Radiology Imaging in

Musculoskeletal (MSK) Disorders

Elysanti Dwi Martadiani

Department of Radiology
Faculty of Medicine, Udayana University
MSK Imaging – Imaging Modalities
• Plain Radiographs
• Ultrasound
• Computed Tomography
• Magnetic Resonance Imaging
• Nuclear Scintigraphy
PLAIN RADIOGRAPH
 Plain Radiographs
• Widely available
• ‘Inexpensive’
• Primary imaging modality
• Sometimes can reveal soft tissue abnormality
 Terms
Radiosclerotic / osteoblastic Radioluscent / osteolytic
Radiographic imaging of the MSK

ADULT CHILD
The important things have to be
evaluated in Plain Radiograph

• Alignment
• Bones
• Joints
• Soft tissue
• Rule of two
 Alignment
Loss of alignment may be due to :
Bone fracture
Joint dislocation
 Normal
alignment
Loss of alignment
Bone structure

• Cortex : outer

• Medulla : inner
 Bone density

Increased density Normal density Decreased Osteopenia

Joint

CARTILAGE
MENISCUS
CARTILAGE
 SOFT TISSUE
SOFT TISSUE SWELLING MASS
 Rules of two
1 . Two views: one view is too few / no view
2 . Two joints: image the joint above and below a long bone
3 . Two sides: compare the other side (difficult cases only)
4 . Two abnormalities: look for a second abnormality
5 . Two occasions: compare current films with old films (especially for
fracture )
6 . Two visits: repeat the film after a procedure or after an interval
7 . Two opinions: ask colleague for opinion for doubtful cases
8 . Two records: write down clinical and radiographic findings
9 . Two specialists: also get a formal radiological report
10 . Two examinations: do not forget other tests such as US,CT, MRI, or
isotope bone scanning for complex cases.
Rule of two : two views, two joints

AP LATERAL
 Ultrasound
• Operator dependent
• Superficial soft tissue elements including
ligaments, tendons and muscle  excellent
 LIGAMENT US

Calcaneus

ATFL
 Computed Tomography (CT)
• Bone assessment  excellent  can reveal
fracture of the complex bones (e.g tarsal,
manus, facial bones)
• Sometimes can reveal soft tissue assessment
• Interventional options  core biopsy for
tumor
CT SCAN : FACIAL BONE FRACTURE
CT SCAN : SPINE
FRACTURE
CALCANEAL
FRACTURE
 Magnetic Resonance Imaging
• Soft tissue abnormality  excellent
• Bone abnormality : Good – excellence for
several cases
SPINAL CORD CONTUSION
KNEE MRI : MENISCAL INJURY
 Nuclear Medicine
• Bone scan : can show whole skeleton at
one time of examination
• Very sensitive but not specific
– fracture
– infection
– inflammation
– tumour
– metabolic
Bone scan – multiple
bony metastases
TRAUMA
 Fracture and dislocation
• Fracture : a break of the structural continuity
of bone or periosteum  cortical
discontinuity

• A dislocation : when the joint surfaces become

completely disengaged
 Fracture Terms
• Complete or incomplete
• Comminution fracture
• Displaced fracture fragments
• Angulation, rotation
• Associated with joint subluxation or
dislocation
Complete Incomplete fracture
: Greenstick fr.
Comminuted fracture
Non displaced Displaced
fracture fracture
Rotation Angulation
Associated with joint subluxation or
dislocation
Joint dislocation
 Fracture Healing
• Essential event : creation of bony bridge
between fracture fragments
• Bony callus begins 3-4 weeks after injury, and
continues until firm union is formed 2-3
month later

• Malunion, delayed union, non union

Callus dan Malunion
 Fracture of the growth plate: Epiphysiolysis

Salter & Harris Classification

S A L T R
slipped above lower through ruined
OSTEOMYELITIS
 Osteomyelitis
• Osteon = bone
Myelos = marrow
Itis = inflammation
Infection of bone CORTEX
marrow
MARROW
• Acute
Chronic osteomyelitis
 Acute Stage Osteomyelitis
Cortex destruction
/ rarefaction Periosteal Reaction

rarefaction

Periost rx
 Chronic Stage Ostemyelitis

Sequestrum
~ set apart
Involucrum ~
wrap

Cloaca~ track,
opening
 Chronic Stage
Involucrum Sequestrum Cloaca : opening /track
BONE TUMOR
HOW TO EVALUATE BONE TUMOR?
 TYPE OF BONE DESTRUCTION
Geographic Moth-eaten Permeative
 PERIOSTEAL REACTION

ONION SKIN SUNBURST/ CODMAN

SUNRAY TRIANGLE
 ONION SKIN SUNBURST CODMAN’S
TRIANGLE

EWING SARCOMA OSTEOSARCOMA

Morfologi : SOFT TISSUE MASS
 Osteoarthritis
• Degenerative joint
disease
• Osteophytes
• Joint space
narrowing
• Sclerotic of
subchondral bone
• Soft tissue
swelling due to
joint effusion
 TAKE HOME MESSAGE
• Do not forget to apply ‘ rule of two’ while
evaluating MSK lesion.

• Important in evaluating bone tumor: age &

sex, pattern of destruction, periosteal
reaction, matrix, soft tissue mass, location,
single or multiple.
THANK YOU