ZENI-Dx Imaging Revisited in the Context of Diff Dx Flashcards
1
Q
Radiology Value for PTs
4:
A
- Screening for patho + dx standpoint
- Info for Eval+Treat
- Improved pt confidence in YOU!
- Essential for autonomous practice
2
Q
Some common studies (imaging)
A
- Radiographs→ X-rays
- Contrast-Enhanced Radiographs
- Computed Tomography (CT)
- Nuclear Imaging
- Magnetic Resonance Imaging (MRI)
- Ultrasonography
3
Q
RadioLUCENT means getting ______
A
DARKER
4
Q
RadioOPAQUE means getting_________
A
LIGHTER
5
Q
RadioLUCENT means DECd ______
A
Radiographic density
6
Q
RadioOPAQUE means INCd _________
A
Radiographic density
7
Q
For Radiographs….
DARK (radiolucent, DEC radiographic density) images→ LiGHT (radioopaque, INC radiographic density) images
A
- AIR→ darkest
- Metal→ lightest
NOTE: Air (darkest)→ Metal (lightest)= INC’ing obj radiodensity
NOTE: Metal (lightest)→ Air (darkest)= DEC’ing obj radiodensity
8
Q
W/ radiographs……..
Need _________ one image
A
MORE THAN ONE! Multiple views
9
Q
Routine Exam Scenarios
What are the outcomes after using imagining to inform your dx?
A
- Positive for suspected dx
- Negative for suspected dx
- Negative for dx, but diff prob ID’d
- Inconclusive→ further imaging reqd
- When?→ not giving you answers you need or no does not match sx’s
- Next?→ MRI, CT, etc..
10
Q
Case Ex.→ Post-FOOSH
Pt fell and had shoulder injury. X-ray taken.
Name everything you see/what is it?
A
*Bone tumor
- Bulge @ tumor site
- Growth plate not fully closed→ child patient
11
Q
Image Ex.
A
- Trauma, young
12
Q
What do you notice?
A
Bone spur @ calcaneus
13
Q
What do you notice? Which is abnormal? Why?
A
Left looks good
Right bad→ Decd joint space
14
Q
How does imaging inform the use of partial over TKA?
A
- No global OA, Iso’d to single compartment, no huge bone spurs, sclerosis (thickening), abnorm alignment
- *Buys this pt time to get back to rec, vocational activities before s/he progresses to ultimately needing TKA (often ultimate outcome)
15
Q
What do you see?
A
L. clavicular fx
16
Q
Why might this repair cause probs for patient?
A
- Screws/plates→ VERY superf→ pain, visible
- Concerns w/ brachial plexus probs if residual abnorm in shape of bone
- Imaging used to sx decision making→ realignment necessary? How approximated are edge of bones in fx?
17
Q
US utility in fx→ Only in ________ cases
A
SUPERFICIAL
18
Q
US utility in Fx- only in superficial cases
A
- Clavicle is so superficial, US imging can be helpful in ID’ing fx’s
- Clear breach of clavicular cortex near is medial end+ associated adjacent soft tissue edema
19
Q
Knee Skyline View
Takeaways?
A
Bone spurs→ abnormal “load”
In response to this new “load”: MORE bone→ bone spurs→ MORE bone (cortical thickening)
20
Q
Post-op TKA w/ Lateral Knee Pain
A
Notice L. patella and spacing with the prosthesis
21
Q
What do you see here ?
A
Loss of disc space
Sclerotic PLL → + excessive bone formation
22
Q
The Scotty Dog
A
What makes the neck of the dog?→ Pars Interarticularis
Dog with a collar?→ Stress fx
Dog w/ a broken neck?→ Spondylolysis, *also look for displacement of the vertebra (possible SC/Cauda equina impingement)
23
Q
What do you see?
A
R. femoral head AVN → flat (collapsing) R. femoral head
24
Q
Whats this?
A
B/L THA
25
Whats this?
B/L THA
## Footnote
**L. side→ HO (calcification)- had to use much larger prosthetic piece deeper into femur**
26
What do you see?
Ask!!!!
27
X-Ray Viewing
## Footnote
**Pros vs. Cons**
* **PROS:**
* INexpensive
* Relatively available
* Fair→Good **Sn** in detecting **Fx**
* **CONS:**
* Radiation
* **Missed patho\***
* Dependent on skill lvl to get proper study
28
Non-Ionizing→Ionizing (Bad radiation)
see pics
29
Medical Procedure Doses: **Radiation**
## Footnote
**HIGHEST→**
**LOWEST→**
**HIGHEST→** Nuclear Medicine
**LOWEST→** X-rays
30
Other form of **X-Ray Imagining**
Contrast X-ray Studies
31
Other form of X-ray Imagining:
## Footnote
**Contrast X-ray Studies**
**What is it + Types**
Injection of **radio-opaque liquid INTO _area of interest_**
1. **Arthro**gram→ Joint
2. **Myelo**gram→ Spinal Column
3. **Angio**/**Arterio**gram→ Artery/Vessel
32
Like an X-ray, **BUT 100's of X-rays _all around body_**
Computed Tomography (CT scan)
33
CT of Lungs Ex.
Soft tissue + Bony anatomy
see pics
34
3D Reconstruction CT Scan
## Footnote
**Radial Head Fx**
see pics
35
CT Scans
## Footnote
**PROS vs. CONS**
* **PROS:**
* Soft tissue + Tumors
* **3D reconstruction\***
* visualization of subtle & complex fxs
* Bone Mineral Density (BMD) test
* DEXA→ MUCH LESS radiation
* **CONS:**
* Avg volume effect
* discerning subtle diff's in small tissue volumes
* tumors of similar tissue density NOT visualized
* Artifacts
* patient mvmt, metal implants
* Radiation exposure
36
Nuclear Imagining aka
**Bone Scan (Scintigraphy)**
37
Nuclear Imagining:
## Footnote
**Bone Scan (Scintigraphy)**
* Injection of **polyphosphate** and **radioactive isotope (tracer)** binds to **hydroxyapatite** found in **metabolically active bone.**
* Pinpoints _molecular activity_ w/in body
* Pot. to ID _disease_ in _earliest stages_
* Before things “look” bad (think MRI or Xray), there may be underlying changes in physiology
* Detecting **bone tumors** and **metastasis**
* **Early detection of _Stress Fx's_**
38
Three-phase Bone Scan measure \_\_\_\_\_\_\_\_\_\_, NOT \_\_\_\_\_\_\_\_\_\_\_
Measure **physiology,** NOT **anatomy**
39
Three Phase Bone Scan
## Footnote
**3 phases?**
A) Perfusion phase
B) Blood pool phase
C) Delayed pool\*\*\*
40
Three-Phase Bone Scan
## Footnote
**All 3 phases**
* A) **Perfusion phase**
* occurs in seconds
* can look @ blood flow
* B) **Blood Pool phase**
* occurs 5-30mins
* where does blood end up in soft tissue
* aka soft-tissue phase
* C) **Delayed Pool**
* looks @ metabolic activity of bone
* AKA bone phase or sequestration phase (looks @ bony uptake)
* **Cx, Stress fx**
41
Three-Phase Bone Scan
A) Perfusion Phase
* A) **Perfusion phase**
* occurs in seconds
* can look @ blood flow
42
Three-Phase Bone Scan
## Footnote
**B) Blood Pool Phase**
* B) **Blood Pool phase**
* occurs 5-30mins
* where does blood end up in soft tissue
* aka soft-tissue phase
43
Three-Phase Bone Scan
C) **Delayed Pool**
* C) **Delayed Pool**
* looks @ metabolic activity of bone
* AKA bone phase or sequestration phase (looks @ bony uptake)
44
Bone Scans
## Footnote
**PROS vs. CONS**
* **PROS:**
* Image based on **physiology**
* provides info not obtained from anatomical studies
* **Detects:**
* Stress fx's, Metastatic bone CA, Bone dis's and infx's
* **CONS:**
* Lacks **specificity for diff dx**
* **NOT an end study→ req's correlation**
* Not the end of the diff dx pathway!
* **Exposure to radiation**
* actually emitting radiation until it is discharged from body
45
This is the **Evolution of Bone Scans**
## Footnote
**(Like how CT is evolution of X-ray….this is evolution of Bone Scans)**
Single-Photon Emission Computed Tomography **(SPECT)**
*Incs **_Sensitivity_ and _Specificity_ compared to Bone scan***
46
See Case Description
See Imaging
\*B. CT on top, SPECT bottom
47
SPECT for **MSK Conditions (PARS Dysf.)**
Bone Scan on LEFT
SPECT on RIGHT
**\*NOTE: INCd ability** to **ID lesion** w/ **SPECT**
see pics
48
**Scintigraphic findings** in a patient w/ **R. L5 pars stress fx on SPECT (A)**
NOT see on **planar bone scintigraphy (B)**
see pics
49
SPECT Summary
## Footnote
**Key Takeaways**
**4:**
1. Important Advance in the field of **Nuclear Medicine**
2. ID's areas of **high bone metabolism (turn over)**
3. **Can be _coupled with_ CT and MRI\***
4. \***SAME _limitations_ as bone scans!**
1. #Radiation
50
SPECT Summary
## Footnote
**Advancement in field of Nuclear Medicine**
* INCd **sensitivity/specificity** of ID'ing **lesions**
* Can locate even **very small abnorms\***
51
SPECT Summary
## Footnote
**ID's areas of high bone metabolism (Turn-over)**
* Occurs in areas where **bone is over-loaded→** Stress fx's, stress conditions
* Also occurs in **areas of tumors** where there is a **high rate of _bone metabolism_**
52
SPECT **CAN (note “Can be”)** BE **coupled w/\_\_\_\_ and \_\_\_\_\_**
CT and MRI
53
Positron Emission Tomography **(PET)**
## Footnote
**Measures what?**
**Measures _Photon Emission_ from _tracers_**
* **Flourine-18** linked to **glucose== MOST COMMON tracer\*\*\* (good for soft tissue\*)**
* Dramatically expands physiology studies to **soft tissue (think about SPECT, but NOW we can look @ _metabolic issues_ in _soft tissues_, NOT JUST BONE\*)**
54
PET is also **OFTEN (note “often coupled w/”)** coupled w/ _____ and \_\_\_\_\_
CT and MRI
55
PET Scan
**Complex and Costly to perform**
SHORT half-life of the **tracer**
56
PET Scan **MOST OFTEN used to what?**
ID and Stage Cx
* **Can _localize_ lesion**
* **Can help w/ _Sx planning_\*\*\***
57
PET Scan
**Combining** PET scan **w/ MRI or CT scan** can help make images **easier to interpret.**
**LEFT→** CT
**CENTER→** PET
**RIGHT→** PET-CT
\***Bright spot in the chest==\>** Lung Cx
58
Ex. PET vs. MRI vs. PET/MRI
59
Diagnostic Ultrasound
Common use….BABIES! `
60
Dx Ultrasound Ex.
## Footnote
**Supraspinatus**
see pics
61
Dx Ultrasound
## Footnote
**What is it?**
Using **sound waves** to recreate a **2D image of tissue** under the probe
**GREAT for:** superf tears, suprasp, Achilles
62
Dx US
## Footnote
**MSK Imaging vs. Doppler US**
* **MSK:**
* Tendon tears/recovery, MM tears, **Calcific tendinosis,** masses or fluid collections, Joint or bursal effusions
* **Doppler US:**
* Measures **velocity of blood flow→** Suspected **DVTs\*\*\***
**\*See pic for Calcific tendinitis example**
63
Dx US
## Footnote
**Achilles Tendon Rupture**
Left→ Normal
Right→ Rupture+hemorrhage
KEEP LOOKING UNTIL YOU “GET IT” YOU GOT THIS!
YOUTUBE HOW TO READ/INTERPRET!!!!
64
MRI aka
Magnetic Resonance Imagining
65
Measures **energy of _Hydrogen atoms_**
MRI
66
MRI
FACTS
* Measures **spatial distribution** of **protons from hydrogen atoms** in the body when excited by radio freq waves in a magnetic field
* Signal emitted→ **Nuclear Magnetic Resonance (NMR)**
* Radiowaves “tuned” to change NMR in order to **visualize diff types of tissues**
67
MRI is **GREAT FOR:**
SOFT TISSUE!
## Footnote
**AND… NO Ionizing radiation!!!!**
68
T1 MRI vs. T2 MRI
## Footnote
**Key diffs to help remember**
* **T1→ FAT** really **bright**
* **T2→ WATER** really **bright**
69
Measures energy from structures such as **FAT**
T1 MRI
70
Measures energy late in decay of transverse relaxation and selectively images structures that **do not readily give up energy→ such as WATER**
T2 MRI
71
T1 MRI:
* Measures energy from structures such as **FAT→ gives up energy _rapidly_→ EARLY in process of remagnetization**
* **Provides images of _good ANATOMIC detail_→** displays tissues in fairly balanced manner
72
T2 MRI
* Measures energy **LATE in decay of transv. relaxation and** selectively images structures that DO NOT readily give up energy→ **WATER**
* \*Particulalry valuable in detecting **_INFLAMMATION_!! → BC _fluid_ is _brighter_**
73
T1 Image components broken down
ex. ankle/foot
Fat→ **HIGH signal (Bright)**
Cartilage→ LOW signal
Cortical Bone→ LOW signal
Fluid→ LOW signal
74
T2 Image components broken down
ex. ankle/foot
Fat→ LOW signal
Cartilage→ LOW signal
Cortical bone→ LOW signal
**Fluid→ HIGH signal (Bright)**
75
MOST COMMON **contrast** used in MRI imaging
Gadolinium (Gad for short)
* **Shorten the _relaxation time_ of most tissues**
* **INCs _intensity_ of _T1_**
76
Gad (contrast) **inc's intensity in ____ image**
T1
77
MRIs and **Contrast**
## Footnote
**Gadolinium most common\***
* Usually IV
* Adverse rxns possible
* **Nephrogenic systemic fibrosis in pts w/ renal failure or kidney disease**
78
Contrast is **MORE COMMONLY USED in…….**
NON-MSK applications
79
Magnetic Resonance **Arteriogram (MRA)**
## Footnote
**Uses and Ex.**
* Aneurysm, Aortic stenosis, Aortic dissection (or bleed), Stroke site, Coronary blockage, Vessel stenosis (Renal artery stenosis, Peripheral vessel stenosis of arms/legs)\*
80
MRA Ex's
see pics
81
ID this condition
\*\*Vesicular based **Thoracic Outlet Syndrome (TOS)**
## Footnote
**\*Note: blockage of vessel in L. image**
82
fMRI **most commonly used in…**
Brain tissue
83
fMRI
## Footnote
**Facts**
* Common use→ **brain tissue**
* Measures→ **change in blood oxygenation and blood flow**
* Uses **BOLD contrast**
* DeO2'd Hb= magnetic
* O2'd Hb= **resistant to magnet**
* Looks @ HOW tissue using O2
* shows areas actively using O2 more/less vs others
* ACTIVE areas of brain/SC create **INC in blood flow**
84
Chronic Back Pain and active brain regions
During **spontaneous LBP,** pts had INCd activity in brain regions assocd w/ **suffering/sense of self.**
This was **different** when SAME pts (+controls) experienced **thermal types of pain**
Moral of story: **move towards _emotional_, _behavioral_ tx's for LBP**
see pics!!!
85
MRI
## Footnote
**PROS vs. CONS**
* **PROS:**
* NON-ionizing radiation
* Ideal for **soft tissue**
* Great **resolutions w/ higher lvl magnets**
* **CONS:**
* Noise
* Claustrophobia
* Contraindications (ex. metal implants, joint replacements)
86
Acute Trauma MSK “Rules”
## Footnote
**ADD EACH AS A SLIDE WHEN YOU START STUDYING!!!!**
* Ottawa Ankle and Foot Rules
* Ottawa Knee Rules
* Pittsburgh Decision Rules
* Cervical Spine:
* NEXUS Low Risk
* Canadian C-Spine (pictured below)
