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Musculoskeletal Imaging – The Basics

Musculoskeletal Imaging – The Basics. Laurie Lomasney, MD Department of Radiology Loyola University Medical Center. Musculoskeletal Imaging. Technology. Advances in Imaging. CONFUSION. MSK Imaging – Imaging Modalities. Plain Radiographs Nuclear Scintigraphy Ultrasound

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Musculoskeletal Imaging – The Basics

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

  2. Musculoskeletal Imaging Technology Advances in Imaging CONFUSION

  3. MSK Imaging – Imaging Modalities • Plain Radiographs • Nuclear Scintigraphy • Ultrasound • Computed Tomography • Magnetic Resonance Imaging

  4. Plain Radiographs • Widely available • Reproducible • Patient friendly • ‘Inexpensive’ • Usually the indicated primary imaging modality

  5. 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

  6. Plain Radiographs - Obvious

  7. Plain Radiographs – 2 views

  8. Plain Radiographs – 2 views Posterior Dislocation

  9. Plain Radiographs – Extra views Radial Head Fx

  10. Plain Radiographs – Extra views Scaphoid Fx

  11. 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

  12. Nuclear Scintigraphy • Excellent for specific pathologies • Osteomyelitis • Metastases – Not Multiple myeloma • Occult fracture • Reasonably reassuring • Normal is usually normal

  13. 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

  14. Nuclear Scintigraphy – Bone Scan Osteomyelitis

  15. Nuclear Scintigraphy 2nd MT stress fracture

  16. 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

  17. 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

  18. Ultrasound Cephalad Ceph Caud Calcaneus Caudad

  19. Ultrasound – Achilles Tendon Intrasubstance tear

  20. Ultrasound – Patellar tendon Proximal patellar tendonitis – Jumper’s Knee

  21. 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

  22. 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

  23. CT - Fractures Scaphoid fracture

  24. CT - Dislocation Lis Franc Fx/Dislocation

  25. CT – Bony anomalies Midsubtalar coalition

  26. 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

  27. 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

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

  29. 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

  30. OPEN CLOSED

  31. MRI – Trauma Osteochondritis dissecans

  32. MRI – Trauma Femoral Neck Fracture

  33. MRI - Trauma Tear vastus medialis

  34. MRI – Internal Derangement

  35. MRI – Internal Derangement Supraspinatus tear= Full thickness, Full width Coronal PD Coronal T2

  36. MRI – Internal Derangement Sagittal NL Sagittal FT, FW Supra

  37. MRI – Internal Derangement Sagittal, Meniscus NL Posterior Horn Tear

  38. MRI – Internal Derangement Bucket handle meniscal tear

  39. MRI – Internal Derangement Sagittal – Intact ACL Torn ACL

  40. 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

  41. THANK YOU Laurie Lomasney, MD

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