Download - Imaging in sports injury
Imaging in Sports
Injury
By Dr. Rajal Sukhiyaji
CONTENTS IntroductionRole of imagingRisks of over imagingThe travelling athleteImaging ModalitiesSafety, Availability and
economic aspectsReferences
Imaging in Medical field Importance of imaging
technique Doubt about the Diagnosis Accurate assessment of injury Helpful to provide the athlete with visual
evidence that a significant injury is present
In cases where conservative management is indicated
Risks of over imaging
No direct relation between clinical symptoms and imaging findings. The diagnosis is already established and
imaging has already been carried out. Repeat studies often lead to confusion in the
mind of the athlete and coach.
Non-significant abnormalities.
Different reports
The Travelling athlete
• Their documentation may be incomplete.• Athlete may not know or remember, which type
of injury they had.
3 options :-• The athlete carries his/her own ‘medical
passport’.• The injuries are registered in an electronic
database.• The information is sent from the previous doctor
to the current doctor by internet or by fax.
Imaging Modalities
• Plain Radiography and Conventional Arthrography
• Ultrasound• Multidetector Spiral CT Scan
– Technique– CT Arthrography
• Magnetic Resonance Imaging– Technique– Direct and Indirect Arthrography
Choice Of Imaging Modalities
Plain Radiography and Conventional Arthrography
Radiographs - diagnostic images needed for the evaluation of sports injuries.
The presence of loose bodies or degenerative joint changes can easily be assessed with plain radiography.
Oblique views may be helpful Stress views may provide indirect
evidence of ligamentous injury.
To confirm the results after internal or external fixation with reduction of dislocations and alignment of displaced fracture fragments
For monitoring the progress of fracture healing with callus formation
Detection of soft tissue calcification after severe muscle trauma
The lack of soft tissue contrast-resolution When complications of the healing process
occur, such as infection or avascular necrosis, the role of plain radiography may be limited and other imaging techniques, such as bone scintigraphy and/or MRI, may be useful for confirming the diagnosis.
Conventional arthrography
The plain film shows
the fractured schaphoid
bone
• Ultrasound (US) plays a major role in sports traumatology, helping the clinician to decide whether the athlete should or should not return to training and competition.
• US keeps its leading edge when dealing with muscle pathology.
• High-frequency (13.5 MHz) probes are used to perform musculoskeletal US examinations.
• Transverse and longitudinal slices are mandatory.
• Dynamic US study may be very helpful.
• US palpation is a very valuable tool.• To avoid artefacts or pitfalls,
comparison with the contralateral side is necessary.
Low cost Availability at short notice Ease of examination Short examination times Lack of radiation exposure
The recent addition of color-power Doppler imaging to US has allowed for
the non-invasive study of blood flow and vascularity within anatomic structures
and lesions.
US provides image guidance for interventional procedures such
as,
Drainage of fluid collections
Drainage of Cysts
Sclerosis of neovascularity in painful chronic tendinosis
Limited depth of penetration and the small, static scan field
If the structure to be visualized is large (e.g., large intramuscular hematoma) or deeply localized (e.g., hip joint)o Extended field of view ultrasonography
(EFOVS) Other disadvantages of ultrasound include
o Operator dependencyo Less graphic imageso Selective and often incomprehensible
documentation and o The inability to penetrate osseous structures
Ultrasound image showing a rotator cuff tear. Afull thickness tear of the supraspinatus tendon
(between the cursors, thick arrow) is shown, where the
tendon traverses the humeral head (thin arrows).
Multidetector Spiral CT Scan
CT imaging, is a valuable imaging tool for the evaluation of all kinds of sports injuries.
Very fast image acquisition times of large volumes with submillimeter section thickness have become the norm.
It is an effective method of documenting injuries particularly in complex bony structures.
Slice thickness : 0.75mm – 1mm
Rotating X-ray tube Computer then processes the
data Technical advances
• All reconstruction methods offer a more effective display of complex anatomic and pathologic structures.
• It may be helpful for the assessment of comminuted fractures, improving visualization of the fracture’s extent and location, shape and position of the fracture fragments and the condition of articular surfaces.
CT Arthrography Intra-articular injection of iodinated contrast
material mixed with 1 ml of a 0.1% solution of epinephrine is performed under fluoroscopic observation.
The volume of contrast medium injected depends on which joint is studied:o Shoulder: 10–15 ml; o Wrist: 5 ml; o Hip: 10 ml; o Knee: 20 ml; o Ankle: 6–12 ml
After injection of contrast material, patients are asked to perform full-range mobilisation of the joint.
Anteroposterior, lateral and oblique views are routinely obtained to image the entire articular cavity.
Subsequently, multidetector CT is performed.
Advantages of CTA The major advantage of CTA for the
assessment of the cartilage is the excellent conspicuity of focal morphologic cartilage lesions.
Other potential advantages of spiral CTA,o The short examination time, o The availability at short notice (short
waiting list) o Limited degree of imaging artefacts
Its invasiveness,
Possible allergic
reaction, Use of ionizing
radiation Poor soft tissue
contrast resolution.
Another major
limitation of CTA
imaging of the cartilage
is its complete
insensitivity to
alterations of the deep
layers of the cartilage.
CT image shows in
3-dimensions the bony morphology
in a case of anterior hip
impingement.
Equipment and techniques for MRI vary widely, and although it is generally accepted that high
field strength magnets provide the highest quality images, there
has been considerable advancement in the technology of low field strength systems
over the past few years, greatly improving their image quality
A complete MR examination requires that images be obtained in the axial, coronal and sagittal planes.
Excessive rotation of a limb, inappropriate positioning of imaging planes may result in images which are difficult to interpret.
Spin echo(SE), gradient echo(GRE) and inversion recovery(IR) sequences
T1- weighted, T2- weighted, proton density and short T1 inversion recovery(STIR) sequences
Fat- suppressed and fat- saturated sequences
The musculoskeletal system, especially in the extremities, is not influenced by motion, and, as a consequence, motion artefacts are rare.
Contrast-enhanced MR studies lead to a prolonged examination time and high costs, and therefore, the use of intravenous contrast agents is not indicated when evaluating a sports lesion.
Recently,
Diffusion Tensor Imaging (DTI) T2-mapping, Spectroscopy, Blood-oxygenation- level-dependent
(BOLD) imaging, and Molecular imaging
These new techniques hold the promise for a more complete and functional
examination of the musculoskeletal system.
• It is not always being well accepted by patients, of being incompatible with dynamic manoeuvres and of not always being possible in emergency conditions.
• It provides the evaluation of an entire anatomical area – bone structures included – but is only good for the study of a limited part of the skeleton.
Direct and Indirect Arthrography
MR arthrography is a technique which is mainly used in the shoulder, wrist, ankle, knee and hip joint.
Two different techniques are described – oDirect MR arthrographyo Indirect MR arthrography
Coronal plane MRI image diagnoses a tear of the medial
meniscus (long arrow), with a
meniscal fragment displaced within the joint (dotted arrow).
Note the normal lateral meniscus
(short arrow).
Safety, Availability and Economic Aspects
Ionizing radiation is harmful and there is no safe lower threshold of radiation
Examinations on children
Therefore, when clinically appropriate, the alternative use of safer nonionizing techniques (such as ultrasound and MRI) or of low dose radiography/CT techniques must always be considered
MRI findings may have a significant impact on diagnosis and treatment planning.
Appropriate selection of patients will probably yield similar results in other anatomic locations.
The advancements in MRI technology may expand the range of usefulness of this modality, leading to even greater utilization of MR imaging in patients with sports injuries, and, eventually, to reduced costs and greater availability.
Neurological investigationo Electromyography oNerve conduction studies oNeuropsychological testing
Muscle assessmentoCompartment pressure testing
Cardiovascular investigationo Electrocardiographyo Stress electrocardiographyo Echocardiography
Respiratory investigation o Pulmonary function tests
Clinical Sports Medicine, Peter Brukner & Karim Khan
Imaging of Orthopedic Sports Injuries, F. M. Vanhoenacker, M. Maas, J.L.Gielen.
Sports Injuries : the Role of Imaging in Diagnosis and Treatment, Dr Paul Jenkins, MA MD FRCP, Medical Director
Diagnostic Imaging of Sports Injuries, Matthew D. Richardson, D.C., DACBR, Director of Clinical Radiology, Palmer Florida Campus.