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Diagnostic Radiology of Diagnostic Radiology of Musculoskeletal SystemMusculoskeletal System

Zhang ZhaohuiZhang Zhaohui

Department of RadiologyDepartment of Radiology

The First Affiliated Hospital of Sun Yat-sen UniversityThe First Affiliated Hospital of Sun Yat-sen University

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Infectious diseases of boneInfectious diseases of bone

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EtiologyEtiologyInfecting organism:Infecting organism: Staphylococcus aureusStaphylococcus aureusRouteS of contaminationRouteS of contamination

Hematogenous seedingHematogenous seeding Direct contaminationDirect contamination

penetrating trauma, post surgicalpenetrating trauma, post surgical Contiguous spreadContiguous spread

soft tissue infection, septic arthritissoft tissue infection, septic arthritis

Acute Pyogenic osteomyelitis

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Location Location MetaphysisMetaphysis

Age:Age: Children most commonly affectedChildren most commonly affected

Clinical presentationClinical presentation Pain, feverPain, fever Restricted motion + point tendernessRestricted motion + point tenderness Soft tissue swelling + erythema + sinus tractSoft tissue swelling + erythema + sinus tract PrognosisPrognosis good if treated early good if treated early Osseous destruction will reoccur if untreatedOsseous destruction will reoccur if untreated Develop into chronic infectionDevelop into chronic infection

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Radiographic findingsRadiographic findings

Soft tissue swellingSoft tissue swelling

Bone changes delayed 10-14 days after onset of feverBone changes delayed 10-14 days after onset of fever

Focal lucency to frank destruction of boneFocal lucency to frank destruction of bone

Periosteal new bone formationPeriosteal new bone formation

SequestrumSequestrum

OsteosclerosisOsteosclerosis

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1 2

Soft tissue swelling without Soft tissue swelling without visibe bone destruction witvisibe bone destruction with increase in diameterh increase in diameter

Focal bone Focal bone destructiondestruction

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第5次

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Bone destruction Bone destruction and osteosclerosisand osteosclerosis

Osteosclerosis, without soft tissue sOsteosclerosis, without soft tissue swellingwelling

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Acute osteomyelitisAcute osteomyelitis

Bone destructionBone destruction

sequestrum ( )sequestrum ( )

periosteal new bone formation ( )periosteal new bone formation ( )

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Acute osteomyelitis of tibiaAcute osteomyelitis of tibia

Extensive bone Extensive bone destruction involving destruction involving whole tibia with different whole tibia with different degree of sclerosisdegree of sclerosis

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Acute osteomyelitis of radiusAcute osteomyelitis of radius

Radiograph shows bone destructiRadiograph shows bone destruction and laminated periosteal new on and laminated periosteal new bone formation.bone formation.

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Radiograph shows moth Radiograph shows moth eaten bone destruction eaten bone destruction at distal metaphysis of tiat distal metaphysis of tibia.bia.

Acute osteomyelitis of tibiaAcute osteomyelitis of tibia

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Acute osteomyelitis of tibiaAcute osteomyelitis of tibia

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T1WI T2WI

T1WI

+C

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Clinical presentationClinical presentationMild fever Mild fever Focal painFocal painSinus tract discharging pus due to the Sinus tract discharging pus due to the

existence of pus cavity or sequestrumexistence of pus cavity or sequestrum

Chronic pyogenic osteomyelitis

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Radiographic findings Radiographic findings Bone destruction with surrounding sclerosisBone destruction with surrounding sclerosis Periosteal new bone formationPeriosteal new bone formation Thickening of cortex and deformation of boneThickening of cortex and deformation of bone SequestrumSequestrum Soft tissue atrophySoft tissue atrophy ，， formation of sinus tractformation of sinus tract

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Radiographs show scleRadiographs show sclerosis, widening and defrosis, widening and deformation of tibia with ormation of tibia with narrowing of medullarnarrowing of medullary cavity.y cavity.

Chronic osteomyelitis Chronic osteomyelitis of tibiaof tibia

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Chronic osteomyelitis Chronic osteomyelitis of humerusof humerus

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Chronic osteomyelits Chronic osteomyelits of fibula with sequestof fibula with sequestrumrum

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Chronic osteomyelits Chronic osteomyelits of radius with sequesof radius with sequestrumtrum

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Brodie’s abscessBrodie’s abscess

Result of a long-standing osteomyelitis Result of a long-standing osteomyelitis

Often situated in the metaphysis Often situated in the metaphysis

Well defined cyst-like bone destruction witWell defined cyst-like bone destruction with pronounced surrounding sclerosish pronounced surrounding sclerosis

Sequestrum usually absentSequestrum usually absent

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Brodie’s abscessBrodie’s abscess

Round bone Round bone destruction ( )with destruction ( )with extensive sclerosis in extensive sclerosis in the lower third of the lower third of tibia.tibia.

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Brodie’s abscess of tibiaBrodie’s abscess of tibia

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Brodie’s abscess Brodie’s abscess

of femurof femur

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EtiologyEtiology Mycobacterium tuberculosisMycobacterium tuberculosis Hematogenous dissemination of pulmonary TBHematogenous dissemination of pulmonary TB

LocationLocation Long boneLong bone Short boneShort bone SpineSpine

Clinical presentationClinical presentation Depend on the stage and location of the diseaseDepend on the stage and location of the disease Acute symptoms rareAcute symptoms rare Swelling, pain, weakness, draining sinusSwelling, pain, weakness, draining sinus

Tuberculosis of boneTuberculosis of bone

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Tuberculosis Tuberculosis of femurof femur

Well defined bone Well defined bone destruction at distdestruction at distal metaphysis of fal metaphysis of femur with a small emur with a small sequestrum. There sequestrum. There is no sclerosis and is no sclerosis and no periosteal new no periosteal new bone formationbone formation

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Location: metaphysis and/or epiphysisLocation: metaphysis and/or epiphysis Well defined focal area of osteolysis Well defined focal area of osteolysis With little or no surrounding sclerosisWith little or no surrounding sclerosis Periosteal new bone formation uncommonPeriosteal new bone formation uncommon Sequestra : tiny irregular particles Sequestra : tiny irregular particles OsteoprosisOsteoprosis

Tuberculosis of long boneTuberculosis of long bone

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Tuberculosis of fibulaTuberculosis of fibula

Well defined bonWell defined bone destruction at pe destruction at proximal metaphyroximal metaphysis of right fibula sis of right fibula with slight margiwith slight marginal sclerosis. Thnal sclerosis. There is no periosteere is no periosteal new bone foral new bone formationmation

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Tuberculosis oTuberculosis of metaphysis af metaphysis and epiphysis of nd epiphysis of proximal tibiaproximal tibia

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Tuberculosis of epiphysis of distal fibula with invasion of jointTuberculosis of epiphysis of distal fibula with invasion of joint

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Pyogenic osteomyelitisPyogenic osteomyelitis TuberculosisTuberculosis

ProgressionProgression Acute and rapidAcute and rapid SlowSlow

ExtentExtentExtensive, may involve wExtensive, may involve whole diaphysishole diaphysis

Focal, may invade joint, seldFocal, may invade joint, seldom extend to diaphysisom extend to diaphysis

Involvement of epiphysisInvolvement of epiphysis UncommonUncommon CommonCommon

Osseous changesOsseous changes Destruction and sclerosisDestruction and sclerosisDestruction and osteoprosis, Destruction and osteoprosis, sclerosis uncommonsclerosis uncommon

Periosteal reactionPeriosteal reaction Common, various patternCommon, various pattern UncommonUncommon

SequestrumSequestrum Common, largeCommon, large Uncommon, smallUncommon, small

Comparison of pyogenic osteomyelitis and tuberculosis of long boneComparison of pyogenic osteomyelitis and tuberculosis of long bone

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Tuberculosis of short boneTuberculosis of short bone

Children younger than 5 yearsChildren younger than 5 years

Expansile bone destruction of diaphysisExpansile bone destruction of diaphysis

Thinning of cortexThinning of cortex

Periosteal reactionPeriosteal reaction

Maybe multipleMaybe multiple

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Expansile bone Expansile bone destruction of first destruction of first metatarsal bone with metatarsal bone with thinning of cortexthinning of cortex

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Expansile bone Expansile bone destruction of fidestruction of first metacarpalrst metacarpal b bone with periostone with periosteal new bone foreal new bone formationmation

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Tuberculosis of SpineTuberculosis of Spine Involvement of vertebral body more common than pInvolvement of vertebral body more common than p

osterior appendagesosterior appendages

Bone destructionBone destruction

Collapse and deformity of vertebral bodyCollapse and deformity of vertebral body

Scoliosis, kyphosisScoliosis, kyphosis

Narrowing or disappearance of intervetebral spaceNarrowing or disappearance of intervetebral space Paravertebral abscess, calcificationParavertebral abscess, calcification

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Tuberculosis of Tuberculosis of cervical spinecervical spine

Destruction and Destruction and collapse of C6 collapse of C6 vertebral body and vertebral body and narrowing of C6/7 narrowing of C6/7 intervertebral spaceintervertebral space

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Destruction , collapse Destruction , collapse and fusion of C4, 5 verand fusion of C4, 5 vertebral body , disappeartebral body , disappearance of C4/5 interverteance of C4/5 intervertebral space and kyphosibral space and kyphosis. s.

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Destruction , collapse Destruction , collapse and fusion of T8,9 verand fusion of T8,9 vertebral body , disappeartebral body , disappearance of T8/9 interverteance of T8/9 intervertebral space and formatibral space and formation of paravertebral abon of paravertebral abscessscess( ). Soft tissue abnor( ). Soft tissue abnormalitymality

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Tuberbulosis of L2, 3Tuberbulosis of L2, 3

L1

39Destruction of vertebral body with paravertebral abscess and calcificationsDestruction of vertebral body with paravertebral abscess and calcifications

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Tuberculosis of spine with paravertebral abscessTuberculosis of spine with paravertebral abscess

T1 before inject contrast

T2 before inject C

T1 after C inject

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Imaging of JointImaging of Joint

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Normal x-ray appearance of elbow jointNormal x-ray appearance of elbow joint

Joint capsule

synovium

Articular cartilage

Joint space

Bone end

Normal X-ray appearance of Normal X-ray appearance of jointsjoints

The articular cartilages, synovium, synovial fluid and joint capsule are undifferentiThe articular cartilages, synovium, synovial fluid and joint capsule are undifferentiated from other soft tissues in a radiogram because of similar densities. ated from other soft tissues in a radiogram because of similar densities.

The thickness of the cartilages may be indicated by the width of the joint space. The thickness of the cartilages may be indicated by the width of the joint space.

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Elbow joint of adolescentElbow joint of adolescentElbow joint of adultElbow joint of adult Elbow joint of childElbow joint of child

Joint space of children is wider than that of adults becJoint space of children is wider than that of adults because of incompletely ossified epiphyseal cartilage.ause of incompletely ossified epiphyseal cartilage.

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Fat plane may outline the contour of joint Fat plane may outline the contour of joint capsule.capsule.

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1. Swelling of joint1. Swelling of joint

Basic X-ray features of joint diseasesBasic X-ray features of joint diseases

Etiology: effusion of joint or congestion, edema, Etiology: effusion of joint or congestion, edema, hemorrhage or inflammation of joint capsule and the hemorrhage or inflammation of joint capsule and the adjacent soft tissue. adjacent soft tissue.

Radiological appearance: increased density, Radiological appearance: increased density, widening of joint space and displacement of fat pad.widening of joint space and displacement of fat pad.

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Osteoporosis and swelling of knee jointOsteoporosis and swelling of knee joint

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Fat pad displacmentFat pad displacment

Like chinese character Like chinese character 八八

Supracondylar fracture

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T1WI +C

T2WI

Effusion of knee joint witEffusion of knee joint with thickened synoviumh thickened synovium

+CT1WI

T1

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2. Dislocation of joint2. Dislocation of joint

Dislocation is a complete loss of contact between two Dislocation is a complete loss of contact between two bone surfaces in a joint that normally articulate. This bone surfaces in a joint that normally articulate. This abnormality is severe than a subluxation, in which abnormality is severe than a subluxation, in which loss of contact is partial.loss of contact is partial.

Usually the joint capsule and ligaments tear when a Usually the joint capsule and ligaments tear when a joint becomes dislocated, and often the nerves are joint becomes dislocated, and often the nerves are injured as well.injured as well.

Traumatic, pathologic, recurrent and congenital Traumatic, pathologic, recurrent and congenital dislocations constitute the variety of dislocation.dislocations constitute the variety of dislocation.

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Inferior dislocation of shoulder jointInferior dislocation of shoulder joint

The humeral head The humeral head is inferior to glenis inferior to glenoid fossa.oid fossa.

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Posterior and lateral displacement of the radius and ulna Posterior and lateral displacement of the radius and ulna

with respect to humeruswith respect to humerus

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Congenital hip dislocationCongenital hip dislocation

Radiograph of pelvis demonstrates an superiorly dislocated femoRadiograph of pelvis demonstrates an superiorly dislocated femoral head as well as the shallow acetabulum on the right side.ral head as well as the shallow acetabulum on the right side.

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Subluxation of knee jointSubluxation of knee joint

Radiograhs show destruction of osteo-articular surface and sublRadiograhs show destruction of osteo-articular surface and subluxation of knee joint with narrowed but visible joint spaceuxation of knee joint with narrowed but visible joint space

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3.Destruction of joint3.Destruction of joint

Definition: the invasion and replacement of articular Definition: the invasion and replacement of articular cartilage and subchondral bone by pathological tissuecartilage and subchondral bone by pathological tissue

Radiological appearance: narrowing of joint space , dRadiological appearance: narrowing of joint space , destruction of bone in affected areas, subluxation and estruction of bone in affected areas, subluxation and deformity of joint.deformity of joint.

Etiology: pyogenic, tuberculous, rheumatoid arthritis,Etiology: pyogenic, tuberculous, rheumatoid arthritis, etc etc

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Narrowing of joint spacNarrowing of joint space and destruction of ostee and destruction of osteo-articular surfaceo-articular surface

Pyogenic arthritis Pyogenic arthritis of left hip jointof left hip joint

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Narrowing of left hip Narrowing of left hip joint space, destruction joint space, destruction of bone and subluxation of bone and subluxation of jointof joint

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Pathologic alterations in articulations result from degePathologic alterations in articulations result from degeneration. Cartilage and bone are the primary sites of abneration. Cartilage and bone are the primary sites of abnormality, with only mild alterations occurring in the snormality, with only mild alterations occurring in the synovial membrane. ynovial membrane.

Radiological appearance: joint space narrowing, subchRadiological appearance: joint space narrowing, subchondral sclerosis/eburnation, subchondral cyst lucencies ondral sclerosis/eburnation, subchondral cyst lucencies and osteophyte formation; subluxation, fibrous ankylosand osteophyte formation; subluxation, fibrous ankylosis, and intra-articular loose bodies.is, and intra-articular loose bodies.

4. Degeneration of Joint 4. Degeneration of Joint (osteoarthritis)(osteoarthritis)

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joint space narrowing, subchondral sclerosis, and osteophyte joint space narrowing, subchondral sclerosis, and osteophyte formation (an outgrowth or excrescence of a bone)formation (an outgrowth or excrescence of a bone)

Osteoarthritis of knee jointOsteoarthritis of knee joint

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Osteoarthritis of hip jointOsteoarthritis of hip joint

Radiograph of pelvis shows joint space narrowing, subchondral sRadiograph of pelvis shows joint space narrowing, subchondral sclerosis, osteophyte and lucency of subchondral cyst ( )clerosis, osteophyte and lucency of subchondral cyst ( )

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Subchondral cystSubchondral cyst Located in subchondral region of a jointLocated in subchondral region of a joint

Tend to occur in weight bearing areas Tend to occur in weight bearing areas

A radiolucent area with sclerotic marginA radiolucent area with sclerotic margin

Pathogenesis Pathogenesis Microfractures in subchonadral bone Microfractures in subchonadral bone Increased synovial fluid pressure Increased synovial fluid pressure

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Intra-articular body within knee jointIntra-articular body within knee joint

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Intra-articular bodiesIntra-articular bodies

Fragments of bone or cartilage (or of a combination Fragments of bone or cartilage (or of a combination of these) that may occur free in the joint cavity. of these) that may occur free in the joint cavity.

May arise from transchondral fractures, disintegration May arise from transchondral fractures, disintegration of the articular surface, synovial metaplasia and of the articular surface, synovial metaplasia and osteoarthritis.osteoarthritis.

Routine radiographs can reveal calcified and ossified Routine radiographs can reveal calcified and ossified bodies within joints, but arthrography and MR bodies within joints, but arthrography and MR imaging can display uncalcified cartilage bodiesimaging can display uncalcified cartilage bodies

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Intra-articular body within right hip jointIntra-articular body within right hip joint

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5. Ankylosis of Joint5. Ankylosis of Joint

Two types: bony ankylosis and fibrous ankylosisTwo types: bony ankylosis and fibrous ankylosisBony ankylosisBony ankylosis Bones of the joint fuse after proliferation of bone Bones of the joint fuse after proliferation of bone

cells, resulting in complete immobilitycells, resulting in complete immobility , , usually occurs iusually occurs in pyogenic arthritis, ankylosing spondylitis, etc. Radioln pyogenic arthritis, ankylosing spondylitis, etc. Radiologically, it appears as bony trabeculae traversing the joiogically, it appears as bony trabeculae traversing the joint space, which is narrowed or disappear.nt space, which is narrowed or disappear.

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Bony ankylosis of elbow jointBony ankylosis of elbow joint

Radiographs show union of bones in elbow jointRadiographs show union of bones in elbow joint and disappearance of joint space. disappearance of joint space.

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Bony ankylosis of hip jointBony ankylosis of hip joint

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5. Ankylosis of Joint5. Ankylosis of Joint

Fibrous ankylosis Fibrous ankylosis Proliferation of fibrous tissue results in partial joint Proliferation of fibrous tissue results in partial joint

immobility, immobility, usually occurs in tuberculous arthritisusually occurs in tuberculous arthritis. . ThThe joint space is narrowed or diminished, but still visible joint space is narrowed or diminished, but still visible. The diagnosis of fibrous ankylosis can only be made. The diagnosis of fibrous ankylosis can only be made clinically.e clinically.

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Fibrous ankylosis of knee jointFibrous ankylosis of knee joint

Radiograhs show destruction of osteo-articular surface and sublRadiograhs show destruction of osteo-articular surface and subluxation of knee joint with narrowed but visible joint spaceuxation of knee joint with narrowed but visible joint space

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Fibrous ankylosis of knee jointFibrous ankylosis of knee joint

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EtiologyEtiology Infecting organism:Infecting organism: staphylococcus aureusstaphylococcus aureus Route of contaminationRoute of contamination

Hematogenous seedingHematogenous seeding

synovium, bone marrow jointsynovium, bone marrow joint Direct contaminationDirect contamination

penetrating trauma, post surgicalpenetrating trauma, post surgical Contiguous spreadContiguous spread

soft tissue infection, osteomyelitissoft tissue infection, osteomyelitis

Pyogenic arthritis

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Location: Location: Weight-bearing joint: hip, kneeWeight-bearing joint: hip, knee

AgeAge: : ChildhoodChildhood

Clinical presentationClinical presentation Acute onset and rapid progressionAcute onset and rapid progression Pain, feverPain, fever Restricted motion + tendernessRestricted motion + tenderness

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Radiographic findingsRadiographic findings

Swelling of joint - widening of joint spaceSwelling of joint - widening of joint space

Destruction of articular cartilage - loss of joint spaceDestruction of articular cartilage - loss of joint space

Early and frank bone destruction at weight bearing areaEarly and frank bone destruction at weight bearing area

Pathological dislocation of jointPathological dislocation of joint

Osteomyelitis at metaphysisOsteomyelitis at metaphysis

Separation of epiphysis in childrenSeparation of epiphysis in children

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Pyogenic arthritis of right hip jointPyogenic arthritis of right hip joint

Radiograph shows narrowRadiograph shows narrowing of joint spaceing of joint space ，， irregirregular and unsmooth osteo-aular and unsmooth osteo-articular surfacerticular surface ，， enlargeenlargement of acetabulum, proximent of acetabulum, proximal and lateral subluxatiomal and lateral subluxation of femoral head.n of femoral head.

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Pyogenic arthritis Pyogenic arthritis

of hip jointof hip joint

Radiograph shows loss of Radiograph shows loss of joint spacejoint space ，， destruction destruction of osteo-articular surface.of osteo-articular surface.

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Pyogenic arthritis of hip jointPyogenic arthritis of hip joint

Radiograph shows loss of Radiograph shows loss of joint spacejoint space ，， destruction destruction of osteo-articular surface, of osteo-articular surface, and osteosclerosis .and osteosclerosis .

Normal

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Chronic pyogenic arthritis of Chronic pyogenic arthritis of hip jointhip joint

Radiograph shows loss of joiRadiograph shows loss of joint spacent space ，， destruction of osdestruction of osteo-articular surface, and proteo-articular surface, and prominent osteosclerosis.minent osteosclerosis.

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Bony ankylosis of right hip joiBony ankylosis of right hip joint after pyogenic arthritisnt after pyogenic arthritis

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EtiologyEtiology Mycobacterium tuberculosisMycobacterium tuberculosis Hematogenous seeding to synovial membraneHematogenous seeding to synovial membrane Spread from adjacent tuberculosis of boneSpread from adjacent tuberculosis of bone

Location Location Knee and hip jointKnee and hip joint

AgeAge ChildhoodChildhood

Tuberculous arthritisTuberculous arthritis

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Clinical presentationClinical presentation

SwellingSwelling

Mild pain Mild pain

Restriction of motionRestriction of motion

Atrophy of muscle in the later stageAtrophy of muscle in the later stage

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Radiographic findingsRadiographic findingsBone destruction (marginal erosion )Bone destruction (marginal erosion )Swelling of jointSwelling of jointGradual narrowing of joint space Gradual narrowing of joint space Osteoporosis Osteoporosis Atrophy of muscle Atrophy of muscle Cold abscess, sinus tractCold abscess, sinus tractFibrous ankylosisFibrous ankylosis

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Tuberculosis of Tuberculosis of knee jointknee joint

Well defined bone destruction at diWell defined bone destruction at distal metaphysis of femur with swellstal metaphysis of femur with swelling of knee jointing of knee joint

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Tuberculosis of hip jointTuberculosis of hip joint

Destruction of fDestruction of femur head, neck emur head, neck and acetabulum and acetabulum with swelling of with swelling of joint and osteopjoint and osteoporosis of left parorosis of left part of pelvis and ut of pelvis and upper third of left pper third of left femurfemur

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Tuberculosis of right hip jointTuberculosis of right hip joint

Narrowing of Narrowing of joint space and joint space and osteoporosisosteoporosis

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Tuberculosis of Tuberculosis of left knee jointleft knee joint

Radiographs of left knee joint show swelling of joint.

right

left

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Radiographs show joint destruction, narrowing of joint Radiographs show joint destruction, narrowing of joint space, swelling of joint, osteoporosis and subluxation.space, swelling of joint, osteoporosis and subluxation.

Tuberculosis of knee jointTuberculosis of knee joint

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Radiographs show maringal erosion( ), narrowing of joint Radiographs show maringal erosion( ), narrowing of joint space, swelling of joint and osteoporosisspace, swelling of joint and osteoporosis

Tuberculosis of knee jointTuberculosis of knee joint

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Tuberculosis of Tuberculosis of knee jointknee joint

Plain CT scan

Contrast enhanced CT scam

Comparison of Comparison of CT and CT and

radiographradiograph

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Comparison of tuberculous and pyogenic arthritisComparison of tuberculous and pyogenic arthritis

Tuberculous artTuberculous arthritishritis

Pyogenic arthritisPyogenic arthritis

OsteoprosisOsteoprosis ++ ±±

OsteosclerosisOsteosclerosis ±± ++

Bone destructionBone destruction marginmargin weight-bearing areaweight-bearing area

Joint space lossJoint space loss latelate earlyearly

AnkylosisAnkylosis fibrousfibrous bonybony

ProgressionProgression slowslow acute and rapidacute and rapid

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