ORTHOPEDIC IMAGING:

A PRACTICAL APPROACH
Adam Greenspan
6th Edition

Introduction to
Orthopedic Imaging
The Role of the Orthopedic Radiologist

• The radiologic diagnosis of many bone and

joint disorders cannot be made solely on the
basis of particular recognizable radiographic
patterns
• Clinical data, such as the patient's age, gender,
symptoms, history, and laboratory findings,
are also important to the radiologist in
correctly interpreting an imaging study
• Radiologist should avoid, as a point of
departure in the examination, the more
technologically advanced imaging modalities
in favor of making a diagnosis, whenever
possible, on the basis of simple conventional
radiographs. This approach is essential not
only to maintain cost-effectiveness but also to
decrease the amount of radiation to which a
patient is exposed
• Certain ways of positioning the patient when
radiographs are obtained allow the radiologist the
opportunity to evaluate otherwise hidden anatomic
sites and to more suitably demonstrate a particular
abnormality
• for example, detecting a nondisplaced or minimally
displaced fracture of the radial head occasionally
requires a special 45-degree angle view (called the
radial head-capitellum view) that projects the radial
head free of adjacent structures, making an otherwise
obscure lesion evident
• An accurate diagnosis depends on the
radiologist's acute observations and careful
analysis, in light of clinical information, of the
radiographic findings regarding the size,
shape, configuration, and density of a lesion;
its location within the bone; and its
distribution in the skeletal system
Shape and contour of bone. Observation of changes in the shape and
contour of a vertebral body on conventional radiographs may disclose
critical information leading to a correct diagnosis
Density and texture of bone. Changes in the density and texture of
a vertebral body on conventional radiographs may offer useful data
for arriving at a diagnosis
• The clinician is interested in demonstrating :
– the crucial features of the lesion, that is, its
character, extent, stage, and other pertinent data
– the location of the lesion in the bone
– the distribution of the lesion in the skeleton
– the progress of treatment
– the emergence of any complications
 Imaging Techniques in Orthopedics

• “What modality should I use for this particular

problem?”
• For example, allergy to ionic or nonionic
iodinated contrast agents may preclude the use
of arthrography; the presence of a pacemaker
would preclude the use of magnetic resonance
imaging (MRI); physiologic states, such as
pregnancy, preclude the use of ionized radiation,
favoring, for instance, the use of ultrasound (US)
 Conventional Radiography
• The most frequently used modality for the
evaluation of bone and joint disorders, and
particularly traumatic conditions
• The radiologist should obtain at least two views
of the bone involved, with each view including
two adjacent joints. the standard radiography
comprises the anteroposterior and lateral views
• In children, it is frequently necessary to obtain a
radiograph of the normal unaffected limb for
comparison
Two views
 Magnification Radiography
• Magnification radiography has been occasionally used
to enhance bony details not well appreciated on the
standard radiographic projections and to maximize the
diagnostic information obtainable from a radiographic
image
• resulting in a geometric enlargement that yields
magnified images of the bones and joints with greater
sharpness and greater bony detail
• This technique has been particularly effective in
demonstrating early changes in some arthritides as
well as in various metabolic disorders
 Stress View
• Stress views are important in evaluating
ligamentous tears and joint stability
• In the hand, abduction-stress film of the thumb
may be obtained when a gamekeeper's thumb,
resulting from a disruption of the ulnar collateral
ligament of the first metacarpophalangeal joint
• In the lower extremity, stress views of the knee
and ankle joints and knee instability caused by
ligament injuries
 Fluoroscopy and Videotaping
• Fluoroscopy is a fundamental diagnostic tool
for many radiologic procedures, including
arthrography, tenography, bursography,
arteriography, and percutaneous bone or soft-
tissue biopsy
• Because of the high dose of radiation,
however, it is only occasionally used, such as
in evaluating the movement of various joints
or to detect transient subluxation (i.e., carpal
instability)
 Digital Radiography
• Digital (computed) radiography (DR or CR) is
the name given to the process of digital image
acquisition using an x-ray detector comprising
a photostimulable phosphor imaging plate
and an image reader-writer that processes the
latent image information for subsequent
brightness scaling and laser printing on film
 Digital subtraction angiography (DSA), the most frequently
used variant of DR, can be used in the evaluation of trauma,
bone and soft-tissue tumors, and in general evaluation of the
vascular system
 Computed Tomography
• The CT computer software converts the x-ray
beam attenuations of the tissue into a CT number
(Hounsfield units) by comparing it with the
attenuation of water. The attenuation of water is
designated as 0 (zero) H, the attenuation of air is
designated as −400 to −1,000 H, fat as −60 to
−100 H, body fluid as +20 to +30 H, muscle as +40
to +80 H, trabecular bone as +100 to +300 H, and
the attenuation of normal cortical bone as +1,000
H
• CT is indispensable in the evaluation of many
traumatic conditions and various bone and
soft-tissue tumors because of its cross-
sectional imaging capability. In trauma, CT is
extremely useful to define the presence and
extent of a fracture or dislocation, to evaluate
various intraarticular abnormalities, and to
evaluate adjacent soft tissues
• This multiplanar reconstruction is particularly
helpful in evaluating the vertebral alignment,
demonstrating horizontally oriented fractures
of the vertebral body; in evaluating complex
fractures of the pelvis, hip, and knee; or in
evaluating calcaneus abnormalities, of the
sacrum and sacroiliac joints, sternum and
sternoclavicular joints, temporomandibular
joints, and wrist
 The newest advances in sophisticated software enable 3D
reconstruction, which is helpful in analyzing regions with complex
anatomy such as the face, pelvis, vertebral column, foot, ankle, and
wrist
 Arthrography
• It is not a technically difficult procedure and is much
simpler to interpret than US, CT, or MRI makes it very
desirable for evaluating various articulations
• Most frequently performed in the shoulder, wrist,
and ankle
• Although arthrography of the knee has been almost
completely replaced by MRI, it still may be used to
demonstrate injuries to the soft-tissue structures
such as the joint capsule, menisci, and various
ligaments
In the examination of any of the joints, arthrography can be
combined with the digitization of image (digital subtraction
arthrography), with CT (CT-arthrography) or with MRI (MRa)
 Tenography and Bursography
• To evaluate the integrity of a tendon and,
contrast material is injected into the tendon
sheath.
• Since the introduction of newer diagnostic
modalities, such as CT and MRI, this
procedure is seldom performed
 Angiography
• The use of a contrast material injected directly
into selective branches of the arterial and venous
circulation has aided greatly in assessing the
involvement of the circulatory system in various
conditions and has provided a precise method for
defining local pathology.
• This procedures are frequently used in the
evaluation of trauma, particularly if a
concomitant injury to the vascular system is
suspected
• In the evaluation of tumors, arteriography is
used mainly to map out bone lesions,
demonstrate the vascularity of the lesion, and
assess the extent of disease
 Ultrasound
• Most modern US equipment displays dynamic information
in “real time”
• Applications of US in orthopedics include an evaluation of
the rotator cuff, injuries to various tendons, and soft-tissue
tumor
• 3D sonography provides functional utility in the evaluation
of the joint in the added sagittal plane (section image) and
craniocaudal projection (revolving spatial image). This
technique permits excellent demonstration of the femoral
head-acetabulum relationship and femoral head
containment
FIGURE 2.21 US of the shoulder. (A) Long axis view of the supraspinatus tendon and its
attachment in the greater tuberosity of the humerus. (B) Long axis view of supraspinatus
tendon shows curvilinear echogenic focus with acoustic shadowing secondary to
intrasubstance calcification consistent with calcific tendinitis (arrow)
(C) US examination in the long axis view in another patient with a partial
articular sided tear of the supraspinatus tendon (SST). The tear is indicated by
a hypoechoic defect in the tendon extending to articular surface (arrow);
calcific tendinosis (arrowhead) is indicated by punctate echogenic foci of
calcification in the tendon insertion (arrowhead)
More recent US techniques such as Doppler US or color-flow imaging,
which expresses motion from moving red blood cells in color, have
found limited applications in orthopedic radiology. This modality is
used mainly to detect arterial narrowing and venous thrombosis
Scintigraphy (Radionuclide Bone Scan)
• Detect radioactive agent’s distribution in the
body
• Interaction between gamma rays from body
and sodium iodide in camera’s head
• Imaging the entire skeleton at once and
evaluating pathologic process
 Bone-seeking Tracers Usage

Diphosphonates (99mTc) • Evaluate benign and malignant skeletal lesion

Gallium 67 (67Ga) • Infectious and inflammatory process in bone and joint

• Differentiate sarcoma from beningn soft tissue lesion
Indium (111In) • Inflammatory abnormalities

Nanocolloid • Tc-labelled colloid of human serum albumin

• Detection of osteomyelitis
Immunoglobulins • Imaging in infection
• Available in kit form and do not require in vivo labeling
Chemotactic Peptides • Imaging infection
• Small size  pass quickly through vascular walls
Iodine (125I) • Measure bone mineral density at peripheral bone site
such as finger and radius
Gadolinium 153Gd • Calculate bone mineral density for compact and
trabecular bone
 Positron Emission Tomography
• Identifify biochemical and physiologic
alteration in the body and assess metabolic
and perfusion in various organ system
• PET-CT & PET-MRI
 Magnetic Resonance Imaging
• Based on re-emission of an absorbed radio
frequency signal while patient in strong
magnetic field
• Signal intensity  the radio wave strenght
emitted by tissue after excitation
• Bright : high signal; Dark : low signal
• May be enchanced using Gd-DTPA
 Advantages of MRI
• Some abnormalities that not seen on
radiography are well demonstrated in MRI
– Bone contussion
– Trabecular microfractures
– Occult fracture
 Magnetic Resonance Arthrogram
• Intraarticular structure are demonstrated
better than conventional MRI
• Predominantly used in evaluating shoulder
abnormalities
– Internal derangement
– Glenohumeral joint instability
– Rotator cuff disorder
– Articular cartilage
 Magnetic Resonance Angiography
• Visualize blood vessels by depicting blood
flow’s property
• Evaluating vascular structure in patients with
trauma
• Assess muscular neoplasm vascularity
3D MRA. A 35-year old woman presented with a history of swelling in the forearm.
Dynamic contrast MRI including arterial, venous, and delayed phase (A-C)shows multiple
enchancing vascular spaces and area of contrast puddling as well as large draining veins
that empty into antecubital artery. (D) 3 color volume MRA Image shows simultaneous
opacification of veins and arteries of the forearm, diagnostic of arteriovenous
malformation
Bone Formation and Growth
 Skeleton
• Cortical
– Solid, compact, only interrupted by haversian systems
• Cancellous
– Trabeculae separated by fatty or hemapoietic marrow
• Bone grows only by apposition on the surface of
an already existing substrate
• Cartilage grow by interstitial cellular proliferation
and matrix formation
 Bone Formation
• 2 process
– Endochondral : spongiosa
– Intramembranous : cortex
• Most of the skeleton is formed by
endochondral
– Tubular and flat bone, vertebra, base of skull,
ethmoid, medial and lateral end of clavicle
 Intramembranous ossification
• Bone is formed directly without intervening
cartilaginous stage
• Condensed mesenchymal cell  differentiate
into osteoprogenitor  fibroblast 
osteoblast
• Active in the endosteal envelope covering the
inner surface of the cortex and in haversian
envelope at the internal surface of all
intracortical canals