Imaging in Clinical Practice

Paul Reuteman PT, DPT, MHS, OCS

2017 WPTA Spring Conference

April 20, 2017

Preuteman@uwlax.edu

What is the purpose of this course!

• Big changes in profession and in State of

Wisconsin!

• Provide clinical guidelines for need of imaging

as part of the SCREENING PROCESS

• If images are ORDERED, what are the routine

series of images

• If images are already taken, how do we educate

patients on RELEVANT FINDINGS

Big Changes!!!• Already an established model of use of imaging in

practice

– Military, IHS

– UK, Canada, Australia, Norway and others

• Development of DPT brought imaging into the classroom

– 2015 - Development of “Imaging Education Manual for DPT

Professional Degree Programs” Imaging SIG of the Ortho

Section

– Provides guidelines for DPT curriculum

• 2016 - White Paper published by Ortho section, APTA on

“Diagnostic and Procedural Imaging in PT Practice”

• 2016 - Changes in the State of Wisconsin Practice Act

Notice any parallels to other legislation in PT Practice

State of Wisconsin Practice Act

• Definition of PT

448.50(4)(b)

“Physical Therapy” does not include using roentgen rays or radium for any purpose, using electricity for surgical purposes, including cauterization, or prescribing drugs or devices

• This language prohibits PTs from actually “taking” x-rays (flipping the switch)

• What can we do?

It’s Law!Recent advances in WI in 2016

Bill AB549 was passed

• Allows for PTs who satisfy certain criteria to

ORDER x-rays!

• PT must satisfy one of following:

– DPT

– Completed a specialty certification program (OCS)

– Completed a residency or fellowship program

– PT completed formal x-ray ordering training

program with MD involvement

– Coordination is completed with primary MD or

other health care coordinater

Full Disclosure

• Not teaching “IMAGING”…why?

• Instead, teaching the following:

– Clinical reasoning for the need of imaging

– Basic foundational images in routine series

– Patient education regarding imaging

• “Don’t you need an x-ray to know what’s wrong”

• “Have you looked at my MRI?”

• “What is PT going to do for me when my knee is ‘bone

on bone’”?

Tools for Clinical Decision Making

• American College of Radiology Criteria

• Clinical Decision Rules

• Diagnostic Imaging Pathways

These will be covered by body region

and summarized for you!!!This article is included in

your readings posted on

D2L

Variables for Imaging Decision Making

In the ACR Appropriateness Criteria• Age

• Trauma presence/absence

• Mechanism of injury

• Prior surgery

• Risk factors

• Appearance

• Pain provocation and physical functional tests

• Weight bearing ability

• Tenderness to palpation.

These are already WELL ESTABLISHED in PT

educational curricula and in clinical practice

Red Flag Screening We Already Use

• Trauma

• Unexplained weight loss

• Age older than 50 years old (esp in

females/males with osteoporosis)

• Hx of CA

• IV drug use

• Prolonged use of corticosteroids

• PROGRESSIVE neuro deficit

• UMN finding

• Prior surgery

Great Resources• Imaging Education Manual for DPT programs by

Imaging SIG

– https://www.orthopt.org/uploads/content_files/ISIG/IMAGI

NG_EDUCATION_MANUAL_FINAL_4.15.15..pdf

• McKinnis L. Fundamentals of Musculoskeletal

Imaging, 4th Edition

• McKinnis L. Musculoskeletal Imaging Handbook: A

Guide for Primary Practitioners.

• Malone T. Imaging in Rehabilitation.

• JOSPT – Musculoskeletal Imaging Series and

Clinical Practic Guidelines

• OTHER HEALTH CARE COLLEAGUES

What are the different types of

imaging?

• Plain film radiography

• Digital radiography

• Computed tomography (CT)

• Arthrogram

• Ultrasound

• Bone scan

• MRI

What is a Radiograph?

• An x-ray film or digital image containing an image of an anatomic part of a patient

• Requires:– X-ray source

– The patient

– An image receptor (film or digital technology)

• Terminology– Radiograph or plain films (preferable term)

– X-ray

• Advantages??

• Disadvantages??

How it works

• X-rays are form of radiant energy with shorter wavelength of visible light

• Materials absorb the x-ray at different rates depending on:– Atomic number (density of tissue)

– Tissue thickness

• The greater x-rays absorbed, the whiter the structure (radiodensity)– Less radiodense (aka: radiolucent): objects appear

darker

– More radiodense (aka: Radiopaque) objects appear lighter)

50 shades of Gray

Radiodensity of structures

Decreasing Radiodensity

Increasing Radiolucency

(Darker)

Increasing Radiodensity

Decreasing Radiolucency

(Whiter)

Air/lungs

Fat/multiple layers of tissue

Thin bone/Water/Muscle

Cancellous Bone/Tendon/Thick muscle

Thick Cortical bone/Metal/Contrast Medium

AP views of the Pelvis

Plain Film Radiography

• Most effective way of demonstrating a bone or joint abnormality

• 1st order of diagnostic study

• 2 dimensional view

– All radiographs are 2 dimensional

– To get 3 dimensional must have a view 90° to the other

(Minimum of 2 views is the rule)

Rationale for multiple views

Varying 2 dimensional views Most common projections

• View same object from different angles

• Most common projections

– AP: Anterior-posterior

– PA: Posterior-anterior

– Lateral (R or L)

– Oblique (R or L / Post or anterior)

Common views of the C-SpineReading a radiograph:

BASIC “Search Patterns”

• View the image as if you are the radiograph

machine (image source)

• ABCs

– Alignment

– Bone Density

– Cartilage space

– Soft tissue

Variations of radiographs

• Stress views: Stress the joint to determine if

structure changes

• Fluoroscopy: Radiograph in real time. Able to

move joints to see what is happening. Also

used to perform epidural and other injections.

Increased amount of exposure to radiation.

Digital Imaging:

Image Quality Factors• Radiographic density: Can be regulated by the

machine or by the digital image viewer

• Radiographic contrast: High contrast increases

anatomic detail

• Detail (sharpness, definition, resolution):

Sharpness of the structural lines

• Distortion: difference in the size and shape of the

actual image and the recorded image

The Radiographic Examination

• Each joint typically has a routine order of films

• May either rule in OR rule out a specific

diagnosis

• Must first perform a THOROUGH history and

examination

– May have a “working diagnosis” that may be

confirmed with plain films

• More often than not, radiographs are not required

and may be avoided when establishing a

diagnosis

TWO Critical Points

• For the radiologist and MD to perform their job, they must be provided with sufficient patient history, signs and symptoms and results of other special tests

• Technology is not infallible: False negatives and positives will occur. It is the clinicians responsibility to recognize that if results of any imaging study do not fit, further evaluation and diagnostic investigation is warranted

“Advanced” Imaging

• Advanced imaging interpretation requires

foundations in:

– Imaging technology

• More complex physics

– Dimensional anatomy

• Sectional anatomy

• Orthogonal planes or relative to the anatomy

– A methodical search pattern

• Develop a sequence to search images

– Characteristics of pathology

• Soft tissue is more complex than bone

In Reality….

Advanced imaging interpretation cannot be

learned as easily as radiographic interpretation

HOWEVER….

an achievable goal is to gain an understanding

of what advanced imaging modality would

best define the pathologies you commonly see

in your PT population

Magnetic Resonance Imaging• Body is imaged within a

powerful magnetic field

with use of nonionizing

radio waves

• NO radiation

• MRI is based on the

process by which nuclei

aligned in a magnetic field

absorb and release energy

• MRI is based on signals

from hydrogen nuclei in

water molecules

• Indications:

– Imaging soft tissue.

Examples:

• Muscle or ligament tears

• Disc herniation

• Meniscus or labral tears

– Changes in bone marrow

(bone bruises, AVN, bone

tumors, etc)

– Staging neoplasm in bone

and/or soft tissue

• Does not give as high resolution of

cortical bone than CT does but still

can be used to diagnose bony

pathologies

Disadvantages/Contraindications

of MRI• Disadvantages

– High cost

– Claustrophobia of the patient

– Length of time to complete (do not get images right away)

– Pt needs to sit still to get adequate image (difficult if they are in pain)

– Cannot do with ferrous metal in the body

– Findings do not always correlate to symptoms

• Contraindications– Magnetic field may lift heavy metal objects and displace them

– Ortho hardware is not ferromagnetic BUT will distort image

– Pacemakers may malfunction

– Cochlear implants

MRI• Weighted images

– T1: Anatomic detail is better• Fat and bone marrow have high signal intensity (bright)

• Water has low signal intensity (dark)

– T2: Detects swelling and water better• Opposite as above

• Water shows up bright

• Muscle is slightly darker

• T2 → H2O

– Muscle has moderate signal intensity on both

– Tendons and ligaments have low signal intensity on

both (dark)

https://mrimaster.com/characterise%20physics.html

Viewing MR or CT Images

• Frontal (Coronal): Images are viewed from the

front, as if facing the patient

• Sagittal: Images on either side of the body are

viewed from side to side

• Axial (transverse): Images are viewed from below,

in a caudo-cephalad direction (similar to a CT)

CT Scan

• Indications

– Images of the brain

– Subtle or complex

fractures

– Degenerative changes

– Intra-articular

abnormalities (loose

bodies)

– Small bone fragments

– Bone density

• Merges radiograph with

computed imagery

• Computer mathematically

reconstructs the image

• Creates a series of axial

(cross-sectional) slices

• Much more sensitive than

radiographs

• Provides additional views

not provided by films

(axial)

CT Scan

• Advantages

– Anatomy in cross section

– Less expensive than MRI

– Less claustrophobic

– Can image soft tissue and osseous structures

in one series

• Disadvantages

– Utilizes ionizing radiation

• High radiation exposure

– More expensive than plain film

Radionuclide Bone Scan

• Radioactive substance

(Technetium-99) is injected

into pt

• Tc99 collects in areas of

increased bone activity

(osteoblastic activity)

• A “hot spot” is present

when taking a picture with

a gamma camera

• Indications

– Fractures: most commonly stress

fractures (indicates the location of

the fracture but not the type of

fracture)

– Bone tumors: again location of

the tumor, but not specific type of

tumor

• Will also see

– Epiphyseal growth plates

– Areas of arthritis

• Disadvantage

– Lack of specificity in differential

diagnosis

– Poor anatomical detail

Diagnostic Ultrasound

• Most often used for soft tissue diagnosis

• Advantages to other imaging:

– Low cost and portable device

– Able to modify the exam while it is being

performed. Ex:

• Can move the affected joint

• Can ask pt to activate muscles (assess cross sectional

area of the muscle)

• Stress the joint

When is imaging appropriate?

PT’s must answer these questions

• Will imaging studies alter plan of care?

• Is imaging needed to feel comfortable proceeding

with PT Treatment?

• Requesting imaging?

– What views?

– Rationale?

• Evolving literature has provided more specific

guidelines to these questions.

If Imaging is needed…

• When contacting an MD or ordering your own

imaging, provide:

– Pt demographics

– Symptoms (location)

– Injury (when, mechanism)

– Physical examination

– Relevant medical history (ex: CA, infection, risk

factors for bone density)

– Concerns

– Type of imaging

Cervical Spine

Guidelines of PLAIN FILM imaging of the C-Spine

in the presence of trauma

Stiell IG, et al. The Canadian C-Spine rule for radiography in alert and stable patients. JAMA.

2001; 286: 1841-1848

Canadian C-Spine Rule

Specificity: 43-91 -LR: .01Sensitivity: 99-100 + LR: 1.8-10.7

(Hoffman J. 2000, Stiell I. 2001, 2003)

The Canadian C-Spine Rule

General Guideline for MRI of Cervical Spine(Adapted from New CPG from JOSPT – Coming out soon)

•Neck pain with Non-radiating pain: In the absence of red flags, no imaging indicated

•Neck pain with radiating pain, indicated when:•Signs of myelopathy (weakness, mm wasting, clonus, sensory loss, hyperactive reflexes)•Progressive neurological findings (sensory deficits, weakness and reflex changes)•Radiating pain not responding to conservative care after 6 weeks (VARIABLE)

Routine Series of the Cervical Spine

Routine1. AP Open mouth2. AP Lower C-Spine

3. Lateral

Sometimes1. Right posterior oblique

2. Left posterior oblique

3. Flexion and extension stress views

1. AP Open mouth radiograph

Assess:• ABCs

• C1-C2 Joint symmetry

• Dens midline between the lateral mass of C1

• C2 spinous process midline

AP Open mouth radiograph

Clinical Relevance?

2. AP Lower Cervical Spine

Assess:•ABCs

•C3 through C7

•C2-C3 IV space

•T1 ribs

•SP and midline

•Pedicles equidistant

•Trachea midline

3. Lateral View C-spineAssess:•ABCs

•Intervetebral disc space

•C1-C7 vertebral bodies and their alignment (3 parallel lines)

•Facet joints

•Dens/C1 relationship

•Curvature of spine

Sometimes:

1. Oblique view C-spine

Right posterior oblique Left posterior oblique

Oblique view C-spine

Assess:•ABCs

•Intervertebral foramen

Sometimes

2. Stress Views•Spine is positioned at end range flexion and extension

•Assess: •Atlanto-dental

interspace (C1-C2 stability)•Preservation of the

spatial relationships of the 3 parallel columns (stability of lower cervical spine)

MRI of C-Spine

•Sagital views: Assess if disc or other tissue encroaches in spinal canal

•Axial views: Assess central spinal canal (central foramen) and if disc or other tissue encroaches on nerve root

To be clinically relevant, clinical findings must corroborate with images

VIDEO TUTORIAL:

https://www.youtube.com/watch?v=Sv3VEnKfY6Y

T1 vs. T2

https://mrimaster.com/PLAN%20C%20SPINE%20t1%20sag.html

Sagital ViewAxial View (T1)

https://mrimaster.com/PLAN%20C%20SPINE%20t1%20sag.html

Evidence Regarding Imaging of the Cervical spine

• Large percentage (73-90%) of asymptomatic patients present with “degenerative changes” (change in signal intensity of disc, posterior disc protrusion, disc space narrowing) and bulging discs. Even those in their 20’s (73%)(Okada E. Eur Spine J. 2013, Matsumoto M. Spine. 2010, Nakashima N. Spine. 2015)

• “Degenerative changes” increase as we age (Matsumoto M. Spine. 2010)

• Comparing patients with WAD and control in 10 year follow-up there was no statistically significant correlation between neck pain and progression of MRI findings…poor correlation between MRI and persistent pain of WAD (Matsumoto M. Spine. 2010)

THORACIC SPINE

Indications for Thoracic spine imaging

• Trauma or fall (Same as C-Spine)

• Thoracic pain and suspected or already diagnosed osteoporosis

• “Non-mechanical” nature of pain

• Potential rib fractures

Routine Plain Film Series

1. AP Thoracic

2. Lateral Thoracic

1. AP Thoracic

•Assess:•Disc spaces•Alignment of the vertebrae (spinous process and pedicles are in line)•Costo-vertebral joints

2. Lateral Thoracic•Assess:•Vertebral bodies and disc spaces•Intervertebral foramen•Alignment of vertebrae

Lumbar Spine

Criteria for L-spine radiographs

Jarvik JG. Diagnostic evaluation of low back pain with emphasis on imaging. (Ann Intern Med.

2002) Radiographs to be taken in pts with:

•Hx of major trauma•Hx of minor trauma and high risk for osteoperosis•No trauma but 2 or more of the following present •>50 y.o., hx of CA, fever, weight loss, hematuria, IV drug

use, failure of conservative care after 4-6 weeks

FLOW SHEET ON NEXT PAGE

If there is a concern for vertebral fracture in LBP

5 variables: (Henschke N. 2008)

•> 50 years old (+LR: 2.2)

•Female gender (+LR: 2.3)

•Major trauma (+LR: 12.8)

•Pain and tenderness (+LR: 6.7)

•Distracting painful injury (+LR: 1.7)

Indications for Lumbar MRI(Delitto. LBP CPG. 2012)

• Leg pain with or without associated back pain and progressive hard neuro signs

•Pain/radiculopathy in adults not improving despite 4-6 weeks of non-surgical treatment, which includes physical therapeutic modalities and appropriate pharmacologic intervention.

•Pain/radiculopathy with history of major trauma.

•Clinical suspicion of an infectious process such as abscess, osteomyelitis, or discitis

•Clinical suspicion of primary lumbar spine cancer (“red flags”) with symptoms and/or findings suggesting involvement of the spine

Indications for Lumbar MRI (cont)(Delitto. LBP CPG. 2012)

•Sign/symptoms suggestive of spinal stenosis that may require surgery (pseudoclaudication; pain/numbness/ tingling with activity, relieved by rest, sitting, spinal flexion; suggestive x-ray findings).

•Clinical suspicion of lumbar myelopathy or lumbar nerve root or cauda equina compression with extremity weakness, bladder/bowel symptoms, ataxia, spasticity, spinal level sensory loss.

Routine Series for plain film

Routine1. AP2. Lateral 3. Lateral L5-S1 (“spot shot”)

Sometimes:•Right oblique•Left oblique

1. AP Lumbar spine•Assess:•Interpediculardistance (a)•Spinous process alignment (b)•Pedicles equidistant (c)•Lamina/sup & infarticular process (d)•Transverse process

2. Lateral View

Assess:

•Intervertebral foramen

•Intervertebral disk space

•Spinous process

•Facet joints

•3 parallel line

3. Lateral L5-S1“spot shot”

Sometime:

Oblique Views

•Described by side closest to the image receptor AND direction of rotation. Example: Right posterior oblique (RPO)

•Assess:•Pedicles•Superior and inferior articular process•Facet joints•“Scottie dog” (presence of fracture of pars interarticularis)

Oblique Views

“Scottie Dog” MRI of Lumbar Spine

•Sagital view: Assess if disc bulge encroaches into spinal canal

•Axial view: Assess central spinal canal and if disc bulge encroaches into spinal canal or nerve root

To be clinically relevant, clinical findings must corroborate with images

VIDEO TUTORIAL:

https://www.youtube.com/watch?v=p4wVMHmGjAU

Axial viewT1 T2 Axial view

• Single most over-requested diagnostic imaging procedure

• Large economic impact leading to increased health care costs

• A large portion of irrelevant findings that lead to inappropriate diagnosis and treatment• Degenerative changes present in 28 to 50% of ASYMPTOMATIC

population

• Creates fear and anxiety in patient

(2011)• Misinterpretation of results by clinicians

resulting in unhelpful advice, needless subsequent investigations (downstream testing) and invasive interventions, including surgery

• Misinterpretation of results by patients resulting in catastrophisation, fear and avoidance of movement and activity, and low expectations of recovery

• Side effects such as exposure to radiation

(BJSM. 2016)

In a recent systematic review…(Brinjikji W. A J of Neuroradiology. 2015)

3110 asymptomatic patients

Hip and Pelvis

When is imaging necessary?Bussieres . 2007 JMPT

• Suspicion of advanced OA changes, stress fx, avulsion fx, avascular necrosis, Slipped Capital Femoral Epiphysis (SCFE)

• Hip Imaging General Guidelines– Failed Conservative Treatment (<4 weeks)

– Complex History

– Hx of non-investigated trauma

– Significant trauma

– Acute/sub acute locking

– Palpable enlarging mass (deformity)

– Severe or progressive pain (inguinal) with WB or end range of IR/ER. May have limited IR also.

– Focal tenderness to bone

• ASIS, AIIS, ischial tuberosity

• MRI recommended if plain films is inadequate at identifying pathology or consideration of soft tissue injury (i.e.: labral tear)

Routine Series

• Pelvis

– AP

• Hip

– AP

– Lateral Frog Leg

• Others

– Cross table lateral view of the hip

AP Pelvis

Assess:

• SI joint symmetry

• Femoral head & acetabulum

• Hip joint symmetry (ABCD’s)

AP Hip (close-up view)

Assess:

• Acetabular roof

• Anterior rim

• Posterior rim

• Iliopubic line

• Ilioischial line

• Iliofemoral line (red)

Hip Lateral Frog Leg

Assess:• Greater trochanter

is superimposed behind the neck

• Lesser trochanter is profiled

• Femoral head well exposed

• Different perspective of femoral neck

Cross Table Lateral view

Assess:

• Preferred from some MD’s over the lateral frog leg

• Presence of femoroacetabularimpingement (FAI)

– CAM impingement

– Pincer impingement

MRI (MRA) of the hip

Assess:

• Labral tears (with Gadolinium)

• Chondral injuries

• Advanced hip pathologies (AVN, etc)

“It is absolutely necessary to have a Gadolinium injection in the hip prior to the MRI for the image

to be useful in diagnosing labral pathology”

MD Colleague

MRI with Gadolinium Injection = MRA (Magnetic Resonance ARTHROGRAM)

MRI of the Hip

Views:

• Axial (A)

• Sagital (S)

• Frontal (F)

Assess for injury to:

• Labral tears (F, A)

• Condral lesions on femoral head or acetabulum(F, A)

• Ligamentum terestear (F)

• Other soft tissue (F, S, A)

Assessing Osteoarthritis

Radiologic Findings

a. Assymetrical joint space

b. Sclerotic subchondral bone

c. Osteophytes at joint margins

d. Superior migration of the femoral head / inferior acetabular protrusion (does not sit appropriately in the acetabulum)

Hip OA in Symptomatic and Asymptomatic Patients

• Weak correlation between symptoms and joint space in a SR (Lin. OA & Cart. 2011)

• 50 years or older, OA (Grade > 2 KL scale) in 20% of asymptomatics (Kim C. A&R. 2014)

– Prevalance increases with age

– Males greater likelihood than males

Educational video

Prevalence of OA in population and prevalence of pain

(Iadaka T. OA & Cart. 2016)

Educational video

Labral Tears of the Hip• Younger patient population (20-40 y/o)

• Bony abutment occurs with flexion, adduction and IR (Impingement sign) (Ganz R. 2003)

• Common etiology of labral tears:

– Macrotrauma

– Repetitive microtrauma

• Associated with femoroacetabular impingement

• Joint laxity (congenital, capsular laxity)

– Combination of these factors

“Measuring” Intraarticular Pathology(Clohisy J. JBJS. 2008)

• Tonnis angle

• Lateral central-edge angle of Wiberg

• Anterior center-edge angle of Lequesne

• Neck-shaft angle

• Lateral alpha angle

• Head-neck offset ratio

• Acetabular retroversion (“cross-over sign”)

Historical perspective• “Surgery is necessary as an early intervention to

avoid progressive degeneration”

• “Physical therapy, with emphasis on improving passive ROM or stretching, is not beneficial but rather counterproductive.”

• “Physical therapy is counterproductive and increases risk of degenerative change because it does not address the underlying impingement.”

Standaert et al 2001 APMR; Lavigne et al 2004 Clin Orth Rel Res

Historical perspective

“Absent any prospective data on the natural history of the diagnosis, the long-term outcomes of those undergoing surgery compared with those who do not, and the prevalence of various findings in the asymptomatic population, this reasoning is troublesome”

Standaert et al 2001 APMR

Hip “Pathology” in Young Asymptomatic Individuals

• Avg age of 34 years old (Schmitz M. AJSM. 2012)

– 26% present with acetabular paralabral cysts

– 85% present with acetabular labral tears

• Avg age of 38 years old (Register B. AJSM. 2012)

– 13% present with acetabular paralabral cysts

– 69% present with acetabular labral tears

– 24% present with chondral defects

– >35 y/o: 13.7x more likely to have a chondral defect and 16.7 x more likely to have a subchondral cyst (Age correlates with labral tears)

Symptomatic vs. Asymptomatic(Tresch F. J of MRI. 2016)

• 20-50 years old

• Articular cartilage and/or labrum

– 80% in symptomatic

– 57% in asymptomatic

• Labrum

– 61% in symptomatic

– 44% in asymptomatic

• Acetabular cartilage defects

– 47% in symptomatic

– 14% in asymptomatic

The Knee

Differential Diagnosis-Atraumatic

Criteria for knee radiographs after trauma:Ottawa Knee Rules

Stiell, IG, et al. Prospective Validation of a Decision Rule for the Use of Radiography in Acute Knee Injuries. JAMA. 1996 . 275(8); 611-615

Radiographs should be ordered after trauma for patients with any of the following (not applied to pts < 18 y/o):

• >55 y/o

• Tenderness over fibular head

• Isolated tenderness of patella

• Inability to flex knee to 90°

• Inability to walk 4 steps

Sensitivity: .85 - 1.00Specificity: .49 - .50

+LR: 1.8-LR: 0.1-0.3

(Richman P. 1997, Jackson J. 2003)

Criteria for knee radiographs in absence of trauma:

Knee Decision Rule of BauerBauer SJ. J Emerg Med. 1995

• Presents with any one of these three variables:

– Inability by patient to bear weight both immediately for FOUR STEPS

– Presence of effusion

– Presence of ecchymosis

• May also indicate a Blood Panel or Arthrocentesis

Sensitivity: .85-1.0, Specificity: .49-.63

Also:

• Perception of popping sound in the knee during twisting maneuver

• Adolescent with tenderness over femoral condyle

Indications for MRI of the knee

• Presence of joint effusion

• Suspicion of

– Ligament tears

– Meniscus tears

– Articular cartilage injury

– Muscle or tendon tears.

Routine Series of the Knee

• AP: NWB vs. WB

• Lateral

• Tangential view of Patellofemoral joint (Sunrise view)

• Sometimes: PA Axial view (Tunnel view)

AP ViewCan be done in either

weightbearing or non-weightbearing

Assess:

• Patellar alignment

• Tibiofemoral joint space

• Varus/valgus alignment (intercondylar tubercles)

• Proximal fibula

Lateral View

Assess:

• Distal femur (joint surface)

• Proximal tibia

• Lateral patella

• Tibial tuberosity

• Patella alta or baja

PA Axial view(Tunnel view)

MAY ALSO BE DONE IN WB AS AN AP VIEW

Assess:

• Distal femur joint surface

• Intercondylar fossa

• Loose bodies / osteochondralconditions

Tangential view of Patellofemoral joint(AKA: Sunrise view / Merchant’s view)

Assess:

• Articular surface of PFJ

• Sulcus angle

• Patellar alignment in femoral sulcus (congruence angle)

MRI of the Knee

Views:

• Axial (A)

• Sagital (S)

• Frontal (F)

Assess for injury to:

• Meniscus (S, F)

• Cruciate ligaments (S)

• Collateral ligaments (F)

• Articular surfaces (F, A)

– Bone bruise on condyles

– Articular cartilage injury

• Other soft tissue

Assessing Osteoarthritis on Plain Films(Kellgren J. 1963)

Kellgren-Lawrence Criteria• Grade 0- No features of OA

• Grade 1- Doubtful narrowing of joint space and possible osteophyte lipping

• Grade 2- Definite osteophytes and possible narrowing of joint space

• Grade 3- Moderate multiple osteophytes, definite narrowing of jtspace, and some sclerosis and possible deformity of bone ends

• Grade 4- Large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of bone ends.

Natural Progression of Knee OABedson J. BMC. 2008

• Prevalenceincreases with age

–Age >45: 36-50%

–Age >55: 40-76%

0%

10%

20%

30%

40%

50%

60%

70%

80%

25-40 Age 45 and older Age 55 and older

OA increases with age

Low High

Should we be assessing Film or Function?

Cubukcu D. Arthritis. 2012

PLAIN FILM IMAGES

Evaluates weight bearing joint space, osteophytes, sclerosis and cysts.

• Significant association with age and increasing Kellgren Lawrence Scale

• NO ASSOCIATION With WOMAC – Pain

– Disability

– Function

– Stiffness

WOMAC QUESTIONNAIRE Evaluates Disability, Functional Status, Pain, Stiffness

• Significant association with Disability and Pain Scales

• Significant association with Disability and Stiffness Scales

“treatment of knee OA could be planned according to the clinical

features and functional status instead of radiological findings”

Foot and Ankle

Need for RadiographsOttawa Ankle Rules

(Stiell I, 1992)• Bone Tenderness of

any of the following

– Dist 6 cm of post edge of the tibia or tip of med. malleolus

– Navicular

– Base of the 5th

metatarsal

• Inability to WB immediately after injury 4 steps (2 each side)OR

Sensitivity =.97-.99

Also• In adolescents with lateral ankle sprain due to potential

injury to growth plate (Salter-Harris Fracture)

• Tender over distal tibio-fibular joint (High ankle sprain)

• Concern of stress fracture (Bone scan):

– Common Locations: tibia, medial malleolus, talus, fibula, navicular, cuboid, metatarsals

– Subjective:• Change in mileage/activity

• Pin point tenderness

• Night pain

• Pain worsens with increased activity

– Objective• Bony Tenderness

• Percussion/Vibration Test

Indications of MRIMartin R. CPG for Ankle Lig. Sprains. JOSPT. 2013

• Potential muscle or tendon tear

– Achilles tendon, posterior tibial or fibularis mm

• Suspect loose bodies (osteochondral lesions)

– Persistent pain, instability, crepitus, catching and/or locking

• Potential neoplasms or infections of the bone

• Congenital or developmental conditions (ex: tarsal coalition)

Routine Series

• Ankle– AP

– AP Oblique (mortise view)

– Lateral

– Sometimes: AP Inversion and Eversion

• Foot– AP

– Lateral

– Oblique

AP AnkleAssess:

• Dome of talus

• Talocrural joint space

• Lateral malleolus

• Medial malleolus and relation to talus

• Tib-fib clear space and overlap

Normal overlap: 10 mm (blue)Normal clear space: 5 mm (red)

Tibiofibular clear space

AP Oblique(Mortise view)

Assess:

• Mortise width

Norm: 3-4 mm over entire surface of talus

• AITF joint integrity

• Articular damage of the dome of the talus

Lateral Ankle

Assess:

• Fibula superimposed on tibia

• Posterior rim of tibia (3rd

malleolus)

• Talus, calcaneus, cuboid and navicular

• Talar dome

AP Foot

Assess:

• Bones of the forefoot

• Bones of the midfoot

• 1st intermetatarsal angle

Norm: 5-15°

Oblique Foot

Assess:

• Metatarsal and phalanges shafts

• Bones of the midfoot

• Interspace of tarsal and metatarsals.

APPObliqueP Lateral

Foot

Assess:

• Bones and joints of the rearfoot and midfoot

MRI of the AnkleViews:

• Axial (A)

• Sagital (S)

• Frontal (F)

Assess:

• Talar dome injury (S, F)

• Ligament injuries (S, A, F)

• Tendon injuries (S, A, F)

• Other soft tissue

http://www.freitasrad.net/pages/Basic_MSK_MRI/Ankle.htm#sag

PATIENT EDUCATION

• 32% of asymptomatic adults show a heel spur on plain films

• What do YOU SEE and what do THEY SEE

The Shoulder Complex

Criteria for shoulder complex radiographs

• Acute trauma: ESPECIALLY if elderly and/or osteoporotic

– FOOSH injury

– Bone deformity (Clavicle, AC, GT, scapula)

– Shoulder dislocation (instability)

– Eccymosis

– Swelling

– Focal tenderness to bone (clavicle, AC, GT, scapula)

Used when suspicion of clavicle fx, AC separation, massive RTC tear, OA, dislocation or humeral fracture

Indications for MRI of the shoulder complex

• Suspicion of:

– Presence of acute rotator cuff tear or biceps tendon tear

– Presence of muscle atrophy/fatty infiltration of rotator cuff in chronic tears

– Labral injuries (Bankart or SLAP)

– Articular cartilage injury (osteochondral lesions)

– Neoplasms or infections

Routine Series

• AP External rotation

• AP Internal rotation

• Others– Anterior oblique view (AKA: Outlet view or

Scapular Y lateral view)

– Axillary view

– AC joint AP bilateral (with and without weights) (stress view)

AP View GH External Rotation

Assess:

• ABCs

• Greater tuberosity in profile, lesser tuberosity midline, bicipital groove

• Coracoid process

• GH and AC joint

• Subacromial space (10-11 mm)

• GH joint space (5 mm)

AP with GH ER

AP View with GH Internal Rotation

Assess

• ABCs

• Lesser tuberosity in profile

• Greater tuberosity toward midline

AP with GH IR

Anterior oblique (outlet view)

Assess subacromial joint space.

Anterior oblique (outlet view)

Anterior oblique (outlet view)

• Assess “type” of acromion

• Large variation of acromion and scapular morphology in asymptomatic population (Chopp-Hurley J.

Sur Rad Anat. 2016)

Axillary view

Assess orientation of head of humerus and glenoid fossa

Axillary view MRI of the ShoulderViews:

• Axial (A)

• Sagital (S)

• Frontal (F)

Assess:

• Rotator cuff TENDON integrity (F)

• Rotator cuff MUSCLE atrophy (S)

• Labrum tears (A, S, F)

– With arthrogram (gadolinium injection)

• Articular cartilage injury

http://www.freitasrad.net/

Tutorial on reading a shoulder MRIhttp://screencast.com/t/UBt9OkUx

Axial Image Frontal (coronal) Image

http://www.radiologyassistant.nl/en/p4f49ef79818c2/shoulder-mr-anatomy.html

Sagital Image

ESPECIALLY if elderly and/or osteoporotic

Something to Consider

• MRI of ASYMPTOMATIC ADULTS show 20% have partial and 15% have full thickness tears. Those >60 y/0, 50% have some type of rotator cuff tear (Siber J. 1995)

• 50% of asymptomatic professional baseball players presented with R/C tear. They remained asymptomatic 5 years after retirement (Conner. 2003)

The Elbow and

Forearm

Indications for Elbow/forearm radiographs

• FOOSH injury with obvious deformity or bone tenderness

• Bone tenderness (esp. in adolescent due to growth plates)

• Traction injury in adolescents (fear of a radial head dislocation)

There have been some specific guidelines published for the elbow

A clinical rule for management of elbow injuryLennon. Emerg Med J.2007

A clinical rule for management of elbow injury:

(1) Patients ≤16 years with a ROM equal to the unaffected side may be safely discharged

(2) Patients with normal extension, flexion and supination do not require emergent elbow

radiographs

If pain and limited motion from a trauma,

radiographs should be considered.

A clinical rule for management of elbow injury(Appelboam A. BMJ. 2009)

• Those patients with extension ROM equal to the unaffected side do not require emergent elbow radiographs

• For those able to fully extend their elbow, radiography can be deferred if the practitioner is confident that a fracture is not present. Patients who do not undergo radiography should return if symptoms have not resolved within 7-10 days.

Indications for MRI of the elbow

• Suspicion of:

– Presence of tendon tears (most common is triceps or biceps tear)

– Signal change in chronic tendinopathies (lateral or medial epicondylosis)

– Fractures not identified on plain films

– Medial Ligament tears and/or lateral articular cartilage damage (“valgus overload syndrome” or “little leaguers elbow”)

Routine Series

• AP

• Lateral

• Sometimes– Internal or External

Oblique

AP Elbow

Assess:

• ABC’s

• Carrying angle– Normal =5-15°

– Increase or decrease may be sign of fx or traumatic deformity

Lateral Elbow

Assess:

• ABC’s

• Fat pad

Oblique Views

• Internal Oblique

– Pronation

– View coronoid process of the ulna

• External Oblique

– Supination

– View radial head

– View growth plate of medial epicondyle

AP Internal oblique (Pronation)

AP External oblique (Supination)Forearm series

AP

Lateral

MRI of the Elbow

Views:

• Axial (A)

• Sagital (S)

• Frontal (F)

Assess:

• TENDON integrity (S)

• Chronic tendinopatheis (A, F)

• Fractures (A, S, F)

• Ligament tears or articular cartilage injury (F)

http://www.freitasrad.net/

The Wrist and Hand

Indications for radiology of wrist and hand

• Tender in anatomical snuffbox following FOOSH injury

• Deformities/tenderness of the wrist and hand

• Tenderness over bone

• Ligament laxity

The Wrist and Hand

• Routine Series

– PA of hand and wrist

– Scaphoid view of wrist (PA with wrist in Ulnar deviation)

– Lateral of hand and wrist

– Oblique of hand and wrist

PA of the wrist Assess

• Arcurate lines - 3 arcs

• Space between ulna and triquetrum

Scaphoid View of wrist(P-A with wrist in Ulnar Deviation) PA Hand

Assess

• Long axis 2nd MC in line with radius

• Ulnar deviation of proximal phalanges (normal)

• Straight diagonal line from 3rd to 5th MC head

• Thumb in an oblique position due to the normal orientation of the trapezium

Lateral wrist: Set up is Same as with hand

Assess

• Long axis of 3rd

MC, capitate, lunate and radius

• Lunate and radius should be line with each other

Lateral handSet up is Same as with wrist

Assess

• Long axis of 3rd

MC, capitate, lunate and radius

• Lunate and radius should be lined up with each other

Oblique WristAssess• Proximal and

distal articulations with trapezium

• Again, a different view of the scaphoid bone

• Radial and

ulnar styloidprocess

Oblique Hand

Assess

• Long bones are seen 45°from PA view

I have to “hand” it to you…you’re hanging in

there George Costanza: The ultimate Hand Model

http://www.youtube.com/watch?v=PZxX3-rJoNI&noredirect=1