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Musculoskeletal Radiology


Description:

The section of musculoskeletal radiology encompasses all radiographic imaging services and interventional procedures related to musculoskeletal radiology. These include: interpretation of plain radiographs, computed tomography and MRI studies of the bones and joints. Also included are procedures such as arthrography, therapeutic joint injections including facet joint and appendicular skeleton joint injections, soft tissue and bone biopsy. This section provides urgent consultations to orthopaedics, rheumatology, emergency medicine and others. Our residents are encouraged to attend Thursday morning Orthopaedic Grand Rounds and once a month, Radiology-Rheumatology Conference.

General Goals:

  • Identify normal anatomy of the bones and joints.
  • Describe the most common indications for plain radiograph, CT and MRI for different bones and joints.
  • Identify the modality of choice for the best and least expensive evaluation of a disease process in an anatomical site.
  • Discuss alternative imaging modalities.
  • Review the radiological and technical steps in setting a protocol for doing tomograms, CT and MRI studies.
  • Discuss the indications and procedural steps for performing arthrograms and other procedures in this section.
  • Develop a viewing pattern and dictating style that answers the clinical questions and presents relevant findings.
  • Discuss common pathologic entities and provide a diagnosis or a differential diagnosis for one or a combination of radiologic findings.

Specific Goals:

  • Discuss radiological reporting of skeletal trauma.  Report the proper description of fractures, position and alignments.
  • Evaluate signs of osteomyelitis and septic joint, spondylodiscitis, tuberculosis, sarcoid and Paget’s disease.
  • Review the differential diagnoses for chondrocalcinosis, bone infarcts, epiphyseal, metaphyseal and diaphyseal lesions of bone.
  • Recognize different bone matrices such as osteoid, fibrous and chondroid matrices.
  • Discuss the differential diagnosis of common osteolytic and osteosclerotic lesions of bone and understand the origin of metastasis from other organ systems to bone.
  • Evaluate differential diagnosis of expansile bone lesions, permeative lesions, punched-out lytic lesions, endocortical erosion, etc.
  • Discuss the differential diagnosis of periosteal new bone formation and differentiate aggressive from benign reactions.
  • Discuss the target joints for different arthritides.
  • Evaluate common bone dysplasias.
  • Understand and recognize common metabolic bone disorders.

Guidelines:

The following are guidelines which radiology residents should follow to ensure a comprehensive educational experience in this section.

The key to a successful rotation is awareness, being prepared and knowing what to expect.

How to Preview:

  1. Start reviewing cases at 7:30 a.m.
  2. Knowing the patient is important. Getting information from requisition, looking at patient’s computerized medical record and prior radiological studies, or calling the physician or the nurse for information and history.
  3. Making certain prior radiology examinations have been loaded into current status on the PACS system.
  4. Making certain the CT or MRI related to an arthrogram is transmitted and loaded onto the PACS system.
  5. Load the bone or PET scan (if available) of patients being evaluated for skeletal metastasis.
  6. If a case is incomplete for any reason, such as missing images or requisitions, call and inform the film library. (Do not try to interpret an incomplete exam).
  7. Read about the cases from books and journals.  Know the disease process and the mechanism.

How to Review:

  1. When a resident is reviewing the cases with attending, he/she is assumed to know the cases and the findings.
  2. Residents are encouraged to analyze the findings and ask questions.
  3. Be prepared to show your knowledge about the disease process. Quote a book or an article you have read about the subject.
  4. Register the interesting cases in the Bone Book.
  5. Show those interesting cases in Rheumatology Conference with review of recent literature.
  6. Review and be prepared to discuss one recent article every day (preferably Radiology, AJR, Skeletal Radiology).

Dictation:

  1. Start with history, then X-ray findings and, at the end, conclusion. Be descriptive and to the point. Answer those pertinent clinical questions. Do not describe too many negative findings unless they are pertinent to the clinical concern.
  2. Sign out your reports on the RIS (Radiology Information System) twice every day (early morning and late afternoon).

Procedures:

  1. Read about the procedure on the night before the procedure is scheduled, and be mentally prepared.
  2. Arthrograms are scheduled in the afternoon, usually at 1, 2, and 3 p.m.
  3. In obtaining the consent form from the patient, get allergy history (especially to contrast agents and Xylocaine). Inform the patient about the risks of bleeding, infection and allergic reactions. Describe the details of the procedure to the patient to be prepared.
  4. Get the follow-up on the patient after surgery or during the clinical course.

Suggested Readings:

  • Arthritis – Black and White.  By Ann Brower
  • Summarized Version of Resnick’s Book (one volume)
  • Keats Book of Normal Variants
  • Meschan Book of Normal Radiological Anatomy
  • Pitt MJ, Speer DP. Radiologic reporting of skeletal trauma. Radiologic Clinics of North America, Vol. 28(2), March 1990
  • Bone Radiology, Felix Chew
  • Orthopaedic Radiology – A Practical Approach. Author: Adam Greenspan