Musculo-

skeletal
Imaging
/ Preface /
for readers who wish to ‘dig deeper’. As a result, Modern Musculo-
skeletal
Radiology covers also topics of the postgraduate levels Imaging
of the European Training Curriculum for Radiology, thus
addressing postgraduate educational needs of residents. CHAPTER OUTLINE:

Modern Radiology is a free educational resource for In addition, it reflects feedback from medical professionals Imaging Anatomy
radiology published online by the European Society of worldwide who wish to update their knowledge in specific Strengths, Weaknesses
Radiology (ESR). The title of this second, rebranded ver- areas of medical imaging and who have already appreci- and Roles of Imaging
Modalities
sion reflects the novel didactic concept of the ESR eBook ated the depth and clarity of the ESR eBook across the
with its unique blend of text, images and schematics in the basic and more advanced educational levels. Arthropathies

form of succinct pages, supplemented by clinical imaging Fractures and

cases, Q&A sections and hyperlinks allowing to switch I would like to express my heartfelt thanks to all authors who Dislocations

quickly between the different sections of organ-based and contributed their time and expertise to this voluntary, non- Infection
more technical chapters, summaries and references. profit endeavour as well as Carlo Catalano, Andrea Laghi
Tumours and Tumour-
and András Palkó, who had the initial idea to create an ESR like Conditions
Its chapters are based on the contributions of over 100 rec- eBook and - finally - to the ESR Office for their technical
Metabolic Diseases
ognised European experts, referring to both general tech- and administrative support.
Developmental
nical and organ-based clinical imaging topics. The new Abnormalities
graphical look showing Asklepios with fashionable glasses, Modern Radiology embodies a collaborative spirit and
unwavering commitment to this fascinating medical disci- Take-Home Messages
symbolises the combination of classical medical teaching
with contemporary style education. pline which is indispensable for modern patient care. I hope Suggested Reading
and Sources
that this educational tool may encourage curiosity and crit-
Although the initial version of the ESR eBook was cre- ical thinking, contributing to the appreciation of the art and Test Your Knowledge
ated to provide basic knowledge for medical students science of radiology across Europe and beyond.
and teachers of undergraduate courses, it has gradually
expanded its scope to include more advanced knowledge Minerva Becker, Editor 2
/ Copyright and Terms of Use /
Musculo-
skeletal
Imaging

CHAPTER OUTLINE:

Imaging Anatomy
This work is licensed under a ­Creative ­Commons Attribution-NonCommercial-­NoDerivatives 4.0 International License.
Strengths, Weaknesses
and Roles of Imaging
You are free to: Modalities
Share, copy and redistribute the material in any medium or format
Arthropathies

Fractures and
Dislocations
Under the following terms: How to cite this work:
Infection
/ AT T R I B U T I O N – You must give appropriate European Society of Radiology, Tumours and Tumour-
credit, provide a link to the license and indicate if Üstün Aydıngöz (2025) like Conditions

changes were made. You may do so in any rea- eBook for Undergraduate Metabolic Diseases
sonable manner, but not in any way that suggests Education in Radiology: Developmental
the licensor endorses you or your use. Abnormalities

Take-Home Messages
/ NONCOMMERCIAL – You may not use the / Musculoskeletal Imaging. DOI 10.26044/
Suggested Reading
material for commercial purposes. esr-undergraduate-ebook-04 and Sources

Test Your Knowledge

/ If you remix, transform
N O D E R I VAT I V E S –
or build upon the material, you may not dis-
tribute the modified material. 3
/ Signage /
Musculo-
skeletal
Imaging

CHAPTER OUTLINE:

Imaging Anatomy

<•> CORE KNOWLEDGE <!> AT T E N T I O N <↑> HYPERLINKS Strengths, Weaknesses

and Roles of Imaging
Modalities

Arthropathies

>•< FURTHER KNOWLEDGE >|< C O M PA R E <∞> REFERENCES Fractures and

Dislocations

Infection

Tumours and Tumour-

<?> QUESTIONS like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

4
 Based on

/
the ESR Musculo-
Curriculum for skeletal
Radiological
Imaging
Education
CHAPTER OUTLINE:

Imaging Anatomy

Musculo-
Strengths, Weaknesses
and Roles of Imaging
Modalities

Arthropathies

skeletal
Fractures and
Dislocations

Infection

Tumours and Tumour-

like Conditions

Imaging
Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources
AUTHOR
Test Your Knowledge
Üstün Aydıngöz
<↑> HYPERLINK
A F F I L I AT I O N

Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey [email protected] 5

/ Chapter Outline /
Musculo-
skeletal
Imaging

CHAPTER OUTLINE:

/ Imaging Anatomy / Fractures and / Metabolic Diseases Imaging Anatomy

/ Bones Dislocations / Osteoporosis
/ Muscles / Osteomalacia Strengths, Weaknesses
/ Basic Principles and Roles of Imaging
/ Joints / Rickets
/ Describing Fractures and Modalities
/ Subcutaneous Tissue / Renal Dystrophy and
Dislocations and Terminology
/ Compartmental Anatomy Hyperparathyroidism
/ Features in Children Arthropathies
/ Stress Fractures
/ Strengths, Weak­nesses / Pathological Fractures / Developmental Fractures and
/ Pearls and Pitfalls Dislocations
and Roles of Imaging Abnormalities
Modalities / Infection / Scoliosis Infection
/ Developmental Dysplasia of
/ Conventional Radiographs Tumours and Tumour-
/ Osteomyelitis the Hip
(CRX) like Conditions
/ Periprosthetic Infection
/ Computed Tomography (CT)
/ Septic Arthritis
/ Ultrasonography (US)
/ Pyomyositis, Septic/Necrotising
/ Take-Home Messages Metabolic Diseases
/ Magnetic Resonance Imaging
Fasciitis, Septic Tenosynovitis
(MRI) Developmental
/ Lymphoedema Versus Cellulitis / Suggested Reading Abnormalities
/ Arthropathies and Sources
/ Tumours and Take-Home Messages
/ Osteoarthritis
/ Rheumatoid Arthritis
Tumour-like Conditions / Test Your Knowledge Suggested Reading
and Sources
/ Seronegative Arthritis / Don’t Touch Lesions
/ Axial Spondyloarthritis / Radiology of Bone Tumours
Test Your Knowledge
/ Metabolic Arthritis / Lesion Borders
/ Lesion Matrix
/ Periosteal Reaction
/ Characteristic Findings
/ Soft Tissue Tumours 6
 /
Musculo-
skeletal
Imaging

CHAPTER OUTLINE:

Imaging Anatomy

Strengths, Weaknesses

/ Imaging
and Roles of Imaging
Modalities

Arthropathies

Fractures and
Dislocations

Anatomy
Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

7
<•> CORE KNOWLEDGE

/ Musculoskeletal (MSK) Imaging /

Musculo-
skeletal
Imaging

Anatomy CHAPTER OUTLINE:

Imaging Anatomy

Strengths, Weaknesses
and Roles of Imaging
Radiology is a fascinating Currently, musculoskeletal Modalities
specialty in medicine, dealing— (MSK) radiologists use a
Arthropathies
by way of its diagnostic and wide array of ingenious
Fractures and
interventional procedures— techniques to diagnose— Dislocations
with not only recognition, but and sometimes treat—
Infection
also treatment or palliation of abnormalities and diseases
abnormalities and diseases. in humans. Knowledge of Tumours and Tumour-
like Conditions
The first known radiological musculoskeletal anatomy
Metabolic Diseases
image of human body from 22 is essential in this context.
December 1895 (Figure 1) is Developmental
Abnormalities
reportedly the hand radiograph The musculoskeletal (MSK)
of Anna Bertha Ludwig, the wife system comprises bones, Take-Home Messages

of the discoverer of X rays, Dr. muscles, joints, subcutaneous Suggested Reading

and Sources
Wilhelm Conrad Röntgen, who tissue and distinct anatomic
is considered to be the founder compartments, which play an Test Your Knowledge
of radiology. This makes mus- important functional role.
culoskeletal imaging literally the F igure 1

first subspecialty in radiology! Image from Wikipedia, Public Domain. 8

<•> CORE KNOWLEDGE

/ Imaging Anatomy of Bones /

Musculo-
skeletal
Imaging

CHAPTER OUTLINE:
All long bones comprise epiphysis, The thickness of the bone cor- The bone medulla (containing
Imaging Anatomy
metaphysis, diaphysis—and some- tex (or cortical bone) can vary medullary bone or trabecular bone)
times apophysis (Figures 2 and 3). among different bones and even comprises trabeculae, red and Strengths, Weaknesses
and Roles of Imaging
Apophyses do not contribute to within the same bone. It is usu- yellow marrow. The trabecular bone Modalities
longitudinal growth and do not form ally thicker in the diaphysis. is also called “cancellous” bone.
Arthropathies
a joint part as do the epiphyses.
Fractures and
The physes nor- Dislocations
mally close during
Infection
adolescence and
no longer remain Tumours and Tumour-
like Conditions
visible as radiolu-
Metabolic Diseases
cent bands by the
end of the second Developmental
Abnormalities
decade or the early
years of the third Take-Home Messages

decade of life. Suggested Reading

and Sources

F igure 2
Test Your Knowledge

Conventional radiographs
illustrating parts of a long
bone (here the femur) in
a child and an adult. 9
<•> CORE KNOWLEDGE

/
Carpal and tarsal bones, apophy- Musculo-
skeletal
ses and sesamoids are considered Imaging
as epiphysis analogues. Lesions
with a predilection for epiphyses, CHAPTER OUTLINE:

therefore, also tend to involve these Imaging Anatomy

analogues, which are an estab- Strengths, Weaknesses
lished location for certain tumours and Roles of Imaging
Modalities
that preferentially involve epiphyses.
Arthropathies

Fractures and
Dislocations
Arrows indicate
direction of Infection
Primary (discoid) growth plate
growth
Tumours and Tumour-
Physis
like Conditions

Metabolic Diseases

Developmental
Abnormalities
Secondary (spherical) growth plate
Epiphyseal cartilage Take-Home Messages
Acrophysis
Suggested Reading
and Sources

Test Your Knowledge

F igure 3
/ Epiphyses of long / Apophyses (including / Carpal and tarsal / Sesamoids
bones ring apophyses of bones (e.g., patella)
Drawing based on Oestreich vertebrae)
AE. Skeletal Radiol 2003. 10
<•> CORE KNOWLEDGE

/
Formerly referred to as growth Musculo-
skeletal
“arrest“ lines, growth “recovery” Imaging
lines indicate periods of renewed
or increased growth, presumably CHAPTER OUTLINE:

after a period of inhibited growth Imaging Anatomy

of the bone (Figure 4). They may, Strengths, Weaknesses
however, occur during normal and Roles of Imaging
Modalities
growth and growth spurts.
Arthropathies

Fractures and
Dislocations

B Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases

F igure 4
Developmental
Abnormalities
Growth recovery lines (arrows on A) on
MRI in a 4-year-old boy with resolved Take-Home Messages
osteomyelitis elsewhere in this extremity.
Growth recovery lines may occasionally Suggested Reading
present as curvilinear intra-epiphyseal and Sources
silhouettes (arrowheads on B and C), giving
the bone-within-bone appearance as in Test Your Knowledge
this 31-year-old woman, who sustained
an ipsilateral femoral diaphyseal fracture
at 10 years of age, whereupon she
had had limited mobility for 6 months.
Her other leg was unremarkable.
A C
11
<•> CORE KNOWLEDGE

/ Imaging Anatomy of Muscles /

Musculo-
skeletal
Imaging

CHAPTER OUTLINE:
Muscles have bellies, myotendinous junctions,
Tendon Imaging Anatomy
­tendons and tendo-osseous junctions (Figure 5).
Strengths, Weaknesses
Myotendinous and Roles of Imaging
The myotendinous junction is the site of most muscle junction Modalities
strains (Figure 6), while the tendo-osseous junction
Arthropathies
is an expected site of overuse injury (Figure 7).
Fractures and
Dislocations

Muscle Infection
belly
Tumours and Tumour-
like Conditions

Metabolic Diseases

Developmental
Abnormalities
Myotendinous
junction Take-Home Messages

Suggested Reading
and Sources
Tendon Test Your Knowledge

Tendo-osseous
F igure 5 junction
Various muscle components. 12
>•< FURTHER KNOWLEDGE

/
Musculo-
skeletal
Imaging

CHAPTER OUTLINE:

Imaging Anatomy

Strengths, Weaknesses
and Roles of Imaging
Modalities

Arthropathies

Fractures and
Dislocations
Tendon
Infection

Tumours and Tumour-

Muscle belly
like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
A B and Sources
F igure 6
Test Your Knowledge
Left hamstring strain involving the myotendinous
F igure 7
junction in an amateur football player. Fluid-
sensitive MRI sequences such as the ones here Chronic overuse injury at the tendo-osseous junctions
show oedema as conspicuously white areas of the proximal (A) and distal (B) aspects of the patellar
and are extensively used in MSK imaging. tendon in two different 13-year-old boys (arrows). 13
<•> CORE KNOWLEDGE

/ Imaging Anatomy of Joints /

Musculo-
skeletal
Imaging

Synovial joints (Figure 8) are surrounded by a CHAPTER OUTLINE:

capsule which is continuous with the perios- joint capsule bone Imaging Anatomy
teum of the articulating bones and sometimes
Strengths, Weaknesses
formed by a continuum of collagen-rich struc- and Roles of Imaging
tures such as ligaments, bands and tendons. bare area Modalities

Arthropathies
Some ligaments (e.g., anterior and posterior cru-
joint Fractures and
ciate ligaments of the knee) and tendons (e.g.,
cartilage Dislocations
biceps long head tendon in the shoulder and pop-
Infection
liteus tendon in the knee) are intraarticular.
Tumours and Tumour-
Ligaments inside a joint are usually covered by like Conditions

synovium—joint-traversing tendons are usually not.

synovial
Metabolic Diseases
fluid
Developmental
Some joints have specialised structures such
bone Abnormalities
as meniscus (knee), labrum (shoulder and hip)
Take-Home Messages
and triangular fibrocartilage complex (TFCC; joint synovium
wrist), which serve primarily as either buffer Suggested Reading
and Sources
(menisci, TFCC) or deepen the socket-type joint (labra).
Test Your Knowledge
The most important component of a synovial joint is the joint car-
tilage, the loss of which is usually associated with a cascade of F igure 8

events leading to the dysfunction and destruction of a joint. A synovial joint. 14

<•> CORE KNOWLEDGE

/
Musculo-
Although they do not provide cross-sectional informa- (MRI, see Figure 9), which gives the most skeletal
tion, radiographs are the first-line imaging modality to comprehensive non-­invasive information Imaging
study joints. Cross-sectional examination of joints is about not only the soft tissue components of
CHAPTER OUTLINE:
best accomplished by magnetic resonance imaging a joint, but also the bones that form it.
Imaging Anatomy

Strengths, Weaknesses
and Roles of Imaging
Modalities

Arthropathies
suprapatellar recess Fractures and
iliotibial band quadriceps tendon of the knee joint Dislocations

Infection

Tumours and Tumour-

like Conditions
joint
joint cartilage joint
cartilage Metabolic Diseases
capsule
Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources
lateral medial
meniscus meniscus Test Your Knowledge
F igure 9
A B
Normal anatomy of the knee joint
as seen on MRI. Coronal plane anterior cruciate joint fluid anterior cruciate
(A) and sagittal plane (B). ligament ligament 15
<•> CORE KNOWLEDGE

/
<!> AT T E N T I O N Musculo-
Radiographs give important clues about bones and soft tis- skeletal
sue components of joints. Uses of such clues include—but Imaging
are not limited to—joint effusion estimation and joint carti-
CHAPTER OUTLINE:
lage loss assessment (see Arthropathies>Osteoarthritis).
Imaging Anatomy

Strengths, Weaknesses
Joint fluid estimation on radiographs and Roles of Imaging
Modalities
The knee is the largest joint in the human
body. The suprapatellar recess (Figure Arthropathies
9) can be used for joint effusion assess-
Fractures and
ment on radiographs. Figure 10A shows a
Dislocations
normal suprapatellar recess (arrows) with a
thickness ≤ 5 mm in a properly obtained lat- Infection
eral radiograph. Figure 10B shows a knee
joint effusion with a distended suprapatellar Tumours and Tumour-
recess (arrows). Also note the increased like Conditions
joint fluid tracks along the femoral trochlea
(arrowheads), a feature not visible on A, Metabolic Diseases
where there is no joint effusion.
Developmental
Suprapatellar recess distention with effu- Abnormalities
sion can also be used to search for intra-ar-
ticular fractures by taking advantage of the Take-Home Messages
gravity-dependent layering of bone marrow
fat and blood that flow into the joint space Suggested Reading
and Sources
with such fractures (see Fractures and Dis- A B
locations>Pearls and Pitfalls in Identifying
Test Your Knowledge
Fractures). Such use entails cross-table
horizontal projection of X-rays to the image B
F igure 10
detector.
Lateral radiographs of a normal knee joint (A)
and a joint with knee effusion (B). 16
<•> CORE KNOWLEDGE

/ Imaging Anatomy of Subcutaneous Tissue /

Musculo-
skeletal
Imaging

Anatomists, surgeons and radiologists tend to use different terms to describe the components of the fas- CHAPTER OUTLINE:

cial system. The radiological approach is illustrated in Figure 11. Where muscles abut bones, the deep inter- Imaging Anatomy
muscular fascia is in continuity with the periosteum. These structures are best depicted on MRI. Strengths, Weaknesses
and Roles of Imaging
Modalities

Arthropathies

F igure 11 B C Fractures and

Dislocations
Anatomy of the subcutaneous
tissue and fasciae.
Infection
Schematic illustration (A).
Axial (B) and sagittal (C)
Tumours and Tumour-
MR images of the pelvis.
like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

A
17
<•> CORE KNOWLEDGE

/ Compartmental Anatomy /
Musculo-
skeletal
Imaging
and How It Relates to Imaging CHAPTER OUTLINE:

Imaging Anatomy
Compartments are anatomic spaces with natu- tumours is an important parameter in the Enneking
ral boundaries to tumour spread. Each bone and staging system (Figure 12), which is used in Strengths, Weaknesses
and Roles of Imaging
each joint is a distinct compartment. Muscles or patient management and outcome prediction. Modalities
muscle groups are compartments. Compartmental
As an example, the thigh muscles are divided into Arthropathies
involvement of primary malignant musculoskeletal
three compartments: anterior, medial and posterior Fractures and
Dislocations
(Figure 13). The femur itself is a distinct compartment.
>•< FURTHER KNOWLEDGE
Infection

STAG E TUMOUR METASTASES GRADE Tumours and Tumour-

like Conditions
IA T1 M0 G1
IB T2 M0 G1 Metabolic Diseases

**
IIA T1 M0 G2
Developmental
IIB T2 M0 G2 Abnormalities
III T1 or T2 M1 G1 or G2
Take-Home Messages
/ T1, tumour is intra-compartmental; T2, tumour is
extra-compartmental.
Suggested Reading
and Sources
/ M0, no regional or distant metastasis; M1, regional or A B
distant metastases.
Test Your Knowledge
/ G1, low histological grade; G2, high histological grade.
F igure 1 3

A. Thigh muscle compartments as seen on axial MRI: anterior (red), medial (yellow),
F igure 12
posterior (blue). Femur (asterisk). B. Intra-compartmental synovial sarcoma (arrow) in a
The Enneking staging system. 44-year-old woman. The mass lesion is limited to the anterior compartment of the thigh. 18
<•> CORE KNOWLEDGE

/
<!> Musculo-
Interventional radiologists or oncologic ortho- AT T E N T I O N
skeletal
paedists perform tumour biopsies. It is best to Imaging
make the biopsy at the medical centre where
CHAPTER OUTLINE:
definitive surgery will be performed.
Imaging Anatomy

The general principles for safe muscu- Strengths, Weaknesses

and Roles of Imaging
lo-skeletal tumour biopsy are (Figure 14): Modalities

/ Use the shortest path between Arthropathies

skin and lesion Fractures and

ü
Dislocations
/ Avoid neurovascular and joint structures,
Infection
lung, bowel, other organs
Tumours and Tumour-
/ Needle path needs to be in the approxi- like Conditions

*
mately same location where the incision for
Metabolic Diseases
the definitive surgery will be made, so that
Developmental
the biopsy tract can be resected Abnormalities
/ Needle should not traverse an uninvolved or critical Take-Home Messages
compartment, joint or neurovascular bundle
Suggested Reading
and Sources
F igure 14
Test Your Knowledge
Axial MRI image. Femur (*). The biopsy tract for this expansile destructive distal
femoral lesion not only should use the shortest path from the skin but also needs B
to avoid the undue contamination of the knee extensor mechanism (the red route),
which, if the red route is used, would have to be considered contaminated (by tumour
seeding) and resected during definitive surgery. The green route is to be preferred. 19
/ Strengths, /
Musculo-
skeletal
Imaging

CHAPTER OUTLINE:

Weaknesses
Imaging Anatomy

Strengths, Weak­
nesses and Roles of
Imaging Modalities

Arthropathies

and Roles
Fractures and
Dislocations

Infection

Tumours and Tumour-

of Imaging
like Conditions

Metabolic Diseases

Developmental
Abnormalities

Modalities
Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

20
<•> CORE KNOWLEDGE

/ The Concept of Resolution in Radiology /

Musculo-
skeletal
Imaging

CHAPTER OUTLINE:
There are three distinct types of resolution in radiology (Figure 15). ­
Imaging Anatomy
Imaging ­modalities vary in their advantages on any given type of resolution.
Strengths, Weak­
nesses and Roles of
Spatial resolution Contrast resolution Temporal resolution Imaging Modalities
/ Types of Resolution

Arthropathies

Fractures and
Dislocations

Infection

Tumours and Tumour-

like Conditions
Ability to discern closeness in Ability to discern Ability to discern
space of two adjacent pixels structural variations of different pixels pixel differences over time Metabolic Diseases

Better: Better: Better: Developmental

As small a pixel size as possible As subtle a pixel variation as possible As short a time period as possible Abnormalities

Take-Home Messages
Conventional radiographs and CT have MRI has excellent contrast resolution, Especially important in dynamic con-
excellent spatial resolution, which, however, which, however, is not usually equally trast-enhanced studies. Digital angiog-
Suggested Reading
is not equally matched with contrast matched with spatial resolution. US has raphy and real-time fluoroscopy have and Sources
resolution. very good contrast and spatial resolution. excellent temporal resolution.
Test Your Knowledge

F igure 1 5

Differences between spatial, contrast and temporal resolution. 21

<•> CORE KNOWLEDGE

/ Conventional Radiographs (CRX): /

Musculo-
skeletal
Imaging
Five Shades of Grey CHAPTER OUTLINE:

>|< Imaging Anatomy

Although not capable of giving cross-sectional information, radio- C O M PA R E

graphs are the first-line imaging tool in the MSK system. Radio- Strengths, Weak­
PROS CONS nesses and Roles of
graphs feature five basic shades of grey, depending on the den- Imaging Modalities
sity (or X-ray attenuation) of the content imaged (Figure 16). + Easy − Not cross- / CRX
sectional
+ Inexpensive
Arthropathies
− Ionising
radiation Fractures and
COSTS Dislocations

Radiographs << US < CT < MRI Infection

Tumours and Tumour-

like Conditions
<!> AT T E N T I O N
Metabolic Diseases
Don’t be surprised to see that Developmental
muscles are of water density Abnormalities
(they contain abundant water)!
Take-Home Messages
Note that subcutaneous fat is of
Suggested Reading
intermediate density between and Sources
ambient air and muscles (mostly
> See next page.
water), which makes sense, Test Your Knowledge
because fat is less dense than
F igure 16
water, but denser than air.
Basic grey shades on conventional radiographs (CRX). 22
<•> CORE KNOWLEDGE

/ Conventional Radiography (CRX): /

Musculo-
skeletal
Imaging
A Chicken Soup of Five Shades of Grey CHAPTER OUTLINE:

Imaging Anatomy
I poured into a paper cup first drinking water, then partly filled cup with a metal lid. I then X-rayed the cup
sunflower oil. I also put in a chicken bone. I covered the (Figure 17, centre). The resulting radiograph (Figure 17, Strengths, Weak­
nesses and Roles of
right) displays densities of air, fat, water, bone and metal. Imaging Modalities
/ Gray Shades on CRX

Arthropathies

Fractures and
Dislocations

Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages
Note fluid menisci at the edges where
fluids meet the container Suggested Reading
and Sources

Test Your Knowledge

F igure 17

Basic grey shades on conventional radiography (CRX). 23

<•> CORE KNOWLEDGE

/
I then made a CT scan of the same cup (Figure 18). CT, like CRX, <!> AT T E N T I O N Musculo-
skeletal
­utilises X-rays (i.e., ­features ionising radiation). Note that on CT Imaging
image bone marrow is largely ­composed of fat. This informa-
tion will be useful when we overview “lipohaemarthrosis”. CHAPTER OUTLINE:

Imaging Anatomy

Strengths, Weak­
nesses and Roles of
Imaging Modalities
/ Gray Shades on CRX

Arthropathies

Fractures and
Dislocations

Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

F igure 18

Basic grey shades on computed tomography (CT) and conventional radiography (CRX). 24
<•> CORE KNOWLEDGE

/ Computed Tomography (CT): Best to Characterise /

Musculo-
skeletal
Imaging
and Classify Fractures and Show Mineralisation CHAPTER OUTLINE:

Imaging Anatomy
/ CT is widely used to identify, character- A

ise and classify fractures (Figure 19). Strengths, Weak­

B
nesses and Roles of
/ Orthopaedic surgeons like to see Imaging Modalities

three-dimensional CT represen- / CT

tations of bone lesions that they Arthropathies

might operate on (Figure 20). Fractures and
Dislocations
/ CT is also used for guidance during
bone biopsies and other interven- C Infection

tional radiological procedures. Tumours and Tumour-

like Conditions
/ CT superbly demonstrates subtle calcifi-
F igure 19 Metabolic Diseases
cations in soft tissues or within the matrix
The ability to obtain from
of a bone lesion (Figure 20). Developmental
source images reformatted
Abnormalities
images in any plane is an
important asset of CT. The
D Take-Home Messages
sagittal oblique image (A) is
>|< C O M PA R E
reformatted from transverse
Suggested Reading
images (B-D). This is a patient
and Sources
PROS CONS with a left acetabular “trans-
verse with posterior wall”
Test Your Knowledge
+ Great spatial resolution − Ionising radiation fracture (arrows). CT is widely
used to identify, characterise
+ Examination times − Contrast resolution is and classify fractures and
are very short not as good as with MRI show associated injuries. 25
<•> CORE KNOWLEDGE

/
A B
Musculo-
skeletal
Imaging

CHAPTER OUTLINE:

Imaging Anatomy

Strengths, Weak­
nesses and Roles of
Imaging Modalities
/ CT

Arthropathies

Fractures and
Dislocations

Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

F igure 20 Suggested Reading

and Sources
Three-dimensional rendering of bone lesions
is another advantage of CT (A), enabling
Test Your Knowledge
orthopaedic surgeons to better visualise what
they will encounter during surgery as in this
23-year-old woman with osteo-chondroma-
tosis (arrows). B is one of the source images. 26
<•> CORE KNOWLEDGE

/ Ultrasonography (US): Great Soft Tissue Detail, /

Musculo-
skeletal
Imaging
No Ionising Radiation CHAPTER OUTLINE:

Imaging Anatomy
US is capable of giving real-time cross-­ Strengths, Weak­
sectional information without any ionising nesses and Roles of
Imaging Modalities
radiation and can be used for ­interventional
F igure 21 / Ultrasonography
procedures (Figures 21 and 22).
Shoulder US Arthropathies
shows a focal
full-thickness tear Fractures and
(asterisk) of the Dislocations
>|< C O M PA R E supraspinatus
(SS) tendon at its Infection
insertion near the
PROS CONS
humeral head (H). Tumours and Tumour-
like Conditions
+ Easy for the patient − Does not show bones
+ Relatively inexpensive − Deep soft tissues are Metabolic Diseases
usually beyond the
+ No ionising radiation F igure 22 Developmental
scope of ultrasound
+ Dynamic exam feasible Abnormalities
probe for subtle lesions US-guided
barbotage for
+ Doppler mode − Operator-dependent Take-Home Messages
calcific tendonitis
shows vascularity
^ This means that (asterisk) entails
Suggested Reading
+ Can be used for significant expertise introduction and
and Sources
guidance in some is needed to be aspiration of
procedures (e.g., physiologic saline
able to identify Test Your Knowledge
through a needle
soft tissue lesion and characterise
(arrow) to disperse
biopsy, barbotage for MSK soft tissues the calcific deposit.
calcific tendonitis) (H, humeral head). 27
<•> CORE KNOWLEDGE

/
Orthopaedic implant impingement on superficial soft Musculo-
skeletal
tissues is exquisitely displayed on US (Figure 23). Imaging

CHAPTER OUTLINE:

A B C
Imaging Anatomy

*
Strengths, Weak­
nesses and Roles of
Imaging Modalities
/ Ultrasonography

Arthropathies

Fractures and
Dislocations

Infection
D
Tumours and Tumour-
like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages
F igure 23
Suggested Reading
This 40-year-old man had sustained a comminuted calcaneal fracture
and Sources
that was internally fixed by a reconstruction plate and screws, all but one
of which was later removed. Lateral CRX (A) before screw removal, sag-
Test Your Knowledge
ittal MRI (B) and US images (C and D) after removal of all but one screw.
The impingement of the remaining screw (arrows) upon the Achilles
tendon (asterisks) was best demonstrated not on MRI (B) but on US
images, which enabled precise measurement of the depth of intrusion. 28
<•> CORE KNOWLEDGE

/ Magnetic Resonance A B

/
Musculo-
skeletal
Imaging
Imaging (MRI): An Excellent
Tool for One-Stop Imaging
CHAPTER OUTLINE:

* Imaging Anatomy

of a Great Variety of Strengths, Weak­

Structures
nesses and Roles of
Imaging Modalities
/ MRI

Arthropathies
MRI is widely used in most MSK problems. Its excel-
lent contrast resolution covers soft tissues and C D Fractures and
Dislocations
bone marrow, making it an excellent tool for one-
stop imaging of all MSK structures (Figure 24). Infection

Tumours and Tumour-

like Conditions
>|< C O M PA R E

Metabolic Diseases
PROS CONS
Developmental
+ Superb contrast resolution − Expensive Abnormalities

+ No ionising radiation − Longer examinations than CT F igure 24

Take-Home Messages
− Not readily tolerated This man had an anterior
shoulder dislocation, during Suggested Reading
by some patients and Sources
which the posterolateral
− Not possible in some patients aspect of the humeral head smashes the anteroinferior part of the
glenoid (CRX, A). MRI shows the resulting humeral head impac- Test Your Knowledge
− Subtle calcifications or tion fracture (B, arrow) with underlying bone marrow contusion (B,
small bone fragments asterisk), shoulder haemarthrosis with layering of blood haematocrit
might be missed (C, arrowheads) and the torn anterior glenoid labrum (D, circle). 29
<•> CORE KNOWLEDGE

/
MRI is the most extensively used imaging modal- full-thickness loss (7, 8). Although US can also show Musculo-
skeletal
ity to show such sports- and other activity-related some of these lesions at superficial locations (e.g., Imaging
injuries (Figure 25, arrows) as tears of the menisci shoulder, ankle; see Figure 21), it can neither display
(1, 2), anterior cruciate ligament (3), rotator cuff ten- as nicely many deeper-seated structures nor any CHAPTER OUTLINE:

dons (4), anterior talofibular ligament (5) and cartilage co-existing bone marrow lesions—as does MRI. Imaging Anatomy
lesions ranging from superficial delamination (6) to Strengths, Weak­
nesses and Roles of
Imaging Modalities
F igure 25
/ MRI
The many uses of MRI in
1 3 5 sports- and other activi- Arthropathies
ty-related conditions.
Fractures and
Dislocations
6
Infection

Tumours and Tumour-

like Conditions

1 3 Metabolic Diseases
5 6 Developmental
2 4 Abnormalities
7 8
Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

2 4 7 8
30
<•> CORE KNOWLEDGE

/ MR-/CT-Arthrography: /
Musculo-
skeletal
Imaging
A Special Method in MSK Imaging CHAPTER OUTLINE:

Imaging Anatomy
Cross-sectional imaging mostly with MRI (sometimes The injected contrast not only distends the joint
with CT) following intraarticular injection of contrast space but also dilutes the joint fluid, making it possi- Strengths, Weak­
nesses and Roles of
material is occasionally used to better delineate ble for the otherwise somewhat viscous joint fluid to Imaging Modalities
small structures within joints (Figures 26 and 27). enter the nooks and crannies and disclose tears. / MR-/CT-
Arthrography

Arthropathies
A B A B Fractures and
Dislocations

Infection

Tumours and Tumour-

like Conditions
D Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
F igure 27 and Sources
F igure 26
This patient had a cardiac defibrillator (D) and could not undergo
Test Your Knowledge
MR-arthrography (B) after intraarticular injection of contrast mate- MRI. Injection of contrast material under fluoroscopic guidance (A)
rial into the left hip joint under fluoroscopy guidance (A) showed a and CT-arthrography (B) showed a tear (arrow) of the infraspinatus
tear at the base of the anterior acetabular labrum (arrow). tendon filling with the intraarticularly injected contrast material. 31
 /
Musculo-
skeletal
Imaging

CHAPTER OUTLINE:

Imaging Anatomy

Strengths, Weaknesses
and Roles of Imaging
Modalities

Arthropathies

/ Arthropathies
Fractures and
Dislocations

Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

32
<•> CORE KNOWLEDGE

General Principles
/
Musculo-
skeletal
Imaging
One of the main tasks while dealing with arthrop- rheumatoid arthritis). Pathophysiologic mecha-
athy in a patient is to decide whether it is degen- nisms and therefore imaging findings in these two CHAPTER OUTLINE:

erative (e.g., osteoarthritis) or inflammatory (e.g., main conditions are quite different (Figure 28).
Imaging Anatomy

Strengths, Weaknesses
and Roles of Imaging
Normal joint Osteoarthritis Rheumatoid arthritis Modalities

Bare areas of the bone (*) are within the Bones rub against each other with Synovial inflammation first erodes Arthropathies
joint space but not covered with joint non-uniform loss of joint cartilage. bare areas and later expands inside
Fractures and
cartilage. Osteophytes attempt to stabilise the and outside the joint. As the disease
Dislocations
joint. Subchondral sclerosis is a stress progresses, the loss of joint cartilage is
response to cartilage loss and mechani- usually uniform, resulting in an evenly Infection
cal imbalance. Cysts may occur. narrowed joint space on radiographs.
Tumours and Tumour-
joint like Conditions
capsule bone
Metabolic Diseases

bare Developmental
* * area Abnormalities
joint
Take-Home Messages
cartilage F igure 28

Schematic Suggested Reading

illustration and Sources
* * of the
synovial differences Test Your Knowledge
fluid between
bone osteoar-

joint
thritis and
rheumatoid
synovium arthritis. 33
<•> CORE KNOWLEDGE

/ Osteoarthritis: The Hallmark /

Musculo-
skeletal
Imaging
of Degenerative Joint Disease CHAPTER OUTLINE:

Imaging Anatomy
Osteoarthritis is the most common joint disease. sclerosis and subchondral cysts in the absence of
Characteristic radiographic features (Figure 29) are such inflammatory features as erosions. Synovitis Strengths, Weaknesses
and Roles of Imaging
asymmetric (non-uniform) joint space narrowing and osteitis, however, can be seen in osteoarthritis.. Modalities
(due to joint cartilage loss) with osteophytes, bone
Arthropathies
/ Osteoarthritis
A B C

Fractures and
Dislocations

Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

F igure 29 Test Your Knowledge

Anteroposterior radiograph showing right>left hip osteoarthritis in a 64-year-old woman (hips enlarged
in B and C). Characteristic features include non-uniform narrowing of the joint space, subchondral
sclerosis (black arrowhead) and cysts (arrows) and marginal osteophytes (white arrowheads). 34
<•> CORE KNOWLEDGE

/ Osteoarthritis: Primary and Secondary /

Musculo-
skeletal
Imaging

Primary (idiopathic) osteoarthritis is the more trauma, infection, developmental dysplasia and CHAPTER OUTLINE:

common form of the disease and occurs without impingement syndromes can all lead to second-
Imaging Anatomy
a prior insult (Figure 30), which is the characteris- ary osteoarthritis (Figures 31 and 32), whereby
Strengths, Weaknesses
tic of secondary osteoarthritis. Crystal deposition, imaging can help establish the background. and Roles of Imaging
inflammatory arthritis and other synovial disease, Modalities

Arthropathies
<!> AT T E N T I O N / Osteoarthritis

Bones in the hands, wrists, feet and Fractures and

ankles make up slightly more than half Dislocations
of all bones in the human body and the
respective joints account for one third of Infection
all our articulations. It should therefore Tumours and Tumour-
come as no surprise that distal aspects like Conditions
of our extremities are extensively exam-
ined in the work-up of arthritis. Metabolic Diseases

Developmental
Abnormalities
F igure 30
Take-Home Messages
Primary osteoarthritis manifestations in a 59-year old woman
include non-uniform narrowing, subchondral cysts and marginal
Suggested Reading
osteophytes at the distal interphalangeal, first carpometacarpal
and Sources
and scaphoid-trapezium joints (yellow arrows). Secondary
osteoarthritis in the form of calcium pyrophosphate dihydrate
Test Your Knowledge
deposition (CPPD) arthropathy is also evident at the right second
and third and left first metacarpohalangeal (MCP) joints with
hook osteophytes in the distal metacarpals (white arrows) and
right second MCP joint cartilage calcification (pink arrow). 35
<•> CORE KNOWLEDGE

Osteoarthritis: Secondary
/
Musculo-
skeletal
Imaging
A B

F igure 31 CHAPTER OUTLINE:

Right hip osteoarthritis Imaging Anatomy

(A) in this 41-year-old
woman resulted from Strengths, Weaknesses
untreated develop- and Roles of Imaging
mental dysplasia of the Modalities
hip (DDH). She ended
up undergoing a total Arthropathies
right hip replacement
surgery (B). She has / Osteoarthritis
DDH also on the left
side, which, too, is on Fractures and
track for secondary Dislocations
osteoarthritis.
Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases
A B
Developmental
Abnormalities

Take-Home Messages
F igure 32
Suggested Reading
An acetabular fracture (A)
and Sources
after a motor vehicle accident
in this 25-year-old woman
Test Your Knowledge
resulted in left hip osteoarthritis
(B) within 7 months. She was
pregnant at the time of her
injury and declined surgery. 36
<•> CORE KNOWLEDGE

/ Degenerative Disease of the Spine: Bones and Discs /

Musculo-
skeletal
Imaging

Degenerative diseases of the intervertebral discs the nucleus pulposus and spondylosis deformans CHAPTER OUTLINE:

are usually in the form of intervertebral osteochon- (Figure 34), which starts in the outer fibres of annulus Imaging Anatomy
drosis (Figures 33 and 34), which originates from fibrosus. Facet joints can also have osteoarthritis. Strengths, Weaknesses
and Roles of Imaging
Modalities
MRI is extensively
“Traction” osteophytes in spondylosis deformans (Figure 34) are char-
used in the diagno- Arthropathies
acteristically transverse or oblique in orientation. They occur second-
sis of disc herniation,
ary to chronic traction of Sharpey fibres (at the periphery of the annulus / Degenerative Spine
which is usually Disease
fibrosus), which are stretched
associated with low
by the bulging disc.
back or neck pain F igure 34 Fractures and
(both of which are Dislocations
Osteophytes (arrowheads) and
among the most
narrowed disc spaces (asterisks)
common complaints Infection
containing accumulated gas (arrows)
in adults). drawn from surrounding tissues into
Tumours and Tumour-
the clefts within degenerated disks
The terms disc like Conditions
(intervertebral osteochondrosis).
bulge, protrusion
(Figure 33), extru- Metabolic Diseases
sion, migration and
Developmental
sequestration on
Abnormalities
MRI reports all have
specific meanings. Take-Home Messages

Suggested Reading
and Sources
F igure 33
Test Your Knowledge
MRI shows protrusions (circle
and arrowheads) of degenerated
discs (C4–5, L5–S1>L4–5). 37
<•> CORE KNOWLEDGE

/ Rheumatoid Arthritis (RA): The Hallmark of /

Musculo-
skeletal
Imaging
Inflammatory Arthritis CHAPTER OUTLINE:

Imaging Anatomy
Characteristic radiographic findings of rheuma- look for erosions are hands, wrists and feet – espe-
toid arthritis (RA) include uniform narrowing of the cially the radial aspects of the second and third Strengths, Weaknesses
and Roles of Imaging
joint space, erosions starting from the bare areas metacarpophalangeal (MCP) joints and the ulnar Modalities
and periarticular osteopenia. Common places to aspect of the fifth MCP joint (Figures 35 and 36).
Arthropathies
/ Rheumatoid Arthritis

Fractures and
F igure 3 5
Dislocations
Hand-wrist and foot radiographs
showing characteristic erosions Infection
(arrows and ellipses) and mild
uniform narrowing of joints in two Tumours and Tumour-
patients with rheumatoid arthritis. like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages
>•< FURTHER KNOWLEDGE
Suggested Reading
and Sources
F igure 36
Test Your Knowledge
Radiographic findings of rheumatoid arthritis can be subtle as in
this 22-year-old woman with narrowing of the second MCP joint
and radiocarpal joint on one side (ellipses, left) and the third MCP
joint on the other side (ellipse, right). No erosions are visible. 38
<•> CORE KNOWLEDGE

/
Musculo-
skeletal
<!> AT T E N T I O N
Imaging

Contrast-enhanced MRI is capable CHAPTER OUTLINE:

of detecting joint involvement in RA in Imaging Anatomy

the absence of radiographic signs on
CRX (Figure 37). Strengths, Weaknesses
and Roles of Imaging
Modalities

Arthropathies
/ Rheumatoid Arthritis

Fractures and
Dislocations

Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

F igure 37

Wrist pansynovitis, extensive MCP joint synovitis and flexor tenosynovitis manifesting as extensive enhancement on contrast enhanced
MRI (centre and right) in a 48-year-old woman with RA. Note also erosions (arrows). Her CRX (left) is unremarkable. 39
>•< FURTHER KNOWLEDGE

/ Common and Distinctive Imaging Features of /

Musculo-
skeletal
Imaging
Seropositive and Seronegative Arthritis CHAPTER OUTLINE:

Imaging Anatomy
Some features are common to both seropositive proliferation, however, are almost exclusively seen
(e.g., RA) and seronegative (e.g., psoriatic arthritis in seronegative spondyloarthritis. A small portion Strengths, Weaknesses
and Roles of Imaging
[PsA]) arthritis: soft tissue swelling, synovitis or teno- of cases with RA are seronegative. Figures 38 and Modalities
synovitis, erosions and osteitis. Enthesitis and bone 39 illustrate MRI features of seronegative arthritis.
Arthropathies
/ Seropositive vs.
Seronegative Arthritis

Fractures and
Dislocations

Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities
F igure 38 F igure 39
Take-Home Messages
Enthesitis at the capsular First through fifth metacar-
attachments of the third pophalangeal and right first
Suggested Reading
proximal interphalangeal joint interphalangeal joint synovitis
and Sources
(arrow) is exquisitely depicted (arrows) and first through fifth
as the earliest imaging finding flexor tenosynovitis (arrow-
Test Your Knowledge
of seronegative arthritis on heads) are seen on MRI of this
this MR image of a 29-year- 8-year-old girl with seronegative
old woman with psoriasis juvenile idiopathic arthritis. 40
>•< FURTHER KNOWLEDGE

/ Periarticular Osteitis on Sacroiliac Joint MRI: /

Musculo-
skeletal
Imaging
A Major Finding for Diagnosing Axial
Spondyloarthritis
CHAPTER OUTLINE:

Imaging Anatomy

Strengths, Weaknesses
and Roles of Imaging
Periarticular bone marrow A
Modalities
edema/osteitis on MRI
Arthropathies
(Figures 40 and 41) is one / Axial
of the cardinal features for Spondyloarthritis

diagnosing axial spondy- Fractures and

loarthritis in patients with Dislocations

inflammatory type back pain Infection

B
≥ 3 months and age at onset Tumours and Tumour-
< 45 years. Axial spon- like Conditions

dyloarthritis is a complex Metabolic Diseases

immune-mediated health
Developmental
condition with characteristic Abnormalities
F igure 40
clinical features such as Take-Home Messages
Bilateral periarticular bone
enthesitis, sacroiliitis and marrow oedema (arrows)
Suggested Reading
spondylitis, and extraartic- and iliac>sacral-sided periar-
F igure 41 and Sources
ticular erosions (arrowheads)
ular manifestations such as are characteristic of acute Periarticular bone marrow oedema denot-
Test Your Knowledge
on chronic sacroiliitis in ing active sacroiliitis on the right (ellipse, A)
anterior uveitis, psoriasis and
this 28-year-old man with has resolved following treatment (B) in this
inflammatory bowel disease. ankylosing spondylitis. 33-year-old man with ankylosing spondylitis. 41
<•> CORE KNOWLEDGE

/ Gout: The Hallmark of Metabolic Arthritis /

Musculo-
skeletal
Imaging

Monosodium urate crystal deposition within joints B CHAPTER OUTLINE:

and surrounding soft tissues (including tendons

Imaging Anatomy
and bursae) in gout results in some characteristic
Strengths, Weaknesses
imaging findings as shown in Figures 42 and 43. and Roles of Imaging
Modalities

Arthropathies
/ Metabolic Arthritis

<!> AT T E N T I O N A C Fractures and

Dislocations

Infection

F igure 42 Tumours and Tumour-

like Conditions
Punched out erosions with
overhanging edges (arrows, A)
Metabolic Diseases
surrounding the first metatar-
sophalangeal joint along with
Developmental
preservation of joint space
Abnormalities
width are characteristic of
gout in this 58-year-old man.
Take-Home Messages
“Double contour” sign in a
sagittal US image (B) denotes
Suggested Reading
crystal deposition across
and Sources
the joint cartilage surface
(arrows). Dual-energy CT (C)
Test Your Knowledge
accurately depicts monoso-
dium urate crystals (green)
and is useful for disease
quantification in the follow-up. 42
<•> CORE KNOWLEDGE

/
Musculo-
skeletal
Imaging

CHAPTER OUTLINE:

Imaging Anatomy

Strengths, Weaknesses
and Roles of Imaging
A B D Modalities

Arthropathies
/ Metabolic Arthritis

Fractures and
Dislocations

Infection

Tumours and Tumour-

C
like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
F igure 4 3 and Sources
Lumpy-bumpy appearance due to tophi around joints and
Test Your Knowledge
periarticular erosions with overhanging edges (A), tarsometatar-
sal joint erosions (ellipses and arrowheads) on foot radiograph
(B) and CT (C and D) are typical imaging findings of gout. Note
the distal tophus along the anterior tibial tendon (arrows). 43
<•> CORE KNOWLEDGE

/
Musculo-
Calcium Pyrophosphate Dihydrate (CPPD) Arthropathy skeletal
Imaging
Although gout is considered as the hallmark of meta- arthritis – and second, in frequency, only to osteoar-
CHAPTER OUTLINE:
bolic arthritis, CPPD is more common than gout, given thritis. Characteristic findings are shown in Figure 44.
Imaging Anatomy
the fact that it is usually seen in an older age group
and that humans have increased longevity. In fact, Strengths, Weaknesses
F igure 44 and Roles of Imaging
CPPD arthropathy is more common than rheumatoid Modalities
CPPD arthropathy in a 94-year old woman. Second
and third metacarpophalangeal (MCP) joint arthritis
(ellipses), hook osteophytes along radial aspects Arthropathies
of second and third distal metacarpals (arrows), / Metabolic Arthritis
calcification at the triangular fibrocartilage (pink arrow-
head), scapholunate ligament (green arrowhead) Fractures and
and third MCP joint cartilage (yellow arrowhead). Dislocations

Infection

>•< F U R T H E R K N OW L E D G E Tumours and Tumour-

like Conditions
Interestingly, CPPD arthropathy
can present without visible Metabolic Diseases
calcifications within joints.
Involvement of the characteristic Developmental
Abnormalities
locations (MCP joints and
radiocarpal compartment, both Take-Home Messages
of which are unusual locations for
primary osteoarthritis) along with Suggested Reading
second and third distal metacarpal and Sources
hook osteophytes in a patient
>50 years would be clues to CPPD Test Your Knowledge
arthropathy, even in the absence
of intraarticular calcifications on
imaging. 44
>•< FURTHER KNOWLEDGE

/ An Algorithm for Imaging Diagnosis of Arthropathies /

Musculo-
skeletal
Imaging

The algorithm shown in Figure 45 can be used for imaging diagnosis of arthritis. It is not CHAPTER OUTLINE:

­without shortcomings, however, and some of the exceptions are given in Figure 46. Imaging Anatomy

Strengths, Weaknesses
and Roles of Imaging
Modalities

Arthropathies
/ An Imaging Algorithm

Fractures and
Dislocations

Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

F igure 4 5 F igure 46

Adapted from Jacobson JA et al. Radiology 2008. Exceptions to the algorithm shown in Figure 41. 45
 /
Musculo-
skeletal
Imaging

CHAPTER OUTLINE:

/ Fractures
Imaging Anatomy

Strengths, Weaknesses
and Roles of Imaging
Modalities

Arthropathies

and
Fractures and
Dislocations

Infection

Tumours and Tumour-

Dislocations
like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

46
<•> CORE KNOWLEDGE

/ Basic Principles in Imaging /

Musculo-
skeletal
Imaging
Fractures and Dislocations CHAPTER OUTLINE:

Imaging Anatomy
/ More than one radiographic / Stress radiographs (e.g.,
projection is needed for scaphoid view for sus- Strengths, Weaknesses
and Roles of Imaging
any part of the body. pected fracture of this wrist Modalities

/ Although radiographs are the bone) or additional projec-

Arthropathies
first-line imaging tool to look for tions (e.g., axillary view and/
Fractures and
fractures and/or dislocations, or Y-view in the shoulder) Dislocations
CT is more appropriate in body can be used in some joints / Basic Principles

parts with complex anatomy and certain conditions.

Infection
(e.g., face, thoracic cage, pelvis). / Radiographs need to cover
Tumours and Tumour-
/ Two radiographic projections the joints adjacent to a like Conditions

perpendicular to each other long bone (Figure 47); if a Metabolic Diseases

need to be used for extremity single X-ray detector plate
Developmental
segments (i.e., arm, forearm, does not suffice to include Abnormalities

thigh and calf; Figure 47). joints at both ends, two

Take-Home Messages
acquisitions are needed
/ Three radiographic projec- for each projection.
Suggested Reading
and Sources
tions (anteroposterior/postero- F igure 47

anterior, lateral, oblique) are / Due to the ongoing Normal anteroposterior and lateral CRX of the calf. Test Your Knowledge

recommended for most joints ossification in children,

(e.g., wrist, hand, ankle, foot). comparative radiographs 47
<•> CORE KNOWLEDGE

/ Describing Fractures and Dislocations on Imaging /

Musculo-
skeletal
Imaging

/ Fractures are commonly described according to / Subluxation refers to an incomplete dis- CHAPTER OUTLINE:

the location/alignment of the DISTAL aspect of location where joint surfaces remain par-
Imaging Anatomy
the major DISTAL fracture fragment (displaced or tially facing each other (Figure 50).
Strengths, Weaknesses
non-displaced, angulated, rotated; Figure 48). / Joint dislocations (and subluxations) are usu- and Roles of Imaging
Modalities
/ Dislocation is an injury resulting in loss of anatom- ally described in terms of the position of the
ical congruence of bones at a joint (Figure 49). distal bone in relation to the proximal bone. Arthropathies

Fractures and
Dislocations
/ Describing Fractures

Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

F igure 48 F igure 49 F igure 50

Spiral fracture of the distal tibial diaphysis with Medial and dorsal dislocation of Medial and dorsal subluxation of the fourth proximal interphalangeal (PIP)
mild lateral and minimal posterior displacement. the fourth PIP joint (arrow). joint with a comminuted intraarticular fracture of the middle phalangeal base. 48
<•> CORE KNOWLEDGE

/ Fractures: Terminology /
Musculo-
skeletal
Imaging
ligaments, due to their sudden pull. Sometimes frac-
There are many ways to describe a fracture depend- ture fragments override each other or one fracture CHAPTER OUTLINE:

ing on its properties (Figures 51 and 52). Based on the fragment impacts onto another. Impaction fractures
Imaging Anatomy
orientation or shape of the fracture line, a fracture can in the spine are called vertebral collapse; there might
Strengths, Weaknesses
be described as transverse, oblique or spiral. Avulsion be retropulsion of the fracture fragments narrowing and Roles of Imaging
fractures happen at the insertion sites of tendons or the spinal canal and compromising its contents. Modalities

Arthropathies
>•< F U R T H E R K N OW L E D G E
Fractures and
Dislocations
Avulsion fracture Traumatic ­vertebral
(ofAAthe
Avvvuuullleft
slsisioo
ionnanterior
nffrfraraacctctuu
turreere TTrraT
awith
uruam muam attiaicctic / Terminology
Transverse Oblique Spiral Overriding collapse
TTrTa
rran
fracture ann ssvsveveerrsrsesee OOObbblliliqiqquuueee
fracture fractureSSppiirraall OOvveerrrriiddiinnnggg
fracture ((o
(ooffftththheeeliliac
superior leelefftfttaaspine)
annntteerririooio
te IIm
rr r Impactedm Im ppfracture
apaccattceetdd
ed vveevrrettee
­retropulsion rbtberrbaalrl acclooclllo
aaplplassepese
sssuuupppeeerririoioorrriilliilaaiacccsspspp iinnin
ee)e) ) Infection
frffraracactcu
ttuurreree ffrfrraaacccttu
tuurrreee ffrraaccttuurree ffrraaccttuurreee ffrrafarca
cttcuutrureere wwiw itthhitrhreetrtrerootprpouupllssuiiolosnn
ion
Tumours and Tumour-
like Conditions

Metabolic Diseases

Developmental

**
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

F igure 51

Different types of fractures (arrows, ellipse and

asterisk). Explanations are given in the text above. 49
<•> CORE KNOWLEDGE

/
When a fracture is comminuted, open or intraarticular (Figure 52), ­management is Musculo-
skeletal
more difficult. Imaging makes it possible to identify such fractures. Imaging

CHAPTER OUTLINE:

Comminuted fracture Open fracture Intraarticular fracture Imaging Anatomy

Strengths, Weaknesses
Radiographs and Roles of Imaging
show three Modalities
or more
fragments in a Arthropathies
fracture. Small
fracture pieces Fractures and
are called Dislocations
“butterfly frag- / Terminology
ments” due to
their similarity Infection
to butterfly
wings. Tumours and Tumour-
The fracture extends into a joint. Intra-articular
like Conditions
fractures usually require surgery. Gap (red double
Metallic
arrow) or step-off between fracture fragments Metabolic Diseases
opacities at the
at the articular surface or fragments within joint
fracture site
space are searched with radiographs – or better Developmental
in this patient
with CT. Fragments (red arrow) within the joint Abnormalities
are bullet
space need to be removed, otherwise they
fragments.
would damage the intact joint cartilage. When an Take-Home Messages
impacted fracture fragment (area outlined in red)
is present, bone grafting may be necessary. Suggested Reading
and Sources
The skin is disrupted and at least one of
the fracture fragments is exposed to the Test Your Knowledge
outside. By default, they are considered
F igure 52
contaminated. A splint is in place on this
patient. Different types of complex fractures. 50
<•> CORE KNOWLEDGE

/ Fractures: Stress (Load) Versus Strain (Deformation) /

Musculo-
skeletal
Imaging

The stress-strain curve for any non-reversible deformation on the CHAPTER OUTLINE:

material (Figure 53) displays fibula and tibia, passing the yield
Imaging Anatomy
the relationship between the and failure points, respectively.
Strengths, Weaknesses
amount of load it can absorb and >•< FURTHER KNOWLEDG E
and Roles of Imaging
the deformation it can tolerate Modalities

before reaching its yield point F igure 54

Arthropathies
Comminuted fracture of the tibial
and ultimately its failure point. diaphysis in this 17-year-old boy, who Fractures and
Figure 54 illustrates the effects of was shot at, shows butterfly fragments. Dislocations
The paperclip is used to mark the
/ Stress vs. Strain
bullet entry site. No exit site is marked
because the bullet hit the tibia, fractured
Infection
Failure
it and was then dispersed into the calf
point muscles (presumed path of the bullet
Ultimate stress Tumours and Tumour-
is shown with dashed arrows on the
Yield stress like Conditions
lateral radiograph below). The fibula
Yield D is bowed (“plastic bowing deformity”).
point Metabolic Diseases
Since the ossification is not yet com-
plete in this boy, the fibula could be bent
Developmental
S back into its normal shape during reduc-
Abnormalities
tion of the tibial fracture, which was then
Elastic region Plastic region fixed with an intramedullary nail and
Stress Take-Home Messages
(Load) Reversible Irreversible locking screws (right). The fibula was in
deformation deformation the “plastic region” on the graph at far
Suggested Reading
left, while the tibia had already passed
Strain (Deformation) Yield Ultimate and Sources
beyond this region. Note that a drain (D)
strain strain
and a splint (S) are in place post-oper-
Test Your Knowledge
atively (right). Also note that the bullet
fragments have not been removed
F igure 53
during surgery, which would have
Drawing adapted from Pathria M et al. Radiology 2016. violated the first principle of medicine. 51
<•> CORE KNOWLEDGE

/ Fractures in Children: Special Features /

Musculo-
skeletal
Imaging

The growing skeleton in children presents challenges and tensile strength of their attachment sites in bones are not CHAPTER OUTLINE:

opportunities to detect fractures. Some fracture types, equally up to task; therefore avulsion fractures, too, are
Imaging Anatomy
such as greenstick and torus (buckle) fractures, are more common in children (Figure 56). The orderly appear-
Strengths, Weaknesses
almost exclusively seen in children (Figure 55). Tendons ance of ossification centres around the elbow can be used and Roles of Imaging
and ligaments are quite strong in children, whereas the to detect fractures in children before their teens (Figure 57). Modalities

Arthropathies

>•< FURTHER KNOWLEDG E F igure 57

Fractures and
Dislocations
Using the orderly appear-
/ Fracture Features
ance of ossification centres
in Children
to detect elbow fractures in
children. Ossification centres
Infection
* around the elbow (drawings)
follows this order: capitellum,
Tumours and Tumour-
radial head, internal (medial)
like Conditions
epicondyle, trochlea,
CT olecranon, lateral epicondyle
Metabolic Diseases
(mnemonic: CRITOL).
Therefore, what appears
F igure 56 Developmental
to be the lateral epicondyle
Abnormalities
Avulsion fracture of the tibial (arrowhead on the CRX) in
eminence at the attachment this 6-year-old boy with a
Take-Home Messages
F igure 5 5
site (pink arrow) of the I capitellar fracture (arrow)
has to be an additional
anterior cruciate ligament Suggested Reading
Difference between greenstick fracture and torus frac- (asterisk) in a 12-year-old girl. C avulsion fracture. Because,
and Sources
ture. In greenstick fracture, the side opposite the bending although the radial head (R)

R
force fractures completely, whereas the side under the and internal epicondyle (I),
Test Your Knowledge
force can remain intact (green arrows). The torus fracture as well as the capitellum (C)
is an impaction fracture in which the cortex around all or have already appeared, the
part of the bone circumference is buckled (red arrows). trochlea is not yet visible. 52
<•> CORE KNOWLEDGE

/
/ The Salter-Harris classification divides / A physeal tongue occurs when Musculo-
<!> AT T E N T I O N physeal and periphyseal fractures into metaphyseal vascular compromise skeletal
nine types. The more common Types disrupts endochondral ossification Imaging
Special emphasis is 1–4 are shown in Figure 58. Type 1 and allows chondrocytes (that later
given to the physis and involves exclusively the physis. Type 2 ossify) to extend into the metaphysis CHAPTER OUTLINE:
its vicinity in children, as is the most common (75%). (Figure 60).
fractures or disturbances / When an insult results in premature
Imaging Anatomy
in this area may negatively closure of the primary growth plate,
Strengths, Weaknesses
affect skeletal growth a physeal bridge (or bar) may occur and Roles of Imaging
(Figure 59). Modalities
>•< FURTHER KNOWLEDG E Arthropathies

Fractures and
Dislocations
/ Fracture Features
in Children

Infection

Type
Type1 1 Type
Type22 Tumours and Tumour-
like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages
F igure 59
Suggested Reading
Physeal bar in the right distal femoral
Type
Type33 Type
Type44 F igure 60 and Sources
physis (circle) in this 4-year-old boy
resulted in limb length discrepancy Physeal tongue (arrow) in a
Test Your Knowledge
(right). Note that the right leg is shorter 9-year-old boy. The only signifi-
F igure 58
than the left. He had been hospital- cant history of trauma was a fall
Salter-Harris classification. ised for infection as a newborn. from a bicycle at 5 years of age. 53
<•> CORE KNOWLEDGE

/ Stress Fractures / Fatigue fracture (overuse fracture) is caused by

abnormal stress or abnormally strenuous activity /
Musculo-
skeletal
Imaging
on a normal bone. The continuous application of an
“Stress fractures” occur without major (i.e., high-energy) increased stress (e.g., running) in a normal body can CHAPTER OUTLINE:

trauma during daily activities due to a mismatch between cause microfractures. When they accumulate faster Imaging Anatomy
repetitive mechanical stress and bone strength. Stress than the body can heal, these microfractures eventu- Strengths, Weaknesses
fractures are usually seen in the lower extremities or ally give way to macroscopic failure (an overt stress and Roles of Imaging
the spine. There are two types of stress fractures: fracture) visible on imaging (Figure 61).
Modalities

Arthropathies
/ Insufficiency fracture is caused by normal stress on
A Fractures and
abnormal bone, e.g., associated with vitamin D defi- Dislocations
ciency or osteoporosis (Figure 62). / Stress Fractures

Infection

F igure 61 Tumours and Tumour-

like Conditions

* *
A. MRI shows
right>left femoral
Metabolic Diseases
neck incomplete
fatigue fractures
Developmental
B (arrows) surrounded
Abnormalities
by bone marrow
oedema in an
Take-Home Messages
otherwise healthy
9-year-old basket-
F igure 62 Suggested Reading
ball player. B. Fol-
and Sources
low-up MRI seven MRI shows a subcortical incomplete insufficiency fracture (arrow) surrounded with
months later shows bone marrow oedema (*) at the weight-bearing portion of the medial femoral con-
Test Your Knowledge
disappearance dyle in this 65-year-old woman with osteoporosis. The posterior root avulsion of the
of fractures and degenerated medial meniscus (arrowheads) resulted in medial meniscus extrusion,
complete resolution likely paving the way for this fracture. A small amount of stress during normal daily
of marrow oedema. activities is sufficient to cause such a fracture in the background of osteoporosis. 54
<•> CORE KNOWLEDGE

/ Stress Fractures in the Spine /

Musculo-
skeletal
Imaging

Spinal column is a common location for stress frac- seen in adolescents and young adults and also known CHAPTER OUTLINE:

tures, especially the insufficiency type (Figure 63). as “spondylolysis”, can result in spondylolisthesis.
Imaging Anatomy
Fatigue fractures of the pars interarticularis (Figure 64),
Strengths, Weaknesses
and Roles of Imaging
Modalities

Arthropathies

Fractures and
* * Dislocations
/ Stress Fractures

* * Infection

* * Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

F igure 6 3 Test Your Knowledge

F igure 64
Radiographs and MRI show insufficiency type vertebral compres-
sion fractures (asterisks) in a 66-year-old woman with osteoporosis, CT shows bilateral L5 pars interarticularis fatigue frac-
confirmed with dual energy X-ray absorptiometry (top right). tures (arrows) with comminution in a 13-year-old girl. 55
<•> CORE KNOWLEDGE

/ Pathological Fractures <!> AT T E N T I O N

/
Musculo-
skeletal
Imaging

There is no “physiological” fracture. Yet, some frac- generalised bone fragility. Generally, however, patho- CHAPTER OUTLINE:

tures are called “pathological”. Some consider insuf- logical fractures are considered to occur at the location
Imaging Anatomy
ficiency type stress fractures also as pathological of a focal benign or malignant lesion (Figure 65).
Strengths, Weaknesses
fractures, because of the underlying condition of and Roles of Imaging
Modalities

Arthropathies

Fractures and
A B C Dislocations
/ Pathological
Fractures

Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases
D
Developmental
Abnormalities

F igure 65 Take-Home Messages

Pelvis radiograph (A) and MR
Suggested Reading
images (B-D) show a right femoral
and Sources
neck fracture that occurred in the
background of a metastatic lesion
Test Your Knowledge
(arrows) in this 53-year-old woman
with breast cancer. Other metas-
tases are marked by arrowheads. 56
<•> CORE KNOWLEDGE

/ Pearls and Pitfalls in Identifying Fractures /

Musculo-
skeletal
Imaging

We use a systematic approach to look for frac- Cortices of all bones on radiographs need to be CHAPTER OUTLINE:

tures on radiographs, making use of some pearls. followed. When there is a break in the cortical con-
Imaging Anatomy
All along, we need to take into account also some tinuity, there might be a fracture (Figure 66).
Strengths, Weaknesses
pitfalls so as not to misidentify a fracture. and Roles of Imaging
Modalities

<!> AT T E N T I O N Arthropathies

Fractures and
Following cortical Dislocations
continuity on radiographs is
/ Pearls and Pitfalls
essential.
Infection
MRI is the best modality to show an
acute fracture (chronic fractures Tumours and Tumour-
and tiny intraarticular fracture like Conditions
fragments, however, might be
easily missed on MRI). There is a Metabolic Diseases
simple reason for this: Two things
* always happen in an acute fracture Developmental
Abnormalities
(even if it is an incomplete fracture):

*
Bone marrow oedema surrounding Take-Home Messages
the fracture line and soft tissue
oedema at the immediate vicinity Suggested Reading
of the fracture. MRI is the only and Sources
imaging modality to show both of
F igure 66 these exquisitely. When a fracture Test Your Knowledge
This 65-year-old woman slipped on ice and fell onto her outstretched hand. The breaks in cor- is not visible on radiographs but
tical continuity of the distal radius (white arrows) represent a fracture, later confirmed by MRI identified on MRI (or sometimes on
(red arrows), which also showed both the bone marrow and soft tissue oedema (*). CT), it is called an occult fracture. 57
<•> CORE KNOWLEDGE

/ Pearls in Identifying Fractures /

Musculo-
skeletal
Imaging

The close vicinity of soft tissue oedema on radiographs CHAPTER OUTLINE:

<!> AT T E N T I O N is a prime suspect area for acute fractures. All radio-
Imaging Anatomy
graphs need to be scrutinised by zooming and chang-
Looking for soft Strengths, Weaknesses
ing brightness and contrast settings. Acute fractures are

ESSENTIAL
tissue oedema and Roles of Imaging
on radiographs. always associated with surrounding soft tissue oedema Modalities

Zooming and (Figures 67 and 68). Not all soft tissue oedema, Arthropathies
changing brightness however, is necessarily associated with fractures.
and contrast settings. Fractures and
Dislocations
/ Pearls and Pitfalls

B C
Infection

Tumours and Tumour-

F igure 67 like Conditions
The only clinical information given
Metabolic Diseases
to the radiologist about this patient
was “pain”. CRX of the calf (A) and
Developmental
zoomed detail (B and C). Careful
Abnormalities
examination of the subcutaneous
fat density reveals oedema (water
Take-Home Messages
density) overlying the medial ankle
(arrowheads). Note that there is
Suggested Reading
an incomplete fracture (arrow)
and Sources
underlying the soft tissue oedema.
The fracture is better appreciated
Test Your Knowledge
on a different brightness and
A
contrast setting (arrow, C). It was
later confirmed with the patient that
her pain was indeed in this location. 58
<•> CORE KNOWLEDGE

/
Musculo-
<!> AT T E N T I O N skeletal
Imaging
Looking for soft tissue edema on radiographs is essential.
CHAPTER OUTLINE:

Imaging Anatomy

Strengths, Weaknesses
and Roles of Imaging
Modalities

Arthropathies

Fractures and
Dislocations
/ Pearls and Pitfalls

Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities
C
Take-Home Messages

Suggested Reading
A B and Sources

Test Your Knowledge

F igure 68

Note mild thickening of the base of the second toe (A), consistent with oedema in this patient (dashed arrows). Oblique radio-
graph (B) and zoomed detail (C) show a fracture at the neck of the proximal phalanx (white arrows). 59
<•> CORE KNOWLEDGE

/
Musculo-
<!> AT T E N T I O N skeletal
Imaging
Lipohaemarthrosis
> Telltale sign of an intraarticular fracture CHAPTER OUTLINE:
X-ray detector
When a fracture extends into a joint, fat and blood from the Imaging Anatomy
bone marrow flow into the joint space (and its recesses),
hence the name "lipohaemarthrosis". Gravity-dependent Strengths, Weaknesses
layering of fat, serum and haematocrit can be seen by and Roles of Imaging
sending a horizontal beam through the joint and picking up X-ray generator Modalities
these “cross-table” X-rays on a detector plate (Figure 69).
Arthropathies

Fractures and
Dislocations
/ Pearls and Pitfalls

Infection

Tumours and Tumour-

like Conditions
Blood and fat from the bone marrow of the
fractured proximal tibia filling the suprapa- Metabolic Diseases
tellar recess.
Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

F igure 69 Test Your Knowledge

Intraarticular extension of the proximal tibial fracture (dashed arrow) in this patient was Radiographic appearance of the layered
ascertained by the use of cross-table radiographic technique showing layering (solid bone marrow fat-serum-haematocrit filling
arrows) of bone marrow fat and blood within the suprapatellar recess of the knee. the suprapatellar recess. 60
<•> CORE KNOWLEDGE

Lipohaemarthrosis
/
Musculo-
skeletal
Imaging
Gravity-dependent layering of fat, serum and hae-
matocrit can be seen not only on a “cross-table” CHAPTER OUTLINE:

radiograph (arrows, right), but also on cross-sec-

Imaging Anatomy
tional imaging such as CT and MRI (Figure 70).
Strengths, Weaknesses
and Roles of Imaging
Modalities

Arthropathies

Fractures and
Dislocations
/ Pearls and Pitfalls

Infection

bone marrow fat Tumours and Tumour-

serum from like Conditions
marrow blood

haematocrit Metabolic Diseases

from marrow
blood
Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

F igure 70

Same patient as in Fig. 69. Intraarticular extension of the proximal tibial fracture (dashed arrow) was also shown on the coronal CT reformation (red arrows). Transverse
CT image and corresponding zoomed detail (in ellipse) display the layering of the bone marrow fat, serum and haematocrit within the suprapatellar recess of the knee. 61
>•< FURTHER KNOWLEDGE

/
Musculo-
Acute Fracture versus Old Fracture >|< C O M PA R E skeletal
Imaging
One of the hallmarks of an acute fracture is the
lack of cortical bone at the fracture edges oppos- CHAPTER OUTLINE:

ing each other. Over time cortication of ununited Imaging Anatomy

fracture fragments occurs. This is an import- Strengths, Weaknesses
ant distinction for estimating fracture age (acute and Roles of Imaging
Modalities
versus old) as shown in Figures 71 and 72.
Arthropathies

Fractures and
Dislocations
/ Pearls and Pitfalls

Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources
F igure 72
Test Your Knowledge
Compare the uncorticated edges at the opposing sur-
F igure 7 1
faces of fracture fragments in this comminuted intra-articular
Note the non-white (i.e., uncorticated) and craggy edges at the opposing sur- fracture of the fifth metacarpal base (circles) with the corti-
faces of fracture fragments in this coracoid fracture (circle, left; arrow, right). cated old fracture of the hook of the hamate (arrows). 62
<!> AT T E N T I O N

/
<!> AT T E N T I O N Musculo-
skeletal
Beware of “satisfaction of search”! Imaging
The hardest fracture to find is “the next one”. This means,
even if we find a fracture (or another one), we do not stop CHAPTER OUTLINE:
there and carry on our systematic search, as other fractures
might be lurking somewhere on the images (Figure 73). Imaging Anatomy

Strengths, Weaknesses
and Roles of Imaging
Modalities

Arthropathies

Fractures and
Dislocations
/ Pearls and Pitfalls

Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

F igure 73

Comminuted fracture of the tibia diaphysis is easily identified in this patient. The fracture of the proximal fibula, (arrows, enlarged views on the right), however, was missed. 63
>•< FURTHER KNOWLEDGE

/ Pitfalls of Fractures: Skin Folds, Intra-articular /

Musculo-
skeletal
Imaging
Gas, Physeal Lines, Nutrient Vessels CHAPTER OUTLINE:

/ A skin fold or intraarticular gas might sometimes Imaging Anatomy

be mistaken for a fracture (Figure 74). Strengths, Weaknesses
and Roles of Imaging
/ A physeal line around the time of its closure can Modalities
also mimic a fracture (Figure 74).
Arthropathies
/ Another common mimicker of fractures is
Fractures and
a nutrient vessel (Figure 75). Dislocations
/ Pearls and Pitfalls

Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

F igure 74 F igure 75 Test Your Knowledge

Skin fold (white arrows), intra-articu- Nutrient vessel (white arrows, top left) mimicking a frac-
lar gas (red arrow) and physeal lines ture on CRX. CT clearly shows that this appearance
(arrowhead) mimicking fractures. is caused by a nutrient vessel (green arrows). 64
<•> CORE KNOWLEDGE

/ Imaging Fracture Healing /

Musculo-
skeletal
Imaging

Fracture healing is a complex process that involves phases, which can be monitored by radiographs. CHAPTER OUTLINE:

inflammatory (days to weeks), reparative (weeks Calcified callus is usually first depicted on radio- Imaging Anatomy
to months) and remodelling (months to years) graphs a few weeks after the injury (Figure 76). Strengths, Weaknesses
and Roles of Imaging
Modalities

Arthropathies

Fractures and
Dislocations
/ Fracture Healing

Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages
T + 10 days T + 2 months T + 3½ months
Suggested Reading
and Sources

Test Your Knowledge

F igure 76

Fracture healing after trauma (T) as seen on CRX. 65

<•> CORE KNOWLEDGE

/ Imaging Fracture Healing – or the Lack of It /

Musculo-
skeletal
Imaging

/ “Non-union” means failure of normal fracture healing in three consecutive radiographs each CHAPTER OUTLINE:

healing, whereby solid bone healing will not taken one month apart (Figure 77) . Imaging Anatomy
occur without further therapeutic intervention. Strengths, Weaknesses
Currently there is no consensus definition of non- / In “malunion”, fracture fragments heal in poor and Roles of Imaging
union. According to one of the proposed defini- position or alignment so that functional or cos- Modalities

tions, however, non-union is considered when a metic problems arise (Figure 78). Arthropathies

fracture does not show evidence of increased Fractures and

Dislocations
/ Absent Fracture
Healing

Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

F igure 7 7 F igure 78 Test Your Knowledge

Absence of calcified callus formation in the distal radius fracture 4 weeks (centre) Malunion of an intra-articular lateral condylar fracture (centre and right)
and 12 weeks (right) after the initial injury (left) is consistent with non-union. in a 20-year-old man two and a half years after the initial injury (left). 66
 /
Musculo-
skeletal
Imaging

CHAPTER OUTLINE:

Imaging Anatomy

Strengths, Weaknesses
and Roles of Imaging
Modalities

Arthropathies

/ Infection
Fractures and
Dislocations

Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

67
<•> CORE KNOWLEDGE

/ Osteomyelitis A B

/
Musculo-
skeletal
Imaging
/ Hematogenous spread of infection—usually to
the metaphysis—triggers a cascade of events CHAPTER OUTLINE:

resulting in subperiosteal abscess, draining sinus, Imaging Anatomy

sequestrum and involucrum formation—although, Strengths, Weaknesses
depending on the microorganism’s virulence and the and Roles of Imaging
Modalities
efficiency of treatment, not every feature in this cas-
cade necessarily appears on imaging (Figure 79). Arthropathies

Fractures and
/ Findings on the combination of radiographs and MRI Dislocations
(Figures 80-83), which are extensively used for diag-
Infection
nosing osteomyelitis, closely reflect pathophysiology.
/ Osteomyelitis
F igure 80
Tumours and Tumour-
<!> AT T E N T I O N In infancy and after adolescence, infection CRX (A) and contrast-enhanced MRI (B) in a child with calca-
like Conditions
may spread into the adjacent epiphysis neal osteomyelitis. A sinus tract (arrowhead, B) drains pus.
through the physis (growth plate). Metabolic Diseases

Developmental
spread into Abnormalities
epiphysis
Take-Home Messages
necrosis à
Blood sequestrum Suggested Reading
supply (dead bone) and Sources
initial blocked
site of infection pus
F igure 79
infection escape Test Your Knowledge
progresses
The cascade subperiosteal
of events in abscess (pus) involucrum
osteomyelitis. (new bone formation) 68
>•< FURTHER KNOWLEDGE

/
pre-contrast post-contrast fluid-sensitive F igure 82
Musculo-
skeletal
MR images display Imaging
subacute osteomyeli-
tis (Brodie abscess,
CHAPTER OUTLINE:
asterisk) in a 20-year-

* * *
old man (S. aureus
infection). Note perios- Imaging Anatomy
teal inflammation with
contrast enhancement Strengths, Weaknesses
and Roles of Imaging

* *
and high signal on the
fluid-sensitive image Modalities
(arrows), more on the
medial than lateral Arthropathies
aspect. The abscess
pre-contrast shows only peripheral Fractures and
rim enhancement and Dislocations
has otherwise a high
signal on the fluid sen- Infection
sitive image (asterisks). / Osteomyelitis

Tumours and Tumour-

abscess like Conditions
post-contrast <!> AT T E N T I O N
Metabolic Diseases
MRI is widely used to confirm or rule
out osteomyelitis in diabetic foot. Developmental
pus Abnormal bone signal adjacent to a skin Abnormalities
escape ulcer, sinus tract or abscess is highly
suggestive of osteomyelitis, which is Take-Home Messages
ruled out when bone signal is normal.
fluid-sensitive Suggested Reading
and Sources
F igure 81

MRI shows how accumulated pus (asterisk) within the

F igure 8 3 Test Your Knowledge
proximal tibial metaphysis (axial fluid-sensitive MR images) MR images show distal phalangeal great toe
finds its way into the skin through a sinus tract (arrow) osteomyelitis (arrows) subjacent to a sinus tract
in a 29-year-old man with S. aureus osteomyelitis. (arrowhead) in a 53-year-old man with diabetes. 69
<•> CORE KNOWLEDGE

/ Periprosthetic Infection /
Musculo-
skeletal
Imaging
/ Hip replacement is the most
A B C D CHAPTER OUTLINE:
common joint replacement surgery
with an OECD average of 174 per
Imaging Anatomy
100,000 population in 2019.
/ Special MRI sequences have been Strengths, Weaknesses
developed for use in suspected and Roles of Imaging
infections adjacent to prosthetic Modalities
implants, which, due to their metallic
components, create image artifacts Arthropathies
and present a challenge for MRI
Fractures and
(Figures 84 and 85).
Dislocations
/ Ultrasonography can be used
for guidance in fluid sampling for Infection
micro-biological analysis. / Periprosthetic
Infection
F igure 84
Tumours and Tumour-
CRX (A) shows a total hip prosthesis. Periprosthetic infection was suspected. MRI before (B) and like Conditions
after i.v. contrast (C and D) show areas consistent with infection. Contrast-enhancement shows
>•<FURTHER active bone (arrowheads) or soft tissue inflammation. Arrows point to an abscess. Metabolic Diseases
KNOWLEDGE

A B C Developmental
Abnormalities
F igure 85

Axial MR images before (A)

Take-Home Messages
and after i.v. contrast (B) and
fluid-sensitive image (C)
Suggested Reading
in an 82-year-old woman
and Sources
with total hip replacement
and suspected infection.
Test Your Knowledge
Arrows point to a large
periprosthetic abscess. 70
<•> CORE KNOWLEDGE

/ Septic Arthritis /
Musculo-
skeletal
Imaging

CHAPTER OUTLINE:
<!> AT T E N T I O N
/ Radiographs may show joint effusion in the early
Imaging Anatomy
stage. MRI is especially suggestive in the presence
Strengths, Weaknesses
/ There is no pathognomonic imaging finding for septic of periarticular abscess(es), but otherwise non- and Roles of Imaging
arthritis. Therefore imaging should not delay joint specific for aetiology of monoarthritis (Figure 86). Modalities

aspiration and microbiological examination when Ultrasonography can be used for ascertaining joint Arthropathies
there is clinical suspicion for septic arthritis. effusion and guides joint fluid aspiration.
Fractures and
Dislocations

Infection
/ Septic Arthritis

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

F igure 86

Fluid-sensitive MR images obtained in two different patients. Septic right sacroiliitis is evidenced by synovitis, osteitis and periarticular abscesses (arrows). 71
>•< FURTHER KNOWLEDGE

/ Pyomyositis, Septic Fasciitis, Necrotising Fasciitis /

Musculo-
skeletal
Imaging
and Septic Tenosynovitis CHAPTER OUTLINE:

/ Infection in a muscle usually presents in the form of scattered / In septic tenosynovitis, infection Imaging Anatomy
small abscesses, termed pyomyositis when caused by bacteria and/or pus are found within the
(Figure 87). tendon sheath (Figure 89). Strengths, Weaknesses
and Roles of Imaging
/ Septic fasciitis is another form of soft tissue infection involving Modalities
muscles and fascia; when necrotising, it can be life threatening
(Figure 88). Arthropathies

Fractures and
*
Dislocations

*
Infection
F igure 89 / Infection of Muscles,

* * MRI (fluid-sensitive
Fascia and Tendons
coronal and axial
images, left) of
Tumours and Tumour-
tuberculous
like Conditions
tenosynovitis in a
28-year-old radiology
Metabolic Diseases
resident following a
* needle puncture during
Developmental
an interventional
Abnormalities
procedure. Note
fluid accumulation
Take-Home Messages
F igure 88
in the tendon sheath
and surrounding
Suggested Reading
MRI (contrast-enhanced image) shows
F igure 87
inflammation (arrows).
and Sources
non-enhancing (dark) geographic areas
Contrast-enhanced MRI displays scattered (asterisks) consistent with necrotising fasciitis Intraoperative image
courtesy of Dr.
Test Your Knowledge
abscesses (arrows) representing pyomyositis involving the superficial, peripheral and deep
in an immune-compromised 58-year- fascia in this adult male i.v.. drug abuser, who Gürsel Leblebicioğlu,
old man with S. aureus septicaemia. had to undergo left arm amputation later. Ankara, Turkey. 72
>•< FURTHER KNOWLEDGE

/ Lymphoedema versus Cellulitis /

Musculo-
skeletal
Imaging

CHAPTER OUTLINE:
/ Cellulitis is an infection of the skin and subcutaneous / Although usually straightforward, differentiating cel-
Imaging Anatomy
fatty tissue, usually caused by bacteria, whereas lulitis from lymphedema clinically can sometimes be
lymphoedema is accumulation of lymph in the soft challenging. Cellulitis shows contrast enhancement Strengths, Weaknesses
and Roles of Imaging
tissues due to impaired lymphatic flow. on MRI, lymphedema does not (Figure 90). Modalities

Arthropathies

Fractures and
Dislocations

Infection
/ Lymphoedema vs.
Cellulitis

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities

F igure 90 Take-Home Messages

Each of these two sets of MR images from a 32-year-old male
Suggested Reading
below-the-knee amputee after trauma features pre- (left) and post-
and Sources
contrast (centre) and fluid-sensitive (right) sequences. Cellulitis (white
arrowheads), which enhances with contrast, surrounds a medial
Test Your Knowledge
subcutaneous abscess (yellow arrowheads). Lymphedema, deep
to cellulitis, does not enhance. Abscesses characteristically show
peripheral enhancement on imaging (see also Figures 82, 84, 85, 87). 73
 /
Musculo-
skeletal
Imaging

CHAPTER OUTLINE:

/ Tumours and
Imaging Anatomy

Strengths, Weaknesses
and Roles of Imaging
Modalities

Arthropathies

Tumour-like
Fractures and
Dislocations

Infection

Tumours and Tumour-

Conditions
like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

74
<•> CORE KNOWLEDGE

/ “Don’t Touch” A C E

/
Musculo-
skeletal
Imaging
Lesions CHAPTER OUTLINE:

Imaging Anatomy
<!> AT T E N T I O N
Strengths, Weaknesses
These are benign lesions where and Roles of Imaging
a radiological diagnosis is made D Modalities
without a differential diagnosis
Arthropathies
list and biopsy is NOT to be
performed (it is unnecessary, Fractures and
may be misleading and may Dislocations
even lead to unnecessary B
surgery). Infection

Tumours and Tumour-

like Conditions
>•< FURTHER KNOWLEDGE
/ “Don’t Touch”
Lesions
“Don’t touch” lesions include:
Metabolic Diseases
/ Fibrous cortical defect (Figure 91)
Developmental
/ Non-ossifying fibroma (Figure 91) F igure 9 1 Abnormalities
/ Bone island (Figure 91) The self-explanatory fibrous cortical defect (A) is called non-os-
Take-Home Messages
sifying fibroma (NOF) when it is > 2cm (B) and features lobulated
/ Bone infarct (Figure 91) contours (arrows). These are usually incidental. NOF may be
Suggested Reading
/ Solitary bone cyst (Figure 91) slightly expansile. Bone island (C) presents as a hyperdense
and Sources
(sclerotic) lesion with spiculated contours (arrow). Bone infarcts
/ Distal femoral cortical irregularity (D) are heterogeneously sclerotic lesions with geographic
Test Your Knowledge
contours. Solitary bone cyst (E) presents as a well defined radio-
(Figures 92 and 93)
lucency. The “fallen fragment” sign denotes pathological cortical
/ Myositis ossificans (Figure 94) fracture fragment(s) that are displaced into the cyst (arrows). 75
>•< FURTHER KNOWLEDGE

/ Distal Femoral Cortical Irregularity (aka “Cortical Desmoid”)

/
Musculo-
skeletal
Imaging

A cortical irregularity at the posterior aspect of the head of gastrocnemius) is a frequent incidental find- CHAPTER OUTLINE:

distal femoral metaphysis corresponding to tendon ing in children at MRI with a presumably mechan- Imaging Anatomy
attachment sites (most commonly that of medial ical stress-related origin (Figures 92 and 93). Strengths, Weaknesses
and Roles of Imaging
Modalities

Arthropathies

Fractures and
Dislocations

* Infection

* Tumours and Tumour-

like Conditions
/ “Don’t Touch”
Lesions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
F igure 92 F igure 93 and Sources
MRI shows an incidental focal cortical lesion (arrows) at the posterome- A lateral radiograph shows mild radiolucency at the lesion location (arrow).
Test Your Knowledge
dial aspect of the distal femoral metaphysis in a child with a large knee Note that no such lesion is present at this location on the radiograph when
joint effusion due to juvenile idiopathic arthritis. The lesion is at the level the child was 2 years old (right). Joint effusion (*), however, is visible on both
of the insertion of medial head of gastrocnemius (curved arrow). radiographs of this child with longstanding juvenile idiopathic arthritis. 76
>•< FURTHER KNOWLEDGE

/ Myositis Ossificans
/
Musculo-
skeletal
Imaging

Myositis ossificans (Figure 94) is the most com- misleading as aggressive histologic appearance CHAPTER OUTLINE:

mon form of heterotopic ossification occurring usu- can mimic sarcoma (and, unfortunately on occa-
Imaging Anatomy
ally after trauma. Biopsy on such a lesion may be sions in the past, resulted in radical surgery).
Strengths, Weaknesses
and Roles of Imaging
Modalities
MRI post-contrast Arthropathies

Fractures and
Dislocations

Infection

Tumours and Tumour-

like Conditions
MRI post-contrast 7 months later / “Don’t Touch”
CT Lesions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages
MRI Suggested Reading
and Sources

F igure 94 Test Your Knowledge

Typical radiographic appearance of myositis ossificans is circumferential calcification with a lucent centre (arrows). MRI
shows extensive soft tissue inflammation (arrowheads) surrounding the lesion which, over time, subsides and resolves. 77
<•> CORE KNOWLEDGE

/ Radiology of Bone Tumours and the Roles /

Musculo-
skeletal
Imaging
of the Radiologist CHAPTER OUTLINE:

Imaging Anatomy
<!> AT T E N T I O N

Strengths, Weaknesses
The role of the radiologist in bone tumours is manifold: to identify and characterise tumours, and Roles of Imaging
to plan (and perform) biopsy, to help stage and (sometimes) treat tumours, to assess Modalities
treatment response and to follow up (Figure 95). Arthropathies

Identification Characterisation Biopsy Staging Treatment Treatment Response Follow-up Fractures and
Dislocations
before
Infection

Tumours and Tumour-

like Conditions
/ Role of Radiology

Metabolic Diseases
Plain films are the
first-line imaging tool Developmental
in the identification
of bone lesions (a Radiofrequency
Abnormalities
Cross-sectional
chondromyxoid fibroma

*
imaging provides ablation of an
in this patient). additional diagnostic osteoid osteoma Take-Home Messages
clues in characterising is performed by Tumour recurrence in
bone lesions (e.g., an interventional a patient operated on
cystic, myxoid, solid, radiology team. for osteosarcoma. Suggested Reading
lesion matrix and its Biopsy of some bone and Sources
mineralisation). tumours is performed after
by radiologists.
Skip metastasis Necrosis (asterisk)
Test Your Knowledge
(arrowhead, left) in a development within an
F igure 95 patient with Ewing sar- osteosarcoma after

Roles of the radiologist in bone tumours

coma (arrow) increases
the tumour stage.
chemotherapy.
78
<•> CORE KNOWLEDGE

/ Patient Age and Location of Tumours /

Musculo-
skeletal
Imaging

<!> AT T E N T I O N CHAPTER OUTLINE:

Imaging Anatomy
Patient age is the key demographic factor attempting to diagnose bone tumours, it is
in bone tumours. Along with lesion location helpful to remember the adage from real Strengths, Weaknesses
across the body and within a bone, it estate business, “Location is everything”, and Roles of Imaging
Modalities
greatly helps to narrow down the differential which, although not absolute, frequently
diagnostic possibilities (Figure 96). When holds true. Arthropathies

Fractures and
>•< FURTHER KNOWLEDGE Dislocations

Infection
Age (years) 10 20 30 40 50 60
Simple bone cyst (SBC) Many bone tumors are quite Tumours and Tumour-
For abbreviations see the left column on the chart at left
Ewing sarcoma age range-specific (some like Conditions
Chondroblastoma are bimodal) FD
Non-ossifying fibroma (NOF) Metastasis
/ Patient Age and
Myeloma Location of Tumours
Osteochondroma Age Lymphoma Age
Fibrous dysplasia (FD) <30
Ewing
EG ≥30
Metabolic Diseases
Osteosarcoma years years
OO
Osteoid osteoma (OO) Osteo-
Aneurysmal bone cyst (ABC) chondroma Metastasis Developmental
NOF Myeloma
Eosinophilic granuloma (EG) Lymphoma
Abnormalities
SBC
Giant cell tumor (GCT) Infection
Enchondroma Enchondroma Take-Home Messages
ABC Enchondroma
Osteo-
Fibrosarcoma sarcoma Infection
Chondrosarcoma

Osteoma Suggested Reading

F igure 96 Parosteal sarcoma and Sources
Chart and Chondrosarcoma Chondro- Infection GCT
Infection blastoma Test Your Knowledge
drawings adapted Myeloma
Geode
from radiolog- Metastases
yassistant.nl Chordoma 79
<•> CORE KNOWLEDGE

/ Lesion Borders /
Musculo-
skeletal
Imaging

<!> AT T E N T I O N CHAPTER OUTLINE:

Sclerotic borders generally imply the successful or due to a highly virulent microorganism). Imaging Anatomy
attempt of the body to contain a lesion. Conversely, Permeative or moth-eaten pattern of bone
ill-defined contours and a wide zone of transition on involvement also suggests aggressiveness. Strengths, Weaknesses
radiographs hint at an aggressive lesion (malignant See Figure 97. and Roles of Imaging
Modalities

>•< FURTHER KNOWLEDGE Arthropathies

Fractures and
F igure 97 Dislocations
Examples Infection
of various
types of lesion Tumours and Tumour-
borders like Conditions
/ Lesion Borders

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Non-ossifying fibroma Suggested Reading

Thin sclerotic borders in a mixed and Sources
lytic and sclerotic lesion involving Giant cell tumor Osteosarcoma
the distal tibial metadiaphysis
Indistinct borders and wider zone Indistinct borders (a wide zone
Test Your Knowledge
in an 11-year-old girl Aneurysmal bone cyst
of transition of a lytic expansile of transition) of a mixed lytic-
Narrow zone of transition and thin lesion involving the proximal sclerotic lesion at the distal femoral
sclerotic borders of an expansile lytic
left iliac lesion in a 7-year-old boy
humeral epiphysis and meta-
physis in a 19-year-old girl
metadiaphysis in a 15-year-old boy
80
<•> CORE KNOWLEDGE

/ Lesion Matrix and its Mineralisation /

Musculo-
skeletal
Imaging

<!> AT T E N T I O N CHAPTER OUTLINE:

Many bone lesions have an underlying matrix, usually discernible on radiological imaging, point to Imaging Anatomy
which can become mineralised. Different types different groups of lesions (Figure 98).
Strengths, Weaknesses
of matrix (and their mineralisation), which are and Roles of Imaging
Modalities
>•< FURTHER KNOWLEDGE F igure 98 Arthropathies
Examples of various types of lesion matrix
CT Fractures and
Osteoma Dislocations

Infection

Tumours and Tumour-

Osteoblastoma like Conditions
/ Lesion Matrix and Its
Osteosarcoma Mineralisation

Metabolic Diseases
MRI Post-contrast MRI
Developmental
Abnormalities

Take-Home Messages

Suggested Reading
Parosteal Atypical cartilaginous tumour and Sources
osteosarcoma
Test Your Knowledge
Cartilaginous matrix Fibrous matrix
Osteoid matrix
81
Focal stippled or flocculent densities or “rings A ground-glass matrix is characteristic for fibrous
Marble-/cloud-like or ill-defined amorphous densities and arcs” of calcifications or enhancement dysplasia. Second through fourth images: MRI, the
are characteristic in osteoid producing lesions are seen in cartilage producing lesions image on the far right is a post-contrast image.
<•> CORE KNOWLEDGE

/ Periosteal Reaction /
Musculo-
skeletal
Imaging

Periosteal reaction associated with a lesion gives (Figure 102), which denotes disruption of an already lamel- CHAPTER OUTLINE:

important clues regarding its behaviour. Benign (or less lated periosteal reaction by aggressively invading tumour.
Imaging Anatomy
aggressive) lesions tend to show a solid periosteal
Strengths, Weaknesses
reaction (Figure 99), whereas more aggressive lesions <!> AT T E N T I O N and Roles of Imaging
display lamellated (Figure 100) or spiculated periosteal Modalities
More than one type of aggressive periosteal
reaction (Figure 101) or the so-called “Codman triangle” reaction can be seen simultaneously Arthropathies

Fractures and
Dislocations
A B A B C D
Infection

Tumours and Tumour-

like Conditions
/ Periosteal Reaction

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

F igure 99 Suggested Reading

Radiograph (A) and
and Sources
axial CT image (B)
show a solid periosteal
Test Your Knowledge
F igure 100
reaction (dashed arrow)
associated with an Radiograph (A), coronal CT reformation (B) and coronal (C) and axial (D) MR images
osteoid osteoma (arrow) show a lamellated (onion skin) periosteal reaction associated with a Ewing sarcoma 82
<•> CORE KNOWLEDGE

/
Musculo-
skeletal
Imaging

CHAPTER OUTLINE:
A B A B

Imaging Anatomy

Strengths, Weaknesses
and Roles of Imaging
Modalities

Arthropathies

* Fractures and
Dislocations
D

*
Infection

Tumours and Tumour-

*
like Conditions

* / Periosteal Reaction

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

F igure 10 1 F igure 102

Radiograph (A) and MRI (B) show spiculated periosteal reac- Coronal CT reformation (A) and MRI (B) show a Codman trian-
tion (arrows) associated with an osteosarcoma (asterisk) gle (arrows) associated with an osteosarcoma (asterisks) 83
>•< FURTHER KNOWLEDGE

/ Characteristic Imaging Features /

Musculo-
skeletal
Imaging

Some bone tumours have characteristic, if not pathognomonic, ­ CHAPTER OUTLINE:

radiological findings that greatly help in their diagnosis (Figure 103).

Imaging Anatomy

Strengths, Weaknesses
and Roles of Imaging
Reactive bone and soft tissue “Fallen fragment” Modalities
inflammation surrounding an sign in solitary “Punched-out” lesions
active osteoid osteoma bone cyst Codman triangle Fluid-fluid levels in multiple myeloma Arthropathies

Fractures and
Dislocations

Infection

Tumours and Tumour-

like Conditions
/ Characteristic
Imaging Features

Metabolic Diseases

Fluid-fluid (or blood) levels are seen

Developmental
Osteoid osteomas (OO) release
prostaglandins and elicit significant reactive in some lesions such as aneurysmal Abnormalities
inflammation (hence their marked response bone cyst (above, transverse MR
This is actually a It shows the aggressiveness image of a left iliac lesion) and
to salicylates/antiprostaglandins), which
pathological fracture of the lesion, usually an Take-Home Messages
is readily shown on fluid-sensitive MR telangiectatic osteosarcoma
in the background osteosarcoma or, less
images (note the OO nidus [arrow] within
the circle that highlights such reaction)
of a benign lesion commonly, osteomyelitis Suggested Reading
and Sources

Test Your Knowledge

F igure 103

Examples of characteristic imaging findings in some bone tumours 84

>•< FURTHER KNOWLEDGE

/ Radiology of Soft Tissue Tumours /

Musculo-
skeletal
Imaging
On imaging, a soft tissue mass with well-defined margins is not MRI is the modality of choice to show compartmental involvement,
necessarily benign. Smaller (≤ 5 cm) and superficial (versus deep- which is important in staging and to plan the route for biopsy, which is CHAPTER OUTLINE:

seated) lesions are more likely benign. Ganglion cysts and lipomas usually performed under US or CT guidance. Examples of soft tissue
Imaging Anatomy
are the most common soft tissue masses. Ultrasonography is useful tumours as seen on MRI are shown in Figure 104.
in discriminating solid versus cystic lesions and further characterising
Strengths, Weaknesses
some solid lesions. The best combination of “MRI plus radiographs” and Roles of Imaging
provides specific diagnosis in only about 30%−50% of cases. Modalities

Arthropathies

Fractures and
Dislocations

Infection

Tumours and Tumour-

like Conditions
/ Soft Tissue Tumours
Subcutaneous lipoma
Metabolic Diseases
Well-differentiated intermuscular liposarcoma
Developmental
Abnormalities

Take-Home Messages

Malignant peripheral Suggested Reading

nerve sheath tumour and Sources
along the sciatic nerve Synovial sarcoma
Wrist ganglion Tenosynovial giant cell tumour Test Your Knowledge

F igure 104

Examples of benign (dashed arrows) and malignant (arrows) soft tissue tumours as depicted by MRI. 85
>•< FURTHER KNOWLEDGE

/ Radiology of Soft Tissue Tumours /

Musculo-
skeletal
Imaging

For subcutaneous lesions, relation with the peripheral soft tissue masses (Figure 106). Some properties of CHAPTER OUTLINE:

muscular fascia (see Figure 11) is important. While a mass lesions such as internal haemorrhage or melanin
Imaging Anatomy
preserved fascial plane between a subcutaneous mass content can also be identified on MRI (Figure 107).
Strengths, Weaknesses
lesion and the peripheral fascia is no guarantee of a and Roles of Imaging
benign histology, fascial violation by the mass lesion is a Modalities

clear sign of aggressive behaviour (Figure 105). MRI is Arthropathies

F igure 106 F igure 107
the best imaging modality in the follow-up of malignant
This patient was operated on for Arrows point to some of the Fractures and
a subcutaneous mass that turned extensive haemorrhagic calf Dislocations
out to be an undifferentiated muscle metastases from an
pleomorphic sarcoma (not shown). alveolar soft part sarcoma in this Infection
A
Postsurgicalchanges are evident special MRI sequence called
in the first MRI shortly after surgery “susceptibility-weighted imag- Tumours and Tumour-
(arrow, A). Ten weeks later, a new ing”. Within the MRI machine, like Conditions
soft tissue mass was identified which features a strong mag- / Soft Tissue Tumours
(arrow, B), which was excised and netic field, the paramagnetic
confirmed to be local recurrence. property of iron content from Metabolic Diseases
Follow-up MRI four months later hemosiderin (due to haemor-
(C) was free of neoplastic masses. rhage) makes these so-called Developmental
“blooming” artifacts (arrows) Abnormalities
F igure 105 and thereby highlights bleeding.
B C
Take-Home Messages
Violation of
the periph-
Suggested Reading
eral fascia
and Sources
(arrows) is a
clear sign of
Test Your Knowledge
malignancy
in this
myxofibro-
sarcoma. 86
 /
Musculo-
skeletal
Imaging

CHAPTER OUTLINE:

Imaging Anatomy

Strengths, Weaknesses

/ Metabolic
and Roles of Imaging
Modalities

Arthropathies

Fractures and
Dislocations

Diseases
Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

87
<•> CORE KNOWLEDGE

/ Metabolic Diseases /
Musculo-
skeletal
Imaging

CHAPTER OUTLINE:

Imaging Anatomy
The musculoskeletal system is the most bulky / Rickets (= “childhood-­equivalent”
organ array in the human body. Because bone is a of osteomalacia) Strengths, Weaknesses
and Roles of Imaging
metabolically active tissue with a continuous cycle Modalities
of synthesis and resorption, numerous metabolic / Hyperparathyroidism (= increased osteoclastic
bone erosion because of excessive parathormone Arthropathies
conditions can affect not only the developing skeleton
but also its final form in adults. Radiology of only a few secretion due to a parathyroid adenoma Fractures and
Dislocations
select conditions are overviewed in this chapter: or parathyroid hyperplasia)
Infection
/ Renal osteodystrophy (= different patterns
/ Osteoporosis (= decreased total bone mass Tumours and Tumour-
of bone abnormalities associated with like Conditions
due to decreased size of bone trabeculae chronic kidney disease)
Metabolic Diseases
and cortical bone thinning; the bone is
otherwise structurally normal) Developmental
Abnormalities
/ Osteomalacia (osteoid = fails to undergo normal Take-Home Messages
mineralisation because of vitamin D deficiency
Suggested Reading
or other causes of calcium depletion) and Sources

Test Your Knowledge

88
<•> CORE KNOWLEDGE

/ Osteoporosis: /
Musculo-
skeletal
Imaging
The Most Common Metabolic Bone Disease CHAPTER OUTLINE:

Osteoporosis is characterised by diminished but Organization defines osteoporosis as a dual-energy Imaging Anatomy
otherwise normal bone. It may be a local phenomenon X-ray absorptiometry-based (DEXA) T-score less than Strengths, Weaknesses
(e.g., disuse osteoporosis, Figure 108) as well as a -2.5 standard deviations (SD) of young healthy adults and Roles of Imaging
Modalities
generalised condition (Figure 109). The World Health (Figure 110). Osteopenia is a mild form of osteoporosis.
Arthropathies
A
Fractures and
Dislocations

Infection

Tumours and Tumour-

like Conditions

B Metabolic Diseases
⁄ Osteoporosis

Developmental
Abnormalities

Take-Home Messages

F igure 109 Suggested Reading

Hip fracture is the most dreaded complication Age Age and Sources
F igure 108
of senile osteoporosis. Incomplete insufficiency
Test Your Knowledge
Disuse osteopenia on CT 5 weeks fracture of the left femoral neck (arrow) in this
F igure 110
(A) and 15 weeks (B) after the initial 71-year-old man with osteoporosis was best
injury in a 25-year-old woman with a shown on same-day MRI. A “hip” fracture denotes DEXA in a 70-year-old woman shows osteoporosis
sustentaculum tali fracture (arrows). fracture of the proximal quarter of the femur. in the spine and osteopenia in the femoral neck. 89
<•> CORE KNOWLEDGE

/ Osteomalacia /
Musculo-
skeletal
Imaging
Occurring after the cessation of growth, osteomalacia, formerly known as Looser zones (Figure 111). Large
CHAPTER OUTLINE:
in contradistinction to rickets, does not predominantly quantities of unmineralised osteoid are observed as
Imaging Anatomy
involve growth plates. Inadequate or abnormal miner- indistinct/ill-defined trabeculae giving the impres-
alisation of trabecular and cortical bone is observed. sion of a “poor-quality” radiograph (Figure 111). Strengths, Weaknesses
and Roles of Imaging
Patients typically present with insufficiency fractures, Modalities

Arthropathies

Fractures and
Dislocations

Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases
⁄ Osteomalacia

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

F igure 111

Looser zones along the bilateral medial femoral cortices, as well as in the right iliac bone (arrowheads), are present in this 74-year-old woman with osteo-
malacia. Large quantities of unmineralised osteoid are observed as indistinct/ill-defined trabeculae (especially in the diaphyses here). 90
<•> CORE KNOWLEDGE

/
Musculo-
skeletal
<!> AT T E N T I O N Imaging

Osteomalacia can also have an oncogenic aetiology CHAPTER OUTLINE:

(Figure 112). This occurs when tumours secrete substances
that inhibit the ability of kidney to absorb phosphate. Imaging Anatomy

Strengths, Weaknesses
and Roles of Imaging
A B
Modalities

Arthropathies

Fractures and
Dislocations

Infection

Tumours and Tumour-

like Conditions
C D

Metabolic Diseases
⁄ Osteomalacia

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources
F igure 112
Test Your Knowledge
Radiograph (A) and cross-sectional images from different MRI examinations of the hips (B), knees (C) and ankle (D). This 53-year-old man had hypophos-
phatemia secondary to a biopsy-proven phosphaturic mesenchymal tumour in the right proximal femur (arrowheads in A and B), resulting in osteomalacia.
Note bilateral femoral neck insufficiency fractures (white arrows) and indistinct/ill-defined trabeculae (representing extensive unmineralised osteoid), giv-
ing the impression of a “poor-quality” radiograph. The patient had insufficiency fractures (yellow arrows) also around his both knees and one ankle. 91
<•> CORE KNOWLEDGE

/ Rickets /
Musculo-
skeletal
Imaging
In rickets, the orderly development and mineralisa- side of the growth plate because of the concentra-
CHAPTER OUTLINE:
tion of growth plates is interrupted (Figures 113 and tion of unmineralized osteoid there (Figure 113).
Imaging Anatomy
114). Imaging findings are seen on the metaphyseal
Strengths, Weaknesses
and Roles of Imaging
Modalities
A C
Arthropathies

Fractures and
A B
Dislocations

Infection

Tumours and Tumour-

like Conditions

B Metabolic Diseases
⁄ Rickets

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

F igure 11 3 F igure 114 Test Your Knowledge

Metaphyseal widening, cupping and fraying in the dis- Rachitic rosary (arrowheads in A) denoting rib widening at the costochondral junctions
tal radius and ulna (ellipse) of a 15-month-old girl in a 16-month-old girl with rickets resolved after treatment (B). Note bowing deformity
with rickets (A) resolved after treatment (B). of the lower extremities with metaphyseal flaring and fraying before treatment (C). 92
<•> CORE KNOWLEDGE

/ Renal Osteodystrophy <!> AT T E N T I O N /

Musculo-
skeletal
Imaging

Renal osteodystrophy encompasses findings seen in

Radiologic findings of
bone resorption are seen CHAPTER OUTLINE:

the s­ etting of chronic renal insufficiency. Among these in hyperparathyroidism Imaging Anatomy
are ­findings of osteomalacia (and rickets in children) and regardless of primary,
Strengths, Weaknesses
­secondary hyperparathyroidism (Figures 115 and 116). secondary or tertiary type and Roles of Imaging
Modalities

Skeletal imaging findings in osteomalacia/rickets and hyperpara­ A

Arthropathies
thyroidism are independent from the aetiology of these three conditions.
Fractures and
Dislocations

Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases
⁄ Renal
Osteodystrophy
B
Developmental
Abnormalities

F igure 11 5 Take-Home Messages

This 50-year-old man with chronic renal insufficiency and
Suggested Reading
secondary hyperparathyroidism has subperiosteal bone
F igure 116 and Sources
resorption (arrows) at the radial aspects of the second and
third middle phalanges and subchondral resorption (dashed Subtendinous bone resorption (arrows) at the insertion
Test Your Knowledge
arrows) in bilateral sacroiliac joints resulting in pseudo-widening. sites of gluteus medius, minimus and hamstring tendons
Note also acro-osteolysis in the second distal phalangeal tuft and trabecular paucity (A and B) because of cancellous
(arrowhead) and extensive vascular calcifications along fingers. bone resorption (B is an edge-on radiograph of the skull). 93
<•> CORE KNOWLEDGE

/ Renal Osteodystrophy:
/
Musculo-
skeletal
Imaging
An Overlap of Osteomalacia/Rickets and Hyperparathyroidism
CHAPTER OUTLINE:
/ Although findings in osteomalacia/rickets and / Soft tissue mineralisation (in the form of vascular calcifications,
hyperparathyroidism tend to overlap, radiographic findings of chondrocalcinosis and tumoral calcinosis) is a characteristic Imaging Anatomy
hyperparathyroidism predominate in adults, whereas those of feature of renal osteodystrophy (Figure 118).
rickets are in the foreground in children. Strengths, Weaknesses
/ Parathyroid adenomas are seen in the primary and tertiary and Roles of Imaging
/ The “rugger jersey spine” appearance (named after the pattern forms of hyperparathyroidism. Ultrasonography is used to detect Modalities
of horizontal stripes on jerseys worn by rugby players), denoting parathyroid adenomas (Figure 119).
alternating bands of sclerosis along the vertebral body endplates Arthropathies
and areas of lucency centrally is a characteristic feature of
secondary hyperparathyroidism seen in renal osteodystrophy Fractures and
(Figure 117). Dislocations

Infection

Tumours and Tumour-

like Conditions
CCA R
Metabolic Diseases
T ⁄ Renal
Osteodystrophy

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
F igure 119 and Sources
Ultrasonography (transverse image) shows a
F igure 117 F igure 118 Test Your Knowledge
parathyroid adenoma (arrow) in a 36-year-old
”Rugger jersey spine“ appearance in a 55-year- Soft tissue calcifications (arrows) in a woman. Right lobe of the thyroid gland (R), right
old woman with end stage renal disease. 50-year-old man with chronic renal failure. common carotid artery (CCA), trachea (T). 94
 /
Musculo-
skeletal
Imaging

CHAPTER OUTLINE:

/ Develop­-
Imaging Anatomy

Strengths, Weaknesses
and Roles of Imaging
Modalities

Arthropathies

mental
Fractures and
Dislocations

Infection

Tumours and Tumour-

Abnormalities
like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

95
<•> CORE KNOWLEDGE

/ Developmental Abnormalities /
Musculo-
skeletal
Imaging

CHAPTER OUTLINE:

Imaging Anatomy
Several examples of the numerous devel- Radiology not only brings diagnostic clues to
opmental abnormalities that can involve developmental abnormalities but also provides Strengths, Weaknesses
and Roles of Imaging
the musculoskeletal system are: information regarding the severity, outcome Modalities
assessment and management follow-up of these
Arthropathies
/ Scoliosis (one of the etiologic factors in sco- conditions. Angular, point-to-point or projectional
Fractures and
liosis is developmental dysplasia) distance measurements on radiologic images Dislocations
/ Developmental dysplasia of the hip are used for acquiring such information.
Infection
/ Femoral trochlear hypoplasia/dysplasia Tumours and Tumour-
like Conditions
/ Glenohumeral dysplasia
Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

96
<•> CORE KNOWLEDGE

/ Imaging in Scoliosis /
Musculo-
skeletal
Imaging

Developmental dysplasia is only one of the causes of of unknown aetiology. Radiographs, CT and MRI are CHAPTER OUTLINE:

scoliosis, the most common type of which (i.e., ado- widely used for the diagnosis and treatment plan-
Imaging Anatomy
lescent idiopathic scoliosis, not shown here) remains ning, as well as follow-up of scoliosis (Figure 120).
Strengths, Weaknesses
and Roles of Imaging
Modalities

1 2 3 4 5 7 Arthropathies

Fractures and
Dislocations

Infection

Tumours and Tumour-

like Conditions
6
Metabolic Diseases

Developmental
Abnormalities
/ Scoliosis

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

F igure 120

Radiographs (1), CT (2, 3, 5) and MRI (4, 6, 7) show scoliosis (1) and associated abnormalities, such as hemivertebra, block ver-
>•< FURTHER KNOWLEDGE
tebra, butterfly vertebra (2–4), diastematomyelia (5, 6), tethered cord and syringomyelia (7) and caudal regression syndrome (7). 97
<•> CORE KNOWLEDGE

/ Imaging in Developmental Dysplasia of the Hip (DDH) /

Musculo-
skeletal
Imaging

Ultrasonography is an excellent tool in screen- possible – but no later than the first six weeks after CHAPTER OUTLINE:

ing for developmental dysplasia of the hip (DDH), delivery (Figure 121). If untreated, DDH can prog-
Imaging Anatomy
which is recommended to take place as early as ress to early-onset hip osteoarthritis (Figure 122).
Strengths, Weaknesses
and Roles of Imaging
Modalities
A B

A Arthropathies

Fractures and

*
Dislocations

Infection

Tumours and Tumour-

like Conditions
C D
Metabolic Diseases

Developmental
A Abnormalities
F igure 121 / Developmental
Dysplasia of the Hip

*
A radiologist performs screening US
in a newborn baby. Coronal plane
US images in two different newborn Take-Home Messages
babies show a normal hip (above) and
a decentred hip (below), where the Suggested Reading
acetabulum (A) is dysplastic and the F igure 122 and Sources
femoral head (asterisks) is not within a Radiographs show an infant with DDH on the right side (A) and a 37-year-old woman
properly developed acetabular fossa. Test Your Knowledge
with DDH on both sides (B). The woman developed early-onset osteoarthritis and
Ultrasonography images courtesy of Dr Konstantinos Chlapoutakis, Heraklion, had a total hip replacement four years later (C). MR-arthrography image of the
Crete, Greece same woman (D) shows a thickened acetabular labrum with a tear (arrow). 98
<•> CORE KNOWLEDGE

/ Take-Home Messages /
Musculo-
skeletal
Imaging

CHAPTER OUTLINE:

/ Sufficient and relevant clinical information needs / Magnetic resonance imaging (MRI) is an
Imaging Anatomy
to be given to the radiologist by the referring excellent tool for imaging soft tissues, joints and
Strengths, Weaknesses
clinician in order to provide the best service to bone marrow—including occult fractures. and Roles of Imaging
the patient, which encompasses the validation or Modalities

determination of the best imaging modality and / An algorithmic approach starting with the
Arthropathies
technique and evaluation of the imaging study. identification of joint space narrowing on
Fractures and
radiographs is useful in many arthropathies. Dislocations
/ First-line diagnostic modality in musculoskeletal
(MSK) imaging is radiography. / After trauma, lipohaemarthrosis on imaging Infection
suggests that an intra-articular fracture is present. Tumours and Tumour-
/ Computed tomography (CT) is usually like Conditions

reserved for the identification and better / Imaging closely reflects pathophysiology
Metabolic Diseases
characterisation of some fractures, assessment in osteomyelitis—but should not delay
Developmental
of bone lesions in complex anatomic areas joint fluid aspiration and microbiologic Abnormalities
and estimation of the mineral load in gout. assessment in suspected septic arthritis.
Take-Home Messages

/ In the MSK system, ultrasonography (US) is mainly / Location across the body and site within a Suggested Reading
and Sources
used in the evaluation of superficial structures. bone are, along with the patient’s age, the
key determinants of a bone tumour. Test Your Knowledge

99
<•> CORE KNOWLEDGE

/
/ Many aggressive bone lesions have / As the largest array of organs in the human Musculo-
skeletal
indistinct margins on radiographs. body, the MSK system gives clues on Imaging
imaging to many metabolic diseases.
/ A soft tissue mass with well-defined (distinct) CHAPTER OUTLINE:

margins on imaging is not necessarily benign. / Imaging is essential in many generalised

Imaging Anatomy
or focal developmental abnormalities.
/ Biopsy of MSK lesions needs to be performed Strengths, Weaknesses
and Roles of Imaging
within the framework of compartmental anatomy. Modalities

Arthropathies

Fractures and
Dislocations

Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

100
<∞> REFERENCES

/ Suggested Reading and Sources /

Musculo-
skeletal
Imaging

CHAPTER OUTLINE:

Imaging Anatomy
/ Helms CA. Fundamentals of Skeletal Radiology. 5th edition. / Aydıngöz Ü. Imaging osteomyelitis: an update. Rofo 2023;
Philadelphia: Elsevier, 2020 195:297‒308
Strengths, Weaknesses
and Roles of Imaging
/ Major NM, Anderson MW, Helms CA, Kaplan PA, Dussault R, eds. / https://radiologyassistant.nl/ Modalities
Musculoskeletal MRI. 3rd edition. Philadelphia: Elsevier, 2020
Arthropathies
/ Wu JS, Hochman MG. Soft-tissue tumors and tumorlike lesions: a
/ Herring W. Learning Radiology: Recognizing the Basics. 4th systematic imaging approach. Radiology 2009; 253:297–316 Fractures and
edition. Philadelphia: Elsevier, 2020 Dislocations
/ Chang CY et al. Imaging findings of metabolic bone disease. Infection
/ Jacobson JA et al. Radiographic evaluation of arthritis: degenera- RadioGraphics 2016; 36:1871–1887
tive joint disease and variations. Radiology 2008; 248:737–747 Tumours and Tumour-
/ O'Beirne JG et al. International Interdisciplinary Consensus like Conditions
/ Jacobson JA et al. Radiographic evaluation of arthritis: inflamma- Meeting on the Evaluation of Developmental Dysplasia of the Hip.
Metabolic Diseases
tory conditions. Radiology 2008; 248:378–389 Ultraschall Med 2019; 40:454–464
Developmental
/ Pathria MN et al. Acute and stress-related injuries of bone and Abnormalities
cartilage: pertinent anatomy, basic biomechanics and imaging
perspective. Radiology 2016; 280:21–38 Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

101
 /
Musculo-
skeletal
Imaging

CHAPTER OUTLINE:

Imaging Anatomy

Strengths, Weaknesses

/ Test Your
and Roles of Imaging
Modalities

Arthropathies

Fractures and
Dislocations

Knowledge
Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

102
>•< FURTHER KNOWLEDGE

/
Musculo-
/ Test Your Knowledge skeletal
Imaging

CHAPTER OUTLINE:

1 Which is the characteristic Imaging Anatomy

<?> QUESTION
Strengths, Weaknesses
site of muscle strains? and Roles of Imaging
Modalities

Arthropathies
□ Muscle belly Fractures and
Dislocations
□ Myotendinous junction
Infection
□ Tendon Tumours and Tumour-
like Conditions
□ Tendo-osseous junction Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

103
>•< FURTHER KNOWLEDGE

/
Musculo-
/ Test Your Knowledge skeletal
Imaging

CHAPTER OUTLINE:

1 Which is the characteristic Imaging Anatomy

<?> ANSWER
Strengths, Weaknesses
site of muscle strains? and Roles of Imaging
Modalities

Arthropathies
□ Muscle belly Fractures and
Dislocations
█ Myotendinous junction
Infection
□ Tendon Tumours and Tumour-
like Conditions
□ Tendo-osseous junction Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

104
<•> CORE KNOWLEDGE

/
Musculo-
/ Test Your Knowledge skeletal
Imaging

CHAPTER OUTLINE:

2 Which is the first-line imaging Imaging Anatomy

<?> QUESTION
Strengths, Weaknesses
modality to examine joints? and Roles of Imaging
Modalities

Arthropathies
□ Ultrasonography Fractures and
Dislocations
□ Computed tomography
Infection
□ Magnetic resonance imaging Tumours and Tumour-
like Conditions
□ Radiography Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

105
<•> CORE KNOWLEDGE

/
Musculo-
/ Test Your Knowledge skeletal
Imaging

CHAPTER OUTLINE:

2 Which is the first-line imaging Imaging Anatomy

<?> ANSWER
Strengths, Weaknesses
modality to examine joints? and Roles of Imaging
Modalities

Arthropathies
□ Ultrasonography Fractures and
Dislocations
□ Computed tomography
Infection
□ Magnetic resonance imaging Tumours and Tumour-
like Conditions
█ Radiography Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

106
<•> CORE KNOWLEDGE

/
Musculo-
/ Test Your Knowledge skeletal
Imaging

CHAPTER OUTLINE:

3 Punched out erosions with Imaging Anatomy

<?> QUESTION
Strengths, Weaknesses
overhanging edges surrounding and Roles of Imaging
Modalities
the 1st metatarsophalangeal joint, Arthropathies
along with preservation of joint Fractures and
space width, are characteristic of: Dislocations

Infection

Tumours and Tumour-

□ Gout like Conditions

□ Rheumatoid arthritis Metabolic Diseases

Developmental
□ Psoriatic arthritis Abnormalities

Take-Home Messages
□ Osteoarthritis
Suggested Reading
and Sources

Test Your Knowledge

107
<•> CORE KNOWLEDGE

/
Musculo-
/ Test Your Knowledge skeletal
Imaging

CHAPTER OUTLINE:

3 Punched out erosions with Imaging Anatomy

<?> ANSWER
Strengths, Weaknesses
overhanging edges surrounding and Roles of Imaging
Modalities
the 1st metatarsophalangeal joint, Arthropathies
along with preservation of joint Fractures and
space width, are characteristic of: Dislocations

Infection

Tumours and Tumour-

█ Gout like Conditions

□ Rheumatoid arthritis Metabolic Diseases

Developmental
□ Psoriatic arthritis Abnormalities

Take-Home Messages
□ Osteoarthritis
Suggested Reading
and Sources

Test Your Knowledge

108
>•< FURTHER KNOWLEDGE

/
Musculo-
/ Test Your Knowledge skeletal
Imaging

CHAPTER OUTLINE:

4 Which of the following is most Imaging Anatomy

<?> QUESTION
Strengths, Weaknesses
likely an insufficiency fracture? and Roles of Imaging
Modalities

Arthropathies
□ Distal femur fracture in a 16-year-old girl Fractures and
following motor vehicle accident Dislocations

Infection
□ Hip fracture in a 72-year-old woman
who fell in a bathroom Tumours and Tumour-
like Conditions

□ Metatarsal fracture in a newly- Metabolic Diseases

recruited 21-year-old soldier Developmental
Abnormalities
□ Distal radius fracture in an otherwise healthy
Take-Home Messages
34-year-old woman who slipped on ice
and fell on her outstretched hand Suggested Reading
and Sources

Test Your Knowledge

109
>•< FURTHER KNOWLEDGE

/
Musculo-
/ Test Your Knowledge skeletal
Imaging

CHAPTER OUTLINE:

4 Which of the following is most Imaging Anatomy

<?> ANSWER
Strengths, Weaknesses
likely an insufficiency fracture? and Roles of Imaging
Modalities

Arthropathies
□ Distal femur fracture in a 16-year-old girl Fractures and
following motor vehicle accident Dislocations

Infection
█ Hip fracture in a 72-year-old woman
who fell in a bathroom Tumours and Tumour-
like Conditions

□ Metatarsal fracture in a newly- Metabolic Diseases

recruited 21-year-old soldier Developmental
Abnormalities
□ Distal radius fracture in an otherwise healthy
Take-Home Messages
34-year-old woman who slipped on ice
and fell on her outstretched hand Suggested Reading
and Sources

Test Your Knowledge

110
<•> CORE KNOWLEDGE

/
Musculo-
/ Test Your Knowledge skeletal
Imaging

CHAPTER OUTLINE:

5 Lipohaemarthrosis on a Imaging Anatomy

<?> QUESTION
Strengths, Weaknesses
horizontal X-ray beam radiograph and Roles of Imaging
Modalities
denotes that a fracture is: Arthropathies

Fractures and
□ Comminuted Dislocations

Infection
□ Open
Tumours and Tumour-
like Conditions
□ Intra-articular
Metabolic Diseases
□ Displaced Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

111
<•> CORE KNOWLEDGE

/
Musculo-
/ Test Your Knowledge skeletal
Imaging

CHAPTER OUTLINE:

5 Lipohaemarthrosis on a Imaging Anatomy

<?> ANSWER
Strengths, Weaknesses
horizontal X-ray beam radiograph and Roles of Imaging
Modalities
denotes that a fracture is: Arthropathies

Fractures and
□ Comminuted Dislocations

Infection
□ Open
Tumours and Tumour-
like Conditions
█ Intra-articular
Metabolic Diseases
□ Displaced Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

112
>•< FURTHER KNOWLEDGE

/
Musculo-
/ Test Your Knowledge skeletal
Imaging

CHAPTER OUTLINE:

6
Imaging Anatomy
<?> QUESTION An otherwise healthy 20-year-old male presents
with knee pain following trauma during a football Strengths, Weaknesses
and Roles of Imaging
game. Radiographs reveal soft tissue swelling Modalities

about the knee and a well-defined 4-cm lytic Arthropathies

cortical-subcortical lesion at the lateral aspect of Fractures and
the distal femur with a thin sclerotic rim and mildly Dislocations
lobulated outline. Later, MRI reveals an anterior Infection
cruciate ligament tear and no fluid-fluid levels
Tumours and Tumour-
within the described femur lesion. The previously like Conditions
asymptomatic distal femur lesion is most likely: Metabolic Diseases

Developmental
Abnormalities
□ an osteosarcoma
Take-Home Messages
□ an osteoid osteoma Suggested Reading
and Sources
□ a non-ossifying fibroma
Test Your Knowledge
□ an aneurysmal bone cyst

113
>•< FURTHER KNOWLEDGE

/
Musculo-
/ Test Your Knowledge skeletal
Imaging

CHAPTER OUTLINE:

6
Imaging Anatomy
<?> ANSWER An otherwise healthy 20-year-old male presents
with knee pain following trauma during a football Strengths, Weaknesses
and Roles of Imaging
game. Radiographs reveal soft tissue swelling Modalities

about the knee and a well-defined 4-cm lytic Arthropathies

cortical-subcortical lesion at the lateral aspect of Fractures and
the distal femur with a thin sclerotic rim and mildly Dislocations
lobulated outline. Later, MRI reveals an anterior Infection
cruciate ligament tear and no fluid-fluid levels
Tumours and Tumour-
within the described femur lesion. The previously like Conditions
asymptomatic distal femur lesion is most likely: Metabolic Diseases

Developmental
Abnormalities
□ an osteosarcoma
Take-Home Messages
□ an osteoid osteoma Suggested Reading
and Sources
█ a non-ossifying fibroma
Test Your Knowledge
□ an aneurysmal bone cyst

114
>•< FURTHER KNOWLEDGE

/
Musculo-
/ Test Your Knowledge skeletal
Imaging

CHAPTER OUTLINE:

7 What would be your recommendation for Imaging Anatomy

<?> QUESTION
Strengths, Weaknesses
the bone lesion in the previous question? and Roles of Imaging
Modalities

Arthropathies
□ Leave it alone Fractures and
Dislocations
□ Close follow-up with MRI every 3 months for a year
Infection
□ Surgical resection Tumours and Tumour-
like Conditions
□ Make a biopsy according to compartmental Metabolic Diseases
anatomy considerations
Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

115
>•< FURTHER KNOWLEDGE

/
Musculo-
/ Test Your Knowledge skeletal
Imaging

CHAPTER OUTLINE:

7 What would be your recommendation for Imaging Anatomy

<?> ANSWER
Strengths, Weaknesses
the bone lesion in the previous question? and Roles of Imaging
Modalities

Arthropathies
█ Leave it alone Fractures and
Dislocations
□ Close follow-up with MRI every 3 months for a year
Infection
□ Surgical resection Tumours and Tumour-
like Conditions
□ Make a biopsy according to compartmental Metabolic Diseases
anatomy considerations
Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

116
<•> CORE KNOWLEDGE

/
Musculo-
/ Test Your Knowledge skeletal
Imaging

CHAPTER OUTLINE:

8 Which of the following suggests Imaging Anatomy

<?> QUESTION
Strengths, Weaknesses
more aggressiveness for bone and Roles of Imaging
Modalities
lesions on radiographs? Arthropathies

Fractures and
□ Solid type periosteal reaction Dislocations

Infection
□ Metaphyseal location
Tumours and Tumour-
like Conditions
□ Involvement of a long bone
Metabolic Diseases
□ Permeative pattern Developmental
Abnormalities
□ Narrow zone of transition
Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

117
<•> CORE KNOWLEDGE

/
Musculo-
/ Test Your Knowledge skeletal
Imaging

CHAPTER OUTLINE:

8 Which of the following suggests Imaging Anatomy

<?> ANSWER
Strengths, Weaknesses
more aggressiveness for bone and Roles of Imaging
Modalities
lesions on radiographs? Arthropathies

Fractures and
□ Solid type periosteal reaction Dislocations

Infection
□ Metaphyseal location
Tumours and Tumour-
like Conditions
□ Involvement of a long bone
Metabolic Diseases
█ Permeative pattern Developmental
Abnormalities
□ Narrow zone of transition
Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

118
<•> CORE KNOWLEDGE

/
Musculo-
/ Test Your Knowledge skeletal
Imaging

CHAPTER OUTLINE:

9 A soft tissue mass with well-defined Imaging Anatomy

<?> QUESTION
Strengths, Weaknesses
(distinct) margins on imaging is benign. and Roles of Imaging
Modalities

Arthropathies
□ True Fractures and
Dislocations
□ False
Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

119
<•> CORE KNOWLEDGE

/
Musculo-
/ Test Your Knowledge skeletal
Imaging

CHAPTER OUTLINE:

9 A soft tissue mass with well-defined Imaging Anatomy

<?> ANSWER
Strengths, Weaknesses
(distinct) margins on imaging is benign. and Roles of Imaging
Modalities

Arthropathies
□ True Fractures and
Dislocations
█ False
Infection

Tumours and Tumour-

like Conditions

Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

120
<•> CORE KNOWLEDGE

/
Musculo-
/ Test Your Knowledge skeletal
Imaging

CHAPTER OUTLINE:

10 Osteoporosis is Imaging Anatomy

<?> QUESTION
Strengths, Weaknesses
best assessed with: and Roles of Imaging
Modalities

Arthropathies
□ Radiographs Fractures and
Dislocations
□ Ultrasonography
Infection
□ Magnetic resonance imaging Tumours and Tumour-
like Conditions
□ Dual-energy X-ray absorptiometry Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

121
<•> CORE KNOWLEDGE

/
Musculo-
/ Test Your Knowledge skeletal
Imaging

CHAPTER OUTLINE:

10 Osteoporosis is Imaging Anatomy

<?> ANSWER
Strengths, Weaknesses
best assessed with: and Roles of Imaging
Modalities

Arthropathies
□ Radiographs Fractures and
Dislocations
□ Ultrasonography
Infection
□ Magnetic resonance imaging Tumours and Tumour-
like Conditions
█ Dual-energy X-ray absorptiometry Metabolic Diseases

Developmental
Abnormalities

Take-Home Messages

Suggested Reading
and Sources

Test Your Knowledge

122
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