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What to Order and How to Interpret the Report
- C. Benjamin Ma, MD
What to Order and How to Interpret the Report C. Benjamin Ma, MD - - PDF document
What to Order and How to Interpret the Report C. Benjamin Ma, MD - - PDF document
12/1/2017 What to Order and How to Interpret the Report C. Benjamin Ma, MD Professor in Residence Shoulder and Sports Medicine University of California, San Francisco Department of Orthopaedic Surgery Imaging Different types of imaging
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Different Modalities
Radiographs Ultrasound CT scan Bone scan MRI
Pearls
Write down what you are concerned
about
- Xrays of ankle with concern of
fibular fracture
- MRI of shoulder with recurrent
instability
Radiologists can help getting the right
studies for you
They can also suggest better studies
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Plain radiographs
Image obtained by projecting of
x-ray beams onto a detector
The amount of ‘whiteness’ is a
function of the radiodensity and thickness of the object
Dense object – whiter image
Plain radiographs
Good first line evaluation Orthogonal views (projection!)
- AP/lateral of the joint
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Lower extremity imaging
Lower extremity are weight
bearing joints.
Joint alignment can be very
different with weight bearing
Can get weight bearing x-rays to
look at joint space and alignment
What to order? Make you look good!
Knee
- AP and Lateral knee
- Weight bearing AP
- Patellofemoral views
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What to order?
Hip
- AP/ frog leg lateral
- AP pelvis
What to order?
Ankle
- AP/lateral ankle
- Mortise view of ankle
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What to order?
Foot
- AP/lateral/oblique foot
- Weight bearing lateral?
Upper extremity imaging - shoulder
AP of GH joint Axillary lateral Supraspinatus
- utlet view
AP of AC joint
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Upper extremity imaging – non weight bearing joints
Elbow AP/lateral
forearm
What to order?
Wrist
- AP/lateral/oblique wrist
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What to order?
AP Hand Lateral Hand
Interpretation
Displaced fractures – always need
attention
Non displaced fracture – can
immobilize
Stress fracture/ cannot rule out….
- Need secondary evaluation
- Further imaging
- Closer followup
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What to look for?
Fractures
- Displaced
- Comminuted
- Impacted
Arthritis
- Mild, moderate, severe
Abnormal morphology
- Spurs, OCD, deformities
Interpretation
Elbow “Sail sign” Occult fractures Pediatric – supracondylar fractures
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Specific Radiographic Studies
Wrist
- Scaphoid view
- Hamate view
Ultrasound
Uses high-frequency sound waves to
produce images
Similar to sonar wave on getting images of
the ocean
Can be helpful to evaluate ganglion cyst
- Knee ganglions
- Foot ganglions
Diagnose tendon tears
- Rotator cuff tears
- Achilles tendon ruptures
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Ultrasound
Advantages
- Non-invasive
- Dynamic
- Tendon instability
Disadvantage
- User-dependent
- Cannot image deep tissue
- Cannot image tissue within bone
Ultrasound
- Use for targeted therapy
- Ultrasound guided injections
- Hip injections
- Calcific tendinitis
- Shoulder injections
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CT scan
Tomographic evaluation of the
region of interest
Good for 3D bony anatomy
- Degenerative joint anatomy
Complex reconstruction Post-traumatic injuries
- Ankle malunion
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
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3D CT scan CT Scan
Hamate Fracture
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CT scan
Disadvantages
- Subject to metal artifact
- Weight limit for obese patients
- Higher radiation
- Contraindicated for pregnant
patients
Nuclear imaging
Uses radioisotope-labelled biological
active drugs
Radioactive tracers administered to
the patient to serve as markers of biologic activity
Images produced by scintigraphy
- Technetium bone scan
- FDG in PET scans
- Measure glycolytic rates
- Higher in tumor cells
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Bone scan
Rule out tumor – multiple lesions,
increase update
Infection – tagged WBC scan Evaluate symptomatic joints
- Such as arthritis
- Nonunion
- Stress fractures
Nuclear medicine
Advantages
- Imaging of metabolic activity
- Healed fracture or nonunion
- Arthritis
- Diagnosis of infection
Disadvantages
- Lack detail and spatial resolution
- Limited early sensitivity
- Fractures usually takes up to
several days to show up
- Low sensitivity for lytic problems
- Multiple myeloma
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MRI
Current gold standard for soft
tissue injuries
- Ligament tears
- Labral tears
- Cartilage injuries
- Meniscus tears
MRI
Helpful to evaluate
ligament integrity
Quality of cartilage
- fraying
- arthritis
Labrum and
meniscus injuries
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MRI
Helpful to evaluate
ligament integrity
Quality of cartilage
- fraying
- arthritis
Labrum and
meniscus injuries
MRI
Helpful to evaluate
ligament integrity
Quality of cartilage
- fraying
- arthritis
Labrum and
meniscus injuries
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MRI
Helpful to evaluate
cuff integrity
Quality of muscle
- Fatty infiltration
- Retracted tear
Labral pathology
OCD of the elbow
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TFCC tear
Triangular FibroCartilage
Complex
Scaphoid fractures
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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
MRI- Gadolinum
Intravenous contrast Evaluate vascularity
- Tumor
- Post-surgical changes, such as
scar tissue
- Concern with kidney
insufficiency and complications
Usually ordered by specialists
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MR arthrogram – elbow
Evaluate
ligament tear
Evaluate OCD
stability
Look for intraarticular problems MCL tear Loose bodies, OCD
MR arthrogram - wrist
Evaluate
ligament tears
Look for
communication between compartments
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Radiology Reports – love adjectives!
Fraying vs Partial tear vs Full
thickness tear vs Retracted tear
Cartilage inhomogeneity vs fissure
vs flap vs unstable flap vs full thickness cartilage loss
Tendon degeneration vs
tendinosus vs tear Clinical Correlation Recommended
CLINICAL HISTORY: 55 yo Posterior shoulder pain x1 year. Denies trauma.
There is adequate distention of the glenohumeral joint with intra-articularly administered contrast. High T2 signal in the anterior subcutaneous fat compatible with iatrogenic injection of anesthetic.
OSSEOUS ACROMIAL OUTLET: There is mild osteoarthrosis at the acromioclavicular joint with fluid in the joint and capsular hypertrophy.. The acromion is type 1 on sagittal imaging. There is no evidence of os acromiale. There is no Thickening of the coracoacromial ligament.
ROTATOR CUFF MUSCLES AND TENDONS:
Mild tendinosis of the supraspinatus tendon and anterior fibers of the infraspinatus tendon. Possible limited interstitial tearing of the posterior fibers of the infraspinatus tendon at the insertion (series 6, image 13).
Normal signal and morphology of the subscapularis and teres minor tendons.
Normal signal and bulk of the rotator cuff muscles.
LABRAL AND CAPSULAR STRUCTURES: Irregularity of the anterosuperior and superior labrum compatible with degenerative changes. Blunting of the anterior labrum without discrete tear. No paralabral cyst formation.
What are they saying?
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What are they saying?
BICEPS TENDON AND ANCHOR: High T1 signal within the intra- articular portion of the long head biceps tendon favored to represent iatrogenic injection. The extra-articular portion of the long head biceps tendon demonstrates normal signal and morphology.
OSSEOUS AND CARTILAGINOUS STRUCTURES: Nonspecific cystic changes at the greater tuberosity. There is no evidence of a fracture or
- dislocation. No focal chondral defects are identified.
MISCELLANEOUS: There are no intra-articular bodies. The remaining muscles demonstrate normal bulk with no evidence of atrophy or edema.
IMPRESSION:
- 1. Irregularity of the anterosuperior and superior labrum compatible with
degenerative changes. Blunting of the anterior labrum without discrete
- tear. The posterior labrum appears intact.
- 2. Mild tendinosis of the supraspinatus tendon and anterior fibers of the
infraspinatus tendon. Possible limited interstitial tearing of the posterior fibers of the infraspinatus tendon at the insertion.
55 yo with no trauma and above findings – AGE Appropriate changes
MENISCUS: There is a complex tear of the body and posterior horn
- f the medial meniscus with large bucket-handle fragment
displaced into the intercondylar notch paralleling the posterior cruciate ligament.
The native torn ACL is seen to be flipped anteriorly and back on itself within the anterior aspect of the intercondylar notch.
IMPRESSION:
- 1. Flipped appearance of the native torn ACL within the anterior
aspect of the intercondylar notch is consistent with stump entrapment/cyclops lesion.
- 2. Large bucket-handle tear of the posterior horn and body of the
medial meniscus.
What are they saying? Knee MRI
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What are they saying? Knee xray
INDICATION: Age: 17 years. Gender: Male. History:
pain vs injury r/o fracture
Bones and joints: Osseous fragment over the superior
pole of patella with marked thickening and irregularity
- f the quadriceps tendon.
Soft tissues: Large joint effusion with patellar soft
tissue swelling.
IMPRESSION: Osseous fragment over the superior pole of the patella
with marked thickening and irregularity of the quadricep tendon with large joint effusion. Findings most compatible with superior pole patellar sleeve fracture.
What are they saying? Foot
CLINICAL HISTORY: r/o fx at left 5th MTP.
jammed foot 3 days ago.
IMPRESSION: 1. Mildly to moderately displaced extra-articular
- blique fracture of the fifth metacarpal shaft. No
evidence of dislocation.
2. Severe degenerative changes of the first MTP
joint compatible with hallux rigidus.
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What are they saying?
65 yo with shoulder pain – evaluate shoulder
MPRESSION:
No evidence of acute fracture or dislocation. Degenerative
changes of the acromioclavicular joint with a hooked type III
acromion and inferiorly projecting osteophytes off the distal
- clavicle. Mild/moderate degenerative changes glenohumeral joint
as well with small marginal osteophytes. Close approximation of
the humeral head and the acromion with weightbearing suggest
underlying rotator cuff pathology.
Additionally noted is an oval ossified fragment along the
posterior superior aspect of the glenoid which may represent an
- steophyte, ossification of the posterior labrum, or old
fracture.
Surgical clips in the right axilla, suggesting prior axillary
lymph node dissection. Additional rounded density medial to the
clips, overlying the lung which could possibly reflect underlying
pulmonary nodule for which dedicated chest radiograph is
recommended..
NORMAL FINDINGS with hooked type III acromion!!! Pulmonary nodules – depends on history May need further evaluation
What are they saying?
CLINICAL HISTORY: 51-year-old male with right shoulder pain after fall, rule out full thickness rotator cuff tear
OSSEOUS ACROMIAL OUTLET: Large inferior clavicular osteophytes indent the
- supraspinatus. Fluid is noted in the acromioclavicular joint with reactive marrow changes.
Type 2 acromion.
ROTATOR CUFF MUSCLES AND TENDONS: Full thickness tear is seen at the anterior footprint of the supraspinatus tendon, with slightly increased intensity within the rest of the supraspinatus tendon compatible with tendinosis. The infraspinatus, subscapularis, and teres minor tendons demonstrate normal signal and morphology. The rotator cuff muscles are unremarkable.
LABRAL AND CAPSULAR STRUCTURES: Unremarkable. No evidence of labral tears.
BICEPS TENDON AND ANCHOR: Unremarkable. Normal signal and morphology of the biceps tendon.
OSSEOUS AND CARTILAGINOUS STRUCTURES: Unremarkable. Normal bone marrow
- signal. No evidence of fractures.
MISCELLANEOUS: The inferior glenohumeral ligament is not well defined and thickened. Fluid is also noted in the subacromial/subdeltoid bursa. Rotator interval synovitis.
IMPRESSION:
- 1. Full thickness tear at the anterior footprint of the supraspinatus tendon with supraspinatus
tendinosis.
- 2. Thickening of the inferior glenohumeral ligament as well as rotator interval synovitis may
reflect adhesive capsulitis.
51 yo with fall and full thickness rotator cuff tears Refer for treatment and repair
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What are they saying?
40 yo with acute elbow pain – concern with biceps rupture
FINDINGS:
MUSCLES AND TENDONS: An acute tear of the biceps tendon at its
insertion on the radius is associated with approximately 5.5 cm
- f retraction of the proximal tendon and large amounts of T1
hypointense and T2 hyperintense fluid within the soft tissues of
the anterior elbow.
The common flexor tendon is normal in signal and thickness. The
common extensor tendon is frayed and irregular and may be
consistent with prior injury.
LIGAMENTS: The ulnar and radial collateral ligament complexes
are intact.
OSSEOUS AND CARTILAGINOUS STRUCTURES: No bone marrow
abnormalities identified. Diffuse thinning of the cartilage is
noted.
What are they saying?
NERVES: The ulnar nerve is normal in signal and caliber.
MISCELLANEOUS: No joint effusion or loose bodies are identified.
IMPRESSION:
- 1. An acute tear of the biceps tendon at its insertion on the
radius is associated with approximately 5.5 cm of retraction of
the proximal tendon.
- 2. The common extensor tendon is frayed and irregular and may be
consistent with prior injury.
Good radiology report Identify acute injuries Downplay chronic injuries Summary or Impression usually are the more important focus
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What are they saying? MRI Hip
LABRUM: Degenerative tearing of the anterior and superior
- labrum. Degenerative ossification is also seen in the anterior
labrum (image 17, series 4).
LIGAMENTS: The ligamentum teres and transverse acetabular ligament are intact. Linear low signal intensity medial to the ligamentum teres may represent a thick acetabular plica.
TENDONS: The visualized rectus femoris, proximal hamstring, and iliopsoas tendons are intact. Edema around the gluteus tendon insertion, greater around the minimus than the medius, is compatible with mild peritendinitis.
IMPRESSION:
- 1. Degenerative tearing of the anterior and superior labrum.
- 2. Focal chondral loss Along the superolateral and anterior
femoral acetabular cartilage. Focal chondral loss along the posterior medial aspect acetabular cartilage.
- 3. Mild peritendinitis of the gluteus tendon insertion, greater
around the minimus than the medius.
65 yo with mild hip arthritis and tendinitis Age appropriate changes
Asymptomatic Knee Lesions
High prevalence of meniscus tears
in older individuals
Especially with osteoarthritis (91%) May not be symptomatic “complex” tear is an appearance,
may not be symptomatic
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MR imaging of Shoulder
Accurate Asymptomatic individuals
- > 60 y.o. – 54% tears (28% full,
26% partial)
- 40 – 60 y.o.– 4% full, 24% partial
- 19 – 39 y.o. – 0% full, 4% partial
Careful Interpretation!!! Treat the patient, not the MRI
Intepretation
Rotator cuff tears
- Age of patients
- Older patients – common to
have partial cuff tears
- Non op rehab
- Full thickness cuff tears
- Referral for discussion of
treatment
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SLAP tears
Common with older age SLAP tear >50 yo
- Operative treatment can lead to
stiffness
- Rarely culprit of symptoms
SLAP tear younger overhead
athletes
- Usually symptomatic
- Surgical treatment
Imaging
Write down what your question is
- Radiology can help answer them
Plain radiography – first start Acute injuries – can order further
imaging or quick referral
Chronic injuries – can order further
imaging and interpret results
Post op injuries - referral
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Thank you
C. Benjamin Ma, M.D.