1. Imaging of bone diseases
Qais A. Altimimy, DMRD, CABMS-RAD.
Lecturer, Radiology
Alkindy college of medicine, university of Baghdad
2015

2. Imaging of bone disease
1- Plain x-ray
2- Radio isotope
3- CT scan
4- MRI

3. Signs of bone disease on plain x-ray
1-bone density decreased or increased(sclerosis)
2-periosteal reaction
3-cortical thickening
4-alteration in trabecular pattern
5-alteration in the shape of bone

4. Role of US in imaging of musculoskeletal diseases
US can not demonstrate bone pathology , but does have a complementary imaging role in:
1.Detecting tenosynovitis, tendons tear and rupture
2.Diagnosis of osteomyelitis

5. Indications of Radioisotope bone scanning (TC-99m labelled phosphate complex)
1-detecion of metastasis
2-detection of osteomyelitis
3-to decide if an abnormality on radiograph not seen
4-investigation of painful prosthesis

6. Indications of CT scan in bone diseases
1- imaging of complex shaped bone difficult to be interpreted by x ray film e.g. pelvis, hip and spine
2- demonstration of extension & characterization of selected bone tumors complementary to MRI
3. as a guide for bone biopsy

7. Role of MRI in musculoskeletal diseases
MRI play a vital important role in MSK disorders
It can demonstrate bone marrow directly, but calcified tissues and cortical bones produce no signal
MRI particularly good for showing soft tissue abnormalities

8. Indications of MRI include:
1.disc herniation, spinal cord/nerve root compression
2.diagnosis of bone metastases
3.demonstartion of extension of primary bone tumor
4.to image soft tissue masses
5.to diagnose osteomyelitis, show any soft tissue abscess
6.to diagnose avascular necrosis & other joint pathologies

9. Radiological approach for diagnosis of solitary bone lesions:
To decide whether the lesion is benign or aggressive (malignant tumor or infection)
1. Age of the patient:
0-10 yrs Ewing sarcoma
10-30 yrs Osteogenic sarcoma
20-40 yrs Reticulum cell sarcoma ,Fibrosarcoma
40-50 yrs Chondrosarcoma , Paraosteal sarcoma
60-70 yrs Metastasis
2.Which bone is involved:
Flat , small or long bone
Centric, eccentric or cortically based location
Epiphyses, metaphyses or diaphyses

10. 3.Pattern of bone destruction:
Geographic pattern:
well defined,
map like lesion
Multiple myeloma
NOF
Leukemia
Mouth eaten pattern:
holes with less well
defined margins,
Permeative pattern:
ill defined elongated holes
very difficult to visualize
Less malignant
More malignant

11. 4.zone of transition: a lesion with a well
defined edge is almost certainly benign , whereas
a lytic area with an ill-defined edge is likely to be
aggressive(include both tumor and infection).
5.Adjacent cortex: any destruction of the
adjacent cortex indicate aggressive lesion

12. 6.Periosteal reaction:
Excess bone produced by the periosteum which occurs in response to such condition: a-neoplasm b-inflammation c-trauma
Solid
Lamellated
Sunburst
Codman’s
Less malignant
More malignant

13. 8. Soft tissue involvement:
7. Expansion: bone expansion with an intact well formed cortex usually indicate a slow growing lesion
8. Soft tissue involvement:
Well defined soft tissue swelling distorting muscle fatty planes= neoplasm
Ill defined soft tissue swelling obliterating muscle fatty planes= infection
Fibrous dysplasia
NOF
Enchodroma

14. 9.Calcified densities within the lesion(tumor matrix):
Diffuse ill defined, fluffy, cotton or cloud-like
calcification = osteoid forming tumor
Patchy calcification of annular, popcorn or
stippled= cartilagenous forming tumor
10. Size of the lesion:
If the lesion > 5 cm, it is more likely to be aggressive lesion, but there are many exception
11.Polyostotic versus monostotic:
Polyostotic lesions automatically restrict the number of the disease processes that may be considered in the differential diagnosis
chondrosarcoma

15. Radiological features of benign bone tumor :
Plain x ray:
1. Well defined sclerotic margins
2. Narrow zone of transition
3. Expansion, but rarely produce cortical breakdown
4. There is no soft tissue mass
5. Periosteal reaction is unusual unless there is associated fracture and it is mainly of solid type
Isotop scan:
little or no increase in activity unless there is associated fracture
CT and MRI:
Rarely needed in their evaluation

16. Radiological features of malignant bone tumor :
Plain x ray:
1. Poorly defined margins
2. Wide zone of transition
3. Cortical destruction
4. Soft tissue mass may be seen
5. Periosteal reaction is often present
and it is mainly of sunburst or Codman triangles types
Isotop scan:
Increased activity
CT and MRI:
Usually needed in their evaluation for further characterization and demonstration of soft tissue extension

17. Benign vs. Malignant

18. Osteomyelitis Usually occur in children and infants
Initial radiographic appearance is normal and bone changes are not visible until days of the infection
Most sensitive imaging modalities are isotope scan and MRI which may show the disease within 1-2 days

19. Acute osteomyelitis: Typically affect the metaphysis of the long bones
X-ray findings:
1.Soft tissue swelling with characteristic obliteration of fat planes is the earliest sign which may be evident within first 2 days
2.Local osteoporosis may be seen within days
3.Bone destruction in the metaphysis with periosteal reaction that eventually may become very extensive & surround the bone to form involucrum which is usually visualized after 3 weeks
4.Part from the original bone may die and separate to form dense fragment called sequestrum
Isotop scan:
Increased activity in both early and delayed phase
MRI:
Is the investigation of choice and may show evidence of bone edema and pus accumulation in the bone and soft tissue

22. Chronic osteomyelitis
Osteomyelitis of Garre
The bone become thickened & loss differentiation between the cortex & medulla= chronic nonpurulent process
Brodie abscess refers to an abscess related to focus of chronic osteomyelitis in a bone
osteomyelitis of Garre
Brodie abscess

23. Cortical thickening
Laying down of new bone, there is no separated lines or spicules of calcification as seen in periosteal reaction
Causes:
1- chronic osteomyelitis
2- healed trauma
3- response to chronic steroid
4- benign neoplasm

24. Multiple focal bone lesions
Metastases and multiple myeloma are the commonest causes
Metastases:
Is the commonest malignant bone tumor
Those bones which contain red marrow are the commonest sites to be affected namely spine, skull, ribs, pelvis, humeri and femora
Lytic metastases: most commonly from carcinoma of breast, bronchus, thyroid , renal and colon. Radiologically appear as well defined or ill defined areas of bone destruction without sclerotic rim
Sclerotic metastases: most commonly from carcinoma of prostate(men), and breast(women). Radiologically appear as ill defined areas of increased density of varying sizes
Mixed metastases: commonly from carcinoma of breast

25. Bone expansion is uncommon in metastases except in renal and thyroid
Periosteal reaction is uncommon
Isotope scan is more sensitive than plain film in detecting metastases and if multiple areas of increased activity are seen in patient with known primary carcinoma, then the diagnosis of metastases is virtually certain
MRI is better than isotope scan for detecting & it show more metastases but it is more difficult to survey the whole skeleton with MRI
CT is less sensitive than MRI for detecting metastases, but can demonstrate lytic sclerotic metastases & the images should be reviewed on bone windows

26. Multiple myeloma
They are most commonly seen in active heamopoetic areas
X-ray findings:
1.numerous, well-circumscribed lytic bone lesions (more common):
punched out lucencies e.g. rain drop skull 
2.endosteal scalloping
3.generalized osteopaenia (less common):
4.often associated with vertebral compression fractures/vertebra plana
Most myeloma deposits show increased activity on isotope scan

27. Rain drop skull
Punched out luciencies

28. Osteopenia
Compression fracture

29. Generalized decreased bone density (osteopenia)
Main causes:
1. Osteoporosis
2. Osteomalacia
3. Hyperparathyroidism
4. Multiple myeloma
Disorder
Specific radiographic clues
osteomalacia
Looser zones
hyperparathyroidism
subperiosteal resorption
disseminated multiple myeloma
focal lytic lesions

30. Osteoporosis Due to deficiency of the protein matrix(osteoid)
Matrix reduced in quantity. But the remaining bone is normally mineralized
Causes:
1-idiopathic: juvenile, senile, postmenopausal
2-cushing syndrome and steroid therapy
3-disuse

31. Radiological features of osteoporosis
1. Changes in bone density usually is unapparent until % of bone mass has been lost. The changes are best seen in the spine
2. Decreased cortical thickness
3. Decreased number of trabeculae present in the bone due to resorption of horizontal trabeculae
4. Empty box appearance of vertebra; apparent increased end plate density due to resorption of spongy bone
5. Vertebral body compression fracture; wedged or biconcave types with apparent widening of disc spaces

33. Rickets & osteomalacia
Lack of calcium in the body tissue with poor mineralization of osteoid . If this occurs before epiphyseal closure it is called rickets while in adults it is called osteomalacia
Radiological findings in osteomalacia:
1. Decreased bone density(osteopenia)
2. Looser zones: are short lucent bands running
through cortex at the right angles& may have
sclerotic margins. Commonest sites are scapula,
medial aspect of femur, pubic rami and ribs
3. Bone deformity due to bone softening e.g.
biconcave vertebral bodies
looser zone

34. Radiological findings in rickets
The changes are maximal where bone growth is occur, so they best seen in the knees, wrist and ankles
1. Loss of provisional zone of calcification
2. Widened growth plate
3. Metaphysis are widened, cupped& irregular
4. Decreased bone density
5. Deformity of bone due to softening
6. Greenstick fractures are common
7. Rachitic rosary refers to expansion
of the anterior rib ends at the
costochondral junction

35. Rachitic rosary
A child with rickets, demonstrating classic metaphyseal fraying and physeal widening

36. Hyperparathyroidism Primary : due to parathyroid adenoma in 90 %
Secondary: due to renal dysfunction
Hyperparathyrodism cause mobilization of calcium from the bone resulting in decreased bone density
Many patient with primary type presented with renal stones & dyspepsia
Radiological findings include:
1. Generalized decrease in bone density (osteopenia)
2. The hallmark is subperiosteal bone resorption
3. Spotty deossification of skull (salt & pepper appearance )
4. Soft tissue and vascular calcification& sometimes chondrocalcification
5. Regional osteosclerosis especially of spine( Rugger jersey spine)
6. Brown tumors are occasionally present which are small lytic lesions either single or multiple

38. Salt and Pepper Skull

40. Generalized increased bone density a-osteopetrosis b-myelosclerosis
c-sclerotic metastasis
d-Pagets disease
Osteopetrosis

41. Alteration in the trabecular pattern
Reduction in number of trabeculae and alteration in the remaining ones
a-osteoporosis: thick cortex, long trabeculae
b-Pagets disease: thick trabeculation in cortex and medulla
c-haemolytic anemia: biconcave bone marrow

42. Hemolytic anemia
There are many types of hemolytic anemia's, but radiological changes are seen in main two types: thalassemia & sickle cell disease
Radiographic findings in sickle cell disease:
1.Osteopenia 2. osteonecrosis (hips and shoulders in particular)
3. "H-shaped" vertebrae 4.bone infarcts (may appear as sclerotic or lucent areas) 5.osteomyelitis (Salmonella is prevalent in this population but Staphylococcus Aureus is still more common) 6.dactylitis (painful enlargement of a digit)
Radiographic findings in thalasemia:
1.expanded marrow space (marrow hyperplasia) 2.widened diploic space in the skull with "hair-on-end" appearance 3."Erlenmeyer flask" deformity of the long bones 4.paravertebral masses 5.premature growth plate closure 6.diffuse bony sclerosis
7."H-shaped" vertebrae

43. hair-on-end" appearance
H-shaped" vertebrae
Expanded ribs
Paravertebral masses

44. Alteration in the shape of the bone
a-achondoplasia
b-multiple exostosis
c-acromegaly
d-expanding bone tumour

45. Diaphyseal aclasia ( multiple exostosis):
Is a congenital disorders
There are multiple bony projections
known as osteochondromas or exostosis
They have cartilaginous cap which may
contain calcifications
Exostosis occur in metaphysis and
directed away from the joint

46. Thanks for attention