Musculoskeletal Radiology

อ.พิมใจ ภาควิชา รังสีวิทยา 2554

Outline• How to describe fracture• Common fracture & dislocation

– Case-based learning• upper & lower extremities

• Approach to non-traumatic problems• Bone disease

– Bone tumor / infection/ metastasis • Joint disease

Site of fractureAlignment• Angulation• Over-ridingDisplacement• Distal fragmentAssociated injury• Other site injury• Hematoma• N,V injury

Describe this fracture

Upper extremities:

- Normal radiographs

- Shoulder, Elbow, Wrist

- Case-based learning

Common Fracture-Dislocation

AP

Radiographic Technique

Lateral Y-viewAP

XR- Shoulder : AP & Lateral Y view

Lateral Y view

Shoulder : AP view

XR showBones- Humeral head- Glenoid fossa- Acromion, coracoid- ClavicleJoints- GH joint- AC joint

HHGl

C A

Shoulder- Lateral Y- view

C

AC

HH

Case 70 YOF

Hx- Fell down

XR - Findings

A B

Which one is False

Most common injury to axillary nerveWhich supply Deltoid muscle

Shoulder- Fracture/ dislocationShoulder Dislocation

• Most frequently dislocated joint• Anterior dislocation (95%)

>> Posterior dislocation (5%)• Associated injury

– Fracture greater tuberosity– Fracture humeral head (Hill-Sach)– Fracture glenoid bone (Bankart )– Axillary nerve injury

Shoulder : Anterior Dislocation

Associated fractures• Hill-Sachs fracture

– Posterolateral humeral head– 74% in recurrent dislocation

• Bony Bankart lesion – Anterior glenoid bone

• Fracture greater tuberosity

XR- Elbow : AP and Lateral view

XR- Elbow : AP view

Lateral side1. Lat. Epicondyle

: non-articular

2.Capitellum

: articular

Medial side1.Med Epicondyle

: non-articular

2.Trochlea

: articular

XR- Elbow: Lateral view

Normal alignment 1.Radiocapitellar line2.Anterior humeral line

point to the middle 1/3 capitellum

XR- Elbow : AP and Lateral view

Relationship between the radial head and capitellum

Hx- Fell down

XR - Findings

Case 30 YOM

Case 10 YO boy- Fell down Wrist : PA view

XR showBones- Distal radius, ulna- Carpal bones- MetacarpalsJoints- Distal radioulnar joint- Wrist ( radiocarpal) joint- Metacarpophalangeal

(MP) joint

Wrist –lateral view

-The central axis of the 3rd MC extend along capitate, lunate & the radius

C

L

PS

XR- Wrist : PA & Lateral view

• Fall on the outstretched

• Dorsiflexed hand

80% 20%

Case 40 YOF – Fell down

A. B. Case 20 YOM – Fell down

Lower extremities:

- Normal radiographs

- Hip, Knee , Ankle

- Case-based learning

Common Fracture-DislocationPelvis – both hips : AP view

Hip Anatomy- Acetabulum- Femur : Head, neck, trochanter

GT

LT

Pelvis – both hips : AP view

Shenton’s line :- Relationship of hip ; continuity of obturator foramen to femoral neck- If discontinuity –look for fracture FN

Case 30 YOM

Case 20 YOM

A. B

Dislocation of the HipClassification• Posterior dislocation, 90%

– Femoral head behind acetabulum– Posterior rim of acetabulum is usually fractured– Sciatic nerve injury**, 10%

• Anterior dislocation, 10 %– Femoral head in front of acetabulum, displaced into obturator,

pubic or iliac region

• Central – intra-pelvic location – Always associated with acetabular fracture

R L

Case 50 YOM XR- Knee : AP & Lateral standing view

Knee :Lateral view -Joint effusion Case 20 YOM

Case 40 YOM Case 40 YOF

Knee Dislocation• Ortho emergency• Look for associated fracture &NV injury• Ligaments & other soft tissue disrupted• Prompt reduction important

Ankle-Foot Trauma

Ottawa Rules XR Ankle if:-tenderness at

- A med malleolus- B lat malleolusA

B

Ankle AP - Mortise

To decide fracture instability Stress view - 15-20o internal oblique projection

Bone Disease

Sign of bone disease• Bone destruction

– Edge/ margin– Adjacent cortex

• Periosteal reaction• Cortical thickening

Differential Dx• Bone tumor

– Benign– Malignant : Primary/ Metastasis

• Infection/ Osteomyelitis

Bone tumor• Bone changes

– Osteolytic destruction– Margin of the lesion– Tumor matrix

• Periosteal reaction

Pattern of Bone Destruction

• Geographic benign• Motheaten malignancy

infection• Permeative malignancy

infection

Pattern of bone destruction

Geographic Motheaten Permeative

Periosteal ResponseSolid type benign Aggressive Malignant• Onion peel • Codman’s triangle• Sunray

Most aggressive

Periosteal Response

Sunray Codman’s Onion peel

Tumor Matrix

Osteoid Chondroid matrix

Age (Yr) Possible diagnosis

< 20 Ewing sarcoma, Osteosarcoma20-40 Giant cell tumor, Osteosarcoma,

lymphoma> 40 Chondrosarcoma, Metastasis,

Multiple Myeloma

Patient age with malignant tumors Malignant bone tumor

Tissue of origin Tumor• Bone Osteosarcoma• Cartilage Chondrosarcoma• Marrow element Ewing’s; MM, Lymphoma• Fibrous tissue Fibrosarcoma• Metastatic Lung, Breast, Prostate,

Kidney, Thyroid

A 9-year-old boy, pain & swelling right knee for 3 months

Pathologic fracture femur

60 YOM Severe pain

Pathologic Fracture

Abnormal bone

Normal Force

Pathologic Fracture

Abnormal bone

Bone tumorPrimary / Metastasis

Multiple Bone lesions

• Metastasis• Multiple

myeloma

Radionuclide bone scan is helpful for further investigation

Radionuclide bone scan : Metastasis