Diagnostic Imaging: Clinical Implications Is Radiology Important to the PT? Ed Mulligan, PT, DPT, OCS, SCS, ATC Clinical Orthopedic Rehabilitation Education JOSPT Musculoskeletal Imaging Series December 2010 – 40:12 z z Femoral Neck Stress Fracture in a Military Trainee Identification of a High-Risk g Anterior Tibial Stress Fracture November 2010 – 40:11 z z Hip Joint Capsule Disruption in a Young Female Gymnast Spinal Schwannoma in a Young Adult October 2010 – 40:10 z z Insufficiency Fracture of the Pubic Rami Ultrasound Assessment of the Tibialis Posterior Tendon September 2010 – 40:9 z z Foot and Ankle Pain in a Young Female Athlete Tibial Spine p Avulsion Fracture August 2010 – 40:8 z z Juvenile Osteochondritis Dissecans of the Knee Lower Thoracic Spine Pain in a 33-Year-Old Female July 2010 – 40:7 z Fracture of the Greater Tuberosity of the Humerus JOSPT Musculoskeletal Imaging Series June 2010 – 40:6 z z Kienbock's Disease Sign of the Buttock Following Total Hip Arthroplasty May 2010 – 40:5 z z Asymptomatic Spondylolisthesis and Pregnancy Hook of the Hamate Fracture April 2010 – 40:4 z February 2010 – 40:2 z z Enchondroma in a Running Athlete With Persistent Mid-Thigh Pain Femoroacetabular Impingement in a R Running i Athl Athlete t January 2010 – 40:1 z Radial Head Fracture Following a Fall December 2009 – 39:12 z Osteochondral Lesion of the Talus Lunate Fracture in an Amateur Soccer Player March 2010 – 40:3 z z Diagnostic Imaging Following Cervical Spine Injury Extreme Skeletal Adaptation to Mechanical Loading JOSPT Musculoskeletal Imaging Series JOSPT Musculoskeletal Imaging Series November 2009 – 39:11 March 2009 Volume 39, No. 3 z z Acute Dislocation of the Proximal Tibiofibular Joint Patellar Tendon Rupture in a Basketball Pl Player October 2009 – 39:10 z z Acute Bony Bankart Lesion and Surgical Fixation Anterior Cruciate Ligament Injury and Bucket Handle Tear of the Medial Meniscus September 2009 – 39:9 z z Acetabular Fracture and Protrusio Acetabuli in an Elderly Patient Following a Fall Thrower's Exostosis in a Collegiate Pitcher August 2009 Volume 39, No. 8 z Limited Knee Extension Following Anterior Cruciate Ligament Injury July 2009 Volume 39, No. 7 z Bipartite Patella in a Young Athlete June 2009 Volume 39, No. 6 z Osteochondral Defect of the Medial Femoral Condyle May 2009 Volume 39, No. 5 z Neck Pain and Headaches in a Patient After a Fall April 2009 Volume 39, No. 4 z Pigmented Villonodular Synovitis in a Military Trainee With Ankle Pain z Differential Diagnosis of Fibular Pain in a Patient With a History of Breast Cancer February 2009 Volume 39, No. 2 z Coincidental Findings of a Vertebral Hemangioma on Magnetic Resonance Imaging January 2009 Volume 39, No. 1 z Tarsometatarsal Joint Injury in a Patient Seen in a Direct-Access Physical Therapy Setting December 2008 Volume 38, No. 12 z Cervical Spondylotic Myelopathy in a Patient Presenting With Low Back Pain November 2008 Volume 38, No. 11 z Cauda Equina Syndrome in a Pregnant Woman Referred to Physical Therapy for Low Back Pain October 2008 Volume 38, No. 10 z Chiari Malformation in a Patient Presenting With Knee Pain September 2008 Volume 38, No. 9 z Femoral Neck Fracture in a Military Trainee August 2008 Volume 38, No. 8 z Femoral Neck Stress Fracture in a Male Runner 1 JOSPT Musculoskeletal Imaging Series July 2008 Volume 38, No. 7 z March 2008 Volume 38, No. 3 Isolated Rupture of the Teres Major Muscle June 2008 Volume 38, No. 6 z Upper Cervical Ligamentous Disruption in a Patient With Persistent Whiplash Associated Disorders May 2008 Volume 38, No. 5 z Excellent Overview z Trochlear Groove Spur in a Patient With Patellofemoral Pain February 2008 Volume 38, No. 2 z Proximal Tibiofibular Dislocation/Sublaxation January 2008 Volume 38, No. 1 Subcutaneous Abscess in a Patient Referred to Physical Therapy Following Spinal Epidural Injection for Lumbar Radiculopathy z Slipped Capital Femoral Epiphysis in a Patient Referred to Physical Therapy for Knee Pain April 2008 Volume 38, No. 4 z Thoracic Spine Compression Fracture in a Patient With Back Pain Free access at http://www.jospt.org/issues/articleID.818/article_detail.asp Deyle GD, JOSPT, 2005;35:708-721 What do you suspect? ACJ Separation PT Scope of Practice z Recognize the need for imaging z Provide rationale and location for imaging to radiologist z Appreciate the accuracy of imaging (false positives/negatives) and the periodic lack of correlation between pathoanatomy and clinical presentation (spine) In an AP View the normal joint space is 0.3-0.8 cm and the normal coracoclavicular distance is 1.0-1.3 cm Anything wrong with ACJ Grading Clavicular Fracture the right shoulder? Deformity Ligaments Instability Surgery Minor Incomplete AC none no Type II Minor step deformity Complete AC Incomplete CC Palpable gapping no Type III Piano key deformity Complete AC/CC Visible gapping Type IV Clavicle displaced posteriorly into trapezius Complete AC/CC; trap/deltoid tear yes Type V CC space Ç 100-300% Complete AC/CC; significant trap/deltoid tearing yes Type VI inferior dislocation of clavicle - frequently locked under conjoined tendon Type I Non-Displaced Displaced possible yes Greenstick 2 What is this? Neer Classification 3-part Proximal Humeral Fracture i involving l i the h surgical neck, greater tubercle, and lesser tubercle Neer Fracture Classification Parameters z Displaced means that any of the four major segments is displaced more than 1 centimeter or angulated more the 45° – – – – Proximal Humeral Fracture Humeral head Humeral shaft - surgical neck Greater Tuberosity Lesser Tuberosity What is this? Os Acromiale Os acromiale from the failure of the acromial secon secondary centers of ossification to fuse which normally occurs at about 18-20 years of age Axillary views of (R) and (L) shoulders with acromion and os acromiale z z results z Failure of fusion of the most anterior ossification center results in a preacromion, failure of fusion of the middle ossification center produces a meso‐acromion, and failure of fusion of the center located at the angle between the scapular spine and the acromion creates a meta‐acromion. The appearance is a normal variant than can be mistaken for a fracture on an axillary lateral view. The reported prevalence of this condition has ranged from 115% in the general population. The finding is present bilaterally in approximately 62% of the cases. 3 Hill Sach’s Lesion Acromial Morphology MRI and X-ray (above) of a Hill-Sachs lesions - an impaction fracture on the posterolateral margin of the humeral head Transscapular Lateral Y view Acromial Morphology Lateral Sagittal View Type II Type III – hooked Acromial Morphology - AP View Type I - flat Acromion Morphology Frontal Plane Orientation TYPE A Normal Type II – curved TYPE B Type B – excessive down sloping 4 What is this? Posterior Humeroulnar Dislocation Complete What is this? Perched Radial Head Fracture Mason-Johnson Classification of Radial head and neck fractures Radial Head Fracture I Nondisplaced (< 2 mm) II Minimally displaced (> 2-3 mm) with depression, angulation, impaction, or involving > 30% of radial head III Comminuted and displaced IV Radial head fractures associated with dislocation of the elbow Distal Radius Fracture – “Colles” dorsal displacement of distal fragment Boxer Fracture – Fractured neck of 4 or 5th metacarpal z Metacarpal head tilts in volar direction causing hyperextened MCP z Metacarpal head angulates and rotates 5 What is this? What is this? Traumatic snuffbox pain should be treated as a scaphoid fracture for at least 2-3 weeks Scaphoid Fracture Spondylolisthesis – “scotty dog” broken collar Pars Defect Superior facet (ear) Lamina (body) Transverse process (nose) Vertebral Body Pars articularis (neck) Inferior Facet (front leg) Thoracic Compression Fracture Dens Fracture Dens Fracture These are two reformatted CT images of the cervical spine. The green arrows point to a transverse fracture of the base of the dens (odontoid) (Type II). The red arrow points to the same fracture in a sagittal reformatted image. The dens is displaced slightly posteriorly on the body of C2. 6 Clay Shoveler’s Fracture An avulsion of the spinous process of the lower cervical vertebrae, classically at C7 Canadian C-Spine Rules SN = .99 SP = .45 Stiell IG, et al, NEJM, 2003 Implementation of the Canadian CSpine Rule led to a significant decrease (12%) in imaging without injuries being missed or patient morbidity. Widespread implementation of this rule could lead to reduced healthcare costs and more efficient patient flow in busy emergency departments Stiell IG, et al, Spine, 2009 What is this? Hip Osteoarthritis Femoral Stress Fracture More obvious … Femoral neck stress fx on MRI AP image. Note sclerosis of the right femoral neck running perpendicular to trabeculae. Bone Scan 7 What is this? Slipped Capital Femoral Epiphysis Femoral head slips in a posteromedial direction on the femoral neck Klein’s Line on Radiograph Legg Calves Perthes - coxa plana avascular necrosis resulting in a flattening of the femoral head Axial non-enhanced CT scan through the hip clearly shows the loss of structural integrity of the right femoral head. Patellofemoral Imaging Sulcus Angle Radiograph z Merchant (sunrise or skyline) View z MRI Sulcus angle representing the femoral condylar depth Normal = 138° + 6° 8 Lateral Patellofemoral Angle Congruence Angle Abnormal frontal plane orientation Abnormal patellar tilt in transverse plane orientation Lines should diverge laterally Bisect Offset GE = GF Patella Alta GE > GF G G Normal Patellar Alta Increased % of patellar width is lateral to the midline – laterally displaced patella Method used to measure medial and lateral displacement . Determined by a line connecting the posterior femoral condyles (AB) and then projecting a perpendicular line anteriorly through the deepest portion of the trochlear groove (CD) to a point where it bisected the patellar width line (EF) (left). The bisect offset is reported as the % of the patellar width lateral to the midline. See anything of concern? MRI of a Patellar Tendon Rupture Standing bilateral AP view: Hint Ratio of P:PT = 1.0 More than 20% variation is abnormal note the superiorly displaced right patella secondary to a patellar tendon rupture Orange arrow: gap between inferior pole and d patellar t ll ttendon d White arrow: distracted patellar tendon fibers Johnson SD, et al, JOSPT, 2009 9 What is this structure? ? color enhanced torn ACL on MRI Normal ACL Common consequence of an acute ACL tear z Extent of damage is quite influential in the speed of non-operative or post-surgical recovery Complete ACL rupture The disruption of ligament makes it appear medium-light grey; compare to normal ACL views. Complete ACL rupture Midsubstance disruption outlined in yellow What is this structure? Osteochondral Bruising z Normal ACL The solid black band is the ACL PCL MRI image of knee with a small geographic bone bruise in the weightbearing lateral femoral condyle and an extensive bruise of the lateral tibial plateau in association with an ACL rupture. Posterior Cruciate Ligament on MRI Ottawa Knee Fracture Rule An x-ray is indicated if any of the following are present within the first 7 days 1. 2. 3. 4. 5. This color enhanced MRI shows a PCL tear (right slide). The non-enhanced image (left) shows the torn PCL as printed after the scan Patient age > 55 Isolated tenderness of the patella Tenderness at the head of the fibula Inability to flex the knee 90° Inability to immediately bear weight for 4 steps (regardless of limping) Sensitivity (95% CI) Specificity (95% CI) + LR - LR 98.5 (93-100) 49 (43-51) 1.93 0.05 Validation from the pooled data of 6 high quality diagnostic studies revealed the following accuracy 10 Pittsburgh Knee Fracture Rule z z z What is this? Mechanism of injury is a blunt trauma or fall and Patient age < 12 or > 55 Inability to walk 4 weight-bearing steps in the emergency room Sensitivity (95% CI) Specificity (95% CI) + LR - LR 99 (94-100) 60 (56-64) 2.48 0.02 Jones Diaphyseal Fracture of the 5th metatarsal Validation from the pooled data of 6 high quality diagnostic studies revealed the following accuracy Hallux Abductovalgus – “Bunion” z z metatarsophalngeal hallux valgus angle (HVA) representing the lateral deviation of the 1st phalanx z should be < 15° Lisfranc Fracture-Dislocation HVA intermetatarsal angle (IMA) should be < 9° Do you see malalignment? Where? The bases of all of the metatarsals have dislocated and there is a fracture at the base of the 2nd metatarsal IMA Tarsals have dislocated in a plantar direction What do you see on this MRI? Osteochondral Fracture/Defect of the Medial Talar Dome Os Trigonum Posterior Impingement Syndrome MRI X-ray 11 Achilles Tendon Tear Do you see the avulsion fracture on the left? What is the avulsion fracture on the right? Sagittal View of the Ankle to evaluate the Achilles Tendon. The mixed signal intensity in the Achilles Tendon represents tendon tear tear. Undisplaced medial malleolar fracture could there be a missed proximal fibular or syndesmosis injury? avulsion fracture at the base of the 5th met Ottawa Ankle Fracture Rules Excellent screening tool because of its high sensitivity and very low negative likelihood ratio Rule 1. Inability to WB 4 steps 2. Localized tenderness in any of 4 spots http://www.learningradiology.com/ toc/tocorgansystems/tocbone.htm z http://rad.usuhs.edu/medpix/ Good web sites 12 http://www.rad.washington.edu/academics/academicsections/msk/teaching-materials/teaching-files QUESTIONS/COMMENTS 13