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Imaging the Musculoskeletal System The Extremities Richard L. Sulek, D.O. Richard L. Sulek, D.O.

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Presentation on theme: "Imaging the Musculoskeletal System The Extremities Richard L. Sulek, D.O. Richard L. Sulek, D.O."— Presentation transcript:

1 Imaging the Musculoskeletal System The Extremities Richard L. Sulek, D.O. Richard L. Sulek, D.O.

2 Objectives Discuss: Discuss: commonly used imaging modalities in the musculoskeletal system commonly used imaging modalities in the musculoskeletal system normal imaging anatomy in the extremities normal imaging anatomy in the extremities fracture description fracture description

3 Imaging Techniques Plain x-rays Plain x-rays CT CT MRI MRI Ultrasound Ultrasound Nuclear Medicine (bone scan) Nuclear Medicine (bone scan)

4 Plain x-rays For joints like the ankle, elbow or wrist we always take 3 views: AP, lateral and oblique

5 3 views: AP, oblique and lateral

6 Advantages of plain x-rays Quick Quick Not expensive Not expensive Relatively low radiation Relatively low radiation

7 Disadvantages of plain x-rays Not 3 dimensional Not 3 dimensional Can miss pathology Can miss pathology May still require other imaging studies May still require other imaging studies

8 CT scanner

9 This is a CT scan: a longitudinal cross section This CT shows a fracture through the medial cunieform Great toe

10 Advantages of CT scanning of the musculoskeletal system Excellent anatomic detail Excellent anatomic detail Will detect almost all pathology related to cortical bone injury Will detect almost all pathology related to cortical bone injury Great for showing displacement or joint involvement Great for showing displacement or joint involvement Now multiplanar Now multiplanar

11 Disadvantages of CT Expensive (x-ray $100, CT $1000) Expensive (x-ray $100, CT $1000) More radiation More radiation Often not necessary Often not necessary

12 MRI scanner Looks more like a tunnel, must be very careful of metal

13 This is an MRI of the knee There is no radiation used Circled is a normal posterior cruciate ligament

14 Advantages of MRI No radiation No radiation We can slice through the body using any imaging plane We can slice through the body using any imaging plane Looks “inside” bone. Marrow evaluation. Looks “inside” bone. Marrow evaluation. MRI is very good for looking at the soft tissues (muscles, ligaments, tendons and cartilage) MRI is very good for looking at the soft tissues (muscles, ligaments, tendons and cartilage) MRI is very sensitive in detecting water MRI is very sensitive in detecting water

15 MRI shows water (fluid) behind the patella Do you see fluid anywhere else?

16 Disadvantages of MRI Very expensive (x-ray $100, CT $1000, Very expensive (x-ray $100, CT $1000, MRI $2000) Not as good as CT for cortical bone Not as good as CT for cortical bone

17 This long black line Is the cortex or cortical bone 3 things are always black on MRI: 1.Air 2.Cortical bone/tendons/ligaments 3.Flowing blood

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19 Posterior cruciate ligament

20 anterior and posterior horns “bow tie”

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25 Normal Imaging Anatomy in the Extremities

26 What are the parts of a long bone? Terms you will need to know: Terms you will need to know: Cortex Cortex Medullary cavity (marrow) Medullary cavity (marrow) Diaphysis Diaphysis Metaphysis Metaphysis Epiphysis Epiphysis DME

27 cortex Medullary cavity (marrow) At each end of a long bone is the _________ The tapered part of the bone is the __________ The shaft of the long bone is the ________ Diaphysis Metaphysis Epiphysis

28 cortex medullary cavity

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30 acromion corocoid glenoid fossa clavicle greater tuberosity lesser tuberosity

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34 Child or adult?

35 Wrist

36 a.Growth plate b.Diaphysis c.Metaphysis d.Epiphysis

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38 SI joint symphysis pubis acetabulum int. iliac spine greater trochanter

39 intercondylar spines Patella condyle fibula

40 Ankle and Foot

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42 lateral maleous medial maleolus Talus

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44 Test your knowledge

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46 Finding a Fracture on X-Ray Start with soft tissue, look for swelling or fat pad displacement Start with soft tissue, look for swelling or fat pad displacement Examine the cortex along the entire length of the bone Examine the cortex along the entire length of the bone Look for cortical irregularities, buckling, or evidence of impaction Look for cortical irregularities, buckling, or evidence of impaction

47 Fracture Terminology Direction of fracture line: Direction of fracture line: Transverse Transverse Oblique Oblique Spiral Spiral Longitudinal Longitudinal Alignment of fracture: Displacement Alignment of fracture: Displacement Angulation Angulation Comminution Comminution Articular Involvement Articular Involvement

48 Fracture Terminolgy Open vs Closed: fracture is open when exposed to air (laceration or gross exposure) Open vs Closed: fracture is open when exposed to air (laceration or gross exposure) Pathologic fracture: implies fracture through weakened bone Pathologic fracture: implies fracture through weakened bone Stress fracture: implies misuse or overuse Stress fracture: implies misuse or overuse

49 Path of the Fracture

50 Normal

51 Transverse Fracture

52 Oblique Fracture

53 Spiral Fracture

54 Longitudinal Fracture

55 Simple vs Comminuted Simple-2 bone fragments Simple-2 bone fragments Comminuted-greater then 2 fragments Comminuted-greater then 2 fragments

56 Avulsion Fracture A bony fragment produced by the pull of ligamentous or tendinous attachment A bony fragment produced by the pull of ligamentous or tendinous attachment

57 Torus Fractures Axial forces cause cortex to buckle Axial forces cause cortex to buckle Occurs most commonly in the metaphysis Occurs most commonly in the metaphysis

58 Greenstick fracture Cortex broken on one side of the bone and only bent or buckled on the other side Cortex broken on one side of the bone and only bent or buckled on the other side

59 Points to take home There are distinct advantages and disadvantages to plain x-rays, CT and MRI. There are distinct advantages and disadvantages to plain x-rays, CT and MRI. Become familiar with terminology: epiphysis, metaphysis, diaphysis, cortex, medullary cavity Become familiar with terminology: epiphysis, metaphysis, diaphysis, cortex, medullary cavity Fracture description requires specific vocabulary Fracture description requires specific vocabulary


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