Role of Radiology in

Musculoskeletal System
Hawler Medical University
College of Medicine
Radiology Unit
Objectives:

By the end of this session, the student should be able to:

1. Describe the imaging modalities and techniques commonly used in

the evaluation of the musculoskeletal system.

2. Describe common indications for the use of each modality.

3. Identify the advantages and disadvantages associated with each

modality.
 What is Radiology?
1. Radiology =Diagnostic Imaging = Diagnostic radiology =
Clinical Imaging

2. Radiology is an essential tool for the modern physician.

3. It allows us to analyze anatomy, detect pathologies and monitor

disease healing or progression.

4. In the musculoskeletal system, imaging is important to detect

injuries and other pathologies.
What do we need in Diagnostic
Imaging?
All imaging modalities have the same principle components:

1. An object to analyze (i.e. the patient)

2. An energy source (i.e. light or sound waves)

3. A detector (i.e. x-ray film, MRI detector)

What are the types of Imaging modalities used in
Musculoskeletal system ?
What are the types of Imaging modalities used in
Musculoskeletal system ?
Each modality has advantages and disadvantages and therefore is best suited
to the investigation of particular clinical scenarios.

The most common types of imaging used in the investigation of the

musculoskeletal system are:

1. Plain radiographs (x-rays) also called conventional radiography .

2. Computed Tomography (CT)

3. Magnetic Resonance Imaging (MRI)

4. Ultrasound (U/S)

5. Bone Scan = Scintigraphy= radio-isotope scanning.

6.Bone Densitometry
 X - Ray =Conventional
Radiography
• Plain radiographs (or x-rays) are the first line in imaging of MSK system.
 X - Ray =Conventional Radiography
How it works?
X-rays contain high-energy photons which are transmitted through a
patient at a specific angle toward a cassette containing photographic
film. The x-rays cause the film
to darken. The relative density of the structures that are imaged
modulates the number of photons that reach the film; dark areas on
the completed radiograph indicate areas of low
density (i.e. air) and light areas indicate a high density structure (i.e.
bone).
 X - Ray =Conventional Radiography

• Advantages:

• X-rays are relatively inexpensive, quick, specific, and highly available.

• Show bone fractures and bone and joint pathology.

• Disadvantages :

• It utilizes x-ray which is an Ionizing Radiation.

• They are less sensitive to bone marrow pathology than bone scan or MRI, and less sensitive to cortical bone
pathology than CT scans.

• No optimal for soft tissue evaluation.

How many densities(shades of grey )
can we see in an x ray image ?
 X - Ray =Conventional
Radiography
• X rays has 5 densities according
• to the tissue absorption of the xa ray beam :
• From brightest to darkest

1.Metallic foreign body

2.Bones and calcification

3.Soft tissue and fluid

4.Fat

5.Air
X - Ray =Conventional
Radiography
• In cases of trauma and injury , X ray of the injured
part is requested in two views at 90o to each other to
exclude fractures or dislocations .
X - Ray =Conventional
Radiography
If a patient is presented with signs and symptoms of
musculoskeletal pathology ( i,e Infection , tumor) without history
of trauma or injury , X-ray is the first imaging modality to send
for, and according to the findings , more advanced imaging
modalities (like CT or MRI) might be required.
• Arthrograpgy : means injecting a contrast media into a joint space
then taking x ray images to study the joint spaces and evaluate them.

• Contrast media ( agent or material) , is a chemical substances used in

diagnostic imaging , in x ray it is usually contains iodine and appears
radio opaque on radiographs.
CT (Computerized Tomography)

• CT scan provides a more detailed picture of the anatomical area that is imaged.

• It is often used as a follow-up to an abnormal radiograph or is requested when

radiographs fail to completely answer the clinical question.

• CT scan provides very good bone detail and improved soft tissue resolution.
 CT (Computerized Tomography)
How it works
• CT uses a rotating X-ray beam to pass through “slices” of the body. These are detected by a
computer and recreated into axial images. These images can be reconstructed in any plane or
three-dimensionally to demonstrate the anatomy and pathology.

X ray source

Row of detectors
 CT scan images of
pelvis in bone window and
soft tissue window
CT (Computerized Tomography)

• Advantages :

• IT shows more anatomical details than x ray .

• Can be reconstructed into 3D images .

• Gives excellent details regarding cortical bone .

• More fast and less time consuming than MRI (more suitable for
emergency setting).

• Main Disadvantage is : It delivers a high radiation exposure , much

more than x ray.
 Magnetic Resonance Imaging-MRI
• MRI stands for Magnetic Resonance Imaging. It is the “gold standard” of soft tissue imaging, and has
the added advantage of requiring no ionizing radiation.

• MRI utilizes a strong magnetic field and radio frequency pulses to produce the MR images.

• Each tissue-type has a unique appearance on MRI which helps the radiologist to identify anatomy and
pathology such as trauma, infection, inflammation or tumor.
 Magnetic Resonance Imaging -MRI

• Advantages

1.Excellent soft tissue contrast , can evaluate muscles , tendons , ligaments and other soft tissue structures better than CT
and detect early pathologies.

2.Multi-planar

3.No radiation
 Magnetic Resonance Imaging -MRI
• Disadvantages

1.Expensive

2.Poor cortical bone detail.

3.More time consuming and long procedure, it also may be uncomfortable for some patients (long, noisy,
claustrophobic) .

4.Children may require general anesthetics because of the need to lie still for extended periods of time

5.Cannot use if patient has certain metal or electronic implants such as pacemakers, heart valves, aneurysm clips, some
orthopedic prosthesis and fixations that are not MR compatible..
What is the advantage of open MRI systems ?
 Ultrasound
• Ultrasound uses sound waves to provide real-time imaging of anatomic structures.

• It is widely used now in MSK imaging and is useful for evaluating soft tissue and identifying
joint effusions and integrity of the joint capsule, ligaments and tendons , even the large
peripheral nerves.

• It has limited use in the evaluation of bony structures.

 Ultrasound
It utilizes high regency sound waves that are non audible to human ear (human ear ranges from 20-20000Hz) —
Ultrasound ranges from 2-20 MHz ..
• How it works

• Sound waves are transmitted from a probe placed in contact with the skin. These waves are
reflected back to a receiver. The characteristics of the returning sound waves are used to
generate a picture, as different tissues cause the sound waves to be reflected differently.
Ultrasound produces a tomographic (cross-sectional) image.
 Ultrasound

• Advantages

• Highly available

• Real-time

• No ionizing radiation

• Good soft tissue contrast

• Disadvantages

• Results vary with expertise of technologist and radiologist ( Operator dependent).

• Ultrasound waves cannot penetrate bone or air.

 Ultrasound

• Ultrasound is the preferred imaging technique to visualize infant hips when congenital hip
dysplasia is suspected (up to 8 months of age when the femoral head is not yet ossified but
once it is ossified the diagnosis can be made by plain x ray ).
 Radioactive Bone Scan ( Nuclear Medicine)
Bone scan is used to detect metabolically active
bone. This is useful to detect occult fractures,
infections, and bony metastases which may be
difficult to detect with other imaging modalities.
 Radioactive Bone Scan ( Nuclear Medicine)
• How it works

• A radioactive tracer (Technetium 99 is commonly used) is injected intravenously. This accumulates in

areas of bone undergoing rapid metabolic activity. Over a period of several hours, the tracer passes
from the vascular system to bone. A gamma- detector is used to produce an image. “Hot spots” occur
where the radionuclide has accumulated, demonstrating areas of high metabolic activity.

• Watch this video in this link- https://www.youtube.com/watch?v=w4XRWLy8Z5Y

 Radioactive Bone Scan ( Nuclear Medicine)
• Advantages

• Early detection of metastases and infection

• Detection of occult fractures not visible on plain radiographs

• High sensitivity

• Disadvantages

• Radiation risk (more than plain films but less than CT)

• May be difficult to interpret in children due to the presence of metabolically active growth
plates.

• Not available in all imaging departments.

• Poor specificity
Bone Densitometry = Dual Energy X Ray
Absorbtiometry DEXA or DXA )
Bone density scanning, also called dual-energy x-ray absorptiometry
(DXA) or bone densitometry, is an enhanced form of x-ray technology
that is used to measure bone loss. DXA is today's established
standard for measuring bone mineral density (BMD).
Bone Densitometry = Dual Energy X Ray
Absorbtiometry DEXA or DXA )
Advantages:

• It is a simple, quick and noninvasive procedure.

• DXA bone density testing is the most accurate method available for the
diagnosis of osteoporosis and is also considered an accurate estimator of
fracture risk.
• No radiation remains in a patient's body after an x-ray examination.

Disadvantages:
• Radiation risk but the amount of radiation used is extremely small—less
than one-tenth the dose of a standard chest x-ray.

• Women should always inform their physician or x-ray technologist if

there is any possibility that they are pregnant. See the Safety page for more
information about pregnancy and x-rays.
 Summary
• You are now familiar with the imaging modalities available to
evaluate the musculoskelteal system.

• Doctors must be send a patient to the proper imaging modality

according to the clinical scenario (History , signs and
symptoms ), in other words, the investigation must be
justified .

• Radiation protection must be concidred when performing the

studies that involve high radiation risk.

• Doctors must follow the rule of Benefit outweighs the risk

when they send a patient for a radiological study.
 Student’s Self Study
• What is PET scan ?
1.65 year old female presented with backache and loss of
height more than 2 inches , her plain radiograph of
lumber spine showed multiple collapsed vertebrae ,
laboratory tests showed vitamin D deficiency
,osteoporosis suspected what will be most accurate
investigation to diagnose it ?
2-Young male presented with sudden sever lower backache
after lifting heavy things , the pain radiate to buttock,
posterior and lateral part of leg, and aggravate by
movements , clinical examination suggest disc prolapse
what is the best radiological investigation of choice ?
1. 60 years old male with history of prostatic carcinoma
presented with sever generalize body ache, bone metastasis
suggested what radiological investigation is recommended to
diagnose it?
 
2-12 years child presented with history of fall from height,
presented with loss of consciousness, fracture or dislocation of
cervical spines suspected what is the best radiological
investigation?
 References
• https://meds.queensu.ca/central/assets/modules/msk_im
aging/attach/imaging_slides.pdf