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Disclosures

What to Order and How to Interpret the  My co-authors and I have no Report relevant financial disclosures related to this work. C. Benjamin Ma, MD • Research: NIH/NIAMS, AOSSM, AANA, Zimmer, Histogenics, Samumed • Consultant: Zimmer, Stryker, Conmed • Membership: AOSSM, AANA, ISAKOS Professor in Residence Shoulder and Sports Medicine University of California, San Francisco Department of Orthopaedic Surgery

Imaging Why image?

 Different types of imaging  New injuries  Imaging orders that make you  Chronic problems look “awesome”  Rule out tumor  Interpretation of reports

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Imaging Different Modalities

 Aid diagnosis  Radiographs

 Determine significance  Ultrasound

 Allow treatment plan  CT scan

 Bone scan

 MRI

Pearls Plain radiographs

 Write down what you are concerned

about  Image obtained by projecting of  Xrays of ankle with concern of x-ray beams onto a detector

fibular fracture  The amount of ‘whiteness’ is a  MRI of shoulder with recurrent function of the radiodensity and instability thickness of the object

 Radiologists can help getting the right  Dense object – whiter image studies for you

 They can also suggest better studies

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Plain radiographs Lower extremity imaging

 Good first line evaluation  Lower extremity are weight

 Orthogonal views (projection!) bearing joints.

 AP/lateral of the joint  Joint alignment can be very different with weight bearing

 Can get weight bearing x-rays to look at joint space and alignment

What to order? Make you look good! What to order?

 Knee  Hip  AP and Lateral knee  AP/ frog leg lateral  Weight bearing AP  AP pelvis  Patellofemoral views

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What to order? What to order?

 Ankle  Foot  AP/lateral ankle  AP/lateral/oblique foot  Mortise view of ankle  Weight bearing lateral?

Upper extremity imaging – Upper extremity imaging - shoulder non weight bearing joints

 Elbow  AP of GH joint

 Axillary lateral  AP/lateral

 Supraspinatus forearm outlet view

 AP of AC joint

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What to order? What to order?

 Wrist  AP Hand

 AP/lateral/oblique wrist  Lateral Hand

Interpretation What to look for?

 Displaced fractures – always need  Fractures attention  Displaced

 Non displaced fracture – can  Comminuted

immobilize  Impacted

 Stress fracture/ cannot rule out….  Arthritis

 Need secondary evaluation  Mild, moderate, severe

 Further imaging  Abnormal morphology

 Closer followup  Spurs, OCD, deformities

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Interpretation Specific Radiographic Studies

 Elbow “Sail sign”  Wrist  Occult fractures  Scaphoid view  Pediatric – supracondylar fractures  Hamate view

Ultrasound Ultrasound

 Uses high-frequency sound waves to  Advantages produce images  Non-invasive  Similar to sonar wave on getting images of the ocean  Dynamic  Can be helpful to evaluate ganglion cyst • Tendon instability  Knee ganglions  Foot ganglions  Disadvantage  Diagnose tendon tears  User-dependent  Rotator cuff tears  Achilles tendon ruptures  Cannot image deep tissue  Cannot image tissue within bone

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Ultrasound CT scan

 Use for targeted therapy  Tomographic evaluation of the • Ultrasound guided injections region of interest - Hip injections  Good for 3D bony anatomy

- Calcific tendinitis  Degenerative joint anatomy

- Shoulder injections  Complex reconstruction

- Reports are very examiner  Post-traumatic injuries dependent  Ankle malunion

CT scan 3D CT scan

 Advantages  Tomographic evaluation  No magnification  Give detail in trabecular and cortical structures (better than MRI) • Measure bone loss • Evaluate fracture pattern • Evaluate healing

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CT Scan CT scan

 Hamate Fracture  Disadvantages

 Subject to metal artifact

 Weight limit for obese patients

 Higher radiation

 Contraindicated for pregnant patients

 Images and reports are always worse because of details

Nuclear imaging Bone scan

 Uses radioisotope-labelled biological  Rule out tumor – multiple lesions, active drugs increase update  Radioactive tracers administered to the patient to serve as markers of  Infection – tagged WBC scan biologic activity  Evaluate symptomatic joints  Images produced by scintigraphy  Such as arthritis  Technetium bone scan  Nonunion  FDG in PET scans • Measure glycolytic rates  Stress fractures • Higher in tumor cells

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Nuclear medicine MRI

 Advantages  Imaging of metabolic activity  Current gold standard for soft • Healed fracture or nonunion tissue injuries • Arthritis  Diagnosis of infection  Ligament tears  Disadvantages  Labral tears  Lack detail and spatial resolution  Limited early sensitivity  Cartilage injuries • Fractures usually takes up to several days to show up  Meniscus tears  Low sensitivity for lytic problems • Multiple myeloma

MRI MRI

 Helpful to evaluate  Helpful to evaluate ligament integrity ligament integrity

 Quality of cartilage  Quality of cartilage

 fraying  fraying

 arthritis  arthritis

 Labrum and  Labrum and meniscus injuries meniscus injuries

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MRI MRI

 Helpful to evaluate  Helpful to evaluate ligament integrity cuff integrity

 Quality of cartilage  Quality of muscle

 fraying  Fatty infiltration

 arthritis  Retracted tear

 Labrum and  Labral pathology meniscus injuries

OCD of the elbow TFCC tear

 Triangular FibroCartilage Complex

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Scaphoid fractures MRI with contrast -Gadolinum

 Intra-articular contrast  Distends the joint  Enable evaluation of ligament and labrum  Hip and shoulder labral tears  Meniscus repairs  Cartilage injuries, such as TFCC

MRI- Gadolinum MR arthrogram – elbow

 Intravenous contrast  Evaluate  Evaluate vascularity ligament tear  Tumor  Evaluate OCD  Post-surgical changes, such as stability scar tissue

 Concern with kidney insufficiency and complications Look for intraarticular problems  Usually ordered by specialists MCL tear Loose bodies, OCD

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MR arthrogram - wrist Radiology Reports – love adjectives!

 Fraying vs Partial tear vs Full  Evaluate thickness tear vs Retracted tear

ligament tears  Cartilage inhomogeneity vs fissure  Look for vs flap vs unstable flap vs full communication thickness cartilage loss

between  Tendon degeneration vs compartments tendinosus vs tear Clinical Correlation Recommended

What are they saying? What are they saying?

 CLINICAL HISTORY: 55 yo Posterior shoulder pain x1 year. Denies trauma.  BICEPS TENDON AND ANCHOR: High T1 signal within the intra-  There is adequate distention of the glenohumeral joint with intra-articularly articular portion of the long head biceps tendon favored to represent administered contrast. High T2 signal in the anterior subcutaneous fat iatrogenic injection. The extra-articular portion of the long head biceps compatible with iatrogenic injection of anesthetic. tendon demonstrates normal signal and morphology.

 OSSEOUS ACROMIAL OUTLET: There is mild osteoarthrosis at the  OSSEOUS AND CARTILAGINOUS STRUCTURES: Nonspecific cystic acromioclavicular joint with fluid in the joint and capsular hypertrophy.. The changes at the greater tuberosity. There is no evidence of a fracture or acromion is type 1 on sagittal imaging. There is no evidence of os acromiale. dislocation. No focal chondral defects are identified. There is no Thickening of the coracoacromial ligament.  MISCELLANEOUS: There are no intra-articular bodies. The remaining  ROTATOR CUFF MUSCLES AND TENDONS: muscles demonstrate normal bulk with no evidence of atrophy or edema.

 Mild tendinosis of the supraspinatus tendon and anterior fibers of the  IMPRESSION: infraspinatus tendon. Possible limited interstitial tearing of the posterior fibers of  1. Irregularity of the anterosuperior and superior labrum compatible with the infraspinatus tendon at the insertion (series 6, image 13). degenerative changes. Blunting of the anterior labrum without discrete  Normal signal and morphology of the subscapularis and teres minor tendons. tear. The posterior labrum appears intact.

 Normal signal and bulk of the rotator cuff muscles.  2. Mild tendinosis of the supraspinatus tendon and anterior fibers of the  LABRAL AND CAPSULAR STRUCTURES: Irregularity of the anterosuperior infraspinatus tendon. Possible limited interstitial tearing of the posterior and superior labrum compatible with degenerative changes. Blunting of the fibers of the infraspinatus tendon at the insertion. anterior labrum without discrete tear. No paralabral cyst formation. 55 yo with no trauma and above findings – AGE Appropriate changes

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What are they saying? Knee MRI What are they saying? Knee xray

 MENISCUS: There is a complex tear of the body and posterior horn of the medial meniscus with large bucket-handle fragment displaced into the intercondylar notch paralleling the posterior  INDICATION: Age: 17 years. Gender: Male. History: cruciate ligament. pain vs injury r/o fracture

 The native torn ACL is seen to be flipped anteriorly and back on  Bones and joints: Osseous fragment over the superior itself within the anterior aspect of the intercondylar notch. pole of patella with marked thickening and irregularity

 IMPRESSION: of the quadriceps tendon.

 1. Flipped appearance of the native torn ACL within the anterior  Soft tissues: Large joint effusion with patellar soft aspect of the intercondylar notch is consistent with stump tissue swelling. entrapment/cyclops lesion.  IMPRESSION:  2. Large bucket-handle tear of the posterior horn and body of the  Osseous fragment over the superior pole of the patella medial meniscus. with marked thickening and irregularity of the quadricep tendon with large joint effusion. Findings most compatible with superior pole patellar sleeve fracture.

What are they saying? Foot What are they saying?

 65 yo with shoulder pain – evaluate shoulder

 MPRESSION:  CLINICAL HISTORY: r/o fx at left 5th MTP. jammed foot 3 days ago.  No evidence of acute fracture or dislocation. Degenerative  changes of the acromioclavicular joint with a hooked type III  IMPRESSION:  NORMALacromion and inferiorly FINDINGS projecting osteophytes with hooked off the distal type III  1. Mildly to moderately displaced extra-articular  clavicle. Mild/moderate degenerative changes glenohumeral joint oblique fracture of the fifth metacarpal shaft. No  as well with small marginalacromion!!! osteophytes. Close approximation of evidence of dislocation.  the humeral head and the acromion with weightbearing suggest  underlying rotator cuff pathology.

 2. Severe degenerative changes of the first MTP  PulmonaryAdditionally noted isnodules an oval ossified – fragment depends along the on history joint compatible with hallux rigidus.  posterior superiorMay aspect need of the further glenoid which evaluation may represent an  osteophyte, ossification of the posterior labrum, or old

 fracture.

 Surgical clips in the right axilla, suggesting prior axillary

 lymph node dissection. Additional rounded density medial to the

 clips, overlying the lung which could possibly reflect underlying

 pulmonary nodule for which dedicated chest radiograph is

 recommended..

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What are they saying? What are they saying?

 CLINICAL HISTORY: 51-year-old male with right shoulder pain after fall, rule out full thickness rotator cuff tear  40 yo with acute elbow pain – concern with biceps rupture  OSSEOUS ACROMIAL OUTLET: Large inferior clavicular osteophytes indent the supraspinatus. Fluid is noted in the acromioclavicular joint with reactive marrow changes.  FINDINGS: Type 2 acromion.  MUSCLES AND TENDONS: An acute tear of the biceps tendon at its

 ROTATOR CUFF MUSCLES AND TENDONS: Full thickness tear is seen at the anterior  insertion on the radius is associated with approximately 5.5 cm footprint of the supraspinatus tendon, with slightly increased intensity within the rest of the supraspinatus tendon compatible with tendinosis. The infraspinatus, subscapularis, and teres  of retraction of the proximal tendon and large amounts of T1 minor51 tendons yo demonstrate with normal fall signal and and morphology. full thicknessThe rotator cuff muscles are  hypointense and T2 hyperintense fluid within the soft tissues of unremarkable.  the anterior elbow.  LABRAL AND CAPSULAR STRUCTURES: Unremarkable. No evidence of labral tears. rotator cuff tears  The common flexor tendon is normal in signal and thickness. The  BICEPS TENDON AND ANCHOR: Unremarkable. Normal signal and morphology of the biceps tendon.  common extensor tendon is frayed and irregular and may be Refer for treatment and repair   OSSEOUS AND CARTILAGINOUS STRUCTURES: Unremarkable. Normal bone marrow consistent with prior injury. signal. No evidence of fractures.  LIGAMENTS: The ulnar and radial collateral ligament complexes  MISCELLANEOUS: The inferior glenohumeral ligament is not well defined and thickened.  are intact. Fluid is also noted in the subacromial/subdeltoid bursa. Rotator interval synovitis.  OSSEOUS AND CARTILAGINOUS STRUCTURES: No bone marrow  IMPRESSION:   1. Full thickness tear at the anterior footprint of the supraspinatus tendon with supraspinatus abnormalities identified. Diffuse thinning of the cartilage is tendinosis.  noted.  2. Thickening of the inferior glenohumeral ligament as well as rotator interval synovitis may reflect adhesive capsulitis.

What are they saying? What are they saying? MRI Hip

 LABRUM: Degenerative tearing of the anterior and superior  NERVES: The ulnar nerve is normal in signal and caliber. labrum. Degenerative ossification is also seen in the anterior  MISCELLANEOUS: No joint effusion or loose bodies are identified. labrum (image 17, series 4).  IMPRESSION:  LIGAMENTS: The ligamentum teres and transverse acetabular  1. An acute tear of the biceps tendon at its insertion on the ligament are intact. Linear low signal intensity medial to the  radius is associated with approximately 5.5 cm of retraction of ligamentum teres may represent a thick acetabular plica.  the proximal tendon.  TENDONS: The visualized rectus femoris, proximal hamstring,  2. The common extensor tendon is frayed and irregular and may be 65and yo iliopsoas with tendons mild are hip intact. arthritis Edema around and the gluteustendinitis  consistent with prior injury. tendon insertion, greater around the minimus than the medius, is compatibleAge with mild appropriate peritendinitis. changes Good radiology report  IMPRESSION: Identify acute injuries  1. Degenerative tearing of the anterior and superior labrum.  2. Focal chondral loss Along the superolateral and anterior Downplay chronic injuries femoral acetabular cartilage. Focal chondral loss along the Summary or Impression usually are the posterior medial aspect acetabular cartilage. more important focus  3. Mild peritendinitis of the gluteus tendon insertion, greater around the minimus than the medius.

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Asymptomatic Knee Lesions MR imaging of Shoulder

 High prevalence of meniscus tears  Accurate

in older individuals  Asymptomatic individuals

 Especially with osteoarthritis (91%)  > 60 y.o. – 54% tears (28% full,  May not be symptomatic 26% partial)

 “complex” tear is an appearance,  40 – 60 y.o.– 4% full, 24% partial may not be symptomatic  19 – 39 y.o. – 0% full, 4% partial

Careful Interpretation!!! Treat the patient, not the MRI

Intepretation SLAP tears

 Common with older age  Rotator cuff tears  SLAP tear >50 yo  Age of patients  Operative treatment can lead to  Older patients – common to stiffness have partial cuff tears  Rarely culprit of symptoms • Non op rehab  SLAP tear younger overhead  Full thickness cuff tears athletes • Referral for discussion of treatment  Usually symptomatic  Surgical treatment

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Imaging Thank you

 Write down what your question is  C. Benjamin Ma, M.D.  Radiology can help answer them Professor in Residence UCSF Department of Orthopaedic  Plain radiography – first start Surgery  Acute injuries – can order further Sports Medicine and Shoulder imaging or quick referral (415) 353-7566 [email protected]  Chronic injuries – can order further imaging and interpret results

 Post op injuries - referral

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