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Musculoskeletal Radiology Nizar A. Al-Nakshabandi MD, FRCPC Part one • Imaging Techniques in Orthopaedics – Conventional Radiography – Fluoroscopy – Computed Tomography – Arthrography – Angiography – Ultrasound – Scintigraphy – Magnetic Resonance Imaging Part two • Upper limb MSK anatomy • Lower limb MSK anatomy Imaging Techniques in Orthopaedics. • Use of Radiological Techniques methods in evaluating the presence, type, and extents of various bone, joints and soft tissue abnormality. • Indications • Limitations • Appropriate imaging approach The question • “What modalities should I use for this particular problem” is frequently asked by Radiologists and Orthopaedic Surgeons alike. • Conventional Radiograph • The choice of imaging technique is dictated by the type of suspected abnormality CONVENTIONAL RADIOGRAPHY: • The most frequently used modality for evaluation of bone and joint disorder • The radiologist should obtain at least two (2) views of the bone involved at 90° angles to each other • with each view including two adjacent joints AP & lat Additional views standard films compromised the anterio-posterior and lateral views. Occasionally, oblique and special views elbow, wrist, ankle, and pelvis Cervical Spine X-ray, 3/4 (Left Neural Foramina). 1, Rib. 2, Clavicle. 3, Neural Foramina. 4, Pedicle. 5, Trachea. FLUOROSCOPY: • Many radiologic procedures – Arthrography – Tenography – Versography – Arteriography – Percutaneous Bone or Soft Tissue Biopsy. COMPUTED TOMOGRAPHY: COMPONENTS: -X ray source -Detectors - Computer data processing system Uses of CT • Trauma – Intraarticular abnormalities – Detection of small bony fragements Complex hip fractures CT Vs. Xray • Advantages: – Excellent contrast resolution. – Measures the tissue attenuation coefficient – Obtain transaxial images – Reformation • Disadvantages: – Radiation – Inability to make a specific diagnosis Uses -Tumors • Delineates tumors extent • Soft tissue extension. • Presence of Calcification • Biopsy Arthrography • Arthrography is introduction of contrast agent positive contrast iodine iodide solution negative contrast, air or combination of both into the joint space. • Advantages: – Simple – Effective Arthrography • Any joint – – – – Shoulder Ankle Elbow Knee Angiography • Advantages: 1. Map-out bone lesions 2. Demonstrate the vascularity of the lesion. 3. Demonstrate the vascular supply of a tumor 4. Locate vessels suitable for pre operative intraarterial chemotherapy. 5. Demonstrating the area suitable for open biopsy. ULTRASOUND: • Rarely used • Advantages: – inexpensive – allows comparison with the opposite side, normal side – uses no ionizing radiation, – performed at bed side or in the operating room. – It is a non invasive modality Applications • Evaluation of the rotator cuff • Injuries to various tendons, e.g. the achilles tendons. • Evaluation of the infant hip for which ultrasound has become the imaging modality of choice Shoulder US SCINTIGRAPHY RADIONUCLIDE BONE SCAN • image the entire skeleton at once. • It provides a metabolic picture. • It is particularly helpful in condition such as fibrodysplasia, Langerhans Cell Histocytosis or metastatic cancer. Prostate Mets MRI • Magnet • RF coils • Computer MRI • The musculoskeletal system is ideally suited for evaluation by MRI since different tissue displayed different signal intensities on T1 & T2 weighted images. The images displayed may have a low signal intensity, intermediate signal intensity, or high signal intensity MRI-uses • Traumatic & nontraumatic conditions – Bone – Soft tissue – Contusions – Microfractures Relation to neurovascular bundle Tumor composition MRI Contraindications • ABSOLOUTE – Patients with cardiac pacemakers – Cerebral aneurysm clips • RELATIVE: – Claustrophobia. Summary • Imaging Techniques in Orthopaedics – Conventional Radiography – Fluoroscopy – Computed Tomography – Arthrography – Angiography – Ultrasound – Scintigraphy – Magnetic Resonance Imaging Radiologic Anatomy of the Musculoskeletal System Upper limb B A C K L J I M F E H G C D A B Radiologic Anatomy of the Musculoskeletal System Lower limb D E A B C F G H I J D E B A F C A D C B F E