RAD 5320: Musculoskeletal and Emergency Radiology (VMS II/III)

Students will spend two weeks in the musculoskeletal/emergency radiology reading room with the course director.   The MSK/ER reading room is a bustling place where MSK-subspecialty trained radiology faculty, MSK fellows, and radiology residents interpret musculoskeletal studies and selected studies performed in the Emergency Department, as well as provide consultation services to a variety of physicians (emergency, trauma team, general surgery, orthopedic surgery, infectious diseases, internal medicine, rheumatology, etc.).  Students will be exposed to a broad spectrum of musculoskeletal pathology including trauma, athletic injuries, arthritis, infection, neoplastic conditions, expected post-operative changes, and post-operative complications.  Imaging modalities will include conventional radiographs, Magnetic Resonance Imaging, Computed Tomography and, possibly, ultrasonography.  Students will have the opportunity to observe interventional procedures such as fluoroscopically guided arthrography and CT/US-guided biopsies.  In addition to daily teaching at the PACS workstations using live cases, there will be didactic lectures focusing on trauma, sports injuries, arthritis, infection, and the basics of musculoskeletal neoplasms.  The advantages and limitations of the various imaging modalities will be emphasized.  The didactic component of the elective will be further enhanced by daily noon radiology conferences.  The course will be of particular interest to students contemplating careers in radiology, orthopedic surgery, sports medicine, and emergency medicine; however, any student interested in learning more about the musculoskeletal system or radiology is encouraged to attend.

At the conclusion of this two‐week elective, students will be able to:

• Accurately describe fractures; recognize commonly used orthopedic hardware; recognize the appearance of healing fractures, incompletely-united fractures, and fracture non-union; recognize some of the common post-operative complications.
• Have an organized approach to diagnosing arthritis; be able to differentiate between degenerative and inflammatory arthritis.
• Recognize significant athletic injuries on MRI (for example, ACL tear, meniscal tear, rotator cuff tear)
• Have a basic understanding of the concept of aggressiveness of musculoskeletal lesions; recognize major conditions such as osteosarcoma and Ewing’s sarcoma; recognize benign lesions such as fibrous dysplasia and non-ossifying fibroma; recognize metastatic disease in the skeleton.
• Recognize the appearance of acute and chronic osteomyelitis on conventional radiography; have a differential diagnosis for this appearance; know the role of MRI in the diagnosis of osteomyelitis and septic arthritis; know the role of arthrocentesis (joint aspiration) in the work-up of septic arthritis.
• Have a basic understanding of the strengths, limitations, relative cost, and associated risks of the various imaging modalities.
• Have a basic understanding of the role of contrast media (iodinated and Gadolinium-based) in medical imaging; know the risks associated with contrast media use, patient risk factors, and prevention/treatment options available.

A. Trauma

Fractures
Fracture fixation
Expected post-operative appearance and post-operative complications following fracture repairs
Traumatic conditions of the head, spine, chest, abdomen and pelvis

B. Sports injuries

A wide variety of sport-related injuries (meniscal, labral, hyaline cartilage, ligamentous, tendon, muscular, osseous, etc.) will be demonstrated using live MRI cases.
The didactic focus will be on MRI of the knee and shoulder because these are the two most frequently imaged joints.  Other joints and anatomic regions will be demonstrated and discussed using live cases.

C. Arthritis

Types of arthritis
Organized approach in the radiographic diagnosis of arthritis          

           i.       Osteoarthritis

          ii.       Rheumatoid arthritis

          iii.      Seronegative spondyloarthropathies

          iv.      Gout

          v.       Pyrophosphate arthritis

          vi.      Septic arthritis

MRI features of arthritis

D. Infection

Osteomyelitis

          i.        Acute vs. chronic

          ii.       Radiographic appearance

          iii.      MRI features

Septic arthritis

          i.        Radiographic appearance

          ii.       Features on MRI

          iii.      The role of arthrocentesis

Septic spondylitis

Radiographic appearance
MRI features

E. Bone tumors and tumor-like conditions

Concept of aggressive vs. non-aggressive bone lesions
Organized approach in the radiographic evaluation of bone lesions
Role of conventional radiography and other modalities (MRI, CT, PET/CT, bone scintigraphy) in the initial diagnosis, staging, and post-treatment follow up of musculoskeletal neoplasms
Examples of bone tumors and tumor-like conditions which will be discussed

          i.          Osteosarcoma

          ii.         Ewing’s sarcoma

          iii.        Multiple myeloma

          iv.        Metastatic disease

                   - Lytic

                   - Blastic

          v.         Fibrous dysplasia

          vi.        Non-ossifying fibroma

          vii.       Unicameral bone cyst

          viii.      Paget’s disease

F. Other general topics

Role of the various imaging modalities: strengths, limitations, relative cost, associated risks
Ionizing radiation
Contrast media-related issues

Course lectures

 Trauma
 Sports injuries (MRI of the knee; MRI of the shoulder)
 Arthritis
 Infection
 Musculoskeletal tumors and tumor-like conditions

 

Live cases teaching at PACS station
Noon conferences

The books referenced below are available for free at http://www.mc.vanderbilt.edu/diglib/

 

Fractures: pp. 59-90 of Orthopedic Imaging: A Practical Approach
Arthritis: pp. 443-460 Orthopedic Imaging: A Practical Approach
Bone lesions: p 547 Orthopedic Imaging: A Practical Approach
or chapter 1 of Visual Guide to Musculoskeletal Tumors: A Clinical-Radiologic - Histologic Approach

Pre-test: Please take the exam before the start of the rotation.

Post-test: Please take the exam on the morning of the last day of the rotation.  We will go over the exam together during the afternoon of your last day on the service.

This is a collection of images that you should see during the course of the rotation.  Many of these you will see as we review hundreds of live cases at the PACS station throughout the course of the elective.  Others you will see in lecture or as teaching cases.  Check the list toward the end of the rotation and, if you still haven't seen an example of some of those conditions, look them up online or in a book.  These are truly "must-see" images.

 

Normal chest

Pneumonia

Pulmonary edema

Increased central vascular volume without edema

Emphysema

Lung cancer

Hilar lymphadenopathy/ mass

Pneumothorax

Pneumomediastinum

Pneumoperitoneum

 

Intracranial hemorrhage

Acute stroke

 

Aortic injury

Liver laceration

Splenic laceration

Pancreatic injury

Renal laceration

Mesenteric hematoma

Acute appendicitis

Diverticulitis

Small bowel obstruction

Ileus

Pneumatosis intestinalis

Portal venous gas

Pneumobilia

 

Fractures

    Simple

    Comminuted

    Intraarticular

Dislocations

    Shoulder

    Hip

    Elbow

LisFranc fracture-dislocation

 

Meniscal tear

Meniscal mucoid degeneration

ACL tear

Distal biceps tear

Cartilage injury

Stress fracture

Subchondral fracture

Osteonecrosis

 

Osteoarthritis

Rheumatoid arthritis

Gout

CPPD arthritis

Septic arthritis

 

Osteomyelitis

    Plain film

    MRI

Septic spondylitis

     Plain film

     MRI

 

Osteosarcoma

Ewing’s sarcoma

Fibrous dysplasia

NOF (non-ossifying fibroma)

Mets

Multiple myeloma

Paget’s disease