Upload
others
View
3
Download
0
Embed Size (px)
Citation preview
Imaging in Clinical Practice
Paul Reuteman PT, DPT, MHS, OCS
2017 WPTA Spring Conference
April 20, 2017
What is the purpose of this course!
• Big changes in profession and in State of
Wisconsin!
• Provide clinical guidelines for need of imaging
as part of the SCREENING PROCESS
• If images are ORDERED, what are the routine
series of images
• If images are already taken, how do we educate
patients on RELEVANT FINDINGS
Big Changes!!!• Already an established model of use of imaging in
practice
– Military, IHS
– UK, Canada, Australia, Norway and others
• Development of DPT brought imaging into the classroom
– 2015 - Development of “Imaging Education Manual for DPT
Professional Degree Programs” Imaging SIG of the Ortho
Section
– Provides guidelines for DPT curriculum
• 2016 - White Paper published by Ortho section, APTA on
“Diagnostic and Procedural Imaging in PT Practice”
• 2016 - Changes in the State of Wisconsin Practice Act
Notice any parallels to other legislation in PT Practice
State of Wisconsin Practice Act
• Definition of PT
448.50(4)(b)
“Physical Therapy” does not include using roentgen rays or radium for any purpose, using electricity for surgical purposes, including cauterization, or prescribing drugs or devices
• This language prohibits PTs from actually “taking” x-rays (flipping the switch)
• What can we do?
It’s Law!Recent advances in WI in 2016
Bill AB549 was passed
• Allows for PTs who satisfy certain criteria to
ORDER x-rays!
• PT must satisfy one of following:
– DPT
– Completed a specialty certification program (OCS)
– Completed a residency or fellowship program
– PT completed formal x-ray ordering training
program with MD involvement
– Coordination is completed with primary MD or
other health care coordinater
Full Disclosure
• Not teaching “IMAGING”…why?
• Instead, teaching the following:
– Clinical reasoning for the need of imaging
– Basic foundational images in routine series
– Patient education regarding imaging
• “Don’t you need an x-ray to know what’s wrong”
• “Have you looked at my MRI?”
• “What is PT going to do for me when my knee is ‘bone
on bone’”?
Tools for Clinical Decision Making
• American College of Radiology Criteria
• Clinical Decision Rules
• Diagnostic Imaging Pathways
These will be covered by body region
and summarized for you!!!This article is included in
your readings posted on
D2L
Variables for Imaging Decision Making
In the ACR Appropriateness Criteria• Age
• Trauma presence/absence
• Mechanism of injury
• Prior surgery
• Risk factors
• Appearance
• Pain provocation and physical functional tests
• Weight bearing ability
• Tenderness to palpation.
These are already WELL ESTABLISHED in PT
educational curricula and in clinical practice
Red Flag Screening We Already Use
• Trauma
• Unexplained weight loss
• Age older than 50 years old (esp in
females/males with osteoporosis)
• Hx of CA
• IV drug use
• Prolonged use of corticosteroids
• PROGRESSIVE neuro deficit
• UMN finding
• Prior surgery
Great Resources• Imaging Education Manual for DPT programs by
Imaging SIG
– https://www.orthopt.org/uploads/content_files/ISIG/IMAGI
NG_EDUCATION_MANUAL_FINAL_4.15.15..pdf
• McKinnis L. Fundamentals of Musculoskeletal
Imaging, 4th Edition
• McKinnis L. Musculoskeletal Imaging Handbook: A
Guide for Primary Practitioners.
• Malone T. Imaging in Rehabilitation.
• JOSPT – Musculoskeletal Imaging Series and
Clinical Practic Guidelines
• OTHER HEALTH CARE COLLEAGUES
What are the different types of
imaging?
• Plain film radiography
• Digital radiography
• Computed tomography (CT)
• Arthrogram
• Ultrasound
• Bone scan
• MRI
What is a Radiograph?
• An x-ray film or digital image containing an image of an anatomic part of a patient
• Requires:– X-ray source
– The patient
– An image receptor (film or digital technology)
• Terminology– Radiograph or plain films (preferable term)
– X-ray
• Advantages??
• Disadvantages??
How it works
• X-rays are form of radiant energy with shorter wavelength of visible light
• Materials absorb the x-ray at different rates depending on:– Atomic number (density of tissue)
– Tissue thickness
• The greater x-rays absorbed, the whiter the structure (radiodensity)– Less radiodense (aka: radiolucent): objects appear
darker
– More radiodense (aka: Radiopaque) objects appear lighter)
50 shades of Gray
Radiodensity of structures
Decreasing Radiodensity
Increasing Radiolucency
(Darker)
Increasing Radiodensity
Decreasing Radiolucency
(Whiter)
Air/lungs
Fat/multiple layers of tissue
Thin bone/Water/Muscle
Cancellous Bone/Tendon/Thick muscle
Thick Cortical bone/Metal/Contrast Medium
AP views of the Pelvis
Plain Film Radiography
• Most effective way of demonstrating a bone or joint abnormality
• 1st order of diagnostic study
• 2 dimensional view
– All radiographs are 2 dimensional
– To get 3 dimensional must have a view 90° to the other
(Minimum of 2 views is the rule)
Rationale for multiple views
Varying 2 dimensional views Most common projections
• View same object from different angles
• Most common projections
– AP: Anterior-posterior
– PA: Posterior-anterior
– Lateral (R or L)
– Oblique (R or L / Post or anterior)
Common views of the C-SpineReading a radiograph:
BASIC “Search Patterns”
• View the image as if you are the radiograph
machine (image source)
• ABCs
– Alignment
– Bone Density
– Cartilage space
– Soft tissue
Variations of radiographs
• Stress views: Stress the joint to determine if
structure changes
• Fluoroscopy: Radiograph in real time. Able to
move joints to see what is happening. Also
used to perform epidural and other injections.
Increased amount of exposure to radiation.
Digital Imaging:
Image Quality Factors• Radiographic density: Can be regulated by the
machine or by the digital image viewer
• Radiographic contrast: High contrast increases
anatomic detail
• Detail (sharpness, definition, resolution):
Sharpness of the structural lines
• Distortion: difference in the size and shape of the
actual image and the recorded image
The Radiographic Examination
• Each joint typically has a routine order of films
• May either rule in OR rule out a specific
diagnosis
• Must first perform a THOROUGH history and
examination
– May have a “working diagnosis” that may be
confirmed with plain films
• More often than not, radiographs are not required
and may be avoided when establishing a
diagnosis
TWO Critical Points
• For the radiologist and MD to perform their job, they must be provided with sufficient patient history, signs and symptoms and results of other special tests
• Technology is not infallible: False negatives and positives will occur. It is the clinicians responsibility to recognize that if results of any imaging study do not fit, further evaluation and diagnostic investigation is warranted
“Advanced” Imaging
• Advanced imaging interpretation requires
foundations in:
– Imaging technology
• More complex physics
– Dimensional anatomy
• Sectional anatomy
• Orthogonal planes or relative to the anatomy
– A methodical search pattern
• Develop a sequence to search images
– Characteristics of pathology
• Soft tissue is more complex than bone
In Reality….
Advanced imaging interpretation cannot be
learned as easily as radiographic interpretation
HOWEVER….
an achievable goal is to gain an understanding
of what advanced imaging modality would
best define the pathologies you commonly see
in your PT population
Magnetic Resonance Imaging• Body is imaged within a
powerful magnetic field
with use of nonionizing
radio waves
• NO radiation
• MRI is based on the
process by which nuclei
aligned in a magnetic field
absorb and release energy
• MRI is based on signals
from hydrogen nuclei in
water molecules
• Indications:
– Imaging soft tissue.
Examples:
• Muscle or ligament tears
• Disc herniation
• Meniscus or labral tears
– Changes in bone marrow
(bone bruises, AVN, bone
tumors, etc)
– Staging neoplasm in bone
and/or soft tissue
• Does not give as high resolution of
cortical bone than CT does but still
can be used to diagnose bony
pathologies
Disadvantages/Contraindications
of MRI• Disadvantages
– High cost
– Claustrophobia of the patient
– Length of time to complete (do not get images right away)
– Pt needs to sit still to get adequate image (difficult if they are in pain)
– Cannot do with ferrous metal in the body
– Findings do not always correlate to symptoms
• Contraindications– Magnetic field may lift heavy metal objects and displace them
– Ortho hardware is not ferromagnetic BUT will distort image
– Pacemakers may malfunction
– Cochlear implants
MRI• Weighted images
– T1: Anatomic detail is better• Fat and bone marrow have high signal intensity (bright)
• Water has low signal intensity (dark)
– T2: Detects swelling and water better• Opposite as above
• Water shows up bright
• Muscle is slightly darker
• T2 → H2O
– Muscle has moderate signal intensity on both
– Tendons and ligaments have low signal intensity on
both (dark)
https://mrimaster.com/characterise%20physics.html
Viewing MR or CT Images
• Frontal (Coronal): Images are viewed from the
front, as if facing the patient
• Sagittal: Images on either side of the body are
viewed from side to side
• Axial (transverse): Images are viewed from below,
in a caudo-cephalad direction (similar to a CT)
CT Scan
• Indications
– Images of the brain
– Subtle or complex
fractures
– Degenerative changes
– Intra-articular
abnormalities (loose
bodies)
– Small bone fragments
– Bone density
• Merges radiograph with
computed imagery
• Computer mathematically
reconstructs the image
• Creates a series of axial
(cross-sectional) slices
• Much more sensitive than
radiographs
• Provides additional views
not provided by films
(axial)
CT Scan
• Advantages
– Anatomy in cross section
– Less expensive than MRI
– Less claustrophobic
– Can image soft tissue and osseous structures
in one series
• Disadvantages
– Utilizes ionizing radiation
• High radiation exposure
– More expensive than plain film
Radionuclide Bone Scan
• Radioactive substance
(Technetium-99) is injected
into pt
• Tc99 collects in areas of
increased bone activity
(osteoblastic activity)
• A “hot spot” is present
when taking a picture with
a gamma camera
• Indications
– Fractures: most commonly stress
fractures (indicates the location of
the fracture but not the type of
fracture)
– Bone tumors: again location of
the tumor, but not specific type of
tumor
• Will also see
– Epiphyseal growth plates
– Areas of arthritis
• Disadvantage
– Lack of specificity in differential
diagnosis
– Poor anatomical detail
Diagnostic Ultrasound
• Most often used for soft tissue diagnosis
• Advantages to other imaging:
– Low cost and portable device
– Able to modify the exam while it is being
performed. Ex:
• Can move the affected joint
• Can ask pt to activate muscles (assess cross sectional
area of the muscle)
• Stress the joint
When is imaging appropriate?
PT’s must answer these questions
• Will imaging studies alter plan of care?
• Is imaging needed to feel comfortable proceeding
with PT Treatment?
• Requesting imaging?
– What views?
– Rationale?
• Evolving literature has provided more specific
guidelines to these questions.
If Imaging is needed…
• When contacting an MD or ordering your own
imaging, provide:
– Pt demographics
– Symptoms (location)
– Injury (when, mechanism)
– Physical examination
– Relevant medical history (ex: CA, infection, risk
factors for bone density)
– Concerns
– Type of imaging
Cervical Spine
Guidelines of PLAIN FILM imaging of the C-Spine
in the presence of trauma
Stiell IG, et al. The Canadian C-Spine rule for radiography in alert and stable patients. JAMA.
2001; 286: 1841-1848
Canadian C-Spine Rule
Specificity: 43-91 -LR: .01Sensitivity: 99-100 + LR: 1.8-10.7
(Hoffman J. 2000, Stiell I. 2001, 2003)
The Canadian C-Spine Rule
General Guideline for MRI of Cervical Spine(Adapted from New CPG from JOSPT – Coming out soon)
•Neck pain with Non-radiating pain: In the absence of red flags, no imaging indicated
•Neck pain with radiating pain, indicated when:•Signs of myelopathy (weakness, mm wasting, clonus, sensory loss, hyperactive reflexes)•Progressive neurological findings (sensory deficits, weakness and reflex changes)•Radiating pain not responding to conservative care after 6 weeks (VARIABLE)
Routine Series of the Cervical Spine
Routine1. AP Open mouth2. AP Lower C-Spine
3. Lateral
Sometimes1. Right posterior oblique
2. Left posterior oblique
3. Flexion and extension stress views
1. AP Open mouth radiograph
Assess:• ABCs
• C1-C2 Joint symmetry
• Dens midline between the lateral mass of C1
• C2 spinous process midline
AP Open mouth radiograph
Clinical Relevance?
2. AP Lower Cervical Spine
Assess:•ABCs
•C3 through C7
•C2-C3 IV space
•T1 ribs
•SP and midline
•Pedicles equidistant
•Trachea midline
3. Lateral View C-spineAssess:•ABCs
•Intervetebral disc space
•C1-C7 vertebral bodies and their alignment (3 parallel lines)
•Facet joints
•Dens/C1 relationship
•Curvature of spine
Sometimes:
1. Oblique view C-spine
Right posterior oblique Left posterior oblique
Oblique view C-spine
Assess:•ABCs
•Intervertebral foramen
Sometimes
2. Stress Views•Spine is positioned at end range flexion and extension
•Assess: •Atlanto-dental
interspace (C1-C2 stability)•Preservation of the
spatial relationships of the 3 parallel columns (stability of lower cervical spine)
MRI of C-Spine
•Sagital views: Assess if disc or other tissue encroaches in spinal canal
•Axial views: Assess central spinal canal (central foramen) and if disc or other tissue encroaches on nerve root
To be clinically relevant, clinical findings must corroborate with images
VIDEO TUTORIAL:
https://www.youtube.com/watch?v=Sv3VEnKfY6Y
T1 vs. T2
https://mrimaster.com/PLAN%20C%20SPINE%20t1%20sag.html
Sagital ViewAxial View (T1)
https://mrimaster.com/PLAN%20C%20SPINE%20t1%20sag.html
Evidence Regarding Imaging of the Cervical spine
• Large percentage (73-90%) of asymptomatic patients present with “degenerative changes” (change in signal intensity of disc, posterior disc protrusion, disc space narrowing) and bulging discs. Even those in their 20’s (73%)(Okada E. Eur Spine J. 2013, Matsumoto M. Spine. 2010, Nakashima N. Spine. 2015)
• “Degenerative changes” increase as we age (Matsumoto M. Spine. 2010)
• Comparing patients with WAD and control in 10 year follow-up there was no statistically significant correlation between neck pain and progression of MRI findings…poor correlation between MRI and persistent pain of WAD (Matsumoto M. Spine. 2010)
THORACIC SPINE
Indications for Thoracic spine imaging
• Trauma or fall (Same as C-Spine)
• Thoracic pain and suspected or already diagnosed osteoporosis
• “Non-mechanical” nature of pain
• Potential rib fractures
Routine Plain Film Series
1. AP Thoracic
2. Lateral Thoracic
1. AP Thoracic
•Assess:•Disc spaces•Alignment of the vertebrae (spinous process and pedicles are in line)•Costo-vertebral joints
2. Lateral Thoracic•Assess:•Vertebral bodies and disc spaces•Intervertebral foramen•Alignment of vertebrae
Lumbar Spine
Criteria for L-spine radiographs
Jarvik JG. Diagnostic evaluation of low back pain with emphasis on imaging. (Ann Intern Med.
2002) Radiographs to be taken in pts with:
•Hx of major trauma•Hx of minor trauma and high risk for osteoperosis•No trauma but 2 or more of the following present •>50 y.o., hx of CA, fever, weight loss, hematuria, IV drug
use, failure of conservative care after 4-6 weeks
FLOW SHEET ON NEXT PAGE
If there is a concern for vertebral fracture in LBP
5 variables: (Henschke N. 2008)
•> 50 years old (+LR: 2.2)
•Female gender (+LR: 2.3)
•Major trauma (+LR: 12.8)
•Pain and tenderness (+LR: 6.7)
•Distracting painful injury (+LR: 1.7)
Indications for Lumbar MRI(Delitto. LBP CPG. 2012)
• Leg pain with or without associated back pain and progressive hard neuro signs
•Pain/radiculopathy in adults not improving despite 4-6 weeks of non-surgical treatment, which includes physical therapeutic modalities and appropriate pharmacologic intervention.
•Pain/radiculopathy with history of major trauma.
•Clinical suspicion of an infectious process such as abscess, osteomyelitis, or discitis
•Clinical suspicion of primary lumbar spine cancer (“red flags”) with symptoms and/or findings suggesting involvement of the spine
Indications for Lumbar MRI (cont)(Delitto. LBP CPG. 2012)
•Sign/symptoms suggestive of spinal stenosis that may require surgery (pseudoclaudication; pain/numbness/ tingling with activity, relieved by rest, sitting, spinal flexion; suggestive x-ray findings).
•Clinical suspicion of lumbar myelopathy or lumbar nerve root or cauda equina compression with extremity weakness, bladder/bowel symptoms, ataxia, spasticity, spinal level sensory loss.
Routine Series for plain film
Routine1. AP2. Lateral 3. Lateral L5-S1 (“spot shot”)
Sometimes:•Right oblique•Left oblique
1. AP Lumbar spine•Assess:•Interpediculardistance (a)•Spinous process alignment (b)•Pedicles equidistant (c)•Lamina/sup & infarticular process (d)•Transverse process
2. Lateral View
Assess:
•Intervertebral foramen
•Intervertebral disk space
•Spinous process
•Facet joints
•3 parallel line
3. Lateral L5-S1“spot shot”
Sometime:
Oblique Views
•Described by side closest to the image receptor AND direction of rotation. Example: Right posterior oblique (RPO)
•Assess:•Pedicles•Superior and inferior articular process•Facet joints•“Scottie dog” (presence of fracture of pars interarticularis)
Oblique Views
“Scottie Dog” MRI of Lumbar Spine
•Sagital view: Assess if disc bulge encroaches into spinal canal
•Axial view: Assess central spinal canal and if disc bulge encroaches into spinal canal or nerve root
To be clinically relevant, clinical findings must corroborate with images
VIDEO TUTORIAL:
https://www.youtube.com/watch?v=p4wVMHmGjAU
Axial viewT1 T2 Axial view
• Single most over-requested diagnostic imaging procedure
• Large economic impact leading to increased health care costs
• A large portion of irrelevant findings that lead to inappropriate diagnosis and treatment• Degenerative changes present in 28 to 50% of ASYMPTOMATIC
population
• Creates fear and anxiety in patient
(2011)• Misinterpretation of results by clinicians
resulting in unhelpful advice, needless subsequent investigations (downstream testing) and invasive interventions, including surgery
• Misinterpretation of results by patients resulting in catastrophisation, fear and avoidance of movement and activity, and low expectations of recovery
• Side effects such as exposure to radiation
(BJSM. 2016)
In a recent systematic review…(Brinjikji W. A J of Neuroradiology. 2015)
3110 asymptomatic patients
Hip and Pelvis
When is imaging necessary?Bussieres . 2007 JMPT
• Suspicion of advanced OA changes, stress fx, avulsion fx, avascular necrosis, Slipped Capital Femoral Epiphysis (SCFE)
• Hip Imaging General Guidelines– Failed Conservative Treatment (<4 weeks)
– Complex History
– Hx of non-investigated trauma
– Significant trauma
– Acute/sub acute locking
– Palpable enlarging mass (deformity)
– Severe or progressive pain (inguinal) with WB or end range of IR/ER. May have limited IR also.
– Focal tenderness to bone
• ASIS, AIIS, ischial tuberosity
• MRI recommended if plain films is inadequate at identifying pathology or consideration of soft tissue injury (i.e.: labral tear)
Routine Series
• Pelvis
– AP
• Hip
– AP
– Lateral Frog Leg
• Others
– Cross table lateral view of the hip
AP Pelvis
Assess:
• SI joint symmetry
• Femoral head & acetabulum
• Hip joint symmetry (ABCD’s)
AP Hip (close-up view)
Assess:
• Acetabular roof
• Anterior rim
• Posterior rim
• Iliopubic line
• Ilioischial line
• Iliofemoral line (red)
Hip Lateral Frog Leg
Assess:• Greater trochanter
is superimposed behind the neck
• Lesser trochanter is profiled
• Femoral head well exposed
• Different perspective of femoral neck
Cross Table Lateral view
Assess:
• Preferred from some MD’s over the lateral frog leg
• Presence of femoroacetabularimpingement (FAI)
– CAM impingement
– Pincer impingement
MRI (MRA) of the hip
Assess:
• Labral tears (with Gadolinium)
• Chondral injuries
• Advanced hip pathologies (AVN, etc)
“It is absolutely necessary to have a Gadolinium injection in the hip prior to the MRI for the image
to be useful in diagnosing labral pathology”
MD Colleague
MRI with Gadolinium Injection = MRA (Magnetic Resonance ARTHROGRAM)
MRI of the Hip
Views:
• Axial (A)
• Sagital (S)
• Frontal (F)
Assess for injury to:
• Labral tears (F, A)
• Condral lesions on femoral head or acetabulum(F, A)
• Ligamentum terestear (F)
• Other soft tissue (F, S, A)
Assessing Osteoarthritis
Radiologic Findings
a. Assymetrical joint space
b. Sclerotic subchondral bone
c. Osteophytes at joint margins
d. Superior migration of the femoral head / inferior acetabular protrusion (does not sit appropriately in the acetabulum)
Hip OA in Symptomatic and Asymptomatic Patients
• Weak correlation between symptoms and joint space in a SR (Lin. OA & Cart. 2011)
• 50 years or older, OA (Grade > 2 KL scale) in 20% of asymptomatics (Kim C. A&R. 2014)
– Prevalance increases with age
– Males greater likelihood than males
Educational video
Prevalence of OA in population and prevalence of pain
(Iadaka T. OA & Cart. 2016)
Educational video
Labral Tears of the Hip• Younger patient population (20-40 y/o)
• Bony abutment occurs with flexion, adduction and IR (Impingement sign) (Ganz R. 2003)
• Common etiology of labral tears:
– Macrotrauma
– Repetitive microtrauma
• Associated with femoroacetabular impingement
• Joint laxity (congenital, capsular laxity)
– Combination of these factors
“Measuring” Intraarticular Pathology(Clohisy J. JBJS. 2008)
• Tonnis angle
• Lateral central-edge angle of Wiberg
• Anterior center-edge angle of Lequesne
• Neck-shaft angle
• Lateral alpha angle
• Head-neck offset ratio
• Acetabular retroversion (“cross-over sign”)
Historical perspective• “Surgery is necessary as an early intervention to
avoid progressive degeneration”
• “Physical therapy, with emphasis on improving passive ROM or stretching, is not beneficial but rather counterproductive.”
• “Physical therapy is counterproductive and increases risk of degenerative change because it does not address the underlying impingement.”
Standaert et al 2001 APMR; Lavigne et al 2004 Clin Orth Rel Res
Historical perspective
“Absent any prospective data on the natural history of the diagnosis, the long-term outcomes of those undergoing surgery compared with those who do not, and the prevalence of various findings in the asymptomatic population, this reasoning is troublesome”
Standaert et al 2001 APMR
Hip “Pathology” in Young Asymptomatic Individuals
• Avg age of 34 years old (Schmitz M. AJSM. 2012)
– 26% present with acetabular paralabral cysts
– 85% present with acetabular labral tears
• Avg age of 38 years old (Register B. AJSM. 2012)
– 13% present with acetabular paralabral cysts
– 69% present with acetabular labral tears
– 24% present with chondral defects
– >35 y/o: 13.7x more likely to have a chondral defect and 16.7 x more likely to have a subchondral cyst (Age correlates with labral tears)
Symptomatic vs. Asymptomatic(Tresch F. J of MRI. 2016)
• 20-50 years old
• Articular cartilage and/or labrum
– 80% in symptomatic
– 57% in asymptomatic
• Labrum
– 61% in symptomatic
– 44% in asymptomatic
• Acetabular cartilage defects
– 47% in symptomatic
– 14% in asymptomatic
The Knee
Differential Diagnosis-Atraumatic
Criteria for knee radiographs after trauma:Ottawa Knee Rules
Stiell, IG, et al. Prospective Validation of a Decision Rule for the Use of Radiography in Acute Knee Injuries. JAMA. 1996 . 275(8); 611-615
Radiographs should be ordered after trauma for patients with any of the following (not applied to pts < 18 y/o):
• >55 y/o
• Tenderness over fibular head
• Isolated tenderness of patella
• Inability to flex knee to 90°
• Inability to walk 4 steps
Sensitivity: .85 - 1.00Specificity: .49 - .50
+LR: 1.8-LR: 0.1-0.3
(Richman P. 1997, Jackson J. 2003)
Criteria for knee radiographs in absence of trauma:
Knee Decision Rule of BauerBauer SJ. J Emerg Med. 1995
• Presents with any one of these three variables:
– Inability by patient to bear weight both immediately for FOUR STEPS
– Presence of effusion
– Presence of ecchymosis
• May also indicate a Blood Panel or Arthrocentesis
Sensitivity: .85-1.0, Specificity: .49-.63
Also:
• Perception of popping sound in the knee during twisting maneuver
• Adolescent with tenderness over femoral condyle
Indications for MRI of the knee
• Presence of joint effusion
• Suspicion of
– Ligament tears
– Meniscus tears
– Articular cartilage injury
– Muscle or tendon tears.
Routine Series of the Knee
• AP: NWB vs. WB
• Lateral
• Tangential view of Patellofemoral joint (Sunrise view)
• Sometimes: PA Axial view (Tunnel view)
AP ViewCan be done in either
weightbearing or non-weightbearing
Assess:
• Patellar alignment
• Tibiofemoral joint space
• Varus/valgus alignment (intercondylar tubercles)
• Proximal fibula
Lateral View
Assess:
• Distal femur (joint surface)
• Proximal tibia
• Lateral patella
• Tibial tuberosity
• Patella alta or baja
PA Axial view(Tunnel view)
MAY ALSO BE DONE IN WB AS AN AP VIEW
Assess:
• Distal femur joint surface
• Intercondylar fossa
• Loose bodies / osteochondralconditions
Tangential view of Patellofemoral joint(AKA: Sunrise view / Merchant’s view)
Assess:
• Articular surface of PFJ
• Sulcus angle
• Patellar alignment in femoral sulcus (congruence angle)
MRI of the Knee
Views:
• Axial (A)
• Sagital (S)
• Frontal (F)
Assess for injury to:
• Meniscus (S, F)
• Cruciate ligaments (S)
• Collateral ligaments (F)
• Articular surfaces (F, A)
– Bone bruise on condyles
– Articular cartilage injury
• Other soft tissue
Assessing Osteoarthritis on Plain Films(Kellgren J. 1963)
Kellgren-Lawrence Criteria• Grade 0- No features of OA
• Grade 1- Doubtful narrowing of joint space and possible osteophyte lipping
• Grade 2- Definite osteophytes and possible narrowing of joint space
• Grade 3- Moderate multiple osteophytes, definite narrowing of jtspace, and some sclerosis and possible deformity of bone ends
• Grade 4- Large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of bone ends.
Natural Progression of Knee OABedson J. BMC. 2008
• Prevalenceincreases with age
–Age >45: 36-50%
–Age >55: 40-76%
0%
10%
20%
30%
40%
50%
60%
70%
80%
25-40 Age 45 and older Age 55 and older
OA increases with age
Low High
Should we be assessing Film or Function?
Cubukcu D. Arthritis. 2012
PLAIN FILM IMAGES
Evaluates weight bearing joint space, osteophytes, sclerosis and cysts.
• Significant association with age and increasing Kellgren Lawrence Scale
• NO ASSOCIATION With WOMAC – Pain
– Disability
– Function
– Stiffness
WOMAC QUESTIONNAIRE Evaluates Disability, Functional Status, Pain, Stiffness
• Significant association with Disability and Pain Scales
• Significant association with Disability and Stiffness Scales
“treatment of knee OA could be planned according to the clinical
features and functional status instead of radiological findings”
Foot and Ankle
Need for RadiographsOttawa Ankle Rules
(Stiell I, 1992)• Bone Tenderness of
any of the following
– Dist 6 cm of post edge of the tibia or tip of med. malleolus
– Navicular
– Base of the 5th
metatarsal
• Inability to WB immediately after injury 4 steps (2 each side)OR
Sensitivity =.97-.99
Also• In adolescents with lateral ankle sprain due to potential
injury to growth plate (Salter-Harris Fracture)
• Tender over distal tibio-fibular joint (High ankle sprain)
• Concern of stress fracture (Bone scan):
– Common Locations: tibia, medial malleolus, talus, fibula, navicular, cuboid, metatarsals
– Subjective:• Change in mileage/activity
• Pin point tenderness
• Night pain
• Pain worsens with increased activity
– Objective• Bony Tenderness
• Percussion/Vibration Test
Indications of MRIMartin R. CPG for Ankle Lig. Sprains. JOSPT. 2013
• Potential muscle or tendon tear
– Achilles tendon, posterior tibial or fibularis mm
• Suspect loose bodies (osteochondral lesions)
– Persistent pain, instability, crepitus, catching and/or locking
• Potential neoplasms or infections of the bone
• Congenital or developmental conditions (ex: tarsal coalition)
Routine Series
• Ankle– AP
– AP Oblique (mortise view)
– Lateral
– Sometimes: AP Inversion and Eversion
• Foot– AP
– Lateral
– Oblique
AP AnkleAssess:
• Dome of talus
• Talocrural joint space
• Lateral malleolus
• Medial malleolus and relation to talus
• Tib-fib clear space and overlap
Normal overlap: 10 mm (blue)Normal clear space: 5 mm (red)
Tibiofibular clear space
AP Oblique(Mortise view)
Assess:
• Mortise width
Norm: 3-4 mm over entire surface of talus
• AITF joint integrity
• Articular damage of the dome of the talus
Lateral Ankle
Assess:
• Fibula superimposed on tibia
• Posterior rim of tibia (3rd
malleolus)
• Talus, calcaneus, cuboid and navicular
• Talar dome
AP Foot
Assess:
• Bones of the forefoot
• Bones of the midfoot
• 1st intermetatarsal angle
Norm: 5-15°
Oblique Foot
Assess:
• Metatarsal and phalanges shafts
• Bones of the midfoot
• Interspace of tarsal and metatarsals.
APPObliqueP Lateral
Foot
Assess:
• Bones and joints of the rearfoot and midfoot
MRI of the AnkleViews:
• Axial (A)
• Sagital (S)
• Frontal (F)
Assess:
• Talar dome injury (S, F)
• Ligament injuries (S, A, F)
• Tendon injuries (S, A, F)
• Other soft tissue
http://www.freitasrad.net/pages/Basic_MSK_MRI/Ankle.htm#sag
PATIENT EDUCATION
• 32% of asymptomatic adults show a heel spur on plain films
• What do YOU SEE and what do THEY SEE
The Shoulder Complex
Criteria for shoulder complex radiographs
• Acute trauma: ESPECIALLY if elderly and/or osteoporotic
– FOOSH injury
– Bone deformity (Clavicle, AC, GT, scapula)
– Shoulder dislocation (instability)
– Eccymosis
– Swelling
– Focal tenderness to bone (clavicle, AC, GT, scapula)
Used when suspicion of clavicle fx, AC separation, massive RTC tear, OA, dislocation or humeral fracture
Indications for MRI of the shoulder complex
• Suspicion of:
– Presence of acute rotator cuff tear or biceps tendon tear
– Presence of muscle atrophy/fatty infiltration of rotator cuff in chronic tears
– Labral injuries (Bankart or SLAP)
– Articular cartilage injury (osteochondral lesions)
– Neoplasms or infections
Routine Series
• AP External rotation
• AP Internal rotation
• Others– Anterior oblique view (AKA: Outlet view or
Scapular Y lateral view)
– Axillary view
– AC joint AP bilateral (with and without weights) (stress view)
AP View GH External Rotation
Assess:
• ABCs
• Greater tuberosity in profile, lesser tuberosity midline, bicipital groove
• Coracoid process
• GH and AC joint
• Subacromial space (10-11 mm)
• GH joint space (5 mm)
AP with GH ER
AP View with GH Internal Rotation
Assess
• ABCs
• Lesser tuberosity in profile
• Greater tuberosity toward midline
AP with GH IR
Anterior oblique (outlet view)
Assess subacromial joint space.
Anterior oblique (outlet view)
Anterior oblique (outlet view)
• Assess “type” of acromion
• Large variation of acromion and scapular morphology in asymptomatic population (Chopp-Hurley J.
Sur Rad Anat. 2016)
Axillary view
Assess orientation of head of humerus and glenoid fossa
Axillary view MRI of the ShoulderViews:
• Axial (A)
• Sagital (S)
• Frontal (F)
Assess:
• Rotator cuff TENDON integrity (F)
• Rotator cuff MUSCLE atrophy (S)
• Labrum tears (A, S, F)
– With arthrogram (gadolinium injection)
• Articular cartilage injury
http://www.freitasrad.net/
Tutorial on reading a shoulder MRIhttp://screencast.com/t/UBt9OkUx
Axial Image Frontal (coronal) Image
http://www.radiologyassistant.nl/en/p4f49ef79818c2/shoulder-mr-anatomy.html
Sagital Image
ESPECIALLY if elderly and/or osteoporotic
Something to Consider
• MRI of ASYMPTOMATIC ADULTS show 20% have partial and 15% have full thickness tears. Those >60 y/0, 50% have some type of rotator cuff tear (Siber J. 1995)
• 50% of asymptomatic professional baseball players presented with R/C tear. They remained asymptomatic 5 years after retirement (Conner. 2003)
The Elbow and
Forearm
Indications for Elbow/forearm radiographs
• FOOSH injury with obvious deformity or bone tenderness
• Bone tenderness (esp. in adolescent due to growth plates)
• Traction injury in adolescents (fear of a radial head dislocation)
There have been some specific guidelines published for the elbow
A clinical rule for management of elbow injuryLennon. Emerg Med J.2007
A clinical rule for management of elbow injury:
(1) Patients ≤16 years with a ROM equal to the unaffected side may be safely discharged
(2) Patients with normal extension, flexion and supination do not require emergent elbow
radiographs
If pain and limited motion from a trauma,
radiographs should be considered.
A clinical rule for management of elbow injury(Appelboam A. BMJ. 2009)
• Those patients with extension ROM equal to the unaffected side do not require emergent elbow radiographs
• For those able to fully extend their elbow, radiography can be deferred if the practitioner is confident that a fracture is not present. Patients who do not undergo radiography should return if symptoms have not resolved within 7-10 days.
Indications for MRI of the elbow
• Suspicion of:
– Presence of tendon tears (most common is triceps or biceps tear)
– Signal change in chronic tendinopathies (lateral or medial epicondylosis)
– Fractures not identified on plain films
– Medial Ligament tears and/or lateral articular cartilage damage (“valgus overload syndrome” or “little leaguers elbow”)
Routine Series
• AP
• Lateral
• Sometimes– Internal or External
Oblique
AP Elbow
Assess:
• ABC’s
• Carrying angle– Normal =5-15°
– Increase or decrease may be sign of fx or traumatic deformity
Lateral Elbow
Assess:
• ABC’s
• Fat pad
Oblique Views
• Internal Oblique
– Pronation
– View coronoid process of the ulna
• External Oblique
– Supination
– View radial head
– View growth plate of medial epicondyle
AP Internal oblique (Pronation)
AP External oblique (Supination)Forearm series
AP
Lateral
MRI of the Elbow
Views:
• Axial (A)
• Sagital (S)
• Frontal (F)
Assess:
• TENDON integrity (S)
• Chronic tendinopatheis (A, F)
• Fractures (A, S, F)
• Ligament tears or articular cartilage injury (F)
http://www.freitasrad.net/
The Wrist and Hand
Indications for radiology of wrist and hand
• Tender in anatomical snuffbox following FOOSH injury
• Deformities/tenderness of the wrist and hand
• Tenderness over bone
• Ligament laxity
The Wrist and Hand
• Routine Series
– PA of hand and wrist
– Scaphoid view of wrist (PA with wrist in Ulnar deviation)
– Lateral of hand and wrist
– Oblique of hand and wrist
PA of the wrist Assess
• Arcurate lines - 3 arcs
• Space between ulna and triquetrum
Scaphoid View of wrist(P-A with wrist in Ulnar Deviation) PA Hand
Assess
• Long axis 2nd MC in line with radius
• Ulnar deviation of proximal phalanges (normal)
• Straight diagonal line from 3rd to 5th MC head
• Thumb in an oblique position due to the normal orientation of the trapezium
Lateral wrist: Set up is Same as with hand
Assess
• Long axis of 3rd
MC, capitate, lunate and radius
• Lunate and radius should be line with each other
Lateral handSet up is Same as with wrist
Assess
• Long axis of 3rd
MC, capitate, lunate and radius
• Lunate and radius should be lined up with each other
Oblique WristAssess• Proximal and
distal articulations with trapezium
• Again, a different view of the scaphoid bone
• Radial and
ulnar styloidprocess
Oblique Hand
Assess
• Long bones are seen 45°from PA view
I have to “hand” it to you…you’re hanging in
there George Costanza: The ultimate Hand Model
http://www.youtube.com/watch?v=PZxX3-rJoNI&noredirect=1