musculoskeltal xray

How to read How to read musculo-skeletal x raysmusculo-skeletal x rays

Dr.Mahesh kumar MSDr.Mahesh kumar MSDept. of OrthopedicsDept. of Orthopedics

General Hospital General Hospital TrivandrumTrivandrum

11www.similima.comwww.similima.com

Rule 1Rule 1

CommonCommonthings -firstthings -first

When you see a black bird in trivandrum

Do not say it is a penguin

Say it is a crow

Appearances can be deceptive-

do not go by appearances55www.similima.comwww.similima.com

Reading an x rayReading an x ray It is not getting the It is not getting the “appearance”“appearance” It is not commenting It is not commenting “oh! I have seen it “oh! I have seen it

before”before” And not distracted by the And not distracted by the “obvious”-“obvious”- it may it may

not be the causative pathologynot be the causative pathology We should have a We should have a systematic approachsystematic approach

ABC’s of bone RadiologyABC’s of bone Radiology

Look for Look for Alignment Alignment Bones Bones

Abnormal lucency Abnormal lucency Abnormal sclerosis Abnormal sclerosis Periosteal reaction Periosteal reaction Abnormal contour Abnormal contour

Cartilage Cartilage Soft TissueSoft Tissue

AlignmentAlignment Subluxation Subluxation

A displacement of a bone in relation to the apposing A displacement of a bone in relation to the apposing bone at the joint, resulting in a partial loss of bone at the joint, resulting in a partial loss of continuity of the joint surfaces. continuity of the joint surfaces.

Dislocation Dislocation A displacement of a bone in relation to the apposing A displacement of a bone in relation to the apposing

bone at the joint, resulting in a complete loss of bone at the joint, resulting in a complete loss of continuity of the joint surfaces. continuity of the joint surfaces.

Diastasis Diastasis A displacement of a bone in relation to the apposing A displacement of a bone in relation to the apposing

bone in a slightly movable (e.g. sacroiliac) or bone in a slightly movable (e.g. sacroiliac) or synarthrodial joint (cranial sutures).synarthrodial joint (cranial sutures).

dislocation1010www.similima.comwww.similima.com

subluxation 1111www.similima.comwww.similima.com

Decreased Opacity (Lucency)Decreased Opacity (Lucency)Lucency comes in several flavors. Depending on the exact Lucency comes in several flavors. Depending on the exact

morphology and distribution of the lucency, our morphology and distribution of the lucency, our differential diagnosis may vary widely. differential diagnosis may vary widely.

Lucent lineLucent line fracturefracture

Focal lucencyFocal lucency tumortumor infectioninfection

Diffuse lucencyDiffuse lucency drugsdrugs endocrine / metabolicendocrine / metabolic tumortumor

Lucent lineLucent line

A A linear lucencylinear lucency is the classic is the classic sign of a fracture. If a fracture sign of a fracture. If a fracture is displaced enough, it is easyis displaced enough, it is easy

Focal lucencyFocal lucency With focal lucencies, bone tumors and osteomyelitis are two of the With focal lucencies, bone tumors and osteomyelitis are two of the

top entities on the differential diagnosis.top entities on the differential diagnosis. In the rest of the world, a handful of benign tumors are seen In the rest of the world, a handful of benign tumors are seen

occasionally, and theoccasionally, and the only malignant tumors commonly seen only malignant tumors commonly seen are metastases and multiple myeloma. are metastases and multiple myeloma.

In practice, the In practice, the patient’s historypatient’s history is often key in is often key in distinguishing tumor and infection, as they sometimes distinguishing tumor and infection, as they sometimes appear quite similar on radiographs.appear quite similar on radiographs.

focal lucenciesfocal lucencies

focal lucencies, bone tumors focal lucencies, bone tumors and osteomyelitis are two of and osteomyelitis are two of the top entities on the the top entities on the differential diagnosis.differential diagnosis.

only malignant tumors only malignant tumors commonly seen are commonly seen are metastases and multiple metastases and multiple myelomamyeloma

Differential Diagnosis of Solitary Lucent Bone LesionsDifferential Diagnosis of Solitary Lucent Bone Lesions

Fibrous Dysplasia Fibrous Dysplasia Osteoblastoma Osteoblastoma Giant Cell Tumor Giant Cell Tumor Metastasis / Myeloma Metastasis / Myeloma Aneurysmal Bone Cyst Aneurysmal Bone Cyst Chondroblastoma / Chondromyxoid Fibroma Chondroblastoma / Chondromyxoid Fibroma Hyperparathyroidism (brown tumors) / Hemangioma Hyperparathyroidism (brown tumors) / Hemangioma Infection Infection Non-ossifying Fibroma Non-ossifying Fibroma Eosinophilic Granuloma / Enchondroma Eosinophilic Granuloma / Enchondroma Solitary Bone CystSolitary Bone Cyst

Look forLook for Age of the patientAge of the patient Size of the lesionSize of the lesion Margins of the lesionMargins of the lesion Matrix- the “inside” of the lesionMatrix- the “inside” of the lesion Location in the boneLocation in the bone Periosteal reaction - present or not?Periosteal reaction - present or not? multiplicitymultiplicity

Age and lucent bone lesionsAge and lucent bone lesions 11

neuroblastomaneuroblastoma 1 - 101 - 10

Ewing's of tubular bonesEwing's of tubular bones 10 - 3010 - 30

osteosarcoma, Ewing's of flat bonesosteosarcoma, Ewing's of flat bones 30 - 4030 - 40

reticulum cell sarcoma (Primary histiocytic lymphoma), reticulum cell sarcoma (Primary histiocytic lymphoma), fibrosarcoma, parosteal osteosarcoma, malignant giant cell fibrosarcoma, parosteal osteosarcoma, malignant giant cell tumor, lymphomatumor, lymphoma

40 +40 + metastatic carcinoma, multiple myeloma, chondrosarcomametastatic carcinoma, multiple myeloma, chondrosarcoma

Normal bone

geographic

Moth eaten

permeative

TYPES OF LESIONS

locationlocation

MultiplicityMultiplicityDifferential Diagnosis of Multiple Lucent Bone LesionsDifferential Diagnosis of Multiple Lucent Bone Lesions

Fibrous Dysplasia Fibrous Dysplasia

Metastasis / Myeloma Metastasis / Myeloma

Hyperparathyroidism (brown tumors) / Hemangioma Hyperparathyroidism (brown tumors) / Hemangioma

Infection Infection

Eosinophilic Granuloma / EnchondromaEosinophilic Granuloma / Enchondroma

Some tips Some tips

a a long lesion in a long bonelong lesion in a long bone, , think of think of

fibrous dysplasiafibrous dysplasia. .

Simple cyst, Simple cyst, enchondroma, enchondroma,

and fibrous dysplasiaand fibrous dysplasia can mimic each other and can be can mimic each other and can be

hard to distinguish. hard to distinguish.

Giant cell tumorsGiant cell tumors nearly alwaysnearly always

occur near a joint surfaceoccur near a joint surface. .

Lucent lesions of the sternumLucent lesions of the sternum should be consideredshould be considered

malignantmalignant until proven otherwise until proven otherwise

(Helms CA, 1983(Helms CA, 1983).).

Certain bones in the body are Certain bones in the body are "epiphyseal equivalents""epiphyseal equivalents". .

lucent lesions in these areas, lucent lesions in these areas, the classic epiphyseal entities such as the classic epiphyseal entities such as chondroblastoma, chondroblastoma, giant cell tumors and aneurysmal bone cysts. giant cell tumors and aneurysmal bone cysts.

They are They are patella, patella, calcaneus, calcaneus, most apophyses. most apophyses.

Diffuse lucencyDiffuse lucency Diffuse lucency usually Diffuse lucency usually

bespeaks some bespeaks some global global processprocess capable of capable of affecting the entire affecting the entire skeleton.skeleton.

A metabolic bone A metabolic bone disorder such as disorder such as osteoporosisosteoporosis

multiple myelomamultiple myeloma

extensive myelomatosis

rheumatoid arthritis treated with steroids

?3232www.similima.comwww.similima.com

Increased Opacity (Sclerosis)Increased Opacity (Sclerosis)Causes of Increased OpacityCauses of Increased Opacity

Bone impaction or rotationBone impaction or rotation fracturefracture

Bone production(reactive sclerosisBone production(reactive sclerosis)) fracturefracture calluscallus tumortumor tumor bone formation or tumor bone formation or

periosteal reactionperiosteal reaction infectioninfection periosteal reactionperiosteal reaction osteoarthritisosteoarthritis subchondral sclerosis or subchondral sclerosis or

osteophytosisosteophytosis Congenital Congenital

Generic Differential Diagnosis of Sclerotic Bone Lesions Generic Differential Diagnosis of Sclerotic Bone Lesions

Vascular Vascular hemangiomas hemangiomas infarct infarct Infection Infection

chronic osteomyelitis chronic osteomyelitis Neoplasm Neoplasm

primaryprimary osteoma osteoma osteosarcoma osteosarcoma

metastatic metastatic prostate prostate breast breast otherother

Drugs Drugs Vitamin D Vitamin D fluoride fluoride

Inflammatory/Idiopathic Inflammatory/Idiopathic Congenital Congenital

bone islands bone islands osteopoikilosis osteopoikilosis osteopetrosis osteopetrosis pyknodysostosis pyknodysostosis

Autoimmune Autoimmune Trauma Trauma fracture (stress) fracture (stress) Endocrine/MetabolicEndocrine/Metabolic

hyperparathyroidism hyperparathyroidism Paget's diseasePaget's disease 3434www.similima.comwww.similima.com

Bone impaction or rotationBone impaction or rotation Although the classic Although the classic

sign of a fracture is a sign of a fracture is a lucent line, some lucent line, some fractures present fractures present otherwise.otherwise.

In cancellous bones

Fracture callusFracture callus Some fractures are so Some fractures are so

subtle that you may subtle that you may miss them altogether miss them altogether at first, and only at first, and only diagnose them once diagnose them once they have started to they have started to heal due to the heal due to the formation of fracture formation of fracture callus.callus.

Reactive sclerosis due to tumorReactive sclerosis due to tumor diffusely sclerotic diffusely sclerotic

metastsis are seen in a metastsis are seen in a very slow process very slow process (prostatic carcinoma) (prostatic carcinoma)

or a patient with diffusely or a patient with diffusely lytic mets who has been lytic mets who has been successfully treated (with successfully treated (with resultant healing and resultant healing and sclerosis of these sclerosis of these metastatic depositsmetastatic deposits).).

Bone island

pagets

melhorrostesisosteoma

Bone island

osteopoikilocytosis

Periosteal reaction Periosteal reaction Depends on whether the lesion is Depends on whether the lesion is

slow growing or rapidly growingslow growing or rapidly growing

Slow growing-Slow growing- periosteum is able to periosteum is able to produce bone at the same rate as tumor produce bone at the same rate as tumor grows- so grows- so solid periosteal reactionsolid periosteal reaction

Rapidly growingRapidly growing lesion -the perisoteum lesion -the perisoteum cannot cope up- hence cannot cope up- hence interrupted patterninterrupted pattern

Periosteum produces bone when stimulatedPeriosteum produces bone when stimulatedType of periosteal reaction Type of periosteal reaction depends on the depends on the

processprocess than the periosteum than the periosteum

Slow growing- Slow growing- solid periosteal reactionsolid periosteal reaction Faster growing Faster growing layered or lamellar typelayered or lamellar type Rapid, steady growth -Rapid, steady growth -sun burst, sun burst,

codeman’s trianglecodeman’s triangle Mixed patternsMixed patterns

Solid Lamellar sunburst Codeman’s triangle

Mixed type

Types of periosteal

reaction

causescauses Solid Periosteal ReactionSolid Periosteal Reaction

infection infection benign neoplasms benign neoplasms

osteoid osteoma osteoid osteoma eosinophilic granuloma eosinophilic granuloma

hypertrophic pulmonary osteoarthropathy hypertrophic pulmonary osteoarthropathy deep venous thrombosis (lower extremity) deep venous thrombosis (lower extremity)

Aggressive Periosteal ReactionAggressive Periosteal Reaction osteomyelitis osteomyelitis malignant neoplasms malignant neoplasms

osteosarcoma osteosarcoma chondrosarcoma chondrosarcoma fibrosarcoma fibrosarcoma lymphoma lymphoma leukemia leukemia

metastasismetastasis 4444www.similima.comwww.similima.com

Causes of Solid Periosteal Causes of Solid Periosteal ReactionReaction

OsteomyelitisOsteomyelitis Benign neoplasmsBenign neoplasms

osteoid osteomaosteoid osteoma Eosinophilic granulomaEosinophilic granuloma Hypertrophic Hypertrophic

osteoarthropathyosteoarthropathy Deep venous thrombosis Deep venous thrombosis

(lower extremity)(lower extremity) Trauma (healing fracture)Trauma (healing fracture)

Causes of Aggressive (Interrupted) Causes of Aggressive (Interrupted) Periosteal ReactionPeriosteal Reaction

OsteomyelitisOsteomyelitis Malignant neoplasmsMalignant neoplasms

osteosarcoma osteosarcoma chondrosarcoma chondrosarcoma fibrosarcoma fibrosarcoma lymphoma lymphoma leukemia leukemia metastasis metastasis

TraumaTrauma

osteogenic sarcoma.

"sunburst".

Abnormal Contour, Size and ShapeAbnormal Contour, Size and Shape

FocalFocalfracturefracturesurgerysurgeryinfectioninfectiontumortumor

DiffuseDiffusedysplasiadysplasiametabolicmetabolic

multiple hereditary exostoses,

Paget’s disease,

CartilageCartilage

decreased joint space decreased joint space

increased joint space increased joint space

chondrocalcinosischondrocalcinosis

we can’t really see we can’t really see cartilage on plain cartilage on plain radiographs, but we can radiographs, but we can still use these films to still use these films to infer a few rough ideas infer a few rough ideas about how the cartilage is about how the cartilage is doing. Hyaline articular doing. Hyaline articular cartilage is what cartilage is what separates the bones in a separates the bones in a synovial joint. This space synovial joint. This space taken up by the cartilage taken up by the cartilage is termed the is termed the "joint "joint space"space" on a plain on a plain radiograph.radiograph.

Marked joint space Marked joint space narrowing is noted in the narrowing is noted in the superior weight-bearing superior weight-bearing portion of the joint space portion of the joint space in this patient with in this patient with osteoarthritis. osteoarthritis. Subchondral sclerosis Subchondral sclerosis and marked and marked osteophytosis are also osteophytosis are also noted.noted.

Chondrocalcinosis Chondrocalcinosis (arrows) is noted in (arrows) is noted in the hyaline articular the hyaline articular cartilage and menisci cartilage and menisci of this patient with of this patient with calcium calcium pyrophosphate pyrophosphate deposition (CPPD) deposition (CPPD) diseasedisease

Soft TissueSoft Tissue

When looking at the soft tissues, one can When looking at the soft tissues, one can occasionally see a variety of useful occasionally see a variety of useful findings on plain films, such as: findings on plain films, such as:

swelling swelling gas gas calcification calcification massmass

DystrophicDystrophic small to large amorphous Ca++ in the small to large amorphous Ca++ in the damaged tissuedamaged tissue -- may progress to -- may progress to ossification (formation of cortex and medullary ossification (formation of cortex and medullary space are then seen)space are then seen)

CPPDCPPD chondrocalcinosis; occasionally chondrocalcinosis; occasionally associated with calcifications in the associated with calcifications in the soft tissues of the spinesoft tissues of the spine

Metastatic calcificationMetastatic calcification finely speckled Ca++ throughout soft finely speckled Ca++ throughout soft tissuestissues

Tumoral calcinosisTumoral calcinosis big globs of Ca++, usually near a big globs of Ca++, usually near a jointjoint

Metastatic osteosarcomaMetastatic osteosarcoma amorphous, fluffy, confluent amorphous, fluffy, confluent collection of Ca++collection of Ca++

Primary soft tissue Primary soft tissue osteosarcomaosteosarcoma

amorphous, fluffy, confluent amorphous, fluffy, confluent collection of Ca++collection of Ca++

cysticercosis5959www.similima.comwww.similima.com

scleroderma

dermatomyositis

Heterotrophic ossification

Metasataic calcifications in soft tissues

chondrocalcinosis6464www.similima.comwww.similima.com

Tumoral calcinosis

Calcific tendinitis

Thank you 6868www.similima.comwww.similima.com

musculoskeltal xray

bone tumors

long bone

aneurysmal bone cysts

abcs of bone radiologylook

lucent lesions

malignant tumors

linear lucency

joint surfaces

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