Monday, March 3, 2008

Famous Duos and the UCL

Chances are that you have no idea who Frank Jobe MD is, but I am willing to bet that most of you have heard about the operation he pioneered, the Tommy John operation. As I tell my kids, life is not fair- the doctor who came up with the operation is far less familiar to people than the first patient, the baseball pitcher Tommy John:


The Tommy John operation reconstructs the ulnar collateral ligament (UCL) of the elbow. It is a tremendously successful procedure, one of the few that is said to result in a functional result that is as good as the native ligament.
MRI is an excellent way to evaluate the UCL.

Direct coronal images of a
baseball pitcher with medial elbow pain. There is a tear of the anterior band of the UCL:

(click on image to enlarge)
Coronal oblique images depict that the tear has occurred at the sublime tubercle of the ulna:


Lewis and Clark. Watson and Crick. Ben and Jerry. These are all famous duos that have changed history. OK, maybe it's going a little far to say that Ben and Jerry changed history, but try some Cherry Garcia ice cream first, and you may feel differently. None of these individuals would have reached their level of success without their partners.

When it comes to MR imaging, the radiologist also needs a partner. That partner is the MRI technologist, who has a simply huge impact on the quality of the images that are obtained. I am lucky enough to work with some fabulous technologists, who go far beyond the level of positioning the patient and pushing some buttons. They understand that MRI is an interactive examination, and that practitioners of the art (and it is very much an art at its best level) perform the sequences necessary to answer the clinical question.

Some people try to "cross-train" x-ray or CT technologists to do MRI, and then wonder why the pictures do not look very good. Well, that is like asking a pianist to play the violin- yeah, they are both musical instruments, but I don't want to be in the room when the piano player is stroking the bow, unless I have a pair of earplugs.

This case is a good example of how a great MRI tech can make a real difference. The technologist recognized that there was a UCL tear on the standard sequences, and then set up the twenty degree coronal oblique scan (Cotton et al., Radiology 1997; 204:806-812) to view the ligament optimally. This obliquity produced the perfect picture, the one you look at and say, "Oh, that's obvious". It takes experience and desire to produce that picture, and not every technologist is able to do it. Those that can should be considered artists.



Vic David MD
Orthoradiology.com

1 comment:

Roar said...

Very nicely illustrated, Vic, both the ligament and your technician´s skills. It is refreshing to see something else in the elbow than the everyday radial epicondylitis...