Diagnostic Imaging in Musculoskeletal Injuries - PowerPoint PPT Presentation

1 / 106
About This Presentation
Title:

Diagnostic Imaging in Musculoskeletal Injuries

Description:

Diagnostic Imaging in Musculoskeletal Injuries – PowerPoint PPT presentation

Number of Views:578
Avg rating:3.0/5.0
Slides: 107
Provided by: Usu190
Category:

less

Transcript and Presenter's Notes

Title: Diagnostic Imaging in Musculoskeletal Injuries


1
Diagnostic Imaging in Musculoskeletal Injuries
  • Rodney S. Gonzalez, MD
  • Primary Care Sports Medicine Fellow
  • Contributors
  • Leslie Rassner, MD (Slides adapted from)
  • Francis OConnor, MD, FACSM
  • Ulrich Rassner, MD

2
Objectives
  • Discuss fundamental imaging strategies for the
    evaluation of site-specific musculoskeletal
    injuries.
  • Review the various imaging modalities available
    to the clinician with an emphasis on
  • Indications
  • Limitations
  • Contraindications

3
Low Back Pain
  • Healthy middle age male with acute onset of low
    back pain after pick-up basketball game.
  • Adolescent female gymnast with gradual onset of
    low back pain.
  • Middle age obese patient with history of
    prolonged oral steroid use and multiple
    co-morbidities s/p car accident with back pain.

4
Low Back Pain
  • Who will you x-ray?
  • What plain film views do you want?
  • When do you order a CT, MRI or CT myelogram?
  • When will you order a bone scan?

5
Low Back Pain
  • Make a pathoanatomic diagnosis or differential
    diagnosis.
  • Decide do we need to rule out tumor, infection,
    or fracture?
  • Would imaging change our treatment such as
    generate referral to surgeon or for epidural
    steroid injection?

6
Low Back Pain
  • Image red flag patients
  • Major trauma
  • Age gt 50
  • Unrelenting pain at rest or night pain
  • Fever, chills, sweats
  • Unexplained weight loss
  • History of cancer
  • Incontinence of bowel or bladder
  • Progressive weakness

7
Low Back Pain
  • Conventional x-ray (plain films)
  • AP, lateral, and lumbosacral (LS) spot view
  • LS spot view
  • L5 centered view eliminates
    potential over-read of disk
    space narrowing from beam
    diversion on standard lateral
  • Initial view to look for disk space
    narrowing, osteophytes, fracture,
    tumor, or spondylolisthesis

8
Low Back Pain
  • Conventional x-ray (plain films)
  • Oblique views best if concern for pars
    interarticularis stress fracture (spondylolysis)
  • Pars interarticularis narrow portion of bone
  • between the superior and inferior articular
    facets

9
Radiography
  • Advantages
  • Inexpensive
  • Readily available
  • Excellent spatial resolution
  • Real-time availability as fluoroscopy

10
Radiography
  • Limitations
  • Two-dimensional
  • Relatively poor soft tissue contrast resolution
  • However,
  • Useful for radio-opaque foreign bodies
  • Useful for soft tissue emphysema or free air
  • Ionizing radiation exposure

Two orthogonal views at a minimum
11
Inservice Question X-ray
  • A 23-year-old male returns from a Florida beach
    vacation, where he sustained a cut to his foot
    while wading.
  • The cut wasnt treated when it happened, and it
    is healing, but he says that it feels like
    something in the wound is poking him.
  • Of the following, which one would most likely be
    easily visible on plain film radiography?
  • A) A wood splinter
  • B) A glass splinter
  • C) A plastic splinter
  • D) A sea urchin spine

12
Radiography
  • Contraindications
  • Pregnancy
  • Most of concern for L-spine and pelvis.
  • Other areas minimal radiation exposure to fetus
    with shielding.

13
Low Back Pain
  • Our middle age patient had no red flags. We
    diagnosed him with mechanical low back pain and
    started him on conservative treatment.
  • Six weeks out patient has no improvement in his
    pain. He has symptoms of sciatica. He has
    normal x-rays.
  • You feel an epidural steroid injection is
    indicated.
  • What imaging study is next?
  • MRI?
  • CT?
  • CT myelogram?

14
Low Back Pain
  • MRI
  • Excellent for disk herniation and cord contusion
  • Also will demonstrate
  • Spinal cord anomalies
  • Tumors
  • Discitis
  • Vertebral osteomyelitis

15
Magnetic Resonance Imaging
  • Vast, vast majority of clinical MRI utilizes the
    magnetic moment of hydrogen nuclei (protons).

16
Magnetic Resonance Imaging
  • Advantages
  • Superior contrast resolution, particularly among
    soft tissues.
  • High degree of sensitivity in diseases involving
    bone marrow.
  • Non-ionizing radiation (instead electromagnetic
    radiation).

17
Magnetic Resonance Imaging
  • Limitations
  • The most artifacts motion and metal.
  • Claustrophobia.
  • Some findings are extremely subtle, can be highly
    dependent upon interpretation (ie.
    glenohumeral labral pathology).
  • High cost.

18
Magnetic Resonance Imaging
  • Contraindications
  • Pacemakers absolute (under investigation)
  • Devices may malfunction or be contraindicated
  • Cardiac valves usually safe after 6 weeks
  • Stents
  • Non-ferromagnetic are safe
  • Ferromagnetic are safe after 6 weeks due to
    epithelialization
  • Abdominal aortic aneurysm stents, check with
    radiologist
  • Pumps, check with radiologist
  • Get radiologists approval documented in the chart

19
Magnetic Resonance Imaging
  • Contraindications (continued)
  • Metal foreign bodies, body piercings, and jewelry
    can migrate, heat up, or torque.
  • Situational clearance
  • Fragment in brain or eye in vast majority
    contraindicated.
  • Bullet imbedded in femur or extremity muscle,
    likely OK.
  • Tattoos and cosmetics can
    heat up (metallic dyes)

20
Magnetic Resonance Imaging
  • Contraindications (continued)
  • Obese patients
  • Scanner table weight limits
  • The gantry opening might be too small even if
    patient qualifies by weight
  • Pregnancy
  • Avoid 1st trimester
  • No gadolinium unless absolutely necessary
  • Animal studies conflicting

21
MRI-Safety
  • The field of the scanner is ALWAYS on.
  • Everything that is sucked into the magnet goes
    into the center, where the patient is lying.
  • Disregard for safety procedures can potentially
    be lethal.

22
Low Back Pain
  • Patient has a pacemaker and some cool tattoos.
    His back pain is not improving and he has
    physical exam findings of nerve impingement.
  • What study can you do?

23
Low Back Pain
  • CT Scan
  • Excellent for delineating bone if concern for
    vertebral fracture with posterior fragment
    displacement (would likely be done in conjunction
    with MRI)
  • CT Myelogram
  • Fluoroscopic guided lumbar puncture with
    placement of non-ionic contrast
  • Indications
  • You are an old-fashioned doctor
  • Contraindication to MRI (or no access to MRI)
  • Evaluate nerve root cysts, can determine
    communication of multiple cysts by contrast fill
    pattern
  • Carries risks of invasive procedure

24
Computed Tomography
  • CT uses x-rays to produce cross sectional images.
  • Sir Godfrey Newbold Hounsfield
  • Built first clinically utilized CT- (brain)
    scanner
  • Nobel prize in medicine 1979, shared with Allan
    Cormack

25
Computed Tomography
  • CT is cool!
  • Images reconstruction - 2D or 3D.
  • Kinematic CT - imaging of joint motion.

26
Computed Tomography
  • Advantages
  • Higher contrast resolution of images
  • Excellent images of bones and lungs
  • IV contrast rarely needed for orthopedic trauma
    (unless soft tissue/organ injury workup)
  • Wide availability

27
Computed Tomography
  • Limitations
  • Can produce artifacts motion and metal
  • More limited soft-tissue contrast than MRI
  • Not as good as ultrasound for superficial
    structures like rotator cuff or Bakers cyst
  • Ionizing radiation
  • Radiation dose much higher than for conventional
    radiography
  • Higher cost than conventional x-ray

28
Computed Tomography
  • Contraindications
  • Scanner weight limits for obese patients
  • Pregnant women should not have CT scans except in
    life-threatening emergencies
  • Pregnant patients can be scanned with shielding
    depending on body part (minimal radiation
    exposure to fetus if ankle or knee is scanned)

29
Low Back Pain
  • Our adolescent gymnast has a pars
    interarticularis defect on LS spot view. We want
    to decide whether she needs back bracing.
  • We have a 20 y.o. male service academy athlete
    with low back pain, worse on single leg extension
    test, but without plain film abnormality.
  • What diagnosis are you concerned about?
  • You have plain
  • filmswhat next?

30
Spondylolysis
  • Defect in pars interarticularis
  • Result from congenital, degenerative, traumatic,
    or stress-related causes.
  • Approximately 5 of Caucasians have on x-ray
  • Can occur with repetitive mechanical loading
  • Increased incidence in football linemen and
    gymnasts

31
Scintigraphy/Bone Scan
  • Biologically active drugs are labeled with
    radioisotopes
  • The images produced by scintigraphy are a
    collection of radiation emissions obtained with a
    special camera (gamma camera)
  • Two principal techniques in sports medicine
  • Planar (traditional bone scan)
  • SPECT cross-sectional

32
SPECT Imaging Single Photon Emission Computed
Tomography
Coronal
Sagittal
Axial
Posterior planar image
  • Enhanced tissue contrast
  • Improved sensitivity and specificity of lesion
    detection
  • and localization

33
Scintigraphy
  • Advantages
  • Ability to image metabolic activity
  • Very sensitive to fractures and tumors

34
Scintigraphy
  • Limitations
  • Lacks of significant detail
  • Poor spatial resolution
  • Poor specificity
  • Displays function of osteoblasts
  • Old fractures (pars defects) may not show up.
  • Certain tumors with little osteoblastic activity
    (multiple myeloma and lytic mets) not reliably
    seen.

35
Scintigraphy
  • Contraindications
  • Exposes patient to ionizing radiation
  • Children and pregnant women should be carefully
    screened

36
Spondylolysis
  • X-ray
  • Cheap, but low sensitivity
  • Not physiologic, does not determine if active
    healing
  • Can be used for monthly f/u for observation of
    healing
  • Scintigraphy
  • Bone scan fairly sensitive, not as specific,
    and does not show detailed anatomy
  • SPECT scan greater accuracy than bone scan and
    x-ray, but expensive and not as readily available
  • Can not be used to follow progression of healing
    as will stay positive one year
  • Thin section CT scan
  • Sensitive and shows anatomic detail
  • Must know level of concern to focus imaging

37
Spondylolithesis
  • Forward slippage of one vertebral body on another
    due to bilateral pars defects at a given
    vertebral level
  • Hot on bone scan, refer
  • Cold on bone scan, refer only
    if slip gt 25 ( gt Grade 1) for
    consideration of
    thoracolumbosacral orthosis
    (TLSO) or surgical stabilization

38
Chronic Low Back Pain
  • Consider guided injections
  • Fluoroscopic SI, facet injections, epidural
    steroids

39
Fluoroscopy
  • Real-time x-ray images with digital detectors.
  • X-ray source is underneath table and detector
    above, thus shield needs to be placed underneath
    patient.

40
Questions?
41
Cervical Spine Injuries
  • All patients with suspected fracture need three
    views
  • Cross-table lateral
  • Anteroposterior (AP)
  • Open-mouth odontoid

42
Cervical Spine Injuries
  • Systematic review of cervical spine radiographs
  • Lateral view
  • All vertebrae on the lateral
  • Presence of lordosis
  • Vertebral alignment
  • Spinolaminal line
  • Spinous processes
  • Soft tissue examination

43
Cervical Spine Injuries
  • Systematic review of cervical spine radiographs
  • Lateral view
  • All vertebrae on the lateral
  • Presence of lordosis
  • Vertebral alignment
  • Spinolaminal line
  • Spinous processes
  • Soft tissue examination

44
Cervical Spine Injuries
  • Soft tissue space r/o occult fracture
  • 6 at 2 and 2 at 6
  • 6mm at C2 and 2cm at C6
  • C1-C3 lt 7mm
  • C4-C7 14-22 mm

45
Cervical Spine Injuries
  • Systematic review of cervical spine radiographs
  • AP view
  • Spinous processes

46
Cervical Spine Injuries
  • Systematic review of cervical spine radiographs
  • Odontoid view
  • C1-2 articulation

Jefferson fracture ring of C1 broken in 4
places from axial loading
47
Cervical Spine Injuries
  • Dynamic flexion-extension
  • Expose undetected ligament disruption
  • Indicated if initial films normal, but suspicion
    persists
  • Require alert, cooperative patient, stopping for
    pain or paresthesias

48
Cervical Spine Injuries
  • Dynamic flexion-extension
  • Widening of the predental space from rupture of
    the transverse ligament.
  • Ligament normally holds C-1 against the dens
    (odontoid) of C-2.

49
Cervical Spine Injuries
  • CT
  • If suspicion high but plain films normal
  • If signs of possible instability on plain films
  • Better visualize fracture, evaluate for
    displacement
  • MRI
  • To clearly define canal compromise and/or soft
    tissue injury

50
Inservice Question Head
  • A 15-year-old white male is being evaluated after
    a fall down one flight of stairs.
  • He walked briefly at the scene and did not lose
    consciousness.
  • His only complaint is a mild, generalized
    headache. One episode of vomiting occurred
    shortly after the accident. No weakness or
    numbness has been noted.
  • Vital signs, mental status, and neurologic
    findings are normal.
  • Radiologic evaluation of the cervical spine is
    remarkable only for an air-fluid level in the
    sphenoid sinus.
  • Which one of the following abnormalities is most
    likely to be associated with this radiologic
    finding?
  • A) A basilar skull fracture
  • B) An orbital floor fracture
  • C) An epidural hematoma
  • D) A zygomatic arch fracture
  • E) A mandible fracture

51
Questions?
52
Shoulder Injuries
53
Acute Shoulder Trauma
  • Acute series
  • Obtained with patient as is, without moving arm
    or sling. Patient can be standing, sitting, or
    lying.
  • AP
  • Lateral scapular view

54
Shoulder Injury
  • Standard series
  • Internal and external rotation AP
  • Axillary view

55
Shoulder Injury
  • Views
  • True AP
  • Arm held in slight internal rotation
  • Identify greater tuberosity fractures
  • Hill-Sachs lesion
  • Impression defect on
    posterolateral aspect
    of humeral head
  • Can miss posterior
  • dislocation

56
Shoulder Injury
  • Views (continued)
  • Supraspinatus outlet view, scapular lateral view,
    or Y view
  • Direction of dislocation and angulation of
    proximal humerus fractures
  • Good view when patient discomfort/injury prevents
    axillary view
  • Axillary views
  • Acromial and coracoid fractures

57
Shoulder Injury
  • MRI and MRI arthrography
  • Nonsurgical diagnostic test of choice for
    internal derangements and structural instability
    assessment
  • Soft tissue and bone lesions well demonstrated

58
Shoulder Impingement - Instability
  • Labral Pathology
  • MRI with gadolinium - a must for labral pathology
  • CT arthrography

59
Shoulder Injury
  • Scintigraphy
  • Indications rare
  • Screening
  • Stress reaction of the bone
  • Osteochondrosis Little League
    Shoulder
  • Bone tumors

60
Inservice Question - Shoulder
  • A 70-year-old white female asks you to evaluate
    her right shoulder because of pain and limited
    motion.
  • Two months ago she remembers catching herself
    while holding the refrigerator door handle when
    she slipped on a wet floor.
  • She demonstrates pain and weakness at 45 of
    abduction and weakness on external rotation.

She should be treated for A) Bicipital
tendinitis B) Disruption of the glenoid fossa
C) Rotator cuff tear D) Acromioclavicular
separation E) Incomplete fracture of the humeral
head
61
Questions?
62
Wrist Injury
63
Wrist Injury
  • Standard views PA and lateral
  • PA view
  • Constant 2 mm intercarpal
    joint space
  • 3 arcs
  • Lateral view
  • 4 Cs

64
Wrist Injury
65
Scapholunate Dissociation
66
Perilunate Injury
67
Lunate Dislocation
68
Radiography
  • Complex Joints may require additional views

Anatomic Snuff Box Tenderness
Scaphoid Fracture
69
Wrist Injury
  • Scaphoid fracture
  • Scaphoid view
  • If negative, immobilization for 2 to 3 weeks,
    followed by repeat films
  • If negative and symptomatic, limited MRI

70
Chronic Wrist Pain
  • Hamate Fracture
  • CT scan
  • Keinbocks Disease
  • X-ray, bone scan, MRI
  • Carpal Instability
  • X-ray angles, MR
    arthrogram
  • TFCC Injury
  • MR arthrogram
  • Occult Ganglion
  • MR arthrogram
  • Complex Regional Pain Syndrome
  • Bone scan delayed periarticular uptake

71
Inservice Question - Wrist
  • A 20-year-old white male presents to your office
    after a fall on an outstretched hand while
    skateboarding.
  • He has pain at the anatomic snuffbox with no
    abrasion.
  • Radiographs are negative.
  • Which one of the following would be the most
    appropriate management?
  • A) A long arm cast for 8 weeks
  • B) A thumb spica splint and follow-up radiographs
    in 2 weeks
  • C) A sugar tong splint and follow-up radiographs
    in 2 weeks
  • D) An Ace bandage and follow-up radiographs in 2
    weeks
  • E) An Ace bandage and follow-up in 2 weeks if the
    patient is still experiencing pain

72
Questions?
73
Hip Pain/Injury
  • X-ray
  • Good place to start
  • Check for arthritis and avascular necrosis
  • Can miss grade 4 cartilage damage
  • May repeat hip x-rays early as one month as can
    have significant interval degenerative change
  • Initial evaluation femoral neck for stress
    fracture

74
Hip Pain/Injury
  • MRI
  • Need strong magnet (1.5 tesla) and surface coil
  • Bad for cartilage
  • 42 false negative for cartilage damage, but may
    show indirect findings
  • Good for diagnosis and localization of femoral
    neck stress fractures

75
Hip Pain/Injury
  • MRA
  • Good at finding labral pathology
  • Increased sensitivity, but also
    increased false positive
  • Sequence for gadolinium can
    obscure bone pathology
  • Get ANESTHETIC injection with contrast!
  • Relief of pain with intraarticular MRA anesthetic
    may give more information than study

76
Hip Pain/Injury
  • Iliopsoas Bursography (Fluoscopic)
  • Can diagnosis snapping hip caused by iliopsoas
    tendon
  • flexion to extention reproduces
  • Can be followed by therapeutic corticosteroid
    injection of bursa
  • Can be difficult to visualize due to C-arm
    getting in way of hip motion
  • Ultrasound
  • Non-invasive, can compare sides
  • Requires excellent technician and advanced
    ultrasound machine

77
Inservice Question - Hip
  • A 19-year-old female runner has a 1-week history
    of constant groin pain.
  • There is limited hip motion on flexion and
    internal rotation of the right hip.
  • Radiographs of the hip and pelvis are normal.
  • Which one of the following is the most likely
    diagnosis?
  • A) Iliotibial band syndrome
  • B) Stress fracture of the right femoral neck
  • C) Osteitis pubis
  • D) Pelvic inflammatory disease

78
Questions?
79
Knee Injury
80
Acute Knee Trauma
  • AP, lateral 30o flexion

81
Acute Knee Trauma
  • Value of cross table lateral
  • Rule out fracture
  • Can reveal fat-fluid level in joint
    (lipohemarthrosis)

82
Segond sign
Small lateral capsular bony avulsion lateral to
the tibia at the level of the joint
83
Acute Knee Trauma
  • Advanced imaging
  • CT scan for complex fractures
  • MRI for soft tissue

- MRI imaging modality of choice - T2 weighted
images - pathology sequence
84
Chronic Knee Series
  • X-rays
  • Lateral
  • Sunrise/Merchant
  • PA/axial/tunnel
  • AP weight bearing

85
Chronic Pain/Instability
  • X-ray
  • 45o weight bearing flexion PA
  • Weight bearing AP on long cassette
  • MRI
  • Meniscal injury
  • Ligamentous insufficiency
  • Osteochondral injury

86
Questions?
87
Leg Pain
  • Exertional leg pain differential diagnosis
  • Shin splints
  • Stress fracture
  • Exertional compartment syndrome
  • Popiteal artery entrapment syndrome

88
Exertional Leg Pain
  • Shin Splints
  • Clinical diagnosis
  • Plain films to r/o stress fracture
  • Triple Phase Bone Scan
  • Phase
  • Blood flow and Pool only classically no uptake
    on delayed images.
  • Appearance
  • Linear not fusiform

Arrows stress fracture Arrowheads periostitis
89
Scintigraphy
  • Triple phase bone scan
  • Flow (perfusion) study
  • 60 seconds after injection
  • Blood flow
  • Blood Pool
  • Increased circulation, blood vessel dilation
  • Delayed
  • 2 -3 hrs after injection
  • Bone uptake (clearance from extraosseous tissues)

90
Stress (Overuse) Fractures
  • Initial radiograph normal in up to 70 of
    athletes at onset of pain
  • Fluffy, ill-defined sclerotic line perpendicular
    to major trabecular lines

91
Stress (Overuse) Fractures
  • Thin incomplete lucent line
  • May proceed to completion
  • Periosteal reaction


92
Imaging of Early Stress Fractures
  • MRI and bone scan near 100 sensitivity
  • MRI improved specificity

93
Chronic Exertional Compartment Syndrome
  • Triple phase bone scan and MRI have not been
    shown to be reliable to date to replace clinical
    judgement with compartment pressure testing.
  • Samuelson DR, Cram RL The three-phase bone scan
    and exercise induced lower-leg pain the tibial
    stress test. Clin Nucl Med 199621(2)89-93.

94
Popliteal Artery Entrapment Syndrome
  • MRA with and without plantarflexion
  • Some experienced ultrasound technicians able to
    examine
  • Angiography

95
Questions?
96
Ankle Injury
97
Acute Ankle Trauma
  • When do you x-ray?
  • Ottawa Ankle Rules

Stiell IG, McKnight RD, Greenberg GH, McDowell
I, Nair RC, Wells GA, et al. Implementation of
the Ottawa ankle rules. JAMA 1994271827-32.
98
Dont forget the foot films!
  • AP, lateral and oblique
  • Contralateral foot films
  • Weight-bearing views
  • On the lateral, metatarsal shaft and tarsal bone
    align
  • On AP and obliques, the 2nd met medial border
    and middle cuneiform align

99
Chronic Ankle Pain
  • Chronic ankle pain
  • MRI is thought to be the imaging modality of
    choice for ligamentous injuries
  • Impingement lesions, tendon problems,
    osteochondral lesions
  • CT is good for ankle fractures/bony pathology
  • Occult fractures
  • Consider bone scan for diffuse non-specific pain
    with F/U CT if needed for superior bone
    resolution
  • Stress fractures

100
Questions?
101
Ultrasonography
102
Ultrasonography
  • Ultrasound uses high-frequency sound waves to
    produce images.
  • Can define masses and localize foreign bodies.
  • MSK use very popular in Europe and Australia.

103
Ultrasonography - Tendons
  • Tendon evaluation (Achilles, patellar, rotator
    cuff)

Normal Achilles Tendon
- Normal tendon bright structure with
longitudinally oriented bundles
Chronic Tendonopathy
- Blurring, thickening, loss of normal
architecture
104
Ultrasonography - Muscles
- Gastrocnemius with hematoma
-Torn rectus femoris muscle
  • Dynamic evaluation of
  • rectus femoris
  • - Complete disruption of fibers

105
Conclusions
  • The initial imaging of choice
    remains plain radiography.
  • CT is good for bone.
  • MRI is good for soft tissue.
  • Scintigraphy is good for finding a process with
    metabolic activity, or determining metabolic
    activity.
  • Ultrasound will (hopefully) increasingly be used
    in musculoskeletal imaging as operator and
    interpreter skills increase.
  • Advanced imaging selection is based upon your
    history and physical, knowing your specialists
    imaging preferences, and consultation with your
    regional radiologist as needed.

106
Thank You
Questions?
Write a Comment
User Comments (0)
About PowerShow.com