Ortho/Vascular/Peds

Question 1

Indications for ortho studies

Answer 1

Injury
Pt is unsure whether injury occurred
Abscesses
Osteomyelitis
Bony tumors
MSK pathologies, think sprains, tears, etc
Pt assurance
Parental assurance

Question 2

How to choose imaging modality for ortho?

Answer 2

Usually start with plain films for injuries and FBs
CT/MRI/NM after plain films usually if re: injury
Abnormal labs?
Length of sx
Mechanism of injury
-Always report this when you order the test
Pt limitations with regard to radiographic principle of 2 views/obliques, etc

Question 3

How to order ortho imaging

Answer 3

If injury: MOI, PE findings (deformity, TTP, test results if any)
If chronic or no injury: labs if applicable, PE findings (same as above)
Order what hurts. However, radiology principles dictate if long bones are ordered they must include both proximal and distal joints. Keep in mind so you don’t overorder

Question 4

General bony pathology

Answer 4

Will have the same general appearance among the pathology regardless of which bone is involved
Osteomyelitis
Bony tumors
RA
OA
Osteopenia/osteoporosis

Question 5

What is the test of choice for sprains/strains/tears?

Answer 5

MRI, without contrast

Question 6

Types of Salter-Harris fractures

Answer 6

Type I: straight
Type II: Above
Type III: Below
Type IV: Through
Type V: Crush

Question 7

Colles fx

Answer 7

Distal radius

Question 8

Greenstick fx

Answer 8

Rare, long bones with angulated longitudinal force, incomplete fx

Question 9

Buckle/torus fx

Answer 9

Primary wrist fx

Incomplete fx

Question 10

Stress fx

Answer 10

10 day rule for feet

Question 11

Shoulder

Answer 11

Includes the clavicle, scapula, and proximal humerus
Complete shoulder is neutral/external/internal rotation and Y view of scapula
Also can do an axillary view (must be at a 90 degree angle) but the Y view is easier on the pt usually and standard in the shoulder series

Question 12

Elbow

Answer 12

Complete is 4 views:
AP
Lateral
Internal rotation
External rotation
If obvious deformity, 2 views (AP/lateral) will suffice

Question 13

Occult fractures

Answer 13

Commonly a concern with the elbow
Nothing seen overtly on radiographic imaging including CT sometimes. MRI/NM will usually show them
Pos fat pad signs (anterior/posterior), sail sign (anterior)
Adults: radial head fx
Children: supracondylar fx
Children don’t lie or fake guarding their extremities, err on side of caution and splint with ortho f/u

Question 14

Pelvic girdle

Answer 14

If ordering a unilateral hip, also order an AP pelvis
Hip fxs and dislocations are pretty straightforward
Pelvis fxs need CT of the pelvis for best detail, regardless of age

Question 15

Pathologies possible in the pelvic girdle

How can they be imaged?

Answer 15

AVN
Slipped capital femoral epiphysis
Legg-Calve-Perthes dz
All can be diagnosed usually with plain films but MRI will give definitive dx
Hip clicks/dysplasia in infants, u/s is test of choice for dx IF sonographers are capable

Question 16

Knees

Answer 16

Fxs are rare
Dislocations are more rare
Knee complete is 4 views: AP, lateral, int/ext obliques
Older people (60 and older) with injury, neg plain films, still with pain days later, do CT will find tibial plateau fxs
Most knee plain films will be negative, high incidence of strain/sprain/tear, good PE, if no improvement after 7-10 days of RICE, MRI warranted

Question 17

Ankles

Answer 17

When examining pts with ankle injuries, always check the fibular head for point tenderness
Many twisting injuries can result in fibular head fractures
If TTP on fibular head order a knee series as well
Ankle complete is 3 views:
AP
Lateral
Internal oblique
Ankle joint should be flexed to see if ankle mortise is intact

Question 18

Feet

Answer 18

Standard exam is 3 views:
AP
Lateral
Oblique
Neg X-ray at time of injury with continued sx 7-10 later pt should be re-imaged with plain film
Foot fxs can show on later films, always caution your pts to return to clinic for re-eval or see PCP if no improvement in sx
Jones fxs must be NWB

Question 19

Specialty ortho

Answer 19

C arm for surgery and reductions (in ER if the doctor wants)
-Reactive when it’s on
Nuclear medicine: bone scans for fx age, bony mets, tumors
MRI: gold standard for eval of sprains/tears
-Not routinely ordered in ER, either in office or by ortho specifically

Question 20

Words of wisdom in ortho

Answer 20

Dislocations must be reduced ASAP, regardless of fracture type
If you have access to ortho, call
When in doubt, splint and refer, treat it like a fracture
Always have help when reducing fractures/dislocations

Question 21

What is considered part of the peripheral vascular system?

Answer 21

Carotid arteries
Jugular veins
Upper extremities
Lower extremities

Question 22

Imaging that is possible on the carotid arteries

Answer 22

U/S (fast, cheap and easy)- good screening tool
Images the common carotid, internal carotid, external carotid, vertebral arteries
Internal carotid/external carotid named for what they feed not where they lie
CTA of neck
MRA of neck
Angiogram

Question 23

Carotid duplex/doppler

Answer 23

CCA/ICA/ECA/vertebrals in black and white, with color, with doppler waveforms and measurements

Question 24

Indications for carotid duplex/doppler

Answer 24

Any neuro complaint, e.g. dizziness, visual changes, weakness
Usually done post CVA/TIA
Bruit on exam
Screening exam now for pts >65 yo with RFs

Question 25

Jugular/subclavian veins

Answer 25

included with an upper extremity venous doppler (ultrasound) Can order separately if needed Can use bedside u/s to localize EJ for IV access in difficult pts

Question 26

Upper/lower extremity imaging options

Answer 26

Arterial doppler ABIs Venous doppler CTA/MRA/Angiography

Question 27

Upper/lower extremity arterial indications

Answer 27

Decreased or absent pulses Skin changes: color, temp Pain in the setting worrisome for vascular dz (think DM, smoking)

Question 28

How to order upper/lower extremity arterial

Answer 28

``` RUE LUE BUE RLE LLE BLE arterial doppler (duplex) ```

Question 29

What you get with upper/lower extremity arterial imaging

Answer 29

Subclavian to as much radial/ulnar arteries as is able to be visualized, includes axillary and brachial Common femoral vein/great saphenous vein/popliteal vein/post tibs Black and white images, color images, doppler with waveforms and measurements

Question 30

Types of extremity arterial waveforms

Answer 30

Triphasic flow is nl Biphasic flow is indicative of early changes/disease Monophasic flow is diseased/pre-occlusive No flow = occlusive Can have collaterals

Question 31

ABI

Answer 31

Screening test, easy, can do in your office if you have a doppler The ankle-brachial pressure index (ABPI) or ABI is the ratio of the BP of the ankle to the BP in the upper arm. Compared to the arm, lower BP in the leg is an indication of diseased arteries d/t PVD

Question 32

Upper/lower extremity venous

Answer 32

Very overused test Fast, cheap, and easy, most bang for your buck Rules out something potential deadly Pt reassurance Images deep venous system from hip to knee and then as far as is possible to image, usually mid-calf region Common femoral vein/great saphenous vein/superficial femoral vein, pop, post tibials Never order venous and arterial together just because you are unsure

Question 33

What you get with upper extremity venous

Answer 33

``` Internal jugular Subclavian Axillary Brachial (s) Cephalic Basilic Radial/ulnar as far as you can see usually mid forearm ```

Question 34

Lower extremity venous- what you get

Answer 34

``` Central femoral vein Great saphenous vein Superficial femoral vein Popliteal vein Posterior tibial ```

Question 35

Pediatric pearls

Answer 35

Good hx from parent/guardian Good PE Learn how to build rapport with the pt AND the parents Both can tell when you're not confident Defer to radiologist whenever possible When in doubt err on side of caution and proceed as needed

Question 36

Pediatric considerations

Answer 36

``` Head injury/LOC Neurologic sx Spine injuries/scoliosis CXR Abd X-ray: common and uncommon pathology Appendicitis Pyloric stenosis Hip dysplasia Ortho Osteogenesis imperfecta Radiation exposure ```

Question 37

Head injury with or without LOC

Answer 37

Assess pt, neuro exam Good hx from parents PE concerns Benign exam findings with no LOC: monitor for concussive sx Benign exam findings with LOC: monitor vs skull X-ray vs CT scan Pos exam findings with or without LOC: scan the pt

Question 38

Neuro sx in the pediatric pt

Answer 38

``` Chronic headaches Syncope New onset seizure Abnl neuro exam CT scan without contrast ```

Question 39

Spine injuries/scoliosis

Answer 39

Start with plain films and proceed based on those results If <18 but adult sized teenager may do CT scans instead Scoliosis series: radiologist will give you the degree of lateral curvature

Question 40

CXR in peds: when to get it

Answer 40

``` Cough, fever, ill-appearing Low O2 sat Unable to correct wheezing/coarse breath sounds with meds Hx of pneumonia Abnl labs: elevated WBC Ingestion of FB ```

Question 41

Abdominal X-ray in peds: when to get it

Answer 41

``` Vague abdominal complaint no worry for appy Constipation Exam findings with no worry for appy Ingestion of FB Worrisome for: Volvulus Intussusception SBO Free air NEC Duodenal atresia These conditions usually require a barium study either under fluoro or CT scan ```

Question 42

Appendicitis

Answer 42

Good hx from parents PE findings worrisome for appy May order u/s first- know the LIMITATIONS Best imaging choice when u/s is not a viable option: CT abd/pelvis with IV/PO contrast If an obese teenager may do without any contrast same as adult

Question 43

Pyloric stenosis

Answer 43

Start with u/s, usually an excellent way to diagnose | If u/s is neg, pt still with sx, proceed to upper GI

Question 44

Hip dysplasia

Answer 44

U/s if PE is concerning Must be done by a confident sonographer Read by a confident radiologist

Question 45

Orthopedics

Answer 45

For small children and infants, it's really difficult to interpret images Treat as a fracture, splint and ortho this DOES NOT AID IN DX Radiograph the unaffected side for comparison when a dx is needed Your decision will be based on parents mostly, some want to know for sure if there is a fx Elbow fxs (supracondylar fx) are emergent and must be found

Question 46

Radiation exposure

Answer 46

Osteogenesis imperfecta pts get imaged a lot d/t multiple fxs, try to order the least amount of exams to limit their lifetime exposure CT head to children is a lot of radiation, be prudent when ordering this, esp if PE if benign and the pt is well-appearing, parent reassurance is important, you must learn to reassure without ordering Sick infants will be imaged a lot, always limit your orders as best you can to decrease their lifetime exposure Use u/s when possible