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The Patient Pathway > Muskuloskelatal > Flashcards

Muskuloskelatal Flashcards

1
Q

What is CT used for in MSK imaging?
(what does it look at)

A

Bones - particularly complex fractures

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2
Q

What is MRI used for in MSK imaging? (what does it look at)

A

Joints, particularly soft tissue structures

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3
Q

What is ultrasound used for in MSK imaging? (what does it look at)

A

dynamic studies of joints, fluid-filled structures, superficial structures and some trauma cases

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4
Q

what causes long waiting times in imaging of MSk using ultrasound?

A

Shortage of skilled operators

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5
Q

What is Radionuclide imaging used for in MSK imaging? (what does it look at)
What kind of info does it provide?

A

Fracture/neoplasm detection
especially occult

sensitive but not specific

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6
Q

What is DEXA used for in MSK imaging? (what does it look at)

A

Bone density

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7
Q

What is athrography used for in MSK imaging? (what does it look at)

A

Assessment of joints

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8
Q

Advantages of CT in imaging MSK?

A

widely available
Quick! – easy and safe in trauma/emergency situations
Multi Planar Reconstructions and 3D recon invaluable in complex fractures – full assessment/ongoing pathway planning
The spinal canal is well visualised and bone fragments impinging on the spinal cord can be seen
Accurate localisation of bone tumours; biopsy guidance
Sensitive for cortical destruction and soft tissues (good resolution)
Staging – distant metastases

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9
Q

Disadvantages of CT?

A

High dose of ionising radiation

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10
Q

Advantages of MRI in MSK imaging?

A

Both sensitive and specific in the diagnosis of:

occult fractures
carpus (carpal bones)

superior soft tissue definition:
injuries to joints/soft tissues,
- ligament laxity/tears, meniscal tears, cartilage and bone injuries

bone bruising (early sign of trauma),
avascular necrosis (later)

definition of tumour extent within marrow and into soft tissues
Excellent assessment of spinal cord and surrounding soft tissues
Very sensitive in the arthritides (Arthritis umbrella term)

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11
Q

Disadvantages of MRI imaging in MSK?

A

Time-consuming
not always readily available
Must consider magnet safety (patients with ferrous foreign objects, Pacemakers etc.)
patient acceptability (claustrophobia)
Limited sensitivity in diagnosis of fractures at the time of the injury (high false positive rate)

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12
Q

What MSK joint is MR arthrography the gold standard in imaging and why?

A

MR arthrography is gold standard procedure for the diagnosis of internal shoulder joint derangements

MR arthrography is gold standard procedure for diagnosis of internal shoulder joint derangements
Excellent tool to assess the joint capsule in shoulders
Excellent for looking at inside the shoulder joint to assess for injury/wear and tear
Can diagnose tendon tears, ligament detachments and cartilage damage

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13
Q

What contrast is injected for a MR arthrography?

A

iodinated and Gadolinium contrasts

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14
Q

What modalities would be used instead of MR Arthrography for the procedure for diagnosis of internal shoulder joint derangements?

A

Fluoroscopy, CT and US

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15
Q

What are the disadvantages of MR Arthrography for the procedure for diagnosis of internal shoulder joint derangements?

A

Slightly invasive technique as contrast injected directly into joint
Need to check for contrast allergies
Joint is painful afterwards plus possible complication of infection in the joint

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16
Q

Advantages of Ultrasound in MSK imaging?

A

Dynamic imaging
no radiation dose
Fast and relatively cheap
Useful to assess neurovascular structures, to demonstrate soft tissue structures, fluid-filled structures and superficial structures
Good ST assessment and readily available

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17
Q

What is Ultrasound used for in MSK imaging?

A

image-guided biopsy

Achilles tendon
rotator cuff
paediatric hips

Used widely in the knee joint:
Patellar tendonitis/apexitis – “jumper’s knee”
Medial meniscus tears
Quadriceps insertion tendinopathy with tendinosis, and calcifications
Joint effusion/cysts

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18
Q

Disadvantages of Ultrasound in the imaging of MSK?

A

can be challenging/not viable for acute injuries if transducer pressure cannot be tolerated

operator dependent

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19
Q

Advantages of Radionuclide imaging in MSK imaging?

A

High sensitivity for bony pathology and trauma
identifies cellular function
Can be combined PET/SPECT

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20
Q

What is Radionuclide imaging used for in MSK imaging?

A

Used in screening for metastatic bone disease
isolating 1° bone tumours
confirming occult fractures
identifying areas of bone infection/osteomyelitis
investigating metabolic bone disease, e.g. Paget’s

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21
Q

Limitation of radionuclide imaging in MSK imaging?

A

Limitation is lack of specificity in disease characterisation, e.g. # scaphoid v. OA CMC joint thumb

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22
Q

What does DEXA stand for?

A

dual energy X-ray absorptiometry or DXA/dual X-rayabsorptiometry

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23
Q

what is DEXA used for in MSK imaging?

A

Assesses bone density and also risk of osteoporosis

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24
Q

What are the indications for a DEXA scan?

A

A fracture after a minor fall or injury

A woman who has hadan early menopause or ovaries removed at a young age (before 45) and hasn’t had HRT

A post-menopausal woman who smokes or drinks heavily, has a family history of hip fractures or a BMI of less than 21

A man or a woman with a condition that leads to low bone density, such as RA

A woman who has large gaps between periods (> a year)

A man or a woman taking oral glucocorticoids for > 3 months (glucocorticoidsare used to help treat inflammation,but can also cause weakened bones)

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25
Q

What is arthrography used for in MSK imaging?

A

Examine the inside of a joint
- shoulder
- knee
- wrist
- ankle
To assess an injury or symptom

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26
Q

How is arthrography undertaken?

A

Contrast medium is injected into the joint capsule which outlines the soft tissue structures (e.g. ligaments and cartilage)

Done under image guidance, usually fluoroscopy
- Fluoroscopy is used to guide the placement of the needle for administration of the contrast medium

May also be done using CT, US or MRI

MR arthrography is widely believed to be the most sensitive non-invasive examination for the evaluation of the joint capsule in shoulders

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27
Q
A
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28
Q

Potential pathways for trauma MSK injury?

A

Depends on severity of presenting symptoms, and location of imaging department, e.g.:

MVA – patient will be referred via A&E

Minor injury to e.g. finger – likely A&E, but patient may also be referred via GP (and may be some time after initial trauma)

If you work in a GP-led community site/MIU – initial presentation here, with transfer to more specialist centre as required?

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29
Q

what other ways other than imaging can a differential diagnosis be reached?

A

Assessment tool? e.g. ATLS, Ottowa….
Mechanism of injury (‘MOI’) – speed, force, twisting/direct blow, everyday activity?……
Presenting symptoms, including pain and functional ability
Patient perspectives
Social/family history, e.g. does the patient live alone?
PMH
Current medication
Specialist intervention e.g. orthopaedics

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30
Q

when would conventional imaging be used in Trauma MSK?

A

In department,
mobile (e.g. in resus.);
in theatre (II for e.g. ORIF, etc.)

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31
Q

when would ultrasound be used in Trauma MSK?

A

Soft tissue/neurovascular structures
Joints
FAST (Focussed Assessment with Sonography for Trauma) – pelvic trauma

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32
Q

when would CT be used in Trauma MSK?

A

Complex fractures; assessment prior to intervention

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33
Q

when would MRI be used in Trauma MSK?

A

Joints, particularly soft tissue structures; unlikely in acute case if patient unstable

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34
Q

when would Radionuclide imaging be used in Trauma MSK?

A

Occult fractures; not in acute patients

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35
Q

when would DEXA be used in Trauma MSK?

A

Bone density assessment after e.g. #NOF

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36
Q

What tumour are children most likely to get?

A

Ewing’s sarcoma; osteosarcoma

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37
Q

What tumour are 30-50s most likely to get?

A

chondrosarcoma

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38
Q

What tumour are >50s most likely to get?

A

myeloma

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39
Q

What tumour are >70s most likely to get?

A

mets more common than 1°

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40
Q
A
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41
Q

Potential pathways for tumour patients?

A

Likely via GP, in first instance

May be A&E if pathological # (trauma) is the presentation

May be via specialist, if referred there first from GP

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42
Q

what is the differential diagnosis pathway for Tumours?
(without imaging)

A

Patient presentation
PMH
Physical examination
Specialist referral
Imaging
Biopsy
Staging (malignancy) – looking for local/distant spread

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43
Q

What is the imaging pathway for tumours?

A

Plain imaging – first line
MRI – bony and soft tissue information; tumour extent
CT – bony detail
RNI bone scan – other lesions
US – soft tissues

Staging – CXR, CT, MRI, RNI bone scan

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44
Q

What are the different radiologic features that can be used to describe tumours?

A

Solitary or multiple?
Lytic or sclerotic?
What type of bone, e.g. long bone, vertebra, etc.?
Where in the bone is the lesion, e.g. cortex, medulla, shaft, etc.?
Well-defined margin?
Cortical destruction?
Bony reaction?
Central calcification?
Soft-tissue involvement?

45
Q

what is a solitary bone cyst also known as?

A

simple bone cyst or unicameral bone cyst

46
Q

what MSK structures are solitary bone cysts most likely to be found?

A

Proximal humerus
femur
iliac bone
calcaneum
in >20 year

47
Q
A
48
Q

What are the symptoms of the Solitary bone cyst?

A

Asymptomatic unless fractured, then pain and limited ROM
Benign

49
Q

Radiological signs for solitary bone cyst?

A

Solitary lytic metaphyseal lesion
Well-defined (possibly thin sclerotic) margin
narrow zone of transition
Can be slightly expansile
Endosteal scalloping/erosion
Often see ‘fallen fragment sign’ when fractured
Healing of the fracture will usually result in disappearance of the cyst

49
Q

What is osteochondroma also known as?

A

Bony exostisis

50
Q

What is Osteochondroma?

A

Most common benign bone tumour

Overgrowth of cartilage at margin of physis (grow away from it);

ossification then produces a bony protruberance with a cartilage cap

Stops growing at skeletal maturity

Often incidental finding, but can produce a mass

<1% can undergo malignant change => chondrosarcoma

May be multiple – ‘hereditary multiple exostoses’

51
Q

What MSK structures is Osteochondroma often found?

A

distal femur, proximal tibia, iliac crest

52
Q

Osteochondroma prevelance?

A

<age 20;
M:F = 3:1

53
Q

Symptoms of Osteochondroma?

A

Usually asymptomatic and vary in size (largest ~4cm)

54
Q

what is multiple myeloma?

A

Most common 1° malignant bone tumour in adults

Cancer of plasma (white blood) cells

55
Q

What imaging is the most effective at imaging Osteochondroma, and why?

A

Visible on plain imaging/CT,
cartilage cap on US,

MRI is the best imaging modality to assess cartilage thickness (and thus assessing for malignant transformation), the presence of oedema in bone or adjacent soft tissues, and visualising neurovascular structures in the vicinity

56
Q

What is the prevalence of multiple myeloma?

A

40 years +; M:F = 2:1

57
Q

What MSK structures will multiple myeloma most likely be found?

A

Multiple sites – vertebra, ribs, skull, shoulder, pelvis, long bones

58
Q

what are the symptoms for multiple myeloma?

A

Present with bone pain and associated fatigue +/- weight loss, anaemia

59
Q

What is the imaging and treatment pathway for multiple myeloma?

A

Skeletal survey first; MRI and PET are also useful
Chemotherapy; palliative radiotherapy for painful lesions or lesions likely to develop pathological #

60
Q

what is osteosarcoma?

A

Arises in medullary canal and grows out and through the periosteum into surrounding ST’s
Esp. long bone metaphyses, but will cross the physis before plate closure in >75% cases

61
Q

What is the prevalence of osteosarcoma?

A

Most common primary malignant bone tumour in older children (rare <5), adolescents and young adults
May also be seen in adults as a result of previous Radiotherapy or Paget’s disease

62
Q

what are the symptoms of osteosarcoma?

A

Clinical presentation is pain – constant, worse at night and gradually increasing in severity
Palpable lump may be present (later), +/- pain on examination

63
Q

What are the radiological signs of osteosarcoma?

A

Radiologically –
large bone lesion >5-6cm when detected;
mixed density;
ill-defined margins;
bone destruction and cortical disruption;
often associated aggressive periosteal reaction

64
Q

What imaging is used for osteosarcoma?

A

CT/MRI to assess tumour extent; RNI bone scan for further lesions; CXR/CT chest for mets

65
Q

How common is Ewing Sarcoma?

A

2nd most common malignant bone tumour in children (after osteosarcoma)

Mets may be present in ~30% of cases at time of initial diagnosis!

66
Q

Prevalence of Ewing Sarcoma?

A

Accounts for ~1/3 of all 1° bone tumours
M>F; age range 5-30 years, esp. 5-15, rare >30

67
Q

where does Ewing Sarcoma occur?

A

long bones
pelvis
Arise in medullary cavity of long bones

68
Q

symptoms of Ewing Sarcoma?

A

Localised pain + swelling
fever
weight loss
anaemia
Ill-defined
lytic
destructive lesion
associated soft-tissue mass/infiltration and periosteal reaction

69
Q

Imaging pathway for Ewing Sarcoma?

A

MRI for full evaluation, esp. ST involvement;
staging
RNI bone scan for mets
CT for bone destruction/extra-osseous involvement

70
Q

Where do bony metastases occur in the MSK?

A

More common than 1° bone tumours
Common in vertebrae, pelvis, proximal femur, proximal humerus
Common adult primary – lung, kidney,
prostate (male)
breast (female)

71
Q

What are clinical digns of bony metastases?

A

Clinical signs depends on the primary, but rest pain and night pain are ‘red flag’ symptoms
May also experience bony pain, systemic upset and pathological #
May present as sudden onset of pain in elderly

72
Q

Radiological appearance of bony mets

A

Radiological appearance depends on primary:

Lytic – kidney, lung, thyroid, breast

Sclerotic – prostate, breast, stomach

Bone destruction; wide zone of transition

May present as an incidental finding on staging

73
Q

What imaging modality is used for bony metastases?

A

RNI bone scan useful to define distribution

74
Q

What is a fibrous Cortical Defect/Non-ossifying Fibroma?
(what is it also known as)

A

Most common benign tumour of bone
Histologically identical, but FCD < 2cm, NOF > 2cm
BENIGN INCIDENTAL FINDING!!!
A “leave me alone” lesion

75
Q

Prevelance

A

Age 10 – 20 years

76
Q

radiographic appearances of fibrous Cortical Defect/Non-ossifying Fibroma?

A

Common femur and tibia
Diametaphyseal
Lucent lesion with well-defined sclerotic margin
May be loculated
Arises from cortex
Slightly expansile

77
Q

Arthritis potential pathways?

A

Most likely via GP

Often incidental finding on images for something else!

Can be specialist referral, e.g. Rheumatology Clinic

78
Q

Differential diagnosis of osteoarthritis (OA)?
What is it?

A

Degenerative joint disorder
Progressive loss of articular cartilage and new bone formation
Can be secondary to e.g. trauma to the joint

Commoner in weight bearing joints – hip, knee, spine (“spondylosis”); IP joints common in females

79
Q

The symptoms of OA?

A

Pain, esp. in the morning or after resting;
aggravated by exertion;
often referred from adjacent joint
Stiffness after inactivity but likely constant with disease progression
Soft tissue swelling

80
Q

Radiological appearance of OA?

A

Radiologically (WB if appropriate) – bone density preserved,
joint space narrowing,
subchondral sclerosis,
marginal osteophytes,
subarticular cysts

81
Q

What imaging modality is the most effective for OA?

A

MRI would be best for identification of cartilage loss, effusions and cysts

82
Q

What is Rheumatoid Arthritis

A

Chronic inflammatory disease affecting synovium and articular surface

Articular erosion and destruction results in joint deformity and disability

83
Q

What is the prevalence of RA?

A

1% population; M=F (F>M in earlier years)

84
Q

RA clinical indications?

A

Acutely involved joints are:
hot,
swollen
painful,
often with effusion/bursitis

Systemic symptoms include:
fever
malaise
weight loss
weakness

Late joint destruction and deformity

Other body systems can be affected too, e.g. chest – pulmonary interstitial fibrosis, aka “rheumatoid lung”

85
Q

RA radiological signs?
(late and early)

A

Early radiological signs –
Soft tissue swelling,
local osteopenia,
marginal and central bone erosions, joint space widening

Late radiological signs –
loss of joint space,
marked destructive changes, subluxations,
fragmentation,
fractures
ankylosis

86
Q

What is the most effective imaging for RA?

A

MRI and US are increasingly being used to demonstrate the presence of RA much earlier than conventional imaging

87
Q

What does MRI assess in regards to RA?

A

Assessment of peripheral joints for active inflammation in the form of joint effusions, synovitis, etc.

Assessment of structural lesions e.g. articular cartilage damage, cortical bone erosions and tendons tears

Assessment of inflammatory changes and post-inflammatory complications in the spine, i.e. assessment of inflammatory activity, atlanto-axial/ atlanto-occipital structural lesions (e.g. subluxations)

88
Q

Why is Ultrasound used for RA?
And what does it assess?

A

High availability,
low cost
high patient acceptance compared to MRI

Assessment of peripheral joints for active inflammation in the form of effusion, synovitis, etc.

Assessment of structural lesions such as tendons tears (cortical bone erosions and articular cartilage damage can be seen to some extent)

Dynamic examination of peripheral joints, useful in the assessment of inflammatory changes

Measurements of inflammation (intensity of vascularization, thickness of synovium)

89
Q

What is metabolic bone disease?

A

Disorders of bone strength, usually caused by abnormalities of minerals (e.g. calcium, phosphorus), vitamin D, bone mass or bone structure, but can also be due to e.g. prolonged steroid use

90
Q

Give examples of metabolic bone disease:

A

They include:
Osteoporosis
Paget’s disease

91
Q

What are the clinical indications of metabolic bone disease?

A

Patients suffer bone pain, and are more predisposed to fractures, including vertebral compression which leads to a loss in height

92
Q

What id the patient pathway and differential diagnosis for metabolic bone disease?

A

Often an incidental finding,- particularly in the case of the pathological #

May be via GP, for bone pain
Loss of height

(more difficult to pin down, as this is seen as part of the ageing process!)

(Need to consider ‘big’ picture, e.g. in the prolonged use of steroids scenario)

Blood tests and imaging for diagnosis

93
Q

What is osteoperosis?

A

Systemic skeletal disease characterised by low bone mass and deterioration of bone tissue
Increased bone fragility and susceptibility to fracture;

94
Q

What are clinical indications/how is it picked up?
osteoporosis

A

often diagnosed secondary to a fracture (esp. NOF, vertebrae, wrist)

Vertebral fractures often asymptomatic and discovered incidentally;

kyphosis and loss of height can result from vertebral compression fractures

Increased resorption compared to formation of bone

95
Q

Prevelance of osteoporosis?

A

Post menopausal women most affected

Prevalence increases with age
(Exclude eating disorders in young patient)

96
Q

Imaging of osteoporosis?

A

Bone density is difficult to interpret on plain images,

‘osteopaenia’ to describe reduced bone density

DEXA is investigation of choice for diagnosis

97
Q

What is pagets disease?

A

causes abnormal remodelling of bone – thickened, disorganised fragile trabeculae result

98
Q

Pagets disease prevelance?

A

Rare before age 40; M>F

99
Q

Clinical indications of pagets disease?

A

Often asymptomatic

Pain;
bowing long bones;
pathological #;
enlarging bone, esp. cranium; deafness,
due to ossicle involvement/cranial nerve compression;
secondary arthritis
Esp. pelvis, lumbar and thoracic vertebrae, proximal femur, skull and tibia

100
Q

Radiological appearances for pagets disease?

A

Radiologically:
“cotton wool bones”;
thickened cortices,
coarse trabeculae;
cyst-like areas during early lytic phase
Potential for sarcomatous change (poor prognosis)

101
Q

Acute osteomyelitis (infection) prevelance?

A

Majority in children;
adults secondary to immunocompromised, e.g. diabetes, drugs, disease

102
Q

How is Acute osteomyelitis (infection) spread and where is common sites in adults and children?

A

Spread via blood supply (haematogenous) or direct implantation from trauma

Metaphysis most common site in children

In adults:
spine or lower extremities in diabetics

103
Q

What is the pathological sequence for Acute osteomyelitis?

A

inflammation,
suppuration,
necrosis,
new bone formation,
resolution

104
Q

Patient presentation of acute osteomyelitis?

A

Feverish and general malaise
Severe pain
Later – local erythema, oedema, warmth
Beware adults with new onset back pain with associated systemic upset
Lymphadenopathy present but not specific
Infants may present as non-specific failure to thrive
Symptoms may also be mild in elderly and immuno-suppressed

105
Q

Imaging of acute osteomyelitis?
X-ray - when/what is it visible

Any other modalities??

A

Plain imaging is initially likely to be normal
Look for displacement of fat planes – due to soft tissue swelling or accumulation of fluid
Visible lucency ~5-7 days
Bony necrosis and periosteal reaction ~10-14 days

MRI useful in early stages – bone marrow changes

NM bone scans useful

106
Q

What is the periosteum lifting/pelling off called and what is it a sign of?

A

Kormans triangle

It is a sign of osteosarcoma - which is an aggressive tumour in the bone (sunburst)

107
Q

what is the main sign of an osteosarcoma on X-RAY?

A

sunburst effect
periosteal and lytic mixed-density tumour

The Patient Pathway (6 decks)

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