NCCA CONVENTION

PINEHURST, NC.

RADIOLOGY for the DC

N.DOMBROWSKY, DC DACBR fldacbr@gmail.com

DIGITAL TECHNOLOGY

• MARCH 22, 2019

• PINEHURST, NC

• N. Dombrowsky , DC DACBR

• © www.ProImaging.ws

WET READ

• Place x-ray on

view-box

• Take pic of area

of interest

• Email – as jpeg

attachment.

12/4/16

CASE – 34 F MVA 5.27.16

6. 14. 2016 -PATIENT PRESENTS TO DC -

DR. M. IOWA

TELERADIOLOGY

jpeg

BOX.COM

CLOUD VENDOR

d ARTIFACT

dARTIFACT

DR SYSTEMS

dARTIFACT

EXPOSURE INDICATORS

d ARTIFACT

FUTURE….

…DIAS in majority

-phosphors - structures

-tighter packing –

-↓ pixel size – SP

-faster processing – line x line

-archiving – “cloud”

- informed decision making

WEB REFERENCES

1. Indrajit IK Digital imaging in rad. Practice J Radiol Imaging 2007; 17:

230-236

2. Digital Radiology. A comparison with modern conventional imaging

GJ Bansal Postgrad Med j. 2006; 82: 425-528

3. RadioGaphics 2007 ; 27-675:685 Advances in Digital

Radiography M.

4. Digital Radiography & PACS 2010 Mosby Elsevier

4. Merrill’s Atlas of Radiographic Positioning

& Procedures 11 Ed. Vol. 1 2007

5. https://en.wikibooks.org/wiki/Basic_Physics_of_Digital_Radiography/The

Image_Receptor

LUMBAR SPINE

POSITIONING CHALLENGES….

TRANSITIONAL SEGMENTS

SPONDYLOLISTHESIS.

VASCULAR

d Hints for Radiation Worker

• Merrill ‘s Atlas of Rad.

Positioning 11th. Ed. Vol. 1,

2007 p. 38

– Collimation!!

– Part centering

– Split cassette– Lead strips

– R/Left Markers

• X-raytees.com

IMAGING TO THE LOWER EXTREMITY –HIP, KNEE & ANKLE

NCCA

PINEHURST, NC

MARCH 22, 2019

HIP- FEMUR

Strongest

Gr.t – 4 facets

Ltr.

Anteverted

Spherical

Cartilage

Intertrochanteric region

fovea

HIP JOINT - CAPSULE

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RESOURCES:

ANATOMY

https://primalpictures.com

-

https://www.netterimages.c

om

-https://www.imaios.com/en/e-

Anatomy

MRI

- http://freitasrad.net

- Xrayhead.com

- STANFORD

MSK MRI ATLAS

- Radassistant.nl

- Pocketradiologist.com

NORMAL RADIOLOGY

12/4/16

TOO MUCH TIME…

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2. DEVELOPMENTAL - Os acetabuli

3/16/2019

SEMINARS IN MSK RADIOLOGY – 2013; JUNE 2013:229-247

2. DEVELOPMENTAL

12/4/16

Herniation pits in the femoral neck: a radiographic indicator of femoroacetabular impingement?

Skeletal Radiol. 2011 Feb;40(2):167-72.

ANATOMY - MUSCLES

12/4/16

EXTENSORS, LAT. ROTATORS

ABDUCTORS

NORMAL RADIOGRAPHIC POSITIONING

3/16.19

Auntminnie.com

OSTEONECROSIS

◼ Trauma

◼ Steroids

◼ Alcohol

◼ Radiation therapy

◼ others

LEGG-CALVE-PERTHES

- 4-10 range

-Possible growth arrest

growth arrest:

-physeal bridging

- signal change

6 yo/M - NC

3. OSTEONECROSIS

Diffuse edema

Focal serpiginous low SI line with fatty center

Double line sign

= T2WI-

Center - ↑SI

Periphery- ↓SI

http://www.physio-pedia.com

4. FRACTURES

STRESS –

femoral neck

sacrum *

supra-acetabular *

pubic bones

INSUFFICENCY

OP patients

no sig. trauma

3. FRACTURE

T1 Linear low SI

with low SI ( fracture

line)

T2 -↓SI = fx. line

T2 -↑

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4. HIP: SOFT TISSUES - MUSCLE

⚫GRADE 1 – preservation

of morphology

⚫ GRADE 2 – 50% of fibers torn.

⚫ GRADE 3 – complete tearing

− +/- retraction

Pocket radiologist – TOP 100 DIAGNOSES - 2001

http://www.auntminnie.com/

BURSA

Gr. Trochanteric bursa

• Hip flexion

• Ddx. Torn Gmed/min

• Middle age- elderly

• ?groin pain, mass

• Lat. To gr. trochanter

MRI

• ↑T2 – fluid paralling gr. Trochanter

CASE

12/4/16

http://www.scbtmr.org/Portals/9/Meetings/2010/Summer/STEINBACH_MRI%20of%20the%20Hip%20-%20Femoroacetabular%20Impingement.pdf

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DDH-- COMPLICATIONS

12/4/16

Clinical Sports Medicine.com 4th Edition (2012)

45 pts. with no history of hip

pain, symptoms, injury, or surgery.

73% -hip abn.

labral tears – mc (69%). chondral

defects (24%), fibrocystic changes of the femoral head/neck junction (22%),

osseous bumps (20%), sub-chondral bone cysts (16%), labral/paralabral cysts (13%), acetabular bone edema (11%), acetabular rim fractures (11%), and ligamentum teres

tears (2.2%)..

12/4/16

PINEHURST 2019

• Did you learn?

• Did you enjoy?

• Is this helpful in

your clinical

practice?

THE KNEE

• AP VIEW– PA VIEW

• LATERAL

• TUNNEL

• SUNRISE

http://eorif.com/knee-xray

http://www.diagnosticimaging.com/mri/weight-bearing-x-rays-knee-pain-preferable-mri

http://www.diagnosticimaging.com/mri/weight-bearing-x-rays-knee-pain-preferable-mri

September 20, 2016

MRI - normal

S-PDAXIAL – FAT SAT

axial

RESOURCES

• http://www.freitasrad.net

• X-rayhead.com– STANFORD - MSK MRI ATLAS

• http://radiologyassistant.nl/

• https://radiopaedia.org/

MENISCOFEMORAL LIG. INSERTION

– 75% of knees

– Menisco-femoral ligament • Anterior portion =lig. Of

Humphrey

• Posterior portion = Wrisberg

MENISCOFEMORAL LIG. INSERTION

– 75% of knees

– Menisco-femoral ligament • Anterior portion =lig. Of

Humphrey

• Posterior portion = Wrisberg

RESOURCES

• http://www.freitasrad.net

• X-rayhead.com– STANFORD - MSK MRI ATLAS

• http://radiologyassistant.nl/

• https://radiopaedia.org/

MENISCOFEMORAL LIG. INSERTION

– 75% of knees

– Menisco-femoral ligament • Anterior portion =lig. Of

Humphrey

• Posterior portion = Wrisberg

RESOURCES

• http://www.freitasrad.net

• X-rayhead.com– STANFORD - MSK MRI ATLAS

• http://radiologyassistant.nl/

• https://radiopaedia.org/

PITFALLS - MFL

LIGAMENTS

• ANTERIOR CRUCIATE LIGAMENT– Straight, taut, parallel to

intercondylar notch

– Striated, some SI- esp. at insertion

– Torn= no normal fibers seen

– Flatter angle,

– cystic appearance/drumstick –mimics tear

– * discontinuity, abn.orientation, nonvisualization

Dreamtimes.com

t ACL

t ACL

ACL

POSTERIOR CRUCIATE LIGAMENT

• Hockey stick appearance

• Infreq. torn and less freq. surgically repaired.

• Stretches…

tPCL

• ↑SI all sequences

• PD

• > 6 mm. thick

MEDIAL COLLATERAL LIGAMENT

• Fibers connected to

joint capsule

• mMEN – attachment

• NOT intrasynovial

– Grade 1 – ↑SI. soft

tissues medial to MCL

– Grade 2 –

hSI+disruption within

MCL

– Grade 3 – complete

tear

LCL

• Bf-fcl – prox.fibula

• -iliotibial band –G. tubercle

• Not as frequent as MCL

• Posterior corner inj. *– LCL inj.

– + pop.tendon tears

– Arculate lig.

– Popliteal-fib.ligament

– +/- ACL OR PCLcFAT-SAT

POSTERIOR CORNER INJURY

J. Magn. Reson. Imaging 2007.

JUMPER’S KNEE

BURSAE

• POPLITEAL

– Between med. Gastroc

& SM

– >5 ml. fluid abn.

OSSEOUS STRUCTURES

• Contusions = microfractures

• May progress if:

– A. geographic

– B. reticulated *

• ACL tear

– Bone contusion – posterior lateral portion of

tibial plateau

– Pivot shift phenomenon

– “kissing” contusion

OSTEOCHONDRAL LESION

PINEHURST 19

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IMAGING TO THE LOWER EXTREMITY –ANKLE

PINEHURST, NC

MARCH, 22 2019.

N. DOMBROWSKY, DC DACBR

http://www.radiologyassistant.nl

MRI – too expensive

- clinical examination

LIGAMENTOUS INJURIES

MSK MRI – 2ND. EDITION – 2009 P. 395

IMAGING OF THE LOWER EXTREMITY –

• OS TRIGNOUM • Post. Ankle impingment• Forced plantar flexion

– BB, hill running, ballet

• 1. BME/fx. Of trigonal process or

• 2. talocalcaneal

• MRI– ↑ si – talus– si – fx. Of

synchondrosis– S. tenosynovitis- FHL

IMAGING OF THE LOWER EXTREMITY –

• Os naviculare

• BME, bursitis, deg.

• +/- PTT tears– B, hill running,

ballet

• MRI– ↑ si – T2- all abn.

• .

IMAGING OF THE LOWER EXTREMITY

– PLANTAR FASCITIS• Obese F, runners, SSA

–

• Chronic rep. stressors

• Tears, myxoid deg. ,

infl.

• RUPTURE:– Forced dorsiflexion

– Thicken. Disrupt. In

midportion

s-FAT SAT

Morton’s neuroma

- F- high heels

- plantar N. entrapment- - 2’

perineural fibrosis.

- tear – drop shaped mass

-T1W – low

-T2W- dependant upon fibrosis

present

- +/- bursal fluid

IMAGING OF THE LOWER EXTREMITY –TRAUMA

• Pf –inconclusive

• Osteochondritis dess.=

osteochondral lesion

• Med. Or lat. Talar

dome

• +/- lig. Injuries

ePainAssist.com

HELMS MSK MRI 2ND. ED.

P. 413

IMAGING OF THE LOWER EXTREMITY –TRAUMA

• MRI– Stable– ↑T2W – around

fragment.– Absent or displaced fr.– Cartilage fr.– Subcondral cysts.

Magnetic resonance imaging features of osteochondral lesions of the talus.Hembree WC1, Wittstein JR, Vinson EN, Queen RM, Larose CR, Singh K, Easley ME.

BACKGROUND: Foot Ankle Int. 2012 Jul;33(7):591-7. doi: 10.3113/FAI.2012.0001

CONCLUSION:

This study refutes traditional teachings regarding the location of OLT and supports recent

studies showing that most lesions are located medially and centrally on the talar dome..

IMAGING OF THE LOWER EXTREMITY –STRESS FRACTURES

• STRESS FRACTURES

Gen. perpendicular

to long axis

• EXCEPT:

• Med. Mall - vertical

JANUARY 2017

CASES

PINEHURST 19

• Did you learn?

• Did you enjoy?

• Is this helpful in

your clinical

practice?