SUMPh “N. Testemitanu” Radiology and Medical imaging department

MUSCULOSKELETAL SYSTEM IMAGING

M. Crivceanschii, assistant professor GOALS AND OBJECTIVES

• to be aware of the role of modern diagnostic imaging modalities

• to be familiar with main radiological signs and syndromes

• tips and tricks in musculoskeletal imaging IMAGING MODALITIES • that every student should now IMAGING MODALITIES

• Conventional Radiography

• Fluoroscopy

• Arthrography

• Computed Tomography

• Magnetic Resonance Imaging

• Ultrasound

• Scintigraphy PLAIN X-RAY FILM

• First line study for most medical issues

• Excellent for fractures/bony detail

• Very limited for soft tissues (ligaments, tendons, muscles)

• Only a screening tool in the spine

• The radiologist should obtain at least two (2) views of the bone involved at 90° angles to each other

• with each view including two adjacent joints FLUOROSCOPY

• Arthrography

• Tenography

• Arteriography

• Percutaneous Bone or Soft Tissue Biopsy CT SCANNING

• Excellent for bony structural anatomy in the setting of complicated fracture

• Less effective than MR for soft tissues and active processes

• High radiation Dose

• Interventional options MRI SCANNING

• Excellent for soft tissue pathology

• Good-excellent for bone pathology

• No ionizing radiation

• NOT patient friendly

• Some absolute and relative contraindications ULTRASOUND

• Reproducible in trained hands

• Excellent for superficial soft tissue elements including tendons and muscles

• No ionizing radiation

• Patient friendly SCINTIGRAPHY

• Image the entire skeleton at once

• It provides a metabolic picture

• It is particularly helpful in condition such as fibrous dysplasia, Langerhans Cell Histocytosis or metastatic cancer. CONGENITAL SKELETAL ANOMALIES CONGENITAL SKELETAL ANOMALIES

• Chromosomal disorders (e. g. Down’s syndrome, Marfan syndrome, Turner’s syndrome, etc.)

• Dwarfism (rhizomelic – proximal segments shortening, mesomelic – middle segments, acromelic – distal segments)

• Skeletal dysplasias (e. g. fibrous dysplasia, chondrodysplasia, etc.) CONGENITAL SKELETAL ANOMALIES

Rhizomelic dwarfism CARDINAL RADIOLOGICAL CRITERIA LONG BONES

• Abnormal length of long bones (e. g. too short in skeletal dysplasia, too long - in Marfan syndrome)

• Diaphyseal abnormalities: thin and overtubulated bones (e.g. neuromuscular disease), short and undertubulated bones (e.g. achondroplasia), diaphyseal sclerosis (Van Buchem disease) CONGENITAL SKELETAL ANOMALIES

Achondroplasia CARDINAL RADIOLOGICAL CRITERIA Long bones • Epiphyseal abnormalities: large epiphyses (e.g. chondrodystrophies), small epiphyses (e.g. hypothyroidism), stippled epiphyses (e.g. dysplasia), irregular epiphyses (e.g. dysplasia)

• Metaphyseal abnormalities: flaring, widening and cupping (e.g. metaphyseal chondrodysplasia), widening without cupping (e.g. Pyle disease), metaphyseal beaking (Menkes kinky hair syndrome) CONGENITAL SKELETAL ANOMALIES

Metaphyseal chondrodysplasia CARDINAL RADIOLOGICAL CRITERIA Hand abnormalities • Abnormal morphology of the hand: e.g. trident hand (e.g. achondroplasia)

• shortening of one or more metacarpals or metatarsals (e.g. achondroplasia, Turner syndrome)

• Abnormalities in the number of hand bones: oligodactyly (e.g. acrocephalosyndactyly) or polydactyly (e.g. aglossia-adactyly) CONGENITAL SKELETAL ANOMALIES

Turner’s syndrome CARDINAL RADIOLOGICAL CRITERIA Hand abnormalities

• Absence of digits: ‘radial ray’ (e.g. Klippel–Feil deformity) or ‘ulnar ray’ syndrome (e.g. acromesomelic dysplasia)

• acro-osteolysis (e.g. progeria)

• fusion of two adjacent fingers (syndactyly) (e.g. acrocephalosyndactyly)

• enlargement of one of more digits (macrodactyly): (e.g. acrocephalosyndactyly) CONGENITAL SKELETAL ANOMALIES

“Ulnar ray’’ syndrome CARDINAL RADIOLOGICAL CRITERIA Pelvic abnormalities

• Abnormal pelvic configuration: type A – the iliac wings are short and squared off (e.g. achondroplasia), type B - the iliac wings have a narrow waist (e.g. Morquio syndrome)

• Delayed or defective ossification of the pubic bones (e.g. chondrodystrophies)

• Protusio acetabuli (e.g. Turner syndrome) CONGENITAL SKELETAL ANOMALIES

Morquio syndrome CARDINAL RADIOLOGICAL CRITERIA Spine abnormalities

• Abnormalities of the C1–C2 area: e.g. atlantodental distance is increased in Morquio’s disease

• Shape of the vertebral bodies: flat vertebrae (e.g. osteogenesis imperfecta), tower vertebrae (trisomy-21), beaked vertebrae (neuromuscular diseases)

• Scalopping of the posterior wall of the vertebrae (e.g. Marfan syndrome) CONGENITAL SKELETAL ANOMALIES

Marfan syndrome SKELETAL TRAUMA: REGIONAL SKULL FRACTURES

• linear

• depressed skull fracture (open fractures)

• diastatic (widening suture lines in childhood)

• basilar

• ping pong fracture SKULL FRACTURES

Basilar fracture FACIAL FRACTURES

Fractures which involve a single facial buttress:

• frontal sinus fracture

• nasal bone fracture

• orbital blow-out fracture

• isolated zygomatic arch fractures

• paranasal sinus fractures

• alveolar process fractures

• mandibular fracture FACIAL FRACTURES

Complex fractures which involve multiple facial buttresses:

• naso-orbitoethmoid (NOE) complex fracture

• Le Fort fractures

• zygomaticomaxillary complex fracture FACIAL FRACTURES

Complex facial fractures SPINAL INJURY

• C1-C2 region: Jefferson fracture (ring fracture of C1), Hangman fracture (bilateral pedicle or pars fracture of C2)

• Thoracolumbar injury: o stable and unstable fractures (based on three column model of Denis) o Hyperflexion Injury (wedge fracture) o Jumper's fracture (burst fracture) o Chance fracture: three column injury with a horizontal orientation of the fracture SPINAL INJURY

Jumper's fracture PELVIC FRACTURES

Unstable pelvic fractures:

• anteroposterior compression: result in open book or sprung pelvis fractures

• lateral compression: result in a windswept pelvis

• vertical shear: results in Malgaigne fracture or bucket handle fracture

• combined mechanical: occur when two different force vectors are involved and results in a complex fracture pattern PELVIC FRACTURES

Combined mechanical fracture PELVIC FRACTURES

Isolated stable pelvic fractures :

• acetabular fracture

• pubic ramus fracture

• iliac wing fracture (Duverney fracture)

• avulsion fractures (e.g. ASIS, iliac crest, ischial tuberosity) PELVIC FRACTURES

Acetabular fracture SHOULDER INJURY

• Rotator cuff tears o causes: trauma, subacromial impingement, tendon degeneration, hypovascularity o Classification: full thickness rotator cuff tear, partial thickness rotator cuff tear SHOULDER INJURY

Rotator cuff tear SHOULDER INJURY

• Shoulder dislocation o Classification: anterior, posterior, inferior o Associated fractures/injuries: Hill-Sachs lesion, bony Bankart lesion, proximal humeral fractures, clavicular fracture, acromioclavicular joint disruption, acromial fracture SHOULDER INJURY

Anterior shoulder dislocation (Hill-Sachs lesion) ELBOW INJURY

• Paediatric common pathology: supracondylar fracture, lateral condyle fracture, medial epicondyle avulsion, radial head dislocation, radial neck fracture

• Adult elbow pathology: posterolateral rotatory instability, osteochondral lesions, ulnar collateral ligament tears, lateral epicondylitis, medial epicondylitis, radiobicipital bursitis, chronic avulsion etc. ELBOW INJURY

“Terrible triad of the elbow” Posterior elbow dislocation with fracture of the coronoid process and radial head fracture WRIST INJURY

• Fractures in children: Torus fracture, green stick fracture, epiphysiolysis fracture

• Adult common injuries: Colles' fracture, Smith's fracture, Barton's fracture, Die- punch fracture, Chauffeur's fracture, carpal instability WRIST INJURY

“Colles' fracture FEMORAL FRACTURES

• Femoral neck fracture: subcapital - femoral head/neck junction, transcervical - midportion of femoral neck, basicervical - base of femoral neck; Garden classification

• Fractures of the femoral shaft

• Fractures of the distal femur FEMORAL FRACTURES

Subcapital femoral neck fracture KNEE INJURY

• Meniscal lesions

• Avulsion fractures of the knee

• Anterior and/or posterior cruciate ligament tears

• Posterolateral Corner injury (fibular collateral ligament, biceps femoris muscle and tendon, popliteal tendon)

• Pre-, supra- and infrapatellar bursitis

• Patellar tendinopathy

• Patellar dislocation

• Osteochondritis Dissecans KNEE INJURY

Meniscal lesions ANKLE INJURY

• Main types of ankle fractures: Weber classification: o Weber A: infrasyndesmotic o Weber B: transsyndesmotic o Weber C: suprasyndesmotic o Malleolus Tertius fracture

• Salter-Harris fractures (fractures that involve the epiphyseal plate or growth plate)

• Maisonneuve fracture (frature of the proximal shaft of the fibula)

• Achilles tendon injury ANKLE INJURY

Weber B ankle fracture FOOT INJURY

• Lisfranc injury (ligament between 1st and 2nd metatarsal bases)

• Chopart injury (fracture / dislocation of the mid-tarsal joint )

• Avulsion fractures associated with ankle sprain

• Jones fracture (base of 5th metatarsal fracture)

• Calcaneal fracture FOOT INJURY

Lisfranc injury Bone tumor Bone tumor

The most important determinators in the analysis of a potential bone tumor are:

• The morphology of the bone lesion on a plain radiograph: o Well-defined osteolytic o ill-defined osteolytic o Sclerotic

• The age of the patient Bone tumor Other clues need to be considered:

• lesion’s localization within the skeleton and within the bone: o epiphysis - metaphysis – diaphysis o centric - eccentric - juxtacortical

• Zone of transition

• Periosteal reaction

• Cortical destruction

• Matrix of the lesion Bone tumor Ill defined osteolytic tumors and tumor-like lesions:

. Malignant bone tumors: o Ewing's sarcoma o Osteosarcoma (most common presentation: sclerotic) o Leukemia o Metastases and Myeloma.

. Aggressive benign lesions: o Infection o Eosinophilic granuloma o locally aggressive Giant Cell Tumor Bone tumor

Ewing sarcoma Bone tumor

Giant cell tumor Bone tumor Most common well-defined osteolytic bone tumors and tumor-like lesions:

. Fibrous dysplasia . Multiple Myeloma

. Enchondroma . Aneurysmal Bone Cyst

. Eosinophilic granuloma . Solitary Bone Cyst

. Giant cell tumor . Hyperparathyroidism

. Osteoblastoma . Infection

. Non Ossifying Fibroma . Chondroblastoma

. Metastases . Chondromyxoid Fibroma Bone tumor Important tips and tricks:

. In patients > 40 years metastases and multiple myeloma are by far the most common well-defined osteolytic bone tumors.

. Patients with Brown tumor in hyperparathyroidism should have other signs of HPT or be on dialysis.

. Differentiation between a benign enchondroma and a low grade chondrosarcoma can be impossible based on imaging findings only.

. Infection is seen in all ages. Bone tumor

Fibrous dysplasia Bone tumor

Non Ossifying Fibroma Bone tumor

Vertebral metastases Bone tumor Most common sclerotic bone tumors and tumor-like lesions:

. Bone infarction . Melorrheostosis

. Bone island . Metastases

. Chondroblastoma . Non-ossifying fibroma

. Chondrosarcoma . Osteochondroma

. Enchondroma . Osteoid osteoma

. Eosinophilic granuloma . Osteomyelitis

. Fibrous dysplasia . Osteosarcoma

. Paget's disease of bone . Reactive processes Bone tumor

Enchondroma Bone tumor

Osteosarcoma