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Musculoskeletal Radiology
อ.พิมใจ ภาควิชา รังสีวิทยา 2554
Outline• How to describe fracture• Common fracture & dislocation
– Case-based learning• upper & lower extremities
• Approach to non-traumatic problems• Bone disease
– Bone tumor / infection/ metastasis • Joint disease
Site of fractureAlignment• Angulation• Over-ridingDisplacement• Distal fragmentAssociated injury• Other site injury• Hematoma• N,V injury
Describe this fracture
Upper extremities:
- Normal radiographs
- Shoulder, Elbow, Wrist
- Case-based learning
Common Fracture-Dislocation
AP
Radiographic Technique
Lateral Y-viewAP
XR- Shoulder : AP & Lateral Y view
Lateral Y view
Shoulder : AP view
XR showBones- Humeral head- Glenoid fossa- Acromion, coracoid- ClavicleJoints- GH joint- AC joint
HHGl
C A
Shoulder- Lateral Y- view
C
AC
HH
Case 70 YOF
Hx- Fell down
XR - Findings
A B
Which one is False
Most common injury to axillary nerveWhich supply Deltoid muscle
Shoulder- Fracture/ dislocationShoulder Dislocation
• Most frequently dislocated joint• Anterior dislocation (95%)
>> Posterior dislocation (5%)• Associated injury
– Fracture greater tuberosity– Fracture humeral head (Hill-Sach)– Fracture glenoid bone (Bankart )– Axillary nerve injury
Shoulder : Anterior Dislocation
Associated fractures• Hill-Sachs fracture
– Posterolateral humeral head– 74% in recurrent dislocation
• Bony Bankart lesion – Anterior glenoid bone
• Fracture greater tuberosity
XR- Elbow : AP and Lateral view
XR- Elbow : AP view
Lateral side1. Lat. Epicondyle
: non-articular
2.Capitellum
: articular
Medial side1.Med Epicondyle
: non-articular
2.Trochlea
: articular
XR- Elbow: Lateral view
Normal alignment 1.Radiocapitellar line2.Anterior humeral line
point to the middle 1/3 capitellum
XR- Elbow : AP and Lateral view
Relationship between the radial head and capitellum
Hx- Fell down
XR - Findings
Case 30 YOM
Case 10 YO boy- Fell down Wrist : PA view
XR showBones- Distal radius, ulna- Carpal bones- MetacarpalsJoints- Distal radioulnar joint- Wrist ( radiocarpal) joint- Metacarpophalangeal
(MP) joint
Wrist –lateral view
-The central axis of the 3rd MC extend along capitate, lunate & the radius
C
L
PS
XR- Wrist : PA & Lateral view
• Fall on the outstretched
• Dorsiflexed hand
80% 20%
Case 40 YOF – Fell down
A. B. Case 20 YOM – Fell down
Lower extremities:
- Normal radiographs
- Hip, Knee , Ankle
- Case-based learning
Common Fracture-DislocationPelvis – both hips : AP view
Hip Anatomy- Acetabulum- Femur : Head, neck, trochanter
GT
LT
Pelvis – both hips : AP view
Shenton’s line :- Relationship of hip ; continuity of obturator foramen to femoral neck- If discontinuity –look for fracture FN
Case 30 YOM
Case 20 YOM
A. B
Dislocation of the HipClassification• Posterior dislocation, 90%
– Femoral head behind acetabulum– Posterior rim of acetabulum is usually fractured– Sciatic nerve injury**, 10%
• Anterior dislocation, 10 %– Femoral head in front of acetabulum, displaced into obturator,
pubic or iliac region
• Central – intra-pelvic location – Always associated with acetabular fracture
R L
Case 50 YOM XR- Knee : AP & Lateral standing view
Knee :Lateral view -Joint effusion Case 20 YOM
Case 40 YOM Case 40 YOF
Knee Dislocation• Ortho emergency• Look for associated fracture &NV injury• Ligaments & other soft tissue disrupted• Prompt reduction important
Ankle-Foot Trauma
Ottawa Rules XR Ankle if:-tenderness at
- A med malleolus- B lat malleolusA
B
Ankle AP - Mortise
To decide fracture instability Stress view - 15-20o internal oblique projection
Bone Disease
Sign of bone disease• Bone destruction
– Edge/ margin– Adjacent cortex
• Periosteal reaction• Cortical thickening
Differential Dx• Bone tumor
– Benign– Malignant : Primary/ Metastasis
• Infection/ Osteomyelitis
Bone tumor• Bone changes
– Osteolytic destruction– Margin of the lesion– Tumor matrix
• Periosteal reaction
Pattern of Bone Destruction
• Geographic benign• Motheaten malignancy
infection• Permeative malignancy
infection
Pattern of bone destruction
Geographic Motheaten Permeative
Periosteal ResponseSolid type benign Aggressive Malignant• Onion peel • Codman’s triangle• Sunray
Most aggressive
Periosteal Response
Sunray Codman’s Onion peel
Tumor Matrix
Osteoid Chondroid matrix
Age (Yr) Possible diagnosis
< 20 Ewing sarcoma, Osteosarcoma20-40 Giant cell tumor, Osteosarcoma,
lymphoma> 40 Chondrosarcoma, Metastasis,
Multiple Myeloma
Patient age with malignant tumors Malignant bone tumor
Tissue of origin Tumor• Bone Osteosarcoma• Cartilage Chondrosarcoma• Marrow element Ewing’s; MM, Lymphoma• Fibrous tissue Fibrosarcoma• Metastatic Lung, Breast, Prostate,
Kidney, Thyroid
A 9-year-old boy, pain & swelling right knee for 3 months
Pathologic fracture femur
60 YOM Severe pain
Pathologic Fracture
Abnormal bone
Normal Force
Pathologic Fracture
Abnormal bone
Bone tumorPrimary / Metastasis
Multiple Bone lesions
• Metastasis• Multiple
myeloma
Radionuclide bone scan is helpful for further investigation
Radionuclide bone scan : Metastasis