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The Basics of Musculoskeletal Imaging

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The Basics of Musculoskeletal Imaging

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    1. The Basics of Musculoskeletal Imaging Jessica Stumbo, MD UL & JHSMH Sports Medicine Med/Peds Noon Conference 9.10.2010

    2. Objectives Discuss basic radiology of the upper & lower extremities Review a few clinical diagnoses & their radiographic findings

    3. Disclaimer

    4. Wrist X-ray Basic views: PA & lateral Carpal bones mnemonic Some Lovers Try Positions That They Cant Handle Trapezium = Thumb Scaphoid fracture: delayed imaging Carpal tunnel view

    5. Wrist X-ray

    8. Case 1 21 y.o. female snowboarding & lost her balance falling backwards she reached out her right hand to catch herself acute onset of wrist pain DDx? What would be the most common injury?

    9. Scaphoid Fracture M/C carpal bone fracture M/C mechanism: FOOSH Pain on radial wrist & TTP in snuff box (ulnar deviation) X-ray: PA, lateral, scaphoid view (ulnar dev) Management pearls clinical suspicion, neg x-rays thumb spica splint/cast re-image in 10-14 days

    10. Scaphoid Fracture

    11. Scaphoid Fracture

    12. Scaphoid Fracture

    13. Case 2 & 3 48 y.o. LH new golfer hard swing & unknowingly hits a tree root pain on ulnar aspect of R palm 29 y.o. LH golfer pain on ulnar aspect of R palm for a few months

    14. Hook of the Hamate Fx Usually seen in individuals who participate in sports involving a racquet, bat, or club Rare but relative common fx in swingers Acute or overuse type injury Imaging carpal tunnel view but notoriously missed on x-ray CT scan Swingers vs ThrowersSwingers vs Throwers

    15. Hook of the Hamate Fx

    16. Hook of the Hamate Imaging

    17. Hook of the Hamate Imaging

    18. Colles Fracture Mechanism: FOOSH Victims young w/ high energy trauma older w/ osteoporotic bones & low energy trauma Fracture of distal radius w/ dorsal angulation of the distal fracture fragments

    19. Colles Fracture Due to the dorsal angulation of the distal fragment, Colles fractures are often said to have a "dinner fork" appearance

    20. Dinner Fork Deformity

    21. Colles Fracture X-rays Dorsal angulation of distal segment

    22. Colles Fracture Management nondisplaced, minimal angulation: sugar-tong splint displaced: refer for reduction Complications median nerve injury, compartment syndrome & vascular compromise Be aware of associated injuries (ulnar styloid, scaphoid, etc)

    24. Elbow X-ray Basic views: AP & lateral Fat pad sign or sail sign In kids, be aware of the apophyses

    25. Elbow X-ray - AP

    26. Elbow X-ray - Lateral

    27. Elbow Fat Pads Fat is normally present within the joint capsule of the elbow, but outside the synovium Typically "hidden" in the concavity of the olecranon and coronoid fossae Injuries that produce intra-articular hemorrhage cause distension of the synovium forcing the fat out of the fossa producing triangular radiolucent shadows anterior and posterior to the distal end of the humerus the FAT PAD SIGNS Synovial membrane then outside that is fibrous joint capsule (fat btwn the 2) (synovial membrane fat fibrous joint capsule)Synovial membrane then outside that is fibrous joint capsule (fat btwn the 2) (synovial membrane fat fibrous joint capsule)

    28. Fat Pad Sign

    29. Fat Pad Sign

    30. Fat Pad Sign Posterior fat pad sign ALWAYS abnormalPosterior fat pad sign ALWAYS abnormal

    31. Fat Pad Sign Pearls X-rays No visible fracture Positive fat pad sign Think occult fracture Kids: supracondylar fracture Adults: radial head fracture

    32. Ossification Centers There are 6 ossification centers around the elbow Always appear in same order: C-R-I-T-O-E Capitellum Radius Internal or medial epicondyle Trochlea Olecranon External or lateral epicondyle Age of appearance is highly variable but as general guide remember 1-3-5-7-9-11 years

    33. Ossification Centers

    34. Ossification Centers Radial & Lateral epi usually last to close; so if have closure of lat & radial but see a widened area along the medial epicon then most likely an avulsion of the apophysis & not a normal unfused growth plateRadial & Lateral epi usually last to close; so if have closure of lat & radial but see a widened area along the medial epicon then most likely an avulsion of the apophysis & not a normal unfused growth plate

    35. Ossification Centers Age of closure is between ages 14-16 Radial & the lateral epicondyle are generally last to close

    36. Case 4 11 y.o. RH year round baseball player pitches on 3 different teams medial sided Rt elbow pain no acute injury Concerns?

    37. Little League Elbow Medial epicondyle apophysitis Overuse injury Common cause of medial sided elbow pain in throwing athletes X-rays: normal or widening of the apophysis Need comparison views No lateral epicon apophysis yet so widening could just be normal unfused growth plate so need hx, PE, x-rays including of the other elbowNo lateral epicon apophysis yet so widening could just be normal unfused growth plate so need hx, PE, x-rays including of the other elbow

    39. Shoulder X-ray Basic view: AP (true versus scapular AP) Other views Axillary useful in pts w/ clinical picture of instability evaluates glenoid, may see Hill-Sachs lesion (defect in posterior humeral head) Scapular Y useful in dislocations External Rotation evaluation of greater tuberosity Internal Rotation: calcific tendinitis, Hill-Sachs lesion Zanca view: AC joint Internal Ice cream cone; picture at top is AP in scapular planeInternal Ice cream cone; picture at top is AP in scapular plane

    40. Axillary View Good look at GH joint & the acromion (os acromionale unfused acrom often mistaken for a fx)Good look at GH joint & the acromion (os acromionale unfused acrom often mistaken for a fx)

    41. Scapular Y View if inferior; is infraspinous; hh humeral head; a acromion; s spine; c - coracoidif inferior; is infraspinous; hh humeral head; a acromion; s spine; c - coracoid

    42. Shoulder - External Rotation Allows better visualization of the greater tuberosity Fracture detection

    44. I internal rotation ice cream cone shape to humeral head; x-ray of calcific tendonitisI internal rotation ice cream cone shape to humeral head; x-ray of calcific tendonitis

    45. AC Joint Zanca View Zanca view: 10-15 degrees superiorly/cephalad and decreasing the voltage/penetration to about 50% of that used for a standard glenohumeral exposure; normal AC joint distance is ~1-3 mmZanca view: 10-15 degrees superiorly/cephalad and decreasing the voltage/penetration to about 50% of that used for a standard glenohumeral exposure; normal AC joint distance is ~1-3 mm

    46. Glenohumeral Arthritis 2nd image shows elevation of HH, central glenoid erosions2nd image shows elevation of HH, central glenoid erosions

    47. AC Joint Arthritis Treat the pt not the xray; if looks like narrowed AC joint on xray but no symptoms dont worry about xray findings; normal AC joint 1-3mmTreat the pt not the xray; if looks like narrowed AC joint on xray but no symptoms dont worry about xray findings; normal AC joint 1-3mm

    48. CLEAR AS MUD!!! No real consensus on what views a shoulder series should include For me Scapular AP in ER (good view of GH joint; greater tuberosity of the humerus) True AP in IR (decent view of AC joint; Hill Sachs lesion posterior humeral head defect ) Axillary If AC joint pain, Zanca view If hx of subluxation/dislocation, maybe scapular Y

    49. Advanced Shoulder Imaging Younger patient labral tears MR arthrogram Older patient rotator cuff pathology MRI

    51. Knee X-ray Basic views: AP & lateral Must be weight bearing to accurately assess joint space Sunrise/merchant view: evaluation of patella & PF joint

    52. Knee X-ray - AP

    53. Knee X-ray - Lateral True lateral the posterior aspects of the condyles should overlapTrue lateral the posterior aspects of the condyles should overlap

    54. Knee Osteoarthritis (OA)

    55. Knee X-ray - OA

    56. Knee X-ray - OA

    57. Patellofemoral Arthritis

    58. Segond Fracture Avulsion fracture of the lateral capsule off of the tibia Suspect ACL tear until proven otherwise

    59. Segond Fracture

    61. Case 5 13 y.o. boy w/ anterior knee pain

    62. OGS vs SLJ Osgood-Schlatter (OSG) traction apophysitis at the tibial tubercle Sinding-Larsen-Johansson traction apophysitis at the inferior patellar pole Both resolve w/ skeletal maturity

    63. Osgood-Schlatter Syndrome

    64. Osgood-Schlatter Sinding-Larson-Johansson

    65. Bipartite Patella Congenital condition in which the patella develops from 2 ossification centers Incidence: ~ 2% of the population Bilateral in 43% of cases M:F ratio of 8:1 M/C location = superolateral pole (75%) Dont confuse with patellar fracture

    66. Bipartite Patella

    67. Common Ortho Pimp Question

    68. Fabella Sesamoid bone in the lateral head of the gastrocnemius muscle Normal variant in 10-20% of the population

    69. Advanced Knee Imaging Ligaments & soft tissues MRI w/out contrast Bones CT scan

    71. Ankle X-ray Basic views: AP, lateral & mortise Weight bearing if at all possible

    72. Mortise View Allows better visualization of the talar dome, the distal tibia & the distal fibula Taken with patients leg slightly internally rotated

    73. Ankle X-ray - AP

    74. Ankle X-ray - Lateral

    75. Ankle X-ray - Mortise

    76. Mortise vs AP Views of Ankle

    77. AP vs Mortise View

    78. Ottawa Foot & Ankle Rules

    79. Maisonneuve Fracture Mechanism: ankle injury (typically eversion) deltoid ligament sprain fracture of medial malleolus Disruption of the tibiofibular syndesmosis Fracture of proximal 1/3 of the fibula Remember to examine above & below the injury

    80. Maisonneuve Fracture

    82. Foot X-ray Basic views: AP, lateral & oblique Weight bearing if at all possible

    83. Foot X-ray AP

    84. Foot X-ray Lateral

    85. Foot X-ray Oblique Good look at cuboid on obliqueGood look at cuboid on oblique

    86. Ottawa Foot & Ankle Rules

    88. Fractures of the 5th Metatarsal

    89. Fractures?

    90. Normal Apophysis Apophysis at the base of the fifth metatarsal Common in girls 9 to 11 and in boys 11 to 14 yrs of age Note the apophyseal line runs parallel to shaft of metatarsal along the lateral-inferior margin of the tubercle

    91. Avulsion Fx 5th MT Tuberosity Usually seen with inversion ankle injuries Implicated structures peroneus brevis tendon lateral band of plantar fascia

    92. Avulsion Fracture Note that the radiolucency is perpendicular to the long axis of the fifth metatarsal Most common fx of the base of the 5th metatarsal

    93. 5th MT Anatomy

    94. Jones Fracture Transverse fracture at the junction of the diaphysis and metaphysis of the 5th MT Located within 1.5 cm distal to tuberosity of 5th MT

    95. Jones Fracture Potentially the worst fracture of the 5th MT due to very limited blood supply thus slow healing w/ potential for no healing Dont confuse with avulsion fracture

    97. Severs Disease Calcaneal apophysitis Heel pain in skeletally immature patients Visualized best on lateral view Need comparison view

    98. Severs Disease

    99. What is the most likely cause of this patients foot/heel pain?

    101. Plantar Fasciitis Common cause of heel pain Very painful first step in the a.m. Spur forms in the toe flexor tendons & is actually unrelated Actually totally unrelated spur forms in the toe flexor tendonsActually totally unrelated spur forms in the toe flexor tendons

    103. Useful Sources http://www.gentili.net/fxintroduction.htm http://www.rad.washington.edu/RadAnatomy.html http://www.wheelessonline.com/ http://www.ota.org/res_slide/index.html

    104. References http://www.wheelessonline.com http://www.uptodate.com http://www.aafp.org http://aaos.org Puffer, James C. 20 Common Problems in Sports Medicine. 2002 See also previous slide

    105. THE END!!!

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