msk emergencies – what the radiologist needs to...
TRANSCRIPT
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MSK Emergencies – What the Radiologist Needs to Know?
Elena Ilieva, MD UMHATEM “N. I. Pirogov”
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What is an MSK Emergency?
Don’t miss diagnoses
Joint dislocation
Infection in a joint
Infection of bone or soft tissue
Fractures with associated neurovascular compromise
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Non-traumatic MSK Emergencies
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Septic arthritis
§ Destructive arthropathy caused by intraarticular infection
§ Usually due to haematogenous seeding in the absence of trauma
§ Large joints with abundant blood supply are most prone to bacterial infection
§ Shoulder, hip and knee most common
! NB: Orthopaedic emergency Prompt treatment required as irreversible joint damage in 24hrs due to proteolytic enzymes of WBCs
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Cor T2 FS Cor T1
24 yo male, IVDU, painful right hip
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Septic arthritis
Joint effusion
Synovial fluid aspiration and analysis may be critical to Dg
Hyperemia periarticular osteoporosis
Cartilage
destruction
Destruction of subchondral
bone on both sides of joint
Reactive juxta-articular sclerosis
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Septic arthritis - imaging
Ultrasound § useful in superficial joints and in
children § shows joint effusion
• echogenic debris may be present
§ colour Doppler may show increased peri-synovial vascularity
§ can be used to guide the joint aspiration
MRI § sensitive and more specific for early cartilaginous damage § T1: low signal within subchondral
bone § T2: perisynovial oedema § C+ (Gd): Synovial enhancement
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Infectious myositis
Infection of skeletal muscle Pyomyositis: refers specifically to a bacterial infection of skeletal muscle.
Potential complications of untreated infectious myositis include: § compartment syndrome
§ spread of infection to adjacent structures • osteomyelitis • septic arthritis
§ systemic spread • septic shock • distant abscess formation
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Cor T2 FS Ax T1 FS + Gad
54 yo woman, history of lymphoma and previous BMT, febrile with a painful swollen upper thigh
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Infectious myositis - imaging
Ultrasound § enlargement of the muscle, with or without abscess formation § echogenicity of the muscle due to oedema § US may be employed to aid
percutaneous drainage of a collection.
MRI § MRI may accurately assessing the
extent of involvement § muscle oedema, characterized by
high T2 signal § there may also be diffuse muscle
enlargement § abscesses (high T2, low T1) with
peripheral contrast enhancement.
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Necrotising fasciitis
§ Rapidly progressive and often fatal infection of soft-tissue
§ Affects the fascia deep to the skin but superficial to the muscles
§ Extremities, perineum, and truncal areas are the most commonly
involved
§ No imaging modality can reliably exclude underlying necrotising
fasciitis in the absence of soft tissue gas
!NB: Imaging plays a very limited role in diagnosis and management of necrotising fasciitis and should not delay surgical intervention
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Traumatic MSK Emergencies
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Joint Dislocation
§ Displacement of bones at a joint from their normal position
§ Risk to circulation and nerves
§ Risk of osteonecrosis (AVN)
X-rays before and after reduction to look for any associated fractures!
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Joint Dislocation - Shoulder
§ Most common major joint dislocation
§ Anterior (95%) - Usually caused by fall on hand
§ Posterior (2-4%) – Electrocution/seizure
§ May be associated with: • Fracture dislocation • Rotator cuff tear • Neurovasculr injury
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Posterior Glenohumeral Dislocation
§ Fixed internal rotation lightbulb sign
§ Throgh line
§ Incongruity of humeral head and glenoid
§ Rim sign
§ Lesser tuberosity
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Posterior Glenohumeral Dislocation
§ Fixed internal rotation lightbulb sign
§ Throgh line
§ Incongruity of humeral head and glenoid
§ Rim sign
§ Lesser tuberosity
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Posterior Glenohumeral Dislocation
§ Fixed internal rotation lightbulb sign
§ Throgh line
§ Incongruity of humeral head and glenoid
§ Rim sign
§ Lesser tuberosity
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Posterior Glenohumeral Dislocation
§ Fixed internal rotation lightbulb sign
§ Throgh line
§ Incongruity of humeral head and glenoid
§ Rim sign >6mm glenohumeral distance
§ Lesser tuberosity
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Scapular Y View
Axial Oblique /Velpeau View
Posterior Glenohumeral Dislocation
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Joint Dislocation – Shoulder Imaging
X-Ray § Diagnosis § Follow-up § Additional views
CT § Assessment of associated Fx
MRI (not acute) § Shoulder instability § Labrum injury
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Joint Dislocation - Knee
Injury to popliteal artery and vein is common
§ Peroneal nerve injury in 20-40% of knee dislocations
§ Associated with ligamentous injury
• Bicruciate (ACL + PCL) ligament tear with either MCL tear or
posterolateral corner injury
• Fx of distal femur or proximal tibia are also common (15%) – Segond fx § Anterior (31%)
§ Posterior (25%) § Lateral (13%) § Medial (3%)
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§ Anterior knee dislocation - high impact injury (60% MVA)
§ Hyperextension injury with tear of posterior structures
§ Posterior knee dislocation - direct blow to proximal tibia
§ Need to assess for injury to the popliteal artery - CTA or
conventional angiogram
§ MRI to assess meniscal and ligament injury
Joint Dislocation - Knee
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Joint Dislocation - Knee
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Joint Dislocation - Hip
§ Loss of normal joint congruency between the femoral head
and acetabulum
§ Mechanism – young Pts with high energy trauma
§ Hip joint inherently stable due to: • bony anatomy • soft tissue constraints including
• labrum • capsule • ligamentum teres
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Posterior dislocation (85%)
§ Femoral head – posterior, superior and lateral to acetabulum
§ Internally rotated so lesser trochanter less visible/obscured
§ Femoral head smaller than contralateral side
Anterior inferior dislocation
§ Femoral head inferior to the acetabulum
§ Lesser trochanter more visible due to external rotation
Joint Dislocation - Hip
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Joint Dislocation - Hip
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Joint Dislocation – Hip Compications
§ Post-traumatic arthritis
• up to 20% for simple dislocation, markedly increased for complex dislocation
§ Femoral head osteonecrosis (AVN) • 5-40% incidence
• Increased risk with increased time to reduction
§ Sciatic nerve injury • 8-20% incidence
• associated with longer time to reduction
§ Recurrent dislocations • less than 2%
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§ Alignment - needs reduction
§ Intra-articular extension
• Articular gap/Depression
§ Common associated injuries
• Fracture patterns
• Associated ligamentous soft tissue injury
§ Open (compound) fracture - needs surgery Open (compound) fracture - needs surgery
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Forearm FracturesForearm Fractures§ Galeazzi
• DRUJ dislocation
• Radial # (distal 1/3)
§ Monteggia • Radial head subluxation (any direction)
• Ulna # (90% proximal)
§ Essex-Lopresti • Comminuted fracture of radial head • Disruption of interosseous membrane
• Dislocation of distal radioulnar joint
§ Nightstick fracture • Isolated midshaft ulnar fracture from direct blow
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Forearm FracturesForearm Fractures§ § Galeazzi
• DRUJ dislocation •
Radial # (distal 1/3) § Monteggia
• Radial head subluxation (any direction)
• Ulna # (90% proximal) § Essex-Lopresti
) •
Comminuted fracture of radial head • Disruption of interosseous
• Dislocation of distal Dislocation of distal
joint § §
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Forearm Fractures
§ Galeazzi • DRUJ dislocation
• Radial # (distal 1/3)
§ Monteggia • Radial head subluxation (any direction)
• Ulna # (90% proximal)
§ Essex-Lopresti§
Galeazzi
• DRUJ dislocation
• Radial # (distal 1/3) § Monteggia
• Radial head subluxation (any direction) • Ulna # (90% proximal)
§ Essex-
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Forearm Fractures
§ Galeazzi • DRUJ dislocation
• Radial # (distal 1/3)
§ Monteggia • Radial head subluxation (any direction)
• Ulna # (90% proximal)
§ Essex-Lopresti • Comminuted fracture of radial head • Disruption of interosseous membrane
• Dislocation of distal radioulnar joint
§ Nightstick fracture • Isolated midshaft ulnar fracture from direct blow
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Forearm Fractures
Potentional complications include:
§ Direct neurovascular injury
§ Physeal arrest if fracture involves the growth plate
§ Radioulnar synostosis after delayed treatment
§ Compartment syndrome - associated with closed shaft Fx of the
radius or ulna and with tight casts (more common in lower
extremities)
§ Loss of supination-pronation after a forearm fracture
Pts with distal radius Fx should receive a post-reduction true lateral X-Ray of the carpus to assess DRUJ alignment.
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Pelvic Fractures § Type of fracture - dependant on mechanism, energy and bone-strength
• direct impact, low energy (solitary localised fractures)
• compression, high energy (unstable pelvic ring fractures)
Mechanism is almost always blunt trauma, e.g. fall or RTC
§ X-Ray useful in all settings
§ CT helpful for assessment of complex fractures • also helpful for assessment of
other injuries (requires contrast)
§ Associated injuries: • pelvic, thigh and/or retroperitoneal haemorrhage • bladder rupture • urethral rupture
Pelvic ring fx
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Pelvic Fractures
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Neurovascular Injuries
§ Fracture • humerus, femur
§ Dislocation • elbow, knee
§ Direct/penetrating trauma § Thrombus § Direct Compression/Acute Compartment Syndrome § Cast, unconscious
Needs to be checked before and after reduction
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Common Vascular Injuries
Injury Vessel
1st rib fracture Subclavian artery/vein
Shoulder dislocation Axillary artery
Humeral supracondylar fracture
Brachial artery
Elbow Dislocation Brachial artery
Pelvic fracture Presacral and internal iliac
Femoral supracondylar fracture
Femoral artery
Knee dislocation Popliteal artery/vein
Proximal tibial Popliteal artery/vein
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Common Nerve Injuries
Injury Nerve Shoulder dislocation Axillary
Humeral shaft fracture Radial
Humeral supracondylar fracture Radial or median
Elbow medial condyle Ulnar
Monteggia fracture-dislocation Posterior interosseus
Hip dislocation Siatic
Knee dislocation Peroneal
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Take home messages:
§ Know which imaging modality to use and when: Ø Non-traumatic MSK emergencies – US, MRI Ø Traumatic MSK emergencies – X-Ray, CT, MRI
§ Do not miss diagnoses § Diagnosis of MSK emergencies should support management
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email: [email protected]