1. The Basics of Musculoskeletal Imaging

2. Objectives Discuss basic radiology of the upper & lower extremities
Review a few clinical diagnoses & their radiographic findings

3. Wrist X-ray Basic views: PA & lateral Carpal bones mnemonic
Some Lovers Try Positions That They Can’t Handle
Trapezium = Thumb
Scaphoid fracture: delayed imaging
Carpal tunnel view

4. Wrist X-ray

5. Some Lovers Try Positions That They Can’t Handle

7. Case 1 21 y.o. female DDx? What would be the most common injury?
snowboarding & lost her balance
falling backwards she reached out her right hand to catch herself
acute onset of wrist pain
DDx? What would be the most common injury?

8. Scaphoid Fracture M/C carpal bone fracture M/C mechanism: FOOSH
Pain on radial wrist & TTP in snuff box (ulnar deviation)
X-ray: PA, lateral, scaphoid view (ulnar dev)
Management pearls
clinical suspicion, neg x-rays
thumb spica splint/cast
re-image in days

9. Scaphoid Fracture

10. Scaphoid Fracture

11. Scaphoid Fracture
Scaphoid view

12. Case 2 & 3 48 y.o. LH new golfer 29 y.o. LH golfer
hard swing & unknowingly hits a tree root
pain on ulnar aspect of R palm
29 y.o. LH golfer
pain on ulnar aspect of R palm for
a few months

13. Hook of the Hamate Fx
Usually seen in individuals who participate in sports involving a racquet, bat, or club
Rare but relative common fx in “swingers”
Acute or overuse type injury
Imaging
carpal tunnel view but notoriously missed on x-ray
CT scan
Swingers vs Throwers

14. Hook of the Hamate Fx

15. Hook of the Hamate Imaging

16. Hook of the Hamate Imaging

17. Colle’s Fracture Mechanism: FOOSH Victims
young w/ high energy trauma
older w/ osteoporotic bones & low energy trauma
Fracture of distal radius w/ dorsal
angulation of the distal
fracture fragments

18. Colle’s Fracture
Due to the dorsal angulation of the distal fragment, Colle’s fractures are often said to have a "dinner fork" appearance

19. Dinner Fork Deformity

20. Colle’s Fracture X-rays
Dorsal angulation of distal segment

21. Colle’s Fracture Management Complications
nondisplaced, minimal angulation: sugar-tong splint
displaced: refer for reduction
Complications
median nerve injury, compartment syndrome & vascular compromise
Be aware of associated injuries (ulnar styloid, scaphoid, etc)

22. Elbow X-ray Basic views: AP & lateral Fat pad sign or “sail sign”
In kids, be aware of the apophyses

23. Elbow X-ray - AP

24. Elbow X-ray - Lateral

25. Elbow Fat Pads
Fat is normally present within the joint capsule of the elbow, but outside the synovium
Typically "hidden" in the concavity of the olecranon and coronoid fossae
Injuries that produce intra-articular hemorrhage cause distension of the synovium forcing the fat out of the fossa producing triangular radiolucent shadows anterior and posterior to the distal end of the humerus – the FAT PAD SIGNS
Synovial membrane then outside that is fibrous joint capsule (fat btwn the 2) (synovial membrane – fat – fibrous joint capsule)

26. Fat Pad Sign

27. Fat Pad Sign
Normal
The Sail Sign

28. Fat Pad Sign
Posterior fat pad sign – ALWAYS abnormal

29. Fat Pad Sign Pearls X-rays Think occult fracture No visible fracture
Positive fat pad sign
Think occult fracture
Kids: supracondylar fracture
Adults: radial head fracture

30. Ossification Centers There are 6 ossification centers around the elbow
Always appear in same order: C-R-I-T-O-E
Capitellum
Radius
Internal or medial epicondyle
Trochlea
Olecranon
External or lateral epicondyle
Age of appearance is highly variable but as general guide remember years

31. Ossification Centers

32. Ossification Centers
Radial & Lateral epi usually last to close; so if have closure of lat & radial but see a widened area along the medial epicon then most likely an avulsion of the apophysis & not a normal unfused growth plate

33. Ossification Centers Age of closure is between ages 14-16
Radial & the lateral epicondyle are generally last to close

34. Case 4 11 y.o. RH year round baseball player Concerns?
pitches on 3 different teams
medial sided Rt elbow pain
no acute injury
Concerns?

35. Little League Elbow Medial epicondyle apophysitis Overuse injury
Common cause of medial sided
elbow pain in throwing athletes
X-rays: normal or widening
of the apophysis
Need comparison views
No lateral epicon apophysis yet so widening could just be normal unfused growth plate so need hx, PE, x-rays including of the other elbow

37. Shoulder X-ray Basic view: AP (“true” versus scapular AP) Other views
Axillary
useful in pts w/ clinical picture of instability
evaluates glenoid, may see Hill-Sachs lesion (defect in posterior humeral head)
Scapular Y
useful in dislocations
External Rotation
evaluation of greater tuberosity
Internal Rotation: calcific tendinitis, Hill-Sachs lesion
Zanca view: AC joint
Internal “Ice” cream cone’; picture at top is AP in scapular plane

38. Axillary View
Good look at GH joint & the acromion (os acromionale – unfused acrom often mistaken for a fx)

39. Scapular Y View
if – inferior; is – infraspinous; hh – humeral head; a – acromion; s – spine; c - coracoid

40. Shoulder - External Rotation
Allows better visualization of the greater tuberosity
Fracture detection

41. External Rotation

42. Internal Rotation
I – internal rotation – ice cream cone shape to humeral head; x-ray of calcific tendonitis

43. AC Joint – Zanca View
Zanca view: degrees superiorly/cephalad and decreasing the voltage/penetration to about 50% of that used for a standard glenohumeral exposure; normal AC joint distance is ~1-3 mm

44. Glenohumeral Arthritis
2nd image shows elevation of HH, central glenoid erosions

45. AC Joint Arthritis
Treat the pt not the xray; if looks like narrowed AC joint on xray but no symptoms – don’t worry about xray findings; normal AC joint 1-3mm

46. CLEAR AS MUD!!!
No real consensus on what views a “shoulder series” should include
For me
Scapular AP in ER (good view of GH joint; greater tuberosity of the humerus)
“True” AP in IR (decent view of AC joint; Hill Sachs lesion – posterior humeral head defect )
Axillary
If AC joint pain, Zanca view
If hx of subluxation/dislocation, maybe scapular Y

47. Advanced Shoulder Imaging
Younger patient
labral tears MR arthrogram
Older patient
rotator cuff pathology MRI

49. Knee X-ray Basic views: AP & lateral
Must be weight bearing to accurately assess joint space
Sunrise/merchant view: evaluation of patella & PF joint

50. Knee X-ray - AP

51. Knee X-ray - Lateral
True lateral the posterior aspects of the condyles should overlap

52. Knee – Osteoarthritis (OA)

53. Knee X-ray - OA

54. Knee X-ray - OA

55. Patellofemoral Arthritis

56. Segond Fracture
Avulsion fracture of the lateral capsule off of the tibia
Suspect ACL tear until proven otherwise

57. Segond Fracture

59. Case 5
13 y.o. boy w/ anterior knee pain

60. OGS vs SLJ Osgood-Schlatter (OSG) Sinding-Larsen-Johansson
traction apophysitis at the tibial tubercle
Sinding-Larsen-Johansson
traction apophysitis at the inferior patellar pole
Both resolve w/ skeletal maturity

61. Osgood-Schlatter Syndrome

62. Sinding-Larson-Johansson
Osgood-Schlatter
Sinding-Larson-Johansson

63. Bipartite Patella
Congenital condition in which the patella develops from 2 ossification centers
Incidence: ~ 2% of the population
Bilateral in 43% of cases
M:F ratio of 8:1
M/C location = superolateral pole (75%)
Don’t confuse with patellar fracture

64. Bipartite Patella

65. Common Ortho Pimp Question

66. Fabella Sesamoid bone in the lateral head of the gastrocnemius muscle
Normal variant in 10-20% of the population

67. Advanced Knee Imaging Ligaments & soft tissues Bones
MRI w/out contrast
Bones
CT scan

69. Ankle X-ray Basic views: AP, lateral & mortise
Weight bearing if at all possible

70. Mortise View
Allows better visualization of the talar dome, the distal tibia & the distal fibula
Taken with patient’s leg slightly internally rotated

71. Ankle X-ray - AP

72. Ankle X-ray - Lateral

73. Ankle X-ray - Mortise

74. Mortise vs AP Views of Ankle

75. AP vs Mortise View
AP View
Mortise View

76. Ottawa Foot & Ankle Rules

77. Remember to examine above & below the injury
Maisonneuve Fracture
Mechanism: ankle injury (typically eversion)
deltoid ligament sprain
fracture of medial malleolus
Disruption of the tibiofibular syndesmosis
Fracture of proximal 1/3 of the fibula
Remember to examine above & below the injury

78. Maisonneuve Fracture

79. Foot X-ray Basic views: AP, lateral & oblique
Weight bearing if at all possible

80. Foot X-ray AP

81. Foot X-ray Lateral

82. Foot X-ray Oblique
Good look at cuboid on oblique

83. Ottawa Foot & Ankle Rules

85. Fractures of the 5th Metatarsal

86. Fractures?

87. Normal Apophysis Apophysis at the base of the fifth metatarsal
Common in girls 9 to 11 and in boys 11 to 14 yrs of age
Note the apophyseal line runs parallel to shaft of metatarsal along the lateral-inferior margin of the tubercle

88. Avulsion Fx 5th MT Tuberosity
Usually seen with inversion ankle injuries
Implicated structures
peroneus brevis tendon
lateral band of plantar fascia

89. Avulsion Fracture
Note that the radiolucency is perpendicular to the long axis of the fifth metatarsal
Most common fx of the base of the 5th metatarsal

90. 5th MT Anatomy

91. Jones Fracture
Transverse fracture at the junction of the diaphysis and metaphysis of the 5th MT
Located within 1.5 cm distal to tuberosity of 5th MT

92. Jones Fracture Potentially the worst fracture of the 5th MT
due to very limited blood supply
thus slow healing w/ potential for no healing
Don’t confuse with avulsion fracture

93. Apophysis
Avulsion Fx
Jones Fx

94. Sever’s Disease Calcaneal apophysitis
Heel pain in skeletally immature patients
Visualized best on lateral view
Need comparison view

95. Sever’s Disease

96. What is the most likely cause of this patient’s foot/heel pain?

97. NOT THE HEEL SPUR!!!!!!

98. Plantar Fasciitis Common cause of heel pain
Very painful first step in the a.m.
Spur forms in the toe flexor tendons & is actually unrelated
Actually totally unrelated – spur forms in the toe flexor tendons

100. Useful Sources http://www.gentili.net/fxintroduction.htm

101. References http://www.wheelessonline.com http://www.uptodate.com
Puffer, James C. 20 Common Problems in Sports Medicine. 2002
See also previous slide

102. THE END!!!