MSK

PGY2 Musculoskeletal Radiology (HSC)

(The Communicator, Collaborator, Manager, Health Advocate, Scholar and Professional CanMEDS Objectives follow the HSC MSK Objectives in Level II below)

Supervisor: Dr. John Hopkins, Health Sciences

The following is an outline of the goals and objectives of the Musculoskeletal rotation during PGY2, incorporated into CANMEDS format. The medical expert expectations have been organized by year. The remaining CANMEDS roles will be assessed throughout all rotations and will remain consistent throughout all of residency.

The assessment tools utilized during the rotation include global faculty ratings including the ITER rotation evaluation sheet. An examination assessing knowledge obtained as per the listed curricula at each stage of training will be given on the last day. The examination will assess the acquisition of knowledge throughout the rotation. The exam questions are derived from the rotation objectives, and consist of multiple choice, fill-in-the-blank, and OSCE type format. A pass mark is 70%. The inability to pass the exam will render the rotation incomplete, and the rotation will be completed at a later date.

Duties and Responsibilities

To learn the anatomy, physiology and associated pathological conditions affecting the musculoskeletal system and to be able to interpret and report associated imaging studies with an emphasis on plain radiographs.

The minimum number of plain radiographs is 30 per day. A list of all Plain Radiographs, MR and CT exam accession numbers of reported exams is to be submitted to Karen on a weekly basis – please discuss an appropriate day with Karen.
All adult MR examinations for the week from both HSC and Janeway sites (4-6 studies on Monday & 15-20 studies on Tuesday).

All MSK CT exams for the week (average 1-2 per day).
Medical Expert

Understand indications, contra-indications as well as advantages and disadvantages of various imaging modalities in the investigation of MSK disorders.

To supervise MSK rounds when scheduled.

Attend Orthopedic Trauma Rounds Tuesday @ 7:30 AM.

Gain exposure to modalities such as ultrasound, CT scanning, MRI and Nuclear Medicine imaging as they apply to the MSK system.

Participate in the education of medical students, interns and residents.

Actively participate and gain increased understanding and proficiency in MSK interventional procedures such as arthrography, joint aspiration and biopsy. Arthrograms are usually scheduled for Tuesday afternoon, but biopsies are random days. It is your duty to check the fluoroscopy list each Tuesday (Room 10, MR Unit) and biopsy list each day (Nursing Station).

Review MR protocols for your MR list each day for Monday & Tuesday.

Submit to Dr. Hopkins (in powerpoint format) 10 researched & prepared MSK cases as assigned to you by the end of the rotation.

Present 1 MSK case each Tuesday at ICR during your rotation.

Observe and understand Basic Radiographic Positioning: Radiography & MRI: approximately 2 Days will be assigned with technologist.

Generate accurate and concise radiographic reports.

Communicate effectively with patients, referring clinicians, technologists and supervisory staff.

Obtain essential patient information pertinent to the radiologic examination.

Demonstrate knowledge of clinical indications for radiography and indications for urgent and emergent computed tomography (CT) and magnetic resonance (MR) examinations.

Demonstrate a responsible work ethic.

Required Reading List

Textbooks will be provided; assigned to resident at beginning of rotation and are the responsibility of resident until their return at end of rotation.

MSK Section of Brant & Helms
Arthritis in Black and White (St. Clare’s Rotation)
Musculoskeletal MRI: Chapters 1,2,10,15 (Introduction, Marrow, Shoulder, Knee)
The Requisites: Musculoskeletal Imaging: Chapters 1, 2, 29-37, 40, 41, 45, 48, 49
Orthopedic Imaging: Chapters 4-10 inclusive, 16, 29,
Arthrography: Chapter 7 (Shoulder)
Research Assigned Topics & Cases: Resnick & related journal articles

Please read the correspondening RSNA physics module, as outlined in the physics curriculum

Learn the musculoskeletal anatomy and the normal variations.

Recognize and describe positioning and anatomy of standard radiographic examinations of the musculoskeletal system.

Demonstrate learning of normal radiographic and CT anatomy of the axial and appendicular skeleton.

Demonstrate learning of normal MRI anatomy of the knee and shoulder.

Recognize & accurately describe common fractures and dislocations of the appendicular skeleton, and know potential complications associated with them.

Recognize and describe fractures and dislocations of the cervical, thoracic and lumbar spine.

Demonstrate learning of pathophysiology and radiology of fracture healing and complications of healing such as delayed union, malunion and nonunion.

Demonstrate learning of radiographic presentation and evaluation of osteomyelitis and septic arthritis.

Recognize and describe complications of orthopedic devices including fracture fixation and spine and arthroplasty hardware.

Recognize and evaluate imaging studies which demonstrate arthopathies including: rheumatoid arthritis, psoriatic arthritis, crystalline arthropathies, osteoarthritis, sero-negative spondyloarthropathies, scleroderma as well as other connective tissue diseases, vasculitic conditions including systemic lupus.

Recognize features of MSK neoplasms including soft tissue and bone tumors. The resident should know the features of aggressive and non-aggressive lesions and be able to recognize them on imaging studies. Should know radiology, pathology, presentation and management of at least the following:

Fibrous dysplasia
Eosinophilic granuloma
Giant cell tumor
Non ossifying fibroma
Osteoid osteoma
Multiple myeloma
Metastatic disease
Aneurysmal bone cyst
Solitary bone cyst
Enchondroma
Ewing’s sarcoma
Chordoma
Pigmented villonodular synovitis
Chondroblastoma
Osteogenic sarcoma
Fibrosarcoma
Liposarcoma
Leiomyosarcoma
Malignant fibrous histiocytoma
Osteoblastoma
Hemangiomas
Osteochondroma (s)
Nerve sheath tumors
Adamantinoma

Recognize features of MSK infection on various imaging studies including:

Osteomyelitis
Septic arthritis
Cellulites
Myositis
Tenosynovitis
Abscess Formation
Discitis
Gangrene

Become proficient and show increased understanding in the interpretation of post operative imaging studies especially related to orthopedic hardware. The resident should also recognize the appearance of various types of hardware.

Know the physiology of bone formation and maintenance and be able to recognize abnormalities of this on imaging studies.

Gain increased knowledge and understanding of various metabolic conditions affecting the MSK system and be able to recognize their manifestations on imaging studies including:

Renal osteodystrophy
Rickets
Scurvy
Paget’s disease
Avascular necrosis/infarct
Neuropathic joint
Osteoporosis

Demonstrate knowledge of MRI safety issues including contraindication to scanning and use of contrast.

Demonstrate learning of the use of various pulse sequences and planes of imaging used in MRI of musculoskeletal disorders (emphasis on knee and shoulder).

Recognize and describe imaging features of internal derangements of joints with an emphasis on the knee and shoulder. The resident should have good understanding of at least the following:

ACL tear
Meniscal injury
MCL tear
Lateral complex injury
Postero-lateral corner injury
Quadriceps/patellar tendon tear
OCD
Rotator cuff tear
Shoulder labral tear

Recognize and give an appropriate differential diagnosis of at least the following imaging findings:

Mono/poly arthropathies
Lytic/radiolucent bony lesion (s)
Sclerotic bony lesion (s)
Osteopenia
Sacroillitis
Periosteal reaction
Soft tissue calcification
Soft tissue mass

PGY2 Musculoskeletal Radiology SCM

Supervisor: Dr. Eric Pike, St. Clare’s

The following is an outline of the goals and objectives of the Musculoskeletal rotation during PGY2, incorporated into CANMEDS format. I will make every effort to make your rotation a positive experience and would appreciate that any problems arising prior to, during or after your rotation be brought directly to my attention first.

The assessment tools utilized during the rotation include global faculty ratings and the ITER rotation evaluation sheet. An examination assessing knowledge obtained as per the listed curricula will be given within the last week and will assess the acquisition of knowledge throughout the rotation. The exam questions are derived from the rotation objectives, and consist of fill-in-the-blank and OSCE type format. A pass mark is 70%. The inability to pass the exam will render the rotation incomplete, and the rotation will be completed at a later date.

Duties and Responsibilities

The musculoskeletal rotation at St. Clare’s Hospital Site offers exposure to all imaging modalities and procedures related to the musculoskeletal system. During each 4 week rotation the resident should:

Concentrate first and foremost on seeing as many plain radiographs related to MSK imaging. This should include daily films from the Emergency Department, Orthopedic Clinics and Out Patient areas.

Check each day for interventional procedures that are booked including arthrograms and biopsies, as well as joint injections and aspirations.

Coordinate with attending staff and technologists in CT and ultrasound areas that MSK cases performed using these modalities should be forwarded to you. Effort should be made to be present for ultrasound studies particularly involving the shoulder and other tendons.

Review MRI cases performed under St. Clare’s. These studies are generally performed on Wednesday evening and during the day/evening on Thursday. The resident can coordinate when the cases can be reviewed. On Friday evening spinal MRI’s are also done which can be reviewed if desired but this is not mandatory. The Junior Resident should concentrate on the common exams of the knee, hip and shoulder and not be concerned about trying to do all of the cases as the workload for the week can be up to 25 cases.

At the end of your rotation, we are going to be administering a short oral exam of approximately 10 cases as part of the evaluation for the rotation. During the rotation, I will try to do some teaching sessions on various MSK topics.

You are required to learn the anatomy, physiology and associated pathological conditions affecting the musculoskeletal system and to be able to interpret and report associated imaging studies with an emphasis on plain radiographs.

The minimum number of plain radiographs is 30 per day. A list of exam accession numbers of reported exams is to be submitted to Karen weekly – please discuss an appropriate day with Karen.
All adult MR examinations for the week performed on Wednesday, Thursday and Friday.

All MSK CT exams for the week (average 1-2 per day).
All risk Ultrasound exams (average 10 – 15 per week)

Understand indications, contra-indications as well as advantages and disadvantages of various imaging modalities in the investigation of MSK disorders.

To supervise MSK rounds when scheduled.

Attend Orthopedic Trauma Rounds Tuesday @ 7:30 AM.

Gain exposure to modalities such as ultrasound, CT scanning, MRI and Nuclear Medicine imaging as they apply to the MSK system.

Participate in the education of medical students, interns and residents.

Actively participate and gain increased understanding and proficiency in MSK interventional procedures such as arthrography, joint aspiration and biopsy.

Review MR protocols for your MR list each day for Wednesday, Thursday and Friday.

Submit to Dr. Pike (in powerpoint format) 10 researched & prepared MSK cases as assigned to you by the end of the rotation.

Present 1 MSK case each Tuesday at ICR during your rotation.

Observe and understand Basic Radiographic Positioning: Radiography & MRI: approximately 2 Days will be assigned with technologist.

Generate accurate and concise radiographic reports.

Communicate effectively with patients, referring clinicians, technologists and supervisory staff.

Obtain essential patient information pertinent to the radiologic examination.

Demonstrate knowledge of clinical indications for radiography and indications for urgent and emergent computed tomography (CT) and magnetic resonance (MR) examinations.

Demonstrate a responsible work ethic.

Required Reading List

RSNA PHYSICS MODULE ON Projection X-Ray Imaging

Textbooks will be provided; assigned to the resident at the beginning of rotation and are the responsibility of the resident until their return at the end of the rotation.

MSK Section of Brant & Helms
Arthritis in Black and White (St. Clare’s Rotation)
Musculoskeletal MRI: Chapters 1,2,10,15 (Introduction, Marrow, Shoulder, Knee)
The Requisites: Musculoskeletal Imaging: Chapters 1, 2, 29-37, 40, 41, 45, 48, 49
Orthopedic Imaging: Chapters 4-10 inclusive, 16, 29,
Arthrography: Chapter 7 (Shoulder)
Research Assigned Topics & Cases: Resnick & related journal articles
Fundamentals of Skeletal Radiology, 3^rd Edition, C.A. Helms, W.B. Saunders/Elsevier 2005
Imaging of the Musculoskeletal System (Expert Radiology) Pope TL et al Saunders/Elsevier 2009
Musculoskeletal MRI, Helms C.A., Major N.M., et al, Saunders/Elsevier, 2009, (2^nd Edition)
Bone and Joint Imaging, 3^rd Edition, D. Resnick, 2004
Orthopedic Radiology, A Practical Approach, A Greenspan, Lippincott, 4^th Edition, 2004
MRI of the Musculoskeletal System, 5^th Edition, Berquist, Lippincott W/W, 2006
Musculoskeletal Imaging: A Teaching File, F. Chew, 2^nd Edition, 2005

Medical Expert
Fibrous dysplasia
Eosinophilic granuloma
Giant cell tumor
Non ossifying fibroma
Osteoid osteoma
Multiple myeloma
Metastatic disease
Aneurysmal bone cyst
Solitary bone cyst
Enchondroma
Ewing’s sarcoma
Chordoma
Pigmented villonodular synovitis
Chondroblastoma
Chondrosarcoma
Osteogenic sarcoma
Fibrosarcoma
Liposarcoma
Leiomyosarcoma
Malignant fibrous histiocytoma
Osteoblastoma
Hemangiomas
Osteochondroma (s)
Nerve sheath tumors
Adamantinoma