Msk Lecture3 1st Hospital

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Msk Lecture3 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. Infectious diseases of bone
  3. 3. <ul><li>Etiology </li></ul><ul><ul><li>Infecting organism: Staphylococcus aureus </li></ul></ul><ul><ul><li>RouteS of contamination </li></ul></ul><ul><ul><ul><li>Hematogenous seeding </li></ul></ul></ul><ul><ul><ul><li>Direct contamination </li></ul></ul></ul><ul><ul><ul><li>penetrating trauma, post surgical </li></ul></ul></ul><ul><ul><ul><li>Contiguous spread </li></ul></ul></ul><ul><ul><ul><li>soft tissue infection, septic arthritis </li></ul></ul></ul>Acute Pyogenic osteomyelitis
  4. 4. <ul><li>Location </li></ul><ul><ul><li>Metaphysis </li></ul></ul><ul><li>Age: </li></ul><ul><ul><li>Children most commonly affected </li></ul></ul><ul><li>Clinical presentation </li></ul><ul><ul><li>Pain, fever </li></ul></ul><ul><ul><li>Restricted motion + point tenderness </li></ul></ul><ul><ul><li>Soft tissue swelling + erythema + sinus tract </li></ul></ul><ul><ul><li>Prognosis good if treated early </li></ul></ul><ul><ul><li>Osseous destruction will reoccur if untreated </li></ul></ul><ul><ul><li>Develop into chronic infection </li></ul></ul>
  5. 5. <ul><li>Radiographic findings </li></ul><ul><ul><li>Soft tissue swelling </li></ul></ul><ul><ul><li>Bone changes delayed 10-14 days after onset of fever </li></ul></ul><ul><ul><li>Focal lucency to frank destruction of bone </li></ul></ul><ul><ul><li>Periosteal new bone formation </li></ul></ul><ul><ul><li>Sequestrum </li></ul></ul><ul><ul><li>Osteosclerosis </li></ul></ul>
  6. 6. Soft tissue swelling without visibe bone destruction with increase in diameter Focal bone destruction 1 2
  7. 7. 第 5 次 3 Bone destruction and osteosclerosis Osteosclerosis, without soft tissue swelling 5 4
  8. 8. Acute osteomyelitis Bone destruction sequestrum ( ) periosteal new bone formation ( )
  9. 9. Acute osteomyelitis of tibia Extensive bone destruction involving whole tibia with different degree of sclerosis
  10. 10. Acute osteomyelitis of radius Radiograph shows bone destruction and laminated periosteal new bone formation.
  11. 11. Radiograph shows moth eaten bone destruction at distal metaphysis of tibia. Acute osteomyelitis of tibia
  12. 12. Acute osteomyelitis of tibia
  13. 13. Acute osteomyelitis of tibia T 1 WI T 2 WI T 1 WI +C
  14. 14. <ul><li>Clinical presentation </li></ul><ul><ul><li>Mild fever </li></ul></ul><ul><ul><li>Focal pain </li></ul></ul><ul><ul><li>Sinus tract discharging pus due to the existence of pus cavity or sequestrum </li></ul></ul>Chronic pyogenic osteomyelitis
  15. 15. <ul><li>Radiographic findings </li></ul><ul><li>Bone destruction with surrounding sclerosis </li></ul><ul><li>Periosteal new bone formation </li></ul><ul><li>Thickening of cortex and deformation of bone </li></ul><ul><li>Sequestrum </li></ul><ul><li>Soft tissue atrophy , formation of sinus tract </li></ul>
  16. 16. Radiographs show sclerosis, widening and deformation of tibia with narrowing of medullary cavity. Chronic osteomyelitis of tibia
  17. 17. Chronic osteomyelitis of humerus
  18. 18. Chronic osteomyelits of fibula with sequestrum
  19. 19. Chronic osteomyelits of radius with sequestrum
  20. 20. <ul><li>Brodie’s abscess </li></ul><ul><li>Result of a long-standing osteomyelitis </li></ul><ul><li>Often situated in the metaphysis </li></ul><ul><li>Well defined cyst-like bone destruction with pronounced surrounding sclerosis </li></ul><ul><li>Sequestrum usually absent </li></ul>
  21. 21. Brodie’s abscess Round bone destruction ( )with extensive sclerosis in the lower third of tibia.
  22. 22. Brodie’s abscess of tibia
  23. 23. Brodie’s abscess of femur
  24. 24. <ul><li>Etiology </li></ul><ul><ul><li>Mycobacterium tuberculosis </li></ul></ul><ul><ul><li>Hematogenous dissemination of pulmonary TB </li></ul></ul><ul><li>Location </li></ul><ul><ul><li>Long bone </li></ul></ul><ul><ul><li>Short bone </li></ul></ul><ul><ul><li>Spine </li></ul></ul><ul><li>Clinical presentation </li></ul><ul><ul><li>Depend on the stage and location of the disease </li></ul></ul><ul><ul><li>Acute symptoms rare </li></ul></ul><ul><ul><li>Swelling, pain, weakness, draining sinus </li></ul></ul>Tuberculosis of bone
  25. 25. Tuberculosis of femur Well defined bone destruction at distal metaphysis of femur with a small sequestrum. There is no sclerosis and no periosteal new bone formation
  26. 26. <ul><ul><li>Location: metaphysis and/or epiphysis </li></ul></ul><ul><ul><li>Well defined focal area of osteolysis </li></ul></ul><ul><ul><li>With little or no surrounding sclerosis </li></ul></ul><ul><ul><li>Periosteal new bone formation uncommon </li></ul></ul><ul><ul><li>Sequestra : tiny irregular particles </li></ul></ul><ul><ul><li>Osteoprosis </li></ul></ul>Tuberculosis of long bone
  27. 27. Tuberculosis of fibula Well defined bone destruction at proximal metaphysis of right fibula with slight marginal sclerosis. There is no periosteal new bone formation
  28. 28. Tuberculosis of metaphysis and epiphysis of proximal tibia
  29. 29. Tuberculosis of epiphysis of distal fibula with invasion of joint
  30. 30. Comparison of pyogenic osteomyelitis and tuberculosis of long bone Uncommon, small Common, large Sequestrum Uncommon Common, various pattern Periosteal reaction Destruction and osteoprosis, sclerosis uncommon Destruction and sclerosis Osseous changes Common Uncommon Involvement of epiphysis Focal, may invade joint, seldom extend to diaphysis Extensive, may involve whole diaphysis Extent Slow Acute and rapid Progression Tuberculosis Pyogenic osteomyelitis
  31. 31. <ul><li>Tuberculosis of short bone </li></ul><ul><ul><li>Children younger than 5 years </li></ul></ul><ul><ul><li>Expansile bone destruction of diaphysis </li></ul></ul><ul><ul><li>Thinning of cortex </li></ul></ul><ul><ul><li>Periosteal reaction </li></ul></ul><ul><ul><li>Maybe multiple </li></ul></ul>
  32. 32. Expansile bone destruction of first metatarsal bone with thinning of cortex
  33. 33. Expansile bone destruction of first metacarpal bone with periosteal new bone formation
  34. 34. <ul><li>Tuberculosis of Spine </li></ul><ul><ul><li>Involvement of vertebral body more common than posterior appendages </li></ul></ul><ul><ul><li>Bone destruction </li></ul></ul><ul><ul><li>Collapse and deformity of vertebral body </li></ul></ul><ul><ul><li>Scoliosis, kyphosis </li></ul></ul><ul><ul><li>Narrowing or disappearance of intervetebral space </li></ul></ul><ul><ul><li>Paravertebral abscess, calcification </li></ul></ul>
  35. 35. Tuberculosis of cervical spine Destruction and collapse of C6 vertebral body and narrowing of C6/7 intervertebral space
  36. 36. Destruction , collapse and fusion of C4, 5 vertebral body , disappearance of C4/5 intervertebral space and kyphosis.
  37. 37. Destruction , collapse and fusion of T8,9 vertebral body , disappearance of T8/9 intervertebral space and formation of paravertebral abscess ( ). Soft tissue abnormality
  38. 38. Tuberbulosis of L2, 3 L1
  39. 39. Destruction of vertebral body with paravertebral abscess and calcifications
  40. 40. Tuberculosis of spine with paravertebral abscess T1 before inject contrast T2 before inject C T1 after C inject
  41. 42. Imaging of Joint
  42. 43. <ul><li>Normal x-ray appearance of elbow joint </li></ul>Joint capsule synovium Articular cartilage Joint space Bone end Normal X-ray appearance of joints <ul><li>The articular cartilages, synovium, synovial fluid and joint capsule are undifferentiated from other soft tissues in a radiogram because of similar densities. </li></ul><ul><li>The thickness of the cartilages may be indicated by the width of the joint space. </li></ul>
  43. 44. Elbow joint of adolescent Elbow joint of adult Elbow joint of child <ul><li>Joint space of children is wider than that of adults because of incompletely ossified epiphyseal cartilage. </li></ul>
  44. 45. <ul><li>Fat plane may outline the contour of joint capsule. </li></ul>
  45. 46. <ul><li>1. Swelling of joint </li></ul>Basic X-ray features of joint diseases <ul><li>Etiology: effusion of joint or congestion, edema, hemorrhage or inflammation of joint capsule and the adjacent soft tissue. </li></ul><ul><li>Radiological appearance: increased density, widening of joint space and displacement of fat pad. </li></ul>
  46. 47. Osteoporosis and swelling of knee joint
  47. 48. A: Normal knee joint B: Swelling of knee joint. Note the increased density and widened space between distal femur and patella. A B
  48. 49. Fat pad displacment Like chinese character 八 Supracondylar fracture
  49. 50. T 1 WI +C T 2 WI Effusion of knee joint with thickened synovium +C T 1 WI T1
  50. 51. <ul><li>2. Dislocation of joint </li></ul><ul><li>Dislocation is a complete loss of contact between two bone surfaces in a joint that normally articulate. This abnormality is severe than a subluxation, in which loss of contact is partial. </li></ul><ul><li>Usually the joint capsule and ligaments tear when a joint becomes dislocated, and often the nerves are injured as well. </li></ul><ul><li>Traumatic, pathologic, recurrent and congenital dislocations constitute the variety of dislocation. </li></ul>
  51. 52. Inferior dislocation of shoulder joint The humeral head is inferior to glenoid fossa.
  52. 53. Posterior and lateral displacement of the radius and ulna with respect to humerus
  53. 54. Congenital hip dislocation Radiograph of pelvis demonstrates an superiorly dislocated femoral head as well as the shallow acetabulum on the right side.
  54. 55. Subluxation of knee joint Radiograhs show destruction of osteo-articular surface and subluxation of knee joint with narrowed but visible joint space
  55. 56. 3.Destruction of joint <ul><li>Definition: the invasion and replacement of articular cartilage and subchondral bone by pathological tissue </li></ul><ul><li>Radiological appearance: narrowing of joint space , destruction of bone in affected areas, subluxation and deformity of joint. </li></ul><ul><li>Etiology: pyogenic, tuberculous, rheumatoid arthritis, etc </li></ul>
  56. 57. Narrowing of joint space and destruction of osteo-articular surface Pyogenic arthritis of left hip joint
  57. 58. Narrowing of left hip joint space, destruction of bone and subluxation of joint
  58. 59. <ul><li>Pathologic alterations in articulations result from degeneration. Cartilage and bone are the primary sites of abnormality, with only mild alterations occurring in the synovial membrane. </li></ul><ul><li>Radiological appearance: joint space narrowing, subchondral sclerosis/eburnation, subchondral cyst lucencies and osteophyte formation; subluxation, fibrous ankylosis, and intra-articular loose bodies. </li></ul>4. Degeneration of Joint (osteoarthritis)
  59. 60. joint space narrowing, subchondral sclerosis, and osteophyte formation (an outgrowth or excrescence of a bone) Osteoarthritis of knee joint
  60. 61. Osteoarthritis of hip joint Radiograph of pelvis shows joint space narrowing, subchondral sclerosis, osteophyte and lucency of subchondral cyst ( )
  61. 62. <ul><li>Subchondral cyst </li></ul><ul><li>Located in subchondral region of a joint </li></ul><ul><li>Tend to occur in weight bearing areas </li></ul><ul><li>A radiolucent area with sclerotic margin </li></ul><ul><li>Pathogenesis </li></ul><ul><ul><li>Microfractures in subchonadral bone </li></ul></ul><ul><ul><li>Increased synovial fluid pressure </li></ul></ul>
  62. 63. Intra-articular body within knee joint
  63. 64. <ul><li>Intra-articular bodies </li></ul><ul><li>Fragments of bone or cartilage (or of a combination of these) that may occur free in the joint cavity. </li></ul><ul><li>May arise from transchondral fractures, disintegration of the articular surface, synovial metaplasia and osteoarthritis. </li></ul><ul><li>Routine radiographs can reveal calcified and ossified bodies within joints, but arthrography and MR imaging can display uncalcified cartilage bodies </li></ul>
  64. 65. Intra-articular body within right hip joint
  65. 66. <ul><li>5. Ankylosis of Joint </li></ul><ul><li>Two types: bony ankylosis and fibrous ankylosis </li></ul><ul><li>Bony ankylosis </li></ul><ul><li>Bones of the joint fuse after proliferation of bone cells, resulting in complete immobility , usually occurs in pyogenic arthritis, ankylosing spondylitis, etc. Radiologically, it appears as bony trabeculae traversing the joint space, which is narrowed or disappear. </li></ul>
  66. 67. Bony ankylosis of elbow joint Radiographs show union of bones in elbow joint and disappearance of joint space.
  67. 68. Bony ankylosis of hip joint
  68. 69. <ul><li>5. Ankylosis of Joint </li></ul><ul><li>Fibrous ankylosis </li></ul><ul><li>Proliferation of fibrous tissue results in partial joint immobility, usually occurs in tuberculous arthritis . The joint space is narrowed or diminished, but still visible. The diagnosis of fibrous ankylosis can only be made clinically. </li></ul>
  69. 70. Fibrous ankylosis of knee joint Radiograhs show destruction of osteo-articular surface and subluxation of knee joint with narrowed but visible joint space
  70. 71. Fibrous ankylosis of knee joint
  71. 73. <ul><li>Etiology </li></ul><ul><ul><li>Infecting organism: staphylococcus aureus </li></ul></ul><ul><ul><li>Route of contamination </li></ul></ul><ul><ul><ul><li>Hematogenous seeding </li></ul></ul></ul><ul><ul><ul><li>synovium, bone marrow joint </li></ul></ul></ul><ul><ul><ul><li>Direct contamination </li></ul></ul></ul><ul><ul><ul><li>penetrating trauma, post surgical </li></ul></ul></ul><ul><ul><ul><li>Contiguous spread </li></ul></ul></ul><ul><ul><ul><li>soft tissue infection, osteomyelitis </li></ul></ul></ul>Pyogenic arthritis
  72. 74. <ul><li>Location: </li></ul><ul><ul><li>Weight-bearing joint: hip, knee </li></ul></ul><ul><li>Age : </li></ul><ul><ul><li>Childhood </li></ul></ul><ul><li>Clinical presentation </li></ul><ul><ul><li>Acute onset and rapid progression </li></ul></ul><ul><ul><li>Pain, fever </li></ul></ul><ul><ul><li>Restricted motion + tenderness </li></ul></ul>
  73. 75. <ul><li>Radiographic findings </li></ul><ul><ul><li>Swelling of joint - widening of joint space </li></ul></ul><ul><ul><li>Destruction of articular cartilage - loss of joint space </li></ul></ul><ul><ul><li>Early and frank bone destruction at weight bearing area </li></ul></ul><ul><ul><li>Pathological dislocation of joint </li></ul></ul><ul><ul><li>Osteomyelitis at metaphysis </li></ul></ul><ul><ul><li>Separation of epiphysis in children </li></ul></ul>
  74. 76. Pyogenic arthritis of right hip joint Radiograph shows narrowing of joint space , irregular and unsmooth osteo-articular surface , enlargement of acetabulum, proximal and lateral subluxation of femoral head.
  75. 77. Pyogenic arthritis of hip joint Radiograph shows loss of joint space , destruction of osteo-articular surface.
  76. 78. Pyogenic arthritis of hip joint Radiograph shows loss of joint space , destruction of osteo-articular surface, and osteosclerosis . Normal
  77. 79. Chronic pyogenic arthritis of hip joint Radiograph shows loss of joint space , destruction of osteo-articular surface, and prominent osteosclerosis.
  78. 80. Bony ankylosis of right hip joint after pyogenic arthritis
  79. 81. <ul><li>Etiology </li></ul><ul><ul><li>Mycobacterium tuberculosis </li></ul></ul><ul><ul><li>Hematogenous seeding to synovial membrane </li></ul></ul><ul><ul><li>Spread from adjacent tuberculosis of bone </li></ul></ul><ul><li>Location </li></ul><ul><ul><li>Knee and hip joint </li></ul></ul><ul><li>Age </li></ul><ul><ul><li>Childhood </li></ul></ul>Tuberculous arthritis
  80. 82. <ul><li>Clinical presentation </li></ul><ul><li>Swelling </li></ul><ul><li>Mild pain </li></ul><ul><li>Restriction of motion </li></ul><ul><li>Atrophy of muscle in the later stage </li></ul>
  81. 83. <ul><li>Radiographic findings </li></ul><ul><li>Bone destruction (marginal erosion ) </li></ul><ul><li>Swelling of joint </li></ul><ul><li>Gradual narrowing of joint space </li></ul><ul><li>Osteoporosis </li></ul><ul><li>Atrophy of muscle </li></ul><ul><li>Cold abscess, sinus tract </li></ul><ul><li>Fibrous ankylosis </li></ul>
  82. 84. Tuberculosis of knee joint Well defined bone destruction at distal metaphysis of femur with swelling of knee joint
  83. 85. Tuberculosis of hip joint Destruction of femur head, neck and acetabulum with swelling of joint and osteoporosis of left part of pelvis and upper third of left femur
  84. 86. Tuberculosis of right hip joint Narrowing of joint space and osteoporosis
  85. 87. Tuberculosis of left knee joint Radiographs of left knee joint show swelling of joint. right left
  86. 88. Radiographs show joint destruction, narrowing of joint space, swelling of joint, osteoporosis and subluxation. Tuberculosis of knee joint
  87. 89. Radiographs show maringal erosion( ), narrowing of joint space, swelling of joint and osteoporosis Tuberculosis of knee joint
  88. 90. Tuberculosis of knee joint Plain CT scan Contrast enhanced CT scam Comparison of CT and radiograph
  89. 91. Comparison of tuberculous and pyogenic arthritis acute and rapid slow Progression bony fibrous Ankylosis early late Joint space loss weight-bearing area margin Bone destruction + ± Osteosclerosis ± + Osteoprosis Pyogenic arthritis Tuberculous arthritis
  90. 92. Thank you for your attention !

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