Principles of Radiologic Interpretation

1. PEMERIKSAAN RADIOLOGI EXTREMITAS UNTUK DOKTER DI LAYANAN PRIMER ( SKDI LEVEL 3 DAN 4)Dr.dr.H.UndanRuhimat,SpRad (K),.M.H.KesDepartemen Radiologi FK UNPAD /RS Hasan Sadikin Bandung

2. Principles of Radiologic Interpretation • Technical Consideration • Skeletal Anatomy and Physiology • The Categorical approach to bone disease • Radiologic predictor variables • Medicolegal implication

3. Technical consideration Plain Film Radiography Tomography Contrast Examination Radionuclide Imaging Computed Tomography Magnetic Resonance Imaging

4. Skeletal Anatomy and Physiology Skeletal Development Intramembranous Ossification Enchondral Ossification Bone Structure Epiphyse – Physis – ZPC – Metaphysis Diaphysis Cortex – Medulla – Periosteum Endosteum Bone Metabolism Bone mineral - Hormones

5. Anatomy

6. Anatomy

7. Anatomy

8. The Categorical approach to bone disease Congenital Arthritis Trauma Blood Infection Tumor Endocrine,Nutritional,Metabolic Soft Tissue

9. Radiologic Predictor Variables Preliminary Analysis Clinical data Number of lesions Symetri of lesions Determination of Systems Involved

10. Radiologic Predictor Variables Analysis of The Lesions Skeletal Location Position Within Bone Site of Origin Shape Size Margination Cortical Integrity

11. Radiologic Predictor Variables Behavior of Lesions Osteolytic Lesions Osteoblastic Lesions Mixed Lesions Matrix Periosteal Response Solid Respons Laminated Respons SpiculatedRespons Codmans’ Triangle

12. Radiologic Predictor Variables Soft Tissue Changes Supplementary Analysis Other imaging Procedures Laboratory Examination Biopsy

13. TRAUMA Fracture and Dislocation The radiographs should be made Include at least one joint Preferably two joints Two position AP – LAT

14. TRAUMA Time intervals between Radiographic Study Initial Diagnostic study Post reduction and post immobilization One or Two weeks later, if position has changed After approximately six eight weeks for Primary callus After each plaster cast or traction change Before final discharge of patient

15. TRAUMA Types of Fracture Closed fracture Does not break the skin or communicate with the outside environment Simple fracture Open fractur Penetrates the skin over fracture site Compound fracture

16. TRAUMA Comminuted fracture Two or more bony fragments have separated Non Comminuted fracture Penetrates completely through the bone Avulsion fracture Tearing away of a portion of the bone Impaction fracture Bone is driven into its adjacent segmen

17. TRAUMA Incomplete Fracture Broken only one side of the bone Greenstick (Hickory Stick) fracture Torus (Buckling) fracture Fracture Orientation Oblique fractur Commonly occurs in the shaft of long tubular bone 45° to the long axis of the bone

18. Fractur

19. Fracture

20. TRAUMA Spiral fractur Torsion, coupled with axial compression and angulation Transverse fractur Run at a right angle to the long axis Uncommon through healthy bone Pathologic fractur

21. Fracture

22. TRAUMA Spatial Relationships of Fracture Aligment Position of the distal fragment in relation to the proximal fragment Apposition Closeness of the bony contact at the fracture site If the ends are pulled referred to as Distraction

23. Galeazzi fracture-dislocation (Reverse Monteggia) • Galeazzifraktur-dislokasiadalahfrakturpertengahanhinggasepertiga distal radius yang disertaidislokasisendiradioulnar distal (DRUJ). Mekanisme cedera adalah jatuh pada tanganposisi pronasi 19

24. Montegia fraktur-dislokasi • Fraktur ulna proksimaldengandislokasisendiradioulnardanradiocapitellarproksimal

25. Colles fracture • Fraktur melintang ekstra-artikular radius distal dengan angulasi fragmen radius distal ke dorsal (posterior) dislokasi ke posterior dan deviasi fragmen distal ke radial • Gambaran klinis fraktur ini dikenal sebagai dinner fork deformity "deformitas garpu makan malam” 19

26. Smith fracture (Goyrand, reverse Colles, reverse Bartons) • Fraktur Smith adalah fraktur transversal radius distal dengan angulasiataudislokasifragmen distal kevolar dan angulasi fragmen fraktur distal.

27. Fracture

28. TRAUMA Rotation Twisting forces on a fractured bone along its longitudinal axis Traumatic Articular Lesions Subluxation Dislocation Diastasis Epiphyseal Fractures Salter-Harris Classification

29. Salter - Harris

30. SELTER HARIS FRAKTUR

31. Dislocation

32. TRAUMA Fracture Healing Main steps in fracture healing Formation of hematoma Organization of hematoma Formation of fibrous callus Replacement of fibrous callus by primary bany callus Absorption primary bany callus Transformation to secondary bony callus Remodeling

33. TRAUMA Complication of Fractures Immediate complication Arterial injury Compartement syndrome Gas gangrene Fat embolism syndrome Thromboembolism

34. TRAUMA • Intermediate complication • Osteomyelitis • Myositis ossificans • Synostosis • Delayed union • Delayed complication • Osteonecrosis • Osteoporosis • Non union – Mal union

35. Myositis Ossificans

36. INFECTION Suppurative Osteomyelitis General Consideration Systemic or Local infections Immunosuppresed patients, alcoholics, newborns, and drug addicts are predisposed Antibiotics have significatly reduced the sepsis-related mortality

37. INFECTION Etiology Staphylococcus aureus causes 90% Pathway for the spread Hematogenous Contigunous Direct Implantation Postoperative

38. INFECTION Radiologic Features Bone scan are the earliest means of diagnosis Radiographic latent period for plain film 10 days for extremities 21 days for spine Soft tissue alteration : elevated fat planes, obliterated fat planes, increased density.

39. INFECTION Bone changes : Moth-eaten bone destruction Usually metaphyseal in origin Periosteal new bone formation Solid – Laminated – Codman’s Triangle Sequestrum Involucrum Joint space destruction (ankylosis)

40. 0steomyelitis

41. Osteomyelitis

42. INFECTION Septic Arthritis General consideration Single joint involvment in the rule Most common rute is hematogenous or direct traumatic implantation Etiology Most frequently is Staphylococcus Aureus

43. INFECTION Radiologic Features The knee and hip are the most common sites Joint effusion leads to distrorsion of the fat folds Positive Waldenstorm’s sign Rapid loss of joint space Bony ankylosis

44. INFECTION Nonsuppurative osteomyelitis (tuberculosis) General Consideration Found in patients such as prepubertal children, debilitated geriatric, silicosis, AIDS sufferers, Lymphoma patients, Alcoholics, corticosteroid and drug abusers

45. INFECTION Etiology Mycobacterium tuberculosis Two mode of spread Inhalation Ingestion

46. INFECTION Radiologic Features Spinal tuberculosis is most common at L-I Early sign for spine are : Lytic endplate destruction loss of disc height Anterior “ gouge defect “ Paraspinal swelling

47. INFECTION Advanced sign for spinal involvement are: Vertebral body collaps Gibbus formation and obliteration of the disc Tubercular arthritis is common in the hip and knee Uniform joint space narowing, early destruction of the subchondral cortex, “moth-eaten” bone destruction and juxtaarticular osteoporosis are the cardinal sign of tubercular arthritis

48. TUMORS AND TUMORLIKEPROCESSES METASTATIC BONE TUMORS PRIMARY MALIGNANT BONE TUMORS Multiple myeloma Osteosarcoma Ewing’s Sarcoma PRIMARY QUASIMALIGNANT BONE TUMOR Giant Cell Tumor

49. TUMORS PRIMARY BENIGN BONE TUMORS Osteochondroma Osteoma Bone island Osteoid osteoma Simple bone cyst Aneurysmal bone cyst

50. TUMORS Metastatic Bone Tumors General Consideration The most common malignant tumors CNS tumors and basal cell Ca rarely Life threatening complication Insidence 70% are metastatic, 30% are primary In females 70% from breast Ca In males 60% from prostate Ca