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CLINICAL ASSESSMENTMRI IMAGING. PANACEA ?PANDORA’S BOX ?

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Presentation on theme: "CLINICAL ASSESSMENTMRI IMAGING. PANACEA ?PANDORA’S BOX ?"— Presentation transcript:

1 CLINICAL ASSESSMENTMRI IMAGING

2 PANACEA ?PANDORA’S BOX ?

3  INCEPTION 1980’S  REVOLUTIONIZED EVALUATION OF STI  SUPERB ST CONTRAST cf OTHER DI  MULTIPLE PLANES

4  PROTONS ALIGN WITH MAGNETIC FIELD  RFW DISTURB ALIGNMENT.  ENERGY RELEASED DURING REALIGNMENT MEASURED AND USED TO GENERATE IMAGE  RF SEQUENCES MANIPULATED TO HIGHLIGHT DIFFERENT TISSUES IN DIFFERENT WAYS

5 TEMPTATIONREALITY  SOPHISTICATED, ELEGANT TECHNOLOGY  ANATOMY TEXT-LIKE IMAGES  TEMPTING TO VIEW AS THE DEFINITIVE Ix  DEPENDING ON TISSUE, SENSITIVITY 80 – 95%  SPECIFICITY LESS  THUS POTENTIALLY SIGNIFICANT FALSE + AND FALSE -

6 MRI 101 (cont) OTHER PROBLEMS  EXPENSIVE  LONG WAITS -> CAN LEAD TO UNNECESSARY DELAY IN RX  PATIENT INTOLERANCE  PRESSURES TO ORDER FROM PTS, PT, DC, LAWYER, ETC (might be easier to say “can’t order” than to spend time explaining why inappropriate)  TIME TO PROPERLY COMPLETE REQUISITION

7

8 ACUTE KNEE INJURIES HISTORY: MECHANISM OF INJURY SWELLING MECHANICAL SYMPTOMS PAIN

9  MECHANISM: Compression usually necessary, rotation, valgus  MEDIAL > LATERAL  SWELLING: Gradual  MECHANICAL SX: Clunking, locking  PAIN: Not necessarily localized

10 MENISCAL TEAR CLINICAL ASSESSMENT: SQUAT

11 MENISCAL TEAR CLLINICAL ASSESSMENT: THESSALY TEST

12 MENISCAL TEAR CLINICAL ASSESSMENT: JOINT LINE TENDERNESS

13 MENISCAL TEAR CLINICAL ASSESSMENT: McMURRAY

14 ACUTE KNEE INJURY: ? XRAY OTTAWA KNEE RULES  AGE > 55  ISOLATED TENDERNESS OF PATELLA (NO OTHER BONY TENDERNESS)  TENDERNESS OF HEAD OF FIBULA  INABILITY TO FLEX KNEE TO 90 DEGREES  INABILITY TO BEAR WEIGHT IMMEDIATELY AND IN ER  (MASSIVE SWELLING)

15 YESNO  EQUIVOCAL CLINICAL PRESENTATION AND NO IMPROVEMENT WITH PT  HIGH SUSPICION OF OTHER INJURY (ACL, PCL, SUBCHONDRAL)  CLASSICAL PRESENTATION  DEGENERATIVE CHANGES

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17  MECHANISM: VALGUS STRESS  IF SIGNIFICANT SWELLING SUSPECT ASSOCIATED INJURY  IF SENSE OF INSTABILITY AND LITTLE PAIN SUSPECT HIGH-GRADE INJURY

18  CLINICAL ASSESSMENT: VALGUS STRESS AT 30 DEGREES AND FULL EXTENSION (if gap at full extension, suspect MCL + ACL)  Gr 1: 1-5 mm, firm EF  Gr 2: 6-10 mm, firm  Gr 3: >10 mm, soft

19 YESNO  HIGH SUSPICION OF ACL OR PCL  ISOLATED MCL

20 NORMAL

21 GR 2GR 3

22  MECHANISM: ROTATION, VALGUS, HYPEREXTENSION  SWELLING: IMMEDIATE, MASSIVE  MECHANICAL SX: INSTABILITY  PAIN: DIFFUSE

23

24  CLINICAL ASSESSMENT: LACHMAN TEST  Gr 1: 1-5mm > contralat  Gr 2: 6-10mm  Gr 3: >10mm  A=firm  B=soft

25  CLINICAL ASSESSMENT: ANTERIOR DRAWER

26  CLINICAL ASSESSMENT: PIVOT SHIFT  Knee relaxed, full ext. Valgus stress to tibia with axial load and int rot. Knee flexed. Lat tibia subluxes, reduces with flex.  Gr 0: no detectable shift  Gr 1: glide  Gr 2: abrupt reduction  Gr 3: temporary lock then reduction

27  CLINICAL ASSESSMENT: PIVOT SHIFT

28 YESNO  HIGH LIKELIHOOD OF ASSOCIATED STI, SUBCHONDRAL INJURY, BONE BRUISING  “OLDER” PATIENT WHO IS BETTER MANAGED WITH PT, ACTIVITY MODIFICATION, BRACING

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30  MECHANISM: DIRECT BLOW TO TIBIA WITH KNEE FLEXED, HYPEREXTENSION, VARUS/VALGUS STRESS IF FIRST LINE OF DEFENCE TORN  SWELLING: OVER 24 HR  MECHANICAL SX: +/- INSTABILITY  PAIN: DIFFUSE, POSTERIOR  (RARELY SEEN AS ISOLATED INJURY)

31  CLINICAL ASSESSMENT: POSTERIOR SAG

32  CLINICAL ASSESSMENT: POSTERIOR DRAWER

33 YES:  HIGH LIKELIHOOD OF ASSOCIATED INJURY

34  MECHANISM: VALGUS, ROTATION  SWELLING: IMMEDIATE, MASSIVE  MECHANICAL SX: NO UNLESS # (SUBCHONDRAL #), ASSOC INJURY  PAIN: DIFFUSE

35 CLINICAL ASSESSMENT  PATELLAR TENDERNESS  MEDIAL SOFT TISSUE TENDERNESS  PATELLAR APPREHENSION TEST  PATELLA ALTA, “J” SIGN

36 XRAY?MRI?  YES: R/O #  NO, UNLESS SUSPICION OF SUBCHONDRAL #, ASSOCIATED STI

37

38 TUBSAMBRI

39  MECHANISM: ABD/ER  XR TO R/O #  SHOULDER IMMOBILIZER FOR COMFORT; D/C ASAP (CONSIDER ER BRACE)  EARLY PT  NO MRI

40  ANTERIOR APPREHENSION TEST/FOWLER’S RELOCATION SIGN  XR: AP, Y VIEW, AXILLARY, WEST POINT (BANKART), STRYKER NOTCH (HILL-SACHS)  REFER  NO MRI

41 ANTERIOR APPREHENSION SIGN FOWLER’S RELOCATION SIGN

42  GENERALIZED JOINT LAXITY  LOAD AND SHIFT TEST, INFERIOR SULCUS SIGN  PT  NO XR, MRI

43 LOAD AND SHIFTINFERIOR SULCUS

44  MECHANISM: DIRECT BLOW, DISLOCATION/SUBLUXATION, REPETITIVE OVERHEAD STRESS (MOST COMMON)  USUALLY ACCOMPANIES OTHER PATHOLOGY WHICH IS MAIN FOCUS OF RX: INSTABILITY, RC TENDINOPATHY/IMPINGEMENT

45  MECHANISM: FALL, LOAD IN FLEX/EXT, OVERHEAD OVERUSE  SX: PAIN, CATCHING WITH LOAD IN FLEX; CLICK; IMPINGEMENT; SENSE OF INSTABILITY

46  BICEPS TENDINOPATHY: SPEED’S

47  SLAP: O’BRIEN’S, CRANK, PAIN PROVOCATIVE, COMPRESSION ROTATION, BICEPS LOAD

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49 LABRAL TEAR/SLAPBICEPS TENDINOPATHY  NO – NEED MRA  NO – EASY CLINICAL DX, WON’T CHANGE RX, WORST CASE OUTCOME IS A COSMETIC PROBLEM

50 MECHANISMSYMPTOMS  TRAUMA  USUALLY OVERHEAD OVERLOAD  PAIN: DIFFUSE, OFTEN SUPERIOR REFERRED TO DELTOID INSERTION  +/- CLICK  IMPINGEMENT: SEVERE PAIN WITH ELEVATION/IR  WEAKNESS: ?PAIN- INHIBITION

51 HAWKINSNEERS

52 SUPRASPINATUS: JOBE’S (EMPTY CAN)

53 INFRASPINATUS

54 TERES MINOR

55 SUBSCAPULARIS: LIFTOFF (CAN ALSO DO BELLY PRESS) NO

56  IF STRONG SUSPICION OF TEAR: YES

57 SS TENDINOPATHYSS TEAR


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