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Musculoskeletal Imaging

The Basics
Ns. Deni Yasmara, M. Kep., Sp. Kep.MB

WHAT IS RADIOLOGY?

Medical specialty that


supervises and interprets
imaging studies.
Reports findings to
referring physicians.

X-RAY
Discovered and named by
Dr. W. C. Rentgen at
University of Wrzburg,
1895
Awarded first Nobel prize
for physics, 1901
Did not patent invention
3

Spondilitis TB (??????)

MSK Imaging Imaging


Modalities
Plain Radiographs
Ultrasound
Computed Tomography
Magnetic Resonance Imaging
Nuclear Scintigraphy

RADIOLOGY TOOLS
X- RAY
ULTRASOUND
NUCLEAR MEDICINE
MAGNETIC RESONANCE
COMPUTED TOMOGRAPHY

Plain Radiographs
Widely available
Reproducible
Patient friendly
Inexpensive
Usually the indicated primary
imaging modality

Plain Radiographs
Standard protocols available
Consider the pathology in question
Image area of question, not the
vicinity

One view is No view


Supplemental views possible in
most locations

Plain Radiographs
- Obvious

Plain Radiographs 2 views

Plain Radiographs 2 views


Posterior
Dislocation

Plain Radiographs Extra views


Radial Head
Fx

Stabilisasi anterior & posterior


spondilitis TB lumbal 3,4,5

Ultrasound
Reproducible in trained hands
Excellent for superficial soft tissue
elements including tendons and
muscle
Patient friendly
Small to moderate expense

Ultrasound
Routine exam room equipped with
adequate imaging devices
Superficial gel (standard or aseptic)
application with touch with
transducer
Usually static exam of architecture
+/- vascularity assessment
Potential for dynamic imaging

Ultrasound
Cranial

Cranial

Cauda
l

Calcaneu
s

Caudal

Ultrasound Achilles Tendon


Intrasubstance
tear

Ultrasound Patellar tendon

Proximal patellar
tendonitis
Jumpers Knee

Computed Tomography (CT)


Widely available
Reproducible, although variety of
techniques
Excellent bone assessment
Occasionally useful for soft tissue
assessment
Patient friendly
Moderate expense
Interventional options

Computed Tomography
Usually supine axial exam, with
some alternative positioning options
Can develop reformatted images
after exam for alternative views
Imaging time in seconds, rarely
minutes
Usually without IV or oral contrast

CT - Fractures

Scaphoid
fracture

CT - Dislocation

Lis Franc Fx/Dislocation

CT Bony anomalies
Midsubtalar
coalition

Magnetic Resonance Imaging


Widely available, but nonstandardized imaging techniques
Reproducible
Excellent for soft tissue pathology
Good-excellent for bone pathology
NOT patient friendly
Large expense

MRI Absolute Contraindications


Cardiac Pacemakers
Electronic stimulators
Metallic foreign bodies in the orbit
Body habitus beyond limits of
physical unit

MRI - Relative Contraindications


Prostheses
IUDs
Cardiac valves
Berry aneurysm clips
Retained bullet fragments
Claustrophobia
Huge listing in MRI facility

MRI
Usually performed with patient supine
Multiplanar imaging obtained without
changing position
One exam = one body part
Average exam time 45 minutes; most
patients cant last >2 hours
Strict guidelines for sedation
Optional contrast Rad usually decides
for body imaging

SPONDILITIS TB L3,4,5

MRI Trauma
Osteochondritis
dissecans

MRI Trauma
Femoral Neck
Fracture

MRI - Trauma

Tear vastus
medialis

MRI Internal Derangement


Bucket handle meniscal
tear

Nuclear Scintigraphy
Most common = Bone Scan
Very sensitive for skeletal pathology
Mildly sensitive for soft tissue
pathology
Usually nonspecific as an isolated test
Mostly patient friendly; no significant
environmental exposure
Small-moderate expense

Nuclear Scintigraphy
Excellent for specific pathologies
Osteomyelitis
Metastases Not Multiple myeloma
Occult fracture

Reasonably reassuring
Normal is usually normal

Nuclear scintigraphy Bone


Scan
IV injection radioisotope (Tc-99m)
bound to phosphate +/- dynamic
imaging
Approx 3 hour delay
Delayed static imaging with a
superficial detector

Nuclear Scintigraphy Bone


Scan
Osteomyeliti
s

Nuclear Scintigraphy
2nd MT stress
fracture

CONTRAST RADIOGRAPHY
Injection, ingestion, or other
placement of opaque material within
the body.
Improves visualization and tissue
separation.
Can demonstrate functional anatomy
and pathology.

46

All about Imaging


Plain radiographs are usually the
starting point
Most x-ray protocols work for most
situations
Secondary imaging techniques have
specific advantages and disadvantages
A specific question is more likely to get
you a direct answer
When in doubt, ask a Radiologist

ABC S APPROACH
A

Assess ADEQUACY of x-ray which includes


proper number of views and penetration.
Assess alingment of x-rays.

Examine BONES throughout their entire


length for fracture lines and or distortions

C Examine CARTILAGES(joint spaces) for


widening
S

Assess SOFT TISSUE for swlling/efusions

ADEQUACY
Semua x-ray seharusnya memiliki
beberapa lapang pandang (views) :
Minimum 2 views AP dan Lateral
3 views jika memungkinkan
Beberapa tulang harus 4 views

Semua x-ray seharusnya mempunyai


daya tembus yang adequat

ALIGNMENT
Normal x-ray seharusnya
mempunyai garis yang normal
Fractur dan dislokasi mungkin
mempengaruhi kesegarisan

BONES
Kaji tulang terhadap garis fraktur
dan penyimpangan lainnya
Kaji panjang dari tulang yang
seharusnya

CARTILAGE
Kaji jarak sendi diantara tulang
rawan (cartilage)
Curigai adanya cedera ligament
atau fraktur pada area di sekitar
sendi

SOFT TISSUE
Kaji terhadap adanya
pembengkakan soft tissue joint
effusions
Ini mungkin merupakan tanda dari
fraktur

BONE ANATOMY
Gambaran lokasi tulang yang abnormal
mengenai : Diaphysis,
metaphisis, atau
epiphisis.

BONE STRUCTURE

JOINT ANATOMY

DESCRIPTIVE TERM
Gambaran umum dapat digunakan
untuk menunjukan
ketidaknormalan.

SYSTEMATIC APPROACH

Patient and image data


Bone and joint alignment
Joint spacing
Cortical outline
Bone texture
Soft tissues

Cortical outline
Check cortical outline (white line) pada semua tulang yang
tampak
Telusuri garis tulang
Jangan hentikan penelusuran ketika menemukan satu
kejanggalan teruskan hingga penelusuran terakhir selesai.
Lihat adanya OSTEOPHITES

BOXER FRACTURE
Boxer fracture

Soft tissue Proximal Femur


Abnormality example : joint effusion mengandung fat
and blood (lipohaemarthrosis) dari kebocoran tulang
akibat trauma.
Garis fraktur
Clinical Information : nyeri sedang di sendi lutut
Diagnosis : Tibial plateau fracture

Principles : Percaya diri saat membaca x-ray


musculoskeletal hanyalah dari
pengalaman

Key Points :
2 views lebih baik dibanding 1
Cek semua foto yang ada
Bandingkan dengan yang sebelah atau sebelumnya (jika ada)

2 views
Clinical Information :
Twisting injury to left ankle
Patient tidak mampu menginjakkan kaki (Non Weight
Bearing )

Diagnosis :
Oblique fracture distal fibula of the ankle joint ( Weber B
Type)

Compare New and Old Image


The 'old X-ray' is said to be the 'cheapest test in radiology.'
The current X-ray shows an obvious displaced fracture(#) of
the femoral shaft
Diagnosis: Metastatic disease of bone with pathological
femoral shaft fracture (example: lytic bone lesion)

Acromioclavicular joint
Acromioclavicular joint dapat diperiksa dengan x-ray standar
Loss of alignment inferior surfaces of the clavicle and acromion
mengindikasikan adanya kelainan (disruption) acromioclavicular
ligament pada sendi acromioclavicular (ACJ)

EXAMPLE # 2WHERE ARE THE FRACTURES?

Jika
A
B
C
S

menggunakan ABCs, ;
Alignment : ada masalah alignment
Bone : garis fraktur 2,3,4
Cartilage : Fracture mid shaft metacarpals
Soft tissue : adanya pembengkakan

REFERENCES
Nilesh Patel (2008). BaSICS OF ORTHOPEDIC
RADIOLOGY
R M Freij (1996). Radiographic interpretation
by nurse practitioners. Emergency medical
journal. London.

THANK YOU

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