Muskuloskelatal Flashcards

Question

What is arthrography used for in MSK imaging?

Answer 1

Examine the inside of a joint - shoulder - knee - wrist - ankle To assess an injury or symptom

Answer 2

Contrast medium is injected into the joint capsule which outlines the soft tissue structures (e.g. ligaments and cartilage) Done under image guidance, usually fluoroscopy - Fluoroscopy is used to guide the placement of the needle for administration of the contrast medium May also be done using CT, US or MRI MR arthrography is widely believed to be the most sensitive non-invasive examination for the evaluation of the joint capsule in shoulders

Answer 3

Depends on severity of presenting symptoms, and location of imaging department, e.g.: MVA – patient will be referred via A&E Minor injury to e.g. finger – likely A&E, but patient may also be referred via GP (and may be some time after initial trauma) If you work in a GP-led community site/MIU – initial presentation here, with transfer to more specialist centre as required?

Answer 4

Assessment tool? e.g. ATLS, Ottowa…. Mechanism of injury (‘MOI’) – speed, force, twisting/direct blow, everyday activity?...... Presenting symptoms, including pain and functional ability Patient perspectives Social/family history, e.g. does the patient live alone? PMH Current medication Specialist intervention e.g. orthopaedics

Answer 5

In department, mobile (e.g. in resus.); in theatre (II for e.g. ORIF, etc.)

Answer 6

Soft tissue/neurovascular structures Joints FAST (Focussed Assessment with Sonography for Trauma) – pelvic trauma

Answer 7

Complex fractures; assessment prior to intervention

Answer 8

Joints, particularly soft tissue structures; unlikely in acute case if patient unstable

Answer 9

Occult fractures; not in acute patients

Answer 10

Bone density assessment after e.g. #NOF

Answer 11

Ewing’s sarcoma; osteosarcoma

Answer 12

chondrosarcoma

Answer 13

mets more common than 1°

Answer 14

Likely via GP, in first instance May be A&E if pathological # (trauma) is the presentation May be via specialist, if referred there first from GP

Answer 15

Patient presentation PMH Physical examination Specialist referral Imaging Biopsy Staging (malignancy) – looking for local/distant spread

Answer 16

Plain imaging – first line MRI – bony and soft tissue information; tumour extent CT – bony detail RNI bone scan – other lesions US – soft tissues Staging – CXR, CT, MRI, RNI bone scan

Answer 17

Solitary or multiple? Lytic or sclerotic? What type of bone, e.g. long bone, vertebra, etc.? Where in the bone is the lesion, e.g. cortex, medulla, shaft, etc.? Well-defined margin? Cortical destruction? Bony reaction? Central calcification? Soft-tissue involvement?

Answer 18

simple bone cyst or unicameral bone cyst

Answer 19

Proximal humerus femur iliac bone calcaneum in >20 year

Answer 20

Asymptomatic unless fractured, then pain and limited ROM Benign

Answer 21

Solitary lytic metaphyseal lesion Well-defined (possibly thin sclerotic) margin narrow zone of transition Can be slightly expansile Endosteal scalloping/erosion Often see ‘fallen fragment sign’ when fractured Healing of the fracture will usually result in disappearance of the cyst

Answer 22

Bony exostisis

Answer 23

Most common benign bone tumour Overgrowth of cartilage at margin of physis (grow away from it); ossification then produces a bony protruberance with a cartilage cap Stops growing at skeletal maturity Often incidental finding, but can produce a mass <1% can undergo malignant change => chondrosarcoma May be multiple – ‘hereditary multiple exostoses’

Answer 24

distal femur, proximal tibia, iliac crest

Answer 25

Usually asymptomatic and vary in size (largest ~4cm)

Answer 26

Most common 1° malignant bone tumour in adults Cancer of plasma (white blood) cells

Answer 27

Visible on plain imaging/CT, cartilage cap on US, MRI is the best imaging modality to assess cartilage thickness (and thus assessing for malignant transformation), the presence of oedema in bone or adjacent soft tissues, and visualising neurovascular structures in the vicinity

Answer 28

40 years +; M:F = 2:1

Answer 29

Multiple sites – vertebra, ribs, skull, shoulder, pelvis, long bones

Answer 30

Present with bone pain and associated fatigue +/- weight loss, anaemia

Answer 31

Skeletal survey first; MRI and PET are also useful Chemotherapy; palliative radiotherapy for painful lesions or lesions likely to develop pathological #

Answer 32

Arises in medullary canal and grows out and through the periosteum into surrounding ST’s Esp. long bone metaphyses, but will cross the physis before plate closure in >75% cases

Answer 33

Most common primary malignant bone tumour in older children (rare <5), adolescents and young adults May also be seen in adults as a result of previous Radiotherapy or Paget’s disease

Answer 34

Clinical presentation is pain – constant, worse at night and gradually increasing in severity Palpable lump may be present (later), +/- pain on examination

Answer 35

Radiologically – large bone lesion >5-6cm when detected; mixed density; ill-defined margins; bone destruction and cortical disruption; often associated aggressive periosteal reaction

Answer 36

CT/MRI to assess tumour extent; RNI bone scan for further lesions; CXR/CT chest for mets

Answer 37

2nd most common malignant bone tumour in children (after osteosarcoma) Mets may be present in ~30% of cases at time of initial diagnosis!

Answer 38

Accounts for ~1/3 of all 1° bone tumours M>F; age range 5-30 years, esp. 5-15, rare >30

Answer 39

long bones pelvis Arise in medullary cavity of long bones

Answer 40

Localised pain + swelling fever weight loss anaemia Ill-defined lytic destructive lesion associated soft-tissue mass/infiltration and periosteal reaction

Answer 41

MRI for full evaluation, esp. ST involvement; staging RNI bone scan for mets CT for bone destruction/extra-osseous involvement

Answer 42

More common than 1° bone tumours Common in vertebrae, pelvis, proximal femur, proximal humerus Common adult primary – lung, kidney, prostate (male) breast (female)

Answer 43

Clinical signs depends on the primary, but rest pain and night pain are ‘red flag’ symptoms May also experience bony pain, systemic upset and pathological # May present as sudden onset of pain in elderly

Answer 44

Radiological appearance depends on primary: Lytic – kidney, lung, thyroid, breast Sclerotic – prostate, breast, stomach Bone destruction; wide zone of transition May present as an incidental finding on staging

Answer 45

RNI bone scan useful to define distribution

Answer 46

Most common benign tumour of bone Histologically identical, but FCD < 2cm, NOF > 2cm BENIGN INCIDENTAL FINDING!!! A “leave me alone” lesion

Answer 47

Age 10 – 20 years

Answer 48

Common femur and tibia Diametaphyseal Lucent lesion with well-defined sclerotic margin May be loculated Arises from cortex Slightly expansile

Answer 49

Most likely via GP Often incidental finding on images for something else! Can be specialist referral, e.g. Rheumatology Clinic

Answer 50

Degenerative joint disorder Progressive loss of articular cartilage and new bone formation Can be secondary to e.g. trauma to the joint Commoner in weight bearing joints – hip, knee, spine (“spondylosis”); IP joints common in females

Answer 51

Pain, esp. in the morning or after resting; aggravated by exertion; often referred from adjacent joint Stiffness after inactivity but likely constant with disease progression Soft tissue swelling

Answer 52

Radiologically (WB if appropriate) – bone density preserved, joint space narrowing, subchondral sclerosis, marginal osteophytes, subarticular cysts

Answer 53

MRI would be best for identification of cartilage loss, effusions and cysts

Answer 54

Chronic inflammatory disease affecting synovium and articular surface Articular erosion and destruction results in joint deformity and disability

Answer 55

1% population; M=F (F>M in earlier years)

Answer 56

Acutely involved joints are: hot, swollen painful, often with effusion/bursitis Systemic symptoms include: fever malaise weight loss weakness Late joint destruction and deformity Other body systems can be affected too, e.g. chest – pulmonary interstitial fibrosis, aka “rheumatoid lung”

Answer 57

Early radiological signs – Soft tissue swelling, local osteopenia, marginal and central bone erosions, joint space widening Late radiological signs – loss of joint space, marked destructive changes, subluxations, fragmentation, fractures ankylosis

Answer 58

MRI and US are increasingly being used to demonstrate the presence of RA much earlier than conventional imaging

Answer 59

Assessment of peripheral joints for active inflammation in the form of joint effusions, synovitis, etc. 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, atlanto-axial/ atlanto-occipital structural lesions (e.g. subluxations)

Answer 60

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)

Answer 61

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

Answer 62

They include: Osteoporosis Paget’s disease

Answer 63

Patients suffer bone pain, and are more predisposed to fractures, including vertebral compression which leads to a loss in height

Answer 64

Often an incidental finding,- particularly in the case of the pathological # May be via GP, for bone pain Loss of height (more difficult to pin down, as this is seen as part of the ageing process!) (Need to consider ‘big’ picture, e.g. in the prolonged use of steroids scenario) Blood tests and imaging for diagnosis

Answer 65

Systemic skeletal disease characterised by low bone mass and deterioration of bone tissue Increased bone fragility and susceptibility to fracture;

Answer 66

often diagnosed secondary to a fracture (esp. NOF, vertebrae, wrist) Vertebral fractures often asymptomatic and discovered incidentally; kyphosis and loss of height can result from vertebral compression fractures Increased resorption compared to formation of bone

Answer 67

Post menopausal women most affected Prevalence increases with age (Exclude eating disorders in young patient)

Answer 68

Bone density is difficult to interpret on plain images, ‘osteopaenia’ to describe reduced bone density DEXA is investigation of choice for diagnosis

Answer 69

causes abnormal remodelling of bone – thickened, disorganised fragile trabeculae result

Answer 70

Rare before age 40; M>F

Answer 71

Often asymptomatic Pain; bowing long bones; pathological #; enlarging bone, esp. cranium; deafness, due to ossicle involvement/cranial nerve compression; secondary arthritis Esp. pelvis, lumbar and thoracic vertebrae, proximal femur, skull and tibia

Answer 72

Radiologically: “cotton wool bones”; thickened cortices, coarse trabeculae; cyst-like areas during early lytic phase Potential for sarcomatous change (poor prognosis)

Answer 73

Majority in children; adults secondary to immunocompromised, e.g. diabetes, drugs, disease

Answer 74

Spread via blood supply (haematogenous) or direct implantation from trauma Metaphysis most common site in children In adults: spine or lower extremities in diabetics

Answer 75

inflammation, suppuration, necrosis, new bone formation, resolution

Answer 76

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

Answer 77

Plain imaging is 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

Answer 78

Kormans triangle It is a sign of osteosarcoma - which is an aggressive tumour in the bone (sunburst)

Answer 79

sunburst effect periosteal and lytic mixed-density tumour