,Chapter 1: General Principles of Musculoskeletal Imaging
Case 1
Case Scenario:
A 32-year-old construction worker presents with recurrent knee pain
following a minor injury six months ago. His primary care physician
orders repeated radiographs despite the chronic nature and poor
diagnostic value of plain films in soft tissue assessment.
Key Issues:
Inappropriate modality selection
Delayed definitive diagnosis
Radiation exposure concerns
Guiding Questions:
When is MRI preferred over plain radiographs?
How does the ALARA principle guide imaging decisions in
chronic conditions?
What educational interventions can reduce unnecessary imaging?
Suggested Solution:
Recommend MRI as the gold standard for soft tissue injuries. Reinforce
the ALARA principle to the care team and incorporate clinical decision-
support tools to guide imaging selection.
,Case 2
Case Scenario:
A rural hospital lacks advanced imaging modalities. A 68-year-old
patient with suspected femoral neck fracture cannot be confirmed via
plain radiographs due to poor image quality and overlapping bowel gas.
Key Issues:
Imaging access disparity
Diagnostic uncertainty
Rural resource limitations
Guiding Questions:
What are alternatives when ideal imaging is unavailable?
How can telemedicine or teleradiology support underserved
settings?
What protocols can mitigate risk while awaiting transfer?
Suggested Solution:
Stabilize the patient and arrange transfer to a regional facility with CT.
Use clinical exam scoring systems and consult via teleradiology.
Advocate for mobile CT units in rural care planning.
Case 3
Case Scenario:
A 10-year-old boy presents with elbow pain after a fall. The physician
hesitates to order X-rays due to concerns over pediatric radiation
exposure.
Key Issues:
Balancing diagnostic necessity vs. radiation risk
, Pediatric imaging standards
Incomplete ossification complicating interpretation
Guiding Questions:
How does ALARA apply to pediatric imaging?
What guidelines determine the necessity for radiographs in
pediatric trauma?
How can non-ionizing modalities be better integrated?
Suggested Solution:
Use the Pediatric Elbow Rule to guide imaging necessity. Employ
ultrasound as a first-line screening. Educate providers on growth plate
considerations in imaging interpretation.
Case 4
Case Scenario:
A patient with suspected metastatic bone disease refuses imaging due to
fear of radiation-induced cancer.
Key Issues:
Patient education
Informed consent
Risk vs. benefit of diagnostic procedures
Guiding Questions:
How should providers address patient radiation fears?
What alternatives are appropriate?
How does informed consent apply in imaging?
Suggested Solution:
Provide comparative risk data and emphasize diagnostic necessity. Offer
Case 1
Case Scenario:
A 32-year-old construction worker presents with recurrent knee pain
following a minor injury six months ago. His primary care physician
orders repeated radiographs despite the chronic nature and poor
diagnostic value of plain films in soft tissue assessment.
Key Issues:
Inappropriate modality selection
Delayed definitive diagnosis
Radiation exposure concerns
Guiding Questions:
When is MRI preferred over plain radiographs?
How does the ALARA principle guide imaging decisions in
chronic conditions?
What educational interventions can reduce unnecessary imaging?
Suggested Solution:
Recommend MRI as the gold standard for soft tissue injuries. Reinforce
the ALARA principle to the care team and incorporate clinical decision-
support tools to guide imaging selection.
,Case 2
Case Scenario:
A rural hospital lacks advanced imaging modalities. A 68-year-old
patient with suspected femoral neck fracture cannot be confirmed via
plain radiographs due to poor image quality and overlapping bowel gas.
Key Issues:
Imaging access disparity
Diagnostic uncertainty
Rural resource limitations
Guiding Questions:
What are alternatives when ideal imaging is unavailable?
How can telemedicine or teleradiology support underserved
settings?
What protocols can mitigate risk while awaiting transfer?
Suggested Solution:
Stabilize the patient and arrange transfer to a regional facility with CT.
Use clinical exam scoring systems and consult via teleradiology.
Advocate for mobile CT units in rural care planning.
Case 3
Case Scenario:
A 10-year-old boy presents with elbow pain after a fall. The physician
hesitates to order X-rays due to concerns over pediatric radiation
exposure.
Key Issues:
Balancing diagnostic necessity vs. radiation risk
, Pediatric imaging standards
Incomplete ossification complicating interpretation
Guiding Questions:
How does ALARA apply to pediatric imaging?
What guidelines determine the necessity for radiographs in
pediatric trauma?
How can non-ionizing modalities be better integrated?
Suggested Solution:
Use the Pediatric Elbow Rule to guide imaging necessity. Employ
ultrasound as a first-line screening. Educate providers on growth plate
considerations in imaging interpretation.
Case 4
Case Scenario:
A patient with suspected metastatic bone disease refuses imaging due to
fear of radiation-induced cancer.
Key Issues:
Patient education
Informed consent
Risk vs. benefit of diagnostic procedures
Guiding Questions:
How should providers address patient radiation fears?
What alternatives are appropriate?
How does informed consent apply in imaging?
Suggested Solution:
Provide comparative risk data and emphasize diagnostic necessity. Offer
