(special thanks to Dr A Raghavan) Bones & Joints Ian Bickle Radiology for Finals Nottingham (special thanks to Dr A Raghavan)

Main Themes Systemic bone diseases Fractures The KEY pathologies

The Aim of the Film Powers of observation Completeness of Search Descriptive abilities ALL FEATURES OF A GOOD JUNIOR DOCTOR

Key Points Have a system of approach Stick to it Don’t forget the soft tissues

Viewing Bones Typically 2 views Essential for Fractures (90 degrees) Compare & Contrast Check bone outline and density

Don’t overcomplicate the simple

Anatomy of the Hand & Wrist Carpal Bones: Proximal Row: Scaphoid (a), Lunate (l), Triquetrum (tq), Pisiform (p) Distal Row: Trapezium (t), Trapezoid (tp), Capitate (c), Hamate (h) tp c t h p tq l

Anatomy of the Pelvis & Hip A = sacral ala B = left sacroiliac joint C = iliopectineal line D = ilium E = ischial spine F = pubic symphysis G = inferior pubic ramus H = obdurator foramen b d e c g h f

Anatomy of Knee femur patella Medial condyle fibula Intercondylar eminence Tibial tuberosity tibia

Anatomy of lumbar spine 1 = vertebral body 2, 3 = intervertebral disc space 4 = pedicle 5 = lamina 6 = spinous process

Anatomy of lumbar spine 1 = vertebral body 2 = intervertebral disc space 3 = lamina 4 = spinous process

Normal Anatomy Childhood Adult cortex diaphysis metaphysis epiphysis medullary space physis physeal scar Childhood Adult

Systemic Bone Diseases

Common Pathologies Osteoarthritis Rheumatoid disease Gout Psoriatic Arthropathy Paget’s disease Osteoporosis Ankylosing Spondylitis Multiple myeloma

Common Pathologies HPOA Osteomyelitis Hyperparathyrodism Osteosarcoma Charcot’s joint Bone Metastases Sclerotic Eg, Prostate Lucent (Lytic) eg. Lung Pathological fracture

Osteoarthritis Key Features Loss of joint space Subchondral bone cysts Subchondral sclerosis Osteophyte formation  Difference in hips 

OA Features Sub-chondral sclerosis   Reduced joint space Sub-chondral cyst

Rheumatoid Arthritis Erosions  Erosive arthropathy Spares DIP joints Periarticular osteopenia Soft tissue swelling Erosions 

Gout Erosions – ‘punched out’ (away from joint) Soft tissue swelling Gouty tophi Erosion  Soft tissue

Psoriatic Arthropathy Erosive arthropathy DIP typically Sarcoiliac joints (may be involved) Pencil and cup deformity DIP’s only

Paget’s Disease (of bone) Key Features Sclerotic Bone Coarse trabecular pattern Expanded Bone Pathological #  Sclerotic bone 1% osteosarcoma

Osteoporosis Key Features Normal biochemical tests Wedge #  Plain x-ray not sensitive DEXA scan best test Sequelae on x-ray – wedge # Wedge # 

Ankylosing Spondylitis Spine and SI joints Sacroilitis Syndesmophye formation Calcification of anterior longitudinal spinous ligament Apophyseal joint fusion  Bamboo Spine

multiple lytic bone lesions Multiple Myeloma multiple lytic bone lesions

Metastases Sclerotic: Lytic: Bowel Bronchus Breast Kidney Prostate  Lytic Met  Sclerotic Met

HPOA Unusual but important diagnosis Bronchial carcinoma Suppurative lung disease Periosteal reaction 

Osteomyelitis Key Features: Peri-osteal reaction Osteopenia Bony destruction Pathological # Both sides of the joint

Hyperparathyroidism Key Features: Sub-periosteal bone resorption – typically middle phalanx of hand Osteopenia Scalloping 

Charcot’s Joint Think Diabetics Disorganized and disrupted joint Sclerosis Destruction of joint Fragmentation Think Diabetics

Osteosarcoma Typically at the knee Frequently young patient Periosteal reaction Soft tissue mass Destructive lesion  Soft tissue mass periosteal reaction

Codman Triangle periosteal reaction Codman Triangle advancing tumor margin destroys periosteal new bone before it ossifies tumor

Fractures

Fractures: Features to Describe Bone Place of Bone Nature of Fracture Special Features of Fracture Management Implications

Fracture Features Black (lucent) line White if overlapping fragments Associated soft tissue abnormalities Displacement & Angulation Always look for another abnormality Another # A dislocation An underlying cause

Fresh & Former  callus Fracture 

Systemic Disease with Bone/Joint Involvement Best Exam Cases Great test of knowledge Test lateral thinking BE THE BEST – think for the test

Erosive Arthropathy & Pulmonary Fibrosis Rheumatoid Disease Erosive Arthropathy & Pulmonary Fibrosis

Bronchial CA & HPOA

Paget’s Disease  Osteosarcoma