Musculoskeletal Radiology Orientation

Musculoskeletal Radiology

OrientationUNC Department ofRadiology


Welcome to UNC MusculoskeletalRadiology!

▪ On this service, you will learn about the imaging of musculoskeletal disease from the basics of boneradiography to high-end MRI of the musculoskeletal system.

▪ This document will describe some of the logistics of the MSK service and our expectations of residentson the service.

UNC Department ofRadiology 2


Location

▪ Main Campus▪ Basement of Women’sHospital

near the ED▪ 2 ReadingRooms

▪ Bone/ED▪ MSK/Procedures (Annex)



Bone/ED RR (Call RR)Attending Work Station



MRI/Procedures RRAttending Work Station

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Location

▪ Attendings also cover:▪ Burlington - Tuesdays▪ Hillsborough - Fridays




Personnel

▪ Attendings – 3 full-time MSK fellowship-trained faculty

Nissman(Chief) Renner Schwartz


Personnel

▪ Fellows – The MSK fellows are here to get advanced training in MSK MRI and procedures

▪ 19-20 Academicyear▪ Miles Dunbar▪ Chris Shuman▪ Josh Wallace



Personnel

▪ Residents – First throughthird years, stationed in the Bone/ED reading room and MSK MRI/Procedures room

▪ Miniselective Resident –A fourth year resident

▪ Medical Students –regularlyrotate on our service and are welcome in both MSK RRs.



RotationsWe have 3 rotations:

1. MSK Radiographs in Bone/ED RR2. MSK MRI/Procedures in Annex RR3. MSK Outreach – 1Workstation in Annex RR and more in the Outreach office in the Old Clinic Bldg.

In general, residents with have 3 weeks onthe MSK Radiographs rotation with 1 weekon MRI/Procedures during the block.

Fellows and Mini-fellows primarilyread outreach studies.



Rotations▪ MSK Radiographs

▪ In Bone/ED RR▪ This rotation focuses on all

MSK radiographs and all trauma CT cervical spines

▪ Staff▪ M-W:

▪ AM Attending 8a-1p (all studies, 1p-2p (statsonly)

▪ PM Attending 2p-7p▪ Th-F:

▪ Attending all day▪ 1 MSKFellow▪ Residents

▪ Worklist▪ MSK PFCheckoutUNC Department ofRadiology 11


MSK Radiographs Rotation▪ This can be an extremely busy,

but rewarding service.▪ On the 1st rotation start slow.▪ Start with one joint and

proceed to others with comfort level (ie start with knees, then go to shoulders, hips, ankles, hands, feet, spine, etc.)

▪ On 2nd rotation review allstudies with a focus on ED studies (ie STATS and CT cervical spines to prepare for independent call. Work on speed/efficiency bc necessary for call



MSK RadiographsRotation▪ Start with reviewing normal anatomy for

each study▪ Then build a Search Pattern:

▪ Bones – Look for fractures, bone lesions,periosteal reaction, erosions, etc.

▪ Joints – Look for dislocation,narrowing, secondary signs of OA (ie osteophytes, subchondral sclerosis, geode formation (no epithelial lining),etc.

▪ Soft tissues – swelling, gas, foreign body, etc.

▪ Search Patterns will include other itemsspecific to each type of study



MSK RadiographsRotation▪ Sample Search Patterns for each joint/study to follow…….stay tuned



MSK Radiographs Rotation▪ Study Reviews

▪ The technologists havebeen instructed to call on the following studies:

▪ Osteomyelitis▪ Shunt Integrity▪ Shunt valve reading▪ Other (when they

have a question concern about order/images.



MSK RadiographsRotation▪ Osteomyelitis - Indication

▪ The technologist will call and ask you to review a study.

▪ Get study info to look up and ask:▪ Do they have any ulcers or is there a

specific region ofconcern?▪ Ensure you can clearly visualize that area

of concern in orthogonalviews▪ If you don’t have those views, ask for them

with suggestions (ie Can you get another lateral view and lift the big toe a little more to see the second toe?)

▪ Look for periosteal reaction,erosions, osteopenia, ulcers, soft tissue gas, etc.




MSK RadiographsRotation▪ Shunt Integrity -Indication


▪ Get study info and look up study.▪ Ensure you can clearly visualize theentire shunt in orthogonal views

▪ If you don’t have those views, ask forthem with suggestions (ie can you get another lateral view to include more of the anterior abdomen so I can see that part of the shunt?)

▪ Look for breaks, disconnections,distal catheter migration,etc.

Wallace AN, McConathy J, Menias CO, Bhalla S, Wippold II FJ. Imaging Evaluation of CSF Shunts. AJR 2014; 202:38–53.


UNCDepartment of Radiology 18

MSK RadiographsRotation▪ Shunt Valve Reading - Indication


▪ Get study info to look up and ask:▪ Do you know what kind of shunt they have? (You

may have to look it up in Epic)▪ For Shunt valve readings you need a perfect AP

view of the shunt.▪ Then, once you figure out what type of shunt it

is, look up the reference paper: Programmable CSF Shunt Valves: Radiographic Identification and Interpretation by Lollis et al. and give a reading (on rads.web.unc.edu)

▪ Do not give a valve reading if you are uncertainand ask an attending first for assistance.

Lollis SS, Mamourian AC, Vaccaro TJ, Duhaime AC. Programmable CSF Shunt Valves: Radiographic Identification and Interpretation. Am J Neuroradiol 31:1343– 46.


Rotations▪ MRI/Procedures

▪ This rotation focusesonall MSK cross-sectional studies (CT/MRI/US) and all MSK procedures (Fluoro/CT/US guidance)

▪ Staff▪ Attending (8a –5p)▪ 1 MSKFellow▪ MF/Residents

▪ Worklist▪ MSK Cross-Sectional New



MRI/Procedures▪ Start with MRI of the knee,

shoulder, hip and ankle and osteomyelitis studies

▪ Begin with anatomy review inone plane and progress to the other planes.

▪ Build a search pattern for eachjoint.

▪ Proceed to other studies (iewrist, elbow, etc.)



MRI/Procedures▪ Sample MRI Search Patterns for each joint/study to follow…….stay tuned



MRI/Procedures▪ Protocols

▪ In general, most MSK MRI studies will be routine.

▪ Contrast is helpful forinfection/inflammation and to characterize lesions.

▪ Follow UNCcontrastguidelines.

▪ CT – state FOV in protocol



MRI/ProceduresProtocol Points to consider:▪ Ensure all contrast studies include pre and

post contrast images in the same plane.▪ Optimize the FOV to as small as possible▪ i.e. If only a certain finger/toe is of concern,

make that theFOV▪ An entire foot should be protocolled only if

needed – Usediscretion▪ Generally Hindfoot or Forefoot FOV will

suffice▪ Ankle (Hindfoot) FOV = Ankle to proximalMetatarsals▪ Forefoot FOV = Metarsals to toes

▪ Have technologists place markers on lesions or regions ofinterest

▪ When in doubt, ask a fellow or attending



MRI/Procedures▪ Fluoro

▪ We perform anestheticand arthrogram injections under fluoroscopy of any joint, large or small.

▪ On the 1st rotation, try to become comfortable performing shoulder and hip injections.

▪ The techniques for these joints can be applied to other joints.



MRI/Procedures▪ Fluoro

▪ In general, fluoroguidedinjections do not need Attending approval, but most aspirations do (ie –hip aspirations)

▪ When in doubt, ask afellow or attending



MRI/Procedures▪ US/CT guidance

▪ All of these studies must approved by an attending.

▪ The clinician willcall andrequest a procedure.

▪ This is the MSK fellows responsibility. Residents may take consults, but please keep MSKfellows informed of case and decision.

▪ If you take the consult,please fill out the procedure request form.



MRI/Procedures▪ Consult Example

▪ Get ordering MD and contact info▪ Review all pertinent imaging▪ Evaluate how a procedure will

affect clinical management▪ Does the benefit outweigh risk?▪ Determine safest routeof

procedure▪ Present case toattending▪ Contact clinician with decision▪ If approved, have themcall biopsy

scheduling to schedule.



MRI/Procedures▪ General things to ask the

clinician if a procedure isapproved:

▪ Do you have a preferredroute for biopsy?

▪ Recent labs? (ie plt and INR)▪ Is the pt on any

anticoagulants?▪ Is the pt consentable?▪ Do we need an interpreter?

▪ CT guided bone marrowaspirations do not needAttending approval



MRI/Procedures▪ Sample Fluoro/CT/US guided MSK tutorials to follow…….stay tuned



Rotations▪ Outreach

▪ This rotation focusesonall MSK studies (XR/ CT/ MRI/ US)primarily from EmergeOrtho and other UNC facilities andcommunity hospitals

▪ Staff▪ Attending (8a-5p)▪ 1 MSKFellow▪ Mini-Fellow as needed


Thank You!

Please let us know if you have suggestions onhow we can improve your MSKtraining!

Musculoskeletal Radiology Orientation

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