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Advanced Patho of 16

File advpatho_unit3_9skeletal_imagingpdf Source C DeCristofaro MD

RESOURCES Citations for this file Many of the images in this file are from the following websites University of Washington Radiology Dept httpradwashingtoneduabout-usacademic-sectionsmusculoskeletal-radiologyteaching-materials and University of Washington Radiology Dept website httpwwwradwashingtoneduacademicsacademic-sectionsmskteaching-materialsonline-musculoskeletal-radiology-book (Click on tab for ldquoOrthopedic Hardwarerdquo and many other topics) (excellent manual) Tutorial on Joint anatomy (Virginia Med School) Fantastic This is EXCELLENT httpwwwmed-edvirginiaeducoursesradext Has a pretest and then gives you modules with examples of Xrays Really awesome (if you are a little ldquofuzzyrdquo on where the acromio-clavicular joint actually IShelliptry this out and you will be all set) Case studies in musculoskeletal pathology ndash if you are interested in application of imaging studies and like case studies ndash check this out Takes a little while to load online httpwwwmypacsnetreposmpv3_repocgicase-managerplcx_breadcrumb_trail=Shared20Cases|Skeletal20System|Allampsearch_accessibility=Sharedampsearch_level=advancedampSEARCH=1ampcx_breadcrumb_trail=Shared20Cases|Skeletal20System|Allampcx_no_search=1ampINDIRECT_SEARCH=1ampsearch_anatomy=Skeletal20Systemampcx_repo=mpv4_repoampcx_from_folder= (click on ldquoGordquo) Note when reading these radiology notes it is sometimes helpful to use the PDF buttons to make the image larger (hit the ldquo+rdquo sign at the top of the page) and thus be able to view the graphics better

Advanced Patho Page 2 of 16


MUSCULOSKELETAL IMAGING Diseases affecting joints DJD (degenerative joint disease)(osteoarthritis) Joint space narrowing and eventual sclerosis with destruction of joint amp osteophytes Distal joints

Rheumatoid arthritis Radio-lucency due to absorption of bone proximal joints Eventual joint space narrowing subchondral cysts erosions subluxations

Ulnar deviation of fingers Subluxation

MCP joints affected and DIP joints spared

Compare to normal Xray of hand

Erosions (white arrows)

OsteophytesDIP and PIP joints



NORMAL APPENDICULAR SKELETAL XRAYS upper extremity Lateral View Elbow External rotation view shoulder AP view wrist Hand



Lower Extremity AP view foot

AP view ankle AP view knee



Common Upper Extremity Trauma fracture of terminal tuft of phalanx Phalangeal dislocations First metacarpal fracture Fifth metacarpal fracture Scaphoid fracture Ulnar fracture with dislocation of radial head Collersquos fracture Smithrsquos fracture Supracondylar fracture Shoulder anterior and posterior dislocation



Common Lower Extremity Trauma Patellar fracture (lateral horizontal view with fatfluid

level) Displaced fracture of tibia (left) Fractures of talus Nondisplaced fracture of tibia (right) Femoral metaphyseal fracture ( note cortical discontinuity at white arrow) Orthopedic Hardware EXCELLENT WEBSITE for viewing multiple types of hardware ndash screws plates pins wires

rods At University of Washington Radiology Dept website

httpwwwradwashingtoneduacademicsacademic-sectionsmskteaching-materialsonline-musculoskeletal-radiology-book (Click on tab for ldquoOrthopedic Hardwarerdquo)



PEDIATRIC Imaging rules for suspected fracture Obtain at least 2 views (AP amp Lateral) at 90 degree (right angle) angles to get that 3-D view Xray the joint ABOVE and the joint BELOW the suspected fracture ndash there may be an

associated dislocation If the site is near paired bones (eg tibia + fibula) check each bone for fracture Many things that look like fractures in pediatrics may be normal variants (radiologists use

manuals to look these things up) o if this is possibly the case order an Xray of the opposite side of the body at the

same site (if the normal variant also appears there it isnrsquot a fracture) remember that many fractures will NOT show up on initial film

o treat conservatively (eg immobilize and treat as though it IS a fracture) o repeat film in 1-2 weeks and look for healing callus (will definitely be seen by 2 weeks)

Special nature of pediatric fractures Diaphyseal fractures (through the diaphysis)

o Childrenrsquos bones are elastic o First they bow (bowing fracture) then fracture through one cortex (torus greenstick

buckle fracture) then fracture through both cortices (complete fracture) Metaphyseal amp Epiphyseal fractures (through the metaphysis amp epiphysis)

o Ligaments are stronger than bones in children so instead of a ligament tear they get a fracture of the metaphyseal-epiphyseal portion of the joint

o This is called a Salter Harris fracture o Since they involve the growth plate (physis) they can cause limb length problems on

healing (always need orthopedic management)

Salter Harris classification

Metaphysis (where the joint flares out)

Ankle fracture (SH-III) (note white arrows)



Pediatric elbow fractures Mostly supracondylar Take lateral film of elbow NORMAL has anterior fat pad up against the anterior humerus (never see posterior fat pad) FRACTURE Xray shows the posterior fat pad and the anterior fat pad is more prominent

o The joint has filled with blood and displaced the fat pads o Anterior pad ndash looks elevated (sail sign) o Posterior pad ndash becomes visible

NOTE you may NOT even SEE the fracture itself The fat pad sign is all you need to make the diagnosis

White arrows showing anterior fat pad

and posterior fat pad now visible (fat pad sign)(white arrows) showing dark shapes coming out from the bone

Sometimes the anterior fat pad looks like a dark triangular sail And is called the ldquosail signrdquo (red arrows) and this should alert you to the possibility of a fracture (although this can also be a normal variant)



Bone age determines the childrsquos TRUE physiologic age (compare to chronologic age) AP view of the hand and wrist Compare this Xray with an atlas of children of known chronologic age if suspect

developmental delay o Useful in diagnosing growth retardation (eg from hypothyroidism) o If the childrsquos bone age is less than his chronologic years he has developmental delay

Serial Xrays over pediatric lifespan show o eventual calcification of epiphyses o appearance of the carpal and tarsal bones (they opacify with age called

OSSIFICATION) and you can count the ossification sites to determine age using the atlas

o once epiphyses are closed then there is no further growth of the long bones ndash child has reached adult height

Age 6 years old note carpal bones are ossified

Age 3 months old note only two sites of carpal bone ossification



OSGOOD-SCHLATTER DISEASE Deformity of the anterior tibial tubercle Causes knee pain Especially common in adolescent athletes since this syndrome is worsened by overuse Treatment includes resting the joint from overuse (no running or sports requiring running) There is a surgical option Once the epiphyseal plates close then the condition is stable Take lateral knee Xray to diagnose Very obvious deformity Less obvious deformity



BONE TUMORS AND BENIGN LYTIC LESIONS Lytic lesion On skeletal Xray looks like a destruction of the bone Can be many etiologies ndash some malignant and some benign Differential diagnosis Benign

o Non-ossifying fibroma (fibrous cortical defect) pediatric common may eventually be replaced by normal bone

o Simple (solitary) bone cyst o Aneurysmal bone cyst o Enchondroma o Hemangioma o Fibrous dysplasia o Giant cell tumor

Malignant o Osteosarcoma o Ewingrsquos sarcoma o Chondrosarcoma o Metastatic disease to bone o Multiple myeloma

Serious but not malignant o Osteomyelitis

Determining what the lesion is Use clinical factors and appearance on Xray Clinical factors

o Patient age o Location of lesion (eg finger hip)

Radiographic factors o Size of lesion o Solitary or multiple lesions o Presence of reactive sclerosis o Bone destruction o Lesion matrix ( Tumor) o Bone and periosteal reaction o Soft tissue involvement

Recommended tutorial ndash note ndash there are British spellings of terms httpwwwimageinterpretationcouktumourhtml

Hard to believe this is benign (pediatric non-ossifying fibroma)



SPINE ndash CERVICAL amp LUMBAR How to look at a C-spine Xray (suggested protocol) Order 3 views AP lateral and open mouth (odontoid) views Identify landmark C7-T1 (identify this landmark) Check alignment of C-spine ndash check 4 lines

o Anterior part of vertebral bodies o Posterior part of vertebral bodies (anterior border of spinal canal) o Posterior border of spinal canal o Posterior border of spinous processes

Check articular facets and neural foramina Check cervical-basilar relationships Check prevertebral soft tissues Check sinuses for air-fluid levels Check for other skull fractures See below AND next page for normal radiographs labeled to identify structures Normal C-spine Xrays Anterior C-spine



More Normal C-spine Xrays Lateral view Open mouth view



What types of imaging in trauma First plain films in case of trauma to rule out cervical fracture Then CT or MRI to follow

MRI Anterior dislocation of C6 on C7 and cord transection

Plain C-spine (same patient) Look at the C6-C7 area



Normal Lumbar Spine Xrays Lumbo-sacral spine AP view Lumbo-sacral spine Lateral view



Common LS spine pathologies Spondylolisthesis Kyphosis (thoracic spine curvature)

(over-riding of vertebrae) see arrow at L4 vertebrae

Scoliosis



MUSCULOSKELETAL IMAGING Diseases affecting joints DJD (degenerative joint disease)(osteoarthritis) Joint space narrowing and eventual sclerosis with destruction of joint amp osteophytes Distal joints

Rheumatoid arthritis Radio-lucency due to absorption of bone proximal joints Eventual joint space narrowing subchondral cysts erosions subluxations

Ulnar deviation of fingers Subluxation

MCP joints affected and DIP joints spared

Compare to normal Xray of hand

Erosions (white arrows)

OsteophytesDIP and PIP joints





















































































Scoliosis





















































































Scoliosis

resources: citations for this filepeople.musc.edu/~decristc/adv patho/unit 3 muscle... · file:...

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