Medical imagery for the field therapist Charlen Berry, January 2013, EATA Conference, Buffalo 1 Medical Imagery for the Field Therapist ●●● T ti C diti Traumatic Conditions Charlen Berry B.Sc., CAT(C), DO(Qc) Certified Athletic Therapist / Osteopath EATA Buffalo 2013 EATA Buffalo 2013 2 Why do we need to know ? Why do we need to know ? Pertinent information about the patient, past Pertinent information about the patient, past and present history and present history Safety (2 aspects) Safety (2 aspects) Better understand the tests, the views, the Better understand the tests, the views, the healing processes and prescription guidelines healing processes and prescription guidelines Which tests are most appropriate? Which tests are most appropriate? Post Post-concussion symptoms concussion symptoms Communication and collaboration Communication and collaboration EATA Buffalo 2013 EATA Buffalo 2013 3 What do we need to know ? What do we need to know ? 80% of imaging in MSK conditions are 80% of imaging in MSK conditions are basic radiographs, basic radiographs, Basic reading of X Basic reading of X-Rays Rays Implications of different fractures Implications of different fractures Basic knowledge on available tests Basic knowledge on available tests Knowledge of prescription guidelines Knowledge of prescription guidelines EATA Buffalo 2013 EATA Buffalo 2013 4 How do we get the knowledge How do we get the knowledge Presentations Presentations Books & articles Books & articles Internet Internet Specific courses Specific courses References at the end of the presentation References at the end of the presentation EATA Buffalo 2013 EATA Buffalo 2013 5 EATA Buffalo 2013 EATA Buffalo 2013 6
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Medical imagery for the field therapist
Charlen Berry, January 2013, EATA Conference, Buffalo 1
Why do we need to know ?Why do we need to know ?Pertinent information about the patient, past Pertinent information about the patient, past and present historyand present historySafety (2 aspects)Safety (2 aspects)Better understand the tests, the views, the Better understand the tests, the views, the e e u de s a d e es s, e e s, ee e u de s a d e es s, e e s, ehealing processes and prescription guidelineshealing processes and prescription guidelinesWhich tests are most appropriate? Which tests are most appropriate? PostPost--concussion symptomsconcussion symptomsCommunication and collaborationCommunication and collaboration
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What do we need to know ?What do we need to know ?
80% of imaging in MSK conditions are 80% of imaging in MSK conditions are basic radiographs, basic radiographs,
Basic reading of XBasic reading of X--RaysRays
Implications of different fracturesImplications of different fractures
Basic knowledge on available testsBasic knowledge on available tests
Knowledge of prescription guidelinesKnowledge of prescription guidelines
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How do we get the knowledgeHow do we get the knowledge
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Why ?Why ?
To have pertinent information in To have pertinent information in the patient file at the beginning the patient file at the beginning
of the seasonof the season
Read the reportsRead the reportsSee the images (radiology)See the images (radiology)
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Patient’s file: Patient’s file: Read the reports / See the imagesRead the reports / See the images
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HISTORY OF THE PASTHISTORY OF THE PAST
Imagery was done Imagery was done W 5 RW 5 RWhy?What for?
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When?Where?Who?
RESULTS ?
HISTORY OF THE PRESENTHISTORY OF THE PRESENTFoot or ankle ?Foot or ankle ?Standard views?Standard views?–– What are they?What are they?–– Ankle: AP, LAT, Ankle: AP, LAT, –– Knee: AP, LAT,Knee: AP, LAT,
Specialised views?Specialised views?–– Oblique views of the fibula?Oblique views of the fibula?–– Plantar flexionPlantar flexion–– DorsiflexionDorsiflexion
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WHAT IS MEDICAL WHAT IS MEDICAL IMAGINGIMAGING
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RADIOLOGYRADIOLOGYBranch of medicine Branch of medicine concerned with concerned with radioactive substances radioactive substances including Xincluding X--Rays, Rays, radioactive isotopes radioactive isotopes
d th li ti fd th li ti f
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and the application of and the application of this information to the this information to the prevention, diagnosis prevention, diagnosis and treatment of and treatment of disease.disease.
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RADIODENSITYRADIODENSITYcomposite composite shadowgramsshadowgrams representing the sum of the densitiesrepresenting the sum of the densities
SquireLFSquireLF, , NovellineNovelline RA,RA,
Physical qualities of an object Physical qualities of an object that determine how much that determine how much radiation it absorbs from the Xradiation it absorbs from the X--Ray beam.Ray beam.
Determined by its composition Determined by its composition (anatomical weight) and (anatomical weight) and thicknessthickness
BONE:BONE: White (the most White (the most radiodenseradiodense substance of substance of the body, teeth are whiter because to their the body, teeth are whiter because to their calcium content)calcium content)
CONTRAST MEDIA:CONTRAST MEDIA: Bright white outlineBright white outline
LAT CERVICALLAT CERVICALAlignment, 3 linesAlignment, 3 lines
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BONE DENSITYBONE DENSITY
Normality: Normality: Sufficient contrast between the Sufficient contrast between the skeleton and soft tissues and between skeleton and soft tissues and between cortex andcortex and medullarymedullary centercentercortex and cortex and medullarymedullary center center
XX--Ray merged with computer Ray merged with computer technologytechnologyProvides geography of body structuresProvides geography of body structuresProvides geography of body structures Provides geography of body structures with much greater sensitivity than plain with much greater sensitivity than plain filmsfilmsXX--Ray beam and detector system is Ray beam and detector system is housed in a circular scanner (arc of housed in a circular scanner (arc of 360360º)º)
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BONE SCAN BONE SCAN Diagnostic use of radioactive Diagnostic use of radioactive isotopesisotopes
Nuclear imaging of the skeletal Nuclear imaging of the skeletal systemsystem
Radiopharmaceuticals that are Radiopharmaceuticals that are tissuetissue--specific to bone are injected specific to bone are injected intravenouslyintravenouslyintravenouslyintravenously
Patient placed under a scintillation Patient placed under a scintillation camera detecting radioactivitycamera detecting radioactivity
Recording of the image is on an XRecording of the image is on an X--Ray filmRay film
Highly sensitive but nonHighly sensitive but non--specificspecific
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MAGNETIC RESONANCE IMAGING MAGNETIC RESONANCE IMAGING MRIMRI
Does not involve ionizing radiationDoes not involve ionizing radiation
Images are produced via the interaction of Images are produced via the interaction of tissue with tissue with radiofrequenciesradiofrequencies in a in a magnetic fieldmagnetic field
RadiowavesRadiowaves are pulsed to the patient, inducing are pulsed to the patient, inducing resonance among nuclei. Different tissues resonance among nuclei. Different tissues resonate at different frequencies.resonate at different frequencies.
When When radiowavesradiowaves are turned off, nuclei relax are turned off, nuclei relax and release the resonant energy, receivers and release the resonant energy, receivers transmit the energy released to a computer.transmit the energy released to a computer.
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WHICH TEST IS THE MOST WHICH TEST IS THE MOST APPROPRIATEAPPROPRIATE
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INDICATIONS FOR INDICATIONS FOR CONVENTIONAL RADIOGRAPHYCONVENTIONAL RADIOGRAPHY
FracturesFracturesPeriostitisPeriostitisArthropathyArthropathyOsteochondritisOsteochondritis dissecansdissecansPostPost--traumatic or congenital bony traumatic or congenital bony deformationdeformationMuscular and Muscular and tendinoustendinous calcification calcification
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INDICATIONS FOR COMPUTERISEDINDICATIONS FOR COMPUTERISEDAXIAL TOMOGRAPHY (CAT Scan)AXIAL TOMOGRAPHY (CAT Scan)
Bone and soft tissue Bone and soft tissue tumorstumorsSubtle or complex fracturesSubtle or complex fracturesIntraIntra--articulararticular abnormalitiesabnormalitiesDetection of small bone fragmentsDetection of small bone fragmentsggQuantitative bone mineral analysis Quantitative bone mineral analysis –– (osteoporosis and metabolic bone disorders(osteoporosis and metabolic bone disorders
Disadvantage: A tumour will not be detected in Disadvantage: A tumour will not be detected in presence of same density tissuepresence of same density tissue
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CAT SCANCAT SCAN
ALSO USED TO ASSESS:ALSO USED TO ASSESS:–– Disk Disk herniationsherniations–– Spinal canal in the presence of a fractureSpinal canal in the presence of a fracture–– Spinal Spinal stenosisstenosis–– SpondylosisSpondylosis
Used for guidance in biopsies and Used for guidance in biopsies and injectionsinjections
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INDICATIONS FOR MRIINDICATIONS FOR MRIMusculoskeletal systemMusculoskeletal systemSoft tissue trauma and Soft tissue trauma and tumorstumorsOstéonecrosisOstéonecrosisSpinal cord oedemaSpinal cord oedemaDisksDisks
CONTRAINDICATED FOR:CONTRAINDICATED FOR:–– Ferrous metal or mechanical devices implantedFerrous metal or mechanical devices implanted–– ClaustrophobiaClaustrophobia–– ObesityObesity–– Severe painSevere pain
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INDICATIONS FOR BONE SCANINDICATIONS FOR BONE SCANIndicates an abnormal process between Indicates an abnormal process between production and production and resorptionresorption of boneof boneCan reveal an early bone loss of 7% in Can reveal an early bone loss of 7% in comparison to the conventional Xcomparison to the conventional X--Ray (25Ray (25--30%) 30%) UsefullUsefull to detect:to detect:–– Stress #, Compound # , Stress #, Compound # , ScaphoidScaphoid ##–– PeriostitisPeriostitis–– Primary and metastatic Primary and metastatic tumorstumors–– Various Various arthridesarthrides–– InfectionsInfections–– AvascularAvascular necrosisnecrosis–– Metabolic bone diseaseMetabolic bone disease–– Any unexplained bone painAny unexplained bone pain
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80% of imaging in MSK 80% of imaging in MSK conditions are basic conditions are basic
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RADIATIONRADIATIONAnnual exposure: 3 Annual exposure: 3 mSvmSv((mSievertmSievert) / year ) / year Radon, Radon, airplane, ground, food, construction materials, cosmic airplane, ground, food, construction materials, cosmic rays, altitude, cities+rays, altitude, cities+
1 / 1000 individual 1 / 1000 individual will develop a cancer with an will develop a cancer with an exposition ofexposition of 10mSv10mSv (low risk)(low risk)exposition of exposition of 10mSv10mSv (low risk)(low risk)
420 / 1000420 / 1000 other causes of cancer other causes of cancer
Risk ↑ in children and ↓ in elderlyRisk ↑ in children and ↓ in elderly
CAT SCAN +++CAT SCAN +++
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Medical Imaging App. dosage Comparison with environmental(background)
Level of irradiation
MRI & US 0 - 0
Bone density testsDEXA 0.001 mSv Less than 1 day ☼
X-Rays, extremities 0.001 mSv Less than 1 day ☼
X-Rays, vertebral 1.5 mSv 6 months ☼☼
X-Rays, Pelvis 0.1-1 mSv 10 days to 6 months ☼☼
CT, vertebral 6 mSv 2 years ☼☼☼
Bone Scan 1-10 mSv 2 years ☼☼☼
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Adapté de http://radiologyinfo.org et ACR Appropriateness Criteria. Radiation Dose Assessment Introduction
Understand the viewsUnderstand the views
Anatomical position Anatomical position Standard most common: AP / LAT / OBLStandard most common: AP / LAT / OBLSpecific projectionsSpecific projectionsRoutines provide maximum visualization Routines provide maximum visualization with minimal number of radiographwith minimal number of radiograph
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AnkleAnkle APAP
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Ankle LATAnkle LAT
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Ankle MortiseAnkle Mortise
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Weber (Danis-Weber) classification of ankle fractures, based on the location of the fibular fracture. The higher the fibular fracture, the greater the likelihood for ankle mortise insufficiency
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The AP and lateral views do not reveal any obvious fractures.
Subtle widening of the medial aspect of the distal fibular growth plate (physis) on the mortise view.
Comparative views
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Comparative views and/or stress views would confirm that this is a fracture versus a normal growth plate closure.
Stress fractures are not Stress fractures are not insignificantinsignificant
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Why imagery ?Why imagery ?
To understand prescription To understand prescription guidelines followed by physicians guidelines followed by physicians
and used for decision making.and used for decision making...
Nexus rulesNexus rulesOttawa rulesOttawa rules
Canadian CCanadian C--Spine rulesSpine rules
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PRESCRIPTION PRINCIPLESPRESCRIPTION PRINCIPLES
ALARAALARA–– A as A as –– L lowL low–– A asA asA asA as–– R reasonablyR reasonably–– A achievableA achievable
EQUATION benefits / RISKEQUATION benefits / RISK
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Line of conductLine of conductNon rigidNon rigidSignificant acute traumaSignificant acute traumaSignificant pain / nauseaSignificant pain / nauseaPositive Positive osteophonyosteophony test (+/test (+/--))os eos e os eop o yos eop o y es ( /es ( / ))Deformation Deformation Significant oedemaSignificant oedema
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Pain on specific bony palpation / Pain on specific bony palpation / CrepitusCrepitusPositive tests: Vibration, stress (Positive tests: Vibration, stress (varusvarus, , valgusvalgus, , axial compression tests, ultrasound)axial compression tests, ultrasound)
LINE OF CONDUCTLINE OF CONDUCTPertinent history / Heard a crack Pertinent history / Heard a crack Reliability of history Reliability of history Non traumatic bony condition of systemic Non traumatic bony condition of systemic origin (Ex. cancer, osteoporosis …)origin (Ex. cancer, osteoporosis …)origin (Ex. cancer, osteoporosis …)origin (Ex. cancer, osteoporosis …)Atypical joint biomechanics Atypical joint biomechanics Atypical local palpationAtypical local palpationValidated rules concerning acute trauma:Validated rules concerning acute trauma:–– Ottawa rules for the ankle and knee Ottawa rules for the ankle and knee
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OTTAWA RULESOTTAWA RULES
Rules established in 1996Rules established in 1996To reduce of the number of XTo reduce of the number of X--rays rays prescribed by emergency room physiciansprescribed by emergency room physiciansp y g y p yp y g y p yHave been established for the foot, the Have been established for the foot, the ankle and the kneeankle and the kneeHave been validated by many studies Have been validated by many studies worldwideworldwide
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OTTAWAOTTAWA KNEE RULESRULESCharacteristics of Patients Who Should Characteristics of Patients Who Should Undergo radiography After Knee TraumaUndergo radiography After Knee Trauma
Age 55 years or olderAge 55 years or olderTenderness at head of fibulaTenderness at head of fibulaIsolated tenderness of patellaIsolated tenderness of patellaInability to flex knee to 90 degreesInability to flex knee to 90 degreesInability to walk four weightInability to walk four weight--bearing steps bearing steps immediately after the injury and in the immediately after the injury and in the emergency departmentemergency department
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OTTAWA OTTAWA ANKLEANKLE RULESRULESCriteria for ankle radiographs Criteria for ankle radiographs
Bone tenderness at posterior edge of Bone tenderness at posterior edge of distal 6cm or tip of medial or lateral distal 6cm or tip of medial or lateral malleolusmalleolus
Unable Unable both both to weight bear immediately to weight bear immediately after injury and walk four steps in ER after injury and walk four steps in ER departmentdepartment
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OTTAWA OTTAWA FOOTFOOT RULESRULESCriteria for ankle radiographsCriteria for ankle radiographs
Bone tenderness at base of 5th metatarsalBone tenderness at base of 5th metatarsal
Bone tenderness overBone tenderness over navicularnavicularBone tenderness over Bone tenderness over navicularnavicular
Unable Unable both both to weight bear immediately to weight bear immediately after injury and walk four steps in ER after injury and walk four steps in ER departmentdepartment
For alert and stable For alert and stable trauma patients trauma patients where cervical spine where cervical spine injury is a concerninjury is a concerninjury is a concerninjury is a concern
GCS = 15 GCS = 15
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Predictable rules CCRPredictable rules CCR
XX--Rays are indicated if at least one high Rays are indicated if at least one high risk criteria is present:risk criteria is present:
Age > 65Age > 65Dangerous mechanismDangerous mechanismParesthesiaParesthesia to extremitiesto extremities
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High risk mechanismsHigh risk mechanisms
Fall from elevation > 3 feet (90cm) / 5 stepsFall from elevation > 3 feet (90cm) / 5 steps
Axial load to the head (diving, football, hockey)Axial load to the head (diving, football, hockey)
MVA high speed (> 100Km/h)MVA high speed (> 100Km/h)
MVA + rollover or ejectionMVA + rollover or ejection
Pedestrian struck by bicycle or collision with Pedestrian struck by bicycle or collision with bicyclebicycle
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CC--Spine mobilitySpine mobilityXX--Rays are indicated if the patient is Rays are indicated if the patient is unable to actively rotate neck to 45unable to actively rotate neck to 45°° to to right and left.right and left.
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Why ? Why ?
T b tt d t dT b tt d t dTo better understand To better understand the healing processthe healing process
REFERENCESREFERENCESAn Atlas of An Atlas of radiographyradiography for sports injuries, for sports injuries, JockJock AndersonAndersonBoneBone and joint and joint imagingimaging, , ResnickResnickFundamentals of Fundamentals of orthopedicorthopedic radiologyradiology, , Lynn N. Lynn N. McKinnisMcKinnisAtlas d’anatomie radiologique et d’imagerie du corps humainAtlas d’anatomie radiologique et d’imagerie du corps humain–– WeirWeir--AbrahamsAbrahams
Accident and emergency radiologyAccident and emergency radiology --A survival guideA survival guide–– RabyRaby--BermanBerman--G de G de LaceyLacey
Merrill’s atlas of radiographic positions and radiologic proceduresMerrill’s atlas of radiographic positions and radiologic procedurese s a as o ad og ap c pos o s a d ad o og c p ocedu ese s a as o ad og ap c pos o s a d ad o og c p ocedu es(tomes I(tomes I--IIII--III)III)–– BallingerBallinger
Acute Knee Injuries: Use of Decision Rules for Selective Radiograph Acute Knee Injuries: Use of Decision Rules for Selective Radiograph OrderingOrdering–– HOWARD B. TANDETER, M.D., and PESACH SHVARTZMAN, HOWARD B. TANDETER, M.D., and PESACH SHVARTZMAN,
M.D. M.D. BenBen--Gurion University of the Negev, BeerGurion University of the Negev, Beer--ShevaSheva, Israel , MAX , Israel , MAX A. STEVENS, M.D. A. STEVENS, M.D. University of Iowa Hospitals and Clinics, Iowa City, Iowa University of Iowa Hospitals and Clinics, Iowa City, Iowa
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REFERENCESREFERENCEShttp://www.acr.org/ http://www.acr.org/ Site internet de l’American Site internet de l’American CollegeCollege of of RadiologyRadiology pour les pour les critères de choix radiologique (pratique factuelle pour les ‘’critères de choix radiologique (pratique factuelle pour les ‘’AppropriatenessAppropriatenessCriteriasCriterias’’ ’’ http://www.rad.washington.edu/academics/academichttp://www.rad.washington.edu/academics/academic--sections/msk/teachingsections/msk/teaching--materials/onlinematerials/online--musculoskeletalmusculoskeletal--radiologyradiology--book/orthopedicbook/orthopedic--hardwarehardware. . http://www.infohttp://www.info--radiologie.chradiologie.ch. . http://www.radpod.orghttp://www.radpod.org. . http://www radpod orghttp://www radpod orghttp://www.radpod.orghttp://www.radpod.org. . http://www.xray2000.co.ukhttp://www.xray2000.co.uk. . http://www.aafp.org/afp/991201ap/2599.html http://www.aafp.org/afp/991201ap/2599.html -- December 1999 December 1999