Diagnostic Imaging_01, Diagnostic Imaging_Lecture 02_Spine 1 and Spine 2, Diagnostic Imaging_Lecture 03_Chest and Thorax, Diagnostic Imaging_Lecture 02, Diagnostic Imaging_03 Back Pain, Diagnostic Imagining_20161116_Knee, Diagnostic Imaging_Imaging o...

Does research support the use of MRI for eval and management of meniscal tears in patients with OA of the knee?

"These data do not support the routine use of magnetic resonance imaging for the evaluation and management of meniscal tears in patients with osteoarthritis of the knee"

"Trigger Finger" Thickened pullies

#3 is a normal pully and #4 is thickened. Note the increased echo within the tendon and the increased hypoechoic ring denoting increased fluid in the area of the tendon If popped, tough to get it back

What type of sprains can US diagnose accurately?

1. ATF lesions with an accuracy as high as 90-100% 2. CF lesions with an accuracy of 87-92% 3. Tears in the anterior tibiofibular ligament with an accuracy of 85%.

Clinical differential insufficiency fracture versus metastasis in sacrum. Radiographs normal, bone scan hot but nonspecific.

1. CT sacrum without contrast 2, MRI sacrum without contrast

Proximal Humeral Fractures: What are some causes to greater tuberosity fx? Is it easy to differentiate from rotator cuff tears?

1. Direct fall onto the point of the shoulder 2. Hyperflexion or hyperabduction 3. Avulsions - fall with the arm adducted and forceful contraction of the rotator cuff Difficult to differentiate from rotator cuff tears without imaging

Stages of Disc Herniation: Disc degeneration

1. Disc Degeneration: chemical changes associated with aging causes discs to weaken, but without a herniation.

Stages of Disc Herniation: what are they?

1. Disc degeneration 2. Prolapse 3. Extrusion 4. Sequestration or Sequestered Disc

What are the 4 stages of LCPD?

1. Femoral head becomes more dense with possible fracture of supporting bone; 2. Fragmentation and reabsorption of bone; 3. Reossification when new bone has regrown; 4. Healing, when new bone reshapes.

What can be seen in a lateral view

1. Femur 2. Lateral condyle of femur 3. Medial condyle of femur 4. Fabella 5. Patella 6. Base of patella 7. Apex of patella 8. Intercondylar eminence 9. Apex of fibula 10. Fibula 11. Tibia 12. Tibial tuberosity

What can be seen in an AP plain film of the knee?

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 12. Tibia 13. Fibula

What are 6 things you can tell from an ultrasound? (more details)

1. Hole - bad cause blood clot can go to brain; can see between atria or between ventricle. 2. Ejection fraction (normal: 55-70) below 40 percent failure 3. Valves- stenosis- getting smaller and smaller 4. Regurgitation- valves not closing all the way 5. Look at integrity of wall- motion or lack thereof with contraction? Hypo, hyper or akinetic? Hypertrophy? 6. Fluid in pericardial sac- external pressure on heart which prevents heart from filling, which is a passive process. Cardiac tampenade is what it is called

ACR ACUTE ANKLE: OTTAWA

1. Inability to bear weight immediately after the injury, OR 2. Point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, talus, or calcaneus, OR 3. Inability to ambulate for 4 steps in the emergency department.

Canadian C Spine Rule

1. Is there a high risk factor that manadates radiography? Age>65 y/o OR dangerous mechanisms OR parasthesias in extremities 2. Is there a low risk factor which allows safe assessment of ROM? 3. Able to act to actively rotate neck- 45 degrees left or right?

Canadian C Spine Rule- Scenario in which radiography NOT needed?

1. Is there a high risk factor that manadates radiography? Age>65 y/o OR dangerous mechanisms OR parasthesias in extremities- NO 2. Is there a low risk factor which allows safe assessment of ROM?- YES 3. Able to act to actively rotate neck- 45 degrees left or right?- ABLE

Canadian C Spine Rule- Scenario in which radiography needed?

1. Is there a high risk factor that manadates radiography? Age>65 y/o OR dangerous mechanisms OR parasthesias in extremities- YES 2. Is there a low risk factor which allows safe assessment of ROM?- NO 3. Able to act to actively rotate neck- 45 degrees left or right?- UNABLE

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. 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

ACR CHRONIC ANKLE: Ankle radiographs normal or nonspecific, suspected ankle impingement syndrome. Next study.

1. MR arthrography ankle 2. US, CT arhrography, MRI

Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other Vertebrae, Suspect stress fracture, not hip or sacrum. Radiographs normal. Bone scan positive and nonspecific.

1. MRI 2. X Ray (repeat in 10-14 days) 3. CT (if MRI contraindicated)

ACR CHRONIC ANKLE: Ankle radiographs normal or nonspecific, suspected ankle instability. Next study.

1. MRI ankle without contrast 2. MR arthrography ankle

ACR CHRONIC ANKLE: Ankle radiographs normal or nonspecific, suspected tendon abnormality. Next study.

1. MRI ankle without contrast 2. US

Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other Vertebrae: Clinical differential fracture versus metastasis in long bone. Radiographs normal, bone scan hot but nonspecific.

1. MRI area of interest without contrast 2. MRI area of interest without and with contrast 3. CT area of interest without contrast

Nexus Low Risk Criteria: Cervical spine radiography is indicated for patients with trauma unless they meet all of the following criteria?

1. No posterior midline cervical spine tenderness 2. No evidence of intoxication 3. A normal level of alertness 4. No focal neurologic deficit 5. No painful distracting injuries

Ottawa ankle rules:

1. Tenderness of posterior edge of tip of lateral malleolus 2. Tenderness of posterior edge of tip ofmedial edge of malleolus 3. Base of 5th metatarsal tenderness 4. Navicular tenderness 5. Inability to bear weight both immediately and in the ED

Suspect stress fracture in patient with "need-to-know diagnosis," not hip or sacrum. Radiographs normal: what are the best options?

1. Top choice: X-ray area of interest repeat in 10-14 days 2. MRI area of interest without contrast 3.Tc-99m bone scan whole body with SPECT area of interest

Weber type C 1. above or below or at level of ankle joint? 2. tibiofibular syndesmosis disrupted or intact? the distal tibiofibular articulation widened or no difference? 3. Malleolus or deltoid ligament damage? 4. Stable or Unstable? Intervention required?

1. above the level of the ankle joint 2. tibiofibular syndesmosis disrupted with widening of the distal tibiofibular articulation 3. medial malleolus fracture or deltoid ligament injury present 4. unstable: requires ORIF

What is Weber Type B 1. Where? 2. tibiofibular syndesmosis- intact, torn? 2a. Widening of distal tibiofibular articulation? 3. Medial malleolus or deltoid ligament- torn, fx, sprained/ 4. Stable?

1. at the level of the ankle joint, extending superiorly and laterally up the fibula 2. tibiofibular syndesmosis intact or only partially torn, but no widening of the distal tibiofibular articulation 3. medial malleolus may be fractured or deltoid ligament my be torn 4. variable stability

Pilon/Plafond Fracture 1. What causes it? 2. What characterizes it? (three things)

1. high energy axial load (motor vehicle accidents, falls from height) 2. often characterized by: a. articular impaction and comminution b. metaphyseal bone comminution c. soft tissue injury

If the diaphragm isn't at the same level what are some possible causes?

1. pressure from pleural space, puncture of diaphragm. 2. If have distended bowels, can push up diapragm. 3. Baby can also push up and reducing lung fields. 4. Unilateral- if you lose phrenic nerve unilaterally, one side will be lower, because not innervated

How long does an an angiography take? What is the radiation dose?

1/2 - 6 hours Dose: little to lots

If the heart is normal, how much of the field should it take up?

1/3

Anterior drawer test- what value is abnormal?

10mm

Normal Achilles Where does the Achilles have the least blood supply?

2-6 cm above insertion into calcaneus is where achilles has the least blood supply

Stages of Disc Herniation: Prolapse

2. Prolapse: the form or position of the disc changes with some slight impingement into the spinal canal. Also called a bulge or protrusion.

What percentage of imaging studies for LBP ordered by PCP were inappropriate?

20% of imaging studies for LBP ordered by PCP were inappropriate 26% of X-rays 66% of CT and MRI

LUNATE FX: is it common? when does it occur?

2nd most common very common with hyperextension

What are the three types of developmental dysplasia of the hip?

3 "types" Dislocated Dislocatable Subluxatable

Stages of Disc Herniation: Extrusion

3. Extrusion: the gel-like nucleus pulposus breaks through the tire-like wall (annulus fibrosus) but remains within the disc.

Stages of Disc Herniation: Sequesatration

4. Sequestration or Sequestered Disc: the nucleus pulposus breaks through the annulus fibrosus and lies outside the disc in the spinal canal (HNP).

What % of MRI requested by PCPs for LBP work up had documented ACR red flags?

58 % of MRI requested by PCPs for LBP work up had no documented ACR red flags

In Joel's study what percentage of MRIs were a result of documented red flags?

58 % of MRI requested by PCPs for LBP work up had no documented ACR red flags Findings suggest over utilization of MRI for LBP by PCP according to ACR red flags

What should the space between the lateral portion of the tibia and the medial portion of the fibula be? What does it mean if it's more?

5mm. Anything greater than that- think disruption of syndesmosis

5th Metatarsal Fractures: Where is stress, jones, avulsion fx?

5th metatarsal fx

What was the result of early referral to PT?

614 patients with LBP 522 (85%) were seen at the back pain clinics within 3-4 days of referral 70% of referred patients required only a single PT clinic visit 5% were referred on to orthopedic specialists

Would patients with LBP want imaging despite understanding that there are no benefits with routine imaging?

80% of patients with LBP would undergo radiography if given the choice, despite understanding no benefits with routine imaging.

What % of all ankle injuries are inversion sprains?

85% of all ankle injuries are inversion ankle sprains

In Shoulder AP IR, how big should the subacromial space be?

9-10 mm

What is the sensitivity and specificity of Pittsburg?

99% sensitive and 60-79% specific for the diagnosis of knee fractures.

Are proximal hip fx common? In what age group are they most common?

> 300,000 hip fractures occur each year Majority over 70 Fracture as a result of fall vs causing fall Uncommon in children and adults

Wells Clinical Prediction Rule for DVT Scoring

>/= 3 points: righ risk (75%) 1-2 points: moderate risk (17%) <1 point low risk (3%)

What's non union for femoral neck?

>3 mo

What's non union for shaft of long bones?

>6 mo

ABC through J checklist for plain films: A

A Airways -Trachea and bronchi midline and patent?

ABC through J checklist for plain films

A Airways -Trachea and bronchi midline and patent? B Bones-Fractures, osteolytic lesions? C Cardiac contours-Normal ratio? D Diaphragm R > L? Flattened? E Effusion- Costophrenic angles present? F Fields of lungs Masses, infiltrates, etc? G- Gastric bubble- Vessels enlarged? H- Hilum Located in the stomach, on the left? I Inspiration 10 posterior ribs? Jazz, all that- Lines, tubes, implants, valves, foreign objects?

Normal Merchant (Sunrise) Radiograph

A Patella B Patello-femoral Joint C MEDIAL femoral Condyle D LATERAL Femoral Condyle E Intercondylar Sulci

What is a PET scan? What is the difference between a MRI/CT and PET?

A brain positron emission tomography (PET) scan is an imaging test that uses a radioactive substance (called a tracer) to look for disease or injury in the brain. Unlike magnetic resonance imaging (MRI) and computed tomography (CT) scans, which reveal the structure of the brain, a PET scan shows how the brain and its tissues are working.

Hangman's fx

A hangman's fracture is the colloquial name given to a fracture of both pedicles or pars interarticularis of the axis vertebra (C2) (or, Epistropheus).

What is this image?

A large Intracranial Hemorrhage (ICH) on CT

Tibial Plateau Fracture: What are some issues to consider?

A lot of times intra-articular Think about scar tissue build up

When is a spine CT most commonly used?

A spine CT test is most commonly used to detect a herniated disc or narrowing of the spinal canal (spinal stenosis) in people with neck, arm, back, and/or leg pain. It is also used to detect a fracture or break in the spine.

Plain films: what should we look for? (hint: there's an acronym)

ABCS Alignment Bone/Bone Density Cartilage Soft tissue

Elbow trauma guidelines

ACR guidelines for chronic elbow pain Always ask about distal sensation

Slide 17 Elbow trauma

ACR guidelines for chronic elbow pain Always ask about distal sensation

What are the ACR red flags for immediate MRI for LBP?

ACR red flags: Recent significant trauma, or milder trauma > age 50 Unexplained weight loss Unexplained fever Immunosuppresion History of cancer IV drug use Prolonged use of corticosteroids, osteoporosis Age > 70

What's in the anterior column?

ALL Anterior annulus Anterior 2/3 vertebral body

What is a typical trauma view?

AP Axillary Y view

What are additional radiographic views of the pelvis? What are they used for?

AP oblique (Judet) AP axial pelvic inlet view AP axial pelvic outlet view Axiolateral (groin-lateral, cross-table lateral) All typically used for trauma

What view is best to measure carrying angle of the elbow?

AP view

Pelvic Avulsion Fractures/Apophysitis What are the muscles? The points of attachment?

Abdominal muscles/Iliac Crest Sartorius/ASIS Rectus femoris/AIIS Gluteal muscles/Greater Trochanter Iliopsoas/Lesser Trochanter Hamstring/Ischial tuberosity Adductor/Pubic Symph

What is a fatigue fx?

Abnormal activity on bone of normal mineralization

What are radiologic signs of cervical trauma?

Abnormal soft tissues Abnormal vertebral alignment Abnormal joint relationships

What can be seen in Lateral (Frogleg view) of the Hip?

Acetabulum Femoral Head Femoral neck Greater troch Lesser troch Femur

What is Developmental dysplasia of the hip?

Acetabulum is too shallow

What population is most likely to injure: Achilles' Posterior Tibealis Flexor Hallicus Longus Peroneal Longus/Brevis Anterior tib and extensors-

Achilles and post tib are weekend warrior FHL - dancers Peroneals- weekend warrior Anterior tib and extensors- very rare

What are the most commonly injured ankle tendons?

Achilles' Posterior Tibealis Flexor Hallicus Longus Peroneal Longus/Brevis

Wells Clinical Prediction Rule for DVT Condition

Active cancer Paralysis, paresis, immobilization of LE Bedridden for >3 days because of suregeery (within four weeks) Localized tenderness along distribution of depe veins Entire leg swollen Unilateral calf swelling of greater than 3 cm (below tibial tuberosity) Unilateral pitting edema Collateral superifical veins Alternative dx as likely or more likely than DVT (-3)

ACR guidelines- ADD IN THESE

Acute Knee Pain Non-traumatic Knee Pain LE DVT IF It's acute trauma and they don't fit those criteria, no xray, just treat Kids non traumatic pain, patellofemoral sx, non-localized- plain film If intiial negative, THEN MRI All MRIs of knee are without contrast. Can see what we need without radiograph

What are ACR LBP red flags that indicate possible Cauda equina syndrome or severe neurologic compromise?

Acute onset of urinary retention or overflow incontinence Loss of anal sphincter tone or fecal incontinence Saddle anesthesia Global or progressive motor weakness in the lower limbs

What are the ACR guidelines for trauma? What should first imaging be? If there is normal result and therapy, and there's still issues, then what imaging? If you can't do MRI, then what? If there's a previous total shoulder, then what?

Acute shoulder pain- any etiology- X Ray After normal X-Ray, therapy, still don't know etiology, then MRI If can't do MRI, then CT or US If previous total shoulder, then XRAy and MRI.

AVN of the femoral head VI

Advanced degenerative changes

What are LBP age related redflags according to the ACR?

Age >70 Milder trauma with age greater than 50

What is arthrography? How is it imaged? And what is it used for?

Air or contrast injected into joint Used with CT, MRI Assess certain internal joint structures Assess joint integrity Ex: Assess TFCC

What does A stand for in the ABCS approach of assessing plain films?

Alignment

CT Scan: how does tissue density affect the color that structures appear on CT?

All images based on gray scale Different tissues are assigned different shade of gray based on tissue density

What is evaluated in a MR arthrogram?

All three orthogonal planes

Pelvic Avulsion Fractures/Apophysitis What are the muscles?

Always - Abdominal muscles Support- Sartorius Rights (for) - Rectus Femoris Girls- Gluteal muscles In- Iliopsoas Hard- Hamstring Areas- Adductor

Plain films: How should alignment be checked?

Always check at least 2 views Plain films 2-d image of 3-d reality

ACR: Nontraumatic Knee Pain When should MRI be used?

An MRI examination for nontraumatic knee pain is indicated when the pain is persistent and conventional radiographs are nondiagnostic or when additional information is necessary before instituting treatment.

ACR: Nontraumatic Knee Pain When should MRI not be used?

An MRI is not indicated before a physical examination or routine conventional radiographs, or when there is diagnostic radiographic evidence of severe degenerative joint diseases, inflammatory arthritis, stress fracture, osteonecrosis, or reflex sympathetic dystrophy, for which additional imaging is not going to alter the treatment plan.

Angle of first ray and down by second ray: what is the typical angle? What if it's more than that?

Angle of first ray and down by second ray- typical angle 5-10 degrees more than that problem with ligaments or some deformity

Knee sonography: Anterior View

Anterior View Pt is supine with their knee flexed to about 30 degrees

Hip Sonography: what are the views?

Anterior View-Pt is supine with leg in slight external rotation Medial View- Pt is supine with hip externally rotated and knee in 45 deg of flexion (frog leg position) Lateral View- Pt is sidelying with pillows between knees Posterior View-Pt is prone with legs extended. Pillow under hips if needed for comfort

Ankle sonography: Structures of Interest - Ankle Anterior/Dorsal view

Anterior tib EHL EDL Anterior joint recess Syndesmosis/Interosseus membrane

What are typical hip imaging views?

Anteroposterior (AP) view of the pelvis AP view of the hip Lateral view of the hip

What causes osgood-schlatter?

Any repeated activity that uses the quad, jumping running, continued stress on tubercle causes it to pull away

What is a apparent diffusion coefficient (ADC)?

Apparent diffusion coefficient (ADC) is a measure of the magnitude of diffusion (of water molecules) within tissue, and is commonly clinically calculated usi)ng MRI with diffusion weighted imaging (DWI)

How large is the joint space? What does it mean if the space is larger than this?

Approx 5 mm Larger than this, it is subluxation or joint effusion

What is the pattern of MRI use in the US?

Areas in US with greater concentration of MRI units: Greater number of Lumbar MRI's completed Greater number of low back surgeries Not consistent with imaging guidelines Baras and Baker, 2009

What does an arthogram help us determine?

Arthogram: does all that material stay in the joint? It can leak out and we will see it extra-articular.

RA: are there articular erosions? If so, where?

Articular erosions, located either centrally or peripherally in the joint

In plain films, which appears smaller: the structures in the front or the structures in the back?

As the beam goes through, structures in front are smaller, structures in the back are bigger.

CT scan: what can you assess?

Assess the alignment and displacement of fracture fragments Identify loose bodies in the glenohumeral joint

Longitudinal view (going straight down) of Anterior Recess

Asterics= fat pad TH= talor head TD: talar done T- tibia

When would an avulsion in the greater tuberosity occur?

Avulsions - fall with the arm adducted and forceful contraction of the rotator cuff

Facet Spondylosis (Arthrosis) Axial CT

Axial CT

GIVE ANSWERS Name View Type of Image Structures

Axial FSE-XL PD

GIVE ANSWERS Name View Type of Image Structures Also what color should the articular cartilage be?

Axial FSE-XL PD articular cartilage should be grey

CT images: how are axial images viewed?

Axial images are always displayed as if the patient was supine and the examiner was positioned at the feet and looking up from below Axial image- chop person in half (side to side) looking from down to up. Your right side is the pt's left side

RA: is there migration of the femoral head? If so, in what direction?

Axial migration of the femoral head

ABC through J checklist for plain films: B

B Bones-Fractures, osteolytic lesions?

Calcaneal inclination or pitch: Is it in a WB or non WB position? If it's bigger, like 50 degrees, is it supinated or pronated?

B. Is a non WB position- got 20-30 deg. If bigger like 50 degrees, this is a very supiinated foot

ACR: Acute Trauma To the Knee Adult or child >1 year old. Fall or twisting injury with a tibial plateau fracture on a radiograph, with additional bone or soft-tissue injury suspected. Next study.

BEST CT knee without IV contrast MRI knee without IV contrast

ACR CHRONIC ANKLE: Ankle radiographs normal, suspected osteochondral injury. Next study.

BEST MRI ankle without contrast then CT or MR arthrography ankle

What is the main surgical indications for clavicle fx?

BIG point- any neurovascular complication Try to avoid if possible- very close to skin, plate would be problematic

What is the basic classification of ankle fx?

Basic classification of ankle fractures: (A) unimalleolar fracture, (B) bimalleolar fractures; (C) trimalleolar fracture (consisting of both malleoli and the posterior margin of the tibia).

Bone scans: Why does the bladder light up?

Because that's where the radiopharmaseutical accumulates

Osteoid Osteoma: Benign or malignant? Short bones or long bones? Age? Gender? Appear immediately or with time? Is there pain? Worst during in the day or night? What activities make it worst? What relieves it?

Benign Mostly in long bones Any age but most common 4-25 Males > females Typically will disappear with time Pain : Worse at night Pain: Not activity related Pain; Relieved by non-steroidal anti-inflammatories

What is the best use of knee sonography?

Best suited for assessment of tendons, bursa, soft tissue and collateral ligaments

What's the best way to view C1, C2 with plain films?

Best view of C1, C2 is open mouth view

ACR Suspected LE DVT Modalities

Best: US LE with doppler Second best: -MR venography lower extremity and pelvis without and with IV contrast -MR venography lower extremity and pelvis without IV contrast -CT venography lower extremity and pelvis with IV contrast if can't do MR V

What are five advantages of an MRI?

Better able to asses the fine details of soft tissues MRI contrast less likely to produce allergic reactions No exposure to radiation Better view of changes in bone marrow (tumors and AVN) Different sequences increase the chances of a disease process being picked up

What can be seen in the oblique view of the hand?

Better view of metacarpals

What color is air in a plain film?

Black

Plain films: color of least dense material?

Black (air)

What is the Blumensatt's line? What is it's relevance to the knee?

Blumensaat's Line-Drawn parallel to distal surface of femur through condyle The ACL should be tight against that line This is most likely a slight sprain of the ACL

Pittsburg Characteristics of patients who should undergo radiography after knee trauma?

Blunt trauma or a fall as mechanism of injury plus either of the following: A. Age younger than 12 years old or older than 50 years B. Inability to walk four weight-bearing steps in the emergency department.

What are four uses of bone scanning?

Bone cancer/mets Fracture Bone infection Metabolic disease (i.e. Paget's disease)

WHICH normal structure doesn't show up black on all MRI? Ligament tendon bone marrow labrum meniscus

Bone marrow

What is the remodeling phase?

Bony matrix becomes more organized Reabsorbs the less organized callous as the organized structure is laid down Callous is reabsorbed and the fx is usually no longer visible Process takes months to years

Multifides contraction: does voluntary contraction improve with imaging?

Both groups improved w/ FB but Group receiving visual FB performed consistently better and retained improved performance 1 week later

Slipped capital femoral epiphysis Population, age? What can increase the risk? What if, any, are the surgical interventions? What are the potential complications?

Boys between 12 and 15, girls between 10 and 13 Obesity can increase risk Surgical intervention is pinning Potential complications: Deformity of the hip AVN

What is the new model for thinking about brain function?

Brain functions are primarily intrinsic, with processing derived from subtle perturbation of high level intrinsic neuronal activity (both awake and asleep!), and coordinated within multiple networks defined by connectivity and function

ABC through J checklist for plain films: C

C Cardiac contours-Normal ratio?

What are other sources of knee pain

CA, infection, gout

Imaging for Osteochondral defects?

CT

Imaging for Pre-operative planning?

CT

Suspected Spine Trauma Blunt trauma meeting criteria for thoracic and lumbar imaging. With or without localizing signs.

CT

What do you use to image Complex fractures/dislocations of the ankle and hind foot?

CT

What imaging would be appropriate to assess: Osteoid Osteoma?

CT

Suspected acute cervical spine trauma. Imaging indicated by clinical criteria (NEXUS or CCR). Clinical or imaging findings suggest arterial injury.

CT MRI

Suspected acute cervical spine trauma. Imaging indicated by clinical criteria (NEXUS or CCR). Myelopathy.

CT MRI

Suspected acute cervical spine trauma. Imaging indicated by clinical criteria (NEXUS or CCR). Patient persistently clinically unevaluable for >48 hours.

CT MRI

Acute cervical spine trauma. Imaging indicated by clinical criteria (NEXUS or CCR). Treatment planning for mechanically unstable spine.

CT MRI

If there are neurological signs with thoracolumbar spine trauma, what imaging modalities should be used?

CT and MRI

Why are CT and MRI better for imaging CNS?

CT and MRI better to evaluate soft tissues such as the brain, liver, and abdominal organs, as well as to visualize subtle abnormalities that may not be apparent on regular X-ray tests.

what are the most common modalities for imaging the CNS?

CT and MRI remain the two most common modalities for imaging of the CNS.

ACR: Acute Hip Pain What is the role of CT, bone scintigraphy, and US?

CT and bone scintigraphy are second-line modalities, and US's role is unclear to date.

ACR ACUTE ANKLE: Adult or child >5 years old. Acute injury to the ankle. Radiographs demonstrate talus fracture. Next study.

CT ankle without contrast

Does CT have a high or low dose of radiation?

CT delivers the highest dose of radiation (as it is a series of x-ray exposures)

ACR: Chronic Hip Pain Radiographs negative, equivocal or nondiagnostic. Suspect osteoid osteoma.

CT hip without contrast

When would CT be needed in identifying bone fx?

CT may be needed to confirm the diagnosis, particularly in cases of insufficiency fractures of the sacrum and pelvis.

IMAGING for Loose bodies in joint?

CT or MRI

Why is CT scan useful?

CT scan- blood flow, particularly in pulmonary arterial system. Can also tell us about valves

What imaging would be appropriate to assess: Fracture alignment Fractures of the sacrum and acetabulum Measure bony alignment

CT scanning

What is CT scanning of the head typically used for?

CT scanning of the head is typically used to detect infarction, tumors, calcifications, hemorrhage and bone trauma. CT head scanning is such a BITCH: Bone Infarction Tumors Calcification Hemorrhage

What urgent conditions would you use CT for?

CT scanning of the head is typically used to detect: bleeding, brain injury and skull fractures in patients with head injuries. bleeding caused by a ruptured or leaking aneurysm in a patient with a sudden severe headache. a blood clot or bleeding within the brain shortly after a patient exhibits symptoms of a stroke.a stroke, especially with a new technique called Perfusion CT. brain tumors.

Is CT quick or slow?

CT scans are widely used in acute neurological injuries in which the speed of the examination is of primary importance.

Suspected acute cervical spine trauma. Imaging indicated by clinical criteria (NEXUS or CCR). Not otherwise specified.

CT top priority X ray

Acute Hand and Wrist Trauma Comminuted, intra-articular distal radius fracture on radiographs. Surgical planning.

CT wrist without IV contrast

CT vs MRI

CT- MORE BONE DETAIL MRI- MORE TISSUE DETAIL

Blunt trauma meeting criteria for thoracic and lumbar imaging. Neurologic abnormalities.

CT/MRI

Suspected acute cervical spine trauma. Imaging indicated by clinical criteria (NEXUS or CCR). Clinical or imaging findings suggest ligamentous injury.

CT/MRI

What are common foot fx? What causes calcaneal fx?

Calcaneal- lovers fx- high level jump Talus Navicular Lisfranc Metatarsal/Jones

Coronal Proton Density, normal and fat sat

Can see bone bruising in fat sat

What can be seen on the Inferosuperior view of the glenohumeral joint (Axillary)

Can see greater tuberosity and joint space

What can be seen in chest plain film?

Can see heart, ribs, lines, tubes, foreign objects Fluid in lungs, pleural effusion, pulmonary edema,

What can be seen in a lateral view of the ankle?

Can see trimalleolar fx - posterior aspect of the tibia

When are CTs useful?

Cancer Cardiovascular disease Infectious disease Internal trauma Musculoskeletal disorders Bone density

Why is cardiac MRI useful? What does it not do?

Cardiac MRI- gettng good, can recreate 3D images, thoracic vessels, chamber side. Doesn't give dynamic components of echiocardiogram

US: cartilage- hyper or hypoechoic? fibro? Hyaline?

Cartilage Hyaline - hypoechoic and uniform Fibro - hyperechoic

Acute Hand and Wrist Trauma Suspect acute distal radius fracture. Radiographs normal. Next procedure.

Cast and repeat x-ray wrist in 10-14 days MRI wrist without IV contrast

Neuroradiology: What does the CNS contain? The PNS?

Central nervous system Brain Spinal cord Cervical Thoracic Lumbosacral Peripheral nervous system Cranial Nerves Brachial Plexus Lumbosacral Plexus

Cervical and lumbar disc in asymptomatic subjects (94) stats

Cervical and lumbar disc in asymptomatic subjects (94) Lumbar pathology 84% Cervical pathology 90%

Cervical discs in asymptomatic subject stats

Cervical discs in asymptomatic subjects (497) 12-17% in subjects in their 20's 86-89% in subjects > 60's Disc bulge 284/497 (57%) Disc prolapse 50/497 (10%)

Based on the previous image, what type of image is this and what direction was it taken in.

Chest film, PA

chronic elbow and wrist pain: how should it be further evaluated?

Chondral and osteochondral abnormalities can be further evaluated with MRI or CT. The addition of arthrography is helpful, especially for detecting intra-articular bodies.

What is the reparitive phase?

Chondroblasts and fibroblasts enter the hematoma and form a callus matrix Osteoblasts enter the callus matrix and form bony callus Delayed and non-union result from errors in this stage

AP View of Foot What is the blue line? What is the associated amputation?

Chopart (transverse tarsal joint)

If there are no flags for immediate radiological work up, what's the next step?

Clinical Exam

What is the herniation pit?

Clinically benign; may represent cartilage or fibrous-type tissues

What are two types of distal radial fx?

Colles Smith

What is a colles fx?

Colles with dorsal movement- fx moves dorsally pic on left

What is an MR Arthrogram?

Combo of MR and arthrography Joint injected with contrast under fluouroscopic guidance

What is a comminuted fx?

Comminuted - mutlple pieces

Plain films- Cartilage: what indicates abnormal epiphyseal plates?

Compare contralaterally for changes in thickness that may be related to abnormal conditions or trauma

What is the affect

Compared patients with LBP and lumbar radiculopathy with or without knowledge of imaging results Early clinical outcomes were the same "Patient knowledge of imaging findings do not alter the outcomes and are associated with a lesser sense of well-being" With knowledge of imaging findings, patients scored lower with health perception Ash et al, 2008

What are surgical indications for clavicle fx? DONT NEED TO MEMORIZE Complete fx displacement/incomplete displacement? Possible risk of severe displacement? Length of shortening? Shape of fragment? Compromise? Displacement of what end of clavicle? Why? Expediting rehab? Open or closed fx? Muscle? Union/Non union? What type of concomitant fx?

Complete fracture displacement Severe displacement causing tenting of the skin with the risk of puncture Fractures with 2 cm of shortening Comminuted fractures with a displaced transverse "zed" (or Z-shaped) fragment Neurovascular compromise Displaced medial clavicular fractures with mediastinal structures at risk[ Polytrauma (with multiple fractures): To expedite rehabilitation Open fractures An inability to tolerate closed treatment Fractures with interposed muscle Established, symptomatic nonunion Concomitant glenoid neck fracture (floating shoulder)

What type of chronic ligament damage of the ATF is best visualized by MRI?

Complete tears Complete Tears Sensitivity 75% Specificity 85% Partial Tears Sensitivity 75% Specificity 78% Sprain Sensitivity 44% Specificity 88%

What are neuroimaging modalities?

Computed Tomography (CT) Magnetic Resonance Imaging (MRI) Ultrasound (US) Positron Emission Tomography (PET) Angiography: Catheter, CTA, MRA Magnetoencephalography (MEG) Radiography Single photon emission computed tomography (SPECT)

Which is better for ankle tendon pathology: US or MRI?

Concluded US and MRI were concordant US was slightly less sensitive but did not affect clinical management

MRI- MCL Tear Is conservative treatment the best option?

Conservative treatment

How should greater tuberosity fx be treated?

Conservative treatment Treated like a full tear

MRI: what's the effect of adding contrast?

Contrast can be added to enhance the visibility of certain tissues or blood vessels

CT: how can images be enhanced?

Contrast can be added to enhance visibility of certain tissues or blood vessels Computer can enhance structures by changing grayscale

What are some benefits of MRI?

Contrast derived from chemical environment No radiation exposure Cost: $$ - $$$

PET: where is the contrast derived from?

Contrast derived from radiotracer uptake

CT: where does the contrast come from? Speed? Cost? Weight limit? When is it contraindicated?

Contrast derived from tissue density, X-ray absorption Fast! Cost: $ - $$ Weight limit: 350 pounds Imaging time: 5 - 90 sec / sequence Resolution: 0.2 - 3 mm Contraindications: medically unstable

What is the contrast in US derived from?

Contrast derived from: Tissue texture Movement (e.g., blood flow)

GIVE THE ANSWERS Name View Type of Image Structures

Coronal SE T1

GIVE THE ANSWERS Name View Type of Image Structures

Coronal SE TI

GIVE THE ANSWERS Name View Type of Image Structures Also- how does this differ from the previous image? And what should the MCL be doing?

Coronal SE TI Further into joint. MCL should be flat against the joint

MRI: how are coronal images viewed? Axial? Sagittal?

Coronal images are viewed as if facing the patient from the front (your right is the pt's left) Axial images are viewed the same as CT (your right is the pt's left) Sagittal images are viewed from left to right on both sides of the body

US: when do you use curvilinear transducers? Are they superficial or deep? Low freq or high freq?

Curvilinear - lower frequency for evaluation of deeper structures or provide guidance of a needle for biopsy 3.5-5 MHz = deeper structures (deeper muscles, bladder, contents of ab/pelvic cavities)- use for deeper structures

What is the benefit of linear vs curvilinear transducers?

Curvilinear transducer allows greater depth but you sacrifice resolution. With higher frequency, linear, more superficial, more attenuation + reflection which produces a better resolution.

ABC through J checklist for plain films: D

D Diaphragm R > L? Flattened?

What is dark in T1? T2?

Dark in T2-fat, bone marrow Dark in T1-fluid, CSF, water

If you have DECREASED radiodensity is the object lighter or darker?

Darker

How do you identify spondylolisthesis?

Decap- pars articularis fx spondylolisthesis

What can be seen with OA?

Decreased joint space Sclerotic changes Cartilage loss Typically asymmetric tightness Glenoid retroversion Posterior glenoid wear Posterior subluxation

Plain films-Cartilage: what does joint space width indicate?

Decreased joint space imply degenerative or traumatic conditions

Pincer Type Impingement

Deep acetabular socket whereby more of the femoral head is covered by the socket. Less available motion

What is the Boehler angle?

Defines the relationship of the talus and calcaneus. Posterior subtalar joint to anterior process of calcaneus Posterior superior margin of the calcaneus 20-40 degrees

What are some factors affecting fx healing?

Degree of fx Age Nutrition Systemic Factors-DM, osteoporosis, immunocompromised Hormones-Thyroid, corticosteroids Vascular injury (AVN) Intra-articular NSAIDs Cipro XRT Smoking

What are three types of abnormal repair?

Delayed union Mal-union Non union

What are the PET scan applications?

Dementia Seizure Tumor imaging Cerebrovascular evaluation Functional imaging PET looks for DeFCTS

How do you increase heart rate to see function when you can't exercise patient?

Denazine- increases HR- debutamine- increase contractility persantine vasodilator- all of these will simulate heart working. This is for people who can't exercise. Increases cardiac workload and compare scans.

What is Calcaneal inclination or pitch?

Describes the angular position of the calcaneus. Plantar surface of the foot Inferior surface of the calcaneus 20-30 degrees

Spondylolysis- how is detected?

Detected by radiographs

What can the PET scan be used to dx?

Diagnose cancer, Prepare for epilepsy surgery, Help diagnose dementia if other tests and exams do not provide enough information, Tell the difference between Parkinson's disease and other movement disorders. Several PET scans may be taken to determine how well you are responding to treatment for cancer or another illness.

What muscles does LBP damage?

Diaphragm Quadratus Lumborum IO, EO Rectus Abdominis TrA Multifidus Pelvic Floor

What should happen with the diaphragm with breath? What will the lung fields look like?

Diaphragm- with breath- should flatten Fields of lungs- should be black

Are there different sequences with MRI? If so, what is the benefit?

Different sequences increase the chances of disease process being picked up

What can you see in the lateral view of the hand?

Difficult to see phalanges and metacarpals, but can see some disruption in carpals

What is dMRI aka diffusion MRI? What is it's main use?

Diffusion MRI (or dMRI) is a Magnetic Resonance Imaging (MRI) method which came into existence in the mid-1980s.[1][2][3] It allows the mapping of the diffusion process of molecules, mainly water, in biological tissues, in vivo and non-invasively. Molecular diffusion in tissues is not free, but reflects interactions with many obstacles, such as macromolecules, fibers, membranes, etc. Water molecule diffusion patterns can therefore reveal microscopic details about tissue architecture, either normal or in a diseased state. Its main clinical application has been in the study and treatment of neurological disorders, especially for the management of patients with acute stroke. Can reveal abnormalities in white matter fiber structure and provide models of brain connectivity.

chronic wrist pain: articular cartilage

Direct MR arthrography and CT arthrography are more accurate

ACR: Chronic Hip Pain When should Direct MR arthrography be performed?

Direct MR arthrography should be performed if acetabular labral tear is suspected, including patients with clinical evidence of FAI.

What is primary bone healing?

Direct contact between bone fragments with compression Rigid internal fixation (ORIF) Osteoclastic reaction followed by osteoblastic reaction Generally no bone callous seen New bone grows directly across the ends of the fracture

What enables the identification of all intra-articular tissues in MR arthrogram?

Distention of the joint capsule via injection of dilute gadolinium

When should you avoid MRI with contrast?

Don't want to get MRI with contrast for pt with renal failure.

ACR CHRONIC ANKLE SUMMARY: _______________ should be considered in assessing any soft-tissue abnormality that requires specific joint movement or positioning to produce symptoms, such as with tendon subluxation.

Dynamic US should be considered in assessing any soft-tissue abnormality that requires specific joint movement or positioning to produce symptoms, such as with tendon subluxation.

chronic elbow and wrist pain

Dynamic assessment with US is effective for diagnosing nerve or muscle subluxation.

ABC through J checklist for plain films: E

E Effusion- Costophrenic angles present?

What is a normal ejection fraction? An abnormal ejection fraction?

Ejection fraction (normal: 55-70) below 40 percent failure

What is it best for?

Emphasizes structures that are fluid-rich Swelling Detects occult fx's the best

What is Osteochondritis Dissecans (OCD)? What is the cause?

End result of aseptic separation of an osteochondral fragment with gradual fragmentation of the articular surface. Associated with loose bodies in the joint Likely a result of trauma

Plain films-Alignment: how do we follow the cortical line of the bone?

Ensure it is intact throughout Fractures tend to appear as a lucent line Any disruption, bulging or buckling of cortical bone is a fracture

Plain films-Density: what indicates local bone density changes?

Excessive sclerosis Reactive sclerosis that walls off a lesion Osteophytes

Plain films-Cartilage: what is abnormal subcondral bone?

Excessive sclerosis as seen in DJD Erosions as seen in the inflammatory arthritides

ABC through J checklist for plain films: F

F Fields of lungs Masses, infiltrates, etc?

Lateral lumbar plain film How will facet joints look with degenerative changes? Why?

Facet joints will be a lot brighter Arthritis- increased force- increased density- will be sclerotic

What are surgical neck fx associated with?

Fall onto outstretched arm Lower impact with elderly with osteoporosis (usually result in impaction fracture)

AP of the Hip/Proximal Femur: what structures can be seen?

Fat pads Gluteal Psoas Obturator Internus

What is an indication of an olecranon fx?

Fat pads become enlarged with damage-fat pad is displaced

Osteoarthritis

Figure 12-54 The pre-operative film of this severely degenerative hip joint of a 44-year-old man demonstrates the classic signs of degenerative joint disease: A. Narrowed joint space with superior migration of the femoral head; B. osteophyte formation at the joint margins of both the acetabulum and the femoral head; C. sclerosis of subchondral bone on both sides of the joint surface; D. acetabular protrusion, a bony outpouching of the acetabular cup in response to the progressive superior and medial migration of the femoral head.

SLIDE 3 HOW DO YOU CALCULATE THE CARRYING ANGLE OF THE ELBOW?

Figure 16-5 The angle formed by the longitudinal axes of the distal humerus and the proximal ulna constitutes the carrying angle of the forearm.

AVN of the Femoral Head Stage V

Flattening of head with joint narrowing and/or acetabular involvement

AVN of the Femoral Head Stage IV

Flattening of head without joint narrowing or acetabular involvement A Mild (<15%) B Moderate (15-30%) C Severe (>30%)

ACR: chronic NP: when are flexion/extension lateral radiographs helpful?

Flexion/extension lateral radiographs may offer supplemental diagnostic information in the setting of suspected instability or in symptomatic patients with a history of prior surgery including ACDF, cervical prosthetic disc placement or posterior instrumentation.

What can be seen within the carpal tunnel?

Flexor retinaculum Flexor digitorum profundus and superficialis Flexor pollicis longus Median nerve Ulnar Artery Ulnar Nerve Palmaris

T2 Spine. How do we know it's T2?

Fluid is bright

T1 Spine. How do we know it's T1?

Fluid is dark

T1: what color is fluid? Fat/bone marrow?

Fluid is dark; fat and bone marrow are brigher

T2: what color is fluid? Fat/bone marrow?

Fluid is light; fat and bone marrow are darker

What activities are associated with spondylolysis?

Football Gymnastics Wrestling Volleyball Weightlifting

What is fat suppression (fat saturated)?

For looking at inflammation process Fat and bone marrow made darker. Edema will be brighter Greater discrimination between fluid signal. Can be added to any sequence Bone bruises can be seen with fat sat.

ACR CHRONIC ANKLE SUMMARY: For suspected osseous abnormality, ___, ____, and possibly ______ can be used.

For suspected osseous abnormality, MRI, CT, and possibly bone scan can be used.

Plain film is the fastest way to assess what five things?

Fractures Bony alignment Arthritis Bone infections Bone CA

What is fMRI?

Functional magnetic resonance imaging or functional MRI (fMRI) is an MRI procedure that measures brain activity by detecting associated changes in blood flow

ACR: Nontraumatic Knee Pain Adult: Initial knee radiographs demonstrate inflammatory, crystalline, or degenerative joint disease (uni- to tri-compartmental sclerosis, hypertrophic spurs, joint space narrowing, and/or subchondral cysts).

Further testing not appropriate

ACR: Nontraumatic Knee Pain Adult: patellofemoral (anterior) symptoms. Initial knee radiographs demonstrate degenerative joint disease and/or chondrocalcinosis.

Further testing not appropriate

ABC through J checklist for plain films: G

G- Gastric bubble- Vessels enlarged?

Gastroc/Soleus

Gastroc on top and black layer of cake is the soleus Frosting= fascia

Structures of Interest - Ankle Posterior/Plantar View

Gastrocnemius Soleus Achilles' Calcaneal bursa Plantaris Plantar fascia

Plain films-Soft Tissue: does it show detail?

Generally does not show up on plain film in detail

What can you see with the tangential aka sunrise radiograph?

Gives good view of Patellofemoral joint- about 45 degree angle for beam

What are the pros of CT?

Good alternative for those who cannot undergo MRI due to metallic implants Generally more readily available Less expensive Less problematic for those with claustrophobia Quicker test time

What is the benefit of using a MRI T2?

Good for detecting inflammation

What is the benefit of using a MRI T1?

Good images/anatomy

What grade sprains can US do a good and reliable job diagnosing?

Grade 1 and 2 ankle sprains

What are the grades of the Kellgren-Lawrence knee OA?

Grade 1: doubtful narrowing of joint space and possible osteophytic lipping Grade 2: definite osteophytes, definite narrowing of joint space Grade 3: moderate multiple osteophytes, definite narrowing of joints space, some sclerosis and possible deformity of bone contour Grade 4: large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of bone contour

What is a good way to identify grade III sprains? US or Clinical Exam?

Grade III- clinical exam is 100% compared to a grade III ankle sprain. Prob need surgery for this

Spondylolisthesis- Myerding Classification What are the five grades?

Graded on the degree of slippage as seen on lateral xray: Grade I — 1 - 25 percent slip Grade II — 26 - 50 percent slip Grade III — 51 - 75 percent slip Grade IV — 76 - 100 percent slip and more than 100% is grade V (spondyloptosis).

Greater Trochanter/Bursa/ITB Sonography

Greater Trochanter/Bursa/ITB

What are the ordering trends in Areas in US with greater concentration of MRI units?

Greater number of Lumbar MRI's completed Greater number of low back surgeries Not consistent with imaging guidelines

ABC through J checklist for plain films: H

H- Hilum Located in the stomach, on the left?

What is proton density imaging? What is it helpful with?

Has T1 and T2 properties Helpful with tendon, meniscus, ligament and cartilage

What is the purpose of cardiac catheterization?

Helps visualize arteries, but more invasive. Go through femoral artery. If brachial artery, need to be on rest for five days

What is the inflammatory phase?

Hematoma forms Inflammatory cells become present Osteoclastic reaction begins Typically lasts several weeks and carries over into second stage

Are labral tears picked up by US?

High PPV

What are some other types of imaging used in the CT region?

High Resolution CT Scan Cardiac MRI Peripheral US

When should there be an immediate radiologic work up for thoracolumbar spine trauma?

High energy mechanism of work Distracting injury Pain Neurological deficits Obtuned Intoxication Unreliable clinical examination

Ankle sonography: Higher frequency? Large or smaller probe?

Higher frequency (up to 15 MHz) Smaller probe

Knee sonography: which is better higher or lower frequency?

Higher frequency is better (7 MHz or above)

What are the cons of US?

Highly operator dependent Cost can be an issue for many clinics Limited evidence regarding its use in PT practice Limited training available for PTs currently

What are ACR LBP red flags that indicate possible cancer or infection?

History of cancer Unexplained weight loss Immunosuppression *Urinary infection* *Intravenous drug use* *Prolonged use of corticosteroids* *Back pain not improved with conservative management*

Full ACR LBP Red flag list

History of cancer Unexplained weight loss Immunosuppression Urinary infection Intravenous drug use Prolonged use of corticosteroids Back pain not improved with conservative management History of significant trauma Minor fall or heavy lift in a potentially osteoporotic or elderly individual Prolonged use of steroids Acute onset of urinary retention or overflow incontinence Loss of anal sphincter tone or fecal incontinence Saddle anesthesia Global or progressive motor weakness in the lower limbs

What are some history issues that are ACR LBP red flags? (2 answers)

History of cancer or significant trauma

What are ACR LBP red flags that indicate possible spinal fracture?

History of significant trauma Minor fall or heavy lift in a potentially osteoporotic or elderly individual Prolonged use of steroids

Stress fx: what are the problems with bone scans?

However, in most cases bone scans lack specificity (with synovitis, arthritis, degenerative joint disease, stress reactions, and tumor appearing similar), and supplemental imaging with magnetic resonance imaging (MRI) or computed tomography (CT) may be necessary for conclusive diagnosis or to avoid false positives [4].

What are 5 forms of non-union?

Hypertrophic Atrophic Fibrous Pseudoarthrosis Septic

ABC through J checklist for plain films: I

I Inspiration 10 posterior ribs?

Lateral epicondylitis Common Extensor Tendon

I am going to jump laterally for a minute and take a look at involvmenet of the common extensor tendon as well. It will appear very similar with a nicely organized common extensor tendon on the left, and a tendon on the right with a significant increase in swelling, again creating a hypoechoic appearance. thickening above

Labral tear: how would it be imaged?

IF THERe's a tear they will do arthograph with contrast, which will exit joint if the tear is bad Can see a bankart here

What grade of radial head fx indicates need for surgery? What type of surgery?

III or IV- surgery Radial head replacement or resection

Oblique Internal Rotation view of the elbow: what is the position? what can be seen?

IR and pronated

In practice, what is MR/arthrography used for most frequently?

Identify tears in acetabular labrum

What are the values associated with these angles and the associated risks?

If flatter- more likely to sublux Congruence ange- where is patella line up within groove Line typically medial- more lateral line, more lateral patella- higher risk of subluxation /dislocation Alex Gufstason: A - sulcus angle 138+/- 6 deg > 138 degrees increased risk of sublux/dislocation B - congruence angle - 6 degrees center of sulcus to lowest point of patella if line is lateral to center line, value is + > 16 degrees increased risk of sublux

In shoulder AP IR, what does it mean if the humeral head is sitting higher

If humeral head sitting higher, might have RC tear. Supraspinatus depresses humeral head

Western Australia Neck Pain: Non Traumatic Neck Pain, Pain only, no red flags

If no red flags, go to conservative treatment. If conservative treatment doesn't work, then plain films If still uncertain about cause, MRI

MRI-PCL Tear What position should the PCL be slack in?

If the knee is extended, PCL should be slack.

ACR: Avascular Necrosis (Osteonecrosis) of the Hip When would an MRI be used?

If the radiograph findings are definite for AVN, an MRI might be indicated if knowledge of asymptomatic AVN in the opposite hip is clinically important. If the radiograph findings are equivocal for AVN or are normal on the symptomatic side, then MRI is indicated to confirm the diagnosis of AVN and to exclude other potential causes for the patient's hip pain.

ACR LBP: If there are persistent or progressive symptoms during or following 6 weeks of conservative management and the patient is a surgery or intervention candidate or diagnostic uncertainty

If there are persistent or progressive symptoms during or following 6 weeks of conservative management and the patient is a surgery or intervention candidate or diagnostic uncertainty remains, MRI of the lumbar spine has become the initial imaging modality of choice in evaluating complicated LBP.

MRI - ACL Tear What happens if there is a tear off the proximal insertion? What happens if there's a mid tear?

If there is a tear, off prox insertion, might lie flat If mid tear, might see some ligament above or below

ACR CHRONIC ANKLE SUMMARY: If there is concern for an intra-articular process such as osteochondral abnormality or ankle impingement, ________ or ______ may be used, with the latter more effective in the presence of a joint effusion than when no effusion is present.

If there is concern for an intra-articular process such as osteochondral abnormality or ankle impingement, MR arthrography or MRI may be used, with the latter more effective in the presence of a joint effusion than when no effusion is present.

ACR CHRONIC ANKLE SUMMARY: If there is concern for focal soft-tissue abnormality, such as tendon or ligament abnormality,

If there is concern for focal soft-tissue abnormality, such as tendon or ligament abnormality, MRI or US may be considered.

Pelvic Avulsion Fractures/Apophysitis The points of attachment? What are the muscles?

Iliac crest: Abdominal muscles Anterior superior iliac crest: Sartorius Anterior inferior iliac crest: Rectus femoris Greater trochanter: Gluteal muscles Lesser trochanter: Iliopsoas. Isolated nontraumatic avulsion fractures of the lesser trochanter in adults is a pathognomonic sign of metastatic disease. Ischial tuberosity: Hamstrings Pubic symphysis: Adductor group

What are the ilioischial and iliopubic lines?

Ilioischial and Iliopubic lines = posterior and anterior columns of acetabulum

ACR CHRONIC ANKLE: Multiple sites of degenerative joint disease in the hindfoot detected by ankle radiographs. Next study.

Image-guided anesthetic injection hindfoot/ankle- May be appropriate Second most "may be appropriate"- MRI hindfoot/ankle without contrast

MRI: can images be taken in multiple body planes?

Images can be taken in several body planes

ACR: Acute Trauma To the Knee Adult or child >1 year old. Fall or twisting injury, no focal tenderness, no effusion; able to walk. First study.

Imaging is inappropriate Xray and MRI without IV contrast are the least inappropriate

Is MRI good for Grade I and Grade II sprains?

Imaging useful in clinical correlation in Gr I & II sprains Clinical Exam 25% accuracy vs. MRI up to 100% accuracy

What's an impaction fx?

Impaction fracture - compression fractures are an example of this Avulsion fxs as well

VQ scan reveals Total left lung ventilation 39% Total right lung ventilation 61% Total left lung perfusion 29% Total right lung perfusion 71% What does this mean clinically? How would you alter your exam and/or intervention?

Impaired gas exchange- huge mismatch- not getting a lot of air in and not absorbing it Short of breath, won't tolerate exercise

ACR ACUTE ANKLE: Summary Meet Ottawa Ankle Rules- what views? If radiograph negative, then what?

In a patient who meets the OAR for a suspected ankle fracture, a 3-view (AP, lateral, and mortise) ankle radiographic study is indicated. If the radiograph is negative, clinical follow-up is warranted to rule out an ankle injury that may eventually need treatment.

ACR: Avascular Necrosis (Osteonecrosis) of the Hip If MRI can't be used, what is used instead?

In patients in whom MRI cannot be performed, a bone scan with SPECT imaging is a reasonable alternative for diagnosing radiographically occult AVN.

ACR: In patients with a history of low-velocity trauma, osteoporosis, or chronic steroid use which should be initial images?

In patients with a history of low-velocity trauma, osteoporosis, or chronic steroid use, initial evaluation with radiographs is recommended.

ACR: absence of red flags, what should be done about chronic LBP?

In the absence of red flags, first-line treatment for chronic LBP remains conservative therapy with both pharmacologic and nonpharmacologic (eg, exercise, remaining active) therapy.

When is imaging not needed?

In the absence of trauma or other "red flags" imaging may not be necessary in the 1st 4-6 weeks.

What is an incomplete fx? Where does it occur? Who does it usually occur in?

Incomplete usually only happen in the smaller bones. Several types that occur in children as a result of their bones being softer and more flexible- Greenstick Incomplete occur with bending and compression of the bone

Plain films- Soft Tissue: what will show up?

Increased area of swelling will show up cloudy Will see fat pads and lines Heterotrophic Ossification Myositis Ossificans HO and MO are important- most common in elbow (HO particularly) and knee

Plain films-Cartilage: how will joint effusion appear? What does it indicate?

Increased joint space Fluid in joint

Meniscal tear: what does an increased signal extending to an articular surface indicate?

Increased signal extending to an articular surface = tear

When should we use a CT scan for the ankle?

Indications: Severe trauma Complex fractures/dislocations of the ankle and hind foot Loose bodies in joint Osteochondral defects Pre-operative planning Any condition typically seen on MRI if MRI is contraindicated (don't forget US)

3D CT Reconstruction

Inf Gleno Hum ligament Bankart lesion

What is a ventilation/perfusion scan?

Inhale radioactive to get imaging of lungs.

Western Australia Neck Pain: Non Traumatic Neck Pain, radiculopathy

Initial conservative therapy If pain not improving/progressive neurological deficit then MRI

ACR Chronic LBP: Summary of imaging

Initial evaluation for inflammatory arthropathy is best performed with radiographs of the sacroiliac joints and symptomatic areas of the spine. MRI plays an essential role in identifying early inflammatory disease when radiographic evidence of disease is absent and should begin with sacroiliac joint imaging. MRI of the spine may be helpful in establishing the diagnosis when other imaging is negative. The MRI request should indicate that the examination is being performed to evaluate for possible axial spondyloarthropathy as the imaging sequences may need to be modified.

ACR CHRONIC ANKLE SUMMARY: what should the initial evaluation imaging be?

Initial evaluation of chronic ankle pain should begin with radiography.

chronic elbow and wrist pain: how should it be initially evaluated?

Initial evaluation of chronic elbow pain should begin with radiography.

What is myocardial perfusion imaging?

Inject radionucleotide so can see blood flow in heart Top image= at rest Then exercise if can Then look at the difference between resting and activity Top image- bright white on both sides- go away when exercise. When increased demand, less white- more work (?) , chest pain, angina. Stop exercising, less pain, stable angina Bottom two: fixed defect. Improve flow, doesn't change function. You can still exercise.

What is a myelogram? What type of imaging is used?

Injection of contrast dye into subarachnoid space Radiograph or CT taken after injection

What views: best demonstrates ring configuration of pelvis and narrowing or widening of diameter of ring is immediately apparent. Evaluates for posterior displacement of pelvic ring or opening of pubic symphysis;

Inlet view

Maisonneurve fracture Syndesmosis injury

Instability of the ankle: wide gap between the talus and medial malleoli deltoid ligament is torn. This severe sprain also disrupted the interosseous membrane on the lateral side of the joint and produced a spiral fracture (arrow) at the proximal fibula seen on the lateral radiograph of the leg (B). T

What should you instruct the pt to do and how will that impact the film?

Instruct deep breaths- that's why majority should be black

What is the MRI star effect?

Interference from screw. Magnetic field is bouncing off the screw

What is the Judet View? ASK/CHECK SLIDE 38

Internal oblique position- demonstrates the ilioipubic column and posterior rim of the right acetabulum External oblique demonstrates the ilioischial column and the anterior rim of the acetabulum

What can angiography be used for? Is it expensive?

Interventional Radiology: Embolization,Thrombectomy /Thrombolysis Very expensive

What are the disadvantages of US?

Intra-articular structures: Limited ability to show joint surfaces and intra-articular structures Bones: can only show cortical outline of bone US doesn't cross air/tissue interfaces

Inversion and eversion: which is associated with soft tissue damage? Bony damage?

Inversion sprains tend to be more soft tissue Eversion generally associated with bony damage-because deltoid ligament is very strong,

Should the diaphragm be at the same or different levels?

It should be at the same level

Plain films: What color will metal be? Why?

It will be white, because radiation doesn't get through

What is a Segond Fracture? When is it seen?

It's a small avulsion fx of tibial plateau Typically seen with ligamentous injuries, more so with ACL More from rotary aspect of ACL tear.

ABC through J checklist for plain films: J

Jazz, all that- Lines, tubes, implants, valves, foreign objects?

ACR: Acute Trauma to the knee What are the clinical parameters for ordering knee radiographs?

Joint effusion within 24 hours of a direct blow or fall [4] Palpable tenderness over the fibular head or patella [6] Inability to walk (4 steps) or bear weight immediately or in the emergency room [6] or within a week of the trauma [67] Inability to flex the knee to 90° [6] Altered mental status [5,13]

Should the joint space in the knee be the same medially to laterally?

Joint space that you see should be roughly the same- shouldn't see difference medial to lateral.

What is one grading system for knee OA?

Kellgren-Lawrence

CT scan: can it be used to look at labral/rotator cuff pathology? Any other pathology?Is it better than MRI?

Labral or rotator cuff pathology if MRI is unavailable/contraindicated (do not forget US) Any other pathology if MRI is not indicated (including if MR contrast is contraindicated) US is almost as good as MRI/CT for cuff tear

What would late radiographic findings show with stress fx?

Late radiographic findings are often suggestive in appearance as well: linear sclerosis, often perpendicular to the major trabecular lines

Knee sonography: Lateral View

Lateral View Pt is either supine with leg internally rotated or sidelying with pillow between knees

Where is the US transducer placed for TrA examination?

Laterally

What are other sources of knee pain in a younger population?

Legg-Calve-Perthes (3-10) Slipped femoral capital epiphysis (10-14)

Developmental Dysplasia 1-2 per 1000 births Symptoms include:

Legs of different lengths Uneven skin folds on the thigh Less mobility or flexibility on one side Limping, toe walking, or a waddling, duck-like gait

Is there more anatomic detail in CT or MRI?

Less anatomic detail in CT vs. MRI but generally sufficient for the appropriate management of an acute CNS injury.

What does an isolated nontraumatic avulsion fx of the lesser trochanter indicate?

Lesser trochanter: Iliopsoas. Isolated nontraumatic avulsion fractures of the lesser trochanter in adults is a pathognomonic sign of metastatic disease.

What are the benefits of early referral to PT with LBP?

Levels of improvement & loss of work time comparable to other intervention studies for LBP Prompt access to physiotherapy in primary care cost less per episode of LBP than conventional management Patients valued early access to PT Questions remain about the availability of sufficient physiotherapists to take on such programs Pinnington,M.A. et al. Fam.Pract. August 2004

Talar Dome Osteochondral Injuries

Lifting away on the talus On right fat saturated MRI

US: ligament- hyper or hypoechoic?

Ligament - Hyperechoic, striated More compact as compared to tendon

What can be seen with MRI of the elbow?

Ligament/muscle/tendon/bursal disorders Occult fractures Osteochondral/chondral lesions Marrow abnormalities Peripheral nerve disorders Neoplasms/infection Forearm interosseous membrane

When would you MRI the elbow?

Ligament/muscle/tendon/bursal disorders Occult fractures Osteochondral/chondral lesions Marrow abnormalities Peripheral nerve disorders Neoplasms/infection Forearm interosseous membrane

What is a lisfranc injury?

Ligamentous damage

Ankle sonography: why would you use oblique angles?

Ligaments and structures seldom oriented parallel to the probe. Have to go at oblique angles

What is light in T1? T2?

Light in T1-fluid: CSF, water, flowing blood Light in T2-fat and bone marrow are darker

AP View of Foot What is the red line? What is the associated amputation?

Lisfranc (tarsometatarsal joint)

Is there contrast between tissues in proton density imaging?

Little contrast between tissues

What is delayed union?

Longer than expected for age, site and severity of injury

Where does a longitudinal fx occur?

LongitudinaL - parallel to the cortex

Lateral view of the forearm: what can we observe

Look at integrity of shaft of bone

What is a good way to view the dens? What does looking at the dens tell you?

Look at the dens. If you have an odontoid fx or there is instability- don't want to do anything manual

Plain films: What should we check when looking at alignment?

Look at the position of the bones Compare to other side if possible Subluxation/dislocation Follow cortical line of the bones for the entire length Stress Fx

How do you identify spondiloysis?

Look for "scotty dog"- if he has a collar- spondylolisis

What should we see when we look at the trachea? What will happen to the trachea with a lung collapse?

Look- is the trachea in the midline. Growth or enlargement, lung collapse can shift trachea to the side. Shift away from the inflated lung

Is LBP a common sx for office visit? In the past 3 months, what % of

Low back pain (LBP) 2nd most common symptom for office visit 1/3 of adults will have reported back pain in the last 3 months ¾ of adults will have at least one episode of LBP in their life

What is bone scanning best at? What is the prob with it?

Low specificity Best for detecting the presence and distribution of lesions; Many conditions demonstrate increased uptake

SLJ: what should be tested?

Lower extremity strength needs to be tested, especially at the ankle and the hip to find any muscle weaknesses that may be contributing to the overuse syndrome.

What frequency should be used for hip sonography?

Lower frequency soundhead 2.5 to 5 MHz

Stress fx: radiograph negative. Lower risk. Next steps?

Lower risk- repeat radiograph in 10-14 days. If positive, treat. if ongoing concerns- MRI after that.

ACR: Chronic Hip Pain Radiographs negative, equivocal, or nondiagnostic. Suspect labral tear with or without clinical findings consistent with or suggestive of femoroacetabular impingement.

MR arthrography hip If can't do MR, then CT arthrography hip

ANSWER TO PREVIOUS IMAGE

MRI

Acute, subacute, or chronic low back pain or radiculopathy. Surgery or intervention candidate with persistent or progressive symptoms during or following 6 weeks of conservative management.

MRI

IImaging for Impingement syndrome

MRI

Imaging Marrow abnormalities

MRI

Imaging Vascular conditions

MRI

Imaging GH chondral/osteochondral defects

MRI

Imaging Intra-articular loose bodies

MRI

Imaging Labral/capsular issues

MRI

Imaging Muscle disorders

MRI

Imaging Neoplasms/infection

MRI

Imaging Neurological conditions

MRI

Imaging Supraspinatus outlet

MRI

Imaging for Infections/neoplasms

MRI

Imaging for Loose bodies

MRI

Imaging for Osteochondral/articular cartilage defects

MRI

Imaging for Sinus tarsi syndrome

MRI

Imaging for Stress fractures/marrow abnormalities

MRI

Imaging for Tendon/Ligament/Fascia pathology

MRI

Imaging for tendon issues

MRI

What is the gold standard for identifying epicondylitis?

MRI

What sort of imaging is appropriate for Adult sequela of childhood disorders

MRI

What sort of imaging is appropriate for Athletic pubalgia

MRI

What sort of imaging is appropriate for FAI

MRI

What sort of imaging is appropriate for Labral tears

MRI

What sort of imaging is appropriate for Marrow abnormalities (transient osteoporosis)

MRI

What sort of imaging is appropriate for Musculotendinous disorders

MRI

What sort of imaging is appropriate for Occult fractures/stress fractures

MRI

What sort of imaging is appropriate for Osteonecrosis of the femoral head

MRI

What sort of imaging is appropriate for Osteonecrosis of the femoral head Marrow abnormalities (transient osteoporosis) Occult fractures/stress fractures Adult sequela of childhood disorders FAI Labral tears Musculotendinous disorders Athletic pubalgia Sacral plexus disorders

MRI

What sort of imaging is appropriate for Sacral plexus disorders

MRI

chronic wrist pain: RA

MRI

If there's a negative clinical exam, but you can't mobilize, and there are neurological signs, what type of images should be taken?

MRI CT

If there's a positive clinical exam and neurological signs, what type of images should be taken?

MRI CT

chronic wrist pain: Ulnar-sided wrist pain is often related to ulnocarpal impaction, TFCC lesions, and/or lunotriquetral ligament tears [1,8,14].

MRI MR arthrography CT

Gluteal Tendon Tears What is best for detecting them?

MRI US

Low back pain or radiculopathy. New or progressing symptoms or clinical findings with history of prior lumbar surgery.

MRI then CT

Low back pain with suspected cauda equina syndrome or rapidly progressive neurologic deficit.

MRI then CT

ACR CHRONIC ANKLE: Suspected inflammatory arthritis detected by ankle radiographs. Next study.

MRI ankle without and with contrast

ACR ACUTE ANKLE: Adult or child >5 years old. Acute injury to the ankle. Radiographs suggest an osteochondral injury. Next study.

MRI ankle without contrast

ACR CHRONIC ANKLE: Ankle radiographs normal, pain of uncertain etiology. Next study.

MRI ankle without contrast

ACR ACUTE ANKLE: Adult or child >5 years old. Acute injury to the ankle with >1 week persistent pain. Initial radiographs negative.

MRI ankle without contrast Might be indicated

Suspect stress fracture in otherwise normal patient. Radiographs normal.

MRI area of interest without contrast

What is the best way to to detect a RC tear?

MRI arthro is best for partial thickness tear US is good if have good operator

ACR: Chronic Hip Pain Radiographs negative, equivocal, or nondiagnostic suspect osteonecrosis. Includes circumstance in which hip is asymptomatic but osteonecrosis is suspected due to known predisposing factors.

MRI hip with or without contrast

ACR: Chronic Hip Pain Radiographs negative, equivocal or nondiagnostic, suspect osseous or surrounding soft-tissue abnormality, excluding osteoid osteoma.

MRI hip without contrast

ACR: Chronic Hip Pain Radiographs positive, suggestive of pigmented villonodular synovitis or osteochondromatosis.

MRI hip without contrast CT arthrography hip if MRI contraindicated

ACR: Avascular Necrosis (Osteonecrosis) of the HIp Avascular necrosis suspected clinically but radiographs are normal. Further evaluation needed.

MRI hips without contrast

ACR: Avascular Necrosis (Osteonecrosis) of the Hip Radiograph shows mottled femoral head, suspicious but not definite for avascular necrosis in the painful hip(s). Further evaluation is needed.

MRI hips without contrast

ACR: Avascular Necrosis (Osteonecrosis) of the Hip Avascular necrosis with femoral head collapse by radiographs in the painful hip. Surgery contemplated.

MRI hips without contrast may be useful

ACR: Avascular Necrosis (Osteonecrosis) of the Hip Avascular necrosis with femoral head collapse detected by radiographs of the painful hip: no surgery contemplated at this time.

MRI if need more info

Limits of CT?

MRI is more suitable to assess very fine details of soft tissue Non-displaced Fx's Images only collected in axial plane

Western Australia Neck Pain: Non Traumatic Neck Pain, possible spinal canal stenosis, imaging indicated

MRI is most appropriate If MRI not available, CT

Is MRI a good choice for stress fx identification?

MRI is the clear-cut choice for imaging, particularly in the elite athlete, in the elderly, and in patients who depend on using the injured limb in their work. As a rule, MRI need not be performed using contrast enhancement except in special circumstances such as adjacent soft-tissue mass or ambiguous findings.

ACR: pts with suspected of cord compression or spinal cord injury.

MRI is the imaging procedure of choice in patients suspected of cord compression or spinal cord injury.

ACR: Acute Hip Pain: When is MRI the best imaging choice?

MRI is the most appropriate imaging choice for evaluating radiographically occult fracture in individuals >50 years old.

ACR: Nontraumatic Knee Pain Child or adolescent: nonpatellofemoral symptoms. Initial knee radiographs are negative or demonstrate a joint effusion.

MRI knee without IV contrast

ACR: Nontraumatic Knee Pain Child or adult: patellofemoral (anterior) symptoms. Initial knee radiographs are negative or demonstrate a joint effusion.

MRI knee without IV contrast

ACR: Nontraumatic Knee Pain Adult: nontrauma, nonlocalized pain. Initial knee radiographs are negative or demonstrate a joint effusion.

MRI knee without IV contrast

ACR: Nontraumatic Knee Pain Initial knee radiographs demonstrate avascular necrosis.

MRI knee without IV contrast

ACR: Nontraumatic Knee Pain Adult: Initial knee radiographs demonstrate evidence of internal derangement (eg, Segond fracture, deep lateral femoral notch sign).

MRI knee without IV contrast CT arthrography knee if MRI couldn't be done

ACR: Acute Trauma To the Knee Adult or child >1 year old. Fall or twisting injury with either no fracture or a Segond fracture seen on a radiograph, suspect internal derangement. Next study.

MRI knee without IV contrast -best CT knee without IV contrast- might be appropriate

ACR: Nontraumatic Knee Pain Child or adolescent: nonpatellofemoral symptoms. Initial knee radiographs demonstrate osteochondral injuries (fracture/osteochondritis dissecans or a loose body).

MRI knee without IV contrast BEST MR arthrography knee (may be appropriate)

Acute, subacute, or chronic low back pain or radiculopathy. One or more of the following: suspicion of cancer, infection, or immunosuppression.

MRI most appropriate Following that CT, Xray, SPECT

MRI vs CT: which only does one plane? What does multiple planes?

MRI multiple planes sag, axial, coronal, oblique Can only do one plane in CAT

ACR: Acute Hip Pain Middle-aged and elderly patients. Negative or indeterminate radiographs.

MRI of pelvis and affected hip without contrast

ACR: when should lumbar spine be MRI'd?

MRI of the lumbar spine should be considered for those patients presenting with red flags raising suspicion for a serious underlying condition, such as cauda equina syndrome (CES), malignancy, or infection.

What is the gold standard for imaging for meniscal tears?

MRI still thought of by most to be the gold standard for imaging

Chronic Back Pain: Suspected Sacroiliitis/Spondyloarthropathy Inflammatory sacroiliac symptoms. Suspected axial spondyloarthropathy. Radiographs negative or equivocal.

MRI top choice, followed by CT

How does MRI work?

MRI uses radio frequency and a strong magnetic field to produce detailed images of internal tissues Based on magnetic behavior of Hydrogen atoms in human tissues

Acute Hand and Wrist Trauma Suspect acute scaphoid fracture. Radiographs normal. Next procedure.

MRI wrist without IV contrast

Order these from lowest to highest radiation dose US CT MRI Radiography

MRI, radiography, computed tomography scan

Stress fx: radiograph negative. High risk location, duration or need of definitive dx?

MRI. If pt can't have MRI, bone scan or CT

If there's a positive clinical exam and NO neurological signs and no visceral damage concerns, but there is an abnormal plain film, what's the next step?

MRI/CT

Do the majority of LBP pts have a high spontaneous recovery rate?

Majority of LBP patients have a high spontaneous recovery rate

What is the difference between male and female pelvis?

Male- narrower, pubic arch <90 degrees Female- wider, public arch >90 degrees

ACR chronic NP: Degen changes with no neuro signs? With failure of conservative management?

Many patients with radiographic evidence of degenerative changes including cervical spondylosis or of previous trauma without neurologic signs or symptoms need no further imaging. In other patients, particularly after failure of conservative management, MRI should be considered. In patients for whom surgery is contemplated, additional imaging with MRI or CT may be indicated for operative planning.

ACR: Chronic Hip Pain Radiographs positive, arthritis of uncertain type. Infection not a consideration.

May be appropriate: MRI hip with or without contrast

OSD: can there be any bumps or deformation?

May develop a bump over tubercle

What is the Transcranial Doppler? What does it help dx? Is it used in conjunction with other imaging modalities?

Measures the velocity of blood flow through the brain's blood vessels. Used to help in the diagnosis of emboli, stenosis, vasospasm from a subarachnoid hemorrhage (bleeding from a ruptured aneurysm), and other problems, Used in conjunction with MRI, MRA, carotid duplex ultrasound and CT scans.

Knee sonography: Medial View

Medial View Pt in supine with knee slightly flexed and hip externally rotated

Oblique Foot: How is the image taken?

Medial foot on plate

What is fx in a trimalleolar fx?

Medial, lateral malleoli and posterior aspect of tibia

What are contraindications for MRI?

Medically unstable Electronics: Pacemaker, Deep Brain Stimulator (DBS), Vagal Nerve Stimulator (VNS), etc.

What is the purpose of bone scanning?

Medication concentrates in any area of increased function Indicates area of increased metabolic activity

Bone scan: where does radiopharmaceutical/meds concentrate? How does that look on the imaging?

Medication concentrates in any area of increased function Looks dark

If a person has mid back pain, what is one possible dx?

Mid back pain- stomach issues.

What is the major issue with olecranon fx?

More likely to get HO

Stress Radiograph: sign of ligamentous issues: ____ degrees of eversion _____ degrees of inversion _____ degrees between sides

More than 15 degrees of eversion Or >10 for inversion Or 5 degrees between sides

What is often associated with symptomatic LBP?

More with symptomatic LBP associated with spondylolysis

ACR: Acute, subacute, or chronic uncomplicated low back pain or radiculopathy. No red flags. No prior management.

Most imaging is inappropriate

What is a humeral head fx associated with?

Mostly associated with dislocations

What can ultrasound see/do/measure?

Muscle length Muscle depth Muscle diameter Muscle cross sectional area Muscle volume Muscle contraction/ timing of contractions Tissue deformation with contraction Qualitative assessment of muscle/tissue density (i.e. fatty infiltrate) Muscle discontinuity / tears

What are the advantages of US vs MRI for imaging muscles, tendons, ligaments cysts and bursa?

Muscles: architecture; imaging while testing with resistance Tendons: fiber structure, degenerative changes, longitudinal tears Ligaments: fiber structure, ability to stress test while imaging Cysts and bursae: septations, debris not seen on MRI

What are some things you might see with knee OA?

Narrowing of medial joint on right Sclerotic changes underneath patella With bad OA, will see lots of changes on borders of patella.

How many views would you need for chest imaging? What is the best position to do imaging

Need at least two views: most common AP and lateral (might see rib fx that you wouldn't see on AP) Best positon: upright and standing

How are brain slices imaged?

Need to be familiar with the position and type of slices presented in images. Three types of slices common to imaging of the CNS are: Sagittal, Coronal, and Horizontal (Transverse) Planes. Many brain images are viewed as Horizontal (or Axial) slices or views.

What is the purpose of neuroimaging and electrophysiological imaging techniques?

Neuroimaging and electrophysiological techniques that make it possible to study the function of the human brain in vivo may play a critical role in guiding the development of evidence-based rehabilitation interventions. Neuroimaging and electrophysiological techniques have the potential to reveal patterns of neural activation after brain damage and, perhaps more importantly, to identify the rehabilitation interventions that will stimulate the restoration of brain activation patterns.

What areas can US look at? Can US tell us about flow? If so, what? Can US tell us about lumen? If so, what?

Neurovascular imaging: Cervical and Intracranial Flow: Patent or occluded?, Velocity , Waveform Lumen: Smooth or Irregular?

What can angiography be used for?

Neurovascular imaging: Cervical, intracranial, spinal Flow: Patent or occluded? Direction Pathology: Stenosis, Thrombus, Aneurysm. Arteriovenous malformation (AVM)

In a chest xray, can we assess total bone integrity?

No

Is there exposure to radiation with MRI?

No

What is secondary bone healing?

No fixation Cast immobilzation External fixation (bad vascular damage) Some movement occurs at the fracture site Callous formation

What is malunion?

No fx line, everything has healed, but distal radius and distal ulna aren't lined up well.

Should you finish an eval if the pt is (+) for Ottawa or Pittsburg?

No- send them for films

Osgood-Schlatter How is it treated?

Non-steroidals, rest, stretch, strengthening are treatment; 4-6 weeks return to activity. Typically no long term issues, but can end up with protruding tubercle

What is normal for tib-fib clear space? What if the value is greater that this?

Normal <5mm >5 think about syndesmosis

What is an insufficiency fx?

Normal activity on bones deficient in mineral

Median nerve compression Carpal tunnel syndrome

Normal on the left, compressed on the R within the carpal tunne

What does an abnormal V/P scan look line?

Normal ventilation + impaired perfusion= pulmonary embolism

Does MRI always distinguish between tumor tissue and edema?

Not always

Nexus Low Risk Criteria: is cervical spine radiography always indicated for pts with trauma?

Not always

Is there evidence to support the use of rapid MRI to detect cancer as a source in LBP in primary care setting?

Not enough evidence to support the use of rapid MRI to detect cancer as a source of LBP in the primary care setting. Hollingworth,W. 2003; J Gen Intern Med

Is it unusual to have meniscal tear with arthritis? Should we treat conservatively? When should

Not unusual to have meniscal tear with arthritis Unless knee locking/buckling, treat conservatively. Just because tear, doesn't need to be taken out. Don't even get MRI until fail conservative therapy

Can you see knee soft tissue in plain films?

Not very well, but you can get an idea of what's going on

What can be seen in lateral view of scapula? What can't? How should the scapula be positioned? What does it mean if it's not in that position?

Now just scapula, take humerus out of the equation Scapula should be flat against rib cage. If inferior angle pushed out- something between thorax in scapula pushing it out OR muscular issue.

Bone scan would help dx all the following except Stress fx Bone cancer OA Bone Infection

OA-Any time increase metabolic activity, the bone scan will light up

What are some complications with femur fx?

Observe pts for fatty embolism or DVT with this fx Will produce scar tissue within that joint, making rehab more difficult

What are other sources of knee pain in an older population?

Older population Hip OA Hip AVN

Osteochondritis Dissecans (OCD): what will you see on the MRI? On T1? On STIR?

On MRI will see cartilage pulling away from bone. On T1 you will see a "bone shift" coming off of condyle. White on Stir is fluid

T2 Scan: Water and fluid Fat and bone marrow T1 Scan: Which is better for determining damaged tissue/edema?

On a T2-weighted scan, water- and fluid-containing tissues are bright (most modern T2 sequences are actually fast T2 sequences) and fat-containing tissues are dark. T The reverse is true for T1-weighted images. Damaged tissue tends to develop edema, which makes a T2-weighted sequence sensitive for pathology, and generally able to distinguish pathologic tissue from normal tissue.

Medial epicondylitis Common flexor tendon

On the left is a normal common flexor tendon shown longitudinally. Again, you're looking at the well organized tissues, even fascial boundaries, all creating a more hyperechoic structure attaching to the medial epicondyle. To the right we have the pathologic presentation with noted microtears throughout the musculature denoted by the arrows, thickening of the fascial boundaries and hypoechoic appearance with the increased fluid in the area.

What is the angiography pocess?

Once the catheter is in place, a special dye (contrast material) is injected into catheter. X-ray images are taken to see how the dye moves through the artery and blood vessels of the brain. The dye helps highlight any blockages in blood flow. Digital subtraction angiography (DSI) uses a computer to "subtract" or take out the bones and tissues in the area viewed, so that only the blood vessels filled with the contrast dye are seen.

What are the 5 parts of the Ottawa Knee Rules? How many need to get films?

One positive and get plain films 1. >55 yrs 2. Isolated tenderness of patella 3. Tenderness of head of fibula 4. Inability to flex to 90 degrees OR 5. Inability to bear weight both immediately and in the ED (4 steps)**

What percent of MDs assessed LBP pts for red flags?

Only 5% of MDs reported specifically assessing their patients presenting with LBP for "red flags"-Bishop and Wing, 2006

When is the onset of osteochondritis dissecans? Age of suffers? Are more males or females affected?

Onset is between childhood and middle age Majority between 10 and 40 years of age Approximately a 2:1 male to female ratio

Does OSD get better without formal treatment? What modalities can be helpful?

Osgood-Schlatter disease usually gets better without formal treatment Over-the-counter pain relievers such as acetaminophen (Tylenol, others), ibuprofen (Advil, Motrin IB, others) or naproxen (Aleve) may be helpful. Ice and stretch the thigh's quadriceps and hamstring muscles, which may help reduce the tension on the spot where the kneecap's tendon attaches to the shinbone.

CAM Type Impingement

Osseous bump on neck

What are MRI of the Hip Indications?

Osteonecrosis of the femoral head Marrow abnormalities (transient osteoporosis) Occult fractures/stress fractures Adult sequela of childhood disorders FAI Labral tears Musculotendinous disorders Athletic pubalgia Sacral plexus disorders

What is RA? FULL

Osteoporosis of periarticular areas, becoming more generalized with advancement of the disease Symmetrical and concentric joint space narrowing Articular erosions, located either centrally or peripherally in the joint Synovial cysts located within nearby bone Periarticular swelling and joint effusions Axial migration of the femoral head Acetabular protrusion

What are the two good sets of rules for identifying knee fx?

Ottawa Knee Rules Pittsburg Knee Rules

ACR CHRONIC ANKLE SUMMARY: Overall, ________ is the imaging method that globally evaluates all structures of the ankle.

Overall, MRI is the imaging method that globally evaluates all structures of the ankle.

What type of scan is considered the best dx tools, when plain radiographs are negative and injury is thought to be stable?

Overall, SPECT scans are considered to be the best diagnostic tools, when plain radiographs are negative and the injury is thought to be acute.

What is important for assessing both Sinding-Larsen-Johansson and Osgood-Schlatter?

PALPATION!!!!!!!!!!!!!!!

Is there PCP underutilization in patients with LBP?

PCP underutilization in patients presenting with LBP History 73% Physical Exam 67%

What's in the middle column?

PLL Posterior 1/3 of vertebral body Posterior annulus

What are the limitations of an MRI?

Pacemaker Any ferromagnetic implants- like aneurysm clips Most metal implants safe but distort images CT better for unstable pts due to time Doesn't always distinguish between tumor tissue and edema

Osgood-Schlatter: Pain? Complications?

Pain can be little to debilitating Complications of Osgood-Schlatter disease are uncommon. They may include chronic pain or localized swelling.

Why is MRI preferred to bone scan?

Panel prefers MRI since it is usually more specific than bone scan.

What is indicative of a patella (ligament) rupture?

Patella is way higher than it should be

ACR: Acute Trauma to the knee For pts of any age, what are the two issues that indicate that imaging is NOT needed?

Patient is able to walk without a limp Patient had a twisting injury, and there is no effusion

ACR: Acute Hip Pain What other evaluation should be done with pts >50 y/o with fx from minimal or no trauma?

Patients >50 years old with fractures from minimal or no trauma should undergo a DXA study for osteoporosis evaluation [47].

ACR: what type of imaging should pts with chronic neck pain get? What type of views?

Patients of any age with chronic neck pain without or with a history of trauma should initially undergo AP and lateral radiographs of the cervical spine; supplemented, in select cases, by swimmer's and/or open mouth views. Oblique views are no longer recommended as a standard part of the initial radiographic evaluation.

ACR Chronic Neck Pain, Full

Patients of any age with chronic neck pain without or with a history of trauma should initially undergo AP and lateral radiographs of the cervical spine; supplemented, in select cases, by swimmer's and/or open mouth views. Oblique views are no longer recommended as a standard part of the initial radiographic evaluation. Patients with a history of C-spine surgery in the past should initially undergo, at minimum, AP and lateral radiographs, with consideration of additional flexion/extension views. Patients with a history of previous malignancy should initially undergo AP and lateral radiographs, supplemented, if necessary, by swimmer's and/or open mouth views. Radionuclide bone scanning should not be the initial procedure of choice [7]. Flexion/extension lateral radiographs may offer supplemental diagnostic information in the setting of suspected instability or in symptomatic patients with a history of prior surgery including ACDF, cervical prosthetic disc placement or posterior instrumentation. Patients with normal radiographs and no neurologic signs or symptoms need no immediate further imaging. Patients with normal radiographs and neurologic signs or symptoms should undergo cervical MRI that includes the craniocervical junction and the upper thoracic region [6,32,38]. If there is a contraindication to the MRI examination such as a cardiac pacemaker or severe claustrophobia, CT or CT myelography with multiplanar reconstruction is recommended. Patients with chronic neck pain from whiplash should undergo imaging following the guidelines above. Many patients with radiographic evidence of degenerative changes including cervical spondylosis or of previous trauma without neurologic signs or symptoms need no further imaging. In other patients, particularly after failure of conservative management, MRI should be considered. In patients for whom surgery is contemplated, additional imaging with MRI or CT may be indicated for operative planning. Patients with radiographic evidence of cervical spondylosis or of previous trauma and neurologic signs or symptoms should undergo MRI. CT or CT myelography may also be of value, particularly if MRI is contraindicated. . Patients with radiographic evidence of bone or disc margin destruction should undergo MRI without and with intravenous contrast. CT with intravenous contrast is indicated only if MRI cannot be performed. While therapeutic injections may offer benefit, diagnostic facet injection to identify the specific level(s) producing symptoms is of more limited value. Confirmation of a specific facet joint as a pain generator may be accomplished with MBB. This can be followed by image-guided thermal ablation. Discography is not recommended [1,50]. The use of additional imaging procedures should be determined in a case-by-case manner, and the evaluation of patients with chronic neck pain should follow this "tailor-made" approach.

What are the outcomes of pts who had plain films vs pts who had no imaging at all?

Patients who had plain films had outcomes similar to those who had no imaging at all. Kendrick,D. 2001 BMJ

ACR: what type of imaging should pts with chronic neck pain and history of C spine surgery get?

Patients with a history of C-spine surgery in the past should initially undergo, at minimum, AP and lateral radiographs, with consideration of additional flexion/extension views.

ACR: what type of imaging should pts with chronic neck pain and history of previous malignancy get? What type of views?

Patients with a history of previous malignancy should initially undergo AP and lateral radiographs, supplemented, if necessary, by swimmer's and/or open mouth views. Radionuclide bone scanning should not be the initial procedure of choice [7].

ACR chronic NP: pts with whiplash?

Patients with chronic neck pain from whiplash should undergo imaging following the guidelines above.

ACR chronic NP: Pts with normal radiographs and neuro sx?

Patients with normal radiographs and neurologic signs or symptoms should undergo cervical MRI that includes the craniocervical junction and the upper thoracic region [6,32,38]. If there is a contraindication to the MRI examination such as a cardiac pacemaker or severe claustrophobia, CT or CT myelography with multiplanar reconstruction is recommended.

ACR chronic NP: Pts with normal radiographs and no neuro signs?

Patients with normal radiographs and no neurologic signs or symptoms need no immediate further imaging.

ACR NP: Patients with radiographic evidence of bone or disc margin destruction

Patients with radiographic evidence of bone or disc margin destruction should undergo MRI without and with intravenous contrast. CT with intravenous contrast is indicated only if MRI cannot be performed.

ACR NP: Patients with radiographic evidence of cervical spondylosis or of previous trauma and neurologic signs or symptoms?

Patients with radiographic evidence of cervical spondylosis or of previous trauma and neurologic signs or symptoms should undergo MRI. CT or CT myelography may also be of value, particularly if MRI is contraindicated. .

ACR: Patients with recurrent low back pain and history of prior surgical intervention?

Patients with recurrent low back pain and history of prior surgical intervention should be evaluated with contrast-enhanced MRI.

If a person has R or L sided LBP, what is one possible dx?

People with R or L sided bp could be kidney issues

RA: is there swelling and joint effusions? Where?

Periarticular swelling and joint effusions

Why is peripheral US good?

Peripheral US- looks at blood flow. Like cardiac cath but less invasive

Structures of Interest - Ankle Lateral View

Peroneus longus and brevis ATFL PTFL CFL

Medial Retinaculum Where should we place the machine? What will we see?

Placed horizontally over medial knee Intact retinaculum attaching to patella.

What are four common imaging techniques for the chest?

Plain Films of heart and lungs Cardiac catheterization (coronary angiography) Echocardiogram (cardiac ultrasound) Myocardial perfusion imaging

What imaging will show stress fx?

Plain Radiograph Bone Scan CT Scan MRI

If there's a positive clinical exam and NO neurological signs and no visceral damage concerns, what type of images should be taken?

Plain film

Which is better for LBP, plain films or rapid MRI?

Plain films and rapid MRI for LBP yielded similar outcomes for patients. Jarvik,J.G. 2003 JAMA

What is the first imaging modality for the hip? Are there any exceptions?

Plain films are ALWAYS the first imaging modality in every case With one exception - Hip dysplasia in the pediatric patient

What view is important for assessing cervical trauma?

Plain films- Open mouth view- this is a big one for trauma

Western Australia Neck Pain: Non Traumatic Neck Pain, Pain only, with red flags

Plain radiography If still uncertain about cause, MRI

What are some pathologies that can be identified in plain film?

Pneumothorax Hemothorax TB Tumors Pneumonia Bacterial pneumonia Can help differentiate between cardiac or pulmonary pathology

Plain films-Density: how will abnormal density appear?

Poor contrast between soft tissue and bone. Bone is less dense looks more like other tissues

Knee sonography: Posterior View

Posterior View Pt is prone with leg extended

What's in the posterior column?

Posterior elements: pedicles, facets, lamina, spinous processes Posterior ligaments

Structures of Interest - Ankle Medial View

Posterior tibialis FDL FHL Tibial nerve/artery/vein Deltoid ligament

When is imaging needed?

Potential imaging is recommended in acute low back pain in the presence of neurologic emergencies, and prior to surgical consideration. "Clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute LBP and without features suggesting a serious underlying condition."

What does dye staying in joint space indicate? If it leaks out?

Pre op: dye leaks out of capsule and cuff suggestive of cuff tear Post op rotator cuff repair: no leakage of dye Dye staying within joint space indicative of intact cuff If not intact- will leak out.

Weber A

Pretty much the same as lateral malleolar fx- we won't have to differentiate below level of the ankle joint tibiofibular syndesmosis intact deltoid ligament intact medial malleolus often fractured usually stable: occasionally requires an open reduction and internal fixation (ORIF)

How does a CT scan work? Do they produce 2-D images or 3-D images?

Produces cross section of body tissue and organs-coronal, sagittal Axial images are obtained and then can be reconstructed using a computer to be viewed in any plane 3-D images can be produced

Spondylolisthesis- is it common?

Progression of the slippage is rare Less than 4%

Early referral to PT vs other intervention: how does prompt access compare price-wise to conventional management?

Prompt access to physiotherapy in primary care cost less per episode of LBP than conventional management

Bilateral AP view of AC joints weighted/unweighted: why would we want weight?

Provides distracted force on the AC joint

What can be seen in Shoulder AP ER?

Proximal 1/3 humerus Lateral 2/3 of clavicle AC Joint Anatomical neck (red) Surgical neck (blue)

What can be seen in shoulder AP IR?

Proximal 1/3 of humerus Lateral 2/3 of clavicle AC joint Upper & lateral scapula Lesser tuberosity Subacromial Space

What is the final stage of non-union?

Pseudoarthrosis

Ankle sonography: Posterior/Plantar View

Pt is prone with leg extended

Ankle sonography position: Anterior/Dorsal View

Pt is supine with their knee flexed and the ankle at about 45 degrees plantarflexion

Ankle sonography position: medial view

Pt is supine with their knee flexed and the ankle flat on the table

Ankle sonography: lateral view

Pt is supine with their knee flexed and the ankle flat on the table with slight inversion

What is Sinding-Larsen-Johansson syndrome?

Pulling away of inferior pole of patella- opposite of osgood, which is a pulling away of tibial tubercle

What is a con of CT?

Radiation dosage - approx 3x what a person is exposed to from background radiation in one year

Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other Vertebrae: what should the first imaging modality be?

Radiograph is a required first step before consideration of other imaging.

What is the purpose of the Y view?

Radiograph of scapular "Y" view. This oblique view of the shoulder demonstrates the relationship of the humeral head to the glenoid cavity and also demonstrates the parts of the scapula projected clear of the rib cage.

chronic elbow and wrist pain: how can occult bone abnormalities be detected?

Radiographically occult bone abnormalities can be detected with MRI, CT, or bone scintigraphy.

ACR: Acute Hip Pain What is the best first test?

Radiographs represent the best first test for evaluation.

ACR: Chronic Hip Pain: generally what should be the first and second studies?

Radiographs should be obtained as the first imaging study and, in general, MRI should be obtained as the next imaging study except in cases of suspected osteoid osteoma or labral tear.

chronic wrist pain:

Radiographs should be the initial imaging study in any patient with chronic wrist pain [1-3,8].

If an image is darker on a plain film is it radiolucent or radiopaque? Is it more or less radio dense?

Radiolucent- DARKER IMAGE. Light passes through, because LESS radiodense. LESS radiodense Ex: air

If an image is lighter on a plain film, is it radiolucent or radiopaque? Is it more or less radio dense?

Radiopaque- LIGHTER IMAGE. Light bounces off. because MORE radiodense MORE radiodense Ex: metal

What is the process of bone scanning? Is part or all of the body scanned?

Radiopharmaceuticals injected into pt Imaging taken 3-4 hours after injection Typically the entire body is scanned

Proximal Humeral Fractures: Lesser Tuberosity Fractures Are they common? Is it an avulsion? If so, what causes it?

Rare Avulsion as a result of forced contraction of the subscapularis Axial view

What are the abridged ACR red flags?

Recent significant trauma, or milder trauma > age 50 Unexplained weight loss Unexplained fever Immunosuppresion History of cancer IV drug use Prolonged use of corticosteroids, osteoporosis Age > 70

ATFL Rupture

Red arrow- complete disruption of insertion on talus

AP View of Foot What is the red line? What is the blue line?

Red line: tarsometatarsal joint Blue line: transverse tarsal joint

What are the contraindications to angiography?

Renal insufficiency as Contrast dye is used and is processed by the kidneys.

What are some common areas for stress fx?

Sacral Pubis Femoral neck Tibia Calcaneal Navicular Metatarsals Sesamoid

What are the benefits of US?

Safe Scans in real time Cost-effective (as compared to MRI, CT, etc...) Portable Clinically accessible (if $$$ available) No ionizing radiation (like in CT)

ANSWERS Image Structure

Sagittal FSE-XL PD

ANSWERS Image Structures

Sagittal FSE-XL PD

ANSWERS Image structures

Sagittal FSE-XL PD

ANSWERS image Structures what does that white line within the tendon indicate?

Sagittal FSE-XL PD Can see a white line within tendon indicating possible proximal tendenosis/degen change KNOW your anatomy.

CT scans: how are sagittal images viewed

Sagittal images are reconstructed so that they are viewed from the left to the right Left knee: start laterally, end medial (left to right) Right knee: start medial, end lateral (left to right)

AVN of the Femoral Head Stage II

Sclerosis and/or cyst formation in femoral head A Mild (<15%) B Moderate (15-30%) C Severe (>30%)

What is the sensitivity and specificity of the Ottawa Knee Rules?

Sensitivity 98.5% Specificity 48.6%

When would you do a CT scan of the elbow?

Severe trauma Alignment and displacement of fractures/fragments Loose bodies in the elbow joint If MRI not available Osteochondral lesions Condition seen on MRI but MRI contraindicated (US imaging if soft tissue and available)

CT Scan of shoulder: when is it appropriate?

Severe trauma Assess the alignment and displacement of fracture fragments Identify loose bodies in the glenohumeral joint Labral or rotator cuff pathology if MRI is unavailable/contraindicated (do not forget US) Any other pathology if MRI is not indicated (including if MR contrast is contraindicated) US is almost as good as MRI/CT for cuff tear

Slide 9 When would you CT scan the elbow?

Severe trauma Alignment and displacement of fractures/fragments Loose bodies in the elbow joint If MRI not available Osteochondral lesions Condition seen on MRI but MRI contraindicated (US imaging if soft tissue and available)

CT Scan of the wrist/hand- When should it be done?

Severe trauma Displaced carpal or distal radius fractures If MRI is contraindicated

When would you use CT scanning?

Severe trauma Fracture alignment Fractures of the sacrum and acetabulum Measure bony alignment Osteoid Osteoma Any condition that MRI is contraindicated (remember ultrasound imaging too) Intra-articular contrast can added

What is non-union?

Shaft of long bones, > 6 months Femoral neck >3 months Sclerosis seen around both ends of fx Pseudoarthrosis final stage

Plain films- Cartilage: what should be norm?

Should be smooth Distance between bones appropriate Joint effusion

Meniscal tear: what does it mean if the signal doesn't extend to the surface?

Signal that does not extend to surface = myxoid degeneration

What is STIR?

Similar to T2 images

Canadian C Spine Rule- what are low risk factors that allow safe assessment of ROM?

Simple rear-end MVC Sitting position in ED Ambulatory at any time Delayed onset of neck pain Absence of c-spine tenderness

What increases the risk of slippage/spondylolisthesis?

Skeletal immaturity and growth spurts increase the risk of slippage

Who does SLJ syndrome occur in?

Skeletally imamture or adolescent athlete

Developmental Pathology

Slipped capital femoral epiphysis Developmental dysplasia of the hip Legg-Calve-Perthes

How do plain films work?

Small dose of radiation

What is a smith fx?

Smith with volarly movement- fx moves anteriorly pic on right

chronic elbow and wrist pain: how can we assess soft tissue abnormalities?

Soft-tissue abnormalities (tendons, ligaments, nerves, joint recesses, and masses) are well demonstrated with MRI or US.

ACR: Acute Trauma To the Knee What is best evaluated by MRI?

Soft-tissue injuries (meniscal injuries, chondral surface injuries, and ligamentous disruption) are best evaluated by MRI [18,28,51]. Although the lateral patellar dislocation may be reduced at the time of presentation in the emergency room, characteristic findings on MRI, including specific bone marrow edema patterns and osteochondral defects [47], can allow accurate diagnosis.

What happens if you can't see the costophrenic angle?

Something in the way- often fluid

What is a CT scan?

Special x-ray equipment used to collect image data from around the body

What is spondylolisthesis?

Spondylolisthesis refers to the forward slippage of one vertebral body with respect to the one beneath it. This most commonly occurs at the lumbosacral junction with L5 slipping over S1, but it can occur at higher levels as well.

What is spondylolsis?

Spondylolysis is a crack or stress fracture in one of the vertebrae, the small bones that make up the spinal column. The injury most often occurs in children and adolescents who participate in sports that involve repeated stress on the lower back, such as gymnastics, football, and weight lifting.

Spondylolysis and Spondylolisthesis: what's the difference?

Spondylolysis: fracture Spondylolistesis: Slide

Are spondylosis and disc degeneration findings every found in asymptomatic pts?

Spondylosis and disc degeneration findings are common in both symptomatic & asymptomatic patients

What type of chronic ligament damage of the CFL is best visualized by MRI?

Sprain Complete tear Sensitivity 50% Specificity 93% Partial tear Sensitivity 83% Specificity 93% Sprain Sensitivity 100% Specificity 90%

OSD: what type of exercises are helpful?

Strengthening exercises for the quadriceps can help stabilize the knee joint.

What are stress fx?

Stress fractures are osseous injuries that are classically believed to result from muscle action on bones [1]. The common denominator for all stress fractures is that they occur as the result of repeated cyclical loading of bone with forces less than that required for an acute traumatic fracture.

What are neuroimaging capabilities? Structure? Function?

Structure: Size & shape Tissue characteristics Histology Chemical structure Function: Cell homeostasis Neuronal activity

AVN of the Femoral Head Stage III

Subchondral collapse (crescent sign) without flattening A Mild (<15%) B Moderate (15-30%) C Severe (>30%)

Oblique External Rotation view of the elbow: how did you get this view? Is it the most or least obstructed? What can be seen?

Supinated and ER at shoulder Most unobstructed view of the three structures Radial head, heck tuberosity

RA: symmetrical or asymmetrical joint space narrowing?

Symmetrical and concentric joint space narrowing

Osteochondritis Dissecans (OCD): are the sx variable? What are they?

Symptoms are variable Asymptomatic to significant pain Locking (suggesting loose body formation). Joint effusions and synovitis are often present

RA: are there synovial cysts? Where?

Synovial cysts located within nearby bone

What can be seen with RA?

Synovitis Cartilage loss Poor bone stock (osteopenia/porosis) Periarticular erosions Soft tissue deficiencies / rotator cuff deficiencies

Is proton density similar to T1 or T2?

T1

What level is the first rib near?

T1

What is STIR?

T1 STIR is very sensitive for fluid, whether within soft tissue or bone, around joints, or along tendon sheaths (including specifically soft tissue and marrow edema).

T1 vs T2: what color does fat and bone marrow appear?

T1: Fat and bone marrow appear brighter T2: Fat and bone marrow appear darker

T1 vs T2: what color do fluids show up as?

T1: fluids (CSF, urine, edema) are dark T2: fluids (Water, CSF, edema appear bright) are light

Is STIR similar to T1 or T2?

T2

Thoracic spine MRI sagittal

T2

What type of image is this? What color are the nerve roots?

T2, MRI (CSF is light), transverse Grey nerve roots.

What level is the clavicle near?

T3

What level is the tracheal bifurcation near?

T4/T5

Ankle sonography: Transverse View Dorsal What can be seen?

TA EHL EDL Talus In box is the neurovascular bundle

US: what are transducers?

TRANSDUCERS: Similar principles of frequency and depth as with Therapeutic ultrasound. Lower the frequency the deeper the sound waves travel. Linear - sound wave is propagated in a linear form parallel to the transducer surface - optimal in evaluation of linear structures (e.g. tendon)

What should the entire Talocrural Joint space (between tibia and talus) be? What if it's more than that?

Talocrural joint (entire joint space) 3-4mm- between tibia and talus- more than that ligamentus injury

What is the "tear drop"?

Teardrop = summation of shadows of medial acetabular wall

US: tendon- hyper or hypoechoic? How is it best imaged?

Tendon - Hyperechoic Fibrilar echotexture Best appreciated when imaged longitudinally

What are some ST pathologies?

Tendon Pathology Hamstring tears Bursitis Sports hernia (Pubalgia)

Achilles' Tendon

Tendon is on the top- it's a very superficial structure

When can MRI be used?

Tendon issues Supraspinatus outlet Labral/capsular issues Muscle disorders Intra-articular loose bodies GH chondral/osteochondral defects Marrow abnormalities Neoplasms/infection Vascular conditions Neurological conditions

What are indications for MRI?

Tendon/Ligament/Fascia pathology Impingement syndrome Osteochondral/articular cartilage defects Loose bodies Sinus tarsi syndrome Stress fractures/marrow abnormalities Infections/neoplasms

What structures will appear black in all MRIs when they are normal?

Tendons Meniscus Labrum Ligaments

Slide 18 How are radial head fx classified?

The Mason classification of radial head fractures identifies three types of injury patterns: type I, undisplaced fractures; type II, marginal fractures with displacement; type III, comminuted fractures. Type IV fractures were later suggested to encompass radial head fractures associated with dislocation.

What is the Mason classification?

The Mason classification of radial head fractures identifies three types of injury patterns: type I, undisplaced fractures; type II, marginal fractures with displacement; type III, comminuted fractures. Type IV fractures were later suggested to encompass radial head fractures associated with dislocation.

Legg-Calve-Perthes' disease Age of dx? Average age?

The age of diagnosis is usually between 2 and 12 years old Average age of 6

Why is contrast used with CTs? Is there any associated risk?

The biggest potential risk is with a contrast (also called dye) injection that is sometimes used in CT scanning. This contrast can help distinguish normal tissues from abnormal tissues. It also helps to help distinguish blood vessels from other structures such as lymph nodes. Like any medication, some people can have a serious reaction to the contrast. The chance of a fatal reaction to the contrast.

When should a post-injury MRI be taken?

The critical time for stress fracture to show up on MRI post-injury has not been established, although it seems that the edema pattern would be present within hours [10,25-27].

Vascular supply for the scaphoid bone in the wrist is most likely to enter in which of the following areas?

The distal pole

ACR: Nontraumatic Knee Pain What is the initial imaging?

The initial imaging examination for nontraumatic knee pain is radiography.

If the radiograph is negative, should CT or bone scan be used?

The literature that cross-sectional imaging should supersede bone scan as the imaging of choice for stress fracture when the radiograph is negative. There are specific sites for which CT is particularly well-suited, such as sacrum and tarsal navicular bones [8]. If the patient was symptomatic for several weeks before imaging was performed, the CT study may show periosteal reaction, sclerosis, or the fracture lines themselves [9-11].

What sort of imaging modalities can be used? What is the cut?

The person is lying supine when undergoing Computed Tomography (CT), Magnetic Resonance Imaging (MRI) or Positron Emission Tomography (PET). Therefore, the imaging process cuts 90 degrees off the horizontal plane of earth in order to achieve horizontal slices of the brain.

What should the spacing be like between the odontoid and dens?

The spaces between odontoid and dens should be the same (side to side)- if there's a difference then there may be pathology.

PET scan: where does the tracer go?

The tracer travels through your blood and collects in organs and tissues. The tracer helps the radiologist see certain areas or diseases more clearly.

T2-weighted axial image reveals a thickened anterior talofibular ligament due to chronic ligamentous injury. Is thicker ligament stronger or weaker?

Thicker ligament is scar tissue- actually weaker

What are 6 pieces of info that can be gathered from an ultrasound?

Thickness of wall Motion of wall Ejection fraction Valves Pericardial effusion PFO or DSV

What is best seen in an oblique view?

This gives a great view of the metatarsals - particularly the 5th metatarsals. Also all the tarsals

Seismoid bone

This is normal

What is important about this angle?

This is the magic angle A lot of times try to do mri in PF because straightens out a lot of tendons. When you get to withing 55 degrees you get disruption and will get more signal- will show more whiteness T2 fat saturated- bone marrow is dark

What should the space between the tibia and fibula be? What would cause it to be more?

This space btwn tibia and fibula should be less than 5mm If it is more- high ankle sprain or sydemotic, most likely caused by eversion or dorsiflexion (anterior portion of talus is bigger, pushes bones apart) NOTE in this pic: There is an osteochondral defect of the talus (left side)

Where are stress fx most common? (5)

Tibia Calcaneus Navicular Metatarsals Sesamoid What stresses me out? My CNTS.

How does bruising occur?

Tibia, coming anterior, tranlate anteriorly off femur, when it goes back, posterior aspect of tibia will hit anterior aspect of femoral condyle

Sinding-Larsen-Johansson syndrome: why does it occur?

Traction injury of the knee extensor mechanism at the junction of the patellar ligament and the inferior pole of the patella.

When does a transverse fx occur?

Transverse happens as a result of bending forces - impact at 90 degrees

What is a cause of Choparts amputation? Where is Choparts amputation?

Transverse tarsal joint Diabetes

Stress fx: radiograph positive. Next steps?

Treat

LCPD: describe treatment?

Treatment generally conservative Surgery involves osteotomy, tenotomy

Developmental dysplasia: how is it treated?

Treatment tends to be conservative given the extent Bracing to allow the ligaments to tighten Spica cast Surgery in the worse case

Malleolar fx: bimalleolar and trimalleolar

Tri- posterior aspect of tibia is fx

MRI of the wrist/hand: when should it be done? (transverse)

Triangular fibrocartilage complex tears Ligamentous structures Evaluation of scaphoid fracture complications Nerve entrapments Flexor or extensor tendon disorders Vascular abnormalities Neoplasms, infections and systemic disorders

Slide 61 What does MRI of the wrist/hand show?

Triangular fibrocartilage complex tears Ligamentous structures Evaluation of scaphoid fracture complications Nerve entrapments Flexor or extensor tendon disorders Vascular abnormalities Neoplasms, infections and systemic disorders

If there's a negative clinical exam, what's the next step?

Try to mobilize If can't, then radiologic work up

How are tumors identified with CT scanning of the head?

Tumors can be detected by the swelling and anatomical distortion they cause, or by surrounding edema.

When should you have surgery according to the mason classification?

Type III comminuted fx Type IV

MRI: how many imaging sequences used? How long does it take?

Typically 2-6 imaging sequences used Each sequence 2-15 minutes

Where is Osteochondritis Dissecans seen (OCD)?

Typically on condyle Significant portion of condyle gone, will be big indent

Red flags CRF- but most use for ACR

Typically there is consensus in regards to the CRF or risk factors, which suggest the presence of serious spinal pathology such as infection, malignancy or trauma. However there are some variations between guidelines re the presence and severity of neurological signs as red flags for MRI Commonly accepted CRF include unexplained weight loss, history of cancer, unexplained fever, over the age of 50 years, Intravenous (IV) drug use, severe unremitting night-time pain, significant trauma, signs of cauda equina syndrome (urinary retention, bilateral neurological lower extremity signs, saddle anasethesia).

chronic wrist pain: suspected wrist mass

US MRI

ACR: Developmental Dysplasia of the Hip—Child Patient younger than 4-6 months of age, female with breech presentation (primiparae most at risk), or positive family history without physical findings.

US hips

ACR: Developmental Dysplasia of the Hip—Child Patient younger than 4-6 months of age, positive physical findings (Ortolani or Barlow maneuvers).

US hips (preferable for kids 4-6 weeks of age)

ACR: Developmental Dysplasia of the Hip—Child Patient younger than 4-6 months of age, equivocal physical findings.

US hips (preferably for kids 4-6 weeks of age)

Can US be used for cuff tear?

US is almost as good as MRI/CT for cuff tear

What is good for grade I and grade II sprains? Bony trauma? Grade III?

US- good for grade I and grade II ankle sprains Plain films rule out boney trauma Grade III- clinical exam is 100% compared to a grade III ankle sprain with US. Prob need surgery for this

ACR Uncomplicated acute LBP and/or radiculopathy - imaging?

Uncomplicated acute LBP and/or radiculopathy are benign, self-limited conditions that do not warrant any imaging studies.

ACR LBP: summary of imaging

Uncomplicated acute LBP and/or radiculopathy are benign, self-limited conditions that do not warrant any imaging studies. MRI of the lumbar spine should be considered for those patients presenting with red flags raising suspicion for a serious underlying condition, such as cauda equina syndrome (CES), malignancy, or infection. In patients with a history of low-velocity trauma, osteoporosis, or chronic steroid use, initial evaluation with radiographs is recommended. In the absence of red flags, first-line treatment for chronic LBP remains conservative therapy with both pharmacologic and nonpharmacologic (eg, exercise, remaining active) therapy. If there are persistent or progressive symptoms during or following 6 weeks of conservative management and the patient is a surgery or intervention candidate or diagnostic uncertainty remains, MRI of the lumbar spine has become the initial imaging modality of choice in evaluating complicated LBP. MRI is the imaging procedure of choice in patients suspected of cord compression or spinal cord injury. Patients with recurrent low back pain and history of prior surgical intervention should be evaluated with contrast-enhanced MRI.

Malleolar Fractures: medial and lateral Unilateral On right- non union

Unilateral On right- non union

What are some location/types of ankle fx?

Unimalleolar Bimalleolar Trimalleolar Weber A/B/C - Pilon Stress

What is mal-union?

Union in poor functional position

Is MRI good at identifying grade III ankle sprains?

Up to 100% accuracy Gr III sprains

Western Australia Neck Pain: Non Traumatic Neck Pain, Possible cord compression

Urgent imaging required Go to suspected cord compression pathway

What can plain film rule in or out?

Use to rule in or rule out pathologies

What does a myelogram assess?

Used to assess Spinal cord Nerve roots Meninges Cysts

Quadriceps Tendon Rupture What does it look like? Will you always need film? Why or why not? If the tendon was intact, where would the patella be?

Usually won't need film, pt can't kick leg straight. If tendon was intact, patella would be closer to groove itself.

What are the pros of MRI and some situations where it would be used?

Valuable for diagnosing broad range of pathology in all parts of body Cancer, heart disease, vascular disease and musculoskeletal disorders

What are the benefits of US?

Very portable, very accessible Cost: $

US: what is hyperechoic? What color are these structures? What is shown?

Views: Longitudinal - Tendon Sonographic Appearance: Hyperechoic = Very Bright - Interfaces btwn bone and ST - Tendon (w/ fiber striations) - Fibrocartilage (Labrum of hip/shoulder, menisci) Ligaments (striated) Surface - Hyperechoic Posterior acoustic shadowing

Heterotropic Ossification- picture with features that can be seen

Weight bearing position in knee, less joint space Knee is basically bent 30, 35 degrees, and that's it. Build up of ossification in the fat pad Above patella- either atrophy or diffusion- most likely attrophy

US: Weight limit? Imaging time? Contraindication?

Weight limit: None Imaging time: 15 - 60 min / examination Contraindications: Body habitus Obscured US windows (Cervical collars, EEG leads, etc.)

ACR CHRONIC ANKLE SUMMARY: When a patient has multiple sites of degenerative change, what does pain relief after fluoroscopically guided anesthetic joint injection indicate?

When a patient has multiple sites of degenerative change, pain relief after fluoroscopically guided anesthetic joint injection can indicate which joint is the source of symptoms.

What is the congruence angle?

Where is patella lined up in the groove

Plain Films - Ottawa Knee Rules What do they help determine?

Whether an X-Ray is needed

Which is better at spatial resolution: CT or MRI? Which is better at contrast resolution?

While CT provides good spatial resolution (the ability to distinguish two separate structures an arbitrarily small distance from each other), MRI provides comparable resolution with far better contrast resolution (the ability to distinguish the differences between two arbitrarily similar but not identical tissues).

Plain films: color of most dense material?

White (metal)

Will acute stress fx appear on plain films? Why or why not?

Will not appear on Plain films if acute- this is because they are non displaced.

Will acute stress fx show up on a radiograph? What is the time period they usually show up?

Will not show up on radiograph if acute, unless displacement has occurred Typically 2-4 weeks when callous is forming

What is the most sensitive way to identify demyelinated diseases like MS?

With the addition of an additional radio frequency pulse and additional manipulation of the magnetic gradients, a T2-weighted sequence can be converted to a FLAIR sequence, in which free water is now dark, but edematous tissues remain bright. This sequence in particular is currently the most sensitive way to evaluate the brain for demyelinating diseases, such as multiple sclerosis

What is the parfait sign?

With tibial plateau fx Suprapatellar pouch here Fat is lighter than blood- floats to top Build up of fluid in suprapatellar pouch- could be build up of scar tissue.

Can US be used for ankle?

Within the ankle US can be used and has good metrics with assisting with dx, for soft tissue

Is US good for the ankle? What specifically?

Within the ankle US can be used and has good metrics with assisting with dx, for soft tissue

When will stress fx appear on plain films? When does this occur?

Won't see until there is an osteoblast reaction- any bone that gets laid down will be sclerotic. You won't see anything until a couple of weeks.

ACR: Acute Trauma To the Knee Adult or child >1 year old. Fall or twisting injury, with one or more of the following: focal tenderness, effusion, inability to bear weight. First study.

X Ray

ACR: Acute Trauma To the Knee Adult or child >1 year old. Injury to knee, mechanism unknown. Focal patellar tenderness, effusion, able to walk.

X Ray

ACR: Acute Trauma To the Knee Adult or child >1 year old. Significant trauma to the knee from motor vehicle accident, suspect knee dislocation.

X Ray

ACR: Developmental Dysplasia of the Hip—Child Patient 4-6 months of age or older, clinically suspicious for DDH (limited abduction or abnormal gait).

X Ray

ACR: Nontraumatic Knee Pain Child or adolescent: nonpatellofemoral symptoms. Initial examination.

X Ray

ACR: Nontraumatic Knee Pain Child or adult: patellofemoral (anterior) symptoms. Initial examination

X Ray

Angiography: where is the contrast derived from?

X Ray

Chronic Back Pain: Suspected Sacroiliitis/Spondyloarthropathy Inflammatory sacroiliac or back symptoms. Suspected axial spondyloarthropathy.

X Ray spine/SI joints

chronic wrist pain: Most bone lesions

X ray

ACR: Chronic Hip Pain Initial evaluation for chronic hip pain. First test.

X ray pelvis X Ray hip (AP and lateral views)

What is the first modality ordered in non-traumatic injury?

X-Ray

If meet Ottawa or Pittsburg, then first image always a_______

X-ray

ACR ACUTE ANKLE: Adult or child >5 years old. Acute injury to the ankle. Does not meet Ottawa Ankle Rules. Patient is not neurologically intact and/or has a peripheral neuropathy that involves the ankle and foot. First study.

X-ray ankle

ACR: Chronic Hip Pain Radiographs negative, equivocal, nondiagnostic, or mild osteoarthritis. Suspect referred pain but wish to exclude hip.

X-ray arthrography hip with anesthetic ± corticosteroid

Suspected cervical spine trauma. Imaging indicated by clinical criteria (NEXUS or CCR). Follow-up imaging on patient with no unstable injury demonstrated initially, but kept in collar for neck pain. Returns for evaluation.

X-ray cervical spine

What is fluroscopy?

X-ray source and fluorescent screen Real time motion Various structures and systems

ACR ACUTE ANKLE: Adult or child >5 years old. Acute injury to the ankle. Radiographs and/or physical examination suggest syndesmotic injury. Next study.

X-ray tibia/fibula Then MRI without contrast

Acute Hand and Wrist Trauma Suspect acute scaphoid fracture, first examination.

X-ray wrist

Acute Hand and Wrist Trauma Suspect distal radioulnar joint subluxation.

X-ray wrist CT wrist without IV contrast bilateral

ACR CHRONIC ANKLE: Chronic ankle pain of any origin — best initial study.

XRAY

ACR ACUTE ANKLE: Adult or child >5 years old. Acute injury to the ankle with persistent pain. Radiographs not obtained at time of injury. Initial study.

XRAY Obtain AP, lateral, and mortise views.

ACR ACUTE ANKLE: Adult or child >5 years old. Patient meets Ottawa Ankle Rules:

XRAY Obtain AP, lateral, and mortise views.

ACR: Nontraumatic Knee Pain Adult: nontrauma, nonlocalized pain. Initial examination.

XRay

Acute Hand and Wrist Trauma suspect hook of the hamate fracture. Initial radiographs normal or equivocal.

XRay CT

Acute, subacute, or chronic uncomplicated low back pain or radiculopathy. One or more of the following: low velocity trauma, osteoporosis, elderly individual, or chronic steroid use.

XRay CT MRI

Acute Hand and Wrist Trauma Suspect gamekeeper injury (thumb metacarpophalangeal ulnar collateral ligament injury).

XRay MRI thumb

Chronic Back Pain: Suspected Sacroiliitis/Spondyloarthropathy Inflammatory sacroiliac symptoms. Suspected axial spondyloarthropathy. Negative radiographs and MRI of the sacroiliac joints.

XRay spine MRI CT

Chronic Back Pain: Suspected Sacroiliitis/Spondyloarthropathy Known axial spondyloarthropathy. Follow-up for treatment response or disease progression.

XRay, SI joint/spine MRI

Acute Hand and Wrist Trauma Suspect metacarpal fracture or dislocation.

Xray

ACR: Acute Hip Pain Acute Hip Pain—Suspected Fracture Middle-aged and elderly patients. First study.

Xray hip: AP and cross table lateral vie Xray pelvis: AP view

ACR: Avascular Necrosis (Osteonecrosis) of the Hip Initial study when avascular necrosis is suspected clinically.

Xray pelvis Xray hips (frog leg view)

Is MRI contrast less likely to produce allergic reactions?

Yes

Is MRI good at assessing fine details of soft tissues?

Yes

Is shoulder AP ER film an anatomical position?

Yes

Is there a better view of changes in bone marrow (tumors and AVN) with MRI?

Yes

Is MRI is more suitable to assess very fine details of soft tissue? If so, what?

Yes Intervertebral discs Shoulder and knee Tissues with similar make up

Is sclerosis seen with non union?

Yes - around both ends of fx

RA: is there acetabular protrusion?

Yes Acetabular protrusion

If there are no ligamentous issues, do you do any manual therapy?

Yes- can do special tests.

Plain films: do various tissues absorb different amount of radiation?

Yes. Denser tissue means more absorption

If you have DECREASED object radiodensity, will you have a more radiolucent image?

Yes. Air

Trochlear Groove: What can be seen in this pic?

You can see articular cartilage on US This was taken in sunrise position We are looking at the trochlear groove

T2 Sagittal Spine- But how can you tell? There is disc fluid in this image- what would it mean if there wasn't?

You can tell because the fluid is light If there's no disc fluid, then this is disc desiction. Usually degenerative- natural loss over time

a d g s 1b ia is

a-------------acromion c------------- coracoid process g------------ glenoid fossa s------------ spine lb----------- lateral border ia----------- inferior angle is----------- infraspinous portion

a c s hh if is

a-------------acromion c------------- coracoid process s------------ spine hh----------- humeral head if----------- inferior angle is----------- infraspinous portion

What is lucency?

abnormal DECREASED opacity. More X-rays are allowed through the tissue and as a result appears darker on the picture.

What is sclerosis?

abnormal INCREASED opacity. Less X-rays are allowed through the tissue and as a result appears lighter on the picture.

Sinding-Larsen-Johansson syndrome: what is it associated with? Is there pain and if so, what makes it worse? Is there any tightness in the muscles- if so, where? If there is tightness, what is the impact?

affects the proximal end of the patellar tendon as it inserts into the inferior pole of the patella. It represents a chronic traction injury of the immature osteotendinous junction. It is a closely related condition to Osgood-Schlatter disease. Some authors classify SLJ as a paediatric version of "jumper's knee" Localized pain which is worsened by exercise. Localized tenderness and soft tissue swelling. Tightness of the surrounding muscles, the quadriceps, hamstrings and gastrocnemius in particular. This tightness usually results in inflexibilities of the knee joint, altering the stress through the patellofemoral joint

Plain films: Put in order of dark to light (radiolucent to radiopaque) bone air fat metal water

air fat water bone metal

Plain films: Put in order of least to most radiodensity bone air fat metal water ?

air fat water bone metal

ACR: Avascular Necrosis (Osteonecrosis) of the Hip When a patient who is at risk for AVN develops hip pain, the initial examination should consist of _____

an anteroposterior pelvis and frogleg lateral radiograph of the symptomatic hip.

Spondylolysis- imaging CT scan

and on the right we have a CT scan showing a bilateral spondylolysis of L5, just so everyone has an idea of how this condition looks on different types of imaging.

Sinding-Larsen-Johansson syndrome: how should it be treated? Modalities? Education? What should we try to strengthen/lengthen? What is the goal?

anti-inflammatories should be initiated. educate the patient on activity modification. Kneeling, jumping, squatting, stair climbing, and running on the affected knee should be avoided at least for the short term. Core strengthening should be initiated al well as exercise addressing flexibility or strength issues. The goal in patients with SLJ is to avoid muscle atrophy Patients who followed a 30 to 60 minute therapy, once a week during six weeks showed a decrease in patellofemoral pain.

What degree of flexion is a knee in in a lateral film?

approx 20 degrees

How would you assess aneurysms or arteriovenous malformations?

assess aneurysms or arteriovenous malformations through a technique called CT angiography.

What does the Inlet view allow?

best demonstrates ring configuration of pelvis and narrowing or widening of diameter of ring is immediately apparent. Evaluates for posterior displacement of pelvic ring or opening of pubic symphysis;

What color are tendons on MRI?

black

Stress fx: what are the benefits of bone scans?

bone scans show stress fractures days to weeks earlier than radiographs in many instances, and differentiate between osseous and soft-tissue injury as well.

Radial Head Fx: Type III

comminuted fx

Spondylolisthesis- Myerding Classification How is it graded?

degree of slippage as seen on lateral xray

What structural and soft tissue issues can CT identify?

enlarged brain cavities (ventricles) in patients with hydrocephalus.diseases or malformations of the skull. CT scanning is also performed to: evaluate the extent of bone and soft tissue damage in patients with facial trauma, and planning surgical reconstruction. diagnose diseases of the temporal bone on the side of the skull, which may be causing hearing problems. determine whether inflammation or other changes are present in the paranasal sinuses. plan radiation therapy for cancer of the brain or other tissues. guide the passage of a needle used to obtain a tissue sample (biopsy) from the brain.

Outlet view: What can be evaluated with it?

evaluates for vertical shift of pelvis (migration of hemipelvis);

What are two varieties of stress fx?

fatigue fx insufficeincy fx

Radial Head Fx: Type IV

fractures were later suggested to encompass radial head fractures associated with dislocation.

How are plain films named?

from direction that beam is passed: anterior to posterior

CT scanning of the head: what do hyperdense (bright) structures indicate?

hyperdense (bright) structures indicate calcifications and hemorrhage and bone trauma can be seen as disjunction in bone windows.

CT scanning of the head: what do hypodense (dark) structures indicate?

hypodense (dark) structures can indicate infarction and edema, Hypo-low-butt-fart-inFARTction, edema=ED=penis which is lower

ACR ACUTE ANKLE: Adult or child >5 years old. Acute injury to the ankle; does not meet the Ottawa Ankle Rules. No point tenderness over the malleoli, talus, or calcaneus on physical examination. Able to walk. Neurologically intact (including no peripheral neuropathy). First study.

imaging not indicated

When would you use CT vs MRI?

k

What does CT show well? Other advantages?

lung, bone, internal organs and blood vessels Very Quick- good images

Radial Head Fx: Type II

mariginal fx with displacement Picture on the right you can see some surgery- screws to bring into alignment

What are conditions that a head/brain CT could be used to find?

mass, stroke, area of bleeding, or blood vessel abnormality. Sometimes used to look at the skull further evaluate an abnormality seen on another test such as an X-ray or an ultrasound. They may also have a CT to check for specific symptoms such as pain or dizziness.

Where is the US transducer placed for multifudus examination?

medial, posterior spine

Is Whiteness/greyness of meniscus necessarily a tear?

not necessarily a tear- may just be degen changes

What is the fastest way to assess bone CA?

plain film

What is the fastest way to assess bone infection?

plain film

What is the fastest way to assess bony alignment?

plain film

What is the fastest way to assess fx?

plain film

What is the first film you always do?

plain film

what is the fastest way to assess arthritis?

plain film

Outlet view: What is best appreciated on this view?

proximal or distal displacements of anterior or posterior portion of ring are best appreciated on this view;

What do "whisps" in the plain film indicate?

pulmonary edema

What are some other things that predispose pt to stress fx?

radiation therapy and long- term osteoporosis treatment with biphosphonates predispose patients to stress fractures.

What's the best way of identifying stress fx?

radiographs are specific but significantly insensitive. Despite this limitation, all authorities agree that radiographs should be the initial imaging modality; if the findings are conclusive, no further imaging need be performed.

If there's a positive clinical exam, what's the next step?

radiologic work up

Can knee pain ever be referred from another area? If so, where?

referred hip pain Lumbar spine

Image of cervical spine, posterior to anterior identify C3 body spinous processes T1 transverse Right first rib

s

Outlet view: How does the sacrum appear here?

sacrum appears in its longest dimension, w/ neural foramina evident.

What should the distance from the inferior pole to the tibial tubercle be? When does it become a problem?

should be the same plus 20% of sides of patella. If it's sitting 2x as high then that's a problem

Outlet view: What does it show?

shows the anterior ring superimposed on the posterior ring.

Outlet view: What does it show? What can be evaluated with it? What is best appreciated on this view? How does the sacrum appear here?

shows the anterior ring superimposed on the posterior ring. evaluates for vertical shift of pelvis (migration of hemipelvis); proximal or distal displacements of anterior or posterior portion of ring are best appreciated on this view; sacrum appears in its longest dimension, w/ neural foramina evident.

US: when do you use linear transducers?

sound wave is propagated in a linear form parallel to the transducer surface - optimal in evaluation of linear structures (e.g. tendon) 7.5-10 MHz = superficial muscles, ligs, tendons (b/c of greater absorption of sound waves with higher frequency)

Spondylolysis- Imaging** Spect scan

the bone scan of a 13 year old boy who had negative xrays but positive uptake noted on L5

Glut Med/Glut Min MORE NEEDED HERE

the longitudinal axis of the gluteus minimus tendon insertion (dotted arrows) with a normal fibrillar pattern. The gluteus medius tendon is also shown (thin arrows), which covers the gluteus minimus in this region. B, This preoperative sonogram shows the insertion of the gluteus medius tendon (thin arrows) in its longitudinal axis with a normal fibrillar pattern. In both images, the thick arrows indicate the trochanter bone contours.

What is the best view to see the schaphoid- ulnar or radial deviation?

ulnar

Radial Head Fx: Type I

undisplaced fx

What is MRI used for? Can it do 3D images? What tissues is it good at? Does it use ionizing radiation?

visualize internal structures of the body in detail. By using gradients in different directions 2D images or 3D volumes can be obtained in any arbitrary orientation. MRI provides good contrast between the different soft tissues of the body, which makes it especially useful in imaging the brain, muscles, the heart, and cancers compared with other medical imaging techniques such as computed tomography (CT) or X-rays. Unlike CT scans or traditional X-rays, MRI does not use ionizing radiation.[3]

Inlet View- how is it taken?

x-ray is parallel to plane of sacrum, & sacrum is seen on end w/ vertebral body anteriorly & sacral lamina posteriorly; - pt is positioned as in AP view of pelvis w/ beam tilted 25 degree caudally; - or taken by directing X-ray beam 60 deg from head to mid pelvis, is best radiographic view to demonstrate posterior displacement;

Acute Hand and Wrist Trauma: Wrist trauma, first examination.

xray wrist

Angiography: can it be used for other systems besides the CNS?

yes

Angiography: is it dynamic imagining?

yes

Can olecranon fx be pinned?

yes

If you have metal implants, can you get a CT?

yes

Would bone scanning be used for bone cancer/mets?

yes

Would bone scanning be used for bone infection?

yes

Would bone scanning be used for fx?

yes

Would bone scanning be used for metabolic disease (paget's disease)?

yes