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Objectives

Five shades of gray (Part Two); • Identify the appropriate imaging modality Advanced Radiographic to evaluate common musculoskeletal interpretation and treatment complaints, what to order when. for the APN • Describe the basic principles used in ordering and interpreting musculoskeletal imaging studies in musculoskeletal Christina M Kurkowski, Nurse Practitioner complaints.

Conflict of Interest Nov 8 , 1895: The Birth of Radiology

I hereby certify that, to the best of my knowledge, no aspect of my current • 11/8/95 Wilhelm Conrad Röntgen personal or professional situation might produces “X - rays” reasonably be expected to affect • 12/28/95 Röntgen presents: “On a significantly my views on the subject on New Kind of Rays” which I am presenting. • 2/11/96 Jones publishes: “The

Discovery of a Bullet Lost in the Wrist 1901:Röntgen wins by Means of the Roentgen Rays” 1st Nobel prize in physics

Learner Outcome How we make radiographs

As a result of this learning activity, the participant will gain knowledge in the area of radiographic interpretation and interventions and implement appropriate changes in practice

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X - rays as Diagnostic Tool What is the best imaging test?

Can See Can’t See • Plain film radiographs Bones Inside skull • MRI • Fractures • Can’t see the brain • CT Joint Width, surfaces Inside joints • US • Arthritis • Can’t see tears • Bone Scan – Osteophytes – Ligaments, • MR Arthrography tendons – Erosions • CT Arthrography – Menisci, cartilage

Tips for requesting films • Consulting radiologist needs info to confirm: – Correct study was requested – Correct patient What is the cause of – Meds, allergies, status caveats musculoskeletal pain? – Cost/benefit ratio favors the patient: • Risk, dose, pain, complication, sometimes $$ • Will it alter management? If not – NO! Clinical Evaluation • DNR, religious beliefs, life expectancy….. • Old images available?

Interpretation – 3 basic steps Tailored to individual joint Tailored to individual patient • First learn how each modality creates an image of internal body structures • Next, be able to accurately label normal anatomy (body structures) • Then, search for structures that don’t belong and for body structures that are abnormal in size, shape, position and/or density

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Musculoskeletal Imaging Suspected occult scaphoid Fx Variant 6: Suspected occult scaphoid fracture. Initial radiographs and repeat radiographs after 10-14 days of cast are normal. Continued Technology clinical suspicion scaphoid fracture. Next procedure.

Advances in Imaging

Five Shades of Gray

Air Fat Soft tissue Bone Metal

least opaque to most opaque most lucent to least lucent Black to White

www.acr.org Five shades of gray

• American College of Radiology From Black to White Appropriateness Criteria – Gas – black – few molecules to stop • Evidence–based guidelines to choose imaging beam • Relative Radiation Risk for each study – Fat – dark gray – Water – lighter than fat • Modality guidelines: CT, MRI, US, NM, PET…. but not as white as • Practice Guidelines: When (in what order) to mineral and has perform uniform appearance – Mineral/Metal - white

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One view equals no view Imaging Planes • Axial Plain Films CAN SEE Plain Films CAN’T SEE • Coronal Bones Inside skull • sagital • Fractures • Can’t see the brain Joint Width, surfaces Inside joints • Arthritis • Can’t see tears – Osteophytes – Ligaments, tendons – Erosions – Menisci, cartilage Radiographs: 2D projection of 3D patient Radiographs flatten everything Can’t tell what’s in front, what’s behind With radiographs: NEED MULTIPLE VIEWS!

One view equals no view CT: Giant Leap Forward

• CT: Computed Tomography(Tomo [Gr]: part, slice) • CAT: Computed Axial Tomography • 1917 Johann Radon, Austrian mathematician, proved image of a 3D object could be reconstructed from an infinite number of 2D projection images of the object. • Had to await the advent of main-frame computers in the 1970’s.

For Joints – need 3 views Why CT is so Great Can see the brain • Strokes, bleeds, tumors Can see organs (lungs, liver, bowel) • Tumors, trauma, acute/chronic diseases Can see fractures otherwise missed • Cervical spine, pelvis And now with ultra-fast, multi-slice… Can scan the heart in a single beat! • Can see coronary arteries, pulmonary emboli • Hospitals have CT scanners in the ER

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What to Order When Biggest problem with CT High radiation dose …We are exposed to low levels of radiation every day, “Background Radiation” Earth: naturally occurring radionuclides; uranium 238 and Potassium 40 Atmosphere: Radon 222 (from uranium 238) – 2nd leading cause of cancer after smoking Space: cosmic rays - Airline crews, who spend a lot of time in the upper atmosphere, receive 2x typical background dose. Average background dose 2.4mSv/year

Other problems with CT CT is great for assessing complex fractures.

• Usually requires IV contrast • 1% patients are allergic to CT contrast & Can affect renal function • Costs more than radiographs: Knee radiographs (4 views): $154 Knee CT (no contrast): $1,200 • Can’t see structures inside joints – Knee: Menisci, Ligaments – Shoulder: Rotator Cuff, Cartilage Labrum – Spine: Disks, Spinal Cord

12 y/o girl with a trampoline injury.

Radiation from Diagnostic Imaging CT - Dislocation • Average background dose ≈2.4mSv/year • Chest Radiograph ≈0.06mSv

– ≈1 week of background radiation “Risks of medical imaging at effective doses below 50 mSv • Chest CT ≈7.0mSv for single procedures or 100 – ≈3 YEARS of background radiation mSv for multiple procedures over short time periods are How much radiation is too much? too low to be detectable and may be nonexistent.” ……….Who the heck knows … http://www.xrayrisk.com Lis Franc Fx/Dislocation

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CT for surgical planning Postop films

CT for Surgical Planning MRI: Giant Leap Sideways

• MRI doesn’t rely on X-rays to see projected shadows of patients – Unlike radiographs, tomography, CT • MRI sees tissues based upon sub - atomic characteristics – Proton nucleus of Hydrogen • MRI – “Magnetic Resonance Imaging”

CT for surgical planning MRI Scanner has 2 components

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How an MRI Scanner Works

Magnet: Aligns spins of protons in hydrogen nuclei – Align in direction of magnetic field, B Coil : 1)Sends RF pulse to flip spinning protons – After RF pulse is off, protons realign to B – As protons realign, resonate RF energy • 2) Measures strength of resonant RF echo – at a specific time “echo time” and at a specific “repetition time” • Steps 1&2 repeated many times / image slice

Things Stuck in Magnets: ICU Bed MR Scanner is just a Tube

MR Scanner is a Tube No Implanted Electronics

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No Cochlear Implants in MRI Metal Inside Patients Safety Issues Imaging Issues • No implanted electronics • Metal can affect the magnetic • No metal that can move field • OK: Orthopedic • “Susceptibility artifact” hardware • May limit diagnostic value of • OK: modern aneurysm the scan… clips • But often the scans come out • OK: modern heart valves just fine • OK: vascular stents • As long as the patient is MR • OK: IVC filters safe, radiology will try • If radiology can’t get useful images, cancel all charges

No Implanted Electronics Metal Inside Patients

Patient with lots of metal

Is it unsafe to put this patient in the magnet?

Of course not!

Patient has unexplained knee pain.

Metal Inside Patients Metal Inside Patients

• Metal that can’t move is not a safety issue – Fillings in the teeth – Orthopedic hardware • Need to worry about metal that CAN move – Metal in/around eyes – Welding equipment, Grinding equipment, Fire guns w/o protection, People who’ve been shot – Old aneurysm clips

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Key to MRI MRI: 4 dimensional • Radiographs are flat projections Specific tissue types have specific resonant echoes Only give information in 2-D • Fluid (Hydrogen ions in water) Need 2+ projections to fully see patient – Cysts, Joint effusions, Edema (in soft tissues, in bone • CT is a stack of slices marrow) Images the patient in 3-D • Fat (Hydrogen ions in fat) • MR is a stack of slices... and more – Subcutaneous fat and Fatty yellow bone marrow Not only shows tissues in 3-D • Dense Stuff (with few Hydrogen protons) It shows the composition of the tissues – Cortical bone, Ligaments, Tendons, Menisci • T1: How Fatty, T2: How Wet MR shows more than just 3-D

How We Make MR Images Comparing Sequences (knee same mid-Sag Slice) Magnetic field divides body into slices Each slice is subdivided into “voxels” • voxel: 3D pixel • voxel size = 2D pixel size X slice thickness Coil measures signal in each voxel ComputerHigh signal: White maps (“Bright”) this onto 2D slices Intermediate signal: Gray (“Iso-intense) Low signal: Black (“Dark”)

MRI: Need Multiple Sequences Comparing sequences (same knee mid sag slice)

T1 shows Fat best – Most normal anatomy surrounded by fat – In essence, T1 shows anatomy best T2 shows Fluid best – Most pathology contains fluid (edema) – In essence, T2 shows pathology best – Fat suppression makes fluid more conspicuous PD shows Dense stuff best – Good for meniscal and tendon tears – Used mostly for MRI of joint pain

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Limitations of MRI MRI Scans Limited Field of View (FOV) • Usually performed with patient supine • • Image resolution related to voxel size Multiplanar imaging obtained without changing position – Smaller FOV = smaller voxels • One exam = one body part – Smaller voxels = higher resolution • Average exam time 45 minutes; most patients – To maximize resolution, try to limit FOV can’t last >2 hours • Can only image inside the coil • Strict guidelines for sedation • Requires an assortment of different coils for • Optional contrast – Rad usually decides for different body parts body imaging

WOW: What to Order When MRI Scans take 30-60 minutes • Should always start with radiographs • • Least expensive study Patient’s need to lie still... like a May show the answer statue...for the entire time. Needed for planning other studies • If the patient is ill the day of the • CT (MSK) scan and can’t stop coughing or • Used in ER for fracture detection (spine) Used for surgical sneezing, should reschedule. planning of known fractures Best ordered by treating • specialist Patients who can’t lie flat, severe heart failure (CHF), can’t get • MRI MRI. • Used for tears, occult fractures, infections, ... Best ordered by treating specialist

MRI Scans are Expensive My Recommendation

Coils are expensive: >$25,000 EACH! Don’t order • Don’t use open low field scanners – knee accuracy only about Scanners are expensive: >$2,000,000 MSK MRI 75% in open scanner as compared to 95% accuracy in 1.5 T Specialty trained technologists are expensive before scanner Always want to use at least a 1.5 T scanner • MR scans take 30-60 minutes getting • Go to a 3 T if available! – more resolution – Run several sequences in several planes Radiographs! – Can scan only a limited number of patients per day • What about obese patients? Patients who don’t fit in the – Have to charge a lot per scan standard 1.5 T? • Knee Radiographs (4 views): $154 – See if there is a Wide Bore 1.5 available in your area…Can fit up to 500 pound patient. • Knee CT (no contrast): $1,200 • Knee MR (no contrast): $2,400

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CT VS MRI: What is the question? Know the limits of your test

CT: “4 B’s radiodense” MRI: Bone Soft tx– ligament, muscle,

Blood (acute (Hemorrhage) tendon, cartilage, Bullets and metal muscle, neural, tumor Barium Better soft tissue detail Lung and chest Direct multiplanar Cancer staging Non-polar materials not Speed overcomes motion visualized ie, bone (calcium) 80 year old fell in bath tub this AM, unable to bear weight = Femoral neck fracture

CT Case Studies Advantages Disadvantages  Eliminates  More expensive than • WOW: What to overlapping x-ray and ultrasound Order When densities  Much more radiation – Shoulder  Excellent resolution  Dense bone (petrous  Excellent for ridge for example) workup detecting and metal cause – Knee workup intracranial bleeding severe artifacts – Other  Excellent in the examples of neck, chest and abdomen advanced imaging  Excellent for evaluating fractures

MRI Shoulder Pain Epidemiology Advantages Disadvantages  No overlapping artifact  Very expensive • Shoulder pain: a common complaint in primary  Excellent resolution  Patients cannot have a care  Very good at detecting pacemaker or fluid ferromagnetic material – 2nd only to knee pain for specialist referrals  Excellent for imaging the  Slower to acquire – Most common causes in adults (peak ages 40-60) images brain, spine and joints • Subacromial impingement syndrome (approximately 45  No radiation • minutes) Rotator cuff problems  Multiple imaging tests within the same study • Athletic injuries (T1, T2, T3, IR, GE) – Shoulder: 8-13% of all athletic injuries

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Diagnostic tests for Shoulder Pain AP View Shoulder

• Radiographs (x-rays) • • Magnetic Resonance Imaging (MRI) Shows alignment of AC – With or without contrast Joint • CT Arthograms • Shows lateral • Bone scans view of Surgical Neck • Electromyography (EMG)/nerve conduction • Velocity Does not profile GH Joint nor GT

PE - Relevance Oblique: Humerus Ext. Rotated • ROM – Joint surface (true A/P, axillary view) • Shows alignment • Muscle testing of AC Joint – Rotator cuff tear supraspinatus (true A/P, Y- View) • Shows AP view of • Special testing Surgical Neck – Cross arm adduction (axillary view) • Does profile GH – Labral injuries (Axillary view) Joint and GT – Impingement (true A/P, Y-view) – Snapping Scapula (Y-view)

Axillary View 3- view shoulder series

Standard (trauma, pain) • Profiles the • 1) AP 2-views of: ACJ glenohumeral joint Proximal Humerus 2) Oblique 2-views of: • Width Arthritis 3) Axillary Glenohumeral Joint Instability (3-views Glenohumeral Joint) • Alignment • 1) Oblique Dislocations 2) Axillary 3)West Point If need orthogonal views Scapula,ACJ • 4)Lateral (“Scapular Y”, “Arch”/“Outlet”)

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West Point vs Axillary Focused History Questions • Consider sources of referred pain – Cervical spine – spondylolysis, arthritis, disc disease – Cardiac – myocardial ischemia – Diaphragmatic irritation – Thoracic outlet syndrome – Gallbladder disease – Complex regional pain syndrome – Trigger Points

Clinical History • Characterize pain • Location of pain • Night pain • Weakness Scapular Y view • Deformity • Instability (PA) • Locking / Clicking / Clunking • Sport / Occupation • Previous treatments • Alleviating / Exacerbating • Acute vs. Chronic • Traumatic vs. Overuse • History of prior injury

Acute Shoulder pain – films for Shoulder Differential Diagnosis • Impingement syndrome fracture or dislocation • Other arthritic disease – Subacromial bursitis – Rotator cuff tendinopathy – Rheumatoid, Gout, SLE – Rotator cuff tear – Septic, Lyme, etc – Biceps tendinopathy • Avascular Necrosis • Adhesive capsulitis • Neoplastic Disease • SC joint arthritis, sprain • Thoracic Outlet syndrome • AC joint arthritis, sprain • Glenohumeral joint OA • CRPS • Instablity • Myofacial pain – GH dislocation • Referred pain – GH subluxation – Cervical Radiculopathy – Labral tear (e.g. Bankart, SLAP, etc.) – Cardiac • Clavicle fracture – Aortic aneurysm • Proximal humerus fracture – Abdomial/diaphragm • Scapular fracture – Other GI

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Characteristics of Pain ACR Shoulder Imaging Guidelines

Night pain when lying on affected side, Rotator cuff tear XR neg, significant persistent pain MR (9); muscle atrophy CT (5) < 30 yo Biomechanical, inflammatory XR neg, under 35, suspect labral tear  MR > 45 yo, Hx of Trauma Rotator cuff tear – 35% of pts arthrog(9), MR(7), CT(5) Painful arc (60-120 abduction) Subacromial impingement XR neg, prior rotator cuff repair, suspect re- Pain >120 abduction Acromioclavicular joint tear  MR (9) w. or w/o Catching, popping clicking GH or AC joint arthritis, labral tear XR neg, suspect septic arthritis  arthrocentesis (9), MR w&w/o (7)

Pain Patterns Acute Shoulder pain – films for fracture

Posterior-least Poorly localized Lateral Anterior common

-Impingement -AC Joint -Usually -Neck syndrome -GH Joint referred from -Nerves -Rotator cuff -Biceps C-spine -Malingering tendonitis tendon Can also be with tear if referred pain also weak from rotator -Frozen cuff shoulder if tendonitis also stiff, loss of movement

58yoM: Cleaning gutters, fell from 6ft ladder. Fell on elbow, presents with shoulder pain

Acute Shoulder pain – films for fracture

58yoM: Cleaning gutters, fell from 6ft ladder. Fell on elbow, presents with shoulder pain

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Acute Shoulder pain – films for fracture Chronic shoulder pain & negative plain films: consider MRI (+/- arthrogram): labral tear.

58yoM: Cleaning gutters, fell from 6ft ladder. Fell on elbow, presents with shoulder pain

Oseous Bankhart Lesion Acute post- traumatic shoulder pain & negative plain films: MRI finds fracture.

Hills Sach Lesion Acute post- traumatic shoulder pain & negative plain films: MRI finds rotator cuff tear.

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MRI for Internal Derangement - RCT 56 year old Male felt a pop

MRI - Full thickness, Full Width, Supraspinatus Tear Shoulder infection

Coronal PD Coronal T2

MRI - Full thickness, Full Width, Supraspinatus Tear Oh! My knee hurts!

Sagittal Normal Sagittal with Tear

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Regions of Pain

• Anterior – patellofemoral syndrome, patellar tendinopathy, chondromalacia of the patella, runner’s knee • Posterior – tendiopathy, PCL injury, meniscal, popliteal bursitis • Lateral – ITB, LCL, Lateral Meniscus • Medial – MCL, Medial cartilage/meniscus injury, arthritis

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Conditions of anterior knee First things First • Patellofemoral Pain Syndrome • Condromalacia patella Take a good history • Prepatellar bursitis • Date of injury • Osteoarthritis • Mechanism of injury • Osgood-Schlatter • Treatment (past and present) • Patellar instability • Tendonopathy • Diagnostic studies – Patellar and quadriceps • How do you feel today? • Anterior Meniscal tear • Can you put one finger on where it hurts? • Anterior cruciate ligament injury/tear

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Conditions associated with Anterior What Hurts??? Hx 95% of exam Knee Pain • Laxity • What, How, When did the injury happen? • Joint hypermobility • Mechanism of injury? • Weakness of the vastus medialis • Where does it hurt? • Genu valgus • Did you hear/feel a “pop”? • Internal femoral torsion • Effusion? If so, immediate (<2 h) or delayed • Tight lateral patellar retinaculum (24-36 h)? • Patellar or trochlear dysplasia • Locking, clicking, giving way, inability to go • Osteoarthritis through active FROM?

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Complaints Ottawa knee rules

• Swelling • Pain behind the knee • age 55 or over • Clicking • Can’t bend the knee • isolated tenderness of the patella (no bone • Noisy • Pain below the kneecap tenderness of the knee other than the patella • Fullness • Something is moving around • Pain with stairs • tenderness at the head of the fibula • Cracking and popping • Cant’ straighten the knee • inability to flex to 90 degrees • Grating • Pain on the inside of the • inability to weight bear both immediately and in • Unstable knee the ED (4 steps - unable to transfer weight twice • Wobbly • Pain on the outside of the onto each lower limb regardless of limping). knee

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History Knee MRI • Traumatic vs. atraumatic (overuse) • Indications – pain, injury • Sudden onset vs. insidious • Imaging Planes – sagittal, axial, coronal • Length of symptoms • MRI scan - gold standard imaging modality for intra- • Aggravators/Relievers articular soft tissue pathology i.e. menisci, ACL/PCL, articular cartilage. • Pain vs. instability complaint? • Still no substitute for taking a GOOD HISTORY AND • Instability: due to quad weakness or CLINICAL EXAMINATION! inhibition, an unstable knee (ligament), or patellar subluxation?

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Knee Imaging Knee MRI Sagittal Images Radiographs (78%)  Primary modality for knee pain • Menisci  Arthritis (joint narrowing, osteophytes) • Cruciate Fractures, loose bodies Ligaments MR (21%) • Articular Internal derangement cartilage Ligament/meniscal tears, cartilage defects • Extensor Occult fractures Mechanism CT (1%) Surgical planning (of fxs seen on radiographs)

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Knee MRI Axial images When to Refer knee to Ortho

• IMMEDIATELY • Patellofemoral • Dislocated knee (tibiofemoral joint) joint • Neurovascular injury • Cruciate • Open injury Ligaments • Compartment syndrome • Popliteal fossa • Septic arthritis • Fractures involving the knee joint • Patella tendon rupture/Quadriceps tendon rupture

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Knee MRI Coronal Images When to Refer

• Menisci • In 24-48 hours • Ligaments – • collateral, cruciate Acute locked knee (bucket handle • Articular cartilage meniscal tear). Do not refer to physiotherapy.

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Common Traps in Dx Knees When to Refer

• ACL rupture vs patella dislocation • In 7-14 days • Giving way • Unstable knee – single ligament MCL, LCL, – ??true ligament instability ACL, PCL – ??Pseudo giving way secondary to pain inhibition of • Meniscal tears – unless acute locked knee quadriceps • Patella dislocations • Beware false positive Anterior Drawer in PCL deficient knee • Referred pain (hip/lumbar spine)

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Fluid in the Joint on X-rays Lipohemarthrosis

Synovial fluid • From inflamed synovium • Arthritis Blood: “Hemarthrosis” • From torn vascularized structure • Anterior Cruciate Ligament tear Fat+Blood: “Lipohemarthrosis” • Fat comes from fatty yellow bone marrow • Indicates presence of intra-articular fracture

“S”oft Tissue Lipohemarthrosis on Lateral Fat-Fluid level - Worry view

“S”oft tissue - lipohemarthrosis X-ray, CT, MRI

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Suprapatellar Pouch Effusion on MR

• The knee can hold a lot of fluid... not between articular surfaces. • Joint effusions collect in the suprapatellar pouch. – Synovial lined space – Normal extension of the joint capsule – Can easily hold > 40ml

Effusion on MR Prepatellar Bursitis

Effusion on MR MRI

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13 year old ran into a closed patio door, knee pain and swelling, OCD lesion (osteochondritis desicans) MR imaging OCD

Osteochondral Defect (OCD) Tibial Plateau Fractures • Very Common • Fairly common • 80% MVA (the rest from falls, sports)* Fx of bone “osteo” & cartilage “chondral” • 60% involve lateral plateau** • Adults: traumatic • CT used for surgical planning • Children: idiopathic “osteochondritis • Schatzker classification system* dissecans” • Femoral condyles Medial 4x > Lateral

Osteochondral Defects (OCD) Tibial Plateau Fracture • Start with radiographs... • CT shows corticated margin • MR shows “stability” – Surgeon will determine CTvsMR

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Non-displaced fractures Occult Fracture – MR doesn’t miss fx The way we diagnose fractures on radiographs is to see displaced fragments. Non-displaced Fx can be radiographically occult. So how do we detect occult knee fractures? CT often doesn’t help. Fxs non-displaced by radiographs are non-displaced on CT MR doesn’t miss non-displaced Fxs. Can’t send every ER patient with knee pain to MR There is a trick! Look for lipohemarthrosis on cross-table lateral!

Radiographically Occult Fx Stress Fractures Fractures too non-displaced Fatigue Fractures Not detected on • to see Abnormal forces on normal bones • Athletes; People who increase activities (Military) radiographs • Femoral neck, scaphoid • Change in habits (Different shoes) • Places with many – CT is not good for these • Occur in lower extremities overlapping fractures • Femur, Tibia, 2nd Metatarsal, Navicular structures – Non-displaced on radiographs Insufficiency Fractures is non-displaced on CT • Normal forces on abnormal bones • Cervical Spine – MR is good for these fractures • Osteoporosis; Osteomalacia • CT is good for these Fractures with is no cortical • OCCUR IN FEMORAL NECK disruption • Occur in Spine; Sacrum fractures – Stress fractures – MR is good for these fractures

Occult Fracture Stress Fractures – Tibia Common site for Fatigue Fractures in athletes • Radiographically may see: – Nothing – most usual finding • Periosteal Reaction • Trabecular Sclerosis • Cortical Lucency – “Dreaded Black Line”

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Patella Ligament Rupture Stress Fracture – Dreaded black line • Most commonly rupture <40yo • More common in African descent • Transversely, patella origin Exam: – Inability to actively extend knee • Radiographs: May show high patella – “patella alta”

Fatigue fracture Mx Patella Ligament Rupture Diagnosis primarily by History/Exam • Patient tells of new or repetitive activities • Pain worse with activity; relieved with rest • Focally tender • Get Radiographs • May confirm diagnosis (periosteal reaction) • Make sure not already a complete fracture • May find something else (arthritis, foreign body,...) • Treat (even if radiographs are negative) • Stop/change activity; hard soled shoe • DON’T NEED TO ORDER MRI

Quad Tendon Rupture • Most commonly Medial Collateral Ligament Tear rupture >50yo – Men 8x > Women • Transversely, patella insertion Exam: – Patella freely mobile – Inability to actively extend knee – Active flexion preserved • Radiographs: May show low patella – “patella baja”

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Lateral Collateral Ligament Tear Red Flag Diagnoses

Fracture Tumor Progressive neurological deficit Infection

Cruciate Ligament Tears Red Flag Risk Factors

• PCL infrequently tears Malignancy- back pain in very young – Surgical reconstruction of the PCL is controversial (<20yo)pts or older pts (>50yo), history of CA • ACL frequently tears Spinal infection- recent/ past infection, – Requires surgical reconstruction immunosuppression, HIV, IVDA – Sports related twisting injury Fracture- age relative trauma (>65yo), – Torn ACL allows anterior displacement of the tibia osteoporosis, steroid use relative to the femur. – Anterior Draw Sign , Lachman’s and Pivot shift

Cruciate Ligament Tears Red Flag - Fracture When to get an x-ray Mechanism of Injury Bony tenderness Ankle and Knee Ottawa Rules Pittsburgh Knee Rules

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Red Flag Diagnoses-Tumor Bone Scan

1:150-200 of pts presenting to PCP with LBP has • Very sensitive for skeletal pathology undiagnosed cancer • Mildly sensitive for soft tissue pathology Age >50 years • Usually nonspecific as an isolated test Constitutional symptoms- recent unexplained weight loss, hair dropping out • Mostly patient friendly; no significant Severe night pain or pain that worsens with lying environmental exposure down • Small-moderate expense

Nuclear Medicine: Bone Scan Bone Scan Was used a lot before CT & MR Shows bone pathology earlier than radiographs • Excellent for specific pathologies Nowadays, seldom used for focal lesions We use MR for: – Osteomyelitis Focal bone pain not seen on radiographs Infections – Metastases – Not Multiple myeloma (osteomyelitis) – Occult fracture Imaging primary bone tumors We still use Nuc Med Bone Scans for: • Reasonably reassuring Looking for bone metastases in entire body – Normal is usually normal Breast Cancer Prostate Cancer

Nuclear Medicine: Bone Scan Bone Scan Most recent innovation in Nuc Med PET: Positron Emission Tomography • IV injection radioisotope (Tc-99m) bound to Uses agents with very short half-lives Flourine-18 phosphate +/- dynamic imaging (100 min) • Approx 3 hour delay Oxygen-15 (2 minutes) • Delayed static imaging with a superficial Made onsite with cyclotron detector Agents taken up by tumors, metastases Well shows abnormal FUNCTION Combined with CT (Computed Tomography) Well shows underlying ANATOMY Used for staging cancer patients

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Bone Scan Red Flag Dx-Radiculopathy

Progressive or severe neuromuscular Osteomyelitis dysfunction (severe weakness, falling, cannot walk, dropping items or unable to carry items) secondary to nerve root pathology

Bone Scan – 2nd Metatarsal Ultrasound Stress Fx • Not available at all institutions • Reproducible in trained hands • Excellent for superficial soft tissue elements including tendons and muscle • Patient friendly • Small to moderate expense

Cancers that go to the bone Ultrasound

• History of cancer- “PT Barnum Loves Kids” • Developed after World War II • Based upon SONAR • P – Prostate – “SOund Navigation And Ranging” • T – Thyroid Sound wave sent out • B – Breast If sound hits an object get reflected back • L – Liver/Lung Measure time for the reflected echo to return • K - Kidney • Multiplying the time by speed of sound (divided x2) = distance from the object • Works best in water Water transmits sound well

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US Patella Tendonitis – Ultrasound Jumper’s Knee • Routine exam room equipped with adequate imaging devices • Superficial gel (standard or aseptic) application with touch with transducer • Usually static exam of architecture +/- vascularity assessment • Potential for dynamic imaging

Ultrasound: When & Where? US-Biceps tendonitis PRO CON • Portable , Safe (no dose no • Fat, bone, air, metal, all risk), Far less expensive block US • GYN, Doppler flow • Low resolution • Echocardiograph • Highly user-dependent • RUQ abdomen • Non-intuitive (weather • Bx, line placement,‘taps’ maps) (pleural, abscess, joints) • Does not work well in • DVT: proximal extremities large or obese patients • Breast: cyst vs solid • Resolution less than CT and MRI • Air or bowel gas prevents visualization of structures

Achilles Tendon US – Able to track needle into soft tissue Instrasubstance Tear

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Dr. Cole’s Saying WOW: What to order When “Trauma is not evenly distributed within the population” • Patients who come in with new fractures have had fractures in the past Foreign bodies – Radiopaque – plain films • People who drive recklessly… do so repeatedly Foreign bodies – non-radiopaque • People who get into fights… do so repeatedly – Wood splinters • Students who get drunk on Friday night and punch – Sea urchin spines walls… do so repeatedly – • It can be hard to tell old from new fractures Can’t be seen with radiographs or CT • This is why it’s important to have a Radiologist formally • Will be able to see with MR interpret all studies! ALL can be seen with Ultrasound! • Sometimes they suggest additional studies

Summary: What to Order When (WOW) 11 yo female wood splinter Should always start with radiographs • Least expensive study • May show the answer • Needed for planning other studies CT (MSK) • Used in ER for fracture detection (spine) • Used for surgical planning of known fractures • Best ordered by treating specialist MRI • Used for tears, occult fractures, infections, ... • Best ordered by treating specialist

35 yo m with finger mass WOW: What to order When • Start w plain films Masses, Infections, Synovitis • Usually • ALWAYS START WITH RADIOGRAPHS! MR is the next imaging evaluated with study of choice • MRI ...or US Usually with IV contrast • Contrast is particularly helpful for synovitis (RA) • But should start • Normal synovium does not enhance with radiographs • Vascular pannus greatly enhances • Mass size • These MR studies should be ordered by the specialist treating • Helps to plan the patient, (ie.) hand specialist, rheumatologist etc scan

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LIST OF POTENTIALLY HELPFUL Points to take home RADIOLOGY WEBSITES • Plain radiographs are usually the starting point • Most x-ray protocols work for most situations; http://www.med-ed.virginia.edu/courses/rad/ Consider supplemental Views Online tutorial series. • Secondary imaging techniques have specific http://radiopaedia.org/ A free educational advantages and disadvantages radiology resource with one of the web's largest • A specific question is more likely to get you a collections of radiology cases and reference direct answer articles. • When in doubt, ask a Radiologist http://www.radiologyassistant.nl/en/p42023a885 587e/welcome-to-the-radiology-assistant.html

Best of luck – hope this was helpful WEBSITES CONTINUED [email protected] http://learningradiology.com/index.htm Seems to [email protected] have some good stuff but difficult to navigate the site. http://www.swansea-radiology.co.uk/index.html http://bubbasoft.org/ Strange name but the website is useful. Breaks it into radiologic anatomy (identification of structures) and clinical radiology (identification of pathology).

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