10/10/13

Imaging Musculoskeletal InjuriesStrengths and Weaknesses of Different Modalities
Samuel R. Ward, PT, PhD
Associa...
10/10/13

Ultrasound

www.terason.com

Healthy

Fatty Atrophy

Sag Obl Ultrasound

Cor Obl Ultrasound

Sag Obl MRI

From S...
10/10/13

Plain film x-ray
Film/detector

http://www.umphysicians.org

Ionizing radiation source

Density contrast

Comput...
10/10/13

Bone Scan (Scintigraphy)
Detector (2D or 3D)

http://www.saintlukeshealthsystem.org

Patient = radiation source
...
10/10/13

Positron emission tomography

Shinozaki, JSES 2013

Patient is the radiation source
Radiopharmaceuticals15O-H2O-...
10/10/13

MRI Spine Stress Films

Standing

Sitting

Knees to chest

Prone on elbows

MRI Stress Films

6
10/10/13

MRI Physiology and Microarchitecture

High-Res Structure
IDEAL

High-Res DTI

Skiing Injury with Epimysial Hemat...
10/10/13

Intramuscular Hematoma from a Kick

Sag US

Ax T2 MRI
Heterogeneous intensity = Subacute

Chronic Subperiosteal ...
10/10/13

Rhabdomyolysis from Fall

G Med
G Max

Ax CT

Ax MRI

Professional Soccer Player
Kick Injury after 5-6 weeks

Ax...
10/10/13

Grade 1- Stress Fracture

X-Ray

Bone Scan

Fat Sup T2 Ax MRI

Fracture

X-Ray

Cor T1 MRI

Cor Fat Sup T2 MRI

...
10/10/13

ACL Tear with Bone Bruise

Sag T1 MRI

Sag Fat Sup T2 MRI

Quadriceps Tendon Tear

Sag T1 MRI

Sag Fat Sup T2 MR...
10/10/13

TE
100 µs

TE
500 µs

TE
2 ms

Achilles Tendon

TE
300 µs

TE
3 ms

TE
5 ms

TE
1 ms

MRI UTE T2* Quantification...
10/10/13

Case 2
•  A very important player
during season experience
increasing symptoms
(pain and stiffness in the
mornin...
10/10/13

Thank You

Mini Pathria, MD

Christine Chung, MD

14
10/10/13

Grade Radiography

Scintigraphy

MR Imaging

0

Normal

Normal

Normal

I

Gray cortex sign; margin is
indistinc...
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Samuel R. Ward. Associate Professor in the Departments of Radiology, Orthopaedic Surgery and Bioengineering at the University of California, San Diego.

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Imaging musculoskeletal injuries—strengths and weaknesses of the different image modalities.

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Samuel R. Ward. Associate Professor in the Departments of Radiology, Orthopaedic Surgery and Bioengineering at the University of California, San Diego.

  1. 1. 10/10/13 Imaging Musculoskeletal InjuriesStrengths 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 Ultrasound Plain film x-ray Computed tomography Bone Scan (scintigraphy) Magnetic resonance imaging Positron emission tomography Safety / easy of use Cost / Complexity Imaging Modalities 1
  2. 2. 10/10/13 Ultrasound www.terason.com Healthy Fatty Atrophy Sag Obl Ultrasound Cor Obl Ultrasound Sag Obl MRI From Strobel et al, Radiology, 2005 2
  3. 3. 10/10/13 Plain film x-ray Film/detector http://www.umphysicians.org Ionizing radiation source Density contrast Computed tomography Density = contrast http://www.cogneuro-lab.org Can use iodine-based contrast 3
  4. 4. 10/10/13 Bone Scan (Scintigraphy) Detector (2D or 3D) http://www.saintlukeshealthsystem.org 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 4
  5. 5. 10/10/13 Positron emission tomography Shinozaki, JSES 2013 Patient is the radiation source Radiopharmaceuticals15O-H2O- blood flow and tissue perfusion FDG- glucose transport/action Rotator Cuff + Nerve Injury Supraspinatus Image Plane Thieme, Atlas of Anatomy 2007 Infraspinatus Sagittal Oblique T1 MRI 5
  6. 6. 10/10/13 MRI Spine Stress Films Standing Sitting Knees to chest Prone on elbows MRI Stress Films 6
  7. 7. 10/10/13 MRI Physiology and Microarchitecture High-Res Structure IDEAL High-Res DTI Skiing Injury with Epimysial Hematoma Gas Tib Tib Sol Sol Gas Sol Sag US Ax T1 MRI Gas Ax T2 MRI Isointense = acute 7
  8. 8. 10/10/13 Intramuscular Hematoma from a Kick Sag US Ax T2 MRI Heterogeneous intensity = Subacute Chronic Subperiosteal Hematoma RF RF VL Ax T2 MRI RF VL VL Fat Sup Ax T2 MRI Ax CT 8
  9. 9. 10/10/13 Rhabdomyolysis from Fall G Med G Max Ax CT Ax MRI Professional Soccer Player Kick Injury after 5-6 weeks Ax T1 MRI Differential diagnosis- neoplasm? Ax CT Myositis Ossificans 9
  10. 10. 10/10/13 Grade 1- Stress Fracture X-Ray Bone Scan Fat Sup T2 Ax MRI Fracture X-Ray Cor T1 MRI Cor Fat Sup T2 MRI CC 10
  11. 11. 10/10/13 ACL Tear with Bone Bruise Sag T1 MRI Sag Fat Sup T2 MRI Quadriceps Tendon Tear Sag T1 MRI Sag Fat Sup T2 MRI 11
  12. 12. 10/10/13 TE 100 µs TE 500 µs TE 2 ms Achilles Tendon TE 300 µs TE 3 ms TE 5 ms TE 1 ms MRI UTE T2* Quantification TE 10 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? 12
  13. 13. 10/10/13 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 ? 13
  14. 14. 10/10/13 Thank You Mini Pathria, MD Christine Chung, MD 14
  15. 15. 10/10/13 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, illdefined 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 15

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