What to Order and How to Interpret the Report

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1 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 Imaging orders that make you look awesome Interpretation of reports 1

2 Why image? New injuries Chronic problems Rule out tumor Imaging Aid diagnosis Determine significance Allow treatment plan 2

3 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 3

4 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 4

bearing x-rays to look at joint space and alignment What to order?

5 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 5

6 What to order? Hip AP/ frog leg lateral AP pelvis What to order? Ankle AP/lateral ankle Mortise view of ankle 6

7 What to order? Foot AP/lateral/oblique foot Weight bearing lateral? Upper extremity imaging - shoulder AP of GH joint Axillary lateral Supraspinatus outlet view AP of AC joint 7

8 Upper extremity imaging non weight bearing joints Elbow AP/lateral forearm What to order? Wrist AP/lateral/oblique wrist 8

$AP Hand Lateral Hand Interpretation Displaced fractures$ $always need attention Non displaced fracture can$

9 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 9

$Elbow Sail sign Occult fractures$

10 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 10

Specific Radiographic Studies Wrist Scaphoid view Hamate view Ultrasound Uses high-frequency sound waves to produce images Similar to sonar wave on getting

11 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 11

tissue within bone Ultrasound Use for targeted therapy Ultrasound

12 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 12

$Advantages Tomographic evaluation No magnification Give detail in trabecular and cortical structures (better than MRI) Measure bone loss Evaluate fracture pattern Evaluate healing$

13 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 13

14 3D CT scan CT Scan Hamate Fracture 14

15 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 15

$Bone scan Rule out tumor multiple lesions, increase update Infection tagged WBC scan Evaluate symptomatic joints Such as arthritis Nonunion Stress fractures Nuclear medicine Advantages Imaging of$

16 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 16

17 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 17

18 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 18

19 MRI Helpful to evaluate cuff integrity Quality of muscle Fatty infiltration Retracted tear Labral pathology OCD of the elbow 19

20 TFCC tear Triangular FibroCartilage Complex Scaphoid fractures 20

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

21 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 21

tear Loose bodies, OCD MR arthrogram - wrist Evaluate

22 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 22

23 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 What are they saying? 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. 23

What are they saying? BICEPS TENDON AND ANCHOR: High T1 signal within the intraarticular portion of the long head biceps tendon favored to represent iatrogenic injection.

24 What are they saying? BICEPS TENDON AND ANCHOR: High T1 signal within the intraarticular 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 What are they saying? Knee MRI MENISCUS: There is a complex tear of the body and posterior horn of 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. 24

$History: pain vs injury r/o fracture Bones and joints: Osseous fragment over the superior pole of patella with marked thickening and$ irregularity of the quadriceps tendon. Soft tissues: Large joint effusion with patellar soft tissue swelling.

irregularity of the quadriceps tendon. Soft tissues: Large joint effusion with patellar soft tissue swelling.

$joint effusion. Findings most compatible with superior pole patellar sleeve fracture. What are they saying?$

25 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 of 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 oblique fracture of the fifth metacarpal shaft. No evidence of dislocation. 2. Severe degenerative changes of the first MTP joint compatible with hallux rigidus. 25

26 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 NORMAL FINDINGS with hooked type III clavicle. Mild/moderate degenerative changes glenohumeral joint as well with small marginal acromion!!! osteophytes. Close approximation of the humeral head and the acromion with weightbearing suggest Pulmonary nodules depends on history May need further evaluation underlying rotator cuff pathology. Additionally noted is an oval ossified fragment along the posterior superior aspect of the glenoid which may represent an osteophyte, 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.. 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 51 tendons yo demonstrate with normal fall signal and morphology. full thickness The rotator cuff muscles are unremarkable. LABRAL AND CAPSULAR STRUCTURES: Unremarkable. No evidence of labral tears. rotator cuff tears BICEPS TENDON AND ANCHOR: Unremarkable. Normal signal and morphology of the biceps tendon. OSSEOUS Refer AND CARTILAGINOUS for treatment STRUCTURES: Unremarkable. and repair 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. 26

27 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 of 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 27

28 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 Age with mild appropriate peritendinitis. changes 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 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 28

29 MR imaging of Shoulder Accurate Asymptomatic individuals > 60 y.o. 54% tears (28% full, 26% partial) y.o. 4% full, 24% partial 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 29

30 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 30

31 Thank you C. Benjamin Ma, M.D. Professor in Residence UCSF Department of Orthopaedic Surgery Sports Medicine and Shoulder (415)

MRI of the Shoulder What to look for and how to find it? Dr. Eric Handley Musculoskeletal Radiologist Cherry Creek Imaging

MRI of the Shoulder What to look for and how to find it? Dr. Eric Handley Musculoskeletal Radiologist Cherry Creek Imaging MRI of the Shoulder Benefits of Ultrasound: * Dynamic * Interactive real time