Adrian_Sampath_Overseas_Case Study_Jan_2017

Adrian Sampath
Left Bicep Rupture
MRI Case Study

Table of Contents
Adrian Sampath
00040384
Introduction ......................................................................................................................................... 2
Client Presentation ........................................................................................................................ 3
Why MRI ................................................................................................................................................... 4
Referral Form Information ........................................................................................................ 5
MRI Zones ............................................................................................................................................... 6
Zone 1: The Waiting Area ........................................................................................................................ 6
Zone 2: Administrative Office .................................................................................................................. 6
Zone 3: MRI Preparation Room ............................................................................................................... 6
Zone 4: MRI Procedure Room. ................................................................................................................ 7
MRI Preparation ................................................................................................................................. 8
MRI Scan of Client ............................................................................................................................ 9
1. Localizer. .............................................................................................................................................. 9
2. Proton Density Fat Saturation Transverse. ........................................................................................ 9
3. T1 Sagittal. ........................................................................................................................................... 9
4. T2 Fat Saturation Sagittal. .................................................................................................................. 9
5. Proton Density Fat Saturation Coronal. .............................................................................................. 9
6. T1 Turbo Inversion Recovery Magnitude (TRIM) Coronal. ................................................................. 9
7. Proton Density Dixon Fat Saturation Transverse. .............................................................................. 9
Diagnoses ............................................................................................................................................. 10
The Bicep Muscle ............................................................................................................................. 11
Pathology ............................................................................................................................................ 12
Possible Prognosis ......................................................................................................................... 13
Non-Surgical Treatment ......................................................................................................................... 13
Phase 1 ............................................................................................................................................... 13
Phase 2 ............................................................................................................................................... 13
Phase 3 ............................................................................................................................................... 13
Surgical Intervention .......................................................................................................................... 13
Client Discharge ............................................................................................................................. 14
Conclusion .......................................................................................................................................... 15
References .......................................................................................................................................... 16
Appendix ................................................................................................................................................ 17
Page 1 of 17

Scarborough General Hospital Tobago
Introduction
MRI Case Study.
Adrian Sampath
00040384
I am a student in radiography, who would like to specialize in the field of MRI. I was also
thankful that, I had a wonderful learning experience at Scarborough General Hospital, in the
MRI department. I spend most of my clinical days aiding and doing scans under the
supervision of the MRI technologist. I was eager to find a case that was ideal for MR imaging,
but at the same time I was looking for a rare case to learn more about the efficiency of the
modality and share my findings with my colleagues. Fortunately, for me I found a case that
suited my criteria of an ideal case study.
A client was presented to the department with a bicep tear! The MR technologist took some
time before greeting the client to show some images of a bicep tear and how it affects the
anatomy. Once the MR technologist was finished, he went through certain MR protocols to
explain how unique the case was and why it was an ideal MRI case study. Before any
interaction with the client, I had to plan my course of action from my experiences days before
and recite it to the MR technologist. Once he was satisfied with the course of action, I began
all the necessary documentation for my case study.
Figure 1 Showing front view of the Scarborough General Hospital.
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Client Presentation
Adrian Sampath
00040384
A forty-year-old male was brought into the MRI department on a wheel chair from the adult
ward. Clinical observations revealed that the client had an abnormal bulging located on the
left bicep region. The client was unable to extend or flex the arm but had perfect finger and
hand movements. It was also observed that the client was in little discomfort while interacting
with the nurse to ensure he was prep for the MRI scan. After the paper work was completed,
the client was sent to the changing room and the request card for the scan was obtained.
Page 3 of 17

Why MRI
Adrian Sampath
00040384
MRI is the modality of choice querying soft tissue injuries. The imaging service it provides,
gives conclusive information to determine a client’s next phase of treatment.
The various pulse sequences cause different molecules of tissue in the affected area to be
excited and then relax at different times. The energy released from the excited molecules in
the tissue is captured by gradient coils which acts like the camera. It then transferred the raw
information to the MRI computer as digital MR images.
Slices of the affected anatomy acquired from different pulse sequences are looked at on the
monitor clearly seeing the tissues. The images do not need to undergo any image
reconstruction since MRI images can be viewed in different planes.
A CT scan could have been done to visualize the area through image reconstruction software,
but the exposure to the ionizing radiation would have negated any possible benefits of
achieving the image. The image quality may be of high quality but the area of interest may not
be visualized enough to conclude the extent of the rupture, thus CT would not be used.
Ultrasound maybe be used to identify the rupture, however the image quality may not be of
diagnostic quality, leaving only MRI as the modality of choice for this case.
Page 4 of 17

Adrian Sampath
00040384
Referral Form Information (See appendix 1 for sample)
1. All the client’s demographics were present.
2. The doctors contact, name and signature was present.
3. The client history was that he fell on left shoulder with pain and bugling on arm on flexion.
Query left bicep tendon rupture.
4. The modality and requested scan type was present.
5. Attached was a screening form (see appendix 2) completed and signed by the client to
ensure that the client was MR compatible and confirming all the information.
Figure 2 Showing Original Referral Information
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MRI Zones
Adrian Sampath
00040384
The MRI department uses 4 different zones to ensure no magnetic object is brought near the
MRI unit.
Zone 1: The Waiting Area
This area is where clients come in to register and fill out the required form (see appendix 2).
Once they successfully complete this stage, they proceed into zone 3.
Zone 2: Administrative Office
This area has a radiologist work station and is where the reports are generated for clients.
Figure 3 Showing Zone 2 Entry
Zone 3: MRI Preparation Room
Figure 4 Showing Inside Zone 2 (Radiologist Work Station)
This is where all clients change into gowns. It is extremely paramount that clients are reminded
to remove all metal objects like watches, dentures, hair clips etc. Height and weight are
recorded in this room. A crash cart and recovery area is also here for clients.
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Adrian Sampath
00040384
Figure 5 Showing Zone 3 Entry
Figure 6 Showing Zone 3 Recovery Area and Change Room
Zone 4: MRI Procedure Room.
This is where the MRI machine is and only screened clients can enter. Only MRI staff are
allowed inside this Zone for safety reasons for both personnel and machine.
Figure 7 Showing Zone 4 Entry
Figure 8 Showing inside Zone 4 with the MRI Machine
Once the client has made it to zone 4, the MRI procedure can begin. The only uncertainty for
clients is being cluster phobic. At this stage, the client has a choice to use anesthesia. If the
client chooses this procedure, this is an additional form that must be signed (see appendix 3)
to continue or if possible try to relax themselves until they are stable enough to continue the
scan.
MRI scans has no adverse effect on organogenesis, which deems it safe by FDA laws.
However, there is still a form that must be signed by the female client (see appendix 4).
Page 7 of 17

Client MRI Preparation
Adrian Sampath
00040384
Once all the information from the paper work was transferred to the MRI computer to program
the scan and create the client folder, the client proceeded into zone four.
A gradient coil which is essentially the camera, was strapped over the left upper arm to
visualize the area of interest. Following protocols, the panic ball was given in the event the
client could no longer continue the scan and a special headset to reduce the noise from the
rotating magnet. The client seemed relaxed and clam during the setup. He was assured that
we had a healthy communication link during the scan and he complied with all the
instructions. After the client was sent into the MRI machine and was set for the scan.
Page 8 of 17

MRI Scan of Client
Adrian Sampath
00040384
The scan began at 9:07am and was successfully completed at 9:45am which was 38mins.
The client had no issue during the scan and remained still, thus producing high quality
diagnostic MR images. Movement would have decreased the sharpness of the images in the
form of blurring. During the scan time, the client was encouraged and coached through the
mic system to remain still as possible. The following pulse sequences was defined by (MRI
MASTER, 2017) and were the scans done on the client:
1. Localizer.
A scout image to set all parameters for the upcoming scans.
2. Proton Density Fat Saturation Transverse.
Shows tissues with the higher concentration or density of protons (hydrogen atoms) which
produce the strongest signals and appear the brightest on the image.
3. T1 Sagittal.
T1 pulse sequence shows different density differently. Muscle tissue shows up grey, whereas
air shows up black.
4. T2 Fat Saturation Sagittal.
This pulse sequence shows adipose tissues dark on T2 weighted fat saturated images.
5. Proton Density Fat Saturation Coronal.
Same concept as number 2, only difference is the coronal view.
6. T1 Turbo Inversion Recovery Magnitude (TRIM) Coronal.
This pulse sequence nulls signals from fat.
7. Proton Density Dixon Fat Saturation Transverse.
This sequence essentially interacts with the water and fat molecules which is good for imaging
the muscle tissue.
Page 9 of 17

Diagnoses
Adrian Sampath
00040384
Clinical observations suggested an obvious bicep rupture. The reason for the MRI was to
identify the location of the tear and how severe the rupture is. This will provide the information
necessary to the physicians, to help plan the best course of treatment for the client.
The MRI images obtained, showed the rupture to the proximal end of the bicep tendon.
Figure 9 Showing the location of the bicep rupture
on T1 image
Figure 10 Showing the location of the bicep rupture
on Proton Density
Page 10 of 17

The Bicep Muscle
Adrian Sampath
00040384
The bicep is a dominant muscle which is located on the upper anterior aspect on both upper
limbs. The muscle is flexed to bring the elbow joint at a 90-degree angle causing the bicep
muscle to bulge, when the bicep relaxes, the elbow joint is extended and the bulge disappears.
There are two heads for a bicep proximal and distal, hence the name bicep. Tendons connect
the bicep muscle tissue to the boney anatomy at three different places. At the proximal head,
there are two attachments to the shoulder and at the distal head, there is one attachment to
the radius.
Figure 11 Showing extension (left) and flexion (right) of the bicep
Page 11 of 17

Pathology
Adrian Sampath
00040384
Due to the location of the rupture, it was revealed as a proximal rupture. This meant that it
caused a disconnection between the attachment of the muscle and the shoulder. The MR
imaging provided enough information to conclude which tendon on the proximal head was
damaged.
The bicep muscle relaxes in a flexed position, therefore the rupture caused a continuous
bulging referred to as a pop eye muscle. The affected arm can no longer extend but finger and
wrist movements were not affected.
According to (Jonathan Cluett, 2016), a bicep rupture is classified into:
1. Proximal Rupture, which is most common, however there are two tendons at this joint.
Statistics shows, that the long tendon is prone to being rupture while the shorter
tendon is less likely to be ruptured.
According to the MR images of the client’s bicep, it was revealed that the shorter
tendon of the proximal head of the bicep was ruptured, making this case study even
more interesting.
2. Distal Rupture, is located at the elbow joint. It is more frequent in people who do heavy
lifting or sports. Distal ruptures are usually surgically repaired.
Figure 12 Showing a proximal bicep rupture at the short tendon
Page 12 of 17

Possible Prognosis
Adrian Sampath
00040384
Surgery is normally the next step to repairing a ruptured bicep. As mentioned earlier, due to
the location of the rupture, other factors are considered such as age, use of arm (left or right
hand dominant), activity level and future use to determine the next step of treatment.
Due to the short period of time, I was unable to follow the case to conclude what course of
action was taken. However, from my interview with the client, it was revealed that the clients
non dominant hand was affected therefore I would assume a non-surgical course of action.
Non-Surgical Treatment
According to (Gary L Branch, 2017), there is set protocols for rehabilitation of bicep ruptures
using physical therapy and/or occupational therapy once the client meets the required
criteria.
Phase 1
The client would visit the physiotherapy lab, and would to extend and flex the arm on an
average of 10-15 days.
Phase 2
The client will be introduced to using a special pulley system or therapy bands. According to
the client’s advancement, more advance uses will take place between 6-8weeks.
Phase 3
Once the client shows promising results, weight bearing is the next stage and exercise will be
given according to the client’s tolerance.
Note: During either phase at any time, occupational therapy can be used to help with swelling
or pain.
Surgical Intervention
Again, according to (Gary L Branch, 2017) surgery is becoming less of an option. Clients who
suffer from a lot of pain or limited function are considered for surgical correction. Normally
clients are referred to non-surgical methods firstly and once there is a need for surgical
intervention, consideration and planning will begin.
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Client Discharge
Adrian Sampath
00040384
After the scan, the client was aided and escorted from zone 4 to zone 3 to change. After
changing, the client was carried out on the wheelchair back to the adult ward. The MR images
was sent to the PACS system for review by the referring physician.
Page 14 of 17

Conclusion
Adrian Sampath
00040384
In the end, I was very satisfied with my case study. I learnt a lot from my oversea practicum in
the MRI department and made new connections. I am proud that I am able to present this as
my case study and I did my best to share the information I obtained. I am truly thankful for the
opportunity, learning experience and memories this practicum provided to me as an individual
and as a student in radiography.
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References
Adrian Sampath
00040384
(2017, February 12). Retrieved from MRI MASTER: https://mrimaster.com/index-2.html
Bontrager, K. L., & Lampignano, J. P. (2010). Textbook of radiographic Positioning and
Related Anantomy. St. Louis Missouri: Carol O' Connell.
Brunilda Nazario, M. (2017, February 09). WebMD. Retrieved from Using the Pain Scale:
How to Talk About Pain: http://www.webmd.com/pain-management/chronic-pain-
11/pain-scale?page=2
Carlton, R. R., & Adler, A. M. (2013). Principles of Radiographic Imaging. Clifton Park, NY :
Delmar Cengage Learning; 5 edition.
Ehrlich, R. A., & Daly, J. A. (2015). Patient Care in Radiography with an Introduction to
Medical Imaging 7th Edition. St. Louis, Missouri 63146: Jeanne Wilke.
Frank, E. D., Long, B. W., & Barbara, S. J. (2007). Merrill's Altas of Radiographic Postioning &
Procedures, Edition 11. St. Louis, Missouri: Andrew Allen.
Gary L Branch, D. (2017, February 13). Biceps Rupture Treatment & Management.
Retrieved from MedScape: http://emedicine.medscape.com/article/327119-
treatment
Jonathan Cluett, M. (2017, February 14). Biceps Tendon Rupture. Retrieved from Very Well:
https://www.verywell.com/biceps-tendon-rupture-2548790
Lillian S. Torres, A. G.-W. (2010). Patient Care in Imaging Technology Seventh Edition.
Baltimore Maryland: Wolter Kluwer Health.
T.R. Goodman, M. (2017, February 9). Ionizing Radiation Effects and Their Risk to Humans.
Retrieved from Image Wisely Radiation Safety in Adult Medical Imaging:
http://www.imagewisely.org/Imaging-Modalities/Computed-Tomography/Imaging-
Physicians/Articles/Ionizing-Radiation-Effects-and-Their-Risk-to-Humans
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Appendix
Adrian Sampath
00040384
The following pages are samples used by the Scarborough General Hospital, MRI
department. The samples mentioned in order are:
Appendix 1. Referral Form mentioned on page 2.
Appendix 2. Screening Form mentioned on page 2.
Appendix 3. Contrast Form mentioned on page 7.
Appendix 4. Pregnancy Form mentioned on page 7.
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