45Imaging Techniques and

Fundamental Observations forthe Musculoskeletal System

• FIGURE 45-1 (A) AP ■radiograph of index finger demonstrates

dislocation of the proximal interphalangeal joint (arrow). (B) Dislocated distal interphalangeal joint is only evident on the

orthogonal view (arrow).

FIGURE 45-2 (A) Lateral radiograph of the elbow ■shows joint effusion displacing the fat pads (*) indicating intra-articular injury. (B) Horizontal beam lateral radiograph of the knee shows lipohaemarthrosis due to occult fracture with a linear fat (white arrow)/fluid (black arrow) level.

FIGURE 45-3 Lateral radiographs of the cervical spine ■in (A) extension and (B) flexion. Atlantoaxial subluxation due to disruption of the transverse ligament is demonstrated on the view taken in flexion with widening of the atlantoaxial distance(black arrows).

• FIGURE 45-4 Fluoroscopic image of the ■shoulder shows contrast medium within the glenohumeral joint extending into the subacromial bursa (arrowhead) indicating a rotator cuff tear.

• FIGURE 45-5 Tomographic image of medial ■right medial clavicle fracture (arrows), normal left side.

FIGURE 45-6 Sonographic image of the medial thigh ■shows heterotopic calcification (*) and posterior acoustic shadowing (arrows) within the adductor musculature not evident on radiographic assessment.

• FIGURE 45-7 Transverse PD sonogram of the ■first extensor compartment tendons (T) at the wrist. Abnormal vascularisation, particularly within the tendon sheath surrounding the tendons, indicates tenosynovitis.

• FIGURE 45-8 Longitudinal ultrasound ■images of the long head of biceps tendon (arrows). (A) Distal anisotropic artefact. (B) Artefact eliminated using beam steer.

• FIGURE 45-9 EFOV sonogram of the lower ■calf shows hypoechoic fascicle bundles covered by hyper echoic perimysium. Echogenic epimysium surrounds each muscle (arrows).

• FIGURE 45-10 Partial thickness tear of the ■Achilles tendon. B-mode US shows focal hypoechogenicity (lower arrow). Elastogram shows decreased tendon stiffness (upper arrow).

• FIGURE 45-11 99mTc-■MDP bone scintogram shows normal distribution of radiotracer within the skeleton and urinary tract. The renal outlines are visible (arrowhead) and radiotracer is evident within the urinary bladder (arrow).

• FIGURE 45-12 SPECT CT ■of the mandible. Axial image shows increased radiotracer uptake (arrows) due to osteonecrosis of the jaw; increased uptake posteriorly is due to degeneration within the cervical spine.

• FIGURE 45-13 (A) ■Longitudinal and (B) transverse ultrasound images of the median nerve (arrowheads) showing hypoechoic fascicles differing from the fibrillar pattern within adjacent tendons (arrows).

• FIGURE 45-14 Coronal MR images of a ■skeletally immature patient. (A) T1-weighted and (B) proton density fat-saturated images

showing yellow marrow in the epiphyses (Y) and red marrow in the metadiaphyses (R).

FIGURE 45-15 Axial MR ■images through the mid-thigh. (A) T1- and (B) T2-weighted fat-saturated images showing skin, normal fat distribution, muscle and bone.

FIGURE 45-16 Pelvic radiograph of a patient ■with chronic renal failure. Extensive vascular calcification and soft-tissue calcification. External artefact from ileostomy bag (arrows), IUCD (I) and right femoral line (F).

FIGURE 45-17 Hip radiograph shows ■phleboliths of the pelvis venous plexus. One phlebolith is en face and so has a central lucency (arrow).

FIGURE 45-18 Hand radiograph of patient with ■Maffucci’s syndrome shows extensive multiple enchondromas with phleboliths in soft-tissue haemangiomas.

FIGURE 45-19 Extensive heterotopic ■ossification with ankylosis (arrows) of the left hip in a patient with post-traumatic quadriplegia.

FIGURE 45-20 AP radiograph of shoulder ■showing dense hydroxyapatite deposit (arrows) in the superior rotator cuff in a patient with calcific tendinosis.

FIGURE 45-21 Radiograph of the forearm ■shows neural calcification (arrows) in leprosy.

FIGURE 45-22 Rice-like calcification of ■cysticercosis (arrows) affecting the psoas muscle.

• FIGURE 45-23 Coiled calcification within ■the subcutaneous tissues of the lower leg in guinea worm infection.

FIGURE 45-24 Radiograph ■of the hand in a patient with progressive systemic sclerosis. Calcinosis circumscripta (arrow), soft-tissue loss of the tip of the index finger and thumb MCP joint arthritis are present.

FIGURE 45-25 Osteosarcoma of the proximal humerus. Ra■ diograph shows dense new bone formation and aggressive periosteal reaction. Ossified lymph node metastases (arrows). (B) 99mTc-MDP bone scintigraphy shows increased radiotracer uptake within the primary humeral lesion, malignant lymph nodes within the axilla and spinal and pelvic bone metastases.

FIGURE 45-25 Osteosarcoma ■of the proximal humerus. Radiograph shows dense new bone formation and aggressive periosteal reaction. Ossified lymph node metastases (arrows). (B) 99mTc-MDP bone scintigraphy shows increased radiotracer uptake within the primary humeral lesion, malignant lymph nodes within the axilla and spinal and pelvic bone metastases.

FIGURE 45-26 Parasagittal MRI images of the ankle. (A) T2-■weighted fat-saturated and (B) T1-weighted images show fluid (F) and air (A) collections posteriorly tracking from a plantar ulcer (arrows). There is osteomyelitis within the calcaneus with intraosseous gas and surrounding bone oedema (O).

FIGURE 45-26 Parasagittal MRI images of the ankle. (A) T2-■weighted fat-saturated and (B) T1-weighted images show fluid (F) and air (A) collections posteriorly tracking from a plantar ulcer (arrows). There is osteomyelitis within the calcaneus with intraosseous gas and surrounding bone oedema (O).

FIGURE 45-27 Soft-tissue gas. (A) Radiograph of the forefoot in ■ a diabetic patient with the dappled low-density appearances of gas in the soft tissues of the second toe; note vascular calcification and osteopenia. (B) Reformatted sagittal CT image shows extensive soft tissue, joint and intraosseous low-density gas due to infection in a different patient.

FIGURE 45-27 Soft-tissue gas. (A) Radiograph of the forefoot in ■ a diabetic patient with the dappled low-density appearances of gas in the soft tissues of the second toe; note vascular calcification and osteopenia. (B) Reformatted sagittal CT image shows extensive soft tissue, joint and intraosseous low-density gas due to infection in a different patient.

FIGURE 45-28 Radiograph of the knee shows ■intra-articular gas (arrows) following penetrating injury.

FIGURE 45-29 Different ■patients. (A) Radiograph shows stress fracture of the second metatarsal with periosteal reaction (arrows). (B) Axial CT of healing ulna fracture. The fracture remains ununited with florid surrounding periosteal reaction and callus

FIGURE 45-29 Different patients. (A) Radiograph shows stress ■fracture of the second metatarsal with periosteal reaction (arrows). (B) Axial CT of healing ulna fracture. The fracture remains ununited with florid surrounding periosteal reaction and callus

FIGURE 45-30 ■Hypertrophic osteoarthropathy in a patient with lung cancer. Periosteal reaction of the distal femur and proximal tibia (arrows). Lytic metastasis (M) within the medial tibia with cortical destruction.

FIGURE 45-31 Osteoid ■osteoma of the tibia. Reformatted sagittal CT shows smooth fusiform periosteal reaction and lucent nidus (arrows).

FIGURE 45-32 Aggressive ■periosteal reaction in Langerhans cell histiocytosis in a pediatric patient. Bone destruction and lamellated periosteal reaction (arrows) shown on (A) AP radiograph and (B) axial T2 MRI.

FIGURE 45-32 Aggressive periosteal reaction in ■Langerhans cell histiocytosis in a paediatric patient. Bone destruction and lamellated periosteal reaction (arrows) shown on (A) AP radiograph and (B) axial T2 MRI.

• FIGURE 45-33 Ewing’s sarcoma of the femur. (A) ■AP and (B) lateral radiographs show lamellated (L) and hair-on-end (H) periosteal reaction with Codman triangle formation (arrows).