MSK

PGY4 Musculoskeletal Radiology HSC

Supervisor: Dr. John Hopkins, Health Sciences

The following is an outline of both the curriculum as well as the goals and objectives of the Musculoskeletal rotation during PGY 4, 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.

The minimum number of plain radiographs is 40 per day. A list of all exam accession numbers of reported exams is to be submitted to Karen on a weekly basis.
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.

Perform with formal guidance 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.

Demonstrate learning of knowledge based objectives and mastery of technical objectives for the first rotation.

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.

Review Arthritis in Black and White
Musculoskeletal MRI: Infection, Tumor, Hip, Wrist & Review Chapters Shoulder, Knee, Infection, Tumor)
The Requisites: Musculoskeletal Imaging: Chapters 16-28, 50
Orthopedic Imaging: Chapters 17-23, 24-28
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.

Review and consolidate knowledge of normal MRI anatomy of the knee and shoulder.

Demonstrate learning of normal MRI anatomy of the hip and wrist.

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

Review recognition and description of 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.

Demonstrate learning of a systematic approach to arthritis. Be able to describe and differentiate salient radiologic (radiographic, CT and MR) features of common arthropathies including osteoarthritis, inflammatory arthropathy (rheumatoid, psoriatic, reactive, juvenile chronic, ser-negative spondyloarthropathies), crystal deposition diseases (calcium pyrophosphate deposition, gout, hydroxyapatite deposition), neuropathic arthropathy, connective tissue disease (systemic lupus erythematosis, scleroderma, dermatomyositis), pigmented villonodular synovitis, and synovial chondromatosis

Demonstrate a systematic assessment of a solitary lesion of bone and be able to categorize the lesion as aggressive or nonaggressive. Develop an appropriate differential diagnosis based on patient age, lesion location, and lesion characteristics (margin, matrix, periosteal reaction, soft tissue extension). Demonstrate knowledge of systematic, safe and cost effective radiologic work-up of bone lesions including biopsy approach and compartmental anatomy.

Recognize and describe common locations of and radiologic manifestations of osteonecrosis.

Recognize features of MSK neoplasms including soft tissue and bone tumors. The resident should know the features of aggressive & 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
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 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 hip and wrist)

Recognize and describe imaging features of internal derangements of joints with an emphasis on the hip and wrist. 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
Knee OCD
Rotator cuff tear
Biceps tendon rupture (proximal and distal)
Shoulder and hip labral tear
Hip AVN
Transient osteoporosis
Hip Fracture
Femoroacetabular Impingement
Kienbock’s
TFCC Tear
Tenosynovitis
Scapholunate/lunotriquetral ligament 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

Communicator
Collaborator

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.

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.

Manager
Health Advocate

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.

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.

Scholar
Professional

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.

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.

PGY4 Musculoskeletal Radiology SCH

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

The following is an outline of the goals and objectives of the Musculoskeletal rotation during PGY 4, incorporated into CANMEDS format. I will make every effort to make your rotation a positive experience. I 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, 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 each week. 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. The more experienced Senior Resident should take on a heavier caseload.

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.

The minimum number of plain radiographs is 40 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.

Perform with formal guidance 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.

Demonstrate learning of knowledge based objectives and mastery of technical objectives for the first rotation.

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 the resident at beginning of the rotation and are the responsibility of the resident until their return at the end of rotation.

Review Arthritis in Black and White
Musculoskeletal MRI: Infection, Tumor, Hip, Wrist & Review Chapters Shoulder, Knee, Infection, Tumor)
The Requisites: Musculoskeletal Imaging: Chapters 16-28, 50
Orthopedic Imaging: Chapters 17-23, 24-28
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