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MUSCULOSKELETAL IMAGING: X-RAY VS ULTRASOUND VS MRI RAKESH MOHANKUMAR MUSCULOSKELETAL RADIOLOGIST JOINT DEPARTMENT OF MEDICAL IMAGING ASSISTANT PROFESSOR, UNIVERSITY OF TORONTO DISCLOSURE I HAVE NO FINANCIAL DISCLOSURES TO MAKE PERTAINING TO THE SUBJECT MATTER OF THIS TALK. OBJECTIVES EVALUATE THE USE OF X-RAYS, ULTRASOUND, CT AND MRI IN DIAGNOSIS OF MUSCULOSKELETAL PATHOLOGY ASSESS THE ROLE OF EACH MODALITY IN THE COMMONLY IMAGED JOINTS KNEE SHOULDER HIP PLAIN RADIOGRAPHY MAINSTAY OF BONE AND JOINT IMAGING, PARTICULARLY IN TRAUMA ADVANTAGES FAST INEXPENSIVE READILY AVAILABLE GOOD FOR ASSESSING BONES AND JOINTS DISADVANTAGES USES IONISING RADIATION (X-RAYS) LIMITED INFORMATION REGARDING SOFT TISSUES COMPUTED TOMOGRAPHY (CT) ADDS CROSS SECTIONAL IMAGING CAPABILITY REFORMATTING IN OTHER PLANES AND 3D BEST FOR BONY CORTEX, OSSEOUS ANATOMY AND CALCIFICATION GOOD AT EVALUATION OF COMMINUTED FRACTURES TO COMPLEX STRUCTURES PELVIS CALCANEUS WRIST COMPUTED TOMOGRAPHY (CT) ADDS CROSS SECTIONAL IMAGING CAPABILITY REFORMATTING IN OTHER PLANES AND 3D BEST FOR BONY CORTEX, OSSEOUS ANATOMY AND CALCIFICATION GOOD AT EVALUATION OF COMMINUTED FRACTURES TO COMPLEX STRUCTURES PELVIS CALCANEUS WRIST COMPUTED TOMOGRAPHY (CT) coronal ADDS CROSS SECTIONAL IMAGING CAPABILITY REFORMATTING IN OTHER PLANES AND 3D BEST FOR BONY CORTEX, OSSEOUS ANATOMY AND CALCIFICATION sagittal GOOD AT EVALUATION OF COMMINUTED FRACTURES TO COMPLEX STRUCTURES PELVIS CALCANEUS WRIST COMPUTED TOMOGRAPHY (CT) ADDS CROSS SECTIONAL IMAGING CAPABILITY REFORMATTING IN OTHER PLANES AND 3D BEST FOR BONY CORTEX, OSSEOUS ANATOMY AND CALCIFICATION GOOD AT EVALUATION OF COMMINUTED FRACTURES TO COMPLEX STRUCTURES PELVIS CALCANEUS WRIST COMPUTED TOMOGRAPHY (CT) DISADVANTAGES RADIATION DOSE TO PATIENT METAL ARTEFACT POOR SOFT TISSUE CHARACTERIZATION ULTRASOUND ADVANTAGES READY ACCESSIBILITY PORTABILITY RELATIVELY QUICK SCAN TIME BETTER PATIENT TOLERABILITY CONTRALATERAL COMPARISON Achilles tendon ULTRASOUND ADVANTAGES (CONTINUED) PERSONAL INTERACTION WITH THE PATIENT DIRECTED / TARGETED EXAMINATION SPECIFIC FOR EACH INDIVIDUAL CLINICAL HISTORY DYNAMIC IMAGING COMPRESSION OF STRUCTURES MOVEMENT OF A JOINT INTERVENTION JOINTS, BURSAE, MASSES INJECTION, ASPIRATION, BIOPSY IMAGING OF TENDONS Longitudinal Transverse SHOULDER ULTRASOUND: SUPRASPINATUS TENDON Longitudinal Full thickness tear of the supraspinatus tendon Transverse ARTHRITIS SCREENING VASCULARITY OF A LESION Glomus tumour VASCULARITY OF A LESION SOLID VS CYSTIC LESION Nerve sheath tumour Baker’s cyst ULTRASOUND DISADVANTAGES HIGHLY OPERATOR DEPENDENT LONG LEARNING CURVE PROPER TRAINING AND EXPERIENCE REQUIRED PHYSICIAN TIME-INTENSIVE EXAMINATION MAGNETIC RESONANCE IMAGING (MRI) PATIENT IN A STRONG MAGNETIC FIELD MULTIPLANAR IMAGING EXCELLENT SOFT TISSUE CONTRAST IDEALLY SUITED FOR MSK BEST IMAGING MODALITY FOR INTRA-ARTICULAR PATHOLOGY Coronal Sagittal Axial Soft tissue contrast and multiplanar imaging help pre-operative assessment of musculoskeletal tumours SOFT TISSUE CONTRAST CT MRI T1 MRI T2 fat sat SOFT TISSUE CONTRAST CT MRI T1 tumour proximal humerus rim of calcification best seen on CT soft tissue anatomy best on MR tumour best seen on T2 MR image MRI T2 fat sat MAGNETIC RESONANCE IMAGING (MRI) DISADVANTAGES CONTRAINDICATIONS ORBITAL METALLIC FOREIGN BODIES PACEMAKERS NEUROSTIMULATORY DEVICES CLAUSTROPHOBIA 1 TRIMESTER THEORETICAL RISK ST ARTEFACTS FROM FERROMAGNETIC OBJECTS IMAGING OF OSSEOUS ANATOMY, FRACTURES AND CALCIFICATION LACKING (CT IS STILL BETTER) KNEE TRAUMATIC KNEE PAIN X-RAY FIRST MODALITY CT TO ASSESS TIBIAL PLATEAU FRACTURE SEEN ON X-RAY FOCAL TENDERNESS EFFUSION NON WEIGHT BEAR NO FRACTURE, TWISTING INJURY, EFFUSION: MRI KNEE ATRAUMATIC KNEE PAIN X-RAY: BEST INITIAL STUDY MRI: IF ADDITIONAL IMAGING IS NECESSARY, AND IF INTERNAL DERANGEMENT IS SUSPECTED. KNEE ULTRASOUND ROLE SHOULD BE LIMITED TO SUPERFICIAL STRUCTURES AND FOR A FOCUSED CLINICAL QUESTION EXTENSOR MECHANISM COLLATERAL LIGAMENTS (MRI IS STILL BETTER) JOINT EFFUSION/BAKER’S CYST DISTAL HAMSTRINGS MENISCI: NON-SPECIFIC AND INCOMPLETE EVALUATION. MRI IS MORE SENSITIVE AND SPECIFIC IN EVALUATION OF MENISCI CRUCIATES: CANNOT BE ASSESSED WITH ULTRASOUND Patellar tendon SHOULDER X-RAY: BEST INITIAL STUDY ULTRASOUND: ROTATOR CUFF LONG HEAD OF BICEPS TENDON (EXTRA-ARTICULAR) JOINT EFFUSION SUB-ACROMIAL BURSA ACJ INTERVENTION SHOULDER MRI: ALL ABOVE LABRUM ARTICULAR CARTILAGE BONE MARROW Full thickness supraspinatus tear HIP CHRONIC HIP PAIN X-RAY INITIAL DIAGNOSTIC TEST USEFUL AS INITIAL INVESTIGATION OF TRAUMA, ARTHRITIS, IMPINGEMENT OA HIP MRI ASSESSMENT OF LABRUM SURROUNDING SOFT TISSUES OSTEONECROSIS OSTEOARTHRITIS: ONLY IF ANOTHER INVESTIGATION IS CLINICALLY INDICATED OSTEOID OSTEOMA: CT IS BETTER T2FS HIP OCCULT HIP FRACTURES 18-85% HIP/PELVIS FRACTURES CAN BE MISSED BY INITIAL RADIOGRAPHS MR IMAGING SUPPLANTED SCINTIGRAPHY AS NEXT IMAGING TEST OF CHOICE ELDERLY PATIENTS OSTEOPOROSIS PAIN WITH MINIMAL TRAUMA EQUIVOCAL OR “NORMAL” PLAIN RADIOGRAPHS T1 STIR METAL IN MSK MRI CHRONIC, IMMOBILE IMPLANTS ARE NOT A CONTRAINDICATION FOR MRI ARTHROPLASTY ORIF PLATES AND SCREWS EMBEDDED FOREIGN BODY: SHRAPNEL CAN PRODUCE ARTEFACT IF SCANNING THE ADJACENT AREA METAL ARTEFACT REDUCTION Without WARP With WARP METAL ARTEFACT REDUCTION CONCLUSION EVALUATE THE ROLE OF X-RAY, ULTRASOUND, CT AND MRI IN MUSCULOSKELETAL PATHOLOGY PLAIN RADIOGRAPHY: INITIAL INVESTIGATION OF JOINT PATHOLOGIES CT: BEST FOR OSSEOUS ANATOMY, FRACTURES, CALCIFICATION MRI: BEST FOR SOFT TISSUE AND INTRA-ARTICULAR PATHOLOGIES US: TENDONS, ARTHRITIS, DYNAMIC ASSESSMENT, INTERVENTION QUESTIONS?
