So You Want to Read MSK Radiography
ZEN & THE ART OF RADIOGRAPHY REPORTING (SO YOU WANT TO READ MSK RADIOGRAPHY??!!)
Donna Magid MD, M.Ed, FAUR
My opinions. Different faculty read differently, as junior residents rapidly learn. Since I will often be your 1st yr. checker on MSK Rads, this is how I'd suggest you approach reports, language and specific areas.
Please read the Elective/MSK handouts on Teamrads.com for a beginner's intro/entrance point to many common MSK radiography studies (fxs, ankle, knee, ...). The MSK Rads Curriculum will offer expanded study options once you dive in.
REPORT FORMAT: Not negotiable, has nothing to do with preferences, how you were taught, opinions.. A.I. now scans reports for billing and needs to find certain words and colons. And all dictation must be inside the relevant BRACKETS!! These are annoying [ ] for each header ( Exam,Indication, Findings, Impression...) and the commentary MUST be inside those brackets-- or Billing rejects. If you try to sign off and get that heavenly harp chord alerting you to "Unfilled fields, are you sure you want to sign?" notice -- go back and cut and paste into the brackets. Making the brackets a contrasting color to whatever background field color you select for reporting helps.
INDICATION: NO abbreviations! If clinician wrote "ORIF", "CRPP", "BBFF", etc either spell it out or substitute other words."F/U", "R/O", need expanding..."F/U wrist fracture'
EXAM: XR (side)(body part) (#views) If it pre-populates with "MIN 3 VW", or "2-3 VW", must edit that to precise #views (ie get rid of "MIN", specify actual #). If study is 'Bilat", needs to be separated into R and L and entered as two lines eg
"EXAM:XR right knee 4 views EXAM:XR left knee two views" Knees are always confusing; if the two studies are 3 views R knee and one view Bilat Knees, it becomes EXAM:XR right knee 4 views.. EXAM:XR left knee one view
Pelvis and Bilat Hips , Bilateral SI joints, can be left as one bilat 'EXAM:XR"
Multiple exams ("Scoli, Lumbar spine, L Ankle...") can/should be reported on one report—clinician doesn't want to have to open 3 separate reports—but each gets its own 'EXAM: XR...." Line. Yes, that means some Rheum reqs—eg 'bilat hands bilat wrists bilat hips bilat SI joints bilat knees bilat feet'—will end up having literally a dozen "EXAM:XR.." lines.These rules are driven by Billing/AI, not by common sense or linguistic grace! And while the Hand and Wrist reports may have overlap, 'see above' or rolling them into one Finding ("Bilat hands, Bilat wrists...") not allowed. Reading tip for Bilats: Newest images show up on L screen. Drag it also to the R screen. Then scroll images so same view of L and of R are on L and R screens respectively--( ie L frontal/R frontal, L lateral/R lateral, etc) allows easier compare/contrast of R/L hands, wrists, feet, ankles since findings often similar/related. When any bilateral findings very similar, one can (esp in Impression) say 'Nearly-symmetric bilateral hands, with demineralization, trapezium-thumb MC osteoarthrosis, no evidence of subluxations, erosions, of soft tissue calcifications." Don't force the clinician to read 2 identical paragraphs, one for R and one for L. If significant differences, report R/L separately.
COMPARISON: Date (or "None"). Sometimes reformatted CT, MR. UGI, abdo XR,provides limited comparison esp. for spine, pelvis. Once a comparison is documented it then needs to be referred to somewhere in Findings or Impression: "Without change from..." "Progressing on the left and not changed on the right since..." "Appearing since.."
FINDINGS: Start with LIMITATIONS if any ("nonvisualization C7, T1, odontoid"; "Habitus, air and feces markedly limit posterior pelvis visualization"; "External fixator markely limits detail"; "limited exam (joint above, joint below)" for long bones. Everything noted, in a hierarchy from important/major progressing to the trivia. Or, addressing the clinical query first and then other findings. Or, when there are no major findings and clinical query vague, organizing your observations—proximal to distal, for instance.
IMPRESSION: Must mention study/side as given in EXAM; easiest to therefore start with "Right shoulder..." Bilateral hands: Right....Left...". This is a Billing/AI requirement that has nothing to do with report clarity, since it would be obvious to a human that an Impression of 'Left radial head fracture' refers to an elbow. One can combine R/L as Bilat here
Headlines go into Impression--significant/relevant info only, not the incidentalomas, normal variants, nor the ancient history.
'Advise F/U if clinically indicated', or 'Further F/U coned and centered to any area of interest", MUST be stated when reading with me. IMHO should be mandatory across board; helps ward off potential litigation or blame-the-radiologist disputes.
Indication/Hx.: Spelunk spelunk spelunk! The oft-given 'pain' or 'R/O" are useless--and we cannot bill. EPIC makes it slightly easier to distinguish EMed or Ortho notes from, say, Ophthal or Phlebotomy; so open and explore—and add to Indications. "Pain 18 months, no hx of trauma", 'Stepped on glass last night', 'Marathoner, 2 weeks anterior tib pain", "Ehlers Danlos, chronic sprains", "Slipped off curb in high heels"—all make your reading more targeted, more accurate, and improve your clinician/radiologist relations. If no old images in Hopkins computer, say so. If outside images in Ambra mentioned, pull them up. Technologists getting great at adding history, be sure to check for their comments in Epic box where tech name stated. If they added history, add it to Indications as : "Technologist adds, 'Fell 5 days ago, now point tender over 4th and 5th MT heads'. "Technologist adds,' Surgery 17 yrs ago, chronic pain since, worse since 3 months ago..." Their comments have to be in quotes. And thank them occasionally (cc me)!.
Possibly serious Incidental findings (lung nodules, neoplasm, foreign matter...) should be pursued vigorously to see if previously seen/documented/changed (eg—?nodule seen on today's shoulder. Look not only for older shoulders, for example, but frontal C spines, Chest, CT, upper GI, Scoliosis-- anything that may allow us to document 'unchanged for more than 2 years"). If no prior documentation/assessment, or change, or anything worrisome, Urgent Notification /Critical macros documentation required-- including confirmation clinician received/responded/discussed.
PHRASING: CAVEATS, PREFERENCES, SUGGESTIONS
Anatomic position reference points do not change with position—ie 'anterior', 'medial', 'distal', etc remain uniform even if the appendage in question is amputated and hung from the ceiling. Remember your Gross Anatomy cadaver: supine, hands supinated, feet plantigrade. Vague descriptors such as 'near', 'next to', behind', above'—meaningless and DANGEROUS. "Apposed" for the two articular surfaces of a joint is fine.
Magid 10 Commandments (TeamRads.com) include "LEND NO FOOTHOLD TO LAWYERS" and "BE LITERAL/VERITABLE WITNESSES". Choose words carefully and precisely; never 'assume' anything unseen or poorly seen can be guesstimated.
Report should be structured like newspaper front page: HEADLINES ("Unchanged from last exam...", "Limited exam...", "Subtle fracture scaphoid ...", "Cannot r/o lytic lesion proximal diaphyseal...", followed other important/relevant/focused info, then incidental or miscellaneous detail ("Again seen is bone island...'Unchanged surgical clips...";"Battery pack again superimposes iliac wing...").
Always start with LIMITATIONS of images/study :
"C7, T1 cut off; no odontoid view; otherwise unremarkable", "Limited exam proximal T spine on lateral due to superimposition", "In cast, markedly limiting detail", "Habitus markedly limits axillary view exposure", "Superimposed surgical material limits detail", "Left hand, one view only", "Fluoroscopy, limited exam", "Visualized portions grossly unremarkable..." "Alignment maintained between flex/ex, visualized levels..." alerts clinicians that even if what is seen is unremarkable, we didn't see it all.
Whether exam limited or just unremarkable (apparently negative), advising F/U if physical findings, mechanism of injury, other comorbidities, soft tissue clues, etc. (ie all those things the clinician knows but the radiologist cannot) is pragmatic both clinically and medically-legally. Many of our trauma images are initially negative but become more definitely radiographically abnormal 10-14 days later.
"Habitus (or exposure, or rotation, or superimposed foreign matter, or cast, or....) limits detail, no definite fracture but F/U coned to any area of interest could be obtained if clinically indicated*"
*If advising F/U, add "If clinically indicated"— otherwise some clinicians have said they feel they are legally obligated to get more studies, even if NOT warranted in their judgment (and they do have the pt. at hand—we don't).
Radiographs are 2D representations of a 3D structure. Unless there are at least 2—for many joints 3-- orthogonal (right angles) views, one can only say that "AA is SUPERIMPOSING BB", not 'in BB"; or one can say there is "apparent...". "One View Is No View".
Don't express excessive certainty when one cannot be sure— "Apparent...", "Incompletely seen...", "Grossly unremarkable on this limited exam..." ,"due to only one view...", or "poorly seen due to habitus"... , or" incompletely seen at edge of image" are important modifiers.
"Normal" is a word I use far less than most. If the pt. were truly normal, their clinician might not be requesting imaging. "Unremarkable", "No significant abnormality visualized areas", or 'Radiographically unremarkable" are the best substitute. "No definite abnormality visualized portions", "No significant radiographic abnormality" all leave room for nasty future surprises, initially radiographically invisible findings, or currently incomplete/limited exams. Also in an era when patients read our reports, leads to less apparent discrepancy between the clinician's possible hands-on perception of abnormalities requiring treatment or follow-up and an apparently radiographically unremarkable image. The report of 'normal' radiograph in a clinically abnormal pt. may falsely reassure a patient they need not comply.
Also with fractures, if date of injury known, "Advise F/U 10-14 days following trauma or onset of sx if clinically indicated"—F/U sooner is NOT a true R/O for subtle fxs. It's the osteocytes—they need 10-14 days to make a radiographically visible change removing debris to make a fracture line 'appear' (osteoclasts) and/or to lay down and start calcifying enough matrix to show healing/reactive change (ostepblasts). When the date of injury/onset is unknown just leave it at 'F/U as clinically indicated.." since, eg, advising 14 day f/u for a 3 month old injury is meaningless.
In MSK one cannot use the word stable to mean 'unchanged'; it more commonly implies biomechanical or physical stability, which is not an imaging determination. If a finding, alignment, hardware, whatever are unchanged from last exam say so – 'unchanged', 'again seen is', but NOT 'Stable alignment proximal tibial fracture..."
Our referring clinicians also include rheumatologists, plastic surgeons, internists, nurse practitioners, ambulatory care , Comp Clinic, ob-gyn...our job is to describe and report with non-ambiguous comprehensible clarity. Fancy Latin names for many normal or anatomic variants are counter-productive if the image was requested by non-Orthopaedists. Describe it as 'normal variant accessory ossicle", not 'os hamuli proprium". Prefacing phrases like 'ulna minus' with 'anatomic variant..." is also helpful if you are not sure the referring clinician is a hand specialist.
REMINDERS, SPECIFIC BONES AND JOINTS (see specific Joint handouts)
BILAT KNEES Knees if quite similar can be read together in Findings and Impression: eg "Early medial compartment narrowing bilaterally left slightly > right with decreasing valgus; left joint effusion, no R lateral. IMPRESSION: approximately symmetric osteoarthrosis L>R" Knees if quite different should be split in Findings/Imoression: "R knee arthroplasty unremarkable and unchanged....Left knee medial tibial plateau fracture unchanged except for progression of healing, since last exam..."
SCOLIOSIS Intro/template is on TeamRads.com, under MSK handouts. COUNT pairs of ribs and ascertain number of lumbar vertebral bodies—many of our pts. anomalous; hypoplastic 12th ribs, lumbosacral segmentation anomalies common (Don't miss the PSEUDARTHROSES!); and many lawsuits drifting around based on fact that radiography/CT/MR reports over time may each call the same lumbar abnormal level by different numbers due to FOV differences.
Currently (initiated Fall 2017) we are NOT dictating actual measurements for Orthopaedic scoli requests* (insurance issue: if our measurements are not precisely matched to Orthopaedics measurements insurance may deny patient care payment; there is about +/- 5 degrees standard deviation of two reviewers measuring from same landmarks, we are avoiding giving insurance an excuse to deny claims: "No definite change in right thoracolumbar scoli compared to 6/2017, see clinician measurements. ".
Add "Scoliosis technique, which markedly limits detail to decrease dose", since the markedly low resolution of EOS and other scoli techniques will preclude reliable assessment of subtle trabecular changes, early implant/bone interface changes, fractures, etc. Describe if in brace or out; if supine or sitting; esp if comparing to older exam which may be different. In-brace can't be compared to out-of-brace; nor upright to supine; it's apples-to-oranges.
(*There will be times, here or in future, one *does* measure the scoliosis (for non-Orthopaedists here,or for future employment): Dictate measurements "From superior endplate of ...to inferior endplate of ..." If measuring-- Comparisons to older images, or to changes when pt. flexes laterally to L or R, must use same endplates, eg 'Using the same landmarks, on previous exam Oct. 19 2015 these curves measured XX and YY respectively...")
Curves are named 'right/dextro' or 'left' by direction of shift from midline ie apex of curve; need not add "convex to..." unless you are unclear abt. Convention.
Measure-remeasure SD is about +/- 5 degrees between 2 observers using same landmarks, 3 degrees if same observer. Less than 5 degree change therefore not significant. IF HOWEVER there is ~5 degree increase since last exam, look for older exams to see if curve is sneaking up 5 degrees each time, therefore stealthily 'increasing' -- "L. 31 degree curve superior endplate of X through inferior endplate of Y. On last exam Oct 10, 2017 using same landmarks, this measured 27 degrees; but on older exam May 3, 2014 this measured 16 degrees, suggesting longitudinal increase"
FRACTURES Read, memorize, and use Fractures 101 handout on TeamRads.com, under Elective/MSK handouts. Orthopaedic convention (describe distal relative to proximal, etc) has very precise and well-described descriptors.
HANDS, WRIST: NAME, do not NUMBER digits, phalanges, MCs.
"Thumb Index Long (NOT 'middle"), Ring, Small" phalanx or MC;
"prox-middle-distal" Phalanges, not "1st-2nd..."
LONG BONE images (humerus, forearm, tib fib) : start with 'Limited exam wrist and elbows" ("Joint above/below") , because beam angle/penumbra is giving you subtle obliques, not true AP/Lat, at edges of such images. (ie magnifying to see ends WILL NOT give same accuracy as actual CONED AND CENTERED view over joints) .
HIPS, PELVIS Position:obturator foramina perfectly symmetric or pelvis rotated. Trochanters thrown off neck, which should project as biconcave femoral neck or LIMITED EXAM. "Hip" means proximal femur and acetabulum; be precise localizing findings.(ie one can report arthritis of the hip, but not 'hip fracture'-- it is either a proximal femoral, or acetabular, fracture) See TeamRads.
FEET mention if weight-bearing (WB) or non-weight-bearing (NWB),since it changes the longitudinal arch and axes of the talus and calcaneus. Don't get too involved trying to dx. pes planus/cavus, esp. on non-WB views. Check TeamRads hand out.
SPINE, Flexion/extension C, T or L spine: DID alignment change and DID Pt. ACTUALLY MOVE?? "Alignment maintained between F/E but virtually no range of motion..." or 'limited motion in extension, adequate in extension...", '.alignment maintained, with unremarkable range of motion between F/E". Did you count vertebral bodies? Is there anomaly/pseudarthrosis at the lumbosacral junction? Any spondylolisthesis between flexion/extension?
Happy to discuss any questions or get feedback on above!
Donna Magid MD, M.Ed, FAUR November 2021