Musculoskeletal Imaging

1. Musculoskeletal Imaging

2. Normal radiological representation

3. Structure of bone and cartilage

4. Epiphysis Epiphysial line Diaphyses

6. Basic pathologic changes

7. Basic Pathologic Changes • Osteoporosis • osteomalacia • Osteosclerosis • Periosteal new bone formation • Sequestrum

8. Osteoporosis • Definition: • Osteoporosis is a common metabolic disorder of bone characterized by qualitatively normal but quantitatively deficient bone

9. The representation of osteoporosis

10. Osteoporosis • Classificaton: It can be divided into generalized, regional，and localized types and accompanies a variety of disease processes

11. Osteoporosis • 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

13. Osteoporosis • Cause of a disease(in child): • Generalised osteoporosis • osteogenesis imperfecta • acute leukaemia • chronic systemic disease, e.g. cystic fibrosis • nutritional causes • storage disorders

14. Osteoporosis • Cause of a disease(in child): • Localised osteoporosis • disuse (e.g. immobilisation post fracture) • atrophy • idiopathic juvenile osteoporosis • AV malformation • previous irradiation therapy

15. Osteoporosis • Cause of a disease(in adult): • Generalized osteoporosis • age-related • accompanied endocrine disorders • Pregnancy • alcoholism • Involvement of the axial skeleton and proximal portions of the long bones

16. Osteoporosis • Cause of a disease(in adult): • Regional osteoporosis • disuse or immobilization • transient osteoporosis of the hip • regional migratory osteoporosis • Changes predominate in the appendicular skeleton.

17. Osteoporosis • Radiographic manifestation • The vertebral bodies may develop a biconcave shape or compression fractures • In tubular bones the trabecular bone loss may cause the metaphyses to appear radiolucent • Pathological fractures may occur at multiple sites • Schmorls nodes • acute and insufficiency fractures

20. Osteoporosis • MR imaging • in transient osteoporosis of the hip manifested as decreased signal intensity on T1-weighted sequences and increased signal intensity on T2-weighted sequences • The patient commonly has associated joint effusions in the affected hip • Chemical shift fat suppression and STIR imaging techniques can be effective in the detection of transient bone marrow oedema

22. How to prevent it ? Milk and physical exercise

23. Osteomalacia • Definition: • Osteomalacia is a group of disorders resulting from inadequate or delayed mineralization of osteoid in mature cortical and spongy bone

24. Osteomalacia • Pathophysiology : • Osteomalacia is characterized by abnormal quantities of osteoid coating the surfaces of trabeculae and lining the haversian canals in the cortex (osteoid seams)

25. Osteomalacia • Cause of a disease • Deficienty of vitamin D • Gastrointestinal malabsorption • Metabolic bone disease of premature infants • Liver disease (hepatic osteodystrophy ) • Drug therapy • Renal osteodystrophy • Tumor-associated osteomalacia

26. Osteomalacia • Radiographic manifestation • Loosers zones or Milkmans pseudofractures are strongly suggestive but not diagnostic of osteomalacia

27. 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.

28. Osteomalacia - Back Pain Condition • Osteomalacia is one of many conditions that can cause back pain. • it is one of the first recognizable symptoms • If your body doesn’t have enough vitamin D ，that can bring about osteomalacia • This condition causes your bones to become softer over time • Your bones may even start to bend under the pressure of your own body weight • The type of back pain associated with osteomalacia is pain along your spinal column

29. Osteosclerosis • Definition: • Osteosclerosis is an abnormal hardening or increased density of bone on radiographs

30. Osteosclerosis • Cause of a disease: • hyperparathyroidism • renal osteodystrophy • osteoarthritis • skeletal metastasis • myelofibrosis • osteomyelitis

31. Osteosclerosis • Location of disease • In renal osteodystrophy • the axial skeleton is the dominant site of involvement; the pelvis, ribs and spine are affected most commonly • Osteosclerosis • the vertebral bodies produces changes at both superior and inferior aspects, leading to an appearance termed the rugger jersey spine

32. Osteosclerosis • Radiographic manifestation • Increased radiodensity of bone that may occur with various conditions including renal osteodystrophy, osteopetrosis and pyknodysostosis

33. Osteosclerosis • Renal osteodystrophy • Renal osteodystrophy is a general term used to describe the bony changes associated with chronic renal disease • usually seen in late childhood

34. Renal osteodystrophy • The radiographic changes • apparent physeal widening (representing a widened zone of provisional calcification) • metaphyseal flaring, cupping and irregularity

35. Renal osteodystrophy • Osteopenia, • subcortical resorption, • lucent metaphyseal bands, • widening of metaphysis

36. Renal osteodystrophy Thinning of cortices

37. Renal osteodystrophy • The radiographic changes： • the radiographic features of secondary hyperparathyroidism ： • focal areas of subperiosteal bone resorption and osteopenia • Common sites of involvement include the radial aspect of the phalanges, distal radius, distal clavicle, symphysis pubis and lateral aspect of the femoral neck

38. Renal osteodystrophy • Radiograph of both hands demonstrating diffuse increased bone density • coarse trabecular pattern and subperiosteal new bone formation • particularly involving the medial aspect of the middle phalanges and distal radius and ulna

39. Renal osteodystrophy • The radiographic changes： • the radiographic features of secondary hyperparathyroidism ： • Osteosclerosis of the vertebral end plates may cause a "rugger jersey" spine. • Ectopic calcification • slipped epiphyses particularly the capital femoral epiphysis

40. “rugger jersey" spine

41. "rugger jersey spine"

42. Renal osteodystrophy • The radiographic changes： • the radiographic features of secondary hyperparathyroidism： • In severe long-standing cases brown tumor may develop, these are rounded lucencies with indistinct margins seen particularly within the pelvis or long bones

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

44. Renal osteodystrophy • Conclusion of radiography: • Early - Osteopenia • Thinning of cortices and trabeculae gives "ground glass" x-ray • Salt and pepper skull • Physeal thickening • Late epiphyseal ossification • Epiphyseal Slips - Preschool age: Proximal and distal femoral and distal tibial

45. Renal osteodystrophy • Conclusion of radiography: • Late - Secondary hyperparathyroidism • Subperiosteal cortical resorption - Distal phalanx, end of clavicle, pubis • Lucent metaphyseal bands - are the best indicator of severity • Bowing of long bones • Rugger Jersey spine - Osteosclerosis of the end plates of the vertebral bodies • Brown Tumor (rare)

46. Osteopetrosis • Osteopetrosis is a thymic defect • The result is generalised osteosclerosis with dense, thick, brittle bones.

47. Osteopetrosis • Radiographic appearance: • most marked with generalized osteosclerosis, cortical thickening, loss of normal cortico-cancellous differentiation and obliteration of normal trabecular pattern

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

49. Osteopetrosis

50. Pyknodysostosis Definition: Pyknodysostosis is a dysplasia manifest clinically by dwarfism, increased bone fragility and sclerotic bones It is a syndrome chararacterized by osteosclerosis, short stature, short broad hands