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Radiology Handbook

Musculoskeletal Imaging


Musculoskeletal Imaging Quick Links The Skeleton (Peripheral Joint) Hand or Foot Long Bones Cervical Spine Cervical Spine - Flexion & Extension Views Thoracic Spine Lumbosacral Spine Acromioclavicular Joint Joint Arthrogram Percutaneous Biopsy

 

THE SKELETON
(Peripheral Joint - Ankle, Knee, Wrist, Elbow, Finger, Toe, Shoulder & Hip)

 

Description:

At least 2 views should be obtained in all cases. At least one additional view is typically obtained in patients with suspected fracture (particularly about a joint). When dealing with digits, we usually obtain 2 oblique views.

Indications:

  1. Trauma: The exact area of the patient’s symptoms should be given on the consultation form. The knowledge of the specific area of suspected abnormalities decreases the miss rate in subtle injuries by up to 50% and should be included on every request form.

  2. Arthritis: Two views are usually sufficient. For hand and foot - frontal and oblique are usually best.

  3. Unexplained pain: Once again this is a very low yield study for unexplained pain – site must be mentioned.

  4. Further evaluation of an abnormal bone scan: In most cases, the x-rays are obtained before one would order a bone scan. The exception would be in patients with suspected metastatic disease – site abnormal on scan.

  5. Suspected infection, not for acute infection.

  6. Suspected tumor, or metastases. This is uncommon peripherally and indication should be strong.

Low Yield Indications:

  1. Trauma but with negative physical findings.

  2. Many joints in polyarthritis; one or two joints may suffice. In the absence of specific clinical findings in patients with trauma, an x-ray is not necessary as it is almost always not helpful and adds to the patient cost without contributing to care.

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HAND OR FOOT

 

Description:

AP and/or PA (hand) and oblique views of the involved part are exposed for arthritis or pain. For trauma, three views often required – four in the digits.

Indications:

  1. Arthritis: Films of the hands are most useful in evaluating any type of polyarthritis with monoarticular problem examined symptomatic area.

  2. Trauma: Specific area MUST be indicated, should be point of tenderness, local swelling or with foot, inability to bear weight. For multi-trauma, limited views are taken. May be sufficient for answering an emergent clinical question, but represents an incomplete examination. If indicated, complete examination should be performed when patient is able to tolerate.

  3. Pain: Indicate SPECIFIC area.

  4. Soft tissue infection or suspected bone infection – specific site – particularly if ulcer present.

Low Yield Indications:

Suspected hypertrophic osteoarthropathy. Knee and hand probably two most common areas involved. Joints ordered should be symptomatic. Often distal femur shows involvement best.

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LONG BONES (HUMERUS, RADIUS AND ULNA, FEMUR, TIBIA AND FIBULA)

 

Description:

An AP and lateral film of the involved area are exposed. This usually involves a joint either proximal or distal to the involved long bone.

Indications:

  1. Trauma-suspected fracture, local pain or swelling should be present.

  2. Suspected osteomyelitis - not early.

  3. Hypertrophic pulmonary osteoarthropathy (see above).

  4. Pain - site (specific).

  5. Suspected metastatic or primary tumor.

  6. Further evaluation of abnormal bone scan - site indicated.

  7. Evaluation of deformity.

Low Yield Indication:

Extensive long bone survey in suspected or known metastatic disease in the asymptomatic patient. The bone scan is a better means of evaluation.

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CERVICAL SPINE

 

Description:

For acute trauma, a cross-table lateral, AP open-mouth view and AP view are usually ordered. In patients with a high index of suspicion for cervical spine facture or particularly those who are to have a head CT or abdominal CT, it is cost effective to perform a spiral CT of the cervical spine after the cross-table lateral view.

In patients with a demonstrated fracture or neurologic systems, a high resolution CT scan or MRI including the vertebrae above and that below are often necessary. In patients with neck pain, AP, lateral and oblique views are often necessary. On occasion, supplementary views may be added to visual all seven cervical vertebrae.

In patients with neck or arm pain, who did not present with acute trauma, oblique views should be obtained routinely.

Indications:

  1. Trauma

  2. Neck, shoulder, arm or hand pain.

  3. Atypical chest pain - low yield.

  4. Neurologic finding suggesting cervical cord or root involvement. These patients frequently require MRI or CT as an additional examination.

  5. Evaluation of abnormal bone scan, often low yield in cervical spine.

  6. Suspected infection or tumor.

Contraindications:

In the patient with acute, severe trauma, a portable cross table lateral film of the cervical spine should be exposed prior to any other films to be certain that the patient does not have an unstable dislocation. This however, is no substitute for a complete examination. The minimal routine for severe trauma should also include an AP, and AP open mouth view. This can be done on a stretcher or through a collar. The AP and open mouth views can follow CT.

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CERVICAL SPINE - FLEXION AND EXTENSION VIEWS

 

Description:

A lateral film is made in extreme flexion and extreme extension of the cervical spine. The patient should not be assisted in the movement of his neck. The exception to this if when a referring physician flexes and extends the neck. This is an unusual indication.

Indications:

Posterior neck pain without neurologic findings after routine films: This is often normal in patients with acute trauma. The patients are often unable to flex and extend because of spasm. If they can flex and extend, the flexion extension radiographs are usually not helpful. If patient is unable to flex and extend, the study is not worth ordering.

Flexion and extension films are most helpful in patients who have neck pain and no spasm. If radiculopathy is present, oblique views are much more helpful than flexion and extension radiographs.

Contraindications:

In trauma patients, flexion and extension films should not be performed until it is determined that the routine films are normal. The patient should be able to flex and extend his/her own neck. This is not commonly helpful in acute injuries, but can be helpful in questionable cases particularly those with continued pain 7-10 days post trauma.

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THORACIC SPINE

 

Description:

AP and lateral films are made in the supine position.

Indications:

  1. Trauma.

  2. Pain - very low yield.

  3. Suspected arthritis - rarely specific.

  4. Suspected metastatic tumor or myeloma.

  5. Osteoporosis with suspected compression fracture.

  6. Suspected infection.

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LUMBOSACRAL SPINE

 

Description:

AP, lateral and oblique films are made. Spot films of the lumbosacral junction are usually done. In acute trauma, AP and lateral views are sufficient.

Indications

  1. Trauma.

  2. Pain: In patients with acute low back pain without trauma, the yield is exceedingly low. If disc disease suspected, radiographs should follow 3-6 weeks of conservative treatment, particularly in younger patients.

  3. Suspected metastatic disease or myeloma.

  4. Suspected doc space infection.

  5. Focal neurologic deficit.

  6. Evaluation of abnormal bone scan (not typical degenerative changes on scan).

  7. Suspected arthritis.

Low Yield Indication:

  1. Chronic symptoms with prior films made within the last 6 months.

  2. Follow up of chronic process such as degenerative joint disease.

  3. Acute low back pain.

Preparation:

The patient should have not have had recent barium study; barium sulfate will obscure the spine.

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ACROMIOCLAVICULAR JOINT

 

Description:

An AP view of each acromioclavicular joint is made with and without weights. This is not a shoulder examination.

Indications:

Trauma to the acromioclavicular joint with suspected separation.

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JOINT ARTHROGRAM

 

Description:

An arthrogram of any joint can be performed.

Indications:

Variable for each joint. Consult with radiologist required.

Preparation:

None.

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PERCUTANEOUS BIOPSY

 

Description:

A small needle is passed into the suspected soft tissue or bony mass and the lesion is aspirated or a core biopsy is obtained.

Indications:

  1. Suspected malignancy.

  2. Culture of a suspected abscess.

Preparation:

Signed consent form required. Must be approved by staff radiologist or musculoskeletal fellow.

Complications:

Seeding of the needle track is a rare but potential complication.

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Last Updated:12/19/06 ALK