Basics of Orthopedic

Imaging
Objectives
• Introduce different modalities of imaging
• Their principles
• Uses
• Limitations
• What to order and When in orthopedics
• Safety and hazards
Contents
• Radiography (X-ray)
• Computed Tomography (CT)
• Magnetic Resonance Imaging (MRI)
• Ultrasound
• Radionuclide Imaging
• SPECT
• PET
•
BMD(DEXA)
Plain radiography (X- Physics
Rays):
Vacuum
 Beam of X-rays

Attenuated by the patient ’s soft

tissues and bones

Cast different ‘shadows’ on a

sensitized plate

Displayed as images
• Wilhelm Roentgen, 50, profes s or
of phys ics (Nobel Prize in Physics in
1901)at Wurzburg University, Bavaria,
had his e ure ka moment in 1895.
• He was studying gases in his lab
when he noticed photographic pla te s
near his equipment had started to
glow

• Cathode rays (electro ns ) le a ving

the ca thode are attracted by high
vo lta ge to the anode, whe re the y
pro duce x- rays and fluorescent light.

• It was due to 'X'-radiation,

composed of X-rays; he labelled
them 'x' - a math s ymbol denoting
the unknown
Roentgen tube s tudying the effects of Roentgen X-ray machine,
pas s ing an elec tric al c urrent thro ugh gas es
at low pres s ure used by German surgeons in
an open-air surgery tent,
during the First World war

.
The first ever X-ray taken of
a human (onDecember 22,
1895) was the left hand,
co mple te with we dding and
engagement rings, of Anna
Be rtha R oentgen - the wife
of the man who accidentally
dis covered a form of
ra dia tio n that would change
the face of medicine
• Over 100 years old.
• Remains the most useful method of diagnostic imaging.
• Plain film provides information simultaneously on the size, shape,
tissue ‘density’ and bone architecture – characteristics which, taken
together, will usually suggest a diagnosis, or at least a range of
possible diagnoses.
Interpretation
ABC ’S
Alignment
Bone density
Cartilage(joints)
Soft tissues
One bone overlying another produces superimposed images.
So, it is important to obtain several images from different projections
A second projection, at right angles to the first, will give the answer.
• More dense and impenetrable the tissue

The greater the X-ray attenuation

More blank, or white image

• Metal implant appears intensely white
• Varying shades of grey of bones
and soft tissues depending on ‘density ’
• Cartilage appears dark.
• Fluid-filled cysts in
bone-‘Radiolucent’
THE SOFT
TISSUES
-Muscle planes may reveal wasting or swelling.
• Generalized change
-Bulging outlines around a joint may suggest a joint effusion;
-Soft-tissue swelling around IP joints may be the first
radiographic sign of rheumatoid arthritis.
-Tumors tend to displace fascial planes, whereas infection tends to
obliterate them.
• Localized change
-mass, soft tissue calcification, ossification, gas (from penetrating
wound or gas-forming organism) or the presence of a radiopaque
foreign body?
Radiographic
findings of ankle
joint effusion
Soft tissue findings in
rheumatoid knee
Synovial effusion in the
suprapatellar pouch and
posterior recesses
BONE
S
Generalized change

• Bone ‘density’ (osteopaenia or osteosclerosis)

• Abnormal trabeculation (eg. Paget ’s disease)
• Metastatic infiltration: either sclerotic or lytic
• Polyostotic lesions: fibrous dysplasia, histiocyotis, Paget
’s
disease, metastases (including myeloma and lymphoma),
• multifocal
Monostoticinfection.
lesions: most primary tumours
Localized
Lesions
• Lesion’s size, site, shape, density and margins, as well as adjacent
periosteal changes and any surrounding soft tissue changes.

• Benign lesions : well defined with sclerotic margins

:smooth periosteal reaction.

• Malignant lesions: Ill-defined areas with permeative bone destruction

:rregular or speculated periosteal reactions
THE J OINTS
The ‘joint space’
Synovial fluid +articular cartilage-1 mm or less the( carpal joints ) to 6 mm (the knee).
Wider in childre n tha n in adults because much of the e piphys is is still cartilaginous
and the re fore ra dio luce nt. Als o assess fors ymmetry

cho ndrocalcinos is
Loos e bodies
Shape
Deformity
Congruity/irregularity/radiolucent subchondral cysts
Narrowing(loss of hyaline cartilage eg. infection, inflammatory arthropathies
and osteoarthritis)
Asymmetry of the joint ‘space’
Osteophytes are typical of osteoarthritis.
Erosions-periarticular(RA- symmetrical MCP & PIP and psoriasis-DIP)
-Juxta-articular(gout)
Inflammatory arthritis= Narrowing of the joint space + osteoporosis +
periarticular Erosions.
Infection or malignancy (until proven otherwise)= Bone destruction + periosteal
new bone formation
#Remember: the next best investigation is either the
previous radiograph or the subsequent follow-up radiograph.
Rheumatoid foot

Subchondral cyst at
the base of the distal
phalanx

Characteristic erosion along the

medial margin of the proximal
phalanx of the great toe
Limita tio ns of conventional radiography
• R adiation haz ard(eg. Risk of cancer, te ra to ge nicity)
• poor soft-tissue contras t(eg.can not distinguish between mus cles ,
tendons , liga me nts and hya line ca rtila ge )

The Sievert (Sv) is the unit of occupational radiation exposure and effective dose.
People are exposed to natural radiation of 2-3 mSv a year.
* In a CT scan, the organ being studied typically receives a radiation dose of 15 mSv in an adult to 30 mSv in a
newborn infant.
A typical chest X-ray involves exposure of about 0.02 mSv, while a dental one can be 0.01 mSv.
• Exposure to 100 mSv a year is the lowest level at which any increase in cancer risk is clearly evident.
• A cumulative 1,000 mSv (1 sievert) would probably cause a fatal cancer many years later in five out of every
100 persons exposed to it.
• One sievert (1,000 mSv) dose causes radiation sickness such as nausea, vomiting, hemorrhaging, but not
death.
• A single dose of 5 sieverts would kill about half of those exposed to it within a month.
Contrast radiography
• Use of substance that alter X-ray attenuation characteristics
• Mostly iodine-based liquids (Ionic, water-soluble iodides)
• Injected into sinuses(sinography), joint cavities(Arthrography) or the
spinal theca(myelography)
• Air or gas also can be injected into joints to produce a ‘negative
image’ outlining the joint cavity.
Sinography
• The medium is injected into
an open sinus
• film shows the track and
whether or not it leads to
the underlying bone or joint.
 A rthro gra phy
• Intra - a rticular loos e bodies will pro duce filling defects
• In the knee, to rn menis ci, ligament tears and caps ular ruptures can be s hown.
• In children’s hips, a rthro gra phy is a useful method of outlining the cartilaginous (and
the re fore ra dio luce nt) femoral head.
• In adults with avascular necrosis of the femoral head, a rthro gra phy may show up to rn
flaps of cartilage.
• After hip re pla ce me nt, loos ening of a pros thes is may be revealed by
s eepage of the contrast medium into the ce me nt/bone inte rfa ce .

• In the hip, a nkle , wrist and s houlder, the inje cte d contrast medium may dis clos e labral
tears or defects in the capsular structures.
• In the s pine, contrast radiography can be us ed to diagnos e dis c de genera tion
(dis cogra phy) and a bno rma litie s of the small facet joints (fa ce togra phy)
A spillage of contrast material from the
joint space ins ide the s ubacromial-
s ubde ltoid burs a is note d that speaks in
favour of full-thickness tear of a rota tor
cuff tendon.
Mye logra phy
Us ed extensively in the pas t for the diagno s is of dis c prolaps e and other spinal canal
les ions (A bulging disc, an intrathecal tumour or narrowing of the bony canal will produce characteristic
distortions of the opaque column in the myelogram )
Largely replaced by non-invasive methods s uch as CT and MR I.
complica tions:
low-pres s ure headache (due to the lumbar puncture), muscular spasms
convulsions (due to neuro to xicity
arachnoiditis (which is a ttribute d to the hype ros mola lity)
P recautions :
keeping the patient s itting upright after myelography, must be
s trictly obs erved
Spinal
stenosis
Brief History of CT
• Also known as "CAT scanning" (Computed Axial
Tomography).
• Tomography: Greek word "tomos" ="slice" or
"section" and "graphia“= "describing".
• Invented in 1972 by British engineer Godfrey
Hounsfield of EMI Laboratories, England
and
South Africa-born physicist Allan Cormack of Tufts
University, Massachusetts. Hounsfield and Cormack
were later awarded the Nobel Peace Prize for their
contributions to medicine and science.

•
CT Scan
continued………..
• produces sectional images of greater resolution
• images are trans-axial exposing anatomical planes
• able to display the size, shape and position of bone and soft-tissue
masses in transverse planes.
• Image acquisition is extremely fast
• The region of interest is selected and a series of cross sectional images
is produced and digitally recorded.
• ‘Slices’ through the larger joints or tissue masses may be 3–5 mm
apart(smaller with smaller joints)
• New multislice CT scanners provide images of high quality from
which
multiplanar reconstructions in all three orthogonal planes can be
produced(may help in demonstrating anatomical contours, but fine
detail is lost in this process)
CT
continued………

Clinical applications
• trauma to the head, s pine, ches t, abdomen and pelvis.
• better than MRI for demonstrating fine bone detail and s oft- tis s ue calcification or
os s ification.
• pre ope rative planning in s econdary fra c ture ma na ge me nt.
• ro utine ly us ed for assessing injurie s of the vertebrae, acetabulum, pro ximal
tibial plateau, ankle and foot – indeed complex fractures and fracture-
dis locatio ns at any s ite
• assessment of bone tumour size and s pread, even if it is unable to characteriz e
the tumour type
CT
continued…….

Limita tio ns
Poor soft-tissue contrast when compared with MR I.
Hig h ra dia tio n expos ure to whic h the patient is s ubjecte d.
It should, the re fore , be us ed with dis cre tion.
MAG NETIC RESONANCE IMAG ING (MR I)
• Ma gne tic res onance imaging produce s cross-sectional images of
any body part in any pla ne .
• Superb s oft-tis s ue co ntras t, a llo wing different soft tissues to be
cle a rly dis tinguis he d, e.g. ligame nts , tendons , mus cle and hyaline
ca rtila ge .
• Another big a dva nta ge of MRI is that itdoes not use ionizing
radiation.
• C ontra indica te d in patients with pacemakers and pos s ible
metallic fo reign bodies in the eye or brain, as thes e could
po te ntia lly mo ve whe n the patient is intro duce d into the scanner’s
s trong ma gne tic field.
MRI physics
• Body is placed ina s trong ma gne tic field (upto
30 000 X the strengthof the Earth’s ma gne tic
field)
• P rotons have a pos itive cha rge and align
thems elves along this ma gne tic field.
• The pro to ns are s pinning and can be furthe r
e xcite d by ra diofre que ncy puls es .
A pro to n dens ity map is reco rded fro m thes e
s ignals and plotted in x, y and z coordinates.
• Different speeds of tissue e xcita tion with
ra diofre que ncy puls es will yield a na tomical
pictures with varying ‘weighting’ and
characteris tics .
• T1 we ighte d (T1W) ima ge s have a high s patial
re s olution and pro vide good a na tomical- looking
picture s .
• T2 we ighte d (T2W) ima ge s give mo re
info rma tio n about the physiological
White areas on an X-ray or CT image = high
chara cte ris tics of the tis s ue. density
White areas on an MRI image = high signal
The timing of radiofrequency puls e s equences us ed to ma ke
T1 ima ge s re s ults in ima ge s whic h highlight fat tissue within the
bo dy.
The timing of radiofrequency puls e s equences us ed to ma ke
T2 ima ge s re s ults in ima ge s whic h highlight fatAND wate r
with in the bo dy.
So, this make s things easy to re me mbe r.
T1 images – 1 tis s ue ty pe is bright– FAT
T2 images – 2 tis s ue type s are bright– FAT and WATER
Clinical application
• excellent detailed limb compartmental anatomy, soft-tissue contrast and multiplanar capability
make it ideal for non-invasive imaging of the musculoskeletal system
• The excellent soft-tissue contrast allows identification of similar density soft tissues, for example
in distinguishing between tendons, cartilage and ligaments.
• By using combinations of T1W, T2W and fat-suppressed sequences, and other specialized MRI
sequences, specific abnormalities can be further characterized with tissue specificity.
• MRI of the hip, knee, ankle, shoulder and wrist is now fairly commonplace.
• Detect the early changes of bone marrow oedema and osteonecrosis before any other imaging
• Knee MRI is as accurate as arthroscopy in diagnosing meniscal tears and cruciate ligament injuries.
• Bone and soft-tissue tumours should be routinely examined by MRI as the intraosseous and
extraosseous extent and spread of disease
• Additional use of fat-suppression sequences determines the extent of perilesional oedema and
intravenous contrast will demonstrate the active part of the tumour.
Intravenous contrast is used to distinguish vascularized from avascular tissue or in
demonstrating
areas of active inflammation.
Limita tio ns
• Soft- tis s ue ca lcifica tio n and os s ification, cha nge s whic h can
eas ily be eas ily overlooked on MRI.
• C onve ntiona l ra dio gra phs s hould the re fore be us ed in
co mbina tio n with MRI to prevent such errors.
• Time consuming, so less helpful in emergency condition
• Claustrophobic patients can not tolerate for longer
duration.
Thank you!!!