medical imagery for the field therapist

Medical imagery for the field therapist

Charlen Berry, January 2013, EATA Conference, Buffalo 1

Medical Imagery for the Field

Therapist ● ● ●

T ti C ditiTraumatic Conditions

Charlen Berry B.Sc., CAT(C), DO(Qc)Certified Athletic Therapist / Osteopath

EATA Buffalo 2013EATA Buffalo 2013 22

Why do we need to know ?Why do we need to know ?Pertinent information about the patient, past Pertinent information about the patient, past and present historyand present historySafety (2 aspects)Safety (2 aspects)Better understand the tests, the views, the Better understand the tests, the views, the e e u de s a d e es s, e e s, ee e u de s a d e es s, e e s, ehealing processes and prescription guidelineshealing processes and prescription guidelinesWhich tests are most appropriate? Which tests are most appropriate? PostPost--concussion symptomsconcussion symptomsCommunication and collaborationCommunication and collaboration


What do we need to know ?What do we need to know ?

80% of imaging in MSK conditions are 80% of imaging in MSK conditions are basic radiographs, basic radiographs,

Basic reading of XBasic reading of X--RaysRays

Implications of different fracturesImplications of different fractures

Basic knowledge on available testsBasic knowledge on available tests

Knowledge of prescription guidelinesKnowledge of prescription guidelines


How do we get the knowledgeHow do we get the knowledge

PresentationsPresentationsBooks & articlesBooks & articlesInternetInternetSpecific coursesSpecific courses

References at the end of the presentationReferences at the end of the presentation

EATA Buffalo 2013EATA Buffalo 2013 55 EATA Buffalo 2013EATA Buffalo 2013 66



Why ?Why ?

To have pertinent information in To have pertinent information in the patient file at the beginning the patient file at the beginning

of the seasonof the season

Read the reportsRead the reportsSee the images (radiology)See the images (radiology)

77EATA Buffalo 2013EATA Buffalo 2013

Patient’s file: Patient’s file: Read the reports / See the imagesRead the reports / See the images


HISTORY OF THE PASTHISTORY OF THE PAST

Imagery was done Imagery was done W 5 RW 5 RWhy?What for?


When?Where?Who?

RESULTS ?

HISTORY OF THE PRESENTHISTORY OF THE PRESENTFoot or ankle ?Foot or ankle ?Standard views?Standard views?–– What are they?What are they?–– Ankle: AP, LAT, Ankle: AP, LAT, –– Knee: AP, LAT,Knee: AP, LAT,

Specialised views?Specialised views?–– Oblique views of the fibula?Oblique views of the fibula?–– Plantar flexionPlantar flexion–– DorsiflexionDorsiflexion


WHAT IS MEDICAL WHAT IS MEDICAL IMAGINGIMAGING


RADIOLOGYRADIOLOGYBranch of medicine Branch of medicine concerned with concerned with radioactive substances radioactive substances including Xincluding X--Rays, Rays, radioactive isotopes radioactive isotopes

d th li ti fd th li ti f


and the application of and the application of this information to the this information to the prevention, diagnosis prevention, diagnosis and treatment of and treatment of disease.disease.



MEDICAL IMAGINGMEDICAL IMAGING

Radiographs (simple films)Radiographs (simple films)Contrast enhanced radiographsContrast enhanced radiographsComputerized tomographyComputerized tomographyNuclear imagingNuclear imagingMagnetic resonance imaging (MRI)Magnetic resonance imaging (MRI)SonographySonography (US)(US)


RADIODENSITYRADIODENSITYcomposite composite shadowgramsshadowgrams representing the sum of the densitiesrepresenting the sum of the densities

SquireLFSquireLF, , NovellineNovelline RA,RA,

Physical qualities of an object Physical qualities of an object that determine how much that determine how much radiation it absorbs from the Xradiation it absorbs from the X--Ray beam.Ray beam.

Determined by its composition Determined by its composition (anatomical weight) and (anatomical weight) and thicknessthickness

RadiopaqueRadiopaque / / RadiodenseRadiodense

RadiotransparentRadiotransparent / / RadioluscentRadioluscent


MAJOR PHYSICAL DENSITIES MAJOR PHYSICAL DENSITIES

AIR :AIR : Black (lungs, stomach, digestive tract)Black (lungs, stomach, digestive tract)

FAT: FAT: GrayGray--Black (more Black (more radiodenseradiodense than air)than air)

WATER:WATER: Grey (fluids, blood, muscles, tendons…)Grey (fluids, blood, muscles, tendons…)

BONE:BONE: White (the most White (the most radiodenseradiodense substance of substance of the body, teeth are whiter because to their the body, teeth are whiter because to their calcium content)calcium content)

CONTRAST MEDIA:CONTRAST MEDIA: Bright white outlineBright white outline

HEAVY METAL:HEAVY METAL: Solid whiteSolid white


MAJOR DENSITIESMAJOR DENSITIES


EXTERNAL DENSITIESEXTERNAL DENSITIESBARIUM BARIUM METALMETAL


SYSTEMATIC APPROACH TO SYSTEMATIC APPROACH TO READING AN XREADING AN X--RAYRAY

AA:: Alignment Alignment

B:B: Bone densityBone densityB:B: Bone density Bone density

C:C: Cartilage spacesCartilage spaces

S:S: Soft tissues Soft tissues




ALIGNEMENT ALIGNEMENT General architectureGeneral architecture

SizeSizeAppearanceAppearanceAccessory bonesAccessory bonesAccessory bonesAccessory bonesCongenital & growth Congenital & growth anomaliesanomaliesPostPost--traumatic traumatic modificationsmodifications


APAP-- ALIGNEMENT ALIGNEMENT spinousspinous processprocess


1 facet sub-luxation Anterior dislocation

LAT CERVICALLAT CERVICALAlignment, 3 linesAlignment, 3 lines


BONE DENSITYBONE DENSITY

Normality: Normality: Sufficient contrast between the Sufficient contrast between the skeleton and soft tissues and between skeleton and soft tissues and between cortex andcortex and medullarymedullary centercentercortex and cortex and medullarymedullary center center

Lost:Lost: osteopeniaosteopenia, osteoporosis, , osteoporosis, osteomalaciaosteomalacia

Increase:Increase: osteopoikilosisosteopoikilosis, , osteopetrosisosteopetrosis


DISTORTIONDISTORTIONshape or sizeshape or size

The pathology should The pathology should be be right in the middle right in the middle of the filmof the film

XX--rays will rays will increase increase the size from 0 to the size from 0 to 30%30%


OTHER RADIOLOGIC EXAMINATIONSOTHER RADIOLOGIC EXAMINATIONS

With contrast With contrast –– ArthrographyArthrography, , myelographymyelography, , arteriographyarteriography……

CAT scan, CT scanCAT scan, CT scan–– Axial tomography assisted by computer Axial tomography assisted by computer

Nuclear imaging Nuclear imaging –– Bone scan, ‘’Bone scan, ‘’scintigraphiescintigraphie osseuseosseuse’’’’




WITH CONTRASTWITH CONTRAST


MyelographyMyelographyArteriographyArteriographyArthro MRI

Computer assisted tomography Computer assisted tomography (CAT Scan)(CAT Scan)

XX--Ray merged with computer Ray merged with computer technologytechnologyProvides geography of body structuresProvides geography of body structuresProvides geography of body structures Provides geography of body structures with much greater sensitivity than plain with much greater sensitivity than plain filmsfilmsXX--Ray beam and detector system is Ray beam and detector system is housed in a circular scanner (arc of housed in a circular scanner (arc of 360360º)º)


CAT Scan / CT ScanCAT Scan / CT Scan



CAT SCAN




BONE SCAN BONE SCAN Diagnostic use of radioactive Diagnostic use of radioactive isotopesisotopes

Nuclear imaging of the skeletal Nuclear imaging of the skeletal systemsystem

Radiopharmaceuticals that are Radiopharmaceuticals that are tissuetissue--specific to bone are injected specific to bone are injected intravenouslyintravenouslyintravenouslyintravenously

Patient placed under a scintillation Patient placed under a scintillation camera detecting radioactivitycamera detecting radioactivity

Recording of the image is on an XRecording of the image is on an X--Ray filmRay film

Highly sensitive but nonHighly sensitive but non--specificspecific


MAGNETIC RESONANCE IMAGING MAGNETIC RESONANCE IMAGING MRIMRI

Does not involve ionizing radiationDoes not involve ionizing radiation

Images are produced via the interaction of Images are produced via the interaction of tissue with tissue with radiofrequenciesradiofrequencies in a in a magnetic fieldmagnetic field

RadiowavesRadiowaves are pulsed to the patient, inducing are pulsed to the patient, inducing resonance among nuclei. Different tissues resonance among nuclei. Different tissues resonate at different frequencies.resonate at different frequencies.

When When radiowavesradiowaves are turned off, nuclei relax are turned off, nuclei relax and release the resonant energy, receivers and release the resonant energy, receivers transmit the energy released to a computer.transmit the energy released to a computer.



WHICH TEST IS THE MOST WHICH TEST IS THE MOST APPROPRIATEAPPROPRIATE


INDICATIONS FOR INDICATIONS FOR CONVENTIONAL RADIOGRAPHYCONVENTIONAL RADIOGRAPHY

FracturesFracturesPeriostitisPeriostitisArthropathyArthropathyOsteochondritisOsteochondritis dissecansdissecansPostPost--traumatic or congenital bony traumatic or congenital bony deformationdeformationMuscular and Muscular and tendinoustendinous calcification calcification


INDICATIONS FOR COMPUTERISEDINDICATIONS FOR COMPUTERISEDAXIAL TOMOGRAPHY (CAT Scan)AXIAL TOMOGRAPHY (CAT Scan)

Bone and soft tissue Bone and soft tissue tumorstumorsSubtle or complex fracturesSubtle or complex fracturesIntraIntra--articulararticular abnormalitiesabnormalitiesDetection of small bone fragmentsDetection of small bone fragmentsggQuantitative bone mineral analysis Quantitative bone mineral analysis –– (osteoporosis and metabolic bone disorders(osteoporosis and metabolic bone disorders

Disadvantage: A tumour will not be detected in Disadvantage: A tumour will not be detected in presence of same density tissuepresence of same density tissue




CAT SCANCAT SCAN

ALSO USED TO ASSESS:ALSO USED TO ASSESS:–– Disk Disk herniationsherniations–– Spinal canal in the presence of a fractureSpinal canal in the presence of a fracture–– Spinal Spinal stenosisstenosis–– SpondylosisSpondylosis

Used for guidance in biopsies and Used for guidance in biopsies and injectionsinjections


INDICATIONS FOR MRIINDICATIONS FOR MRIMusculoskeletal systemMusculoskeletal systemSoft tissue trauma and Soft tissue trauma and tumorstumorsOstéonecrosisOstéonecrosisSpinal cord oedemaSpinal cord oedemaDisksDisks

CONTRAINDICATED FOR:CONTRAINDICATED FOR:–– Ferrous metal or mechanical devices implantedFerrous metal or mechanical devices implanted–– ClaustrophobiaClaustrophobia–– ObesityObesity–– Severe painSevere pain


INDICATIONS FOR BONE SCANINDICATIONS FOR BONE SCANIndicates an abnormal process between Indicates an abnormal process between production and production and resorptionresorption of boneof boneCan reveal an early bone loss of 7% in Can reveal an early bone loss of 7% in comparison to the conventional Xcomparison to the conventional X--Ray (25Ray (25--30%) 30%) UsefullUsefull to detect:to detect:–– Stress #, Compound # , Stress #, Compound # , ScaphoidScaphoid ##–– PeriostitisPeriostitis–– Primary and metastatic Primary and metastatic tumorstumors–– Various Various arthridesarthrides–– InfectionsInfections–– AvascularAvascular necrosisnecrosis–– Metabolic bone diseaseMetabolic bone disease–– Any unexplained bone painAny unexplained bone pain


80% of imaging in MSK 80% of imaging in MSK conditions are basic conditions are basic

radiographsradiographsradiographsradiographs(X(X--Rays)Rays)


More informationMore informationMaster class tutorialsMaster class tutorials

http://radiologymasterclass.co.uk/tutorials/http://radiologymasterclass.co.uk/tutorials/musculoskeletal/xmusculoskeletal/xmusculoskeletal/xmusculoskeletal/x--ray_trauma_lower_limb/ankle_fracture_xray_trauma_lower_limb/ankle_fracture_x--ray.html#top_first_imgray.html#top_first_img


SAFETY OF IMAGERYSAFETY OF IMAGERY




RADIATIONRADIATIONAnnual exposure: 3 Annual exposure: 3 mSvmSv((mSievertmSievert) / year ) / year Radon, Radon, airplane, ground, food, construction materials, cosmic airplane, ground, food, construction materials, cosmic rays, altitude, cities+rays, altitude, cities+

1 / 1000 individual 1 / 1000 individual will develop a cancer with an will develop a cancer with an exposition ofexposition of 10mSv10mSv (low risk)(low risk)exposition of exposition of 10mSv10mSv (low risk)(low risk)

420 / 1000420 / 1000 other causes of cancer other causes of cancer

Risk ↑ in children and ↓ in elderlyRisk ↑ in children and ↓ in elderly

CAT SCAN +++CAT SCAN +++


Medical Imaging App. dosage Comparison with environmental(background)

Level of irradiation

MRI & US 0 - 0

Bone density testsDEXA 0.001 mSv Less than 1 day ☼

X-Rays, extremities 0.001 mSv Less than 1 day ☼

X-Rays, vertebral 1.5 mSv 6 months ☼☼

X-Rays, Pelvis 0.1-1 mSv 10 days to 6 months ☼☼

CT, vertebral 6 mSv 2 years ☼☼☼

Bone Scan 1-10 mSv 2 years ☼☼☼


Adapté de http://radiologyinfo.org et ACR Appropriateness Criteria. Radiation Dose Assessment Introduction

Understand the viewsUnderstand the views

Anatomical position Anatomical position Standard most common: AP / LAT / OBLStandard most common: AP / LAT / OBLSpecific projectionsSpecific projectionsRoutines provide maximum visualization Routines provide maximum visualization with minimal number of radiographwith minimal number of radiograph


AnkleAnkle APAP


Ankle LATAnkle LAT


Ankle MortiseAnkle Mortise




http://www.wikiradiography.com/page/Anklehttp://www.wikiradiography.com/page/Ankle+Radiographic+Anatomy+Radiographic+Anatomy

AnkleAnkle LinksLinksAnkleAnkle -- ProtocolsProtocolsAnkleAnkle -- ExposuresExposuresAnkleAnkle PositioningPositioningAnkleAnkle -- APAPAnkleAnkle -- MortiseMortiseAnkleAnkle -- AP Oblique (AP Oblique (MedialMedial rotation)rotation)AnkleAnkle -- AP Oblique (AP Oblique (LateralLateral rotation)rotation)AnkleAnkle AP Oblique (AP Oblique (LateralLateral rotation)rotation)AnkleAnkle -- LateralLateralAnkleAnkle RadiographicRadiographic AnatomyAnatomyAnkleAnkle -- PaediatricPaediatric

AnkleAnkle MiscellaneousMiscellaneousThe The LateralLateral AnkleAnkle TrapTrapPosteriorPosterior MalleolusMalleolus FracturesFracturesSoft Tissue Soft Tissue SignsSigns--The The AnkleAnkleAnkleAnkle Image Image InterpretationInterpretationAnkleAnkle Trauma 1 (Trauma 1 (levellevel 11--10)10)AnkleAnkle Trauma 2 (Trauma 2 (levellevel 11--10)10)AnkleAnkle Trauma 3 (Trauma 3 (levellevel 11--10)10)AnkleAnkle Trauma 4 (Trauma 4 (levellevel 1 1 -- 3)3)AnkleAnkle Trauma 5 (Trauma 5 (levellevel 5 5 --10)10)


CERVICAL APCERVICAL AP


CERVICAL LATCERVICAL LAT


CERVICAL OBLCERVICAL OBLAllows us to visualise the Allows us to visualise the intervertebralintervertebral foramenforamen



SPECIALIZED PROJECTIONSSPECIALIZED PROJECTIONS

SkiSki--line of patella line of patella

Axial view (Axial view (intercondylarintercondylarfossafossa))

Stress testStress test

Weight bearingWeight bearing

AxillaryAxillary view (GH)view (GH)

AP mouth open (AP mouth open (odontoidodontoid))

Etc.Etc.




Why ? Why ?

T b tt h d thT b tt h d thTo better comprehend the To better comprehend the implicationsimplications

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Weber (Danis-Weber) classification of ankle fractures, based on the location of the fibular fracture. The higher the fibular fracture, the greater the likelihood for ankle mortise insufficiency


The AP and lateral views do not reveal any obvious fractures.

Subtle widening of the medial aspect of the distal fibular growth plate (physis) on the mortise view.

Comparative views


Comparative views and/or stress views would confirm that this is a fracture versus a normal growth plate closure.

Stress fractures are not Stress fractures are not insignificantinsignificant


Why imagery ?Why imagery ?

To understand prescription To understand prescription guidelines followed by physicians guidelines followed by physicians

and used for decision making.and used for decision making...

Nexus rulesNexus rulesOttawa rulesOttawa rules

Canadian CCanadian C--Spine rulesSpine rules




PRESCRIPTION PRINCIPLESPRESCRIPTION PRINCIPLES

ALARAALARA–– A as A as –– L lowL low–– A asA asA asA as–– R reasonablyR reasonably–– A achievableA achievable

EQUATION benefits / RISKEQUATION benefits / RISK


Line of conductLine of conductNon rigidNon rigidSignificant acute traumaSignificant acute traumaSignificant pain / nauseaSignificant pain / nauseaPositive Positive osteophonyosteophony test (+/test (+/--))os eos e os eop o yos eop o y es ( /es ( / ))Deformation Deformation Significant oedemaSignificant oedema


Pain on specific bony palpation / Pain on specific bony palpation / CrepitusCrepitusPositive tests: Vibration, stress (Positive tests: Vibration, stress (varusvarus, , valgusvalgus, , axial compression tests, ultrasound)axial compression tests, ultrasound)

LINE OF CONDUCTLINE OF CONDUCTPertinent history / Heard a crack Pertinent history / Heard a crack Reliability of history Reliability of history Non traumatic bony condition of systemic Non traumatic bony condition of systemic origin (Ex. cancer, osteoporosis …)origin (Ex. cancer, osteoporosis …)origin (Ex. cancer, osteoporosis …)origin (Ex. cancer, osteoporosis …)Atypical joint biomechanics Atypical joint biomechanics Atypical local palpationAtypical local palpationValidated rules concerning acute trauma:Validated rules concerning acute trauma:–– Ottawa rules for the ankle and knee Ottawa rules for the ankle and knee


OTTAWA RULESOTTAWA RULES

Rules established in 1996Rules established in 1996To reduce of the number of XTo reduce of the number of X--rays rays prescribed by emergency room physiciansprescribed by emergency room physiciansp y g y p yp y g y p yHave been established for the foot, the Have been established for the foot, the ankle and the kneeankle and the kneeHave been validated by many studies Have been validated by many studies worldwideworldwide


OTTAWAOTTAWA KNEE RULESRULESCharacteristics of Patients Who Should Characteristics of Patients Who Should Undergo radiography After Knee TraumaUndergo radiography After Knee Trauma

Age 55 years or olderAge 55 years or olderTenderness at head of fibulaTenderness at head of fibulaIsolated tenderness of patellaIsolated tenderness of patellaInability to flex knee to 90 degreesInability to flex knee to 90 degreesInability to walk four weightInability to walk four weight--bearing steps bearing steps immediately after the injury and in the immediately after the injury and in the emergency departmentemergency department


OTTAWA OTTAWA ANKLEANKLE RULESRULESCriteria for ankle radiographs Criteria for ankle radiographs

Bone tenderness at posterior edge of Bone tenderness at posterior edge of distal 6cm or tip of medial or lateral distal 6cm or tip of medial or lateral malleolusmalleolus

Unable Unable both both to weight bear immediately to weight bear immediately after injury and walk four steps in ER after injury and walk four steps in ER departmentdepartment




OTTAWA OTTAWA FOOTFOOT RULESRULESCriteria for ankle radiographsCriteria for ankle radiographs

Bone tenderness at base of 5th metatarsalBone tenderness at base of 5th metatarsal

Bone tenderness overBone tenderness over navicularnavicularBone tenderness over Bone tenderness over navicularnavicular

Unable Unable both both to weight bear immediately to weight bear immediately after injury and walk four steps in ER after injury and walk four steps in ER departmentdepartment


CANADIAN CCANADIAN C--SPINE RULESPINE RULE

For alert and stable For alert and stable trauma patients trauma patients where cervical spine where cervical spine injury is a concerninjury is a concerninjury is a concerninjury is a concern

GCS = 15 GCS = 15


Predictable rules CCRPredictable rules CCR

XX--Rays are indicated if at least one high Rays are indicated if at least one high risk criteria is present:risk criteria is present:

Age > 65Age > 65Dangerous mechanismDangerous mechanismParesthesiaParesthesia to extremitiesto extremities


High risk mechanismsHigh risk mechanisms

Fall from elevation > 3 feet (90cm) / 5 stepsFall from elevation > 3 feet (90cm) / 5 steps

Axial load to the head (diving, football, hockey)Axial load to the head (diving, football, hockey)

MVA high speed (> 100Km/h)MVA high speed (> 100Km/h)

MVA + rollover or ejectionMVA + rollover or ejection

Motorized recreational vehiclesMotorized recreational vehicles

Pedestrian struck by bicycle or collision with Pedestrian struck by bicycle or collision with bicyclebicycle


CC--Spine mobilitySpine mobilityXX--Rays are indicated if the patient is Rays are indicated if the patient is unable to actively rotate neck to 45unable to actively rotate neck to 45°° to to right and left.right and left.




Why ? Why ?

T b tt d t dT b tt d t dTo better understand To better understand the healing processthe healing process


CALCIFICATION CALCIFICATION INTEROSSEOUS MEMBRANEINTEROSSEOUS MEMBRANE


Why ? Why ?

Contribution in understanding Contribution in understanding postpost--concussion symptoms of concussion symptoms of

neck origin (positional Xneck origin (positional X Rays )Rays )neck origin (positional Xneck origin (positional X--Rays,)Rays,)

SpasmSpasmHypo / Hypo / HypermobilityHypermobility

Rotation, side bendingRotation, side bending7575EATA Buffalo 2013EATA Buffalo 2013

LAT LAT SPACE BETWEEN ODONTOÏD / C1SPACE BETWEEN ODONTOÏD / C1


3mm adultes 5mm enfants

FIXATION FIXATION ROTATION ROTATION

C1/C2C1/C2


To improve communicationTo improve communication

Why ? Why ?

To improve communicationTo improve communication

To improve clinical outcomes To improve clinical outcomes




Don’t trust the report / See the pictureDon’t trust the report / See the picture

Radiation is radiation; ALARA principleRadiation is radiation; ALARA principle

Be curious see the fracture to improveBe curious see the fracture to improve

TAKE HOME MESSAGETAKE HOME MESSAGE

Be curious, see the fracture to improve Be curious, see the fracture to improve your rehab outcomeyour rehab outcome

Imagery is not only for pathology but also Imagery is not only for pathology but also for positional Xfor positional X--RaysRays



For safetyFor safety

AT’s should know more about AT’s should know more about medical imaging:medical imaging:

For safetyFor safetyTo answer clinical questionsTo answer clinical questionsTo improve their communicationTo improve their communication



Guidelines are for hospital Guidelines are for hospital care but they can be an care but they can be an yy

important tool for the AT’simportant tool for the AT’s


REMEMBER:REMEMBER:

80% of imaging in MSK 80% of imaging in MSK conditions are basic conditions are basic

radiographsradiographs

First tool to add to your toolboxFirst tool to add to your toolbox


THANKTHANK YOU !YOU !

8383

[email protected]

REFERENCESREFERENCESAn Atlas of An Atlas of radiographyradiography for sports injuries, for sports injuries, JockJock AndersonAndersonBoneBone and joint and joint imagingimaging, , ResnickResnickFundamentals of Fundamentals of orthopedicorthopedic radiologyradiology, , Lynn N. Lynn N. McKinnisMcKinnisAtlas d’anatomie radiologique et d’imagerie du corps humainAtlas d’anatomie radiologique et d’imagerie du corps humain–– WeirWeir--AbrahamsAbrahams

Accident and emergency radiologyAccident and emergency radiology --A survival guideA survival guide–– RabyRaby--BermanBerman--G de G de LaceyLacey

Merrill’s atlas of radiographic positions and radiologic proceduresMerrill’s atlas of radiographic positions and radiologic procedurese s a as o ad og ap c pos o s a d ad o og c p ocedu ese s a as o ad og ap c pos o s a d ad o og c p ocedu es(tomes I(tomes I--IIII--III)III)–– BallingerBallinger

Acute Knee Injuries: Use of Decision Rules for Selective Radiograph Acute Knee Injuries: Use of Decision Rules for Selective Radiograph OrderingOrdering–– HOWARD B. TANDETER, M.D., and PESACH SHVARTZMAN, HOWARD B. TANDETER, M.D., and PESACH SHVARTZMAN,

M.D. M.D. BenBen--Gurion University of the Negev, BeerGurion University of the Negev, Beer--ShevaSheva, Israel , MAX , Israel , MAX A. STEVENS, M.D. A. STEVENS, M.D. University of Iowa Hospitals and Clinics, Iowa City, Iowa University of Iowa Hospitals and Clinics, Iowa City, Iowa




REFERENCESREFERENCEShttp://www.acr.org/ http://www.acr.org/ Site internet de l’American Site internet de l’American CollegeCollege of of RadiologyRadiology pour les pour les critères de choix radiologique (pratique factuelle pour les ‘’critères de choix radiologique (pratique factuelle pour les ‘’AppropriatenessAppropriatenessCriteriasCriterias’’ ’’ http://www.rad.washington.edu/academics/academichttp://www.rad.washington.edu/academics/academic--sections/msk/teachingsections/msk/teaching--materials/onlinematerials/online--musculoskeletalmusculoskeletal--radiologyradiology--book/orthopedicbook/orthopedic--hardwarehardware. . http://www.infohttp://www.info--radiologie.chradiologie.ch. . http://www.radpod.orghttp://www.radpod.org. . http://www radpod orghttp://www radpod orghttp://www.radpod.orghttp://www.radpod.org. . http://www.xray2000.co.ukhttp://www.xray2000.co.uk. . http://www.aafp.org/afp/991201ap/2599.html http://www.aafp.org/afp/991201ap/2599.html -- December 1999 December 1999


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