Introduction to MSK Introduction to MSK Imaging Studies:Imaging Studies:

“Don’t Panic”“Don’t Panic”

Donna Magid, MD, M.EdDonna Magid, MD, M.Ed

Director, Horizontal Strand in Diagnostic Imaging Director, Horizontal Strand in Diagnostic Imaging

Professor, Radiology, Orthopaedic Surgery, and Professor, Radiology, Orthopaedic Surgery, and Functional Anatomy and EvolutionFunctional Anatomy and Evolution

‘‘REQUESTINGREQUESTING’’ vs ‘ORDERING’ studies vs ‘ORDERING’ studies SequencingSequencing MSK studies: MSK studies: what to do whenwhat to do when

ACR Appropriateness Criteria to the rescue!ACR Appropriateness Criteria to the rescue!

Give you life-long fishing skills rather than handing over fish. Give you life-long fishing skills rather than handing over fish.

Common errorsCommon errors: :

Forgetting “One view is no view” Forgetting “One view is no view”

Skipping usual stepsSkipping usual steps

Not reviewing older studies Not reviewing older studies

Pro/cons of common imaging modalities: Pro/cons of common imaging modalities: XR, CT, MR, USXR, CT, MR, US

ObjectivesObjectivesIntroductory concepts of MSK ImagingIntroductory concepts of MSK Imaging

YOU: Intelligent Consumers YOU: Intelligent Consumers of of Medical Resources Medical Resources (not optional)(not optional)

Common indix. head CT = “R/o stroke, dizzy”Common indix. head CT = “R/o stroke, dizzy” Legitimate concern for stroke (Legitimate concern for stroke (but but overinclusiveoverinclusive).).

Inner-ear-pt. subset: Inner-ear-pt. subset: benign, conservative tt.benign, conservative tt.

Better clinical ED screen for benign ear Better clinical ED screen for benign ear etiologies could reduce CT in US by etiologies could reduce CT in US by

$500 million/year. $500 million/year. Newman-Toker et al, Academic Emergency Medicine July 2013 Newman-Toker et al, Academic Emergency Medicine July 2013

“ “ Intelligent Consumer” Intelligent Consumer” may may mean mean NOTNOT utilizing imaging utilizing imaging

(unnecessarily…$, dose)(unnecessarily…$, dose)

EDED((USA)USA) 2006: 34% radiographed 2006: 34% radiographed (more, JHH)(more, JHH)

12% CT 12% CT Pitts, Niska et al National Health Statistics report (7)2006Pitts, Niska et al National Health Statistics report (7)2006

CT tripled, 1996CT tripled, 19962010 2010 Smith-Bindeman, JAMA June 2012Smith-Bindeman, JAMA June 2012

““KISS” : KISS” : Import old studies! Outside studies reduce new by: Import old studies! Outside studies reduce new by: 17% overall 17% overall

CT: 29% CT: 29% Sodickson, Opraseuth, LedbetterSodickson, Opraseuth, Ledbetter; ; RADIOLOGY 2011:260 (2)RADIOLOGY 2011:260 (2)

Remember one does not ‘Remember one does not ‘ORDERORDER an exam’, an exam’,

one ‘one ‘REQUESTSREQUESTS a CONSULT’ a CONSULT’

Consulting Radiologist Consulting Radiologist needs info. to confirm:needs info. to confirm:

Correct study requestedCorrect study requested

Correct Pt. Correct Pt.

Meds, allergies, status, caveats Meds, allergies, status, caveats

Cost/benefit ratio favors the patient:Cost/benefit ratio favors the patient:

Risk, dose, pain, complications, sometimes $$Risk, dose, pain, complications, sometimes $$

‘ ‘Will it alter management?’ If not—NO!Will it alter management?’ If not—NO!

DNR, religious beliefs, life expectancy…DNR, religious beliefs, life expectancy…

Info already known or available (old images)Info already known or available (old images)

The Imaging RequisitionThe Imaging Requisition

Electronic, faxed, written….. Varies, morphs oftenElectronic, faxed, written….. Varies, morphs oftenPt. Name – MRN – DOB – Location Pt. Name – MRN – DOB – Location (wrist band, paperwork, chart)(wrist band, paperwork, chart)

Deal-breakersDeal-breakers = Misspelling, mismatches = Misspelling, mismatches

Contact/Requesting Clinician, ACCURATE phone, page:Contact/Requesting Clinician, ACCURATE phone, page:

Questions before test performedQuestions before test performed

URGENT findings, emergenciesURGENT findings, emergencies

Females of child-bearing age (~9 to 90): Pregnancy statusFemales of child-bearing age (~9 to 90): Pregnancy status

Known allergies Known allergies

Known caveats or contraindications (dialysis stent, implants, Known caveats or contraindications (dialysis stent, implants, metal, 1 day post-op, deaf, non-English speaking…)metal, 1 day post-op, deaf, non-English speaking…)

Imaging Request asks a questionImaging Request asks a question “Worry/Don’t Worry”“Worry/Don’t Worry”

““Normal/Abnormal” Normal/Abnormal” (old images!)(old images!)

““Better/Worse” Better/Worse” (size, radiodensity, signal, fluid…)(size, radiodensity, signal, fluid…)

““Bigger/Smaller/Unchanged” Bigger/Smaller/Unchanged”

Narrow or confirm initial DDxNarrow or confirm initial DDx Better localize a finding Better localize a finding (in 3D, organ, tissue, …)(in 3D, organ, tissue, …)

Better characterize a finding Better characterize a finding (cystic, solid,…)(cystic, solid,…)

Requistion: Clinical InfoRequistion: Clinical Info Concise and Precise Concise and Precise (“G.I.G.O.”)(“G.I.G.O.”)

“ “Fx”,“R/O”,“Pain”,“Fell” … inadequate!Fx”,“R/O”,“Pain”,“Fell” … inadequate!

Localize with ONE finger Localize with ONE finger

Describe mechanism/force if trauma:Describe mechanism/force if trauma: “ “MVC” MVC” vsvs “Belted passenger, T-boned on R high veloc.’ “Belted passenger, T-boned on R high veloc.’

oror ”Pedestrian, struck laterally in parking lot, ”Pedestrian, struck laterally in parking lot, landed on/pain R hip”landed on/pain R hip”

Time frameTime frame: : new; older; chronicnew; older; chronic

‘Today…5 days ago… ‘Today…5 days ago…4 months4 months…..…..5 years……’5 years……’

Give us Give us adequate info adequate info andand query, query,notnot a protocol a protocol

Clinical info, DDx, concerns, clues, labs, queryClinical info, DDx, concerns, clues, labs, query Let Let usus protocol the technical details of exam protocol the technical details of exam Let Let usus decide on which machine decide on which machine (esp. CT, MR) (esp. CT, MR)

CT: CT: “R/O intracranial bleed, fell 8 ft, LOC“R/O intracranial bleed, fell 8 ft, LOC”, ”,

notnot just “Dry head CT, reformats” w/o clinical info just “Dry head CT, reformats” w/o clinical info

MRMR: : “Adenoca lung, confusion, R/O brain mets”; “Adenoca lung, confusion, R/O brain mets”; notnot ‘T1, T2, brain w/, w/o, contrast”, no other info ‘T1, T2, brain w/, w/o, contrast”, no other info

INTRODUCTORY MSK INTRODUCTORY MSK IMAGING: ‘IMAGING: ‘Don’t Panic’Don’t Panic’

Musculoskeletal Imaging:Musculoskeletal Imaging:

Bones Bones (cortical, articular, marrow, physis)(cortical, articular, marrow, physis)

Joints Joints (cartilage, ligament, tendon, fluid) (cartilage, ligament, tendon, fluid)

Ligaments, Tendons Ligaments, Tendons (XR, MR) (XR, MR)

Cartilage Cartilage (articular, meniscal, fibro-: (articular, meniscal, fibro-: XRXR, , MR, CT,)MR, CT,)

Soft tissue Soft tissue (muscle, fascia, fat: (muscle, fascia, fat: XR, CT, MR, US)XR, CT, MR, US)

Vascular Vascular (vessels, blood supply: (vessels, blood supply: XRXR,,CT, MR, USCT, MR, US))

Neurography Neurography ((MR)MR)

MSK Imaging: MSK Imaging: cost/benefitcost/benefit

Pediatric vs Adult Pediatric vs Adult (hip, appx, brain: US v CT)(hip, appx, brain: US v CT)

Fertility, Life expectancyFertility, Life expectancy DDx (differential diagnosis)DDx (differential diagnosis)

TraumaTrauma

Infectious/inflammatoryInfectious/inflammatory

NeoplasticNeoplastic

VascularVascular

IatrogenicIatrogenic

Arthritis, connective tissueArthritis, connective tissue

Metabolic Metabolic

Developmental/congenital/geneDevelopmental/congenital/genetictic

Normal or Nl. VariantNormal or Nl. Variant

MSK ImagingMSK Imaging Tx- and Dx-SpecificTx- and Dx-Specific

DDxDDx (differential diagnosis)(differential diagnosis)

Trauma Trauma (acute, chronic, velocity or force)(acute, chronic, velocity or force)

Infectious/inflammatory Infectious/inflammatory (acute, chronic, (acute, chronic, immunocomp.)immunocomp.)

Neoplastic Neoplastic (new, treated, recurrent)(new, treated, recurrent)

VascularVascular

Iatrogenic Iatrogenic (surgery, foreign matter, Rx)(surgery, foreign matter, Rx)

Arthritis, connective tissueArthritis, connective tissue

Metabolic Metabolic Developmental/congenital/geneDevelopmental/congenital/genetictic

Imaging techniques, equipment, changing rapidly. . Unlikely a non-Radiologist canUnlikely a non-Radiologist can keep up; even Radiologists keep up; even Radiologists are scrambling. are scrambling. On-line Mind Palaces….On-line Mind Palaces….

Give us adequate info, query; not a protocol

Modalities: ‘First Things First’Modalities: ‘First Things First’Short-cuts counterproductive Short-cuts counterproductive

RADIOGRAPHYRADIOGRAPHY (conventional images) remains (conventional images) remains the gateway to (MSK) imaging assessment. the gateway to (MSK) imaging assessment.

It is It is NOTNOT going away going away..

XR plus Time may still XR plus Time may still

Trump Tissue, MR, CTTrump Tissue, MR, CT

RADIOGRAPHY:RADIOGRAPHY:“One View Is No View” “One View Is No View”

Once a study indicated – Once a study indicated – nono shortcuts. shortcuts.

Not for age, gender, cost, dose…….Not for age, gender, cost, dose……. Many findings underwhelm on one viewMany findings underwhelm on one view Complex 3D structures need 2 Views Complex 3D structures need 2 Views

Fractures, DislocationsFractures, Dislocations

Toddler’s FractureToddler’s Fracture

Slipped Capital Femoral EpiphysisSlipped Capital Femoral Epiphysis

CT vs MR: CT vs MR: pro/compro/com CTCT:: Rapid (7 seconds) Rapid (7 seconds) movement, cooperationmovement, cooperation

Freely reformattableFreely reformattable

Windows ex post factoWindows ex post facto

Superb resolutionSuperb resolution

Contrast rxn. rareContrast rxn. rare

Metal can be imaged Metal can be imaged

High-dose radiationHigh-dose radiation

Metal can degrade image Metal can degrade image

Expensive but ~$1/2 MRExpensive but ~$1/2 MR

MRMR:: No radiation No radiation

Contrast rxn. v. rareContrast rxn. v. rare

Superb soft tx. info.Superb soft tx. info.

“ “WYSIWYG” WYSIWYG” per sequenceper sequence

Much slower (45-90 min)Much slower (45-90 min)

ClaustrophobicClaustrophobic

Metal = abs. contraindx, 2xMetal = abs. contraindx, 2x

Less resolution Less resolution

Expensive (~2x CT)Expensive (~2x CT)

Weight, size limits: bothWeight, size limits: both

CT vs MR: What is the Question? CT vs MR: What is the Question?

CTCT: “4 Bs” radiodense: “4 Bs” radiodense

BoneBone

Blood Blood ((acuteacute hemorrhage) hemorrhage)

Bullets and metalBullets and metal

Barium (Barium (ie contrast)ie contrast)

Lung and chest Lung and chest

Cancer stagingCancer staging

Speed overcomes motionSpeed overcomes motion

MRMR::

Soft tx– ligament, muscle, Soft tx– ligament, muscle, tendon, cartilage, tendon, cartilage,

muscle, neural, muscle, neural, tumor tumor

Molecular differencesMolecular differences

Better soft tissue detailBetter soft tissue detail

Direct multiplanar Direct multiplanar

Non-polarNon-polar materials not visualized materials not visualized ie, bone (calcium).ie, bone (calcium).

<-- CT MR

CT MR

US: When and Where?US: When and Where?MSK: CurrentlyMSK: Currently limited in adults; rapidly changing limited in adults; rapidly changing

PROPRO:: Portable Portable

Safe (no dose no risk), Safe (no dose no risk), Far less expensiveFar less expensive

GYN, Doppler flowGYN, Doppler flow EchocardiographEchocardiograph RUQ abdomenRUQ abdomen Bx, line placement,‘taps’ Bx, line placement,‘taps’

(pleural, abscess, joints)(pleural, abscess, joints)

DVT: DVT: proximal extremitiesproximal extremities Breast: Breast: cyst vs solidcyst vs solid

CON:CON: Fat, bone, air, metal,Fat, bone, air, metal,

all block USall block US Low resolutionLow resolution Highly user-dependentHighly user-dependent Non-intuitive Non-intuitive (‘weather maps’)(‘weather maps’)

Rheumatoid arthritis.

Gutierrez M et al. Ann Rheum Dis 2011;70:1111-1114©2011 by BMJ Publishing Group Ltd and European League Against Rheumatism

US: Soft tissue, FlowUS: Soft tissue, FlowBarriers: Bone, Fat, metal, air…Barriers: Bone, Fat, metal, air…

ACR ACACR ACAmerican College of Radiology Appropriateness CriteriaAmerican College of Radiology Appropriateness Criteria

www.acr.orgwww.acr.org

Evidence-based guidelinesEvidence-based guidelines to choose imaging to choose imaging

200 Dx with 900 scenarios/variants; referenced200 Dx with 900 scenarios/variants; referenced

Relative Radiation Risk Relative Radiation Risk each studyeach study Modality guidelines Modality guidelines CT, MR, US, Nucs, PET,…CT, MR, US, Nucs, PET,… Practice GuidelinesPractice Guidelines: When : When (in what order) (in what order) to perform:to perform:

Radiography, CT, MR of the extremitiesRadiography, CT, MR of the extremities

Spine Radiography, CT, MRSpine Radiography, CT, MR

Scoliosis radiographyScoliosis radiography

(Portable chest, Abdominal radiography, hysterosalpingograms, Dxc Ct, Pediatric CT, (Portable chest, Abdominal radiography, hysterosalpingograms, Dxc Ct, Pediatric CT,

Ct colonoscopy, MR knee, MR brain, US, …) Ct colonoscopy, MR knee, MR brain, US, …)

Varied Clinical Scenarios per DDxVaried Clinical Scenarios per DDx

200 Dx with 900 variants (modifiers)200 Dx with 900 variants (modifiers); eg:; eg: Blunt Chest TraumaBlunt Chest Trauma: 3 variations per clinical/XR: 3 variations per clinical/XR

Acute hip pain, suspected fx.: Acute hip pain, suspected fx.: 2 variations, 4 pgs discussion 2 variations, 4 pgs discussion

Acute shoulder painAcute shoulder pain

Chronic wrist painChronic wrist pain

Chronic neck painChronic neck pain

Imaging after arthroplasty (joint replacement)Imaging after arthroplasty (joint replacement)

Non-traumatic knee painNon-traumatic knee pain

Soft tissue massesSoft tissue masses

Suspected avascular necrosis Suspected avascular necrosis

““Acute Shoulder Pain”Acute Shoulder Pain”Initial =s XR, Initial =s XR, thenthen branches into detailed specifics branches into detailed specifics

Acute shoulder pain Acute shoulder pain (leave choice of initial XR views to us) (leave choice of initial XR views to us)

‘‘Any etiology, initial study’: Any etiology, initial study’: XR=9(best)XR=9(best); ; CT, MR, US=1(worst)CT, MR, US=1(worst)

‘ ‘XR neg, significant persistant pain’XR neg, significant persistant pain’ MR (9)MR (9); CT (5); CT (5)

‘ ‘XR neg, under 35, suspect labral tear’XR neg, under 35, suspect labral tear’ MR arthrog(9MR arthrog(9), MR(7), CT(5) ), MR(7), CT(5)

‘ ‘XR neg, prior rotator cuff repair, suspect re-tear ‘XR neg, prior rotator cuff repair, suspect re-tear ‘ MR (9) w. or w/oMR (9) w. or w/o

‘ ‘XR neg, suspect septic arthritis’ XR neg, suspect septic arthritis’ arthrocentesis (9)arthrocentesis (9), MR w&w/o (7), MR w&w/o (7)

Jumping straight to sophisticated imaging = mistake.Jumping straight to sophisticated imaging = mistake. Short-cuts, ‘time-savers’, pervert accurate diagnosis.Short-cuts, ‘time-savers’, pervert accurate diagnosis. Radiography (‘plain film”) NOT going away! Radiography (‘plain film”) NOT going away!

““LOW BACK PAIN”LOW BACK PAIN”80% of over-45 yo80% of over-45 yo

““Uncomplicated, no red flagsUncomplicated, no red flags(explained)(explained)”: ”: All imaging = ‘2’All imaging = ‘2’

‘‘With radiculopathy, surg. candidate”With radiculopathy, surg. candidate” MR w/o (8); MR w/o (8); CT (5)CT (5)

““Low-veloc trauma, osteoporosis, focal/progressive Low-veloc trauma, osteoporosis, focal/progressive deficit, prolonged sx, deficit, prolonged sx, oror >70 yo” >70 yo” XR then MRXR then MR

““Possible cancer, infection, and/or known Possible cancer, infection, and/or known immunosuppression” -> immunosuppression” -> MR w&w/o (8); MR w&w/o (8); MR w/o (7); CT(6); MR w/o (7); CT(6);

““Prior lumbar surgery” Prior lumbar surgery” MR w&w/o (8); MR w&w/o (8); MR w/o (6) CT (6)MR w/o (6) CT (6)

By the time you straighten this out…By the time you straighten this out…

Standard of Care (SOC) may have changed againStandard of Care (SOC) may have changed again

EPIPHANY: One need not understand EPIPHANY: One need not understand physics to request proper exam physics to request proper exam

Understand Understand what what each modality can/cannot do, not each modality can/cannot do, not ‘why’, nor ‘how’.‘why’, nor ‘how’.

Use resources– ACR AC, Radiologists– to confirm Use resources– ACR AC, Radiologists– to confirm appropriate next-step.appropriate next-step.

RESOURCES constant, ANSWERS change often. RESOURCES constant, ANSWERS change often. Commonly used studies will become familiar. Commonly used studies will become familiar. Less-common….won’t. Don’t worry. Less-common….won’t. Don’t worry.

ASK US!ASK US!

http://3rads.jhmi.edu/All imaging phone numbers All imaging phone numbers

WhenWhen to use contrast, to use contrast, whatwhat study to get, study to get, can be counter-intuitive and subtle.can be counter-intuitive and subtle.

Include us on the patient care team; we are Include us on the patient care team; we are CONSULTANTSCONSULTANTS, not lab techs. , not lab techs.

On-call techs, all modalities/subspecialties:On-call techs, all modalities/subspecialties:

use use 3Rads.jhmi.edu3Rads.jhmi.edu

Back-up: ask Emed Radiology Resident 7-5442 Back-up: ask Emed Radiology Resident 7-5442

Dxc. Imaging: Dxc. Imaging: TTW 2014TTW 2014

““REPETITION IS THE KEY TO LEARNING”REPETITION IS THE KEY TO LEARNING”

Intro to Chest Radiographs: Intro to Chest Radiographs:

The Ur-unit of imagingThe Ur-unit of imaging

Thank you!Thank you!Donna Magid, MD, M.EdDonna Magid, MD, M.Ed