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SKELETAL RADIOLOGY dr. H.Undang Ruhimat,SpRad

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Title: SKELETAL RADIOLOGY dr. H.Undang Ruhimat,SpRad


1
SKELETAL RADIOLOGY
dr. H.Undang Ruhimat,SpRad
2
Principles of Radiologic Interpretation
  • Technical Consideration
  • Skeletal Anatomy and Physiology
  • The Categorical approach to bone disease
  • Radiologic predictor variables
  • Medicolegal implication

3
Technical consideration
  • Plain Film Radiography
  • Tomography
  • Contrast Examination
  • Radionuclide Imaging
  • Computed Tomography
  • Magnetic Resonance Imaging

4
Skeletal Anatomy and Physiology
  • Skeletal Development
  • Intramembranous Ossification
  • Enchondral Ossification
  • Bone Structure
  • Epiphyse Physis ZPC Metaphysis
  • Diaphysis
  • Cortex Medulla Periosteum
  • Endosteum
  • Bone Metabolism
  • Bone mineral - Hormones

5
Anatomy
6
Anatomy
7
Anatomy
8
The Categorical approach to bone disease
  • Congenital
  • Arthritis
  • Trauma
  • Blood
  • Infection
  • Tumor
  • Endocrine,Nutritional,Metabolic
  • Soft Tissue

9
Radiologic Predictor Variables
  • Preliminary Analysis
  • Clinical data
  • Number of lesions
  • Symetri of lesions
  • Determination of Systems Involved

10
Radiologic Predictor Variables
  • Analysis of The Lesions
  • Skeletal Location
  • Position Within Bone
  • Site of Origin
  • Shape
  • Size
  • Margination
  • Cortical Integrity

11
Radiologic Predictor Variables
  • Behavior of Lesions
  • Osteolytic Lesions
  • Osteoblastic Lesions
  • Mixed Lesions
  • Matrix
  • Periosteal Response
  • Solid Respons
  • Laminated Respons
  • Spiculated Respons
  • Codmans Triangle

12
Radiologic Predictor Variables
  • Soft Tissue Changes
  • Supplementary Analysis
  • Other imaging Procedures
  • Laboratory Examination
  • Biopsy

13
TRAUMA
  • Fracture and Dislocation
  • The radiographs should be made
  • Include at least one joint
  • Preferably two joints
  • Two position AP LAT

14
TRAUMA
  • Time intervals between Radiographic Study
  • Initial Diagnostic study
  • Post reduction and post immobilization
  • One or Two weeks later, if position has
  • changed
  • After approximately six eight weeks for
  • Primary callus
  • After each plaster cast or traction change
  • Before final discharge of patient

15
TRAUMA
  • Types of Fracture
  • Closed fracture
  • Does not break the skin or communicate
  • with the outside environment
  • Simple fracture
  • Open fractur
  • Penetrates the skin over fracture site
  • Compound fracture

16
TRAUMA
  • Comminuted fracture
  • Two or more bony fragments have separated
  • Non Comminuted fracture
  • Penetrates completely through the bone
  • Avulsion fracture
  • Tearing away of a portion of the bone
  • Impaction fracture
  • Bone is driven into its adjacent segmen

17
TRAUMA
  • Incomplete Fracture
  • Broken only one side of the bone
  • Greenstick (Hickory Stick) fracture
  • Torus (Buckling) fracture
  • Fracture Orientation
  • Oblique fractur
  • Commonly occurs in the shaft of long
  • tubular bone
  • 45 to the long axis of the bone

18
Fractur
19
Fracture
20
TRAUMA
  • Spiral fractur
  • Torsion, coupled with axial compression
  • and angulation
  • Transverse fractur
  • Run at a right angle to the lonh axis
  • Uncommon through healthy bone
  • Pathologic fractur

21
Fracture
22
TRAUMA
  • Spatial Relationships of Fracture
  • Aligment
  • Position of the distal fragment in relation
  • to the proximal fragment
  • Apposition
  • Closeness of the bony contact at the
  • fracture site
  • If the ends are pulled referred to as
  • Distraction

23
Fracture
24
TRAUMA
  • Rotation
  • Twisting forces on a fractured bone along
  • its longitudinal axis
  • Traumatic Articular Lesions
  • Subluxation
  • Dislocation
  • Diastasis
  • Epiphyseal Fractures
  • Salter-Harris Classification

25
Salter - Harris
26
Dislocation
27
TRAUMA
  • Fracture Healing
  • Main steps in fracture healing
  • Formation of hematoma
  • Organization of hematoma
  • Formation of fibrous callus
  • Replacement of fibrous callus by
  • primary bany callus
  • Absorption primary bany callus
  • Transformation to secondary bony callus
  • Remodeling

28
TRAUMA
  • Complication of Fractures
  • Immediate complication
  • Arterial injury
  • Compartement syndrome
  • Gas gangrene
  • Fat embolism syndrome
  • Thromboembolism

29
TRAUMA
  • Intermediate complication
  • Osteomyelitis
  • Myositis ossificans
  • Synostosis
  • Delayed union
  • Delayed complication
  • Osteonecrosis
  • Osteoporosis
  • Non union Mal union

30
Myositis Ossificans
31
INFECTION
  • Suppurative Osteomyelitis
  • General Consideration
  • Systemic or Local infections
  • Immunosuppresed patients, alcoholics,
  • newborns, and drug addicts are predisposed
  • Antibiotics have significatly reduced the
  • sepsis-related mortality

32
INFECTION
  • Etiology
  • Staphylococcus aureus causes 90
  • Pathway for the spread
  • Hematogenous
  • Contigunous
  • Direct Implantation
  • Postoperative

33
INFECTION
  • Radiologic Features
  • Bone scan are the earliest means of
  • diagnosis
  • Radiographic latent period for plain film
  • 10 days for extremities
  • 21 days for spine
  • Soft tissue alteration elevated fat planes,
  • obliterated fat planes, increased density.

34
INFECTION
  • Bone changes
  • Moth-eaten bone destruction
  • Usually metaphyseal in origin
  • Periosteal new bone formation
  • Solid Laminated Codmans Triangle
  • Sequestrum
  • Involucrum
  • Joint space destruction (ankylosis)

35
  • 0steomyelitis

36
Osteomyelitis
37
INFECTION
  • Septic Arthritis
  • General consideration
  • Single joint involvment in the rule
  • Most common rute is hematogenous
  • or direct traumatic implantation
  • Etiology
  • Most frequently is Staphylococcus Aureus

38
INFECTION
  • Radiologic Features
  • The knee and hip are the most common
  • sites
  • Joint effusion leads to distrorsion of the
  • fat folds
  • Positive Waldenstorms sign
  • Rapid loss of joint space
  • Bony ankylosis

39
INFECTION
  • Nonsuppurative osteomyelitis
  • (tuberculosis)
  • General Consideration
  • Found in patients such as prepubertal
  • children, debilitated geriatric, silicosis,
  • AIDS sufferers, Lymphoma patients,
  • Alcoholics, corticosteroid and drug abusers

40
INFECTION
  • Etiology
  • Mycobacterium tuberculosis
  • Two mode of spread
  • Inhalation
  • Ingestion

41
INFECTION
  • Radiologic Features
  • Spinal tuberculosis is most common at L-I
  • Early sign for spine are
  • Lytic endplate destruction
  • loss of disc height
  • Anterior gouge defect
  • Paraspinal swelling

42
INFECTION
  • Advanced sign for spinal involvement are
  • Vertebral body collaps
  • Gibbus formation and obliteration of the
  • disc
  • Tubercular arthritis is common in the hip and
  • knee
  • Uniform joint space narowing, early destruction
  • of the subchondral cortex, moth-eaten bone
  • destruction and juxtaarticular osteoporosis
    are
  • the cardinal sign of tubercular arthritis

43
Tuberculosis
44
Tuberculosis
45
TUMORS AND TUMORLIKEPROCESSES
  • METASTATIC BONE TUMORS
  • PRIMARY MALIGNANT BONE TUMORS
  • Multiple myeloma
  • Osteosarcoma
  • Ewings Sarcoma
  • PRIMARY QUASIMALIGNANT BONE TUMOR
  • Giant Cell Tumor

46
TUMORS
  • PRIMARY BENIGN BONE TUMORS
  • Osteochondroma
  • Osteoma
  • Bone island
  • Osteoid osteoma
  • Simple bone cyst
  • Aneurysmal bone cyst

47
TUMORS
  • Metastatic Bone Tumors
  • General Consideration
  • The most common malignant tumors
  • CNS tumors and basal cell Ca rarely
  • Life threatening complication
  • Insidence
  • 70 are metastatic, 30 are primary
  • In females 70 from breast Ca
  • In males 60 from prostate Ca

48
TUMORS
  • Radiologic Features
  • Technetium bone scan
  • 80 of all metastase are located in the
  • central or axial skeleton
  • - Spine and Pelvis being a most common
  • Alteration in bone density and architecture
  • 75 osteolytic, moth eaten or permeative
  • 15 osteoblastic
  • Periosteal respose is rare

49
Metastatic
50
TUMORS
  • Primary Malignant Bone Tumors
  • Multiple Myeloma
  • Bone scan are cold
  • Gross Osteoporosis may be the only early
  • sign
  • Punched out lesions
  • Vertebra plana or wrinkled vertebra
  • Preservation of pedicles

51
Multiple Myeloma
52
Multiple Myeloma
53
TUMORS
  • Osteosarcoma
  • 75 of cases occurs in the 10 to 25 age
  • Metaphyses of the distal femur, proximal
  • humerus are the most common sites
  • Permeative or ivory medulary lesion in
  • metaphysis of a long tubular bone
  • A sunburst or sunray periosteal response
  • Cortical disruption with soft tissue mass
  • formation
  • Sclerotic Lytic Mixed lesion

54
Osteosarcoma
55
Osteosarcoma
56
TUMORS
  • Ewings Sarcoma
  • Most cases occur in the 10 25 age range
  • May mimic infection
  • Diaphyseal permeative lesion
  • Femur, tibia and fibula
  • Onion skin periosteal response
  • Most common primary malignant bone
  • tumor to metastasize to bone

57
Ewings Sarcoma
58
TUMORS
  • Primary quasimalignant bone tumor
  • Giant cell Tumor
  • Osteoclastoma
  • 20-40 years is the usual age range
  • Distal femur, proximal tibia
  • distal radius, proximal humerus
  • Metaphysis and extend to subarticular
  • Radiolucent, excentric
  • Soap Buble appearance

59
Giant Cell Tumor
60
TUMOR
  • Primary Benign Bone Tumors
  • Osteochondroma
  • Painless and hard mass near a joint
  • Humerus, tibia, femur, ribs
  • Two types - sessile
  • - pedunculated
  • Coat hanger exostose cauliflower mass
  • The cortex and spongiosa blend
  • imperceptibly

61
Osteochondroma
62
TUMOR
  • Osteoma
  • A rise in membranous bones
  • Sinuses frontal, ethmoid
  • Mandible
  • Skull bones
  • Homogenously opaque

63
Osteoma

64
TUMOR
  • Bone Island
  • Epiphyseal, metaphyseal
  • Medulary
  • Round oval Long axis oriented
  • Smooth or radiating
    border
  • Opaque
  • Normal adjecent
    cortex
  • May change size

65
TUMOR
  • Osteoid osteoma
  • Consists a nidus, thst usually 1 cm or less
  • Target calsification
  • Most common location is in the cortex
  • Radiolucent nidus surrounded by perifocal
  • reactive sclerosis

66
Osteoid Osteoma
67
TUMOR
  • Simple Bone Cyst
  • Expansile radiolucent
  • Proximal humerus, femur, calcaneus
  • No periosteal reaction
  • Pathologic fracture
  • Aneurysmal Bone Cyst
  • Some lesion may reach 8 10 cm
  • Cortical ballooning blown out app

68
Aneurysmal Bone Cyst
69
Aneurysmal Bone Cyst
70
ARTHRITIC DISORDERS
  • Degenerative Disorders
  • Degenerative Joint Disease
  • etc
  • Inflamatory Disorders
  • Rheumatoid Arthritis
  • etc
  • Metabolic Disorders
  • Gout
  • etc

71
ARTHRITIC
  • Degenerative Joint Disease
  • Osteoarthritis Osteoarthrosis
  • Asimetric distribution
  • Non uniform loss of the joint space
  • Osteophytes
  • Subchondral sclerosis
  • Subchondral cyst
  • Loose bodies
  • Subluxation

72
Osteoarthrosis
73
ARTHRITIC
  • Rheumatoid Arthritis
  • Generalized Connective tissue disorder
  • Higest insidence among the 40 50 year
  • Symetric peripheral joint pain and swelling
  • Early - Soft tissue swelling
  • Marginal erosions
  • Osteoporosis - Periostitis
  • Loss of joint space
  • Late - Ankylosis
  • Deformities

74
Rheumatoid Arthritis
75
Rheumatoid Arthritis
76
ARTHRITIC
  • Gout
  • Disorder of purin metabolism
  • Deposite of Sodium monourate crystals
  • into cartilage, synovium, periarticular
  • and subcutaneous tissues
  • Dense soft tissue Tophi, preservation
  • of joint space, Bone erosions (marginal
  • periarticular) overhanging margin sign
  • Metatarsophalangeal joint

77
Gout
78
OsteoporosisDiagnosis Radiologi
79
Primer
  • Type I Post menopouse osteoclast mediated
  • ? radius dan vertebra
  • Type II Senile osteoporosis osteoblast
    mediated
  • ? proksimal femur

80
Compotition mineral
  • Normal ? gt 833 mg / cm2
  • Osteopeni ? 833 648 mg / cm2
  • Osteoporosis ? lt 648 mg / cm2
  • Established osteoporosis

81
Diagnosa Radiologi
Radiografi Konvensional
  • Peningkatan radiolusensi
  • Penurunan kandungan mineral? lt30-50
  • Penipisan korteks
  • Gambaran trabekula menonjol
  • Perubahan bentuk

82
Vertebra
  • Penurunan densitas
  • Perubahan trabekula
  • ? trabekula vertikal
  • ? Wash out
  • Penipisan korteks
  • Perubahan bentuk

83
Femur
  • Penurunan densitas ? kolum femoris
  • trochanter mayor
  • Perubahan trabekula

1.Principal Compressive group
2.Secondary Compressive Group
Wards triangle
3. Tensile Group
84
CT Scanogram
  • Penipisan korteks

Pelebaran diameter intrameduler
CT Scanogram
85
Densitometri
  • Penurunan kandungan mineral
  • ?umur 30-35 th
  • Penurunan ? 3-5 / dekade
  • Menopause ? gt 2 / tahun

86
Dexa
  • Dua panjang gelombang ? Energi
  • Antero-posterior

BMC Bone mineral content (gram)
BMD Bone mineral density (gram/cm2)
87
T. Score
  • Normal gt -1
  • Osteopeni -1 2,5
  • Osteoporosis lt -2.5

88
QUS
  • Dua buah transduser ? 0,1 1 MHz
  • Transmitter Receiver
  • BUA (Boardband Ultrasound Attenuation)?Bone Mass
  • SOS (Speed of Sound)? Internal Arsitektur dari
    trabekula?elastisitas

89
Kesimpulan.
  • USG Skrining massal
  • DEXA Gold standard
  • Konvensional radiografi
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