Musculoskeletal Radiology (SCM)

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.

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:
1. 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.

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

3. 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.

4. 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.

5. 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.

1. The minimum number of plain radiographs is 30 per day. A list of exam accession numbers of reported exams is to be submitted to the Academic Program Administrator (APA) weekly – please discuss an appropriate day with the APA.

2. All adult MR examinations for the week performed on Wednesday, Thursday and Friday.

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

4. 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.


Please read corresponding RSNA PHYSICS MODULE as outlined on the physics curriculum

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.

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

1. Medical Expert
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
• Chondrosarcoma
• 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
• Cellulitis
• 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

• 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 and PCL tear
• Meniscal injury
• MCL tear
• Lateral complex injury
• Postero-lateral corner injury
• Quadriceps/patellar tendon tear
• Rotator cuff tear
• Shoulder labral tear and Variants (Spectrum of labral injury)

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

2. Communicator
Dictate clear, detailed, and accurate reports that include all pertinent information as established in the American College of Radiology (ACR) Guidelines for Communication.

Use appropriate nomenclature when reporting radiographic, CT, MR or ultrasound (US) findings of musculoskeletal disease.

Communicate all unexpected or significant findings to the ordering provider and document whom was called and the date and time of the discussion in the report.

Obtain relevant patient history from electronic records, dictated reports, the patient, or by communication with referring provider.

Establish a therapeutic relationship with patients and communicate well with family.

Provide clear and thorough explanations of diagnosis and investigation.

Produce succinct reports that describe findings, most likely diagnosis, and, where appropriate, recommend further investigation or management.

3. Collaborator
Effectively provide feedback to radiology technologists regarding quality of exposure and patient positioning.

Recognize when it is appropriate to obtain help from senior residents or faculty when assisting referring clinicians.

Establish good relationships with peers and other health professionals. Effectively provide and receive information. Learn to deal with conflict situations.

The skills of being a collaborator are developed on a day to day basis. Residents are strongly encouraged to interact with house staff and referring physicians as “first contact” in order to better develop these skills. In addition, residents will be required to be active participants in inter and intra discipline rounds.

Consult effectively with other physicians and health care professionals.

Contribute effectively to other interdisciplinary team activities.

4. Manager
Learn competence in and make use of computer science/information technology as it pertains to Diagnostic Radiology.

Learn to set realistic priorities and use time effectively in order to optimize professional performance.

Understand the fundamentals of quality assurance.

Utilize resources effectively to balance patient care, learning needs, and outside activities.

5. Health Advocate
Learn to recognize the Radiologist’s role in ensuring appropriate radiological investigation and to act as an advocate for patients in terms of their diagnostic imaging needs.

Understands and communicates the benefits and risks of radiological investigation and treatment, including population screening and the risk of radiation exposure to the pediatric population.

To recognize the burden of illness upon the patients served by Radiology.

Benefits/risks of radiologic investigation. Consult CAR and ACR appropriateness guidelines.

6. Scholar
Participate in discussions with faculty and staff regarding operational challenges and potential system solutions regarding all aspects of radiologic services and patient care

Demonstrate an understanding and a commitment to the need for continuous learning. Develop and implement an ongoing and effective personal learning strategy.

Be able to critically appraise medical information and demonstrates basic knowledge in biostatistics and experimental design with respect to Radiology.

Demonstrate an ability to be an effective teacher of radiology.

Research & submit cases for the teaching file.

Identify potential research project with supervisors.

7. Professional
Demonstrate responsible, ethical behavior; positive work habits; and professional appearance; and adhere to principles of patient confidentiality

Demonstrate integrity, honesty, compassion and respect for diversity.

Fulfill medical, legal and professional obligations of a Diagnostic Radiologist.

Demonstrate timeliness, reliability and conscientiousness.

Understand the principles of ethics and apply these in critical situations.

Demonstrate an awareness of personal limitations, seeking advice when necessary. Accept advice graciously.