Msk Lecture2 1st Hospital

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Msk Lecture2 1st Hospital

  1. 1. Diagnostic Radiology of Musculoskeletal System Zhang Zhaohui Department of Radiology The First Affiliated Hospital of Sun Yat-sen University
  2. 2. Fracture
  3. 3. Definition: complete or incomplete break in the continuity of bone or cartilage Clinical presentation: traumatic history, local tenderness, swelling, functionally disorder, deformity Radiological appearance: fracture line General introduction of fracture
  4. 4. <ul><li>Classification </li></ul><ul><li>Complete versus incomplete </li></ul><ul><li>Complete fractures involves the entire circumference (tubular bone) or both cortical surfaces (flat bone) of a bone. It can be subdivided into several types, such as transverse, oblique, spiral fracture. In incomplete fracture , the break in the cortex does not extend completely through the bone. </li></ul><ul><li>Comminution fracture </li></ul><ul><li>Fracture with more than two fragments are comminution fracture. </li></ul>
  5. 5. Transverse fracture
  6. 6. Oblique fracture
  7. 7. Spiral fracture
  8. 8. Spiral fracture
  9. 9. Comminution fracture
  10. 10. Incomplete fracture The break in the cortex does not extend completely through the bone
  11. 11. <ul><li>Position </li></ul><ul><li>By convention, long bones are divided into thirds, and lesions are described as being in the proximal, middle, or distal third or at the junction of the proximal and middle or middle and distal third. </li></ul><ul><li>If a fracture is located near an articular cortex, it should be described as either intra- or extra-articular. </li></ul>
  12. 12. <ul><li>Apposition </li></ul><ul><li>The term apposition refers to the state of contact of the ends of the fracture fragments. Complete and normal apposition is termed anatomical apposition. </li></ul><ul><li>Displacement: If fracture fragments are in partial apposition, the term displacement is used. By convention, the distal fragment is said to be displaced in the designated direction with respect to the proximal fragment. </li></ul>
  13. 13. Fracture at the junction of the proximal and middle third of femora There is later displacement of distal fragment with respect to the proximal fragment.
  14. 14. <ul><li>Bayonet apposition refers to a fracture in which the fragment ends are not in contact with one another but the fragments overlap one another, leaving the shafts of the fragments in contact and causing loss of length of involved bone. </li></ul>
  15. 15. Fracture at the junction of the middle and distal third of tibia and fibula with bayonet apposition There is also anterior and later displacement of distal fragment with respect to the proximal fragment.
  16. 16. <ul><li>Distraction is complete lack of apposition, and most commonly secondary to either excessive traction or interposed tissue. In a non-acute fracture, the appearance of distraction may be due to resorption of the ends of the fragments. </li></ul>
  17. 17. Alignment Alignment refers to the relationship of the long axes of the fracture fragments. Loss of normal alignment is angulation. Direction of angulation may be correctly described in two ways. The least confusing description is the direction of angulation of the apex of the fracture site. Alternatively, angulation of the distal fragment with respect to the proximal one may be described. These two descriptions are exactly reversed in a given fracture. For example, a fracture of the femur pointing anteriorly would be described either as apex anterior angulation or as posterior angular displacement of the distal fragment. Either description is correct as long as it is clearly stated.
  18. 18. Fracture at the middle third of tibia and fibula with apex anterior angulation There is anterior displacement of the distal facture fragment of tibia with respect to the proximal fragment. The aposition of fracture fragments of fibula is normal.
  19. 19. Rotation Rotation of fracture fragments can be evaluated by comparison of the direction of the joints proximal and distal to the fracture. If this is not possible, malrotation can often be inferred from a radiograph if the anteroposterior and lateral diameters of a long bone are different and the fracture fragments do not appear congruent.
  20. 20. Healing of fracture Healing of fracture begins with the immediate hemorrhage in and around it. This is followed by ingrowth of granulation tissue, the formation of an osseous and sometimes cartilaginous matrix, decalcification and resorption of the devitalized bone in the opposing ends of the fragments, progressive calcification of the osseous and cartilaginous matrix (callus formation) and finally, shaping of the shaft at the junction of the fragments.
  21. 21. Formation of a small amount of calli around the fracture of clavicle Factors that have influence on the healing of fracture include age, fracture type, nutrition, treatment, etc. Callus usually cannot be detected earlier than the 3rd week after fracture in older children or adults but becomes visible during the 2nd week in the new born.
  22. 22. Formation of calli around the fracture at distal third of radius
  23. 23. Development of callus: more opaque, more clearly defined, and take a fusiform shape
  24. 24. Bony union of the fracture at proximal humerus Disappearance of fracture line, anatomical apposition, normal alignment, slight irregularity of humerus at the fracture site.
  25. 25. Complications of fractures include: un-union or delayed union; deformity of union; osteoporosis after trauma; infection of bone and joint; necrosis of bone; degeneration of joint; myositis ossificans, etc.
  26. 26. Un-union fracture The opposing ends of fracture fragments become thin with increased density
  27. 27. Deformity of union
  28. 28. Deformity of union with post-traumatic osteoporosis
  29. 29. Un-union of femoral neck fracture with necrosis of femoral head (collapse of femoral head with increased density)
  30. 30. Post fracture myositis ossificans Radiographs show high density ossifications in the soft tissue ()
  31. 31. Greenstick fracture An incomplete fracture in the developing tubular bone caused by bending stress. Greenstick fractures are characterized by angling or buckling of the cortex , and a lucent fracture line often invisible. Common fractures
  32. 32. Radiographs show angling (lateral view) and slight buckling (AP view) of the cortex of distal third of radius without a lucent fracture line. Green stick fracture
  33. 33. Epiphyseal separations Epiphysis and most of the cellular elements of the contiguous growth plate separate from the metaphysis. In an older child, it may create a metaphyseal fragment.
  34. 34. The lateral radiograph shows posterior displacement of epiphysis with no radiographically visible osseous fragments.
  35. 35. Epiphyseal separation of proximal phalange with a small metaphyseal osseous fragment
  36. 36. Epiphyseal separation of medial epicondyle of distal humerus Normal elbow joint
  37. 37. <ul><li>Colles fracture </li></ul><ul><li>Distal metaphysis of radius </li></ul><ul><li>Within 2cm of articular surface </li></ul><ul><li>Dorsal displacement & apex anterior angulation </li></ul><ul><li>Radial dispacement & shortening </li></ul><ul><li>Concomitant fracture of styloid process of ulna </li></ul><ul><li>Concomitant dislocation of distal radioulnar joint </li></ul>
  38. 38. Colles fracture
  39. 39. Colles fracture with concomitant fracture of styloid process of ulna and dislocation of distal radioulnar joint
  40. 40. <ul><li>Supracondylar fracture </li></ul><ul><li>A transverse metaphyseal fracture of the distal humerus </li></ul><ul><li>Commonest elbow fracture in childhood </li></ul><ul><li>Extension type: transcondylar fracture with posterior and proximal displacement and apex anterior angulation (95%) </li></ul><ul><li>Flexion type: anterior displacement and apex posterior angulation </li></ul><ul><li>Fat pad displacement indicating a joint effusion </li></ul>
  41. 41. Supracondylar fracture with posterior displacement of distal fragment and slight apex anterior angulation
  42. 42. Supracondylar fracture with minimal displacement
  43. 43. fat pad displacment
  44. 44. <ul><li>Compression fracture </li></ul><ul><ul><li>Wedge-shaped vertebral body with anterior part being compressed </li></ul></ul><ul><ul><li>Increased-density line instead of the fracture line </li></ul></ul><ul><ul><li>Adjacent vertebral discs intact </li></ul></ul><ul><ul><li>Stable lesion unless more than 30% compression </li></ul></ul>Vertebral Fracture
  45. 45. Compression fracture of C6 vertebral body
  46. 46. Compresion fracture of T12 vertebral body with kyphosis
  47. 47. <ul><li>Burst Fracture </li></ul><ul><ul><li>Caused by axial compression, which drives the vertebral disc into the vertebral body below it, causing it to shatter. </li></ul></ul><ul><ul><li>It is an unstable lesion. The prognosis depends upon the displacement of the posterior aspect of the vertebral body and whether the vertebral arches are intact. </li></ul></ul>Vertebral Fracture
  48. 48. <ul><li>CT is of considerable value in evaluating the posterior elements, classifying injuries, and determining the site for vertebral decompression. CT scanning is also able to identify small cortical breaks. </li></ul><ul><li>MR is valuable in detecting injury of spinal cord and ligament. </li></ul>Vertebral Fracture
  49. 49. Comminution fracture of vertebral body with posterior displacement of fracture fragments. Right posterior elements are also involved.
  50. 50. T 1 WI T 2 WI Fracture of L2 vertebral body with injury of adjacent spinal cord
  51. 51. Tumor and tumor like lesions
  52. 52. <ul><li>Definition </li></ul><ul><ul><li>Malignant tumor with ability to produce osteoid or immature bone directly from neoplastic cells </li></ul></ul><ul><li>Etiology </li></ul><ul><ul><li>Of unknown etiology = primary (majority ) </li></ul></ul><ul><ul><li>Secondary to predisposing factors (Paget disease, bone infarct, radiation) = secondary </li></ul></ul>Osteosarcoma
  53. 53. <ul><li>Demographics </li></ul><ul><ul><li>Age: second and third decades of life (children and adolescents) </li></ul></ul><ul><ul><li>Gender: M:F=2:1 </li></ul></ul><ul><li>Skeletal location </li></ul><ul><ul><li>Metaphysis of long tubular bone </li></ul></ul><ul><ul><li>Femur(40%), tibia(16%), and humerus(15%) </li></ul></ul>
  54. 54. <ul><li>Clinical presentation </li></ul><ul><ul><li>Soft tissue mass, pain, swelling, warmth, and restriction of motion </li></ul></ul><ul><ul><li>Pathological fracture </li></ul></ul><ul><ul><li>Increased serum alkaline phosphatase </li></ul></ul><ul><ul><li>Early metastasis: lungs , bones and other sites </li></ul></ul>
  55. 55. <ul><li>Radiographic findings </li></ul><ul><li>The pattern of osseous involvement depends to a large extent on the amount of immature bone produced by the tumor. A mixed pattern consisting of both osteolysis and osteosclerosis is most typical, with purely osteolytic or osteosclerotic lesions being encountered less frequently. </li></ul>
  56. 56. Radiograph shows a lesion with osteosclerosis and osteolysis. Note the Codman triangle( ). Osteosarcoma on the upper third of tibia (mixed pattern)
  57. 57. <ul><li>Radiographic findings </li></ul><ul><ul><li>Ill-defined intramedullary, metaphyseal lesion </li></ul></ul><ul><ul><li>Formation of immature bone by tumor </li></ul></ul><ul><ul><li>Bone destruction </li></ul></ul><ul><ul><li>Soft tissue mass </li></ul></ul><ul><ul><li>Aggressive periosteal reaction: </li></ul></ul><ul><ul><ul><li>Codman triangle </li></ul></ul></ul><ul><ul><ul><li>Sunburst pattern </li></ul></ul></ul>
  58. 58. Osteosarcoma on the lower third of femur (osteosclerotic pattern)
  59. 59. Radiograph shows ivory-like appearance. Osteosarcoma on the femur (osteosclerotic pattern)
  60. 60. Osteosarcoma of the femur (osteosclerotic pattern) with multiple pulmonary metastases
  61. 61. Osteosarcoma on the lower third of femur (osteolytic pattern) Radiograph shows bone destruction in the distal metaphysis and diaphysis of the femur, with soft tissue mass and Codman triangle( ).
  62. 62. Radiograph shows a lesion with both osteolysis and osteosclerosis on the upper metaphysis of tibia. Soft tissue mass ( ) is evident. Osteosarcoma on the upper metaphysis of tibia (mixed pattern)
  63. 63. <ul><li>Radiographic findings </li></ul><ul><li>Conventional radiograph is essential in establishing the specific diagnosis of osteosarcoma, but often cause underestimation of the extent of the tumor, both within and outside the bone. </li></ul>
  64. 64. <ul><li>Other imaging techniques </li></ul><ul><li>CT and MR imaging are more useful in defining the extent of tumor and its relationship to surrounding neurovascular structures and in evaluating the response of the tumor to therapy. </li></ul>
  65. 65. <ul><li>CT </li></ul><ul><ul><li>Intramedullary and soft tissue extent </li></ul></ul><ul><ul><li>Lesions in complex osseous structures such as pelvis, scapula, or spine </li></ul></ul><ul><li>Other imaging techniques </li></ul>
  66. 66. Osteosarcoma on the lower third of femur
  67. 67. <ul><li>MRI </li></ul><ul><ul><li>Signal: Low on T 1 WI and high on T 2 WI </li></ul></ul><ul><ul><li>Evident enhancement </li></ul></ul><ul><ul><li>Detecting skip lesions </li></ul></ul><ul><ul><li>Superior to CT in defining the intraosseous and extraosseous extent of the tumor </li></ul></ul><ul><li>Other imaging techniques </li></ul>
  68. 68. <ul><li>Skip lesions </li></ul><ul><ul><li>synchronous foci of tumor that are anatomically separate from the primary lesion and that occur within the same bone or on the other side of a joint </li></ul></ul>
  69. 69. T 1 WI T 1 WI T 2 WI +C Osteosarcoma on the upper third of tibia
  70. 70. Osteosarcoma with skip lesions
  71. 71. Pearls <ul><li>Producing osteoid or immature bone directly </li></ul><ul><li>Affects patients in their teens and twenties </li></ul><ul><li>Favors the metaphysis of long tubular bone </li></ul><ul><li>Plain film : essential for diagnosis </li></ul><ul><ul><li>Bone destruction, formation of immature bone </li></ul></ul><ul><ul><li>soft tissue mass, aggressive periosteal reaction </li></ul></ul><ul><li>Other modalities : determining extent of disease </li></ul>
  72. 73. <ul><li>Definitions </li></ul><ul><ul><li>Locally aggressive neoplasm composed of osteoclast like giant cells, usually involving the end of mature long bone </li></ul></ul><ul><li>Etiology : Unknown </li></ul><ul><li>Staging : Latent, Active, Aggressive </li></ul>Giant cell tumor of bone
  73. 74. <ul><li>Demographics </li></ul><ul><ul><ul><li>Age: 20~40 years </li></ul></ul></ul><ul><ul><ul><li>Gender: F: M=2:1 </li></ul></ul></ul><ul><li>Skeletal location </li></ul><ul><ul><ul><li>Ends of mature long bone </li></ul></ul></ul><ul><ul><ul><li>Knee joint and distal end of radius </li></ul></ul></ul>
  74. 75. <ul><li>Clinical presentation </li></ul><ul><ul><ul><li>Pain and swelling at affected area </li></ul></ul></ul><ul><ul><ul><li>Pathologic fracture in 30% </li></ul></ul></ul><ul><ul><ul><li>Limited range of motion of adjacent joint </li></ul></ul></ul><ul><ul><ul><li>Pulmonary metastases :1-2% </li></ul></ul></ul>
  75. 76. GCT of radius
  76. 77. <ul><li>Radiographic findings </li></ul><ul><ul><li>Expansile, lytic epiphyseal lesion extending to subchondral bone, with well-defined margins </li></ul></ul><ul><ul><li>Periosteal reaction and sclerotic rim: uncommon </li></ul></ul><ul><ul><li>Without calcification or ossification </li></ul></ul><ul><ul><li>Peripheral trabeculae — multi-locular appearance </li></ul></ul>
  77. 78. Radiographs show a well defined lytic lesion at upper end of tibia with pathological fracture ( ). There is no sclerosis, no periosteal reaction, and no calcification GCT of tibia
  78. 79. Pathological fracture Fracture occurring at a site of previous abnormality, often by means of a stress that would not normally cause fracture.
  79. 80. GCT of tibia
  80. 81. Radiographs show expansile and lytic lesion with cortical break through and formation of soft tissue mass ( ). GCT of radius
  81. 82. <ul><li>CT findings </li></ul><ul><ul><li>Soft tissue attenuation, foci of low attenuation </li></ul></ul><ul><ul><li>Breakthrough of cortex with soft tissue invasion </li></ul></ul><ul><li>MRI findings </li></ul><ul><ul><li>Low-intermediate signal intensity on T1WI and T2WI </li></ul></ul><ul><ul><li>Strong enhancement </li></ul></ul>
  82. 83. GCT of femur
  83. 84. T 1 WI T 2 WI T 1 WI T 2 WI + C GCT of tibia
  84. 85. Pearls <ul><li>Locally aggressive neoplasm </li></ul><ul><li>Favoring the ends of mature long bones </li></ul><ul><li>Occurring most frequently in 20-40 </li></ul><ul><li>Imaging findings : expansile, lytic epiphyseal lesion extending to subchondral bone, without calcification or ossification </li></ul>
  85. 86. Definition: Fluid containing lesion of bone, lined by mesenchymal cells Etiology: tumor like lesion of unknown etiology, attributed to local disturbance of bone growth Simple bone cyst
  86. 87. <ul><li>Location </li></ul><ul><ul><li>Metaphysis, migration to diaphysis with growth </li></ul></ul><ul><ul><li>Humerus and femur </li></ul></ul><ul><li>Demographics </li></ul><ul><ul><li>Age: children and adolescents </li></ul></ul><ul><ul><li>Gender: M:F=2-3:1 </li></ul></ul>
  87. 88. <ul><li>Clinical presentation </li></ul><ul><ul><li>Most lesions asymptomatic </li></ul></ul><ul><ul><li>Pain, swelling, stiffness at closed joint </li></ul></ul><ul><ul><li>66% of cysts present with pathologic fractures </li></ul></ul><ul><ul><li>Inactive, latent after skeletal maturity </li></ul></ul><ul><ul><li>Spontaneous regression in some cases </li></ul></ul>
  88. 89. Simple bone cyst at upper third of humerus with pathological fracture
  89. 90. <ul><li>Radiographic findings </li></ul><ul><li>Centrally located, well-defined, expansile, lytic lesion </li></ul><ul><li>Long axis parallel to that of host bone </li></ul><ul><li>No periosteal reaction unless fractured </li></ul><ul><li>No extension into soft tissues </li></ul><ul><li>Fallen fragment sign secondary to pathologic fracture </li></ul><ul><li>(a fragment of cortex falls into the fluid within the cavity of a bone cyst) </li></ul>
  90. 91. Simple bone cyst at upper third of humerus with pathological fracture
  91. 92. <ul><li>CT findings </li></ul><ul><ul><li>Fluid-filled cavity </li></ul></ul><ul><ul><li>No enhancement </li></ul></ul><ul><ul><li>Helpful in evaluating anatomic complex areas </li></ul></ul><ul><ul><li>Determination of extent </li></ul></ul>
  92. 93. Simple bone cyst at up third of femur
  93. 94. Bone cyst with fallen fragment sign
  94. 95. <ul><li>MRI findings </li></ul><ul><li>T1WI: low to intermediate signal intensity </li></ul><ul><li>T2WI: high signal intensity; </li></ul><ul><li>Heterogeneous signal in case of fracture </li></ul><ul><li>No enhancement </li></ul>
  95. 96. Simple bone cyst at up third of femur T 1 WI T 2 WI radiograph
  96. 97. Pearls <ul><li>Tumor like lesion of unknown etiology </li></ul><ul><li>Occurring in children and adolescents </li></ul><ul><li>Common location: metaphysis, migration to diaphysis with growth </li></ul><ul><li>Imaging findings : centrally located, well-defined, expansile, lytic lesion with long axis parallel to that of host bone </li></ul>
  97. 98. <ul><li>Spread of malignant tumors to osseous structures (usually through haematogenous dissemination ) </li></ul><ul><li>Primary lesions : carcinoma of breast, lung, prostate, thyroid, kidney, neuroblastoma etc </li></ul>Skeletal Metastasis
  98. 99. <ul><li>Age: middle-aged and elderly patients </li></ul><ul><li> children younger than 5 (neuroblastoma) </li></ul><ul><li>Skeletal location </li></ul><ul><ul><li>Spine, pelvis, ribs, skull, femur and humerus, etc </li></ul></ul><ul><ul><li>Involvement of bones distal to knee and elbow rare </li></ul></ul><ul><li>Clinical presentations : </li></ul><ul><ul><li>Pain, pathological fracture, etc. </li></ul></ul>
  99. 100. <ul><li>Radiographic findings </li></ul><ul><li>Osteolytic pattern: multiple poorly defined or well defined osteolytic bone destruction, perhaps with soft tissue mass or pathological fracture, usually without periosteal reaction; destruction of pedicle and vertebral body with intact intervertebral space. </li></ul>
  100. 101. Osteolytic metastasis M Radiograph shows osteolytic bone destruction at upper third of humerus, lateral end of clavicle with formation of soft tissue mass.
  101. 102. Multiple round bone destruction in the skull without sclerosis Osteolytic metastasis
  102. 103. Osteolytic destruction of left 5, 6 rib with formation of soft tissue mass Osteolytic metastasis
  103. 104. Osteolytic metastasis
  104. 105. <ul><li>Osteoblastic pattern: multiple round or patchy radiodense lesion, or diffuse increased density </li></ul><ul><li>Mixed pattern : osteolytic + osteoblastic </li></ul>
  105. 106. Radiograph shows multiple round or patchy radiodense lesion in the pelvis and lumbar spine. Osteoblastic metastasis
  106. 107. Radiograph shows diffuse increased density in pelvis, vertebral body of lumbar spine and upper third of bilateral femurs Osteoblastic metastasis
  107. 108. Diffuse increased density in vertebral body of L2, L4, L5 , sacrum and ilium. Osteoblastic metastasis
  108. 109. Mixed pattern of skeletal metastasis
  109. 110. Comparison of benign and malignant bone tumors Common, ill defined Uncommon, well defined if present soft tissue mass Various pattern, destruction by tumor Uncommon, secondary to pathologic fracture, without destruction by tumor Periosteal reaction Ill defined and infiltrative bone destruction, break through of cortex, immature bone produced by tumor Well defined bone destruction, thinning of cortex without interruption Osseous changes Rapid, invasion of adjacent tissue, metastasis Slow, compression and displacement of adjacent tissue, without metastasis Growth Malignant tumor Benign tumor Items
  110. 111. Thank you for your attention !

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