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

2. Musculoskeletal Imaging Technology Advances in Imaging

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

7. Plain Radiographs - Obvious

8. Plain Radiographs – 2 views

9. Posterior Dislocation

10. Plain Radiographs – Extra views Radial Head Fx

11. Plain Radiographs – Extra views Scaphoid Fx

12. 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

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

14. 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

16. Nuclear Scintigraphy – Bone Scan Osteomyelitis

17. Nuclear Scintigraphy 2 nd MT stress fracture

18. 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

19. 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

21. Ultrasound CephCaud Cephalad Caudad Calcaneus

22. Ultrasound – Achilles Tendon Intrasubstance tear

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

24. 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

25. 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

27. CT - Fractures Scaphoid fracture

28. CT - Dislocation Lis Franc Fx/Dislocation

29. CT – Bony anomalies Midsubtalar coalition

30. 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

31. 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

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

33. 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

35. MRI – Trauma Osteochondritis dissecans

36. MRI – Trauma Femoral Neck Fracture

37. MRI - Trauma Tear vastus medialis

38. MRI – Internal Derangement

39. Supraspinatus tear= Full thickness, Full width Coronal PDCoronal T2

40. MRI – Internal Derangement Sagittal NLSagittal FT, FW Supra

41. MRI – Internal Derangement Sagittal, Meniscus NLPosterior Horn Tear

42. MRI – Internal Derangement Bucket handle meniscal tear

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

44. 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

45. THANK YOU Laurie Lomasney, MD