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12/1/2017
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What to Order and How to Interpret the Report
C. Benjamin Ma, MD
Professor in Residence
Shoulder and Sports Medicine
University of California, San Francisco
Department of Orthopaedic Surgery
Imaging
Different types of imaging
Imaging orders that make you look “awesome”
Interpretation of reports
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Why image?
New injuries
Chronic problems
Rule out tumor
Imaging
Aid diagnosis
Determine significance
Allow treatment plan
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Different Modalities
Radiographs
Ultrasound
CT scan
Bone scan
MRI
Pearls
Write down what you are concerned about
Xrays of ankle with concern of fibular fracture
MRI of shoulder with recurrent instability
Radiologists can help getting the right studies for you
They can also suggest better studies
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Plain radiographs
Image obtained by projecting of x-ray beams onto a detector
The amount of ‘whiteness’ is a function of the radiodensity and thickness of the object
Dense object – whiter image
Plain radiographs
Good first line evaluation
Orthogonal views (projection!)
AP/lateral of the joint
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Lower extremity imaging
Lower extremity are weight bearing joints.
Joint alignment can be very different with weight bearing
Can get weight bearing x-rays to look at joint space and alignment
What to order? Make you look good!
Knee
AP and Lateral knee
Weight bearing AP
Patellofemoral views
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What to order?
Hip
AP/ frog leg lateral
AP pelvis
What to order?
Ankle
AP/lateral ankle
Mortise view of ankle
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What to order?
Foot
AP/lateral/oblique foot
Weight bearing lateral?
Upper extremity imaging - shoulder
AP of GH joint
Axillary lateral
Supraspinatus outlet view
AP of AC joint
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Upper extremity imaging –non weight bearing joints
Elbow
AP/lateral forearm
What to order?
Wrist
AP/lateral/oblique wrist
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What to order?
AP Hand
Lateral Hand
Interpretation
Displaced fractures – always need attention
Non displaced fracture – can immobilize
Stress fracture/ cannot rule out….
Need secondary evaluation
Further imaging
Closer followup
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What to look for?
Fractures
Displaced
Comminuted
Impacted
Arthritis
Mild, moderate, severe
Abnormal morphology
Spurs, OCD, deformities
Interpretation
Elbow “Sail sign”
Occult fractures
Pediatric – supracondylar fractures
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Specific Radiographic Studies
Wrist
Scaphoid view
Hamate view
Ultrasound
Uses high-frequency sound waves to produce images
Similar to sonar wave on getting images of the ocean
Can be helpful to evaluate ganglion cyst Knee ganglions Foot ganglions
Diagnose tendon tears Rotator cuff tears Achilles tendon ruptures
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Ultrasound
Advantages
Non-invasive
Dynamic
• Tendon instability
Disadvantage
User-dependent
Cannot image deep tissue
Cannot image tissue within bone
Ultrasound
Use for targeted therapy
• Ultrasound guided injections
- Hip injections
- Calcific tendinitis
- Shoulder injections
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CT scan
Tomographic evaluation of the region of interest
Good for 3D bony anatomy
Degenerative joint anatomy
Complex reconstruction
Post-traumatic injuries
Ankle malunion
CT scan
Advantages Tomographic evaluation No magnification Give detail in trabecular and cortical
structures (better than MRI)• Measure bone loss• Evaluate fracture pattern• Evaluate healing
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3D CT scan
CT Scan
Hamate Fracture
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CT scan
Disadvantages
Subject to metal artifact
Weight limit for obese patients
Higher radiation
Contraindicated for pregnant patients
Nuclear imaging
Uses radioisotope-labelled biological active drugs
Radioactive tracers administered to the patient to serve as markers of biologic activity
Images produced by scintigraphy Technetium bone scan FDG in PET scans
• Measure glycolytic rates• Higher in tumor cells
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Bone scan
Rule out tumor – multiple lesions, increase update
Infection – tagged WBC scan
Evaluate symptomatic joints
Such as arthritis
Nonunion
Stress fractures
Nuclear medicine
Advantages Imaging of metabolic activity
• Healed fracture or nonunion• Arthritis
Diagnosis of infection Disadvantages
Lack detail and spatial resolution Limited early sensitivity
• Fractures usually takes up to several days to show up
Low sensitivity for lytic problems• Multiple myeloma
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MRI
Current gold standard for soft tissue injuries
Ligament tears
Labral tears
Cartilage injuries
Meniscus tears
MRI
Helpful to evaluate ligament integrity
Quality of cartilage fraying
arthritis
Labrum and meniscus injuries
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MRI
Helpful to evaluate ligament integrity
Quality of cartilage fraying
arthritis
Labrum and meniscus injuries
MRI
Helpful to evaluate ligament integrity
Quality of cartilage fraying
arthritis
Labrum and meniscus injuries
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MRI
Helpful to evaluate cuff integrity
Quality of muscle Fatty infiltration
Retracted tear
Labral pathology
OCD of the elbow
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TFCC tear
Triangular FibroCartilageComplex
Scaphoid fractures
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MRI with contrast -Gadolinum
Intra-articular contrast Distends the joint Enable evaluation of
ligament and labrum Hip and shoulder labral
tears Meniscus repairs Cartilage injuries, such
as TFCC
MRI- Gadolinum
Intravenous contrast
Evaluate vascularity
Tumor
Post-surgical changes, such as scar tissue
Concern with kidney insufficiency and complications
Usually ordered by specialists
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MR arthrogram – elbow
Evaluate ligament tear
Evaluate OCD stability
Look for intraarticular problemsMCL tear
Loose bodies, OCD
MR arthrogram - wrist
Evaluate ligament tears
Look for communication between compartments
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Radiology Reports – love adjectives!
Fraying vs Partial tear vs Full thickness tear vs Retracted tear
Cartilage inhomogeneity vs fissure vs flap vs unstable flap vs full thickness cartilage loss
Tendon degeneration vstendinosus vs tear
Clinical Correlation Recommended
CLINICAL HISTORY: 55 yo Posterior shoulder pain x1 year. Denies trauma.
There is adequate distention of the glenohumeral joint with intra-articularlyadministered contrast. High T2 signal in the anterior subcutaneous fat compatible with iatrogenic injection of anesthetic.
OSSEOUS ACROMIAL OUTLET: There is mild osteoarthrosis at the acromioclavicular joint with fluid in the joint and capsular hypertrophy.. The acromion is type 1 on sagittal imaging. There is no evidence of os acromiale. There is no Thickening of the coracoacromial ligament.
ROTATOR CUFF MUSCLES AND TENDONS:
Mild tendinosis of the supraspinatus tendon and anterior fibers of the infraspinatus tendon. Possible limited interstitial tearing of the posterior fibers of the infraspinatus tendon at the insertion (series 6, image 13).
Normal signal and morphology of the subscapularis and teres minor tendons.
Normal signal and bulk of the rotator cuff muscles.
LABRAL AND CAPSULAR STRUCTURES: Irregularity of the anterosuperiorand superior labrum compatible with degenerative changes. Blunting of the anterior labrum without discrete tear. No paralabral cyst formation.
What are they saying?
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What are they saying?
BICEPS TENDON AND ANCHOR: High T1 signal within the intra-articular portion of the long head biceps tendon favored to represent iatrogenic injection. The extra-articular portion of the long head biceps tendon demonstrates normal signal and morphology.
OSSEOUS AND CARTILAGINOUS STRUCTURES: Nonspecific cystic changes at the greater tuberosity. There is no evidence of a fracture or dislocation. No focal chondral defects are identified.
MISCELLANEOUS: There are no intra-articular bodies. The remaining muscles demonstrate normal bulk with no evidence of atrophy or edema.
IMPRESSION:
1. Irregularity of the anterosuperior and superior labrum compatible with degenerative changes. Blunting of the anterior labrum without discrete tear. The posterior labrum appears intact.
2. Mild tendinosis of the supraspinatus tendon and anterior fibers of the infraspinatus tendon. Possible limited interstitial tearing of the posterior fibers of the infraspinatus tendon at the insertion.
55 yo with no trauma and above findings – AGE Appropriate changes
MENISCUS: There is a complex tear of the body and posterior horn of the medial meniscus with large bucket-handle fragment displaced into the intercondylar notch paralleling the posterior cruciate ligament.
The native torn ACL is seen to be flipped anteriorly and back on itself within the anterior aspect of the intercondylar notch.
IMPRESSION:
1. Flipped appearance of the native torn ACL within the anterior aspect of the intercondylar notch is consistent with stump entrapment/cyclops lesion.
2. Large bucket-handle tear of the posterior horn and body of the medial meniscus.
What are they saying? Knee MRI
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What are they saying? Knee xray
INDICATION: Age: 17 years. Gender: Male. History: pain vs injury r/o fracture
Bones and joints: Osseous fragment over the superior pole of patella with marked thickening and irregularity of the quadriceps tendon.
Soft tissues: Large joint effusion with patellar soft tissue swelling.
IMPRESSION:
Osseous fragment over the superior pole of the patella with marked thickening and irregularity of the quadriceptendon with large joint effusion. Findings most compatible with superior pole patellar sleeve fracture.
What are they saying? Foot
CLINICAL HISTORY: r/o fx at left 5th MTP. jammed foot 3 days ago.
IMPRESSION:
1. Mildly to moderately displaced extra-articular oblique fracture of the fifth metacarpal shaft. No evidence of dislocation.
2. Severe degenerative changes of the first MTP joint compatible with hallux rigidus.
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What are they saying? 65 yo with shoulder pain – evaluate shoulder
MPRESSION:
No evidence of acute fracture or dislocation. Degenerative
changes of the acromioclavicular joint with a hooked type III
acromion and inferiorly projecting osteophytes off the distal
clavicle. Mild/moderate degenerative changes glenohumeral joint
as well with small marginal osteophytes. Close approximation of
the humeral head and the acromion with weightbearing suggest
underlying rotator cuff pathology.
Additionally noted is an oval ossified fragment along the
posterior superior aspect of the glenoid which may represent an
osteophyte, ossification of the posterior labrum, or old
fracture.
Surgical clips in the right axilla, suggesting prior axillary
lymph node dissection. Additional rounded density medial to the
clips, overlying the lung which could possibly reflect underlying
pulmonary nodule for which dedicated chest radiograph is
recommended..
NORMAL FINDINGS with hooked type III acromion!!!
Pulmonary nodules – depends on historyMay need further evaluation
What are they saying? CLINICAL HISTORY: 51-year-old male with right shoulder pain after fall, rule out full
thickness rotator cuff tear
OSSEOUS ACROMIAL OUTLET: Large inferior clavicular osteophytes indent the supraspinatus. Fluid is noted in the acromioclavicular joint with reactive marrow changes. Type 2 acromion.
ROTATOR CUFF MUSCLES AND TENDONS: Full thickness tear is seen at the anterior footprint of the supraspinatus tendon, with slightly increased intensity within the rest of the supraspinatus tendon compatible with tendinosis. The infraspinatus, subscapularis, and teresminor tendons demonstrate normal signal and morphology. The rotator cuff muscles are unremarkable.
LABRAL AND CAPSULAR STRUCTURES: Unremarkable. No evidence of labral tears.
BICEPS TENDON AND ANCHOR: Unremarkable. Normal signal and morphology of the biceps tendon.
OSSEOUS AND CARTILAGINOUS STRUCTURES: Unremarkable. Normal bone marrow signal. No evidence of fractures.
MISCELLANEOUS: The inferior glenohumeral ligament is not well defined and thickened. Fluid is also noted in the subacromial/subdeltoid bursa. Rotator interval synovitis.
IMPRESSION:
1. Full thickness tear at the anterior footprint of the supraspinatus tendon with supraspinatus tendinosis.
2. Thickening of the inferior glenohumeral ligament as well as rotator interval synovitis may reflect adhesive capsulitis.
51 yo with fall and full thickness rotator cuff tears
Refer for treatment and repair
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What are they saying?
40 yo with acute elbow pain – concern with biceps rupture
FINDINGS:
MUSCLES AND TENDONS: An acute tear of the biceps tendon at its
insertion on the radius is associated with approximately 5.5 cm
of retraction of the proximal tendon and large amounts of T1
hypointense and T2 hyperintense fluid within the soft tissues of
the anterior elbow.
The common flexor tendon is normal in signal and thickness. The
common extensor tendon is frayed and irregular and may be
consistent with prior injury.
LIGAMENTS: The ulnar and radial collateral ligament complexes
are intact.
OSSEOUS AND CARTILAGINOUS STRUCTURES: No bone marrow
abnormalities identified. Diffuse thinning of the cartilage is
noted.
What are they saying?
NERVES: The ulnar nerve is normal in signal and caliber.
MISCELLANEOUS: No joint effusion or loose bodies are identified.
IMPRESSION:
1. An acute tear of the biceps tendon at its insertion on the
radius is associated with approximately 5.5 cm of retraction of
the proximal tendon.
2. The common extensor tendon is frayed and irregular and may be
consistent with prior injury.
Good radiology reportIdentify acute injuriesDownplay chronic injuriesSummary or Impression usually are the more important focus
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What are they saying? MRI Hip
LABRUM: Degenerative tearing of the anterior and superior labrum. Degenerative ossification is also seen in the anterior labrum (image 17, series 4).
LIGAMENTS: The ligamentum teres and transverse acetabularligament are intact. Linear low signal intensity medial to the ligamentum teres may represent a thick acetabular plica.
TENDONS: The visualized rectus femoris, proximal hamstring, and iliopsoas tendons are intact. Edema around the gluteus tendon insertion, greater around the minimus than the medius, is compatible with mild peritendinitis.
IMPRESSION:
1. Degenerative tearing of the anterior and superior labrum.
2. Focal chondral loss Along the superolateral and anterior femoral acetabular cartilage. Focal chondral loss along the posterior medial aspect acetabular cartilage.
3. Mild peritendinitis of the gluteus tendon insertion, greater around the minimus than the medius.
65 yo with mild hip arthritis and tendinitisAge appropriate changes
Asymptomatic Knee Lesions
High prevalence of meniscus tears in older individuals
Especially with osteoarthritis (91%)
May not be symptomatic
“complex” tear is an appearance, may not be symptomatic
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MR imaging of Shoulder
Accurate
Asymptomatic individuals
> 60 y.o. – 54% tears (28% full, 26% partial)
40 – 60 y.o.– 4% full, 24% partial
19 – 39 y.o. – 0% full, 4% partial
Careful Interpretation!!!
Treat the patient, not the MRI
Intepretation
Rotator cuff tears
Age of patients
Older patients – common to have partial cuff tears
• Non op rehab
Full thickness cuff tears
• Referral for discussion of treatment
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SLAP tears
Common with older age
SLAP tear >50 yo
Operative treatment can lead to stiffness
Rarely culprit of symptoms
SLAP tear younger overhead athletes
Usually symptomatic
Surgical treatment
Imaging
Write down what your question is
Radiology can help answer them
Plain radiography – first start
Acute injuries – can order further imaging or quick referral
Chronic injuries – can order further imaging and interpret results
Post op injuries - referral
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Thank you
C. Benjamin Ma, M.D.
Professor in Residence
UCSF Department of OrthopaedicSurgery
Sports Medicine and Shoulder
(415) 353-7566
