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  1. 1. MUSCULOSKELETAL IMAGING LSUHSC-Shreveport Rotation Director: Alberto Simoncini, M.D. General Goals: The field of musculoskeletal radiology consists of a diversity of topics that can be more easily learned by categorization into subdivisions of bone pathology: metabolic, tumor, dysplasias, arthritis, and trauma. The use of an algorithmic approach to musculoskeletal imaging allows the resident to properly arrive at a concise and well- thought out differential diagnosis. The first year resident should obtain a fundamental grasp of basic orthopedic radiology, and should also begin to categorize and organize subdivisions of musculoskeletal radiology such as rheumatology, neoplasms, etc. The second year resident should be increasingly knowledgeable in orthopedic radiology, particularly with increased experience in the Emergency Department. At this point, more detailed knowledge of neoplastic and metabolic processes as well as rheumatologic disorders is warranted. Third and fourth year residents should become increasingly capable of diagnosing musculoskeletal pathology on all modalities and in applying the algorithmic approach to differential diagnoses. Daily Work: The radiology resident assigned to “Musculoskeletal Imaging” should begin review of radiographic, CT, and MR cases via PACS immediately after arrival from the 7:30 am conference. All pertinent previous radiographs and CT scans must be reviewed, if available. The staff radiologist assigned to the section, primarily Dr. Alberto Simoncini, will subsequently review cases as they are presented by the resident. Requests for consultation made by the clinical staff should be handled by the resident working with the staff radiologist. During their second, third and fourth months on the musculoskeletal rotation, residents should take increasing responsibility in those consultations. The staff radiologist will be available at all times. Resident presence in the reading area, except for conference periods including the noon conference (you will have enough time to get your lunch prior to the noon conference), is maintained until at least 4:00 p.m. All dictations should be completed prior to leaving the area. Dr. Simoncini will be primarily responsible for supervising this curriculum and evaluating resident performance. Suggested Reading: 1. Fundamentals of Skeletal Radiology. Clyde A. Helms. 2. Arthritis in Black and White. Anne C. Brower 3. Musculoskeletal MRI. Kaplan, Helms, Dussault, Anderson, Major.
  2. 2. Educational Goals and Objectives: First Year Residents Patient Care: Be able to critique the technical quality of a radiograph Understand the indications for more advanced imaging (ultrasound/CT/arthrography/MRI) Be able to protocol, with assistance, musculoskeletal examinations Medical Knowledge: Fundamental understanding of basic orthopedic radiology, pertinent normal anatomy on a musculoskeletal radiograph Recognize and describe, in a systematic fashion, radiographic findings on a radiograph Beginto categorize and organize subdivisions of musculoskeletal radiology such as rheumatology, neoplasm, infection, etc. Should be able to distinguish an aggressive process, such as malignant tumor or infection, from a more benign process, such as a benign bone tumor, based on specific radiographic findings Be facile with basic orthopedic concepts. The resident should be able to very specifically and accurately describe a fracture such that the referring orthopedic surgeon would be able to envision the fracture in three dimensions. The resident should have a grasp on basic classification systems of fractures such as intraarticular vs. extraarticular, as well as named fractures such as Monteggia, Galeazzi, etc. Discuss the most common musculoskeletal pathologic entities Have a basic understanding of technique and indications for arthrography, bone biopsy and other invasive procedures. Additionally, the residents should be well aware of the strengths and limitations of musculoskeletal MRI and computed tomography (CT) in the evaluation of musculoskeletal disorders. Indications for radionuclide bone scanning should also be understood, as should the basic concepts of this imaging modality, and interpretation of some of the more common bone scans (which will be read with the Nuclear Medicine staff). Interpersonal and Communication Skills: Call referring physicians for positive results or for any further pertinent history needed prior to advanced imaging or a MSK procedure. Communicate effectively with all members of the health care team. * Dictate a concise, accurate report which will allow the referring clinician to understand the findings and the differential diagnosis for these findings. If a pertinent finding was called to the clinician, documentation of this including the clinician’s name should be included on the dictated report.
  3. 3. Practice-Based Learning and Improvement: Identify, rectify and learn from personal error Incorporate feedback into improved performance Use electronic and print resources to access information Professionalism: Demonstrate respect for patients and members of the health care team Respect patient confidentiality Come to work with a professional appearance Demonstrate a responsible work ethic Systems-Based Practice: Demonstrate knowledge of ACR standards Attend imaging conferences Attend journal club and other pertinent conferences Second and Third Year Residents Patient Care: * All of the objectives listed for first year residents should be reviewed with increased mastery. Protocol CT and MRI exams without assistance Monitor musculoskeletal CT exams Understand indications for MRI Medical Knowledge: Increasingly facile with orthopedic radiology More detailed knowledge of neoplastic, metabolic, infectious and rheumatologic disorders is warranted Discuss the most common techniques in musculoskeletal imaging, the indications and contra-indications and complications of the following: - Radiography and fluoroscopy - Musculoskeletal scintigraphy - Arthrography - Musculoskeletal biopsy - CT - MRI Describe pertinent normal anatomy on MRI’s of shoulder, knee, hip, elbow, wrist, hand, foot and ankle Interpersonal and Communication Skills: Communicate effectively with patients and all member of the health care team Function as a consultant in musculoskeletal radiology yet be free to obtain more
  4. 4. experienced opinions. * Demonstratea leadership role in communications/interactions with technical personneland patients, including explanation of delays related to emergencies. * Demonstrateincreasing skill in clearly and concisely communicating via the radiology dictated report. Practice-based Learning and Improvement: Identify, rectify and learn from personal error Incorporate feedback into improved performance Use electronic and print resources to access information Professionalism: Demonstrate respect for patients and members of the health care team Respect patient confidentiality Come to work with a professional appearance Demonstrate a responsible work ethic * Demonstratealtruism(putting the interests of patients and others above own self-interest). The residentshould teach the above objectives to medical students and junior residents directly as well as by modeling behavior consistentwith these objectives. Systems-Based Practice: Demonstrate knowledge of ACR standards Attend imaging conferences Greater participation in unknown case analysis at noon conference is expected. * Demonstrateknowledgeof hospital-based systems thateffect physician practice, including physician code of ethics, medical staff bylaws, quality assurancecommittees, and credentialing processes. This includes knowledgeof how these processes may affect the scope of practice of any one physician and competition among practitioners. * Demonstratethe ability to design cost-effectiveimaging strategies/careplans based on knowledgeof best practices. Fourth Year Residents: Patient Care: Protocol CT and MRI examinations without assistance Monitor musculoskeletal CT and MRI exams Understand indications for CT contrast and gadolinium
  5. 5. Medical Knowledge: Discuss the radiographic findings of all musculoskeletal pathology Establish a precise diagnosis and provide a pertinent differential diagnosis Orient and supervise the investigation of a patient or of a specific disease Discuss MRI findings of musculoskeletal pathology Understand and appreciate orthopedic procedures of greater complexity such as joint replacement, osteotomies, spinal fixation Be able to streamline the diagnostic imaging work-up for a specific musculoskeletal abnormality. * Teaching of the above objectives to medical students and junior residents should be increasingly emphasized. Interpersonal and Communication Skills: Communicate effectively with patients and all member of the health care team Function as a consultant in musculoskeletal radiology yet be free to obtain more experienced opinions. * Demonstrateincreased ability to communicate effectively with providers at all levels of the health care systemas well as thosein outside agencies, etc. * Mastered the skill in clearly and concisely communicating via the radiology dictated report. Practice-Based Learning and Improvement: Identify, rectify and learn from personal error Incorporate feedback into improved performance Demonstrateawareness of resources availableto practicing radiologists for lifelong learning, including print, CD-ROM, and internet products of the ACR. * Demonstrateknowledgeof the above objectives by supervision of medical students and junior residents as well as by directly teaching these objectives. Professionalism: All of the objectives listed for first, second, and third year residents should be reviewed with increased mastery. * The senior resident should increasingly superviseand mentor medical students and junior residents in achieving these objectives. Systems-Based Practice: All of the objectives listed for first, second, and third year residents should be reviewed with increased mastery. * Demonstrateknowledgeof how decisions about the timing/availability of imaging studies may affect hospital length of stay, referralpatterns for specific examinations and useof diagnostic studies outside the Department of
  6. 6. Radiology. * Demonstrateknowledgeof the regulatory environment. Demonstrate knowledgeof basic management principles such as budgeting, record keeping, medical records, and the recruitment, hiring, supervision and management of staff. Resident Evaluation: Medical knowledge in musculoskeletal radiology will be specifically evaluated by the annual ACR in-service examination and the mock oral board examination (OSCE) held twice per year. Patient care, practice based learning and systems-based practice relevant to musculoskeletal radiology will be evaluated by imaging conference presentations and monthly electronic global evaluations by the faculty. Knowledge BasedObjectivesRotation 1 I. Aspectsof BasicScience RelatedtoBone A. Histogenesisof developingbone includingintramembranousandenchondral ossification B. Bone Anatomy 1. Cellularconstituents - osteoblasts,osteoclasts,chondroblasts, chondrocytes 1. Non-cellularconstituents - organicmatrix,inorganicmatrix 2. Structure of cortical and cancellousbone C. Bone Physiology 1. Bone mineralization 2. Regulationof calciumhomeostasis 3. Regulationof bone formationandresorption a. Humoral - PTH, Calcitonin,VitaminD, b. Paraneoplastic- PTH like protein II.TechniquesRelatedtoMusculoskeletal Radiology A. Radiography a. Understandthe standardviewsobtainedandpatientpositioningfor
  7. 7. plainfilmexaminationsof the: i.Spine - cervical,thoracic,and lumbosacral ii.Ribs iii.Pelvis iv.Extremities v. Joints - shoulder,elbow,wrist,hip,knee,ankle B. ConventionalTomographyandMRI a. Methodology,indications,interpretation C. FluoroscopicandUltrasonographicprocedures III.Normal FeaturesandVariants A. Sequence of ossificationatjoints(e.g.elbow) B. Physiologicradiolucencies C. Bone island D. Vascularchannels,nutrientcanals E. Epiphyseal /apophyseal ossificationcenters - normal,multiple (e.g.bipartite patella IV.Trauma A. General principles 1. Biomechanicsof fractures 2. Relationshipof force anddeformation 3. Relevantanatomyandterminology B. Fracture description - closed,open,comminuted,segmental 1. Descriptionof distal fragmentpositionvs.fracture /apex C. Subluxations/Dislocations 1. Definition,description D. StressInjuries E. Evaluationof healing 1. Malunion
  8. 8. 2. Nonunion 3. Delayedhealing V.Infection A. BasicConcepts B. Routesof Spread C. Sitesof localization - neonates,infants,children,adults D. Septicarthritis E. Osteomyelitis VI.JointDisorders A. Normal anatomy 1. Typesof joints - fibrous,cartilaginous,synovial 2. Intervertebral discs B. Featurestobe evaluatedforeachdisorder 1. Bone density 2. Soft tissue changes 3. Bone sclerosis,production,osteophyte formation /appearance 4. Bone erosions 5. Jointspace 6. Alignment/deformity 7. Distribution C. Specificarthropathies 1. Osteoarthritis a. Primary b. Secondary c. Erosive 2. Inflammatory a. Rheumatoid b. Psoriatic
  9. 9. c. Reiter's d. Ankylosingspondylitis VII.Neoplasms A. Radiographicfeatures Single vs.multiple Lytic,blastic,mixed Zone of transition Cortical destruction Matrix Periosteal response Softtissue mass VIII.SkeletalDysplasias A. Paget's 1. Radiographicfeatures 2. Appearance onbone scans 3. Commonsitesof involvement 4. Associatedlaboratoryfindings IX.Differential Diagnosis A. Understandandknowthe differential diagnosisof imagingfindingsasthey include manyof the pathologicprocesseslistedinthe previoussectionsIII.Normal Featuresand VariantsthroughVIII.Skeletal Dysplasias. Knowledge BasedObjectivesRotation 2 A. All knowledge basedobjectivesfromrotation1 I. Infection 1. Conceptscontinued 2. Septicarthritis 3. Osteomyelitis 4. Terminology- sequestrum, involucrum, cloaca,Brodie'sabscess 5. Acute vs. Subacute
  10. 10. 6 Chronic a. Sclerosingosteomyelitisof Garre 7. Organisms a. bacterial b. tuberculous c. fungal II.JointDisorders 1. Normal anatomy 2. Typesof joints - fibrous,cartilaginous,synovial 3. Intervertebral discs 4. Featuresto be evaluatedforeachdisorder a. Bone density b. Softtissue changes c. Bone sclerosis,production,osteophyteformation/appearance d. Bone erosions e.Jointspace f.Alignment/deformity g. Distribution 5. Specificarthropathies a. Osteoarthritis i.Primary ii.Secondary iii.Erosive b. Inflammatory i.Rheumatoid ii.Psoriatic iii.Reiter's
  11. 11. iv.Ankylosingspondylitis v. Enteropathic vi.Juvenilechronic c. Connective tissue i.SLE ii.Scleroderma 6. Depositional III.Neoplasms 1. Radiographicfeatures a. Single vs.multiple b. Lytic,blastic,mixed c. Zone of transition d. Cortical destruction e.Matrix f.Periosteal response g. Softtissue mass 2. Featuresonadvancedimagingmodalities - Nuclearstudies,CT,US, MRI 3. Osseouslesions 4. Chondroidlesions 5. Fibrouslesions 6. Vascularlesions 7. Associatedsyndromes 8. Primaryvs. secondarylesions Bone lesions 1. Cartilaginous a. Enchondroma i. Ollierdisease
  12. 12. ii. Maffucci syndrome b. Chondromyxoidfibroma c. Chondroblastoma d. Osteochondroma i. Hereditarymultiple exostoses e. Juxtacortical (periosteal) chondroma f. Chondrosarcoma i. Primary ii. Secondary iii. Clearcell iv. Dedifferentiated 2. Osseous a. Osteoma b. Osteoidosteoma c. Osteoblastoma d. Osteosarcoma i. Parosteal ii. Periosteal iii.Telangiectatic 3. Fibrousandfibrohistiocytic a. Fibroxanthoma(nonossifyingfibroma) b. Fibrousdyplasia i. McCune - Albrightsyndrome c. Fibrosarcoma d. Malignantfibroushistiocytoma
  13. 13. 4. Vascular a. Hemangioma b. Angiosarcoma 5. Miscellaneous a. Simple (unicameral) bone cyst b. Langerhanscell histiocytosis(histiocytosisX) c. Giantcell tumor d. Aneurysmal bone cyst e. Adamantinoma f. Ewingsarcoma g. Chordoma h. Multiple myeloma/plasmacytoma i. Leukemia j. Lymphoma i. Hodgkin ii. Non-Hodgkin k. Metastasis D. Softtissue lesions 1. Adipose tissue a. Lipoma i. Intramuscular ii. Intermuscular b. Liposarcoma 2. Vascularand lymphatic a. Hemangioma
  14. 14. b. Lymphangioma c. Angiosarcoma/lymphangiosarcoma 3. Fibrousandfibrohistiocytic a. Fibromatoses i. Palmar(Dupuytrencontracture) ii. Plantar iii.Intraabdominal(Gardnersyndrome) iv.Extraabdominal (aggressive) b. Fibrosarcoma c. Malignantfibroushistiocytoma 4. Muscle a. Leiomyosarcoma b. Rhabdomyosarcoma 5. Peripheral nerve a. Neurofibroma b. Schwannoma c. Malignantperipheral nervesheathtumor d. Morton neuroma 6. Synovial a. Localizedgiantcell tumorof tendonsheath(nodular tenosynovitis) b. Ganglion c. Synovial sarcoma 7. Bone and cartilage forming a. Myositisossificans b. Extraskeletal osteosarcoma
  15. 15. c. Extraskeletalchondrosarcoma IX. Tumors and Tumor-Like Lesions (Advanced) A. Bone lesions 1. Cartilaginous a. Mesenchymal chondrosarcoma 2. Osseous a. Highgrade surface osteosarcoma 3. Fibrousandfibrohistiocytic a. Benignfibroushistiocytoma b. Osteofibrousdysplasia(ossifyingfibromaof longbone) c. Desmoplasticfibroma 4. Vascular a. Hemangiomatosis(angiomatosis) b. Gorham disease c. Glomustumor d. Hemangiopericytoma e. Lymphangioma f. Hemophilicpseudotumor 5. Miscellaneous a. Lipoma b. Adamantinoma c. Primitive neuroectodermal tumor d. Intraosseousganglion e. Epidermoidinclusioncyst
  16. 16. B. Softtissue lesions 1. Adipose tissue a. Fibrolipomatoushamartomaof nerve b. Lipomatosis c. Parosteal lipoma d. Liposarcoma(types) i. Well differentiated(atypicallipoma) ii. Myxoid iii.Roundcell iv. Pleomorphic v. Dedifferentiated 2. Vascularand lymphatic a. Glomustumor b. Hemangiopericytoma c. Hemangioendothelioma d. Kaposi sarcoma e. Lymphangiomatosis 3. Fibrousandfibrohistiocytic a. Elastofibroma b. Infantile fibromatosis c. Juvenileaponeuroticfibroma(calcifyingjuvenile fibroma) d. Fibroushamartomaof infancy e. Myofibromatosis f. Fibromatosiscoli
  17. 17. g. Dermatofibrosarcomaprotuberans 4. Muscle a. Leiomyoma b. Rhabdomyoma 5. Peripheral nerve a. Plexiformneurofibroma b. Granular cell tumor c. Clearcell sarcoma d. Extraskeletal Ewingsarcoma i. Primitive neuroectodermal tumor ii. Askintumor 6. Bone and cartilage forming a. Fibro-osseouspseudotumorof the digit 7. Miscellaneous a. Myxoma b. Alveolarsoftpartsarcoma c. Epithelioidsarcoma d. Malignantmesenchymoma e. Lymphoma f. Metastasis IV.Metabolic/ HematologicDisorders V.Skeletal Dysplasias Congenital AnomaliesandDysplasias(Basic) A. Developmental dyplasiaof the hip
  18. 18. B. Proximal femoral focal deficiency C. Blountdisease D. Discoidmeniscus E. Footdeformity 1. Tarsal coalition 2. Talipesequinovarus(clubfoot) 3. Pesplanus 4. Pescavus 5. Metatarsusadductusvarus 6. Vertical talus 7. Rocker-bottomfoot F. Congenital pseudarthrosis G. Madelungdeformity H. Pectusexcavatum I. Pectuscarinatum J. Asphyxiatingthoracicdysplasia(Jeune) K. Thanatophoricdwarfism L. Achondroplasia M. Chondrodysplasiapunctata(stippledepiphyses) N. Chondroectodermaldysplasia(Ellis-vanCreveld) O. Cleidocranial dysplasia(dysostosis) P. Spondyloepiphyseal dyplasia Q. Multiple epiphysealdysplasia R. Dysplasiaepiphysealishemimelica S. Osteogenesisimperfecta
  19. 19. T. Osteopetrosis U. Pyknodysostosis V. Osteopoikilosis W. Melorheostosis X. Osteopathiastriata Y. Diaphyseal dysplasia 1. Engelmann 2. VanBuchem Z. Metaphyseal dysplasia(Pyle) AA. Pachydermoperiostosis BB. Nail-patellasyndrome CC.Holt-Oram DD. Macrodystrophialipomatosa EE. Fibrodysplasia(myositis) ossificansprogressiva FF. Mucopolysaccharidosis(general findings) GG. Neurofibromatosis HH. Tuberoussclerosis II. Trisomy21 (Downsyndrome) JJ. Marfan syndrome KK. Ehlers-Danlossyndrome LL. Turnersyndrome VI.Syndromes Knowledge BasedObjectivesRotation 3 and 4 All knowledge basedobjectivesfromrotations1and 2 to a greaterdepth.
  20. 20. References: Associationof ProgramDirectorsinRadiology( StonyBrook UniversityRadiologyResidency JamesA. HaleyVA Hospital RadiologyResidency The EducationCommittee of the AmericanSocietyof MusculoskeletalRadiology (1997-98) Musculoskeletal Core Lectures:AlbertoSimoncini,M.D. 1 Histogenesis,bone anatomyandphysiology 2 TechniquesrelevanttoMSKimaging 3 Normal featuresandvariants 4 Congenital and developmental abnormalitiesof the spine 5 Congenital anomaliesanddysplasias(basic) 6 Congenital anomaliesanddysplasias(advanced) 7 Infection 8 Tumorsand tumor-like lesions(basic) 9 Tumorsand tumor-like lesions(advanced) 10 Trauma 11 Metabolic,systemicandhematologicdisorders,Disordersof the joints