Imaging in Musculoskeletal

(MSK) Disorders
Elysanti Dwi Martadiani
Department of Radiology
Faculty of Medicine, Udayana University
The important things have to be
evaluated in MSK Radiology
• Bones
• Joints
• Soft tissue  muscle
ligaments
tendon
 IMAGING CHOICE
• Plain radiograph  initial examination 
bone, soft tissue (in general)
• Ultrasound  soft tissue (muscle, tendon,
some superficial ligaments)
• CT scan  complex joints, spine, overlapping
bones (hand, feet)
• MRI  soft tissue (muscle, ligaments,
tendons), cartilage, marrow changes
PLAIN RADIOGRAPH
 Terms
Radiosclerotic ~ osteoblastic Radioluscent ~ osteolytic
Radiographic imaging of the MSK

ADULT CHILD
MEDULLA

CORTEX
EPIPHYSIS
GROWTH PLATE
METAPHYSIS PROXIMAL

DIAPHYSIS METAPHYSIS
EPIPHYSIS GROWTH
PLATE

METAPHYSIS DISTAL
 Interpretation of skeletal radiograph
• Adequacy
• Alignment
• Bone
• Cartilage, sub-Chondral bone
• Density
• Soft tissue
Alignment GOOD DISRUPTED

Bone and
joint conqruency
 Bone Density
INCREASE NORMAL DECREASE/OSTEOPENIA
 CARTILAGE
• Non ossified
could not seen
in radiograph
• Joint space

NORMAL NARROWING
SUBCHONDRAL BONE LAYER

CHONDRAL /CARTILAGE
SOFT TISSUE
 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 ultrasonography,
computed tomography, magnetic resonance imaging, or isotope bone
scanning for complex cases.
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 Incomplete
fracture fracture
Comminuted fracture
Non displaced Displaced
fracture fracture
Rotation Angulation
Intra articular Extra articular
Associated with joint subluxation or
dislocation
Joint dislocation
 Fracture that Involve Growth Plate :
Epiphysiolysis
SALTER-HARRIS FRACTURES

Image source : http://openi.nlm.nih.gov/detailedresult.php?img=3019033_JMedLife-03-70-g003&req=4

 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
BONE INFECTION :
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

Periosteal
reaction
 Chronic Stage Ostemyelitis

Dead bone 
New bone Sequestrum ~
formation set apart
Involucrum ~
wrap
Pus try to find a way
out from bone
Cloaca~ track,
opening
 Chronic Stage
Involucrum Sequestrum Cloaca : opening /track
BONE TUMOR
HOW EVALUATE BONE TUMOR?
TYPE OF BONE DESTRUCTION More malignant
Geographic Moth-eaten Permeative
 PERIOSTEAL REACTION

ONION SKIN SUNBURST/ CODMAN

SUNRAY TRIANGLE
ONION SKIN SUNBURST CODMAN’S
TRIANGLE

EWING SARCOMA OSTEOSARCOMA

SOFT TISSUE MASS
OSTEOSARCOMA
 Osteoarthritis
• Degenerative joint disease
• Weight bearing joint
• Cartilage destruction  Joint space
narrowing
• Osteophytes
• Soft tissue swelling due to joint effusion
OSTEOPHYTE / BONY SPUR/LIPPING
Osteoarthritis: reduce joint space
 TAKE HOME MESSAGE
• Do not forget to apply ‘ rule of two’ while
evaluating MSK lesion.
• Remember to describe fracture completely
• Bone infection in acute and chronic stage has
different radiographic appearance
• Remember to confirm age of the patient when
evaluating bone tumor
THANK YOU