The document provides guidance on systematically reading musculoskeletal x-rays. It outlines key things to look for including alignment of bones, abnormalities in bones such as lucencies or sclerosis, cartilage, and soft tissues. Specific abnormalities are described such as fractures appearing as lucent lines, tumors appearing as focal lucencies, and diffuse processes causing diffuse lucency. Differential diagnoses for common abnormalities are also listed to aid in evaluation.

1. How to read
musculo-skeletal x rays
Dr.Mahesh kumar MS
Dept. of Orthopedics
General Hospital
Trivandrum
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2. Rule 1
Common
things -first
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3. When you see a black
bird in trivandrum
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4. Do not say it is a penguin
Say it is a crow
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5. Appearances can be deceptive-
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do not go by appearances

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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
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8. ABC’s of bone Radiology
Look for
 Alignment
 Bones
 Abnormal lucency
 Abnormal sclerosis
 Periosteal reaction
 Abnormal contour
 Cartilage
 Soft Tissue
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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).
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10. dislocation
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subluxation

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
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13. Lucent line
 A linear lucency is the classic
sign of a fracture. If a fracture
is displaced enough, it is easy
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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.
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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
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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
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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
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20. Age and lucent bone lesions
 1
 neuroblastoma
 1 - 10
 Ewing's of tubular bones
 10 - 30
 osteosarcoma, Ewing's 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
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21. geographic
Normal bone
Moth eaten
TYPES OF
LESIONS
permeative
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22. location
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23. Multiplicity
Differential Diagnosis of Multiple Lucent Bone Lesions
 Fibrous Dysplasia
 Metastasis / Myeloma
 Hyperparathyroidism (brown tumors) / Hemangioma
 Infection
 Eosinophilic Granuloma / Enchondroma
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24. Some tips
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25. a long lesion in a long bone,
think of
fibrous dysplasia.
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26.  Simple cyst,
 enchondroma,
 and fibrous dysplasia
can mimic each other and can be
hard to distinguish.
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27. Giant cell tumors
nearly always
occur near a joint surface.
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28. Lucent lesions of the sternum
should be considered
malignant
until proven otherwise
(Helms CA, 1983).
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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.
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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
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31. extensive
myelomatosis
rheumatoid arthritis
treated with steroids
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32. ?
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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
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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
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 Paget's disease

35. Bone impaction or rotation
 Although the classic
sign of a fracture is a
lucent line, some
fractures present
otherwise.
In cancellous
bones
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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.
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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).
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38. pagets
Bone island
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39. osteopoikilocytosis
melhorrostesis
osteoma
Bone island
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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
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42. Periosteum produces bone when stimulated
Type 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
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43. Solid Lamellar sunburst Codeman’s
triangle
Types of periosteal
reaction
Mixed type
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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

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46. Causes of Solid Periosteal
Reaction
 Osteomyelitis
 Benign neoplasms
osteoid osteoma
 Eosinophilic granuloma
 Hypertrophic
osteoarthropathy
 Deep venous thrombosis
(lower extremity)
 Trauma (healing fracture)
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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. Abnormal Contour, Size and Shape
 Focal
fracture
surgery
infection
tumor
 Diffuse
dysplasia
metabolic
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49. multiple hereditary exostoses,
Paget’s disease,
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Paget’s disease,

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.
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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.
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52.  Chondrocalcinosis
(arrows) is noted in
the hyaline articular
cartilage and menisci
of this patient with
calcium
pyrophosphate
deposition (CPPD)
disease
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53. Soft Tissue
When looking at the soft tissues, one can
occasionally see a variety of useful
findings on plain films, such as:
 swelling
 gas
 calcification
 mass
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56. small to large amorphous Ca++ in the
Dystrophic 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 spine
Metastatic calcification finely speckled Ca++ throughout soft
tissues
Tumoral calcinosis big globs of Ca++, usually near a
joint
Metastatic osteosarcoma amorphous, fluffy, confluent
collection of Ca++
Primary soft tissue amorphous, fluffy, confluent
collection of Ca++
osteosarcoma www.similima.com 56

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cysticercosis

60. scleroderma
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61. dermatomyositis
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62. Heterotrophic ossification
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63. ?
SLE
Metasataic
calcifications in
soft tissues
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chondrocalcinosis

65. Tumoral
calcinosis
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66. Calcific tendinitis
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68. Thank you
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