Detailed Exam Notes

1. Radiological and Ultrasound Techniques Used in Diagnosis of Orthopedic Injuries

Conventional Radiography (X-rays)

 Principle: X-rays are a form of ionizing radiation that can penetrate the body to
varying degrees depending on tissue density. Dense structures like bones absorb more
X-rays and appear white on the radiograph, while less dense tissues, such as muscles
and organs, appear in varying shades of gray.
 Applications:
o Bone Fractures: X-rays are the first imaging modality used to diagnose bone
fractures. They are especially valuable in emergency settings due to their
speed and wide availability.
o Joint Dislocations: X-rays help in visualizing joint alignment and detecting
dislocations.
 Limitations:
o X-rays are less effective for imaging soft tissues like muscles, tendons, and
ligaments.
o Projectional imaging can sometimes miss fractures or dislocations depending
on the view taken, necessitating multiple views (e.g., AP and lateral).

Fluoroscopy

 Principle: Fluoroscopy uses continuous X-ray beams to create real-time images,

displayed on a monitor. This is particularly useful in procedures that require guidance.
 Applications:
o Intraoperative Guidance: Used by orthopedic surgeons during procedures
like fracture reduction and joint replacements.
o Dynamic Assessments: Fluoroscopy allows for the assessment of joint
movement and instability.
 Advantages: Provides real-time imaging which is crucial for guiding needles or
implants during procedures.
 Limitations: The spatial resolution is lower than that of static X-rays, and there is a
higher dose of radiation involved.

Computed Tomography (CT)

 Principle: CT scans use a series of X-ray images taken from different angles and
computer processing to create cross-sectional images of the body. This provides
detailed images of bone structures.
 Applications:
o Complex Fractures: CT is superior to X-rays for detecting complex fractures,
particularly those involving joints (e.g., tibial plateau fractures).
o Bone Tumors: CT helps in assessing bone tumors, especially in determining
the extent of cortical bone involvement.
 Advantages:
o Detailed Bone Imaging: Provides detailed images of bone, making it
indispensable in the assessment of fractures and bone integrity.
 o Multiplanar Reconstruction: Allows for the reconstruction of images in
different planes (coronal, sagittal), aiding in comprehensive evaluation.
 Limitations:
o Radiation Exposure: CT scans involve higher radiation doses than
conventional X-rays.
o Soft Tissue Imaging: While CT can visualize soft tissues, its contrast
resolution is inferior to MRI.

Magnetic Resonance Imaging (MRI)

 Principle: MRI uses powerful magnetic fields and radio waves to generate detailed
images of organs and tissues. It does not use ionizing radiation.
 Applications:
o Soft Tissue Injuries: MRI is the gold standard for imaging soft tissues,
including muscles, ligaments, tendons, and cartilage. It is especially useful for
diagnosing tears, sprains, and degenerative changes.
o Bone Marrow Pathology: MRI can detect changes in bone marrow, such as
those seen in osteomyelitis or bone tumors.
 Advantages:
o Superior Soft Tissue Contrast: MRI provides excellent contrast between
different soft tissues, which is crucial in musculoskeletal imaging.
o No Radiation: MRI does not expose patients to radiation, making it a safer
option for repeated imaging.
 Limitations:
o Cost and Accessibility: MRI is more expensive and less available than other
imaging modalities like X-ray or CT.
o Contraindications: Patients with certain implants (e.g., pacemakers) cannot
undergo MRI.

Ultrasonography

 Principle: Ultrasound imaging uses high-frequency sound waves to produce images

of internal body structures. The sound waves are emitted by a transducer, which then
receives the echoes reflected from tissue interfaces.
 Applications:
o Tendon and Ligament Injuries: Ultrasound is often used as a first-line
investigation for assessing tendon and ligament injuries, such as rotator cuff
tears or Achilles tendinopathy.
o Soft Tissue Masses: Ultrasound helps in differentiating between cystic and
solid masses, aiding in diagnosis and management.
 Advantages:
o Real-Time Imaging: Allows for dynamic assessment, making it useful for
visualizing structures during movement (e.g., assessing the movement of
tendons).
o No Radiation: Safe for all patients, including pregnant women and children.
o Cost-Effective: Ultrasound is relatively inexpensive compared to CT and MRI
and is widely available.
 Limitations:
o Operator Dependency: The quality of the ultrasound image and its
interpretation heavily depend on the skill of the operator.
 o Limited Penetration: High-frequency transducers, while providing high
resolution, cannot penetrate deeply, limiting their use to superficial structures.

2. Basic X-ray and MRI Interpretation Techniques

X-ray Interpretation

 Radiographic Densities:
o Bone: Appears white due to high density and X-ray absorption.
o Soft Tissue: Appears in varying shades of gray, depending on the type and
density of tissue.
o Fat: Darker gray due to lower density compared to muscle.
o Air: Appears black, as it does not absorb X-rays.
 Fracture Evaluation:
o Alignment: Check for any misalignment of bone structures, which may
indicate a fracture or dislocation.
o Cortical Disruption: Look for breaks or irregularities in the bone cortex,
which suggest a fracture.
o Joint Spaces: Narrowed or widened joint spaces can indicate conditions like
arthritis or dislocation.
o Soft Tissue Signs: Swelling or the presence of gas in soft tissues can indicate
an underlying fracture or infection.
 Importance of Multiple Views: Since X-rays are two-dimensional, multiple views
(e.g., anteroposterior, lateral) are necessary to fully evaluate a structure and avoid
missing fractures.

MRI Interpretation

 T1 vs. T2-Weighted Images:

o T1-Weighted: Best for anatomical detail. Fat appears bright, and fluid appears
dark. Useful for assessing bone marrow and detecting fatty infiltration or
hemorrhage.
o T2-Weighted: Best for detecting pathology. Fluid appears bright, making it
useful for identifying edema, inflammation, and other fluid-rich lesions.
 Soft Tissue Evaluation:
o Ligaments and Tendons: Appear as low signal (dark) structures on both T1
and T2 images. Tears or inflammation will appear as areas of altered signal
intensity.
o Cartilage: Normal cartilage has a smooth, uniform signal. Degeneration or
injury may cause thinning or signal changes.
o Bone Marrow: On T1-weighted images, bone marrow has a high signal
intensity due to fat content. Pathological conditions, such as tumors or
infections, alter this signal.
 Pathology Detection:
o Edema and Inflammation: Best seen on T2-weighted images due to the high
fluid content.
o Tears and Ruptures: Appear as areas of discontinuity or altered signal
intensity in ligaments, tendons, or muscles.

3. Ultrasonic Imaging of Soft Tissue Injuries

Ultrasound Technique

 Transducers:
o Linear Array Probes: Commonly used in musculoskeletal imaging, operating
at frequencies between 10 and 15 MHz. High-frequency probes provide
excellent resolution for superficial structures.
o Curved Array Probes: Used for deeper structures but with lower resolution.
 Image Interpretation:
o Tendons: Appear as bright, linear (fibrillar) structures. Healthy tendons are
uniformly echogenic, whereas tendinosis or tears result in hypoechoic areas or
discontinuity of fibers.
o Muscles: Normal muscle tissue is hypoechoic with echogenic septations.
Tears can manifest as areas of disruption, fluid collections, or hematomas.
o Ligaments: Appear as compact, hyperechoic bands. Partial or complete tears
result in thickened, hypoechoic areas with possible fiber discontinuity.
 Dynamic Imaging:
o Real-Time Assessment: Ultrasound allows the operator to move the joint or
muscle during imaging to assess how structures behave in motion. This is
crucial for diagnosing dynamic conditions such as tendon subluxations or
muscle tears that may not be visible in static images.
o Guidance for Interventions: Used to guide needle placements for injections,
aspirations, or biopsies in real-time, ensuring precision and safety.

Advanced Ultrasound Techniques

 Elastography:
o Principle: Measures tissue stiffness by applying slight pressure with the
transducer. The elasticity of tissues can indicate health or disease, as normal
tendons and muscles are relatively stiff.
o Applications:
 Achilles Tendon: Elastography can detect areas of softening within
the tendon, which is indicative of tendinopathy.
 Muscle Stiffness: Useful in rehabilitation, as it can measure changes in
muscle stiffness during recovery from injury.
 Color Doppler:
o Blood Flow Assessment: Doppler ultrasound evaluates blood flow within
tissues. Increased blood flow (hyperemia) can indicate inflammation or active
healing.
o Applications:
 Inflammation Detection: Useful for identifying inflamed areas in
conditions like tendinitis or myositis.
 Tumor Vascularity: Helps differentiate between benign and
malignant masses based on their vascular patterns.