Radiology Imaging in

Musculoskeletal (MSK) Disorders

Elysanti Dwi Martadiani
Department of Radiology
Faculty of Medicine, Udayana University

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The important things have to be
evaluated in MSK Radiology

• Bones
• Joints
• Soft tissue
• Rule of two

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 IMAGING MODALITY
• Radiograph / plain x-photo : initial
• CT scan : complex bone (spine, hand,feet,
maxillofacial)
• Ultrasound (US): superficial soft tissue (tendon,
superficial ligament, muscle)
• Magnetic Resonance Imaging (MRI) : soft tissue
(superficial and deep located soft tissue)
• Radioisotop scanning (metastases, tumor
recurrence, infection, bone infarction)

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Radiograph

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CT SCAN

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MRI

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ULTRASOUND

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Radioisotop scanning

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RADIOGRAPH

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 Terms
Radiosclerotic ~ osteoblastic Radioluscent ~ osteolytic

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 Radiographic imaging of the MSK

ADULT CHILD
Epiphyseal
Epiphyseal
growth
growth plate (+)
plate (-)

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

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 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.
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 BONE
CARTILAGE

JOINT
SPACE
SUBCHONDRAL
BONE

CORTEX
MEDULLA

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 Bone density

Increased density Normal density Decrease density : Osteopenia

Cortex-medulla border Obvious cortex-medulla Cortex –medulla
dissapear border border very obvious
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TRAUMA

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 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

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 Fracture Terms
• Complete or incomplete
• Comminution fracture
• Displaced fracture fragments
• Angulation, rotation
• Associated with joint subluxation or
dislocation

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Complete Incomplete
fracture fracture

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Comminuted fracture

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Non displaced Displaced
fracture fracture

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Rotation Angulation

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Associated with joint subluxation or
dislocation

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Joint dislocation

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PEDIATRIC FRACTURES

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 PLASTIC DEFORMITY
/ BOWING FRACTURE

https://www.med-ed.virginia.edu/courses/rad/ext/2elbow/
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TORUS /
BUCKLE
FRACTURE

http://o.quizlet.com/

http://www.healio.com/~/media/Journals/PedAnn/2014/5/_
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Greenstick Fracture

http://www.kidsfractures.com/forearm/
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 PHYSEAL INJURY

Salter-Harris Fractures

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 SALTER HARRIS FRACTURE
• Classification system to delineate
risk of growth disturbance
• Higher grade fractures are more
likely to cause growth disturbance
• Growth disturbance can happen
with ANY physeal injury

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 SALTER-HARRIS FRACTURES

S A L T R
SLIPPED ABOVE LOWER THROUGH RUINED

Image source :
http://openi.nlm.nih.gov/detailedresult.php?img=3019033_JMedLife-03-70- 31
g003&req=4
Fracture healing

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 Fracture healing

http://www.rch.org.au/fracture-education/fracture_healing/

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 Fracture Healing
• Essential event : creation of bony bridge
between fracture fragments

• Bony callus begins about 2-3 weeks after

injury, and continues until firm union is
formed 3-6 month later

• Malunion, delayed union, non union

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 Disturbed fracture healing
• Delayed union
– fracture healing takes about twice as long as
expected for a specific location

• Non-union (pseudoarthrosis)
– fracture healing does not occur within 6-9 months

• Malunion
– healing in the wrong position

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Callus dan Malunion

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BONE INFECTION :
OSTEOMYELITIS

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 Osteomyelitis
• Osteon = bone
Myelos = marrow
Itis = inflammation
Infection of bone CORTEX
marrow
MARROW
• Acute
Chronic osteomyelitis

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 Acute Stage Osteomyelitis
•Cortex destruction/
Cortex destruction
rarefaction
/ rarefaction Periosteal Reaction
•Periosteal Reaction

rarefaction

Periost rx

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 Chronic Stage Ostemyelitis

Sequestrum
~ set apart
Involucrum ~
wrap

Cloaca~ track,
opening
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 Chronic Stage
Involucrum Sequestrum Cloaca : opening /track

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BONE TUMOR

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HOW EVALUATE BONE TUMOR?

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 TYPE OF BONE DESTRUCTION
Geographic Moth-eaten Permeative

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 PERIOSTEAL REACTION

ONION SKIN SUNBURST/ CODMAN

SUNRAY TRIANGLE

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ONION SKIN SUNBURST CODMAN’S
TRIANGLE

EWING SARCOMA OSTEOSARCOMA

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SOFT TISSUE MASS

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OSTEOSARCOMA

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 EWING SARCOMA

https://www.studyblue.com/notes/note/n/msk-bone-cancer/deck/5953508
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DEGENERATIVE

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 Osteoarthritis
• Degenerative joint
disease
• Osteophytes
• Joint space
narrowing
• Sclerotic of
subchondral bone
• Soft tissue swelling
due to joint
effusion

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 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.

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THANK YOU

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