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CURRENT PATHOLOGY IMAGING GUIDELINES

CONTENTS

A. Neck and thorax

B. Upper abdomen

C. Genitourinary system

D. Vascular system

E. Central nervous system

F. Spine

G. Extremities

Imaging resources

Problem management

1. Trauma
2. Infection
3. Tumors
4. Degenerative, inflammatory and et metabolic diseases
5. Malformations
6. Prostheses and implants

H. Nuclear Medicine

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IMAGING RESOURCES

Plain X-rays (mandatory before any further imaging)

  • two orthogonal views should be obtained (AP*/lateral), or AP/axial - AP/oblique according to the region examined
  • obliques or special projections may be added
  • x-rays should demonstrate:
    • soft parts, vascular or extravascular calcifications, ossifications
    • cortical and cancellous bone (periostal reaction, erosion, bone destruction, bone sclerosis, sequestrum)
    • joint configuration (axes, subluxation, joint space narrowing, subchondral bone plates, osteophytes, joint calcifications or ossifications)
  • weight bearing films: allow better demonstration of joint space narrowing in case of joint diseases

*AP = anteroposterior projection

Oblique views

  • used for feet, hands, fingers and toes
  • hip: Lauenstein projection, Lequesne pseudolateral view
  • knees and ankles (fracture, bone avulsion)
  • tunnel view for intercondylar notch of the knee

Axial projections

  • shoulder: luxation, joint surfaces relationships, glenoid rim fracture
  • scapula lateral view
  • Neer projection (a variant of the former one): shows subacromial space
  • hip axial view: mainly used to show relationships between femoral neck and diaphysis
  • patella: fracture, subluxation, excentration, tilting, dysplasia; may be imaged at various angles of flexion
  • calcaneum: posterior tuberosity, osteitis, fracture

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Conventional tomography

  • almost completely replaced by thin CT-scan sections with multiplanar and 3-D reconstructions or by MRI
  • may replace CT-scan or MRI when metallic implants generate severe artifacts

Arthrography

  • still sometimes performed, in particular before arthroMRI
  • still useful for small joints of wrist and hand (ligamentous disruptions sometimes difficult to see with MRI), hip (preoperative imaging in hip dysplasia, labrum lesions)
  • may be followed by CT-scan imaging (shoulder, elbow, knee for meniscus diagnosis instead of MRI)

Arteriography

  • preoperative vascularisation study and embolisation of highly vascular tumors
  • arteriovenous fistula, vascular malformations
  • arteries stenoses angioplasty

Ultrasound

  • small parts (tendons, muscle tear, hernia or haematoma, tumor, cyst, collections, blood vessels)
  • bone surface imaging (periosteum, osteophytes, tumor invasion, occult fractures)
  • joints (effusion, synovial cyst, synovial thickening)
  • guided puncture, infiltration and drainage

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MRI

  • first choice imaging tool for joint disease (cartilage, menisci, ligaments, inflammation, tumor spread) in addition to conventional X-rays
    • optimized by gadolinium joint opacification, mainly for shoulder, knee (suspicion of recurrent meniscal tear), hip (labrum tears)
  • excellent for cancellous bone diagnosis:
    • edema (bone contusion, occult fracture, algodystrophy, osteomyelitis)
    • aseptic necrosis
    • tumor spread
    • medullary conversion (haemopathies, myeloma)
  • optimal tissue contrast to evaluate bone or soft tissue tumor extension or recurrent grow
  • less accurate analysis of calcification and operated sites (metallic artifacts)
  • MR angiography of a limb (malformation, tumors)

CT-scan

  • preferred imaging tool for 3-D study of complex fractures
  • complementary to Plain X-rays and MRI for diagnosis and extension study of neoplasia (cortical destruction, calcifications)
  • infections (sequestrum, bone destruction, collections)
  • measurement of lower limbs rotation defects
  • guided puncture or drainage
  • lower contrast resolution than MRI to analyse cancellous bone and soft parts tumor spread, doesn't show bone edema
  • limited accuracy in a region containing thick pieces of metal (artifacts)
  • CT angiography (malformation, tumors, traumatic lesions)

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PROBLEM MANAGEMENT

1. Trauma

  • Plain films: should include at least two joint segments with two different projections, looking at: fracture, bony avulsion, callus, angulation, shortening, luxation; soft parts: swelling, joint effusion. Later: bone union, algodystrophy, posttraumatic osteoporosis, heterotopic calcifications
  • MRI: joint lesion, ligaments, tendons, menisci, labrum, bone contusion, occult or stress fracture, osteochondral fracture (osteochondritis dissecans), muscular lesion (muscle tear, atrophy, myositis ossificans), algodystrophy
  • CT-scan with multiplanar reconstructions: preoperative study of a complex fracture (elbow, wrist, acetabulum, tibial plateau, ankle and tarsal bones)
  • US: tendon or muscle rupture, haematoma, rib fracture, immature bone partial fracture in children, effusion
  • Scintigraphy: aseptic necrosis, stress fracture, algodystrophy (highly sensitive but not specific)

2. Infection

  • Plain X-rays: osteopenia, bone destruction, bone sclerosis, sequestrum, joint space narrowing, soft parts calcifications, gas
  • CT-scan: complementary to plain X-rays for infection diagnosis, abscess detection, guided puncture, drainage
  • MRI: cancellous bone involvement, soft parts
  • scintigraphy: infection location
  • US: bone surface, collections, effusion, guided puncture, drainage

3. Tumors

  • Plain X-rays: bone destruction, bone sclerosis, periosteal reaction, pathologic fractures, soft parts calcifications; mandatory for tumor classification (image may be typical) and grading
  • MRI: tumor spread to bone and soft parts, skip lesions, tumor recurrence
  • CT-scan: bone destruction, calcifications (tumor classification in correlation with conventional X-rays), guided biopsy. Detection of thoraco-abdominal metastases
  • US: bone surface lesions, soft parts, guided biopsy
  • Scintigraphy: metastatic dissemination to bone (from breast, prostate, lung, kidney, thyroid tumors, etc.)

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4. Degenerative, inflammatory and metabolic lesions

  • Plain films supine or weight bearing: congenital or posttraumatic alignment defects, malformations, degenerative osteoarthritis, chondrocalcinosis, erosions, periarticular osteopenia, subluxation, intraarticular loose bodies, soft parts calcification
  • MRI: shoulder pain (rotator cuff tendons, labrum, ligaments), knee pain (menisci, ligaments, cartilage, subchondral bone, synovial membrane, loose bodies), hip (aseptic necrosis, occult fracture, algodystrophy, labrum, loose bodies, femoroacetabular impingement) and other joints, tendons (Achille's), bone or soft parts edema, muscle atrophy
  • CT-scan: deformity, erosions, calcifications, loose bodies
  • US: effusion and synovial cyst (knee), tendinopathy, rotator cuff complete tears, osteophytes, bone surface erosions. Guided infiltration

5. Malformation, long bone deformity

  • Plain X-rays, weight bearing: min. 2 joint segments, lower limbs angles, dynamic views
  • Fluoroscopy (joint rebound, subluxation, mobility)
  • CT-scan: measurement of torsion angles of the lower limbs, patellar index, 3D reconstructions
  • US: hip dysplasia diagnosis in the neonate (from 6 weeks to 6 months old)

6. Prostheses and implants

  • Plain X-rays: axes, limbs length differences, secondary fracture, implant rupture, loosening, infection signs, luxation, foreign bodies, heterotopic ossifications
  • Arthrography: septic or aseptic loosening, fistula
  • MRI, CT-scan may be useful in spite of metallic artifacts
  • US: collection, effusion; allows guided puncture
  • Scintigraphy: fracture, loosening, infection proof.

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Pierre Bénédict, MD, FMH radiologist, Lausanne, 1997-2018

References:

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