LTC (Ret) Peter Van Geertruyden, MD, discusses the how to best utilize advanced imaging (CT, MRI, and Ultrasound) in Evaluating Common Musculoskeletal Conditions, paying special attention to the American College of Radiology Appropriateness Criteria and when contrast (intravenous or intra-articular) is most appropriate in the ordering of advanced MSK imaging.
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Return to Main Symposium Page Hello. This is Dr Peter Van Gertrude in on the staff radiologists with medical center radiologists. My subspecialty is musculoskeletal radiology. And today I'll be giving you a talk on advanced musculoskeletal imaging, how and when to best utilize C T. Marie and ultrasound in evaluating common musculoskeletal conditions. I have no relevant disclosures. So the agenda will be taking a joint by joint approach, asking ourselves when C t memory or ultrasound might be useful on evaluating each specific joint towards the end of the talk. Will also be talking about soft tissue masses as its own entity again when to use ultrasound armory and how we utilize contrasts as well. I'll be touching on that throughout the talk when to give when to consider giving intravenous contrast. When do we consider giving intra articular contrast and we're gonna start with shoulder and all the information from the slides really derives from the A c R. Appropriateness criteria and this is ah, collection of pdf files that have been made available, their open source on the Internet. You can google a CR appropriateness criteria for basically almost any medical condition, and it will give you an idea of what type of imaging. What modality might be the most appropriate for utilization? And you often see a graft like this when we're talking about variants such as traumatic shoulder pain. Any ideology, initial imaging, and it will give you a list of procedures, and then it will evaluate the appropriateness. Usually appropriate is the highest rating. Usually not appropriate is the lowest rating and may be appropriate is in the middle and sometimes could be considered clinically appropriate. Also, the relative radiation level is listed. So the mawr icons, the larger the radiation dose and something we should always consider when evaluating patients is how much radiation we're delivering. When we trying to answer a clinical question, yeah, so let's talk about the shoulder and you'll be hearing me refer to the following that Radiographs are always the most appropriate initial imaging study, and that's regardless off joint. And even when evaluating a soft tissue mass, you should always start with the radiographs weaken drive. A lot of information. It's the cheapest modality onboard. It is widely readily available, so it's something that we should always start with. But when should we move on to advanced imaging and you'll see listed below the various modalities and again, whether we're giving contrast, whether that be intravenous or intra articular contrast. So what does Emery the shoulder without contrast? Best evaluate for would say, the number one diagnosis that we are evaluating for is a rotator cuff tear, whether that be acute or chronic is there typically found in older patients. And along with that, we often will see bursitis. And that's typically the subway criminal sub deltoid bursitis that comes along with rotator cuff, uh, pathology. When we're talking about patients who have limited range of motion, that is a nen titty we described as adhesive capsule itis also referred to as frozen shoulder and emery. The shoulder, without contrast, is good for not only helping to diagnose these entities, but also finding out what the underlying cause off the adhesive capsule itis is. Usually this is a secondary process. Biceps tendonitis memory is very good at evaluating whether a biceps tendon is intact. Whether it extends whether by such pathology extends to involve the origin and the superior labrum and then pain after rotator cuff repair, Emery could be very good at evaluating whether or not there is a re tear in the rotator cuff post repair. When should we consider evaluating patients with Emery Shoulder? Are Thakkar AFI? Typically, these are our younger patients, and we're specifically looking for labral pathology and trying to delineate the type of labral injury. So when I see patients being ordered for a memory Artha Graham and a 65 year old typically a low yield exam again, I would recommend labral pathology sticking with our ordering it for our younger patients. Because the reason is that labral pathology is theme main source of shoulder pain in our younger population. As we get older, it is very normal to see a tear or degeneration of the labor room, and it is usually not the cause of a patient's symptoms. That being said specifically for dislocation events in our younger patients with this location, we want to get a look, a better look at the labrum and how that might have been injured. And so we used Marie Shoulder Arthur Graham. Pain after rotator cuff repair can be useful in that it will evaluate whether contrast extends past. The rotator cuff, threw a thorn rotator cuff and into the several chromium sub deltoid bursa So our orthopedic surgeon and colleagues will sometimes order Emery Shoulder Arthur Rock graffiti after rotator cuff repair. Typically without contrast, when should we consider ordering a CT shoulder? Non contrast? This is when radiographs show a human head, human all neck or scapula fracture. When should we consider C T shoulder? Are three ah, graffiti? Typically, patients who are unable to undergo Emery and so C T shoulder are thermography can be a nice alternative again, these air should be generally are younger patients with either a injury or a sports related injury. Pain after rotator cuff repair against et shoulder Arth Ah, graffiti can be a nice alternative when patients are unable to go undergo Marie. Ultrasound of the shoulder is very operator dependent and can be useful for patients who are unable to go undergo emery for whatever. Whatever reason, it is good at assessing the rotator cuff, the biceps tendon and for bursitis. However, it cannot assess the labrum or masius structures through the sin. Ah, graffiti. Not being able to penetrate those structures or evaluate structures joint structures deep in the joint. We're going to shift to the elbow and talk about advanced elbow image ing again. Radiographs are always the most appropriate initial imaging study. When do we talk about moving onto an emery of the elbow without contrast? Most commonly, it's going to be in patients with mechanical symptoms such as locking, clicking or limited range of motion. Emery can be also very good when you suspect him a cult fracture or for high level athletes assessing for bone contusion can also assess stability. Oven osteo, condo injury or lesion so, typically either being overuse injury or a post traumatic astrakhan role injury, we can assess for instability. Oven Aussie condo fragment within the joint so Emery could be useful there also for chronic epic candle itis refractory to empirical treatment, whether that be a medial or lateral tennis elbow or golfers elbow patients who are not getting better with conservative management, Ameri can be useful not only to assess the degree of terror or inflammation. Associate ID with the common extensive or common tendon. Origin attended Nanosys tendonitis, but can also look for other potential causes of pain when we suspect collateral ligament tear again. These air, typically in our higher level athletes, such as pictures we're looking for on our collateral ligament injury and memory can be very useful for that when we suspect biceps, tendon tear or suspect nerve abnormality. So, in a nutshell, again, memory is very good at looking at the soft tissue structures that C, T and X ray do not evaluate that well. Emery elbow are throttle. AFI can be useful again in our higher level, athletes suspecting collateral ligament injury whether they are potential surgical candidate again for mechanical symptoms were looking for loose into articular osteo conta fragments. Loose bodies as they're known and our photography this tends that potential space of the joint capsule allows us basically to look at the joint itself. The lining of the joint, the cartilage on the ligaments. Um, intrinsic. Yeah, Marie elbow without And with contrast and you'll hear me repeat. This is an important point throughout the talk. With contrast, we are almost always looking for an infectious or inflammatory process or bursitis or a palpable soft tissue mass. Those were really the two main reasons we give contrasts, infection, inflammation or a mass lesion. The contrast allowing us to evaluate the pattern of enhancement, especially for a soft tissue mass. Whether there is internal enhancement In the case of infectious or inflammatory arthritis, it can give us a look inside the joint and evaluating for Aussies erosions C t elbow Non contrast is very useful when you suspect on occult fracture CT being much more readily available than an Emory. So if a patient typically when we see patient emergency department and there's no obvious fracture. But there might be a joint effusion or the patient is has ongoing symptoms and you suspect an occult fracture. Typically treat these patients conservatively with a splint and then consideration for C T to evaluate for an occult or non displaced fracture to explain their symptoms. Ultrasound of the elbow is again very operator dependent. Thes air patients unable to undergo Emery most often used in and around the elbow, looking to evaluate superficial soft tissue mass lesions or biceps tendon tear moving on to the hand and wrist After we've obtained radiographs of the hand and wrist, we consider M. R. I, C T and ultrasound for the following reasons. Marie wrist or hand. Without contrast when initial radiographs or negative or equivocal, you can really consider repeating a radiograph in 10 to 14 days and what we're really looking for is signs of interval healing early Perry Oster reaction that might clue us into, ah, fracture that might not have been picked up because it was non displaced. So treating patients conservatively, getting a repeat radiograph in 10 to 14 days if patients cannot wait that long for whatever reason, and you're highly suspicious for a fracture or a bone contusion, given the mechanism of trauma, that's when memory can be very useful. So acute risk or hand fracture when you suspect attendant or a ligament tear or trauma, and also very important when there's any sense or concern for radio owner or carpal mala alignment. In absence of the fracture, you can damage terror ligament structures in about the hand and risk that will call cause a mala alignment, so we might not necessarily see a fracture. That's where Marie can be very useful. Assessing ligament of structures typically again in the hand when we use emery fingers and hands were looking for mala alignments in the absence of a fracture or potentially a thorn tendon, such as in the case of Jersey Finger C T risk. Non contrast is an alternative for looking for a cult fracture. Initial radiographs When there is just a radio owner or carpal mala alignment in absence of a fracture, we can utilize bilateral C T. Of the wrist to evaluate from side to side whether there's any sort of sense of instability at the distal radio owner. Joint these air typically patients that fall on outstretched hands. They might not have a fracture, but they might have significant ligament injury of the distal radio owner. Joint ultrasound of the hand and risk could be very useful when suspecting penetrating trauma with foreign bodies, especially those foreign bodies that might not show up on plain film radiographs. Remember that typically we see metallic fragments, but we don't see would plastic fragments foreign body fragments very well on plane film technique, so ultrasound can be very useful and the patient can point to the area of concern on typically will see a small fluid collection or irritation around it, retained foreign body and helpful for potential hand surgeon toe thio. Remove that those entities. I just discussed her in the more acute setting. When you talk about chronic hand and wrist pain, start always with radiographs, and when we talk about Emery of the risk in hand without contrast. Ongoing chronic risk pain. Unexplained, persistent symptoms. I wouldn't jump to it initially, but definitely with patients with a unknown ideology of chronic risk. Pain Memory can be helpful if you're suspecting an occult or a stress fracture in a patient with chronic risk pain, memory can be useful for an old skate FOID fracture. It is useful to evaluate for evidence of non union Mallya union or osteonecrosis. We can help identify which portions of a skate would fracture might have its blood supply in jeopardy. And we start to see early osteonecrosis when we suspect carpal tunnel syndrome. Emery Risk. Very useful. We can look for caliber change of the median nerve at the carpal tunnel. We also look for Boeing of the flexor retina. Akyel Um thes are signs of carpal tunnel syndrome, a central Asian. This also be both in the acute and chronic setting. Thes are very important lesions to detect these air ulnar collateral ligament injuries of the thumb, also known as game keepers, thumb in the past. More recently, you often will see it with a ski pole injury, thumb, ulnar collateral ligament, a Stenner Lesion Marie. Very useful to assess whether those are complete tears of the ligament, partial tears or whether they involve toe. What degree the masius origin in the setting of an avulsion injury. When do we use wrist emery Risk? Arthur Grams. We don't use it as much, given the advance in imaging technology, especially with our three t emery. We can get a good look at structures inside the wrist to include the T FCC triangular fire Village cartilage complex, but patients with chronic owner cited risk pain. We're looking for T FCC injury at the request off a hand surgeon, we can inject contrast into the radio carpal joint and evaluate where that contrast does or does not go, and that can help us determine whether we're dealing with partial thickness or full thickness. T FCC INJURIES When do we give Ivy contrast in the hand of the wrist again? We're talking about inflammatory arthritis, very common in the wrist and hand to see a wide variety of inflammatory arthritis. If you have a possible soft tissue mass or suspected occult, gangly, insist emery hand or wrist with and without contrast can be order c t risk non contrast is best utilized for suspecting a cult or stress fracture, and also in combination with Emery can help to evaluate for nonunion Mallya union or osteonecrosis. Ultrasound of the hand and wrist is very useful and assessing for Sina Vitus and when we're looking for even weaken, evaluate for Aussies erosions actually with ultrasound in conjunction with looking for Sina Vitus and hyper Reema increased blood flow to the Sino Veum that would indicate a more acute inflammatory process. Ultrasound. Very good for superficial soft tissue masses anywhere in the body. And as I mentioned before, for a foreign body about the hand and wrist, ultrasound can be very useful. We're going to switch gears and move on toothy lower extremities. We're gonna talk about the hip and pelvis in the acute settings. We always start with playing film radiographs, usually to view. And when there is initial radiographs that air negative or equivocal, we often will go on to either CT, hip, non contrast or Marie hip. Non contrast, I think, given the increased availability of C T and the rapid acquisition, I think a CT for negative radiographs or equivocal radiographs with a high pre test probability for a fracture. I think CT can get your answer very quickly. It's not as good as when you're talking about injury to soft tissue structures. So how do we evaluate advanced hip and pelvis imaging in the chronic setting after we've obtained radiographs? Emery hip, without contrast, is very good at evaluating for soft tissue abnormalities such as tendonitis. If patient has chronic hip pain, with a negative or mild osteoarthritis on a radiograph that does not explain out of proportion to the degree of the patient's pain. That's when we should consider Emery hip without contrast. Also, when we are evaluating tronic hip, lower back pain, pelvic ornithology you want to exclude the hip is a source. Oftentimes, patients with symptoms and around pain or in and around the hip, even potentially in the mid thigh back can be The pain can be originating from the hip itself and so chronic hip pain or chronic hip, lower back public or pain where again, the radiographs have not shown significant osteoarthritis or any significant abnormalities to explain the patient's symptoms, consider Emery, and then a little more advanced. But when radiographs are suggestive off entities such as P V. N s pigmented villain, ocular Sina Vitus or osteo Condra mitosis. These are synovial abnormalities and Marie being the best modality to evaluate for that. Yeah, when do we order Emery hip Artha Graham similarly to the shoulder? We're suspecting a labral tear as the patients potential underlying ideology for their pain. We also talk about Morrissey tabular impingement, whether that be a camp or pincer them as Tyler impingement or combination of the two. Typically, again, consider these four patients under the age of 40 years old, where we're looking for label pathology, label terror memory, hip without and with contrast, not very commonly used but can be useful when we're looking for inflammatory arthritis. Septic arthritis of the hip, looking for a potential abscess. Palpable soft tissue mass again superficial. Being better evaluated with ultrasound mawr. Deep, deep, palpable soft tissue mass or concerned for soft tissue mass should be evaluated with and without intravenous contrast, moving down to the knee after we've obtained radiographs off the knee. Being the most appropriate initial imaging study in the acute setting, Emery and the knee is very good at suspecting for evaluating for a suspected occult fracture or internal derangement. So you have a patient, especially a younger patient who has significant trauma twisting, injury, ski injury X rays are negative. With the exception of a joint of fusion, A joint effusion could be very telling as to whether or not there's internal derangement. So if you have a negative plain film, but with a joint effusion, you're suspecting internal derangement. Marie is going to be the way to G O for evaluating for ligament ISS and meniscal injuries of the knee. C T Non contrast, fall or twisting injury with a tibial plateau fracture. Suspect additional bone or soft tissue injury we're looking for, especially with tibial plateau fractures assessing the degree of cortical step off at the Tibial Plateau Fracture site. It is not good for assessing meniscal or ligament is injury as well as Marie. So I would most often recommend CT knee, shoulder wrist for those patients where you have a high pre test probability of a fracture that might not be evident on plain film X rays. C t a. That CT angiography. Lower extremities with ivy contrast are for those patients with significant trauma to the knee. Most often, these there are patients involved in a motor vehicle accident or need dislocation. C T. A. Similar to a C T. A of the chest allows evaluation of arterial structures. And so we time the contrast such that we are able to delineate the arterial structures in and around the knee. And we're looking for pseudo aneurysm or internal flap evidence of aortic injury in patients with significant trauma to the knee in the chronic setting. After radiographs, we look for Marie of the knee without contrast when evaluating radiographs that air negative or demonstrated joint effusion history of cartilage or meniscal repair for patients that have a history of surgery of the knee, memory is going to be your optimal modality when we suspect a sub condo insufficiency fracture. These were previously known as spontaneous osteonecrosis. We're sunk thes patients typically present with pain out of proportion to the X ray. So the X ray not showing any significant arthritis or fracture, but they can get thes non displaced Connell insufficiency fractures patients who present with severe pain out of proportion to the X ray. Consider Emory I. If a radiograph demonstrates in Austria Condra lesion, a loose body or signs of prior injury. Sadan fractured tibial spine avulsion. We then look for Emory Thio. Further assess again the soft tissue structures of the knee and inside the joint Marie or see teen er Throgs AFI, typically reserved for patients with prior meniscal surgery. Prior Condra or astrakhan dra lesion repair prior cartilage repair or suspected loose buys. We don't do these very frequently, but they can be nice studies when evaluating the postoperative knee. And the reason we don't USA's much are Thakkar a fee of the knee. And the risk, for that matter again, is through the high level off high resolution imaging that were able to obtain with three t emery of thes joint structures. Very important consideration for Emery of the knee is not usually indicated in patients for whom radiographs or diagnostic of osteoarthritis. So when we have patients that come in for a new memory of their knee and they're plain film shows, try compartment osteoarthritis. Marie is can be low yield because it really just shows the same thing. It's because just going to show the degenerative changes in much finer detail. But it might not change the patient's clinical management. In other words, they're probably a candidate for knee replacement, and Marie is not going to change that decision making. So when we start talking about try compartment of Austria threat especially mild, moderate, moderate, especially severe. I would try to avoid using Emory in those patients, unless again you're concerned patients had osteoarthritis for X number of years and suddenly comes in with severe pain, such that there might be a stress fracture. Subcontinent Since insufficiency fracture, you can consider Emery moving down to the ankle and then the foot. So I hope we all have heard and utilize the auto ankle rules for when to order radiographs of the ankle. These air patients that are unable to bear weight immediately after an injury there point tender over the media mileage Olis tip of the latter malley Olis. Tell us, Tell us or Cal, Kanye's or they have inability to emulate four steps in the emergency department immediately after injury. These air all indications to obtain plain film radiographs of the ankle absent thes most ligament sprains don't need an X ray. Yeah, When do we move on? Thio Marie without contrast again, since ankle sprains air so prevalent we really on Lee, consider Emery of the ankle. Once the patient has failed, UM, or conservative management, physical therapy, ice elevation and these sorts of things, and especially if initial radiographs or negative, the patient has ongoing, persistent symptoms. If there's any evidence of a nasty contra lesion, injury of the Taylor Dome is a common injury with high grade sprains of the ankle. Then we can consider Emery of the ankle when we have a physical exam or radiographs with stress views that demonstrate an alignment abnormality suggesting ace and despotic injury. These are significant injuries of the distal tibia fibula Cindy's Moses. These air, also called high ankle sprains Emery can be useful for evaluating these. Ascend is Monica ligaments and can be very important to identify early on so the patient doesn't go on to chronic instability. SETI the ankle is also good when we have initial radiographs that are negative. Patient is ongoing pain. There are several subtle fractures of the ankle that might not be identified on plane film. The main one that comes to mind is the anterior process of the Cal can. Yous could be difficult to evaluate on plain films secondary thio overlying structures. But if the patient has ongoing pain. Initial radiographs negative. SETI The ankle will be good for evaluating for a fracture. Yeah, acute trauma with radiographs similar to Emory for potential lost O'Connell injury. SETI can be good In conjunction with Marie, I would defer to our podiatry and orthopedic ankles surgeon colleagues in assessing when that might be the best modality in the setting of an acute Astrakhan Drel injury. Definitely in a chronic Astrakhan religion. It can also assess for instability of the fragment Onda similar to Emory. When there's any evidence of instability. Stress fused, demonstrating alignment abnormality. Cintas Vanek injury CTN memory can be used in conjunction. So for chronic ankle pain or ankle symptoms after we've obtained radiographs are four main reasons for evaluating the ankle With Marie. With in the setting of normal radiographs is a suspected osteo Condra legion of the tailor down These could be debilitating injuries Suspected tendon abnormality Whether that be a thorn tendon, Tina Santa Vitus tendon. Oh, sis, I think of posterior tibial dysfunction para Neil dysfunction with interstitial split tearing common things we see, um, if they're suspected ankle instability, we're looking for assessing ligament of structures or whether There's a suspected ankle impingement, and we have various impingement syndromes around the ankle torso tunnel. We have interior ankle impingement. Post your impingement. We have various nerve impingement syndromes on memory can be useful when we use ultrasound in the ankle. When we suspect attendant abnormality. We're looking for Para Neil instability. When you have ah, potential clicking or subluxation of the tendon, we can evaluate with ultrasound real time what is actually happening. What is what is making that clicking sound? Sometimes you can get paranormal tendons that are subluxation with within the tendon sheath. Eso in unstable. A parallel tendons within the tendon sheath can be identified with ultrasound. The foot in the acute setting similar to the auto ankle rules. We have the Ottawa foot rules, and these are three. The point tenderness of the navicular bone point tenderness at the base of the fifth metatarsal, or inability to emulate four steps in the emergency department immediately after injury. Very important. If you suspect a Lisfranc injury that is a mid foot injury Tarso metatarsal injury. You should get weight bearing foot radiographs, and the reason for this is that these injuries might not show up is a fracture and they'll Onley show up. The widening or the evidence of instability will only show up with weight bearing foot radiographs. So we need suspected Lisfranc injury order weight bearing foot radiographs in the acute setting and Emery. The foot is good at evaluating for these list frank ligament injuries and exactly what ligaments are injured. If you suspect an acute tendon injury, whether that be a laceration or the such that is best evaluated with Marie, if you suspect an occult fracture or dislocation and then lastly, with turf toe plant er plate injury. These are mawr commonly with our high level athletes, football players, Um, you can get plantar plate injuries, whether that be the first foot that's referred to as turf toe or second plantar plate injuries common more seen in the chronic setting patients with Alex Valdas deformities and chronic second plant er plate to generation to the point where they subluxation or might even dislocate at their second MTP. Joint 60 ft is most often utilized in complex fractures of the foot and poly. Trauma Patient, also in conjunction with Emery, can be useful. You know, suspected Lisfranc injury. We're looking for subtle avulsion fractures in a pattern that would suggest a Lisfranc injury on occult fracture dislocation. CC foot. Very good at assessing small non displaced fractures as the potential calls for a patient's ongoing pain with negative plain film radiographs. As with the hand and the risk, consider ultrasound. When you have a patient with penetrating trauma with foreign body and initial radiographs are negative. Ultrasound could be very good for evaluating these. When do we use advanced imaging in the foot in the chronic setting after plain films? Emery The Foot are for the following chronic mid foot pain. Um, ongoing post traumatic pain. Despite physical therapy, we're looking for a cult fractures. We can also see painful accessory obstacles numerous obstacles around the mid foot that could potentially, um, be fractured or irritated. And Emery will show those nicely for metatarsal. Al Gia Marie. Very good at assessing for your Morton's neuroma that's typically at the plant are 2nd and 3rd in a metatarsal spaces, sesamoid itis of the plantar first ray at the great toe plantar plate injury and Freiburg's infraction, a vascular necrosis of the second metatarsal head for chronic plantar heel pain, I would reserve memory for those patients who have failed conservative therapy for plantar fasciitis. If there's a concern for a high grade plantar fascia tear, we see those rarely. But I would not jump to Emory for patients with run of the mill plantar fasciitis unless they've again failed conservative treatment. Suspected nerve entrapment, Baxter's neuropathy. We see we can. Well, we might not see the actual nerve entrapment. What we'll see are the secondary findings off a neuropathy, mainly muscle oedema, muscle D innovation, a Dema those air. Really, Oftentimes we'll just see secondary signs of a nerve entrapment. So when do we? This is something we haven't talked about yet is the modality of bone scan imaging and in the foot, especially This can also actually be in the elbow in the hand on the wrist when you're suspecting chronic regional pain syndrome. This is a complex entity no and often seen in patients with ongoing chronic pain of a joint. And the bone scan Multiphase bone scan can evaluate for on alterations in blood flow Ah to that area. And so bone scan imaging can be useful for chronic regional pain syndrome. So or towards the end of the lecture, and we're gonna be talking about soft tissue masses something that I have, ah, personal interest in evaluating. And we're going to talk about three different variants when evaluating for soft tissue mass variant number one is a alluded to earlier. A few times when you're dealing with a superficial or palpable mass. Ultrasound of the area is probably your best bet now, at the same time very useful to get a plane, film radiograph and X ray of the area of interest. Because sometimes we can pick up abnormalities on the plane film in the soft tissues that might help explain that area. Some examples or post traumatic my size ossification hands or maybe a flea believeth in the in a hemangioma. So when you're evaluating superficial or palpable masses, please consider ordering plain films of the area of interest and ultrasound. Variant two is a non diagnostic evaluation by ultrasound of radiograph. There's still a clinical concern for a soft tissue mass. Emery without and with contrast, is recommended. Remember that Onley 5% of banon soft tissue tumors exceed five centimeters. Most malignancies are deep seated, so 1% of benign soft tissue tumor so in other words, super more superficial things generally are benign processes. Smaller entities are typically benign entities. Soft tissue Nia plasm, malignant Nia Plasm Yeah, typically are measuring over five centimeters, and they are deep whether that be intra muscular inter muscular along a nerve, um, along a nerve vascular bundle or a potential Aussies malignancy, um, dealing with the bone. And that's where Emery without and with contrast, is useful variant three soft tissue mass presenting with spontaneous hemorrhage or suspicion of vascular mass memory, or C t. I prefer emery for these entities. Patients do not develop spontaneous inter muscular hemorrhage. And consider using Emory to evaluate why what might be the underlying cost. Sometimes, oftentimes, there will be a mass underlying that has hemorrhaged, Um, but outside of patients that are on, um, blunt getting medications that might show up with a rectus sheath hematoma that could be common but an intra muscular hematoma of Let's say, the rectus femoris. A spontaneous hemorrhage is very uncommon and should probably be evaluated with Emery with and without contrast. So in the remaining minutes, I'm going to discuss the main takeaways from today's talk. Probably heard me mention it. Many times. Radiographs are always the most appropriate initial imaging study, especially in the knee and the hip and the shoulder advanced imaging with C T or Emory in older patients, when radiograph show, osteoarthritis is low yield because the memory or the C T, is basically going to show the same thing just to a greater detail the amount of arthritis. The exception is again patients out of proportion in paying out of proportion to the degree of osteoarthritis or the plane film. Overall, that's when you want to consider going to see Tiara Marie for our shoulder and hip. Arthur Grams. These are should be generally reserved for our younger patients, where labral pathology is suspected. Radiographs that are negative or equivocal, suspecting occult fracture. Proceed to Emory or C T. And these are the main clinical scenarios where in you should jump to C. T and Mariah little bit quicker than others because of the potential long term people. To me, morbidity is a hip pain post fall, so negative or equivocal. X rays. Clinical concern for fracture, proceed to Emery or C T, especially in emergency department probably C T risk pain, post fall. We're looking specifically most often for skateboard fractures that might not be displaced. That might not be evident on on X ray. Proceed Thio, Emery or SETI in the acute setting in the emergency department. Typically, SETI when you suspect a Lisfranc injury, these are very important to pick up. And so, after we've obtained, are again weight bearing radiographs. When you suspect a lisfranc injury and you suspect in a cult fracture in that pattern of the mid foot, you proceed to Emory or C T superficial or palpable masses again, X ray the area of interest ultrasound, the area of interests. And it is best when we have these performed at the same time or available if patients are getting X X rays. Um, and we don't have availability when we're interpreting and that goes along with Emery or C T. It really puts us at a disadvantage. So if patients are getting advanced imaging and they might have gotten an X ray somewhere else, we can always upload that into our pack system to allow us to compare the two when to give Ivy contrast. And this goes for pretty much the whole body. When we're suspecting an infectious or inflammatory process or a mass. So even when it relates to neuroimaging and we have patients where there is a clinical concern for a new infectious process or inflammatory process of the brain meningitis or where there's a suspected inter cranial mass, whether that's metastatic lesion or primary, you want to give intravenous contrast in the when we're talking about musculoskeletal imaging. Specifically, we're talking about infectious, inflammatory, arthropod thes, even when you start getting into rheumatoid arthritis, rheumatoid variants, septic arthritis, Lyme arthritis, all these different variants. It is very useful for us at the same time. Also, if you're looking for an abscess, intravenous contrast can be very useful to delineate. And that would go for the C. T of the neck if you're evaluating for a parrot insular abscess. If your last, then you want to get a C T neck with intravenous contrast. If you're looking for an abscess within the abdomen. In a patient whose post surgical we want to give intravenous contrast for masses, we want to give intravenous contrast and so we can allows us to then evaluate the patients with and without contrast. And what we do is subtract the images so we can see exactly what areas are enhancing and what areas or not. If you have any questions or concerns or at any point, need a radiology consultation. This is my personal email and my personal cell phone as radiologists, we are here to help. We are here to help guide you as to what modality is the best to answer a clinical question. I will admit that even as a radiologist, this could be These sorts of issues can be very confusing. And that's why we should make ourselves available and give talks like like this today. Toe hopefully guide you as to when and why to use advanced imaging. And the last thing I'll say is don't forget Thio access. The A C R appropriateness criteria on the website is open source. You can utilize it. Onda help again help you decide what imaging modality is best. And with that, I would like to thank you for your attention and please email me or call me if you have any questions or comments. Thank you