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Musculoskeletal Imaging The Basics Laurie Lomasney, MD Department of Radiology Loyola University Medical Center

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Page 1: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

Musculoskeletal Imaging – The Basics

Laurie Lomasney, MDDepartment of Radiology

Loyola University Medical Center

Page 2: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

Musculoskeletal Imaging

Technology

Advances in Imaging

Page 3: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

MSK Imaging – Imaging Modalities

• Plain Radiographs• Nuclear Scintigraphy• Ultrasound• Computed Tomography• Magnetic Resonance Imaging

Page 4: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

Plain Radiographs

• Widely available• Reproducible• Patient friendly• ‘Inexpensive’• Usually the indicated primary

imaging modality

Page 5: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

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

Page 6: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD
Page 7: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

Plain Radiographs - Obvious

Page 8: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

Plain Radiographs – 2 views

Page 9: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

Plain Radiographs – 2 views

Posterior Dislocation

Page 10: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

Plain Radiographs – Extra views

Radial Head Fx

Page 11: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

Plain Radiographs – Extra viewsScaphoid Fx

Page 12: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

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

Page 13: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

Nuclear Scintigraphy

• Excellent for specific pathologies – Osteomyelitis– Metastases – Not Multiple myeloma– Occult fracture

• Reasonably reassuring– Normal is usually normal

Page 14: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

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

Page 15: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD
Page 16: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

Nuclear Scintigraphy – Bone Scan

Osteomyelitis

Page 17: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

Nuclear Scintigraphy

2nd MT stress fracture

Page 18: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

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

Page 19: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

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

Page 20: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD
Page 21: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

Ultrasound

Ceph

Caud

Cephalad

Caudad

Calcaneus

Page 22: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

Ultrasound – Achilles Tendon

Intrasubstance tear

Page 23: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

Ultrasound – Patellar tendon

Proximal patellar tendonitis –

Jumper’s Knee

Page 24: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

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

Page 25: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

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

Page 26: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD
Page 27: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

CT - Fractures

Scaphoid fracture

Page 28: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

CT - Dislocation

Lis Franc Fx/Dislocation

Page 29: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

CT – Bony anomalies

Midsubtalar coalition

Page 30: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

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

Page 31: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

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

Page 32: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

MRI - Relative Contraindications

• Penile prostheses• IUD’s• Cardiac valves• Berry aneurysm clips• Retained bullet fragments• Claustrophobia• Huge listing in MRI facility

Page 33: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

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

Page 34: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD
Page 35: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

MRI – TraumaOsteochondritis dissecans

Page 36: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

MRI – Trauma

Femoral Neck Fracture

Page 37: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

MRI - Trauma

Tear vastus medialis

Page 38: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

MRI – Internal Derangement

Page 39: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

MRI – Internal DerangementSupraspinatus tear= Full thickness, Full width

Coronal PD Coronal T2

Page 40: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

MRI – Internal Derangement

Sagittal NL

Sagittal FT, FW Supra

Page 41: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

MRI – Internal Derangement

Sagittal, Meniscus NL

Posterior Horn Tear

Page 42: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

MRI – Internal DerangementBucket handle meniscal tear

Page 43: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

MRI – Internal Derangement

Sagittal – Intact ACL

Torn ACL

Page 44: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

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

Page 45: Musculoskeletal Imaging – The Basics Laurie Lomasney, MD

THANK YOU

Laurie Lomasney, MD