CT more specific and sensitive than X-ray

Less available, more radiation, more expensive

Some fractures hard to see on x-ray
Can manipulate angles to see from other side xrays only have 2 views
Cannot see the spinal cord
MRI excellent soft tissue contrast resolution ligament, tendon, cartilage, soft tissue, staging
of bones and soft tissues check resectability of tumours, spinal infection/trauma -> check
extension of bone into the spinal canal, occult fracture
Can see the disc and its approximate water content good disc or degenerative disc
Signet changes of cord compression, can see Tb spondylitis -> can only see destruction of
vertebrae body in CT
Ligament and tendon tears MRI can see tears
Bone growth bone contusion etc can also be seen on MRI
Tumour staging can see involvement of the soft tissues by the tumour
Radionuclide bone scan look at bone mets, osteomyelitis, occult and stress fracture
Can see bone scan, but hard to see the extent of mets in one area
Mostly used for bone metastases
Bone diseases
Diffuse affects all bones - congenital, metabolic, haematological,
Local - Infection, tumour
All sacrum and femur and ileum etc become denser -> osteopetrosis
Focal bone disease acute vs chronic
Osteomyelitis bony destruction, periosteal reaction in acute; chronic devitalized infected
bone (sequestra) and new bone formation (involucrum)
Bone destruction more lucent/darker
Periosteal reaction
Chronic OM Abx not working, bone not working -> bone deformity, distorted bone bony
sclerosis, cortical thickening and irregularity, sequestra and involucrum
Bone lesions benign vs malignant
Location epi/meta/diaphysis, intramedullary, cortical
Pattern permeative, lytic (increased lucency), sclerotic (more white/dense)
Zone of transition margin narrow or white
Periosteal reaction codmans reaction
Cortical destruction
Epiphyseal GCT, chondroblastoma
Metaphyseal osteosarcoma, osteomyelitis
Diaphyseal Ewings
Pattern of bone involvement permeative, wide zone of transition (progression from abnormal
to normal bone), cortical erosion aggressive do biopsy to check for malignancy
Lytic, narrow transition zone (means can see margin well), marginal sclerosis, intact cortex
slow growing likely benign
Spiculated/sunburst periosteal reaction, also includes Codmans triangle periosteum
elevated, multilayered onion skin
Most of these esp spiculated indicates malignancy

Lytic, narrow margin, no periosteal reaction, cortical based lesion, well defined likely benign
Enchondroma, bone cyst/unicameral bone cyst, GCT benign
Regardless of benign or malignant bone lesions, all can cause pathological fracture
Most common malignant bone tumour in adults MM
Metastases is the overall most common malignant bone tumour
Sclerotic osteoblastic type of mets, lytic osteolytic type of mets
Joints
Arthritis affects bone on both sides of joints and space in between the bones
Monoarthritis infection, degenerative, traumatic
Polyarthritis systemic disease RA, psoriasis, gout
Symmetrical vs asymmetrical symmetrical in RA, asymmetrical in psoriasis, gout
Distribution of joint involvement
Degenerative joint OA degeneration of cartilage commonly in knee joints
Marginal osteophytes formation at the joints can break off and form loose bodies
Neuropathic joint charcot joint commonly diabetic neuropathy
Prone to recurrent microfractures
No pain
Fragmentation, soft tissue swelling, sclerosis, osteophytosis
Lots of swelling. Subluxation/dislocation, fractures etc -> usually no pain
Erosive arthritis a/w synovial inflammation
Better seen in small joints
RA, gout, haemophilia, AS, etc
RA
Bilateral, symmetrical, earliest erosive changes in MCP, PIP, ulnar styloid, radiocarpal joint
commonly narrowed
Deformity, joint subluxation and dislocation
Will see lots of lucency soft tissue swelling
Gout usually big toe, asymmetrical, monoarticular, most common in 1 st MTPJ
Juxta-articular erosions, sharply marginated, sclerotic rims, overhanging edges
AVN trauma, steroids
Increased bone density, collapse/flattening/irregularity of articular surface/bone fragmentation
Usually in femoral head
Septic arthritis
Usually involve one joint usually staph and TB
Destroy cartilage and cortex
Severe OP
Heals with ankyloses bone and bone fusion
In adults usually in joints
In paeds usually in spine loss of disc spaces, a/w endplate irregularity, soft tissue swelling,
irregular vertebra margins
Fractures
x-ray is the mainstay

x-ray the site of pain

ABCS
Alignment anatomical relationship between bones are normal,
Adequacy positon and exposure,
Bones fracture line usually a lucent gap, some harder to see see as sclerotic area,
Cartilage joint space or joit destruction
Soft tissue changes distortion of fat planes, effusion, swelling
2 views AP, lateral right angles to each other
Hands and toes AP and oblique lateral view cannot see as all bones in line
Pelvis only AP needed usually
Describe site, fracture line (transverse 90 degrees to bone, oblique, spiral), distal bone
displacement (comminuted >2 fragments)
Colles fracture need 2 views to see
Pitfalls
Vascular markings nutrient vessels
Accessory ossicles well defined sclerotic margins, adjacent bone normal, no pain
Physis and growth plates fusion occurs during 12/13 years old
Avulsion fractures fractures at sites of tendon, ligaments small bony fragment detached at
the margin of a joint
Dorsal aspect base of phalanges extensor ligament, flexion deformity of mallet finger results
Also at 1st MCPJ ulnar collateral lig
5th MTP joint brevis muscle attached here
Galeazzi radial shaft # with associated dislocation of the write joint
Scaphoid fracture most common carpal joint # - easily missed AVN
Ask for scaphoid view
Anatomical snuff box tenderness!
Patellar # - skyline view vertical fracture
# can be comminuted or horizontal
Knee joint injury
Cross table lateral view lipohaemarthrosis (fat-fluid level) in suprapatellar bursa -> intraarticular #
Posterior fat pad sign supracondylar humeral fracture displaced anterior humeral line
Blood lifts the fat pad up, giving the sign
Elbow lines
Anterior humeral line (anterior surface line pass through middle third of capitulum
supracondylar #) and radiocapitellar line (should also pass through capitulum dislocation of
radial head)
Calcaneum fracture Bohlers angle
Normally 30 to 40 degress, if angle less than 30 degrees, mean # of calcaneum flattening of
calcaneum
Spinal injury

Lateral view 3 line contour anterior margin of body, posterior line of body, spinous process
line
Vertebral body height uniform square or rectangular
Intervertebral disc space
Prevertebral soft tissues C2/3/4 thin, lower ones more thick if not means haematoma or
injury
Spinous process should be straight, equal interspinous process
Open mouth view for odoitoid process etc
Flexion teardrio fracture unstable
Swollen prevertebral space
Jefferson # - burst fracture of C1 CT better for cervical fractures
Burst # - axial compression shattered pieces sideways
Conus medullaris
Chance # - seat belt injury T12 to L2, a/w intraabdominal organ injuries
# in children
Greenstick # -break in one cortex whilte theother cortex no break
Plastic bowing # - bending or bowing of bone without any cortical brea
Torus # - cortical ripple with no discontinuity
All these heal very well in kids
Salter harris # - involves growth place prognosis worse with increasing grade, most common
is grade 2
Joint dislocation and subluxation
Dislocation articular surface lose all contact with each other
Subluxation alignment out but some parts still in contact
Shoulder usually anterior-inferior dislocated
Hip posterior dislocation dashboard trauma
When to order what
PID MRI -> lumbosacral spine x-ray not necessary as will radiate gonads not in young
patients with suspected PID
Used in severe trauma, malignancy, infection of bone in IVDU/immunosuppression
Old lady x-ray, bone scan exclude bone mets