Image Evaluation

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Image Evaluation

• Upper Limb

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There are numerous categories of pathology in the
evaluation of skeletal disease

• Developmental and congenital disorders
• Inflammatory
• Skeletal dysplasias
• Traumatic
• Neoplastic
• Metabolic disorders
• Vascular disorders
• Miscellaneous

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Pathological Classification

• Developmental Significant deviation from the
  norm resulting from a congenital or hereditary
  defect. E.g. Achondroplasia
• Inflammatory Disorders resulting from a
  inflammatory origin. E.g. Rheumatoid
• Skeletal dysplasias Dysplasia (Latin for Bad
  Form), abnormalities of skeletal growth and
  strength, e.g Osteopetrosis
• Traumatic Physical Injury
• Neoplastic Tumours benign and Malignant.
• Metabolic Resulting from biochemical processes
  e.g Rickets, Fluorosis
• Vascular Originating from a blood disorder and
  causing bony changes, e.g Thalassemia
• Miscellaneous Others which dont easily fit any
  other category, e.g joint infections and
  arthritis

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Today

• Osteoarthritis
• Fractures of the wrist
• Elbow Fat pad sign or sail sign
• Skeletal Dysplasia - Osteopetrosis
• Tumours

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Degenerative Joint Disease Many varieties and
causes

• Osteoarthritis
• Diffuse idiopathic skeletal hyperostosis
• Rheumatoid arthritis
• Ankylosing Spondylitis
• Psoriatic spondyloarthropathy
• Reiters syndrome
• Gout
• Neuropathic osteoarthropathy
• Juvenile chronic arthritis

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Osteoarthritis
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Markers of Osteoarthritis

• Non-uniform joint space narrowing.
• Subchondral sclerosis (sclerosis dense white
  appearance radiographically, corresponding with
  overgrowth of bone).
• Osteophyte formation.
• Subchondral cyst formation
• Subluxation (partial dislocation), deformity,
  malalignment.

McKinnis, L. 1997
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sclerosis
Osteophyte formation
Nonuniform joint space narrowing
Taylor Resnick, 2000
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Taylor Resnick, 2000
Arthritic
Baseball finger
Normal
Compare appearances
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Osteoarthritis degenerative disease
Osteophyte formation
Compared with normal appearances
Sclerosis and joint space narrowing
Taylor Resnick, 2000
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Osteophyte formation
Subchondral sclerosis
None arthritic appearance
Joint space narrowing
Taylor Resnick, 2000
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Fractures
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Frequently encountered fracture types
Eisenberg R, 2003
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Torus or buckle fracture
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Colles fracture

• Mechanism dorsiflexion.
• Fracture of the distal portion of the radius with
  dorsal displacement.
• Appearance referred to as the dinner fork
  deformity.

Posterior angulation of distal radial fracture
fragment dinner fork deformity
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Smiths fracture

• Reverse colles fracture.
• Mechanism variable.
• Fracture of distal portion of radius with palmer
  displacement.
• Less common than Colles fracture.

Anterior, or palmer angulation
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Fat pad sign intracapsular fat pad displacement
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Fat pad sign intracapsular fat pad displacement

• Fat pads are anterior and posterior.
• Fat pad performs a triangular lucency anterior to
  the distal humerus.
• Intracapsular fat pad displacement indicates a
  joint effusion.
• This sign usually indicates the existence of
  intracapsular fluid or blood and is often
  indicative of a fracture not always well seen!

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Fat pad extending down to joint
Normal
Abnormal
Posterior
Anterior
Taylor Resnick, 2000
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• In the absence of and obvious fracture,
  this sign very often will indicate the presence
  of a fracture of the Radial head that is not
  easily seen with standard projections, and
  additional objections should be performed in this
  case in an attempt to exclude fracture.
• Need a true lateral projection in order to
  visualise the fat pad. Obliquity of the humerus
  will hid the fat pad!

Always check the fat pad contour on your lateral
elbow! You may need extra projections.
Taylor Resnick, 2000
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• Chisel Fracture

Taylor Resnick, 2000
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Skeletal Dysplasias
Eisenberg R, 2003
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Skeletal Dysplasias - Osteopetrosis

• Is a rare hereditary bone disorder may also be
  called marble bone disease.
• Sclerosing dysplasia.
• May be benign or malignant!
• Patterns off diffuse osteosclerosis.
• This bone, while dense, is very brittle, fragile
  and fractures easily.

Eisenberg R, 2003
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Osteopetrosis Normal
Eisenberg R, 2003
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Tumour Radiographic appearances

• Osteolytic lesion in the metaphyseal portion or
  the distal radius.
• Extension into the subchondral region.
• Tumour extension to the cortical rim.
• eggshell cortical rim still intact.
• Mild bony expansion
• No obvious extension into the soft tissues

Osteolytic bone destroying
Taylor Resnick, 2000
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Giant Cell Tumour

• Usually affect the metaphyseal portion of long
  bones.
• 10 are malignant.
• Most occur in the distal radius, distal femur and
  proximal tibia and humerus.
• Typical age at onset 30-50yrs.
• Giant cell tumours of the distal radius are more
  likely malignant than at any other site.

Taylor Resnick, 2000
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Normal appearance
Taylor Resnick, 2000
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Ouch!

• Amputation at the wrist in an industrial accident

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Terminology

• Sclerosis extra bony growth
• Subchondral area of bone under the articular
  cartilage
• Cyst fluid filled
• Osteophyte extra bone growth to strengthen area
  of weakness
• Osteopetrosis sclerosing skeletal dysplasia
• Chisel fracture a form of radial head fracture
• Torus or buckle fracture
• Fat pad sign
• Colles fracture angulation of fracture fragment
  posteriorly (dinner fork deformity)
• Smiths fracture angulation of fracture fragment
  anteriorly
• Radiolucent radiographically lacking density
• Osteosclerotic Bone forming
• Osteolytic Bone destroying
• Dysplasia bad growth

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Homework

• Monteggias Fracture dislocation (Forearm)
• Galeazzis Fracture dislocation (Forearm)
• Bennetts Fracture (Thumb)

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References

• Eisenberg, R.L. Johnson, N.M. Comprehensive
  Radiographic Pathology. Mosby. 2003.
• Taylor, J. Resnick, D. Skeletal Imaging of the
  spine and extremities, Saunders.
• McKinnis, L.N. 1997, Radiographic evaluation of
  normal versus pathologic bone. In Fundamentals of
  orthopaedic radiology, F.A. Davis Company,
  Philadelphia, pp 30-70