复旦大学附属华山医院

Antero-posterior View Normal cervical plain film vertebra ( pl. vertebrae) vertebral body (arch) 椎骨 椎体 ( 弓 ) pedicle of vertebral arch 椎弓根 lamina of vertebral arch 椎弓板 vertebral foramen 椎孔 spinous process 棘突 transverse process 横突 superior (inferior) articular process 上 ( 下 ) Lateral View Oblique View

Lateral View

Normal thoracic vertebrae

Antero-posterior View

Normal lumbar vertebrae

Normal sacrum & coccyx

Normal thoracic vertebrae of child

hip bone ilium Pubis 耻骨 Ischium 坐骨 Normal pelvis head (neck) of femur 股 骨头 ( 颈 )

Greater tubercle Lesser tubercle head of humerus 肱骨头 anatomical(surgical)neck 解剖 ( 外科 ) 颈 greater(lesser)tubercle 大 ( 小 ) 结节 Normal Humerus

Normal Femur

clavicle acromion glenoid process Normal Shoulder joint greater tubercle

With calcified epiphysis and carpals bones fully formed Normal finger

Epiphyseal gaps

Normal finger of infant

carpal

Normal Wrist

olecranon upper (proximal) end of the ulna 鹰嘴

radius

Normal Forearm

ulna

Normal Knee

Epiphyseal gap

Normal Knee of Child

Normal Tibia & Fibula

talus 距骨 calcaneus 跟骨 navicular bone 足舟骨 medial cuneiform bone 内侧楔骨 lateral cuneiform bone 中间楔骨 intermediate cuneiform bone 内侧楔骨 cuboid bone 骰骨 Normal Ankle

骨骼肌肉系统的检查方法

examination methods of musculoskeletal system

Plain Film CT MRI Arthrography: evaluating conditions of joints.(contrast enhanced)

常见骨骼肌肉系统病的

X

线表现

Radiograms of musculoskeletal diseases

骨折

Fracture

关 节脱位：完全脱位和半脱位 Dislocation

( 5)Linear fracture: A fracture that is parallel to the bone's long axis. (6)Transverse fracture: A fracture that is at a right angle to the bone's long axis.

(7) Oblique fracture: A fracture that is diagonal to a bone's long axis. (8)Spiral fracture: A fracture where at least one part of the bone has been twisted.

(9)Impacted fracture: A fracture caused when bone fragments are driven into each other.

股骨粗隆间骨折 Intertrochanteric fracture of femur

L 3

椎体断裂 Lumbar Vertebral body fracture

胫骨骨干上段疲劳骨折 Fatigue Fracture in the Proximal Segment of Tibia with periosteal rxn

Colles

骨折 Colles’ fracture Distal Radius fracture; dorsal (posterior) displacement of the wrist and hand

椎体压缩骨折 Vertebral Compression fracture

胫骨骨折线 Tibia fracture line

骨折的 对位与对线 骨折断端的内外、前后和上下 移位称 对位不良 。成角移位称 对线 不良 。

青枝骨折 Greenstick fracture (during infancy and childhood when bones are soft.)

儿童青枝骨折 Greenstick fracture

 Bone tumors are diverse in their gross and morphologic features and range from benign to rapidly fatal. This diversity makes it critical to accurately diagnose and stage tumors.  Timely, accurate diagnosis allows appropriate treatment so that the patients can not only survive, but also maintain optimal function of the affected body parts.

 Most bone tumors are classified according to the normal cell or tissue of origin. Lesions that do not have normal tissue counterparts are grouped according to their distinct clinicopathologic features.  Overall, matrix-producing and fibrous tumors are the most common. Among the defect are most frequent. neoplasms of marrow origin, benign tumors, osteochondroma and fibrous cortical Excluding malignant osteosarcoma is the most common primary cancer of bone , followed by chondrosarcoma and Ewing sarcoma.

 The precise incidence of different bone tumors is not known because many benign lesions are not biopsied. hundredfold. Benign tumors outnumber malignant tumors by at least several  Benign tumors have their greatest frequency within the first three decades of life, whereas malignant tumors are much more common in the elderly.  In the United States, about 2,100 new cases of bone sarcoma are diagnosed annually, and approximately 1,300 deaths from bone sarcoma occur each year.

 Clinically, bone tumors present in various ways. The more common benign lesions are frequently asymptomatic and are detected as incidental findings.  Many tumors, however, produce pain or are noticed as a slow-growing mass.

Sometimes, the first hint of a tumor's presence is a sudden pathologic fracture .

Diagnosis

• Radiographic analysis plays an important role in diagnosing bone tumors. In addition to providing the exact location and extent of the tumor , imaging studies can detect features that help limit the differential diagnosis and give clues to the aggressiveness of the tumor. Ultimately, in most instances, biopsy and histological study are necessary.

 Osteosarcoma is defined as a malignant mesenchymal tumor in which the cancerous cells produce bone matrix.

 Osteosarcomas occur in all age groups but have a bimodal age distribution; 75% occur in patients younger than age 20.  In adolescents, is almost equal.

and about half of them metaphysis around the knee, either in the distal femur or proximal tibia .

arise in the These are the sites of greatest skeletal growth activity. In persons over age 25, the incidence in flat bones and long bones

Major sites of origin of osteosarcomas. The numbers are approximate percentages.

 Osteosarcomas typically present as painful and progressively enlarging masses . Sometimes a sudden fracture of the bone is the first symptom.

 Grossly, osteosarcomas are bulky tumors areas of degeneration that are gritty, gray-white, and often contain hemorrhage and cystic . The formation of bone by the tumor cells is characteristic of osteosarcoma. Osteosarcoma of the upper end of the tibia. The tan-white tumor fills most of the medullary cavity of the metaphysis and proximal diaphysis. It has infiltrated through the cortex, lifted the periosteum, and formed soft tissue masses on both sides of the bone.

  Radiographs of the primary tumor usually show a mass large, destructive, mixed lytic and blastic . The tumor frequently breaks through the cortex and lifts the periosteum , resulting in reactive periosteal bone formation. The triangular shadow between the cortex and raised ends of periosteum is known radiographically as

Codman triangle

and is characteristic, but not diagnostic of this tumor . ‘Sunburst’ dense radiating bony speculations Distal femoral osteosarcoma with prominent bone formation extending into the soft tissues. The periosteum, which has been lifted, has laid down a proximal triangular shell of reactive bone known as a Codman triangle

(arrow)

.

Osteosarcoma

Central osteosarcoma. A, A destructive lesion is seen in the metaphysis on this anteroposterior view of the knee in a young teenager with pain.

B,

A magnetic resonance scan of both legs shows the soft tissue extent of the tumor

(arrows).

Osteosarcoma in right scapula (osteoblastic:dense and structureless) 右肩胛盂骨肉瘤 ( 成骨型 )

Osteosarcoma (mixed osteoblastic and osteolytic) 肱骨远段肉瘤 ( 混合型 )

Osteosarcoma of the tibia 胫骨近端骨肉瘤

股骨干骺端骨肉瘤 Osteoblastic osteosarcoma

Osteolytic type osteosarcoma 溶骨性骨肉瘤

混合性骨肉瘤 Mixed type osteosarcoma

T1WI

Osteosarcoma

T2WI T1WI +C

 Osteoid osteomas are bone tumors less than 2 cm in greatest dimension and usually occur in patients in their teens and twenties. In fact, 75% of patients are under age 25.

 Osteoid osteomas can arise in any bone but have a tibia, predilection for the appendicular skeleton. 50% of cases involve the femur or where they commonly arise in the cortex.  Osteoid osteomas are painful lesions . The pain is caused by excess prostaglandin E produced by the proliferating osteoblasts. It characteristically occurs at night 2 which is and is dramatically relieved by aspirin.

 Osteoid osteoma. A lateral view (A) of the proximal tibia shows a very dense lesion in the posterior cortex. A darker central area contains a white nidus. This lesion in a 20-year-old man caused pain in this area, relieved by aspirin. B, A nuclear medicine bone scan in a different patient with an osteoid osteoma in the left lower tibia shows increased activity (arrows) at the site of the lesion.

Specimen radiograph of intracortical osteoid osteoma. The round radiolucency with central mineralization represents the lesion and is surrounded by abundant reactive bone that has massively thickened the cortex.  Osteoid osteomas, especially those that arise beneath the periosteum, usually elicit a tremendous amount of reactive bone formation that encircles the lesion . The actual tumor, known as the nidus , manifests radiographically as a small round lucency that is variably mineralized

 Osteoid osteomas’ are considered benign and are normally treated by conservative surgery.  However there is a possibility of malignant transformation. This is rare except when treated with radiation, which promotes this complication.

 Osteochondroma, also known as an exostosis, is a benign cartilage-capped outgrowth stalk.

It is a relatively common lesion that is attached to the underlying skeleton by a bony and can be solitary or multiple.  Multiple osteochondromas become apparent during childhood but solitary osteochondromas are usually not diagnosed until late adolescence .  Men are affected 3 times more often than women.  They arise from the metaphysis near the growth plate of long tubular bones , especially the knee.

 Clinically, osteochondromas present as slow-growing masses , which can be painful if they impinge on a nerve or if the stalk is fractured .  In many cases, they are detected as an incidental finding.

Osteochondroma.

On this lateral view of the ankle, a benign osteochondroma is seen projecting posteriorly on a stalk. The end

(arrows)

is often covered with a cartilaginous cap. These lesions always occur near a joint but point away from it.

Osteochondroma

 Fibrous cortical defects are extremely common, found in 30% to 50% of all children older than age 2 years.

They are believed to be developmental defects rather than neoplasms.  The vast majority arise in the metaphysis of the distal femur and proximal tibia , and almost one half are bilateral or multiple.  Fibrous cortical defects are small and those that grow to 5 or 6 cm in size are called non ossifying fibromas.

 Fibrous cortical defects are asymptomatic and are usually detected on x-ray as an incidental finding . The vast majority have limited growth potential and undergo spontaneous resolution within several years.

 The few that progressively enlarge into non ossifying fibromas usually show up in adolescence. They may present with pathologic fracture and then require biopsy to exclude other types of tumors.

 Both fibrous cortical defects and nonossifying fibromas produce elongated, sharply demarcated radiolucencies that are surrounded by a thin zone of sclerosis.

Nonossifying fibromas of the distal tibial metaphysis, producing an eccentric lobulated radiolucency surrounded by a sclerotic margin.

Nonossifying Fibroma

Non-ossifying Fibroma

 Occurs in childhood, rare in adults , more in males  Most in prox. Humerus or prox. Femur        Two forms: active - inactive In their fluid has been reported PGE2 Malignant transformation has been reported asymtomatic unless fracture is present Obliteration after healing of fracture X.Ray : lytic lesion Treatment: -curettage with or without bone graft.

-aspiration followed by instillation of . . Methylprednisolone F.I.N

单 纯 骨 囊 肿

股骨颈下和股骨干上端骨囊肿 Unicameral bone cyst

肱骨骨干骨囊肿 Unicameral bone cyst

Giant cell tumor

-occur in mature long bones(dis. femur & prox. Tibia), in age 20-40 and rarely in adolescent -located in epiphysis abut subchondral bone -pulmonary metastases occur in 3% of pat.

-pul. Metas. May have spontaneous regression or lead to death -path. Fractures occur in 10-30% -x-ray: purely lytic lesion and expands through cortex . Malignant expands to soft tissues MRI; determine the extent of the lesion -treatment: extended curettage with phenol or argon beam arthroplasty or aethrodesis may be indicated =radiation may be used for inoperable lesions(spine , pelvis)

肱骨大结节下骨巨细胞瘤 Greater tubercle of humerus GCT

股骨干骺端骨巨细胞瘤 GCT of femoral metaphysis

桡骨远端骨巨细胞瘤 GCT of the distal radius

腓骨骨巨细胞瘤 GCT of fibula

T1WI T2WI T2*WI

T1WI T2WI

GCT of the distal end of the ulna

 Most common malignant lesion of bone  Bone is # 3 on the list of favorite places for mobile cancers to go  Malignant lesions are more likely to be in axial bones  Typically multifocal BUT renal and thyroid carcinomas are notorious for producing only a solitary lesion  Can be lytic, blastic, or both :  Lung is Lytic , Prostate Produces blastic , Breast does Both

  其它 肿瘤

Other tumors

多发性骨髓瘤 Multiple myeloma of skull and pelvic

骨质坏死

Bone necrosis

股骨头坏死 Avascular necrosis of the femoral head

Avascular necrosis of the femoral head Stage

Ⅰ

Avascular necrosis of the femoral head Stage

Ⅱ

Avascular necrosis of the femoral head Stage

Ⅰ

Avascular necrosis of the femoral head Stage

Ⅱ

 Pathogenesis In developed countries skeletal TB is a disease of adults and represents reactivation of an old focus of infection.

 In the developing world most cases of skeletal TB occur in patients who recently acquired TB. Therefore, most skeletal TB occurs in childhood. Many patients give a history of recent trauma to the involved area.

Clinically  Accounts for 35% of cases of extra-pulmonary TB and 2% of all cases of TB  Indolent course, average duration of symptoms prior to diagnosis: 16 to 19 months.

 Local swelling, pain, fluctuance; systemic symptoms (fever, sweats, etc) often absent.

 Pulmonary disease present in 30%. PPD+ in > 85%

Clinically  Pott’s disease (tuberculous spondylitis)     Responsible for 1/3 of cases of skeletal TB.

Infection begins in the anterior aspect of the vertebral body leading to anterior collapse and spread of the infection along the anterior ligament Most cases involve the lumbar and lower thoracic spine 50% of cases have associated abscesses (if calcified is diagnostic for TB)

Vertebral tuberculosis

冷脓肿

Cold abscess

冷脓肿

T 12

、

L 1

椎体结核 Vertebral tuberculosis

冷脓肿 冷脓肿

Cold abscess

T 10

椎体结核

T10 Vertebral tuberculosis

桡骨下端结核

Tuberculosis of distal end of radius

L3

、

4

椎体结核（中心型） L3,4 Vertebral tuberculosis

L 3

、

L 4

椎体结核 L3,4 Vertebral tuberculosis

冷脓肿 冷脓肿

T 12

、

L 1

椎体结核 ( 边缘型 ) T12 ， L1 Vertebral tuberculosis

T 11

、

T 12

椎体结核（边缘型） T12 ， L1 Vertebral tuberculosis

L 1

、

L 2

椎体结核 L1,L2 Vertebral tuberculosis

椎 间 隙 狭 窄 坏 椎 板 和 椎 间 盘 破

同上病例T1、T2显示广泛性椎体及椎间盘破 坏，其下的骨有水肿，炎性肿块侵犯椎管

X线平片显示椎旁梭形软组织 影， 向肺野内突出；T

1

显示椎间盘和 椎板破坏，椎旁巨大软组织肿块

脂肪抑制像和T

1

显示椎 体破坏及椎旁脓肿

结核性关节炎 Tuberculous arthritis

Intervertebral Disc Herniation IDH

Cervical 3-4

，

4-5

，

5-6 IDH

lumbar disc herniation

lumbar disc herniation

lumbar disc herniation with calcification

MRI T2WI lumbar disc herniation

lumbar disc herniation with Posterior longitudinal ligament calcification



X线 CT MRI 同位素

 敏感性 低  特异性 高 较高 较高 高 高 高 低