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  • 1. MUSCULOSKELETAL RADIOLOGY Components of Subpsecialty Training, Goals & Objectives, Reading List, Resources, Daily Work, Evaluation, Pathology Outline, Conferences & Reference TextsINTRODUCTION The Clinical Radiology of Oklahoma Subspecialty Residency Program iscommitted to the integrating high academic and professional competency standards into acomprehensive residency training curriculum. The program provides subspecialtyresident education in the subspecialty of musculoskeletal radiology through the academiccore curriculum and provides professional development via the general competencies forsubspecialty residents. Our goal is to train highly competent and qualified radiologysubspecialists in musculoskeletal radiology who will support patient care as effectivemembers of the clinical care team with strong interpretive skills, knowledge ofappropriate diagnostic radiology tools and cost effective resource utilization. They arerequired to demonstrate professionalism in their role as a subspecialist and must showproficiency in each of the areas as defined by the subpecialty curriculum.The following curriculum guide has attached reading lists for the various sections. This readinglist contains reading material that is designed to supplement the teaching, personal instructions,and lectures provided by the section and its personnel. This reading list is not meant to beexhaustive and contains only the material that is most germane to the referenced topics. Thereading list is also designed to fulfill the three basic requirements of the subspecialtycurriculum of musculoskeletal radiology: 1. To provide practicing radiologists with the fundamentals needed to be valuable consultants to orthopedic surgeons, rheumatologists, and other referring physicians 2. To provide radiology residency program directors with a guide to subjects that should be covered in a four year teaching curriculum 3. To serve as a “study guide” for diagnostic radiology subspecialty residents.The reading material has been selected to further each subspecialty resident’s knowledge base thatis needed for the successful practice of musculoskeletal radiogy. The subspecialty focus will beaugmented by exposure to other portions of the general diagnostic radiology academiccore curriculum as it is germane to the subspecialty education and training of thesubspecialty residents.14
  • 2. Radiology Subspecialty Residency Programs Clinical Radiology of Oklahoma Goals and Objectives: General CompetenciesThe CRO Radiology Subspecialty Programs will further the general competencies developed forthe Diagnostic Radiology training program. The basic general requirements enable and requireresidents to develop the characteristics of a new practitioner of Diagnostic Radiology. Thegeneral competencies include: Patient Care Medical Knowledge Practice-based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems Based PracticeThe subspecialty program will utilize these general requirements as a basis and augment themwith a focus that is designed to be applicable to subspecialty patient care in the highlyspecialized environment that is found in our tertiary care academic medical center andsubspecialty clinics. Goals and Objectives: Academic Core CurriculumEach of the subspecialty core curriculums are outlined in their specific sections. The core curriculum foreach subspecialty builds upon the basic residency curriculum and provides additional expertise for thesubspecialty resident. COMPONENTS 1. Plainfilm Radiography 2. Interventional Procedures 3. Magnetic Resonance Imaging 4. Computed Tomography, Ultrasound, Nuclear Radiology, and Bone Mineral Density Evaluation Component: Conventional Radiography Cognitive Objectives 14
  • 3. At the end of the first MSK rotation, a radiology subspecialty resident should be able to: 1. Dictate a succinct, precise and coherent radiology report 2. Describe pertinent normal and abnormal anatomy on an MSK radiograph 3. Establish a diagnosis and provide an appropriate description of the differential diagnostic possibilities that may be present 4. Discuss the imaging findings of trauma (to include soft tissue injuries and fractures) septic arthritis, osteomyelitis, and metastatic diseases 5. Evaluate orthopedic follow-up imaging including the imaging findings of loosening and infection of orthopedic hardware. 6. Discuss the most common techniques in MSK imaging, the indications and contra- indications, and complications of the following: 1. Radiographs & fluoroscopy 2. Arthrography 3. MSK BiopsyAffective ObjectivesAt the end of the rotation on conventional radiography the subspecialty resident should be able to: 1. Project a professional image 2. Demonstrate empathy and respect towards patients, referring clinicians, radiology personnel, and colleagues 3. Function as a consultant to clinicians for radiographic evaluation of MSK trauma and orthopedic follow-up (e.g. - if a clinician enters the reading room, he or she should be greeted within 30 seconds and then assisted as soon as possible with image retrieval and/or interpretation) 4. Participate actively in the MSK division’s academic program (e.g. teaching medical students and residents on the rotation)Components: Conventional Radiography & Interventional MSK ProceduresCognitive Objectives 14
  • 4. At the end of the second MSK rotation, a radiology subspecialty resident should be able to:Discuss the imaging findings and provide an appropriate differential diagnosis for: 1. Articular diseases 2. Benign and malignant bone tumors 3. Metabolic and endocrine diseases 4. Miscellaneous diseases entities (as listed in addendum) 5. Soft tissue lesions 6. Congenital syndromesAffective ObjectivesAt the end of the second MSK rotation, a radiology subspecialty resident should be able to: 1. Consolidate the objectives of the first rotation 2. Function as a consultant for conventional radiographic evaluation of MSK pathology and for planning the MSK imaging and interventional procedures to solve a particular problemPsychomotor ObjectivesAt the end of the second component, a radiology resident should be able to: 1. Perform placement of needles into different joints for arthrography and joint aspiration 2. Perform biopsies of the axial and appendicular skeleton and surrounding musculature and connective tissue. 3. Perform interventions of the spine to include: discography, nerve root injections, epidural injections, facet/SI joint injections, vertebroplasty, kyphoplasty, etc.Components: Magnetic Resonance Imaging, Computed Tomography, Ultrasound, NuclearRadiology, and Bone Mineral Density EvaluationCognitive ObjectivesAt the end of the third MSK rotation, a radiology subspecialty resident should be able to: 1. Plan, protocol and interpret MR imaging studies based on the clinical information 14
  • 5. 2. Interpret with competence MR imaging studies of the spine, shoulder, pelvis, and kneeAffective ObjectivesAt the end of the third and fourth MSK rotation, a radiology subspecialty resident should be able to: 1. Act as a consultant on MSK imaging studies 2. Participate actively in the teaching of junior residents, other residents, interns, and medical studentsRESOURCESInstructors • Doctor Douglas P. Beall is responsible for the organization and supervision of the Musculoskeletal Radiology rotation. • The teaching of musculoskeletal Radiology is done by Doctors Douglas P. Beall and Byron H. Christie. CT and MRI of spine will be taught by both neuroradiologists and musculoskeletal radiologists.BibliographyRequired Reading • All required books can be checked out from our library. Books should be read in the order listed. The departmental teaching file should be studied in relation to the reading material.Component 1 1. Fundamentals of Skeletal Radiology. Clyde Helms, W.B. Saunders. 2. Orthopedic Radiology, A Practical Approach. Adam Greenspan. Lippincott (read trauma section only - chapters 2 through 8). 3. Bone and Joint Imaging, second edition. Donald Resnick. W. B. Saunders. The first chapters you read should be: Chapters 19-20, 59-61, 62, 80Component 2 1. Brower, A.C., Arthritis in Black and White, 2nd ed., W.B. Saunders, Philadelphia, PA, 1996. 2. CD: ACR learning file: Skeletal 3. Read the remaining required chapters in Bone and Joint Imaging in any order you want: Chapters 1, 2,14, 18, 28, 30, 32, 33, 34, 38, 46-58, 63-79, 81-85. 14
  • 6. 4. ** The following chapters in Bone and Joint Imaging are good for learning but NOT required: 5-10, 12, 13, 15-17, 21-27, 29, 31, 35-37, 39-44.Components 3 and 4MRI of the Musculoskeletal System 1. MRI of the MSK System, Kaplan, et al. 2. Berquist, T.H., ed., MRI of the Musculoskeletal System, 4th ed., Lippincott Williams & Wilkins, Philadelphia, PA, 2001. 3. Chew, F.S., Musculoskeletal Imaging: A Teaching File, Lippincott Williams & Wilkins, Philadelphia, PA, 1999.Daily WorkDaily work starts no later than 8:00 AM and finishes not earlier than 5:00 PM. • Interpretation/dictation of musculoskeletal examinations • Reports: Edit and sign reports at least three times a day. • Exam Supervision • Throughout the day, the subspecialty resident is the first consultant for the technical personnel as for the indication and type of exam to perform and as to the technical quality of the exams. • The subspecialty resident supervises all cases of musculoskeletal MR and biopsies. He/she is to collect the clinical information, existing films, lab data, etc. and present it to the MSK staff in order to plan the exam appropriately in advance. • The staff radiologist is available at all times for consultation.Procedures • Subspecialty residents will participate with staff in as many procedures as possible in the musculoskeletal section (arthrography, injections, fluoroscopy, CT and MR). All of these procedures are performed by or under direct supervision of the staff person covering the section. Responsibilities are dependent on the residents expertise.Consultation • Throughout the day, the subspecialty resident is the first consultant to his colleagues or referring physicians. The staff person covering the section is available at all times for consultation.Conferences (ADDENDUM II) 14
  • 7. • Each subspecialty resident is expected to participate in all MSK Conferences that are held during their time on the service (e.g. Rheumatology, Orthopedics, Family Practice Sports Medicine, Boards-Review, etc.) They are also welcome and encouraged to attend any of these conferences during the year.Log BookThe residents are responsible for covering the reading rooms from 8 AM to 5 PM daily. Absencefrom the reading rooms from 12 noon to 1:00 p.m. for lunch and conference will be covered by staff.Any conference or absence for other reasons between 8 AM and 5 PM is to be cleared with theattending staff you are working with on bone. • A log book of all biopsy cases must be kept by the subsecialty resident • Entering the follow-up results on bone biopsies and joint aspirations into the log book is the responsibility of the resident or fellow who participated in the procedure.Consultation • The subspecialty resident is the initial consultant for colleagues and referring physicians.SUBSPECIALTY RESIDENTS EVALUATIONThe subspecialty residents evaluation is based on many parameters according to specific cognitive,psychomotor and affective objectives: 1. Evaluation of the daily work. 2. Behavior (clerical and technical personnel, consultants and other radiologists may be asked to contribute to this evaluation). 3. Discussion of the evaluation with the subspecialty resident. The evaluation is performed at the end of the quarter. The subspecialty resident may ask for an evaluation during the course of the quarter. The staff radiologist may present an evaluation to the resident mid-way through the quarter if deemed necessary.SPECIAL ASSIGNMENTSThe subspecialty resident may be asked to participate on special projects: • Preparation or presentation of a lecture or conference • Preparation and writing of a scientific paperADDENDUM I: Musculoskeletal Pathology Outline 14
  • 8. Following completion of 16 weeks of musculoskeletal radiology, subspecialty residents should beable to discuss: 1. Traumatic osteoarticular lesions of the axial and peripheral skeleton. o Classification of fracture type o Radiographic findings of a fracture o Physiopathology and radiologic correlation of fracture healing o Radiographic findings according to anatomic site 2. Articular Disease o Classification of articular disease o Radiographic findings of articular lesions o Physiopathology and radiologic correlation of articular disease:  infections  inflammatory/immune  degenerative  neuropathic  metabolic and endocrine  synovial tumors 3. Benign and malignant bone tumors o Classification of bone tumors o Radiographic findings of benign and malignant features of bone tumors o Characteristics (age, site, location, radiographic findings) of benign and malignant bone tumors:  cartilaginous origin  osseous origin  fibrous origin  cyst 14
  • 9.  myelogenous origin  metastasis 4. Infectious lesions o Classification of infections o Radiographic findings of infectious lesions o Physiopathology and radiographic correlation of infectious diseases 5. Metabolic and endocrine diseases o Classification of osteopenia o Radiographic findings of the three forms of diffuse osteopenia  Osteoporosis  Osteomalacia  Hyperparathyroidism o Physiopathology and radiographic correlation of diffuse and localized osteopenia o Physiopathology and radiographic correlation of endocrine disorders originating from:  hypophysis  thyroid  parathyroid  adrenals  gonads  diabetes o Physiopathology and radiographic correlation of hypo and hypervitaminoses  vitamin A  vitamin D 6. Miscellaneous disease entities o Pagets disease14
  • 10. o Reticulo-endothelioses (histiocytosis x/Langerhans cell histiocytosis) o Storage Disease (Gauchers disease) o Ischemic Disease (Osteonecrosis, osteochondrosis) o Anemias o Marrow disease Radiographic findings of these entities Physiopathology and radiographic correlation of these entities Complications and radiographic findings of these entities 7. Soft tissue lesions o Classifications of soft tissue lesions o Radiographic findings of soft tissue lesions o Physiopathology and radiographic correlations of soft tissue lesions 8. Congenital Syndromes o Radiographic findings of:  Congenital dislocation of the hip  Flat foot and club foot  Osteochondrodysplasia  Failure of growth of tubular bones and spine  achondroplasia  spondylo-epiphyseal dysplasia o Failure of growth and development of cartilage and fibrous tissue  dysplasia epiphysialis hemimelica  multiple exostoses  enchondromatosis  fibrous dysplasia o Anomaly in density and modeling  osteogenesis imperfecta14
  • 11.  juvenile osteoporosis  osteopetrosis  osteopoikilosis  melorheostosis  diaphyseal dysplasia o Dysostosis  Klippel Feil  Sprengel deformity o Marfan syndrome o Neurofibromatosis o Chromosomal anomalies  Turner  Trisomy-21ADDENDUM II. CONFERENCESDaily 06:30 am – Orthopedics Conference WP-1380Daily 7:15 – 8:00 AM - Radiology CHO Conf Rm ConferenceFriday 7:00-8:00 AM – Ortho Grand Rounds Byrd LibraryFirst Wed. of month 1:00 to 3:00 PM – Rhematology OMRF, 3rd Floor Conf. Conference RoomFirst Thurs of Month 5:00 – 6:00 PM Orthopedics Coussins Conference Morbiditiy & Mortality Conference Room (2E109)Addendum III: ReferencesBooksAnatomy 1. Netter FH, Atlas of Human Anatomy, CB_GEIGY 2. Kang HS, Resnick D, MRI of the Extremities an Anatomic Atlas, Saunders. 14
  • 12. 3. El Khoury GY, Bergman RA, et al, Sectional Anatomy by MRI/CT, Churchill Livingstone. 4. Möller TB, Reif E, MRI Atlas of the Musculoskeletal System, Blackwell Scientific Pub., 1993.Arthrography 1. Freiberger and Kaye, Arthrography. Appleton-Century-Crofts.CT 1. Lee & Sagel, Computed Body Tomography with MRI Correlation. 3rd Edition, 1998, Lippincott-Raven, Chapter 22 - Musculoskeletal. 2. Pretorius ES, Fishman EK. Helical (Spiral) CT of the Musculoskeletal System. Radiol Clin N Amer 1995; 33:949-979.DEXA 1. Lenchik L, Rochmis P, Sartoris DJ. Optimized reporting of dual x-ray absorptiometry (DXA) scans. AJR 1998; 171:1509-1520.Emergency Radiology 1. Harris, The Radiology of Emergency Medicine, Williams & Wilkins.General MSR: 1. Resnick & Niwayama, Diagnosis of Bone and Joint Disorders 2nd ed., Saunders, Vols. 1-6.Orthopedics 1. Berquist TH, Imaging Atlas of Orthopedic Appliances and Prostheses, Raven Press, 1995.Pediatrics 1. Ozonoff, Pediatric Orthopedic Radiology, W. B. Saunders and Co. 2. Taybi, Radiology of Syndromes, Year Book Medical Publishers.Spine 1. Modic MT, Masaryk TJ, Ross JS, Magnetic Resonance Imaging of the Spine, Year Book Medical Publishers. 2. Maneffe C. Imaging of the Spine and Spinal Cord, Raven Press 1992. 3. Daffner R. Imaging of Vertebral Trauma. Aspen Publishing. 4. Denis F. Spinal Instability as Defined by the Three-Column Spine Concept in Acute Spinal 14
  • 13. Trauma. Clin Ortho 1984; 189:65-76.Technique 1. Bernau & Berquist, Orthopedic Positioning in Diagnostic Radiology, Urban & Schwarzenberg. 2. Lusted & Keats, An Atlas of Roentgenography Measurement, Year Book Medical Publishers. 3. Greulich and Pyle, Radiographic Atlas of Skeletal Development of the Hand and Wrist, Stanford University Press.Trauma 1. Rogers LF, Radiology of Skeletal Trauma, Vol. I & II, Churchill Livingston.Tumor 1. Wilner, Radiology of Bone Tumors and Allied Disorders, Vols. I, II, III, IV, Saunders. 2. Mirra JM, Bone Tumors: Clinical, Radiologic, and Pathologic Correlations, Lea & Feabiger. 14