msk radiology - common cases · novelline, robert. squire’s fundamentals of radiology, 6th ed....
TRANSCRIPT
![Page 1: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/1.jpg)
1
![Page 2: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/2.jpg)
MSK Radiology - Common Cases
Mark H. Mirabelli, MD, FAAFP
Associate Professor, Departments of Orthopaedics, Family Medicine and Physical Medicine and Rehabilitation
University of Rochester
![Page 3: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/3.jpg)
Disclosures, Affiliations, Acknowledgments
I have no relevant financial disclosures
Program Director: UR Primary Care Sports Medicine Fellowship
Faculty: URMC Sports Concussion Center, Hip and Knee Arthritis Clinic
Team Physician: St John Fisher College, Rochester Knighthawks,
SUNY Geneseo, US Lacrosse
Ringside Physician for New York State and Seneca Nation Athletic
Commissions
![Page 4: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/4.jpg)
Goals and Objectives
•Describe the role of diagnostic imaging as an extension of the physical
exam
•Review the indications for x-ray
•Describe different x-ray views, why they are used and their
interpretations
•Differentiate indications and contraindications for advanced diagnostic
imaging such as US, MRI, CT and nuclear
•Recognize the growing utility of point of care MSK ultrasound
•Discuss application of MSK radiology and findings in common cases
4
![Page 5: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/5.jpg)
Case 1 – Ankle Pain
5
•21 year male soccer player twists ankle while running,
feels a pop
•PMHx unremarkable
•Having a hard time walking
•Physical exam shows tenderness over lateral malleolus
•Foot and ankle are swollen diffusely
•What to do next?
![Page 6: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/6.jpg)
Ottawa Ankle Rules
![Page 7: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/7.jpg)
Xray Basics
• “Plain film” / radiography / xray
•Oldest and most commonly used technology in
medical imaging
•Discovered by Wilhelm Rontgen in 1895
earning Nobel Prize
•Utilizes electron sourced ionizing radiation to
penetrate soft tissue and evaluate bone (50%
total dose yearly)
•Same basic technology for ”plain film”,
computed tomography (CT) and fluoroscopy7Image from Wikipedia
![Page 8: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/8.jpg)
X-ray Radiation
8Image from Wikipedia
![Page 9: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/9.jpg)
X-Ray Basics
•Any patient with “significant” trauma should have plain films done
•Consider imaging for pain > 6 weeks without trauma
•Any patient with concern for cancer or infection
•Quality of plain films altered by:
• Positioning – often limited with injury/pain
• Habitus
• Atypical anatomy/biomechanics
•Always look at your own films!
• Clinical correlation adds a lot to the image
• Be clear when ordering “evaluate for “
![Page 10: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/10.jpg)
X-Ray Basics
Findings in Fracture
• Cortical interruption
• Deformity
• Periosteal reaction (Stress or
insufficiency)
Findings for Tendon and cartilage injury
• Enthesophytes (spurs)
• Calcific tendonitis
• High riding humeral head (RTC tear)
• Patella alta (quad or patellar tendon tear)
• Chondrocalcinosis (OA or CPPD)
Findings in OA
• Joint space narrowing
• Subchondral sclerosis
• Osteophytes (spurs)
• Subchondral cysts
![Page 11: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/11.jpg)
Ankle/Foot
Why order plain films
•Trauma
• Ottawa ankle and foot rules
•Chronic pain that isn’t responding to conservative
therapy
Why order MRI
•Pain that isn’t responding to conservative therapy and
more significant injury is suspected
![Page 12: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/12.jpg)
Ankle/Foot
When to order plain films
• Immediately for any trauma that meets Ottawa Criteria or
there is deformity, etc.
•After no improvement from a course of conservative
treatment
When to order MRI
•After course of conservative treatment and a more
significant injury is suspected
![Page 13: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/13.jpg)
Ankle/Foot
What films to order – Ankle
• AP, lateral and mortise – on all patients
• Weight bearing AP and lateral – if OA suspected
What films to order – Foot
• AP, lateral and oblique
• Weight bearing AP and lateral – if OA is suspected
![Page 14: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/14.jpg)
AP and Lateral Views of the Ankle
www.e-radiography.net
![Page 15: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/15.jpg)
Mortise View of the Ankle
http://uwmsk.org/RadAnatomy.html
15- 20 degree medial rotation
![Page 16: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/16.jpg)
Ankle
AP vs Mortise
![Page 17: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/17.jpg)
Foot
AP/lat/oblique
![Page 18: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/18.jpg)
AP and Lateral of the Foot
www.e-radiography.net
![Page 19: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/19.jpg)
Oblique View of the Foot
www.e-radiography.net
![Page 20: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/20.jpg)
What do you see?
20
![Page 21: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/21.jpg)
Weber Fracture Classification
21
![Page 22: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/22.jpg)
Case 2 – Foot Pain
22
•23 year female dance twists ankle landing awkwardly
from a leap, feels a sharp pain in her lateral foot
•PMHx unremarkable
•Having a hard time walking
•Physical exam shows tenderness over 5th Metatarsal
•Foot is mildly swollen
•What to do next?
![Page 23: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/23.jpg)
Ottawa Foot Rules
![Page 24: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/24.jpg)
What do you see?
24
![Page 25: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/25.jpg)
Other possible x-ray outcome
25
![Page 26: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/26.jpg)
Types of Proximal 5th Metatarsal Fractures
26
![Page 27: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/27.jpg)
Case 3 – Shin Pain
27
•57 year white female runner complains of progressive
left shin pain over several weeks, no trauma
•PMHx - postmenopausal
•Physical exam shows tenderness over midshaft tibia
•What to do next?
![Page 28: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/28.jpg)
Tibial stress fracture
28
![Page 29: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/29.jpg)
But what if it shows this….
29
![Page 30: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/30.jpg)
Why get a CT scan?
•Calcaneal fractures
•Fracture severity for surgical planning (e.g.
depressed tibial plateau)
•Neck fracture concern (time sensitive)
• If a patient can’t have a MRI (pacemaker,
metal)
•Sternoclavicular joint
•CT myelogram in spine
•CT with 3D reconstruction for complex
anatomy
![Page 31: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/31.jpg)
Why get an MRI?
•Soft tissue tears and strains, sprains
•Concern for missed fracture on x-
ray including stress, insufficiency
•Concern for tumor (benign or
malignant)
•Concern for infection
![Page 32: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/32.jpg)
MR or CT with contrast
32
• IV contrast
• Infection
• Inflammation
• Cartilage Degeneration (DGEMRIC)
• Malignancy
• Vascular injury
• Oral contrast
• Intraarticular - Arthrogram
• Myelogram
![Page 33: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/33.jpg)
MRI safety considerations
33
• Caution with CKD or AKI (GFR needs to be > 30) for
contrast use
• Ask patient about metal fragments (bullets, shrapnel,
shavings, etc) – may need xray first
• Metal contraindication if near vessels, nerves, eyes or
hollow viscous, no concern in bone
• Pacemaker and AICD, aneurysm clips and pain pump
safety- consult with manufacturer
![Page 34: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/34.jpg)
Why get a Bone Scan?
•When you can’t do an MRI and are concerned for fracture
•Rapidly becoming extinct in orthopaedics
•Continued use in oncology
![Page 35: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/35.jpg)
Tibial Stress Fracture
35
![Page 36: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/36.jpg)
Case 4 – Shoulder Pain
36
•48 year male construction worker complains of acute on
chronic right shoulder pain, sharp pain recently while
lifting
•PMHx - smoker
•Physical exam shows + impingement and + drop arm
test
•What to do next?
![Page 37: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/37.jpg)
Shoulder
Why order plain films•Trauma/acute injury – order at time of exam•Look for fracture, dislocation•Presentation of radicular symptoms•Chronic pain >6 weeks that isn’t responding to conservative therapy, looking for OA, crystal diseases, tumor, chronic RTC disease
Why order MRI•Suspicion of RTC tear- order at time if suspected massive tear
•Chronic pain > 6 weeks with negative x-rays•Suspicion of labral injury (get MRI Arthrogram)
Why order U/S•Suspicion of RTC tear (only in some markets)•Dynamic studies for impingement, biceps subluxation
![Page 38: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/38.jpg)
Shoulder
What films to order
• AP and a lateral view – on all patients
• Lateral views include: axillary, scapular Y
• Supraspinatus outlet view – shoulder impingement/RC
tendinopathy
• Clavicle views – with clavicle injury
• AC joint Views – with AC injury (shoulder separation
![Page 39: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/39.jpg)
Shoulder views
ER: can see Hill-Sachs/humeral head
Axillary view: Hill-Sachs, OA
Y/scapula view: scapular fractures
![Page 40: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/40.jpg)
AP vs. “True AP”
www.orthop.washington.edu
www.e-radiography.net
![Page 41: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/41.jpg)
Axillary
www.e-radiography.net
![Page 42: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/42.jpg)
Scapular Y View
www.e-radiography.net
![Page 43: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/43.jpg)
Scapular Y for dislocation
![Page 44: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/44.jpg)
Supraspinatus Outlet View
www.ORIF.com
![Page 45: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/45.jpg)
Clavicle
AP
Zanca view
![Page 46: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/46.jpg)
AC Joint View
www.e-radiography.net
![Page 47: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/47.jpg)
Sternoclavicular Joint
Anterior 2/3
CT is best for SC dislocation or fracture
Serendipity view
![Page 48: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/48.jpg)
What do you see? What next?
48
![Page 49: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/49.jpg)
Why get an US
49
• If you can perform the test yourself at time of
service
• Less expense
• Faster to obtain
• Excellent soft tissue resolution
• Dynamic exam
• If patient cannot have an MRI for a soft tissue
injury
•Operator dependent – not every radiology office
can provide, emerging popularity with sports
medicine, PMR, rheumatology and orthopaedics
![Page 50: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/50.jpg)
Ultrasound results
50
![Page 51: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/51.jpg)
Case 5 – Knee Pain
51
•68 year male golfer complains of acute bilateral knee
pain s/p fall while walking on the course
•PMHx – hip osteoarthritis
•Physical exam shows bilateral knees with mild effusions
and joint line tenderness
•What to do next?
![Page 52: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/52.jpg)
Knee
Why order plain films•Trauma•Chronic pain that isn’t responding to conservative therapy
Why order CT•Tibial plateau fracture
Why order MRI•Suspect internal derangement that needs surgery•Patient isn’t responding to conservative treatment and something more serious is suspected
![Page 53: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/53.jpg)
Knee
When to order plain films•Immediately for any trauma –Ottawa Knee rules•At presentation for suspected OA•After course of conservative treatment for young patients
When to order MRI•At presentation for probable internal derangement that needs surgery
•After course of conservative treatment that fails for young patients (not typically helpful if OA is the etiology)
![Page 54: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/54.jpg)
Ottawa Knee Rules
XR knee for acute injury if
meets 1 of the following
criteria:
•>55 y/o
• Isolated tenderness of patella
•Tenderness of head of the fibula
• Inability to flex knee to 90 degrees
• Inability to bear weight for 4 steps
![Page 55: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/55.jpg)
Knee
What films to order
•AP, lateral, merchant – on all patients
•Weightbearing if possible
•Oblique view for trauma for fibular head and tibial
plateau
•Weight-bearing PA (Skier’s view or Tunnel or
Rosenberg views) – on all patients over age 40
and those with suspected OA
•With comparison view
![Page 56: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/56.jpg)
Knee AP
Arthritis views are
weightbearing
![Page 57: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/57.jpg)
AP vs Tunnel (Flexion PA/ Skier’s / Notch)
www.e-radiography.net
![Page 58: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/58.jpg)
Lateral and Merchant Views
www.ORIF.com
![Page 59: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/59.jpg)
What do you see?
![Page 60: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/60.jpg)
Cardinal signs of osteoarthritis
60
![Page 61: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/61.jpg)
Case 6 – Wrist Pain
61
•33 year female complains of acute left wrist pain
following trauma – fall on outstretched hand (“FOOSH”
•PMHx - unremarkable
•Physical exam shows tenderness over anatomic
snuffbox
•What to do next?
![Page 62: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/62.jpg)
Hand/Wrist
Why order plain films
•Trauma/acute injury
•Chronic pain that isn’t responding to conservative therapy
Why order MRI
•Suspicion of more significant soft tissue injury
•Suspicion of scaphoid fracture not seen on plain film
•Evaluation of AVN of scaphoid with nonunion
Why order CT
•Evaluation of nonunion of scaphoid
![Page 63: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/63.jpg)
Hand/Wrist
When to order plain films
• Immediately for any trauma
•After course of conservative treatment for pain (acute or
chronic without trauma)
When to order MRI
•After a course of conservative treatment if scaphoid fracture
is suspected and plain films remain negative
When to order CT
•After course of appropriate treatment for scaphoid fracture
and pain remains (nonunion vs. AVN)
![Page 64: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/64.jpg)
Hand/Wrist
What films to order - Wrist
•PA, lateral and oblique views – on all patients
•Scaphoid view – if fracture suspected
What films to order – Hand
•PA, lateral and oblique views – on all patients
•Fingers – as warranted for finger injuries
![Page 65: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/65.jpg)
PA and Lateral Wrist Views
www.auntminnie.comwww.e-radiograph.net
![Page 66: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/66.jpg)
Oblique Wrist and Scaphoid Views
www.e-radiography.net
![Page 67: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/67.jpg)
PA and Fan Lateral Hand Views
www.auntminnie.com
![Page 68: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/68.jpg)
Oblique Hand View
www.auntminnie.org
![Page 69: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/69.jpg)
Ball-Catcher (Norgaard’s) View
69
• Hands are in a “ball-catching” position
• Best view to look for early erosions at the base corners of the proximal phalanges
![Page 70: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/70.jpg)
70
![Page 71: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/71.jpg)
71
![Page 72: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/72.jpg)
Conclusion
Common cases to illustrate use of MSK Radiology
Important to order the proper views
Important to get weight bearing views for lower extremity OA eval
Get x-ray films regularly
Use judgement on when to get advanced imaging
Important to review your own films to correlate with what you are seeing
clinically
![Page 73: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/73.jpg)
Educational Websites
•http://www.learningradiology.com
•http://uwmsk.org/RadAnatomy.html
•https://radiopaedia.org/encyclopaedia/all/musculoskeletal
•https://skeletalrad.org/web-resources
•http://www.radiologyassistant.nl/en/
•http://www.wikiradiography.net
•http://xrayhead.com
•https://www.radiologymasterclass.co.uk/
73
![Page 74: MSK Radiology - Common Cases · Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004 Johnson, TR and Steinbach L. Essentials of Musculoskeletal](https://reader033.vdocument.in/reader033/viewer/2022042710/5f69e6f5a2836032bc66e5db/html5/thumbnails/74.jpg)
References
Bernstein JB. Musculoskeletal Medicine, American Academy of Orthopaedic Surgeons, American Academy of Family Physicians, American Academy of Pediatrics 2003
Armstrong, A and Hubbard M. Essentials of Musculoskeletal Care 5th Edition, American Academy of OrthopaedicSurgeons, American Academy of Pediatrics 2015
Hoppenfeld S. Physical Examination of the Spine & Extremities, Appleton 1979.
Novelline, Robert. Squire’s Fundamentals of Radiology, 6th Ed. Harvard University Press, 2004
Johnson, TR and Steinbach L. Essentials of Musculoskeletal Imaging, American Academy of Family Physicians, American Academy of Pediatrics 2003
Hollenberg, G, Weinberg, E, and Myers, S. Differential Diagnosis in MSK MRI. Thieme, 2015.
Jacobson, J. Fundamentals of MSK Ultrasound, 3rd Ed. Elsevier, 2017.