Imaging Modalities: Clinical Reasoning and Key Instructional Elements: Radiography
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1 Imaging Modalities: Clinical Reasoning and Key Instructional Elements: Radiography Michael D. Ross, PT, DHSc, OCS Disclosure No relevant financial relationship exists Objectives Determine the most appropriate radiographic views according to patient/client presentation, current best evidence for diagnosis, and current best evidence for reducing ionizing radiation exposure. Understand basic concepts of radiographic image acquisition and interpretation. Determine the relevance of visualized pathology to clinical decision-making. 1
2 Bussieres et al, Boissonnault,
3 Diagnostic Imaging Reveals Pathology But, The Patient History and Clinical Examination Provides Relevance Fig 3 Prevalence of osteoarthritis features on MRI in knees without radiographic osteoarthritis stratified by age group with standard and more stringent definitions of MRI abnormalities. Guermazi A et al. BMJ 2012;345:bmj.e by British Medical Journal Publishing Group Fig 2 Knee with multiple abnormalities on MRI indicating early stage osteoarthritis despite lack of radiographic osteoarthritis. Guermazi A et al. BMJ 2012;345:bmj.e by British Medical Journal Publishing Group 3
4 Knee with multiple abnormalities on MRI indicating early stage osteoarthritis despite lack of radiographic osteoarthritis. A: coronal fat suppressed proton density weighted image shows several features of early OA detectable only by MRI. White arrowhead shows focal full thickness cartilage defect at central weight bearing part of medial femur. In addition there is adjacent subchondral bone marrow lesion presenting as area of ill defined hyperintensity (arrows). Black arrowheads show meniscal extrusion at medial joint line causing bulging of neighbouring medial collateral ligament (no arrow). B: sagittal proton density weighted image shows isolated degenerative horizontal oblique tear of posterior horn of medial meniscus extending to undersurface of meniscus adjacent to posterior tibial surface (arrows). No associatedcartilage damage or subchondralbonyalterations are seen Guermazi A et al. BMJ 2012;345:bmj.e by British Medical Journal Publishing Group Key Principles of Diagnostic Imaging Do no harm Use diagnostic imaging only when you are positive findings will alter the intervention Always get at least 2 views Need 2 views to be interpretable Diagnostic imaging is a small component of the greater examination Diagnostic images are special tests Should be placed in the context of the entire examination Consider mechanism of injury, history and physical exam 4
5 Key Principles of Diagnostic Imaging Do no harm Consider diagnostic yield Conventional radiographs generally first Use shielding whenever possible Lowest dose view A-P and lateral but not obliques for L-spine P-A rather than A-P for scoliosis views 3-7x reduction in lifetime ionizing radiation Reduces risk of breast cancer by 3-4x and thyroid cancer by 2x (Levy et al, 1996) Oblique Projection Patency of facet joint Pars Interarticularis 5
6 Diagnostic Imaging In Physical Therapist Practice When to request imaging? How quickly is imaging needed? Patient education What is required for this? The Canadian C-Spine Rule Stiell, I. G. et al. JAMA 2001;286:
7 Incidence / Diagnosis of Severe C-spine Injury 1.7 % of those with head and neck injuries presenting to the ED will actually have significant pathology (n=8924) Canadian C-Spine Rules in alert patients following trauma (for significant c-spine injury) 100% sensitive 43% specific (Stiell I, 2000) ACR Appropriateness Criteria Radiographic Terminology Osteoblastic Radiopaque Opacity Sclerosis Hypertrophic bone Increased radiodensity Blastic lesion Reparative Reactive bone Osteoclastic Radiolucent Lucency Osteopenia Decreased radiodensity Lytic lesion or lysis Bone destroying 7
8 Wong DA et al, Spine, 1990 Shades of Gray & Radiodensity Lipoma 8
9 Radiographic Evaluation (The ABCs) Alignment Bone Density Cartilage Spaces Soft Tissues Alignment 1. Size of bone 2. Number of bones 3. Shape and contour of bone 4. Bone and joint position 9
10 Case Discussion 35 yo male; presents to urgent care clinic after falling onto outstretched arm off of his front porch CC: Pain and decreased AROM Anterior to Posterior Projection 10
11 Axillary Projection c coracoid process, scapula cl g hh gt clavicle glenoid humeral head greater tuberosity, humerus ac acromion process, scapula acj acromioclavicular joint Axillary Projection Posterior Shoulder Dislocation 11
12 Bone Density 1. General bone density 2. Focal bone density 3. Trabecular alteration Cartilage Space 1. Joint Space Width Symmetry 2. Subchondral Bone Contour Density 3. Growth plates/epiphyses Soft Tissue 1. Gross musculature 2. Joint Capsule Increase volume Fat Pad Sign 3. Periosteum 12
13 Soft Tissue 1. Gross musculature 2. Joint Capsule Increase volume Fat Pad Sign 3. Periosteal elevation Positive Fat Pad or Sail Sign - Suggestive of occult radial head fracture Positive Fat Pad Sign 13
14 34-year-old female deployed soldier with a chief complaint of worsening bilateral anterior shin pain for the past 8 weeks with running References Boyles RE, Gorman I, Pinto D, Ross MD. Physical Therapist Practice and the Role of Diagnostic Imaging. J Orthop Sports Phys Ther 2011;41: Deyle GD. Musculoskeletal imaging in physical therapist practice. J Orthop Sports Phys Ther. 2005; 35: Deyle GD. The role of MRI in musculoskeletal practice: a clinical perspective. J Man Manip Ther. 2011; 19: Haverstock BD. Foot and ankle imaging in the athlete. Clin Podiatr Med Surg. 2008;25: Hillman BJ, Goldsmith JC. The uncritical use of high-tech medical imaging. N Engl J Med. 2010;363(1):4-6. Epub 2010 Jun 23. Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 2002;137: Lennon RI, Riyat MS, Hilliam R, Anathkrishnan G, Alderson G. Can a normal range of elbow movement predict a normal elbow x ray? Emerg Med J. 2007;24: Stiell IG, Greenberg GH, McKnight RD, et al. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med 1992;21: Stiell IG, Greenberg GH, Wells GA, et al. Derivation of a decision rule for the use of radiography in acute knee injuries. Ann Emerg Med 1995;26: Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001;286: Thank you! 14
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