Principles of radiologic interpretation of skeletal system

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Principles of radiologic interpretation of bone lesions:

Principles of radiologic interpretation of bone lesions Dr. Varun Babu In radiography, as in photography and microscopy, and many other observations, the appearance which seems the most obvious does not always correspond with the real condition - Anonymous

Skeletal Imaging Modalities:

Skeletal Imaging Modalities Conventional Imaging Contrast Imaging Radioisotopic Imaging Advanced Imaging Radioisotop e Imaging Advanced Imaging Bone Scan Ultrasound Cineroentgenology CT MRI

Some Basic Concepts :

Some Basic Concepts Normal Radiographic Densities Air Fat Water Bone Air Fat Water Bone

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Air Fat Water Bone Metal

Some Basic Concepts :

Some Basic Concepts Normal Radiographic Densities Air Fat Water Bone Minimum of 2 views, preferably perpendicular to each other

Why 2 views?:

Why 2 views?

Skeletal Anatomy and Physiology:

Skeletal Anatomy and Physiology Mesodermal tissue

Intramembranous ossification:

Intramembranous ossification

Enchondral ossification:

Enchondral ossification

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Densest and strongest of all bone Densely packed compact lamellar bone & osteons , interconnected by haversian canal systems Externally enveloped by periosteum Internally lined with endosteum Internal cavity of bone is traversed by thin, interconnecting trabeculae & contains bone marrow Children – red marrow in all bones Adults – red marrow in axial skeleton, epiphyses, metaphyses Cortex Medulla

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Thin membrane of tissue enveloping diaphysis and metaphysis of bone Histology: 2 layers Outer fibrous Inner cambium All trabeculae and inner cortical margins are covered with a single layer that had both osteoclastic and osteoblastic properties Periosteum Endosteum

Bone Structure:

Bone Structure Epiphysis Physis Zone of provisional calcification Metaphysis Diaphysis A pophysis

Epiphysis :

Epiphysis End of a growing bone Undergoes enchondral ossification Eventually fuses with shaft Primary function – produce and support articular cartilage Apophysis -

Physis :

Physis Cartilage growth plate between epiphysis and metaphysis Layers of progressively maturing cartilage and developing bone

Zone of provisional calcification:

Zone of provisional calcification A thin line of increased density at junction of physis and metaphysis , Region of calcification of physis cartilage – precursor of bone formation Residuals of intermittent growth arrests from systemic diseases – transverse, opaque metaphyseal lines

Metaphysis :

Metaphysis Between ZPC and diaphysis Most metabolically active region of a bone Most common site for tumors and infections

Diaphysis :

Diaphysis Between both metaphyses , longest part of the bone (shaft) Thickened cortex, decreased medullary space Provide mechanical strength, contains bone marrow

Bone metabolism:

Bone metabolism Bone Minerals: calcium:phosporus (2:1) Main Ca-P complex Crystalline hydroxyapatite Ca 10 (PO 4 ) 6 (OH) 2 Most active sites: haversian canal systems and resorption cavities Mechanical stress, vitamin D, parathormone , trace minerals, alkaline phosphatase Serum P levels – inversely related to Ca P allows precipitation of calcium at the bony crystal surface

Hormones :

Hormones Caclitonin Estrogen Androgen Growth hormone Parathormone glucocorticoids Anabolic Catabolic

The Categorical Approach to Bone Disease:

The Categorical Approach to Bone Disease - Proposed by Howe C ongenital A rthritis T rauma B lood I nfection T umor E ndocrine S oft tissue

A 3 step approach.. :

A 3 step approach.. Preliminary Analysis Analysis of the lesion Supplementary Analysis

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Preliminary analysis Clinical data Number of lesions Symmetry of lesions Systems involved

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History Sex Age Clinical data

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Monostotic Polyostotic

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Monostotic Polyostotic Congenital Block vertebra Polydactyly Bone dysplasia Achondroplasia Arthritis Degenerative joint disease Rheumatoid arthritis Traumatic Localized injury Battered child Severe injury Blood Perthe’s Disease Sickle cell anemia Infection Staphylococcal Salmonella Tumor Osteoi d osteoma Osteosarcoma Multiple myeloma Metastases Endocrine/Nutritional/Metabolic None Hyperparathyroidism Number of lesions

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Analysis of the Lesion Skeletal location Position within bone Site of Origin Shape Size Margin Cortical integrity Behavior of lesion Matrix Periosteal response Soft tissue changes Joint changes

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Skeletal location

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Skeletal location Malignant Tumors Location Adamantinoma Mandible, tibia Chondrosarcoma Pelvis, scapula, sternum, femur, humerus Chordoma Sacrococcygeal , skull base, C2 body Ewing’s sarcoma Pelvis, femur, humerus Fibrosarcoma Femur, tibia Multiple myeloma Pelvis, spine, sternum, femur, humerus Osteosarcoma Femur, tibia, humerus Parosteal sarcoma Femur Non-Hodgkin’s lymphoma Femur, humerus , pelvis, spine

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Position within bone

Position within bone :

Position within bone 10 year old 7 year old

Position within bone :

Position within bone

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Position within bone Site Tumors Epiphyseal Chondroblastoma , GCT Epiphyseal – Metaphyseal Aneurysmal bone cyst, GCT, metastases Metaphyseal Bone island, enchondroma , fibrous cortical defect, non-ossifying fibroma , osteochondroma , osteoid osteoma , simple bone cyst, chondrosarcoma , fibrosarcoma , metastases, osteosarcoma Metaphyseal – Diaphyseal Chondromyxoid fibroma , non-ossifying fibroma , osteoid osteoma , chondrosarcoma , metastases, osteosarcoma , multiple myeloma Diaphyseal Osteoid osteoma , latent bone cyst, adamantinoma , ewing’s sarcoma, metastases, multiple myeloma, non- hodgkin’s lymphoma

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Site of origin Cortical Medullary Periosteal Extraosseous Centric Eccentric

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Site of origin

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Slow growing lesions – progress along long axis of bone Rapidly growing lesions - pleomorphic Shape Slow growing tumors <6cm Aggressive lesions – larger SBC, ABC, GCT, fibrous dysplasia Size Short lesions <6cm – secondaries ( osteolytic / osteoblastic metastases) Long lesions – primary disorders (fibrous dysplasia, Paget’s, multiple myeloma, chondrosarcoma , enchondromatosis , Ollier’s disease) Length

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Margination Imperceptible Poor, hazy, ill defined Wide zone of transition Aggressive bone destruction – infections, malignancy Sharp Definite sclerotic margins Narrow zone of transition Slow growing - fibrous dysplasia, simple bone cyst

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Cortical integrity Thinning Thickening Expansion Destruction Fracture

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Lesion Behavior Osteolytic Geographic Moth-eaten Permeative Osteoblastic Diffuse Localized Mixed

Osteolytic behavior:

Osteolytic behavior Geographic Moth eaten

Osteolytic behavior:

Osteolytic behavior Permeative

Osteoblastic behavior:

Osteoblastic behavior Localized (snowball) Diffuse (ivory)

Matrix :

Matrix Fat matrix Fibrous matrix

Matrix :

Matrix Cartilage matrix Stippled Flocculent Arc and Ring

Matrix :

Matrix Bone Matrix

Periosteal response :

Periosteal response

Periosteal response :

Periosteal response Solid Laminated Spiculated Codman’s triangle

Soft tissue changes:

Soft tissue changes

Soft tissue changes:

Soft tissue changes Inside-out Outside-in

Joint changes:

Joint changes Malignancy Infection

Joint space loss:

Joint space loss Non - uniform Uniform

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Analysis of the Lesion Skeletal location Position within bone Site of Origin Shape Size Margin Cortical integrity Behavior of lesion Matrix Periosteal response Soft tissue changes Joint changes

Supplementary analysis:

Supplementary analysis Other imaging procedures Lab parameters Skeletal profile – CBC, ESR, CRP, serum Ca, P, ALP, acid phosphatase , serum proteins Biopsy – incisional , needle aspiration

Few pearls..:

Few pearls.. Lack of knowledge Reading the reports, NOT reading the film Poor or inadequate studies – repeat/additional views/other modalities Perceptual errors Previous reports Second opinion

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Expertise in radiologic interpretation is related to developing a knowledge base in anatomy, pathology, and differential diagnosis; being exposed to a wide range of exemplary case materials; being able to correlate radiologic information with clinical data; and engaging in continuing education and experience. Thank you 

Congenital :

Congenital Segmentation defects in spine – block vertebrae, hemivertebra Pelvic – DDH Limb variations – polydactyly Generalized congenital dysplasias – achondroplasia , osteopetrosis , cleidocranial dysplasia

Arthritis :

Arthritis A lignment Ulnar deviation of digits - rheumatoid arthritis Anterolisthesis of vertebral body – defect in posterior arch ( spondylolysis , facet joint arthrosis , fracture-dislocation) B one changes Juxta articular osteopenia - inflammatory arthropathy Sclerosis – mechanical arthropathy C artilage effects Joint space integrity Uniform loss of joint space – inflammatory joint disease Non uniform loss – degenerative disease s oft tissue Swelling – inflammatory/rheumatoid arthritis Masses – deposition arthropathies , gout, amyloid Calicification – calcinosis , scleroderma

Trauma :

Trauma Fractures, dislocations, soft tissue abnormalities like myositis Blood Various hemolytic anemias Osteonecrosis Infection Osteomyelitis , septic arthritis Tumor Destructive and productive features Endocrine, nutritional, metabolic Scurvy, rickets etc Soft tissue

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