2. ObjectivesObjectives
1. Discuss the localisation of disease processes (bone, cartilage, synovium, soft tissue)1. Discuss the localisation of disease processes (bone, cartilage, synovium, soft tissue)
as identified by the plain radiograph and demonstrate a systematic approach to theas identified by the plain radiograph and demonstrate a systematic approach to the
interpretation of the plain radiograph.interpretation of the plain radiograph.
2. Recognise and describe the principal radiographic features of the major arthropathies2. Recognise and describe the principal radiographic features of the major arthropathies
including osteoarthritis, rheumatoid arthritis, seronegative spondarthropathies andincluding osteoarthritis, rheumatoid arthritis, seronegative spondarthropathies and
septic arthritis and osteomyelitis.septic arthritis and osteomyelitis.
3. Recognise and describe the radiographic features of common adult fractures including:3. Recognise and describe the radiographic features of common adult fractures including:
CollesColles
ScaphoidScaphoid
Femoral neckFemoral neck
VertebralVertebral
TibialTibial
AnkleAnkle
4. Recognise and describe the radiographic features of major bone disease including4. Recognise and describe the radiographic features of major bone disease including
primary and secondary malignancy, Paget’s disease, osteomalacia andprimary and secondary malignancy, Paget’s disease, osteomalacia and
osteonecrosis.osteonecrosis.
5. Discuss the most appropriate further investigations following the plain radiograph5. Discuss the most appropriate further investigations following the plain radiograph
including the indications for other bone imaging techniques such as technetium boneincluding the indications for other bone imaging techniques such as technetium bone
scanning, ultrasound and MR imaging.scanning, ultrasound and MR imaging.
6. Interpret the results of DEXA assessment of bone density in the assessment of6. Interpret the results of DEXA assessment of bone density in the assessment of
osteoporosisosteoporosis
3. Systematic Approach to theSystematic Approach to the
Musculoskeletal RadiographMusculoskeletal Radiograph
AlignmentAlignment
BonesBones
CartilageCartilage
Soft tissuesSoft tissues
4. AlignmentAlignment
Compare the alignment of each boneCompare the alignment of each bone
relative to the remaining structuresrelative to the remaining structures
Position of adjacent articular surfaces isPosition of adjacent articular surfaces is
Normally should be 100% appositionNormally should be 100% apposition
between the two surfacesbetween the two surfaces
Partial apposition = subluxationPartial apposition = subluxation
No apposition = dislocationNo apposition = dislocation
6. BonesBones
Assess for variations or abnormality of:Assess for variations or abnormality of:
Shape and size of each boneShape and size of each bone
Lucency and opacityLucency and opacity
Cortical continuityCortical continuity
Growth & Growth PlateGrowth & Growth Plate
7. CartilageCartilage
Decreased joint spaceDecreased joint space
Increased joint spaceIncreased joint space
ChondrocalcinosisChondrocalcinosis
12. Describing FracturesDescribing Fractures
By theBy the number of fragmentsnumber of fragments
ByBy communication of the fracture with the outsidecommunication of the fracture with the outside
atmosphereatmosphere
By theirBy their relationship to the jointrelationship to the joint
By theBy the direction of the fracture linedirection of the fracture line
By theBy the relationship of the fragmentsrelationship of the fragments to each otherto each other
13. Describing FracturesDescribing Fractures
Describing fractures by the number of fracture fragmentsDescribing fractures by the number of fracture fragments
TwoTwo fragments-fragments-simplesimple
More than twoMore than two fragments-fragments-comminutedcomminuted
Describing fractures by the presence or absence of communication of the fracture withDescribing fractures by the presence or absence of communication of the fracture with
outside atmosphere (best evaluated clinically)outside atmosphere (best evaluated clinically)
Closed – No communicationClosed – No communication
Open – CommunicationOpen – Communication
Describing fractures by their relationship to the jointDescribing fractures by their relationship to the joint
Not involving the joint – extra-articularNot involving the joint – extra-articular
Involving the joint – intra-articularInvolving the joint – intra-articular
Describing fractures by the direction of the fracture lineDescribing fractures by the direction of the fracture line
TransverseTransverse - the fracture line is perpendicular to the long axis of the bone.- the fracture line is perpendicular to the long axis of the bone.
Transverse fractures are caused by a force directed perpendicular to shaftTransverse fractures are caused by a force directed perpendicular to shaft
Diagonal or obliqueDiagonal or oblique - the fracture line is diagonal in orientation relative to the normal axis of the- the fracture line is diagonal in orientation relative to the normal axis of the
bone.bone.
Diagonal or oblique fractures are caused by a force usually applied in the same direction asDiagonal or oblique fractures are caused by a force usually applied in the same direction as
the long axis of the bonethe long axis of the bone
SpiralSpiral - a twisting fracture caused by a torque injury, such as might be caused by planting the foot- a twisting fracture caused by a torque injury, such as might be caused by planting the foot
in a hole while running.in a hole while running.
Spiral fractures are often associated with soft tissue injuries such as tears in ligaments orSpiral fractures are often associated with soft tissue injuries such as tears in ligaments or
tendonstendons
14. Describing FracturesDescribing Fractures
Describing fractures byDescribing fractures by thethe relationship of the fragmentsrelationship of the fragments to each otherto each other
Four parametersFour parameters
Described in terms of the relationship of the distal fracture fragment relative to theDescribed in terms of the relationship of the distal fracture fragment relative to the
proximal fragment.proximal fragment.
DisplacementDisplacement
• Describes the amount by which the distal fragment is offset, front-to-backDescribes the amount by which the distal fragment is offset, front-to-back
and side-to-side, from the proximal fragmentand side-to-side, from the proximal fragment
AngulationAngulation
Describes the angle between the distal and proximal fragments as a function ofDescribes the angle between the distal and proximal fragments as a function of
the degree to which the distal fragment is deviated from its normal positionthe degree to which the distal fragment is deviated from its normal position
ShorteningShortening
Describes how much, if any, overlap there is of the ends of the fractureDescribes how much, if any, overlap there is of the ends of the fracture
fragments, which translates into how much shorter the fractured bone is than itfragments, which translates into how much shorter the fractured bone is than it
would be had it not been fracturedwould be had it not been fractured
RotationRotation
Almost always involves the long bones, such as the femur or humerus, whichAlmost always involves the long bones, such as the femur or humerus, which
describes the orientation of the joint at one end of the fractured bone relative todescribes the orientation of the joint at one end of the fractured bone relative to
the orientation of the joint at the other end of the same bone. To appreciatethe orientation of the joint at the other end of the same bone. To appreciate
rotation, both the joint above and the joint below a fracture must be visualized,rotation, both the joint above and the joint below a fracture must be visualized,
preferably on the same radiograph.preferably on the same radiograph.
15. Tibial FracturesTibial Fractures
ShaftShaft
Plateau – Intra-articular at the kneePlateau – Intra-articular at the knee
Plafond – Intra-articular at the anklePlafond – Intra-articular at the ankle
Use the general rules for describingUse the general rules for describing
fracturesfractures
If in doubt, management will be:If in doubt, management will be:
ReduceReduce
ImmobiliseImmobilise
RehabilitateRehabilitate
16. Colles FracturesColles Fractures
Colles fracture, frontal (A) and lateral (B) views.Colles fracture, frontal (A) and lateral (B) views.
Displacement ("Dinner Fork" Deformity)Displacement ("Dinner Fork" Deformity)
Dorsal AngulationDorsal Angulation
ShorteningShortening
Radial Deviation of handRadial Deviation of hand
Ulnar styloid Injury often associated (60%)Ulnar styloid Injury often associated (60%)
Ulnar collateral ligament injury often associatedUlnar collateral ligament injury often associated
17. ScaphoidScaphoid
FracturesFractures
Suspected clinically ifSuspected clinically if
there is tenderness inthere is tenderness in
the anatomic snuff boxthe anatomic snuff box
after a fall on anafter a fall on an
outstretched hand.outstretched hand.
Look for hairline-thinLook for hairline-thin
radiolucencies on specialradiolucencies on special
angled views of theangled views of the
scaphoid (closed whitescaphoid (closed white
arrow).arrow).
Fractures across theFractures across the
waist of the scaphoidwaist of the scaphoid
can lead to avascularcan lead to avascular
necrosis of proximal polenecrosis of proximal pole
of that boneof that bone
18. FemoralFemoral
NeckNeck
FracturesFractures
Hip fractures can beHip fractures can be
very subtle andvery subtle and
sometimes requiresometimes require
additional imaging suchadditional imaging such
as bone scan or MRI foras bone scan or MRI for
their diagnosis.their diagnosis.
Look for angulation ofLook for angulation of
the cortex and zones ofthe cortex and zones of
increased densityincreased density
(closed white arrows)(closed white arrows)
indicating impaction.indicating impaction.
ConventionalConventional
radiographs of theradiographs of the
femoral neck should befemoral neck should be
obtained with theobtained with the
patient's leg in internalpatient's leg in internal
rotation so as to displayrotation so as to display
the neck in profile.the neck in profile.
19. Weber FracturesWeber Fractures
Weber ClassificationWeber Classification
Relates to fibular fracture position in relation to syndesmosis between tibia and fibulaRelates to fibular fracture position in relation to syndesmosis between tibia and fibula
Weber AWeber A
Below syndesmosisBelow syndesmosis
Usually stableUsually stable
Weber B –Weber B –
Oblique fracture at level of syndesmosisOblique fracture at level of syndesmosis
Variable stabilityVariable stability
Weber C –Weber C –
Fracture above syndesmosisFracture above syndesmosis
UnstableUnstable
20. Salter-Harris FracturesSalter-Harris Fractures
S – Straight (through physis)S – Straight (through physis)
A – Above (only metaphysis)A – Above (only metaphysis)
L – Lower (only epiphysis)L – Lower (only epiphysis)
T – Through (metaphysis & epiphysis)T – Through (metaphysis & epiphysis)
R – Ram (compression injury)R – Ram (compression injury)
21. Bone DiseasesBone Diseases
Bone is undergoing continuous change from a combination of forcesBone is undergoing continuous change from a combination of forces
including biochemical and mechanical.including biochemical and mechanical.
Increased osteoclastic activity can produce focal or generalized decrease inIncreased osteoclastic activity can produce focal or generalized decrease in
bone density, and increased osteoblastic activity can produce focal orbone density, and increased osteoblastic activity can produce focal or
diffuse increased bone density.diffuse increased bone density.
Osteoblastic metastases, especially from carcinoma of the prostate andOsteoblastic metastases, especially from carcinoma of the prostate and
breast, can produce focal or generalized increase in bony density.breast, can produce focal or generalized increase in bony density.
Other diseases that can increase bone density include osteopetrosis,Other diseases that can increase bone density include osteopetrosis,
avascular necrosis of bone, and Paget's disease.avascular necrosis of bone, and Paget's disease.
Osteolytic metastases, especially from lung, renal, thyroid, and breastOsteolytic metastases, especially from lung, renal, thyroid, and breast
cancer, can produce focal areas of decreased bone density, as can multiplecancer, can produce focal areas of decreased bone density, as can multiple
myeloma, the most common primary tumor of bonemyeloma, the most common primary tumor of bone
There must be a reduction of bone mass of almost 50% to produce aThere must be a reduction of bone mass of almost 50% to produce a
recognizable abnormality on conventional radiographs.recognizable abnormality on conventional radiographs.
Examples of diseases that can cause a generalized decrease in boneExamples of diseases that can cause a generalized decrease in bone
density include osteoporosis, hyperparathyroidism, rickets (in children), anddensity include osteoporosis, hyperparathyroidism, rickets (in children), and
osteomalacia (in adults).osteomalacia (in adults).
Pathologic fractures occur with minimal or no trauma in bones that had aPathologic fractures occur with minimal or no trauma in bones that had a
preexisting abnormality.preexisting abnormality.
22. Primary Bone TumourPrimary Bone Tumour
A 26-year-old male gaveA 26-year-old male gave
a history of pain in hisa history of pain in his
forearm for two months.forearm for two months.
This AP radiograph of theThis AP radiograph of the
forearm shows aforearm shows a
destructive, lytic lesion indestructive, lytic lesion in
the radius, typical for athe radius, typical for a
primary centralprimary central
chondrosarcoma.chondrosarcoma.
Staples are seen in placeStaples are seen in place
as a result of the biopsyas a result of the biopsy
which proved this to be awhich proved this to be a
chondrosarcoma.chondrosarcoma.
23. Lytic Bone MetastasesLytic Bone Metastases
Lateral radiograph of theLateral radiograph of the
lumbodorsal spine in alumbodorsal spine in a
54-year-old female with54-year-old female with
metastatic breastmetastatic breast
carcinoma shows acarcinoma shows a
pathological collapse ofpathological collapse of
the vertebral bodythe vertebral body
anteriorly, associated withanteriorly, associated with
severe back pain butsevere back pain but
without paraplegia.without paraplegia.
24. Sclerotic Bone MetastasesSclerotic Bone Metastases
This AP radiograph of the pelvis shows multiple scleroticThis AP radiograph of the pelvis shows multiple sclerotic
lesions throughout the entire pelvis as well as diffuselesions throughout the entire pelvis as well as diffuse
sclerotic changes in the L5 vertebra and the upper thirdsclerotic changes in the L5 vertebra and the upper third
of the sacrum, consistent with metastasis from prostateof the sacrum, consistent with metastasis from prostate
cancer.cancer.
25. Paget’s DiseasePaget’s Disease
This is an APThis is an AP
radiograph of the pelvisradiograph of the pelvis
showing thickening ofshowing thickening of
the femoral neck andthe femoral neck and
diffuse sclerosis ofdiffuse sclerosis of
bone, consistent withbone, consistent with
Paget's disease.Paget's disease.
26. OsteoarthritisOsteoarthritis
These are all radiographicThese are all radiographic
changes consistent with achanges consistent with a
diagnosis of degenerativediagnosis of degenerative
disease, either primary ordisease, either primary or
secondary osteoarthritis.secondary osteoarthritis.
This is an AP radiograph ofThis is an AP radiograph of
the left hip, showing:the left hip, showing:
Narrowing of jointNarrowing of joint
space (A)space (A)
Subchondral cysts (B)Subchondral cysts (B)
Subchondral sclerosisSubchondral sclerosis
(C)(C)
Marginal osteophyteMarginal osteophyte
formation (D)formation (D)
27. Rheumatoid ArthritisRheumatoid Arthritis
In the handIn the hand (A),(A), the erosions tend to involve the proximal joints: the carpal-the erosions tend to involve the proximal joints: the carpal-
metacarpal, metacarpal-phalangeal (closed white arrows), and proximalmetacarpal, metacarpal-phalangeal (closed white arrows), and proximal
interphalangeal joints, with periarticular osteopeniainterphalangeal joints, with periarticular osteopenia
In the wristIn the wrist (B),(B), erosions of the carpals (dotted black arrow), ulnar styloid (closederosions of the carpals (dotted black arrow), ulnar styloid (closed
black arrow), and narrowing of the radiocarpal joint space (open black arrow) areblack arrow), and narrowing of the radiocarpal joint space (open black arrow) are
frequently seen. Late findings in the hands include deformities such as ulnar deviationfrequently seen. Late findings in the hands include deformities such as ulnar deviation
of the fingers at the MCP joints, subluxation of the MCP joints, and ligamentous laxityof the fingers at the MCP joints, subluxation of the MCP joints, and ligamentous laxity
leading to deformities of the fingers (all present in this case).leading to deformities of the fingers (all present in this case).
28. Psoriatic ArthritisPsoriatic Arthritis
A -A - Psoriatic arthritis typically involves the small joints of the hands,Psoriatic arthritis typically involves the small joints of the hands,
especially the distal interphalangeal (DIP) joints (closed white arrows) andespecially the distal interphalangeal (DIP) joints (closed white arrows) and
resorption of the terminal phalanges or the DIP joints with telescoping of oneresorption of the terminal phalanges or the DIP joints with telescoping of one
phalanx into another (pencil-in-cup deformity) (closed white arrows).phalanx into another (pencil-in-cup deformity) (closed white arrows).
B -B - There is ankylosis of the second toe (open white arrow) and moreThere is ankylosis of the second toe (open white arrow) and more
pencil-in-cup deformities (closed white arrows).pencil-in-cup deformities (closed white arrows).
29. Seronegative SpondarthropathiesSeronegative Spondarthropathies
This is an APThis is an AP radiographradiograph
of the upper pelvis andof the upper pelvis and
lumbar spine.lumbar spine.
Both sacroiliac jointsBoth sacroiliac joints
(large arrows) are fused(large arrows) are fused
There are bilateral,There are bilateral,
symmetricsymmetric
syndesmophytes (smallsyndesmophytes (small
arrow), resulting in thearrow), resulting in the
typical "bamboo spine"typical "bamboo spine"
appearance of ankylosingappearance of ankylosing
spondylitis.spondylitis.
30. Septic ArthritisSeptic Arthritis
This plain radiograph of part ofThis plain radiograph of part of
the right foot showsthe right foot shows
destruction of the articulardestruction of the articular
cartilage and the adjacentcartilage and the adjacent
articular cortex (closed blackarticular cortex (closed black
arrow) from proteolyticarrow) from proteolytic
enzymes released by theenzymes released by the
inflamed synovium.inflamed synovium.
There is associatedThere is associated
osteopenia from the hyperemiaosteopenia from the hyperemia
of inflammation (open whiteof inflammation (open white
arrow).arrow).
Small bubbles of gas (closedSmall bubbles of gas (closed
white arrow) are present in thewhite arrow) are present in the
soft tissues from gas-formingsoft tissues from gas-forming
bacterial cellulitis.bacterial cellulitis.
31. Progression of Septic ArthritisProgression of Septic Arthritis
8 months after the initial examination,8 months after the initial examination,
osteonecrosis and completeosteonecrosis and complete
collapse of the femoral head arecollapse of the femoral head are
present.present.
Early in the disease and radiographicEarly in the disease and radiographic
changes are limited to concentricchanges are limited to concentric
joint-space loss.joint-space loss.
Later, subchondral erosions andLater, subchondral erosions and
sclerosis of the femoral head aresclerosis of the femoral head are
present.present.
32. OsteoarthritisOsteoarthritis
Loss of joint spaceLoss of joint space
Subchondral bone cystsSubchondral bone cysts
Subchondral sclerosisSubchondral sclerosis
Osteophyte formationOsteophyte formation
33. What other conditions isWhat other conditions is
sacroileitis a feature of?sacroileitis a feature of?
Sacroileitis is a feature of allSacroileitis is a feature of all
seronegativeseronegative
spondyarthritides; psoriasis,spondyarthritides; psoriasis,
inflammatory bowel disease,inflammatory bowel disease,
Reiter’s syndrome.Reiter’s syndrome.
51. Posterior dislocation with lightbulb signPosterior dislocation with lightbulb sign
(don’t forget to mention the growth plate if it’s there!)(don’t forget to mention the growth plate if it’s there!)
52. Inferior dislocation ofInferior dislocation of
the shoulderthe shoulder
The arm is abducted,The arm is abducted,
elevated, andelevated, and
fixed. The humeralfixed. The humeral
head ishead is
subcoracoid insubcoracoid in
position, with aposition, with a
parallel humeralparallel humeral
shaft and a parallelshaft and a parallel
scapular spine.scapular spine.
An associated greaterAn associated greater
tuberosity fracturetuberosity fracture
is present.is present.
Anterior dislocation (96%)Anterior dislocation (96%)
Posterior dislocation (2-4%)Posterior dislocation (2-4%)
Inferior dislocation (1-2%)Inferior dislocation (1-2%)
Superior dislocation (<1%)Superior dislocation (<1%)
