Advanced Musculoskeletal Physiotherapy Self-Directed Learning Modules

Advanced Musculoskeletal Physiotherapy Self-directed Learning Modules:

Screening clinics/

Soft tissue review clinic

2014

Module 2: Radiology

Prepared by Alfred Health on behalf of the Victorian Department of Health 2014

Module 2: Radiology

Contents

2.1: Radiation Safety 4

2.2: Indications for Imaging 6

2.3 Requesting Imaging 13

2.4: Interpreting Plain Film Imaging (Screening /soft tissue review clinics) 16

2

Understanding Imaging for Advanced Musculoskeletal Physiotherapists
PRACTICE CONTEXT
This learning module has been developed in the practice context of an experienced musculoskeletal physiotherapist working according to the defined scope of practice in an Orthopaedic or Neurosurgery screening clinic or a soft tissue ED review clinic setting. It should be read in conjunction with the organisation’s policy and procedures for imaging requested by physiotherapists and the operational guidelines for advanced musculoskeletal physiotherapy services. The learning included in this module supports the physiotherapist working in a advanced practice role where they can request plain film imaging only for the management of musculoskeletal conditions.
In circumstances where red flags are identified, and/or non-musculoskeletal conditions are suspected on initial assessment, handover to the parent medical team will occur in a timely manner. When imaging ordered for a suspected musculoskeletal condition suggests red flags or a potential non musculoskeletal cause, the physiotherapist will liaise with the Orthopaedic or Neurosurgery consultant before proceeding any further. To support their ability to do this, the learning module addresses a basic knowledge of radiological imaging for non-musculoskeletal presentations. The physiotherapist should be able to identify the clinical significance and limitation of their scope of practice in regards to imaging and management of non-musculoskeletal conditions if they arise and act appropriately to ensure a timely referral onto the medical team.

2

2.1: Radiation Safety

LEARNING OBJECTIVES
1.  To understand the key principles of ionizing and non ionizing radiation and the commonly used modalities within each category
2.  To understand the importance of guidelines and referral criteria
3.  To understand the risks and contraindications with each modality with a focus on plain film imaging
4.  To understand radiation safety in relation to pregnancy and protection of the foetus
5.  To understand the importance of optimising radiation dose
6.  To complete the radiation safety learning module and quiz prior to commencing the ordering of plain film imaging
KNOWLEDGE
Ionizing and non ionizing radiation
·  Define each and list modalities categorized as either ionizing or non-ionizing.
Guidelines and referral criteria5
·  Has it been done before?
·  Does it need to be done?
·  Is it needed?
·  Is it needed now?
·  Is it the best investigation
·  Has the problem been adequately described?
·  Are too many investigations being performed?
Risks and contraindications
For the following modalities
·  Plain film imaging
·  CT
·  MRI
·  Nuclear medicine
·  Ultrasound
·  Describe the risk of childhood cancer associated with imaging1, 3, 4
·  Who is at risk and what questioning is required to ascertain high risk populations?1-4, 7-11
·  Understand the relative risks associated with each modality
·  How is risk minimized?
Optimizing radiation dose
·  What are the contributing factors that help the referrer understand the magnitude of radiation dose of various investigations3
RECOMMENDED RESOURCES
1. Australian Radiation Protection & Nuclear Safety Agency (2013) Protecting people and the environment from the harmful effects of radiation. www.arpansa.gov.au
2. Australian Radiation Protection and Nuclear safety agency Commonwealth of Australia (2008) Radiation protection in nuclear medicine. Radiation protection series publication no.14.2
http://www.arpansa.gov.au/pubs/rps/rps14_2.pdf
3. Cain, T & Wallace, A (2009) Radiation risk of medical imaging for adults and children. Inside Radiology. http://www.insideradiology.com.au/pages/view.php?T_id=57
4. Dickie G & Fitchew R (2004) Medical Radiation and the Risk of Cancer. Editorial, 7 June 2004. Medical Journal of Australia. 180, 11, 548 – 549.
https://www.mja.com.au/journal/2004/180/11/medical-radiation-and-risk-cancer
5. European Commission Directorate-General for the environment (2000) Referral Guidelines for Imaging. Radiation Protection 118.
http://ec.europa.eu/energy/nuclear/radioprotection/publication/doc/118_en.pdf
6. Image Gently (2013) http://www.pedrad.org/associations/5364/ig/
7. International Atomic Energy Agency (2013) Radiation protection of patients
http://rpop.iaea.org/RPoP/RPoP/Content/index.htm
8. National Council on Radiation Protection & Measurements (2012) http://www.ncrponline.org/
9. National Occupational Health & Safety Commission Commonwealth of Australia (1995) Recommendations for Limiting Exposure to Ionizing Radiation.
http://www.arpansa.gov.au/pubs/rps/rps1.pdf
10. National Occupational Health & Safety commission Commonwealth of Australia (1995) National standard for limiting occupational exposure to ionizing radiation.
http://www.arpansa.gov.au/pubs/rps/rps1.pdf
11. Radiological Society of North America (2013) The radiology information resource for patients. Patient safety. http://www.radiologyinfo.org/
12. Stuchly M, Szabo L & Duchene A (1991) Protection of the patient undergoing a magnetic resonance examination. IRPA/INIRC Guidelines. Health Physics 61(6) December, 923-928.
13. Shellock, R & D services inc (2012) MRI safety.com. Magnetic Resonance Procedures: Summary of Bioeffects and Safety Research 1985-1999.
http://www.mrisafety.com/
Check local organizational policies and procedures from intranet

Module 2. 1 Radiology – Radiation Safety 5

2.2: Indications for Imaging

LEARNING OBJECTIVES
To understand the following:
1.  Clinical decision rules to determine the need for ankle and foot radiographs following injury
2.  Clinical decision rules to determine the need for knee and lower leg imaging following injury
3.  Clinical decision rules to determine the need for hip imaging following injury
4.  Clinical decision rules to determine the need for scaphoid imaging following injury
5.  Clinical decision rules to determine the need for shoulder and arm imaging following injury
6.  Clinical decision rules to determine the need for cervical imaging
7.  Clinical decision rules to determine imaging in non-traumatic cervical spinal pain
8.  Clinical decision rules to determine the need for thoracolumbar imaging following injury
9.  Clinical guidelines for imaging in back pain
10.  Indications for imaging of non-traumatic musculoskeletal pain/symptoms of the upper and lower limbs
11.  Indications for imaging of suspected stress fracture
12.  Indications for imaging of suspected AVN of hip
13.  Indications for imaging of the following suspected non-musculoskeletal conditions:
a.  suspected bony metastases*
b.  suspected multiple myeloma*
c.  suspected soft tissue mass*
d.  suspected acute osteomyelitis*
e.  suspected DVT*
(*all patients to be reviewed by and handed over to the Orthopaedic or Neurosurgical consultant if non-musculoskeletal conditions are suspected)
KNOWLEDGE
Musculoskeletal Presentations
Foot and ankle1, 4, 5, 24
·  Define Ottawa foot and ankle rules
·  Describe indications, advantages and limitations for radiography of foot and ankle injuries,
·  Describe indications, advantages and limitations for CT of foot and ankle injuries
·  Describe indications, advantages and limitations for US of foot and ankle injuries
·  Describe indications, advantages and limitations for MRI of foot and ankle injuries
·  For non-traumatic foot and ankle pain, consider potential diagnoses, describe indications for imaging, advantages and limitations of each imaging modality
Knee and lower leg1, 5, 6, 9, 16, 24, 27, 28
·  Define Ottawa knee rules and Pittsburgh decision rules
·  Describe indications, advantages and limitations for radiography of knee and lower leg injuries
·  Describe indications, advantages and limitations for CT of knee and lower leg injuries
·  Describe indications, advantages and limitations for US of knee and lower leg injuries
·  Describe indications, advantages and limitations for MRI of knee and lower leg injuries
·  For non traumatic knee pain, consider potential diagnoses, describe indications for imaging, advantages and limitations of each imaging modality
Hip and thigh1, 5, 12, 16, 17, 24
·  Describe indications, advantages and limitations for radiography of hip and thigh injuries
·  Describe indications, advantages and limitations for CT of hip and thigh injuries
·  Describe indications, advantages and limitations for US of hip and thigh injuries
·  Describe indications, advantages and limitations for MRI of hip and thigh injuries
·  For non traumatic hip and thigh pain, consider potential diagnoses, describe indications for imaging, advantages and limitations of each imaging modality
Shoulder and arm1, 5, 10, 24
·  Describe indications, advantages and limitations for radiography of shoulder and arm injuries, including shoulder dislocation, rotator cuff tears, calcific tendonitis and acromio-clavicular injuries
·  Describe indications, advantages and limitations for CT of shoulder and arm injuries
·  Describe indications, advantages and limitations for US of shoulder and arm injuries
·  Describe indications, advantages and limitations for MRI of shoulder and arm injuries
·  For non traumatic shoulder and arm pain, consider potential diagnoses, describe indications for imaging, advantages and limitations of each imaging modality
·  Describe clinical decision for imaging for frozen shoulder and OA. What is the appropriate imaging and indicate advantages and limitations.
Elbow and forearm1. 5. 24
·  Describe indications, advantages and limitations for radiography of elbow and forearm injuries
·  Describe indications, advantages and limitations for CT of elbow and forearm injuries
·  Describe indications, advantages and limitations for US of elbow and forearm injuries
·  Describe indications, advantages and limitations for MRI of elbow and forearm injuries
·  For non traumatic elbow and forearm pain, consider potential diagnoses, describe indications for imaging, advantages and limitations of each imaging modality
Wrist and hand1, 5, 11, 24
·  Describe indications, advantages and limitations for radiography of wrist and hand injuries
·  Describe indications, advantages and limitations for CT of wrist and hand injuries
·  Describe indications, advantages and limitations for US of wrist and hand injuries
·  Describe indications, advantages and limitations for MRI of wrist and hand injuries
·  For non traumatic wrist and hand pain, consider potential diagnoses, describe indications for imaging, advantages and limitations of each imaging modality
Scaphoid1, 5, 11, 24
·  List the factors that contribute to the suspicion of a scaphoid injury
·  Describe a positive scapholunate ligament disruption and describe adolescent versus adult imaging
·  Describe the factors that contribute to local variations in managing a scaphoid injury without positive initial plain film imaging
·  Describe different pathways in managing a suspected scaphoid fracture that isn’t positive with initial imaging. Outline advantages and limitations of each
Cervical Spine1, 5, 7, 8, 13, 15
·  Describe the NEXUS and Canadian C spine criteria for cervical spine imaging following trauma. Identify the purpose of the criteria. List the sensitivities and specificities of using each tool.
·  Describe the Harbour View Clinical Decision Rule for predicting high risk cervical spine fracture.
·  List plain film views, the advantages and limitations of plain film imaging
·  Describe why CT is useful. List advantages and limitations.
·  Describe indications and limitations for use of MRI.
·  Describe clinical decision rules for imaging the non trauma patients with neck pain only, radiculopathy, possible cord compression or possible spinal canal stenosis.
Thoracolumbar Spine1, 5, 14, 18, 25, 26
·  Describe clinical principles for imaging of patients presenting with thoracolumbar spinal pain
·  Describe clinical decision making rules for imaging of patients presenting with low back pain alone.
·  Describe imaging for patients presenting with suspected sciatica/radiculopathy.
·  Describe imaging for patients with suspected cord or cauda equina compression.
·  Describe imaging for patients with suspected spinal canal stenosis.
·  Describe imaging of choice for suspected stress fracture
·  Describe imaging of choice for suspected infection
·  List plain film views, the advantages and limitations of plain film imaging
·  Describe why CT is useful. List advantages and limitations.
·  Describe indications and limitations for use of MRI
Suspected stress fracture1, 5, 23
·  Describe the imaging of choice for suspected stress fracture
·  What should happen if plain film imaging is inconclusive with continued high clinical suspicion? List advantages and limitations of each modality.
Suspected AVN of the hip1, 5, 17
·  Describe the imaging of choice for suspected AVN of the hip. Describe what you would see and outline advantages of plain film and limitations.
·  Describe indications for MRI, advantages and limitations.
·  Describe indications for nuclear bone scan, advantages and limitations.
·  Outline the procedure for consultation and referral if AVN is suspected
Osteoarthritis1, 5
·  Discuss the imaging of choice for suspected osteoarthritis of the hip or knee
·  List plain film views, advantages and limitations of plain film imaging
Non-musculoskeletal presentations (*all patients to be reviewed by and handed over to the Orthopaedic or Neurosurgical consultant if non-musculoskeletal presentations suspected)
Suspected acute osteomyelitis19
·  Define osteomyelitis
·  Discuss imaging pathway for suspected osteomyelitis.
·  Discuss plain film findings and limitations.
·  Discuss bone scan findings and limitations.
·  List other imaging that may be useful.
·  Outline the procedure for consultation and referral if osteomyelitis is suspected
Suspected DVT2
·  Outline the Wells criteria
·  Describe the value of ultrasound. Discuss limitations.
·  Outline the procedure for consultation and referral if a DVT is suspected
Suspected bony metastases21
·  Define bony metastases
·  Describe the preferred first line of imaging for suspected multiple myeloma
·  Outline the procedure for consultation and referral if multiple myeloma is suspected
·  What other imaging maybe requested by the medical team?
Suspected soft tissue mass20
·  Describe the preferred first line of imaging for a suspected soft tissue mass
·  Outline the procedure for consultation and referral if a soft tissue mass is suspected
·  What other imaging maybe requested by the medical team?
RECOMMENDED RESOURCES
1. Anderson J & Read J (2008) Atlas of Imaging in Sports Medicine. 2nd edition. McGraw Hill.
2. Anderson, D, Bormanis, J, Clement, C, Gray, L, Guy, F, Lewandowski, B, Mitchell, M, Robinson, K.,
Wells, P (1997) Value of assessment of pretest probability of deep-vein thrombosis in clinical management. The Lancet. 350, 1795-1798.
http://www.udel.edu/PT/PT%20Clinical%20Services/journalclub/caserounds/
05_06/apr06/valueofassessmentdvt.pdf
3. Bessen, T, Clark, R, Shakib, S & Hughes, G (2009) A multifaceted strategy for implementation of the Ottawa ankle rules in two emergency departments. British Medical Journal. 339, 396-403.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2726279/
4. Government of Western Australia Department of Health, Diagnostic imaging pathways (2012) Ankle injury http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/bone-and-joint-trauma/ankle-injury
5. Raby, N, Berman, L & de Lacey, G (2005) Accident and Emergency Radiology: A Survival Guide. 2nd edition. Elsevier Saunders.
6. Stiell, I, Wells, G, Hoag, R, Sivilotti, M, Cacciotti, T, Verbeek, P, Greenway, K, McDowell, I, Cwinn, A, Greenberg, G, Nichol, G & Michael, G (1997) Implementation of the Ottawa knee rules for the use of radiography in acute knee injuries. Journal of American Medical Association. 278, 23 2075-2079.
http://www.ncbi.nlm.nih.gov/pubmed/9403421
7. Stiell, I, Clement, C, McKnight, R, Brison, R, Schull, M, Rowe, B, Worthington, J, Eisenhaurer, M, Cass, D, Greenberg, G, MacPhail, I, Dreyer, J, Lee, J, Bandiera, G, Reardon, M, Holroyd, B, Lesiuk,H & Wells, G (2003) The Canadian C-Spine Rule versus the NEXUS Low- Risk Criteria in patients with trauma. New England Journal of Medicine. 349, 26, 2510-2518.
http://www.ncbi.nlm.nih.gov/pubmed/14695411
8. Stiell, I, Wells, G, Vandemheen, K, Clement, C, Lesiuk, H, De Maio, V, Laupacis, A, Schull, M, McKnight, R, Verbeek, R, Brison, R, Cass, D, Dreyer, J, Eisenhauer, M, Greenberg, G, MacPhail, I, Morrison, L, Reardon, M & Worthington, J (2001) The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients. Journal of American Medical Association. 286,15,1841-8.
http://calgaryem.com/files/Stiell_Canadian_C-spine.pdf
9. Diagnostic imaging pathways (2012) Post traumatic knee pain or instability
http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/bone-and-joint-trauma/knee-injury
10. Diagnostic imaging pathways (2012) Shoulder pain/instability
http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/bone-and-joint-trauma/shoulder-injury
11. Diagnostic imaging pathways (2012) Scaphoid fracture
http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/bone-and-joint-trauma/scaphoid-fracture
12. Diagnostic imaging pathways (2011) Suspected hip fracture
http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/bone-and-joint-trauma/suspected-hip-fracture
13. Diagnostic imaging pathways (2011) Cervical spine injury
http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/bone-and-joint-trauma/cervical-spine-injury
14. Diagnostic imaging pathways (2012) Thoraco-lumbar spine injury
http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/bone-and-joint-trauma/thoraco-lumbar-spine-trauma
15. Diagnostic imaging pathways (2012) Non traumatic neck pain
http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/musculoskeletal/non-traumatic-neck-pain
16. Diagnostic imaging pathways (2012) Non traumatic hip or knee pain
http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/musculoskeletal/non-traumatic-hip-or-knee-pain
17. Diagnostic imaging pathways (2012) Avascular necrosis of the hip
http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/musculoskeletal/avascular-necrosis-of-the-hip
18. Diagnostic imaging pathways (2012) Low back pain
http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/musculoskeletal/low-back-pain
19. Diagnostic imaging pathways (2012) Suspected acute osteomyelitis
http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/musculoskeletal/suspected-acute-osteomyelitis
20. Diagnostic imaging pathways (2012) Soft tissue mass
http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/musculoskeletal/soft-tissue-mass
21. Diagnostic imaging pathways (2012) Bone metastases
http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/musculoskeletal/bone-metastases
22. Diagnostic imaging pathways (2012) Multiple myeloma
http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/musculoskeletal/multiple-myeloma
23. Diagnostic imaging pathways (2012) Suspected stress fracture
http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/musculoskeletal/suspected-stress-fracture
Up to Date
24. Baccei, S, Kim, C & Weissman, B (2013) Imaging techniques for evaluation of the painful joint
http://www.uptodate.com/contents/diagnostic-imaging-of-joint-pain?source=see_link
25. Deyo, R, Gatewood, M, Staiger, T & Wipf, J (2012) Diagnostic testing for low back pain
http://www.uptodate.com/contents/diagnostic-testing-for-low-back-pain?source=search_result&search=lumbar+spine&selectedTitle=5%7E150
26. Hockberger, R & Kaji, A (2012) Evaluation of thoracic and lumbar spinal column injury
http://www.uptodate.com/contents/evaluation-of-thoracic-and-lumbar-spinal-column-injury?source=search_result&search=lumbar+spine&selectedTitle=2%7E150
27. Jude, C & Modarressi, S (2012) Radiologic evaluation of the acutely painful knee in adults
http://www.uptodate.com/contents/radiologic-evaluation-of-the-acutely-painful-knee-in-adults?source=search_result&search=actue+knee+injuries&selectedTitle=9~35
28. Jude, C & Modarressi, S (2012) Radiologic evaluation of the chronically painful knee in adults
http://www.uptodate.com/contents/radiologic-evaluation-of-the-chronically-painful-knee-in-adults?source=search_result&search=radiologic+evaluation+of+knee&selectedTitle=1~150

Module 2. 2 Radiology – Indications for imaging 12