Nuclear Medicine in the Evaluation of Trauma Helena Balon, MD Helena Balon, MD Wm. Beaumont Hospital Wm. Beaumont Hospital Royal Oak, MI, USA Royal Oak, MI, USA Charles University Charles University 3rd 3rd School School of of Medicine Medicine Dept Dept Nucl Nucl Med, Med, Prague Prague Materials Materials for for medical medical students students
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Nuclear Medicine in the Evaluation
of Trauma
Helena Balon, MDHelena Balon, MD
Wm. Beaumont HospitalWm. Beaumont Hospital
Royal Oak, MI, USARoyal Oak, MI, USA
Charles UniversityCharles University
3rd 3rd SchoolSchoolofof MedicineMedicine
DeptDeptNuclNucl Med, Med, PraguePrague
MaterialsMaterials for for medicalmedical studentsstudents
Radionuclide methods in traumatology
�� Musculoskeletal trauma Musculoskeletal trauma �� Bone scanBone scan
�� Trauma to internal organs (Trauma to internal organs (hematomahematoma, laceration, , laceration, fracture, perforation, leaks)fracture, perforation, leaks)
�� Tracer localization (chemisorption onto surface Tracer localization (chemisorption onto surface of bone of bone trabeculaetrabeculae) depends on: ) depends on:
�� blood flowblood flow
�� capillary permeabilitycapillary permeability
�� bone metabolism (activity of osteoblasts, bone metabolism (activity of osteoblasts, osteoclastsosteoclasts, new bone formation), new bone formation)
Bone scan
�� Patient preparationPatient preparation�� PrePre--test: nonetest: none�� PostPost--injection: good oral hydration injection: good oral hydration �� Frequent voidingFrequent voiding�� Perchlorate p.o. Perchlorate p.o. preinjpreinj. to decrease rad. . to decrease rad.
dose to thyroiddose to thyroid
�� MethodsMethods�� Regular Regular -- imaging @ 2imaging @ 2--4 hrs post injection4 hrs post injection
�� 33--phase (dynamic angiogram + blood pool + phase (dynamic angiogram + blood pool + delay)delay)
�� Planar or SPECTPlanar or SPECT
�� Whole body ANT & POST, additional views Whole body ANT & POST, additional views (lat.,oblique)(lat.,oblique)
�� Parallel hole or pinhole collimator (for small Parallel hole or pinhole collimator (for small structures)structures)
�� Plain X ray, X ray tomography Plain X ray, X ray tomography -- if neg if neg >>>>>>�� Bone scanBone scan
�� if neg if neg >>>>>> stop workstop work--upup�� if diagnostic if diagnostic >>>>>> treattreat�� if more information needed if more information needed >>>>>>
�� X ray may be initially negative (2X ray may be initially negative (2--4 wks)4 wks)
�� Bone scan, MRI Bone scan, MRI –– positive earlier positive earlier
�� Bone scan Bone scan 33--phase positivityphase positivity
�� FlowFlow + for ~ 1 mo+ for ~ 1 mo
�� Blood poolBlood pool + for ~ 2 mo+ for ~ 2 mo
�� DelayDelay + for ~ 9+ for ~ 9--12 mo12 mo
�� Rx Rx -- restrict sports for 4restrict sports for 4--6 wks6 wks
Stress fx ?
Stress fractures
Metatarsal stress fracture
Metatarsal stress fracture
Metatarsal stress fx
Plantar fasciitis
�� Heel painHeel pain�� PostPost--traumatic inflammation of plantar traumatic inflammation of plantar
ligament due to ligament due to �� athletic overuse athletic overuse �� prolonged standingprolonged standing�� walking on hard surfacewalking on hard surface
�� Bone scanBone scanFocal blood pool + delayed uptake Focal blood pool + delayed uptake in inferior posterior calcaneusin inferior posterior calcaneus
�� Pathophysiology: bone ischemiaPathophysiology: bone ischemia�� DiagnosisDiagnosis
�� MRI most sensitiveMRI most sensitive�� bone scan useful bone scan useful
AVN
�� Common locationsCommon locations�� Femoral head (LeggFemoral head (Legg--Perthes in children)Perthes in children)�� Carpal (scaphoid, lunate), tarsal (talus) Carpal (scaphoid, lunate), tarsal (talus) �� Long bones, ribs in SSLong bones, ribs in SS
�� Bone scanBone scan�� Initially Initially ““ coldcold””�� Revascularization starts in 1Revascularization starts in 1--3 wks, from 3 wks, from
periphery, diffusely periphery, diffusely ““ hothot”” , lasts for months, lasts for months
IT Fx + AVN
50 M w fall a few weeks ago50 M w fall a few weeks ago
MRIMRI
IT fx + AVN
Sacrococcygeal Fx
ANTANT POST POST
Sacral insufficiency fx
ANT POSTANT POST
79 F fell 1 mo ago(“Honda” sign)
Pelvic fractures
4 days 4 days post fallpost fall
1 month 1 month laterlater
Spine traumaSpine trauma
Spondylolysis
�� Stress fx of posterior vertebral elements Stress fx of posterior vertebral elements (pars interarticularis) due to(pars interarticularis) due torepetitive traumarepetitive trauma