MUSCULOSKELETAL RADIOLOGY
Components of Subpsecialty Training, Goals & Objectives, Reading
List, Resources, Daily Work, Evaluation, Pathology Outline,
Conferences & Reference Texts
INTRODUCTION
The Clinical Radiology of Oklahoma Subspecialty Residency Program is
committed to the integrating high academic and professional competency standards into a
comprehensive residency training curriculum. The program provides subspecialty
resident education in the subspecialty of musculoskeletal radiology through the academic
core curriculum and provides professional development via the general competencies for
subspecialty residents. Our goal is to train highly competent and qualified radiology
subspecialists in musculoskeletal radiology who will support patient care as effective
members of the clinical care team with strong interpretive skills, knowledge of
appropriate diagnostic radiology tools and cost effective resource utilization. They are
required to demonstrate professionalism in their role as a subspecialist and must show
proficiency in each of the areas as defined by the subpecialty curriculum.
The following curriculum guide has attached reading lists for the various sections. This reading
list contains reading material that is designed to supplement the teaching, personal instructions,
and lectures provided by the section and its personnel. This reading list is not meant to be
exhaustive and contains only the material that is most germane to the referenced topics. The
reading list is also designed to fulfill the three basic requirements of the subspecialty
curriculum of musculoskeletal radiology:
1. To provide practicing radiologists with the fundamentals needed to be
valuable consultants to orthopedic surgeons, rheumatologists, and other
referring physicians
2. To provide radiology residency program directors with a guide to subjects that
should be covered in a four year teaching curriculum
3. To serve as a “study guide” for diagnostic radiology subspecialty residents.
The reading material has been selected to further each subspecialty resident’s knowledge base that
is needed for the successful practice of musculoskeletal radiogy. The subspecialty focus will be
augmented by exposure to other portions of the general diagnostic radiology academic
core curriculum as it is germane to the subspecialty education and training of the
subspecialty residents.
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Radiology Subspecialty Residency Programs
Clinical Radiology of Oklahoma
Goals and Objectives: General Competencies
The CRO Radiology Subspecialty Programs will further the general competencies developed for
the Diagnostic Radiology training program. The basic general requirements enable and require
residents to develop the characteristics of a new practitioner of Diagnostic Radiology. The
general competencies include:
Patient Care
Medical Knowledge
Practice-based Learning and Improvement
Interpersonal and Communication Skills
Professionalism
Systems Based Practice
The subspecialty program will utilize these general requirements as a basis and augment them
with a focus that is designed to be applicable to subspecialty patient care in the highly
specialized environment that is found in our tertiary care academic medical center and
subspecialty clinics.
Goals and Objectives: Academic Core Curriculum
Each of the subspecialty core curriculums are outlined in their specific sections. The core curriculum for
each subspecialty builds upon the basic residency curriculum and provides additional expertise for the
subspecialty resident.
COMPONENTS
1. Plainfilm Radiography
2. Interventional Procedures
3. Magnetic Resonance Imaging
4. Computed Tomography, Ultrasound, Nuclear Radiology, and Bone Mineral Density
Evaluation
Component: Conventional Radiography
Cognitive Objectives
At the end of the first MSK rotation, a radiology subspecialty resident should be able to:
1.
Dictate a succinct, precise and coherent radiology report
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2.
Describe pertinent normal and abnormal anatomy on an MSK radiograph
3.
Establish a diagnosis and provide an appropriate description of the differential diagnostic
possibilities that may be present
4.
Discuss the imaging findings of trauma (to include soft tissue injuries and fractures) septic
arthritis, osteomyelitis, and metastatic diseases
5.
Evaluate orthopedic follow-up imaging including the imaging findings of loosening and
infection of orthopedic hardware.
6.
Discuss the most common techniques in MSK imaging, the indications and contraindications, and complications of the following:
1.
Radiographs & fluoroscopy
2.
Arthrography
3.
MSK Biopsy
Affective Objectives
At the end of the rotation on conventional radiography the subspecialty resident should be able to:
1.
Project a professional image
2.
Demonstrate empathy and respect towards patients, referring clinicians, radiology
personnel, and colleagues
3.
Function as a consultant to clinicians for radiographic evaluation of MSK trauma and
orthopedic follow-up (e.g. - if a clinician enters the reading room, he or she should be
greeted within 30 seconds and then assisted as soon as possible with image retrieval and/or
interpretation)
4.
Participate actively in the MSK division’s academic program (e.g. teaching medical
students and residents on the rotation)
Components: Conventional Radiography & Interventional MSK Procedures
Cognitive Objectives
At the end of the second MSK rotation, a radiology subspecialty resident should be able to:
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Discuss the imaging findings and provide an appropriate differential diagnosis for:
1.
Articular diseases
2.
Benign and malignant bone tumors
3.
Metabolic and endocrine diseases
4.
Miscellaneous diseases entities (as listed in addendum)
5.
Soft tissue lesions
6.
Congenital syndromes
Affective Objectives
At the end of the second MSK rotation, a radiology subspecialty resident should be able to:
1.
Consolidate the objectives of the first rotation
2.
Function as a consultant for conventional radiographic evaluation of MSK pathology and
for planning the MSK imaging and interventional procedures to solve a particular problem
Psychomotor Objectives
At the end of the second component, a radiology resident should be able to:
1.
Perform placement of needles into different joints for arthrography and joint aspiration
2.
Perform biopsies of the axial and appendicular skeleton and surrounding musculature and
connective tissue.
3.
Perform interventions of the spine to include: discography, nerve root injections, epidural
injections, facet/SI joint injections, vertebroplasty, kyphoplasty, etc.
Components: Magnetic Resonance Imaging, Computed Tomography, Ultrasound, Nuclear
Radiology, and Bone Mineral Density Evaluation
Cognitive Objectives
At the end of the third MSK rotation, a radiology subspecialty resident should be able to:
1.
Plan, protocol and interpret MR imaging studies based on the clinical information
2.
Interpret with competence MR imaging studies of the spine, shoulder, pelvis, and knee
Affective Objectives
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At the end of the third and fourth MSK rotation, a radiology subspecialty resident should be able to:
1.
Act as a consultant on MSK imaging studies
2.
Participate actively in the teaching of junior residents, other residents, interns, and medical
students
RESOURCES
Instructors

Doctor Douglas P. Beall is responsible for the organization and supervision of the
Musculoskeletal Radiology rotation.

The teaching of musculoskeletal Radiology is done by Doctors Douglas P. Beall and Byron
H. Christie. CT and MRI of spine will be taught by both neuroradiologists and
musculoskeletal radiologists.
Bibliography
Required Reading

All required books can be checked out from our library. Books should be read in the order
listed. The departmental teaching file should be studied in relation to the reading material.
Component 1
1.
Fundamentals of Skeletal Radiology. Clyde Helms, W.B. Saunders.
2.
Orthopedic Radiology, A Practical Approach. Adam Greenspan. Lippincott (read trauma
section only - chapters 2 through 8).
3.
Bone and Joint Imaging, second edition. Donald Resnick. W. B. Saunders. The first
chapters you read should be: Chapters 19-20, 59-61, 62, 80
Component 2
1.
Brower, A.C., Arthritis in Black and White, 2nd ed., W.B. Saunders, Philadelphia, PA,
1996.
2.
CD: ACR learning file: Skeletal
3.
Read the remaining required chapters in Bone and Joint Imaging in any order you want:
Chapters 1, 2,14, 18, 28, 30, 32, 33, 34, 38, 46-58, 63-79, 81-85.
4.
** The following chapters in Bone and Joint Imaging are good for learning but NOT
required: 5-10, 12, 13, 15-17, 21-27, 29, 31, 35-37, 39-44.
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Components 3 and 4
MRI of the Musculoskeletal System
1.
MRI of the MSK System, Kaplan, et al.
2.
Berquist, T.H., ed., MRI of the Musculoskeletal System, 4th ed., Lippincott Williams &
Wilkins, Philadelphia, PA, 2001.
3.
Chew, F.S., Musculoskeletal Imaging: A Teaching File, Lippincott Williams & Wilkins,
Philadelphia, PA, 1999.
Daily Work
Daily work starts no later than 8:00 AM and finishes not earlier than 5:00 PM.

Interpretation/dictation of musculoskeletal examinations

Reports: Edit and sign reports at least three times a day.

Exam Supervision

Throughout the day, the subspecialty resident is the first consultant for the technical
personnel as for the indication and type of exam to perform and as to the technical quality
of the exams.

The subspecialty resident supervises all cases of musculoskeletal MR and biopsies. He/she
is to collect the clinical information, existing films, lab data, etc. and present it to the MSK
staff in order to plan the exam appropriately in advance.

The staff radiologist is available at all times for consultation.
Procedures

Subspecialty residents will participate with staff in as many procedures as possible in the
musculoskeletal section (arthrography, injections, fluoroscopy, CT and MR). All of these
procedures are performed by or under direct supervision of the staff person covering the
section. Responsibilities are dependent on the resident's expertise.
Consultation

Throughout the day, the subspecialty resident is the first consultant to his colleagues or
referring physicians. The staff person covering the section is available at all times for
consultation.
Conferences (ADDENDUM II)

Each subspecialty resident is expected to participate in all MSK Conferences that are held
during their time on the service (e.g. Rheumatology, Orthopedics, Family Practice Sports
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Medicine, Boards-Review, etc.) They are also welcome and encouraged to attend any of
these conferences during the year.
Log Book
The residents are responsible for covering the reading rooms from 8 AM to 5 PM daily. Absence
from the reading rooms from 12 noon to 1:00 p.m. for lunch and conference will be covered by
staff. Any conference or absence for other reasons between 8 AM and 5 PM is to be cleared with the
attending staff you are working with on bone.

A log book of all biopsy cases must be kept by the subsecialty resident

Entering the follow-up results on bone biopsies and joint aspirations into the log book is
the responsibility of the resident or fellow who participated in the procedure.
Consultation

The subspecialty resident is the initial consultant for colleagues and referring physicians.
SUBSPECIALTY RESIDENT'S EVALUATION
The subspecialty resident's evaluation is based on many parameters according to specific cognitive,
psychomotor and affective objectives:
1.
Evaluation of the daily work.
2.
Behavior (clerical and technical personnel, consultants and other radiologists may be asked
to contribute to this evaluation).
3.
Discussion of the evaluation with the subspecialty resident. The evaluation is performed at
the end of the quarter. The subspecialty resident may ask for an evaluation during the
course of the quarter. The staff radiologist may present an evaluation to the resident midway through the quarter if deemed necessary.
SPECIAL ASSIGNMENTS
The subspecialty resident may be asked to participate on special projects:

Preparation or presentation of a lecture or conference

Preparation and writing of a scientific paper
ADDENDUM I: Musculoskeletal Pathology Outline
Following completion of 16 weeks of musculoskeletal radiology, subspecialty residents should be
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able to discuss:
1.
2.
3.
Traumatic osteoarticular lesions of the axial and peripheral skeleton.
o
Classification of fracture type
o
Radiographic findings of a fracture
o
Physiopathology and radiologic correlation of fracture healing
o
Radiographic findings according to anatomic site
Articular Disease
o
Classification of articular disease
o
Radiographic findings of articular lesions
o
Physiopathology and radiologic correlation of articular disease:

infections

inflammatory/immune

degenerative

neuropathic

metabolic and endocrine

synovial tumors
Benign and malignant bone tumors
o
Classification of bone tumors
o
Radiographic findings of benign and malignant features of bone tumors
o
Characteristics (age, site, location, radiographic findings) of benign and malignant
bone tumors:

cartilaginous origin

osseous origin

fibrous origin

cyst

myelogenous origin
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
4.
5.
Infectious lesions
o
Classification of infections
o
Radiographic findings of infectious lesions
o
Physiopathology and radiographic correlation of infectious diseases
Metabolic and endocrine diseases
o
Classification of osteopenia
o
Radiographic findings of the three forms of diffuse osteopenia

Osteoporosis

Osteomalacia

Hyperparathyroidism
o
Physiopathology and radiographic correlation of diffuse and localized osteopenia
o
Physiopathology and radiographic correlation of endocrine disorders originating
from:
o
6.
metastasis

hypophysis

thyroid

parathyroid

adrenals

gonads

diabetes
Physiopathology and radiographic correlation of hypo and hypervitaminoses

vitamin A

vitamin D
Miscellaneous disease entities
o
Paget's disease
o
Reticulo-endothelioses (histiocytosis x/Langerhans cell histiocytosis)
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7.
8.
o
Storage Disease (Gaucher's disease)
o
Ischemic Disease (Osteonecrosis, osteochondrosis)
o
Anemias
o
Marrow disease
Radiographic findings of these entities
Physiopathology and radiographic correlation of these entities
Complications and radiographic findings of these entities
Soft tissue lesions
o
Classifications of soft tissue lesions
o
Radiographic findings of soft tissue lesions
o
Physiopathology and radiographic correlations of soft tissue lesions
Congenital Syndromes
o
Radiographic findings of:

Congenital dislocation of the hip

Flat foot and club foot

Osteochondrodysplasia

o
o
Failure of growth of tubular bones and spine

achondroplasia

spondylo-epiphyseal dysplasia
Failure of growth and development of cartilage and fibrous tissue

dysplasia epiphysialis hemimelica

multiple exostoses

enchondromatosis

fibrous dysplasia
Anomaly in density and modeling

osteogenesis imperfecta

juvenile osteoporosis
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o

osteopetrosis

osteopoikilosis

melorheostosis

diaphyseal dysplasia
Dysostosis

Klippel Feil

Sprengel deformity
o
Marfan syndrome
o
Neurofibromatosis
o
Chromosomal anomalies

Turner

Trisomy-21
ADDENDUM II. CONFERENCES
Daily
Daily
Friday
First Wed. of month
First Thurs of Month
06:30 am – Orthopedics Conference
7:15 – 8:00 AM - Radiology
Conference
7:00-8:00 AM – Ortho Grand Rounds
1:00 to 3:00 PM – Rhematology
Conference
WP-1380
CHO Conf Rm
5:00 – 6:00 PM Orthopedics
Morbiditiy & Mortality Conference
Coussins Conference
Room (2E109)
Byrd Library
OMRF, 3rd Floor Conf.
Room
Addendum III: References
Books
Anatomy
1.
Netter FH, Atlas of Human Anatomy, CB_GEIGY
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2.
Kang HS, Resnick D, MRI of the Extremities an Anatomic Atlas, Saunders.
3.
El Khoury GY, Bergman RA, et al, Sectional Anatomy by MRI/CT, Churchill Livingstone.
4.
Möller TB, Reif E, MRI Atlas of the Musculoskeletal System, Blackwell Scientific Pub.,
1993.
Arthrography
1.
Freiberger and Kaye, Arthrography. Appleton-Century-Crofts.
1.
Lee & Sagel, Computed Body Tomography with MRI Correlation. 3rd Edition, 1998,
Lippincott-Raven, Chapter 22 - Musculoskeletal.
2.
Pretorius ES, Fishman EK. Helical (Spiral) CT of the Musculoskeletal System. Radiol
Clin N Amer 1995; 33:949-979.
CT
DEXA
1.
Lenchik L, Rochmis P, Sartoris DJ. Optimized reporting of dual x-ray absorptiometry
(DXA) scans. AJR 1998; 171:1509-1520.
Emergency Radiology
1.
Harris, The Radiology of Emergency Medicine, Williams & Wilkins.
General MSR:
1.
Resnick & Niwayama, Diagnosis of Bone and Joint Disorders 2nd ed., Saunders, Vols. 1-6.
Orthopedics
1.
Berquist TH, Imaging Atlas of Orthopedic Appliances and Prostheses, Raven Press, 1995.
Pediatrics
1.
Ozonoff, Pediatric Orthopedic Radiology, W. B. Saunders and Co.
2.
Taybi, Radiology of Syndromes, Year Book Medical Publishers.
Spine
1.
Modic MT, Masaryk TJ, Ross JS, Magnetic Resonance Imaging of the Spine, Year Book
Medical Publishers.
2.
Maneffe C. Imaging of the Spine and Spinal Cord, Raven Press 1992.
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3.
Daffner R. Imaging of Vertebral Trauma. Aspen Publishing.
4.
Denis F. Spinal Instability as Defined by the Three-Column Spine Concept in Acute
Spinal Trauma. Clin Ortho 1984; 189:65-76.
Technique
1.
Bernau & Berquist, Orthopedic Positioning in Diagnostic Radiology, Urban &
Schwarzenberg.
2.
Lusted & Keats, An Atlas of Roentgenography Measurement, Year Book Medical
Publishers.
3.
Greulich and Pyle, Radiographic Atlas of Skeletal Development of the Hand and Wrist,
Stanford University Press.
Trauma
1.
Rogers LF, Radiology of Skeletal Trauma, Vol. I & II, Churchill Livingston.
Tumor
1.
Wilner, Radiology of Bone Tumors and Allied Disorders, Vols. I, II, III, IV, Saunders.
2.
Mirra JM, Bone Tumors: Clinical, Radiologic, and Pathologic Correlations, Lea &
Feabiger.
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