Imaging for Knee and Shoulder Injuries
■ Knee radiographs of the acutely injured knee in the emergency department are rarely useful for determining therapy, except in patients with any of the following conditions: isolated tenderness of the patella, tenderness at the head of fibula, inability to flex 90°, inability to bear weight both immediately and in the emergency department for a total of four steps, or if the patient is an adult aged 55 or older (strong evidence).
■ Physical examination by an experienced pediatric physician is as accurate as an MRI to diagnose articular cartilage injury, discoid lateral meniscus, anterior cruciate ligament tears, and medial meniscal tear (limited evidence). An MRI is likely more accurate for lateral meniscal tears. However, if the MRI study is interpreted by a physician experienced with the skeletally immature patient, the accuracy could be superior, and additional associated pathology can be identified (limited evidence).
■ An MRI in the setting of osteochondritis dissecans plays an important role in a specific subgroup of patients where it is imperative to assess the integrity of the overlying cartilage (limited evidence).
■ An MRI in the setting of discoid lateral meniscus plays a role in identifying the state of the meniscus in order to assess surgical reparability and also to identify superimposed pathology, such as articular cartilage damage (limited evidence).
■ The use of radiography to evaluate children with first-time acute shoulder trauma is to confirm a fracture or a dislocation and to evaluate the alignment and possible extension into the physeal plate (limited evidence).
■ The use of radiography to evaluate patients with suspected recurrent atraumatic shoulder dislocation is unnecessary in most cases (limited evidence). Furthermore, selective imaging strategies may be able to reduce the number of pre-reduction and/or post-reduction radiographs required in suspected first-time or traumatic shoulder dislocations (limited evidence).
■ Identification of labral and glenohumeral ligament tears is important especially in patients with a history of shoulder dislocations, as they have a high recurrence rate. No dedicated MRI or Magnetic Resonance Arthrogram (MRA) studies have been done in children. However, studies in adults show that MR arthrogram has a high sensitivity and specificity to identify and classify these lesions (limited to moderate evidence). This information is useful to the orthopedic surgeon in preoperative planning of joint stabilization procedures.
KeywordsIschemia Drilling Osteoarthritis Expense Gadolinium
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