There are already plenty of good books out there on introductory musculoskeletal radiology. Why did I write this syllabus? Because, it seemed to me that most of these books were doing a great job of telling one about diseases, but not how to approach their diagnosis. Most books tell you the names of lots of disorders and the findings you see in each of them. This is handy if you already know what disorder a patient has, and you just want to learn more facts about it.
However when one starts out looking at a film, one often has no idea what the diagnosis is. Experienced musculoskeletal radiologists usually have no trouble generating an appropriate differential diagnosis. But what do you do if you are just starting out in radiology? While books like Reeder's or Taybi's list long differential diagnoses for many findings in musculoskeletal radiology, the lists in these books are usually fairly long, and are listed alphabetically, rather than in order of prevalence. One of my favorite books as a resident was a book called Chest Radiology - Patterns and Differential Diagnoses. Even though I am now a musculoskeletal radiologist, I still use the updated version of this book occasionally. In this book, the author, Dr. Reed, recognized that while there are hundreds of potential diagnoses lurking out there for the chest radiologist, in real life, one keeps bumping into the same old stuff over and over, and only rarely finds cases of the unusual disorders.
Ninety percent of the time, what one really needs, then, is some way to approach the 20 or 30 common presentations of disease. Dr. Reed's book presents 23 different problems in chest radiology, and gives a real-world approach to working them up. I kept hoping that someone would write something like this about musculoskeletal radiology. Alas, no one else did. Nature abhors a vacuum, so this syllabus has emerged to help fill this gap.
This syllabus, then, consciously tries to emulate some of the overall philosophy of Dr. Reed's book. In it, I present common, recurring problems in musculoskeletal radiology and how one can approach them. The algorithms I present here have been consciously kept simple-minded. Learning them will not make you a master of musculoskeletal diagnosis, nor will you be ready to earn big bucks in the glamorous world of musculoskeletal radiology. You certainly won't be ready to take the skeletal section of radiology boards. BUT! You will be able to give an intelligent differential diagnosis and imaging workup for about 90 % of what you see coming across the average musculoskeletal board.
When I was interviewing for a residency position, a wise old radiologist once told me in graphic detail of a theoretical model that he had constructed of a radiology resident's mind. "Think of a chicken-wire fence." he said. "You then take a bucket full of really runny used chicken food and throw it up against the fence. Most of it runs off, but a little bit sticks and dries. You repeat this process over and over, and you finally end up with a lot of stuff built up there." The approaches in this book are designed to act as that chicken-wire fence in your brain. So, keep reading about musculoskeletal radiology and you'll end up with a lot of stuff built up there.
This is a good place to add a caveat to the reader, in the form of Sturgeon's Law. Before his death, Theodore Sturgeon was one of the very gods of science fiction writing, and one of the many wise things that he said was:
"90% of everything in print is B. S.!"
Depending on how you feel about the stuff that is currently in print in radiology books and journals, you may or may not agree with this. If you are a believer in Murphy's Law, you may even feel that Sturgeon was an optimist. Even if he was a bit pessimistic, there is an awful lot of rubbish and bilge printed in textbooks and journals. What if you find, someday, that parts of this syllabus are B.S.? First of all, congratulations on developing your powers of discrimination to the point that you no longer blindly believe everything you see in print. When you find what you consider to be rubbish in this book, please let me know what it is and why you think so. Any suggestions for improvements would be greatly appreciated. I'd like to learn something from this process too.
So, take these approaches with a grain of salt. They are not Revealed Truth, but they have worked for me and for many of the residents that I have taught. I encourage you to add knowledge from other sources to what you learn here, throw away the obvious nonsense, and end up with The One True Way to approach these problems, which will, of course, be your way.
- Reeder MM, Bradley WG Jr. Reeder and Felson's Gamuts in Radiology: Comprehensive Lists of Roentgen Differential Diagnosis. 3rd ed. New York: Springer-Verlag, 1992.
- Taybi H, Lachman RS. Radiology of syndromes, metabolic disorders, and skeletal dysplasias. (4th ed.) Chicago: Year Book, 1996.
- Reed JC. Chest radiology: plain film patterns and differential diagnoses. (4th ed.) Chicago: Mosby-Year Book, 1996.