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Diagnostic Imaging:Clinical Implications

Ed Mulligan, PT, DPT, OCS, SCS, ATCClinical Orthopedic Rehabilitation Education

Is Radiology Important to the PT?

JOSPT Musculoskeletal Imaging Series

December 2010 – 40:12Femoral Neck Stress Fracture in a Military TraineeIdentification of a High-Risk Anterior Tibial

September 2010 – 40:9Foot and Ankle Pain in a Young Female AthleteTibial Spine Avulsion Fractureg

Stress FractureNovember 2010 – 40:11

Hip Joint Capsule Disruption in a Young Female GymnastSpinal Schwannoma in a Young Adult

October 2010 – 40:10Insufficiency Fracture of the Pubic RamiUltrasound Assessment of the Tibialis Posterior Tendon

pAugust 2010 – 40:8

Juvenile Osteochondritis Dissecans of the KneeLower Thoracic Spine Pain in a 33-Year-Old Female

July 2010 – 40:7Fracture of the Greater Tuberosity of the Humerus

JOSPT Musculoskeletal Imaging Series

June 2010 – 40:6Kienbock's DiseaseSign of the Buttock Following Total Hip Arthroplasty

February 2010 – 40:2Enchondroma in a Running Athlete With Persistent Mid-Thigh PainFemoroacetabular Impingement in a R i Athl tMay 2010 – 40:5

Asymptomatic Spondylolisthesis and PregnancyHook of the Hamate Fracture

April 2010 – 40:4Osteochondral Lesion of the Talus

March 2010 – 40:3Diagnostic Imaging Following Cervical Spine InjuryExtreme Skeletal Adaptation to Mechanical Loading

Running AthleteJanuary 2010 – 40:1

Radial Head Fracture Following a FallDecember 2009 – 39:12

Lunate Fracture in an Amateur Soccer Player

JOSPT Musculoskeletal Imaging Series

November 2009 – 39:11Acute Dislocation of the Proximal Tibiofibular JointPatellar Tendon Rupture in a Basketball Pl

August 2009 Volume 39, No. 8 Limited Knee Extension Following Anterior Cruciate Ligament Injury

July 2009 Volume 39, No. 7 Player

October 2009 – 39:10Acute Bony Bankart Lesion and Surgical FixationAnterior Cruciate Ligament Injury and Bucket Handle Tear of the Medial Meniscus

September 2009 – 39:9 Acetabular Fracture and Protrusio Acetabuli in an Elderly Patient Following a FallThrower's Exostosis in a Collegiate Pitcher

Bipartite Patella in a Young AthleteJune 2009 Volume 39, No. 6

Osteochondral Defect of the Medial Femoral Condyle

May 2009 Volume 39, No. 5 Neck Pain and Headaches in a Patient After a Fall

April 2009 Volume 39, No. 4 Pigmented Villonodular Synovitis in a Military Trainee With Ankle Pain

JOSPT Musculoskeletal Imaging Series

March 2009 Volume 39, No. 3 Differential Diagnosis of Fibular Pain in a Patient With a History of Breast Cancer

February 2009 Volume 39, No. 2

November 2008 Volume 38, No. 11 Cauda Equina Syndrome in a Pregnant Woman Referred to Physical Therapy for Low Back PainFebruary 2009 Volume 39, No. 2

Coincidental Findings of a Vertebral Hemangioma on Magnetic Resonance Imaging

January 2009 Volume 39, No. 1Tarsometatarsal Joint Injury in a Patient Seen in a Direct-Access Physical Therapy Setting

December 2008 Volume 38, No. 12 Cervical Spondylotic Myelopathy in a Patient Presenting With Low Back Pain

October 2008 Volume 38, No. 10 Chiari Malformation in a Patient Presenting With Knee Pain

September 2008 Volume 38, No. 9 Femoral Neck Fracture in a Military Trainee

August 2008 Volume 38, No. 8 Femoral Neck Stress Fracture in a Male Runner

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JOSPT Musculoskeletal Imaging Series

July 2008 Volume 38, No. 7 Isolated Rupture of the Teres Major Muscle

June 2008 Volume 38, No. 6 Upper Cervical Ligamentous Disruption in

March 2008 Volume 38, No. 3Trochlear Groove Spur in a Patient With Patellofemoral Pain

February 2008 Volume 38, No. 2Upper Cervical Ligamentous Disruption in a Patient With Persistent Whiplash Associated Disorders

May 2008 Volume 38, No. 5 Subcutaneous Abscess in a Patient Referred to Physical Therapy Following Spinal Epidural Injection for Lumbar Radiculopathy

April 2008 Volume 38, No. 4 Thoracic Spine Compression Fracture in a Patient With Back Pain

February 2008 Volume 38, No. 2 Proximal Tibiofibular Dislocation/Sublaxation

January 2008 Volume 38, No. 1 Slipped Capital Femoral Epiphysis in a Patient Referred to Physical Therapy for Knee Pain

Excellent Overview

Free access at http://www.jospt.org/issues/articleID.818/article_detail.aspDeyle GD, JOSPT, 2005;35:708-721

PT Scope of Practice

Recognize the need for imaging

Provide rationale and location for imaging to radiologist

Appreciate the accuracy of imaging (false positives/negatives) and the periodic lack of correlation between pathoanatomy and clinical presentation (spine)

What do you suspect? ACJ Separation

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

ACJ Grading

Deformity Ligaments Instability Surgery

Type I Minor Incomplete AC none no

Type II Minor step deformity Complete AC Palpable gapping noType II Minor step deformity Incomplete CC Palpable gapping no

Type III Piano key deformity Complete AC/CC Visible gapping possible

Type IV Clavicle displaced posteriorly into trapezius Complete AC/CC; trap/deltoid tear yes

Type V CC space 100-300% Complete AC/CC; significant trap/deltoid tearing yes

Type VI inferior dislocation of clavicle - frequently locked under conjoined tendon yes

Anything wrong with the right shoulder?

Non-Displaced Displaced

Clavicular Fracture

Greenstick

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What is this?

3-part Proximal Humeral Fracture i l i hinvolving the surgical neck, greater tubercle, and lesser tubercle

Neer Classification

Neer Fracture Classification Parameters

Displaced means that any of the four major segments is displaced more than 1is displaced more than 1 centimeter or angulated more the 45°

– Humeral head– Humeral shaft - surgical neck– Greater Tuberosity– Lesser Tuberosity

Proximal Humeral Fracture

What is this?

Os acromialeresults from the failure of the acromial seconof the acromial secon-dary centers of ossifi-cation to fuse which normally occurs at about 18-20 years of age

Os Acromiale

The appearance is a normal variant than can be mistaken for a fracture on an axillary lateral

Axillary views of (R) and (L) shoulders with acromion and os acromiale

a fracture on an axillary lateral view. The reported prevalence of this condition has ranged from 1-15% in the general population. The finding is present bilaterally in approximately 62% of the cases.

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.

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Hill Sach’s Lesion

MRI and X-ray (above) of a Hill-Sachs lesions - an impaction fracture on the posterolateral margin of the humeral head

Acromial Morphology

Transscapular Lateral Y view

Type II

Acromial Morphology Lateral Sagittal View

Type III – hooked Type II – curved Type I - flat

Acromial Morphology - AP View

Normal Type B – excessive down sloping

Acromion MorphologyFrontal Plane Orientation

TYPE A TYPE B

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What is this? Posterior Humeroulnar Dislocation

Complete Perched

What is this?

Radial Head FFracture

Radial Head Fracture

Mason-Johnson Classification of Radial head and neck fracturesI Nondisplaced (< 2 mm)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 Metacarpal head tilts in volar direction causing hyperextened MCP

Boxer Fracture –Fractured neck of 4 or 5th metacarpal

hyperextened MCP

Metacarpal head angulates and rotates

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What is this?

Traumatic snuffbox pain should be treatedshould be treated as a scaphoid fracture for at least 2-3 weeks

Scaphoid Fracture

What is this?

Spondylolisthesis – “scotty dog” broken collar

Pars Defect

Transverse process (nose)

Superior facet (ear)

Pars articularis (neck)

Vertebral Body

Inferior Facet (front leg)

Lamina (body)

Thoracic Compression Fracture Dens Fracture

Dens FractureThese are two reformatted CT images of the cervical spine. The green arrows point to a transversefracture of the base of the dens (odontoid) (Type II).

The red arrow points to the same fracture in a sagittalreformatted image.

The dens is displaced slightly posteriorly on the body of C2.

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Clay Shoveler’s Fracture

An avulsion of the spinous process of the lower cervical vertebrae, classically at C7

Canadian C-Spine Rules

SN = .99SP = .45Stiell IG, et al, NEJM, 2003Stiell IG, et al, NEJM, 2003

Implementation of the Canadian C-Spine Rule led to a significant de-crease (12%) in imaging without in-juries being missed or patient morbid-ity. Widespread implementation of this rule could lead to reduced health-care costs and more efficient patient flow in busy emergency departmentsStiell IG, et al, Spine, 2009

What is this? Hip Osteoarthritis

Femoral Stress Fracture

AP image. Note sclerosis of the right femoral neck running perpendicular to trabeculae.

Femoral neck stress fx on MRI

More obvious …

Bone Scan

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What is this? Slipped Capital Femoral Epiphysis

Femoral head slips in a posteromedial direction on the femoral neck

Klein’s Line on RadiographLegg Calves Perthes - coxa planaavascular 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

Merchant (sunrise or skyline) View

Sulcus Angle

Radiograph MRI

Sulcus angle representing the femoral condylar depthNormal = 138° + 6°

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Lateral Patellofemoral Angle

Abnormal patellar tilt in transverse plane orientation Lines should diverge laterally

Abnormal

Congruence Angle

frontal plane orientation

Bisect Offset

G

GE > GF

G

GE = GF

Method used to measure medial and lateral displacement . Determined by a line connecting the posteriorfemoral 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 isreported as the % of the patellar width lateral to the midline.

Increased % of patellar width is lateral to the midline – laterally displaced patella

Normal Patellar Alta

Patella Alta

Ratio of P:PT = 1.0More than 20% variation is abnormal

See anything of concern?

Standing bilateral AP view:

note the superiorly displaced right patella secondary to a patellar tendon rupture

Hint

Orange arrow: gap between inferior pole

d t ll t d

MRI of a Patellar Tendon Rupture

and patellar tendon

WhiteWhite arrow: distracted patellar tendon fibers

Johnson SD, et al, JOSPT, 2009

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What is this structure?

color enhanced torn ACL on MRI

NormalACL

?

Normal ACL The solid black band is the ACL

Complete ACL ruptureThe disruption of ligament makes it appear medium-light grey; compare to normal ACL views.

Complete ACL ruptureMidsubstance disruption outlined in yellow

Osteochondral Bruising

Common consequence of an acute ACL tear

Extent of damage is quite influential in the speed of non-operative or post-surgical recovery

MRI image of knee with a small geo-graphic bone bruise in the weight-bearing lateral femoral condyle and an extensive bruise of the lateral tibial plateau in association with an ACL rupture.

What is this structure?

PCL

Posterior Cruciate Ligament on MRI

This color enhanced MRI shows a PCL tear (right slide). The non-enhanced image (left) shows the torn PCL as printed after the scan

Ottawa Knee Fracture Rule

An x-ray is indicated if any of the following are present within the first 7 days

1. Patient age > 552. Isolated tenderness of the patella3. Tenderness at the head of the fibula4. Inability to flex the knee 90°5. Inability to immediately bear weight for 4 steps

(regardless of limping)

Sensitivity (95% CI)Sensitivity (95% CI) Specificity (95% CI)Specificity (95% CI) + LR+ LR -- LRLR

98.5 (93-100) 49 (43-51) 1.93 0.05Validation from the pooled data of 6 high quality diagnostic studies revealed the following accuracy

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Pittsburgh Knee Fracture Rule

Mechanism of injury is a blunt trauma or falland

Patient age < 12 or > 55Patient age < 12 or > 55Inability to walk 4 weight-bearing steps in the emergency room

Sensitivity (95% CI)Sensitivity (95% CI) Specificity (95% CI)Specificity (95% CI) + LR+ LR -- LRLR

99 (94-100) 60 (56-64) 2.48 0.02Validation from the pooled data of 6 high quality diagnostic studies revealed the following accuracy

What is this?

Jones Diaphyseal Fracture of the 5th

metatarsal

Hallux Abductovalgus – “Bunion”

metatarsophalngeal hallux valgus angle (HVA) representing the lateral deviation

HVA

the lateral deviation of the 1st phalanx

should be < 15°

intermetatarsal angle (IMA) should be < 9° IMAIMA

Do you see malalignment? Where?

Lisfranc Fracture-DislocationThe bases of all of the metatarsals have dislocated and

there is a fracture at the base of the 2nd metatarsal

Tarsals have dislocated in a plantar direction

What do you see on this MRI?

Osteochondral Fracture/Defect of the Medial Talar Dome

Os TrigonumPosterior Impingement Syndrome

MRI X-ray

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Achilles Tendon Tear

Sagittal View of the Ankle to evaluate the Achilles Tendon. The mixed signal intensity in the Achilles Tendon represents tendon tearrepresents tendon tear.

Do you see the avulsion fracture on the left?What is the avulsion fracture on the right?

avulsion fracture at the base of the 5th metUndisplaced medial malleolar fracture -could there be a missed proximal fibular or syndesmosis injury?

Ottawa Ankle Fracture Rules

Excellent screening tool because of its high sensitivityand very low negative likelihood ratio

Rule1. Inability to WB 4 steps2. Localized tenderness in any of

4 spots

http://www.learningradiology.com/toc/tocorgansystems/tocbone.htm

Good web sites

http://rad.usuhs.edu/medpix/

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http://www.rad.washington.edu/academics/academic-sections/msk/teaching-materials/teaching-files QUESTIONS/COMMENTS