CD B [RADIO]: MUSCULOSKELETAL RADIOLOGY I & II

FEBRUARY 2018

IMAGING TECHNIQUES OF THE BONES MAGNETIC RESONANCE IMAGING

Radiography
Provides superior soft tissue contrast ideal for evaluating soft
Fluoroscopy
tissue
Computed Tomography
Used for diagnosis of injuries to muscles, tendons or ligaments
Magnetic Resonance Imaging
about joints
Nuclear Medicine
Useful for evaluating bone marrow disorders
Very sensitive but non-specific
RADIOGRAPHY
Most frequently obtained imaging study TECNHIQUE SELECTION
Primarily used in assessment of the bones
Trauma
Some information on the soft tissue may also be depicted Radiography should be the first test
Usually two views at right angles or perpendicular (orthogonal) If a fracture is not seen on x-ray but is still highly suspected,
to one another are obtained in assessing the bones a repeat radiograph in 7 to 10 days , bone scanning, CT
Example: standard views for x-ray of the leg is an AP view and a
scan or MRI may be done
lateral view CT scan is best in giving information on the location of the
fracture fragments
FLUOROSCOPY Bone or soft tissue tumors
Used to monitor and guide orthopedic surgeries MRI is best in staging of bone/soft tissue tumors and in
detecting a bone tumor which is not seen on x-ray
Metastases
If symptomatic sites are assessed, this is best evaluated
initially with x-ray
Overall survey may be done by bone scan or MRI
Suspected soft tissue metastases is best evaluated by MRI
PET-CT scan are useful in staging many tumors
Infection
Radiographs should be obtained first for suspected
COMPUTED TOMOGRAPHY osteomyelitis
Two major uses If radiographs are inconclusive, MRI or bone scan may be
To evaluate position of fracture fragment/s done
Multislice scanners make evaluation of anatomy in MRI is useful in detecting the extent of involvement and
various planes (e.g. coronal, sagittal, axial) possible complications
3D reconstruction is also possible
To evaluate bone tumor and tumor-like diseases IMAGING TECHNIQUES OF THE JOINTS
Radiography
Arthrography
Computed tomography
Magnetic resonance imaging
Ultrasonography

RADIOGRAPHY
Most commonly used imaging technique in evaluating the joints
Should be the initial imaging in patients with suspected joint
problem
Orthogonal views should be obtained (just like in bones)
On x-rays, joints are only seen as spaces between the
articulating bones
The tissues (hyaline cartilage, menisci, joint fluid) that make up
the joint space cannot be visualized on x-rays

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CD B: RADIO | MUSCULOSKELETAL RADIOLOGY
FEBRUARY 2018

If normal radiograph and injury is still suspected, MRI may

be done
MRI is suited for investigation of intraarticular and
periarticular soft tissue structures and cartilage
Non-traumatic cases
Radiographs are still the initial imaging technique
If radiograph is normal, MRI should be the next modality

VERTEBRAE
ARTHROGRAPHY VERTEBRAL COLUMN
Contrast is injected into the joint using guidance joint is 33 vertebrae:
imaged either with ultrasound, CT scan or MRI 7 cervical
MR arthrography is mainly used to evaluate the labrum of the 12 thoracic
hip or glenohumeral joint 5 lumbar
5 sacral segments (fused)
4 coccygeal segments (fused)

IMAGING MODALITIES
PLAIN RADIOGRAPH
Most commonly performed investigation of the vertebral
column especially in trauma.
Easy to assess and bone detail is well shown
MAGNETIC RESONANCE IMAGING COMPUTED TOMOGRAPHY
Has a remarkable advantage over other techniques in imaging Provides cross sectional images of bone and soft tissue.
MAGNETIC RESONANCE IMAGING
the joints because of its superior soft tissue contrast
Primary imaging for vertebral column
Can image in any plane
Displays excellent anatomical and pathological
May show early changes that cannot be detected on x-rays or
information.
CT scan yet
Tissue discrimination is superior to CT the only method
MRI can clearly depict the normal components of the joint
that can show intrinsic abnormalities of the spinal cord
(hyaline cartilage, menisci, joint fluid)
substance.

ULTRASONOGRAPHY
Can evaluate soft tissues, tendons, ligaments and joint cartilage
Cannot penetrate bones
Highly operator dependent

JOINTS: TECHNIQUE SELECTION
Radiography should always be the initial imaging
Acute trauma
Radiograph remains the mainstay of initial imaging
CT scan may be used in surgical planning
Subacute and remote trauma
Radiographs are obtained initially to assess the integrity of
the joint
VERTEBRAE
Four curves on sagittal plane
Cervical and lumbar are convex anteriorly (lordotic) –
secondary curves
Thoracic and sacrococcygeal are concave anteriorly
(kyphotic) – primary curves
Components of the vertebra – the body, pedicles, laminae, and
the transverse, articular and spinous processes.

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CD B: RADIO | MUSCULOSKELETAL RADIOLOGY
FEBRUARY 2018

The neural arch surrounds the spinal canal and consists on each MRI of the cervical spine
side, of a pedicle laterally and a lamina posteriorly

INTERVERTEBRAL DISC
The intervertebral disc is a cartilaginous cushion between
adjacent vertebral bodies consists of a central nucleus pulposus
surrounded by an annulus fibrosus

VERTEBRAL and INTERVERTEBRAL CANAL

Transmits the spinal cord
The intervertebral canals transmit the segmental spinal nerves
between adjacent pedicles

Cervical spine – AP and lateral THE THORACIC VERTEBRAL COLUMN

12 thoracic vertebrae distinguished by articulations for the ribs.
The ribs attached at two places: the head of the rib attaches to
the vertebrae at the disk and additionally the tubercle of the ribs
attaches to the transverse process costotransverse joint.

Thoracic spine – AP and lateral

Cervical spine – open mouth view

CT scan of the cervical spine

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CD B: RADIO | MUSCULOSKELETAL RADIOLOGY
FEBRUARY 2018

CT scan of the thoracic spine Lumbar spine radiograph oblique view

MRI of the thoracic spine

THE LUMBAR VERTEBRAL COLUMN

5 lumbar vertebrae, the 3rd being the largest.

Lumbosacral radiograph- AP and lateral

Radiograph of the Sacrum

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CD B: RADIO | MUSCULOSKELETAL RADIOLOGY
FEBRUARY 2018

JEFFERSON FRACTURE
MOI: blow to the top of the head or axial loading Causing the
lateral masses of C1 to slide apart, splitting the bony ring of C1
Lateral masses of C1 extends beyond the margins of the C2 body

CLAY-SHOVELER’S FRACTURE
Stable fracture of the C6 or C7 spinous process

HANGMAN’S FRACTURE
MOI: secondary to hyperextension and distraction
Unstable and serious fracture of the posterior elements of C2
with displacement of the C2 body anterior to C3

SCOLIOSIS
Abnormal curving of the physiologic thoracic and lumbar spine
Dextroscoliosis – towards the right
Levoscoliosis – towards the left
Grading (Cobb’s angle):
10-20 degree - mild
20 – 40 degree– moderate
> 40 degree - severe

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CD B: RADIO | MUSCULOSKELETAL RADIOLOGY
FEBRUARY 2018

BURST FRACTURE
Type of compression fracture related to high-energy axial
loading spinal trauma that results in disruption of the posterior
vertebral body cortex with retropulsion into the spinal canal.
S/S: back pain and or lower limbs neurologic deficits in the
clinical scenario of trauma.
Most commonly occur at L1 with the majority (~90%) occurring
from T9-L5.
WEDGE COMPRESSION FRACTURE It is a result of a high-energy compressive injury (axial
Most commonly affecting the anterior aspect of vertebral loading). The intervertebral disc is driven into the vertebral body
body, wedge fractures are considered a single- below.
column (i.e. stable) fracture.
Thoracolumbar area- most common location.
Typically it is an osteoporotic compression fracture but can also
be a pathological fracture or secondary to trauma.
Hyperflexion injuries to the vertebral body resulting from axial
loading.

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CD B: RADIO | MUSCULOSKELETAL RADIOLOGY
FEBRUARY 2018

SPONDYLOLYSIS
Breaks in the pars interarticularis
May or may not be caused by trauma is spondylolysis.
CHANCE – SEATBELT INJURY
MOI: hyperflexion with distraction
Anterior, middle and posterior columns are involved
Unstable injury perpendicular to the spinal axis
Chance fracture
Location
This fracture most commonly occurs about the upper
lumbar spine (with the thoracolumbar junction accounting
for ~50% of cases 3), but it may be observed in the
midlumbar region in children.
Associations
There is a high incidence of associated intra-abdominal
injuries (especially the pancreas and duodenum) that can
result in increased morbidity and mortality. Associated
intra-abdominal injuries appear to be more common in the
paediatric age group with an incidence approaching 50%.

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CD B: RADIO | MUSCULOSKELETAL RADIOLOGY
FEBRUARY 2018

SPONDYLOLISTHESIS & RETROLISTHESIS

Spondylolisthesis – anterior slippage of a vertebral body in
relation to its inferior vertebra.
Retrolisthesis – posterior slipping of a vertebra in relation to
inferior vertebra.

THORACIC CAGE

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