0:00

Yeah, the minimum slice, thickness

0:02

and gap, uh, thickness, uh, we don't do a lot

0:06

of 3D uh, uh, uh, imaging.

0:09

Um, I find that

0:12

although the spatial resolution might allow you

0:14

to see things that, uh, the contrast is not ideal.

0:19

So we rely a lot on the 2D.

0:21

And so generally we're talking about a thickness of three

0:24

or four millimeters for most of the, uh, images that I do.

0:28

Maybe Steve, I don't know if you wanna answer.

0:32

Sure. Um, in our practice,

0:34

it really depends on the scanner.

0:35

For instance, I've, I've shown don quite a,

0:38

quite a few images coming off the Hitachi oval.

0:41

Uh, I'm not advocating any vendor by the way,

0:43

but they happen to make an additive gradient echo

0:46

that is very rich in signal.

0:48

So I can easily get away every time

0:50

with a 1.2 millimeter coronal cut,

0:53

and I get a beautiful view

0:54

of the triangular fibrocartilage in the cartilage

0:57

at three T on other scanners.

1:00

And at three TII will use, you know, a two millimeter

1:03

or 1.5 millimeter cut when I have the image quality.

1:06

Otherwise I'll stay with 2D on routine 1.5 T. Yeah.

1:11

Okay. And then the, the next question is kind

1:13

of an interesting one.

1:14

Uh, uh, better for the patient emergency

1:18

to do fast MR rather than x-ray to assess

1:22

for carpal fracture.

1:24

Let me broaden that question just

1:25

through the general question.

1:27

Following an injury

1:28

and a patient comes into the emergency room, be it the wrist

1:32

or be it the knee or a hip or what have you,

1:35

and they're concerned about a fracture, what is the order

1:38

of the examinations that you might wanna do?

1:41

Because there is a bit of a debate about it.

1:43

In our practice, we always begin

1:45

with conventional radiography.

1:48

So that's what we start with.

1:50

If we see the fracture with conventional radiography,

1:54

depending on where it is

1:55

and how complex we could get CT

1:57

to better look at the components of the fracture,

2:01

the radiograph is negative, then the question comes up.

2:04

If it's a place where a fracture would make a difference

2:08

to the condition, should you turn to CT

2:11

or should you turn to mr?

2:13

And it's not an easy question to answer.

2:16

If you turn to MR and it's negative, you're done.

2:20

But if you turn to MR and you see a contusion

2:23

and you're not sure about a fracture, you have

2:25

to follow it with a ct.

2:28

And, and I have many examples of this

2:30

because the CT shows the fracture line better than the mr.

2:35

Now, if you start with a CT and you don't see,

2:39

and you see a fracture, fine,

2:41

but if you don't see a fracture,

2:43

you can't rule out a bone contusion,

2:44

although windowing of the CT now will show you

2:49

some patterns of marrow edema.

2:51

So I don't have a real clear cut answer.

2:53

You're talking about a carpal fracture.

2:56

Again, we would start with radiographs

2:58

and probably in our emergency room

3:00

because, uh, in the nighttime our MR Tech has limited hours,

3:05

we would probably go to a CT as the second exam.

3:09

But there's a big argument about this,

3:11

and I don't think the answer is that easy.

3:13

What, what's your philosophy? Yeah,

3:15

I think you framed it perfectly.

3:16

Um, you know, we, we run a, a couple

3:19

of large hospitals down in Naples, uh, where a lot

3:22

of people, uh, who are 90 fall down playing pickleball.

3:25

So they're very active down there.

3:27

And, um, uh, for, for the wrist, obviously at night,

3:30

we don't have technologists readily available either.

3:33

So we'll go to x-ray and or CT to begin with.

3:37

But I can see coming down the road,

3:39

remember it took 20 years for them

3:40

to decide you need an x-ray for a lung, I'm sorry,

3:43

CT for a lung nodule.

3:44

They were doing X-ray all this time.

3:46

And I think what's going to happen, we do now a one

3:50

to two minute screen with proton density stir

3:53

or spur or spare.

3:55

And if that's negative in the scaphoid

3:57

or in the hip, for instance, rather than put the patient

4:00

through view like juda views

4:02

and frog leg views, you have the answer right away.

4:05

So in that situation, I think we're gonna migrate more

4:08

and more to initial MRI for things like hip fractures,

4:12

we'll probably still always start

4:14

with an X-ray for the wrist.

4:15

But I do like MR.

4:16

A lot for the wrist for scaphoid fractures.

4:19

Yeah. And I think it, it,

4:20

there's no question if the MR is negative, you're done.

4:23

You, you're done. It's, it's the cases

4:25

where it isn't negative, you see edema,

4:29

and I've always said once you see edema, you see lines.

4:32

You could put arrows anywhere you want

4:34

and call it a fracture, but a lot of times you're not sure.

4:37

And it's in those cases when the orthopedic surgeon wants

4:40

to know, for example, oid, should we get a ct?

4:43

And it's not easy sometimes to answer.

4:47

Well, I always, I always tell my fellows the absence

4:50

of edema is probably more valuable than the presence

4:52

of edema in terms of specificity.

4:54

Yeah.