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Musculoskeletal Radiography. Dr. LeeAnn Pack Dipl. ACVR. Musculoskeletal Radiography. Permit localization and characterization of a lesion Size, shape, margination, number, position, opacity Normal radiographic anatomy Diseases are often bilateral in the appendicular skeleton

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Musculoskeletal radiography l.jpg

Musculoskeletal Radiography

Dr. LeeAnn Pack

Dipl. ACVR


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Musculoskeletal Radiography

  • Permit localization and characterization of a lesion

  • Size, shape, margination, number, position, opacity

  • Normal radiographic anatomy

  • Diseases are often bilateral in the appendicular skeleton

  • Radiographic terms – use appropriately


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Traditional - ABCD’S

  • Alignment

    • Judgment based on appropriate radiographic views

    • Pertains to the bone as well as joint alignment

    • May require “stress” views to demonstrate abnormal joint alignment

  • Bone

    • Assess size, shape, position, opacity, margin and number

    • Evaluate the periosteum (soft tissue border with a bright light)

    • Cortex, endosteum, medullary cavity (+/- cancellous bone), endosteum, cortex and periosteum

    • Subchondral bone plate, epiphysis, metaphysis, diaphysis, metaphysis, epiphysis, subchondral bone plate and any apophyses

  • Cartilage

    • Soft tissue opacity of both articular and physeal locations

    • Relies on knowledge of anticipated joint space width and physeal configuration

  • Devices

    • Implant complications

  • Soft tissue

    • Extracapsular and intracapsular soft tissues evaluated with a bright light

    • Opacity changes (mineralization, emphysema, foreign bodies)


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Approach to Interpretation

  • Soft tissues

    • Intra-capsular or extra-capsular

  • Bones

    • Evaluate periosteal margins for new bone

    • Evaluate all cortices and subchondral bone

    • Evaluate the medullary cavity for changes in opacity

  • Joints

    • Evaluate joint capsule attachments

    • Evaluate joint spaces and peri-articular margins


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Gas in Soft Tissues

  • Area of decreased opacity in the ST’s

  • Causes:

    • Open wound

    • Compound fracture

    • Gas producing organism

    • Iatrogenic

      • Post op

      • Needle stick


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Mineralization of Soft Tissues

  • Increased opacity in the soft tissues

  • Causes:

    • Dystrophic mineralization

    • Metastatic mineralization

    • Neoplastic mineralization



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Soft Tissue Abnormalities

  • Intra-capsular soft tissues

    • Enlargement of soft tissue within the joint

      • Stifle, tarsus and carpus easiest to evaluate

    • Swelling usually conforms to joint margins

    • Can be caused by:

      • Effusion

      • Soft tissue proliferation

      • tumor



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Intra-capsular ST Swelling

Normal

IC Swelling



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Soft Tissue Abnormalities

  • Extra-capsular soft tissues

    • Enlargement of the soft tissues outside the joint

    • Swelling may be diffuse or focal

    • Great indicator of underlying bony change

    • Caused by

      • Edema, hemorrhage, tumor, inflammation


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Bone Abnormalities

  • Bones response

    • Bone production - osteoblast

      • Periosteal reaction and sclerosis

      • Takes 12-14 days after insult

    • Bone loss – osteoclast

      • Lysis

      • 30-50% bone loss required to be seen on radiographs


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Bone Loss

  • Generalized bone loss

    • Metabolic or Nutritional disease, disuse

  • Called  osteopenia

  • Radiographic findings:

    • Decreased bone opacity, cortical thinning, coarse trabeculation, bone deformity or pathological fractures may occur

    • Loss of lamina dura – 2ary HPTism



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Bone Loss

  • Localized bone loss

    • Trauma, infection, tumor

  • Easier to detect than generalized


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Bone Loss

  • Determining Aggressiveness

    • Zone of transition

    • The less distinct the margin  the more aggressive the lesion


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Bone Loss

  • If the cortex is destroyed, the process is more aggressive than if the cortex is allowed to remodel

Intact

Destroyed


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Focal Bone Loss

  • Geographic Lysis

    • Large area of lysis

    • Usually less aggressive

    • If destroys the cortex  aggressive


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Focal Bone Loss

  • Geographic lysis

    • Expansile appearance

    • Expansion of the cortex around an enlarging mass  less aggressive

    • Note the intact cortex in the picture



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Focal Bone Loss

  • Moth Eaten lysis

    • Multiple smaller areas of lysis

    • Areas may become confluent

    • More aggressive than geographic lysis


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Focal Bone Loss

  • Permeative Lysis

    • Numerous small and pin point areas of lysis whose margins are indistinct and fade gradually into normal bone



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Periosteal Reactions - Activity

  • Classification is based on sharpness of reaction margins

    • Active = indistinct margins

    • Inactive = well defined margins



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Active Periosteal Reactions(indistinct margins)


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Periosteal Rxns - Duration

  • The older the lesion is  the more opaque (bone like) it becomes

  • The area under the periosteum is initially soft then as it matures becomes more bone like



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Solid Periosteal Reaction

  • Bone completely fills in the area under the reaction

  • Surface can be smooth or irregular


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Solid Periosteal Reaction

  • The margins are fuzzy so it is still active


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Lamellated Periosteal Reaction

  • Reaction has a layered or onion skin appearance

  • Indicates a cyclic or intermittent process


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Periosteal Reactions

Lamellated Periosteal Reaction

This is a semi-aggressive

reaction

Note the three layers

The distal portion is fuzzy so

the reaction is active

The reaction is of bone opacity

so it is chronic or mature


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Spiculated Periosteal Reaction

  • Bone incompletely fills the area under the periosteum

  • More aggressive type of periosteal reaction



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Amorphous Periosteal Reaction

  • Bone is formed in a disorganized fashion

  • Process may destroy spicules of bone as they are being formed

  • This is a very aggressive process



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Codman’s Triangle

  • There is a solid periosteal reaction seen at the edge of and aggressive reaction


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Description

  • Mono-ostotic vs. polyostotic vs. joint centered

    • Location/s

  • Periosteal reaction

    • Active or inactive

    • Type (solid smooth, solid irregular, spiculated, amorphous)

    • Duration

  • Lysis

    • Type

    • Cortex destruction

    • Zone of transition


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Aggressive Lesions

Poorly demarcated

Long zone of transition

Poorly marginated osteolysis

Cortex interrupted

Interrupted irregular periosteal reaction

No surrounding sclerosis

Rapid rate of change

Non-aggressive Lesions

Well demarcated

Short zone of transition

Absent or geographic osteolysis

Cortex may be displaced, remodeled and thin, but not broken

Solid, smooth periosteal reaction

+/- surrounding sclerosis

Static or slow rate of change

The most aggressive feature of the lesion is how the lesion is characterized


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Differentials

  • Based on aggressiveness of lesion

  • Location/s

  • Mono/ poly-ostotic / joint centered

  • Must assess signalment and history, location, additional tests…

  • Many diseases have similar radiographic appearance – may require biopsy


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Primary Bone Tumors

  • Radiographic Signs:

    • Lesion may be primarily productive, lytic or both

    • Lytic or productive lesions usually have an aggressive appearance

    • Away from the elbow and toward the knee


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Primary Bone Tumors

  • Radiographic Signs:

    • Typically mono-ostotic

    • Typically located in the metaphysis

    • Lesions typically do not cross joints





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Fungal Osteomyelitis

  • Radiographic Signs:

    • Typically lesions are seen in the metaphysis

    • Appear similar to primary bone tumor

    • Often extensive destruction when a joint is infected (septic arthritis)

    • Often is poly-ostotic


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Fungal Osteomyelitis

  • Etiological Agents:

  • Blastomyces dermatitidis

    • Southern states, mid-west and south-west

  • Coccidioides immitis

    • Westernstates

  • Histoplasma capsulatum

    • mid-western states

  • Cryptococcus neoformans & Aspergillosis

    • Throughout the US





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Differential Diagnosis

  • Single aggressive lesion of long bones

    • Primary bone tumor

    • Fungal osteomyelitis

    • Metastatic bone tumors

      • Carcinomas

  • Use signalment, geographic location, and clinical findings to prioritize the differential list

    • May require a biopsy with culture


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Bacterial Osteomyelitis

  • Usually secondary to:

    • Gunshot wound

    • Penetrating wound ( dog or cat bite)

    • Previous surgery (implants)

    • Open fracture

  • May be seen secondary to septicemia in young animals or animals which are immuno-compromised


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Bacterial Osteomyelitis

  • Radiographic Findings

    • Early = ST swelling

    • May take 10-14 days before periosteal reaction is seen

    • Periosteal reaction is typically solid and extends along the shaft of the diaphysis


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Bacterial Osteomyelitis

  • The periosteal reaction may extend beyond the limits of the fracture or surgical site

    • Often seen circumferentially on all cortices

  • Typically has irregular margin

  • Exuberant periosteal reaction

  • Lucency or lysis around implants

  • Rarely extends into adjacent joints


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Bacterial Osteomyelitis

Note the solid immature

periosteal reaction seen

circumferentially along the

entire diaphysis of the femur


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Bacterial Osteomyelitis

This is the same dog 3 weeks

later. Note the maturing of the

periosteal reaction which is no

longer active