MUSCULOSKELETAL IMAGINGLSUHSC-ShreveportRotation Director: Alberto Simoncini, M.D.

General Goals: The field of musculoskeletal radiology consists of a diversity of topics that can be more easily learned by categorization into subdivisions of bone pathology: metabolic, tumor, dysplasias, arthritis, and trauma. The use of an algorithmic approach to musculoskeletal imaging allows the resident to properly arrive at a concise and well-thought out differential diagnosis.The first year resident should obtain a fundamental grasp of basic orthopedic radiology, and should also begin to categorize and organize subdivisions of musculoskeletal radiology such as rheumatology, neoplasms, etc. The second year resident should be increasingly knowledgeable in orthopedic radiology, particularly with increased experience in the Emergency Department. At this point, more detailed knowledge of neoplastic and metabolic processes as well as rheumatologic disorders is warranted.Third and fourth year residents should become increasingly capable of diagnosingmusculoskeletal pathology on all modalities and in applying the algorithmic approach todifferential diagnoses.

Daily Work: The radiology resident assigned to “Musculoskeletal Imaging” should beginreview of radiographic, CT, and MR cases via PACS immediately after arrival from the 7:30 am conference. All pertinent previous radiographs and CT scans must be reviewed, if available. The staff radiologist assigned to the section, primarily Dr. Alberto Simoncini, will subsequently review cases as they are presented by the resident.Requests for consultation made by the clinical staff should be handled by the residentworking with the staff radiologist. During their second, third and fourth months on themusculoskeletal rotation, residents should take increasing responsibility in thoseconsultations. The staff radiologist will be available at all times. Resident presence in the reading area, except for conference periods including the noon conference (you will have enough time to get your lunch prior to the noon conference), is maintained until at least 4:00 p.m. All dictations should be completed prior to leaving the area. Dr. Simoncini will be primarily responsible for supervising this curriculum and evaluating resident performance.

Suggested Reading:1. Fundamentals of Skeletal Radiology. Clyde A. Helms.2. Arthritis in Black and White. Anne C. Brower3. Musculoskeletal MRI. Kaplan, Helms, Dussault, Anderson, Major.

Educational Goals and Objectives:

First Year Residents

Patient Care:Be able to critique the technical quality of a radiographUnderstand the indications for more advanced imaging (ultrasound/CT/arthrography/MRI)Be able to protocol, with assistance, musculoskeletal examinations

Medical Knowledge:Fundamental understanding of basic orthopedic radiology, pertinent normal anatomy on a musculoskeletal radiographRecognize and describe, in a systematic fashion, radiographic findings on a radiographBegin to categorize and organize subdivisions of musculoskeletal radiology such as rheumatology, neoplasm, infection, etc.Should be able to distinguish an aggressive process, such as malignant tumor or infection, from a more benign process, such as a benign bone tumor, based on specific radiographic findingsBe facile with basic orthopedic concepts. The resident should be able to very specifically and accurately describe a fracture such that the referring orthopedic surgeon would be able to envision the fracture in three dimensions. The resident should have a grasp on basic classification systems of fractures such as intraarticular vs. extraarticular, as well as named fractures such as Monteggia, Galeazzi, etc.Discuss the most common musculoskeletal pathologic entitiesHave a basic understanding of technique and indications for arthrography, bone biopsy and other invasive procedures. Additionally, the residents should be well aware of the strengths and limitations of musculoskeletal MRI and computed tomography (CT) in the evaluation of musculoskeletal disorders. Indications for radionuclide bone scanning should also be understood, as should the basic concepts

of this imaging modality, and interpretation of some of the more common bone scans (which will be read with the Nuclear Medicine staff).

Interpersonal and Communication Skills:Call referring physicians for positive results or for any further pertinent history needed prior to advanced imaging or a MSK procedure.Communicate effectively with all members of the health care team.* Dictate a concise, accurate report which will allow the referring clinician to understand the findings and the differential diagnosis for these findings. If a pertinent finding was called to the clinician, documentation of this including the clinician’s name should be included on the dictated report.

Practice-Based Learning and Improvement:Identify, rectify and learn from personal errorIncorporate feedback into improved performanceUse electronic and print resources to access information

Professionalism:Demonstrate respect for patients and members of the health care teamRespect patient confidentialityCome to work with a professional appearanceDemonstrate a responsible work ethic

Systems-Based Practice:Demonstrate knowledge of ACR standardsAttend imaging conferencesAttend journal club and other pertinent conferences

Second and Third Year Residents

Patient Care:* All of the objectives listed for first year residents should be reviewed with increased mastery. Protocol CT and MRI exams without assistanceMonitor musculoskeletal CT examsUnderstand indications for MRI

Medical Knowledge:Increasingly facile with orthopedic radiologyMore detailed knowledge of neoplastic, metabolic, infectious and rheumatologic disorders is warrantedDiscuss the most common techniques in musculoskeletal imaging, the indications and contra-indications and complications of the following:

- Radiography and fluoroscopy- Musculoskeletal scintigraphy- Arthrography- Musculoskeletal biopsy- CT- MRI

Describe pertinent normal anatomy on MRI’s of shoulder, knee, hip, elbow, wrist, hand, foot and ankle

Interpersonal and Communication Skills:Communicate effectively with patients and all member of the health care teamFunction as a consultant in musculoskeletal radiology yet be free to obtain more experienced opinions.

* Demonstrate a leadership role in communications/interactions with technical personnel and patients, including explanation of delays related to emergencies.

* Demonstrate increasing skill in clearly and concisely communicating via the radiology dictated report.

Practice-based Learning and Improvement:Identify, rectify and learn from personal errorIncorporate feedback into improved performanceUse electronic and print resources to access information

Professionalism:Demonstrate respect for patients and members of the health care teamRespect patient confidentialityCome to work with a professional appearanceDemonstrate a responsible work ethic* Demonstrate altruism (putting the interests of patients and others above own self-interest). The resident should teach the above objectives to medical students and junior residents directly as well as by modeling behavior consistent with these objectives.

Systems-Based Practice:Demonstrate knowledge of ACR standardsAttend imaging conferencesGreater participation in unknown case analysis at noon conference is expected.* Demonstrate knowledge of hospital-based systems that effect physician practice, including physician code of ethics, medical staff bylaws, quality assurance committees, and credentialing processes. This includes knowledge of how these processes may affect the scope of practice of any one physician and competition among practitioners. * Demonstrate the ability to design cost-effective imaging strategies/care plans based on knowledge of best practices.

Fourth Year Residents:

Patient Care:Protocol CT and MRI examinations without assistanceMonitor musculoskeletal CT and MRI examsUnderstand indications for CT contrast and gadolinium

Medical Knowledge:Discuss the radiographic findings of all musculoskeletal pathology

Establish a precise diagnosis and provide a pertinent differential diagnosisOrient and supervise the investigation of a patient or of a specific diseaseDiscuss MRI findings of musculoskeletal pathologyUnderstand and appreciate orthopedic procedures of greater complexity such as joint replacement, osteotomies, spinal fixationBe able to streamline the diagnostic imaging work-up for a specific musculoskeletal abnormality.* Teaching of the above objectives to medical students and junior residents should be increasingly emphasized.

Interpersonal and Communication Skills:Communicate effectively with patients and all member of the health care teamFunction as a consultant in musculoskeletal radiology yet be free to obtain more experienced opinions.* Demonstrate increased ability to communicate effectively with providers at all levels of the health care system as well as those in outside agencies, etc.* Mastered the skill in clearly and concisely communicating via the radiology

dictated report.

Practice-Based Learning and Improvement:Identify, rectify and learn from personal errorIncorporate feedback into improved performanceDemonstrate awareness of resources available to practicing radiologists for

lifelong learning, including print, CD-ROM, and internet products of the ACR.* Demonstrate knowledge of the above objectives by supervision of medical

students and junior residents as well as by directly teaching these objectives.

Professionalism:All of the objectives listed for first, second, and third year residents should be

reviewed with increased mastery.* The senior resident should increasingly supervise and mentor medical students and junior residents in achieving these objectives.

Systems-Based Practice:All of the objectives listed for first, second, and third year residents should be

reviewed with increased mastery.* Demonstrate knowledge of how decisions about the timing/availability of

imaging studies may affect hospital length of stay, referral patterns for specific examinations and use of diagnostic studies outside the Department of Radiology.

* Demonstrate knowledge of the regulatory environment. Demonstrate

knowledge of basic management principles such as budgeting, record keeping, medical records, and the recruitment, hiring, supervision and management of staff.

Resident Evaluation: Medical knowledge in musculoskeletal radiology will be specifically evaluated by the annual ACR in-service examination and the mock oral board examination (OSCE) held twice per year. Patient care, practice based learning and systems-based practice relevant to musculoskeletal radiology will be evaluated by imaging conference presentations and monthly electronic global evaluations by the faculty.

Knowledge Based Objectives Rotation 1

I. Aspects of Basic Science Related to Bone

A. Histogenesis of developing bone including intramembranous and enchondral ossification

B. Bone Anatomy

1. Cellular constituents - osteoblasts, osteoclasts, chondroblasts, chondrocytes

1. Non-cellular constituents - organic matrix, inorganic matrix

2. Structure of cortical and cancellous bone

C. Bone Physiology1. Bone mineralization

2. Regulation of calcium homeostasis

3. Regulation of bone formation and resorption

a. Humoral - PTH, Calcitonin, Vitamin D,

b. Paraneoplastic - PTH like protein

II. Techniques Related to Musculoskeletal Radiology

A. Radiographya. Understand the standard views obtained and patient positioning for

plain film examinations of the:

i. Spine - cervical, thoracic, and lumbosacral

ii. Ribs

iii. Pelvis

iv. Extremities

v. Joints - shoulder, elbow, wrist, hip, knee, ankle

B. Conventional Tomography and MRIa. Methodology, indications, interpretation

C. Fluoroscopic and Ultrasonographic procedures

III. Normal Features and Variants

A. Sequence of ossification at joints (e.g. elbow)

B. Physiologic radiolucencies

C. Bone island

D. Vascular channels, nutrient canals

E. Epiphyseal / apophyseal ossification centers - normal, multiple (e.g. bipartite patella

IV. Trauma

A. General principles

1. Biomechanics of fractures

2. Relationship of force and deformation

3. Relevant anatomy and terminology

B. Fracture description - closed, open, comminuted, segmental1. Description of distal fragment position vs. fracture / apex

C. Subluxations / Dislocations1. Definition, description

D. Stress InjuriesE. Evaluation of healing

1. Malunion

2. Nonunion

3. Delayed healing

V. Infection

A. Basic Concepts

B. Routes of Spread

C. Sites of localization - neonates, infants, children, adultsD. Septic arthritis

E. Osteomyelitis

VI. Joint Disorders

A. Normal anatomy1. Types of joints - fibrous, cartilaginous, synovial

2. Intervertebral discs

B. Features to be evaluated for each disorder

1. Bone density

2. Soft tissue changes

3. Bone sclerosis, production, osteophyte formation / appearance4. Bone erosions

5. Joint space

6. Alignment / deformity

7. Distribution

C. Specific arthropathies

1. Osteoarthritis

a. Primaryb. Secondaryc. Erosive

2. Inflammatory

a. Rheumatoid

b. Psoriatic

c. Reiter's

d. Ankylosing spondylitis

VII. Neoplasms

A. Radiographic featuresSingle vs. multipleLytic, blastic, mixedZone of transitionCortical destructionMatrix

Periosteal responseSoft tissue mass

VIII. Skeletal Dysplasias

A. Paget's

1. Radiographic features

2. Appearance on bone scans

3. Common sites of involvement4. Associated laboratory findings

IX. Differential Diagnosis

A. Understand and know the differential diagnosis of imaging findings as they include many of the pathologic processes listed in the previous sections III. Normal Features and Variants through VIII. Skeletal Dysplasias.

Knowledge Based Objectives Rotation 2

A. All knowledge based objectives from rotation 1

I. Infection

1. Concepts continued

2. Septic arthritis

3. Osteomyelitis

4. Terminology- sequestrum, involucrum, cloaca, Brodie's abscess5. Acute vs. Subacute

6 Chronic

a. Sclerosing osteomyelitis of Garre7. Organisms

a. bacterial

b. tuberculous

c. fungal

II. Joint Disorders

1. Normal anatomy

2. Types of joints - fibrous, cartilaginous, synovial3. Intervertebral discs

4. Features to be evaluated for each disorder

a. Bone density

b. Soft tissue changes

c. Bone sclerosis, production, osteophyte formation / appearanced. Bone erosions

e. Joint space

f. Alignment / deformity

g. Distribution

5. Specific arthropathies

a. Osteoarthritis

i. Primary

ii. Secondary

iii. Erosive

b. Inflammatory

i. Rheumatoid

ii. Psoriatic

iii. Reiter's

iv. Ankylosing spondylitisv. Enteropathic

vi. Juvenile chronic

c. Connective tissue

i. SLE

ii. Scleroderma

6. Depositional

III. Neoplasms

1. Radiographic featuresa. Single vs. multipleb. Lytic, blastic, mixedc. Zone of transitiond. Cortical destructione. Matrix

f. Periosteal responseg. Soft tissue mass

2. Features on advanced imaging modalities - Nuclear studies, CT, US, MRI

3. Osseous lesions

4. Chondroid lesions

5. Fibrous lesions

6. Vascular lesions

7. Associated syndromes

8. Primary vs. secondary lesions

Bone lesions

1. Cartilaginous

a. Enchondroma

i. Ollier disease

ii. Maffucci syndrome

b. Chondromyxoid fibroma

c. Chondroblastoma

d. Osteochondroma

i. Hereditary multiple exostoses

e. Juxtacortical (periosteal) chondroma

f. Chondrosarcoma

i. Primary

ii. Secondary

iii. Clear cell

iv. Dedifferentiated

2. Osseous

a. Osteoma

b. Osteoid osteoma

c. Osteoblastoma

d. Osteosarcoma

i. Parosteal

ii. Periosteal

iii. Telangiectatic

3. Fibrous and fibrohistiocytic

a. Fibroxanthoma (nonossifying fibroma)

b. Fibrous dyplasia

i. McCune - Albright syndrome

c. Fibrosarcoma

d. Malignant fibrous histiocytoma

4. Vascular

a. Hemangioma

b. Angiosarcoma

5. Miscellaneous

a. Simple (unicameral) bone cyst

b. Langerhans cell histiocytosis (histiocytosis X)

c. Giant cell tumor

d. Aneurysmal bone cyst

e. Adamantinoma

f. Ewing sarcoma

g. Chordoma

h. Multiple myeloma/plasmacytoma

i. Leukemia

j. Lymphoma

i. Hodgkin

ii. Non-Hodgkin

k. Metastasis

D. Soft tissue lesions

1. Adipose tissue

a. Lipoma

i. Intramuscular

ii. Intermuscular

b. Liposarcoma

2. Vascular and lymphatic

a. Hemangioma

b. Lymphangioma

c. Angiosarcoma/lymphangiosarcoma

3. Fibrous and fibrohistiocytic

a. Fibromatoses

i. Palmar (Dupuytren contracture)

ii. Plantar

iii. Intraabdominal (Gardner syndrome)

iv. Extraabdominal (aggressive)

b. Fibrosarcoma

c. Malignant fibrous histiocytoma

4. Muscle

a. Leiomyosarcoma

b. Rhabdomyosarcoma

5. Peripheral nerve

a. Neurofibroma

b. Schwannoma

c. Malignant peripheral nerve sheath tumor

d. Morton neuroma

6. Synovial

a. Localized giant cell tumor of tendon sheath (nodular tenosynovitis)

b. Ganglion

c. Synovial sarcoma

7. Bone and cartilage forming

a. Myositis ossificans

b. Extraskeletal osteosarcoma

c. Extraskeletal chondrosarcoma

IX. Tumors and Tumor-Like Lesions (Advanced)

A. Bone lesions

1. Cartilaginous

a. Mesenchymal chondrosarcoma

2. Osseous

a. High grade surface osteosarcoma

3. Fibrous and fibrohistiocytic

a. Benign fibrous histiocytoma

b. Osteofibrous dysplasia (ossifying fibroma of long bone)

c. Desmoplastic fibroma

4. Vascular

a. Hemangiomatosis (angiomatosis)

b. Gorham disease

c. Glomus tumor

d. Hemangiopericytoma

e. Lymphangioma

f. Hemophilic pseudotumor

5. Miscellaneous

a. Lipoma

b. Adamantinoma

c. Primitive neuroectodermal tumor

d. Intraosseous ganglion

e. Epidermoid inclusion cyst

B. Soft tissue lesions

1. Adipose tissue

a. Fibrolipomatous hamartoma of nerve

b. Lipomatosis

c. Parosteal lipoma

d. Liposarcoma (types)

i. Well differentiated (atypical lipoma)

ii. Myxoid

iii. Round cell

iv. Pleomorphic

v. Dedifferentiated

2. Vascular and lymphatic

a. Glomus tumor

b. Hemangiopericytoma

c. Hemangioendothelioma

d. Kaposi sarcoma

e. Lymphangiomatosis

3. Fibrous and fibrohistiocytic

a. Elastofibroma

b. Infantile fibromatosis

c. Juvenile aponeurotic fibroma (calcifying juvenile fibroma)

d. Fibrous hamartoma of infancy

e. Myofibromatosis

f. Fibromatosis coli

g. Dermatofibrosarcoma protuberans

4. Muscle

a. Leiomyoma

b. Rhabdomyoma

5. Peripheral nerve

a. Plexiform neurofibroma

b. Granular cell tumor

c. Clear cell sarcoma

d. Extraskeletal Ewing sarcoma

i. Primitive neuroectodermal tumor

ii. Askin tumor

6. Bone and cartilage forming

a. Fibro-osseous pseudotumor of the digit

7. Miscellaneous

a. Myxoma

b. Alveolar soft part sarcoma

c. Epithelioid sarcoma

d. Malignant mesenchymoma

e. Lymphoma

f. Metastasis

IV. Metabolic / Hematologic Disorders

V. Skeletal Dysplasias

Congenital Anomalies and Dysplasias (Basic)

A. Developmental dyplasia of the hip

B. Proximal femoral focal deficiency

C. Blount disease

D. Discoid meniscus

E. Foot deformity

1. Tarsal coalition

2. Talipes equinovarus (clubfoot)

3. Pes planus

4. Pes cavus

5. Metatarsus adductus varus

6. Vertical talus

7. Rocker-bottom foot

F. Congenital pseudarthrosis

G. Madelung deformity

H. Pectus excavatum

I. Pectus carinatum

J. Asphyxiating thoracic dysplasia (Jeune)

K. Thanatophoric dwarfism

L. Achondroplasia

M. Chondrodysplasia punctata (stippled epiphyses)

N. Chondroectodermal dysplasia (Ellis-van Creveld)

O. Cleidocranial dysplasia (dysostosis)

P. Spondyloepiphyseal dyplasia

Q. Multiple epiphyseal dysplasia

R. Dysplasia epiphysealis hemimelica

S. Osteogenesis imperfecta

T. Osteopetrosis

U. Pyknodysostosis

V. Osteopoikilosis

W. Melorheostosis

X. Osteopathia striata

Y. Diaphyseal dysplasia

1. Engelmann

2. Van Buchem

Z. Metaphyseal dysplasia (Pyle)

AA. Pachydermoperiostosis

BB. Nail-patella syndrome

CC. Holt-Oram

DD. Macrodystrophia lipomatosa

EE. Fibrodysplasia (myositis) ossificans progressiva

FF. Mucopolysaccharidosis (general findings)

GG. Neurofibromatosis

HH. Tuberous sclerosis

II. Trisomy 21 (Down syndrome)

JJ. Marfan syndrome

KK. Ehlers-Danlos syndrome

LL. Turner syndrome

VI. Syndromes

Knowledge Based Objectives Rotation 3 and 4

All knowledge based objectives from rotations 1 and 2 to a greater depth.

References:

Association of Program Directors in Radiology (www.apdr.org)

Stony Brook University Radiology Residency

James A. Haley VA Hospital Radiology Residency

The Education Committee of the American Society of Musculoskeletal Radiology

(1997-98)

Musculoskeletal Core Lectures: Alberto Simoncini, M.D.

1 Histogenesis, bone anatomy and physiology

2 Techniques relevant to MSK imaging

3 Normal features and variants

4 Congenital and developmental abnormalities of the spine

5 Congenital anomalies and dysplasias (basic)

6 Congenital anomalies and dysplasias (advanced)

7 Infection

8 Tumors and tumor-like lesions (basic)

9 Tumors and tumor-like lesions (advanced)

10 Trauma

11 Metabolic, systemic and hematologic disorders,Disorders of the joints