Musculoskeletal Imaging. Normal radiological representation

Musculoskeletal Musculoskeletal ImagingImaging

Normal Normal radiological radiological

representationrepresentation

Structure of bone and cartilage

Epiphysis

Epiphysial lineEpiphysial line

Diaphyses

Basic pathologic changesBasic pathologic changes

Basic Pathologic Basic Pathologic ChangesChanges

OsteoporosisOsteoporosis osteomalaciaosteomalacia OsteosclerosisOsteosclerosis Periosteal new bone formationPeriosteal new bone formation SequestrumSequestrum

OsteoporosisOsteoporosis

DefinitionDefinition:: OsteoporosisOsteoporosis is is a common metabolic diso a common metabolic diso

rder of bone characterized by qualitatively rder of bone characterized by qualitatively normal but quantitatively deficient bonenormal but quantitatively deficient bone

The

representa

tion

of

osteoporosis


Classificaton:Classificaton: It can be divided into generalized, rIt can be divided into generalized, r

egionalegional ，， and localized types and accoand localized types and accompanies a variety of disease processesmpanies a variety of disease processes


Pathophysiology Condition accounting for reduced bone

density ,however,the quantity of bone is deficient but the quality is normal

The normal equilibrium between the rate of bone formation and resorption is lost with resorption predominating


Cause of a disease(in child): Generalised osteoporosis

osteogenesis imperfecta acute leukaemia chronic systemic disease, e.g. cystic fibrosis nutritional causes storage disorders


Cause of a disease(in child): Localised osteoporosis

disuse (e.g. immobilisation post fracture) atrophy idiopathic juvenile osteoporosis AV malformation previous irradiation therapy


Cause of a disease(in adult): Generalized osteoporosis

age-relatedage-related accompanied endocrine disordersaccompanied endocrine disorders PregnancyPregnancy alcoholismalcoholism

Involvement of the axial skeleton and Involvement of the axial skeleton and proximal portions of the long bonesproximal portions of the long bones


Cause of a disease(in adult): Regional osteoporosis Regional osteoporosis

disuse or immobilizationdisuse or immobilization transient osteoporosis of the hip transient osteoporosis of the hip regional migratory osteoporosis regional migratory osteoporosis

Changes predominate in the appendicChanges predominate in the appendicular skeleton. ular skeleton.


Radiographic manifestationRadiographic manifestation The vertebral bodies may develop a biconcThe vertebral bodies may develop a biconc

ave shape or compression fracturesave shape or compression fractures In tubular bones the trabecular bone loss mIn tubular bones the trabecular bone loss m

ay cause the metaphyses to appear radiolucay cause the metaphyses to appear radiolucentent

Pathological fractures may occur at multiplPathological fractures may occur at multiple sitese sites

Schmorls nodesSchmorls nodes acute and insufficiency fractures acute and insufficiency fractures


MR MR imaging imaging iinn transient osteoporosis of the hip transient osteoporosis of the hip

manifested manifested as decreased signal intensity as decreased signal intensity on T1-weighted sequences and increased son T1-weighted sequences and increased signal intensity on T2-weighted sequencesignal intensity on T2-weighted sequences

The patient commonly has associated joiThe patient commonly has associated joint effusions in the affected hipnt effusions in the affected hip

Chemical shift fat suppression and STIR iChemical shift fat suppression and STIR imaging techniques can be effective in the maging techniques can be effective in the detection of transient bone marrow oededetection of transient bone marrow oedema ma

How to prevent it ?

Milk and physical exercise

OsteomalaciaOsteomalacia DefinitionDefinition:: OsteomalaciaOsteomalacia is is a group of disorders ra group of disorders r

esulting from inadequate or delayed mesulting from inadequate or delayed mineralization of osteoid in mature cortiineralization of osteoid in mature cortical and spongy bonecal and spongy bone

Osteomalacia Osteomalacia Pathophysiology :

Osteomalacia is characterized by abnormOsteomalacia is characterized by abnormal quantities of osteoid coating the surfaceal quantities of osteoid coating the surfaces of trabeculae and lining the haversian cas of trabeculae and lining the haversian canals in the cortex (osteoid seams)nals in the cortex (osteoid seams)

OsteomalaciaOsteomalacia Cause of a disease

Deficienty of vitamin D Gastrointestinal malabsorption Metabolic bone disease of premature inf

ants Liver disease (hepatic osteodystrophy ) Drug therapy Renal osteodystrophy Tumor-associated osteomalacia

OsteomalaciaOsteomalacia Radiographic manifestationRadiographic manifestation

Loosers zones or Milkmans pseudofracturLoosers zones or Milkmans pseudofractures are strongly suggestive but not diagnostes are strongly suggestive but not diagnostic of osteomalaciaic of osteomalacia

Osteomalacia AP radiograph of the hip demonstrates generalized osteopenia and a linear lucency (representing a Looser's zone) in the medial cortex of the femur.

Osteomalacia - Back Pain ConOsteomalacia - Back Pain Conditiondition

Osteomalacia is one of many conditions that can cOsteomalacia is one of many conditions that can cause back pain. ause back pain.

it is one of the first recognizable symptomsit is one of the first recognizable symptoms If your body doesn’t have enough vitamin D If your body doesn’t have enough vitamin D ，， tt

hat can bring about osteomalaciahat can bring about osteomalacia This condition causes your bones to become softeThis condition causes your bones to become softe

r over timer over time Your bones may even start to bend under the presYour bones may even start to bend under the pres

sure of your own body weightsure of your own body weight The type of back pain associated with osteomalacThe type of back pain associated with osteomalac

ia is pain along your spinal column ia is pain along your spinal column

Osteosclerosis Osteosclerosis Definition:Definition:

OsteosclerosisOsteosclerosis is an is an abnormal hardenin abnormal hardening or increased density of bone on radiogg or increased density of bone on radiographsraphs

OsteosclerosisOsteosclerosis Cause of a disease:

hyperparathyroidism renal osteodystrophy osteoarthritis skeletal metastasis myelofibrosis osteomyelitis

OsteosclerosisOsteosclerosis Location of diseaseLocation of disease

IIn renal osteodystrophy n renal osteodystrophy the axial skeleton is the dominant site of involthe axial skeleton is the dominant site of invol

vement; the pelvis, ribs and spine are affected vement; the pelvis, ribs and spine are affected most commonly most commonly

Osteosclerosis Osteosclerosis the vertebral bodies produces changes at both the vertebral bodies produces changes at both

superior and inferior aspects, leading to an apsuperior and inferior aspects, leading to an appearance termed the rugger jersey spine pearance termed the rugger jersey spine

OsteosclerosisOsteosclerosis Radiographic manifestationRadiographic manifestation

Increased radiodensity of bone that may oIncreased radiodensity of bone that may occur with various conditions including reccur with various conditions including renal osteodystrophy, osteopetrosis and pyknal osteodystrophy, osteopetrosis and pyknodysostosis nodysostosis

OsteosclerosisOsteosclerosis Renal osteodystrophyRenal osteodystrophy

Renal osteodystrophy is a general term usRenal osteodystrophy is a general term used to describe the bony changes associateed to describe the bony changes associated with chronic renal diseased with chronic renal disease

usually seen in late childhood usually seen in late childhood

Renal osteodystrophyRenal osteodystrophy The radiographic changes The radiographic changes apparent physeal widening (representiapparent physeal widening (representi

ng a widened zone of provisional calcifng a widened zone of provisional calcification)ication)

metaphyseal flaring, cupping and irregmetaphyseal flaring, cupping and irregularityularity

Renal osteoRenal osteodystrophydystrophy

Osteopenia, subcortical resorption, lucent metaphyseal bands, widening of metaphysis

Renal osteodystrophyRenal osteodystrophy

Thinning of cortices

Renal osteodystrophyRenal osteodystrophy The radiographic changesThe radiographic changes ：：

the radiographic features of secondary hythe radiographic features of secondary hyperparathyroidism perparathyroidism ：： focal areas of subperiosteal bone resorption afocal areas of subperiosteal bone resorption a

nd osteopenia nd osteopenia Common sites of involvement include the Common sites of involvement include the

radial aspect of the phalanges, distal radiuradial aspect of the phalanges, distal radius, distal clavicle, symphysis pubis and lates, distal clavicle, symphysis pubis and lateral aspect of the femoral neck ral aspect of the femoral neck

Renal osteodystrophy Radiograph of both hands demonstrating diffuse increased bone densitycoarse trabecular pattern and subperiosteal new bone formationparticularly involving the medial aspect of the middle phalanges and distal radius and ulna


the radiographic features of secondary hythe radiographic features of secondary hyperparathyroidism perparathyroidism ：： Osteosclerosis of the vertebral end plates may Osteosclerosis of the vertebral end plates may

cause a "rugger jersey" spine. cause a "rugger jersey" spine. Ectopic calcificationEctopic calcification slipped epiphyses particularly the capital femslipped epiphyses particularly the capital fem

oral epiphysis oral epiphysis

““rugger jersey" spinerugger jersey" spine

"rugger jersey spine"


the radiographic features of secondary hythe radiographic features of secondary hyperparathyroidismperparathyroidism：：

In severe long-standing cases brown tumoIn severe long-standing cases brown tumor may develop, these are rounded lucencier may develop, these are rounded lucencies with indistinct margins seen particularly s with indistinct margins seen particularly within the pelvis or long bones within the pelvis or long bones

Renal osteodystrophy Knee radiograph demonstrating a Brown tumor in the proximal right fibular metaphysis

Renal osteodystrophyRenal osteodystrophy Conclusion of radiography:Conclusion of radiography:

Early - Osteopenia Early - Osteopenia Thinning of cortices and trabeculae gives "groThinning of cortices and trabeculae gives "gro

und glass" x-rayund glass" x-ray Salt and pepper skull Salt and pepper skull Physeal thickeningPhyseal thickening Late epiphyseal ossification Late epiphyseal ossification Epiphyseal Slips - Preschool age: Proximal and Epiphyseal Slips - Preschool age: Proximal and

distal femoral and distal tibial distal femoral and distal tibial

Renal osteodystrophyRenal osteodystrophy Conclusion of radiography:Conclusion of radiography:

Late - Secondary hyperparathyroidism Late - Secondary hyperparathyroidism Subperiosteal cortical resorption - Distal phalaSubperiosteal cortical resorption - Distal phala

nx, end of clavicle, pubisnx, end of clavicle, pubis Lucent metaphyseal bands - are the best indicLucent metaphyseal bands - are the best indic

ator of severityator of severity Bowing of long bones Bowing of long bones Rugger Jersey spine - Osteosclerosis of the end Rugger Jersey spine - Osteosclerosis of the end

plates of the vertebral bodies plates of the vertebral bodies Brown Tumor (rare) Brown Tumor (rare)

Osteopetrosis Osteopetrosis Osteopetrosis is a thymic defect Osteopetrosis is a thymic defect The result is generalised osteosclerosis The result is generalised osteosclerosis

with dense, thick, brittle bones. with dense, thick, brittle bones.

OsteopetrosisOsteopetrosis Radiographic appearance:Radiographic appearance:

most marked with generalimost marked with generalizzed osteoscleroed osteosclerosis, cortical thickening, loss of normal corsis, cortical thickening, loss of normal cortico-cancellous differentiation and oblitertico-cancellous differentiation and obliteration of normal trabecular pattern ation of normal trabecular pattern

Osteopetrosis a. Right lower leg, b, pelvis and femora, c. lateral spinal radiograph Note the marked sclerosis of the bones and pathological fracture in the fibula.

OsteopetrosisOsteopetrosis

Pyknodysostosis Pyknodysostosis

Definition:Definition:Pyknodysostosis is a dysplasia manifest clinPyknodysostosis is a dysplasia manifest clin

ically by dwarfism, increased bone fragilitically by dwarfism, increased bone fragility and sclerotic bones y and sclerotic bones

It is a syndrome chararacterized by osteoscIt is a syndrome chararacterized by osteosclerosis, short stature, short broad handslerosis, short stature, short broad hands

PyknodysostosisPyknodysostosis Radiological appearance:Radiological appearance: a widely open persistent anterior fontaa widely open persistent anterior fonta

nelle nelle 。。 The angle of the mandible is vThe angle of the mandible is very obtuse with severe micrognathia ery obtuse with severe micrognathia

The vertebral bodies and long bones arThe vertebral bodies and long bones are sclerotic and with narrowing of the e sclerotic and with narrowing of the medullary canals medullary canals

Pyknodysostosis Lateral skull radiograph showing sclerosis of the skull .

Both fontanelles are open.

PyknodysostosisRadiograph of the lower limbs with very dense bones and fractures.

Periosteal new bone formatiPeriosteal new bone formationon

DefinitionDefinition ：： Periosteal new bone formation is a noPeriosteal new bone formation is a no

nspecific response of the periosteum tnspecific response of the periosteum to a variety of causes; it may be focal or o a variety of causes; it may be focal or diffuse diffuse


CauseCause ：： physiological, congenital, infective, infphysiological, congenital, infective, inf

lammatory, traumatic, metabolic, neolammatory, traumatic, metabolic, neoplasticplastic


a spiculated "sunburst" pattern with una spiculated "sunburst" pattern with undercutting of the margins (Codmans tridercutting of the margins (Codmans triangle) suggests a primary bone malignangle) suggests a primary bone malignancy; ancy;

a laminated "onion skin" pattern can ba laminated "onion skin" pattern can be seen with an aggressive lesion e seen with an aggressive lesion


Following trauma, focal periosteal neFollowing trauma, focal periosteal new bone formation may be seen radiogrw bone formation may be seen radiographically at 5aphically at 5~~ 14 days 14 days

The exact timing is dependent on the The exact timing is dependent on the age of the child (earlier in the younger age of the child (earlier in the younger child, later in the older child)child, later in the older child)


Periosteal new bone formation in non Periosteal new bone formation in non accidental injury is often more extensiaccidental injury is often more extensive than in accidental trauma ve than in accidental trauma

In non-accidental injury periosteal neIn non-accidental injury periosteal new bone formation can also occur in the w bone formation can also occur in the absence of fracturesabsence of fractures


Periosteal new bone formation may be Periosteal new bone formation may be the only radiographic evidence of a strthe only radiographic evidence of a stress fracture and occurs at the site of deess fracture and occurs at the site of deforming forceforming force

Periosteal new bone formation There is periosteal new bone in the tibial diaphysis secondary to a healing spiral fracture. The endosteal cortical thickening on the tibia medially

new bone formation Axial CT image of the proximal tibia demonstrating periosteal new bone on the posteromedial aspect secondary to a healing stress fracture.

Periosteal new bonPeriosteal new bone formatione formation （（ Radiograph of the Radiograph of the

humerushumerus ）） in a child with a Ewiin a child with a Ewi

ng's sarcoma demong's sarcoma demonstrating spiculatenstrating spiculated sunburst periosted sunburst periosteal new bone formatal new bone formation. ion.

SequestrumSequestrum Sequestrum is a fragment of necrotic bSequestrum is a fragment of necrotic b

one that becomes separated from healtone that becomes separated from healthy bonehy bone

Sequestra may occur in various conditiSequestra may occur in various conditions, such as osteomyelitis, tuberculouons, such as osteomyelitis, tuberculous arthritiss arthritis

SequestrumSequestrum raradiographs of thdiographs of the femur demone femur demonstrate a healed strate a healed fracture of the fracture of the femoral diaphyfemoral diaphysis. sis.

A large rod-like sA large rod-like sequestrum is oequestrum is observed in the bserved in the medullary canmedullary canal owing to chral owing to chronic osteomyelonic osteomyelitis itis

SequestrumSequestrum In haematogenous osteomyelitis, a shaIn haematogenous osteomyelitis, a sha

rply marginated bone lesion is seen as rply marginated bone lesion is seen as radiodense bone spicules caused by osradiodense bone spicules caused by osseous necrosis seous necrosis

The sequestrum frequently lies in a spThe sequestrum frequently lies in a space surrounded by granulation tissueace surrounded by granulation tissue

SequestrumSequestrum In some cases the sequestrum may breIn some cases the sequestrum may bre

ak through the cortex and enter the sofak through the cortex and enter the soft tissues, sometimes being discharged tt tissues, sometimes being discharged through draining sinuses hrough draining sinuses

Sequestra are best visualized using conSequestra are best visualized using conventional tomography, CT scanning ventional tomography, CT scanning

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Musculoskeletal Imaging. Normal radiological representation