4. Musculoskeletal X ray For health student

It's about the musculoskeletal x ray reading and criteria

1. Musculoskeletal Radi ology Dr. Girma Lobe (MD, Radiologist)

2. Introduction Knowledge of normal bone, joint and soft tissue appearances enables accurate description of abnormalities seen. As for all X-rays, a systematic approach is required. Assess image quality and if clinically appropriate consider requesting a repeat X-ray. Look at all views available. If available compare with old images . Look for the unexpected .

3. Bone Anatomy Most bones develop from cartilaginous ossification centers to form a diaphysis (shaft), or epiphysis (end). During bone growth the diaphysis and epiphysis are separated by the epiphyseal line (growth plate) which fuses later in life. The zone adjacent to the growth plate on the diaphyseal side is called the metaphysis Sesamoid is a bone that ossifies within a tendon . The largest is the patella. Sesamoids are also common at the first metatarsophalangeal joint (big toe) and the first metacarpophalangeal joint (thumb).

4. Normal B one Anatomy

5. Normal hand & Foot x-ray of an Adult

6. Apophysis is a normal developmental outgrowth of a bone which arises from a separate ossification center, and fuses to the bone later in development. An apophysis usually does not form a direct articulation with another bone at a joint. It often forms an important insertion point for a tendon or ligament. Occasionally an apophysis can persist into adult life and if injured may become symptomatic. The many apophyses in the body have variable appearances and are often mistaken for fractures.

7. Bone structure In simple terms bone is made of an outer cortex and an inner medulla . Difference in density allows for differentiation on X-rays - cortex being denser and therefore whiter. Descriptive terms Once the skeleton is fused the distinction between epiphysis, metaphysis and diaphysis becomes less clear, and is less important. General terms can be used to describe the location of an abnormality. More general terms may be appropriate - such as proximal or distal end. Many bones also have proximal and distal articular surfaces When describing abnormalities of an articular surfaces remember to mention whether it is proximal or distal .

8. Although the system for viewing X-rays of bones and joints varies depending on the anatomy being examined, there are some broad principles which can be applied in a number of situations. ABCDS- A -for alignment, anatomic appearance B - for bone details. C - for cartilage/ joint spaces D – distribution, deformity ,density. S - for soft tissue Systematic approach

9. Patient and image data Start by checking at the correct labeling of image. The patient's details should be checked and the date and time of the X-ray noted. The skeletal system is symmetrical and therefore it is particularly important to be sure you are looking at the correct side. Bone and joint alignment Loss of alignment may be due to bone fracture or joint dislocation. Both may be associated with soft tissue injury that may not be directly visualized.

10. Bone Cortical outline Careful assessment of the bone cortex is required because a check that is too brief will lead to incorrect or incomplete diagnosis. In the context of trauma the clinical features of a significant injury may be masked by other injuries. Remember to be systematic, and if you spot one abnormality, do not stop until you are sure you have focused on all areas of the anatomy shown i.e Always avoid satisfaction of search(SOS).

11. Bone texture and density In some bones a fine matrix of fine white lines (trabeculae) is seen. Occasionally bone injury or disease will result in abnormality of this texture. Joint spacing Joint spacing may be narrowed due to cartilage loss or widened due to dislocation/dissociation Soft tissues Carefully examining the soft tissues can often provide helpful information. Not uncommonly an abnormality of soft tissues is more obvious than a bone injury, or may even imply a bone injury that is not visible at all.

12. Viewing principles Confidence in assessing musculoskeletal system X-rays comes from experience and a knowledge of normal appearances. All patients are different, so being sure of the distinction between normal and abnormal is often difficult. 2 views In the context of trauma at least 2 views of the body part in question are usually required. In some cases, such as possible scaphoid injury, more than 2 images are required. Compare with the other side (if imaged) or needed. If available ALWAYS compare with old X-rays

13. Images of the asymptomatic contralateral side to a suspected abnormality are not routinely acquired for assessment of all bones or joints. If an old image of the contralateral side is available, or if the other side is included as standard (for example hip/pelvis) then comparison between symptomatic and asymptomatic appearances can be very helpful. Compare current with previous images The 'old X-ray' is said to be the 'cheapest test in radiology.' When looking at an X-ray always keep the current clinical features at the forefront of your mind. Remember - ' Treat the patient and not the X-ray !'

14. Image quality Certain X-rays which require careful patient positioning may not be possible due to pain or reduced patient co-operation. High quality images may not be achievable, in which case you will have to work with the images provided. If an image is sub-optimal you can ask the radiographer/technician if there were particular technical reasons for this. Requesting a repeat image may be reasonable, if clinically justified. Affected by artifacts, adequacy, exposure, projections

15. Artifact Many musculoskeletal system X-rays contain artifact, either due to previous orthopedic surgery, or due to foreign bodies relating to the injury. If there is external artifact that obscures the area of anatomical interest then this should be removed if possible.

16. Conclusion: Be systematic Look at all views available If available compare with old images Look for the unexpected Assess image quality and if clinically appropriate consider requesting a repeat X-ray

17. Trauma Fracture - Is disruption in the continuity of bone, complete Vs incomplete Dislocation -disruption of a joint, articular surfaces are no longer in contact Subluxation - minor disruption of a joint . Fracture Incomplete (children) Green stick Torus Complete Single fracture line Comminuted Open Vs closed

18. Green stick & torus fractures

19. Pulled elbow  (also known as  nursemaid's elbow ) is a subluxation of the radial head into the annular ligament Occurs due to axial force Pulled elbow syndrome

20. Salter- Harris classification

21. Skull fracture Depressed Linear

22. E xamples Colles ’ Fracture Galeazzi Fracture

23. Subtle or hairline fractures Indirect signs Soft tissue swelling Obliteration or displacement of the fat planes Joint effusion(elbow) Intracapsular fat-fluid levels(knee) Buckling of the cortex

24. Monteggia fracture Radiocapittelar line Radial head dislocation Supracondylar # Anterior humeral line Normally passes through middle 3 rd of capitelum

25. Vertebral alignment 4 parallel lines Body height IVD spaces Posterior elements Vertebral X-ray

26. Preverteral soft tissue swelling is important in trauma because it is usually due to hematoma formation secondary to occult fractures. Unfortunately, it is extremely variable and nonspecific . Maximum allowable thickness of preverteral spaces is as follows : Nasopharyngeal space (C1) - 10 mm (adult ) Retropharyngeal space (C2-C4) - 5-7 mm Retrotracheal space (C5-C7) - 14 mm (children), 22 mm (adults ). Soft tissue swelling in symptomatic patients should be considered an indication for further radiographic evaluation. If the space between the lower anterior border of C3 and the pharyngeal air shadow is > 7 mm, one should suspect retropharyngeal swelling (e.g. hemorrhage ). This is often a useful indirect sign of a C2 fracture. Space between lower cervical vertebrae and trachea should be < 1 vertebral body.

27. Dislocated C5 on C6 C7 should be included in setting of trauma!

28. Normal Vs. dislocated C1/C2

29. Pyogenic 3-5 days…soft tissue edema 7-10days…>66% normal 28days….90% positive xray Lucent lytic lesions of cortical bone destruction Advanced…dense sclerotic bone… sequestra Tuberculous Bone Involvement Metaphyseal Focal osteolysis , eccentrically located Little or no reactive new bone Joint Phemister triad Juxta-articular osteoporosis Peripheral osseous erosions Gradual joint space narrowing Bone Infections

30. Bone Infection, Images Acute Chronic

31. Pyogenic V s T b spondilytis

32. MRI

33. Benign Sharp margins. Narrow zone of transition Variable marginal sclerosis Intact cortex Solitary bone cyst Bone Tumors

34. Aggressive Wide zone of transition Cortical destruction Codman‘s triangle or laminated periosteal reaction Ewing sarcoma Images

35. Points to consider Age Site of involvement i.e. which bone & where Characteristics of the lesion Rate of growth Presence of known malignancy elsewhere in the body

36. Arthritis Osteoarthritis Hallmarks asymmetric joint space narrowing Sclerosis osteophytes Rheumatoid Arthritis

37. Hallmarks of Gout Gouty Arthritis

38. Most common in children Usually monoarticular Hip & knee mostly involved Radiographic appearance Early-normal or effusion Intermediate-osteopenia & early cortical destructions Late-marginal destruction & bone erosion becomes clear Septic Arthritis

39. Shoulder dislocation osteochondroma Miscellaneous cases

40. Myositis ossificans osteosarcoma

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