Transcript 骨与关节影像诊断学

Musculoskeletal Radiology
Department of Radiology
Peking University First Hospital
王继琛
内容及重点
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骨与关节的解剖特点＋影像学检查方法
骨与关节正常影像学表现
骨骼肌肉系统基本病变及放射学表现
骨与关节外伤的影像学表现
椎间盘退行性病变的影像学表现
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一.the anatomic features & evaluation
with Radiological methods
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contrast in density materials:
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Between bone and soft tissue: good with x-ray
Between compact bone and cancellous bone: good with xray
X-ray can be used to differentiate the difference of density
contrast in soft tissue:
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Between muscle and vessels: poor with x-ray, good at MR
Between muscle and cartilage: poor with x-ray, good at MR
MR play an important role in soft tissue
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• With x-ray: CT and x-ray radiography
• Spatial resolution: x-ray film >> CT
• Contrast resolution: CT >> x-ray film
• Overlap of structure:
not at CT;
with some tissue at x-ray film
Easy to identify the calcification & small
ossification
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• high soft tissue contrast in MR imaging
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Identify bone marrow diseases
Muscle and vessels involvement
Cartilage change
Tendon and ligament injury
Sensitive to edema
Not sensitive to small calcification
• The modalities of choice: adopt ones good points
and avoid his short-comings
• Anyway, X-ray radiography is basic examination.
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HR with small FOV and thin slices
FOV 10 ép 0
512x256
frFSE T2
3’25”
SE T1
2’40”
SE T1 FS Gd
3’52”
FOV 10 ép 2mm
512x256
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二. Bone and Joints:
Normal appearance of Radiology
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(一). The skeleton：histology &
Radiological appearance
1. Three functions of bone:
• the structural support of the body
• to protect the bone marrow
• a source of calcium ions
2. Macroscopic organization of bone
• compact bone:
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about 70% of bone;
very dense + few visible spaces;
Cortex is made up of compact bone.
The cortex provides most of the structural strength of the
skeletal frame.
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• cancellous bone: also spongy bone
• inside the cortices and forms an interconnecting
network of plates or bars called trabeculae.
• The trabeculae are continuous with the inner surface
of the cortex, and
• the spaces between trabeculae are filled with
hematopoietic or fatty bone marrow.
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• Cancellous bone: two important features.
• First, cancellous bone assists the cortex in structural
support
• Second, more metabolically active
• The proportion of compact and spongy bone varies
in different portions of any particular bone.
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High Resolution Wrist Joint
24lp/cm
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Bone Structure
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3. The growth of the bone
• Ossification
Intramembranous Ossification
Endochondral Ossification
• Centers of ossification
• Epiphyseal plate （骺hóu板）
• Modeling
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4. the factors influence the bone growth
• Calcium-phosphorus metabolism
• Incretion
• Vitamin
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5. Normal appearances
• The diaphysis: the midportion of a long bone is
a cylindrical rod composed mainly of compact
bone.
• The medullary canal: the area between the
cortices contains marrow and a few spicules of
cancellous bone.
• The epiphysis: the end of a long bone is called.
This segment consists of abundant cancellous
bone and a thin shell of cortical bone. Because
the epiphysis often articulates with another
bone, it is usually covered by articular cartilage.
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• The metaphysis: between the epiphysis and the
diaphysis. This segment also contains abundant
cancellous bone, which is surrounded by cortex.
The metaphysis is the zone where a bone
narrows from the wide epiphysis to the
narrower diaphysis.
• The cartilaginous epiphyseal plate (the physis ):
in growing children, the epiphysis is separated
from the metaphysis by the physis.
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epiphysis
the cartilaginous
epiphyseal plate
(the physis ):
metaphysis
diaphysis
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normal long bone
of child
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Normal appearance
• Tuber-like bone
• Major large articulation
• spine
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6. Bone development & bone age
• X-ray characters in premature bone
• diaphysis（骨干）
• Metaphysis（干骺端）
• Epiphysis（骺）
• epiphyseal plate（骺板）
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Bone age: using the bone feature of x-ray appearances
to judge the patients age
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(二). The joints：histology &
Radiological appearance
• 327 joints in the human body.
• vary greatly in size and complexity.
• the largest joint: the knee;
• the smallest one: the tiny ossicles of the middle
ear.
• the knee is far more complex than the simple
ball-and-socket structure of the hip joint.
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• different degrees of motion.
• syndesmoses, the bone+ thin connective
tissue ligament+bone (the cranial sutures);
almost no movement.
• synchondroses, the bone+cartilage + bone;
slight motion: The joints between the vertebral
bodies, the intervertebral discs.
• diarthrodial joints, the bones move freely
relative to one another.: most joints in the body.
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• Diarthrodial joints
• articular cartilage
• synovial membrane
• articular fluid
• supporting tissues
• joint capsule
• various ligaments
• tendons
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• Fibrocartilage
• Function: stabilize the joint or facilitates motion
• Location: labra of the glenoid, acetabulum, the menisci
of the knee, the annulus fibrosus of the intervertebral
discs, the terminal portion of a tendon or ligament, at its
insertion into bone
• Radiological appearance:
• X-ray: slightly higher density than that of the muscle
• MR: low signal intensity on both T1WI & T2WI
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• Hyaline cartilage
• Function: provides a smooth, slippery surface;
absorbs mechanical shock and spreads forces evenly
onto the supporting bone underneath
• Component: chondrocytes + abundant extracellular
matrix
• Radiological appearances:
• almost can not be identified on x-ray or CT imaging;
• MR: slightly high signal intensity
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• Synovial membrane
• Function: secrete some of the components of the
synovial fluid
• composed of loose fibrovascular tissue + fat + the
synovial lining cells
• Too thin to be identified on radiological exam. except at
villous fronds
• Synovial fluid
• Function: lubricates the articular cartilage
• thick, viscous liquid: water+ solutes from the blood;
hyaluronic acid, glycoprotein, and lubricin from
synovial membrane
• Radiological appearance: like water in the body
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Normal knee joint
(adult vs child)
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A: 3D T1;
B: FSE T2;
软骨下骨质水肿提示局部全层软骨缺损
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三. Muscular-skeleton system:
basic abnormality & Radiological
appearances
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(一). The basic appearances of
bone lesions
1.osteoporosis：decreasing both the calcium
salt and collagen tissue , and the ratio
between them is normal
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normal
osteoporosis
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Right hip transient osteoporosis; left normal
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Osteoporosis :Hyperparathyroidism
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2. osteomalacia：
decreasing
calcium salt and
with normal
collagen tissue
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Osteomalacia, incomplete fracture
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3. Destruction of bone：normal bone structure was
replaced by pathologic tissue
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bone destruction
（fibrosarcoma ）
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4 . Hyperosteosis &
osteosclerosis：
increasing the
calcium salts in
local bone
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CT
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5 . periosteal
reaction：
when he
periosteum is
stimulated
appropriately,
the reactive
bone formation
occur. Usually
reminder having
lesion.
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solid
lamellated
lamellated
periosteal reaction type
"sunburst" or
"hair-on-end"
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a Codman's triangle
complex pattern
periosteal reaction type
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6.osteal & chondral calcification
Benign solitary sessile osteochondroma of the fibula
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Bone infarction
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7. Osteonecrosis： bespeaks bone death. Synonyms include aseptic
necrosis, bone necrosis, avascular necrosis, and ischemic necrosis.
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osteonecrosis
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multiple segmental
areas of
osteonecrosis in the
distal femur in this
patient with
Gaucher's syndrome
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8.mineral aggregation or deposition：
lead(铅)、phosphorus(磷)、bismuth(铋)et
al deposit in the bone ；when the fluorin
combined with calcium in the bone, is
called skeletal fluorosis.
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plumbism (Chronic lead poisoning)
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9. deformation
of bone
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Fibrous dysplasia of bone
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10. Reaction of soft-tissue
• Edema
• Swelling
• Gas in the tissue
• Atrophy of muscle
• Deposit of calcium salts (myositis ossificans)
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(二). The basic appearances of joints
lesions
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1. The swelling of joint
Reason: joint effusion, hemorrhage,
inflammatory reaction,or soft tissue
bruise
Radiological appearance: high density on
X-ray, CT around articuli, with or
without articular space enlargement
Often in septic, collagen/collagen-like disease,
biochemical, degenerative, traumatic
arthritis
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2. The bone destruction of joint
Bone destruction underneath joint surface or
margin, invading or replacing by inflammatory
tissue or tumor
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3. The degenerative change
• Decreased chondroitin sulfate with age creates
unsupported collagen fibrils followed by cartilage
degeneration
• Radiological Appearance: joint space narrowing,
sclerosis, subchondral cyst formation, osteophytosis at
articular margin
• Most of aged people, major large joint: knee, spine
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4. The ankylosis：
• Fixation and immobility of a joint
• 骨性强直是关节明显破坏后，关节骨端由骨
组织所连接。X线表现为关节间隙明显变窄
或消失，并有骨小梁通过关节连接两侧骨端。
多见于急性化脓性关节炎愈合后。
• 纤维性强直也是关节破坏的后果。虽然关节
活动消失，但X线片上仍可见狭窄的关节间
隙，且无骨小梁贯穿。常见于关节结核。
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5. The dislocation of articulation
关节脱位是组成关节骨骼的相互位置关系
发生异常，包括分离，移位。有完全脱
位和半脱位两种。
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四. Bone and joint injury
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(一). Basic appearances of bone
trauma
1. Fracture
• OPEN VERSUS CLOSED
Communication of the fracture site with the external
environment or not
• INCOMPLETE VERSUS COMPLETE
Incomplete fractures in all age groups but most
commonly in children, three types: buckle, or torus,
fracture; greenstick fracture; plastic fracture
Complete fractures: transverse fracture; An oblique
fracture, Spiral fractures
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• COMMINUTION
more than two fragments; Segmental and butterfly
fractures
• POSITION
Accurate description of the site of the fracture is
required.
intra- or extra-articular fracture
• APPOSITION
• Anatomical Apposition
Complete and normal apposition is termed anatomical
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• Displacement
the fragments in partial apposition
• Lack of Apposition
complete loss of contact of the bone ends
• ALIGNMENT
refers to the relationship of the long axes of the
fracture fragments
• ROTATION
comparison of the direction of the joints proximal
and distal to the fracture
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• ADDITIONAL DEFINITIONS
• chip fracture
• avulsion fracture
• Dislocation: in joint injuries
• Diastasis: pubic symphysis, sacroiliac joint, or distal
tibiofibular joint
• Stress fractures: abnormal stress, is placed on normal
bone
• Pathologic fractures: normal stress is placed on abnormal
bone
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• Childhood fractures: unique in three major
ways
• more porous in children than in adults, often
resulting in incomplete fractures.
• greater potential for remodeling malaligned
fractures than do adults
• attributable to the epiphyseal plate, the weakest
and therefore one of the most easily fractured
sites in the long bone
The complication of premature epiphyseal plate
closure must be recognized early, since it can
cause significant deformity.
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2. Periosteal reaction
3. Soft-tissue swelling
4. Complication of fracture
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5. The role of Planar tomography, CT, and
MRI
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(二). Basic appearances of joint
trauma
1. Dislocation：
2. Cartilage injuries：cartilage fracture, defect
3. Tendon & ligamental injuries：partial tear
& complete tear
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Helical CT of a comminuted
intraarticular distal radial fracture.
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CT
X-ray plain
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a 76-year-old man with a hyperflexion injury to the
cervical spine with quadriparesis
Conventional lateral radiograph and MR images
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32-year-old, hit by a truck 10 months.
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PCL complete tear
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Dislocation of joint
• traumatic
• Non-traumatic
• Congenital dislocation of hip joint
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Osteomyelitis in a patient who had undergone below-knee amputation.
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Soft-tissue abscesses in a 33-year-old woman with SLE.
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Pain in both legs in
a 32-year-old
woman.
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(三). Soft tissue injuries
1．Muscle & tendons: injury and tear
2. Haemorrhage in musculus
3. Contusion (bruise)
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(四). Musculoskeletal injuries：
modalities of choice
• First choice: x-ray radiography: detection
and diagnosis most of injuries
• CT: skull, spine injury with CNS trauma
• MR: joints, tendon and lig. & soft-tissue
injury injuries
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The advantage of x-ray radiography
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Cheap
convenience
Clearly demonstrate bone structure
Diagnostic experience for over 100
years
• Possibility in clarify the nature of
disease
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The limitation of x-ray radiography
• Early diagnosis: micro-fracture
• Overlapping structure: skull base
• Differential diagnosis
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五. The intervertebral disks
degeneration
• And so from hour to hour We ripe and ripe, And
then from hour to hour We rot and rot.
-Shakespeare-
disc bulging：
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disc bulging
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discal herniation：
Herniation of an intervertebral disk represents a
focal protrusion of disk material beyond the
margin of the disk.
Free fragment herniation ：
Free fragment herniation is a term indicating
separation of the focal herniation from the
remainder of the disk, with penetration of the
separated fragment through the fibers of the
posterior longitudinal ligament.
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discal herniation
Free fragment herniation
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