Nadia Quiz 2 Study PDF

4.1 general priniciples and radiology I. Unnecessary Examinations and Overutilization of X-rays -Overutilization Defined: - Excessive radiation per unit of diagnostic info or therapeutic impact. - Aim to limit radiation exposure per useful bit of knowledge. -Examples of Overutilization:...

4.1 general priniciples and radiology I. Unnecessary Examinations and Overutilization of X-rays -Overutilization Defined: - Excessive radiation per unit of diagnostic info or therapeutic impact. - Aim to limit radiation exposure per useful bit of knowledge. -Examples of Overutilization: - Imaging the skull for headache, neck pain, vertigo, seizures—lat imaging could reduce radiation exposure by 75-80%. - Lat chest imaging in individuals under 40—often adds no new info - Oblique lumbar spine films in children—high radiation, often unnecessary. II. Causes of Overutilization -Lack of Knowledge: - Clinicians may not fully understand the limitations of radiology. -Reliance on Radiologic vs. Clinical Findings: - Potential for undue dependence on radiology over clinical judgment. - Question the necessity of repeat examinations, especially in routine cases. -Need for Certainty: - Clinicians may feel the need to use radiology to eliminate uncertainty, potentially leading to unnecessary imaging. -Pt Demand: - Pts may request x-rays even when not clinically indicated. -Reimbursement Policies: - Insurance coverage can affect the frequency of ordered imaging. -Defensive Medicine: - Fear of malpractice leads to unnecessary imaging to avoid missing dx’s. -Economic Incentives: - Physician-owned imaging facilities may lead to more frequent use of imaging. III. Summary of Unnecessary Examinations -Nasal Bone Imaging: - Unnecessary for ruling out fxs as tx remains unchanged. -Rib Imaging: - Rib fxs rarely alter tx, making rib series unnecessary. -Coccyx Imaging: - Fxs of the coccyx do not change tx; high gonadal radiation risk. -Lumbar Spine X-rays: - Most abused radiology examination; high radiation dose with little diagnostic value, especially in pts under 40. -Ankle Series: - Evidence-based criteria (e.g., Ottawa ankle rules) can reduce unnecessary imaging by 50%. -Cervical Spine X-rays: - Often unnecessary in trauma pts w/out specific sxs; CT scans preferred. IV. Interpreting Images in Radiology V. Pitfalls in Radiology Interpretation -Developing a Search Pattern: -Errors of Observation: - Importance of a systematic - Often due to faulty search patterns. approach to interpreting images. -Errors of Interpretation: -Challenges in Diagnosis: - Failure to link abnormal radiologic signs - Normal anatomic variance. with clinical data. - Multiple diagnoses (e.g., second fx). -Reducing Errors: - Variations in disease presentation. - Effective communication with radiologists - Insignificant findings that may can reduce errors. become significant over time. -Acceptance of Errors: - Acknowledge that errors in reading images are inevitable; some findings will be missed.  4.2 general principles and radiology cont I. Bone Remodeling and Fxn -Wolff's Law: - Bones remodel continuously thru-out life based on the fxn. -"Use it or lose it." - Julius Wolff’s 1870 publication: Bones change architecture according to loading and mathematical rules. - The pattern of trabecular framework influenced by direction and pattern of loading. -Example: - Comparison of stress trajectories in a beam vs. trabecular patterns in the femur. - Wolff hypothesized a direct mathematical relationship bw bone shape and load over time. -Examples in Bone Remodeling: -ACL Tear: - Variations in bone shape post-ACL tear. - Differences in med femoral condyle shape and tibial slope bw affected and non-affected bones. -Coxa Valga: - Stress changes due to increased angle bw the femur head and neck. -Osteoarthritis: - Bone remodeling in response to osteoarthritis and bone marrow edema. II. Errors in Interpreting Radiologic Images - Types of Errors: 1. Error of Observation: - Caused by incomplete or faulty search patterns. 2. Error of Interpretation: - Failure to link imaging findings w meaningful clinical data. - Reducing Errors: - Collaboration bw referring providers (e.g., PTs) and radiologists enhances information quality and improves pt outcomes. III. ABCS of Radiographic Image Interpretation -Alignment: - Skeletal Architecture: - Examine bone size, extra bones, congenital anomalies, absence of bones, and developmental deformities. - Examples: - Paget's Disease: Random proliferation of osteoblastic/osteoplastic activity, e.g., cotton wool appearance in skull. -Polydactyly: Presence of an extra digit in a child. -Congenital Deformities: Bowing of femurs/tibias w absence of fibulas. -Contour of Bone: - Includes internal/external irregularities, cortical outline, osteophytes, and surgical markings. -Examples: - Osteophyte (Heel Spur): Radio-dense projection at the calcaneus margin. - Cortical Fracture: Boxer's fx of the 5th metacarpal neck. - Surgical Sites: Radiolucent lines and remnants of drill holes from past surgeries. -Position of Bones Relative to Other Bones: - Assess normal positional relationships, check for fractures, dislocations, or subluxations. - Examples: - Normal Shldr vs. Posterior Shldr Dislocation: Comparison of humerus position in relation to the glenoid. - Dislocated Hip: Rare, often trauma-related, as seen in road accidents. - Bone Density: -Cartilage Spaces: he didnt cover it -Soft Tissues:  Bone density 4.3 Bone Remodeling and ABCs: B · architecture : contrast · texture : trabeculae B: Bone Density (1-3) #1 = Skeletal Architecture - general bone density: assess shade of grey looking for shades of grey implying sufficient radiographic contrast b/w bone & soft tissue & sufficient contrast w/in bone itself AKA: healthy bone and soft tissue can be clearly distinct from each other sureough Ex: Sufficient contrast in bone denser cortical shell (brighter) with less dense cancerous bone (less bright) ake meres cl ne normal bone heal= more radiodensity !! num thickness of margins bones loserzon wack the loser: It Osteomalacia: Rickets ↑ hypocalcification disorder can produce bone but cant calcify it wide porous bone radiologic finding: looser zone M arrow: radiolucent band transverse to cortex = stress fx bc demineralized cortex with increased radiodensity on either side bc bone trying to repair #2 Textural abnormalities look for changes in appearance of the trabeculae changes in mineralization result in change in appearance of trabeculae change in trabeculae = radiologic hallmark in diagnosis of disease process Descriptors used for trabeculae thin, delicate, smudge, fluffy Hyperparathyroidism decalcification of bones erosion of cortex tibia should have straight line = cortex - she squiggly = bad - texture inside is translucent = bad too Coley’s anemia inherited blood disorder = destruction of RBC metacarpals & phalanges - cortical thickening - osteopenia - marrow proliferation - all causes a loss of normal tubulation making the fingers look square or like sausages consider the lacy appearance of the inside of bones #3 local density changes assess for localized density changes - look for increases in bone density in WB areas (sclerosis) - look for excessive increases (excessive sclerosis) in OA conditions - look for reactive changes (reactive sclerosis) which occur when body acts to contain a diseased area Sclerosis normal increases in bone density in areas subjected to increased stress (wb jts) sign of repair extra bone to withstand the wb Excessive sclerosis can be normal: when bone heals it forms callus can be degenerative: arthritis/reactive sclerosis - reaction to tumor or cancer - lays down bone to surround the dx area Pic on L hallmark sign of arthritis - decreased medial jt space combined with sclerotic subchondral bone of medial tibial plateaus (oval) white part in oval - repair response to thinning of articular cartilage - spurs can also occcur Pic on R osteomyelitis on prox tibia reactive sclerosis trying to surround the infected area - really bright white parts white arrows on bottom showing draining effect to relieve pressure of pus on bone (dent) which is why the soft tissue enlarged C: Cartilage Spaces #1 Jt spaces asses the width of the jt spaces - is it well preserved with normal thickness of cartilage/disc/tissue if space is decreased - this is likely a result of degenerative changes Pic on L bands of fatty bone marrow parallel to L5 disk Pic on R hallmarks of degenerative disk dx at C5-C6 with narrow jt space & osteophyte formation @ vertebral end plates C: Cartilage #2 Subchondral bone assess the subchondral bone - look for changes in density/irregularities - Ex: sclerosis, OA subchondral bone becomes more sclerotic as new bone form to help WB - Ex: RA/Gout - little reactive sclerosis in subchondral bone, instead see erosion of subchondral bone in form of radiolucencies on jt margin (very transparent which isn’t normal for sclerosis) What is OA destructive jt dx that can result in - pain - stiffness - loss of ROM i - loss of activity tolerance tinci x-rays help identify jt space narrowing redneed - sclerosis almost always present (bright white) umum - can also have osteophyte formation to help WB - subchondral lucency bc focal loss of bone density C: Cartilage Spaces #3 Epiphyseal plates assess the epiphysis - look for changes in the position of the growth plate, size of the epiphyses, whether the borders are smooth & whether there is presence of disruption or gaps in the plates position of growth plate designated by relationship of ossified portion of secondary epiphysis to metaphysis is there a smooth margin, band of sclerosis - indicates increased bone activity associated with linear growth disruptions in growth plates from trauma or metabolic dx can be visualized & can be hard to dx bc need CL film for comparison Key idea for imaging: symmetry comparing one side to the other mmm  4.4 ABCs: Soft Tissue Salter- Harris Fx (left pic) fx thru the metaphysis, growth plate, and epiphysis triplanar fx normally happen at distal tibia brigherosis Normal radiograph of 8 y/o child borders of epiphysis normally bounded by smooth margin w/ sclerosis meaning increased bone activity Soft Tissues #1 Muscles assess the soft tissue of the muscles - look for changes in muscle girth that may represent muscle wasting or gross swelling of muscle and soft tissue gross muscle wasting = primary muscle disease paralysis or severe illness or disuse atrophy secondary to trauma Gross swelling: inflammation/edema/hemorrhage/tumor - looking at size/girth of muscle can be indicative of different pathologies Disuse atrophy of quadriceps this specific example secondary to a traumatic patellar dislocation shrunken concave of soft tissue outlining ⑧ the thigh Soft Tissues #2 Fat Pads assess the fat pads - look for changes in the position of fat pads, usually a result of swelling & possibly an injury to an adjacent structure look @ girth or location of soft tissue compared to the other extremity Lateral view pronator fat pad = thin radiolucent triangle w/ base attached to palmar surface of distal radius Right pic bowing bc fall/muscle strain/ inflammatory condition/ infxn/ septic arthritis bow is a result of fluid causing bulging in x-ray Soft tissue #3 jt capsule assess the jt capsule - usually you cant see these well, but become visible when swelling is present exacerbations of arthritic conditions like - infxn/hemophilia/acute jt trauma/ effusion from trauma & intrarticular fx can produce lipohemoarthrosis in jt capsule lipohemoarthrosis: mixture of fat & blood from marrow entering the jt space through osteochondral defect - fat less dense than blood it floats to surface of blood - aka on radiographs: fat fluid level or fat blood interface (FBI) - sign of potentially overlooked intraarticular fx FBI example marrow & blood seeping thru intra-articular tibial patella fx accumulated in suprapatellar area & divided into layers bc fluid density fx needs to happen in order to have FBI Make sure to recognize in this pic m densities to identify fat and blood interface look @ contour of skin being pushed out bc fluid accumulation Soft tissue #4 Periosteum assess the periosteum for any kind of reactive process - solid fxn from fx healing or osteomyelitis, laminated process due to repetitive injury, sunburst bc malignancy, or codmman’s triangle bc of tumor, hemorrhage or other trauma 4 different periosteal rxns - solid: indolent or slow rolling process (seen in fx healing, chronic osteomyelitis) - laminated/onion skin indicating repetitive injury Battered child syndrome associated w/ sarcomas - sunburst or speculated pattern - malignant bone lesions, metastatic squamous cell tumors appearance bc repeated breakthrough of tumor, neoplastic process, and new periosteal response Codman’s Triangle piece of periosteum elevated by abnormal conditions & ossifies in triangular shape can be seen in tumor or subperiosteal hemorrhage in battered child syndrome looks like something pushing the bone out making triangle shape - & - - these are the 4 periosteal rxns! - - Soft Tissues #5 Miscellaneous soft tissue findings assess for out of the ordinary soft tissue findings - gas as the result of gangrene or trauma, calcifications or foreign bodies gas in soft tissue: gas forming organisms like gangrene or trauma calcifications in soft tissue: old trauma where hemorrhage is coagulated & calcified - can also happen in vessels/organs - ex: renal calculi, gallstones, calcifications in abdominal organs can also see metal shards in soft tissue radiographs Myositis Ossificans hardwareneterotopic heterotrophic bone developed a  4.5 Skeletal Pathology - Categories, Distribution, Predictors Radiologic Diagnosis of Skeletal Pathology - Identify category of pathology - Identify distribution of lesion - Identify predictor variables that characterize disease features Identify Category - Congenital (Presence of cervical rib) - Inflammatory (Osteomyelitis, RA, gout) - Metabolic (Paget's Disease, Fibrous Dysplasia) - Neoplastic (Primary Bone Tumor) - Traumatic (Fractures) - Vascular (Avascular Necrosis) - - Miscellaneous or Other (MSK, Infection, OA) Inflammatory Category (Ankylosing Spondylitis) - 66 yr old man - Ossification of outer fibers of the disc - Amylose fibers & aphophyseal joints have fused - Takeaway, the amount of bone present in the pictures Metabolic Category (Nutritional Rickets) - Femoral Fracture in 3 yr old - - Fractures of both tibia & fibula - Right image is 2 yrs later - Diffuse osteopenia, Bowing, widened growth plates, Identify Distribution of Lesion - Monoarticular (Fracture) - Polyarticular (RA) - Diffuse (Osteoporosis, Metastases) Diffuse Distribution (Metastases) - - Wide Spread Sclerosis - Increased bone density, thoracic & lumbar appear sclerotic Identify Predictor Variables (Table 2-4) - Behavior of Lesion (Osteolytic, Osteoblastic, mixed) - Bone or Joint Involved - Locus, area, within bone - Age, Gender, Race of patient - Age can be risk factor for tumors - Margin of Lesion (Sharp or poorly defined) - Sharp is slow growing - Poor is more aggressive - Shape of Lesion (Long vs. Wide) - Longer is slow growing - Wide is more aggressive - Joint Space (Crossed or Preserved) - Bony Reaction - Periosteal reaction characterized by interuptted or uninterrupted - Interuptted is malignant or aggressive - Uninteruptted is benign - Matrix Production - Matrix is tissue produced by primary bone & neoplasms - Osteoid appears like white clouds (light density) - Conjoined appears more like popcorn - Soft Tissue Changes - Edema, hemorrhage, joint effusion - History of Trauma or Surgery  4.6 The Radiologic Report Purposes of Radiologic Report - Link radiologic signs w/ patient history & exam findings - Provide comparison w/ earlier or later radiological exams - Permanent Record - Supports treatment through identified indications & contraindications for med intervention - Can be used in research - Facilitates communication - Typical Info - Patient demographics, imaging findings, conclusions, name of radiologist 4 D's - Basic Sequential tests performed - Detect - First thing radiologist needs to do - Much improved w/ information referral regarding patients history & exam findings - Describe - Findings are described clearly & concisely using medical terminology - Written for radiologist so another one can come to the same conclusion based on description only - Diagnosis or Differential Diagnosis - Heart of the report & the answer to the clinical question that referring provider is asking - Differentials are ordered in most likely sequence w/ max of 3 - Decision - What to do next, how important is it to inform others & how urgently - Is immediate communication required - Any more tests recommended? Example of Radiology Report Patient Friendly Revised Design - Explain medical terminology > - - Link locations on report w/ current complaints Errors in Diagnostic Radiology (Classification Renfrew) - Type 1 (Complacency) - Finding identified but attributed to wrong cause - Type 2 (Faulty Reasoning) - Finding identified as abnormal but atttributed to wrong cause - Type 3 (Lack of Knowledge) - Finding identified but attributed to wrong cause due to lack of knowledge - Type 4 (Under-Reading) - Missed abnormality that was appreciable in retrospect - Type 5 (Poor Communication) - Finding identifed as abnormal but poor communication to relevant clinician - Type 6 (Technique) - Abnormality was not identifiable secondart to poor technique - Type 7 (Prior Exam) - Failure to review previous imaging results in missed finding - Type 8 (History) - Finding missed due to incomplete clinical information - Type 9 (Location) - Finding missed because it was outside of region of interest - Type 10 (Satisfaction of search) - Failure to find subsequent abnormality after intial abnormality was detected - Type 11 (Complication) - Most often interventional procedures - Type 12 (Satisfaction of Report) - Over reliance on prior report Errors in Diagnostic Radiology - Brooks Classification - Latent Errors - 'in built' system or technical faults that predispose to errors - Active Failures or Human error - Diagnostic errors or misinterpretation - Complications from procedures - Can involve more than 1 person or be secondary to latent errors - External Causes - Beyond control of radiologist - Customer Causes - Related to patient & non-radiology staff