Radiology &

Diagnostic Imaging
Dr Zoya Zafar (PT)
 Musculoskeletal Disorders
• Fractures
• Degenerative disorder
• Rheumatoid Arthritis
• Osteoarthritis
• Gout
• Rickets & Osteomalacia
• Multiple Myeloma &
Other Bone Cancers
• Endocrine Bone
disorders
 Fractures
• Fractures are generally imaged using plain radiographs, however, there
are a number of situations in which CT, MRI, bone scans or ultrasound
are useful:
• when 3D anatomy is complex (e.g. joints, wrists, feet, the base of skull,
spine)
• when plain films are insensitive to non-displaced fractures (e.g. base of
skull, spine, sacrum, or proximal neck of femur) when a pathological
fracture is suspected
• Both plain radiographs and CT rely on the identification of discontinuity
of bone at the fracture site. In contrast, MRI relies primarily on
visualizing soft tissue and bone marrow changes, whereas nuclear
medicine (e.g. bone scans) visualizes bone metabolic changes.
• Historically ultrasound was not considered to be the first-line modality to
diagnose fractures and has been more commonly used for children.
However, there is now renewed interest in its use as a POCUS tool in the
emergency setting
• Plain radiograph includes: short acquisition time,
• The radiographic positions should ability to acquire volumetric image
be optimal for the evaluation on of the bone, with good spatial
plain radiograph to be valid. resolution. CT is also useful in
Radiographic features include 3: excluding bone marrow edema,
space-occupying lesions such as
• discontinuity of the cortical and malignancy, and osteomyelitis.
trabecular bone Some features of fractures include 3:
• step off in cortical and trabecular • discontinuity of the cortical and
bone trabecular bone
• displacement of osseous fragments • depressed/depressed articular
• presence of abnormal fat pad or surfaces
elevation of fat pad • increased medullary density
• Impaction lines or sclerotic bands • endosteal sclerosis
• CT • sclerotic lines in trabecular bone
• CT is useful in detecting occult • periosteal thickening
fractures. Several advantages of CT
Osteoarthritis
Radiographic Features (Fig.
5-116)
Five hallmarks:
• Narrowing of joint space,
usually asymmetrical
• Subchondral sclerosis
• Subchondral cysts (true
cysts or pseudocysts)
• Osteophytes
Osteoarthritis in specific locations
• Hip
• • Joint space is narrowest superiorly at weightbearing portion.
• • Subchondral cyst formation (intrusion of synovium and
synovial fluid into the altered bone);
• Egger's cysts: subchondral acetabular cysts
• • Superolateral migration of the femoral head is common.
• • Secondary OA of the hip is common and can be
radiographically confusing.
• • Postel's coxarthropathy: rapidly destructive OA of the hip
joint that mimics Charcot's joint
• • Protrusio acetabuli is uncommon.
• Knee • • Asymmetrical peripheral
• Medial femorotibial compartment involvement
is most commonly narrowed. • Spine (Fig. 5-118)
• Weight-bearing views are often • • OA of the spine occurs in the
helpful for assessment of joint apophyseal joints (diarthroses).
space narrowing • • Lower cervical and low lumbar
• Osteochondral bodies spine are most commonly affected.
• Patellar tooth sign (enthesopathy • • Osteophytes may encroach on
at the patellar attachment of the neural foramina (best seen on
quadriceps tendon) oblique views).
• Secondary OA occurs commonly • • Vacuum phenomenon: gas (N2)
after trauma in apophyseal joints is
• Hand (Fig. 5-117) pathognomonic of the
degenerative process.
• • Heberden's nodes in DIP
• • Degenerative spondylolisthesis
• • Bouchard's nodes in PIP (pseudospondylolisthesis)
Rheumatoid Arthritis
• Rheumatoid manifestations are non-
arthritis (RA) is a osseous in nature,
chronic multisystem ultrasound and MRI have
disease with been shown to be
predominant musculosk superior to radiographs
eletal manifestations. and CT. Plain
It is a disease that radiography, however,
primarily affects synovial remains the mainstay of
tissues, i.e. synovial imaging in the diagnosis
joints, tendons, and and follow-up of
bursae. rheumatoid arthritis 2.
• Radiographic features • Plain radiograph
• The radiographic hallmarks of rheumatoid arthritis
are:
• marginal erosions; important early finding, in the “
bare areas”, frequently in the radial side of the
metacarpophalangeal (MCP) joints 7
• soft tissue swelling
• fusiform and periarticular; it represents a
combination of joint effusion, edema and
tenosynovitis 5
• this can be an early/only radiographic finding
• osteoporosis: initially juxta-articular, and later
generalized; compounded by corticosteroid therapy
• Hands and wrists • Rheumatoid arthritis is a
• Diagnosis and follow-up of synovial-based process, with a
patients with rheumatoid predilection for the:
arthritis commonly involve • proximal interphalangeal and
imaging of the hands and metacarpophalangeal joints
wrists. (especially those of the index
• The disease tends to affect and middle fingers)
the proximal joints in a • ulnar styloid
bilaterally symmetrical • triquetrum
distribution. Although
performing both hands on one • As a rule, the distal
radiograph is convenient, interphalangeal joints are
research has shown that the spared.
distortion due to divergent ray • Late changes include:
when imaging bilaterally can • subchondral cyst formation:
impact diagnosis and x-raying
• subluxation causing: rupture (
• ulnar deviation of the Vaughan-Jackson syndrome)
metacarpophalangeal • pencil-in-cup deformity:
joints classically
• boutonniere and psoriatic arthropathy but
swan neck deformities well-recognized in
• hitchhiker’s thumb deformity rheumatoid arthritis
• carpal instability: • Elbow
scapholunate dissociation, • joint effusion (elevated fat
ulnar translocation pads)
• ankylosis • joint space narrowing
• scallop sign: erosion of the • periarticular erosions
ulnar aspect of the distal • cystic changes
radius which may be
predictive of extensor tendon
• Feet rotator cuff tear
• similar to the hands, there is a • Hip
predilection for the proximal • concentric loss of joint
interphalangeal and space, compared with osteoarthritis
metatarsophalangeal joints (OA) where there is a tendency for
(especially of the fourth and fifth superior loss of joint space
toes)
• acetabular protrusion
• subtalar joint involvement
• Knee
• posterior calcaneal tubercle erosion
• joint effusion
• hammer toe deformity
• typically involves the lateral or non-
• hallux valgus weight bearing portion of the joint
• Shoulder • loss of joint space involving all
• erosion of the distal clavicle three compartments
• marginal erosions of the humeral • lack of subchondral sclerosis and
head: the superolateral aspect is a osteophytes, compared with
typical location 2 osteoarthritis
• Spine flexion radiograph
• The cervical spine is • atlantoaxial impaction (c
frequently involved in ranial settling)
rheumatoid arthritis (in : cephalad migration of
approximately 50% of C2
patients), whereas • erosion and fusion of
thoracic and lumbar uncovertebral (
involvement is apophyseal joints) and
rare. Findings include: facet joints
• erosion of the dens • osteoporosis and
• atlantoaxial subluxation osteoporotic fractures
• atlantoaxial distance is• erosion of spinous
more than 3 mm on a processes
• Ultrasound saturation and T2-weighted spin-echo or
gradient-echo sequences 2.
• Sonography can assess the soft tissue
manifestations of rheumatoid arthritis. In • Features of rheumatoid arthritis best
particular: demonstrated with MRI include 2:
• synovial proliferation and inflammation of the • synovial hyperemia: an indication of acute
superficial joints, which is often evident before inflammation
bone changes are visible on radiographs
• synovial hyperplasia (rice bodies)
• tenosynovitis: extensor carpi ulnaris tendon
• pannus formation
involvement is common in early disease and
may lead to erosion of the ulnar styloid 2 • decreased thickness of cartilage
• bursitis • subchondral cysts and erosions:
• Ultrasound also has a role in guiding • MRI is much more sensitive than
corticosteroid injections in this setting. radiography
• it is thought that subchondral cysts in
• CT
rheumatoid arthritis eventually
• CT is not routinely used in the evaluation of progress to erosions (i.e. constitute
peripheral rheumatoid arthritis. It has "pre-erosions")
applications in imaging of the spine, and peri- • contrast enhancement may distinguish
operative assessment 2. erosions or pre-erosions from degenerative
• MRI subchondral cysts
• MRI is particularly sensitive to the early and • juxta-articular bone marrow edema
subtle features of rheumatoid arthritis. • joint effusions
• Hand (Fig. 5-122)
• • MCP ulnar deviation
• • Boutonnière deformity: hyperextension of
DIP, flexion of PIP
• • Swan-neck deformity: hyperextension of
PIP, flexion of DIP
• • Hitchhiker's thumb
• • Telescope fingers: shortening of phalanges
due to dislocations
• • Ulnar and radial styloid erosions are
common.
• • Wrist instability: ulnar translocation,
scapholunate dissociation
• Shoulder (Fig. 5-123)
• • Lysis of distal clavicle
• • Rotator cuff tear
• • Marginal erosions of humeral head
• Hip
• • Concentric decrease in joint space
• • Protrusio deformity
• • Secondary OA is common
• Spine
• • Synovial joint erosions
• Erosions in odontoid
• Erosions in apophyseal joints
• • Atlantoaxial subluxation and impaction
• >3 mm separation between odontoid and C1 in
lateral flexion
• Due to laxity of transverse cruciate ligament and
Gout
• Heterogeneous group of entities
characterized by recurrent attacks
of arthritis secondary to deposition
of sodium urate crystals in and
around joints.
• Hyperuricemia not always present;
90% of patients are male.
• Urate crystals are strongly
birefringent under polarized
microscopy
Radiographic Features (Fig. 5-132)
• • Lower extremity > upper extremity; small joints > large joints
• • First MTP is most common site: podagra
• • Marginal, paraarticular erosions: overhanging edge
• • Erosions may have sclerotic borders.
• • Joint space is preserved.
• • Soft tissue and bursa deposition
• Tophi: juxtaarticular, helix of ear
• Bursitis: olecranon, prepatellar
• • Erosions and tophi only seen in long-standing disease
• • Tophi calcification, 50%
• • Chondrocalcinosis
 Tuberculous arthritis
Tuberculous arthropathy is Radiographic Features
a type of • • Phemister triad
musculoskeletal manifestation
of tuberculosis (TB) • Cartilage destruction (occurs
and a common cause of late)
infectious arthritis in • Marginal erosions
developing countries. Any
• Osteoporosis
pathological joint lesion where
the exact diagnosis is • • Kissing sequestra in bones
equivocal should be adjacent to joints
considered tubercular in origin • • Location: hip, knee, tarsal
unless proven otherwise. joints, spine
• • Spine: Pott disease
Osteoporosis
• Radiographic Features (Fig. 5-134) • spongy bone
• • Osteopenia: 30%-50% of bone has • • Vertebral body compression
to be lost to be detectable by plain fractures: wedge, biconcave codfish
film bodies, true compression
• • Diminution of cortical thickness: • • Pathologic fractures
width of both MCP cortices should be • • Qualitative assessment: Singh index
less than half the shaft diameter is based on trabecular pattern of
• • Decrease in number and thickness proximal femur. Patterns:
of trabeculae in bone • Mild: loss of secondary trabeculae
• • Vertebral bodies show earliest • Intermediate: loss of tensile
changes: resorption of horizontal trabeculae
trabeculae
• Severe: loss of principal compressive
• • Empty box vertebra: apparent trabeculae
increased density of vertebral
endplates due to resorption of
 Osteomalacia & Rickets
• Abnormal mineralization of bone zones
is termed osteomalacia in adults • Typical location of Looser's
and rickets in children. In the past, zones (often symmetrical)
the most common cause was
deficient intake of vitamin D • Axillary margin of scapula
• Inner margin of femoral neck
• Radiographic Features
• Rib
• • Generalized osteopenia • Pubic, ischial rami
• • Looser's zones (Fig. 5-136) • • Osteomalacia may be
(pseudofractures): indistinguishable from
• cortical stress fractures filled with osteoporosis; however, Looser's
poorly mineralized osteoid tissue. zones are a reliable differentiating
• • Milkman's syndrome: feature.
osteomalacia with many Looser's
 Rickets
• R: reaction of the periosteum
• I: indistinct cortex
• C: coarse trabeculation
• K: knees, wrists and ankles mainly
• E: epiphyseal plates widened and irregular
• T: tremendous metaphysis
• S: spur (metaphyseal)​
Scurvy
• Deficiency of vitamin C (ascorbic • • Wimberger's sign: dense
acid) impairs the ability of epiphyseal rim
connective tissue to produce • • Corner sign: metaphyseal
collagen. Never occurs before 6 fractures (Pelkan spurs)
months of age because maternal
stores are transmitted to fetus. • • Periosteal reaction (ossification)
Findings are most evident at sites due to subperiosteal bleeding
of rapid bone growth (long bones). • • Hemarthrosis: bleeding into joint
Rare.
• Adults
• Radiographic Features (Fig. 5-
• • Osteopenia and pathologic
137)
fractures
• Children
• • Generalized osteopenia
• • Dense metaphyseal line (Frankel)
Endocrine Bone Disease
• Hyperparathyroidism (HPT) • • Phalangeal tufts
• Parathyroid hormone stimulates • Trabecular resorption
osteoclastic resorption of bone. HPT • • Salt-and-pepper skull
is usually detected by elevated • Cortical resorption
serum levels of calcium during
routine biochemical screening • • Tunneling of MCP bones
(nonspecific)
• Radiographic Features (Fig. 5-
138) • Subchondral resorption
• • General osteopenia • • Widened SI joint
• • Bone resorption is virtually • • Distal end of clavicle
pathognomonic • • Widened symphysis pubis
• Subperiosteal resorption • • Can lead to articular disease
• • Radial aspect of middle phalanges
(especially index and middle finger)
• Subligamentous/subtendinous resorption
• • Inferior calcaneus
• • Trochanters, tuberosities
• • Anterior inferior iliac spine
• Brown tumors (cystlike lesions) may be found anywhere in the
skeleton but
especially in the pelvis, jaw, and femur.
• • Loss of the lamina dura
• • Soft tissue calcification
• • Chondrocalcinosis
• • Complication: fractures
Hyperthyroidism
• Hyperthyroidism refers to • Thyrotoxicosis predisposes
increased production and patients to a variety of
secretion of thyroid hormone tachydysrhythmias, as well as
from the thyroid gland. atrial and ventricular ectopy 2:
• Hyperthyroidism is not • paroxysmal supraventricular
synonymous with thyrotoxicosis, tachycardia (PSVT)
the latter referring to a clinical • non-specific ST segment and T
syndrome of excess thyroid wave changes
hormone • elderly patients may have
• ECG rate-related ischemia
• sinus tachycardia • premature ventricular
• high voltage QRS complexes complexes (PVCs)
• atrial fibrillation
• In hyperthyroidism, the increased especially in long bones. This is due to
production of thyroid hormones can affect the accelerated bone turnover
various systems in the body, including the associated with hyperthyroidism.
bones. The radiographic (X-ray) features in 4.Fractures:
bones related to hyperthyroidism are often
subtle but may include the following: • Due to weakened bones, hyperthyroid
patients are more prone to fractures,
1.Osteopenia or Osteoporosis: especially in areas of high stress like
• Hyperthyroidism accelerates bone the vertebrae, ribs, and long bones.
turnover, leading to increased bone Stress fractures or insufficiency
resorption (breakdown) and decreased fractures may be visible on
bone mineral density. On X-rays, this radiographs.
may appear as generalized osteopenia 5.Acropachy (Rare):
(decreased bone density) or
osteoporosis, with bones appearing • In cases of severe or long-standing
thinner and more fragile than normal. hyperthyroidism, particularly with
Graves' disease, a rare feature called
2.Subperiosteal Resorption: thyroid acropachy may be seen. This
• Hyperthyroidism, especially when presents as soft tissue swelling and
associated with hyperparathyroidism, periosteal reaction (new bone
can lead to subperiosteal bone formation) around the shafts of long
resorption. This may be seen on X-rays bones, usually in the fingers and toes.
as irregularities or erosions along the • Though these findings can be detected on
edges of bones, particularly in the X-rays, bone density changes are often
 Acromegaly (Fig. 5-139)
• Elevated growth hormone (adenoma, • • Exostoses at tufts
hyperplasia) results in: • • Widened joint spaces due to cartilage
• • Children (open growth plates): gigantism growth
• • Adults (closed growth plates): • • Secondary DJD
acromegaly = gradual enlargement of • Feet
hands and feet and exaggeration of facial
features • • Heel pad >25 mm (typical)
• Radiographic Features • • Increased number of sesamoid bones
• The key feature is appositional bone
growth: ends of bones, exostoses on toes,
increase in size and number of sesamoid
bones:
• Hands
• • Spade-shaped tufts due to overall
enlargement
Hemolytic Anemia
• In the evaluation of hemolytic anemia, various • 2. Magnetic Resonance Imaging (MRI)
radiographic modalities are used to assess the
•
bone changes and complications that arise due to Findings:
the condition. Below is a summary of these • Bone Marrow Changes: MRI is particularly
modalities and the associated findings: sensitive to detecting changes in bone marrow
• 1. Plain X-ray (Conventional Radiography) composition. Hyperplasia of the bone marrow in
hemolytic anemia is seen as abnormal signal
• Findings: intensities in the marrow spaces of long bones
and flat bones like the skull, spine, and pelvis.
• "Hair-on-End" Appearance: Seen mainly in the
skull, it presents as perpendicular, spiculated • Extramedullary Hematopoiesis: MRI can detect
bone growth due to bone marrow hyperplasia, soft tissue masses in the thoracic spine or
typically in chronic hemolytic anemias like paravertebral areas due to blood production
thalassemia or sickle cell disease. occurring outside the bone marrow.
• Thinning of Cortical Bone: In long bones, such as • 3. Computed Tomography (CT) Scan
the femur or humerus, cortical thinning occurs
• Findings:
due to the expansion of the medullary cavity.
• Frontal Bossing: Widening of the diploic space in • Bone Expansion and Thinning: CT scans provide
the skull can lead to an abnormal prominence of more detailed cross-sectional imaging, allowing
the forehead. clearer visualization of cortical bone thinning,
medullary cavity expansion, and the "hair-on-end"
• Osteopenia/Osteoporosis: Generalized reduction appearance in the skull.
in bone density, common in long-standing cases,
• Extramedullary Hematopoiesis: CT is useful for
particularly affecting the spine and pelvis.
identifying and characterizing extramedullary
4. Dual-Energy X-ray Absorptiometry (DEXA) • Increased Bone Turnover: Bone scintigraphy
• Findings: can demonstrate increased bone turnover and
metabolic activity in bones affected by marrow
• Osteopenia/Osteoporosis: DEXA scans are hyperplasia or extramedullary hematopoiesis.
used to assess bone mineral density (BMD) Areas of increased uptake may indicate bone
with greater precision, especially in patients remodeling in response to anemia.
with chronic hemolytic anemia who are prone
to bone loss and fractures. 7. Positron Emission Tomography (PET)
5. Ultrasound • Findings:
• Findings: • Extramedullary Hematopoiesis: PET scans may
show areas of active bone marrow expansion
• Splenomegaly: Hemolytic anemia often causes or extramedullary hematopoiesis as regions of
an enlarged spleen due to increased increased metabolic activity.
breakdown of red blood cells. Ultrasound is
used to measure spleen size and detect • Each modality has its strengths in detecting
associated complications like splenic specific bone and soft tissue changes
infarctions. associated with hemolytic anemia. X-rays
provide a general overview of structural
• Soft Tissue Masses: In the context of changes, while MRI and CT offer more detailed
extramedullary hematopoiesis, ultrasound can insights into marrow changes and
sometimes help identify soft tissue masses in complications like extramedullary
areas such as the liver or paraspinal regions. hematopoiesis. DEXA focuses on bone density,
6. Bone Scintigraphy (Bone Scan) and ultrasound assists with organ assessment
• Findings: like splenomegaly
Multiple Myeloma
• Multiple myeloma is the most common primary malignant neoplasm of
the skeletal system. The disease is a malignancy of plasma cells. Clinical
definitions of the various myeloma subtypes have been updated, as have
the imaging definitions of what constitutes bone marrow disease and
individual bony involvement.
• Conventionally, the skeletal survey consists of a lateral radiograph of the
skull, anteroposterior (AP) and lateral views of the spine, and AP views of
the humeri, ribs, pelvis, and femora.
• Inclusion of at least these bones is important for both diagnosis and
staging.
• CT and MRI are considered most effective for making the diagnosis.
• MRI is the gold-standard imaging modality for detection of bone marrow
involvement and the preferred imaging technique to rule out spinal cord
compression in patients with multiple myeloma, whereas PET/CT provides
valuable prognostic data and aids in assessment of response to therapy.
 Radiographic features
• Radiology has a number of roles in the diagnosis and management for
multiple myeloma:
1.suggest the diagnosis / exclude other causes
2.assess possible mechanical complications (e.g. pathological fracture)
3.assess disease progression
• Disseminated multiple myeloma has two common radiological appearances,
although it should be noted that initially, radiographs may be normal,
despite the presence of symptoms. The two main diffuse patterns are 12:
1.numerous, well-circumscribed, lytic bone lesions (70% of cases 14)
• punched out lucencies
• raindrop skull 7

• endosteal scalloping
2.generalized osteopenia (less common)
• often associated with vertebral compression fractures/vertebra plana
• Plain radiograph ~90% with a dose 1-2x that of a
• A skeletal survey is essential not only skeletal survey 12. Whole-body low dose
for the diagnosis of multiple myeloma CT is also better to assess the risk of
but also in pre-empting potential pathological fracture in severely
complications (e.g. pathological affected bones as well as the presence
fracture) and assessing response to of extramedullary lesions 12.
therapy. ~40% bone destruction is • MRI
required for lesion detection, thus • A whole-body MRI technique may be
giving the skeletal survey a high false- deployed. MRI is more sensitive in
negative rate of ~50% (range 30- detecting multiple lesions compared to
70%) 12. the standard plain film skeletal survey
• The vast majority of lesions are purely and CT 8,12. Five patterns have been
lytic, sharply defined/punched out, with described 12:
endosteal scalloping when abutting the • normal bone marrow signal
cortex. Lesions are sclerotic in only 3%
of patients 7. • diffuse involvement
• CT • focal involvement
• Whole-body low dose CT is more • combined diffuse and focal involvement
accurate than a skeletal survey with a • variegated ("salt and pepper"
sensitivity of ~70% and specificity of
• Nuclear medicine
• Bone scintigraphy
• Bone scintigraphy appearances of disseminated multiple myeloma is
variable due to the potential lack of osteoblastic activity. Larger lesions
may be either hyperactive (hot) or photopenic (cold). Bone scans may
also be normal. Therefore, bone scans usually do not contribute
significant information to the workup of patients with suspected or
established disseminated multiple myeloma, as the sensitivity of
detecting lesions is less than that of a plain film skeletal survey 7.
• FDG PET-CT
• FDG PET-CT is effective in identifying the distribution of disease 14. F-18
FDG uptake by the myeloma lesions corresponds to lytic bone lesions
or soft tissue plasmacytomas seen on CT. However, focal high FDG
uptake in the bone may be considered a positive lesion even in the
absence of osteolysis on CT.