Diagnostic Techniques Appropriate use of imaging techniques is essential for diagnosis, treatment decisions, and cost containment in today's

medical environment. Routine Radiography - It is the most appropriate screening technique for musculoskeletal disorders. - Appropriate evaluation of routine radiographs results in diagnosis or selection of the next most appropriate imaging procedure. - Screen-film radiography is being replaced by computed radiography at many institutions. - Regardless of the system used, it is essential to ensure proper patient positioning and chronologic labeling of images. - Multiple views are required for minimal evaluation of osseous and articular anatomy. - In some cases, fluoroscopically positioned spot views are useful to optimize positioning and reduce bony overlap. Ultrasound - The term refers to mechanical vibrations whose frequencies are above human detection. Ultrasound imaging uses frequencies from 2 to 12 MHz. - Most musculoskeletal structures examined are superficial, requiring a 7- to 12-MHz transducer. - Doppler ultrasound for peripheral vascular disease is approximately 8 MHz. - The joints, soft tissues, and vascular structures are particularly suited to ultrasound examination. - Because of its low cost and availability, ultrasound now is being used more frequently to evaluate various conditions. Indications:

1- Soft tissue masses 2- Vascular disease 3- Ligament/tendon tears 4- Articular disorders 5- Cartilage 6- Effusions 7- Foreign bodies Radionuclide Imaging - Multiple agents (radiopharmaceuticals) are available for bone imaging. - The agents selected and imaging techniques used vary with the clinical indication for examination. Bone Scans - Patients are injected intravenously with technetium-labeled diphosphonate. - Images are obtained 3 to 4 hours after injection.

Indications:
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Primary or metastatic bone lesions Subtle fractures, i.e., stress fractures Battered child Differentiation of osteomyelitis from cellulitis Detection of infarction or avascular necrosis Evaluation of reflex sympathetic dystrophy

Three-phase bone scans are performed using the same radiopharmaceutical, but with a different imaging sequence. Blood flow images are obtained in the initial 60 seconds after injection followed by blood-pool images 2 to 5 minutes after injection and delayed images at 3 to 5 hours.

Computed Tomography - CT is a fast and efficacious technique for evaluating the musculoskeletal system. - The basic components of the system are: 1- Gantry, which houses a rotating x-ray tube. 2- Radiation detectors. 3- Movable patient table. 4- Computer to manipulate the output of the radiation detectors to produce the images. - The computer presents data on a grid matrix, usually consisting of 512x512 picture elements (pixels). Each pixel represents a volume element (voxel) whose depth is chosen by slice thickness. Skeletal imaging typically is performed using sections 3 to 5 mm thick, but thinner sections are used for fine detail, reformatting, or threedimensional reconstruction. - CT is particularly suited for evaluating complex skeletal anatomy in the spine, shoulder, pelvis, foot, ankle, hand, and wrist. - Precontrast and postcontrast images (intravenous iodinated contrast) are useful for evaluation of soft tissue lesions. Magnetic Resonance Imaging - MRI is a proven technique with expanding musculoskeletal applications. - Most imaging is performed at 1.5 Tesla (T) - Before considering MRI as an imaging technique, one must consider certain patient safety factors (cardiac pacemakers, cerebral aneurysm clips, metallic foreign bodies, and electronic devices) - Patient age, clinical status, and length of MR examination must be considered before determining whether sedation or pain medication is required. - Claustrophobia, a problem in high-field imaging gantries, is a less significant problem in lower-field open-bore magnets. - Patient positioning considerations include patient size, body part and structures to be examined and expected examination time. The patient

should be studied with the most closely coupled coil (smallest coil that covers anatomy of interest) to achieve the optimal signal-to-noise ratio and spatial resolution. - Pulse sequences should be selected to optimize anatomic display, enhance lesion conspicuity, and characterize lesions. - In many cases, conventional T1-weighted and T2-weighted sequences are adequate for lesion detection and characterization. - At least two image planes typically are obtained to clearly define the extent of lesions.

Arthrotenography - Arthrography has been replaced by MRI, especially for imaging the knee and shoulder. - Today, we most commonly perform arthrograms to confirm joint access for anesthetic injection to determine the source of pain or to aspirate fluid to exclude infection. - Tenograms are performed most commonly in the hand, wrist, foot, and ankle. - Entering the joint or tendon sheath is monitored fluoroscopically to ensure proper needle position. - The main concerns are the contrast media and drug allergies, infection, acute synovitis, nerve block with numbness and reduced function. These problems generally are transient. Angiography Angiography is performed for selected musculoskeletal disorders. Trauma, neoplasms, and treatment of posttraumatic bleeding or preoperative tumor embolic therapy are indications. Embolotherapy Trauma Posttraumatic hemorrhage can be controlled by selective catheterization and embolization.Embolization should be selective to prevent tissue ischemia or necrosis.Embolic agents most commonly used are microcoils,

Gelfoam, and glue. Preoperative Tumor Preoperative arterial embolization is particularly helpful in controlling intraoperative bleeding from hypervascular neoplasms. Selective embolization should be performed to prevent nontarget tissue ischemia and necrosis. Embolic agents most commonly used are polyvinyl alcohol particles, microspheres, Gelfoam, and glue.