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Musculoskeletal System Flashcards

1
Q

When answering the questions, what should be considered for each pathology?

A

For each pathology: -
- Patient presentation
- Potential pathway
- Differential diagnosis (DD)
- Appropriate imaging/diagnostics

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2
Q

What imaging modality is best used for bones and complex fractures?

A

CT

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3
Q

MRI is the best imaging modality for?

A

Joints and soft tissue structures

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4
Q

What is US used for in relation to MSK pathology?

A

Studies of joint
Fluid filled structures
Superficial structures
Some trauma cases (operator dependent - long wait)

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5
Q

What is RNI used for?

A

Fracture/ neoplasm detection

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6
Q

What is DEXA and Arthrography used for?

A

DEXA - Bone density
Arthrography - Assessment of joints

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7
Q

Why is CT most commonly used?

A
  • Widely available
  • Quick, easy and safe in trauma/emergency situation
  • MPR and 3D recon in complex fractures –(full assessment/ongoing pathway planning)
  • The spinal canal is well visualised and bone fragments impinging on the spinal cord can be seen
  • Sensitive for cortical destruction and soft tissues (good resolution)
  • Staging – distant
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8
Q

Why is MRI used?

A
  • Can diagnose bone bruising (early sign of trauma), and avascular necrosis (later)
  • Useful in the carpus, especially occult fractures of the scaphoid which are often missed on conventional images)
  • MRI provides superior ST definition & is invaluable for diagnosing injuries to joints/soft tissues, e.g. ligament laxity/tears, meniscal tears, cartilage and bone injuries
  • Accurate definition of tumor extent within marrow and into soft tissues
  • Very sensitive in the arthritides
  • Both sensitive and specific in the diagnosis of occult fractures
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9
Q

What are the negatives of using MRI?

A
  • Time consuming and not always readily available
  • Must consider magnet safety (patients with ferrous foreign objects etc.) and patient acceptability (claustrophobia)
  • Limited sensitivity in diagnosis of fractures at the time of the injury (high false positive rate)
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10
Q

What is MR Arthrography used for?

A

Used for diagnosis of internal shoulder joint derangements
Assess the joint capsule in shoulders
For looking at inside the shoulder joint to assess for injury/wear and tear
Can diagnose tendon tears, ligament detachments and cartilage damage

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11
Q

What contrast agent is used in MR Arthrography?

A

Gadolinium and Iodinated contrast

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12
Q

What are the negatives with using contrast for MR Arthrography?

A
  • Slightly invasive technique as contrast is injected directly into the joint
  • Joint is painful afterwards plus possible complication of infection in the joint
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13
Q

Why is US useful in MSK imaging?

A

No radiation dose
Fast, cheap and readily available
Assessing neurovascular structures (soft tissues, fluid filled & superficial structures)
Good ST assessment & useful for image guided biopsy

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14
Q

What pathologies on the knee is US widely used for?

A
  • Patellar tendonitis/apexitis – “jumper’s knee”
  • Medial meniscus tears
  • Quadriceps insertion tendinopathy with tendinosis, and calcifications
  • Joint effusion/cysts
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15
Q

How is Patellar tendonitis/apexitis – “jumper’s knee” visualised on US?

A

The patellar tendon is inflamed and thickened
Intrasubstance high signal intensity
Partial tearing of the proximal patellar tendon

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16
Q

What is tendinosis?

A

Tendinosis is the non-inflammatory degeneration of a tendon. This degeneration can include changes to the structure or composition of the tendon.

These changes often result from repetitive strain-injuries to a tendon without adequate time to heal.

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17
Q

What are the signs & symptoms of Achilles Tendinopathy?

A
  • Aching (occasionally sharp) pain in the heel.
  • Pain isaggravated by activity or pressure to the area.
  • Stiffness in the tendon, which may occur in the morning or after a period of prolonged sitting.
  • Tenderness, swelling, and crepitus along the tendon.
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18
Q

Why is RNI used for MSK?

A
  • High sensitivity for bony pathology and trauma, identifies cellular function
  • Can be combined PET/SPECT
  • Used in screening for metastatic bone disease
  • Confirming occult fractures and identifying areas of bone infection/osteomyelitis
  • Investigating metabolic bone disease, e.g. Paget’s
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19
Q

What are the negatives of using RNI?

A
  • Less readily available/longer examinations
  • Ionising radiation & aftercare requirements
  • Lack of specificity in disease characterisation, e.g. # scaphoid v. OA CMC joint thumb
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20
Q

What is DEXA used for in MSK imaging?

A

To assess bone density and also risk osteoporosis

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21
Q

What are the indications required for a DEXA scan?

A

Fracture: minor fall or injury
Early menopause
Ovaries removed (before 45)
Hasn’t had a HRT
Post-menopausal who smokes and drinks heavily
Family history of hip fractures
BMI < 21
Condition such as RA that leads to low bone density (male and female)
Large gaps between periods (> year)
Oral glucocorticoids for > 3 months (male and female)

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22
Q

Why is Arthrography used?

A

Examines the inside of a joint to assess an injury or symptom (shoulder, knee, wrist, ankle)

The most sensitive non-invasive examination for the evaluation of the joint capsule in shoulders

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23
Q

How is Arthrography conducted?

A

The contrast medium is injected into the joint capsule, which outlines the soft tissue structures (ligaments and cartilage)

Done under fluoroscopy to guide the placement of the needle for the contrast to be administered

It can be done using CT, US or MRI

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24
Q

What are the radiological features of tumors?

A

Solitary or multiple
Lytic or sclerotic
Type of bone (long bone, vertebra)
Where in the bone is the lesion (cortex, medulla, shaft)?
well-defined margin?
Cortical destruction?
Bony reaction?
Central calcification?
Soft tissue involvement?

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25
What are solitary bone cysts?
- Asymptomatic unless fractured, then pain and limited ROM - Solitary lytic metaphyseal lesion well-defined (possibly thin sclerotic) margin; narrow zone of transition - 'Fallen fragment sign' when fractured Healing fracture results in disappearance of the cyst
26
What is Osteochondroma?
--> Most common benign bone tumors: distal femur, proximal tibia, iliac crest ( Overgrowth of cartilage at margin of physis (grow away from it); ossification then produces a bony protuberance with a cartilage cap --> Stop growing at skeletal maturity often incidental finding but can produce a mass --> Usually asymptomatic, they vary in size Visible on x-ray/CT, and cartilage cap on US, MRI is the best
27
What is multiple Myeloma?
Cancer of the plasma (white blood cells) M:F = 2:1 Multiple sites - vertebra, ribs, skull, shoulder, pelvis, long bones
28
What is the clinical presentation of multiple myeloma?
Presents with bone pain and associated fatigue +/- weight loss, anaemia
29
What are the radiological signs of multiple myeloma?
Early onset shows widespread osteoporosis and prominent trabeculae (spine 'punched out' lesions, 'moth eaten' pattern)
30
What imaging modality and treatment are required for multiple myeloma?
Skeletal survey first; MRI and PET Chemotherapy; palliative radiography for painful lesions or lesions likely to develop pathological #
31
What is Osteosarcoma?
The most common primary malignant bone tumour in older children (rare <5) May be seen in adults as a result of previous radiotherapy or Paget's disease It arises in medullary canal and grows out and through the periosteum into surrounding ST's Long bone metaphyses, but will cross the physis before plate closure (>75% cases)
32
What is the clinical presentation of osteosarcoma?
Pain - constant, worse at night and gradually increasing in severity A palpable lump may be present later; +/- pain on examination
33
What is the imaging modality and radiolographic appearance of osteosarcoma?
CT/MRI to assess tumour extent; RNI bone scan for further lesions; CXR/CT chest for mets Radiologically: large bone lesion when detected; mixed density; ill-defined margins; bone destruction and cortical disruption; often associated aggressive periosteal reaction
34
What is Ewing Sarcoma?
2nd most common malignant bone tumour in children M>F; 5-30 yrs; rare >30 Arise in medullary cavity of long bones (pelvis, femur)
35
What is the clinical presentation of ewing sarcoma?
Localised pain and swelling; also fever, weight loss and anaemia
36
What is the radiographic appearance of Ewing sarcoma?
Ill-defined Lytic Destructive lesion; associated soft tissue mass/infiltration; and periosteal reaction Mets may be present in 30% of cases at initial involvement
37
What imaging modalities are used for Ewing sarcoma and why?
MRI for full evaluation (ST involvement; also staging) RNI bone scan for mets CT for bone destruction/extra-osseous involvement
38
Where are bony metastases common?
In vertebrae Pelvis Proximal femur Proximal humerus Lung Kidney Prostate (male) Breast (female)Wh
39
What are the clinical presentations of bony mets?
It depends on the primary but rest pain and night pain are 'red flag' symptoms Bony pain, systemic upset and pathological # Sudden onset pain in elderly Incidental finding on staging
40
What are the radiological aprearence of the bony mets?
Lytic: kidney, lung, thyroid, breast Sclerotic: prostate, breast, stomach Bone destruction; wide zone of transition
41
What imaging modality is used to define bony mets distribution?
RNI bone scan
42
Where does fibrous cortical defect/non-ossifying fibroma occur in?
Femur and tibia
43
What is the radiological appearance of fibrous cortical defect/non-ossifying fibroma?
Lucent lesion with well-defined sclerotic margin May be loculated Arises from cortex Slightly expansile
44
What is the potential patient pathway for arthritis?
GP Often, incidental findings on images Specialist referral (rheumatology clinic)
45
What is Osteoarthritis?
Degenerative joint disorder Progressive loss of articular cartilage and new bone formation Can be secondary (trauma to the joint)
46
In what part of the body is osteoarthritis more common?
In weight bearing joints - - hip - knee - spine ('spondylosis') - IP joints (females)
47
What is the clinical presentation of osteoarthritis?
Pain (morning or after rest) Aggravated by exertion (adjacent joint) Stiffness after inactivity (constant with disease progression) Soft tissue swelling
48
What are the radiological apprearance of osteoarthritis?
Bone density preserved Joint space narrowing Subchondral sclerosis Marginal osteophytes Subarticular cysts
49
What is the best imaging modality for osteoarthritis?
MRI to identify cartilage loss, effusions and cysts
50
What is rheumatoid arthritis?
Chronic inflammatory disease affecting synovium and articular surface M=F (F>M in earlier years) Articular erosion and destruction results in joint deformity and disability Late joint destruction and deformity
51
What are the clinical presentation of rheumatoid arthritis?
Fever Hot joints - Swollen and painful Effusion/bursitis Malaise Weight loss Weakness
52
What other body systems are affected by rheumatoid arthritis?
Chest - pulmonary interstitial fibrosis aka 'rheumatoid lung'
53
What are the early radiological signs of rheumatoid arthritis?
ST swelling Local osteopaenia Marginal and central bone erosions Joint space widening
54
What are the late radiological signs of rheumatoid arthritis?
Loss of joint space Marked destructive changes Subluxations Fragmentation Fractures and Ankylosis (fusion)
55
What imaging modality is best used to visualise rheumatoid arthritis?
MRI and US
56
What is MRI used for RA?
Assessment of peripheral joints for active inflammation in the form of joint effusions, synovitis Assessment of structural lesions e.g. articular cartilage damage, cortical bone erosions and tendons tears Assessment of inflammatory changes and post-inflammatory complications in the spine, i.e. assessment of inflammatory activity
57
Why is US used in RA?
High availability low cost high patient acceptance compared to MRI Assessment of peripheral joints for active inflammation in the form of effusion, synovitis, etc. Assessment of structural lesions such as tendons tears (cortical bone erosions and articular cartilage damage can be seen to some extent) Dynamic examination of peripheral joints, useful in the assessment of inflammatory changes Measurements of inflammation (intensity of vascularization, thickness of synovium)
58
What is metabolic bone disease?
Disorders of bone strength, usually caused by abnormalities of minerals (e.g. calcium, phosphorus), vitamin D, bone mass or bone structure, but can also be due to e.g. prolonged steroid use
59
What does metabolic bone disease include?
Osteoporosis Paget's disease
60
Patients who suffer bone pain due to metabolic disease are more predisposed to what?
Fractures including vertebral compression, which leads to loss of height
61
What is osteoporosis?
Systemic skeletal disease characterised by low bone mass and deterioration of bone tissue Systemic skeletal disease characterised by low bone mass and deterioration of bone tissue Vertebral fractures often asymptomatic and discovered incidentally; kyphosis and loss of height can result from vertebral compression fractures
62
Who is most affected by osteoporosis?
Post-menopausal women
63
What is the prevalence of osteoporosis?
Increases with age
64
What is the imaging modality for osteoporosis?
DEXA is investigation of choice for diagnosis
65
What is the aetiology for paget's disease?
Unknown aetiology; causes abnormal remodelling of bone – thickened, disorganised fragile trabeculae result
66
What is the radiological appearance of paget's disease?
Radiologically: “cotton wool bones”; thickened cortices, coarse trabeculae; cyst-like areas during early lytic phase
67
What is the prognosis of pagets disease?
Poor - Potential for sarcomatous change
68
What part of the body is affected by paget's disease?
pelvis lumbar and thoracic vertebrae, proximal femur, skull and tibia
69
What is acute osteomyelitis?
Pathological sequence is inflammation, suppuration, necrosis, new bone formation, resolution
70
How does acute osteomyelitis spread?
Spread via blood supply (haematogenous) or direct implantation from trauma
71
Who are affected by acute osteomyelitis?
Majority children Immunocompromised adults (diabetes, drugs, disease) Adults (spine or lower extremities in diabetics)
72
What is the patient presentation of acute osteomyelitis?
Feverish and general malaise Severe pain Later – local erythema, oedema, warmth Beware adults with new onset back pain with associated systemic upset Lymphadenopathy present but not specific Infants may present as non-specific failure to thrive Symptoms may also be mild in elderly and immuno-suppressed
73
What imaging modalities are used for acute osteomyelitis?
Plain imaging initially likely to be normal Look for displacement of fat planes – due to soft tissue swelling or accumulation of fluid Visible lucency ~5-7 days Bony necrosis and periosteal reaction ~10-14 days MRI useful in early stages – bone marrow changes NM bone scans useful
74
What are the future trends and treatments for spinal stenosis?
Neurosurgical treatment Physical therapy Medicine (muscle relaxant) Steroid Injection
75
What are the MSK interventions?
Facet joint injection (fluro/ CT) Nerve root block (Fluoro) Radio-frequency ablation (Fluoro, CT, MRI) Thermal ablation (CT, MRI, or US) Discography Percutaneous vertebroplasty/balloon kyphoplasty
76
What is the future trend for MSK pathologies?
Digital Tomosynthesis: An imaging technique that uses standard X-ray equipment with digital flat panel detectors to create tomographic images from very low-dose projections obtained at different angles
77
Why is digital tomosynthesis used?
Lower dose to CT and standard radiography It is superior to conventional radiography when there are bone superimpositions or when metal structures hide regions of interest The high resolution and its ability to perform examinations in weight-bearing positions are some of the main advantages of this technique

The Patient Pathway (6 decks)

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