Musculoskeletal X-ray
Dr lai quoc thai
Dr lai quoc thai
People's Hospital 115
Content
• Bone and joint anatomy
• Systematic approach
• Viewing principles
• Musculoskeletal Pathology Xrays
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
Bone anatomy
• Most bones develop from cartilaginous ossification centres to form a diaphysis
(shaft), or epiphysis (end). During bone growth the diaphysis and epiphysis are
separated by the epiphyseal line (growth plate) which fuses later in life. The zone
adjacent to the growth plate on the diaphyseal side is called the metaphysis.
• Sesamoid: A sesamoid bone is a bone that ossifies within a tendon.
• Apophysis: An apophysis is a normal developmental outgrowth of a bone which
arises from a separate ossification centre, and fuses to the bone later in
development
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
Bone anatomy example - Knee
Long bones comprise diaphysis, metaphysis and epiphysis
The growth plate separates the metaphysis from the epiphysis until fusion in adult life
A sesamoid is a bone that ossifies within a tendon
An apophysis is a normal bony outgrowth of a bon
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
Descriptive terms example -
metacarpal
The metacarpal bone shown has a
base, shaft, neck and head
Many bones also have proximal
and distal articular surfaces
When describing abnormalities of
an articular surfaces remember to
mention whether it is proximal or
distal
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
Bone structure
Cortex v medulla example - Tibia and
fibula
Cortex denser - therefore whiter
Medulla - note the fine trabecular
pattern
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
Joint anatomy
• Most joints are synovial and comprise two
articulating bones lined with hyaline cartilage
and contained by a synovial lined capsule.
•
Although soft tissues such as cartilage and
capsular structures are of low density, and
therefore less well-defined on X-ray images
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
Joint anatomy example - Knee
Certain peri-articular soft tissues such as ligaments and tendons, or even
cartilaginous structures such as the meniscus, can be seen on X-ray
If there is narrowing of a joint - this implies abnormal thinning of cartilage
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
Systematic approach
Systematic checklist
• Patient and image data
• Bone and joint alignment
• Joint spacing
• Cortical outline
• Bone texture
•
Soft tissues
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
Bone and joint alignment
Clinical information
Trauma to forefoot
Clinically evident dislocation
X-ray performed to exclude underlying fracture
Alignment
Loss of bone alignment at the middle toe
metatarsophalangeal joint due to dislocation
Alignment and joint spacing elsewhere is
norma
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
Joint spacing
Clinical information
Longstanding forefoot pain
Diagnosis
Osteoarthritis of the 1st metatarsophalangeal joint
Note also the large osteophytes - a sign of osteoarthritis
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
Cortical outline
Clinical information
Punched brick wall when drunk
Diagnosis
Fractured ring finger metacarpal bone
- a so called 'boxer's fracture
Cortical outline
Check the cortical outline (white lines) of ALLbones
visible on every X-ray available
Check for any breach in this outline (red line ! )
Do not stop when you find one abnormality - keep
going until your eyes have covered all bones
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
Bone texture
Bone texture example - Proximal femur
Well defined trabecular pattern visible forming
the femoral neck architecture
Distortion of this trabecular pattern may make
an abnormality more conspicuous
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
Clinical information
Severe knee pain following a fall from
height
Diagnosis
Tibial plateau fracture
Soft tissue abnormality
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
Viewing principles
• 2 views are better than 1
• Check all available images
• Compare with the other side (if imaged)
•
If available ALWAYS compare with old X-rays
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
2 views are better than 1
Clinical information
Twisting injury to
left ankle
Patient unable to
bear weight
Lateral malleolus
bone tenderness
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
Right v left
Clinical information
Right groin pain after a fall
Shortened and externally rotated right leg
Diagnosis
Fractured neck of right femur
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
New v old
The old image
demonstrates the cause of
the fracture - the bone
has been weakened by a
lytic bone lesion
The current X-ray shows
an obvious displaced
fracture(#) of the
femoral shaft
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
Keep your eye on the ball
Clinical information
Elderly woman - mechanical fall
Right hip pain
Shortened and externally rotated right leg
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
Look for the unexpected
Clinical information
Clinically suspected rotator cuff disease
Pain distal to the elbow - rarely if ever caused by shoulder pathology
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
Look for the unexpected
Diagnosis
Minor rotator cuff disease
'Pancoast' tumour - apical lung cancer (cause of distal pain - referred from brachial plexus)
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
Clinical information
Wrist pain after a fall
Suspected carpal bone
fracture
Diagnosis
The jewellery artifact
makes it impossible to
exclude bone injury
Artifact
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
Arthritis
Alignment (is there subluxation or
dislocation?)
Bone mineralisation (is sclerosis or
osteopenia present?)
Cartilage (including a search for
erosions, plus loss of joint space)
Soft tissues (is there soft tissue
swelling, tophi of gout, calcification in
the soft tissues as in scleroderma?)
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
Arthritis
• Osteoarthritis (OA) is the commonest chronic
joint disease, characterised by the progressive
erosion of articular cartilag
• The radiographic hallmarks of OA are:
sclerosis
osteophytes
joint space narrowing
distal distribution in the hands.
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
Dr lai quoc thai
People's Hospital 115
Musculoskeletal Xray
