dasar-dasar radiologi musculoskeletal
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DASAR-DASARRADIOLOGI
MUSCULOSKELETAL
dr. Donny Susilawardhono SpRad
Bagian Radiologi RSAL RML
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CVMiliter Profesi
• Rumkital Sabang
• Yonif-3 Marinir• Pasmar 1 Surabaya
• Lanmar Surabaya
• Kobangdikal
• Lantamal II Padang
• Kasubdep Radiotherapi RSAL
• Spesialis Radiologi
keseminatan Musculoskeletal
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Introduction– role of MSK Radiologist
1. To diagnose an unknown disorder, preferably by usingstandard projection along with the special views andtechniques obtainable in conventional radiography before
using the more sophisticated modalities now available2. To perform examination in the proper sequence to know
what should be performed next in radiologic investigation3. To demonstrate the determining radiologic features of a
known disorder, the distribution of a lesion in the skeleton,and its location in the bone
4. To monitor the progress of therapy and possiblecomplication
5. To be aware of what specific information is important to theorthopedic surgeon
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6. To recognize the limits of noninvasive radiologicinvestigation and to know when to proceed withinvasive techniques
7. To recognize lesions that require biopsy and thosethat do not (the “don’t touch lesion”)
8. To assume a more active role in therapeuticmanagement, such as performing an embolizationprocedure, delivering chemotherapeutic material bymean of selective catheteriztion, or performing
(usulaly CT-guided) radiofrequency thermal ablationof osseus lesion (such as osteoid osteoma)
Adam Greenspan
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Modalitas• Plain foto
• USG
• CT Scan• MRI
• PET dan SPECT
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Contoh foto dengan view khusus
Carpal– Tunnel View
Diagram topografi Hasil Radiografi
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View Khusus• Sangat banyak template foto dengan view khusus, mulai
kepala sd kaki, misalnya :▫ Di kepala : rheese, schuller, towne, submentovertex▫ Cervical : swimmer, dll▫ Shoulder : Y-view, aksial, dll▫ Extremitas superior dan inferior : carpal-tunnel, ulnar
deviation, dll▫ Pelvis : fergueson, frog, anterior oblique, dll
▫ Spine : mcNemar, scoliosis, dll
• Bila tidak menguasai, konsultasi ke ahli Radiologidengan mencantumkan persangkaan klinis dan tujuanfoto
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Ultrasonography• Relatif murah
• Hanya untuk tujuan khusus, terutama sendi-
sendi besar, seperti shoulder, genu, dll• Diperlukan keahlian khusus
• Limitasi terbatas
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CT Scan
• Modalitas X-Ray yang sangat membantu dalam bidang MSK Radiologi
• Pemeriksaan relatif cepat dan dapatmemberikan image 3D
• Bila berbidai, tidak perlu melepaskan bidai
• Kelemahan : bila mengandung logam makaartefak logam sangat mengganggu
• Relatif lebih mahal
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Contoh 3D CT Scan
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Contoh 3D CT Scan
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Magnetic Resonance Imaging
• Superior untuk melihat soft tissue
• Diperlukan untuk local staging
• Relatif mahal
• Memerlukan scan time yang cukup lama dan
penderita tidak boleh bergerak• Tidak boleh ada logam
• Kontraindikasi thd pace maker
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Contoh MRI
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Kedokteran Nuklir
• Memerlukan alat yang khusus dengan ijinkhusus (radioaktif)
• Keahlian khusus
• Relatif mahal
• Efek samping besar
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The Basic– keterangan sakit
• Identitas (umur, jenis kelamin, pekerjaan)• Anamnesa dan Klinis, kalau perlu Lab dan tindakan
yang telah dilakukan)• Kenali mode of the disease (Trauma,
Tumor/tumorlike lesion, Degenerative, Autoimmun,Metabolik, Kongenital)
• Kenali apa yang dicari dari foto (memastikandiagnosis, menyingkirkan DD, melihat kemajuanpengobatan, komplikasi, dll)
• Kemungkinan prognosis• Follow up secara radiologis
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The Basic– dari foto
• Lihat kelengkapan Identitas (nama, umur,nomor RM/foto)
• Marker foto (R atau L, Tidur, dll)
• Lihat optimalisasi kondisi foto (apakah fotokondisi sudah optimal)
• Lihat view pembuatan foto (rule of two, posisi view, dll)
• Note : posisi default foto harus diketahui
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Pedoman Pembacaan
• A = Alignment
•B = Bone
•C = Cartilage
•S = Soft Tissue
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Rule of Two
• Two different projection
• Two joint (terutama kasus trauma)
• Two times
• Two condition
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Alignment
• Garis imajiner yangmenghubungkan
suatu rangkaiantulang menjadi garis yang kontinyu
• Alignment berbeda- beda pada setiapregio foto
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Alignment Malalignment
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Alignment
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Alignment – Shenton line
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Bone• Bagaimana “tulang” nya?
▫ Trabeculasi porotik/tidak
▫ Adakah lesi lytic/blastic
▫ Adakah kelainan lain
▫ Adakah pattern
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Pattern -
vertebra
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Cartilage– plain foto
• Cartilage pada kondisi normal tak tampak olehplain foto
• Cartilage akan tampak bila ada calcificasi
• Pada foto polos yang perlu diperhatikan adanya“space” dari cartilage tersebut
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Cartilage - osteochondroma
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Soft tissue• Secara umum soft tissue tidak tampak jelas pada
plain foto
• Perlu diketahui jarak normal “space” antartulang
• Pada umumnya soft tissue mass memberikan
gambaran slight hyperdens dan memberikanefek penekanan (SOP)
• Bila soft tissue calcificasi maka akan calcificasi yang akan tampak
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Soft tissue
Bulging soft tissue mass darimalignant bone tumor(Ewing)
Soft tissue tumor (soft tissueorigin)
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Basic Radiologi untuk tumor/tumorlike lesion
• Identitas
• Single/Multiple
• Location• Morfologi
• Reaksi yangditimbulkan
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Identitas :age related disease
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Location• Di dalam skeleton : os Tibia, dll
• Di dalam tulang :
▫ Epifise
▫ Metafise
▫ Diafise
▫ Centric/eccentric
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Location – di dalam tulang
Epifise, metafise dan diafise
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Location
Location – centric/eccentric
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Contoh fotoCentric Eccentric
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Morfologi• Bony destruction :
osteolytic/osteoblastic/campuran
• Bentuk lesi• Borders :
▫ Geographic▫ Moth Eaten
▫ Permeative• Matrix type• Adakah soft tissue replacement/bulging soft
tissue mass
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Margin
Morfologi - border
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Border : slow growing vs aggresive
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Border
Geographic Pattern Moth Eaten
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Border -
permeative
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matrix
Matrix lesion
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MatrixOsteoid - fluffy Chondroid - popcorn
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Periosteal reaction• Interrupted periosteal reaction
▫ Codman
▫ sunburst
• Uninterrupted periosteal reaction
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Periosteal
reaction
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Contoh Periosteal Reaction
Sunburst Codman
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Onion Skin
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Onion Skin
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Benign vs malignant
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mass, bone vs soft tissue origin
Bulging soft tissue mass darimalignant bone tumor(Ewing)
Soft tissue tumor (soft tissueorigin)
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Soft tissue tumor vs bone tumor
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Basic Radiologi for Trauma• Primary sign
• Secondary sign
• Diskontinyuitas korteks line
• Joint involvement ?
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Rule of Two
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Type of Fracture
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Alignment
of
Fractures
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Direction of Fractures Line
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Special Fractures
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Associated
abnormalities
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Special types of Fractures
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Growth Plate
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Osteoporotik
• Trabeculasi yang menurun
• Striae verticalis lebih dominan
• Pada vertebra :
▫ Codfish/mouth fishappearence
▫ Picture frame
▫ Vertebra plana
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Spondylosis
• Osteophyte
• Osteophyte yang saling berhadapan - lipping
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Osteoarthrosis
• Osteophyte
• Erosive – gull wing
• Penyempitan celah sendi
• Sclerosis
• Pseudocyst
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Introduction• Relatif sulit, gambaran tulang saling menumpuk
• Variasi posisi banyak
▫ Skull AP/Lat▫ Waters
▫ Mentovertex
▫ Towne
▫ Basis Cranii
▫ Eissler
▫ dll
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Important view• Normal suture dan accessory suture
▫ Tiga sutura besar (lambdoid, coronal dan sagital)
▫ Sutura-sutura kecil sekitar mastoid▫ Sutura accessory di anak-anak
• Metopic suture
▫ Sutura accessory yang paling umum pada dewasa
• Vascular impression
• Sinus sphenoidalis
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Suture• Suture berkelok-kelok
• Suture lebar adalah normal pada neonatus
• Suture normal, accessory suture, wormian bonesdapat menyerupai fracture
• Kesesuaian terhadap posisi trauma dangambaran radiografis adalah hal penting
• Seringkali pada anak diagnosa menjadi sulit,seringkali diperlukan tambahan foto, kp CT Scan
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Suture pada anak• Normal suture
▫ Lambdoid, coronal dan sagital
▫ Squamousal▫ Suture-suture sekitar mastoid
• Accessory suture
▫ Metopic
▫ Mendosal
▫ Accsessory parietal
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NORMAL SUTURES OF NEWBORN
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• 1 = lambdoidea suture
• 2 = coronarius suture• 3 = sagitalis suture
• P1 = P2 = accessoryparietal suture
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Gambar a :
• Accessory parietal suturecomplete
Gambar b :
• Accessory parietal sutureincomplete
Sk ll AP d k b l
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Skull AP – pada anak gambaran normal
1 = lambdoidea suture3 = sagital suture4 = squamousal sutureP1 = P2 = accessory parietal suture
Sk ll AP d k b l
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Skull AP – pada anak gambaran normal
1 = lambdoidea suture
3 = sagital suture
W = wormian bone
Sk ll AP d k b l
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Skull AP – pada anak gambaran normal
• metopic suture
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Vascular marking vs Fractures Vascular Marking Fracture
• Biasanya abu-abu, karenamasih ada bayangan tabulainterna
• Mempunyai cabang yangsecara graduil mengecil kearah perifer
• Biasanya terdapat tepisclerotic
• Biasanya hitam, karena tabulainterna dan eksterna terkena
• Peercabangan biasanya tidaksecara graduil kaliber mengecil
• Tidak mempunyai tepisclerotic
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Waters– on trauma
• McGrigor 1
• McGrigor 2• McGrigor 3
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Important landmark for arthritis
Pasien Radiograph
• Identitas (usia, sex)
• Anamnesa, onset penyakit
• Nyeri / tidak nyeri
• Simetris / tidak
• Sendi besar atau sendi kecil
• Single joint / multiple joint
• Associated with food• Underlying disease
• Simetris / tidak
• Pattern dari tulang-tulang
• Synovial atau tepi subchindral
• Permukaan sendi
• Spur / deposit mineral
• Penyempitan celah sendi
• Sclerosis permukaan sendi• Deformitas
• Pseudocyst
• Erosi
• Gasforming
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Osteoarthrosis - genu
• Osteophyte
• Penyempitan celah sendilateral compartement
• Sclerosis
• Pseudocyst (tidak ada)
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Erosive osteoarthrosis
• Osteophyte
• Gull wing erosion
• Heberden nodes
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Gouty Arthritis
• Asimetrical,sharperosion withoverhanging
edge• tophus
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RA
• Simetris
• Juxta arthricular porosis
• Swanneck & boutonierideformity (tidak ada)
• Subluksasi (tidak ada)• Soft tissue swelling (tidak
jelas)
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