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1、医学影像学教学片Musculoskeletal system part twopart twoImaging of common diseasesImaging of common diseases Infective diseases of bone bone tumors Common chronic diseases of joints医学影像学教学片Infective diseases of boneInfective diseases of bone医学影像学教学片OsteomyelitisDefinitionOsteomyelitis is an inflammation of t
2、he bone or bone marrow, usually caused by a bacterial infection. Staphylococcus aureus is the most common bacterium. Patients often present with pain. Patients may have systemic symptoms such as fatigue and fever.医学影像学教学片Radiographic feature of acute osteomyelitisRadiographs performed early in the c
3、ourse of disease may show subtle swelling of the deep soft tissue or edematous subcutaneous soft tissues, but radiographs are often normal in the first 7-10 days of infection. By 10-14 days, a focal area of bone opacity develops in the metaphysis. This progresses to lytic destruction with surroundin
4、g sclerotic margin and associated focal periosteal reaction. 医学影像学教学片Osteomyelitis, which is an acute or chronic bone infection, can result from the bacteria that causes Septic Arthritis. pus医学影像学教学片医学影像学教学片Radiograph of a shoulder in a patient presenting with shoulder pain shows no abnormality (lef
5、t). Another radiograph obtained 3 weeks later shows patchy destruction (right). Acute Osteomyelitis医学影像学教学片Acute osteomyelitisThe x-ray of the distal tibia demonstrates periosteal elevation (left-image arrowhead) and osteolysis (right-image arrowhead) findings consistent with osteomyelitis. 医学影像学教学片
6、The x-ray shown is from a 13-year-old girl with pneumonia who developed patchy destruction of the glenoid capsule (arrowhead) due to osteomyelitis. 医学影像学教学片Rarefaction is seen in the lower tibia associated with periosteal reaction in the same patient as in the previous images. Acute Osteomyelitis医学影
7、像学教学片Radiograph of the foot (same patient as in the previous 2 images) shows periosteal reaction around the first metatarsal bone. 医学影像学教学片Acute OsteomyelitisA 2-year-old girl with proximal lower leg painan area of faint sclerosis at the lateral diametaphysis of the tibia.医学影像学教学片Acute pyogenic oste
8、omyelitis医学影像学教学片 Subacute Osteomyelitis An 11-year-old girl with ankle pain a lucent lesion with sclerotic margins. 医学影像学教学片Radiographic feature of chronic osteomyelitisThe chronic phase of the disease is characterized by thick, irregular, sclerotic bone interspersed with radiolucencies, an elevate
9、d periosteum, and chronic draining sinuses.医学影像学教学片chronic osteomyelitis with significant bone sclerosis and deformity 医学影像学教学片Chronic pyogenic osteomyelitis Sequestrum of the upper tibia. 医学影像学教学片Chronic OsteomyelitisA 56-year-old man with diabetes shows chronic osteomyelitis of the calcaneum. Note
10、 air in the soft tissues. 医学影像学教学片Garrs sclerosing osteomyelitis. a rare sclerotic nonpurulent form of osteomyelitis Note the bone expansion and marked sclerosis. 医学影像学教学片2-cm osteolytic lesionextensive sclerosis.A 6-year-old girl with a history of chronic osteomyelitisBrodie abscess医学影像学教学片Osteomye
11、litis (Foot)soft tissue swelling (long arrows) rarefaction (lucency) of the fifth metatarsal head (short arrow) slight narrowing 医学影像学教学片Osteomyelitis (Head and Neck)Osteomyelitis with periostitis. Axial CT (bony window setting) shows multilayered periosteal reaction of irregular thickness in the ri
12、ght side of the mandible (arrowheads).医学影像学教学片Osteomyelitis (Head and Neck)Chronic suppurative osteomyelitis. Axial CT shows osteolytic and sclerotic changes in the right side of the mandible. Cortex has been destroyed (arrows).医学影像学教学片In general, infectious arthritis is classified as pyogenic (sept
13、ic) or nonpyogenic. Pyogenic septic arthritis is most frequently caused by Staphylococcus aureus. Infection can lead to rapid and severe joint destruction. Septic Arthritis(Pyogenic Arthritis)医学影像学教学片Radiographic featureThe earliest plain film radiographic findings of septic arthritis are soft tissu
14、e swelling around the joint and a widened joint space from joint effusion. With progression of the disease, plain films reveal joint-space narrowing as articular cartilage is destroyed. Loss of visualization of the white cortical line over large areas of the joint surface soon ensues as bone destruc
15、tion begins to develop. This is followed by marginal erosions as uncovered, intracapsular bone is destroyed. Plain film findings of superimposed osteomyelitis may develop (periosteal reaction, bone destruction, sequestrum formation).医学影像学教学片During the progression of infectious arthritis of the hip,
16、this image was obtained early in the disease and shows only concentric joint-space loss. 医学影像学教学片During the progression of infectious arthritis of the hip, subchondral erosions and sclerosis of the femoral head are present. 医学影像学教学片During the progression of infectious arthritis of the hip, 8 months
17、after the initial examination, osteonecrosis and complete collapse of the femoral head are present. 医学影像学教学片Septic arthritis. AP view of the shoulder demonstrates subchondral erosions and sclerosis in the humeral head. These are relatively late findings of septic arthritis. Periosteal reaction due t
18、o coincident osteomyelitis is present adjacent to the surgical neck of the humerus. 医学影像学教学片Diabetic pedal infection: radiographic appearance. Osteomyelitis and septic arthritis - late. AP radiograph of the medial forefoot shows marked narrowing of the first MTP joint with adjacent bone destruction
19、and soft tissue swelling. Note periostitis (arrowheads) along the proximal phalanx.医学影像学教学片Acute Septic Arthritis the metacarpophalangeal joint of the index finger is seen as rarefaction of bone either side of the joint. Narrowing of the joint space and marginal erosion. 医学影像学教学片Vertebral Osteomyeli
20、tis disc space narrowing (arrow) Lateral view of the lumbar spine demonstrates L 3-4 disc space narrowing (arrow) and end-plate irregularity. 医学影像学教学片A. T1-weighted images of the lumbar spine demonstrate T1-hypointense signal (solid arrows) centered around the L3-4 interspace. B. Post gadolinium sag
21、ittal fat-suppressed T1-weighted images shows marrow (dashed arrows) and disc enhancement with endplate erosions. 医学影像学教学片Tuberculosis of bones and jointsThe most common tuberculous bone lesion is in the spine; the most frequent tuberculous arthritis is in the hip or knee. The great majority of tube
22、rculous bone and joint lesions begin in childhood and adolescence.医学影像学教学片Tuberculous SpondylitisClinical HistoryA 37-year-old woman after bone marrow transplantation who presented with low-grade fever and back pain, undergoing computed tomography (CT).医学影像学教学片Tuberculous Spondylitis The patient was
23、 a 37-year-old woman with pulmonary tuberculosis and tuberculous spondylitis CT using lung windows shows a cavity in the apical segment of the right upper lobe. 医学影像学教学片 In the same patient, CT at the level of the lower thoracic spine using soft tissue windows shows paravertebral soft tissue masses
24、and partial destruction of the adjacent vertebra.医学影像学教学片Spondylitis, TuberculousFigure : 31 year old man complaining of persistent neck pain. CT shows soft tissue mass with calcific debris and bone destruction. 医学影像学教学片Thoracic vertebrae tuberculosisparavertebral abscessdisc narrowed 医学影像学教学片Lumber
25、 vertebrae tuberculosisparavertebral abscessvertebral body destroyed医学影像学教学片Tuberculosis of long bonesFeatures:metaphyseal destroyed医学影像学教学片Tuberculosis of long bonesFeatures:metaphyseal destroyedepiphysis invadedjoint invaded医学影像学教学片Radiographic featureA triad of radiographic abnormalities known as
26、 Phemister triad is characteristic of tuberculous arthritis: peripherally located bony erosions, juxta-articular osteoporosis, and gradual narrowing of the joint space. 医学影像学教学片peripherally located bony erosionsOsteoporosisnarrowing of the joint space医学影像学教学片bone tumorsbone tumors医学影像学教学片Osteoid ost
27、eomaOsteoid osteoma is a benign skeletal neoplasm of unknown etiology that is composed of osteoid and woven bone. The tumor is usually smaller than 1.5 cm in diameter. Osteoid osteoma can occur in any bone, but in approximately two thirds of patients, the appendicular skeleton is involved. The skull
28、 and facial bones are involved exceptionally. Most patients with osteoid osteoma are young. The classic presentation is that of focal bone pain at the site of the tumor. The pain worsens at night and increases with activity; it is dramatically relieved with small doses of aspirin.医学影像学教学片Radiographi
29、c featureThe lesion initially appears as a small sclerotic bone island within a circular lucent defect. This central nidus is seldom larger than 1.5 cm in diameter, and it may be associated with considerable overlying cortical and endosteal bone sclerosis. The tumors may regress spontaneously. The s
30、ite of the tumor determines the degree of bone sclerosis. In medullary tumors, sclerosis is minimal or absent. Cortical and subperiosteal tumors provoke considerable sclerosis. Long-standing tumors demonstrate more sclerosis. Children also mount more of a sclerotic response than do adults. 医学影像学教学片T
31、ransaxial CT scan through the proximal shaft of the right femur in a 17-year-old boy. The scan localizes the osteoid osteoma adjacent to the endosteal margin of the cortex. Note a central sclerotic focus in the radiolucent nidus, which is characteristic of osteoid osteoma. 医学影像学教学片Osteoid Osteoma Fi
32、gure : Axial image from a CT scan through the right femoral neck clearly shows a well-defined lucency with a central sclerotic focus (arrow).医学影像学教学片Osteoid Osteoma sclerosisnidusNidus surrounded by dense reactive bone 医学影像学教学片Plain radiograph of the pelvis in a 6-year-old child who presented with l
33、eft hip pain. The radiograph shows a well-defined area of sclerosis surrounded by a ring of radiolucency in the left femoral neck. Note the absence of periosteal reaction that suggests intramedullary or cancellous osteoid osteoma. 医学影像学教学片OsteosarcomaOsteosarcoma is the most common primary malignant
34、 tumor of bone, excluding plasma cell myeloma. It is most common among people aged 10 to 25, although it can occur at any age. Metaphysis of long bone,50% around the knee. Presentation: pain, mass, pathologic fracture 医学影像学教学片Radiographic featureRadiographic appearances are variable, most lesions sh
35、ow a mixture of lytic and sclerotic areas. Rarely, purely lytic or sclerotic lesions occur. Lesions appear aggressive; they may appear moth eaten, with ill-defined edges.Soft tissue extension of osteosarcoma is common; on radiographs, such extension is seen as a soft tissue mass. Cloudlike areas of
36、sclerosis, resulting from malignant osteoid production and calcification, may be seen within the mass. Periosteal reactions are commonly seen once the tumor extends through the cortex. A spectrum of changes occur; these include Codman triangles and multilaminated, spiculated, and sunburst reactions,
37、 all of which indicate an aggressive process. 医学影像学教学片Osteosarcoma, Conventional (High Grade Intramedullary)mixed lytic with minor malignant osteoid production purely lyticpurely sclerotic 医学影像学教学片Osteosarcoma, Conventional (High Grade Intramedullary)Radiograph shows lysis, malignant osteoid formati
38、on, complex periosteal new bone formation and soft tissue extension. 医学影像学教学片Conventional Osteosarcomaa large 7-cm bone-forming lesion involving the shaft of the femur with aggressive sunburst periosteal reaction. 22-year-old male with leg pain 医学影像学教学片Osteosarcoma(osteoblastic)Anteroposterior (AP)
39、radiograph in a patient with osteosarcoma of the proximal humerus. Note the extensive soft tissue mass containing a considerable amount of mineralized osteoid. 医学影像学教学片The radiograph shows mixed medullary sclerosis and lucency, cortical destruction medially, aggressive periosteal changes, and a larg
40、e soft-tissue mass with peripheral ossification. 医学影像学教学片Coronal T1-weighted MRI. Note the abnormal signal intensity in the metaphyseal marrow and the soft tissue mass (black arrow). Early tumor extension is shown beyond the growth plate into the epiphysis (white arrows). 医学影像学教学片Osteosarcoma, Paros
41、tealParosteal osteosarcomas are typically densely ossified tumors arising from a broad base on the adjacent bone. Unlike osteochondromas, parosteal osteosarcomas involve no continuation of the medullary cavity into the tumor. The prognosis for a parosteal osteosarcoma is generally excellent .37-year
42、-old female with leg pain5-cm well-defined surface-based bone-forming lesion 医学影像学教学片Giant cell tumorGiant cell tumor of the bone is a relatively uncommon tumor that is characterized by the presence of multinucleated giant cells. This type of tumor is usually regarded as benign. By far most giant ce
43、ll tumors are seen around the knee. Most common bone tumor in adults aged 25 - 40 y.医学影像学教学片Radiographic featureThe most important radiographic findings of giant cell tumor are the location of the tumor, its lytic nature, and the lack of a host response. GCT is located in the epiphysis with or witho
44、ut extension to metaphysis and frequently abuts the articular surface. Typically, giant cell tumors are eccentric expansile, osteolytic radiolucent lesions without sclerotic margins and usually without a periosteal reaction. Septa, found in the image below, may be seen in the lesion in 33-57% of pat
45、ients; these represent nonuniform growth of the tumor rather than true septa. The tumors are typically in the range of 5-7 cm in diameter when they are discovered.医学影像学教学片A giant cell tumor presenting as an eccentric lytic lesion in the medial epi- and metaphysis of the distal femur. 医学影像学教学片CT scan
46、 shows the full extent of a giant cell tumor in the left ilium. Septa are seen in the lesion. 医学影像学教学片T2-weighted axial MRI of the knee shows multiple fluid-fluid levels in a giant cell tumor of the distal femur. 医学影像学教学片On the left a giant cell tumor of the distal radius with ill-defined margins, d
47、estruction of the subchondral bone plate and extension towards the soft tissues. 医学影像学教学片Metastatic tumor in boneMetastases are the most common malignant bone tumors.Bone metastases are often multiple at the time of diagnosis. In adults, the lesions generally occur in the axial skeleton and other si
48、tes with residual red marrow, although the lesions may be found anywhere in the skeletal system. Common sites for metastases are the vertebrae, pelvis, proximal parts of the femur, ribs, proximal part of the humerus, and skull. Most common osteolytic metastases: kidney, lung, colon and melanoma.Most
49、 common osteosclerotic metastases: prostate and breast. 医学影像学教学片Metastatic tumor in bone医学影像学教学片Lateral radiograph shows sclerotic metastasis of the L2 vertebra in a 54-year-old man with prostatic carcinoma. 医学影像学教学片Radiograph shows osteolytic metastasis in the distal femur of a 51-year-old woman wi
50、th breast carcinoma. 医学影像学教学片Axial CT scan shows 2 rounded, mixed osteolytic-sclerotic lesions in the thoracic vertebral body of a 44-year-old woman with lung carcinoma. 医学影像学教学片The bulls-eye or halo sign has been reported to be useful in distinguishing metastatic from benign lesions. In vertebrae,
51、additional criteria for malignancy include bulging of the posterior margin of the vertebral body, signal intensity changes that extend into the pedicle, and paraosseous tumor spread .医学影像学教学片A 68-year-old man with thyroid carcinoma. This image shows heterogeneous enhancement of the T11-L2 vertebrae,
52、 with prominent epidural component enhancement and spinal canal compromise. 医学影像学教学片caseA 13-year-old boy complained of malaise, weight loss and a progressive painful swelling over the distal left thigh for 3 months. There was no fever or history of recent trauma. Physical examination showed a hard
53、mass over the distal thigh with mild localized tenderness. The left knee was unremarkable. Laboratory investigations revealed raised ESR and normal WBC. In view of the history, radiographs of the distal femur were performed (Fig.).医学影像学教学片Questions(1) What abnormalities do you see on this radiograph
54、 ?Overlying soft tissue mass Spiculated new bone formationCortical thinning and disruptionA mixed osteolytic and sclerotic lesion with ill-defined margins (2) What is the diagnosis ?Osteosarcoma医学影像学教学片Common chronic diseases of jointsDegenerative arthritis(osteoarthritis)Rheumatoid arthritisGouty a
55、rthritis医学影像学教学片Degenerative arthritis(osteoarthritis OA)ClassificationPrimary osteoarthritis - most common in the older age group as the result of wear and tear on articular cartilage over time. Secondary osteoarthritis - results from a previous process that damaged cartilage such as trauma, or inf
56、lammatory arthritis. The most commonly involved joints in primary osteoarthritis are:Distal interphalangeal joints First carpometacarpal joint Weight bearing joints: spine, hips, knees 医学影像学教学片Diagnosis by plain films includes identification of:Asymmetric joint space narrowing Osteophytes-bony spurs
57、 Degenerative cysts Sclerosis of subchondral bone 医学影像学教学片degenerative arthritis(osteoarthritis)Features:1, Asymmetric narrowed joint space 2,subarticular reactive sclerosis3,spur formation医学影像学教学片Cervical verterbranormaldegenerativenarrowed joint spacespur formation医学影像学教学片Lumber vertebra degenerat
58、ion医学影像学教学片Lumber vertebra degeneration医学影像学教学片OA of the Hipjoint space is almost completely obliterated sclerosis and osteophyte formation (arrow). 医学影像学教学片narrowing of the joint spaces and the increased density around the joints due to the subchondral sclerosis (black arrows). osteophytes (white a
59、rrow). OA of the Fingers医学影像学教学片subchondral sclerosis asymmetric disk space osteophytes 医学影像学教学片Rheumatoid arthritis(RA)Diagnosis usually made by plain film confirmation of:Osteopenia - a demineralization of the bone - is the result of increased blood flow, due to inflammation, which washes out the
60、calcium. Early on in the inflammatory process,only the periarticular portion of the bones are affected. Over time, the inflammatory pain causes disuse of affected joints leading to generalized osteopenia of whole bones. Uniform joint space narrowing - a feature which helps differentiate RA from OA.
61、Marginal erosions at bare areas where synovium lies on bone Subluxation due to ligamentous or capsular laxity 医学影像学教学片OsteopeniaUniform joint space narrowingMarginal erosionsSubluxation医学影像学教学片Rheumatoid arthritis1，fusiform pericapsular swelling2, narrowing of joint space3, marginal erosion医学影像学教学片R
62、heumatoid arthritismultiple erosions carpal bones 医学影像学教学片ankylosis of most of the carpal bones Rheumatoid arthritis医学影像学教学片Gout DefinitionAn inherited disorder of purine metabolism, occurring especially in men, characterized by a raised but variable blood uric acid level and severe recurrent acute
63、arthritis of sudden onset resulting from deposition of crystals of sodium urate in connective tissues and articular cartilage. 医学影像学教学片Gouty arthritis医学影像学教学片Gouty arthritisFeatures:1, asymmetric soft tissue swelling(Early-phase) 2,articular or para-articular erosion(intermediate phase )3,tophus for
64、mation(late-phase ) 4, joint-space narrowing 医学影像学教学片医学影像学教学片A 60-year-old man, a heavy drinker for 30 years, complains of severe pain over the right big toe for 2 days. Similar attacks of pain have occurred intermittently over the past10 years. Physical examination showed a hot, red and swollen met
65、atarso-phalangeal joint of the big toe with marked tenderness. Hard subcutaneous whitish masses were also noted in this area. A radiograph of his foot was performed (Fig. next).Case医学影像学教学片Questions(1) What abnormalities do you see on this radiograph ?Soft tissue swellingBony defectLoss of joint spaceLateral subluxation(dislocation)(2) What is the diagnosis ?Gouty arthritis医学影像学教学片医学影像学教学片
