Tulang

Pendahuluan
Pemeriksaan Rongen Tulang memberi
informasi :
1. Lesil tulang & jaringan Lunak sekitarnya
2. Adanya fraktur/ancaman fraktur patologis
3. Asal/Sifat suatu lesi(jinak/ganas)
4. Sebagai guide untuk biopsi
5. Follow Up perjalanan penyakit

Anatomi Tulang Panjang

Struktur tulang
keras
(Kalsifikasi) &
elastitas
(serabut
organik)
Bentuk Tubuler
Panjang >
Lebar

Gambar 2 . A.
Skema tulang
system haversian

Struktur tulang kompak

Mikroskopi
s
arsitektu
r tulang

Arteri nutrisi
tulang
Suplai darah
kaya
(10-20% CO)
1. a. Nutrisi
diafisis
2. a. metafisis
dan epifisis
3. a. Periosteal

Neonatus : P. d penetrasi plate

epifisis
Anak
: bbrp P. D
menembus plate epifise mll
periosteum, .P. D metafisis
berakhir di sinusoid dg aliran
lambat
Dewasa : Plate epifise telah
menyatu P.D
metafisis&Epifise menyatu

KELAINAN TULANG DAN

SENDI
1. Anomali perkembangan / kongenital
2. Infeksi
3. Trauma & Fraktur
4. Penyakit defisiensi tulang
5. Penyakit displasia tulang
6. Tumor tulang
7. Osteochondritis/Aseptik nekrosis
8. Penyakit2 degeneratif sendi

Positioning
Routine
PA / AP
Lateral

Additional
Oblique (RAO/LAO)
Tangential

Specific
Skull :

Waters and Caldwel : Paranasalis Sinus

Schuller and Stenver : Mastoid
Eisler
: Mandible
Rheese
: Opticum Foramen
Towne
: Canalis Acusticus Interna
Basis Cranii
: Fossa Cranii

Patella : Sunrise (Mountain View)

Tulang
panjang

Seri foto tangan yang normal

Anatomi sendi
siku normal

Foto lateral Elbow

Mengenali FRAKTUR
Fracture
Dislocation
Subluxation

Fracture
A disruption in all or
part of the cortex of a
bone
All = complete
Part = incomplete =
children

Dislocation
The bony
components of a joint
no longer are in
contact with each
other
There is complete
disruption of the joint

SUBLUXATION
he bony components
of a joint are partially
in contact with each
other
There is partial
disruption of the joint

Incomplete fracture

Green Stick # #
mengenai 1 cortex

Torus buckling of the cortex

How Fractures Are Described

By the direction of the fracture line

By the relationship of the fragments
By the number of fragments
By communication with the atmosphere

 By the direction of the

fracture line

Transverse
Diagonal or oblique
Longitudinal
Spiral

 By the direction of the

fracture line
Transverse

 By the direction of the

fracture line
Diagonal or oblique

 By the direction of the

fracture line
Longitudinal along
the long axis of the
bone

 By the direction of the

fracture line
Spiral a twisting
fracture caused by a
torque injury such as
planting the foot in a
hole while running

 By the relationship of one fracture

fragment to another

Displacement
Angulation
Shortening
Rotation

Most fractures display more than one

of these abnormalities of position

Displacement
The amount of off-set
of the distal fracture
fragment relative to
the proximal
There is lateral
displacement of the
distal femoral fracture
fragment in this case
Later
al

Media
l

ANGULATION

SHORTENING
Overlapping of the
ends of the fracture
fragments
Shortening is usually
described by the
number of
centimeters of overlap

ROTATION
Almost always
involves long bones
(humerus and femur)
Knee joint is in AP
position (points
forward) but ankle
points lateral, in this
case

By the number of
fracture
fragments:
1

Two fragments
: Simple
More than two
fragments :
Comminuted

1
2
3
2

Simp
le

Comminut
ed

 By the relationship of
the fracture to the
atmosphere
Closed
Open or compound
Best evaluated
clinically

Open or compound fracture of the tibia

communicates with outside air

Salter-Harris Classification

Type I Epiphyseal plate alone

Type II Epiphyseal plate and metaphysis
Type III Epiphyseal plate and epiphysis
Type IV Epiphyseal plate, metaphysis and
epiphysis
Type V crush fracture of epiphyseal plate

Common Fracture Eponyms

Colles fracture
Smiths fracture
Jones fracture
Boxers fracture

A.

CD,SV

B.

Fraktur
Galleazzi

GRUM

Fraktur Monteggia

Jones fracture fx base 5th metatarsal

 Boxers fracture fx
head 5th metacarpal
with palmar
angulation
Most often the result
of punching a person
or wall

Easily Missed Fractures

Scaphoid fractures
Buckle fractures of
radius/ulna
Radial head fracture
Supracondylar
fractures in children
Posterior dislocation
of the shoulder
Hip fractures

 Scaphoid fractures
common
Pain in anatomical
snuff box
Fall on outstretched
hand
Can lead to avascular
necrosis

 Radial head fracture

Common
May require multiple
views to see it

 Supracondylar
fractures in children

Supracondylar fractures can be difficult especially in children

(this is an adult)

 Buckle fractures of
radius/ulna
Children
Look for angulation of
cortex
Heal quickly

 Posterior dislocation
of the shoulder
Humeral head looks
like lightbulb
Usually need another
view like axillary or Y
view

 Hip fractures
May be very subtle
and require bone
scan or MRI for
diagnosis
In this case, white
zone of sclerosis is an
impacted subcapital
fracture

Set into place

Posterior dislocation of right hip

Set into place

Normal Knee Anatomy

AP View

Lateral View

Oblique view

AP view

Sunrise view

Anatomi pergelangan kaki/Ankle

Foto Lateral dari

Ankle normal

Foto AP dari Ankle Normal

Foto posisi Mortise dari Ankle

Normal

Look at the radiographs below. The labels show the fracture component, but also note
the dislocation. The medial border of the second metatarsal is not aligned with the
medial border of the second cuneiform. The dislocation is the main radiographic feature
of a Lisfranc injury.

Metatarsal Fracture
It is important to remember that a fracture may only be visible on one view.
Therefore, a careful look at each metatarsal in each view is necessary.

Fracture Healing
Indistinctness of
fracture line
Bony callous
production
Bridging of fracture
Obliteration of
fracture line

Remodeling of
bone

Normal joint

1 Degenerative Arthritis
X-ray Findings
Narrowing of joint space
Subchondral sclerosis
Marginal osteophyte formation
Subchondral cysts

1.

2.

Osteoartritis of knees affects medial,

weight-bearing surface

Osteoartritis of hips affects

superior, weight-bearing
surface

2 Degenerative Arthritis
Causes

Trauma
Infection
Avascular necrosis
CPPD
RA
Hemophilia

Septic artritis

Rheumatoid artritis

Bilaretal, symmetrical
Radiocarpal jct
commonly narrowed,
Periarticullar
demineralizasion
Erotion Metacarpal,carpal

Bilateral, simetris
Psoriasis artritis of
Bengkak jaringan lunak
hands
Erosi tulang, t u : distal
phalang

Osteomielitis
Kronis
Pada seluruh
Tibia dan distal
fibula kanan
Tampak
sequester
( Tanda Panah )

Ankylosing
Spondilits

HLA-B27 positive

B/L SI arthritis

Squaring of
vertebral bodies
Bamboo-spine
from continuous
syndesmophytes
Peripheral large
joint erosive
arthritis

Bone tumor

Dapat benigna/maligna serta bisa primer/

Sekunder (metastase) :
Untuk membedakan maligna atau tidak :
1. Umur penderita
2. Lamanya gejala2 nyeri & pembengkakan

serta kecepatan pembesaran

3. Besar kecilnya tumor

4. Jumlah lesi (mono/polistatik)

5. Lokalisasi dalam tulang
6. Densitas : osteolitik, osteosklerotik &
campuran
7. Struktur tumor : tepinya, destruksi:
sentral/
tepi, bentuk
kontinuitas cortex

reaksi periosteal,

8. Bentuk tulang keseluruhan : bengkok,

ada

Klasifikasi tumor tulang :

A. Dari jaringan Skeletal
1. Jaringan tulang:

a. Jinak: bone island, osteoma,

osteoid
osteoma, osteoblastoma
b. Ganas ; Osteosarkoma, periosteal
sarcoma

2. Kartilago :
a. Jinak :Khondroma,Khondroblastoma,
Khondromixoid Fibroma
b. Ganas ( Khondrosarcoma )
3. Jaringan Fibrosa :
a. Jinak : Fibrosa, Brown Tumor
b. Ganas: Fibrosarkoma
4. Giant Cell ( Giant Cell Tumor )
a. Jinak : GCT,ABC {Aneurysma Bone Cyste}
b. Ganas: Giant Cell Tumor Maligna

Klasifikasi Tumor Tulang :

B. Dari Jaringan Lain Dalam Tulang :
1. Pembuluh Darah : Hemangioma,Glomus
Tumor,Hemagio Sarcoma
2. Saraf : Neurofibroma,Neuroblastoma,
Neurofibrosarcoma
3. Lemak : Lipoma,Liposarcoma
4. Natokord : Chordoma
5. Epitel : Dermoid, Adamantinoma
6. Limfoid/Hemopoetik ; Limfoma, Leukimia,
Plasmositoma,Multipel Mieloma

Clues Bone tumor by

Appearance
of Lesion

Patterns of Destruction

Geographic
Less malignant

Moth-eaten

Permeative
More malignant

Periosteal Reactions
l

Benign
n

None

Solid

More aggressive or
malignant
n

Lamellated or onion-skinning

Sunburst

Codmans triangle

Periosteal Reactions
n

Benign
n

None

Solid

Aggressive/maligna
nt
n

Onion-skinning

Sunburst

Codmans triangle
Non-ossifying fibroma

Periosteal Reactions
n

Benign
n

None

Solid

Aggressive/maligna
nt
n

Onion-skinning

Sunburst

Codmans triangle
Chronic osteomyelitis

Periosteal Reactions
n

Benign
n

None

Solid

Aggressive/maligna
nt
n

Onion-skinning

Sunburst

Codmans triangle
Ewings sarcoma

Periosteal Reactions
n

Benign
n

None

Solid

Aggressive/maligna
nt
n

Onion-skinning

Sunburst

Codmans triangle
Osteosarcoma

Periosteal Reactions
n

Benign
n

None

Solid

Aggressive/maligna
nt
n

Onion-skinning

Sunburst

Codmans triangle
Ewings-Codmans
triangle

Periosteal Reactions

Solid
Less malignant

Lamellated

Sunburst

Codmans
More malignant

Expansile lesions
n

Multiple myeloma

Mets

Aneurysmal bone cyst

Fibrous dysplasia

Brown tumor

Enchondroma

Lymphoma

Multiple Myeloma

Expansile lesions
n

Multiple myeloma

Mets

Aneurysmal bone cyst

Fibrous dysplasia

Brown tumor

Enchondroma

Lymphoma

Renal Cell Carcinoma

Expansile lesions
n

Multiple myeloma

Mets

Aneurysmal bone cyst

Fibrous dysplasia

Brown tumor

Enchondroma

Lymphoma

Aneurysmal Bone Cyst

Expansile lesions
n

Multiple myeloma

Mets

Aneurysmal bone cyst

Fibrous dysplasia

Brown tumor

Enchondroma

Lymphoma

Fibrous Dysplasia

Expansile lesions
n

Multiple myeloma

Mets

Aneurysmal bone cyst

Fibrous dysplasia

Brown tumor

Enchondroma

Lymphoma

Brown Tumor

Expansile lesions
n

Multiple myeloma

Mets

Aneurysmal bone cyst

Fibrous dysplasia

Brown tumor

Enchondroma

Lymphoma

Enchondroma

Expansile lesions
n

Multiple myeloma

Mets

Aneurysmal bone cyst

Fibrous dysplasia

Brown tumor

Enchondroma

Lymphoma

Lymphoma

Clues Bone tumor by

Location
of Lesion

In the Transverse Plane

n

Central
n

Eccentric
n

GCT, osteosarcoma, chondromyxoid fibroma

Cortical
n

Enchondroma

Non-ossifying fibroma, osteoid osteoma

Parosteal
n

Parosteal osteosarcoma, osteochondroma

Osteosarcoma

Parosteal sarcoma
Osteochondroma

In The Transverse Plane

In the Longitudinal Plane

l

Epiphyseal
n

Metaphyseal
n

GCT, chondroblastoma
Osteomyelitis, osteo- and chondrosarcoma

Diaphyseal
n

Round cell lesions, ABC, enchondroma

Tumor Types

Characteristic Locations
n

Simple bone cyst

n

Chondroblastoma
n

Proximal humerus
Epiphyses

Giant Cell tumor

n

Epiphyses

Characteristic locations
n

Simple bone cyst

n

Chondroblastoma
n

Proximal humerus
Epiphyses

Giant Cell tumor

n

Epiphyses

Characteristic locations
n

Simple bone cyst

n

Chondroblastoma
n

Proximal humerus
Epiphyses

Giant Cell tumor

n

Epiphyses

Chondroblastoma

Characteristic locations
n

Simple bone cyst

n

Chondroblastoma
n

Proximal humerus
Epiphyses

Giant Cell tumor

n

Epiphyses

Giant Cell Tumor

Tumor Types

Characteristic Locations
n

Adamantinoma
n

Chordoma
n

Tibia
Sacrum, clivus

Osteoblastoma
n

Spine, posterior

Characteristic locations
n

Adamantinom
a
n

Chordoma
n

Tibia
Sacrum,
clivus

Osteoblastom
a
n

Spine,
posterior

Adamantinoma

Characteristic locations
n

Adamantino
ma
n

Chordoma
n

Tibia
Sacrum,
clivus

Osteoblasto
ma
n

Spine,
posterior

Chordoma

Characteristic locations
n

Adamantinom
a
n

Chordoma
n

Tibia
Sacrum,
clivus

Osteoblastom
a
n

Spine,
posterior

Osteoblastoma

Tumor Types

Characteristic Locations

Parosteal sarcoma
n

Distal femur

Periosteal sarcoma
n

Tibia

Characteristic locations

Parosteal
sarcoma
n

Distal femur

Periosteal
sarcoma
n

Tibia
Parosteal sarcoma

Characteristic locations

Parosteal
sarcoma
n

Distal femur

Periosteal
sarcoma
n

Tibia

Lytic Lesions in Adults

n

Metastatic lesions
n

Lung

Renal

Thyroid

Multiple myeloma

Primary bone tumor

Lytic Lesions in Adults

n

Mets

Myeloma

Primary bone
tumor

Met from Thyroid Carcinoma

Lytic Lesions in Adults

n

Mets

Myeloma

Primary bone
tumor

Multiple myeloma

Lytic Lesions in Adults

n

Mets

Myeloma

Primary bone
tumor

Chondrosarcoma

Blastic Lesions in Adults

n

Mets

Lymphoma

Pagets

Prostate Mets

Blastic Lesions in Adults

n

Mets

Lymphoma

Pagets

Breast Mets

Blastic Lesions in Adults

n

Mets

Lymphoma

Pagets

Lymphoma

Blastic Lesions in Adults

n

Mets

Lymphoma

Pagets

Pagets of Spine

Other Clues

Benign Lesions
Without Sclerotic Boarders

Giant Cell tumor

Brown tumor

Osteolytic phase of Pagets Disease

Benign Lesions without Sclerotic

Borders

Giant cell tumor

Brown tumor

Osteolytic Pagets

Giant Cell Tumor

Benign Lesions without Sclerotic

Borders

Giant cell tumor

Brown tumor

Osteolytic Pagets

Osteolytic Pagets

Soft Tissue Extension

n

Usually implies malignancy

n

More likely to form discrete soft tissue mass

Benign conditions with soft tissue

extension
n

Osteomyelitis
s

Usually infiltration of fat

Osteosarcoma

Multiple Lesions
n

More often benign

Malignancies with multiple lesions

n

Metastatic disease

Multiple myeloma

Lymphoma

Ewings sarcoma (rarely)

Osteosarcoma (rarely)

Multiple lesions

Metastatic

Multiple myeloma

Lymphoma

Mets from Ca of Prostate

Multiple lesions

Metastatic

Multiple myeloma

Lymphoma

Multiple Myeloma

Multiple lesions

Metastatic

Multiple myeloma

Lymphoma

Lymphoma

Multiple lesions

Metastatic

Multiple myeloma

Lymphoma

Osteosarcomatosis

Osteosarcomatosis

Summary
Radiographs are essential
Aggressiveness of process dictates
the response of the bone
Most helpful information in analysis
Age
Location
Margins

The End