Nuclear Medicine in the Evaluation

of Trauma

Helena Balon, MDHelena Balon, MD

Wm. Beaumont HospitalWm. Beaumont Hospital

Royal Oak, MI, USARoyal Oak, MI, USA

Charles UniversityCharles University

3rd School of Medicine3rd School of Medicine

Dept Nucl Med, PragueDept Nucl Med, Prague

Materials for medical studentsMaterials for medical students

Radionuclide methods in traumatology

Musculoskeletal trauma Musculoskeletal trauma Bone scanBone scan

Trauma to internal organs (Trauma to internal organs (hematoma, laceration, hematoma, laceration, fracture, perforation, leaks)fracture, perforation, leaks)

Renal scan Renal scan Myocardial scan Myocardial scan Hepatobiliary scan Hepatobiliary scan (Liver / spleen scan) - CT preferred(Liver / spleen scan) - CT preferred (Testicular scan) - US preferred(Testicular scan) - US preferred

Head traumaHead trauma CT preferredCT preferred Cerebral perfusion scan - brain deathCerebral perfusion scan - brain death Cisternography - CSF leakCisternography - CSF leak

Bone scan in trauma

Very sensitiveVery sensitive Detects areas of abnormal bone turnoverDetects areas of abnormal bone turnover Shows areas that need further radiol.evaluationShows areas that need further radiol.evaluation Provides objective evidence of disorder Provides objective evidence of disorder

when X ray negativewhen X ray negative

Bone scan

Tracers:Tracers: diphosphonates (Tcdiphosphonates (Tc--99m MDP, HDP)99m MDP, HDP) Dose:Dose: 500-900MBq 500-900MBq Tracer localization (chemisorption onto surface Tracer localization (chemisorption onto surface

of bone trabeculae) depends on: of bone trabeculae) depends on: blood flowblood flow capillary permeabilitycapillary permeability bone metabolism (activity of osteoblasts, bone metabolism (activity of osteoblasts,

osteoclasts, new bone formation)osteoclasts, new bone formation)

Bone scan

Patient preparationPatient preparation Pre-test: nonePre-test: none Post-injection: good oral hydration Post-injection: good oral hydration Frequent voidingFrequent voiding Perchlorate p.o. preinj. to decrease rad. Perchlorate p.o. preinj. to decrease rad.

dose to thyroiddose to thyroid

MethodsMethods Regular - imaging @ 2-4 hrs post injectionRegular - imaging @ 2-4 hrs post injection 3-phase (dynamic angiogram + blood pool + 3-phase (dynamic angiogram + blood pool +

delay)delay) Planar or SPECTPlanar or SPECT Whole body ANT & POST, additional views Whole body ANT & POST, additional views

(lat.,oblique)(lat.,oblique) Parallel hole or pinhole collimator (for small Parallel hole or pinhole collimator (for small

structures)structures)

Bone scan

Bone Scan in Trauma

Fractures & occult fxFractures & occult fx Child abuse (except skull fx)Child abuse (except skull fx) Stress fractures (insufficiency fx, fatigue fx)Stress fractures (insufficiency fx, fatigue fx) Avulsion injuriesAvulsion injuries Shin splintsShin splints Bone bruises (contusion)Bone bruises (contusion) RSD (reflex sympathetic dystrophy)RSD (reflex sympathetic dystrophy) Osteochondral lesionsOsteochondral lesions

Diagnosis of Fractures

Plain X ray, X ray tomography - if neg Plain X ray, X ray tomography - if neg >>>>>> Bone scanBone scan

if neg if neg >>>>>> stop work-up stop work-up if diagnostic if diagnostic >>>>>> treat treat if more information needed if more information needed >>>>>>

CT (subtle changes) CT (subtle changes) oror MRI (subtle changes, soft tissue trauma, MRI (subtle changes, soft tissue trauma,

bone bruise, precise dx of limited area) bone bruise, precise dx of limited area)

Fractures on Bone scan

Acute fxAcute fx Positive on all 3 phasesPositive on all 3 phases Positive immediately after trauma in most ptsPositive immediately after trauma in most pts 90% sensitivity if imaged in < 48 hrs90% sensitivity if imaged in < 48 hrs If scan neg. in pts > 75y If scan neg. in pts > 75y >>>>>> repeat scan in 3-7 d repeat scan in 3-7 d

Bone scan remains positive for 6-24 mo Bone scan remains positive for 6-24 mo

(healing fx) (healing fx)

Acute compression fractures

80 y/o F w osteopenia80 y/o F w osteopeniafell 6 wks priorfell 6 wks prior

Rib fractures

Multiple fx’s

59 F w breast ca59 F w breast caMVA 10 d agoMVA 10 d ago

Osteogenesis imperfecta

Bone Bruise

Direct trauma with disruption of trabecular Direct trauma with disruption of trabecular bone but not cortical bone bone but not cortical bone

X ray - negativeX ray - negative Bone scan - 3-phase positivityBone scan - 3-phase positivity MRI - bone marrow involvement MRI - bone marrow involvement

(hemorrhage)(hemorrhage)

Leg & Foot Leg & Foot TraumaTrauma

Shin / thigh splints

Continuous spectrum from shin splint to stress fxContinuous spectrum from shin splint to stress fx Stress related periostitis along muscle insertion sites Stress related periostitis along muscle insertion sites (soleus, (soleus,

tibialis posterior, adductor longus/brevis, gluteus max)tibialis posterior, adductor longus/brevis, gluteus max)

X ray - negativeX ray - negative

Bone scanBone scan

Flow, blood pool - normalFlow, blood pool - normal

Delay-Delay- vertical, linear uptake alongvertical, linear uptake alongposteromedial tibial cortex (mid- or distal 1/3) posteromedial tibial cortex (mid- or distal 1/3) medial or lateral femoral cortex (proximal 1/3)medial or lateral femoral cortex (proximal 1/3)

Shin Splints

Shin splints, thigh splints

Thigh splints - mechanism

Stress Fractures

Fatigue fracturesFatigue fractures

Abnormal stress on normal boneAbnormal stress on normal bone

(jogging, gymnastics, skating, military)(jogging, gymnastics, skating, military)

Insufficiency fracturesInsufficiency fractures

Normal stress on abnormal boneNormal stress on abnormal bone

(osteoporosis, osteomalacia, RA, HPT, steroids, (osteoporosis, osteomalacia, RA, HPT, steroids, radiation Rx)radiation Rx)

Stress fractures

Pathophysiology - repetitive microtrauma Pathophysiology - repetitive microtrauma (athletes) (athletes)

Symptoms - pain, swellingSymptoms - pain, swelling Common locations:Common locations:

Tibia - proximal or distal 1/3 Tibia - proximal or distal 1/3 Fibula - distal 1/3Fibula - distal 1/3 Metatarsals (2Metatarsals (2ndnd, 3, 3rdrd)) Tarsal bones (calcaneus, navicular)Tarsal bones (calcaneus, navicular) Femoral neck Femoral neck Inferior pubic ramusInferior pubic ramus Lower lumbar spine (spondylolysis)Lower lumbar spine (spondylolysis)

Stress fractures

X ray may be initially negative (2-4 wks)X ray may be initially negative (2-4 wks)

Bone scan, MRI – positive earlier Bone scan, MRI – positive earlier

Bone scan Bone scan 3-phase positivity3-phase positivity

FlowFlow + for ~ 1 mo+ for ~ 1 mo

Blood poolBlood pool + for ~ 2 mo+ for ~ 2 mo

DelayDelay + for ~ 9-12 mo+ for ~ 9-12 mo

Rx - restrict sports for 4-6 wksRx - restrict sports for 4-6 wks

Stress fx ?

Stress fractures

Metatarsal stress fracture

Metatarsal stress fracture

Metatarsal stress fx

Plantar fasciitis

Heel painHeel pain Post-traumatic inflammation of plantar ligament Post-traumatic inflammation of plantar ligament

due to due to athletic overuse athletic overuse prolonged standingprolonged standing walking on hard surfacewalking on hard surface

Bone scanBone scanFocal blood pool + delayed uptake Focal blood pool + delayed uptake in inferior posterior calcaneusin inferior posterior calcaneus

Plantar fasciitis

Achilles tendonitis

Impingement syndromes

Posterior impingement sy (os trigonum sy)Posterior impingement sy (os trigonum sy) Excessive repeat plantar flexion (compression Excessive repeat plantar flexion (compression

between posterior calcaneus & posterior tibia)between posterior calcaneus & posterior tibia) Ballet dancers, gymnastsBallet dancers, gymnasts

Anterior impingement sy Anterior impingement sy Excessive repeat dorsal flexion >>> hypertrophic Excessive repeat dorsal flexion >>> hypertrophic

spur on dorsum (talus & anterior tibia)spur on dorsum (talus & anterior tibia) Ballet dancers, gymnasts, high jumpingBallet dancers, gymnasts, high jumping

Posterior impingement syndromePosterior impingement syndrome(os trigonum stress fx)(os trigonum stress fx)

2078102

Hip & PelvisHip & PelvisTraumaTrauma

Femoral neck stress fracture

Thigh or groin pain in athletesThigh or groin pain in athletes Must distinguish femoral neck stress fx Must distinguish femoral neck stress fx

from pubic ramus stress fxfrom pubic ramus stress fx Must treat / immobilize early to prevent Must treat / immobilize early to prevent

complete fx, AVNcomplete fx, AVN

Femoral neck Fx

76F w L groin pain76F w L groin painX ray negX ray neg

X ray X ray 2 weeks later2 weeks later

Intertrochanteric fracture

93 F, fall 6 days ago, Rt hip pain

IT fx

Avascular necrosis (AVN) EtiologyEtiology

trauma (fx)trauma (fx) steroids, alcohol abusesteroids, alcohol abuse pancreatitis, fat embolismpancreatitis, fat embolism vasculitis, SS diseasevasculitis, SS disease idiopathicidiopathic

Pathophysiology: bone ischemiaPathophysiology: bone ischemia DiagnosisDiagnosis

MRI most sensitiveMRI most sensitive bone scan useful bone scan useful

AVN

Common locationsCommon locations Femoral head (Legg-Perthes in children)Femoral head (Legg-Perthes in children) Carpal (scaphoid, lunate), tarsal (talus) Carpal (scaphoid, lunate), tarsal (talus) Long bones, ribs in SSLong bones, ribs in SS

Bone scanBone scan Initially “cold”Initially “cold” Revascularization starts in 1-3 wks, from Revascularization starts in 1-3 wks, from

periphery, diffusely “hot”, lasts for monthsperiphery, diffusely “hot”, lasts for months

IT Fx + AVN

50 M w fall a few weeks ago50 M w fall a few weeks ago

MRIMRI

IT fx + AVN

Sacrococcygeal Fx

ANTANT POST POST

Sacral insufficiency fx

ANT POSTANT POST

79 F fell 1 mo ago(“Honda” sign)

Pelvic fractures

4 days 4 days post fallpost fall

1 month 1 month laterlater

Spine traumaSpine trauma

Spondylolysis

Stress fx of posterior vertebral elements Stress fx of posterior vertebral elements (pars interarticularis) due to(pars interarticularis) due to repetitive trauma repetitive trauma

Teenagers, young adultsTeenagers, young adults Hyperextension sports Hyperextension sports

(gymnastics, diving, weight lifting, soccer,hockey)(gymnastics, diving, weight lifting, soccer,hockey)

Genetic predisposition?Genetic predisposition? L5 > L4 > L3L5 > L4 > L3 Frequently bilateral >>> spondylolisthesisFrequently bilateral >>> spondylolisthesis

Spondylolysis

X ray X ray

Normal or sclerosis, later lucency 2Normal or sclerosis, later lucency 2º fxº fx Bone scanBone scan

increased uptake in pars interarticularisincreased uptake in pars interarticularis

SPECT better than planarSPECT better than planar

Rx – discontinue activityRx – discontinue activity

Pars interarticularis defect

14 y/o F14 y/o Fbasketball playerbasketball playertrauma 1 mo priortrauma 1 mo prior

Pars defectPars defect

CNM 2001:863

planar SPECT

Transverse process fracture

Hand & Wrist Trauma

Wrist fractures

Scaphoid fx Scaphoid fx - most common - most common 70-80% carpal fx70-80% carpal fx Fall on outstretched handFall on outstretched hand Common complications - AVN, non-unionCommon complications - AVN, non-union

Hook of hamate fxHook of hamate fx Direct injury from handles (tennis, golf, baseball)Direct injury from handles (tennis, golf, baseball)

Radial / ulnar styloid fxRadial / ulnar styloid fx

fall, injured Rt wristfall, injured Rt wrist

Fracture of radius + scaphoid

S/P fall, suspect scaphoid fxS/P fall, suspect scaphoid fxX ray neg.X ray neg.

Scaphoid Fx

14 y/o M 14 y/o M fell 6 wks ago, fell 6 wks ago, X ray negativeX ray negative

Hook of the hamate fracture

R wrist painR wrist pain

Hook of the hamate injury - mechanism

Reflex Sympathetic Dystrophy (Sudeck’s atrophy, Shoulder-hand sy, Causalgia, Chronic regional pain sy)

Sympathetically mediated disorder Sympathetically mediated disorder (vasomotor instability)(vasomotor instability)

EtiologyEtiology Trauma (blunt, fracture)Trauma (blunt, fracture) MIMI Stroke/CVAStroke/CVA InfectionInfection IdiopathicIdiopathic

Symptoms:Symptoms: exquisite pain, tenderness, edema, exquisite pain, tenderness, edema, skin changes, locally warm or cold UE or LEskin changes, locally warm or cold UE or LE

Reflex Sympathetic Dystrophy (RSD)

Bone scanBone scan Early stage: 3-phase positiveEarly stage: 3-phase positive Later stage (> 6 mo): only delayed phase posit.Later stage (> 6 mo): only delayed phase posit. Delayed phase MDP: diffuse increased uptake in entire limb, “periarticular Delayed phase MDP: diffuse increased uptake in entire limb, “periarticular

accentuation” accentuation” in small jointsin small joints

Children: often all 3 phases or Children: often all 3 phases or Sensitivity: 60-95%Sensitivity: 60-95%

X rayX ray Periarticular ST edemaPeriarticular ST edema Late changes- bone resorption, osteopeniaLate changes- bone resorption, osteopenia

73 F w Rt hand/wrist pain73 F w Rt hand/wrist painno traumano trauma

Reflex sympathetic dystrophy(RSD)

Non-accidental injuryNon-accidental injury

1 mo old baby1 mo old babyw intracranial w intracranial hemorrhage, hemorrhage, Lt parietal fxLt parietal fx

MDP

CNM 2001: 344CNM 2001: 344

Muscle trauma(RhabdomyolysisRhabdomyolysis)

weight liftingweight lifting

Muscle uptake (Rhabdomyolysis)Muscle uptake (Rhabdomyolysis)

pt w Ewing sarcoma, pt w Ewing sarcoma, s/p BKA, s/p BKA, walking on crutcheswalking on crutches

Trauma to internal organs

Hepatobiliary Scan Tc-99m IDA (disofenin, mebrofenin)Tc-99m IDA (disofenin, mebrofenin)

dose ~ 150-250 MBq i.v.dose ~ 150-250 MBq i.v. imaging of liver, abdomen, pelvis over 1 hrimaging of liver, abdomen, pelvis over 1 hr delayed images if 1delayed images if 1stst hr negative hr negative

Bile leak - activity anywhere in peritoneal cavity Bile leak - activity anywhere in peritoneal cavity

Common after laparoscopic cholecystectomyCommon after laparoscopic cholecystectomy

Usually seals off spontaneouslyUsually seals off spontaneously

Leak clin. more significant if no transit into bowel seen Leak clin. more significant if no transit into bowel seen

(needs surgical intervention)(needs surgical intervention)

Bile leak

Liver - Spleen Scan

Tc-99m sulfur colloidTc-99m sulfur colloid dose ~ 150-250 MBq i.v.dose ~ 150-250 MBq i.v.

SPECT imaging better than planar SPECT imaging better than planar

Parenchymal defectsParenchymal defects laceration, rupture, hematomalaceration, rupture, hematoma

Splenosis Splenosis splenic implants on peritoneum following spleen rupturesplenic implants on peritoneum following spleen rupture

Splenosis

MVA 30 y ago, MVA 30 y ago, S/P splenectomyS/P splenectomy

Tc-99m S.C.Tc-99m S.C.

Pleuroperitoneal leak

Pt. on peritoneal dialysisPt. on peritoneal dialysis

Rt LATRt LATANTANT

Renal Scans Tc-99m MAG3 or DTPATc-99m MAG3 or DTPA

~ 100-300 MBq~ 100-300 MBq Dynamic images over 20-30 minDynamic images over 20-30 min Assessment of perfusion, function, leaksAssessment of perfusion, function, leaks

Tc-99m DMSA Tc-99m DMSA ~ 150-250 MBq~ 150-250 MBq Static images @ 2-4 hrs post injectionStatic images @ 2-4 hrs post injection High resolution needed for renal morphology High resolution needed for renal morphology

pinhole, SPECTpinhole, SPECT Parenchymal defects - laceration, rupture, hematomaParenchymal defects - laceration, rupture, hematoma Extrinsic defects - perinephric / retroperiton. hematomaExtrinsic defects - perinephric / retroperiton. hematoma

CNM 2001:724

Urine leak

Testicular scan Indications:Indications:

Acute torsionAcute torsion Delayed torsionDelayed torsion Epidymitis / orchitisEpidymitis / orchitis

Tc-99m pertechnetateTc-99m pertechnetate Flow + immediate static imagesFlow + immediate static images ““Donut sign”Donut sign”

Late torsionLate torsion AbscessAbscess Trauma (hematoma)Trauma (hematoma) TumorTumor

Cisternography

In-111 DTPA intrathecallyIn-111 DTPA intrathecally CSF leak - paraspinal (meningeal tears)CSF leak - paraspinal (meningeal tears) CSF rhinorrhea, otorrheaCSF rhinorrhea, otorrhea

imagingimaging counting nasal pledgets for radioactivitycounting nasal pledgets for radioactivity pledget / plasma ratiopledget / plasma ratio

Cerebral perfusion

Tc-99m HMPAO or ECDTc-99m HMPAO or ECD dose ~ 800 MBqdose ~ 800 MBq

Post-traumatic perfusion defects Post-traumatic perfusion defects Assessment of brain death - role of NM Assessment of brain death - role of NM

complementarycomplementary no flowno flow no parenchymal uptakeno parenchymal uptake

1717870

Head Trauma? Brain death?

15 y/o F withintracranial bleed

Brain death

Radionuclide synovectomy(radiosynoviorthesis, RSO)

Intraarticular treatment using beta raysIntraarticular treatment using beta rays Goal is to destroy inflammed synoviaGoal is to destroy inflammed synovia Alternative to surgical synovectomyAlternative to surgical synovectomy Mostly in out-patientsMostly in out-patients More than one joint treatment possiblityMore than one joint treatment possiblity Repeated treatmentRepeated treatment More than 40 years experienceMore than 40 years experience

Indications

Patients resistent to steroid injectionPatients resistent to steroid injection Rheumatoid arthritisRheumatoid arthritis Repetitive idiopatic swellingRepetitive idiopatic swelling Repetitive decompensated arthrosisRepetitive decompensated arthrosis Psoriatic arthropathyPsoriatic arthropathy Haemophillic arthropathyHaemophillic arthropathy

Contraindications

Pregnancy, breast feedingPregnancy, breast feeding Septic arthritis, infection around the jointSeptic arthritis, infection around the joint Tumor of the jointTumor of the joint Children (relative)Children (relative) Massive haemarthrosMassive haemarthros Popliteal cyst rupturePopliteal cyst rupture There are no side effectsThere are no side effects

Radiopharmaceuticals

Sterile colloidal suspensionSterile colloidal suspension Beta radiation (or mixed – imaging)Beta radiation (or mixed – imaging) Large joints (knee)Large joints (knee) Y-90 citrate, silikateY-90 citrate, silikate Middle joints (shoulder, elbow, wrist, hip)Middle joints (shoulder, elbow, wrist, hip) Re -186 sulphateRe -186 sulphate Small joints (hands)Small joints (hands) Er-169 citrateEr-169 citrate

How it works Colloidal particlesColloidal particles

SSmall enough to be phagocytozed mall enough to be phagocytozed LLarge enough to remainarge enough to remain within the joint within the joint

cavitycavity SShould be biodegradablehould be biodegradable

EEnergy sufficient to penetrate and ablate the nergy sufficient to penetrate and ablate the synovial tissuesynovial tissue

Not to damage underlying articularNot to damage underlying articular cartilage or cartilage or overlying skinoverlying skin

Side effects

Radiation synovitisRadiation synovitis Reduced with simultaneous steroids injectionReduced with simultaneous steroids injection

InfectionInfection Less frequent than in steroids aloneLess frequent than in steroids alone

Tissue necrosisTissue necrosis Fistula around injection, paraarticular injectionFistula around injection, paraarticular injection

ThrombosisThrombosis Due to join fixationDue to join fixation

Procedure

Joint punctureJoint puncture Withdrawing of the fluidWithdrawing of the fluid Injection of the RP Injection of the RP Injection of the steroidInjection of the steroid Joint fixation for 24 to 72 hoursJoint fixation for 24 to 72 hours

Effectiveness

Local hyperthermia and swelling decrease Local hyperthermia and swelling decrease within 3-4 months.within 3-4 months.

> > 75% 75% patients significant decrease in pain patients significant decrease in pain and swellingand swelling in rheumatoid arthritis, in rheumatoid arthritis,

> 90> 90% i% in hemophiliac joints reduction of n hemophiliac joints reduction of bleedingbleeding episodes episodes

52 ± 24% effect in osteoarthritis52 ± 24% effect in osteoarthritis

Effectiveness depends on

Precise diagnosisPrecise diagnosis Stage of the diseaseStage of the disease Correct indicationCorrect indication Correct applicationCorrect application Joint fixationJoint fixation Another injection could be performed Another injection could be performed

6 moths later6 moths later Better repetitive injection of less Better repetitive injection of less

radioactivityradioactivity

Conclusion

RSORSO is cost effective, safe is cost effective, safe and improves and improves quality of life in patients with disablingquality of life in patients with disabling arthritisarthritis

The fear of developing cancer has beenThe fear of developing cancer has been conclusively ruled out in extensive studiesconclusively ruled out in extensive studies