Diagnostic Imaging UE/LE

what indicates the need for imaging for the UE

-trauma

-dislocation

-chronic pain

what clinical presentations would indicate a patient should be referred for a shoulder radiograph

-FOOSH

-bone deformity/instability

-ecchymosis

-swelling

-focal tenderness to bone

-used when suspicion of clavicle fracture, AC separation, massive RTC tear, DJD, dislocation, or humeral fracture

what are the standard projections for the shoulder

-AP (external rotation and internal rotation)

-Axillary OR Scapular Y Lateral

What can be visualized in the AP Shoulder +ER view

-proximal humerus

-greater tuberosity

-lesser tuberosity

-anatomic neck

-surgical neck

-borders of the scapula

-clavicle

-spine of scapula

-coracoid process

-glenoid process

-acromion

what can be visualized in the AP Shoulder + IR view?

-proximal humerus

-greater tuberosity

-lesser tuberosity

-anatomic neck

-surgical neck

-borders of the scapula

-clavicle

-spine of scapula

-coracoid process

-glenoid process

-acromion

which AP view will better visualize the lesser tubercle

AP Shoulder + IR

what can be seen in the shoulder axillary view

-relationship of the humeral head in the glenoid fossa

-rims of glenoid fossa and coracoid process

-good to visualized glenoid humeral dislocation

what can be visualized in a scapular Y lateral view?

fractures or dislocations of the proximal humerus and scapula

what are the standard radiologic evaluation of the AC joint

AP Bilateral with and without weights

what can be visualized on a shoulder MRI

-GH dislocation

-Acute RCT

-Chronic RCT

what views can be visualized with an MRI of the shoulder

-axial

-sagittal

-coronal

what MRI view would assess rotator cuff tendon integrity

coronal

what MRI view would assess Rotator cuff muscle atrophy

sagittal

what MRI view would assess for labrum tears

-axial

-sagittal

-coronal

when would you use conventional radiograph for the shoulder

-acute shoulder pain

-septic arthritis

-TOS

when would you use MRI/MRA for the shoulder

-persistent significant pain

-labral injury

-bursitis or long head of biceps tenosynovitis

-impingement

-re-tear status post prior RCT

-TOS

when would you use CT for the shoulder

-scapular fracture

-osseous glenoid fossa lesion

when would you use ultrasound for the shoulder

-bursitis

-long head of bicep tendinopathy or displacement

-impingement

-RC tendinopathy

-re-tear status post prior RC repair

-AC joint integrity, degeneration of effusion

what are some common clinical situations that would indicate radiography for the elbow

-FOOSH injury with obvious deformity or bone tenderness

-bone tenderness

-traction injury in younger individuals

what is the clinical rule for management of elbow injury in regards to elbow extension

-those patients with extension ROM equal to the unaffected side do not require emergent elbow radiographs

-those able to fully extend their elbow, radiography can be deferred

-if symptoms do not resolve within 7-10 days, these patients should return

what are some abnormal elbow findings

-fat pad sign

-elbow dislocation

-lateral osteochondritis dissecans

-medial growth plate avulsion

-radial head dislocation

what two abnormal findings make up little leaguers elbow

-lateral osteochondritis dissecans

-medial growth plate avulsion

what are the standard projections for elbow radiographs

-AP

-Lateral

what can be viewed in an AP elbow radiograph

-distal humerus

-medial epicondyle

-lateral epicondyle

-capitulum

-trochlea

-olecranon fossa

-ulna

-olecranon process

-coronoid process

-ulnar shaft

-radius

-humeroulnar joint

-humeroradial joint

-carrying angle of the elbow

what can be viewed in a lateral elbow view

-olecranon

-coronoid process

-radius

-distal humerus

-anterior fat pads

when would conventional radiograph be used for the elbow

-acute injury, initial screening for fracture

-chronic elbow pain

when would MRI/MRA be used for the elbow

-intraarticular osteocartilaginous body/osteochondral injury

-soft tissue mass

-chronic epicondylitis

-collateral lig tear

-tendon lesion or bursitis

-nerve abnormality

-osseous tumor

when would CT be used for the elbow

-heterotopic ossification

-osteophytosis

when would ultrasound be used for the elbow

-chronic epicondylitis

-tendon lesion or bursitis

-collateral lig tear

-nerve abnormality

what are some common clinical situations that would indicate radiography of the wrist and hand

-tender in anatomical snuffbox following a FOOSH injury

-deformities and tenderness of the wrist and hone and

-tenderness over other b

what are the standard projections of the wrist and hand

-PA

-oblique

-lateral

what can be viewed in a PA view of the hand

-phalanges

-metacarpals

-sesamoid bones at the first MCP joint

-carpal bones

-joints of the hand

what can be viewed in the PA view of the wrist

-metacarpals

-carpals

-three arcuate lines formed by the carpals

-distal radius/ulna

-ulnar variance

-radial articular angle

what is it called when the ulna is longer than the radius

positive ulnar variance

what is it called when the ulna is shorter than the radius

negative ulnar variance

what is it called when the ulna and radius are equal

neutral ulnar variance

what can be viewed in an oblique projection of the hand

-phalanges

-metacarpals

-DIP

-PIP

-MCP

-CMC

-sesamoid bones at first MCP

what can be viewed in an oblique projection of the wrist

-metacarpals

-trapezium, trapezoid, scaphoid

-triquetrum and hamate

-distal radius and ulna

what can be viewed in a lateral projection of the hand

-bones of the thumb

-phalanges

-metacarpals

-metacarpal neck angle

-joints of the hand

what can be viewed in a lateral projection of the wrist

-first Metacarpal and trapezium

-distal radius and ulna

-volar tilt of the radius

-scapholunate angle

-capitolunate angle

-stacked arrangement of the radius-lunate-capitate relationship

when would you use radiography for the hand/wrist

-wrist, hand, and distal forearm trauma including suspected fractures and dislocations

-chronic wrist pain

-carpal tunnel syndrome

when would you use MRI/MRA for the hand/wrist

-occult or stress fractures, including scaphoid

-non-union, malunion, osteonecrosis, and/or posttraumatic arthritis

-ganglion cyst or palpable wrist mass

-ligamentous injury, including thumb UCL

-inflammatory arthritis

-chronic wrist pain

-possible infection

when would you use CT for the hand/wrist

-occult fracture, including hook of hamate and scaphoid

-non-union, malunion, osteonecrosis, and/or posttraumatic arthritis

-distal radio-ulnar joint dislocation

--intraarticular fracture

when would you use ultrasound for the hand/wrist

-tendon injury

-nerve lesion

-ganglion cyst and soft tissue masses

which type of imaging is typically used to examine inflammatory arthritis

a.conventional radiograph

b. MRI

c. CT

d. ultrasound

MRI

which type of imaging is typically recommended to visualize a RCT

a. conventional radiograph

b. MRI

c. CT

d. bone scan

MRI

with a shoulder dislocation, a glenoid labrum injury can occur. Which imaging modality would best evaluate this pathology?

a. conventional radiograph

b. CT

c. MRA

d. MRI

MRA

what happens with a Colles fracture

posterior displacement of distal radius

what happens with a Smith's fracture

anterior displacement of the distal radius

what is the recommended length of immobilization for scaphoid fractures

a. 4-6 weeks

b. 6-12 weeks

c. 12-18 weeks

d. 18-24 weeks

6-12 weeks

what are some common clinical situations for hip and pelvis radiography?

-high velocity trauma events

-deformity

-severe or progressive pain with WB or end range IR/ER

-focal tenderness to bone

-suspicious of a degenerative joint disease, stress fracture, avulsion fracture, AVN, slipped femoral capital epiphysis, and any skeletally immature patient with traumatic injury

what is the standard projection for the pelvis

AP

what are the standard projections for the HIP

-AP

-Lateral Frog Leg

what can be viewed in an AP pelvis view

-two coxal bones

-L5 vertebra

-scarum

-coccyx

-proximal femurs

-acetabulum

-acetabular roof, anterior and posterior rims

-iliopubic, ilioischial, and teardrop lines

what can be viewed in an AP hip view

-acetabulum, roof, anterior and posterior rims

-proximal femur

-femoral head, neck, and shaft

-greater trochanter

-lesser trochanter

-intertrochanteric crest

-increased cortical densities of the femoral shaft

what can be viewed in the lateral frog leg hip view

-acetabulum

-proximal femur

-femoral head, neck, and shaft

-greater trochanter superimposed behind the femoral neck

-lesser trochanter as it projects beyond the lower margin of the femur

when would you use radiography for the hip/pelvis

-fracture

-AVN

-chronic pain

-possible referred pain to exclude the hip

-stress fracture

when would you use MRI/MRA for the hip/pelvis

-fracture

-AVN

-osseous or surrounding soft tissue abnormality

-labral tear or femoroacetabular impingement

-pigmented villonodular synovitis

-osteochondromatosis

when would you use CT for the hip/pelvis

-osteoid osteoma

-acetabular fracture

when would you use dual energy x-ray absorptiometry for the hip/pelvis

identification and follow up of low bone density and fracture risk assessment in absence of symptoms but elevated risk

when would you use ultrasound for the hip/pelvis

development of dysplasia in infants

what are some common indications for radiography of the knee

-trauma

-pain

-instability

what are the ottawa knee rules?

-age 55 or older

-isolated tenderness of patella

-tenderness at head of fibula

-inability to flex to 90

-inability to bear weight both immediately and in the emergency department (4 steps)

what are the standard projections of the knee

-AP

-Lateral

what are the other projections of the knee outside of the standard two

-PA axial tunnel view of the intercondylar fossa

-tangenital view of the PF joint

what can be seen in the AP knee view

-distal femur

-medial and alteral condyles

-proximal tibia

-femorotibial space

-patella

-proximal fibula

what can be seen in the lateral knee

-distal femur

-proximal tibia

-proximal fibula

-patella

what can be viewed in the PA axial tunnel view of the intercondylar fossa

-distal femur

-proximal tibia

-fibula

-patella superimposed behind the femur

what can be viewed on the tangenital view of the PF joint

-patella

-femoral condyles

-sulcus angle

-congruence angle

what views are there for knee MRI

-axial

-sagittal

-coronal

what MRI views would assess the meniscus

-sagittal

-coronal

what MRI views would assess the cruciate ligaments

-sagittal

what MRI views would asses the collateral ligaments

coronal

what MRI views would assess for articular surfaces and bone bruises

-sagittal

-coronal

-axial

when would you use radiography of the knee

-fracture or dislocation

-routine monitoring after arthroplasty

-suspected periprosthetic infection

-atraumatic knee pain

when would you use MRI/MRA for the knee

-persistent pain

-osteochondral lesion, internal derangement, or joint effusion

-avascular necrosis

-posterior dislocation following significant trauma

when would you use CT for the knee

-tibial plateau fracture

-periprosthetic infection or prosthesis loosening

when would you use ultrasound for the knee

-tendon lesion

-popliteal cyst

-superficial ligament lesion

what are some common clinical scenarios that would indicate radiography for the ankle and foot

-trauma

-pain

-instability

what are the ottawa ankle rules

-bone tenderness at posterior edge or tip of lateral malleolus

-bone tenderness at posterior edge or tip of medial malleoulus

-bone tenderness at base of the 5th metatarsal

-bone tenderness at navicular

-inability to bear weight both immediately and in the ED

what are the standard projections of the ankle

-AP

-AP Oblique/Mortise

-Lateral

what can be seen in AP Ankle view

-distal tibia

-distal fibula

-proximal talus

-ankle mortise

what can be seen in AP oblique view of the ankle

-distal tibia

-distal fibula

-proximal talus

-entire ankle mortise

what can be seen in lateral ankle view

-distal tibia

-distal fibula

-tarsal bones (talus, calcaneus, navicular, cuboid)

-tibiotalar joint

-talocalcaneonavicular/subtalar joint

-calcaneocuboid joint

-talonavicular joint

what are the standard projections of the foot

-AP

-Lateral

-Oblique

what can be seen in the AP foot view

-phalanges

-DIP

-PIP

-metatarsals

-first intermetatarsal angle

-sesamoid bones at the first metatarsal head

-tarsals of the midfoot

-transverse tarsal joint

-tarsometatarsal joint

what can be seen in the lateral foot view

-tibia

-fibula

-transverse tarsal joint

-tarsometatarsal joint

-talus

-calcaneus

-tarsal sinus and the subtalar joint

what can be seen in the oblique foot view

-first through fifth digits

-first through fifth metatarsals

-cuboid

-third cuneiform

-talus

-calcaneus

-navicular

when would you use radiography for the foot/ankle

-acute injury imaging for suspected fracture, instability, or penetrating trauma

-osteonecrosis

-degenerative joint disease

-chronic pain

-osteomyelitis in presence of DM

when would you use MRI/MRA for the foot/ankle

-ankle impingement syndrome

-osteochondral lesion

-musculotendinous disruption

-ligamentous injury or instability, including syndesmotic injury

-stress injury or occult fracture

-RA, inflammatory arthropathy, or other inflammatory disorder

-neuroma or local neuropathy, including tarsal tunnel syndrome

-chronic heel pain or plantar fascitis

-osteomyelitis in presence of DM

when would CT scan be used for the foot/ankle

-talus or calcaneus fracture

-tarsal coalition or bony anomaly

when would ultrasound be used for the foot/ankle

-muscle or tendon lesion

-penetrating trauma/foreign body

-neuroma or local neuropathy, including tarsal tunnel syndrome

-plantar fascia lesion

-ligament lesion

when would scintigraphy be used for the foot/ankle

complex regional pain syndrome

which of the following is not included in the ottawa ankle rules

a. tenderness at the base of the 5th metatarsal

b. tenderness at the posterior edge of the lateral malleolus

c. inability to WB immediately after injury for 4 steps; 2 each side

d. tenderness at cuboid

tenderness at the cuboid

which type of imaging typically evaluates for osteochondral lesion of the foot/ankle?

a. conventional radiograph

b. CT

c. MRI

d. Ultrasound

MRI

what is the crescent sign associated with AVN

flattening of the femoral head