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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 mesoacromion, and failure of fusion of the center located at the angle between the scapular spine and the acromion creates a metaacromion.

  • 4

    Hill Sachs 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

  • 5

    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

  • 6

    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.

  • 7

    Clay Shovelers 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.