In 1997, the first edition of this book posed the question: What is to be gained in patient care if rehabilitation clinicians have an understanding of radiology? By 2005, the second edition had drawn on the experiences of educators, students, and clinicians to provide concrete examples of the answer: The correlation of imaging findings to clinical findings can result in more comprehensive patient evaluations, more specific treatment plans, and better patient outcomes.
Now, in 2014, the inclusion of imaging content in all physical therapy curriculums in the United States is verification of that answer. And now, in this new century, in this fourth edition of the book, that answer is even more critical as the profession struggles to encompass and adapt to the new politics and economics of how health care is delivered.
Imaging is a science, a product, and a tool that drives patient care—either directly, or in its overutilization (well documented in the last decades), or in its underutilization (due to insurance regulations). It is an understatement to say we now live in a transitional era: transitional between a wealth of imaging technology and a dearth of equitable distribution of services, between a wealth of specialists on the health-care team and a dearth of interprofessional communication, between a wealth of insurance regulations and a dearth of enlightened decision making. “Imaging” is no longer a niche topic tangent to those interested in orthopedics. Knowledge of imaging is prerequisite to being a valuable player on the health-care team, to negotiating for preauthorizations for our patients, to being able to communicate effectively with other medical professionals, and to being able to intelligently inform insurance professionals, as well as our own professional and political colleagues.
Overwhelmed? Don't be. Remember—you are not the radiologist—you are a member of the health-care team who has to learn enough about imaging to function competently and collaboratively. Collaboration requires an understanding of what the other parties have to offer. This text strives to be an excellent primer—the place to gain an overview of musculoskeletal imaging interwoven with your knowledge of anatomy and clinical pathology. Imaging will then become one more brick in your foundation to build clinical work upon.
If you have no background in imaging, this text will introduce it to you in logical steps. I want all students to feel as though they are learning to swim in the shallow end of the pool instead of being thrown into the deep end! So, it is desirable to wade through these chapters in the order intended. Read the first three chapters to gain a foundation in radiologic science, search patterns, and common pathological and fracture characteristics on radiograph. Read the next three chapters to understand advanced imaging modalities. After that, you can paddle around the next eleven anatomy chapters at your leisure.
Each anatomy chapter has a similar organization. First, a brief anatomy review to refamiliarize yourself with the joint structures. Next, the routine radiologic evaluation is explained in detail. Radiologic observations are taught for each projection with illustrations to point out anatomic relationships. The tracings of the radiographs are most valuable for teaching you to “see” radiographic anatomy. Ideally, you will make your own tracings of the radiograph with a transparency sheet and marker, and then compare their results to the printed tracing. Drawing is an invaluable intellectual exercise for teaching anatomy and will enhance your perception of radiographic anatomy in a dimension not afforded by point-and-click exercises.
After the routine radiographic section is completed, the advanced imaging protocols for CT and MRI are presented. The order of this content is significant: The value of learning the routine radiographic exam prior to advanced imaging is that radiographs serve as anatomical “road maps” to help you understand the orthogonal planes of sectional imaging. The advanced imaging protocols are organized to allow you to see each advanced imaging exam “at a glance” on a two-page spread. Basic observations are listed for each orthogonal plane.
Finally, the remainder of each anatomy chapter covers the trauma and pathologies most often seen at that body region. Brief descriptions, etiologies, treatments, and prognoses are accompanied by images that encompass that condition. Each chapter concludes with a Summary of Key Points to help reinforce main ideas and Self-Tests using unknown images to challenge the reader's visual interpretation skills.
Of curious note in the anatomy chapters is Chapter 10, “The Chest Radiograph and Cardiopulmonary Imaging.” I do recognize this anatomy is not part of our musculoskeletal system, strictly speaking! However, this material was requested by educators. And, after being included in the last edition, it has made perfect sense, and continues to make sense—especially now in light of our more integrated role in the health-care team. The chest radiograph is the most commonly made radiograph on any given day in any country in the world. It is undeniably a standard tool of basic health care. In that respect, it is easily covered with the other radiologic fundamentals of this book, especially following the related anatomy of the thoracic spine/sternum/ribs in Chapter 9. In another respect, the results of the chest radiograph will determine what treatment we can do safely with our patients—whether it is musculoskeletal or cardiopulmonary in nature. The final consensus is that it is very fitting for physical therapy students and clinicians to understand the language and the fundamentals of the chest radiograph.
The book wraps up appropriately with the final chapter, “Integration of Imaging into Physical Therapy Practice.” This content is important in understanding the increasing role of nonphysician clinicians as first-access providers and referral sources. It also explores some practical issues and evolving issues regarding practice environments and how they relate to ordering imaging in the military, in civilian roles, and outside the United States.
The access code that comes with this book opens the door to several excellent online resources. These resources are specific to the book's content and should not be overlooked:
Interactive radiographic exercises are designed to teach you to identify normal anatomy on every routine radiographic projection of each joint. Also, another set of exercises requires the viewer to identify different pathologies on radiographs.
An MRI Anatomy Tutorial lets you scroll through all three orthogonal planes, slice by slice, of each joint. Pertinent anatomy is labelled and also color-coded to make it as easy as possible to learn sectional anatomy.
Glossaries for each chapter are available with an active search feature.
Focus On research topics, related to each chapter, are in-depth articles written on specific pathologies and related imaging.
Access to the entire current American College of Radiology (ACR) Musculoskeletal Appropriateness Criteria for 180 musculoskeletal conditions. These evidence-based criteria rank imaging modalities for their efficacy in diagnosing a suspected pathology. Not every physician can be aware of what imaging is best in every situation. And because physical therapists are often in a position to make imaging recommendations, they must be aware of and have ready access to this resource!
To conclude, this fourth edition preserves the vision of the original edition: to provide an organized introduction to the fundamentals of musculoskeletal imaging. By the time you get to the end of this book, my hope is that you have (1) an awareness of the capabilities and limitations of the different imaging modalities, (2) an understanding of the information given on the radiologist's report, and (3) the ability to look at images yourself and appreciate what you can see. Viewing the image independently can be a critical skill, especially if you are seeking information not provided on the radiologist's report, which is written from and to a medical physician's perspective. The information the rehabilitation clinician seeks can be of a different nature.
So, it is the wish of this author that you find satisfaction in gaining a new vision with which to see anatomy and the potential to develop the skill of correlating imaging findings with clinical findings. It is hoped that this skill will become a valuable tool that contributes to the rehabilitation of patients, helps you collaborate with the other professionals, and furthers your individual growth.
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