MUSCULOSKELETAL RADIOLOGY

Dr. Aoife Mc Erlean,

Specialist Registrar in Radiology, Department of Radiology, Beaumont Hospital

Basic anatomy
Imaging modalities
Trauma
Metabolic bone disease
Arthritis
Neoplastic disease

BASIC ANATOMY
Bone
Bone is a rigid form of connective tissue which forms most of the skeleton and is the
main supporting tissue of the body. Like all other living tissues it is dynamic and has its
own arterial supply and venous and lymphatic drainage. In addition to being affected by
many pathological processes, bone can also remodel itself according to different
stressors- for example it may atrophy in a paralysed limb or become absorbed (e.g. in
mandible following tooth extraction).
The structure of a typical bone consists of three main parts:
1.

Spongy (cancellous) /trabecular bone which occupies the centre of each bone
and may contain a central medullary or marrow cavity (long bones) or an air
space (e.g. maxillary sinus)

2.

Compact / cortical bone dense and forms the outer shell of each bone,
surrounding the central mass of spongy bone.

3.

Periosteum is the fibrous connective tissue membrane which invests all bones.
The blood supply to the cortical bone comes from the periosteal arteries. A
nutrient artery passes obliquely through the compact bone near the centre of the
bone and supplies the cancellous bone and the bone marrow. (Figure 2)

The different parts of bone can be easily distinguished on radiographs. (Figure 1)

Cancellous bone

Medullary cavity

Cortical bone

Figure 1

Figure 2 Radiograph of a long

bone demonstrating the site of the
nutrient artery, which is visible as
a linear lucency. It is important
not to mistake this for a fracture

Nutrient

vessel

Development of bone
Bones develop from mesenchyme (embryonic connective tissue). The mesenchyme
model of a bone can undergo one of two methods of ossification.
Membranous bone formation direct ossification, where mesenchyme becomes bone
(intramembranous ossification)
Endochondral bone formation mesenchyme is first converted into cartilage and then
later becomes ossified by intracartilagenous ossification
The long bones can be divided into a number of different parts. (Figure 3)
Diaphysis

-body of the long bone,

-formed from a primary ossification centre during embryonic development

Metaphysis

-part of the diaphysis near the epiphysis

Epiphysis

-end of the long bone,

-formed from a secondary ossification centre after birth

Figure 3

The diaphysis grows in length by proliferation of cartilage at the metaphysis. In order for
bones to grow in length, the bone formed from the diaphysis does not fuse with the bone
formed from the epiphysis until adult size is reached. The epiphyseal plate (growth
plate) is a plate of cartilage that intervenes between the diaphysis and epiphysis during
the growth phase of bone. The epiphyseal cartilagenous plates are eventually replaced by
bone when the diaphysis and metaphysis fuse. The bone formed at this site is particularly
dense and on a radiograph it is recognisable as an epiphyseal line.
Bone Marrow
In adults there are two types of bone marrow which occupy the medullary (marrow)
cavity
Red marrow active in haematopoiesis
Yellow marrow- relatively inert and eventually becomes replaced by fat
Types of bones
The skeleton can be divided into:
Axial skeleton skull, vertebrae, ribs and sternum
Appendicular skeleton- (limb bones) - femur, humerus etc.
Bones can be classified as:
Long bones
Short bones- occur in the foot and wrist
Flat bones- often serve a protective function sternum , bones of the skull
Sesamoid bones- round or oval nodules that develop in certain tendons (e.g. the
patella develops in the lower part of the quadriceps tendon called the patellar
tendon). They protect the tendon from excessive wear.
Accessory bones common in the foot, and often occur where multiple
ossification centres for a particular bone fail to fuse. It is important not to confuse
them with fracture fragments
Pedicle

Vertebral
body

Figure 4
Radiographic anatomy of a
normal lumbar vertebra

Spinous
process
Intervertebral disk space

Distal
phalanx

Figure 5 Normal radiographic

anatomy of the foot

Middle
phalanx
Proximal
phalanx

5th
MT

4th
MT

3rd
MT

MT metatarsal bone

2nd st
MT 1 MT
Cuneiforms
Navicular

Cuboid

Calcaneus

Talus

2nd
MC

Figure 6 Radiograph of
the carpal bones
R
U
SC
L
TQ
P
H
C
TZ
TM
MC

radius
ulna
scaphoid
lunate
triquetral
pisiform
hamate
capitate
trapezoid
trapezium
metacarpal

1st
MC

3rd
MC

4th
MC

TZ

5th
MC

TM

C
H
P

TQ

SC
L
R

Joints
Classification of joints
1. Fibrous joints
Bones are united by fibrous tissue (synarthrosis).
Examples:
Interosseous membranes e.g. tibia and fibula, radius and ulna
Skull sutures
Gomphosis joint between tooth and bone
2. Cartilagenous joints
Bones are united by hyaline cartilage or a combination of fibrous tissue and
cartilage (fibrocartilage)

Primary cartilagenous joints (synchondroses)

Bones are united by hyaline cartilage
Examples:
Epiphyseal growth plate
First costosternal joint

Secondary cartilagenous joints (symphyses)

The articulating surface of the bones is covered by hyaline cartilage and the
bones are joined by fibrous tissue +/- fibrocartilage.
Examples:
Pubic symphysis
Intervertebral disks
Manubriosternal joint

3. Synovial joints
Synovial joints have a number of distinguishing features (figure 7)
Joint cavity containing synovial fluid
Hyaline articular cartilage
Articular capsule consisting of an inner synovial membrane and outer fibrous
capsule, which is usually re-inforced by accessory ligaments
Synovial joints allow a wide range of motion and are classified according to their
axes of movement, e.g. ball and socket joint (hip/glenohumeral joint), hinge joint
(knee/elbow), plane joint (acromioclavicular joint), pivot joint (atlantoaxial joint)
Examples:
Appendicular skeleton
Facet joints of spine
Apophyseal joints of cervical spine
Atlantoaxial joint
Lower 2/3 of sacro-iliac joint
Acromioclavicular joint

Figure 7 A typical synovial joint

IMAGING TECHNIQUES
There are many different ways to image the musculoskeletal system. The chosen
technique depends usually on the clinical information provided by the referring doctor
and on the suspected diagnosis. If a muscular injury is suspected, plain radiographs
would not be sufficient, whereas an ultrasound or MR imaging may be more appropriate.
On the other hand a series of plain radiographs is adequate to outrule a fracture in most
situations.
Some common imaging modalities include:
Plain radiographs
Ultrasound
Computed tomography (CT)
Magnetic resonance (MR)
Nuclear medicine
1.

Plain radiographs

Basic principles of X-ray image formation

A highly penetrating beam of x-rays pass through the patient. These x-rays are absorbed
by the parts of the body according to the tissue density, thus creating an image made up
of different densities. Dense tissues (e.g. cortical bone or calcified renal stones) stop
more x-rays than less dense tissues such as muscle or fat. Therefore dense substances are
termed radiopaque and less dense substances are radiolucent. (Table 1)
Radiograph appearance
(see figure 8)
Most radiolucent Air

Least radiodense

Black image

fat
Water/soft tissues
Grey image
Cancellous bone
Cortical bone
Most radiopaque

Most radiodense

White image

Table 1

Soft tissues

Fat
pad

Figure 8

Cortical
bone

Cancellous bone

Lateral radiograph of a normal adult elbow demonstrating

the densities of the different types of tissue

Common indications
Trauma- suspected bony injury
Arthritis assessment
Suspected bony pathology- tumour etc.

2.

Ultrasound

Ultrasound is an imaging modality that uses high frequency sound waves to create an
image. It does not involve ionising radiation. It is useful for imaging solid organs and
soft tissues, including tendons, muscles and superficial masses. Sound waves do not
penetrate bone so ultrasound plays no role in the assessment of adult bones.
Common indications
Rotator cuff injury assessment
Suspected Achilles tendon rupture
Bakers cyst diagnosis
Children assessment of congenital hip dysplasia

Figure 9 Ultrasound of the Achilles tendon

A
ultrasound image of a normal Achilles tendon demonstrating the
longitudinal tendon fibres
B
swollen disorganised tendon fibres consistent with complete rupture
of the Achilles tendon

10

3.

CT

Computed tomography is most commonly used in the trauma situation. Although plain
radiographs remain the cornerstone of basic trauma assessments, CT is often required to
diagnose intra-abdominal/intracranial injuries prior to exploratory surgery. Modern
technology and new software packages also enable 3D reconstruction of complex trauma
which allows better surgical planning.
Figure 10 fracture of lateral tibial plateau
A
AP radiograph of knee showing an impacted
fracture of the lateral tibial plateau
B

Saggittal CT reconstruction images showing

the extent of the fracture

Axial CT images

11

4.

MR

Magnetic resonance creates images of the tissues from the response of the magnetic
moments of protons in the body to different magnetic fields. It provides superb soft
tissue imaging and is therefore widely used in musculoskeletal radiology. MR can be
used to assess bones, muscles, tendons and joints. It also does not involve ionising
radiation.
Common indications
Shoulder injuries- rotator cuff tears, loose bodies
Knee- evaluating meniscal injuries
Spine suspected spinal cord compression
-assessing disc disease
Figure 11 MR knee
Saggittal image of a knee demonstrating
the excellent soft tissue detail of MR
imaging

P
F

P
F
T
M
Me

Me

patella
femur
tibia
muscles
meniscus

M
T

5.
Nuclear medicine
Nuclear medicine is different to other forms of radiology as it involves injecting a radioisotope intravenously and then the patient is scanned using a gamma-camera which
detects the emitted gamma rays from the body and creates an image. The specific radioisotope used depends on the organ being imaged. In an isotope bone scan the radioisotope is preferentially taken up by the bony skeleton. Areas of increased activity either
due to inflammation, infection or malignancy will appear as focal hot spots.
Common indications
Suspected bony metastases (Fig.64)
Osteomyelitis
Pagets disease (Fig.47)

12

FRACTURES
Imaging fractures
When there is clinical suspicion of a fracture, it is standard practice to obtain at least two
views, usually at 900 to each other.

Description
There is a standard method of describing the radiographic appearance of a fracture, thus
allowing consistent reporting and precise communication between radiologists and
orthopaedic or trauma specialists.

Site
Divide the shaft of long bone into thirds- proximal, middle or distal
Use anatomical landmarks for description

Pattern of fracture
Simple fracture- no fragments
Describe the direction of the fracture line

transverse at 900 to the long axis of bone

oblique- at angle less than 900 to long axis of bone

spiral curving and twisting along bone

Comminuted fracture more than two fragments
Impaction- one fragment is driven into the other

Position/alignment
Always expressed in relation to the position of the distal fragment
If there is a deformity present you need to describe it under the following
headings
Displacement
- medial, lateral, posterior or anterior
Angulation
- indicate the direction of tilt of the distal fragment
- medial, lateral, anterior or posterior
Rotation
- internal or external
Distracted/separated fragments

Adjacent joints
Normal
Intra-articular extension of fracture line
Dislocation
Subluxation

13

Figure 12 Different fracture patterns

Figure 13 spiral and

transverse fracture of
the tibia

Transverse
fracture

Spiral
fracture

14

Fracture healing
A healing fracture undergoes a number of phases, which can be seen on radiographs
(Figure 14)
Inflammatory phase

- torn periosteum
- haemorrhage and clot in fracture line
- inflammatory reaction

Reparative phase

- granulation tissue replaces clot

- callus formation

Remodelling phase

- callus is gradually replaced by compact and cancellous

bone

A
Figure 14

A: acute undisplaced fracture of mid tibia

B: fracture healing with callus formation

15

Specific fracture types

Salter- Harris fracture classification
This particular type of fracture occurs through the epiphyseal growth plate and therefore
only happens in the paediatric population

Salter and Harris have described five different types of epiphyseal fracture (figure 15)
Type 1 -fracture is restricted to the growth plate
Type 2 -fracture of growth plate involving part of adjacent metaphysis
Type 3 -fracture of growth plate involving part of adjacent epiphysis
Type 4 -fracture of growth plate involving both metaphysis and epiphysis*
Type 5 -impaction fracture of entire growth plate*

* Type 4 and 5 are clinically the most important as they can result in premature fusion of
the growth plate with consequent limb shortening

Figure 15 Salter-Harris classification of epiphyseal plate fractures

Image courtesy of the Medical Journal of Australia

16

Figure 16 Grade 2
Salter Harris fracture
of proximal phalanx

Figure 18 Grade 4 Salter

Harris fracture of distal tibia

Figure 17 Grade 3 Salter

Harris fracture of distal tibia

Figure 19 Grade 5 Salter

Harris fracture of distal tibia
17

Pathological fractures
This type of fracture occurs through underlying diseased bone, for example through a
bony metastasis. (Figure 20)

Figure 20 Pathological fracture of the

mid-shaft of the humerus. Multiple
lytic metastases can be seen in the
underlying bone.

Avulsion fractures
The fracture fragment is pulled away from bone at the site of a tendon or ligament
insertion, commonly at tuberosities. (Figure 21)

Figure 21 Avulsion
fracture of the medial
epicondyle of the
humerus

18

Some common fractures

Upper limb
Figure 22

Scaphoid fracture

This is clinically an important fracture because very

often the fracture will not be visible on the initial
radiograph. If there is a high clinical suspicion of a
fracture (e.g. anatomical snuff-box tenderness), a
follow-up radiograph should be performed 10-14 days
after the injury. If a scaphoid fracture is not diagnosed,
avascular necrosis of the bone can occur with longterm
sequelae.

Figure 23

Colles fracture

Fracture of the distal radius with

dorsal angulation. It commonly
occurs after a fall on an outstretched hand.
Note that it is important to obtain
two radiographic views (APanteroposterior, and lateral) in
order to fully assess the fracture.

AP wrist radiograph

Lateral wrist radiograph

19

Figure 24 Bennetts fracture

Fracture dislocation of the base of
first metacarpal

Figure 25 Boxers fracture

Fracture of the fifth metacarpal
neck. This type of hand injury
usually occurs following a
punching incident (e.g. boxing
fight).

20

Lower limb

Figure 26 radiograph of the pelvis demonstrating a normal left hip and

a fracture of the neck of the right femur.

Figure 27 lateral radiograph of the

knee showing a comminuted
fracture of the patella

21

Figure 28 Comminuted fracture of the tibial

plateau. There is an associated
lipohaemarthrosis of the knee joint which is
visible on the lateral radiograph of the knee as a
fat-fluid level. When this sign is present, there
is always high index of suspicion of an
underlying fracture, even if it is not definitely
seen. The lipohaemarthrosis is only visible when
a horizontal x-ray beam is used for the
radiograph. It is therefore vital in the setting of
trauma to the knee to perform a horizontal beam
lateral view of the joint.

fat
fluid

22

Figure 29 trimalleolar ankle fracture

This is a complex injury with fractures of the medial, lateral and posterior
malleoli. Compare with the normal ankle in figure 30

F
Figure 30
AP radiograph of a normal
ankle.
MM
LM
TL
T
F

MM
TL

medial malleolus
lateral malleolus
talus
tibia
fibula

LM

23

Skull

Figure 31 Depressed skull fracture

Figure 32 Linear skull fracture

24

Spine
Cervical spine
Figure 33
Vertebral alignment
1 pre-vertebral soft tissue

QUIZ DESCRIBING FRACTURES

2 anterior spinal line

3 posterior spinal line
4 spinolaminar line
5 spinous process line

Cervical spine assessment in the trauma situation

1. Adequate radiographs must be taken in order to assess the cervical spine correctly
Lateral radiograph including C1 to the upper aspect of T1
AP radiograph
open-mouth or peg view, which is an AP radiograph taken through
the patients open mouth to demonstrate the odontoid peg
2. All 7 cervical vertebrae must be entirely visualised. If the entire cervical spine is
not adequately visualised, additional views e.g. swimmers view or a CT should
be performed
3. Evaluate the vertebral alignment on the lateral radiograph (figure 33), looking
particularly for step-offs. The five lines in figure 33 should be traced out.

25

Figure 34
Lateral C-spine radiograph of a
patient who was involved in a road
traffic accident.
Check the vertebral alignment.
There is a step off in the posterior
spinal line between C2 and C3.
The patient was also tender in this
region on clinical examination and
therefore he then had a CT scan of his
upper cervical spine (figure 35)

Figure 35 CT of cervical spine

Image A- axial CT image of C2 vertebrae showing a fracture through the body of C2
Image B- saggittal reconstruction demonstrating the same fracture in a different plane

26

Lumbar spine
Figure 36
Traumatic compression fracture of a
mid lumbar vertebral body.

27

Miscellaneous Trauma
Shoulder dislocation

Figure 37 Anterior shoulder dislocation

This is a Y-view radiograph of the shoulder.
The head of the humerus (H) is displaced
anterior to the glenoid fossa (G). It is important
to always look for associated injuries such as
an underlying fracture. Approximately 90% of
shoulder dislocations are anterior while only
10% are posterior.

scapula

Figure 38
Complications of
fractures are
important clinically.
This radiograph
demonstrates a rib
fracture (circle) and
an associated
pneumothorax
(arrowheads).

28

Key points

At least two radiographic views required usually at 900 to each other

Describe fractures under the following headings

Key points
At-site
least two radiographic views required usually at 900 to eachother
-pattern fractures
of fracture
simple/comminuted/impacted
Describe
under
the following headings
-position/alignment

displacement/angulation
-site
-adjacent
jointsof fracture simple/comminuted/impacted
-pattern

29

METABOLIC BONE DISEASE

As we have seen, bone is a dynamic tissue. It is constantly being absorbed and replaced
by new bone. The two main cells involved in bone turnover are osteoblasts (forms new
bone) and osteoclasts (resorb bone). Therefore a number of different conditions which
alter bone metabolism and disturb this equilibrium may result in altered bone structure.
These conditions have characteristic radiological appearances which we will review in
this section. Excess new bone formation results in osteosclerosis (increased radiodensity)
while too little bone formation causes osteopaenia (decreased radiodensity).

Osteoporosis
In osteoporosis the bone density is reduced. There are many causes, but by far the
commonest is primary osteoporosis which occurs in post-menopausal women and in the
elderly population.
Diagnosis
Quantitative measurement of bone density is carried out using a DEXA (dual-energy xray absorptiometry) scan.
Radiographic features
Osteopaenia decreased
radiodensity
Decrease in number and thickness of
bony trabeculae
Vertebral body compression
fractures
- biconcave codfish appearance
- true wedge compression
Pathological fractures

30

Figure 39 Lumbar spine

radiograph showing
wedge compression vertebral
fractures due to osteoporosis

Osteomalacia
Abnormal mineralization of bone in adults is called osteomalacia and in children is called
rickets. In the past, dietary vitamin D deficiency was the commonest cause however
renal disorders are probably more common today.
Radiographic appearance
Identical appearance to osteoporosis
Loosers zones or pseudofractures (rare)
Cortical stress fractures filled with poorly mineralised osteoid
Common sites include scapula, inner margin of femoral neck and in the pelvis

Figure 40 Loosers zones

31

Renal osteodystrophy
Patients with chronic renal failure develop a variety of metabolic bone disorders
including osteomalacia and secondary hyperparathyroidism, which are grouped under the
umbrella term of renal osteodystrophy.
Radiographic appearances
1. Osteomalacia- as described before
2. Secondary hyperparathyroidism

Subperiosteal bone resorption

Common sites include

-radial aspect of middle phalanges of hand

-medial aspect of proximal tibia
-sacro-iliac joints

Figure 41 Subperiosteal
resorption of the radial
aspect of the middle
phalanges

32

Diffuse osteosclerosis - most commonly manifest as rugger-jersey spine

Figure 42
Rugger-jersey spine sclerosis
adjacent to the vertebral body
endplates

Vertebral body
Sclerotic end plate of
body
Intervertebral disk
space

33

Browns tumours
- cystic lesions which can appear lytic, expansile and quite aggressive
- occur in almost any bone
- nearly always associated with sub-periosteal bone resorption

Figure 43
Lytic lesion in
proximal right femur
in a patient with
chronic renal failure

Figure 44
Browns tumour of the
proximal tibia

34

Pagets disease
Pagets disease is a chronic disorder characterised by excessive osteoclastic bone
resorption followed by disordered osteoblastic activity resulting in the formation of new
bone that is structurally abnormal and weak.
Diagnosis

Biochemical

Radiological
Radiographic appearances
1. Plain radiographs
Localised bony expansion most common in the pelvis
Osteosclerosis thickening of the cortex
Osteolytic changes
Bowing of long bones
Skull cotton-wool type appearance mixed lytic/sclerotic
- narrowing of neural foramina in the base of skull hearing loss
Figure 45 the right hemi-pelvis is
expanded and thickened. The
trabecular pattern is more
prominent and coarsened. This
patient has Pagets disease of the
right hemi-pelvis. Compare these
changes with the normal pelvis in
figure 46.

Figure 46 AP radiograph of a
normal pelvis

35

2. Radionuclide bone scan

Usually hot lesions

Figure 47 Isotope bone scan

The entire left humerus is expanded
and hot (i.e. increased radio-isotope
uptake) when compared to the right
humerus.
The distal right femur is also hot.
This patient has Pagets disease.

36

ARTHRITIS
Types

Degenerative arthritis
-Osteoarthritis

Inflammatory arthritis
-Rheumatoid arthritis
-Seronegative
spondylarthropathies

Metabolic arthritis
-Gout
-Calcium pyrophosphate
deposition disease

Miscellaneous
-Septic arthritis/osteomyelitis
-Neuropathic/Charcots joint

Describing arthritis on radiographs

It is important to use a systematic approach when looking at radiographs. Many
rheumatological diseases have characteristic radiographic appearances, so through careful
review of the radiographs an appropriate differential diagnosis can be obtained.
1. Pattern of Joint involvement
-identify the specific joints involved
-is the process a mono-arthritis (involving a single joint) or is it polyarthritis (multiple
joints affected?
-distribution of involved joints- symmetrical (e.g. small joints of both hands are involved)
or asymmetrical (e.g. only one knee is affected)
2. Specific joint changes
-joint space- is there narrowing?
-articular surfaces- are erosions present?
-peri-articular changes- e.g. osteoporosis, subchondral sclerosis
-new bone formation- e.g. osteophytes
-deformity- e.g. swan-neck deformity in rheumatoid arthritis
3. Surrounding structures
-soft-tissue swelling
4. Extra-articular features
-look for a pleural effusion or the changes of interstitial lung disease or on chest
radiograph

37

Degenerative Joint Disease - Osteoarthritis

Disease is characterised by progressive loss of articular cartilage, which results in
peri-articular bony changes.
Not a systemic disorder
Two types
Primary OA- due to abnormal mechanical forces on normal joints
so-called wear and tear arthritis
- age-related
Secondary OA - normal mechanical forces on an abnormal joint
- aetiologies trauma
-congenital hip dysplasia
-haemochromatosis
-acromegaly
Joint distribution
Hands:
distal interphalangeal (DIP) Heberedens nodes
proximal interphalangeal (PIP) - Bouchards nodes
first carpometacarpal joint
Lower limb:

hip
knee
first metatarsophalangeal (MTP)

Spine:

facet joints

*Commonly spared joints: metacarpophalangeal (MCP), wrist, elbow, shoulder, ankle

Radiographic appearances
Asymmetric joint space narrowing
Subchondral sclerosis
Subchondral cysts (geodes)
Osteophytes
Normal soft tissues
Localised osteoporosis around joint is not a feature

38

geode

Figure 48
Osteoarthritis of the
right hip with
evidence of geodes,
joint space
narrowing and
subchondral
sclerosis. Compare
these changes with
the normal pelvis in
figure 38.

Subchondral
sclerosis

H
B

Figure 49 Osteoarthritis of both hands. Note the changes (osteophytes, joint space
narrowing) predominantly involve the distal interphalangeal joints (DIP) Heberedens
nodes (H) and the proximal interphalangeal joints (PIP) - Bouchards nodes (B)

39

Inflammatory arthritis
Rheumatoid arthritis

chronic symmetrical polyarthropathy of unknown aetiology

systemic disorder
females>males
disease of the synovium
- synovium becomes infiltrated by chronic inflammatory cells
- inflamed synovium then proliferates as pannus, which grows over the articular
cartilage and destroys the cartilage and underlying bone, resulting in erosions

Joint distribution
Upper limb
Hands: MCP joints ulnar deviation
Boutonnire deformity- hyperextension of DIP, flexion of PIP
Swan-neck deformity- hyperextension of PIP, flexion of DIP
Subluxation of carpal bones
Shoulder
Lower limb
Hip
Feet

Spine
Atlantoaxial subluxation
Erosions of odontoid peg

Radiological appearances
Symmetrical joint space narrowing
Peri-articular osteoporosis
Marginal erosions
Subchondral cysts (geodes)
Soft tissue swelling
Proximal and bilateral symmetric changes in hands

40

E
A AP radiograph

Figure 50 A, B
Rheumatoid arthritis of
the hands
There are symmetrical
bilateral changes
involving the
metacarpophalangeal and
proximal interphalangeal
joints. Note the periarticular erosions (E). On
the oblique radiograph the
MCP joints are dislocated.

B - Oblique radiograph

41

Figure 51
Severe Rheumatoid arthritis of the hands
Marked destruction and deformity of the MCP joints bilaterally.
Note the z deformity of the right thumb

Extra-articular manifestations
It is very easy to focus on the joint abnormalities when assessing patients with
rheumatoid arthritis. However it is important not to forget that it is a systemic disorder
with many extra-articular features that are visible on radiographs.
Chest radiograph
Pleural effusion
Pulmonary nodules
Interstitial fibrosis lower lobes
Pericardial effusion
Pericarditis

Caplans syndrome
-pneumoconiosis,
-RA,
-pulmonary nodules

Abdominal imaging (ultrasound/CT)

Splenomegaly

42

Seronegative spondylarthropathies
This refers to a group of inflammatory arthropathies that are rheumatoid factor negative
and are associated with HLA-B27.

Ankylosing Spondylitis

Disorder primarily of the spine which presents usually with the insidious onset of
lower back pain
Males>>> females
Onset 15-30 years

Radiographic appearances
Sacro-iliac joints
-bilateral symmetrical involvement
-erosions
sclerosis
(early)

ankylosis/fusion
(late)

Spine (thoraco-lumbar)
-loss of lumbar lordosis
-vertebral body squaring
-syndesmophytes- calcification of outer part of the annulus fibrosus
- bamboo spine fusion of the spine and ossification of the spinal ligaments
(late feature)
Proximal monoarthritis of large joints hips> shoulder
Enthesopathy- inflammation at the sites where a tendon inserts onto bone
-Achilles tendonitis
-plantar fasciitis
Extra-articular features
Ankylosing spondylitis is a multi-system disorder so some patients will have extraarticular manifestations that may be visible on radiographs.
Chest radiographs
Pulmonary fibrosis- apical

Abdominal imaging
Inflammatory bowel disease

43

Figure 52 Ankylosing spondylitis

AP and lateral radiographs of the lumbosacral spine,
demonstrating ossification of the spinal ligaments and
syndesmophytes formation (arrows). There is also fusion of both
sacro-iliac joints (arrowheads).

44

Enteropathic arthropathies
Patients with inflammatory bowel disease (ulcerative colitis or Crohns disease) may
develop arthritis. The activity of the arthritis parallels that of the bowel disease. It often
mimics ankylosing spondylitis. Bilateral symmetric sacro-ileitis is a feature as is spinal
ankylosis as seen in ankylosing spondylitis.

Reiters Syndrome

Clinical triad:
Urethritis/cervicitis
Conjunctivitis
Arthritis
Develops following an episode of either nongonococcal urethritis or after
gastroenteritis

Radiographic features

Distal lower limb predominantly

-erosive arthropathy, often begins in the feet

Bilateral sacroilitis
- less common than in ankylosing spondylitis and often asymmetric

Enthesopathy plantar fasciitis, calcaneal spur formation

Psoriatic arthritis
Occurs in approximately 5% of patients with psoriasis
In 90% patients the skin changes precede the arthritis
Several types of arthritis
-asymmetrical oligoarthritis of small joints of the hand
-symmetrical polyarthritis similar to rheumatoid arthritis
-arthritis mutilans aggressive form with destruction of small bones of
hands/feet
-spondyloarthropathy of sacro-iliac joints and spine often asymmetric as
opposed to ankylosing spondylitis
-polyarthritis predominantly involving DIPs
Radiographic features

Predominantly affects the hands

Erosions , which can be quite aggressive

Soft-tissue swelling of entire digit sausage digit

Loss of joint space

Pencil-in-cup deformities

Resorption of terminal tufts of digits

Bone density preserved

Sacroilitis

45

Figure 53
Psoriatic arthropathy with evidence of resorption of the distal tufts of the digits (circle)
and peri-articular erosions (E)

Figure 54 Psoriatic hands with showing pencil-in-cup deformities (circles)

46

Key points
Describe radiographic changes of arthritis under the following headings
Joints
-identify the specific joints involved
-mono-arthritis/polyarthritis
-joint distribution- symmetrical/asymmetrical
Specific changes
-joint space-articular surfaces
-peri-articular changes
-new bone formation
-deformity
Surrounding structures
-soft-tissue swelling
Extra-articular features

Osteoarthritis

Rheumatoid arthritis

Radiological appearance
Asymmetric joint space
narrowing
Subchondral sclerosis
Osteophytes
Normal soft tissues
Localised osteoporosis
around joint is not a
feature

Symmetrical joint space

narrowing
Marginal erosions
Soft tissue swelling
Proximal and bilateral
symmetric changes in hands
Peri-articular osteoporosis

Common features
Subchondral cysts (geodes)

Metabolic arthritis

Joint distribution
Weight bearing large joints
Hands: DIPs, PIPs
Not systemic

Hands : MCPs,
Systemic disorder

47

Gout
Recurrent episodes of arthritis secondary to the deposition of sodium urate crystals in
and around joints.
Causes
-uric acid under excretion e.g. chronic renal failure, drugs (thiazide diuretics)
-uric acid overproduction- e.g. chemotherapy, myeloproliferative disorders
Uric acid crystals are bi-refringent under polarised light
Radiographic appearances
Metatarsophalangeal joint of the hallux is typically involved (podagra)
Well defined erosions with sclerotic margins or overhanging edges
Joint space is preserved
Focal soft-tissue swellings - tophi

Figure 55 Gout
There are multiple erosions with
overhanging edges (arrowheads)
with soft tissue tophus formation
(arrow).

48

Figure 56 Gout
Erosions and tophi
affecting the joints of the
hallux

Calcium pyrophosphate deposition disease

Disorder of unknown aetiology but is associated with other diseases such as

haemochromatosis, gout and primary hyperparathyroidism
Calcium pyrophosphate is deposited in articular cartilage and peri-articular tissues
This crystal deposition causes
-chondrocalcinosis- calcification of cartilage
-arthropathy caused by calcium pyrophosphate crystals eroding the cartilage and is
radiologically similar to osteoarthritis except in its pattern of distribution
The acute symptomatic attacks of synovitis are called pseudogout

49

Radiographic appearance
chondrocalcinosis
- hyaline cartilage: knee
- fibrocartilage: menisci, glenoid and acetabular labra, symphysis pubis
arthropathy similar to osteoarthritis except in pattern of distribution
Upper limb
Shoulder
Elbow
radiocarpal joint
MCP joints

Lower limb
patellofemoral joint of the knee with no
involvement of medial/lateral
compartments

subchondral cysts

Figure 57 CPPD
Chondrocalcinosis of
the lateral meniscus
(arrowhead).

50

Septic arthritis
usually due to haematogenous spread to the synovium and the joint
Diagnosis is by joint aspiration not radiology
Radiographic findings
Plain film
Joint effusion
Juxtaarticular osteoporosis

Bone scan
If osteomyelitis is suspected

Osteomyelitis
Infection of bone
Can occur at any site
Radiographic appearance
Wide variety of appearances
Plain films
Periosteal reaction
-thin and linear
-thick and ill-defined
Bone destruction
-lytic lesion with or without a
sclerotic margin
-moth-eaten appearance

Bone scan
Hot spot
MRI
Variety of appearances

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Neuropathic or Charcots joint

Primary loss of sensation in a joint resulting in arthropathy and joint destruction

Joint distribution can be useful in indicating an aetiology
Diabetes mellitus
foot
Syringomyelia
upper limb: shoulder, elbow, wrist
Tabes dorsalis (syphilis)
lower limb: knee, hip, ankle
Myelomeningocele (spina bifida)
ankle

Radiographic appearances
Joint destruction - severe
Dislocation varies in severity
Heterotopic new bone- soft tissue calcification adjacent to the joint

Figure 58
This radiograph of
the distal foot of a
patient with a long
history of poorly
controlled diabetes
mellitus, shows
marked destruction
of the first and fifth
MTP joints. These
findings are
consistent with
neuropathic joints.

52

NEOPLASMS
Primary

Secondary

Multiple Myeloma
Osteosarcoma
Ewings sarcoma
Chondrosarcoma

Metastases

Primary bone tumours

Rare
Most tumours occur at specific ages

Multiple Myeloma

Commonest primary bone tumour

Malignant clonal proliferation of plasma cells in the bone marrow which produce
monoclonal immunoglobulins (paraproteins)
Age > 40 years, peak age of presentation 60 years

Radiographic features
Multiple well defined lytic lesions
Usually involves the axial skeleton
-skull
-ribs
-spine
-pelvis
Radiological diagnosis is based on a skeletal survey - plain radiographs of the entire
skeleton
Bone scan will often be normal

Figure 59
Multiple lytic lesions in the skull due to
multiple myeloma

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Osteogenic sarcoma

Second commonest primary bone tumour

Age <30 years
Secondary osteosarcoma can occur in older patients who have malignant change in
Pagets disease

Radiological features
Poorly defined mass that extends through the cortex
Usually occurs towards the end of a long bone (metaphysis)
Lower limb predominantly
Osteosclerosis often present due to tumour new bone or reactive sclerosis
Lesions can also be entirely lytic
Aggressive periosteal reaction

Figure 60 Osteogenic sarcoma

A mass lesion in the
diametaphysis of the distal
femur of a teenager (note the
epiphyses have not yet fused).
This lesion extends through the
bony cortex. There is a marked
periosteal reaction and an
associated soft tissue mass
(arrowheads). Note the also the
presence of a Codman triangle
(arrow). This lesion has an
aggressive radiographic
appearance.

54

Figures 61&62 Osteosarcoma Sagittal

(left) and axial (below) post contrast MRI
scans shows the destructive bone lesion
with a large soft tissue component
(arrowhead) extending to the suprapatellar
fat pad and posteriorly towards the
neurovascular bundle (arrow). Note the
normal left femur, thigh and neurovascular
bundle on the axial images. MRI shows the
extent of the tumour and is helpful in
planning surgery with a view to limb
salvage.

55

Ewings sarcoma

Malignant tumour of undifferentiated mesenchymal cells (primitive neuroectodermal

cells)
Age 5-15years

Radiological appearances
Most commonly occur in diaphysis of lower limb
Aggressive tumour
Osteolytic lesion with cortical erosion
onion-skin type periostitis
Associated soft tissue mass
Metastases (usually lung) are present in approximately 30% at diagnosis

Chondrosarcoma
Malignant cartilage producing tumour
Majority are low-grade
Age >40 years
Radiological appearance
Lytic destructive mass
Snow-flake type calcification
Metaphysis of long bones, especially the femur

Figure 63 Chondrosarcoma
A destructive partially lytic lesion
is seen in the proximal femur.

56

Secondary bone tumours

Metastases

Spread of metastases is usually haematogenous

More common than primary bone tumours
Variable appearance
Pathological fractures are common

Figure 64
Anterior and posterior views of a radionuclide bone scan demonstrating multiple
hot spots (black arrows) due to widespread metastases. This patient also has
Pagets disease of the right femur (white arrows).

57

Aetiology
Adults
Male

Children
Female

Prostate

Breast

Neuroblastoma

Lung

Lung

Leukaemia

Kidney

Kidney

Lymphoma

Thyroid

Thyroid

Medulloblastoma
Wilms tumour

Radiographic features
Lytic metastases

Sclerotic metastases

Breast
Kidney
Thyroid
Lung

Prostate
Breast
Rare
Hodgkins disease
Carcinoid
Neuroblastoma

58

Figure 65 ivory vertebrae

sclerotic metastases secondary
to prostate cancer in the lumbar
vertebral bodies

Figure 66
Sclerotic
metastases in the
right hemipelvis. Compare
with the normal
pelvis (figure
46).

59

Figure 67
Lytic metastasis in the
proximal tibia due to renal
cell cancer

Figure 68
Axial CT image of the
lytic metastasis seen in
figure

60

Key points

Metastases are more common than primary bone tumours

Malignant tumours and patients age

Age
1-30 years
>40 years

Ewings sarcoma
Osteosarcoma
Metastases
Multiple Myeloma
Chondrosarcoma

61

ACKNOWLEDGEMENTS
Images courtesy of M.J.Lee, J.OCallaghan, C.Shortt, K.Abdulla, B.Hogan and S.Looby,
Department of Radiology, Beaumont Hospital.

62