Northwestern University Musculoskeletal Radiology Fellowship
Musculoskeletal Radiology Orientation
Transcript of Musculoskeletal Radiology Orientation
Musculoskeletal Radiology
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.
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Location
▪ Main Campus▪ Basement of Women’sHospital
near the ED▪ 2 ReadingRooms
▪ Bone/ED▪ MSK/Procedures (Annex)
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MRI/Procedures RRAttending Work Station
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Musculoskeletal Radiology
Location
▪ Attendings also cover:▪ Burlington - Tuesdays▪ Hillsborough - Fridays
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Personnel
▪ Attendings – 3 full-time MSK fellowship-trained faculty
Nissman(Chief) Renner Schwartz
Musculoskeletal Radiology
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
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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.
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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.
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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
Musculoskeletal Radiology
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
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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
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MSK RadiographsRotation▪ Sample Search Patterns for each joint/study to follow…….stay tuned
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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.
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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.
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MSK RadiographsRotation▪ Shunt Integrity -Indication
▪ The technologist will call and ask you to review a study.
▪ 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.
Musculoskeletal Radiology
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MSK RadiographsRotation▪ Shunt Valve Reading - Indication
▪ The technologist will call and ask you to review a study.
▪ 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.
Musculoskeletal Radiology
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
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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.)
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MRI/Procedures▪ Sample MRI Search Patterns for each joint/study to follow…….stay tuned
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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
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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
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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.
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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
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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.
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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.
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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
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MRI/Procedures▪ Sample Fluoro/CT/US guided MSK tutorials to follow…….stay tuned
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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
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