Disclosures What to Order and How to Interpret the My co-authors - PowerPoint PPT Presentation

12/15/2018 Disclosures What to Order and How to Interpret the  My co-authors and I have no Report relevant financial disclosures related to this work. C. Benjamin Ma, MD • Research: NIH/NIAMS, AOSSM, AANA, Zimmer, Histogenics, Samumed • Consultant: Zimmer, Stryker, Conmed • Membership: AOSSM, AANA, ISAKOS Professor in Residence Shoulder and Sports Medicine University of California, San Francisco Department of Orthopaedic Surgery Imaging Why image?  Different types of imaging  New injuries  Imaging orders that make you  Chronic problems look “awesome”  Rule out tumor  Interpretation of reports 1

12/15/2018 Imaging Different Modalities  Aid diagnosis  Radiographs  Determine significance  Ultrasound  Allow treatment plan  CT scan  Bone scan  MRI Pearls Plain radiographs  Write down what you are concerned about  Image obtained by projecting of  Xrays of ankle with concern of x-ray beams onto a detector fibular fracture  The amount of ‘ whiteness ’ is a  MRI of shoulder with recurrent function of the radiodensity and instability thickness of the object  Radiologists can help getting the right  Dense object – whiter image studies for you  They can also suggest better studies 2

12/15/2018 Plain radiographs Lower extremity imaging  Good first line evaluation  Lower extremity are weight bearing joints.  Orthogonal views (projection!)  Joint alignment can be very  AP/lateral of the joint different with weight bearing  Can get weight bearing x-rays to look at joint space and alignment What to order? Make you look good! What to order?  Knee  Hip  AP and Lateral knee  AP/ frog leg lateral  Weight bearing AP  AP pelvis  Patellofemoral views 3

12/15/2018 What to order? What to order?  Ankle  Foot  AP/lateral ankle  AP/lateral/oblique foot  Mortise view of ankle  Weight bearing lateral? Upper extremity imaging – Upper extremity imaging - shoulder non weight bearing joints  Elbow  AP of GH joint  AP/lateral  Axillary lateral forearm  Supraspinatus outlet view  AP of AC joint 4

12/15/2018 What to order? What to order?  Wrist  AP Hand  AP/lateral/oblique wrist  Lateral Hand Interpretation What to look for?  Fractures  Displaced fractures – always need attention  Displaced  Non displaced fracture – can  Comminuted immobilize  Impacted  Stress fracture/ cannot rule out….  Arthritis  Need secondary evaluation  Mild, moderate, severe  Further imaging  Abnormal morphology  Closer followup  Spurs, OCD, deformities 5

12/15/2018 Interpretation Specific Radiographic Studies  Elbow “Sail sign”  Wrist  Occult fractures  Scaphoid view  Pediatric – supracondylar fractures  Hamate view Ultrasound Ultrasound  Advantages  Uses high-frequency sound waves to produce images  Non-invasive  Similar to sonar wave on getting images of  Dynamic the ocean  Can be helpful to evaluate ganglion cyst • Tendon instability  Knee ganglions  Disadvantage  Foot ganglions  Diagnose tendon tears  User-dependent  Rotator cuff tears  Cannot image deep tissue  Achilles tendon ruptures  Cannot image tissue within bone 6

12/15/2018 Ultrasound CT scan  Use for targeted therapy  Tomographic evaluation of the region of interest • Ultrasound guided injections  Good for 3D bony anatomy - Hip injections  Degenerative joint anatomy - Calcific tendinitis - Shoulder injections  Complex reconstruction - Reports are very examiner  Post-traumatic injuries dependent  Ankle malunion CT scan 3D CT scan  Advantages  Tomographic evaluation  No magnification  Give detail in trabecular and cortical structures (better than MRI) • Measure bone loss • Evaluate fracture pattern • Evaluate healing 7

12/15/2018 CT Scan CT scan  Hamate Fracture  Disadvantages  Subject to metal artifact  Weight limit for obese patients  Higher radiation  Contraindicated for pregnant patients  Images and reports are always worse because of details Nuclear imaging Bone scan  Uses radioisotope-labelled biological  Rule out tumor – multiple lesions, active drugs increase update  Radioactive tracers administered to  Infection – tagged WBC scan the patient to serve as markers of biologic activity  Evaluate symptomatic joints  Images produced by scintigraphy  Such as arthritis  Technetium bone scan  Nonunion  FDG in PET scans  Stress fractures • Measure glycolytic rates • Higher in tumor cells 8

12/15/2018 Nuclear medicine MRI  Advantages  Current gold standard for soft  Imaging of metabolic activity • Healed fracture or nonunion tissue injuries • Arthritis  Ligament tears  Diagnosis of infection  Disadvantages  Labral tears  Lack detail and spatial resolution  Cartilage injuries  Limited early sensitivity • Fractures usually takes up to  Meniscus tears several days to show up  Low sensitivity for lytic problems • Multiple myeloma MRI MRI  Helpful to evaluate  Helpful to evaluate ligament integrity ligament integrity  Quality of cartilage  Quality of cartilage  fraying  fraying  arthritis  arthritis  Labrum and  Labrum and meniscus injuries meniscus injuries 9

12/15/2018 MRI MRI  Helpful to evaluate  Helpful to evaluate ligament integrity cuff integrity  Quality of cartilage  Quality of muscle  fraying  Fatty infiltration  arthritis  Retracted tear  Labrum and  Labral pathology meniscus injuries OCD of the elbow TFCC tear  Triangular FibroCartilage Complex 10

12/15/2018 Scaphoid fractures MRI with contrast -Gadolinum  Intra-articular contrast  Distends the joint  Enable evaluation of ligament and labrum  Hip and shoulder labral tears  Meniscus repairs  Cartilage injuries, such as TFCC MR arthrogram – elbow MRI- Gadolinum  Intravenous contrast  Evaluate  Evaluate vascularity ligament tear  Tumor  Evaluate OCD  Post-surgical changes, such as stability scar tissue  Concern with kidney insufficiency and complications Look for intraarticular problems  Usually ordered by specialists MCL tear Loose bodies, OCD 11

12/15/2018 MR arthrogram - wrist Radiology Reports – love adjectives!  Fraying vs Partial tear vs Full thickness tear vs Retracted tear  Evaluate ligament tears  Cartilage inhomogeneity vs fissure vs flap vs unstable flap vs full  Look for thickness cartilage loss communication between  Tendon degeneration vs compartments tendinosus vs tear Clinical Correlation Recommended What are they saying? What are they saying? CLINICAL HISTORY: 55 yo Posterior shoulder pain x1 year. Denies trauma.  BICEPS TENDON AND ANCHOR: High T1 signal within the intra-  There is adequate distention of the glenohumeral joint with intra-articularly articular portion of the long head biceps tendon favored to represent  administered contrast. High T2 signal in the anterior subcutaneous fat iatrogenic injection. The extra-articular portion of the long head biceps compatible with iatrogenic injection of anesthetic. tendon demonstrates normal signal and morphology. OSSEOUS ACROMIAL OUTLET: There is mild osteoarthrosis at the OSSEOUS AND CARTILAGINOUS STRUCTURES: Nonspecific cystic   acromioclavicular joint with fluid in the joint and capsular hypertrophy.. The changes at the greater tuberosity. There is no evidence of a fracture or acromion is type 1 on sagittal imaging. There is no evidence of os acromiale. dislocation. No focal chondral defects are identified. There is no Thickening of the coracoacromial ligament. MISCELLANEOUS: There are no intra-articular bodies. The remaining  ROTATOR CUFF MUSCLES AND TENDONS: muscles demonstrate normal bulk with no evidence of atrophy or edema.  Mild tendinosis of the supraspinatus tendon and anterior fibers of the IMPRESSION:   infraspinatus tendon. Possible limited interstitial tearing of the posterior fibers of 1. Irregularity of the anterosuperior and superior labrum compatible with  the infraspinatus tendon at the insertion (series 6, image 13). degenerative changes. Blunting of the anterior labrum without discrete Normal signal and morphology of the subscapularis and teres minor tendons. tear. The posterior labrum appears intact.  Normal signal and bulk of the rotator cuff muscles. 2. Mild tendinosis of the supraspinatus tendon and anterior fibers of the   infraspinatus tendon. Possible limited interstitial tearing of the posterior LABRAL AND CAPSULAR STRUCTURES: Irregularity of the anterosuperior  fibers of the infraspinatus tendon at the insertion. and superior labrum compatible with degenerative changes. Blunting of the anterior labrum without discrete tear. No paralabral cyst formation. 55 yo with no trauma and above findings – AGE Appropriate changes 12