Radiology of the Spine and Musculoskeletal System

NRMSM 2013 3rd Year

Learning Objectives

1. Understand radiological anatomy of :O Spine, cervical, thoracic and lumbarO Hip and pelvisO Lower limbs ,knee and ankle joint.O Upper limbs, elbow and shoulder,

wrist joint 2. Identify some basic abnormalities

Overview of lectureO Introduction O General PrinciplesO Systematic approach O Viewing principles

IntroductionO Conventional radiographs are the most frequently obtained

imaging studies.O They are chiefly useful for evaluation of the bones, but

useful information about the adjacent soft tissues may also be obtained.

O Gas in the soft tissues may be a clue to an open wound, ulcer, or infection with a gas-producing organism.

O Calcifications in the soft tissues can indicate a tumour or systemic disorders such as hyperparathyroidism

O To get the most information possible from conventional radiographs, you should carefully choose the study to be ordered.

O At most hospitals and clinics, standardized sets of views have been developed that are routinely obtained together for evaluation of specific body areas in certain clinical settings.

Introduction cntnd

O In general, as in most other organ systems, the radiograph is the initial imaging test after history and physical examination.

O The selection of subsequent (often more expensive) imaging tests depends not only on medical need but also on a variety of other factors, including availability, expense, and the preferences of the radiologist, clinician, and patient.

O Understanding the surface anatomy of the body is vital as a clinician, as we use surface anatomy landmarks to conduct various procedures.

General PrinciplesBone structure O In simple terms bone is made of an outer cortex and an inner

medulla.O Difference in density allows for differentiation on X-rays -

cortex being denser and therefore whiter. Descriptive terms O Once the skeleton is fused the distinction between epiphysis,

metaphysis and diaphysis becomes less clear, and is less important.

O General terms can be used to describe the location of an abnormality.

Joint anatomyO Most joints are synovial and comprise two articulating bones

lined with hyaline cartilage and contained by a synovial lined capsule.

O Although soft tissues such as cartilage and capsular structures are of low density, and therefore less well-defined on X-ray images, it is a mistake to think they are not visible.

Systematic ChecklistAlthough the system for viewing X-rays of bones and joints varies depending on the anatomy being examined, there are some broad principles which can be applied in a number of situationsO Patient and image dataO Bone and joint alignmentO Joint spacing O Cortical outline O Bone textureO Soft tissues

Systematic Approach cntd

Patient and image data O Start by checking you are looking at the correct

image. O The patient's details should be checked and the date

and time of the X-ray noted.O The skeletal system is symmetrical and therefore it is

particularly important to be sure you are looking at the correct side.

Bone and joint alignmentO Loss of alignment may be due to bone fracture or

joint dislocation.O Both are associated with soft tissue injury that may

not be directly visualised.

Systematic Approach cntd

Joint spacingO Joint spacing may be narrowed due to cartilage

loss or widened due to dislocation/dissociationCortical outline O Careful scrutiny of the bone cortex is required

because a check that is too brief will lead to incorrect or incomplete diagnosis.

O In the context of trauma the clinical features of a significant injury may be masked by other injuries.

O Remember to be systematic, and if you spot one abnormality, do not stop until you are sure you have focussed on all areas of the anatomy shown

Systematic Approach cntd

Bone textureO In some bones a fine matrix of fine white lines

(trabeculae) is seen. O Occasionally bone injury or disease will result in

abnormality of this texture. Soft tissues O Scrutinising the soft tissues can often provide

helpful information. O Not uncommonly an abnormality of soft tissues

is more obvious than a bone injury, or may even imply a bone injury that is not visible at all.

Viewing PrinciplesO Confidence in assessing musculoskeletal system X-

rays comes from experience and a knowledge of normal appearances.

O All patients are different, so being sure of the distinction between normal and abnormal is often difficult.

O Here are some principles that may help you to determine if a finding is normal

Key pointsO 2 views are better than 1O Check all available imagesO Compare with the other side (if imaged) O If available ALWAYS compare with old X-rays

Viewing Principles cntnd2 views are better than 1 O In the context of trauma at least 2 views of the body part in question are

usually required. If looking for specific disease entities, for example erosions in rheumatoid arthritis, this may be less important.

O In some cases, such as possible scaphoid injury, more than 2 images are required.

Compare with other side O Images of the asymptomatic contralateral side to a suspected

abnormality are not routinely acquired for assessment of all bones or joints.

O If an old image of the contralateral side is available, or if the other side is included as standard (for example hip/pelvis) then comparison between symptomatic and asymptomatic appearances can be very helpful

O The 'old X-ray' is said to be the 'cheapest test in radiology.' If you are uncertain of an abnormality and there is an old image available of the area in question, then ALWAYS look at it. Doing this often increases diagnostic confidence, and shows progression over time.

Viewing Principles cntndKeep your eye on the ball O When looking at an X-ray always keep the current

clinical features at the forefront of your mind.O Remember - 'Treat the patient and not the X-ray!'Look for the unexpected O Not all disease that presents with skeletal symptoms is

primarily related to bone or joints. O Very often pain is referred to the symptomatic area and

is explained by disease of another system.O For example, shoulder pain is usually due to shoulder

pathology, but always keep in mind that pain may be referred to the shoulder from the cervical spine, brachial plexus or diaphragm

Viewing Principles cntnd

Image qualityO Certain X-rays which require careful patient positioning may

not be possible due to pain or reduced patient co-operation. O High quality images may not be achievable, in which case

you will have to work with the images provided. O If an image is sub-optimal you can ask the

radiographer/technician if there were particular technical reasons for this. Requesting a repeat image may be reasonable, if clinically justified.

Artifact O Many musculoskeletal system X-rays contain artifact, either

due to previous orthopaedic surgery, or due to foreign bodies relating to the injury.

O If there is external artifact that obscures the area of anatomical interest then this should be removed if possible

SPINEO Anterior-posterior full-length view of the

spine and Lateral full-length view of the spine

O Cervical vertebrae : Anterior viewO Cervical vertebrae : Lateral ViewO Vertebral column - Thoracic vertebrae :

Anterior-posterior viewO Lumbar vertebrae

Anterior-posterior full-length view of the spine and Lateral full-length view of the spine

Atlas

AXIS

Typical cervical vertebra

Cervical vertebrae : Radiography - Anterior view

Cervical vertebrae lateral View

Thoracic Vertebra

Vertebral column - Thoracic vertebrae : Anterior-posterior view

Lumbar Vertebra

Lumbar Vertebrae AP view

Lumbosacral joint - - Lateral view

PELVISO AP view

PELVIS

LOWER LIMBSO Full-length anterior-posterior weight-

bearing view of the legO  AP view Tibia and FibulaO Knee : AP and lateral ViewO Ankle Anterior viewO Ankle : lateral ViewO Foot Superior and lateral view

Full-length anterior-posterior weight-bearing view of the leg

AP VIEW TIBIA and FIBULA

HIP JOINT AP VIEW

Knee anteroposterior view

Knee Lateral

Ankle Anterior View

Ankle Lateral View

Osteology Foot

FOOT Superior View

Lateral View Foot

Foot Lateral View

UPPER LIMBSO Pectoral girdle; Shoulder girdle -

Radiography : Anterior viewO Humerus AP ViewO Forearm radius and ulna AP ViewO Elbow Joint - Cubital region : AP and

Lateral viewO WRIST AP View O Hand Oblique View

Shoulder

Shoulder AP VIEW

Humerus

Humerus AP View

Radius and Ulna

Forearm radius and ulna AP View

Elbow : Anterior-posterior view

Elbow Joint - Cubital region : Lateral view

Hand and Wrist

WRIST AP View

Hand Finger Oblique View

ChecklistO Plain radiographs provide information

about bone, joint and soft tissue structures

O Be systematic O Look at all views available O If available compare with old images O Look for the unexpected O Assess image quality and if clinically

appropriate consider requesting a repeat

ReferencesO http://www.imaios.com/en/e-Anatom

y/Limbs/Leg-arteries-bones-3DO http://www.imaios.com/en/e-Anatom

y/Limbs/Upper-extremity-radiography-images

O http://radiologymasterclass.co.uk/tutorials/musculoskeletal/trauma/trauma_x-ray_start.html

O Radiologymasterclass.co.uk