Dr.salah.radiology.radiological approach to bone diseases


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Dr.salah.radiology.radiological approach to bone diseases

  1. 1. Prepared by Dr.Salah Mohammad Fatih MBChB,DMRD,FIBMS(radiology)
  2. 2. <ul><li>X-ray </li></ul><ul><li>Isotope </li></ul><ul><li>US </li></ul><ul><li>CT </li></ul><ul><li>MRI </li></ul>
  3. 3. <ul><li>1-Plain bone radiograph </li></ul>
  4. 4. <ul><li>Initially, a musculoskeletal lesion should be simply imaged with a plain film. It should be remembered that plain films remain the most reliable imaging method for assessment of both biological activity and probable histological diagnosis of an osseous lesion. </li></ul>
  5. 5. <ul><li>Signs of bone diseases in plain X-ray are; </li></ul>
  6. 6. <ul><li>1 -Decreased bone density </li></ul><ul><li>2 -Increased bone density (sclerosis). </li></ul><ul><li>3- Periosteal reaction </li></ul><ul><li>4 - Cortical thickening </li></ul><ul><li>5 - Alteration in the trabecular pattern </li></ul><ul><li>6- Alteration in the shape of a bone </li></ul><ul><li>7 -Altreration in bone age </li></ul>
  7. 7. <ul><li>Localize (lytic area or area of ‘ bone distruction’) </li></ul><ul><li>Generalize </li></ul>
  8. 8. Giant cell tumor
  9. 9. osteoporosis
  10. 10. <ul><li>2-increased bone density (sclerosis). </li></ul><ul><li>Focal </li></ul><ul><li>Generalized </li></ul>
  11. 11. Osteopetrosis
  12. 12. osteosarcoma
  13. 13. <ul><li>It refers to excessive bone produced by the periosteum, which occur in response to infection , trauma & tumors </li></ul>
  14. 14. <ul><li>Patterns of periosteal reaction; </li></ul>
  15. 15. 1- Linear
  16. 19. <ul><li>Also involve laying down of new bone by the periosteum,but the process is very slow & it has the same homogeneous density as does the normal cortex& there is no separate lines or specules of calcification as seen in a periosteal reaction </li></ul>
  17. 20. <ul><li>causes </li></ul><ul><li>1- chronic osteomylitis. </li></ul><ul><li>2-healed truama </li></ul><ul><li>3- response to chronic stress or benign tumor </li></ul>
  18. 21. Chronic osteomylitis
  19. 22. <ul><li>Usually involving a reduction in the no. of trabeculae with an alteration in the remaining trabeculae. </li></ul><ul><li>e.g in osteoporosis , there is reduction in the no. of the trabeculae & remaining trabiculae are more prominent than usual associated with thinning of the cortex. </li></ul><ul><li>in paget‘s disease , there is thickening of the trabeculae & associated with thickening of the cortex & bone expansion </li></ul>
  20. 23. Local osteoporosis Normal
  21. 24. Paget disease
  22. 25. <ul><li>Congenital </li></ul><ul><li>Acquired , e.g Acromegaly, expanding bone tumors </li></ul>
  23. 28. <ul><li>US can not demonstrate bone pathology but does have a complementary imaging role; </li></ul><ul><li>Dtecting tenosynovitis, tendon tear & rupture. </li></ul><ul><li>In diagnosis of ostiomyelitis </li></ul>
  24. 29. Technetium-99m lablled phosphate complexes
  25. 30. <ul><li>Dtection of metastasis. </li></ul><ul><li>Detection of oseomylitis . </li></ul><ul><li>Determination of whether a lesion in solitary or multiple. </li></ul><ul><li>Investigation of clinically suspected lesion when the Plain radiograph is –ve. </li></ul><ul><li>Investigation of radiographically equivocal cases whether is significant or not. </li></ul><ul><li>Investigation of pain full prosthesis . </li></ul>
  26. 32. <ul><li>Is only needed in selected cases. </li></ul><ul><li>Indications for bone CT are </li></ul><ul><li>Demonstrating abnormalities in the areas where plain films are frequently difficult to be interpretated for exam. Spine , hip &pelvis </li></ul><ul><li>As a guide for bone biopsy. </li></ul><ul><li>Demonstration of the extent &characterization of the bone tumor in selected cases to complement MRI </li></ul>
  27. 36. <ul><li>Play a vital important role in musculoskeletal disorders. </li></ul><ul><li>In can demonstrate bone marrow directly but calcified tissues & cortical bones produces no signal. </li></ul><ul><li>MRI particularly good for showing soft tissue abnormalities </li></ul>
  28. 37. <ul><li>Disc herniation & spinal cord or nerve root compression. </li></ul><ul><li>Dx of bone metastasis. </li></ul><ul><li>Extend of primary bone tumor. </li></ul><ul><li>To image soft tissue masses </li></ul><ul><li>To Dx osteomyelitis & shows any soft tissue abscess. </li></ul><ul><li>To Dx avascular necrosis & other joint pathologies </li></ul>
  29. 40. <ul><li>Bone disease can be devided in to; </li></ul><ul><li>1- focal : lytic , sclerotic or mixed </li></ul><ul><li>solitory </li></ul><ul><li>multiple </li></ul><ul><li>2- generalized ; where all the bones show diffuse increase or decease in bone density </li></ul><ul><li>3- alteration in the trabecular pattern or changes in the shape </li></ul>
  30. 41. <ul><li>Lytic </li></ul><ul><li>Sclerotic </li></ul><ul><li>Mixed </li></ul>
  31. 42. <ul><li>Radiological approach for diagnosis of solitary bone lesions </li></ul><ul><li>to decide whether the lesion is benign (i.e. stable or very slow growing) or whether the lesion is aggressive (malignant tumor or infection). </li></ul>
  32. 43. <ul><li>1. Age of the patient. </li></ul><ul><li>This can be an extremely important determinant in some lesions in which the age range of occurrence may be quite narrow. For example, </li></ul><ul><li>Malignant osseous lesions in patients under one year of age are usually metastatic neuroblastoma. </li></ul><ul><li>Malignant osseous lesions in the age range of 1 to 30 years are usually osteosarcoma or Ewing's sarcoma. </li></ul><ul><li>Malignant osseous lesions in the 30- to 60-years range most commonly will be either chondrosarcoma, primary lymphoma, or malignant fibrous histiocytoma, </li></ul><ul><li>Malignant lesions in the age range over 50 most commonly will be due to metastatic disease or multiple myeloma. </li></ul>
  33. 44. <ul><li>Three different types of locations should be noted: </li></ul><ul><li>1- the particular bone that is involved. ( long bone ,flat bone , small bones) </li></ul><ul><li>3- the location in a transverse axis. (central, eccentric, or a cortically-based epicenter). </li></ul><ul><li>3- the location in a longitudinal axis of a long bone. (epiphysis, metaphysis or diaphysis). </li></ul><ul><li>Certain lesion occur at the certain sites; </li></ul><ul><li>E.g. Osteomyelitis characteristically occur in the metaphyseal areas specially of the knee & lower tibia whereas giant cell tumor occur in subarticular areas </li></ul>
  34. 46. <ul><li>i.e. Zone of transition of the lesion from abnormal to normal bone; </li></ul><ul><li>A wide zone of transition denotes an aggressive lesion. </li></ul><ul><li>A narrow zone is a much less aggressive lesion. </li></ul><ul><li>well defined sclerotic edge is almost certainly benign. </li></ul>
  35. 47. <ul><li>Any destruction of the adjacent cortex indicates an aggressive lesion such as a malignant tumor or osteomyelitis </li></ul>
  36. 48. <ul><li>Bone expansion with an intact well formed cortex usually indicate a slow growing lesion such as an encondroma or fibrous dysplasia. </li></ul>
  37. 49. <ul><li>Presence of an active periosteal reaction in the absence of the trauma usually indicates an aggressive lesion </li></ul>
  38. 50. <ul><li>. Cortical breakthrough of a bone lesion to create a soft tissue mass generally suggest an aggressive lesion(infection or tumor) . </li></ul><ul><li>ill define soft tissue swelling adjacent to focal bone disruction lesion suggest infection . </li></ul><ul><li>well define soft tissue swelling adjacent to the bone lesion suggest neoplasm& such soft tissue masses will often distort but not obliterate nearby muscle planes. </li></ul>
  39. 51. <ul><li>Common terminology includes ; </li></ul><ul><li>&quot;geographic&quot; (well-defined or map-like lesion, the least aggressive pattern), </li></ul><ul><li>&quot;moth-eaten&quot; (holes, with less well-defined margins, appearing more aggressive) </li></ul><ul><li>&quot;permeative&quot; (a poorly demarcated pattern which is often very difficult to visualize and represents a highly aggressive lesion) </li></ul>
  40. 52. <ul><li>allow categorization of a lesion as bone producing versus cartilage producing. </li></ul><ul><li>Diffuse ill defined calcification within the lesion suggest osteoid lesion . </li></ul><ul><li>presence of a patchy calcification of popcorn or stippled type with density more than normal bone usually indicate cartilagenous tumor </li></ul>
  41. 53. <ul><li>Generally, a larger lesion (greater than 5 cm) is more likely to be malignant or aggressive, but there are many exceptions to this statement, and other determinants are generally more important than this one. </li></ul>
  42. 54. <ul><li>This is the last most important point , since polyostotic lesions automatically restrict the number of disease processes that might be considered. For example, </li></ul><ul><li>nonaggressive polyostotic lesions should be confined to; </li></ul><ul><li>fibrous dysplasia </li></ul><ul><li>Paget's disease </li></ul><ul><li>Histiocytosis </li></ul><ul><li>multiple exostosis </li></ul><ul><li>multiple enchondromatosis </li></ul><ul><li>Aggressive polyostotic lesions would be confined to </li></ul><ul><li>osseous metastases </li></ul><ul><li>multiple myeloma </li></ul><ul><li>primary bone tumor with osseous metastases, </li></ul><ul><li>multifocal osteomyelitis, aggressive histiocytosis, and multifocal vascular bone tumors. </li></ul>