samuel r. ward. associate professor in the departments of radiology, orthopaedic surgery and...
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10/10/13
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Imaging Musculoskeletal Injuries- Strengths and Weaknesses of Different Modalities
Samuel R. Ward, PT, PhD
Associate Professor Muscle Physiology Lab
Departments of Radiology, Orthopaedic Surgery, and Bioengineering University of California San Diego
VA Medical Center San Diego
MuscleTech Network, Barcelona, Oct 14, 2013
Imaging Modalities
Ultrasound Plain film x-ray
Computed tomography Bone Scan (scintigraphy)
Magnetic resonance imaging Positron emission tomography C
ost /
Com
plex
ity
Saf
ety
/ eas
y of
use
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Ultrasound
www.terason.com
From Strobel et al, Radiology, 2005
Healthy
Fatty Atrophy
Sag Obl Ultrasound Cor Obl Ultrasound Sag Obl MRI
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Plain film x-ray
http://www.umphysicians.org
Film/detector
Ionizing radiation source Density contrast
Computed tomography
http://www.cogneuro-lab.org
Density = contrast
Can use iodine-based contrast
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Bone Scan (Scintigraphy)
http://www.saintlukeshealthsystem.org
Detector (2D or 3D)
Patient = radiation source Metabolic/Remodeling activity contrast
Fracture, tumor- 99mTC-MDP- Osteoblasts Infection- Induim-111 or Galium-neutrophils
Magnetic resonance imaging
http://www.magnet.fsu.edu
Proton imaging (H2O)
Contrast = intrinsic properties of soft tissues Very good at imaging water
Very flexible imaging technique
Gadolinium or Iron- based contrast agents
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Positron emission tomography
Patient is the radiation source Radiopharmaceuticals-
15O-H2O- blood flow and tissue perfusion FDG- glucose transport/action
Shinozaki, JSES 2013
Rotator Cuff + Nerve Injury
Thieme, Atlas of Anatomy 2007 Sagittal Oblique T1 MRI
Supraspinatus
Infraspinatus Image Plane
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MRI Spine Stress Films
Standing Sitting
Kne
es to
che
st
Pron
e on
elb
ows
MRI Stress Films
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High-Res Structure
High-Res DTI
IDEAL
MRI Physiology and Microarchitecture
Skiing Injury with Epimysial Hematoma
Gas
Gas Gas
Sol
Sol Sol
Sag US Ax T1 MRI Ax T2 MRI
Tib Tib
Isointense = acute
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Intramuscular Hematoma from a Kick
Sag US Ax T2 MRI
Heterogeneous intensity = Subacute
Chronic Subperiosteal Hematoma
Ax T2 MRI Fat Sup Ax T2 MRI Ax CT
RF RF RF
VL VL VL
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Rhabdomyolysis from Fall
Ax CT Ax MRI
G Max
G Med
Professional Soccer Player Kick Injury after 5-6 weeks
Ax CT Myositis Ossificans
Ax T1 MRI Differential diagnosis- neoplasm?
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Grade 1- Stress Fracture
Bone Scan Fat Sup T2 Ax MRI X-Ray
Fracture
CC
Cor Fat Sup T2 MRI Cor T1 MRI X-Ray
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ACL Tear with Bone Bruise
Sag T1 MRI Sag Fat Sup T2 MRI
Quadriceps Tendon Tear
Sag T1 MRI Sag Fat Sup T2 MRI
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Achilles Tendon MRI UTE T2* Quantification
TE 100 µs
TE 300 µs
TE 500 µs
TE 1 ms
TE 10 ms
TE 2 ms
TE 3 ms
TE 5 ms
UCSD MSK Imaging Research Group cbchung@ucsd.edu
Case 1 • A young talented player
with symptoms in the patella tendon (on and off pain during warm up or after training, better during activity) during the preseason training
• what to do? • continue training? adjust
training? add treatment?
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Case 2 • A very important player
during season experience increasing symptoms (pain and stiffness in the morning) in the Patellar Tendon weeks before an important match
• What to do ??
Case 3
• One of you players experiences sudden unset of pain in the Insertional Achilles tendon during training but only during high loading.
• What to do ?
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Thank You
Mini Pathria, MD Christine Chung, MD
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Grade Radiography Scintigraphy MR Imaging
0 Normal Normal Normal
I Gray cortex sign; margin is indistinct, density lower
Linear increased cortical activity
Mild to moderate periosteal edema on T2-w images with normal marrow
II Acute periosteal reaction, density differs from rest of cortex showing incomplete mineralization
Small focus of increased activity
Periosteal edema and bone marrow edema on only T2-w images
III Lucent areas in cortex, ill-defined foci at site of pain
Larger focal lesion with highly increased activity in cortical region
Marrow edema on T1-w and T2-w images with/without periostitis and loss of cortical signal void, intracortical increased intensity and intracortical linear hyperintensity
IV Fracture line present Very large focal region of highly increased activity
Low signal intensity fracture line on all sequences, periosteal and marrow edema, may show muscle edema
Beck BR, Bergman G, Miner M et al, Radiology 263:811, 2012
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