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Differential Diagnosis & Med Screening > ZENI-Dx Imaging Revisited in the Context of Diff Dx > Flashcards

ZENI-Dx Imaging Revisited in the Context of Diff Dx Flashcards

1
Q

Radiology Value for PTs

4:

A
  1. Screening for patho + dx standpoint
  2. Info for Eval+Treat
  3. Improved pt confidence in YOU!
  4. Essential for autonomous practice
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2
Q

Some common studies (imaging)

A
  • Radiographs→ X-rays
  • Contrast-Enhanced Radiographs
  • Computed Tomography (CT)
  • Nuclear Imaging
  • Magnetic Resonance Imaging (MRI)
  • Ultrasonography
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3
Q

RadioLUCENT means getting ______

A

DARKER

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4
Q

RadioOPAQUE means getting_________

A

LIGHTER

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5
Q

RadioLUCENT means DECd ______

A

Radiographic density

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6
Q

RadioOPAQUE means INCd _________

A

Radiographic density

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7
Q

For Radiographs….

DARK (radiolucent, DEC radiographic density) images→ LiGHT (radioopaque, INC radiographic density) images

A
  • AIR→ darkest
  • Metal→ lightest

NOTE: Air (darkest)→ Metal (lightest)= INC’ing obj radiodensity

NOTE: Metal (lightest)→ Air (darkest)= DEC’ing obj radiodensity

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8
Q

W/ radiographs……..

Need _________ one image

A

MORE THAN ONE! Multiple views

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9
Q

Routine Exam Scenarios

What are the outcomes after using imagining to inform your dx?

A
  1. Positive for suspected dx
  2. Negative for suspected dx
  3. Negative for dx, but diff prob ID’d
  4. Inconclusive→ further imaging reqd
    1. When?→ not giving you answers you need or no does not match sx’s
    2. Next?→ MRI, CT, etc..
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10
Q

Case Ex.→ Post-FOOSH

Pt fell and had shoulder injury. X-ray taken.

Name everything you see/what is it?

A

*Bone tumor

  • Bulge @ tumor site
  • Growth plate not fully closed→ child patient
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11
Q

Image Ex.

A
  • Trauma, young
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12
Q

What do you notice?

A

Bone spur @ calcaneus

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13
Q

What do you notice? Which is abnormal? Why?

A

Left looks good

Right bad→ Decd joint space

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14
Q

How does imaging inform the use of partial over TKA?

A
  • No global OA, Iso’d to single compartment, no huge bone spurs, sclerosis (thickening), abnorm alignment
  • *Buys this pt time to get back to rec, vocational activities before s/he progresses to ultimately needing TKA (often ultimate outcome)
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15
Q

What do you see?

A

L. clavicular fx

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16
Q

Why might this repair cause probs for patient?

A
  • Screws/plates→ VERY superf→ pain, visible
  • Concerns w/ brachial plexus probs if residual abnorm in shape of bone
  • Imaging used to sx decision making→ realignment necessary? How approximated are edge of bones in fx?
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17
Q

US utility in fx→ Only in ________ cases

A

SUPERFICIAL

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18
Q

US utility in Fx- only in superficial cases

A
  • Clavicle is so superficial, US imging can be helpful in ID’ing fx’s
  • Clear breach of clavicular cortex near is medial end+ associated adjacent soft tissue edema
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19
Q

Knee Skyline View

Takeaways?

A

Bone spurs→ abnormal “load”

In response to this new “load”: MORE bone→ bone spurs→ MORE bone (cortical thickening)

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20
Q

Post-op TKA w/ Lateral Knee Pain

A

Notice L. patella and spacing with the prosthesis

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21
Q

What do you see here ?

A

Loss of disc space

Sclerotic PLL → + excessive bone formation

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22
Q

The Scotty Dog

A

What makes the neck of the dog?→ Pars Interarticularis

Dog with a collar?→ Stress fx

Dog w/ a broken neck?→ Spondylolysis, *also look for displacement of the vertebra (possible SC/Cauda equina impingement)

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23
Q

What do you see?

A

R. femoral head AVN → flat (collapsing) R. femoral head

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24
Q

Whats this?

A

B/L THA

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25
Q

Whats this?

A

B/L THA

L. side→ HO (calcification)- had to use much larger prosthetic piece deeper into femur

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26
Q

What do you see?

A

Ask!!!!

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27
Q

X-Ray Viewing

Pros vs. Cons

A
  • PROS:
    • INexpensive
    • Relatively available
    • Fair→Good Sn in detecting Fx
  • CONS:
    • Radiation
    • Missed patho*
    • Dependent on skill lvl to get proper study
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28
Q

Non-Ionizing→Ionizing (Bad radiation)

A

see pics

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29
Q

Medical Procedure Doses: Radiation

HIGHEST→

LOWEST→

A

HIGHEST→ Nuclear Medicine

LOWEST→ X-rays

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30
Q

Other form of X-Ray Imagining

A

Contrast X-ray Studies

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31
Q

Other form of X-ray Imagining:

Contrast X-ray Studies

What is it + Types

A

Injection of radio-opaque liquid INTO area of interest

  1. Arthrogram→ Joint
  2. Myelogram→ Spinal Column
  3. Angio/Arteriogram→ Artery/Vessel
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32
Q

Like an X-ray, BUT 100’s of X-rays all around body

A

Computed Tomography (CT scan)

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33
Q

CT of Lungs Ex.

Soft tissue + Bony anatomy

A

see pics

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34
Q

3D Reconstruction CT Scan

Radial Head Fx

A

see pics

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35
Q

CT Scans

PROS vs. CONS

A
  • PROS:
    • Soft tissue + Tumors
    • 3D reconstruction*
      • visualization of subtle & complex fxs
    • Bone Mineral Density (BMD) test
      • DEXA→ MUCH LESS radiation
  • CONS:
    • Avg volume effect
      • discerning subtle diff’s in small tissue volumes
      • tumors of similar tissue density NOT visualized
    • Artifacts
      • patient mvmt, metal implants
    • Radiation exposure
36
Q

Nuclear Imagining aka

A

Bone Scan (Scintigraphy)

37
Q

Nuclear Imagining:

Bone Scan (Scintigraphy)

A
  • Injection of polyphosphate and radioactive isotope (tracer) binds to hydroxyapatite found in metabolically active bone.
    • Pinpoints molecular activity w/in body
    • Pot. to ID disease in earliest stages
    • Before things “look” bad (think MRI or Xray), there may be underlying changes in physiology
  • Detecting bone tumors and metastasis
  • Early detection of Stress Fx’s
38
Q

Three-phase Bone Scan measure __________, NOT ___________

A

Measure physiology, NOT anatomy

39
Q

Three Phase Bone Scan

3 phases?

A

A) Perfusion phase

B) Blood pool phase

C) Delayed pool***

40
Q

Three-Phase Bone Scan

All 3 phases

A
  • A) Perfusion phase
    • occurs in seconds
    • can look @ blood flow
  • B) Blood Pool phase
    • occurs 5-30mins
    • where does blood end up in soft tissue
    • aka soft-tissue phase
  • C) Delayed Pool
    • looks @ metabolic activity of bone
    • AKA bone phase or sequestration phase (looks @ bony uptake)
  • Cx, Stress fx
41
Q

Three-Phase Bone Scan

A) Perfusion Phase

A
  • A) Perfusion phase
    • occurs in seconds
    • can look @ blood flow
42
Q

Three-Phase Bone Scan

B) Blood Pool Phase

A
  • B) Blood Pool phase
    • occurs 5-30mins
    • where does blood end up in soft tissue
    • aka soft-tissue phase
43
Q

Three-Phase Bone Scan

C) Delayed Pool

A
  • C) Delayed Pool
    • looks @ metabolic activity of bone
    • AKA bone phase or sequestration phase (looks @ bony uptake)
44
Q

Bone Scans

PROS vs. CONS

A
  • PROS:
    • Image based on physiology
      • provides info not obtained from anatomical studies
    • Detects:
      • Stress fx’s, Metastatic bone CA, Bone dis’s and infx’s
  • CONS:
    • Lacks specificity for diff dx
    • NOT an end study→ req’s correlation
      • Not the end of the diff dx pathway!
    • Exposure to radiation
      • actually emitting radiation until it is discharged from body
45
Q

This is the Evolution of Bone Scans

(Like how CT is evolution of X-ray….this is evolution of Bone Scans)

A

Single-Photon Emission Computed Tomography (SPECT)

Incs _Sensitivity_ and _Specificity_ compared to Bone scan

46
Q

See Case Description

A

See Imaging

*B. CT on top, SPECT bottom

47
Q

SPECT for MSK Conditions (PARS Dysf.)

Bone Scan on LEFT

SPECT on RIGHT

*NOTE: INCd ability to ID lesion w/ SPECT

A

see pics

48
Q

Scintigraphic findings in a patient w/ R. L5 pars stress fx on SPECT (A)

NOT see on planar bone scintigraphy (B)

A

see pics

49
Q

SPECT Summary

Key Takeaways

4:

A
  1. Important Advance in the field of Nuclear Medicine
  2. ID’s areas of high bone metabolism (turn over)
  3. Can be coupled with CT and MRI*
  4. *SAME limitations as bone scans!
    1. # Radiation
50
Q

SPECT Summary

Advancement in field of Nuclear Medicine

A
  • INCd sensitivity/specificity of ID’ing lesions
  • Can locate even very small abnorms*
51
Q

SPECT Summary

ID’s areas of high bone metabolism (Turn-over)

A
  • Occurs in areas where bone is over-loaded→ Stress fx’s, stress conditions
  • Also occurs in areas of tumors where there is a high rate of bone metabolism
52
Q

SPECT CAN (note “Can be”) BE coupled w/____ and _____

A

CT and MRI

53
Q

Positron Emission Tomography (PET)

Measures what?

A

Measures Photon Emission from tracers

  • Flourine-18 linked to glucose== MOST COMMON tracer*** (good for soft tissue*)
  • Dramatically expands physiology studies to soft tissue (think about SPECT, but NOW we can look @ metabolic issues in soft tissues, NOT JUST BONE*)
54
Q

PET is also OFTEN (note “often coupled w/”) coupled w/ _____ and _____

A

CT and MRI

55
Q

PET Scan

Complex and Costly to perform

A

SHORT half-life of the tracer

56
Q

PET Scan MOST OFTEN used to what?

A

ID and Stage Cx

  • Can localize lesion
  • Can help w/ Sx planning***
57
Q

PET Scan

Combining PET scan w/ MRI or CT scan can help make images easier to interpret.

LEFT→ CT

CENTER→ PET

RIGHT→ PET-CT

A

*Bright spot in the chest==> Lung Cx

58
Q

Ex. PET vs. MRI vs. PET/MRI

A
59
Q

Diagnostic Ultrasound

A

Common use….BABIES! `

60
Q

Dx Ultrasound Ex.

Supraspinatus

A

see pics

61
Q

Dx Ultrasound

What is it?

A

Using sound waves to recreate a 2D image of tissue under the probe

GREAT for: superf tears, suprasp, Achilles

62
Q

Dx US

MSK Imaging vs. Doppler US

A
  • MSK:
    • Tendon tears/recovery, MM tears, Calcific tendinosis, masses or fluid collections, Joint or bursal effusions
  • Doppler US:
    • Measures velocity of blood flow→ Suspected DVTs***

*See pic for Calcific tendinitis example

63
Q

Dx US

Achilles Tendon Rupture

A

Left→ Normal

Right→ Rupture+hemorrhage

KEEP LOOKING UNTIL YOU “GET IT” YOU GOT THIS!

YOUTUBE HOW TO READ/INTERPRET!!!!

64
Q

MRI aka

A

Magnetic Resonance Imagining

65
Q

Measures energy of Hydrogen atoms

A

MRI

66
Q

MRI

FACTS

A
  • Measures spatial distribution of protons from hydrogen atoms in the body when excited by radio freq waves in a magnetic field
    • Signal emitted→ Nuclear Magnetic Resonance (NMR)
  • Radiowaves “tuned” to change NMR in order to visualize diff types of tissues
67
Q

MRI is GREAT FOR:

A

SOFT TISSUE!

AND… NO Ionizing radiation!!!!

68
Q

T1 MRI vs. T2 MRI

Key diffs to help remember

A
  • T1→ FAT really bright
  • T2→ WATER really bright
69
Q

Measures energy from structures such as FAT

A

T1 MRI

70
Q

Measures energy late in decay of transverse relaxation and selectively images structures that do not readily give up energy→ such as WATER

A

T2 MRI

71
Q

T1 MRI:

A
  • Measures energy from structures such as FAT→ gives up energy rapidly→ EARLY in process of remagnetization
  • Provides images of good ANATOMIC detail→ displays tissues in fairly balanced manner
72
Q

T2 MRI

A
  • Measures energy LATE in decay of transv. relaxation and selectively images structures that DO NOT readily give up energy→ WATER
  • *Particulalry valuable in detecting INFLAMMATION!! → BC fluid is brighter
73
Q

T1 Image components broken down

ex. ankle/foot

A

Fat→ HIGH signal (Bright)

Cartilage→ LOW signal

Cortical Bone→ LOW signal

Fluid→ LOW signal

74
Q

T2 Image components broken down

ex. ankle/foot

A

Fat→ LOW signal

Cartilage→ LOW signal

Cortical bone→ LOW signal

Fluid→ HIGH signal (Bright)

75
Q

MOST COMMON contrast used in MRI imaging

A

Gadolinium (Gad for short)

  • Shorten the relaxation time of most tissues
  • INCs intensity of T1
76
Q

Gad (contrast) inc’s intensity in ____ image

A

T1

77
Q

MRIs and Contrast

Gadolinium most common*

A
  • Usually IV
  • Adverse rxns possible
    • Nephrogenic systemic fibrosis in pts w/ renal failure or kidney disease
78
Q

Contrast is MORE COMMONLY USED in…….

A

NON-MSK applications

79
Q

Magnetic Resonance Arteriogram (MRA)

Uses and Ex.

A
  • Aneurysm, Aortic stenosis, Aortic dissection (or bleed), Stroke site, Coronary blockage, Vessel stenosis (Renal artery stenosis, Peripheral vessel stenosis of arms/legs)*
80
Q

MRA Ex’s

A

see pics

81
Q

ID this condition

A

**Vesicular based Thoracic Outlet Syndrome (TOS)

*Note: blockage of vessel in L. image

82
Q

fMRI most commonly used in…

A

Brain tissue

83
Q

fMRI

Facts

A
  • Common use→ brain tissue
  • Measures→ change in blood oxygenation and blood flow
  • Uses BOLD contrast
    • DeO2’d Hb= magnetic
    • O2’d Hb= resistant to magnet
  • Looks @ HOW tissue using O2
    • shows areas actively using O2 more/less vs others
  • ACTIVE areas of brain/SC create INC in blood flow
84
Q

Chronic Back Pain and active brain regions

During spontaneous LBP, pts had INCd activity in brain regions assocd w/ suffering/sense of self.

This was different when SAME pts (+controls) experienced thermal types of pain

Moral of story: move towards emotional, behavioral tx’s for LBP

A

see pics!!!

85
Q

MRI

PROS vs. CONS

A
  • PROS:
    • NON-ionizing radiation
    • Ideal for soft tissue
    • Great resolutions w/ higher lvl magnets
  • CONS:
    • Noise
    • Claustrophobia
    • Contraindications (ex. metal implants, joint replacements)
86
Q

Acute Trauma MSK “Rules”

ADD EACH AS A SLIDE WHEN YOU START STUDYING!!!!

A
  • Ottawa Ankle and Foot Rules
  • Ottawa Knee Rules
  • Pittsburgh Decision Rules
  • Cervical Spine:
    • NEXUS Low Risk
    • Canadian C-Spine (pictured below)

Differential Diagnosis & Med Screening (12 decks)

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