adv diagnosis - exam 1 desiree study guide

imaging in US physical therapy practice is increasing but inconsistent

describe the current state of imaging within the respect to physical therapists practice within the united states

most state practices do not have the same language - some are silent, others restrictive. a few states (maryland, colorado, and wisconsin) now allow PTs to refer or order imaging with specific training

do most states within the US have the same practice act language regarding a physical therapist practice and imaging referral

almost all state practice acts include a "duty to refer", making it a legal responsibility for PTs to refer patients when findings are beyond our scope

do all, or at least most state practice acts include the "duty to refer" as a legal duty and responsibility of a physical therapist

our role is to recognize when imaging is not needed, integrate imaging findings into our PT POC, understand the image/report to gather PT relevant information, knowing what tissues that is at fault to know what modality to use, and how to communicate imaging information with the radiologist, physician, and especially the patient

list the physical therapist role relative to imaging. what do you need to know, integrate, understand, and communicate

false

true or false: imaging should be conducted for every patient who presents with musculoskeletal complaints

its not always warranted. many injury locations/types have their own set of rules on how to rule the need for imaging in or out

why is "imaging should be conducted for every patient who presents with musculoskeletal complaints" a false statement

true

true or false: imaging should only be considered when the provider expects the results to influence decision making and plan of care

"imaging is indicated when the information yielded would change the treatment plan"

why is "imaging should only be considered when the provider expects the results to influence decision making and plan of care" a true statement

true

true or false: knowing when a patient should have imaging is a responsibility of a physical therapists

in most cases there are subsets of criteria where PTs should be able to rule in or out especially with direct access patients

why is "knowing when a patient should have imaging is a responsibility of a physical therapists" a true statement

true

true or false: knowing when the results of imaging would impact the physical therapist's plan of care and physical therapist's management of a patient is the responsibility of the physical therapist

there are clinical decision aids available once this decision is made such as: evidence based clinical decision rules, ACR, west australia diagnostic imaging pathways, and discussion with PCP or radiologist

why is "knowing when the results of imaging would impact the physical therapist's plan of care and physical therapist's management of a patient is the responsibility of the physical therapist" a true statement

clinical decision rules

american college of radiology appropriateness criteria (ACR)

western australia diagnostic imaging pathways

discussion with PCP or radiologists

list the type of clinical decision aids that are available to help determine if imaging is indicated

evidence based

determine risk level to not miss serious conditions

clinical decision rules

evidence based consensus

IDs high and low values studies based on clinical variants

american college of radiology appropriateness criteria (ACR)

pathways based on suspected diagnoses

western australia diagnostic imaging pathways

acute cervical trauma - canadian C spine rules

acute ankle injury/ottawa ankle rules

acute knee trauma/ottawa knee rules

lumbar guidelines (ACR criteria)

shoulder dislocation

suspected compression fracture

elbow extension sign (elbow fracture)

acute radial wrist fracture (scaphoid fracture)

recall the following clinical decision rules related to imaging

purpose: decide if C-spine x-ray is needed after trauma

imaging needed if: high risk factor (age ≥65, dangerous mechanism, or paresthesias in extremities), unable to actively rotate neck 45 degrees left and right

no imaging: low-risk factors present (simple rear-end crash, sitting in ED, ambulatory, delayed pain, no midline tenderness) and can rotate 45 degrees bilaterally

acute cervical trauma - canadian C-spine rules

purpose: determine needed for ankle/foot x-rays after trauma

imaging needed if: pain in malleolar or midfoot zone and bone tenderness at posterior edge/tip of lateral or medial malleolus, base of 5th metatarsal or navicular, or unable to bear weight immediately and in ER (4steps)

acute ankle injury/ottawa ankle rules

purpose: decide if knee x-ray is required

imaging needed if: age ≥ 55, tenderness at fibular head, isolated patellar tenderness, inability to flex knee to 90 degrees, unable to bear weight 4 steps immediately and in ER

acute knee trauma/ottawa knee rules

purpose: imaging only when serious pathology suspected or persistent symptoms

imaging needed if: red flags (severe/progressive neuro deficits, cauda equina signs, cancer history, infection, fracture risk, trauma, unexplained weight loss)

no red flags: try conservative management for 6 weeks before imaging

lumbar guidelines (ACR criteria)

imaging needed if: first time dislocation or traumatic event, suspicion of fracture (especially hill-sachs or bankart lesion), persistent pain, deformity, or instability after reduction

shoulder dislocation

imaging needed if: trauma in older adult or osteoporotic patient, midline spinal tenderness or sudden severe back pain, prolonged corticosteroid use or known osteoporosis

suspected compression fracture

purpose: quick rule out test

imaging needed if: unable to fully extend elbow after injury

if full extension = fracture very unlikely (sensitive rule)

elbow extension sign (elbow fracture)

imaging needed if: snuffbox tenderness, pain with axial thumb compression or wrist extension, swelling over scaphoid after fall on outstretched hand (FOOSH)

if negative x-ray but high suspicion -> immobilize and re-image in 10-14 days

acute radial wrist fracture (scaphoid fracture)

conventional radiograph (X-ray)

most of the time, what is the initial imaging modality that is used

if there is a fracture and/or any need for surgery, the patient may have weightbearing precautions where their TRX will be delayed

list some examples of when imaging results would change your plan of care

clinical hypothesis, who's writing the order, will results change, POC, cost, radiation exposure, contraindications or fear

considerations for making a recommendation for imaging or directly ordering images

age, MOI, signs and symptoms, other test results (neuro/special test), modality requested, RL side specified, your hypothesis, contact number for if results are urgent

information needed for radiology orders

ASAP: contact PCP/specialist when the findings align with - neoplasms, complete contractile ruptures, posterolateral corner injury, high ankle sprains, lisfranc sprain

indicate when a discussion when a patient's primary care physician or physician specialist would be appropriate prior to ordering or referring for image

accuracy for ordering imaging when it is needed: PT's were 74%, ortho surgeons 80%, but non-ortho doctors were at 35%

what was the summary of the Moore et al 2005 study

PT's especially when board certified in determining when imaging is necessary are 3x more likely to have accuracy agreement between diagnosis and imaging results, PTs average visits before ordering MRI, percent of orders complying with ACR = 83.2%, (great accuracy of PTs deciding appropriately when imaging is needed)

what was the summary of the Crowell et al 2016 study

1st ordered diagnostic study, little risk, time effective, cost effective

why are conventional radiographs the most common imaging modality

the image is produced on a sensitive plate or film using x-rays, gamma rays, or other type of similar radiation. the radiation passes through the patient where there is attenuation (meaning where it is changed or blocked depending on the density of the tissue). the remnant radiation incepted by receptor to create a visual image

describe how standard radiograph creates a visual image

where the radiation is changed or blocked by pathologic tissue

define the term attenuation

on density of the tissue

what does attenuation depend on

harm is done when using radiation. it affects neural atoms gains/loses of electrons, disrupts composition of matter, disrupts life processes. you must use shielding/diagnostic yield to protect patient from the harm of radiation

indicate the effects of ionizing radiation

energy that is deposited in patients

define absorbed dose

absorbed dose that is adjusted for harmful effects

define equivalent dose

equivalent dose that is adjusted for the harm that is causes to different tissues

define effective dose

single chest x-ray

single mammogram

full body CT scan

rank single mammogram, fully body CT scan, and single chest x-ray from low to high in terms mSV (radiation)

0.1 msV

what is a safe level of radiation for single chest x-ray

3 mSV

what is a safe level of radiation for single mammogram

10 mSV

what is a safe level of radiation for full body CT scan

true

true or false: radiation exposure is cumulative

false

true or false: all body tissues absorb radiation equally

physical qualities of an object that determine how much radiation it absorbs (composition, thickness). the greater the atomic number, the volume density and/or thickness, the greater this is

define radiodensity

minimal absorption of radiation = show up as black

define radiolucent

air

what would be an example of something that is radiolucent

whiter color more absorption gets through

define radiopaque

heavy metals in joint replacement

what would be an example of something that is radiopaque

composition and thickness

what factors influence an objects radiodensity

air

fat

water

bone

metal

place in order air, fat, water, bone, metal from lowest radiodensity (most radiolucent) to highest radiodensity (most radiopaque)

air

fat

water

bone

metal

place in order air, fat, water, bone, metal as how the substance would appear on radiography from the darkest to lightest

true

true or false: the greater the radiodensity of objective, the greater the amount of radiation will be absorbed resulting in less of the x-ray beam reaching the film

true

true or false: an object or tissue that has greater radiodensity will be more radiopaque and will appear whiter (lighter) on radiograph

lead, bone

examples of things that have higher radiodensity and more radiopaque

true

true or false: an object or tissue that has lower radiodensity will be more radiolucent and will appear darker (blacker) on a radiograph

air

examples of things that have lower radiodensity and more radiolucent

lighter

does bone appear darker or lighter on a radiograph compared to air or fatty tissues

more radio dense

why does bone appear lighter/more white on radiograph than air and fat

frontal plane (beam located above supine lying patient)

what plane and how is a person situated for an anterior to posterior view

frontal plane (beam located above prone lying patient)

what plane and how is a person situated for a posterior to anterior view

sagittal plane (lateral projecting beams)

what plane and how is a person situated for lateral to medial view

transverse plane (depends on what is being imaged)

what plane and how is a person situated for an axial view

oblique plane (beams aligned 45 or 0 degree angle for better anatomic visualization)

what plane and how is a person situated for oblique view

true

true or false: imaging reveals pathology, but the history and physical exam provides relevance

highly specific

when generally describing the psychometric properties of radiographs, radiographs are best described as being highly specific or highly sensitive

all the way across

define complete fracture

not all the way across

define incomplete fracture

incomplete (splintering usually Peds)

define greenstick fracture

diagonal across bone

define oblique fracture

straight line across bone

define transverse fracture

break wraps around bone

define spiral/torsional fracture

bone comes through the skin

define compound fracture

partial without skin wound

define simple fracture

bone breaks into 2 or less pieces (complete or incomplete)

define non-comminuted fracture

bone breaks into 3 or more pieces (3, 4, 5 = mild and more than 5 is severely)

define comminuted

left translated completed fracture

left angulated completed fracture

left angulated incomplete fracture

complete fracture with shortening

peds growth plate (physis)

what type of fracture is salter harris fracture

pediatric

who is most likely to get a salter harris fracture

fracture across physis without metaphysical or epiphyseal injury

type 1 salter harris fracture

extends into metaphysis

type 2 salter harris fracture

extends into epiphysis

type 3 salter harris fracture

through metaphysis and epiphysis

type 4 salter harris fracture

crush injury

type 5 salter harris fracture

open fractures

what type of fractures does the gustilo classification apply

skin has been disrupted

what does gustilo classification describe

fracture of anatomic neck, surgical neck, greater tuberosity, or lesser tuberosity - displacement is angulation of more than 45 degrees or more than 1 cm form anatomic position

neer classification relates to what type of fractures

no displacement

neer classification: one part

one displacement

neer classification: two part

two displacements but humeral head in contact with glenoid

neer classification: three part

three or more displacements and dislocation of articular surface

neer classification: four part

validated system on name type of fracture that may be used post op you may see in chart but won't use in clinical practice

muller AO classification

alignment, bone density, cartilage, soft tissue

ABCs of radiographic eval

it accounts for all possible findings and decreases chance for observational error

why is a "search pattern" such as the ABCs system a requirement

observation and interpretation

what is a key reason for errors in interpretation of imaging