The current presentation explains about the pathological and pathological investigation required for the skeletal disorders. The basic requirement for a good prognostic and diagnostic feature which helps in evaluation of any skeletal disorders.

1. Principles of Pathological
Investigation and imaging
techniques in Skeletal Disorder.
Presented By – Purvi Verma
M.P.T 1st Year

2. Contents
 Pathological Investigation
I. Introduction to Pathological Investigations
II. Needs of Pathological Investigations
III. Selection of Appropriate Pathological Investigations
IV. Commonly Used Pathological Investigations in Skeletal Disorders

3. Contents Contd...
 Imaging Techniques
I. Introduction to Imaging Techniques
II. Types of Imaging Techniques
III. ABCs Search Pattern for Radiologic Image Interpretation
IV. Diagnostic Association of Imaging Techniques
V. Limitations of Imaging Techniques
VI. Recent Updates in Imaging

4. Pathological Investigations

5. Introduction to Pathological Investigation
 Pathology is the knowledge of the principles and
effects of disease or injury over body.
 This can be achieved by examining different organs,
tissues, body fluids and others.
 These tests on different parts and fluids of the body
support to detection of the underlying cause and
further known about the nature and progression of the
disease.

6. Needs of Pathological Investigation
 Laboratory tests are generally requested in primary
care for the following reason:
1. Diagnosis – to include or exclude a pathology
2. Establishing a baseline prior to treatment initiation
3. Monitoring – therapeutic range of medicine, adverse
effect of treatment if any, response to treatment,
long term condition for disease control and associated
complication.
4. Targeted testing

7. Selection of Appropriate pathological
investigations
 Half of the errors occurs in the process of laboratory investigation
during test selection process.
 To reduce the likelihood of errors clinicians should be careful not to
request tests that are likely to cause confusion or false reassurance.
 Even if the tests are appropriate, it needs to be requested at the
right time for the patients, with right preparations wherever
necessary
 Decision for test selection may be influenced by many factors
including family or individual expectations, emerging evidence,
changing guidelines, clinical experiences and individual clinical,
social and cultural factors

8. Commonly Used Pathological Investigations in
Skeletal Disorders
1. Complete Blood Count
2. Erythrocyte Sedimentation Rate
3. Rheumatoid Factor
4. Anti cyclic Citrullinate peptide
5. Anti Nuclear Antibody
6. HLA-B27
7. C- Reactive Protein (CRP)
8. Serum Uric Acid Blood Test

9. Complete Blood Count
 The complete blood count is a group of tests that evaluate the cells
that circulate in blood, including red blood cells (RBCs), White
blood cells (WBCs) and Platelets.
 CBC can evaluate your overall health and detects a variety of
diseases and condition, such as infection, anaemia, leukaemia, etc.
 CBC includes – Red blood cell counts, haemoglobin level,
Haematocrit values ( Mean corpuscular volume (MCV), Mean
Corpuscular Haemoglobin (MCH), Mean Corpuscular haemoglobin
concentration (MCHC), Red cell distribution with (RDW),
White Blood cells (White blood cell counts and White blood cell
differential)
Platelets (Platelets count, Mean Platelet Volume and Platelet
distribution width)

11. Diagnostic Association
 Anaemia of Various etiologies
 Infection
 Inflammation
 Bone marrow disorders

12. Erythrocyte Sedimentation Rate (ESR)
 ESR is measurement of the distance in millimetres that
RCBs fall within the a specific tube (Westergreen or
Wintrobe) over 1 to 2 hours and the average of two hours
of fall is calculated.
 It is indirect measurement of alteration in acute phase
reaction ( A heterogenous group of proteins which are
synthesised in liver in response to inflammation)

13. Normal Ranges

14. Diagnostic Association
 Tuberculosis of Spine
 Systemic Lupus Erythematosus
 Polymyalgia Rheumatica
 Any Other Auto-immune disorders
 Arthritis

15. Rheumatoid Factor
 The rheumatoid factor is an antibody present in the blood of
many patients with rheumatoid arthritis. Doctors measure the
level of rheumatoid factor by performing a blood test.
 A positive rheumatoid factor test means that the level of
rheumatoid factor in the patient’s blood is considered to be high.
 Rheumatoid factor can be present in patients several months or
even years before clinical rheumatoid arthritis symptoms
develop. Depending on the level of symptoms a patient exhibits,
the rheumatoid factor test results can assist doctors in reaching
a rheumatoid arthritis diagnosis.

16.  Positive titre - >8mg/dL
 Positive test – Rheumatoid Arthritis
 False Positive in
i. Other auto immune disease
ii. Drugs – methyldopa, etc
iii. 1-4% of normal individuals, acute immune responses, chronic bacterial
infections
 False Negative – 20% of Rheumatoid Arthritis

17. Anti Cyclic Citrullinate Peptide
 Anti-CCP or Anti-Cyclic Citrullinated Peptide is an
autoantibody also known as ACPAs or anti-citrullinated
protein antibodies. These antibodies are produced by
the person’s immune system and identify the body’s
tissue cells as foreign bodies and attack them.
 Anti-CCP or ACPAs is a protein and is mostly found in the
joints of patients who are suffering from rheumatoid
arthritis. These antibodies can be present in the body of
a patient for years even before he has started to
develop the symptoms of rheumatoid arthritis.

18.  The Anti-CCP test is important for several reasons such as:
– It helps to detect the aggressiveness of the disease.
– A positive ACCP test is a clear indication that an otherwise
healthy person with no joint problems can develop
rheumatoid arthritis in the future.
– Anti-CCP test helps to detect erosive diseases which cause
the erosion of the bones which is a very severe condition.

19. Type Gender Range
Anti-CCP or ACCP Male and Female Less than 20 u/ml
Normal Ranges

20. Anti Nuclear Antibody
 Antinuclear antibodies (ANAs, also known as antinuclear
factor or ANF) are autoantibodies that bind to contents of the cell
nucleus. In normal individuals, the immune system produces
antibodies to foreign proteins (antigens) but not to human
proteins (autoantigens). In some cases, antibodies to human
antigens are produced.
 The ANA test detects the autoantibodies present in an
individual's blood serum. The common tests used for detecting
and quantifying ANAs are indirect
immunofluorescence and enzyme-linked immunosorbent
assay (ELISA).

21.  In immunofluorescence, the level of autoantibodies is reported as
a titre. This is the highest dilution of the serum at which
autoantibodies are still detectable.
 Positive autoantibody titre at a dilution equal to or greater than
1:160 are usually considered as clinically significant. Positive
titres of less than 1:160 are present in up to 20% of the healthy
population, especially the elderly. Although positive titres of
1:160 or higher are strongly associated with autoimmune
disorders, they are also found in 5% of healthy individuals

22. Diagnostic Association
 Polymyositis
 Dermatomyositis
 Polyarteritis Nodosa
 Rheumatoid Arthritis
 Connective Tissue Disorders

23. HLA-B27
 HLA-B27 is a blood test to look for a protein that is found on the
surface of white blood cells. The protein is called human leukocyte
antigen B27 (HLA-B27).
 Human leukocyte antigens (HLAs) are proteins that help the body's
immune system tell the difference between its own cells and foreign,
harmful substances. They are made from instructions by inherited
genes.

24.  Although most HLAs protect your body from harm, HLA-B27
is a specific type of protein that contributes to immune
system dysfunction.
 The presence of HLA-B27 on your white blood cells can
cause your immune system to attack those otherwise
healthy cells. When this occurs, it can result in
an autoimmune disease or immune-mediated disease, such
as juvenile rheumatoid arthritis or ankylosing spondylitis.

25. Diagnostic Association
 Ankylosing spondylitis
 Juvenile rheumatoid arthritis
 Reactive arthritis

26. C – Reactive Proteins
 C-reactive protein (CRP) is produced by the liver. The level of CRP rises
when there is inflammation throughout the body.
 It is one of a group of proteins, called acute phase reactants, that go
up in response to inflammation.
 The levels of acute phase reactants increase in response to certain
inflammatory proteins called cytokines. These proteins are produced
by white blood cells during inflammation.
 Normal Range - >5 mg/L

27. Diagnostic Association
 Inflammatory disease
 Rheumatoid Arthritis
 Systemic Lupus Erythematosus
 Vasculitis

28. Serum Uric Blood Test
 A uric acid blood test, also known as a serum uric acid measurement,
determines how much uric acid is present in your blood. The test can
help determine how well your body produces and removes uric acid.
 Uric acid is a chemical produced when your body breaks down foods
that contain organic compounds called purines.
 Most uric acid is dissolved in the blood, filtered through the kidneys, and
expelled in the urine. Sometimes the body produces too much uric acid
or doesn’t filter out enough of it.
 Hyperuricemia is the name of the disorder that occurs when you have
too much uric acid in your body.

29. Normal Ranges
 Normal level in Women – For Adults 2.5 to 6 mg/dL
 Normal level in Men – For Adults 3.4 to 7 mg/dL

30. Diagnostic Association
 Gout
 Hyperuricemia
 Liver or Kidney Disease
 Fanconi Syndrome

31. Imaging techniques

32. Introduction to Imaging Techniques
 Radiologic image interpretation requires foundations in
imaging technology, dimensional perceptions of anatomy,
characteristic patterns of pathology, and an organized
method of visually searching the image for abnormalities.
 In General, Imaging tests have high sensitivity (Few false
negatives), but low specificity (High False positive rate)

33. Types of imaging techniques
1. Plain Film Radiography
2. X-rays with contrast media
3. Plain Tomography
4. Computed Tomography
5. Magnetic Resonance Imaging
6. Diagnostic Ultrasound
7. Radionuclide Imaging
8. Single – Photon emission
computed tomography (SPECT)
9. Positron emission tomography
10. Bone mineral densitometry

34. ABCs Search Pattern for Radiologic
Image Interpretation

36. Plain Film Radiography
 Most useful method of Diagnostic Imaging.
 Provides Information on Size, shape, Tissue density and bone
architecture
 Xrays is the part of electromagnetic spectrum – ability to
penetrate body tissue of various size of varying densities.
 Exposure to the Xray particles causes the film to darken, while
on areas od absorptions, appear lighter on Xray film
 Structures in order of decreasing density
METAL > BONE > SOFT TISSUE > WATER (BODY FLUID) > FAT > AIR

37. Diagnostic Association
 Osteoarthritis – Narrowing of joint space + subchondral
sclerosis + cyst
 Inflammatory arthritis – narrowing of Joint space +
osteoporosis + periarticular erosions
 Infection/Malignancy – Bone destruction + periosteal new
bone formations
 Fractures and Dislocations and the related clinical signs

38. Limitations
 Exposure to ionizing radiation – radiation induced cancer.
 Provides poor soft tissue contrast.
 Does not provide 3d information.
 Bones block the diagnostic data as it absorbs the
radiation.

39. Routine Radiologic Examination Series

44. X-rays with Contrast Media
 Sinography – Simplest form of contrast radiography for sinuses
 Arthrography – Knee (Torn menisci, Ligament tears, Capsular
ruptures, AVN – Femoral head in adults – Torn Flaps of Cartilages
Spine – Diagnose disc degeneration (Discography)
 Myelography - an imaging examination that involves the
introduction of a spinal needle into the spinal canal and the
injection of contrast material in the space around the spinal cord
and nerve roots (the subarachnoid space) using a real-time form
of x-ray called fluoroscopy

45. Shoulder Arthrography Spinal Arthrography

46. Knee Arthrography Hip Arthrography

47. Sinography – for Cavernous sinus

48. Plain Tomography
 Images are provided as ‘ Focused ‘ in a selected plane.
 Useful in diagnosing segmental bone necrosis and
depressed fractures of cancellous bone.
 Conventional tomography has been replaced by CT scan
and MRI.

49. Computed Tomography
 CT Scan produces sectional images through selected tissue
plane – But with greater resolution.
 As compared to conventional tomography. Computed
tomography produces trans – axial images with greater
resolution (Transverse anatomical sections)
 In new multislice CT scanners, 3D Surface rendered
reconstruction and volume rendered reconstructions –
helps in demonstrating anatomical contours.

50. Diagnostic Association and Clinical
Applications
 Acute Trauma to head, spine, chest, abdomen and pelvis
 Fine bone detail and soft tissue calcification
 Pre – operative planning in secondary fracture
management
 Routine examination for vertebrae, acetabulum, tibial
plateau, ankle & foot injuries – Complex (Intraarticular
fractures) & Fractures, dislocations
 Bone tumours assessment (size and spread)

51. Limitations
 Atelectasis blends with tumour in approximately half of
the patients, thus obscuring tumour boundaries.
 CT numbers and contrast enhancement did not help to
differentiate between these two structures.

52. Magnetic Resonance Imaging
 Magnetic resonance image (MRI) is a cross-sectional
imaging technology that uses a magnetic field and
radiofrequency signals to cause hydrogen nuclei to emit
their own signals, which then are converted to images by
a computer.
 Provides absolute soft tissue contrast, distinguishing
different soft tissues eg. Ligaments, Tendons, Muscles and
Hyaline Cartilage.

53.  T1 and T2 weighted Imaging
 The difference between T1 and T2 can be summarized a
follows:
I. T1 imaging measures energy from structures such as fat, which
give up energy rapidly, early in the process of longitudinal
remagnetization. T1 imaging provides images of good anatomic
detail, displaying the tissues in a fairly balanced manner.
II. T2 imaging measures energy late in the decay of transverse
relaxation and selectively images structures that do not readily
give up energy, such as water. It is particularly valuable for
detecting inflammation

54. MRI of Knee – T1 weighted (left) T2 weighted
(Right) –suggestive of Necrotic centre in hind
lower end of femur with metastasis of lower end
of femur
MRI of Spine – T1 weighted (left) T2
weighted (right) Lumbar disc herniation
at L4-5 on sagittal section

55. Diagnostic Association and Clinical
Applications
 Non invasive imaging for musculoskeletal system – excellent
anatomical detail, soft tissue contrast and multiplanar capability.
 MRI of Hip, Knee, Ankle, Shoulder and Wrist – detects early changes of
bone marrow oedema and osteonecrosis.
 MRI of Knee – Meniscal tears and Cruciate ligament injuries.
 Fat suppression sequences – extend of perilesional oedema and IV
contrast – active part of tumour (it distinguish vascular from avascular
tissues).
 Direct MRI arthrography – distent joint capsule.
 Diagnosis of Labral Tears in shoulder and hip.
 Ankle – Assess integrity of capsule ligaments.

56. Limitations
 MRI is very expensive and time consuming investigation
compared to other methods such as x-ray and CT scan.
 Conventional Radiographs and CT are more sensitive to
Soft tissue Calcification and ossification as compared MRI

57. Diagnostic Ultrasound
 Ultrasound is a cross-sectional imaging method based on sound
waves reflected off tissue interfaces. Ultrasound predates CT
and MRI for soft tissue imaging. In the las 30 years it has been
increasingly employed in imaging of the musculoskeletal
system.
 Different tissue display varying echogenicity
 Fluid – Filled cyst – echo free
 Fat – highly echogenic
 Semi solid organs – Varying degree of echogenicity
 Real Time displays gives dynamic image – more useful than
static images.

58. Ultrasonography of Hamstring Muscle having micro tears

59. Diagnostic Association and Clinical
Applications
 Hidden Cystic lesions – Hematomas, abscess, popliteal
cysts and arterial aneurysms.
 Detect intra articular fluid, synovial effusions and Monitor
Irritable hip.
 Used to detect tendinitis and partial or complete tears.
 For guiding needle placement in diagnostic and
therapeutic joint and soft tissue injections.
 Screening new born babies for CDH, Cartilaginous femoral
head and acetabulum.

60. Limitations
 It has limited filed of view and limited penetration thus
potentially resulting in incomplete evaluation of bony and
joint anatomy.

61. 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 colours representations –
colour doppler.

62. 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 – metabolic uptake in target tissue
Radioisotopes tracer – emit photons for detection
 Radionuclide compound used are – Gallium -67 (inflammatory
cells -hidden infection)
 Indium – 111 – Labelled leucocytes (Distinguish sites of active
infection from chronic inflammation)

63. Radionuclide bone scan showing
markedly increased uptake affecting the
left femur.

64. Diagnostic Association and Clinical
Applications
 Diagnosis of Stress fracture / undisplaced fracture.
 Detection of small bone abscess or osteoid osteoma.
 Investigation of loosening or infection around prostheses.
 Diagnosis of femoral head ischemia in perthes’ disease or
avascular necrosis in adults.
 Early detection of bone metastasis.

65. Limitations
 Significant Radiation burden
 Image yielded make anatomic localization difficult.

66. Single – Photon Emission Computed
Tomography)
 SPECT – Bone scan – images are recorded and displayed in
all 3 orthogonal planes (Coronal, Sagittal and axial Plane).
 Single photon emission computed tomography (SPECT) is
especially useful in such an evaluation because it allows
for precise localization of a lesion to the vertebral body,
disc space, or vertebral arch.
 Vertebral diseases tend to conform to predictable
patterns that can be more readily identified by SPECT
than planar imaging.

67. SPECT/CT images (axial, sagittal, coronal) localizing intense, focal tracer uptake
to the right L3/L4 facet joint (continuous arrow). Note is made of mild tracer
uptake in the right L5/S1 facet joint (dashed arrow).

68. Positron Emission Tomography
 A positron emission tomography scan is an imaging test that can
help reveal the metabolic or biochemical function of your
tissues and organs.
 The pet scan uses a radioactive (drug tracer) to show both
normal and abnormal metabolic activity.
 A PET scan can often detect the abnormal metabolism of the
tracer in diseases before the disease shows up on other
imaging test, such as computerized tomography and magnetic
resonance imaging.
 Used in oncology to identify occult malignant tumour and
distinguish active residual tumour from inactive post surgical
scarring and necrotic tumour.

70. Bone Mineral Densitometry
 Bone densitometry, also called dual-energy x-ray
absorptiometry, DEXA or DXA, uses a very small dose of
ionizing radiation to produce pictures of the inside of the
body (usually the lower (or lumbar) spine and hips) to
measure bone loss.
 It is commonly used to diagnose osteoporosis, to assess an
individual's risk for developing osteoporotic fractures. DXA
is simple, quick and noninvasive. It's also the most
commonly used and the most standard method for
diagnosing osteoporosis.

72. THANKYOU