SWISSRADIOLOGY.COM	SWISSRADIOLOGY.COM
SWISS RADIOLOGY PORTAL

Magnetic Resonance CT-Scan Digital Radiology Mammography Densitometry Ultrasound / Interventional Radiology i Current pathology imaging guidelines @ Swiss Physicians email directory Tips page Links Abbreviations The Hippocratic Oath Institute access map Patient prepararation Site map Home Website in french

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 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 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 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) 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.) 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. Pierre Bénédict, MD, FMH radiologist, Lausanne, 1997-2018 References: Guide du bon usage de la SFR ACR (American College of Radiology) guidelines Radiation protection 118: Referral guidelines for imaging (Office for official publications of the European Communities)