Radiology in orthopaedics

Radiology in orthopaedics

1. ROLE OF RADIOLOGY IN ORTHOPAEDICS PRESENTER:PUTHOTA ROOPA SAI MODERATOR: Dr. VAMSI KRISHNA SIR CHAIRPERSON: Dr. A.SRINIVASA RAO SIR DEPARTMENT OF ORTHOPAEDICS

2. Imaging Techniques in Orthopaedics Conventional Radiography Flouroscopy Digital radiography Computed tomography Magnetic resonance imaging Scintigraphy PET scan Ultrasound Scanogram DEXA Arthrography,Tenography,Bursography Angiography Myelography

3. CONVENTIONAL RADIOGRAPHY The first x-ray was invented by Wilhelm Conrad Roentgen on 22 Dec 1895 when he produced the first human x-ray of his wife Bertha’s hand.

4. CONVENTIONAL RADIOGRAPHY : The most frequently used modality for evaluation of bone and joint disorder. Plain film radiography remains as the 1 st order diagnostic imaging modality. X-rays are a form of electromagnetic radiation similar to visible light but of shorter wavelength. Xray tube generates x-rays and beams them toward the patient. Some of the energy is absorbed; rest passes through patient and hits the film plate. Shades of gray on film are a representation of the different densities of the anatomic tissues through which the xrays have passed

5. Tissues with greater density will absorb more of the xray so less of the beam reaches the film plate. The resultant image is therefore lighter . Tissues with less density will allow more x ray to reach the film so it will be darker . This is called radiodensity and is determined by : thickness and composition of structure. Air : black eg : trachea, lungs, stomach, digestive tract. Fat : gray black eg : subcutaneously along muscle sheaths ; around viscera. Water : gray eg : muscles, nerves, tendons, ligaments, vessels (all of these structures have the same density and therefore are hard to distinguish on plain x rays.) Bone : gray/white. (Calcium with higher atomic number absorbs higher proportions of x-rays resulting in less crystal formation in the film – Radioopaque appearance of bone Contrast medium : white outline. Heavy metals : white solid.

6. ABC’S Approach A ◦ Adequacy, Alignment B ◦ Bones C ◦ Cartilage S ◦ Soft Tissues ABCs approach applies to every x-ray image

7. ADEQUACY Adequate views: At least 2 views of the bone involved at 90-degree angles to each other with each view including two adjacent joints should be obtained. 3 views even better (oblique view) In children it is necessary to obtain radiographs of normal unaffected limb for comparison . Normally anteroposterior and lateral views are taken, occasionally oblique and special views are necessary Sufficient exposure!- visibility, image resolution, technical adequacy.

8. Fracture of the radial head. A patient presented with elbow pain after a fall. Anteroposterior (A) and lateral (B) radiographs are normal; however, the radial head and coronoid processes are not well demonstrated because of a bony overlap. A special 45-degree angle view of the elbow (C) is used to project the radial head ventrad, free of the overlap of other bones. A short, intraarticular fracture of the radial head is now clearly visible (arrow).

9. ALINGMENT Assess the size of the bones. Assess the number of bones. Assess each bone for normal shape and contour; irregularities can be from trauma, congenital, developmental or pathological. Assess joint position: trauma, inflammatory or degenerative disease. Anomalies of bone formation. sacral agenesis (A), bilateral agenesis of the fibulae (B), supernumerary bones, polydactyly in both hands (C), Polydactyly in the right foot (D).

10. BONES BONE DENSITY Assess general bone density contrast between soft tissues and bone contrast between cortical margin and the cancellous bone and medullary cavity loss of contrast means loss of bone density ie : osteoporosis labeled as osteopenia, demineralization or rarefaction .

11. Assess local bone density : looking for sclerosis: sign of repair in the bone, Excessive sclerosis is indicative of DJD Bone Lesions: Osteolytic- bone destroying so appear radiolucent as in RA or Gout Osteoblastic- bone forming; osteoblastomas, osteoid osteomas

12. Osteoblastic matrix. The matrix of a typical osteoblastic lesion, in this case an osteosarcoma, is characterized by the presence of fluffy, cotton-like densities within the medullary cavity of the distal femur. Chondroid matrix. (A) Schematic representation of various appearances of chondroid matrix calcifications: stippled, flocculent, and rings and arcs. (B) The matrix of enchondroma C) The matrix of chondrosarcoma.

13. Pattern of bone destruction. (B) The geographic type of bone destruction, characterized by a uniformly affected area within sharply defined borders, typifies slow-growing benign lesions, in this case a chondromyxoid fibroma. (C) Moth-eaten bone destruction is characteristic of rapidly growing infiltrating lesions, in this case myeloma. (D) The permeative type of bone destruction is characteristic of round cell tumors, in this case Ewing sarcoma .

14. Assess texture abnormalities: looking at trabeculae appearance

15. CARTILAGE Cartilage is not visible on x-ray; Evaluate joint spaces. Abnormally wide joint spaces may speak for ligament injury or impression fracture. Narrow joint spaces mean thin cartilage due to degeneration- osteoarthrosis. SOFT TISSUE Evaluate soft tissue swelling. May speak for an occult fracture.

16. A ◦ evaluate adequacy: adequate views and image quality. evaluate alignment- long axes of bones. B ◦ Examine bones (whole)- look for cracks and deformities. C ◦ Examine cartilage- joint space- width, asymmetry. S ◦ Evaluate soft tissues: swelling, joint effusion (relate image to clinical exam)

17. The center of the xray beam is always perpendicular to the film plate. The position of the body will determine the outline of the image. Consists of the angles of projection that best demonstrate the anatomy while utilizing the least amount of exposures. Common Views: Anteroposterior (AP) Lateral (R and L) Oblique (R and L)

18. PLANES

19. POSITION

20. PROJECTION

21. SHOULDER AP VIEW Anteroposterior view . A) The patient may be either supine, as shown here, or erect; the arm of the affected side is fully extended in the neutral position. The central beam is directed toward the humeral head. (B) The humeral head is seen overlapping the glenoid fossa. The glenohumeral joint is not well demonstrated.

22. SHOULDER AP VIEW - Arm in neutral position demonstrates Fracture of Humeral head and neck Clavicle Scapula Anterior dislocation Bankart lesion

23. SHOULDER AP VIEW Arm in external rotation demonstrates Compression fracture of humeral head (trough line impaction) secondary to posterior dislocation

24. SHOULDER AP VIEW ON INTERNAL ROTATION- The proximal humerus in true lateral position , Site of insertion of subscapular tendon. Demonstrates Hill- sachs lesion

25. SHOULDER GRASHEY VIEW Demonstrates Glenohumeral joint space Glenoid in profile Posterior dislocation Grashey view . (A) The patient may be either erect, as shown here, or supine. He or she is rotated approximately 40 degrees toward the side of the suspected injury, and the central beam is directed toward the glenohumeral joint. (B) glenoid in true profile.

26. SHOULDER AP AXIAL PROJECTION- Useful in diagnosing post. Dislocation.

27. SHOULDER Demonstrates Relationship of humeral head and glenoid fossa Os acromiale Anterior and posterior dislocations Compression fractures secondary to anterior and posterior dislocations Fractures of Proximal humerus scapula Axillary view . (A) the patient is seated at the side of the radiographic table, with the arm abducted so that the axilla is positioned over the film cassette. The radiographic tube is angled approximately 5 to 10 degrees toward the elbow, and the central beam is directed through the shoulder joint.

28. SHOULDER AP OBLIQUE PROJECTION ( APPLE METHOD)- Demonstrate the loss of articular cartilage.

29. SHOULDER INFERO-SUPERIOR AXIAL PROJECTION- When chronic instability of shoulder is suspected. Bony abnormality of the ant. Inf. Glenoid rim. Hill- Sach defect of post-lat humeral head.

30. SHOULDER A Variation of lateral axillary view Demonstrates Bankart fracture of inferior glenoid rim West Point view . (A) the patient lies prone on the radiographic table, with a pillow placed under the affected shoulder to raise it approximately 8 cm . The film cassette is positioned against the superior aspect of the shoulder. The radiographic tube is angled toward the axilla at 25 degrees to the patient's midline and 25 degrees to the table's surface.

31. SHOULDER Lateral Transthoracic demonstrates Relationship of humeral head and glenoid fossa Fractures of proximal humerus Transthoracic lateral view . (A) The patient is erect with the injured arm against the radiographic table . The opposite arm is abducted so that the forearm rests on the head. The central beam is directed below the axilla, slightly above the level of the nipple. (B) Demonstrates the true lateral view of the proximal humerus .

32. SHOULDER BICIPITAL GROOVE VIEW Bicipital groove view . (A) The patient is standing and leaning forward, with the forearm resting on the table and the hand in supination. The film cassette rests on the patient’s forearm. The central beam is directed vertically toward the bicipital groove, which has been marked on the skin. (B) The bicipital groove is clearly demonstrated.

33. SHOULDER Acromioclavicular view . (A) The patient is erect, with the arm of the affected side in the neutral position. The central beam is directed 15 degrees cephalad toward the clavicle. Demonstrates Acromioclavicular joint Acromioclavicular separation Fracture of clavicle

34. SHOULDER T ransscapular (or Y) projection the patient is erect, with the injured side against the radiographic table. The patient's trunk is rotated approximately 20 degrees from the table to allow for separation of the two shoulders (inset). The arm on the injured side is slightly abducted and the elbow flexed, with the hand resting on the ipsilateral hip. The central beam is directed toward the medial border of the protruding scapula. Transscapular (Y) view demonstrates Relationship of humeral head and glenoid fossa Fractures of Proximal humerus Body of scapula Coracoid process Acromion

35. SHOULDER AP AXIAL PROJECTION ( STRYKER NOTCH METHOD)- Defects on the post-lat head of the humerus.

36. SHOULDER TANGENTIAL PROJECTION – SUPRASPINATUS OUTLET VIEW Demonstrate coraco-acromial arch or outlet to diagnose shoulder impingement.

37. ACROMIO-CLAVICULAR JOINT AP AXIAL PROJECTION ( ALEXANDER METHOD)- Useful in suspected AC subluxation or dislocation.

38. SCAP U LA AP AXIAL PROJECTION – To visualize coracoid process clearly.

39. CLAVICLE AP AXIAL PROJECTION ( LORDOTIC POSITION)-

40. SCAP U LA AP PROJECTION-

41. SCAP U LA PA OBLIQUE PROJECTION-

42. ELBOW Anteroposterior view . (A) The forearm is positioned supine (palm up) on the radiographic table, with the elbow joint fully extended and the fingers slightly flexed.The central beam is directed perpendicularly toward the elbow joint. Demonstrates Supracondylar, transcondylar, and intercondylar fractures of the distal humerus Fractures of Medial and lateral epicondyles Lateral aspect of capitellum Medial aspect of trochlea Lateral aspect of radial head Valgus and varus deformities Secondary ossification centers of distal humerus

43. ELBOW Lateral view . (A) The forearm rests on its ulnar side on the radiographic cassette, with the joint flexed 90 degrees, the thumb pointing upward, and the fingers slightly flexed. The central beam is directed vertically toward the radial head. Demonstrates Supracondylar fracture of the distal humerus Fractures of Anterior aspect of radial head Olecranon process Complex dislocations in elbow joint Dislocation of radial head Fat-pad sign

44. ELBOW Radial head-capitellum view . (A) the patient is seated at the side of the radiographic table, with the forearm resting on its ulnar side, the elbow joint flexed 90 degrees and the thumb pointing upward. The central beam is directed toward the radial head at a 45-degree angle to the forearm . Demonstrates Fractures of Radial head Capitellum Coronoid process Abnormalities of humeroradial and humeroulnar articulations

45. E L B O W AP OBLIQUE PROJECTION ( ON MEDIAL ROTATION)- Coronoid process free of superimposition

46. E L B O W AP OBLIQUE PROJECTION ( ON LATERAL ROTATION) Radial head & neck free of superimposition.

47. E L B O W AP PROJECTION ( ACUTE FLEXION )- Demonstrate olecranon process clearly

48. E L B O W PA AXIAL PROJECTION-

49. WRI S T PA OBLIQUE PROJECTION- Gives distinct radiograph of trapezium & scaphoid.

50. WRI S T AP OBLIQUE PROJECTION- Separates the pisiform from adjacent carpal bones.

51. WRI S T PA PROJECTION (ON RADIAL & ULNAR DEVIATION)- Opens the interspaces between the carpals .

52. WRI S T PA AXIAL PROJECTION FOR SCAPHOID ( STECHER METHOD)-

53. WRI S T TANGENTIAL INFERO SUPERIOR PROJECTION- Demonstrate the carpal canal.

54. Neutral ulnar variance. (A) As a rule, the radial styloid process rises 9 to 12 mm above the articular surface of the distal ulna. This distance is also known as the radial length. (B) At the site of articulation with the lunate, the articular surfaces of the radius and the ulna are on the same level. Negative and positive ulnar variance. (A) Negative ulnar variance. The articular surface of the ulna projects 5 mm proximal to the site of radiolunate articulation. (B) Positive ulnar variance. The articular surface of the ulna projects 8 mm distal to the site of radiolunate articulation.

55. Ulnar slant. The ulnar slant of the articular surface of the radius is determined, with the wrist in the neutral position, by the angle formed by two lines: one perpendicular to the long axis of the radius at the level of the radioulnar articular surface (a) and a tangent connecting the radial styloid process and the ulnar aspect of the radius (b). Palmar inclination. The palmar inclination of the radial articular surface is determined by measuring the angle formed by a line perpendicular to the long axis of the radius at the level of the styloid process (a) and a tangent connecting the dorsal and volar aspects of the radial articular surface (b).

56. HA N D PA OBLIQUE PROJECTION-

57. HA N D AP OBLIQUE PROJECTION ( BALL – CATCHER POSITION)- Significant in making the diagnosis of RA .

58. PELVIS AND HIP Anteroposterior view. (A) The patient is supine with the feet in slight (15 degrees) internal rotation (inset), which compensates for the normal anteversion of the femoral neck , elongating its image . For a view of the entire pelvis, the central beam is directed vertically toward the midportion of the pelvis; for selective examination of either hip joint, it is directed toward the affected femoral head.

59. (b) ilioischial line, formed by the posterior portion of the quadrilateral plate (surface) of the iliac bone; (c) teardrop, formed by the medial acetabular wall, the acetabular notch, and the anterior portion of the quadrilateral plate; (d) roof of the acetabulum; (e) anterior rim of the acetabulum; and (f) posterior rim of the acetabulum. Distortion of any of these normal radiographic landmarks indicates the possible presence of abnormality. Radiographic landmarks of the hip. (A,B) On the anteroposterior radiograph of the hip, six lines relating to the acetabulum and its surrounding structures can be distinguished: (a) iliopubic or iliopectineal (arcuate) line;

60. PELVIS AND HIP Ferguson view . (A) the patient is in the same position as for the standard anteroposterior projection. The radiographic tube, however, is angled approximately 30 to 35 degrees cephalad, and the central beam is directed toward the midportion of the pelvis. Fractures of Sacrum Pubis ramus Ischium Injury to sacroiliac joints

61. PELVIS AND HIP Anterior oblique view . (A) The patient is supine and anteriorly rotated, with the affected hip elevated 45 degrees (inset). The central beam is directed vertically toward the affected hip. (B) the iliopubic (anterior) column (arrows) and the posterior lip (rim) of the acetabulum (open arrow) are well delineated.

62. PELVIS AND HIP Posterior oblique view . (A) The patient is supine and anteriorly rotated, with the unaffected hip elevated 45 degrees (inset). The central beam is directed vertically through the affected hip. (B) Th e ilioischial (posterior) column (arrows), the posterior acetabular lip (open arrow), and the anterior acetabular rim (curved arrow) are well demonstrated .

63. PELVIS AND HIP Frog-lateral view . (A) Patient is supine with the knees flexed, the soles of the feet together, and the thighs maximally abducted. For simultaneous imaging of both hips, the central beam is directed vertically or with 10 to 15 degrees cephalad angulation to a point slightly above the pubic symphysis (inset); for selective examination of one hip, it is directed toward the affected hip joint. (B) De monstrates the lateral aspect of the femoral head and both trochanters.

64. PELVIS AND HIP Groin-lateral view . (A) The patient is supine with the affected extremity extended and the opposite leg elevated and abducted. The cassette is placed against the affected hip on the lateral aspect, and the central beam is directed horizontally toward the groin with approximately 20 degrees cephalad angulation. (B)provides true lateral image of the femoral head , thereby allowing evaluation of its anterior and posterior aspects. It also demonstrates the anteversion of the femoral neck, which normally ranges from 25 to 30 degrees.

65. PELVIS & HIP AP & PA OBLIQUE PROJECTION- Resulting image shows entire ilium

66. KNEE Anteroposterior view . (A) The patient is supine, with the knee fully extended and the leg in the neutral position. The central beam is directed vertically to the knee with a 5- to 7-degree cephalad angulation. (B) D emonstrates the medial and lateral femoral and tibial condyles, the tibial plateaus and spines, and both the medial and lateral joint compartments . The patella is seen en face as an oval structure between the femoral condyles.

67. KNEE Lateral view . (A) The patient is lying flat on the same side as the affected knee, which is flexed approximately 25 to 30 degrees . The central beam is directed vertically toward the medial aspect of the knee joint with an approximately 5- to 7-degree cephalad angulation. (B) demonstrates the patella in profile , as well as the femoropatellar joint compartment and a faint outline of the quadriceps tendon.

68. KNEE Tunnel view . (A)The patient is prone with the knee flexed approximately 40 degrees, with the foot supported by a cylindrical sponge. The central beam is directed caudally toward the knee joint at a 40-degree angle from the vertical. (B) Demonstrates the posterior aspect of the femoral condyles, the intercondylar notch, and the intercondylar eminence of the tibia.

69. KNEE Sunrise view . (A) The patient is prone, with the knee flexed 115 degrees. The central beam is directed toward the patella with approximately 15-degree cephalad angulation. (B) Demonstrates a tangential (axial) view of the patella. Merchant view . (A) The patient is supine on the table, with the knee flexed approximately 45 degrees at the table’s edge. A device keeping the knee at this angle also holds the film cassette. The central beam is directed caudally through the patella at a 60-degree angle from the vertical. (B) the articular facets of the patella and femur are well demonstrated.

70. Skyline view

71. ANKLE Anteroposterior view . (A) The patient is supine on the radiographic table with the heel resting on the film cassette. The foot is in neutral position, with the sole perpendicular to the leg and the cassette. The central beam (red broken line) is directed vertically to the ankle joint at the midpoint between both malleoli. (B) D emonstrates the distal tibia, particularly the medial malleolus, the body of the talus, and the tibiotalar joint . The mortise view , a variant of the anteroposterior projection obtained with 10- degree internal rotation of the ankle , eliminates the overlap of the medial aspect of the distal fibula and the lateral aspect of the talus, so the space between these bones is well demonstrated

72. ANKLE Lateral view . (A) The patient is placed on his or her side with the fibula resting on the film cassette and the foot in the neutral position. The central beam is directed vertically to the medial malleolus. The distal tibia, talus, and calcaneus are seen in profile. The tibiotalar and subtalar joints are well demonstrated.

73. ANKLE Internal oblique view . (A) The patient is supine, and the leg and foot are rotated medially approximately 35 degrees (inset). The foot is in the neutral position, forming a 90-degree angle with the distal leg. The central beam is directed perpendicular to the lateral malleolus. (B) The medial and lateral malleoli, the tibial plafond, the dome of the talus, the tibiotalar joint, and the tibiofibular syndesmosis are well demonstrated.

74. FOOT Anteroposterior view . (A) The patient is supine , with the knee flexed and the sole placed firmly on the film cassette. The central beam is directed vertically to the base of the first metatarsal bone. (B) injury to the metatarsal bones and phalanges can be adequately assessed. (C) The first intermetatarsal angle is formed by the intersection of the lines bisecting the shafts of the first (a) and second (b) metatarsals.

75. FOOT Lateral view . A) The patient lies on his or her side with the knee slightly flexed and the lateral aspect of the foot against the film cassette . The central beam is directed vertically to the midtarsus . (B) demonstrates the posterior tuberosity where the Achilles tendon inserts; the medial tuberosity on the plantar surface where the plantar fascia inserts; the anterior tuberosity ; the anterosuperior spine of the calcaneus; the posterior facet of the subtalar joint ; the sustentaculum tali ; and the talonavicular and calcaneocuboid articulations. The Chopart and Lisfranc joints are also well visualized.

76. Boehler angle . This feature is determined by the intersection of a line (a) drawn from the posterosuperior margin of the calcaneal tuberosity (bursal projection) through the tip of the posterior facet of the subtalar joint, and a second line (b) drawn from the tip of the posterior facet through the superior margin of the anterior process of the calcaneus. Normally, 20-40 degrees . Calcaneal pitch is described by the intersection of a line drawn tangentially to the inferior surface of the calcaneus and one drawn along the plantar surface of The angle of Gissane . The angle is formed by intersection of the lines drawn along the downward and upward slopes of the calcaneal dorsal surfaces, with normal values between 125 and 140 degrees.

77. FOOT Oblique view . (A) The patient is supine on the table with the knee flexed. The lateral border of the foot is elevated about 40 to 45 degrees (inset) so that the medial border of the foot is forced against the film cassette . The central beam is directed vertically to the base of the third metatarsal. (B) the phalanges and metatarsals are well demonstrated, as are the anterior part of the subtalar joint and the talonavicular, naviculocuneiform , and calcaneocuboid joints.

78. FOOT Harris-Beath view . (A) The patient is erect, with the sole of the foot flat on the film cassette. The central beam is usually angled 45 degrees toward the midline of the heel, but 35 or 55 degrees of angulation may also be used. (B) the middle facet of the subtalar joint is seen, oriented horizontally; the sustentaculum tali projects medially. The posterior facet projects laterally and is parallel to the middle facet. The body of the calcaneus is well demonstrated.

79. CALCANEUS AXIAL PROJECTION ( PLANTO DORSAL)-

80. CALCANEUS AXIAL PROJECTION ( DORSO PLANTAR)-

81. F O O T TANGENTIAL PROJECTION-

82. CHEST AP PROJECTION-

83. CHEST AP & PA OBLIQUE PROJECTION-

84. Cervical vertebrae Lateral view Anteroposterior view.

85. CERVICAL VERTEBRA AP PROJECTION ( OPEN MOUTH)-

86. CERVICAL VERTEBRA AP AXIAL PROJECTION-

87. CERVICAL VERTEBRA AP AXIAL OBLIQUE PROJECTION- The image shows the intervertebral foramina & pedicles.

88. Pillar view for lateral masses of vertebrae Swimmer's view for c7 vertebrae

89. Anteroposterior view of the thoracic spine Anteroposterior view of the lumbar spine

90. Lateral view of the lumbar spine Oblique view of the lumbar spine

91. LUMBO-SACRAL VERTEBRA AP & PA AXIAL PROJECTION- ( FERGUSON METHOD)- L-S joint & S-I joint free of superimposition.

92. Stress Views Stress views are important in evaluating ligamentous tears and joint stability . In the hand , abduction-stress film of the thumb may be obtained when a gamekeeper's thumb, resulting from a disruption of the ulnar collateral ligament of the first metacarpophalangeal joint, is suspected In the lower extremity , stress views of the knee and ankle joints are occasionally obtained. The evaluation of knee instability caused by ligament injuries may require the use of this technique in cases of a suspected tear of the medial collateral ligament and, less frequently, in evaluating an insufficiency of the anterior and posterior cruciate ligaments. The evaluation of ankle ligaments also may require stress radiography. Inversion (adduction) and anterior-draw stress films are the most frequently obtained stress views . Gamekeeper's thumbThe stress radiograph (B) demonstrates subluxation of the joint by an increase to more than 30 degrees in the angle between the first metacarpal and the proximal phalanx of the thumb, confirming gamekeeper's thumb.

93. Anterior-drawer stress. For a stress film of the knee evaluating the ACL, the patient is placed in the device on his or her side, with the knee flexed 90 degrees. The pressure plate is applied against the anterior aspect of the knee. (The arrows show the direction of the applied stresses.) Radiographs are then obtained in the lateral projection. Valgus stress. For a stress film of the knee evaluating the medial collateral ligament, the patient is supine, with the knee flexed approximately 15 to 20 degrees. The leg is placed in the device, and the pressure plate is applied against the lateral aspect of the knee. (The arrows show the direction of the applied stresses.) Radiographs are then obtained in the anteroposterior projection.

94. Flouroscopy Fluoroscopy is a fundamental diagnostic tool for many radiologic procedures,including arthrography, tenography , bursography , arteriography, and percutaneous bone or soft-tissue biopsy. Fluoroscopy combined with videotaping is useful in evaluating the kinematics of joints. Used in conjunction with Myelography - to observe the movement of the contrast column in the subarachnoid space Arthrography - to check the proper placement of the needle and to monitor the flow of the contrast agent Intraoperatively - to assess the reduction of a fracture or placement of hardware

95. Digital Radiography I s the name given to the process of digital image acquisition using an x-ray detector comprising a photostimulable phosphor imaging plate and an image reader-writer that processes the latent image information for subsequent brightness scaling and laser printing on film. The system works on the principle of photostimulated luminescence . When the screen absorbs x-rays, the xray energy is converted to light energy by the process of fluorescence, with the intensity of light being proportional to the energy absorbed by the phosphor. The stimulated light is used to create a digital image (a computed radiograph). A dvantage of CR over conventional film/screen radiography is that T he digital image data are readily manipulated to produce alternative renderings. Two images, acquired either sequentially or simultaneously with different filtration, are used to reconstruct a soft-tissue-only image or a bone-only image.)

96. In digital subtraction radiography, a video processor and a digital disk are added to a fluoroscopy imaging complex to provide online viewing of subtraction images. This technique is most widely used in the evaluation of the vascular system, but it may also be used in conjunction with arthrography to evaluate various joints. The use of high-performance video cameras with low-noise characteristics allows single video frames of precontrast and postcontrast images to be used for subtraction. The subtraction technique removes surrounding anatomic structures and thus isolates the opacified vessel or joint, making it more conspicuous. Digital subtraction arthrography. Digital subtraction arthrogram demonstrates tears of the lunotriquetral ligament and the triangular fibrocartilage complex. (A) This image was obtained by subtracting the digitally acquired preinjection image (B) from postinjection film.

97. Digital subtraction angiography (DSA) , the most frequently used variant of DR, can be used in the evaluation of trauma, bone and soft-tissue tumors, and in general evaluation of the vascular system. In trauma to the extremity, DSA is effectively used to evaluate Arterial occlusion Pseudoaneurysms Arteriovenous fistulas Transection of the arteries Bone subtraction is useful in clearly delineating the vascular structures. In the evaluation of bone and soft-tissue tumors, DSA is an effective tool for mapping tumor vascularity. Low Osmolar non ionic iodine based contrast media( Iohexol , Iopromide , Iodixanol) are used. In patients with renal failure or allergic to iodine based media, gadolinum is used. Digital subtraction angiography. Digital radiograph (A) and digital subtraction angiogram (B) of a 23- year-old man who sustained fractures of the proximal tibia and fibula show disruption of the distal segment of the popliteal artery.

98. Computed Tomography(CT) Essential components of CT system include Circular scanning gantry which houses x-ray tube and image sensors Table for the patient An x-ray generator Computerized data processing unit The x-ray tube is rotated 360 degrees around the patient while the computer collects the data and formulates an axial image, or “slice.” Each cross-sectional slice represents a thickness between 0.1 and 1.5 cm of body tissue.

99. The tissues absorb the x-ray beam to various degrees depending on the atomic number and density of the specific tissue. The remaining, unabsorbed (unattenuated) beam passes through the tissues and is detected and processed by the computer. The CT computer software converts the x-ray beam attenuations of the tissue into a CT number (Hounsfield units) by comparing it with the attenuation of water. Tissue H

100. Spiral ( Helical ) CT – Data gathering system using a continuous rotation of the x-ray source and the detectors. It allows the rapid acquisition of volumes of CT data and renders the ability to reformat the images at any predetermined intervals ranging from 0.5 to 10.0 mm. Acquires all data in 24 or 32 seconds, generating up to 92 sections compared to standard CT where 12 scans can be done over 1 minute. This technology has markedly reduced scan times and has eliminated interscan delay and hence interscan motion. It also has decreased the motion artifacts, improved the definition of scanned structures, and markedly facilitated the ability to obtain three-dimensional (3D) reconstructions.

101. MDCT Multichannel multidetector row CT Images can be generated with subsecond gantry rotation times yielding high resolution volume data sets, and at the same time minimizing the radiation dose to the patient. fpVCT High-resolution flat-panel volume CT Uses digital flat-panel detectors and provides volumetric coverage as well as ultra-high spatial resolution in two-dimensional (2D) and 3D projections. Furthermore, it reduces metal and beam-hardening artifacts. 3D CT-angiography Used to determine the presence or absence of injury to the vessels near the fractured bones

102. CT scan of spine Bone structure Facet arthritis Disc prolapse Trauma spondylitis Tumor Spinal stenosis(central) Spinal stenosis (lateral)

103. Spinal canal stenosis

104. Disc prolapse Fracture in spine

105. Ct scan of pelvis

106. CT SCAN OF PELVIS AND HIP Position of fragments and extension of fracture line in complex fractures, particularly of pelvis, acetabulum, and sacrum Weight-bearing parts of joints Sacroiliac joints Intraarticular fragments Soft-tissue injuries Concomitant injury to ureters, urinary bladder, and urethra Acetabular fracture Sacral fracture

107. CT SCAN KNEE Injuries to: Articular cartilage Cruciate ligaments Menisci Osteochondral bodies in joint Osteochondritis dissecans

108. CT SCAN OF ANKLE nd fracture Trimalleolar fracture Talus fracture Calcaneus fracture Bony lesion around ankle

109. CT SCAN OF SHOULDER Arthrography Fracture of proximal humerus Labral lesion Scapular fracture Imaging joint capsule Glenoid fracture Rotator cuff pathology Bony bankart lesion Biceps tendon pathology Hill –Sachs lesion Arthritis of GH joint Arthritis of AC joint Calcific tendinitis Communited glenoid fracture

110. CT SCAN OF ELBOW Complex fractures about the elbow joint, particularly to assess the position of fragments in comminution Healing process: Nonunion Secondary infection Arthrography (single or doublecontrast ) Subtle abnormalities of articular cartilage Capsular ruptures Synovial abnormalities Chondral and osteochondral fractures Osteochondritis dissecans Osteochondral bodies in joint

111. CT SCAN OF HAND pal . -diagnosis of initial degenerative changes. -visualization of bone tumors . -demonstration of distal radio-ulnar instability. -demonstration of intra-articular loose bodies -demonstration of pathological rotation in pronation supination Post-operative follow up in scaphoid pseudoarthrosis

112. DECT Dual-energy CT Equipped with two x-ray tubes with different peak kilovoltages (80 and 140 kVp ), thus allowing simultaneous acquisition of two sets of images of the desired anatomic region. The material-specific differences in attenuation of various elements enable classification of the chemical composition of scanned tissue, allowing accurate and specific characterization and separation of monosodium urate from calcium containing mineralizations . DECT data yields color-coded cross-sectional images, clearly depicting the foci of accumulation of urate crystals.

113. QCT : Quantitative CT Method for measuring the lumbar spine mineral content. Measurements are performed on a CT scanner using a mineral standard for simultaneous calibration and computed radiograph for localization. CT guided biopsy : CT is a very important modality for successful aspiration or biopsy of bone or soft tissue lesions – provides visible guidance for precise placement of instrument within the lesion.

114. Advantages : Direct transaxial images can be obtained Bone can be imaged in multiple planes- coronal,sagittal and oblique using reformation technique Helps in evaluating complex fractures of pelvis,hip and knee. 3D reconstruction possible which helps in analyzing regions with complex anatomy like wrist,foot,ankle,pelvis .

115. 3D CT demonstrating subcapital femoral neck fracture with angulation Fracture surgical neck of humerus and displaced fracture of greater tubercle 3D CT reformation of thoracic spine shows sagittal cleft with anterior defect of T11

116. DISADVANTAGES : Lack of homogeneity in the composition of small volume of tissue. Poor tissue characterization. Despite the ability of CT to discriminate among some differences in density, a simple analysis of attenuation values does not permit precise histologic characterization. Motion artifacts degrade the image quality An area that contains metal (e.g., prosthesis or various rods and screws) will produce significant artifacts. Finally, the radiation dose may occasionally be high, particularly when contiguous and overlapping sections are obtained during examination. Children – More sensitive to radiation and prone to develop radiation induced neoplasm. Lens and thyroid are at risk. Inferior to MRI in imaging of bone marrow and soft tissue details like marrow injury/ trabecular injury/ bone contusion.

117. SPECT : Single Photon Emission CT In comparison with planar images, SPECT provides increased contrast resolution , which eliminates noise from the tissue outside the plane of imaging. Benefit : Improvement of lesion detection and anatomic localization Helps in localization to different parts of the vertebra like body,pedicle,articular process,lamina,pars interarticularis,spinous process etc Helps in detection of meniscal tears in knee

118. MRI MRI is a noninvasive procedure and allows to visualise the structures.  Felix bloch and EM purcell discovered the physical phenomenon of MRI in 1946.  Medical application – odebald and lindstorm in 1955 Paul C Lauterbur and Peter Mansfield were awarded nobel prize in 2003 for introducing three dimensional MRI.  The system includes

119. MECHANISM

120. T1 and T2 weighed images The T1 relaxation time ( longitudinal relaxation time) - used to describe the return of protons back to equilibrium after application and removal of the rf pulse. -- Provide good anatomic detail T2 relaxation time (transverse relaxation time) - used to describe the associated loss of coherence or phase between individual protons immediately after the application of the rf pulse. - used for evaluation of pathologic processes. T1 weighted images are : Sharp Well defined , Anatomic imaging  Fat-bright; fluid-dark  T2 weighted imaging is traditionally known as “ PATHOLOGICAL IMAGING”  They are sensitive for detecting edema.  On traditional spin echo T2 imaging  fat-dark; fluid-bright

121. USES OF MRI IN ORTHOPAEDICS MRI SPINE : Axial/Saggital/Coronal INTER VERTEBRAL DISC : Bulge, protrusion, extrusion,sequestration

122. SPINAL TUMORS: Excellent delineation of vertebral body marrow allows detection of primary and metastatic diseases on T1 weighed sequences .

123. SPINAL TRAUMA : It helps in suspected spinal cord injury, epidural hematoma, disc herniation.

124. MRI HIP : Osteonecrosis, Occult femoral fractures, Labral tears Soft-tissue injuries, including various tendon abnormalities, compressive and entrapment neuropathies ( piriformis syndrome), and Morel- Lavallée lesion Posttraumatic osteonecrosis Occult fractures Bone contusions (trabecular microfractures Morel- Lavallée lesion

125. MRI KNEE Best evaluated in saggital images. Meniscal injuries ACL and PCL injuries Collateral ligament injuries • OTHER USES : Osteonecrosis, synovial pathological conditions, occult fractures, tears of patellar and quadriceps tendon.

126. NORMAL ACL ACL TEAR

127. Jumper's knee. A young athletic man presented with anterior knee pain, localized inferiorly to the patella. Sagittal T2-weighted MR image shows a focal area of hyperintensity and thickening of the proximal patellar tendon (arrow) consistent with tendinosis and partial tear of the deep fibers. NORMAL PCL PCL TEAR

128. MRI of Osgood-Schlatter disease. A sagittal T2-weighted image of the knee of a 14-year-old boy demonstrates inflammatory changes along the distal patellar ligament (arrowheads). MRI of osteochondritis dissecans. A loose osteochondral body in the medial femoral condyle is seen on T1-weighted coronal (A) and sagittal (B) images (white arrows).

129. MENISCAL CYST

130. MRI FOOT AND ANKLE : Detects tendon injuries,bone marrow disorders, fractures, osteonecrosis, osteomyelitis, ligament injuries. MRI of the posterior talofibular and calcaneofibular ligaments. Coronal T2-weighted MR image of the ankle shows normal posterior talofibular (arrow) and calcaneofibular (arrowhead) ligaments.

131. MRI SHOULDER : Coronal oblique/axial/ Saggital /oblique Indicated in : Rotator cuff tears Impingement syndromes Labral tears Occult fractures Osteonecrosis Long head of biceps pathology ROTATOR CUFF TEAR OSTEONECROSIS OF HUMERAL HEAD

132. MRI OF ELBOW Abnormalities of the ligaments,a tendons, muscles, and nerves Capsular ruptures Joint effusion Synovial cysts Hematomas Subtle abnormalities of bones (e.g., bone contusion) Osteochondritis dissecans Epiphyseal fractures (in children) MRI of osteochondritis dissecans of the capitellum

133. MRI OF WRIST AND HAND : To detect carpal ligament disruption , avascular necrosis of lunate MRI of the tear of the TFCC. MRI of the ulnar impaction syndrome

134. TUMOR IMAGING MRI should only be done after x-ray. • Imaging should be performed in atleast 2 planes one of which should be axial. • T1 weighed images are useful in identifying areas of marrow replacement or edema . • T2 weighed sequences delineates soft tissue extension

135. ADVANTAGES DISADVANTADVANTAGES DISADVANT ADVANTAGES DISADVANTAGES No ionizing radiation Takes longer time for sequences Better soft tissue contrast than CT More expensive and claustrophobic Non invasive, specific, accurate. Dynamic testing is not possible Gantry narrower than in CT Gadalonium contrast cant be used in pregnant women noisy

136. Contraindications • Intra cerebral aneurysm clips. • Internal hearing aids. • Middle ear prosthesis. • Cardiac pace makers. • Implants. • 1st trimester of pregnancy. • Metallic orbital foreign bodies .

137. BONE SCAN A bone scan is a test that detects areas of increased or decreased bone activity by injecting a certain radiopharmaceutical ie . Tc-99m MDP. A/K/A Radionuclide bone scan or Bone ADVANTAGES • Whole-body evaluation in one test/ same rad exposure. • Low radiation exposure • Sensitive evaluationscintigraphy

138. DISADVANTAGES • Needs radiopharms & gamma camera not widely available • Low specificity • COST… Radiopharmaceutical (“Tracer”) • The most widely used is Tc-99m labeled diphosphonates; Tc-99m Methylene diphosphonate (Tc-99m MDP) ; Tc-99m Medronate . Phosphonates concentrate in the mineral phase of bone: nearly twothirds in hydroxyapatite crystals and one third in calcium phosphate .

139. PATHOPHYSIOLOGY Two major factors control accumulation of phosphonates in bone 1) Blood flow , 2) Extraction efficiency. which in turn depend on capillary permeability, acid-base balance, parathyroid hormone levels, etc. Maximum bone accumulation is reached 1 h after injection and the level remains practically constant up to 72 h. Tc-99m MDP uptake depends on osteoblast and osteoclast activity Increased uptake - osteoblastic activity present Decreased uptake - pure lytic lesion , osteoclast activity

140. Technique of Bone Scan Preparation: None • Injection of Tc-99m 20-25mCi IV, good hydration afterwards & frequent voiding • Wait for about 3 hrs to start imaging, avoid contamination • Empty bladder prior to scanning • Change the cloth and remove things likely cause artifact.

141. IMAGING ACQUISITION Can be performed as: – a) Limited bone scintigraphy or spot views (planar images of a selected portion of the skeleton) – b) Whole-body bone scintigraphy (planar images of the entire skeleton in anterior and posterior views) – c) SPECT (single photon emission computed tomography- image of a portion of the skeleton) – d) Multiphase bone scintigraphy (immediate and delayed images to study blood flow)

142. Clinical indications Oncological indications • Primary tumours (e.g. Ewing’s sarcoma, osteosarcoma) Staging, evaluation of response to therapy and follow up of primary bone tumors • Secondary tumours (metastases) – Staging and follow-up of neoplastic diseases – Distribution of osteoblastic activity prior to radiometabolic therapy. Non-neoplastic diseases Whenever there is an increase in blood flow to a lesion or there is an alteration in osteoblastic activity. – Stress and/or occult fractures. – Trauma – Musculoskeletal inflammation and infection – Bone viability (grafts, infarcts, osteonecrosis). – Metabolic bone disease. – Arthritis

143. Complications of hardware/prosthetic joint replacement, loose or infected joint prosthesis. Heterotopic ossification. Complex regional pain syndrome (CRPS) Other bone disease, such as Paget disease, Langerhans cell histiocytosis, or fibrous dysplasia. Congenital or developmental anomalies. Heterotopic ossification Complex regional pain syndrome

144. Normal Bone Scan Tracer uptake greatest in axial skeleton • Background activity of soft tissue Kidneys routinely visualized Skull can appear uneven (variations in calvarial thickness) Sites of persistently increased symmetric uptake are- Acromial and Coracoid processes of the scapulae, Medial ends of the clavicles, Junction of the body and manubrium of the sternum and the sacral alae.

145. Normal Bone Scan- Pediatrics  Growth Center most intense: distal femur-proximal tibia, proximal humerus (which is also the order of relative occurence of osteosarcoma in children)  Costochondral junctions

146. METASTATIC BONE DISEASE The presence of multiple, randomly distributed areas of increased uptake of varying size, shape, and intensity is highly suggestive of bone metastases.

147. Metastatic Bone Disease Multiple Fractures Radiotracer accumulation in both the vertebral body + pedicles =metastatic disease , whereas vertebral body and facets but spare the pedicles =benign lesions Activity confined to the vertebral body can be due to tumor , trauma, or infection

148. Flare phenomenon Seen in patients who are responding to treatment, reflects healing of the bone lesions and has been described as the “flare” phenomenon. Usually observed within 3 months after initiation of treatment and is often associated radiographically with the sclerotic changes that indicate healing. Continued increase in the number and intensity of lesions beyond 6 months is usually indicative of disease progression.

149. SUPERSCAN When the metastatic process is diffuse, virtually all of the radiotracer is concentrated in the skeleton, with little or no activity in the soft tissues or urinary tract. The resulting pattern, with excellent bone detail, known as SUPERSCAN. A superscan may also be associated with metabolic bone disease. Unlike in metastatic disease, however, the uptake in metabolic bone disease is more uniform in appearance and extends into the distal appendicular skeleton.

150. TRAUMA Bone scintigraphy is a very sensitive exam for the detection of acute fractures . About 80% of bone scans will show increased activity at a site of fracture by 24 hours, and 95% by 72 hours. Whole body bone scan showing multiple occult bilateral rib fractures (arrowed). The linear alignment is typical of fractures.

151. Stress Fractures Plain radiograph can be negative Occurs in normal bone that undergoes abnormal stress (insufficiency fractures occur with normal stress in bones that are weakened) Common sites are the femoral neck and tibia . Typical pattern is oval area of increased uptake with long axis parallel to axis of bone

152. 3 PHASE BONE SCAN 3 stages which follow IV injection of the tracer. 1) Flow phase 2 to 5-sec images are obtained for 60 seconds after injection Demonstrates perfusion and characterises the blood flow to a particular area 2) Blood pool phase T he blood-pool image is obtained 5 min after injection D emonstrated the blood pool, not the blood flow I nflammation causes capillary dilatation and increased blood flow If the study is going to be a triphasic bone scan , a third phase is added. 3) Delayed phase T he bone image is obtained 2 - 4 hours later U rinary excretion has decreased the amount of the radionuclide in soft tissue DIFFERNTIATE OSTEOMYELITIS FROM CELLULITIS

153. OSTEOMYELITIS The classic appearance of osteomyelitis on three-phase bone scans consists of focal hyperperfusion , focal hyperemia, and focally increased bone uptake Phase I + Phase II with negative Phase III Cellulitis All positive- OM. SOME OTHER TRACERS GALLIUM-67 - Sensitive for detection of inflammatory process. - HOT in ABSCESS ( Vertebral OM) LYMPHOMA SARCOIDOSIS

154. INDIUM 111- Tagged with leucocytes. More sensitive than Ga67 scans. Used with Sulfur Colloid Scan – Delineate areas of normal bone activity IN 111 labelled Leucocyte- Highlight involved region. - SO INCONGURENCE OF BOTH IS HIGHLY SUGGESTIVE OF INFECTION PAINFUL PROSTHESISLOSSENING OR INFECTION 3 PHASE BONE SCAN- Focally increased uptake- Loosening Diffuse , Uniformly distribution – Infection Not very specific Ga-67 SCAN- Differntiate between pure mechanical loosening and infection.

155. Positron Emission Tomography Diagnostic imaging modality that allows the identification of biochemical and physiologic alterations in the body and assesses the level of metabolic activity and perfusion in various organ systems. The process produces biologic images based on the detection of gamma rays that are emitted by a radioactive substance, such as 18F-labeled 2-fluoro-2-deoxyglucose (18FDG). Main application : oncology including the detection of primary and metastatic tumors and recurrences of the tumors after treatment Recent : Diagnosing infections associated with metallic implants in patients with traumatic conditions Normal whole body PET Stage 4 adenocarcinoma pt with widespread skeletal metastases

156. PET-CT : Sequential acquisition of images derived from both systems at the same time and thus combining them into a single superimposed image. Functional images – PET – Depict spatial distribution of metabolic and biochemical activities in the tissues are correlated with – Anatomic images – CT

157. PET-MRI Newest hybrid technology with capability of instantaneous fusion of anatomic and functional data that allows an integrated scanning for simultaneous PET and MRI. Limited clinical applications – evaluation of the progress of treatment of some inflammatory arthritides Mapping of metastatic disease.

158. ULTRASOUND Based on the interaction of propagated sound waves with tissue interfaces in the body. Whenever the directed pulsing of sound waves encounters an interface between tissues of different acoustic impedance, reflection or refraction occurs. The sound waves reflected back to the US transducer are recorded and converted into images. Curvilinear echogenic focus with acoustic shadowing sec to intrasubstance calcification- calcific tendinitis

159. ULTRASOUND IN ORTHOPAEDICS CLINICAL APPLICATION S - Evaluation of rotator cuff Injuries to various tendons( Tendoachilles ) Osgood-Schlatter disease Soft tissue tumors occasionally Imaging method of choice – evaluation of infant hip 3D US for DDH( Newest development) Recently used in rheumatic disorders Differentiation of popliteal fossa masses(Aneurysm/Baker’s cyst/Hypertrophied synovium) Disdvantages : Difficult to visualize deeper/bony structures DOPLER ULTRASOUND is used in cases where there is abnormal increase in blood flow as in the areas of inflamation & aggressive tumours & other condition like DVT, Peripheral vascular disease.

160. Scanogram Most widely used method for limb length measurement The radiographic tube moves in the long axis of the radiographic table. During an exposure the tube traverses through the whole length of the film scanning the entire extremity. This technique allows the x-ray beam to intersect the bone ends perpendicularly; therefore, comparative limb lengths can be measured.

161. DUAL ENERGY X-RAY ABSORPTIOMETRY Most effective technique for measuring bone mineral density (BMD) Osteoporosis – deficient bone matrix with normal mineralization Women after menopause and estrogen deficiency Vertebral anomalies, medications causing bone loss and thyroid conditions Hip and spine

162. Photons produced from a low dose energy source 2 X-ray beams with 2 different energy peaks are passed through the body, one peak gets absorbed by the soft tissue and the other by the bone Generates a two dimensional image Soft tissue amount is subtracted from the total area, giving the bone mineral density. These measurements are then compared with the normal ranges matched for chronological age(T and Z scores)

163. T score shows the amount of bone that is compared with a young adult of the same gender with peak bone mass. The T score is used to estimate your risk of developing a fracture . A score above -1 is considered normal A score between -1 and -2.5 - Osteopenia(low bone mass) A score below -2.5 is defined as osteoporosis. Z score shows the amount of bone, compared with other people in your age group and of the same size and gender. Z score mainly diagnoses to the risk of having a fracture. T score shows the amount of bone that is compared with a young adult of the same gender with peak bone mass. The T score is used to estimate your risk of developing a fracture . A score above -1 is considered normal A score between -1 and -2.5 - Osteopenia(low bone mass) A score below -2.5 is defined as osteoporosis. Z score shows the amount of bone, compared with other people in your age group and of the same size and gender. Z score mainly diagnoses to the risk of having a fracture .

164. Advantages Quick and non invasive procedure No anaesthesia required Accurately measures the fracture risk Less radiation exposure

165. Arthrography Introduction of a contrast agent into the joint space Positive contrast – Iodide solution Negative contrast – Air or combination of both Most frequently performed in the shoulder, wrist and ankle Preliminary films prior to any arthrographic procedure should be obtained. Shoulder arthrogram – rotator cuff tear(Filling of subacromial and subdeltoid bursae ) Filling of DRUJ- tear of triangular fibrocartilage complex

166. Tenography and Bursography Contrast is injected into tendon sheath to evaluate intergrity – Tenogram . Injection of contrast into bursa – abandoned Occasionally used in the subacromial-subdeltoid bursae complex to demonstrate partial tears of rotator cuff

167. Angiography Contrast material injected directly into selective branches of the arterial and venous circulation. Tumor evaluation – to map out bone lesion, demonstrate vascularity of lesion , to assess extent of disease. Helpful in planning for limb salvage procedures Tranverse fracture of distal femur resulted in transsection of the superficial femoral artery

168. Myelography Water soluble contrast agents injected into subarachnoid space, freely mixes with CSF to produce a column of opacified fluid with a higher specific gravity than non opacified fluid. Tilting the patient will allow the opacified fluid to run up or down the thecal sac under the influence of gravity. R eplaced by high-resolution CT and high quality MRI