When to image an injury

In today’s society, imaging an injury has become the “norm”. There are a multitude of reasons for this transition, but for the sake of our discussion here, we will assume that litigation of medical professionals have played a significant role in the increase of medical imaging.

When a new patient goes to see a physician for an othopeadic condition, more often then not, they are provided with a prescription for an x-ray or possibly an MRI. But why is this? The inconvenient truth is that in most cases, the physician (that is trained in taking in-depth histories and that has performed a physical evaluation and exam of the injury) already knows what the injury is, but they are ordering a medical test to provide them protection from potential litigation. They may have questions about the severity of an injury, but the actual diagnosis has already been already identified and a treatment plan is already taking shape. Imaging then, is often used to confirm a diagnosis, not create one. Patients of all ages and activity levels will think they need an MRI and if they do not have one, they will transfer their care to a physician that will order one.

We will not go into the cost associated with ordering tests that may not be completely “medically necessary”, but suffice it to say, they are rapidly increasing. This cost gets placed on all of us, not just the individuals that are having the tests completed. An appropriate question patients should be asking a physician during their evaluation is “how will this information shape the treatment plan?” If an image will only help confirm that a structure is torn when there is an obvious deficit in that structure on exam, will it change the treatment plan from surgical intervention? This a question that is as individual, unique, and important as you are.

Here are two scenarios that may better demonstrate this:

1. A 23 year-old, male baseball player injuries his knee while running the bases. He felt a slight “pop” when he landed on first base. He was unable to finish his game. He sees his athletic trainer after the game and reports with some swelling in and around his knee. The ligaments in his knee are found to be intact and all have good endpoints. He does appear to have pain with tests that are used to test the medial meniscus. He is referred on to the team physician the next day for confirmation of the initial assessment of a torn medial meniscus. At this visit, the swelling and pain have decreased significantly and all ligaments are found to be stable. The doctor presents the athlete with the diagnosis  of a torn medial meniscus. He is given two options: surgical and non-surgical intervention. The athlete feels that in another day or two he will be feeling better and decides against surgery at this time. He agrees to work with the athletic trainer and attempt to return to play.

– Should this athlete have received an MRI prior to being released back to activity? How would an MRI have effected his return to play? Should the medical staff have let him return to play with a torn meniscus or forced the athlete to have surgery immediately?

2. A 17 year-old, female soccer player is playing in a match against a rival school and plants her right foot in order to cut and change directions, hoping to avoid an opposing player. As she does, she feels a “pop” and begins to have immediate pain in her right knee. She is helped off the field by her athletic trainer and has a sideline evaluation completed. She is found to have a “soft” endpoint in her ACL and excessive translation of her femur on the tibia. She is sent the following morning to her team physician and the diagnosis of a torn ACL is confirmed. She is scheduled for surgery when she is able to exhibit full range of motion in her knee and has strength that is comparable to her uninvolved side.

– Should this athlete have received and MRI? Would an MRI have changed her treatment plan?

While there are exceptions to any situation, imaging decisions should be left to the medical professionals. MRI’s and other forms of imaging can be valuable tools, but in orthopeadics, a good history and evaluation can tell far more.

Please feel free to post comments to this post. We would love to hear what you think!


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