Week 2 Flashcards
What patients does the C-spine rules not apply to?
- Non-traumatic cases
- Unconscious patients
- Those with unstable vital signs
- Younger age
- Acute paralysis
- Known vertebral disease
- Previous C-spine surgery
- Pregnancy
What does the canadian C- spine rules do and not do?
- Does not diagnose fracture
* Indicates the need for a radiograph
What radiograph views does the canadian C-spine rules indicate the need for?
- Anteroposterior
- Lateral
- Oblique
- Open mouth*
- Flexion/extension view*
What is the sensitivity of the canadian C-spine rules?
0.99
What are the indications for when closed cervical fractures are missed?
- Younger
- Single (marital status)
- Shorter duration of symptoms
- Non-full time work status
- Involved emergency room visit
- No history of physical therapy
If someone has two or less factors on the indications for a missed closed cervical fractures, what is the likelihood ratio of not having a fracture?
0.0, very sure that there isnt
If someone has 3 or more factors on the indications for a missed closed cervical fractures, what is the likelihood ratio of not having a fracture?
LR: 32. Very sure that is
According to the Ottawa ankle rules, what are the findings at the ankle that indicate the need of a radiograph?
Pain in the malleolar zone and any of these findings:
- Bone tenderness at the posterior edge or tip of the lateral or medial malleolus or
- Inability to bear weight both immediately and in the ED
According to the Ottawa ankle rules, what are the findings at the foot that indicate the need of a radiograph?
Pain in the midfoot zone and any of these findings:
- Bone tenderness at the base of the 5th metatarsal or navicular or
- Inability to bear weight both immediately and in the ED
According to the ottawa knee rules, an x-ray is indicated if the patient has what features?
- Age > 55 or under 5
- Inability to bear weight both immediately and in the ED for more than 4 steps
- Isolated tenderness of the patella
- Tenderness at the head of the fibula
- Inability to flex to 90 degs
For radiographs of the lumbar spine, laboratory test, radiographs and advanced imaging are not recommended except in what situation?
- Age > 50
- History of cancer
- Unexplained weight loss
- Progressive neurological deficit
- Severe radicular pain
- Suspicion of fracture
- Suspicion of infection
For a person with a first time shoulder dislocation, we use the quebec decision rule for shoulder dislocation, and are at high risk of what types of lesions?
- Bankart Lesion
- Hills-Sachs lesion
- Neurovascular Injury
- Humeral fracture
Where there is a suspicion of suspected thoracic-lumbar compression fracture, what are the indications for a radiograph?
- Age >52
- No presence of leg symptoms
- Body mass index <22
- Does not exercise regularly
- Female gender
What is the sensitivity for when there are 2 factors or less for a suspected thoracic-lumbar compression fracture?
0.95
What is the specificity for when there are 4 factors or more for a suspected thoracic-lumbar compression fracture?
0.96
What is the sensitivity and specificity of the elbow extension sign in adults?
Sensitivity 0.98
Specificity 0.48
What is the sensitivity and specificity of the elbow extension sign in children?
Sensitivity 0.95
Specificity 0.50
What is the sensitivity and specificity of the elbow extension sign combined in adults and children?
Sensitivity 0.96
Specificity 0.55
Given poor accuracy and potential risk for malunion
or avascular necrosis, what should be done with all lateral wrist pain and why?
All lateral wrist pain should possibly be immobilized for
6 weeks regardless of radiographic findings. Because scaphoid fractures do not generally visualize well on radiographs and is one of the top 3 wrist fractures
What are the indications for a radiograph of lateral wrist pain?
• Male gender • Sport activity • Snuff box pain on ulnar deviation • Scaphoid tubercle tenderness *No patient had fracture who did not have snuff box pain within 72 hours
What is the PT’s role in imaging?
• Know your scope of practice – and follow for changes!
• Know when imaging is and is not needed
• Integrate findings into PT plan of care
• Understand image and report to gather PT relevant information
• Know which modality to utilize
- What is the type of tissue hypothesized to be at fault?
- NOTE: Essentially all imaging should be plain films first.
• Communicate imaging information with radiologist, physician and patient
What is the rating scale used for the ottawa ankle rules used to determine the need for a radiograph?
- 1-3: Usually not appropriate
- 4-6: May be appropriate
- 7-9: Usually appropriate
For a patient older than 5 and with an acute ankle injury with more than a week of persistent pain, what is the radiologic procedure?
- MRI ankle without IV contrast
- Xray ankle
- CT ankle without IV contrast
- US ankle
- CT ankle with IV contrast
- Ct ankle without and with IV contrast
- MRI ankle without and with IV contrast
When we have an ankle injury with chronic persistent pain and a suspected osteochondral injury, what is the order in which radiographs should be ordered?
- MRI ankle without contrast
- CT arthrography ankle
- MRI arthrography ankle
- CT ankle without contrast
What are the considerations when deciding whether or not to order an image?
- Clinical hypothesis
- Am I the one who should be ordering?
- Will results change my management?
- Costs & availability for appropriate study
- Contraindications & radiation
What are the information needed to order radiology?
- Age, MOI, clinical signs/sxs, results of other tests (i.e. neurovascular, special tests, or other imaging)
- Modality requested
- R or L side specified
- Your contact # in case results are urgent
When reading the results of an imaging order, what should be read?
Read full results…not just the “impression”
What are the key points to keep in mind when sharing the results of an image?
• Call them with results
• Discuss in clinic
• Provide within relevance to your physical examination
• Make sure all communication is patient-centered language
- May not always happen from other providers, so you may have to “translate”
What are the things to document after receiving the results of an image?
- Document results
* Document what you shared / questions answered
What are the types of imaging results that will be considered STAT intervention and will require immediate active transport to the ER?
Vascular findings (DVT, Aneurisms, Pseudo-aneurysms, Dissections), Fractures, Critical region stress fractures
What are the types of imaging results that will be considered ASAP intervention and will require contacting a primary physicians /specialist?
Neoplasms, complete contractile ruptures, posterolateral corner injuries. High ankle sprains, Lisfranc sprains
On average, how many visits to the DA PT does a patient have before being referred for a MRI?
3 visits
In terms of the interpretation of the imaging what are the things that a clinician needs to know?
• Knowledge of imaging technology
- Including limitations
• Knowledge of dimensional anatomy
• Knowledge of patterns of pathology
What are the most common errors made when interpreting a radiograph?
- Observation: incomplete and faulty search patterns
* Interpretation: failure of linking signs to relevant clinical data
What does the ABC’s of radiographic evaluation stand for?
- Alignment
- Bone density
- Cartilage spaces
- Soft tissues
What does the A-alignment in the ABC’s of radiographic evaluation mean?
General skeletal architecture • Gross normal sizes of bones • Normal number of bones General contour of bones • Smooth and continuous cortical outlines Alignment of bones to adjacent bones • Normal joint articulations • Normal spatial relationships
What does the Bone density in the ABC’s of radiographic evaluation mean?
General Bone Density • Contrast soft tissue and bone shade of gray • Contrast within each bone - Cortical shell - Cancellous center • Textural Abnormalities - Normal trabecular architecture • Local Bone Density Changes • Sclerosis at areas of increased stress or ligament/tendon/muscle attachment
What does the Cartilage spaces in the ABC’s of radiographic evaluation mean?
• Joint Space Width - Well preserved joint space - Comparison to normal • Subchondral Bone - Smooth surface • Epiphyseal plates - Normal size relative to epiphysis and skeletal age
What does the Soft tissues in the ABC’s of radiographic evaluation mean?
• Muscles: normal size of soft tissue image
• Fat pads and fat lines
- Radiolucent crescent parallel to bone
- Radiolucent lines parallel to length of muscle
• Joint Capsules, which is normally indistinct
• Periosteum which is normally indistinct with a solid periosteal
• Miscellaneous soft tissue findings such as normally exhibit a water-density shade of grey
What are the findings to look at as it relates to the periosteum?
- Smooth changes, which can be indicative of slow growing tumors
- Laminated or onion skin changes which may present with repetitive injury or potentially repeated trauma
- Speculated or sunburst which is often indicative of malignant bone lesions
- Caudman’s triangle, which can be associated with tumor, bony hemorrhage, or repeated battering
What are fracture classifications required for?
The communication of specific diagnostic imaging findings from professionals to another and also for the identification of occult fractures
What are the components of the classic anatomic description of fractures?
- Type
- Comminution
- Location
- Displacement
What are the anatomic descriptions of the type of a fracture?
- Oblique
- Comminuted
- Spiral (Torsion)
- Compound
- Greenstick
- Transverse
- Simple
What does the oblique type of fracture mean?
Diagonal across bone
What does the comminuted type of fracture mean?
Splintered or crushed bones
What does the spiral (torsion) type of fracture mean?
Break wraps around bone
What does the compound type of fracture mean?
A fracture that goes through/ breaks the skin
What does the greenstick type of fracture mean?
Incomplete fracture often seen in pediatrics
What does the transverse type of fracture mean?
A complete break across the bone without a diagonal oblique orientation
What does the simple type of fracture mean?
A partial fracture without skin wound
What does the anatomic description- communition mean?
Measure of the number of pieces of broken bone
• Non-comminuted
• Mild
• Severe
What does the anatomic description- location refer to?
Anatomic approximation • Distal • Proximal • Proximal 1/3rd • Tibial plateau • Inter-articular distal tibia
What does the anatomic description- displacement refer to?
Amount of movement from normal location • Displaced or non-displaced • Translation • Angulation: described to apex or direction of distal fragment • Shortening: expressed in centimeters
What is the Salter-Harris Classification of fractures used for?
Pediatric growth plate (physis) fractures
What does a type 1 on the salter- harris classification mean?
Type I- fracture across physis without metaphysical or epiphyseal injury
What does a type 2 on the salter- harris classification mean?
Type II- extends into metaphysis
What does a type 3 on the salter- harris classification mean?
Type III- extends into epiphysis
What does a type 4 on the salter- harris classification mean?
Type IV- through metaphysis and epiphysis
What does a type 5 on the salter- harris classification mean?
Type V- crush injury
What is the Gustillo Classification used for?
Open fractures, where the skin has been disrupted, whether you can directly visualize bone or not
What does the grade 1 used to quantify tissue damage using the gustillo classification mean?
<1 cm, of soft tissue damage and it is clean
What does the grade 2 used to quantify tissue damage using the gustillo classification mean?
> 1 cm, contaminated wound bed, mod comminution
What does the grade 3A used to quantify tissue damage using the gustillo classification mean?
> 10 cm with crushed tissue and contamination
• Soft tissue coverage is possible, meaning the borders of the wound can be brought together
What does the grade 3B used to quantify tissue damage using the gustillo classification mean?
> 10 cm with crushed tissue and contamination
• No local soft tissue coverage, regional or free flap
What does the grade 3C used to quantify tissue damage using the gustillo classification mean?
Major vascular injury requiring repair
• May indicate amputation
What does the neer proximal humerus fracture classification mean?
Speaks to the relationship of the anatomic neck, surgical neck, greater tuberosity, and lesser tuberosity of the proximal humerus. And to the displacement which can either be angulation of more than 45 degs or > 1cm from anatomic position
What does the “one part” on the neer classification mean?
No displacement
What does the “two part” on the neer classification mean?
One displacement
What does the “three part” on the neer classification mean?
Two displacements but humeral
head in contact with glenoid
What does the “four part” on the neer classification mean?
Three or more displacements and dislocation of articular surface
____ is the most comprehensive and studied fracture classification that includes all anatomic variations
Muller AO Classification is the most comprehensive and studied fracture classification that includes all anatomic variations
What does the 1st, 2nd, and letter in the muller AO classification stand for?
1st= long bone 2nd= bone segment Letter= fracture type
