Bones & Joints

1
Bones Joints

• Ian Bickle
• Radiology for Finals
• Nottingham
• (special thanks to Dr A Raghavan)

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Main Themes

• Systemic bone diseases
• Fractures
• The KEY pathologies

3
The Aim of the Film

• Powers of observation
• Completeness of Search
• Descriptive abilities
• ALL FEATURES OF A GOOD JUNIOR DOCTOR

4
Key Points

• Have a system of approach
• Stick to it
• Dont forget the soft tissues

5
Viewing Bones

• Typically 2 views
• Essential for Fractures (90 degrees)
• Compare Contrast
• Check bone outline and density

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• Dont overcomplicate the
• simple

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Anatomy of the Hand Wrist

• Carpal Bones
• Proximal Row
• Scaphoid (a),
• Lunate (l),
• Triquetrum (tq),
• Pisiform (p)
• Distal Row
• Trapezium (t),
• Trapezoid (tp),
• Capitate (c),
• Hamate (h)

tp
c
t
h
p
tq
l
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Anatomy of the Pelvis Hip
a

• A sacral ala
• B left sacroiliac joint
• C iliopectineal line
• D ilium
• E ischial spine
• F pubic symphysis
• G inferior pubic ramus
• H obdurator foramen

b
d
c
e
g
h
f
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Anatomy of Knee
femur
patella
Medial condyle
fibula
Intercondylar eminence
Tibial tuberosity
tibia
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Anatomy of lumbar spine

• 1 vertebral body
• 2, 3 intervertebral disc space
• 4 pedicle
• 5 lamina
• 6 spinous process

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Anatomy of lumbar spine

• 1 vertebral body
• 2 intervertebral disc space
• 3 lamina
• 4 spinous process

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Normal Anatomy
cortex
diaphysis
metaphysis
medullary space
epiphysis
physis
physeal scar
Childhood
Adult
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• Systemic Bone Diseases

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Common Pathologies

• Osteoarthritis
• Rheumatoid disease
• Gout
• Psoriatic Arthropathy

• Pagets disease
• Osteoporosis
• Ankylosing Spondylitis
• Multiple myeloma

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Common Pathologies

• HPOA
• Osteomyelitis
• Hyperparathyrodism
• Osteosarcoma
• Charcots joint

• Bone Metastases
• Sclerotic Eg, Prostate
• Lucent (Lytic) eg. Lung
• Pathological fracture

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Osteoarthritis

• Key Features
• Loss of joint space
• Subchondral bone cysts
• Subchondral sclerosis
• Osteophyte formation

? Difference in hips ?
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OA Features
Sub-chondral sclerosis ?
? Reduced joint space
?Sub-chondral cyst
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Rheumatoid Arthritis

• Erosive arthropathy
• Spares DIP joints
• Periarticular osteopenia
• Soft tissue swelling

Erosions ?
19
Gout

• Erosions punched out
• (away from joint)
• Soft tissue swelling
• Gouty tophi

Erosion ?
Soft tissue?
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Psoriatic Arthropathy

• Erosive arthropathy
• DIP typically
• Sarcoiliac joints
• (may be involved)
• Pencil and cup deformity

DIPs only
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Pagets Disease (of bone)

• Key Features
• Sclerotic Bone
• Coarse trabecular pattern
• Expanded Bone
• Pathological

? Sclerotic bone
1 osteosarcoma
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Osteoporosis

• Key Features
• Normal biochemical tests
• Plain x-ray not sensitive
• DEXA scan best test
• Sequelae on x-ray wedge

Wedge ?
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Ankylosing Spondylitis

• Spine and SI joints
• Sacroilitis
• Syndesmophye formation
• Calcification of anterior longitudinal spinous
  ligament
• Apophyseal joint fusion

? Bamboo Spine
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Multiple Myeloma
multiple lytic bone lesions
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Metastases

• Lytic
• Bowel
• Bronchus
• Breast
• Kidney

• Sclerotic
• Prostate

? Lytic Met
? Sclerotic Met
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HPOA

• Unusual but important diagnosis
• Bronchial carcinoma
• Suppurative lung disease

Periosteal reaction ?
27
Osteomyelitis

• Key Features
• Peri-osteal reaction
• Osteopenia
• Bony destruction
• Pathological

Both sides of the joint
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Hyperparathyroidism

• Key Features
• Sub-periosteal bone resorption typically middle
  phalanx of hand
• Osteopenia

Scalloping ?
29
Charcots Joint

• Disorganized and disrupted joint
• Sclerosis
• Destruction of joint
• Fragmentation
• Think Diabetics

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Osteosarcoma

• Typically at the knee
• Frequently young patient
• Periosteal reaction
• Soft tissue mass
• Destructive lesion

? Soft tissue mass
periosteal reaction
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Codman Triangle
periosteal reaction
Codman Triangle
advancing tumor margin destroys periosteal new
bone before it ossifies
tumor
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• Fractures

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Fractures Features to Describe

• Bone
• Place of Bone
• Nature of Fracture
• Special Features of Fracture

• Management Implications

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Fracture Features

• Black (lucent) line
• White if overlapping fragments
• Associated soft tissue abnormalities
• Displacement Angulation

• Always look for another abnormality
• Another
• A dislocation
• An underlying cause

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Fresh Former
? callus
Fracture ?
36
Systemic Disease with Bone/Joint Involvement

• Best Exam Cases
• Great test of knowledge
• Test lateral thinking
• BE THE BEST think for the test

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Rheumatoid Disease

• Erosive Arthropathy Pulmonary Fibrosis

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Bronchial CA HPOA
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Pagets Disease ? Osteosarcoma