1

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Radiologic Technologist:-Training programs at the associate, certificate, or baccalaureate level

-Receive standard training in the physics

of radiology and anatomy for proper patient positioning

-Additional training for sonographers; MR

scanners

2

Radiologist-A medical physician.

-4 additional years of radiology

residencies after med school.

-Many continue with additional

years of subspecialty training.

1. The radiologist does not see or examine the patient.

2. The more info the radiologist has about the particular patient’s problem, the better they can suggest appropriate studies

3. Diagnostic imaging can provide clear and specific answers, but only in response to clear and specific clinical questions.

Transition and Expansion of Professional and

Educational Standards

3

Signs in physical therapy treatment booths,

directed to the Therapist

“NO TALKING TO THE PATIENT”

Evolving Since the 1970’s- Political and educational

enhancement

- Clinical decision making: Initial focus related to treatment decisions, with an assumption that good medical screening has occurred by the medical referral process

- Now by APTA accreditation standards, entry level programs are expected to prepare the clinician for practice without referral, and the associated need to effectively diagnose

APTA's Guide to Practice:

…integrate data from comprehensive screening….

…identify problems requiring consultation and referral to other professionals….

……diagnostic imaging information is an expected resource to be used in physical therapy strategies of practice……

4

State Practice RegulationsCA BUSINESS AND PROFESSIONS CODE

SECTION 2620-2622

2620. ……..The use of roentgen rays and radioactive materials, for diagnostic and therapeutic purposes …… are not authorized under the term "physical therapy" as used in this chapter……

“So, just this week I spent 45 minutes calming a patient down after the therapist I referred her to described what they thought was something

wrong on the X-ray to the patient!!!”

An orthopedic surgeon and friend

Not to order or interpret actual images

But to Understand: -when and why images are INDICATED

-the implications of imaging information related to the management and prognosis of the clinical presentation

5

X-rays

CT Scan

MRI

Bone Scan

Ultrasonaography

A. Basic physics

B. Procedures

C. Indications: -What can be visualized well? -Clinical questions to be addressed?

D. Costs, challenges and drawbacks

X-rays

CT Scan

MRI

Bone Scan

Ultrasonaography

6

1895 Wilhelm Roentgen (rent’gen)

German Physicist attributed with the discovery ofX-rays.

Known as: plain films radiographs radiograms

:

A form of ionizing electromagnetic radiation

Made by accelerated electrons hitting a tungsten target

Quality of image depends on kVolts, mA and exposure time

Depends on differential absorption by different tissues

From M Cameron

The work horse of

Medical Imaging:

Quick

Inexpensive

7

Primary value is in documenting bony defects.

Production of an X-ray requires 3 things:

An X-ray source

An object

(patient)

The image

receptor

(Film or digital)

Black White (Radiolucent) (Radiopaque)

Air Fat Blood Muscle Bone Lead

Low Molecular Weight High Molecular Weight

8

The Grey ScaleBone: white

Blood, muscle: grey

Fat: dark shadows

Air: black From Erkonen

Radiograph is viewed

as if the patient were

standing in front of

the viewer in anatomic

position

What is this??

9

A hollow plastic

cylinder

Minimum of

two views

always

neededFrom Richardson

AP (Anterior- Posterior) Lateral

Notch (Tunnel, Merchant) Sunrise View of Intercondyler Tangential view of

Fossa Patellofemoral joint

10

To understand thethree dimensional object being presented in a two dimensional Image

From McKinnis

From McKinnis

11

PT’s are pretty

comfortable

with visualizing

images of the

Musculoskeletal

System

Types of tests done?

A normal study, or Abnormalities reported? ◦ Structure

◦ Location

◦ Severity

Decision Making: do reported findings

Correlate with clinical signs and symptoms?

19 year old male soccer Player

c initial Dx of knee sprain

Acute contact knee injury-

hyperextended knee with

foot planted

Immediate effusion

Varus and valgus tests –

Lachmans -

Posterior sag -

12

Planted foot

Valgus internal

rotation stress

Immediate medial knee pain

Kneecap not in the

right place

Sulcus angle140 degrees or greater

Is a “shallow groove”

Congruence AngleA positive angle greater than 16 degrees

is associated with patellar instability

Patellar Tilt angle 10 degrees or greater is considered

abnormal

José Luis del Cura, MD, PhD

http://mariorad.com/lectures/mskexpert/data/html/app_1.html

A= Alignment

B= Bone Quality

C= Cartilage

S = Soft Tissues

13

Break or Irregularity in the cortex?

Deformity?

Sclerotic

Abnormally dense

Osteopenia

Abnormally lucent

Osteoporotic

14

Bone tumors Lytic Lesions Starburst

- Joint space width

- Subchondral bone

-Heterotrophic

bone formation

-Joint space narrowing

-Sclerotic bone

-Bone spurs

15

A-P Frog Leg

The ShadowsMuscles

Fat pads

Periosteum

Left hip radiograph shows: Lateral

subluxation

Periosteal

reaction of

femur

16

(from Chew: Musculoskeletal imaging)

Clinical Applications

Real time movement documentation

Flexion and extension c-spine

Wrist motions

Ankle stress

“Seeing the needle into the joint”

Septic hip aspiration studies

Spinal facet joint, S-I joint injections

Injection of a contrast material into a joint prior to imaging

17

X-rays

CT Scan

MRI

Bone Scan

Ultrasonaography

From M Cameron

From Erkonen

18

Standard x-ray CT scan- Axial slice

Background Radiation 0.01 mSv in 1 day

Cross country airline trip 4 days

CXR single 1 day

Extremity Xray 3 hours

XR Spine 6 months

CT Head 8 months

CT Abdomen 20 months

CT Spine 2 years

Advantages◦ Cross sectional

images◦ Can enhance with

contrast◦ Better sensitivity than

plain film x-ray◦ OK with metal◦ Fast

Disadvantages◦ High radiation

exposure

◦ Less sensitive than MRI for soft tissue

◦ Cost

19

X-rays

CT Scan

MRI

Bone Scan

Ultrasonaography

Use of Radiofrequency (RF) pulses

(radio waves)

Applied to the patient, within

static and gradient magnetic fields

The computerized collection of

MR pulse sequences (signal) provide

Soft tissue contrast (brightness)

No radiation

involved

Ideal for

soft tissue

contrasts

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Produces “slice” images

Can be in any plane

The grey scale does not apply

Any structure can be

highlighted

Posterior Cruciate (Intact)

Popliteal Vein

Anterior Cruciate(Intact)

A 22 y.o. bicyclist

Thrown from bike

Landed heavily on L hip

Pain, loss of mobility, and

Inability to walk

Differential?

21

- MR “scanner” (magnet) sends short bursts of radiofrequency waves into the body

- Such are absorbed by protons (hydrogen) which become energized (resonate)

- Once radio wave discontinued, resonated protons “relax” (decay), emitting radio signals back to the unit’s coil (radio wave receiver)

Emitted radio signals from tissue protons can be “read” (listened for) early (T1) or late (T2) in the decay sequence.

T1 sequence focuses

on Fat in tissue

T2 sequence focuses

on Water in tissue

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T1 Image- Fat is white

- Gray of soft tissue

detail is excellent

- Used when an anatomic

study is the focus

T2 Image- Water content is “lit up”

- overall “lighter greys”

- Used when looking for

pathology (inflammation,

bleeds)

Pregnancy (unless an emergency)

Surgical clips/implants of ferrous nature (cardiac pacemakers)

Exposure to foreign bodies in and about eyes (metal workers)

From M

Cameron

23

X-rays

CT Scan

MRI

Bone Scan

Ultrasonaography

A tool of nuclear

medicine.

A physiologic study.

Radioactive substances

injected into the

bloodstream

Patient is given a rapidly decaying radioisotope

Emitted radiation is detected

Highly sensitive

Very non specific

24

Thyroid masses – with radio-labeled iodine

Bone metastases from cancer – PET scan. A radio-labeled form of glucose (18 fluorodeoxyglucose) is administered. It decays by positron emission.

Lung circulation and ventilation – labeled Xenon

Used diagnostically in the suspicion of:

metastatic disease

stress fractures

osteomyelitis

loosening of implants

multiple trauma

X-rays

CT Scan

MRI

Bone Scan

Ultrasonaography

25

Use of high frequency

sound waves

Good for real time images

of soft tissues that are

-solid and uniform

-filled with fluid.

Highly operator dependent

Sends in ~ 35 MHz range US signals (transmitter)

Picks up (receiver) and examines timing and amplitude of the reflections for echo, examines frequency change for doppler

Produces a 2-D image in real time, can be moving

Fetus

Children

Abdominal organs – gall stones,

kidneys, pelvic organs/masses

Aorta – aortic aneurysms

Blood flow (with doppler)

26

Advantages◦ Biologically harmless◦ Records and displays

motion◦ Requires no contrast◦ Portable◦ Distinguishes solid

from fluid

Disadvantages◦ Does not penetrate

bone well◦ Does not go through

air/gas◦ Skill dependent

What body region is being displayed?

What imaging modality was used?

Is there obvious clinical pathology present?

-What clinical signs and symptoms would

correlate with radiographic findings?

-Implications and prognosis in management?

27

Sal – a 34 yo healthy male

Trauma to R LE 3 years ago

playing soccer . Minimal medical

Care. No rehab

Ambulates with a marked limp over R

Can not ascend stairs over R

R leg 1 ¼ “ shorter than L

Patellar deformity

Marked atrophy R quads

R knee passive flexion to

100 degrees

Old Femur Fx with

Mal union

Old Old patellar Fx

with Non union

19 year old male football

lineman

Acute contact knee injury-

Foot planted at bottom of

the pile

Immediate effusion

Varus and valgus tests +

Lachmans +

+ posterior sag

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Following trauma to the knee, obtain

radiographs if….

-55 years or older

-12 years or younger

-Tender at fibular head

-Isolated patellar tenderness

-Can not flex beyond 90 degrees

-Can not weight bear more than 4 steps

97% sensitive, 27% specific- (Seaburg 1998)

X-rays and CT scan rules out bone involvement

Does not rule out injury to :

Ligaments Hx of:

Meniscus Swelling

Cartilage LockingBuckling

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41 year old winery worker fell and landed wrong from 3 foot platform c initial Dx of R knee sprain

X-rays negative

Effusion within 2 hours

Varus and valgus tests -

Lachmans +

Posterior sag -

41 year old winery worker’s twin brother twisted while rising from a prolonged squat position c initial Dx of R knee sprain

X-rays negative

Effusion within 24 hours

Varus and valgus tests –

Lachmans –

Posterior sag -

McMurry +

(from Chew: Musculoskeletal Imaging)

17 y.o. skateborder who fell and landed hard on concrete steps 6 months ago . Was not wearing

knee pads. Initial Dx of R

knee sprain

Initial X-rays questionable

Effusion within 48 hours

Varus and valgus tests –

Lachmans –

Posterior sag -

McMurry +

from Chew: Musculoskeletal Imaging

30

14 y.o. female soccer player who sustained a valgus injury to knee 6 weeks ago. Still quite painful. Initial Dx of R MCL sprain

X-rays negative

Effusion within 12 hours

Varus – Valgus initially +; now -

Lachmans – Posterior sag -

McMurry -

Still quite tender about medial

condyles of knee (from Chew: Musculoskeletal Imaging)

-15 y.o muscular male

-Has been training heavily

in gym for upcoming

football season

-insidious onset

infrapatellar knee pain

69/M avid basketball player

Pain along joint lines limiting activity

Catching and popping

EXAM:No effusion Ligamentous exam stable

ROM 0-130 + crepitations

Patellar grind+

31

- 32 yo female school teacher training for

marathon

- Insidious onset of R hip, groin pain over the

past 6 months

- X-rays across lower spine and hips negative.

-10 week course of NSAIDS and PT for tendonitis

and lower quarter muscle imbalances not helpful

Differential?Suggested course of further work up ?

(from Chew: Musculoskeletal imaging)

32

Thorough history and exam is the

foundation of clinical diagnosis.

Form a differential diagnosis.

Tailor imaging investigations to your DDX list.

Start with simplest investigations first.

Think of risks/ contraindications.

garyl@csufresno.edu