orthopedics radiography sanil
TRANSCRIPT
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Musculoskeletal Imaging – The Basics
SANIL VARGHESE
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Musculoskeletal Imaging
Technology
Advances in Imaging
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MSK Imaging – Imaging Modalities
• Plain Radiographs• Nuclear Scintigraphy• Ultrasound• Computed Tomography• Magnetic Resonance Imaging
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Plain Radiographs
• Widely available• Reproducible• Patient friendly• ‘Inexpensive’• Usually the indicated primary
imaging modality
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Plain Radiographs
• Standard protocols available• Consider the pathology in question
– Image area of question, not the vicinity
• “One view is No view”• Supplemental views possible in
most locations
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Plain Radiographs - Obvious
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Plain Radiographs – 2 views
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Plain Radiographs – 2 views
Posterior Dislocation
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Plain Radiographs – Extra views
Radial Head Fx
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Plain Radiographs – Extra viewsScaphoid Fx
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Nuclear Scintigraphy
• Most common = Bone Scan• Very sensitive for skeletal pathology• Mildly sensitive for soft tissue
pathology• Usually nonspecific as an isolated test• Mostly patient friendly; no significant
environmental exposure• Small-moderate expense
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Nuclear Scintigraphy
• Excellent for specific pathologies – Osteomyelitis– Metastases – Not Multiple myeloma– Occult fracture
• Reasonably reassuring– Normal is usually normal
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Nuclear scintigraphy – Bone Scan
• IV injection radioisotope (Tc-99m) bound to phosphate +/- dynamic imaging
• Approx 3 hour delay• Delayed static imaging with a
superficial detector
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Nuclear Scintigraphy – Bone Scan
Osteomyelitis
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Nuclear Scintigraphy
2nd MT stress fracture
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Ultrasound
• Not available at all institutions• Reproducible in trained hands• Excellent for superficial soft tissue
elements including tendons and muscle
• Patient friendly• Small to moderate expense
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Ultrasound
• Routine exam room equipped with adequate imaging devices
• Superficial gel (standard or aseptic) application with touch with transducer
• Usually static exam of architecture +/- vascularity assessment
• Potential for dynamic imaging
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Ultrasound
Ceph
Caud
Cephalad
Caudad
Calcaneus
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Ultrasound – Achilles Tendon
Intrasubstance tear
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Ultrasound – Patellar tendon
Proximal patellar tendonitis –
Jumper’s Knee
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Computed Tomography (CT)• Widely available• Reproducible, although variety of
techniques• Excellent bone assessment• Occasionally useful for soft tissue
assessment• Patient friendly• Moderate expense• Interventional options
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Computed Tomography
• Usually supine axial exam, with some alternative positioning options
• Can develop reformatted images after exam for alternative views
• Imaging time in seconds, rarely minutes
• Usually without IV or oral contrast
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CT - Fractures
Scaphoid fracture
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CT - Dislocation
Lis Franc Fx/Dislocation
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CT – Bony anomalies
Midsubtalar coalition
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Magnetic Resonance Imaging
• Widely available, but non-standardized imaging techniques
• Reproducible • Excellent for soft tissue pathology• Good-excellent for bone pathology• NOT patient friendly• Large expense
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MRI – Absolute Contraindications
• Cardiac Pacemakers• Electronic stimulators• Metallic foreign bodies in the orbit• Body habitus beyond limits of
physical unit• Huge listing maintained in MRI
facility
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MRI - Relative Contraindications
• Penile prostheses• IUD’s• Cardiac valves• Berry aneurysm clips• Retained bullet fragments• Claustrophobia• Huge listing in MRI facility
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MRI• Usually performed with patient supine• Multiplanar imaging obtained without
changing position• One exam = one body part• Average exam time 45 minutes; most
patients can’t last >2 hours• Strict guidelines for sedation• Optional contrast – Rad usually decides
for body imaging
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MRI – TraumaOsteochondritis dissecans
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MRI – Trauma
Femoral Neck Fracture
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MRI - Trauma
Tear vastus medialis
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MRI – Internal Derangement
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MRI – Internal DerangementSupraspinatus tear= Full thickness, Full width
Coronal PD Coronal T2
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MRI – Internal Derangement
Sagittal NL
Sagittal FT, FW Supra
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MRI – Internal Derangement
Sagittal, Meniscus NL
Posterior Horn Tear
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MRI – Internal DerangementBucket handle meniscal tear
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MRI – Internal Derangement
Sagittal – Intact ACL
Torn ACL
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Imaging• Plain radiographs are usually the
starting point• Most x-ray protocols work for most
situations; Consider suppl. Views• Secondary imaging techniques have
specific advantages and disadvantages• A specific question is more likely to get
you a direct answer• When in doubt, ask a Radiologist
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THANK YOU
Sanil Varghese