This document discusses various imaging modalities used in orthopaedics including plain film radiography, computed tomography, magnetic resonance imaging, ultrasound, bone scintigraphy, positron emission tomography, and bone densitometry. It provides details on the physics, clinical applications, advantages, and limitations of each technique. Recently developed imaging tools like fluoroscopy, contrast-enhanced ultrasound, elastography, and arthrography are also covered.
Avascular necrosis (AVN) of the femoral head is a pathologic process that results from interruption of blood supply to the bone. AVN of the hip is poorly understood, but this process is the final common pathway of traumatic or nontraumatic factors that compromise the already precarious circulation of the femoral head. Femoral head ischemia results in the death of marrow and osteocytes and usually results in the collapse of the necrotic segment
This video explains Lumbar Disc Replacement in Detail. When degenerative disc disease begins to affect the spine this is called degenerative disc disease. This video highlights the history, epidemiology, and treatment options both conservative and surgical. If you or someone you know needs to be seen in regards to Lumbar Disc Replacement feel free to look us up online www.beverlyspine.com or www.santamonicaspine.com OR call toll free 1-8SPINECAL-1
Rotator cuff tear is a very common orthopedic condition, which causes shoulder pain and stiffness. The slides are on rotator cuff tears and its management by open repair, mini open repair & by arthroscopy
Please find the power point on Fracture of Talus with well diagrammatic explanation from very reliable sources. If you need such a power point on different topics related with MBBS then please write it on comment section. Thank you
Second year PG Resident of I Q City Medical College and Hospital, Durgapur, West Bengal.
Covers the scope and use of Imaging technology in Orthopaedics.
Avascular necrosis (AVN) of the femoral head is a pathologic process that results from interruption of blood supply to the bone. AVN of the hip is poorly understood, but this process is the final common pathway of traumatic or nontraumatic factors that compromise the already precarious circulation of the femoral head. Femoral head ischemia results in the death of marrow and osteocytes and usually results in the collapse of the necrotic segment
This video explains Lumbar Disc Replacement in Detail. When degenerative disc disease begins to affect the spine this is called degenerative disc disease. This video highlights the history, epidemiology, and treatment options both conservative and surgical. If you or someone you know needs to be seen in regards to Lumbar Disc Replacement feel free to look us up online www.beverlyspine.com or www.santamonicaspine.com OR call toll free 1-8SPINECAL-1
Rotator cuff tear is a very common orthopedic condition, which causes shoulder pain and stiffness. The slides are on rotator cuff tears and its management by open repair, mini open repair & by arthroscopy
Please find the power point on Fracture of Talus with well diagrammatic explanation from very reliable sources. If you need such a power point on different topics related with MBBS then please write it on comment section. Thank you
Second year PG Resident of I Q City Medical College and Hospital, Durgapur, West Bengal.
Covers the scope and use of Imaging technology in Orthopaedics.
With the pandemic overclouding the whole world it has effected every strato of people including the Orthopaedic groups. This is to highlight the impact of COVID 19 on the orthopaedic in general.
Conservative management in 3 and 4 part proximal humerus fractureBipulBorthakur
Proximal humerus fracture is common in both young as well as elderly people with most of the elderly patients unable to undergo operative management. This study is to see the aspect of conservative management in proximal humerus fracture.
DISSERTATION on NEW DRUG DISCOVERY AND DEVELOPMENT STAGES OF DRUG DISCOVERYNEHA GUPTA
The process of drug discovery and development is a complex and multi-step endeavor aimed at bringing new pharmaceutical drugs to market. It begins with identifying and validating a biological target, such as a protein, gene, or RNA, that is associated with a disease. This step involves understanding the target's role in the disease and confirming that modulating it can have therapeutic effects. The next stage, hit identification, employs high-throughput screening (HTS) and other methods to find compounds that interact with the target. Computational techniques may also be used to identify potential hits from large compound libraries.
Following hit identification, the hits are optimized to improve their efficacy, selectivity, and pharmacokinetic properties, resulting in lead compounds. These leads undergo further refinement to enhance their potency, reduce toxicity, and improve drug-like characteristics, creating drug candidates suitable for preclinical testing. In the preclinical development phase, drug candidates are tested in vitro (in cell cultures) and in vivo (in animal models) to evaluate their safety, efficacy, pharmacokinetics, and pharmacodynamics. Toxicology studies are conducted to assess potential risks.
Before clinical trials can begin, an Investigational New Drug (IND) application must be submitted to regulatory authorities. This application includes data from preclinical studies and plans for clinical trials. Clinical development involves human trials in three phases: Phase I tests the drug's safety and dosage in a small group of healthy volunteers, Phase II assesses the drug's efficacy and side effects in a larger group of patients with the target disease, and Phase III confirms the drug's efficacy and monitors adverse reactions in a large population, often compared to existing treatments.
After successful clinical trials, a New Drug Application (NDA) is submitted to regulatory authorities for approval, including all data from preclinical and clinical studies, as well as proposed labeling and manufacturing information. Regulatory authorities then review the NDA to ensure the drug is safe, effective, and of high quality, potentially requiring additional studies. Finally, after a drug is approved and marketed, it undergoes post-marketing surveillance, which includes continuous monitoring for long-term safety and effectiveness, pharmacovigilance, and reporting of any adverse effects.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
2. INTRODUCTION
• The availability of diagnostic images to physical therapists
greatly depends on the practice setting
• The results from imaging studies should be used in conjuction
with other clinical findings
• In general , imaging tests have a high sensitivity ( few false
negatives ) , but low specificity ( high false positive rate )
3. IMAGING TECHNIQUES
• Plain film Radiography
• X – rays with contrast media
• Plain tomography
• Computed tomography ( CT )
• Magnetic resonance imaging ( MRI )
• Diagnostic Ultrasound
• Radionuclide imaging
• Single – photon emission computed tomography
( SPECT )
• Positron emission tomography ( PET )
• Bone mineral densitometry ( BMD )
4. PLAIN FILM RADIOGRAPHY
• First order & Most useful method of diagnostic imaging
• Provides information on size , shape , tissue density & bone
architecture
• Overview - Radiographic image
Radiographic interpretation
Diagnostic associations
Limitations
5. RADIOGRAPHIC IMAGE
• X- Rays :- part of elecro-magnetic spectrum - ability to penetrate
body tissues of varying densities
• Exposure to xray particles causes the film to darken , while on
areas of absorption , appear lighter on x-ray film
• Denser the tissue - lighter it appears on the film
• Structures in order of deceasing density
METAL > BONE > SOFT TISSUE > WATER ( BODY FLUID ) > FAT > AIR
BONE - Cancellous bone is less dense than cortical bone &
appear lighter than cortical bone
6. RADIOGRAPHIC INTERPRETATION
• Convenient sequence of examination is
Patient
Soft tissues
Bones
Joints
PATIENT - AGE - important criteria
< 10 yrs – ewing’s sarcoma
10 – 20 yrs - osteosarcoma
> 50 yrs – metastatic deposit
7. • SOFT TISSUES
1) GENERALIZED CHANGE - Muscle planes
Bulging - joint effusion ( hip ) / rheumatoid arthritis (
interphalangeal joint )
Displaced - tumours
Obliterated – infection
2) LOCALIZED CHANGE - in case of mass , soft tissue calcification ,
ossification , gas , radioopaque foreign body
8. BONES
Shape
Generalized change – bone density ( osteopenia/osteosclerosis)
abnormal trabeculations ( Paget’s disease )
sclerotic /lytic lesions ( diffuse metastatic infiltration)
Localized change - BENIGN TUMOURS – well defined , sclerotic
margin, smooth periosteal reaction
MALIGNANT TUMOUR - Ill defined areas , permeative
bone destruction & speculated periosteal reactions
9.
10.
11. JOINTS
JOINT SPACE
appears wider in children > adults
chondrocalcinosis ( lines of increased within radiographic
articular space )
SHAPE - narrowing / asymmetry of joint space
1) infection
2) inflammatory arthropathies
3) osteoarthritis
EROSIONS - Periarticular erosions - Rheumatoid arthritis , psoriasis
juxta articular erosions - Gout
12. DIAGNOSTIC ASSOCIATIONS
• Osteoarthritis -Narrowing of joint space+subchondral sclerosis +cyst
– Inflammatory arthritis -Narrowing of joint space + osteoporosis
+ periarticular erosions
– Infection / malignancy - Bone destruction + periosteal new bone
formation
13. • LIMITATIONS OF PLAIN RADIOGRAPHY
1) Exposure to ionizing radiation - radiation induced cancer
2) Provides poor soft tissue contrast
14. X RAYS WITH CONTRAST MEDIA
• SINOGRAPHY - simplest form of contrast radiography
• ARTHROGRAPHY -
knee – torn menisci , ligament tears , capsular ruptures
AVN ( femoral head ) in adults - torn flaps of cartilage
spine - diagnose disc degeneration ( DISCOGRAPHY )
small facet joints abnormalities ( FACETOGRAPHY )
MYELOGRAPHY - for diagnosing nerve root lesion
15.
16. PLAIN TOMOGRAPHY
• Provides image ‘ focussed ‘ on a selected plane
• Useful in diagnosing segmental bone necrosis & depressed
fractures in cancellous bone
• Conventional tomography has been supplanted by CT & MRI
17. COMPUTED TOMOGRAPHY ( CT )
• CT SCAN produces sectional images through selected tissue
planes - but with greater resolution
• As compared to conventional tomography , computed tomography
produces trans – axial images ( transverse anatomical sections )
• In new multislice CT scanners , 3D surface rendered
reconstructions & volume rendered reconstructions - help in
demonstrating anatomical contours
18. CLINICAL APPLICATIONS OF CT SCAN
• Since it provides excellent contrast resolution and spatial localization
it’s ideal for evaluating
Acute trauma to the head , spine , chest , abdomen & pelvis
• Better than MRI - fine bone detail & soft tissue calcification
• Invaluable tool in pre operative planning in secondary fracture
management
• Routinely used for vertebrae , acetabulum , tibial plataeu , ankle & foot
injuries - complex ( intraarticular fractures ) & fracture dislocations
• Assessment of bone tumours ( size & spread )
• Can be employed for guiding soft tissues & bone biopsy
19.
20. LIMITATIONS OF CT SCAN
• Provides relatively poor soft – tissue contrast
when compared with MRI
• Major diadvantage is - high radiation exposure
21. MAGNETIC RESONANCE IMAGING ( MRI )
• Provides superb soft tissue contrast , distinguishing
different soft tissues eg. Ligaments , tendons ,
muscle & hyaline cartilage
• Utilizes Non – Ionizing radiation
• Contraindicated in patients with pacemakers &
possible metallic foreign body
22. MRI PHYSICS
Patient’s body placed in a strong magnetic field
Body’s protons ( having + charge ) align themselves along
this
strong magnetic field
Spinning protons further excited by radiofrequency
pulses
spinning positive charges induce their own small
magnetic field , & also produce a signal as they relax
( slow down ) at different -
rates
23. • Proton density map is recorded from these signals and
plotted in x, y , z coordinates
• T1 weighted ( T1W) images - high spatial resolution & good
anatomical looking pictures
• T2 weighted ( T2W ) images - physiological characterstics of
tissue
• Proton density ( PD) images - balanced / intermediate – are
combination of T1 & T2 images
• Fat suppression sequences - assessing soft – tissues & bone
marrow
oedema
24. CONTRAST ENHANCED – MRI
• Enhancement by intravenous contrast – active blood supply &
leaky cell membrane
• INDIRECT ARTHROGRAPHY
Gadolinium compounds – Intravenous – secreted through joint
synovium - into joint effusion
No additional distension of the joint
• DIRECT ARTHROGRAPHY
Dilute gadolinium ( 1:2000 concentration ) solution directly
punctured into joints under image guidance
Distention of joint capsule occurs
25. CLINICAL APPILICATIONS OF MRI
• Ideal for non – invasive imaging of the musculoskeletal system - excellent
anatomical detail , soft tissue contrast & multiplanar capability
• MRI of hip , knee , ankle , shoulder & wrist is common - can detect early
changes of bone marrow oedema & osteonecrosis
• MRI Knee - for meniscal tears & cruciate ligament injuries
• Fat suppresion sequences – extent of perilesional oedema & IV contrast –
active part of the tumour ( it distinguish vascular from avascular tissues
• Direct MRI arthrography - distent joint capsule
diagnose labral tears in shoulder & hip
ankle – assess integrity of the capsular ligaments
26.
27. LIMITATIONS OF MRI
• Conventional radiographs & CT are more
sensitive to
SOFT TISSUE CALCIFICATION & OSSIFICATION
as compared
to MRI
28. DIAGNOSTIC ULTRASOUND
High frequency sound waves by TRANSDUCER
penetrate into soft tissues
some waves are reflected back - registered as electric signals
and display images on a screen
• Image produce , depend upon reflective surface & soft tissue interface
• Different tissues display varying echogenicity
Fluid –filled cyst - echo free
fat - highly echogenic
semi solid organs – varying degree of echogenicity
• REAL TIME display gives dynamic image – more useful than static image
29. ULTRASOUND(US)
Ultrasound probes used in musculoskeletal imaging: from left to right 14 Hz Hockey stick 14 Hz linear, 9
Hz linear, 6 Hz curvilinear, 18 Hz linear probe
US of the shoulder demonstrating a full-thickness tear of the supraspinatus tendon (a and b) with
fluid (*) within the subacromial subdeltoid bursa (c)
30. CLINICAL APPLICATIONS
• Identify hidden cystic lesions – haematomas ,
abcesses , popliteal cysts & arterial aneurysms
• Detect intra- articular fluid , synovial effusions &
monitor ‘ irritable hip ‘
• Use to detect tendinitis & partial or complete tears
• For guiding needle placement in diagnostic &
therapeutic joint & soft – tissue injections
• Screening of newborn babies for CDH , catilaginous
femoral head & acetabulum
31. DOPPLER ULTRASOUND
• Blood flow detected – principle of change in sound
frequency – material moving – towards or away
from USG transducer
• Abnormal increased blood flow – areas of
inflammation / aggressive tumours
• Different flow rates – different colour
representations – colour doppler
32. RADIONUCLIDE IMAGING
• Photon emission by radionuclide taken by specific
tissues – recorded by gamma camera - reflects
physiological activity of that tissue
• Radiopharmaceutical used – 2 components
chemical compound – metaboloic uptake in
target tissue
radioisotope tracer – emit photons for
detection
33. ISOTOPE BONE SCAN
• Bone imaging - technetium – 99 m – ideal isotope
short half life – 6 hrs
rapidly excreted in urine
• Technetium – labelled hydroxymethylene
diphosphonate ( 99mTc-HDP) given intravenously &
recorded at 2 stages
1) Early perfusion phase - isotope in blood stream –
reflecting local
blood flow difference
2) Delayed bone phase – 3 hrs later – isotope in bone
tissue
34.
35. • 4 types of abnormality seen
1) Increased activity in perfusion phase - inflammation , fracture ,
high
vascular tumour , regional sympathetic dystrophy
2) Decreased activity in perfusion phase – local vascular
insufficiency
3) Increased activity in the delayed bone phase – fracture , implant
loosening , infection , local tumour
4) Diminished activity in the bone phase - femoral head after
fracture in the femoral neck
36. CLINICAL APPLICATIONS
• Diagnosis of stress fracture /undisplaced fracture
• Detection of a small bone abcess or osteoid osteoma
• Investigation of loosening or infection around
prostheses
• Diagnosis of femoral head ischaemia in perthes’
disease or avascular necrosis in adults
• Early detection of bone metastasis
37. ADVANTAGE & DISADVANTAGE
• ADVANTAGE
whole body can be imaged for multiple sites of
pathology ( occult metastasis , multifocal infection )
provides physiological activity of examined tissues
• DISADVANTAGE
significant radiation burden
image yeilded make anatomic localization difficult
38. OTHER RADIONUCLIDE
COMPOUNDS
• GALLIUM - 67
concentrates in inflammatory cells – identify
hidden infection
• INDIUM – 111 – LABELLED LEUCOCYTES
distinguish sites of active infection from chronic
inflammation
39. SINGLE – PHOTON EMISSION
COMPUTED
TOMOGRAPHY ( SPECT )
• SPECT - bone scan – images are recorded &
displayed in all 3 orthogonal planes ( coronal ,
sagittal & axial plane )
spatial localization of pathology
40. POSITRON EMISSION TOMOGRAPHY
( PET )
• Positron – emitting isotopes - short half life – produced by cyclotron
• M/C used – 18 – fluro – 2 – deoxy – D – glucose ( 18 – FDG )
measures rate of consumption of glucose
• Malignant tumours metabolize glucose faster than benign tumours
• PET/CT – hybrid examination – superimpose the 2 image produced
• Use in ONCOLOGY to identify occult malignant tumours & distinguish
active residual tumour from inactive post – surgical scarring &
necrotic tumour .
41. BONE MINERAL DENSITOMETRY
• Bone mineral density measurement – widely used in
oseoporosis & increased risk of osteoporotic fractures
• Various techniques developed
RADIOGRAPHIC ABSORPTIOMETRY ( RA )
QUANTITATIVE COMPUTED TOMOGRAPHY ( QCT )
QUANTITATIVE ULTRASONOMETRY ( QUS )
DUAL ENERGY X- RAY ABSORPTIOMETRY ( DEXA ) – M/C
accepted
42. • RA - conventional radiographic equipment – bone density in
phalanges
• QCT – trabecular bone density in vertebral bodies
• QUS - measures bone mineral density in peripheral skeleton
( wrist & calcaneum )
• DEXA - columnated low – dose X ray beams to distinguish bone density from
soft tissue
• Advantage of DXA – develop huge international database – express bone mineral
density in comparison to age & sex matched population. (Z-score) and peak adult
bone mass (T score)
• According to WHO, T score <-1- osteopenia & T-score <-2.5 – osteoporosis.
45. FLUOROSCOPY
• Fluoroscopy is an imaging technique that uses a continuous or pulsed
X-ray beam to obtain real-time, dynamic images.
• This imaging technique is a useful diagnostic tool for radiologists and
is used to guide interventional procedures such as needle placement
in joint and spinal injections, vertebroplasty and arthrography.
• Fluoroscopy is also used by orthopedic surgeons to guide
intraoperative prosthetic placement and to assess fracture
reduction.
46. CONTRAST-ENHANCED
ULTRASOUND(CEUS)
– A contrast agent containing gas microbubbles is injected intravenously
and enhances the Doppler signal.
– CEUS is more sensitive than conventional ultrasound in identifying active
synovitis as a marker for disease activity in arthritis.
– It may also be used to characterize soft-tissue lesions and assess the
vascularity of repaired rotator cuff tendons.
47. Extended Field of View (EFOV) US:-
– This is a useful tool in musculoskeletal imaging which allows for a
panoramic, continuous image of a soft-tissue structure to be obtained.
Superb Microvascular Imaging:-
– This technique has been developed to detect perfusion of tiny vessels
with slow flow without the need for intravenous contrast.
– It may also be used to stage progression of tendinosis in sports medicine
and can be used to monitor healing in chronic injuries such as tendinitis.
– It is useful diagnostic tool in carpal tunnel syndrome by detecting low-
flow blood flow in the median nerve.
48. US image of a soft-tissue lesion with intra-
lesional vascularity
(a) An US-guided biopsy was performed
(b) with the arrows outlining the biopsy
needle passing through the lesion.
Histology confirmed a soft-tissue sarcoma
contrast-enhanced ultrasound for
detection of synovial vascularity in
experimental rheumatoid arthritis
50. SONOELASTOGRAPHY
• Noninvasive, qualitative assessment of soft-tissue elasticity and
stiffness.
• The use of sonoelastography to identify Achilles, patellar, and
common extensor tendinopathy of the elbow have been
encouraging.
• Limitations include its reliance on skilled, repetitive manual
compression to obtain high-quality images.
.
51. SHEAR WAVE ELASTOGRAPHY
(SWE)
• SWE provides a quantitative assessment of tissue elasticity.
• This technique involves the transfer of an acoustic pulse from the
ultrasound probe into the target tissue.
• This produces a shear wave which extends laterally in the insonated
tissue.
• This technique has shown promise in assessing tendon , muscle, and
nerve disorders
52. ARTHROGRAPHY
• Arthrography is the introduction of a contrast agent (iodine or gadolinium)
into a joint space.
• This is performed under fluoroscopic guidance, which ensures correct
needle placement and intra-articular injection of contrast.
• It is in combination with CT or MRI allows for optimal visualization of the
internal joint structures.
• Dynamic assessment of joints following injection of contrast can also be
performed under fluoroscopic guidance.
53. IMAGING MODALITIES
• Fluoroscopy: AP fluoroscopic
views of the lumbar spine
during a vertebroplasty with
needles in situ (a) and
following introduction of
cement (b)
• AP Arthrogram of the
glenohumeral joint with
contrast in situ which was
introduced via a 22G needle
54. DUAL-ENERGY CT (DECT)
• DECT allows for the contemporaneous acquisition of images using two
different X-ray energies, and therefore showing different tissue
contrasts.
• DECT has a number of advantages over conventional CT;
– DECT can reduce artifact,
– Aid in image optimization, and
– Provide additional information on tissue composition.
56. CONE BEAM CT(CBCT)
• CBCT allows for high spatial resolution assessment of bony architecture
at a lower radiation dose than conventional CT.
• CBCT can be combined with arthrography which allows for detailed
assessment of the articular cartilage, identification of intra-articular
loose bodies and synovial tumors/PVNS, and evaluation of
osteochondral defects.
• Limitations :-
– Small field of view
– Limited soft-tissue assessment.
57. CT- ARTHROGRAPHY
• CT arthrography involves the intra-articular injection of
iodine contrast under fluoroscopic guidance followed by a
CT of the region of interest.
• It can be used to assess the meniscus for a tear following
meniscal repair and has been shown to be superior to MR
arthrography in assessing the cartilage in the hip.
58. CT arthrogram of the knee showing tear of the anterior cruciate ligament (ACL) graft and trochlear cartilage erosion.
CT arthrogram of the knee showing a meniscal tear.
59. CT-GUIDED INTERVENTION
• CT is commonly used in the musculoskeletal setting to guide needle
placement in minimally invasive procedures such as steroid and
botulinum toxin injections, vertebroplasty, sacroplasty , and bone
biopsies.
60. CHEMICAL SHIFT IMAGING (CSI):
• It is used to differentiate between benign and malignant tumors
based on the premise that a lesion containing fat is highly suggestive
of a benign lesion.
• USES:-
– Benign fat-containing lesion can be differentiated from a malignant
lesion
– Benign pathological fractures may be differentiated from malignant
pathological fractures.
61. 45-year-old man, a known case of bronchogenic carcinoma, presented with back pain after
falling from height. Conventional and chemical shift MRI sequences revealed
benign vertebral compression confirmed with 6 month follow up negative MRI
study for marrow infiltration. Conventional MRI (A) sagittal T1-weighted spin-
echo (B) sagittal T2-weighted spin-echo and (C) sagittal STIR shows D12 vertebral
body compression with mild convex retropulsion and mild bone marrow edema.
Chemical shift MRI (D) in/phase (E) out/phase gradient-echo MR images show a
marked signal dropout of the compressed (arrows) as well as normal vertebral
marrow on out-of-phase image compared with in-phase
62. DIFFUSION PERFUSION IMAGING
• Used to evaluate
musculoskeletal tumors by
monitoring the early
enhancement of a tumor and
displaying the enhancement
pattern as a time-intensity
curve.
• Used to assess epiphyseal
perfusion and to exclude
avascular necrosis in the setting
of slipped upper femoral
epiphysis.
63. MR NEUROGRAPHY(MRN)
• Also known as MRI of peripheral
nerves.
• MRN can directly assess nerve
pathologies by detecting
abnormalities in nerve contour and
signal or indirectly by signs of
muscle denervation.
• It can be used to identify non-
discogenic sources of sciatica such
as distal nerve entrapment,
piriformis syndrome, ischial tunnel
syndrome, and nerve compression
from tumor.
High-Resolution MR Neurography of
the Brachial Plexus and Its Branches,
with Emphasis on 3D Imaging
64. Whole-Body MRI (WB MRI):
• WB MRI is used in the screening and staging of
hematological cancers such as multiple myeloma and
lymphoma.
• Also used to detect skeletal metastases in cancer staging.
• Also used to evaluate systemic arthritis such as
ankylosing spondylitis and psoriatic arthritis.
MR Arthrography (MRA):
• Fluoroscopic guided injection of gadolinium contrast prior to MRI
allows for joint distension and improved visualization of the internal
structures of the imaged joint.
• It is used in the assessment of labral injuries of the shoulder and the
hip.
65. Whole-Body MRI (WB
MRI):
• Staging WB MRI T1 (a) and STIR (b)coronal images
demonstrating multifocal Ewing’s sarcoma with lesions in
the bilateral femora and in the right humerus.
MR Arthrography
(MRA):
• MR arthrogram of the shoulder demonstrating a normal
labrum and intact glenohumeral articular cartilage
66. BONE SCINTIGRAPHY
• Bone scintigraphy is the most commonly performed SPE NM study in the
musculoskeletal setting.
• It uses technetium-99m labelled methylene diphosphonate (99mTcMDP) which
accumulates at sites of high bone turnover (osteoblastic activity).
• Clinical indications for bone scintigraphy :-
1. Identification of osteoblastic bone lesions/metastases,
2. Radiographically occult fractures,
3. Acute osteomyelitis,
4. Reflex sympathetic dystrophy,
5. Metabolic bone disease (for example, Paget’s disease), and
6. Evaluation of joint prostheses for infection or loosening.
67. NUCLEAR MEDICINE
White-Cell Scan:-
– Isotope-labelled white-cell scans can be performed using indium-
111 (111In) to assess for bone infection.
Single-Photon Emission Computed Tomography CT (SPECT-CT):-
– This technique is more accurate at identifying bone metastases than
standard bone scintigraphy or SPECT and decreases the number of
equivocal lesions by improving anatomic localization of uptake.
68. NUCLEAR MEDICINE
PET-CT:-
• PET-CT is a key imaging tool in the staging and treatment response monitoring
of oncology patients.
• It is most commonly used in the staging of non-sarcomatous malignancies and
lymphoma.
• It is also indicated for use in the initial staging of bone and soft-tissue
sarcomas and assessment of response to treatment.
69. PET-CT
• Non-oncological musculoskeletal
applications are
– Identifying sites of suspected
osteomyelitis in patients with
pyrexia of unknown origin,
– Evaluating knee and hip
prostheses for infection, and
– Differentiating insufficiency
fractures from pathological
fractures.
Coronal PET-CT image (a) demonstrating increased
uptake in the left tonsil in keeping with the patient’s
known tonsillar carcinoma. A focal area of increased
uptake was also noted at the inferior aspect of the
left glenoid rim (b). A biopsy was performed which
confirmed focal pigmented villonodular synovitis
(PVNS)
70. NUCLEAR MEDICINE(NM)
PET-MR:
– It is used in the staging of primary malignant bone soft-tissue
tumors due to its excellent soft-tissue resolution and reduced
ionizing radiation compared to PET-CT.