M-2

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M-2 MUSCULOSKELETAL IMAGING
DR. F. NEUFFER
RADIOLOGY 09-10
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SPINE AND EXTREMITY

• TRAUMA
• DEGENERATIVE
• INFECTIOUS
• INFLAMATORY
• X-RAY PLAIN FILM
• CT
• MR
• NUCLEAR MEDICINE
• ULTRASOUND

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LATERAL LUMBAR SPINE
POSTERIOR
ANTERIOR
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TRANSVERSE OR AXIAL
PROJECTION
ANTERIOR
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HISTORY OF CHRONIC NECK PAIN

• PLAIN FILM
• SCREEN
• BONY ANATOMY
• ALIGNMENT

DEGENERATIVE DISC DISEASE
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CERVICAL SPINE LATERAL VIEW
DENS
SPINOUS PROCESS
C-4
DISC SPACE
TRACHEA
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SPINE LINES
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HYPERFLEXION INJURY
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HX OF PAIN -- POST FALL
CT GIVES MORE DETAIL OF FINDINGS ON PLAIN X-RAYS
COMPRESSION FRACTURE
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RECONSTRUCTION SAGITTAL CT
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NEW COMPRESSION FRACTURE?
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NUCLEAR BONE SCAN
Increased activity on bone scan supports recent
event.
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Progressive collapse of vertebra
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VERTEBROPLASTY
COLLAPSED VERTEBRA
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NUCLEAR MEDICINE DEXA SCAN
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HX OF RADIATING PAIN TO RIGHT LEG
MR FOR NEUROLOGICAL FINDINGS
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UPPER EXTREMITY
ACROMION
CLAVICLE
ANATOMY REVIEW
HUMERAL HEAD
GLENOID FOSSA
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ROTATOR CUFF TENDON
SSM
ANTERIOR
CORONAL
SUPRAPINATUS MUSCLE ROTATOR CUFF TENDON
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SHOULDER TANGENTIAL / Y VIEW
CLAVICLE
ACROMION
A
C
H
SCAPULA SPINE
HUMERAL HEAD
HUMERUS
THE Y VIEW IS USED TO DETERMINE ANTERIOR /
POSTERIOR DISLOCATION OF THE HUMERUS
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TORN ROTATOR CUFF TENDON
SSM
NORMAL
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CLAVICLE
NORMAL
FRACTURED
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AC JOINT ACROMIO-CLAVICULAR JOINT
NORMAL
AC JOINT SEPARATION
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NORMAL
SHOULDER DISLOCATION
ANTERIOR DISLOCATION
AXILLARY NERVE INJURY TO C5-6 CAN OCCUR WITH
ANTERIOR DISLOCATION
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NORMAL
HILL-SACHS DEFORMITIES OCCUR IN 35-40 OF ANTERIOR DISLOCATIONS AND UP TO 80 OF RECURRENT DISLOCATIONS
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WHO WOULD BE THE TYPICAL PATIENT?
Elderly female with osteoporosis and decreased
upper extremity muscle mass.
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PA HAND
Roentgens wifes hand
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FRACTURED RADIAL METAPHYSIS
LAT. VIEW
PA VIEW
Fall on outstretched hand. Colles fracture is a
radial metaphyseal fracture with dorsal
angulation.
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NOTE THE NECROSIS

WHY?
FRACTURED NAVICULAR
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BLOOD FLOW THROUGH THE NAVICULAR BONE
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FRACTURED WRIST
LAT. VIEW
PA VIEW
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SALTER FRACTURES
SALTER

• I "Slipped epiphysis".
• I I "Above the growth plate"
• I I I "Lower than the growth plate
• IV "Through the growth plate".
• V "Raised epiphysis".

II
I
III
IV
V
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ARTHRITIS OF THE HAND

• OSTEOARTHRITIS
• RHEUMATOID ARTHRITIS
• GOUTY ARTHRITIS
• PSORIATIC ARTHRITIS
• SCLERADERMA

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OSTEOARTHRITIS
Classic findings are osteophytes,joint space
narrowing and sclerotic bony change symetrically
present. This involves DIP,PIP and base of thumb
preferentially.
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Osteoarthritis (DJD) Plain film of a finger with
osteoarthritis (DJD) Of the distal and proximal
interphalangeal joints. Both Joints demonstrate
joint space narrowing, subchondral Sclerosis,
and osteophytosis, which are hallmarks of DJD.
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RHEUMATOID ARTHRITIS
Osteoporosis, erosions and joint swelling are
seen. The carpal bones and MCP joints are
preferentially involved. Disease is usually
symmetric.
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RA
OA
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GOUT
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ADVANCED GOUT. Marked diffuse and focal soft
tissue is present throughout the hand and wrist
in this patient with long-standing gout.
Destructive, large, wellmarginated erosions, some
with overhanging edges, are noted near multiple
joints. The focal areas of soft tissue swelling
are called tophi, some of which are calcified.
These only calcify with coexistent renal disease.
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PSORIATIC ARTHRITIS
EROSIONS WITH PENCIL POINT DEFORMITY
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PROLIFERATIVE EROSION AND ANKYLOSIS CAN OCCUR.
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SCLERADERMA
Soft tissue atrophy, calcifications and
contractures are seen. Bones are osteoporotic.
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ANATOMY REVIEW
ACETABLUM
FEMORAL HEAD
FEMORAL NECK
AP HIP
FOVEA CAPITIS
GREATER TROCHANTER
LESSER TROCHANTER
CORTICAL BONE
MEDULLARY BONE
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CORONAL MRI
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BONE SCAN
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BONE DENSITY MEASUREMENT NUCLEAR MEDICINE DUAL
ENERGY X-RAY ABSORBTIONOMETRY DEXA
DEXA imaging is used to assess risk of
osteoporotic fracture.
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INTERTROCHANTERIC FRACTURE
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PAIN WITH HISTORY OF MARATHON TRAINING
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STRESS FRACTURE
CORONAL MRI
T 1 scan
T 2 scan
T1 and T2 weighted scans show increased edema in
Rt femoral neck with linear fracture line
visualized. Typically MR shows marrow pathology
well and not cortical bone detail. A recongized
risk in female athletes with loss of body fat
decreses active estrogen and leads to premature
osteoporosis.
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LONG TERM STEROID TREATMENT AVASCULAR
NECROSIS
Bone scan
X-ray
MRI
Loss of blood supply to the femoral head can lead
to collapse, fragmentation and arthritis. Note
sclerotic Rt femoral head with increased activity
on bone scan and altered geographic signal on MR
scan. Multiple causes exist with steroid use,
Sickle Cell disease and trauma of note. Recent
reports of mandible osteonecrosis with
Biphosphonate therapy.
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FEMUR FRACTURE - MVC
LAT
AP
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DESCRIBE THE FRACTURE
AP

• BONE AND WHICH PART
• FRACTURE ORIENTATION AND
• PARTS
• DISPLACEMENT AND ANGULATION
• JOINT INVOLVEMENT

LAT
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EXAMPLE
There is an oblique fracture through the
diaphysis of the femur with approximately 1cm of
lateral and anterior displacement of the distal
fragments relative to the proximal fragments.
There is no angulation at the fracture margin.
There is some shortening due to unopposed muscle
pull. The fracture does not extend into the joint.
AP
LAT
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AP AND LATERAL KNEE
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LATERAL SAGITTAL
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ANTERIOR CRUCIATE LIGAMENT INJURY
Normal
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MENISCUS
normal
torn
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MEDIAL COLLATERAL LIGAMENT INJURY
Triad of O'Donahue-- A sports injury that
includes anterior ligament tear, medial
collateral ligament tear, and medial meniscal
tear.
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CT FOR PRE-OPERATIVE PLANNING
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DIABETIC OSTEOMYLITIS
Note air in soft tissues on right due to
bacterial growth.
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BONE SCAN OSTEOMYELITIS
Increased activity on bone scan supports
osteomylitis in metatarsal.
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GOUT
Urate crystals deposit and cause inflamation and
erosion.
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SUMMARY PLAIN FILMS - TRAUMA- INITIAL
CT - DETAIL -TRAUMA - PRE-OPERATIVE MR
- JOINTS - LIGAMENTS - DISCS-
OSTEOMYLITIS - SOFT TISSUE NM -
BONE DENSITY- OSTEOMYLITIS -
MALIGNANCY STAGING US - EFFUSIONS -
TENDONS
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CLASSIC MSK IMAGING CASES

• METASTATIC DISEASE
• ANKYLOSING SPONDYLITIS
• PROSTATE METASTASIS
• RENAL DISEASE HYPER PARA
  THYROID
• MULTIPLE MYELOMA
• SPONDYLSIS--SPONDYLOLITHES
  IS

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NORMAL BONE SCAN
METASTATIC BONE DISEASE
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ANKYLOSING SPONDYLITIS
BAMBOO SPINE SI JOINT- ANKYLOSIS
Bilateral marginal syndesmophytes are seen
bridging the disc spaces at multiple levels. This
is a so-called bamboo spine and is classic for
ankylosing spondylitis.
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SCURVY
RICKETS
Roebuck, D. J. Radiographics 199919873-885
Weinstein, M. et al. Pediatrics 2001108e55
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RUGGAR JERSEY SPINE
Sclerotic bands present at the vertebral body
endplates are characteristic of Ruggar Jersey
spine. This is seen in Hyperparathyroidism
usually related to underlying renal failure.
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IVORY VERTEBRA
Prostate metastasis
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PROSTATE METASTASIS
Increased activity at the L4 level is supportive
of Prostate malignancy with metastasis.
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MULTIPLE MYELOMA
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MULTIPLE MYELOMA
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normal
MULTIPLE MYELOMA
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OBLIQUE LUMBAR SPINE
SPONDYLOSIS
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SPONDYLOLITHTHESIS
Bony defect in spinal ring (Spondylysis) can
lead to subluxation (Spondyloliththesis)
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CHRISTMAS PAST
CHRISTMAS PRESENT
CHRISTMAS FUTURE