1. Nuclear Medicine in the Evaluation of Trauma
Materials for medical students
Helena Balon, MD
Wm. Beaumont Hospital
Royal Oak, MI, USA
Charles University
3rd School of Medicine
Dept Nucl Med, Prague

3. Radionuclide methods in traumatology
Musculoskeletal trauma
Bone scan
Trauma to internal organs (hematoma, laceration, fracture, perforation, leaks)
Renal scan
Myocardial scan
Hepatobiliary scan
(Liver / spleen scan) - CT preferred
(Testicular scan) - US preferred
Head trauma
CT preferred
Cerebral perfusion scan - brain death
Cisternography - CSF leak

4. Bone scan in trauma Very sensitive
Detects areas of abnormal bone turnover
Shows areas that need further radiol.evaluation
Provides objective evidence of disorder when X ray negative

5. Bone scan Tracers: diphosphonates (Tc-99m MDP, HDP) Dose: 500-900MBq
Tracer localization (chemisorption onto surface of bone trabeculae) depends on:
blood flow
capillary permeability
bone metabolism (activity of osteoblasts, osteoclasts, new bone formation)

6. Bone scan Patient preparation Pre-test: none
Post-injection: good oral hydration
Frequent voiding
Perchlorate p.o. preinj. to decrease rad. dose to thyroid

7. Bone scan Methods Regular - imaging @ 2-4 hrs post injection
3-phase (dynamic angiogram + blood pool + delay)
Planar or SPECT
Whole body ANT & POST, additional views (lat.,oblique)
Parallel hole or pinhole collimator (for small structures)

8. Bone Scan in Trauma Fractures & occult fx
Child abuse (except skull fx)
Stress fractures (insufficiency fx, fatigue fx)
Avulsion injuries
Shin splints
Bone bruises (contusion)
RSD (reflex sympathetic dystrophy)
Osteochondral lesions

9. Diagnosis of Fractures
Plain X ray, X ray tomography - if neg >>>
Bone scan
if neg >>> stop work-up
if diagnostic >>> treat
if more information needed >>>
CT (subtle changes) or
MRI (subtle changes, soft tissue trauma, bone bruise, precise dx of limited area)

10. Fractures on Bone scan Acute fx
Positive on all 3 phases
Positive immediately after trauma in most pts
90% sensitivity if imaged in < 48 hrs
If scan neg. in pts > 75y >>> repeat scan in 3-7 d
Bone scan remains positive for 6-24 mo (healing fx)

11. Acute compression fractures
80 y/o F w osteopenia fell 6 wks prior

12. Rib fractures

13. Multiple fx’s
59 F w breast ca MVA 10 d ago

14. Osteogenesis imperfecta

15. Bone Bruise
Direct trauma with disruption of trabecular bone but not cortical bone
X ray - negative
Bone scan - 3-phase positivity
MRI - bone marrow involvement (hemorrhage)

16. Leg & Foot Trauma

17. Shin / thigh splints Continuous spectrum from shin splint to stress fx
Stress related periostitis along muscle insertion sites (soleus, tibialis posterior, adductor longus/brevis, gluteus max)
X ray - negative
Bone scan
Flow, blood pool - normal
Delay- vertical, linear uptake along posteromedial tibial cortex (mid- or distal 1/3) medial or lateral femoral cortex (proximal 1/3)

18. Shin Splints

19. Shin splints, thigh splints

20. Thigh splints - mechanism

21. Stress Fractures Fatigue fractures Abnormal stress on normal bone
(jogging, gymnastics, skating, military)
Insufficiency fractures
Normal stress on abnormal bone
(osteoporosis, osteomalacia, RA, HPT, steroids, radiation Rx)

22. Stress fractures Pathophysiology - repetitive microtrauma (athletes)
Symptoms - pain, swelling
Common locations:
Tibia - proximal or distal 1/3
Fibula - distal 1/3
Metatarsals (2nd, 3rd)
Tarsal bones (calcaneus, navicular)
Femoral neck
Inferior pubic ramus
Lower lumbar spine (spondylolysis)

23. Stress fractures X ray may be initially negative (2-4 wks)
Bone scan, MRI – positive earlier
Bone scan 3-phase positivity
Flow + for ~ 1 mo
Blood pool + for ~ 2 mo
Delay + for ~ 9-12 mo
Rx - restrict sports for 4-6 wks

24. Stress fx ?

25. Stress fractures

26. Metatarsal stress fracture

27. Metatarsal stress fracture

28. Metatarsal stress fx

29. Plantar fasciitis Heel pain
Post-traumatic inflammation of plantar ligament due to
athletic overuse
prolonged standing
walking on hard surface
Bone scan
Focal blood pool + delayed uptake in inferior posterior calcaneus

30. Plantar fasciitis

31. Achilles tendonitis

32. Impingement syndromes
Posterior impingement sy (os trigonum sy)
Excessive repeat plantar flexion (compression between posterior calcaneus & posterior tibia)
Ballet dancers, gymnasts
Anterior impingement sy
Excessive repeat dorsal flexion >>> hypertrophic spur on dorsum (talus & anterior tibia)
Ballet dancers, gymnasts, high jumping

33. Posterior impingement syndrome (os trigonum stress fx)

34. Hip & Pelvis Trauma

35. Femoral neck stress fracture
Thigh or groin pain in athletes
Must distinguish femoral neck stress fx from pubic ramus stress fx
Must treat / immobilize early to prevent complete fx, AVN

36. Femoral neck Fx
76F w L groin pain
X ray neg

37. X ray 2 weeks later

38. Intertrochanteric fracture
93 F, fall 6 days ago, Rt hip pain

39. IT fx

40. Avascular necrosis (AVN)
Etiology
trauma (fx)
steroids, alcohol abuse
pancreatitis, fat embolism
vasculitis, SS disease
idiopathic
Pathophysiology: bone ischemia
Diagnosis
MRI most sensitive
bone scan useful

41. AVN Common locations Bone scan Femoral head (Legg-Perthes in children)
Carpal (scaphoid, lunate), tarsal (talus)
Long bones, ribs in SS
Bone scan
Initially “cold”
Revascularization starts in 1-3 wks, from periphery, diffusely “hot”, lasts for months

42. IT Fx + AVN
50 M w fall a few weeks ago

43. IT fx + AVN
MRI

44. Sacrococcygeal Fx
ANT POST

45. Sacral insufficiency fx
ANT POST
79 F fell 1 mo ago (“Honda” sign)

46. Pelvic fractures
4 days post fall
1 month later

48. Spine trauma

49. Spondylolysis
Stress fx of posterior vertebral elements (pars interarticularis) due to repetitive trauma
Teenagers, young adults
Hyperextension sports (gymnastics, diving, weight lifting, soccer,hockey)
Genetic predisposition?
L5 > L4 > L3
Frequently bilateral >>> spondylolisthesis

51. Spondylolysis X ray Normal or sclerosis, later lucency 2º fx
Bone scan increased uptake in pars interarticularis SPECT better than planar
Rx – discontinue activity

52. Pars interarticularis defect
14 y/o F basketball player trauma 1 mo prior

53. Pars defect

54. Transverse process fracture
planar SPECT
CNM 2001:863

55. Hand & Wrist Trauma

56. Wrist fractures Scaphoid fx - most common Hook of hamate fx
70-80% carpal fx
Fall on outstretched hand
Common complications - AVN, non-union
Hook of hamate fx
Direct injury from handles (tennis, golf, baseball)
Radial / ulnar styloid fx

57. fall, injured Rt wrist

58. Fracture of radius + scaphoid
S/P fall, suspect scaphoid fx X ray neg.

59. Scaphoid Fx
14 y/o M fell 6 wks ago, X ray negative

60. Hook of the hamate fracture
R wrist pain

61. Hook of the hamate injury - mechanism

62. Reflex Sympathetic Dystrophy (Sudeck’s atrophy, Shoulder-hand sy, Causalgia, Chronic regional pain sy)
Sympathetically mediated disorder (vasomotor instability)
Etiology
Trauma (blunt, fracture) MI
Stroke/CVA
Infection
Idiopathic
Symptoms: exquisite pain, tenderness, edema, skin changes, locally warm or cold UE or LE

63. Reflex Sympathetic Dystrophy (RSD)
Bone scan
Early stage: 3-phase positive
Later stage (> 6 mo): only delayed phase posit.
Delayed phase MDP: diffuse increased uptake in entire limb, “periarticular accentuation” in small joints
Children: often all 3 phases or
Sensitivity: 60-95%
X ray
Periarticular ST edema
Late changes- bone resorption, osteopenia

64. Reflex sympathetic dystrophy
(RSD)
73 F w Rt hand/wrist pain no trauma

65. Non-accidental injury
1 mo old baby w intracranial hemorrhage,
Lt parietal fx

67. Muscle trauma (Rhabdomyolysis)
MDP
weight lifting
CNM 2001: 344

68. Muscle uptake (Rhabdomyolysis)
pt w Ewing sarcoma, s/p BKA,
walking on crutches

69. Trauma to internal organs

70. Hepatobiliary Scan Tc-99m IDA (disofenin, mebrofenin)
dose ~ MBq i.v.
imaging of liver, abdomen, pelvis over 1 hr
delayed images if 1st hr negative
Bile leak - activity anywhere in peritoneal cavity
Common after laparoscopic cholecystectomy
Usually seals off spontaneously
Leak clin. more significant if no transit into bowel seen (needs surgical intervention)

71. Bile leak

72. Liver - Spleen Scan Tc-99m sulfur colloid Parenchymal defects
dose ~ MBq i.v.
SPECT imaging better than planar
Parenchymal defects
laceration, rupture, hematoma
Splenosis
splenic implants on peritoneum following spleen rupture

73. Splenosis
MVA 30 y ago, S/P splenectomy
Tc-99m S.C.

74. Pleuroperitoneal leak
Rt LAT
ANT
Pt. on peritoneal dialysis

75. Renal Scans Tc-99m MAG3 or DTPA Tc-99m DMSA ~ 100-300 MBq
Dynamic images over min
Assessment of perfusion, function, leaks
Tc-99m DMSA
~ MBq
Static 2-4 hrs post injection
High resolution needed for renal morphology
pinhole, SPECT
Parenchymal defects - laceration, rupture, hematoma
Extrinsic defects - perinephric / retroperiton. hematoma

76. Urine leak
CNM 2001:724

77. Testicular scan Indications: Acute torsion Delayed torsion
Epidymitis / orchitis
Tc-99m pertechnetate
Flow + immediate static images
“Donut sign”
Late torsion
Abscess
Trauma (hematoma)
Tumor

79. Cisternography In-111 DTPA intrathecally
CSF leak - paraspinal (meningeal tears)
CSF rhinorrhea, otorrhea
imaging
counting nasal pledgets for radioactivity
pledget / plasma ratio

80. Cerebral perfusion Tc-99m HMPAO or ECD dose ~ 800 MBq
Post-traumatic perfusion defects
Assessment of brain death - role of NM complementary
no flow
no parenchymal uptake

81. Head Trauma ? Brain death?
15 y/o F with intracranial bleed

82. Brain death

83. Radionuclide synovectomy (radiosynoviorthesis, RSO)
Intraarticular treatment using beta rays
Goal is to destroy inflammed synovia
Alternative to surgical synovectomy
Mostly in out-patients
More than one joint treatment possiblity
Repeated treatment
More than 40 years experience

84. Indications Patients resistent to steroid injection
Rheumatoid arthritis
Repetitive idiopatic swelling
Repetitive decompensated arthrosis
Psoriatic arthropathy
Haemophillic arthropathy

85. Contraindications Pregnancy, breast feeding
Septic arthritis, infection around the joint
Tumor of the joint
Children (relative)
Massive haemarthros
Popliteal cyst rupture
There are no side effects

86. Radiopharmaceuticals
Sterile colloidal suspension
Beta radiation (or mixed – imaging)
Large joints (knee)
Y-90 citrate, silikate
Middle joints (shoulder, elbow, wrist, hip)
Re -186 sulphate
Small joints (hands)
Er-169 citrate

87. How it works Colloidal particles Small enough to be phagocytozed
Large enough to remain within the joint cavity
Should be biodegradable
Energy sufficient to penetrate and ablate the synovial tissue
Not to damage underlying articular cartilage or overlying skin

88. Side effects Radiation synovitis
Reduced with simultaneous steroids injection
Infection
Less frequent than in steroids alone
Tissue necrosis
Fistula around injection, paraarticular injection
Thrombosis
Due to join fixation

89. Procedure Joint puncture Withdrawing of the fluid Injection of the RP
Injection of the steroid
Joint fixation for 24 to 72 hours

90. Effectiveness
Local hyperthermia and swelling decrease within 3-4 months.
> 75% patients significant decrease in pain and swelling in rheumatoid arthritis,
> 90% in hemophiliac joints reduction of bleeding episodes
52 ± 24% effect in osteoarthritis

91. Effectiveness depends on
Precise diagnosis
Stage of the disease
Correct indication
Correct application
Joint fixation
Another injection could be performed 6 moths later
Better repetitive injection of less radioactivity

92. Conclusion
RSO is cost effective, safe and improves quality of life in patients with disabling arthritis
The fear of developing cancer has been conclusively ruled out in extensive studies