Dr.

Bangun Nusantoro,
Sp.Rad
Bone Formation

• Long Bone : Form in cartilage by

endochondral/enchondral
ossification process
• Flat Bone : Laid down by direct
conversion of a fibrous matrix in
intra membranous ossification
process
Centers of Ossification :
1.Epiphyseal plate
2.Epiphyse
Enchondral Ossification
1. Mesenchyme to differentiate into
cartilage with a surrounding membrane
(perichondrium)

2. Maturation and vacuolation with secretion of

phophatase of cartilage cells

3. Intra cellular calcification of cartilagenous

matrix
 4. Cartilage cells die & fragmented of calcified intra
cellular matrix

5. Perichondrium derive blood vessels & osteogenic cells

invade calcific area

6. Osteogenic cells lay down a layer of osteoid

arround the calcific foci
7. Ostoeid become calcified forming bony
trabeculae

Perichondrium transformed to periosteum and

center of chondrification has become a center for
ossification

8. Gradual replacement of chondrified anlage By blood

vessels, osteoid, osteoblast and new bone formation,
until epiphyseal plate/disk is reached
•Chondrification precedes ossification in
balanced fashion untilchondrification
ceases, and epiphyseal plate itself
became ossified

•Center of ossification has appeared in

epiphyses and growth has precedes toward the
distal end of the bone or toward the adjoining
joint

Blood supply :
1. Nutrient artery
Blood supply :
1. Nutrient artery
2. Metaphyseal and epiphyseal vessels
3. Periosteal vessels
Methods of Roentgen Analysis of Bones

1. Always have at least two perpendicular view

and one joint view

2. Determine wether or n ot single or multiple f

oci are involve by a bone survey :
Two v iews of skull
Two views of lumbar or thoracic spine
AP view of pelvis
AP view of arms and thighs
 3. Make comparison studies of the t wo
comparable sides of the body
when appropriate
4. Know age and sex of patient

5. Know hereditary factors, occupational

history, and whenever possible
clinical and laboratory data

6. Study bone in following sequences :

• soft tissue adjoining
• periostal region
• cortex
• medulla
• joint capsule
• subarticular bone
• epiphysis, epiphyseal plate,
metaphysis
• systematic review general roentgen
pathology,
such as alteration in position, size,
contour,
density, architecture, (internal and
marginal),
number, function, change occuring
over a
RADIOLOGY OF JOINTS

dr. Bangun Nusantoro,

SpRad
Classification of Joint
Alignment of
Joint
1. Frontal sinus
2. Crista galli
3. Cribriform plate
4. Lesser wing of sphenoid
5. Superior orbital fissure
6. Superior border of petrous part of temporal
bone
7. Dense shadow of petrous part of temporal
bone
8. Perpendicular plate of the ethmoid
9. Vomer
10. Maxillary sinus
11. Inferior concha
12. Ramus of mandible
13. Body of mandible
1. Bifid spinous process of C3
2. Superimposed articular processes
3. Uncinate processes
4. Air filled trachea
5. Transverse process of C7
6. Transverse process of T1
7. 1st rib
8. Clavicle

4th-7th: The bodies of 4th to 7th cervical

vertebrae
1. Anterior arch of the atlas
2. Dens of axis
3. Posterior arch of the atlas
4. Soft palate
5. Root of the tongue
6. Transverse process
7. Intervertebral disc
8. Inferior articular process
9. Superior articular process
10. Zygapophyseal (facet)
joint
11. Spinous process of C7
1. Femur
2. Patella
3. Medial epicondyle of
femur
4. Lateral epicondyle of
femur
5. Medial condyle of femur
6. Lateral condyle of femur
7. Intercondylar eminence
8. Intercondylar notch
9. Knee joint
10. Lateral condyle of tibia
11. Medial condyle of tibia
1. Clavicle
2. Acromioclavicular joint
3. Acromion
4. Greater tubercle of
humerus
5. Head of humerus
6. Lesser tubercle of humerus
7. Surgical neck of humerus
8. Coracoid process
9. Glenoid fossa
10. Shoulder joint
11. Lateral border of scapula
1. Lateral supracondylar ridge
2. Medial supracondylar ridge
3. Olecranon fossa
4. Medial epicondyle
5. Lateral epicondyle
6. Capitulum
7. Olecranon
8. Trochlea
9. Coronoid process of ulna
10. Proximal radioulnar joint
11. Head of radius
12. Neck of radius
13. Tuberosity of radius
14. Ulna
1. Supracondylar ridge
2. Trochlea
3. Olecranon
4. Trochlear notch
5. Coronoid process of ulna
6. Head of radius
7. Neck of radius
8. Tuberosity of radius
9. Ulna
1. Scaphoid
2. Lunate
3. Styloid process of radius
4. Styloid process of ulna
5. Head of ulna

6. Radius
7. Ulna

8. Tuberosity of radius
9. Neck of radius
10. Head of radius
11. Proximal radioulnar join
I-V: Metacarpals

1. Trapezium
2. Trapezoid
3. Capitate
4. Head of capitate
5. Hamate
6. Hook of hamate
7. Scaphoid
8. Lunate
9. Triquetrum
10. Pisiform
11. Styloid process of radius
12. Head of ulna
13. Styloid process of ulna
14. Radiocarpal joint
15. Distal radioulnar joint
1. 1st metacarpal
2. Metacarpals II-V

3. Trapezium
4. Tubercle of scaphoid
5. Lunate
6. Triquetrum
7. Radiocarpal joint
8. Distal end of radius
9. Distal end of ulna
A. Thumb
B. Index
C. Middle finger
D. Ring finger
E. Little finger

I-V. Metacarpal bones

11. Trapezium
1,4. Distal phalanx 12. Trapezoid
2. Middle phalanx 13. Capitate
3,5. Proximal phalanx 14. Hamate
6. Sesamoid bones 15. Scaphoid
7. Distal interphalangeal joint (DIP) 16. Lunate
17. Triquetrum
8. Proximal interphalangeal joint (PIP)
9. Metacarpophalangeal joint (V.) 18. Pisiform
10. Carpometacarpal joints
19. Radius
20. Ulna
A. Thumb
B. Index
C. Middle finger
D. Ring finger
E. Little finger 11. Trapezium
12. Trapezoid
1,4. Distal phalanx 13. Capitate
2. Middle phalanx 14. Hamate
3,5. Proximal phalanx 15. Scaphoid
6. Sesamoid bones 16. Lunate
7. Distal interphalangeal joint (DIP) 17. Triquetrum
8. Proximal interphalangeal joint (PIP)
9. Metacarpophalangeal joint (V.) 19. Radius
10. Carpometacarpal joints 20. Ulna
1. Pisiform
2. Triquetrum
3. Hook of hamate
4. Capitate
5. Scaphoid
6. Trapezium

7. Ulna
8. Radius
1. Lateral part of the sacrum
2. Gas in colon
3. Ilium
4. Sacroiliac joint
5. Ischial spine
6. Superior ramus of pubis
7. Inferior ramus of pubis
8. Ischial tuberosity
9. Obturator foramen
10. Intertrochanteric crest
11. Pubic symphysis
12. Pubic tubercle
13. Lesser trochanter
14. Neck of femur
15. Greater trochanter
16. Head of femur
17. Acetabular fossa
18. Anterior inferior iliac spine
19. Anterior superior iliac spine
20. Posterior inferior iliac spine
21. Posterior superior iliac spine
22. Iliac crest
1. Anterior superior iliac spine
2. Ilium
3. Anterior inferior iliac spine
4. Pelvic brim
5. Acetabular fossa
6. Head of femur
7. Fovea
8. Superior ramus of pubis
9. Obturator foramen
10. Inferior ramus of pubis
11. Pubic symphysis
12. Ischium
13. Lesser trochanter
14. Intertrochanteric crest
15. Greater trochanter
16. Neck of femur
1. Greater trochanter
2. Intertrochanteric crest
3. Lesser trochanter
4. Neck of femur
5. Head of femur
6. Acetabular fossa
7. Superior ramus of pubis
8. Obturator foramen
9. Inferior ramus of pubis
10. Ischium
1. Patella
2. Medial part of patella
3. Lateral part of patella
4-5. Patellofemoral joint
6. Lateral femoral condyle
7. Medial femoral condyle
1. Femur 7. Apex of patella
2. Lateral condyle of femur 8. Intercondylar eminence
3. Medial condyle of femur 9. Apex of fibula
4. Fabella 10. Fibula
5. Patella 11. Tibia
6. Base of patella 12. Tibial tuberosity
1. Femur
2. Medial condyle of femur
3. Lateral condyle of femur
4. Knee joint
5. Intercondylar eminence
6. Lateral condyle of tibia
7. Medial condyle of tibia
8. Fibula
9. Tibia
10. Head of fibula
11. Neck of fibula
1. Femur
2. Knee joint
3. Intercondylar eminence
4. Tibial tuberosity
5. Fibula
6. Tibia
7. Ankle joint
8. Talus
9. Calcaneus
1. Fibula
2. Tibia
3. Distal tibiofibular joint
4. Malleolar fossa 5. Lateral malleolus
6. Ankle joint
7. Medial malleolus
8. Talus
1. Fibula
2. Tibia
3. Ankle joint
4. Promontory of tibia
5. Trochlear surface of talus
6. Talus
7. Posterior tubercle of talus
8. Calcaneus
9. Sustentaculum tali
10. Tarsal tunnel
11. Navicular
12. Cuneiforms
13. Cuboid
A-E: Toes 1-5. (A:Great toe)
I-V. Metatarsals

1,3: Distal phalax

4: Middle phalax
2,5: Proximal phalax

6. Interphalangeal joints
7. Metatarsophalangeal joints
8. Sesamoids
9. Head of metatarsal
10. Shaft (body) of metatarsal
11. Base of metatarsal
12. Cuneiforms
13. Navicular
14. Cuboid
15. Talus
16. Calcaneus
17. Tibia
18. Fibula
19. Tarsometatarsal joints
20. Transverse midtarsal join
A-E: Toes 1-5. (A:Great toe)

1,3: Distal phalax

4: Middle phalax
2,5: Proximal phalax

6. Interphalangeal joints
7. Metatarsophalangeal joints
8. Sesamoids
9. Head of metatarsal
10. Shaft (body) of metatarsal
11. Base of metatarsal
12. Cuneiforms
13. Navicular
14. Cuboid
15. Talus
16. Calcaneus
17. Tibia
18. Fibula
19. Tarsometatarsal joints
20. Transverse midtarsal joint
 TRAUMATOLOGY
 Definition :
 Traumatology: The branch of surgery that deals with trauma patients
 and their injuries.

 "Trauma" is the Greek word for "a wound" (and for "damage or
defeat").

 Patients who have suffered significant physical trauma, as from a car
accident, may be cared for in a trauma center, a specialized hospital
facility designed to provide diagnostic and therapeutic services for
trauma.

 GLASGOW COMA SCALE
Definition

Scales and terms to classify the

levels of consciousness differ, but
in general, reduction in response to
stimuli indicates an altered level of
consciousness:
 Levels Of Consciousness
 Conscious : Normal
 Confused : Disoriented; impaired thinking and
responses
 Delirious : Disoriented; restlessness, hallucinations,
 sometimes delusions
 Somnolent : Sleepy
 Obtunded : Decreased alertness; slowed psychomotor
 responses
 Stuporous : Sleep-like state (not unconscious);
little/no
 spontaneous activity
 Comatose : Cannot be aroused; no response to stimuli
 Glascow Coma
Scale
Eye Opening Response

Spontaneous--open with blinking at baseline

4 points

To verbal stimuli, command, speech 3 points

To pain only (not applied to face) 2 points

No response 1 point
 Glascow Coma Scale
Verbal Response :

Oriented 5 points

Confused conversation, but able to answer questions 4

points

Inappropriate words 3 points

Incomprehensible speech 2 points

No response 1 point

 Glascow Coma
Scale
Motor Response :
Obeys commands for movement 6 points
Purposeful movement to painful stimulus 5 points
Withdraws in response to pain 4 points
Flexion in response to pain (decorticate posturing) 3
points
Extension response in response to pain (decerebrate
posturing)
 2 points
CT SCAN MACHINE
 Typical screen layout for diagnostic
software, showing one 3D and three
MPR views
Bone reconstructed in 3D
 This example shows a more unusual, lower
location. Note also the gas within the haematoma
- this indicates a basal skull fracture or, as in this
case, it is post surgical. Note also the dilated
lateral ventricle on the opposite side.
Head Injury
Head Injury
This is the typical appearance and location of an
acute extradural haematoma. Note the high
density of the haematoma. Slight midline shift is
present.
 Right frontal acute extradural
haematoma with an air bubble, and
midline shift.
Cerebral Infarction, Post-Traumatic

Post-traumatic infarction in a 67-year-old

man. Despite evacuation of the subdural
hematoma, both anterior cerebral (arrow)
and posterior cerebral (arrowhead) artery
distribution infarcts are present.
 These two illustrations show a falcine subdural
haematoma, a more unusual distribution. Note the
abnormally bright falx due to the adjacent fresh blood.
Note the crescentic low density collection
typical of a chronic subdural haematoma,
with associated midline shift.
Cerebral Injury
 Sudural hematoma

Axial T1-weighted magnetic resonance

imaging demonstrates bilateral subacute
subdural hematomas with increased signal
intensity. Areas of intermediate intensity
represent more acute hemorrhage into the
subacute collections.

Subacute subdural hematoma with

extension into the anterior
interhemispheric cistern. Note that
the sutures do not contain the spread
of these hemorrhages.
 Intracerebral Hemorrhage

When blood vessels within the brain become A ruptured blood vessel will leak blood into
damaged, they are more likely to burst and the brain, eventually causing the brain to
cause a hemorrhage. compress due to the added amount of
fluid.
 Intracerebral hemorrhage
This CT scan and MRI revealed midbrain
intracerebral hemorrhage (ICH) and
intraventricular hemorrhage (IVH) associated with
a cavernous angioma

Intracranial hemorrhage. CT scan of right

frontal intracerebral hemorrhage
complicating thrombolysis of an ischemic
stroke.
Anatomy
Normal Hand and Wrist
Anatomy
Boxer's Fracture

Boxer's Fracture of Fifth

Metacarpal
Bennett Fracture

Bennett Fracture

An intra-articular fracture-dislocation of the

base of the first metacarpal .
The most common mechanism of fracture
is axial loading of the first metacarpal (i.e.,
during a fist fight).
Dorsal subluxation is the most common
dislocation.
Bennett Fracture
Normal Elbow Anatomy

Lateral and AP views of normal elbow

Normal Elbow Anatomy

Lateral view of elbow with anatomical lines

 Galeazzi Fracture

Patient 1 Patient 3
Patient 2
Supracondylar Fracture
 Monteggia Fracture
 Monteggia Fracture

 Fracture of the ulna with accompanying radial head

dislocation.
 May result from a direct blow to the posterior ulna or a fall
accompanied with forced pronation of the forearm.
 Most commonly, physical exam reveals radial head
displacement into the antecubital fossa with elbow pain
and tenderness.
 One way to remember the difference between Galeazzi and
Monteggia fractures is the mnemonic GRUM: Galeazzi
Radius, Ulna Monteggia.
In the image below, note the ulnar
fracture and accompanying radial
head dislocation.
 Shoulder Normal Anatomy

AP view with shoulder in external rotation

AP view with shoulder in internal rotation
 Scapular Fracture
Scapular Fracture :
 Results from direct trauma to the scapula, often
sustained during a fall or vehicle accident.
 Scapular fractures are the most difficult fracture to
diagnose in the shoulder region. Fractures can
sometimes be seen on AP view, but more often are
best evaluated in the transscapular "Y" view.
 It is common to find other injuries associated with
scapular fractures, especially injury to the thoracic
spine. For this reason, is important to look
carefully for a scapular fracture.
Scapular Fracture

Transscapular "Y" view of left shoulder

scapular fracture
 Anterior Dislocation

As the name implies, an anterior dislocation of the shoulder

results in displacement of the humeral head anterior to the
glenoid cavity.

More then 95% of all shoulder dislocations are anterior.

This injury results from application of indirect force to the arm

through a combination of abduction, extension, and external
rotation.

Impaction of the humeral head on the glenoid can cause

avulsion of the inferior aspect of the anterior labrum.

This injury is known as a Bankart fracture and is commonly

associated with anterior shoulder dislocation
 Anterior Dislocation

AP View of Anterior Dislocation Axillary View of Anterior Dislocation

 Anterior Inferior Dislocation

 As indicated before, anterior

dislocation of the shoulder is common.
 In most cases of anterior dislocation,
the humeral head lies anterior and
inferior to the glenoid. Sometimes this
positioning can be extreme and the
dislocation is termed an anterior
inferior dislocation.
Anterior Inferior Dislocation
Look at the images below. Notice that
the anterior dislocation is in the normal
inferior direction.

AP View of Anterior Inferior Dislocation

Anterior Inferior Dislocation

Axillary Views of Anterior Inferior Dislocation

 Posterior Dislocation
 Posterior Shoulder Dislocation :

 Unlike anterior dislocation, posterior dislocation of

the shoulder is very uncommon.
 Usually results from direct force to the anterior
shoulder or indirect force applied to the arm
combining adduction, extension and internal rotation.
 This diagnosis can often be missed on standard AP
view.
 A standard axillary projection and/or an AP projection
in which the patient has been rotated 40° toward the
affected side is key!
 Posterior Dislocation
Transscapular Y View
of Posterior
Dislocation

AP View of Posterior Dislocation

Axillary View of Posterior Dislocation

Notice that the posterior dislocation is more

easily observed on the axillary view. Also
notice that in the image above, there is an
impaction fracture (arrow) of the humerus
from its contact with the glenoid.
 Acromio-Clavicular Joint
Separation

Type I Type III Type II

Partial tear of the Disruption of the Disruption of the
acromioclavicular acromioclavicular acromioclavicular and
ligament with no ligament and widening coracoclavicular
displacement. of the ligaments and widening
acromioclavicular joint. of the
acromioclavicular and
coracoclavicular joints.
Acromio-Clavicular Joint
Separation

AP stress view of Type II separation

Acromio-Clavicular Joint
Separation
To differentiate Type II from Type III, one
can take an AP stress view of the AC joint,
where the patient suspends 10-15 pound
weights from each wrist

AP stress view of Type II separation

Acromio-Clavicular Joint
Separation
To differentiate Type II from Type III, one
can take an AP stress view of the AC joint,
where the patient suspends 10-15 pound
weights from each wrist.

AP stress view of Type III separation

Thoracic Compression Fracture
 Thoracic Compression Fracture :

 Compression injuries (burst fractures) are due to axial loading.

 Multiple noncontiguous fractures are associated with burst fracture in
nearly 50%, so finding a fracture should make one continue to look and
not give up on the search.
 One should not confuse the normal 1.5 mm anterior tapering of the
anterior thoracic vertebral bodies for compression.
 With compression, there is loss of vertebral height and usually
disruption of the posterior vertebral line. If the body has lost stature, it
may be impossible to tell if this is an acute fracture without old films
for comparison.
 CT should be performed for full assessment of the spinal canal in
compression fracture cases because neurological deficit occurs in 65%
of patients.
Thoracic Compression Fracture
 Rib Fracture
Rib Fracture :

 Fractures are occasionally present in

association with fractures of the
thoracic spine.
 Make sure not to miss an associated rib
or transverse process fracture.
 Rib Fracture

AP view of chest showing rib fracture

Rib Fracture

AP view of chest showing rib fracture

Lumbar Spine Anatomy
The following radiographs show normal
lumbar spine anatomy.

AP View Lateral View

Lumbar Compression Fracture
Lumbar Compression
Fracture :

 The general information for lumbar

compression fractures is the same as for
thoracic compression fractures. Please
review that material, which appeared
previously, if you feel the need.
Lumbar Compression Fracture

AP view
Lateral view
Lumbar Compression Fracture

Sagittal reconstruction of CT data

Lumbar Compression Fracture

CT of lumbar compression fracture

 Spondylolysis
Spondylolysis :
 Spondylolysis is a bony defect of the pars
interarticularis.
 It happens most often in adolescent athletes
and at the L5 vertebrae.
 The defect results in formation of a "collar"
around the Scotty Dog Model of the lumbar
vertebrae.
Spondylolysis

The Scotty Dog Model of the lumbar spine

 Spondylolyisthesis
 Spondylolisthesis is the anterior slippage of the
vertebral column relative to an adjacent inferior
vertebra.
 Spondylolisthesis is usually a result of bilateral
spondylolysis and most commonly occurs at the
L4-5 or L5-S1 level.
 Look carefully at the location of the spinous
process step off to assess for spondylolisthesis.
 Spondylolisthesis is usually a result of bilateral
spondylolysis and most commonly occurs at the
L4-5 or L5-S1 level.

Spondylolisthesis

Look carefully at the

location of the spinous
process step off to assess
 Pelvis and Hips Anatomy

AP view of normal pelvis AP view showing important anatomical lines of

the pelvis
 Femoral Neck Fracture
 Femoral Neck Fracture :

 Full evaluation requires internal rotation of the femur on

AP pelvic radiograph. If the femurs are neutrally positioned
or externally rotated, the femoral neck will be
foreshortened and a fracture may be missed.
 Occur most commonly in the subcapital region.
 Associated with postmenopausal osteoporosis.
 Avascular necrosis of the femoral head is a complication
that occurs in 10-30% of subcapital fractures secondary to
disruption of the femoral circumflex arteries.
 Nonunion may occur.
Femoral Neck Fracture

AP view of pelvis Frog-lateral view of hip

Normal Knee Anatomy
The following radiographs show the normal
anatomy of the knee.

AP View Lateral View

 Patellar Fracture
Patellar Fracture :

 Patellar fractures can be caused by direct

truama such as a blow to the anterior aspect
of the knee or may be due to indirect forces
generated by the tension of the quadriceps
tendon.
 The fracture is best seen on a Sunrise or
Merchant's view.
 Patellar Fracture

Oblique view AP view Sunrise view

Fractures of the patella can be confused with bipartite or
multipartite patella. The radiographs below show bipartite patella.
Compare the images below with those shown above. Notice that
the fractured patella has pieces that fit together like a jigsaw
puzzle. The bipartite or multipartite patella has pieces with more
rounded margins that do not fit together.

Sunrise view
Oblique view
Ankle Anatomy

Lateral View of Normal Ankle

Ankle Anatomy

AP View of Normal Ankle

Ankle Anatomy

Mortise View of Normal Ankle

Ankle Anatomy

Lateral view of ankle showing Boehler's angle

The angle normally ranges from 20 to 40 degrees.
 Ankle Sprain
 Ankle Sprain :
 Damage or disruption of the soft tissue structures
surrounding the ankle.
 Injury results from severe inversion or eversion of the
ankle. Severe inversion injuries are much more common
and result in damage to the lateral soft tissue structures.
 Patient presentation may range from mild pain and
swelling to severe pain and swelling with an inability to
walk.
 It is critical to realize that this presentation is the same for
fracture of the distal fibula. Therefore, radiologic exam is
necessary to rule out fracture and to direct clinical
treatment.
 CT and/or MRI may be required to fully assess the extent of
 Ankle Sprain

AP view of right ankle Mortise view of right ankle AP view of left ankle
Does this patient have a
fracture?
Foot & Heel Anatomy
Foot & Heel Anatomy
GOOD LUCK