguous  Direct Implantation  Postoperative
  33. 33. 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.
  34. 34. 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)
  35. 35. 0steomyelitis
  36. 36. Osteomyelitis
  37. 37. 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
  38. 38. 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
  39. 39. 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
  40. 40. INFECTION  Etiology  Mycobacterium tuberculosis  Two mode of spread  Inhalation  Ingestion
  41. 41. 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
  42. 42. INFECTION Advanced 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 
  43. 43. Tuberculosis
  44. 44. Tuberculosis
  45. 45. TUMORS AND TUMORLIKE PROCESSES METASTATIC BONE TUMORS PRIMARY MALIGNANT BONE TUMORS  Multiple myeloma  Osteosarcoma  Ewing’s Sarcoma PRIMARY QUASIMALIGNANT BONE TUMOR  Giant Cell Tumor
  46. 46. TUMORS PRIMARY BENIGN BONE TUMORS  Osteochondroma  Osteoma  Bone island  Osteoid osteoma  Simple bone cyst  Aneurysmal bone cyst
  47. 47. 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
  48. 48. 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
  49. 49. Metastatic
  50. 50. 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
  51. 51. Multiple Myeloma
  52. 52. Multiple Myeloma
  53. 53. 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
  54. 54. Osteosarcoma
  55. 55. Osteosarcoma
  56. 56. 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
  57. 57. Ewing’s Sarcoma
  58. 58. 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, eccentric  Soap Bubble appearance
  59. 59. Giant Cell Tumor
  60. 60. 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
  61. 61. Osteochondroma
  62. 62. TUMOR  Osteoma  A rise in membranous bones  Sinuses – frontal, ethmoid Mandible Skull bones  Homogenously opaque
  63. 63. Osteoma 
  64. 64. TUMOR  Bone Island  Epiphyseal, metaphyseal  Medullary  Round – oval : Long axis oriented Smooth or radiating border Opaque Normal adjacent cortex May change size
  65. 65. 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
  66. 66. Osteoid Osteoma
  67. 67. 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” 
  68. 68. Aneurysmal Bone Cyst
  69. 69. Aneurysmal Bone Cyst
  70. 70. ARTHRITIC DISORDERS Degenerative Disorders  Degenerative Joint Disease  etc Inflammatory Disorders  Rheumatoid Arthritis  etc Metabolic Disorders  Gout  etc
  71. 71. ARTHRITIC  Degenerative Joint Disease Osteoarthritis – Osteoarthrosis  Asymmetric distribution  Non uniform loss of the joint space  Osteophytes  Subchondral sclerosis  Subchondral cyst  Loose bodies  Subluxation
  72. 72. Osteoarthrosis
  73. 73. 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 
  74. 74. Rheumatoid Arthritis
  75. 75. Rheumatoid Arthritis
  76. 76. ARTHRITIS Gout 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 
  77. 77. Gout
  78. 78. QUESTIONS
  79. 79. THANK YOU

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