IAGNOSTIC IMAGING
David W. Stoller, MD, FACR Director, California Advanced Imaging and MRI California Pacific Medical Center Director, National Orthopaedic Imaging Associates San Francisco, California Director, Musculoskeletal MRI California Pacific Medical Center
Phillip F. J.Tirman, MD Director, California Advanced Imaging California Pacific Medical Center Director, National Orthopaedic Imaging Associates San Francisco, California Director, Musculoskeletal MRI California Pacific Medical Center
Miriam A. Bredella, MD Department of Radiology University of California San Francisco San Francisco, California
Salvador Beltran, MD Medical Illustrator
Robert M. Branstetter Ill, MD Diversified Radiology of Colorado Denver, Colorado
Simon C. P. Blease, MD, FRCR Honorary Senior Clinical Lecturer University of Bristol United Kingdom
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Library of Stoller,
Congress Cataloging-in-Publication Data
David W.
Diagnostic imaging, orthopaedics / David W. Stoller, Phillip F.J. Tirman, Miriam A. B r e d e l l a ;S a l v a d o r Beltran, medical illustrator.1st ed. p. ;cm. I n c l u d e s bibliographical r e f e r e n c e s and index. I S B N 0-7216-2920-2 1. Musculoskeletal s y s t e m - R a d i o g r a p h y - A t l a s e s .
2. Diagnostic imaging-Atlases. [ D N L M : 1. Musculoskeletal S y s t e m - r a d i o g r a p h y - A t l a s e s . 2. Diagnostic I m a g i n g - m e t h o d s - A t l a s e s . 3. Orthopedic Procedures-methods-Atlases. WE 17 S875d 20041 I. Title: Orthopaedics. 11. Tirman, Phillip F. J. 111. B r e d e l l a , Miriam A. IV. Title.
To m y cherished son, GrifFn, and m y lovely wife, Marcia for their extraordinary love and support &
to the exceptional team of Phillip F. J. Tirman, MD, Miriam A. Bredella, MD, Salvador Beltran, MD, Robert M. Branstetter III, MD and Simon C. P. Blease, MD, FRCR whose cohesive partnership on the production of this book truly represented a force of nature.
D. WS.
To m y father, the late Robert M. Tirman, MD who was an inspiration. To Collin and Skye, m y children and Linda whose patience and understanding was truly appreciated.
To m y parents, Erika and Lothar, and to Harold, for their love and encouragement.
M.A.B.
CONTRIBUTORS David W. Stoller, MD, FACR Director, California Advanced Imaging and MRI California Pacific Medical Center Director, National Orthopaedic Imaging Associates San Francisco, California Director, Musculoskeletal MRI California Pacific Medical Center
Phillip F. J. Tirman, M D Director, California Advanced Imaging California Pacific Medical Center Director, National Orthopaedic Imaging Associates San Francisco, California Director, Musculoskeletal MRI California Pacific Medical Center
Miriam A. Bredella, M D Department of Radiology University of California San Francisco San Francisco, California
Salvador Beltran, M D Medical Illustrator
Robert M. Branstetter Ill, M D Diversified Radiology of Colorado Denver, Colorado
Simon C. F! Blease, MD, FRCR Consultant Musculoskeletal Radiologist Med-Tel International Corporation McLean, Virginia Honorary Senior Clinical Lecturer University of Bristol United Kingdom
Jana M. Crain, M D Medical Director National Orthopaedic Imaging Associates
Niku F! Wasudev, M D Musculoskeletal MRI National Orthopaedic Imaging Associates
James 0.Johnston, M D Professor Orthopaedic Oncology University of California, San Francisco Director Orthopaedic Oncology Kaiser South San Francisco
vii
DIAGNOSTIC IMAGING: ORTHOPAEDICS
The imaging, orthopedics and sports medicine communities have been waiting a long time for a new "Stoller". We at Amirsys and Elsevier are proud to present a precedent-setting, image- and graphics-packed series that debuts with a brand-new work by David Stoller and colleagues. This splendid work represents the textbook of the twenty-first century: Not your old-fashioned, dense prose exposition with comparatively few images. The unique bulleted format of the Diagnostic Imaging books allow our authors t o present approximately twice the information and four times the images per diagnosis, compared to the old-fashioned traditional prose textbook. These richly illustrated books will cover all major body areas and follow a similar format. The same information is in the same place: Every time! A welcome innovation is the new visual differential diagnosis "thumbnail" that provides at-a-glance looks at entities that can mimic the diagnosis in question. "Key Facts" boxes provide a succinct summary for quick, easy review. In short, this is a product designed with you, the reader, in mind. Today's typical practice settings demand efficiency i n both image interpretation and learning. We think you'll find the Diagnostic Imaging format a highly efficient and wonderfully rich resource. Enjoy!
Anne G. Osborn, MD Executive Vice-President and Editor-in-Chief, Amirsys H. Ric Harnsberger, MD Chairman and CEO, Amirsys Inc
David W. Stoller, MD, FACR Editor Diagnostic Imaging Orthopaedics
FOREWORD
Over the last 20 years, MR imaging has become a significant diagnostic test performed in orthopaedic and sports medicine. Surgeons have come to depend on this modality to provide crucial information, which assists not only in understanding the underlying pathology, but also in making the critical decision regarding surgical intervention. With the rapid growth and sophistication of MR technology, MR imaging is an indispensable step in the workup of patients with joint disorders and sports injuries. It has especially become important in the evaluation and treatment of professional athletes who often depend on quick and accurate diagnosis in order that they can resume their activities.
Diagnostic Imaging i n Orthopaedics is an invaluable text to orthopedists and radiologists alike. This thousand-page text contains over 550 color illustration plates and over 1000 radiographic images. Each radiographic diagnosis is discussed in outline format with thumbnail images of other differential considerations. While the unique correlative color illustrations for each diagnosis allow the reader to better understand anatomy and mechanism of disease, the concise yet complete format of the textbook allows for quick reference in the clinical setting. Dr. Stoller has successfully expanded the collaboration between orthopedic surgeons and radiologists with Diagnostic Imaging in Orthopaedics as exemplified by the representative images and correlative discussions of topics including pathophysiology, anatomy, and patient management. Not only does this text focus on orthopaedic diagnosis involving the appendicular skeleton, but he also covers bone, soft tissue, and marrow tumors. Many of the techniques and applications described in this text were either originated or improved by Dr. Stoller and his co-authors. This comprehensive text is the first of its kind in encompassing an understanding of orthopaedics with correlative color illustrations and therefore will become an invaluable reference and establish a higher standard of imaging for orthopaedists and radiologists.
W. Dilworth Cannon Jr., MD Professor of Clinical Orthopaedic Surgery UCSF Sports Medicine Center University of California San Francisco, California
xii
PREFACE
Joint efforts from the fields of radiology and orthopaedics have continued to define the growing indications and current issues for the use of MR in orthopaedics and sports medicine. Since the mid19801s,skeletal radiology has undergone an accelerated transformation with the infusion of MR technology and applications. Credit is acknowledged to my early contemporaries including Jerrold H. Mink, M.D. and John V. Crues 111, M.D. Our collaborative research in 1984-5 helped contribute to the initial MR applications for the meniscus; and thus, hastened the integration of MR in routine musculoskeletal imaging.
Diagnostic Imaging Orthopaedics represents the culmination of a collaborative vision I share with Anne Osborn, M.D. and Ric Harnsberger, M.D. to further and improve the landscape of education of residents, fellows, academic institutions, and private practice centers of excellence. This text reflects the manner in which the authors presently utilize MR in clinical imaging and explains the reliance of MR applications over CT and US in the appendicular joints. Each diagnosis consists of a classic color illustration and MR image. Differential diagnosis thumbnails are provided as a reference guide to help address related topics without competing or distracting the reader from the image galleries for each diagnosis. The outline style of writing not only provides more information than a comparable prose format, but also allows the reader to rapidly scan information in selected subsections or within the key facts box. Our team has performed an excellent job in organizing the orthopaedic topics into nine categories: six chapters concerning the appendicular joints and three chapters addressing marrow, bone and soft tissue tumors. Salvador Beltran, M.D. has provided one of the largest correlative collections of superbly illustrated orthopaedic pathology in color found in a single text.
Diagnostic Imaging Orthopaedics is a comprehensive and current reference that addresses the growing need of radiologists, orthopedists, and sports medicine physicians to understand and incorporate new clinical applications of bone and joint imaging into their practices. David W Stoller, MD Director, California Advanced Imaging and MRI California Pacific Medical Center Director, National Orthopaedic Imaging Associates San Francisco, California Director, Musculoskeletal MRI California Pacific Medical Center
...
Xlll
ACKNOWLEDGMENTS Illustrations Salvador Beltran, MD
Art Direction and Design Richard Coombs, MS Lane R. Bennion, MS James A. Cooper, MD
ImageIText Editing Mingqian Huang, MD Melissa Morris Cassie Dearth Kaerli Main
Medical Text Editing Mingqian Huang, MD Richard H. Wiggins 111, MD Karen L. Salzman, MD Bernard Chow, MD Janaki N. Ramanathan, MD
Research Contributors Lesley J. Anderson, MD Frank M. Cmkovich, MD David M. Lichtman, MD Richard D. Ferkel, MD Wesley M. Nottage, MD
Technological Assistance Christopher Govea, MD Philip Tran, MD Margie Garbarino, CRT, ARRT, (R,MR) Peter R. Osuna
Manuscript Preparation Mingqian Huang, MD Susan Bybee, CRT, ARRT, (R,MR)
Image Contribution Me1 Senac, MD Rob Campbell, MD Andrew Grainger, MD John Feller, MD Oliver Cuitanic, MD Britta Gooding, MD
Production Director Pattie R. Dawson
SECTIONS
Shoulder Elbow Wrist and Hand Hip Knee
151
Ankle and Foot Bone Marrow
Soft Tissue Tumors index
xvii
TABLE OF CONTENTS ECTiON I:Shoul Rotator Cuff Rotator Cuff Tendinopathy Rotator Cuff Partial Thickness Tear Internal Impingement, Shoulder Rotator Cuff Full Thickness Tear Rotator Interval Tears Microinstability, Shoulder Rotator Cuff Post-Operative Repair Rotator Cuff Calcific Tendinitis Parsonage-Turner Syndrome Subscapularis Rupture Pectoralis Major Tear
Labral Cyst, Shoulder Anterosuperior Variations, Shoulder Adhesive Capsulitis, Shoulder Bankart Lesion Perthes Lesion ALPSA Lesion GLAD Lesion HAGL Lesion IGL Tears Bennett Lesion Posterior Labral Tear, Shoulder Hidden Lesion, Shoulder
Biceps TendonIAnchor Biceps Tendinosis Biceps Tendon Tear SLAP Lesions I-IV SLAP Lesions V-IX Biceps Tendon Dislocation
Osseous Structures Subacromial Impingement 0 s Acromiale Acromioclavicular Joint Arthritis AVN, Shoulder Osteochondral Injuries, Shoulder Greater Tuberosity Fracture
Arthritis Osteoarthritis, Shoulder Rheumatoid Arthritis, Shoulder
xviii
Neural Impingement Quadrilateral Space Syndrome Suprascapular, Spinoglenoid Notch
SECTiON 2: Elbow Tendinopathy Lateral Epicondylitis Medial Epicondylitis Biceps Tendon Rupture Triceps Tendon Rupture
Instability Lateral Collateral Ligament Injury Posterior Dislocation, Elbow MCL Elbow Injury Little Leaguer's Elbow
Neuropathy Ulnar Neuropathy Radial Neuropathy Median Neuropathy Anconeus Epitrochlearis
Osseous Trauma Coronoid Process Fracture Capitellar Osteochondritis Radial Head Fracture Loose Bodies and 0 s Supratrochleare Olecranon Fracture Lateral Condylar Fracture Capitellum Fracture Supracondylar Fracture Medial Condylar Fracture
Inflammation Bicipital Radial Bursitis Olecranon Bursitis Synovial Fringe, Elbow
Arthritis Osteoarthritis, Elbow Rheumatoid Arthritis, Elbow
Infection Osteomyelitis, Elbow
1-146 1-150
I
1
SECTION 3: Wrist and Hand
I
SECTION 4: Hip Osteonecrosis
Ligaments Scapholunate Ligament Tear Lunotriquetral Instability
3-2 3-6
Avascular Necrosis, Femoral Head Legg-Calve-Perthes
Marrow
Carpal Instabilities Mid Carpal Instability
3-10
Transient Osteoporosis of the Hip
Dysplasia
Distal Radioulnar Joint Ulnocarpal Abutment Distal Radioulnar Joint Instability
3-14 3-18
Triangular Fibrocartilage Complex Triangular Fibrocartilage Tear
3-22
Fractures, Distal Radius and Ulna Distal Radius Fractures Die Punch Fracture, Distal Radius Ulnar Styloid Fracture
3-26 3-30 3-34
3-38 3-42
Avascular Necrosis Scaphoid Non-Union Kienbock's Disease
Developmental Dysplasia of the Hip
Overuse Syndromes and Muscle Trauma Muscle Strain, Hip Rectus Femoris Muscle Strain Gluteus Medius Muscle Strain Hamstring Tendinosis Piriformis Syndrome Iliopsoas Bursitis Snapping Hip Syndrome
3-46 3-50
Femoral Head Fractures Femoral Neck Fractures Acetabular Fractures Hip Dislocations Avulsion Fracture Pubic Rami Stress Fractures Sacral Insufficiency Fractures
Carpal Tunnel Carpal Tunnel Syndrome
3-54
Labral Tear, Hip Paralabral Cysts, Hip
Arthritis
3-58
Arthritis Degenerative Arthritis, Wrist Hamato-Lunate Impingement Rheumatoid Arthritis, Wrist and Hand Madelung's Deformity
3-62 3-66 3-70 3-74
Femoroacetabular Impingement Osteoarthritis, Hip Loose Bodies, Hip Rheumatoid Arthritis, Hip
Infection Osteomyelitis, Hip
Cysts Ganglion Cyst, Wrist
4-46 4-50 4-54 4-58 4-62 4-66 4-70
Labrum
Guyon's Canal Syndrome Ulnar Tunnel Syndrome
4-18 4-22 4-26 4-30 4-34 4-38 4-42
Osseous Trauma
Carpal Fractures Scaphoid Fractures Hamate Fractures
4-10
3-78
SECTION 5: Knee
3-82 3-86 3-90
Menisci
Tendons De Quervain's Tenosynovitis Extensor Carpi Ulnaris Tendinitis Giant Cell Tumor Tendon Sheath
Finger Ulnar Collateral Ligament Tear, Thumb Flexor Annular Pulley Tears Flexor Digitorum Profundus Avulsions
3-94 3-98 3-102
Discoid Meniscus Meniscal Degeneration Meniscal Horizontal Tear Meniscal Cyst Meniscal Longitudinal Tear Meniscal Radial Tear Meniscal Flap Tear Meniscal Bucket-Handle Tear Meniscocapsular Separation Post-Operative Meniscus Change
xix
Anterior Cruciate Ligament Anterior Cruciate Ligament (ACL) Tear ACL Reconstruction
5-42 5-46
Posterior Cruciate Ligament Posterior Cruciate Ligament Tear
5-50
Deltoid Ligament Sprain Syndesmosis Sprain Anterolateral Impingement Anterior Impingement Syndesmotic Impingement Posterior Impingement Sinus Tarsi Syndrome
Osseous Fractures
Medial Collateral Ligament Medial Collateral Ligament Tear Medial Bursitis, Knee
Lateral Collateral Ligament Complex Lateral Collateral Ligament (LCL) Tear Posterolateral Complex Injuries Iliotibial Band Syndrome
5-62 5-66 5-70
Osseous/Cartilagenous Structures Osteochondral Injuries, Knee Osteochondritis Dissecans, Knee Bone Infarct, Knee Spontaneous Osteonecrosis, Knee Patellar Fracture Lateral Tibial Plateau Fracture
Ankle Fractures Talus Fractures Calcaneal Fractures Navicular Fractures Metatarsal Fractures Lisfranc Fracture-Dislocation Osteochondral Lesion of the Talus Avascular Necrosis (AVN) of the Talus Freiberg's Infraction Medial Tibial Stress Syndrome Tarsal Coalition
Overuse Syndromes and Soft Tissue Injury 0 s Trigonum Syndrome Accessory Navicular Sesamoid Dysfunction Compartment Syndrome, Lower Extremity Gastrocnemius Soleus Strain Plantaris Rupture Tarsal Tunnel Syndrome Plantar Fasciitis Plantar Fibromatosis Morton's Neuroma Diabetic Foot
Extensor Mechanism Patellar Tendinitis Osgood-Schlatter Disease Patellar (Anterior) Bursitis Synovitis, Knee Patellar Tendon Tears Chondromalacia Patella Quadriceps Tendon Tear Transient Patellar Dislocation Medial Plica Syndrome
SECTION 2 Bone Marrow Osteoarthritis, Knee Rheumatoid Arthritis, Knee Pigmented Villonodular Synovitis, Knee Lipoma Arborescens, Knee Reflex Sympathetic Dystrophy, Knee Chondrocalcinosis, Knee
5-132 5-136 5-140 5-144 5-146 5-150
SynovialIDegenerative Cysts Intercondylar Notch Cyst Popliteal Cyst
SECTION 6: Ankle and Foot
Round Cell Tumors Langerhans Cell Histiocytosis Ewing Sarcoma Leukemia Lymphoma Multiple Myeloma
Hemoglobinopathies Sickle Cell Anemia Thalassemia
Lipid Storage Diseases Gaucher's Disease
Tendons Achilles Tendinitis Achilles Tendon Tear Tibialis Posterior Tendon Tear Flexor Hallucis Longus Abnormalities Tibialis Anterior Tendon Tear Peroneus Brevis Tendon Tear
Ligaments Anterior Talofibular Ligament Tear Calcaneofibular Ligament Sprain
7-22 7-26
7-30
Miscellaneous Marrow Lesions Metastases, Bone Marrow Paget Disease
SECTION 8: Bone Tumors Osteoblastic Tumors Osteoma Osteoid Osteoma
8-2 8-6
Osteoblastoma Osteosarcoma
Cartilaginous Tumors Enchondroma Osteochondroma Chondroblastoma Chondromyxoid Fibroma Chondrosarcoma
8-18 8-22 8-26 8-30 8-34
Fibrous Tumors Fibrous Dysplasia Fibroxanthoma Malignant Fibrous Histiocytoma, Bone Fibrosarcoma
8-38 8-42 8-46 8-50
Miscellaneous Tumors and Tumor-Like Lesions Giant Cell Tumor Intraosseous Hemangioma Unicameral Bone Cyst Aneurysmal Bone Cyst Intraosseous Lipoma Adamantinoma
I
8-54 8-58 8-62 8-66 8-70 8-74
SECTION 9: Soft Tissue Tumors
1
Fibrous Tumors Fibrosarcoma, Soft Tissue Fibromatosis Malignant Fibrous Histiocytoma
Synovial Tumors Pigmented Villonodular Synovitis Synovial Sarcoma
Fatty Tumors Lipoma, Soft Tissue Liposarcoma, Soft Tissue
Neural Tumors Benign Peripheral Nerve Sheath Tumor Malignant Peripheral Nerve Sheath Tumor
Muscular Tumors Rhabdomyosarcoma, Soft Tissue
Vascular Tumors Hemangioma, Soft Tissue
xxi
DEFlNlTlON OF TERMS Also used when fat suppression fails with FSE sequences Sensitive t o magnetic field inhomogeneties, paramagnetics and ferromagnetic micrometallic artifacts compared to SE and FSE (secondary to gradient rephrasing)
T I Wl
-
.
T1 Weighted Image Includes spin echo (SE), fast spin echo (FSE) and gradient echo (GRE) Used to show hypointense signal in sclerosis and subchondral edema Marrow fat signal is hyperintense on T1 weighted images
-
T2WI 4
T2 Weighted Image Includes SE and FSE sequences T2 FSE used to evaluate the rotator cuff (complementing FS PD FSE images) by differentiating tendinosis and tears T2 FSE application limited because of hyperintense fat signal, (FS PD FSE used more commonly for this reason) FS T2 FSE produces an image with poor SNR (signal-tonoise) with TE values of greater than 60 msec
PDWl
. .
Proton Density Weighted or Intermediate Weighted Image Long TR and short TE images High SNR Useful for articular cartilage evaluation as an alternative to FS PD FSE May obscure sclerosis or marrow edema due to poor marrow fat contrast compared to TlWI or FS PD FSE
STIR (SHORT TI INVERSION RECOVERY)
-
. .
.
GRE Gradient Echo
Inversion Recovery Fat Suppressed Spin Echo Pulse Sequence Initial 180 degree inversion pulse prior to 90 degree pulse STIR has more uniform fat suppression because IR is less sensitive to magnetic field inhomegeneties and off center field-of-view (FOV) effects Used when FS PD FSE not available or when fat suppression inadequate in FSE images T1 & T2 contrast additive in STIR however SNR is low secondruy to reduced transverse magnetization Limited by prolonged scan times
T I C+
.
FS PD FSE Fat Suppressed Proton Density Weighted Fast Spin Echo Evaluates marrow edema, articular cartilage, ligaments, tendons, synovium, and meniscal morphology Commonly used sequence for all appendicular joint imaging Often referred to as FS T2 FSE although TE values are typically less than 60 msec TR values greater than or equal to 3000 msec TE values of 40-50 msec to optimize image quality
ZIP Zero-fill Interpolation Processing Reconstruction technique to enhance apparent image resolution without actually creating resolution
Intravenous contrast administration in conjunction with fat suppression to increase the conspicuity of synovium vascularity, inflammation and tumors Also used to improve visualization of intraarticular structures by delayed enhancement of joint fluid without the benefit of capsular distension
ABER Abduction External Rotation position of the shoulder to optimize visualization of the inferior glenohumeral ligament labral complex (IGLLC), biceps labral complex (BLC) and articular surface of the rotator cuff
MR ARTHRO
-
- echoes Reverse gradient polarity to rephrase protons and form . Usually used to create images with T2* contrast . - T2* contrast used t o evaluate TFC (triangular fibrocartilage), patellar tendon, intrameniscal signal,
MR arthrography Dilute intraarticular MR contrast agent and saline or nonionic contrast Distend joint capsule to improve visualization of intraarticular and capsular structures Used in selective applications for the shoulder, wrist, hip, elbow and knee Used in conjunction with T1 fat suppression and FS PD FSE sequences
subscapularis tendon and chondrocalcinosis
xxiii
xxiv
-
SECTION 1: Shoulder Rotator Cuff Rotator Cuff Tendinopathy Rotator Cuff Partial Thickness Tear Internal Impingement, Shoulder Rotator Cuff Full Thickness Tear Rotator Interval Tears Microinstability, Shoulder Rotator Cuff Post-Operative Repair Rotator Cuff Calcific Tendinitis Parsonage-Turner Syndrome Subscapularis Rupture Pectoralis Major Tear
Labral Cyst, Shoulder Anterosuperior Variations, Shoulder Adhesive Capsulitis, Shoulder Bankart Lesion Perthes Lesion ALPSA Lesion GLAD Lesion HAGL Lesion IGL Tears Bennett Lesion Posterior Labral Tear, Shoulder Hidden Lesion, Shoulder
Biceps TendonIAnchor Biceps Tendinosis Biceps Tendon Tear SLAP Lesions I-IV SLAP Lesions V-IX Biceps Tendon Dislocation
Osseous Structures Subacromial Impingement 0 s Acromiale Acromioclavicular Joint Arthritis AVN, Shoulder Osteochondral Injuries, Shoulder Greater Tuberosity Fracture
Arthritis Osteoarthritis, Shoulder Rheumatoid Arthritis, Shoulder
Neural Impingement Quadrilateral Space Syndrome Suprascapular, Spinoglenoid Notch
ROTATOR CUFF TEN1
Coronal graphic shows thickening and degeneration of the distal aspect of the supraspinatus tendon, consistent with tendinopathy.
BPATHY
Coronal FS PD FSE MR shows thickening and increased signal intensity (arrow) of the distal supraspinatus tendon, representing tendinopathy (tendinosis).
Radiographic Findings ~adiograph~ 0 Acromial remodeling/sclerosis + acromioclavicular (AC) joint hypertrophy o Acromial spurs (impingement) o Humeral head subchondral sclerosis/cysts
Abbreviations and Synonyms Rotator cuff (RTC) impingement, subacromial impingement, supraspinatus impingement Rotator cuff tendinitis (tendinosis), supraspinatus tendinitis, shoulder periarthritis, painful shoulder syndrome
MR Findings -
Definitions Collagenous degeneration of the rotator cuff tendons most commonly involving the supraspinatus tendon
General Features Best diagnostic clue: Thickened inhomogeneous rotator cuff tendon with increased signal intensity on all pulse sequences Location: Anterior leading edge of supraspinatus Size: Tendon thickened but may be thinned by attrition Morphology 0 Thickened, inhomogeneous tendon with visible surface fraying o Tendon torn or partially torn in advanced cases with fluid entering defect
TlWI o Thickened tendon with intermediate signal intensity Heterogeneous tendon(s) signal o Intermediate signal intensity in the long head of biceps tendon with associated tendinosis 0 Hypointense to intermediate signal intensity in thickened or fluid containing subacromialsubdeltoid bursa T2WI 0 Increased signal intensity of tendon on PD FSE, FS PD FSE, STIR & T2* GRE Heterogeneous tendon(s) signal o Hyperintense tendon degeneration on FS PD FSE FS PD FSE visualizes tendon degeneration as hyperintense while T2 FSE shows degeneration as low to intermediate in signal o +/- Hyperintense effusion (glenohumeral joint) 0 Hyperintense (fluid signal intensity) bursitis Subacromial/subdeltoid Subcoracoid - esp. with anterior pathology
wmmu DDx: Rotator Cuff Tendinopathy
d;
Cor FS PD FSE
Cuff Strain
-
Cor FS PD FSE
Cor FS PD FSE
~r FS PD FSE
Cor FS PD FSE
-
ROTATOR CUFF TENDINOPATHY Key Facts Terminology
Full Thickness Tears
' POSterOsuperior
Collagenous degeneration of the rotator cuff tendons most commonly involving the supraspinatus tendon
Microinstability
Imaging Findings
Impingement
Pathology
Overuse, degeneration and tearing of the rotator cuff
Best diagnostic clue: Thickened inhomogeneous rotator cuff tendon with increased signal intensity on all pulse sequences Increased signal intensity of tendon on PD FSE, FS PD FSE,STIR ST ~ 2 GRE *
- intrinsic theory
Secondary to impingement syndrome - extrinsic
Clinical Issues Painful even without tendon tear Most common reason for MRI referral of the shoulder
Top Differential Diagnoses Calcific Tendinitis Intratendinous Cyst Magic Angle Artifact Normal Variations Partial Thickness Tears
Diagnostic Checklist FS PD FSE may overestimate cuff pathology (tendinosis mistaken for a cuff tear)
-
o +/- AC arthritis + acromial spurs
Associated with partial tear of rotator cuff Elongated
Chondromalacia (surface defects, hyperintense hyaline articular cartilage & marrow edema) o Prominence of greater tuberosity + subcortical cystic change o Post dislocation findings in case of tendinopathy due to supraspinatus strain Hyperintense bone marrow edema with +/hypointense fractures Bankart, Hill-Sachs fracture Type I11 (hooked) acromion MR arthrography o No cuff defect identified
Magic Angle Artifact Leads to artifactual increased signal at curved portion of tendon without thickening on short TE sequences 55 degrees to external magnetic field Affects biceps tendon, supraspinatus tendon and labrum
Normal Variations Muscle/tendon overlap o In internal rotation o Muscle fibers, esp. posteriorly may extend to the tendon insertion
Ultrasonographic Findings Thickened decreased echogenicity/hypoechoic Tears directly visible Less sensitive for partial thickness tears Advantage - allows dynamic evaluation with pain correlation
Partial Thickness Tears Fluid within but not transversing tendon Hyperintense partial defect on T2WI o Bursal (Bursal Part Tear) o Interstitial o Articular
Imaging Recommendations Best imaging tool: MRI Protocol advice o Coronal, sagittal FS PD FSE and T2 FSE are both required Tears best seen on coronal and sagittal images
1 DIFFERENTIAL DIAGNOSIS Calcific Tendinitis Form of tendinopathy Tendon thickened and with decreased signal intensity on all pulse sequences o Calcium hydroxyapatite within hypointense cuff tendon@) o Hypointense calcium deposit +/- Hyperintense surrounding edema on T2WI +/- Adjacent bursitis
lntratendinous Cyst Thickened tendon, cyst visible on T2WI o Hyperintense on T2WI
Full Thickness Tears +/- Impingement Hyperintense defect on T2WI Anterior aspect often involved as in tendinopathy o Tendinopathy often precursor to tear
I
Posterosuperior Glenoid Impingement Internal impingement Posterosuperior cuff, labrum, humeral head o Triad of findings Overuse Throwing athletes +/- Occupational risk
Microinstability Superior labrum, MGL (middle glenohumeral ligament), anterior cuff abnormalities Usually partial supraspinatus tear Abnormal movement of shoulder joint results
-
ROTATOR CUFF TENDlNOPATHY
1 PATHOLOGY
1
Separates musculotendinous junction from crescent o Crescent = lateral portion of supraspinatus tendon at risk for most cuff tears Cuff tears in this lateral location may respond to debridement
General Features General path comments: Common degenerative, pain producing disorder Etiology o Overuse, degeneration and tearing of the rotator cuff - intrinsic theory o Secondary to impingement syndrome - extrinsic theory Subacromial spur formation AC joint osteoarthritis Type 3 (hooked) acromion Laterallanterior downsloping acromion 0 s acromiale o Acute but usually in the setting of preexisting tendinosis o Eccentric tensile overload of the rotator cuff tendons o Begins where load is greatest on tendon - on articular side of anterior insertion of the supraspinatus tendon o Combination of extrinsic, intrinsic, and biomechanical factors o Collagen vascular diseases along with tendinosis of other tendons Epidemiology o Shoulder pain is 3rd most common cause of musculoskeletal pain syndrome After low back pain (LBP) and cervical pain o 7-25% in Western general population
Presentation Most common signs/symptoms o Progressive onset of shoulder pain Pain, weakness, and loss of shoulder motion common Pain over anterolateral part of the shoulder worsened by overhead activities in impingement Night pain Clinical profile o Pain in athletics (internal impingement) Younger patient population Painful even without tendon tear Most common reason for MRI referral of the shoulder Posttraumatic continued pain
Demographics Age: Peak: > 40 years for impingement, most common 55 years Gender: M:F = 1:l or slight female predominance
Natural History & Prognosis Insidious onset of pain in adult patient with impingement syndrome +/- Progression to tear
Gross Pathologic & Surgical Features
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Thickened, indurated tendon Loss of integrity of tendon in partially torn (bursal, articular or interstitial) and through-and-through torn tendons Partial tear may be on the bursal surface, articular surface or interstitial
Microscopic Features Collagen degeneration without influx of inflammatory cells: "Tendinosis"is preferred term over tendinitis Increase in collagen type I11 o Protein involved in healing and repair Increase in glycosaminoglycan and proteoglycan Tendon cell apoptosis (cell death) within supraspinatus Mucoid/eosinophilic/fibrillary degeneration and scarring Angiofibroblastic hyperplasia
Treatment Physical therapy Corticosteroids via injection to decrease inflammation Subacromial decompression for impingement
I DIAGNOSTIC CHECKLIST Image Interpretation Pearls
FS PD FSE may overestimate cuff pathology (tendinosis mistaken for a cuff tear) T2 FSE (without fat suppression) is used to show the diminished signal in tendinosis as compared to the hyperintensity of a true cuff tear
Staging, Grading or Classification Criteria Impingement o Stage I: Reversible edema & hemorrhage typically in active patient I 25 years o Stage 11: Fibrosis and tendinitis o Stage 111: Degeneration & rupture often associated with osseous changes in patients > 40 years Burkhart's cable/crescent theory of cuff tears o Cable = thickened supraspinatus tissue connecting anterior & posterior tendon edges medially Well-perfused Identified histologically
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3. 4.
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Teefey SA et al: Ultrasonography of the rotator cuff. A comparison of ultrasonographic and arthroscopic findings in one hundred consecutive cases. J Bone Joint Surg Am 82(4):498-504,2000 Gartsman GM: Arthroscopic management of rotator cuff disease. J Am Acad Orthop Surg 6(4):259-66, 1998 Cohen RB et al: Impingement syndrome and rotator cuff disease as repetitive motion disorders. Clin Orthop (351):95-101,1998 Fritz RC et al: MR imaging of the rotator cuff. Magn Reson Imaging Clin N Am 5(4):735-54,1997 Neer CD et al: Cuff-tear arthropathy. J Bone Joint Surg 65(9):1232-44, 1983
ROTATOR CUFF TENDINOPATHY
Typical (LLfl) Coronal PD FSE MR shows increased signal intensity within the supraspinatus critical zone (arrow), consistent with tendinopathy. (Right) Coronal FS PD FSE MR shows increased signal of the critical zone, consistent with tendinopathy & articular surface fraying. This sequence visualizes tendinosis as hyperintense.
Typical (LLB) Sagittal FS PD FSE MR shows thickening and increased signal intensity (arrow) within the supraspinatus, consistent with tendinopathy. (Right) Axial PD FSE MR shows increased signal intensity (arrow) within the lateral supraspinatus tendon (crescent area where cuff tears occur). Note the rotator cable (open arrows).
Tvsical (Lef)Coronal PD FSE MR shows marked thickening (arrow) of the posterior aspect of the supraspinatus tendon, consistent with tendinopathy. The patient has PSCl (posterior superior glenoid impingement). (Right) Sagittal FS PD FSE MR shows tendinopathy (arrow) predominantly affecting the posterior cuff tendon.
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ROTATOR CUFF PARTIAL THICKNESS TEAR
Coronal graphic shows a partial undersurface tear of the supraspinatus tendon involving the critical zone.
Coronal FS PD FSE M R shows an articular surface partial tear (arrow) of the supraspinatus involving the critical zone.
o
Abbreviations and Synonyms
+/- Anatomically sealed (closed) in the adducted shoulder imaging position
Radiographic Findings
Partial rotator cuff tear (PRTC Tear)
Radiography o Findings associated with impingement Acromial spurs Type I11 (hooked) acromion Humeral head (HH) arthritic changes of greater tuberosity Acromioclavicular (AC) degenerative changes
Definitions Incomplete (partial) tear of tendon of rotator cuff o Supraspinatus tendon most common o Three types Bursa1 surface Interstitial (within substance noncommunicating) Articular surface
MR Findings
General Features Best diagnostic clue o Incomplete tear or gap in the RTC tendon filled with joint bursal fluid, +/- granulation tissue o FS PD FSE or T2WI Location: Supraspinatus (SST) bursal or articular surfaces or within tendon Size: Varies from fraying to large dissecting partial tear Morphology o Irregularity (fraying) to flap morphology
TlWI o Thickening of RTC tendons, of intermediate signal intensity o Calcifications in the supraspinatus, infraspinatus or teres minor = calcific tendinitis o Hypointense bone impaction (Hill-Sachs) - anterior dislocation Rotator cuff strain associated o Marrow containing acromial spur (marrow fat) T2WI o Fluid signal intensity filling an incomplete gap in the tendon FS PD FSE Gap - articular surface or bursal surface Interstitial, noncommunicating gap o +/- Fluid within the subacromial bursa
EH
DDx: Rotator Cuff Partial Thickness Tear Ca++ Tendinitis
Cor FS PD FSE
Cor Tl Arthro.
Sag FS PD FSE -
ROTATOR CUFF PARTIAL THICKNESS TEAR Key Facts Terminology Incomplete (partial) tear of tendon of rotator cuff Bursa1 surface Interstitial (within substance - noncommunicating) Articular surface
Imaging Findings Incomplete tear or gap in the RTC tendon filled with joint bursa1 fluid, +I- granulation tissue Findings associated with impingement
Top Differential Diagnoses Intratendinous Cyst Full Thickness Tear without Visible Communication Calcific Tendinitis (Ca++Tendinitis) Rotator Cuff Tendinopathy Adhesive Capsulitis Increased signal intensity on FS PD FSE o
+/- Fluid within the subcoracoid
Anterior supraspinatus tear, rotator interval tear Subcoracoid impingement o Intermediate signal intensity in long head of biceps tendon, + associated tendinosis o Hyperintense effusion o FS PD FSE Sensitive for evaluating partial tears o +I- Retraction and degeneration of the tendon edges Articular or bursal surface partial o Hypointense bone impaction (Hill-Sachs) - post anterior dislocation Rotator cuff strain commonly associated o Fluid within the substance of the tendon between layers in interstitial tear No communication with surface Not seen at arthroscopy T1 C+: Enhancement of granulation tissue indicating partial tear (imbibition) MR arthrography o Arthrography: Contrast may fill tear if articular surface communicates with joint
Ultrasonographic Findings Decreased echogenicity and thinning of partially torn region Lost of convexity of tendonlbursa interface in bursal surface partial tears Calcium = hyperechoic foci + shadowing
Imaging Recommendations Best imaging tool o MRI FS PD FSE (hyperintense for tendinosis & partial tears) T2 FSE (hyperintense for partial tears and not tendinosis) Protocol advice o FS PD FSE and T2 FSE coronal and sagittal images o +I- MR arthrography
Pathology Acute strain Chronic microtrauma/persistent strain
Clinical Issues
Pain with abduction flexion maneuverslimpingement tests Shoulder pain with use of RTC after trauma Partial tears are more painful than full thickness tears
Diagnostic Checklist Partial tear in setting of intramuscular cyst Interstitial partial tear with fluid in the tendon not communicating with joint or bursa Identify fluid on FS PD FSE, and use the T2 FSE sequence to differentiate tendinosis from partial tear
I DIFFERENTIAL DIAGNOSIS lntratendinous Cyst Associated with partial tears Thickened tendon Cyst visible on T2WI 0 Hyperintense smoothly marginatedlelongated mass Cyst usually flattened
Full Thickness Tear without Visible Communication +I- Closed by granulation +/- Closed by fibrosis/adhesions Uncommon Technique 0 Non fat saturation sequences may be less sensitive
Calcific Tendinitis (Ca++ Tendinitis) Calcium hydroxyapatite o Hypointense on all pulse sequences Deposit not visible in following conditions o Hypointense deposit within hypointense tendon o Quiescent lesions (silent phase) +I- Surrounding hyperintense edema on T2WI
Rotator Cuff Tendinopathy Thickened hyperintense (T2WI) tendons +/- Impingement No tear +/- Chronic repetitive microtrauma/impingement
Adhesive Capsulitis Thickened hyperintense capsule o Axillary pouch inferior glenohumeral ligament (IGHL) o Rotator interval Frozen shoulder +I-Cuff tear
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ROTATOR CUFF PARTIAL THICKNESS TEAR
1 PATHOLOGY General Features
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General path comments o Three types partial tears of RTC Articular surface partial tear - most common, associated with ciassical impingement Interstitial - not seen at arthroscopy Bursa1 surface o Partial thickness tears cause muscle contraction pain similar to other partial tendon injuries (Achilles tendon, extensor carpi radialis brevis) o Pain with reflex inhibition of muscle action and loss of strength o Partial tear fiber detachment makes muscle less effective for proprioception function o Altered cuff function - HH ascends under deltoid contraction o Impinging cuff between HH & coracoacromial arch causative o Abrasion of cuff occurs with altered humeroscapular motion = cuff degeneration Etiology o Acute strain o Chronic microtrauma/persistent strain o Impingement syndromes o Collagen vascular diseases along with tears of other tendons o Altered concavity compression leading to microtrauma Epidemiology: Incidence of partial thickness tears 32-37%after 40 years * Associated abnormalities o Intratendinous cyst o Posterosuperior labral frayingltears internal impingement o Posterosuperior humeral head chronic impaction internal impingement o Bankart and Hill-Sachs anterior dislocation o SLAP tears associated with articular surface partial tears both anterior (SLAC lesion) and posterior (posterior peelback lesion) subclassificationof type I1 SLAP lesions
o Partial articular supraspinatus tendon avulsion
(PASTA) lesion Type IV - severe tear with fraying, fragmentation and flap o Often involves more than one tendon
Presentation Most common signslsymptoms o Pain with abduction flexion maneuvers/impingement tests o Shoulder pain with use of RTC after trauma o Partial tears are more painful than full thickness tears Clinical profile: Athlete, patient after 40 years of age with impingement
Demographics Age o Younger athlete in case of internal impingement o Older than 40 years in subacromial impingement Gender: M = F, M > F in throwing athletes and heavy laborers
Natural History & Prognosis Insidious onset of pain in adult patient with impingement syndrome Sudden onset of pain in acute traumatic event Most partial tears progress to full thickness tears within 2 years May heal with cessation of impingement activitieslphysical therapy (PT)
Treatment PT for minor partial tears Arthroscopic debridement for more extensive tears o Subacromial decompression for bursa1 surface tears and acromial degenerative change
I DIAGNOSTIC CHECKLIST Consider Partial tear in setting of intramuscular cyst Interstitial partial tear with fluid in the tendon not communicating with joint or bursa
Gross Pathologic & Surgical Features Thickened, indurated tendon edges Loss of integrity of tendon collagen fibers Hemorrhage in interstitial tears
Image Interpretation Pearls Identify fluid on FS PD FSE, and use the T2 FSE sequence to differentiate tendinosis from partial tear
Microscopic Features Collagen degeneration without influx of inflammatory cells Inflammatory cells in adjacent bursa = bursitis Increased levels of smooth muscle actin (SMA) o SMA-positive cells + glycosaminoglycan and proteoglycan promote retraction of torn fibers
Staging, Grading or Classification Criteria Type I - superficial capsular fraying, small local area, < 1 cm Type I1 - mild fraying, some failure of tendon fibers, < 2 cm Type I11 - moderate fragmentation and fraying, often involves entire SST surface, usually < 3 cm
1 SELECTEDREFERENCES 1. 2. 3.
Kibler WB et al: Clinics in sports medicine. current concepts in tendinopathy. vol22. W.B. Saunders, Philadelphia PA, 791-812, 2003 Read JW et al: Shoulder ultrasound: Diagnostic accuracy for impingement syndrome, rotator cuff tear, and biceps tendon pathology. J Shoulder Elbow Surg 7(3):264-71, 1998 Tirman PF et al: Posterosuperior glenoid impingement of the shoulder: Findings at MR imaging and MR arthrography with arthroscopic correlation. Radiology 193(2):431-6, 1994
ROTATOR CUFF PARTIAL THICKNESS TEAR
(Lef)Coronal graphic shows a bursal surface partial tear with reactive bursal changes. (Right) Coronal FS PD FSE MR shows a bursal surface partial tear of the supraspinatus tendon distal insertion.
(Lef)Coronal graphic shows an interstitial delamination partial tear. (Right) Coronal FS PD FSE MR shows interstitial delamination partial tear (arrow). There are associated degenerative changes of the humeral head.
(Lef)Coronal FS PD FSE MR shows an interstitial delamination partial tear with fluid signal intensity within the substance of the distal tendon. (Right) Coronal FS PD FSE MR shows multiloculated intramuscular hyperintense cyst (arrow) dissecting from myotendinous junction. There is associated partial cuff tearing. Intramuscular cysts are associated with RTC tears (particularly partial).
INTERNAL IMPINGEMENT, SHOULDER P
Coronal graphic shows an undersurface partial cuff lesion and a posterosuperior glenoid labral tear.
Abbreviations and Synonyms Posterosuperior glenoid impingement (PSGI), internal impingement
Coronal FS PD FSE MR shows an undersurface posterior supraspinatus tendon tear (arrow) + posterior superior labral fraying and cystic degenerative changes of posterosuperior humeral head.
Size: Minimal fraying to full thickness tears of RT( posterosuperior labrum and osteochondral impacl of posterosuperior HH Morphology: Thickened irregular tendon, frayed labrum, degenerative change - HH
Radiographic Findings
Definitions Impingement of undersurface, posterior supraspinatus and anterior undersurface infraspinatus by posterosuperior labrum and humeral head (HH) Overhead throwing athletes and occupations which require overhead work (ABER - abduction external rotation) Posterior peelback - posterosuperior labral tear o Subclassification of type I1 SLAP lesion o Also referred to as internal impingement and includes associated undersurface tear of cuff at junction of supraspinatus and infraspinatus
Radiography o May be normal o +/- Subcortical cystic changes, posterosuperior humeral head rn Mimics Hill-Sachs deformity
CT Findings NECT o +/- Cystic changes, posterosuperior humeral he: o Posteroinferior calcification in throwing athlete rn Bennett lesion CT arthrography o Posterosuperior labral fraying, +/- tear o Undersurface posterior supraspinatus/anterior infraspinatus partial tear Contrast extends into tear rn Coronal/sagittal reconstructions helpful
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General Features
Best diagnostic clue: Triad of undersurface rotator cuff (RTC), posterosuperior labrum and HH damage Location: Posterosuperior aspect of glenoid and rotator cuff
MR Findings
TlWI o Thickened increased signal posterior supraspina and anterior infraspinatus = tendinosis
DDx: Internal Impingement, Shoulder
Ca++ Tendinitis
Cor STIR M R
:or FS P D FSE
Cor P
Cor FS P D FSE
Sag FS P D FSE
INTERNAL IMPINGEMENT, SHOULDER -
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Key Facts Imaging Findings ABER (abduction and external rotation) imaging demonstrates undersurface tears
Top Differential Diagnoses Subacromial Impingement SLAP Lesions - without RTC Pathology Microinstability - Affects Anterior Leading Edge RTC Anterior Instability/Subluxation Hidden Lesion Calcific Tendinitis Supraspinatus Tear
Pathology General path comments: Dynamic compression of the posterior superior aspect of RTC between posterosuperior labrum and HH o Junction of articular surface of supraspinatus and
infraspinatus o Posterosuperior labral surface irregularity, hyperintensity = fraying o +/- Tear of posterosuperior labrum Increased signal intensity or avulsion o Posterosuperior humeral head irregularity with +/- Hypointense sclerosis +/- Hypointense subchondral cysts T2WI o Undersurface tear of posterior supraspinatus and anterior infraspinatus: Hyperintense o +/- Visible partial to complete tear - disrupted fibers Partial articular surface or interstitial tear +/- Surrounding hyperintense edema o Full thickness tear in more advanced cases o Posterosuperior humeral head chondromalacia Hyperintense (FS PD FSE) +/- Surface defect o Normal "bare area" of posterosuperior humeral head devoid of cartilage may be located adjacent to point of contract between humeral head and glenoid o Subchondral cystic changes +/- Hyperintense Similar location as Hill-Sachs lesion o Fraying +/- tearing of the posterosuperior glenoid labrum Surface irregularity, hyperintensity T2 not as sensitive as short TE sequences (TI, T2* GRE, PD) o Inferior glenohumeral ligament and anterior inferior labral injuries associated as IGL is under tension during abduction and external rotation STIR o Less spatial resolution compared to FS PD FSE o Necessary at low field strength as fat saturation important for detecting subtle edema MR arthrography o Posterosuperior labral fraying, +/- tear demonstrated by contrast outline o ABER (abduction and external rotation) imaging demonstrates undersurface tears
Degeneration and tearing of the supraspinatus and infraspinatus tendon due to sheer forces secondary to friction between the posterosuperior RTC, labrum and HH during overhead throwing activities Epidemiology: Young athletes and adults performing overhead motion
Clinical Issues Most common signs/symptoms: Pain with abduction and external rotation Athletes participating in overhead throwing sports Non athletes who frequently abduct and externally rotate the arm (occupational)
Diagnostic Checklist Primary impingement, and SLAP lesion
Uncovering posterosuperior labrum with improved visualization I "Touching"of cuff to labrum on ABER view not correlated with PSGI (seen in asymptomatic shoulders) I Demonstrates any nondisplaced/healed/partial healed anterior inferior labral tear ABER places traction on IGHLC (inferior glenohumeral ligament complex) o Chondromalacia outlined by contrast Surface irregularity +/- Defect of cartilage
Imaging Recommendations Best imaging tool: MRI Protocol advice: ABER imaging helps define associated articular sided cuff lesion
I DIFFERENTIAL DIAGNOSIS Subacromial Impingement History is usually suggestive of internal impingement o Athlete involved in overhead throwing activities o Instability may be present o Subluxation while throwing
SLAP Lesions - without RTC Pathology Superior labral tear Propagate outside superior labrum + Speed's test (bicipital resistance), O'Briens test (anterosuperior pain in labral tear) +/- Flap component Hyperintense signal abnormality on short TE sequences within biceps anchor Hyperintensity within substance of biceps anchor specific finding on T2WI
Microinstability - Affects Anterior Leading Edge RTC Anterior supraspinatus tear o Undersurface +/- Superior labrum tear
INTERNAL IMPINGEMENT, SHOULDER Hyperintense tear of cuff on T2WI +/- Middle glenohumeral (MGHL) tear
Chondral degeneration and thinning, subchondral sclerosis, and geode formation of the posterosuperior humeral head
Anterior Instability/Subluxation +/- Anterior inferior labral tear o Bankart lesion o Bankart variation o +/- Small nondisplaced tear in case of subluxation
Presentation
+/- Bankart fracture, Hill-Sachs lesion 12
Most common signs/symptoms: Pain with abduction - and external rotation Clinical profile o Athletes participating in overhead throwing sports o Non athletes who frequently abduct and externally rotate the arm (occupational) 0 Varying degrees of RTC disease both and shoulder instability (positive physical examination signs )
Hidden Lesion Rotator interval Biceps instability Superior glenohumeral ligament (SGHL)/coracohumeral ligament (CHL) abnormality +/- Subscapularis tear
Calcific Tendinitis Hypointense calcium deposit (calcium hydroxyapatite) on all pulse sequences o Obscured within hypointense cuff tendon(s) +/- Hyperintense surrounding edema on T2WI +/- Adjacent bursitis
Supraspinatus Tear
Demographics Age: Adolescent (athlete), adult (occupational) Gender: M > F
Natural History & Prognosis Typically improves with rest, RTC strengthening
Treatment
+/- Impingement
Physical therapy Arthroscopic debridement of rotator cuff and labral fraying Repair of rotator cuff tear Humeral derotational osteotomy o Absence of instability is required
Hyperintense defect on T2WI Anterior aspect often involved as opposed to PSGI o PSGI extends to involve anterior cuff in advanced cases
1 PATHOLOGY General Features General path comments: Dynamic compression of the posterior superior aspect of RTC between posterosuperior labrum and HH Etiology o Degeneration and tearing of the supraspinatus and infraspinatus tendon due to sheer forces secondary to friction between the posterosuperior RTC, labrum and HH during overhead throwing activities o Glenoid rim comes in contact with the deep surface of the tendon in 120" abduction, retropulsion, and extreme external rotation Late cocking phase in throwers External rotation of biceps causes posterior peelback lesion Epidemiology: Young athletes and adults performing overhead motion Associated abnormalities: +/- Anterior instability
Gross Pathologic & Surgical Features Tendinosis and tearing of supraspinatus, infraspinatus, labrum o Humeral head impaction Cuff tendon is indurated, inflamed, frayed or torn Degenerative fraying and/or tearing of the posterosuperior labrum = posterior peelback lesion
Microscopic Features Degeneration and varying degrees of inflammation associated with rotator cuff tendons and posterosuperior labrum
I DIAGNOSTIC CHECKLIST Consider Primary impingement, and SLAP lesion
Image Interpretation Pearls Posterior articular sided RTC pathology in throwing athlete
1 SELECTEDREFERENCES 1. 2.
3. 4.
Matsen FA 111: Rotator cuff. The Shoulder. 3rd ed. WB Saunders, Philadelphia PA, 1998 Resnick D: Shoulder. Internal derangements of joints: Emphasis on MR imaging. WB Saunders, Philadelphia PA, 163-333, 1997 Hawkins RH et al: Nonoperative treatment of rotator cuff tears. Clin Orthop (321):178-88,1995 Tirman PF et al: Posterosuperior glenoid impingement of the shoulder: Findings at MR imaging and MR arthrography with arthroscopic correlation. Radiology 193(2):431-6,1994
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INTERNAL IMPINCEMENT, SHOUl
( k p ) Coronal graphic demonstrates tearing of the infraspinatus tendon which can be seen with posterosuperior impingement. This undersurface cuff tear usually involves the anterior articular surface of the infraspinatus. (Right) Coronal STIR MR demonstrates a tear (arrow) of the infraspinatus/posterior supraspinatus in a patient with posterosuperior glenoid impingement.
(Left) Clinical photograph of a baseball pitcher demonstrates posterior contracture and inability to raise throwing hand - R hand (arrow) symmetrically with the left hand. Note the shoulder asymmetry. (Right) Axial PD FSE MR demonstrates synovitis (arrow) within the posterosuperior aspect of the joint. There is associated labral fraying, sclerosis of the posterosuperior glenoid and cystic changes in the posterolateral humeral head.
(Lef)Sagittal oblique arthroscopic view demonstrates an undersurface rotator cuff tear (arrow) adjacent to the humeral head (right side). (Right) T2 FSE ABER shows internal impingement in professional throwing athlete, including posterior peelback subtype SLAP I1 lesion (arrow), undersurface supraspinatus fraying & humeral head impaction (open arrow).
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ROTATOR CUFF FULL THICKNESS TEAR
Coronal graphic shows a full thickness tear through the mid substance of the supraspinatus tendon.
Abbreviations and Synonyms Rotator cuff (RTC) tear, supraspinatus (SST) tear
Definitions Tear of one of the tendons of rotator cuff o Supraspinatus tendon most common Tendon defect extends to both articular & bursal surfaces
Coronal FS PD FSE MR shows full thickness tear (arrow) of the distal aspect of supraspinatus tendon with retraction & reactive subacromial bursitis. There is secondary adhesive capsulitis.
o Anterior-posterior,medial-lateral Morphology o Gap in thickened irregular hyperintense tendon rn +/- Thinning o Repairable tears Crescent within the distal tendon at insertion U-shaped extensive tear L-shaped tear indicates a longitudinal component o Massive tear: > 5 cm not repaired Debridement if associated with fatty atrophy of the muscle Surgical repair uncommon
Radiographic Findings General Features Best diagnostic clue: Tear or gap in RTC tendon, +/joint bursal fluid, fibrosis and/or granulation tissue Location o Insertional tear within rotator crescent Rotator crescent: Lateral more avascular portion of cuff; at risk for tear o Extensive tear involving crescent and cable Rotator cable: More vascularized tissue medial to the crescent which joins anterior & posterior margins of RTC Biomechanically less stable Size o Millimeter to several centimeters
DDx: Rotator Cuff Full ~hicknessTear
Radiography o Acromial spurs o Type I11 (hooked) acromion o Acromioclavicular (AC) arthritis o Humeral head (HH) flattening or hypertrophy o HH greater tuberosity cysts o Superior HH migration
MR Findings TlWI o Thickened indistinct tendon Tear edges not delineated on TlWI o Calcifications in the supraspinatus, infraspinatus or teres minor in cases of calcific tendinitis Hypointense calcium deposits
ROTATOR CUFF FULL THICKNESS TEAR
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Kev Facts I
Imaging Findings
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Insertional tear within rotator crescent Retraction and degeneration of tendon edges Full thickness tear associated with fatty atrophy of muscles chronic cases (fat signal on TlWI)
Top Differential Diagnoses Intratendinous Cyst Partial Tear of Rotator Cuff Adhesive Capsulitis Acromioclavicular Arthritis Rheumatoid Arthritis (RA) Rotator Cuff Tendinopathy
Pathology
Clinical Issues Pain with impingement test Insidious onset of pain, continuously increases with time - impingement
Diagnostic Checklist Assess tendons involved, status of tendon edges, status of biceps tendon and muscle atrophy Identify fluid signal intensity especially on FS PD FSE and PD and STIR sequences
General path comments: Tear occurring in otherwise degenerated tendon due to chronic overuse T2WI o Hyperintense fluid signal intensity filling a gap in the tendon T2 FSE & FS PD FSE o Bald spot sign Hyperintense fluid "bald spot" within hypointense tendon "head of hair" Sagittal, axial T2WI o Fluid in subacromial bursa Increased signal intensity on T2 FSE & FS PD FSE Fluid may also be visualized in bursa without a cuff tear o Hyperintense (fluid signal intensity) bursitis Subacromial/subdeltoid fluid or bursa1 thickening Subcoracoid - esp. anterior tears and rotator interval tears o Hyperintense effusion Retraction and degeneration of tendon edges Full thickness tear associated with fatty atrophy of muscles chronic cases (fat signal on TlWI) Intermediate signal intensity in long head of biceps tendon - in tendinosis AC arthritis o AC joint hypertrophy o Chondromalacia (surface defects, hyperintense hyaline articular cartilage defects) Type 111 acromion - impingement
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Ultrasonographic Findings Focal tendon interruption Fluid-filled gap (hypoechoic) Loss of convexity of tendonlbursa interface Hypoechoic tendon Tendon retraction Uncovered cartilage sign Calcium = hyperechoic foci + shadowing
Imaging Recommendations Best imaging tool: MRI Protocol advice o FS PD FSE & T2 FSE FS PD FSE more sensitive for tendinosis T2 FSE more specific for tears
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Overuse, degeneration and complete tearing of RTC +/- Secondary to impingement (hooked acromion, overuse) or acute trauma Shoulder pain 7-25% of general population
o Coronal, sagittal and axial images
I DIFFERENTIAL DIAGNOSIS lntratendinous Cyst Thickened tendon Cyst (hyperintense mass) visible on T2WI o Cyst usually flattened Associated with partial tear of the cuff
Partial Tear of Rotator Cuff Incomplete tendon defect Fluid within not traversing tendon Hyperintense partial defect on T2WI o Bursal, interstitial, articular Low grade (superficial), intermediate grade (< 50% of cuff thickness), and high grade (> 50% of cuff thickness)
Adhesive Capsulitis Thickened hyperintense capsule o Axially pouch inferior glenohumeral ligament (IGHL) involved o Rotator interval (synovitis) Frozen shoulder +/- Cuff tear
Acromioclavicular Arthritis Anterosuperior pain Lidocaine injection challenge - diagnostic Hyperintense edema on T2WI Chondromalacia (hyperintense T2 +/- defects) +/- Hyperintense T2 subchondral cysts
Rheumatoid Arthritis (RA) Inflammatory arthritides Hyperintense (PD/T2) synovitis o Thickened synovium +/- Rice bodies o Bursae +/- Rheumatoid factor
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ROTATOR CUFF FULL THICKNESS TEAR Rotator Cuff Tendinopathy Thickened (T2WI) cuff tendons o Hyperintense on FS PD FSE o Intermediate on T2 FSE +I- Impingement No tear +/- Chronic repetitive microtrauma/impingement
Presentation Most common signslsymptoms o Pain with impingement test Hand on unaffected shoulder and gradual forward flexion of the affected shoulder Clinical profile o Insidious onset of pain, continuously increases with time - impingement o Pain in athletics - internal impingement - younger patient, athlete, occupation o Continued pain post trauma
General Features General path comments: Tear occurring in otherwise degenerated tendon due to chronic overuse Etiology o Overuse, degeneration and complete tearing of RTC o +/- Secondary to impingement (hooked acromion, overuse) or acute trauma o Collagen vascular diseases with tears of other tendons o Acutely in the setting of preexisting tendinosis, acute trauma Epidemiology o Shoulder pain 7-25% of general population Full thickness tears - lower percentage o Shoulder pain in 10/1000 population Peaks at 2511000 population (42-46 years) o > 60 years - 28% demonstrate full thickness tears o Cadaver studies: Incidence of full thickness tears 18-26% o MRI studies: Tears in 34% of asymptomatic individuals of all ages Associated abnormalities o Hill-Sachs deformity - anterior dislocation o Patients > 40 years supraspinatus tear after anterior dislocation o Biceps tendinosis/tears/SLAP lesions with microinstability
. .
Demographics Age: Peak age > 40 years Gender: M 2 F
Natural History & Prognosis Insidious onset of pain in adult patient with impingement syndrome May heal with cessation of impingement activitieslphysical therapy Large tear: Cuff arthropathy
Treatment Level of activity, cause of tear Impingement o Subacromial decompression (acromioplasty) o Tendon repair unless massive cuff tear or tear associated with atrophy Massive cuff tears and associated with atrophy debridement occasionally repair Repaired arthroscopically small tear crescent Mini-open repair partial tears > 50% thickness of the cuff o + Small to moderate sized tears
Gross Pathologic & Surgical Features Involved tendons o Supraspinatus, infraspinatus, subscapularis Thickened, indurated tendon edges Defect in tendon Tendon retraction & atrophy with largelchronic tears
Microscopic Features
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Preexisting collagen degeneration without influx of inflammatory cells o "Tendinosis"is preferred term over tendinitis Associated tendinosis o Muscoid, eosinophilic and fibrillary degeneration Fatty infiltration of muscle tissue in chronically torn tendons
Staging, Grading or Classification Criteria Classification by size o Measure retraction Small < 1 cm Medium or moderate < 3 cm Large 3 to 5 cm Massive > 5 cm o Tear measured on coronal (medial to lateral) and sagittal (anterior to posterior) images
..
Consider Tear after trauma especially status post anterior dislocation in patient > 40 years Assess tendons involved, status of tendon edges, status of biceps tendon and muscle atrophy
Image Interpretation Pearls Identify fluid signal intensity especially on FS PD FSE and PD and STIR sequences A non fat suppressed sequence (T2 FSE) is required to distinguish between tendinosis and tear
KLECTED REFERENCES I
I
Severud EL et al: All-arthroscopicversus mini-open rotator cuff repair: A long-term retrospective outcome comparison. Arthroscopy 19(3):234-8,2003 2. Ruotolo C et al: Surgical and nonsurgical management of rotator cuff tears. Arthroscopy 18(5):527-31, 2002 3. Handelberg FW: Treatment options in full thickness rotator cuff tears. Acta Orthop Belg 67(2):110-5, 2001 4. Murrell GA et al: Diagnosis of rotator cuff tears. Lancet 1.
357(9258):769-70, 2001
ROTATOR CUFF FULL THlCKNESS TEAR IMAGE GALLERY Typical
(Lef)Coronal graphic shows rupture of the deltoid muscle (most often seen in post-operative patients) and underlying rupture of the supraspinatus tendon. (Right) Axial FS PD FSE MR shows tear of the lateral deltoid (arrow) and tearing of the supraspinatus tendon (open arrow).
I
Typical (I&)
Coronal graphic shows a tear of the infraspinatus component of the rotator cuff. This is often seen in posterosuperior (internal) glenoid impingement (PSCI). (Right) Coronal FS PD FSE MR shows a tear of the infraspinatus tendon (arrow).
(Left) Sagittal FS PD FSE MR shows tearing of the posterior supraspinatus and infraspinatus (arrow) in a patient with posterosuperior (internal) glenoid impingement (PSCI). (Right) Axial FS PD FSE MR shows a full thickness tear (arrow) of the supraspinatus tendon.
ROTATOR BNTERVAL TEARS
Coronal graphic shows a tear of the bursa1 aspect of the rotator interval (coracohumeral ligament component). The biceps tendon is visualized through the tear.
Coronal PD FSE MR shows a tear of the rotator interval with tendinosis of the biceps tendon (arrow). Magic angle contributes to the hyperintensity of the biceps tendon.
o Arthrography shows leak of contrast through RI
Abbreviations and Synonyms Rotator interval (RI)
Definitions Subtype of rotator cuff tear Tear or lax enlarged capsule between the supraspinatus and subscapularis tendons RI lesions: Spectrum of injuries from biceps anchor to rotator interval capsule to the bicipital groove o Range: Lax RI capsule, small holes, lesions in which most of the RI capsule is torn RI limits flexion and external rotation Disruptions of the superior glenohumeral/coracohumeral ligament complex = hidden RI lesion RI = tunnel through which long head of biceps travels from its origin on supraglenoid tubercle
with intact SST and subscapularis Location o Interval between the SST and subscapularis tendon o Triangular space with apex centered at transverse humeral ligament over the biceps sulcus Greatest width located at base of coracoid process o Posterior margin SST, anterior margin subscapularis o Roof of interval: Fibers from SST and subscapularis o Floor of interval: SST, subscapularis and portion of the superior glenohumeral ligament (SGHLISGL), joint capsule, coracohumeral ligament (CHL) Size o Tear may be small (slit like) or large split in integrity of cuff Collagenous fibers of the SST and subscapularis are contiguous through the RI Morphology: Tear represents irregular disruption of RI (usually roof)
Radiographic Findings
1 IMAGING FINDINGS General Features Best diagnostic clue o Tear of RI between supraspinatus tendon (SST) and subscapularis with hemorrhageledema
Radiography o Subcortical cysts of lesser tuberosity with subcoracoid impingement o Normal radiographic findings
MR Findings TlWI
DDx: Rotator Interval Tears RTC Tear
RTC Tear
Antertor lnstabil
H~ddenLesion
Ca++ Tendinitis
Cor FS PD FSE
Cor FS PD FSE
Ax FS PD FSE
Ax FS PD FSE
Ax PD FSE MR
ROTATOR INTERVAL TEARS Key Facts Terminology
Pathology
RI lesions: Spectrum of injuries from biceps anchor to rotator interval capsule to the bicipital groove
Imaging Findings
Clinical Issues
Tear of RI between supraspinatus tendon (SST) and subscapularis with hemorrhageledema
Limited external rotation - type I interval lesion Inferior instability, posterior or MDI - type I1 interval lesion MDI - lax RI with capacious capsule
Top Differential Diagnoses Rotator Cuff Tear (RTC Tear) Adhesive Capsulitis Anterior Instability (Anterior Instab)/Multidirectional Instability (MDI) Hidden Lesion Calcific Tendinitis (Ca++Tendinitis)
Diagnostic Checklist
Consider RI "hidden lesion" if biceps tendinosis + subluxation present FS PD FSE sagittal images are sensitive to synovitis and abnormal fluid extension across the rotator interval
+ variable degrees of intermediate signal intensity = adjacent synovitis o Intermediate signal tendinosis +/- subluxation of long head of biceps (LHB) with "hidden lesion" T2WI o +/- Irregular high signal tear of SGHLICHL complex "hidden lesion" of the RI o Hyperintense fluid in subacromial and often subcoracoid bursa = reactive bursitis o Visible tear of RI (roof) Disruption of fibers Hyperintense edema o Thickened roof of RI with surrounding edema o +/- Associated tear of adjacent supraspinatus tendon Hyperintense discontinuous fibers RI tear in this case represents anterior extension of a SST tear o Hyperintense subchondral cysts of lesser tuberosity with subcoracoid impingement MR arthrography o Leakage of contrast through the tear of the RI Intact SST and subscapularis o Thickened roof of RI
Imaging Recommendations Best imaging tool: MRI and MR arthrography Protocol advice: MR arthrography for small isolated RI tears, FS PD FSE or PD images
I DIFFERENTIAL DIAGNOSIS -
Rotator Cuff Tear (RTC Tear) Superior subscapularis tendon tears without RI involvement Anterior SST tears without involvement of RI o Difficult to differentiate +/- Supraspinatus labral instability pattern (SLIP) lesion +/- Superior labrum anterior-posterior (SLAP) lesion Partial or full thickness RTC tear o PASTA (partial articular supraspinatus tendon avulsion) lesion
Associated with posterior and inferior instability and posttraumatic anterior instability Limitation of external rotation if fibrosis present
Adhesive Capsulitis Type I interval lesion Axillary pouch - inferior glenohumeral ligament (IGHL), RI thickened synovium Frozen shoulder
Anterior Instability (Anterior Instab)/Multidirectional Instability (MDI) Type I1 interval lesion +/- Bankart, Hill-Sachs lesion Fall on outstretched hand (FOOSH)
Hidden Lesion SGHLICHL dysfunction Represents type I1 of RI lesion Biceps instability
Calcific Tendinitis (Ca++ Tendinitis) Calcium hydroxyapatite o Hypointense on all pulse sequences Deposit not visible in following conditions o Hypointense deposit within hypointense tendon o Especially quiescent lesions (silent phase) +/- Surrounding hyperintense edema on T2WI
1 PATHOLOGY
1
General Features General path comments o ~esionisolatedfrom supraspinatus tear o Associated with posterior and inferior instability and posttraumatic anterior instability o Limitation of external rotation if fibrosis present Contracture/fibrosis of RI +/- = chronic adhesive capsulitis +/- Tear of capsule Etiology o Subacromial or subcoracoid impingement may lead to RI tear/dysfunction Isolated RI lesion - subcoracoid > subacromial impingement o Acute traumatic injury (esp. anterior dislocation)
ROTATOR INTERVAL TEARS
-
o Forced internal rotation on externally rotated arm -
o Multidirectional instability: F > M
acute traumatic etiology o Congenital laxity of the RI capsule or absence of the CHL and SGHL Predispose increased humeral head translation anteriorly and posterior-inferiorly Enlargement of RI and instability Epidemiology o Rare lesion in isolation o Distal subscapularis tendon disruptions with rotator cuff pathology = 35% Associated abnormalities o Multidirectional instability Treatment = plication of RI o Posterior/inferior instability RI important for posterior stability Contracture - limited external rotation (tear - to fibrosis) o RI hidden lesion o RI lesions (tears) associated with anterior dislocations o Microinstability o Superior labrum anterior cuff (SLAC) lesions
o Acute traumatic abnormality: M > F
. .
Gross Pathologic & Surgical Features Disruption of collagen fibers Fibrotic contracture Hypertrophic synovitis
Natural History & Prognosis +/- Progression of tear requires repair - active patient Type I1 treated initially with strengthening physical therapy or arthroscopy o Failure of conservative treatment
Treatment Conservative: Physical therapy Release of fibrotic tissue - type I RI lesion Arthroscopic repair or plication if type I1 RI lesion
I DIAGNOSTIC CHECKLIST Consider Anterior cuff tear RI lesion rare in isolation Consider RI "hidden lesion" if biceps tendinosis + subluxation present
Image Interpretation Pearls Arthrography may show contrast leakage in case of intact SST in isolated tear of RI FS PD FSE sagittal images are sensitive to synovitis and abnormal fluid extension across the rotator interval
Microscopic Features Inflammatory changes in superficial bursal area, fibrosis Influx of PMNs with inflammation
Staging, Grading or Classification Criteria Type I interval lesion - inflammatory changes in superficial bursal area o Contracted state o Subcoracoid impingement and anterior pain without instability Type I1 interval lesion - extensive inflammation of deeper tissues in the RI o Unstable condition after anterior dislocation o Enlargement or tear of RI
Presentation Most common signs/symptoms o Limited external rotation - type I interval lesion o Inferior instability, posterior or MDI - type I1 interval lesion Clinical profile o Athlete after acute sprain - traumatic RI tear o Chronic impingement + LHB abnormalities Anterior RTC tear in impingement patient +/- "Hidden lesion" o MDI - lax RI with capacious capsule
..
Demographics Age o Younger patient - acute traumatic event o > 40 years - impingement Gender
Burkhart SS et al: Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 7:677-94, 2000 Dumontier C et al: Rotator interval lesions and their relation to coracoid impingement syndrome. J Shoulder Elbow Surg 8:130-5, 1999 Treacy SH et al: Rotator interval closure: An arthroscopic technique. Arthroscopy 13:103-6, 1997 Le Huec JC et al: Traumatic tear of the rotator interval. J Shoulder Elbow Surg 5:41-6, 1996 Field LLD et al: Isolated closure of rotator interval defects for shoulder instability. Am J Sports Med 235.56-63, 1995 Walch G et al: Tears of the supraspinatus tendon associated with "hidden"lesions of the rotator interval. J Shoulder Elbow Surg 3:353-60, 1994 Harryman DT et al: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 7453-66, 1992 Grauer JD et al: Biceps tendon and superior labral injuries. Arthroscopy 8:488-97, 1992 Nobuhara-K et al: The rotator interval lesion. Clin-Orthop (223):44-50, 1987
ROTATOR INTERVAL TEARS
2
(Ltft) Sagittal T2 FSE MR shows a hyperintense tear (arrow) of the rotator interval anteriorly. (Right) Sagittal FS PD FSE MR shows a tear (arrow) of the anterior aspect of the supraspinatus tendon extending to involve the rotator interval.
(Left) Coronal FS PD FSE MR shows a tear of the rotator interval with exposure of the biceps tendon (open arrow). There is surrounding bursitis and a tear of the subscapularis tendon (arrow). (Right) Sagittal FS PD FSE MR shows marked tendinosis and degenerative frayinghearing of the biceps tendon (arrow) in association with a rotator interval tear.
(Left) Axial FS PD FSE MR shows fluid (arrow) within the subcoracoid bursa indicating subcoracoid bursitis. Subcoracoid bursitis is found with rotator interval tears and anterior rotator cuff tears. (Right) Axial PD FSE MR shows a tear of the rotator interval (arrow) at the level of the superior aspect of the bicipital groove.
MICROINSTABILITY, SHOULDER
Sagittalgraphicshowsa tearoftheanteriorsuperior labrum.
Abbreviations and Synonyms Microinstability (MI)
Definitions Lesions within anterior superior half of shoulder, primarily centered around rotator interval (RI) o Microinstability refers: Coracoid limits anterior translation and acromion ST rotator cuff (RTC)limits superior translation o Spectrum of lesions include Superior glenohumeral ligament (SGHL) avulsion or laxity ~iddle*~lenohumeral ligament (MGHLIMGL) avulsion Superior labrum anterior cuff (SLAC) lesion Classic superior labrum anterior to posterior tear (SLAP) Posterior peelback SLAP I1 variation RI lesions
General Features Best diagnostic clue: Anterior RTC frayingltearing and biceps anchor tear
Sagittal PD FSE MR shows a tear of the anterosuperior labrum (arrow) associated with adjacent glenoid chondromalacia.
Location: Lesions that involve the RI, biceps anchor, superior labrum, MGHL insertion, RTC Size: Varies from fraying to frank tearing involving an area of a few centimeters Morphology: Varies from discrete tears to fraying, thickening, - edematous structures
Radiographic Findings Radiography 0 Small subchondral cysts of the superior glenoid with SLAP lesions o Cystic (degenerative) change at superior aspect of lesser tuberosity especially with subcoracoid impingement
CT Findings NECT: Cystic change due to abnormal concavity compression of the humerus/instability leading to abnormal contact CT arthrography: +/- Torn labrum and cuff
MR Findings TlWI: Thickened irregular anterior cuff, mild increase in signal T2WI o Hyperintense fluid signal intensity within or involving attachment of the superior labrum at the biceps anchor - SLAP lesion o +I- Irregular, torn MGHL
m, a r
DDx: Microinstability, Shoulder Suh~capTear 1
I
I
4 ~ ,
Ax PD FSE MR
SLAP
Cor FS PD FSE
Cor T2 FSE MR
Cor PD FSE MR
MICROINSTABILITY, SHOULDER Key Facts Terminology Spectrum of lesions include Superior glenohumeral ligament (SGHL) avulsion or laxity Middle glenohumeral ligament (MGHLIMGL) avulsion Superior labrum anterior cuff (SLAC) lesion Classic superior labrum anterior to posterior tear (SLAP) Posterior peelback SLAP I1 variation RI lesions
Imaging Findings Best diagnostic clue: Anterior RTC frayingltearing and biceps anchor tear
Hyperintense, thickened, +/- discontinuous fibers o Increased signal, tear of LHBT (long head biceps
tendon) o Fluid signal intensity filling a gap in the
supraspinatus tendon (SST) Partial tearlgap common STIR o Less spatial resolution than FS PD FSE o More homogeneous in presence of metal (post-op) MR arthrography o Sensitive to articular surface RTC tear and labral tearing
Imaging Recommendations Best imaging tool: MRI/MR arthrography Protocol advice o FS PD FSE & PD FSE o T2* GRE for intralabral signal on axial images
1 DIFFERENTIAL DIAGNOSIS Anterior Instability Associated with RI tears +/- Bankart or Bankart variation lesions +/- Hill-Sachs lesion
Classic Impingement Hooked acromion +/- Supraspinatus tear Anterior supraspinatus involved
Subcoracoid Impingement Coracoid on subscapularis tendon/lesser tuberosity +/- Subscapularis tear +/- Lesser tuberosity cysts
Hidden Lesion Biceps instability SGHL/CHL (coracohume~alligament) abnormality +/- Subscapularis tear
SLAP Lesion Superior labrum tear
Top Differential Diagnoses Anterior Instability Classic Impingement Subcoracoid Impingement Hidden Lesion SLAP Lesion Subscapularis Tear Supraspinatus Tear (RTC Tear) 'Supraspinatus Tendinopathy
Clinical Issues RTC (cuff tendinitis) or parascapular pain
Diagnostic Checklist Consider microinstability when clinical diagnosis is impingement with MRI findings of superior labral/MGHL/SGHL pathology
+/- Biceps anchor instability +/- Microinstability Tear may propagate
Subscapularis Tear +/- Anterior dislocation +/- Posterior dislocation +/- Lesser tuberosity fracture or avulsion May result from classical impingement
Supraspinatus Tear (RTC Tear) +/- Impingement +/- Anterior dislocation o > 40 years old Thickened increased signal intensity tendon with fluid signal intensity gap - T2WI
Supraspinatus Tendinopathy +/- Impingement Overuse syndrome Thickened increased signal intensity tendon without fluid signal intensity gap - T2WI
1 PATHOLOGY General Features General path comments o Classic SLAP + multiple pathologic lesions in superior shoulder o Superior labral anterior cuff (SLAC) rn SGHL/interval failure Rotator cuff articular lesion secondary to abnormal translation and chafing on glenoid rim Requires both an anterior cuff lesion (frayinglpartial tear) and ligamentous laxity (detachment or stretching) o Posterior peelback rn Acquired tight posterior capsule Peelback SLAP lesion Tight posterior band lifts humeral head up and posteriorly o Lax anterior capsule secondary to posterior shift of humeral head
MICROINSTABILITY, SHOULDER Etiology o Traction forces in overhead position - SLAP, SLAC o Roll around seat belt during accident - SLAC o Fall on abducted arm - SLAP variations o "Throwing out" of arm - MGHL injury o Professional overhand athletes (posterior peelback SLAP with posterior superior instability) Epidemiology: Approximately 6% of shoulder patients seen by orthopedists 21
Presentation Most common signs/symptoms 0 RTC (cuff tendinitis) or parascapular pain o Subjective feeling of slipping when not in abduction external rotation (ABER) position o Extension and superior movement of humeral head with the arm abducted is predictive pre-op test o Impingement like pain Clinical profile o Athletes or workers participating in overhead activities o Patient after acute trauma
Gross Pathologic & Surgical Features Biceps anchor failure (classic SLAP) Posterior biceps peelback SLAP Anterior superior labral detachments (anterior component of a SLAP I1 in SLAC) Superior glenohumeral ligament laxityttear Middle glenohumeral ligament detachment (straight anterior instability) Articular partial thickness cuff lesions Arthroscopic findings in microinstability o Superior labral detachmenttlabral extensions (synovial reaction, chondral erosion) o Capsular (SGHL, MGHL) tearstlaxity o Laxity of rotator interval o Articular sided rotator cuff partial thickness lesions (non-crescentic location in avascular lateral portion of cuff) Arthroscopic findings in posterior peelback o Displaceable vertex of biceps o Associated rotator cuff tear (posterior undersurface at junction of supraspinatus and infraspinatus) o Posterior component of a SLAP I1 lesion
Demographics Age: Young adultsladults Gender: M > F
Natural History & Prognosis Often improves with cessation of repetitive motions leading to disorder Post trauma o Respond to conservative therapy o Arthroscopic treatment
Treatment Conservative o Reduce pain and inflammation (NSAIDs), restoring range of motion, strengthening (physical therapy) Surgical o Tighten (imbricate) RI if lax o Repair attachment of SGHL and/or MGHL if detachedldisplaced o Repair SLAPIbiceps anchor if detached
Microscopic Features Fibrocartilaginous degeneration and/or tear of the superior labrumlbiceps anchor - SLAPISLAC Collagen degeneration without influx of inflammatory cells o "Tendinosis"is preferred term over tendinitis; RTC degenerationttear o Cuff tendinopathy associated with an increase of type I1 collagen, glycosaminoglycan, proteoglycan and smooth muscle actin (SMA) Activation of intracellular protein kinases results in tendon cell apoptosis (cell death), a weaker collagenous matrix and tendon tear
Consider Consider microinstability when clinical diagnosis is impingement with MRI findings of superior 1abraltMGHLISGHL pathology Not all articular sided cuff lesions represent microinstability
Image Interpretation Pearls
Staging, Grading or Classification Criteria Microinstability SLAP I1 subtypes o Classic SLAP (superior labral anterior-to-posterior) o SLAC lesion with anterior component of SLAP I1 + articular sided anterior supraspinatus tear o Posterior peelback with posterior component of SLAP I1 + posterior partial thickness articular sided cuff tear (also described as posterior superior microinstability) o Rotator interval defects SGHL (superior glenohumeral ligament) CHL (coracohumeral ligament)
FS PD FSE and PD FSE images to demonstrate the spectrum of changes Consider MR arthrography for subtle changes
1 SELECTEDREFERENCES -
1.
2. 3. 4.
Miller M et al: Clinics in sports medicine. Cell death and tendinopathy. vol22. 4th ed. Philadelphia PA, W. B. Saunders, 693-702, 791-812, 2003 Ruotolo C et al: Surgical and nonsurgical management of rotator cuff tears. Arthroscopy 18(5):527-31,2002 Murrell GA et al: Diagnosis of rotator cuff tears. Lancet 357(9258):769-70,2001 Stoller DW et al: Magnetic resonance imaging in orthopaedics and sports medicine. vol 1. 2nd ed. Philadelphia PA, J.B. Lippincott, 597-742, 1997
MICROINSTABILITY, SHOULDER
(Left)Axial FS PD FSE MR shows biceps tendinosis (arrow) and degenerative fraying as well as tearing of the superior labrum. There was undersurface rotator cuff tearing in this patient with microinstability. (Right) Coronal FS PD FSE MR shows tearing of superior labrum (arrow), moderate tendinosis and interstitial partial tearing + articular surface fraying of supraspinatus tendon. There was fraying of the middle glenohumeral attachment (not shown).
(Left) Coronal FS PD FSE MR shows marked thickening/tendinosis and partial tearing of the supraspinatus tendon in association with a SLAP lesion (arrow) in a patient with microinstability. (Right) Sagittal FS PD FSE MR shows thickening and edema (arrow) of the superior glenohumeral ligament attachment adiacent to the biceps in a with microinstability. This could represent a hidden lesion.
(Left) Coronal FS PD FSE MR shows partial undersurface tearing of the distal anterior supraspinatus tendon in association with an anterior SLAP /I lesion (arrow), or SLAC lesion (superior labrum anterior cuff). (Right) Coronal PD FSE MR shows a SLAC lesion with articular sided supraspinatus fraying/partial tear (arrow) and anterior component of a SLAP I1 lesion (open arrow).
ROTATOR CUFF POST-OPERATIVE REPAIR
Coronal graphic shows sutures within a repaired supraspinatus tendon.
Coronal FS PD FSE shows an intact supraspinatus tendon repair. Note diffuse increased signal intensity & irregularity of intact tendon - common findings of recently post-op rotator cuff.
o Similar to normal RTC +/- micrometallic artifact
Radiographic Findings
Abbreviations and Synonyms Rotator cuff repair, rotator cuff operative treatment
Definitions Operative (open or arthroscopic) repair or debridement of the RTC tendons
Radiography o +/- Post acromioplasty changes ~ c r o m i o ~ l a s~ransforms t~: type I1 (curved) and type I11 (anterior inferior hook) acromions into a type I (flat) acromion o +/- Trough of lateral aspect of greater tuberosity 0 +/- Sclerosis and/or cysts of greater tuberosity indicative of chronic impingement syndrome
CT Findings
General Features Best diagnostic clue o Micrometallic artifact within decreased signal intensity rotator cuff tendon on all pulse sequences Indicates surgery has been performed "Trough"at level of the greater tuberosity where repaired tendon is attached o Disruption of repair results in discontinuous fibers + Hemorrhage and generalized increased signal intensity on T2WI +/- Retraction Location: Rotator cuff (RTC) tendons Size: Tears small partial to large complete disruptions Morphology o Normal tendon appears as linear decreased signal intensity structure attaching to greater tuberosity
.
CT arthrography o Contrast extending through defect of retear into the subacromial bursa
MR Findings TlWI o Thickened tendon with moderate increased signal in cases of degeneration without tear o Torn tendon may be difficult to visualize on TlWI T2WI o Tendon-to-tendon or tendon-to-bone repair Intermediate signal intensity of repaired tendon Associated granulation tissue o Fluid signal intensity filling a gap in tendon retear o Micrometallic artifact
DDx: Rotator Cuff Post-Operative Repair Loose Hardware
Loose Hardware
Perthes Lesion
P 0p0
5
~lcromiale
.c
Ax PD FSE M R
A x STIR M R
Sag PD FSE M R
PD FSE M R ABER
Ax FS PD FSE
-
ROTATOR CUFF POST-OPERATIVE REPAIR Key Facts Imaging Findings Micrometallic artifact within decreased signal intensity rotator cuff tendon on all pulse sequences Fluid signal intensity filling a gap in tendon retear Variable retraction and degeneration of tendon edges in retear
Top Differential Diagnoses Intact but not Water Tight Tendon After Repair Post Op Change not Including Rotator Cuff Loose Hardware Instability 0 s Acromiale
Pathology Rotator cuff tears are repaired utilizing arthroscopic technique, miniopen procedure or open procedure o Variable retraction and degeneration of tendon
edges in retear o In chronic, low signal intensity retears (granulation tissue) need to evaluate tendon morphology o Full thickness tear, +/- fatty atrophy of muscles in chronic cases Decreased cuff size, associated with fatty atrophy and retraction Secondary superior ascent of humeral head in direct contact with acromion o +/- Fluid within the subcoracoid bursa Anterior supraspinatus tears and rotator interval tears Normal communication of fluid across rotator interval post arthroscopy o Hyperintense effusion + subacromial fluid in bursa -common in immediate post-op period o Intermediate signal intensity in the long head of biceps tendon + associated tendinosis o Calcifications in supraspinatus, infraspinatus or teres minor = calcific tendinitis Hypointense deposits o Flattened undersurface of anterior acromion after acromioplasty o Tear obscured if micrometallic (ferromagnetic) artifact present o Deltoid detachment as a complication of cuff repair STIR o Decreased spatial resolution o Artifact decreased T2* GRE: Susceptibility artifact from metal exaggerated T1 C+: Granulation and bursae will enhance even in the absence of tear MR arthrography o Contrast extending through defect of retear into subacromial bursa
Imaging Recommendations Best imaging tool: MRI/MR arthrography Protocol advice: T2 FSE, FS PD FSE +/- STIR for characterization of RTC
Retear occurring in otherwise repaired but also degenerated tendon Retear +I-trauma Preexisting collagen degeneration without influx of inflammatory cells: "Tendinosis"is preferred term over tendinitis
Clinical Issues
Recurrent pain especially with impingement test Consider repair if patient with persistent pain is unresponsive to conservative measures and muscle dysfunction interferes with daily activities
Diagnostic Checklist Retear after trauma MR arthrography is helpful in the post operative setting to demonstrate the morphology of the tendon
I DIFFERENTIAL DIAGNOSIS Intact but not Water Tight Tendon After Repair Arthrography shows contrast extending into subacromial bursa Common finding after repair Perforation site difficult to visualize
Post O p Change not Including Rotator Cuff Biceps tenodesis Mumford procedure - distal clavicle resection o Often accompanies acromioplasty Labral repair Superior labrum anterior-posterior (SLAP) repair Metallic or micrometallic artifact in location other than RTC
Loose Hardware Loose hardware in joint Arthrography helpful Some anchors prone to migration o SLAP repair Evaluate dependent recesses Sometimes erode out of joint into adjacent structures
Instability Anterior instability o Bankart lesion o Bankart variants Anterior labral ligamentous periosteal sleeve avulsion (ALPSA) Perthes Humeral avulsion of glenohumeral ligament (HAGL), inferior glenohumeral ligament (IGL) tears Relevant history Fall on outstretched hand (FOOSH) injury
0 s Acromiale Failure of fusion of ossification center Predisposes to rotator cuff tear Diagnosis and treatment important
-
ROTATOR CUFF POST-OPERATIVE REPAIR o Acromioplasty of os acromiale inadequate (P Op 0 s
Acromiale) o Resection or fixation required
Deltoid Dehiscence
LH
Status post open/mini open procedure May become redetached Discontinuous fibers at acromion attachment site o + Hyperintensity on T2WI weakness with abduction
1 PATHOLOGY General Features General path comments o Rotator cuff tears are repaired utilizing arthroscopic technique, miniopen procedure or open procedure o Retear occurring in otherwise repaired but also degenerated tendon o Retear +/- trauma Etiology o Tendon repair - tear in association with a healthy muscle belly (non fatty atrophy) o Tears in previously repaired tendons occur in variety of circumstances Acute trauma Recurrent impingement/chronic microtrauma Hardware failure (especially if trough repair) Epidemiology o Shoulder pain 7-25% in western population Full thickness tears less common o > 60 years - 28% demonstrate full thickness tears * Associated abnormalities o Greater tuberosity fractures with trauma o Degenerative arthritis o Labral tears
Gross Pathologic & Surgical Features Thickened, indurated tendon edges Loss of tendon integrity with post repair tear
Microscopic Features Preexisting collagen degeneration without influx of inflammatory cells: "Tendinosis"is preferred term over tendinitis Fibrosis/granulation after repair Fatty infiltration of muscle tissue in chronically torn tendons o Indication for debridement rather than repair especially for large tendons
Presentation Most common signs/symptoms o Recurrent pain especially with impingement test o Consider repair if patient with persistent pain is unresponsive to conservative measures and muscle dysfunction interferes with daily activities o Recurrent night pain associated with retear o Recurrent weakness seen with retear
Hand on the unaffected shoulder and gradual forward flexion the of shoulder producing pain = positive impingement test Clinical profile 0 Post operative rotator cuff repair patient +/- Pain with retear +/- Impingement symptoms 0
Demographics Age: Peak age: > 40 years (especially for impingement) Gender: M r F
Natural History & Prognosis Recurrent partial tear may heal with cessation of impingement activities/physical therapy (PT) Recurrent tear often requires second repair Repairs of small to moderate size tears = excellent prognosis
Treatment Physical therapy Revision surgery
Consider Retear after trauma The presence of contrast material in the subacromial bursa is a normal finding if the repair was not "water tight"
Image Interpretation Pearls MR arthrography is helpful in the post operative setting to demonstrate the morphology of the tendon
Ruotolo C et al: Surgical and nonsurgical management of rotator cuff tears. Arthroscopy 18(5):527-31, 2002 Weber SC et al: Complications associated with arthroscopic shoulder surgery. Arthroscopy 18(2 Suppl 1):88-95, 2002 Handelberg FW: Treatment options in full thickness rotator cuff tears. Acta Orthop Belg 67(2):110-5, 2001 Goutallier D et al: Impact of fatty degeneration of the supraspinatus and infraspinatus muscles on the prognosis of surgical repair of the rotator cuff. Rev Chir Orthop Reparatrice Appar Mot 85(7):668-76, 1999 Neviaser RJ: Evaluation and management of failed rotator cuff repairs. Orthop Clin North Am 28(2):215-24, 1997 Tirman PF et al: A practical approach to imaging of the shoulder with emphasis on MR imaging. Orthop Clin North Am 28(4):483-515, 1997 Bigliani LU et al: Operative treatment of failed repairs of the rotator cuff. J Bone Joint Surg Am 74(10):1505-15, 1992
I
ROTATOR CUFF POST-OPERATIVE REPAIR
(Lefl) Sagittal PD FSE MR shows post-operative changes of an acromioplasty with resulting type I acromion. (Right) Coronal PD FSE MR shows a repaired rotator cuff tendon with partial tearing of the undersurface and retraction of the partially torn undersurface (arrow). The superior surface was intact.
Variant
(Left) Coronal PD FSE MR shows a retorn rotator cuff with retraction. Note the developing degenerative changes of the joint. (Right) Coronal FS PD FSE MR shows a retear of the supraspinatus. Note the exaggerated metallic artifact due to the use of frequency selective fat saturation.
Variant (Left) Axial PD FSE MR shows a dislocation of the long head of the biceps tendon (arrow) in a post-operative patient. Note the post-operative changes of the greater tuberosity. The patient also had a retear of the supraspinatus. (Right) Coronal PD FSE MR shows a tear of the anterior supraspinatus tendon and rotator interval (arrow). The biceps tendon anchor is degenerated and frayed.
1
ROTATOR CUFF CALClFlC TENDlNlT
Coronal graphic shows focus of calcific tendinitis within supraspinatus tendon. Note subacromial bursitis & surrounding edema (common) as in silent phase with elevation of subacromial bursa.
Abbreviations and Synonyms Calcium hydroxyapatite deposition disease (HADD), peritendinitis, calcifying bursitis, periarthropathy
Definitions Deposits of calcium hydroxyapatite - in rotator cuff tendons
General Features Best diagnostic clue o Globular decreased signal intensity mass (all pulse sequences) of rotator cuff (RTC) tendons, often surrounded by edema or partial tear Calcific deposit may be occult at MRI Location o Supraspinatus (SST) most commonly affected > infraspinatus (IST) > teres minor (TM) > subscapularis (SSC) 0 Periarticular soft tissues in addition to tendons Ligaments Capsule Bursae
Coronal PD FSE MR of mechanical phase of calcific tendonitis shows at least 3 foci of hypointense (arrow) hydroxyapatite within infraspinatus tendon with surrounding edema.
Size: Varies from small (mm) deposition to several cm in size Morphology o Globular Hood-like configuration Linear Angular Round shapes
Radiographic Findings Radiography o Calcific deposits: Increased density on radiography, CT o Appearance of calcification depends on location and radiographic view obtained In internal rotation posterior calcifications are seen (infraspinatus, teres minor deposits) o Routine views including Anteroposterior views with shoulder in internallexternal rotation Axillary view Supraspinatus outlet view (lateral view of scapula) o Focal well-defined deposit to diffuse, homogeneous, amorphous, fluffy deposit with poor margins
CT Findings NECT o Focal well-defined calcific deposits: Increased density
DDx: Rotator Cuff Calcifie Tendinitis Osteochondromas
Osteochondromas
Loose Bodies
Ax TlWI MR
Ax T2 FSE MR
Cor PD FSE MR
ROTATOR CUFF CALClFlC TENDINITIS Key Facts Imaging Findings Globular decreased signal intensity mass (all pulse sequences) of rotator cuff (RTC) tendons, often surrounded by edema or partial tear calcific deposits: ~~~~~~~~d density on radiography, PT L. I
Hyperintense edema may present around hypointense calcium deposits Associated tears not common compared to pericalcific edema
Top Differential Diagnoses Degenerative calcification in Torn Tendon Loose Bodies Osteochondromatosis
Pathology Mechanical block if calcific deposit large enough
Clinical Issues Chronic mild pain especially in formative and resting phases Mechanical symptoms may be present Clinical profile: Discovered during imaging examination of shoulder in asymptomatic patients Resolve and heal spontaneously Needling, aspiration, and lavage if symptomatic Surgical treatment helpful in recalcitrant cases
Diagnostic Checklist Hydroxyapatite deposits have the same signal as normal cuff tendons
o Dense, granular, well-demarcated calcifications
Indistinct calcification indictor of acute symptoms
MR Findings TlWI o Hypointense homogeneous signal o +/- Adjacent thickened tendon T2WI o Hyperintense edema may present around hypointense calcium deposits Associated tears not common compared to pericalcific edema o Hyperintense subacromial-subdeltoid fluid T2* GRE o Calcifications may bloom due to susceptibility o Sensitive sequence for identification of hydroxyapatite T1 C+: Perilesional edema may enhance due to inflammation Globular decreased signal intensity of the calcifications deposit on all pulse sequences No involvement of articular cartilage MR arthrography o +/- Partial rotator cuff tear
Ultrasonographic Findings Increased echogenicity mass with shadowing More sensitive and accurate than radiographs and MRI
Nuclear Medicine Findings Bone Scan: Calcific deposit may take up tracer
Imaging Recommendations Best imaging tool o Ultrasound o MRI: Accuracy 95% Protocol advice o Experienced ultrasonographic technologist o PD, T2* GRE or FS PD, T2 FSE
Degenerative Calcification in Torn Tendon Degenerative calcification generally smaller than calcific tendinitis Chemical composition is different Age group slightly older than HADD
Loose Bodies +/- Chondral defect nidus +/- Osteoarthritis Hypointense structure within joint on all pulse sequences +/- Marrow fat signal intensity center (TlWI, PDWI) vs. sclerosis o Hypointense on FS PD FSE Osteochondral lesions
Osteochondromatosis Synovial metaplasia Cartilage bodies, +/- osseous bodies Multiple bodies in joint
1 PATHOLOGY General Features General path comments o Mechanical block if calcific deposit large enough o Housewives and clerical workers affected o Crystalline hydroxyapatite: Not typical Ca++ of degenerative disease of tendons o HADD often asymptomatic Etiology o Avascular change o Trauma o Abnormal mineral metabolism Epidemiology o 3-20% of painless shoulders and 7% of painful shoulders o 13-4796 bilateral
ROTATOR CUFF CALCIFIC TENDINITIS Gross Pathologic & Surgical Features Macroscopic clumps of calcification often surrounded by indurated inflamed tendon o Intraosseous loculation Unusual intraosseous extension of calcific deposit into the greater tuberosity of the humerus Cystic lesions of humerus o Dumbbell loculation Dumbbell appearance of the subbursal deposit beneath the coracoacromial (CA) ligament
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Microscopic Features Crystalline hydroxyapatite in tendon Tendon often edematous with influx of inflammatory cells (esp. in resorptive phase) Macrophages and multinuclear giant cells present during resorptive phase Fibroblasts present in postcalcific phase
Staging, Grading or Classification Criteria Calcific tendinitis o Formative phase: Fibrocartilaginoustransformation with deposit of calcium Deposit chalk-like o Resting phase: No enlargement, +/- pain, may cause mechanical symptoms if large o Resorptive phase: Inflammation with cells resorbing calcium Leak into bursa (subbursal and intrabursal rupture) May be very symptomatic Described as toothpaste like Usually self limited o Postcalcific phase: Tendon integrity reconstituted Moseley classification o Silent phase Calcium salts deposited in the tendons in the arterial anastomosis of the critical zone Often asymptomatic o Mechanical phase Calcifications increase in volume causing increased intratendinous stress and causing pain +/- Bursitis Intrabursal rupture: Intrabursal rupture of the tendinous or subbursal collection; associated with severe pain m Subbursal rupture: Partial extrusion of the calcific deposit beneath the bursa; +/- complete expulsion of the deposit from the tendon o Adhesive periarthritis phase D Tendinous calcification + adhesive bursitis
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Presentation Most common signs/symptoms o Chronic mild pain especially in formative and resting phases o Mechanical symptoms may be present o Painful in resorptive phase Clinical profile: Discovered during imaging examination of shoulder in asymptomatic patients
Demographics Age: Incidence 30-50 years Gender: F > M
Natural History & Prognosis Resolve and heal spontaneously Progress, causing symptoms and requiring treatment Milwaukee shoulder o Destructive arthropathy with hydroxyapatite deposits and rotator cuff tears
Treatment Needling, aspiration, and lavage if symptomatic Extracorporeal shock wave therapy (ECSW) may be helpful Surgical treatment helpful in recalcitrant cases
Consider Globular hypointense signal (TI & T2WI) in tendon, bursa or capsular tissue
Image Interpretation Pearls Hydroxyapatite deposits have the same signal as normal cuff tendons T2* GRE will increase conspicuity of hypointense calcifications relative to soft tissues including tendons
Rupp S et al: Preoperative ultrasonographic mapping of calcium deposits facilitates localization during arthroscopic surgery f~r'calcifyin~ tendinitis of the rotator-cuff. Arthroscopy 14(5):540-2, 1998 Uhthoff HK et al: Calcific tendinopathy of the rotator cuff: Pathogenesis, diagnosis, and management. J Am Acad Orthop Surg 5(4):183-191, 1997 Farin PU et al: Consistency of rotator-cuff calcifications. Observations on plain radiography, Sonography, computed tomography, and at needle treatment. Invest Radiol 31(5):300-4, 1996 Loew M et al: Relationship between calcifying tendinitis and subacromial impingement: A prospective radiography and magnetic resonance imaging study. J Shoulder Elbow Surg 5(4):314-9, 1996 Riley GP et al: Prevalence and possible pathological significance of calcium phosphate salt accumulation in tendon matrix degeneration. Ann Rheum Dis 55(2):109-15, 1996 Jim YF et al: Coexistence of calcific tendinitis and rotator cuff tear: an arthrographic study. Skeletal Radiol 22(3):183-5, 1993 Re LP Jr Karzel RP: Management of rotator cuff calcifications. Orthop Clin North Am 24(1):125-32, 1993 Moseley HF: Shoulder lesions. Edinburgh London, E&S Livingstone, 99, 1969
ROTATOR CUFF CALCIFIC TENDlN 'IS
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IMAGE GALLERY (Left) Coronal PD FSE MR shows clump-like calcification (arrow) within the supraspinatus tendon, consistent with the silent phase of calcific tendinitis. (Right) Coronal FS PD FSE MR shows hypointense clumped calcification with subacromial bursal hyperintensity.
(Left) Axial PD FSE MR shows a large clump of calcification (arrow) within the infraspinatus tendon, consistent with calcific tendinitis. There is extension into the bursa. (Right) Axial PD FSE MR shows calcific tendinitis (arrow) within the supraspinatus tendon with extension of the calcium into the bursa. In the mechanical phase, there may be associated bursal elevation.
(Left) Coronal graphic shows the mechanical phase of calcific tendinitis with bursal rupture of calcium and reactive bursitis. Calcific deposits are present within the subacromial/subdeltoid bursa. (Right) Coronal FS PD FSE MR shows mechanical phase of calcific tendinitis with extension of calcification (arrow) into the hyperintense bursa.
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PARSONAGE-TURNER SYNDROME
Coronal graphic shows denervation changes within the deltoid and teres minor muscles.
Size o Muscles may be swollen and slightly enlarged in acute and subacute phase o Muscles - atrophic in chronic phase Morphology o Slightly enlarged muscle bellies maintaining shape without focal alteration Acute, subacute o Atrophic muscle bellies Chronic, fatty atrophy
Abbreviations and Synonyms PTS, neuralgic amyotrophy, acute brachial neuritis, acute brachial radiculitis, nontraumatic neuropathy, shoulder girdle syndrome
Definitions Idiopathic denervation syndrome of the shoulder musculature More than one nerve distribution may be involved Denervation affects mainly the lower motor neurons of the brachial plexus and/or individual nerves or nerve branches
CT Findings
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I General Features Best diagnostic clue o Increased signal within muscle bellies on FS PD FSE/PD WI in patient with muscle weakness = Acute to subacute changes o Fatty atrophy - chronic cases Location o Muscles of the shoulder girdle Rare distal form involving the forearmlwrist muscles described
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DDx: Parsonage-Turner Syndrome
Cor FS
Coronal FS PD FSE MR shows denervation changes within the teres minor (arrow), deltoid and the triceps tendon in a patient with idiopathic brachial neuritis/Parsonage-Turner syndrome.
NECT o Fatty infiltration in chronic cases Decreased attenuation - fat Often streaky
MR Findings T~WI o Streaky regions of fat signal in association with small size of muscles in chronic cases (fatty atrophy) o Decreased in signal - early phases = edema T2WI o Increased signal intensity (T2) in muscles of acute and subacute denervation o +/- Nerve distribution pattern o +/- Muscle enlargement: Acute, subacute o +/- Muscle atrophy, slight increase in signal: Chronic, fatty atrophy
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PARSONAGE-TURNER SYNDROME Key Facts Imaging Findings Increased signal within muscle bellies on FS PD FSE/PD WI in patient with muscle weakness +/- Muscle enlargement: Acute, subacute +/- Muscle atrophy, slight increase in signal: Chronic, fatty atrophy
Top Differential Diagnoses I
Traumatic Neurapraxia Nerve Severing Cervical Spine Disease (Neuropathy) Diabetic Neuropathy Nonspecific Myositis Trauma to Muscle Belly Carcinomatous or Granulomatous Brachial Plexus Infiltration
o FS PD FSE
Increased signal intensity (increased cellular water) within muscle PDIIntermediate: Increased signal intensity in muscles in acute and subacute cases = swelling STIR o Similar contrast as FS PD FSE o Less spatial resolution T1 C+: Muscle bellies enhance in acute and subacute phase MRI abnormalities appear after approximately 2 weeks
Imaging Recommendations Best imaging tool o FS PD FSE or STIR in acute or subacute phase o PD, T1 in chronic atrophic phase Protocol advice: T1 and FS PD FSE in axial, coronal and sagittal planes
Traumatic Neurapraxia Posttraumatic Transient in most cases Leads to denervation changes of affected muscles Traction with resulting hemorrhageledema
Nerve Severing Disrupts function Possibility of resumed function o Depends on proximity of severed ends o Axon (recovers) vs. cell body (cell death) History of laceration o Regeneration does not occur with disruption of the axon, its myelin sheath and connective tissue elements
Cervical Spine Disease (Neuropathy) Radiculitis/radiculopathy Radiating pain from neck +/- Weakness of muscles supplied by compressed nerves +/- Muscle signal changes
Nerve Compression Rotator Cuff Tear
Pathology Neuritis of mainly lower motor neurons of the brachial plexus
Clinical Issues ~ b r u ponset t of pain, may follow recent illness, surgery, immunization, or trauma
Diagnostic Checklist Other causes of denervation such as posttraumatic neurapraxia FS PD FSE and STIR sequences are sensitive for hyperintensity in early and subacute cases
Diabetic Neuropathy Ischemic neuropathy +/- Single nerve involvement +/- Osseous changes
Nonspecific Myositis Muscle signal increased on FS PD images, muscle dysfunction Usually not within a single nerve distribution pattern +/- Infection/fasciitis +/- Strain injury
Trauma t o Muscle Belly Muscle signal increased on FS PD images = edema No single nerve distribution pattern History is critical
Carcinomatous or Granulomatous Brachial Plexus Infiltration Metastatic disease Usually with known primary disease Pancoast's tumor +/- Brachial plexitis
Nerve Compression Extrinsic compression Mass o Benign: Cyst, lipoma o Malignant Thickened fibrotic transverse scapular ligament Single nerve distribution
Rotator Cuff Tear Shoulder weakness secondary to tendon tear Generalized shoulder pain vs. anterior shoulder pain (impingement) +/- Proprioceptive loss +/- Impingement o Classical subacrominal o Posterosuperior glenoid impingement (PSGI) Visible tear - fluid signal on T2WI
PARSONAGE-TURNER SYNDROME
1 PATHOLOGY General Features
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General path comments o Neuritis of mainly lower motor neurons of the brachial ulexus o +/- 1ndi;dual nerves or nerve branches Etiology o Immune-mediated inflammatory reaction against nerve fibers o Possible causes include: Infection, surgery, trauma, childbirth, vaccinations, systemic illness Epidemiology: > 1% of general population Associated abnormalities: Rare distal form affecting arm, forearm, wrist and hand
Gross Pathologic & Surgical Features Denervation changes within the affected muscles Swollen muscle belly - early and subacute Fatty atrophy - chronic
Microscopic Features Enlarged extracellular fluid space = early and subacute Fatty infiltration = chronic Myofibers atrophy - small and angular with early denervation
Staging, Grading or Classification Criteria Early, subacute: - 3-6 months Chronic - corresponds to fatty atrophy
Presentation Most common signs/symptoms o Abrupt onset of pain, may follow recent illness, surgery, immunization, or trauma o Followed by weakness, and possible numbness Clinical profile o Up to 50% report viral illness or vaccination that occurred days or weeks prior to the onset of symptoms o Pain: Sharp, throbbing and intense at onset Pain duration: Few hours to several weeks
Demographics Age: 3 months - 74 years Gender: M:F = 2-4:l Ethnicity: Seen in Native American population with increased frequency
Natural History & Prognosis Majority resolves o Up to over a year Residual denervation in 10-20% after 2 years
Treatment Conservative treatment - physical therapy Nerve graftingltendon transfers for patients without adequate recovery by 2 years o Surgery to improve shoulder abduction
I 1 DIAGNOSTICCHECKLIST Consider Other causes of denervation such as posttraumatic neurapraxia
Image Interpretation Pearls FS PD FSE and STIR sequences are sensitive for hyperintensity in early and subacute cases
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Helms CA: The impact of MR imaging in sports medicine. Radiology 224(3):631-5, 2002 Simon JP et al: Parsonage-Turner syndrome after total-hip arthroplasty. J Arthroplasty 16(4):518-20, 2001 Petit E et al: Bilateral phrenic involvement disclosing Parsonage Turner syndrome. Rev Neurol (Paris) 156(4):403-4, 2000 Auge WK et al: Parsonage-Turner syndrome in the Native American Indian. J Shoulder Elbow Surg 9(2):99-103,2000 Saleem F et al: Neuralgic amyotrophy (Parsonage-Turner syndrome): An often misdiagnosed diagnosis. J Pak Med ASSOC 49(4):101-3, 1999 Helms CA et al: Acute brachial neuritis (Parsonage-Turner syndrome): MR imaging appearance-report of three cases. Radiology 207(1):255-9, 1998 Sallomi D et al: Muscle denervation patterns in upper limb nerve injuries: MR imaging findings and anatomic basis. AJR 171(3):779-84,1998
PARSONACE-TURNER SYNDROME
Tvoical
(Left) Axial STlR MR shows increased signal intensity within the deltoid (arrow), consistent with denervation change. (Right) Coronal STlR M R in the same patient shows the denervation changes within the deltoid (arrow) and within the teres minor (open arrow) axillary nerve distribution.
(LQjI) Coronal STlR MR of chest shows increased signal intensity within brachial plexus (arrow) indicating neuritis in a patient with Parsonage-Turner syndrome. (Right) Sagittal STlR MR in the same patient shows denervation changes in the supraspinatus and infraspinatus.
(LQjI)Sagittal PD FSE MR demonstrates denervation changes in the shoulder girdle muscles. (Right) Coronal PD FSE in a patient with Parsonage-Turner syndrome and deltoid weakness shows the changes of denervation.
SUBSCAPULARlS RUPTURE
Coronal graphic shows an extensive tear of the insertion site of the subscapularis tendon adjacent to the rotator interval.
Axial FS PD FSE MR shows a full thickness tear of the subscapularis tendon with retraction. There is synovitis within the tendon gap.
o Partial tear of distal tendon with delamination and
retraction of deep fibers
Definitions Subscapularis rupture secondary to anterior shoulder dislocation (> 40 years old) Subscapularis rupture secondary to posterior dislocation In association with tearing of the other components of the rotator cuff Subcoracoid impingement
Radiographic Findings Radiography o Lesser tuberosity fracture when associated with posterior dislocation Lesser tuberosity avulsion fracture can occur with intact subscapularis tendon after posterior dislocation o Lesser tuberosity cystic degenerative changes when associated with subcoracoid impingement
CT Findings General Features Best diagnostic clue: Tear or gap in subscapularis tendon, filled with fluidlhemorrhage or granulation tissue Location o Interruption of the normal course of the hypointense tendon o Distal tear Size: Range from millimeters to centimeters Morphology o Gap in thickened irregular tendon Tendon may be thinned o Thickened tendon with intrasubstance (interstitial) partial tear
NECT o Cyst in lesser tuberosity o Prominent coracoid in subcoracoid impingement
MR Findings TlWI o Thick inhomogeneous tendon, intermediate signal o Hypointense edema in lesser tuberosity, Bankart, reverse Bankart, Hill-Sachs, reverse Hill-Sachs fractures Bankart fracture: Fracture of anteroinferior glenoid pony Bankart lesion) Reverse Bankart fracture: Posterior glenoid rim fracture Hill-Sachs: Posterolateral humeral head fracture
DDx: Subscapularis Rupture HACL
A'
A x FS PD FSE
A x FS PD FSE
Sag T2 FSE MR
Cor T2 FSE MR
A x FS PD FSE
SUBSCAPULARIS RUPTURE Key Facts Terminology Subscapularis rupture secondary to anterior shoulder ,dislocation (> 40 years old)
Imaging Findings Hyperintense fluid Signal intensity filling a gap in the tendon; visualized with FS PD FSE
Top Differential Diagnoses Tendinosis without Rupture Hidden Lesion HAGL Lesion Debris in Subscapularis Recess Rotator Interval Lesion Axillary Neurapraxia Adhesive Capsulitis
Reverse Hill-Sachs: Anteromedial humeral head fracture T2WI o Hyperintense fluid signal intensity filling a gap in the tendon; visualized with FS PD FSE o Tendon edges frayed and increased in signal o underlying capsular tear o +/- Rotator interval hidden lesion Hyperintense superior glenohumeral/coracohumeral ligament (SGHLJCHL),+/- tear +/- Biceps subluxation/dislocation medially o +/- Hyperintense cysts of lesser tuberosity o +/- Hyperintense edema of lesser tuberosity with fracture +/- Hypointense fracture line Avulsion or impaction o +I- Hill-Sachs fracture in case of anterior/posterior dislocation o +/- Reverse Hill-Sachs fracture if posterior dislocation o +/- Humeral avulsion of glenohumeral ligament (HAGL) lesion T2* GRE: Greatest sensitivity of tendon degeneration compared to other pulse sequences Partial tear: Fluid entering a segment of tendon o Intrasubstance o Deep fibers Through-and-through (full thickness) tear o Fluid extending through gap in tendon with variable retraction o Demonstrated on axial images
Imaging Recommendations Best imaging tool: MRI Protocol advice o FS PD FSE axial images o T2* GRE sensitive to subscapularis tendon degeneration and tear As used in the axial plane Not utilized in coronal plane to avoid false positive findings of supraspinatus/infraspinatus tears
Pathology Isolated tear after anterior dislocation especially in patients > 40 years With or without avulsion of lesser tuberosity in patient after posterior dislocation Preefisting degeneration as seen with subacromial impingement Subcoracoid impingement
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Clinical Issues Patients > 40 years of age presenting with 1st time anterior dislocation Secondary to posterior dislocation at any age
Diagnostic Checklist After trauma, especially in older patient
I DIFFERENTIAL DIAGNOSIS Tendinosis without Rupture No evidence of gap Acute traumatic history Thickened increased signal intensity tendon on T2* GRE o Short TE sequences
Hidden Lesion Partial subscapularis tear, superior aspect Biceps instability +/- Biceps tendinosis "Hidden" at arthroscopy (difficult to visualize) SGHL/CHL dysfunction/tear
HAGL Lesion Humeral avulsion of inferior glenohumeral ligamentous complex (IGHLC) Associated with anterior dislocation '7" sign of avulsion of humeral attachment of inferior glenohumeral ligament (IGL) on coronal images o IGL hyperintensity on T2WI Subscapularis tearlpartial tear often present
Debris in Subscapularis Recess Loose bodies Osteochondromatosis (chondromatosis) +/- Glenoid, humeral head chondral defects +/- Trauma Fluid in recess adjacent to subscapularis may mimic tearlpartial tear (esp. on coronals)
Rotator Interval Lesion +/- Involvement of superior subscapularis CHL/SGHL involved +/- Anterior supraspinatus tear +/- Subcoracoid impingement
Axillary Neurapraxia Clinical diagnosis after anterior dislocation Subscapularis tear often misdiagnosed as axillary neurapraxia o After anterior dislocation
SUBSCAPULARIS RUPTURE o Shoulder pain after dislocation o Insidious onset of pain when associated with
Hyperintensity in teres minor and deltoid on FS PD FSEISTIR MR + Electromyograph (EMG) findings
impingementlchronic overuse Clinical profile: Clinical positive lift-off test (inability to lift hand against resistance from small of back) Secondary to posterior dislocation especially in the case of tonic-clonic seizures May be misdiagnosed clinically as axillary neurapraxia
Adhesive Capsulitis
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Thickened edematous capsule Hyperintense on T2WI Frozen shoulder +I- Secondary (known disorders)
Demographics Age o Patients > 40 years of age presenting with 1st time anterior dislocation o Secondary to posterior dislocation at any age Gender: M > F
1 PATHOLOGY General Features General ~ a t comments h o Important stabilizer of anterior joint o "Weak link" in older patients rupturing after dislocation o Rupture after dislocation o susceptible to chronic overuse o Anterior fibers of subscapularis merge with the CHL and traverse bicipital groove Majority of subscapularis fibers may tear but maintain position o Subscapularis + superior glenohumeral ligament and coracohumeral ligament stabilize biceps tendon Tears = hidden lesion Etiology o Isolated tear after anterior dislocation especially in patients > 40 years o With or without avulsion of lesser tuberosity in patient after posterior dislocation o Preexisting degeneration as seen with subacromial impingement o Subcoracoid impingement Epidemiology o - 30% of older patients after first time anterior dislocation o Uncommon with posterior dislocation Posterior dislocation accounts for 5% of all shoulder dislocations o 2% of rotator cuff tears involve subscapularis o Extension of rotator cuff tear Supraspinous (79%) rn Infraspinous (56%) o Bicipital dislocations 49% of subscapularis tears
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Gross Pathologic & Surgical Features Disruption in integrity (loss of collagen fiber bundles) of tendon in partial and complete tendon tears
Microscopic Features Disruption of tendon fiber bundles in partially torn & through-and-through tendon tears o Decrease tensile strength in degeneration Decrease in total collagen content Fatty infiltration of muscle tissue in chronically torn tendons
Presentation Most common signslsyrnptoms
Natural History & Prognosis Sudden trauma leads to complete rupture & Surgical repair
Treatment Open surgical repair
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Consider After trauma, especially in older patient
Image Interpretation Pearls FS PD FSE and T2* GRE in axial plane to appreciate retraction, tendinosis and associated biceps pathology
1 SELECTED REFERENCES Beall DP et al: Association of biceps tendon tears with rotator cuff abnormalities: Degree of correlation with tears of the anterior and superior portions of the rotator cuff. AJR 180(3):633-9, 2003 Burkhart SS et al: Arthroscopic subscapularis tendon repair: Technique and preliminary results. Arthroscopy 18(5):454-63, 2002 Tung GA et al: Subscapularis tendon tear: Primary and associated signs on MRI. J Comput Assist Tomogr 25(3):417-24,2001 Travis RD et al: Technique for repair of the subscapularis tendon. Orthop Clin North Am 32(3):495-500, 2001 Stoller DW et al: Magnetic resonance imaging in orthopaedics and sports medicine. vol 1. 2nd ed. Philadelphia PA, J.B. Lippincott, 597-742, 1997 Tirman PF et al: A practical approach to imaging of the shoulder with emphasis on MR imaging. Orthop Clin North Am 28(4):483-515, 1997 Tirman et al: Humeral avulsion of the anterior shoulder stabilizing structures after anterior shoulder dislocation: Demonstration by MRI and MR arthrography. Skeletal Radio1 25(8):743-8, 1996 Neviaser RJ et al: Recurrent instability of the shoulder after age 40. J Shoulder Elbow Surg 4(6):416-8, 1995 Patten RM: Tears of the anterior portion of the rotator cuff (the subscapularis tendon): MR imaging findings. AJR 162(2):351-4,1994
SUBSCAPULARIS RUPTURE -IMAGE GALLERY (Left) Coronal graphic shows a full thickness tear of the subscapularis tendon with dislocation of the biceps tendon due to biceps instability. (Right) Coronal PD FSE MR shows a tear of the subscapularis tendon with dislocation of the biceps (arrow) from the bicipital groove.
(Left) Axial FS PD FSE MR shows a partial tear (arrow) of the distal aspect of the subscapularis tendon. (Right) Sagittal FS PD FSE MR shows a partial tear of the distal aspect of the subscapularis tendon (arrow) in this patient with pain on internal rotation - a clinical test for subscapularis dysfunction.
(Lef)Axial FS PD FSE MR shows a full thickness tear of the subscapularis tendon with retraction and debris in the gap. (Right) Sagittal FS PD FSE MR shows a full thickness tear (arrow) of the subscapularis tendon from the lesser tuberosity.
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PECTORALBS MAJOR TEAR
Coronal graphic shows a tear of the pectoralis major tendon with retraction from the humerus.
Coronal STlR MR shows a tear of pectoralis tendon with retraction. There is a surrounding hematoma which is of increased signal intensity.
Uncommon Avulsion of enthesis o Several anatomical variants which may be unusual cause of injury (e.g., accessory insertions adjacent to median nerve) Myotendinous junction partial and full thickness tears of the long head of the biceps tendon may mimic pectoralis major tendon tears clinically o Pain localized to the same anatomic area 0
Abbreviations and Synonyms Muscle strain Muscle pull
Definitions Disruption of pectoralis myotendinous unit at the humeral insertion site 2 major portions of the tendon o Sternal (sternocostal) head: Originates from sternum o Clavicular head: Originates from undersurface of the clavicle
Radiographic Findings Radiography: Flake avulsion from lateral lip of bicipital groove if enthesis fails (rare)
CT Findings
General Features Best diagnostic clue: High signal on FS PD FSE or STIR at pectoralis major tendon tear site Location: Anterior chest wall and upper arm Size: Variable from physically undetectable myofibrillar tears to full thickness defect of muscle belly * Morphology o Variable tendinous defect +/- Hematoma o Avulsion of musculotendinous junction
NECT o Soft tissue swelling of anterior chest wall o Late finding: Calcified hematoma and soft tissue defects, indicating focal muscle atrophy and scarring
MR Findings TlWI o Decreased marrow signal in clavicle, sternum or ribs indicating response to strain o Muscle enlargement, +I-low signal zones indicating subacute hematoma o Low signal in myofascial region indicating perifascial edema T2WI -
DDx: Pectoralis Major Tear
Cor P D FSE M R
Cor STIR M R
Sag P D FSE M R
Sag P D FSE M R
PECTORALIS MAJOR TEAR I
Key Facts Terminology Disruption of pectoralis myotendinous unit at the humeral insertion site
Imaging Findings Best diagnostic clue: High signal on FS PD FSE or STIR at pectoralis major tendon tear site Location: Anterior chest wall and upper arm Several anatomical variants which may be unusual cause of injury (e.g., accessory insertions adjacent to median nerve)
Top Differential Diagnoses Pectoralis Minor, Latissimus Dorsi or Subscapularis Inferior Glenohumeral Ligament Injuries Fracture Manubrium-Sternum Dislocation
Pathology Resisted forced abduction and external rotation Heavy lifting (bench press weightlifting) Most injuries involve musculotendinous junction or distal tendon insertion partial tears most common
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Clinical Issues Pain (severe onset in acute rupture) Weakness (weak internal rotation) Deformity, especially on attempted contraction
Diagnostic Checklist Anomalous anatomy may cause unexpected collateral injury (e.g., to median nerve)
o Increased marrow signal in clavicle, sternum or ribs
indicating edema Visualization improved by using FS sequence o High signal at humeral insertion indicating tendon tears Insertion to lateral lip of bicipital groove o High signal within muscle indicating site of tear, +/moderate internal signal indicating fresh hematoma o High signal in perifascial zone and subcutaneous fat STIR o Sensitive for bony injury o High signal areas in marrow space o Sensitive to edema within muscle o Useful for homogeneous fat saturation at large fields of view o Useful at low field strength Normal myotendinous unit hypointense on T1 & T2WI
Ultrasonographic Findings Acute injuries with edema may show only subtle high echogenicity zones Larger injuries show low echogenicity zones representing physical defect within muscle + acute hemorrhage Muscle activation may show increased size of defect Organizing hematoma becomes hyperechoic Chronic hematomata become very hypoechoic Hyperechoic scar tissue and hyperechoic calcification (late stage) Hypoechoic edema plus visualized separation at humeral enthesis
Imaging Recommendations Best imaging tool: MRI Protocol advice o FS PD FSE or STIR sensitive for edema associated with tear o Axial and coronal FS PD FSE or STIR
Pectoralis Minor, Latissimus Dorsi or Subscapularis Inferior Glenohumeral Ligament Injuries Deep upper outer chest pain MRI diagnostic Rare injuries Usually sports related
Fracture Rib Scapula Sternum Humerus o Anatomic neck o Surgical neck o Hill-Sachs o Bankart o +/- Comminution Fractures in proximity of muscle may mimic pectoralis major pain, disability
Manubrium-Sternum Dislocation Pathology located center of chest rather than lateral chest or proximal humerus +/- Radiating pain from sternum CT/MR diagnostic Direct trauma Myotendinous long head of biceps strain o Associated with pectoralis tear o Mimics pectoralis injury if biceps strain is isolated
General Features General path comments o Relevant anatomy of pectoralis major tendon Broad bilaminar tendon Insertion - lateral lip of bicipital groove Two heads - sternocostal and clavicular
PECTORALlS MAJOR TEAR
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Upper clavicular head forms anterior tendon insertion Sternocostal head forms posterior tendon insertion Sternocostal head - produces anterior axillary fold prominence with spiral layering of muscle fibers Sternocostal head more susceptible to avulsion than clavicular head Pectoralis - innervated by medial and lateral pectoral nerves (from medial and lateral cords) Pectoralis - functions in adduction and medial rotation of the humerus Etiology o Resisted forced abduction and external rotation o Forceful contraction with arm adducted, flexed and internally rotated o Rupture in bench press weightlifting Overload of short inferior fibers in eccentric phase of lifting (sternal head failure) Direct blow (sternoclavicular head) Epidemiology o Heavy lifting (bench press weightlifting) 0 Recreational weight lifting Distribution o Most injuries involve musculotendinous junction or distal tendon insertion o Partial tears most common o Combined sternal and clavicular head injuries more common than individual head injuries o Silent injuries in the elderly
o Deformity, especially on attempted contraction
o Swelling o May present as a chest wall mass in elderly without
significant history of trauma Clinical profile o Weightlifter most common During humeral extension at the beginning of lift Hematoma proximal medial arm or chest wall Musculotendinous ruptures - chest wall hematoma Tendinous avulsions from humerus - ecchymosis
Demographics Age: Young adult Gender: M > F
Natural History & Prognosis Complete tear usually retracts and fibrosis occurs with visible deformity of chest wall Loss of strength with conservative treatment Primary and delayed repair have > 90% restoration of strength and function
Treatment Conservative: RICE (rest, ice, compression, elevation) Surgical o Primary or delayed repair o Complete rupture = indication for repair Complications: Re-rupture, infection, heterotopic ossification
Gross Pathologic & Surgical Features Tearing of muscle fibers Bleeding and hematoma formation Deformity from retraction of muscle bellies or tendon avulsion Partial or incomplete rupture Strains of muscle belly or musculotendinous junction Avulsion - type o At or adjacent to humeral insertion
Microscopic Features Disruption of myofibrillar structure Vascular rupture with hemorrhage Myotendinous separation Inflammatory cell infiltration Gradual replacement of devitalized tissue and hematoma by granulation tissue Increased myoblastic activity
Staging, Grading or Classification Criteria Grade 1 = localized edema within muscle, damage at microscopic level Grade 2 = partial tearing, perifascial edema Grade 3 = full thickness tearing, significant hematoma formation
Presentation Most common signs/symptoms o Pain (severe onset in acute rupture) o Weakness (weak internal rotation)
Consider Surgical repair in athletes in order to restore strength Anomalous anatomy may cause unexpected collateral injury (e.g., to median nerve)
Image Interpretation Pearls Coronal and axial FS PD FSE or STIR Axial images to include lateral lip of bicipital groove of proximal humeral diaphysis
Miller M: Surgical atlas of sports medicine. Treatment of suprascapular nerve entrapment. Philadelphia PA, Saunders, 341-6, 2003 Dodds SD et al: Injuries to the pectoralis major. Sports Med 32(14):945-52, 2002 Hanna CM et al: Pectoralis major tears: Comparison of surgical and conservative treatment. Br J Sports Med 35(3):202-6, 2001 Carrino JA et al: Pectoralis major muscle and tendon tears: Diagnosis and grading using magnetic resonance imaging. Skeletal Radio1 29(6):305-13, 2000 Anbari A et al: Delayed repair of a ruptured pectoralis major muscle. A case report. Am J Sports Med 28(2):254-6, 2000 Schepsis AA et al: Rupture of the pectoralis major muscle. Outcome after repair of acute and chronic injuries. Am J Sports Med 28(1):9-15, 2000 Connell DA et al: Injuries of the pectoralis major muscle: Evaluation with MR imaging. Radiology 210(3):785-9, 1999
PECTORALlS MAJOR TEAR
1 IMAGE GALLERY Typical (Left) Axial TZ* CRE MR of the left chest demonstrates a tear of the pectoralis major tendon with retraction (arrow). The retracted tendon edge is surrounded by hematoma. (Right) Coronal STlR MR shows a full thickness tear of the pectoralis tendon with an adjacent hematoma.
Typical (Left) Coronal T2 FSE MR shows the frayed tendon edge retracted from the humerus and surrounded by hemorrhage. (Right) Coronal STlR MR shows a full thickness tear of the pectoralis tendon with retraction and hyperintense hematoma.
(Left) Axial STlR MR shows hemorrhage surrounding a myotendinous junction strain oithe long head of the biceps tendon (arrow) sustained while weightlifting. (Right) Axial STIR MR of left upper arm demonstrates subcutaneous hemorrhage and partial tearing of the biceps tendon. This is also a common injury of weightlifting and may be associated with a pectoralis tear.
LABRAL CYST, SHOULDER
Coronal graphic demonstrates a labral cyst extending from a superior labral tear into the spinoglenoid notch compressing the suprascapular nerve.
Axial FS PD FSE MR shows a large cyst in the spinoglenoid notch associated with a tear of the posterosuperior labrum and denervation changes of the infraspinatus.
Size: Varies from few mms to large dissecting cyst (several cms) Morphology o Flattened to round o +/- Loculations o Cyst within (intralabral) or adjacent to (paralabral) labrum in continuity with a labral tear o +/- Labral/capsular tear healed
Abbreviations and Synonyms Paralabral cysts, paralabral ganglion cysts
Definitions Cyst arising from labral tear, capsular tear
M R Findings General Features Best diagnostic clue o Cystic mass extending from a labral and/or capsular tear o Hyperintense cystic mass on T2WI o Often multiloculated Location o Most commonly adjacent to posterosuperior labrum Including superior labrum anterior to posterior (SLAP) tears o Multiple locations adjacent to labrum o Funneled between supraspinatus (SS) and infraspinatus (IS) "Path of least resistance" to spinoglenoid notch or suprascapular notch to compress suprascapular nerve (SSN)
Llq
TlWI o Decreased signal intensity cystic mass +/- Intraosseous cystic mass o Fatty atrophy of affected muscles with chronic denervation T2WI o Cystic-appearing mass arising from or immediately adjacent to labrum or capsule Hyperintense o +/- Increased signal intensity intraosseous cystic mass o +/- Denervation - high signal and/or atrophy of affected muscles (supraspinatus infraspinatus) FS PD FSE most sensitive for acute and subacute changes of muscle o Labral tear fluid signal extending through labrum (specific not sensitive) o Irregular intermediate signal granulation tissue, low signal fibrosis with healed tear
DDx: Labral Cyst, Shoulder
I
4'
Sag PD FSE MR
Ax FS PD FSE MR
Cor FS PD FSE
*
a Cor T 1FS Arthro
Cor FS PD FSE
LABRAL CYST, SHOULDER Key Facts Terminology Cyst arising from labral tear, capsular tear
Imaging Findings Hyperintense cystic mass on T2WI Often multiloculated Most commonly adjacent to posterosuperior labrum +/- Cyst filled with contrast material
Top Differential Diagnoses 1
I
Neoplasm Muscle Denervation Normal Blood Vessels Hematoma of Non Communicating Cyst Posterior Superior Glenoid Impingement (PSGI)
STIR: Decreased spatial resolution, increased contrast resolution Labral tear = intermediate to increased signal at surface of labrum on short TE sequences MR arthrography o +/- Cyst filled with contrast material Depends on if original tear has healed or not o Cysts, +/- communicate with joint (uncommon without communication) +/- Visualization of cyst with TlWI (esp. with fat saturation) T2WI (FS PD FSE) required if paralabral cyst does not fill with contrast
Ultrasonographic Findings Hypoechoic/anechoic cystic mass through transmission +/- Visualization with ultrasound, associated abnormalities not seen (e.g., labral tear)
Imaging Recommendations Best imaging tool: MRI - identifies associated labral pathology Protocol advice: FS PD FSE images to identify the smaller paralabral cysts
I DIFFERENTIAL DIAGNOSIS Neoplasm
+ Internal enhancement No association with labral or capsular tear Benign o Lipoma Malignant o Metastasis o Lymphoma, myeloma extension from scapula Muscle Denervation Posttraumatic neurapraxia Parsonage-Turner syndrome o Idiopathic denervation of shoulder girdle muscles o Acute brachial neuritis No labrocapsular abnormality
Pathology Cyst arises from break in integrity of joint: Labral tear, degeneration, capsular tear or capsular diverticulum Instability, especially if labral tear remains patent (nonhealed)
Clinical Issues Suprascapular nerve compression syndrome if cyst located posterosuperiorly Axillary nerve compression syndrome if cyst inferior and dissects into quadrilateral space
Diagnostic Checklist FS PD FSE for detection and characterization of all paralabral cysts
+/- Nerve distribution
Normal Blood Vessels Normal plexus in spinoglenoid notch, suprascapular notch +/- Varices +/- Mass effect on suprascapular nerve Enlarged with congestive heart failure
Hematoma of Non Communicating Cyst
+ History of trauma +/- Scapular fracture Hyperintense fluid signal intensity on T2WI Chronic cases: Blooming with TZ* GRE One way valve mechanism in non communicating paralabral cyst
Posterior Superior Glenoid Impingement (PSG I) Internal impingement Undersurface posterior supraspinatus tendon tear o Partial tear most common o +/- Anterior infraspinatus tendon tear Triad o Undersurface cuff tear o Posterior superior labral frayingltear o Humeral head chronic impaction injury Athletes Occupational o Overhead activities, (e.g., mechanic)
1 PATHOLOGY General Features General path comments o +/- Compression neuropathy o +/- Asymptomatic o "Ball-valve"mechanism o Draining cyst without repairing labral tear leads to recurrence Etiology
LABRAL CYST, SHOULDER Cyst arises from break in integrity of joint: Labral tear, degeneration, capsular tear or capsular diverticulum o Slow growing 0 Original tear may heal Epidemiology: 3-5% of labral tears associated with cyst Associated abnormalities o Instability, especially if labral tear remains patent (nonhealed) o SLAP (superior labrum anterior to posterior) lesion Cyst posterosuperiorly, anterosuperiorly Superior cyst diagnostic of SLAP lesion o Denervation of supraspinatus and infraspinatus muscles = compression neuropathy 0 Deltoid and teres minor denervation Inferior cyst compressing axillary nerve Athletes o Bankart fracture (anteroinferior glenoid rim fx) 0 Bankart lesion (anterior inferior labral tear) o Bankart variation lesion Perthes Anterior labroligamentous periosteal sleeve avulsion lesion (ALPSA) o Clinical instability Anterior Posterior Multi directional Microinstability 0
.Tn
Gross Pathologic & Surgical Features
Demographics Age o Adolescent status post athletic injury 0 Adult with gradual onset of SSN denervation syndrome Gender: M > F
Natural History & Prognosis If symptomatic + nerve compression (may lead to irreversible damage), drainage required to relieve compression 0 Address labral damage to prevent recurrence Labral tear may heal and cyst remains or becomes asymptomatic o Conservative treatment may be successful
Treatment * Removal of cyst if symptomatic and repair of labral +
I DIAGNOSTIC CHECKLIST Consider Instability, SLAP lesion, other labral tear in association with SSN compression in setting of a cyst
Image Interpretation Pearls FS PD FSE for detection and characterization of all
Glistening mass: Various sizes usually adjacent to labrum
paralabral cysts TZ* sensitive to intralabral signal in tears and less sensitive to small paralabral cysts Paralabral cysts communicate with a labral tear until proven otherwise
Microscopic Features Cyst with wall containing spindle-shaped cells Cyst contains mucoid material Fatty infiltration of muscle tissue in chronically denervated muscles 1. 2.
Presentation Most common signs/symptoms o Suprascapular nerve compression syndrome Pain, weakness of SS and IS Proprioceptive change Mimics rotator cuff tear Clinical profile o Suprascapular nerve compression syndrome if cyst located posterosuperiorly o Axillary nerve compression syndrome if cyst inferior and dissects into quadrilateral space o Patient with instability history (labral tear) o Patient with history suggesting SLAP lesion (superior labral tear) o Pain and weakness of supraspinatus and infraspinatus and proprioceptive changes (suprascapular denervation) o Weakness of deltoid and teres minor (axillary denervation) o +/- Asymptomatic patient
tear if present Arthroscopic approach
3. 4.
5.
Grainger AJ et al: Direct MR arthrography: A review of current use. Clin Radiol 55(3):163-76,2000 Tirman PF et al: A practical approach to imaging of the shoulder with emphasis on MR imaging, Orthop Clin North Am 28(4):483-515,1997 Steiner E et al: Ganglia and cysts around joints. Radiol Clin North Am 34(2):395-425,1996 Tirman PF et al: Association of glenoid labral cysts with labral tears and glenohumeral instability: Radiologic findings and clinical significance. Radiology 190(3):653-8, 1994 Fritz RC et al: Suprascapular nerve entrapment: Evaluation with MR imaging. Radiology 182(2):437-44,1992
LABRAL CYST, SHOULDER
(Lef)Coronal graphic shows a spinoglenoid notch cyst extending from a posterosuperior labral tear. The cyst courses between the supraspinatus and infraspinatus as the "path of least resistance". (Right) Axial PD FSE MR shows a large paralabral cyst (arrow) extending into the spinoglenoid notch, associated with bony erosion and intraosseous cyst formation. Note the infraspinatus denervation (open arrow).
(Left) Coronal graphic shows a paralabral cyst extending from a superior labral tear into the suprascapular notch. (Right) Coronal FS PD FSE MR shows a large paralabral cyst within the suprascapular notch.
(Left) Axial T1 arthrogram shows filling of a posterior superior labral cyst (arrow), indicating a patent communicating labral tear. (Right) Sagittal FS PD FSE MR shows an anterior multiloculated cyst associated with an anterior superior labral tear.
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ANTEROSUPERIOR VARIATIONS, SHOULDER
Sagittal graphic shows normal separation of the anterior superior labrum between the equator anteriorly and biceps anchor superiorly consistent with a sublabral foramen.
Abbreviations and Synonyms
Sagittal T1 MR-arthrographic image demonstrates a sublabral foramen (arrow) in the anterosuperior quadrant. Foramen of Rouviere (open arrow) and Weitbrecht (curved arrow).
General Features
Sublabral foramen or sublabral hole (SH), Buford complex (BC), labral types, synovial recesses, cord-like middle glenohumeral ligament (MGHLIMGL)
Definitions Sublabral foramen 0 Relative lack of attachment of the anterior labrum to the glenoid rim in the anterior superior quadrant Buford complex o Cord-like MGL o MGL attaches directly to superior labrum anterior to biceps o Absent anterosuperior labrum Labral types o Superior wedge labrum o Posterior wedge labrum o Anterior wedge labrum 0 Superior and anterior wedge labrum o Meniscoid labrum Synovial recesses o Six anatomic types with respect to the glenohumeral ligaments o Cord-like MGL Prominent - thickened middle glenohumeral ligament
Best diagnostic clue o Sublabral foramen: Fluid undermining anterosuperior labrum on axial images o Buford complex: Thickened MGL in cross sectional diameter + absent anterosuperior labrum o Labral types Labrum attached to glenoid in its periphery Labrum mobile along its central border Labrum secured to glenoid o Synovial recesses Visualized on sagittal images as capsular variations relative to MGL o Cord-like MGL: Hypointense thick MGL on T1 and T2WI axial and sagittal images Location: Anterior superior quadrant Size: Anterior superior (anterosuperior) quadrant from equator (anterior indentation of glenoid rim as visualized on sagittal images) to biceps labral complex in a 12 o'clock position Morphology 0 Sublabral foramen A gap or potential space between anterosuperior labrum and glenoid rim Linear or slit-like morphology
DDx: Anterosuperior Variations, Shoulder Ant Sup Tear
Ant Sup Tear
Bankart Lesion
Biceps Disloc
Type VII SLAP
Sag FS P D FSE
Ax FS P D FSE
Ax FS P D FSE
Ax T2* CRE M R
Ax FS PD FSE M R
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ANTEROSUPERIOR VARIATIONS, SHOULDER -
Key Facts Imaging Findings Sublabral foramen: Fluid undermining anterosuperior labrum on axial images Buford complex: Thickened MGL in cross sectional diameter + absent anterosuperior labrum Cord-like MGL: Hypointense thick MGL on T1 and T2WI axial and sagittal images
Top Differential Diagnoses Anterosuperior Labrum Tear Superior Labrum Anterior to Posterior (SLAP) Lesion Superior Dissection of Bankart Lesion ~ l ~~~b~~ ~ ~~ i d ~~ i i(GLAD) ~ ~~~i~~ ~ ~ Biceps Dislocation Subscapularis Tear
Focal up to contour of entire anterosuperior quadrant o Buford Complex Direct attachment of cord-like MGL to superior labrum at biceps labral complex merging of superior glenohumeral (SGL), MGL, and superior labrum o Meniscoid labrum Circumferential free central margin with symmetric anterior and posterior labral tissue o Synovial recesses Type 1: One recess above MGL Type 2: One recess below MGL Type 3: Two recesses (superior subscapular recess above MGL & inferior subscapular recess below MGL) Type 4: No MGL (one large recess above inferior glenohumeral ligament or IGL) Type 5: MGL as two small synovial folds Type 6: Complete absence of synovial recesses o Cord-like MGL Cord-like compared to more normal sheet-like appearance of ligamentous tissue
M R Findings TlWI 0 Sublabral foramen Difficult to visualize as fluid signal beneath anterosuperior labrum is hypointense o Buford complex Complete absence of anterosuperior labrum above the level of the subscapularis Thick cord-like MGL anterior to anterosuperior glenoid rim deep to subscapularis tendon o Labral types Except for meniscoid labrum requires T2WI to appreciate fluid underneath labral free edge Synovial recesses require the presence of fluid and/or FS PD FSE to identify capsular variations on sagittal images o Cord-like MGL
Pathology Congenital variation of anatomy May be developmental 530%of shoulder MRI
Clinical Issues Most common signs/symptoms: Asymptomatic Meniscoid labrum at risk for SLAP lesions Avoid tacking down cord-like MGHL arthroscopically as frozen shoulder may result
Diagnostic Checklist quadrant ~ lNormal~variants ~ ~exist ~ in anterosuperior i ~ ~ above or at level of the subscapularis The anterior labrum is firmly attached to the glenoid rim below the level of the subscapularis
Thick hypointense MGL may be mistaken for a detached anterior labrum above the epiphyseal line T2WI o Sublabral foramen Hyperintense fluid signal which undermines anterosuperior labrum Not to be confused with a SLAP lesion Superior to anterior glenoid notch (above the equator or physeal line) representing superior third of anterior glenoid The Bankart lesion in comparison exists below the physeal line o Buford complex Hyperintense fluid signal surrounding hypointense MGL on axial and sagittal images & Remnant or hypoplastic anterosuperior labral tissue at level of subscapularis Normal labral attachment in anteroinferior quadrant 0 Labral types Hyperintense fluid beneath detached free edge (superior quadrant) of labrum overhanging articular cartilage + labrum, well attached peripherally No fluid seen beneath central or peripheral attachment of labrum to articular cartilage o Synovial recesses Hypointense MGL and IGL define recesses in contrast to adjacent hyperintense fluid o Cord-like MGL Hyperintense fluid surrounding hypointense MGL on multiple axial images MGL crosses superior border of subscapularis on sagittal images
imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE (coronal, axial and sagittal), T2* GRE (axial plane), MR arthrography
ANTEROSUPERIOR VARIATIONS, SHOULDER
I DIFFERENTIAL DIAGNOSIS
o Cord-like MGL + deficient anterior superior labrum
(Buford) is less common than a cord-like MGL + sublabral foramen beneath a normal anterior superior labrum
Anterosuperior Labrum Tear Labrum irregular and of high signal on T2WI +/- Throwing sports history Irregular labral morphology No anterior inferior instability o TlWI, T2* GRE WI, PD WI
Staging, Grading or Classification Criteria Six arrangements of synovial recesses Type A labrum o Unattached free edge Type B labrum o Attached to articular cartilage centrally Foramen of Weitbrecht o Normal foramen between MGL and superior glenohumeral ligament (SGL) creating a synovial recess Foramen of Rouviere o Normal foramen between MGL and IGL defining a synovial recess
Superior Labrum Anterior to Posterior (SLAP) Lesion Abduction/external rotation injury Torn superior labrum May propagate anteriorly, posteriorly, or involve MGHL +/- Microinstability +/- Superior labrum anterior cuff (SLAC) lesion
Superior Dissection of Bankart Lesion History of dislocation Abnormal anterior inferior quadrant abnormal +/- Type V SLAP lesion - inferior extension of a SLAP I1 +/- Bankart fracture +/- Hill-Sachs fracture
Glenoid Labrum Articular Disruption (GLAD) Lesion History of trauma Localized to anterior inferior quadrant Labral tear Chondral defect Forced adduction injury
Presentation Most common signs/symptoms: Asymptomatic
Demographics Age: Adolescents and adults Gender: M = F
Natural History & Prognosis Meniscoid labmm at risk for SLAP lesions
Treatment Avoid tacking down cord-like MGHL arthroscopically as frozen shoulder may result Sublabral foramen should not be reattached
Biceps Dislocation Mimics cord-like middle glenohumeral ligament +/- Subscapularis tear o +/- Partial tear +/- Predisposing hidden lesion +/- Biceps tendinosis
Consider
Subscapularis Tear +/- Impingement +/- Supraspinatus tear +/- Anterior dislocation o > 40 years old Hyperintense gap on T2WI +/- Hidden lesion
Normal variants exist in anterosuperior quadrant above or at level of the subscapularis The anterior labrum is firmly attached to the glenoid rim below the level of the subscapularis
1 SELECTED REFERENCES 1.
1 PATHOLOGY
2.
General Features
3.
Etiology o Congenital variation of anatomy o May be developmental ~~id'rniology o Common o 5-30% of shoulder MRI
Gross Pathologic & Surgical Features Sublabral foramen normal communication between sublabral foramen and subscapularis bursa Buford complex
Grigorian M et al: Magnetic resonance imaging of the glenoid labrum. Semin Roentgen01 35(3):277-85,2000 Beltran JJ et al: MR arthrography of the shoulder: Variants and pitfalls. Radiographics 17(6):1403-12,1997 Stoller DW: MR arthrography of the glenohumeral joint. Radio1 Clin North Am 35(1):97-116,1997
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ANTEROSUPERIOR VARIATIONS, SHOULDER
Tvnical
(Lef)Sagittal graphic shows a firmly normal attached anterosuperior labrum. (Right) Axial FS PD FSE MR shows an anterosuperior labrum attached directly to the glenoid articular cartilage.
(Left) Sagittal graphic shows a Buford complex with absence of the anterosuperior labrum in association with a cord-like middle glenohumeral ligament. (Right) Sagittal PD FSE MR shows absence (arrow) of the anterosuperior labrum in a patient with a Buford complex.
(Left) Axial FS PD FSE shows the absent anterosuperior labrum in association with cord-like middle glenohumeral ligament (arrow). Note absent anterosuperior labrum in associated Buford complex. This should not be mistaken for a labral tear. (Right) Axial MR arthrogram demonstrates a sublabral foramen (arrow) anterosuperiorly.
ADHESIVE CAPSULITIS, SHOULDER
Coronal graphic shows thickening of the inferior capsule with synovitis (arrow) in a patient with limitation of shoulder movement.
Abbreviations and Synonyms Frozen shoulder (FS), frozen shoulder syndrome (FSS)
Definitions Painful restriction of active and passive shoulder movement and scapulothoracic motion o Primary - no predisposing history or cause o Secondary - antecedent event such as trauma or previous surgery Duration: At least 1 month, stable vs. progression
I IMAGING
Coronal FS PD FSE MR shows thickening and edema (arrow) within the inferior aspect of the capsule (the axillary pouch of inferior glenohumeral ligament).
Size: Thickened capsule measuring > 3 mm on coronal images Morphology o Edematous o Thickened o Indistinct inferior capsule o +/- Rotator interval synovitis
Radiographic Findings Arthrography o Contracted irregular capsule o +Decreased Ivolume o Over injection leading to capsular rupture often therapeutic Results in increased mobility
FINDINGS
MR Findings
General Features Best diagnostic clue: Indistinct edematous inferior capsule (axillary pouch) on TZWI, on coronal and axial image Location o Axillary pouch, synovium of rotator interval o Involvement of entire axillary pouch from inferior pole of glenoid to humeral head o Segmental involvement of IGL (inferior glenohumeral ligament) Parahumeral portion Paraglenoid portion
TlWI o Thickened indistinct hypointense capsule Diffuse Adjacent to humerus Adjacent to glenoid o Hypointense capsule measuring greater than 3 mm thick on coronal images T2WI o Thickening and increased signal on T2WI of the rotator interval o Thickening conspicuous on FS PD FSE, T2* GRE and STIR
DDx: Adhesive Capsulitis, Shoulder OA Synov~t~s
Capcul~fear
Capsule Sprarn
Cor FS PD FSE
Ax FS PD FSE
Cor PD FSE MR
ADHESIVE CAPSULITIS, SHOULDER Key Facts Terminology Painful restriction of active and passive shoulder movement and scapulothoracic motion Primary - no predisposing history or cause Secondary - antecedent event such as trauma or previous surgery
Imaging Findings Best diagnostic clue: Indistinct edematous inferior capsule (axillary pouch) on T2W1, on coronal and axial image
,
Top Differential Diagnoses Impingement Syndrome Neuromuscular Dysfunction Osteoarthritis (OA) Cervical Disease o FS PD FSE sensitive to capsular edema and synovitis
o Thickened indistinct hyperintense capsule o Loss of normal hypointense linear capsule
Coronal images to evaluate inferior capsule below glenohumeral osseous structures Sagittal images helpful in evaluating rotator interval o Capsular scarring shown on PD FSE as intermediate signal fibrosis between IGL and inferior labrum o Intermediate signal in synovitis contained within the axillary pouch o +/- Effusion Hyperintense on T2WI +/- Capsular contraction STIR: Thickened indistinct hyperintense capsule MR arthrography o Capsule enhances diffusely, acutely o Restricted capsular volume
Imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE and PD FSE in coronal plane
Capsular Injury Secondary Adhesive Capsulitis (2"Adhesive Caps )
Pathology Inflammation of the inferior shoulder capsule causing Limited range of motion Frozen shoulder 10-20% patients with diabetes
Clinical Issues +/- History of trauma Often considered rotator cuff disease clinically
Diagnostic Checklist Diffuse edema with indistinct appearance of IGL on coronal FS PD FSE
o Parsonage-Turner syndrome
Osteoarthritis (OA) +/- History of trauma +/- Limitation of movement Common findings of OA o Chronic symptoms o Subchondral cysts, edema, sclerosis Synovitis mimics adhesive capsulitis
Cervical Disease +/- Disc abnormality on MRI Radiating pain without global loss of movement
+/- Neuromuscular dysfunction
Capsular Injury +/- Thickening of capsule secondary to injury and swelling Hyperintense on T2WI +/- Discrete tear + History of trauma o Dislocation o Abduction and external rotation injury +/- Complete rupture
Secondary Adhesive Capsulitis (2"Adhesive Caps Impingement Syndrome Impingement associated with painful shoulder movement mimicking adhesive capsulitis Capsular swelling associated with RTC (rotator cuff) disease as a secondary adhesive capsulitis Anterior shoulder pain with abduction +/- Thickening, increased signal of supraspinatus tendon on short and long TE sequences +/- Thickened coracoacromial ligament
Neuromuscular Dysfunction +/- History of nerve injury Specific muscle groups affected rather than global frozen shoulder o Except in paresis +/- History of antecedent viral prodrome
Trauma Surgery Regional abnormality Inflammatory disease Metabolic disease
1 PATHOLOGY General Features General path comments o Inflammation of the inferior shoulder capsule causing Limited range of motion Frozen shoulder o Accompanying other shoulder disorders such as impingement (secondary adhesive capsulitis)
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ADHESIVE CAPSULITIS, SHOULDER
Etiology o Idiopathic o Secondary (known disorders) Trauma Surgery Degenerative (acromioclaviculararthritis) Intrinsic rotator cuff and biceps tendinitisltear Inflammatory disease Metabolic disease (including diabetes mellitus) o Autoimmune theory proposed Increased C-reactive protein and HLA-B27 Epidemiology o Affects approximately 3% of general population 0 10-20% patients with diabetes 36% Insulin dependent diabetes
Treatment Conservative o Typically physical therapy o Passive stretching exercises Overhead elevation External rotation 90 degrees of abduction Internal rotation o NSAIDs, then possible corticosteroids Surgical o Injection of fluid into joint leading to capsular rupture often therapeutic o Brisement or distension arthrography o Manipulation under anesthesia o Surgical if failure of conservative management o Arthroscopic capsular release Complications o Biceps tendon sheath and subscapularis rupture reported with some conservative treatments
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Gross Pathologic & Surgical Features Thickened, indurated inferior capsule (axillary pouch of IGL) Rotator interval involvement Capsule often contracted Effusion Arthroscopic o Proliferative synovitis o Capsular and intraarticular subscapularis tendon thickening o Fibrosis
Microscopic Features
Consider Primary or secondary adhesive capsulitis when MRI findings of IGL involvement are demonstrated
Image Interpretation Pearls Diffuse edema with indistinct appearance of IGL on coronal FS PD FSE Synovitis is intermediate relative to hyperintense joint fluid within axillary pouch on FS PD FSE images Adhesive capsulitis and capsular sprain of the IGL have a similar appearance on MR
Influx of fibrosis and chronic inflammatory cells
Staging, Grading or Classification Criteria Adhesive capsulitis 0 Primary (idiopathic) o Secondary (known disorders) Systemic (e.g., diabetes mellitus) Extrinsic (e.g., humeral fractures) Intrinsic (e.g., cuff tendinitis, tears and acromioclavicular arthritis)
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CLINICAL ISSUES Presentation
1 SELECTEDREFERENCES 1. 2. 3.
Most common signs/symptoms o Adult patient with painful limited range of shoulder motion o Restricted active and passive motion with loss of anterior elevation, external and internal rotation o +/- History of trauma o Often considered rotator cuff disease clinically Clinical profile o Associated rotator cuff disease o Painful and restricted passive and active range of shoulder motion at physical examination
Demographics Age: 40-70 years Gender: F > M
Natural History & Prognosis Usually self limiting and effectively treated conservatively Small percentage 10% have persistent symptoms
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4. 5. 6.
7. 8.
Hannafin JA et al: Adhesive capsulitis. A treatment approach. Clin Orthop 372:95-109, 2000 Carrillon Y et al. Magnetic resonance imaging findings in idiopathic adhesive capsulitis of the shoulder. Rev Rhum Engl Ed 66(4):201-6,1999 Warner JJ: Frozen shoulder: Diagnosis and management. J Am Acad Orthop Surg 5(3):130-40, 1997 Warner JJ et al: Arthroscopic release for chronic, refractory adhesive capsulitis of the shoulder. J Bone Joint Surg 78(12):1808-16, 1996 Shaffer B et al: Frozen shoulder. A long-term follow-up.J Bone Joint Surg 74(5):738-46, 1992 Bigliani LU et al: Operative management of failed rotator cuff repairs. Orthop Trans 12:674, 1988 Bulgen DY et al: Immunological studies in frozen shoulder. J Rheumatol9(6):893-8, 1982 DePalma AF: Loss of scapulohumeral motion (frozen shoulder). Ann Surg 135:193-204, 1952
ADHESIVE CAPSULITIS, SHOULDER
(Left) Axial FS PD FSE MR shows diffuse edema and an indistinct appearance (arrow) of the inferior capsule in a patient with limitation of motion, consistent with adhesive capsulitis. (Right) Coronal FS PD FSE MR shows diffuse edema and indistinctness of the inferior capsule (arrow), in adhesive capsulitis. Differential would include a capsular sprain.
(Left)Axial FS PD FSE MR in a oatient without clinical fiAdings of adhesive ca~sulitisdemonstrates normal decreased signal intensity of the capsule and labral complex. (Right) Axial FS PD FSE MR shows the poorly defined and thickened (synovitis) capsule (arrow) of adhesive capsulitis.
(Lefl) Coronal FS PD FSE MR shows the normal hypointense appearance of the axillary pouch (arrow). (Right) Coronal FS PD FSE MR shows the thickened, edematous and indistinct morphology of the axillary pouch of the ICL (arrow) in adhesive capsulitis.
BANKART LESlON
Axial graphic shows avulsion of the inferior glenohumeral labroligamentous attachment to the glenoid with disruption of the scapular periosteum.
Axial PD shows avulsion of anteroinferior labrum (arrow) & ligament. Note disrupted scapular periosteum & deep surface of subscapularis tendon (open arrow).
General Features
Abbreviations and Synonyms Inferior glenohumeral ligament labral complex (IGHLC or IGLLC) avulsion, osseous Bankart, soft tissue Bankart
Definitions Detachment of the inferior glenohumeral ligament (IGHL) and labrum from the anterior glenoid after anterior dislocation o Periosteum ruptured o Bankart lesion encompasses both soft tissue Bankart lesions with an anterior inferior labral avulsion, and osseous or bony Bankart lesions with an associated fracture of the anteroinferior glenoid rim o Bankart variants encompass other anterior labral tears based on the type of detachment of the labrum and capsule from the anterior glenoid Perthes lesion (intact scapular periosteum) ALPSA (anterior labroligamentous periosteal sleeve avulsion) Capsular & intraligamentous IGL (inferior glenoid ligament) tears associated +/- Bankart lesion HAGL (humeral avulsion of the glenohumeral ligament) - may be associated with a Bankart lesion
Best diagnostic clue o Detached IGHLJlabrum from underlying glenoid, +/fracture of adjacent glenoid History of dislocation Location: Anterior inferior glenoid labrum Size o Varies from small discrete tear to displaced avulsions Labral tear may extend superiorly to equator (level of subscapularis or BLC - biceps labral complex) Morphology: Varies from linear tear to frank avulsion
Radiographic Findings Radiography o +/- Glenoid rim fracture with variable amount of displacement/comminution Subglenoid or subcoracoid dislocation
CT Findings CT arthrography o Contrast extending into anterior labral tear
M R Findings TlWI o Hypointense edema (acute) or sclerosis (chronic Bankart) in anteroinferior glenoid rim
DDx: Bankart Lesion Adhhes Caprul.
Perthes
ABER PD FSE
Ax PD FSE M R
Ax FS PD FSE M R
Ax T2* CRE M R
Cor
E
BANKART LESION Key Facts Terminology Detachment of the inferior glenohumeral ligament (IGHL) and labrum from the anterior glenoid after anterior dislocation
Imaging Findings Morphology: Varies from linear tear to frank avulsion +/- Fracture of the underlying glenoid (Bankart fx)
Top Differential Diagnoses ALPSA Lesion Partially Torn Non-Distracted Labrum after Subluxation Perthes Lesion HAGL Lesion IGL Tear Supraspinatus Tear
Subscapularis Tear
Pathology Scapular periosteum is disrupted Etiology: Occurs after initial anterior dislocation of the shoulder of patient < 40 years old
Clinical Issues Results in recurrent instability if improper healing of initial lesion occurs
Diagnostic Checklist Bankart variation lesions if labrum displaced medially (ALPSA) or in normal position (Perthes) with intact scapular periosteum
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o Glenoid rim fracture visualized in contrast to
adjacent marrow fat signal Axial Sagittal shows entire extent of anterior inferior glenoid quadrant TZWI o +/- Fracture of the underlying glenoid (Bankart fx) Increased signal intensity and visible hypointense fracture line o Hyperintense Hill-Sachs fracture (posterolateral humeral head) o Thickened, hyperintense IGHLC - acute dislocation o Hypointense - chronic osseous and capsular changes Fibrosislhealing of labrum o Labrum - discretely torn with hyperintense fluid, within or undermining labrum o ABER (abduction and external rotation) view demonstrates avulsion or absence of the anterior inferior labrum with associated tears of the IGL (inferior glenohumeral ligament) Use in conjunction with MR arthrography o Scar tissue - intermediate signal intensity TZ* GRE o Demonstrates intralabral signal intensity with greater sensitivity than FS PD FSE or PD FSE images o Osseous Bankart fx visualized with poor contrast on TZ* GRE Avulsed, distracted labrum on coronal images at or medial to the inferior pole of the glenoid
Imaging Recommendations Best imaging tool: MRI and MR arthrography Protocol advice o TZ* GRE for intralabral signal/tears o FS PD FSE to identify paralabral cysts and fluid undermining labral tears
IGHLC avulsion +/- Bankart fracture +/- Hill-Sachs lesion
Partially Torn Non-Distracted Labrum after Subluxation +/- Glenoid labrum articular disruption (GLAD) lesion History suggestive ABER (abduction external rotation) injury Labral tear = increased signal intensity on short TE sequence
Perthes Lesion Bankart variant No medial displacement No periosteal disruption ABER position used for diagnosis
HAGL Lesion Humeral capsular disruption Injury at humeral attachment of IGL Status post dislocation Hyperintense on T2WI (esp. FS PD FSE) o Soft tissue edema (capsule) o Effusion o J-shaped axillary pouch of IGL
IGL Tear Discontinuous decreased signal capsule with interposed hyperintensity on T2WI Anterior dislocation/subluxation
Supraspinatus Tear Impingement related Status post anterior dislocation o > 40 years old o +/- Bankart fracture o +/- Hill-Sachs lesion
Subscapularis Tear ALPSA Lesion Bankart variant Intact periosteum
Status post anterior dislocation o > 40 years old o +/- Bankart fracture o +I- Hill-Sachs lesion
BANKART LESION Posterior dislocation o +I- History of tonic-clonic seizure o Forward fall onto adducted internally rotated shoulder
Presentation Most common signs/symptoms o Status post anterior dislocation (single or multiple dislocations) o Pain and apprehension with abduction and external rotation Clinical profile: Positive apprehension (feeling of instability) test in patients with recurrent instability
Adhesive Capsulitis (Adhes Capsul) Thickened edematous capsule detected at the axillary pouch of the IGL Hyperintense capsule on T2WI Frozen shoulder
SLAP Lesion (Esp. Type V and IX) Superior labrum tear SLAP V (superior extension of a Bankart lesion) and IX (circumferential labral tear) involve the anterior inferior labrum Increased signal intensity linear abnormality on short TE sequences
1 PATHOLOGY
Demographics Age: Younger patient (< 40 years) Gender: M > F
Natural History & Prognosis Results in recurrent instability if improper healing of initial lesion occurs o Medial displacement = ALPSA lesion, Bankart variation o Nondisplaced but with intact periosteum = Perthes lesion, Bankart variation
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General Features General path comments 0 Scapular periosteum is disrupted o IGHLC "weak link" of static stabilizer in young shoulders Ruptures after dislocation Etiology: Occurs after initial anterior dislocation of the shoulder of patient < 40 years old Epidemiology o 50% of all joint dislocations o Bankart lesion most common lesion in under 40 age group accounting for > 90% of lesions Associated abnormalities 0 Accompanied by osteochondral fracture (bony Bankart) in some cases Glenoid deficiency = bony Bankart resulting in inverted pear appearance of glenoid (high recurrence rate) o Tears of the rotator interval lead to continued instability o Hill-Sachs fracture of posterolateral superior humeral head Engaging = catching and click when moving in and out of ABER position o Partial or complete rotator cuff tears o Biceps tendonlanchor lesions in 12% of patients post anterior dislocation o Brachial plexus injuries, posterior glenoid labral tear in up to 11% of patients post anterior dislocation
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Treatment Conservative with a sling Surgical or arthroscopic repair for repeat dislocations o Glenoid deficiency = open repair o No deficiency - arthroscopic repair restoring normal anatomy Place labrum on the "corner"of the glenoid
1 DIAGNOSTIC CHECKLIST Consider Consider in younger patient with history of dislocation Does not occur spontaneously without dislocation
Image Interpretation Pearls Bankart variation lesions if labrum displaced medially (ALPSA) or in normal position (Perthes)with intact scapular periosteum Identify anterior inferior labral tears, scarring and tears of the IGL on coronal images at or medial to the inferior pole of the glenoid
1 SELECTEDREFERENCES 1.
Gross Pathologic & Surgical Features Avulsion of IGHLC attachment to the glenoid after anterior dislocation of the shoulder Glenoid deficiency Posterolateral humeral head impaction fx
Microscopic Features Hemorrhagic, torn, fibrocartilaginous labrum with variable degrees of fibrosis depending on chronicity Ligamentous failure of IGL at glenoid insertion + capsular deformation or stretch with recurrent dislocation
2. 3.
DeBerardino TM et al: Prospective evaluation of arthroscopic stabilization of acute, initial anterior shoulder dislocations in young athletes. Two to five-year follow-up. Am J Sports Med 29(5):586-92, 2001 Gartsman GM et al: Arthroscopic treatment of anterior-inferior glenohumeral instability. Two to five-year follow-up.J Bone Joint Surg Am 82-A (7): 991-1003, 2000 Burkhart SS et al: Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 16(7): 677-94, 2000
1
BANKART LESION
(Lef)Sagittal graphic shows a fracture through the anteroinferior glenoid, consistent with a Bankart fracture. A large fracture results in glenoid deficiency and is treated with an open surgical procedure. (Right) Sagittal PD FSE MR shows fracture through the anteroinferior glenoid (arrow), representing an osseous Bankart lesion. The patient developed glenoid deficiency.
Typical
(Left) Sagittal graphic shows fibrocartilaginous Bankart (avulsion of the inferior glenohumeral labroligamentous attachment to the glenoid) as a result of anterior dislocation. (Right) Sagittal PD FSE MR shows a Bankart lesion (arrow) anteroinferiorly.
Typical (Left) Axial T2" CRE MR in a patient after anterior dislocation shows a posterolateral Hill-Sachs fracture (arrow) involving the superior humeral head (engaging Hill-Sachs). Bankart lesion - anteriorly. (Right) Axial T2* GRE MR shows fragmentation and avulsion of the anterior inferior glenoid labrum (arrow).
PERTHES LESION
Axial graphic demonstrates an avulsion of the inferior glenohumeral labroligamentous attachment to the glenoid with an intact periosteum (Perthes lesion).
Axial FS PD FSE MR demonstrates linear increased signal intensity (arrow) beneath an avulsed labrum. The labrum is only minimally displaced and the scapular periosteum is intact.
Radiographic Findings Abbreviations and Synonyms Bankart variant
Definitions Detached inferior glenohumeral ligamentous complex (IGHLC or IGLLC) with intact scapular periosteum, which is stripped medially Nondisplaced with neutral positioning of the shoulder, labral attachment often incompetent
General Features Best diagnostic clue o Normal position of the inferior glenohumeral ligament and labrum relative to underlying glenoid Accompanied by hemorrhageledema of inferior glenohumeral ligament (IGL) attachment site + Anterior dislocation/subluxation Location: Anterior inferior glenoid at insertion of IGL to labrum Size: Small tear at base of nondisplaced or mildly displaced IGHLC after anterior dislocation Morphology: Periosteum redundanttlax
Radiography o +/- Bankart fracture (anterior inferior glenoid fracture) o +/- Hill-Sachs deformity (posterolateral humeral head impaction)
CT Findings NECT o +/- Bankart fracture o +/- Hill-Sachs deformity CT arthrography o Nondisplaced IGHLC o +/- Extension of contrast underneath nondisplaced labrum and periosteum
MR Findings TlWI o Often normal (scapular periosteum intact) o Not recommended for primary diagnosis of Perthes lesion T2WI o Subtle linear increased signal intensity at base of usually nondisplaced labrum - sublabral hyperintensity o +/- Fracture (fx) of underlying glenoid Increased signal intensity and visible hypointense fracture line at site of Bankart fx
DDx: Perthes Lesion
Cor T l Wl MR
Normal ABER
Bankart Osseous
T I ABER
Ax FS PD FSE MR
Bankart Lesion
Cor FS PD FSE
Ax PO FSE MR
PERTHES LESION Key Facts Terminology Detached inferior glenohumeral ligamentous complex (IGHLC or IGLLC) with intact scapular periosteum, which is stripped medially
Imaging Findings Normal position of the inferior glenohumeral ligament and labrum relative to underlying glenoid Accompanied by hemorrhagetedema of inferior glenohumeral ligament (IGL) attachment site + Anterior dislocation/subluxation Morphology: Periosteum redundantllax Subtle linear increased signal intensity at base of usually nondisplaced labrum - sublabral hyperintensity
+/- Distraction of fracture fragment o Associated posterolateral superior humeral head
Hill-Sachs fx o Hypointense redundant periosteum o Edema and hemorrhage: Increased signal in
surrounding soft tissues in acute cases o +/- Hyperintense edemathemorrhage between intact
periosteum and adjacent glenoid o FS PD FSE
Sensitive for edema and fluid Greater contrast compared to long TE (T2 FSE) PDtIntermediate o High resolution PD good for anatomic delineation of IGHLC o +/- Fracture of the underlying glenoid, posterosuperior humeral head o Intermediate signal in resynovialized labrum STIR o Hyperintense edema and hemorrhage in surrounding soft tissues o Provides improved contrast resolution to visualize medially stripped scapular periosteum o Sensitive to associated anterior inferior bony glenoid hyperintense edema and cystic changes Normal position of the inferior glenohumeral ligament and labrum ~ a b r u mmay be normal in appearance o Labmm maintains hypoiitinsity on axial images (TI & T2WI) In chronic Perthes the labmm is partially healed and fibrosed o +/- Heterogeneous hypointense to intermediate signal intensity on all pulse sequences MRI arthrography o Chronic cases with resynovialization and nondisplacement o ABER position = = Abduction external rotation (arm placed behind the head) Coronal localizer to prescribe axial images
Top Differential Diagnoses Bankart Lesion Subscapularis Rupture Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) Lesion Normal Labrum and Attachment SLAP Lesion (esp. Type V & IX) ~ d hcapsulitis ~ ~ i ~ ~ Supraspinatus Tear
.
Clinical Issues Most common signs/symptoms: Status post anterior dislocation (single or multiple dislocations)
Diagnostic Checklist
Intact hypointense scapular periosteum
Imaging Recommendations Best imaging tool: MRI, consider MR arthrography especially with ABER positioning Protocol advice o FS PD FSE axial, coronal; high resolution PD axial; MR arthrography Abduction and external rotation (ABER) imaging to detect detached labrum
I DIFFERENTIAL DIAGNOSIS Bankart Lesion Includes soft tissue (labrum only) Bankart and osseous Bankart (fracture of anterior inferior glenoid rim) Disrupted scapular periosteum Fibrosis of disrupted scapular periosteum may mimic intact periosteum as seen in the Perthes lesion Most common lesion after anterior dislocation o Under 40 years of age +/- Hill-Sachs lesion of posterolateral humeral head Labrum often fragmented of avulsed +/- Anterior distraction/displacement of labrum Hyperintense on T2WI (esp. FS PD FSE) o Soft tissue edema and effusion o Hyperintense labral tear
Subscapularis Rupture Status post anterior dislocation o > 40 years o +/- Bankart fracture o +/- Hill-Sachs lesion Posterior dislocation o +/- History of tonic-clonic seizure o Forward fall onto adducted internally rotated shoulder Discontinuous decreased signal subscapularis tendon with interposed hyperintensity on T2WI Hyperintense edema T2W1, (FS PD FSE) surrounding edema
PERTHES LESION Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) Lesion Medially and inferiorly displaced labrum and IGL Intact periosteum IGHLC avulsion A type of Bankart variant +/- Bankart fracture +/- Hill-Sachs fracture 64
Normal Labrum and Attachment No history of dislocation No sublabral hyperintensity on T2WI No signal abnormalities including base of labrum
Presentation Most common signs/symptoms: Status post anterior dislocation (single or multiple dislocations)
Demographics Age: Younger patient (< 40 years) Gender: M > F
Natural History & Prognosis Recurrent instability if improper healing of initial lesion
Treatment
SLAP Lesion (esp. Type V & IX) Superior labral tear SLAP V (superior extension of a Bankart) and IX (circumferential labral tear) involve anterior inferior labrum Increased linear signal intensity on short TE sequences
Adhesive Capsulitis Thickened edematous capsule Hyperintense T2WI Frozen shoulder
Supraspinatus Tear Impingement - most common cause Status post anterior dislocation o > 40 years of age o +/- Bankart fracture o +/- Hill-Sachs lesion Hyperintense signal at tear site on T2WI +/- Tendon retraction +/- Fatty atrophy of cuff muscles Tendon size measured on coronal and sagittal images in centimeters
Mobilized surgically or arthroscopically Normal anatomy is reapproximated and then repaired Bone block procedure in case of glenoid deficiency (large Bankart fracture)
[DIAGNOSTIC CHECKLIST Consider Intact hypointense scapular periosteum Use fluid sensitive sequence (FS PD FSE) in the axial plane
1 SELECTED REFERENCES I. 2.
3.
1 PATHOLOGY
4.
General Features General path comments: The scapular periosteum is intact Etiology o Occurs after anterior shoulder dislocation Often after initial dislocation Epidemiology o Shoulder is the most common dislocated joint, 50% of all joint dislocations Perthes is uncommon Bankart variation - 5-10%
Gross Pathologic & Surgical Features Avulsion of the inferior glenohumeral labral ligamentous attachment to the glenoid after anterior dislocation of the shoulder Fibrosis and resynovialization in chronic cases +/- Normal at arthroscopy especially in the chronic state +/- Osteochondral fracture
Microscopic Features Hemorrhagic, torn, fibrocartilaginous labrum with variable degrees of fibrosis depending on chronicity
5. 6.
Wischer TK et al: Perthes lesion (a variant of the Bankart lesion): MR imaging and MR arthrographic findings with surgical correlation. AJR 178(1):233-7, 2002 Burkhart SS et al: Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 16(7):677-94, 2000 Grainger AJ et al: Direct MR arthrography: A review of current use. Clin Radio1 55(3):163-76,2000 Cvitanic OP et al: Using abduction and external rotation of the shoulder to increase the sensitivity of MR arthrography in revealing tears of the anterior glenoid labrum. AJR 169(3):837-44,1997 Tirman PF et al: A practical approach to imaging of the shoulder with emphasis on MR imaging. Orthop Clin North Am 28(4):483-515, 1997 Neviaser TJ: The anterior labroligamentous periosteal sleeve avulsion lesion: A cause of anterior instability of the shoulder. Arthroscopy 9(1):17-21, 1993
PERTHES LESlON
I IMAGE GALLERY (Left) Axial T 1 MR arthrogram image demonstrates tearing of the anterior labrum (arrow) at the mid glenoid level. (Right) Sagittal oblique post-arthrographic T I ABER MR arthrogram image shows a Perthes lesion (arrow) with an intact scapular periosteum. The labrum was slightly fragmented but in relatively normal position at arthroscopy.
(Left) Sagittal oblique arthroscopic view shows a normal positioned labrum. The cannula is lifting the meniscoid edge of the labrum up. (Right) Axial oblique arthroscopic view demonstrates mobility of the labrum with traction, consistent with a Perthes lesion. At first inspection, the patient was considered normal and capsulorraphy was initially considered as a treatment option.
Tvnica I
(Left) Axial FS PD FSE MR demonstrates increased signal intensity at the base of the labrum (arrow) in this patient after anterior dislocation. (Right) PD FSE MR ABER image in the same pa tient demonstrates a Perthes lesion with increased signal intensity (arrow) "rounding the corner" of the glenoid beneath the detached labrum.
ALPSA LESION
Axial graphic shows medial displacement and inferior rotation of the inferior glenohumeral labroligamentous attachment to the glenoid. This is the most important feature of an ALPSA lesion.
Abbreviations and Synonyms Anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion
Definitions Avulsion of inferior glenohumeral labroligamentous complex (IGHLC or IGLLC) from anterior inferior glenoid with an intact scapular periosteum Medial displacement and inferior shifting of the IGHLC Bankart variation lesion (ALPSA has intact anterior scapular periosteum) Glenoid deficiency o Bankart fracture decreases inferior glenoid surface area resulting in continued instability
Axial T I arthrogram of ALPSA lesion demonstrates medial displacement of the ICHLC (arrow) along the anterior neck of glenoid & surrounding hemorrhage.
Chronic cases: Variable degrees of fibrosis, fibrous mass Location: Anterior inferior shoulder Size o Varies from Subtle medial displacement and inferior rotation Displacement up to a few centimeters especially if associated with an underlying glenoid fracture Morphology o Irregular, often amorphous mass Fibrotic IGHL complex Medially displaced along scapular neck
Radiographic Findings Radiography o +/- Anterior inferior glenoid fracture = Bankart fracture o +/- Hill-Sachs impaction fracture (posterolateral superior humeral head)
CT Findings
General Features Best diagnostic clue o Medial displacement of IGHLC on axial and coronal MR images in patient with history of anterior dislocation Acute cases: Edemalhemorrhage
NECT o +I-Anterior inferior glenoid fracture = Bankart fracture Posterolateral superior humeral head (HH) fracture (Hill-Sachs) CT arthrography o Medial displacement of IGHLC
+,-
amLHu DDx: ALPSA Lesion Bankart Lesion
Non LIISPI feat
Adhes Capsul~ri~
+ >
ABER T I Arthro
Sag PD FSE MR
Ax PD FSE MR
'
Ax T 1 Arthro
Ax FS PD FSE
ALPSA LESION Key Facts Terminology Avulsion of inferior glenohumeral labroligamentous complex (IGHLC or IGLLC) from anterior inferior glenoid with an intact scapular periosteum Medial displacement and inferior shifting of the IGHLC
lmaging Findings * Medial displacement of IGHLC on axial and coronal
I
MR images in patient with history of anterior dislocation Acute cases: Edemalhemorrhage Chronic cases: Variable degrees of fibrosis, fibrous mass Medial and inferior displacement of labrum
M R Findings TlWI o Deformity of axillary pouch with medial displacement of anteroinferior labrum and IGL o Hypointense osseous edema associated with Bankart and Hill-Sachs fractures T2WI o Hyperintense edema and hemorrhage in joint capsule and surrounding soft tissues o +/- Fracture of the underlying glenoid Increased signal intensity and visible hypointense fracture line +/- Distraction of fracture fragment = Bankart fracture o +/- Hill-Sachs fracture o Medial displacement of thickenedlhyperintense IGHLC - acute Hypointense - chronic o FS PD FSEIPD FSE sensitive for osseous and capsular edema PDIIntermediate o Less sensitive for osseous edema o Visualization of articular cartilage and labral tears o High resolution PD for anatomic delineation of IGHLC and fibrosis (chronic) o +/- Fracture of the underlying glenoid, posterosuperior humeral head STIR o Hyperintense edema and hemorrhage in surrounding soft tissues o Increased contrast resolution for hyperintense osseous edema o Improved visualization of axillary pouch displacement adjacent to hyperintense fluid and edema MR arthrography o Medial and inferior displacement of labrum o Chronic cases with resynovialization and minimal medial displacement o ABER (abduction external rotation) position helpful o Inferior ALPSA with medial and inferior displacement below inferior pole of glenoid
Top Differential Diagnoses Bankart Lesion Perthes Lesion HAGL Lesion Subscapularis Tear Supraspinatus Tear IGL Tear
Clinical Issues Most common signs/symptoms: Status post anterior dislocation (single or multiple dislocations) - pain ST apprehension with abduction and external rotation
Diagnostic Checklist Bankart lesion in differential diagnosis Identify medial or inferior labral displacement
lmaging Recommendations Best imaging tool: MRI Protocol advice o High resolution PD, FS PD FSE in axial and coronal plane o MR arthrography helpful especially with ABER positioning
I DIFFERENTIALDIAGNOSIS Bankart Lesion No medial displacement/inferior shift Most common lesion after anterior dislocation o < 40 years Periosteal disruption +/- Bankart fracture o +/- Glenoid deficiency +/- Hill-Sachs lesion Labrum often fragmented +/- Anterior distraction/displacement of labrum Hyperintense on T2WI (esp. FS PD FSE) o Soft tissue edema o Effusion
Perthes Lesion No medial displacement No periosteal disruption ABER position helpful A type of Bankart variant +I- Bankart fracture +/- Hill-Sachs lesion Hyperintense on T2WI (esp. FS PD FSE) o Soft tissue edema o Effusion
HAGL Lesion Humeral capsular disruption of IGL attachment Status post dislocation +/- Bankart fracture +/- Hill-Sachs lesion Hyperintense on T2WI (esp. FS PD FSE) o Soft tissue edema
ALPSA LESION o Effusion o Injured capsule 0-shaped axillary pouch)
Fibrous tissue deposited in chronic ALPSA
Microscopic Features
Subscapularis Tear
08
Status post anterior dislocation o > 40 years; +/- Bankart fracture; +/- Hill-Sachs lesion posterior dislocation o +/- History of tonic-clonic seizure o Forward fall onto adducted internally rotated shoulder Discontinuous decreased signal of subscapularis tendon with interposed hyperintensity on T2WI Surrounding edema - hyperintense on T2WI (esp. FS PD FSE)
Supraspinatus Tear Impingement Status post anterior dislocation o > 40 years old o +/- Bankart fracture o +/- Hill-Sachs lesion Thickened, increased signal intensity tendon on T2WI most common o Discontinuous tendon with interposed hyperintensity
Hemorrhagic, torn, fibrocartilaginous labrum with variable degrees of fibrosis depending on chronicity
Presentation Most common signs/symptoms: Status post anterior dislocation (single or multiple dislocations) - pain ST apprehension with abduction and external rotation Clinical profile: Positive apprehension test in patients with recurrent shoulder instability
Demographics Age: Typically younger patient (< 40 years) Gender: M > F
Natural History & Prognosis Recurrent shoulder instability if improper (in displaced position) healing of initial lesion IGL incompetence
Treatment Surgical o Dissection of ALPSA away from glenoid and conversion to Bankart (mobilize and disrupt scapular periosteum) Place labrum on anterior lateral corner of glenoid back in anatomic location for treatment of recurrent instability Correct IGL capsular stretch or injury
IGL Tear Discontinuous decreased signal capsule with interposed hyperintensity on T2WI Status post anterior dislocation/subluxation +/- Bankart fracture +/- Hill-Sachs lesion
Adhesive Capsulitis (Adhes Capsulitis) Thickened edematous capsule Hyperintense on T2WI Frozen shoulder +/- Secondary to abduction external rotation injury or systemic disease (diabetes)
1 PATHOLOGY
Consider Bankart lesion in differential diagnosis
Image Interpretation Pearls Identify medial or inferior labral displacement Do not confuse a cord-like middle glenohumeral ligament for an ALPSA lesion
General Features General path comments o Medial displacement of labroligamentous structures leads to healing of IGHLC medially on scapular neck Decreases chances for stable healing Etiology: Anterior shoulder dislocation resulting in IGHLC avulsion with medial displacement of intact scapular periosteum and "rolling up" of IGHLC Epidemiology: Shoulder dislocations account for 50% of all joint dislocations Associated abnormalities o Glenoid fracture o Hill-Sachs fracture o Rotator interval tear o Superior labrum anterior-posterior (SLAP) lesion o Rotator cuff tear
Gross Pathologic & Surgical Features Avulsion of IGHLC attachment to glenoid with medial displacement after anterior dislocation of shoulder Glenoid deficiency requires open procedure (usually bone block)
I SELECTED REFERENCES 1.
2. 3.
4.
5.
Gartsman GM et al: Arthroscopic treatment of anterior-inferior glenohumeral instability. Two to five-year follow-up.J Bone Joint Surg 82-A(7):991-1003, 2000 Grainger AJ et al: Direct MR arthrography: A review of current use. Clin Radio1 55(3):163-76, 2000 Burkhart SS et al: Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs. Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 16(7):677-94,2000 Tirman PF et al: A practical approach to imaging of the shoulder with emphasis on MR imaging, Orthop Clin North 28(4):483-515, 1997 Cvitanic 0 et al: Using abduction and external rotation of the shoulder to increase the sensitivity of MR arthrography in revealing tears of the anterior glenoid labrum. AJR 169(3):837-44,1997
ALPSA LESION
Typical (Left) Axial oblique arthroscopic view of an ALPSA lesion demonstrates medial displacement of the ICHLC along the neck of the glenoid + surrounding hemorrhage. Face of glenoid is far right, humeral head is at the top right of the picture. (Right) ABER MR T I arthrogram shows medial displacement of the ICHLC attachment (arrow) to the glenoid consistent with an ALPSA lesion.
Typical (Left) Coronal graphic shows medial and inferior labral ligamentous displacement along the inferior neck of the scapula. (Right) Coronal PD FSE MR image demonstrates medial dispbcement (arrow) along the scapular neck of the labroligamentous attachment, consistent with an ALPSA lesion.
Typical (Lef)Axial FS PD FSE MR demonstrates medial displacement (arrow) of the labroligamentous attachment in association with disruption of the subscapularis tendon in this post-operative unstable patient. (Right) Sagittal T2 FSE MR demonstrates inferior and medial shifting of the labroligamentous attachment on the glenoid (arrow).
GLAD LESlON
Axial graphic shows a flap tear of the anterior glenoid labrum and a small articular cartilage defect (chondral flap) adjacent to the labral tear.
Axial FS T I arthrogram shows a hyaline articular cartilage defect (arrow) with adjacent fraying/partial tearing of the base of the labrurn in a clinically stable patient.
M R Findings TlWI o Irregular intermediate signal in substance of the labrum or at interface with glenoid = tear, fraying o Labral irregularity and chondral lesion not well seen on TlWI o Hypointense subchondral sclerosis anterior inferior glenoid rim o Anterior inferior capsular thickening o Labral tear is typically non detached o +/- Underlying hypointense bone marrow edema T2WI o Irregular hyperintense signal in substance of labrum or at interface with glenoid o +/- Hyperintense fluid within the tear o Hyperintense chondral defect Divot Flap o +/- Underlying hyperintense bone marrow edema o Labral tear usually nondisplaced o FS PD FSE Increased signal at labral attachment, or in substance of the labrum Chondral defect visualized on FS PD FSE Glenoid rim edema is hyperintense o T2 FSE Chondral defect not well visualized PDJIntermediate
Abbreviations and Synonyms Glenoid labrum articular disruption (GLAD), glenoid articular rim divot (GARD)
Definitions Partial tear of the anterior glenoid labrum with adjacent articular cartilage chondral defect in clinically stable patient Labrum is not detached
I IMAGING FINDINGS General Features Best diagnostic clue: Irregular increased signal intensity on FS PD FSElT2WI sequences within the anterior labrum and adjacent cartilage Location: Anterior glenoid rim and adjacent hyaline articular cartilage Size: Varies from small tear (1-2 mm) to approximately 1 centimeter Morphology o Irregular interface between fluid and/or granulation in tear and adjacent labrum o Larger tears +/- instability o Chondral lesion as flap tear or divot
DDx: GLAD Lesion
EMmB4H /
-I
--
Cor FS PD FSE
Sag FS PD FSE
A x T2* CRE M
A x FS PD FSE
4 ' . -. , .-
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2 * CRE rZ/
Key Facts Terminology Partial tear of the anterior glenoid labrum with adjacent articular cartilage chondral defect in clinically stable patient
Imaging Findings Best diagnostic clue: Irregular increased signal intensity on FS PD FSEITZWI sequences within the anterior labrum and adjacent cartilage
Top Differential Diagnoses Bankart Lesion Loose Body Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) Lesion SLAP Lesion Posterior Labral Tear o Intermediate to increased signal in labrum or at the
interface with the glenoid = tear, fraying = Especially if fluid is found within the tear PD high resolution images useful +/- Intermediate signal intensity of underlying bone reactive changes (less sensitive compared to FS PD FSE) T2* GRE o Labral tear hyperintense o Cartilage defect not seen if joint fluid is isointense to hyaline cartilage T1 C+: Defect may enhance with intravenous contrast thus increasing it's conspicuity MR arthrography o Contrast filling tear o Contrast extends into chondral defect
Imaging Recommendations Best imaging tool: MRI Protocol advice o FS PD FSE o Arthrography in the ABER position demonstrates partial labral tear by placing stress on the capsular ligamentous attachments
1 DIFFERENTIAL DIAGNOSIS Bankart Lesion Unstable patient Underlying fracture or chondral defect History of anterior dislocation (not seen in GLAD lesion) +/- Underlying Bankart fracture +/- Hill-Sachs fracture
Loose Body Clinical differential diagnosis in physical exam +/- Catching, locking, and/or clicking Absence of labral tear Round lesion of decreased signal intensity on all pulse sequences
Perthes Lesion
Pathology Labral tear without associated capsular ligament disruption Forced adduction injury on abducted arm in external rotation Abduction external rotation injury in case of subluxation without dislocation
Clinical Issues
Pain, especially with internal rotation or with adduction
DiagnOSf icChecklist Small anterior labral tear with adjacent chondral defect seen on FS PD FSE or PD FSE
Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) Lesion Intact scapular periosteum History of anterior dislocation +I- Underlying Bankart fracture +I- Hill-Sachs fracture Medial displacement of IGHLC (inferior glenohumeral labral ligament complex)
SLAP Lesion Superior labral biceps anchor tear Lesion propagates to o Anterior labrum (type V) o MGL (middle glenohumeral ligament) (type VII) o Posterior labrum (type VIII) o Circumferentially (type IX) 0 +/- Flap labral component +/- Speed's (bicipital resistance) test, O'Brien's test (active compression test for SLAP lesions) +/- Traction injury Increased signal intensity abnormality on short TE sequences in biceps anchor +/- Hyperintense tear on T2WI +/- Paralabral cyst
Posterior Labral Tear History of posterior dislocation/subluxation Increased signal intensity on short TE sequences in posterior labrum +/- Underlying Bankart fracture +/- Hill-Sachs fracture Pain with adduction, internal rotation
Perthes Lesion Intact scapular periosteum History of anterior dislocation +/- Underlying Bankart fracture +/- Hill-Sachs fracture Cyst beneath periosteum Normal labral position
GLAD LESION
I DIAGNOSTIC CHECKLIST General Features
72
General path comments o Labral tear without associated capsular ligament disruption Described initially in stable patients Etiology o Forced adduction injury on abducted arm in external rotation o Abduction external rotation injury in case of subluxation without dislocation o Impaction of humeral head against glenoid fossa Epidemiology: Uncommon injury Associated abnormalities: Underlying trabecular injury of glenoid may occur
Consider Bankart lesion in patient that has dislocated and/or is unstable
Image Interpretation Pearls Small anterior labral tear with adjacent chondral defect seen on FS PD FSE or PD FSE Accurate history important MR arthrography useful for the detection of the partial labral tear
1.
Gross Pathologic & Surgical Features Torn labrum o Superficial anterior inferior labrum o Inferior flap-type labral tear o IGL firmly attached to labrum and glenoid rim Adjacent hyaline chondral defect o Anterior inferior quadrant of glenoid fossa o Fibrillation o Erosion Variable amounts of hemorrhage +/- Granulation +/- Fibrosis depending on chronicity of lesion
Microscopic Features Hemorrhagic, torn, fibrocartilaginous labrum with variable degrees of fibrosis depending on chronicity Articular cartilage defect +/- Infiltration of inflammatory cells +/- Inflamed synovium
Presentation Most common signs/symptoms o Pain, especially with internal rotation or with adduction o Clicking, locking
Demographics Age: Younger physically active patient Gender: M > F, due to injury during physical activity with extreme range of motion
Natural History & Prognosis Continued pain unless healing/resynovialization occurs Continued pain is indication for arthroscopic debridement Focal osteoarthritic change
Treatment Conservative o Physical therapy until healing Surgical o Arthroscopic debridement
2. 3. 4.
Amrami KK et al: Radiologic case study. Glenolabral articular disruption (GLAD) lesion. Orthopedics 25(1):29, 95-6, 2002 Grainger AJ et al: Direct MR arthrography: A review of current use. Clin Radio1 55(3):163-76,2000 Sanders TG et al: The glenolabral articular disruption lesion: MR arthrography with arthroscopic correlation. AJR 172(1):171-5,1999 Neviaser TJ: The GLAD lesion: Another cause of anterior shoulder pain. Arthroscopy 9(1):22-3, 1993
GLAD LESlON
-
Typical (Left) Axial FS PD FSE MR shows a small articular cartilage defect (arrow) with underlying reactive bone marrow edema. There is fraying at the base of the labrum. A small posterior paralabral cyst was associated with an old healed posterior tear. (Right) Axial FS PD FSE MR shows an articular cartilage defect (arrow) with adjacent torn labrum in a clinically stable patient.
Tvaical (Lefl) Axial FS PD FSE MR shows small corner fracture (arrow) of anterior glenoid with an adjacent tear of anterior labrum. Patient was stable clinically but experienced pain & a clunk with humeral rotation. Positive history of remote subluxation. (Right) Coronal PD FSE MR Shows the chondral defect (arrow).
(Lef)Axial PD FSE MR demonstrates a GLAD lesion (arrow) in this patient with a dislocated biceps tendon (open arrow) and extensive partial tearing of the subscapularis tendon. (Right) Axial FS PD FSE MR shows GLAD lesion (arrow) in addition to biceps instability (open arrow) resulting from chronic impingement and a rotator interval "hidden lesion ".
HAGL LESION -
Coronal graphic shows a tear of inferior glenohumeral ligament at its humeral attachment, consistent with a HAGL lesion (humeral avulsion of the glenohumeral ligament).
Coronal PD FSE MR shows a HAGL lesion (arrow) with the torn inferior axillary pouch retracted from its anatomic neck attachment.
Radiographic Findings Abbreviations and Synonyms Humeral avulsion of the glenohumeral ligament HAGL + humeral bone avulsion = BHAGL (bone humeral avulsion of glenohumeral ligament)
Definitions Tearinglavulsion of the inferior glenohumeral ligament (IGHL or IGL) attachment to the humerus after anterior dislocation/subluxation
General Features Best diagnostic clue o Discontinuous IGHL fibers at the humeral interface Capsule assumes '7" shape on coronal images (normal axillary pouch has a U-shaped contour) o + Surrounding edemalhemorrhage seen best on coronal PDIT2 images Location: Humeral avulsion of the inferior glenohumeral ligament attachment site Size: Varies from a partial tear in capsule to large avulsion Morphology: Varies from discrete tear to edematous markedly irregular tear
Radiography o +I-Bankart fracture (anterior inferior glenoid fracture) o +/- Hill-Sachs deformity (posterolateral humeral head impaction) o +I-Avulsion of bone fragment of humeral necklhead = BHAGL
CT Findings NECT o +/- Bankart fracture (anterior inferior glenoid fracture) o +/- Hill-Sachs deformity - posterolateral humeral head impaction fracture CT arthrography o Extravasation of contrast through humeral interface defect into anterior parahumeral soft tissues
MR Findings TlWI o Decreased signal intensity at humeral interface of capsule o +/- Fat signal within bone fragment (marrow) T2WI o Discontinuous capsule at the humeral interface anatomic neck attachment of IGL (inferior glenohumeral ligament)
mLaumD DDx: HAGL Lesion Adhes Capsulitis
Adhm Capsulitis
Cor FS PD FSE
Ax FS PD FSE
Ax FS PD FSE
Cor PD FSE MR
Cor PD FSE MR
HAGL LESION Key Facts Terminology
Synovitis Reverse HAGL
TearingJavulsionof the inferior glenohumeral ligament (IGHL or IGL) attachment to the humerus after anterior dislocation/subluxation
Pathology Humeral avulsion of the inferior glenohumeral ligament Torn capsule at the humeral attachment
Imaging Findings Discontinuous IGHL fibers at the humeral interface Capsule assumes "J" shape on coronal images (normal axillary pouch has a U-shaped contour)
Clinical Issues Most common signs/syrnptoms: Patient with recent anterior shoulder dislocation complaining of continued pain, with apprehension
Top Differential Diagnoses Midcapsular Disruption (IGL Tear) Bankart Lesion Perthes Lesion ALPSA Lesion Adhesive Capsulitis (Adhes Capsulitis) Subscapularis Tear
Diagnostic Checklist High index of suspicion for capsular damage after anterior dislocation of the shoulder
o Edema and hemorrhage at humeral interface on
axial T2 images Hyperintensity o +/- Hill-Sachs lesion Hyperintense edema associated with fx +/- Depression or flattening posterolateral humeral head o Hyperintense supraspinatus tearslstrains Fluid signal intensity filled gap (hyperintense) PDJIntermediate o High resolution images show discontinuous capsule o PD FSE sensitive to scarring of axillary pouch while FS PD FSE is sensitive to edema in acute stretching injuries or tears T2* GRE: Hemorrhage in chronic cases may "bloom" MR arthrography o Extravasation of contrast through tear Contrast inferior to axillary pouch
Imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE, PD FSE coronal and axial images
1 DIFFERENTIAL DIAGNOSIS I
Midcapsular Disruption (IGL Tear) Axillary pouch sprain Status post anterior dislocation/subluxation ~iscon~inuou capsule s o Axillary pouch/IGHL o Normally decreased in signal intensity Hyperintense on T2WI 113 lesions seen in cadaveric study on anterior dislocation lesions
Bankart Lesion Difficult to asses exact location of IGL in cases of extensive labral capsular trauma Most common lesion after anterior dislocation < 40 years old Periosteal disruption
+I-Bankart fracture o +/- Glenoid deficiency +/- Hill-Sachs lesion Labrum often fragmented +/- Anterior distraction/displacement of labrum
Perthes Lesion Intact periosteum Abduction with external rotation (ABER) imaging helpful A type of Bankart variant +/- Bankart fracture +/- Hill-Sachs lesion
ALPSA Lesion Medial displacement A type of Bankart variant +/- Bankart fracture +/- Hill-Sachs lesion ABER imaging helpful
Adhesive Capsulitis (Adhes Capsulitis)
d
Thickened edematous capsule Hyperintense capsule on T2WI Frozen shoulder +/- Secondary to primary cause (e.g., rotator cuff disease)
Subscapularis Tear Status post anterior dislocation o > 40 years old o +/- Bankart fracture o +/- Hill-Sachs lesion Posterior dislocation o +/- History of tonic-clonic seizure o Forward fall onto adducted and internally rotated shoulder Discontinuous decreased signal subscapularis tendon with interposed hyperintensity on T2WI Hyperintense on T2WI (esp. FS PD FSE) - surrounding edema
Synovitis Multiple causes
HAGL LESION +/- Osteoarthritis (OA) Thickened synovium Intermediate signal synovium on FS PD FSE Fluid is hyperintense on FS PD FSE Synovitis frequently seen in axillary pouch
Presentation Most common signs/symptoms: Patient with recent anterior shoulder dislocation complaining of continued pain, with apprehension Clinical profile: Positive apprehension test in patients with recurrent instability
Reverse HAGL Avulsion of posterior shoulder stabilizers +/- Teres minor tears Hyperintense edema at injury site on T2WI
Demographics Age: Adults Gender: M > F
1 PATHOLOGY
Natural History & Prognosis
General Features General path comments o Humeral avulsion of the inferior glenohumeral ligament o Unusual compared to classic Bankart lesion after anterior dislocation o May be associated with small bone fragment from humerus = BHAGL lesion Etiology: Anterior shoulder dislocation or severe subluxation Epidemiology o Anterior shoulder dislocation = 50% of all joint dislocations o Cadaveric study showed - 30% of experimental dislocations are associated with HAGL + subscapularis tendon tears o Isolated HAGL lesions uncommon Associated abnormalities o Tears of the rotator interval may lead to continued instability o Hill-Sachs fracture of posterosuperior humeral head o Partial or complete rotator cuff tears post anterior dislocation o Biceps tendonlanchor lesions in 12% of patients post anterior dislocation o Brachial plexus injuries, posterior glenoid labral tear in up to 11%of patients post anterior dislocation
Recurrent instability in selected cases +I- Healing with conservative treatment
Treatment Conservative treatment in selected cases o Small tears with surrounding hemorrhage allowing fibrinogenidhealing factors to accomplish healing o Physical therapy Surgical or arthroscopic repair if continued instability Need angled arthroscope for adequate visualization
Consider Associated Bankart lesion, rotator cuff tear, Hill-Sachs lesion
Image Interpretation Pearls Coronal and axial images helpful High index of suspicion for capsular damage after anterior dislocation of the shoulder Abnormal morphology of axillary pouch of IGL with '7" shaped configuration on coronal images
-
Gross Pathologic & Surgical Features Torn capsule at the humeral attachment Angled scope is often needed to visualize the defect
Microscopic Features Torn glenohumeral capsule + Variable amounts of hemorrhage + Inflammatory cells
Staging, Grading or Classification Criteria IGL labral complex (IGLLC) lesions o Bankart lesion = avulsion of IGLLC from the glenoid rim Labral avulsion Labral avulsion + anterior inferior glenoid rim fracture o Axillary pouch sprain = IGL complex tears at its mid portion o HAGL - IGL complex tears from its humeral insertion
Bokor DJ et al: Anterior instability of the glenohumeral joint with humeral avulsion of the glenohumeral ligament. A review of 41 cases. J Bone Joint Surg Br 81(1):93-6, 1999 2. Stoller DW et al: The Shoulder. Magnetic resonance imaging in orthopaedics and sports medicine. vol 1. 2nd ed. Philadelphia PA, J.B. Lippincott, 597-742, 1997 3. Beltran J et al: Glenohumeral instability: Evaluation with MR arthrography. Radiographics 17(3):657-73, 1997 4. Tirman PF et al: A practical approach to imaging of the shoulder with emphasis on MR imaging. Orthop Clin North Am 28(4):483-515, 1997 5. Tirman PF et al: Humeral avulsion of the anterior shoulder stabilizing structures after anterior shoulder dislocation: Demonstration by MRI and MR arthrography. Skeletal Radio1 25(8):743-8, 1996 6. Wolf EM et al: Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 11(5):600-7, 1995 1.
HAGL LESION
1 IMAGE GALLERY (Left) Coronal graphic shows HACL lesion with tearing of the axillary pouch and extension into the mid inferior glenohumeral ligament. (Right) Coronal STlR MR shows a HACL lesion (arrow) with the inferior capsule forming a "1" shape. The residual capsule is markedly edematous.
Typical
Typical
(Lej?) Sagittal T2 FSE MR shows a HACL lesion (arrow) with retraction and edema of the inferior capsule (ICL). (Right) Axial FS PD FSE MR in a patient with a proven HACL lesion. The inferior capsule is distorted and hyperintense (arrow).
(Lef)Coronal FS PD FSE MR shows a partial tear of the capsule attachment to the humerus (arrow), consistent with a HACL lesion without retraction. (Right) Coronal STlR MR shows a blow out of the inferior capsule (arrow) which was described as a HACL lesion at surgery. This is indistinguishable from a mid capsular rupture in this image.
ICL TEARS
Coronal graphic shows a tear through the mid portion of the inferior glenohumeral ligament.
Coronal PD FSE MR shows a tear (arrow) of the mid aspect of the inferior glenohumeral ligament seen as distortion and disorganization of the ligament.
o +/- Hill-Sachs deformity (posterolateral humeral
head impaction)
Abbreviations and Synonyms
CT Findings
Inferior glenohumeral ligament (IGL) tears, IGL disruption
Definitions Ligament substance tears of IGL after anterior dislocation/severe subluxation (excluding Bankart and HAGL lesions)
I IMAGING FINDINGS General Features Best diagnostic clue: Discontinuous fibers of mid IGL (within the substance) on coronal images with surrounding edemalhemorrhage Location: Axillary pouch component of IGL Size: Varies from intrasubstance stretch injury to large tear Morphology: From discrete tear to diffuse edematous ligament
Radiographic Findings
CT arthrography o Coronal reformatting o Extravasation of contrast material through the capsular tear o Single or double contrast (air)
M R Findings TlWI o Axillary pouch signal change from hypointense to intermediate o Axillary pouch IGL thickening o Increased laxity of IGL on coronal images T2WI o Hyperintense edema of thickened axillary pouch (coronal) on FS PD FSE o Edema (without impaction fx) or cystic change in posterolateral humeral head (same location as Hill-Sachs lesion) o +/- Associated Hill-SachsIBankart lesions o Chronic IGL scarring demonstrated with increased sensitivity on PD FSE as intermediate signal intensity o IGL edema may be asymmetric toward humeral or glenoid attachment site of axillary pouch o Associated hyperintense supraspinatus strainsltears
mDSulqm
Radiography o +/- Bankart fracture (anterior inferior glenoid fracture)
DDx: IGL Tears
7-
-_ Cor FS P D FSE
Cor FS P D FSE
Ax FS PDFSE MR
Ax FS P D FSE MR
-
\
Sag T2 FSE MR
IGL TEARS Key Facts Imaging Findings Best diagnostic clue: Discontinuous fibers of mid IGL (within the substance) on coronal images with surrounding edemalhemorrhage ~xtravasationof contrast material through the capsular tear (extends inferior to axillary pouch)
Top Differential Diagnoses Bankart Lesion Humeral Avulsion of Inferior Glenohumeral Linament (HAGL) Lesion capsular Sprain without Disruption Subscapularis Tear (Subscap. Tear) Adhesive Capsulitis (Adhes Capsulitis)
Fluid signal intensity filled gap o A GAGL (glenoid avulsion of glenohumeral
ligament) lesion represents a tear of the axillary pouch (IGL) attachment to glenoid rim without avulsion of anterior inferior or inferior labrum Hyperintense fluid signal or intermediate signal fibrosis between IGL and anterior inferior, inferior labrum or posteroinferior labrum MR arthrography o Extravasation of contrast material through the capsular tear (extends inferior to axillary pouch) o Sensitive in chronic cases where edemalhemorrhage is absent
Imaging Recommendations Best imaging tool o MRI and MR arthrography MR arthrography in chronic cases Protocol advice: FS PD FSE and PD FSE in coronal and axial planes
Bankart Lesion Anterior dislocation o IGL labral complex failure from glenoid rim < 40 years old Periosteal disruption +/- Bankart fracture o +/- Glenoid deficiency +/- Hill-Sachs lesion Labrum fragmented or avulsed o +/- Anterior distraction/displacement of labrum
Humeral Avulsion of Inferior Glenohumeral Ligament (HAGL) Lesion Tear of IGHL at humeral interface +/- Bankart fracture +/- Hill-Sachs lesion Mimics IGL tear 113 of lesions associated with subscapularis tears
Pathology General path comments: Mid ligament tear of the IGL less common than Bankart lesion and more common than HAGL
Clinical Issues Most common signs/symptoms: Patient with recent anterior shoulder dislocation presenting with joint pain, +/- instability Clinical profile: Positive apprehension test in patients with recurrent instability
Diagnostic Checklist Associated Bankart lesion, RTC tear, Hill-Sachs lesion Use PD FSE & FS PD FSE coronal images to evaluate morphology and signal changes in axillary pouch of IGL
Capsular Sprain without Disruption Thickened edematous capsule with ligament failure Hyperintense on T2WI Mimics adhesive capsulitis +/- Bankart lesion +/- Hill-Sachs lesion
Subscapularis Tear (Subscap. Tear) Status post anterior dislocation o > 40 years old o +/- Bankart fracture o +/- Hill-Sachs lesion Posterior dislocation o +/- History of tonic-clonic seizure o Forward fall onto adducted internally rotated shoulder Discontinuous decreased signal subscapularis tendon with interposed hyperintensity on T2WI
Adhesive Capsulitis (Adhes Capsulitis) Thickened edematous capsule Hyperintense capsule on T2WI Frozen shoulder o Primary (idiopathic) o Secondary (e.g., diabetes, humerus fx, rotator cuff tendinosisltears)
PATHOLOGY General Features General path comments: Mid ligament tear of the IGL less common than Bankart lesion and more common than HAGL Etiology: Anterior shoulder dislocation or external rotation abduction injury Epidemiology o 50% of all joint dislocations o Cadaveric study showed - 35% of experimental dislocations of the shoulder involved mid ligament Primarily older age group o Isolated HAGL lesions uncommon Associated abnormalities
IGL TEARS o Tears of the rotator interval o Hill-Sachs fracture of posterosuperior humeral head o Partial or complete rotator cuff tears after anterior
Image Interpretation Pearls Use PD FSE & FS PD FSE coronal images to evaluate morphology and signal changes in axillary pouch of IGL
dislocation o Biceps tendonlanchor lesions in - 12% of patients after anterior dislocation o Brachial plexus injuries, posterior glenoid labral tear in up to 11%of patients after anterior dislocation
Gross Pathologic & Surgical Features liO
Torn capsule at its mid portion Angled scope to visualize the defect Torn glenohumeral capsule with variable amounts of hemorrhage
1. 2. 3.
Microscopic Features Normal IGL complex o Three layers of collagen fibers from glenoid to humerus + circumferential orientation o Normal IGL complex thicker adjacent to glenoid compared to humerus o Biomechanical failure including ligament lengthening when stretching forces exceed tensile properties of IGL
Staging, Grading or Classification Criteria IGL injuries o Bankart - IGL labral avulsion from glenoid rim o Mid ligament GAGL - IGL tear without labral avulsion o HAGL - humeral avulsion of glenohumeral ligament
Presentation Most common signslsymptoms: Patient with recent anterior shoulder dislocation presenting with joint pain, +/- instability Clinical profile: Positive apprehension test in patients with recurrent instability
Demographics Age: 2 40 years of age Gender: M > F
Natural History & Prognosis May heal with conservative treatment Recurrent instability in some cases
Treatment Conservative especially where instability is not clinically apparent o Small tears with surrounding hemorrhage allowing fibrinogeniclhealing factors to accomplish healing o Physical therapy Surgical or arthroscopic repair if continued instability Angled arthroscope for adequate visualization in some cases
1 DIAGNOSTIC CHECKLIST Consider Associated Bankart lesion, RTC tear, Hill-Sachs lesion
4.
Neviaser RJ et al: Concurrent rupture of the rotator cuff and anterior dislocation of the shoulder in the older patient. J Bone Joint Surg Am 70(9):1308-11, 1998 Tirman PF et al: A practical approach to imaging of the shoulder with emphasis on MR imaging, Orthop Clin North Am 28(4):483-515, 1997 Beltran J et al: Glenohumeral instability: Evaluation with MR arthrography. Radiographics 17(3):657-73, 1997 Tirman PF et al: Humeral avulsion of the anterior shoulder stabilizing structures after anterior shoulder dislocation: Demonstration by MRI and MR arthrography. Skeletal Radio1 25(8):743-8, 1996
IGL TEARS
1 IMAGE GALLERY
1 (Left) Coronal FS PD FSE MR shows a discrete tear of the inferior glenohumeral ligament (arrow) adjacent to the inferior labrum (GAGL lesion). This was a proven inferior glenohumeral ligament tear. (Right) Coronal FS PD FSE MR shows inferior glenohumeral tear involving the entire axillary pouch. There is ligament thickening, edema and disruption (arrow).
(Lef)Axial FS PD FSE MR shows an inferior glenohumeral ligament sprain (arrow) after anterior dislocation. (Right) Axial FS PD FSE MR shows an inferior glenohumeral sprain with thickening of IGL (arrow) after a Bankart repair.
(Left) Axial PD FSE MR shows a sprain (arrow) of the inferior capsule in a patient after anterior dislocation. (Right) Coronal T2 FSE MR shows disruption (arrow) of the mid portion of the inferior glenohumeral ligament after anterior dislocation.
BENNETT LESION
Coronal graphic shows heterotopic ossification posterior to posterior aspect of shoulder joint associated with capsular inflammatory changes and fibrosis.
Coronal PD FSE MR shows identical findings with graphic: Heterotopic ossification (arrow) posterior to the glenohumeral joint with thickening of the posterior capsule.
Short TE sequences = TlWI, PDIIntermediate WI, T2* GRE WI o +/- Thickened, scarred posterior capsule
Abbreviations and Synonyms Bennett lesion (BL)
Radiographic Findings
Definitions Extraarticular, posterior ossification associated with posterior labral injury and posterior articular surface cuff pathology in throwing athletes
Radiography o Mineralization adjacent to posterior glenoid on axillary view o Subchondral sclerosis - posterior glenoid o Subchondral lucencies representing cysts
CT Findings General Features Best diagnostic clue o Globular hypointense ossification on T1 & T2WI o Adjacent to torn or degenerated posterior labrum Location: Soft tissues adjacent to posterior/posteroinferior glenoid rim Size o Ossification several mms to > 1 cm o Labral tear focal to extensive Morphology o Ossification is crescentic o +/- Fragmentation o Labral tear is irregular and increased in signal on short TE sequences
)
NECT o Ossification adjacent to posterior glenoid o Subchondral posterior glenoid rim sclerosis o Subchondral glenoid rim cysts CT arthrography o +/- Posterior labral tear with contrast extending into tear
MR Findings TlWI o Decreased signal intensity, globular to crescent-like ossification within posterior soft tissues o Subchondral decreased signal, sclerosis common o +/- Subchondral rounded hypointensity cysts T2WI o Hypointense crescent-shaped area of ossification posteroinferior glenoid rim
DDx: Bennett Lesion Post. Labr. Tear
Port Caps. Tear
A<,1
I
A'
A
* I
Ax FS PD FSE MR
Ax
-
+
.-A
I
SE MR
Ax T I Arthro
Cor FS PD FSE
Ax FS PD FSE MR
BENNETT LESION
I
Key Facts Imaging Findings Globular hypointense ossification on T1 & T2WI Location: Soft tissues adjacent to posterior/posteroinferior glenoid rim Ossification several mms to > 1cm Ossification adjacent to posterior glenoid Decreased signal intensity, globular to crescent-like ossification within posterior soft tissues T2* GRE: Calcium may "bloom",thus increasing sensitivity due to susceptibility
Top Differential Diagnoses Posterior Labral Tear Posterosuperior Glenoid Impingement (PSGI) Posterior Capsular Tear (Post. Caps Tear)
I At insertion of posterior joint capsule Hypointense thickening of posterior capsule Associated hyperintense joint effusion Ossification (or calcification) may be segmental 01 uninterrupted o +/- Adjacent chondromalacia Increased signal intensity within the hyaline articular cartilage +/- Surface irregularity, ulceration, defect o FS PD FSE Edema and hemorrhage in surrounding soft tissues: Increased signal Labrum may be discretely torn or markedly heterogeneous Hypointense ossification may blend in with capsule Detection of chondral degeneration T2* GRE: Calcium may "bloom",thus increasing sensitivity due to susceptibility MR arthrography o Associated with posterior labral tear with contrast extending into tear
o o o o
Nuclear Medicine Findings Bone Scan: Increased uptake if posterior glenoid rim is remodeledldamaged
lmaging Recommendations Best imaging tool: MRI for posterior labrum and articular sided cuff lesions Protocol advice o PD, FS PD FSE/T2 WI + T2* GRE o MR arthrography
(DIFFERENTIALDIAGNOSIS Posterior Labral Tear Increased signal intensity on short TE sequences Status post posterior dislocation/subluxation +/- Distraction of labrum +/- Bony glenoid rim fracture o + Reverse Bankart
Scapular Fracture, Scapular Stress Fracture (Scap Stress Fx) Calcific
Pathology Extraarticular posterior ossification associated with posterior labral injury Dystrophic/heterotopic ossification
Clinical issues Posterior shoulder pain especially with throwing activities
Diagnostic Checklist PD, T2* GRE to identify images calcification or ossification CT confirmation for bone detail
+/- Lesser tuberosity fracture o = Reverse Hill-Sachs POLPSA (posterior labrocapsular periosteal sleeve avulsion) o Medial displacement of posterior capsule, labrum and posterior scapular periosteum
Posterosuperior Glenoid Impingement (PSG I) Throwing athletes Internal impingement Impingement of undersurface of posterior supraspinatus o Humeral head o Posterosuperior labrum Triad of findings o Partial tear of undersurface posterior supraspinatus/anterior infraspinatus +/- Complete tear o Posterosuperior labral degenerationhearing o Humeral head posterosuperior subcortical cystic changes
Posterior Capsular Tear (Post. Caps Tear) Posterior band of inferior glenohumeral ligament +/- Associated IGL (inferior glenohumeral ligament) tear at glenoid, humeral neck or axillary pouch segments Status post posterior dislocation/subluxation MR arthrography helpful
Scapular Fracture, Scapular Stress Fracture (Scap Stress Fx) Status post excessive throwing activity Baseball athletes Abnormal forces on normal bone +/- Decreased signal intensity callus/fracture line on all pulse sequences * +/- Increased signal intensity edema on T2WI especially FS PD FSE
BENNETT LESION
I
Calcific Calcium hydroxyapatite deposition in rotator cuff tendons o Hypointense hydroxyapatite deposits on T1 & T2W1 May fragment Silent phase (subclinical):Limited to tendons Mechanical phase (clinical):+/- Subbursal and intrabursal rupture Hyperintense inflammatory fluid (T2WI)
Natural History & Prognosis Pain may subside with cessation of throwing Arthroscopic debridement of posterior labral tear
Treatment Conservative: Physical therapy, NSAIDs Surgical: Arthroscopic debridement of soft tissue ossification
Consider General Features General path comments o Extraarticular posterior ossification associated with posterior labral injury o Dystrophic/heterotopic ossification Etiology o Posterior capsular avulsion secondary to traction from the posterior band of the IGHL o Deceleration phase of pitching Posterior subluxation during cocking of the arm o Described by Edward Bennett 1837-1907 (Irish surgeon) Originally thought to be secondary to traction injury of the long head of the triceps brachii Epidemiology o Posterior capsule - 36% of posterior shoulder instability o Posterior labral injuries - 86% of posterior shoulder instability Associated abnormalities: Posterosuperior glenoid impingement
Gross Pathologic & Surgical Features Posterior labrum degenerationhearing with surrounding hemorrhage Dystrophic/heterotopic calcification or ossification Associated posterior articular surface rotator cuff tear
Microscopic Features Hemorrhagic, torn, fibrocartilaginous posterior labrum with variable degrees of fibrosis depending on chronicity Ossification or calcification within variable degrees of soft tissue fibrosis +/- inflammatory cells
Presentation Most common signs/syrnptoms o Posterior shoulder pain especially with throwing activities o Tenderness at posterior inferior glenoid region Clinical profile o Young athlete o Common in baseball players
Demographics Age: Adolescent/young adult Gender: M > F
Posterior labral tearlinstability
Image Interpretation Pearls PD, T2* GRE to identify images calcification or ossification CT confirmation for bone detail
1 SELECTEDREFERENCES 1. Miniaci A et al: Magnetic resonance imaging of the shoulder in asymptomatic professional baseball pitchers. Am J Sports Med 30(1):66-73, 2002 2. Yoneda M et al: Arthroscopic removal of symptomatic Bennett lesions in the shoulders of baseball players. Arthroscopic Bennett-plasty. Am J Sports Med 30(5):728-36,2002 3. Yu JS et al: The POLPSA lesion: MR imaging findings with arthroscopic correlation in patients with posterior instability. Skeletal Radiol 31(7):396-9, 2002 4. Grainger AJ et al: Direct MR arthrography. A review of current use. Clin Radiol 55(3):163-76, 2000 5. De Maeseneer M et al: The Bennett lesion of the shoulder. J Comput Assist Tomogr 22(1):31-4, 1998 6. Tirman PF et al: A practical approach to imaging of the shoulder with emphasis on MR imaging. Orthop Clin North Am 28(4):483-515, 1997 7. Ferrari JD et al: Posterior ossification of the shoulder: The Bennett lesion. Etiology, diagnosis, and treatment. Am J Sports Med 22(2):171-5; discussion 175-6, 1994
BENNETT LESlON
( L ~ f tSagittal ) PD FSE MR shows heterotopic ossification (arrow) posterior to the joint in a professional baseball pitcher, consistent with a Bennett lesion. (Right) Coronal FS PD FSE MR shows the irregular ossification adjacent to the posteroinferior glenoid. The pa tient was a professional baseball pitcher.
Tvaical
(Left)Axial NECT shows ossification (arrow) posterior to the joint in a throwing athlete consistent with a Bennett lesion. (Right) Axial T2" CRE MR shows heterotopic ossification (arrow) in a baseball pitcher. The posterior labrum was torn.
Tvaical (Left) Axial NECT shows ossification posterior to the joint in a throwing athlete. (Right) Axial T2* CRE MR shows hypointense, heterotopic ossification (arrow) in a baseball pitcher posterior to the posteroinferior glenoid.
POSTERIOR LABRAL TEAR, SHOULDER
Axial graphic shows a tear at the base of the avulsed posterior labrum.
Abbreviations and Synonyms
Axial FS PD FSE MR shows a hyperintense tear (arrow) at the base of the posterior labrurn with mild posterior displacement after posterior dislocation.
0
Reverse Bankart (RB), posterior band inferior glenohumeral ligament (PBIGHL)
. ..
Deep reverse Hill-Sachs lesion appearing as a "trough"of the anterior humerus Lesser tuberosity avulsion Subscapularis intact +/- History of seizures
CT Findings
Definitions Posterior labral/capsular/glenoid rim injury secondary to posterior dislocation/subluxation
General Features Best diagnostic clue: Tornldetached posterior glenohumeral ligament/labrum from underlying glenoid, +/- fracture of glenoid Location: Posterior glenoid/labrum extending for variable distance anteriorly/inferiorly/superiorly Size: Discrete tear to large complete avulsion Morphology: Varies from discrete to irregular edematous tear
Radiographic Findings Radiography o +/- Posterior glenoid rim fracture with variable amount of displacement/comminution o Trough sign
NECT o +/- Glenoid rim fracture with variable amount of displacement/comminution o Trough sign Reverse Hill-Sachs lesion of the anterior humerus creating an anterior defect or "trough" Coronal/sagittal reconstruction o Lesser tuberosity avulsion fracture Subscapularis attached to bone History of seizures common 0 +/- Glenoid version - hypoplasia CT arthrography o Contrast extending into posterior labral tear
. .
MR Findings TlWI 0 Increased signal tear in substance of labrum 0 +/- Fracture of the underlying glenoid: Reverse Bankart Hypointense fracture line Hypointense surrounding edema
.
DDx: Posterior Labral Tear, Shoulder Reverse HAG1
Ax T l Arthro.
Ax FS PD,FSE MR
Sag FS PD FSE
Glenold Version
Vascularrtv
Ax PD FSE
Ax FS PD FSE MR
'
POSTERIOR LABRAL TEAR, SHOULDER Key Facts Imaging Findings Best diagnostic clue: Tornldetached posterior glenohumeral ligamentllabrum from underlying glenoid, +/- fracture of glenoid
Top Differential Diagnoses Bennett Lesion Humeral Fracture Teres Minor Avulsion/Reverse HAGL Glenoid Version (Retroversion) Normal Vascularity/Anatomy
Pathology Posterior band of IGHLC "weak link" static stabilizer in most shoulders Posterior force on flexed, adducted internally rotated shoulder at risk Avulsion of lesser tuberosity fragment hyperintense - (contains bone marrow) T2WI o +/- Accompanied by a fracture of underlying glenoid Reverse Bankart: Increased signal intensity edema with visible fracture line, +/- distraction o FS PD FSE Sensitive for marrow edema in reverse Hill-Sachs and reverse Bankart lesions Linear hyperintense fluid often visualized underneath labral attachment to glenoid rim in posterosuperior or posteroinferior quadrant on sagittal images o Avulsion of lesser tuberosity fragment +/- Subscapularis tear or partial tear Hyperintense edemalfluid in tear Interrupted fibers o +/- Paralabral cyst - chronic cases Focal Dissect superiorly or inferiorly o +/- Glenoid version - hypoplasia PDIIntermediate o High resolution PD good for anatomic delineation of posterior band of inferior glenohumeral ligament complex o Increased signal tear within labrum MR arthrography o Contrast extending through posterior labral tear o Redundancy of posterior capsule and IGL stretching Labrum focally torn or with multiple linear tears and/or diffuse signal intensity o Axial images Chronic lesion partially healed and fibrosed o Heterogeneous but predominantly decreased signal intensity on all pulse sequences
Epidemiology: 2-12% shoulder dislocations are posterior and result in posterior labral tear
Clinical Issues Pain after trauma Pain with activities that require flexion, adduction, and internal rotation Recurrent posterior subluxation more common than dislocation
Diagnostic Checklist Requires high index of suspicion identify labral tear, anterior humerus (lesser tuberosity) bone edema Indicators of posterior dislocation/subluxation
I DIFFERENTIAL DIAGNOSIS Bennett Lesion Ossification adjacent to posterior labrum/glenoid injury Throwing athlete Baseball players Posterior contractures common
Humeral Fracture Distal to lesser tuberosity fracture indicating different mechanism Anatomic/surgical neck o +/- Comminution, distraction Radiographs/CT/MRI diagnostic
Teres Minor Avulsion/Reverse HAGL Results from posterior dislocation Avulsion from humerus Forced external rotation on internally rotated shoulder Direct trauma on anterior joint
Glenoid Version (Retroversion) Posteriorly angulated glenoid Congenitally small posterior glenoid (hypoplasia) Compensatory hypertrophy of hyaline cartilage to stabilize posterior glenoid Predisposes to posterior instability
Normal Vascularity/Anatomy Vessels may be found in and around posterior inferior labrum Capsule may fold, mimicking labral abnormality o Especially in external rotation
Nuclear Medicine Findings Bone Scan: Increased uptake with reverse Bankart fracture
Imaging Recommendations Best imaging tool: MRI, consider MR arthrography Protocol advice: FS PD FSE axial, coronal and sagittal
1
General Features General path comments o Posterior band of IGHLC "weak link" static stabilizer in most shoulders o Injured after dislocation
POSTERIOR LABRAL TEAR, SHOULDER o Avulsion of posterior band IGHL +/- teres minor
insertion = reverse HAGL lesion Etiology o Posterior force on flexed, adducted internally rotated shoulder at risk o Tonic-clonic seizure resulting in decerebrate rigidity + fall onto anterior shoulder +/- Posterior dislocation o Dislocation can occur after major injury, repetitive minor trauma, and atraumatic processes Epidemiology: 2-12% shoulder dislocations are posterior and result in posterior labral tear Associated abnormalities o Lesser tuberosity humeral avulsion fracture o Reverse Bankart fracture of posterior glenoid rim o Reverse Hill-Sachs fracture (impaction) of anterior humerus (lesser tuberosity) o +/- Subscapularis and teres minor tears o Predisposing bony anatomy for posterior dislocation includes Increased humeral retroversion Glenoid retroversion (version) Glenoid hypoplasia o Posterior instability associated with labral tears Capsular laxity Rotator interval (coracohumeral and superior glenohumeral ligaments) laxity/incompetence Superior glenohumeral ligament tear o Microinstability with posterosuperior labral tears as a subtype of SLAP I1 Posterior peelback lesion includes the posterior labral component of a SLAP I1 + partial articular surface tear of the posterior cuff (between the supraspinatus and infraspinatus) Abnormal obligate translation as a result of posterior capsular contracture elevating humeral head as external rotation occurs Seen in overhand throwing (late cocking phase)
Gross Pathologic & Surgical Features Avulsion of the inferior glenohumeral labral ligamentous attachment to the glenoid Posterior labrocapsular periosteal sleeve avulsion (POLPSA) with posterior capsular stripping of the labrum
Microscopic Features Hemorrhagic, torn, fibrocartilaginous labrum with variable degrees of fibrosis depending on chronicity
Swimming (pull through) Rowing
Demographics Age: Typically younger patient Gender: M > F in athletics; seizures M = F
Natural History & Prognosis Pain and dysfunction may be insidious May resolve with conservative therapy Recurrence with atraumatic and traumatic posterior dislocations with humeral and glenoid osseous defects o Recurrent posterior subluxation more common than dislocation Often requires surgery
Treatment Conservative treatment if associated with posterior dislocation: Attempt closed reduction Non dislocation: Physical therapy aimed at strengthening, NSAIDs Surgical: Correcting anatomic deformities, repair of labrum/capsule
/ DIAGNOSTIC CHECKLIST Consider Isolated muscle damage, Bennett lesion
Image Interpretation Pearls Requires high index of suspicion Identify posterior labral tear, anterior humerus (lesser tuberosity) bone edema o Indicators of posterior dislocation/subluxation
1 SELECTED REFERENCES 1. 2. 3. 4. 5. 6. 7.
Presentation Most common signs/symptoms o Pain after trauma o Pain with activities that require flexion, adduction, and internal rotation Clinical profile o Difficulty in performing activities of daily living, including hair combing, shaving, and eating o Patients describing pain with Throwing (follow through) Bench press (lock out)
Wolf EM et al: Arthroscopic capsular plication for posterior shoulder instability. Arthroscopy 14(2):153-63, 1998 Tirman PF et al: A practical approach to imaging of the shoulder with emphasis on MR imaging. Orthop Clin North Am 28(4):483-515, 1997 Pollock RG et al: Recurrent posterior shoulder instability. Diagnosis and treatment. Clin Orthop (291):85-96, 1993 Matsen FA et al: Glenohumeral instability. The Shoulder. Philadeplphia PA, WB Saunders, 26-622, 1990 Neer CS: Fractures and dislocation of the shouldecFractures. Philadelphia PA, JB Lippincott, 686-7, 1975 Scott DJ Jr: Treatment of recurrent posterior dislocations of the shoulder by glenoplasty. Report of three cases. J Bone Joint Surg Am 49(3):471-6, 1967 Wilson JC et al: Traumatic posterior (retroglenoid) dislocation of the hyumerus. J Bone Joint Surg 31(A):160-72,1949
POSTERIOR LABRAL TEAR, SHOULDER
Typical (Lef)Axial FS PD FSE MR shows a reverse Bankart lesion (open arrow) and an anterior (reverse) Hill-Sachs bone trabecular injury (arrow). (Right) Axial FS PD FSE MR shows a reverse Bankart lesion (arrow) and a reverse Hill-Sachs lesion. Note the flattening of the posterior glenoid rim.
(Left)Axial FS PD FSE MR shows an avulsion of the teres minor muscle and the capsule from the humerus (arrow) indicating reverse HAG L lesion. (Right) Coronal FS PD FSE MR shows a reverse HAGL lesion (arrow).
(Lef)Sagittal graphic shows a posterior labral tear after a posterior dislocation. (Right) Sagittal FS PD FSE MR shows a posterior labral tear (arrow) with fluid signal between the labrum and glenoid rim.
HIDDEN LESION, SHOULDER
Coronal graphic shows subluxation of the biceps tendon medially indicating biceps instability - a hallmark of the hidden lesion.
Definitions Superolateral region of rotator interval receives insertions from o Superior glenohumeral ligament (SGHL) o Coracohumeral ligament (CHL) o Subscapularis tendon Hidden (difficult to visualize at arthroscopy) rotator interval lesions = lesions of SGHLICHL complex
General Features Best diagnostic clue 0 Subluxation or dislocation of long head biceps tendon (LHBT) from the superior aspect of bicipital groove Distal subscapularis tearing o Tear of SGHLICHL complex Location: Lateral aspect of the rotator interval (RI), medial wall of the bicipital sheath Size o Range Lax SGHLICHL complex; small tear +/- Additional involvement of the subscapularis tendon insertion
I
I
Coronal PD FSE MR shows biceps subluxation from the superior aspect of the bicipital groove (biceps instability).
Morphology o Irregular thickened SGHLIMCHL complex (lax) to frank tear +/- subscapularis o Subscapularis tear, +/- SGHL/CHL complex
Radiographic Findings Radiography 0 Lesser tuberosity cystic degenerative changes +/- Clinical subcoracoid impingement o Secondary findings associated with subacromial impingement - predisposing factor Acromial spurs Type I11 acromion (hooked) Humeral head (HH) subcortical greater tuberosity cysts Superior HH migration - rotator cuff (RTC) full thickness tear
.
CT Findings NECT o Upper aspect of lesser tuberosity: Subcortical cystic (degenerative) changes +/- Clinical subcoracoid impingement o Secondary findings associated with subacromial impingement - predisposing 8 Use coronal & sagittal reconstruction images to visualize CT arthrography o +/- Torn labrum, cuff, biceps subluxation/dislocation
.
DDx: Hidden Lesion, Shoulder SLAC Lesion
Subcoracoid Imo.
Sf A P Svnovitis
Mirroinst~ bilitv
Cor FS PD FSE
Ax FS PD FSE MR
Cor FS PD FSE
Cor STIR MR
I
I
HIDDEN LESION, SHOULDER Kev Facts Imaging Findings Subluxation or dislocation of long head biceps tendon (LHBT) from the superior aspect of bicipital groove Location: Lateral aspect of the rotator interval (RI), medial wall of the bicipital sheath Hyperintensity within distal subscapularis tendon Increased signal intensitylfrank tear of SGHLICHL complex +/- Biceps tendinosis
Top Differential Diagnoses Microinstability Su~eriorLabrum Anterior Cuff (SLAC) Lesion gato or Interval Tear Biceps Tendinosis
MR Findings TlWI o Frayedltear of the anterior cuff, +/- intermediate signal o Anterior cuff as represented by anterior supraspinatus, subscapularis and rotator cuff interval o +/- Increased signal of biceps tendon = tendinosis o Biceps flattened if subluxed T2WI o Hyperintensity within distal subscapularis tendon +/- Small interstitial tear (hyperintense fluid synovium in gap) +/- Frank tear (hyperintense fluid synovium in gap) o Increased signal intensitylfrank tear of SGHLICHL complex Sagittal images hyperintense focus in area of the SGHLICHL complex o +/- Hyperintense tear of anterior rotator cuff with fluid signal filled gap o Subluxation/dislocation of biceps tendon o +/- Biceps tendinosis Thickening Hyperintensity o +/- Fluid filled subcoracoid bursa (hyperintense) o +/- Subchondral hyperintense cysts at lesser tuberosity Subcoracoid impingement PDIIntermediate o High resolution image Zip 5 12/interpolation o Tear of SGHLICHL complex at insertion on humeral head o Thickened/hyperintense/lax SGHL/CHL complex o +/- Subscapularis partial or complete tear Partial tear most common o +/- Supraspinatus anterior tear STIR o Less spatial resolution than FS PD FSE o SGHLICHL complex difficult to visualize MR arthrography
Biceps Tendon Rupture SLAP Lesion Subcoracoid Impingement
Pathology Superior aspect of the bicipital groove and lateral aspect of the RI Subscapularis insertion Tears of SGHLICHL complex and subscapularis
Clinical Issues Impingement pain with biceps symptoms Repair of torn structures
Diagnostic Checklist ~xTalimages for detection of biceps subluxation
o
+/- Extravasation of contrast material into subacromial bursa - complete RTC tears
o +/- Torn, thickened SGHLICHL complex
Imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE in axial and sagittal planes
Microinstability Hidden lesion is a component of microinstability Supraspinatus anterior undersurface partial tear Superior labrum/glenohumeral ligament dysfunction "Superior instability"
Superior Labrum Anterior Cuff (SLAC) ~esion +/- Microinstability Abnormal translation and chafing of cuff on glenoid rim Partial undersurface cuff tear +/- Unstable superior labrum anterior to posterior (SLAP) lesion SGHLIinterval failure
Rotator Interval Tear Rarely isolated CHL = RI roof, torn +/- Subcoracoid bursitis +/- Subcoracoid impingement Extravasation of contrast into subacromial space with arthrography o +/- Supraspinatus tear
Biceps Tendinosis +/- Impingement o Impingement most common cause Thickened intermediate to hyperintense tendon Short TE sequences sensitive for tendon degeneration o TlWI, PDIIntermediate WI, T2* GRE WI
HIDDEN LESION, SHOULDER o "Tendinosis"is preferred term over tendinitis
Biceps Tendon Rupture
RTC degenerationhear Inflammatory cells
+/- Impingement: Most common cause Fluid signal intensity fills gap o Hyperintense on T2W1, STIR, T2* GRE
SLAP Lesion
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(.)-I
Biceps anchor tear +/- LHB tendon tear Propagate - extended SLAP lesion + Speed's test (bicipital resistance test) O'Brien's test (active compression test to entrap anterosuperior labrum)
Presentation Most common signs/symptoms o Impingement pain with biceps symptoms Pain radiating down anterior arm Pain with elbow flexionlsupination Clinical profile o Impingement patient o Athletes or workers participating in overhead activities - common o Acute trauma o Associated with Bankart or Bankart variant
Subcoracoid Impingement +/- Hidden lesion +/- Anterior RTC tear +/- Subcoracoid bursitis o Bursa anterior to subscapularis tendon o Bursa lateral to subscapularis joint recess +/- Hyperintense subcortical lesser tuberosity cysts (T2) o Subcoracoid impingement
Demographics Age: > 40 years Gender: M > F
Natural History & Prognosis General Features General path comments o Superior aspect of the bicipital groove and lateral aspect of the RI o Subscapularis insertion Anterior fibers of the subscapularis merge with CHL and transverse the bicipital groove Deep fibers of subscapularis may tear without retraction of entire tendon Etiology o Lax or torn SGHL/CHL complex allows LHBT to sublux or dislocate o Subscapularis tearlpartial tear allows subluxation of LHBT Medial insertion of subscapularis may be disrupted without associated biceps instability if CHL intact laterally o The SGHLICHL complex and the insertion of the subscapularis tendon must be torn to allow medial dislocation of the biceps tendon o Tears of SGHLICHL complex and subscapularis Chronic overuse; acute trauma Epidemiology o Subscapularis tears: 47% involve the SGHLICHL complex o Incidence of SGHLICHL lesions in 165 arthroscopically treated shoulder patients: 18% Associated abnormalities: Anterior instability; impingement
Improve with cessation of repetitive overhead motion Post trauma, +/- responds to conservative therapy
Treatment Conservative o Reduce pain and inflammation (NSAIDs), restore range of motion, strengthening (physical therapy) Surgical o Repair of torn structures o Arthroscopic treatment to repair nonresponsive RTC tear
/ DIAGNOSTIC CHECKLIST Consider This lesion in setting of biceps subluxation/instability
Image Interpretation Pearls Axial images for detection of biceps subluxation Pseudosubluxation may be present above level of superior biceps groove where LHBT courses through RI Identify tears of distal subscapularis tendon on axial images
1 SELECTEDREFERENCES 1.
2.
Gross Pathologic & Surgical Features Frayed, degenerated or frankly tom structures in superolateral & anterior aspect of the joint (lateral RI) CHL is a bursa1 structure and is not visualized from the articular side at arthroscopy
Microscopic Features Collagen degeneration without influx of inflammatory cells
1
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Bennett WF: Subscapularis, medial, and lateral head coracohumeral ligament insertion anatomy: Arthroscopic appearance and incidence of "hidden" rotator interval lesions. Arthroscopy 2173-80, 2001 Bennett WF: The specificity of the speed's test. Arthroscopic evaluation of the biceps tendon at the level of the bicipital groove. Arthroscopy 14:789-96, 1998 Walch G et al: Subluxations and dislocations of the tendon of the long head of the biceps. J Shoulder Elbow Surg 7:lOO-8, 1998
HIDDEN LESION, SHOULDER IMAGE GALLERY (Left) Sagittal PD FSE MR shows an intact superior glenohumeral ligament attachment (arrow) to the humerus adjacent to the biceps tendon. (Right) Sagittal T2 FSE MR shows a torn attachment (arrow) of the distal SCHL.
( L e f ) Axial graphic shows dislocation of the biceps tendon indicating instability in the presence of a hidden lesion. (Right) Axial FS PD FSE MR shows tearing (arrow) of the distal aspect of the subscapularis tendon just below the insertion site of the SCHL. There is minimal biceps subluxation.
(Left) Axial PD FSE MR shows subluxation of the degenerated biceps because of the presence of a rotator interval hidden lesion. The partially torn subscapularis is demonstrated (arrow). (Right) Axial FS PD FSE MR shows subluxation and near-complete dislocation of the biceps tendon (arrow) indicating a hidden lesion.
BICEPS TENDlNOSlS
Coronal graphic shows an indurated, degenerated biceps tendon consistent with tendinosis.
Coronal FS PD FSE MR shows thickening and longitudinal splitting (arrow) of the biceps tendon within the bicipital groove surrounded by inflamed biceps sheath.
o Tendon torn or partially torn in advanced cases with
fluid entering defect
Abbreviations and Synonyms
Radiographic Findings
Biceps tendinitis, biceps tendon degeneration
Definitions Degeneration of the long head biceps (LHB) as a result of chronic microtrauma or acute traumatic injury
General Features Best diagnostic clue: Thickening and increased signal intensity of LHB within rotator interval (RI) or bicipital groove on FS PD FSE and PD FSE images Location o LHBT originates on the supraglenoid tubercle/superior labrum o Passes through the anterosuperior joint to enter the humeral bicipital groove Size o Thickened enlarged tendon (> 5 mm) +/- Thinned if chronically partially torn Morphology o Thickened, inhomogeneous tendon with visible surface fraying
Radiography o +/- Sclerosis of superior aspect bicipital groove Chronic cases if accompanied by biceps instability o +/- Small associated subchondral cysts in chronic cases on either side of bicipital groove = degenerative change o +/- Acromial remodeling/sclerosis o +/- Acromial spurs (impingement) o Humeral head subchondral sclerosis/cysts
CT Findings NECT o Acromial spurs (impingement) o Acromial remodeling/sclerosis o Sagittal reconstruction CT arthrography o Thickened tendon - tendinosis o Small irregular tendon in RI or groove if frayed/partially torn
M R Findings TlWI o Thickened intermediate signal intensity tendon
tendinosis
DDx: Biceps Tendinosis Magic An
Typc I1 BLC
Cor PO FSE MR
Cor FS PO FSE
Cor PD FSE MR
Ie
Sag PO FSE MR
Cor PD FSE MR
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BICEPS TENDlNOSlS Key Facts Terminology Degeneration of the long head biceps (LHB) as a result of chronic microtrauma or acute traumatic injury
Imaging Findings Best diagnostic clue: Thickening and increased signal intensity of LHB within rotator interval (RI) or bicipital groove on FS PD FSE and PD FSE images FS PD FSE to show morphology and signal alterations
Top Differential Diagnoses SLAP Lesion (Superior Labrum Anterior to Posterior) Rotator Cuff Tear Subscapularis Tear Magic Angle Normal Biceps Labral Complex (BLC) o Small, frayed/partially torn, irregular tendon in RI or
groove
.
o +/- Supraspinatus tendinopathy
Thickened, intermediate signal intensity tendon o Acromial spurs (impingement) Spur with marrow fat signal T2WI o Thickened, irregular tendon frayed and increased in signal intensity o Attenuated biceps tendon in partial tear or longitudinal split o +/- Supraspinatus tendinopathy FS PD FSE and PD FSE are sensitive to tendinosis while partial tearing or fraying usually requires confirmation of T2 FSE images o Acromial remodeling Hypointense sclerosis Impingement (predisposing) MR arthrography o Thickened filling defect = enlarged tendon/tendinosis Thinning of chronic partial tears Subluxation or dislocation with biceps instability o Flattened against bicipital groove/lesser tuberosity Sagittal images - thickened abnormal tendon in RI
..
Ultrasonographic Findings Thickened decreased attenuation tendon Tears often directly visible Advantage - allows dynamic evaluation with pain correlation
Imaging Recommendations Best imaging tool: MRI Protocol advice o FS PD FSE to show morphology and signal alterations o T2 FSE to distinguish between tendinosis and tears
Pathology Accompanies rotator cuff disease, especially impingement
Clinical Issues Upper arm/shoulder pain often radiating into upper arm especially in overhead athletes Typical complaint of dull anterior shoulder pain, esp. with lifting, elevated pushing or pulling Pain with Yergason's, Speed's +/- O'Brien's tests
Diagnostic Checklist Sagittal images show thickened tendon in RI Magic angle produces pseudo hyperintensity of intraarticular biceps tendon on sagittal images
I DIFFERENTIAL DIAGNOSIS
SLAP Lesion (Superior Labrum Anterior to Posterior) At the level of biceps labral complex 9 types May extend to anterior, posterior labrum, middle glenohumeral ligament (MGHL) Traction injury
Rotator Cuff Tear Especially SLAC (superior labrum anterior cuff) lesion o SLAP lesion + undersurface anterior supraspinatus partial tear Thickened, increased signal intensity tendon with partial or full thickness gap (T2WI) Impingement common cause of tear and biceps tendinosis
Subscapularis Tear +/- Anterior dislocation in older patient +/- Posterior dislocation at any age o Especially after seizures Discontinuous tendon fibers Anterior extension of impingement tear
Magic Angle At curve between RI and bicipital groove 55 degrees to the external magnetic field Artifact Increased signal on short TE sequences o TlWI, PDIIntermediate WI, TZ* GRE WI
Normal Biceps Labral Complex (BLC) Type I o No biceps labral sulcus Type I1 o Small biceps labral sulcus at superior pole of glenoid Type I11 o Meniscoid labrum o Deep biceps labral sulcus o Sulcus extends around the supraglenoid tubercle corner
o Associated with SLAP lesions
Typical complaint of dull anterior shoulder pain, esp. with lifting, elevated pushing or pulling 0 Often positive impingement signs 0 Pain with Yergason's, Speed's +I- O'Brien's tests Yergason's test - bicipital groove pain with resisted supination Speed's test - bicipital resistance test O'Brien's test - active compression test to entrap anterosuperior labrum (SLAP lesions) Clinical profile: Active athlete or patient with subacromial impingement 0
1 PATHOLOGY General Features
36
General path comments o Accompanies rotator cuff disease, especially impingement When anterior cuff is torn, biceps is impinged upon by exposure to acromion through rotator cuff tear gap Etiology o Chronic overuse leads to impingement syndrome o Biceps instability associated with impingementlhidden lesion o Overhead athletes, esp. baseball pitchers, tennis players, and swimmers - chronic microtrauma Epidemiology: Common with subacromial impingement, 20-60% association Associated abnormalities o Tears of medial head coracohumeral ligament and superior glenohumeral ligament (hidden lesion) o Rotator interval tear o Subacromial impingement syndrome o SLAP lesions o Biceps tenosynovitis
Demographics Age o Young athlete o Adult with impingement Gender: M = F
Natural History & Prognosis Rest and conservative treatment to allow healing
Treatment Conservative o NSAIDs o Physical therapy Surgical o Recalcitrant pain without tear Release of transverse humeral ligament Tenosynovectomy as in treating de Quervain's tenosynovitis o Biceps tenodesis in cases of partial or complete tears
Gross Pathologic & Surgical Features Thickened, indurated tendon Loss of integrity in partially or completely torn tendons Synovitis biceps in proximal extraarticular course Osteophytes
Microscopic Features
I DIAGNOSTIC CHECKLIST Consider Associated with rotator cuff tear or SLAP lesion o Biceps tendinosis in conjunction with impingement syndrome
Collagen degeneration without influx of inflammatory cells: "Tendinosis"is preferred term over tendinitis Hypertrophy of tendon
Staging, Grading or Classification Criteria Biceps tendon lesions o Type A - impingement tendinitis o Type B - subluxation o Type C - attritional tendinitis Biceps tendinitis criteria for tenodesis o Reversible tendon change < 25% partial thickness tear from a normal width tendon Normal bicipital groove location Normal tendon size o Irreversible tendon change Partial thickness tearlfraying > 25% of normal tendon width Subluxation Disruption of bicipital groove osseous or ligamentous anatomy
Image Interpretation Pearls Sagittal images show thickened tendon in RI Magic angle produces pseudo hyperintensity of intraarticular biceps tendon on sagittal images
1.
2. 3. 4. 5. A.
Presentation Most common signs/symptoms o Upper arm/shoulder pain often radiating into upper arm especially in overhead athletes
7.
Beall DB et al: Association of biceps tendon tears with rotator cuff abnormalities: Degree of correlation with tears of the anterior and superior portions of the rotator cuff. AJR 180(3):633-9,2003 Beltran J et al: Shoulder: Labrum and bicipital tendon. Top Magn Reson Imaging 14(1):35-49,2003 Patton WC et al: Biceps tendinitis and subluxation. Clin Sports Med 20(3):505-29, 2001 Gartsman GM et al: Arthroscopic biceps tenodesis: Operative technique. Arthroscopy 16(5):550-2,2000 Iannotti JP et al: Disorders of the shoulder: diagnosis and management. Disorders of the bicpes tendon. Lippincott Williams & Willkins, Philadelphia PA, 159-90, 1999 Read JW et al: Shoulder ultrasound: Diagnostic accuracy for impingement syndrome, rotator cuff tear, and biceps tendon pathology. J Shoulder Elbow Surg 7(3):264-71, 1998 Beltran J et al: MR arthrography of the shoulder: Variants and pitfalls. Radiographics 17(6):1403-12;discussion 1412-5. 1997
(Left) Sagittal PD FSE MR shows normal biceps tendon (open arrow) within the rotator interval. Note the coracohumeral ligament (arrow) extending from the coracoid to form the roof of the rota tor interval. (Right) Sagittal PD FSE MR shows biceps tendinosis with thickening and increased signal intensity (arrow) in the tendon.
( L e f ) Sagittal PD FSE MR shows marked thickening and moderate increased signal intensity (arrow) in severe biceps tendinosis. (Right) Coronal graphic shows a type I biceps labral complex with labrum adherent to superior pole of glenoid.
(Left) Coronal graphic shows a type I1 biceps labral complex with small sulcus. (Right) Coronal graphic shows a type 111 biceps labral complex with a meniscoid superior labrum and deep sulcus.
BlCEPS TENDON TEAR
Coronal graphic shows a tear of the long head of the biceps tendon with retraction of the distal end into the mid bicipital groove.
Coronal PD FSE MR shows biceps stump (arrow) in the superior aspect of the joint in a patient with a tear of the biceps tendon. Note the empty bicipital groove superiorly.
rn
Definitions Rupture of long head biceps tendon (LHBT)
I IMAG~NGFINDINGS General Features Best diagnostic clue o Tear or gap in the biceps tendon, +I- retraction of tendon edges Proximal stump is often extending from supraglenoid tubercle Location o Rotator interval (RI) most common o Adjacent to biceps anchor Size: Tear varies from millimeter range to extensive (several centimeters) Morphology o Gap in thickened, irregular increased signal intensity tendon on all pulse sequences o Thinned tendon = chronic partial tear
Radiographic Findings Radiography o Secondary findings associated with subacromial impingement - predisposing
Acromial spurs Humeral head (HH) subchondral greater tuberosity cysts Type 111acromion (hooked) Superior HH migration with rotator cuff (RTC) tears
CT Findings NECT o Secondary findings associated primarily with subacromial impingement rn Subacromial spurs HH subcortical degenerative cysts Osteophytes, cysts at bicipital groove CT arthrography o Bicipital groove filled with contrast, lack of biceps "filling defect" o +/- Supraspinatus tendon tear with contrast extending through tear
MR Findings TlWI o Hypointense biceps stump visualized in superior aspect of the joint Stump degeneratedlfrayed (intermediate signal intensity) o Superior labrum anterior-posterior (SLAP) lesions SLAP IV bucket-handle tear of meniscoid labrum + biceps tendon extension
DDx: Biceps Tendon Tear Hidden Lesion
BICEPS TENDON TEAR Key Facts Rotator Interval Tear (RI Tear) Hidden Lesion
Imaging Findings Tear or gap in the biceps tendon, +/- retraction of tendon edges Fluid signal intensity (hyperintense) filling gap in the tendon +/- Fluid (hyperintensity) within subacromial +/subcoracoid bursae = reactive Irregular biceps stump visualized in superior aspect of the joint
Top Differential Diagnoses SLAP lesion Supraspinatus Impingement Greater Tuberosity Bone Trabecular InjuryIFracture Subcoracoid Impingement Biceps Tenodesis
Pathology a
Seen with supraspinatus impingement/tear Distal tendon edge may retract into upper arm Predisposing tendinosis Subacromial impingement Subcoracoid impingement
Clinical Issues Asymmetrical pain over bicipital groove compared to contralateral shoulder
Diagnostic Checklist Check for empty bicipital groove in all three planes Identify biceps stump in RI
I
Increased signal intensity within biceps anchor,
+/- fragment o HH subchondral hypointense greater tuberosity
cysts T2WI o Fluid signal intensity (hyperintense) filling gap in the tendon o +/- Rotator cuff tear Fluid signal hyperintensity filling gap of torn tendon = complete tear Fluid signal hyperintensity extending into partial gap of torn tendon = partial tear o +/- Fluid (hyperintensity) within subacromial +/subcoracoid bursae = reactive o +/- Hyperintense effusion o Irregular biceps stump visualized in superior aspect of the joint w Stump degeneratedlfrayed (intermediate to hyperintense) o +/- SLAP lesion o Hyperintense greater tuberosity cysts PDIIntermediate o Gap in tendon o + ~ynovitis Thickened increased signal intensity synovial lining Seen on PDIIntermediate Variable retraction and degeneration of the tendon edges Type 111 acromion (impingement): Visualized on sagittal images
Imaging Recommendations Best imaging tool: MRI Protocol advice o FS PD FSE/T2WI o Tl/PD for tendinosislpretear
I DIFFERENTIAL DIAGNOSIS SLAP lesion Tear of biceps anchor
+/- Tendon tear May propagate into o Anterior labrum, posterior labrum o Middle glenohumeral ligament (MGHLIMGL) o Circumferentially + Speed's test (bicipital resistance test) OIBrienlstest (active compression test to entrap anterosuperior labrum)
Supraspinatus Impingement Pain anteriorly with abduction +/- Hyperintense fluid signal on T2WI extending into tearlpartial tear +/- Thickening, increased signal of supraspinatus tendon on short and long TE sequences +/- Thickened coracoacromial ligament
Greater Tuberosity Bone Trabecular InjuryIFracture Hyperintense greater tuberosity on T2WI + History of trauma +/- Visualized fracture fragment o Hypointense fracture line o Hyperintense edema on T2WI +/- Anterior dislocation
Subcoracoid lmpingement Impingement of coracoid on subscapularis/bicep Pain with internal rotation +/- Hyperintense subchondral cysts on T2WI Predisposes to biceps tendinosislinstability Elongated coracoid predisposing +/- Rotator interval (coracohumeral ligament component) tear
Biceps Tenodesis Absent biceps in rotator interval + Micrometallic artifact + Surgical history
Rotator Interval Tear (RI Tear) Roof = coracohumeral ligament (CHL) and supraspinatus History of impingement
-BlCEPS TENDON TEAR +/- History of anterior dislocation +/- Subcoracoid impingement Leads to contrast extension into subacromial bursa at arthrography +/- Synovitis Hyperintense roof of RI - T2WI
Hidden Lesion 100
Disruption of bicipital groove osseous or ligamentous anatomy
Presentation Most common signs/symptoms o Asymmetrical pain over bicipital groove compared to contralateral shoulder o Positive impingement signs o Pain with Yergason's, Speed's +/- O'Brien's tests Yergason's test - bicipital pain with resisted supination Speed's test - bicipital resistance O'Brien's test - active compression test for SLAP lesions o Muscle belly may retract Leads to "Popeye sign" Less obvious than with distal biceps tear because of anchor of short head tendon preventing retraction Clinical profile: Impingement patient, athlete
Subcategory of RI lesion Deep fiber subscapularis + CHL dysfunction Biceps instability +/- Biceps tendon tear Hyperintensity, irregularity on T2WI
General Features General path comments o Seen with supraspinatus impingementhear o Distal tendon edge may retract into upper arm o Predisposing tendinosis Etiology o chronic overuse/microtrauma Subacromial impingement with tear "exposing" biceps tendon to repetitive trauma of acromion o Acute traction to shoulder Epidemiology o Shoulder pain in 7-25% Western general population o Biceps tear commonly accompanies impingement (rotator cuff disease) Associated abnormalities o Subacromial impingement o Subcoracoid impingement o SLAP lesions o Lesser tuberosity degenerative change, subcortical cysts o Biceps tenosynovitis
Gross Pathologic & Surgical Features Usually thickened, indurated tendon edges Disruption in integrity of tendon Muscle belly may retract o Less obvious than with distal biceps tear o Muscle edematous
Demographics Age: Adult with impingement, athletes Gender: M > F
Natural History & Prognosis Tenosynovitis and tendinosis without tear will often improve with conservative management Pain from full thickness tears and partial tears often progresses o Requires arthroscopic/surgical management
Treatment Conservative: Physical therapy and NSAIDs Partial full thickness tears - tenodesis
I DIAGNOSTIC CHECKLIST Consider Impingement syndrome
Image Interpretation Pearls check for empty bicipital groove in all three planes Identify biceps stump in RI Distinguish between intraarticular or extraarticular tear Inspect biceps labral complex on coronal images for an intact biceps tendon
Microscopic Features Preexisting collagen degeneration = tendinosis
Staging, Grading or Classification Criteria Biceps tendon lesions o Type A - impingement tendinitis o Type B - subluxation o Type C - attritional tendinitis Biceps tendinitis criteria for tenodesis o Reversible tendon change < 25% partial thickness tear from a normal width tendon Normal bicipital groove location Normal tendon size o Irreversible tendon change Partial thickness tearifraying > 25% of normal tendon width Subluxation
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3.
4.
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Beltran JM et al: Shoulder: Labrum and bicipital tendon. Top Magn Reson Imaging 14(1):35-49,2003 Gartsman GM et al: Arthroscopic biceps tenodesis: Operative technique. Arthroscopy 16(5):550-2, 2001 Ken Yamaguchi et al: Disorders of the Shoulder. Disorders of the biceps tendon. Philadelphia PA, Lippincott Williams & Wilkins, 159-90, 1999 Tirman PF et al: A practical approach to imaging of the shoulder with emphasis on MR imaging. Orthop Clin North Am 28(4):483-515, 1997
BlCEPS TENDON TEAR -
I IMAGE GALLERY (Left) Coronal PD FSE MR shows the biceps stump (arrow) directed superiorly. (Right) Coronal FS PD FSE MR shows the distal stump (arrow) within the bicipital groove surrounded by edema and fluid in a patient with biceps rupture.
(Left) Coronal FS PD FSE MR shows stump (arrow) of the biceps anchor in the superior aspect of shoulder joint in a patient with biceps rupture. (Right) Axial STIR MR shows the top of the distal stump (arrow) of the biceps and an empty bicipital tendon sheath within the groove.
Typical (LRP) Sagittal PD FSE MR shows normal biceps tendon (arrow) in the rotator interval. (Right) Sagittal FS PD FSE MR shows an empty rotator interval in a patient with a biceps rupture.
SLAP LESIONS l-lV
Sagittal graphic demonstrates detachment of the superior labrum extending from anterior to posterior in a type 11 SLAP lesion.
Coronal FS PD FSE MR demonstrates irregular increased signal intensity (arrow) within the superior labrum in a patient with a type I1 SLAP lesion.
o Posterior peelback - posterosuperior labrum +
Abbreviations and Synonyms Superior labrum from anterior-to-posterior (SLAP) lesions or tears
Definitions SLAP lesions I through IV vary from simple fraying and fragmentation of the biceps labral complex (BLC) to a bucket-handle tear +/- biceps extension o Extended SLAP lesions = types V through IX
General Features Best diagnostic clue: Hyperintense linear fluid signal within superior labrum on FS PD FSE coronal images Location o SLAP I - superior labrum o SLAP I1 - superior labrum and biceps anchor o SLAP 111 - superior labrum o SLAP IV - superior labrum + biceps tendon o SLAC (superior labral anterior cuff) - labral tear restricted to anterior aspect of superior labrum Represents a subtype of SLAP I1 Associated with anterior supraspinatus articular sided partial tear
posterior undersurface cuff tear Represents a subtype of SLAP I1 Size o Focal of frayed and degeneration labrum in SLAP I o Complete anterior to posterior extension in SLAP 11-IV Morphology o SLAP I - indistinct margins vs. normal triangular shape with intrasubstance degeneration Normal variant in degenerative shoulder o SLAP I1 Detachment of superior labrum from superior pole of glenoid vs. linear labral tear from anterior-to-posterior o SLAP 111 8 Bucket-handle tear of a meniscoid superior labrum o SLAP IV Bucket-handle tear of superior meniscoid labrum Extension into f complete avulsion of biceps tendon
M R Findings TlWI o SLAP I Intermediate signal within the boundaries of superior labrum at level of biceps labral complex o SLAP 11-IV -
DDx: SLAP Lesions I-IV
Cor PD FSE MR
Cor FS PD FSE
Hidden Lesion
Micro-lnsta/SLAC
Supraglen Cyst
Ax FS PD FSE
Cor PD FSE MR
Cor FS PD FSE
SLAP LESIONS I - I V Key Facts Terminology SLAP lesions I through IV vary from simple fraying and fragmentation of the biceps labral complex (BLC) to a bucket-handle tear +I-biceps extension
Imaging Findings Best diagnostic clue: Hyperintense linear fluid signal within superior labrum on FS PD FSE coronal images Focal of frayed and degeneration labrum in SLAP I
Top Differential Diagnoses Impingement Sublabral Foramen (Hole) Buford Complex Rotator Cuff Tendinopathy/Partial Tear
Pathology Anterior rotator cuff tears Posterosuperior rotator cuff tears Paralabral cyst
Clinical Issues Patient status post traction injury (forced extension on flexed forearm), typically type I1 Patient status post fall on outstretched hand (31%), usually type 111, IV or extended SLAP (type V with anterior labral extension) Patient status post anterior dislocation (16%), often extended SLAP (type V) .-
Diagnostic Checklist Age related degeneration in SLAP I as a normal finding
Intermediate signal intensity within superior labrum visualized anterior and posterior to BLC where biceps tendon attaches to superior labrum T2WI o SLAP I Intermediate to hyperintense labral degeneration without linear tear o SLAP I1 Linear hyperintense tear along long axis of superior labrum (coronal plane) Fluid signal between superior labrum and superior pole of glenoid creating a greater than 5 mm displacement of labrum and biceps anchor on coronal images +/- Paralabral cyst o SLAP I11 Identify fragmented superior labrum into two separate components on coronal & sagittal images through BLC o SLAP IV Split of biceps tendon with hyperintense linear longitudinal tear vs. avulsion with absent intraarticular tendon o Associated anterior inferior, posterior inferior extension in extended SLAP lesions o Hyperintense signal on FS PD FSE and T2 FSE images in associated partial articular surface rotator cuff tears SLAP I1 subtypes: Classic SLAP 11, posterior peelback, SLAC lesion o Confusing terminology (not recommended) used in describing labral tract GLOM (glenoid labrum ovoid mass) sign: Low signal intensity mass anterior to glenoid rim as sign of avulsed anterior labrum "Cheerio"sign - displaced fragment of a bucket-handle SLAP tear MR arthrography o Contrast extension into SLAP lesion o +/- Communication with a paralabral cyst
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Imaging Recommendations Best imaging tool: MRI, MR arthrography
Protocol advice o FS PD FSE, PD FSE, T2* GRE o Coronal, axial and sagittal images of BLC
Impingement Clinical signs may mimic impingement as the long head of the biceps is involved in both processes Shoulder pain anteriorly with abduction +/- Thickening, increased signal of supraspinatus tendon (SST) on short and long TE sequences +/- Thickened coracoacromial ligament
Sublabral Foramen (Hole) Sublabral hole confined to anterior superior labrum No involvement of BLC
Buford Complex Buford complex confined to anterior superior labrum Absent anterior superior labrum above equator Cord-like glenohumeral ligament o Mimics displaced labral fragment
Rotator Cuff TendinopathyIPartial Tear Seen with SLAC lesions +/- Thickening, increased signal of supraspinatus tendon on FS PD FSE images FS PD FSE and T2 FSE most sensitive Microinstability - associated Seen with posterior peelback lesions Evaluate for associated hidden lesion
IPATHOLOGY General Features General path comments o Normal anatomy of biceps labral complex (BLC) o Type 1: BLC firmly attached to superior pole of glenoid o Type 2: Biceps attached to superior labrum lateral to superior glenoid
1
SLAP LESIONS I-IV -
Fluid-filled sublabral sulcus formed at superior pole of glenoid o Type 3: Meniscoid labrum associated with a large sulcus Should not be mistaken for a SLAP lesion Etiology o Eccentric overload of biceps during followthrough o Compression of superior glenoid rim Fall on outstretched arm o Repetitive pull on long head of biceps tendon (LHBT) with overhead sports o Microinstability Epidemiology: Most common (40% of all SLAP lesions) Associated abnormalities o Anterior rotator cuff tears Anterior cuff undersurface secondary to failure of the SGHLICHLIRI (microinstability and abnormal translation of the cuff) Results in "impingement"/chaffing of the cuff undersurface on the superior glenoid rim = SLAC lesion SLAC as a SLAP type I1 subtype with anterior component of SLAP I1 o Posterosuperior rotator cuff tears rn Posterior subtype SLAP type I1 lesion = posterior peelback lesion (posterosuperior component of a SLAP I1 tear) rn Posterior capsular contractions lead to abnormal obligate translation rn Undersurface posterior SST anterior infraspinatus tendon and posterior peelback lesion + HH chondral chaffinglimpaction o Paralabral cyst Often associated with SLAP lesionllabral tear especially (SLAP 11) rn Represents joint fluid extruded through tear
Presentation Most common signslsymptoms o Patient status post traction injury (forced extension on flexed forearm), typically type I1 o Patient status post fall on outstretched hand (31%), usually type 111, IV or extended SLAP (type V with anterior labral extension) o Patient status post anterior dislocation (16%), often extended SLAP (type V) Clinical profile o Posttraumatic patient o Only approximately one-third with symptoms referable to the biceps tendon o Rotator cuff pain common especially with type I1 lesions o Active compression and provocation tests
Demographics Age o Typically young patient for most SLAP lesions o Type I lesions (degenerative) seen in older patients Gender: M > F
Natural History & Prognosis Small tearslstable tears may heal but unstable tears require surgical stabilization
Treatment Conservative o Reducing pain and inflammation (NSAIDs), restoring range of motion, strengthening (physical therapy) Surgical o Type I - debridement o Type I1 - stabilize Bioabsorbable tack o Type 111 - debride o Type IV - suture of biceps, reattachment of labrum Biceps tenodesis
Gross Pathologic & Surgical Features Bare labral footprint > 5 mm sublabral sulcus Displaceable biceps root (rolls over glenoid) Effects of SLAP lesions o Biceps anchor disruption o Humeral head translation (microinstability) o Strain of humeral head restraints o Glenohumeral laxitylinstability
Microscopic Features Fibrocartilaginous degeneration and/or tear of the superior labrum/biceps anchor Hemorrhagic synovium
Consider Age related degeneration in SLAP I as a normal finding
Image Interpretation Pearls Fluid signal intensity within the substance of the labrum vs. detachment of the entire labrum at the BLC; characterize SLAP lesions
Staging, Grading or Classification Criteria Type I: Degenerative fraying Type 11: Detachment of the biceps anchor and superior labrum o Anterior variety = SLAC (superior labral anterior cuff) lesion o Anterior to posterior variety = classical type I1 SLAP o Posterior variety = posterior peelback lesion = internal impingement Type 111: Bucket-handle tear of superior labrum leaving biceps intact still Type IV: Bucket-handle tear extending into biceps
1 SELECTEDREFERENCES - -
1. 2. 3.
Beltran JM et al: Shoulder. Labrum and bicipital tendon. Top Magn Reson Imaging 14(1):35-49, 2003 Musgrave DS et al: SLAP lesions: Current concepts. Am J Orthop 30(1):29-38,2001 Stoller DW et al: The shoulder. Magnetic resonance imaging in orthopaedics and sports medicine. vol 1. 2nd ed. Philadelphia PA, J.B. Lippincott, 597-742, 1997
SLAP LESIONS I-IV
(Left) Sagittal graphic demonstrates a type I SLAP lesion as degenerative fraying and induration. (Right) Coronal PD FSE MR demonstrates diffuse increased signal intensity within the superior labrum (arrow) in a patient with a type I SLAP lesion.
(Lej?) Sagittal graphic shows a type 111 SLAP lesion with bucket handle tear at the superior labrum/biceps anchor. (Right) Coronal STIR MR demonstrates a type 111 SLAP lesion with a bucket-handle fragment (arrow).
( L ~ f tSagittal ) graphic demonstrates a type IV SLAP lesion with the bucket handle tear extending into the biceps tendon itself. (Right) Coronal FS TI arthrogram demonstrates a SLAP I1 lesion with extension into the biceps tendon (arrow). The superior labrum was divided into two fragments.
SLAP LESlONS V-IX
Sagittal graphic demonstrates a tear of the superior labrum (biceps labral complex) extending into the middle glenohumeral ligament (SLAP VII Lesion).
Abbreviations and Synonyms Superior labrum anterior to posterior (SLAP) lesions
Definitions Tear of the superior labrum at the biceps labral complex Extension of the SLAP lesion into surrounding structures = extended SLAP lesions o Anterior labrum (type V) o Flap tear superior labrum (type VI) o MGHL (type VII) o Posterior labrum (type VIII) o Circumferential involvement (type IX) Classic SLAP I1 - a tear extending from the anterior aspect to the posterior aspect of the superior labrum
General Features Best diagnostic clue 0 Fluid signal intensity on T2WI (FS PD FSE) within the substance of the superior labrum of biceps labral complex (BLC)
Axial FS PD FSE M R shows a type VII SLAP lesion extending into the middle glenohumeral ligament which is thickened and edematous (arrow).
Signal may be linear and involve irregularityltearing of: Anterior/posterior labrum f inferior labrum, MGHL Location o Biceps labral complex o SLAP tears may be associated with Bankart lesion (type V) Reverse Bankart lesion (type VIII) Middle glenohumeral ligament (type VII) Circumferential labral involvement (type IX) Size: Up to all four quadrants of the glenoid rim Morphology: Tears vary from focal flap tear in type VI to complete labral detachment of anterior, posterior, superior and inferior labrum in type IX
M R Findings TlWI o SLAP V Intermediate signal of tear with superior extension of an anteroinferior Bankart lesion Bony Bankart fracture - anterior inferior glenoid rim Hill-Sachs posterolateral impaction fracture (superior humeral head) 0 SLAP VI - IV Difficult to visualize without FS PD FSE, PD FSE or T2* GRE T2WI o SLAP V
* *
DDx: SLAP Lesions V-IX
Cor FS PD FSE
Ax FS PD FSE
Sag PO FSE MR
Sag PD FSE MR
Ax PD FSE MR
SLAP LESIONS V-IX Key Facts Terminology Tear of the superior labrum at the biceps labral complex Extension of the SLAP lesion into surrounding structures = extended SLAP lesions Anterior labrum (type V) Flap tear superior labrum (type VI) MGHL (type VII) Posterior labrum (type VIII) Circumferential involvement (type IX)
Imaging Findings Fluid signal intensity on T2WI (FS PD FSE) within the substance of the superior labrum of biceps labral complex (BLC)
Hyperintense fluid undermining anterior labrum from anterosuperior to anteroinferior quadrant + SLAP I1 findings (linear hyperintensity vs. detachment of superior labrum at BLC) o SLAP VI Hypointense anteroposterior labral flap tear + SLAP I1 surrounded by hyperintense joint fluid Visualized on sagittal images with either superior or inferior displacement of unstable flap o SLAP VII Hypointense fluid within a split MGL secondary to anterior extension of a type I1 SLAP lesion Thickened edematous MGL o SLAP VIII Fluid undermining posterior labrum Posterosuperior to posteroinferior Posterior instability = Reverse Hill-Sachs lesion (anteromedial impaction fracture humeral head) = Lesser tuberosity fracture in posterior dislocation k Subscapularis stretched or detached k teres minor tendon tear k Posterior labrocapsular periosteal sleeve avulsion (POLPSA) o SLAP IX Avulsion f fluid undermining the entire labrum circumferentially BLC involved IGL labral complex involved (lower two thirds of labrum) Labrum k severe degeneration & osseous glenoid cystic changes associated with the concentric labral avulsion PDIIntermediate o +/- Synovitis Intermediate to increased signal intensity thickened synovium Increased signal compared to joint fluid MR arthrography o Contrast extending into SLAP lesion o +/- Reverse Bankart lesion (SLAP VIII) o Contrast delineates avulsion o Define healedlpartially healed resynovialized lesion
Top Differential Diagnoses Impingement Sublabral Foramen Buford Complex Rotator Cuff TendinopathyIPartial tear
Pathology Eccentric overload of biceps during follow through
Clinical Issues Patient status post fall on outstretched hand (31%), usually type 111, IV or v lesion
DiagnosticChecklist Evaluate all labral quadrants including BLC and inferior glenohumeral ligament labral complex
o f Communication with a paralabral cyst
Irregularity and/or widening of recess beneath the superior labrum
Imaging Recommendations Best imaging tool: MRI, MR arthrography Protocol advice: FS PD FSE/PD FSE , T2* GRE in coronal, axial, and sagittal planes at BLC
[DIFFERENTIALDIAGNOSIS Impingement Clinical signs may mimic impingement (as the long head of the biceps is involved) Pain anteriorly with abduction +/- Thickening, increased signal of supraspinatus tendon on short and long TE sequences +/- Thickened coracoacromial ligament
Sublabral Foramen Anterior superior labrum involved without osseous glenoid attachment Sublabral hole confined to anterior superior quadrant Normal anatomical finding at imaging No involvement of BLC
Buford Complex Buford complex confined to anterior superior labrum Absent anterior superior labrum Above equator Cord-like MGHL o Mimics displaced labral fragment
Rotator Cuff TendinopathyIPartial tear Microinstability o Includes both SLAP + rotator cuff tendinopathy +/- Thickening, increased signal of supraspinatus tendon on FS PD FSE (for tendinosis) and T2 FSE (for tear) Associated with SLAC lesion and posterior peel back lesions +/- Hidden lesion of internal
SLAP LESIONS V-IX
1PATHOLOGY General Features
I OH;
General path comments: With microinstability Etiology o Eccentric overload of biceps during follow through o Compression of superior glenoid rim Fall on outstretched arm o Repetitive pull on long head of biceps tendon (LHBT) with overhead sports Epidemiology: 6% of shoulder arthroscopy Associated abnormalities 0 Microinstabilitiy SGHL avulsion or laxity MGHLIMGL avulsion (straight anterior laxity) SLAC (superior labrum anterior cuff) SLAP lesions I through IX Posterior peelback SLAP Interval tears
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Gross Pathologic & Surgical Features Bare labral footprint > 5 mm sublabral sulcus Displaceable biceps (root rolls over glenoid) Effects of SLAP lesions o Biceps anchor disruption o Humeral head translation (microinstability) o Strain of humeral head restraints o Glenohumeral laxitylinstability
Microscopic Features Fibrocartilaginous degeneration and/or tear of the superior labrum/biceps anchor Hemorrhagic synovium
Staging, Grading or Classification Criteria Type V, VI, VII, VIII, IX
Presentation Most common signslsymptoms o Patient status post fall on outstretched hand (31%), usually type 111, IV or V lesion o Patient status post anterior dislocation (16%), often a type V Clinical profile 0 Posttraumatic patient o Approximately one-third have symptoms referable to the biceps tendon o Bicipital groove tenderness Speed's test (resisted forward flexion of a supinated arm) Yergason's test (resisted supination with the elbow flexed 90 degrees) o Crank or clunk test - pain +/- popping with compression and rotation o O'Brien's active compression test for SLAP lesions pain with resisted elevation with forearm fully pronated
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Demographics Age: Typically young patient for most SLAP lesion
Gender: M > F
Natural History & Prognosis Small tearslstable tears may heal but unstable tears require surgical stabilization
Treatment Conservative o Reduction of pain and inflammation (NSAIDs), restoration of range of motion, strengthening (physical therapy) Surgical o Restoration of anatomy including MGHLIIGHLC o Stabilize and reattach labrum
I DIAGNOSTIC CHECKLIST Consider Anterior, posterior or inferior labral tears in association with a SLAP I1 lesion Identify subchondral glenoid erosions as a secondary finding of associated labral pathology
Image Interpretation Pearls Fluid signal intensity within substance of the labrum vs. complete avulsion with fluid signal at labral tear Evaluate all labral quadrants including BLC and inferior glenohumeral ligament labral complex
1 SELECTEDREFERENCES 1. Beltran JM et al: Shoulder: Labrum and bicipital tendon. Top Magn Reson Imaging 14(1):35-49,2003 2. Bencardino JT et al: Superior labrum anterior-posterior lesions: Diagnosis with MR arthrography of the shoulder. Radiology 214(1):267-71,2001 3. Musgrave DS et al: SLAP lesions: Current concepts. Am J Orthop 30(1):29-38,2001 4. Grainger AJ et al: Direct MR arthrography: A review of current use. Clin Radio1 55(3):163-76,2000 5. Snyder SJ et al: SLAP lesions of the shoulder. Arthroscopy 6(4):274-9, 1990
SLAP LESIONS V-IX
I IMAGE GALLERY (Left)Sagittal graphic demonstrates a type Vlll SLAP lesion with tearing and inflammation of the biceps anchor extending posteriorly to involve the posterior labrum. (Right) Sagittal PD FSE MR demonstrates a type Vlll SLAP (arrow) with extension into the posterior labrum.
(Left) Sagittal graphic shows a type IX SLAP with tearing of the biceps anchor and circumferential labral tearing. (Right) Sagittal PD FSE MR demonstrates circumferential labral tearing in a patient with a type IX SLAP lesion.
(Left) Sagittal graphic demonstrates a type V SLAP involving the biceps anchor in association with a Bankart lesion. (Right) Sagittal graphic demonstrates a type VI SLAP with a flap component displaced inferiorly with the anterior component attached.
BICEPS TENDON DISLOCATION
Coronal graphic shows a tear of the subscapularis tendon and a dislocation of the biceps from the bicipital groove.
Coronal PO FSE MR shows torn subscapularis tendon and medial dislocation of the biceps (arrow). Irregular bicipital groove is lateral to the dislocated biceps tendon.
Radiographic Findings Abbreviations and Synonyms Biceps instability
Definitions Dislocation of the long head of biceps tendon (LHBTILBT) from the bicipital groove Disruption of stabilizing ligaments including transverse ligament, coracohumeral ligament (CHL) and superior glenohumeral ligament (SGHLISGL) & subscapularis tendon
General Features
CT Findings NECT o +/- Degenerative changes of lesser and greater tuberosities o +/- Empty bicipital groove CT arthrography o Empty bicipital groove o Tendon sheath filled with contrast
MR Findings
Best diagnostic clue: Empty bicipital groove with oval decreased signal structure outside the groove on all pulse sequences Location: Bicipital groove and rotator interval (RI) Size: Tendon flattened, enlarged or partially torn Morphology o Dislocated tendon +I- Flattenedlthickened due to preexisting tendinosis o Normal tendon: Oval shape, hypointense
I
Radiography o +/- Degenerative changes (degenerative cysts) surrounding bicipital groove of humerus o Acromial remodeling/sclerosis - impingement o Acromial spurs (impingement)
TlWI: Increased signal intensity fat fills bicipital groove T2WI o Decreased signal intensity fat within bicipital groove with FS Hemorrhage hyperintense Surrounding edema hyperintense o Increased signal intensity subchondral cysts of humerus at bicipital groove = degenerative change +I- Adjacent bone marrow edema Subcoracoid impingement
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DDx: Biceps Tendon Dislocation Ant.dL
PD FSE MR
Buford MCL
1 L bf
AX FS PD FSE MR
sag FS PD F S E
AX PD FSE MR
AX PD FSE MR
BICEPS TENDON DlSLOCATlON Key Facts Terminology Dislocation of the long head of biceps tendon (LHBTILBT) from the bicipital groove Disruption of stabilizing ligaments including transverse ligament, coracohumeral ligament (CHL) and superior glenohumeral ligament (SGHL/SGL)& subscapularis tendon
Imaging Findings Best diagnostic clue: Empty bicipital groove with oval decreased signal structure outside the groove on all pulse sequences
Top Differential Diagnoses Torn Detached Labrum Rotator Interval "Hidden Lesion" Biceps Tendinosis o +/- Subscapularis tear or partial tear - hyperintense
with discontinuous fibers Subscapularis interstitial split with interposed dislocated tendon Superficial fibers may be preserved with deep fibers torn Rarely deep fibers preserved and superficial fibers + CHL torn, allowing superficial subluxation o Distal SGHL, CHL tear (hidden lesion) in association with biceps dislocation Increased signal intensity replacing decreased signal intensity ligamentous structures SGHL, CHL may be thickened and degenerated and lax without complete tear T2* GRE: Sensitive to visualization of hypointense fibers of biceps Tendon flattened against bicipital groove/lesser tuberosity - subluxation MR arthrography o Empty bicipital groove o Tendon sheath filled with contrast
Ultrasonographic Findings Dislocation of the biceps tendon with an empty bicipital groove
Imaging Recommendations Best imaging tool: MRI Protocol advice: Axial FS PD FSE + T2* GRE
I DIFFERENTIAL DIAGNOSIS Torn Detached Labrum Fall on abducted externally rotated arm Mimics dislocated biceps +/- Anterior dislocation/subluxation Detached fragment hypointense on all pulse sequences Follow on consecutive axial images to confirm structure is labrum not LHBT
Rotator Interval "Hidden Lesion" Common cause of LHBT dislocation SGHLICHL dysfunction
Biceps Rupture SLAP Lesion Subcoracoid Impingement
Pathology +/- Dislocation into joint deep to subscapularis +/- Dissection into subscapularis tendon Rarely dislocates superficial to tendon
.upper
Clinical Issues arm/shoulder pain often radiating into upper
arm
Diagnostic Checklist Identify empty bicipital groove Document biceps anterior, posterior or within torn subscapularis fibers on axial images
LHBT subluxation progresses to dislocation LHBT subluxation deep to subscapularis Irregular increased signal of SGHL/CHL on FS PD FSE at lateral aspect of joint
Biceps Tendinosis Thickened hyperintense tendon on all pulse sequences Short TE sequences most sensitive Associated with impingement +/- SLAP (superior labrum anterior to posterior) lesion
Biceps Rupture Discontinuous, irregular, frayed tendon on all pulse sequences +/- Impingement syndrome +/- Stump visualization in superior part of shoulder joint by supraglenoid tubercle Distal end may retract into upper arm Pain often relieved at time of rupture
SLAP Lesion At the level of biceps labral complex Involves tendon itself Propagates into o Anterior labrum o Posterior labrum (SLAP VIII) o Middle glenohumeral ligament or MGL (SLAP VII) o Circumferentially (SLAP IX) Positive Speed's test (bicipital resistance test)
Subcoracoid Impingement Impingement of coracoid on subscapularis/biceps Internal rotation +/- Hyperintense subcortical cysts on T2WI Predisposes to biceps tendinosislinstability Elongated coracoid (predisposing)
Anterosuperior Variations, Shoulder Buford complex Sublabral foramen Cord-like MGL may mimic dislocated biceps Above equator of glenoid 20% of general population Follow cord-like MGL to confirm its identity
BICEPS TENDON DISLOCATION
1 PATHOLOGY
Yergason's test - bicipital groove pain with resisted supination of forearm in 90 degrees of elbow flexion Speed's test - bicipital resistance test with bicipital groove pain in a flexed arm, forearm supination at 30 degrees of elbow flexion O'Brien's test - active compression test to entrap anterosuperior labrum (SLAP lesions) between humeral head and glenoid in 90 degrees of flexion and 20 degrees of cross-body adduction (downward force applied to internally rotated arm) Clinical profile: Common complaint of dull anterior shoulder pain (esp. with lifting, elevated pushing or pulling)
.
General Features General path comments o Dislocates after loss of stabilizing structures o +/- Dislocation into joint deep to subscapularis o +/- Dissection into subscapularis tendon o Rarely dislocates superficial to tendon o Superficial fibers of subscapularis + inferior fibers of CHL continue as transverse bicipital ligament Covers biceps groove Etiology o Torn rotator cuff leads to tear of stabilizing structures allowing dislocation of LHBT o Deep fibers of subscapularis must be torn o Shallow bicipital groove predisposes to dislocation o Rotator interval hidden lesion common cause of instability Predisposes to subluxation/dislocation o Subscapularis tendon & coracohumeral ligament Major restraints of biceps dislocation o Transverse ligament Less important role in stabilizing LBT within groove Epidemiology: More common with impingement, up to 30% of impingement patients Associated abnormalities o Subscapularis rupture Deep surface partial tear Interstitial partial tear Superficial fiber partial tear o Supraspinatus tear Predisposes to LHBT tendinosis/dislocation o Subcoracoid impingement - predisposes
.
Demographics Age o Adult (impingement) o Athletes Gender: M > F
Natural History & Prognosis Continued pain with use of biceps Often requires surgical management
Treatment Conservative: Physical therapy, NSAIDs Tenodesis/tenotomy for recalcitrant cases of pain Rotator cuff/SGHL/CHL repair with LHBT reduction
.. .
Consider Torn labrum as differential diagnosis Evaluate subscapularis
Gross Pathologic & Surgical Features Degenerated tendon dislocated out of bicipital groove Associated with torn subscapularis tendon Flattening, fraying, and degenerative changes at surgery
Image Interpretation Pearls Identify empty bicipital groove Document biceps anterior, posterior or within torn subscapularis fibers on axial images Note medial location of biceps on anterior coronal images
Microscopic Features Collagen degeneration without influx of inflammatory cells: "Tendinosis"is preferred term over tendinitis
Staging, Grading or Classification Criteria Two types of LBT dislocation o Type 1: Intact insertional fibers of subscapularis LBT anterior to subscapularis o Type 2: Detached subscapularis tendon LBT deep to subscapularis tendon
.
1 SELECTEDREFERENCES 1. 2.
3. 4.
Presentation Most common signs/symptoms o Upper arm/shoulder pain often radiating into upper arm o Asymmetrical pain over the bicipital groove compared to contralateral shoulder o Pain with Yergason's, Speed's +/- O'Brien's tests
5. 6.
Beltran JM et al: Shoulder: Labrum and bicipital tendon. Top Magn Reson Imaging 14(1):35-49,2003 Beall DP et al: Association of biceps tendon tears with rotator cuff abnormalities:Degree of correlation with tears of the anterior and superior portions of the rotator cuff. AJR 180(3):633-9,2003 Gartsman et al: Arthroscopic biceps tenodesis: Operative technique. Arthroscopy 16(5):550-2,2000 Read JW et al: Shoulder ultrasound: Diagnostic accuracy for impingement syndrome, rotator cuff tear, and biceps tendon pathology. J Shoulder Elbow Surg 7(3):264-71, 1998 Sethi N et al: Disorders of the long head of the biceps tendon. J Shoulder Elbow Surg 8(6):644-54, 1998 Beltran J et al: MR arthrography of the shoulder: Variants and pitfalls. Radiographics 17(6):1403-12;discussion 1412-5, 1997
BICEPS TENDON DISLOCATION
(Lef)Axial PD FSE MR shows tendinosis within a dislocated biceps tendon adjacent to the lesser tuberosity (arrow). The superior aspect of the bicipital groove can be seen laterally in association with a tear of the coracohumeral ligament. (Right) Axial PD FSE MR shows dislocated biceps tendon in the anterosuperior aspect of the joint (arrow). This should not be mistaken for a middle glenohumeral ligament in association with a sublabral foramen or Buford complex.
(Left) Axial PD FSE MR shows dislocation of the biceps tendon (arrow) through a partially torn subscapularis tendon and superior glenohumeral ligament. The superficial fibers of the subscapularis and coracohumeral ligament are intact. (Right) Axial TZ* CRE MR shows complete dislocation of a degenerated biceps tendon (arrow) in association with a complete tear of the subscapularis tendon.
Typical , rn
(Left)Axral graph~cshows drslocatron of the brceps tendon deep to the st111rntact superficral fibers of the subscapular~stendon and coracohumeral Irgament (Right) Axral PD FSE MR shows subluxatron and near-complete drslocatron of the brceps (arrow) secondary to partral tear of the subscapularrs tendon and tear of the superror glenohumeral Irgament
SUBACROMIAL IMPINGEMENT
Coronal graphic shows impingement of the supraspinatus tendon on the acromion. ( 1 . Lesser tub. 2. SST 3. LAB 4. Ant cap. 5. Clenoid)
Coronal PD FSE MR shows marked lateral downsloping of the anterior acromion (type 6 ) in a patient with subacromial impingement.
o Hooked acromion (type I11 acromion) on outlet view
associated with increased risk o Subacromial spurs
Abbreviations and Synonyms Primary extrinsic impingement, rotator cuff (RTC) impingement, subacromial impingement syndrome (SAIS), supraspinatus impingement
Definitions Progressively painful compression of supraspinatus tendon (SST) & subacromial bursa o Between humeral head and coracoacromial arch
1 IMAGING
FINDINGS
General Features Best diagnostic clue o Hooked acromion on sagittal images with supraspinatus degeneration +/- tearing +/- Reactive bursitis (bursa1 fluid) Location: Osseous acromial outlet and RTC Size o Diminished subacromial outlet o Subacromial space < 7 mm considered increased risk Morphology: Impingement risk depends on shape of acromion
Radiographic Findings Radiography
.
o +/- Acromioclavicular (AC) joint arthritis
Subchondral cysts, spurs
CT Findings NECT o Subacromial spurs o +/- AC sclerosis, hypertrophy Cysts Anterior inferior acromial spurs o Coronal, sagittal reconstruction Sagittal reconstruction helpful for acromial shape CT arthrography o Contrast enters rotator cuff tear
.. .
M R Findings TlWI o Thickened tendon with intermediate signal intensity in impingement related tendinopathy o +/- Thick coracoacromial (CA) ligament (narrows subacromial space on sagittal images) o Hooked acromion on sagittal images o +/- Hypointense greater tuberosity cysts T2WI o Tendon degeneration Thickened tendon with increased signal intensity o Full thickness, supraspinatus tear
.
DDx: Subacromial Impingement Hidden Lesion
PSCl
Q ,:
. Ax P D FSE MR
Sag FS P D FSE
Ax P D FSE MR
Ax FS P D FSE
.
Ax FS P D FSE
.
Key Facts Terminology Progressively painful compression of supraspinatus tendon (SST) 8 subacromial bursa
Imaging Findings Hooked acromion on sagittal images with supraspinatus degeneration +/- tearing Morphology: Impingement risk depends on shape of acromion
Top Differential Diagnoses Internal Impingement (PosterosuperiorGlenoid Impingement - PSGI) Suprascapular Denervation Adhesive Capsulitis Subcoracoid Impingement Hidden Lesion Hyperintense fluid-filled gap o Partial tear
Hyperintensity undersurface Hyperintensity bursa1 surface Hyperintensity in interstitium o +/- Hyperintense greater tuberosity cysts o +/- Fluid signal intensity (hyperintense) in bursae Subacromial Subcoracoid o +/- Thickened coracoacromial ligament T1 C+ o Partial tears, +/- enhancement o Full thickness tears, +/- enhancement o Bursitis - enhancement inflamed synovium MR arthrography o Tendon tear may be filled with contrast (partial and complete) Thickened heterogeneous tendon or torn tendon Type I11 acromion as a congenital variant or acquired osteophyte Type I11 (anterior inferiorly hooked) acromion process predisposes to subacromial impingement Acromion enthesophyte formation o Marrow containing o Marrow fat signal on TlWI Lateral downsloping predisposes to subacromial impingement o Coronal images
Imaging Recommendations Best imaging tool: MRI in all three planes Protocol advice o FS PD/T2 FSE in coronal plane for evaluation of RTC o Sagittal PD/T2 FSE or T2 FSE for evaluation of osseous acromial outlet
Internal Impingement (Posterosuperior Glenoid Impingement - PSGI) Throwing athletes Occupational
Pathology Epidemiology: 95% of rotator cuff tears secondary to chronic impingement beneath coracoacromial arch
Clinical Issues Most common signs/symptoms: Insidious onset of shoulder pain especially with abduction and forward flexion Pain to palpation of the rotator cuff within the range of extension
Diagnostic Checklist Impingement syndrome = clinical diagnosis MR osseous and soft tissue findings are associated with clinical syndrome
Triad of findings o Posterosuperior humeral head impaction injury o Posterosuperior labrum frayinglfrank tearing o Posterosuperior rotator cuff tearing (partial) Impingement inside shoulder joint Abduction with external rotation (ABER) MR arthrography used for the detection of partial undersurface tears
Acute Trauma Rotator cuff tear on acute traumatic basis +/- Preexisting impingement +/- Fracture of humerus, glenoid or both Hyperintense edemalhemorrhage on T2WI
0 s Acromiale Degenerative changes may lead to pain with abduction Failure of fusion of normal ossification Preacromion (most distal type of os acromiale) excised o Others surgically fused +/- Rotator cuff tear
+
Suprascapular Denervation Mimics impingement clinically o Weakness and pain of supraspinatus and infraspinatus Denervation hyperintense muscles on T2W1, STIR, FS PD FSE +/- Paralabral cyst - compression neuropathy
Adhesive Capsulitis Limitation in both active & passive range of motion o Impingement: Usually no limitation in passive range of motion Thickened hyperintense capsule on coronal images o Axillary pouch of inferior glenohumeral ligament (IGHL) o Rotator interval Frozen shoulder +/- Rotator cuff tear
-
-
SUBACROMIAL lMPINCEMENT o Type I: Flat undersurface - sagittal MR o Type 11: Curved undersurface - sagittal MR o Type 111: Anterior 113 hook - sagittal MR
Subcoracoid Impingement +/- Subscapularis tendon tear +/- Hyperintense lesser tuberosity cysts - T2WI Pain with internal rotation +/- Hidden lesion
Associated with impingement o Type IV: Convex undersurface
Not associated with impingement Lateral downsloping of anterior acromion on coronal MR images o Type A: Mild or non lateral downsloping o Type B: Moderate to marked lateral downsloping
Hidden Lesion Biceps instability Superior glenohumeral ligament (SGHL)/coracohumeralligament (CHL) abnormality +/- Subscapularis tear
1 PATHOLOGY
Presentation Most common signs/symptoms: Insidious onset of shoulder pain especially with abduction and forward flexion Clinical profile o Pain to palpation of the rotator cuff within the range of extension o Pain and weakness to supraspinatus testing o Younger athletes participating in sports requiring overhead arm movements o Range of motion often preserved o Painful range of motion
General Features General path comments: Physical impingement with repetitive microtrauma Etiology o Primary extrinsic (coracoacromial arch) Subacromial spur Acromioclavicular joint OA Coracoacromial (CA) ligament Variation in size and thickness Calcification/ossification less common o Type I11 (hooked) acromion o Lateral downsloping of the anterior acromion o 0 s acromiale Unfused apophysis of anterior acromion o Secondary extrinsic Impingement associated with instability (glenohumeral) Athletes in overhead throwing activities No osseous abnormality of the coracoacromial arch Continuum from instability to subluxation resulting in impingement Anterior instability Epidemiology: 95% of rotator cuff tears secondary to chronic impingement beneath coracoacromial arch Associated abnormalities: Biceps tendinosisltears
Gross Pathologic & Surgical Features Type I11 (anterior inferiorly hooked) acromion process Enthesophyte formation acromion Lateral downsloping of anterior acromion
Demographics Age: Adult > 40 years Gender: M > F
Natural History & Prognosis Improves with cessation of inciting activities Subacromial decompression - recalcitrant cases
Treatment Initial treatment conservative: Physical therapy Steroid injections Recalcitrant cases: Subacromial decompression/acromioplasty
1 DIAGNOSTIC CHECKLIST Image Interpretation Pearls 1mpingement syndrome = clinical diagnosis MR osseous and soft tissue findings are associated with clinical syndrome ~ c r o m i ashape l & slope AC joint osteophytes Anterior inferior acromial spur
Microscopic Features Collagen degeneration with apoptosis (cell death) of tendon cells o Increase in collagen type 111, glycosaminoglycan, proteoglycan and smooth muscle actin (SMA) Hypertrophic & inflammatory bursitis o Inflammatory changes are peritendinous
Staging, Grading or Classification Criteria Clinical subacromial impingement o Stage I: Reversible edema & hemorrhage typically in active patient I25 years o Stage 11: Fibrosis and tendinitis o Stage 111: Degeneration & rupture often associated with osseous changes most commonly in patients > 40 years Acromial shape
I
1
1. 2. 3. 4.
I
Fritz RC et al: MR imaging of the rotator cuff. Magn Reson Imaging Clin N Am 5(4):735-54, 1997 Bigliani LU et al: Subacrornial impingement syndrome. J Bone Joint Surg Am 79(12):1854-68, 1997 Bigliani LU et al: Arthroscopic resection of the distal clavicle. Orthop Clin North Am 24(1):133-41, 1993 Bigliani LU et al: Relationship of acrornial architecture and diseases of the rotator cuff Orthopad 20(5):302-9, 1991
SUBACROMIAL IMPINGEMENT
Typical (Left) Coronal graphic in abduction and external rotation demonstrates approximation of the coracoacromial arch with the greater tuberosity. (Right) Coronal PD FSE MR shows marked thickening of the coracoacromial ligament (arrow) and moderate tendinosis with thickening of the supraspinatus tendon.
(Left) Sagittal T I FSE MR shows type I acrornion process. The patient has a rotator cuff tear and HillSachs deformity secondary to trauma. (Right) Sagittal PD FSE MR shows type I1 acromion (lower association of cuff tears compared to type 111) with thickened coracoacromial ligament.
(Left) Sagittal PD FSE MR shows type 111 acrornion (arrow) process with an anterior hook. (Right) Sagittal PD FSE MR shows a large enthesophyte of the anterior acromion at the insertion of the coracoacromial ligament (arrow).
Coronal graphic shows the ossification centers of the acromion where an os acromiale may develop as a failure of fusion of the pre; meso-, meta or basiacromion.
Axial FS PO FSE MR shows a meso os acromiale (most common) with degenerative changes at the synchondrosis. There are also mild degenerative changes of os acromiale clavicular joint.
o Disc shaped secondary ossification center o +I- Degenerative change
Abbreviations and Synonyms
Radiographic Findings
Acromioclavicular (AC), usually in reference to the acromioclavicular joint, mesoacromion-preacromion (meso-pre)variety
Definitions Unfused acromial ossification center which normally fuses at approximately age 25-30 o Relatively mobile with shoulder abduction causing impingement
Radiography o Secondary ossification center of the acromion in one of three locations Line of demarcation rn Axillary view o +/- Degenerative changes o +I- Osteophyte formation Medullary bone extends into osteophyte allowing identification o Patient 2 30 years
CT Findings
General Features Best diagnostic clue: Separate articulation at the distal acromion separate from the AC joint Location o At one of three acromial ossification centers in patient older than 25-30 years Basiacromion-metaacromion (most proximal) Metaacromion-mesoacromion Mesoacromion-preacromion (most distal) Size: 1-2 cm (size of secondary ossification center if meso-pre variation) Morphology
NECT o Failure of fusion of secondary ossification center of the acromion Line of demarcation = lucency o Degenerative changes common Peri-synchondrosis sclerosis rn +/- Lucencies (cysts) o Reconstruction in coronal, sagittal plane helpful
MR Findings TlWI
urn -
1
DDx: OS Acromiale
Subacrorn. Vessels
Clavicle Fx
kf?! .
->4
.--
Cor PD FSE
-
Cor FS PD FSE
Cor PD FSE
Ax
FS PD *FSE
Ax STIR MR
Key Facts Imaging Findings
Acromioclavicular Joint Separation
Best diagnostic clue: Separate articulation at the distal acromion separate from the AC joint At one of three acromial ossification centers in patient older than 25-30 years Basiacromion-metaacromion (most proximal)
Pathology
Metaacromion-mesoacromion Mesoacromion-preacromion (most distal)
Clinical Issues
Top Differential Diagnoses Acromial FractureIStress Response Normal Childhood/Adolescent Ossification Center Subacromial Vessel Acromioclavicular Joint Arthritis Impingement Clavicle Fracture
Failure of fusion of the normal acromial ossification center, +/- mobile distal acromion f Impingement Insidious onset of shoulder pain Pain especially with abduction and forward flexion (impingement symptoms)
Diagnostic Checklist Use axial and sagittal images to identify "a second AC joint (pseudo - AC joint)" in os acromiale
-
o Unfused secondary acromial ossification center with
increased signal intensity (marrow) within the ossification o +/- Peri-synchondrosis sclerosis (hypointensity) o +/- Hypointense cysts o +/- Hypointense sclerosis throughout os acromion T2WI o Pseudo-double AC joint appearance o Corticated structure with marrow center o +/- Edema (hyperintense) ~ e ~ e n e r a t i -change ve Stress response o +/- Hyperintense cysts o +/- Hypointense sclerosis o +/- Supraspinatus tendinopathy Thickening Fluid signal (hyperintensity) fills gap PDlIntermediate: Corticated structure with marrow center T2* GRE o Unfused ossification demarcation - hyperintense o Bone marrow edema often obscured Secondary to susceptibility Not a marrow sensitive technique
Imaging Recommendations Best imaging tool: MRI Protocol advice o Obtain axial MR images in superior location to include acromion o FS PD FSE to visualize edema across articulation
Normal Childhood/Adolescent Ossification Center Unfused ossification center normal < 25 years Normal structure mimics os acromiale Other ossification centers usually present allowing differentiation o Acromion: One of last ossification centers to fuse No signal alterations Children have normal high signal hyaline articular cartilage on T2WI
Subacromial Vessel Mimics ossification center junction (synchondrosis) High signal intensity on T2WI Artery and/or vein +/- Misregistration artifact
Acromioclavicular JointArthritis Involves AC joint + Hyperintense edema T2WI + Hyperintense subchondral cysts T2WI + Hypointense subchondral sclerosis all pulse sequences Hyperintense synovitis PD, T2W1, TlWI
Impingement Anterior pain with abduction Lidocaine injection into AC joint/os acromiale to differentiate origin of pain +/- Thickening, increased signal of supraspinatus tendon on short and long TE sequences +/- Thickened coracoacromial ligament
Clavicle Fracture Acromial FractureIStress Response History of trauma (direct impact) Hyperintensity on T2WI FS PD FSE sensitive for marrow edema Lymphoma of the scapular spine may mimic stress response (rare)
+/- AC separation
+ History of trauma Hypointense fracture line mimics os acromiale on all pulse sequences + Hyperintense edema on T2WI
Acromioclavicular Joint Separation Type I injuries - sprained but intact coracoclavicular (CC) and AC ligaments
OS ACROMIALE
120
Type I1 injuries - complete disruption of the AC ligaments with sprained but intact CC ligament Type I11 injury - both CC and AC ligaments completely disrupted Type IV injuries - posterior displacement of the clavicle relative to the acromion + buttonholing through the trapezius muscle Type V injuries - clavicle markedly displaced superiorly - disruption of muscle attachments Type VI injuries - inferior displacement of distal clavicle below the acromion or the coracoid process o Rare Fracture line hypointense on all pulse sequences Perilesional hyperintense edema on T2WI
1 PATHOLOGY General Features General path comments o Failure of fusion of the normal acromial ossification center, +/- mobile distal acromion k Impingement o Coracoacromial ligament inserts onto os acromiale May lead to instability - impingement o Failure of recognition of os acromiale associated with ineffective acromioplasty Cause of failed acromioplasty Etiology: Failure of fusion of the normal acromial ossification at one of three locations before age 25-30 Epidemiology: 8.2% of general population over 25 years old Associated abnormalities: Rotator cuff (RTC) tears
.
.
Gross Pathologic & Surgical Features Mature bone with synchondrosis between the os acromiale and acromion
Microscopic Features Articulation with acromion o Fibrous tissue o Cartilage o Periosteum o Synovium
Staging, Grading or Classification Criteria Acromial ossification center failure of fusion o Basiacromion-metaacromion (type C) o Metaacromion-mesoacromion (type A) o Mesoacromion-preacromion (type B - most common)
Presentation Most common signslsymptoms o Insidious onset of shoulder pain o Pain especially with abduction and forward flexion (impingement symptoms) o Most common types are meso or metaacromial
Demographics Age o 2 30 years
.
Impingement in older patients Not clear if os acromiale predisposes to earlier onset of impingement o 0 s acromiale represents normal ossification center before age 25-30 Gender: M 2 F
Natural History & Prognosis Improve with conservative treatment for impingement syndrome
Treatment Conservative: Physical therapy, NSAIDs Surgical treatment for recalcitrant cases o Excision of preacromion o Symptomatic meso-, meta-, or basiacromion may be stabilized and fixed to the remainder of the acromion
1 DIAGNOSTIC CHECKLIST image Interpretation Pearls Use axial and sagittal images to identify "a second AC joint (pseudo - AC joint)" in os acromiale
Gumina S et al: Relationship between os acromiale and acromioclavicular joint anatomic position. J Shoulder Elbow Surg 12(1):6-8,2003 Carlson DW et al: 0 s acromiale. Am J Orthop 31(8):458, 2002 Sammarco VG: 0 s acromiale, Frequency, anatomy, and clinical implications. J Bone Joint Surg Am 82(3):394-400, 2000 Ryu RK et al: The treatment of symptomatic os acromiale. Orthopedics 22(3):325-8, 1999 Nicholson GP et al: The acromion: Morphologic condition and age-related changes. A study of 420 scapulas. J Shoulder Elbow Surg 5(1):1-11, 1996 Hutchinson MR et al: Arthroscopic decompression of shoulder impingement secondary to os acromiale. Arthroscopy 28-32, 1993 Edelson JG et al: 0 s acromiale. Anatomy and surgical implications. J Bone Joint Surg Br 75(4):551-5, 1993 MK Mudge et al: Rotator cuff tears associated with os acromiale.J Bone Joint Surg 427-9, 1984
I IMAGE GALLERY (Left) Axial PD/lntermediate MR through the superior aspect of the joint demonstrates failure of fusion of the mesoacromion ossification center resulting in an os acromiale. (Right) Axial STlR MR shows the meso os acromiale.
(Left) Axial STlR MR shows hyperin tense stress response at the level of a symptomatic os acromiale. (Right) Coronal STlR MR shows the stress response at the junction of the acromion and os acromiale resulting in increased signal intensity.
(Left) Sagittal PD FSE MR shows changes of an acromioplasty anteriorly (arrow) with the presence of an os acromiale posteriorly. The patient was symptomatic at the osseous acromion outlet. (Right) Coronal PD FSE MR shows degenerative changes of the more posteriorly located os acromiale formed between the meta- and rnesoacromion.
Coronal FS PD FSE MR shows osteoarthritic changes of the AC joint including minimal subchondral cyst formation of the distal clavicle, synovitis, and joint effusion.
Coronal graphic shows osteoarthritic changes of the AC joint including mild chondromalacia, subchondral cyst formation, reactive bone changes, and effusion.
. .. .
Distal clavicular and/or proximal acromial cysts, edema Synovitis Subchondral sclerosis Periarticular edema Location: Articulation between the acromion and clavicle Size o Osteoarthritis (OA) +/- Alteration of morphology +/- Hypertrophic spur formation +/- Increase in size of joint (esp. with spurs) Morphology o Progressive loss of articular cartilage Associated new bone formation +/- Capsular fibrosis
Abbreviations and Synonyms Degenerative joint disease (DJD), osteoarthritis (OA), acromioclavicular (AC) joint arthrosis
Definitions Degenerative osteoarthritis of the acromioclavicular joint (AC joint) Primary: Gradual process of destruction & regeneration as a result of chronic microtrauma o Chronic "wear and tear" Secondary: Non-inflammatory degenerative joint disease o Secondary to Previous trauma Congenital deformity Infection Metabolic disorder
.. ..
Radiographic Findings Radiography o Views used Anterior and posterior Coracoacromial outlet "Y" view 15 degree cephalic tilt o Joint space narrowing o Subchondral sclerosis/eburnation o Subchondral cysts o Osteophyte formation o +/- Attrition/remodeling
1
(IMAGING FINDINGS General Features Best diagnostic clue o Osteoarthritic changes including Chondromalacia
.
I
DDx: Acromioclavicular JointArthritis Clavicle Fx
;;/;
1[17 1
0 s Acromiale
*
* '4
Cor PD FSE MI
Cor FS PD FSE
Cor PD FSE MR
Cor FS PD FSE
'
Ax FS PD FSE MR
ACROMIOCLAVICULAR JOINT ARTHRITIS Key Facts Terminology Degenerative osteoarthritis of the acromioclavicular joint (AC joint) Secondary: Non-inflammatory degenerative joint disease
Imaging Findings Location: Articulation between the acromion and clavicle Joint space narrowing Subchondral sclerosis/eburnation Subchondral cysts Osteophyte formation +/- Attritionlremodeling Hyperintensity in hyaline cartilage degeneration
CT Findings NECT o Tomographic imaging option Characterization in cases of fragmentation/fx o Narrowing o Sclerosis 0 Cysts o Osteophytes o AC joint hypertrophy
MR Findings TlWI o Decreased signal intensity subchondral cysts = Decreased signal also visualized in sclerosis and/or degenerative edema o Marrow fat signal seen extending into osteophytes Marrow extension into spur = Differentiation from hypointense ligament T2WI o Hyperintensity in hyaline cartilage degeneration o Subchondral bone marrow edema (hyperintense) o +/- Hyperintense effusion o Intermediate signal synovial thickening = +/- Irregularity/frond formation o FS PD FSE - edema demonstrated with fat saturation Subchondral decreased signal indicating sclerosis Subchondral cysts (hyperintense) PDIIntermediate o Cartilage seen on both FS PD FSE and PD FSE o Edema not as hyperintense compared to FS PD FSE or STIR T2* GRE: Cartilage abnormalities may be overlooked as both cartilage and fluid are of similar signal intensity T1 C+: Synovium enhances in case of synovitis
Nuclear Medicine Findings
+ Uptake Imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE
Top Differential Diagnoses Posttraumatic Osteolysis Degenerative Changes of an 0 s Acromiale Subacromial Impingement AC Separation
Pathology Secondary to acromioclavicular separation or as typical degenerative change Joint instabilities may be predisposing
Clinical Issues Most common signs/symptoms: Anterosuperior shoulder pain Positive cross-body or horizontal adduction test Positive lidocaine injection test Associated rotator cuff disease in the elderly
I D~FFERENT~AL DIAGNOSIS
I
Posttraumatic Osteolysis History of trauma, often weight lifting Edema and clavicular destruction FS PD FSE sensitive
Degenerative Changes of an 0 s Acromiale Occurs between os acromiale and remaining acromion Lateral and posterior to AC joint Common findings of OA o Chronic symptoms and characteristic radiographic and MRI findings o Synchondrosis irregularity o Subchondral cysts, edema, sclerosis
Subacromial Impingement Anterior shoulder pain with abduction Lidocaine injection into AC joint to differentiate AC vs. subacromial pathology +/- Thickening, increased signal of supraspinatus tendon on short and long TE sequences +/- Thickened coracoacromial ligament
AC Separation Posttraumatic Torn coracoclavicular ligament in more advanced cases +/- Fracture of clavicle
General Features General path comments o Fatigue fracture of the collagen meshwork followed by increased hydration of the articular cartilage (as opposed to desiccated cartilage seen with aging) and loss of proteoglycans from the matrix into the synovial fluid Secondary to instability of AC joint Fibrillation of the cartilage follows + deep clefts and regeneration/proliferation of chondrocytes
ACROMlOCLAVlCULAR JOINT ARTHRlTlS Proliferative changes occur at the joint margins with formation of osteophytes Articular cartilage thins and is fissured in areas of maximum mechanical stress, underlying bone becomes sclerotic and subchondral cysts form Compression of weakened bone with variable degrees of collapse Loose bodies Synovial hypertrophy produces joint pain by nerve stimulation and weeping of synovial fluid producing increased intraarticular pressure thereby stretching joint lining Molecular changes in osteoarthritic cartilage include: Increased water, weakening of type I1 collagen network, shorter collagen chains and alteration of proteoglycans Increased levels of degrading enzymes including matrix metalloproteinase (MMPs or collagenase, gelatinase, and stromelysin) Etiology o Secondary to acromioclavicular separation or as typical degenerative change o Joint instabilities may be predisposing Epidemiology: Common abnormality (between 30-70% of population) especially > 50 years Associated abnormalities o Deformities occur o Subluxations o Coracoclavicular ligament fibrosis, heterotopic calcifications
Gross Pathologic & Surgical Features Osteoarthritic changes consisting of chondromalacia, synovitis, subchondral sclerosis, periarticular edema, and distal clavicular and/or proximal acromial cysts and edema Degraded cartilage with loss of sheen, fissured and/ or ulcerated cartilage surface, variable degrees of articular surface collapse o Subchondral geodes (cysts) containing variable degrees of debris o Buttressing osteophytes to increase surface area
Presentation Most common signs/symptoms: Anterosuperior shoulder pain Clinical profile o Pain includes top of shoulder, AC joint and upper arm (referred) o Positive cross-body or horizontal adduction test o Positive lidocaine injection test o Associated rotator cuff disease in the elderly o Clicking o Catching Clinical profile o Athlete o Middle aged to elderly active patient
Demographics Age: Adult Gender: M > F
Natural History & Prognosis Progressive debilitating disease without medical intervention
Treatment Non-steroidal antiinflammatory drugs, physical therapy Mumford procedure for advanced cases
1 DIAGNOSTIC CHECKLIST Consider Posttraumatic osteolysis
Image Interpretation Pearls FS PD FSE images are sensitive to subchondral marrow edema and fluid within AC joint proper AC hypertrophy Association between moderate AC joint arthrosis (with edema of distal clavicle and acromion) and posterosuperior labral tears
Microscopic Features Degenerative arthritis with variable amounts of inflammatory cells, chondral degeneration, subarticular geodes, and subchondral osteocytic buildup (sclerosis) o Diminution of chondrocytes in superficial zones with chondrocyte swelling to variable degrees o Cartilage matrix loses its ability to stain for proteoglycans with Alcian blue or safranin-0 o Matrix chondrocytes demonstrate proliferation in clusters (brood capsules) o Neovascularity penetrates layer of calcified cartilage and new chondrocytes extend up from deeper layers o Hypertrophied synovium becomes folded into villous folds with variable infiltration of plasma cells, and lymphocytes
- -
Stein BE et al: Detection of acromioclavicular joint pathology in asymptomatic shoulders with magnetic resonance imaging. J Shoulder Elbow Surg 10(3):204-8, 2001 2. Clarke HD et al: Acromioclavicular joint injuries. Orthop Clin North Am 31(2):177-87, 2000 3. Shaffer B S Painful conditions of the acromioclavicula~ joint. J Am Acad Orthop Surg 7(3):176-88, 1999 4. Fukuda K et al: Biomechanical study of the ligamentous system of the acromioclavicular joint J Bone Joint Surg 68(3):434-40, 1986 5. Cahill BR: Osteolysis of the distal part of the clavicle in male athletes. J Bone Joint Surg 64(7):1053-8, 1982 1.
ACROMlOCLAVlCULAR JOlNT ARTH
I IMAGE GALLERY
1 (Lefr) Coronal FS PD FSE MR shows hyperintense bone marrowedema within proximal aspect of acromion and surrounding soft tissue edema in a weight-lifter with distal clavicular posttraumatic osteolysis. (Right) Axial TZ* CRE MR shows degenerative cyst (arrow) extending anteriorly & superiorly from the osteoarthritic AC joint.
(Lef)Coronal FS PD FSE MR shows AC degenerative disease as chondromalacia with underlying bone reactive change, synovitis, and joint effusion. (Right) Sagittal T2 FSE MR shows hypertrophic AC joint with narrowing of the supraspinatus outlet.
(Left) Coronal graphic shows normal coracoacromial ligament and the two components of the coracochvicular ligament (trapezoid & conoid). (Right) Coronal graphic shows tear of the coracoacromial and coracochvicuhr ligaments in an AC separation.
AVN, SHOULDER
Coronal graphic shows avascular necrosis of the superomedial aspect of the humeral head with mild articular surface collapse.
Coronal FS PO FSE MR shows avascular necrosis of the superomedial humeral head including "double line sign" (arrow).
Radiographic Findings Abbreviations and Synonyms Avascular necrosis (AVN) o Subchondral Bone infarct (BI), bone necrosis, bone death, bone infarction Osteonecrosis, aseptic necrosis, ischemic necrosis, ischemic bone death
Definitions AVN is ischemic death of the cellular elements of bone and marrow
Radiography o Arclike, subchondral, lucent lesion may be associated with areas of patchy loss of bone opacity with sclerotic areas and subchondral collapse o Eventually sclerotic +I-collapse o Radiographic findings may be delayed relative to initial clinical event
CT Findings NECT o Serpiginous outline o Interface of increased density
MR Findings General Features Best diagnostic clue o Serpiginous lines in subchondral cancellous marrow o "Double line sign": Decreased hypointense periphery lines with adjacent hyperintense inner border on T2WI Location: Superomedial aspect of humeral head most common Size: Varies from small to large areas of affected bone Morphology: Irregular serpiginous linear morphology of peripheral outline
TlWI 0 Edema: Moderate decrease in signal intensity 0 Predominately decreased signal intensity serpiginous lines o Central focus with marrow fat signal as most common appearance T2WI o Double line sign: Decreased signal intensity peripheral with adjacent increased signal intensity inner margin o Nonspecific area of edema within cancellous bone associated with AVN focus
DDx: AVN, Shoulder
Ax T2* CRE MR
Cor FS PD FSE
Cor PD FSE MI
Osteoarthritis
Charcot Shoulocl
4x FS PD FSE MR
Cor PD FSE MR
AVN, SHOULDER 7
Key Facts Terminology AVN is ischemic death of the cellular elements of bone and marrow
Imaging Findings Serpiginous lines in subchondral cancellous marrow Size: Varies from small to large areas of affected bone Morphology: Irregular serpiginous linear morphology of peripheral outline Double line sign: Decreased signal intensity peripheral with adjacent increased signal intensity inner margin
Top Differential Diagnoses Osteoarthritis (OA) Marrow Tumor Bone Tumors & Metastases o Collapse of subchondral surface in more advanced
cases o Well-marginated cyst in cystic degeneration o FS PD FSE is sensitive to ischemic marrow related edema in acute AVN T2* GRE o Double line sign may be accentuated o Edema may be obscured because of susceptibility T1 C+: Granulation component of double line sign may enhance with contrast MR arthrography 0 Contrast extension underneath unstable devitalized bone
Nuclear Medicine Findings Bone Scan o "Cold spot": Absent uptake where blood supply has been disrupted preventing radiotracer from accumulating o Nonspecific uptake in acute cases where revascularization has occurred
Imaging Recommendations Best imaging tool: MRI (both T1 and T2 are diagnostic) Protocol advice: TI, FS PD FSE, T2WI and STIR
Osteoarthritis (OA) +I- History of antecedent trauma Subchondral changes but often with chronic symptoms and typical radiographic and MRI finding 0 Chondromalacia 0 Hyperintense subchondral cysts on T2WI 0 Hyperintense edema on T2WI 0 Hypointense sclerosis on all pulse sequences
Marrow Tumor Internal marrow replaced Lack of cortical disruption in AVN differentiates from malignant degeneration Well-marginated cyst differentiate cystic degeneration of infarct from malignant degeneration
Osteochondral Injury
Pathology General path comments: Patient with predisposing factor - steroid use or underlying disease such as sickle cell anemia Steroid-induced osteonecrosis range from 2% to < 25%
Clinical Issues Clinical features of AVN depend on the stage of the disease, often asymptomatic Generalized shoulder pain
Diagnostic Checklist Evaluate for underlying abnormalitiesldisease -
Vague areas of radiolucencies in infarct may mimic neoplastic processes
Bone Tumors & Metastases Enchondroma o Stippled hypointense calcifications o Chondroid matrix o Metaphyseal, diaphyseal or diametaphyseal Chondrosarcoma o Endosteal scalloping Myeloma Metastases
Osteochondral Injury History of trauma Affects chondral surface and subchondral bone Osteochondritis dissecans (OCD) +I- history of trauma o Young patient o Fracture unusual in humeral head epiphyseal area
General Features General path comments: Patient with predisposing factor - steroid use or underlying disease such as sickle cell anemia Etiology o Conditions which disrupt blood supply to the bone o Intrinsic or extrinsic abnormality in the blood vessel supplying part of the bone may lead to infarct o Common predisposing factors Trauma Renal transplant Steroids (endogenous and exogenous including Cushing syndrome) Collagen vascular disease (lupus) Pancreatitis Alcoholism Gaucher disease, Fabry's disease, sickle cell anemia, gout Arteritis (radiation and other causes) Idiopathic
AVN, SHOULDER Epidemiology o Second most frequent (femoral head is most common) site ofinvolvement for osteonecrosis o Steroid-induced osteonecrosis range from 2% to < 25% o Systemic lupus erythematosus (SLE) AVN incidence of 5-6% of patients o Alcohol intake and hyperuricemia account for up to 60% and 40% of cases of idiopathic bone infarct respectively ~ssociatedabnormalities o Signs and symptoms of underlying disease or physiologic state that led to infarct o Secondary osteoarthritis with associated
Gross Pathologic & Surgical Features Pale bone marrow with variable degrees of necrosis depending on age of infarct and duration of ischemia Secondary osteoarthritis develops after structural failure and collapse of articular surface Cystic degeneration in areas of bone infarction may occur
Microscopic Features Medullary necrosis appears yellowish with occasional flecks of calcium Serpiginous capsule of grayish glistening collagen surrounds area of necrosis Necrotic marrow fat in subchondral ischemia Bone trabeculae devoid of osteocytes Vascular granulation tissue or grayish glistening collagen separates dead tissue from underlying living bone contributing to increased signal of the double line sign
Staging, Grading or Classification Criteria Stage 0:Asymptomatic, normal radiograph, histology abnormal Stage 1: +I- Symptoms, radiographs normal, MRI shows abnormal signal, histology abnormal Stage 2: Symptomatic, radiographs show osteopenia, sclerosis, MRI characteristic (Chinese figuresldouble line sign) Stage 3: Symptomatic, subchondral lucency (crescent sign), subchondral collapse, articular shape preserved Stage 4: Articular surface collapse + superimposed osteoarthritic change
Presentation Most common signs/symptoms o Clinical features of AVN depend on the stage of the disease, often asymptomatic o Generalized shoulder pain o Presentation depends on underlying disease if present Clinical profile: Patients with underlying disease e.g., SLE
Demographics Age o Depends on underlying disease if present
Patients with sickle cell anemia present with bone infarcts in the first few decades of life Gender: M:F = 8:l Ethnicity o Infarcts associated with sickle cell anemia o Bone infarcts associated with Gaucher's disease
Natural History & Prognosis Occurs suddenly and often heals well without residua unless progression of underlying disease influences infarct
Treatment Idiopathic lesions are treated conservatively (symptomatically) Treatment of underlying disease
1 DIAGNOSTIC CHECKLIST Consider Evaluate for underlying abnormalities/disease
Image Interpretation Pearls AVN if double line on T2WI o Especially if superior medial humeral head affected Central marrow fat signal is the most common finding
I SELECTED REFERENCES
1 I
Kim SK et al: Natural history and distribution of bone and bone marrow infarction in sickle hemoglobinopathies. J Nucl Med 43(7):896-900, 2002 Lau WF et al: Extensive bone infarct in myeloid leukemia correlation of bone scan and magnetic resonance imaging. Clin Nucl Med 26(2):165-6, 2001 Umans H et al: The diagnostic role of gadolinium enhanced MRI in distinguishing between acute medullary bone infarct and osteomyelitis. Magn Reson Imaging 18(3):255-62, 2000 Cerilli LA et al: Angiosarcoma arising in a bone infarct. Ann Diagn Path01 3(6):370-3, 1999 Ahn BC et al: Intramedullary fat necrosis of multiple bones associated with pancreatitis. J Nucl Med 39(8):1401-4, 1998 Butt WP: MRI diagnosis of bone marrow infarction in the child with leukaemia. Clin Radio1 53(1):77, 1998 Stoller DW et al: The Shoulder. Magnetic resonance imaging in orthopaedics and sports medicine. vol 1. 2nd ed. Philadelphia PA, J.B. Lippincott, 597-742, 1997
AVN, SHOULDER
I IMAGE GALLERY Typical (LA$) Coronal T1WI MR shows serpiginous linear decreased signal intensity line within the superomedial aspect of the humeral head, consistent with avascular necrosis. (Right) Coronal STIR MR subacute to chronic lesion of avascular necrosis with suppression of central marrow fat containing region.
(Left) Coronal FS PD FSE MR shows fragmentation and loss of the spherical humeral head in a patient with advanced chronic AVN. (Right) Axial FS PD FSE MR shows fragmentation of the superomedial humeral head in image of the same patient.
Typical (Left)Axial T2 FSE MR shows the typical double line sign in a patient with chronic avascular necrosis of the humeral head. The patient had Caissons disease. (Right) Axial T2" CRE MR shows the double line sign (arrow) at humeral head.
OSTEOCHONDRAL INJURIES,SHOULDER -
Coronal graphic shows a chondral defect involving the superior aspect of the humeral head with associated bone marrow edema.
Abbreviations and Synonyms Osteochondral injury (OCI)
Definitions Injury to articular cartilage +/- underlying bone fracture, bone trabecular injury or associated reactive stress response (edema)
-
Coronal STlR MR shows a chondral defect of the superior aspect of the humeral head (arrow) with underlying bone marrow edema in a symptomatic young athlete.
Supraglenoid tubercle - associated with superior labrum anterior to posterior (SLAP) lesion Size: Varies from small chondral defect (millimeter) to large area of cartilage denudation Morphology o From defined chondral defect to irregular chondral lesion Associated with underlying osseous changes
Radiographic Findings Radiography o +/- Fracture of humeral headtglenoid o +/- Subchondral sclerosis in chronic cases
General Features Best diagnostic clue: Alteration in contour and/or signal of hyaline articular cartilage with underlying bone changes Location o Glenoid, esp. anterior inferior after anterior dislocation o Other common sites of involvement Posterosuperior humeral head (HH) - Hill-Sachs deformity after anterior dislocation Posterior glenoid - reverse Bankart after posterior dislocation Lesser tuberosity - reverse Hill-Sachs after posterior dislocation HH - hyaline articular cartilage, superior aspect
CT Findings CT arthrography o Chondral defect filled with contrast o
+I-Glenoid or humeral head fracture
M R Findings TlWI o Subchondral sclerosis (decreased signal intensity) o +/- Hypointense fracture o Hypointense subchondral edema T2WI o Increased signal intensity in hyaline articular cartilage, well defined or irregular chondral defect o Underling bone marrow edema - hyperintense signal (impaction)
Hwww DDx: Osteochondral Injuries, Shoulder
f -
Ax T1 Arthro.
Ax STIR
Sag T2 FSE
Cor FS PD FSE
-
OSTEOCHONDRAL INJURIES, SHOULDER Key Facts Imaging Findings Best diagnostic clue: Alteration in contour and/or signal of hyaline articular cartilage with underlying bone changes Increased signal intensity in hyaline articular cartilage, well defined or irregular chondral defect Underling bone marrow edema - hyperintense signal (impaction)
Top Differential Diagnoses Osteoarthritis (OA) Bare Area of Humerus (Posterosuperior)or Glenoid (Central) Reactive Edema Humeral Head or Glenoid Fracture Surgical neck fracture
Anatomic neck fracture Lesser tuberosity fracture ' fracture
Pathology Tidemark zone is weakest part of hyaline articular cartilage and most often disrupted
Clinical Issues Most common signslsymptoms: Intermittent locking, recurrent effusions, crepitus, and persistent pain Clinical profile: Active patient, often athlete Age: Younger active patient < 40 years old
Diagnostic Checklist Check for increased signal intensity or fluid in hyaline cartilage on FS PD FSE or PD FSE images -
o FS PD FSE - increased signal intensity in hyaline
articular cartilage Well defined or irregular chondral defect evaluated with FS PD/T2 FSE PDIIntermediate: Edema is not well visualized without fat saturation STIR o Spatial resolution is decreased o Increased signal intensity in hyaline articular cartilage o Chondral defect, +I-filled with hyperintense fluid o +/- Underlying bone marrow edema (hyperintense) T2* GRE o Bone edema often obscured by susceptibility artifact o T2* GRE WI may show joint fluid isointense to cartilage o T2* only sensitive to larger chondral defects relative to FS PD FSE images TI C+: Bone reactive changes (edema) may enhance following IV gadolinium administration MR arthrography o Contrast fills articular cartilage defect
Nuclear Medicine Findings Bone Scan: Increased uptake of radiotracer in bone involvement
Imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE or PD sequence in at least 2 planes
Bare Area of Humerus (Posterosuperior) or Glenoid (Central) Cartilage thinning to absence Normal variant Posterosuperior humeral head Central glenoid
Reactive Edema Edematous changes in reaction to adjacent inflammatory process o Rotator cuff disease o Reactive osteitis Early OA Associated with bone trabecular injury
Humeral Head or Glenoid Fracture Surgical neck fracture o History of acute trauma o Edema Anatomic neck fracture o History of acute trauma o Edema mimics OCI Lesser tuberosity fracture o After seizure o +/- Subscapularis tear Scapular stress fracture o Athlete o Baseball o Hyperintense edema (T2) o +I-Fragmentation
Avascular Necrosis (AVN) Osteoarthritis (OA) Gradual, insidious onset Osteochondral injuryldefect Subchondral cysts Subchondral edema Subchondral sclerosis Older patientlpost traumatic patient
-
Predisposing condition o Steroids o Alcoholism Double line sign +/- Synovitis +/- Articular surface collapse
OSTEOCHONDRAL INJURIES, SHOULDER
1 PATHOLOGY
Demographics Age: Younger active patient < 40 years old Gender: M > F
General Features
132
General path comments o Tidemark zone is weakest part of hyaline articular cartilage and most often disrupted Between overlying cartilage and subchondral bone o Shearing injuries produce chondral injury rather than osteochondral injury o Mild fibrillation, fissuring, flap lesion, defect or osteochondral fracture Etiology o Rotational forces and direct trauma - injury to articular cartilage o Secondarily involve underlying bone Epidemiology: Young active patients most common Associated abnormalities: SLAP lesions, soft tissue injury, hematoma
Gross Pathologic & Surgical Features Mild lesion on MRI may show no discernible abnormality at gross inspection Fibrillation Cartilage softening Fissures and chondral flaps Partial and full thickness chondral defects Bone injuries ranging from bone trabecular injury to fracture
Natural History & Prognosis Heal or form isolated defect with underlying secondary arthritic change with increased symptoms
Treatment Conservative o Rest followed by physical therapy 0 NSAIDs Surgical o Chondral defects: Debridement, microfracture, mosaicplasty and other chondral resurfacing techniques depending on severity of lesion o Less experience with surgical treatments compared to knee
1 DIAGNOSTIC CHECKLIST Consider In posttraumatic setting
Image Interpretation Pearls Underlying bone marrow edema associated with chondral injury Check for increased signal intensity or fluid in hyaline cartilage on FS PD FSE or PD FSE images
Microscopic Features Chondrocyte disruption followed by swelling If underlying bone involved, blood vessels are ruptured and hematoma is formed Cell death due to interrupted blood supply Avulsion of articular cartilage o Between deep calcified and juxta-articular noncalcified cartilage Subchondral compression and trabecular fractures o +I- Injury to articular cartilage
Staging, Grading or Classification Criteria Outerbridge classification for chondromalacia o Grade 0: Normal cartilage o Grade I: Chondral softening and swelling MRI: Increased signal intensity FS PD FSE o Grade 11: Partial thickness defect with fissures on the surface not reaching subchondral bone or not exceeding 1.5 cm in diameter MRI: Surface irregularity o Grade 111: Fissuring to the level of subchondral bone in area with a diameter more than 1.5 cm MRI: Partial to small full thickness defect o Grade IV: Exposed bone MRI: Cartilage loss down to bone
Presentation Most common signslsymptoms: Intermittent locking, recurrent effusions, crepitus, and persistent pain Clinical profile: Active patient, often athlete
1 SELECTEDREFERENCES 1. 2. 3.
4.
Farmer JM: Chondral and osteochondral injuries. Diagnosis and management. Clin Sports Med 20(2):299-320, 2001 Martinek V et al: Treatment of osteochondral injuries. Genetic engineering. Clin Sports Med 20(2):403-16, 2001 Bredella MA et al: Accuracy of T2-weighted fast spin-echo MR imaging with fat saturation in detecting cartilage defects in the knee: Comparison with arthroscopy in 130 patients. AJR 172(4):1073-80, 1999 Yu JS et al: Osteochondral defect of the glenoid fossa: Cross-sectional imaging features. Radiology 206:35-40, 1998
OSTEOCHONDRAL INJURIES, SHOULDER IMAGE GALLERY Tvpical (Left) Coronal FS PD FSE MR shows a chondral flap lesion (arrow) involving the mid glenoid hyaline articular cartilage. There is a small chondral defect of the superior humeral head. (Right) Sagittal FS PD FSE MR shows the chondral flap lesion (arrow) involving the hyaline articular cartilage of the glenoid fossa.
(Loft) Coronal PD FSE MR shows a subtle osteochondral injury (arrow) of the superior aspect of the humeral head adjacent to a mild strain of the supraspinatus. (Right) Coronal PD FSE MR shows grade Ill-IV chondromalacia of the superomedial aspect of the humeral head. Note the small loose chondral fragment in the joint adjacent to the inferior labrum (arrow).
Tvpical (Left) Coronal FS PD FSE MR shows chondromalacia of the superomedial HH (arrow). (Right) Axial PD FSE MR in a patient after anterior dislocation shows an osteochondral fracture of the anterior glenoid (arrow) Bankart lesion.
GREATER TUBEROSITY FRACTURE
Coronal graphic shows a fracture of the greater tuberosity that is still attached to the supraspinatus tendon. There is mild fracture diastasis.
Coronal PD FSE MR shows a minimally displaced greater tuberosity fracture with an intact supraspinatus tendon.
= Bone contusion o Fracture line or comminuted fragment o Variable displacement o +/- Heal in displaced/malaligned position
Abbreviations and Synonyms Greater tuberosity fracture (GTFx)
CT Findings
Definitions Fracture of the greater tuberosity of the humerus after direct impact injury or anterior dislocation impact o Extended Hill-Sachs fracture in case of anterior dislocation
General Features Best diagnostic clue o Increased signal within the greater tuberosity on FS PD FSE o +/- Linear decreased signal intensity line on all pulse sequences Location: Greater tuberosity of the humerus Size: Nondisplaced trabecular injury to displaced comminuted fracture 2-5 cm in size Morphology: Nondisplaced fracture to comminuted fracture with distracted fragments
NECT o Subtle disruption of trabecular pattern = Bone contusion o Fracture line or comminuted fragment o Characterization of fracture fragments Displacement Angulation o May heal in displaced/malaligned position o Reconstruction in coronal, sagittal plane
MR Findings TlWI o Decreased signal intensity Perifracture edema Bone trabecular injury without fracture line o Fracture line of decreased signal intensity o Displaced fragments seen as marrow containing +/- Displacement +/- Comminution T2WI o Increased signal at the fracture site Perifracture hyperintense edema Bone trabecular injury without fracture line
mMHB
Radiographic Findings
Radiography o Occult in case of trabecular injury
DDx: Greater Tuberosity Fracture Anatom~cNeck Fx
- *-
*
Failure FS
1
; I
Cor FS PD FSE
Cor Oblq T 1 WI
Ax FS PD FSE MR
Cor PD FSE MR
Ax FS PD FSE MR
GREATER TUBEROSITY FRACTURE Key Facts Imaging Findings I
Increased signal within the greater tuberosity on FS PD FSE +/- Linear decreased signal intensity line on all pulse sequences Occult in case of trabecular injury Increased signal at the fracture site Perifracture hyperintense edema Bone trabecular injury without fracture line FS PD FSE images sensitive
Top Differential Diagnoses Supraspinatus Tear Subscapularis Rupture Bankart Lesion Perthes Lesion
Subcortical Degenerative Cystic Change Humera' fractures Failure of Fat Saturation (Failure FS)
Pathology Direct impact Greater tuberosity avulsion after anterior dislocation Occurs after anterior dislocation of the shoulder or direct impact
Clinical Issues Posttraumatic after anterior dislocation Association with anterior dislocation (5-33% of cases)
Diagnostic Checklist FS PD FSE or STIR coronals images are sensitive to associated marrow edema -
o Fracture line = decreased signal intensity +/-
interposed hyperintensity fluid o +/- Increased signal rotator cuff strain +/- Partial to complete tear +/- Fluid-filled (hyperintense) gap o +/- Capsular sprain Thickened hyperintense sprain o FS PD FSE images sensitive Esp. with bone trabecular injury Non FS images may not identify edema or fracture morphology PDlIntermediate o Edema not well seen without FS o Without FS perifracture reactive change is intermediate in signal intensity o PD FSE useful for chondral evaluation STIR o Increased signal at the fracture site Perifracture edema Bone trabecular contusion without fracture line T2* GRE o Hypo or hyperintense fracture line easily visualized o Edema often obscured by susceptibility artifact
Imaging Recommendations Best imaging tool: MRI Protocol advice: TlWI + FS PD FSE
[DIFFERENTIAL DIAGNOSIS Supraspinatus Tear +/- Impingement +/- Anterior dislocation o > 40 years
Hyperintense gap on T2WI
+/- SLAP (superior labrum anterior posterior) lesion o SLAC (superior labrum anterior cuff) lesion Associated bursitis
Subscapularis Rupture +/- Impingement +/- Anterior dislocation
o > 40 years Hyperintense gap on T2WI in case of tear +/- Associated capsular tear o Esp. with dislocation +/- Biceps instability o Subluxation o Dislocation
Bankart Lesion
+ Anterior dislocation Posttraumatic pain and decreased range of motion Disrupted scapular periosteum Hyperintensity on T2WI = edema Displacement of labrum Perthes Lesion Intact periosteum A type of Bankart variation + Anterior dislocation, subluxation Hyperintensity on T2WI = edema Abduction with external reduction (ABER) imaging useful
Subcortical Degenerative Cystic Change Common finding in older age group Exaggerated with athletic activity No associated history of trauma Involves "bare area" Vascular perforation channels in some cases Filled with contrast at arthrography +/- Adjacent degenerative chondromalacia outside the "bare area"
Proximal Humeral fractures Anatomic neck Surgical neck Lesser tuberosity +/- Comminution +/- Displacement
Failure of Fat Saturation (Failure FS) Due to curved shoulder surface Susceptibility Frequency selective fat saturation
GREATER TUBEROSlTY FRACTURE
-
o Type I - no displaced segment o Type I1 to V - one segment is displaced
o Usually not seen with STIR Paradoxical water saturation o Leads to hypointense deltoid o Due to shift of water precessional frequency into saturation frequency range Leads to bright signal in marrow containing humerus Mimics bone trabecular injury/nondisplaced fracture No fracture line identified TZ* GRE or STIR sequence used when fat suppression fails with FS PD FSE
Type I1 - anatomic neck Type I11 - surgical neck rn Type IV - avulsion of greater tuberosity rn Type V - avulsion of the lesser tuberosity o Type VI - fracture dislocation rn
Presentation Most common signs/symptoms o Posttraumatic after anterior dislocation o Limited range of motion and pain Clinical profile o Anterior dislocation o +/- Direct trauma o Common in sports Snow skiing
General Features General path comments o Direct impact o Anterior dislocation with IGHLC (inferior glenohumeral ligament complex) or RTC (rotator cuff) abnormality o Greater tuberosity avulsion after anterior dislocation Supraspinatus tendon remains intact Etiology o Occurs after anterior dislocation of the shoulder or direct impact o Hill-Sachs fracture represents variant of greater tuberosity fracture Epidemiology o Greater tuberosity fracture is common, especially after anterior dislocation o Proximal humeral 4-5% of all fractures in adult < 1%of children's fractures 40% involve greater tuberosity Associated abnormalities o Dislocation findings rn Bankart lesion Perthes lesion ALPSA lesion Supraspinatus tear Subscapularis tendon tear Capsular sprain Hill-Sachs deformity = variant of greater tuberosity fracture o Rotator cuff strain rn +/- Tear
Demographics Age: Proximal humerus fractures - 75% of fractures in patients older than 40 years Gender: After age 50 increase incidence in females
Natural History & Prognosis Typically heals after conservative therapy Association with anterior dislocation (5-33% of cases)
Treatment Conservative measures unless a large fragment with displacement is present
I DIAGNOSTIC CHECKLIST Consider In setting of direct trauma or anterior dislocation
Image Interpretation Pearls FS PD FSE or STIR coronals images are sensitive to associated marrow edema
1.
Gross Pathologic & Surgical Features Fracture of greater tuberosity often involving chondral surface Nondisplaced, displaced or comminuted Displaced o Superior - supraspinatus involved o Posterior - infraspinatus or teres minor involved
Microscopic Features Disruption of trabeculae +/- Involving the subchondral endplate and hyaline cartilage Surrounding hemorrhage
Staging, Grading or Classification Criteria Modified Neer classification of proximal humeral fractures
I
2.
3.
4.
Burkhart SS et al: Traumatic . glenohumeral bone defects , and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 16(7):677-94,2000 Kim SH et al: Arthroscopic treatment of symptomatic shoulders with minimally displaced greater tuberosity fracture. Arthroscopy 16(7):695-700,2000 Reinus WR et al: Fractures of the greater tuberosity presenting as rotator cuff abnormality: Magnetic resonance demonstration. J Trauma 44(4):670-5, 1998 Tirman PF et al: A practical approach to imaging of the shoulder with emphasis on MR imaging. Orthop Clin North Am 28(4):483-515, 1997
GREATER TUBEROSITY FRACTURE
Typical
(Lef)Axial FS PD FSE MR shows a nondisplaced greater tuberosity fracture with the fracture line seen as linear decreased signal intensity. There is surrounding edema. (Right) Coronal FS PD FSE MR shows a nondisplaced greater tuberosity fracture with rotator cuff strain. There is a capsular sprain (arrow) present in this patient status post anterior dislocation while skiing.
Typical
(Lef)Coronal graphic shows a surgical neck transverse fracture. (Right) Coronal graphic shows an anatomic neck fracture with minimal displacement.
(Left) Coronal PD FSE MR shows a depressed Hill-Sachs fracture (greater tuberosity impaction fracture) in a patient post anterior dislocation. The rotator cuff is strained. (Right) Coronal FS PD FSE MR shows a slightly displaced fracture of the greater tuberosity with slight elevation, associated supraspinatus strain and hyperintense marrow edema.
OSTEOARTHRITIS, SHOULDER
Axial graphic shows chondromalacia, subchondral cystic change & surrounding sclerosis of glenoid & humeral head. Note the asymmetric wear of the posterior glenoid.
Axial PD FSE MR shows advanced osteoarthritic changes: Subchondral cyst formation with sclerosis of humeral head & glenoid. Osteophytes, loose bodies, and synovitis are associated.
o Progressive loss of articular cartilage with associated
new bone formation and capsular fibrosis o Osteophytes prominent
Abbreviations and Synonyms Osteoarthritis (OA), degenerative joint disease (DJD)
Definitions Degenerative arthritis characterized by chondromalacia, osteophyte formation, subchondral cysts and synovitis o Primary: Gradual process of destruction & regeneration as a result of chronic microtrauma o Secondary: Non-inflammatory degenerative joint disease resulting from predisposing event such as previous trauma, congenital deformity, infection or a metabolic disorder
Radiographic Findings Radiography o Joint space narrowing o Subchondral sclerosis/eburnation of increased density o Subchondral cysts o Osteophyte formation
MR Findings TlWI o Decreased signal intensity subchondral cysts o Marrow fat signal extends into osteophytes o Subchondral decreased signal indicating sclerosis
and/or edema o Evaluate posterior glenoid version
T2WI
General Features Best diagnostic clue: Chondromalacia +/- subchondral sclerosis, subchondral cysts and/or edema, and osteophytes Location: Shoulder joint hyaline chondral surfaces and subchondral bone Size: Small localized area (typically post trauma) to entire glenohumeral joint Morphology
o Subarticular cysts seen as high signal rounded
o o o o
lesions Hyperintensity in hyaline cartilage Subchondral bone marrow edema (bright signal) Subchondral decreased signal = sclerosis General thinning of articular (hyaline) cartilage with occasional focal defects
DDx: Osteoarthritis, Shoulder AVN
Cor PD FSE MR
Cor PD FSE MR
Ax PD FSE MR
Cor FS P13 FSE
Cor FS PD FSE
OSTEOARTHRITIS, SHOULDER Key Facts Terminology Degenerative arthritis characterized by chondromalacia, osteophyte formation, subchondral cysts and synovitis
Imaging Findings
,
Joint space narrowing Subchondral sclero$s/eburnation of increased density Subchondral cysts Osteophyte formation especially involving the humeral head Loose bodies Posterior glenoid wear leads to increased retroversion of the glenoid
Top Differential Diagnoses Inflammatory Arthritis o FS PD FSE (more sensitive sequence than T2 FSE)
shows hyperintensity in hyaline cartilage and subchondral bone marrow edema PDIIntermediate o Synovitis seen as thickening of the synovium especially on proton density images o PD FSE: Cartilage not as well seen * TZ* GRE: Subarticular cysts seen as high signal erosions on gradient echo images T1 C+: Synovium enhances with synovitis Osteophyte formation especially involving the humeral head Loose bodies Posterior glenoid wear leads to increased retroversion of the glenoid Asymmetric joint space narrowing
Imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE
I DIFFERENTIAL DIAGNOSIS Inflammatory Arthritis Polyarticular systemic disease (e.g., rheumatoid arthritis ) +/- Serum indicators Synovitis +/- erosions
Synovitis Septic Arthritis Neuropathic Arthritis
Pathology Begins as fatigue fracture of the collagen meshwork followed by increased hydration of the articular desiccated seen with (as aging) and loss of proteoglycans from the matrix into the synovial fluid
Clinical Issues Slowly progressive pain with utilization of the joint and variable degrees of swelling (effusion)
Diagnostic Checklist Utilize FS PD FSE to visualize chondral findings
Cuff Tear Arthropathy Secondary to long-standing chronic massive rotator cuff tear Considered form of osteoarthritic change in shoulder
Milwaukee Shoulder Secondary to hydroxyapatite crystal deposition disease Severe degenerative changes
Capsulorrhaphy Arthropathy Secondary to over tightening for instability Osteoarthritis changes may be focal depending on exact type of resulting disability
Avascular Necrosis (AVN) Double line sign may mimic subchondral cysts
Humeral Head Osteochondral Defect (HH OCD) Focal articular cartilage defect + History of trauma
Posterosuperior Glenoid Impingement (PSG I) Internal impingement Athletes Undersurface supraspinatus tear, posterosuperior labral frayingltear, humeral head posterosuperior chronic impaction injury
Synovitis Associated with prominent erosions that may mimic subarticular cysts +/- Polyarticular
Septic Arthritis Positive blood cultures o White cell count of more than 75,000/mm3
Neuropathic Arthritis Secondary to loss of nerve supply Fragmentation, destruction Secondary to diabetes (diab. arthropathy)
General Features General path comments o Begins as fatigue fracture of the collagen meshwork followed by increased hydration of the articular cartilage (as opposed to desiccated cartilage seen with aging) and loss of proteoglycans from the matrix into the synovial fluid Shoulder predisposed to unique instabilities because of non weight-bearing anatomy
OSTEOARTHRITIS, SHOULDER
n 140
Compression of weakened bone with subchondral collapse Loose bodies - fragmentation of osteochondral surfaces +/- Osteonecrosis Synovial hypertrophy - joint pain by nerve stimulation Synovial fluid - increased intraarticular pressure "stretching the joint lining" = pain Etiology o Post-operative instability patients (secondary arthritis) o Younger patient if posttraumatic or post-operative (secondary arthritis) o Leading theory - chronic microtrauma leading to disruption of the articular surface, fibrillation, eburnation, eventually subchondral cysts, and osteophytes 0 If asymmetric capsular contracture is present, premature obligate translation results in chondral damage/DJD Obligate translation - movement of the humeral head in a direction opposite that of the tight capsule 0 Tendon ruptureslweakness of muscle group lead to eccentric loading of the joint = OA Epidemiology: Relatively uncommon compared to impingement Associated abnormalities o Rotator cuff tears Often indication for MRI with known shoulder OA
Gross Pathologic & Surgical Features Chondromalacia, osteophyte formation, subchondral cysts, synovitis Degraded cartilage with loss of sheen, fissured andlor ulcerated cartilage surface, articular surface collapse Subchondral geodes (cysts) with debris Buttressing osteophytes to increase surface area Eccentric glenoid wear (posteriorly) contracture of anterior capsule and subscapularis
Microscopic Features Synovial infiltration with polymorphonuclear leukocytes (PMNs) (synovitis) Diminution of chondrocytes in superficial zones with chondrocyte swelling Cartilage matrix loses its ability to stain for proteoglycans with Alcian blue or safranin-0 Matrix chondrocytes demonstrate proliferation in clusters (brood capsules) Neovascularity penetrates layer of calcified cartilage New chondrocytes extend up from the deeper layers Hypertrophied synovium becomes folded into villous folds with variable infiltration of plasma cells, and lymphocytes
Presentation Most common signs/symptoms
o Slowly progressive pain with utilization of the joint
and variable degrees of swelling (effusion) o Often antecedent traumatic history o Decreased motion (external rotation loss > internal
rotation loss) o Crepitus
Demographics Age: Elderly patient or younger patient if posttraumatic or post-operative Gender: M 2 F
Natural History & Prognosis Progressively debilitating disease unless medical intervention
Treatment Usually conservative o Physical therapy o NSAIDs Total shoulder replacement in severe cases
I DIAGNOSTIC CHECKLIST Consider Secondary OA if findings are focal
Image Interpretation Pearls Utilize FS PD FSE to visualize chondral findings Asymmetrical wear of the posterior glenoid
1 SELECTED 1.
REFERENCES -
-
Kelley MJ et al: Osteoarthritis and traumatic arthritis of the shoulder. J Hand Ther 13(2):148-62, 2000 2. Rockwood CA Jr et al: Disorders of the acromioclavicular joint. 2nd ed. Philadelphia PA, WB Saunders, 483-553, 1998 3. Stoller DW et al: Magnetic resonance imaging in orthopaedics and sports medicine. vol 1. 2nd ed. Philadelphia PA, J.B. Lippincott, 597-742, 1997 4. Matsen FA 111: Early effectiveness of shoulder arthroplasty for patients who have primary glenohumeral degenerative joint disease. J Bone Joint Surg Am 78(2):260-4, 1996 5. Bigliani LU et al: Glenohumeral arthroplasty for arthritis after instability surgery. J Shoulder Elbow Surg 4(2):87-94, 1995 6. Matsen FA I11 et al: Practical evaluation and management of the shoulder. Philadelphia PA, WB Saunders, PAGE, 1994 7. Resnick D: Bone and Joint Imaging. 1st ed. Philadephia PA, WB Saunders, 1330, 1989
OSTEOARTHRITIS, SHOULDER
I IMAGE GALLERY (Left) Coronal PD FSE MR shows a chondral flap lesion (arrow) of the glenoid in a patient with early manifestations of osteoarthritis. There is minimal chondromalacia of the humeral head and osteophyte formation. (Right) Sagittal PD FSE shows posterior glenoid subchondral cysts in this patient with chronic posterior instability and secondary osteoarthritis. Note the synovitis in the anterior joint.
(Left) Coronal FS PD FSE MR shows marked synovitis with synovial fronds (arrow) visible in the axillary pouch. Humeral head chondromalacia with underlying bone marrow reactive edema is present. (Right) Coronal PD FSE MR shows advanced osteoarthritic change with some foci of osteonecrosis/subcortical cystic change, osteophyte formation, synovitis, and joint debris.
(Left) Coronal PD FSE MR shows advanced osteoarthritis changes including full thickness chondral loss, subcortical cyst formation, and large osteophytes. There is partial rotator cuff tearing. (Right) Sagittal PD FSE MR shows marked osteoarthritic change of the glenoid. A chronic fracture of the inferior glenoid is seen as transverse linear signal intensity.
RHEUMATOID ARTHRITIS, SHOULDER
Axial graphic shows erosive changes, cartilage degradation and joint debris in a patient with rheumatoid arthritis.
Coronal PD FSE MR shows severe synovitis within the shoulder joint as well as hypertrophic bursitis. There are erosive changes within the humeral head. The rotator cuff is torn.
o Thickened edematous synovium with effusion in
Abbreviations and Synonyms
patient with chronic articular inflammation Erosions common Location o Affects synovium first secondary cartilage and bone destructive changes -- deformity o Paraarticular nodules - in 20% of RA patients Mixed signal intensity masses in the skin, synovium, tendons, sclera, viscera o Joint space, greater tuberosity and acromioclavicular joint Size: Usually diffuse involvement of synovium Morphology o Thickened irregular synovium usually in the presence of joint effusion Synovitis followed by erosive/destructive changes
-
Rheumatoid arthritis (RA)
Definitions Systemic inflammatory arthritic condition requiring the presence of 4 of the following 7 criteria for > 6 weeks Classification criteria for rheumatoid arthritis o Morning stiffness o Oligo or polyarthritis in three or more joints or several joint groups o Arthritis of either wrist, metacarpophalangeal joint or proximal interphalangeal joint o Symmetric arthritis o Rheumatoid nodules over bony prominences, extensor surfaces or juxta-articular o Abnormal amounts of serum rheumatoid factor o Radiographic changes including erosions and juxta-articular demineralization
Radiographic Findings Radiography o Joint space narrowing Flattening of glenoid fossa o Effusion and erosion o Occasional cyst formation (cystic rheumatoid) o +/-Joint destruction
mmIEIHfl CT Findings
General Features
NECT Joint space narrowing, effusion, occasional cyst formation (cystic rheumatoid) followed by destruction CECT: Inflamed synovium enhances
Best diagnostic clue
DDx: Rheumatoid Arthritis, Shoulder
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RHEUMATOID ARTHRITIS, SHOULDER Key Facts Terminology
Extraarticular Mass
Systemic inflammatory arthritic condition requiring the presence of 4 of the following 7 criteria for > 6 weeks
imaging Findings
Pathology Pannus (granulation/synovium) tissue erodes cartilage & bone
Clinical issues
Thickened edematous synovium with effusion in patient with chronic articular inflammation Affects synovium first -- secondary cartilage and bone destructive changes deformity Erosions and fluid are decreased in signal intensity
-
Top Differential Diagnoses Systemic Lupus Erythematosus Osteoarthritis (OA) Greater Tuberosity Fracture (Gr Tuberosity Fx) Neuropathic Joint (Charcot Joint)
MR Findings TlWI o Erosions and fluid are decreased in signal intensity o Elevation of humeral head o Distal clavicle resorption T2WI o Hyperintense joint effusion & subacromial-subdeltoid bursitis o Diffuse hyaline cartilage loss o Rice bodies - decreased signal masses within effusion o Erosions: Increased signal intensity defects in the subchondral bone (marginal, central) o FS PD FSE shows subchondral edema o Cuff atrophy PDlIntermediate: Demonstrates inflamed synovium as thickened increased signal intensity joint lining T2* GRE: Erosions visualized (less sensitive compared to FS PD FSE) TI C+: Inflamed synovium will enhance
Nuclear Medicine Findings Bone Scan: Bone reactive change will demonstrate increased uptake
imaging Recommendations Best imaging tool: MRI Protocol advice o T1 and FS PD FSE, +/- PD FSE PD FSE & FS PD FSE demonstrates hypertrophied synovium and chondral erosions
Pain, swelling, morning stiffness 10% improve after first attack of synovitis and up to 60% remissions Up to 10% disabled
Diagnostic Checklist Evaluate PD images for synovial thickening, effusions and erosions
Proliferative osseous changes Primarily involves wrist/hands, feet, sacroiliac joint and spine
Osteoarthritis (OA) Primary vs. secondary: Secondary to trauma Subchondral cysts Osteophytes Not systemic disease
Greater Tuberosity Fracture (Gr Tuberosity Fx)
+ History of trauma
Bone trabecular injury, comminuted fracture Hyperintense on T2WI of greater tuberosity FS PD FSE most sensitive Mimics erosion(s)
Neuropathic Joint (Charcot Joint) No neural supply to joint Fragmentation/disorganization Diabetes associated Mimics erosion(s)
Extraarticular Mass Mimics bursa1 effusion/enlargement Hemangioma/lipoma/metastaticdisease Extraarticular Hyperintense on T2WI o Few exceptions (desmoid) Hypointense on TlWI o Exceptions (lipoma, fatty components of hemangioma)
Systemic Lupus Erythematosus Characteristic rash and other symptoms/signs Bone involvement different from RA Erosions uncommon +/- Subluxation
Psoriatic Arthritis Seronegative spondyloarthropathy Asymmetric, erosive, destructive articular process
General Features General path comments o Rheumatoid factor (RF): IgM o Lab tests alone do not confirm the diagnosis of RA RF present in normal individuals: Often low titers Present in other diseases
RHEUMATOID ARTHRITIS, SHOULDER
144
Genetics: HLA-D allele DR4 is associated with RA patients Etiology o Combination of genetic and environmental factors o The interaction of antigen presenting macrophages with T cells Helperlinducer theory likely inciting event o Complexes of IgM & IgG rheumatoid factor can deposit in blood vessels and lead to vasculitis Leads to vasculitis with secondary effects o Hepatitis B vaccine may be causative in a small number of patients Epidemiology: 2% of general population Associated abnormalities o Felty's syndrome characterized by splenomegaly and leukopenia o Still's disease characterized by fever, rash and splenomegaly o Sjogren syndrome characterized by decreased salivary and lacrimal gland secretion Lymphoid proliferation o Extraarticular manifestations Nodules, lymphadenopathy, splenomegaly, vasculitis, myopathy, sensory changes Neuropathy Direct compression of nerves/vessels from synovitis Visceral changes including pericarditis, pulmonary fibrosis, nodules, and pleuritic pain
.
o + Criteria of stage 111 o Fibrous or bony ankylosis
Remission of RA - 5 or more of the following conditions present for at least 2 consecutive months o Duration of morning stiffness not exceeding 15 minutes o No fatigue o No joint pain o No joint tenderness or pain with motion o No soft tissue swelling in joints or tendon sheath
Presentation Most common signs/symptoms o Pain, swelling, morning stiffness o 7 inclusion criteria
Demographics Age: Adult for classical RA, variants (juvenile) affect younger patients Gender o Female - 3% of overall population o Male - 1% of overall population
Natural History & Prognosis 10% improve after first attack of synovitis and up to 60% remissions Up to 10% disabled Poor prognostic indicators include o High RF, periarticular erosions, rheumatoid nodules, muscle wasting, joint contractures
Gross Pathologic & Surgical Features Pannus (granulation/synovium) tissue erodes cartilage & bone o Direct extension of pannus occurs at the margins of the joint o Pannus +/- tendon sheaths o Rice bodies as detached fibrotic synovial villi Uniform joint space narrowing
Treatment Conservative o Rest, physical therapy o Pyramid pharmaceutical approach including NSAIDs, antimalarials, disease modifying agents MTX, sulfasalazine, gold, penicillamine, steroids and cytotoxic drugs Surgical o Synovectomy, arthroplasty, arthrodesis, osteotomy
.
Microscopic Features Vascular congestion and synovial cell proliferation Infiltration of subsynovial layers by PMNs, lymphocytes & plasma cells Synovial villous formation
Staging, Grading or Classification Criteria Stage I o No destructive changes - radiographic examination o +/- Radiographic evidence of osteoporosis Stage 11 o Radiographic evidence of periarticular osteoporosis +/- subchondral bone destruction o +/- Mild cartilage destruction o +/- Limited joint mobility o No joint deformities o + Muscle atrophy o +/- Extraarticular soft tissue lesions nodules, tenosynovitis Stage 111 o Radiographic evidence of cartilage and bone destruction + periarticular osteoporosis o Joint deformity (e.g., subluxation, ulnar deviation, hyperextension) without fibrous or bony ankylosis Stage IV
Consider Other causes of synovitis o Clinical picture, are the findings monoarticular or polyarticular, etc.
Image Interpretation Pearls Evaluate PD images for synovial thickening, effusions and erosions
1.
2.
Gibbons CE et al: Long-term results of arthroscopic synovectomy for seropositive rheumatoid arthritis: 6-16 year review. Int Orthop 26(2):98-100, 2002 Matsuno H et al: Relationship between histological findings and clinical findings in rheumatoid arthritis. Path01 Int 52(8):527-33,2002
I
RHEUMATOID ARTHRITIS, SHOULDER
I IMAGE GALLERY (Lef)Axial PD FSE MR shows large erosions within the humeral head in a patient with rheumatoid arthritis. There is severe synovitis. (Right) Axial FS PD FSE MR shows the synovial pannus.
(Lef)Coronal STlR MR shows numerous rice bodies within subacromial bursa in a patient with rheumatoid arthritis. The patient presented with a palpable mass which was initially diagnosed as soft tissue sarcoma. Note axillary pouch synovitis. (Right) Coronal STlR MR shows rice bodies and synovitis within the subacromial bursa in a patient with rheumatoid arthritis.
(Lef)Coronal PD FSE MR shows rice bodies within the bursa and marked proliferative pannus. (Right) Sagittal FS PD FSE MR shows rice bodies within the subacromial bursa and marked synovitis and rice bodies within the joint.
QUADRILATERAL SPACE SYNDROME
Coronal graphic shows an abnormal axillary nerve within the quadrilateral space. There are resulting denervation changes of the teres minor.
Coronal T2 FSE MR shows denervation within the deltoid and teres minor (arrow) muscles. These findings are consistent with axillary involvement.
0
Abbreviations and Synonyms
Fracture Fatty atrophy of deltoid or teres minor
Radiographic Findings
Quadrilateral space syndrome (QSS)
Definitions Entrapment neuropathy (compression) of the axillary nerve (AN) in quadrilateral space
I IMAGING FINDINGS General Features Best diagnostic clue: Increased signal intensity within teres minor (TM) and deltoid muscle (DM) indicating denervation on FS PD FSE or STIR images Location: Humerus laterally, teres major (TMA) inferiorly, teres minor (TM) superiorly, long head of triceps medially Size o Mass: Variable size range - millimeters to centimeters o Fibrosis: Strands of variable size Morphology 0 Compression within boundaries of quadrilateral space Mass Fibrous band
Radiography 0 +I- Osseous changes associated with anteriorlposterior dislocation if labral cyst responsible for QSS (mass compression) +/- Bankart fracture (anterior inferior glenoid rim) +I- Hill-Sachs deformity (posterolateral humeral head) Cyst dissects from inferior labrum
CT Findings NECT o +/- Anteriorlposterior dislocation findings as clue to cystic mass responsible for QSS +/- Bankart fracture +/- Hill-Sachs deformity Cyst dissects from inferior labrum tear Anterior dislocation cause of axillary neurapraxia CT arthrography o +I- Inferior labral tearlcyst Contrast fills tearlcyst Anteroinferior or posteroinferior
mmw MR Findings
TlWI 0 +/- Streaky decreased signal intensity = fibrosis
DDx: Quadrilateral Space Syndrome
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QUADRlLATERAL SPACE SYNDROME Key Facts Imaging Findings Best diagnostic clue: Increased signal intensity within teres minor (TM) and deltoid muscle (DM) indicating denervation on FS PD FSE or STIR images +/- Streaky decreased signal intensity = fibrosis
Top Differential Diagnoses Anterior Shoulder Dislocation Proximal Humeral Fracture Brachial Neuritis Mass Lesion
Pathology Nerve & vessel damaged/occluded in QSS Distal branch of axillary nerve involved f Involvement of posterior humeral circumflex artery
o
Clinical Issues Paresthesias, muscle weakness and tenderness on palpation of the quadrilateral space * Paresthesias involve lateral shoulder and upper posterior arm * Resolution with time in case of posttraumatic neurapraxia Progress if secondary to compressing mass
Diagnostic Checklist Posttraumatic axillary neurapraxia if patient presents with TM and DM increased signal after anterior dislocation on FS PD FSE or STIR FS PD FSE show demonstrates in muscle in acute and subacute phases, TlWI demonstrates fatty atrophy
+/- Decreased signal intensity mass - compressive
neuropathy T2WI o +/- Hypointense fibrosis - compression o Increased signal intensity mass - compressive neuropathy (FS PD FSE - STIR) +/- Cystic mass: Paralabral cyst extending into space o Muscles atrophic + mildly increased in signal = chronic denervation Decreased size o Muscles increased in size + increased in signal intensity = acute + subacute denervation = Swelling o T2 FSE less sensitive to edema PDJIntermediate: Masses of intermediate signal intensity T2* GRE o Fatty atrophy of chronic denervation as decreased signal within the TM +/- DM o Decreased muscle volume (mass) + hypointensity of fatty infiltration T1 C+ o Cystic mass may demonstrate rim enhancement o Denervated muscles show enhancement in acute, subacute phase MR arthrography o Inferior labral tear associated with inferiorly directed paralabral cyst
Ultrasonographic Findings +/- Cystic mass o Anechoic o Through transmission
Imaging Recommendations Best imaging tool: MRI Protocol advice o Tl/PD + FS PD FSE in all three planes o Consider using intravenous contrast to differentiate cystic and solid soft tissue mass
Anterior Shoulder Dislocation +/- Axillary neurapraxia (axillary praxia) +/- Labral tear o Bankart lesion o Bankart variant lesion o +/- Rotator cuff tear
+/- Hill-Sachs fracture
Proximal Humeral Fracture History of trauma Anatomic neck, surgical neck +/- Comminution Shoulder pain with abduction
Brachial Neuritis +/- Parsonage-Turner syndrome (idiopathic brachial neuritis) Posttraumatic neurapraxia +/- Viral prodrome +/- History of trauma
Mass Lesion Benign o Lipoma o Hemangioma Metastasis Compression of nerve by mass effect Central fibrosis = neuroma + Contrast enhancement if solid tumor Rim enhancement of benign cystic mass
Hematoma History of trauma Compression of nerve by mass effect Hyperintense on T2WI +/- Blooming: Chronic on GRE o Hemosiderin
1 PATHOLOGY
o Neurotmesis: Nerve sheath and connective tissue
elements are torn Regeneration does not occur
General Features General path comments o Nerve & vessel damaged/occluded in QSS o Distal branch of axillary nerve involved + Involvement of posterior humeral circumflex artery Etiology o Nerve +/- artery compressed with resulting denervation/ischemia o Compression Proximal humeral and scapular fractures Fibrous bands (posttraumatic) Mass (including teres minor hypertrophy) o Axillary nerve innervates teres minor, deltoid muscles and posterolateral cutaneous area of upper arm/shoulder Epidemiology o Uncommon abnormality o > 3% patients presenting with shoulder pain/dysfunction Associated abnormalities o Inferior labral tears o TM, DM muscle denervation changes o Anterior instability if labral tear present Bankart lesion Perthes lesion Anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion Extended superior labrum anterior to posterior (SLAP) lesion (type V)
Presentation Most common signs/symptoms o Paresthesias, muscle weakness and tenderness on palpation of the quadrilateral space Paresthesias involve lateral shoulder and upper posterior arm Clinical profile o Athletes o Pain increased by abduction & external rotation of arm
Demographics Age: 22 to 35 years Gender: M > F
Natural History & Prognosis Resolution with time in case of posttraumatic neurapraxia Progress if secondary to compressing mass
Treatment Conservative in case of neurapraxia Relief of compression due to mass or fibrous bands may be necessary Surgical extirpation
Gross Pathologic & Surgical Features Axillary nerve passes through quadrilateral space with posterior circumflex artery Denervation changes within the affected muscles Swollen muscle belly - early and subacute phase Fatty atrophy = chronic phase o Deltoid and teres minor
Consider Posttraumatic axillary neurapraxia if patient presents with TM and DM increased signal after anterior dislocation on FS PD FSE or STIR
Image Interpretation Pearls
Microscopic Features Enlarged extracellular fluid space = early and subacute (phase) Fatty infiltration = chronic Myofibril atrophy become small and angular with early denervation
-
Staging, Grading or Classification Criteria
-
Early, subacute 0-3 months Chronic - corresponds to fatty atrophy > 3 months Three stages of nerve injury o Neurapraxia: Transient episode of motor paralysis with little or no sensory or autonomic dysfunction No disruption of the nerve or its sheath occurs With removal of the compressing force, recovery should be complete o Axonotmesis: More severe nerve injury with disruption of the axon and myelin sheath with preservation of connective tissue Motor, sensory, and autonomic paralysis results Degeneration of axon distal to site of injury ~egenerationof axon is spontaneous
FS PD FSE show demonstrates in muscle in acute and subacute phases, TlWI demonstrates fatty atrophy
~ C T E REFERENCES D --
1.
DeLee J et al: Orthopaedic sports medicine. Basic science and injury of muscle, tendon and ligaments. vol 1. 2nd ed. Philadelphia PA, Saunders, 1-66, 2003 2. Sallomi D et al: Muscle denervation patterns in upper limb nerve injuries: MR imaging findings and anatomic basis. AJR 171(3):779-84,1998 3. Helms CA et al: Acute brachial neuritis (Parsonage-Turner syndrome): MR imaging appearance--report of three cases. Radiology 207(1):255-9, 1998 4. France1 TJ: Quadrilateral space syndrome: Diagnosis and operative decompression technique. Plast Reconstr Surg 87:911-6, 1991 5. Cahill BR et al: Quadrilateral space syndrome. J Hand Surg 65-9, 1983
QUADRILATERAL SPACE SYNDROME
Typical (Left) Sagittal PD FSE MR image in a patient with quadrilateral space syndrome shows an inferiorly dissecting paralabral cyst (arrow) in a professional football player. (Right) Sagittal PD FSE MR shows denervation atrophy of the teres minor (arrow). This is a manifestation of quadrilateral space syndrome.
Typical (Left) Sagittal PD FSE shows a large lipoma (arrow) within the quadrilateral space. It is difficult without fat saturation to differentiate between fat and a cyst. (Right) Coronal FS PD FSE MR in the same patient shows the mass in the quadrilateral space which represents a lipoma with suppression of fat signal.
(Left) Sagittal FS PD FSE MR shows an inferiorly dissecting cyst into the quadrilateral space. (Right) Coronal STIR MR shows varices within the quadrilateral space as a cause of quadrilateral space syndrome. Deltoid muscle is hyperintense.
SUPRASCAPULAR, SPlNOGLENOlD NOTCH
Coronal graphic shows suprascapular nerve extending beneath transverse scapular ligament (arrow) of the suprascapular notch & distributing terminal branches in spinoglenoid notch.
Coronal PD FSE MR shows the suprascapular nerve (arrow) within the suprascapular and spinoglenoid notch.
o Subtle widening of the SGN on axillary view
Chronic cyst and erosion formation
Abbreviations and Synonyms Suprascapular notch (SSN), spinoglenoid notch (SGN)
Definitions Impingement of the suprascapular nerve within the SSN or SGN
General Features Best diagnostic clue: Denervation as increased (T2WI) signal (acute/subacute) or atrophy (chronic) of supraspinatus (SS) and/or infraspinatus Location o SSN is at superior glenoid o SGN is at posterior glenoid o Suprascapular nerve exits brachial plexus Traverses underneath the transverse scapular ligament to enter the SSN Travels posteriorly/inferiorly to enter the SGN Size: Notches 1-3 cms in size Morphology: Fibroosseous tunnel at scapular notch and posterior concavity in spinoglenoid notch
Radiographic Findings
CT Findings NECT o Widening of the SGN on axial view Cyst and erosion Coronal reformations CT arthrography o Labral tear associated with cyst causing denervation Contrast extends through tear Coronal reconstructions Superior labrum anterior-posterior (SLAP) lesion most common
MR Findings TlWI o Fatty atrophy (increased signal of fat) of affected muscles with chronic denervation Supraspinatus Infraspinatus o Labral tear as intermediate signal extending through labrum or base of labrum SLAP lesion most common Posterosuperior labral tear T2WI o Denervation: High signal of affected muscles +/- Atrophy (hypointense on FS PD FSE)
Radiography
DDx: Suprascapular, Spinoglenoid Notch Parsonage-Turner
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Liporna
Normal Vessels
Ax FS PD FSE
Cor FS PD FSE
SUPRASCAPULAR, SPlNOCLENOlD NOTCH Key Facts Best diagnostic clue: Denervation as increased (TZWI) signal (acute/subacute) or atrophy (chronic) of supraspinatus (SS) and/or infraspinatus Suprascapular nerve exits brachial plexus Traverses underneath the transverse scapular ligament to enter the SSN Travels posteriorly/inferiorly to enter the SGN Denervation: High signal of affected muscles +/- Hyperintense cystic septated mass arising from or adjacent to labrum or capsule
Top Differential Diagnoses
Cervical Spine Disease Infraspinatus Tear
Pathology Suprascapular nerve originates from brachial plexus (C5-C6)
Clinical Issues SSN compression syndrome Pain, weakness of SS and IS Proprioceptive change Mimics rotator cuff tear clinically
Diagnostic Checklist
Mass Compression of Suprascapular Nerve Effect of Adjacent Trauma Parsonage-Turner Syndrome
Assume paralabral cysts communicate with labral tears -
o +/- Hyperintense cystic septated mass arising from or
adiacent to labrum or ca~sule o Labral tear as linear hyperintensity or avulsion o FS PD FSE sensitive for showing acute and subacute changes of muscle edema (denervation) o Intraosseous cyst + Hv~erintensebone reactive edema Intraosseous extension of paralabral cyst
-
Cervical Spine Disease
+ Radiculitis pain
+/- Weakness +/- Disc herniation +/- Stenosis
'L
Imaging Recommendations Best imaging tool: MRI Protocol advice o FS PD FSE for denervation in acute/subacute phase o TlWI demonstrates chronic fatty atrophy
Mass Compression of Suprascapular Nerve Neoplasm o Extension from scapula Metastatic disease Varices o Compression neuropathy o Congestive heart failure (CHF) Lipoma
Effect of Adjacent Trauma Neurapraxia (failure of conduction) Callus from adjacent fracture +I-Hematoma Axonotmesis (disruption axon and myelin sheath) Direct neurotmesis (severance of nerve)
Parsonage-Turner Syndrome Shoulder girdle muscles o Supraspinatus o Infraspinatus o Deltoid +/- Viral prodrome Shoulder pain + weakness Self limiting
lnfraspinatus Tear Rare in isolation +/- Internal impingement o Throwing athletes o Occupational o Posterosuperior labrum tear o Posterosuperior cuff (supraspinatus/infraspinatus) partial articular surface tear o Posterosuperior humeral head - cystic erosions Discontinuous fibers + hyperintense edemalhemorrhage on T2WI
1 PATHOLOGY General Features General path comments o Suprascapular nerve originates from brachial plexus (C5-C6) o Location of nerve compression Proximal entrapment at scapular incisura Distal entrapment at spinoglenoid notch o Cysts arising from posterosuperior aspect of the joint are "funneled" between the supraspinatus and infraspinatus To SSN and SGN Path of least resistance Etiology o Sling effect with contact between suprascapular nerve and transverse scapular ligament o Proximal entrapment - muscle denervation Supraspinatus Infraspinatus o Distal entrapment - muscle denervation Infraspinatus
SUPRASCAPULAR, SPlNOGLENOlD NOTCH o Paralabral cysts (suprascapular or spinoglenoid
notch) o Stretch injury to nerve
o Scapular fractures o Adduction and internal rotation - increased
Presentation Most common signs/symptoms o SSN compression syndrome Pain, weakness of SS and IS Proprioceptive change Mimics rotator cuff tear clinically Clinical profile o Suprascapular nerve compression syndrome if located posterosuperiorly 0 Instability and/or SLAP lesion (labral tear) 0 Pain and weakness of supraspinatus and infraspinatus, proprioceptive changes (suprascapular denervation) o EMG Nerve conduction studies from Erb's point to supraspinatus
suprascapular nerve tension deep to spinoglenoid ligaments o Hyperabduction + eccentric contraction of infraspinatus o Overhead activities Volleyball and tennis o Soft tissue masses o Osseous tumors 0 Vascular malformations Epidemiology o Most common cause: Compression by cyst o Spinoglenoid ligament in 50-80% of cases Associated abnormalities: Erosion of SGN in case of chronic cyst
Gross Pathologic & Surgical Features Anatomic fossa that transmits the SSN Compression may be by cyst, mass, varix or thickenec transverse scapular ligament Spinoglenoid ligament (lateral to transverse scapular ligament) 0 Type I - thin fibrous band o Type I1 - distinct ligament o Inserts into posterior capsule o Tightens with adduction and internal rotation o Additional potential site of nerve injury Suprascapular notch o U-shaped morphology o Wide open to enclosed with bone
Demographics Age o Adult with gradual onset of SSN denervation syndrome o Occasionally teen athlete with labral tear Gender: M > F
Natural History & Prognosis Nerve compression may lead to irreversible damage and requires drainage to relieve compression o Address labral damage to prevent recurrence if caused by cyst 0 Treat neoplasm, metastatic lesion
Treatment Relief of mass compression
Microscopic Features Nerve undergoes Wallerian degeneration if compressed If compressed by cyst: Cyst with wall containing spindle-shaped cells o Cyst contains mucoid material Fatty infiltration of muscle tissue in chronically denervated muscles
Staging, Grading or Classification Criteria Three stages of nerve injury o Neurapraxia: Transient episode of motor paralysis with little or no sensory or autonomic dysfunction No disruption of the nerve or its sheath occurs With removal of the compressing force, recovery should be complete o Axonotmesis: More severe nerve injury with disruption of the axon and myelin sheath with preservation of connective tissue Motor, sensory, and autonomic paralysis results Degeneration of axon distal to site of injury Regeneration of axon is spontaneous o Neurotmesis: Nerve sheath and connective tissue elements are torn Regeneration does not occur
I DIAGNOSTIC CHECKLIST Consider Identify mass in SSN +/- SGN if increased signal in supraspinatus and infraspinatus muscle Assume paralabral cysts communicate with labral tears
1 SELECTEDREFERENCES 1. 2. 3. 4.
5.
DeLee J et al: Orthopaedic sports medicine. vol 1. 2nd ed. Philadelphia PA, Saunders, 1154-60, 2003 Tirman PF et al: A practical approach to imaging of the shoulder with emphasis on MR imaging. Orthop Clin North Am 28(4):483-515, 1997 Steiner E et al: Ganglia and cysts around joints. Radio1 Clin North Am 34(2):395-425, 1996 Tirman PF et al: Association of glenoid labral cysts with labral tears and glenohumeral instability: Radiologic findings and clinical significance. ~adiology190(3):653-8, 1994 Fritz RC et al: Suprascapular nerve entrapment: Evaluation with MR imaging. Radiology 182(2):437-44,1992
1
SUPRASCAPULAR, SPlNOCLENOlD NOTCH
Tvpical (Lef)Sagittal PD FSE MR shows a fracture (arrow) through the base of the coracoid with surrounding callus. Subtle hyperintensity in the supraspinatus and infraspinatus muscles, consistent with suprascapular denervation. (Right) Axial TZXGRE MR shows a fracture through the base of the coracoid process and edema within the infraspinatus muscle.
Tvpical
(Left)Axial PD FSE MR shows normal suprascapular neurovascular bundle (arrow) within the suprascapular and spinoglenoid notch. (Right) Axial PD FSE MR shows the suprascapular neurovascular bundle (arrow) within the spinoglenoid notch at the posterior aspect of the scapula.
(Left)Axial PD FSE MR shows intraosseous (arrow) extension of a spinoglenoid notch cyst into the posterior glenoid rim. Chronic changes of infraspinatus atrophy (open arrow) are present. (Right) Axial PD FSE MR shows a cyst extending from a posterosuperior labral tear into the spinoglenoid notch with compression neuropathy involving the infraspinatus (arrow).
SECTlON 2: Elbow Tendinopathy Lateral Epicondylitis Medial Epicondylitis Biceps Tendon Rupture Triceps Tendon Rupture
Instability Lateral Collateral Ligament Injury Posterior Dislocation, Elbow MCL Elbow Injury Little Leaguer's Elbow
Neuropathy Ulnar Neuropathy Radial Neuropathy Median Neuropathy Anconeus Epitrochlearis
Osseous Trauma Coronoid Process Fracture Capitellar Osteochondritis Radial Head Fracture Loose Bodies and 0 s Supratrochleare Olecranon Fracture Lateral Condylar Fracture Capitellum Fracture Supracondylar Fracture Medial Condylar Fracture
Inflammation Bicipital Radial Bursitis Olecranon Bursitis Synovial Fringe, Elbow
Arthritis Osteoarthritis, Elbow Rheumatoid Arthritis, Elbow
Infection Osteomyelitis, Elbow
LATERAL EPlCONDYLlTlS
Coronal graphic shows degeneration and extensive partial tearing of the common extensor tendon origin from the lateral epicondyle. The ECRB is affected first.
Coronal FS PD FSE MR shows an extensive partial tear of the common extensor tendon origin (arrow).
Morphology o Varies from thickening and heterogenous appearance = tendinosis o +I- Discrete tear o +I- Large irregular tear
Abbreviations and Synonyms Tennis elbow, extensor carpi radialis brevis (ECRB) partial avulsion
Radiographic Findings
Definitions Chronic microtrauma (overuse) injury of the extensorttendons originating on the lateral epicondyle
1
IMAGING FINDINGS General Features Best diagnostic clue: Thickening and increased signal intensity within the common extensor origin from the lateral epicondyle on all pulse sequence Location o Common extensor tendon origin from the lateral epicondyle Extensor carpi radialis brevis (ECRB) usually affected first o +/- Degeneration, tear of the underlying lateral collateral ligamentous complex (especially the lateral ulnar collateral ligament) Size: Varies from tendon being subjectively thickened to small interstitial partial tear to complete avulsion including tear of underlying collateral ligaments
Radiography o +/- Lateral soft tissue swelling o +/- Fracturestbone trabecular injury if posterior dislocation trauma Capitellum Radial headlneck Coronoid process o +/- Osteoarthritis (OA) if old trauma Loose bodies Osteophytes rn Subchondral sclerosis Subchondral cysts
CT Findings NECT o +I- Fractureslbone trabecular injury if posterior dislocation trauma o +/- OA if chronic trauma CT arthrography o Posterior capsular rupture with extravasation of contrast if post trauma
DDx: Lateral Epicondylitis
Cor PD FSE MR
Sag FS PD FSE
Cor STIR MR
Post Dislocation
Post Dislocation
Cor FS PD FSE
Cor PD FSE MR
LATERAL EPlCONDYLlTlS Key Facts Terminology Tennis elbow, extensor carpi radialis brevis (ECRB) partial avulsion
Imaging Findings Best diagnostic clue: Thickening and increased signal intensity within the common extensor origin from the lateral epicondyle on all pulse sequence
Top Differential Diagnoses Trauma and Fibrosis of the Radiohumeral Meniscus Synovial Fringe Radial HeadINeck Fracture Radial Neuropathy Capitellum Fracture Posterior Dislocation
Pathology Degeneration of the common extensor tendon secondary to chronic varus stress overload The ECRB muscle lies deep to the extensor carpi radialis longus muscle and superficial to the joint capsule Up to 50% of tennis players
Clinical Issues Adult patient with lateral elbow pain 90% of patients respond to conservative measures
Diagnostic Checklist Associated findings if posttraumatic tendon tear Coronal FS PD FSE or STIR to visualize common extensor origin
-
o Through disrupted lateral ulnar collateral
ligamenthadial collateral ligament (RCL) if ligaments torn
MR Findings TlWI o Increased signal intensity within the common extensor tendon origin at the lateral epicondyle o Tendon often thickened o Intermediate signal lateral ulnar collateral ligament (LUCL) in advanced cases = sprains +/- tear o Decreased signal intensity loose bodies may be present o Decreased signal intensity edemalfracture lines post trauma T2WI o Increased signallthickening of common extensor tendon with tendinosis o Increased signal intensity within the tendon - partial tear to complete tears Variable disruption of fibers ECRB macroscopic tear, +/- tear of extensor digitorum communis 0 Increase signal intensity within the common extensor muscle belly in case of muscle strain o Strains and tears of the LUCL in advanced cases (increased signal, +/- discontinuous fibers) 0 Osteochondral injuries Increased signal intensity bone marrow with fractureltrabecular injury: Posterior dislocation Capitellum Humeral trochlea Coronoid process Radial headlneck PDIIntermediate 0 Spatial resolution excellent o Synovitis seen as intermediate to increased signal thickened synovium STIR 0 Improved contrast resolution o Lower spatial resolution o Necessary at low field
..
Imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE or STIR coronal and axial images
I DIFFERENTIAL DIAGNOSIS Trauma and Fibrosis of the Radiohumeral Meniscus Synovial Fringe MRI can define the normal tendonlsynovial fringe = Radiocapitellar meniscus o Not true fibrocartilaginous meniscus +/- Inflammation, thickening Posterolateral joint
Radial HeadINeck Fracture Acute traumatic injury with positive X-rays1MRI +/- Posterior dislocation +/- Coronoid process fracturelother fractures Impaction injury due to axial overloading in a fall onto the outstretched arm Radial head injuries - rare in children o Occur in the radial neck Most common elbow fracture in adults
Radial Neuropathy Tenderness located over the lateral epicondyle with epicondylitis Pain over arcade of Frohselsupinator muscle (upper border) o Symptoms of radial tunnel syndrome Difficulty with writing +I- Humeral fracture Forearm pain common
Capitellum Fracture Shear injury due to transmitted axial overload from radial head in fall on outstretched arm Rare o 6% of elbow fractures o Rare in children < 10 years Coronal defect with variable anterior displacement
LATERAL EPlCONDYLlTlS Stage 11: Nonreversible pathologic changes to origin of the ECRB muscle Stage 111: Rupture of ECRB muscle origin Stage IV: Secondary changes such as fibrosis or calcification
Fracture occurs in coronal plane and is identified on sagittal images
Posterior Dislocation Fall on outstretched hand (FOOSH) injury +/- Capitellar fx Lateral ligamentous disruptions 0 LUCL +/- Common extensor tendon tear +/- Coronoid fx Sudden posterior force Osteoarthritis as a complication
Presentation Most common signs/symptoms o Adult patient with lateral elbow pain o Most common reason for visit to the doctor's office for elbow pain Clinical profile o Tennis player or other activity resulting in chronic, repeated varus stress o Tenderness to palpation over insertion of conjoined tendon just distal to lateral epicondyle vs. tenderness more distally over arcade of Frohse (radial tunnel syndrome) o Lateral epicondylitis pain aggravated by resisted wrist extension and passive flexion with full elbow extension
General Features General path comments o ~elevantanatomy Lateral epicondyle - orgin for extensor carpi radialis brevis, extensor digitorum communis, extensor carpi ulnaris Posterior interosseous branch of the radial nerve (PIN) - innervation of dorsal compartment of forearm PIN passes deep to the mobile wad (brachioradialis, extensor carpi radialis longus and extensor carpi radialis brevisjin entering dorsal compartment PIN enters supinator (deep to ECRB) passing through arcade of Frohse o Degeneration of the common extensor tendon secondary to chronic varus stress overload o The ECRB muscle lies deep to the extensor carpi radialis longus muscle and superficial to the joint capsule Etiology o overuse syndrome caused by chronic varus stress across the elbow o Overuse of wrist extension and/or supination Epidemiology o Up to 50% of tennis players o 95% of reported cases in general population other than tennis players Associated abnormalities o Loose bodies o Ulnohumeral osteophytes o Chondral lesions o Synovitis
Gross Pathologic & Surgical Features Thickening of the tendon, +/- macroscopic partial tearing (superficial or deep) or through-and-through tearing o ECRB tendon with grayish, gelatinous, and friable immature tissue, +/- tear of the LUCL
Microscopic Features Angiofibroblastic tendinosis with lack of inflammation o Microscopic tearing with formation of reparative tissue o Involves extensor carpi radialis brevis tendon
Staging, Grading or Classification Criteria Stage I: Reversible inflammatory changes
Demographics Age: Adults Gender: F = M depending on activities (equal among male and female tennis players)
Natural History & Prognosis Surgical treatment = 85% of patients with pain relief and return to full activity
Treatment Conservative o Physical therapy and steroid injection with decrease in physical activity 90% of patients respond to conservative measures Surgical o Unhealthy amorphous tissue excised o Tendon repair o Tendon release
1 D~AGNOST~C CHECKLIST Consider Associated findings if posttraumatic tendon tear o Esp. posterior dislocation
Image Interpretation Pearls Coronal FS PD FSE or STIR to visualize common extensor origin Evaluate underlying ligaments
1 SELECTEDREFERENCES I.
2.
Miller M et al: Elbow arthroscopy. Surgical atlas of sports medicine. Philadelphia PA, Saunders, 53:375-85, 2003 Ciccotti MG et al: Epicondylitis in the athlete. Clin Sports Med 20(1):77-93,2001
LATERAL EPlCONDYLlTlS (IMAGE GALLERY (Lef)Sagittal graphic shows a complete tear of the common extensor tendon origin and the underlying lateral ulnar collateral ligament from the lateral epicondyle. (Right) Coronal 12 FSE MR shows a tear of the origin of the lateral ulnar collateral ligament (open arrow) with an extensively partially torn common extensor tendon origin (arrow).
(Left) Axial PD FSE MR shows extensive partial tearing (intermediate signal) of the common extensor tendon origin from the lateral epicondyle. (Right) Axial FS PD FSE MR shows (hyperintense) extensive partial tearing of the common extensor tendon origin from the lateral epicondyle (arrow).
(Left) Coronal FS PD FSE shows partial tearing (arrow) with retraction of the extensor carpi radialis brevis portion of the common extensor tendon origin. The LUCL is intact but degenerated and frayed. (Right) Coronal PD FSE MR shows extensive partial tearing (arrow) of the common extensor tendon origin with a complete tear of the origin of the lateral ulnar collateral ligament.
MEDIAL EPICONDYLITIS
Coronal graphic shows a tear of the flexor pronator origin from the medial epicondyle. Typical patient suffers from acute repetitive valgus stress.
Morphology: Varies from thickening and heterogenous appearance, discrete tear to large irregular tear
Abbreviations and Synonyms Golfer's elbow, pitcher's elbow, medial tennis elbow
Radiographic Findings
Definitions Overuse tendinopathy of flexor pronator group (FPG) Due to chronic valgus stress o Associated with dominant hand in golf Golfer's elbow o Associated with throwing sports Baseball Thrower's elbow
I IMAGING FINDINGS
1
General Features Best diagnostic clue: Thickening and increased signal intensity within flexor pronator group muscle, tendon at level of medial epicondyle Location: FPG origin from the medial epicondyle Size o Varies: Tendon thickened o Small interstitial partial tear o Complete avulsion Including sprainhear of underlying collateral ligaments
,m
DDx: Medial Epicondylitis
Coronal STIR shows partial tearing of flexor pronator origin medial epicondyle (arrow). Chronic thickening of medial collateral ligament with chronic repetitive valgus stress (open arrow).
Radiography 0 +/- Medial soft tissue swelling o +/- Medial epicondyle avulsion (little leaguer's elbow - related) o +/- Sublime tubercle hypertrophy Medial collateral ligament (MCL) chronic valgus stress o +I- Traction spur and calcification o Lateral impaction Capitellarlradial head fx/osteoarthritis (fx rare) +/- Loose bodies
CT Findings CT arthrography o +/- Medial capsular disruption o +/- MCL tear Acute valgus stress
MR Findings TlWI o Intermediate signal intensity tendon o +/- Reactive hypointense epicondylar edema o Partial MCL tear o Lateral impaction
M d , i l post DISIOC
.'.
Sag FS PD FSE
Cor STIR M R
Cor PD FSE M R
Sag FS PD FSE
Sag FS PD FSE
Key Facts Terminology Overuse tendinovathy . of flexor pronator group - (FPG) Due to chronic valgus stress Associated with dominant hand in golf Associated with throwing sports
Imaging Findings Best diagnostic clue: Thickening and increased signal intensitv within flexor vronator group muscle, tendon i t level of medial e p i ~ o n ~ ~ l e Fluid signal intensity within the tendon in the case of partial or complete tear Lateral compression
Top Differential Diagnoses MCL Strain without Tendon Disruption Medial Elbow Bone Injury T2WI o Thickened increased signal intensity tendon o +/- Discontinuous fibers = tear o +/- Reactive hyperintense epicondylar edema o +/- Hyperintense MCL tear if acute o +/- Hyperintense (FS PD FSE & STIR) FPG muscle swelling/edema o Lateral impaction Hyperintense capitellum when edematous Hyperintense subchondral cysts (chronic) Hypointense subchondral sclerosis Hypointense loose bodies (osteoarthritis) o Ulnar neuritis Hyperintensity and thickening of the nerve usually within the cubital tunnel FS PD FSE or STIR PDIIntermediate o Synovitis intermediate to hyperintense relative to joint fluid o High spatial resolution and signal MR arthrography o +/- Medial capsular disruption/MCL Medial tension overload o Increased signal intensity within the common flexor tendon origin at the medial epicondyle, tendon often thickened Fluid signal intensity within the tendon in the case of partial or complete tear Increase signal intensity within the common flexor muscle belly in case of muscle strain Avulsion of medial epicondyle in skeletally immature individuals Strains and tears of the MCL Lateral compression o Osteochondral injuries of the humeral capitellum Chondromalacia and underlying bone marrow edema or cysts Loose bodies
Imaging Recommendations Best imaging tool: MRI Protocol advice o To detect increased signal intensity within the FPG
Ulnar Neuritis
Pathology Degeneration of the common flexor tendon secondary to overload caused by chronic valgus stress ~ o scommon t site is interface between pronator teres
and carpi Origins Repeated valgus stress causing tendon degeneration
.
Clinical Issues Athlete participating in throwing sports with onset of medial elbow pain
Diagnostic Checklist Coronal FS PD FSE Hyperintense flexor pronator origin
= FS PD FSE or STIR images
ID~FFERENT~AL DIAGNOSIS MCL Strain without Tendon Disruption Coronal T2 images useful to distinguish between MCL tear and medial epicondylitis Discontinuous ligament fibers + Surrounding edema o Hyperintense on T2WI FS PD FSE sensitive Coronal, axial images
Medial Elbow Bone Injury MRI for diagnosis of bone contusion and fracture Acute traumatic event vs. chronic repetitive microtrauma Include epicondylar avulsion (Chronic Med Epi Av) o Acute or chronic o +/- Posttraumatic osteoarthritis (OA) Coronoid/trochlea Acute and chronic little league (little leag) +/- Comminution Acute valgus stress or impact
Ulnar Neuritis Associated medial epicondylitis +/- Nerve swelling Neurapraxia often seen with MCL injury +/- Anconeus epitrochlearis +/- Cubital tunnel mass Hyperintense on T2WI (FS PD FSE)
Posterior Dislocation Fall on outstretched arm injury Lateral bone injuries o Mimics chronic impaction of medial epicondylitis +/- Lateral ulnar collateral ligament (LUCL) tear +/- Coronoid process fracture
1
MEDIAL EPICONDYLlTIS General Features General path comments o Relevant anatomy Medial epicondyle is origin for: Pronator teres, flexor carpi radialis, flexor digitorum superficialis, palmaris longus, flexor carpi ulnaris Soft tissue lesion (medial epicondylitis): Interval between pronator teres & extensor carpi radialis o Degeneration of the common flexor tendon secondary to overload caused by chronic valgus stress o Bowlers, archers, and weightlifters o Little leaguer's elbow a traction apophysitis, requires different treatment o Most common site is interface between pronator teres and flexor carpi radialis origins o Valgus stress on medial elbow is high during late cocking and acceleration phases of the throw Golfers - valgus stress - from top of the backswing to just before ball impact Etiology o Repeated valgus stress causing tendon degeneration o Early acceleration phase of throwing o Dominant elbow of a golfer o Tennis players who hit forehand with heavy topspin are at risk Epidemiology o 10-20% of reported epicondylitis o Less common than lateral epicondylitis 10 to 20 times less frequent
Gross Pathologic & Surgical Features Thickening of the tendon +/- Macroscopic partial tearing of flexor pronator origin +/- Macroscopic through-and-through tearing Avulsed epicondyle in the case of some children +/- Tear of the medial collateral ligament
o Clinical diagnosis confused with ulnar neuropathy or MCL instability o Limitation of elbow extension in severe cases o In children the injury is often to the medial epicondyle itself manifesting as a stress fracture or avulsion of the epicondyle
Demographics Age: 30 to 50 years old Gender oM=F o Most common in throwing athletes
Natural History & Prognosis Duration of symptoms is related to length of time prior to receiving treatment Athletes who delay treatment tend to have a slower recovery course
Treatment Conservative o Physical therapy and steroid injection with decrease in physical activity Surgical o Release of the common flexor origin and extirpation of pathologic surrounding tissue o Tendon repair o Ulnar neuritis + common flexor tendinosis Transposition or decompression of ulnar nerve
Consider Chronic repetitive valgus stress on acute valgus trauma o Golf, baseball
Image Interpretation Pearls Coronal FS PD FSE Hyperintense flexor pronator origin
Microscopic Features Microscopic tendon degeneration Partial or complete tear Injury surrounded by hemorrhage and inflammation
Presentation Most common signs/symptoms o Athlete participating in throwing sports with onset of medial elbow pain o +/- Acute traumatic event Clinical profile o Overuse syndrome found in athletes participating in throwing sports o Tenderness (point tenderness) distal & anterior to medial epicondyle Flexor carpi radialis Pronator teres origin o Pain with resisted wrist flexion & forearm pronation with elbow extended o +/- Associated ulnar neuropathy
I
Miller MD et al: Surgical atlas of sports medicine. Philadelphia PA, Saunders, 375-442, 2003 Fitzgerald RH Jr. et al: Orthopaedics. St. Louis MO, Mosby, 1223-1331,2002 Chen FS et al: Medial elbow problems in the overhead-throwing athlete. J Am Acad Orthop Surg. 9(2):99-113, 2001 Fritz RC: MR imaging of sports injuries of the elbow. Magn Reson Imaging Clin N Am 7(1):51-72, 1999 Ciccotti MG: Epicondylitis in the athlete. Instr Course Lect 48:375-81, 1999 Nirschl RP: Prevention and treatment of elbow and shoulder injuries in the tennis player. Clin Sports Med 7(2):289-308, 1998 Plancher KD et al: Medial and lateral epicondylitis in the athlete. Clin Sports Med 15(2):283-305, 1996 Hannah GA et al: The elbow in athletics. Sports Medicine Secrets. Philadelphia PA, Hanley & Belfus, 249-55, 1994
MEDIAL EPICONDYLITIS
1
[IMAGE GALLERY (Left) Axial PD FSE MR shows an acute valgus injury in a patient with an acute "medial joint blow out ". This represents acute post-traumatic medial epicondylitis. (Right) Coronal STIR MR shows hyperintensity in an acute valgus injury with medial blow out of the conjoined tendon (arrow).
Variant
(Lef) Coronal graphic shows inflammatory changes in the pronator teres humeral head origin which can be seen with an acute strain causing medial pain. (Right) Sagittal FS PD FSE MR shows an acute strain of the humeral head of the pronator teres with increased signal intensity (arrow) in a patient with medial epicondylar pain.
(Lef)Coronal FS PD FSE MR shows both medial and lateral epicondylitis with partial tearing of both tendon origins (arrows). (Right) Axial FS PD FSE MR shows medial epicondylitis with tearing and thickening of the flexor pronator origin (arrow). Note the intact (hypointense) posterior band of the medial collateral ligament.
I
BICEPS TENDON RUPTURE
Coronal graphic shows a rupture of the biceps tendon from the radial tuberosity Note the lacertus fibrosus (arrow) preventing retraction of the tendon.
Coronal PD FSE MR ruptured segment of distal biceps tendon (arrow). Fibers of lacertus are still intact. Linear decreased signal intensity structure to right represents brachial vein.
o +/- Antecubital swelling
CT Findings
Abbreviations and Synonyms Distal biceps avulsion, distal biceps tendon (DBT) rupture
Definitions Rupture of distal biceps tendon DBT from its insertion on the radial tuberosity
General Features Best diagnostic clue o Complete disruption of DBT from the radial tuberosity o +/- Retraction o Discontinuous decreased signal intensity tendon on all imaging sequences Location: Distal biceps tendon insertion on the radius represents site of rupture Size: Small, partial to complete tear, +/- large gap with retraction Morphology: Tendon thickened and retracted
rTl
Radiographic Findings Radiography o +/- Hypertrophy of the radial tuberosity
NECT o +/- Hypertrophy of radial tuberosity associated with chronic tendinosis o +/- Antecubital density = soft tissue swelling o Sagittal reconstruction for measuring tear gap
MR Findings TlWI o Decreased signal intensity fluid surrounds tendon o Hypointense tendon thickened and retracted o Distal tendon end frayed, hyperintense due to preexisting degeneration o +/- Hypertrophy of the radial tuberosity o +/- Hyperintense common extensor tendon origin Lateral epicondylitis association T2WI o Increased signal intensity fluid surrounds the torn tendon o +/- Retraction of torn tendon o Fluid filled bicipital bursa (hyperintense) o Discontinuous decreased signal intensity tendon = tear o FS PD FSE sensitive to edema o +/- Hyperintense common extensor tendon origin rn Lateral epicondylitis +/- Lateral collateral ligament damage
DDx: Biceps Tendon Rupture Rad~alHead Fx
Ax FS PD FSE MR
Normal
Sag FS PD FSE
Ax FS PD FSE MR
Sag PD FSE MR
Ax TI Wl MR
BICEPS TENDON RUPTURE Key Facts Terminology Rupture of distal biceps tendon DBT from its insertion on the radial tuberosity
Imaging Findings Complete disruption of DBT from the radial tuberosity Location: Distal biceps tendon insertion on the radius represents site of rupture +/- Hypertrophy of the radial tuberosity Increased signal intensity fluid surrounds the torn tendon +/- Retraction of torn tendon
Pathology Aponeurosis is the lacertus fibrosus Eccentric contraction against resistance such as sudden forced extension of a flexed forearm
Clinical Issues Forced extension of a flexed forearm Biceps muscle belly "balls up" in proximal forearm +/- Retraction Body builders/weight lifters may present earlier
Diagnostic Checklist Measure retraction to help surgeon with planning Axial images must include radial tuberosity
Top Differential Diagnoses Bicipital Radial Bursitis
PDIIntermediate o Hyperintense hemorrhage adjacent to torn tendon o Visualization of lacertus o Fluid filled bicipital bursa intermediate to increased signal intensity o Discontinuous decreased signal intensity tendon fibers o +/- Synovitis PD sensitive to synovial thickening STIR o Useful at low mid field or when fat suppression is inadequate at high field o Fluid filled bicipital bursa hyperintense * Partial tears with fluid not completely through the tendon - uncommon Tendinosis: Increased signal intensity within a variably thickened tendon Measure retraction on sagittal images using internal anatomic reference for surgical planning
Ultrasonographic Findings Torn tendon edge can be localized and seen surrounded by hypoechoic fluid
Imaging Recommendations Best imaging tool: MRI Protocol advice: Sagittal FS PD FSE to identify torn tendon +/- retraction
/DIFFERENTIALDIAGNOSIS Bicipital Radial Bursitis Fluid within the bursae of the antecubital fossa Intact biceps tendon seen on MRI Hyperintense on T2WI Cystic mass +/- Rim enhancement with I.V. Gadolinium
Brachialis Strain Inserts on coronoid process Musculocutaneous innervation Similar mechanism of injury Deep to biceps
Biceps Mass Lipoma may mimic myotendinous junction tear Fat saturation used for differentiation o FS PD FSE o STIR Malignancy (rare) Neuroma
Normal Biceps Biceps "spreadsout" on sagittal images o Mimics tendinosis
1 PATHOLOGY General Features General path comments o History of preexisting pain (chronic tendinosis) o May present suddenly without antecedent symptoms o Lacertus fibrosus may prevent retraction of completely torn tendon +/- Preserves supination and forearm flexion o Aponeurosis is the lacertus fibrosus Extends from the myotendinous junction to the medial deep fascia of the forearm Etiology o Eccentric contraction against resistance such as sudden forced extension of a flexed forearm o Heavy weightlifting o Traumatic fall o Sports activities Snow boarding Football Epidemiology o Increasing frequency esp. in 40-60 year olds Typical patient - 50 years old o Rupture of proximal biceps tendon 90-97% of all biceps ruptures Involves the long head o Most common tendon rupture in elbow region Associated abnormalities
BICEPS TENDON RUPTURE o +/- Lacertus fibrosus tear
Intact tendon preserves some supination o +/- Lateral epicondylitis Seen with biceps tears Secondary instability may predispose Possible association of lateral epicondylitis and biceps tear o Bicipital bursitis Hemorrhage
Gross Pathologic & Surgical Features Disrupted tendon with variable degrees of retraction +/- Hypertrophic bicipital radial bursitis Tendinosis and macroscopic tear of the tendon
Microscopic Features Variable amounts of hemorrhage and inflammatory cells
Presentation Most common signs/symptoms o Forced extension of a flexed forearm o Dominant arm Clinical profile o Ecchymosis anterior to elbow o Limited elbow motion Acute inflammation and swelling o Partial rupture Palpable crepitus with pronation and supination o Biceps muscle belly "balls up" in proximal forearm "Popeye"sign Absence of biceps tendon with palpation of antecubital fossa o +/- Retraction Aponeurosis (intact lacertus limits retraction)
. .
Demographics Age: Average age = 55 years Gender: M > F (rare in female patients)
Natural History & Prognosis Body builders/weight lifters may present earlier With retraction, tendon will not regain function Intact lacertus may preserve supination improving prognosis Complete rupture - deformity of the arm
Treatment Goal - restore supination and flexion Conservative o Mild strainlpartial tear Rest, ice, immobilization, physical therapy, NSAIDs Surgical o Repair of complete tear Biceps tendon inserted to apex of tuberosity to maximize mechanical efficiency o MRI useful for presurgical planning - measuring gap using landmark reference o Tenodesis Complications (surgical) o Radial nerve palsy
o Posterior interosseous nerve palsy o Heterotopic ossification
o Radioulnar synostosis 0 Elbow flexion contracture
Consider Bursitis o Partial tear o Intact lacertus fibrosis
Image Interpretation Pearls Measure retraction to help surgeon with planning Axial images must include radial tuberosity
F SELECTED REFERENCES Morrison KD et al: Comparing and contrasting methods for tenodesis of the ruptured distal biceps tendon. Hand Clin 18(1):169-78,2002 Toczylowski HM et al: Complete rupture of the distal biceps brachii tendon in female patients. A report of 2 cases. J Shoulder Elbow Surg 11(5):516-8,2002 Gifuni P et al: Avulsion of the distal tendon of the biceps brachii. Reattachment to the radial tuberosity via 1-incision technique. Chir Organi Mov 86(1):29-35,2001 Williams BD et al: Partial tears of the distal biceps tendon. MR appearance and associated clinical findings. Skeletal Radio1 30(10):560-4,2001 Belli P et al: Sonographic diagnosis of distal biceps tendon rupture: a prospective study of 25 cases. J Ultrasound Med 20(6):587-95,2001 Bell RH et al: Repair of distal biceps brachii tendon ruptures. J Shoulder Elbow Surg 9(3):223-6,2000 Fritz RC: MR imaging of sports injuries of the elbow. Magn Reson Imaging Clin N Am 7(1):51-72, 1999 Le Huec JC et al: Distal rupture of the tendon of biceps brachii. Evaluation by MRI and the results of repair. J Bone Joint Surg Br 78(5):767-70, 1996
BICEPS TENDON RUPTURE IMAGE GALLERY (Lef)Sagrttal FS PD FSE shows torn retracted drstal brceps tendon (arrow) surrounded by hemorrhage (Rzght) Axral FS PD FSE MR shows torn proxrmally retracted tendon (arrow) assoc~atedwrth hyperrntense
13
Typical (Left) Axral PD FSE MR Shows a normal b~ceps rnsertlon onto the radral tuberosrty (Rzght) Axral PD FSE MR shows a chronrc brceps rnsertronal rupture (arrow) wrth partral atrophy of the suprnator muscle
Typical (Lef)Axral FS PD FSE MR shows a normal rnsertron of the brceps tendons Note the absence of edema (Right) Axral T2 FSE MR shows an acute drstal brceps rupture wrth hyperrntense edema (arrow) Note the hemorrhage coursrng along the lacertus frbrosus (open arrow) whrch rs ruptured
TRlCEPS TENDON RUPTURE
I
Coronal graphic shows a transverse tear through the distal aspect of the triceps tendon.
o Lateral radiograph - small avulsion of olecranon o Flecks of osseous tissue < 20% of patients o +/- Soft tissue swelling
Abbreviations and Synonyms
Olecranon bursitis
Triceps rupture
o +/- Olecranon destructive changes in late
Definitions
osteomyelitis
Rupture of triceps tendon From the insertion site on the olecranon
CT Findings
]IMAGING FINDINGS General Features Best diagnostic clue o A tear or gap in the triceps tendon which can become filled with Hemorrhage Granulation tissue Location o Affects the distal portion of the triceps tendon o Mid tendon ruptures uncommon o Myotendinous ruptures uncommon (direct trauma) Size: Tear may vary from millimeter range to large (several centimeters) Morphology: Tear may vary from partial disruption to complete disruption with irregular gap
NECT o +/- Olecranon destructive changes (osteomyelitis) o +/- Soft tissue swelling (bursitis) o +/- Small avulsion from olecranon o +/- Olecranon commonly fractured Partial tears
M R Findings TlWI o Partial or complete disruption from the olecranon (interrupted fibers) o Discontinuous decreased signal intensity tendon o +/- Tendon retraction o Tendinosis is seen as increased signal intensity within a variably thickened tendon o Fluid (decreased) signal intensity gap o +/- Hypointense bursa1 fluid Hemorrhagic bursitis o +/- Hypointense soft tissue fluidtedema T2WI o Increased signal intensity fluid gap in complete tear
MaHm
Radiographic Findings Radiography
Sagittal FS PD FSE MR shows a complete tear of the distal aspect of the triceps tendon (arrow) in a patient who suffered direct trauma to an extended elbow.
DDx: Triceps Tendon Rupture Olec Stress Fx
7
Sag PD FSE MR
Ax STIR MR
Sag PD FSE MR
Sag STIR MR
Sag FS TIC+ MR
TRICEPS TENDON RUPTURE Key Facts Terminology Rupture of triceps tendon From the insertion site on the olecranon
Imaging Findings Partial or complete disruption from the olecranon (interrupted fibers) +/- Tendon retraction Increased signal intensity fluid gap in complete tear
Top Differential Diagnoses Olecranon Bursitis Triceps Muscle Contusion/Hematoma Olecranon Fracture Mass Posterior Dislocation
. .
Tendo-osseous attachment - avulsion of insertion +/- osseous flecklfragment rn Musculotendinous Gar less common +/- Bursitis Visualized on FS PD FSE o Partial tears - intermediate fluid signal intensity of anterior to posterior surface defect through the tendon o Tendinosis - intermediate signal intensity within a thickened tendon o +/- Reactive hyperintense hyperemia in olecranon o +/- Hyperemic bone trabecular injurylfracture Especially with trauma, partial triceps tear o +/- Hyperintense hemorrhage within muscle if myotendinous junction tear/muscle tear Direct trauma o TZ* GRE used when fat suppression fails PDIIntermediate o Excellent spatial resolution o Delineate morphology of tendon edges STIR o Useful at low field rn Esp. sagittal plane o Less spatial resolution o When frequency selective fat saturation is not available
.
Imaging Recommendations Best imaging tool: MRl Protocol advice: FS PD FSE - tears best seen on sagittal images
Olecranon Bursitis Adult men Dominant arm +/- Infection +/- Sports activity
Triceps Muscle Contusion/Hematoma + History of trauma
Pathology Deceleration stress on a contracted triceps muscle Eccentric contraction against resistance Olecranon hemorrhagic bursitis Radial head fractures
Clinical Issues Pain at the posterior aspect of the elbow Age: Typically a middle-aged man who suffered forced flexion of an extended forearm
Diagnostic Checklist
Sagittal FS PD FSE for tear detection
Hyperintense on T2WI
+/- Hematoma
Olecranon Fracture Fall on a flexed, supinated forearm Olecranon epiphysis fuses at 16-18 years Direct trauma Throwing injury (pitchers) o +/- Stress response/fx Hyperintense edema on T2WI
Mass Tendon xanthoma o Hyperlipidemia Lipoma Adjacent neuroma Adjacent synovitis o In joint distending recess adjacent to triceps
Posterior Dislocation Fall on outstretched hand (FOOSH) injury +/- Capitellar fx Lateral ligamentous disruptions o Lateral ulnar collateral ligament (LUCL) +/- Common extensor tendon tear +/- Coronoid fx Lateral, posterior pain
1 PATHOLOGY General Features General path comments: Previous olecranon bursectomy - predisposing Etiology o Deceleration stress on a contracted triceps muscle o Eccentric contraction against resistance Sudden forced flexion of an extended forearm Direct trauma onto the tendon with muscle contracted and forearm extended o Motorcycle accidents o Football/soccer/rugbytrauma o Systemic disease process Hyperparathyroidism
.
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Reconstruction: Periosteal flap, fascia flap, split triceps into reinforcing flap, rotation anconeus flap
Steroid use of lupus erythematosus
* Epidemiology: Uncommon, < 1%of tendon tears at the elbow Associated abnormalities o Olecranon hemorrhagic bursitis o Radial head fractures
Gross Pathologic & Surgical Features
3 16
Thickened indurated tendon edges Disru~tionof tendon o ~aAable retraction An intratendinous bursa +/- involved with tears of the triceps tendon
Microscopic Features Preexisting collagen degeneration without influx of inflammatory cells "Tendinosis"is preferred term over tendinitis Fatty infiltration of muscle tissue in chronically torn tendons Tendinosis and macroscopic tear of the tendon Variable amounts of hemorrhage and inflammatory cells
Staging, Grading or Classification Criteria Grade I - mild strain Grade I1 - intermediate partial tear Grade 111 - complete disruption
Presentation Most common signs/symptoms o Pain at the posterior aspect of the elbow o At the level of the olecranon insertion of the triceps tendon Clinical profile o Palpable depression proximal to olecranon o Swelling and posterior ecchymosis o Increased incidence in patients who have undergone a previous olecranon bursectomy o Traumatic event o Sports - football o Motorcycle accidents
Demographics Age: Typically a middle-aged man who suffered forced flexion of an extended forearm Gender: M > F
Natural History & Prognosis Complete ruptures need surgical repair Partial tears may heal with appropriate conservative measures
Treatment Conservative management: Partial tear o Rest, ice, temporary splinting Surgical management o Full tear - repair o Acute tear Repair recommended o Delayed operative treatment
Consider Olecranon bursitis Olecranon osteomvelitis
Image Interpretation Pearls Sagittal FS PD FSE for tear detection
1 SELECTEDREFERENCES 1. 2.
3. 4.
5. 6.
Pina A et al: Traumatic avulsion of the triceps brachii. J Orthop Trauma 16(4):273-6,2002 Dev S et al: Rupture of the triceps muscle at its attachments. Injury 30(1):70-1, 1999 Strauch RJ: Biceps and triceps injuries of the elbow. Orthop Clin North Am 30(1):95-107, 1999 Dev S et al: Rupture of the triceps muscle at its attachments. Injury 30(1):70-1, 1999 Strauch RJ: Biceps and triceps injuries of the elbow. Orthop Clin North Am 30(1):95-107, 1999 Fritz RC et al: The Elbow. Magnetic resonance imaging in orthopaedic and sports medicine. vol 1. 2nd ed. Philadelphia PA, J.B. Lippincott, 743-849, 1997
TRICEPS TENDON RUPTURE IMAGE GALLERY
LATERAL COLLATERAL LlCAMENT INJURY
Sagittal graphic shows tear at lateral ulnar collateral ligament & extensor tendon origin. Injury to structures are associated with posterior dislocation or chronic lateral epicondylitis.
Coronal PD FSE MR shows a complete tear of the origin of LUCL (arrow) and common extensor tendon origin in this posterior dislocation patient.
o Irregularity and increased signal seen on
Abbreviations and Synonyms Lateral ulnar collateral ligament (LUCL) injury, radial collateral ligament (RCL) injury, lateral collateral ligament (LCL) complex injury = LUCL + RCL, posterolateral rotatory instability (PLRI)
Definitions Elbow instability primarily from injury to the lateral collateral ligament complex o Posttraumatic - fall on an outstretched hand o LUCL tear +/- secondary to chronic lateral epicondylitis Progresses to subluxations, dislocation Component of PLRI as a result of axial compression, supination and valgus force o Lateral instability is spectrum of disease from PLRI to posterior dislocation
/IMAGINGFINDINGS General Features Best diagnostic clue o Tears - disruption of the normal continuous decreased signal intensity ligament
T2-weighted MR images Location o RCL (also known as radial collateral ligament proper) - undersurface of lateral epicondyle (anterior aspect) to annular ligament holding radial head o LUCL - undersurface of lateral epicondyle (more posterior aspect) beneath radial neck to lateral ulnar diametaphysis o Tear usually occurs at humeral side Size: Tear may be small discrete or complete "blowout" Morphology: Disruption in the normal continuous linear ligament appearance
Radiographic Findings Radiography o Dislocation 0 Perched elbow o +/- Normal, if spontaneous reduction has occurred o +/- Coronoid process fracture o +/- Radial headlneck fracture o +/- Capitellar fracture o Intercondylar, medial condylar/lateral condylar fractures with posterior dislocation - unusual
CT Findings
HmDm NECT o +/- Dislocation o +I-Perched elbow
DDx: Lateral Collateral Ligament Injury La t Epicnndylr ti3
Cor FS PD FSE
Cor FS; PD FSE
Lat Fprrondylil~s
FSE
Cor STIR M R
LATERAL COLLATERAL LIGAMENT INJURY Key Facts Terminology Elbow instability primarily from injury to the lateral collateral ligament complex
Imaging Findings
Tears - disruption of the normal continuous decreased signal intensity ligament Irregularity and increased signal seen on T2-weighted MR images Perched elbow
Top Differential Diagnoses Lateral Epicondylitis Capitellum Osteochondritis Dissecans (OCD) Lateral EpicondylarICondylar Fracture Radial Head/Neck Fracture
o +/- Coronoid process fracture o +/- Radial headlneck fracture o +/- Capitellar fracture o Intercondylar, medial condylar/lateral condylar
fractures with posterior dislocation - unusual o Reconstructions helpful o +/- Loose bodies CT arthrography o Contrast extends through lateral capsular defect when torn
MR Findings TlWI o Tear of LUCL at origin on the humerus = discontinuous fibers o Surrounding hypointense edemalhemorrhage * T2WI o Disruption of ligamentous fibers with fluid signal intensity o Perched elbow Coronoid perched on dorsal aspect of trochlea Disruption of anterior and posterior capsule High signal intensity (edema) around the injury o Dislocation = PLRI, perched elbow Complete dislocation of the radius and ulna Progressive disruption of the medial collateral ligament o Fractures common especially after elbow dislocation, hyperintense edema Coronoid process Capitellum rn Radial head Multiple STIR o Useful at low, mid field o Less spatial resolution
Imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE in all three planes
Pathology General path comments: Ligament tear results in abnormal motion in which the radius and ulna move away from the humerus most often resulting in PLRI
Clinical Issues Elbow pain Pain with lateral pivot shift apprehension test Three stages of progressive instability beginning with subluxation and progressing to dislocation
Diagnostic Checklist Associated with LUCL tear of lateral ligament complex Coronal FS PD to evaluate the disruption of the LUCL deep to the common extensor (if intact) origin
Lateral Epicondylitis Mimics PLRI Advanced cases may include disruption of the LUCL, therefore overlapping signs may develop
Clinically Swollen Tender Elbow Posttraumatic PLRI may be a diagnosis of exclusion MRI used for soft tissue discrimination
Capitellum Osteochondritis Dissecans (OCD) Necrosis of bone followed by healing response and reossification 12-16 year age group 0 After ossification of capitellum 20% bilateral Chronic valgus stress with lateral impaction Seen in gymnasts and adolescent baseball pitchers
Lateral Epicondylar/Condylar Fracture Fall on an outstretched hand o +/- Radial head impaction Varus stress with elbow flexedlsupinated, avulsion by common extensor action 17% of distal humerus fractures Common in 5-10 year (peak = 6 years) Rotation of fracture fragment due to action of forearm extensors/supinators
Radial HeadINeck Fracture +/- Posterior dislocation +/- Coronoid process fracturelother fractures Impaction injury due to axial overloading in a fall on to the outstretched arm Radial head injuries are rare in children o Occur in the radial neck Most common elbow fracture in adults
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LATERAL COLLATERAL LIGAMENT INJURY
(PATHOLOGY
o Swelling and pain after traumatic event
o Patient is often guarding leading to difficult
diagnosis at presentation
General Features
20
General path comments: Ligament tear results in abnormal motion in which the radius and ulna move away from the humerus most often resulting in PLRI Etiology o Oblique orientation of normal LUCL allows for lateral and posterior stabilization o Fall on outstretched hand o Chronic tennis elbow o Elbow instability spectrum of soft tissue and bone injury From lateral to medial in three different stages: PLRI, perched elbow, dislocation Instability progressing from lateral to medial encircling elbow = Horii circle o Most common cause of PLRI is elbow dislocation Epidemiology: Relatively uncommon Associated abnormalities: +/- Lateral epicondylitis (tendinosis and or tearing of the common extensor tendon origin)
o Rotational instability o Positive elbow pivot shift test o Supination/valgus added during flexion causing the o
Demographics Age: Recurrent complete dislocation occurs more frequently in children Gender: M 2 F
Natural History & Prognosis Three stages of progressive instability beginning with subluxation and progressing to dislocation Develops insidiously after initial injury
Treatment Conservative o Mild sprain Rest, ice, temporary splinting, physical therapy Surgical o LUCL isolated tear Repair if PLRI o Post dislocation Repair of tendon avulsions Preservation of radial head if possible Excision of interposed fracture fragments Reconstruction of coronoid fracture Complications o Deformity o Laxity o Heterotopic calcification o ~ontracture o Neuropathy
Gross Pathologic & Surgical Features Tear at origin of LUCL with or without lateral epicondylitis for PLRI Dislocated ulna and radius in more advanced stages
Microscopic Features Microscopic and macroscopic tearing of the LUCL (early) o Followed by the anterior and posterior elbow joint capsule o Then medial ligamentous structures Variable amounts of hemorrhage and inflammatory cells
Staging, Grading or Classification Criteria Posterolateral instability o Stage I PLRI: Posterolateral subluxation of the ulna and radius relative to the humerus Tear of the LUCL o Stage I1 Perched elbow: Coronoid perched on trochlea o Stage IIIA Complete dislocation with tear of the posterior band of the ulnar (medial) collateral ligament Elbow is stable to valgus stress o Stage IIIB Complete dislocation with tear of the entire ulnar (medial) collateral ligament Elbow is unstable in all directions o = Horii circle (progressive lateral to medial instability)
Consider Associated with LUCL tear of lateral ligament complex
Image Interpretation Pearls Coronal FS PD to evaluate the disruption of the LUCL deep to the common extensor (if intact) origin
1 SELECTED REFERENCES 1.
O'DriscollSW: Elbow instability. Acta Orthop Belg
2.
Bredella MA et al: MR imaging findings of lateral ulnar collateral ligament abnormalities in patients with lateral epicondylitis. AJR. 173(5):1379-82, 1999 Fritz RC: MR imaging of sports injuries of the elbow. Magn Reson Imaging Clin N Am 7(1):5 1-72, 1999 Putnam MD et al: Painful conditions around the elbow. Orthop Clin North Am 30(1):109-18, 1999 Potter HG et al: Posterolateral rotatory instability of the elbow: Usefulness of MR imaging in diagnosis. Radiology
65(4):404-15, 1999
3.
Presentation Most common signs/symptoms o Elbow pain o Pain with lateral pivot shift apprehension test Clinical profile
radius and ulna to sublux posteriorly + Lateral pivot shift test and posterolateral rotatory drawer test with examination under anesthesia Subluxation of radiocapitellar joint with "dimple sign" during examination under anesthesia
4. 5.
204(1):185-9, 1997
LATERAL COLLATERAL LIGAMENT INJURY IMAGE GALLERY Typical (Left) Sagittal graphic shows post-operative changes of the common extensor tendon origin with an over-aggressive release resulting in an iatrogenic disruption of the lateral ulnar collateral ligament. (Right) Coronal STIR MR shows a tear of the lateral ulnar collateral ligament (arrow) after common extensor tendon origin release. The ligament disruption may have been preexisting.
(Left) Coronal FS PD FSE MR shows an avulsion of the lateral epicondyle cortex (arrow) after posterior dislocation of the elbow. The majority of the lateral ulnar collateral ligament is intact. (Right) Coronal T 1 arthrogram shows a complete blow out of lateral aspect of joint (arrow).
( L e f ) Coronal graphic shows the normal anatomy of the radial collateral ligament (laterally) and the lateral ulnar collateral ligament (deep to the radial head/neck). (Right) Coronal FS PD FSE shows tear of the origin of the lateral ulnar collateral ligament (arrow) adjacent to-an intact common extensor tendon origin and a bone trabecular injury of the lateral aspect of the radial head.
POSTERIOR DISLOCATION, ELBOW
Sagittal graphic shows posterior dislocation of the olecranon and radius with tearing of the soft tissue constraints.
Morphology o Posterior, posteromedial or posterolateral dislocation o +/- Disrupted ligaments o +I-Impaction or avulsion fractures
Abbreviations and Synonyms Elbow dislocation
Radiographic Findings
Definitions In a posterior dislocation, the ulna is normally dislocated posteriorly to the humerus, with associated posterior displacement of the radius Posterior, posterolateral or posteromedial, open or closed, simple or complex types
I IMAGING
Sagittal PD FSE MR shows fracture pattern in posterior dislocation: Anterior radial head (open arrow) & posterior capitellum. There are loose fragments (arrow) from impaction fracture.
FINDINGS
General Features Best diagnostic clue o Empty semilunar notch on lateral radiograph + Distal humerus aligned with radial head on 90 degree flexed view o Posterior displacement of ulna and radius on sagittal MR images Location: Typically in the humeroulnar joint +/medial epicondylar injury Size o Size of the injury is related to associated bony and ligamentous injuries o +/- Delayed healing results in residual instability
Radiography o Lateral views - the humeral epicondyles will be aligned with the radial head Anterior to the empty cup-shaped semilunar notch of the ulna 0 A horizontal lucency may be seen in the coronoid process of the ulna +/- Displacement, indicating a fracture o Lucent lines and or distortion may also be seen in the radial head indicating fractures o On AP views, medial humeral epicondylar lucent lines may be seen in adults indicating fractures o Below 15 years of age, there may be increased distance between the medial condylar epiphysis and the humerus = An epiphyseal (Salter type 1)fracture o Fat pad signs will not be reliable Secondary to severe distortion of the anatomy and potential rupture of the joint capsule
CT Findings NECT
DDx: Posterior Dislocation, Elbow Old Post D~sloc
l.at fpr I.UCI. Tear
Cor STIR MR
Cor STIR MR
Cor T 1 Arthro.
Cor PO FSE MR
Sag PO FSE MR
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POSTERIOR DISLOCATION, ELBOW P
Key Facts Terminology In a posterior dislocation, the ulna is normally dislocated posteriorly to the humerus, with associated posterior displacement of the radius
Imaging Findings Empty semilunar notch on lateral radiograph Posterior displacement of ulna and radius on sagittal MR images Disruption of normal anatomy and low signal of medial collateral ligament (MCL) on coronal views
Top Differential Diagnoses Supracondylar Fracture Radial HeadINeck Fracture Lateral Ulnar Collateral Ligament Tear (LUCL Tear) Lateral Epicondylitis o Linear lucencies in medial epicondyle, radial head or
coronoid process indicating fractures o Fracture comminution and displacement assessed Coronal, sagittal reconstructions helpful o Soft tissue swelling evident on soft tissue windows
MR Findings TlWI o Decreased marrow signal indicating areas of bone stress o Low signal joint effusion o Disruption of normal anatomy and low signal of medial collateral ligament (MCL) on coronal views o Low signal lines indicating fracture lines +/- bony displacement T2WI o Increased marrow signal indicating edema o FS PD FSE visualization improved High signal joint effusion +/- periarticular leakage with capsular rupture Disruption of MCL anatomy with high signal tears High signal stress lesions at bony attachments of torn ligaments Edemaldisruption of neurovascular structures Disruption of LCL anatomy with high signal tears: RCL, LUCL +/- Medial epicondylar avulsion in children (+ hyperintense surrounding edema) o Characteristic associated fxs "Kissing"fxs of radial head, capitellum Coronoid fx STIR o Bright signal edema o Alternative at low and midfield T2* GRE o Coronal images show damage to articular cartilage for larger defects o FS PD FSE is a more sensitive chondral imaging sequence
Imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE/T2 sagittal images
1
Medial Collateral Ligament Sprain
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Pathology Commonly associated with ligamentous injury
Etiology: Fall onto an outstretched hand Posterior dislocations are the most common type of elbow dislocation
Clinical Issues Most common signs/symptoms: Pain and swelling of posterior mass within palpable semilunar notch
Diagnostic Checklist Nerve damage, vascular damage, interposed epicondylar fractures Characteristic associated fractures (e.g., coronoid)
~ F E R E N T I A DIAGNOSIS L Supracondylar Fracture Fall on outstretched hand (FOOSH) injury Transverse lucency in metaphysis on AP or angled AP view Anterior humeral line displaced to anterior to mid third of capitellum in 94% Extraarticular in children but may be intraarticular in adults 60% of pediatric elbow fractures
Radial HeadINeck Fracture Radial head - adults, radial neck - children Most common elbow fracture in adults Fall on out stretched hand injury
Lateral Ulnar Collateral Ligament Tear (LUCL Tear) Predisposes to posterior dislocation Hyperintense edema and tear are demonstrated on FS PD FSE Best visualized on posterior coronal images
Lateral Epicondylitis Most commonly extensor carpi radialis brevis (ECRB) affected Tendon may tear with posterior dislocation +/- LUCL tear
Medial Collateral Ligament Sprain May tear with posterior dislocation Valgus stress Disrupted ligament + hyperintensity on T2WI
General Features General path comments o Commonly associated with ligamentous injury o Endstage instability following posterolateral rotatory instability
POSTERIOR DISLOCATION, ELBOW Perched elbow Frank dislocation o +/- Single traumatic event without predisposing instability Etiology: Fall onto an outstretched hand Epidemiology o Incidence: 6 of every 100,000 individuals o Posterior dislocations are the most common type of elbow dislocation o More common in children; peak incidence is 11-15 years Associated abnormalities o The semilunar notch of the ulna may show variable morphology A shallower notch or one with a reduced angle of circumference may predispose to dislocation o Ligament injuries and fractures associated with later onset of osteoarthritis o Associated fractures Radial head (10% and most common) Coronoid Olecranon Medial and lateral epicondyles o Neurapraxia may occur in up to 20% of cases involving ulnar nerve or anterior interosseus branch of the median nerve
Natural History & Prognosis In uncomplicated dislocations, 60% will have late symptoms of pain Pain on valgus stressing and flexion contracture Incomplete recovery more likely with fractures, posterolateral direction, delayed reduction and rigid immobilization Fractures associated with secondary osteoarthritis Duration of immobilization has negative association with later complications of reduced range of motion and flexion contractions Redislocation associated with poor outcome
Treatment Conservative o Reduction, bracing in pronation, protected mobilization Surgical o Repair of MCL, repair of tendon avulsions o Preservation of radial head if possible, excision of interposed soft tissue or osteochondral fragment within epicondylar fractures o Reconstruction of coronoid process Complications o Failed reduction may be due to entrapped medial epicondyle fracture fragment, inverted cartilaginous flap or osteochondral fragment o Late complications include MCL laxity, posterolateral instability, heterotopic ossification, flexion contracture, median and ulnar nerve palsy o Volkmann's ischemic contracture o Brachial artery injury
Gross Pathologic & Surgical Features Dislocation of ulna and radius, +/- fractures with varying degrees of depression/displacement with surrounding hemorrhage and soft tissue injury
Microscopic Features Disruption of bone cortex and trabeculae with surrounding hemorrhage in acute cases
Staging, Grading or Classification Criteria Instability o Stage I: Posterolateral subluxation of ulna and radius + disruption of lateral ulnar collateral ligament o Stage 11: Complete dislocation with cornoid perched on trochlea + disruption anterior and posterior joint capsule = perched elbow o Stage 111: Complete posterior dislocation + disruption medial collateral complex
I DIAGNOSTIC CHECKLIST Consider Nerve damage, vascular damage, interposed epicondylar fractures
Image Interpretation Pearls Characteristic associated fractures (e.g., coronoid)
1 SELECTED REFERENCES Ring D et al: Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am 84-A(4):547-51,2002 2. Kumar A et al: Closed reduction of posterior dislocation of the elbow. A simple technique. J Orthop Trauma 13(1):58-9,1999 3. Limb D et al: Median nerve palsy after posterolateral elbow dislocation. J Bone Joint Surg Br 76(6):987-8, 1994 4. Josefsson PO et al: Dislocations of the elbow and intraarticular fractures. Clin-Orthop (246):126-30, 1989 5. Mehlhoff TL et al: Simple dislocation of the elbow in the adult. Results after closed treatment Div of Orthopedic Surgery.J Bone Joint Surg Am 70(2):244-9, 1988 6. Josefsson PO et al: Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow joint. A prospective randomized study. J Bone Joint Surg Am 69(4):605-8,1987 1.
Presentation Most common signs/symptoms: Pain and swelling of posterior mass within palpable semilunar notch Clinical profile o In children - avulsion of the medial humeral epicondylar epiphysis (Salter type 1 injury) common o In adults, fractures may occur to the radial head, coronoid process and medial epicondyle - common
Demographics Age: Usually young active patients (30 years = mean age) Gender: M:F = 2-2.5:l
POSTERIOR DISLOCATION, ELBOW
Typical (Left) Sagittal graphic shows a tear of the lateral ulnar collateral ligament - the soft tissue findings of stage I instability (posterolateral rotatory instability). (Right) Coronal PD FSE MR shows a tear of the LUCL (arrow) in a patient with posterolateral rotatory instability (PLRI).
( h f t ) Sagittal graphic sho~ stage I1 lateral instability known as the perched elbow. (Right) Lateral radiography shows a perched elbow nearly dislocated.
(Left) Sagittal graphic shows the bony injury seen with posterior dislocation including a fracture of the anterior aspect of the radial head and a posterior capitellar fracture. (Right) Sagittal STIR MR shows associated bony injuries of a recent posterior dislocation including the radial head and posterior capitellum.
MCL ELBOW INJURY
Sagittal graphic shows a complete tear of the distal aspect of the medial collateral ligament - anterior band.
Coronal STIR MR shows a tear of the distal aspect of the medial collateral ligament (arrow) a t its insertion on the sublime tubercle.
o Disruption in the normal continuous linear
ligament o
Abbreviations and Synonyms Medial collateral ligament (MCL) elbow injury
+/- Thickening in chronic cases
Radiographic Findings
Definitions Injury to the medial collateral ligament (anterior band of MCL) Valgus stress, injury to the elbow
Radiography o +/- Sublime tubercle hypertrophy o +/- Medial epicondyle avulsion o +/- Medial soft tissue swelling o +/- Traction spur
CT Findings General Features Best diagnostic clue o Tears as disruption of the normally continuous hypointense MCL o + Irregularity and increased signal seen on T2 weighted MR images o Anterior band - most important medial structure injured Location o Undersurface of medial epicondyle to sublime tubercle of ulna Proximal to distal Size: Tear may be small discrete or complete "blowout" Morphology
NECT o +/- Sublime tubercle degenerative changes o +/- Avulsion of medial epicondyle o +/- Medial soft tissue edema Streaky medium attenuation in paraarticular fat o +/- Traction spur o Lateral impaction injuries Capitellar/radial head fx/osteoarthritis (OA) CT arthrography o +/- Medial capsular disruption o Contrast extends "around corner" of sublime tubercle in distal deep partial tear o Coronal reconstructions o "T" sign
M R Findings TlWI
DDx: MCL Elbow Injury Ulnar Spur
dnc Epiirochlear
Prox Hvmrintefi-
Subl~meFx
Normal MCL
Cor PD FSE MR
Ax PD FSE MR
Cor PD FSE MR
Cor PD FSE MR
Cor T 1 arth FS
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MCL ELBOW lNJURY Key Facts
Imaging Findings tears as disruption of the normally continuous hypointense MCL + Irregularity and increased signal seen on T2 weighted MR images Anterior band - most important medial structure injured Arthrography demonstrates "T" sign - distal partial tears that spare the superficial fibers
Top Differential Diagnoses Medial Epicondylitis with Intact MCL Little Leaguer's Elbow Ulnar Neuropathy Traction Spur of MCL Sublime Tubercle Fracture
o +/- Heterotopic ossification Increased signal = fat in bone marrow
o Epicondylar avulsion Corticated structure Donor site on humerus Surrounding hypointense edema Little leaguer's elbow o +/- Thickened increased signal intensity ligament Chronic cases o +/- Traction spur Hyperintense if contains marrow Hypointense if purely calcification o Lateral impaction injury Hypointense capitellum when edematous Hypointense subchondral cysts (chronic) Hypointense subchondral sclerosis Hypointense loose bodies (OA) T2WI o Increased signal within the ligament Most commonly anterior band o +/- Discontinuous fibers (through and through tear) o Tear may be Proximal Mid substance Distal 0 +/- Sublime tubercle hyperintensity Stress response/avulsive stress o +/- Sublime tubercle hypertrophy o +/- Hyperintense flexor pronator straidtear o Increased signal (stress response or fracture) at humeral orgin site or attachment site on the ulnar coronoid PDIIntermediate o Heterotopic ossification or epicondylar avulsion: Increased signal (fat in bone marrow), corticated structure 0 Synovitis hyperintense relative to joint fluid STIR: Increased signal within the ligament, most commonly the anterior band T1 C+ o Enhancement of inflamedlinjured MCL 0 FS used in conjunction with TlWI MR arthrography
Normal MCL
Pathology Degeneration and tearing of the MCL caused by repetitive valgus stress
Clinical Issues Pain after valgus stress injury Medial pain especially at overhand throwing Usually acute episode superimposed on chronic repetitive valgus stress
Diagnostic Checklist Partial tear, flexor pronator group strain without ligamentous damage Coronal and axial FS PD FSE or STIR
o Extravasation of contrast in cases of complete ruptures o Contrast extends "around corner" of sublime tubercle in distal deep partial tear o Arthrography demonstrates "T"sign - distal partial tears that spare the superficial fibers 'IT" sign: Contrast interposed between the partially torn ligament and the medial aspect of the coronoid Seen on coronal images Increased signal (stress response or fracture) at humeral origin site or attachment site on the ulnar coronoid
Imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE in coronal/axial plane
1 DIFFERENTIAL DIAGNOSIS Medial Epicondylitis with Intact MCL MRI can differentiate Chronic valgus stress +/- Ulnar neuritis Thrower's/golfer's elbow Traction tendinosis
Little Leaguer's Elbow MCL sprain often accompanies little leaguer's elbow (component of little league elbow) Traction apophysitis Common in adolescent pitchers Valgus stress +/- Medial epicondyle avulsion
Ulnar Neuropathy Neurapraxia often seen with MCL injury +/- Anconeus epitrochlearis Traction neurapraxia +/- Cubital tunnel mass
Traction Spur of MCL Chronic valgus stress
MCL ELBOW INJURY +/- Visible marrow in calcification Throwers Rare
Sublime Tubercle Fracture Type of coronoid process fracture MCL avulsion o Unusual Hyperintense edema on T2WI
Normal MCL Thin decreased signal intensity ligament Spreads out at humeral origin (proximal hyperintensity) Oblique orientation from ventral to dorsal
General Features General path comments o Relevant anatomy Anterior band MCL = primary soft tissue restraint to valgus stress Normal anterior band extends from medial epicondyle to the coronoid tubercle (sublime tubercle) Osseous anatomy = primary source of stability Posterior band - thickening of posterior capsule with insertion along margin of semilunar notch Transverse ligament no role in elbow stability o Excessive valgus stress o At 90" of flexion, MCL provides 55% of the resistance to valgus stress at the elbow o In full extension, the MCL + bony architecture + anterior capsule maintain valgus stability o Anterior band inserts on sublime tubercle and provides major contribution to valgus stability o Acceleration phase overhead throw = most valgus stress to the elbow - risk of damage to MCL o Valgus force can overcome tensile strength of MCL chronic microscopic tears or tear Etiology o Degeneration and tearing of the MCL caused by repetitive valgus stress o Athletes during the acceleration phase of throwing or as acute valgus injury o Mid substance ruptures most common followed by distal then proximal ruptures Epidemiology: Common in throwing athletes
Presentation Most common signs/symptoms o Pain after valgus stress injury o Medial pain especially at overhand throwing Clinical profile o 40% - symptoms of ulnar neuropathy o Acute " p o p - specific injury o Limited elbow extension o Crepitus with range of motion o Tinel's signltenderness along cubital tunnel o Palpation to distinguish flexor - pronator musculotendinous origin straidtear from MCL tenderness o Pain with resisted wrist pronationlsupination in musculotendinous unit injury
Demographics Age: Children (usually athletes) or adults Gender: M > F
Natural History & Prognosis Usually acute episode superimposed on chronic repetitive valgus stress Return to competitive throwing after successful rehabilitation and reconstruction when indicated Patients are often asymptomatic with a lax MCL since osseous anatomy is intact
Treatment Conservative management o Mild sprain Rest, ice, temporary splinting, training modification Surgical o Repair or reconstruction of complete disruption in athletes Bunnell suture technique to reattach ligament Graft harvest - palmaris longus weaved in a figure-eight pattern Complications (surgical) o ~ e b injury e Medial antebrachial cutaneous nerve branches ulnar nerve
Consider Partial tear, flexor pronator group strain without ligamentous damage
Gross Pathologic & Surgical Features Thickened, partially torn or completely torn anterior band of the medial collateral ligament
Image Interpretation Pearls Coronal and axial FS PD FSE or STIR
Microscopic Features Degeneration, partial or complete rupture Variable amounts of hemorrhage and inflammatory cells
1 SELECTED REFERENCES 1.
Staging, Grading or Classification Criteria Partial tear o Proximal, mid substance, distal Complete tear
2.
Chen FS et al: Medial elbow problems in the overhead-throwing athlete. J Am Acad Orthop Surg 9(2):99-113, 2001 Maloney MD et al: Elbow injuries in the throwing athlete. Difficult diagnoses and surgical complications. Clin Sports Med 18(4):795-809, 1999
MCL ELBOW lNJURY
(Lef)Sagittal graphic shows a partial tear of the anterior band of the medial collateral ligament at its insertion on the sublime tubercle. (Right) Coronal STlR MR shows a partial tear (arrow) with high signal going "around the corner" of the sublime tubercle with an adjacent bone trabecular injury.
(Left) Sagittal graphic shows a proximal tear of the UCL. (Right) Coronal STlR MR shows a sprain of the proximal aspect of the medial collateral ligament (arrow) in this symptomatic patient.
(Lef) Sagittal graphic shows a tear of the medial collateral ligament with a strain of the flexor pronator origin. (Right) Coronal STlR MR shows a complete tear of the distal aspect of the medial collateral ligament anterior band (arrow) and an adjacent flexor pronator origin strain (open arrow).
-
LlTTLE LEAGUER'S ELBOW
Coronal graphic shows an avulsion of the medial epicondyle, consistent with little leaguer's elbow.
Coronal PD FSE MR shows slight distraction (arrow) of the medial epicondylar ossification center in a baseball pitcher. There is a strain of the flexor pronator origin.
o Displaced ossific nucleus of medial epicondyle
(child) o Crescentic avulsion of bony margin (adolescent) o Medial soft tissue swelling +/- calcification (adult)
Abbreviations and Synonyms Little leaguer's elbow, extension overload injury, medial epicondylar avulsion, medial epicondylitis Medial epicondyle apophysitis, thrower's elbow
'
Definitions Valgus stress injury o Results in tension injuries on the medial aspect of the elbow o Compressive injuries on the lateral aspect Traction apophysitis of medial epicondyle (stress fx, avulsion or delayed closure of medial epicondylar apophysis)
General Features Best diagnostic clue o Lucent line running through medial epicondyle on radiograph o Focal high signal on fluid sensitive MR sequences Location: Medial epicondyle of the distal humerus and attached soft tissues Size: 1-2 cm Morphology
Radiographic Findings Radiography o Fragmentation or widening of medial epicondyle apophysis o Early callus formation o Overgrowth of apophysis o Avulsion of medial epicondyle May become entrapped within joint in children
CT Findings NECT o Lucent line indicating separation of epicondyle o Overgrowth of apophysis o Avulsion of medial epicondyle CT arthrography o +/- Medial capsular tear with extravasation of contrast o +/- Medial collateral ligament (MCL) tear
MR Findings TlWI o Low signal zone of separation through epicondylar region o +/- Hypointense epicondylar edema
DDx: Little Leaguer's Elbow Med Eprrondyltrr~
Ulnar Neuritis
Part Tear MCL
..
.-. I
Sag FS PD FSE
Ax FS PD FSE
Cor PD FSE MR
Cor STIR MR
Ax T2 FSE MR
LITTLE LEAGUER'S ELBOW Key Facts Imaging Findings Variable signal within fragment depending on sclerosis Marrow edema in parent bone/humems High signal fluid in medial collateral ligament (MCL) tears
Top Differential Diagnoses Capitellar Osteochondritis (OCD) MedialILateral Epicondylitis MCL Sprain Stress Fracture Ulnar Neuritis Muscle Strain
Pathology
Repetitive throwing motion Childhood injury pattern (pre-fusion) is microtrauma to apophysis and ossification center for medial epicondyle Adolescent pattern = avulsion of medial epicondyle +/- nonunion Adult pattern = ligament avulsions and muscle strains
Clinical Issues Pain localized to medial epicondyle Pain may also involve posterior and lateral aspects
Diagnostic Checklist Presence of lateral pathology (OCD) FS PD FSE to identify subchondral marrow edema and signal changes in the adjacent flexor pronator origin
Excessive valgus stress o +/- Discontinuous MCL = tear T2WI o Variable signal within fragment depending on sclerosis Sclerosis - hypointense Edema - hyperintense o Marrow edeia in parent bone/humerus o High signal fluid in medial collateral ligament (MCL) tears Incomplete tear Complete tear STIR o High signal within the fragment and in parent bone o High signal edema in MCL complex +/- defects o High sensitivity for edema o ~ o w e spatial r resolution
..
Ultrasonographic Findings Hypoechoic areas in soft tissues attaching to medial epicondyle Instability on valgus stressing with ligament injuries Hyperechoic separated fragments and soft tissue calcification
Imaging Recommendations Best imaging tool o Acute phase: AP radiograph o Static and dynamic ultrasound +/- therapeutic injection o Full assessment = MR in coronal and axial planes Protocol advice: Tl/PD + FS PD FSE in all three planes
MedialILateral Epicondylitis Overuse tendinopathy Medial epicondylitis often component of little league elbow Lateral epicondylitis = tennis elbow Failure of underlying collateral ligament Hyperintense tendons on T2WI
MCL Sprain Affects primarily anterior band of MCL Common with little league elbow +/- Acute valgus stress o MCL + flexor pronator avulsion = medial blowout Often chronic repetitive microtrauma Proximal, mid-ligament or distal tears
Stress Fracture May affect different bones in elbow (esp. olecranon) Chronic repetitive microtrauma Abnormal stresses on normal bone Stress response - pre-fracture stress phenomenon
Ulnar Neuritis Often accompanies medial epicondylitis and little leaguer's elbow Traction/overuse neurapraxia in throwers +/- Anconeus epitrochlearis +/- Ulnar/humeral osteophytes Hyperintense on T2WI +/- swelling o Normal ulnar nerve is intermediate on FS PD FSE signal
Muscle Strain Capitellar Osteochondritis (OCD) Necrosis of bone followed by healing response and reossification Lateral elbow 12-16 year age group (after ossification of capitellum) 20% bilateral Chronic valgus stress with lateral impaction seen in gymnasts and adolescent pitchers
Muscle fiber tearing Typically at myotendinous junction Hyperintense on T2WI +I-Intramuscular hematoma
1 PATHOLOGY General Features General path comments
1's ELBOW
LITTLE LEAC
.
o Relevant anatomy
Valgus stress is resisted by the medial collateral ligament complex ~nteriorbundle - most important Posterior bundle Transverse ligament Static support is given by the ulnohumeral joint and radial head o Excessive valgus stress Etiology o Repetitive throwing motion Baseball pitch Tennis serve Javelin throw Football pass o Acute valgus stress less common than repetitive throwing motion ~~idemiology o Highest incidence in the 5-14 year age group o Overuse injuries 30-50% of all elbow injuries o Increased incidence with family history of osteochondritis Associated abnormalities o Capitellar osteochondritis o Radial head osteochondrosis o Olecranon apophysitis o MCL sprain o Ulnar hypertrophy o Olecranon osteophytosis
.. ..
32
.
Gross Pathologic & Surgical Features Childhood injury pattern (pre-fusion) is microtrauma to apophysis and ossification center for medial epicondyle Adolescent pattern = avulsion of medial epicondyle +/nonunion Adult pattern = ligament avulsions and muscle strains
Gender: M:F = 6:l (mainly reflects sports)
Natural History & Prognosis May heal with cessation of valps stress overload (medial tension) Prognosis o Depends on expert rehabilitation o After rest, gradual build up of throwing activity over 3 weeks Cessation if symptoms return o Most cases recover well o Late osteoarthritis (OA) and deformities occur in both under treated and appropriately treated cases
.
Treatment Conservative: Rest, ice, temporary splinting, training modification Surgical 0 Closed reduction or open repair with internal fixation 0 MCL injury (less common in young throwing athletes) is treated with reconstruction using a tendon graft with anterior submuscular transposition of the ulnar nerve Complications: Instability, early osteoarthritis, epicondylar underlovergrowth giving varus and valgus deformities
Consider Avulsionlentrapment of apophysis in unfused skeleton Presence of lateral pathology (OCD) Ulnar neuropathy Ligament damage
Image Interpretation Pearls AP radiograph MR o FS PD FSE to identify subchondral marrow edema and signal changes in the adjacent flexor pronator origin o Coronal images demonstrate the medial tension injury with widening and fragmentation of the medial epicondylar ossification center ~taticld~namic ultrasound
Microscopic Features Irregular ossification of medial epicondyle apophysis Disruption of collagen fibrils in medial ligament complex and common flexor origin Increased number of fibroblasts Increased number of osteoblasts and osteoclasts
Staging, Grading or Classification Criteria Type 1 avulsions = entire apophysis separates and rotates Type 2 avulsions = smaller 'flake' avulsion in more mature bone
1 SELECTED REFERENCES 1.
Presentation Most common signslsymptoms o Pain localized to medial epicondyle o Pain may also involve posterior and lateral aspects o Loss of range of motion o Flexion contracture o Recent change in activity patterns Clinical profile: Throwing athlete, often children
Demographics Age: Children through adults
2. 3. 4.
Klingele KE et al: Little league elbow. Valgus overload injury in the paediatric athlete. Sports Med 32(15):1005-15, 2002 Sofka CM et al: Imaging of elbow injuries in the child and adult athlete. Radio1 Clin North Am 40(2):251-65,2002 Farsetti P et al: Long-term results of treatment of fractures of the medial humeral epicondyle in children. J Bone Joint Surg Am 83-A(9):1299-305,2001 Grana W: Medial epicondylitis and cubital tunnel syndrome in the throwing athlete. Clin Sports Med 20(3:541-8, 2001
LlTTLE LEAGUER'S ELBOW
Typical (Left) Sagittal PD FSE MR shows partial avulsion of the medial epicondyle in a symptomatic young baseball pitcher. (Right) Sagittal STIR MR shows avulsion of the medial epicondyle (arrow) with surrounding edema extending into the flexor pronator muscle origin.
Typical
(Lef)Coronal FS PD shows avulsion of the medial epicondyle (arrow) in a little league pitcher, consistent with little leaguer's elbow. (Right) Axial FS PD FSE MR shows increased signal intensity at the base of the rnedial epicondyle (arrow) representing a medial epicondylar epiphyseal stress fx.
Typical (Left) Coronal PD FSE MR shows partial avulsion of the rnedial epicondyle (arrow) with strain of the flexor prona tor origin. (Right) Coronal STIR MR shows a tear of the proximal aspect of the medial collateral ligament (arrow) with surrounding edema and subchondral changes of the medial epicondyle in a patient with little leaguer's elbow.
ULNAR NEUROPATHY
Sagittal graphic shows an inflamed ulnar nerve traversing deep to the cubital tunnel retinaculum.
Sagittal FS PD FSE MR shows an inflamed hyperintense ulnar nerve (arrow) posteriorly in a patient with ulnar neuritis. The focal area of the signal abnormality indicates neuritis.
o Nerve flattening: Mass compression o Traumatic injury : +/- Severing, discontinuity
Abbreviations and Synonyms
Radiographic Findings
Cubital tunnel syndrome (CTS), cubital tunnel retinaculum (CTR)
Radiography o +/- Soft tissue swelling at level of cubital tunnel o +/- Soft tissue mass +/- Anconeus epitrochlearis
Definitions Compression of the ulnar nerve within the cubital tunnel at the level of the elbow
CT Findings NECT o Fatty atrophy of affected muscles in chronic cases Decreased attenuation o +/- Soft tissue mass o +/- Anconeus epitrochlearis CECT o +/- Enhancement of nerve o +/- Synovial enhancement in cases of synovitis
General Features Best diagnostic clue o Thickening and increased signal intensity of the ulnar nerve o Patient with clinical evidence of ulnar neuropathy Location: Occurs most commonly at the level of the cubital tunnel of the elbow Size o The nerve is normally flattened to oval shaped and mildly increased in signal on FS PD FSE/T2WI Asymptomatic o Neuropathy - nerve swollen, edematous, increased in size Morphology o +/- Swelling
MR Findings TlWI o Displacement, flattening, or thickening of the nerve o Thickened cubital tunnel retinaculum o +/- Anconeus epitrochlearis Normal muscle signal intensity o +/- Hypointense mass o Osteophytes with marrow fat signal o +/- Intermediate to mildly hyperintense synovial mass/synovitis
DDx: Ulnar Neuropathy Prom Mcd Trtccps
~
1 - Sag PD FSE MR
Prom Med Tricep~
Leprory
Epicondvlttrs
Ax f - FS PD rG FSE MR 4.
dAx'"FS TIC+ MR
Cor PD FSE MR dl
Uh' Tran~posit~on
~
Ax T2 FSE 1MR
ULNAR NEUROPATHY Key Facts Terminology
Pathology Subject to entrapment and injury by a wide variety of causes Mass compression of the nerve or as the result of a posttraumatic neurapraxia
Compression of the ulnar nerve within the cubital tunnel at the level of the elbow
Imaging Findings Thickening and increased signal intensity of the ulnar nerve Location: Occurs most commonly at the level of the cubital tunnel of the elbow
Clinical Issues 8
Top Differential Diagnoses
I I
8
Enlarged Perineural Veins Increased Signal Intensity Nerve in Normal Cases Brachial PlexitisIParsonage-TurnerSyndrome Prominent Medial Head of Triceps ~eprosy Medial Epicondylitis
Diagnostic Checklist Identify anconeus epitrochlearis or prominent medial head of triceps
T2WI o Mass lesion with proximal swelling of the nerve Fat saturated images (FS PD FSE) o Increased signal intensity of the nerve (FS PD FSE) o +/- Anconeus epitrochlearis Muscle signal intensity on T2WI o +/- Hyperintense mass o Nerve enlarged with leprosy PDIIntermediate o Excellent spatial resolution o Visualize synovitis/synovial mass Intermediate to hyperintense synovial thickening Relative to hypointense fluid STIR o Similar contrast as FS PD FSE except less spatial resolution o Improved for low mid field TI C+ o +/- Enhancing nerve o +/- Enhancing compressing mass o +/- Perineural enhancement with inflammation
Brachial Plexitis/Parsonage-Turner Syndrome Other nerves/muscles most often involved
+/- Viral prodrome Pain followed by weakness Rare distal form: Shoulder girdle muscles
Prominent Medial Head of Triceps Cause of nerve compression Rare +/- Hyperintensity on T2WI: Stress myositis
Leprosy Hansen's bacillus Enlarged nerve +/- Calcification Distal wasting
Medial Epicondylitis Chronic valgus stress Throwers, golfer's elbow +/- MCL tear +/- Hyperintensity in flexor pronator muscle belly Chronic repetitive microtrauma
Imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE demonstrates signal abnormality of the nerve and associated compressing mass
I DIFFERENTIAL DIAGNOSIS
Severe pain at elbow or wrist with radiation into hand or up into the shoulder and neck Athletes with medial epicondylitis and pain and paresthesias in ulnar nerve distribution Age: Most commonly seen in adults
1 PATHOLOGY
1
Enlarged Perineural Veins Contain hypointense flow void Common in cubital tunnel Increased venous pressure
Increased Signal Intensity Nerve in Normal Cases Pathologic nerve is of greater increased signal intensity on T2WI o Fat saturated images (FS PD FSE) sensitive to neural edema +/- Thickening of pathologic nerve
General Features General path comments o Relevant anatomy Ulnar nerve - in anterior compartment of proximal arm, along medial intermuscular septum Ulnar nerve enters posterior compartment: Mid humerus, through medial intermuscular septum at arcade of Struthers Ulnar nerve passes distally: Posterior aspect medial intermuscular septum, deep into Osborne's fascia, enters cubital tunnel Distal to cubital tunnel - Ulnar nerve passes between two heads of flexor carpi ulnaris (FCU) muscle (most frequent site of compression)
ULNAR NEUROPATHY
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Cubital tunnel bordered: Anteriorly - medial epicondyle, laterally - olecranon process, posteriorly - Osborne's fascia 0 Subject to entrapment and injury by a wide variety of causes o Compression, traction, friction, or direct trauma Etiology o Mass compression of the nerve or as the result of a posttraumatic neurapraxia o Commonly caused by a thickened cubital tunnel retinaculum (Osborne's ligament) Results in dynamic compression during flexion o Ulnar neurapraxia often secondary to repeated valgus stress injury and medial epicondylitis (athletes) o Throwing athletes Chronic ulnar nerve traction injury Increase ulnar nerve pressure with elbow flexionlwrist extension & with arm in the cocking position of a throw Flexor carpi ulnaris generates compressive force o Other causes of compression Intermuscular septum: Arcade of Struthers (musculofascial band 5-8 cms proximal to medial epicondyle) Medial intermuscular septum Fascia of FCU heads Medial head of the triceps muscle Malunion of condylar fracture, nonunion of condylar fracture, epiphyseal injury to the lateral side of the elbow may cause chronic neurapraxia Congenitally shallow groove or dysfunctional or absent retinaculum +/- subluxation and dysfunction Epidemiology o 22% of population suffers from dynamic compression during flexion in association with a thickened cubital tunnel retinaculum o 10% of population suffers from static compression in association with an anomalous muscle, the anconeus epitrochlearis o Second most common entrapment neuropathy in the upper extremity (after median) Associated abnormalities: Anconeus epitrochlearis
Regeneration of axon o Neurotmesis: Nerve, myelin sheath and connective
tissue elements are severed Regeneration does not occur
Presentation Most common signs/syrnptoms o Ranges from transient paraesthesias in ring and small fingers to clawing of these digits and severe intrinsic muscle atrophy o Severe pain at elbow or wrist with radiation into hand or up into the shoulder and neck Clinical profile o Adult or child with pain and paresthesias in forearm in the ulnar nerve distribution 0 Athletes with medial epicondylitis and pain and paresthesias in ulnar nerve distribution
Demographics Age: Most commonly seen in adults Gender: F 2 M
Natural
Treatment Physical therapy Removal of osteophyte or anconeus if paresthesias present Decompression in situ - relief almost immediate but may not be as favorable prognosis Nerve transposition - favorable prognosis after healing of post operative swelling
1 DIAGNOSTIC CHECKLIST Image Interpretation Pearls Identify anconeus epitrochlearis or prominent medial head of triceps
Gross Pathologic & Surgical Features Edematouslindurated nerve often surrounded by fibrous stranding Heterotopic ossification or other mass may be found compressing the nerve Anconeus epitrochlearis may be found in place of the cubital tunnel retinaculum
Microscopic Features Edematous nerve with variable numbers of inflammatory cells
Staging, Grading or Classification Criteria Three stages of nerve injury 0 Neurapraxia: Transient (failure of conduction) No disruption of the nerve or its sheath occurs 0 Axonotmesis: Disruption of axon and myelin sheath with preservation of connective tissues Motor, sensory, and autonomic paralysis results
i is tory & Prognosis
Return to normal function with adequate decompression Chronic compression associated with pain, muscle weakness, andlor atrophy, outcome favorable
1 SELECTED 1. 2.
3.
REFERENCES
Miller MD et al: Surgical Atlas of Sports Medicine. Philadelphia PA, Saunders, 407-12, 2003 Chen FS et al: Medial elbow problems in the overhead-throwing athlete. J Am Acad Orthop Surg 9(2):99-113,2001 Ciccotti MG: Medial collateral ligament instability and ulnar neuritis in the athlete's elbow. Instr Course Lect 48:383-91, 1999
I
ULNAR NEUROPATHY
I IMAGE GALLERY
RADIAL NEUROPATHY
Coronal graphic shows inflamed radial N adjacent to biceps tendon. Deep branch pierces supinator, becomes posterior interosseous N. Fibrous arcade of Frohse = potential entrapment site.
Coronal FS PD FSE MR shows increased signal intensity within the supinator muscle (arrow) and the proximal extensor muscle belly in a patient with proven high radial neuropathy.
Denervation findings in all or some of the muscles supplied by the radial nerve Diffuse increased signal intensity on T2 or proton density fat saturated images with or without atrophy changes o PIN syndrome - denervation findings in all or some of the muscles supplied by the posterior interosseous nerve Location o Entrapment neuropathy usually occurring proximal to the elbow most commonly by a fibrous arch of the long head of the triceps or the lateral head of the triceps o Entrapped by humeral fracture and callus formation (Holstein-Lewisfracture) High radial lesion (before takeoff of PIN) Size: Affected muscles may be atrophic Morphology: Usually fibrous entrapment of the long head or the lateral head of the triceps, mass compression or traumatic injury to nerve less commonly 0
Abbreviations and Synonyms Radial neuropathy (RN), RN entrapment syndrome, posterior interosseous nerve (PIN) syndrome
Definitions Compression syndrome of the radial nerve o Including the supinator, triceps, anconeus brachioradialis, extensor carpi radialis longus, extensor digitorum communis, extensor indicis, extensor digiti quinti (minimi), extensor carpi ulnaris, abductor pollicis longus and extensor pollicis brevis muscle bellies o Sensory disturbance of the dorsal and radial aspects of the wrist indicating the entrapment or compression occurred before the split into the superficial and deep components at the level of the supinator muscle o No sensory disturbance with posterior interosseous compression alone
MR Findings TlWI: Fibrosis (streaky hypointense signal intensity on all pulse sequences) at the arcade of Frohse entrapment site T2WI
General Features Best diagnostic clue
DDx: Radial Neuropathy l.ar ~picondy/itfs
C o r FS PD FSE
Ax PD FSE MR
Sag FS PD FSE
Ax FS PD FSE
C o r PD FSE MR
RADIAL NEUROPATHY Key Facts Imaging Findings Denervation findings in all or some of the muscles supplied by the radial nerve Diffuse increased signal intensity on FS PD FSE in all or some of the muscles supplied by PIN (indicating denervation) Reduced muscle belly size +I- fatty infiltration indicating atrophy
Top Differential Diagnoses Nonspecific MyositisITrauma Median Neuropathy Recalcitrant Lateral Epicondylitis
Pathology High radial lesion - entrapment neuropathy occurring proximal to the elbow
Entrapment neuropathy occurring distal to elbow Epidemiology: Rare
.
Clinical Issues A high radial lesion will lead to functional loss of Accessory forearm supination (supinator), flexion (brachioradialis),wrist digital extension Radial: 213 dorsal sensation/abduction of thumb Clinical profile: After fracture or with muscle hypertrophy
Diagnostic Checklist In patient with abrupt weakness or total paralysis in distribution of PIN Identify muscle groups with high signal on FS PD FSE nerve in distribution of
o Diffuse increased signal intensity on FS PD FSE in all
or some of the muscles supplied by PIN (indicating denervation) o Reduced muscle belly size +/- fatty infiltration indicating atrophy STIR: Increased signal in muscle with denervation T1 C+: +/- Muscle enhancement with denervation
Imaging Recommendations Best imaging tool: MRI Protocol advice o FS PD FSE shows the increased muscle signal to best advantage o TlWI demonstrates the interstitial fatty tissues as fat signal intensity
I DIFFERENTIAL DIAGNOSIS Nonspecific MyositisITrauma Muscle signal increase on FS PD FSE and muscle dysfunction Trauma with asymmetric muscle involvement
Median Neuropathy Anterior interosseous syndrome (AIN syndrome) o Abrupt weakness or total paralysis of flexor pollicis longus and usually profundus tendon to index finger o Median branch Pronator syndrome - little weakness or sensory loss
Recalcitrant Lateral Epicondylitis Tenderness located over the lateral epicondyle not radial nerve as in compression neuropathy Constant aching pain at the arcade of Frohse and difficulty with writing
Ulnar Neuropathy +/- Anconeus epitrochlearis Hyperintensity of nerve +/- increased diameter on FS PD FSE
General Features General path comments o Relevant anatomy (PIN & potential sites of compression) Radial nerve (RN) between brachialis & brachioradialis at cubital fossa RN divides in superficial & PIN branches at elbow PIN enters radial tunnel proximal to radiocapitellar (RC) joint Fascia superficial to PIN anterior to RC joint Leash of Henry (radial recurrent artery & venae comitantes) PIN deep to fibrous edge extensor carpi radialis brevis (ECRB) PIN passes through arcade of Frohse (tendinous origin of supinator) Fascia1 bands at exit from supinator distally o Entrapment or neuritis o Radial nerve splits at the level of the supinator muscle with the deep branch becoming the PIN After exiting the muscle, the nerve passes beneath the fibrous arcade of Frohse where it can become entrapped o PIN - compression after take off of the branches to the radial wrist extensors and the radial sensory nerve Paralysis of digital extensors and dorsoradial deviation of the wrist due to paralysis of the ECU o Compression of lateral branch Paralysis of the abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, and extensor indicis Compression of medial branch Paralysis of ECU, extensor digiti quinti, and extensor digitorum communis o Radial tunnel syndrome - controversial, thought to be a result of overuse May represent early posterior interosseous nerve syndrome Diagnosis based on subjective symptoms
RADIAL NEUROPATHY
40
Etiology o High radial lesion - entrapment neuropathy occurring proximal to the elbow rn Most commonly by a fibrous arch of the long head or the lateralhead of the triceps rn Humeral diaphyseal fracture Weakness of supination o Entrapment neuropathy occurring distal to elbow rn Most commonly arcade of Frohse fibrous entrapment (PIN syndrome) Exit from the supinator muscle Fracture dislocation humeral shaft Holstein-Lewis fracture Fracture dislocation (especially Monteggia fx) Mass (lipomas or ganglions) * Epidemiology: Rare
Gross Pathologic & Surgical Features Swollen muscle belly - early and subacute
Wrist movement or when tightly pinching the thumb and index digit may increase symptoms Positive Tinel's sign over the radial sensory nerve + local tenderness Clinical profile: After fracture or with muscle hypertrophy
Demographics Age: Childrenladults Gender: M > F
Natural History & Prognosis Surgical treatment of PIN syndrome more reliable than RTS Usually progressive and requires surgical decompression Excellent if signs of recovery occur within six months Good results in recalcitrant cases after surgery
Treatment Conservative o Typically surgical treatment is required Surgical o Vessels or fibrous bands at the arcade of Frohse are released and the arcade is divided if tight o Supinator tunnel may be widened if necessary Complications o Nerve injury, hematoma, other complications of surgery
Microscopic Features Enlarged extracellular fluid space = early and subacute Fatty infiltration = chronic Myofibrils atrophy and become small and angular early denervation
Staging, Grading or Classification Criteria Two syndromes associated with PIN o Posterior interosseous nerve syndrome: Loss of motor function to muscles innervated by PIN (electrophysiologicstudies usually diagnostic) o Radial tunnel syndrome (RTS): Vague forearm pain without motor function loss & associated with lateral epicondylitis (limited objective findings in radial tunnel syndrome in contrast to PIN syndrome) 3 Stages of nerve injury o Neurapraxia = transient episode of motor paralysis with little or no sensory or autonomic dysfunction o Axonotmesis = more severe nerve injury with disruption of the axon and myelin sheath but with preservation of connective tissues o Neurotmesis = nerve, myelin sheath, and connective tissue elements are severed
Consider In patient with abrupt weakness or total paralysis in distribution of PIN
Image Interpretation Pearls Identify muscle groups with high signal on FS PD FSE in distribution of radial nerve
1. 2.
Presentation Most common signslsymptoms o A high radial lesion will lead to functional loss of Accessory forearm supination (supinator), flexion (brachioradialis),wrist digital extension Radial: 213 dorsal sensationlabduction of thumb o Radial tunnel syndrome - pain over the anterolateral proximal forearm in the region of the radial neck without weakness or sensory deficit o PINS - inability to extend the metacarpal phalangeal joints of the thumb and fingers + radial deviation of the wrist with extension o Wartenberg's syndrome - pain over distal radial forearm associated with paresthesias over dorsal radial hand
3.
Miller MD et al: Surgical atlas of sports medicine. Philadelphia PA, Saunders, 407-12, 2003 Dickerman RD et al: Radial tunnel syndrome in an elite power athlete: A case of direct compressive neuropathy.J Peripher Nerv Syst 7(4):229-32,2002 Chen WS et al: Posterior interosseous neuropathy associated with tuberculous arthritis of the elbow joint: Report of two cases. J Hand Surg Am 19(4):611-3,1994
RADIAL NEUROPATHY
(Left) Axial PD FSE MR shows hyperintensity within the supinator and extensor muscle bellies (arrow) in a patient with post surgical radial neuropathy. There are post-surgical changes of biceps repair. (Right) Axial FS PD FSE in the same patient shows increased signal intensity within the denervated muscles. The neuropathy was post-surgical but the patient regained function.
(Left) Axial PD FSE MR shows increased signal intensity within the extensor muscle bellies in a patient with posterior in terosseous syndrome. (Right) Axial STIR MR of the same patient shows the denervation changes.
(LA$) Sagittal PDNntermediate MR shows a fracture (arrow) of the mid humerus with developing callus formation in a patient with radial neuropathy at the spiral groove level. (Right) Axial PD/lntermediate MR in the same patient shows the mass effect on area structures by the developing callus. This patient had radial neuropathy with paralysis of the hand extensors.
MEDIAN NEUROPATHY
Coronal graphic shows median nerve passing through the antecubital fossa deep to the lacertus fibrosus adjacent to long head of the biceps tendon.
Axial FS PD FSE MR shows denervation changes within the pronator quadratus (arrow) muscle at the wrist. This often indicates anterior interosseous nerve syndrome.
Pronator teres Size: Affected muscles may be atrophic Morphology o +/- Mass compression Mass identified on MR, CT, ultrasound
Abbreviations and Synonyms Anterior interosseous nerve syndrome (AINS) o Kiloh-Nevin syndrome Pronator syndrome (PS)
Radiographic Findings
Definitions AINS - denervation of flexor pollicis longus and profundus flexor to second and third digits o +/- Pronator quadratus muscle Pronator syndrome o Motor nerve involvement rare o Sensory symptoms +/- paresthesias in median nerve distribution
Radiography o +/- Supracondylar process compression for proximal lesion o +/- Humeral fracture
CT Findings NECT o +/- Supracondylar process visualized on sagittal reconstruction o +/- Humeral fracture adjacent to nerve
M R Findings General Features Best diagnostic clue: Denervation findings in affected muscles Location o Compression/injury at Level of the humeral shaft (Holstein-Lewis fracture) Humeral supracondylar process/ligament of Struthers
TlWI o Fatty atrophy of affected muscles - chronic cases o +/- Hypointense fracture of humerus o +/- Angulation/callus T2WI o Affected muscle shows diffuse increased signal intensity o Flexor pollicis longus and profundus flexor to index finger swellinglhyperintensity o +/- Findings in pronator quadratus
mHuwu DDx: Median Neuropathy
. A x FS PD FSE
A x FS PD FSE M R
A x STIR M R
A x FS PD FSE
A x FS PD FSE M R
MEDlAN NEUROPATHY Key Facts Terminology Anterior interosseous nerve syndrome (AINS) Pronator syndrome (PS)
Imaging Findings Affected muscle shows diffuse increased signal intensity Flexor pollicis longus and profundus flexor to index finger swelling/hyperintensity +/- Findings in pronator quadratus
Top Differential Diagnoses C6/7 Radiculopathy Flexor Superficialis Crossover Syndrome Brachial NeuritisIParsonage-TurnerDistal Form Radial Neuropathy Muscle Trauma Indicating denervation o +/- Ligament of Struthers: Compression site o FS PD FSE
Variable amounts of hemorrhage - hyperintense STIR o Muscle: Increased signal with denervation o Effective at low field * T1 C+ o +/- Muscle enhancement with denervation o Portion of large muscle belly may be affected o +/- Nerve enhancement Reduced muscle size with or without fatty infiltration indicating atrophy Fibrosis (streaky decreased signal intensity on all pulse sequences) in the entrapment region
Imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE/T2 for visualization of muscle changes
C6/7 Radiculopathy Check for dysfunction of contribution from radial nerve o Radial nerve involvement = radiculopathy vs. compression neuropathy Cervical spine MRI findings o Disc abnormalities, stenosis
Flexor Superficialis Crossover Syndrome Paresthesias in forearm & hand while pronating wrist Resisted flexion of flexor superficialis of 3rd finger Entrapment at pronator teres & flexor superficialis cross over - variant of pronator syndrome
Brachial NeuritisIParsonage-Turner Distal Form Difficult to differentiate +/- Viral prodrome + Pain followed by weakness
Pathology AINS: Motor loss without sensory loss Pronator syndrome: Entrapment syndrome of median nerve with similar etiology than AINS but different clinical picture Three types of median nerve compression (compression at elbow occurs as either AINS or PS)
Clinical Issues Pain along the course of median nerve
Diagnostic Checklist FS PD FSE or STIR are sensitive for muscle signal intensity changes; identify appropriate muscle involvement
Self limiting
Radial Neuropathy Denervation of extensor muscles Posterior interosseous (PIN) syndrome High lesion - supinator atrophy (high radial atrop)
Muscle Trauma Strain Hyperintense on T2WI Mimics subacute denervation Stress response Acute trauma
1 PATHOLOGY General Features General path comments o AIN = largest branch of median nerve and is completely motor Supplies fibers for deep pain and proprioception in the radiocarpal, radioulnar, intercarpal, and carpometacarpal joints = No cutaneous sensory involvement Separates from superficial branch approximately 5-8 cm distal to lateral epicondyle Supplies flexor pollicis longus, pronator quadratus and radial aspect of flexor digitorum profundus o AINS: Motor loss without sensory loss Compression with weakness of thumb and index fingers Includes intrinsic hand weakness in the presence of a Martin-Gruber anastomosis o Martin-Gruber anastomosis (15% of normal population) branches from median to ulnar nerve in forearm Innervates: 1st dorsal interosseus, adductor pollicis, abductor digiti minimi o Pronator syndrome: Entrapment syndrome of median nerve with similar etiology than AINS but different clinical picture Negative Phalen's test and Tinel's sign
34
.. . .. .. .
MEDIAN NEUROPATHY
.
Absent specific weaknesses associated with AINS Negative EMG as opposed to positive findings with AINS Distal skin sensory changes in the distribution of the median nerve More proximal compression (often in muscular athletes) than AINS and includes sensory loss Etiology 0 Anterior interosseous nerve syndrome Neuritis, brachial plexitis Local fracture (supracondylar) Soft tissue trauma to the forearm Thrombosed vessels Enlarged bursae Aberrant fibrous bands +/- Idiopathic 0 Pronator syndrome Compression of median nerve: Ligament of Struthers and supracondylar process of humerus Lacertus fibrosus (bicipital aponeurosis) Heads of pronator muscle Fibrous bands within pronator muscle Tendinous origin of flexor digitorum superficialis Aberrant median artery Fibrous component of flexor carpi radialis muscle originating from ulna Soft tissue trauma Overuse (heavy use) of forearm muscle +/- Occurs spontaneously Epidemiology o Median nerve compression in athletes (elbow) o Median nerve compression in the general population occurs at the wrist
o Carpal tunnel syndrome (CTS)
Intermittent pain, paresthesias and numbness Median nerve distribution Thenar atrophy and weakness Permanent loss of median sensation in hand secondary to median nerve compression deep to transverse carpal ligament o AINS Palsy of flexor pollicis longus, flexor digitorum profundus of index finger and pronator quadratus Spontaneous or posttraumatic onset 0 PS Pain proximal third forearm anteriorly Intermittent median paresthesias No motor symptoms No permanent loss of sensation
. . .. .
.
Presentation
.. . .. .
Most common signs/symptoms 0 Pain along the course of median nerve o PS: No weakness or sensory loss +/- paresthesias Aching pain in the proximal volar forearm 0 AINS: Abrupt weakness or total paralysis of flexor pollicis longus & profundus tendon to 2nd & 3rd digits - proximal forearm pain Clinical profile: Pronator syndrome: Exacerbated by practicing tennis serves or throwing actions which require forearm pronation and wrist flexion
Demographics Age: Children after fractureladults - repetitive microtrauma Gender: F > M overall for median neuropathy (including carpal tunnel)
Gross Pathologic & Surgical Features Swollen muscle belly - early and subacute Fatty atrophy = chronic Anterior interosseous nerve compression o Fibrous bands of deep head of pronator teres or flexor digitorum superficialis (FDS) o Aberrant or anomalous vessels o Anomalous muscles Gantzer's muscle (anomalous slip of the origin of the flexor pollicis longus) Pronator syndrome compression o Ligament of Struthers +/- Connects (1% of limbs) supracondylar process (anomalous rt osseous excrescence) from anteromedial distal humerus to medial epicondyle o Thickened lacertus fibrosus connection to pronator teres o Pronator teres hypertrophy o Thickened fibrous arch of FDS o Persistent median artery 0 Enlarged bursa
.
Natural History & Prognosis +/- Resolution with conservative therapy +/- Decompressive surgery for treatment
Treatment Rest, modify activities, NSAIDs, decompressive surgery
I DIAGNOSTIC CHECKLIST Image Interpretation Pearls FS PD FSE or STIR are sensitive for muscle signal intensity changes; identify appropriate muscle involvement
I
1
1.
Microscopic Features Enlarged extracellular fluid space = early and subacute Myofibrils atrophy and become small and angular in early denervation
Staging, Grading or Classification Criteria Three types of median nerve compression (compression at elbow occurs as either AINS or PS)
2.
Fitzgerald RH et al: Orthopaedics. Hand and peripheral nerve soft-tissue and bone injuries. St. Louis MO, Mosby, 1936-40, 2003 Nicholas JA et al: The Upper Extremity in Sports Medicine. 2nd ed. St. Louis MO, Mosby, 1995
MEDIAN NEUROPATHY IMAGE GALLERY Typical (Left) Coronal graphic shows inflammatory changes in the pronator teres muscle. The muscle can hypertrophy as a result of exercise and impinge upon the median nerve. (Right) Coronal FS PD FSE MR shows increased signal within the pronator teres muscle (arrow) indicative of strain.
Typical (Left) Axial PD FSE MR shows scarring within the antecubital fossa in a patient with clinical anterior interosseous nerve syndrome. (Right) Axial STIR MR image shows early denervation (arrow) of increased signal intensity within a flexor muscle belly in a patient with median neuropathy.
(Left) Coronal PD FSE MR using a large field of view shows a Holstein-Lewis fracture (arrow) which caused median neuropathy. (Right) Axial FS PD FSE MR shows increased signal intensity (arrow) within anterior fibers of the pronator teres in median neuropathy.
ANCONEUS EPlTROCHLEARlS
Sagittal graphic shows an anconeus epitrochlearis superficial to the ulnar nerve. The accessory muscle may exert mass effect upon the nerve causing ulnar neuropathy.
Sagittal PD FSE MR shows an anconeus epitrochlearis muscle belly (arrow) posterior to the medial epicondyle.
PDtIntermediate: Intermediate, normal muscle signal intensity surrounded by hyperintense fat STIR o Decreased normal signal intensity muscle o Less spatial resolution T1 C+: No enhancement unless inflammation/myositis
Abbreviations and Synonyms Anomalous muscle
Definitions Accessory/anomalous muscle replacing cubital tunnel retinaculum which may cause compression ulnar neuropathy
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Imaging Recommendations Best imaging tool: MRI Protocol advice: TI, PD and FS PD FSE demonstrate this anomalous muscle
(IMAGING FINDINGS General Features Best diagnostic clue: Muscle covering cubital tunnel seen best on axial images (follows normal muscle signal intensity on all pulse sequences) Location: Roof of cubital tunnel Size: Varies from small thin to bulky muscle Morphology: Oval shaped muscle on axial images
CT Findings NECT: To identify muscle in correct location
MR Findings TlWI: Follows muscle signal intensity in correct anatomic location - intermediate signal T2WI: Normal hypointense muscle signal intensity covering cubital tunnel
DDx: Anconeus Epitrochlearis Prom Med T r ~ c e p ~
5ynovrtrs
I
I
Hematoma Increased signal on T2WI History of trauma/contusion
Neuroma Increased signal on T2W1, variable amounts of fibrous tissue centrally Enhances diffusely
mm Synovial Mass
Seen with inflammatory arthritides (rheumatoid-RA), inflammatory osteoarthritis (OA) and post trauma
, Ax PD FSE MR
Ax PD FSE MR
Sag STIR MR
Ax T l W l MR
ANCONEUS EPlTROCHLEARlS Key Facts Terminology Accessory/anomalous muscle replacing cubital tunnel retinaculum which may cause compression ulnar neuropathy
Synovial Mass
Pathology Etiology: Muscle compresses ulnar nerve causing neuropathy or produces relative vascular steal phenomenon
Imaging Findings Best diagnostic clue: Muscle covering cubital tunnel seen best on axial images (follows normal muscle signal intensity on all pulse sequences) Location: Roof of cubital tunnel Best imaging tool: MRI Protocol advice: TI, PD and FS PD FSE demonstrate this anomalous muscle
Clinical Issues Most common signs/symptoms: Ulnar neuritis if symptomatic Clinical profile: Athlete with ulnar neuritis
Diagnostic Checklist Other causes of ulnar neuritis Follows muscle signal intensity on all pulse sequences
Top Differential Diagnoses Hematorna Neuroma
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Conservative o Rest, ice, NSAIDs - acute neuritis Surgical o Removal of muscle for chronic recalcitrant cases
Prominent Medial Head of Triceps Muscle Causes mass effect and compression of ulnar nerve Proximal to majority of cubital tunnel Hypertrophied component of triceps muscle
1 PATHOLOGY General Features General path comments o Accessory muscle o Causes ulnar neuropathy Etiology: Muscle compresses ulnar nerve causing neuropathy or produces relative vascular steal phenomenon Epidemiology: 11%of general population Associated abnormalities: Ulnar neuritis
Gross Pathologic & Surgical Features Normal to inflamed muscle
Microscopic Features
Consider Other causes of ulnar neuritis
Image Interpretation Pearls Follows muscle signal intensity on all pulse sequences
1.
2.
Fritz RC et al: Magnetic resonance imaging of the musculoskeletal system: Part 3 . The elbow. Clin Orthop (324):321-39, 1996 Masear VR et al: Ulnar compression neuropathy secondary to the anconeus epitrochlearis muscle. J Hand Surg 14(5):917-9, 1989
Normal to inflamed muscle with variable influx of inflammatory cells
Presentation Most common signs/symptoms: Ulnar neuritis if symptomatic Clinical profile: Athlete with ulnar neuritis
Demographics Age: Adolescent/adult Gender: M = F
Natural History & Prognosis May progress requiring extirpation of muscle for refractory ulnar neuritis
Treatment Physical therapy, NSAIDs, then surgery if nonresponsive to conservative measures
(Left) Coronal PD FSE MR shows an anconeus epitrochlearis (arrow) adjacent to the olecranon process. (Right) Axial PD FSE MR shows a small anconeus epitrochlearis covering the cubital tunnel (arrow).
:ORONOIDPROCESS FRACTURE
Sagittal graphic shows a fracture through base of coronoid process with distraction of fracture fragment centrally. The finding is usually diagnostic of posterior subluxa tion/disloca tion.
Sagittal CT reconstruction image shows a comminuted fracture through the base of the coronoid process in a patient who is status post dislocation.
o Transverse through tip o Oblique through anteromedial facet
Abbreviations and Synonyms
Radiographic Findings
ReganIMorrey fracture, posterior elbow dislocation, terrible triad of the elbow, sublime tubercle fracture
Definitions A distraction injury due to bony avulsion of brachialis
insertion by posterior dislocation of ulna Hyperextension or posterior dislocation
(IMAGING FINDINGS
Radiography o Linear lucency = fracture line with variable fragment size Displacement on lateral or angled lateral views o Associated fractures of radius and distal humerus, esp. on radial head view o Associated posterior dislocation of elbow o Positive fat pad sign on lateral view
CT Findings
General Features Best diagnostic clue o Linear decreased signal intensity surrounded by edema on FS PD FSE/T2WI of the coronoid process o Lucent fracture line passing through coronoid process on laterallangled lateral radiograph Location: Coronoid process on the anteriorlcubital articular margin of the proximal ulna Size o Varies Tip only < 50% of process avulsed = > 50% of process avulsed Morphology
NECT o Linear lucencies in coronoid process indicating fractures o Soft tissue swelling will be evident on soft tissue windows o Fracture comminution and displacement can be assessed o Sagittal reconstructions helpful
MR Findings TlWI o Decreased marrow signal indicating bone stress o Hypointense lines indicating fracture o +/- Bony displacement on sagittal views o Hypointense joint effusion
DDx: Coronoid Process Fracture Radial Head Fx
Normal Marrow
WBBMU Cor FS P D FSE
A x P D FSE MR
Cor FS P D FSE
Cor FS P D FSE
r FS P D FSE
CORONOlD PROCESS FRACTURE Key Facts Terminology
Olecranon Fracture Posterior Dislocation (Post Dislocation) Valgus Stress Normal Marrow
A distraction injury due to bony avulsion of brachialis insertion by posterior dislocation of ulna Hyperextension or posterior dislocation
Imaging Findings
Pathology
Associated fractures of radius and distal humerus, esp. on radial head view Associated posterior dislocation of elbow Linear lucencies in coronoid process indicating fractures Sagittal reconstructions helpful
On
an outstretched arm
Clinical Issues Pain and loss of function Swelling and discoloration Early mobilization important
Diagnostic Checklist
Top Differential Diagnoses
The percentage size of avulsed fragment Fat sat/STIR MR for MCL assessment and marrow edema to show occult fractures
Supracondylar Fracture Medial Epicondylar Avulsion Fracture Radial HeadINeck Fracture o Disruption of normal anatomy and signal of medial
Accounts for about 60% of pediatric elbow fractures Rare in adults (< 3%)
collat&al ligament (MCL) on coronal views T2WI o Increased marrow signal indicating edema o Visualization improved by using FS sequence (FS PD FSE) o FS PD FSE Very sensitive for bony injury shown as high signal areas in marrow space Graphic illustration of joint effusionlleakage Most sensitive method for demonstrating MCL injury o High signal joint effusion 0 +/--~eriarticular leakage with capsular rupture 0 Low signal fracture lines +/- ~ n t e r ~ o s efluid d o Disruption of MCL anatomy ~ i g signal h tears Associated high signal stress lesions (marrow edema) at bony attachments STIR o Less signal (decreased signal to noise ratio) o improved results for low field imaging T2* GRE o Coronal images to show larger defects of articular cartilage Deficiencies with subchondral low signal areas Application useful when fat suppression techniques show inhomogeneous signal
Medial Epicondylar Avulsion Fracture Acute valgus stress Chronic repetitive valgus injury < 2% of elbow fractures in children 10% of elbow fractures in adolescence Associated with olecranon fracture
Radial HeadINeck Fracture Posterior dislocation +/- Coronoid process fracture An impaction injury due to axial overloading in a fall on to the outstretched arm Radial head injuries are rare in children and usually occur in the radial neck Is the most common elbow fracture in adults
Olecranon Fracture Acute flexion on extended forearm Clinical presentation similar Fall on a flexed, supinated forearm Throwing injury (pitchers) Accounts for about 20% of adult elbow fractures
Posterior Dislocation (Post Dislocation) Seen as overall picture with coronoid process fracture Fall on out stretched hand injury (FOOSH) +I- Capitellar fx Lateral ligamentous disruptions 0 LUCL + Surrounding hemorrhage Associated with coronoid fracture +I- Radial head fracture
Imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE/T2WI
Valgus Stress I
Supracondylar Fracture Anterior humeral line displaced anterior to mid third of capitellum in 94% Often seen in children Fracture line may not be visible in up to 25% Hyperextension from fall onto extended forearm
Acute traumatic injury Chronic repetitive microtrauma Baseball pitchers are predisposed Medial epicondylitis +I- MCL tear
CORONOlD PROCESS FRACTURE -
Prognosis deteriorates with fracture complexity Improved by early mobilization Improved by maintaining integrity of radioulnar joint May be improved by repair of collateral ligaments
Normal Marrow Relative increased signal of red marrow on T2WI o FS PD FSE and STIR o Red marrow hypointensity does not usually extend across the physeal scar Fat signal intensity on TlWI
Treatment Conservative o Viable option if < 50% of coronoid is fractured and no other elbow fractures exist o Early mobilization important Surgical o If > 50% of coronoid is involved, other fractures exist or valgus instability is found o ORIF, external fixation or reconstruction with osteo-cartilaginous graft from olecranon o Coronoid fracture + olecranon fracture Lag screw fixation from posterior during fixation of olecranon
General Features Etiology o Fall on an outstretched arm o Hyperextension of elbow Epidemiology o Occurs in 10-15% of elbow dislocations o 40% are associated with elbow dislocation Associated abnormalities o Associated with other elbow fractures, esp. radial head o Posterior dislocation (in 15%) o Injury to anterior band of MCL and anterior capsule o Terrible triad - coronoid fx, radial head fx, MCL sprain
Gross Pathologic & Surgical Features Caused by humeral trochlea during posterior dislocation/subluxation Larger fragment size associated with injury to anterior band of medial collateral ligament
1 D~AGNOST~C CHECKLIST Consider Presence of other fractures Presence of valgus instability The percentage size of avulsed fragment
Image Interpretation Pearls Lateral and angled lateral radiographs for judging size of fragment Fat sat1STIR MR for MCL assessment and marrow edema to show occult fractures
Microscopic Features Disruption of cortex and trabeculae Avulsion of osteo-tendinous complex of brachialis Hemorrhage with cellular infiltrate ranging from osteoblast and osteoclast to inflammatory cells depending on fracture age Avulsion of the osteo-ligamentous complex of the anterior band of the MCL
Staging, Grading or Classification Criteria Based on classification of Regan and Morrey o Type I: Avulsion of tip of coronoid process o Type 11: Involves < 50% of coronoid process o Type 111: Involves > 50% of coronoid process
1.
2. 3. 4. 5. 6.
Presentation Most common signs/symptoms o Pain and loss of function o Swelling and discoloration o Loss of joint stability (late)
Demographics Age: Usually young active patient Gender: M > F
Natural History & Prognosis Small fracture responds well with conservative therapy Delayed mobilization - failure to heal properly Prognosis worsened by presence of other fractures, especially radial head fractures
O'Driscoll SW et al: Difficult elbow fractures. Pearls and pitfalls. Instr Course Lect 52:113-34, 2003 Ring D et al: Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am 84-A(4):547-51,2002 Closkey RF et al: The role of the coronoid process in elbow stability. A biomechanical analysis of axial loading. J Bone Joint Surg Am 82-A(12):1749-53,2000 Sonin A: Fractures of the elbow and forearm. Semin Musculoskelet Radio1 4(2) p171-91, 2000 Akagi M: Avulsion fracture of the sublime (coronoid) tubercle of the ulna in throwing athletes. Am J Roentgen01 173(3):849-50,1999 Moritomo H et al: Reconstruction of the coronoid for chronic dislocation of the elbow. Use of a graft from the olecranon in two cases. J Bone Joint Surg Br 80(3):490-2, 1998
CORONOlD PROCESS FRACTURE IMAGE GALLERY (Lef)Coronal STIR MR shows an extensor bone trabecular injury of the coronoid process with a small fracture (arrow) involving the coronoid tip, nondisplaced. (Right) Sagittal STIR MR shows a fracture at the tip of the coronoid process (arrow) and a bone trabecular injury of the olecranon process after posterior dislocation.
Typical (Left) Sagittal PD FSE MR shows a small nondisplaced nonunited distal tip coronoid fracture (arrow) in a patient with a remote history of trauma. (Right) Sagittal PD FSE MR in the same patient demonstrates an irregular appearance of the coronoid tip that healed and united.
Typical (Left) Lateral radiography shows fracture at the base of the coronoid process. (Right) Sagittal T2* CRE MR shows a fracture through the base of the coronoid process (arrow). There is (intermediate signal intensity) synovitis (open arrow) in the anterior joint capsule.
Sagittal graphic shows osteochondritis dissecans lesion of the anterior aspect of the capitellum with chondral fragmentation.
Sagittal PD FSE MR shows subchondral cystic change (arrow) in a patient with capitellar osteochondritis dissecans.
Radiographic Findings Abbreviations and Synonyms Osteochondritis dissecans (OCD)
Definitions Overuse of the elbow causing a subchondral reactive process of the humeral capitellum Resulting in the loosening of a fragment of cartilage and bone Osteocartilaginous osteochondritis dissecans fragment o Necrosis of bone followed by healing response and reossification
General Features Best diagnostic clue o Decreased or intermediate signal intensity within the capitellum In contrast to normal marrow fat (increased signal intensity) Location: Anterior surface of the capitellum within the elbow joint Size: 1-2 cm affected area Morphology: Semilunar large fragment to multiple smaller fragments
Radiography o Flattening of capitellar profile - earliest sign o Enlarging lucent zone o Patchy sclerosis and fragmentation o Loose body formation o Radiohumeral degeneration
CT Findings NECT o Lucent zone surrounding an area of separating bone o Intraarticular loose bodies
MR Findings TlWI o Hypointense (low signal) zone of separation around developing fragment o Low signal within the fragment o +/- Intermediate signal intensity synovial thickening = synovitis T2WI o Variable signal within fragment depending on degree of sclerosis o Hyperintense fluid rim surrounding loose fragments STIR o High signal within the fragment and in deeper bone = edema o High signal rim signifies loose fragment -
DDx: capitellat- Osteochondritis
Cor STIR M R
Sag PO FSE M R
Cor PD FSE M R
Sag PD FSE M R
Cor PO FSE M R
CAPITELLAR OSTEOCHONDRlTlS Key Facts Terminology Overuse of the elbow causing a subchondral reactive process of the humeral capitellum
Imaging Findings Decreased or intermediate signal intensity within the capitellum In contrast to normal marrow fat (increased signal intensity) Location: Anterior surface of the capitellum within the elbow joint Hyperintense fluid rim surrounding loose fragments
Top Differential Diagnoses Pannerls Disease Pseudodefect of the Capitellum Posterior Dislocation TZ* GRE o Low signal fragment o Loose body detection T1 C+ o IV gad will cause enhancement of granulation tissue in defect (not as hyperintense as joint fluid) o Enhancing synovium = synovitis MR arthrography o Evaluation of extension of fluid into subchondral bone Loose osteochondrotic fragment visualized Fluid between interface of fragment and donor site in capitellum in unstable lesions Cyst-like lesions in capitellum underneath the fragment in unstable lesions
Imaging Recommendations Best imaging tool: MRI Protocol advice: PD/FS PD FSE for lesion detection and characterization
Panner's Disease Seen in younger patients (5-11 year old patients) Loose body formation and residual deformity usually not seen in Panner's disease Probably avascular necrosis secondary to trauma Osteochondrosis of entire capitellum
Valgus Impaction Fracture
Pathology Loose body formation and residual deformity often present ' Chronic valgus stress with lateral impacti0n gymnasts and adolescent pitchers
Clinical Issues Often athletes with insidious onset of pain or history of trauma
Diagnostic Checklist Pannerls disease in younger (5-11 years) patients 45 degree flexed AP view, FS T1 C+, MR arthrogram
Posterior Dislocation Fall on out stretched hand (FOOSH) injury
+/- Capitellar fracture Lateral ligamentous disruptions 0 LUCL +/- Common extensor tendon tear +/- Coronoid fx Lateral pain Sudden posterior force rt Osteoarthritis (OA) o Sclerosis o Chondromalacia o Loose bodies
Posterolateral Rotatory Instability (PLRI) Spectrum of disease from PLRI to posterior dislocation Disruption of ligamentous fibers with hyperintense fluid signal intensity on T2WI Chronic tennis elbow Often fall on outstretched hand Tear of origin of LUCL with or without lateral epicondylitis
Valgus Impaction Fracture Acute valgus injury +/- Chronic repetitive trauma (valgus extension overload) Hyperintense bone marrow on T2WI FS PD FSE or STIR more sensitive to marrow edema Medial collateral ligament (MCL) sprain common
Pseudodefect of the Capitellum Normal anatomy Posteriorly located
Capitellum Fracture Shear injury due to transmitted axial overload from radial head in fall on outstretched arm Rare o 6% of elbow fractures o Not in children < 10 years old Coronal defect with variable anterior displacement Fracture is in coronal plane (best seen on sagittal images)
1 PATHOLOGY General Features General path comments o Loose body formation and residual deformity often present o The capitellum has a relatively poor blood supply End arteries are vulnerable Etiology o Chronic valgus stress with lateral impaction gymnasts and adolescent pitchers
CAPITELLAR OSTEOCHONDRlTlS o Increased rotary, compressive or axial loads -
throwing athletes o Radiocapitellar compressive and shearing forces during acceleration and deceleration phases o Increased valgus forces (esp. if MCL is lax) * Epidemiology o Occurs in the 12-16 year age group (after ossification of capitellum) o Accounts for 6% of all cases of OCD o 20% bilateral o Common in relatives of affected patients Associated abnormalities o Flexion contracture o OCD in other joints 51
Gross Pathologic & Surgical Features Necrotic desiccated bone fragment in unstable lesions Early features consist of flattening of the profile of the capitellum As condition progresses, attrition of hyaline cartilage occurs with similar features seen in radial head Trabecular shearing injuries with microtrauma response (hemorrhage) demarcates zone of stress overloading Zone of stress overloading fills with granulation tissue as fragment starts to separate and move Joint fluid penetrates along weakened zone of stress overloading and promotes separation
o Flexion contracture
Demographics Age: 13-16 year children Gender: M:F = 6:l (mainly reflects sports)
Natural History & Prognosis 50% of cases with radiographic change will progress to osteoarthritis Early arthroscopic debridement results in good response 50% of cases with loose body removal show poor outcome Poor prognosis o Advanced lesion o Large fragment o Established OA
Treatment Stable lesions treated with rest and splinting Unstable lesions often treated with abrasion chondroplasty or microfracture unless large, displaced fragment is found Conservative: Grade 1-2 - 50% will recover with rest Surgical: Grade 2-4 - drilling, microfracture, autologous chondrocyte transplantation, arthroscopic debridement, wiring and bone graft, wedge osteotomy Complications: Residual flattening of capitellum, arthrofibrosis, recurrent loose bodies
Microscopic Features Osteonecrosis with variable amounts of healing Initial changes consistent with avascular necrosis Development of osteochondral fragment Granulation tissue fills the zone of separation
Staging, Grading or Classification Criteria Stable lesions o Small size o No fluid between interface of humerus and osteochondritis fragment Unstable lesions o Large size (typically > 1 cm) o Cyst-like lesion beneath the osteochondrotic lesion o Contains loose granulation tissue o Loose fragment o Fluid insinuating beneath the fragment at arthrography Osteochondritis grading o Grade 1: Intact hyaline cartilage o Grade 2: Prominent zone of separation (which enhances), stable o Grade 3: Fluid fills zone of separation, unstable o Grade 4: Fragment has become loose intraarticular body
Presentation
I
Most common signslsymptoms o Often athletes with insidious onset of pain or history of trauma o poorly localized lateral pain with activity o Catching or locking
Consider Panner's disease in younger (5-11 years) patients
Image Interpretation Pearls 45 degree flexed AP view, FS T1 C+, MR arthrogram
Harada M et al: Fragment fixation with a bone graft and dynamic stavles for osteochondritis dissecans of the hLmeral ca&tellum. J Shoulder Elbow Surg 11(4):368-72, 2002 Byrd JW et al: Arthroscopic surgery for isolated capitellar osteochondritis dissecans in adolescent baseball players. Minimum three-year follow-up. Am J Sports Med 30(4):474-8, 2002 Bradley JP et al: Osteochondritis dissecans of the humeral capitellum. Diagnosis and treatment. Clin Sports Med 20(3):565-90,2001 Bowen RE et al: Osteochondral lesions of the capitellum in pediatric patients. Role of magnetic resonance imaging. J Pediatr Orthop 21(3):298-301, 2001 Kiyoshige Y et al: Closed-wedge osteotomy for osteochondritis dissecans of the capitellum. A 7- to 12-year follow-up. Am J Sports Med 28(4):534-7,2000 Takahara M et al: Nonoperative treatment of osteochondritis dissecans of the humeral capitellum. Am J Sports Med 27(6):728-32, 1999 Takahara M et al: Long term outcome of osteochondritis dissecans of the humeral capitellum. Clin Orthop (363):lOS-15, 1999 Kaeding CC: Musculoskeletal injuries in adolescents. Prim Care 25(1):211-23, 1998
CAPITELLAR OSTEOCHONDRITIS
Typical (Left) Coronal T I Wl MR shows hypointense focus of osteochondritis dissecans (arrow) of the capitellum. No collapse of the articular surface is seen. (Right) Coronal STIR MR of the same patient demonstrates the OCD lesion as hyperintense. No loose fragment is seen.
(Left)Anteroposterior radiography shows an osteochondritis dissecans lesion at the capitellum adjacent to the radial head. (Right) Lateral radiography shows the lesion involving the mid aspect of the capitellum.
Other (Lefi) Coronal graphic shows capitellar osteochondrosis (fanner's disease) involving the lateral aspect of the capitellum. (Right) Sagittal T2 FSE MR shows subchondral cystic change of the anterior aspect of the capitellum in association with linear changes in a patient with Panner's disease - capitellar osteochondrosis.
RADIAL HEAD FRACTURE
Coronal graphic shows a comminuted radial head fracture.
Coronal T I arthrogram shows a nondisplaced radial head fracture (arrow).
Radiographic Findings - -
Radiography o Linear lucencies representing fracture lines Variable fragment size and number on lateral or angled lateral views o Associated fractures of ulna and distal humerus, especially on lateral head view o +I- Associated posterior dislocation of elbow o Positive fat pad sign on lateral view
Abbreviations and Synonyms Essex-Lopresti fracture, terrible triad of the elbow, lateral column fracture
Definitions Impaction injury due to axial overloading in a fall on to the outstretched arm
I
[IMAGING FINDINGS General Features Best diagnostic clue o Linear decreased signal intensity within the radial head surrounded by edema o Positive fat pad sign on radiographs in the absence of other findings is suggestive Location o Radial head o Anterolateral aspect of head more vulnerable because of lack of subchondral bone Size: Small nondisplaced to comminuted complex fracture Morphology o Nondisplaced cortical disruption o Severely comminuted/displaced
I
CT Findings NECT o Linear lucencies in radial head indicating fracture o Fracture comminution and displacement can be assessed o Soft tissue swelling evident on soft tissue windows o Assessment of occult coronoid fractures o Best method to detect osteochondral fragments (+/arthrogram)
MR Findings TlWI o Decreased marrow signal indicating bone stress (contusion) o Low signal lines indicating fracture +I- bony displacement on axial views o Low signal joint effusion
1
DDx: Radial Head Fracture
Lat Radiography
Sag STIR MR
Sag PD FSE MR
Cor STIR MR
Sag STIR MR
RADIAL HEAD FRACTURE Key Facts Radial Neck Fracture
Imaging Findings Linear decreased signal intensity within the radial head surrounded by edema Positive fat pad sign on radiographs in the absence of other findings is suggestive Anterolateral aspect of head more vulnerable because of lack of subchondral bone Increased marrow signal indicating edema +/- Capitellar fx, coronoid fx in posterior dislocation
Pathology
.
Etiology: Fall on an outstretched arm (FOOSH) A~~~~~~~ for about 30% of adult elbow fractures Posterior dislocation of elbow
Clinical Issues Pain and loss of function
Diagnostic Checklist
Top Differential Diagnoses
Presence of other fractures, especially coronoid and scaphoid Presence of valgus instability Fat sat/STIR MR for MCL assessment and marrow edema to show occult fractures
Capitellar Fracture Olecranon Fracture Capitellum Osteochondritis Dissecans (OCD) Posterior Dislocation Osteoarthritis (OA)
o Disruption of normal anatomy and signal of
collateral ligaments on coronal views T2WI o Increased marrow signal indicating edema o High signal joint effusion, +/- periarticular leakage of fluid or hemorrhage with capsular rupture o Low signal fracture line surrounded by high signal edema o Disruption of ligamentous anatomy Hyperintense tears and associated high signal stress lesions at bony attachments o FS PD FSE: Visualization of edema improved with fat saturation o +/- Capitellar fx, coronoid fx in posterior dislocation PDIIntermediate o High resolution delineation of anatomy o Synovitis intermediate signal o Fracture lines hypointense STIR o Very sensitive for bony injury shown, as high signal areas in marrow space o Less spatial resolution than FS PD FSEIPD T2* GRE: Coronal images helpful for showing damage to articular cartilage, focal deficiencies with variable subchondral increased signal intensity
Fall on a flexed, supinated forearm Olecranon epiphysis fuses at 16-18 years Direct trauma Throwing injury (pitchers) Stress injury seen in throwing sports
Capitellum Osteochondritis Dissecans (OCD) Necrosis of bone followed by healing response and reossification 12-16 year age group (after ossification of capitellum) o Panner's disease younger (7-10 years old) 20% bilateral Chronic valgus stress with lateral impaction seen in gymnasts and adolescent pitchers
Posterior Dislocation +/- Lateral ligamentous damage +/- Fractures/trabecular injuries of posterior capitellum, anterior radial head Fall on outstretched hand (FOOSH) injury +/- Extensor tendon tear End stage instability
Osteoarthritis (OA)
Imaging Recommendations
+/- Antecedent trauma +/- Subchondral cysts +/- Osteophytes +/- Loose bodies
Best imaging tool: MRI Protocol advice o FS PD FSE for edema and articular cartilage o TlWI for visualization of hypointense fracture line o Coronal, sagittal and axial planes for fracture morphology, displacement and angulation
I DIFFERENTIAL DIAGNOSIS
Olecranon Fracture
Radial Neck Fracture
1
Usually children/adolescents Essentially same lesion as radial head fracture Hyperintense edema on T2WI +/- Cortical buckle
Capitellar Fracture Uncommon Coronal plane Shear fracture Rare - 6% elbow fractures Rare in children < 10 years
General Features Etiology: Fall on an outstretched arm (FOOSH) Epidemiology
RADIAL HEAD FRACTURE o Accounts for about 30% of adult elbow fractures o Most common elbow fracture in adults o Proximal radial injuries are rare in children and usually occur in the radial neck Associated abnormalities o Posterior dislocation of elbow o Capitellar fracture 0 Disruption of anterior band of medial collateral ligament (MCL) o Triceps tendon rupture o Dislocation of the distal radioulnar joint (Essex Lopresti Fx) o Scaphoid fracture o Terrible triad = radial head and coronoid fractures MCL tear
Gross Pathologic & Surgical Features Disruption of radial head with variable bone fragmei size and number Osteochondral injury to adjacent capitellum Osteochondral free fragments Avulsion of insertion of anterior band of MCL
Microscopic Features Break of cortex and trabeculae Hemorrhage with cellular infiltrate Osteoblasts, osteoclasts, and inflammatory cells o Depending on fracture age Avulsion of the osteo-ligamentous complex of the anterior band of the MCL Flap-tearing, fissuring or fibrillation of articular cartilage on capitellum
Staging, Grading or Classification Criteria Based on classification by Mason o Type I = displacement < 2 mm o Type I1 = displacement > 2 mm o Type I11 = comminuted o Type IV = comminution + dislocation
Presentation Most common signs/symptoms o Pain and loss of function o Swelling and discoloration o Point tenderness over radial head 0 Crepitus if fracture is displaced 0 Associated wrist tenderness o Loss of joint stability (late) Clinical profile: FOOSH injury
Demographics Age: Young to adult Gender: M > F
Natural History & Prognosis Prognosis decreased by o Delayed mobilization o Presence of other fractures, especially coronoid fractures o Deteriorates with increase in grade of fracture o Potentially decreased by radial head excision Improved by
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o early mobilization o Maintaining integrity of radioulnar joint o Repair of collateral ligaments
Treatment Conservative o NSAIDs, physical therapy Surgical o Fixation or excision in extreme cases
Consider Presence of other fractures, especially coronoid and scaphoid Presence of valgus instability Extent of fracture comminution
Image Interpretation Pearls Lateral and angled lateral radiographs (radial head view) NECT for associated coronoid fracture Fat sat1STIR MR for MCL assessment and marrow edema to show occult fractures
O'Driscoll SW et al: Difficult elbow fractures. Pearls and pitfalls. Instr Course Lect 52:113-34, 2003 Ring D et al: Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg Am 84-A(10):1811-5,2002 Ring D et al: Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am 84-A(4):547-51,2002 Wildin CJ et al: The incidence of simultaneous fractures of the scaphoid and radial head. J Hand Surg Br 26(1):25-7, 2001 Van Glabbeek F et al: Current concepts in the treatment of radial head fractures in the adult. A clinical and biomechanical approach. Acta Orthop Belg 67(5):430-41, 2001 Sonin A: Fractures of the elbow and forearm. Semin Musculoskelet Radio1 4(2):171-91,2000 Heim U: Combined fractures of the radius and the ulna at the elbow level in the adult. Analysis of 120 cases after more than 1 year. Rev Chir Orthop 84(2):142-53, 1998 Janssen RP et al: Resection of the radial head after Mason type-111fractures of the elbow. Follow-up at 16 to 30 years. J Bone Joint Surg Br 80(2):231-3,1998
RADIAL HEAD FRACTURE IMAGE GALLERY (Left) Axial STlR M R shows mildly impacted central radial head fracture. Note the fracture line of linear decreased signal intensity and associated hyperintense marrow edema. (Right) Sagittal STlR M R shows a radial neck fracture (arrow) as the result of a recent posterior dislocation.
Tvoical
Variant
( k f t ) Sagittal PD FSE MR shows the slightly angulated radial neck fracture at the junction of the head and neck and a posterior capsular blow out in a patient who is status post posterior dislocation. (Right) Coronal STlR M R shows a fracture at the base of the radial head with discontinuity of hypointense cortex.
(Lef)Anteroposterior radiography shows a comminuted radial head fracture which also involves radial head and neck junction - a common finding. (Right) Coronal STIR M R shows hyperintense bone marrow edema and surrounding periostitis and soft tissue edema with a radial head/neck fracture just proximal to the physis.
LOOSE BODIES AND OS SUPRATROCHLEARE
Sagittal graphic shows loose body within the anterior aspect of the joint.
Abbreviations and Synonyms 0 s supratrochleare dorsale (OSD), loose bodies (LB)
Definitions Loose bodies are osteochondral fragments within the joint capsule Accessory ossicles are developmental variations of normal ossification of a joint, often in relation to a tendon
General Features Best diagnostic clue: Corticated rounded opacity intimately related to the joint Location o Loose bodies are most common anteriorly but are also found in the bare area of the ulnar trochlear notch Also seen in olecranon fossa (esp. in throwing athletes) o 0 s supratrochleare is found in olecranon fossa Size o Loose bodies may be minute to several millimeters o 0 s supratrochleare typically 1-2 cm
Coronal PD FSE MR shows loose body (arrow) within the posterior aspect of the joint adjacent to the olecranon process. There is synovitis present.
Morphology o Loose bodies are laminated, rounded osteochondral particles Usually calcified but may be purely cartilaginous 0 0 s supratrochleare is a thickly corticated, ovoid bony structure
Radiographic Findings Radiography o Rounded opacities of varying size and location o Non-calcified forms will be invisible o May vary location or remain fixed indicating synovial attachment o 0 s supratrochleare shows dense cortication +/remodeling of olecranon fossa o Fragmentation/sclerosis suggests increasing impingement
CT Findings NECT: To confirm presence and location of loose bodies, especially when small CT arthrogram o To show synovial attachment and differentiate from periarticular calcification/osteophytes
MR Findings TlWI 0 Low signal round structures with variable internal high signal equivalent to fat (marrow)
DDx: Loose Bodies and 0 s Supratrochleare Com Troch Fx
Lat Condyle Su
Chondromatosis
Cor PD FsE MR
AX PD FsE MR
H Cor PD FsE MR
LOOSE BODIES AND OS SUPRATROCHLEARE Key Facts Imaging Findings
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Best diagnostic clue: Corticated rounded opacity intimately related to the joint Remodeling of olecranon fossa on sagittal images with os supratrochleare
Top Differential Diagnoses Osteochondritis Dissecans Panner's Disease (Osteochondrosis of Capitellum) Synovial Osteochondromatosis (Chondromatosis) Fracture
Pathology The trochlear notch is an area devoid of articular cartilage in the mid portion of the ulnar articulating surface Acts as a trap for loose bodies o Adjacent moderate signal synovial thickening o Remodeling of olecranon fossa on sagittal images
with os supratrochleare T2WI o High signal joint effusion o Low signal loose bodies and synovial foldslhypertrophy o FS PD FSE for chondral (intermediate signal) fragment visualization STIR: May show increased signal within loose bodies/os and adjacent bone in impingement TZ* GRE: Useful for showing calcified loose bodies MR arthrography o Demonstrates loose bodies o Air bubbles (hypointense) may mimic loose bodies
Ultrasonographic Findings Rounded highly reflective intraarticular structures of variable size Free mobility within the joint or local attachment to synovium Dynamic imaging may demonstrate joint locking
Imaging Recommendations Best imaging tool o Plain films, 30% sensitive o MR +/- arthrogram MR superior for chondral fragments o NECT for presence of very small loose bodies o Ultrasound popular where access to expertise exists Protocol advice: CT, MR with TI; FS PD FSE +/- TZ* GRE
I DIFFERENTIAL DIAGNOSIS Osteochondritis Dissecans Typical presentation Most commonly affects humeral capitellum May produce loose bodies 20% bilateral Chronic valgus stress with lateral impaction seen in gymnasts and adolescent pitchers
Elbow is second most common location for loose bodies 0 s supratrochleare is more common in males and usually found in dominant arm
Clinical Issues Presentation: Reduced range of motion Extension only in the case of os supratrochleare Elbow joint pain +/- Grating True locking and catching
Diagnostic Checklist
Presence of other injuries in traumatic origin Possibility of ~steochondritisesor synovial chondromatosis AP/Lateral radiographs
Necrosis of bone followed by healing response and reossification 13-16 year olds
Panner's Disease (Osteochondrosis of Capitellum) Typical age group o 5-11 year old patients Usually heals Residual deformity usually not seen in Panner's disease Loose body formation usually not seen in Panner's disease Probably avascular necrosis secondary to trauma
Synovial Osteochondromatosis (Chondromatosis) May be indistinguishable Chondral bodies often calcify Synovial metaplasia Hypointense bodies in joint
Fracture Especially comminuted +/- Displaced Avulsion of epicondyle extraarticular o Little leaguer's elbow Hyperintense edema on T2WI +I- Posterior dislocation
General Features General path comments o The trochlear notch is an area devoid of articular cartilage in the mid portion of the ulnar articulating surface Should not be mistaken for osteochondral defect Acts as a trap for loose bodies +/- A bony ridge o The os supratrochleare is intraarticular and may therefore grow through synovial nutrition Etiology
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LOOSE BODIES AND OS SUPRATROCHLEARE o 0 s supratrochleare is an accessory bone of
developmental origin o Loose bodies arise from osteochondral injuries or degeneration Epidemiology o Elbow is second most common location for loose bodies o 0 s supratrochleare is more common in males and usually found in dominant arm Associated abnormalities o Articular cartilage defects o Synovial hypertrophy o Remodeling of olecranon fossa by os supratrochleare
Gross Pathologic & Surgical Features Variable number of intraarticular osteochondral fragments Articular cartilage attrition, fraying or defect Synovial hypertrophy and hyperemia
Microscopic Features Laminated articular cartilage Variable attachment to locally hypervascular synovium Variable matrix calcification/ossification Inflammatory infiltrate may be seen if acute impingement occurring
Presentation Most common signslsymptoms o Presentation: Reduced range of motion Extension only in the case of os supratrochleare o Elbow joint pain o +I- Grating o True locking and catching
Demographics Age: Children/adults Gender: M > F
Natural History & Prognosis Premature arthritis if loose bodies left untreated Altered elbow function from growing os supratrochleare Generally excellent results from arthroscopic removal
Treatment Conservative: Direct blow to previously asymptomatic os supratrochleare may settle with rest Surgical: Arthroscopic removal or limited arthrotomy for very large os supratrochleare Complications: Infection, neurovascular damage, hematoma, contractures, arthrofibrosis
1 DIAGNOSTIC CHECKLIST Consider Presence of other injuries in traumatic origin Possibility of osteochondritises or synovial chondromatosis
Image Interpretation Pearls APILateral radiographs MR for lesion location and characterization o TlWI for detection of loose bodies containing non-sclerotic marrow fat o FS PD FSE for articular cartilage fragments adjacent to hyperintense joint fluid
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Clasper JC et al: Arthroscopy of the elbow for loose bodies. Ann R Coll Surg 83(1):34-6,2001 Miller JH et al: Detection of intraarticular bodies of the elbow with saline arthrosonography. Clin Radiol 56(3):231-4,2001 Kelly EW et al: Complications of elbow arthroscopy J Bone Joint Surg 83A:25-34, 2001 Bianchi S et al: Detection of loose bodies in joints. Radiol Clin North Am 37(4):679-90, 1999 Hsu HC et al: 0 s supratrochleare dorsale of the elbow. A report of two cases. Zhonghua Yi Xue Za Zhi 61(11):667-72, 1998 Quinn SFet al: Evaluation of loose bodies in the elbow with MR imaging. J Magn Reson Imaging 4(2):169-72,1994 Ogilvie-HarrisDJ et al: Arthroscopy of the elbow for removal of loose bodies. Arthroscopy 9(1):5-8, 1993
LOOSE BODIES AND OS SUPRATROCHLEARE
I IMAGE GALLERY (Left) Sagittal PD FSE MR shows a loose body within the olecranon fossa adjacent to the olecranon tip (arrow). This mimics an os supratrochlear dorsale. (Right) Coronal graphic shows an supertrochleare dorsale at the proximal aspect of the olecranon process.
(Left) Axial PD FSE MR shows a hypointense sclerotic loose body within the posterior lateral aspect of the joint (arrow). (Right) Sagittal FS PD FSE MR shows a loose body within the olecranon fossa adjacent to the olecranon tip (arrow), and a small loose body within the anterior coronoid fossa.
Variant
(Lef)Sagittal graphic shows multiple loose bodies in elbow joint capsule synovial osteochondromatosis. (Right) Coronal PD FSE MR shows a loose body adjacent to the olecranon tip (arrow).
OLECRANON FRACTURE
Sagittal graphic shows a transverse fracture through the olecranon process.
Sagittal PD FSE shows a nondisplaced fracture through the olecranon process (arrow).
Variable fragment size and displacement on lateral view o Positive fat pad sign on lateral view
Definitions Distraction injury due to resisted triceps contraction o Forced flexion on an extended forearm o High energy direct impact injury
General Features Best diagnostic clue o Proximal displacement of olecranon fragment, positive fat pad sign - radiographs o Linear decreased signal intensity surrounded by edema of olecranon on FSE PDIT2WI Location: Olecranon process of the proximal ulna Size o Varies from a flake to complete involvement o Usually isolated injury Morphology o Nondisplaced cortical disruption o Small "flake"avulsion o Transverse oblique defect near base
CT Findings NECT o Linear lucencies in olecranon indicating fractures o Fracture comminution and displacement can be assessed o Soft tissue swelling evident on soft tissue windows o Sagittal reconstruction for best assessment
MR Findings TlWI o Decreased marrow signal indicating bone stress o Low signal lines indicating fracture lines, +/- bony displacement on sagittal/coronal views o Low signal joint effusion o Disruption of normal anatomy and signal of triceps tendon on sagittal views T2WI o Increased marrow signal indicating edema o Low signal fracture lines +/- High signal hemorrhage interposed between fracture lines o FS PD FSE visualization improved by using FS o High signal joint effusion
nnmm
Radiographic Findings
Radiography o Linear lucency representing fracture line
DDx: Olecranon Fracture Cortrcal Notch
Cortical Notch
Sag PD FSE MR
Sag PD FSE MR
Ulnar Stress Fx
Sag T l W l MR
Ax STIR MR
OLECRANON FRACTURE Key Facts Terminology Distraction injury due ro resisted triceps contraction Forced flexion on an extended forearm High energy direct impact injury
Imaging Findings Proximal displacement of olecranon fragment, positive fat pad sign - radiographs Linear decreased signal intensitv surrounded by edema of olecranon on FSE PDl
Top Differential Diagnoses Posterior Dislocation Radial HeadINeck Fractures Cortical Notch Ulnar Stress Fracture Normal Ossification CenterIVariation o Disruption of triceps tendon anatomy with high
signal tears and associated high signal stress lesions at bony attachments STIR o Very sensitive for bony injury, shown as high signal areas in marrow space o Especially at low field o Less spatial resolution than FS PD FSE
Pathology Olecranon epiphysis fuses at 16-18years Fall on a flexed, supinated forearm
Clinical Issues Pain and loss of function Swelling and hemorrhagic effusion
Diagnostic Checklist Always ensure there is not a concomitant fracture of coronoid process Identify location of fracture with respect to midpoint of trochlear notch Lateral radiograph, FS PD FSE/STIR MR for occult fractures and triceps status
Normal Ossification CenterNariation Normal childhood development May mimic fractures Absent edema in adjacent ossified bone Normally fuses at 16-18 years Failure of fusion = os supratrochleare dorsale Bipartite olecranon Patella cubiti
Imaging Recommendations Best imaging tool: Radiographs, MRI Protocol advice: FS PD FSElT2WI
General Features Posterior Dislocation Fall on outstretched hand injury (FOOSH)
+/- Capitellar fx Lateral ligamentous disruptions +/- Common extensor tendon tear +/- Coronoid fx
Radial HeadINeck Fractures Essex-Lopresti fracture May accompany posterior dislocation +/- Coronoid process fracturelother fractures Impaction injury due to axial overloading in a fall on to the outstretched arm Radial head injuries are rare in children o Usually occur in the radial neck Most common elbow fracture in adults
Cortical Notch Normal variation "Bare area" Mimics osteochondral defect
Ulnar Stress Fracture Abnormal stresses on normal bone Increased signal intensity on T2WI Fat suppression sequences sensitive (FS PD FSE) +I- Periostitis
General path comments o Olecranon epiphysis fuses at 16-18 years o Midpoint of trochlear notch critical in determining stability of healing Etiology o Fall on a flexed, supinated forearm o Direct trauma (direct blow to olecranon in flexed position) o Hyperextension o Throwing injury (pitchers) Epidemiology o Accounts for about 20% of adult elbow fractures o Approximately 6% of childhood elbow injuries Associated abnormalities o High velocity injuries, +I- other upper limb fractures o Hyperextension injuries, +/- fractures of radial head or lateral epicondyle due to varus/valgus loads with olecranon locked into olecranon fossa
Gross Pathologic & Surgical Features Transverse disruption of olecranon typically with one fragment o Most common pattern Most fractures are intraarticular Avulsion of insertion of triceps Tearing of fibrous sheath formed from capsule, lateral ligaments, triceps tendon and periosteum 2-31%will be open fractures
o o o o o o
Microscopic Features Disruption of cortex and trabeculae Hemorrhage with cellular infiltrate ranging from osteoblast and osteoclast to inflammatory cells depending on fracture age Separation of collagen bundles of triceps aponeurosis
Staging, Grading or Classification Criteria cdlton's classification for displacement & pattern of fracture o Type I: Nondisplaced (< 2 mm) and stable o Type 11: Displaced A - avulsion B - transverse C - comminuted D - fracture/dislocations Number of fractures, displacement and location will determine management 80% will have little (< 2 mm) or no displacement Displacement of > 2 mm is usual indication for ORIF is placement of > 1.5 cm is unusual Olecranon stress fracture o Pain during acceleration phase of throwing o Also seen in adults
1 DIAGNOSTIC CHECKLIST Consider Presence of other fractures, especially coronoid Always ensure there is not a concomitant fracture of coronoid process Identify location of fracture with respect to midpoint of trochlear notch In high velocity injury, exclude injuries elsewhere In low velocity, consider general medical condition of patient
Image Interpretation Pearls Lateral radiograph, FS PD FSEISTIR MR for occult fractures and triceps status
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Presentation Most common signs/symptoms o Pain and loss of function o Swelling and hemorrhagic effusion o Point tenderness over olecranon o Inability to extend against gravity o Ulnar neuropathy Pain with extension and flexion Clinical profile o Athlete o After severe trauma Direct impact to extended elbow
Demographics Age: Childrenladults Gender: M > F
Natural History & Prognosis Best outcome seen in minimally/nondisplaced fractures Degenerative changes seen in < 20% > 80% of patients have good outcome
Treatment Conservative: For nondisplaced fractures, 3 weeks cast in 90 degrees flexion o Acceptable for displaced fractures in elderly patients with concomitant illness Surgical: Tension band wiring for fractures proximal to midpoint of trochlear notch, plate fixation for fractures distal to midpoint o Locking nails and screws are also used o Severe comminution or poor bone quality may require excision and triceps advancement o Percutaneous techniques Complications
Loss of extension Nonunion Ulnar nerve palsies Heterotopic bone formation Ulna-humeral arthrosis Painful hardware
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O'Driscoll SW et al: Difficult elbow fractures: Pearls and pitfalls. Instr Course Lect 52:113-34, 2003 Gicquel P et al: Biomechanical analysis of olecranon fracture fixation in children. J Pediatr Orthop 22(1):17-21, 2002 Caterini R et al: Fractures of the olecranon in children. Long-term follow-up of 39 cases. J Pediatr Orthop B 11(4):320-8,2002 Karlsson MK et al: Fractures of the olecranon: A 15- to 25-year followup of 73 patients. Clin Orthop (403):205-12, 2002 Akman S et al: Long-term results of olecranon fractures treated with tension-band wiring technique. Acta Orthop Traumatol Turc 36(5):401-7,2002 Bailey CS et al: Outcome of plate fixation of olecranon fractures. J Orthop Trauma 15(8):542-8, 2001 Sonin A: Fractures of the elbow and forearm. Semin Musculoskelet Radio1 4(2):171-9,2000
OLECRANON FRACTURE
(Left) Coronal graphic shows a nondisplaced fracture of the olecranon process. (Right) Coronal PD FSE MR shows a hypointense nondisplaced fracture of the olecranon process (arrow).
(Left) Lateral radiography shows an olecranon fracture and an olecranon ossification center. (Right) Sagittal STIR MR shows a stress fracture (arrow) line surrounded by adjacent hyperintense edema.
(Left) Sagittal PD FSE MR shows an old ununited olecranon fracture (arrow) still attached to the triceps tendon. There is also a loose body in the olecranon fossa. (Right) Coronal FS PD FSE MR shows a nondisplaced olecranon fracture (arrow) obscured by hyperintense trabecular edema.
LATERAL CONDYLAR FRACTURE
Coronal graphic shows a lateral condylar fracture, The lateral condylar fragment is slightly displaced.
Coronal PD FSE MR shows a lateral condylar fracture (arrow) with rotation and slight distraction of the lateral condylar fragment still attached to the common extensor tendon origin.
o Varies from a subtle crack to an extensively
displaced lesion o ~ifficultto detect in immature skeleton
Abbreviations and Synonyms
Morphology o Undisplaced cortical/physeal disruption o Postero-inferiorlydisplaced fragment
Lateral condylar fx, lateral condyle fracture
Definitions An avulsion injury caused by contraction of forearm extensor/supinator muscles o Fall on to an out stretched hand (FOOSH) o Impaction injury caused by transmitted load through the radial head o Intraarticular extension
General Features Best diagnostic clue o + Posterior fat pad sign on radiography o Lucent fracture line, +/- displacement seen on NECT o Linear decreased signal intensity fracture with surrounding edema on MRI Location o Lateral column of distal humerus Between lateral metaphysis and articular surface o Through medial trochlear notch or capitellotrochlear groove Size
Radiographic Findings Radiography o Linear lucency representing fracture line with variable fragment size and displacement on AP view o Associated fractures of radial head on lateral view 0 Widenine " of intercondvlar distance on AP view 0 Posterior fat pad sign is reliable indicator of injury o Oblique views may be needed to show posteriorly displaced fragment
CT Findings NECT o Linear lucency in condyle o Fracture comminution and displacement can be assessed o Soft tissue swelling evident on soft tissue windows
M R Findings TlWI 0 Decreased marrow signal indicating bone stress o Hypointense fracture lines, +I- bony displacement on axial views
DDx: Lateral Condylar Fracture Post Dislocation
Sag PD FSE MR
Post Dislocation
Capit~llurnOCD
Rad Head/Neck Fx
Rad Head/Neck Fx
Cor PD FSE MR
A P Radiography
Cor STIR MR
LATERAL CONDYLAR FRACTURE Key Facts Capitellum Osteochondritis Dissecans (Capitellum OCD) Olecranon Fracture Posterior Dislocation
Terminology An avulsion injury causea ~y conrracuun of forearm extensor/supinator muscles Fall on to an out stretched hand (FOOSH) Impaction injury caused by transmitted load through the radial head
Imaging Findings Linear lucency representing fracture line with variable fragment size and displacement on AP view Associated fractures of radial head on lateral view Increased marrow signal indicating edema
Pathology Associated with delayed complications
Clinical Issues Pain and loss of function Swelling and discoloration
Diagnostic Checklist Presence of neurovascular complications Presence of other injuries in elbow and upper limb Fat satjSTIR MR for assessment of physeal injury, articular cartilage and common extensor origin
Top Differential Diagnoses Supracondylar Fracture Radial Head/Neck Fracture (Rad Head/Neck Fx)
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o Hypointense joint effusion T2WI o Increased marrow signal indicating edema o Fracture lines through condylar and physis o Surrounded by hyperintense edema o Fx visualization improved by using FS PD FSE o Hyperintense joint effusion STIR o Sensitive for bony marrow edema o Hyperintense areas in marrow space
An impaction injury due to axial overloading in a fall on to the outstretched arm Radial head injuries are rare in children o Usually occur in the neck of radius Most common elbow fracture in adults
Capitellum Osteochondritis Dissecans (Capitellum OCD) ~ e c r o s i of s bone followed by healing response and reossification 12-16 year age group o After ossification of capitellum Panner's disease (osteochondrosis) o 7-10 years o Degenerationlnecrosis capitellum + regeneration and recalcification 20% bilateral Chronic valgus stress with lateral impaction Seen in gymnasts and adolescent baseball pitchers
Nuclear Medicine Findings Bone Scan: + Uptake after 24-72 hours
Imaging Recommendations Best imaging tool: CTIMRI Protocol advice o Acute phase: Lateral and AP radiograph +/- oblique view o Late phase: Axial and coronal MR to evaluate presence of physeal and ligamentous/capsular injuries plus status of articular cartilage
Olecranon Fracture Acute flexion on extended forearm Clinical presentation similar Fall on a flexed, supinated forearm Throwing injury (pitchers) Accounts for about 20% of adult elbow fractures
(DIFFERENTIAL DIAGNOSIS Supracondylar Fracture
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Fall on outstretched hand (FOOSH) injury Transverse lucency in metaphysis on AP or angled AP view Anterior humeral line displaced anterior to mid third of capitellum in 94% Extraarticular in children but may be intraarticular in adults 60% of pediatric elbow fractures Rare in adults (< 3%)
Radial Head/Neck Fracture (Rad Head/Neck Fx) Associated posterior dislocation Associated with coronoid process fracturelother fractures
Posterior Dislocation Fall on outstretched hand injury +/- Capitellar fxlcoronoid fx Lateral ligamentous disruptions 0 LUCL + Surrounding hemorrhage +/- Capsular disruption
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General Features General path comments o Associated with delayed complications Deformity Nonunion
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LATERAL CONDYLAR FRACTURE Complications result of inadequate fixation at the time of fracture Etiology 0 Fall on an outstretched hand, with impaction of radial head o Varus stress with elbow flexedlsupinated, avulsion by common extensor action Epidemiology o 18% of distal humerus fractures o Common in 5-10 year age (peak = 6 years) o Second most common elbow fx Associated abnormalities: Olecranon fractures
Cross Pathologic & Surgical Features 711
Rotation of fracture fragment due to action of forearm extensorslsupinators Disruption of blood supply if significant soft tissue injury occurs Articular cartilage may remain intact and preserve stability
Microscopic Features Disruption of cortex and trabeculae Hemorrhage with cellular infiltrate ranging from osteoblast and osteoclast to inflammatory cells depending on fracture age Avulsion of the osteo-tendinous complex of the common extensor origin
Staging, Grading or Classification Criteria Classification of Milch for unicondylar humeral fractures o Milch type I fx: Lateral trochlear ridge intact prese~vedmedio-lateral stability (Salter Harris type 11) o Milch type I1 fx: Fracture line medial to trochlear groove so lateral trochlear ridge is part of fragment Unstable (Salter Harris type IV), more common Stability may. be -preserved by articular cartilage hinge even with complete physeal injury Jakob classification based on displacement o Type 1: Incomplete & nondisplaced o Type 2: Extends through epiphysis - fragment laterally displaced o Type 3: Lateral condyle rotates or is completely displaced
Presentation Most common signslsymptoms o Pain and loss of function o Swelling and discoloration o Point tenderness lateral condyle o Crepitus Clinical profile: Trauma patient
Demographics Age: Childladult Gender: M > F
Natural History & Prognosis Poor prognosis associated with comminution, delayed reduction and unstable fixation
Undisplaced type I injuries have excellent outcome (98% asymptomatic) Delayed reduction has worse outcome Aggressive dissection (iatrogenic soft tissue stripping) or the injury itself associated with AVN
Treatment Conservative: Undisplaced Milch type I - splint or percutaneous pinning Surgical: Displaced (> 3 mm) Milch type I + type I1 = ORIF with K-wires or screws Complications: Seen in 3396, loss of flexionlextension, nonunion and malunion, cubitus varus (lateral spur formation), AVN, valgus angulation, ulnar nerve palsy, myositis ossificans
Consider Displacement of fragment Stability of fracture Presence of neurovascular complications Presence of other injuries in elbow and upper limb
Image Interpretation Pearls Lateral and AP radiographs Fat satISTIR MR for assessment of physeal injury, articular cartilage and common extensor origin T2* GRE also visualizes physis and provides visualization of epiphyseal cartilage (thick in a child)
O'Driscoll SW et al: Difficult elbow fractures. Pearls and pitfalls. Instr Course Lect 52:113-34, 2003 Fitzgerald RH Jr. et al: Orthopaedics. St. Louis MO, Mosby, 286-95, 2002 Horn BD et al: Fractures of the lateral humeral condyle. Role of the cartilage hinge in fracture stability. J Pediatr Orthop 22(1):8-11, 2002 Toh S et al: Long-standing nonunion of fractures of the lateral humeral condyle. J Bone Joint Surg Am 84-A(4):593-8,2002 Vocke-Hell AK et al: Sonographic differentiation of stable and unstable lateral condyle fractures of the humerus in children. J Pediatr Orthop B 10(2):138-41, 2001 Sonin A: Fractures of the elbow and forearm. Semin Musculoskelet Radio1 4(2):171-91, 2000 Kamegaya M et al: Assessment of stability in children's minimally displaced lateral humeral condyle fracture by magnetic resonance imaging. J Pediatr Orthop 19(5):570-2, 1999 Bast SC et al: Nonoperative treatment for minimally and nondisplaced lateral humeral condyle fractures in children. J Pediatr Orthop 18(4):448-50,1998
LATERAL CONDYLAR FRACTURE (IMAGE GALLERY
I (Left) Anteroposterior radiography shows a lateral condylar fracture with marked lateral soft tissue swelling. (Right) Coronal PD FSE MR shows a chronic lateral condylar fracture in a 57 year old patient who suffered the fracture at age 10.
(Left)Axial PD FSE MR shows the lateral condylar fracture with slight distraction and separation of the condylar fragment. (Right) Coronal PD FSE MR shows lateral condylar fracture with slight rotation of the fracture fragment in an adolescent.
(Lef)Coronal PD FSE MR shows slight rotation of a lateral condylar fracture and intraarticular synovitis. (Right) Coronal graphic shows a lateral condylar fracture with distal extension into the lateral aspect of the trochlea (type 11 fx).
CAPITELLUM FRACTURE
Coronal graphic shows fracture through humeral capitellum oriented in coronal plane. Other elbow fractures commonly associated, esp. radial head (20%). Also seen with posterior dislocation.
Lateral radiography shows coronally oriented displaced rotated capitellar fracture (arrow). Fractures occur coronal plane. Radial head is dislocated anteriorly indicating capsular rupture.
CT Findings NECT: Linear lucency (lucencies if comminuted) indicating fractures
Abbreviations and Synonyms Hahn-Steinthal, Kocher-Lorenz, Broberg-Morrey, McKee, coronal shear fracture
MR Findings
Definitions Shear injury due to transmitted axial overload from radial head in fall on out stretched arm
TlWI: Decreased marrow signal indicating edema with low signal lines indicating fracture lines T2WI: Increased marrow signal indicating edema and effusion, +I-displaced fragment
Imaging Recommendations
[IMAGING FINDINGS General Features Best diagnostic clue: Fracture line seen on NECT, or linear decreased signal intensity fracture with surrounding edema on MRI Location: Distal end of lateral column of the humerus, osseous or articular cartilage, in coronal plane Size: Nondisplaced cortical break to anteriorly displaced fragment Morphology: Nondisplaced cortical disruption, sleeve avulsion of articular cartilage, comminuted and displaced
Best imaging tool: Radiographs in acute phase = lateral, angled lateral, MRI Protocol advice: FS PD FSE
Pseudodefect Posterior normal variation
Capitellar Osteochondritis (OCD)
mnm
Radiographic Findings
Radiography: Linear lucency fracture line - seen best on lateral view with positive fat pad sign
Usually insidious in onset
Capitellum Bone Injury from Posterior Dislocation Posterior aspect secondary to radial head impaction
DDx: Capitellum Fracture Bone Trab lnjury
Caprte/!um OCD
Ax FS PD FSE
Cor FS PD FSI
Cor FS PD FSE
CAPITELLUM FRACTURE Key Facts Terminology
* Radiography: Linear lucency fracture line - seen best on lateral view with positive fat pad sign T2WI: Increased marrow signal indicating edema and effusion, +/- displaced fragment
Hahn-Steinthal, Kocher-Lorenz, Broberg-Morrey, McKee, coronal shear fracture
Imaging Findings Best diagnostic clue: Fracture line seen on NECT, or linear decreased signal intensity fracture with surrounding edema on MRI Location: Distal end of lateral column of the humerus, osseous or articular cartilage, in coronal plane Size: Nondisplaced cortical break to anteriorly displaced fragment Morphology: Nondisplaced cortical disruption, sleeve avulsion of articular cartilage, comminuted and displaced
Top Differential Diagnoses Pseudodefect Capitellar Osteochondritis (OCD) Capitellum Bone Injury from Posterior Dislocation
Clinical Issues Most common signs/symptoms: Pain and swelling after fall on outstretch arm
Diagnostic Checklist Fracture is in coronal plane and best visualized on sagittal images
1 PATHOLOGY General Features Etiology: Fall on an out stretched arm or direct blow to elbow Epidemiology: Rare - 6% of elbow fractures (not usually seen in children < 10 years old)
Consider Presence of other fractures, especially radial head
Image Interpretation Pearls Fracture is in coronal plane and best visualized on sagittal images
Gross Pathologic & Surgical Features Coronal defect with variable anterior displacement
Microscopic Features Disruption of cortex and trabeculae
Staging, Grading or Classification Criteria Type I: Hahn-Steinthal - coronal fracture of capitellum with no extension to trochlea Type 11: Kocher-Lorenz - sleeve avulsion of articular cartilage Type 111: Broberg and Morrey - comminuted Type IV: McKee - type 111 + extension to trochlea
SELECTED REFERENCES 1. 2. 3.
Ring D et al: Articular fractures of the distal part of the humerus. J Bone Joint Surg Am 85-A(2):232-8,2003 Mehdian H et al: Fractures of capitellurn and trochlea. Orthop Clin North Am 31(1):115-27,2000 Tomas FJ et al: Modified radial head--capitellurn projection in elbow trauma. Br J Radio1 71(841):74-5, 1998
Presentation Most common signs/symptoms: Pain and swelling after fall on outstretch arm
Demographics Age: Adolescents, adults Gender: F > M
Natural History & Prognosis Delayed mobilization and presence of other fractures complicates recovery
Treatment Conservative o Type I: Closed reduction, sling in flexion; early mobilization important Surgical o Type I: Wire or screw fixation, type 11: Excision, type III/IV: Cancellous 1agIAcutrac screws
(Lef)Anteroposterior
radiography shows a coronal shear fracture (arrow) of the capitellum with displacement. The center of rotation at the radiocapitellar joint is anterior to axis of humeral shaft, predisposing to shear injuries. (Right) Coronal NECT demonstrates a shear fracture of the capitellum with displacement in this patient who is status post posterior dislocation.
SUPRACONDYLAR FRACTURE
Coronal graphic shows a supracondylar fracture. Fracture line may not be visible on radiographs requiring utilization of the anterior humeral line sign.
Lateral radiography shows a posteriorly displaced distal humerus (anterior humeral line displaced) and a positive fat pad sign (arrow) in this young patient with a supracondylar fracture.
o Plastic deformity of distal humerus o Posterior angulation/displacement o Fracture line angles from anterior distal to posterior
Abbreviations and Synonyms
proximal
Gartland fracture
Radiographic Findings
Definitions
Radiography o Transverse lucency in metaphysis on AP or angled AP view o Fracture line may not be visible in up to 25% o Positive fat pad sign on lateral view o Anterior humeral line displaced anterior to mid third of capitellum in 94%
Transverse fracture of the distal humerus from a bending force in hyperextension Transmitted posterior force in flexion of elbow
LIMAGING
FINDINGS
General Features Best diagnostic clue o Radiographs Positive fat pad sign Transverse metaphyseal lucency Disruption of anterior humeral line o Linear decreased signal intensity surrounded by edema on PD FSE/T2WI of supracondylar humerus Location o Thin distal humerus at risk between the olecranon and coronoid fossae o Extraarticular in children Size: Involves entire distal humerus above condylar epiphyses Morphology
CT Findings NECT Linear lucencies in distal humeral metaphysis indicating fracture CTA: CT angiography to assess vascular injury
MR Findings TlWI o Decreased marrow signal indicating bone edema o Low signal line indicating fracture line +/- Fragment rotation/displacement on sagittal views o Low signal joint effusion T2WI o Increased marrow signal indicating edema o FS PD FSE - visualization improved by using FS
DDx: Supracondylar Fracture Post Dislocation
Post Dislocation
Lat Condylar FY
Olecranon Fx
Olecranon Fx
A P Radiography
Sag FS PD FSE
Cor PD FSE MR
Lat Radiography
Lat Radiography
SUPRACONDYLAR FRACTURE Key Facts
, Terminology Gartland fract Transverse fracture ot the distal humerus from a bending force in hyperextension
Imaging Findings Disruption of anterior humeral line Transverse lucency in metaphysis on AP or angled AP view Fracture line may not be visible in up to 25% Positive fat pad sign on lateral view Anterior humeral line displaced anterior to mid third of capitellum in 94%
Top Differential Diagnoses Lateral Condylar Fracture
o High signal joint effusion
+/- Periarticular extension of fluid with capsular rupture and vascular injury o Low signal fracture lines surrounded by edema STIR o Very sensitive for bony injury shown as high signal areas in marrow space o Especially useful at mid and low-field T2* GRE o Thin slice capability useful for detailed analysis of fragment and adjacent soft tissues o Susceptibility decreases utility for detection of edema in bone
Imaging Recommendations Best imaging tool: Radiographs, CT, MRI Protocol advice o FS PD FSE, TI o CT to assess for comminution
Pathology @
Extension injury more common (95% of cases) than flexion type Type I: Nondisplaced fracture (30%) Type 11: Displaced but intact posterior cortex (24%) Type 111: Displaced plus complete cortical disruption (45%)
Clinical Issues Clinical profile: Typically active child
Diagnostic Checklist Presence of other fractures, especially olecranon and medial epicondyle Associated vascular and neural injuries T1W and FS PD FSE sagittal and coronal views for assessment of occult bony and soft tissue injuries
Olecranon Fracture Fall on a flexed, supinated forearm Olecranon epiphysis fuses at 16-18 years Direct trauma Throwing injury (pitchers)
Valgus Injury Throwing activities Includes trabecular injury +/- Bone trabecular injury of the capitellum +/- MCL tear
Capitellum Osteochondritis Dissecans Necrosis of the bone followed by healing response and reossification 12-16 year age group (after ossification of capitellum) 20% bilateral Chronic valgus stress with lateral impaction seen in gymnasts and adolescent pitchers Panner's disease (ages 7-10 years) as a osteochondrosis
Posterior Dislocation Lateral Condylar Fracture Fall on an outstretched hand, with impaction of radial head Varus stress with elbow flexedlsupinated, avulsion by common extensor action 17% of distal humerus fractures Common in 5-10 year (peak = 6 years)
Other Distal Humerus Fractures Medial epicondyle o Varus force on extended arm Medial condyle o Uncommon o Avulsion with forced varus and direct impact on flexed elbow T-condylar and lateral epicondyle fractures o Less common distal humerus fractures o T-condylar = supracondylar with intraarticular extension
Ulna and radius displaced proximally +/- Extensor tendon tear +/- Fractures o Coronoid, radial head, posterior capitellum Lateral ulnar collateral ligament (LUCL) tear common LUCL tear, posterolateral rotating instability (PLRI) predisposing Supracondylar fx associated
1 PATHOLOGY
1
General Features General path comments o Extension injury more common (95% of cases) than flexion type o Is extraarticular in children but may be intraarticular in adults o Brachial artery and median nerve are vulnerable to traction over angulated fracture fragment Etiology
SUPRACONDYLAR FRACTURE o Hyperextension form - fall onto extended forearm
Radial nerve Brachial artery Use of crossed pins may increase incidence of nerve injury Olecranon osteotomy reduces functional outcome compared to triceps splitting approach to open reduction with internal fixation (ORIF) 0
o Flexion type - fall onto point of elbow
Epidemiology o Accounts for about 60% of pediatric elbow fractures Most common pediatric elbow fracture o Rare in adults (< 3%) o Common in nondominant side ( 1 5 1 ) Associated abnormalities o Other elbow fractures, esp. olecranon and medial condylar o Distal radial fracture (5-6%) o Olecranon avulsion fracture o Medial condyle impaction o Traction injuries to brachial artery (0.5%) and anterior interosseous branch of median nerve (4%) o Median neuropathy
0
Treatment Conservative o Type I, splinting in 90 degrees flexion Surgical o Type I1 and I11 = percutaneous lateral pin fixation or ORIF with cross pinning ORIF may be needed in up to 20% Complications o ~afiureof reduction o Vascular injury (rare) o Median nerve injury (traumatic and iatrogenic - up to 5%) o Volkmann's contracture secondary to unrecognized untreated acute vascular iniurv , , o Cubitus varus as most common complication (Baumann angle 2-5 degrees greater than unaffected side) o Loss of function
Gross Pathologic & Surgical Features Oblique transverse fracture through thin aspect of distal humerus between medial and lateral pillars Failure of anterior cortex (tensile side) Plastic deformity of posterior cortex (compression side) Posterior rotation +/- varus malalignment
Microscopic Features Disruption of cortex and trabeculae Hemorrhage with cellular infiltrate ranging from osteoblast and osteoclast to inflammatory cells o Depends on fracture age
Staging, Grading or Classification Criteria Flexion or extension fracture (extension = 96% of fractures) Based on classification of Gartland (for extension injuries) o Type I: Nondisplaced fracture (30%) o Type 11: Displaced but intact posterior cortex (24%) o Type 111: Displaced plus complete cortical disruption (45%)
1 DIAGNOSTIC CHECKLIST Consider Presence of other fractures, especially olecranon and medial epicondyle Associated vascular and neural injuries
Image Interpretation Pearls T1W and FS PD FSE sagittal and coronal views for assessment of occult bony and soft tissue injuries
[SELECTED REFERENCES O'Driscoll SW et al: Difficult elbow fractures. Pearls and pitfalls. Instr Course Lect 52:113-34, 2003 2. Gosens T et al: Neurovascular complications and functional outcome in displaced supracondylar fractures of the humerus in children. Injury 34(4):267-73, 2003 3. Skaggs DL et al: Operative treatment of supracondylar fractures of the humerus in children. The consequences of pin placement. J Bone Joint Surg Am 83-A(5):735-40, 2001 4. Cheng JC et al: Epidemiological features of supracondylar fractures of the humerus in Chinese children. J Pediatr Orthop B 10(1):63-7,2001 5. O'Hara LJ et al: Displaced supracondylar fractures of the humerus in children. Audit changes practice. J Bone Joint Surg Br 82(2):204-10,2000 6. Sonin A: Fractures of the elbow and forearm. Semin Musculoskelet Radio1 4(2):171-91, 2000 7. McKee MD et al: Functional outcome after open supracondylar fractures of the humerus. The effect of the surgical approach. J Bone Joint Surg Br 82(5):646-51, 2000 8. Fleuriau-Chateau P et al: An analysis of open reduction of irreducible supracondylar fractures of the humerus in children. Can J Surg 41(2):112-8, 1998 1.
Presentation Most common signslsymptoms o Pain and loss of function o Swelling and discoloration o Decreased distal pulse Clinical profile: Typically active child
Demographics Age o Common in children < 10 years old o Median age of incidence = 6 years Gender: M > F
Natural History & Prognosis Return of function in over 90% Temporary nerve impairment in 10-16% but most recover Return of range of motion (ROM) may take a year Neurovascular injuries in displaced supracondylar fractures o Anterior interosseous branch of median nerve
1
1
SUPRACONDYLAR FRACTURE
Typical
(Lef)Lateral radiography shows a supracondylar fracture and fracture of a supracondylar process. Note the supracondylar fracture line seen as a linear lucency. (Right) Lateral radiography shows supracondylar fracture with a visible lucency.
Typical (Left) An teroposterior radiography shows no visible fracture lines in this patient with a supracondylar fracture. (Right) Anteroposterior radiography shows medial lucency (arrow) in a patient with supracondylar fracture. AP radiography is not as sensitive as lateral radiography for the detection of supracondylar fractures.
Tvaical (Left) Anteroposterior radiography shows a visible fracture line medially in this patient with supracondylar fracture. (Right) Lateral radiography shows the supracondylar fracture and associated olecranon fracture. Note the soft tissue swelling and positive posterior fat pad sign (arrow).
MEDlAL CONDYLAR FRACTURE
Coronal graphic shows a fracture extending through the humeral trochlea and separating the medial condyle, consistent with a medial condylar fracture.
Lateral radiography shows a chronic medial condylar fracture with rotation and separation of the medial condylar fragment.
o The articular portion of the medial column of the
Abbreviations and Synonyms Medial condyle (MC) fracture, medial sided injuries
Definitions An avulsion injury caused by varus & direct impact on flexed elbow o Contraction of forearm flexor muscles in a fall on to the outstretched arm o Impaction injury by transmitted load through the olecranon process in a fall onto olecranon Fracture lineincludes the trochlear articular surface o Epicondylar injury remains extraarticular not affecting the trochlea
General Features Best diagnostic clue o Lucent fracture line, +/- displacement Fracture line extends to and includes the trochlear articular surface isolating medial condyle o Decreased signal intensity fracture line surrounded by edema on T2WI Location
I
distal humerus Medial epicondyle injuries are purely extraarticular and not referred to as medial condylar fractures Size o Varies from a subtle crack to an extensively displaced lesion o Difficult to detect in immature skeleton Morphology o Nondisplaced cortical disruption o Antero-inferiorly displaced fragment
Radiographic Findings Radiography o Linear lucency representing fracture line with variable fragment size and displacement on AP view o Associated fractures of olecranon on lateral view o Widening of intercondylar distance on AP view o Displaced epiphysis in children before ossification of trochlea o Fat pad sign is variable depending upon extension to articular surface o Wide separation of fragment in children - unstable fracture
,m1171 [IB CT Findings
NECT o Linear lucency in condyle
I
DDx: Medial Condvlar Fracture Lateral Con Fx
Cor PD FSE MR
Valgu.~ Injury
Cor FS PD FSE
Sag FS PD FSE
Valgus Injury
IR MR
Sag PD FSE MR
MED1AL CONDYLAR FRACTURE
-
Key Facts Terminology An avulsion injury caused by varus & direct impact on flexed elbow Contraction of forearm flexor muscles in a fall on to the outstretched arm Impaction injury by transmitted load through the olecranon process in a fall onto olecranon
lmaging Findings Lucent fracture line, +/- displacement Fracture line extends to and includes the trochlear articular surface isolating medial condyle Decreased signal intensity fracture line surrounded by edema on T2WI
Top Differential Diagnoses Supracondylar Fracture o Fracture comminution and displacement can be
assessed o Soft tissue swelling will be evident on soft tissue windows
M R Findings TlWI o Decreased marrow signal indicating bone stress o Hypointense fx lines +/- bony displacement on axia views o Hypointense joint effusion T2WI o Increased marrow signal indicating edema o High signal joint effusion o Low signal fracture line in bone and high signal fracture line cartilage o Alteration of signal within ulnar nerve + surrounding edema o FS PD FSE provides superior contrast & spatial resolution STIR o Very sensitive for bony injury shown as high signal areas in marrow space o Critical at low field
Imaging Recommendations Best imaging tool: Radiographs, MRI Protocol advice o Axial and coronal MR Especially to evaluate ulnar nerve (TI and FS PD FSE or STIR) Physeal injury in children and ligamentous/capsular injuries
Olecranon Fracture Lateral Condylar Fracture
.
Pathology Olecranon fracture Ulnar nerve damage - forms base of cubital tunnel
Clinical Issues Pain and loss of function Swelling and discoloration
Diagnostic Checklist Ulnar nerve injury Forearm compartment syndrome Fat sat/STIR MR for assessment of ulnar nerve, physeal fracture, forearm muscles and common flexor origin
Extraarticular in children but may be intraarticular in adults 60% of pediatric elbow fractures Rare in adults (c 3%)
Olecranon Fracture Fall on a flexed, supinated forearm Olecranon epiphysis fuses at 16-18 years Direct trauma Throwing injury (pitchers)
Lateral Condylar Fracture Fall on an outstretched hand, with impaction of radial head Varus stress with elbow flexedlsupinated, avulsion by common extensor action 17% of distal humerus fractures Common in 5-10 year (peak = 6 years)
Valgus Injury Throwing activities Includes trabecular injury +/- Bone trabecular injury of the capitellum +/- MCL tear
Capitellum Osteochondritis Dissecans (OCD) Necrosis of bone followed by healing response and reossification 12-16 year age group (after ossification of capitellum) 20% bilateral Chronic valgus stress with lateral impaction seen in gymnasts and adolescent pitchers Panner's disease (ages 7-10 years) as an osteochondrosis
Posterior Dislocation Supracondylar Fracture Fall on outstretched hand (FOOSH) injury Transverse lucency in metaphysis on AP or angled AP view Anterior humeral line displaced anterior to mid third of capitellum in 94%
+/- Lateral ligamentous damage +/- Fractures/trabecular injuries of posterior capitellum, anterior radial head FOOSH injury +/- Extensor tendon tear End stage instability
MEDlAL CONDYLAR FRACTURE o Pain and loss of function
General Features General path comments o Developmental appearances o Diagnosis may be difficult before ossification of trochlea o Ossification mnemonic = CRITOL C = capitellum at 1-2 years R = radial head at 2-4 years = I = internal (medial) epicondyle at 4-6 years T = trochlea at 8-11 years O= olecranon at 9-11 years L = lateral epicondyle at 10-11 years Etiology o Fall on an outstretched arm, with avulsion from contraction of forearm flexor muscles o Fall onto point of elbow in flexion, with impact of olecranon Epidemiology o < 2% of elbow fractures in children o 10% of elbow fractures in adolescence o < 5% of elbow fractures in adults Associated abnormalities o Olecranon fracture o Ulnar nerve damage - forms base of cubital tunnel
o Swelling and discoloration o Point tinderness medial condyle o Ulnar nerve palsy
o Forearm compartment syndrome Clinical profile: Post trauma patient
Demographics Age: Childrenladults Gender: M > F
Natural History & Prognosis Poor prognosis if comminution, failed reduction and unstable fixation Nondisplaced Milch type I injuries have excellent outcome Incarcerated fragments in children may be missed and result in poor outcome, mainly due to ulnar nerve dysfunction
Treatment Conservative: Nondisplaced Milch type I; splint in elbow + wrist flexion to reduce tension of forearm flexors Surgical: Displaced (> 3 mm) Milch type I + type I1 = ORIF with reconstruction plates +/- anterior transposition of ulnar nerve; excision of fragment has variable outcomes Complications: Seen in 33% o Loss of flexion/extension, nonunion and pseudoarthrosis, cubitus varus (undergrowth of trochlea) or valgus (overgrowth of medial condyle), AVN, ulnohumeral arthrosis, myositis ossificans
Gross Pathologic & Surgical Features Epiphysis may become trapped within the joint in children Rotation of fracture fragment due to action of forearm flexors Disruption of blood supply if significant soft tissue injury occurs
Microscopic Features Disruption of cortex and trabeculae Hemorrhage with cellular infiltrate ranging from osteoblast and osteoclast to inflammatory cells depending on fracture age Avulsion of the osteo-tendinous complex of the common flexor origin Avulsion of osteo-ligamentous complex of medial collateral ligament
1 DIAGNOSTIC CHECKLIST Consider Ulnar nerve injury Forearm compartment syndrome Extent of fracture displacement Incarceration of fracture fragment
Image Interpretation Pearls Lateral and AP radiographs Fat sat/STIR MR for assessment of ulnar nerve, physeal fracture, forearm muscles and common flexor origin
Staging, Grading or Classification Criteria Based on classification of Milch for unicondylar fracture o Type I: Lateral trochlear ridge intact, preserved medio-lateral stability (Salter Harris type 11) o Type 11: Originates in capitotrochlear sulcus so lateral trochlear ridge is part of fragment Unstable (Salter Harris type IV) Kilfoyle classification (similar to Jakob of lateral condyle fx) o Type I: Incomplete & nondisplaced o Type 11: Through epiphysis o Type 111: Lateral condyle rotates or displaced
Presentation Most common signs/symptoms
[SELECTEDREFERENCES 1. 2. 3. 4. 5.
OtDriscollSW et al: Difficult elbow fractures. Pearls and pitfalls. Instr Course Lect 52:113-34, 2003 Leet A1 et al: Medial condyle fractures of the humerus in children. J Pediatr Orthop 22(1):2-7, 2002 Farsetti P et al: Long-term results of treatment of fractures of the medial humeral epicondyle in children. J Bone Joint Surg Am 83-A(9):1299-305, 2001 Nagi ON et al: Fractures of the medial humeral condyle in adults. Singapore Med J 41(7):347-51,2000 Sonin A: Fractures of the elbow and forearm. Semin Musculoskelet Radio1 4(2):171-91,2000
MEDIAL CONDYLAR FRACTURE
I IMAGE GALLERY
I
Variant
(Left) Coronal graphic shows a chronic medial and lateral epicondylar fracture. This is an unusual injury. (Right) Coronal PO FSE MR shows chronic medial and lateral epicondylar fractures with hypointense fracture lines. There is osteophyte formation on the lateral aspect of the joint.
Variant (Lefl) Lateral radiography shows a chronic medial condylar fracture with rotation and slight proximal migration of the medial condylar fragment still articulating with the ulna. (Right) Anteroposterior radiography shows an intercondylar fracture (arrow) extending from the lateral aspect of the trochlea up to the lateral diametaphysis.
Variant ( k f l ) Coronal graphic shows an avulsion of the medial condyle/epicondyle in a patient after closure of the physis analogous to a little leaguer's elbow in a pre-adolescent pa tient. (Right) Axial PO FSE MR shows chronic avulsion of the medial epicondyle in a patient who suffered a fracture in childhood with resulting fibrous union.
BlClPITAt RADIAL BURSITIS
Coronal graphic shows a distended bicipital radial bursa adjacent to the distal biceps tendon.
-
-
-
Axial FS PD FSE MR shows marked tendinosis (arrow) of the distal biceps insertion with surrounding distal bicipital radial bursitis (cubital bursitis) (open arrow).
Radiographic Findings Abbreviations and Synonyms Cubital bursitis, antecubital bursitis, distal bicipital radial bursitis
Definitions Inflammation of the bicipital radial bursa Sac-like cavities/potential cavity containing synovial fluid at frictional sites o Tendons/muscles pass over bone prominence
CT Findings NECT o +/- Antecubital mass o Fluid attenuation CECT o +/- Rim enhancement o Smooth border
MR Findings * TlWI
General Features
o Homogeneous decreased signal intensity mass in
Best diagnostic clue: High signal, fluid intensity mass Location o Interposed between distal biceps tendon and anterior aspect of the radial tuberosity o +/- Communication with the elbow joint below the annular ligament Size: Varies from a few mms to several cms depending on the amount of fluid contained Morphology o Flattened synovial sac not visualized on MRI unless distended with fluid o Variable amounts of internal debris
I
Radiography o Nonspecific soft tissue swelling o +/- Antecubital mass
characteristic location o +/- Associated tendinosis of biceps tendon
Thickening and intermediate signal intensity at insertion o Decreased signal in adjacent bone - reactive edema o Thick intermediate intensity lining in case of chronic bursitis T2WI o Increased signal intensity fluid on FS PD FSE o Hyperintense flattened, oval, or round shaped cystic appearing mass
DDx: Bicipital Radial Bursitis Normal Vessels
Sag FS PD FSE
Sag PD FSE MR
Sag FS PD FSE
Post D~slocat~on
Ax FS PD FSE
Ax FS PD FSE
Key Facts Terminology Inflammation of the bicipital radial bursa
.
Imaging Findings
1
fluid intensity mass Best diagnostic clue: High Interposed between distal biceps tendon and anterior aspect of the radial tuberosity +/- Communication with the elbow joint below the annular ligament Increased signal intensity fluid on FS PD FSE flattened, or appearing mass
Top Differential Diagnoses Biceps Tendinosis or Partial Tear Capitellum Osteochondritis Dissecans Posterior Dislocation o Fluid signal intensity on all pulse sequences unles
containing inflammatory debris or calcification Decreased signal structures if calcified Intermediate signal if contains inflammatory, hemorrhagic o r exudative debris +/- Rice bodies in patients with rheumatoid arthritis STIR o Similar contrast as FS PD FSE o Less spatial resolution o More homogeneous fat saturation T2* GRE o Hypointense rimldebris if chronic hemorrhage o Hyperintense mass T1 C+ o May demonstrate thin rim enhancement after gadolinium administration o Homogeneous decreased signal intensity center simple-cyst o +/- Thickened rind, enhancing - previous inflammation
Ultrasonographic Findings Typically hypo or anechoic mass with through transmission
Imaging Recommendations Best imaging tool: MRI Protocol advice o FS PD FSE demonstrates fluid filled bursa T2* GRE if fat suppression inadequate in axial plane
I DIFFERENTIAL DIAGNOSIS Biceps Tendinosis or Partial Tear Tendinopathy on MR images May coexist Forced extension on flexed forearm o Tear Chronic repetitive microtrauma o Tendinosis
Radial Head Fracture Normal Structures
Pathology
May 611 with fluid and present as mass on antecubital
fossa
.
Clinical Issues Antecubital mass (if large) or pain associated with supination Clinical profile: History of biceps pain May present insidiously: Found after athletic activity
Diagnostic Checklist FS PD FSE most sensitive for hyperintense fluid detection Axial imaging plane recommended
+/- Hypertrophy of radial tubercle
Antecubital Mass Neoplastic o Diffuse enhancement o In contrast to rim enhancement with bursitis Benign o Neuroma o Lipoma Fat signal on TlWI Saturates with fat suppression o Hematoma + History of trauma
Capitellum Osteochondritis Dissecans Overuse syndrome of the elbow Subchondral reactive process of the humeral capitellum Flattening of capitellar profile is earliest sign Necrosis of bone followed by healing response and reossification Chronic valgus stress with lateral impaction seen in gymnasts and adolescent pitchers Increased rotary, compressive or axial loads seen in throwing athletes Occurs in the 12-16 year age group o After ossification of capitellum Lateral pain
Posterior Dislocation Fall on out stretched hand (FOOSH) +/- Capitellar fx +/- Radial head fx Lateral ligamentous disruptions o Lateral ulnar collateral ligament injury (LUCL) + Surrounding hemorrhage +/- Coronoid fracture Lateral pain
Radial Head Fracture Fall on outstretched hand injury (FOOSH) Accounts for 30% of adult elbow fractures Most common elbow fracture in adults Proximal radial injuries rare in children
BlClPlTAL RADIAL BURSITIS o High pose NSAIDs o +/- Narcotic analgesics
o Usually occur in the radial neck Osteochondral injury to adjacent capitellum common +/- Osteochondral free fragments
o Aspiration, steroid injection after anesthetic o Systemic corticosteroid for resistant acute cases
.
Normal Structures
After rule out infection, gout Chronic bursitis o Splintinglrest less helpful o Remove calcium if present
Blood vessels o Hyperintense on T2W1, STIR
1 PATHOLOGY
-
[DIAGNOSTIC CHECKLIST
General Features
Consider
General path comments o May fill with fluid and present as mass on antecubital fossa Often mistaken for neoplasm Etiology o Inflammation of the bursa with variable amounts of fluid Friction of tendon with supination/pronation leads to inflammation of bursa Radial tuberosity hypertrophy predisposing Epidemiology: Relatively uncommon Associated abnormalities o Associated with biceps tendinopathyltear Radial tuberosity hypertrophy
8-1
In the setting of overuse
Image Interpretation Pearls FS PD FSE most sensitive for hyperintense fluid detection Axial imaging plane recommended
. .
1.
2.
Gross Pathologic & Surgical Features Indurated, fluid-filled bursa of variable size
3.
Microscopic Features
4.
Hypertrophied bursa1 synovial lining with infiltration of inflammatory cells Fibrosis and granulation tissue
5. 6.
(CLINICALISSUES
7.
Presentation
Bond JR et al: Radiologic case study. Partial tear of the distal biceps tendon with mass-like bicipitoradial bursitis and associated hyperostosis of the radial tuberosity. Orthopedics 26(4):376, 448-50, 2003 Yamamoto T et al: Bicipital radial bursitis. CT and MR appearance. Comput Med Imaging Graph 25(6):531-3, 2001 Ramsey ML: Distal biceps tendon injuries. Diagnosis and management. J Am Acad Orthop Surg 7(3):199-207,1999 Brinker MR et al: The adult elbow. Fundamentals of Orthopaedics. Philadelphia PA, WB Saunders, 153-64, 1999 Chen WS et al: Recalcitrant bicipital radial bursitis. Arch Orthop Trauma Surg 119(1-2):105-8,1999 Fritz RC et al: MR imaging of the elbow. An update. Radio1 Clin North Am 35(1):117-44, 1997 Fritz RC et al: The Elbow. Magnetic resonance imaging in orthopedica and sports medicine. vol 1. 2nd ed. Philadelphia PA,J.B. Lippincott, 743-849, 1997
Most common signs/symptoms o Antecubital mass (if large) or pain associated with supination o Acute bursitis Pain Tenderness Limited motion +/- Swelling/redness o Chronic bursitis Recurrent bursitis Limited motion Clinical profile: History of biceps pain
.. .
Demographics Age: Typically adult patient Gender: Most likely M > F due to higher incidence of biceps disease in males
Natural History & Prognosis May present insidiously: Found after athletic activity +/- Resolution with cessation of predisposing activities Conservative treatment leads to resolution
Treatment Acute bursitis o Rest immobilization
A
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Y
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0
&
.A
*
LL
L
u
h
.
BlClPlTAL RADIAL BURSlTlS
1 IMAGE GALLERY ( b f t ) Axial FS PD FSE MR shows a distended cubital bursa consistent with bicipital radial bursitis. (Right) Axial 12 FSE MR shows a distended bursa surrounding the biceps tendon. This mimics a tenosynovium. The distal biceps tendon is invested by paratenon, not tenosynovium.
(Left) Coronal STIR MR shows fluid surrounding the distal biceps insertion consistent with bicipital radial bursitis. (Right) Axial 72 FSE MR shows a distended distal bicipital radial bursa surrounding the biceps tendon. There is hypertrophic synovitis present within the bursa which may mimic a neoplasm.
7 -
I
(Left) Axial FS PD FSE shows tendinosis (arrow) of the insertion of the biceps on the radius with surrounding distal radial bursitis. (Right) Axial FS PD FSE MR shdws the distended bursa (arrow) indicating inflammatory change (same patient as the image on the left).
OLECRANON BURSITIS
Coronal graphic shows a distended olecranon bursa in a patient with olecranon bursitis.
Sagittal STlR MR shows hyperintense fluid-filled olecranon bursa (arrow) in a patient with clinical olecranon bursitis.
T1 C+: +/- Rim enhancement Variable amounts of internal, typically hemorrhagic debris Osteomyelitis rare
Abbreviations and Synonyms Miner's elbow, student's elbow, draftsman's elbow
Definitions
Ultrasonographic Findings
Typically hypo or anechoic mass with through transmission
Inflammation of the bursa overlying the olecranon process at the proximal aspect of the ulna
I ~MAG~NC FINDINGS
1
Imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE demonstrates bursa1 fluid
General Features Best diagnostic clue: Fluid containing mass (fluid signal intensity) in olecranon bursa in symptomatic patient Location: Superficial bursa between integument and olecranon, intratendinous bursa, and subtendinous bursa between the triceps and tip of the olecranon Size: Varies from a few mms to several cms depending on the amount of fluid contained within Morphology: The olecranon bursa is a flattened svnovial sacs not usuallv visualized on MRI unless distended with fluid
MR Findings T2WI: High-signal, fluid intensity mass in superficial soft tissues adjacent to the olecranon process and triceps insertion
Triceps Tendinosis or Partial Tear Tendinopathy on MR images, +/- edema
MasslNonspecific Edema In area of bursa - hemangioma, synovitis, neuroma
General Features General ~ a t comments: h Inflammation of the olecran& bursa with variable amounts of fluid Etiology
DDx: Olecranon Bursitis
Sag FS P D FSE
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OLECRANON BURSlTlS Key Facts
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Terminology
Top Differential Diagnoses
Miner's elbow, student's elbow, draftsman's elbow Inflammation of the bursa overlying the olecranon process at the proximal aspect of the ulna
Triceps Tendinosis or Partial Tear Mass/Nonspecific Edema
Pathology
Imaging Findings Best diagnostic clue: Fluid containing mass (fluid signal intensity) in olecranon bursa in symptomatic patient Location: Superficial bursa between integument and olecranon, intratendinous bursa, and subtendinous bursa between the triceps and tip of the olecranon T2WI: High-signal, fluid intensity mass in superficial soft tissues adjacent to the olecranon process and triceps insertion Protocol advice: FS PD FSE demonstrates bursal fluid
General path comments: Inflammation of the olecranon bursa with variable amounts of fluid Associated abnormalities: Associated with triceps tendinopathy and tears
Clinical Issues Clinical profile: May be seen in patients with underlying systemic disease
Diagnostic Checklist FS PD FSE sensitive for demonstrating fluid
o Secondary to acute or repetitive trauma or systemic
disease o Traumatic bursitis commonly a football injury
Consider
associated with artificial turf o Ice hockey Epidemiology: Relatively common Associated abnormalities: Associated with triceps tendinopathy and tears
In case of fluid, pain and swelling in the superficial soft tissues adjacent to the olecranon process
Image Interpretation Pearls FS PD FSE sensitive for demonstrating fluid
Gross Pathologic & Surgical Features Indurated, fluid-filled bursa of variable size o Subcutaneous bursa A.
Microscopic Features Hypertrophied bursal synovial lining with infiltration of inflammatory cells +/- fibrosis May be infected o Staphylococcus aureus common -
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2.
3. 4.
Brinker MR et a1 : The adult elbow. Fundamentals of Orthopaedics. Philadelphia PA, WB Saunders Co, 153-64, 1999 Fritz RC et al: MR imaging of the elbow. An update. Radiol Clin North Am 35(1):117-44, 1997 Steiner E et al: Ganglia and cysts around joints. Radiol Clin North Am 34(2):395-425, 1996 Olsen NK et al: Bursa1 injections. Physiatric Procedures in Clinical Practice. Philadelphia PA, Hanley & Belfus, 36-43, 1995
Presentation Most common signs/symptoms o Acute - painless distention after direct blow o chronic - recurrent traumatic episodes - large rubbery mass +/- pain Clinical profile: May be seen in patients with underlying systemic disease
Demographics Age: Adolescent or adult patient Gender: M = F
Natural History & Prognosis Will subside with cessation of causative activities and anti-inflammatory drugs in most cases
Treatment Conservative treatment unless extensive o Antibiotics for infected bursitis Extensive cases require bursectomy
(Left) Sagittal T l Wl MR shows decreased signal intensity fluid within the olecranon bursa and thickened synovial lining in a patient with a bursal infection. (Right) Sagittal STIR MR shows the distended infected olecranon bursa.
SYNOVIAL FRINGE, ELBOW
Coronal graphic shows the folding of the lateral capsule between the capitellurn and radius known as the synovial fringe or radiocapitellar labrum. This is not a true labrurn or meniscus.
Coronal PD FSE MR shows the fold of synovium known as the synovial fringe (arrow) laterally. This synovial plica is triangular shaped.
CT Findings Abbreviations and Synonyms Synovial fold, synovial plica, radiohumeral meniscus, radiocapitellar labrum
Definitions A thickened fold or fibrotic fringe of synovial tissue at the lateral margin of the radiocapitellar joint
General Features
NECT: Shows areas of lucency and/or sclerosis in radial head and capitellum indicating chondromalacia
MR Findings T2WI: High signal in capitellum, radial head = chondromalacia PDtIntermediate: +/- Synovitis - thickening hyperintensity relative to fluid MR arthrography o Coronal images - synovial fold, articular cartilage damage and lateral soft tissue damage
Ultrasonographic Findings
Best diagnostic clue: Synovial fold projecting into the joint (directed medially) from posterior/lateral fat pad on MR arthrography Location: Lateral capsule of radiohumeral joint Size: Length 1-5 cm, width 1-10 mm, thickness 1-4 mm Morphology: Rigid fibrous meniscoid fold - pliable thin band, no fibromyxoid components, therefore not a meniscus
Radiographic Findings
Localized thickening of lateral joint capsule, detection increased with saline sonoarthrography
Imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE/T2WI
Osteoarthritis (OA)/Loose Bodies
Radiography: Areas of lucency and/or sclerosis on radial head and capitellum indicating chondromalacia
+/- Synovitis
MDpJM Synovitis
May be mass like (posterolateral aspect of joint)
DDx: Synovial Fringe, Elbow
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SYNOVlAL FRINGE, ELBOW Key Facts PDIIntermediate: +/- Synovitis - thickening hyperintensity relative to fluid
Terminology Synovial fold, a y u v v l a l plica, radiohumeral meniscus, radiocapitellar labrum
Top Differential Diagnoses Osteoarthritis (0A)ILooseBodies Synovitis
Imaging Findings Best diagnostic clue: Synovial fold projecting into the joint (directed medially) from posterior/lateral fat pad on MR arthrography Location: Lateral capsule of radiohumeral joint Size: Length 1-5 cm, width 1-10mm, thickness 1-4 mm Morphology: Rigid fibrous meniscoid fold - pliable thin band, no fibromyxoid components, therefore not a meniscus T2WI: High signal in capitellum, radial head = chondromalacia
Normal Variant Bifid synovial fringe
Pathology Etiology: Chronic repetitive trauma in pronationlsupination Symptomatic folds show hypertrophy and increase in number of nerve fibers
Diagnostic Checklist MR arthrography will effectively characterize the lesion
I DIAGNOSTIC CHECKLIST Consider Loose bodies, lateral epicondylitis
Image Interpretation Pearls MR arthrography will effectively characterize the lesion
General Features Etiology: Chronic repetitive trauma in pronation/supination Epidemiology: Up to 50% of elbows
Gross Pathologic & Surgical Features Thin membrane with fibrillar free edge and rigid shelf with triangular profile attached to capsule Originate from synovium adjacent to posterior fat pad
1 SELECTED REFERENCES 1.
2.
Microscopic Features Two synovial layers separated by thin fatty stroma with villous free edge - tough fibrous core projecting from capsule with synovial covering Symptomatic folds show hypertrophy and increase in number of nerve fibers
3.
Duparc F et al: The synovial fold of the humeroradial joint: Anatomical and histological features, and clinical relevance in lateral epicondylalgia of the elbow. Surg Radio1 Anat 24(5):302-7,2002 Antuna SA et al: Snapping plicae associated with radiocapitellar chondromalacia. Arthroscopy 17(5):491-5, 2001 Awaya H et al: Synovial fold syndrome. MR imaging findings. Am J Roentgen01 177(6):1377-81,2001
Presentation Most common signs/symptoms: Pain on lateral joint line +/- locking, snapping elbow (flexion/pronation test), over radial head
Demographics Age: Adult (mid life) Gender: M = F
Natural History & Prognosis Excellent outcome after resection
Treatment Conservative: If symptoms are mild and rest is possible Surgical: Arthroscopic resection
(Left) Coronal PO FSE MR shows a slightly irregular synovial fringe with central radial chondromalacia. (Right) Coronal PD FSE MR shows heterotopic ossification within the synovial fringe.
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OSTEOARTHRITIS, ELBOW
Coronal graphic demonstrates early findings of OA including erosions of the ulna and radial head.
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Coronal PD FSE MR demonstrates arthrosis of the capitellum and radius with osteophyte formation, subchondral sclerosis and loss of articular cartilage.
Radiographic Findings Abbreviations and Synonyms Osteoarthritis (OA), degenerative joint disease (DJD)
Definitions Degenerative arthritis characterized by chondromalacia, osteophyte formation, subchondral cysts and synovitis Primary - gradual process of destruction & regeneration as a result of chronic microtrauma Secondary - non-inflammatory DJD 0 Previous trauma, congenital deformity, infection or metabolic disorder
1 IMAGING FINDINGS General Features Best diagnostic clue: Chondromalacia, +/- subchondral sclerosis, subchondral cysts and/or edema, and osteophytes Location: Hyaline chondral surfaces of the elbow Size: Small localized area (typically post trauma), compartment or whole elbow Morphology: Progressive loss of articular cartilage with associated new bone formation and capsular fibrosis
Radiography 0 Joint space narrowing 0 Subchondral sclerosis/eburnation: Increased density o Subchondral cyst lucencies o Osteophyte formation
CT Findings CT arthrography: Loose bodies as filling defects
M R Findings TlWI o Decreased signal intensity subchondral cysts: High signal marrow extends into osteophytes o Subchondral decreased signal indicates sclerosis and/or edema T2WI o FS PD FSE hyperintensity in hyaline cartilage and subchondral bone marrow edema Thinning of articular (hyaline) cartilage with occasional focal defects Edema well demonstrated with fat saturation Subchondral decreased signal indicating sclerosis (sclerosis best visualized on TlWI) Subchondral cysts (increased signal), and osteophytes PDIIntermediate 0 PD FSE cartilage can be visualized
dmmE"Y DDx: Osteoarthritis, Elbow
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OSTEOARTHRITIS, ELBOW Key Facts Terminology Primary - gradual process of destruction ST
Pathology Affects up to 90% of older individuals Elbow is affected less commonly than weight bearing joint such as the knee and hip Loose bodies: Cause catching and locking Deformities Subluxation~ Ankylosis
regeneration as a result of chronic microtrauma Secondary - non-inflammatory DJD
Imaging Findings Best diagnostic clue: Chondromalacia, +/subchondral sclerosis, subchondral cysts and/or edema, and osteophytes
Clinical Issues
Top Differential Diagnoses
Pain with utilization of the joint
Inflammatory Arthritis Crystal Deposition Disease Osteochondral Defects in Acute Trauma Osteochondromatosis Normal Elbow Anatomy
+/- Swelling (effusion)
Diagnostic Checklist Secondary OA in cases where the findings are focal Utilize FS PD FSE to visualize the chondral erosions
Hyperintense edema on T2WI
Synovial thickening seen well
+/- Synovitis
o Edema may not be quite as bright on PD relative to
FS PD FSE T2* GRE: With fat suppression, cartilage abnormalities - decreased signal areas on T1 weighted GRE images T1 C+: Synovium enhances in cases of synovitis
Osteochondromatosis Loose bodies Synovial metaplasia +/- Calcifications TZ*GRE images to detect osteochondral loose bodies
Nuclear Medicine Findings Bone Scan: Increased tracer uptake with subchondral fractures or cysts or general sclerosis
Normal Elbow Anatomy Posterolateral pseudodefect (Pseudodefect) o Between capitellum and lateral epicondyle o Mimics OA and OCD Cortical Notch o Ulna "bare area" o Mimics chondromalacia
lmaging Recommendations Best imaging tool: MRI Protocol advice o FS PD FSE MRI o TlWI & T2* GRE to identify loose bodies
1 DIFFERENTIALDIAGNOSIS I
Inflammatory Arthritis Polyarticular systemic disease Rheumatoid arthritis (RA) affects elbow frequently +/- RA factor Synovitis common +/- Erosions
Crystal Deposition Disease Polyarticular arthritis Calcium pyrophosphate dihydrate o Chondrocalcinosis o Pseudogout o Pyrophosphate arthropathy Calcium hydroxyapatite o Asymptomatic calcification o Calcific tendonitis, bursitis & periarthritis o Chronic, destructive joint disease Monosodium urate monohydrate o Hyperuricemia o Gouty arthritis o Tophaceous gout
Osteochondral Defects in Acute Trauma +/- Hypointense fracture line
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General Features General path comments o Begins as fatigue fracture of the collagen meshwork followed by increased hydration of the articular cartilage and loss of proteoglycans from the matrix into the synovial fluid Fibrillation of the cartilage follows with deep clefts appearing and regeneration/proliferation of chondrocytes Proliferative changes occur at the joint margins with formation of osteophytes Loose bodies - fragmentation of osteochondral surfaces follows Synovial hypertrophy produces joint pain by nerve stimulation and weeping of synovial fluid produces increased intraarticular pressure thereby "stretching" the joint lining = pain Increased levels of degrading enzymes including matrix metalloproteinase Increased intraarticular levels of collagenase, neutral proteases and degradative products of proteoglycans Desiccated cartilage seen early with aging
OSTEOARTHRITIS, ELBOW Etiology o Multiple theories - chronic microtrauma (primary) leading to disruption of the articular surface Fibrillation, eburnation, subchondral cysts, and osteophytes form Secondary OA results from healing of major trauma or other predisposing events Joint instability may be predisposing Epidemiology o Affects up to 90% of older individuals o Elbow is affected less commonly than weight bearing joint such as the knee and hip Associated abnormalities o Loose bodies: Cause catching and locking o Deformities o Subluxations o Ankylosis
Limitation of forearm rotation - radial head osteophytes 0 Chronic posterior elbow impingement Valgus extension overload Progressive posterior elbow pain Limited elbow extension Younger group than posttraumatic arthritis Associated neuropathy (ulnar nerve) numbness/tingling in ring & small fingers Posterior fossa impingement pain relieved with local anesthetic injection Integrity of medial collateral ligament - chronic laxity associated with radiocapitellar arthritis, with pain aggravated by valgus load & forearm rotation
Demographics Age o Typically older patients (over 50 years) unless history of trauma Posttraumatic - 4th to 6th decades 40 years Chronic posterior impingement I Gender: M > F
Gross Pathologic & Surgical Features Degraded cartilage with loss of sheen o Subchondral geodes (cysts) containing variable degrees of debris o Buttressing osteophytes to increase surface area Fissured and/or ulcerated cartilage surface Articular surface collapse
Natural History & Prognosis Progressively debilitating disease without medical intervention
Microscopic Features Diminution of chondrocytes in superficial zones with chondrocyte swelling to variable degrees Cartilage matrix loses its ability to stain for proteoglycans with Alcian blue or safranin-0 Matrix chondrocytes demonstrate proliferation in clusters (brood capsules) Neovascularity penetrates layer of calcified cartilage & new chondrocytes extend up from deeper layers Hypertrophied synovium becomes folded into villous folds with variable infiltration of plasma cells, and lymphocytes
Treatment Conservative 0 Physical therapy (PT); NSAIDs for pain management; hyaluronic acid injections, glucosamine & chondroitin supplements Surgical 0 Indicated for patients with persistent symptoms and pain o Arthroscopy (debridement) o Arthroplasty o Total joint replacement
Staging, Grading or Classification Criteria Cartilage damage o Fissuring o Abnormal matrix calcification 0 Osteocyte formation o Osteoarthritis Posttraumatic & valgus extension overload injury as two common groups of degenerative arthritis
ST Consider Secondary OA in cases where the findings are focal 0 Instability is predisposing
Image Interpretation Pearls Utilize FS PD FSE to visualize the chondral erosions
Presentation Most common signs/symptoms o Pain with utilization of the joint o +/- Swelling (effusion) Clinical profile 0 Primary osteoarthritis Posttraumatic Usually affects men Ulnar neuropathy findings are rare Arthrosis changes are more global - osteophytes in anterior & posterior compartments Limited flexion & extension
1. 2.
3. 4.
Miller MD et al: Surgical atlas of sports medicine. Philadelphia PA, Saunders, 436-42, 2003 Bredella MA et al: Accuracy of T2-weighted fast spin-echo MR imaging with fat saturation in detecting cartilage defects in the knee. Comparison with arthroscopy in 130 patients. AJR 172(4):1073-80, 1999 Fritz RC et al: The elbow. Magnetic resonance imaging in orthopedics and sports medicine. vol 1. 2nd ed. J.B. Lippincott 743-849, 1997 Fritz RC et al: MR imaging of the elbow. An update. Radio1 Clin North Am 35(1):117-44, 1997
OSTEOARTHRITIS, ELBOW
Tvpical
(Left) Sagittal PD FSE MR shows osteoarthritic changes of the radiocapitellar joint including post traumatic bone deformities, chondral erosions, and osteophyte formation. (Right) Coronal PD FSE MR shows osteoarthritic changes medially including osteophyte formation in an old ununited sublime tubercle fracture and adjacent trochlear osteophyte formation.
(Left) Sagittal PD FSE MR shows findings of osteoarthritis including chondral loss, subchondral cyst formation, subchondral sclerosis, synovitis, and joint debris. (Right) Sagittal PD FSE MR shows loose body formation in the posterolateral recess.
Variant
(Left) Sagittal graphic shows chondroid metaplasia and chondral body formation in a patient with synovial chondromatosis. These bodies would be intermediate on PD and T2WI. (Right) Coronal FS T 1 MR high resolution arthrogram shows superficial chondral erosions of the radial head (arrow) without joint space narrowing.
1
RHEUMATOID ARTHRITIS, ELBOW
Sagittal graphic shows inflamed synovium within the joint and erosive changes within the posterior aspect of the olecranon. This patient has olecranon rheumatoid bursitis.
Abbreviations and Synonyms Rheumatoid arthritis (RA), degenerative joint disease (DJD)
Definitions Systemic inflammatory arthritic condition requiring the presence of 4 out of the following 7 criteria for > 6 weeks 0 Classification criteria for rheumatoid arthritis Morning stiffness Oligo or polyarthritis in three or more joints or several joint groups Arthritis of either wrist, metacarpophalangeal joint or proximal interphalangeal joint Symmetric arthritis Rheumatoid nodules over boney prominences, extensor surfaces or juxta-articular Abnormal amounts of serum rheumatoid factor Radiographic changes including erosions and juxta-articular demineralization
Sagittal FS PD FSE shows marked synovial changes (arrows) and reactive bone marrow edema in a patient with rheumatoid arthritis.
o Thickened edematous synovium in association with effusion in patient with suggestive clinical symptomatology o Erosions common Location o Synovium of elbow joint o Affects synovium first then secondarily cartilage and bone leading to deformity o Nodules - in 20% of RA patients as mixed signal intensity masses in the skin, synovium, tendons, sclera, viscera Size: Usually diffuse involvement of synovium or tenosynovium Morphology o Thickened irregular synovium in the presence of a -joint effusion Synovitis followed by erosive/destructive changes
Radiographic Findings Radiography: Joint space narrowing, effusion, occasional cyst formation (cystic rheumatoid) followed by destruction
CT Findings
I IMAGING FINDINGS
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NECT: Joint space narrowing, effusion, occasional cyst formation (cystic rheumatoid) followed by destruction CECT: ~nhancementof inflamed synovium (pannus)
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General Features Best diagnostic clue
DDx: Rheumatoid Arthritis, Elbow Med Epicondv/itr~
Ricip Rur.citis
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Cor STIR M R -
Ax FS PD FSE
Cor PD FSE MR
Sag Tl Wl MR
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RHEUMATOID ARTHRITIS, ELBOW Key Facts Imaging Findings Thickened edematous synovium in association with effusion in patient with suggestive clinical syrnptomatology Best imaging tool: MRI
Top Differential Diagnoses Synovitis Other Inflammatory/Crystal Deposition Arthritis Osteoarthritis (OA) Medial Epicondylitis (Med Epicondylitis) Olecranon Bursitis (Olecranon Bursit) Bicipital Radial Bursitis (Bicip Bursitis) Tumor
MR Findings TlWI o Erosions, effusions are decreased in signal intensity o FS T1 shows thickened edematous synovium as a relative increase in signal intensity T2WI o Joint effusion - hyperintense fluid o Hyperintense olecranon bursitis o Narrowed hyaline articular cartilage o Erosions - increased signal intensity defects in the subchondral bone at the joint edges o FS PD FSE sensitive to edema = Hyperintense ulnar nerve associated with impingement related to synovitis, articular destruction and instability PDIIntermediate: Demonstrates inflamed synovium as thickened increased signal intensity joint lining STIR o Generally less effective because of low signal (standard STIR) and blurriness (FSE STIR) o Used at low and mid field more commonly T2* GRE o Less sensitive to chondral erosions or subchondral edema o Sensitive for loose body identification o Rheumatoid nodules (intermediated signal) on extensor surface of elbow T1 C+: Enhancement of synovium especially with fat saturation
Nuclear Medicine Findings Bone Scan: Bone reactive change will demonstrate increased uptake
lmaging Recommendations Best imaging tool: MRI Protocol advice o PD FSE with and without FS o PD & FS PD FSE images show thickened synovium or cartilage loss
Pathology * Rheumatoid factor (RF) against Fc portion of autologous IgG Lab tests alone do not confirm the diagnosis of RA RF can be present (usually low titers) in normal individuals and other disease states
Clinical Issues
= Most common signs/symptoms: Elbow stiffness, pain and swelling Age: Adult for classical RA; variants (juvenile) younger patients
Diagnostic Checklist Evaluate PD or FS PD FSE images for synovial thickening
I DIFFERENTIAL DIAGNOSIS Synovitis Characteristic symptoms/signs especially bone involvement different from RA o Subchondral edema and chondral erosions unusual PD demonstrates synovitis o Hyperintense compared to relatively hypointense fluid
Other Inflammatory/Crystal Deposition Arthritis Calcium pyrophosphate dihydrate crystal deposition disease (CPDD) +/- Tophi - gout - uric acid crystals Pseudogout - gout like pain attacks Chondrocalcinosis - asymptomatic
Osteoarthritis (OA) +/- Antecedent trauma +/- Subchondral cysts +/- Monoarticular +/- Osteophytes
Medial Epicondylitis (Med Epicondylitis) Valgus stress injury Usually chronic repetitive microtrauma Thrower's, golfer's elbow
Olecranon Bursitis (Olecranon Bursit) Without RA Fluid signal intensity on T2WI +/- Infection +/- Olecranon osteomyelitis
Bicipital Radial Bursitis (Bicip Bursitis) Without RA Fluid signal intensity on T2WI +/- Biceps tendinosis +/- Biceps tear
Tumor Bone destruction may mimic erosion Giant cell tumor
RHEUMATOID ARTHRITIS, ELBOW +/- Synovitis
1 PATHOLOGY
Presentation Most common signs/symptoms: Elbow stiffness, pain and swelling
General Features General path comments o Rheumatoid factor (RF) against Fc portion of autologous IgG Most RF = IgM RF may also be IgG, IgA or IgE All types of RF form immune complexes with autologous IgG o Lab tests alone do not confirm the diagnosis of RA RF can be present (usually low titers) in normal individuals and other disease states Genetics: HLA-D allele DR4 is associated with RA patients Etiology o Combination of genetic and environmental factors o Interaction of antigen presenting macrophages with T cells (helpertinducer theory) likely inciting event o Complexes of IgG rheumatoid factor can deposit in blood vessels and lead to vasculitis causing secondary effects o Hepatitis B vaccine may be causative in a small number of patients Epidemiology: 3% of women ST 1% of men overall Associated abnormalities 0 Extraarticular manifestations Nodules, lymphadenopathy, splenomegaly, vasculitis, myopathy, sensory changes from neuropathy or direct compression from synovitis Visceral changes including pericarditis, pulmonary fibrosis, nodules, and pleuritic pain 0 Elbow entrapment neuropathies caused by pannus Anterior interosseous syndrome reported
Gross Pathologic & Surgical Features Pannus (granulation/synovium) tissue erodes cartilage ST bone o Direct extension of pannus occurs at the margins of the joint o Tendon sheaths can be involved with pannus
Demographics
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Natural History & Prognosis
Staging, Grading or Classification Criteria Inclusion classification criteria (as described in definition above) Progression of RA o Polypoid fibrovascular thickening of synovium + synoviocyte hyperplasia = pannus eroding into articular cartilage o Pannus growth + chondral erosions = subchondral extension + cyst formation o Ankylosis of joint
10% improve after first attack of synovitis and up to 60% can have remissions Up to 10% can become disabled Poor prognostic indicators include o High rheumatoid factor, periarticular erosions, rheumatoid nodules, muscle wasting, joint contractures
Treatment Conservative o Rest o Pharmaceutical approach including NSAIDs, antimalarials, disease modifying agents (MTX, s~l~hasalazine, gold, penicillamine), steroids and cytotoxic drugs 0 Physical therapy -. surgical o Synovectomy o Arthroplasty, arthrodesis, osteotomy
Consider Synovitis o Etiologies monoarticular or polyarticular
Image Interpretation Pearls Evaluate PD or FS PD FSE images for synovial thickening Subchondral marrow edema, synovitis (pannus) + pancompartmental chondral erosions are characteristic of rheumatoid arthritis Effusions often distend joint capsule
Microscopic Features Vascular congestion and synovial cell proliferation occurs Infiltration of subsynovial layers by PMNs, lymphocytes & plasma cells Synovial villous formation is seen
Age: Adult for classical RA; variants (juvenile) younger patients Gender: Female 3% of overall population, male 1%
ISELECTEDREFERENCES 1. 2. 3.
4.
5.
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Kauffman JI et al: Surgical management of the rheumatoid elbow. J Am Acad Orthop Surg 11(2):100-8,2003 Murphy MS: Management of inflammatory arthritis around the elbow. Hand Clin 18(1):161-8,2002 Rahme H: The Kudo elbow prosthesis in rheumatoid arthritis. A consecutive series of 26 elbow replacements in 24 patients followed prospectively for a mean of 5 years. Acta Orthop Scand 73(3):251-6,2002 Matsuno h et al: Relationship between histological findings and clinical findings in rheumatoid arthritis. Path01 Int 52(8):527-33,2002 Fink B et al: Results of elbow endoprostheses in patients with rheumatoid arthritis in correlation with previous operations. J Shoulder Elbow Surg 11(4):360-7,2000
RHEUMATOID ARTHRITIS, ELBOW
(LA$) Sagittal PD FSE MR shows marked synovial proliferation in a patient with rheumatoid arthritis. (Right) Coronal FS PD FSE MR shows marked synovial proliferation in a patient with rheumatoid arthritis. The patient also has lateral epicondylitis with tearing of the common extensor tendon origin.
(Left) Sagittal PD FSE MR shows an erosion (arrow) of the capitellum in association with synovial proliferation in a patient with RA. (Right) Sagittal FS PD FSE MR shows synovial thickening in a patient with antecubital pain.
(Left) Axial FS PD FSE MR shows the thickened increased signal intensity synovium. (Right) Axial FS PD FSE MR shows markedly thickened synovium and bone reactive edema.
OSTEOMYELITIS, ELBOW
Sagittal graphic shows infected olecranon bursitis with adjacent olecranon cortical destruction and medullary osteomyelitis.
Lateral radiography shows bone destruction (arrow) on the olecranon and bursa1 soft tissue swelling in this pediatric patient with osteomyelitis.
Radiographic Findings Abbreviations and Synonyms Acute hematogenous osteomyelitis, chronic osteomyelitis
Definitions Acute hematogenous osteomyelitis in pediatric patient Chronic posttraumatic osteomyelitis in adult patient Often due to adjacent infectious bursitis in adult
General Features Best diagnostic clue o Bone marrow hyperintensity on T2WI o Osseous erosion + sinus tract identified on T2WI o Bone destructive change with cortical irregularity identified on TlWI Location o Bone marrow in hematogenous osteomyelitis o Osteitis + marrow involvement in secondary (trauma or surgery) osteomyelitis Size: Variable from epiphyseal involvement to diaphyseal + soft tissue involvement Morphology: Focal, Brodie abscess or larger area of medullary or cortical destruction
Radiography o Insensitive for early osteomyelitis o Changes delayed 10-14 days after onset of fever o Soft tissue edemalswelling o Focal lucency to frank destruction of bone o Periosteal elevation + underlying lucency (subperiosteal abscess) o Intramedullary abscess - focal lucency f tract to cortical surface o Sequestration (necrotic fragments) + involucrum (periosteal bone) as parosteal ossification o Joint effusion
CT Findings NECT o Early bone destruction o Cortical + trabecular bone detail o Periosteal elevation, cortical destruction, intramedullary abscess + sinus tracts o Joint effusions = hypodense CECT o Infected regions enhance o Soft tissue findings: Abscesses enhance peripherally, sinus tracts enhance
MR Findings TlWI
DDx: Osteomyelitis, Elbow Stress Fracture
Stress Response
Humeral Fracture
Olecranon Fx
Sag STIR MR
Ax STIR MR
Sag FS PD FSE
Ax FS PD FSE
Olecranon Burs
A
OSTEOMYELITIS, ELBOW Key Facts Imaging Findings Bone marrow hyperintensity on T2WI Osseous erosion + sinus tract identified on T2WI Bone destructive change with cortical irregularity identified on TlWI
Top Differential Diagnoses Cellulitis Septic Arthritis ~ l b o wFracture Osteoid Osteoma Other Bone Tumors Panner's Disease Olecranon Bursitis without Osteomyelitis (Olec Bursitis)
Pathology Staphylococcus aureus = most common infecrlng organism in all age groups Chronic osteomyelitis = most common form of osteomyelitis in adult & 2" to trauma * Hematogenous seeding r Direct contamination Contiguous spread
Clinical Issues
Most common signs/symptoms: Pain Fever
Diagnostic Checklist Identify association of marrow edema with disruption/erosion of cortex + soft tissue sinus tract
o Hypointense marrow edema + cortical destruction o Hypointense reactive joint effusion
I DIFFERENTIAL DIAGNOSIS
o Soft tissue hypointense abscess
Cellulitis
o Tract from skin to cortex o Hypointense to intermediate signal in
metaphysis/diametaphysis in child T2WI o Hyperintense marrow involvement o Hyperintense intraosseous abscess o Cortical destruction: Intermediate to hyperintense o Cloaca (periosteal opening): Focal hyperintensity in hypointense periosteum o Sinus tract: Intermediate to hyperintense o Brodie abscess (round abscess cavity due to chronic pyogenic infection): Hyperintense + hypointense sclerotic rim o Cellulitis: Reticulated subcutaneous hyperintensity o Myositis: Hyperintense muscle + enlargement T1 C+ o Enhancement Bone marrow - inflammation Abscess - peripheral enhancement of adjacent infected soft tissue (thick wall) Sequestrum - enhancement peripheral to sequestrum Cortical erosion/destruction - f enhancement Sinus tract - peripheral enhancement Sequestrum: Hypointense on T1 + T2WI Involucrum (periosteal reaction): Hypointense on T1 & T2WI
Nuclear Medicine Findings Bone Scan: Increased uptake with bone destructive changes of osteomyelitis
Imaging Recommendations Best imaging tool: MR sensitive to marrow edema & soft tissue involvement Protocol advice: TI + FS PD FSE or STIR axial, coronal & sagittal
Subcutaneous fat involvement Hypointense on TI, hyperintense on T2 Reticulated pattern on TI & T2 Underlying muscle or deep fascia1 planes intact
Septic Arthritis Large hyperintense (T2WI) joint effusion with capsular distension, f scalloping of capsule (synovitis) Diabetes, steroids, intravenous drug use = predisposing factors
Crystal Induced Arthropathies Requires T2* gradient echo for visualization of susceptibility Effusion Degenerative findings including labral tears Chondral - hyaline cartilage degeneration
Elbow Fracture Hypo or hyperintense fracture line Adjacent hyperintensity of soft tissue without sinus tract or osseous erosion Olecranon fracture may mimic osteomyelitis Radiographs often helpful for differentiation History of trauma
Eosinophilic Granuloma Proliferating histiocytes Punched-out calvarial lesions + button sequestrum Tubular bones - osteolytic destruction f lamellar periosteal reaction
Osteoid Osteoma Lesion < 2 cm Painful lesion Requires FS PD, T2 or STIR to demonstrate hyperintensity of lesion & edema
Other Bone Tumors Ewing sarcoma Osteosarcoma
-
-
-
OSTEOMYELITIS, ELBOW Posttraumatic osteomyelitis
Solid lesion = central enhancement & peritumoral edema
-
-
Myositis Ossificans Mass of calcified or ossified granulation tissue +_ Reactive hyperintense soft tissue edema on T2WI adjacent to ossification
Presentation Most common signs/symptoms: Pain Clinical profile o Fever o Restricted motion + point tenderness o Elevated sedimentation rate, C-reactive protein & WBC count o Soft tissue swelling + erythema + sinus tract
Panner's Disease Osteochondrosis seen in 5-11 years old Bone destruction without clinical picture of infection Unusual location for infection
Olecranon Bursitis without Osteomyelitis (Olec Bursitis)
Demographics
Hyperintense mass on T2WI Cystic appearing +/- Rim enhancement No bone changes without osteomyelitis
Age o Young children most commonly affected o Adults with direct contamination (trauma, post-op) Gender: M = F
Natural History & Prognosis
-
-
Osseous destruction will reoccur if untreated Prognosis good if treated early Develop into chronic infection Intramedullary, subperiosteal abscesses Soft tissue extension
General Features General path comments o Relevant anatomy for infection
Periosteum (periostitis) Cortex (osteitis) Marrow (osteomyelitis) Metaphysis: > 1 year to skeletal maturity Metaphysis/epiphysis - hematogenous involvement in infants Subcutaneous fat (cellulitis)
Treatment Conservative 0 IV antibiotics Surgical o Debridement & antibiotic-impregnated beads
o Staphylococcus aureus = most common infecting
organism in all age groups o Common organisms = Streptococcus, Pseudomonas,
,
Consider Identify association of marrow edema with disruption/erosion of cortex + soft tissue sinus tract Axial images to identify hypointense sequestrum
Haernophilus, Enterobacter Epidemiology o Chronic osteomyelitis = most common form of osteomyelitis in adult & 2" to trauma o Staphylococcus aureus = 80-90%
Gross Pathologic & Surgical Features
1.
Hematogenous seeding o Children o Via vasculature o Vascular metaphyseal bone Direct contamination o Penetrating trauma 0 Post-surgical Contiguous spread o Soft tissue infection o Septic arthritis
2. 3. 4.
Van Holsbeeck MT et al: Musculoskeletal Ultrasound. 2nd ed. Philadelphia PA, Mosby, 265-8, 2001 Greenspan A: Osteomyelitis, infectious arthritis, and soft-tissue infections. Orthopaedic Radio1 3rd ed. 753-84, 2000 Mettler FA et al: Skeletal System. Essentials of Nuclear Medicine Imaging. 4th ed. Philadelphia PA, WB Saunders, 285-333, 1998 Resnick D: Pelvis and Hip. Internal Derangements of joints. 1st ed. Philadelphia PA, WB Saunders, 473-554, 1997
Microscopic Features Leukocytic infiltration of marrow Vascular compression Necrosis, abscesses + sequestra
Staging, Grading or Classification Criteria Acute/subacute & chronic hematogenous osteomyelitis Brodie abscess Chronic recurrent multifocal osteomyelitis (CRMO)
-
L
-
A
,
OSTEOMYELITIS, ELBOW
I IMAGE GALLERY (Left) Sagittal T 1 WI MR shows infected olecranon bursitis (arrow). Note the early olecranon cortical (open arrow) erosion without associated hypointense bone marrow edema. No osteomyelitis .developed. (Right) Anteroposterior radiography shows bone destructive change in the olecranon in this 4 year old with proven osteomyelitis.
Typical
I
(Lef) Bone scan from posterior projection shows increased tracer activity in the right olecranon in this pediatric patient with olecranon osteomyelitis. (Right) Anteroposterior radiography shows lucency of the olecranon at presentation in this room with pain and an increased white blood cell count.
(Lef)Sagittal graphic shows an intramedullary abscess. Osseous related changes are hyperintense on T2 WI, especially FS PD FSE. (Right) Sagittal graphic shows a sequestrum in the olecranon in this patient with chronic osteomyelitis. A sequestrum is hypointense on T I & T2 WI.
SECTION 3: Wrist and Hand Ligaments Scapholunate Ligament Tear Lunotriquetral Instability
3-2 3-6
Carpal Instabilities Mid Carpal Instability
3-10
Distal Radioulnar Joint Ulnocarpal Abutment Distal Radioulnar Joint Instability
3-14 3-18
Triangular Fibrocartilage Complex Triangular Fibrocartilage Tear
3-22
Fractures, Distal Radius and Ulna Distal Radius Fractures Die Punch Fracture, Distal Radius Ulnar Styloid Fracture
3-26 3-30 3-34
Carpal Fractures Scaphoid Fractures Hamate Fractures
3-38 3-42
Avascular Necrosis Scaphoid Non-Union Kienbock's Disease
3-46 3-50
Carpal Tunnel Carpal Tunnel Syndrome
3-54
Guyon's Canal Syndrome Ulnar Tunnel Syndrome
3-58
Arthritis Degenerative Arthritis, Wrist Hamato-Lunate Impingement Rheumatoid Arthritis, Wrist and Hand Madelung's Deformity
3-62 3-66 3-70 3-74
Cysts Ganglion Cyst, Wrist
Tendons De Quervain's Tenosynovitis Extensor Carpi Ulnaris Tendinitis Giant Cell Tumor Tendon Sheath
Finger Ulnar Collateral Ligament Tear, Thumb Flexor Annular Pulley Tears Flexor Digitorurn Profundus Avulsions
3-94 3-98 3-102
SCAPHOLUNATE LIGAMENT TEAR
Coronal " era~hic shows tear of the volar comDonent r of the scapholunate ligament. Intact membranous component is seen proximally.
Coronal 1 1 C+ MR (intraarticular contrast) shows complete dissociation (arrow) between scaphoid and lunate. Hyperintense fluid extends across the membranous and volar scapholunate ligament.
Short radiolunate Radioscapholunate (RSL) (ligament of Testut) o Scaphotrapeziotrapezoid ligament complex Size o Variable based on associated osseous vs. ligamentous disruption of major carpal links Scaphotrapeziotrapezoid (STl')= radial link Triquetrohamate (TH) = ulnar link Morphology o Scapholunate interosseous ligament Dorsal component = trapezoidal Membranous = wedge-shaped Volar = thin slightly oblique fibers m
Abbreviations and Synonyms SL or scapholunate instability, stage I perilunate instability
Definitions Dissociation = ligamentous disruption between scaphoid + lunate Instability = inability to withstand normal loading Rotatory subluxation - abnormal radiographic alignment of dissociated scaphoid
Radiographic Findings General Features Best diagnostic clue: Discontinuity of the scapholunate ligament Location o Intrinsic scapholunate ligament complex = scapholunate interosseous ligament Dorsal component (important key stabilizer) = Membranous component Volar component o Extrinsic SL ligament complex Radioscaphocapitate (RSC) Long radiolunate (radiolunotriquetral) (RLT)
Radiography o Anteroposterior view - signs of unstable injuries Loss of scapholunate articular parallelism Scapholunate interval diastasis > 3 mm Decreased scaphoid cortical ring-to-pole interval (> 4 mm asymmetry or absolute value c 7 mm) Asymmetric radioscaphoid interval (normal = 4 mm) Lunate extension Degenerative arthritis o Lateral view - signs of unstable injuries Radioscaphoid angle > 80" Capitolunate angle > 20" SL angle > 70"
mmm DDx: Scapholunate Ligament Tear Dorsal Ganglion
Scaphoid Fracrure
Radius Fracture
-
Cor FS PD MR
Cor T I WI MR
r.
Cor TlWl MR
SCAPHOLUNATE LIGAMENT TEAR Key Facts Imaging Findings Best diagnostic clue: Discontinuity of the scapholunate ligament Intrinsic scapholunate ligament complex = scapholunate interosseous ligament Scapholunate interval diastasis > 3 mm Key structure = disruption of dorsal component of SL ligament
Top Differential Diagnoses Dorsal Wrist Ganglion De Quervain's Stenosing Tenosynovitis Scaphoid Fracture Radius Fracture Avascular Necrosis of Scaphoid
Pathology SL dissociation requires injury to both SL intrinsic ligament + the extrinsic RSC ligament Scapholunate advanced collapse (SLAC) wrist = progressive proximal capitate migration, radioscaphoid & capitolunate arthrosis in untreated SL dissociation
Clinical Issues ~ o scommon t signsIsymptoms: Pain ST soft tissue swelling involving dorsoradial wrist Watson test (scaphoid shift test) for SL instability = pain on ulnar to radial deviation Audible click at SL interval
Diagnostic Checklist Evaluate all three components of SL ligament
Dorsal intercalated segment instability (DISI) deformity
MR Findings TlWI o Scapholunate gap increased to > 3 mm (equivalent of the Terry Thomas sign on radiography) = dissociation o Volar or palmar flexion of scaphoid on sagittal images o DISI with dorsal tilting of lunate, increased capitolunate angle to > 30' & increased scapholunate angle > 80" T2WI o Hyperintense linear signal in partial or complete tear o Complete ligamentous disruption with hyperintense fluid-filled gap o Hyperintense synovial fluid communication between radiocarpal & midcarpal compartment o Key structure = disruption of dorsal component of SL ligament o Associated synovitis of extrinsic volar radiocarpal ligaments o Degenerative perforations may exist in membranous portion with intact volar + dorsal components T1 C+ o MR arthrography Flap tears Perforations Integrity of dorsal component SL ligament
Imaging Recommendations Best imaging tool: MR to identify separate components of SL interosseous ligament + associated scaphoid or distal radius fractures Protocol advice o T1 or PD + FS PD FSE coronal & axial plane o FS PD FSE sagittal
1 DIFFERENTIAL DIAGNOSIS Dorsal Wrist Ganglion Most common soft tissue mass in wrist From capsule over SL joint Painless mass associated with injuries to SL ligament Weakness of grip, pain or paresthesias from nerve compression or irritation
*
De Quervain's Stenosing Tenosynovitis Radial sided wrist pain Inability to abduct thumb + swelling, crepitus and pain on radial side of wrist Affects abductor pollicis longus (APL) + extensor pollicis brevis (EPB) tendons
Scaphoid Fracture Tuberosity Distal pole Waist Proximal pole Fracture line = horizontal oblique, vertical oblique or transverse Hypointense fracture line + variable edema of subchondral marrow on T2WI
Radius Fracture
-
Low energy metaphyseal injuries Colles' fx Articular injuries - violent injuries, frequently comminuted + unstable Identify components of articular fractures: Metaphyseal or shaft, radial styloid, dorsal mediallpalmar medial articular fragments
Avascular Necrosis of Scaphoid 2" to proximal pole or waist fractures Necrotic bone hypointense on T1 + hyperintense on FS PD FSE or STIR in acute + subacute stages Reactive marrow edema of distal pole may not represent necrosis
Kienbock's Disease Avascular necrosis lunate Related to ulnar + lunar negative variance
-
SCAPHOLUNATE LIGAMENT TEAR Lunate marrow hypointense on TlWI + hyperintense on FS PD or T2 FSE images in early stages Hypointense lunate on all pulse sequences in advanced degenerative arthrosis
1 PATHOLOGY General Features General path comments o Relevant anatomy Scapholunate ligament complex = intrinsic + extrinsic ligaments Extrinsic ligaments = gross stability Intrinsic = fine tuning of stability Scaphotrapeziotrapezoid (STT) ligament complex = significant volar constraint Etiology o Axial compression/hyperextension + intercarpal supination 0 Ulnar deviation o Forward fall onto outstretched hand, or backward on a pronated hand o SL dissociation requires injury to both SL intrinsic ligament + the extrinsic RSC ligament Epidemiology o Most common type of carpal instability o Residual of perilunate injury or as isolated injury o Association with scaphoid + distal radial fractures
. .. .
Gross Pathologic & Surgical Features Classification o Acute (< 6 weeks) Stable - partial ligament disruption Unstable (dynamic or static) - complete ligament disruption 0 Chronic Stable, unstable, fixed Pancarpal arthrosis Scapholunate advanced collapse (SLAC) wrist = progressive proximal capitate migration, radioscaphoid & capitolunate arthrosis in untreated SL dissociation DISI deformity with midcarpal collapse
..
..
Microscopic Features Scaphoid attachment of SL ligament has fewer Sharpey's fibers than lunate attachment (more susceptible to tear) Histology of ligaments = collagen fibers, connective tissue with fat, vessels + elastic fibers
Staging, Grading or Classification Criteria Arthroscopic o Grade I & I1 = partial tear SL ligament o Grade I11 & IV = complete disruption Perilunar instability (PLI) o Stage I PLI: Scapholunate failure o Stage I1 PLI: Capitolunate failure o Stage I11 PLI: Triquetrolunate failure o Stage IV PLI: Dorsal radiocarpal ligament failure with volar rotation of the lunate
Presentation Most common signslsymptoms: Pain & soft tissue swelling involving dorsoradial wrist Clinical profile o Pain & tenderness anatomic snuffbox o Watson test (scaphoid shift test) for SL instability = pain on ulnar to radial deviation o Audible click at SL interval
Demographics Age: Adult population Gender: No bias Association with sports that place dorsal stress on carpus (loading wrist in palmar flexion)
Natural History & Prognosis Secondary changes in chronic SL injuries o Capsular contractures o Intercarpal collapse o Scaphoid + midcarpal fixation o Degenerative arthritis o SLAC
Treatment Conservative o Cast immobilization Surgical - acute o Close reduction + internal fixation o Open reduction + lo repair or reconstruction Surgical - chronic o Open reduction + reconstruction 0 Arthrodesis
Consider Evaluate all three components of SL ligament Dorsal component SL ligament tears are more symptomatic
1 SELECTED REFERENCES
I
Theumann NH et al: Extrinsic carpal ligaments: Normal MR arthrographic appearance in cadavers. Radiol 226(1):171-9, 2003 Szabo RM et al: Dorsal intercarpal ligament capsulodesis for chronic, stable scapholunate dissociation: Clinical results. J Hand Surg 27(6):978-84,2002 Totterman SM et al: MRI findings of scapholunate instabilities in coronal images: A short communication. Semin Musculoskelet Radiol 5(3):251-6,2001 Lewis DM et al: Scapholunate instability in athletes. Clin Sports Med 20(1):131-40, 2001 Blatt G et al: The wrist and its disorders. Scapholunate injuries. 2nd ed. Philadelphia Pennsylvania, W.B. Saunders, (15):268-306,1997 Larsen CF et al: Analysis of carpal instability. Description of the scheme. J Hand Surg 20A:757-64, 1995 Dobyns JH et al: Carpal instability - nondissociative.J Hand Surg 19B:763-73, 1994 Berger RA et al: Magnetic resource imaging of anterior radiocarpal ligament. J Hand Surg 19A:295-303, 1994
SCAPHOL.UNATE LIGAMENT TEA
(Left) Coronal graphic shows tear of the dorsal component of the scapholunate interosseous ligament. The dorsal component of the SL ligament is biomechanically the strongest. (Right) Axial T I C+ (MR arthrogram) shows absence of the dorsal component (arrow) of the scapholunate ligament in scapholunate instability (scaphoid on the left, lunate is on the right, dorsal is superior).
Tvnical
(Left) Coronal T 1 C+ MR (intraarticular contrast) shows scapholunate diastasis between scaphoid and lunate in complete scapholunate ligament disruption. The remnant of the membranous component of SL ligament is shown. (Right) Sagittal graphic shows dorsal tilting of the lunate in 0151 deformity. The capitate lunate angle is r 30 degrees.
(Left) Coronal T1WI MR shows triangular shaped membranous component of scapholunate ligament with direct attachment to articular cartilage surfaces of scaphoid and lunate (scaphoid on left, lunate on right). (Right) Coronal graphic through triangular shaped membranous component of SL ligament. The apex of the triangle is directed distally. The membranous component of SL ligament is the weakest structure of SL complex (lunate shown).
LUNOTRIQUETRAL INSTABILITY
Coronal graphic shows tear of volar and membranous components of LT ligament. The volar fibers of LT ligament are biomechanically the strongest.
Coronal T I MR arthrography shows flap tear (arrow) of lunate attachment of membranous component of LT ligament. Fluid extends across LT interval. Meniscus homologue & TFC are present.
o Flap tears or complete absence of ligament
o Focal membranous injuries with ulnocarpal
impaction - positive ulnar variance
Abbreviations and Synonyms LT ligament sprain or tear, lunotriquetral ligament sprain, lunotriquetral ligament tear
Radiographic Findings Radiography o Disruption of normal convex arc (Gilula's lines) proximal carpal row Step off between lunate & triquetrum
Definitions Partial or complete tear of lunotriquetral ligament
MR Findings General Features Best diagnostic clue: Discontinuity of normally hypointense LT ligament across LT interval Location o LT ligament components Dorsal Membranous Volar Size o Variable based on associated injuries Distal radioulnar joint (DRUJ) subluxation + arthritis Chondromalacia distal ulna Triangular fibrocartilage complex (TFCC) injury Triquetrohamate instability Morphology
TlWI o Delta-shaped or linear ligament best visualized on coronal images o Absence of hypointense horseshoe-shaped structure o Loss of normal smooth convexity of proximal carpal row o Disruption of LT interval is pronounced with ulnar deviation o Dorsiflexion of triquetrum relative to lunate on sagittal images T2WI o Normal LT ligament does not extend into interval o Axial images to separate volar, membranous & dorsal components of ligament o Separate components more difficult to appreciate on coronal images o FS PD FSE or MR arthrography for insertional site tears or perforations
*
DDx: ~unotri~uetral lnrtability TFCC Tear
Ulnar Impaction
Chondromalacia
Cor T I Arthro.
Cor T 1Arthro.
Cor T l Wl MR
LUNOTRIQUETRAL INSTABILITY Key Facts Imaging Findings Best diagnostic clue: Discontinuity of normally hypointense LT ligament across LT interval Flap tears or complete absence of ligament Focal membranous injuries with ulnocarpal impaction - positive ulnar variance
Top Differential Diagnoses TFCC Tear Subluxation or Dislocation DRUJ Subluxation Extensor Carpi Ulnaris (ECU) Midcarpal Instability Ulnar Impaction Syndrome
Pathology LT injury = stage I11 PLI (triquetral dislocation + radiotriquetral ligament failure)
+ Triquetral offset distal relative to lunate convexity on coronal images o + Flap tears at triquetral attachment o
o Hyperintense linear fluid communicating between
radiocarpal & midcarpal compartments through LT mace o Less common - increased distance between lunate & triquetrum o Extension of hyperintense fluid possible with membranous degeneration but intact dorsal & volar LT components o + Volar intercalated segment instability (VISI) pattern on sagittal MR (LT dissociation) Scapholunate angle < 30 or 40 degrees Capitolunate angle > 10 degrees T1 C+ o MR arthrography Identification of flap tears Separation of LT components Improved visualization of radiocarpal & midcarpal communication Associated chondral lesions of proximal lunate, triquetrum & distal ulna in cases of positive ulnar variance Increased sensitivity for associated TFCC lesions
Imaging Recommendations Best imaging tool o MR superior to conventional arthrography, motion studies & cineradiography o MR for LT morphology & fluid extension o MR arthrography increases sensitivity & specificity of conventional MR Protocol advice: T1 or PD & FS PD FSE coronal, sagittal & axial images
I DIFFERENTIAL DIAGNOSIS TFCC Tear Traumatic vs. degenerative Centrum of TFCC is thin & most common site of tear Ulnar-sided wrist pain
Isolated LT sprain 2" to ulnar sided injury = more common pattern of injury (than concomitant radial injury) LT injury associated with increased load transmission across ulnar side wrist + ulnar positive variance
Clinical Issues Most common signs/symptoms: Pain on ulnar aspect of wrist rt Painful wrist click in radial or ulnar deviation Traumatic event = fall on outstretched hand or twisting/rotatory injury Eventual VISI deformity
Diagnostic Checklist Identify associated ulnocarpal impaction syndrome
Subluxation or Dislocation DRUJ
Tear of dorsal or volar margins TFCC + centrum (disc) = DRUJ instability images at Compare supination Lr pronation On level of sigmoid notch of distal radius
Subluxation Extensor Carpi Ulnaris (ECU) Ulnar to fovea on axial images Associated with hyperintense fluid on T2WI + Inhomogeneous boggy synovial thickening
Midcarpal Instability "Catch-up clunk" with movement from radial to ulnar deviation Proximal row snaps (clunks) into extension in delayed movement with ulnar deviation Associated with VISI
Ulnar Impaction Syndrome Triad of LT, TFCC tear, chondromalacia of proximal ulnar lunate & proximal radial aspect triquetrum
Ulnar Head Chondromalacia Subchondral sclerosis (hypointense) distal ulna + Cystic changes Attenuation of subchondral plate
Partial LT Coalition More symptomatic than complete coalition + Associated subchondral sclerosis & degenerative marrow edema
I PATHOLOGY General Features General path comments o Relevant anatomy LT ligament: Dorsal, volar + membranous (fibro~artila~inous membrane) components Other palmar or volar constraints to ulnar carpal bones = palmar radiocarpal, ulnocarpal + midcarpal ligaments
LUNOTRIQUETRAL INSTABILITY Dorsal constraints = dorsal scaphotriquetral & radiotriquetral ligaments Lunate & triquetium stabilized by intrinsic & extrinsic carpal ligaments Proximal carpal row = intercalated segment between radius & distal row Etiology o PLI (progressive perilunar injurylinstability) - palmar radial force with dorsiflexion + ulnar deviation o LT injury = stage 111 PLI (triquetral dislocation + radiotriquetral ligament failure) o LT injury occurs after SL injury or fx (stage I PLI) & lunocapitate dissociation (stage I1 PLI) o Perilunar instability results in DISI unless SL ligament heals, then VISI pattern predominates (forme fruste of stage 111 PLI) o Perilunar pattern - intercarpal supination with injury from radial to ulnar direction o Isolated LT sprain 2" to ulnar sided injury = more common pattern of injury (than concomitant radial injury) o Reverse perilunar injury originating on ulnar side of wrist instead of radial side o Reverse perilunar pattern - intracarpal pronation + radial deviation forces capitate into LT joint o Isolated LT injury also seen with wrist palmar flexed mechanism o Combined SL dissociation + LT injury = less common o Inflammatory arthritis - LT lesions o Ulnar positive variance associated with degenerative LT membranous tears o LT injury associated with increased load transmission across ulnar side wrist + ulnar positive variance o Ulnar positive variance Ulnar & triquetral chondromalacia TFCC tear LT instability Epidemiology o Less common relative to SL injuries o Part of perilunar injury pattern o Membranous perforations in 13% of individuals > 40 yrs.
Presentation Most common signslsymptoms: Pain on ulnar aspect of wrist Clinical profile o Symptoms related to partial vs. complete tears o k Painful wrist click in radial or ulnar deviation o Stiffness, weakness, instability o Traumatic event = fall on outstretched hand or twisting/rotatory injury o Complete LT dissociation = static carpal collapse o Stress tests - for LT mobility, pain & crepitus Ulnar-side compression test LT ballottement test Dorsal-palmar shear test
Demographics Age: Adult population Gender: No bias
Natural History & Prognosis Progression from minimal symptoms to ulnar wrist pain Sensation of instability Ulnar nerve paresthesias Eventual VISI deformity
Treatment Conservative o Immobilization o Anti-inflammatory agents o Wrist splint for acute injuries Surgical o Chronic symptoms not responsive to immobilization o Acute LT dissociation with static deformity o Arthroscopic debridement + pinning o Ligament repair vs. reconstruction with free tendon graft vs. arthrodesis
I DIAGNOSTIC CHECKLIST Consider Identify associated ulnocarpal impaction syndrome Assess carpal arc offset between triquetrum & lunate
Gross Pathologic & Surgical Features LT ligament partial to complete tear Palmar flexion lunate Fx of radial styloid or scaphoid, disruption of SL joint as part of stage 111 PLI
*
Microscopic Features Synovitis Joint weartdegeneration Abnormal ligament tension Variable amounts of collagen fibers, connective tissue + elastic fibers
Staging, Grading or Classification Criteria Static VISI = palmar flexion of lunate Static VISI = ligament injuries 0 Dorsal radiotriquetral o Scaphotriquetral o Lunotriquetral
(SELECTED REFERENCES -
1. 2. 3. 4.
-
Weiss LE et al: Lunotriauetral iniuries in the athlete. Hand Clin 16(3):170-9,2000Shin AY et al: Lunotriquetral instability: Diagnosis and treatment. J Am Acad Orthop Surg 8(3):170-9,2000 Bishop AT et al: The wrist. Diagnosis and operative treatment. Lunotriquetral sprains. St. Louis Missouri, Mosby, 527-49, 1998 Alexander CE et al: The wrist and it's disorders. Triquetrolunate instability. 2nd ed. Philadelphia Pennsylvania, W.B. Saunders, 307-15, 1997
LUNOTRIQUETRAL INSTABILITY IMAGE GALLERY ( L e f ) Anteroposterior radiography (arthrogram) shows contrast communicating across LT interval into midcarpal space in the presence of a LT ligament tear. (Right) Coronal T1 C+ MR (MR arthrogram) shows subtle offset (arrow) of LT convexity in association with LT ligament tear (lunate on left, triquetrum on right).
Typical
(Left) Coronal T I C+ MR (MR arthrogram) shows the combination of both SL and LT ligament tears. There is loss of normal smooth convexity of the proxirnal carpal row. (Right) Coronal T I C+ MR (MR arthrogram) shows mild distal offset of (arrow) the triquetrum (right) relative to lunate (IeftJ in torn volar and membranous components of LT ligament.
(Left) Coronal T I C+ MR (MR arthrogram) shows ulnar impaction syndrome with the triad of findings including LT ligament tear, TFC tear, and chondromalacia of the proxirnal ulnar aspect of lunate. (Right) Coronal graphic shows ulnar impaction syndrome with disruption of the LT ligament. Chondromalacia of the lunate and triquetral surfaces are shown in red. The central disk of TFC is torn.
MID CARPAL INSTABILITY
Coronal graphic shows palmar MCI with laxity of ulnar arm of arcuate ligament. Palmar MCI is also associated with laxity of dorsal radiolunotriquetral ligament.
Sagittal TIWI MR shows static VISI with subchondral sclerosis of the distal lunate and proximal capitate.
It VISI
* Mild palmar translation of distal carpal row
o Videofluoroscopy in posteroanterior (PA)+ lateral
Abbreviations and Synonyms MCI, PMCI = palmar MCI, DMCI=dorsal MCI, carpal instability nondissociative
planes with wrist from radial to ulnar deviation
CT Findings -
NECT o VISI pattern posterior with volar tilt of lunate + palmar translocation of distal row o Sclerosis between distal lunate and proximal capitate
Definitions Lack of support of the proximal carpal row & midcarpal joint
MR Findings General Features Best diagnostic clue: Volar intercalated segmental instability (VISI) on sagittal MR images Location: Loss of normal joint forces between proximal & distal carpal rows Size: Varies based on etiology and classification Morphology o Palmar o Dorsal o Extrinsic: 2" to distal radius malunion
Radiographic Findings Radiography o Normal o PMCI = dynamic condition o Lateral radiography in neutral radioulnar deviation
TlWI o VISI pattern with volar tilt of lunate + palmar translocation of distal row o VISI = palmar flexion instability Scapholunate < 30" Capitolunate angle r 30" Scaphoid & lunate both tilt volarly Lunate translates dorsally Distal pole capitate tilts dorsally Proximal pole (head) capitate tilts volarly o Hypointense sclerosis between distal lunate and proximal capitate T2WI o Attenuated or disrupted lunotriquetral ligament o Hyperintense fluid extension across LT or SL (scapholunate) interval
DDx: Mid Carpal Instability LT Instability
,
Cor T1 Arthro.
Impaction
Cor T l Arthro.
Cor T 1 Arthro.
MID CARPAL INSTABILITY
I
-
Key Facts Imaging Findings Best diagnostic clue: Volar intercalated segmental instability (VISI) on sagittal MR images VISI pattern with volar tilt of lunate + palmar translocation of distal row Hypointense sclerosis between distal lunate and proximal capitate
Top Differential Diagnoses Lunotriquetral (LT) Instability Distal Radioulnar Joint (DRUJ) Instability Triangular Fibrocartilage Complex (TFCC) Tears Ulnocarpal Impaction Syndrome Extensor Carpi Ulnaris (ECU) Subluxation
Pathology
Dorsiflexion - injury PMCI = most common pattern of MCI Palmar MCI = ulnar midcarpal instability or carpal instability nondissociative (CIND)
Clinical Issues Most common signs/symptoms: Painful clunk ulnar side of carpus Clunk with ulnar deviation with forearm in pronation ("catch-up clunk") Tenderness over ulnar carpus & triquetrohamate joint Positive midcarpal shift test - painful clunk with passive ulnar deviation
Diagnostic Checklist Associated capitolunate sclerosis or VISI
Injury to ulnar arm arcuate ligament 11
o k Hyperintense synovitis vs. ligament attenuation
associated with ulnar arm of arcuate ligament + dorsal radiotriquetral ligament (palmar MCI) o k Ulnar minus variance T1 C+ o MR arthrography Associated extension of contrast directly communicating across SL or LT interval
Imaging Recommendations Best imaging tool o Videofluoroscopy in PA + lateral planes if available o Static VISI + ligamentous abnormalities best identified on MR o Chronic ligamentous laxity difficult to visualize Protocol advice: T1 or PD + FS PD FSE coronal, sagittal and axial images
Ulnar-sided wrist pain Associated with positive ulnar variance
Ulnocarpal Impaction Syndrome Positive ulnar variance TFCC tear LT tear Chondromalacia proximal lunate + triquetrum Eccentric sclerosis proximal ulnar lunate Painful compression between distal ulna & lunate
Extensor Carpi Ulnaris (ECU) Subluxation Normal ECU is ulnar to ulnar styloid Recurrent subluxation = sudden palpable snap in forearm with active supination & wrist flexion + ulnar deviation + Thickened synovial tendon sheath
I DIFFERENTIAL DIAGNOSIS
1 PATHOLOGY
Lunotriquetral (LT) Instability
General Features
Dissociation between triquetrum + lunate Volar flexion of lunate Absence or flap tear of normal delta-shaped or linear ligament on coronal images
Distal Radioulnar Joint (DRUJ) Instability Dorsal or volar radioulnar ligament involvement + TFCC centrum tear Fracture of sigmoid notch of distal radius Axial MR in full supination + pronation to document ulnar subluxation relative to sigmoid notch of distal radius Volar margin tears = dorsal subluxation Dorsal tears = volar subluxation
Triangular Fibrocartilage Complex (TFCC) Tears Traumatic Degenerative Tear of dorsal or volar margins of TFCC + centrum (disc) = DRUJ instability
--
General path comments o Arcuate ligament complex = major stabilizer of midcarpal joint o Triquetrohamatocapitate ligament = ulnar arm of arcuate ligament o Radial arm arcuate extends from distal aspect of radioscaphocapitate (RSC) ligament o Space of Poirier = weak area between capitate & lunate Etiology o Injury to ulnar arm arcuate ligament o Dorsal radiotriquetral (RLT) = check-rein to prevent flexion of proximal row (laxity may be present in PMCI) o Dorsiflexion - injury o ~ l s flexion, o compression, rotation ST distraction injuries o 50% - minimal trauma history Epidemiology o MCI incidence c scapholunate dissociation o MCI incidence 2 lunotriquetral instability
MID CARPAL INSTABILITY o PMCI = most common pattern of MCI
Gross Pathologic & Surgical Features Palmar MCI o Laxity ulnar arm arcuate ligament o Laxity dorsal radiolunotriquetral ligament Dorsal MCI o Laxity palmar radioscaphocapitate ligament Extrinsic MCI o Dorsal displacement & angulation of distal radius o Adaptive Z-deformity of carpus
Microscopic Features
o Nonsteroidal anti-inflammatorv medications o Steroid injections o Wrist immobilization o Dorsally directed pressure on pisiform with splint = reduces ulnar carpal sag & VISI o Activating hypothenar muscles + extensor carpi ulnaris + flexor carpi ulnaris = reset midcarpal position Surgical o Ligament reconstruction o Capsular tightening o Limited midcarpal arthrodesis
Stretching of collagen & elastic fibers of affected ligaments
Staging, Grading or Classification Criteria
12
Palmar MCI = ulnar midcarpal instability or carpal instability nondissociative (CIND) Dorsal MCI = capitolunate instability pattern (CLIP) or chronic capitolunate instability Extrinsic MCI = associated with distal radius malunion
Consider Clinical exam of characteristic clunk as well as symptoms must be assessed in combination with MRI findings Associated capitolunate sclerosis or VISI Clunking of the carpus may be present in asymptomatic wrists
Presentation Most common signs/symptoms: Painful clunk ulnar side of carpus Clinical profile o Clunk with ulnar deviation with forearm in pronation ("catch-up clunk") o History of trauma o Asymptomatic phase prior to presentation o Bilateral presentation o Palmar sag of ulnar side of carpus o Prominent ulnar head with wrist in neutral deviation o Localized synovitis o Tenderness over ulnar carpus & triquetrohamate joint o Reproduce clunk - active ulnar deviation of pronated wrist o With extreme ulnar deviation (after clunk) the volar sag of ulnar carpus is absent o Positive midcarpal shift test - painful clunk with passive ulnar deviation
* *
Demographics Age: Adult population Gender: F = M
Natural History & Prognosis Dynamic becomes fixed VISI Loss of normal physiologic VISI to DISI with radial to ulnar deviation Proximal carpal row remains flexed & distal row palmarly subluxed until extreme ulnar deviation With ulnar deviation of wrist distal row abruptly reduces & proximal row snaps into extension = "catch-up clunk"
Treatment Conservative o Activity modification for milder cases of PMCI
Lichtman DM et al: The wrist and its disorders. Midcarpal and proximal carpal instabilities. 2nd ed. Philadelphia Pennsylvania, W.B.Saunders, (17):316-328,1997 Wright TW et al: The wrist and its disorders. Carpal instability nondissociative. 2nd ed. Philadelphia Pennsylvania, W.B. Saunders, (23):550-68, 1997 Viegas SF et al: Extrinsic wrist ligaments in the pathomechanics of ulnar translocation instability. J Hand Surg 20A:312-8, 1995 Sennwald GR et al: Kinematics of the wrist and its ligaments. J Hand Surg 18:805-14, 1993 Ambrose L et al: Lunate-triquetral and midcarpal joint instability. Han Clin 8:653-68, 1992 Trumble T et al: Kinematics of the ulnar carpus related to the volar intercalated segment instability pattern. J Hand Surg 15A:364-92, 1990 Viegas SF et al: Ulnar sided perilunate instability: An anatomic and biomechanic study. J Hand Surg 15A:268-77, 1990 Lichtman DM et al: The ulnar arcuate ligament complex: Its anatomy and functional significance. Presented at the 43rd Annual Meeting of the Am Society for Surg of the Hand, 1988 Brown DE et al: Midcarpal instability. Hand Clin 3:135-40, 1987 Louis DS et al: Central carpal instability-capitate lunate instability pattern: Diagnosis by dynamic displacement. Orthopedics 7:1693-6, 1984 Mayfield JK: Patterns of injury to carpal ligaments. Clin Orthop 187:36-42, 1984 Johnston RP et al: Chronic capitolunate instability. J Bone Joint Surg 68A:1164-76, 1980 Mayfield JK et al: Carpal dislocations: Pathomechanics and progressive perilunar instability. J Hand Surg 5226-41, 1980
MID CARPAL INSTABILITY
ULNOCARPAL ABUTMENT
Coronal graphic shows chondromalacia of the distal ulna, proximal lunate and triquetrum. With tear of the LT ligament and central TFC, ulnar positive variance is not required.
o Posteroanterior (PA) + lateral view o Ulnar plus or ulnar neutral position o Lunate subchondral sclerosis o Triquetral sclerosis more difficult to identify o & Cyst formation in ulnar head, lunate or triquetrum
Abbreviations and Synonyms Ulnar impaction syndrome, ulnolunate abutment, ulnolunate impaction syndrome, ulnar impaction, ulnocarpal loading
M R Findings
Definitions Degenerative condition caused by excessive load-bearing across the ulnar aspect of the wrist
General Features Best diagnostic clue: Eccentric sclerosis proximal ulnar lunate Location o Lunate o Triquetrum o Triangular fibrocartilage (TFC) o Distal ulna o Lunotriquetral (LT) ligament Size: Lunate sclerosis restricted to proximal ulnar lunate usually < 40% subchondral area Morphology: Positive ulnar variance is associated
TlWI o Hypointense eccentric sclerosis proximal ulnar aspect lunate & proximal radial aspect triquetrum o Area of subchondral sclerosis in lunate > triquetrum o Normal marrow fat signal identified distal & radial to sclerosis in lunate o Triquetral sclerosis may not be present o Neutral or positive ulnar variance o Less commonly negative ulnar variance o Hypointense cystic change lunate > triquetrum > distal ulna o Associated trauma Distal radius Ulnar styloid T2WI o Hyperintense central perforation TFC (FS PD FSE) o Eccentric sclerosis either hypointense or hyperintense - based on degenerative marrow edema o Hyperintense cystic change > in proximal ulnar aspect lunate o Chondromalacia in normally intermediate signal intensity articular cartilage of distal ulna
* *
mmm
Radiographic Findings Radiography
Coronal T I C+ MR (MR arthrogram) shows hypointense eccentric sclerosis (arrow) of the proximal ulnar aspect of the lunate opposite the TFC tear. The LT ligament is disrupted.
DDx: Ulnocarpal Abutment TFCC Tear
Kienbock's
IT Ligament Tear
'4
I 'I
Cor T2* CRE MR
Cor TI Wl MR
*r
Cor T 7 Arthro.
ULNOCARPAL ABUTMENT Key Facts Imaging Findings Best diagnostic clue: Eccentric sclerosis proximal ulnar lunate Morphology: Positive ulnar variance is associated Area of subchondral sclerosis in lunate > triquetrum Hyperintense central perforation TFC (FS PD FSE)
Top Differential Diagnoses Traumatic Triangular Fibrocartilage Complex (TFCC) Abnormalities Kienbock's Disease Ulnar Impingement Distal Radioulnar Joint (DRUJ) Instability
Pathology Increase ulnar length = increased forces across ulnocarpal articulation o Hyperintense fluid across torn LT ligament on FS PD
FSE o Lunate-triquetrum proximal arc offset associated with LT ligament tear o Attenuated centrum of TFC
Imaging Recommendations Best imaging tool: MR to identify sclerosis, ligament disruption, cystic change and chondromalacia Protocol advice o T1 & FS PD FSE coronal, axial & sagittal o T1 = improved visualization of sclerosis compared with proton density (PD) o FS PD FSE = hyperintensity associated with sclerosis or cystic change
Traumatic Triangular Fibrocartilage Complex (TFCC) Abnormalities Central perforations Ulnar avulsion Distal avulsion Radial avulsion Without associated lunate, triquetral or ulnar chondromalacia
Kienbock's Disease Avascular necrosis lunate Related to trauma + ulnar negative variance Centralized lunate sclerosis & Visualized lunate fracture
Ulnar Impingement Ulnar negative (minus) variance Scalloped concavity of ulnar aspect distal radius Convergence of ulna toward distal radius Pain with pronation & supination
Distal Radioulnar Joint (DRUJ)Instability Subluxation Dislocation Fractured ulnar head or sigmoid notch
Chondromalacia distal ulna, proximal lunate & triquetrum Palmer class 2 degenerative lesions of TFCC = ulnocarpal abutment
Clinical Issues Most common signs/symptoms: Pain over DRUJ Chronic or subacute dorsal painldiscomfort Pain increased with extremes of rotation + ulnar deviation Tenderness between ulnar head & triquetrumllunate In contrast to DRUJ pathology, pain not present throughout entire range of pronation to supination
Diagnostic Checklist
Positive ulnar variance not required
Ligament insufficiency (radioulnar) Pain throughout range of pronation - supination Intercarpal pathology Lunotriquetral instability Midcarpal instability k LT ligament tear & volar intercalated segment instability (VISI)
1 PATHOLOGY General Features General path comments o TFC = articular disk (centrum) + dorsal & volar radioulnar ligaments o TFCC = TFC, meniscus homologue (ulnocarpal meniscus), ulnar collateral ligament, sheath of extensor carpi ulnaris + ulnolunate & ulnotriquetral ligaments o Ulnar variance = level of distal ulna relative to radius o Positive variance = ulna is too long o Pronation causes relative ulnar lengthening o Lunate articulates with lunate facet of distal radius & TFC Etiology o Acquired - trauma Distal radius fractures with shortening + angulation Fractures with ligamentous injuries of DRUJ (e.g., Galeazzi & Essex-Lopresti) o Congenital Madelung's deformity (dyschondroplasia) Ulnar plus variance Increase ulnar length = increased forces across ulnocarpal articulation Epidemiology o TFC perforations - 40% prevalence by end of 5th decade o 73% of wrists with TFC perforation, ulna + lunate erosions have positive or neutral ulnar variance
Gross Pathologic & Surgical Features TFCC degenerationltear
ULNOCARPAL ABUTMENT o Anti-inflammatory medication Surgical = unloading distal ulna o Debridement - TFCC o Wafer procedure (resect distal ulna beneath TFC) o Hemiresection distal ulna o Ulnar shortening osteotomy o Arthroscopic treatment (except for ulnar shortening osteotomy) o Fusion of DRUJ - SauvC-Kapandji procedure o Ulnar recession (shortening) = procedure of choice Complications o Weakness + instability post Darrach procedure (resection of distal ulna) o Hemiresection impingement o SauvC-Kapandji instability
Chondromalacia distal ulna, proximal lunate & triquetrum LT ligament disruption Central TFC attenuated in positive ulnar variance Degeneration of avascular central articular disc of TFC
Microscopic Features Degeneration TFC Chondral fibrillation, fraying, erosions Subchondral sclerosis Central zone of avascularity in TFC
Staging, Grading or Classification Criteria
Q Ih
Palmer class 2 degenerative lesions of TFCC = ulnocarpal abutment o A = TFCC wear o B = TFCC wear + lunate, triquetrum ~tulnar chondromalacia o C = TFCC perforation + lunate, triquetrum f ulnar chondrom~lacia o D = TFCC perforation + lunate, triquetrum f ulnar chondromalacia & LT ligament perforation o E = TFCC perforation + lunate, triquetrum f ulnar chondromalacia, LT perforation & ulnocarpal arthritis
--
1 DIAGNOSTIC CHECKLIST Consider Eccentric lunate sclerosis (ulnar sided) associated with ulnocarpal abutment Positive ulnar variance not required
1.
Presentation Most common signslsymptoms: Pain over DRUJ Clinical profile o chronic or subacute dorsal painldiscomfort o Pain increased with extremes of rotation + ulnar deviation o Intermittent clicking o Swelling o Decreased strength & motion o f History of trauma o Positive ulnar variance o Tenderness between ulnar head & triquetrumllunate o Pain exacerbated with ulnar deviation + forearm pronation (ulnar head displaced volar) o Ballottement distal ulna + ulnar deviation increases pain o LT ligament disruption - discomfort with loading of LT joint o In contrast to DRUJ pathology, pain not present throughout entire range of pronation to supination
Demographics Age: 50 years or above Gender: No bias
Natural History & Prognosis Increased load transmission through ulna = progression kddress malunion of distal radial fractures, physeal arrest or Essex-Lopresti injury, positive ulnar variance o Essex-Lopresti: Fxldislocation radial head + dislocation DRUJ
Treatment Conservative o Activity modification
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Sofka CM et al: Magnetic resonance imaging of the wrist. Semin Musculoskelet Radiol 5(3):217-26, 2001 Moy OJ et al: The wrist. Diagnosis and operative treatment. Ulnocarpal abutment. St. Louis MO, Mosby, 773-87, 1998 Loftus JB et al: The wrist and it's disorders: Disorders of the distal radioulnar joint and triangular fibrocartilage complex. 2nd ed. Philadelphia Pennsylvania, Saunders 385-414, 1997 Escobedo EM et al: MR imaging of ulnar impaction. Skeletal Radiol 24(2):85-90,1995 Chun S et al: The ulnar impaction syndrome: Follow-up of ulnar shortening osteotomy. J Hand Surg 18:46-53, 1993 Uchiyama S et al: Radiographic changes in wrists with ulnar plus variance observed over a ten-year period. J Hand Surg 16:45-48, 1991 Boulas HJ et al: Ulnar shortening for tears of the triangular fibrocartilaginous complex. J Hand Surg 15:415-20, 1990 Palmer AK: Triangular fibrocartilage disorders: Injury patterns and treatment. Arthroscopy 6:125-32, 1990 Watson HK et al: Ulnar impingement syndrome after Darrach procedure: Treatment by advancement lengthening osteotomy of the ulna. J Hand Surg 14:302-6, 1989 Czitrom AA et al: Ulnar variance in carpal instability. J Hand Surg 12:205-8, 1987 Linscheid RL: Ulnar lengthening and shortening. Hand Clin 3:69-79, 1987 Viegas SF et al: Attritional lesions of the wrist joint. J Hand Surg 12:1025-29, 1987 Bell MJ et al: Ulnar impingement syndrome. J Bone Joint Surg Br 67:126-9, 1985 Palmer AK: Relationship between ulnar variance and triangular fibrocartilage complex of the wrist - anatomy and function. J Hand Surg 6:153-62, 1981
ULNOCARPAL ABUTMENT
I IMAGE GALLERY
DISTAL RADIOULNAR JOINT INSTABILITY
Axial graphic shows palmar dislocation of ulnar head relative to the sigmoid notch of distal radius.
Axial T l Wl MR shows DRUI with volar subluxation of distal ulna secondary to disruption of dorsal DRUI.
Ulnalradius superimposition in ulnar palmar dislocation False negative rate - 60%
Abbreviations and Synonyms DRUJ instability, dislocation or subluxation of the DRUJ, sprained wrist
CT Findings
Definitions Loss of normal anatomic or kinematic relationship between distal radius + ulna with carpus
NECT o Assess sigmoid notch morphology on axial images (e.g., abnormal convex or shallow arch post distal radius fracture) o Trace radioulnar lines (criterion of Mino) to establish ulnar head lies between dorsal & palmar borders of the radius
MR Findings
General Features Best diagnostic clue: Dorsal or volar displacement of distal ulna relative to sigmoid notch of distal radius Location: DRUJ, including articular surfaces & soft tissue constraints Size: Variable based on subluxation, dislocation & fractures of the distal radius Morphology: Ulnar dorsal or ulnar palmar dislocation
Radiographic Findings Radiography o Difficult to diagnose o True lateral - dorsal or volar displacement of ulna o Posteroanterior view Increased gap between ulnar head & radius with dorsal subluxation of ulna
TlWI o Dorsal or volar (palmar) subluxation of ulnar head relative to sigmoid notch on axial images o Dorsal prominence of ulna (ulna-dorsal) on sagitta images o Flattened or shallow sigmoid notch 0 Distal radioulnar joint diastasis on coronal images ulnar dorsal subluxation o Massive disruption of stabilizing capsuloligamentc structures (e.g., Galeazzi fracture) o Subluxation or interposition of extensor carpi ulnaris (ECU tendon) o k Intercalated segment instability pattern (VISI = volar, DISI = dorsal) T2WI
Jm!Blp
DDx: Distal ~ a d i o i n aJoint r Instability TFCC Tear
Cor T l Wl MR
Cor T 7 Arthro
Kienbock's
Cor T l Wl MR
DISTAL RADIOULNAR JOINT INSTABILITY Key Facts Imaging Findings Best diagnostic clue: Dorsal or volar displacement of distal ulna relative to sigmoid notch of distal radius Flattened or shallow sigmoid notch Palmar (volar) distal radioulnar ligament (DRUL) disruption associated with ulnar dorsal dislocation Disruption of dorsal DRUL associated with ulnar palmar dislocation
Top Differential Diagnoses Traumatic Triangular Fibrocartilage Complex (TFCC) Abnormalities Ulnocarpal Abutment Syndrome Kienbock's Disease Subluxation of Extensor Carpi Ulnaris (ECU) Intercarpal Pathology
o Palmar (volar) distal radioulnar ligament (DRUL) o
o
o
o
disruption associated with ulnar dorsal dislocation Disruption of dorsal DRUL associated with ulnar palmar dislocation Ulnocarpal ligamentous (ULC) complex hyperintensity: Tear associated with ulnar dorsal pattern Tear dorsal infratendinous extensor retinaculum (subsheath of ECU seen in ulnar dorsal dislocation) Pronator quadratus + distal interosseous membrane (IOM) hyperintensity as part of forced hypersupination & ulnar palmar dislocation
Imaging Recommendations Best imaging tool: MR identifies soft tissue (muscle, tendon & ligamentous) associated injuries Protocol advice o T1 or PD & FS PD FSE MR coronal, axial & sagittal o Axial images (PD or FS PD FSE) in full pronation & supination to establish location of ulna in sigmoid notch
Traumatic Triangular Fibrocartilage Complex (TFCC) Abnormalities Central perforation Ulnar, radial, or distal avulsion
Ulnocarpal Abutment Syndrome TFCC degenerationlperforation Lunate, triquetral & ulnar chondromalacia Lunotriquetral ligament perforationltear Ulnocarpal arthritis
Kienbock's Disease Avascular necrosis of lunate Related to trauma + ulnar negative variance Centralized lunate sclerosis Visualized lunate fracture
*
Pathology Fall on outstretched hand High energy hyperextension - rotation = radius or ulna fx + ligament disruption Majority of injuries = combination of osseous + ligamentous damage with DRUJ instability
Clinical Issues Most common signs/symptoms: Pain ulnar aspect wrist Increased symptoms in pronosupination
Diagnostic Checklist Use axial images in full pronation & supination to identify location of ulna relative to sigmoid notch
Subluxation of Extensor Carpi Ulnaris (ECU) Palpable snap with forearm supination + wrist ulnar deviation Thickened tendon sheath Tenosynovitis
* *
Intercarpal Pathology Lunotriquetral instability Midcarpal instability
* LT ligament tear & VISI
General Features General path comments o Relevant anatomy DRUJ = diarthrodial trochoid articulation between head of ulna & sigmoid cavity of distal radius TFC = articular disc + dorsal & palmar (volar) distal radioulnar ligaments Palmar (volar) DRUL taut in supination Dorsal DRUL taut in pronation Ulnocarpal ligamentous (UCL) complex Infratendinous extensor retinaculum (ECU subsheath) Pronator quadratus muscle Interosseous membrane (IOM) Etiology o Palmar & dorsal DRUL tension exists at both extremes of rotation (pronation & supination) o Rotational injury with forced pronation/supination + hyperextension o Fall on outstretched hand o High energy hyperextension - rotation = radius or ulna fx + ligament disruption Epidemiology o Traumatic DRUJ dislocations or subluxations common o Majority of injuries = combination of osseous + ligamentous damage with DRUJ instability o DRUJ instability without associated fracture usually misdiagnosed
. . .. . ..
DISTAL RADIOULNAR JOINT INSTABILITY Gross Pathologic & Surgical Features
2 II
Distal radius + carpal bones undergoes abnormal displacement relative to ulna Ulna is not the mobile bone dislocating from radius Physiologic radius translation dorsally in supination Physiologic radius translation in palmar direction in pronation Disruption of sigmoid notch congruity (e.g., displaced by fracture) Palmar & dorsal DRUL must be intact to maintain DRUJ stability in full range of forearm rotation Dorsal DRUL tear + tightening UCL complex = destabilizing effect = ulnar palmar DRUJ Disruption of infratendinous extensor retinaculum (ECU subsheath) with subluxation of ECU tendon in ulnar dorsal dislocation Essex Lopresti = IOM injury, dislocation or fracture of proximal radial head, distal ulna dorsally & longitudinally displaced Ulnar dorsal dislocation in hyperpronation o Disruption of palmar DRUL o UCL complex injury o Dorsal infratendinous extensor retinaculum tear Ulnopalmar dislocation in hypersupination o Disruption of dorsal DRUL o Stretching of pronator quadratus o Distal IOM tear
Microscopic Features Failure of tensile ligament restraint Tear of collagen fibers + interstitial connective tissue in ligament injury
Staging, Grading or Classification Criteria DRUJ dislocations in acute trauma divided into three groups o Type I: Dislocation DRUJ 2" to disruption of primary soft tissue structures or osseous injury (ulnar styloid fracture) o Type 11: Intraarticular DRUJ fracture dislocations o Type 111: Extraarticular DRUJ fracture dislocations
Presentation Most common signs/symptoms: Pain ulnar aspect wrist Clinical profile o Increased symptoms in pronosupination o Swelling & tenderness o Decrease/loss of wrist motion o Grip weakness o piano key sign = prominent distal ulna in dorsal dislocations o Ulnar nerve dysesthesias o Audible snap
Demographics Age o Includes age ranges of Colles', Smith's, Galeazzi's & Essex Lopresti's injury o Young individuals - trauma o ~ l d e rin l ~association with osteoporosis fracture
Gender: No bias
Natural History & Prognosis Delayed diagnosis common Recurrent DRUJ instability Limited range of rotation (forearm) Degenerative arthritis Complications o Malunion distal radius + distal/dorsal subluxation of distal ulna in type I1 injuries o Galeazzi fracture dislocation - malunion radius + residual DRUJ subluxation
Treatment Conservative o Type I: True DRUJ dislocations = reduction + immobilization 0 Type 11: Intraarticular DRUJ fx dislocation = reduction + cast Surgical o Type I: Interposition of soft tissue (TFCC, ECU entrapment, osteochondral) = open reduction + K-wire fixation o Type 11: Percutaneous K-wire fixation or external fixation vs. open repair to achieve anatomic reduction vs. osteotomy vs. hemiresection arthroplasty o Type 111: Extraarticular DRUJ fx dislocation reduction + internal fixation
I DIAGNOSTIC CHECKLIST Consider Use axial images in full pronation & supination to identify location of ulna relative to sigmoid notch Evaluate dorsal & volar (palmar) radioulnar ligaments of TFC on coronal, axial + sagittal images
May MM et al: Ulnar styloid fractures associated with distal radius fractures: Incidence and implications for distal radioulnar joint instability. J Hand Surg 27(6):965-71,2002 Adams BD et al: An anatomic reconstruction of the distal radioulnar ligaments for posttraumatic distal radioulnar joint instability. J Hand Surg 27(2):243-51, 2002 Garcia-Elias M et al: The wrist. Diagnosis and operative treatment. Dorsal and palmar dislocations of the distal radioulnar joint. St. Louis Missouri, Mosby, 758-72, 1998 Bowers WH et al: The wrist and it's disorders. Treatment of chronic disorders of the distal radioulnar joint. 2nd ed. Philadelphia Pennsylvania, WB Saunders, 429-42, 1997 Aulicino PL et al: Acute injuries of the distal radioulnar joint. Hand Clin 7:283-93, 1991 Bowers WH: Instability of the distal radioulnar articulation. Hand Clin 7:311-27, 1991 Nathan R et al: Classification of distal radioulnar joint disorders. Hand Clin 7:239-47, 1991 Schuind F et al: The distal radioulnar ligaments: A biomechanical study. J Hand Surg 16:1106-14, 1991 Mino DE et al: Radiography and computerized tomography in the diagnosis of incongruity of the distal radio-ulnar joint. A prospective study. J Bone Joint Surg 67:247-52, 1985
DISTAL RADIOULNAR JOINT INSTABILITY IMAGE GALLERY
TRIANGULAR FIBROCARTILAGE TEAR
Coronal graphic shows traumatic (class 1) tear of the radial aspect of the TFC.
Coronal T I C+ MR (MR arthrogram) shows focal tear (arrow) of the radial aspect of TFC disk.
o Absent fibrocartilaginous disk
Radiographic Findings
Abbreviations and Synonyms TFC tears, TFC complex (TFCC) lesions, tears of the TFC
Definitions Tear of the TFC including central (disc) & peripheral margins
Radiography o Not useful o Associated with ulnar styloid fractures o Positive ulnar variance o Conventional arthrography cannot characterize TFC morphology or differentiate normal communications from tears
M R Findings General Features Best diagnostic clue: Direct extension of fluid across TFC Location o TFC Articular disk rn Dorsal radioulnar ligament rn Volar (palmar) radioulnar ligament Size: Variable from perforation, linear tear, to frank disruption Morphology o Circular perforation o Linear vertical or horizontal tear o Attenuation + tear o Gross disruption with gap
I
I
TlWI o Normal TFC = biconcave disk o Intermediate signal intensity intrasubstance degeneration o Volar margin tears associated with dorsal subluxation of ulna relative to radius o Dorsal tears associated with volar subluxation of ulna o Volar instability seen on supination in axial plane o Dorsal instability seen on pronation in axial plane o Radial sided tears: Dorsal to volar orientation o Ulnar avulsion + ulnar styloid fracture o Radial avulsion sigmoid notch fractures o Hypointense sclerosis lunate, triquetrum & distal ulna in ulnolunate abutment syndrome T2WI o Traumatic lesions - perforation or avulsion
*
I
DDx: Triangular Fibrocartilage Tear
Cor T I Arthro.
Cor T l Wl MR
Cor T l Arthro.
1
TRIANGULAR FIBROCARTILACE TEAR Key Facts Imaging Findings B ~ diagnostic S ~ due:~ iextension ~ of ~ fluid ~ across t TFC Traumatic lesions - perforation or avulsion Degenerative lesions = spectrum of ulnocarpal abutment (impaction) syndrome
Top Differential Diagnoses Ulnocarpal Abutment Kienbock's Disease Lunotriquetral (LT) Dissociation Extensor Carpi Ulnaris Tendinitis Instability of the Distal Radioulnar Joint (DRUJ)
Pathology Hyperextension of wrist + rotational load Degenerative = ulnocarpal abutment syndrome
Palmer class 1 - traumatic Palmer class 2 - degenerative (ulnocar~alabutment syndrome)
Clinical Issues Most common signs/symptoms: Ulnar wrist pain Painful DRUJ rotation Pain with stress loading of DRUJ in pronation & supination Traumatic tears more common < 40 yrs Degenerative tears more common > 40 yrs
Diagnostic Checklist Coronal images using T1 or TZ* gradient echo for intrasubstance degeneration & FS PD FSE for contour irregularities
o Degenerative lesions = spectrum of ulnocarpal
Centralized lunate sclerosis
abutment (impaction) syndrome o FS PD FSE - improved definition of proximal & distal surfaces o Partial tears = contour irregularity of proximal (undersurface) or distal surfaces o Primary sign of TFC tear = hyperintense fluid extension across articular disk or discontinuity o Intermediate to hyperintense synovitis 0 Chondromalacia of proximal lunate, triquetrum & ulna - loss of normal intermediate signal intensity articular cartilage TZ* GRE: Improved visualization of intrasubstance degeneration & tears T1 C+ o Intravenous contrast ?r. improved conspicuity of partial tears o MR arthrography Differentiate severe degeneration from partial tear Performed with radiocarpal injection
k Visualized lunate fracture
Imaging Recommendations Best imaging tool: MR highly sensitive & specific for fluid extension, TFC morphology/tear pattern + chondromalacia of ulnar side of wrist Protocol advice o TlIPD + FS PD FSE coronal, axial & sagittal o TZ* = additional value in augmenting intrasubstance degeneration o MR arthrography - not routinely required
I DIFFERENTIAL DIAGNOSIS Ulnocarpal Abutment TFCC degeneration/perforation Lunate, triquetral & ulnar chondromalacia Lunotriquetral ligament perforationltear Ulnocarpal arthritis
Kienbock's Disease Avascular necrosis lunate Related to trauma + ulnar negative variance
Lunotriquetral (LT) Dissociation Dissociation between lunate & triquetrum Volar flexion lunate (VISI) Absence of horseshoe-shaped ligament Degenerative etiology vs. ulnar-sided trauma on outstretched hand
Extensor Carpi Ulnaris Tendinitis Dorsal ulnar-sided pain Thickened tendon sheath Hyperintense fluid (TZWI) surrounding tendon Synovial thickening intermediate signal (TZWI) k Associated subchondral marrow edema distal ulna
Instability of the Distal Radioulnar Joint (DRUJ) Ulnar dorsal dislocation in hyperpronation Ulnar palmar dislocation in hypersupination Rotational injury with forced pronationlsupination hyperextension
+
-
/PATHOLOCYI General Features General path comments o Relevant anatomy TFC = articular disc, palmar (volar) radioulnar + dorsal radioulnar ligaments TFCC = TFC, ulnolunate & ulnotriquetral ligaments, meniscus homologue, extensor carpi ulnaris tendon subsheath Etiology o Forearm pronation o Hyperextension of wrist + rotational load o Degenerative = ulnocarpal abutment syndrome Epidemiology o TFC tears associated with positive ulnar variance
TRIANGULAR FIBROCARTILAGE TEAR o Higher incidence of radial-sided lesions, except ulnar-sided tears seen more commonly in younger patients o Asymptomatic perforations common after age 40
Natural History & Prognosis Attenuated central disc = communications, perforations & tears Increased perforation rate with excessive loading of TFC in setting of positive ulnar variance & ulnocarpal abutment syndrome Congenital perforations documented in infants & asymptomatic adults + degenerative wrists Traumatic tears may be associated with injuries to ECU tendon sheath & LT ligament Peripheral tears at ulnar fovea or radius result in reduced TFC tension with loss of suspensory trampoline effect
Gross Pathologic & Surgical Features Palmer class 1 - traumatic
2 :I
o A = central perforation o B = ulnar avulsion + distal ulnar fracture o C = distal avulsion o D = radial avulsion + sigmoid notch fracture Palmer class 2 - degenerative (ulnocarpal abutment syndrome) o A = TFCC wear (degeneration) o B = TFCC wear + lunate, triquetral +/- ulnar chondromalacia 0 C = TFCC perforation + lunate, triquetral, ulnar chondromalacia 0 D = TFCC perforation + lunate, triquetral, ulnar chondrom~lacia& LT ligament per?oratidns o E = TFCC perforation + lunate, triquetral, ulnar chondromalacia, LT ligament tear & ulnocarpal arthritis
Treatment Conservative o Relieve overloading of distal ulna o Activity modification & anti-inflammatory medications Surgical o Debridelrepair tear o Resection + debridement of flap tear o Augmentation if repair not possible o Reconstruction - better long term results than resection o Triquetral impingement of ulnar styloid - limited ulnar styloidectomy
Microscopic Features TFC microstructure o Short collagen fibers in central region in response to compression loads o Superficial & deep layer (less organized) within articular disk o Radial border = avascular 0 Central disk = avascular o Mucinous or myxoid degeneration in degenerative tears
1 DIAGNOSTIC CHECKLIST Consider Coronal images using T1 or T2* gradient echo for intrasubstance degeneration & FS PD FSE for contour irregularities Evaluate distal radioulnar ligaments (volar & dorsal margins of TFC)
Staging, Grading or Classification Criteria Palmer classification (1= traumatic tears, 2 = degenerative tears) Bowers = classification of disorders of DRUJ & TFC Mayo classification = treatment and location based for traumatic & degenerative tear types
[SELECTEDREFERENCES 1.
Presentation Most common signs/symptoms: Ulnar wrist pain Clinical profile o Loss of strength 0 Painful DRUJ rotation 0 Catching or snapping o Tenderness & pain over TFC o Pain with stress loading of DRUJ in pronation & supination o Dorsal-palmar ballottement of distal ulna = stress test (piano-key sign) o Associated fractures (Colles', Galeazzi's & Essex Lopresti)
2. 3.
4.
5.
6.
Demographics Age o Traumatic tears more common < 40 yrs o Degenerative tears more common > 40 yrs Gender: No bias
1
7.
Haims AH et al: Limitations of MR imaging in the diagnosis of peripheral tears of the triangular fibrocartilage of the wrist. AJR 178(2):419-22,2002 Cooney WP: The wrist. Diagnosis and operative treatment. Tears of the triangular fibrocartilage of the wrist. vol 1. St. Louis Missouri, Mosby, (30):710-42, 1998 Loftus JB et al: The wrist and it's disorders. Disorders of the distal radioulnar joint and triangular fibrocartilage complex. 2nd ed. Philadelphia Pennsylvania, W.B. Saunders, (21):385-414,1997 Totterman SMS et al: Lesions of the triangular fibrocartilage complex: MR findings with a three-dimensional gradient-recalled-echosequence. Radiology 199:277-32, 1996 Totterman SMS et al: Triangular fibrocartilage complex: Normal appearance on coronal three-dimensional gradient-recalled-echoMR images. Radiology 195:521-7, 1995 Rettig ME et al: Clinical applications of MR imaging in hand and wrist surgery-magneticresonance imaging. Magn Reson Imaging Clin North Am 3:361-8, 1995 Sugimoto H et al: Triangular fibrocartilage in asymptomatic subjects: Investigation of abnormal MR signal intensity. Radiology 191:193-7, 1994
TRIANGULAR FIBROCARTILAGE TEAR
Typical
1
the TFCC. Class 2 lesions of the TFCC re~resentr art of the spectrum of ulnocarpal abutment syndrome. (Right) Coronal T1 C+ MR (MR arthrogram) shows degenerative (class 2) tear of the TFC.
Typical (LLft) Coronal T I Wl MR shows traumatic (class 1 ) tear (arrow) of the TFC associated with clinical DRUI instability. (Right) Coronal FS PD FSE MR shows hyperintense central defect of the TFCC at the junction of the disk and dorsal radioulnar ligament (dorsal margin of the TFC).
Other (Left) Coronal T1 C+ MR (MR arthrogram) shows degeneratrve TFC lesron wrth hor~zontaltear and chondromalacra of the dlstal ulna, lunate, and tnquetrum (Right) Coronal T I C+ MR (MR arthrogram) shows normal foveal and stylord attachments of the TFC
DISTAL RADIUS FRACTURES
Coronal graphic shows intraarticular distal radius fracture with involvement of lunate fossa. The fractured lunate fossa is divided into a palmar and a dorsal medial component.
-
Coronal T l Wl MR shows transverse distal radius fracture with secondary extension into radiocarpal joint & distal radioulnar joint. There is congruity of the distal radial articular surface.
o Barton's fracture: Intraarticular fracture-dislocation
or subluxation (palmar vs. dorsal fracture) with displacement of carpus o Melone classification: 5 fracture types based on 4 fracture components
Abbreviations and Synonyms Distal radius fractures, Colles' fracture, Smith's fracture
Definitions Extraarticular & intraarticular fractures of distal radius
IIMAGING
Radiographic Findings Radiography o Extraarticular nondisplaced & displaced o Intraarticular nondisplaced & displaced o Lateral radiography - useful for dorsal + volar displacement
FINDINGS
General Features Best diagnostic clue: Linear fx line involving distal radius Location o Scaphoid fossa (SF) o Lunate fossa (LF) o Sigmoid notch (SN) - at distal radioulnar joint (DRUJ) Size: Variable with respect to extra vs. intraarticular & displacement of fragments Morphology o Colles' fracture: Distal metaphysis with dorsal displacement, angulation (silver fork deformity), radial angulation & radial shortening o Smith's fracture (reverse Colles'): Palmarly angulated fracture (garden spade deformity)
CT Findings NECT o Bone technique with coronal & sagittal reformations o 3-D rendering for surgical planning o Identify displacement of key medial fragments (ulnar aspect of distal radius) & disruption of radiocarpal + distal radioulnar joints (DRUJ)
MR Findings TlWI o Fracture diastasis directly measured on coronal, axial or sagittal images o Scaphoid + lunate fossa evaluated on coronal images o Hypointense fracture line(s) extension to distal radius o Articular involvement
Brn J !p jJ l! DDx: Distal Radius Fracture
.@
SL Ligament Tear
',
Cor T 1WI MR
Cor T1 Arthro
Cor T1 Arthro.
-
DISTAL R A D I U S FRACTURES
1
Kev Facts I
Imaging Findings
1
Best diagnostic clue: Linear fx line involving distal radius Melone classification: 5 fracture types based on 4 fracture components
Top Differential Diagnoses Traumatic Triangular Fibrocartilage Complex (TFCC) Abnormalities Ulnocarpal Abutment Syndrome Kienbock's Disease Instability of Distal Radioulnar Joint (DRUJ) Intrinsic Ligament Patholow " -*
Pathology Fall onto outstretched hand
.
Radial shaft & styloid T2WI o Hypo to hyperintense fracture line o Hyperintense marrow edema & joint effusion o Intermediate to hyperintense synovitis + subcutaneus edema D~~~~~~~~~of intermediate signal intensity chondral surfaces o Associated partial or complete ligament tears o Hyperintense edema of associated carpal fractures
Imaging Recommendations Best imaging tool: MR for osseous + soft tissue injury Protocol advice o Coronal, axial & sagittal TI, FS PD FSE o TZ* GRE Helpful in identifying fragments if subchondral edema is severe and obscures fracture detail
.
I DIFFERENTIAL DIAGNOSIS Traumatic Triangular Fibrocartilage Complex (TFCC) Abnormalities Central perforation Ulnar avulsion Distal avulsion Radial avulsion
Ulnocarpal Abutment Syndrome TFCC degeneration/perforation Lunate, triquetral & ulnar chondromalacia Lunotriquetral ligament perforationltear
Kienbock's Disease Avascular necrosis of lunate Related to trauma + ulnar negative variance Centralized lunate sclerosis + Visualized lunate fracture
Instability of Distal Radioulnar Joint (DRUJ) Ulnar dorsal dislocation in hyperpronation Ulna palmar dislocation in hypersupination
Weaker dorsal cortex associated with extraarticular metaphyseal fracture in elderly Greater longitudinal compression force in younger patient = intraarticular fracture + displacement
I
Clinical Issues Most common signs/symptoms: Pain at distal radius
radius Deformity Over Displacement of hand dorsally in Colles' fracture or palmarly in Smith fracture Swelling dorsum of hand & wrist with ecchymosis Radiocarpal arthrosis - associated with > 2 mm incongruity of articular surface
Diagnostic Checklist Characterize lunate fossa involvement into dorsal & palmar medial components on sagittal images
Rotational injury with forced pronationlsupination hyperextension
+
Intrinsic Ligament Pathology Lunotriquetral dissociation with volar flexion of lunate & discontinuity of hypointense ligament Scapholunate dissociation with scaphoid flexion, ligamentous tear k scapholunate interval diastasis
General Features General path comments o Relevant anatomy = medial (ulnar) complex Ulnar styloid Triquetrum Lunate and lunate fossa TFC Ulnocarpal meniscus Ulnolunate ligament Radiocarpal ligaments Etiology o Fall onto outstretched hand o Osteoporotic elderly woman - low energy injuries o Dorsiflexion hyperextension o Tension along palmar surface of wrist o Compression + comminution dorsal surface o Weaker dorsal cortex associated with extraarticular metaphyseal fracture in elderly o Greater longitudinal compression force in younger patient = intraarticular fracture + displacement Epidemiology o Distal radius fracture = one of the most common skeletal injuries o One-sixth of all fractures seen in acute setting o Majority = articular with disruption of radiocarpal & distal radioulnar joints
.. . .. .
Gross Pathologic & Surgical Features Colles' fracture o Distal metaphysis radius o Dorsally displaced & angulated
DISTAL RADIUS FRACTURES o Within 2 cm of articular surface o
+ Distal radiocarpal or radioulnar joint
o Radial angulation & shortening Smith's fracture o Reverse Colles' o Palmarly angulated fracture o Hand & wrist displaced palmarly o Extra or intraarticular Barton's fracture o Fracture dislocation of distal radius o Intraarticular (rim) fracture o Displaced dorsally or palmarly with carpus o Dislocation = primary feature Intraarticular fracture o Melone classification (attention to medial complex at level of lunate fossa) - 4 fracture components: Radial shaft, radial styloid, dorsal-medial, and volar-medial fragments Type I: Minimally displaced Type IIA: Dorsally displaced (most common) vs. volar displacement Type IIB: Die-punch fracture with lunate impaction, most commonly on dorsal medial component Type 111: Addition of spike fragment from volar metaphysis Type IV: Separation or rotation of dorsal & palmar medial fragments & disruption of distal radius articulations Type V: Explosion fracture with comminution from articular surfaces to diaphysis
Microscopic Features Fracture histology - failure of trabecular & cortical
Demographics Age: Young to elderly Gender o High energy injuries in young male o Low energy in elderly female with osteoporosis
Natural History & Prognosis Stable vs. unstable reduction DRUJ instability Median nerve dysfunction & carpal tunnel syndrome Tendon injury & carpal injury Radiocarpal arthrosis - associated with > 2 mm incongruity of articular surface
Treatment Conservative o Melone type I: Stable Surgical o Melone type IIA: Unstable (dorsal or volar displacement), treatment with reduction + external fixation o Melone type IIB: Irreducible by closed techniques o Melone type 111: Volar spike fragment from metaphysis places adjacent nerves & tendons at risk o Melone type IV Arthroscopic percutaneous reduction & pinning Open reduction and internal fixation (type IIB, 111, IV)
1 DIAGNOSTIC CHECKLIST
I
Consider Associated involvement of radial styloid & ulnar styloid Characterize lunate fossa involvement into dorsal & palmar medial components on sagittal images
bone Ligament histology o Capsular - collagen bundles or fascicles o Intraarticular - lined by synoviocytes o Mesocapsular synovial capsular structure
-
Staging, Grading or Classification Criteria
Frykman classification - intra or extraarticular fxs (including involvement of DRUJ) +/- ulnar styloid fx Universal classification - replaced Frykman classification including treatment algorithm Melone classification - based on degree & direction of displaced articular fragments + indications for open reduction Mayo classification - scaphoid, lunate, sigmoid notch as separate articulations with involvement of one or more articular fossae
Presentation Most common signs/symptoms: Pain at distal radius Clinical profile o Deformity over distal radius o Displacement of hand dorsally in Colles' fracture or palmarly in Smith fracture o Swelling dorsum of hand & wrist with ecchymosis
-
1.
-
--
Freeland AE et al: The arthrosco~icmanagement of intra-articular distal radius fracthres. ~anvdSurg 5(2):93-102,2000 Trumble TE et al: Intra-articular fractures of the distal aspect of the radius. Instr Course Lect 48:465-80, 1999 Cooney WP: The wrist. Diagnosis and operative treatment. Fractures of the distal radius. Philadelphia PA, WB Saunders, (30):310-55, 1998 Rettig ME et al: The wrist and it's disorders: Fractures of the distal radius. 2nd ed. Philadelphia PA, WB Saunders, 347-72, 1997 Pruitt DL et al: Computed tomography scanning with image reconstruction in evaluation of distal radius fractures. J Hand Surg 19A:720, 1994 Leibovic SJ et al: Treatment of complex intraarticular distal radius fractures. Orthop Clin North Am 25685, 1994 Metz VM et al: Imaging techniques for distal radius fractures and related injuries. Orthop Clin North Am 24:217, 1993 Johnston GHF et al: Computerized tomographic evaluation of acute distal radial fractures. J Hand Surg 17A:738, 1992 Bartosh RA et al: lntraarticular fractures of the distal radius: A cadaveric study to determine if ligamentotaxis restores radiopalmar tilt. J Hand Surg 15A:18, 1990
DISTAL RADIUS FRACTURES IMAGE GALLERY Typical (Left) Sagittal NECT shows Melone type I1 fracture secondary to a die-punch mechanism of injury. The lunate has impacted the palmar medial fragment of the distal radius. (Right) Coronal FS PD FSE MR shows intraarticular distal radius fracture with die-punch mechanism of injury. Degenerative changes are shown between the lunate and lunate fossa of the distal radius.
(Left) Coronal T 1 WI MR shows depressed lunate fossa (arrow) and diastasis of the distal radioulnar joint secondary to an unstable diepunch compression force. (Right) Coronal graphic shows depressed lunate fossa in an unstable type I1 fracture. In a double die-punch there would be the additional impaction of the scaphoid on distal radius.
(Lef?) Coronal FS PD FSE MR shows hyperintense marrow edema associated with a transverse Colles' fracture of distal radius. (Right) Sagittal graphic shows Colles' fracture (extraarticular) with dorsal displacement of distal fragment.
D I E PUNCH FRACTURE, DISTAL RADIUS
Coronal graphic shows articular injury with associated ulnar styloid fracture and involvement of the lunate fossa of distal radius (dorsal perspective).
Sagittal TlWl MR shows unstable Melone type I1 fracture with lunate impaction on the dorsal medial fragment.
.. ..
Metaphyseal Radial styloid Dorsal medial Palmar medial
Abbreviations and Synonyms Lunate load fx, medial cuneiform fx
CT Findings
Definitions Intraarticular comminuted distal radius fx occurring 2" to lunate impaction of distal radius, splitting the distal radius in both coronal and sagittal planes
General Features Best diagnostic clue: Fracture that extends to involve lunate fossa of distal radius Location: Lunate fossa (dorsal medial or palmar medial) Size: Variable based on displacement of fragments Morphology: Dorsal displacement of articular surfaces vs. volar displacement
Radiographic Findings Radiography o Initial exam - anteroposterior (AP) and lateral views of wrist o Diagnostic o Typically 4 main fx fragments identified (Melone classification)
*
NECT o Excellent bony detail o Better definition of fx fragments & patterns o Multiplanar reconstruction Define fx displacement in 3-dimensions Pre-operative planning o Accurate measurements Articular step-off Fragment displacement Shortening
.. ..
MR Findings TlWI o Fracture diastasis directly measured on coronal, axial or sagittal images o Scaphoid + lunate fossa evaluated on coronal images o Articular fractures o Radial shaft & styloid o Lunate fossa, dorsal medial & palmar medial fragments T2WI o Hypointense to hyperintense fracture line o Hyperintense marrow edema & joint effusion
DDx: Die Punch Fracture, Distal Radius TFCC Tear
Abutment
Kienbock's
51 Ligament Tear
Cor FS PD MR
Cor T 1 Arthro.
Sag T l W l MR
Cor FS PD MR
D I E PUNCH FRACTURE, DISTAL RADIUS
-
Key Facts Imaging Findings I
Pathology
Best diagnostic clue: Fracture that extends to involve lunate fossa of distal radius Fracture diastasis directly measured on coronal, axial or sagittal images Scaphoid + lunate fossa evaluated on coronal images Hypointense fracture line($ extension to distal radius (TI & T2WI)
Top Differential Diagnoses Traumatic Triangular Fibrocartilage Complex (TFCC) Abnormalities Ulnocarpal Abutment Syndrome Kienbock's Disease Instability of Distal Radioulnar Joint (DRUJ) Intrinsic Ligament Pathology
o Intermediate to hyperintense synovitis +
subcutaneous edema o Disruption of intermediate signal intensity of chondral surfaces o Discontinuity of associated ligament tears o Hyperintense edema of associated carpal fractures T2* GRE: Helpful in identifying fragments if subchondral edema is severe & obscures fracture detail Hypointense fracture line(s) extension to distal radius (TI & T2WI)
Imaging Recommendations Best imaging tool: MR for osseous + soft tissue injury Protocol advice: T1, FS PD FSE MR coronal, axial & sagittal
1 DIFFERENTIAL DIAGNOSIS Traumatic Triangular Fibrocartilage Complex (TFCC) Abnormalities Central perforation Ulnar avulsion Distal avulsion Radial avulsion
Ulnocarpal Abutment Syndrome TFCC degenerationlperforation Lunate, triquetral & ulnar chondromalacia Lunotriquetral ligament perforationltear
Clinical Issues Most common signslsymptoms: Fx secondary to fall on outstretched hand
Diagnostic Checklist Characterize lunate fossa into dorsal medial & palmar medial components of die punch fracture on sagittal images
Intrinsic Ligament Pathology Lunotriquetral dissociation with volar flexion of lunate & discontinuity of hypointense ligament Scapholunate (SL) dissociation with scaphoid flexion, ligamentous tear + interval diastasis
General Features General path comments o Relevant anatomy rn Ulnar styloid Lunate fossa Triquetrum Lunate TFC rn Ulnocarpal meniscus rn Ulnolunate ligament Radiocarpal ligament Etiology: Occurs primarily 2" to axial compression with lunate driven proximally, impacting dorsal medial aspect of distal radius Epidemiology o Distal radius fracture = one of the most common skeletal injuries o One-sixth of all fractures presenting acutely o Majority = articular with disruption of radiocarpal & distal radioulnar joints
Gross Pathologic & Surgical Features
Kienbock's Disease Avascular necrosis of lunate Related to trauma - ulnar negative variance Centralized lunate sclerosis + Visualized lunate fractures
Instability of Distal Radioulnar Joint (DRUJ) Ulnar dorsal dislocation in hyperpronation Ulnar palmar dislocation in hypersupination Rotational injury with forced pronation/supination hyperextension
Etiology: Occurs primarily 2" to axial compression with lunate driven proximally, impacting dorsal medial aspect of distal radius Lunate impaction on dorsal medial component of lunate fossa with dorsal displacement
+
Lunate impaction on dorsal medial component of lunate fossa with dorsal displacement Comminution of dorsal metaphysis Dorsal tilting Shortening of the radius Less common is lunate impaction on palmar medial fragment with volar displacement Double die punch = scaphoid & lunate impaction of distal radius articular surface
DIE PUNCH FRACTURE, DISTAL RADIUS Microscopic Features
Treatment Conservative o Type I fx - treated with closed reduction Surgical o Type IIa, b, I11 + IV - open reduction almost always necessary Internal and external fixation often used o Indications for open reduction Persistent articular step-off > 2 mm = Radial shortening exceeding 3-5 mm Dorsal tilt in excess of 10"
Fracture histology = failure of trabecular & cortical bone Ligament histology o Capsular - collagen bundles or fascicles o Intraarticular - lined by synoviocytes o Mesocapsular - synovial capsular structure
Staging, Grading or Classification Criteria Fracture patterns o Type I - no significant displacement or angulation o Type IIa - classic die punch fx; unstable fx with dorsal displacement of dorsal medial fragment, dorsal tilt, shortening of radius o Type IIb - lunate impaction of palmar medial component of distal radius resulting in greater comminution and volar tilt o Type 111 - similar to type I1 fx with extra comminuted "spike"fragment displaced volarly o Type IV - wide separation of dorsal and palmar medial fragments o Type V - severely comminuted fx with severe disruption of distal radius articulations Melone fracture classification - four primary fx fragments o Metaphyseal o Radial styloid o Dorsal medial o Palmar medial
1 DIAGNOSTIC CHECKLIST Consider Associated involvement of radial styloid & ulnar styloid Characterize lunate fossa into dorsal medial & palmar medial components of die punch fracture on sagittal images
1 SELECTED REFERENCES 1.
2.
3.
Presentation Most common signs/symptoms: Fx secondary to fall on outstretched hand Clinical profile o Pain o Swelling o Deformity o Decreased range of motion o Winter months > summer months
4. 5. 6. 7.
Putman MD et al: Rockwood and Green's fractures in adults. Fractures of the distal radius. Philadelphia Pennsylvania, Lippincott Williams & Wilkins Publishers, 815-67, 2001 Fernandez DL et al: Green's operative hand surgery. Fractures of the distal radius. Philadelphia Pennsylvania, Churchill Livingstone, 934-5, 1999 Stoller DW: Magnetic resonance imaging in orthopaedics and sports medicine. 2nd ed. Philadelphia Pennsylvania, Lippincott Williams & Wilkins, 934-5, 1997 Leibovic SJ et al: Treatment of complex intra-articular distal radius fractures. Orthop Clin North Am 25685, 1994 Pruitt DL et al: Computed tomography scanning with image reconstruction in evaluation of distal radius fractures. J Hand Surg 19A:720, 1994 Melone Jr. CP: Distal radius fractures: Patterns of articular fragmentation. Ortho Clin of N Am 24(2):239-53, 1993 Metz VM et al: Imaging techniques for distal radius fractures and related injuries. Orthop Clin North Am 24:217. 1993 - - - -
Demographics Age: Adults (60-80 years most common) Gender: F > M
Natural History & Prognosis Dependent upon severity of comminution Dependent upon amount of articular step-off Degree of displacement + ability to achieve anatomic reduction Type I fx - best prognosis Type IIb, 111, IV fx - worst prognosis Complications o Chondral injury - eventual degenerative arthrosis o TFCC, SL, LT + extrinsic ligament tears 0 Tendinous disruptions 2"to lacerations by fx fragments o Nerve injuries (ulnar, radial, or median nerves) 0 Arterial injuries 0 Reflex sympathetic dystrophy
8. 9. 10. 11. 12. 13. 14. 15.
Johnson GHF et al: Computerized tomographic evaluation of acute distal radial fractures. J Hand Surg 17A:738, 1992 Cooney WE et al: Symposium: Management of intra-articular fractures of the distal radius. Contemp Ortho 21:71, 1990 Xelrod TS et al: Open reduction and internal fixation of comminuted, intra-articular fractures of the distal radius. J Hand Surg 15A:1, 1990 Axelrod T et al: Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius. J Hand Surg 13A:38, 1988 Bartosh RA et al: Intraarticular fractures of the distal radius: A cadaveric study to determine if ligamentotaxis restores radiopalmar tilt. J Hand Surg 15A:18, 1990 Bassett RL: Displaced intraarticular fractures of the distal radius. Clin Ortho 214:148. 1987 Melone CP Jr: Open treatment for displaced articular fractures of the distal radius. Clin Orthop 202:103, 1986 Melone CP Jr: Articular fractures of the distal radius. Orthop Clin North Am 15:217, 1984
DIE PUNCH FRACTURE, DISTAL RADIUS
I
(Left) Coronal T l Wl MR shows distal radius fracture involving ulnar styloid and lunate fossa without depression or displacement of dorsal or medial components of lunate fossa. (Right) Sagittal T 1 WI MR shows lunate impaction of the dorsal medial fragment resulting in dorsal displacement (type I1 fx).
(Lef?) Coronal graphic (dorsal view) shows type I1 articular fracture with dorsal displacement of the dorsal medial fragment. (Right) Coronal graphic (volar view) shows an unstable type 111 fracture with additional metaphyseal spike fragment (arrow).
(Left) Coronal graphic (dorsal view) shows unstable type IV distal radius fracture with wide separation of the dorsal and palmar medial fragments. (Right) Coronal graphic (dorsal view) shows type V explosion fracture of the distal radius with severe comminution.
ULNAR STYLOID FRACTURE
Coronal graphic shows drstal ulnar styloid fracture without displacement of the TFCC attachments
I4
Coronal T l Wl MR shows hypointense marrow edema assocrated with a nondisplaced ulnar stylord fracture
CT Findings
Abbreviations and Synonyms
NECT o Usually not performed for simple ulnar styloid fractures o To evaluate associated complex distal radius fractures o Accurate measurements for displaced fragments o Assess healing, callus formation, non-union
Fracture of the ulnar styloid, avulsion fracture of ulnar styloid
Definitions Distal avulsion fractures or ulnar base fractures
I IMAGING FINDINGS
MR Findings
General Features Best diagnostic clue: Transverse fracture line of ulnar styloid Location o Base o Mid styloid 0 Tip Size: Medial to lateral extent of base or less Morphology: Transverse fracture orientation
Radiographic Findings Radiography o Anteroposterior, lateral views o Associated distal radius fracture o Transverse fx of ulnar styloid o Fracture displacement
* *
TlWI o Hypointense fracture line o Hypointense marrow edema proximal & distal to
*fracture site
o Displacement of fragments o Associated traumatic avulsion of triangular
fibrocartilage (TFC) at its insertion at base of ulnar styloid o Distal radioulnar joint instability T2WI o Hypointense fracture line o Acute injuries with subchondral hyperintense marrow edema o Fluid & edema - hyperintense o Distal radioulnar joint (DRUJ) instability Greatest risk with base fractures Interosseous membrane hyperintensity (tears)
*
-
DDx: Ulnar Styloid Fracture Ulnar Arthrit~s
Ax T l W l MR
-
Kienbock's
TFC Tear
Sag T l W l MR
Cor FS PD M R
ULNAR STYLOID FRACTURE Key Facts
,
Imaging Findings Best diagnostic clue: Transverse fracture line of ulnar styloid Base Mid styloid Tip
Top Differential Diagnoses
1
Ulnocarpal Abutment Kienbock's Disease Lunotriquetral Dissociation Extensor Carpi Ulnaris Tendinitis Instability of DRUJ
Pathology Fall on outstretched hand Isolated vs. in association with distal radius fractures Hyperintense fluid interposed between triangular fibrocartilage (TFC) & attachment to styloid base o Associated distal radius articular fractures Ulnar styloid as part of the medial complex o Soft tissue injury Ulnar collateral ligament of wrist TFCC Tendon injuries (e.g., extensor carpi ulnaris)
Imaging Recommendations ~ e simaging t tool o MR for nondisplaced fractures & associated TFCC traumatic lesions o Articular fracture (distal radius) classification Protocol advice: TlIPD & FS PD FSE coronal, axial & sagittal images
I DIFFERENTIAL DIAGNOSIS Ulnocarpal Abutment TFCC degenerationlperforation Lunate, triquetral & ulna chondromalacia Lunotriquetral ligament perforationltear Ulnocarpal arthritis
Kienbock's Disease Avascular necrosis lunate Related to trauma + ulnar negative variance Centralized lunate sclerosis k Visualized lunate fracture
Lunotriquetral Dissociation Dissociation between lunate & triquetrum Volar flexion lunate (volar intercalated segment instability - VISI) Absence of horseshoe-shaped ligament Degenerative tear vs. ulnar-sided trauma on outstretched hand
Extensor Carpi Ulnaris Tendinitis Dorsal ulnar-sided pain Thickened tendon sheath Hyperintense fluid (T2WI) surrounding tendon
Class I traumatic ulnar avulsion injuries of TFCC
Clinical issues Most common signs/symptoms: Ulnar pain Point tenderness Swelling Associated wrist instability with base fxs Associated with Colles' fxs Associated with Essex-Lopresti (fx or fx-dislocation radial head + interosseous membrane disruption + dislocation DRUJ) Rate of non-union = 26% Nondisplaced base fx + unstable DRUJ = open repair
Diagnostic Checklist
Identify base vs. distal ulnar styloid fractures & TFCC attachments
Synovial thickening intermediate signal (T2WI) Associated subchondral marrow edema distal ulna
Instability of DRUJ Ulnar dorsal dislocation in hyperpronation Ulna palmar dislocation in hypersupination Rotational injury with forced pronationlsupination hyperextension
+
1 PATHOLOGY General Features General path comments o Relevant anatomy = the medial complex Ulnar styloid Triangular fibrocartilage Dorsal medial component (lunate fossa) Palmar medial component (lunate fossa) Triquetrum Lunate Ulnocarpal meniscus rn Ulnolunate ligament Radiolunate ligament Etiology o Fall on outstretched hand o Isolated vs. in association with distal radius fractures Articular fractures o Tip of ulnar styloid Avulsion by ulnar collateral ligament complex o Class I traumatic ulnar avulsion injuries of TFCC Epidemiology o Distal radius fractures - one of most common (74% of forearm fxs) skeletal injuries Associated ulnar styloid fx in 61% o Subtype of traumatic TFCC tears o Association with Colles' fx > 50%
Gross Pathologic & Surgical Features Disruption of TFC medially (ulnar aspect) Styloid fracture o Tip o Midway from base to tip
ULNAR STYLOID FRACTURE o Base Fracture of tip 0 Styloid-carpal impaction o Avulsion may be associated with intact periosteal sleeve Fracture of base o Avulsion of TFC styloid attachment o Avulsion of foveal attachment (proximal to styloid tip) o Destabilizes ulnar attachment of TFC complex Distal radius articular fractures Extensor carpi ulnaris subsheath avulsion or stripped adjacent to styloid
o Associated with Colles' fxs o Associated with Essex-Lopresti (fx or fx-dislocation
radial head + interosseous membrane disruption dislocation DRUJ)
Demographics Age o Older adult women o Peak age (60-80 years) o Ulnar-sided TFC lesions more common in younger population Gender: F > M
Natural History & Prognosis
Microscopic Features
Isolated ulnar styloid tip fxs clinically insignificant Displaced fractures of ulnar styloid base o Associated with ligamentous & TFC tears o DRUJ instability o Non-union risk Non-union of ulnar styloid o Type 1 associated with stable DRUJ (TFC insertion intact) o Type 2 associated with unstable DRUJ o Rate of non-union = 26%
Fracture histology - failure of trabecular & cortical bone TFC histology o Disruption of collagen fibers
Staging, Grading or Classification Criteria Class 1 traumatic TFCC abnormalities (not associated with class 2 degenerative tears) 0 A: Central perforation 0 B: Ulnar avulsion Distal ulnar fracture o C: Distal avulsion o D: Radial avulsion k Sigmoid notch fracture * Melone distal radius articular fractures o Components = radial shaft, radial styloid, dorsal medial fragment, palmar medial fragment & ulnar styloid + ligamentous attachments to carpus (medially) Type I: Minimally displaced Type 11: Die punch fracture with dorsal vs. volar displacement (medial fragment) = Type IIa: Minimallmild separation of fragments Type IIb: Comminution & displacement of medial fragments (dorsally) + double die punch (scaphoid + lunate) Type 111: Addition of a spike fragment from volar metaphysis Type IV: Separation or rotation of dorsal & palmar medial fragment + disruption distal radius articulations Type V: Explosion fracture with severe comminution Ulnar styloid non-unions 0 Type 1: Distal styloid fx o Type 2: Base of styloid fx
*
Treatment Conservative 0 Isolated ulnar styloid tip fractures = closed reduction/immobilization o Nondisplaced fx base of styloid + stable DRUJ = immobilization Surgical o Nondisplaced base fx + unstable DRUJ = open repair o Base fx > 2 mm displacement or associated severe ligamentous or TFC injuries = open reduction
Consider Identify base vs. distal ulnar styloid fractures & TFCC attachments Associated with distal radius fractures
1 SELECTED REFERENCES 1. 2. 3. 4.
Presentation Most common signs/symptoms: Ulnar pain Clinical profile o Point tenderness o Swelling o Restricted range of motion o Associated wrist instability with base fxs Radiocarpal = DRUJ (fx displacement > 3 mm)
+
5.
6. 7.
May MM et al: Ulnar styloid fractures associated with distal radius fractures: Incidence and implications for distal radioulnar joint instability. J Hand Surg 27(6):965-71, 2002 Kiyono Y et al: Ulnar-styloid nonunion and partial rupture of extensor carpi ulnaris tendon: Two case reports and review of the literature. J Orthop Trauma 16(9):674-7,2002 Yanagida H et al: Radiologic evaluation of the ulnar styloid. J Hand Surg 27(1):49-56,2002 Linscheid RL: The Wrist. Diagnosis and operative treatment. Disorders of the distal radioulnar joint. St. Louis Missouri, Mosby, 819-69, 1998 Hauck RM et al: Classification and treatment of ulnar styloid non-union. J Hand Surg 21A:418-22, 1996 Mann FA et al: Radiographic evaluation of the wrist: What does the hand surgeon want to know? Radiology 184:15-24, 1992 Melone CP et al: Traumatic disruption of the triangular fibrocartilage complex: Pathoanatomy. Clin Orthop 275:65-73, 1992
ULNAR STYLOID FRACTURE
(Left) Coronal FS PO FSE MR shows hyperintense marrow edema associated with distal styloid fracture. (Right) Coronal T I C+ MR (MR arthrogram) shows displaced ulnar styloid fracture with attachment of the ulnar margin of the TFCC.
(Left) Coronal T l Wl MR shows ulnar styloid fracture with impingement of the ulnotriquetral articulation. (Right) Coronal FS PO FSE MR shows hyperintense marrow edema of the distal ulnar epiphysis in trabecular microfracture.
(Left) Coronal FS PD FSE MR shows hypointense chronic ulnar styloid fracture fragment. There is relative distal displacement of the TFCC as measured from the distal articular surface of the ulna. (Right) Axial T l Wl MR shows the distal displacement of the ulnar styloid relative to the radiocarpal joint. The TFC articular disk is located to the right of styloid.
SCAPHOlD FRACTURES
-
Coronal graphic shows transverse fracture of the middle third or waist of the scaphoid.
Coronal T l W l MR shows hypointense fracture line and adjacent marrow edema in fracture of middle third of the scaphoid.
o Absence or displacement of navicular fat stripe (NFS) o Four radiographic views 20" supination 20" pronation
.. .
Abbreviations and Synonyms Fractures of the scaphoid, navicular fracture
Definitions Disruption of scaphoid trabecular and/or cortical bone
Neutral posteroanterior & lateral o Distal tilt view for transverse fractures o Scaphoid profile maximal in oblique views while making a fist + ulnar deviation
o Nondisplaced fractures - difficult to visualize
CT Findings General Features Best diagnostic clue: Transverse fracture line most commonly seen in middle third or waist of scaphoid Location o Tuberosity (distal volar prominence) o Distal third o Waist (middle third) o Proximal pole Size: Tuberosity & distal articular surface fxs usually smaller than distal third, middle third or proximal pole fxs Morphology o Horizontal oblique o Vertical oblique o Transverse
Radiographic Findings Radiography
NECT o Identify fractures when conventional radiographs
negative
o Bone technique I1 mm slice thickness + coronal ST
sagittal reformations o 3-D rendering for complex fractures & dislocations o Most commonly used to assess fracture healing
MR Findings TlWI o Hypointense fracture line o Scaphoid flexion (humpback deformity) on sagittal images o Fracture extension to cortex differentiates acute from chronic fractures (intact cortex implies chronic) o Displacement (implies instability) o Angulation
*
DDx: Scaphoid Fractures Radrus Fracture
Cor T 1 Arthro.
Cor FS PD MR
Cor FS PD MR
SCAPHOlD FRACTURES Key Facts Imaging Findings Best diagnostic clue: Transverse fracture line most commonly seen in middle third or waist of scaphoid Scaphoid flexion (humpback deformity) on sagittal images Evaluate for proximal pole hypointensity (avascular necrosis) Early scapholunate advanced collapse (SLAC) with chondral loss between distal pole scaphoid & distal radius (styloid)
*
Top Differential Diagnoses Scapholunate Ligament Tear Distal Radius Fractures Dorsal Wrist Ganglion De Quervain's Stenosing Tenosynovitis
o Intercarpal instability - dorsal intercalated segment
instability (DISI) o Displaced and unstable = > 1 mm step-off or increased capitolunate angle (> 30") T2WI o Hypo to hyperintense fracture line o Hyperintense subchondral marrow edema adjacent to or on both sides of fracture o Less common - diffuse scaphoid hyperintense marrow edema within scaphoid o FS PD FSE or STIR sensitive to proximal pole edema o Hyperintense signal associated with injury to scapholunate ligament + volar capsule (radioscaphocapitate & radiolunotriquetral ligaments) o Evaluate for proximal pole hypointensity (avascular necrosis) o Early scapholunate advanced collapse (SLAC) with chondral loss between distal pole scaphoid & distal radius (styloid) T2* GRE: Identifies loss of normal trabecular pattern (marrow edema is diminished relative to fx line) TI C+: Document viability of proximal pole with enhancement
Imaging Recommendations Best imaging tool o MR more sensitive & specific than radiography or
Pathology Dorsiflexion secondary to fall Tensile fractures = transverse 8 begin in palmar cortex 80% in waist (middle third) 10% proximal pole 10% tuberosity or distal pole osteochondral injuries
Clinical Issues Most common signs/symptoms: Pain over anatomic snuffbox Limited range of motion Decreased grip strength Proximal third fx AVN = 14 to 39%
Diagnostic Checklist Evaluate scaphoid flexion deformity
Distal Radius Fractures Low energy metaphyseal injuries (Colles') Violent (high energy) articular injuries k comminuted & unstable Four components of articular fxs: Metaphyseal or shaft, radial styloid, dorsal medial & palmar medial components
Dorsal Wrist Ganglion Most common soft tissue mass in wrist Dorsal to SL interval 3rd to 5th decades Painless mass k weakness of grip, pain or paresthesias
De Quervain's Stenosing Tenosynovitis Radial sided wrist pain Racquet sports, golf, occupational overuse Inability to abduct thumb, radial sided swelling, crepitus & pain Affects abductor pollicis longus (APL) + extensor pollicis brevis (EPR)
Capitate Fracture Isolated Fx + perilunate dislocation (scaphocapitate syndrome) Direct trauma Dorsiflexion mechanism Avascular necrosis & non-union
-I-
o CT best for chip fxs, tuberosity or articular surface +
post op healing Protocol advice: TI, FS PD FSE coronal, axial & sagittal images
Scapholunate Ligament Tear Dissociation between scaphoid & lunate Scaphoid flexion relative to lunate Scapholunate (SL) angle > 70 degrees Associated with dorsal intercalated segment instability (DISI) & avulsion fracture
-
1 PATHOLOGY General Features General path comments o Relevant anatomy = scaphoid Largest + most radial in proximal row Proximal surface is biconvex for articulation with radius Distal surface convex for articulation with trapezium & trapezoid r Dorsal surface = attachment of dorsal radiocarpal & radial collateral ligaments
SCAPHOID FRACTURES Palmar (volar) surface concavity containing radioscaphocapitate (RSC) ligament Flexor retinaculum attaches to scaphoid tubercle Medial - semilunar surface for lunate articulation Medial - large concavity for capitate articulation Vascular supply (radial artery): Dorsal ridge vessels supply proximal 70 to 80% of scaphoid; scaphoid tubercle branches distal 20 to 30% Absence of separate proximal pole blood supply = propensity for delayed healing & AVN of proximal pole Etiology o Dorsiflexion secondary to fall o Protective maneuver with outstretched arm o Forceful extension (hyperextension) + radial . deviation - maximize forces across scaphoid o Tensile fractures = transverse & begin in palmar cortex Epidemiology: 79% of carpal fractures , A
J I1
o Nonunion
o Malunion o o o o
Degenerative changes Proximal pole AVN DISI Humpback deformity
Treatment Conservative o Immobilization & cast application Surgical o Internal fixation for displaced fxs o Herbert screws - interfragmentary compression = 92% success rate (Kirschner wires) Complications o Proximal third fx AVN = 1 4 to 39% o Middle third non-union = 20% o Pseudoarthrosis at fracture site
Gross Pathologic & Surgical Features 80% in waist (middle third) 10% proximal pole 10% tuberosity or distal pole osteochondral injuries Waist fxs stable if noncomminuted & perpendicular to
long axis of scaphoid Increased obliquity, dorsal comminution & displacement = instability Distal osteochondral fracture = flake of bone
Consider Trabecular fracture line may persist with intact radiallulnar cortices in healing phase Evaluate scaphoid flexion deformity Assess presence of SLAC arthritis Fracture line may be obscured on PD or conventional T2WI vs. T I & FS PD FSE MR
Microscopic Features Internal vascularity o Dorsal scaphoid branch of radial artery o Volar scaphoid branch of radial artery o Nutrient vessels entering dorsal ridge o Bone failure initiated at palmar (volar) cortex
Presentation Most common signs/symptoms: Pain over anatomic snuffbox Clinical profile o Weakness o History of contact sport, fall or accident o Delayed diagnosis common o Limited range of motion o Pain with radial deviation & flexion o Decreased grip strength
Demographics Age o Young & elderly o Most common in adolescents & young athletes Gender: M > F
Natural History & Prognosis Uncomplicated fx = union rate up to 95% Associated injuries o SL dissociation o Capitate head shear fx & triquetral fx o Proximal pole fx - delayed healing o Tuberosity fx - good healing Complications
Brydie A et al: Early MRI in the management of clinical scaphoid fracture. Br J Radiol 76(905):296-300, 2003 Cooney WP: Scaphoid fractures: Current treatments and techniques. Instr Course Lect 52:197-208, 2003 Rennie WJ et al: Posttraumatic cyst-like defects of the scaphoid: Late sign of occult microfracture and useful indicator of delayed union. AJR 180(3):655-8,2003 McCallister WV et al: Central placement of the screw in simulated fractures of the scaphoid waist: A biomechanical study. J Bone Joint Surg Am 85A(1):72-7,2003 Wu WC: Percutaneous cannulated screw fixation of acute scaphoid fractures. Hand Surg 7(2):271-8, 2002 Akahane M et al: Static scapholunate dissociation diagnosed by scapholunate gap view in wrists with or without distal radius fractures. Hand Surg 7(2):191-5, 2002 McGrory BJ et al: The wrist. Diagnosis and operative treatment. Malunion of the distal radius. vol 1. St. Louis Missouri, Mosby, 385-430, 1998 Markiewitz AD et al: The wrist and it's disorders. Carpal fractures and dislocations. 2nd ed. Philadelphia Pennsylvania, W.B. Saunders, 189-233, 1997 Duppe H et al: Long term results of fracture of the scaphoid. J Bone Joint Surg 76A:249-52, 1994 Adams BD et al: Treatment of scaphoid non-union with casting and pulse electromagnetic fields. A study continuation. J Hand Surg 17A:910-14, 1992 Diao G et al: Anatomic scaphoid classification: An algorithm for management of scaphoid fractures. Presented at the Am Soc for Surg of the Hand, 1992 Cope JR: Rotatory subluxation of the scaphoid. Clin Radiol 35:495-501, 1984
SCAPHOlD FRACTURES IMAGE GALLERY (Left) Sagittal graphic shows scaphoid flexion with humpback deformity resulting in foreshortening of the carpus. (Right) Sagittal T l Wl MR shows humpback deformity of the scaphoid post internal fixation with a Herbert screw. This flexion deformity is associated with a DlSl pattern even in the absence of a SL ligament tear.
(Left) Coronal graphic shows flexion of the scaphoid with mild rotation in rotatory instability. (Right) Coronal FS PD FSE MR shows hyperintense marrow edema both proximal and distal to the s c a ~ h o i dfracture site.
Typical (Left) Coronal T 1 WI MR shows selective avulsion fracture from the scaphoid attachment of the SL ligament. (Right) Coronal T l Wl MR shows persistent hypointense fracture line (arrow) across the proximal pole of the scaphoid despite intact radial and ulnar cortical margins in a healing scaphoid fracture. Radiographs were normal.
HAMATE FRACTURES
Coronal graphic shows hook of the hamate fracture with mild diastasis.
Sagittal TlWl MR shows nondisplaced hook of hamate fracture (arrow).
Radiographic Findings Radiography o Not diagnosed early o Carpal tunnel view = unreliable o 20" supination oblique = unreliable o 30" lateral & flexion/extension views often helpful o Loss of normal dense "C" (hook) on posteroanterior view
Abbreviations and Synonyms Fractures of the hamate, hamulus (hook of hamate) fracture, carpometacarpal fracture dislocation
Definitions Cortical & trabecular fracture involving the body or the hook of hamate
1
I IMAGING FINDINGS General Features Best diagnostic clue: Fracture line in hamate on direct axial images Location o Body - across articular surfaces 0 Hook o Proximal pole Size o Variable o Hook fx: rt Diastasis o Body fx: Nondisplaced vs. fracture dislocation Morphology o Usually transverse o Oblique or comminuted in body fractures
*
CT Findings NECT o Bone technique, I 1 mm slice thickness o Coronal & sagittal reformations or direct acquisition o Cortical disruption o Lucent fracture line + displacement o Loss of normal osseous concavity of hook o Have option of 3-D renderings for surgical planning
MR Findings TlWI o Hypointense fracture line o Hook fractures transverse on axial & vertical on sagittal images o Hypointense marrow edema of hook or body in acute injury o Subacute to chronic hook fxs may be missed on coronal images o rt Displacement of hook fxs (axial or sagittal plane)
-
DDx: Hamate ~ G t u r e s
?J* AX T2* CRE MR
.. Cor T 1 Arthro.
111
Cor T 1 Arthro.
HAMATE FRACTURES Key Facts Imaging Findings B~~~ diagnostic clue: Fracture line in hamate on direct axial images Body - across articular surfaces Hook Proximal pole
Top Differential Diagnoses Ulnar Tunnel Syndrome Carpal Tunnel Syndrome Ligament SprainICarpal Instability Flexor Tenosynovitis/Tendinitis Triangular Fibrocartilage (TFC) Tear
Pathology Fall on outstretched wrist (dorsiflexion) Direct trauma T2WI o Hypointense fracture line o Hyperintense marrow edema with body or hook fractures (hook or body edema) o Requires FS PD FSE or STIR to appreciate acute/subacute marrow edema o rt Displaced articular fx o k Osteochondral fx o & Dislocations o Effacement of ulnar aspect carpal tunnel Level of ulnar sided flexor digitorum profundus tendons
Imaging Recommendations Best imaging tool o MR or CT o MR identifies subchondral marrow edema + associated chondral/soft tissue abnormalities Protocol advice: TI (for edema & sclerosis detection) & FS PD FSE coronal, axial & sagittal
Fall or direct blow on flexed + ulnarly deviated fist Impaction against lunate articular surface (wrist in dorsiflexion & ulnar deviation)
Clinical Issues Most common signslsymptoms: Soreness in palm Distribution - ulnar aspect wrist Ulnar nerve palsy Decrease in grip strength Painful finger flexion & Carpal tunnel syndrome Hook fxs at risk for non-union if involvement is palmar & not base
*
Diagnostic Checklist
Always evaluate axial & sagittal images before excluding a fracture
Palmar carpometacarpal ligament Dorsal carpometacarpal ligament
Flexor Tenosynovitis/Tendinitis Ulnar profundus tendons Single traumatic event or repetitive use Repair response: Inflammation, proliferation & maturation Hyperintensity of sheath (fluid) on T2WI
Triangular Fibrocartilage (TFC) Tear Traumatic vs. degenerative Centrum or disk = communication or perforation Tearing of dorsal or volar margins (radioulnar ligaments) + centrum = distal radioulnar joint (DRUJ) instability Primary sign = fluid extension across articular disk or discontinuity
Ulnar Styloid Fracture Complex distal radioulnar joint (DRUJ) dislocations Distal radial fxs - commonly associated TFCC injuries o Ulnar styloid avulsion at base destabilizes DRUJ
Ulnar Tunnel Syndrome Irritation of ulnar nerve in Guyon's canal Numbness or paresthesias Distribution = 5th finger & ulnar side of ring finger
Carpal Tunnel Syndrome Compromised motorlsensory function of median nerve at level of carpal tunnel Trauma + repetitive wrist activities Hemorrhage Infection Infiltrative disease Pain & numbness at thumb, index, middle fingers & radial lh ring finger
Ligament SprainICarpal Instability * Interosseous ligament sprain: Scapholunate, lunotriquetral Palmar carpal ligament Pisohamate ligament
General Features General path comments o Relevant anatomy = hamate or related structures Pisohamate ligament - connects pisiform to hook of hamate (distally) Hamate - supports 4th & 5th metacarpal bases Most ulnar bone in distal row Hook - projects from palmar surface Distal surface articulates with 4th & 5th metacarpals by two facets with dividing anteroposterior ridge Dorsal surface = triangular + roughened for ligamentous attachment Palmar surface - pronounced hook
-
HAMATE FRACTURES Hook serves as ulnar attachment to distal flexor retinaculum + origins of flexor digiti minimi (FDM) & opponens digiti minimi (ODM) Palmar surface - insertion of flexor carpi ulnaris via pisohamate ligament Radial surface concavity = pulley mechanism for flexor tendons Ulnar surface articulates with triquetrum Triquetrohamate joint has spiral orientation influences motion between carpal rows Etiology o Hook fracture Fall on outstretched wrist (dorsiflexion) Tension applied through transverse carpal & pisohamate ligament Direct trauma Catching a ball Bat, hockey stick or golf club related Dominant hand in racquet sports Nondominant hand in other causes o Distal hamate - displaced articular fracture Force propagated along 5th metacarpal shaft Fall or direct blow on flexed + ulnarly deviated fis o Proximal pole osteochondral fracture Impaction against lunate articular surface (wrist il dorsiflexion & ulnar deviation) o Osteochondral fractures of triquetral articular surface Shearing injury or impaction against lunate o Bony fractures & dislocations Direct crushing injuries Punch-press accidents Fall on hyperdorsiflexed & ulnar deviated wrist Posterior dislocation or subluxation of 4th/5th metacarpals Epidemiology: 1.5% of carpal fxs
Gross Pathologic & Surgical Features Fx body - involvement of articular surfaces Intraarticular fracture involvement o Capitohamate o Triquetrohamate o Hamatometacarpal Base fxs of hook = good blood supply Palmar fxs of hook (towards tip) = greater displacement and risk of nonunion
o o o o o o
Demographics Age: Young, active patients, especially athletes Gender: M > F, as a function of participation in baseball, hockey, golf & tennis
Natural History & Prognosis Majority of body fxs heal with immobilization Hook fxs at risk for non-union if involvement is palmar & not base
Treatment Conservative o Cast or splint immobilization o Nondisplaced hook fxs Surgical o Excision of displaced comminuted fx or non-union o Distal articular body fxs + dislocation of 4th & 5th metacarpals require open reduction and internal fixation (ORIF) Complications o Non-union
Consider A bipartite hook or os hamuli proprium (incomplete
fusion of ossification center of hook) may mimic a fracture Always evaluate axial & sagittal images before excluding a fracture
1 SELECTEDREFERENCES 1. 2.
3.
Microscopic Features Palmar hook non-union o Inadequate fracture site callus o Osseous resorption o Decreased cancellous vascularity
Staging, Grading or Classification Criteria Body fractures (described relative to hook) o Medial (ulnar) o Lateral (radial)
Presentation Most common signs/symptoms: Soreness in palm Clinical profile
Acute or chronic pain & tenderness Distribution - ulnar aspect wrist + Ulnar nerve palsy Decrease in grip strength Painful finger flexion & Carpal tunnel syndrome
4.
5. 6.
David TS et al: Symptomatic, partial union of the hook of the hamate fracture in athletes. Am J Sports Med 31(1):106-200,2003 Guha AR et al: Stress fracture of the hook of the hamate. Br J Sports Med 36(3):224-5,2002 DeSchrijver F et al: Fracture of the hook of the hamate, often misdiagnosed as "wrist sprain". J Emerg Med 20(1):57-60, 2000 Akahane M et al: Fracture of hamate hook - diagnosis by the hamate hook lateral view 5(2):131-7, 2000 Cooney WP: The wrist. Diagnosis and operative treatment. Isolated carpal fractures. vol 1. St. Louis Missouri, Mosby, (19):474-89, 1998 Markiewit AD et al: The wrist and it's disorders. Carpal fractures and dislocations. 2nd ed. Philadelphia Pennsylvania, W.B. Saunders, (13):189-233, 1997
I
HAMATE FRACTURES
I IMAGE GALLERY
SCAPHOID NON-UNION
I
Coronal graphic shows fracture of proximal pole of scaphoid with avascular necrosis. The vascular supply via the radial artery is received from the distal pole.
o Arthritic change o Obtain grip compression PA in ulnar deviation if scapholunate (SL)angle < 70" with positive degenerative changes o PA-ulnar deviation: Fragment separation = unstable non-union = pseudoarthrosis o Assessment of healing inferior to CT or MRI
Abbreviations and Synonyms Non-union, non-union of scaphoid, scaphoid pseudoarthrosis
Definitions Scaphoid fracture fails to unite within 6 months of injury
CT Findings
NECT o Bone technique o 5 1 mm sections o Direct coronal images or coronal & sagittal reformations o Assessment of healing + detection of pseudoarthrosis
1 IMAGING FINDINGS General Features Best diagnostic clue: Absence of bridging trabecular bone on coronal or sagittal images Location o Proximal third fracture o Vertical oblique fracture middle third Size: Bridging radial to ulnar (lateral to medial cortex) Morphology: Non-union defect prismatic in shape with quadrilateral base
MR Findings TlWI o Hypointensity across fracture site o Displacement - cortical offset 2 1 mm Dorsal intercalated segment instability (DISI) on sagittal images Dorsal gap on sagittal images through scaphoid Non-union = loss of coaptation o Instability Between proximal & distal carpal rows Increased scapholunate & capitolunate angles on sagittal images DISI (sagittal plane)
Radiographic Findings Radiography o Posteroanterior (PA), lateral & oblique o Fracture pattern o Location + displacement o Carpal instability
D
D
x
Coronal T l Wl MR shows hypointense AVN secondary to proximal pole fracture. Radioscaphoid sclerosis (arrow) represents stage I SLAC. SNAC represents SLAC and scaphoid non-union.
c
a
p
h
Scaphoid Fracture
SL Ligament Tear
Radlus Fracture
AP Radiography
Cor T 1 Arthro
Cor FS PD MR
S
SCAPHOID NON-UNION Key Facts Imaging Findings Best diagnostic clue: Absence of bridging trabecular bone on coronal or sagittal images Proximal third fracture Vertical oblique fracture middle third Morphology: Non-union defect prismatic in shape with quadrilateral base
Top Differential Diagnoses Scaphoid Fractures Scapholunate Ligament Tear Distal Radius Fractures De Quervain's Stenosing Tenosynovitis
Pathology DISI Loss of proximal fragment blood supply Trabecular erosion - volar defect at fx site o Avascular necrosis (AVN)
Hypointense proximal pole AVN Predisposed fx pattern & location = proximal third, vertical oblique middle third T2WI o Displacement Offset + interruption of intermediate signal articular cartilage Non-union site with persistent intermediate signal intensity Hypointense - intermediate signal in pseudoarthrosis o Instability & Hyperintensity in prismatic volar defect associated with scaphoid angulation Degenerative loss of joint space (chondral loss) radioscaphoid, scaphocapitate & capitolunate joints Scaphoid non-union advanced collapse (SNAC) o vascular necrosis Hypointensity in chronic phase with nonviable marrow Hyperintensity in acute/subacute phase with viable marrow Diffuse marrow hyperintensity may represent proximal pole ischemia + reactive edema of distal pole T1 C+ o Define non-union site o Enhancement of viable proximal pole marrow
Imaging Recommendations Best imaging tool o MR defines marrow changes in AVN + associated instability o CT for best detection of fracture healing & pseudoarthrosis
Epidemiology: Non-union rate up to 12% Fragmentation collapse proximal pole = late stage
Clinical Issues Most common signs/symptoms: Wrist pain Weakness of grip Loss of dorsiflexion Initially symptomatic post injury vs. delayed onset symptoms until degenerative changes or re-injury Displaced non-union more severe symptoms than nondisplaced non-union SNAC = greater arc injury (scaphoid non-union) 97% with arthritis in non-union 2 5 years in duration
Diagnostic Checklist Identify degenerative changes of SNAC
I DIFFERENTIAL DIAGNOSIS Scaphoid Fractures Most common fracture of carpus Associated dorsiflexion loading & radial deviation mechanism 70 to 80% involve middle third (scaphoid waist) Waist and proximal pole fractures at risk for delayed union & AVN Pain over anatomic snuffbox
Scapholunate Ligament Tear Dissociation between scaphoid & lunate Scaphoid flexion Scapholunate angle > 70 degrees Associated with DISI & avulsion fracture
Distal Radius Fractures Low energy metaphyseal injuries (Colles') Violent (high energy) articular injuries ? comminuted & unstable Articular fxs
De Quervain's Stenosing Tenosynovitis Radial sided wrist pain Racquet sports, golf, occupational overuse Inability to abduct thumb, radial sided swelling, crepitus & pain Affects abductor pollicis longus (APL) + extensor pollicis brevis (EPB)
1 PATHOLOGY General Features General path comments o Relevant anatomy Normal intact scaphoid exerts a flexion moment on radial side of the proximal row balanced by extension moment on ulnar side Etiology o Etiology of non-union Severity of injury
SCAPHOlD NON-UNION Fracture pattern (vertical oblique fracture) Location (proximal third) Displacement of fragments Ligamentous injury DISI Loss of proximal fragment blood supply Smaller diameter proximal pole - at risk Delayed diagnosis Ineffective immobilization Epidemiology: Non-union rate up to 12%
Gross Pathologic & Surgical Features
o Degenerative change in nondisplaced non-unions confined to radioscaphoid joint 0 Sparing of radiolunate joint o SNAC Late degenerative change with DISI Stage 1 perilunar instability like SLAC SNAC = greater arc injury (scaphoid non-union) SLAC = lesser arc injury (scapholunate dissociation)
Treatment Conservative o Non displaced fxs < 6 months from injury immobilization o Electrical stimulation Surgical o Symptomatic non-union in young patient o Type I simple = inlay bone graft o Type 2 unstable = volar wedge graft o Type 3 early = wedge graft, ORIF & styloidectomy o Type 4 SNAC = midcarpal fusion with scaphoid excision o Type 5 SNAC-plus = arthrodesis
Fx proximal thirds vs. vertical oblique fx middle third Cortical offset 2 1 mm Stage 1 perilunar instability (triquetrum, lunate & proximal fragment of scaphoid slide volarly into extension) Volar defect - trabecular erosion Fragmentation & collapse proximal pole = late stage 48
Microscopic Features Inadequate fracture site trabeculation Osseous resorption Interruption of blood supply with decreased cancellous vascularity
Staging, Grading or Classification Criteria * Type 1:Simple non-union o Nondisplaced & no degenerative change
Consider Identify degenerative changes of SNAC Evaluate for AVN or small fragment size of proximal pole (poor candidates for bone grafting)
* Type 2: Unstable non-union o Displacement (> 1 mm) or DISI (SL angle > 70°),no degenerative change Type 3: Early arthritic non-union o Radioscaphoid arthritis * Type 4: Scaphoid non-union advanced collapse (SNAC wrist) Type 5: Scaphoid non-union advanced collapse-plus (SNAC plus) o Arthritis throughout wrist
1. 2. 3.
Presentation
4.
Most common signs/symptoms: Wrist pain Clinical profile 0 Weakness of grip 0 Loss of dorsiflexion o Initially symptomatic post injury vs. delayed onset symptoms until degenerative changes or re-injury o Displaced non-union more severe symptoms than nondisplaced non-union 0 SNAC = greater arc injury (scaphoid non-union)
5.
6.
7.
8.
Demographics Age: 2nd or 3rd decade most common Gender: M > F
Natural History & Prognosis 97% with arthritis in non-union Degenerative arthritis sequence 0 Radioscaphoid (first) o Scaphocapitate (second) 0 Capitolunate (third)
2
5 years in duration
9. 10. 11.
Linscheid RL et al: The wrist. Diagnosis and operative treatment: Scaphoid fractures and nonunion. St. Louis MO, Mosby, (17):385-430, 1998 Kerluke L et al: Nonunion of the scaphoid: A critical analysis of recent natural history studies. J Hand Surg 18A:l-3, 1993 Kirschenbaum D et al: Scaphoid excision and capitolunate arthrodesis for radioscaphoid arthritis. J Hand Surg 18A:780-85, 1993 Jirenek WA et al: Long-term results after Russe bone-grafting: The effect of malunion of the scaphoid. J Bone Joint Surg 74A:1217-27, 1992 Krimmer VA et al: Advanced carpal collapse in scaphoid nonunion: Partial mediocarpal fusion as a therapeutic concept. Handchir Mikochir Plas Chir 24:191-8, 1992 Lundstrom G et al: Natural history of scaphoid non-union, with special reference to "asymptomatic" cases. J Hand Surg 17B:697-700, 1992 Barton NJ: Twenty questions about scaphoid fractures.J Hand Surg 17B:289-310, 1992 Balsole RJ et al: Computed analyses of the pathomechanics of scaphoid waist non-unions. J Hand Surg 16k899-908, 1991 Nakamura R et al: Analysis of scaphoid fractures displacement by three-dimensional computed tomography. J Hand Surg 16:485-92, 1991 Dias JJ et al: Patterns of union in fractures of the waist of the scaphoid. J Bone Joint Surg 71B:307-310, 1989 Amadio PC et al: Scaphoid malunion. J Hand Surg 14A:679-87. 1989
SCAPHOID NON-UNION
Typical (Left) Coronal T 1 WI MR shows proximal pole AVN. (Right) Coronal FS PD FSE MR shows hyperintense marrow edema corresponding to intact scaphoid vascularity Proximal pole shows greater hyperintensity compared to the distal two thirds of the scaphoid.
Typical
(Left) Coronal T I WI MR shows SNAC as a greater arc injury representing scaphoid non-union with the complication of AVN. Radial styloid-scaphoid sclerosis is present. (Right) Coronal T l Wl MR shows AVN with fragmentation of the proximal pole.
Typical (Left) Coronal T l Wl MR shows non-union with AVN of the proximal pole and fracture diastasis. (Right) Coronal T l Wl MR shows non-union with a double fracture pattern of both the proximal and distal poles of the scaphoid. This pattern has a greater risk for instability.
KIENBOCK'S DISEASE
Coronal graphic shows AVN of the lunate with diffuse marrow ischemia.
Coronal T l Wl MR shows stage I Kienbock's with uniform hypointense sclerosis/edema.
Lunate collapse Proximal migration capitate Widening proximal carpal row Rotation of scaphoid with foreshortening on anteroposterior (AP) views = "ring" sign
Abbreviations and Synonyms Lunatomalacia, aseptic necrosis, avascular necrosis, osteochondritis, traumatic osteoporosis, osteitis
CT Findings
Definitions
NECT o Bone technique o 1 mm sections o Coronal & sagittal reformations or direct coronal + sagittal o Identify linear fracture or sclerosis
Avascular necrosis of lunate
General Features Best diagnostic clue: Hypointense lunate on TlWI Location o Lunate o Centralized or diffuse (sclerosis not eccentric) Size: Fracture to complete lunate collapse + degenerative changes at carpus Morphology o Fracture - linear (transverse) or compression o Marrow involvement centralized to diffuse involvement of lunate
MR Findings TlWI o Hypointense transverse fracture line (stage I) o Centralized to diffuse marrow hypointensity (stage 11) o Intact shape of lunate in (stage 11) o Subtle collapse (stage 11) of lunate on radial border (coronal images) o Lunate collapse + proximal migration of capitate (stage 111) o Hypointense sclerosis + osteophyte formation (stage IV) T2WI o Stage I Marrow hyperintensity
mmm
Radiographic Findings
Radiography o Increased density of lunate (early) or normal o & Visualization of a fracture o Severe disease
DDx: Kienbock's Disease Acute Fracture
Cor FS PD MR
Cor T1 WI MR
Ax FS PD MR
KIENBOCK'S DISEASE Key Facts Imaging Findings Best diagnostic clue: Hypointense lunate on TlWI Size: Fracture to complete lunate collapse + degenerative changes at carpus Fracture - linear (transverse) or compression Marrow involvement centralized to diffuse involvement of lunate
Top Differential Diagnoses Carpal Instability Ulnar Impaction Syndrome Rheumatoid Arthritis Inflammatory Arthritis (Non-Rheumatoid)
Pathology Acute trauma Repeated minor trauma - 2" to excessive shear force Hypointense to hyperintense fracture (transverse) Microtrabecular compression fractures more common than well-defined transverse fracture Intermediate signal intensity synovitis o Stage I1 f Fracture lines usually hypointense if present Viable marrow hyperintense on FS PD FSE or STIR Use coronal & sagittal images to identify decreased height of radial aspect of lunate o Stage 111 Lunate collapse in coronal plane Anteroposterior elongation of lunate in sagittal plane Proximal migration of capitate on coronal images + Scapholunate (SL) dissociation with hyperintensity of SL ligament o Stage IV Hypointense sclerosis with areas of reactive marrow hyperintensity (degenerative) Loss of intermediate signal intensity articular cartilage in radiocarpal & midcarpal articulations T1 C+: Enhancement of viable marrow (use intravenous contrast with fat suppression)
Imaging Recommendations Best imaging tool o MR superior in early detection of stage I changes including identification of fracture & marrow edemalsclerosis o MR - also used to follow outcome of radial shortening for revascularization of lunate
IDIFFERENTIAL DIAGNOSIS Acute Lunate Fracture 1.1 to 6.5% of carpal fxs Unusual as most fxs associated with Kienbock's disease Volar pole fractures - most common Treatment - cast immobilization
Carpal Instability Scapholunate
Mechanism - interruption of blood supply to anatomically susceptible lunate Susceptible lunate = lunate with single nutrient vessel or compromised intraosseous blood supply
Clinical Issues Most common signs/symptoms: Dorsal tenderness about lunate Limited motion Diffuse swelling, localized synovitis Grip weakness Unilateral presentation (bilateral incidence low)
Diagnostic Checklist Sclerosis/marrow edema is typically central (not ulnar-sided or eccentric)
Lunotriquetral Midcarpal
Ulnar Impaction Syndrome Triangular fibrocartilage (TFC) tear Chondromalacia proximal ulnar lunate & triquetrum
Rheumatoid Arthritis Polyarticular & symmetric Wrist & hand joints Active synovitis Median nerve compression 2" to volar tenosynovitis Fibrous or bony ankylosis
Inflammatory Arthritis (Non-Rheumatoid) Systemic lupus erythematosus (SLE) Progressive systemic sclerosis Psoriatic arthritis Gout, pseudogout
1 PATHOLOGY General Features General path comments o Relevant anatomy 80% lunates - both palmar and dorsal nutrient vessels 20% lunates - single palmar vessel provides sole blood supply There are three patterns of intraosseous blood supply to the lunate: Y pattern (59%), I pattern (31%), X pattern (10%) Etiology o Acute trauma o Repeated minor trauma - 2" to excessive shear force o Mechanism - interruption of blood supply to anatomically susceptible lunate o Susceptible lunate = lunate with single nutrient vessel or compromised intraosseous blood supply o Risk factors Negative ulnar variance (ulnar minus) Susceptible lunate geometry (oblong or square) Vulnerable lunate vascularity
KIENBOCK'S DISEASE TFCC compliance (thicker TFCC in negative variance) Epidemiology: Incidence of 2.5% (stage I11 or IV disease)
Gross Pathologic & Surgical Features
0
1 DIAGNOSTIC CHECKLIST Sclerosis/marrow edema is typically central (not ulnar-sided or eccentric) More common pattern is without a defined transverse fx in early stages FS PD FSE or STIR to identify viable marrow
Microscopic Features
Staging, Grading or Classification Criteria
-5 2
Stahl's classification based on clinical and radiographic criteria Decoulx = modified Stahl's (presence of fracture not required in early stages) Lichtman o Stage I: Normal radiographs k fracture o Stage 11: Sclerosis without collapse o Stage 111: Fragmentation + collapse IIIA = no instability IIIB = instability o Stage IV: Perilunate arthritis MR classification based on Lichtman stage I1 o A: Focal central hypointense TI, hyperintense T2 o B: Focal central hypointense T1 & T2 o C: Generalized hypointense T1 & hyperintense T2 o D: Generalized hypointense T1 & T2
ISELECTED I. 2.
3. 4. 5. 6. 7.
8. 9.
Presentation Most common signs/symptoms: Dorsal tenderness about lunate Clinical profile 0 Limited motion 0 Diffuse swelling, localized synovitis o Grip weakness o Unilateral presentation (bilateral incidence low)
Demographics Age: 20 to 40 yrs. Gender: M:F = 2:l
Natural History & Prognosis Chronic wrist pain
* Associated flexor tendon or ligamentous tear
Arthrosis of radiocarpal or midcarpal joints after lunate collapse
Treatment Conservative o Immobilization to differentiate transient ischemia from Kienbock's disease Surgical o Revascularization o Radial wedge osteotomy o Scaphoid-trapezium-trapezoid or scaphocapitate fusion
1
Consider
Fracture Cystic changes Fragmentation & collapse Radiocarpal or midcarpal arthritis Venous stasis Necrosis of bone Inflammatory response
Salvage (proximal row carpectomy, arthrodesis)
10. 11. 12. 13. 14. 15. 16.
REFERENCES
1
Palmer AK et al: The wrist. Diagnosis and operative treatment. Lunate fractures: Kienbock's disease. vol 1. St. Louis Missouri, Mosby, (18):431-739, 1998 Alexander CE et al: The wrist and it's disorders. Kienbock's disease and idiopathic necrosis of carpal bones. 2nd ed. Philadelphia Pennsylvania, W.B. Saunders, (18):329-46, 1997 Golimbu CN et al: Avascular necrosis of carpal bones. Magn Reson Imaging Clin N Am 3:281-303,1995 Williams CS et al: Vascularity of the lunate. Hand Clin 9:391, 1993 Desser TS et al: Scaphoid fractures and Kienbock's disease of the lunate: MR imaging with histopathologic correlation. Magn Reson Imaging 8:357-61, 1995 Trumble TE et al: Histologic and magnetic resonance imaging correlations in Kienbock's disease. J Hand Surg 15:879-84, 1990 Sowa DT et al: Application of magnetic resonance imaging to ischemic necrosis of lunate. J Hand Surg 14A:lOOS-16, 1989 Amido PC et al: The genesis of Kienbock's disease: Evaluation of a case by magnetic resonance imaging. J Hand Surg Am 12:1044,1987 Kristensen SS et al: Ulnar variance in Kienbock's disease. J Hand Surg Br 11:258, 1986 Gelberman RH et al: ~ienbock'sdisease. Orthop Clin North Am 15:355-67, 1984 Kinnard P et al: Radial shortening for Kienbock's disease. Can J Surg 3:261-2, 1983 Morgan RF et al: Bilateral Kienbock's disease. J Hand Surg 8:928-32, 1983 Armistead RB et al: Ulnar lengthening in the treatment of Kienbock's disease. J Bone Joint Surg 6A:170-78, 1982 Eiken 0 et al: Radius shortening in malacia of the lunate. Scand J Plast Reconstr Surg 14:191-6, 1980 Gelberman RH et al: Ulnar variance in Kienbock's disease. J Bone Joint Surg 57A:674-6, 1975 Stahl F: On lunatomalacia (Kienbock's disease), a clinical and roentgenological study, especially on its pathogenesis and the late results of immobilization treatment. Acta Chir Scand 126:l-133, 1947
KIENBOCK'S DISEASE IMAGE GALLERY (Left) Coronal graphic shows transverse fracture of the lunate in stage I Kienbock's. (Right) Coronal T 1 WI MR shows transverse fracture (arrow) pattern with early lunate collapse. Kienb6ck1s disease may present either with a discrete fracturr or trabecular microfracture with diffuse marrow changes.
Tvpical (Left) Coronal T 1 WI MR shows hypointen5e marrow edema with marrow fat inhomogeneity in stage I Kienhock',. (Right) Sagittal graphic 5hows the three common patterns of lunate'i intraosseous vascular supply.
Tvpical (Left) Sagittal graphic shows the progressive stages of lunale collapse. (Right) Sagittal T l Wl MR shows elongation of the anteroposterior dimension of lunale collapse in stage 111 Kienhock's.
CARPAL TUNNEL SYNDROME
Coronal graphic shows inflammatory tenosynovitis of flexor tendons with compression of median nerve. Connective tissue degeneration is a more common cause of carpal tunnel syndrome.
Axial T2" CRE MR shows edema surrounding the flexor tendons with hyperintensity within an enlarged medial nerve (arrow).
MR Findings Abbreviations and Synonyms CTS
Definitions Clinical symptom complex secondary to compression of the median nerve at carpal tunnel
General Features Best diagnostic clue: Cross sectional enlargement & hyperintensity (FS PD FSE or STIR) of median nerve Location: Deep to flexor retinaculum (transverse carpal ligament) Size: Variable based on course of increased pressure on median nerve Morphology o Swelling or segmental enlargement of median nerve at level of pisiform o Flattening of median nerve at level of hamate
Radiographic Findings Radiography o Not diagnostic o Displaced capitate fracture o Visible deposits of amyloid
TlWI o Intermediate signal intensity in swelling or segmental enlargement of median nerve at level of pisiform Flattening of median nerve (level of hamate) Palmar bowing of hypointense flexor retinaculum at level of hamate Displaced proximal half of capitate fracture Impingement in perilunar dislocation Fracture of radius: Colles' or Smith's T2WI o Hyperintensity (diffuse or involving specific fascicles) of enlarged median nerve identified on axial cross section o FS PD FSE or STIR = improved sensitivity for nerve edema over non-fat suppression images o Incomplete release of flexor retinaculum associated with residual nerve hyperintensity o Pseudoneuroma - swelling of median nerve proximal to carpal tunnel o Hyperintense ganglions (e.g., triscaphe origin) which project deep to carpal tunnel ST compress canal o Intermediate to hyperintense thickening of tenosynovium of flexor tendons T1 C+: Enhancement of synovium Fibrosis of median nerve = hypointense on T1 & T2WI
ra
DDx: Carpal Tunnel Syndrome CMC Arthritis
1
- 5 Cor FS PD MR
Colles ' Fracture
30
NE
Instability
Cor Tl WI MR
CARPAL TUNNEL SYNDROME Key Facts Imaging Findings Best diagnostic clue: Cross sectional enlargement & hyperintensity (FS PD FSE or STIR) of median nerve Swelling or segmental enlargement of median nerve at level of pisiform Flattening of median nerve at level of hamate FS PD FSE or STIR = improved sensitivity for nerve edema over non-fat suppression images
Top Differential Diagnoses De Quervain's Tenosynovitis Carpometacarpal (CMC) Arthritis Fractures of the Distal Radius Carpal Instabilities
Pathology Idiopathic - most common (associated with aging)
Imaging Recommendations Best imaging tool: MR for nerve size, morphology & signal intensity and changes in carpal tunnel size or volume Protocol advice o T1 or PD + FS PD FSE or STIR axial, coronal & sagittal o Axial plane is essential o Intravenous contrast optional to enhance synovium
I DIFFERENTIAL DIAGNOSIS Cervical Radiculopathy Disc protrusion/extrusion Osteophytes Central canal or foramina1 stenosis C5-C6 commonly simulates symptoms
Colles' fracture Inflammatory processes Median nerve extrinsic median nerve ( s ~ a c e - O c c u ~ ~ i n g )
Clinical Issues Most common signs/symptoms: Numbness & tingling (median nerve distribution) Thumb, index, middle fingers + radial half of ring finger commonly affected Sensory findings minimal, hypesthesia to complete anesthesia Muscle atrophy & loss of function late findings
Diagnostic Checklist Thenar muscle hyperintensity (T2) in association with median nerve findings
Fractures of the Distal Radius Colles' fracture Median nerve involvement in 0.2 to 12% Laceration or contusion of nerve Comminuted fractures Melone type 111 (volar spike fragment) = greater incidence of median nerve involvement Edema and hematoma contribute to mass effect Callus or bony deformity
Carpal Instabilities Degenerative changes - hypertrophic bone Dorsal intercalated segment instability (DISI) o Lunate displaced toward proximal carpal canal o Scaphoid palmar flexes & contributes to decrease volume of carpal tunnel
Pronator Teres Syndrome Findings overlap with CTS
+ Signal changes in median nerve distribution on FS PD FSE or STIR
Thoracic Outlet Syndrome Findings overlap with CTS k Cervical rib, fibrous fascia1 bands - compression of
brachial plexus
De Quervain's Tenosynovitis Radial-sided wrist pain Inability to abduct thumb Swelling, crepitus & pain on radial side Affects abductor pollicis longus (APL) & extensor pollicis brevis (EPB)
Carpometacarpal (CMC) Arthritis Sclerosis between trapezium & proximal 1st metacarpal 1st CMC subluxation Stretch of opponens pollicis muscle mimicking atrophy
General Features General path comments o Relevant anatomy Flexor retinaculum = transverse carpal ligament (TCL) Proximal & distal margins of carpal tunnel = proximal & distal borders of flexor retinaculum TCL radial attachment: Scaphoid, trapezium & fascia of thenar muscles TCL ulnar attachment: Fascia proximal to pisiform + hook of hamate & distally to fascia of hypothenar muscles Etiology o Idiopathic - most common (associated with aging) o Colles' fracture Decreased volume of carpal tunnel or direct nerve trauma o Inflammatory processes Rheumatoid arthritis Gout & pseudogout Amyloid o Median nerve tumors
CARPAL TUNNEL SYNDROME Neurilemmomas (schwannomas) Fibromas Hamartomas o Tumors extrinsic to median nerve (space-occupying) Ganglion, lipoma & hemangioma Epidemiology o > 50% incidence during lifetime o Up to 100% incidence with repetitive motion activity rn
Gross Pathologic & Surgical Features
Demographics Age: Peak - 5th or 6th decade Gender: F > M
Natural History & Prognosis Progression of pain with paresthesias Numbness from intermittent to constant Thumb weakness with chronic compression
Treatment Conservative o Neutral position wrist splint o Avoid prolonged palmar flexion or extension activities o Steroid injections into carpal canal Surgical o History of increasing symptoms (years) + increase in distal sensory latency of median nerve (> 8.0 milliseconds) o Transverse carpal ligament release - open vs. endoscopic
Inflammation present in only 10% Edema present in 85% Vascular sclerosis in 98% Tenosynovitis: Uncommon Connective tissue degeneration: Common
Microscopic Features Increased pressure Impairment of intraneural microcirculation Ischemia correlates with symptoms Thin afferent nerve fibers most susceptible to pressure Fibrosynovial non-inflammatory synovium (response to chronic frictional/mechanical stresses)
Staging, Grading or Classification Criteria No widely used grading scheme Can be classified as mild, moderate, severe based on electrodiagnostic data (e.g., motor nerve conduction velocity) or by severity of clinical symptoms (sensory early, motor late)
Presentation Most common signs/symptoms: Numbness & tingling (median nerve distribution) Clinical profile o Thumb, index, middle fingers + radial half of ring finger commonly affected o Increased nocturnal pain % burning o Sensory findings minimal, hypesthesia to complete anesthesia o Muscle atrophy & loss of function late findings opponens weakness: Earlier finding Atrophy of opponens: Late finding o Abductor pollicis brevis muscle - early involvement o Positive Tinel's sign - paresthesias reproduced by tapping over nerve o Phalen's test: Symptoms in 30 seconds with wrist in forced palmar flexion o Carpal tunnel compression test - most accurate sign: ~ a n u acompression l with wrist in flexion o Sensory threshold tests Semmes-Weinstein monofilament test with wrist in both neutral & flexed positions Tests for early CTS o Electrodiagnostic tests of median nerve conduction rn Distal sensory latency rn Midpalmar latency Distal motor latency for advanced CTS Kimura inching technique & ring finger differential measurements for early CTS
Consider Thenar muscle hyperintensity (T2) in association with median nerve findings Partial to complete involvement of median nerve fascicles FS PD FSE, STIR or T1 C+ to enhance synovium
1.
Bland JD: Carpal tunnel syndrome. Br J Gen Pract 53(487):149-50,2003 2. Ruess L et al: Carpal tunnel syndrome and cubital tunnel syndrome: Work-related musculoskeletal disorders in four symptomatic radiologists. AJR 181(1):37-42, 2003 3. Beckenbaugh RD: The wrist. Diagnosis and operative treatment. Carpal tunnel syndrome. St. Louis Missouri, Mosby, (51):1197-1239, 1998 4. Relton H: The wrist and it's disorders. Nerve injuries associated with wrist trauma and entrapment. 2nd ed. Philadelphia Pennsylvania, W.B. Saunders, (27):473-86, 1997 5. Plancher KD et al: Compressive neuropathies and tendinopathies in the athlete elbow and wrist. Clin Sports Med 15:331-72, 1996 6. Ikeda K et al: Correlative MR-anatomic study of the median nerve. AJR 167:1233-36, 1996 7. Palmer DH et al: Endoscopic carpal tunnel release: A comparison of the two techniques with open release. Arthroscopy 9:498-508, 1993 8. Murphy RX et al: Magnetic resonance imaging in the evaluation of persistent carpal tunnel syndrome. J Hand Surg 18:113-20, 1993 9. Binkovitz LA et al: Masses of the hand and wrist: Detection and characterization with MR imaging. AJR 154:323-326, 1990 10. Mesgarzadeh M et al: Carpal tunnel: MR imaging I: Normal anatomy. Radiology 171:743-48, 1989
CARPAL TUNNEL SYNDROME -
-
1 IMAGE GALLERY Typical (Left) Axial FS PD FSE MR shows carpal tunnel hyperintensity with discrete focus of median nerve edema (arrow). (Right) Axial FS PD FSE MR shows hyperintense volar ganglion (arrow) compressing the deep surface of the carpal tunnel in a patient with clinical carpal tunnel syndrome.
(Left) Axial T l Wl MR shows accessory superficialis muscle resulting in median nerve compression. (Right) Coronal graphic shows anomalous muscle belly of the flexor digitorum superficialis diminishing the carpal tunnel volume.
Typical
(Left) Axial STIR MR shows benign peripheral nerve sheath tumor with hyperintensity of the median nerve (arrow) and subtle hyperintense changes of thenar muscle denervation. (Right) Coronal graphic shows edematous median nerve in carpal tunnel syndrome. Impairment of intraneural microcirculation leads to nerve ischemia.
ULNAR TUNNEL SYNDROME
Coronal graphic shows potential sites of ulnar nerve involvement. Yellow represents sensory fibers, brown represents motor branch, and mixed yellow-brown represents both.
Axial T l Wl MR shows normal division of the ulnar nerve into one motor (arrow) branch (deep) and two sensory (open arrows) branches (superficial) between the pisiform and ulnar artery.
MR Findings Abbreviations and Synonyms Ulnar neuropathy, Guyon's canal syndrome
Definitions Numbness & tingling 5th (little) finger + ulnar side 4th (ring) finger palmar surface from irritation of ulnar nerve in Guyon's canal
(IMAGING FINDINGS General Features Best diagnostic clue: Compression of ulnar nerve in Guyon's canal Location: Guyon's canal Size: Variable, usually < 1 cm length of involvement Morphology: Round to ovoid mass
Radiographic Findings Radiography o Hamate hook fx Impingement on ulnar nerve o Intercarpal arthritis k spurring o Joint space narrowing k soft tissue calcifications
CT Findings
TlWI o Diffuse swelling (intermediate signal) o Enlargement of ulnar nerve T2WI o Hyperintense signal within ulnar nerve best demonstrated on axial FS PD FSE or STIR o May identify mass (usually with hyperintense signal) Ganglion cyst Aneurysm Fracture Anomalous muscle T2* GRE: Helpful to visualize increased neural edema
Imaging Recommendations Best imaging tool: MR identifies ulnar nerve edema, ganglion cyst formation & other compressive etiologies Protocol advice: TlIPD & FS PD FSE axial, coronal & sagittal images
I DIFFERENTIAL DIAGNOSIS Carpal Tunnel Syndrome Compressive neuropathy Infrequent in athletic population
NECT: Sensitive to identifying fx fragment
1
DDx: Ulnar Tunnel Syndrome Carpal Tunnel
Cubital Tunnel
Hamate Fracture
Ax FS PD MR
Cor T I Arthro.
Ax T l W l MR
-
ULNAR TUNNEL SYNDROME Key Facts
Findings ' Imaging Best diagnostic clue: Compression of ulnar nerve in Guyon's canal Enlargement of ulnar nerve Hyperintense signal within ulnar nerve best demonstrated on axial FS PD FSE or STIR
Top Differential Diagnoses Carpal Tunnel Syndrome Cubital Tunnel Syndrome Cervical Radiculopathy/Thoracic Outlet Syndrome Hamate Fracture
Pathology Soft tissue tumors Ganglion cysts Ulnar artery thrombosis or aneurysm Median nerve compression in osteofibrous canal (transverse carpal ligament & carpal bones) Result of direct trauma, repetitive use or anatomic anomalies
Cubital Tunnel Syndrome Weakness of wrist flexors Weakness flexors 4th & 5th digits Ulnar neuropathy at wrist produces a sensory deficit of the 5th digit and ulnar half of 4th digit With compression at the elbow (high ulnar lesion) get additional sensory deficit of dorsal ulnar hand Electromyogram (EMG) may be needed to distinguish ulnar neuropathy at elbow vs. wrist
Cervical Radiculopathy/Thoracic Outlet Syndrome Disc protrusion/extrusion Osteophytes Central canal or foramina1 stenosis Compression of brachial plexus by cervical rib, fascia1 slip, clavicle fx
Hamate Fracture Hook, body, proximal pole Soreness in palm k Ulnar nerve palsy Ulnar sided pain + tenderness Bat, hockey stick, golf club or racquet sports related
General Features General path comments o Relevant anatomy Guyon's canal = tunnel formed by pisiform and hamate bones Ulnar nerve passes deep to palmar carpal ligament and superficial to flexor retinaculum Ulnar nerve divides into superficial and deep branches
Carpal fractures - hook of hamate most common
Clinical Issues Most common signs/symptoms: Paresthesias followed by decreased sensation at 4th & 5th fingers Hand weakness may develop Sensory and/or motor changes may be present based on pressure point Positive Tinel's sign over ulnar nerve Positive Phalen's test with paresthesias in 4th & 5th fingers
Diagnostic Checklist
Axial FS PD FSE to visualize ulnar nerve edema
Deep ulnar nerve = motor to hypothenar, interosseous, 3rd & 4th lumbricales & adductor pollicis muscles Superficial ulnar nerve = sensory to skin of hypothenar eminence + 4th & 5th digits & motor function to palmaris brevis Etiology o Soft tissue tumors o Ganglion cysts o Scar tissue o Ulnar artery thrombosis or aneurysm Chronic repetitive trauma (hypothenar hammer syndrome) o Carpal fractures - hook of hamate most common o Synovitis o Anomalous muscle belly o Arthritic changes Epidemiology o Less common than median nerve compression o Less common than ulnar nerve entrapment at elbow o Cyclists at risk from intermittent impaction o Golfers and baseball players at risk o Repetitive flexion/extension of wrist o Vibrating hand tools against hypothenar eminence
Gross Pathologic & Surgical Features Compression of ulnar nerve o Entrance to ulnar tunnel o Superficial branch (sensory) o Deep branch (motor) Hamate fx Distal radius fx Anomalous muscle Lipoma Ganglion Ulnar artery aneurysm or thrombosis Compression at level of elbow rarely associated with median nerve findings of fixed motor deficits in the hand Martin Gruber anastomosis (15% of population) o Anomalous motor & sensory findings o Ulnar-to-median anastomosis Riche-Cannieu anastomosis
ULNAR TUNNEL SYNDROME o Deep branch of ulnar nerve & median nerve in the
hand
Microscopic Features Increased pressure Impairment of intraneural microcirculation Ischemia
Staging, Grading or Classification Criteria
~,n
Three distinct zones within Guyon's canal o Zone 1 = proximal to bifurcation of deep (motor) branch and superficial (sensor) branch Compression produces motor and sensory deficits Commonly caused by ganglion cysts or hamate hook fx o Zone 2 = deep branch producing motor deficit Often caused by ganglion cyst or fx hook hamate o Zone 3 = superficial branch producing sensory deficit Related to ulnar artery aneurysm or thrombosis
Surgical o Mass in ulnar tunnel must be treated surgically Resection of cysts, scar tissue results in improved sensation + decreased symptoms o Resection ligament that forms roof of Guyon's canal (palmar carpal ligament) to relieve pressure Complications o ~ e i v regrowth e may be associated with pain May last > 6 weeks and require additional medication, massage, therapy o Resection of ligament forming roof of Guyon's canal causes scar tissue formation and may result in recurring symptoms
1 DIAGNOSTIC CHECKLIST Consider Eliminate injuries to forearm and upper neck ("double crush" injuries) when evaluating injuries to nerves of the handlwrist Axial FS PD FSE to visualize ulnar nerve edema
Presentation Most common signslsymptoms: Paresthesias followed by decreased sensation at 4th & 5th fingers Clinical profile o Hand weakness may develop o Symptoms develop gradually Leads to difficulty opening jars, holding objects, coordinating fingers while typinglplaying musical instruments o Sensory andlor motor changes may be present based on pressure point o Positive Tinel's sign over ulnar nerve o Positive Phalen's test with paresthesias in 4th & 5th fingers o EMG's (+ positive) Denervation potentials in interosseous muscle Motor nerve latency prolongation to 1st dorsal interossei o Compression at or proximal to origin of dorsal sensory branch ulnar nerve in distal third of forearm Sensory deficit of dorsoulnar aspect of hand o Compression at elbow Median nerve involvement possible Fixed motor deficits Ulnar clawhand (unopposed extensor digitorum communis & flexor digitorum profundus)
Demographics Age: Young to middle age adult in sports injuries Gender: No predilection
Natural History & Prognosis Recovery several months to years o Longer for older patients o With severe compression recovery may be incomplete
Treatment Conservative o Wrist splint o Anti-inflammatory medications
Miller MD et al: Surgical atlas of sports medicine. Treatment of ~ u y a n ' scanal syndrome (ulnar nerve compression at the wrist). Philadelphia Pennsylvania, Saunders, (66):477-89,2003 McCue FC 111 et al: DeLee & Drez's orthopaedic sports medicine. The wrist in the adult. Philadelphia Pennsylvania, Saunders, (24):1337-63, 2003 Konig PSA et al: Variations of the ulnar nerve and ulnar artery in Guyon's canal: A cadaveric study. J Hand Surg 19:617, 1994 Beltran J et al: Diagnosis of compressive and entrapment neuropathies of the upper extremity. Value of MR imaging. AJR 163525, 1994 Zeiss J et al: The ulnar tunnel at the wrist (Guyon's canal): Normal MR anatomy and variants. AJR 158:1081, 1992 Gross MS et al: The anatomy of the distal ulnar tunnel. Clin Orthop 196238-47, 1985 Stern PJ et al: Compression of the deep branch of the ulnar nerve. A case report. J Hand Surg 8:72-4, 1983 Shea JD et al: Ulnar nerve compression syndromes at and below the wrists. J Bone Joint Surg 51:1095-1103, 1969 Thompson WAL et al: Peripheral entrapment neuropathies of the upper extremities. N Eng J Med 260:1261, 1959 Grundberg AB: Ulnar tunnel syndrome. Hand 9:72, 1934
ULNAR TUNNEL SYNDROME IMAGE GALLERY (Left) Coronal graphic shows edema of the motor branch of the ulnar nerve. (Right) Coronal graphic shows ulnar artery aneurysm with compression of the ulnar nerve.
( L 4 ) Axial graphic shows extrinsic compression of the ulnar tunnel secondary to a palmar lipoma. The ischemic ulnar nerve is located between the hook of the hamate and the lipoma. (Right) Axial T 1 WI M R shows lipomatous mass (arrow) occupying the ulnar tunnel.
(IRft) Axial graphic shows ganglion as a space occupying lesion within the ulnar tunnel. (Right) Axial T l Wl M R shows hemorrhagic soft tissue mass superficial to the hook of the hamate with secondary compression of the ulnar nerve.
DEGENERATIVE ARTHRITIS, WRIST
Coronal graphic shows stage Ill SLAC with arthrosis of the radioscaphoid and capitolunate articulations.
-
Coronal FS PD FSE MR shows widening of the scapholunate interval and proximal migration of the capitate in SLAC arthritis.
o Rotatory subluxation progression 0 SLAC = radioscaphoid narrowing & proximal
migration of capitate
Abbreviations and Synonyms SLAC wrist, scapholunate advanced collapse, triscaphe arthritis
Definitions Carpal degeneration involving scaphoid occurring in three separate patterns
General Features Best diagnostic clue: Scaphoradial joint space narrowing in SLAC & sclerosis of triscaphe articulation Location o SLAC Scaphoradial (SR) Capitolunate (CL) Scaphocapitate (SC) o Triscaphe Scaphotrapezial Scaphotrapezoidal Trapeziotrapezoidal Size: SLAC - from isolated scaphoradial articulation to SR, CL, SC & hamate-lunate involvement Morphology
. .
o Narrowing of triscaphe articulations
Radiographic Findings Radiography o SLAC SR, CL, SC narrowing + sclerosis Foreshortening of scaphoid Scapholunate gap Scaphoid ring sign (anteroposterior view) Dorsal intercalated segment instability (DISI) on lateral view Degenerative changes between radius & distal scaphoid fragment in non-union of scaphoid o Triscaphe arthritis Sclerosis & narrowing between scaphoid, trapezium & trapezoid
. .. . .
MR Findings TlWI o SLAC Hypointense sclerosis, narrowing with chondral loss between radial styloid & scaphoid articulation Narrowing + hypointense sclerosis involving entire radioscaphoid articulation Hypointense sclerosis + narrowing capitolunate joint
. .
DDx: Degenerative Arthritis, Wrist Sf Inst~bility
Ax T 1 Arthro.
Scaphoid Fracture
Cor T l Wl MR
Sag FS PD MR
-
-
DEGENERATIVE ARTHRITIS, WRIST
SLAC also caused by abnormal articular loading in scaphoid fx, non-union, Kienbock's & carpal fxs o Triscaphe arthrosis Load changes and articular pathology analogous to SLAC wrist Disruption in ligamentous support of scaphoid distally Epidemiology o Degenerative arthrosis in 5% of wrists o SLAC wrist = most common pattern comprising 55% of degenerative arthritis of wrist o Triscaphe arthritis = 20% degenerative wrist arthritis o Both SLAC wrist + triscaphe arthritis = 10% of wrist degenerative arthritis rn
Presentation Most common signs/symptoms: Wrist pain with activity Clinical profile o Decreased grip strength in SLAC o Stiffness with dorsiflexion & radial deviation o Asymptomatic subgroup = older patients o Localized tenderness o STT arthritis associated with carpal tunnel syndrome, radiopalmar ganglion & de Quervain's
Demographics Age o Middle-aged for symptomatic patients o Older age group for asymptomatic patients Gender: M > F
Gross Pathologic & Surgical Features -
5 64
SLAC stage I o Arthrosis limited to radial styloid - scaphoid articulation SLAC stage I1 o Arthrosis of the entire radioscaphoid articulation SLAC stage I11 o Capitolunate arthrosis Additional destruction of scaphocapitate articulation with capitate impingement (proximal migration on radius) f Secondary hamate-lunate joint narrowing Triscaphe o Scaphotrapezial involvement twice as common as isolated scaphotrapezoidal o Trapezium & trapezoid migrate proximally Ulnolunate & lunotriquetral arthritis related to ulnocarpal impaction syndrome
Microscopic Features
Natural History & Prognosis Progression of post-traumatic arthritis with degenerative arthritis & ligament attenuation
Treatment Conservative o Immobilization o Anti-inflammatory medications Surgical o SLAC wrist reconstruction o Triscaphe arthrodesis
1 DIAGNOSTIC CHECKLIST Consider SLAC changes identified early by observing radial styloid sclerosis SLAC & triscaphe arthritis may coexist
Weakening of ligamentous collagen fibers, connective tissue & elastic fibers Trabecular stress loading with sclerosis Chondral & subchondral degeneration (fibrillation, fraying, erosions)
Staging, Grading or Classification Criteria SLAC arthritis involvement o Stage I: Distal radius (radial-styloid)& distal radial aspect of scaphoid o Stage IIa: Entire radioscaphoid joint o Stage IIb: Radioscaphoid & secondary involvement SlT joint o Stage 111: Periscaphoid arthritis with radioscaphoid & capitolunate joints Scaphotrapeziotrapezoid (STT) arthritis o Involvement in either stage I, I1 or I11 SLAC Scaphoid non-union advanced collapse arthritis o Stage I: Distal scaphoid & radial styloid o Stage 11: Addition of scaphocapitate with capitolunate preservation o Stage 111: Periscaphoid arthritis with radiostyloid distal scaphoid, scaphocapitate, & capitolunate (proximal scaphoid & lunate preserved)
I
1.
2. 3. 4. 5. 6.
I
Sauerbier M et al: Midcarpal arthrodesis with complete scaphoid excision an interposition bone graft in the treatment of advanced carpal collapse. (SNACISLAC wrist): Operative technique and outcome assessment. J Hand Surg 25(4):341-5, 2000 Schweitzer AF et al: Frequency and spectrum of abnormalities in the bone marrow of the wrist: MR imaging findings. Skeletal Radio1 28(6):312-7, 1999 Cooney WP: The wrist. Diagnosis and operative treatment. Post-traumatic arthritis of the wrist. St. Louis MO, Mosby, (25):588-631, 1998 Watson HK et al: The wrist and it's disorders. Degenerative disorder of the carpus. 2nd ed. Philadelphia Pennsylvania, WB Saunders, (32):583-91, 1997 Krakauer JD et al: Surgical treatment of scapholunate advanced collapse. J Hand Surg 19(5):751-9,1994 Fassler PR: Asymptomatic SLAC wrist: Does it exist? J Hand Surg 18(4):682-6, 1993
DEGENERATIVE ARTHRITIS, WRIST IMAGE GALLERY Typical (Left) Coronal graphic shows stage I SLAC with arthrosis limited to the radial styloid-scaphoid articulation. The entire radioscaphoid articulation is involved in the progression to stage I1 SLAC. (Right) Coronal T l Wl MR shows SLAC with scaphoid non-union (scaphoid non-union advanced collapsei. Sclerosis (arrow) is shown in AVN of proximal pole of the scaphoid. Radial styloid-scaphoid arthritis is present.
Typical (Leji) Sagittal graphic shows normal radioscaphoid congruous joint surfaces. (Right) Sagittal graphic shows rotational instability secondary to rotatory subluxation ofscaphoid with abnormal load transfer to the volar and dorsal margins of distal radius.
(Left) Coronal graphic shows triscaphe arthritis with degeneration of the scaphotrapeziotrapezoid articulation. (Right) Coronal T 1 C+ MR (MR arthrogram) shows hypointense sclerosis with loss of articular cartilage in the triscaphe joint.
HAMATO-LUNATE IMPINGEMENT
Coronal graphic shows type I1 lunate or medial lunate facet with subchondral erosion of proximal pole of hamate and accessory lunate facet.
Coronal TI C+ MR (MR arthrogram) shows early chondral erosions (arrow) between the medial lunate facet and the proximal pole of hamate.
CT Findings Abbreviations and Synonyms ?Lpe I1 lunate, chondromalacia of the hamate, medial lunate facet; hamate facet
Definitions Degenerative arthritis between a type I1 lunate with an extra facet and proximal hamate, a type I lunate has no extra or medial facet
I IMAGING FINDINGS General Features Best diagnostic clue: Chondral erosions between the medial lunate facet & proximal pole of the hamate Location: Between accessory lunate facet (medial) & proximal pole hamate Size: Accessory facet - 1to 6 mm Morphology: Blunted to convex
Radiographic Findings Radiography o Difficult to visualize a small medial lunate facet (radiography is inaccurate) Sclerosis proximal pole hamate Demonstrates advanced changes
NECT o Bone technique o 1mm sections + reformations or direct coronal plane o Excellent bone detail (edge) o Poor articular cartilage visualization o Subchondral trabecular sclerosis
MR Findings TlWI o Extra medial lunate facet o Subchondral sclerosis proximal hamate or medial lunate facet = advanced finding o k Associated capitolunate arthrosis o Hypointense subchondral edema of hamate = uncommon finding o Narrowing of hamate-lunate joint space T2WI o Inhomogeneity of intermediate intensity chondral surfaces of medial lunate facet & proximal hamate o Surface fibrillation, fraying or full thickness chondral defects o Four corner arthritis = chondral degeneration proximal hamate, proximal capitate, radial distal triquetrum & medial lunate facet o Hyperintense hamate or lunate marrow edema = unusual finding
DDx: Hamato-Lunate Impingement Hamate Fracture
Klenbock's
Capitate Fracture
AX ~1 WI MR
Cor ~1 WI MR
Cor ~1 WI MR
rn Triquerral Fx
Cor ~1 WI MR
HAMATO-LUNATE IMPINGEMENT Key Facts Imaging Findings Best diagnostic clue: Chondral erosions between the medial lunate facet & proximal pole of the hamate Extra medial lunate facet Narrowing of hamate-lunate joint space Surface fibrillation, fraying or full thickness chondral defects
Top Differential Diagnoses Hamate Fracture Kienbock's Disease Capitate Fracture Lunotriquetral Ligament Tear Triquetral Fracture
Pathology a
Type 11 lunate = alteration of normal uniform loading o
+ Small subchondral cystic changes proximal pole
hamate (intermediate to hyperintense) o Subchondral bone loss proximal pole hamate & medial lunate facet o k Association with lunotriquetral (LT) ligament tears
lmaging Recommendations Best imaging tool: MR to detect size, apposition & early chondral degeneration Protocol advice: TI (for sclerosis detection), FS PD FSE coronal, sagittal & axial images
IDIFFERENTIAL DIAGNOSIS Hamate Fracture Body or hook Hook fractures - most common Falls, direct trauma, use of a racquet or club Pain distal to pisiform, painful grip & pain over hook
Kienbock's Disease Avascular necrosis lunate Related to trauma & ulnar negative variance Dorsal tenderness lunate Synovitis
Capitate Fracture Direct trauma to dorsum wrist Dorsiflexion in neutral or ulnar deviation Dorsiflexion in radial deviation At risk for avascular necrosis & non-union of proximal pole in proximal fxs
Lunotriquetral Ligament Tear Dissociation between triquetrum & lunate Volar flexion lunate Flap morphology or absence of normal delta-shaped or linear ligament Volar intercalated segment instability
Triquetral Fracture Dorsal aspect - small fractures Hyperextension injury
Altered biomechanics leads to chondromalacia Increased pressure at lunate fossa in wrist extension & ulnar deviation Full ulnar deviation: Hamate & lunate impinge at articulation Chondromalacia secondary to impingement & abrasion of hamate & lunate
Clinical Issues
Most common signs/symptoms: Ulnar-sided wrist pain Pain on radial & ulnar deviation of wrist Forced ulnar deviation intensifies pain LT instability
Diagnostic Checklist FS PD FSE
erOsiOris
Secondary to ulnar styloid impingement on dorsal proximal aspect of bone Shear pattern of fx 2" to impingement Forced dorsiflexion & ulnar deviation Body fractures o & Displaced & associated with perilunate dislocations, crush trauma o Volar intercalated segment instability (VISI)
PATHOLOGY General Features General path comments o Relevant anatomy of lunate Between scaphoid radially & triquetrum medially (ulnarly) Deep concave distal surface = articulation with head of capitate Convex proximally with lunate facet of distal radius & triangular fibrocartilage Medially = large flattened facet for articulation with triquetrum Medial lunate facet seen in type 11 lunate for articulation with hamate Radially - flattened facet for articulation with proximal (medial) end of scaphoid Distal articular surface narrower than proximal (lunate = wedge-shaped) Lunate narrower dorsally Articular cartilage covers most of lunate Articulation with radius, capitate, hamate, scaphoid & triquetrum o Relevant anatomy of hamate Most medial bone in distal row Proximal surface = narrow, convex & smooth for lunate articulation Distal surface articulates with forth & fifth metacarpals via two facets Dorsal surface = triangular Palmar surface = hook Lateral surface = concavity of body & hook Ulnar surface articulates with triquetrum
HAMATO-LUNATE IMPINGEMENT Spiral orientation of triquetrohamate joint facilitates motion between proximal and distal carpal rows Etiology o Type I1 lunate = alteration of normal uniform loading o Altered biomechanics leads to chondromalacia o Increased pressure at lunate fossa in wrist extension & ulnar deviation o Full ulnar deviation: Hamate & lunate impinge at articulation o Chondromalacia secondary to impingement & abrasion of hamate & lunate Epidemiology: Prevalence of type I1 lunates = 57%
Gross Pathologic & Surgical Features Cartilage erosion Exposed bone Chondromalacia in medial lunate facet & proximal pole hamate LT ligament disruption Scapholunate dissociation less common than LT ligament disruption Facet size 10-50% of distal aspect lunate
Microscopic Features Cartilage edema Fragmentation & fibrillation Cartilage denudation ~~novitis Marrow edema Microhemorrhage Microfracture Hyperemia Cellular infiltration Fibrovascular tissue proliferation Subchondral cysts o Fluid o Myxoid o Fibrous o Cartilaginous Cartilage repair o Chondrocyte hypertrophy & increased.nuclei o Irregular
Staging, Grading or Classification Criteria Type I lunate = conventional morphology (no lunate facet) Type I1 lunate = medial or hamate facet of lunate present
Presentation Most common signs/symptoms: Ulnar-sided wrist pain Clinical profile o Pain on radial & ulnar deviation of wrist o Ulnar-sided tenderness o Forced ulnar deviation intensifies pain o LT instability o Bilateral & symmetric o Ranges from asymptomatic to focally tender over proximal pole hamate
Demographics Age: Hamato-lunate impingement most common between 30 and 60 years (2" to medial lunate facet) Gender: M = F
Natural History & Prognosis Slow progression Good response to resection of head of the hamate
Treatment Conservative o Rest, activity modification o Anti-inflammatory medications Surgical o Resection of head of hamate for hamato-lunate impingement o Open vs. arthroscopic procedure o Relief of symptoms typical
Consider FS PD FSE to identify early cartilage erosions Medial lunate facet may be prominent with concave surface or small flattened corner
1 SELECTEDREFERENCES Thurston AJ et al: Hamato-lunate impingement: An uncommon cause of ulnar-sided wrist pain. Arthro Assn N Am 540-4, 2000 Malik AM et al: MR imaging of the type I1 lunate bone: Frequency, extent, and associated findings. AJR 335-8, 1999 Sagerman SD et al: Lunate morphology: Can it be predicted with routine X-ray films? J Hand Surg 20k38-41, 1995 Green DP: Operative hand surgery. Carpal dislocations and instabilities. 3rd ed. New York NY, Churchill Livingstone, 1993 Viegas SF et al: The medial (hamate) facet of the lunate. J Hand Surg 15A:564-71, 1990 Burgess RC: Anatomic variations of the midcarpal joint. J Hand Surg 15A:129-31, 1990 Viegas SF: The lunato-hamate articulation of the midcarpal joint. Arthroscopy 6:s-10, 1990 Cantor RM et al: Diagnosis of dorsal and palmar rotation of the lunate on a frontal radiograph. J Hand Surg 13A:1897-93, 1989 Gilula La: Carpal injuries. Analytic approach and case exercises. AJR 133:503-17, 1979 Warwick R et al: Gray's anatomy, 35th Br ed. Philadelphia PA, WB Saunders 336-41,1973
HAMATO-LUNATE IMPINGEMENT
I IMAGE GALLERY
RHEUMATOID ARTHRITIS, WRIST AND HAND
Coronal graphic shows ulnar deviation of the metacarpal phalangeal joints, proximal migration of the capitate, SL dissociation with ulnar and carpal erosions.
Coronal TlWl MR shows multiple carpal erosions with distal ulnar erosive changes and TFC destruction. Pannus tissue is intermediate in signal intensity.
o Negative in early stages of disease
Abbreviations and Synonyms RA, chronic polyarthritis
Definitions Systemic autoimmune inflammatory disorder of unknown etiology, primarily affecting synovial membranes and articular surfaces
I IMAGING
FINDINGS
General Features Best diagnostic clue: Inflammatory synovial/pannus tissue Location o Distal radioulnar joint o Ulnar & radial styloid o Scaphoid, triquetrum, pisiform o Radiocarpal, midcarpal, carpometacarpal o Metacarpal phalangeal, proximal interphalangeal Size: Variable from localized synovitis to involvement of the entire carpus (pancompartmental) Morphology: Erosions, joint space narrowing, soft tissue swelling & ulnar translocation
Radiographic Findings
o Soft tissue swelling visible - early stages o First radiographic evidence of disease - ulnar styloid
tip erosion o Erosions are common at distal radius & ulna o Triquetrum and pisiform - in early stages o Marginal erosion at radial aspect trapezium common o Juxta-articular osteopenia o Pan-carpal progressive chondral loss
Gradual joint space narrowing Joint obliteration o Bony ankylosis - most common in midcarpal compartment in late stages o Zig-zag deformity - radial deviation at radiocarpal joint & ulnar deviation at MCP joints o Dorsal subluxation of ulna - common finding
CT Findings NECT o Sensitive for early subchondral erosions o Hypodense joint effusion o Joint space narrowing o Insensitive for early chondral loss o Superimposed osteoarthritic change visualized sclerosis, osteophytosis o Bony ankylosis - late complication CECT Pannus demonstrates vigorous enhancement
Radiography
I
DDx: Rheumatoid Arthritis, Wrist and Hand
I
RHEUMATOID ARTHRITIS, WRlST AND HAND Key Facts Imaging Findings Best diagnostic clue: Inflammatory synoviallpannus tissue Morphology: Erosions, joint space narrowing, soft tissue swelling & ulnar translocation
Top Differential Diagnoses Osteoarthritis Autoimmune Chronic Polyarthritis Psoriatic Arthritis Infectious Arthritis Juvenile Chronic Arthritis Crystal Deposition Disease Reflex Sympathic Dystrophy (Sudeck's)
MR Findings TlWI o Hypointense subchondral sclerosis o Early erosions can be easily seen with reactive hypointense marrow edema o Early joint effusions - hypointense o Hypointense debris o Hypertrophied synovium o Tenosynovitis - hypointense T2WI o Hyperintense marrow edema visualized o Early joint effusions - hyperintense o Tenosynovitis - hyperintense o Partial tendon tears - hyperintense o Intermediate to hyperintense pannus T1 C+: Pannus will vigorously enhance
Ultrasonographic Findings Sonography o Hypoechoic joint effusion = common finding o Synovitis/precipitated fibrin - tiny floating hyperechoic foci = common finding o Thickened hypoechoic synovium (normal synovium not visualized by sonography) o Pannus - hypoechoic synovial masses o Tenosynovitis - hyperechoic o Tendon rupture - can be directly visualized 0 Synovial cysts - hypoechoic o Rheumatoid nodules - homogeneous hypoechoic masses
Nuclear Medicine Findings Skeletal scintigraphy o Limited due to lack of specificity o Increased nonspecific radiotracer accumulation in joint-centered distribution o Bilateral, symmetrical o May reveal extent of disease
Imaging Recommendations Best imaging tool: MR for synovium, articular cartilage & marrow Protocol advice
Pathology Characterized by bilateral, symmetrical joint involvement Characteristically involves carpal joints, MCP joints, PIP joints Hyperplasia of synovial cells
Clinical Issues Most common signslsymptoms: Insidious onset typical Joint swelling Bilateral involvement
Diagnostic Checklist 30% patients are rheumatoid factor negative
0
TI, FS PD FSE coronal, axial & sagittal
o TIC+ with fat suppression for pannus
I DIFFERENTIAL DIAGNOSIS Osteoarthritis Scapholunate advanced collapse pattern (SLAC wrist) Triscaphe arthritis Combination of SLAC wrist & triscaphe arthritis
Autoimmune Chronic Polyarthritis Scleroderma (soft tissue calcification + tuft resorption) Systemic lupus erythematosus (no erosions) Dermatomyositis (intermuscular calcification)
Psoriatic Arthritis 2% of patients with psoriasis Polyarthritis with distal interphalangeal involvement Asymmetric oligoarthritis Arthritis mutilans
Infectious Arthritis Synovitis, soft tissue swelling, and effusion Juxta-articular osteoporosis
JuvenileChronic Arthritis Effusion Metacarpophalangeal & interphalangeal joints Contracted tendons Capsular laxity
Crystal Deposition Disease Calcium pyrophosphate dihydrate crystal deposition disease (CPPD) Inflammatory arthritis Joint space loss (uniform) SLAC wrist
Reflex Sympathic Dystrophy (Sudeck's) Response to trauma Pain, vasomotor disturbance, decreased function & trophic changes Inhomogeneous marrow - patchy on FS PD FSE
RHEUMATOID ARTHRITIS, WRIST AND HAND
..
1 PATHOLOGY
Malaise Weakness Weight loss Myalgias Fever of unknown origin o Physical exam Joint swelling Bilateral involvement Erythema Pain with active/passive range of motion Tenderness to palpation Joint malalignment Neuropathy in mediantulnar nerve distribution
General Features General path comments o Relevant anatomy Synovium Etiology: Unknown etiology Epidemiology o RA incidence = 1% of population o Serum antinuclear antibodies (ANA) found in approximately 30% of patients
.. . .
Gross Pathologic & Surgical Features
72
Characterized by bilateral, symmetrical joint involvement Characteristically involves carpal joints, MCP joints, PIP joints Pannus: Synovial mass which results in marginal erosions at junction of articular cartilage & bare area of bone Chronic synovial-based inflammation can permanently damage tendons Chronic synovitislinflammation may lead to capsular & ligamentous laxity Chronic synovitis leads to destruction of TFCC Tenosynovitis/swellingmay lead to compression of median or ulnar nerves resulting in neuropathies Caput ulnar syndrome o Synovitis results in stretching of ulnar carpal ligaments o Pain, decreased range of motion, dorsal subluxation of ulna o Subluxed ulna may contact extensor tendons resulting in attrition & tearing
Demographics Age o 25-60 years most common o 40-60 years - peak incidence Gender: F:M = 3:l
Natural History & Prognosis Typically patients have slowly progressive disease with intermittent "flare-ups" Slowly, progressive joint destruction is typical Complications o Joint effusions -- capsular distention -- pain o Large synovial cysts o Tendinous tearsldisruptions o Cartilaginous & bony destruction o Median and ulnar nerve neuropathies
Treatment Conservative o Decrease inflammation delay joint effusion preserve function o Pharmacotherapy o Physical therapy Surgical o Synovectomy & tenosynovectomy o Tendon ruptures Attachment to adjoining tendon preferable to segmental grafting o Arthroplasty or arthrodesis
-
Microscopic Features Extensive synovial inflammation o Hyperplasia of synovial cells o Lymphocytes & plasma cells infiltrate synovial membrane o Fibrinous exudates Rheumatoid factor o Serum IgM antibody found in approximately 70% of patients o Directed against Fc fragment of IgG o High titers of RH factors are associated with severe disease
-
Consider 30% patients are rheumatoid factor negative
Presentation Most common signs/symptoms: Insidious onset typical Clinical profile o 4 of 7 criteria must be met for diagnosis Morning stiffness lasting more than 1 hour Arthritis of 3 or more joints Arthritis of hand joints Symmetric arthritis Positive serum rheumatoid factor Rheumatoid nodules Radiographic changes o Other common signs/symptoms
. .
1 SELECTEDREFERENCES 1. 2. 3. 4. 5.
Nakahara N et al: Gadolinium-enhanced MR imaging of the wrist in rheumatoid arthritis: Value of fat suppression pulse sequences. Skeletal Radio1 25:639, 1996 Adolfsson L et al: Arthroscopic synovectomy of the rheumatoid wrist. J Hand Surg 18B:92-6, 1993 Taleisnik J: Rheumatoid arthritis of the wrist. Hand Clin 5:257-78, 1989 Ertel AN et al: Flexor tendon ruptures in patients with rheumatoid arthritis. J Hand Surg 13A:860-6, 1988 Abernathy PJ et al: Decompression of the extensor tendons at the wrist in rheumatoid arthritis. J Bone Joint Surg 61B:64, 1979
I
RHEUMATOID ARTHRITIS, WRIST AND HAND
(Left) Coronal FS PD FSE MR shows dorsal pannus tissue with intermediate signal intensity of hypertrophied synovium. (Right) Axial FS PD FSE MR shows synovitis of distal radioulnar joint with heterogenous signal.
(Left) Coronal FS PD FSE MR shows scapholunate dissociation with carpal erosions and marrow edema. (Right) Coronal T l Wl MR shows hypointense subchondral erosions and carpal cysts.
Variant (Left) Coronal graphic shows tenosynovitis of flexor carpi radialis in association with scapholunate dissociation. These changes may also be seen in psoriatic arthritis, especially with isolated tendon involvement. (Right) Coronal graphic shows osteopenia of carpus in association with rheumatoid disease. Inflammatory arthritis usually demonstrates juxta-articular osteopenia similar to Sudeck's atrophy.
-
MADELUNG'S DEFORMITY
Coronal graphic shows Madelung's deformity with medial angulation of the distal radial articular surface and triangulation of the carpus.
Coronal T l Wl MR shows the hypointense thickened radiolunate ligament (arrow) extending to the medial aspect of the distal radial metaphysis (area of metaphyseal bone spike).
o Premature closure of anteromedial quadrant of distal
Abbreviations and Synonyms Dysplasia, dyschondrosteosis
Definitions Developmental growth disturbance of distal radial physis
General Features Best diagnostic clue: Distal radius epiphysis is triangular & medially tilted Location: Distal radial epiphysis Size: Involvement can range from changes in the distal radius & ulna to changes in carpal morphology Morphology: Distal radius epiphysis is triangular and medially beaked
Radiographic Findings Radiography o Radius short + dorsolateral curvature o Radial distal articular surface - excessive volar & ulnar inclination o Distal radial epiphysis - triangular & medially tilted o Lucent area in ulnar aspect distal radius + osteophytes
I
radius physis Distal ulna is long & shows dorsal subluxation Ulnar head enlarged & deformed Distal ulnar physis - radially inclined Carpus - triangular shape Lunate - wedged in widened distal radioulnar interosseous space o Dorsal curvature carpus + radial bowing of lateral column o Reverse Madelung's deformity Radius with volar convexity Distal radial articular surface inclined dorsally
o o o o o
MR Findings TlWI o Ulnar angulation distal radial articular surface o Ulnar head - dorsoulnar configuration (dorsally prominent ulnar head) o Radius bowed o Physeal lesion - palmar ulnar aspect of distal radial physis o Triangulation of carpus o Groove & osseous spike develops at ulnar aspect of metaphyseal-diaphyseal junction from tethering effect of radiolunate ligament (hypointense & thick ligament) o Oblique radial triangular fibrocartilage (TFC) attachment
DDx: Madelung's Deformity
DRUl instability
Cor T 1 Arthro.
Ax T l Wl MR
I
MADELUNG'S DEFORMITY Key Facts Imaging Findings Best diagnostic clue: Distal radius epiphysis is triangular & medially tilted Distal ulna is long & shows dorsal subluxation Distal ulnar physis - radially inclined Lunate - wedged in widened distal radioulnar interosseous space
Top Differential Diagnoses Distal Radius Fracture Die punch Fracture Osteochondroma Ulna Impingement Syndrome Distal Radioulnar Joint (DRUJ) Instability
Pathology
Dyschondrosteosis form of mesomelic dwarfism Localized lesion = ulnopalmar zone distal radius Chevron carpus = osseous lesion midway between Madelung's & reverse Madelung's deformity Metaphyseal groove & spike at radiolunate ligament attachment to area of growth retardation
Clinical Issues ~ o scommon t signs/symptoms: Wrist pain Deformity at infancy or adolescence Loss of motion Derangement of DRUJ Loss of supination
Diagnostic Checklist Identify radiolunate ligament on coronal images
Focal dysplasia distal radial physis o & Ischemic changes of lunate (hypointensity) T2WI o Hypointense radiolunate ligament (palmar location) o ~hysis- hyperintense o Chevron carpus = mid-ulnar zone dyschondrosteosis o Advanced dvschondrosteosis Lack of p;oximal lunate support by radius o Thick hypointense radiolunate ligament attached to distal radial physis
Imaging Recommendations Best imaging tool o MR identifies soft tissue contributions (radiolunate ligament) in addition to marrow & chondral changes o Monitoring of children Protocol advice 0 T1 & FS PD FSE coronal, axial & sagittal o T2* gradient echo = improved visualization of physis (hyperintense)
Spectrum: Asymmetric beaking of metaphyseal cortex to pedunculated metaphyseal osteochondromas
Ulna Impingement Syndrome Pain during pronation & supination Ulnar minus (negative) variance Scalloped concavity distal radius Ulnar convergence to distal radius & Osteophytes Chondromalacia distal ulna
*
Distal Radioulnar Joint (DRUJ) Instability Dorsal or volar displacement of distal ulna Ulnar dorsal vs. ulnar palmar Rotational injury - fall on outstretched hand Injury to palmar or dorsal distal radioulnar ligaments (margins of TFC) Ulnar-sided wrist pain
1 PATHOLOGY General Features
Distal Radius Fracture Intra- vs. extraarticular Articular components o Metaphyseal 0 Radial styloid 0 Dorsal mediallpalmar medial articular surface
Die punch Fracture Lunate load fracture Lunate impaction on lunate fossa of distal radius Dorsal displacement (dorsal medial fragment) Volar displacement (palmar medial fragment)
Osteochondroma Endochondral growth disorder Osteocartilaginous tumors Metaphyseal remodeling Multiple hereditary exostosis Osteochondroma in distal radius & ulna
General path comments o Relevant anatomy Distal radial physis Radiolunate ligament = volar structure Triangular fibrocartilage Distal radioulnar joint Genetics o Dominant, familial deformity o Incomplete penetrance o Bilateral occurrence documented o Familial dysplasia profile Hypoplasia of radius Mesomelic dwarfism Etiology 0 Focal dysplasia distal radial physis o Dyschondrosteosis form of mesomelic dwarfism o Primary or idiopathic form - nonheritable o Bony lesions = dyschondrosteosis Epidemiology 0 Rare in occurrence
MADELUNG'S DEFORMITY o Distal radius turned in ulnar + palmar direction o Carpus & hand appear volar to forearm while ulna
o Increased incidence in West Indies
Gross Pathologic & Surgical Features Ulnar head - dorsoulnar prominence Hand displaced radiopalmarly Tilting & bowing distal radius Variable forearm shortening Reverse Madelung's deformity o Ulnar head palmar o Wrist arched dorsally Extreme manifestation - hypoplasia entire radius Localized lesion = ulnopalmar zone distal radius Medial radial epiphysis deformity (tethering of epiphysis proximally) Chevron carpus = osseous lesion midway between Madelung's & reverse Madelung's deformity Metaphyseal groove & spike at radiolunate ligament attachment to area of growth retardation Oblique radial attachment TFC ifl
shows dorsal subluxation
Treatment Conservative o Bracing Surgical o Indications: Persistent pain, loss of normal anatomy, grip weakness & severe deformity o Resection of distal ulna Darrach procedure o Sauve-Kapandji procedure: DRUJ fusion and ulnar osteotomy o Open or closed wedge osteotomy of radius o External fixators o Epiphysiodesis (distal ulna or radius) o Radiocarpal & total wrist fusion o Prophylactic excision of physeal bar in symptomatic adolescents
Microscopic Features Normal chondrocytes Abnormally arranged cell columns Cambium layer cells of periosteum stream from periphery of physis o Zone of Ranvier
1 DIAGNOSTIC CHECKLIST Consider Symptoms & imaging findings may not correlate Identify radiolunate ligament on coronal images
Staging, Grading or Classification Criteria Madelung's Reverse Madelung's Chevron carpus o Clinical deformity absent o Triangulation of carpus, wedged between radius & ulna
Presentation Most common signs/symptoms: Wrist pain Clinical profile o Deformity at infancy or adolescence o Loss of motion o Weakness o Ligamentous stretching + carpal translation o Derangement of DRUJ o Poor correlation between symptoms & imaging findings o Extensor tendon attrition over deformed ulnar head in adults o Marked obliquity of carpal tunnel associated with susceptibility to median neuropathy in trauma o Midcarpal joint involved 2" to triangular morphology of carpus o LOSS-of supination o Dorsiflexion, radial deviation also restricted
Demographics Age: Clinical manifestation during adolescence Gender: Female predominance
Natural History & Prognosis Progressive radiologic deterioration Bracing used to control symptoms End stage
ISELECTED 1.
REFERENCES
Vickers D: The wrist. Diagnosis and operative treatment. Madelung's deformity. vol 1. St. Louis Missouri, Mosby, (41):966-81, 1998 2. Rao, SB et al: The wrist and it's disorders. Congenital and developmental wrist disorders in children. 2nd ed. Philadelphia PA, W.B. Saunders, (29):509-39, 1997 3. Murphy MS et al: Radial opening wedge osteotomy in Madelung's deformity.J Hand Surg 21:1035-44, 1996 4. Watson HK et al: Madelung's deformity: A surgical technique. J Hand Surg 18:601-5, 1993 5. Langenskiold A et al: Specific collagen mRNAs elucidate the histogentic relationship between the growth plate, the tissue in the ossification groove of Ranvier, and the cambium layer of the adjacent periosteum. A prelimary report. Clin Orthop 29751-4, 1993 6, Vickers D et al: Madelung deformity: Surgical prophylaxis (physiolysis) during the late growth period by resection of the dyschondrosteosis lesion. J Hand Surg 17:401-7, 1992 7. Fagg PS: Wrist pain in the Madelung's deformity of dyschondrosteosis.J Hand Surg 13:ll-15, 1988 8. Nielson JB: Madelung's deformity: A follow-up study of 256 cases and a review of the literature. Acta Orthop Scand 48:379-84, 1977. 9. Golding JS et al: ~adelung'sdisease of the wrist and dyschondrosteosis.J Bone Joint Surg 58:350-2, 1976 10. Langenskiold A: An operation for partial closure of an epiphyseal plate in children, and its experimental basis. J Bone Joint Surg 57:325-30, 1975
1
MADELUNG'S DEFORMITY
I IMAGE GALLERY ( k j l ) Coronal FS PD FSE MR shows Madelung's deformity with proximal migration of the lunate (triangulation of the carpus), medial angulation of the distal radius and oblique orientation of the TFC. (Right) Coronal T l Wl MR shows Madelung's deformity complicated by lunate ischemia.
(Left) Coronal graphic shows advanced changes of Madelung's deformity with complete lack of a lunate fossa. The lunate is suspended without osseous support and is impinged between the radius and ulna. (Right) Sagittal graphic shows Madelung's deformity with dorsoulnar prominence of the ulnar head.
(Lef)Sagittal graphic shows reverse Madelung's deformity with the ulnar head displaced in a palmar direction. (Right) Sagittal graphic shows Chevron carpus without displacement of distal ulna (no clinical deformity) despite triangulation of the carpus and wedging between the radius and ulna.
GANGLION CYST, WRIST
Coronal graphic shows dorsal ganglion cyst in communication with the dorsal and membranous fibers of the scapholunate ligament.
Coronal FS PD FSE MR shows dorsal ganglion (arrow) originating from dorsal component of the scapholunate ligament. This is adjacent to the dorsal interosseous nerve branch.
Morphology: Oval with narrow stalk extending from origin
Abbreviations and Synonyms
Radiographic Findings
Ganglion, ganglia, carpal ganglion, dorsal wrist ganglion, dorsal ganglions, palmar wrist ganglion
Definitions Cystic mucinous soft tissue masses occurring about the wrist & hand in predictable locations
Radiography o Usually normal o Scapholunate (SL) dissociation with interval gap o Osteoarthritis o Intraosseous carpal ganglion o + Soft tissue density
M R Findings General Features Best diagnostic clue: Homogeneous fluid-filled mass in communication with the scapholunate interval Location o Dorsal scapholunate (SL) interval o Volar (palmar) radiocarpal joint o Dorsal retinaculum of 1st extensor component o Carpal tunnel o ~ u y o n ' canal s o Triscaphe joint o Ulnocarpal o 2nd metacarpal-trapezia1 joint Size o Varies (usually 5 mm to 2 cm) o Size increases with activity
TlWI o Hypointense to intermediate signal intensity mass o Normal adjacent subcutaneous tissue o Arthrosis scaphotrapezial or radioscaphoid o SL diastasis on coronal images o Stalk difficult to visualized on TlWI T2WI o Uniformly hyperintense soft tissue cystic mass o Unilocular or multiloculated o Hypointense capsule o Inhomogeneity of cyst related to mucin content o Narrow hyperintense stalk in communication with main cyst o Stalk extension through joint capsule o Stalk with elongated pedicle allows cyst presentation away from origin (e.g., cysts originating from SL interval maybe ulnar to extensor tendons)
*
Mmm DDx: Ganglion Cyst
Giant Cell Tumor
Cor FS PD MR
Ax FS PD MR
Ax T l Wl MR
GANGLION CYST, WRIST Key Facts Imaging Findings Best diagnostic clue: Homogeneous fluid-filled mass in communication with the scapholunate interval Dorsal scapholunate (SL) interval Volar (palmar) radiocarpal joint Morphology: Oval with narrow stalk extending from origin
Top Differential Diagnoses Rheumatoid Arthritis Synovitis Tenosynovitis Giant Cell Tumor of Tendon Sheath Benign Tumors
Pathology SL ligament - membranous & dorsal component origin Weakness in dorsal capsule Dorsal location where dorsal interosseous nerve approaches joint capsule
Clinical Issues Most common signs/symptoms: Localized soft tissue mass Localized pain + weakness (pain with dorsiflexion) Associated intraosseous carpal ganglion Recurrence rate with conservative treatment: 14-74%
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Diagnostic Checklist Extension from SL joint = typical origin of ganglion which presents dorsally
o Small hyperintense carpal tunnel ganglions
frequently traced to scaphotrapeziotrapezoid ( S T ) joint 2" compression of median nerve o Cyst communication with adjacent tendon sheath o Intraosseous carpal ganglions - hyperintense T1 C+: To confirm cystic contents (peripheral enhancement) vs. soft tissue neoplasm
Imaging Recommendations Best imaging tool: MR identifies cyst vs. solid tumor, location, morphology, proximity to neurovascular structures, joint or tendon sheath communication Protocol advice: TI, PD, FS PD FSE or STIR coronal, axial & sagittal images (coronal & axial planes required)
I DIFFERENTIAL DIAGNOSIS Rheumatoid Arthritis Synovitis Articular cartilage destruction Ligamentous laxity, joint subluxations/dislocations Reactive subchondral edema (carpus) Tenosynovitis Rheumatoid nodule
Synovitis Inflammatory response - variety of stimuli Intermediate signal on TlWI Intermediate + hyperintensity on FS PD FSE Enhancement with TIC+
Tenosynovitis Trauma vs. repetitive use Hyperintensity on T2WI within tendon sheath Pain with activity Lockingltriggering - sheath constriction or stenosing
Giant Cell Tumor of Tendon Sheath Benign fibrous histiocytoma originating from tendon sheath or joint capsule Soft tissue mass
Inhomogeneous hypo to intermediate signal intensity on FS PD FSE images
Benign Tumors Lipoma Xanthoma Fibroma Hemangioma Osteochondroma Lymphangioma
Malignant Tumors Malignant fibrous histiocytoma Synovial sarcoma Chondrosarcoma
Infection Mycobacterial (TB) Fungal Pyogenic abscess
Vascular Aneurysm Arteriovenous malformation
1 PATHOLOGY General Features General path comments o Relevant anatomy SL interval Radiocarpal joint Guyon's canal Dorsal interosseous nerve branch Etiology o SL ligament - membranous & dorsal component origin o Stress forces epicentered between scaphoid & lunate o Joint fluid pumped (one way valve) between collagen bundles o Weakness in dorsal capsule o Palmar radiocarpal ganglion near origin of radiocarpal ligament from triscaphe joints
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GANGLION CYST, WRIST Epidemiology o Most common soft tissue mass of wrist o 50-70% of all soft tissue masses of wristlhand o Dorsal SL origin incidence: 60-70% of all ganglions 0 Palmar radiocarpal incidence: 18-20%
Palmar ganglion = highest rate of recurrence post aspiration & steroid injection
Treatment Conservative o Manual rupture o Cyst wall puncture o Aspiration & steroid injection Surgical o Excision including stalk
Gross Pathologic & Surgical Features Cystic rnucinous joint fluid in pseudocapsule Ganglion protrusion through SL ligament confined deep to radiocarpal ligament Protrusion through dorsal wrist capsule Palpable, firm & smooth Multilobular mass Dorsal location where dorsal interosseous nerve approaches joint capsule Cyst connects to joint capsule or tendon sheath via narrow stalk Palmar radiocarpal ganglion protrudes along flexor carpi radialis tendon sheath Retinacular ganglions associated with hypertrophic retinaculum superficial to stenosing tenosynovitis (de Quervain's) Guyon's canal ganglion from weak region in pisohamate ligament
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Microscopic Features Collagen fiber break-down products Intercellular mucin Microscopic rnucinous pools o Coalesce o Expand Dissection through subcutaneous tissue Compacted fibrous tissue = pseudocapsule Capsule lining o Compressed collagen fibers o Flat nonendothelial cells (nonsynovial)
Presentation Most common signslsymptoms: Localized soft tissue mass Clinical profile o Localized pain + weakness (pain with dorsiflexion) o Neurologic findings only with carpal tunnel or Guyon's canal involvement 0 Ganglion soft to firm o Does not move with adjacent tendon o +_ Associated intraosseous carpal ganglion o Size & symptoms may increase after activity o Allen's test + doppler to confirm patency of radial artery
Demographics Age o Dorsal ganglion = Znd, 3rd, 4th decades o Radiocarpal palmar ganglions: 5th, 6th & 7th decades Gender: F > M
Natural History & Prognosis Varying size & discomfort Resolution without treatment: 38-58% Recurrence rate with conservative treatment: 14-74%
Consider Extension from SL joint = typical origin of ganglion which presents dorsally Intravenous contrast required for diagnosis when there is inhomogeneity of ganglion signal on FS PD FSE or STIR
1.
Kozin SH et al: The wrist. Diagnosis and operative treatment. Soft-tissue problems and neoplasms. vol 1. St. Louis Missouri, Mosby, (49):1166-80, 1998 2. Bogumill GP: The wrist and it's disorders. Tumors of the wrist. 2nd ed. Philadelphia Pennsylvania, W.B. Saunders, (31):563-82, 1997 3. Vo P et al: Evaluating dorsal wrist pain: MRI diagnosis of occult dorsal wrist ganglion. J Hand Surg 20:667, 1995 4. Bianchi S et al: Ultrasonographic evaluation of wrist ganglia. Skel Radio1 23:201, 1994 5. Cardinal E et al: Occult dorsal carpal ganglion: Comparison of US and MR imaging. Radiolog 193:259, 1994 6. Greendyke SD et al: Anterior wrist ganglia from the scaphotrapezial joint. J Hand Surg 17:487-90, 1992 7. Jacobs LG et al: The volar wrist ganglion: Just a simple cyst? J Hand Surg 15:342-6, 1990 8. Hollister AM et al: The use of MRI in the diagnosis of an occult wrist ganglion cyst. Orthop Rev 18:1210-2, 1989 9. DeVilliers CM et al: Dorsal ganglion of the wrist pathogenesis and biomechanics. Operative vs. conservative treatment. S Afr Med J 75:214-6, 1989 10. Harvey FJ et al: Carpal tunnel syndrome caused by a simple ganglion. Hand 13:164-6, 1981 11. Bowers WH et al: An intraarticular-intraosseous carpal ganglion. J Hand Surg 4:375-7, 1979 12. Dellon AL et al: Anatomic dissections relating the posterior interosseous nerve to the carpus, and the etiology of dorsal wrist ganglion pain. J Hand Surg 3:326-32, 1978
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GANGLION CYST, WRIST
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(Lef)Coronal graphic shows the narrow stalk extending from scapholunate origin of this dorsal ganglion. Joint fluid extends through a one way valve mechanism in a dorsal capsule defect. (Right) Coronal FS PD FSE MR shows distal extension of a dorsal scapholunate ligament ganglion (arrow) between the capitate and trapezoid adjacent to the dorsal intercarpal ligament.
(Left) Coronal FS PD FSE MR shows radial and distal extension of a scapholunate ligament ganglion. This dorsal ganglion extends between the 2nd and 3rd metacarpals. (Right) Axial T l Wl MR shows hypointense ganglion adjacent to the flexor tendon sheath of the 2nd digit.
(Lef)Axial FS PD FSE MR shows hyperintense ganglion dissecting into the 1st web space. The origin of this ganglion was the scapholunate interval. (Right) Coronal TZX CRE MR shows cystic ganglion communicating with the hamate triquetral joint.
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D E QUERVAIN'S TENOSYNOVITIS
Sagittal graphic shows edema of the first extensor compartment tendons in de Quervain's tenosynovitis. The APL is located volar to the EPB at the level of radial styloid.
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Axial FS PD FSE MR shows hyperintense tenosynovitis and tendon enlargement. The APL demonstrates a striated appearance secondary to enlargement of multiple slips (arrow).
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Carpometacarpal (CMC) arthritis
CT Findings
Abbreviations and Synonyms Washer woman's sprain, stenosing tenosynovitis
Definitions Tenosynovitis & tendonitis of first dorsal extensor compartment
General Features Best diagnostic clue: Edemalfluid associated with first extensor compartment Location o Abductor pollicis longus (APL) o Extensor pollicis brevis (EPB) o Level of radial styloid Size: Variable - enlargement of tendons within fibroosseous tunnel Morphology: Cross sectional enlargement
Radiographic Findings Radiography o Rarely positive o + Soft tissue swelling o Exclude other pathology Fractures
NECT o Limited usefulness due to limited soft tissue detail o Insensitive for intratendinous pathology o Tendon thickening Surrounding hypodense fluid Tenosynovitis o Multi-detector thin section CT + 3-D reformatted images Emerging technique to evaluate tendon pathology Promising results in evaluation of skeletally mature patients
MR Findings TlWI o Tenosynovitis Hypo to intermediate signal intensity of fluid in distended sheath Debris within sheath = intermediate signal Hypointense effacement of subcutaneous fat radial to EPB & APL o Tendonitisltendinosis Hypointense with centralleccentric intermediate signal in grossly enlarged tendons (EPB & APL) Enlargement from medial to lateral on coronal images & cross sectional on axial images
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DDx: De Quervain's Tenosynovitis Scaphoid Fracture
Cor T l WI MR
Rheumatoid
Ax
FS PD MR
Carpal Tunnel
Ax FS PD MR
Key Facts Imaging Findings Best diagnostic clue: Edemalfluid associated with first extensor compartment Abductor pollicis longus (APL) Extensor pollicis brevis (EPB) Morphology: Cross sectional enlargement
Top Differential Diagnoses Scaphoid Fracture First Carpometacarpal Arthritis Inflammatory Arthropathies Carpal Tunnel Syndrome Dorsal Ganglion
Pathology Repetitive activities (chronic micro-overuse) leading to increased friction & inflammation Maximum enlargement at and immediately distal to radial styloid Longitudinal split - intermediate signal intensity T2WI o Tenosynovitis Intermediate to hyperintense fluid surrounding EPB & APL Adjacent subcutaneous fat - hyperintense Chronic changes - intermediate signal o Tendinitisltendinosis Hypo to intermediate signal intensity Medial & lateral convexity to tendon margins on coronal images = Tendon degeneration - tendinosis intermediate unless associated with hyperintense longitudinal split f Hypointense septum between tendons (subcompartment for EPB) Striated APL related to enlargement of multiple slips Longitudinal splitting more common in APL
Imaging Recommendations Best imaging tool: MR sensitive & specific for tenosynovitis + tendinosis Protocol advice o TI or PD and FS PD FSE coronal, sagittal & axial o TZ* optional for intratendinous degeneration
/ DIFFERENTIAL DIAGNOSIS Scaphoid Fracture Most common fracture of carpus Dorsiflexion loading & radial deviation mechanism 70 to 80% involve middle third (waist) Pain over anatomic snuffbox Scaphoid flexion = humpback deformity
First Carpometacarpal Arthritis Sclerosis, hypertrophic bone, chondral loss Associated with triscaphe arthritis
Wringing Forceful grasp + repetitive use of thumb in ulnar deviation Tendons undergo stretch Epidemiology: Most common stenosing tenosynovitis in athletes
Clinical Issues Most common signs/symptoms: Pain at radial styloid Pain increased with wrist & thumb motion Swelling k Tender nodule over radial styloid Point tenderness over 1st dorsal compartment f Triggering or crepitus
Diagnostic Checklist Assess tendon enlargement at level of radial styloid
Inflammatory Arthropathies
hic + Rheumatoid arthritis (RA) - h ~ ~ e m o ~synovium erosions Systemic lupus erythematosus - deformities similar to RA Psoriatic - distal interphalangeal joints, selective tenosynovitis, arthritis mutilans Gout & pseudogout (gout - multiarticular, pseudogout - polyarticular)
Carpal Tunnel Syndrome Compromise of motion/sensory function of median nerve Trauma + repetitive activities: Hemorrhage, infection & infiltrative disease Swelling - median nerve at level of pisiform Partial to complete cross sectional hyperintensity on T2WI
Dorsal Ganglion Cystic mucinous mass Related to scapholunate interval Hyperintense, unilocular or multiloculated on T2WI Narrow stalk Weakness in dorsal capsule
Flexor Carpi Radialis (FCR) Tenosynovitis Repetitive wrist motion Pain with wrist flexion - radiates along FCR course FCR tendon - tight fit in tunnel
Intersection Syndrome Pain dorsal radial wrist 5 cm proximal to Lister's tubercle - where APL & EPB cross over 2nd extensor compartment Repetitive wrist motion & trauma Swelling, tenderness and crepitus
Wartenberg's Syndrome Irritation of superficial branch of radial nerve Extrinsic compression (wrist bands) Intrinsic pressure (dorsal fascia of brachioradialis muscle)
D E QUERVAIN'S TENOSYNOVITIS Clinical profile o Pain increased with wrist & thumb motion o Radiation of pain to radial side of forearm o Swelling o k Tender nodule over radial styloid o Point tenderness over 1st dorsal compartment o Positive Finkelstein test - not pathognomonic Passive ulnar deviation reproduces pain o +_ Triggering or crepitus
Pain with ulnar deviation Tenderness & Tinel's sign over superficial radial nerve
1 PATHOLOGY
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General Features General path comments o Relevant anatomy First extensor compartment - directly over radial styloid process Fibroosseous tunnel = tubular passageway 2.5 cm in length formed by groove in radial styloid & overlying extensor retinaculum Large APL & small EPB pass through fibroosseous tunnel - represents radial side of anatomic snuff box Anatomic variations: Complete compartmentalization of EPB & multiple slips of APL First dorsal compartment - serves as a pulley to align tendons with dorsum of thumb proximal to 1st metacarpal (APL) & proximal phalanx (EPB) insertions Superficial radial nerve branch overlies first dorsal extensor compartment Etiology o Repetitive activities (chronic micro-overuse) leading to increased friction & inflammation Grasping Pinching Wringing o Trauma = scarring with friction & inflammation Direct blow Fall onto thumb o Athletes at risk Forceful grasp + repetitive use of thumb in ulnar deviation Racquet sports Golf - hyperabduction during golf swing Fly fishing Javelin & discus throwing o Tendons undergo stretch Tunnel approach angle increases with ulnar deviation Epidemiology: Most common stenosing tenosynovitis in athletes
Gross Pathologic & Surgical Features Tendon inflammation Tendon enlargement Longitudinal septum divides APL & EPB in 20 to 30% of patients
Microscopic Features Inflammatory cells infiltrate common tendon sheath Tenosynovitis originates at tendon sheath or tenosynovium
Presentation Most common signs/symptoms: Pain at radial styloid
Demographics Age: 35 - 55 years Gender: F: M = 8 - 10:1
Natural History & Prognosis Majority (80%) improve with conservative treatment Surgery for recalcitrant cases Fibrosis develops within tendon sheath without treatment o Trigger finger with limited motion
Treatment Conservative ~oAnti-inflammatory medications
Rest, ceasing aggravating activities Splinting (thumb spica splint) Steroid injections: Excellent results Physical therapy Surgical o Failure of conservative care o Decompression of common tendon sheath o Lysis of dividing septum if present Complications o Perineural fibrosis of superficial radial nerve o Inadequate decompression - tendon instability & adherence to scar tissue
o o o o
Consider Assess tendon enlargement at level of radial styloid
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Miller MD et al: Surgical atlas of sports medicine. Treatment of Guyan's canal syndrome (ulnar nerve compression at the wrist). Philadelphia Pennsylvania, W.B. Saunders, (66):477-89, 2003 Topper SM et al: The wrist. Diagnosis and operative treatment. Athletic injuries of the wrist. vol 1. St. Louis Missouri, Mosby, (45):1031-75, 1998 Novotny SR et al: The wrist and it's disorders. Occupational and sports injuries of the wrist. 2nd ed. Philadelphia Pennsylvania, W.B. Saunders, (28):487-508, 1997 Plancher KD et al: Compressive neuropathies and tendinopathies in the athletic elbow and wrist. Clin Sports Med 15:331-71, 1996
D E QUERVAIN'S TENOSYNOVITIS
FSE MR kid hyperir synovitis ;sociated wit and tendon degeneration of EPB and APL. (Right) Coronal FS PD FSE MR shows increased transverse dimension of the first extensor compartment (arrow). kft) Coronal JOWS
Tvnira I
(Left) Axial T I Wl MR shows hypointense fluid and effacement of subcutaneous fat along the radial aspect of EPB and APL. (Right) Axial FS PD FSE MR shows intermediate signal intensity in chronic changes of EPB and APL tendon inflammation.
Other
(Left) Sagittal graphic shows normal tendons of the first extensor compartment at level of the radial styloid. The EPB is associated with a separate subcompartment. (Right) Sagittal graphic shows intersection syndrome which also involves APL and EPB. In this syndrome there is inflammation as the first compartment tendons cross over the wrist extensors (second compartment).
EXTENSOR CARPI ULNARIS TENDINITIS
Coronal graphic shows ECU tenosynovitis with inflammation (red) of ECU tendon sheath ulnar to the extensor digiti minimi tendon (to the left).
Axial FS PD FSE MR shows intermediate to hyperintense signal (arrow) in chronic ECU tenosynovitis.
MR Findings Abbreviations and Synonyms ECU tendinitis or tendinosis 1
Definitions Inflammation of the synovial lining of extensor carpi ulnaris (ECU) tendon sheath from chronic strenuous use
General Features Best diagnostic clue: Distention of tendon sheath with fluid Location o Dorsal ulnar aspect of wrist o Sixth extensor compartment Size: Variable extent of tenosynovitis +/- subluxation & dislocation Morphology: Fluid in thickened sheath
Radiographic Findings
TlWI o Hypo to intermediate signal intensity fluid within sixth extensor compartment tendon sheath o Thickening - hypo to intermediate signal intensity of tendon sheath o Increased cross sectional diameter of ECU tendon o k Fraying of tendon margins o Tendon degeneration with intermediate signal intensity o ECU subluxation or dislocation T2WI o Hyperintense fluid within ECU tendon sheath o Intermediate signal intensity of fluid - chronic tenosynovitis o Intermediate signal tendinosis - degeneration o Longitudinal splitting of tendon - hyperintense o Complete ECU rupture = replacement by hyperintense signal fluid o Hypointense foci = calcifications T1 C+: Intravenous contrast to enhance inflamed synovium
Imaging Recommendations
Radiography o Usually negative o Osteoarthritis o Calcific tendinitis
Best imaging tool: MR evaluates sixth extensor compartment for fluid, tendon integrity & subluxation Protocol advice: TI, FS PD FSE axial, coronal & sagittal images
DDx: Extensor Carpi Ulnaris Tendinitis TFCC Tear
Kienbock's
Abutment
Sag T I Arthro.
Cor T l Wl MR
Cor FS PD M R
EXTENSOR CARPI ULNARIS TENDINITIS Key Facts Imaging Findings Best diagnostic clue: Distention of tendon sheath with fluid Sixth extensor compartment Size: Variable extent of tenosynovitis +/- subluxation & dislocation Increased cross sectional diameter of ECU tendon
Top Differential Diagnoses Traumatic TFCC Abnormalities Kienbock's Disease DRUJ Instability Ulnocarpal Abutment Syndrome
Pathology Repetitive activities using ulnar deviation Reactive ECU tenosynovitis
DIFFERENTIAL DIAGNOSIS Traumatic TFCC Abnormalities Central perforations Ulnar avulsion Distal avulsion Radial avulsion Without associated lunate, triquetral or ulnar chondromalacia
Kienbock's Disease Avascular necrosis of lunate Related to trauma + ulnar negative variance Centralized lunate sclerosis & Visualized lunate fracture
DRUJ Instability Subluxation Dislocation Fracture ulnar head in sigmoid notch Ligament insufficiency (radioulnar) Pain throughout range of pronation - supination Intercarpal pathology Lunotriquetral instability Midcarpal instability & Lunotriquetral tear & volar intercalated segment instability (VISI)
Ulnocarpal Abutment Syndrome TFCC degenerationlperforation Lunate, triquetral & ulnar chondromalacia Lunotriquetral ligament perforationltear Ulnocarpal arthritis
lntercarpal Pathology Lunotriquetral instability Midcarpal instability + LT ligament tear and VISI
1 PATHOLOGY General Features General path comments
Primary ECU tenosynovitis Epidemiology: Second most frequent site of stenosing tenosynovitis in upper extremity Supination & ulnar deviation reproduces ECU instability
Clinical Issues Most common signs/symptoms: Pain dorsally at distal ulna Traumatic rupture of ECU subsheath = painful subluxation syndrome ECU subsheath rupture + extensor retinaculum disruption = chronic dislocation
Diagnostic Checklist Axial images in full pronation & supination to identify tendon subluxation
o Relevant anatomy = sixth extensor compartment
Contains ECU tendon and sheath Contributes to stability of ulnar aspect of wrist Separate subsheath forms fibro-osseous tunnel Subsheath attachments to ulnar styloid & head Fibro-osseous tunnel maintains ECU position during rotation Septum anchors fibro-osseous tunnel to radius dorsally Retinaculum attaches to volar aspect of pisiform & triquetrum Subsheath merges with capsule of distal radioulnar joint (DRUJ) proximally & triangular fibrocartilage complex (TFCC) distally Etiology o Repetitive activities using ulnar deviation o Reactive ECU tenosynovitis Recurrent subluxation Loss of sixth compartment integrity o Primary ECU tenosynovitis cut-e trauma Repetitive wrist motion Ulnar styloid non-union with roughened surface Epidemiology: Second most frequent site of stenosing tenosynovitis in upper extremity
Gross Pathologic & Surgical Features Supination o ECU tendon in dorsal position (normal) Pronation o ECU tendon in ulnar position (normal) ECU subluxation ECU dislocation Supination & ulnar deviation reproduces ECU instability ECU relocation o Pronation & radial deviation - relocates ECU tendon
Microscopic Features Tendon degeneration o ~ecreasedcollagen content o Loss of collagen cross linking = tendon stiffness o Decreased resistance to shear forces
EXTENSOR CARPI ULNARIS TENDINITIS Staging, Grading or Classification Criteria Tenosynovitis - primary or reactive Tendinosis Longitudinal splitting Rupture
Presentation Most common signs/symptoms: Pain dorsally at distal ulna Clinical profile o Swelling o + Crepitus o Traumatic rupture of ECU subsheath = painful subluxation syndrome Painful snap with pronation & supination o ECU subsheath rupture + extensor retinaculum disruption = chronic dislocation Forced supination Palmar flexion Ulnar deviation
Demographics Age o Athlete population Racquet sports Baseball Golf o Association with rheumatoid arthritis (synovial ,cysts, subluxation/dislocation) Gender: No bias
Natural History & Prognosis Return to sports o Range of motion = 70% of opposite extremity Prognosis o Good with early & adequate treatment o Modification of racquet weight & biomechanics of swing patterns
Treatment Conservative (ECU tendinitis) o Diagnostic & therapeutic injection of lidocaine & cortisone o Splinting o Non-steroidal anti-inflammatories o Rest, ice, compression, elevation Conservative (ECU rupture) o Acute injury - long-arm cast in full supination & neutral wrist flexion/extension Surgical (ECU tendinitis) o Progressive fibrosis of sixth compartment requires release Surgical (traumatic rupture of ECU) o Chronic or non-responsive to conservative treatment = surgical reconstruction of retinaculum
1 DIAGNOSTIC CHECKLIST Consider FS PD FSE or STIR to visualize tenosynovitis
T2* gradient echo if fat-suppression inadequate Axial images in full pronation & supination to identify tendon subluxation
1 SELECTED REFERENCES
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Kozin SH et al: The wrist. Tendinitis of the wrist. Diagnosis and operative treatment. vol 1. St. Louis Missouri, Mosby, (50):1181-96, 1998 Novotny SR et al: The wrist and it's disorders. Occupational and sports injuries of the wrist. 2nd ed. Philadelphia Pennsylvania, W.B. Saunders, (28):487-508, 1997 Thorson E et al: Common tendinitis problems in the hand and forearm. Orthop Clin North Am 23:65-74, 1992 Pitner MA: Pathophysiology of overuse injuries in the hand and wrist. Hand Clin 6:355-64, 1990 Stern PJ: Tendinitis, overuse syndromes and tendon injuries. Hand Clin 6:467-76, 1990 Osterman AL et al: Soft tissue injuries of the hand and wrist in racquet sports. Clin Sports Med 7:329-48, 1988 Herring SA et al: Introduction to overuse injuries. Clin Sports Med 6:255-39, 1987 Rowland SA: Acute traumatic subluxation of the extensor carpi ulnaris tendon at the wrist. J Hand Surg 11A:809-11, 1986 Haji AA et al: Stenosing tenosynovitis of the extensor carpi ulnaris. J Hand Surg 11A:515-20, 1986 Wood MD et al: Sports related extra-articular wrist syndrome. Clin Orthop 2020:93-102, 1986 Rayan GM: Recurrent dislocation of the extensor carpi ulnaris in athletes. Am J Sports Med 11:183-4, 1983 Burkhart SS et al: Post-traumatic recurrent subluxation of the extensor carpi ulnaris tendon. J Hand Surg 7A:l-3, 1982 Eckhardt WA et al: Recurrent dislocation of the extensor carpi ulnaris tendon. J Hand Surg 61:629-31, 1981 Dobyns JH et al: Sports stress syndromes of the hand and wrist. Am J Sports Med 6:236-54, 1978 Spinner M et al: Extensor carpi ulnaris: Its relationship to the stability of the distal radioulnar joint. Clin Orthop 68:124-9, 1970
EXTENSOR CARP1 ULNARBS TENDBNBTIS
GIANT CELL TUMOR TENDON SHEATH
Coronal graphic shows giant cell tumor of the flexor tendon sheath of 3rd digit. Characteristic lobulations are present.
Sagittal T l Wl MR shows hypointense to intermediate signal intensity volar ;oft tissue giant cell tumor with hypointense septations.
o Intra-tumoral calcification occasionally present
MR Findings
Abbreviations and Synonyms Extraarticular pigmented villonodular synovitis, GCTTS, histiocytoma, benign synovioma
Definitions Non-neoplastic benign tumor of giant cells in vicinity of joints, most commonly the hand, closely related to pigmented villonodular synovitis
General Features Best diagnostic clue: Intermediate signal intensity soft tissue mass on T1 & T2WIs Location o Volar aspect of hand and fingers adjacent to distal interphalangeal (DIP) joint o Two-thirds of masses located volar aspect of fingers index and long finger most common o Slight predominance for right hand Size: Usually small (0.5-5 cm) Morphology: Well-circumscribed fibrous mass
Radiographic Findings
TlWI o Hypointense to intermediate signal intensity o Hypointense septations o Lobulations o Signal: f Inhomogeneous o Convex bowinglbulge toward skin from tendon sheath o Flexor or extensor tendon related o Extension in transverse and longitudinal planes o Less common origin deep to tendon (between tendon & bone) T2WI o Low to intermediate signal intensity o Inhomogeneous o Hypointense hemosiderin foci o Hemosiderin distribution Peripheral hypointense foci (& clumped) Small hypointense foci throughout lesion o Fibrous septations - hypointense o Sharply defined interface without reactive edema of adjacent subcutaneous tissue o Adjacent osseous erosion - unusual but can occur o Greater long axis growth common o Minimal associated fluid T1 C+: Intense enhancement with intravenous contrast f inhomogeneity
Hma
Radiography o Adjacent cortical erosion due to pressure effect
DDx: Giant Cell Tumor Tendon Sheath
Hemorrhagic Mass
r %
Sag FS PD MR
Ax T l Wl MR
Cor FS PD MR
GIANT CELL TUMOR TENDON SHEATH Key Facts Imaging Findings Best diagnostic clue: Intermediate signal intensity soft tissue mass on T1 & T2WIs Two-thirds of masses located volar aspect of fingers index and long finger most common Morphology: Well-circumscribed fibrous mass ~ibrousseptations - hypointense Sharply defined interface without reactive edema of adjacent subcutaneous tissue
Top Differential Diagnoses Ganglion Cyst Lipomas ~eman~iomas Foreign Bodies Synovial Sarcoma
Imaging Recommendations Best imaging tool o MR to document size, morphology, location o MR diagnosis is sensitive & specific Protocol advice o TI, PD, FS PD FSE, STIR & TZ* gradient echo in axial plane o FS PD FSE or TZ* in coronal & sagittal plane o TIC+ for enhancement optional
Pathology
Accepted theory - reactive or regenerative hyperplasia associated with inflammatory process 2nd most common mass of hand behind ganglions High rate of recurrence Firm, well-circumscribed lobulated mass
Clinical Issues Most common signs/symptoms: Painless slow growing mass present for weeks to years May cause limited function of digit due to size of lesion Osseous erosions related to lesion hypervascularity
Diagnostic Checklist T2* gradient echo to document hemosiderin
Gradient echo to emphasize susceptibility artifacts from metallic foreign bodies
Synovial Sarcoma Multipotential mesenchymal cell origin 15-35 years of age Close proximity to joints, however most are extraarticular in location Spotty calcification - 15% Aggressive tracking along tendons possible Thick septations are unusual k Central necrosis
Ganglion Cyst Thin-walled Mucinous fluid Related to trauma Hypointense on TlWI, hyperintense on FS PD FSE or STIR Nonenhancing except peripherally
Lipomas Fat signal on TlWI Suppressed signal on FS T2 FSE or STIR k Fibrous bands Lobulations & septations Enhancement in areas of malignant change
Hemangiomas Cavernous Capillary Intramuscular Noncircumscribed Low to intermediate signal on TlWI Hyperintense serpiginous vessels on FS PD FSE Hypointense foci secondary to hemosiderin
Foreign Bodies Intermediate signal intensity of granulomatous reaction (TI & T2WI) Adjacent subcutaneous tissue edema Inflammatory reaction k Peripheral rim-like enhancement
General Features General path comments o Relevant anatomy Synovial tissue of joints Tendon sheaths Etiology o Accepted theory - reactive or regenerative hyperplasia associated with inflammatory process o Other theories Trauma Disturbed lipid metabolism Osteoclastic proliferation Infection Vascular disturbances Immune mechanisms Inflammation Neoplasia Metabolic disturbances Epidemiology o 2nd most common mass of hand behind ganglions o High " rate of recurrence
Gross Pathologic & Surgical Features Firm, well-circumscribed lobulated mass Tumors have mottled appearance Vary in color from grayish-brown to yellow-orange Nodular & villous morphology
GIANT CELL TUMOR TENDON SHEATH Microscopic Features Mononuclear rounded or polygonal cells - lipid-laden histiocytes 6 multinucleated giant cells Variable number of giant cells present Hemosiderin-containing xanthoma cells in periphery of lesion
Staging, Grading or Classification Criteria Localized type and rare diffuse type o Rare diffuse form is soft tissue counterpart of pigmented villonodular synovitis (PVNS)
ISELECTED 1.
2. 3. 4. 5.
Presentation Most common signs/syrnptoms: Painless slow growing mass present for weeks to years Clinical profile o May cause occasional distal numbness o May cause limited function of digit due to size of lesion o Mass is non-transilluminating
Demographics Age o 30 to 50 years, peak 40-50 Rare < 10 or > 60 years Gender: F:M = 3:2
Natural History & Prognosis Progressive slow growth Late stage = exuberant, heavily pigmented villous synovial overgrowth Osseous erosions related to lesion hypervascularity
Treatment Surgical o Marginal excision o Complete excision - difficult 0 Bony debridement may be necessary Complications o Satellite lesions are common - incomplete resection o Puncturing lesions may result in seeding of operative bed o Tendon reconstruction may be necessary o Even with careful dissection, recurrence rates are 9-44% o No malignant degeneration reported
1 DIAGNOSTIC CHECKLIST Consider True bone invasion is not typical and is suggestive of an aggressive neoplasm Reactive soft tissue edema is atypical T2* gradient echo to document hemosiderin
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9. 10. 11. 12. 13. 14.
REFERENCES
Hitora T et al: Multicentric localized giant cell tumour of the tendon sheath: Two separate lesions at different sites in a finger. Br J Dermatol 147(2):403-5,2002 Al-Qattan MM: Giant cell tumours of tendon sheath: Classification and recurrence rate. J Hand Surg 26(1):72-5, 200 1 Daniel JN et al: Giant cell tumor of the middle phalanx. Orthopedics 10:1097-9, 2000 Galliani I et al: Giant cell tumor of tendon sheath: A light and electron microscopic study. J Submicrosc Cytol Path01 32 (1):69-76, 2000 Bogumill GP: The wrist and it's disorders. Tumors of the wrist. 2nd ed. Philadelphia Pennsylvania, Saunders, (31):563-82, 1997 Hughes TH et al: Pigmented villonodular synovitis: MRI characteristics. Skeletal Radiol 24:7-13, 1995 Miller 'IT et al: Benign soft tissue masses of the wrist and hand: MRI appearances. Skeletal Radiol 23:327-32, 1994 Jelinek J et al: Giant cell tumor of the tendon sheath: MR findings in nine cases. AJR 162:919-22, 1994 Kransdorf MJ et al: Fat containing soft-tissue masses of the extremities. Radiographics 11:81-106, 1991 Binkovitz LA et al: Masses of the hand and wrist: Detection and characterization with MR imaging. AJR 154:323-6, 1990 Poletti SC et al: The use of magnetic resonance imaging in the diagnosis of pigmented villonodular synovitis. Orthopedics 13:185-90, 1990 Jelinek JS et al: Imaging of pigmented villonodular synovitis with emphasis on MR imaging. AJR 152:337-42, 1989 Kottal RA et al: Pigmented villonodular synovitis: A report of imaging in two cases. Radiology 163:551-3, 1987 Patel MR et al: Pigmented villonodular synovitis of the writ invading bone - report of a case. J Hand Surg 9:854-58, 1984.
GIANT CELL TUMOR TENDON SHEATH IMAGE GALLERY
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(Left) Lateral radiography shows volar soft tissue density adjacent to the proximal interphalangeal joint. (Right) Sagittal T l Wl MR shows hypointense giant cell tumor associated with flexor tendon. The lesion bulges toward the skin from the tendon sheath.
(Left) Coronal T l Wl MR shows volar giant cell tumor with septations and lobulations. (Right) Coronal FS PD FSE MR shows characteristic intermediate signal with septations, lobulations, and hemosiderin foci.
Typical (Left) Axial T I C+ MR shows intense enhancement with origin of the giant cell tumor between the tendon and bone. This is a less common presentation (deep to tendon). (Right) Axial T I C+ MR shows inhomogeneous enhancement with the more typical pattern of giant cell tumor origin form superficial surface of the tendon sheath.
ULNAR COLLATERAL LIGAMENT TEAR, THUMB
Sagittal graphic shows UCL tear without displacement or retraction. This represents gamekeeper's thumb.
Coronal FS PD FSE MR shows gamekeeper's thumb with rupture of the distal attachment (arrow) of the UCL. The torn UCL remains deep to the overlying adductor aponeurosis.
o Nondisplaced to minimal displacement (< 2 mm)
Abbreviations and Synonyms UCL rupture, gamekeeper's thumb, ulnar collateral ligament rupture, skier's thumb
Definitions Disruption of the ulnar collateral ligament of the thumb
avulsion fracture of proximal phalanx base = UCL avulsion without Stener lesion o Roberts' view = hyperpronated anteroposterior view o Arthrogram: Extravasation of contrast = capsular rupture Adductor muscle Sheath of extensor pollicis brevis Sheath of extensor pollicis longus UCL disruption - contrast outlines ruptured ligament
MR Findings General Features Best diagnostic clue: Discontinuity of ulnar collateral ligament attachment to proximal phalanx Location: 1st metacarpophalangeal (MCP) joint Size: Variable based on UCL retraction deep to or superficial (Stener lesion) to adductor aponeurosis Morphology o Thickened, foreshortened UCL with proximal retraction o Mass-like tissue vs. horizontally directed UCL in Stener lesion
Radiographic Findings Radiography o Prior to stressing the MCP joint
TlWI o Incomplete rupture or complete rupture without a Stener lesion Hypo to intermediate signal intensity UCL remains deep to overlying hypointense adductor aponeurosis UCL thickening Discontinuity at UCL attachment to proximal aspect proximal phalanx (thumb) Intermediate signal intensity edema & fluid superficial & deep to UCL Ulnar displacement of UCL & adductor aponeurosis UCL orientation remains along long axis of 1st ray (thumb) o Complete rupture with a Stener lesion
DDx: Ulnar Collateral Ligament Tear, Thumb MCP Dalocat~on
Cor FS PD MR
Ax T1WI MR
FPL Tear
Ax FS PD MR
Ax TlWI MR
ULNAR COLLATERAL LIGAMENT TEAR, THUMB Key Facts Imaging Findings Best diagnostic clue: Discontinuity of ulnar collateral ligament attachment to proximal phalanx Size: Variable based on UCL retraction deep to or superficial (Stener lesion) to adductor aponeurosis Thickened, foreshortened UCL with proximal retraction Mass-like tissue vs. horizontally directed UCL in Stener lesion
Top Differential Diagnoses MCP Joint Capsular Trauma Degenerative Arthritis MCP Joint Dislocations Carpal Metacarpal (CMC) Joint Fractures/Dislocations
Intermediate signal intensity in retracted mass of UCL UCL trapped beneath adductor aponeurosis UCL directed superficial to linear adductor aponeurosis T2WI 0 Incomplete or complete rupture without Stener lesion Thickened hypointense UCL with central signal inhomogeneity (focal hyperintense areas of edema) Hyperintense fluid interposed between base of proximal phalanx & retracted ligament Hyperintense fluid plane between distal ulnar aspect of 1st metacarpal & UCL + UCL & adductor aponeurosis Hyperintense soft tissue edema superficial to adductor aponeurosis Hyperintense subchondral edema + osseous avulsion at UCL distal attachment to proximal phalanx o complete rupture with Stener lesion Gross displacement of UCL medial to adductor aponeurosis Hypo to intermediate signal UCL retracted proximal to MCP Trapped UCL either completely superficial to or intersecting the overlying adductor aponeurosis UCL directional vector with increased horizontal orientation (no longer parallel to long axis of 1st digit) "Yo-yo on a string" appearance of Stener lesion = retracted & balled-up UCL (yo-yo)with the more proximal linear adductor aponeurosis (the string)
Imaging Recommendations Best imaging tool: MR identifies UCL morphology, location, retraction, & position relative to adductor aponeurosis Protocol advice o TI, PD & FS PD FSE (vs. STIR or T2* gradient echo) in true coronal orthogonal plane through MCP joint o Axial images next most important plane
Pathology Gamekeeper's thumb = chronic injury to UCL (vs. acute trauma of skier's thumb) Displaced UCL = Stener lesion with proximal retraction (ligament folding) proximal to MCP joint
Clinical Issues
Most common signs/symptoms: MCP joint pain Pain greatest on ulnar side of MCP joint Mass = displaced UCL stump on ulnar side of MCP joint or proximal to MCP joint
Diagnostic Checklist
Identify retracted UCL with folded or horizontally directed fibers
o Sagittal - may document retracted UCL & mass-like
effect on ulnar-sided images
I DIFFERENTIAL D I A G N O S I S MCP Joint Capsular Trauma Capsule o Proper radial & UCL's (UCL sprain) Volar (palmar) plate = anterior or glenoid ligament o Two asymmetric checkrein ligaments o Origin = volar distal thumb metacarpal o Insertion = palmar edge proximal phalanx o Two sesamoid bones associated 0 Thickening of volar capsule o Edema & disruption of capsule in trauma
Degenerative Arthritis Sclerosis, osteophytosis, joint space narrowing, subluxation + Reactive subchondral marrow edema
MCP Joint Dislocations Hyperextension Dorsal subluxation or dislocation = hyperextended position of proximal phalanx Associated palmar (volar plate) injury and thenar sprain
Carpal Metacarpal (CMC) Joint Fractures/Dislocations Occur at base of thumb not MCP joint Bennett's fx/dislocation Rolando's y-shaped fracture Extraarticular transverse vs. oblique fx Epiphyseal - Salter-Harris type I11 - V
1 PATHOLOGY General Features General path comments o Relevant anatomy = MCP joint of the thumb
ULNAR COLLATERAL LlCAMENT TEAR, THUMB Capsule - reinforced by volar plate, collateral ligaments, & extensor pollicis brevis tendon Adductor aponeurosis = adductor pollicis aponeurosis Etiology o Forceful abduction of thumb o Hyperextension stress to UCL of thumb o Fall (skier's thumb) with hyperextension + abduction = UCL tear o Gamekeeper's thumb = chronic injury to UCL (vs. acute trauma of skier's thumb) Epidemiology o UCL injury of thumb MCP joint is common o UCL rupture - majority occur distally o Stener lesion - 50 to 70% of complete tears o Increased incidence of Stener lesions in skiers (80%)
o Instability in MCP flexion = proper collateral ligament tear with intact accessory collateral + volar plate o Instability in flexion & extension = complete ulnar complex disruption o Stability r 10 degrees of opening o Instability 2 30 degrees abduction arc on stress relative to contralateral side
Demographics Age o Young to middle aged adults o ~ctivityrelated age groups Football, hockey, wrestling, basketball & ski injuries Gender oM>F o Activity related
Gross Pathologic & Surgical Features Partial tears UCL Complete rupture UCL: Distal > midsubstance Complete rupture + Stener Avulsed bone fragment (not required for Stener lesion) & Volar subluxation proximal phalanx Nondisplaced UCL tear = discontinuity without retraction + intact adductor aponeurosis covering distal UCL Displaced UCL = Stener lesion with proximal retraction (ligament folding) proximal to MCP joint Proximal margin of adductor aponeurosis intersects or abuts folded UCL in Stener lesion Distal UCL end turned 180 degrees & directed proximally in Stener lesion
Natural History & Prognosis Partial tears & complete without Stener lesion may heal without surgery Fibrosis & granulation tissue in complete tears may delay or preclude ligament reattachment
*
Treatment Conservative o Partial tears (grade I & 11) o Thumb spica cast vs. custom splint o Complete rupture without Stener lesion Surgical o Complete rupture with Stener lesion o Volar subluxation proximal phalanx o Primary repair of torn UCL - acute/subacute injuries o Reconstruction of chronic complete UCL ruptures Complications o Superficial branch of radial nerve injury o Failure of UCL repair o Loss of joint motion
Microscopic Features Collagen, elastin & connective tissue failure Hemorrhagic & inflammatory cellular response Fracture healing
Staging, Grading or Classification Criteria Partial tears o Grade I - stretching o Grade I1 - incomplete but discrete tear Complete rupture o Grade 111 (with or without Stener lesion)
1 D~AGNOST~C CHECKLIST Consider Evaluation of UCL tears & Stener lesions require coronal images through MCP parallel to the collateral ligament plane Identify retracted UCL with folded or horizontally directed fibers
Presentation Most common signs/symptoms: MCP joint pain Clinical profile o Swelling o Tenderness MCP joint o Weakness in pinch o Pain greatest on ulnar side of MCP joint o Pain radiates from metacarpal head to proximal phalanx o Mass = displaced UCL stump on ulnar side of MCP joint or proximal to MCP joint o Abnormal thumb rotation (rotation of proximal phalanx on intact axis of radial collateral ligament) o Absent endpoint on joint stress test = complete tear UCL
[SELECTED REFERENCES I 1. 2.
3. 4.
1 1
Miller MD et al: Surgical atlas of sports medicine. Treatment of skier1s/gamekeeper'sthumb. Philadelphia Pennsylvania, WB Saunders, (67): 491-6, 2003 Graham TJ et al: DeLee & ~ r e z ' sorthopaedic sports medicine. Athletic injuries of the adult hand. vol2. 2nd ed. Philadelphia Pennsylvania, WB Saunders, (24):1381-1430,2002 Plancher KD et al: Role of MR imaging in the management of skier's thumb injuries. MRI Clin North Am 7:73-84, 1999 Heyman T et al: Injuries of the ulnar collateral ligament of the thumb metacarpophalangeal joint. Biomechanical and prospective clinical studies on the usefulness of valgus stress testing. Clin Orthop 292:lS-71, 1993
ULNAR COLLATERAL LIGAMENT TEAR, THUMB
1 IMAGE GALLERY (Left) Coronal T l Wl MR shows gamekeeper's thumb with thickening and partial retraction of the torn UCL. The UCL is still located deep to the adductor aponeurosis. (Right) Axial FS PD FSE MR shows displacement of the thickened UCL (arrow) superficial to the adductor aponeurosis in a Stener lesion.
(Ltj?) Sagittal graphic shows displacement of the retracted UCL superficial to the overlying adductor aponeurosis in a Stener lesion. (Right) Coronal FS PD FSE MR shows proximal retraction of the trapped UCL (open arrow) intersecting the overlying adductor aponeurosis (arrow) mimics yo-yo on a string.
(Left) Coronal STIR MR shows retracted mass (open arrow) of the UCL (proximal to the MCP) intersecting the linear adductor aponeurosis (arrow) in a Stener lesion (skier's thumb). (Right) Intra-operative photograph shows Stener lesion at the level of the metacarpophalangealjoint.
FLEXOR ANNULAR PULLEY TEARS
Sagittal graphic shows disruption of the A2 pulley with palmar bowing of the flexor tendon.
Axial T I WI MR shows discontinuity of the A2 pulley (arrow) with mild subluxation of the flexor tendon of the ring finger.
M R Findings
Abbreviations and Synonyms Digital annular pulley (DAP) tears, flexor pulley tears
Definitions Lesion of fibro-osseous theca or flexor tendon sheath
General Features Best diagnostic clue: Attenuation or rupture of flexor tendon sheath pulley on axial images Location o Long finger (baseball) & ring finger o A4 pulley (annular) o Interval between A2 & A4 pulley o A5 pulley o First two cruciate pulleys Size: Attenuation to frank disruption Morphology: Severe injury = overt bowstringing
Radiographic Findings Radiography o Not diagnostic o Nonspecific soft tissue swelling o No evidence of fracture or cortical avulsion
TlWI o Bowstringing from proximal interphalangeal joint (PIP) to base of proximal phalanx on sagittal images = complete rupture of A2 pulley o Bowstringing from PIP - not reaching base of proximal phalanx = incomplete rupture of A2 pulley o Bowstringing at level of proximal phalanx to region distal to PIP joint = A2 + A3 rupture o Bowstringing at level of middle phalanx = A4 rupture o Hypointense to intermediate signal fluid associated with affected pulley o Hypointense cysts 0 Hypo to intermediate signal intensity fibrous tissue T2WI 0 Hyperintense fluid associated with affected tendon pulley o Discontinuity of pulley on axial images o Tendon displacement Anterior displacement relative to proximal aspect proximal phalanx in A2 pulley area Anterior displacement relative to middle phalanx in A4 pulley area f Medial or lateral subluxation Hypointense fibrous scar tissue o Hyperintense
.
DDx: Flexor Annular Pulley Tears
Ax FS PD MR
Cor FS PD MR
Ax FS PD MR
Ax T I C + MR
FLEXOR ANNULAR PULLEY TEARS Key Facts Imaging Findings Best diagnostic clue: Attenuation or rupture of flexor tendon sheath pulley on axial images Long finger (baseball) & ring finger Morphology: Severe injury = overt bowstringing
Top Differential Diagnoses Tenosynovitis Flexor Tendon Tear Degenerative Arthritis Inflammatory Arthritis Joint Trauma
Pathology Forcible contraction flexor digitorum profundus (FDP) against extreme force Professional baseball injury - pitching
1
PIP or distal interphalangeal joints (DIP) joint fluid Tenosynovitis Tendon sheath cyst
Ultrasonographic Findings Dynamic studies Scan with resisted flexion Measurement of flexor tendon bowstringing o Flexor tendon - phalanx (TP) distance > 1.0 mm = pulley injury o TP measurement (with forced flexion) > 3.0 mm = complete rupture of A2 pulley o TP distance (with forced flexion) > 5 mm = rupture A2 & A3 pulley o TP distance 2 2.5 mm at middle phalanx = complete rupture A4 pulley Assessment of tendon gliding (superficialis, profundus & sheaths)
lmaging Recommendations Best imaging tool o MR and dynamic ultrasound o MR resolution allows direct pulley visualization Protocol advice o TI, FS PD FSE, T2* gradient echo axial images o T1 & FS PD FSE sagittal and coronal images
IDIFFERENTIAL DIAGNOSIS Tenosynovitis ~nflakmationof tendon sheath Fluid within tendon sheath (hyperintense on T2WI) f Thickened sheath f Associated tendon degeneration f Tendon fraying Fluid intermediate on T2WI with chronic changes
Flexor Tendon Tear Avulsion of flexor digitorum profundus o Type I - retracts to palm o Type I1 - retracts to PIP joint o Type 111 - osseous avulsion + retraction to A4 pulley
~ o c climbing k injury Pulley tears = 50% of lesions in elite climbers Ring & middle finger affected in climbing vs. middle finger in baseball pitchers Bowstringing of flexor tendon Failure A4 pulley Disruption of interval between A2 & A4 A5 pulley & first 2 cruciate pulleys involved
Clinical Issues Most common signs/symptoms: Pain & tenderness over palmar (volar) & lateral aspects of flexor tendon DIP flexion with discomfort Restricted range of motion
*
Diagnostic Checklist Evaluate flexor tendon bowing on sagittal images
Degenerative Arthritis Sclerosis Osteophytosis Joint space narrowing Subluxation Reactive subchondral marrow edema DIP or PIP joints most common
Inflammatory Arthritis Rheumatoid Rheumatoid variants Tenosynovitis + intermediate signal intensity synovial hypertrophy on T2WI (FS PD FSE)
JointTrauma Dislocations of metacarpophalangeal (MCP) joint (f avulsion fracture) o Lateral (coronal plane) injury o Dorsal MCP dislocations o Volar MCP dislocations Proximal interphalangeal joint dislocation o Coach's finger = jammed finger o Collateral ligaments - accessory & proper o Dorsal & volar dislocation Pilon fractures o Middle phalanx o Axial loading o Intraarticular comminution & displacement Distal interphalangeal dislocations o Ball-handling & contact sports o Dorsal dislocation
1 PATHOLOGY General Features General path comments o Relevant anatomy = fibrous portion of fibroosseous flexion tunnel Five digital annular pulleys (DAP) (condensations of transversely oriented fibrous bands) Annular pulleys A1 to A5 Cruciate pulleys C1 to C3
FLEXOR ANNULAR PULLEY TEARS
1 00
A2 (proximal aspect proximal phalanx) & A4 (mid aspect middle phalanx) = most important function of DAP DAP - stabilizes flexor tendons during flexion & resist ulnarlradial displacement as well as palmar bowing Etiology 0 Forcible contraction flexor digitorum profundus (FDP) against extreme force o Professional baseball injury - pitching Distal tip of long finger for control Increased angular velocity in throwing mechanism o Rock climbing injury Support of body weight with DIP joint in flexion High stress Repetitive microtrauma Local trauma varies with grip techniques (loads up to 700N) crimped technique - MCP joint extension, PIP flexion & DIP extension = excessive forces on A2 & A3 DAP Epidemiology o Pulley tears = 50% of lesions in elite climbers o Ring & middle finger affected in climbing vs. middle finger in baseball pitchers 0 30% of finger injuries
Demographics Age o Young adult 0 At risk age groups includes professional baseball pitchers (20-30 years) & rock climbers (20-40 years) Gender: M > F (related to activities with forcible contraction of FDP)
Natural History & Prognosis Delayed diagnosis = fixed contractures of PIP joint Fibrosislscar tissue Weakness Tenosynovitis or partial tear of DAP - treated conservatively
Treatment Conservative o Immobilization o Anti-inflammatory medication o & Steroid injection if strong inflammatory component (may alter healing process) o Indicated in absence of bowstringing Surgical o Complete rupture of flexor pulley system = reconstruction
Gross Pathologic & Surgical Features Bowstringing of flexor tendon o Failure A4 pulley 0 Disruption of interval between A2 & A4 o A5 pulley & first 2 cruciate pulleys involved Less common - combined injury of A2 & A4 pulleys Partial tears - no tendon bowstringing Volar subluxation of tendon = DAP tear Associated tenosynovitis Fibrous tissue A2 & A3 pulley injuries (proximal phalanx) vs. A2 pulley rupture - requires forced flexion to differentiate
Microscopic Features Inflammatory infiltrate Fibrous tissue Tendons - low resistance to shear forces Tendon failure at end of linear portion of load-deformation relationship Collagen breakdown
Presentation Most common signs/symptoms: Pain & tenderness over palmar (volar) & lateral aspects of flexor tendon Clinical profile o Increased tenderness associated with inflammation o Tendon fullness - fluid or hemorrhage o DIP flexion with discomfort o Weakness o Pitcher - decreased velocity of pitches o Tendon bowstringing o Soft tissue swelling o Restricted range of motion
*
Consider Evaluate flexor tendon bowing on sagittal images Evaluate pulley integrity directly on axial images
ISELECTED REFERENCES Klauser A et al: Finger pulley injuries in extreme rock climbers: Depiction with dynamic US. Musculoskeletal Imag 3:755-761, 2002 2. McCue FC 111 et al: The wrist in the adult. Orthopaedic sports medicine. vol 1. 2nd ed. Philadelphia PA, Saunders, (24):1337-63, 2002 3. Martinoli C et al: Sonographic evaluation of digital annular pulley tears. Skeletal Radiol 29:387-91, 2000 4. Hauger 0 et al: Pulley system in the fingers: Normal anatomy and simulated lesions in cadavers at MR imaging, CT, and US with and without contrast material distension of the tendon sheath. Radiol 217:201-12, 2000 5. Klauser A et al: Finger injuries in extreme rock climbers: Assessment of high resolution ultrasonography. Am J Sports Med 27:733-37, 1999 6. Gab1 M et al: Disruption of the finger flexor pulley system in elite rock climbers. Am J Sports Med 26:651-55, 1998 7. Marco RA et al: Pathomechanics of closed rupture of the flexor tendon pulleys in rock climbers. J Bone Joint Surg 80:1012-9, 1998 8. Parellada JA et al: Bowstring injury of the flexor tendon pulley system: MR imaging. AJR 167:347-9, 1996 9. LeViet D et al: Diagnosis of digital pulley rupture by computed tomography. J Hand Surg 21:245-8, 1996 10. Rooks MD et al: Injury patterns in recreational climbers. Am J Sports Med 23:683-5, 1995 11. Bollen SR: Injury to the A2 pulley in rock climbers. J Hand Surg 12:268-70, 1990 1.
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FLEXOR ANNULAR PULLEY TEARS
(Left) Sagittal graphic shows normal intact annular pulley system of the finger. (Right) Coronal graphic shows normal palmar digital fascia1 anatomy with intact cruciate and annular pulleys.
(Left) Axial T l Wl MR shows ulnar subluxation of the flexor tendon in association with an A 1 pulley tear. (Right) Axial FS PD FSE MR shows discontinuity of the annular ligament on the radial side of the flexor tendon.
(Left) Axial T I C+ MR shows tenosynovitis associated with an annular pulley sprain. (Right) Coronal graphic shows disruption of the A4 pulley at the level of the middle phalanx. The A2 and A4 pulleys are considered critical pulleys for finger flexion.
FLEXOR DIGITORUM PROFUNDUS AVULSIONS
I
Key Facts
Imaging Findings Best diagnostic clue: Absentlretracted FDP tendon on axial or sagittal MR images Ring finger = most frequently involved Size: Tendon retraction to palm, proximal interphalangeal (PIP) joint or A4 annular pulley (osseous avulsions are caught at level of A4 pulley)
Top Differential Diagnoses Fractures of the Distal Phalanx Flexor Pulley System Injury Dislocations of the Metacarpophalangeal (MCP)Joint Proximal Interphalangeal Joint Dislocation Tenosynovitis of Flexor Compartments
Forced extension of flexed distal interphalangeal joint (DIP) Ring finger at highest risk FDP avulsions = unique to athletes
Clinical Issues Most common signslsyrnptoms: Tenderness along FDP Inability to flex DIP joint Local tenderness greatest at FDP stump site (PIP level at A4 pulley or distal palm)
Diagnosfic Checklist T2* gradient echo images in axial plane may provide improved tendon contrast
Pathology Traumatic disruptions o Hyperintense fluid surrounding FDS slips (divisions) & centrally (within FDP tendon gap) on axial images
Normal tendons = homogeneous hypointensity on T1 & T2WI
lmaging Recommendations Best imaging tool: MR to document FDP vs. FDS, site of avulsion & extent of retraction Protocol advice: Axial T1 or PD, FS PD FSE & TZ* (gradient echo technique provides excellent tendon visualization)
IDIFFERENTIAL DIAGNOSIS Fractures of the Distal Phalanx Longitudinal - nondisplaced Transverse - often angulated Tuft - comminuted Distal phalanx of long finger most common
Flexor Pulley System Injury Fibro-osseous theca or flexor sheath Baseball pitchers & rock climbers - attenuation or rupture Forcible contraction of FDP Tenderness at volar & lateral aspects of middle phalanx
Dislocations of the Metacarpophalangeal (MCP) Joint Lateral or coronal plane injury (pain in collateral area) Dorsal MCP dislocations Volar MCP dislocations
Proximal lnterphalangeal Joint Dislocation Coach's finger Jammed finger Collateral ligaments (accessory & proper) + volar plate = resistance to lateral deviation Swelling Tenderness (volar, lateral or dorsal)
Tenosynovitis of Flexor Compartments Flexor carpi ulnaris (FCU) tenosynovitis (at wrist and insertion) Flexor carpi radialis tenosynovitis (pain, swelling, tenderness over palmar radial wrist) Restrictive thumb-index tenosynovitis (Linburg's syndrome) at anatomic (variant) interconnection between flexor pollicis longus & index FDP Nonspecific trauma or inflammatory tenosynovitis of FDP or FDS tendons o Hypointense fluid on TlWI, hyperintense on T2WI o Single traumatic event o Repetitive use o Repair response
General Features General path comments o Relevant anatomy (flexor tendon sheath pulley system) Critical A2 & A4 pulleys (for maximal finger flexion) originate from bone Annular pulleys: A1-A5 (thick, well defined) Cruciate pulleys: C1-C3 (thin, collapse in flexion) Palmar aponeurosis Short & long vincula - dorsal mesotenon that carries blood supply Etiology o Traumatic disruptions Athlete grasps the jersey of another athlete: Soccer, football (tight-ends, defensive players) Basketball - catching a finger on a basketball rim during a slam dunk o Forced extension of flexed distal interphalangeal joint (DIP) o Ring finger at highest risk Common muscle belly of long, middle & ring finger FDP insertion has low threshold for disruption
FLEXOR DlClTORUM PROFUNDUS AVULSIONS Ring finger more prominent during grip relative to long finger + tethered by bipennate lumbrical muscles Epidemiology o FDP avulsions = unique to athletes o Ring finger in 75% of cases
Gross Pathologic & Surgical Features
104
3 types of FDP avulsion injuries o Type I Tendon retraction into palm Blood supply disruption Tendon sheath scar o Type I1 Tendon retracts to proximal interphalangeal (PIP) joint FDP caught at chiasm of FDS o Type 111 FDP avulsion + large osseous fragment Bony fragment lodged at distal edge of A4 pulley
o Local tenderness greatest at FDP stump site (PIP level at A4 pulley or distal palm)
Demographics Age: Young athletes most commonly affected Gender: Differences related to activity (M > F)
Natural History & Prognosis Untreated - deformity & loss of function Delay in treatment - tendon degradation by inflammatory cells making operative repair difficult
Treatment Conservative o No role with delayed treatment Surgical o Gold standard = primary repair o Reinsertion into base of distal phalanx o Reconstruction
Microscopic Features Tendon histology o Collagen - fibers parallel to long axis o Endotenon- binds collagen o Epitenon - similar to synovium o Paratenon - surrounds epitenon & contains elastic fibers = tenosynovium of wrist flexors o Collagen failureldisruption in tears Type I collagen in tendons o Elastin - small amount in tendon o Ground substance provides viscoelastic properties of tendon (proteoglycans, glycosaminoglycans, plasma proteins)
Staging, Grading or Classification Criteria Tendon disruptions are classified according to 5 zones o Zone 1 - From fingertip to midportion of middle phalanx o Zone 2 - From midportion middle phalanx to distal palmar crease o Zone 3 - From distal palmar crease to distal edge of carpal tunnel o Zone 4 - In carpal tunnel o Zone 5 - Proximal to carpal tunnel FDP disruptions (avulsion injuries) o Type I - FDP retracts to palm o Type I1 - Vincula vessels intact & tether retracting FDP o Type I11 - Large fragment of bone catches on A4 or A5 pulley o Type IV - Fx at FDP insertion, retraction permitted by separation of tendon from bone
Consider TZ* gradient echo images in axial plane may provide improved tendon contrast Use TlWI sagittal images to identify osseous fragment
1.
2. 3. 4. 5.
6. 7.
8. 9. 10. 11.
Presentation Most common signs/symptoms: Tenderness along FDP Clinical profile o Inability to flex DIP joint o Swelling o Ecchymosis I
12. 13.
Sunagawa T et al: Three-dimensional CT imaging of the flexor tendon ruptures in the hand and wrist. J of Comp Assisted Tomog 27(2):169-74,2003 Wright I1 PE: Arthritic hand. Cambell's operative orthopaedics. St. Louis MO, Mosby, 3707, 2003 Miller MD et al: Treatment of flexor digitorum profundus avulsions. Surgical atlas of sports medicine. Philadelphia PA, WB Saunders, (67):481-6, 2003 Graham TJ et al: Athletic injuries of the adult hand. Orthopaedic sports medicine. vol 1. 2nd ed. Philadelphia PA, WB Saunders, (24):1381-1430,2002 Henry M: Fractures and dislocations of the hand. Rockwood and Green's fractures in adults. 3rd ed. Philadelphia PA, Lippincott Williams and Wilkins, 670, 2001 Perron AD et al: Orthopedic pitfalls in the emergency department. J of Emerg Med 19(1):76-80,2001 VanHolsbeeck MT et al: Musculoskeletal ultrasound. 2nd ed. St. Louis MO, Mosby 541-7, 2001 Strickland JW: Flexor tendons - acute injuries. Green's operative hand surgery. 4th ed. Philadelphia PA, Elsevier Science, 1851-97, 1999 Schneider LH: Flexor tendons - late reconstruction. re en's operative hand surgery. 4th ed. Philadelphia PA, Elsevier Science, 1898-1949, 1999 Strickland JW: Flexor tendon-acute injuries. Green's operative hand surgery 4th ed. Philadelphia PA, Elsevier Science, 1866-8, 1999 Stoller DW. Magnetic resonance imaging. Orthopaedics and sports medicine. vol 1. 2nd ed. Philadelphia PA, Saunders, 987-90, 1997 Smith JH: Avulsion of the profundus tendon and simultaneous intraarticular fracture of the distal phalanx. J Hand Surg 6:600-1, 1981 Leddy JP et al: Avulsion of the profundus tendon insertion in athletes. J Hand Surg 2:66-9, 1977
1
FLEXOR DIGIT0IRUM PROFUNDUS AV
(Left) Coronal graphic show. type I1 FDP avulsion with tendon retraction to level of the PIP joint. The retracted tendon is caught at chiasm of the flexor digitorum superficialis. (Right) Coronal graphic shows type 111 FDP avulsion associated with a large bony fragment lodged at the level of distal A4 pulley.
(Left) Axial T 1 Wl MR shows abnormal morphology (arrow) of the retracted FDP tendon between the flexor digitorum superiicialis slips. (Right) Axial TZ* CRE MR shows normal position of the FDP tendon (arrow) superficial to the slips of the flexor digitorum superficialis tendon. This is at the level of the proximal aspect of the middle phalanx.
(LLfi) Axial T l Wl MR shows high grade tearing (arrow) of the FDP tendon superficial to flexor digitorum superficialis slips. (Right) Axial FS PD FSE MR shows hyperintense edema surrounding the retracted torn fibers of FDP tendon.
SECTION 4: Hip Osteonecrosis Avascular Necrosis, Femoral Head Legg-Calve-Perthes
Marrow Transient Osteoporosis of the Hip
4-10
Dysplasia Developmental Dysplasia of the Hip
4-14
Overuse Syndromes and Muscle Trauma Muscle Strain, Hip Rectus Femoris Muscle Strain Gluteus Medius Muscle Strain Hamstring Tendinosis Piriformis Syndrome Iliopsoas Bursitis Snapping Hip Syndrome
Osseous Trauma Femoral Head Fractures Femoral Neck Fractures Acetabular Fractures Hip Dislocations Avulsion Fracture Pubic Rami Stress Fractures Sacral Insufficiency Fractures
Labrum Labral Tear, Hip Paralabral Cysts, Hip
4-74 4-78
Arthritis Femoroacetabular Impingement Osteoarthritis, Hip Loose Bodies, Hip Rheumatoid Arthritis, Hip
Infection Osteomyelitis, Hip
4-98
AVASCULAR NECROSIS, FEMORAL HEAD
Coronal graphic shows anterolateral subchondral ischemic focus in early stage AVN. The overlying articular cartilage and subchondral plate are normal.
Coronal T 1 Wl MR shows wedge-shaped subchondral ischemic focus with central marrow fat signal intensity. Hypointense peripheral band represents the reactive interface.
o Involvement of femoral head greater than I +
Abbreviations and Synonyms AVN, aseptic necrosis, osteonecrosis of the femoral head, ischemic necrosis
Definitions Region of dead trabecular bone + marrow extending to subchondral plate of femoral head
General Features Best diagnostic clue: Wedge-shaped subchondral ischemic focus Location: Anterolateral weightbearing femoral head most common Size: Variable from < 15% (mild) to > 30% (severe) involvement of femoral head Morphology: Linear to wedge-shaped subchondral necrotic focus
Radiographic Findings Radiography o Anteroposterior (AP) + frog lateral o Used in staging (not sensitive to stage 0 and I AVN)
I
o
o o o
involvement of joint space narrowing or acetabular findings Femoral head sclerosis Subchondral collapse = advanced sign Ficat classification (stage 0 - IV) Steinberg staging based on radiographs, bone scan + MRI
CT Findings NECT o More accurate than conventional radiographs for staging (extent of disease at stages I1 and higher) o Less sensitive relative to MR o Osteoporosis = first sign o Sclerosis + distortion of central bony asterisk (normal thickening of trabeculae in center of femoral head)
MR Findings TlWI o Hypointense peripheral band outlining central region of bone marrow = reactive interface between necrotic + reparative zones o + Hypointense bone marrow edema of head + neck o Sagittal images to assess femoral head morphology for cortical flattening (supplemental to routine imaging with coronal + axial images) o + Hypointense joint effusion
1
DDx: Avascular Necrosis, Femoral Head OA
Femoral Neck Fx
Cor FS PD MR
Cor T l Wl MR
Metastases
I Cor F.
AVASCULAR NECROSIS, FEMORAL HEAD Key Facts Imaging Findings Best diagnostic clue: Wedge-shaped subchondral ischemic focus Location: Anterolateral weightbearing femoral head most common Double line sign in 80% (hyperintense inner border parallel to hypointense periphery)
Top Differential Diagnoses Transient Osteoporosis of Hip (TOH) Degenerative Arthrosis Fracture (Fx)
1 Pathology -#
Traumatic AVN - 1090non-displaced femoral neck fxs + 15-30% displaced fxs + 10% dislocations
o Wedge-shaped subchondral infarct T2WI o Double line sign in 80% (hyperintense inner border parallel to hypointense periphery) o Hypointense peripheral border more difficult to visualize on FS PD or T2 FSE images o Hypointense periphery = reparative tissue interface with necrotic region o + Hyperintense femoral head + hyperintense neck edema + effusion o Staging Ficat + Arlet Stage 1: Trabeculae normal to porotic double line sign Stage 2: Sclerosis of trabeculae Stage 3: Loss of spherical shape of femoral head Stage 4: Collapse of femoral head, articular cartilage destruction + joint space narrowing o Mitchell MR classification Qualitative assessment of alterations in MR signal in central region of osteonecrotic focus TI C+ o Decreased enhancement with gadolinium in early AVN o Nonviable trabeculae + marrow = no enhancement o Enhancement corresponds to reparative zone of hypointense band
*
Nuclear Medicine Findings Bone Scan o Earlier detection than conventional radiographs (less sensitive relative to MR) o Technetium labeled phosphate analogues + sulfur colloid
Corticosteroid use = 5-25% of cases of atraumatic AVN Double line sign = inflammatory response with granulation tissue inside reactive bone interface
.
Clinical Issues Most common signs/symptoms: Hip, groin or gluteal pain rt referred thigh or knee pain increased risk of contralateral AVN Endstage = destruction of femoral head + joint osteoarthritis Core decompression for stage I & 11: Best results with < 25% involvement of weight-bearing surface of femoral head
checklist Early femoral head collapse requires sagittal images
[DIFFERENTIALDIAGNOSIS Transient Osteoporosis of Hip (TOH) Osteoporosis femoral head + neck Resolves over a 10-12 month period k Involvement of acetabular + femoral sides of the joint
Degenerative Arthrosis Articular cartilage degeneration Acetabular changes usually first Femoroacetabular impingement = osteoarthritis (OA) in a younger patient with a non-dysplastic hip-
Fracture (Fx) Subchondral insufficiency fractures may mimic AVN-related subchondral capsule Capital + femoral neck stress fractures
Metastatic Disease Hypointense to hyperintense lesion not centered in subchondral femoral head Gross trabecular destruction as confirmed by CT
Infection Hyperintense marrow edema on both sides of joint Adjacent soft tissue hyperintense edema & fluid Joint synovitis prominent
Osseous Contusion Localized subchondral marrow edema without fracture segment
Imaging Recommendations Best imaging tool: MR more sensitive than CT or bone scintigraphy Protocol advice o TI + FS PD FSE or STIR coronal + axials o Small FOV coronal o Sagittal T1 or FS PD FSE for evaluating femoral head sphericity (for early subchondral collapse)
General Features General path comments o Relevant anatomy Blood supply to femoral head = medial + lateral circumflex branches of the profunda femoral artery Etiology o Traumatic (most common)
AVASCULAR NECROSIS, FEMORAL HEAD Fracture of femoral head or neck Hip dislocation Disrupted vascular supply at time of injury o Atraumatic Corticosteroid use and alcohol abuse = most common Idiopathic m Sickle-cell anemia, Gaucher's disease, lupus, coagulopathies, hyperlipidemia, organ transplantation, Caisson's disease + thyroid disease Epidemiology o AVN responsible for 10% of total hip replacements o Traumatic AVN - 10% non-displaced femoral neck fxs + 15-30% displaced fxs + 10% dislocations o Corticosteroid use = 5-25% of cases of atraumatic AVN
Gross Pathologic & Surgical Features
Cancellous bone - yellow necrosis extending to subarticular region Softening within necrotic cancellous bone at interface with viable bone = resorption of necrotic focus Collapse of femoral head load-bearing segment Collapse of femoral head + articular cartilage destruction + loose bodies + marginal osteophytes
Gender: M:F = 4:l
Natural History & Prognosis Endstage = destruction of femoral head + joint osteoarthritis Early identification + intervention may not alter result Disease progression greater with non-surgical treatment
Treatment Conservative = limited utility 0 Observation + protected weight-bearing Surgical o Core decompression +_ bone grafts, osteotomy + electrical stimulation 0 Core decompression for stage I & 11: Best results with i25% involvement of weight-bearing surface of femoral head o Arthroplasty
~ D ~ A G N O S TCHECKLIST ~C
I
Consider Identify subchondral fracture using high resolution coronal or sagittal images Early femoral head collapse requires sagittal images
Microscopic Features Central region of hyperintensity = necrosis of bone + marrow prior to capillary mesenchymal ingrowth Hypointense peripheral band = sclerotic margin of reactive tissue at necrotic + viable bone interface Double line sign = inflammatory response with granulation tissue inside reactive bone interface
Staging, Grading or Classification Criteria International classification o Stage 0 : Bone biopsy = osteonecrosis; normal imaging o Stage I: Positive bone scan +_ MR o Stage 11: Mottled femoral head with sclerosis/cyst/osteopenia on radiographs + no collapse + positive bone scan & MR o Stage 111: Crescent sign lesions + depression femoral head articular surface o Stage IV: Flattening articular surface + joint space narrowing + secondary acetabular changes
Presentation Most common signs/symptoms: Hip, groin or gluteal pain +_ referred thigh or knee pain Clinical profile o Decreased hip rotation + range of motion (worse in presence of a joint effusion) o Increased risk of contralateral AVN o Pain = deep + throbbing + worse with ambulation o k Catching or popping sensation o History of trauma, steroid use, alcohol use or abusc o Trendelenburg gait
*
Demographics Age: Third to sixth decades most common
ISELECTED
REFERENCES
Newberg ~ F e al: t Imaging of the painful hip. Clin Orthop 406: 19-28 Review, 2003 Cherian SF et al: Quantifying the extent of femoral head involvement in osteonecrosis.J Bone Joint Surg AM 85-A(2):309-15,2003 Tsuji T et al: Evaluation of femoral perfusion in a non-traumatic rabbi osteonecrosismodel with T2*-weighteddynamic MRI. J Orthop Res 21(2):341-51, 2003 May DA et al: Screening for avascular necrosis of the hip with rapid MRI: Preliminary experience.J Comput Assis Tomogr 24(2):284-7, 2000 Staudenherz A et al: Diagnostic patterns for bone marrow oedema syndrome and avascular necrosis of the femoral head in dynamic bone scintigraphy. Nucl Med Commun 18(12):1178-88,1997 Mulliken BD et al: Prevalence of previously undetected osteonecrosis of the femoral head in renal transplant recipients. Radiology 192:831-4, 1994 Chang CC et al: Osteonecrosis: Current perspectives on pathogenesis and treatment. Semin Arthritis Theum 23:47-69, 1993 Tervonen 0 et al: Clinically occult avascular necrosis of the hip: Prevalence in an asymptomatic population at risk. Radiology 1822345-7, 1992 Beltran J et al: Core decompression for avascular necrosis of the femoral head: Correlation between long-term results and preoperative MR staging. Radiology 175533-6, 1990 Meyers MH: Osteonecrosis of the femoral head: Pathogenesis and long-term results of treatment. Clin Orthop 231:51-61, 1988 Ficat RP: Idiopathic bone necrosis of the femoral head. J Bone Joint Surg Br 67B:3-9, 1985
AVASCULAR NECROSIS, FEMORAL HEAD
( I . ~ j i(:oronal ) f 5 I'll I SF MK 5hoivi exlc.ncirtl h)pvintt'n\e boric, nwrro\v c,dcrn,~p ~ t t e r r10 ~ thr ier~ior.~l head aritl neck ,,ssoc.iated ivith AVN. (Right) Coron~l
LEGC-CALVE-PERTHES
Coronal graphic shows subchondral necrosis in the proximal femoral epiphysis in early Legg-CalvC-Perthes.
-
Coronal FS PD FSE MR shows hypointense ischemic focus (arrow) of the capital epiphysis associated with medial hyperintense metaphyseal irregularity. joint effusion is hyperintense.
o Metaphyseal irregularity (rarefaction of lateral +
medial metaphysis + cystic changes)
o Joint space (inferomedial) widening + intact
Abbreviations and Synonyms Perthes', avascular or ischemic necrosis of the proximal femoral epiphysis, Legg-Perthes disease, osteochondritis coxae juvenilis, coxa plana
Definitions Necrosis of osseous epiphysis of femoral head classified as an osteochondrosis
General Features Best diagnostic clue: Hypointensity of capital epiphysis on coronal MR images (TI or T2) Location: Proximal femoral epiphysis Size: Variable size from peripheral irregularity of epiphyseal ossification center to complete replacement of normal marrow fat Morphology o Initially confined to epiphysis o Late remodeling = coxa plana & coxa magna
Radiographic Findings Radiography o Effusion, fragmentation capital epiphysis
+ flattening of sclerotic
subchondral plate o Catterall classification (group I-IV) estimates amount of femoral head involvement o Waldenstrom's radiographic staging Initial stage = increased head-socket distance, subchondral plate thinning + dense epiphysis Fragmentation stage = subchondral fracture, inhomogeneous dense epiphysis + porous appearance + metaphyseal cysts Reparative stage = normal bone in areas of resorption + removal of sclerotic bone + more homogeneous epiphysis Growth stage = approaches normal femoral shape Definite stage = final shape (joint congruency vs. incongruency)
MR Findings TlWI o Hypointense intraarticular effusion o Hypointense irregularity along periphery of ossific nucleus o Linear hypointensity traversing femoral ossification center in early stages o Revascularization of necrotic epiphysis = replacement of hypointense focus with marrow fat signal intensity
DDx: Legg-Calvk-Perthes ICA
Osteonecrosis
Slipped Epiphyqis
Osteoid Osteoma
Cor T l Wl MR
Sag FS PD MR
Cor T l Wl MR
Ax NECT
LEGG-CALVE-PERTHES Key Facts Imaging Findings Best diagnostic clue: Hypointensity of capital epiphysis on coronal MR images (TI or T2) Size: Variable size from peripheral irregularity of epiphyseal ossification center to complete replacement of normal marrow fat Late remodeling = coxa plana & coxa magna Hypointense epiphyseal marrow center on T1 + T2WI
Top Differential Diagnoses Toxic Synovitis Septic Hip Juvenile Chronic Arthritis UCA) Juvenile Osteonecrosis
o Coxa plana + coxa magna = late remodeling T2WI o FS PD or T2 FSE images to assess articular cartilage thickness + chondral irregularities o Physeal cartilage hyperintense on T2WI - in early stage disease o Loss of femoral head containment in acetabulum Intermediate signal hypertrophied synovium in iliopsoas recess Thickening of intermediate signal epiphyseal cartilage o Hyperintense joint effusion Hypointense epiphyseal marrow center on T1 + T2WI Sagittal TI + T2WI also useful to display acetabular + femoral head cartilage
*
Nuclear Medicine Findings Bone scintigraphy o Early decrease secondary to interruption of blood supply o Increased uptake late - with secondary revascularization + repair + degenerative arthritis
Imaging Recommendations Best imaging tool: MR for early detection of epiphyseal ossification center irregularity Protocol advice o Coronal TI, FS PD FSE + T2* o Axial TI, PD + FS PD FSE o Sagittal FS PD FSE
Pathology Insufficiency of capital epiphyseal blood supply with physis acting as a barrier Ischemia may be arterial or venous-based leading to intraepiphyseal infarction 15 to 20% with bilateral involvement
Clinical Issues
Most common signslsymptoms: Limp + groin, thigh or knee pain (referred) 3-12 years Gender: M:F = 4-5:l
Iiagnostic Checklist Use coronal TlWI to detect subtle peripheral or linear areas of epiphyseal marrow hypointensity
Increased white blood cell count + sedimentation rate Hips held in flexion, abduction + external rotation vs. hip adduction in Perthes' Joint effusion +/- joint debris +/- reactive marrow edema
Juvenile Chronic Arthritis (JCA) Limp + hip pain Chronicity + thigh atrophy Fever + rash + positive antinuclear antibody Epiphyseal erosions
Juvenile Osteonecrosis Distinction = identifiable etiology Sickle cell + thalassemia Idiopathic thrombocytopenia purpura Hip dislocation
Slipped Capital Femoral Epiphysis Posterior-inferiordisplacement of proximal femoral epiphysis Pain + limp Limitation of internal rotation + abduction
Osteoid Osteoma Local pain worse at night, decreased by salicylates Local swelling + point tenderness Extensive marrow edema on FS PD FSE or STIR
1 PATHOLOGY General Features
Toxic Synovitis Self-limitingacute synovitis (3 to 10 days) Boys < 4 years Minimal thigh atrophy Improves in < 5 days with bedrest + anti-inflammatory medications Significant effusion + capsular distension
Septic Hip Acutely ill + fever
General path comments: Capital femoral epiphysis at risk Etiology o Insufficiency of capital epiphyseal blood supply with physis acting as a barrier o Overgrowth of articular cartilage medially + laterally o Infarction - trabecular fracture with decreased epiphyseal height o Disease progressive o Ischemia may be arterial or venous-based leading to intraepiphyseal infarction
LEGG-CALVE-PERTHES Epidemiology o 15 to 20% with bilateral involvement o One in 1200 children < 15 years affected
Natural History & Prognosis Leg length inequality Thigh atrophy Epiphyseal changes + metaphyseal changes associated with poor prognosis Younger age of presentation = better prognosis > 8 years old = poor prognosis Classification post skeletal maturity 0 Mose - evaluate shape of femoral head o Stulberg - predicts long-term performance o Coxa plana, coxa magna o Arthritis = patients with Mose "fair"to "poor" outcomes Defined by a 2 mm or > deviation of spherical femoral head compared to a circular template o > 20% epiphyseal extrusion or > 50% femoral head involvement = poor prognosis
Gross Pathologic & Surgical Features Initial stage o Necrosis of epiphyseal bone + marrow 0 Vascular invasion of dead bone 0 Epiphyseal cartilage hypertrophy Fragmentation o Dead bone resorbed o Unossified physeal cartilage in metaphysis develops cysts o Cartilage hypertrophy Reparative o Replacement of dead bone
Microscopic Features Epiphyseal cartilage o Disordered collagen fibrosis 0 Increased proteoglycan concentration o Decrease in structural glycoproteins Infarction o Necrosis of epiphyseal bone + marrow o New blood vessels invade o Resorption of dead bone + new bone formation
Staging, Grading or Classification Criteria Catterall - distribution of epiphyseal abnormalities
based on anteroposterior + lateral radiographs 0 Group I: < % epiphysis involved o Group I1 : < lh epiphysis involved 0 Group 111: Most of epiphysis involved o Group IV: Total epiphysis involved 0 Risk factors = lateral subluxation, calcification lateral to epiphysis, Gage's sign (radiolucent V in lateral epiphysis) + a horizontal physis Salter - Thompson: Extent + location of subchondral fracture 0 A = fracture < 50% span of epiphysis o B = fracture > 50% span of epiphysis Herring system: Based on lateral pillar involvement (lateral 15 to 30% of epiphysis = lateral pillar) 0 A = uninvolved lateral pillar o B = < 50% involvement of lateral pillar 0 C=>50%
Presentation Most common signs/symptoms: Limp + groin, thigh or knee pain (referred) Clinical profile o No specific history of trauma o Decreased range of motion (internal rotation + abduction) + painful gait & muscle atrophy
Demographics Age o 3-12 years 0 Median = 7 years Gender: M:F = 4-5:1
Treatment Conservative o 50% improve with no treatment o Bed rest + abduction stretching & bracing Surgical o Femoral/pelvic osteotomies to contain hip
LDlACNOSTlC CHECKLIST Consider Use coronal TlWI to detect subtle peripheral or linear areas of epiphyseal marrow hypointensity
I
Fitzgerald RH et al: Orthopaedics. Legg-Calvk-Perthes. St. Louis MO, Mosby, Sect 9 (9-19):1420-32, 2002 2. Cho TJ et al: Femoral head deformity in Catterall groups I11 and IV Legg-Calve-Perthes disease: Magnetic resonance imaging analysis in coronal and sagittal planes. J Pediatr Orthop 22(5):601-6, 2002 3. De Sanctis N et al: Prognostic evaluation of Legg-Calve-Perthes disease by MRI. Part I: The role of physeal involvement. J Pediatr Orthop 20(4):455-62, 2000 4. De Sanctis N et al: Legg-Calve-Perthes disease by MRI. Part 11: Pathomorphologenesis and new classification. J Pediatr Orthop 20(4):463-70, 2000 5. Gabriel H et al: MR imaging of hip disorders. Radiographics 14:763-81, 1994 6 . Bos CFA et al: Sequential magnetic resonance imaging in Perthes' disease. J Bone Joint Surg 73:219-24, 1991 7. Egund N et al: Legg-Calve-Perthes disease: Imaging with MR. Radiology 17939-92, 1991 8. Rush BH et al: Legg-Calve-Perthes disease: Detection of cartilaginous and synovial changes with MR imaging. Radiology 167:473-6, 1988 9. Thompson GH et al: Legg-Calve-Perthes disease: Current concepts and controversies. Orthop Clin North Am 18:617, 1987 10. Toby EB et al: Magnetic resonance imaging of pediatric hip disorders. J Pediatr Orthop 5:665-71, 1985 1.
( L e f ) Coronal graphic shows ischemic injury to the physis leading to disorganization and bridging of the cartilage. (Right) Coronal graphic shows abnormal growth of the proximal femur as a late change of Legg-CalvePerthes (coxa magna, coxa plana).
(Left) Coronal T l Wl MR shows early Legg-Calve-Perthes with hypointense ischemic change in the superior aspect of the right capital epiphysis (arrow). Bilateral physeal irregularity is present. (Right) Coronal T l Wl MR shows left Legg-Calve-Perthes with subchondral collapse associated with DDH.
Tvnical (Left) Coronal T I WI MR shows left ischemic capital epiphysis and medial metaphyseal sclerosis/cystic change. (Right) Coronal T l Wl MR shows bilateral advanced remodeling with coxa plana and coxa magna deformity of the femoral heads.
C
-
I
TRANSIENT OSTEOPOROSIS OF THE H I P
Coronal graphic shows transient osteoporosis of the hip with diffuse extension of marrow edema into the femoral head and neck.
Coronal T l W l MR shows hypointense marrow edema involving right femoral head, neck and distal intertrochanteric region with partial sparing of the greater trochanter and lateral femoral head.
o Osteopenia with decreased bone density =
Abbreviations and Synonyms TOH, transient osteoporosis, transient osteonecrosis, algodystrophy
Definitions Self-limited diffusebone marrow edema of femoral head and neck
o o o o
radiolucency + indistinct trabeculae + cortex Osteopenia may be diffuse vs. patchy + band-like Demineralization of subchondral plate Preservation of joint space Remineralization within 10 months
CT Findings NECT o Decreased bone density with intact trabeculae o Attenuated subchondral plate o Normal joint space - view on coronal reformations
MR Findings
General Features Best diagnostic clue: Hyperintense marrow signal in femoral head + neck on T2WI Location: Femoral head + extension to femoral neck Size: Diffuse involvement of majority of femoral head + variable extension into neck to intertrochanteric region Morphology o Variable within confines of femoral head + neck Homogeneous Partial marrow sparing may exist (greater trochanter)
Radiographic Findings Radiography o Initial radiographs = normal first few days
TlWI o Hypointensity (large areas or diffusely) within femoral head, neck + intertrochanteric region + acetabulum o Edema pattern homogenous + well-marginated o + Hypointense joint effusion o May see marrow sparing in medial + lateral-most margins of femoral head + greater trochanter 2" to greater concentration of fat marrow o Resolution associated with web-like or reticular areas of hypointensity T2WI o Hyperintensity femoral head + neck o Hyperintensity most conspicuous on T2 fat-suppression or STIR techniques
mm
DDx: Transient Osteoporosis of the Hip AVN
Stress Fx
Inflammatory OA ,
Metastases
* re
.,.
I?-'
Cor T l Wl MR
Cor FS PD MR
Cor FS PD MR
sl.
-4
Cor FS PD MR
TRANSIENT OSTEOPOROSIS OF THE HIP Key Facts Imaging Findings
Infiltrative Neoplasm
Best diagnostic clue: Hyperintense marrow signal in femoral head + neck on T2WI Size: Diffuse involvement of majority of femoral head + variable extension into neck to intertrochanteric region Hyperintensity most conspicuous o n T2 fat-suppression or STIR techniques Contrast enhancement prominent
Pathology
.
Self-limited + unknown etiology Healthy middle-aged men affected Elevation of pressure within bone marrow Hydroxyapatite shift - reduced mineral content
Clinical Issues Most common signs/symptoms: Progressive hip pain Resolution of symptoms 6 to 10 months post onset Age: Third + fourth decades most common
Top Differential Diagnoses Osteonecrosis Stress Fracture Inflammatory Osteoarthritis (OA) Osseous Contusion Osteomyelitis
Diagnostic Checklist
Small FOV T1 + FS PD FSE to document marrow edema i n the absence of a subchondral fracture
o MR sensitive to marrow edema within 48 hours of
Osseous Contusion
onset of clinical symptoms o Less common association of acetabular hyperintensity o Hyperintensity may spare marrow within anterior, posterior, medial or lateral aspect femoral head o Marrow hyperintensity may show variability of anatomic distribution on sequential studies o Edema interface well-defined without a demarcating hypointense line or band (no double-line sign) o Normal cortex + subchondral plate o Normal adjacent soft tissues o Small to moderate hyperintense joint effusion TI C+ o Contrast enhancement prominent o Heterogenous
Femoral head + neck marrow edema hypointense on T1 + hyperintense on T2WI without stress fracture +/- Trauma history
Osteomyelitis Hyperintense marrow edema adjacent to hyperintense soft tissue edema & fluid + sinus tract +/- Suggestive clinical/laboratory findings
Infiltrative Neoplasm Replacement of normal trabecula k aggressive features of cortical destruction + soft tissue extension
Normal Weight-Bearing Trabeculae Forms boundaries of Ward's triangle Band-like areas of hypointensity on TlWI No increased signal intensity on T2WI
Imaging Recommendations Best imaging tool: MR sensitive + specific for bone marrow edema (sensitive to influx of free water) Protocol advice o T1 (not PD) to show hypointense marrow edema in contrast to normal marrow fat signal o Coronal FS PD FSE or STIR required (axial + sagittal are secondary planes of choice)
1 DIFFERENTIAL DIAGNOSIS
I -
Regional Migratory Osteoporosis
1
Osteonecrosis Early phase with subtle subchondral hypointense fracture on high resolution images + hyperintense marrow edema pattern on T2WI
Stress Fracture Hyperintense (T2WI) marrow centered within calcar Hypointense fracture line or medial cortical thickening of femoral neck
Inflammatory Osteoarthritis (OA) Synovitis + effusion o Intermediate to hyperintense on T2WI Joint space narrowing, sclerosis + osteophytes
Multiple anatomic sites involved sequentially typically foot, knee, or hip Middle-aged men Localized pain + swelling in one joint Resolution < 12 months Large joints lower extremity Recovery associated with development of new site either ipsilateral or contralateral in location Synchronous involvement unusual May be closely related to TOH
Transient Bone Marrow Edema Syndrome Normal radiographic findings (no osteopenia) MR finding identical to transient osteoporosis of the hip May represent an earlier stage of TOH
Reflex Sympathetic Dystrophy More patchy + subarticular signal changes Prolonged clinical course Favors lower extremity joints other than hip
TRANSIENT OSTEOPOROSIS OF THE HIP
1 PATHOLOGY General Features
12
General path comments o Relevant anatomy Femoral head = multiaxial, synovial ball-and-socket joint Acetabulum = 40% bony coverage of femoral head Femoral head forms two-thirds of a sphere with proximal transition into the femoral neck = weight-bearing bone in femur ~ a l c a femorale r from inferomedial femoral neck cortex to lesser trochanter Weight-bearing stress trabeculae - form the boundaries of Ward's triangle in femoral neck + head 95% of femoral neck = intracapsular Etiology o Self-limited + unknown etiology o Women in third trimester (original description) with predilection for left hip o Healthy middle-aged men affected o Progressive demineralization Epidemiology: May represent an early stage of osteonecrosis
Gross Pathologic & Surgical Features Elevation of pressure within bone marrow Normal appearance of articular cartilage, cortex ST subchondral bone Small joint effusion Synovial inflammation
Microscopic Features ~ e c r o t i cfat cells Fibrovascular regenerative tissue Increased osteoid Edema: Difficult to document increased free water on histologic study Hydroxyapatite shift - reduced mineral content
&
Presentation Most common signs/symptoms: Progressive hip pain Clinical profile o Acute onset o Groin pain o Pain exacerbated by weight-bearing o Decreased range of motion + limp o Absence of infection or trauma o Involvement of one joint o Resolution of symptoms 6 to 10 months post onset
Demographics Age: Third + fourth decades most common Gender o More common in males o Also reported in pregnant women in third trimester
Natural History & Prognosis Self-limited
I
Resolution of symptoms + radiographic + MR findings < 10 months Decreased joint effusion with resolution of symptoms No double-line sign develops
Treatment Conservative = clinical observation o Serial MR to document resolution Surgical o Core decompression - may produce rapid decrease in pain + shortened resolution time
I DIAGNOSTIC CHECKLIST Consider Small FOV T1+ FS PD FSE to document marrow edema in the absence of a subchondral fracture
Koo KH et al: Increased perfusion of the femoral head in transient bone marrow edema syndrome. Clin Orthop 402:171-5, 2002 Papadopoulos EC et al: Bone marrow edema syndrome. Orthopedics 24(1):69-73Review, 2001 Bohndorf K et al: Musculoskeletal imaging: A concise multimodality approach. Germany, Thieme, 230-1, 2001 Kim YM et al: The pattern of bone marrow oedema on MRI in osteonecrosis of the femoral head. J Bone Joint Surg Br 82(6):837-41,2000 Calvo E et al: Core decompression shortens the duration of pain in bone marrow oedema syndrome. Int Orthop 24(2):88-91,2000 Koo KH et al: Borderline necrosis of the femoral head. Clin Orthop 358:158-65, 1999 Deutsch A et al: MRI of the musculoskeletal system: A teaching file. 2nd ed. Philadelphia PA, Lippincott Williams & Wilkins, (4):197-272,1997 Doury P: Bone-marrow oedema, transient osteoporosis, and algodystrophy.J Bone Joint Surg Br 76:993, 1994 Richardson ML: Can MR imaging distinguishing transient osteoporosis of the femoral head and osteonecrosis?AJR 162:1244, 1994 Hayes CW et al: MR imaging of bone marrow edema pattern: Transient osteoporosis, transient bone marrow edema syndrome, or osteonecrosis. Radiographics 13:lOOl-11,1993 Hofman S et al: Bone marrow oedema syndrome and transient osteoporosis of the hip: An MRI-controlled study of treatment by core decompression.J Bone Joint Surg Br 75:210, 1993 Potter H et al: Magnetic resonance imaging in diagnosis of transient osteoporosis of the hip. Clin Orthop 280:233-9, 1992 Schapira D: Transient osteoporosis of the hip. Semin Arthritis Rheum 22:98-105, 1992 Daniel WW et al: The early diagnosis of transient osteoporosis by magnetic resonance imaging. J Bone Joint Surg 74:1262-4, 1992 Hauzeur J et al: Study of magnetic resonance imaging in transient osteoporosis of the hip. J Rheumatol 18:1211-7, 1991 Wilson AJ et al: Transient osteoporosis: Transient bone marrow edema? Radiology 167:757, 1988 Curtiss PH Jr et al: Transient demineralization of the hip in pregnancy: A report of three cases. J Bone Joint Surg AM 41:1327, 1959
TRANSIENT OSTEOPOROSIS OF THE HIP
Variant (Left) Coronal T1 WI MR shows extended marrow edema pattern distal to the intertrochanteric area on the left. Note partial marrow sparing in the greater trochanter and medial femoral head (TOH). (Right) Coronal FS PD FSE MR shows hyperintense marrow edema of the acetabulum and femoral head/neck associated with early ischemic change mimicking TOH.
Variant (Left) Coronal graphic shows extended marrow edema pattern of AVN simulating the changes of TOH. (Right) Coronal FS PD FSE MR shows hyperintense marrow edema associated with early femoral head ischemia. High resolution images are required to identify the AVN focus or subchondral fracture in early osteonecrosis.
DEVELOPMENTAL DYSPLASIA O F THE HIP
Coronal graphic shows characteristic of DDH.
shallow
acetabulum
Coronal FS PD FSE MR shows shallow acetabulum (arrow) in an adult associated with an acetabular labral tear. Adult DDH is best identified on anterior coronal images.
o Perkin's line (perpendicular to Hilgenreiner's)
through lateral acetabular rim o Lateral subluxation of capital epiphysis = 2 mm or >
Abbreviations and Synonyms Developmental dysplasia of the hip (DDH), congenital dysplasia of the hip (CDH), congenital hip dysplasia
Definitions
Shallow (dysplastic) acetabular fossa + superolateral migration of the femoral head
I MAGING
FINDINGS
General Features Best diagnostic clue: Shallow acetabulum + subluxation of the femoral head Location o Left hip involvement: Up to 60% o Bilateral involvement: 20% Size: Subluxation to complete dislocation of femoral head Morphology: Shallow to false acetabulum in complete dislocation + acetabular labral deformity
Radiographic Findings Radiography o False negative diagnosis < six months o Femoral capital epiphysis in inner lower quadrant o Hilgenreiner's line through triradiate cartilage
from teardrop to metaphysis o Superior subluxation - delta of 2 mm or > from
~ i l ~ e n r e i n e rline ' s to metaphysis compared with normal side o Disruption of Shenton's curved line: Formed by inferior aspect of superior pubic ramus o Center edge angle < 25": Associated with instability o Secondary signs Excessive femoral head anteversion Delayed ossification of femoral capital epiphysis
CT Findings NECT o Use coronal + axial CT images or reformations o Sector angle for acetabular coverage (capital epiphysis to acetabular rim relative to the horizontal axis)
MR Findings TlWI o Epiphyseal articular cartilage - intermediate signal (TlWI) o Coronal + axial planes to identify position of capital epiphysis o Can visualize ossific nucleus (hypoplastic) when not visible on conventional radiographs or CT
DDx: Developmental Dysplasia of the Hip Svnovitis
Slippcd Epiph ysk
Coxa Vara
Cor FS PD MR
Ax T l W I MR
Cor FS PD MR
DEVELOPMENTAL DYSPLASIA O F THE HIP Key Facts Imaging Findings
,
Best diagnostic clue: Shallow acetabulum + subluxation of the femoral head Epiphyseal articular cartilage - intermediate signal (TIWI)
Top Differential Diagnoses Synovitis Septic Arthritis Slipped Capital Femoral Epiphysis Congenital Coxa Vara
Pathology First 6 postnatal weeks - acetabulum susceptible to remodeling Hourglass joint capsule: Compression between limbus + ligamentum teres
Deficient superior + posterior acetabular rim
Clinical Issues Most common signs/symptoms: Palpable click or clunk using Ortolani & Barlow stress maneuvers Age: Newborns Gender: F:M = 6:l Positive family history, breech presentation, torticollis, scoliosis + metatarsus adductus Decreased range of motion Degenerative changes
Diagnostic Checklist
Anterior coronal images t o identify dysplastic acetabulum in adult
--
o Hypointense joint effusions o Superolateral dislocation - use coronal plane o Anteroposterior (AP) relationship + dysplasia of
acetabulum - use axial images o Mild acetabular dysplasia shown on anterior coronal
images o Pulvinar - hyperintense signal of fat T2WI o Epiphyseal articular cartilage intermediate on FS PD FSE o Effusions hyperintense on T2WI o Failure to reduce dislocated hip Hourglass acetabulum, hypointense inverted labrum Hypointense interposed iliopsoas tendon (seen on coronal, axial + sagittal images) Direct visualization of fat suppressed pulvinar fibrofatty tissue Hypertrophy of hypointense ligamentum teres Acetabular labral coverage lateral to dysplastic acetabulum visualized on coronal images Deformed labral limbus = horizontal slope vs. normal downward lateral slope Inverted limbus of acetabular roof = inferomedial displacement with long axis superoinferior orientation on coronal images 0 Serial follow-up studies for position of femoral head + acetabular morphology + labral coverage o Acetabular index calculation from coronal MR (Hilgenreiner's line through triradiate cartilage + tangent through acetabular roof: > 30") T2* GRE: Epiphyseal articular cartilage: Hyperintense Associated ischemic necrosis hypointense on TlWI + T2WI
Ultrasonographic Findings Up to 6 months: Application of ultrasound Visualized iliac bone, acetabulum, labrum, + femoral capital epiphysis Evaluate subluxation, dislocation, pulvinar, inverted labrum, hypoplastic ossific nucleus, acetabular dysplasia + ossification
Imaging Recommendations Best imaging tool o Ultrasound dynamic exam diagnostic up to 6 months but operator dependent o MR: Best visualization of deformed or inverted labrum + cartilaginous components of acetabular roof + capital epiphysis Protocol advice: TI, FS PD FSE + T2* gradient echo coronal images to identify acetabular concavity, decentralized femoral head + deformedlinverted labrum
I DIFFERENTIAL DIAGNOSIS Synovitis Intermediate signal synovium Hyperintense fluid + capsular distension on T2WI
Septic Arthritis Nonuniform hyperintense fluid on T2WI Reactive marrow edema + soft tissue edema Clinical signs of infection
Slipped Capital Femoral Epiphysis Posterior-inferior displacement of proximal femoral epiphysis Vertical growth plate + retroversion femoral neck Capital epiphysis retains acetabular coverage
Congenital Coxa Vara Decrease of femoral necktshaft angle (< 120") Limb bud insult
Hip Dislocations Post-traumatic with joint hemorrhage, osseous contusions + acetabular column fracture
Proximal Focal Femoral Deficiency Congenital hypoplasia or aplasia of proximal femur Acetabular dysplasia
DEVELOPMENTAL DYSPLASIA OF THE HIP -
Natural History & Prognosis General Features General path comments o Relevant anatomy Triradiate or Y cartilage: Center of acetabulum separates the ilium, ischium + pubis Genetics o Multifactorial o Increased joint laxity = dominant pattern o Acetabular dysplasia = polygenic Etiology o Laxity of joint capsule ligaments o Mechanical versus physiologic (elevated maternal estrogen levels) o First 6 postnatal weeks - acetabulum susceptible to remodeling o Inadequate contact between acetabulum + femoral head Epidemiology: Incidence: 1.5% of neonates
Limb shortening Decreased range of motion Degenerative changes Avascular necrosis Prognosis o Delayed diagnosisltreatment = irreversible dysplasia o Early diagnosis = good result with harness or splint
Treatment Conservative o Closed reduction + harnesslspica cast Surgical o Adductor tenotomy + release of iliopsoas o Open reduction o Varus (derotational) vs. reconstructive osteotomy (Salter opening wedge, triple innominate, Chiari-medialization of femoral head)
Gross Pathologic & Surgical Features Hourglass joint capsule: Compression between limbus 1b
+ ligamentum teres
Thick + tight transverse ligament Femoral head flattened medially Deficient superior + posterior acetabular rim
Microscopic Features
Consider T2* gradient echo coronal images defines hypointense deformed limbus + displays articular cartilage as hyperintense ~ n t e r i o rcoronal images to identify dysplastic acetabulum in adult
Hyperplastic ligamentum teres Hypertrophic pulvinar
Staging, Grading or Classification Criteria Modified Graf staging o Type 1 = mature hip - alpha (acetabular roof) angle > 60" (alpha is geometric complement of acetabular index angle) o Type 2a = physiologic immaturity < 3 months with alpha 50-59" o Type 2b = immature > 3 months with alpha 50-59" o Type 2c = critical hip, subluxation - alpha 43-49" o Type 3 = eccentric head, dislocation - alpha < 43" o Type 4 = severe dysplasia, inverted labrum, alpha < 43"
Presentation Most common signs/symptoms: Palpable click or clunk using Ortolani & Barlow stress maneuvers Clinical profile o Ortolani's test: Hip abduction at 90" flexion + anteriorly directed pressure relocates femoral head o Barlow's test: Unstable femoral had dislocated by posteriorly directed pressure
Demographics Age: Newborns Gender: F:M = 6:l Risk factors o Positive family history, breech presentation, torticollis, scoliosis + metatarsus adductus
I
Murray KA et al: Radiographic imaging for treatment and follow-up of developmental dysplasia of the hip. Semin Ultrasound CT MR 22(4):306-40,2001 Laor T et al: Limited magnetic resonance imaging examination after surgical reduction of developmental dysplasia of the hip. J Pediatr Orthop 20(5):572-4,2000 Bassett GS et al: Fate of the psoas muscle after open reduction for developmental dislocation of the hip (DDH). J Pediatr Orthop 19(4):425-32,1999 McNally EG et al: MRI after operative reduction for developmental dysplasia of the hip. J Bone Joint Surg Br 79(5):724-6, 1997 Gabriel H et al: MR imaging of hip disorders. Radiographics 14:763-81, 1994 Guidera KJ et al: Magnetic resonance imaging evaluation of congenital dislocation of the hips. Clin Orthop 261:96-101, 1990 Harcke HT et al: Preforming dynamic sonography of the infant hip. AJR 155:837-44, 1990 Johnson DN et al: MR imaging anatomy of the infant hip. AJR 153:127-33, 1989 Johnson ND et al: Complex infantile and congenital hip dislocation: Assessment with MR imaging. Radiology 168:151-6, 1988 Hensinger RN: Congenital dislocation of the hip: Treatment in infancy to walking age. Orthop Clin North Am 18597, 1987
DEVELOPMENTAL DYSPLASlA O F THE HIP
I IMAGE GALLERY Typical (Left) Coronal graphic shows normal acetabular and labral coverage of the femoral head in a non dysplastic hip. (Right) An teroposterior radiography shows uncovered capital epiphysis with shallow acetabulurn in DDH.
(Left) Axial NECT fails to show the superolateral position of the capital epiphysis. There is posterior subluxation of the capital epiphysis. (Right) Coronal TZ* CRE MR shows superolateral dislocation of the right capital epiphysis with a false acetabulurn and acetabular labral deformity (arrow). The left acetabulum is shallow.
(Left) Coronal FS PD FSE MR shows chondral degeneration (arrow) as an early sign of osteoarthritis or lateral acetabular rim syndrome. Lateral acetabular rim syndrome in DDH is equivalent to femoroacetabular impingement in non dysplastic hips. (Right) Coronal T l Wl MR shows remodeling of right femoral head and neck as a chronic complication of DDH.
MUSCLE STRAIN, HIP
Coronal graphic shows partial tear of the adductor magnus muscle with associated edema.
18
Abbreviations and Synonyms Muscle-tendon-unit (MTU) injuries, stretch-induced injuries, stretch injury, muscle ruptures
Definitions Stretch-induced injury to muscle fibers
General Features Best diagnostic clue: Hyperintense edema k hemorrhage within affected muscle group on T2WI Location: Rectus femoris, hamstring, adductor longus + magnus involved Size: Variable with stretch-induced injuries involving distal junction of muscle-tendon-unit Morphology: Variable from feathery distribution of edema, to focal hemorrhage, to frank muscle disruption
M R Findings TlWI o No abnormality o Blurring of muscle fiber striations o Hypointense to hyperintense hemorrhagic fluid collection
Coronal FS PD FSE MR shows adductor muscle group edema in grade 1 strain.
o Hypointense subcutaneous tissue edema T2WI o Grade I strain Hyperintense edema k hemorrhage with preservation of muscle morphology Edema pattern = interstitial hyperintensity + feathery distribution on FS PD or T2 FSE + STIR images = hy per intense subcutaneous tissue edema + intermuscular fluid o Grade I1 strain Hyperintense hemorrhage with tearing of up to 50% of muscle fibers II Interstitial hyperintensity with focal hyperintensity representing hemorrhage in muscle belly k intramuscular fluid Hyperintense focal defect + partial retraction of muscle fibers Associated myotendinous + tendinous injuries Hyperintensity + interruption k widening of muscle-tendon-unit o Grade I11 strain Complete tearing k muscle retraction Hyperintense fluid filled gap = hyperintense on FS PD FSE + STIR Associated adjacent hyperintense interstitial muscle changes
+
DDx: Muscle Strain, Hip DOMS
Ax
FS PD MR
Ax FS PD MR
Ax T l Wl MR
MUSCLE ST Key Facts Imaging Findings
Best diagnostic clue: Hyperintense edema + hemorrhage within affected muscle group on T2WI Location: Rectus femoris, hamstring, adductor longus + magnus involved Morphology: Variable from feathery distribution of edema, to focal hemorrhage, to frank muscle disruption
Top Differential Diagnoses
,
Delayed Onset Muscle Soreness (DOMS) Muscle Contusion Hemangioma Soft Tissue Tumor
Pathology
Eccentric loading Muscles at risk cross multiple joints or have complex architecture
Clinical issues Most common signs/symptoms: Muscle pain Weakness absent in primary (grade I) strain - no myofascial disruption Secondary strain: Weakness associated with separation of muscle from tendon or fascia * Third-degree strain: Loss of function with complete myofascial separation Proximal hamstring injury most frequent site of involvement
Diagnostic Checklist
Indirect injury secondary to excessive stretch Retracted muscle fibers: Atrophy + hypertrophic appearance 2" to retraction
Imaging Recommendations Best imaging tool: MR to document edema, hemorrhage + muscle1MTU tears Protocol advice o Axial FS PD, T2 FSE or STIR + T1 o Coronal or sagittal FS PD FSE for longitudinal extent
1 DIFFERENTIAL DIAGNOSIS Delayed Onset Muscle Soreness (DOMS) Non-acute injury Painful symptoms increase first 24 hours post exertion + peak 24 to 72 hours then subside Denervation - diffuse muscle group involvement + hyperintense signal on STIR or FS PD FSE Interstitial hemorrhage + hematoma Associated with muscle injury increased muscle size Grade I strain & DOMS = similar MR signal intensity changes
+
Muscle Contusion Compressive or concussive direct trauma Direct trauma - hematoma in blunt injuries + lacerations from penetrating injuries Fluid collections - swelling + weakness Muscle contracture + rhabdomyolysis Associated with metabolic disorders Muscle edema, atrophy + fatty infiltration = myopathic or neurogenic association
Infection Hyperintenselintermediate fluid on FS PD/T2 FSE or STIR images Focal involvement superficial tract Extensive subcutaneous tissue edema
*
Hemangioma Soft tissue intramuscular hemangioma 0 Non-circumscribed with predilection for thigh muscles of young adults
Axial FS PD FSE or STIR to identify muscle edema
o Pain = presenting symptom
Deep Venous Thrombosis Enlarged thrombosed popliteal vein Watershed hyperintensity in gastrocnemius/soleus muscle complex on T2WI Venous collateral development
Soft Tissue Tumor Lipoma Desmoid Malignant fibrous histiocytoma Liposarcoma Synovial sarcoma
1 PATHOLOGY General Features General path comments o Relevant anatomy Contractile element of muscle fibers = Z-lines Muscle-tendon-unit - distal junction at risk Etiology o Indirect injury secondary to excessive stretch o Overuse - microtrauma 0 Muscle + myotendinous tears 0 Eccentric loading 0 Strains involve muscles with highest proportion of fast-twitch type I1 muscle fibers (e.g., rectus femoris, biceps femoris + medial head gastrocnemius) 0 Muscle-tendon-unit (MTU) = weakest biomechanical link site of muscle failure o Muscles at risk cross multiple joints or have complex architecture o Risk factors include improper warm-up, fatigue, previous orthopedic injury Epidemiology: Muscle strains = 30% of sports-related injuries
-
Gross Pathologic & Surgical Features Irregular thinning myotendinous junction Hematoma Partial tear MTU
r
MUSCLE STRAIN, HIP o Rupture of musculotendinous complex from origin
Complete tear MTU Avulsion fracture
or insertion o Repair for avulsions with > 2 to 3 cm displacement
Microscopic Features
of bone fragment Complications o Fibrosis + retraction of muscle o Reinjury o Myositis ossificans o Malunion or nonunion of osseous avulsions
Hemorrhagic response at injured fibers Muscle fiber necrosis Edema + macrophages Inflammatory cells + fibroblastic activity Random disruptions of Z-lines = damage to contractile elements of muscle
Staging, Grading or Classification Criteria Muscle strain o Grade I = minimal disruption musculotendinous junction o Grade I1 = partial tear with intact musculotendinous fibers present o Grade I11 = complete rupture of musculotendinous unit o Grade IIIB = avulsion fracture tendon origin or insertion
Consider Axial FS PD FSE or STIR to identify muscle edema TlWI to visualize fatty atrophy Sagittal + coronal images to show longitudinal extent
I
I
1.
2.
Presentation Most common signs/symptoms: Muscle pain Clinical profile o Weakness absent in primary (grade I) strain - no myofascial disruption o Edema + swelling o Secondary strain: Weakness associated with separation of muscle from tendon or fascia o Third-degree strain: Loss of function with complete myofascial separation o Proximal hamstring injury most frequent site of involvement
3. 4. 5. 6. 7. 8.
Demographics Age: Usually young athletes - speed athletes (especially sprinters), football, basketball, soccer Gender: Increased male incidence due to participation in sports requiring highly eccentric muscle activities
Natural History & Prognosis Incomplete to complete extension of injury Fibrous replacement Fatty replacement Muscle ossification Compartment syndrome Up to 25% recurrence rate for hamstring injuries
Treatment Conservative o Small fascia1 or tendinous tears o RICE protocol (rest, ice, compression, elevation) o Nonsteroidal antiinflammatory drugs o Protective exercises + passive stretching to prevent stiffness, atrophy, weakness o Isometric to isotonic exercises o Recovery period from two weeks (grade I) to > 2 months (grade 11) Surgical o Rupture of muscle = possible surgical management
9. 10. 11. 12. 13. 14.
15. 16. 17.
DeLee JC et al: Orthopaedic sports medicine. Principles and practice. vol 2. 2nd ed. Philadelphia PA, WB Saunders, (26):1481-1504, 2003 Fitzgerald RH et al: Orthopaedics. St. Lois MO, Mosby, Sect 4(4-4):544-50, 2002 Sallay PI et al: Hamstring injuries among water skiers: Functional outcome and prevention. Am J Sports Med 24:130, 1996 Best T et al: Hamstring injuries: Expediting return to play. The Physician and Sportsmedicine 2433, 1996 Clarkson PM et al: Associations between muscle soreness, damage and fatigue. Adv Exp Med Biol384:457, 1995 Pomeranz SJ et al: MU imaging in the prognostication of hamstring injury. Radiology 189:897-900, 1993 Taylor DC et al: Experimental muscle strain injury: Early functional and structural deficits and the increased risk for reinjury. Am J Sports Med 21:190, 1993 Friden J et al: Structural and mechanical basis of exercise-induced muscle injury. Med Sci Sports Exerc 24521, 1992 Taylor DC et al: Viscoelastic properties of muscle-tendon untis: The biomechanical effects of stretching. Am J Sports Med 18:300,1990 DeSmet AA et al: Magnetic resonance imaging of muscle tears. Skel Radio1 19:283-6, 1990 Garrett WE JR: Muscle strain injuries: Clinical and basic aspects. Med Sci Sports Exerc 22:436, 1990 Garrett WE et al: Computed tomography of hamstring muscle strains. Med Sci Sports Exerc 21(5):506-14, 1989 Fleckenstein JL et al: Sports-related muscle injuries: evaluation with MR imaging. Radiology 172:793-8, 1989 Stauber WT: Eccentric action of muscles: Physiology, injury and adaptation. Exerc Sports Sci Rev 17:157, 1989 Garrett WE JR et al: Biomechanics of muscle tears and stretching injuries. Trans Orthop Res Soc 9:384, 1984 Zarins B et al: Acute muscle and tendon injuries in athletes. Clin Sports Med 2(1):167-82, 1983 Glick JM: Muscle strains: Prevention and treatment. Phys Sports Med 8:73, 1980
MUSCLE STRAIN, HIP
(Left) Coronal graphic shows grade I muscle strain with edema of the obturator externus (horizontally oriented) and adductor longus muscle (vertically oriented). Interstitial hyperintensity without muscle fiber discontinuity is shown. (Right) Coronal FS PD FSE MR shows interstitial muscle edema in a grade I muscle strain of proximal rectus femoris. The straight head originates from anterior inferior iliac spine and reflected head originates from upper acetabular rim.
(Left) Coronal FS PD FSE MR shows focal hemorrhage (arrow) in a grade I1 strain of the biceps femoris muscle. Adjacent areas of grade I strain are seen with feathery distribution of edema. (Right) Axial FS PD FSE MR shows partial muscle tearing of the biceps femoris (arrow) at the myotendinous junction.
Tvaical (Left) Axial PD/lntermediate MR shows grade I muscle strain of the left semitendinosus and medial aspect of the biceps femoris muscle in an olympic sprinter. There is normal muscle morphology. (Right) Axial T2WI MR shows hyperintense edema and muscle hemorrhage of left semitendinosus and medial biceps femoris muscle. The biceps femoris muscle is at risk for strain because of a higher proportion of fast-twitch muscle fibers.
RECTUS FEMORlS MUSCLE STRAIN
Axial graphic shows acute muscle strain involving deep tendon of the indirect head with surrounding hemorrhage in red. Chronic fibrous encasement and fluid are shown in blue.
Axial T2* CRE MR shows focal hypointensity (arrow) secondary to trauma to deep intramuscular tendon of indirect head of left rectus femoris. The hypointensity represents fibrous encasement.
o k Soft tissue mass in mid-substance strains 2" to hemorrhage + deranged architecture o Complete rupture of distal musculotendinous junction + high riding patella (patella alta)
Abbreviations and Synonyms Muscle pull, Charlie horse, quadriceps strain
CT Findings
Definitions
NECT o Unreliable for mild strains 0 Low attenuation 2" to edema o Hyperdense regions 2" to hemorrhage o Affected muscle acutely enlarged compared to contralateral side o Soft tissue mass may be identified in mid-substance strains CECT ? Enhancement
Stretch injury of rectus femoris during eccentric contraction
General Features Best diagnostic clue: Hyperintensity of affected muscle on T2WI Location o Distal musculotendinous junction (most common) 0 Midsubstance - strain of deep tendon of indirect (reflected)head Size: From focal hemorrhage to distal retraction of muscle fibers Morphology: Acute strain involving deep intramuscular tendon with associated local hemorrhage +/- edema leading to chronic pseudocyst
MR Findings TlWI 0 Low to intermediate signal intensity hemorrhage 0 k Hyperintense subacute hemorrhage o Peripheral hypointense hemosiderin o Loss of normal musclelfat striations T2WI o Hyperintense edema in affected muscle o Inhomogeneous signal intensity mass in mid-substance strains o Hypointense to intermediate signal = more organized central component of hematoma o Subacute injury = hyperintense edema + atrophy
mmri
Radiographic Findings Radiography 0 Normal in mild strains
DDx: Rectus Femoris Muscle Strain Femoral Neck Fx
-
I
i
Cor FS PD MR
Cor TIWI MR
Sag FS PL -
RECTUS FEMORlS MUSCLE STRAIN Key Facts Imaging Findings Best diagnostic clue: Hyperintensity of affected muscle on T2WI Distal musculotendinous junction (most common) Morphology: Acute strain involving deep intramuscular tendon with associated local hemorrhage +I- edema leading to chronic pseudocyst Hypointense signal with fibrous encasement of deep tendon + scar tissue on T2WI
Top Differential Diagnoses Fracture Radiculopathy Intrinsic Hip Pathology
Rectus femoris = most frequently injured quadriceps muscle Injury to deep intramuscular tendon indirect head: Tear fibrosis pseudocyst formation
-
-
Clinical Issues Most common signs/symptoms: Groin or anterior thigh pain Common in sprinting or kicking sports - track and field, soccer, martial arts Mid-substance strains may present as anterior thigh soft tissue mass
.
Diagnostic Checklist Hypointense scar involving deep intramuscular
Pathology
tendon of indirect head
Overuselrepetitive overload o Adjacent hyperintense fluid signal o Hypointense signal with fibrous encasement of deep
tendon + scar tissue on T2WI o Tendon of indirect head = cylindrical shape * T2* GRE: Demonstrates susceptibility artifact 2" to hemorrhage T1 C+ o Variable synovial peripheral enhancement of hemorrhagic focus or muscle disruption o "Bulls eye lesion" - peripherally enhancing muscular component of a mid-substance strain
*
Imaging Recommendations Best imaging tool o MR to identify grade + anatomic extent of injury o Origin vs. insertion injuries o MR required for complete tears Protocol advice: T1 + FS PD FSE or STIR in axial coronal, sagittal planes
*
Fracture Avulsion: Anterior superior iliac spine, anterior inferior iliac spine, lesser trochanter Stress fracture - pelvic + femoral neck
Radiculopathy Lateral vs. central disk protrusion Neurologic exam o Motor and sensory of lower extremities o Reflex testing knees + ankles Associated low back pain
Intrinsic Hip Pathology Hip dislocation - traumatic dislocation = posterior Acetabular labral tears - trauma vs. degenerative disease (catching or clicking + pain) Avascular necrosis (AVN) of femoral head
Intrinsic Knee Pathology Meniscal tear Patellar trauma
Retinacular injury Osseous contusion + osteochondral fracture
Sarcoma May mimic mid-substance strain + palpable mass Sarcomas - demonstrate central enhancement not seen in hemorrhage Disruption or gross invasion of muscle Neovascularity
1 PATHOLOGY General Features General path comments o Relevant anatomy Quadriceps converge through a conjoined tendon to insert on superior aspect patella Rectus femoris - origin crosses hip joint = knee extension + hip flexion Quadriceps muscle fibers = type I1 (rapid forceful activity) Etiology o Overuselrepetitive overload o hadequate-stretching & warm-up exercises predisposes to strain o violent eccentric contraction Epidemiology o Rectus femoris = most frequently injured quadriceps muscle o Muscle strains = 30% of sports-related injuries o Track & field, football, soccer, basketball o Soccer has highest association with deep intramuscular tendon injuries of indirect head (requires sudden acceleration and bursts of speed)
Gross Pathologic & Surgical Features Musculotendinous junction Intrasubstance tear at muscle-tendon junction involving indirect head Injury to deep intramuscular tendon indirect head: Tear fibrosis pseudocyst formation
-
-
C 2
RECTUS FEMORIS MUSCLE STRAIN Microscopic Features Hemorrhagic response Muscle fiber necrotic change Edema + macrophages Inflammatory cells + fibroblastic activity
Consider Hypointense scar involving deep intramuscular tendon of indirect head
Staging, Grading or Classification Criteria First-degree - small area muscle involvement without loss of function Second-degree - partial tear musculotendinous unit + mass or hematoma Third-degree - complete tear musculotendinous unit & mass or palpable defect & retraction of mass or detached muscle segment
1. 2. 3. 4.
Presentation Most common signs/symptoms: Groin or anterior thigh pain Clinical profile o Common in sprinting or kicking sports - track and field, soccer, martial arts 0 Localized swelling o Loss of knee extension o Mid-substance strains may present as anterior thigh soft tissue mass o Chronic mid-substance strains - intramuscular fibrosis + recurrent hemorrhage 0 Tender to palpation 0 Thigh asymmetry in partial or complete tears o Complete rupture = palpable defect with retracted mass
5. 6. 7. 8. 9. 10. 11. 12.
Demographics Age: Young athletes Gender: As a function of participation in sports associated with powerful eccentric contraction of the quadriceps
Natural History & Prognosis Majority of cases improve with conservative treatment Surgery indicated for compartment syndrome, chronic strains + complete tears Compartment syndrome - occurs with severe strains, partial/full-thickness tears Full thickness tendon ruptures associated with renal failure, diabetes + rheumatoid arthritis
Treatment Conservative o RICE (rest, ice, compression, elevation) o Physical therapy = stretching + exercises o NSAIDs o Gradual return to activity Surgical o ~ecom~ressio for n compartment syndrome o Hematoma evacuation 0 Complete rupture: Repair o Resection of fibrosis in chronic strains
13. 14. 15. 16. 17. 18. 19.
DeLee JC et al: Orthopaedic sports medicine. Principles and practice. vol 1. 2nd ed. Philadelphia PA, Saunders, 26(A):1481-505, 2003 Van Holsbeeck MT et al: Musculoskeletal ultrasound. 2nd ed. Philadelphia PA, WB Saunders, 30-7, 578-81, 2001 Temple HT et al: Rectus femoris muscle tear appearing as a pseudotumor. Am Jour Sports Med 26544-8, 1998 Stoller DW: Magnetic resonance imaging in orthopaedics and sports med. vol 1. 2nd ed. Philadelphia PA, Saunders, 158-64, 1997 Garrett WE Jr: Muscle strain injuries. Am Jour Sports Med 2452-8, 1996 Sallay PI et al: Hamstring injuries among water skiers: Functional outcome and prevention. Am J Sports Med 24:130, 1996 Hughes C IV et al: Incomplete, intrasubstance strain injuries of the rectus femoris muscle. Am Jour Sports Med 23:500-6, 1995 Hasselman CT et al: An explanation for various rectus femoris strain injuries using previously undescribed muscle architecture. Am Jour Sports Med (23):493-99, 1995 Clarkson PM: Associations between muscle soreness, damage, and fatigue. Adv Exp Med Biol384:457, 1995 Speer KP et al: Radiographic imaging of muscle strain injury. Am Jour Sports Med 21339-96, 1993 Taylor DC et al: Experimental muscle strain injury: Early functional and structural deficits and the increased risk for reinjury. Am J Sports Med 21:190, 1993 Friden J et al: Structural and mechanical basis of exercise-induced muscle injury. Med Sci Sports Exerc 24:521, 1992 Taylor DC et al: Viscoelastic properties of muscle-tendon units: The biomechanical effects of stretching. Am J Sports Med 18:300, 1990 Garrett WE Jr: Muscle strain injuries: Clinical and basic aspects. Med Sci Sports Exerc 22:436, 1990 Stauber WT: Eccentric action of muscles: Physiology, injury and adaptation. Exerc Sports Sci Rev 17:157, 1989 Garrett WE Jr et al: The effect of muscle architecture on the biomechanical failure properties of skeletal muscle under passive extension. Am J Sports Med 16:7, 1988 Garrett WE Jr et al: Biomechanics of muscle tears and stretching injuries. Trans Orthop Res Soc 9:384, 1984 Zarins B et al: Acute muscle and tendon injuries in athletes. Clin Sports Med 2:167, 1983 Glick JM: Muscle strains: Prevention and treatment. Phys Sports Med 8:73, 1980
RECTUS FEMORlS MUSCLE STRAIN
CLUTEUS MEDIUS MUSCLE STRAIN
Coronal graphic shows partial tear of the gluteus medius muscle with surrounding edema.
Coronal FS PD FSE MR shows partial tear (arrow) of gluteus medius muscle-tendon unit. Edema is hyperintense.
CT Findings
Abbreviations and Synonyms Muscle pull, "Charlie horse", greater trochanter pain syndrome
Definitions Indirect injury secondary to repetitive microtrauma, excessive force or stretch
I MACING
FINDINGS
General Features Best diagnostic clue: Muscle with hyperintense edema on T2WI (FS PD FSE) Location: Gluteus medius - anterior, middle + posterior parts muscle + tendon Size: Usually involves distal 113 of muscle (muscle-tendon unit) Morphology: Edema directed along long axis of muscle fibers + thickening of tendon
Radiographic Findings Radiography o Usually normal o Helpful to exclude other diagnoses o Intramuscular calcification or metaplastic bone + cartilage (myositis ossificans)
NECT o Intramuscular edema = hypodense o Acute hemorrhage = hyperdense o Affected muscle is enlarged o Disruption of muscle architecture in partiallfull thickness tears + fluid-filled gap
M R Findings TlWI o Intramuscular edema - blurring of muscle fibers o Hypointense intramuscular fluid o Focal muscular defects with retraction or tendon laxity o Thickening with intermediate signal in tendinous/myotendinous injuries o Subacute hemorrhage (methemoglobin) hyperintense on TlWI T2WI o Mild strains: Intramuscular edemalhemorrhage (increased T2 signal) o Preservation of muscle morphology o Hyperintense subcutaneous edema + intramuscular fluid o Hyperintense fluidlhemorrhage in disrupted muscle fibers or gaps o Variable increased signal in tendinous + myotendinous degeneration or tearing
DDx: Gluteus Medius Muscle Strain Femoral Neck Fx
Piriforrnrs Syn,
Cor T l Wl MR
Cor FS PD MR
1.rpnsarcoma
Cor FS PD MR
Ax T l W l MR
GLUTEUS M E D I U S MUSCLE STRAIN Key Facts Imaging Findings Best diagnostic clue: Muscle with hyperintense edema on T2WI (FS PD FSE) Size: Usually involves distal 113 of muscle (muscle-tendon unit) Morphology: Edema directed along long axis of muscle fibers + thickening of tendon
Top Differential Diagnoses Fracture/Stress Fracture Greater Trochanteric Bursitis Intrinsic Hip Pathology Piriformis Syndrome Gluteal Tendon Avulsion
Pathology
Microtrauma Stretch Occasionally in athletes - football, swimming, ice hockey
Clinical Issues Most common signs/symptoms: Lateral hip pain Pain radiating to the groin Trochanteric bursitis Pain at greater trochanter Altered gait Swelling - muscle enlargement
Diagnostic Checklist Associated with greater trochanteric bursitis + muscle-tendon injuries of gluteus minimus
Overuse o Tears - more localized hyperintense hemorrhage o Chronic hematomas demonstrate hypointense
peripheral rim o Hypointense scarlfibrosis = chronic injury
Imaging Recommendations Best imaging tool: MR superior for soft tissuelmuscle signal changes + differentiation of medius, minimus vs. maximus involvement Protocol advice o T1 or PD + FS PD FSE or STIR in the coronal + axial plane o +_ Sagittal plane with FS PD FSE
Hypertrophy of piriformis Trauma to gluteal region Fibrosis following trauma Piriformis muscle spasm
Lumbar Radiculopathy Disc protrusion - central, paracentral or lateral Disc extrusion Central + neural foramina1 stenosis Spondylolisthesis
Gluteal Tendon Avulsion Muscle-tendon unit injury Hyperintense edema at insertion site on T2WI Associated with hyperintense trochanteric bursitis
Soft Tissue Tumor of the Hip + Pelvis FractureIStress Fracture Femoral neck = overuse vs. insufficiency in osteoporosis Calcar hyperintensity on FS PD FSE MR Frank cortical disruption Cortical sclerosis
Greater Trochanteric Bursitis Lateral aspect hip History of repetitive hip flexion Hypo to intermediate signal adjacent to greater trochanter on TlWI Hyperintense fluid parallel to lateral aspect of greater trochanter on T2WI
Intrinsic Hip Pathology Labral tears - traumatic vs. degenerative + painful catching or clicking Avascular necrosis of the femoral head - necrotic segment typically with double line sign (associated history of femoral neck fracture, dislocations or corticosteroid use) Osteoarthritis +/- femoroacetabular impingement
Piriformis Syndrome Sciatic nerve variations = increased risk for compression
Lipoma - fat signal Desmoid - hypointense fibrous bands on T1 & T2WI Malignant fibrous histiocytoma - inhomogeneous signal on T2WI Liposarcoma - variable fat + malignant foci o Hypointense on TlWI + hyperintense on T2WI Synovial cell sarcoma - variable hyperintensity on T2WI (may mimic fluid but solid component is appreciated if window/level is adjusted correctly)
General Features General path comments o Relevant anatomy = gluteus medius Anterior fibers: Active in hip flexion + internal rotation Posterior fibers: Active in extension + external rotation Entire muscle contributes to hip abduction Gluteus minimus + medius + piriformis attach to greater trochanter Bursa deep to gluteus medius is larger than bursa deep to gluteus minimus Etiology o Overuse
-
GLUTEUS MEDIUS MUSCLE STRAIN o Microtrauma o Stretch injury
Epidemiology o Occasionally in athletes - football, swimming, ice hockey o Subset of muscular + musculotendinous injuries (MTU injuries most frequent athletic related condition of hip + pelvis)
Gross Pathologic & Surgical Features Strains Tendinosis Tendonitis Tendon tears Avulsions Trochanteric bursitis
Microscopic Features Hemorrhagic elements Lack of inflammatory cells Fibrous tissue Tendinosis - degeneration similar to tendinosis of rotator cuff
Staging, Grading or Classification Criteria Grade I: Edema, hemorrhage + preservation of muscle morphology Grade 11: Strain or tear involving up to 50% of muscle Grade 111: Complete tear k muscle retraction
Presentation Most common signs/symptoms: Lateral hip pain Clinical profile 0 Pain radiating to the groin o Trochanteric bursitis o Tenderness to palpation o Pain at greater trochanter o Altered gait o Pain with resisted extension/external rotation o Edema o Swelling - muscle enlargement o Palpable mass in complete tear + retraction
Demographics Age o Elderly population at greatest risk o Occasionally high-level athletes Gender: Females > males
Natural History & Prognosis Majority show improvement with conservative treatment Surgery for tendon avulsions or complete ruptures
Treatment Conservative o Rest, ice, compression, elevation (RICE) o Physical therapy o Steroid injections Surgical o Hematoma evacuation o Primary repair of complete ruptures
o Reattachment of avulsed tendon
Consider Associated with greater trochanteric bursitis k muscle-tendon injuries of gluteus minimus Coronal FS PD FSE or STIR images required to demonstrate muscle + muscle/tendon hyperintensity
[SELECTEDREFERENCES Van Holsbeeck MT et al: Musculoskeletal ultrasound. 2nd ed. St. Louis MO, Mosby, 30-7578-81, 2001 Kingzett-Taylor A et al: Tendinosis and tears of gluteus medius and minimus muscles as a cause of hip pain: MR imaging findings. Am J Roentg 173:1123-26, 1999 Chung CB et al: Gluteus medius tendon tears and avulsive injuries in elderly women: Imaging findings in six patients. Am J Roentg 173:351-53, 1999 Stoller DW: Magnetic resonance imaging in orthopaedics and sports medicine. 2nd ed. Philadelphia PA, Lippincott Williams & Wilkins, 158-64, 1347-56, 1997 Garrett WE Jr.: Muscle strain injuries. Am J Sports Med 24:SZ-8, 1996 Sallay PI et al: Hamstring injuries among water skiers: Functional outcome and prevention. Am J Sports Med 24:130, 1996 Nicholas JA et al: The lower extremity and spine in sports medicine. 2nd ed. St. Louis MO, Mosby, 1042, 1995 Hughes C et al: Incomplete, intrasubstance strain injuries of the rectus femoris. Am J Sports Med 23:500, 1995 Speer KP et al: Radiographic imaging of muscle strain injury. Am J Sports Med 212389-96, 1993 Taylor DC et al: Experimental muscle strain injury: Early functional and structural deficits and the increased risk for reinjury. Am J Sports Med 21:190, 1993 Friden J et al: Structural and mechanical basis of exercise-induced muscle injury. Med Sci Sports Exerc 24:521, 1992 Garrett WE Jr: Muscle strain injuries: Clinical and basic aspects. Med Sci Sports Exerc 22:436, 1990 Taylor DC et al: Viscoelastic properties of muscle-tendon units: The biomechanical effects of stretching. Am J Sports Med 18:300, 1990 Stauber WT: Eccentric action of muscles: Physiology, injury and adaptation. Exerc Sports Sci Rev 17:157, 1989 Garrett WE Jr et al: The effect of muscle architecture on the biomechanical failure properties of skeletal muscle under passive extension. Am J Sports Med 16:7, 1988 Garrett WE Jr et al: Biomechanics of muscle tears and stretching injuries. Trans Orthop Res Soc 9:384, 1984 Zarins B et al: Acute muscle and tendon injuries in athletes. Clin Sports Med 2:167, 1983 Glick JM: Muscle strains: Prevention and treatment. Phys Sports Med 8:73, 1980
GLUTEUS MEDIUS MUSCLE STRAIN IMAGE GALLERY Typical (Left) Coronal FS PD FSE MR shows gluteus medius strain associated with a greater trochanter fracture. (Right) Coronal FS PD FSE MR shows subtle hyperintense grade I gluteus medius muscle strain.
(Left) Coronal FS PD FSE MR shows musculotendinous unit hyperintensity in gluteus medius tendinosis. (Right) Coronal FS PD FSE MR shows greater trochanteric bursitis and adjacent subchondral edema. This often is often associated with gluteus medius strain.
Typical (Left) Coronal T2* CRE MR shows tear of the gluteus medius insertion from the lateral aspect of the greater trochanter. (Right) Axial FS PD FSE MR shows grade I strain of the gluteus medius muscle posterior to the lesser trochanter.
*
HAMSTRING TENDlNOSlS
Coronal graphic shows edema and thickening of the common hamstring tendon, bilaterally. The semimembranosus, semitendinosus, and biceps femoris contributions are affected.
Coronal FS PD FSE MR shows hyperintense edema (arrow) surrounding a thickened common hamstring tendon. The attachment to the ischial tuberosity is intact.
CT Findings NECT o Limited soft tissue detail o k Visualization of thickened conjoined tendon
Abbreviations and Synonyms Hamstring strains
Definitions Collagenous degeneration of the conjoined tendon of the hamstring muscles
General Features Best diagnostic clue: Hyperintensity associated with proximal conjoined tendon of common hamstring attachment on FS PD FSE MR Location o Ischial tuberosity o Proximal tendon Size: Proximal 113 (or less) of common hamstring tendon Morphology: Thickening of involved tendon segment f splaying of proximal tendon attachment
Radiographic Findings Radiography o Usually normal o To exclude bony avulsion injury
MR Findings TlWI o Intermediate signal intensity in thickened hypointense tendon o Partial detachment of hamstring tendon from ischial tuberosity o Small osseous avulsion k hypointense edema ischial tuberosity o Complete avulsion with distal retraction of common hamstring tendon T2WI o Intermediate to hyperintense signal within thickened proximal hamstring tendon o Soft tissue hyperintensity parallel to medial + lateral margins of cGmmon hamstring tendon o Localized hyperintense fluid adjacent to tendon degeneration o Adjacent hyperintense subchondral edema of ischial tuberosity o Hyperintense fluid influx in area of partial tear o Asymmetric involvement of hamstring tendons is a common finding
DDx: Hamstring Tendinosis Femoral Neck Fx
Ax T2WI MR
Cor FS P D MR
Sag FS P D M R
HAMSTRING TENDlNOSlS Key Facts Imaging Findings '
Clinical Issues
Best diagnostic clue: Hyperintensity associated with proximal conjoined tendon of common hamstring attachment on FS PD FSE MR Morphology: Thickening of involved tendon segment f splaying of proximal tendon attachment
Top Differential Diagnoses Hamstring Muscle StrainITear Hip Stress Fractures Sacral Stress Fracture Intrinsic (Internal) Hip Pathology
Diagnostic Checklist Visualize proximal hamstring tendon origin on FS PD FSE or STIR posterior coronal images
Pathology Hip hyperflexion + knee extension Chronic repetitive microtrauma Ballistic stretching of hamstring T1 C+: Synovial enhancement + partial enhancement of degenerative foci within proximal hamstring tendons
Unilateral in most spondyloarthropathies Peripheral joint involvement in psoriatic, reactive + inflammatory bowel-associated arthritis Sacroiliitis with marrow edema + osseous erosions
Imaging Recommendations
Avascular Necrosis of Hip
Best imaging tool: MR sensitive + specific for tendon thickening + signal changes Protocol advice: T1 + FS PD FSE or STIR coronal + axial images
(DIFFERENTIAL DIAGNOSIS Hamstring Muscle StrainITear Biceps femoris, semimembranous + semitendinosus Any location along course of musculotendinous junction Spectrum of grade I to grade I11 strains Local tenderness + palpation of injured site Ecchymosis Transient sciatica - in acute grade 111 hamstring strain
Hip Stress Fractures Femoral neck - with overuse + repetitive stress + insufficiency fractures in osteoporosis Hyperintense marrow (TZWI) + localized cortical thickening Extensive edema may obscure fracture line in acetabular stress fractures
Sacral Stress Fracture Disproportionate edema with sacral alar stress fxs relative to insufficiency fractures
Intrinsic (Internal) Hip Pathology Loose bodies Acetabular roof edema Labral tear AVN Femoral head erosion
Sacroiliitis Bilateral in ankylosing spondylitis or inflammatory bowel disease-associated arthritis
Most common signs/symptoms: Gluteal pain + point tenderness Pain + tightness with forward kicking motion or dynamic hamstring stretch Painful static stretch of hamstring group Ecchymosis or palpable knot uncommon in proximal tendinosis Common in sports requiring bursts of speed, and repetitive hip stretch
Wedge-shaped subchondral bone infarct Double line sign in 80%
1
General Features General path comments o Relevant anatomy Hamstring group = biceps femoris, semimembranosus + semitendinosus Except short head of biceps all muscles of hamstring group cross hip and knee joint Hamstring origin = ischial tuberosity Hamstring insertion = proximal tibia Short head of biceps femoris has origin from linea aspera + posterior femur Musculotendinous junctions of biceps femoris extends along entire length of muscle (overlap) Short head innervated by peroneal branch sciatic nerve; tibia1 branch for rest of hamstring group Etiology o Hip hyperflexion + knee extension o Chronic repetitive microtrauma o Medial hamstrings at risk during swing segment of recovery phase of running Follow-through, forward swing, foot descent o Lateral hamstring at risk in take off segment of support phase Foot strike, midsupport, take off o Inadequate warmup o Inflexibility o Fatigue o Hamstring-to-hamstring 8 hamstring-to-quadriceps imbalances o Ballistic stretching of hamstring
HAMSTRING TENDINOSIS Epidemiology: Hamstring strains = most common strain-related injury
Gross Pathologic & Surgical Features Partial disruption musculotendinous junction Partial tear Complete tear Avulsion fractures Thickened proximal tendon + degenerative origin
Microscopic Features Collagenous degeneration Increased intratendon ground substance Proliferation of fibroblasts/myofibroblasts Inflammatory cells absent
Staging, Grading or Classification Criteria Grade I: Small disruption musculotendinous junction Grade 11: Partial tear Grade IIIa: Complete rupture Grade IIIb: Avulsion fracture origin or insertion of tendon
I DIAGNOSTIC CHECKLIST Consider Visualize proximal hamstring tendon origin on FS PD FSE or STIR posterior coronal images Identify associated muscle edema
]SELECTED REFERENCES 1. 2.
3. 4. 5. 6.
7. 8.
Presentation Most common signs/symptoms: Gluteal pain + point tenderness Clinical profile o Painful when sitting o Pain + tightness with forward kicking motion or dynamic hamstring stretch o Painful static stretch of hamstring group o Ecchymosis or palpable knot uncommon in proximal tendinosis o Common in sports requiring bursts of speed, and repetitive hip stretch o Feeling of impending "pull"of muscle
Demographics Age: Young athletes Gender: M > F as a function of activity in football, soccer, basketball, sprinting, rowing, kickboxing
Natural History & Prognosis Improvement with conservative treatment Recovery process lengthy - up to 6 months Advanced tendinosis - untreated leads to tendon tears
Treatment Conservative o RICE (rest, ice, compression, elevation) o Reduce inflammatory process o Gradually progressive muscle strength + stretching program o Steroid injections = controversial + may result in tendon weakening + tear Surgical o Limited role in tendinosis 0 Debridement of involved tissue o Does not promote collagen synthesis o For treatment of tendon tears/avulsions
I
9. 10.
11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
DeLee JC et al: Orthopaedic sports medicine. Principles and practice. vol 1. 2nd ed. Philadelphia PA, Saunders 26(A):1481-504, 2003 Palmer WE et al: MR imaging of myotendinous strain. AJR 173:703-9, 1999 Clanton TO: Hamstring strains in athletes: Diagnosis and treatment. J Am Acad Orthop Surg 6:237-48, 1998 Orchard J: Preseason hamstring muscle weakness associated with hamstring muscle injury in Australian footballers. Am J Sports Med 25:81-5, 1997 El-Khoury GY et al: Imaging of muscle injuries. Skeletal Radio1 253-11, 1996 Orava S et al: Rupture of the ischial origin of the hamstring muscles. Am J Sports Med 23:702-5, 1995 Garrett WE et al: Computed tomography of the hamstrings muscle strain. J Med Sci Sports Exerc 21:508-14, 1989 Cross MJ et al: Surgical repair of chronic complete hamstring tendon rupture in the adult patient. Am J Sports Med 26:785-88, 1988 Oh I et al: Proximal strain distribution in the loaded femur. J Bone Joint Surg Am 60:75-85, 1988 Safran MR et al: The role of warmup in muscular injury and prevention. AM J Sports Med 16:123, 1988 Garrett WE et al: Biomechanical comparison of stimulated and nonstimulated skeletal muscle pulled to failure. Am J Sports Med 15:448-54, 1987 Garrett WE et al: Biomechanical comparison of stimulated and nonstimulated muscle pulled to failure. Am J Sports Med 15:448,1987 Sim FH et al: Injuries of the pelvis and hip in athletes: The lower extremity and spine in sports medicine. St. Louis MO, CV Mosby, 1986 Metzmaker JN et al: Avulsion fractures of the pelvis. Am J Sports Med 13:349, 1985 Heiser TM et al: Prophylaxis and management of hamstring muscle injuries in intercollegiate football players. Am J Sports Med 12:368-70, 1984 Garrett WE et al: Histochemical correlates of hamstring injuries. Am J Sports Med 12:98-103, 1984 Casperson PC: Groin and hamstring injuries. J Athlet Train 17:43-5, 1982 Burkett LN: Investigation into hamstring strains: The case of the hybrid muscle. J Sports Med 3:228-31, 1976 Burkett LN: Causative factors in hamstring strain. Med Sci Sports Exerc 2:39-42, 1970 McMaster PE: Tendon and muscle ruptures: Clinical and experimental studies on the causes and location of subcutaneous ruptures. J Bone Joint Surg 15:705, 1933
I
IMAGE GALLERY
PIRIFORMIS SYNDROME
Coronal graphic shows entrapment (red) of sciatic nerve secondary to piriformis muscle hypertrophy (posterior to sciatic nerve). The nerve is involved as it passes through the sciatic notch.
Coronal FS PD FSE MR shows hyperintense edema (arrow) of the left piriformis muscle.
CT Findings NECT o Hypertrophy of piriformis o Infiltrative tumor or space occupying lesion o Inflammation
Abbreviations and Synonyms Pseudosciatica, wallet sciatica, hip socket neuropathy, deep gluteal syndrome
Definitions
MR Findings
Neuritis of proximal sciatic nerve secondary to irritation or compression by the piriformis muscle
General Features Best diagnostic clue: Piriformis hypertrophy Location: Piriformis - emerges from greater sciatic foramen + inserts on upper border greater trochanter Size: Variable piriformis hypertrophy - conforming to muscle boundaries Morphology o Variable based on presence of muscle hypertrophy o Piriformis = pyramid-shaped
Radiographic Findings Radiography o Usually normal o Intrinsic abnormality (of myositis ossificans, tumor with calcification)
TlWI o Piriformis hypertrophy o Effacement of fat in greater sciatic foramen with muscle signal intensity o Loss of longitudinal muscle striations o Mass effect resulting in displacement of muscle from anterior to posterior T2WI o Diffuse muscle edema with hyperintensity on T2WI o Edema associated with tumor, abscess or hematoma o Hypointense fibrosis 2" to previous trauma o Normal gluteus minimus, medius + tensor fascia lata muscles o + Signal changes within gluteus maximus o + Gluteal atrophy with suppression of fat signal intensity (with fat suppression or STIR)
Imaging Recommendations Best imaging tool: MR to evaluate muscle asymmetry + signal intensity changes
-DDx: Piriformis Syndrome Muscle Strain
m Sacroiliitis
I
Ax T I Wl MR
I1
Cor FS PD MR
Femoral Neck Fx
Labral Tear
Cor T l W l MR
Cor FS PO MR
,
Key Facts Imaging Findings Best diagnostic clue: Piriformis hypertrophy Size: Variable piriformis hypertrophy - conforming to muscle boundaries muscle edema with hyperintensity on TZWI
Anatomic variations include divisions of sciatic nerve splitting piriformis = predisposing to nerve compression Tumor compression Prolonged sitting = bilateral piriformis syndrome
Clinical Issues
Top Differential Diagnoses Hamstring Muscle Injury Lumbar Radiculopathy/DiscogenicPainIFacet Arthropathy Sacroiliitis or Sacroiliac Joint Injury Gluteal Muscle Strains Ischial Tuberosity Bursitis
Pathology
Most common signs/symptoms: Chronic gluteal pain which radiates into lower extremity similar to L5-S1 radiculopathy Pain with hip adduction + internal rotation
Diagnostic Checklist
Evaluate morphology + signal intensity changes in piriformis muscle
Trauma to gluteal region = most common cause Overuse (high performance athletes) Protocol advice: Tl coronal planes
+ FS PD FSE or STIR in the axial +
Avascular necrosis Loose bodies
[DIFFERENTIAL DIAGNOSIS General Features
Hamstring Muscle Injury Hamstring muscle edema Common hamstring tendon degeneration at origin Focal tear with fiber retraction
Lumbar Radiculopathy/Discogenic PainIFacet Arthropathy Central, paracentral or lateral protrusion Facet hypertrophy + degenerative spondylolisthesis Paraspinal muscle strain Central vs. neural foramina1 stenosis
Sacroiliitis or Sacroiliac Joint Injury Sclerosis on TlWI Hyperintensity on FS PD FSE or STIR Erosions in sacroiliitis Sacral alar fracture
Gluteal Muscle Strains Secondary to blunt trauma Edema vs. hematoma formation
lschial Tuberosity Bursitis Hyperintensity (TZWI) on posterior coronal images & Association with common hamstring tendon degeneration
Trochanteric Bursitis Curvilinear hyperintensity conforming to greater trochanter & Effacement of adjacent subcutaneous tissue
Stress Fractures of Hip or Pelvis Acetabular hypointensity on TlWI on T2WI
+ hyperintensity
Intrinsic Hip Pathology Labral tears Chondral erosions of acetabulum + femoral head
General path comments o Relevant anatomy = piriformis Origin - anterior to S2-S4 vertebrae + sacrotuberous ligament + upper margin greater sciatic foramen Passes through greater sciatic notch Inserts superior aspect of greater trochanter Function: External rotation with hip extended Hip abductor with hip in flexion Innervated by L5, S1 + S2 nerve roots Developmental variations exist in anatomic relationship between sciatic nerve + piriformis Etiology o Trauma to gluteal region = most common cause o Overuse (high performance athletes) o Compensatory contraction of hip external rotators in foot instability secondary to Morton's foot with prominent 2nd metatarsal head o Spinal stenosis o Anatomic variations include divisions of sciatic nerve splitting piriformis = predisposing to nerve compression o Intrinsic piriformis strain o Myositis o Tumor compression o Irritation of piriformis by sacroiliitis o Prolonged sitting = bilateral piriformis syndrome o Pseudoaneurysm of inferior gluteal artery Epidemiology: Up to 6% of sciatica cases
Gross Pathologic & Surgical Features Hypertrophy of piriformis Compression of sciatic nerve Myositis ossificans Associated mass lesion/entrapment (tumor, abscess or hematoma)
PIRIFORMIS SYNDROME o Local injections with steroid/local anesthetic o Anti-inflammatories
Piriformis split by sciatic nerve
Microscopic Features
o ~otox injections Surgical o Release of piriformis from greater tuberosity insertion o Lysis of adhesionstfibrosis surrounding piriformis or sciatic nerve
Inflammation Interstitial myofibrositis o Extravasation of blood o Serotonin release from platelets 0 Prostaglandin E o Bradykinin o Histamine release 0 Neuritis o Fibrosis
1 D~AGNOST~C CHECKLIST Consider
Staging, Grading or Classification Criteria 6 cardinal features o Positive LasCque sign (pain at greater sciatic notch in knee extension + hip flexion) o Sausage-shaped mass - piriformis muscle o Gluteal atrophy - chronic o Trauma o Sacroiliac joint, gluteal muscle or greater sciatic notch pain o Pain increased by lifting the extremity + decreased by traction on involved extremity
Piriformis syndrome = absence of neurologic deficit (unlike typical sciatic pain) Evaluate morphology signal intensity changes in piriformis muscle +
1. 2.
3. h
[CLINICAL ISSUES
3.
Presentation Most common signs/symptoms: Chronic gluteal pain which radiates into lower extremity similar to L5-S1 radiculopathy Clinical profile o Pain with hip adduction + internal rotation o Tenderness of piriformis on digital rectal examination + external palpation o Pain with passive hip flexion + internal rotation (Freiberg'ssign) o Pain with resisted abduction + external rotation (Pace's sign) o LasCque sign o Sacroiliac jointtgreater sciatic notch pain 0 Pain with Valsalva maneuver o Dyspareunia; pain radiating to genitals
4. 5. 6. 7.
8. 9. 10. 11.
Demographics Age: 18-55 years (overlap with age range for low back pain) Gender: F:M = 6:l
Natural History & Prognosis
12. 13. 14.
Progression is typical without treatment Most cases improve with conservative treatment Surgery for refractory cases Functional biomechanical deficits o Tight piriformis muscle o Contraction and tightness of external rotators + adductors o Lumbosacral spine dysfunction o Sacroiliac joint hypomobility
Dezawa A et al: Arthroscopic release of the piriformis muscle under local anesthesia for piriformis syndrome. Arthroscopy 19(5):554-7,2003 Nakamura H et al: Piriformis syndrome diagnosed by cauda equina action potentials: Report of two cases. Spine 15:28(2):E37-40,2003 Fishman LM et al: BOTOX and physical therapy in the treatment of piriformis syndrome. Am J Phys Med Rehabil 81(12):936-42,2002 Foster MR: Piriformis syndrome. Orthopedics 25(8):821-5, 2002 Fishman LM et al: Piriformis syndrome: Diagnosis, treatment, and outcome - a 10-year study. Arch Phys Med Rehabil 83(3):295-301,2002 Reat MT: The piriformis syndrome - math or reality? Br J Sports Med 36(1):76, 2002 Rossi P et al: Magnetic resonance imaging findings in piriformis syndrome: A case report. Arch Phys Med Rehabil 82(4):519-21, 2001 Levin SM: Piriformis syndrome. Orthopaedics 23(3):183-4, 2000 Benson ER et al: Post-traumatic piriformis syndrome: Diagnosis and results of operative treatment. J Bone Surg Am 81:941,1999 Fishman L et al: Electrophysiologic evidence of piriformis syndrome. Arch Phys Med Rehabil 73:359, 1992 Vandertop W et al: The piriformis syndrome. J Bone Joint Surg Am 73:1095, 1991 Silver JK: Piriformis syndrome: Assessment of current practice and literature review. Orthopaedics 21:1133, 1988 Pavlov H et al: Stress fractures of the pubic ramus. J Bone Surg Am 64:1020, 1982 Robinson DR: Piriformis syndrome in relation to sciatic pain. AM J Surge 73:355, 1947
Treatment Conservative o Rest o Physical therapytstretching
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PIRIFORMIS SYNDROME IMAGE GALLERY
I (Left) Coronal FS PD FSE MR shows normal anatomy of the piriformis muscle (arrows). The piriformis originates from the sacrum, greater sciatic foramen, and sacrotuberous ligament and inserts on the greater trochanter of the femur. (Right) Coronal T l Wl MR shows asymmetric hypertrophy (arrow) of the left piriformis muscle (wallet sciatica) in a fighter pilot who carried his money in his left back pocket.
(Left) Axial FS PD FSE MR shows lymphoma (arrow) compressing and displacing left sciatic nerve. (Right) Axial FS PD FSE MR shows edema of the right piriformis muscle and adjacent sciatic nerve, which abuts its anterior margin.
Typical (Left) Coronal T l Wl MR shows the course of the sciatic nerve (arrow) directly lateral and parallel to the hypointense semimembranosus tendon. (Right) Coronal graphic (posterior view) shows benign peripheral nerve sheath tumor of the sciatic nerve mimicking piriformis syndrome.
ILIOPSOAS BURSITIS
Coronal graphic shows distension of the iliopsoas bursa anterior to the joint capsule.
I, 3"
1
TERMINOLOGY
Abbreviations and Synonyms Iliopectineal bursitis, iliofemoral bursitis, sub-psoas bursitis, iliopsoas syndrome
Definitions Inflammation of the iliopsoas bursa
Axial FS PD FSE MR shows hyperintense iliopsoas bursal (arrow) distension medial to the right iliopsoas tendon. Note the anterior convexity and tear-drop morphology
CT Findings NECT o Thin-walled fluid density mass o Thickened wall in synovial proliferative process (rheumatoid) CECT: Wall & enhancement
MR Findings
General Features Best diagnostic clue: Hyperintense fluid collection medial to iliopsoas muscle on T2WI Location: Bursa between anterior hip capsule + iliopsoas muscle Size: Variable (1 to 3 cm most common) Morphology: & Tear-drop shaped on axial with anterior convexity + posterior communication with bursa
Radiographic Findings Radiography o Usually normal o Rarely a soft tissue mass is visualized o Concomitant disease of the hip may be identified o Bursography - incidentally filled during hip arthrography
TlWI o Hypointense to intermediate signal intensity mass o Displacement of adjacent iliopsoas tendon laterally T2WI o Hyperintensity with bursal distension o Usually uniformly increased signal o Less commonly heterogeneous signal = hemorrhage or proteinaceous debris o Axial images to show direct communication with hip = tail-like extension tapering medial to iliopsoas tendon o Well marginated borders o Long axis oriented superior to inferior on coronal images o Bursa1 fluid > volume than hip joint fluid TI C+ o Peripheral enhancement with intravenous contrast (bursa1 lining) o Fluid - no enhancement unless complicated by synovial proliferation
DDx: lliopsoas Bursitis P~ralabralCwt
Muscle Straln
Osteoarthr~t~s
f
Cor FS PD MR
Cor FS PD MR
Cor FS PD MR
Ax FS PD FSE MR
Key Facts Imaging Findings Best diagnostic clue: Hyperintense fluid collection medial to iliopsoas muscle on T2WI + Location: Bursa between anterior hip - capsule iliopsoas muscle Morphology: k Tear-drop shaped on axial with anterior convexity + posterior communication with bursa
Top Differential Diagnoses Paralabral Cyst Muscle Strain Osteoarthritis Snapping Hip Syndrome
Rheumatoid arthritis: Synovial proliferation k Snapping hip syndrome Discrete soft tissue cystic mass adjacent to femoral neurovascular bundle
Clinical Issues
.
Most common signs/symptoms: Anterior groin mass Tender to palpation in femoral triangle Pain with activity progressing to pain at rest Delay in diagnosis common Improvement with conservative measures
Diagnostic Checklist FS PD FSE or STIR to document bursal origin
Pathology Overuse
Ultrasonographic Findings Anechoic to hv~oechoicfluid Well circumsc;ibed fluid collection Hyperechoic if hemorrhage present
Imaging Recommendations Best imaging tool o Ultrasound = most cost-effective diagnostic test o MR = superior for soft tissue contrast + specificity (e.g., distinguishing from paralabral cyst or abscess) Protocol advice: FS PD FSE axial and coronal required k T1 C+ (fat suppression)
[DIFFERENTIAL DIAGNOSIS Paralabral Cyst Associated with acetabular labral tears May project anteriorly
Muscle Strain Anterior muscle edema (e.g., rectus femoris) Not associated with bursal fluid distension
Osteoarthritis Joint effusion Synovitis Capsular distension Subchondral cysts
Snapping Hip Syndrome Iliotibial band irritation of greater trochanteric bursa with flexion + extension + internal rotation Sensation of hip dislocation Responds to conservative therapy
Effusion Capsular distension Scalloping of capsule with synovitis
Malignancy Malignant fibrous histiocytoma Liposarcoma Synovial cell sarcoma
Metastatic lesions
Inflammatory Arthritides Rheumatoid --symmetrical+ bilateral + uniform axial joint space narrowing Pannus + effusion + subchondral edema k cysts
General Features General path comments o Relevant anatomy = iliopsoas bursa Largest bursa of hip 8 body f ordered mediallyby iliopectineal muscle Bordered laterally by anterior inferior iliac spine o Iliopsoas tendon crosses inferior aspect hip joint canwle ..r - - - o Psoas major origin = T12-L5 transverse processes + bodies o Iliacus origin = iliac wing o Psoas major + iliacus forms iliopsoas with insertion on lesser trochanter of femur * Etiology o Overuse Repetitive/strenuous hip flexion + extension o Rheumatoid arthritis: Synovial proliferation o Trauma o Degenerative + inflammatory component o Associated tendonitis/tenosynovitis o k Snapping hip syndrome o Associated intraarticular pathology (e.g., avascular necrosis) Epidemiology: Iliopsoas bursal communication with hip in 15% of healthy individuals & 30% individuals with hip pathology
Gross Pathologic & Surgical Features Discrete soft tissue cystic mass adjacent to femoral neurovascular bundle k Hemorrhage k Communication with hip joint
I L I O P S O A S BURSlTlS Microscopic Features Synovial cells inflamed + hypertrophied Fibrosis Fibrin
Presentation Most common signs/symptoms: Anterior groin mass Clinical profile o Tender to palpation in femoral triangle o & Pulsatile secondary to adjacent femoral vessels o & Presentation as a pelvic mass from cephalad extension + compression of intrapelvic contents (colon, bladder, etc.) o Pain + radiation distally to anterior thigh & knee 0 Exacerbating movements Flexion Abduction External rotation o Pain with activity progressing to pain at rest 0 Delay in diagnosis common
Demographics Age: Young active adults Gender: Females slightly > males
17.
Natural History & Prognosis
18.
Improvement with conservative measures Associated with snapping hip syndrome
19.
Treatment
20.
Conservative o Anti-inflammatory medications o Hip abduction + external rotation stretching exercises 0 Deep heat o Ultrasound therapy - . 0 Steroid injection Surgical 0 Iliopsoas tendon release (rarely required)
1 DIAGNOSTIC CHECKLIST 1
1
Consider FS PD FSE or STIR to document bursa1 origin T I C+ to exclude soft tissue malignant tumor
1.
2. 3. 4. 5. 6.
DeLee JC et al: Orthopaedic sports medicine. Principles and practice. vol 2. 2nd ed. Philadelphia PA, Saunders, (25):1443-62,2003 Boutin FJ Sr: Bursitis: Operative orthopaedics. vol 4. 4th ed. Philadelphia PA, JB Lippincott Company, 3019-375, 2002 Wunderbaldinger P et al: Imaging features of iliopsoas bursitis. Eur Radiol 12(2):409-15,2002 Morelli V et al: Groin injuries in athletes. Am Family Physician (8):1405-14,2001 Van Holsbeeck MT et al: Musculoskeletal ultrasound. 2nd ed. St. Louis MO, Mosby, 576-7, 2001 Ruddy S et al: Kelley's textbook of rheumatology. 6th ed. Philadelphia PA, Saunders, 541-2, 2001
I
Pfirrmann CW et al: Greater trochanter of the hip: Attachment of the abductor mechanism and a complex of three bursae-MR imaging and MR bursography in cadavers and MR imaging in asymptomatic volunteers. Radiology 221(2):469-77,2001 Chung CB et al: Gluteus medius tendon tears and avulsive injuries in elderly women: Imaging findings in six patients. AJR 173(2):351-3,1999 Johnston CA et al: Iliopsoas bursitis and tendinitis. A review. Sports Med 25(4):271-83, 1998 Kozlov DB et al: Iliopsoas bursitis: Diagnosis by MRI. J Computer Assisted Tomog 22(4):625-8, 1998 Amrar-Vennier F et al: Subcutaneous trochanteric bursitis: An unrecognized cause of peritrochanteric pain revealed by imaging. J Radiol 79(6):557-62, 1998 Stoller DW: Magnetic resonance imaging in orthopaedics and sports medicine. vol 1. 2nd ed. Philadelphia PA, Saunders, 164-7, 1997 Fortin L et al: Bursitis of the iliopsoas: Four cases with pain as the only clinical indicator. J Rheumatol22(10):1971-3, 1995 Toohey AK et al: Iliopsoas bursitis: Clinical features, radiographic findings, and disease associations. Semin Arthritis Rheum 20(1):41-7, 1990 Underwood PL et al: The varied clinical manifestations of iliopsoas bursitis. J of Rheum 15(11):1683-5,1988 Weinreb JC et al: Iliopsoas muscles: MR study of normal anatomy and disease: Radiology 156(2):435-40,1985 Sartoris DJ et al: Synovial cyst of the hip joint and iliopsoas bursitis: A spectrum of imaging abnormalities. Skeletal Radiol 14(2):85-94,1985 Steinbach LS et al: Bursae and abscess cavities communicating with the hip. Diagnosis using arthrography and CT. Radiology 156(2):303-7,1985 Penkava RR: Iliopsoas bursitis demonstrated by computed tomography. ~m J of Roentg 153(1):175-6,1980 Armstrong P et al: Iliopsoas bursa. Br J Radiol 45(535):493-5, 1972
ILIOPSOAS BURSITIS
-
1
SNAPPING HIP SYNDROME
Coronal graphic shows iliopsoas impingement on the iliopectineal eminence during extension of the leg.
I
Sagittal FS PD FSE MR shows hyperintense edema parallel and anterior to the iliopsoas tendon (arrow).
Radiographic Findings Abbreviations and Synonyms Snapping hip, coxa saltans
Definitions Snapping or clicking sensation upon movement of hip
Radiography o Rarely helpful in internal or external etiologies o & Identification for intraarticular etiologies (loose bodies, etc.) o Bursography: Injection of iliopsoas bursa with contrast during hip motion to assess iliopsoas muscle motion (rapid or jerky)
CT Findings General Features Best diagnostic clue: Hyperintense inflammation of the greater trochanteric bursa or thickened iliotibial band on T2WI (external type) Location o External: Iliotibial tract o Internal : Iliopsoas tendon o Intraarticular: Loose bodies within hip joint Size o Variable based on causative factor Iliotibial band, greater trochanteric bursa, anterior border gluteus maximus, femoral head, iliopectineal ridge, iliopectineal bursa, + lesser trochanter Morphology: Medial to lateral thickening of iliotibial band = snapping over greater trochanter
NECT o + Intraarticular etiology o Loose bodies + osteochondromatosis
MR Findings TlWI o External Hypointense thickening of posterior iliotibial tract Intermediate signal intensity thickening of greater trochanteric bursa o Internal Iliopsoas bursa fluid (hypointense) distension medial to tendon Marrow-containing (vs. cortical) exostosis projecting from lesser trochanter o Intraarticular Hypointense, intermediate, or marrow fat signal intensity in loose bodies
.
DDx: Snapping Hip Syndrome LWFP 13ndv
Ilrop~.Rursitrs
Labral Tear
Impingement
Ax PD MR
Ax FS PD FSE MR
Cor T I Arthro.
Cor FS PD MR
SNAPPING HIP SYNDROME Key Facts Imaging Findings Best diagnostic clue: Hyperintense inflammation of the greater trochanteric bursa or thickened iliotibial band on T2WI (external type) Morphology: Medial to lateral thickening of iliotibial band = snapping over greater trochanter Hyperintense iliopsoas bursa fluid vs. tenosynovitis on T2WI
Top Differential Diagnoses Loose Bodies Iliopsoas Bursitis Labral Tears Synovial Chondromatosis Greater Trochanteric Bursitis
T2WI o External Hypointense to hyperintense iliotibial band + anterior border gluteus maximus Hyperintense greater trochanteric bursa o Internal Hyperintense iliopsoas bursa fluid vs. tenosynovitis on T2WI o Intraarticular Hypointense to intermediate signal intensity of loose bodies adjacent to hyperintense joint fluid T1 C+: MR arthrography for labral tears + other intraarticular etiologies
Ultrasonographic Findings Real-time imaging during hip movement Sudden, abnormal movement of iliotibial band or gluteus maximus over greater trochanter Iliopsoas muscle movement over iliopectineal eminence, femoral head or lesser trochanter
Imaging Recommendations Best imaging tool o MR excellent for all etiologies o Ultrasound quick, non-invasive, but operator dependent Protocol advice: T1 + FS PD FSE in coronal, axial, + sagittal planes
1 DIFFERENTIALDIAGNOSIS Loose Bodies Cartilaginous or osteocartilaginous bodies in capsule or acetabular fossa Best visualized in contrast to adjacent hyperintense joint fluid on T2WI
Iliopsoas Bursitis Medial to iliopsoas tendon Enlargement of bursa with anterior convexity Uniform hyperintensity - most common appearance
Pathology Intraarticular - labral or chondral fragments Epidemiology: Internal + external - individuals in dancing or athletics with no specific history of trauma Tight or thickened iliotibial band Tight iliopsoas
Clinical Issues Most common signslsyrnptoms: Palpable snap during hip flexion and extension Click (not snap) > intraarticular causes Pain with intraarticular etiologies
Diagnostic Checklist History + physical: Internal, external or intraarticular?
Labral Tears Anterosuperior + posterosuperior tears most common Associated paralabral cysts
Synovial Chondromatosis Multiple intermediate signal intensity defects in joint fluid Morphology similar to synovial hyperplasia
Greater Trochanteric Bursitis Hyperintense thickening of bursa adjacent to greater trochanter on T2WI Frequently bilateral
Femoroacetabular Impingement Osteoarthritis in patients < 50 years Preferential acetabular chondral disease + labral tear prior to femoral head disease Non-dysplastic hips
1 PATHOLOGY General Features General path comments o Relevant anatomy Proximal iliotibial tract Greater trochanter Anterior margin gluteus maximus Lesser trochanter Iliopsoas tendon rn Iliopectineal ridge Iliopectineal bursa Acetabulum Femoral head Etiology o External - proximal iliotibial band slides over greater trochanter as hip extends from flexed position o Internal - iliopsoas tendon snaps over iliopectineal eminence o Intraarticular - labral or chondral fragments o Often related to tight tendons (taut iliotibial band) o Bursitis associated
SNAPPING HIP SYNDROME o Overuse Epidemiology: Internal + external - individuals in dancing or athletics with no specific history of trauma
Gross Pathologic & Surgical Features External o Tight or thickened iliotibial band o Bursitis or tendonitis o Gluteus maximus as causative structure associated with bursitisltendonitis Internal o Tight iliopsoas o Associated bursitisltendonitis Intraarticular o Loose bodies o Labral tear o Chondral lesions
Microscopic Features Inflammatory cells Synovial cells Fibrinlhemorrhage Fibrosis
0
body removal, debridement of chondral lesions)
I DIAGNOSTIC CHECKLIST History + physical: Internal, external or intraarticular? MRI excellent for intraarticular evaluation Sonography to evaluate iliotibial band, gluteus maximus or iliopsoas
I
J
1.
2. 3.
5.
Most common signs/symptoms: Palpable snap during hip flexion and extension Clinical profile o Pressure applied to greater trochanter will stop snapping with hip motion in external etiologies (iliotibial band reduced posterior to trochanter) o Snapping eliminated with internal etiologies by applying pressure over iliopsoas tendon at level of femoral head o Painful o Audible snap o Click (not snap) > intraarticular causes o Pain with intraarticular etiologies
6.
7. 8. 9. 10. 11. 12. 13.
Demographics Age: Young adults 15-40 years most common Gender: Females with slight predilection (depending on type of activity) At risk o Ballet dancers
Natural History & Prognosis Most cases mildly symptomatic Intraarticular pathology may show continued progression of pathology and symptoms (e.g., chondral degeneration) Improvement with conservative measures including activity modification
Treatment Conservative o Decrease causative activity o Anti-inflammatory medications o Steroid injections o Physical therapy Surgical o Partial tendon + bursa resection
I
Consider
4.
Presentation
Tendon lengthening procedures
o Arthroscopy for intraarticular lesions (e.g., loose
14. 15. 16.
DeLee JC et al: Orthopaedic sports medicine. Principles and practice. vol 2. 2nd ed. Philadelphia PA, Saunders, (25 k):1443-62, 2003 Bellabarba C et al: Idiopathic hip instability. An unrecognized cause of coxa saltans in the adult. Clin Orthop 355:261, 1998 Cardinal E et al: Ultrasound of the snapping iliopsoas tendon. Radiology 198521, 1996 Janzen DL et al: The snapping hip: Clinical and imaging findings in the transient subluxation of the iliopsoas tendon. Can Assoc Radiol J 47:202, 1996 Allen WC et al: Coxa saltans: The snapping hip syndrome. J Am Acad Orthop Surg 3:303, 1995 Taylor GR et al: Surgical release of the "snapping iliopsoas tendon." J Bone Joint Surg Br 775381, 1995 Vaccaro JP et al: Iliopsoas bursa imaging: Efficacy in snapping hip syndrome. Radiology 1972353, 1995 Brignall CG et al: The snapping hip syndrome: Treatment by Z-plasty.J Bone Joint Surg Br 73:253, 1991 Jacobson T et al: Surgical correction of the snapping iliopsoas tendon. Am J Sports Med 18:470, 1990 Silver SF et al: Case report 550. Skel Radiol 18:327, 1989 Glick JM: Hip arthroscopy using the lateral approach. Instr Course Lect 37:223, 1988 Staple TW et al: Snapping tendon syndrome: Hip tenography with fluoroscopic monitoring. Radiology 166:873, 1988 Harper MC et al: Primary iliopsoas bursography in the diagnosis of disorders of the hip. Clin Orthop 221:238, 1987 Scharberg JE et al: The snapping hip syndrome. Am J Sprots Med 12:361, 1984 Lyons JC et al: The snapping iliopsoas tendon. Mayo Clin Proc 59:327, 1984 House AJG: Orthopaedists and ballet. Clin Orthop 8952, 1972
SNAPPING H I P SYNDROME
(Left) Axial FS PD FSE MR shows focal hyperintensity (arrow) adjacent and lateral to the iliopsoas tendon (hypointense structure abutting anterior acetabulum). (Right) Axial FS PD FSE MR shows hyperintense fluid collection (arrow) deep to the iliopsoas muscle and adjacent to the anterior inferior iliac spine.
Typical (Left) Axial T2 WI MR shows an iliopsoas bursa1 fluid collection which was treated conservatively in a patient with snapping hip syndrome. (Right) Axial FS PD FSE MR shows anterior intramuscular extension of left iliopsoas bursa.
Typical (Left) Axial FS PD FSE MR of the left hip shows posttraumatic hyperintense edema (arrow) medial to the iliotibial band. (Right) Coronal graphic of thickened iliotibial band in contact with greater trochanter.
FEMORAL HEAD FRACTURES
Coronal graphic shows nondisplaced femoral head fracture.
Axial T l Wl MR shows medial capital fracture on the left with complete anterior to posterior extension.
o Oblique view Uudet views)
Fracture evaluation + acetabular evaluation
4h
Abbreviations and Synonyms
CT Findings
Fractures of femoral head, capital fracture
Definitions Fracture (fx) of femoral head, usually associated with posterior hip dislocation
General Features Best diagnostic clue: Oblique fx femoral head relative to long axis of femoral neck Location: Femoral head Size o Fracture size increases if involves central fossa (fovea) o Smaller fractures located below central fossa Morphology: Oblique to vertical as viewed in coronal plane - most common
Radiographic Findings Radiography o Initial diagnostic examination o Anteroposterior view usually diagnostic o Lateral view - location of femoral head + fracture fragments
NECT o Intraarticular fragments visualized o Multiplanar capability - for surgical planning
M R Findings TlWI o Hypointense fracture line o Localized to more diffuse hypointense femoral head edema o Hypointense to intermediate signal intensity hemorrhagic effusion T2WI o Hyperintense femoral head edema + effusions on T2WI o Evaluate complications Muscle strainsltears - hyperintense Labral tears: Hyperintense paralabral cysts Chondral injuries - interruption of intermediate signal chondral surface Avascular necrosis
*
Imaging Recommendations Best imaging tool o CT used for hip dislocations with fracture of the femoral head
r
DDx: Femoral Head Fractures Snapping Hip
Femoral Neck Fx
Cor T l W l MR
Cor FS PD MR
Ax FS PD FSE MR
FEMORAL HEAD FRACTURES Key Facts Imaging Findings Best diagnostic clue: oblique fx femoral head relative to long axis of femoral neck Fracture size increases if involves central fossa (fovea) Hyperintense femoral head edema + effusions on T~WI
High energy injuries Associated sciatic nerve compression in posterior dislocation for head fracture dislocations
Clinical issues ~ o scommon t signs/syrnptoms: Pain in hip area Reduce hip ASAP - risk of AVN increases > 6 hrs Associated morbiditylmortality 2" to associated head, abdominal + pelvic trauma Age: Young adults - high-energy trauma victims (< 35 years) + trauma 2" to fall ( > 65 years)
Top Differential Diagnoses Femoral Neck Fracture Acetabular Fracture Pelvic Fracture Femoral Head Avascular Necrosis (AVN)
Pathology
Diagnostic Checklist
Shearing force from dislocation of hip Most commonly with posterior dislocation 20 motor vehicle accident (MVA)
Association of femoral head fractures with posterior hip dislocations
-
-
Pubic bone stress fractures - associated with long-distance running Sacrum - runners at risk; bilateral stress fractures with "H" sign on MRI
o MR used as primary exam in isolated capital
fractures Protocol advice o 1 mm thin section CT through acetabulum + femoral head Coronal & sagittal reformations o MR: Coronal, axial & sagittal T1 + FS PD FSE
[DIFFERENTIAL DIAGNOSIS Femoral Neck Fracture Subcortical Stress - groin, anterior thigh or knee pain (transverse + compression) Pauwels' classification - based on angulation of fracture line to the horizontal plane Garden classification - based on displacement of fragments
Acetabular Fracture Blunt high energy injuries Judet-Letournel classification of five elementary fractures based on column 8 wall involvement Complications = heterotropic ossification
Pelvic Fracture High energy pelvic fractures associated with hemorrhage Benign avulsion to massive pelvic disruptions Stable, rotationally unstable/vertically stable to rationally & vertically unstable
Femoral Head Avascular Necrosis (AVN)
-
Necrotic segment collapse anterosuperior aspect femoral head Traumatic vs. non-traumatic Associated with displaced fracture femoral neck + hip dislocation Groin or hip pain
Stress Fracture Pelvic stress fractures
-
Snapping Hip Syndrome
I
Painful, audible snap in hip flexion + extension External, internal or intraarticular etiologies Iliotibial band = external cause (sliding over greater trochanter), internal type = iliopsoas tendon catching
Slipped Capital Femoral Epiphysis Posterior inferior displacement proximal femoral epiphysis Childhood disorder Slip - in zone of hypertrophy in growth plate Pain + limp
I PATHOLOGY General Features General path comments o Relevant anatomy Vascular supply to head + neck originates from medial + lateral femoral circumflex arteries Extracapsular vascular ring - cervical arteries Ligamentum teres vascular supply to head insignificant in adult Femoral head = multiaxial, synovial ball-and-socket joint Etiology o Shearing force from dislocation of hip o Most commonly with posterior dislocation 2" motor vehicle accident (MVA) o High energy injuries Epidemiology o Fractures of femoral head associated with posterior dislocations o Rare relative to incidence of dislocations
Gross Pathologic & Surgical Features Fragmentation of surrounding osseous + cartilaginous structures
?
FEMORAL HEAD FRACTURES Entrapped fragments in joint Associated sciatic nerve compression in posterior dislocation Pipkin classification for femoral head fracture dislocations o I: Fracture caudad (below) central fovea + disrupted ligamentum teres o 11: Fracture cephalad to fovea + ligamentum teres remains attached to fracture fragment o 111: Femoral head fracture (Pipkin I or 11) associated femoral neck fracture (k due to over aggressive closed reduction) o IV: Femoral head fracture (Pipkin I or 11) + superoposterior acetabular rim fracture k Impaction fracture Adolescents may shear off capital femoral epiphysis
Microscopic Features Fracture - vascular disruption o Hematoma o Revascularization o Callus vs. primary bone repair
Staging, Grading or Classification Criteria Pipkin classification for femoral head fracture o I: Below ligamentum teres - no associated injuries o 11: Above ligamentum teres - no associated injuries o 111: Either below or above - femoral neck fracture associated o IV: Either below or above - acetabular fracture
o Fracture repair
Treatment Conservative = Pipkin I o Closed reduction preferred o Displaced inferior fragment acceptable if does not involve weight bearing portion o Pipkin I1 - closed reduction only if fracture fragments congruent Surgical o Pipkin I1 - open reduction with internal fixation (ORIF) for displaced/unstable fracture fragments o Pipkin I11 - ORIF for younger patients (rigid pinning) & hemiprosthesis for older patients o Pipkin IV - ORIF for displaced/unstable acetabular fracture in younger patient + total arthroplasty in older individuals o Impacted femoral head fractures - surgically elevate & graft o Post reduction treatment - traction, minimal weight bearing, physical therapy Complications o AVN o Post-traumatic arthritis o Recurrent dislocation o Sciatic nerve injury
I DIAGNOSTIC CHECKLIST
1
Consider
Presentation Most common signs/symptoms: Pain in hip area Clinical profile o Dislocated hip = 1st concern o Reduce hip ASAP - risk of AVN increases > 6 hrs o Maximum 2-3 attempts at closed reduction due to risk of AVN + iatrogenic injury o Associated morbidity/mortality 2' to associated head, abdominal + pelvic trauma
Demographics Age: Young adults - high-energy trauma victims (< 35 years) + trauma 2" to fall ( > 65 years) Gender: Young males most common
Natural History & Prognosis Anatomiclnear anatomic fracture alignment essential in younger patients o Preserve function and avoid complications (AVN, osteoarthritis) Outcome dependent on o Femoral head fracture type o k Associated fractures (acetabular, femoral neck, pelvic ring) o Length of time until reduction Pipkin I & I1 - better prognosis than 111 & IV Open reduction indications o Failed closed reduction o Femoral neck fracture o Incongruent reduction o Intraarticular fragments
Association of femoral head fractures with posterior hip dislocations Identify femoral head fracture orientation relative to fovea
ISELECTEDREFERENCES LaVelle DG: Campbell's operative orthopaedics. vol 4. 10th ed. Philadelphia PA, Elsevier Science, 2922-8, 2003 2. Fitzgerald RH et al: Orthopaedics. St. Louis MO, Mosby, (3-13):346-88, 2002 3. Mostafa MM: Femoral head fractures. International Orthop 25:51-4, 2001 4. Bucholz RW et al: Rockwood and Green's fractures i n adults. 5th ed. Philadelphia PA, Lippincott Williams & Wilkins, 1547-78, 2001 5. Harris JH Jr: Pelvis, acetabulum and hips. The radiology of emergency medicine. 4th ed. Philadelphia PA, Lippincott Williams & Wilkins, 796-97, 2000 6. Dreinhofer KE et al: Isolated traumatic dislocation of the hip: Long-term results in 50 patients. J Bone Joint Surg Br 76:6, 1994 7. Levin PE: Hip dislocations: Skeletal Trauma. vol 2. Philadelphia PA, WB Saunders, 1992 8. Epstein HC: Traumatic dislocation of the hip. Baltimore MA, Williams & Wilkins, 1980 1.
FEMORAL HEAD FRACTURES
I IMAGE GALLERY Typical (Left) Coronal T l Wl MR shows right nondisplaced fracture (arrow) of anterosuperior femoral head with hypointense fracture line. (Right) Coronal FS PD FSE MR shows hyperintense marrow edema (arrow) in a nondisplaced capital fracture involving the right hip.
Typical (Left) Coronal T 1 WI MR shows left medial capital fracture (arrow). (Right) Sagittal T l Wl MR shows anterior capital fracture.
(Left) Coronal T 1 WI MR shows left osseous contusion with linear trabecular fracture (arrowj line parallel to physeal scar. (Right) Coronal graphic shows nondisplaced capital fracture with reactive marrow edema (red). Fracture line extends to the chondral surfaces.
FEMORAL NECK FRACTURES
Coronal graphic shows stress fracture perpendicular to the long axis of the femoral neck.
Coronal FS PD FSE MR shows medial femoral neck stress fracture (arrow) with associated subchondral hyperintense marrow edema.
o Transverse vs. compression (medial) stress fractures
Radiographic Findings
Abbreviations and Synonyms
Radiography o Subcapital fracture Pauwels classification based on direction of fracture angle from 0 to > 70 degrees Garden classification based on displacement of fracture fragments
Fracture of the proximal femur, subcapital femoral neck fracture, stress fracture, insufficiency fracture (fx)
Definitions Intracapsular femoral neck fractures = subcapital (common), transcervical (uncommon) or basicervical (uncommon)
CT Findings NECT o Coronal reformations o Assess fracture obliquity (more vertical fractures are less stable) + displacement
General Features
MR Findings
Best diagnostic clue: Medial femoral neck hyperintensity on FS PD FSE or STIR images Location o Subcapital o Transcervical o Basicervical Size o Incomplete to complete traversing femoral neck o Subchondral edema t extensive than associated fx Morphology o Focal involvement of medial cortex o Fracture plane obliquity ranges from 30 degrees or less to > than 70 degrees (from horizontal)
TlWI o Hypointense signal medial femoral neck in stress fracture o Discrete well-defined hypointense fracture line complete extension across femoral neck o Microtrabecular stress fracture with intact medial + lateral cortices o Hypointense joint effusion/hemorrhage + synovitis o Early detection of hypointense sclerosis in avascular necrosis (AVN) T2WI o Hyperintense marrow edema on T2WI
*
DDx: Femoral Neck Fractures AVN
Osteoarthritrs
TOH
um Metastases
2
Sag T I WI MR
Cor T l W l MR
Cor T 1 Wl MR
/
Cor FS PD MR
Cor T l Wl MR
FEMORAL NECK FRACTURES Key Facts Imaging Findings Best diagnostic clue: Medial femoral neck hyperintensity on FS PD FSE or STIR images Incomplete to complete traversing femoral neck Subchondral edema t extensive than associated fx Hyperintense marrow edema on T2WI
Top Differential Diagnoses Contusion AVN of the Femoral Head Osteoarthritis Transient Osteoporosis of Hip (TOH) Osseous Lesions I
Pathology Fall with impact on greater trochanter + lateral rotation of femur
Cyclic loading + microfracture + torsional force
Clinical Issues Most common signs/symptoms: Pain in groin, anterior thigh or knee Pain increased with weight-bearing or exertion Limitation of hip motion (internal rotation) Pain with axial compression or greater trochanter percussion Transverse stress fractures - risk for displacement Compression stress fractures - low risk for displacement
Diagnostic Checklist MR evaluation of contralateral side to evaluate for bilateral stress fractures -
o Hypointense fracture line on T2WI - common
o Pathologic fractures associated with marrow
replacement + trabecular destruction
o Direct visualization of associated chondral lesions in
acetabulum + femoral head + Associated hyperintense acetabulum & edema in trabecular microfracture o Adjacent soft tissue edema + hemorrhage demonstrates hyperintensity T1 C+: Assess femoral head perfusion: Uniform increased signal intensity with intact perfusion o
Imaging Recommendations Best imaging tool o MR identifies stress fracture, microtrabecular fracture + edema o Nondisplaced femoral neck fractures may not be visualized on conventional radiographs Protocol advice o Coronal T1 (for marrow fat signal contrast) + FS PD FSE or STIR o Secondary use of axial + sagittal planes
I DIFFERENTIAL DIAGNOSIS Contusion Hyperintense trabecular edema without fracture line or cortical irregularity on T2WI Symptoms may mimic stress fracture Pre-stress fracture stage
AVN of the Femoral Head
Transient Osteoporosis of Hip (TOH) Self-limiting Middle-aged males > pregnant females Progressive demineralization of femoral head Joint space preserved Diffuse hyperintensity femoral head + neck
Piriformis Syndrome Piriformis hypertrophy Muscle edema on FS PD FSE MR Fibrosis
Snapping Hip Syndrome Audible snap during hip flexion + extension External, internal or intraarticular etiologies External = iliotibial tract contact with greater trochanter Internal = iliopsoas tendon catching on structures posterior to it
Osseous Lesions Cyst - hypointense on TlWI, hyperintense on T2WI Metastatic'disease - e.g., breast, prostate + lung Cystic erosion 2" to synovial inflammatory process
Greater Trochanteric Bursitis Tenderness over greater trochanter Symptoms increased with hip external rotation + adduction Irritation by iliotibial band Hyperintense edema or fluid adjacent + parallel to greater trochanter on FS PD FSE MR
Wedge-shaped subchondral bone infarct Double-line sign in 80%) Articular cartilage intact initially
Osteoarthritis Loss of joint space with loss of articular cartilage Hypointense thickened stress trabeculae (calcar buttressing) on T1 + T2WI Ring of osteophytes Superolateral migration of femoral head
General Features General path comments o Relevant anatomy Calcar femorale = weight-bearing bone of femur from inferomedial femoral neck cortex toward lesser trochanter
FEMORAL NECK FRACTURES Blood supply to femoral head - via femoral neck from branches of circumflex arteries Etiology o Fall with impact on greater trochanter + lateral rotation of femur o Cyclic loading + microfracture + torsional force o Direct trauma o Training errors, improper footwear + uneven running surfaces (stress fxs) o Coxa vara = predisposes athlete to risk of fracture Epidemiology o 15% of runners develop a stress fracture 5-10% of stress fractures involve femoral neck
Gross Pathologic & Surgical Features Pauwels classification of femoral neck fractures o Pauwels I: Fracture line 0-30 degrees to horizontal o Pauwels 11: Fracture line 30 to 70 degrees to horizontal o Pauwels 111: Fracture line > 70 degrees to horizontal Garden classification of femoral neck fractures o Garden I: Incomplete or impacted o Garden 11: Complete nondisplaced ' o Garden 111: Complete with partial displacement o Garden IV: Complete fracture with total displacement Stress fracture - Blickenstaff & Morris classification o Type I: Endosteal or periosteal callus without fracture line o Type 11: Fracture line o Type 111: Displaced
Microscopic Features
o Military population - male trainees with increased
body mass index + poor fitness
o Female athletes - at risk with eating disorder,
amenorrhea, premature osteoporosis
Natural History & Prognosis Transverse stress fractures - risk for displacement Compression stress fractures - low risk for displacement Surgical treatment for distraction injuries Early diagnosis + aggressive treatment required Healing: 6-12 months Complications: Delayed union, non-union, AVN (10-30%), secondary degenerative osteoarthritis
Treatment Conservative o Pre-fracture stress reaction = non weight-bearing until pain free progressive weight-bearing o Compression stress fractures (medial) if nondisplaced = non weight-bearing Surgical o Tension-transverse stress fractures = immediate internal fixation regardless of the degree of displacement o Displaced = anatomic reduction + internal fixation o Knowles pinning o Endoprosthesis
-
1 D~AGNOST~C CHECKLIST Consider MR evaluation of contralateral side to evaluate for bilateral stress fractures Hyperintense bone marrow edema (T2WI) in the absence of a fracture line - document cortical + trabecular integrity with CT
Vascular disruption of bone Hematoma Revascularization Resorption of devascularized bone Healing with callus vs. primary bone repair
Staging, Grading or Classification Criteria Blickenstaff/Morris classification for stress fractures Pauwels & Garden classification for femoral neck fractures
Presentation Most common signs/symptoms: Pain in groin, anterior thigh or knee Clinical profile o Pain increased with weight-bearing or exertion o Limitation of hip motion (internal rotation) o Pain with axial compression or greater trochanter percussion
Demographics Age o Transverse stress fractures (typically insufficiency fxs) = common in older patients (involves superior cortex of neck) o Compression stress fractures = common in younger patients (50% of fractures < 60 years) Gender
-
1.
DeLee JC et al: Orthopaedic sports medicine. Principles and practice. vol2. 2nd ed. Philadelphia PA, Saunders, (25):1443-62,2003 2. Spitz DJ et al: Imaging of stress fractures in the athlete. Radiol Clin North Am 40(2):313-31,2002 3. Jackson M et al: The treatment of non-union after intracapsular fracture of the proximal femur. Clin Orthop 399:119-28, 2002 4. Bailie DS et al: Bilateral femoral neck stress fractures in a adolescent male runner. A case report. Am J Sports Med 29(6):811-3,2001 5. Bosch E et al: Difficult-to-detect osseous injuries. Physician Sportsmed 21:116-22, 1993 6. Daffner RH et al: Stress fractures: Current concepts. AJR 159:245-52, 1992 7. Meaney JEM et al: Femoral stress fractures in children. Skeletal Radiol 21:173-6, 1992 8. Mink JH et al: Occult cartilage and bone injuries of the knee: Detection, classification, and assessment with MR. Radiology 170:823-9, 1989 9. Lee JK et al: Stress fractures: MR imaging. Radiology 169:217-20, 1988 10. Stafford SA et al: MRI in stress fracture. AJR 147:553-6, 1986
FEMORAL NECK FRACTURES
(Left) Coronal FS PD FSE MR shows hyperintense edema associated with acute femoral neck stress fracture (arrow). Note the more vertical orientation of the fracture. (Right) Coronal FS PD FSE MR shows early or pre-stress fracture stage with subtle trabecular linear hyperintensity (arrow). The medial and lateral cortices are intact.
Typical (Left) Coronal FS PD FSE MR shows complete transverse femoral neck fracture. (Right) Coronal graphic shows complete femoral neck fracture with displacement.
Variant (Left) Coronal graphic shows intertrochanteric fracture extending from the greater to the lesser trochanter. (Right) Coronal T I * CRE MR shows hyperintense edema associated with hypointense fracture line (arrow) in an acute intertrochanteric fracture.
ACETABULAR FRACTURES
Coronal graphic shows posterior wall acetabular fracture.
Axial FS PD FSE MR shows posterior wall fracture after posterior dislocation of the hip.
Posterior column o Combination
Posterior column + posterior wall Transverse + posterior wall Complete (both column) = anterior + posterior columns T-shaped Anterior column + posterior hemitransverse
Abbreviations and Synonyms Acetabular trauma, fractures of the acetabulum
Definitions Fracture of the acetabulum of the hip, usually secondary to significant trauma
Radiographic Findings General Features Best diagnostic clue: Interruption of acetabular osseous column cortices Location 0 Anterior (iliopubic/iliopectineal) column o Posterior (ilioischial)column o Anteriorlposterior (transverse) o Complex (T-shaped or stellate) Size: Variable based on simple vs. combination fracture types Morphology o Simple Posterior wall Anterior wall Transverse Anterior column
Radiography o Anteroposterior (AP) view pelvis 0 Oblique views Uudet views) = Iliac oblique view = 45" external oblique for evaluation of posterior column + anterior wall Obturator oblique view = 45" internal oblique for evaluation of anterior column + posterior wall o Iliopectineal or iliopubic line: Disruption = fracture anterior column o Ilioischial line: Disruption = fracture posterior column o Pelvic inletloutlet views: Pelvic ring fractures o Radiographs may underestimate fracture complexity & intraarticular fragments
CT Findings NECT 0 Intraarticular fragment visualization I
DDx: Acetabular Fractures Pubic Ramus Fx
Osteoarthritis
Metastases
Ax FS PD FSE
Cor T l Wl MR
Cor T l Wl MR
ACETABULAR FRACTURES Key Facts Imaging Findings Best diagnostic clue: Interruption of acetabular osseous column cortices Anterior (iliopubic/iliopectineal) column Posterior (ilioischial) column Anterior/posterior (transverse) Complex (T-shaped or stellate)
Top Differential Diagnoses
Position of femur determines type of acetabular fractures Hip flexion + internal rotation = posterior wall + column injuries Hip extension + external rotation = anterior wall + column injuries Common (> 20%) = both columns, transverse + posterior wall, posterior wall
Clinical Issues
Hip Dislocations Avulsion Fractures Pelvic Ring Fractures Stress Fractures
Most common signs/syrnptoms: Pain at fracture site Pelvic ring fracture + associated bladder rupture
Diagnostic Checklist CT for displaced fragments or communition
Pathology Significant (high-energy) trauma
-
-
o Associated pelvic ring, soft tissue injuries +/or
hematoma o Improved visualization of weight bearing dome of
joint (not detected on conventional radiographs) o Femoral head fracture detection o 3-dimensional reformation delineates fracture pattern for surgical planning
MR Findings TlWI o Hypointense fracture line + associated subchondral edema o 3 orthogonal plane visualization of fracture with direct coronal, sagittal and axial images o Intraarticular fragments: Marrow fat signal or sclerotic - hypointense o Coronal & axial pelvic ring fracture detection T2WI o Hyperintense marrow edema adjacent to fracture site 0 Associated fracture detection of pelvic ring + femoral head o Hypointense free fragments o Improved visualization of medial wall acetabular fossa o Disruption of intermediate signal intensity chondral surfaces o Muscle trauma - hyperintense edema + hemorrhage on FS PD FSE
Imaging Recommendations Best imaging tool 0 CT superior for osseous detail + spatial relationships for complex fractures + 3-D capability 0 MRI - also helpful to appreciate 3 plane orthogonal anatomy, chondral + soft tissue pathology Protocol advice o 1 mm thin section CT + reformation coronal + sagittal + 3-D rendering 0 MR: Coronal, axial + sagittal T1 + FS PD FSE
Hip Dislocations Dislocation without acetabular fracture - severe trauma Dislocation with femoral head fracture - typically with posterior hip dislocation
Avulsion Fractures Anterior superior iliac spine (ASIS) Anterior inferior iliac spine (AIIS) Ischial apophysis
Pelvic Ring Fractures Stable = avulsion, Duverney's fracture (iliac wing), sacral (transverse) + ischiopubic rami Unstable = Malgaigne (unilateral ischiopubic rami), Straddle (obturator rings), bucket-handle (unilateral ischiopubic rami + contralateral sacroiliac joint) + dislocation (unilateral vs. bilateral)
Stress Fractures Pelvic - pubic ramus & sacrum (hyperintensity on FS PD FSE or STIR) Femoral neck stress - hypointense fracture line + hyperintense edema on T2WI (FS PD FSE or STIR) Groin, anterior thigh or knee pain
lntraarticular Derangements Avascular necrosis of the femoral head Hip osteoarthritis Acetabular labral tears
Osseous Lesions Cysts Metastatic trabecular destruction
General Features General path comments o Relevant anatomy Acetabulum = contributions of ilium, ischium 8 pubic bone (form innominate bone)
ACETABULAR FRACTURES Superior gluteal artery + sciatic nerve exits pelvis at greater sciatic notch Etiology o Significant (high-energy) trauma Femoral force transmitted to acetabulum o Position of femur determines type of acetabular fractures o Motor vehicle accident or fall from a height o Osteoporosis - low energy fractures in elderly (fall directly onto hip) o Hip flexion + internal rotation = posterior wall + column injuries o Hip extension + external rotation = anterior wall + column injuries Epidemiology o Common (> 20%) = both columns, transverse + posterior wall, posterior wall o Uncommon (< 10%) = T-shaped, transverse, anterior column, anterior column + posterior hemitransverse, posterior column + wall, anterior wall
o o o o
Demographics Age: Elderly patients + osteoporosis population at risk Gender: M > F Activity at risk 0 Motor vehicle collisions
Natural History & Prognosis Most injuries treated surgically Non-displaced or minimally displaced fractures treated conservatively Complications o Heterotropic ossification o Infection o Avascular necrosis o Post-traumatic arthritis o Deep venous thrombosis (DVT) Deep pelvis + lower extremity veins o Nerve damage - sciatic, superior gluteal, femoral o Morel-Lavellee lesion Internal degloving injury associated with crush or shearing component to hip girdle (local + regional hemorrhage)
Gross Pathologic & Surgical Features Anterior column fracture o Anterior column (larger of the two columns) extends from iliac wing to anterior acetabulum to superior pubic ramus Posterior column fractures o Posterior column - extends from sciatic notch to posterior acetabulum to ischium Acetabular wall fracture o Medial wall (quadrilateral plate) o Anterior wall o Posterior wall o Dome (superior, most weight-bearing surface of acetabulum)
Hip dislocations + femoral headlneck fractures Severe hemorrhage Solid organ injuries Head, thoracic + abdominal injuries
Treatment Conservative o Bed rest o Femoral traction o Non-weight bearing with crutches Surgical o ORIF (open reduction with internal fixation) o Total hip arthroplasty
Microscopic Features Vascular disruption of bone Hematoma Revascularization Devascularized bone ends resorbed Callus vs. primary bone repair
Consider CT for displaced fragments or communition
Staging, Grading or Classification Criteria Judet and Letournel o Simple or elementary fractures with single fracture plane o Combination fractures = consist of > 1 elementary type fractures Matta o Acetabular roof arcs o Force per unit area (pressure on acetabulum) o Nonoperative treatment for fracture lines outside roof arc measurements & femoral head congruent to roof in 3 projections
1.
2. 3. 4. 5.
6.
Presentation Most common signs/symptoms: Pain at fracture site Clinical profile o Pelvic ring fracture + associated bladder rupture
Guyton J et al: Cambell's operative orthopaedics. vol 1. 10th ed. St. Louis MO, Mosby, 2948-61, 2003 Fitzgerald RH et al: Orthopaedics. St. Louis MO, Mosby, 3:338-46, 2002 Bohndorf K et al: Musculoskeletal imaging: A concise multimodality approach. Germany, Thieme, Sect 1:58-9, 2001 Erb RE: Current concepts in imaging the adult hip. Clin in Sports Med 20(4):661-96, 2001 Saks BJ: Normal acetabular anatomy for acetabular fracture assessment: CT and plain film correlation. Radiology 159:139-45, 1986 Letournel E: Acetabular fracture classification and management. Clin Orthop 151:81-106, 1980
- -
ACETA,BULAR FRACTURES
1 IMAGE GALLERY (Left) Coronal graphic shows posterior column fracture. (Right) Axial FS PD FSE MR shows displaced osseous fragment (arrow) in posterior column fracture.
(Lef)Axial FS PD FSE MR shows bone marrow edema of right anterior column (arrow) secondary to a non displaced fracture. (Right) Axial NECT (three dimensional rendering) shows acetabular roof fracture (arrow).
(Left) Coronal FS PD FSE MR shows hyperintense edema (arrow) in acetabular insufficiency fracture. The fracture line may not be seen in acetabular trabecular injuries. (Right) Coronal T l Wl MR shows medial bowing of the left acetabulum with hypointense (arrow) bone marrow signal associated with osteoporotic acetabular insufficiency fractures.
HIP DISLOCATIONS
Coronal graphic shows posterior dislocation of the hip. The femoral head overlaps the posterior margin of the acetabulum.
Axial NECT shows posterior rollover M VA.
dislocation after
o Posterior dislocation - femoral head lies lateral +
superior to acetabulum
58
o Central - femoral head protrudes into pelvic cavity
Abbreviations and Synonyms Dislocation of the hip, traumatic hip dislocation, dislocation of the femoral head
Radiographic Findings Radiography o Initial diagnostic examination o Anteroposterior (AP) view is usually diagnostic o Lateral view - dislocated hip anterior or posterior to acetabulum o Oblique views Uudet views) Iliac oblique view - 45" external oblique Obturator oblique view - 45" internal oblique o Inletloutlet views
Definitions Disarticulation of femoral head from acetabulum of the hip
General Features Best diagnostic clue: Most common dislocation = posterior dislocation with femoral internal rotation + adduction placing femoral head lateral & superior to acetabulum Location: Anterior, posterior, central (medial) Size o Variable based on associated osseous, cartilage, joint space, muscle + ligament injuries o Femoral head fractures associated with posterior hip dislocation * Morphology o Anterior dislocations - femoral head displaced into obturator, pubic or iliac region
CT Findings NECT
o Intraarticular fragments o Associated fractures + pelvic soft tissue injury
M R Findings TlWI o Evaluate complications Avascular necrosis (AVN) - hypointense subchondral fracture k central marrow fat Loose bodies f central marrow Labral tears - intermediate signal rn Chondral injuries Occult fractures
DDx: Hip Dislocations Femoral Neck Fx
AVN
Metastases
Cor FS PD MR
Cor FS PD MR
Ax NECT
HIP DISLOCATIONS Key Facts Imaging Findings
Pathology
Best diagnostic clue: Most common dislocation = posterior dislocation with femoral internal rotation + adduction placing femoral head lateral & superior to acetabulum Femoral head fractures associated with posterior hip dislocation Posterior dislocation - femoral head lies lateral + superior to acetabulum
High level of force required to dislocate hip Posterior dislocations - 90% of hip dislocations Anterior dislocations & central fractures/dislocations < 10% of hip dislocations 70% of all hip dislocations 2" to motor vehicle accidents (e.g., dashboard mechanism)
Clinical Issues
Most common signslsymptoms: Pain, characteristic deformity
Top Differential Diagnoses Femoral Neck Fracture (Fx) Femoral Head Fracture Acetabular Fracture Pelvic Fracture Femoral Head Avascular Necrosis (AVN)
Diagnostic Checklist Evaluate for associated fracture of femoral head + acetabulum
T2WI 0 Hyperintense marrow edema anterior or posterior acetabular rim 0 k Anteroinferior fragment off femoral head with posterior displacement
Groin or hip pain
Stress Fracture Pubic stress fracture - associated with long distance running Sacrum - runners at risk; bilateral stress fractures with "H" sign on MRI
Imaging Recommendations Best imaging tool o CT superior for fracture fragment location + spatial relationships of femoral head with 3D-CT o MR also excellent for 3 orthogonal plane visualization + complications including AVN Protocol advice o Thin section CT bone algorithm with coronal and sagittal reformations 0 MR with coronal, axial FS PD FSE or STIR
Snapping Hip Syndrome Painful, audible snap in hip flexion + extension External, internal or intraarticular etiologies
Slipped Capital Femoral Epiphysis Posterior-inferior displacement proximal femoral epiphysis Childhood disorder
Acetabular Tumor
1 DIFFERENTIAL DIAGNOSIS I
1
Primary or metastatic
I
Femoral Neck Fracture (Fx) Stress - pain in groin, anterior thigh or knee (transverse vs. compression)
Femoral Head Fracture Capital fractures = uncommon Linear hypointense fracture line Hyperintense marrow edema
Acetabular Fracture Blunt high energy injuries Judet - Letournel classification of five elementary fractures based on column & wall involvement
Pelvic Fracture High energy pelvic fractures associated with hemorrhage Benign avulsion to massive pelvic disruptions
1
Femoral Head Avascular Necrosis (AVN) Necrotic segment collapse anterosuperior aspect femoral head Associated with displaced fractures femoral neck & hip dislocations
General Features General path comments 0 Relevant anatomy Iliofemoral, pubofemoral, ischiofemoral, transverse + femoral head ligaments maintain femur in acetabulum Etiology 0 High level of force required to dislocate hip 0 Posterior dislocation Most common type (90%) Force to flexed knee transmitted to hip with dislocation of femoral head posteriorly Epidemiology o Posterior dislocations - 90% of hip dislocations o Anterior dislocations & central fractures/dislocations < 10% of hip dislocations 0 70% of all hip dislocations 2" to motor vehicle accidents (e.g., dashboard mechanism)
.
Gross Pathologic & Surgical Features Osseous fragments
-
HIP DISLOCATIONS
Joint space widening Posterior dislocation - associated sciatic nerve injury 2" to compression or laceration f local hematoma Anterior dislocation - f injury to femoral nerve + artery
Microscopic Features Fracture - vascular disruption Staging, Grading or Classification Criteria Hip dislocation with fracture of femoral head using Pipkin classification o Pipkin I: Fx femoral head below central fossa o Pipkin 11: Fx femoral head involving central fossa o Pipkin 111: Fx femoral head + neck o Pipkin IV: Fx femoral head + superoposterior acetabular rim
Presentation
60
Most common signs/symptoms: Pain, characteristic deformity Clinical profile o Posterior dislocation Hip + gluteal pain Lower extremity shortened, adducted, internally rotated and flexed Lack of range of motion, inability to bear weight Sciatic nerve injury with loss of sensation posterior leglfoot + inability to dorsiflexlplantar flex HematomaJsoft tissue swelling o Anterior dislocation Hip, gluteal, groin pain Hip externally rotated, abducted, extended = Inability to walklbear weight Femoral nervelartery injury with pain, pallor, pulselessness, loss of motor function & absent reflexes o Central dislocation Shortened affected limb Abductedladducted or internallyJexternally rotated Intra-pelvic soft tissue injury + hemorrhage
Demographics Age o Traumatic injuries motor vehicle accidents (MVA) < 35 years most common o Trauma 2" to falls > 65 years Gender o More common in young males o Associated with MVAs & sports injuries
Natural History & Prognosis Orthopaedic emergency o High incidence of AVN with prolonged dislocation o Reduce as soon as possible High morbidity/mortality o 2" to significant trauma o Severe intra-abdominal, intra-pelvic & head injuries o Pelvic ring fractures - severe hemorrhage
Uncomplicated cases - closed reduction successful (76-93%) Poorer prognosis when fractures present Recurrent dislocations - ligamentous support disrupted Complications o AVN o Osteoarthritis o Sciatic nerve injuries o Femoral nervelartery injuries o Deep venous thrombosis
Treatment Conservative o Closed reduction o Maneuvers recreated deforming force + applied longitudinal traction o Posterior dislocation - flexion, adduction, internal rotation1Stimson maneuver (prone)/Allismaneuver (supine) o Anterior dislocation - abduction, external rotation, extension Surgical o Open reduction for failed closed reduction, inira-articular loose bodies, interposed soft tissue, concomitant femoral headlneck fractures
Consider
Evaluate for associated fracture of femoral head + acetabulum May require follow-up MR to exclude complication of AVN of femoral head
ISELECTED
REFERENCES
I
DeLee JC et al: Orthopaedic sports medicine. Principles and practice. Hip and pelvis. vol2. 2nd ed. Philadelphia PA, Saunders, (25):1443-62, 2003 Brooks RA et al: Diagnosis and imaging studies of traumatic hip dislocations in the adult. Clin Orthop 377:15-23, 2000 Yang EC et al: Initial treatment of traumatic hip dislocations in the adult. Clin Orthop 377:24-31, 2000 Walden PD et al: Whistler technique used to reduce traumatic dislocation of the hip in the emergency department setting. J Emerg Med 17(3):441-4,1999 Conway WF et al: CT and MR imaging of the hip. Radiology 198(2):297-307,1996 Dreinhofer KE et al: Isolated traumatic dislocation of the hip: Long-term results in 50 patients. J Bone Joint Surg Br 76:6, 1994 Levin PE: Hip dislocations: Skeletal Trauma. vol 2. Philadelphia PA, WB Saunders, 1992 Epstein HC: Traumatic Dislocation of the Hip. Clin Orthop 92:116-42, 1973
HIP DISLOCATIONS
-
IMAGE GALLERY (Left) Coronal graphic shows anterior-in ferior dislocation of the hip below the iliofemoral (lateral) and pubofemoral (medial) ligaments. (Right) Coronal graphic shows anterior dislocation with the femoral head anterior to the pubofemoral ligament.
(Left) Arthroscopic view shows acetabular (Ac) chondral fracture with associated loose body (LB) secondary to a posterior hip dislocation. Femoral head (FH) is shown superiorly. (Right) Surgical pathology shows surgical dislocation of the femoral head.
Typical (Left) Coronal PD/lntermediate M R shows right posterior hip dislocation after reduction with osseous contusion of the femoral head, joint effusion, loose bodies, and acetabular rim fracture. (Right) Coronal graphic shows normal vascular supply of the proximal femur. The profunda femoral artery is shown medially The medial and lateral circumflex branches encircle the femoral neck.
AVUtSlON FRACTURE
Coronal graphic shows osseous avulsion of the hamstring tendon attachment to the ischial tuberosity.
Coronal T l W l MR shows avulsed and retracted (arrow) left common hamstring tendon.
Radiographic Findings Abbreviations and Synonyms Avulsion injury, tug injury, tug lesion, pelvic avulsions
Definitions Bony or cartilaginous failure resulting in fracture 2" to a force applied by a musculotendinous unit
Radiography o Osseous fragment identified adjacent to donor site o Contralateral views to distinguish open apophysis from avulsion fracture o Normal if apophysis not yet calcified o Exuberant callus o Changes may appear aggressive - mimicking primary or metastatic bone tumors
CT Findings General Features Best diagnostic clue: Hyperintense marrow edema (T2WI) at avulsion fracture donor site Location o Anterior superior iliac spine (ASIS) o Anterior inferior iliac spine (AIIS) o Ischial apophysis o Iliac crest o Lesser trochanter Size o Variable based on location o Along course of apophyseal physis Morphology o Slight displacement ASIS o Displacement of AIIS fragment distally o Displaced fragment ischial tuberosity -
NECT o Osseous detail of fracture fragment and donor site o Hematoma (heterogeneous fluid collection) at site of injury o Callus visualized k simulating aggressive lesions
MR Findings TlWI o Contralateral side - MR to distinguish avulsed fragment from normal, open apophysis o Osseous avulsion may be difficult to visualize in bed of soft tissue + hematoma o Involved tendon often lax (redundant morphology) o ASIS Mild displacement k Hypointense edema of adjacent marrow k Fluid adjacent to sartorius origin
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DDx: Avulsion Fracture Piriformis Syndr.
Metastases
Tendinosis
Cor FS PD MR
Cor FS PD MR
Cor FS PD MR
Ill Cor FS PD MR
AVULSION FRACTURE P
Key Facts Fracture 2" forceful concentric or eccentric muscle contraction Fractures 2" extreme passive stretch (dancers & gymnasts)
Imaging Findings Best diagnostic clue: Hyperintense marrow edema (TZWI) at avulsion fracture donor site Anterior superior iliac spine (ASIS) Anterior inferior iliac spine (AIIS) Ischial apophysis
Top Differential Diagnoses Piriformis Syndrome Primary or Metastatic Bone Lesion Sacroiliac Sprain Muscle Strain Tendinosis
Clinical Issues Most common signs/symptoms: Local pain Iliac crest avulsion: RLQ pain mimicking appendicitis Point tenderness Altered gait
*
Diagnostic Checklist T1 to show avulsed fragment vs. FS PD FSE for donor site edema
Pathology Adolescents - traction on unfused apophysis
o AIIS
Distal fragment displacement Laxity straight head rectus femoris o Ischial apophysis Displaced fragment + hypointense edema at donor site T2WI o Hyperintense marrow edema at donor site o Hyperintense fluid, soft tissue edema + hemorrhage at site of avulsion o Associated muscle strain - hyperintense signal on FS PD FSE or STIR o Hyperintense edema of iliopsoas adjacent to lesser trochanter FS Avulsed osseous fragment often hypointense On PD FSE or STIR
Imaging Recommendations Best imaging tool 0 MR to document status of musculotendinous unit + donor site marrow edema o CT to identify subtle avulsion fragment with fleck or shell-like morphology Protocol advice o T1 (to optimize fat marrow signal) + FS PD FSE in coronal & axial planes o Sagittal plane helpful for rectus femoris injuries of straight head (AIIS) + reflected head (upper rim acetabulum)
Malignant fibrous histiocytoma: Inhomogeneous on T2WI
+ areas of fat hyperintensity on T2WI Synovial cell sarcoma: Increased signal on T2WI Metastatic prostate: May be hypointense on T2WI Or On be Metastatic breast: T2WI
SacroiliacSprain
.
Anterior + posterior sacroiliac ligament injury Interosseous sacroiliac ligament Sacrotuberous ligament injury
Violent contraction of the hamstrings or abdominal muscles Torsion vs. direct trauma Forceful extension of flexed hip
Muscle Strain Musculotendinous injuries Abdominal muscle insertion on iliac wing Origin of gluteals from ilium + insertion on proximal femur Adductor origin from pubis Insertion of iliopsoas o n lesser trochanter Hyperintense edema on FS PD FSE
Tendinosis Thickening of tendon origin + insertions Intermediate signal on T1 + T2WI Common hamstring tendinosis Gluteus medius tendinosis
I DIFFERENTIAL DIAGNOSIS Piriformis Syndrome Compression of sciatic nerve History of blunt trauma Lower sacroiliac joint, greater sciatic notch piriformis pain Hypertrophy of piriformis k palpable mass Muscle hyperintensity on T2WI
Primary or Metastatic Bone Lesion
Tendon Tear
+
Common hamstring retraction with proximal tear Gluteus medius tear lateral surface greater trochanter Adductor injuries = "pulled groin"
Stress Fracture Repetitive stress Pubic ramus - long distance runners & joggers Sacral stress fractures - insufficiency vs. stress (runners)
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63
AVULSlON FRACTURE o Biopsy may show mitoses in healing bone
(PATHOLOGY General Features General path comments o Relevant anatomy Sartorius: Origin = ASIS + upper half iliac notch; insertion = medial surface proximal tibia Rectus femoris: Origin = AIIS (straight head) + upper acetabular rim (reflected head); insertion = superior patella + patellar tendon to tibia1 tuberosity Biceps femoris, semitendinosus + semimembranosus origin = ischial tuberosity Etiology o Adolescents - traction on unfused apophysis o Fracture 2' forceful concentric or eccentric muscle contraction o Fractures 2" extreme passive stretch (dancers & gymnasts) o Less common - avulsions 2" to chronic repetitive microtrauma Epidemiology: Avulsion fractures = 13.4% of children's pelvic fractures c14
Demographics Age: 14-25 years = most common Gender: ales > females Related activity o ASIS - forceful contraction of sartorius in kicking sports, jumping or running o AIIS - rectus femoris in kicking sports o Ischial tuberosity - hamstring in dancers, gymnasts, sprinting (hurdling) + football
Natural History & Prognosis Most injuries heal with conservative treatment Poor healing - chronic pain 2" to repetitive micromotion Surgery - for recalcitrant pain or severely displaced fragments
Treatment
Gross Pathologic & Surgical Features
Conservative o Recovery slow: Average 4-8 weeks up to 4 months o Initial bedrest to non-weight bearing + crutches o Ice, anti-inflammatories o Physical therapy - gradual strengthening + progressive weight bearing o Re-injury if return to high level activity prematurely Surgical o Re-attachment of severely displaced avulsed fragment o Chronic pain: Resection of weak bony union + surgical reattachment
Displacement of ASIS limited by fascia lata + lateral inguinal ligament Displacement of AIIS limited by dual insertion of straight head of rectus + reflected head Ischial apophysis displacement limited by sacrotuberous ligament
Microscopic Features Hematoma Revascularization + resorption of devascularized bone fragment Callus + fibrous scar tissue
Staging, Grading or Classification Criteria By location o ASIS o AIIS o Ischial tuberosity
1 D~AGNOST~C CHECKLIST Consider T1 to show avulsed fragment vs. FS PD FSE for donor site edema
I
Presentation Most common signs/symptoms: Local pain Clinical profile o Swelling after activity o Limitation of activity o Iliac crest avulsion: & RLQ pain mimicking appendicitis o Point tenderness o Discoloration 2" to hematoma o Altered gait o Pain + weakness - involved muscle placed under stress o Most commonly 2" to athletic-type injury o If no history of trauma - exclude infection + tumor o ~traumatic~avulsion in adult - exclude metastatic t metabolic bone disease
-
mistaken for high-grade malignancy o Less common avulsion sites Greater trochanter (gluteus min./med.) Pubic bone (gracilis + adductors) Iliac crest (abdominal musculature)
I
1. 2. 3. 4. 5. 6.
7.
DeLee JC et al: Orthopaedic sports medicine. Principles and practice. vol2. 2nd ed. Philadelphia PA, Saunders, (25):1443-62,2003 Bui-Mansfield LT et al: Nontraumatic avulsion of the pelvis. Am J of Roentg 178:423-27, 2002 Bencardino JT et al: Imaging of hip disorders in athletes. Rad Clin of North Am 40(2):277-80, 2002 Van Holsbeeck MT et al: Musculoskeletal ultrasound. 2nd ed. St. Louis MO, Mosby, 190, 2001 Metzmaker JN et al: Avulsion fractures of the pelvis. Am J Sports Med 13:349, 1985 Kane WJ: Fractures of the pelvis: Fractures in adults. vol2. Philadelphia PA, JB Lippincott, 1094-1196, 1984 Key JA et al: Management of fractures, dislocations, and sprains. St. Louis, MO, CV Mosby, 1951
I
AVI lLSlON FRACTURE
(Lef)Coronal graphic shows avulsion of the anterior superior iliac spine at the sartorius origin. (Right) Coronal FS PD FSE MR shows hyperintense edema (arrow) of right sartorius muscle in association with a more proximal avulsion.
Typical (Left) Coronal graphic shows avulsion of the anterior inferior iliac spine with origin of the straight head of the rectus femoris. (Right) Coronal FS PD FSE MR shows strain (arrow) of the straight head (rectus femorisi attachment to the anterior inferior iliac spine.
Typical
(Lef)Coronal T l Wl MR shows chronic lateral acetabular avulsion injury (arrow) from the reflected head of right rectus femoris attachment. (Right) Coronal FS PD FSE MR shows lateral acetabular rim avulsion.
h
PUBlC RAMl STRESS FRACTURES
Coronal graphic shows bilateral pubic rami stress fractures.
Coronal FS PD FSE MR shows hyperintense marrow edema associated with microtrabecular stress injuries to both superior pubic rami.
o Oblique view may be useful Oblique view - 45 degree anterior oblique o If radiograph negative consider MR or bone scintigraphy
Abbreviations and Synonyms Stress fracture (fx), pubic rami, pelvic stress fx
CT Findings
Definitions
NECT o Sclerosis 0 Trabecular or cortical fx 0 No trabecular destruction o Surrounding callus formation - healing stage
Incomplete or complete fx of pubic ramus, 2" repetitive loading
MR Findings
General Features Best diagnostic clue: Hyperintense subchondral edema on FS PD FSE f fx line Location: Superior + inferior pubic rami adjacent to pubic symphysis Size: Variable - unilateral or bilateral involvement Morphology: Stress fx perpendicular to cortices + diffuse medullary edema pattern
Radiographic Findings Radiography o Often negative, especially early o Sclerosis o Callus formation in healing stages o Fx f visualized as linear lucency o Anteroposterior (AP) view: Usually diagnostic if radiographic signs present
TlWI 0 Hypointense marrow edema on TlWI o Unilateral vs. bilateral o Fx line f visualized 0 k Hypointense edema or soft tissue thickening T2WI 0 Hyperintense marrow edema 0 + Fx visualization usually as single fx line perpendicular to long axis of superior pubic ramus 0 f Thickened cortex - hypointense o It Hyperintense edema parallel to superiorlinferior border pubic ramus o Requires FS PD FSE or STIR
Nuclear Medicine Findings Bone Scan
DDx: Pubic Rami Stress Fractures Femoral Neck Fx
Labral Tear
Metastases
t
Cor TI Wl MR
Ax T 1 Arthro.
r
Cor PD FS MR
PUBIC RAM1 STRESS FRACTURES Key Facts Imaging Findings Best diagnostic clue: Hyperintense subchondral edema on FS PD FSE k fx line Location: Superior + inferior pubic rami adjacent to pubic symphysis Morphology: Stress fx perpendicular to cortices + diffuse medullary edema pattern Hypointense marrow edema on TlWI
Top Differential Diagnoses Muscle StrainITear Femoral Neck Stress Fx Delayed Onset Muscle Soreness (DOMS) Osteomyelitis
Insufficiency fx - normal forces applied to abnormal or weakened bone Bone failure 2" cyclic, repetitive muscle contraction runners + recruits
Clinical Issues Most common signslsyrnptoms: Groin pain Point tenderness inferior pubic ramus Painful abduction + resisted adduction Painful external hip rotation
Diagnostic Checklist Marrow edema without visible fx requires CT evaluation
Pathology Fatigue fx - repetitive loading normal bone o Sensitive o k Positive before onset of symptoms o Positive 2-3 wks before radiographic changes evident o Diagnostic if increased uptake on 3rd phase of bone scan o Tumor & osteomyelitis also demonstrate increased uptake on 3rd phase o Increased uptake persists for months in healing fractures
Imaging Recommendations Best imaging tool o MR superior in defining pubic ramus with associated edema of marrow + adjacent muscle o Bone scintigraphy nonspecific Protocol advice: T1 + FS PD FSE in coronal + axial planes
Denervation - muscle group involvement hyperintense on STIR + FS PD FSE Grade I (partial tearing of muscle fibers with no loss of function) strain & DOMS overlap in MR signal intensity changes
Osteomyelitis Erosions Hyperintense marrow edema - FS PD FSE + STIR Adjacent soft tissue mass Subcutaneous tissue edema
Metastatic Disease Cortical + trabecular destruction Reactive muscle edema Pathologic fx Prostate & breast may be hypointense on T1 & T2WI
~ D ~ F F E R E N T ~DIAGNOSIS AL Muscle StrainITear Muscle belly + musculotendinous Violent muscular contraction Hyperintense edema FS PD FSE or STIR Inter + intramuscular hemorrhage
Femoral Neck Stress Fx Military recruits + runners Insufficiency fractures in osteoporosis Hyperintense marrow edema on FS PD FSE or STIR Calcar fx hypointense on T1 + T2WI
Intrinsic Hip Pathology Hip dislocation k associated fx Acetabular labral tears - femoroacetabular impingement or osteoarthritis Avascular necrosis Osteoarthritis - superior joint space narrowing
Delayed Onset Muscle Soreness (DOMS) Nonacute injury Painful symptoms peak 24-72 hrs. post exertion
General Features General path comments o ~elevantanatomy Gracilis origin = lower half pubic symphysis + upper half pubic arch Pectineus origin = pectineal line, pubis between iliopectineal eminence + pubic tubercle Adductor longus origin = anterior pubis angle between crest + symphysis Adductor brevis origin = outer surface inferior ramus pubis Adductor magnus origin = ischial tuberosity, rami of ischium & pubis Obturator externus orgin = outer margin obturator foramen Etiology o Fatigue fx - repetitive loading normal bone 0 Insufficiency fx - normal forces applied to abnormal or weakened bone 0 Bone failure 2" cyclic, repetitive muscle contraction Insufficient repair time
PUBIC RAM1 STRESS FRACTURES Osteoclastic resorption > osteoblastic bone formation o Female runners + military recruits Female vs. male pelvic geometry Increased stride (gait) length to height ratio relative to taller male recruits Decreased muscle bulk subjecting bones to greater force o Post hip arthroplasty Increased activity with new prosthesis-stress fx o Insufficiency fx Older women Post menopausal osteoporosis k Secondary to sacral insufficiency fx - increased forces to pubic arch o Tensile stress - generated by muscle mass originating from pubic ramus o Excessive repetition of muscle contractions o Malgaigne fx Post traumatic ischiopubic rami fx associated with ipsilateral sacroillic joint disruption may mimic a pubic rami stress fx Epidemiology: Insufficiency fx - 1%females > 55 years
Gross Pathologic & Surgical Features Fx - unilateral or bilateral parasymphyseal Callus Absent soft tissue mass
Microscopic Features Osteoclastic resorption Lamellated bone filling osteoclastic cavities New periosteal + endosteal bone Periosteal reaction
Presentation Most common signs/symptoms: Groin pain Clinical profile o Gluteal + thigh pain o Point tenderness inferior pubic ramus o Painful abduction + resisted adduction o Painful external hip rotation o Antalgic gait o Athletes: Fx associated with intensified training o Pain relieved by rest o Pain inguinal, perineal or adductor o Standing sign: Unable to stand unsupported with affected leg
Demographics Age o Young adult: Stress fx o Older population (> 55 years): Insufficiency fx Gender: F > M Activity at risk o Military recruits
Natural History & Prognosis Most fxs heal with rest Cease training or causative activity Improper treatment or failure to rest = fx non-union Healing process slow: 4-12 wks up to 5 months
Treatment Conservative o Rest o Cessation of training regimen o Analgesics o Physical therapy o Stretching o Range-of-motion activity o Muscle strengthening o Non-union - most heal with rest Surgical o Rare except non-union or displaced fx
Consider Document fx in trabecular or cortical bone Marrow edema without visible fx requires CT evaluation Identify associated sacral stress/insufficiency fx
1 SELECTED REFERENCES Bencardino JT et al: Imaging of hip disorders in athletes. Radiol Clin of N America 40(2):267-87,2002 Spitz DJ et al: Imaging of stress fractures in athletes. Radiol Clin of N America 40(2):313-31,2002 Mabrey JD et al: Periprosthetic fractures. Rockwood and green's fractures in adults. 5th ed. Philadelphia PA, Lippincott Wiliams & Wilkinson, 611-12, 2001 Hosono M et al: MR appearance of parasymphyseal insufficiency fractures of the os pubis. Skeletal Radiol 26(9):525-8, 1997 Otte MT et al: MR imaging of supra-acetabular insufficiency fractures. Skeletal Radiol 26(5):279-83, 1997 Schapira D et al: Insufficiency fractures of the pubic ramus. Semin Arthritis Rheum 25(6):373-82, 1996 Hill PF et al: Stress fracture of the pubic ramus in female recruits. J Bone Joint Surg Br 78(3):383-6,1996 Peh WC et al: Imaging of pelvic insufficiency fractures. Radiographics 16(2):355-48,1996 Pavlov H: Roentgen examination of groin and hip in the athlete. Clin in Sports Med 6(4):829-43, 1987 Noakes TD et al: Pelvic Stress fractures in long distance runners. Am J Sports Med 13:120, 1985 Pavlov H et al: Stress fractures of the pubic ramus. J Bone Joint Surg 64:1020, 1982 Koch R et al: Pubic symphysitis in runners. AM J Sports Med 9:62, 1981 Latshaw RF et al: A pelvic stress fracture in a female jogger. Am J Sports Med 9:54, 1981 McBryde Am Jr: Stress fractures in athletes. Am J Sports Med 3:212. 1976
PUBIC RAM1 STRESS FRACTURES
Variant
(Left) Coronal graphic shows Malgaigne fracture involving unilateral fracture of the ischiopubic rami and disruption of the ipsilateral sacroiliac joint. (Right) Coronal FS PD FSE MR shows unilateral sacroiliac disruption (arrow) associated with a left Malgaigne fracture.
(Left) Axial FS PD FSE MR shows complete fracture (arrow) of the right superior pubic ramus with hyperintense soft tissue edema. (Right) Coronal FS PD FSE MR shows stress fracture of the left superior pubic ramus (arrow) with adjacent proximal adductor muscle edema.
(Left) Axial T2WI MR shows hyperintense superior pubic rami adjacent to the symphysis from bilateral stress fractures in a marathon runner. (Right) Coronal FS PD FSE MR shows degenerative superior pubic rami without defined rami fractures.
SACRAL lNSUFFlClENCY FRACTURES
Coronal graphic shows bilateral sacral insufficiency fractures with vertical fracture orientation.
Coronal FS PD FSE MR shows diffuse hyperintense sacral alar marrow edema in bilateral sacral alar insufficiency fractures. The edema obscures fracture detail.
CT Findings
Abbreviations and Synonyms Insufficiency fracture (fx) sacrum, sacral alar fx
Definitions Stress fx of sacrum 2" to normal forces applied to weakened or abnormal bone
I
[IMAGING FINDINGS General Features Best diagnostic clue: Hyperintense sacral marrow on coronal oblique FS PD FSE or STIR images Location: Sacral ala Size o Unilateral or bilateral o Unilateral does not cross midline Morphology o Vertical fx with diffuse alar edema o "H"sign on MR for bilateral fx
Radiographic Findings Radiography o Insensitive o + Osteopenia
NECT o Indicated when MRI not available and bone scan inconclusive o Fx oriented vertically along sacral ala, parallel to sacroiliac (SI) joint o Linear fx with sclerosis o Fx unilateral or bilateral o Transverse fx component may not be visualized on axial images (fx in plane of scan) o Associated pubic arch fx 2" to altered biomechanics
M R Findings TlWI o Hypointense sacral ala o + Visualized hypointense fx line o Fx lines parallel to SI joints o Transverse fx component in bilateral fx T2WI o Hyperintense sacral ala marrow edema o Hypointense fx line o "H"or "Honda" sign in bilateral fx connecting ala on T2WI o No trabecular destruction o + Adjacent soft tissue edema (no mass) o + Concomitant pubic arch stress fx o High resolution images may be required to identify fx
Kj
DDx: Sacral Insufficiency Fractures Muscle Strain
Labral Tear
C
Ax PD MR
Sag T 1 Wl MA
Cor FS PD MR
I
SACRAL lNSUFFlClENCY FRACTURES Key Facts Imaging Findings Best diagnostic clue: Hyperintense sacral marrow on coronal oblique FS PD FSE or STIR images Unilateral does not cross midline Vertical fx with diffuse alar edema "H"or "Honda" sign in bilateral fx connecting ala on T2WI
Top Differential Diagnoses Lumbar Radiculopathy Muscle StrainITear Bursitis (Trochanteric, Iliopsoas) Intrinsic Hip Pathology Femoral Neck Stress Fracture
Pathology Normal forces applied to abnormal bone (insufficiency) vs. abnormal forces to normal bone (stress) Runners susceptible Postmenopausal osteoporosis
Clinical Issues ~ o scommon t signs/symptoms: Pain with weight-bearing or ambulation No history of trauma Symptoms > physical signs Gender: F > M
Diagnostic Checklist Coronal oblique + axial planes most useful
Nuclear Medicine Findings Bone Scan o Non-specific if atypical pattern of tracer uptake o Sensitive + moderate specificity if classic radiotracer distribution (bilateral involvement) o Classic "H"pattern or "Honda" sign with transverse component connecting 2 vertical fxs o Incomplete "H"or "Honda" sign in unilateral fx o Increased tracer uptake in sacrum + pubic bone = insufficiency fx
Imaging Recommendations Best imaging tool: MR identifies fx line, morphology, sacral alar edema + lack of osseous destruction Protocol advice: T1 (improved marrow fat contrast > PD) + FS PD FSE or STIR in coronal oblique + axial planes
I DIFFERENTIAL DIAGNOSIS Lumbar Radiculopathy
AVN of femoral head Osteoarthritis (OA) Femoroacetabular impingement (OA in younger patient without dysplastic hips)
Femoral Neck Stress Fracture Cyclic loading + microfracture Hypointense fx line + adjacent calcar hyperintensity (T2WI) Edema often more extensive than fx involvement
Pubic Stress Fracture Military recruits, long-distance runners Hypointense fx with parasymphyseal hyperintensity on FS PD FSE or STIR Vertical fx unilateral or bilateral
Metastatic Disease Interruption of cortex Destruction of cortex Marrow edema without defined fx May require CT documentation of loss of normal trabecular morphology
Disk protrusion, extrusion, sequestration Foramina1 or central stenosis Spondylolisthesis
Muscle StrainITear Overuse vs. indirect trauma Muscle + myotendinous tears Strains (grade I, 11, 111) Muscle hyperintensity secondary to hemorrhage on T2WI
Bursitis (Trochanteric, Iliopsoas) Lateral hip pain (trochanteric) Hyperintensity parallel to greater trochanter on FS PD FSE or STIR Iliopsoas bursa1 inflammation = groin pain + findings anterior to hip + lateral to neurovascular structures
Intrinsic Hip Pathology Hip dislocation Acetabular labral tears
General Features General path comments o Relevant anatomy Pelvic ring = sacrum + 2 innominate bones Innominate bone = fusion of 3 ossification centers (ilium, ischium, pubis) SI joints = junction of innominate bones and sacrum posteriorly Ligaments = posterior SI, sacrotuberous, sacrospinous, iliolumbar Sciatic nerve (from roots of L4, L5, S1-3) Lumbosacral trunk of lumbosacral plexus crosses anterior to sacral ala Etiology o Normal forces applied to abnormal bone (insufficiency)vs. abnormal forces to normal bone (stress)
SACRAL INSUFFICIENCY FRACTURES o Runners susceptible o Impact sport participants o Postmenopausal osteoporosis
o Less common Rheumatoid arthritis Corticosteroid use Pelvic irradiation Tumor Epidemiology o 1% females > 55: Insufficiency fxs 0 Stress fx of sacrum less common than pubis
o Nearly instantaneous relief of pain
Consider Identify hypointense fx line, otherwise supplement with CT to assess trabecular bone destruction or microfracture Associated pubic fx shown on TI, FS PD FSE or STIR Coronal oblique + axial planes most useful Sacral insufficiency fracture not to be confused with osteitis condensans ilii (mechanical stress induced osteosclerosis in the ilium involving inferior 113 of the SI joint)
Gross Pathologic & Surgical Features Fx sacral ala Vertical orientation of fx Parallel to SI joints Transverse fx component Secondary pubic bone fx
+
Microscopic Features Osteoclastic resorption > osteoblastic activity Microfractures Reduced bone mineral density
1. 2. 3.
Presentation Most common signs/symptoms: Pain with weight-bearing or ambulation Clinical profile 0 No history of trauma 0 Minimal to low velocity trauma 0 Hip, gluteal or groin pain 0 May be non-ambulatory o Point tenderness over sacrum o Gait abnormality o Limited range of motion o Symptoms > physical signs
Demographics Age: > 55 yrs Gender: F > M
Natural History & Prognosis Majority heal with conservative treatment May progress to complete fx without treatment Healing: Slow process (2-5 months) Complications: Related to prolonged immobilization o Deep venous thrombosis o Pulmonary embolus o Decubitus ulcers 0 Falls (with use of crutches, walkers)
Treatment Conservative o Analgesics o Bed rest 0 Reduced weight bearing o Physical therapy (range-of-motion, gait training, muscle strengtheninglstretching) Surgical = sacroplasty o Interventional radiologic technique o Similar to vertebroplasty o Percutaneous injection polymethylmethacrylate
4.
5. 6. 7. 8. 9.
Boissonnault WG et al: Differential diagnosis of a sacral stress fracture. J Orthop Sports Phys Ther 32(12):613-21, 2002 Shah MK et al: Sacral stress fractures: An unusual case of low back pain in an athlete. Spine 27(4):E104-8, 2002 Garant M: Sacroplasty: A new treatment for sacral insufficiency fracture. J of Vasc Interventional Radiol 12(12):1265-7, 2002 Springfield DS: Pathologic fractures. Rockwood and Green's fractures in adults. 5th ed. Philadelphia PA, Lippincott Williams and Wilkins, 578-9, 2001 Peh WC: lntrafracture fluid: A new diagnostic sign of insufficiency fractures of the sacrum and ilium. Br J Radiol 73(872):895-8, 2000 Major NM et al: Sacral stress fractures in long-distance runners. AJR 174(3):727-9, 2000 Oliver TB et al: Defects in the pelvic ring as a cause of sacral insufficiency fractures. Clin Radio1 12852-4, 1999 Connolly JF: Fractures and dislocations: Closed management. 1st ed. Philadelphia PA, WB Saunders, 471-2, 1995 Weber M et al: Insufficiency fractures of the sacrum. Twenty cases and review of the literature. Spine
18(16):2.~07-12,1993 10. Blomlie V et al: Radiation induced insufficiency fractures of the sacrum: Evaluation with MR imaging. Radiology 188:241-44, 1993 11. Daffner RH et al: Stress fractures: Current concepts. AJR 159:245-52, 1992 12. Peh WC et al: Tarlov Cysts; Another cause of sacral insufficiency fractures? Clin Radio1 46:329-30, 1992 13. Abe H et al: Radiation-induced insufficiency fractures of the pelvis: Evaluation with 99mTc-methylene diphosphonate scintigraphy. AJR 158599-602, 1992 14. Brahme SK et al: Magnetic resonance appearance of sacral insufficiency fractures. Skeletal Radiol 19:489-493, 1990 15. Schneider R et al: Unsuspected sacral fractures: Detection by radionuclide bone scanning. AJR 144:337-41, 1985 16. Cooper KL et al: Supraacetabular insufficiency fractures. Radiology 157:15-17, 1985 17. DeSmet AA et al: Public and sacral insufficiency fractures: Clinical course and radiologic findings. AJR 145:601-6, 1985 18. Cooper KL et al: Insufficiency fractures of the sacrum. Radiology 156:15-20, 1985
SACRAL INSUFFICIENCY FRACTURES
Tvoical
(Left) Coronal T I WI MR shows bilateral insufficiency fractures with diffuse hypointense marrow edema. (Right) Coronal T l W l MR shows left unilateral insufficiency fracture with a linear orientation.
(Left) Coronal graphic shows
unilateral sacral insufficiency fracture. (Right) Coronal FS PD FSE MR shows bilateral sacroiliitis with sacral erosions and marrow hyperintensity. The marrow edema may mimic an insufficiency fx.
(Left) Coronal FS PD FSE MR shows subtle edema of left sacral ala in unilateral stress injury. (Right) Coronal T 1 Wl MR shows hypointense sclerosis on the right in osteitis condensans ilii.
LABRAL TEAR, HIP
Coronal graphic shows labral detachment associated with labral degeneration and thickening (yellow).
Coronal FS PD FSE MR shows hyperintense fluid signal within tear at the base of the acetabular labrum (arrow).
o Subchondral cysts of the acetabulum o Lateral acetabular rimlcapsular avulsions
Not sensitive for visualizing tear with or without contrast
Abbreviations and Synonyms Acetabular labral tear, labral avulsion
MR Findings
Definitions Tear of acetabular labrum secondary to traumatic injury or degeneration of the labrum
General Features Best diagnostic clue: Linear hyperintensity within hypointense labrum on coronal FS PD FSE images Location: Anterosuperior + posterosuperior = common locations Size: Base of labrum or along long axis as a longitudinal tear Morphology: Linear tear to bucket-handle tear
Radiographic Findings Radiography 0 Usually negative in acute traumatic tears 0 + Associated degenerative arthrosis 0 + Developmental dysplasia of hip (DDH)
CT Findings NECT
TlWI 0 Normal labrum Hypointense Covers hyaline articular cartilage at lateral peripheral margin of acetabulum o Intermediate linear signal vs. diffuse abnormal signal in labrum o Intralabral degeneration 0 Separation of the labrum at its base o Diastasis between acetabular articular cartilage + labral attachment o Assess for associated acetabular dysplasia on anterior coronal images T2WI o Linear hyperintensity contrasts hypointense labrum on FS PD FSE or STIR images o Radial images useful - perpendicular to tear plane 0 Hyperintense paralabral cyst on FS PD or T2 FSE or STIR images septations or lobulations o Surface irregularities associated with base of degenerated labrum
*
Hmm DDx: Labral Tear, Hip L a l l r ~D l ~gen.
Impinp~n~nl
Cor T I Arthro +
Cor FS PD MR
Osteoarthrit~s
Cor T l Wl MR
-
-
LABRAL TEAR, HIP Key Facts Pathology
hypointense labrum on coronal FS PD FSE images Location: Anterosuperior + posterosuperior = common locations Morphology: Linear tear to bucket-handle tear
Top Differential Diagnoses Degenerative Labrum Normal Labral Attachment Femoroacetabular Impingement Osteoarthritis Developmental Dysplasia of Hip (DDH)
Acute, traumatic tears - common in sports requiring extreme hip rotation + flexion (soccer, hockey, golf, gymnastics, dancing, kickboxing) Degenerative tears - associated with degenerative disease of the hip Femoroacetabular impingement in younger population (< 50 years)
Clinical Issues Most common signs/symptoms: Hip pain Episodes of sharp pain associated with pivoting or twisting
Diagnostic Checklist Labral tear as part of femoroacetabular impingement syndrome *
o Femoroacetabular impingement: Associated labral
tears + acetabular chondral erosions + subchondral acetabular hyperintensity o Hyperintense macerated to absent labrum in osteoarthritis 0 Labral displacement/bucket-handle tears 0 Loss of triangular morphology 0 Hyperintense joint effusion T1 C+ 0 Intraarticular contrast - fills tear o Promotes uplifting or separation of torn labrum from acetabular articular cartilage o Czerny classification: Based on MR arthrography (91% sensitive, 71% specific)
Imaging Recommendations Best imaging tool: MR for labral + chondral visualization Protocol advice 0 T1 + FS PD FSE coronal, sagittal & axial planes o Small FOV (16 to 18 cm) coronal k intraarticular contrast
Osteoarthritis Superior joint space narrowing Osteophytes Loss of femoral + acetabular articular cartilage
Developmental Dysplasia of Hip (DDH) Associated with labral pathology Predisposed to acetabular rim syndrome - similar to femoroacetabular impingement in nondysplastic hips Shallow acetabulum on anterior coronal images
Normal lliopsoas Tendon Pitfall on axial and sagittal images Hypointense iliopsoas tendon anterior to anterior labrum k associated fluid
Sublabral Foramen Inconsistent recess, sulcus or nonattachment without tear
1 PATHOLOGY General Features
Degenerative Labrum Intralabral signal k mild free edge blunting Normal margins No fluid across base of labrum
Normal Labral Attachment Normal intermediate signal intensity articular cartilage at labral base No contrast or fluid extension Normal fibrovascular bundles may mimic a tear
Femoroacetabular Impingement Osteoarthritis in younger patient population Acetabular sided pathology (chondral erosions) Femoral dysplasia - lateral femoral head/neck dysplastic bump Abnormal contact in flexion + internal rotation
General path comments 0 Relevant anatomy = labrum Fibrocartilaginous rim which deepens acetabulum Attachment to osseous acetabular rim + transverse acetabular ligament Not important in load transmission Etiology 0 Acute, traumatic tears - common in sports requiring extreme hip rotation + flexion (soccer, hockey, golf, gymnastics, dancing, kickboxing) 0 Trauma ranges from twisting injury to hip dislocation o Degenerative tears - associated with degenerative disease of the hip 0 Femoroacetabular impingement in younger population (i 50 years) o DDH at increased risk o Hip dislocations Epidemiology
1
-
LABRAL TEAR, HIP
o 28% of asymptomatic individuals have labral
abnormalities (includes labral degeneration) o 20% of symptomatic DDH - labral tears
Gross Pathologic & Surgical Features Reciprocal injury to femoral head chondral surface Anterosuperior labrum most frequent Posterosuperior more common in younger population Traumatic tears o Radial flap = along inner free margin (most common) o Longitudinal = k unstable & displaced + Associated paralabral cysts Subchondral acetabular cystic changes Gross labral detachment - less common Intraarticular displacement of labrum
Microscopic Features
76
Degeneration o Eosinophilic o Mucoid o Vascular o Focal cavitation o Cystic o separation from underlying bone interface Avascular regions preclude healing
Staging, Grading or Classification Criteria Czerny classification (MR arthrography) o Stage IA: Hyperintense signal with no communication to articular surface + visualized perilabral sulcus o Stage IB: No perilabral sulcus o Stage IIA: Contrast extension into articular surface + visualized perilabral sulcus o Stage IIB: No perilabral sulcus o Stage IIIA: Labral detachment f with triangular shape maintained + visualized perilabral sulcus o Stage IIIB: Labral detachment + thickened labrum with labral hyperintensity + no perilabral sulcus o Anterosuperior = common location for tears
Presentation Most common signs/symptoms: Hip pain Clinical profile o Snapping o Clicking o Locking o Episodes of sharp pain associated with pivoting or twisting o Manipulation of hip from flexion, external rotation + abduction into extension + internal rotation + adduction = click for anterior labral tears o Full flexion, adduction + internal rotation to extension + abduction + external rotation = symptoms of posterior labral tear o Acetabular dysplasia associated o Association with Legg-Calve-Perthes and slipped capital femoral epiphysis o End stage degenerative hip disease
Demographics Age o 20 to 50 years = most common o Spectrum ranges 18 to 75 years o Young athletes = acute, traumatic o Middle-aged associated with femoroacetabular impingement o Older patients = degenerative tears Gender o F slightly > M Except increased male rate with high exposure to sports which increase the risk of femoroacetabular impingement
Natural History & Prognosis Progression of labral tear is typical Development of osteoarthritis especially as part of femoroacetabular impingement
Treatment Conservative o Activity modification (limit flexion + internal rotation) o Anti-inflammatory medication o Intraarticular steroid injection during acute episodes of pain Surgical o Debridement o Modified Bankart
Consider Labral tear as part of femoroacetabular impingement syndrome Identify associated paralabral cysts Assess acetabular chondral surface for erosions
DeLee JC et al: Orthopaedic sports medicine. Principles and practice. vol2. 2nd ed. Philadelphia PA, Saunders, 25(A):1443-63, 2003 McCarthy J et al: The role of hip arthroscopy in the elite athlete. Clin Orthop and Related Research 406:71-4, 2003 McCarthy J et al: Anatomy, pathologic features and treatment of acetabular labral tears. Clin Orthop and Related Research 406:38-47, 2003 Czerny C et al: Magnetic resonance imaging and magnetic resonance arthrography of the acetabular labrum: Comparison with surgical findings. Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 173(8):702-8,2001 Aydingoz U et al: MR imaging of the acetabular labrum: A comparative study of both hips in 180 asymptomatic volunteers. Eur Radio1 11(4)567-74,2001 Plotz GM et al: Magnetic resonance arthrography of the acetabular labrum. Macroscopic and histological correlation in 20 cadavers. J Bone Joint Surg Br 82(3)426-32, 2000 Abe I et al: Acetabular labrum: Abnormal findings at MR imaging in asymptomatic hips. Radiology 216(2)576-81, 2000
LABRAL TEAR, HIP
(Left) Coronal graphic shows normal acetabular labral anatomy. The normal labrum is triangular shaped with a well defined apex. (Right) Coronal graphic shows thickened labrum with fibrocartilaginous degeneration (yellow). N o paralabral recess is identified.
Typical (Left) Coronal graphic shows normal undercutting of the labrum (gray) by articular cartilage (blue). (Right) Coronal FS PD FSE MR shows hyperintense longitudinal tear (arrow) of the labrum.
Variant (Left) Coronal T I C+ (MR arthrogrami shows hyperintense degeneration (arrow) at the base of an ossified labrum. (Right) Coronal T 1 C+ (MR arthrogram) shows obliterated labrum (arrow) in osteoarthritis.
PARALABRAL CYSTS, HIP
Coronal graphic shows paralabral cyst (blue) communicating with linear tear and detachment of the acetabular labrum.
Coronal FS PD FSE MR shows hyperintense paralabral (intralabral) cyst (arrow) extending into the substance of acetabular labrum.
'0Osteoarthritis
o Not sensitive for femoroacetabular impingement
Abbreviations and Synonyms Ganglion cyst, synovial cyst of the hip, cystic degeneration of the labrum, acetabular ganglion cysts, para-acetabular soft tissue ganglion
Definitions Juxta-articular cyst formed secondary to a labral tear of the hip
General Features Best diagnostic clue: Hyperintense cyst adjacent to the labrum on coronal FS PD or T2 FSE images Location o Located lateral to anterosuperior or posterosuperior labrum 0 May communicate with any location of labral tear including anteroinferior or posteroinferior Size: Variable (1 mm to > 1 cm) Morphology: Septated & lobulated
CT Findings NECT o Hypodense (fluid attenuation) juxta-articular mass o Labral tears cannot be reliably visualized, even with intraarticular contrast o Exclude intrinsic hip pathology
MR Findings TlWI o k Septated + lobulated o Hypo to intermediate signal intensity 0 Well-defined margins without reactive soft tissue edema o Mucin contents may result in increased signal intensity o k Associated hyperintense intraosseous ganglion cysts of acetabular roof or lateral rim 0 Associated intermediate signal in labral tear or separation of labrum at its base T2WI o Hyperintense juxta-articular mass 0 Longitudinal extension of cyst usually superior to inferior + anterior to posterior 0 Hypointense septations o Intermediate signal synovial thickening
lam
Radiographic Findings Radiography o Usually normal o Acetabular dysplasia
DDx: Paralabral Cysts, Hip
Impingemen!
Osteoarthritis
M yositi.~Ossific.
Cor FS PD MR
Cor FS PD MR
Cor FS PD MR
I
Cor FS PD MR
PARALABRAL CYSTS, HIP -
-
Key Facts Imaging Findings
'
Best diagnostic clue: Hyperintense cyst adjacent to the labrum on coronal FS PD or T2 FSE images Located lateral to anterosuperior or posterosuperior labrum May communicate with any location of labral tear including anteroinferior or posteroinferior Morphology: Septated & lobulated
Pathology Increased/abnormal load on lateral aspect acetabular roof Increased intraarticular pressure forcing synovial fluid through a labral tear Anterosuperior > posterosuperior > inferior location
Clinical Issues Most common signs/syrnptoms: Hip pain Sudden sharp pain Clicking Locking of joint Deep anterior groin pain
Top Differential Diagnoses Femoroacetabular Impingement Osteoarthritis Developmental Dysplasia of the Hip (DDH) Soft Tissue Tumors
Diagnostic Checklist Paralabral cysts may occur adjacent to any portion of the fibrocartilaginous labrum
o Linear hyperintense tear or detachment of adjacent
labrum o Femoroacetabular impingement
Hyperintense edema progressing to cyst formation in acetabular roof rn Torn labrum Acetabular roof chondral erosions Dysplastic lateral femoral osseous bump lateral to physeal scar o Hyperintense intraosseous ganglion + labral tear o Associated acetabular dysplasia with shallow acetabulum on anterior coronal images T1 C+ o Intravenous contrast: Peripheral enhancement of cysts o Intraarticular contrast: Variable demonstration of paralabral cyst (also requires FS PD FSE images to visualize cysts without joint communication)
Imaging Recommendations Best imaging tool: MR for labrum + cyst Protocol advice: T1 + FS PD FSE or STIR in coronal (+ small FOV), sagittal + axial planes
I DIFFERENTIAL DIAGNOSIS Femoroacetabular Impingement Osteoarthritis in younger patient population (< 50 years) Acetabular roof subchondral edema Labral tears associated in 50% Chondral erosions in acetabulum f Femoral dysplastic osseous bump or lateral prominence
Osteoarthritis Superior joint space narrowing Chondral loss acetabulum + femoral head Joint effusion Osteophytes f Subchondral marrow edema acetabulum + femoral head
=
Developmental Dysplasia of the Hip (DDH)
.
Shallow acetabulum on anterior coronal images with labra' tears 'ysts Subchondral sclerosis lateral acetabular rim Chondral fissures + erosions lateral acetabulum +
.
Greater Trochanteric Bursitis Lateral hip pain Hyperintense fluid signal adjacent to and parallel with greater trochanter f Associated with gluteus medius muscle-tendon pathology
Soft Tissue Tumors Lipoma Desmoid Malignant fibrous histiocytoma Liposarcoma Synovial cell sarcoma
Tumor-Like Soft Tissue Masses Abscess Hematoma Seroma Intramuscular cyst
Myositis Ossificans Calcified or ossified mass of granulation tissue History of blunt muscle trauma Inhomogeneity on T2WI ? surrounding edema
General Features
General path comments o Relevant anatomy = labrum Fibrocartilaginous rim - deepens acetabulum Not important in load transmission Etiology o Increased/abnormal load on lateral aspect acetabular roof Femoroacetabular impingement
PARALABRAL CYSTS, H I P Gender: Increased male rate as a function of sports related to risk of femoroacetabular impingement
Osteoarthritis Developmental dysplasia Femoral dysplasia (lateral aspect femoral head) o Intraosseous ganglion cyst becoming a soft tissue ganglion o Increased intraarticular pressure forcing synovial fluid through a labral tear o Post-traumatic Epidemiology o 28% of asymptomatic population have labral abnormalities (including labral degeneration) o 20% of DDH with symptoms have a labral tear
Gross Pathologic & Surgical Features Paralabral cysts adjacent to lateral acetabular labrum soft tissue dissection Anterosuperior > posterosuperior > inferior location Associated labral tears o Traumatic o Degenerative + Subchondral acetabular cystic changes + chondral erosions
Natural History & Prognosis Will not spontaneously resolve Conservative treatment for temporary pain relief Labral tear or underlying labral abnormality (e.g., femoroacetabular impingement) must be addressed or cyst will recur
Treatment
*
Microscopic Features Ganglion cyst o Lined with connective tissue o Contains mucinous material o Communication with joint Synovial cyst o Lined with synovial cells o Contains synovial fluid o & Communication with joint Associated labral degeneration or tear o Eosinophilic, mucoid, + vacuolar degeneration of labrum
Presentation Most common signs/symptoms: Hip pain Clinical profile o Similar presentation as seen for labral tears o Sudden sharp pain o Clicking o Popping & snapping o Locking of joint o Deep anterior groin pain o Lateral hip gluteal radiation pain o Symptoms correlate with underlying labral tear > than paralabral cyst o A large paralabral cyst - symptoms of local mass effect
*
Demographics Age o 20 to 50 years most common for labral tears o Age spectrum ranges from 18 to 75 years o Common in sports requiring hip rotation + flexion: Golf, hockey, soccer, gymnastics, ballet o Common in middle-aged adults secondary to degenerative labral tears in femoroacetabular impingement
Conservative o Anti-inflammatories for pain relief o Percutaneous aspiration: Temporary, as cyst will recur o Intraarticular steroids Surgical o Repair/debridement/resection of labrum o Debridement + microfracture of acetabular roof o Femoral resurfacing in femoroacetabular impingement o Acetabular osteotomy in fernoroacetabular impingement o Arthroscopic techniques available
Consider Paralabral cysts are associated with acetabular labral tears Paralabral cysts are seen in femoroacetabular impingement Paralabral cysts may occur adjacent to any portion of the fibrocartilaginous labrum
McCarthy J et al: The role of hip arthroscopy i n the elite athlete. Clin Orthop and Related Research 406:71-4, 2003 McCarthy J et al: Anatomy, pathologic features and treatment of acetabular labral tears. Clin Orthop and Related Research 406:38-47, 2003 Van Holsbeeck MT et al: Musculoskeletal ultrasound. 2nd ed. St. Louis MO, Mosby, 254-65, 2001 Mason JB: Acetabular labral tears in the athlete. Clin Sports Med 20(4):779-89, 2001 Aydingoz U et al: MR imaging of the acetabular labrum: A comparative study of both hips in 180 asymptomatic volunteers. Eur Radio1 11(4):567-74, 2001 Tan V et al: Contribution of acetabular labrum t o articulating surface area and femoral head coverage in adult hip joints: An anatomic study in cadavera. Am J Orthop 30(11):809-12, 2001 Plotz GM et al: Magnetic resonance arthrography of the acetabular labrum. Macroscopic and histological correlation in 20 cadavers. J Bone Joint Surg Br 82(3):426-32, 2000 Abe I et al: Acetabular labrum: Abnormal findings at MR imaging in asymptomatic hips. Radiology 216(2):576-81, 2000 Lecouvet FE et al: MR imaging of the acetabular labrum: Variations i n 200 asymptomatic hips. AJR 167(4):1025-8, 1996
PARALABRAL CYSTS, H I P
(Left) Coronal FS PD FSE MR shows lateral and superior dissection deep to the gluteus medius muscle. (Right) Coronal FS PD FSE MR shows focal paralabral cyst (arrow) undermining the superior acetabular labrum.
Typical (Left) Axial FS PD FSE MR shows posterior paralabral cyst (arrow) in association with a posterosuperior labral tear. (Right) Coronal FS PD FSE MR shows extension of paralabral cyst lateral to the joint capsule (lateral to the iliofemoral ligarnen t).
Typical (Left)Anterior coronal FS PD FSE MR image shows paralabral cyst (arrow) presenting anteroinferiorly. (Right) Coronal FS PD FSE MR shows far anterior extension of an anterosuperior paralabral cyst (arrow).
FEMOROACETABULAR IMPINGEMENT
Coronal graphic shows femoroacetabular impingement with torn acetabular labrum, subchondral cystic change of lateral acetabular roof, dysplastic femoral "bump" and subchondral cyst.
Coronal FS PD FSE MR shows femoroacetabular impingement with articular cartilage erosion (arrow) of the lateral margin of the acetabular roof. The acetabular labrum is torn.
o Focal acetabular chondral erosions + focal underlying subchondral sclerosis, edema k cyst o k Dysplastic lateral femoral bump adjacent to physeal scar
Abbreviations and Synonyms Cam-effect, acetabular rim syndrome
Radiographic Findings
Definitions
Radiography 0 Early stage: Normal o Advanced stage Joint space narrowing Subchondral sclerosis Subchondral cysts Osteophyte formation o Loss of anterior femoral offset (defined as anterior offset of head relative to anterior surface of femoral neck)
Repetitive microtrauma from impingement of femoral head against acetabulum Lateral acetabular rim syndrome is equivalent to femoroacetabular impingement in patients with hip dysplasia
.
General Features Best diagnostic clue: Abnormal signal of lateral femoral head + acetabular rim associated with labral tears & cartilage defects Location 0 Lateral femoral head o Acetabular rim Size o Variable acetabular subchondral cystic change, sclerosis + edema o Acetabular changes typically 5 mm to 2 cm in coronal plane Morphology
MR Findings TlWI o Hypointense edema + sclerosis lateral acetabular subchondral bone o Hypointense to intermediate signal intensity acetabular subchondral cysts 0 Abnormal contour (blunted) acetabular labrum o k Dysplastic femoral "bump" lateral to physeal scar + loss of anterior femoral offset T2WI o Hyperintense subchondral marrow edema - laterally located
DDx: Femoroacetabular Impingement DDH
Osteoarthritls
AVN
Labral Tear
Cor Tl Wl MR
Cor TI WI MR
Cor TI WI MR
Cor FS PD MR
FEMOROACETABULAR IMPlNGEMENT Key Facts Imaging Findings Best diagnostic clue: Abnormal signal of lateral femoral head + acetabular rim associated with labral tears & cartilage defects Focal acetabular chondral erosions + focal underlying subchondral sclerosis, edema cyst k Dysplastic lateral femoral bump adjacent to physeal scar
*
Top Differential Diagnoses Developmental Dysplasia of the Hip (DDH) Osteoarthritis (OA) Avascular Necrosis (AVN) of the Hip Labral Tear
Occurs in non-dysplastic hips Femoral head is in contact with acetabular rim in flexion + internal rotation
.
Clinical Issues Most common signs~symptoms:Recurrent episodes of sharp hip, groin pain Pain with weight bearing Pain may also radiate laterally or posterolaterally Symptom increase with axial loading of hip - running Age: 20-50 years
Diagnostic Checklist Identify associated femoral dysplasia (anterior coronal images)
Pathology Labral damage occurs during impingement Intermediate signal labral degeneration Hyperintense linear or diffuse signal in labral tear Absent labral tissue Inhomogeneous to hyperintense signal in acetabular subchondral cysts o Defect, attenuation or fissure in normally intermediate signal intensity articular cartilage o Dysplastic femoral "bump"- normal marrow fat signal or hyperintense + small hyperintense femoral headlneck cysts o Hypointense thickened hip capsule (iliofemoral ligament) T1 C+ o MR arthrography Detects labral tears Acetabular surface chondral erosions Radial imaging useful Subchondral acetabular sclerosis hypointense on T1 + T2WI o o o o
Avascular Necrosis (AVN) of the Hip Wedge-shaped subchondral bone infarct Double line sign in 80% + Femoral head + neck hyperintense edema Articular cartilage intact at presentation
Labral Tear
+ Paralabral cyst Linear hyperintensity on T2WI Labral blunting Labral base degeneration Pain, clicking, locking
.
Imaging Recommendations Best imaging tool: MR superior for early signs of acetabular chondral erosions + subchondral bone changes Protocol advice o Coronal T1 for sclerosis + FS PD FSE (small FOV) to visualize extent of chondral fissures or erosions o Radial imaging to improve sensitivity for labral tears o Axial + sagittal planes also used
I DIFFERENTIAL DIAGNOSIS Developmental Dysplasia of the Hip (DDH) Shallow acetabulum Identified on anteroposterior (AP) radiograph or anterior slices of coronal MR
Osteoarthritis (OA) Joint space narrowing Osteophyte formation Cartilage thinning
General Features General path comments o Intact labrum limits extent of cartilage deformation + stress through sealing mechanism o Labral damage occurs during impingement o Pain is result of stimulation of nociceptive and proprioceptive receptors in innervated labrum o Femoroacetabular impingement represents a previously unrecognized cause of arthritis in young adults Etiology o Occurs in non-dysplastic hips o Repetitive microtrauma from impingement of femoral head against acetabulum o Femoral head is in contact with acetabular rim in flexion + internal rotation o Leads to degeneration of labrum + articular cartilage o Might be due to anatomical variations of proximal femur Reduction in mean femoral anteversion + mean head-neck offset relative to anterior aspect of neck "Pistol-grip"or "post-slip"deformity Epidemiology o Etiology of majority of "idiopathic" hip OA 0 OA: 5%
. .
-
FEMOROACETABULAR IMPINGEMENT Gross Pathologic & Surgical Features Absent or thinned articular cartilage Polished subchondral bone if articular cartilage is absent Labral degeneration or tear Cystic changes: Cysts filled with loose fibromyxoid tissue Osteophytes
Consider TlWI sensitive for acetabular roof subchondral sclerosis FS PD FSE coronal sensitive for subchondral edema, chondral fissures + labral tear Identify associated femoral dysplasia (anterior coronal images)
Microscopic Features Vertical clefting of articular cartilage Villous hyperplasia of synovium 1.
Presentation Most common signs/symptoms: Recurrent episodes of sharp hip, groin pain Clinical profile 0 Pain out of proportion to radiographic findings 0 Positive impingement provocation test: Pain during flexion + internal rotation 0 Pain with weight bearing 0 Pain during hip flexion: Walking uphill, sitting, jumping 0 Pain may also radiate laterally or posterolaterally 0 Symptom increase with axial loading of hip running
2. 3. 4. 5.
6. 7.
Demographics Age: 20-50 years Gender: M > F A function of hours of activity exposure with increasing age Flexion + internal rotation + axial loading activities at risk (e.g., kickboxing, squatting)
8. 9. 10.
Natural History & Prognosis If unrecognized can lead to severe osteoarthritis requiring hip replacement Activity modification may stabilize symptoms with synovialization of subchondral cysts Full thickness chondral lesions of the acetabulum accelerate progression of joint space narrowing
11. 12. 13.
Treatment Conservative o Non-weight bearing (short term) 0 Anti-inflammatory medication 0 Muscle strengthening to relieve hip joint stress 0 Non-loading activities (bicycle, elliptical) to cycle the hip joint while stimulating articular cartilage healing Surgical 0 Arthroscopic debridement of labral tears o Femoroacetabular debridement + femoral reshaping (resection of dysplastic "bump") 0 Periacetabular osteotomy 0 Hip replacement in advanced cases
14. 15.
Siebenrock KA et al: Anterior femoro-acetabular impingement due to acetabular retroversion: Treatment with periacetabular osteotomy. J Bone Joint Surg Am 85-A(2):278-86,2003 Schmidt MR et al: Cartilage lesions in the hip: Diagnostic effectiveness of MR arthrography. Radiol 226:382-6, 2002 Kloen P et al: Early lesions of the labrum and acetabular cartilage in osteonecrosis of the femoral head. J Bone Joint Surg Br 84(1):66-9,2002 Notzli HP et al: The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement. J Bone Joint Surg Br 84(4):556-60,2002 Ito K et al: Femoroacetabular impingement and the cam-effect. A MRI-based quantitative anatomical study of the femoral head-neck offset. J Bone Joint Surg 83-B:171-6, 2001 Abe I et al: Acetabular labrum: Abnormal findings at MR imaging in asymptomatic hips. Radiol 216576-81, 2000 Ferguson SJ et al: The influence of the acetabular labrum on hip cartilage consolidations: A poroelastic finite element model. J Biomechanics 33:953-60, 1999 Myers SR et al: Anterior femoroacetabular impingement after periacetabular osteotomy. Clin Orthop Re1 Res 363:93-9, 1999 Toennis D et al: Acetabular and femoral anteversion: Relationship with osteoarthritis of the hip. J Bone Joint Surg 81-A:1747-70, 1999 McGibbon CA et al: Cartilage and subchondral bone thickness distribution with MR imaging. Acad Radiol 5(1):20-5, 1998 McGibbon CA et al: A general computing method for spatial cartilage thickness from co-planar MRI. Med Eng Phys 20(3):169-76,1998 Leung M et al: Evaluation of the acetabular labrum by MR arthrography. J Bone Joint Surg 79-B:230-4, 1997 Varich L et al: Patterns of central acetabular osteophytosis in osteoarthritis of the hip. Invest Radiol 28(12):1120-7, 1993 Klaue K et al: The acetabular rim syndrome. A clincial presentation of dysplasia of the hip. J Bone Joint Surg 73-B:423-9, 1991 Kurrat HJ et al: The thickness of the cartilage in the hip joint. J Anat 126(1):145-55,1978
I
FEMOROACETABULAR IMPINGEMENT
Tvnicaf (Left) Coronal graphic shows femoroacetabular impingement with subchondral acetabular roof edema, focal chondral erosion, and labral tear. (Right) Coronal FS PD FSE MR shows early changes of femoroacetabular impingement with subchondral marrow edema (arrow) and articular cartilage fissures. The acetabular labrum is torn.
(Left) Coronal FS PD FSE MR shows hyperintense marrow edema (arrow) in an area of femoral dysplasia adjacent to the physeal scar. This is the contact point for impingement of the acetabular roof. (Right) Coronal FS PD FSE MR shows femoroacetabular impingement with dysplastic femoral "bump" and subchondral cyst (arrow). Acetabular chondral erosions and labral tear are present. Incidental finding of AVN.
Typical (Left) Coronal FS PD FSE MR shows lateral femoral subchondral cyst (arrow) characteristically located adjacent to the physeal scar. (Right) Coronal FS PD FSE MR shows postoperative removal offemoral cyst (open arrow) and debridement of acetabular (arrow) articular cartilage.
OSTEOARTHRITIS, HIP
Coronal graphic shows superior joint space narrowing, acetabular and femoral subchondral cysts, chondral erosions, subcapital osteophytes. The acetabular labrum demonstrates degeneration.
Coronal FS PD FSE MR shows hyperintense subchondral acetabular and femoral cysts and extended femoral head/neck marrow edema. Superior joint space narrowing and joint effusion are seen.
o Superior or superolateral migration femoral head
Abbreviations and Synonyms Degenerative joint disease (DJD), osteoarthritis (OA), femoroacetabular impingement
Definitions Articular cartilage degenerative change with hip joint space narrowing
General Features Best diagnostic clue: Superior joint space narrowing Location o OA changes Acetabular roof Chondral surfaces of acetabulum Femoral head articular surface Size: Unilateral to bilateral involvement Morphology o Variable based on extent of cartilage loss 0 Active OA with extensive inflammatory reaction, osteophytes, subchondral cysts & sclerosis
Radiographic Findings Radiography o Narrowing of load-bearing joint space
I
I
(80%) Medial migration plus protrusio acetabuli (20%) Egger's subchondral acetabular cyst Calcar buttressing Ring of osteophytes (lateral acetabulum + medial subcapital) o Sclerosis of femoral head + acetabular roof o o o o
CT Findings NECT o Superior joint space narrowing 0 Sclerosis o Subchondral cysts o Osteophytes o Normal mineralization (no juxta-articular osteoporosis)
MR Findings TlWI 0 Attenuated or denuded chondral surface o Hypointense sclerosis acetabular roof + opposing surface femoral head o Hypointense effusion + paralabral cysts 0 Marrow fat signal in osteophytes o Relative preservation of medial joint space relative to narrowed superior joint space o Single vs. multiple load-bearing zone subchondral cysts - hypointense to intermediate signal intensity
--
DDx: Osteoarthritis, Hip
Cor T 7 Arthro.
Sag T7Wl MR
Cor FS T I Arth
Cor FS
OSTEOARTHRITIS, HIP Key Facts Imaging Findings
I
Best diagnostic clue: Superior joint space narrowing Relative preservation of medial joint space relative to narrowed superior joint space Subchondral cysts hyperintense to intermediate signal + marginal hypointense sclerosis on T2WI
*
Femoroacetabular Impingement Avascular Necrosis (AVN) Developmental Dysplasia of the Hip (DDH) Labral Tears Pigmented Villonodular Synovitis (PVNS)
Diagnostic Checklist Inflammatory OA with reactive subchondral edema involving both sides of joint Younger patient may present with femoroacetabular impingement as precursor to OA
Pathology Articular cartilage overload
T2WI o Linear hyperintensity in chondral fissures o Subchondral hyperintensity lateral acetabular roof femoral head superior surface o Subchondral cysts hyperintense to intermediate signal + marginal hypointense sclerosis on T2WI o Subchondral cysts may be multiple + variable in size o Hyperintense paralabral cysts adjacent to acetabular labral tear o Hyperintense femoral head & neck edema in active OA o Hyperintense fluid + inhomogeneity of synovium in active inflammatory form of OA T1 C+: Intravenous contrast to enhance synovium Hypointense thickened stress trabeculae on T1 & T2WI
*
Imaging Recommendations Best imaging tool: MR indicated in early OA esp. younger population to identify femoroacetabular impingement, initial chondral degeneration, labral pathology + lateral acetabular roof edema Protocol advice o T1 (visualize sclerosis) + FS PD FSE in coronal, axial, sagittal planes o Non fat-suppressed PD imaging less sensitive to sclerosis & edema
Femoroacetabular Impingement Findings of OA in non-dysplastic hips in younger population Repetitive microtrauma 2" impingement of femoral head against acetabulum Hyperintense signal (T2WI) lateral femoral head + acetabular rim + labral tears & chondral defects
Avascular Necrosis (AVN) Wedge-shaped subchondral bone infarct Articular cartilage intact at presentation Double line sign on T2WI in 80%
Clinical Issues Most common signs/symptoms: Joint pain Insidious onset groin + thigh pain Gluteal pain radiation
Top Differential Diagnoses
I DIFFERENTIAL DIAGNOSIS
Primary (idiopathic) vs. secondary (pre-existing joint disorder) - fragmentation Joint space narrowing: Weight-bearing zones Subchondral cysts (detritic cysts)
Developmental Dysplasia of the Hip (DDH) Acetabular dysplasia - shallow acetabulum Lateral acetabular rim syndrome findings similar to femoroacetabular impingement in non-dysplastic hips Identified on anterior coronal images
Labral Tears Linear hyperintensity f abnormal morphology on T2WI + Paralabral cyst communicating with tear Associated with trauma, DDH or OA
Pigmented Villonodular Synovitis (PVNS) Proliferation of synovial lining Hemosiderin-containing Inhomogeneous signal on T2WI typically involving the medial capsule adjacent to femoral headlneck junction Hemosiderin - increased susceptibility on T2* GRE
Synovial Chondromatosis - ~ u l t i ~cartilaginous le or osseous intraarticular loose bodies Related to synovial metaplasia Effusion + pain + restricted joint motion Loose bodies - round + hypointense to intermediate signal adjacent to hyperintense effusion on T2WI
Pyrophosphate Arthropathy CPPD (calcium pyrophosphate dihydrate crystal deposition disease) Calcified labrum Subchondral cysts Crystal deposition in chondral surfaces May cause or accelerate OA
Rheumatoid DiseasesIVariants Hyperintense effusion on T2WI Intermediate signal synovial hypertrophy (T2WI) Bursa1 fluid distension Subchondral marrow edema on T2WI (FS PD FSE) Concentric joint space narrowing Synovial cysts
7
OSTEOARTHRITIS, HIP o Limited ability to sit, stand or walk o Symptoms worse in mornings & exacerbated by
axial loading or weight-bearing activity
General Features General path comments o Relevant anatomy Hyaline cartilage - resists mechanical stress (elastic) Subchondral plate + calcified cartilage = less compressible than articular cartilage Synovial fluid - produced by synoviocytes of synovial membrane (provides nutrients & viscosity + elasticity for shock absorption) Etiology o Articular cartilage overload o Primary (idiopathic) vs. secondary (pre-existing joint disorder) o Inflammation contributes to cartilage degeneration o Pathophysiologic changes also occur in synovial fluid, subchondral bone + capsular tissue o Cartilage may also be damaged by a metabolic process Epidemiology: 23% incidence at 55-74 years
o Pain & loss of internal rotation
Demographics Age: Usually > 55 years Gender: OA of hips > in males (OA knees > females)
Natural History & Prognosis Incidence of OA increases with age Clinical stabilization vs. progressive course Gait abnormalities Femoroacetabular impingement in the young patient may rapidly progress to advanced OA changes Unilateral involvement is common
Treatment Conservative o NSAIDs o Physical therapy o Intraarticular steroids in acute episodes o Intraarticular hyaluronate injections Surgical o Total hip arthroplasty
Gross Pathologic & Surgical Features Articular cartilage o Fibrillation - fragmentation Pressure erosion Joint space narrowing: Weight-bearing zones Subchondral cysts Sclerosis, osteophytes & labral tear End-stage ankylosis
Consider Inflammatory OA with reactive subchondral edema involving both sides of joint Younger patient may present with femoroacetabular impingement as precursor to OA Primary process involves chondral degeneration as seen on FS PD FSE (small FOV) coronal images
Microscopic Features Osteonecrosis of subchondral bone Hypervascularity Osteoblastic activity Trabecular thickening Subchondral cysts (detritic cysts) 0 Myxoid material o Proteoglycans o Articular cartilage fragments o Metaplastic cartilage Chondrocyte replication Decreased concentration of hyaluronic acid
Staging, Grading or Classification Criteria Grade I: Chondral inhomogeneity Grade 11: Inhomogeneity + discontinuity of chondral surface & hypointensity of femoral headlneck on TlWI Grade 111: Grade I1 + irregular cortical morphology of femoral head/acetabulum, cystic changes & indistinct zone between femoral headlacetabulum Grade IV: Addition of femoral head deformity
Presentation Most common signs/symptoms: Joint pain Clinical profile o Insidious onset groin + thigh pain o k Gluteal pain radiation o Stiffness
[SELECTED REFERENCES 1.
2. 3.
4. 5. 6. 7.
1
DeLee JC et al: Orthopaedic sports medicine. Principles and practice. Hip and pelvis. vol 2. 2nd ed. Philadelphia PA, WB Saunders, (25):1443-62, 2003 Fitzgerald RH et al: Orthopaedics. Arthritis of the hip. St. Louis MO, Mosby, (6-8):869-76,2002 Meyers S: Synovial fluid markers in osteoarthritis. Rheum Dis Clin North Am 25:433, 1999 Buckwalter J et al: Articular cartilage: Degeneration and osteoarthritis, repair, regeneration, and transplantation. Instr Course Lect. Rosemont IL, WB Saunders, 487, 1998 Vingard E et al: Sports and osteoarthritis of the hip. An epidemiological study. Am J Sports Med 21:195, 1993 Schumacher JR: Secondary osteoarthritis: Osteoarthritis: Diagnosis and management. Philadelphia PA, WB Saunders, 367-98, 1992 Haller J et al: Juxtaacetabular ganglionic (or synovial) cysts: CT and MR features. J Comput Assist Tomogr 13:976, 1989
OSTEOARTHRITIS, HIP
I IMAGE GALLERY (Left) Coronal graphic shows focal femoral head chondral erosion. (Right) Coronal graphic shows degenerative acetabular labrurn associated with subchondral acetabular cysts.
(Left) Surgical pathology shows intact labrum in a degenerative hip specimen. (Right) Surgical pathology shows chondral erosion of articular surface of acetabulurn (lunate surface).
Typical (Left) Coronal FS PD FSE MR shows superior joint space narrowing with full thickness acetabular chondral loss (arrow) and subchondral marrow edema. Osteophytes are present at the femoral headheck junction. (Right) Coronal FS PD FSE MR shows narrowing of the superior joint space with loss of both femoral and acetabular articular cartilage. Subchondral cysts, (open arrow) labral tear, and osteophytes (arrows) are shown
LOOSE BODIES, HIP
Coronal graphic shows loose body lodged within the acetabular fossa.
Axial NECT shows osseous loose bodies within the acetabular fossa.
Particulate matterldebris typically cannot be visualized o Causative etiology or donor site can be identified Fractures (acetabular, osteochondral, femoral head) Osteoarthritis Avascular necrosis (AVN) or Legg-Calve-Perthes 0
Abbreviations and Synonyms Free fragments, joint mice, rice bodies
Definitions Free-floating or adherent intraarticular body
CT Findings NECT o Excellent bony detail o Multi-planar capability o Chondral fragments cannot be visualized o Arthrography will increase sensitivity for non-ossified or non-calcified loose bodies o Associated fractures/dislocations o Causative etiology often identified Fracture NI Osteoarthritis (OA) AVN rn Osteochondral lesion
General Features Best diagnostic clue: Low to intermediate signal intensity focus within joint capsule on TI & T2WI Location o Acetabular fossa common location o Other intracapsular locations including zona orbicularis Size: Variable from small chondral to larger osteochondral fragment Morphology: Roundloval to elongated
MR Findings
Radiographic Findings Radiography o Anteroposterior + frog-leg views o Usually insensitive, even for bony or calcified bodies o Chondral loose bodies (non-radiopaque) cannot be visualized
TlWI o Hypointense to intermediate fragment 0 Less common - osteochondral fragment with marrow fat signal + hypointense sclerotic border T2WI 0 Hypointense to intermediate on T2WI
mmw?4jl DDx: Loose Bodies, Hip Osteoarthritis
' .+ Cor PD FSE MR
Cor FS PD MR
Cor T1 Arthro.
LOOSE BODIES, HIP Key Facts Imaging Findings Best diagnostic clue: Low to intermediate signal intensity focus within joint capsule on T1 & T2WI Acetabular fossa common location Hypointense to intermediate on T2WI Defect in chondral surface of femoral head or acetabulum
Top Differential Diagnoses Osteoarthritis Synovial Disorders Acetabular Labral Tears Artifacts
Osteoarthritis PVNS Synovial chondromatosis/osteochondromatosis
Clinical Issues Pain secondary to retained material in acetabular fossa Clicking Snapping Popping Increased symptoms with activity
Diagnostic Checklist Match loose body with donor site if possible
Pathology Trauma - commonly 2" to posterior dislocation + acetabular fracture o o o o
Hyperintense adjacent synovial fluid f Adherent to synovium
Requires FS PD FSE or STIR Donor site evaluation Defect in chondral surface of femoral head or acetabulum TI C+ o MR arthrography Osseous, calcified, chondral, osteochondral bodies visualized Particulate mattertdebris demonstrated Donor sites shown Less sensitive to subchondral changes or basal chondral degeneration
Ultrasonographic Findings Real Time o Effusions help in searching for loose bodies o Loose bodies = small hyperechoic foci in a hypo or anechoic background (effusion) o Loose bodies in children with non-ossified epiphyses o Particulate debris - tiny floating hyperechoic foci (inflammatory arthritis, infection) o Chondral fragments: Hyperechoic, polygonal in shape o Osseous or calcified loose bodies: Hyperechoic - may produce shadowing
Imaging Recommendations Best imaging tool: MR for spectrum of chondral to osteochondral fragments, donor site location + associated subchondral changes Protocol advice: T1 or PD + FS PD FSE or STIR in coronal, axial f sagittal planes
Osteoarthritis Joint space narrowing Osteophytes Subchondral sclerosis Cystic changes
Chondral degeneration anterosuperior femoral head or acetabulum
Synovial Disorders Rheumatoid - synovial proliferation Chondromatosis/osteochondromatosis - cartilaginous metaplasia Pigmented villonodular synovitis (PVNS) - periarticular erosions + synovial proliferation + hemosiderin Inflammatory osteoarthritis - synovitis k reactive subchondral marrow edema
Acetabular Labral Tears Catching, locking, clicking and pain Associated with femoroacetabular impingement osteoarthritis Bucket-handle labral tears
+
Artifacts Physiologic nitrogen Iatrogenically introduced air in MR arthrography Microscopic post-surgical metallic susceptibility artifact (MRI)
1 PATHOLOGY General Features General path comments o Relevant anatomy Inelastic fibrous capsule of hip - reinforced by iliofemoral, pubofemoral + ischiofemoral ligaments Zona orbicularis = deep circular fibers from ischiofemoral ligament (may be mistaken for labrum arthroscopically) Fovea capitis of femoral head = no articular cartilage surface Etiology o Trauma - commonly 2"to posterior dislocation + acetabular fracture o Osteoarthritis o PVNS o Synovial chondromatosis/osteochondromatosis
-
LOOSE BODIES, HIP o Crystal induced arthropathies
Gout Calcium pyrophosphate dihydrate deposition (CPPD) o Rheumatoid arthritis o Infectionlseptic arthritis o AVN o Legg-Calvk-Perthes Epidemiology o Variable based on etiology o Osteoarthritis - most common source of chondral debris
Gross Pathologic & Surgical Features Osseous fracture fragment Acetabular fractures Osteochondral fractures Chondral fractures Traumatic labral tears + free-floating labral fragments Chondral degeneration + sloughing Svnovial ~roliferations Proteinaceous debris in setting of infection Loose bodies may be identified in acetabular fossa, recesses around zona orbicularis 92
Microscopic Features Proliferation of concentric layers of new cartilage + bone Laminated appearance Cartilaginous metaplasia in osteochondromatosis
0
1 DIAGNOSTIC CHECKLIST Consider Match loose body with donor site if possible FS PD FSE or STIR images to provide hyperintensity of joint fluidleffusion to facilitate loose body identification Evaluate for underlying joint disorder with patient history of clicking, locking, trauma
1. 2. 3. 4. 5. 6.
Presentation Most common signs/symptoms: Locking or catching Clinical profile o Pain secondary to retained material in acetabular fossa o Clicking o Snapping o Popping o Increased symptoms with activity
Demographics Age: Older adults most commonly affected (due to association with OA) Gender: M slightly > F
Natural History & Prognosis Most loose bodies remain in joint unless surgically removed May enlarge over time Rarely resorb Synovitis/debris o Treated conservatively o Improves when underlying pathology improves
Treatment Conservative for bodies secondary to underlying joint disorder o Synovitis o + Debris - particulate o Infection - antibiotics to avoid joint destruction Surgical
Most loose bodies arthroscopically removed Osseous fracture fragments Ossified or calcified loose bodies Chondral/osteochondral fragments - reattach to donor site or remove Chondromatosislosteochondromatosis PVNS Free floating labral fragment
7. 8. 9. 10, 11. 12. 13.
Kramer J et al: MR arthrography of the lower extremity. Radiol Clin of N America 40(5):1211-32,2002 Bencardino JT et al: Imaging of hip disorders in athletes. Radiol Clin of N America 40(2):267-87,2002 Attarian DE et al: Observations on the growth of loose bodies in joints. Arthroscopy 18(8):930-4,2002 Resnick D: Diagnosis of bone and joint disorders. Degenerative disease of extraspinal lesions. 4th ed. Philadelphia PA, WB Saunders, 1351-52, 2002 Van Holsbeeck MT et al: Musculoskeletal ultrasound. 2nd ed. St. Louis MO, Mosby, 265-8, 2001 McCarthy JC et al: The adult hip. Alternative to arthroplasty. vol 1. Iowa City IA, Lippincott-Raven, (43):721-36, 1998 Stoller DW: Magnetic resonance imaging in orthopaedics and sports medicine. 2nd ed. Philadelphia PA, WB Saunders, 802-12, 1997 McCarthy JC et al: The role of hip arthroscopy in the diagnosis and treatment of hip disease. Orthopaedics 18(8):753-6,1995 Edwards DJ et al: Diagnosis of the painful hip by magnetic resonance imaging and arthroscopy. J Bone Joint Surg 77B(3):374-6, 1992 Berquist TH et al: Imaging of orthopaedic trauma. The pelvis and hips. 2nd ed. New York NY, Raven Press, 298-9, 1992 Hawkins RB: Arthroscopy of the hip. Clin Orthop 24944-7, 1989 Harris WH: Etiology of osteoarthritis of the hip. Clin Orthop 213:20-33, 1986 Burman MS: Arthroscopy or the direct visulization of joints. J Bone Joint Surg 4:669-95, 1931
I
LOOSE BODIES, HIP
(Left) Axial T2WI MR shows cartilaginous loose body (arrow) in anterior left hip capsule. (Right) Axial graphic shows anterior capsule loose body.
Typical (Left) Coronal graphic shows synovial chondromatosis within the acetabular fossa. (Right) Axial PD/lntermediate MR shows synovial chondromatosis as hypointense defects (arrow) within the left hip joint effusion.
Typical (Left) Coronal T I C+ MR (MR arthrography) shows inferior capsule loose body (arrow) associated with adherent synovium. (Right) Axial FS PD FSE MR shows small corticated loose body (arrow) anterior to the femoral neck.
I
I
RHEUMATOID ARTHRITIS, HIP
Coronal graphic shows multiple bilateral symmetric chondral and subchondral erosions in juvenile chronic arthritis.
Coronal T l Wl MR shows bilateral epiphyseal erosions in juvenile chronic arthritis.
Radiographic Findings Radiography o Negative in early stages o Loss of joint space (chondral loss) o Progressive worsening of joint space loss o Juxta-articular osteoporosis o Soft tissue swelling o Loss of subchondral plate o Erosion - bare areas/capsular insertions o Subchondral cysts usually c 1 cm o Axial migration of femoral head o Protrusio acetabuli - medial femoral head cortex medial to ilioischial line
Abbreviations and Synonyms RA, inflammatory arthritis, rheumatoid disease, juvenile chronic arthritis
Definitions Systemic autoimmune inflammatory disorder of unknown etiology primarily affecting synovial membranes + articular surfaces
General Features Best diagnostic clue: Effusion and synovial proliferation Location o Femoral head o Acetabulum o Joint capsule Size o Diffuse involvement of femoral head o Entire joint at risk Morphology o Concentric loss of joint space o Protrusio deformity (medial displacement of femoral head)
CT Findings NECT o Sensitive to subchondral erosions o Hypodense joint effusion o Joint space narrowing o & Sclerosis, osteophytosis - superimposed osteoarthritic change
MR Findings TlWI o Hypointense joint effusion o Hypointense subchondral erosions o Hypointense mass - fluid in iliopsoas bursa o Hypointense acetabular + femoral head edema
DDx: Rheumatoid Arthritis, Hip
Cor FS PD MR
AVN
DDH
Cor ~1 WI MR
Cor T I WI MR
Labral Tear
BD Cor FS PD MR
Sag FS PD MR
RHEUMATOID ARTHRITIS, HIP Key Facts Imaging Findings Best diagnostic clue: Effusion and synovial Concentric loss of joint space Protrusio deformity (medial displacement of femoral Inhomogeneity of effusions, synovium + debris relative to hyperintense fluid on T2WI
Top Differential Diagnoses Femoroacetabular Impingement Avascular Necrosis (AVN) Developmental Dysplasia of the Hip (DDH) Labral Tears Pigmented Villonodular Synovitis (PVNS)
T2WI o Hyperintense joint effusion o Capsular distension (joint capsule) o ~emineralization(juxta-articular bone loss) with marrow hyperintensity on FS PD FSE or STIR o AttenuationJloss of subchondral plate (normally hypointense) o Intermediate to hyperintense subchondral cysts without sclerotic reactive interface o Femoral + acetabular erosions not confined to any specific quadrant (vs. osteoarthritis) o Hyperintense marrow edema o Inhomogeneity of effusions, synovium + debris relative to hyperintense fluid on T2WI T1 C+ o Intravenous contrast to enhance pannus tissue 0 Map extent + distribution of synovial involvement
Imaging Recommendations Best imaging tool o MR Detection of synovial pannus, erosions, cartilage loss, small subchondral cysts + marrow edema distribution Protocol advice: TI, FS PD FSE or STIR + FS T1 C+ in the coronal, axial, sagittal planes
Femoroacetabular Impingement Findings of osteoarthritis in non-dysplastic hips in younger patient population Repetitive microtrauma 2" impingement of femoral head against acetabulum Hyperintense signal (T2WI) of lateral femoral head + acetabular rim + labral tears & chondral defects
Avascular Necrosis (AVN) Wedge-shaped subchondral bone infarct Articular cartilage intact at presentation Double line sign on T2WI in 80%
Pathology Unknown etiology Bilateral, symmetrical joint involvement Hip joints involved later in disease process Inflammatory condition of synovial tissue Faulty immune response
Clinical Issues
Most common signslsymptoms: Hip pain + stiffness Insidious onset Joint swelling, tenderness to palpation Pain with activelpassive range of motion (ROM)
Diagnostic Checklist
Intravenous contrast to enhance pannus
Developmental Dysplasia of the Hip (DDH) Acetabular dysplasia - shallow acetabulum Lateral acetabular rim syndrome findings similar to femoroacetabular impingement in non-dysplastic hips Identified on anterior coronal images
Labral Tears Linear hyperintensity f abnormal morphology on T2WI f Paralabral cyst communication with tear
Pigmented Villonodular Synovitis (PVNS) Proliferation of synovial lining Hemosiderin-containing Inhomogeneous signal on T2WI typically involving the medial capsule adjacent to femoral headlneck junction Hemosiderin - increased susceptibility on T2* gradient echo
Synovial Chondromatosis Multiple cartilaginous or osseous intraarticular loose bodies Related to synovial metaplasia Effusion + pain + restricted joint motion
Pyrophosphate Arthropathy CPPD (calcium pyrophosphate dihydrate crystal deposition disease) Calcified labrum Subchondral cysts Crystal deposition in chondral surfaces May cause or accelerate osteoarthritis
Seronegative Arthritis Asymmetric Osteosclerosis Osseous proliferations Ankylosis
Inflammatory Systemic Connective Tissue Diseases Systemic lupus erythematosus
RHEUMATOID ARTHRITIS, HIP Scleroderma Polymyositis & dermatomyositis
1 PATHOLOGY General Features General path comments o Relevant anatomy Subchondral plate - supports articular cartilage Articular cartilage = hyaline Joint capsule = fibrous + synovial lining Synovial fluid - diffusion of nutrients to articular cartilage Genetics: Genetic predisposition - HLA-D antigen Etiology o Unknown etiology o Bilateral, symmetrical joint involvement o Hip joints involved later in disease process o Inflammatory condition of synovial tissue o Faulty immune response o Arthrotropic parvoviruses & lentiviruses - induce T4 helper cells + cytokine-medicated oligoclonal B cell resDonse (InG + InM rheumatoid factors) Epidemiology: Prevalence of RA = 1Yo of population ~
qh
- -
Gross Pathologic & Surgical Features Synovial inflammation Pannus Tendon tears/ruptures Articular cartilage erosions Superior + medial protrusion of hip into pelvis Synovial cysts - subchondral
Microscopic Features Hyperplasia of synovial cells o Redundant synovial folds, villae + masses Lymphocytes + plasma cells infiltrate synovial membrane Fibrinous exudates
Presentation Most common signs/symptoms: Hip pain + stiffness Clinical profile o Insidious onset o 4 of 7 criteria for diagnosis Morning stiffness > 1 hr., 3 or more joints, hand joints, symmetric, + Rh factor, nodules, radiographic changes o Malaise, weakness, weight loss, myalgias, fever o Joint swelling, tenderness to palpation o Pain with active/passive range of motion (ROM) o Rheumatoid factor Serum IgM antibody - 70% Directed against Fc fragment of IgG 30% rheumatoid negative o Serum ANA (antinuclear antibodies) - 30%
Demographics Age o Adults - 25 to 60 years o Peak incidence 40-60 years
Gender: F:M > 3:l
Natural History & Prognosis Slowly progressive disease with intermittent "flare-ups" + Indolent course Joint destruction Complications o Joint effusions - capsular distention - pain o Large synovial cysts o Tendinous tears/disruptions o Cartilaginous destruction - joint obliteration o Osseous destruction o Fibrous/bony ankylosis o AVN (secondary to steroid use)
Treatment Conservative o Decrease inflammation, delay joint destruction + preserve function o Pharmacotherapy Decrease inflammation NSAIDs; immune mediating agents o Physical therapy Heat, maintain ROM, strength, flexibility Surgical o Synovectomy (controversial) o Total hip arthroplasty - end stage disease
Consider Intravenous contrast to enhance pannus FS PD FSE or STIR for visualization of pannus + subchondral edema
Dablov G: Miscellaneous nontraumatic disorders: Cambell's operative orthopaedics. 10th ed. Philadelphia PA, Mosby, 905-13, 2003 Resnick D: Degenerative disease of extraspinal lesions: Diagnosis of bone and joint disorders. 4th ed. Philadelphia PA, WB Saunders, 891-939, 2002 Van Holsbeeck MT et al: Musculoskeletal ultrasound. 2nd ed. St. Louis MO, Mosby, 373-91, 2001 Mettler FA et al: Skeletal system: Essentials of nuclear medicine imaging. 4th ed. Philadelphia PA, WB Saunders, 326-9, 1998 Stoller DW: Magnetic resonance imaging in orthopaedics and sports medicine. 2nd Ed. Philadelphia PA, Lippincott Williams, 187-91, 1997 Anderson RJ: Rheumatoid arthritis: Primer on the rheumatic diseases. The arthritis foundation 90-5, 1993 Schumacher JR: Secondary osteoarthritis: Osteoarthritis-diagnosis and management. Philadelphia PA, WB Saunders, 367-98, 1992 Wallace CA et al: Juvenile rheumatoid arthritis: Outcome and treatment for the 1990's. Rheum Dis Clin North Am 175391-906, 1991
RHEUMATOID ARTHRITIS, HIP
I IMAGE GALLERY
OSTEOMYELITIS, HIP
Coronal graphic shows synovitis and infectious nidus of the femoral head with reactive marrow edema involving both the acetabulum and femoral head.
Coronal FS PD FSE MR shows septic right hip with hyperintensejoint effusion and capsular distension.
Changes delayed 10-14 days after onset of fever Soft tissue edema/swelling Focal lucency to frank destruction of bone Periosteal elevation + underlying lucency (subperiosteal abscess) o Intramedullary abscess - focal lucency tract to cortical surface o Sequestration (necrotic fragments) + involucrum (periosteal bone) as parosteal ossification o Joint effusion - widening of affected hip joint o o o o
Abbreviations and Synonyms Acute hematogenous osteomyelitis, chronic osteomyelitis
+
Definitions Acute hematogenous osteomyelitis in pediatric patient & chronic post-traumatic osteomyelitis in adult patient
CT Findings General Features Best diagnostic clue: Bone marrow hyperintensity, erosion + sinus tract on T2WI Location o Bone marrow in hematogenous osteomyelitis o Osteitis f marrow involvement in secondary (trauma or surgery) osteomyelitis Size: Variable from epiphyseal involvement to diaphyseal + soft tissue involvement Morphology: Focal, Brodie's abscess or larger area of medullary or cortical destruction
Radiographic Findings Radiography o Insensitive for early osteomyelitis
DDx: Osteomyelitis, Hip Avid
Cor PD FS MR
Sag T7 WI MR
NECT o Early bone destruction o Assessment of cortical + trabecular bone detail o Periosteal elevation, cortical destruction, intramedullary abscess + sinus tracts o Joint effusions = hypodense CECT o Infected regions enhance o Soft tissue complications: Abscesses enhance peripherally, sinus tracts enhance
wmw MR Findings
TlWI o Hypointense marrow edema + cortical destruction o Hypointense reactive joint effusion o Hypointense soft tissue abscess o Tract from skin to cortex
bt yositis ~ s r i l i c .
Sag FS PD MR
Cor T l W l MR
Cor FS PD MR
-
OSTEOMYELITIS, HIP Key Facts Chronic osteomyelitis = most common form of osteomyelitis in adult & 2' to trauma Hematogenous seeding Direct contamination 'pread
Imaging Findings Best diagnostic clue: Bone marrow hyperintensity, erosion + sinus tract on T2WI Sequestrum: Hypointense on TI + T2WI Involucrum (periosteal reaction): Hypointense on T1 EX T2WI
Clinical Issues ~ o scommon t signs/symptoms: Pain Fever
Top Differential Diagnoses Transient Osteoporosis of the Hip (TOH) Avascular Necrosis (AVN) Cellulitis Septic Arthritis Amyloid
Diagnostic Checklist Identify marrow edema as well as associated extension through cortex + soft tissue tract Axial images to identify hypointense sequestrum
Pathology Staph aureus = most common infecting organism in all age groups Double-line sign on T2WI in 80% Fat signal in ischemic lesion in earlier stages f Hyperintense marrow edema extending to femoral neck on T2WI
o Hypointense to intermediate signal in
metaphysis/diametaphysis in child T2WI o Hyperintense marrow involvement o Hyperintense intraosseous abscess o Cortical destruction: Intermediate to hyperintense o Cloaca (periosteal opening): Focal hyperintensity in hypointense periosteum o Sinus tract: Intermediate to hyperintense o Brodie's abscess (round abscess cavity representing a chronic pyogenic infection): Hyperintense + hypointense sclerotic rim o ~ellulitis:Reticulated subcutaneous hyperintensity o Myositis: Hyperintense muscle + enlargement TI C+ o Enhancement Bone marrow - inflammation = Abscess - peripheral enhancement within medullary canal or soft tissue (thick wall) ~nhancementperipheral to sequestrum Cortical erosion/destruction - + enhancement Sinus tract - peripheral enhancement Sequestrum: Hypointense on T1 + T2WI ~n
Fracture (Fx) Hyperintense fracture line on T2WI Adjacent hyperintensity of soft tissue without sinus tract or erosion
Cellulitis Subcutaneous fat involvement Hypointense on TI, hyperintense on T2WI Reticulated pattern on T1 & T2WI Underlying muscle or deep fascia1 planes intact
Septic Arthritis Large hyperintense (TZWI) joint effusion with capsular distension f scalloping of capsule (synovitis) Diabetes, steroids, intravenous drug use = risk factors
Crystal-Induced Arthropathies Requires T2* gradient echo for visualization of susceptibility Effusion Degenerative findings including labral tears Chondral - hyaline cartilage degeneration
Tumor
Imaging Recommendations
Ewing sarcoma Osteosarcoma Solid lesion = central enhancement & peritumoral edema
Best imaging tool: MR sensitive to marrow edema & soft tissue involvement Protocol advice: T1 + FS PD FSE or STIR in axial, coronal & sagittal planes
Amyloid
1 DIFFERENTIAL DIAGNOSIS Transient Osteoporosis of the Hip (TOH) Middle-aged males Self-limited Hypointense on TI, hyperintense on T2WI
Avascular Necrosis (AVN) Trauma, steroid use, alcoholism
I
Long-term hemodialysis Large cystic erosions B-microglobulin deposition
Legg-Calvii- Perthes Infarction of bony epiphysis of femoral head Age: 4-8 most common Hypointense capital epiphysis on TI & T2WI
OSTEOMYELITIS, HIP Eosinophilic Granuloma Proliferating histiocytes Punched-out calvarial lesions + button sequestrum Tubular bones - osteolytic destruction + lamellar periosteal reaction
Osteoid Osteoma <2cm Painful lesion Requires FS PD or T2 or STIR to demonstrate hyperintensity of lesion + reactive edema
Myositis Ossificans Mass of calcified or ossified granulation tissue k Reactive hyperintense soft tissue edema on T2WI adjacent to ossification
Presentation Most common signs/symptoms: Pain Clinical profile o Fever o Restricted motion + point tenderness o Elevated sedimentation rate, C-reactive protein & WBC count o Soft tissue swelling + erythema + sinus tract
Demographics Age o Young children most commonly affected o Adults secondary to direct contamination (trauma, post-op) Gender: No bias
Natural History & Prognosis General Features
T 00
General path comments o Relevant anatomy for infection Periosteum (periostitis) Cortex (osteitis) Marrow (osteomyelitis) Metaphysis: > 1 year (physis acts as barrier to epiphyseal spread + metaphyseal capillary sinusoidal lakes and slow blood flow) Metaphysis/epiphysis - hematogenous involvement in infants Subcutaneous fat (cellulitis) Etiology o Staph aureus = most common infecting organism in all age groups o Other common organisms = streptococcus, pseudomonas, haemophilus, Enterobacter Epidemiology o Chronic osteomyelitis = most common form of osteomyelitis in~adult& 2" to trauma o Staphylococcus aureus = 80-90% of cases
Gross Pathologic & Surgical Features Hematogenous seeding o Children o Vascular metaphyseal bone Direct contamination o Penetrating trauma o Post-surgical Contiguous spread o Soft tissue infection o Septic arthritis
Microscopic Features Leukocytic infiltration of marrow Vascular compression Necrosis, abscesses + sequestra
Staging, Grading or Classification Criteria Acute, subacute & chronic hematogenous forms Brodie's abscess Chronic recurrent multifocal osteomyelitis (CRMO) Post-traumatic osteomyelitis
Osseous destruction will recur if untreated Prognosis good if treated early Progression to chronic infection Intramedullary, subperiosteal abscesses Soft tissue extension
Treatment Conservative o IV antibiotics Surgical 0 Debridement & antibiotic-impregnated beads
Consider Identify marrow edema as well as associated extension through cortex + soft tissue tract Axial images to identify hypointense sequestrum
Greenspan A: Orthopedic radiology: A practical approach. 3rd ed. Philadelphia PA, Lippencott Williams & Wilkins, 753-84, 2000 Mettler FA et al: Essentials of nuclear medicine imaging. 4th ed. Philadelphia PA, WB Saunders, 285-333, 1998 Resnick D: Internal derangements of joints: Emphasis on MR imaging. 1st ed. Philadelphia PA, WB Saunders, 473-554, 1997 Morrison WB et al: Diagnosis of osteomyelitis: Utility of fat-suppressed contrast-enhanced MR imaging. Radiology 189:251-7, 1993 Dangman BC et al: Osteomyelitis in children: Gadolinium-enhanced MR imaging. Radiology 182:743-7, 1992 Erdman WA et al: Osteomyelitis: Characteristics and pitfalls of diagnosis with MR imaging. Radiology 180533-9, 1991 Gold RH et al: Bacterial osteomyelitis: Findings on plain radiography, CT, MR, and scintigraphy. AJR 1%7:365-70, 1991 Beltran J et al: Experimental infections of the musculoskeletal system: Evaluation with MR imaging and Tc-99m and ~ a - 6 ;scintigraphy. Radiology 167:167-72, 1988
OSTEOMYELITIS, HIP
Typical (Left) Axial graphic shows osteomyelitis with sequestrum and sinus tract. (Right) Axial FS PO FSE MR shows hyperintense signal in medullary cavity (arrow) of proximal femur from osteomyelitis. Periosteal hyperintense reaction identified as an early stage o i the involucrum.
Variant (Lef) Axial FS PD FSE MR shows scalloping of capsular margins associated with infected joint fluid (septic hip). (Right) Axial FS PO FSE MR shows Ewing sarcoma mimicking soft tissue involvement and marrow edema as seen in osteomyelitis.
Varian (Left) Coronal T I WI MR shows joint space collapse and subchondral marrow edema in active inflammatory osteoarthritis mimicking osteomyelitis. (Right) Coronal FS PD FSE MR shows diffuse involvement of multiple myeloma (arrows) in the acetabulum and femur mimicking osteomyelitis. Unlike osteomyelitis, there is relative sparing of marrow fat in the greater trochanter and femoral head.
SECTION 5: Knee Menisci Discoid Meniscus Meniscal Degeneration Meniscal Horizontal Tear Meniscal Cyst Meniscal Longitudinal Tear Meniscal Radial Tear Meniscal Flap Tear Meniscal Bucket-Handle Tear Meniscocapsular Separation Post-Operative Meniscus Change
Anterior Cruciate Ligament Anterior Cruciate Ligament (ACL) Tear ACL Reconstruction
5-42 5-46
Posterior Cruciate Ligament Posterior Cruciate Ligament Tear
5-50
Medial Collateral Ligament Medial Collateral Ligament Tear Medial Bursitis, Knee
5-54 5-58
Lateral Collateral Ligament Complex Lateral Collateral Ligament (LCL) Tear Posterolateral Complex Injuries Iliotibial Band Syndrome
5-62 5-66 5-70
OsseousICartilagenous Structures Osteochondral Injuries, Knee Osteochondritis Dissecans, Knee Bone Infarct, Knee Spontaneous Osteonecrosis, Knee Patellar Fracture Lateral Tibia1 Plateau Fracture
5-74 5-78 5-82 5-86 5-90 5-94
Extensor Mechanism Patellar Tendinitis Osgood-Schlatter Disease Patellar (Anterior) Bursitis Synovitis, Knee Patellar Tendon Tears Chondromalacia Patella Quadriceps Tendon Tear Transient Patellar Dislocation Medial Plica Syndrome
Arthritis/Synovitis/Bursitis Osteoarthritis, Knee Rheumatoid Arthritis, Knee Pigmented Villonodular Synovitis, Knee Lipoma Arborescens, Knee Reflex Sympathetic Dystrophy, Knee Chondrocalcinosis, Knee
5-132 5-136 5-140 5-144 5-146 5-150
SynovialIDegenerative Cysts Intercondylar Notch Cyst Popliteal Cyst
5-154 5-158
DISCOID MENISCUS
Axial graphic shows a discoid lateral meniscus with minimal resorption of the central portion of the meniscus.
Coronal PD FSE MR shows a discoid lateral meniscus with meniscal tissue occupying the lateral compartment.
o Widening of joint space with hypoplastic femoral
condyle and high fibular head in lateral discoid meniscus o Cupping of lateral tibial plateau
Abbreviations and Synonyms Discoid meniscus (DM)
2
M R Findings
Definitions Large, congenitally dysplastic meniscus with loss of normal semilunar shape Result of failure of resorption of central portion
General Features Best diagnostic clue: Large meniscus with loss of normal semilunar shape filling lateral or medial compartment (50% or greater coverage of lateral tibial plateau) on sagittal and coronal images Location o Lateral discoid meniscus is more common than medial discoid meniscus o Can be bilateral Size: > 13 mm Morphology o Pancake shaped meniscus with intact central portion o Large but incomplete disc commonly seen
Radiographic Findings Radiography
TlWI o Meniscal size > 13 mm in cross section Normal hypointense meniscus is 5-13 mm from the capsular margin to the free edge on a central coronal image o Discoid meniscus exhibits continuous body segment appearance on 2 3 consecutive sagittal 4-5 mm thick images T2WI o Meniscus is hypointense o Intrameniscal mucoid degeneration or cyst may be intermediate to hyperintense on T2* GRE or FS PD FSE PDIIntermediate: Short TE sequence showing uniformly hypointense large meniscus TZ* GRE o Mucinous degeneration and intrameniscal cystic cavities are hyperintense o Tear as hyperintense signal o Horizontal tear morphology common o Discoid meniscus is larger and disc shaped, filling a greater surface area of the central compartment Tear is seen as hyperintense signal (TI, PD, GRE TZ*)
DDx: Discoid Meniscus
--
Dicplac~dBucket
Bucket-Handle
Flrpped Meniscur
Cor FS PD FSE
Sag FS PD FSE
Sag FS PD FSE
Key Facts Terminology Large, congenitally dysplastic meniscus with loss of normal semilunar shape
Imaging Findings I
Best diagnostic clue: Large meniscus with loss of normal semilunar shape filling lateral or medial compartment (50% or greater coverage of lateral tibia1 plateau) on sagittal and coronal images Lateral discoid meniscus is more common than medial discoid meniscus Can be bilateral Meniscal size > 13 mm in cross section Tear is seen as hyperintense signal (TI, PD, GRE T2*)
Top Differential Diagnoses Flipped Meniscus o Seen on all short TE sequences Complete discoid meniscus has "pancake"appearance o Extending from intercondylar notch to the periphery of compartment MR arthrography o Contrast extends into discoid meniscal tear o Closed meniscal tears without contrast communication
Imaging Recommendations Best imaging tool: MRI Protocol advice o Include short TE sequence to detect tears in discoid meniscus FS PD FSE and T2* GRE Direct axial images to show circumferential morphology
Vacuum Phenomenon Typically in hyperextended knee Decreased signal intensity on all pulse sequences in the joint between weightbearing surfaces Rarely homogeneous like discoid meniscus Exaggerated on TZ* GRE MRI
Flipped Meniscus Meniscus is torn and often displaced anteriorly Portions of meniscus are missing - usually posterior horn "flipped"anteriorly o Missing meniscus allows distinction from discoid meniscus +/- Extension block
Bucket-Handle Tear Displaced longitudinal tear Fragment usually migrates to notch of the knee Seen on coronal and sagittal images Donor site meniscal body usually smaller than normal Traumatic with identifiable antecedent event
Bucket-Handle Tear
Pathology Etiology: Failure of resorption of the central portion of meniscus Microscopically normal meniscus
Clinical Issues Patients often present with pain, clicking and snapping Often asymptomatic in children
Diagnostic Checklist Identify the number of images with meniscus body segment visualized, if more than three consider DM Absent clear space at center of weightbearing surface of lateral compartment
Displaced Flap Meniscal Tear Meniscal donor site small Vertical signal in inner third of meniscus or blunted meniscal morphology Symptomatic adult Often reactive change in adjacent tibia = Oblique tear +/- Reactive tibial edema +/- MCL (medial collateral ligament) bursitis Hypointense mass on all pulse sequences = displaced fragment
General Features General path comments: Pancake or large meniscus demonstrates intrameniscal degeneration or meniscal tear Genetics: Congenital deformities Etiology: Failure of resorption of the central portion of meniscus Epidemiology: 5% of population
Gross Pathologic & Surgical Features Pancake or large, otherwise normal-appearing meniscus in medial or lateral compartment o Lateral compartment more common Wrisberg-ligament type discoid meniscus lacks posterior capsular (meniscotibial) attachment unstable o Horizontal tear in middle and posterior segments of meniscus
Microscopic Features Microscopically normal meniscus o Meniscus may demonstrate rnucinous intrasubstance degeneration +/- tearing Tear - separating cleavage plane surrounded by regenerative chondrocytes Degeneration - rnucinous ground substance within the fibrocartilaginous meniscus +I- cystic areas or cavities
DISCOID MENISCUS Staging, Grading or Classification Criteria Watanabe classification o Complete: Discoid meniscus extending into the intercondylar notch on coronal images o Incomplete: Partial discoid morphology +/extension toward the intercondylar notch on coronal images o Wrisberg-ligament type: Lacks posterolateral meniscotibial attachment Classification by surface configuration - associated tear patterns (arthroscopic) o Vertical Longitudinal tear (primary tear pattern is in vertical plane) Flap tear (primary tear pattern is in vertical plane) Radial tear o Horizontal Horizontal cleavage tear Longitudinal tear (primary tear pattern is in horizontal plane) Flap tear (primary tear pattern is in horizontal plane)
Consider Displaced flap tearlbucket-handle tear as differential diagnosis
Image Interpretation Pearls Identify the number of images with meniscus body segment visualized, if more than three consider DM Absent clear space at center of weightbearing surface of lateral compartment o Less common involvement of medial compartment
1. 2. 3. 4. 5.
Presentation Most common signs/symptoms o Patients often present with pain, clicking and snapping o Often asymptomatic in children o Locking is a common presentation in children Clinical profile o Symptoms may not develop until adolescence or young adulthood o Bilaterality: 20-90% o Click or clunk at the joint line during terminal 15-20 degrees of extension
Demographics Age o Children asymptomatic o Adults usually symptomatic Gender: No predilection
Natural History & Prognosis Extension loss Snapping (Wrisberg type) Giving way Palpable joint line mass Progression to a meniscal tear Painful intrameniscal cystic cavities of mucinous degeneration
Treatment Conservative initially Partial meniscectomy Saucerization/partial resection of the discoid portion to create a more normal shaped meniscus
6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
Samoto N et al: Diagnosis of discoid lateral meniscus of the knee on MR imaging. Magn Reson Imaging 20(1):59-64, 2002 Choi NH et al: Medial and lateral discoid meniscus in the same knee. Arthroscopy 17(2):E9, 2001 Rao PS et al: Clinical, radiologic, and arthroscopic assessment of discoid lateral meniscus. Arthroscopy 17(3):275-7,2001 Rohren EM et al: Discoid lateral meniscus and the frequency of meniscal tears. Skeletal Radiol 30(6):316-20, 2001 Arnold MP et al: Symptomatic ring-shaped lateral meniscus. Arthroscopy 16(8):852-4,2000 Araki Y et al: MR imaging of meniscal tears with discoid lateral meniscus. Eur J Radiol 27(2):153-60, 1998 Raber DA et al: Discoid lateral meniscus in children. Long-term follow-up after total meniscectomy. Bone J Joint Surg 80(11):1579-86, 1998 Ryu KN et al: MR imaging of tears of discoid lateral menisci. AJR 171(4):963-7,1998 Maffulli N et al: Knee arthroscopy in Chinese children and adolescents: An eight-year prospective study. Arthroscopy 13(1):18-23,1997 Connolly B et al: Discoid meniscus in children: Magnetic resonance imaging characteristics. Canadian Association of Radiologists Journal 47(5):347-54, 1996 Washington ER et al: Discoid lateral meniscuc in children. Long-term follow-up after excision. Bone J Joint Surg 77(9):1357-61,1995 Pellacci F et al: Lateral discoid meniscus: Treatment and results. Arthroscopy 8(4):526-30, 1992 Aichroth PM et al: Congenital discoid lateral meniscus in children. A follow-up study and evolution of management. Bone J Joint Surg 73(6):932-6, 1991 Fritschy D et al: Discoid lateral meniscus. International Orthopaedics 15(2):145-7, 1991 Sugawara 0 et al: Problems with repeated arthroscopic surgery in the discoid meniscus. Arthroscopy 7(1):68-71, 1991 Dimakopoulos P et al: Partial excision of discoid meniscus. Arthroscopic operation of 10 patients. Acta Orthopaedica Scandinavica 61(1):40-1, 1990 Bellier G et al: Lateral discoid menisci in children. Arthroscopy 5(1):52-6, 1989 Vandermeer RD et al: Arthroscopic treatment of the discoid meniscus: Results of long-term follow-up. Arthroscopy 5(2):101-9, 1989 Hayashi LK et al: Arthroscopic meniscectomy for discoid lateral meniscus in children. Bone J Joint Surg 70(10):1495-500,1988 Dickhaut SD et al: The discoid lasteral-meniscus syndrome. J Bone Joint Surg 64:1068-73, 1982
DISCOID MENISCUS
I IMAGE GALLERY Typical (Lejl) Sagittal FS PD FSE MR shows a discoid lateral rneniscus. Meniscal tissue that is continuous with the anterior and posterior horn throughout multiple sagittal images is characteristic. (Right) Coronal PD FSE MR shows a discoid lateral meniscus.
Variant (Left) Sagittal FS PD FSE MR shows a torn and degenerated discoid lateral meniscus (arrow). (Right) Coronal FS PD FSE MR shows a torn and degenerated discoid lateral meniscus (arrow).
Variant (Left) Axial oblique graphic shows a large lateral meniscus that is discoid-like. (Right) Coronal PD FSE MR shows a large, discoid-like lateral meniscus.
Sagittal graphic shows globular intrameniscal degeneration (yellow) within the central meniscal shear plane (dark blue).
Sagittal PD FSE MR shows meniscal grade 1 signal intensity (degeneration) within the posterior horn of the medial meniscus. There is no extension (communication) with an articular surface.
o Horizontal linear intrasubstance increased signal
intensity (grade 2 signal)
Abbreviations and Synonyms
h
MR Findings
Meniscal grade 1 and meniscal grade 2 signal intensity = meniscal degeneration, intrasubstance signal, intrasubstance degeneration
Definitions Internal degeneration of meniscal fibrocartilage resulting from chronic shear stresses + axial loading Caused by rotation, flexion & extension of knee during normal walking as well as cumulative effects of traumatic injuries of knee
1 IMAGING FINDINGS
I
General Features Best diagnostic clue: Increased signal intensity within meniscal substance on short TE MR images not extending to articular surface Location: Can occur in either meniscus but most common in posterior horn of medial meniscus Size: Variable from focal area to linear distribution extending from capsular periphery Morphology o Nonarticular focal or globular intrasubstance increased signal intensity (grade 1 signal)
TlWI o TlWI & short TE images are sensitive to meniscal degeneration Short TE sequences: TI, PD, T2* GRE T2WI o Moderate to extensive lesions demonstrate mild increased signal intensity on T2WI o Intrameniscal degenerative cyst detection Increased signal intensity (fluid) on T2WI Increased signal intensity o Globular o Linear Within the substance of the meniscus MR arthrography o Arthrography does not show communication with an articular surface of the meniscus
Imaging Recommendations Best imaging tool: MRI Protocol advice o Short TE images TI, PD and/or gradient echo (T2* GRE) images
7
DDx: Meniscal Degeneration Men~scusVessels
Men~scusVessels
1% C
Sag P D FSE MR
Sag PD FSE MR
Sag t' D FSE MI<
C
SE MR
Cor PD FSE MR
MENISCAL DEGENERATlON Key Facts Terminology Internal degeneration of meniscal fibrocartilage resulting from chronic shear stresses + axial loading Caused by rotation, flexion & extension of knee during normal walking as well as cumulative effects of traumatic injuries of knee
Imaging Findings Best diagnostic clue: Increased signal intensity within meniscal substance on short TE MR images not extending to articular surface Location: Can occur in either meniscus but most common in posterior horn of medial meniscus
Top Differential Diagnoses Prominent, Sometimes Linear Appearing Normal Vascularity Seen in Younger Patients
Intrameniscal Tear not Communicating with an Articular Surface
Pathology Epidemiology: Common meniscal abnormality
Clinical Issues Typically asymptomatic Symptoms are suggestive of meniscal teartintrameniscal closed tear Clinical profile: May present with pain without typical signs of clicking
Diagnostic Checklist Meniscal degeneration may be underestimated on FSE images secondary to blurring effect with increased echo spacing
1 DIFFERENTIAL DIAGNOSIS
1 PATHOLOGY
Prominent, Sometimes Linear Appearing Normal Vascularity Seen in Younger Patients
General Features
Typically less than 12 years of age Corresponds to mid perforating collagen bundle
Marrow Fat Containing Meniscal Ossicle Focally expansile without fluid intensity Corticated Posterior horn medial meniscus most common
lntrameniscal Tear not Communicating with an Articular Surface Prominent grade 2 signal Suggestive clinical signs and symptoms Grade 3 signal intensity which weakens as it approaches an articular surface = closed meniscal tear
Magic Angle Phenomenon in Upsloping Posterior Horn Lateral Meniscus Typical location Orientated 55 degrees to external magnetic field in 1.5T magnets Shift of position or longer TE values differentiates Common location for meniscal teartinjury in setting of anterior cruciate ligament (ACL) injury
Fat Planes within Meniscotibial Attachments Linear & vertical located at meniscal attachments only Anterior horn lateral meniscus Mimics meniscal tear
Meniscal Tear Signal abnormality extends to articular surface Communication with surface, maybe difficult to identify especially in peripheral body tears Suggestive clinical presentation +/- Displaced flap +/- Adjacent inflammatory change
General path comments: May be mimicked in young person by prominent, linear vascularity in plane of middle perforating collagen bundle Etiology o Internal degeneration of the meniscal substance resulting from chronic stresses (abnormal shear forces) caused by Rotation, flexion and extension of knee during normal walking Cumulative effects of traumatic injuries of the knee Epidemiology: Common meniscal abnormality
Gross Pathologic & Surgical Features Pale, often mucinous regions of discoloration in a variety of patterns within meniscal substance No tear identified
Microscopic Features Mucinous degeneration and chondrocyte deficient regions o Pale staining with hematoxylin and eosin (H&E) Increased production of mucopolysaccharide ground substance o Myxoid, mucinous or hyaline degeneration May have linear appearance (grade 2 degeneration) o Microscopic clefting and collagen fragmentation may be seen in hypocellular regions of the fibrocartilaginous matrix Central (middle) perforating bundle of the meniscus is a horizontal buffer zone between the different frictional forces o Between the femur and tibia is a preferential site for accumulation of mucinous ground substance (degeneration) o Common location for the development of grade 2 signal intensity
Staging, Grading or Classification Criteria Grading of meniscal signal
o Grade 1: Nonarticular, focal or globular increased
l$
signal intensity within the meniscal substance on short TE sequences o Grade 2: Horizontal, linear increased signal intensity within the meniscal substance on short TE sequences Extending from the capsular periphery of the meniscus but not extending to an articular surface Histologically usually more extensive degeneration than that seen with MRI grade 1 o Grade 3: Increased signal intensity that communicates or extends to at least one articular surface of the meniscus Represents a meniscal tear with fibrocartilaginous separation * Classification based on location - vascular zones o White zone (whitelwhite zone) Completely avascular central portion of the meniscus including inner one third Menisci debrided o Red-white junction (redlwhite zone) Middle third between free edge and peripheral third Incompletely vascularized area Debridement vs. repair Repair especially if iascular pedicle can be established o Red zone (redlred zone) Peripheral one third Vascularized area Primary repair usually possible if tear confined to redlred zone or peripheral portion of redlwhite zone
Presentation Most common signs/symptoms o Typically asymptomatic o Symptoms are suggestive of meniscal tearlintrameniscal closed tear Clinical profile: May present with pain without typical signs of clicking If symptomatic with meniscal grade 2 signal, the findings may represent an intrameniscal closed tear o A closed tear is associated with grade 3 signal intensity which weakens as it approaches an articular surface of the meniscus
Demographics Age o Typically older patient o Also seen in younger, active patients Gender: No predilection
Natural History & Prognosis May progress to tear, especially horizontal cleavage tear when in the posterior horn of the medial meniscus Does not necessarily indicate that a tear will occur Mucinous degeneration does represent potential structural weakening within the meniscus
Treatment Conservative o Meniscal degeneration is treated conservatively Surgical o None for pure degeneration
/DIAGNOSTICCHECKLIST
1
Consider Vascularity in a young person Intrameniscal tear especially if fluid signal is present within the meniscus
Image Interpretation Pearls Use short TE sequences o T2* GRE images sensitive for intrasubstance degeneration Meniscal degeneration may be underestimated on FSE images secondary to blurring effect with increased echo spacing o Blurring seen with shorter effective TE, a longer echo train length & a lower acquisition matrix
Anderson MW: MR imaging of the meniscus. Radio1 Clin North Am 40(5):1081-94, 2002 Fukuta SK et al: Prevalence of abnormal findings in magnetic resonance images of asymptomatic knees. J Orthop Sci 7(3):287-91, 2002 Greis PE et al: Meniscal injury: Management. J Am Acad Orthop Surg 10(3):177-87,2002 Nawata K et al: Magnetic resonance imaging of meniscal degeneration in torn menisci: A comparison between anterior cruciate ligament deficient knees and stable knees. Knee Surg Sports Traumatol Arthrosc 7(5):274-7, 1999 Crues JV 111: The impact of MRI on our understanding of the pathology of sports injuries. Sportverletz Sportschaden 8(4):156-9, 1994 Peterfy CG et al: "Magic-angle"phenomenon: A cause of increased signal in the normal lateral meniscus on short-TE MR images of the knee. AJR 163(1):149-54, 1994 Raunest J et al: Magnetic resonance imaging (MRI) and arthroscopy in the detection of meniscal degenerations: Correlation of arthroscopy and MRI with histology findings. Arthroscopy 10(6):634-40, 1994 Stoller DW et al: Meniscal tears: Pathologic correlation with MR imaging. Radiology 163(3):731-5, 1987
MENISCAL DEGENERATION
Tveical
(Lef)Sagittal graphic shows linear intrasubstance degeneration (grade 2 degeneration). (Right) Sagittal PD FSE MR shows linear grade 2 intrameniscal degeneration (arrow).
Variant (Left) Coronal PD FSE MR shows diffuse intrameniscal degeneration (arrow) of the posterior horn of the medial meniscus adjacent to a radial tear of the posterior horn root attachment. There is slight enlargement of the degenerated posterior horn. (Right) Coronal PD FSE MR shows grade 2 intrameniscal degeneration of the lateral meniscus body and grade 1 intrameniscal degeneration of the medial meniscus body.
(Lef)Sagittal graphic shows free edge fraying. (Right) Sagittal PD FSE MR shows increased signal (arrow) within the free edge of the medial meniscus confirmed at arthroscopy as free edge fraying.
MENlSCAL HORlZONTAL TEAR
Sagittal graphic shows a horizontal tear extending from the free edge to an area of meniscal degeneration toward the more stable periphery of the meniscus .
Free edge: White zone Deeper substance: Red-white junction Peripheral aspect: Red zone Size: Varies from small tear involving free edge to completely bisecting meniscus Morphology 0 Horizontally-oriented (in superior to inferior plane) 0 Mesial to peripheral
.
Abbreviations and Synonyms Horizontal tear (HT), cleavage tear, fishmouth tear I0
Sagittal PD FSE MR shows a horizontal medial meniscal tear with linear increased signal intensity reaching the surface at the free edge of the meniscus.
Definitions Meniscal tear that occurs in horizontal plane, dissecting through circumferential collagen fibers Tear most often extends from free edge inward along horizontally located central perforating bundle of meniscus, resulting in two separate shelves (leaves) of meniscal tissue
CT Findings ' CT arthrography o Contrast extends into tear of meniscus body Sagittal, coronal reconstructions
M R Findings General Features Best diagnostic clue o Linear, horizontally-oriented, increased signal intensity on short TE sequences Within meniscus extending from free edge inward Short TE sequences: TI, PD, gradient echo Location o Most common within posterior horn of medial meniscus o Initially involves free edge then propagates transversely involving deeper substance then peripheral aspect
TlWI o Increased signal intensity extending to the articular surface in the plane of the middle perforating collagen fibers Involves free edge Horizontal orientation T2WI o Linear hyperintense signal on T2WI including FSE Especially if fluid is present within tear and decompresses into a meniscal cyst Posterior horn of the medial meniscus (PHMM) hyperintense cystic mass Communication with cyst often identified PDIIntermediate
.
.
DDx: Meniscal Horizontal Tear Pediatric Vessels
Normal Meniscus
P
Sag PD FSE MR
Sag PD FSE MR
Sag PD FSE MR
Cor PD FSE MR
Sag PD FSE MR
MENISCAL HORIZONTAL TEAR Key Facts Terminology Meniscal tear that occurs in horizontal plane, dissecting through circumferential collagen fibers
Imaging Findings Linear, horizontally-oriented, increased signal intensity on short TE sequences Most common within posterior horn of medial meniscus Horizontally-oriented (in superior to inferior plane)
Top Differential Diagnoses Linear Intrameniscal Signal Abnormality Normal Vascularity Seen in Younger Patients Meniscal Flap Tear
Pathology Tear occurs in horizontal plane and dissects circumferential collagen fibers (splitting of fibers along their transverse axis)
Clinical Issues Tenderness typically at the joint line adjacent to the main portion of the tear if the tear reaches the peripheral, innervated, vascularized portion Asymptomatic if confined to the free edge and small in size
Diagnostic Checklist Signal intensity directed toward meniscal apex in horizontal plane (cleavage tear)
o Linear hyperintensity extending to the articular
surface = tear o Parallels tibia1 articular surface orientation in
cleavage tear MR arthrography o Arthrogram - contrast extending into tear o Arthrography typically not necessary Useful in post operative setting o May fill meniscal cyst if present +/- Separation of the two components of tear Coronal images - horizontal linear increased signal sequence intensity (short TE sequence) separating two resultant meniscal fragments Meniscal cyst formation
Imaging Recommendations Best imaging tool: Most accurately diagnosed on short TE MR images Protocol advice o T1, PD and/or gradient echo (TZ*)sequences o FS PD FSE for detection of meniscal cyst
1 DIFFERENTIAL DIAGNOSIS Linear lntrameniscal Signal Abnormality Linear degeneration Intrameniscal closed tear Visualized on short TE sequences
Normal Vascularity Seen in Younger Patients Typically less than 15 years of age Prominent, sometimes linear appearing Mimics meniscal tear/degeneration
Meniscal Flap Tear Complex tear of the meniscus with longitudinal and radial components Seen on short TE sequences +/- Displaced flap component o Into meniscotibial or femoral attachment recesses
General Features General path comments o HT originates as a small free edge tear After initial trauma in the setting of meniscal degeneration o Tear occurs in horizontal plane and dissects circumferential collagen fibers (splitting of fibers along their transverse axis) o Pure HT maintains a horizontal orientation toward meniscal apex o Partial cleavage tear begins as horizontal tear o Develop superior or inferior extension resulting in a mobile fragment of meniscus (flap of meniscus) known as flap tear Flap tears may also result from a radial tear with secondary longitudinal component o Most often occurs in a nontraumatic setting in an older person Etiology o Shear forces resulting from difference in coefficient of friction between superior and inferior articular surfaces Lead to horizontally-oriented degeneration Eventually leading to tear after minor trauma Epidemiology: Common meniscal tear especially as a component of a flap tear
Gross Pathologic & Surgical Features Disruption of meniscal surface in a horizontal direction
Microscopic Features Mucinous ground substance within the fibrocartilaginous meniscus with a separating cleavage plane surrounded by regenerative chondrocytes along the free edge of the tear Variable degrees of synovial ingrowth Neovascularity in more chronic cases
1
r -
MENiSCAL HORiZONTAL TEAR
I I 1
Extensive resection may lead to osteoarthritis Clinical course depends in part on other structures damaged in traumatic cases Extensive injuries more likely to develop osteoarthritis
Staging, Grading or Classification Criteria Classification by surface configuration - tear patterns (arthroscopic) o Vertical Longitudinal tear (primary tear pattern is in vertical plane) Flap tear (primary tear pattern is in vertical plane) Radial tear 0 Horizontal Horizontal cleavage tear = Longitudinal tear (primary tear pattern is in horizontal plane) Flap tear (primary tear pattern is in horizontal plane) Classification based on location-vascular zones o White zone (whitelwhite zone) Inner third of meniscus (free edge) Debridement o Red-white junction (redlwhite zone) Middle third between free edge and peripheral third Debridement vs. repair Repair especially if vascular pedicle can be established o Red zone (redlred zone) Peripheral third Vascularized Primary repair usually possible if tear confined to redlred zone or portion of redlwhite zone
Treatment Conservative o If isolated to the peripheral third ("red zone") and small in size (uncommon) Surgical o Amenable to meniscal resectionldebridement to stable intact or stable meniscus with residual grade 3 signal intensity (meniscal signal extending to an articular surface of either the superior or inferior leaf or apex) Complications o Immediate post operative complications include Infection Popliteal artery or venous thrombosis or laceration Articular cartilage abrasions Scuffing or defect formation o Development of osteoarthritis if the meniscus is resected Altered load transfer o Malalignment secondary to meniscectomy
.
.
. . .
12
.
I DIAGNOSTIC CHECKLIST Consider In the absence of acute trauma A pseudolesion o Vascularity in a young patient 0 Grade 2 degeneration mistaken for grade 3 signal Grade 2 degeneration: Linear intrasubstance meniscal signal Grade 3 signal: Tear Could it be a flap tear with a secondary horizontal component vs. a classic horizontal cleavage tear which extends to the meniscal apex
Presentation Most common signs/symptoms o Tenderness typically at the joint line adjacent to the main portion of the tear if the tear reaches the peripheral, innervated, vascularized portion o Tears involving only the free edge may be asymptomatic o Joint line tenderness and positive clinical meniscal testing Positive McMurray's test, Steinmann's test, Apley's test Clinical profile o Middle aged or older patient, +I- physical activity o Patient often unaware when tear occurs
Demographics Age: Adult Gender: No predilection
Natural History & Prognosis Asymptomatic if confined to the free edge and small in size Progression to flap tear, fragment may displace peripherally into coronary recess or meniscofemoral attachment recess Reactive tibia1 edema common Small tears usually propagate peripherally Extension of debrided meniscus o Especially in traumatic setting
Image Interpretation Pearls Utilize short TE images (TI, GRE, PD) Signal intensity directed toward meniscal apex in horizontal plane (cleavage tear)
1. 2. 3. 4. 5.
6.
Jee WH et al: Meniscal tear configurations: Categorization with MR imaging. AJR 180(1):93-7,2003 Anderson MW: MR imaging of the meniscus. Radio1 Clin North Am 40(5):1081-94, 2002 Greis PE et al: Meniscal injury: Management. J Am Acad Orthop Surg 10(3):177-87,2002 Menetrey J et al: Medial meniscectomy in patients over the age of fifty: A six year follow-up study. Swiss Surg 8(3):113-9,2002 Imhoff A et al: Comparison between magnetic resonance imaging and arthroscopy for the diagnosis of knee meniscal lesions. Rev Chir Orthop Reparatrice Appar Mot 83(3):229-36,1997 Stoller DW et al: Meniscal tears: Pathologic correlation with MR imaging. Radiology 163(3):731-5,1987
MENISCAL HORIZONTAL TEAR
I IMAGE GALLERY Variant (Left) Sagittal PD FSE MR shows a subtle peripheral horizontal tear (arrow) of free edge of body of the medial meniscus. (Right) Coronal PD FSE MR shows the horizontal tear extending to the free edge of the body of the medial meniscus.
(Lef)Coronal PD FSE MR shows a horizontal tear farrow) of the body of the medial meniscus. (Right) Sagittal PD FSE MR (same case) shows where the tear (arrow) is difficult to identify due to involvement of the body of the meniscus. The findings include irregularity of the undersurface in this peripheral image.
(Lef)Coronal PD FSE MR shows an intrameniscal cyst (arrow) within the peripheral aspect of the body of the lateral meniscus adjacent to meniscal signal abnormality. (Right) Sagittal PD FSE MR shows inferior extension (arrow) of a horizontal tear. Note in this case the orientation of the tear is slightly oblique but would appear as a horizontal flap tear at arthroscopy.
MENISCAL CYST
Sagittal graphic shows a horizontal tear of the body of the meniscus with associated meniscal cyst projecting peripherally.
Cyst within (intrameniscal) or adjacent to (parameniscal) meniscus typically in continuity with meniscal tear o Meniscal tear horizontal cleavage or complex tear also known as a radial split tear with radial and horizontal component (lateral meniscus) Posterior horn of medial meniscus Anterior horn of lateral meniscus Body of lateral meniscus Lateral meniscal tear may be radial/complex
Abbreviations and Synonyms Parameniscal cyst, meniscal cyst (MC) 14
Sagittal FS PD FSE MR shows a horizontal tear of the peripheral aspect of the medial meniscus with a small posteriorly projecting meniscal cyst.
Definitions Cyst extending from meniscal tear o Horizontal tear most common
CT Findings General Features Best diagnostic clue: Cystic mass extending from a meniscal tear Location o ~ o scommon t locations Anterior horn of the lateral meniscus (AHLM) m Posterior horn of the medial meniscus (PHMM) Size: Varies from a few mms to large dissecting cyst (> 1 cm) Morphology o Round +/- loculations o May be flattened o Dissection around medial collateral ligament (MCL) conforming to adjacent structures
CT arthrography o Contrast extends into tear o +/- Filling of cyst Partial or complete filling
M R Findings TlWI o Intermediate to low signal intensity mass = cyst o If proteinaceous, the cyst may be of variable signal intensity T2WI o Rounded, homogenous increased signal intensity mass o If chronic, increased signal intensity hyperemia in adjacent tibia, femur = "reactiveedema" o ~ncreasedsignal intensity with soft tissue edema PDIIntermediate
DDx: Meniscal Cyst SMTCL Bursit~s
Sag FS PD FSE
Sag PD FSE
Cor PD FSE
Sag FS PD FSE
.
MENlSCAL CYST Key Facts Imaging Findings Best diagnostic clue: Cystic mass extending from a meniscal tear Cyst within (intrameniscal) or adjacent to (parameniscal) meniscus typically in continuity with meniscal tear Rounded, homogenous increased signal intensity mass Protocol advice: T2WI show cyst as increased signal intensity mass (FS PD FSE is more sensitive)
Top Differential Diagnoses Synovial CystIGanglion Cyst Bursitis Cystic Masses Meniscal Ossicle
o Intermediate signal intensity mass = cyst o PD intermediate = short TE sequence
T2* GRE o Intermediate to hyperintense mass = cyst o GRE progressive T2* effect with increasing TE and decreased theta values T1 C+ o +/- Rim enhancement o Greater enhancement if chronic cyst with thickened synovium Increased signal on short TE sequences extending to articular surface = tear Mass lobulated and septate especially if parameniscal location Cyst mass dissects around the knee into the paraarticular soft tissues o When medial the cyst dissects around the MCL or between the deep and superficial components
Imaging Recommendations Best imaging tool: MRI Protocol advice: T2WI show cyst as increased signal intensity mass (FS PD FSE is more sensitive)
Synovial CystIGanglion Cyst Does not originate from meniscal tear +/- Osteoarthritis (OA) Synovial cyst originates from joint Ganglion cyst - nonspecific origin May or may not contain synovial lining +/- History of trauma Often reflects past effusions (synovial cyst)
Bursitis Semimembranosus tibia1 collateral ligament (SMTCL) bursa mimics a medial parameniscal cyst (sagittal) Tibia1 collateral ligament bursa mimics a medial parameniscal cyst (coronal) Deep infrapatellar bursa can mimic anterior lateral parameniscal cyst with inferior extension
Pathology Cyst develops from forcing of joint fluid into or through meniscal tear, typically horizontal tear
Clinical Issues Pain and palpable mass near joint line in cases of large cysts Palpable mass that disappears with flexion = Pisani's sign Cysts tend to be larger when lateral due to loose soft tissue constraints compared to the medial side
Diagnostic Checklist Bursitis, especially SMTCL bursitis if adjacent to PHMM and no tear seen Search for associated meniscal tear on short TE sequence Pes anserinus bursa mimics inferiorly dissecting medial cyst
Cystic Masses Neoplastic masses tend to be heterogeneous with visible cellular elements o Hemangioma o Varices o Hematoma o Neoplasm (rare) No demonstrable connection to meniscus MRI useful for differentiation
Meniscal Ossicle Hyperintense on Tl/PD, not on conventional T2 o Due to marrow fat content Marrow fat ossicle may expand meniscus like intrameniscal cyst Posterior horn medial meniscus (PHMM) most common location Rare
Popliteus Tendon Sheath (Pop Tendon Sheath) Normal structure may be filled with fluid Mimics posterior horn lateral meniscus (PHLM) cyst In continuity with joint capsule Tendon within fluid-filled sheath
1 PATHOLOGY General Features General path comments o Results from "ball valve" mechanism o Associated tear most commonly horizontal when associated with PHMM tear o Associated tear most commonly complex when associated with AHLM tear Extends anteriorly from tear involving the body of the lateral meniscus
-
MENlSCAL CYST
o Associated tear most commonly complex when
body segment of lateral meniscus is torn leading to cyst Prominent radial component Etiology o Cyst develops from forcing of joint fluid into or through meniscal tear, typically horizontal tear o Cyst arising from extrusion of joint fluid through meniscal tear often with a "ball valve" mechanism leading to build-up of pressure and cyst formation Epidemiology 0 Relatively common o 7% in surgically removed menisci o Seen in age groups in which meniscal tears are present
Consider Bursitis, especially SMTCL bursitis if adjacent to PHMM and no tear seen
Image Interpretation Pearls If communicating meniscal tear visualized or cyst is present at the joint line then assume the cyst is meniscal in origin Search for associated meniscal tear on short TE sequence Associated meniscal tear patterns include horizontal cleavage and radial split tears (horizontal and radial tear components)
Gross Pathologic & Surgical Features Cyst filled with mucinous, proteinaceous fluid o Within or adjacent to meniscus o In continuity with horizontal cleavage meniscal tear or flap (oblique) tear with a predominately horizontal component o Associated with discoid menisci
Microscopic Features
I0
Cyst formed within meniscus lined by o Compressed meniscal collagen with areas of mucinous degeneration in adjacent meniscus Cyst outside the meniscus (parameniscal) formed by o Compressed, paraarticular loose areolar tissue with hemorrhage and inflammatory cells
Presentation Most common signs/symptoms o Pain and palpable mass near joint line in cases of large cysts Palpable mass that disappears with flexion = Pisani's sign Palpable cyst prominent at 15 to 30 degrees of flexion and disappears at full extension and flexion greater than 90 degrees o Cysts tend to be larger when lateral due to loose soft tissue constraints compared to the medial side o Vary in size depending on position of knee
Demographics Age: Adult patient Gender o More frequent in females o M:F = 1:l to 1:10
Natural History & Prognosis Mass grows with time Will recur in cases of communicating meniscal tear If arthroscopy performed for meniscus, tear must be closed to prevent recurrence or growth of cyst
Treatment Arthroscopic resection of cyst and repair of tear
Rath E et al: The menisci: Basic science and advances in treatment. Br J Sports Med 34(4):252-7,2000 2. Stoller DW et al: Magnetic resonance imaging in orthopaedics and sports medicine. vol 1.2nd ed. Philadelphia PA, J.B. Lippincott, 203-442, 1997 3. Rothstein CP et al: Semimembranosus-tibia1collateral ligament bursitis: MR imaging findings. Am J Roentgenol 166(4):875-7, 1996 4. Steiner E et al: Ganglia and cysts around joints. Radio1 Clin North Am 34(2):395-425, 1996 5. Janzen DL et al: Cystic lesions around the knee joint: MR imaging findings. Am J Roentgenol 163(1):155-61,1994 6. Stoller DW et al: Meniscal tears: Pathologic correlation with MR imaging. Radiology 163(3):731-5,1987 7. Fitzgerald R et al: Orthopaedics. Meniscal injury. 2nd ed. St Louis MO, Mosby, 663-77, 1984
1.
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MENlSCAL CYST IMAGE GALLERY Typical (Left) Sagittal FS PD FSE MR shows a hyperintense meniscal cyst arising from the anterior horn of the lateral meniscus - a common location. (Right) Axial FS PD FSE MR (same case) showing anterior soft tissue extension of the cyst.
Typical (Left) Coronal FS PD FSE MR shows a cyst anterior to the lateral meniscus, a common location for meniscal cysts. (Right) Sagittal FS PD FSE MR shows a small radial tear at the junction of the anterior horn and body of the lateral meniscus and an anteriorly projecting parameniscal cyst.
(Lef)Sagittal FS PD FSE MR shows a moderate sized meniscal cyst projecting anteriorly from an anterior lateral meniscus tear. This is a common location for meniscal cyst. (Right) Coronal PD FSE MR shows a small meniscal cyst (arrow) adjacent to a lateral meniscal tear of the body segment.
MENISCAL LONGITUDINAL TEAR
Sagittal graphic shows a longitudinal tear involving the peripheral aspect of the meniscus. A small horizontal intrameniscal component extends toward the free edge.
Sagittal PD FSE MR shows a longitudinal tear (arrow) within the posterior horn of the medial meniscus.
o Vertically oriented tear in the superoinferior plane o Extends from posterior to anterior
Abbreviations and Synonyms
Radiographic Findings
Vertical peripheral tear, longitudinal tear = LT 1X
Definitions Tear along longitudinal axis of meniscus Begins in peripheral aspect of posterior horn and advances in direction of circumferential collagen fibers
Radiography o Associated fractures o Deepened sulcus terminalis of lateral femoral condyle Associated with anterior cruciate ligament (ACL) tears
CT Findings General Features Best diagnostic clue o Linear, vertically oriented increased signal intensity on short TE sequences within the meniscus o Extends to superior articular surface, inferior articular surface or both Location o Typically within the outer third of the meniscus Vascularized portion of the meniscus or "red zone" o Propagates longitudinally (circumferentially) Posterior horn body anterior horn = Anterior horn rarely involved Size: Varies from small longitudinal tear to circumferential longitudinal tear Morphology
-
-
NECT +/- Fractures CT arthrography o Contrast extends into tear of meniscal body o Sagittal reconstructions
MR Findings TlWI o Increased signal intensity extending to the articular surface = tear Typically peripheral; vertical orientation T2WI o Linear hyperintense signal if fluid is present within tear or when a T2* GRE sequence is used T2* GRE is more sensitive (hyperintense) to meniscal degeneration and tears compared to conventional spin echo or fast spin echo
DDx: Meniscal Longitudinal Tear
-
.
T r a n s v ~ r Lig s~
Transverse Lig
Sag FS PD FSE
Sag FS PD FSE
q r
Poplitrur Tinrlnn
'.
Sag F'D FSE MI.?
Sag PD FSE MR
Sag FS PD FSE
MENISCAL LONGITUDINAL TEAR Key Facts Terminology
Pathology
Tear along longitudinal axis of meniscus Begins in peripheral aspect of posterior horn and advances in direction of circumferential collagen fibers
Imaging Findings
Normal anatomic structures may mimic LT Insertion of anterior transverse intermeniscal ligament
Clinical Issues Conservative treatment most common
Typically within the outer third of the meniscus Vascularized portion of the meniscus or "red zone" Size: Varies from small longitudinal tear to circumferential longitudinal tear
Top Differential Diagnoses Anterior Transverse Ligament Insertion Meniscofemoral Femoral Ligament Insertion Popliteus Tendon -
Diagnostic Checklist Identify vertical signal abnormality on sagittal and coronal images Signal intensity follows contour of meniscus on axial images in a longitudinal tear Meniscal tear pattern does not change direction on multiple sagittal images as seen in some flap tears
-
PDIIntermediate: Increased signal on short TE sequences extending to the articular surface of the superior and/or inferior leaf of the meniscus: Vertical orientation common on meniscal cross section MR arthrography 0 Contrast extending into tear o MR arthrography not routinely used Post operative setting for retear detection +/- Separation of two components of tear 0 Displacement (bucket-handle or flap tear) Often seen as a vertical tear within posterior horn Longitudinal tears also possible with horizontal component on meniscal cross section (sagittal plane) Coronal images identify body segment involvement Thin section axial images demonstrate linear signal intensity following the long axis of meniscus
Imaging Recommendations Best imaging tool: MRI Protocol advice 0 Accurately diagnosed on short TE MR images TI weighted, proton density weighted and/or TZ* gradient echo images o PD FSE or T2* GRE
Anterior Transverse Ligament Insertion Ligament-meniscusinterface (connects the anterior horns of the medial and lateral meniscus) Seen on successive sagittal images adjacent to anterior horn Isolated anterior meniscal tears are rare
Meniscofemoral Femoral Ligament Insertion Interface of the meniscofemoral ligament and posterior horn lateral meniscus (PHLM) Mesial third of posterior horn (near the posterior horn meniscotibial attachment) Ligament can be followed on successive contiguous images Ligament of Humphrey (anterior to PCL)
Ligament of Wrisberg (posterior to PCL)
Popliteus Tendon Normal structure adjacent to posterior horn lateral meniscus Tendon sheath intracapsular at posterior aspect of joint Tendon may mimic posterior third of torn meniscus
I PATHOLOGY General Features General path comments o Normal anatomic structures may mimic LT Insertion of anterior transverse intermeniscal ligament Insertion of meniscofemoral (Humphrey's, Wrisberg's) ligament to PHLM 0 LT originates as a small longitudinal split Disrupts posterior horn Advances along the plane of circumferential collagen fibers Splitting of the fibers along their long axis o Multiple tears can occur o Occurs in an acute traumatic setting o Accompanied by ACL and/or medial collateral ligament (MCL) tears 0 Inner fragment displaced resulting in a bucket-handle or flap fragment Etiology 0 Increased axial load (compressive force) Resulting radial strain and subsequent splitting of meniscus longitudinally Epidemiology o Second most common tear pattern o Seen in ACL deficient knees
Gross Pathologic & Surgical Features Disruption of meniscal surface in longitudinal direction (parallel to the longitudinal axis)
MENISCAL LONGITUDINAL TEAR Microscopic Features Mucinous ground substance within fibrocartilaginous meniscus with separating cleavage plane surrounded by regenerative chondrocytes and fibrosis Synovial ingrowth into the meniscal tear Neovascularity in chronic cases
Demographics Age: Younger patient Gender: M > F
Natural History & Prognosis May heal if isolated to the peripheral third ("red zone") and small in size Often propagates longitudinally Fragment may displace transiently giving a locked knee presentation (posterior spring sign) Small tear may heal Retear of repair in traumatic setting Extensive resection may lead to osteoarthritis Clinical course depends on associated injured structures o Extensive injuries have an increased chance of developing osteoarthritis
Staging, Grading or Classification Criteria
28
Classification by surface configuration - tear patterns (arthroscopic) o Vertical Longitudinal tear (primary tear pattern is in vertical plane) Flap tear (primary tear pattern is in vertical plane) Radial tear o Horizontal Horizontal cleavage tear Longitudinal tear (primary tear pattern is in horizontal plane) Flap tear (primary tear pattern is in horizontal plane) o Complex degenerative Classification based on location-vascular zones o White zone (whitelwhite zone) Menisci debrided in free edge (medial third) o Red-white junction (redlwhite zone) Middle third between free edge and peripheral third Debridement vs. repair Repair if vascular pedicle can be established o Red zone (redlred zone) Peripheral third Vascularized Primary repair usually possible if tear confined to red/red zone or peripheral portion of redlwhite zone
Treatment Conservative treatment most common o If isolated to the peripheral third ("red zone") and small in size Surgical o Amenable to meniscal repair if isolated to the peripheral third ("red zone") o Resection of the inner fragment if not amenable to repair Complications o Immediate post operative complications include infection, popliteal artery/venous thrombosis or laceration o Development of osteoarthritis if the meniscus is resected due to altered load transfer o Malalignment secondary to meniscectomy
1 D~ACNOST~C CHECKLIST Consider In the setting of trauma Signal hyperintensity could be pseudolesion: Meniscofemoral & anterior transverse ligament attachment Could the tear pattern identified on sagittal images represent a flap tear
Presentation Most common signslsymptoms o Tenderness typically at the joint line adjacent to the apex of the tear Due to greatest tension exerted on surrounding nerve fibers o Locking if inner fragment becomes displaced Tension on the abnormally mobile fragment leads to pain and spasm o Posterior spring sign (clinically)which dissipates with general anesthesia Spasmodic origin rather that true physical extension lock (displaced bucket-handle tear, flap tear or flipped meniscus) o Joint line tenderness and often positive clinical meniscal testing Positive tests: McMurray's, Steinmann's & Apley's Clinical profile o Younger, physically active patient o Often posttraumatic and occurs after a single traumatic event o Common in a sports setting
Image Interpretation Pearls Identify vertical signal abnormality on sagittal and coronal images Signal intensity follows contour of meniscus on axial images in a longitudinal tear Meniscal tear pattern does not change direction on multiple sagittal images as seen in some flap tears
ISELECTED 1. 2. 3.
REFERENCES
Jee WH et al: Meniscal tear configurations: Categorization with MR imaging. AJR 180(1):93-7, 2003 Greis PE et al: Meniscal injury: Management. J Am Acad Orthop Surg 10(3):177-87, 2002 Stoller DW et al: Meniscal tears: Pathologic correlation with MR imaging. Radiology 163(3):731-5, 1997
I
MENISCAL LONGITUDINAL TEAR
/ IMAGE GALLERY Typical (Left) Sagittal PD FSE MR shows a typical nondisplaced longitudinal tear. (Right) Axial FS PD FSE MR shows longitudinal increased signal within the posterior horn of the medial meniscus (arrow) in the same case.
Typical (Lef)Sagittal PD FSE MR shows a vertical longitudinal tear through the posterior horn also referred to as a "corner fracture" seen in acute traumatic cases. (Right) Coronal FS PD FSE MR shows extension to and involvement of the peripheral aspect of the body of the meniscus.
(Left) Sagittal FS PD FSE MR shows a longitudinal tear (lateral meniscus) at the insertion of the meniscofemoral ligament (Humphrey's or Wrisberg's ligament). This is seen with an ACL tear mechanism of injury. (Right) Sagittal FS PD FSE MR of the same case shows peripheral extension of the tear (arrow).
MENlSCAL RADlAL TEAR
Axial oblique graphic shows a radial tear involving the posterior horn of the lateral meniscus at meniscotibial attachment.
Sagittal PD FSE MR shows a radial tear (arrow) of posterior horn of the medial meniscus at the root attachment giving a "ghost meniscus" appearance.
Morphology: Radially-oriented (perpendicular to long axis of meniscus)
Abbreviations and Synonyms
Radiographic Findings
Radial tear (RT) '2
Definitions Vertical tear oriented perpendicular to the free edge of meniscus Includes root tear at meniscotibial attachment
Radiography o +/- Associated fractures in acute cases o Posterolateral tibia, anterolateral femur (sulcus terminalis) - with anterior cruciate ligament (ACL) tears
CT Findings General Features Best diagnostic clue o Vertical tear perpendicular to the free edge of the meniscus o "Ghost meniscus" when in plane of acquisition in root tears Location o Most common at junction of the anterior horn and body of the lateral meniscus o Meniscotibial attachment posterior horn of the meniscus (root tear) Common in posterior horn of medial meniscus as a degenerative tear Size: Small free edge tear, or tear through entire meniscus
I
NECT o +/- Associated fractures in acute cases o Posterolateral tibia, anterolateral femur (sulcus terminalis) - associated with ACL tears CT arthrography o Contrast extends into tear of meniscus body o Sagittal, coronal reconstructions
M R Findings TlWI o Increased signal intensity extending to articular surface = tear Involves free edge extending variably to involve red-white junction, +/- red zone Bisects meniscus in post traumatic cases Radially-oriented (vertical on cross section) T2WI o Linear hyperintense signal on T2WI/(FSE PD FSE)
I
DDx: Meniscal Radial Tear Meniscal Ossicle
Sag PD FSE MR
Sag PD FSE MR
Sag FS PD FSE
Sag PD FSE MR
Sag PD FSE MR
MENISCAL RADIAL TEAR Key Facts Imaging Findings Vertical tear perpendicular to the free edge of the meniscus Morphology: Radially-oriented (perpendicular to long axis of meniscus) Diffuse, increased signal on one or two sagittal images seen in root attachment type of radial tears
Top Differential Diagnoses Meniscal Degeneration
Pathology Degenerative or acute (mostly a traumatic origin) Disruption of "hoop containment" results in subluxation of the body of the meniscus peripherally Posterior horn lateral meniscus radial tears associated with ACL tears
+/- Hyperintense bone edema = stress responselfx o Associated with meniscal cyst - increased signal intensity mass on T2WI Body, anterior horn lateral meniscus PDIIntermediate o Increased signal on short TE sequences extending to articular surface = tear Involves free edge extending variably to involve periphery Radially-oriented T2* GRE o Radially-oriented increased signal extending to articular surface Involves free edge MR arthrography o Arthrogram - contrast extending into tear o Contrast may communicate with meniscal cyst if present o Arthrography useful in post operative setting Diffuse, increased signal on one or two sagittal images seen in root attachment type of radial tears o = "Ghost meniscus" in tear of root attachment Blunting of the free edge on coronal images
Imaging Recommendations Best imaging tool: MRI Protocol advice o High resolution (ZIP512linterpolation) FSE o Short TE sequences (TI, GRE, PD); PD FSE
I DIFFERENTIAL DIAGNOSIS Oblique Meniscal TearIFlap Tear Contains longitudinal component in addition to radial component Associated with flap displacement No "ghost meniscus" sign Donor site may resemble radial tear
Meniscal Degeneration Leads to increased signal on short TE sequence without extending to surface
Clinical Issues Most common signs/symptoms: Pain after single traumatic event or insidious onset of pain Joint line tenderness anterior to lateral collateral ligament (LCL) Feeling of "giving way" Progresses to larger tear Asymptomatic if confined to the free edge & small in size Often propagates peripherally
Diagnostic Checklist Flap tear if not purely radial (radial + longitudinal) "Ghost meniscus" (root tear) if there is no history of surgery and posterior horn tissue is absent adjacent to the intercondylar notch
May resemble "ghost meniscus" but surface integrity preserved Usually asymptomatic Free edge fraying
Meniscal Ossicle Rare Usually intrarneniscal Leads to diffuse intrameniscal increased signal on TlWI and PD Ossicle low signal on fat suppressed images
Post Operative Meniscal resection mimics "ghost meniscus" sign Appropriate history for differentiation Variable amounts resected to stable fibrocartilage Increased signal on short TE sequences
1 PATHOLOGY General Features General path comments o Degenerative at junction of anterior hornlbody lateral meniscus o Involvement medially and laterally in acute setting o Common posterior horn of lateral meniscus (PHLM) at meniscotibial attachment with ACL tear mechanism Etiology o Degenerative or acute (mostly a traumatic origin) o Usually develops insidiously in the lateral meniscus Rotational forces across meniscus at "fulcrum"of movement - junction of anterior horn and body Between the anterior and posterior horns: Susceptible to tear in the flexed and rotated (loaded) knee Screw home mechanism results in torque of the meniscal fibrocartilage o Acutely with a sudden impact Epidemiology o Up to 15% incidence
MENlSCAL RADIAL TEAR o Recognized with greater frequency at posterior horn
of medial meniscus (PHMM) root attachment Degenerative tear Associated abnormalities o Disruption of "hoop containment" results in subluxation of the body of the meniscus peripherally o Loss of hoop containment leads to altered forces through joint: +I- Stress response, stress fx o Posterior horn lateral meniscus radial tears associated with ACL tears o Deepened sulcus terminalis with ACL tear mechanism
Gross Pathologic & Surgical Features Disruption of meniscal surface with a radial component (perpendicular to the longitudinal axis) May include displaced flap component
Microscopic Features Mucinous ground substance within the fibrocartilaginous meniscus with a separating cleavage plane surrounded by regenerative chondrocytes Variable degrees of synovial ingrowth Neovascularity in more chronic cases
Staging, Grading or Classification Criteria Classification by surface configuration - tear patterns 21
(tear of meniscal root attachment also classified as a iadial tear) o Vertical Longitudinal tear (primary tear pattern is in vertical plane) Flap tear (primary tear pattern is in vertical plane) Radial tear o Horizontal Horizontal cleavage tear Longitudinal tear (primary tear pattern is in horizontal plane) Flap tear (primary tear pattern is in horizontal plane) Classification based on location - vascular zones o White zone (whitelwhite zone) Medial third of meniscus (free edge) Debridement o Red-white junction (redlwhite zone) Middle third between free edge and peripheral third Debridement vs. repair Repair if vascular pedicle can be established o Red zone (redlred zone) rn Peripheral third Vascularized Primary repair possible if tear confined to redlred zone or peripheral portion of redlwhite zone MRI classification o Parrot-beak Poor terminology - not widely used Radial tear + curved inner component May in fact represent a flap tear (radial + longitudinal component) o Four MR patterns based on location of the tear and imaging plane Ghost (root tear)
rn
Cleft - free edge radial tear pattern Truncated triangle - free edge radial tear Marching cleft - free edge radial tear in different locations on consecutive sagittal images (this pattern may actually represent a developing flap tear)
I
I
Presentation Most common signs/symptoms: Pain after single traumatic event or insidious onset of pain Clinical profile o Joint line tenderness anterior to lateral collateral ligament (LCL) o Feeling of "givingway" o Clicking o Locking if fragment displaced o "Pseudolocking"if hamstring spasm is present
Demographics Age: Adult Gender: No predilection
Natural History & Prognosis Progresses to larger tear Asymptomatic if confined to the free edge & small in size Often propagates peripherally Extension of debrided meniscus can occur o Especially in traumatic setting Clinical course depends on associated structures damaged in traumatic cases
Treatment Debridement; repair in young individuals
-
Consider Flap tear if not purely radial (radial + longitudinal) Classic radial tear involves anterior horn body junction without root involvement "Ghost meniscus" (root tear) if there is no history of surgery and posterior horn tissue is absent adjacent to the intercondylar notch
Image Interpretation Pearls Consider radial tear if "ghost meniscus" (absent meniscus) appearance of posterior horn medial meniscus root attachment site on sagittal images
[SELECTED REFERENCES of the meniscus. Radio1 Clin 1.
2. 3.
Anderson MW: MR imaging North Am 40(5):1081-94,2002 Stoller DW et al: Magnetic resonance imaging in orthopaedics and sports medicine. vol 1. 2nd ed. Philadelphia PA, J.B. Lippincott, 203-442, 1997 Jones RS et al: Direct measurement of hoop strains in the intact and torn human medial meniscus. Clin Biomech 11(5):295-300,1996
I
MENISCAL RADIAL TEAR
(Left) Axial FS PD FSE MR shows a radial tear of the posterior horn of the medial meniscus (arrow). The meniscus abruptly ends at the meniscotibial attachment. (Right) Coronal FS PD FSE MR shows the radial tear as increased signal through the meniscotibial attachment (arrow). This is associated with loss of "hoop containment" thereby leading to instability.
(Left) Coronal PD FSE MR shows subluxation (arrow) of body of meniscus as a result of meniscal instability and subchondral fracture. Instability leads to altered forces through joint and stress response, stress fractures, and/or osteoarthritis. (Right) Coronal PD FSE MR shows a obliquely oriented radial tear through posterior horn lateral meniscus associated with irregular tearing of the meniscotibial attachment. This type of tear is often associated with ACL tears.
Typical (Left) Axial oblique graphic shows a typical location for a degenerative radial tear at the junction of the anterior horn and body of the lateral meniscus which is the location of the fulcrum of movement of the meniscus with normal walking. (Right) Sagittal PD FSE MR shows a radial tear (arrow) at the junction of the anterior horn and body of the lateral meniscus as is depicted in the illustration.
MENlSCAL FLAP TEAR
Axial oblique graphic shows a flap tear of the posterior horn of the medial meniscus.
Sagittal PD FSE MR shows displacement of a flap of the free edge (arrow) of the posterior horn of the medial meniscus in association with a large horizontal component.
Radiographic Findings ~adiography o Subtle erosion due to chronic displaced flap rn Involves tibia adjacent to coronary ligament insertion and meniscal body
Abbreviations and Synonyms Meniscus oblique tear, meniscus flap tear Lh
Definitions Tear of the meniscus with both longitudinal and radial components forming a flap of meniscal tissue that may become displaced
Best diagnostic clue o Obliquely oriented tear of the meniscus containing Longitudinal (long axis of meniscus) component Radial (perpendicular to long axis) component Location: Most commonly affects posterior horn and posterior aspect of body of medial meniscus Size: Varies from small (few mms) to large (cms) Morphology o Variable horizontal, radial components and connecting vertical/oblique components o Often begins as horizontal tear Develops radial component resulting in flap at junction of horizontal tear and non-torn meniscus
1
CT arthrography o Contrast extends into tear of meniscus body +/- Displaced fragment surrounded by contrast Sagittal and coronal reconstructions helpful
MR Findings
General Features
I
CT Findings
TlWI o Increased signal extending to the articular surface = tear o Horizontal tear + fragment rn +/- Displacement o Fragment - decreased signal intensity of meniscal fragment with displacement peripherally o Increased signal of tear within donor meniscus +/tearing of displaced fragment T2WI o +/- Fluid signal intensity in tear plane Specific, not sensitive o Not sensitive for intrasubstance meniscal tear excepl when using T2* GRE sequence
DDx: Meniscal F l a Tear ~
Cor FS P D FSE
Sag P D FSE M R
Sag FS P D FSE
Sag P D FSE M R
Cor P D FSE M R
MENISCAL FLAP TEAR Key Facts Terminology
Pathology
Meniscus oblique tear, meniscus flap tear
Imaging Findings Location: Most commonly affects posterior horn and posterior aspect of body of medial meniscus Variable horizontal, radial components and connecting vertical/oblique components Tear often horizontal on sagittal images originating along the inferior surface at the free edge
Top Differential Diagnoses Horizontal Cleavage Tear Bucket-Handle Tear with Displacement Chondral Lesions Loose Bodies Meniscal Degeneration (Meniscal Degen) o If chronic, increased signal intensity hyperemia in
adjacent tibia, femur = "reactive edema" FS PD FSE shows hyperintense edema PDIIntermediate o Increased signal intensity extending to the articular surface is diagnostic of tear = Vertical peripheral tear giving rise to fragment and donor o Displaced fragment = decreased signal mass +/displacement peripherally Into coronary recess or between meniscofemoral ligament attachment and femur o Increased signal tear within donor meniscus body +/- tearing of displaced fragment TZ* GRE o Increased signal, most often linear, extending to the articular surface = tear o +/- Displaced fragment MR arthrography o Contrast extending into tear o Arthrography typically not necessary Useful in post operative setting Tear often horizontal on sagittal images originating along the inferior surface at the free edge Vertical tear also common involving inner third of meniscus on sagittal images Displaced fragment is decreased in signal intensity on all pulse sequences, located within o Recess formed by the coronary ligament o Meniscofemoral attachment o In case of displaced flap (sequestered fragment) ~
-
Imaging Recommendations Best imaging tool: MRI Protocol advice: Short TE MR images including TZ* GRE (FS PD FSE for meniscal morphology)
I DIFFERENTIAL DIAGNOSIS Horizontal Cleavage Tear Lacks vertical component
rn
General path comments: Complex tear pattern Acutely with a sudden impact on the meniscus usually with a twisting component Insidiously as a result of chronic shear forces across the meniscus
Clinical Issues Most common signs/symptoms: Pain after single traumatic event or insidious onset of pain Joint line tenderness Feeling of "giving way" May progress to displaced flap
Diagnostic Checklist Use sagittal images to predict flap tear pattern
Degenerative tear extending from the free edge apex horizontally into the meniscus No displaced fragment
Bucket-Handle Tear with Displacement Originates from longitudinal vertical peripheral tear Inner fragment displaced Fragment displaced medially into notch (or towards notch)
Bone Trabecular Injuries Direct impact trauma vs. chronic repetitive microtrauma Diffuse increased signal intensity on T2WI FS PD FSE most sensitive Reactive and associated with meniscal tear
Chondral Lesions Hyaline chondral defect +/- Underlying bone marrow edema +/- Other findings of osteoarthritis (OA) Usually no displaced fragment in recesses
Loose Bodies May be displaced into recesses formed by meniscal attachments Often calcified +/- OA No donor meniscal site
Meniscal Degeneration (Meniscal Degen) Increased signal on short TE sequences without extension to surface o Short TE = TI, PD, TZ* GRE o Globular or linear
General Features General path comments: Complex tear pattern Etiology o Acutely with a sudden impact on the meniscus usually with a twisting component
MENlSCAL FLAP TEAR o Insidiously as a result of chronic shear forces across
o Relative deficiency of inner one third of inferior leaf
the meniscus Epidemiology: Most common tear pattern
o Changing slope of superior surface of meniscus as
Gross Pathologic & Surgical Features
with associated blunting evaluated on a sagittal image
Disruption of meniscal surface with variable longitudinal, radial and oblique (flap) components Displaced or coapted flap component
Microscopic Features Mucinous ground substance within fibrocartilaginous meniscus Separating cleavage plane surrounded by regenerative chondrocytes Variable synovial ingrowth Neovascularity in more chronic cases
Staging, Grading or Classification Criteria Classification by surface configuration - tear patterns
2H
(arthroscopic) o Vertical Longitudinal tear (primary tear pattern is in vertical plane) Radial tear o Flap tear (primary tear pattern is in vertical plane) o Horizontal Horizontal cleavage tear Longitudinal tear (primary tear pattern is in horizontal plane) Flap tear (primary tear pattern is in horizontal plane) o Flap tear also referred to as an oblique tear classification based on location-vascular zones o White zone (whitelwhite zone) Central third of meniscus (free edge) Debridement o Red-white junction (redlwhite zone) Middle third between free edge and peripheral third Debridenlent vs. repair Repair if vascular pedicle can be established o Red zone (redlred zone) Peripheral one third ~asiularized Primary repair usually possible if tear confined to redlred zone or peripheral portion of redlwhite zone MRI classification of meniscal signal intensity o Grade 1: Globular increased signal intensity on short TE sequences within meniscus not extending to an articuiar surface o Grade 2: Linear increased signal intensity on short TE sequences not extending to an articular surface o Grade 3: Increased signal intensity on short TE sequences extending to an articular surface o Grade 1 and 2 are often referred to as meniscal degeneration, either globular or linear o Grade 3 signal represents a meniscal tear Criteria for prospective diagnosis (based on sagittal MR images) of flap tear morphology o Vertical tear inner one third of meniscus (coapted vs. noncoapted) o Blunted free edge of meniscus with displaced meniscal tissue inferior to periphery of meniscus
Presentation Most common signs/symptoms: Pain after single traumatic event or insidious onset of pain Clinical profile o Joint line tenderness o Feeling of "giving way" o Clicking o Locking with displaced fragment o "Pseudolocking"if hamstring spasm is present
Demographics Age: Adult (peak age: 31-40 years for men and 11-20 years for women) Gender: No predilection
Natural History & Prognosis May progress to displaced flap
Treatment Meniscal repair, debridementlpartial meniscectomy o Partial meniscectomy for short flap tears o Repair for long tears to prevent loss of meniscal function
1 DIAGNOSTIC CHECKLIST Consider Differentiate from horizontal cleavage tear Flap tear = oblique tear pattern
Image Interpretation Pearls Identify displaced flap especially within the coronary recess Use sagittal images to predict flap tear pattern
1 SELECTEDREFERENCES Boyd KT et al: Meniscus preservation: Rationale, repair techniaues and results. 1011):l-11. 2003 ~, Jee wH' et al: Meniscal tear confi&rations: Categorization with MR imaging. AJR 180(1):93-7, 2003 Greis PE et al: Meniscal injury: Management. J Am Acad Orthop Surg 10(3):177-87, 2002 Anderson MW: MR imaging of the meniscus. Radio1 Clin North Am 40(5):1081-94, 2002 Matava MJ et al: Magnetic resonance imaging as a tool to predict meniscal reparability. Am J Sports Med. 27(4):436-43,1999 Stoller DW et al: Magnetic resonance imaging in orthopaedics and sports medicine. vol 1. 2nd ed. Philadelphia PA, J.B. Lippincott, 203-442, 1997 Shino K et al: Arthroscopic repair for a flap tear of the posterior horn of the lateral meniscus adjacent to its tibia1 insertion. Arthroscopy 11(4):495-8, 1995 Belzer JP et al: Meniscus Tears: Treatment in the stable and unstable knee. J Am Acad Orthop Surg 1(1):41-7, 1993
I I IMAGE GALLERY
MENlSCAL FLAP TEAR
(Left)Sagittal graphic shows both a vertical and horizontal components to a flap tear. Note the blunting of the free edge of the inferior leaf (arrow). (Right) Sagittal PD FSE MR shows a slightly displaced flap tear of the medial meniscus with characteristic vertical signal intensity involving the inner third of the meniscal fibrocartilage.
Tvnical
(Left) Sagittal PD FSE MR shows a large displaced meniscal flap (arrow) into a posterior superior recess adjacent to the posterior horn of the medial meniscus. (Right) Coronal FS PD FSE MR shows the large flap tear (arrow) extending into the notch of the knee
(Left) Coronal FS PD FSE MR shows a displaced flap (arrow) of inferior leaf into the recess formed by coronary ligament adjacent to body of medial meniscus with adjacent reactive hyperemia in the medial and proximal tibia. (Right) Axial FS PD FSE MR shows reactive hyperemia of medial tibia (arrow) as well as hyperemic vessel recruitment of the proximal medial tibia. Edema is likely a stress related response secondary to meniscal instability and load transference.
-
MENlSCAL BUCKET-HANDLE TEAR
Axial oblique graphic shows a displaced bucket-handle tear of the medial meniscus.
Coronal FS PD FSE MR shows a displaced bucket-handle fragment (arrow) of the medial meniscus into the intercondylar notch of the knee. The remnant of the body of the meniscus is small.
o Displaced fragment attached to donor meniscus at
both ends Free at one end = displaced flap
Abbreviations and Synonyms Bucket-handle tear (BHT) 30
CT Findings NECT o Displaced bucket-handle fragment - low density mass with variable displacement towards or into notch o Coronal and sagittal reconstructions helpful CT arthrography o Contrast extends into tear within donor meniscus body +/- tearing of displaced fragment
Definitions Vertical peripheral tear with displaced mesial portion to the notch of knee
General Features Best diagnostic clue o Coronal images show small meniscus body and meniscal fragments at the notch resulting in 2 meniscal fragments o Double posterior cruciate ligament (PCL) sign on sagittal images Location: Medial > lateral meniscus Size: 2-5 mm displaced fragment (most common) Morphology o Displaced meniscus fragment resembles the handle of a bucket Donor meniscus (residual body), remains in place - bucket o Displaced fragment partially displaced or displaced to the notch of knee
M R Findings TlWI o Increased signal on short TE sequences extending to the articular surface = tear Vertical longitudinal tear giving rise to fragment and donor o Displaced bucket-handle fragment - decreased signal mass with variable displacement towards or into notch o Increased signal tear within donor meniscus body +/- tearing of displaced fragment T2WI o Not as sensitive for intrasubstance meniscal signal or tear unless T2* GRE sequence is used o Sensitive for morphology of meniscal fragments
DDx: Meniscal Bucket-Handle Tear Chron~cTorn ACL
0bl Intramen tig
Oh! Intramen Liq
,. <
im I
I
I
.Sag T2 FSE M R
Ax FS
PD FSE M R
Cor
PD FSE M R
Cor
-PD FSE M R
Cor PD FSE M R
.
MENlSCAL BUCKET-HANDLE TEAR Key Facts Terminology Vertical peripheral tear with displaced mesial portion to the notch of knee
Imaging Findings Coronal images show small meniscus body and meniscal fragments at the notch resulting in 2 meniscal fragments Location: Medial > lateral meniscus "Double PCL sign": Displaced fragment beneath the PCL at the notch of knee resembling two PCL ligaments "Double delta sign": Flipped inner meniscal fragment adjacent to anterior horn of the donor meniscus producing two triangle shaped structures adjacent to each other anteriorly
o 3rd structure in notch (besides ACL & PCL) o Chronic, increased signal intensity hyperemia in adjacent tibia, femur = "reactive edema" PDIIntermediate o +/- Displaced bucket-handle fragment - hypointense meniscal fragment o Increased signal tear within donor meniscus body +/- Tearing of displaced fragment o +/- Displaced anterior horn: Anterior to the bucket-handle fragment T2* GRE o 3D T2* GRE axial images provide direct visualization of bucket-handle tear pattern o Displaced bucket-handle fragment - best visualized on coronal and sagittal images o +/- Donor meniscus body tear o +I-Tearing of displaced fragment MR arthrography o Displaced bucket-handle fragment - surrounded by contrast o Contrast extends into tear within donor meniscus body +/- tearing of displaced fragment "Double PCL sign": Displaced fragment beneath the PCL at the notch of knee resembling two PCL ligaments "Double delta sign": Flipped inner meniscal fragment adjacent to anterior horn of the donor meniscus producing two triangle shaped structures adjacent to each other anteriorly Coronal and sagittal images demonstrate blunting of the meniscus donor with the remaining meniscus smaller than normal Axial images show fragment as deceased signal intensity linearlfusiform mass on all pulse sequences
Imaging Recommendations Best imaging tool: MRI Protocol advice o Sagittal and coronal images (T2* GRE, PD & FS PD FSE) 0 Axial FS PD FSE or 3D T2* GRE to show circumferential morphology of the bucket-handle tear
Top Differential Diagnoses Oblique Intermeniscal Ligament
Pathology General path comments: Typically an acute meniscal tear Displaced inner fragment of a vertical longitudinal tear of the meniscus
Clinical Issues Painllocking after single traumatic event Locking, typically a block preventing full extension
Diagnostic Checklist Evaluate coronal and sagittal images for extra fragment within the intercondylar notch
I DIFFERENTIAL DIAGNOSIS Oblique lntermeniscal Ligament Normal ligament extending between the menisci mimicking a displaced fragment o Anterior horn of the lateral meniscus to the posterior horn of the medial meniscus 0 Anterior horn of the medial meniscus to the posterior horn of the lateral meniscus o Both present rarely o Beneath synovium at arthroscopy The menisci are normal in size without a recognizable donor site
Scarred Chronic Disruption of the Anterior Cruciate Ligament (ACL) Normally two structures in the notch (ACL and PCL) o Bucket-handle = 3rd structure in notch History of trauma Associated typical bone injuries +/- Meniscal tear (non bucket handle) Torn ACL one of two structures in notch when bucket-handle tear not present
Meniscal Flap Tear A potential cause of locking of the knee joint Vertical peripheral tear, complex tear with horizontal, radial, +/- longitudinal components Anterior extension of the displaced flap is not seen
I PATHOLOGY General Features General path comments: Typically an acute meniscal tear Etiology: Acutely with sudden impact splitting the meniscus longitudinally Epidemiology: Relatively uncommon meniscal tear
Gross Pathologic & Surgical Features Displaced inner fragment of a vertical longitudinal tear of the meniscus
MENlSCAL BUCKET-HANDLE TEAR Disruption of meniscal surface typically with a long longitudinal component involving the entire meniscus
Microscopic Features Mucinous ground substance within the fibrocartilaginous meniscus with a separating cleavage plane surrounded by regenerative chondrocytes Variable degrees of synovial ingrowth Neovascularity in more chronic cases
Staging, Grading or Classification Criteria Classification by surface morphology - tear patterns (bucket-handle = displaced longitudinal tear) o Vertical
32
Longitudinal tear (primary tear pattern is in vertical plane) Flap tear (primary tear pattern is in vertical plane) Radial tear o Horizontal Horizontal cleavage tear Longitudinal tear (primary tear pattern is in horizontal plane) Flap tear (primary tear pattern is in horizontal plane) Classification of bucket-handle tears o Vertical longitudinal tears Single vertical longitudinal tears Displaced bucket-handle tears Broken bucket-handle tears o Horizontal (or cross section) longitudinal (circumferential)tears Also produces a nondisplaced or displaced bucket-handle tear Residual horizontal tear component seen in posterior horn Classification based on location-vascular zones o White zone (whitelwhite zone) Free edge one third Debridement o Red-white junction (redlwhite zone) Middle third between free edge and peripheral third Debridement vs. repair Repair especially if vascular pedicle can be established o Red zone (redlred zone) Peripheral third Vascularized Primary repair usually possible if tear confined to redlred zone or peripheral portion of redlwhite zone
Presentation Most common signs/symptoms o Pain/locking after single traumatic event o Difficulty in ambulation secondary to extension block If displaced to central weightbearing surface or notch Clinical profile o Joint line tenderness
o Feeling of "givingway" o Clicking o Locking, typically a block preventing full extension
Results in difficulty in ambulation
Demographics Age: Usually younger patient, physically active Gender: M > F
Natural History & Prognosis Displacement leads to locked knee o Surgery necessary o Extension block
Treatment Repair if nondisplaced and affects the peripheral vascularized zone "red zone" o MR arthrography sometimes requested to check status of repaired meniscus Excision of fragment if tear extends through nonvascularized free edge or if fragment is separated from parent meniscus
Consider Oblique intermeniscal ligament Torn and chronically scarred ACL
Image Interpretation Pearls Evaluate coronal and sagittal images for extra fragment within the intercondylar notch
Elliott JM et al: MR appearances of the locked knee. Br J Radio1 73(874):1120-6, 2000 Sanders TG et al: Oblique meniscomeniscal ligament: Another potential pitfall for a meniscal tear--anatomic description and appearance at MR imaging in three cases. Radiology 213(1):213-6,1999 Helms CA et al: The absent bow tie sign in bucket-handle tears of the menisci in the knee. AJR 170(1):57-61, 1998 Belzer JP et al: Meniscus tears: Treatment in the stable and unstable knee. J Am Acad Orthop Surg 1(1):41-7,1993 Singson RD et al: MR imaging of displaced bucket-handle tear of the medial meniscus. Am J Roentgen01 156(1):121-4,1991 Dandy DJ: The arthroscopic anatomy of symptomatic meniscal lesions. J Bone Joint Surg Br 72(4):628-33, 1990 Stoller DW et al: Meniscal tears: Pathologic correlation with MR imaging. Radiology 163(3):731-5, 1987 Northmore-Ball MD et al: Arthroscopic, open partial, and total meniscectomy. A comparative study. J Bone Joint Surg Br 65(4):400-4,1983 Sprague NF 111: The bucket handle meniscal tear. A technique using two incisions. Orthop Clin North Am 13(2):337-48, 1982
MENlSCAL BUCKET-HANDLE TEAR IMAGE GALLERY Variant
(Lef)Axial oblique graphic shows a longitudinal tear of the lateral meniscus with a flipped anterior horn into the central portion of the lateral compartment. (Right) Sagittal PD FSE MR shows a "double delta " sign referring to a displaced posterior horn (arrow) compressing the free edge of the more anteriorly located anterior horn.
(Left) Sagittal PD FSE MR shows a bucket-handle fragment at the notch of knee producing a "double PCL" and a "double delta " (arrow) at the anterior aspect of the notch of knee indicating a displaced fragment. (Right) Sagittal PD FSE MR shows a small medial meniscus remnant indicating loss of meniscal tissue.
(Lef)Coronal PD FSE MR shows a displaced medial meniscus bucket-handle fragment (arrow) at the notch of the knee producing an additional structure within the notch of the knee besides the ACL (graft) and PCL. (Right) Coronal PD FSE MR shows the 2 normal structures of the notch, the ACL and PCL, as well as a bucket-handle fragment (arrow).
Sagittal graphic shows a tear of the meniscofemoral portion of the deep capsular attachment of the meniscus.
Coronal PD FSE MR shows a tear of the meniscofemoral attachment (arrow) from the femoral origin. There is medial meniscal subluxation.
CT Findings Abbreviations and Synonyms Capsular sprain, fascicle tear, meniscocapsular separation (MCS) 34
Definitions Tear of the supporting meniscotibial (coronary) or meniscofemoral ligaments typically at attachment to meniscus
General Features Best diagnostic clue: Disruption of capsular attachment of meniscus, in trauma, with irregularity, and increased signal intensity within meniscofemoral or coronary ligament on T2WI Location: Most commonly adjacent to posterior horn/posterior aspect of body of medial meniscus Size: Varies from a few mms to more extensive tearing > 1 cm in size Morphology: Loss of normal linear ligamentous attachment
Radiographic Findings Radiography: +/- Associated fracture
CT arthrography o Extravasation of contrast through defect
MR Findings TlWI o +/- Associated meniscal tear Increased signal extending from meniscal substance to articular surface o Capsule thickened - decreased signal intensity o Associated fracture - decreased in signal intensity +/- Surrounding hypointense edema T2WI o Irregularity + increased signal intensity within meniscofemoral or coronary ligament especially on T2WI o Hyperintense fluid interposed between peripheral portion of posterior horn of medial meniscus and joint capsule Coronal & sagittal T2WI (FS PD FSE) +/- Surrounding hyperintense edema FS PD FSE more sensitive than PD FSE or T2* GRE o Osseous fx or contusion - increased in signal intensity o Medial collateral ligament (MCL) tear + meniscocapsular separation are associated injuries T2* GRE
-
DDx: Meniscocapsular Separation Longttud~nalTear
Sag FS P D FSE
Sag FS P D FSE
Sag FS P D FSE
Sag P D FSE MR
Key Facts Terminology
,
Tear of the supporting meniscotibial (coronary) or meniscofemoral ligaments typically at attachment to meniscus
Imaging Findings Best diagnostic clue: Disruption of capsular attachment of meniscus, in trauma, with irregularity, and increased signal intensity within meniscofemoral or coronary ligament on T2WI Meniscofemoral ligament tear frequently seen with medial collateral ligament disruption +/- Meniscal corner tear
Top Differential Diagnoses Popliteus Hiatus
o Increased signal intensity edema interposed between
peripheral portion of posterior horn of medial meniscus and joint capsule (TZ* GRE improves visualization of intrameniscal signal) Coronal & sagittal images o +/- Linear hyperintensity meniscal tear Increased signal extending from meniscal substance to articular surface MR arthrography o Interposition of contrast between the meniscus and the MCL Loss of the normal decreased signal intensity linear appearance of meniscal attachments (TI ST T2WI) Displacement of the posterior horn of the medial meniscus by 2 5 mm o Measurement of this distance has been found to be unreliable Uncovering of the articular cartilage of the tibia o Nonspecific Meniscofemoral ligament tear frequently seen with medial collateral ligament disruption A free floating meniscus or flipped meniscus, indicates a meniscocapsular disruption Adjacent bone injury (contusion) is common o Edema visualized on fast spin echo images with fat saturation +/- Meniscal corner tear
lmaging Recommendations Best imaging tool: MR Protocol advice o PD FSE or FS PD FSE o Radial imaging to define meniscocapsular attachments
1 DIFFERENTIAL DIAGNOSIS Popliteus Hiatus Normal hiatus laterally and posteriorly where the popliteus tendon pierces the capsule Posterolateral location Without history of trauma not likely to be tear
Fluid Distending the Normal Meniscal Attachment Recesses MCL Bursitis
Clinical Issues Tenderness and pain at site of the tear Less than 1 cm tear owing to a propensity to heal secondary to rich vascularity of peripheral aspect of meniscus Large tears are repaired
Diagnostic Checklist Bone injury of adjacent tibia is "signpost"often indicating injury to the meniscal attachments Always correlate meniscocapsular signal between sagittal and coronal images to increase diagnostic specificity
Fascicles at this location can be torn in setting of trauma adjacent to the normal hiatus o Discontinuity of fascicles o Loss of the normal decreased signal intensity (all pulse sequences) linear ligamentous attachment o Hemorrhage and surrounding edema A vertical longitudinal tear is frequently located parallel to the popliteus hiatus
Fluid Distending the Normal Meniscal Attachment Recesses Visualized laterally Rarely adjacent to the medial meniscus o Large or chronic effusion
MCL Bursitis Fluid between deep and superficial components of MCL +/- Meniscal tear Post traumatic o +/- Hemorrhage Increased signal on T2WI
Meniscal Tear and Cyst Meniscal tear usually visualized Extends between deep and superficial MCL Round or flattened cystic appearing mass o Increased signal intensity on T2WI
MCL Superficial Tear, Joint Effusion Difficult to distinguish Valgus injury Hyperintense on T2WI
1 PATHOLOGY General Features General path comments o MCS originates as a tear of capsular attachment usually involving the posterior horn of the medial meniscus o Multiple tears can occur and size varies o Trauma
Twisting injury or impaction
o Less than 1 cm tear owing to a propensity to heal
secondary to rich vascularity of peripheral aspect of meniscus Fibrinogenic and other healing agents due to increased vascularity in this location (perimeniscal capillary plexus) Surgical o Large tears are repaired Complications: Failure to diagnose or inadequate repair may lead to meniscal instability o Subluxation o Displacement o Flipped meniscus
o Associated with an anterior cruciate ligament (ACL)
andlor MCL tears 0 Associated with small "corner fracture tear" of the adjacent meniscus o The lateral capsule is more loosely attached to the lateral meniscus than is the medial attachments The lateral attachments may balloon out when filled with fluid + Effusion Should not be misinterpreted as a tear Etiology o Injuryltrauma: Twisting injury to knee o MCL and deep medial capsular layer injured with valgus torque to the knee o Direct blow to lateral knee with the foot planted o Noncontact injuries ACL injury mechanism Epidemiology: Less common than superficial MCL tears
Consider In the setting of trauma Pseudolesions o Popliteus hiatus o Fluid distending the normal meniscal attachment recesses
Gross Pathologic & Surgical Features Disruption of the meniscotibial attachment, meniscofemoral attachment or both Variable amounts of hemorrhage and swelling Associated ACL tear usually present with tears of the meniscotibial, meniscofemoral ligament or intrasubstance tear of the meniscus
Image Interpretation Pearls Bone injury of adjacent tibia is "signpost"often indicating injury to the meniscal attachments Meniscocapsular separation may be overestimated because knee is imaged in excessive external rotation Always correlate meniscocapsular signal between sagittal and coronal images to increase diagnostic specificity
Microscopic Features ~ i s r u ~ t i oofncollagenous, ligamentous structure(s) Variable surrounding hemorrhage, edema and inflammatory cells
Staging, Grading or Classification Criteria Tear less than 1 cm is often left alone because of propensity to heal due to rich vascularity of meniscal rim at the site of sprain Tear greater than 1 cm may be surgically addressed (repaired) if discovered at arthroscopy
1. 2. 3.
Presentation Most common signslsymptoms o Tenderness and pain at site of the tear Nonspecific and may represent pain from other damaged structures Clinical profile: Usually seen post trauma in young, active patients, especially athletes
Demographics Age: Younger, physically active patient Gender: M > F
Natural History & Prognosis May heal especially if less than 1 cm in size If large may lead to unstable meniscus Excellent if the tearlseparation is small Meniscal instability if large and unrecognized
Treatment Conservative
4.
5. 6. 7.
De Maeseneer M et al: Normal and abnormal medial meniscocapsular structures: MR imaging and sonography in cadavers. Am J Roentgenol 171(4):969-76, 1998 Stoller DW et al: Magnetic resonance imaging in orthopaedics and sports medicine. vol 1. 2nd ed. Philadelphia PA, J.B. Lippincott, 203-442, 1997 Applegate GR et al: MR diagnosis of recurrent tears in the knee: Value of intraarticular contrast material. Am J Roentgenol 161(4):821-5,1993 Kimura M et al: Anatomy and pathophysiology of the popliteal tendon area in the lateral meniscus: Clinical investigation. Arthroscopy 8(4):424-7, 1992 Stoller DW et al: Meniscal tears: Pathologic correlation with MR imaging. Radiology 163(3):731-5, 1987 El-Khoury GY et al: Meniscotibial (coronary) ligament tears. Skeletal Radio1 11(3):191-6,1984 Woods GW et al: Repairable posterior menisco-capsular disruption in anterior cruciate ligament injuries. Am J Sports Med 12(5):381-5, 1984
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MENlSCOCAPSULAR SEPARATION IMAGE GALLERY (Left) Coronal oblique graphic shows edema within the coronary (open arrow) and meniscofemoral (arrow) attachments of the medial meniscus associated with a grade I MCL sprain. (Right) Coronal FS PD FSE MR shows disruption of the lateral and medial meniscofemoral attachments (arrows) associated with lateral and medial collateral ligament injuries.
(Left) Sagittal FS PD FSE MR with a sprain of the coronary ligament attachment to the posterior horn of the medial meniscus. Trabecular injury of the posterior corner of the medial tibia is also noted (arrow) and commonly seen with ACL tears. (Right) Sagittal FS PD FSE MR shows a sprain of the coronary ligament (arrow) adjacent to a posteromedial tibia1 corner injury. There is a meniscal tear and small trabecular contusion of the femur associated.
(Lefl) Sagittal FS PD FSE MR shows tear of coronary ligament (arrow) adjacent to attachment on the posterior horn of lateral meniscus. (Right) Sagittal graphic shows normal popliteus hiatus. Tendon pierces superior capsule lat. (# 1 ) then travels through popliteus tendon sheath (#2) in communication with joint. Tendon pierces infer. meniscal attachment (coronary lig.) med. (#3).
POST-OPERATIVE MENISCUS CHANGE
Sagittal graphic shows a meniscal tear trimmed back to intact meniscus. Note small amount of residual degeneration in post operative meniscus which may lead to increased signal.
5 -1 R
Abbreviations and Synonyms Post op meniscus, post debridement meniscus Status post (Slp) surgery, post arthroscopy, S/p arthroscopy, S/p Sx (surgery),post meniscectomy, S/p meniscectomy
Sagittal PD FSE MR shows changes from a partial meniscectomy of the posterior horn medial meniscus with no residual degeneration.
o After partial or complete (usually near complete) meniscectomy the meniscus is blunted o Regenerating meniscus is usually dark but smaller than normal meniscus
M R Findings TlWI o Small meniscus +I-blunting = partial
meniscectomy/debridement
Definitions Meniscus that has been either repaired (primary repair) or partialltotal meniscectomy has been performed
General Features Best diagnostic clue: Blunted appearance of meniscus,
+/- micrometallic artifact Location: Medial, lateral meniscus, any location Size o Size of repair/resection area varies depending upon the amount of surgery performed Depends on size of the original tear or amount debrided or resected Morphology o After primary repair the meniscus shape is preserved +I-surrounding metal artifact
o Free edge irregularity = fraying
o Linear increased signal +/- surface extension residual tear vs. recurrent tear +/- Arthrography to distinguish Discrete linear signal on short TE sequence Pre-existing meniscal signal changes mistaken for remnant tears T2WI o Fluid signal intensity extending into the meniscus on T2WI 90% specific, 40-70s sensitive for retear o Grade 3 signal intensity in primary meniscal repair represents fibrovascular healing response without retear PDIIntermediate o Small meniscus +/- linear increased signal extending to surface o - 70% sensitive for retearing o +/- Susceptibility artifact in cases of meniscal repair of red zone tears
DDx: Post-Operative Meniscus Change Radial Tear
Bucket Remnant
Sag PD FSE MR
Sag PD FSE MR
h w d Remnant
Cor PD FSE MR
Sag PD FSE
OA D P Men ~
Cor PD FSE
POST-OPERATIVE MENISCUS CHANCE Key Facts Terminology Meniscus that has been either repaired (primary repair) or partialltotal meniscectomy has been performed
Imaging Findings Best diagnostic clue: Blunted appearance of meniscus, +/- micrometallic artifact Fluid signal intensity extending into the meniscus on T2WI New area of high signal
Top Differential Diagnoses Displaced Flap Tear of Meniscus Chondrocyte "Healing" of the Tear or Area of Degeneration
Usually longitudinal tears o Residual grade 3 signal without imbibed fluid may
exist in meniscal remnant o Evaluate collagen meniscus implants (CMI) and
meniscal transplants T2* GRE: Susceptibility may obscure recurrent tear in case of meniscal repair MR arthrography o Dilute gadolinium into meniscus at site of retear or new tear in previously normal area of the meniscus o Dilute gadolinium - increased signal intensity on T1 and proton density weighted images o 88-95% sensitivity New area of high signal o Previous study to directly compare Displaced meniscal fragment (decreased signal intensity structure) on all pulse sequences Regenerating meniscus (at the vascularized rim - "red zone") o Fibrous in composition o Generally decreased or intermediate in signal intensity on all pulse sequences Primary meniscal repairs +/ - diffuse or linear high signal (residual degeneration), on short TE sequence Short TE sequences - 70% sensitive in the setting of discrete signal abnormality MRI 66% accuracy overall in the post operative meniscus setting without arthrography
Imaging Recommendations Best imaging tool: In the setting of prior partial or complete meniscectomy, MRI arthrography or FS PD FSE recommended Protocol advice o Most accurately diagnosed on short TE MR images TI, PD, FS PD FSE or GRE sequences
I
Displaced Flap Tear of Meniscus Blunted appearance of the meniscal free edge
Pathology Meniscal retear originates as a small split of meniscus at site of the old tear or in a new location Meniscal tear may undergo healing by fibrosis if the tear involves the vascularized "red zone" Healing tear may be blunted or irregular and still be intact
Clinical ~ S S U ~ S Most common signs/symptoms: Post operative pain Arthritis Loose body - causes grinding, locking, pain
Diagnostic Checklist Recurrent symptoms after meniscal surgery Consider MR arthrography in post-op setting
With or without surgical changes elsewhere in the knee
Chondrocyte "Healing"of the Tear or Area of Degeneration Leading to recurrent or persistent intermediate signal at the former tear site (TI& T2WI) MR arthrography to identify free influx of contrast
Bucket-Handle Tear in Post Operative Setting Where a Meniscal Repair was not Performed Leaves a small meniscal remnant mimicking a partial meniscectomy Radial tear Partial remnant visualized as a foreshortened meniscus
Osteoarthritis (OA) +/- New degeneration, osteophytes
General Features General path comments o Meniscal retear originates as a small split of meniscus at site of the old tear or in a new location o Simple/or complex pattern retear o Meniscal tear may undergo healing by fibrosis if the tear involves the vascularized "red zone" Peripheral one third o Tear may heal with increased regenerative chondrocyte activity Decreased signal intensity relative to original tear Etiology: Post operative state Epidemiology o Meniscal tears - 50% of knee injuries that require surgery o Healing rate 90% for lesions in 3 mm peripheral location o Healing rate 50-60% for treated lesions 5 mm or greater from periphery
POST-OPERATIVE MENISCUS CHANGE o Meniscal retear o Development or progression of arthritis o Malalignment develops o Osteonecrosis (possible stress or insufficiency
Gross Pathologic & Surgical Features Meniscal retear - disruption of meniscal substance Healing tear may be blunted or irregular and still be intact
fracture) o Arthrofibrosis (adhesions)
Microscopic Features
Fragment from retear may displace transiently giving a locked knee presentation (posterior spring sign) Meniscectomy outcome generally favorable but these results may deteriorate over time Variations in outcome attributed to a poor prognosis o Amount of meniscus resected; greater amount resected o Degree of preexisting arthritic change Greater the degree of preexisting arthritis o Limb alignment Greater the degree of preexisting malalignment o Location of meniscal tear Lateral meniscus surgery (increased incidence of lateral compartment arthrosis) o Ligamentous instability Greater the degree of preexisting ligamentous instability o Age: Increased age at time of operation
Meniscal retear Mucinous ground substance within the fibrocartilaginous meniscus With a separating cleavage plane surrounded by regenerative chondrocytes and fibrosis Peripheral synovial ingrowth Regenerating meniscus (at the vascularized rim - red zone) o Composed of fibrous tissue o Typically smaller than adjacent meniscus
Staging, Grading or Classification Criteria
El
Meniscal shape and post operative arthritis (Smith and colleagues) o Group I menisci - near normal length, no osteoarthritis o Group I1 menisci - significantly shortened menisci, no osteoarthritis o Group 111 menisci - any length but with superimposed osteoarthritis
Treatment Conservative o If retear is isolated to the peripheral one third ("red zone"), small in size (uncommon) Surgical o Reoperation of those tears that are amenable to meniscal resectionldebridement back to stable meniscus Complications following surgery o 13% incidence o Osteonecrosis Esp. in older patients, post meniscal surgery May represent insufficiency fractures of weightbearing surface in osteoporotic especially immobile patients o Arthrofibrosis (adhesions) o Deep venous thrombosis
40
Presentation Most common signslsymptoms: Post operative pain Clinical profile: Patients of any age who have had meniscal surgery Retear of meniscus o Tenderness at joint line adjacent to apex of the tear Due to the greatest tension being exerted on the surrounding nerve fibers o Joint line tenderness and often positive clinical meniscal testing Positive McMurray's test, Steinmann's test and Apley's test Displaced meniscal fragment - locking if the inner fragment becomes displaced Arthritis o Grinding, pain locking o Patients with preexisting arthritic change may have a greater propensity to progression of arthritis after meniscectomy than individuals without preexisting disease Loose body - causes grinding, locking, pain Malalignment o Preexisting or the result of meniscectomy
Consider Recurrent symptoms after meniscal surgery
Image Interpretation Pearls Consider MR arthrography in post-op setting FS PD FSE demonstrates post operative meniscal morphology
Demographics Age: No predilection Gender: No predilection
Natural History & Prognosis Patients status post meniscal surgery may show resolution of symptoms or recurrent symptoms o Abnormal intermediate to hyperintense signal may persist up to 27 months postoperatively Causes of recurrent symptoms include
1. 2. 3.
Rangger C et al: Osteoarthritis after arthroscropic partial meniscectomy. Am J Sports Med 23:240, 1995 Applegate GR et al: MR diagnosis of recurrent tears in the knee. Value of intraarticular contrast material. AJR 161(4):821-5,1993 Ihn JC et al: In vitro study of contact area and pressure distribution in the human knee after partial and total meniscectomy. Int Orthop 17(4):214-8,1993
POST-OPERATIVE M E N I S C U S C H A N C E
Variant (Left) Sagittal graphic shows an irregular free edge of the rneniscus after debridement. This will mimic free edge fraying at MRI evaluation. (Right) Sagittal PD FSE MR shows degeneration of the rneniscus remnant with fraying (arrow) of the free edge and inferior surface.
(Left) Sagittal PD FSE MR shows linear increased signal intensity within posterior horn meniscal remnant. This appearance is associated with a 70% sensitivitv for retear at second look arthroscopy. (Right) Sagittal PD FSE MR shows a healing cleft within the posterior horn of the medial meniscus remnant. There was no retear at arthroscopy and in this case MR arthrography would be of benefit to exclude a retear.
( L e f ) Sagittal PD FSE MR shows a failed repair of the posterior horn of the medial meniscus with a displaced fragment (arrow) flipped superior to the posterior horn. (Right) Coronal PD FSE MR shows the displaced meniscal fragment (arrow) from a failed repair adjacent to the posterior horn at the meniscotibial attachment.
ANTERIOR CRUClATE LlCAMENT (ACL) TEAR
Coronal graphic shows a grade 111 tear of the proximal aspect of the anterior cruciate ligament.
Sagittal FS PD FSE MR shows a grade 111 tear (arrow) of the anterior cruciate ligament resulting in a "blowout" appearance. This is often seen in contact sports and downhill snow skiing.
Avulsion of meniscotibial portion of the middle third of lateral capsular ligament from the lateral tibial plateau
Abbreviations and Synonyms ACL tear, ACL rupture
CT Findings
Definitions Disruption of ACL
'
General Features Best diagnostic clue: Disruption of normal continuous low signal intensity ACL with irregularity and increased signal on T2WI Location: ACL in the intercondylar notch of knee Size: Tear may be small discrete or complete "blowout" Morphology o Disruption of linear ligament appearance o Torn ligament no longer parallel to Blumensaat's line (intercondylar notch roof angle)
Radiographic Findings Radiography o Deepening of the lateral femoral condylar notch "lateral notch sign" of the condylopatellar sulcus terminalis Depression > 1.5 mm in depth at sulcus terminalis o Segond fracture (associated with ACL tear)
NECT o Associated fractures rn Posterolateral and posteromedial tibia Sulcus terminalis of lateral femoral condyle CT arthrography o Chondral defects seen as contrast collection/ulceration of articular surface
MR Findings TlWI o Intermediate signal intensity of disrupted pattern of ACL fascicles o Bone injuries appear as hypointense edematous contusions rn +/- Fracture (nondisplaced) T2WI 0 Increased signal intensity with disorganized and thickened fibers + discontinuity 0 Increased signal intensity with or without fracture lines or subchondral contusions involving The posterolateral corner of tibia Lateral femoral condyle = +/- Posteromedial tibial plateau
DDx: Anterior Cruciate Ligament (ACL) Tear Partial PL Bundle
Sag FS PD FSE
Sag FS PD FSE
Sag FS PD FSE
Radial Tear Lt Mn
B-H Meniscal Tear
Cor FS PO FSE
Sag PD FSE MR
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ANTERIOR CRUClATE LIGAMENT (ACL) TEAR Key Facts Terminology
Pathology Tears are most commonly caused by forward translation of the tibia, external rotation of the femur with respect to the tibia, valgus stress and axial loading
Disruption of ACL
Imaging Findings Best diagnostic clue: Disruption of normal continuous low signal intensity ACL with irregularity and increased signal on T2WI Size: Tear may be small discrete or complete "blowout" Segond fracture (associated with ACL tear) Avulsion fracture of anterior tibial spine (especially in children)
Top Differential Diagnoses Partial Tear Bucket-Handle Meniscal Tear Mucoid Degeneration of ACL (Mucoid Degen) o Axial images - thickening and increased signal
intensity adjacent to the lateral intercondylar notch wall Normal ligament - flat, decreased in signal intensity adjacent to lateral wall of intercondylar notch o Coronal images show increased signal intensity replacing normal hypointense ligament o Increased signal intensity hemorrhagic effusion common o FS PD FSE sensitive for hyperintense edema associated with ACL tear T2* GRE o Associated fractures as increased signal line Not sensitive for bone edema Disruption of normal linear low signal intensity ligament within the notch of knee on all sequences Avulsion fracture of anterior tibial spine (especially in children) Buckling of posterior cruciate ligament (PCL) on sagittal images due to anterior translation of tibia Difficult to identify ACL fiber morphology secondary to increased sensitivity to ligamentous edema on T2* GRE or STIR
Imaging Recommendations Best imaging tool: MRI Protocol advice o Sagittal axial and coronal FS PD FSE and Tl/PD FSE for detection of tear o Coronal images very sensitive to partial ACL tears on T1 or PD FSE images (intermediate signal within normally hypointense ligament)
Partial Tear May be difficult to diagnose on MRI o Grade I vs. grade I1 partial tears Thickening, disruption or abnormal orientation of some fibers
Clinical Issues
+
Anterior drawer sign (forward translation of tibia) Lachman's test (drawer test performed with 15 to 30 degrees knee flexion) ACL reconstruction in active patients
Diagnostic Checklist Coronal images can increase sensitivity and specificity for the detection of partial (grade I and 11) ACL tears
Anteromedial bundle (AM) disruption more common than posterolateral (PL) bundle disruption
Bucket-Handle Meniscal Tear Bucket-handle fragment mimics chronically torn, fibrotic ACL Horizontally oriented fragment seen as "extra structure" in the notch in addition to ACL and PCL Difficult to identify on clinical exam in setting of an ACL tear
Mucoid Degeneration of ACL (Mucoid Degen) Expands ligament Increased signal within ligament on T2WI (FS PD FSE) "Celery stalk" appearance of fluid + ACL fascicles
Radial Tear Lateral Meniscus (Radial Tear Lt Mn) Associated with ACL tear Posterolateral pain
1 PATHOLOGY General Features General path comments o Most commonly disrupted ligament in the knee o Partial tear may affect posterolateral bundle or anteromedial bundle Bundles not histologically distinct Posterolateral bundle tightened in extension, larger and bulkier than anteromedial bundle Anteromedial band = primary restraint against anterior translation of tibia on the femur when anterior drawer test performed in usual manner (the knee flexed) Etiology o Three common mechanisms of injury (force that stresses the ligament and exceeds its capacity to maintain integrity)
ANTERlOR CRUCIATE LIGAMENT (ACL) TEAR Joint effusion in the acute case Anterior drawer sign (forward translation of tibia) Lachman's test (drawer test performed with 15 to 30 degrees knee flexion) Pivot shift test - applied valgus force during flexion and extension to accentuate subluxation or reduction of the tibia KT-1000 arthrometry for partial tears vs. complete tears Clinical profile o Athletically active individuals o Common injury in sports activities characterized by rapid stopping, starting and pivoting Snow skiing, soccer, football, basketball, tennis
o Tears are most commonly caused by forward
translation of the tibia, external rotation of the femur with respect to the tibia, valgus stress and axial loading Associated with posterolateral corner injury and lateral femoral condylar injury Seen with foot plant and external rotation of the thigh o Varus stress (associated with Segond fracture) o Hyperextension (uncommon) Epidemiology o Common injury especially in sports where foot plant is a risk Football, soccer, rugby, snow skiing and tennis o Incidence in general population is 1 in 3000 Associated abnormalities o Bone trabecular injuries or impaction fractures of the posterolateral tibia and weight-bearing surface of lateral femoral condyle (sulcus) o Meniscal tears (lateral greater than medial) o Posterolateral corner injuries rn Lateral collateral ligament Arcuate ligament ~ o ~ l i t etendon us Posterolateral capsule 8 Popliteofibular ligament
Demographics Age: Younger active patients Gender o F>M o Increased rate of ACL injuries in women collegiate athletes o Risk factor 4-8 times greater in women (basketballlsoccer)
Natural History & Prognosis Partial tears (difficult to assess) o Less than 25% fiber disruption associated with more favorable prognosis o > 50% leads to insufficiency o Excellent results in 80 to 90% of ACL reconstructions
Cross Pathologic & Surgical Features 44
Disruption of ligament within its midsubstance, origin, or at its attachment associated with hemorrhage and synovitis Avulsion of anterior tibial spine seen in younger patients Empty lateral wall sign (absent attachment to lateral femoral condyle) Fallen ACL (loss of normal tension & tear) & Stenotic notch
Treatment Conservative treatment may be effective o Osteoarthritis is a possibility in active patient without reconstruction ACL reconstruction in active patients o Bone-patellar tendon-bone graft Associated with patellar fractures if activity is resumed too quickly o Hamstring graft 8 Quadruped hamstring (semitendinosus f gracilis)
Microscopic Features Disruption of normal collagen bundles accompanied by hemorrhage of fibrosis, and inflammatory infiltration Normal ACL cells resemble fibrocartilage Femoral and tibial attachment sites consist of four morphologic zones from flexible tissue to rigid bone (for dissipation of shearing forces) o Zone 1 - ligament proper o Zone 2 - fibrocartilage o Zone 3 - tidemark and mineralized fibrocartilage o Zone 4 - bone ACL matrix - primarily type I collagen
Consider Bucket-handle tear of meniscus as a differential for chronically torn, fibrotic ACL on MRI
Image Interpretation Pearls Coronal images can increase sensitivity and specificity for the detection of partial (grade I and 11) ACL tears
Staging, Grading or Classification Criteria Grade I: Intraligamentous injury Grade 11: Intraligamentous injury + increase in ligament length Grade 111: Complete ligament disruption
1 SELECTEDREFERENCES 1.
2.
Presentation Most common signslsymptoms o Physical examination findings
Fithian DC et al: Fate of the anterior cruciate ligament-injured knee. Orthop Clin North Am 33(4):621-36, 2002 Fujimoto E et al: Spontaneous healing of acute anterior cruciate ligament (ACL) injuries - conservative treatment using an extension block soft brace without anterior stabilization. Arch Orthop Trauma Surg 122(4):212-6,2002
I
ANTERIOR CRUCIATE LIGAMENT (ACL) TEAR
(Left) Sagittal PD FSE MR shows the typical appearance of a proximal ACL tear (arrow). (Right) Coronal FS PD FSE MR shows an "empty lateral intercondylar notch wall" representing a grade 111 ACL tear (arrow).
(Left) Sagittal graphic shows the associated bone contusions after an internal rotation valgus mechanism of injury involving the lateral femoral condyle (sulcus terrninalis) and the posterolateral tibia. (Right) Sagittal FS PD FSE MR shows the lateral bone injuries associated with an ACL tear including the posterolateral tibia and sulcus terminalis of the lateral femoral condyle. The proximal fibula is also injured (osseous contusion).
Variant (Left) Coronal oblique graphic shows avulsion fracture of the tibial spine at the insertion of the ACL. This injury is often seen in younger patients. (Right) Coronal PD FSE MR shows a nondisplaced tibial spine fracture (arrow).
ACL RECONSTRUCTlON
Sagittal graphic shows fraying of the anterior aspect of the graft from chronic roof impingement by the adjacent intercondylar notch roof.
Abbreviations and Synonyms Anterior cruciate ligament (ACL), ACL reconstruction -1h
Definitions Operative (open or arthroscopic) replacement of ACL Graft disruption after trauma Graft disruption secondary to chronic frictional trauma = roof impingement
General Features Best diagnostic clue o Normal bone-patellar tendon-bone graft = continuous linear structure coursing through the notch o Normal hamstring graft seen as two linear hypointense structures on all pulse sequences o Other grafts (including synthetic) seen as linear hypointense structures on all pulse sequences o Disruption of graft as discontinuous fibers within the notch + associated hemorrhage and generalized increased signal intensity of grafts on T2WI
I
K3
Sagittal PD FSE MR shows a degenerated partially torn graft secondary to impingement by an osteophyte (arrow) of the adjacent intercondylar notch roof.
Location: Tibial tunnel superior through anterior medial aspect of tibia at notch (spine) t o posterolateral intercondylar notch wall to femoral tunnel Size o Complete replacement of the ACL by graft approximating normal ACL size o Tears may be small partial or large complete disruptions Morphology o Bone-patellar tendon-bone graft - linear graft o Hamstring graft - 2 linear grafts adjacent to each other (quadrupled hamstring) Semitendinosus +/- gracilis tendon Increased signal intensity between grafts on all sequences (fluid and/or synovium) o Allograft (patellar tendon1Achilles) Normal graft o Linear hypointense signal intensity (TI and T2WI) structure parallel to the roof of intercondylar notch (~lumensaat'sline) o Tibial tunnel Posterior to the midpoint of the tibial ACL footprint Posterior and parallel to Blumensaat's line tibial intersection in knee extension o Femoral tunnel Intersection of posterior femoral cortex and the physeal scar
DDx: ACL Reconstruction Pat Tendonit~s
Tunnkll C Y S ~
,
t r
-
Sag P D FSE MR
Sag FS P D FSE
Sag P D FSE MR
Sag FS P D FSE
Cor NECT
ACL RECONSTRUCTION Key Facts Terminology Operative (open or arthroscopic) replacement of ACL Graft disruption after trauma Graft disruption secondary to chronic frictional trauma = roof impingement
Imaging Findings Normal bone-patellar tendon-bone graft = continuous linear structure coursing through the notch Cyclops lesion - rounded decreased SI mass (fibrotic) on all sequences anterior to the graft
Top Differential Diagnoses Apparent Anterior Placement of Tibia1 Tunnel Mimicking Roof Impingement (Pseudo Impinge) Revascularization Fractured Hardware
0
Intermediate SI on short TE sequence from 1 to 6 months after grafting due to ligamentization and development of a synovial envelope
MR Findings TlWI o Intermediate to increased signal intensity 6 weeks to 8 months after grafting (revascularization) o Torn graft intermediate to increased signal with disorganized graft fibers Typical bone injuries appear as hypointense edematous regions +/- Fracture T2WI 0 Normal bone-patellar tendon-bone graft is hypointense 0 ~ a m s t r i graft n ~ +/- small amounts of increased signal intensity between two components within tibial or femoral tunnel o Intermediate to increased signal intensity 6 to 8 months after grafting (revascularization) o Graft rupture = Increased signal intensity with discontinuity +/thickening and laxity of graft Axial images - thickening and increased signal intensity adjacent to the lateral intercondylar notch wall Increased signal intensity with nondisplaced fractures or subchondral impaction involving the lateral compartment similar to native ACL tear Reinjury, improper graft placement and failure bone plugtinterference screw fixation T1 C+ o Synovial envelope will enhance after I.V. gadolinium administration Confirms intact graft Graft impingement o Forward placement of tibial tunnel with impingement of intercondylar notch roof on graft (roof impingement) 0 Sidewall impingement (less common) secondary to incomplete notchplasty
. .
.
Pathology General path comments: Bone-patellar tendon-bone and hamstring grafts most common
Clinical Issues Most common signs/symptoms: Pain, instability after operation and usually after repeat trauma if failed reconstruction Maintenance of ligament isometric tension to keep distance between tibia1 & femoral attachment points from changing > 2-3 mm through 0 to 90" flexion
Diagnostic Checklist Roof impingement if osteophyte develops at the notch in a symptomatic patient
o Increased signal on all sequences and variable
disruption of fibers Graft disruption - associated findings o Discontinuous fibers, associated with meniscal tears, bony injuries & collateral ligament tears As with native ACL tears Cyclops lesion - rounded decreased SI mass (fibrotic) on all sequences anterior to the graft o Extension block and pain
Imaging Recommendations Best imaging tool: MRI Protocol advice o FS PD and FS PD FSE in all planes Consider T1 C+ in difficult cases to enhance synovial reflection
.
DIFFERENTIAL DIAGNOSIS Apparent Anterior Placement of Tibial Tunnel Mimicking Roof Impingement (Pseudo Impinge) Forward translation of tibia may result from graft/disruption & tibial translation and 2" instability Not due to improper surgical placement
Revascularization Graft may exhibit intermediate signal on short TE sequence normally from 6 weeks to 8 months after repair Important to have accurate history of surgery, and presence of pain
Fractured Hardware Pain and graft dysfunction Visualized on MR, radiographs
Meniscal Tear with Resultant Locking Mimics cyclops lesion clinically Increased signal on short TE sequence extending to surface of meniscus 0 Usually associated with displaced fragment
ACL RECONSTRUCTION o Maintenance of ligament isometric tension to keep distance between tibial & femoral attachment points
o Bucket-handle tear
Osteochondral Injury
from changing > 2-3 mm through 0 to 90" flexion Graft placement depends upon activity level of patients o Active patients are encouraged to undergo reconstruction to prevent development of osteoarthritis Roof impingement leads to pain and may eventually lead to graft disruption o Associated findings of impingement Joint effusion, decreased extension, pain, and recurrent instability Cyclops lesion may lead to pain and extension block Patellar tendinitis can occur at donor site o Middle third of patellar tendon
Posttraumatic pain, +/- locking, +/- graft tear Acute on chronic injury with acute development of hyperintense (T2WI) bone contusions
Donor Site Abnormalities Patellar tendonitis o Thickened increased signal intensity of tendon on T2W1, +/- tear o Normal post surgical (persist up to 18 months post harvest) Post graft patellar insufficiency fracture o Decreased surface area and secondary weakening of bone o Premature resumption of sport activities
Tunnel Cyst +/- Mass effect, pain Hamstring grafts Tibia1 tunnel Hyperintense on T2WI
1 PATHOLOGY
Demographics Age: Typically younger active patient Gender: F > M
Natural History & Prognosis Post operative patient does well with no new trauma o Helps prevent arthritis (seen with unstable patient)
Treatment Graft impingement treated with resection of osteophytes and replacement of graft if torn Cyclops lesion resected if symptomatic
General Features 48
General path comments: Bone-patellar tendon-bone and hamstring grafts most common Etiology o Most ACL reconstructions (intraarticular): Either hamstring or bone-patellar tendon-bone grafts o Abnormal placement of tibial tunnel (usually anterior) can result in graft impingement Epidemiology: Common procedure of ACL tear in active patients to prevent development of arthritis
Consider Roof impingement if osteophyte develops at the notch in a symptomatic patient
Image Interpretation Pearls
Gross Pathologic & Surgical Features
Intact graft as continuous fibers Evaluate the posterolateral tibial plateau articular cartilage for erosions secondary to osteochondral injury associated with the initial ACL tear
Disrupted graft: Discontinuous tendon fibers within notch of knee with variable degrees of hemorrhage and synovitis
Microscopic Features Tendon grafts progress through 4 stages of "ligamentization" o Avascular necrosis o Revascularization o Cellular proliferation o Remodeling, resulting in histology closely resembling native ACL Fibroblast healing occurs through synovial membrane Revascularization occurs from the synovial membrane and endosteal vessels
Presentation Most common signs/symptoms: Pain, instability after operation and usually after repeat trauma if failed reconstruction Reconstruction goal
I
I
1. Boni DM et al: Hamstring tendon graft for anterior cruciate ligament reconstruction. Aorn J 76(4):610-5,617-9, 621-4; quiz 625-8, 2002 2. Jansson KA et al: MRI of anterior cruciate ligament repair with patellar and hamstring tendon autografts. Skeletal Radio1 30(1):8-14,2001 3. Jarvela TP et al: Anterior cruciate ligament reconstruction in patients with or without accompanying injuries. A re-examination of subjects 5 to 9 years after reconstruction. Arthroscopy 17(8):818-25,2001 4. Veselko MA et al: Cyclops syndrome occurring after partial rupture of the anterior cruciate ligament not treated by surgical reconstruction. Arthroscopy 16(3):328-31,2000
ACL RECONSTRUCTlON /IMAGE GALLERY Variant
Variant
(Left) Sagittal PD FSE MR shows a torn ACL graft. Note the discontinuous and lax fibers (arrow) and antenor displacement of the tibia as a result of the instability. (Right) Coronal PD FSE MR shows the torn graft in the notch of the knee. The fibers are discontinuous and distorted. Note the soft tissue edema adjacent to the MCL Indicating recent injury.
(Left) Sagittal graphic shows arthrofibrosis of the anterior intercondylar notch adjacent to the ACL graft [mass like = cyclops lesion). This may result in terminal extension block. (Right) Sagittal FS PD FSE MR shows an intact ACL graft with a rounded decreased signal intensity mass in the anterior notch consistent with a cyclops lesion (arrow). There is surrounding synovial proliferation
(Left) Sagittal PD FSE MR shows an intact ACL graft wlth decreased signal intensity. (Right) Sagittal PD FSE MR shows fixation of ACL graft within femoral tunnel. There is scarring of Hoffa's fat pad [arrow). A cyclops lesion 1s usually more round and well-defined.
POSTERIOR CRUCIATE LIGAMENT TEAR
Sagittal PD FSE MR shows a high grade partial tear (arrow) in the middle third of the PCL.
Coronal oblique graphic shows a torn PCL,
CT Findings
Abbreviations and Synonyms Posterior cruciate ligament (PCL) tear 50
Definitions Disruption of the PCL usually after forced posterior displacement of the tibia
NECT o Associated fractures Anterior hyperextension fractures CT arthrography o Torn ligament seen in contrast pool o Chondral defects seen as contrast collection/ulceration of chondral surface if fractured
M R Findings General Features Best diagnostic clue: Discontinuous and/or thickened PCL fibers of increased signal intensity on all pulse sequences Location: Posterior tibia insertion site avulsion fracture common Size: Small discrete tear to complex tear Morphology: Discrete to complete disorganized tear
TlWI o Complete rupture - decreased signal intensity and discontinuous fibers +/- Thickening of attached ligament portions o Partial tear (grade I and I1 sprains) - variable thickening, decreased signal intensity continuous fibers partially intact o Avulsion fractures of the posterior mid-tibia hypointense line Hypointense fx surrounded by hypointense edema . T ~ W- Io Interstitial tear: Diffuse thickening, increased signal intensity o Complete rupture: Increased signal intensity and discontinuous fibers o Partial tear (grade I and I1 sprains) - variable thickening, increased signal intensity, continuous fibers generally intact -
Radiographic Findings Radiography o Avulsion fractures of the posterior tibia o Subtle anterior impaction fractures o Reverse Segond fracture rare Avulsion at tibia1 insertion site at deep portion of MCL associated with PCL & peripheral medial meniscus tear
r@1-i
DDx: Posterior Cruciate Ligament Tear 1
Fx Normal PCL
PCL Craft Intact
~
'
7
I
Sag FS PD FSE
Sag STIR MR
Cor PD FSE MR
Sag T2 FSE MR
Sag FS PO FSE
POSTERlOR CRUClATE LIGAMENT TEAR Kev Facts I
PCL Graft Surgery Posterolateral Corner (PLC) InjuryISurgery (Post Lat Cor Sx)
Terminology Disruption of the PCL usually after forced posterior displacement of the tibia
lmaging Findings Best diagnostic clue: Discontinuous and/or thickened PCL fibers of increased signal intensity on all pulse sequences Normal ligament appears as decreased signal intensity on all pulse sequences "hockey stick" in the notch of the knee (sagittal images) Protocol advice: FS PD FSE in sagittal and coronal planes
Top Differential Diagnoses
Pathology Most commonly occurs by direct trauma impacting the anterior knee in a posterior direction (dashboard injury with the knee in flexion)
Clinical Issues Most common signs/symptoms: Positive posterior drawer sign (excessive mobility of the tibia posteriorly)
Diagnostic Checklist In setting of anterior tibial trabecular injury
Mucoid Degeneration Osteochondral Injuries o Coronal images - thickening and increased intensity
within the medial intercondylar notch Partial or complete tear Replacing normal "hockey puck" appearance o Avulsion fractures of the posterior mid tibia hypointense fracture line Surrounded by hyperintense edema o Anterior tibial trabecular injury or fracture + posterior femur injury (hyperintense contusion) Forced posterior displacement of tibia in a flexed knee Dashboard injury o Increased signal intensity anterior tibia and anterior femur "kissing fractures" = hyperextension injury o FS increases conspicuity of edema PDIIntermediate o Interstitial tear may appear as diffuse thickening and increased signal intensity o Complete rupture seen as increased signal intensity and discontinuous fibers STIR o Hyperintensity similar to FS PD FSE o Fat saturation increases edema conspicuity T2* GRE o Complete rupture: Increased signal intensity and discontinuous fibers o Interstitial tear: Diffuse thickening and increased signal intensity Increased signal intensity on all pulse sequences is abnormal o Tear vs. degeneration maybe difficult to differentiate Normal ligament appears as decreased signal intensity on all pulse sequences "hockey stick" in the notch of the knee (sagittal images)
Imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE in sagittal and coronal planes
Mucoid Degeneration Normal aging of ligament Increased signal intensity of PCL and slight thickening on T2WI +/- Intraligamentous cyst
Osteochondral Injuries "Kissingfractures"of hyperextension in absence of PCL tear Hypointense fx line on all pulse sequences Hyperintense edema on T2WI
PCL Graft Surgery Graft normally decreased in signal Retear Enters posterior tibia at notch
Posterolateral Corner (PLC) InjuryISurgery (Post Lat Cor Sx) Posterolateral corner injury associated with PCL tears PLC injury + PCL arthritistinstability Hyperintense ligaments/tendons o Including popliteus, arcuate complex, posterolateral capsule
L
I
General Features General path comments o PCL is twice as strong as anterior cruciate ligament (ACL) o Posteromedial bundle of PCL is taut in extension and lax in flexion o Anterolateral bundle is tight in flexion and lax in extension o PCL fibers attach in an anterior-to-posterior direction on the femur and medial-to-lateral direction on the tibia o Medial intercondylar notch wall origin (in the form of a semicircle)
POSTERIOR CRUCIATE LIGAMENT TEAR o Quadriceps active test results in translation of tibia
o PCL insertion = central fovea on the posterior tibia
1.5 cm inferior to the joint line o Humphry's (anterior) and Wrisberg's (posterior) meniscofemoral ligaments extend from posterior horn lateral meniscus to insert anteriorly & posteriorly relative to the PCL on the medial femoral condyle o Main vascular supply of the cruciate ligaments = middle geniculate artery Etiology o Most commonly occurs by direct trauma impacting the anterior knee in a posterior direction (dashboard injury with the knee in flexion) o Also occurs in hyperextension, dislocation and rotational injuries o Flexed knee decelerates quickly - fall on flexed knee Epidemiology o Accounts for only 5 to 20% of all knee ligament injuries (38%incidence reported in regional trauma centers) o Less common than other ligament tears of the'knee Associated abnormalities o Posterolateral corner injury Early arthritislinstability if unrecognized o Hyperextension "kissing fractures" Anterior tibia Anterior femur Increased signal T2WI = +/- Hypointense (all pulse sequences) fracture line
anteriorly during quadriceps contraction o External rotation of the tibia (Dial test)
To evaluate posterolateral structures (PLS) Patient prone + external rotation force to feet (knee in 30" and 90" of flexion) 10" difference with contralateral side is abnormal o Reverse pivot shift test Passive extension of knee from 90" of flexion with foot externally rotated + valgus force applied to the tibia Positive result = reduction of tibial plateau at 20-30" of flexion
Demographics Age: Children or adults Gender o No predilection o 2% of National Football League players have PCL instability
Natural History & Prognosis Patient may do without intervention for isolated PCL injuries Increased articular cartilage wear as tibiofemoral contact shifts anteriorly
Treatment Usually conservative Repair if multiple abnormalities associated with ligament tear
Gross Pathologic & Surgical Features Disruption of the ligament within midsubstance, at origin, or at attachment +/- Hemorrhage and synovitis (in chronic cases)
Microscopic Features Disruption of normal collagen bundles o Hemorrhage o Fibrosis o Inflammatory infiltration
Consider In setting of anterior tibial trabecular injury
Image Interpretation Pearls FS PD FSE in sagittal and coronal planes show lesion as loss of "hockey stick" appearance (sagittal) or hockey puck (coronal)
Staging, Grading or Classification Criteria Grade I sprain: Minimal tear without joint laxity o Intraligamentous injury Grade I1 sprain: Moderate tear with joint laxity Grade 111 sprain: High grade sprain to complete tear with no firm endpoint o > 10 mm of tibial translation
1. 2. 3.
Presentation Most common signslsymptoms: Positive posterior drawer sign (excessive mobility of the tibia posteriorly) Clinical profile o Posterior drawer test Accurate test for PCL integrity Patient supine, knee flexed 90" + posterior directed force on tibia o Posterior sag test in complete tears (Godfrey's test) Tibia sags into a posterior subluxation relative to femur with patient supine and knee flexed to 90 degrees
4. 5. 6.
DeLee J et al: Orthopaedics sports medicine. vol 1. 2nd ed. Philadelphia PA, Saunders, 1577-2154, 2003 Freeman RT et al: Combined chronic posterior cruciate and posterolateral corner ligamentous injuries. vol9. Philadelphia PA, Elsevier (4):309-12, 2002 Bergfeld JA et al: The effects of tibial rotation on posterior translation in knees in which the posterior cruciate ligament has been cut. J Bone Joint Surg Am 83-A(9):1339-43,2001 Covey DC: Injuries of the posterolateral corner of the knee. J Bone Joint Surg Am 83-A(1):106-18, 2001 Feltham GT et al: The diagnosis of PCL injury: Literature review and introduction of two novel tests. Iowa Orthop J 21:36-42, 2001 Fanelli GC: Treatment of combined anterior cruciate ligament-posterior cruciate ligament-lateral side injuries of the knee. Clin Sports Med. 19(3):493-502,2000
POSTERIOR CRUCIATE LIGAMENT TEAR
1 IMAGE GALLERY (Left) Sagittal FS PD FSE MR shows a complete tear of the PCL. (Right) Sagittal FS PD FSE MR shows a complete tear of the PCL mid portion.
(Left) Coronal oblique graphic shows a partial tear of the PCL. (Right) Sagittal FS PD FSE MR shows a partial PCL tear of the proximal and mid portion.
(Left) Sagittal graphic shows the typical anterior bone contusion pattern of hyperextension often seen with PCL tears. (Right) Sagittal STIR MR shows a partial PCL tear (arrow) and an anterior subchondral contusion of the tibia (open arrow) in a patient who suffered a dashboard injury.
MEDIAL COLLATERAL LlGAMENT TEAR
Coronal oblique graphic shows a grade 111 tear of the proximal aspect of the medial collateral ligament. Both the superficial and deep layers are torn. Note the soft tissue edema.
Coronal FS PD FSE shows a grade 111 MCL tear (arrow) after valgus injury.
o Disruption of normal continuous linear ligament
appearance
Abbreviations and Synonyms Medial collateral ligament (MCL) tear, tibial collateral ligament tear 54
Definitions Disruption of MCL fibers after trauma Secondary to valgus stress
NECT o Nonspecific soft tissue edema o Heterotopic ossification if Pellegrini-Stieda lesion o +I-Fracture
M R Findings
General Features Best diagnostic clue: Discontinuous MCL with thickening and increased signal intensity on all sequences within ligament remnant Location o Superficial and deep (medial capsular ligament) layers can be disrupted completely or partially Superficial component: Medial (tibial) collateral ligament proper Deep layer: Meniscofemoral and meniscotibial attachments Size: Tears vary from small discrete partial disruption to complete grade I11 "blowout" Morphology o Varies from discrete tear to massive disruption
.
CT Findings
TlWI o Intermediate signal intensity of disorganized appearing ligament o +I-Bone trabecular injury Medial femoral condyle - direct impact Lateral femoral condyle - clipping injury o Heterotopic ossification (Pellegrini-Stiedadisease) Increased signal (fat in bone marrow) corticated structure = Chronic tear T2WI o Increased signal intensity disorganization and often thickening within the normally hypointense ligament o Increased signal intensity with or without visible fracture lines or subchondral impaction involving Medial femoral condyle Posterolateral femoral condyle Lateral tibial plateau
.
.
1
DDx: Medial ColZateral Ligament Tear
Cor FS PD FSE
Cor FS PD FSE
Cor FS PD F:
Ax FS PD FSE MR
S;
MEDIAL COLLATERAL LIGAMENT TEAR Key Facts Imaging Findings Best diagnostic clue: Discontinuous MCL with thickening and increased signal intensity on all sequences within ligament remnant Superficial and deep (medial capsular ligament) layers can be disrupted completely or partially Coronal and axial FS PD FSE, for diagnosis and characterization
Top Differential Diagnoses Tibia1 Collateral Ligament Bursitis (TCL Bursitis) Semimembranosus Tibial Collateral Ligament Bursitis Semimembranosus Tendinosis
Pathology Ligament disrupted by valgus stress on the knee which "opens up" the medial joint o Hyperintense hemorrhagic effusion common o Coronal images show increased signal intensity with
disorganized tissue replacing normal hypointense ligament o FS PD FSE sensitive for edema associated with MCL tear PDIIntermediate o Heterotopic ossification (Pellegrini-Stiedadisease): Increased signal (fat in bone marrow), corticated structure o Loss of normal decreased signal intensity ligament in tear STIR o Increased signal within the ligament o Disorganization of fibers and thickening within the normally decreased signal intensity ligament Discontinuity of ligament fibers Bone contusions involving the lateral femur and lateral tibia indicating valgus stress Partial tear: Some fibers are still continuous and intact -
-
Imaging Recommendations Best imaging tool: MRI Protocol advice 0 Coronal and axial FS PD FSE, for diagnosis and characterization T2* GRE for Pellegrini-Stieda
1 DIFFERENTIAL DIAGNOSIS
Anterior cruciate ligament (ACL) tear in injury to peripheral aspect of the medial meniscus or meniscal attachments
.
Clinical Issues valgus injury Usually heals, even grade I11 disruptions with no associated "collateral"damage to other structures in the joint Isolated MCL sprains are treated with functional rehabilitation Child or adult
DiagnosticChecklist Damage to other ligaments or menisci may necessitate surgery Coronal and axial images show either proximal or distal tears
o +/- Intact ligament Inflammatory condition +/- Hyperemia (reactive) in tibia and/or femur in inflammation o Edema in association with meniscal tear
Semimembranosus Tibial Collateral Ligament Bursitis Fluid signal intensity posterior to semimembranosus (SM) o Increased signal on T2WI +/- Trauma +/- SM tendinosis Inflammatory condition
Semimembranosus Tendinosis Overuse syndrome Increased (relative) signal intensity on all pulse sequences within SM attachment Associated with tibia1 collateral ligament semimembranosus bursitis
Medial Meniscus Tear Linear increased signal intensity on short TE sequences extending to the articular margin of the meniscus Positive clinical signs of meniscal tear - i.e., McMurray test +/- Associated edema within the medial tibia and femur (tear hyperemia)
Osseous Injury Medial bone trabecular or osteochondral injuries History of trauma common Affects chondral surface and subchondral bone Increased signal on T2WI
Tibial Collateral Ligament Bursitis (TCL Bursitis) Fluid signal intensity between layers of MCL 0 Increased signal on T2WI +/- Trauma Hemorrhagic with trauma
General Features Etiology o Ligament disrupted by valgus stress on the knee which "opens up" the medial joint o Acute with valgus stress injury o Acute episode superimposed on chronic repetitive valgus stress Epidemiology: Common in sports injuries (5-10% of college football players) Associated abnormalities
I
MEDIAL COLLATERAL LIGAMENT TEAR o Anterior cruciate ligament (ACL) tear in injury to
peripheral aspect of the medial meniscus or meniscal attachments o Pellegrini-Stieda disease is a chronic ligament sprain Calcification or ossification of proximal ligament adjacent to the medial femoral epicondyle
Gross Pathologic & Surgical Features Thickened, partially or completely torn ligament Disruption of ligament within its midsubstance, at its origin, or at its attachment accompanied by surrounding hemorrhage
Microscopic Features ~ e ~ e n e r a t i opartial n, or complete rupture variable amounts of hemorrhage and inflammatory cells MCL heals with scar formation o Scar contracts (3-14 weeks) then stretches o Scar is biomechanically inferior to normal ligament o Increased cellularity, decreased total collagen and increased type I11 (immature) collagen
Staging, Grading or Classification Criteria MR (grades) o Grade I: Hyperintensity in soft tissues medial to
MCL o Grade 11: Hyperintensity in soft tissues medial to
36
MCL + hyperintensity within a portion of the MCL itself o Grade 111: Complete disruption of MCL fibers + interposed fluid or fibrosis (chronic) Clinical (grades) o Grade 1 sprain: Interstitial tear with no joint laxity No increased medial opening to valgus stress o Grade 2 sprain: Partial tear 1+ or 2+ mm opening No pathologic laxity o Grade 3 sprain: Complete tear with no firm endpointto abduction stress 3+ mm opening (pathologic laxity) Pathologic laxity grades (amount of joint opening with displacing forces) o 0 = normal
Presentation Most common signslsymptoms o Child or adult after valgus injury o Pain (grade I sprain) o Pain and instability (grade I1 and grade I11 sprains)
Demographics Age: Child or adult Gender: M > F
Natural History & Prognosis Usually heals, even grade I11 disruptions with no associated "collateral"damage to other structures in the joint
Stage 1: Inflammation o Within 3 days of injury o Fibroblasts produce type I11 collagen Stage 2: Repair and regeneration o 6 weeks after injury o Type I collagen replaces type I11 collagen Stage 3: Remodeling o Continues for up to and > 1 year after injury o 50-70% of elasticity and strength by 1 year Injury characteristics that slow healing o Grade I11 sprains heal c grades I and I1
Treatment Isolated MCL sprains are treated with functional rehabilitation MCL sprains associated with ACL injuries are treated by repair of the ACL tear o +/- MCL repair
I DIAGNOSTIC CHECKLIST Consider Damage to other ligaments or menisci may necessitate surgery
Image Interpretation Pearls Coronal and axial images show either proximal or distal tears
Twaddle BC et al: Knee dislocations: Where are the lesions? A prospective evaluation of surgical findings in 63 cases. J Orthop Trauma 17(3):198-202,2003 Borden PS et al: Medial collateral ligament reconstruction with allograft using a double-bundle technique. Arthroscopy 18(4):E19,2002 Bergin D et al: A traumatic medial collateral ligament edema in medial compartment knee osteoarthritis. Skeletal Radiol 31(1):14-8,2002 Koehle MS et al: Alpine ski injuries and their prevention. Sports Med 32(12):785-93,2002 Gardiner JC et al: Strain in the human medial collateral ligament during valgus loading of the knee. Clin Orthop (391):266-74, 2001 Woo SL et al: Injury and repair of ligaments and tendons. Annu Rev Biomed Eng 2:83-118, 2000 Woo SL et al: Healing and repair of ligament injuries in the knee. J Am Acad Orthop Surg 8(6):364-72, 2000 Elliott JM et al: MR appearances of the locked knee. Br J Radiol 73(874):1120-6, 2000 Lundberg M et al: Ten-year prognosis of isolated and combined medial collateral ligament ruptures. A matched comparison in 40 patients using clinical and radiographic evaluations. Am J Sports Med 25(1):2-6, 1997 Stoller DW et al: Magnetic resonance imaging in orthopaedics and sports medicine. vol 1. 2nd ed. Philadelphia PA, Lippincott Williams & Wilkins, 203-442, 1997 Reider B et al: Medial collateral ligament injuries in athletes. Sports Med 21(2):147-56, 1996 Albright JP et al: Medial collateral ligament knee sprains in college football. Effectiveness of preventive braces. Am J Sports Med 22(1):12-8, 1994
1
MEDIAL COLLATERAL LIGAMENT TEAR
Variant (Lef) Coronal oblique graphic shows a grade I sprain of the MCL with adjacent edema. (Right) Coronal FS PD FSE MR shows a grade I1 sprain of the MCL. Note the intraligamentous hyperintensity.
Variant (Left) Coronal graphic shows a grade 111 sprain of the distal MCL. Note laxity of distal fibers. (Right) Coronal FS PD FSE MR shows a grade 111 sprain of the distal MCL (arrow). Laxity of distal fibers are demonstrated.
Variant (Left) Coronal graphic shows an avulsion iracture (Stieda fracture) at the origin of the MCL with adjacent hemorrhage in surrounding soft tissues. (Right) Coronal PD FSE MR shows osseous marrow signal (arrow) o i the proximal aspect of the MCL consistent with Pellegrini-Stieda disease. This represents the ossiiication of a chronic tear.
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MEDIAL BURSITIS, KNEE
Coronal graphic shows the tibial collateral ligament bursa deep to the superficial component of the ligament. The pes anserinus bursa is beneath the insertion of the pes anserine tendons.
R
Abbreviations and Synonyms Pes anserinus (PA) bursitis Medial collateral ligament (MCL) bursitis Tibia1 collateral ligament (TCL) bursitis Semimembranosus-tibia1collateral ligament (SMTCL) bursitis
iH
Definitions Synovial lining: Inflammation of the medial bursae of the knee o Including TCL bursa (bursa of Voshell between superficial and deep layers of MCL) o Pes bursa overlies tendinous attachments of sartorius, gracilis and semitendinosus tendons distal to Voshell's bursa
General Features Best diagnostic clue: Fluid containing mass (fluid signal intensity) in location of a medial bursae Location o MCL bursa Between deep and superficial components of medial collateral ligament
I
Coronal FS PD FSE MR shows hyperintense fluid signal intensity (arrow) within the TCL bursa consistent with bursitis.
Five locations described including between the meniscofemoral attachment and superficial MCL, coronary ligament and superficial MCL, and an anterior to posterior distribution/location o Semimembranosus tibial collateral ligament bursa Posteromedial to semimembranosus tendon extending anteriorly for variable distance o Pes anserinus bursa Interposed between tendons of pes anserine (sartorius, gracilis, semitendinosus) and medial tibia Approximately 1-2cm below joint line Size: Varies from a few mms to several cms depending on amount of fluid contained Morphology o Flattened synovial sacs not usually visualized on MRI unless distended with fluid o Moderate amount of fluid - distended bursa with oval shaped morphology o Large amount of fluid distends bursa proximally toward knee joint o Semimembranosus tibial collateral ligament bursa inverted "U" shape (drapes over semimembranosus tendon)
Radiographic Findings Radiography o Nonspecific soft tissue swelling of medial knee o +I-Well-defined medial mass
DDx: Medial Bursitis, Knee S M Tendrnosis
Cc
SE
Sag FS P D FSE
Ax FS P D FSE
Sag FS P D FSE
Sag P D FSE MR
MEDlAL BURSITIS, KNEE Key Facts Terminology Synovial lining: Inflammation of the medial bursae of the knee
Imaging Findings Best diagnostic clue: Fluid containing mass (fluid signal intensity) in location of a medial bursae Flattened synovial sacs not usually visualized on MRI unless distended with fluid
Top Differential Diagnoses Meniscal Cyst * Fluid Distending Normal Meniscal Attachment
Recesses * Hemorrhage between Deep & Superficial Components of MCL in Trauma Soft Tissue Cystic Appearing Mass adjacent to Bursa
MR Findings TlWI o Homogeneous decreased signal intensity mass in characteristic location o Associated tendinosis of semimembranosus with SMTCL bursitis Thickening and increased signal intensity of insertion o Decreased signal in adjacent bone if reactive edema o +/- Meniscal tear Increased signal in substance of meniscus extending to surface Bursitis associated as "reactive"phenomenon T2WI o Hyperintense fluid distending bursa o Hyperintense flattened, oval, or round shaped cystic masses in characteristic locations o Hypointense structures if calcified o Intermediate signal debris during inflammatory, hemorrhagic or exudative process o +/- Rice bodies in patients with rheumatoid arthritis Intermediate to decreased signal "rice"shaped fibrinous bodies o +/- Associated tendinosis of semimembranosus Thickening and variable increased signal intensity of insertion +/- Associated bursitis o Decreased signal in adjacent bone if reactive edema T2* GRE o Fluid intensity masses o Decreased signal intensity rim if hemorrhagic T1 C+ o +/- Rim enhancement o Greater enhancement if longstanding with thickened svnovium
Ultrasonographic Findings Typically hypo or anechoic mass with through transmission
Imaging Recommendations Best imaging tool: MRI
MCL Sprain or Stress Response Semimembranosus (SM) Tendinosis
Pathology Epidemiology: Common; accompanies meniscal tears
Clinical Issues Medial to anterior knee pain and well-localized tenderness Conservative: Local injection of corticosteroids - good relief and confirmation of diagnosis
Diagnostic Checklist FS PD FSE most sensitive to fluid collections and synovial thickening
Protocol advice: T2W1, especially FS PD FSE demonstrates fluid-filled bursa
I DIFFERENTIAL DIAGNOSIS Meniscal Cyst +/- Meniscal tear SMTCL bursitis commonly mistaken for meniscal cyst (sagittal) TCL bursa mimics meniscal cyst (coronal) Usually deep to capsule Immediately adjacent to meniscus
Fluid Distending Normal Meniscal Attachment Recesses Deep to the coronary ligament Dee~ to meniscofemoral attachment Lateral meniscus more common, larger recess
Hemorrhage between Deep & Superficial Components of MCL in Trauma Appropriate history +/- MCL tear Frequently indistinguishable
SynovialIGanglion Cyst Ganglion cyst - nonspecific origin Synovial cyst - from joint +/- Synovial lining Variable location +/- History of trauma Often reflects past effusions (synovial cyst)
Soft Tissue Cystic Appearing Mass adjacent to Bursa No demonstrable connection to bursa Different anatomic location MRI useful for differentiation Varices may mimic distended bursa
Meniscal Tear Associated bursitis common
MEDIAL BURSITIS, KNEE See reactive edema "hyperemia"in tibia and femur commonly Increased signal on short TE sequences within meniscus extending to surface
MCL Sprain or Stress Response Edema within, around ligament
+/- Osteoarthritis (OA) Acute traumatic event Chronic repetitive microtrauma
Semimembranosus (SM) Tendinosis Thickening and variable increased signal intensity of insertion on all pulse sequences +/- Bursitis (common) Chronic repetitive microtrauma
Natural History & Prognosis Presents insidiously or after athletic activity +/- Resolution with cessation of activities that led to condition Conservative treatment usually successful
Treatment Conservative: Local injection of corticosteroids - good relief and confirmation of diagnosis Surgical extirpation for o Recalcitrant cases 0 Infectious bursitis Complications 0 Tendon weakening, +/- tear, if corticosteroid injected into bursa and onto tendon
/OST~C General Features General path comments: Fluid distending normal meniscal attachment recesses mimic bursitis, especially TCL bursitis Etiology: Chronic frictional trauma or overuse centered upon bursal glide plane results in inflammation of bursa Epidemiology: Common; accompanies meniscal tears h0
Gross Pathologic & Surgical Features
CHECKLIST
Consider In overuse o Consider mimickers such as Meniscal cyst Fluid in normal joint recesses Hematoma
Image Interpretation Pearls FS PD FSE most sensitive to fluid collections and synovial thickening
Synovial lined bursal sac variable degrees of thickening of the lining Variable amounts of fluid
Microscopic Features Thickened synovial lining with variable degree of inflammatory infiltration Rice bodies especially in bursitis associated with rheumatoid arthritis Variable degrees of hemorrhagic byproducts Exudate in case of infectious bursitis
Staging, Grading or Classification Criteria No grading criteria described for imaging
Presentation Most common signs/symptoms o Medial to anterior knee pain and well-localized tenderness o Fullness, ranging from joint line to extend approx. 5 cm distally (medial portion of knee to anterior tibia) Clinical profile o Overweight, middle-aged or elderly women o Medial to anterior knee pain o Localized tenderness o OA of knee common and may mask presentation of bursitis o Athletes - overuse phenomenon
Demographics Age: Middle age or elderly
Koh WL et al: Clinics in diagnostic imaging (77). Pes anserine bursitis. Singapore Med J 43(9):485-91,2002 Uson J et al: Pes anserinus tendino-bursitis: What are we talking about? Scand J Rheumatol29(3):184-6, 2000 Kerlan RK et al: Tibia1 collateral ligament bursitis. Am J Sports Med 16(4):344-6,1998 Handy JR et al: Anserine bursitis: A brief review. South Med J 90(4):376-7, 1997 Rothstein CP et al: Semimembranosus-tibia1collateral ligament bursitis: MR imaging findings. AJR 166(4):875-7, 1996 Cohen SE et al: Anserine bursitis and non-insuln dependent diabetes mellitus. J Rheumatol 24(11): 2162-5, 1995 Forbes JR et al: Acute pes anserine bursitis: MR imaging. Radiology 194(2):525-7,1995 Zeiss J et al: Chronic bursitis presenting as a mass in the pes anserine bursa: MR diagnosis. J Comput Assist Tomog~ 17(1):137-40,1993
MEDlAL BURSITIS, KNEE
(ZAft) Sagittal graphic demonstrates distention of the pes anserinus bursa indicating inflammation. (Right) Sagittal FS PD FSE MR shows a small amount of fluid within the pes anserinus bursa in a patient with pain approximately 2 cm below joint line (arrow).
Tvpical
(Left) Sagittal FS PD FSE MR shows the typical appearance of semimembranosus tibia1 collateral ligament bursitis. The bursa has been described as " U " or " 7" shaped in the sagittal plane. There is a small amount of fluid within a popliteal cyst. (Right) Coronal FS PD FSE MR at the posterior aspect of the joint shows the distended bursa.
Tvpical
(L@) Coronal FS PD FSE MR shows a large distended pes anserinus bursa in a severe case of bursitis. A mass was palpable. (Right) Coronal T2 FSE MR shows TCL bursitis with thickened synovial tissue (arrow).
LATERAL COLLATERAL LlCAMENT (LCL) TEAR
Sagittal graphic shows a tear of the distal aspect of the lateral collateral ligament with mild retraction of the ligament proximally.
Sagittal FS PD FSE MR shows a tear of the lateral collateral ligament (arrow).
o o
Abbreviations and Synonyms
CT Findings
Lateral collateral ligament (LCL) tear, fibular collateral ligament (FCL) tear, FCL = LCL 6:
+/- Associated fracture of femur or tibia +/- Effusion
NECT o Associated fractures seen and characterized Fibular head, adjacent tibia, medial or lateral femur rn +/- Effusion
Definitions Tear of the lateral collateral ligament after varus +/external rotation stress
M R Findings
1 IMAGING FINDINGS
I
General Features Best diagnostic clue: Discontinuous LCL fibers +/thickening, hyperintense on FS PD FSE or T2WI Location o Extends from lateral femoral condyle to insertion with the biceps femoris on the fibular head Injury usually occurs at the proximal origin Size: Normal size 5-7 cm Morphology o Alteration in the linear shape of normal ligament o Relevant anatomy Normal ligament is extracapsular and free from rneniscal attachment
a
TlWI o Intermediate signal intensity with disorganized appearing ligament o Typical bone injuries appear as hypointense edematous regions +/- Fracture (fx) o Effusions - hypointense T2WI o Discontinuous fibers +/- thickening and increased signal intensity on FS PD FSE o Increased signal intensity bone injury rn Impaction bone trabecular injuries of medial femur and tibia indicating varus injury +/- Decreased signal intensity fx line o Injury to other posterolateral ligamentous and capsular supporting structures
Radiographic Findings Radiography
DDx: Lateral Collateral Ligament (LCL) Tear Arcuate and LCL
Sag PD FSE MR
Lat Tib Plt Fx
Sag FS PD FSE
Cor FS PD F
Fa Sag PD FSE MR
O~teochondr;llInj
Sag FS PD FSE
LATERAL COLLATERAL LlCAMENT (LCL) TEAR Key Facts Terminology Tear of the lateral collateral ligament after varus +/external rotation stress
lmaging Findings Best diagnostic clue: Discontinuous LCL fibers +/thickening, hyperintense on FS PD FSE or T2WI Protocol advice: Best seen on FS PD FSE or T2WI
Top Differential Diagnoses Lateral Bone Trabecular/Capsular Injuries Isolated cases of LCL injury are rare Lateral Gastrocnemius Insertional TearITendinosis Popliteus Insertional TendinosisITear
Pathology
Associated with tear of other posterolateral corner structures Ligament disrupted by varus stress on the knee (a blow to the medial aspect of the knee)
Clinical Issues Posterolateral pain Posterolateral rotatory instability if combined with injury to other posterolateral supporting structures Effusion indicates associated intraarticular pathology Healing ligament scars and stability gradually restored unless major posterolateral corner disruption
Diagnostic Checklist Damage to other posterolateral corner ligaments as isolated LCL tears are unusual
Rarely torn in isolation
Arcuate complex, biceps femoris tendon, popliteus tendon, popliteofibular & fabellofibular ligaments, and posterolateral capsule Discontinuous fibers +/- thickening Increase in signal intensity Visualized on FS PD FSE to T2WIs Hemorrhage = diffuse increased signal intensity o Associated tears of the iliotibial band and popliteus tendon (posterolateral corner) Discontinuous fibers +/- hyperintense T2* GRE o Associated fractures seen as increased signal line in acute stage Not sensitive for the identification of bone edema Sensitive for fracture morphology
Imaging Recommendations Best imaging tool: MRI Protocol advice: Best seen on FS PD FSE or T2WI
Lateral Bone Trabecular/Capsular Injuries Isolated cases of LCL injury are rare
+/- Posterolateral tendon ligament tears o Popliteus strainltear
o Arcuate complex sprainltear
Lateral Gastrocnemius Insertional TearITendinosis Chronic repetitive microtrauma Pain at insertion site Thickening +/- increased signal intensity on all pulse sequences FS PD FSE images in sagittal plane
Popliteus Insertional TendinosisITear Acute trauma Chronic repetitive microtrauma Thickening +/- increased signal intensity on all pulse sequences Visualized on FS PD FSE
Lateral Meniscal Tear Pain with twisting movements Visualized on MRI as increased signal intensity linear region on short TE sequences Tear at posterior peripheral aspect may mimic LCL sprain Acutely after trauma +/- Meniscal cyst
Posterior Cruciate Ligament (PCL) Tear Associated with posterolateral corner injury Failure of recognition of associated injury may lead to osteoarthritis (OA), dysfunction Seen as discontinuous fibers or thickening with an increase in signal intensity on all pulse sequence Visualized on FS PD FSE sagittal images
Lateral Tibia1 Plateau Fracture (Lat Tib Plt Fx) Depressed vs. nondepressed Bumper Fx Associated with lateral meniscus tear, +I-capsular injury +/- LCL sprain Osteochondral injury
1 PATHOLOGY General Features General path comments o Rarely torn in isolation o Associated with tear of other posterolateral corner structures o Lateral collateral ligament - primary restraint to varus angulation o Primary restraint to external rotation in the posterolateral complex o LCL resists internal rotation forces o Transecting LCL with either ACL or PCL results in large increase in varus instability Etiology o Ligament disrupted by varus stress on the knee (a blow to the medial aspect of the knee)
LATERAL COLLATERAL LIGAMENT (LCL) TEAR o Varus force + full knee extension is associated with
LCL and PCL involvement and straight lateral instability Straight lateral instability = disruption of all lateral ligaments, the PCL +/- the ACL Epidemiology o Isolated LCL injuries - 2% or knee ligament injuries o Associated LCL injury - 4% or knee ligament injuries Associated abnormalities o Injury to other posterolateral corner structures o Fracture of proximal fibula
Gross Pathologic & Surgical Features Thickened, partially torn or completely torn ligament
Microscopic Features Degeneration, partial or complete rupture Variable amounts of hemorrhage and inflammatory cells
Staging, Grading or Classification Criteria General MRI grading of ligamentous disruptions o Grade I: Mild sprain (stretching of ligament) o Grade 11: Intermediate grade o Grade 111: High grade to complete disruption (instability with > 10 mm of medial joint opening)
Injury characteristics that slow healing o Grade 111 sprains heal < grades I and I1 o LCL tears heal more slowly than MCL tears
Treatment Conservative o Isolated tears of the LCL are treated conservatively (closed) Similar to treatment of most MCL tears o Splint in full extension for two weeks o Motion and weightbearing as tolerated afterward Surgical o Open fixation Cases where cruciate abnormalities or extensive posterolateral corner injuries are additionally involved
Consider Damage to other posterolateral corner ligaments as isolated LCL tears are unusual
Image Interpretation Pearls FS PD FSE sensitive for detecting tears
1 SELECTEDREFERENCES Presentation Most common signs/symptoms o Posterolateral pain o Buckling into hyperextension with weightbearing o Varus instability o Posterolateral rotatory instability if combined with injury to other posterolateral supporting structures o +/- Cruciate and lateral meniscus tears Pain with clinical meniscal testing Clinical profile o Seen in sports activities: Football, soccer, tennis o Motor vehicle accident, motorcycle accident o Adduction or varus stress test with knee in 30 degrees of flexion (no resistance from secondary restraints) o Effusion indicates associated intraarticular pathology o Varus alignment o Medial thrust on weightbearing o +I-Injury to peroneal nerve
Demographics Age: Typically young active patient Gender: No predilection
Natural History & Prognosis * Healing ligament scars and stability gradually restored unless major posterolateral corner disruption Stage 1: Inflammation o 3 days of injury o Fibroblasts-type 111 collagen Stage 2: Repair and regeneration o 6 weeks after injury o Type I collagen replaces type I11 collagen Stage 3: Remodeling o Continues for up to and > 1year after injury
I
Twaddle BC et al: Knee dislocations: Where are the lesions? A prospective evaluation of surgical findings in 63 cases. J Orthop Trauma 17(3):198-202, 2003 Huang GS et al: Avulsion fracture of the head of the fibula (the "arcuate"sign): MR imaging findings predictive of injuries to the posterolateral ligaments and posterior cruciate ligament. AJR 180(2):381-7,2003 Munshi M et al: MR Imaging, MR arthrography, and specimen correlation of the posterolateral corner of the knee: An anatomic study. AJR 180(4):1095-101, 2003 Krudwig WK et al: Posterolateral aspect and stability of the knee joint. Posterolateral instability and effect of isolated and combined posterolateral reconstruction on knee stability: A biomechanical study. Knee Surg Sports Traumatol Arthrosc 10(2):91-5,2002 Fitzgerald R et al: Knee ligaments injuries: Epidemiology, mechanism, diagnosis and natural history. Orthopaedics. St. Louis, MO, Mosby, 564-76, 2002 Chen CH et al: Lateral collateral ligament reconstruction using quadriceps tendon-patellar bone autograft with bioscrew fixation. Arthroscopy 17(5):551-4,2001 Meister BR et al: Anatomy and kinematics of the lateral collateral ligament of the knee. Am J Sports Med 28(6):869-78,2000 Harfe DT et al: Elongation patterns of the collateral ligaments of the human knee. Clin Biomech (Bristol, Avon) 13(3):163-75,1998
LATERAL COLLATERAL LIGAMENT (LCL) TEAR IMAGE GALLERY Typical (Left) Axial FS PD FSE MR shows the torn LCL deep to the conjoined tendon. (Right) Axial FS PD FSE MR adjacent image shows the thickened edematous LCL (arrow).
Tvsical (Left) Sagittal PD FSE MR shows a normal LCL. (Right) Coronal PD FSE MR shows a normal LCL.
(Left) Coronal PD FSE MR shows a grade 111 sprain (arrow) of the proximal aspect of the LCL. (Right) Sagittal FS PD FSE MR shows a mid and distal aspect LCL tear (arrow).
POSTEROLATERAL COMPLEX INJURIES
Coronal oblique graphic shows a tear of the lateral aspect of the arcuate ligament and tear of the popliteus muscle.
Abbreviations and Synonyms Posterolateral corner injuries (PLCI), posterolateral complex (PLC) injuries, posterolateral instability (PLI), arcuate complex injuries
Definitions Sprainistrain of the supporting structures of the posterolateral corner of the knee o Arcuate ligament, medial & lateral limbs o Popliteal tendon o Lateral (fibular) collateral ligament o Fabellofibular ligament o Popliteofibular ligament o Posterolateral joint capsule; many of the ligaments represent thickenings of the posterolateral capsule
General Features
Coronal FS PD FSE MR shows a sprain of the popliteofibular ligament/arcuate complex (arrow) and surrounding edema.
Size: Tear of structures varies from grade I sprainistrain to grade I11 "blowout" Morphology: Disrupted fibers ranging from discrete tear to markedly irregular ligamentous thickened fibers Varus overload with variable degrees of rotation
Radiographic.Findings Radiography o +/- Fractures Posterolateral tibia Fibular styloid Sulcus terminalis - lateral femoral condyle Segond fracture - lateral tibia avulsion fx Posterior tibia at notch at posterior cruciate ligament insertion Reverse Segond medial tibia avulsion fx (rare with posterolateral corner (PLC) injury) = Fractures seen with anterior cruciate ligament (ACL), and posterior cruciate ligament (PCL)tears o Effusion o Posterolateral soft tissue swelling
CT Findings
Best diagnostic clue o Discontinuous ligament +/- tendon fibers + edema in the posterolateral aspect of the knee Posttraumatic, best seen on FS PD FSE Location: Adjacent to tibiofibular joint
NECT o Associated fractures assessed and characterized o Reconstructions used in comminuted fracture cases
MR Findings TlWI
DDx: Posterolateral Complex Injuries IT8 Friction
Pooliteus Hiatit.\
Fibular Fracture
Fibular Fracture
Cor FS .
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Popliteus Strain
POSTEROLATERAL COMPLEX lNJURlES Key Facts Terminology Spraintstrain of the supporting structures of the posterolateral corner of the knee
Imaging Findings
Discontinuous ligament +/- tendon fibers + edema in the posterolateral aspect of the knee Fibular head avulsion fracture diagnostic of posterolateral complex injuries
Top Differential Diagnoses Lateral Meniscus Tear Iliotibial Band Friction Syndrome Popliteus Hiatus Fracture without PLC LigamentITendon Involvement Popliteus/Biceps Strain
Pathology Leg internal rotation valgus stress: Typical ACL mechanism Direct blow to the tibia with the knee flexed or extended ~ ~abnormalities: ~ ~ ~~ ~with ~ ~cruciate ~i i ligament tears: ACL > PCL
.
Clinical Issues Posterolateral pain Buckling in hyper-extension with weight bearing and variable instability Combined PCL and posterolateral complex injuries are often missed at initial clinical presentation
Diagnostic Checklist Use FS PD FSE in all three planes (sagittal = key plane)
o Complete rupture - decreased signal intensity and
discontinuous fibers +/- Thickening of attached ligament portions o Partial tear (grade I and I1 sprains) - variable thickening, decreased signal intensity some continuous fibers intact o Fractures - hypointense linear signal abnormality Surrounded by hypointense edema T2WI o Increased signal intensity within the structures of the arcuate complex +/- Thickening of attached ligament portions Hyperintense fluid posterior to popliteus tendon sheath o Complete rupture - increased signal intensity and discontinuous fibers +/- Thickening of attached ligament portions o Partial tear (grade I and I1 sprains) - variable thickening, increased signal intensity some continuous fibers intact o Fractures: Decreased signal intensity fracture lines surrounded by hyperintense edema Assessed on FS PD FSEISTIR Involve posterolateral tibia, sulcus terminalis, Segond and reverse Segond, lateral tibia1 plateau fracture Other knee fractures possible o Soft tissue edema best assessed at level of and surrounding fibular head o ACL/PCL sprain Variable thickening, increased signal intensity +/continuous fibers Traumatic history, appropriate mechanism of injury STIR o Increased signal intensity of the posterolateral corner structures 0 Fractures: Decreased signal intensity fracture lines surrounded by hyperintense edema 0 Sensitive for edema but less signal than FS PD FSE Fibular head avulsion fracture diagnostic of posterolateral complex injuries
Imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE or STIR images; FS PD FSE increased signal, optimized spatial resolution
I DIFFERENTIAL DIAGNOSIS Lateral Meniscus Tear No injury to capsule, ligaments or tendons Suggestive clinical testing Increased signal intensity on short TE sequence extending to articular surface +/- Cyst
lliotibial Band Friction Syndrome Chronic frictional trauma iliotibial band and lateral femoral condyle o Increased signal intensity between the two structures o FS PD weighted images most sensitive o +/- Thickening and increased signal intensity within iliotibial band (ITB) Suggestive history Anterolateral pain
Popliteus Hiatus Normal anatomy Popliteus tendon sheath pierces inferior capsule medial aspectlsuperior capsule lateral aspect o Behind lateral meniscus o Contiguous with joint o +/- Fluid May be mistaken for meniscal tearlligament tear
Fracture without PLC LigamentITendon Involvement Posterior lateral corner Unusual, typically associated with ligamentous/capsular/tendon injuries Decreased signal intensity line surrounded by hyperintense edema on T2WI
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POSTEROLATERAL COMPLEX INJURIES o Grade 11: Partial tear with some instability (50% or greater) o Grade 111: Complete disruption PLI types o A = increased external rotation without varus instability (injury to popliteofibular ligament and popliteus tendon) o B = increased external rotation + moderate varus laxity (injury to popliteofibular ligament, popliteus tendon and LCL) o C = increased external rotation plus complete varus laxity (injury to popliteofibular ligament, popliteus tendon, LCL, lateral capsule and cruciate ligaments)
Popliteus/Biceps Strain Antagonist force on contracted muscle Thickened, increased signal tendon and/or muscle belly on T2WI FS PD FSE used to identify edema
1 PATHOLOGY General Features General path comments o Posterolateral complex includes LCL Popliteal tendon Arcuate ligament Popliteofibular ligament Fabellofibular ligament Posterolateral capsule Lateral head of the gastrocnemius muscle (also part of the arcuate ligament complex as defined by Baker) The biceps femoris tendon + ITB although not usually listed as components of complex contribute to stability of lateral and posterolateral knee o The arcuate complex stabilizes posterolateral aspect of knee against varus stress + external rotation o Isolated lateral collateral ligament iniurv is less common than medial coll~teralligament injury o Lateral collateral ligament joins tendon of the biceps femoris - conjoined tendon Rarely injured alone without injury to the remainder of the PLC Etiology o Leg internal rotation valgus stress: Typical ACL mechanism o Direct blow to the tibia with the knee flexed or extended o Rotational injury +/- cruciate ligament disruption and/or posterolateral instability o Varus stress o Noncontact hyperextension is the mechanism for isolated posterolateral rotatory instability o Blow to anteromedial tibia in~kneeextension results in arcuate ligament disruption and PLI Epidemiology o Overall common injury in athletics Especially snow skiing, soccer, football, tennis Associated abnormalities: Associated with cruciate ligament tears: ACL > PCL
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Gross Pathologic & Surgical Features Tear of the structures of the PLC with variable amounts of hemorrhage
Presentation Most common signs/symptoms o Posterolateral pain o Buckling in hyper-extension with weight bearing and variable instability o +I-Cruciate ligament instability Clinical profile 0 Posttraumatic abnormality secondary to rotational mechanisms of injury described above o Combined PCL and posterolateral complex injuries are often missed at initial clinical presentation
Demographics Age: Children & adults, active adolescents & adults more common Gender: M > F
Natural History & Prognosis Grade 111 - posterolateral rotatory instability can develop
Treatment Ligament & tendon disruptions treated with repair Cruciate ligament disruption associated with PCL injury - cruciate is repaired to prevent instability
1 DIAGNOSTIC CHECKLIST Consider This injury is in association with cruciate ligament tears
Image Interpretation Pearls Use FS PD FSE in all three planes (sagittal = key plane)
ISELECTED 1.
Microscopic Features ~ i c r o s c o ~and i c macroscopic tearing of the posterolateral corner structures Variable amounts: Hemorrhage + inflammatory cells
Staging, Grading or Classification Criteria ~igamentinjury o Grade I: Pain without instability, minimal tear
2.
3.
REFERENCES
Fitzgerald R et al: Orthopaedics. Knee ligament injuries: Epidemiology, mechanism, diagnosis, and natural history. St. Louis MO, Saunders, 619-35,2003 Huang GS et al: Avulsion fracture of the head of the fibula (the "arcuate"sign): MR imaging findings predictive of injuries to the posterolateral ligaments and posterior cruciate ligament. AJR 180(2):381-7,2003 Munshi M et al: MR Imaging, MR Arthrography, and specimen correlation of the posterolateral corner of the knee: An Anatomic Study. AJR 180(4):1095-1101, 2003
POSTEROLATERAL COMPLEX INJURIES
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IMAGE GALLERY Variant
(Left) Axial FS PD FSE MR shows a sprain of the posterolateral corner structures after a fall while snow skiing. Note the intact (at this axial level) fibular collateral ligament (arrow). (Right) Sagittal FS PD FSE MR shows the sprain of the posterolateral corner structures including a grade 111 sprain of the arcuate complex (arrow).
Tvaical
(Lef)Coronal FS PD FSE MR shows a normal popliteofibular ligament extending from the fibular styloid to the popliteus tendon (arrow). (Right) Axial FS PD FSE MR shows the normal anatomy of the posterolateral corner. Note the lack of edema and observe the popliteofibular ligament (arrow) extending obliquely from the conjoined tendon medially to the popliteus tendon.
Tvwical (LLfl) Sagittal FS PD FSE MR shows a torn superior fascicle of the posterior horn of the lateral meniscus (arrow). (Right) Sagittal FS PD FSE MR shows a lateral head of the gastrocnemius strain and sprain of the posterolateral corner ligaments (arrow).
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ILIOTIBIAL BAND
Axialgraphic shows edema interposed between the iliotibial band and lateral femoral condyle. Associated thickening of the iliotibial band may be present.
DROME
Axial FS PD FSE MR shows hyperintense edema (arrow) between iliotibial band and lateral femoral condyle in a runner with lateral pain and suspected lateral meniscal tear.
o Subjective thickening of the ITB
No specific size criteria established o Thickening typically adjacent to insertion on tibia
Abbreviations and Synonyms
Morphology: Normal to thickened ITB, +/- fraying and longitudinal partial tearing
Iliotibial friction syndrome, iliotibial band (ITB) syndrome, ITB friction
Radiographic Findings
Definitions Inflammatory overuse disorder affecting soft tissues caused by chronic frictional trauma o Interposed between iliotibial band and lateral femoral condyle (LFC)
Radiography o Nonspecific soft tissue swelling interposed between ITB and LFC o Usually negative
M R Findings
General Features Best diagnostic clue o Increased signal intensity within soft tissues interposed between iliotibial band and lateral femoral condyle on T2WI Coronal and axial plane History of running activity helpful Location o Lateral aspect of knee joint o Soft tissues interposed between ITB and lateral femoral condyle, ITB itself, lateral condyle and lateral synovial recess Size -
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TlWI: Hypointense edema in soft tissues interposed between ITB and LFC T2WI o Increased signal intensity within soft tissues interposed between iliotibial band and lateral femoral condyle = Edema On T2WIs and FS PD FSE sequence Best seen in coronal and axial plane STIR: Sensitive to underlying subchondral edema of lateral femoral condyle T2* GRE o Hyperintense soft tissues interposed between the iliotibial band and lateral femoral condyle Coronal and axial plane +I-Thickened ITB
urnmu
DDx: lliotibial Band Syndrome Mapat BU~F~~IF
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ILIOTIBIAL BAND SYNDROME Key Facts Terminology Inflammatory overuse disorder affecting soft tissues caused by chronic frictional trauma
Imaging Findings Increased signal intensity within soft tissues interposed between iliotibial band and lateral femoral condyle on T2WI Protocol advice: FS PD FSE in coronal and axial planes
Top Differential Diagnoses Large Joint Effusion Distending Lateral Synovial Recess Lateral Meniscus Tear/Cyst Lateral Collateral Ligament (LCL) Injuries Excessive Lateral Pressure Syndrome (Ex Lat Pressure)
Lateral synovial recess of knee may contain fluid and findings of synovitis
Imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE in coronal and axial planes
/ DIFFERENTIAL DIAGNOSIS Large Joint Effusion Distending Lateral Synovial Recess Associated with synovitis May be posttraumatic +/- Hemorrhage +/- Osteoarthritis Hyperintense on TZWI
Lateral Meniscus TearICyst Suggestive clinical examination symptoms Antecedent trauma MRI diagnostic Tear often filled with fluid o Hyperintense on T2WI Anterior horntbody
Lateral Collateral Ligament (LCL) Injuries Posttraumatic Pain with stress on injured structures Varus stress injury or complex twisting injury Hyperintense on T2WI
Popliteus Tendinosis Pain during external rotation May be posttraumatic or often due to chronic microtrauma +/- Fluid in tendon sheath
Lateral Hamstring (Biceps Femoris) Strains Painful to direct palpation More posterior to ITB Posttraumatic or due to chronic microtrauma Hyperintense on T2WI Isolated injury is rare
Pathology Lateral synovial recess of the knee can be visualized arthroscopically Typically not inflamed or distended with fluid unless ITB friction syndrome is present Chronic frictional trauma when ITB rubs on outer aspect of the lateral femoral
Clinical Issues
.
Most common signs/syrnptoms: Patients present with anterolateral knee pain at the level of ITB Responds to conservative therapy
Diagnostic Checklist Consider when history suggests lateral meniscal tear in athlete
+/- Injury to anterior oblique band
Excessive Lateral Pressure Syndrome (Ex Lat Pressure) Chondromalacia of lateral patella Edema in superolateral Hoffa's fat pad Abnormal tracking of patella Chronic microtrauma Hyperintense on T2WI
lnfrapatellar Bursitis (Infrapat Bursitis) Fluid inferior and anterior to ITB on MRI o Hyperintense fluid on T2WI More anterior than lateral pain Seen with occupational stresses o Carpet layers, housemaids
Lateral Bone Injuries Including Lateral Tibial Plateau (LTPI Fx) Posttraumatic Associated with ACL tears Segond fx (avulsion fx of lateral tibia1 plateau) Posterior lateral tibia fx Sulcus terminalis impaction fx
1 PATHOLOGY
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General Features General path comments o Lateral synovial recess of the knee can be visualized arthroscopically Typically not inflamed or distended with fluid unless ITB friction syndrome is present o Contact of the ITB against the condyle greatest between 20" and 30" o Adventitial bursa1 extension from the synovial capsule deep to ITB and superficial to LFC = Lateral synovial recess (LSR) rn +/- Inflammation Etiology o Chronic frictional trauma when ITB rubs on outer aspect of the lateral femoral condyle
lLlOTlBlAL BAND SYNDROME o Overuse injury especially in runners o Nonrunning knee flexion activities are also at risk
Cyclists Football Soccer Tennis players Skiers Weightlifters Epidemiology o 1.6-52% depending on the population studied o Most common cause of lateral knee pain in long-distance runners
Resolution of symptoms excellent with cessation of inciting activity
Treatment Conservative o Steroid injection into painful site o Orthotics designed to alleviate frictional trauma
1 DIAGNOSTIC CHECKLIST Consider Synovitis or other cause of effusion distending the lateral aspect of the joint
Gross Pathologic & Surgical Features Nonspecific soft tissue edema Thickened iliotibial band in some cases Inflamed lateral synovial recess of the knee
Image Interpretation Pearls FS PD FSE most sensitive Consider when history suggests lateral meniscal tear in athlete
Microscopic Features Nonspecific soft tissue edema and inflammatory infiltration within soft tissues Thickened synovium with variable amount of inflammation within the lateral synovial recess
Staging, Grading or Classification Criteria Extrinsic - training technique Intrinsic - patient's anatomic alignment
1. 2. 3.
Presentation Most common signslsymptoms: Patients present with anterolateral knee pain at the level of ITB Clinical profile o Typically seen in runners (especially long distance), cyclists and in some contact sport athletes o Point tenderness - 3 cm proximal to lateral joint line (superficial to lateral epicondyle) o Full extension Iliotibial band anterior to femoral epicondyle o With flexion - iliotibial band rides over lateral epicondyle o Symptoms progressive usually after 2 to 3 miles of running o Asymptomatic at rest Clinical tests o Ober's test to assess iliotibial band tightness Affected knee is flexed to 90 degrees with ipsilateral hip abduction and hyperextension Positive Ober's test: Tight iliotibial band prevents leg from dropping inferior to a horizontal plane (patient is on their side with examined extremity on top) o Positive Noble's test Patient lying supine with kneed flexed 90 degrees Pain at 30 to 40 degrees of flexion with applied pressure to iliotibial band during knee extension
Demographics Age: Young active patient Gender: No predilection
Natural History & Prognosis Responds to conservative therapy
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5. 6. 7. 8.
9. 10. 11.
12. 13. 14. 15. 16.
DeLee J et al: Orthopaedic sports medicine: Principles and practice. vol 1. 2nd ed. Philadelphia PA, Saunders 28:1577-2154, 2003 Farrell KC et al: Force and repetition in cycling: Possible implications for iliotibial band friction syndrome. Philadelphia PA, Elsevier Science 10(1):103-9,2003 Kirk KL et al: Iliotibial band friction syndrome. Orthopedics. 23(11):1209-14; discussion 1214-5; quiz 1216-7,2000 Muhle C et al: Iliotibial band friction syndrome: MR imaging findings in 16 patients and MR arthrographic study of six cadaveric knees. Radiology 212(1):103-10, 1999 Krivickas LS: Anatomical factors associated with overuse sports injuries. Sports Med 24(2):132-46, 1997 Nemeth WC et al: The lateral synovial recess of the knee: Anatomy and role in chronic Iliotibial band friction syndrome. Arthroscopy 12(5):574-80, 1996 Orchard JW et al: Biomechanics of iliotibial band friction syndrome in runners. Am J Sports Med 24(3): 375-9, 1996 Messier SP et al: Etiology of iliotibial band friction syndrome in distance runners. Med Sci Sports Exerc 27(7):951-60, 1995 DeLee JC: Orthopaedic sports medicine: Principles and practice. vol 2. Philadelphia PA, WB Saunders, 1251-2, 1994 Ekman EF et al: Magnetic resonance imaging of iliotibial band syndrome. Am J Sports Med 22(6):851-4, 1994 Holmes JC et al: Iliotibial band syndrome in cyclists. Am J Sports Med 419-24, 1993 Firer P et al: Results of surgical management for iliotibial band friction syndrome. Clin J Sport Med 2247-50, 1992 Linenger JM et al: Is iliotibial band syndrome overlooked? Phys Sports Med 20:98-108, 1992 Murphy BJ et al: Iliotibial band friction syndrome: MR imaging findings. Radiology 185(2):569-71, 1992 Lebsack D et al: Iliotibial band friction syndrome. JNATA 356-61,1990 Noble CA: Iliotibial band friction syndrome in runners. Am J Sports Med 8(4):232-4, 1980
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I IMAGE GALLERY
ILIOTIBIAL BAND SYNDROME -
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(Left) Coronal FS PD FSE MR shows edema (arrow) interposed between the iliotibial band and the lateral femoral condyle in a cyclist complaining of anterolateral knee pain. (Right) Axial FS PD FSE MR demonstrates edema/hyperemia posterior to the lateral suprapatellar joint recess.
(Lef)Coronal FS PD FSE MR shows the typical findings of ITB friction with edema (arrow) interposed between the ITB and the lateral femoral condyle in a runner with lateral knee pain. (Right) Axial PD FSE MR shows thickened indurated soft tissue (arrow) between the ITB and LFC.
(Left) Coronal FS PD FSE MR shows a thickened IT5 (arrow) with surrounding edema in a patient with chronic symptoms of ITB friction. (Right) Axial FS PD FSE MR shows edema and fluid in the superolateral aspect of Hoffa's fat pad as well as deep to the ITB (arrow) in association with femoral trochlear chondromalacia. Chronic frictional syndromes may coexist.
OSTEOCHONDRAL INJURIES, KNEE
Coronal oblique graphic shows a grade IV chondral defect of the posterior medial femoral condyle. Note the underlying edema of the medial femoral condyle.
Sagittal FS PD FSE MR shows a large osteochondral defect of the posterior lateral femoral condyle with a displaced fragment (arrow) into the anterior aspect of the joint.
Radiographic Findings Radiography o +/- Fracture o +/- Subchondral sclerosis in chronic cases
Abbreviations and Synonyms Osteochondral injury (OCI) 74
Definitions Injury to articular cartilage, +/- underlying bone fracture, bone trabecular injury or associated reactive stress response
I IMAGING FINDINGS
CT Findings NECT o +/- Visible fracture o +/- Subchondral sclerosis in chronic cases CT arthrography o Chondral defect filled with contrast
MR Findings -
General Features
TlWI o Hypointense subchondral edema o +I-~ypointense fracture T2WI o Focal hyaline articular cartilage defect o Well-defined chondral defect or defect with irregular borders, +/- filled with hyperintense fluid o +/- Underlying bone marrow edema (hyperintense) o +/- ~ ~ ~ o i n t e n s- itrabecular ty compaction o FS PD FSE - increased signal intensity in hyaline articular cartilage defects Bone marrow edema (hyperintense) associated with presence of chondral injury Chondral defect visualized with hyperintense tissue, flap or full thickness gap
Best diagnostic clue: Alteration in contour and/or signal of hyaline articular cartilage with underlying bone changes Location o Weight bearing hyaline cartilaginous surfaces of the knee Medial compartment four times more common than lateral compartment Size: From small chondral defect (mm) to large area of cartilage injury including denudation Morphology: Varies from well-defined to irregular chondral defect, associated with underlying bone changes
I
HH DDx: Osteochondral Iniuries. Knee , Pl~ysealClosure
OCD
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OSTEOCHONDRAL INJURIES, KNEE Key Facts Terminology Injury to articular cartilage, +I-underlying bone fracture, bone trabecular injury or associated reactive stress response
Imaging Findings Best diagnostic clue: Alteration in contour and/or signal of hyaline articular cartilage with underlying bone changes Focal hyalge articular cartilage defect FS PD FSE - increased signal intensity in hyaline articular cartilage defects Protocol advice: FS PD FSE in at least 2 planes
Pathology
Meniscal tears, ligamentous sprains, soft tissue injuries, hematomas Loose bodies
Clinical Issues Most common signs/symptoms: Intermittent locking, recurrent effusions, crepitus, and persistent pain Chondral repair or isolated defect with secondary arthritic change
Diagnostic Checklist Underlying bone marrow edema associated with presence of chondral injury Check for increased signal intensity or fluid in hyaline cartilage
Etiology: Rotational forces and direct trauma most common, may secondarily involve subchondral bone Chondral fragments are intermediate in signal intensity +/- displacement o T2 FSE similar to FS PD FSE except marrow edema is not well shown PDIIntermediate o Increased signal intensity in hyaline articular cartilage defect o Suboptimal visualization of subchondral marrow edema or sclerosis STIR o Hyperintense as in FS PD FSE but with less spatial resolution o Increased signal intensity in hyaline articular cartilage +/- underlying bone o Chondral defect +/- filled with hyperintense fluid more difficult to appreciate than on T2WI at high field strength T2* GRE o Bone marrow edema can be obscured by susceptibility artifact o T2* WI shows joint fluid isointense to cartilage Defects difficult to visualize Useful for free fragment (hypointense) visualization within joint capsule
Nuclear Medicine Findings Bone Scan: Increased uptake of radiotracer in case of bone involvement
lmaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE in at least 2 planes
Osteochondritis Dissecans (OCD) Affects specific areas in adolescent patients o Lateral aspect of medial femoral condyle o +/- Synovitis o Single focal area o Variant of osteochondral defect
Osteoarthritis (OA) Initial osteochondral injuryldefect Gradual, insidious onset Subchondral cysts Subchondral edema Subchondral sclerosis Older patient and/or post traumatic patient
Magic Angle Artifact Mild high signal especially with shorter TE sequence In areas oriented at 55 degrees to the external magnetic field o Upsloping areas of hyaline articular cartilage adjacent to the notch
Bucket-Handle Tear Displaced hypointense meniscus into intercondylar notch Foreshortened posterior horn of meniscus Locked knee in flexion
Healing Nonossifying Fibroma (NOF) Not subchondral Well-defined sclerotic border Eccentric
Physeal Closure Normal development Mimics subchondral fracture Mistaken for avascular necrosis (AVN) sclerotic interface
General Features General path comments o Tidemark zone is the weakest part of hyaline articular cartilage and is most often disrupted Between the overlying cartilage and subchondral bone o Shearing injuries often produce chondral rather than osteochondral injury
OSTEOCHONDRAL INJURIES, KNEE o Mild lesion as increased signal intensity on FS PD FSE in hyaline articular cartilage o Fibrillation, fissuring, flap lesion, defect or osteochondral fracture in severe case * Etiology: Rotational forces and direct trauma most common, may secondarily involve subchondral bone Epidemiology: Occurs in young active patients Associated abnormalities o Meniscal tears, ligamentous sprains, soft tissue injuries, hematomas o Loose bodies
Improve mobility, decrease pain No long term benefits reported Surgical o Abrasion chondroplasty vs. debridement Debridement alone - 66% good results at 5 years o Chondral resurfacing techniques Chondral defects without malalignment and intact meniscus o Microfracture-marrowstimulating procedure causing development of fibrocartilage/hyaline cartilage 97% compliance, improvement at follow up Steadman technique o Osteochondral autografts = OATS Resurfacing grade IV defects with small plugs OATS small plugs (mosaicplasty)- multiple small plugs, 4 mm OATS large plugs - 6-10 mm plugs, greater stability Favorable results - 80-94% improvement o Osteochondral allograft - larger defects, tumor, OCD Increased complications compared to autografts infection o Autologous chondrocyte implantation (ACI) 4 Large defects (> 15 mm) - femur, patella, trochlea Unipolar lesion in normally aligned knee, intact meniscus, no inflammatory disease Expensive Biopsies have shown more fibrocartilage in ACI vs. hyaline cartilage in OATS
Gross Pathologic & Surgical Features Mild lesion on MRI may show minimal abnormality at gross inspection Progresses to mild fibrillation (discoloration with soft cartilage) Fissures to chondral flaps followed by partial and full thickness chondral defects Bone injuries ranging from bone trabecular injury to displaced fracture
Microscopic Features Chondrocyte disruption followed by swelling If underlying bone is involved, blood vessels are ru~tured& hematoma is formed ~ d n cells e without blood flow die, while perfused bone cells undergo healing process
Staging, Grading or Classification Criteria Outerbridge classification for chondromalacia o Grade 07 ~ o r m acartilage l o Grade I: Chondral softening and swelling MRI: Increased signal intensity o Grade 11: Partial thickness defect with fissuring surface that does not extend to subchondral bone 01 defect which does not exceed 1.5 cm in diameter MRI: Surface irregularity o Grade 111: Fissuring to the level of subchondral bone in an area with a diameter more than 1.5 cm MRI: Partial to small full thickness defect o Grade IV: Exposed bone MRI: Subchondral involvement
1 DIAGNOSTIC CHECKLIST Consider In posttraumatic setting Underlying bone marrow edema associated with presence of chondral injury
Image Interpretation Pearls Check for increased signal intensity or fluid in hyaline cartilage
1 SELECTED REFERENCES I.
Presentation Most common signs/symptoms: Intermittent locking, recurrent effusions, crepitus, and persistent pain
Demographics Age: Younger active patient, usually < 40 years Gender: M > F
2. 3. 4.
Natural History & Prognosis Chondral repair or isolated defect with secondary arthritic change
5.
Treatment Conservative o Rest followed by physical therapy o NSAIDs o Glucosamine/Chondroitin Not monitored by FDA
1
6.
McCauley TR: MR imaging of chondral and osteochondral injuries of the knee. Radiol Clin North Am 40(5):1095-107, 2002 Morelli M et al: Management of chondral injuries of the knee by osteochondral autogenous transfer (mosaicplasty). J Knee Surg 15(3):185-90, 2002 Hjelle K et al: Articular cartilage defects in 1,000 knee arthroscopies. Arthroscopy 18(7):730-4, 2002 Wang CJ: Treatment of focal articular cartilage lesions of the knee with autogenous osteochondral grafts A2 - to 4-year follow-up study. Arch Orthop Trauma Surg 122(3):169-72, 2002 Sanders TG et al: Autogenous osteochondral "plug"transfer for the treatment of focal chondral defects: Postoperative MR appearance with clinical correlation. Skeletal Radiol 30(10):570-8,2001 Sledge SL: Microfracture techniques in the treatment of osteochondral injuries. Clin Sports Med 20(2):365-77, 2001
OSTEOCHONDRAL INJURIES, KNEE
I IMAGE GALLERY Variant
(Left) Sagittal oblique graphic shows an osteochondral defect with slight displacement of the weightbearing surface of the medial femoral condyle. (Right) Sagittal FS PD FSE MR shows a hyaline chondral fracture with the flipped cartilaginous fragment (arrow) located adjacent to the donor site of lateral femoral condyle.
(Left) Coronal FS PD FSE MR shows a grade IV chondral defect of the weightbearing surface of the medial femoral condyle with underlying edema. (Right) Sagittal T2 FSE MR shows a displaced hyaline chondral fragment (arrow) within the suprapatellar recess laterally.
Variant (Left) Sagittal PD FSE MR shows a grade 11-111hyaline chondral defect (arrow) of the posterolateral tibia1 plateau. (Right) Axial FS PD FSE MR shows a chondral defect (arrow) of the medial femoral condyle. On axial images the fluid filled defect appears as a puddle giving rise to the "puddle sign. "
OSTEOCHONDRlTlS DISSECANS, KNEE
Coronal oblique graphic shows an osteochondral defect of the lateral aspect of the weightbearing surface of the medial femoral condyle. This findings is characteristic of OCD.
-
Coronal PD FSE MR shows osteochondritis dissecans of the lateral aspect of the medial femoral condyle. This is a classic location for this lesion.
o Enhancement of granulation tissue on post MR
contrast enhanced images between donor site and fragment
Abbreviations and Synonyms Osteochondritis dissecans (OCD) -.> / II
Radiographic Findings Radiography o Area of sclerosis Affecting the lateral aspect of the medial femoral condyle with or without loose fragment
Definitions
Osteochondrosis/osteonecrosis followed by reossification and healing
CT Findings General Features Best diagnostic clue: Osteochondral segment with +/stable or unstable osteochondral fragment in typical location in young males Location: Lateral aspect of medial femoral condyle subarticular surface, can also affect weight bearing surface of the lateral femoral condyle, tibia or patella Size: Osteochondral fragment of variable size either contiguous with the donor site or detached from it Morphology: Hyaline cartilage with underlying bone forming a crescentic/oval bonelcartilage fragment Predictors of instability of bonelcartilage fragment include o Large size (greater than 1 cm) o Fluid interface between the fragment and donor site o Cystic areas within the donor site
NECT o Osteochondral fragment o Helpful in identifying and characterizing fragments CT arthrography o Contrast beneath fragment - indicator for instability o Loose fragments identified within contrast pool
MR Findings TlWI o Osteochondritis dissecans site Hypointense intensity with variable amounts of edema +/- Adjacent donor site o Hypointense subchondral edema o Slightly hyperintense thickened synovium = synovitis T2WI 0 Osteochondritis dissecans site
mHM -
DDx: Osteochondritis Dissecans,
Knee
Cor FS PD FSE
Cor PD FSE MR
Cor FS PD FSE
Volume Averaging
Sag FS PD FSE
Osteochondral In/
; PD FSE h4R
OSTEOCHONDRITIS DISSECANS, KNEE Key Facts Terminology Osteochondrosis/osteonecrosisfollowed by reossification and healing
Imaging Findings Best diagnostic clue: Osteochondral segment with +/stable or unstable osteochondral fragment in typical location in young males Location: Lateral aspect of medial femoral condyle subarticular surface, can also affect weight bearing surface of the lateral femoral condyle, tibia or patella
Top Differential Diagnoses Osteochondral Fracture Normal Pediatric Fusing Apophysis
Hyperintense signal intensity with variable amounts of edema o FS PD FSE demonstrates direct extension of subchondral fluid indicating instability o +/- Hyperintense subchondral edema o +/- Hyperintense subchondral cysts PDIIntermediate o Focus of osteochondritis dissecans Hyperintense with variable amounts of edema Edema may be relatively isointense to marrow o Hyperintense thickened synovium = synovitis * MR arthrography o Contrast beneath fragment - indicator for instability o Loose fragments All pulse sequences may demonstrate loose osteochondral fragments
Nuclear Medicine Findings Bone Scan: Increased uptake with bone reactive change +/- instability
Imaging Recommendations Best imaging tool: MRI, MR arthrography Protocol advice o Overlying defects in articular cartilage best appreciated on FS PD FSE and STIR o Chondral fragments are best seen on FS PD FSE o MR arthrography: Improves visualization of fluid across the articular cartilage surface thus helping determine whether the lesion is stable or unstable
I DIFFERENTIAL DIAGNOSIS Insufficiency Fracture Typically older osteoporotic patient Spontaneous osteonecrosis (SONK) Postoperative patient with disuse osteoporosis
Stress Fracture Usually in sports setting Hyperintense subchondral edema (T2) Stress response without fracture line
Pathology Unstable lesions Loose fragment
Clinical Issues Insidious onset with gradual increase in pain followed by healing Predisposing trauma history found in approximately 50% of patients Spontaneously heal unless unstable fragment forms
Diagnostic Checklist Measure size of fragment and evaluate underlying bone for stability
Osteochondral Fracture Post traumatic Not in typical OCD location
Normal Pediatric Fusing Apophysis Posterior lateral femoral condyle Can be medial Usually asymptomatic
Volume Averaging May mimic OCD in region of intercondylar notch Not typical location of OCD
1 PATHOLOGY General Features General path comments o Unstable lesions Large size (typically > 1 cm) Cyst-like lesion beneath osteochondrotic lesion Contains loose granulation tissue o Loose fragment Fluid insinuating beneath the fragment at arthrography Loose body formation and residual deformity often present Etiology o Idiopathic Trauma implicated in up to 50% Cyclic, cumulative stress to subchondral bone Epidemiology o Common disorder in young adults o Peak prevalence in preteen age group Distribution o Bilaterality in 20-25% rn Bilateral lesions - asymmetric
Gross Pathologic & Surgical Features Lateral posterior aspect of medial femoral condyle in 70-80% of cases Necrotic desiccated bone fragment in unstable lesions
1
OSTEOCHONDRlTlS DISSECANS, KNEE Extended classic lesion also involves medial femoral trochlea
Microscopic Features Osteonecrosis with variable amounts of healing Fracture, inflammation and vascular compromise Subchondral avascularity Alteration of articular cartilage basilar growth Creeping substitution in revascularization Inadequate repair - avascular centrum + articular cartilage disruption Modulus mismatch between lesion and surrounding articular surface + subchondral zones o Subchondral fracture Synovial fluid intrusion at junction of subchondral centrum o Limits healing
Staging, Grading or Classification Criteria
811
Based on arthroscopic findings o Stage 1: Lesion measures 1 to 3 cm with intact articular cartilage o Stage 2: Articular cartilage defect without loose body o Stage 3: Partially detached osteochondral fragments with or without fibrous tissue interposition o Stage 4: Loose body formation Cahill classification into five stages based on radiographic and bone scan findings o Stage 0: Normal o stage I: Radiographs abnormal and normal bone scan o Stage 11: Increased uptake on bone scan o Stage 111: Increased bone scan uptake in lesion and femoral condyle o Stage IV: Increased uptake in adjacent tibia1 plateau
Not monitored by FDA Might lead to improved mobility, decreased pain No long term benefits reported Chondral resurfacing technique 0 Chondral defects without malalignment and with intact meniscus * Microfracture - marrow stimulating procedure o Leads to development of fibrocartilage/hyaline cartilage o 97% compliance, improvement at follow up Steadman technique Osteochondral autografts = OATS 0 Resurfacing of full thickness defects with small plugs 0 OATS small plugs (mosaicplasty)- multiple small plugs, 4 mm o OATS large plugs - 6-10 mm plugs, greater stability Favorable results - 80-94% improvement Donor site morbiditv Osteochondral allograft - gross, larger defects, tumor, OCD o Increased complications compared to autografts infection Chondrocyte implantation o Large defects (> 15 mm) - femur, patella, trochlea o Unipolar lesion in normally aligned knee, intact meniscus, no inflammatory disease o Expensive o Good results
Consider If osseous fragment is in lateral aspect of medial femoral condyle
Image Interpretation Pearls Presentation Most common signs/symptoms o Insidious onset with gradual increase in pain followed by healing Lockinglpain if unstable fragment forms Clinical profile o Predisposing trauma history found in approximately 50% of patients o Young athletes o Activity-related pain o +/- Clicking and catching o Localized tenderness over the lesion o Antalgic gait
Demographics Age: Primarily affects patients 10 to 20 years Gender: M > F (M:F = 5:3)
Natural History & Prognosis Spontaneously heal unless unstable fragment forms
Treatment Conservative o Rest followed by physical therapy 0 NSAIDs o Glucosamine/chondroitin
Measure size of fragment and evaluate underlying bone for stability
1 SELECTEDREFERENCES
I
DeLee J et al: Orthopaedics. vol 1. 2nd ed. Philadelphia PA, Saunders, 1577-2154, 2003 Yoshizumi Y et al: Cylindrical osteochondral graft for osteochondritis dessecans of the knee: A report of three cases. Am J Sports Med 30(3):441-5, 2002 Fitzgerald R Jr et al: Orthopaedics. Pediatric orthopaedics. St. Louis MO, Mosby, 1489-95, 2002 Gaweda K et al: Repair of focal chondral lesions of femoral condyles treated with osteochondral autograft. Ruchu Ortop Pol 67(3):247-53, 2002 Farmer JM et al: Chondral and osteochondral injuries. Diagnosis and management. Clin Sports Med 20(2):299-320,2001 Sales de Gauzy JC et al: Natural course of osteochondritis dissecans in children. J Pediatr Orthop B 8(1):26-8, 1999 Long G et al: Magnetic resonance imaging of injuries in the child athlete. Clin Radio1 54(12):781-91, 1999 Lafforgue P et al: Insufficiency fractures of the medial femoral condyle. Rev Rhum Engl Ed 63(4):262-9, 1996 Cahill BR: Osteochondritis dissecans of the knee: Treatment of juvenile and adult forms. J Am Acad Orthop Surg 3(4)237-47, 1995
OSTEOCHONDRlTlS DISSECANS, KNEE IMAGE GALLERY (Left) Coronal PD FSE MR shows a large defect indicating a displaced fragment. (Right) Sagittal PD FSE MR shows the inverted fragnient (arrow) in the anterior aspect of the notch of the knee, anterior to the ACL.
(Left) Sagittal PD FSE MR shows a fragmented OCD lesion with a grade IV defect (full thickness) of the anterior aspect. Thi5 finding should prompt a search for a loose fragment in other joint recesses. (Right) Axial FS PD FSE MR shows the free osteochondral fragment (arrow) within the suprapatellar pouch.
(Left) Sagittal FS PD FSE MR shows an osteochondritis lesion greater than 1 cm with fluid signal intensity between the fragment and the donor site. These are signs of instability even if the fragment is "in situ". (Right) Coronal FS PD FSE MR shows high signal at the base of the osteochondrotic lesion. Note the congruous hyaline cartilage surface. This lesion has remained stable.
BONE INFARCT, KNEE
-
Coronal graphic shows medullary infarcts involving the posterior aspect of the femoral condyles. Note the geographic appearance of the infarcts.
Coronal FS PD FSE MR shows the double line sign of a medullary infarct in the proximal tibia.
o Irregular serpiginous linear structures described as "chinese figures" o Serpiginous hypointense peripheral sclerosis and central marrow fat signal intensity
Abbreviations and Synonyms Bone infarct (BI), avascular necrosis (AVN), osteonecrosis, aseptic necrosis, ischemic necrosis, ischemic bone death, bone necrosis, bone death
Radiographic Findings Radiography o Epiphysis: Arc-like, subchondral, lucent lesion +/areas of patchy bone loss mixed with sclerotic areas (subchondral fracture may occur) o In diametaphyseal region, sheetlike lucency surrounded by shell-like sclerosis and/or calcification and periostitis 0 Findings delayed from initial event
Definitions Ischemic death of cellular elements of bone and marrow
General Features Best diagnostic clue o Serpiginous border or outline in subchondral cancellous marrow o "Double line sign" of decreased signal intensity periphery with adjacent increased signal intensity inner border on T2WI Location 0 Subchondral cancellous bone, can extend to subchondral plate o Metaphyseal more common than epiphyseal or diaphyseal Size: Varies from small to large areas of affected bone Morphology
CT Findings NECT o Serpiginous outline o Increased density
MR Findings TlWI o Serpiginous lines of decreased signal intensity o Edema: Moderate decrease in signal intensity T2WI o Double line sign of decreased signal intensity periphery with adjacent hyperintense inner border
DDx: Bone Infarct, Knee OCD
/
6
=
4
3
* Cor PD FSE MR
1-
Cor FS PD FSE
C ,
Sag PD FSE MR
Cor PD FSE MR
Sag FS PD FSE
BONE INFARCT, KNEE Key Facts Terminology Ischemic death of cellular elements of bone and marrow
Imaging Findings "Double line sign" of decreased signal intensity periphery with adjacent increased signal intensity inner border on T2WI Protocol advice: TI, FS PD FSE or T2WI and STIR sensitive
Top Differential Diagnoses Osteoarthritis (OA) Enchondroma (MRI and Radiography) Osteochondral Injury
o Double lines may form pseudomass in chronic cases
and internal marrow fat is preserved distinguishing infarct from tumor o Variable degrees of collapse of articular surface in advanced cases o Acute infarct as a less well-defined area of edema within cancellous bone o Well-marginated cyst in cystic degeneration PDIIntermediate o Generally same as T2 but less sensitive for edema o PD FSE less sensitive for sclerosis compared to TlWI o FS PD FSE contrast with increased sensitivity for edema compared to PD or T2 FSE o To evaluate overlying chondral surfaces in subarticular infarcts STIR: More hyperintense periphery but with less spatial resolution than FS PD FSE T2*'GRE o Double line sign o Edema may be obscured because of susceptibility T1 C+: Peripheral rim of reactive tissue may enhance
Nuclear Medicine Findings Bone Scan o "Cold spot" (no uptake) in region of disrupted blood supply o Uptake in acute cases where revascularization has occurred (nonspecific and somewhat diffuse)
Imaging Recommendations Best imaging tool: MRI - T1 and T2 are diagnostic Protocol advice: TI, FS PD FSE or T2WI and STIR sensitive
I DIFFERENTIAL DIAGNOSIS Osteoarthritis (OA) Subchondral changes o Chronic symptoms and typical radiographic and MRI findings o Chondromalacia o Subchondral cysts, edema, sclerosis
Pathology General path comments: Patient with predisposing factor - steroid use or underlying disease such as sickle cell anemia Compromises of blood supply to the bone Steroid-induced osteonecrosis: 2% to > 25%
Clinical Issues Clinical features of bone infarct depend on stage of disease, often asymptomatic
Diagnostic Checklist Underlying abnormality that led to infarct In contrast to spontaneous osteonecrosis infarcts are usually metaphyseal
Stress Fracture Lacks double line sign morphology Abnormal stresses of activity (usually athletic) on normal bone Suggestive history
Enchondroma (MRI and Radiography) Marrow involved in center of lesion on MRI Chondroid matrix
Infection Vague areas of radiolucencies in infarct may mimic infection
Marrow Tumor Areas of radiolucencies in infarct may mimic neoplastic processes Medullary marrow replaced in neoplasm Lack of cortical disruption in infarct Well-marginated cyst differentiates cystic degeneration of infarct from malignant degeneration
Non Ossifying Fibroma (NOF) Children and adolescents Healing NOF may mimic infarct o Seen in younger patients without predisposing disease
Osteochondral Injury History of trauma Affects chondral surface and subchondral bone Osteochondritis dissecans (OCD) +/- history of trauma o Young patient
Normal Marrow Red marrow inhomogeneity in metaphyseal region will not extend distal to physeal scar
BONE INFARCT, KNEE
1
Stage 4: Articular surface collapse + superimposed osteoarthritic changes
General Features General path comments: Patient with predisposing factor - steroid use or underlying disease such as sickle cell anemia Etiology o Compromises of blood supply to the bone o Intrinsic or extrinsic abnormality in blood vessel supplying part of the bone may lead to infarct o Predisposing factor or disease 9 Trauma Renal transplant Steroids (endogenous and exogenous including Cushing's syndrome) Collagen vascular disease (e.g., systemic lupus erythematosus - SLE) Pancreatitis Alcoholism Gaucher's disease, Fabry's disease, sickle cell anemia, gout Arteritis (radiation and other causes) Epidemiology o Steroid-induced osteonecrosis: 2% to > 25% o SLE: 5-40% o Alcohol: Up to 60% Associated abnormalities: Secondary osteoarthritis may occur with associated complications
.
n4
Gross Pathologic & Surgical Features Pale bone marrow with variable degrees of necrosis depending on age of infarct and duration of ischemia Secondary osteoarthritis develops after structural failure and collapse of articular surface cartilage Cystic degeneration in areas of bone infarction in diaphysis of femur and tibia
Microscopic Features Medullary necrosis appears yellowish with occasional flecks of calcium Serpiginous capsule of grayish glistening collagen may surround the area of necrosis Variability in depth of the yellow necrotic marrow in subchondral necrosis Vascular granulation tissue or grayish glistening collagen separates dead tissue from underlying viable bone At border zone between dead and living bone o Dead bone trabeculae may be broadened by formation of new bone on surface Leads to decreased and increased signal intensity of double line sign
Presentation Most common signs/symptoms o Clinical features of bone infarct depend on stage of disease, often asymptomatic o +I- Generalized pain
Demographics Age o Varies and depends on underlying disease Patients with sickle cell anemia may present with bone infarcts in the first few decades of life Gender o Posttraumatic infarcts are more common in young males o Spontaneous infarcts around knee in adults, F > M 0 Malignant transformation occurs more frequently in men Ethnicity o Infarcts associated with sickle cell anemia are seen in patients of African descent o Bone infarcts associated with Gaucher's disease are seen in the Ashkenazi population
Natural History & Prognosis Occurs suddenly and often heals without residue unless progression of underlying disease Malignant transformation rare
Treatment Idiopathic lesions treated conservatively
~D~AGNOST CHECKLIST ~C Consider Underlying abnormality that led to infarct
Image Interpretation Pearls Infarct in case of serpiginous lineldouble line findings In contrast to spontaneous osteonecrosis infarcts are usually metaphyseal Epiphyseal and diaphyseal locations also occur for bone infarcts
1.
Staging, Grading or Classification Criteria Stage 0: Asymptomatic, normal radiograph, abnormal histology Stage 1: +I- Symptoms, normal radiograph, abnormal signal on MRI, abnormal histology Stage 2: Symptomatic, radiograph shows osteopenia, sclerosis, MRI characteristic (serpiginous lineldouble line sign) Stage 3: Symptomatic, subchondral lucency, subchondral collapse, joint space preserved
2.
3. 4.
Lau WF et al: Extensive bone infarct in myeloid leukemia correlation of bone scan and magnetic resonance imaging. Clin Nucl Med 26(2):165-6, 2001 Skaggs DL et al: Differentiation between bone infarction and acute osteomyelitis in children with sickle-cell disease with use of sequential radionuclide bone-marrow and bone scans. J Bone Joint Surg Am 83(12):1810-3,2001 Cerilli LA et al: Angiosarcoma arising in a bone infarct. Ann Diagn Path01 3(6):370-3,1999 Ahn BC et al: Intramedullary fat necrosis of multiple bones associated with pancreatitis. J Nucl Med 39(8):1401-4, 1998.
BONE INFARCT, KNEE IMAGE GALLERY Typical (Left) Sagittal PD FSE MR shows an extensive infarct of the proximal tibia with a characteristic double line sign (arrow). (Right) Sagittal FS PD FSE MR shows the T2-like appearance of the chronic infarct.
Typical (Left) Axial FS PD FSE MR shows a chronic medullary infarct with lack of internal edema. The patient is asymp toma tic. (Right) Coronal FS PD FSE MR shows an acute hyperintense infarct of the medial femoral condyle & tibia1 plateau.
(Left) Sagittal PD FSE MR shows a chronic infarct within the posterior aspect of the medial femoral condyle. Note the preservation of bone marrow within the borders of the lesion differentiating this from a neoplasm. (Right) Axial FS PD FSE MR shows a chronic infarct of the posterior aspect of the medial femoral condyle with acute edematous changes at the anterior margin = extending infarct.
SPONTANEOUS OSTEONECROSIS, KNEE
Oblique coronal graphic shows a focus of subchondral devitalized bone involving the weightbearing surface of the medial femoral condyle.
Coronal FS PD FSE MR shows SONK of the medial femoral condyle as a nondisplaced fx (arrow), in an elderly osteoporotic female with pain after climbing stairs with a heavy sack ofgroceries.
o Focus of edema varies from small to large area of the
condvle o Fracture line (if present) varies from few millimeters
Abbreviations and Synonyms
to centimeters Morphology: Diffuse increased signal intensity (edema) within the subchondral bone +/- crescentic linear iacture line in subchondral location
Spontaneous osteonecrosis (SONK), spontaneous idiopathic osteonecrosis, Ahlback disease
Definitions Necrosis of the weight-bearing portion of the femur or tibia with associated subchondral fracture and collapse o Affects weight-bearing portion of the medial femoral ,-,.n~.,~c. L U l L U Yl C
Radiographic Findings Radiography +/- Subchondral sclerosis o +/- Articular surface collapse o Effusion o
o May affect lateral femoral condyle
M R Findings General Features Best diagnostic clue o Diffuse increased signal intensity on FS PD FSE within subchondral bone o Crescentic linear subchondral fracture line common o Elderly patient, usually female Location o Weight-bearing portion of the medial femoral condyle o +/- Weight-bearing portion of the lateral femoral condyle or either tibia1 plateau Size
I
1
TlWI o Necrosis: Discrete area of subchondral decreased signal intensity o Lesion surrounded by area of intermediate signal intensity Mixture of edema and normal fatty marrow T2WI o Focus of low signal intensity ischemia or fracture surrounded by diffuse increased signal intensity edema o +/- Linear often serpiginous low signal abnormality adjacent to the edema Probable fracture o +/- Articular surface collapse
1
DDx: Spontaneous Osteonecrosis, Knee
Sag PD FSE M R
Sag FS PD FSE
Cor FS PD FSE
Cor FS PD FSE
Cor PD FSE MR
I
SPONTANEOUS OSTEONECROSIS, KNEE Key Facts Terminology Necrosis of the weight-bearing portion of the femur or tibia with associated subchondral fracture and collapse Affects weight-bearing portion of the medial femoral condyle
Imaging Findings Morphology: Diffuse increased signal intensity (edema) within the subchondral bone +I- crescentic linear fracture line in subchondral location * Focus of low signal intensity ischemia or fracture surrounded by diffuse increased signal intensity edema +/- Linear often serpiginous low signal abnormality adjacent to the edema
o Overlying hyaline articular cartilage may remain
o
o o o
intact or may become detached Hypointense, hyperintense or normal signal Advanced cases may be accompanied by secondary degenerative changes in the adjacent or opposing bone Osteophyte formation rn Subchondral sclerosis Subchondral cyst formation Hyperintense effusion +/- Synovial thickening subchondral marrow edema shows the greatest hyperintensity on FS PD FSE or STIR images
Nuclear Medicine Findings Bone Scan: Positive after 72 hours
Imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE coronal & sagittal
I DIFFERENTIAL DIAGNOSIS Subchondral Fracture Younger active patient May be indistinguishable Stress fx, insufficiency fx (typically older or post-op) or posttraumatic fx
Osteoarthritis Diffuse edema in the early stages before cyst formation (hyperemia) Hyperintense T2WI +/- Overlying chondromalacia +/- Subchondral cyst (geode) +/- Subchondral sclerosis
Osteochondritis Dissecans (OCD) Lateral aspect of the medial femoral condyle (most common) o Non-weight bearing portion Teenage males Usually insidious onset of pain
+/- Articular surface collapse
TOP Differential Diagnoses Subchondral Fracture Osteoarthritis Osteochondritis Dissecans (OCD) Meniscal Tears
Clinical Issues Intense pain often after trivial trauma, typically in elderly female
Diagnostic Checklist Elderly patients, especially female who experiences sudden onset of pain after trivial trauma Identify subchondral fracture line in patient with typical clinical profile
o 50% association with trauma as opposed to sudden
onset with SONK Bone typically not necrotic unless completely detached in OCD
Meniscal Tears Grade 3 meniscal signal (hyperintensity extending to meniscal articular surface or apex) Increased signal on short TE sequence Normal femoral condyle SONK associated with meniscal tears
Medial Bursitis Fluid deep to superficial medial collateral ligament Fluid-filled mass at insertion of pes anserine bursa (hyperintense T2WI) Pain inferior to joint line
Stress ResponseIFracture (HyperemiaIStress) Hyperintense edema on T2WI Reactive edema to adjacent inflammation vs. response to increased mechanical stress +/- Meniscal tear +/- Fracture line
1 PATHOLOGY General Features General path comments: Subchondral osteonecrosis often following trauma in elderly osteoporotic patient Etiology o Controversial rn Traumatic theory - osteoporotic patient suffers insufficiency fracture following trivial trauma, bone subsequently becomes necrotic Vascular theory - thrombotic venous occlusion leading to venous hypertension and hypoxic death - recently less accepted in the knee Epidemiology: Middle-aged and elderly patients Distribution o Weight bearing portion of medial femoral condyle
SPONTANEOUS OSTEONECROSIS, KNEE Surgical o Core decompression Stage I and I1 lesions o Osteochondral allograft Variable results o Proximal tibia1 osteotomy Younger active patients with varus deformity due to collapse of femoral condyle Often performed with arthroscopy for inspection and loose body removal o Knee replacement Advanced cases Complications o Immediate post-operative complications including infection, popliteal artery or venous thrombosis or laceration, articular cartilage abrasions, scuffing or defect formation o Development of progressive osteoarthritis o Malalignment (varus or valgus)
Gross Pathologic & Surgical Features Early stage: Area of slight flattening or discoloration in the articular cartilage over an area of the condyle of variable size, similar to the indentation of a golf ball o Irregular line of demarcation at the edge of the lesion on the surface with a ridge of blemished chondral surface Later stages: Demarcation line becomes more pronounced and flap develops Advanced stages: Fragmentation and degenerative changes
Microscopic Features Early stages: Fibrillation/erosions appear in the layer of the tidemark o Marrow cell lysis, fat cell necrosis, trabecular area demonstrates osteolytic areas Advanced cases: Advanced necrosis with dusky appearance to marrow o Necrotic trabeculae fibrovascular granulation and histiocytic and osteoclastic resorption of necrotic tissue o New bone formation surrounding crater
)DIAGNOSTIC CHECKLIST Consider Elderly patients, especially female who experiences sudden onset of pain after trivial trauma
Staging, Grading or Classification Criteria
8$1
Based on radiography (femoral condyle) o Stage I: Normal, lesion may resolve, may be diagnosed at MRI with diffuse edema, serpiginous fracture line o Stage 11: Subtle flattening of condyle o Stage 111: Lucent subchondral area with sclerotic halo o Stage IV: Sclerotic halo enlarges, collapse ensues o Stage V: Stage IV and degenerative changes
Image Interpretation Pearls Identify subchondral fracture line in patient with typical clinical profile
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1. 2.
Presentation Most common signs/symptoms o Intense pain often after trivial trauma, typically in elderly female o Osteoporotic Clinical profile: Elderly female
Demographics Age: Elderly, most patients > 60 years Gender: F > M
Natural History & Prognosis Resolve spontaneously Advance with development of secondary degenerative change requiring knee replacement Satisfactory result: Decrease in symptoms after 6 weeks with persistent mild pain for up to 15 months o Radiographically normal or small lesion Poor result: Lesions with greater than 50% of femoral condylar width on radiography/MRI and persistent symptoms proceeding to destruction
Treatment Conservative o Small lesions o Protective weightbearing and analgesia
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3.
4. 5. 6. 7.
Pape D et al: Prevalence of spontaneous osteonecrosis of the medial femoral condyle in elderly patients. Knee Surg SportsTraumatol Arthrosc 10(4):233-40,2002 Yamamoto T et al: Spontaneous osteonecrosis of the knee: The result of subchondral insufficiency fracture. J Bone Joint Surg Am 82(6):858-66,2002 Ecker ML: Spontaneous osteonecrosis of the distal femur. Instr Course Lect 50:495-8, 2001 Pate1 DV et al: Osteonecrosis of the knee: Current clinical concepts. Knee Surg Sports Traumatol Arthrosc 6(1):2-11, 1998 Stoller DW et al: Magnetic resonance imaging in orthopaedics and sports medicine, vol 1. 2nd ed. Philadelphia PA, J.B. Lippincott, 203-442, 1997 Perez Carro Let al: Core decompression and arthroscopic bone grafting for avascular necrosis of the knee. Arthroscopy 12(3):323-6, 1996 Ecker ML et al: Spontaneous osteonecrosis of the knee. J Am Acad Orthop Surg 2(3):173-178, 1994
1
SPONTANEOUS OSTEONECROSIS, KNEE
(Left) Coronal PD FSE MR shows changes of SONK including a subchondral fracture (arrow) in the MFC in an elderly female who complained of sudden excruciating pain after stepping off of a curb. (Right) Coronal STIR MR shows the edema in the medial femoral condyle.
Typical
(Left) Coronal T1WI MR of a preoperative patient with osteopenia of the medial femoral condyle without SONK. (Right) Coronal T 1 Wl MR of the same patient post operatively after sudden onset of pain shows subchondral hypointense sclerosis (arrow). Spontaneous osteonecrosis may represent an insufficiency fracture.
Typical (Left) Sagittal PD FSE MR Shows a SONK lesion (arrow) with underlying edema but no evidence of subchondral collapse. (Right) Coronal FS PD FSE MR shows the SONK lesion of the medial femoral condyle. There is diffuse hyperintense edema within the medial condyle.
PATELLAR FRACTURE
Coronalgraphic shows a transverse fracture through the inferior half of the patella.
90
Sagittal FS PD FSE MR shows a transverse fracture of the lower third of patella with hyperintense bone marrow edema.
o Include anteroposterior (AP), lateral, tangential, or
Merchant views o Cross-table lateral radiographs demonstrate
Abbreviations and Synonyms
lipohemarthrosis
Kneecap fracture, fractured kneecap, fractured patella
o Occult on plain films (bone trabecular injury)
Definitions
o Fracture line or comminuted fragment
Fracture of the patella either transverse, vertical, marginal, or osteochondral
CT Findings NECT o Linear lucency representing fracture line with variable comminution and/or displacement of fragments o Localization of the fragments in case of reconstruction o Confirm anatomic relationship of fracture fragments with complex fractures
General Features Best diagnostic clue o Linear decreased signal intensity on all pulse sequence within the patella o Variable displacement of fragments Location: Within patella Size: Fracture sizes vary from small nondisplaced to large and completely displaced Morphology: Transverse, vertical, marginal, or osteochondral
Radiographic Findings
M R Findings TlWI o Variable comminution (multifragmentary) and displacement of fracture fragments o High-energy fractures - highly comminuted (stellate) o Decreased signal intensity in single fracture line o Decreased signal intensity marrow edema T2WI o Linear decreased signal intensity within the patella, increased signal bone marrow and surrounding soft tissue edema Variable displacement of fragments, comminution
rQJ
Radiography o Linear lucency representing fracture line with variable degrees of comminution and/or displacement
DDx: Patellar Fracture
Ax FS PD FSE
Sag TZ* CRE MR
8.
-4
Ax PD FSE
.4 Ax FS PD FSE
Ax FS PD FSE
PATELLAR FRACTURE Key Facts Terminology Fracture of the patella either transverse, vertical, marginal, or osteochondral
Imaging Findings Morphology: Transverse, vertical, marginal, or osteochondral Linear decreased signal intensity within the patella, increased signal bone marrow and surrounding soft tissue edema
Top Differential Diagnoses Dorsal Defect of the Patella Extensor TendonitisITear Sinding-Larsen-JohanssonSyndrome (SLJ or Sinding-L-J) Bipartite Patella Variable displacement of fragments, comminution o +/- Ligament, tendon tears
Increased signal within thickened ligamenthendon Discontinuous fibers o Hemorrhagic effusion: Increased (fluid) signal intensity, +/- fluid-fluid level and debris/synovitis o Non-hemorrhagic effusion = hyperintense fluid in joint without fluid-fluid layering of hemorrhagic components STIR: Hypointense fracture line + surrounding hyperintense edema T2* GRE o Fracture line emphasized secondary to loss of trabeculae o Identify longitudinal displacement o Step-off between fragments at the articular surface o Detection for associated injuries including other bone, or soft tissue injury (retinaculum), and loose bone fragments
Nuclear Medicine Findings Bone Scan: Increased uptake typically after 24-72 hours indicating fracture
Imaging Recommendations Best imaging tool: MRI, CT Protocol advice: FS PD FSE or T2 or STIR to show fracture and edema
I DIFFERENTIAL DIAGNOSIS Dorsal Defect of the Patella Benign defect of the posterior patella covered by articular cartilage Developmental variation, +/- symptomatic Mimics osteochondral defect
Extensor TendonitisITear Jumping sports activities Increased signal within thickened tendon on all pulse sequences +/- Tear (hyperintense on T2WI)
Failure of Fat Saturation (Failure Fat Sat) Chondromalacia Patella
Pathology Direct and indirect mechanisms Direct, e.g., fall, usually greater comminution, less displacement, more articular cartilage damage
Clinical Issues persistent patellar tenderness and pain and/or joint effusion with history of direct or indirect injury
Diagnostic Checklist Patella alta on sagittal images associated with patellar fracture or patellar tendon rupture Evaluate for displacement, loose chondral fragments FS PD FSE or T2WI sensitive for edema
Sinding-Larsen-JohanssonSyndrome (SLJ or Sinding-L-J) Osteochondrosis of the distal pole of the patella at the tendinous insertion Related to chronic traction injury Hypertrophic bone +/- stress edema
Bipartite Patella Secondary ossification center in superolateral pole (type 111 in the Saupe's classification of accessory ossification centers) is most common location Usually asymptomatic May include stress response Male to female ratio of 9:l
Failure of Fat Saturation (Failure Fat Sat) Susceptibility artifact o Due to curved surface "bump" of patella, disrupting cylinder of remainder of knee Hyperintense fat signal without edema
Chondromalacia Patella Increased signal with surface irregularity on FS PD FSE Anterior pain, especially with stair climbing
1 PATHOLOGY General Features General path comments o Direct and indirect mechanisms Direct, e.g., fall, usually greater comminution, less displacement, more articular cartilage damage Indirect, e.g., forced flexion on tight quadriceps jumping, less comminution, increased displacement, less articular cartilage damage o Transverse fractures primarily indirect mechanism Displaced or nondisplaced Central or distal third rn +I-Comminution o Vertical fractures rare o Marginal fractures - edge of the patella, no extension across the bone
PATELLAR FRACTURE Not associated with disruption of extensor mechanism o Osteochondral defect or injury usually medial or inferior, result of dislocation of the patella Associated with lateral femoral condyle (LFC) and retinacular injury Medial patellofemoral ligament (MPFL) Vastus medialis obliquus (VMO) o Sleeve fracture Avulsion of portion of the articular surface (typically involves periphery) Forced extension on flexed knee - lower pole Small inferior fragment with articular cartilage and large superiorly migrated superior fragment o Lateral stress avulsion may occur at vastus lateralis insertion o Pathologic fractures can occur Etiology o Direct trauma or indirect mechanism Rapid or forced flexion on extended knee or extension on a flexed knee o Secondary to anterior cruciate ligament (ACL) reconstruction with an autologous patellar tendon at site of bone plug removal Epidemiology 0- 1%of all skeletal injuries in both adults and children o 5% of all acute dislocations of the patella in children Associated abnormalities o Quadriceps tears o Patellar tendon tears o Retinacular injury o LFC injury o Loose bodies
. .. . ..
Demographics
Age: Children or adolescents > adults Gender: M = F
Natural History & Prognosis If displaced, considered relative surgical emergency to prevent fibrosis with resulting inability to reduce
Treatment Conservative 0 Nondisplaced vertical, peripheral, comminuted, and transverse fractures with step-off of I 2 mm Immobilization cylinders or above-the-knee cast with the knee in extension for 4-6 weeks Surgical 0 Surgical treatment, displaced fractures - step-off of > 2 mm or separation > 3 mm o Patellar fracture fixation Modified tension band wiring (circular configuration) Modified tension band wiring (figure-eight) Lag screw Lag screw + tension band wiring o Patellectomy
.
.
92
.. .
Consider In setting of acute trauma with patellar pain Rule out bipartite patella
Image Interpretation Pearls Patella alta on sagittal images associated with patellar fracture or patellar tendon rupture Evaluate for displacement, loose chondral fragments FS PD FSE or T2WI sensitive for edema
Gross Pathologic & Surgical Features Fracture of patella with variable degrees of comminution, displacement
Microscopic Features Disruption of cortex and trabecula with hemorrhage, osteoblasts, osteoclasts and inflammatory cells depending on the age of fracture
Staging, Grading or Classification Criteria Transverse, vertical, marginal, or osteochondral Comminuted Pediatric sleeve fracture with large chondral component
[SELECTEDREFERENCES 1. 2. 3.
4.
5.
Presentation Most common signs/symptoms o Persistent patellar tenderness and pain and/or joint effusion with history of direct or indirect injury o Swelling, tenderness and hemarthrosis o Proximal displacement of the patella, difficulty weight bearing and extending knee Clinical profile o Child or adolescent after injury, often indirect trauma o Child or adult after fall onto patella
6. 7.
8.
DeLee J et al: Orthopaedic sports medicine. Knee. vol 1. 2nd ed. Philadelphia PA, Saunders, 1577-2154,2003 Fortis AP et al: Experimental investigation of the tension band in fractures of the patella. Injury 33(6):489-93, 2002 DuMontier TA et al: Patella fracture after anterior cruciate ligament reconstruction with the patellar tendon: A comparison between different shaped bone block excisions. Am J Knee Surg 14(1):9-15,2001 Atkinson PJ et al: Injuries produced by blunt trauma to the human patellofemoral joint vary with flexion angle of the knee. J Orthop Res 19(5):827-33, 2001 Dai LY et al: Fractures of the patella in children. Knee Surg Sports Traumatol Arthrosc 7(4):243-5, 1999 Kaeding CC et al: Musculoskeletal injuries in adolescents. Prim Care 25(1):211-23, 1998 Stoller DW: Patellofemoral joint and the extensor mechanism. Magnetic resonance imaging in orthopaedics and sports medicine. vol 1. 2nd ed. Philadelphia PA, Lippincott-Raven,361-85, 1997 Brownstein B: Patella fractures associated with accelerated ACL rehabilitation in patients with autogenous patella tendon reconstructions. J Orthop Sports Phys Ther 26(3):168-72, 1997
PATELLAR FRACTURE IMAGE GALLERY (Left) Sagittal graphic shows a patellar sleeve avulsion (oblique fracture of the patella with segment of articular cartilage making up a large part of one of the fragments). (Right) Sagittal PD FSE MR shows a complete fracture through the inferior aspect of the patella with retraction. This is considered an indication for an urgent surgical repair to prevent fibrosis.
(Left) Axial FS PD FSE MR shows findings of patellar dislocation including bone injury (arrows) of lateral femoral condyle and medial patella. There is mild sprain of medial retinaculum and its patellar interface. (Right) Axial FS PD FSE MR shows a vertical fracture through the lateral aspect of the patella with slight distraction of the fracture fragments. This fracture was probably through a preexisting bipartite patella.
(hj2) Sagittal PD FSE MR shows a transverse fracture of the patella with minimal distraction of the fracture fragments. (Right) Coronal PD FSE MR shows a transverse fracture through the central portion of the patella.
LATERAL TlBIAL PLATEAU FRACTURE
Axial oblique graphic shows a coronally oriented nondepressed tibia1 plateau fracture.
-
Sagittal PD FSE MR shows a depressed lateral tibial plateau fracture.
o Depressed LTP, with no splitting through the
articular surface o Medial tibial plateau (+/- associated with lateral plateau fx in type V and VI tibial plateau fx)
Abbreviations and Synonyms Lateral tibial plateau (LTP) fracture, bumper or fender fracture
+/- Split fractures +/- Depression o Split fractures of medial + lateral tibial plateaus o Severe fx + dissociation of tibial plateau from diaphysis m
Definitions Fracture of LTP as a result of axial loading, +/rotational injury, +/- valgus angulation
I IMAGING FINDINGS General Features Best diagnostic clue: Oblique or vertical linear decreased signal intensity fracture line (all pulse sequences) Location: LTP with variable extension medially to involve intercondylar eminence +/- medial plateau Size: Varies from trabecular injury to small nondisplaced fracture to comminuted depressed fracture Morphology o Vertical splitting fracture: Younger patients o Depressed fractures: More common in older osteoporotic patients o Depressed split fractures - lateral articular surface
I
DDx: Lateral Tibial Plateau Fracture
I
Radiographic Findings Radiography o Most depressed fractures of tibial plateau can be diagnosed by conventional radiography o Oblique views helpful o Cross-table lateral radiographs - lipohemarthrosis o +/- Occult on conventional radiography o Fracture line or comminuted fragment
CT Findings NECT o Confirm anatomic relationship of fracture fragments - more complex and nondisplaced fractures o Precise localization of surgical landmarks and fracture fragments o Surgical planning for Schatzker type IV, V, and VI fractures
I
LATERAL TlBlAL PLATEAU FRACTURE Key Facts Imaging Findings Best diagnostic clue: Oblique or vertical linear decreased signal intensity fracture line (all pulse sequences) Location: LTP with variable extension medially to involve intercondylar eminence +/- medial plateau Size: Varies from trabecular injury to small nondisplaced fracture to comminuted depressed fracture Vertical splitting fracture: Younger patients Depressed fractures: More common in older osteoporotic patients
Top Differential Diagnoses Medial Condyle Fracture (Med Condyle Fx) Segond Fracture
MR Findings TlWI ,oDecreased signal intensity fracture line
,
Fracture may propagate inferiorly, vertically, horizontally, medially o Decreased signal intensity (hypointense) edema o Depression of fragments seen and measured o +/- Meniscal tear Increased signal intensity within meniscus extending to surface on short TE sequences T2WI o Decreased signal intensity fracture line with surrounding increased signal intensity edema o +/- Ligament tendon tears Thickened increased signal within ligamenthendon Discontinuous fibers o Hemorrhagic effusion as increased (fluid) signal intensity effusion, +/- fluid-fluid level STIR: Decreased signal intensity fracture line with surrounding increased signal intensity edema T2* GRE: Fracture line visualized secondary to loss of normal trabeculae
Imaging Recommendations Best imaging tool: CT with 3D reconstruction, MRI (direct visualization of fracture components in 3 planes) Protocol advice o CT 3D with sagittal and coronal reconstruction o MRI FS PD FSE for diagnosis and hyaline cartilage involvement, and associated injury to soft tissue structures Short TE sequence for menisci (TI, PD or T2* GRE)
DIFFERENTIAL DIAGNOSIS Medial Condyle Fracture (Med Condyle Fx) Uncommon
Posterolateral Corner Injury (PLCorner Injury)
Pathology
LTP fxs - more common than medial Trauma with axial load +/- blending force
Clinical Issues Most common signs/symptoms: Knee effusion, pain, and joint stiffness after trauma Typically older person, female, after fall or twisting injury
Diagnostic Checklist
Posterolateral tibial corner injury typically associated with ACL tears Measure degree of depression
Decreased signal intensity fracture line on all pulse sequences Surrounding increased signal intensity edema on T2WI & Associated medial tibial plateau fracture
Segond Fracture Associated with anterior cruciate ligament (ACL) tears Small avulsion of lateral tibial plateau margin +/- Meniscal tear
Tibial Osteotomy Correct varus deformity usually Treatment for osteoarthritis, malalignment Healed changes mimic chronic LTP Fx
Posterolateral Corner Injury (PL Corner Injury) Posterior lateral bone bruise associated with ACL tears LTP fx variant Injury to arcuate ligament, lateral collateral ligament (LCL), popliteofibular & fabellofibular ligaments, + popliteus & lateral head of gastrocnemius strains
I PATHOLOGY General Features General path comments o LTP fxs - more common than medial Medial plateau of tibia is stronger than lateral Varus stresses less common than valgus stresses due to carrying angle of knee and protection by other extremity o Forces producing LTP fxs (75-80% of fractures) directed medially o +/- Tear of ACL, medial collateral ligament (MCL) o Forces producing MTP fxs (5-10% of fractures) directed laterally are much more violent o Tear posterior cruciate ligament (PCL), popliteal artery, or lateral ligaments Etiology o Trauma with axial load +/- blending force
LATERAL TIBiAL PLATEAU FRACTURE o Fall, +I- with twisting and valgus force, leading to
LTP fxs o Motor vehicle accident Epidemiology: 1%of all fractures (approximately) Associated abnormalities o Soft tissue abnormalities including menisci and ligaments o Posttraumatic osteoarthritis
Natural History & Prognosis Nondepressed fractures may heal with conservative management Posttraumatic osteoarthritis from associated ligamentous injurieslinstability
Treatment Conservative for nondepressed (under 4-5 mm) lesions Surgical treatment for those with 4-5 mm of articular depression and 3-4 mm of diastasis o Goal of therapy is to reduce the fracture and begin early mobilization 0 If patient immobilized for > 3 weeks, joint often will not return to full range of motion o Inadequately corrected depression results in a varus or valgus deformity and accelerated osteoarthritis
Gross Pathologic & Surgical Features Fractured tibial plateau with varying degrees of depressionldisplacernent Surrounding hemorrhage and soft tissue injury
Microscopic Features Disruption of bone cortex and trabeculae with surrounding hemorrhage in acute cases
Staging, Grading or Classification Criteria Schatzker classification is the most widely accepted (tibial plateau fractures) o Type I - split fractures LTP, usually younger patients, no depression o Type I1 - depressed split fractures lateral articular surface, usually older patients + osteoporosis o Type I11 - depressed LTP, no splitting through the articular surface o Type IV - medial tibial plateau and may be split fractures with or without depression o Type V - split fractures of both medial and lateral tibial plateaus o Type VI - severe stress resulting in dissociation of the tibial plateau from the underlying diaphysis Fracture component separates metaphysis from diaphysis
]CLINICALISSUES Presentation Most common signs/symptoms: Knee effusion, pain, and joint stiffness after trauma Clinical profile o Typically older person, female, after fall or twisting injury o Called bumper fracture because of auto bumpers (25%) as etiology o Compartment syndrome of the leg must be ruled out o Open wounds need to be identified o Varus & valgus stress test to the knee in full extension Laxity > 10 degrees = articular depression/ligamentous injury
Demographics Age: Incidence in older persons > general population secondary to osteoporosis Gender o Older patients: F > M, because of greater incidence of osteoporosis in women o Younger patients: M > F, because of involvement in high-energy contact sports
Consider Posterolateral tibial corner injury typically associated with ACL tears
Image Interpretation Pearls FS PD FSE identifies subchondral marrow edema and associated ligament pathology TlWI provides accurate visualization of fracture morphology Measure degree of depression
1. 2. 3.
4. 5.
6. 7. 8. 9. 10. 11. 12. 13.
Patel RV et al: Diagnosis and immediate care of fractures of the knee. Hosp Med 63(4):238-9,2002 Bai B et al: Effect of articular step-off and meniscectomy on joint alignment and contact pressures for fractures of the lateral tibial plateau. J Orthop Trauma 15(2):101-6,2001 Wicky S et al: Comparison between standard radiography and spiral CT with 3D reconstruction in the evaluation, classification and management of tibial plateau fractures. Eur Radio1 10(8):1227-32,2000 Schwartsman R et al: Patient self-assessment of tibial plateau fractures in 40 older adults. Am J Orthop 27(7):512-9, 1998 Dirschl DR et al: Current treatment of tibial plateau fractures. J South Orthop Assoc 6(1):54-61, 1997 Bernfeld BM et al: Arthroscopic assistance for unselected tibial plateau fractures. Arthroscopy 12(5):598-602,1996 Cameron HU: Lateral tibial plateau fractures. Can J Surg 39(4):339, 1996 Colletti P et al: MR findings in patients with acute tibial plateau fractures. Comput Med Imaging Graph 20(5):389-94, 1996 Barrow BA et al: Tibial plateau fractures: Evaluation with MR imaging. Radiographics 14(3):553-9, 1994 Watson JT et al: High-energy fractures of the tibial plateau. Orthop Clin North Am 25(4):723-52, 1994 Kode L et al: Evaluation of tibial plateau fractures: Efficacy of MR imaging compared with CT. AJR 163(1):141-7, 1994 Benirschke SK et al: Open reduction internal fixation of complex proximal tibial plateau fractures. J Orthop Trauma 5:236, 1991 Anglen Jo et al: Tibial plateau fractures. Orthopedics 11(11):1527-34,1988
1 IMAGE GALLERY (Lef)Coronal graphic shows a type I lateral tibial plateau fracture. (Right) Coronal PD FSE MR shows depressed (type 11) lateral tibial plateau fracture.
Tvaical
(Left) Coronal PD FSE MR shows a nondisplaced lateral tibial plateau fracture including a fracture line through the hyaline articular cartilage. (Right) Axial PD FSE MR shows a fracture line (arrow) through the hyaline cartilage of the lateral tibial plateau.
Variant (Left) Axial FS PD FSE MR shows a fracture through the lateral tibial plateau with a depressed (hyperintense) central component. (Right) Sagittal FS PD FSE MR shows the depressed lateral tibial plateau fracture involving the hyaline articular cartilage and subchondral plate. Tibia1 edema is hyperintense.
PATELLAR TENDINITIS
Sagittal graphic shows degeneration (tendinosis) of the proximal patellar tendon.
1
TERMINOLOGY Abbreviations and Synonyms
o +IOsgood-Schlatter Tibia1 tubercledisease hypertrophylfragrnentation =
CT Findings
Jumper's knee, chronic patellar tendinitis, patellar tendinosis, patellar tendinopathy 98
Sagittal PD FSE MR shows patellar tendinitis (tendinosis) involving proximal posterior fibers with tendon thickening and hyperintensity (arrow).
NECT o Thickening of the patellar tendon with edematous changes within Hoffa's fat pad o Sagittal reconstruction to show tendon in long axis + fat pad o Axial or coronal images to identify medial or central involvement
Definitions Inflammation (tendinosis) of patellar tendon secondary to repetitive trauma (jumping sports)
MR Findings General Features Best diagnostic clue: MRI demonstrates patellar tendon thickening, +I- partial or complete tearing and edema Location: Most commonly affects the proximal third of the patellar tendon (proximal posterior fibers) Size: Affected tendon (medial to central tendon involvement) usually thickenedlexpanded Morphology o Increased signal intensity of thickened tendon on short TE sequence o Increased anterior to posterior dimension with convex posterior margin
mw
TlWI 0 Hypointense edema in the peritenon without visible change in the tendon itself (early) o Chronic tendinosis Thickening and areas of intermediate signal intensity (collagen degeneration) = Decreased (normal) signal intensity indicates fibrosis in chronic tendinosis o Hypointense fluid signal intensity within the substance of the tendon = partial tear o Hypointense reactive edema within the lower pole of the patella (reactive osteitis) o Hypointense edema of adjacent proximal Hoffa's fat
Radiographic Findings
Radiography o Thickening of the patellar tendon
-
DDx: Patellar Tendinitis Bursitis
Sag FS P D FSE
Fnth~~ophytes/Cm
Sag P D FSE M R
P r ~ p a tH ~ m toma a
Magic Angle
Prepatel!ar [denla
Sag FS P D FSE
Sag T2* CRE MR
Sag FS P D FSE
PATELLAR TENDINITIS Kev Facts 1
Imaging Findings Best diagnostic clue: MRI demonstrates patellar tendon thickening, +/- partial or complete tearing and edema Location: Most commonly affects the proximal third of the patellar tendon (proximal posterior fibers) Hyperintense edema in the peritenon without visible change in the tendon itself (early) on T2WI Chronic tendinitis - thickening and areas of intermediate to hyperintense signal intensity (collagen degeneration) Protocol advice: Sagittal FS PD FSE or T2* GRE
Top Differential Diagnoses
1
Prepatellar Bursitis (Housemaid's Knee) Stress ResponselFracture of the Patella
o Hyperintense edema in the peritenon without
visible change in the tendon itself (early) on T2WI o Chronic tendinitis - thickening and areas of intermediate to hyperintense signal intensity (collagen degeneration) o Affected tendon may maintain hypointensity on T2WI unless T2* GRE or STIR sequence used o Hyperintense fluid signal intensity within the substance of the tendon = partial tear o Hyperintense reactive edema within the lower pole of the patella (reactive osteitis) and adjacent fat pad T2* GRE o Chronic tendinitis - thickening and areas of hyperintense signal intensity o Involvement typical in proximal posterior fibers o T2* shows greater sensitivity for tendon hyperintensity o T2* is often positive for tendon degeneration when FS PD FSE is normal o T2* not as sensitive to edema of Hoffa's fat pad or prelinfrapatellar bursa compared to FS PD FSE
Ultrasonographic Findings Thickened hypoechoic tendon
Imaging Recommendations Best imaging tool: MRI Protocol advice: Sagittal FS PD FSE or TZ* GRE
DIFFERENTIAL DIAGNOSIS Prepatellar Bursitis (Housemaid's Knee) Localized fluid and inflammatory debris in the prepatellar bursa Occupational Cystic appearing mass o Hyperintense on T2WI
Stress ResponseIFracture of the Patella Increased signal intensity with or without fracture lines in the presence of a normal patellar tendon on T2WI +I- Trauma
Osgood-Schlatter Disease Sinding-Larsen-JohanssonDisease Magic Angle Artifact
Pathology Chronic overuse tendinitis often due to sports containing jumping activities (jumper's knee) Usually thickened, indurated tendon
Clinical Issues Will heallsubside with cessation of jumping sports May progress to tear
Diagnostic Checklist Identify fluid signal intensity in tendon on T2WI T2* GRE sagittal images are most sensitive & specific sequence for identifying tendon degeneration
+/- Repetitive microtrauma +/- Chondromalacia patella
Osgood-Schlatter Disease Osteochondrosis with variable hypertrophy of the tibia1 tuberosity +/- Deep and/or superficial infrapatellar bursitis Childhood/adolescence presentation Adults (usually chronic)
Sinding-Larsen-JohanssonDisease Osteochondrosis of the distal pole of the patella +/- Irregularity/fragmentation Inferior patellar pain Adolescent/adult
Magic Angle Artifact At 55 degrees to external magnetic field Proximal mid and distal patellar tendon Short TE sequences o TlWI o ~~11nte;mediate WI o T2*GRE WI Tendon not thickened Asymptomatic
Prepatellar Edema Nonspecific anterior edema Hyperintense on T2WI (FS PD FSE) +/- Trauma Common finding
Prepatellar Hematoma (Prepat Hematoma) Trauma history Hyperintense prepatellar fluid collection on T2WI +/- Hyperintensity on TlWI related to hemorrhage Hemosiderin as hypointense rim on T2* GRE WI Mimics prepatellar bursitis
Osteoarthritis (OA) Degenerative arthritis +/- Osteophytes/enthesophytes o Enthesophytes at patellar tendon origin or quadriceps tendon insertion
PATELLAR TENDINITIS o Marrow fat in osteophytelenthesophyte
hyperintense (fat signal) on TlWI, saturates with FS PD FSE +/- Hyperintense cysts on T2WI +/- Hyperintense marrow edema on T2WI +/- Chondromalacia
Presentation Most common signs/symptoms: Pain, excessive foot pronation, and tenderness over the patellar tendon +/inferior pole of patella, especially with resisted extension
Demographics Age o Usually occurs in adults o Athletic adolescents Gender: No predilection
General Features
El 100
General path comments o Degeneration, thickening and edema with collagen breakdown o Short TE sequences sensitive to early changes > long TE (T2WI) Short TE = TlWI, GRE, PDIIntermediate Increased signal intensity as a result of degeneration Magic angle mimics tendinosis o Earliest changes manifest as edema in peritenon + normal tendon Etiology o Chronic overuse tendinitis often due to sports containing jumping activities (jumper's knee) o In collagen vascular diseases along with tendinosis of other tendons o May occur acutely but usually in the setting of preexisting tendinosis o Malalignment of the extensor mechanism Epidemiology o Common in athletes participating in jumping sports Basketball, tennis
Will heallsubside with cessation of jumping sports May progress to tear o Acute direct trauma, laceration risk for full thickness tear
Treatment Conservative at first o Rest o Ice o Non steroidal anti-inflammatory agents o Steroids - may lead to increase risk of rupture Surgical o Maquet's procedure - anterior tibia1 tubercle elevation Decrease in the forces that lead to overuse
Consider
Gross Pathologic & Surgical Features
Diagnosis with anterior knee pain and increased signal in proximal tendon especially on short TE sequences Magic angle artifact may mimic tendon degeneration
Usually thickened, indurated tendon Loss of integrity of tendon fibers in partially or completely tom tendons Partial tear may be proximal or distal
I
Natural History & Prognosis
Image Interpretation Pearls
Microscopic Features Collagen degeneration without influx of inflammatory cells: "Tendinosis"is more accurate term than tendinitis Tenocyte hyperplasia Angiogenesis with endothelial hypoplasia Loss of collagen architecture Microtears with collagen fiber separation Bursal, articular or interstitial partial tears vs. through-and-through torn tendon fibers Fatty infiltration of muscle tissue in chronically torn tendons Affected tendon tissue with increased levels of cyclooxygenase-2 (COX-2) o COX-2 - enzyme which controls production of proinflammatory prostaglandins (PGE2)
Identify fluid signal intensity in tendon on T2WI T2* GRE sagittal images are most sensitive & specific sequence for identifying tendon degeneration
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Staging, Grading or Classification Criteria Phase I: Pain after activity Phase 11: Pain/discomfort during activity, without interfering with participation Phase 111: Pain during & after participation, which interferes with activity Phase IV: Complete tendon disruption
6.
McGrory JE: Disruption of the extensor mechanism of the knee. J Emerg Med 24(2):163-8, 2003 Panni AS et al: Overuse injuries of the extensor mechanism in athletes. Clin Sports Med 21(3):483-98,2002 Kasten P et al: Rupture of the patellar tendon: A review of 68 cases and a retrospective study of 29 ruptures comparing two methods of augmentation. Arch Orthop Trauma Surg 121(10):578-82,2001 Duri ZA et al: Patellar tendonitis and anterior knee pain. Am J Knee Surg 12(2):99-108, 1999 Verheyden FG et al: Jumper's knee: Results of surgical treatment. Acta Orthop Belg 63(2):102-5, 1997 Stoller DW: Magnetic resonance imaging in orthopaedics and sports medicine. vol 1. 2nd ed. Philadelphia PA, J.B. Lippincott, 203-442, 1997
PATELLAR TENDlNlTlS
Typical (Left) Sagittal graphic shows severe patellar tendinosis of the proximal aspect of the tendon. (Right) Sagittal FS PD FSE MR shows severe proximal patellar tendinosis with slight expansion of the tendon and surrounding edema.
(Left) Axial graphic shows severe tendinosis of the proximal aspect of the tendon. There is an interstitial partial tear present. (Right) Axial PD FSt MR shows a focus of increased signal intensity within the tendon consistent with a focus of tendinosis (arrow). Note greater involvement of posterior fibers.
Typical (Left) Sagittal PD FSE MR shows a thickened indurated tendon with surrounding edema consistent with tendinosis. (Right) Sagittal FS PD FSE MR shows the surrounding edema. Note the reactive edema within the infrapatellar soft tissues and Hoffa's fat pad (arrow).
OSGOOD-SCHLATTER DISEASE
Sagittal graphic shows distal patellar tendinosis with adjacent deep infrapatellar bursa1 inflammation. Tibial tubercle hypertrophy and fragmentation with adjacent edema may also be seen.
Sagittal PD FSE MR shows fragmentation (arrow) of the tibial tuberosity in a patient with pain over this region consistent with Osgood-Schlatter disease. The patient is an athlete.
o +/- Distension of deep and/or superficial
infrapatellar bursae o
Abbreviations and Synonyms Osgood-Schlatter disease (OSD), tibial osteochondrosis 102
Definitions Traction apophysitis of the patellar ligament insertion on the tibial tubercle
General Features Best diagnostic clue o Acute: Increased signal intensity on FS PD images Within and around the distal patellar tendon at its insertion on tibial tubercle Variable amounts of fluid within the surrounding infrapatellar bursae o Deep infrapatellar bursa can normally contain a small amount of fluid and should not be confused with OSD Location: Tibial tubercle apophysis and distal patellar ligament Size: Tibial tubercle and patellar tendon of normal size or enlarged Morphology o +/- Hypertrophy of the tibial tubercle
DDx: Osgood-Schlatter Disease 5-L)
Sag T2* CRE MR
Ax FS P1
+/- Thickening of the distal patellar ligament (tendon)
o +/- Fragmentation of the tibial tubercle
Radiographic Findings Radiography o Hypertrophy of the tibial tubercle on lateral view o +/- Fragmentation o Greater than 4 mm soft tissue swelling over the anterior proximal surface of tibia
CT Findings NECT o Hypertrophic change of the tibial tubercle o +/- Fragmentation of the ossific nucleus, on sagittal
reconstruction views o Sagittal and 3D reconstruction helpful
M R Findings TlWI o Hypertrophy and/or fragmentation of the tibial tubercle o Fragmentation of the ossific nucleus with a discrete ossicle o Heterotopic ossification within the distal patellar tendon T2WI
HBn Sag PD FSE MR
S lnfra Bursitis
Normal Tubercle
Ax PD FSE MR
Sag FS PD FSE
OSCOOD-SCHLATTER DISEASE Key Facts Terminology Osgood-Schlatter disease (OSD), tibia1 osteochondrosis Traction apophysitis of the patellar ligament insertion on the tibial tubercle
Imaging Findings I 1
Acute: Increased signal intensity on FS PD images Location: Tibia1 tubercle apophysis and distal patellar ligament +/- Hypertrophy of the tibia1 tubercle +/- Distension of deep and/or superficial infrapatellar bursae +/- Thickening of the distal patellar ligament (tendon)
o Distension of the deep and/or superficial
infrapatellar bursae indicating reactive bursitis o Non-specific edema can be seen in the surrounding soft tissues including Hoffa's fat pad on FS PD images o FS PD FSE and T2* GRE are the most sensitive sequences Signal increase is variable: From intermediate to hyperintense (subchondral edema of tibial tubercle) Thickening of the distal patellar ligament (tendon) with increase in signal intensity
Nuclear Medicine Findings Bone Scan: Positive in cases of tubercle apophysitis
lmaging Recommendations Best imaging tool: MRI Protocol advice o Edema and tendon tears are identified on FS PD FSE, T2* GRE or STIR images o Bony hypertrophy is visualized on T1 or PD FSE images o FS PD FSE in sagittal and axial plane
1 DIFFERENTIAL DIAGNOSIS Isolated Deep or Superficial lnfrapatellar Bursitis (S lnfra Bursitis) Patients with kneeling occupations Different age group compared to OSD Fluid signal intensity on T2WI
Patellar Tendonitis Jumper's knee Same age group and similar circumstances as OSD May be differentiated by MRI in many cases
Sinding-Larsen-JohanssonDisease (SLJ Disease) Traction apophysitis of inferior pole of patella
Top Differential Diagnoses Isolated Deep or Superficial Infrapatellar Bursitis (S Infra Bursitis) Patellar Tendonitis
Pathology General path comments: Traction apophysitis Repetitive microtraction trauma
Clinical Issues Most common signs/symptoms: Insidious onset of low-grade ache associated with activity localized to tibial tubercle
Diagnostic Checklist Hypertrophied, edematous tibial tubercle on FS PD FSE key for diagnosis
Irregular and sometimes fragmented appearance of inferior patella o Bony avulsion o Soft tissue calcification o Elongation of inferior pole of patella Pain superiorly located compared to OSD
1 PATHOLOGY
General Features General path comments: Traction apophysitis Etiology o Repetitive microtraction trauma Anterior tibial tubercle During formation of the secondary ossification center o Multiple submaximal avulsion fractures of patellar tendon insertion caused by traction microtrauma Occurs particularly during eccentric contractions of strong extensor mechanism Common in jumping sports: Basketball and volleyball - boys; gymnastics, soccer, other jumping sports - girls Associated abnormalities: Patellar tendon tears (partial tears) in some cases Distribution: Young active patients
Gross Pathologic & Surgical Features Thickened, indurated patellar tendon Multiple ossific bodies may be present within the tendon or about the tubercle
Microscopic Features Focal tendon collagen degeneration Tendon microtears Influx of inflammatory cells in surrounding soft tissues Bursa1 synovial hypertrophy and inflammatory infiltrate Heterotopic bone formation and/or fragmentation Three normal histologic zones within immature tibial tubercle
OSGOOD-SCHLATTER DISEASE o Proximal - columnar cartilage 0 Midzone - fibrocartilage 0 Distal - fibrous tissue blending with tibial perichondrium Physiologic epiphysiodesis of the tubercle starts proximally and extends centrifugally and distally
o Tuberosity drilling: Less common o Bone plug placement: Less common o Tuberosity debulking o Linear osteotomy with excision of the tuberosity
Complications: Excision before skeletal maturity can result in o Residual prominence of the tubercle o Decreased range of motion o Recurvatum deformity
Presentation Most common signslsymptoms: Insidious onset of low-grade ache associated with activity localized to tibial tubercle Clinical profile o Young active patient with anterior knee pain o Symptoms occur during rapid growth period as tibial tubercle is maturing o Aggravated by accelerationldeceleration, direct blows o Bilateral 20-30% o Tubercle prominence often bilateral although symptoms are usually unilateral Ossicle at tibial tubercle in 30-50% of cases +/- Tenderness also around patella and patellar tendon Quadriceps atrophy Extensor lag Tightness 0~uadrice~s 0 Hamstrings o Gastrocnemius o Iliotibial band Resisted knee extension = pain -
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Demographics Age o Typically occurs at the onset of the adolescent growth spurt, ranging from 10-15 years of age 10-15 years of age boys 8-13 years of age girls o Increasing in girls usually at age 10-11 years (range 8-13 years) Skeletal maturity equivalent to boys at age 13-14 Gender: M > F
Natural History & Prognosis -
0
Usually self-limked Patellar tendinitis and bursitis are common sources of pain independent of fracture healing Residual hypertrophy of the tibial tubercle or fragmentation Ossification within the patellar tendon Prognosis excellent Post surgical prognosis improved in older child near skeletal maturity
Treatment Conservative o Exercises to restore strength and flexibility of the extensor mechanism Surgical o For recalcitrant cases o For those patients with ossification around the tibial tubercle or within the patellar tendon
Consider Uncomplicated patellar tendonitis in the absence of tuberosity changes
Image Interpretation Pearls Hypertrophied, edematous tibial tubercle on FS PD FSE key for diagnosis
Adirim TA et al: Overview of injuries in the young athlete. Sports Med 33(1):75-81,2003 Delee J et al: Orthopaedic Sports Medicine. Hip and Pelvis. vol 1. 2nd ed. Philadelphia PA, Saunders, 25:1443-80, 2003 Olivieri I et al: Enthesitis of spondylarthritis can masquerade as Osgood-Schlatter disease by radiographic findings. Arthritis Rheum 49(1):147-8,2003 Duri ZA et al: The immature athlete. Clin Sports Med 21(3):461-82, 2002 Hirano A et al: Magnetic resonance imaging of Osgood-Schlatter disease. The course of the disease. Skeletal Radio1 31(6):334-42,2002 Orava S et al: Results of surgical treatment of unresolved Osgood-Schlatter lesion. Ann Chir Gynaecol89(4):298-302, 2000 Nowinski RJ et al: Hyphenated history: Osgood-Schlatter disease. Am J Orthop 27(8):584-5, 1998 de Inocencio J: Musculoskeletal pain in primary pediatric care: Analysis of 1000 consecutive general pediatric clinic visits. Pediatrics 102(6):E63, 1998 Aparicio G et al: Radiologic study of patellar height in Osgood-Schlatter disease. J Pediatr Orthop 17(1):63-6, 1997 McCarroll JR et al: Anterior cruciate ligament reconstruction in athletes with an ossicle associated with Osgood-Schlatter'sdisease. Arthroscopy 12(5):556-60, 1996
OSGOOD-SCHLATTER DISEASE
I IMAGE GALLERY (Ltft) Sagittal FS PD FSE MR shows findings of Osgood-Schlatter disease including edema within the nonfused tibial tubercle apophysis (arrow) and surrounding edema. (Right) Sagittal FS PD FSE MR shows hyperintense inflammation at the patellar tendon insertion site in a patient with Osgood-Schlatter disease.
(Left) Sagittal FS PD FSE MR shows inflammation within the deep infrapatellar bursa (arrow) and reactive edema within the anterior proximal tibia in a patient with clinical presentation of acute Osgood-Schlatter disease. (Right) Sagittal FS PD FSE MR of the same patient shows the associated edema within the anterior tibia.
(Ltft) Sagittal PD FSE MR shows heterotopic ossification within the patellar tendon and at the tibial tubercle as well as patellar tendinosis in a patient with chronic Osgood-Schlatter disease. (Right) Axial FS PD FSE MR shows minimal amount of fluid in deep infrapatellar bursa, tendinosis of the distal patellar tendon and edema in the adjacent tibia (arrow) in patient with acute changes superimposed upon chronic Osgood-Schlatter disease.
PATELLAR (ANTERIOR) BURSlTlS
Sagittal graphic shows an inflamed fluid-filled prepa tellar bursa (purple).
Abbreviations and Synonyms 1 ()ti
Prepatellar bursitis, deep infrapatellar bursitis, superficial infra~atellarbursitis, housemaid's knee (p;epatellar), pkachers's or cle;gyman's knee (superficial infrapatellar)
Definitions Inflammation of synovial lining of bursae o Prepatellar bursitis - anterior to inferior pole of the patella and proximal patellar tendon o Deep infrapatellar bursitis - between the patellar tendon and anterior aspect of the proximal tibia o Superficial infrapatellar bursitis - anterior and superficial to distal aspect of patellar tendon
Sagittal FS PD FSE MR shows large amount of hyperintense fluid within the prepatellar bursa in prepatellar bursitis.
o Superficial infrapatellar bursa 0 Deep infrapatellar bursa Small amount of fluid may be found normally in the deep infrapatellar bursa Size: Few mms to several cms depending on the distension of involved bursae Morphology o Bursae present as flattened synovial sacs are usually not visualized on MRI unless distended with fluid o If filled with mild amount of fluid, bursa may remain flattened or collapsed o If distended with moderate amount of fluid, bursa may be oval shaped o If distended with extensive amount of fluid, bursa may be rounded (convex margins)
Radiographic Findings Radiography o Soft tissue swelling in anterior soft tissues of the patellofemoral joint o +I-Anterior mass
General Features Best diagnostic clue o Fluid containing mass (fluid signal intensity) in one of the anterior bursae of knee o History of occupation or activities including large amounts of kneeling Location o Prepatellar bursa
M R Findings
hlmmmw
TlWI o Homogeneous decreased signal intensity mass o Associated tendinosis of patellar tendon common Thickening and increased signal intensity of tendon origin
DDx: Patellar (Anterior) Bursitis Hematoma
Antenor Edema
Bursa1 Hrmorrhag~
%
.?
A
Ax FS PD FSE
Sag FS PD FSE
Sag FS PD FSE
Sag FS PD FSE
Ax FS PD FSE
PATELLAR (ANTERIOR) BURSITIS Key Facts Terminology Inflammation of synovial lining of bursae
Imaging Findings Fluid containing mass (fluid signal intensity) in one of the anterior bursae of knee Prepatellar bursa Superficial infrapatellar bursa Deep infrapatellar bursa Small amount of fluid may be found normally in the deep infrapatellar bursa
Top Differential Diagnoses Meniscal Cyst Hemorrhage Ganglion Cyst Cystic Appearing Mass in or near Bursa o Decreased signal in adjacent patella if reactive
edema T2WI o Fluid signal intensity of flattened, oval, or round cystic mass in characteristic location o Follows fluid signal intensity on all pulse sequences unless containing inflammatory debris or calcification Decreased signal structures if calcified Intermediate signal if contains inflammatory, hemorrhagic or exudative debris o Rice bodies especially in patients with rheumatoid arthritis (fibrin filled synovium and thickened synovial membrane forming villous projections that become detached) Intermediate to decreased signal "rice"shaped fibrinous bodies o +/- Associated tendinosis of patellar/quadriceps tendon(s) Thickening and variable increased signal intensity of tendon insertion with associated bursitis T2* GRE o Hyperintense fluid intensity structures o Decreased signal intensity bursa1 rim if hemorrhagic T I C+ 0 +/- Rim enhancement o Greater enhancement if longstanding with thickened synovium
Imaging Recommendations Best imaging tool: MRI Protocol advice: T2W1, + fat saturation (FS PD FSE) demonstrates fluid-filled bursa
Pathology Found in occupations requiring kneeling Housemaids, clergy, carpet layers Bursa1 sac with variable thickening of the synovial-like lining
Clinical Issues Most common signs/symptoms: Anterior knee pain, +/- mass Local injection of corticosteroids with pain relief helps for confirmation of diagnosis
Diagnostic Checklist Hyperintense fluid in collection anterior, anteroinferior or inferior and deep to the patellar on FS PD FSE
Hemorrhage Appropriate history o Posttraumatic Often accompanied by patellar bone trabecular injury Prepatellar soft tissues Within bursa proper o Hemorrhagic bursitis
Ganglion Cyst Nonspecific origin +/- Synovial lining Hoffa's fat pad near the deep infrapatellar bursa Uncommon
Cystic Appearing Mass in or near Bursa Rare Neoplasm Varices Hemangioma
Patellar Chondromalacia Increased signal with surface irregularity on FS PD FSE
+/- Surface defect +I-Decreased signal abnormalities (desiccation) Anterior pain, especially with stair climbing
Patellar Tendinitis Jumping sports activities Increased signal within thickened proximal posterior tendon fibers on all pulse sequences o Hypointense fibrosis + thickening = chronic tendinosis +/- Tear (hyperintense on T2WI)
I DIFFERENTIAL DIAGNOSIS
1 PATHOLOGY
Meniscal Cyst
General Features
Visible meniscal tear (most commonly) May be mistaken for deep infrapatellar bursitis + Meniscal test (clinically) +I-Dissection into Hoffa's fat pad
General path comments: Inflammation of bursa with effusion Etiology
PATELLAR (ANTERIOR) BURSITIS o Chronic frictional trauma or overuse centered upon
the bursal glide plane resulting in inflammation of the bursa o Infected in case of penetrating trauma o Crystalline deposit (gout) Epidemiology o Found in occupations requiring kneeling rn Housemaids, clergy, carpet layers 9% incidence in wrestlers
Demographics Age: Usually adult Gender o Prepatellar bursitis - F > M o Superficial infrapatellar bursitis - M > F
Natural History & Prognosis Insidiously or after athleticlwork activity Found in patients with predisposing activities o Repetitive kneeling May resolve with cessation of activities that led to condition Conservative treatment leads to resolution
Gross Pathologic & Surgical Features
1138
Bursa1 sac with variable thickening of the synovial-like lining Contains variable amounts of fluid Three potential bursal spaces anterior to patella o Prepatellar bursa Most superficial bursa Between skin and arciform fascia (transverse fibers from iliotibial tract extending over patellar tendon) o Bursa between the arciform layer and the intermediate oblique layer (intermediate layer between arciform layer and deeper longitudinal fibers of the rectus femoris) o Bursa between intermediate oblique layer and deep fibers of the rectus femoris Deep infrapatellar bursa o Integral to the extensor mechanism o Scarring " or adherence to ~atellartendon associated with trochlear groove chondral abnormalities o Infrapatellar bursa, Hoffa's fat pad and tibia1 tuberosity prevent impingement between the patellar tendon and bone in full knee flexion
Treatment Conservative o Local injection of corticosteroids with pain relief helps for confirmation of diagnosis o Antibiotics used if infectious Surgical o Extirpation for recalcitrant cases o Extirpation for infectious bursitis and in some cases calcific bursitis o Extirpation for selected cases with rice bodies Complications o Tendon weakening and/or tearing if corticosteroid injected into bursa and surrounding tendon
Consider In the setting of overuse or if typical patient profile is met o Anterior trauma (wrestling) o Work-related kneeling Consider mimics such as o Hematoma o Small amount of fluid in normal deep infrapatellar bursa
Microscopic Features Thickened synovial lining with variable degree of inflammatory infiltration Rice bodies can be seen, especially in bursitis associated with rheumatoid arthritis Hemorrhagic by-products Exudate in infectious bursitis Polymorphonuclear cell percentage greater than 75% in fluid Infection related to Staphylococcus aureus or Streptococcus
Presentation Most common signs/symptoms: Anterior knee pain, +I- mass Clinical profile o Typically middle aged or older patients with anterior knee pain and localized tenderness o Sometimes with puffiness, ranging from level of the patella to about 5 cm below knee joint to anterior tibia Extensor mechanism abnormalities of knee are often present and may distract from clinical consideration of bursitis In athletes as overuse phenomenon Prepatellar bursal hematoma can be present after direct trauma
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Image Interpretation Pearls Hyperintense fluid in collection anterior, anteroinferior or inferior and deep to the patellar on FS PD FSE
1.
2.
3. 4. 5. 6. 7.
DeLee J et al: Orthopaedic sports medicine. vol2. Philadelphia Pennsylvania, Saunders, 1577-2135, 2003 Stell IM: Management of acute bursitis: Outcome study of a structured approach. J R Soc Med 92(10):516-21, 1999 Gomez-Rodriguez N et al: Infectious bursitis: Study of 40 cases in the pre-patellar and olecranon regions. Enferm Infecc Microbiol Clin 15(5):237-42,1997 Dawn B et al: Prepatellar bursitis: A unique presentation of tophaceous gout in an normouricemic patient. J Rheumatol24(5):976-8, 1997 Butcher JD et al: Lower extremity bursitis. Am Fam Physician 53(7):2317-24, 1996 Davis JM et al: Prepatellar bursitis caused by Brucella abortus. Med J Aust 165(8):460, 1996 Myllymaki T et al: Carpet-layer's knee. An ultrasonographic study. Acta Radio1 34(5):496-9, 1993
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PATELLAR (ANTERIOR) BURSITIS IMAGE GALLERY (Left) Sagittal graphic shows an inflamed superficial in frapa tellar bursa. Deep infrapatellar bursitis (along the deep surface of the distal tendon) often accompanies Osgood-Schlatter disease or may be isolated. (Right) Sagittal FS PD FSE MR shows fluid within the superficial infrapatellar bursa in a patient with bursitis and clinical "preacher's knee".
(Left) Sagittal PD FSE MR shows deep infrapatellar bursitis (arrow). (Right) Axial FS PD FSE MR of the same patient shows a large amount of fluid within the deep infrapatellar bursa.
(Left) Sagittal T2 FSE MR shows prepatellar bursitis with the bursal fluid collection containing a large amount of debris. (Right) Axial PD FSE MR shows a large prepatellar bursal fluid collection.
SYNOVITIS, KNEE
Sagittal graphic shows an inflamed thickened synovium in this patient with Lyme arthritis. Note the irregular free edge of Hoffa's fat pad.
Abbreviations and Synonyms Synovitis, Hoffa's disease, irregular fat pad sign 110
Definitions Inflammation of the synovial lining of the knee from various causes including trauma (hemorrhagic effusions), inflammatory arthritis, PVNS, Lyme arthritis, crystal deposition, metal deposition, infection, and neoplasm Hoffa's disease = inflammation and enlargement of the synovium of Hoffa's fat pad with variable enlargement of the fat pad itself on either side of the patellar tendon with pain or aching in the anterior compartment
Sagittal PD FSE MR shows extensive synovial thickening (arrow) consistent with synovitis. Hypertrophied synovium is seen adjacent to suprapatellar joint fluid.
Size: Thickened synovium in the case of synovitis varies from a few millimeters to greater than 1 cm with hypertrophic villous fronds Morphology o Normal synovium is not seen on MRI as a distinct structure o Thickening indicates synovitis o Relevant anatomy Prefemoral fat and Hoffa's fat pad may have variable morphology - pliability of adipose tissue with respect to joint capsule Should not be confused with synovitis
Radiographic Findings Radiography: Effusion
CT Findings NECT: Effusion CECT o Inflamed synovium enhances markedly o +I-Villous fronds
General Features Best diagnostic clue o Thickened intermediate signal intensity of synovium between periarticular fat and joint fluid on proton density images (PD or FS PD FSE) + Effusion Location: Synovial lining of the joint adjacent to Hoffa's fat pad and in the suprapatellar pouch
M R Findings TlWI o Low to intermediate in signal intensity in suprapatellar bursa and posterior to free edge of Hoffa's fat pad Irregular fat pad sign (irregular free edge contour of Hoffa's fat pad)
DDx: Synovitis, Knee
I,aMLM Ax- FS .GI PD , FSE
Ax FS PD FSE
*Sag , T2 FSE MR
-
Cor FS PD FSE
t---'
Sag PD FSE MR
SYNOVITIS, KNEE Key Facts Terminology Inflammation of the synovial lining of the knee from various causes including trauma (hemorrhagic effusions), inflammatory arthritis, PVNS, Lyme arthritis, crystal deposition, metal deposition, infection, and neoplasm I
Imaging Findings Thickened intermediate signal intensity of synovium between periarticular fat and joint fluid on proton density images (PD or FS PD FSE) Location: Synovial lining of the joint adjacent to Hoffa's fat pad and in the suprapatellar pouch Thickening indicates synovitis
Top Differential Diagnoses
Indolent Infection Inflammatory Arthritis Degenerative Arthritis Neoplasm/Pseudoneoplasm
Pathology Synovial inflammation
.
Clinical Issues
Most common signs/symptoms: synovitis is a cause of knee pain and should be considered as an etiology Commonly seen as reaction to underlying internal derangement of a joint
Diagnostic Checklist Irregular contour to free edge of Hoffa's fat pad
Post Traumatic Synovitis T2WI o Hyperintense effusion o FS PD FSE low to intermediate in signal intensity PDIIntermediate o Thickened intermediate signal intensity interposed between periarticular fat and joint fluid Effusion relatively hypointense o Synovial signal intensity varies depending on the cause of synovitis o Hemorrhagic areas of decreased signal intensity within the thickened synovium - hemosiderin deposition Due to trauma, pigmented villonodular synovitis, hemophilia or any cause of hemorrhage T2* GRE o Low to intermediate signal intensity in hemorrhage related synovitis o Blooming can be seen in the synovium in cases of iron deposition, hemosiderin along synovial reflection T1 C+ o Inflamed synovium enhances markedly o Visualization of irregular contour of Hoffa's fat pad Fibrinous villous hypertrophy can lead to the formation of rice bodies Micrometallic artifact on all pulse sequences can be seen in the synovium in cases of metallic deposition Decreased signal intensity foci on all pulse sequences indicate calcification Ossified bodies in synovial osteochondromatosis
Imaging Recommendations Best imaging tool: MRI Protocol advice o PD and FS PD FSE images to define irregular free edge of Hoffa's fat pad and synovial thickening within joint capsule o T1 C+ (intravenous contrast) + FS is sensitive and specific for synovitis
Post Traumatic Synovitis +/- Hemorrhagic effusion Appropriate history Sports trauma Mildly thickened synovium +/- Periarticular inflammatory change Chronic frictional trauma o Iliotibial band (ITB) syndrome o Excessive lateral pressure syndrome (Ex Lat Press)
Indolent Infection Tuberculosis Lyme arthritis o Consider the above in cases of marked effusion and synovitis without trauma or internal derangement
Inflammatory Arthritis Rheumatoid arthritis (RA) Juvenile chronic arthritis UCA) Other collagen vascular disease o Scleroderma, systemic lupus erythematosus
Degenerative Arthritis Degenerative arthritis - +/- synovitis in inflammatory osteoarthritis o Chondromalacia and underlying bone reactive changes Crystal induced arthropathies may demonstrate decreased signal intensity foci on all pulse sequence Intra- or periarticular
Neoplasm/Pseudoneoplasm Pigmented villonodular synovitis (PVNS) o Decreased signal intensity on all pulse sequences synovial thickening o Hemosiderin deposition in macrophages o Focal nodular or diffuse o Hemophilic arthropathy has a similar MR appearance with respect to synovial involvement Synovioma o Nonspecific focal synovial mass o Diffuse enhancement characteristic
11
SYNOVITIS, KNEE Osteochondromatosis o Synovial masses of various sizes of intermediate to decreased signal intensity on all pulse sequences depending on composition o +/- Calcification Synovial hemangioma o Increased signal intensity mass (T2WI) with septated, tubular structures o FS PD FSE useful Rice bodies o Fibrin filled villous structures typically found in rheumatoid arthritis o Typically fragments from the synovium to fill the joint or a nearby bursa with masses that resemble rice
Presentation Most common signs/symptoms: Synovitis is a cause of knee pain and should be considered as an etiology Clinical profile o Depending on the underlying disease o Commonly seen as reaction to underlying internal derangement of a joint
Demographics Age: Varies (greater than 45 years for arthritis population) Gender: Depends on specific disease state
Natural History & Prognosis Resolves in uncomplicated posttraumatic synovitis
Treatment General Features General path comments o Synovial inflammation o Inflammation + enlargement of the synovium of Hoffa's fat pad with variable enlargement of the fat pad itself + pain or aching in the anterior compartment Genetics: Genetic predisposition in cases of inflammatory arthritis Etiology: Varied depending on cause, may be seen in posttraumatic setting, osteoarthritis and rheumatoid arthritis Epidemiology o Commonly observed after variety of insults to knee o 75 to 85% of older individuals with arthritis and synovitis
*
112
Gross Pathologic & Surgical Features Thick dull opaque synovium develops as a result of synovitis o Normally transparent, smooth and thin Turns red with hemorrhagic synovitis and turns reddish-brown with chronic hemarthrosis due to hemosiderin o May turn purple in chronic, severe cases Darkening maybe result of metallic deposition Ochronosis can result in grey appearance White foci may indicate crystal deposition or calcification
Microscopic Features 1
Degenerative joint disease - mild villous hypertrophy without pannus formation Rheumatoid arthritis - nodular lymphocyte and plasma cell infiltration + villous hypertrophy & proliferation of synoviocytes Septic arthritis - leukocytic infiltration Traumatic synovitis - fibrinous change Neuropathic joint - bone and cartilage detritus
Staging, Grading or Classification Criteria Staging criteria have been proposed based on individual arthritides o Conventional radiographs insensitive to mild effusions and irregular Hoffa's fat pad sign
Conservative - minor trauma Surgical - neoplasm, pseudoneoplasm, severe cases (synovectomy)
Image Interpretation Pearls Thickened synovium with intermediate to increased signal intensity: Posttraumatic, degenerative arthritis, inflammatory arthritis, neoplasm, crystal deposition, infection Thickened synovium with decreased signal intensity: PVNS, synovial osteochondromatosis (ossified bodies), any cause of hemorrhagic synovitis, crystal deposition disease in some cases, metallic deposition (lead synovitis) Irregular contour to free edge of Hoffa's fat pad Synovitis will enhance with intravenous contrast
Saito I et al: Increased cellular infiltrate in inflammatory synovia of osteoarthritic knees. Osteoarthritis Cartilage 10(2):156-62, 2002 Abdelwahab F et al: True bursa1 pigmented villonodular synovitis. Skeletal Radiol 31(6):354-8, 2002 Dabby D et al: Synovial knee pain arising from chronic inflammatory disorders of the knee. J Knee Surg 15(1):53-6, 2002 Gibbons CE et al: Long-term results of arthroscopic synovectomy for seropositive rheumatoid arthritis: 6-16 year review. Int Orthop, 26(2):98-100, 2002 Hoffman EB et al: Tuberculosis of the knee. Clin Orthop (398):100-6, 2002 Jackson RW: Arthroscopic synovectomy. J Rheumatol 28(7):1474-5, 2001 Jaswal TS et al: Synovial hemangioma--a case report. Indian J Path01 Microbiol44(3):353-4,2001 Hill CL et al: Knee effusions, popliteal cysts, and synovial thickening: Association with knee pain in osteoarthritis. J Rheumatol28(6):1330-7, 2001 Bredella MA et al: Reactive synovitis of the knee joint: MR imaging appearance with arthroscopic correlation. Skeletal Radiol 29(10):577-82, 2000
I
SYNOVITIS, KNEE
( L e f ) Sagittal graphic shows Hoffa 's irregular fat pad sign. An irregular posterior surface indicates synovitis in this location. (Right) Sagittal FS PD FSE MR shows synovitis (arrow) along the posterior margin of Hoffa's fat pad.
(Left) Sagittal PD FSE MR shows synovitis (arrow) in the suprapatellar pouch and an irregular fat pad sign. (Right) Axial FS PD FSE MR shows thickened synovium as frond-like projections (arrow) into the suprapatellar portion of the joint. This synovitis has the arthroscopic appearance of "hair".
(Left) Axial T 1 C+ MR shows synovial enhancement consistent with synovitis. Normal synovium does not enhance. (Right) Coronal PD FSE MR shows subtle synovitis as thickened, intermediate signal intensity synovium (arrows) compared to slightly decreased signal intensity joint fluid best seen laterally
PATELLAR TENDON TEARS
I
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Coronal graphic shows a tear of the proximal patellar tendon (ligament). This is often considered an orthopedic emergency and is treated quickly to prevent fibrosis after retraction.
Sagittal FS PD FSE shows rupture of patellar tendon with preexisting patellar tendinitis in a patient who had multiple steroid injections. Patient was performing a "lay-up" basketball move.
Imaging Recommendations Best imaging tool: MRI to document partial vs. complete retraction Protocol advice: FS PD FSE & T2* GRE
Abbreviations and Synonyms Patellar tendon rupture
Definitions Disruption of the patellar tendon
~ N T I A DIAGNOSIS L Patellar Tendinitis/Tendinosis without Tear Jumper's knee, injured by steroid use +/- Deep infrapatellar bursa1 fluid
General Features Best diagnostic clue: Tear or gap in patellar tendon, +/hemorrhage & granulation tissue Location 0 Proximal third of the patellar tendon (most common) o Inferior pole of patellar Size: Range from mm to several cms Morphology: Irregular thickened tendon edges, retracted
Radiographic Findings Radiography: Lateral radiograph - small avulsion at inferior patellar pole, patella alta
MR Findings T2WI: Fluid signal intensity filling a gap in the tendon, +/- surrounding reactive edema
Hematoma Increased signal mass on T2WI
Sinding-Larsen-Johansson Disease Traction apophysitis at inferior pole of patella
Bipartite Patella Failure of superolateral ossification fusion, +/- stress response/fracture
1 PATHOLOGY General Features General path comments o Degeneration & deterioration as a predisposing factor to tendon rupture
DDx: Patellar Tendon Tears
I
Deep Bursitis
Stress Ri~anite
Sag FS PD FSE
Ax FS PD FSE
Hematoma
Tendinitis
Sag FS PD FSE
Sag PD FSE MR
I
PATELLAR TENDON TEARS Key Facts Terminology
Pathology Degeneration & deterioration as a predisposing factor to tendon rupture Etiology: Jumping sports (dynamic loading), steroid injections, previous surgery (ACL reconstruction)
Patellar tendon rupture
Imaging Findings Best diagnostic clue: Tear or gap in patellar tendon,
+/- hemorrhage & granulation tissue Proximal third of the patellar tendon (most common) Radiography: Lateral radiograph - small avulsion at inferior patellar pole, patella alta T2WI: Fluid signal intensity filling a gap in the tendon, +/- surrounding reactive edema
Clinical Issues Complete tear results in inability to extend knee Partial tear: Incomplete knee extension without full range of motion
Diagnostic Checklist
Top Differential Diagnoses
Partial tear in the setting of peripatellar pain FS PD FSE sagittal images demonstrate tendon tear morphology
Patellar TendinitisITendinosiswithout Tear Hematoma Sinding-Larsen-JohanssonDisease Bipartite Patella Tensile & viscoelastic properties of the patellar tendon, however remain relatively stable between younger and older age groups Etiology: Jumping sports (dynamic loading), steroid injections, previous surgery (ACL reconstruction) * Epidemiology o Acute tear in patient < 40 yrs of age, +/- preexisting disease (e.g., rheumatoid arthritis, diabetes) o Less common than quadriceps tendon rupture
Surgical: Repair using end-to-end sutures, +/- delayed or late repair
I DIAGNOSTIC CHECKLIST Partial tear in the setting of peripatellar pain
Image Interpretation Pearls
Gross Pathologic & Surgical Features
FS PD FSE sagittal images demonstrate tendon tear morphology
Thickened, indurated tendon edges with discontinuity
Microscopic Features Preexisting collagen degeneration without significant influx of inflammatory cells
Staging, Grading or Classification Criteria Grade I - mild strain with minimal functional impairment, grade I1 - intermediate tear, grade 111 complete disruption
1 SELECTED REFERENCES 1. 2. 3.
4.
Presentation Most common signs/symptoms: Pain, physical examination reveals palpable defect in patellar ligament with complete tear Clinical profile o Complete tear results in inability to extend knee o Partial tear: Incomplete knee extension without full range of motion
McGrory JE: Disruption of the extensor mechanism of the knee. J Emerg Med 24(2):163-8, 2003 Enad JG et al: Primary patellar tendon repair and early mobilization: Results in an active-duty population. J South Orthop Assoc 10(1):17-23, 2001 Kasten P et al: Rupture of the patellar tendon: A review of 68 cases and a retrospective study of 29 ruptures comparing two methods of augmentation. Arch Orthop Trauma Surg 121(10):578-82,2001 Casey MR et al: Neglected ruptures of the patellar tendon. A case series of four patients. Am J Sports Med 29(4):457-60, 2001
Demographics Age: Physically active patients < 40 years Gender: Male > female
Natural History & Prognosis Complete tear requires surgical repair and is often considered an orthopedic emergency
Treatment a
Conservative: Partial tear can be treated with immobilization for 3-6 weeks
(Lefl) Sagittal FS PD FSE MR shows a partial patellar tendon tear. (Right) Sagittal PD FSE MR shows a complete rupture of the patellar
tendon.
11
CHONDROMALACIA PATELLA Key Facts Terminology Degradation and eventually ulceration of hyaline cartilage of the patella usually with underlying bone reactive changes
Imaging Findings Best diagnostic clue: Signal alteration of patella hyaline cartilage with variable degrees of ulceration and underlying bone reactive change FS PD & PD FSE MR sequences sensitive to the changes of chondromalacia Fraying of hyaline articular cartilage surface (crab meat morphology by arthroscopy and MRI) intermediate stage Full thickness chondral loss & subchondral erosion end stage
Acute changes (acute inflammatory chondromalacia) Stress vs. a bone trabecular injury in cases of direct trauma 0 Subchondral cysts are seen in more chronic cases and are hyperintense Identified with full thickness chondral loss TZ* GRE 0 TZ* weighted GRE demonstrates larger defects as hyperintense Normal cartilage may be isointense to joint fluid and therefore surface defects may be inconspicuous T2 * GRE not a recommended cartilage imaging sequence (not sensitive to fibrillation & fissures)
Imaging Recommendations Best imaging tool o MRI Detects early & late stages of chondromalacia Protocol advice: PD or FS PD FSE in axial plane for patellar facets and sagittal plane for trochlear groove
Osteochondral Injuries of Femoral Trochlea Hyaline articular cartilage abnormalities of femoral trochlea +/- Underlying bone changes +/- Normal patella Traumatic - direct impact Chronic microtrauma and associated with CMP Associated with thickened infrapatellar plica
Patellar Tendinitis Increased signal intensity and/or thickening within the patellar tendon Associated with jumping sports activity Pain at proximal tendon inferior to patella
Dorsal Defect of Patella Located along the superolateral aspect of the articular surface of patella
Top Differential Diagnoses Osteochondral Injuries of Femoral Trochlea Patellar Tendinitis Dorsal Defect of Patella
Pathology Degenerative in nature (50%) but can be acute and posttraumatic (15%)
Clinical Issues Anterior knee pain
Diagnostic Checklist Chondral edema as an early marker of articular cartilage softening
Radiolucency with sclerotic margins and intact overlying articular cartilage
Anterior Meniscal Tears
Uncommon as isolated abnormality
+ Horizontal tear and meniscal cyst
Diagnostic MRI finding of increased signal on short TE sequence extending to surface
Inflammation of Hoffa's Fat Pad (Hoffitis) Associated with generalized synovitis Irregular posterior margin o Irregular fat pad sign
Prepatellar Edema (Prepat Edema) Superficial subcutaneous edema
+ Associated trauma Nonspecific
1 PATHOLOGY General Features General path comments: Softening of articular cartilage with associated degenerative changes includes fissuring, ulceration, chondral defects and underlying bone changes Etiology o Degenerative in nature (50%) but can be acute and posttraumatic (15%) o 20% secondary to tracking abnormalities - lateral patellar compression syndrome o 15% secondary to chronic dislocations o Causes of acute chondromalacia include instability, direct trauma, and fracture 0 Causes of chronic chondromalacia include Patellar subluxation, increased quadriceps angle (Q-angle),quadriceps imbalance, posttraumatic malalignment, excessive lateral pressure syndrome and posterior cruciate ligament (PCL) injuries o Painful chondromalacia Excessive mechanical overload Increased intraosseous pressure of the patella
CHONDROMAlAClA PATELLA Transient venous outflow obstruction (pain with prolonged knee flexion) Excessive load transference to innervated subchondral and cancellous bone Malalignment - shifting and transference of load with excessive mechanical forces Chronic triggering of pain producing cytokines Epidemiology: Young women Associated abnormalities: Patella alta, increased valgus angle, and femoral condyle hypoplasia
Gross Pathologic & Surgical Features Softening, discoloration, fissuring and/or ulceration and desiccation
Treatment Initial treatment is conservative and consists of rest and rehabilitation If instability is present surgical correction may be needed Direct surgical treatment of chondromalacia includes chondroplasty microfracturing and chondral implantation
1 DIAGNOSTIC CHECKLIST Image Interpretation Pearls Utilize FS PD FSE and PD FSE axial images to optimize visualization of cartilage fibrillation, blister, fissure, ulceration and fragmentation Chondral edema as an early marker of articular cartilage softening
Microscopic Features Histologic changes of articular cartilage softening occur in transitional zone deep to superficial zone o Reorientation and disorganization of collagen and fibers into collapsed segments associated with decrease in matrix proteoglycans
Staging, Grading or Classification Criteria
118
MRI adaptation of Outerbridge arthroscopic grading system o Grade 1 FS PD FSE display focal areas of hyperintensity within normal contour k Focal basal degeneration Softening by arthroscopy o Grade 2 FS PD FSE demonstrates blister-like swelling of articular cartilage extending to surface Fissuring and fibrillation within soft areas of articular cartilage and extending to a depth of 1 to 2 mm within an area of 1.3 cm or less in diameter arthroscopically o Grade 3 FS PD FSE demonstrates focal ulcerations and "crab meat" lesions Partial thickness cartilage loss (> 2 mm depth in area and > 1.3 cm in diameter) arthroscopically o Grade 4 FS PD FSE demonstrate full thickness cartilage loss with underlying bone reactive changes Ulceration with exposed subchondral bone (end-stage) arthroscopically
1 SELECTED REFERENCES 1.
2. 3. 4. 5. 6. 7.
8. 9. 10. 11. 12.
Presentation Most common signs/symptoms o Anterior knee pain o Patellofemoral joint pain Especially during flexion as can occur in ascending or descending stairs: Associated crepitus
Demographics Age: Most often affects adolescents and young adults Gender: F > M
Natural History & Prognosis Insidious onset or acute onset subsequent to patellar trauma
13. 14. 15.
-
Peterson L et al: Treatment of osteochondritis dissecans of the knee with autologous chondrocyte transplantation: Results at two to ten years. J Bone Joint Surg Am 85-A Suppl2: 17-24, 2003 Fitzgerald R Jr et al: Orthopaedics. Pediatric Orthopaedics. St. Louis, MO, Mosby, 1489-95, 2002 Kerrigan DC et al: Women's shoes and knee osteoarthritis. Lancet 357(9262):1097-8, 2001 Outerbridge RE: The etiology of chondromalacia patellae. Clin Orthop (389):5-8, 2001 Bosch JJ: Chondromalacia patella. J Pediatr Health Care 13(3:1):144; quiz 155-6, 1999 Kim BS et al: Selective patellar nonresurfacing in total knee arthroplasty. 10 year results. Clin Orthop (367):81-8, 1999 Kannus P et al: An outcome study of chronic patellofemoral pain syndrome. Seven-year follow-up of patients in a randomized, controlled trial. J Bone Joint Surg Am 81(3):355-63,1999 Holmes SW Jr et al: Clinical classification of patellofemoral pain and dysfunction. J Orthop Sports Phys Ther 28(5):299-306, 1998 Johnson LL et al: Clinical assessment of asymptomatic knees: Comparison of men and women. Arthroscopy 14(4):347-59,1998 Barrack RL et al: Resurfacing of the patella in total knee arthroplasty. A prospective, randomized, double-blind study. J Bone Joint Surg Am 79(8):1121-31, 1997 Minas T et al: Current concepts in the treatment of articular carilage defects. Orthopaedics 20:525-38, 1997 Van Leersum M et al: Chondromalacia patellae: An in vitro study. Comparison of MR criteria with histologic and macroscopic findings. Skeletal Radio1 25(8):727-32, 1996 Joshi AB et al: Total knee arthroplasty after patellectomy.J Bone Joint Surg 76(6):926-9,1994 Kelly MA et al: Historical perspectives of chondromalacia patellae. Orthop Clin North Am 23(4):517-21, 1992 Kolettis GT et al: Patellar resurfacing for patellofemoral arthritis. Orthop Clin North Am 23(4):665-73, 1992
1
CHONDROMALAClA PATELLA IMAGE GALLERY (Lef)Axial graphic demonstrates chondromalacia of the lateral patella and femoral trochlea with underlying cystic resorptive changes of the subchondral bone. This constellation of findings is associated with excessive lateral pressure syndrome. (Right) Axial FS PD FSE MR shows patellofemoral arthrosis with full thickness chondral loss and subchondral irregularity of the lateral facet.
Typical (Left)Axial FS PD FSE MR shows a "subchondral bubble" area (arrow) of chondral dehiscence with adjacent bone marrow edema, also referred to as "acute inflammatory chondromalacia". (Right) Sagittal FS PD FSE MR of the same patient demonstrates hyperintense inferior pole edema.
Typical (Left) Axial FS PD FSE MR shows mild surface irregularity (arrow) in early chondromalacia (arrow). (Right) Axial FS PD FSE MR shows lateral patellar facet chondral fissuring (arrow) and a thick medial plica with a normal medial facet.
QUADRlCEPS TENDON TEAR Key Facts Terminology Rupture of the quadriceps tendon at the patellar insertion site
Imaging Findings Discontinuous hypointense signal (TI ST T2WI) fibers of the quadriceps tendon Commonly occurs above level of the patellar insertion site of the tendon (expansion)
Top Differential Diagnoses Patellar Chondromalacia Patellar Tendinosis Medial Plica Osteoarthritis/Chondromalacia Patella Surgery
o T2 FSE is less sensitive for the depiction of edema
compared to FS PD FSE o +/- Inferior migration of patella o Surrounding soft tissue hyperintensity edema
PDIIntermediate: Less sensitive for the depiction of edema compared to FS PD FSE or STIR STIR o Hyperintense fluid as FS PD FSE except with less resolution of tendon o Superior soft tissue contrast including degenerative area within tendon o Altered tendon structure (incomplete ruptures with focal discontinuities of individual layers) o Tendon laxity secondary to loss of extensor mechanism tension o +/- Patellar hyperintense edema T2* GRE o Discontinuous fibers of the tendon with intermediate to hyperintense signal in tendon edges o Magic angle may cause increased signal intensity at tendon patella junction
Imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE images preferably in the sagittal and axial planes
1 DIFFERENTIAL DIAGNOSIS Patellar Chondromalacia Increased signal with surface irregularity on FS PD FSE +/- Surface defect +/- Decreased signal (FS PD FSE) abnormalities (desiccation) Anterior knee pain, especially with stair climbing Trochlear osteoarthritis (OA)
Pathology Begins centrally and progresses peripherally
Clinical Issues Large hemarthrosis with freely mobile patella Age: 5th and 6th decade Full thickness tears need to be repaired within 48 hours if possible
Diagnostic Checklist Expanding FOV to completely evaluate tendon rupture Identify discontinuous fibers on FS PD FSE in the sagittal plane Evaluate superior aspect of the sagittal images to detect tendinosis or tear
Magic Angle Artifact At 55" to external magnetic field Upper patellar tendon Short TE sequences o TlWI o PDIintermediate o T2* GRE Tendon not thickened Asymptomatic Quad patella interface Unusual cause of increased signal o Less common than in patellar tendon
Stress ResponseIFracture of the Patella Increased signal intensity on T2WI with or without fracture lines in the presence of a normal quadriceps tendon +/- Trauma +/- Repetitive microtrauma +/- Chondromalacia patella
Medial Plica Failure of resorption of embryologic remnant
+/- Thickening of plica (hypointense on T1 and T2WI) Adolescent/young adult usually Medial anterior pain and sometimes suprapatellar pain
Osteoarthritis/Chondromalacia Patella Subchondral cysts Subchondral edema Subchondral sclerosis Anterior pain, especially with stair climbing
Surgery Post operative healing - thickeninglfibrosis Patellectomy Appropriate history
Patellar Tendinosis Jumping sports Increased signal on short TE sequence +/- Partial tearltear
General Features General path comments
-
QUADRICEPS TENDON TEAR
o Begins centrally and progresses peripherally o Superficial and deep tears rarely involve the
trilaminar tendon at the same level Etiology o Decreased vascularity, predisposing conditions Cortisone injections Diabetes Chronic renal failure Hyperthyroidism Gout o Acute flexion of extended knee Usually in setting of preexisting tendinosis Chronic repetitive microtrauma - tendinosis Eccentric contraction leads to tendon failure Epidemiology: Uncommon < 1% Associated abnormalities: Inferior migration of patella in complete tears
Gender: No predilection
Natural History & Prognosis Full thickness tears need to be repaired within 48 hours if possible
Treatment * Conservative: Partial tears with immobilization and early range of motion exercises Surgical: Within 48 hours as early intervention allows end-to-end repair of the tendon
Consider Expanding FOV to completely evaluate tendon rupture o If history of injury is absent or technologist unaware of diagnosis, rupture may be incompletely imaged
Gross Pathologic & Surgical Features Discontinuous tendon fibers with surrounding edemathemorrhage in complete tears
Image Interpretation Pearls Identify discontinuous fibers on FS PD FSE in the sagittal plane Evaluate superior aspect of the sagittal images to detect tendinosis or tear
Microscopic Features Discontinuous tendon fibers with surrounding edemathemorrhage Tendinosis associated with neovascularization o Attempt at healing Tendinosis with angioblastic hyperplasia Absence of inflammatory cells in tendon microtearslpartial rupture
Staging, Grading or Classification Criteria Tendon strain o Grade I (mild) Tear of only few tendon fibers + Mild swelling, pain, disability Functional, painful, muscle contractions o Grade I1 (moderate) Moderate disruption of a number tendon fibers Muscle-tendon unit still intact Moderate swelling, pain and disability Weak and painful, muscle contractions o Grade I11 (high grade) Near complete to complete disruption of tendon unit Extremely weak but painless attempts at muscle contraction
CLINICAL ISSUES Presentation Most common signs/symptoms o Large hemarthrosis with freely mobile patella o Loss of extensor function with full thickness tears o Palpable defect with full thickness tears o Partial tears present with extensor lag Clinical profile o A "pop" felt or heard in acute rupture o Inability to walk with full thickness tears o More commonly associated with pain than Achilles tears
Demographics Age: 5th and 6th decade
SELECTED REFERENCES 1. 2. 3.
4. 5. 6.
7. 8. 9.
McGrory JE: Disruption of the extensor mechanism of the knee. J Emerg Med 24(2):163-8, 2003 Shah MK: Simultaneous bilateral rupture of quadriceps tendons: Analysis of risk factors and associations. South Med J 95(8):860-6, 2002 Richards DP et al: Repair of quadriceps tendon ruptures using suture anchors. Arthroscopy 18(5):556-9,2003 Panni AS et al: Overuse injuries of the extensor mechanism in athletes. Clin Sports Med 21(3):483-98, 2002 De Baere T et al: Functional results after surgical repair of quadriceps tendon rupture. Acta Orthop Belg 68(2):146-9, 2002 Bikkina RS et al: Magnetic resonance imaging of simultaneous bilateral quadriceps tendon rupture in a weightlifter: Case report. J Trauma 52(3):582-4, 2002 O'Shea K et al: Outcomes following quadriceps tendon ruptures. Injury 33(3):257-60, 2002 Omololu B et al: Quadriceps tendon rupture in an adolescent. West Afr J Med 20(3):272-3, 1998 Konrath GA et al: Outcomes following repair of quadriceps tendon ruptures. J. Orthop Trauma. vol 12. (4)273-279, 1998
QUADRlCEPS TENDON TEAR
(Left) Sagittal PD FSE MR shows marked thickening of the quadriceps tendon consistent with tendinosis. (Right) Sagittal FS PD FSE MR shows the tendinosis in the anterior aspect of the quadriceps tendon.
Typical (Left) Sagittal FS PD FSE MR shows an extensive partial tear through the posterior two-thirds of the quadriceps tendon. (Right) Coronal FS PD FSE MR shows the high grade partial tear (arrow) with retraction.
(Lef)Sagittal PD FSE MR shows thickening of the quadriceps and patellar tendons consistent with tendinosis. (Right) Sagittal TZ FSE MR shows a full thickness quadriceps tendon tear (arrow) at the top of the field of view. These complete tears may be overlooked at the edge of the FOV especially if appropriate history is not available.
TRANSIENT PATELLAR DISLOCATION
Axial graphic shows the hallmarks of a transient patellar dislocation: Osteochondral injury of medial patella, lateral femoral condyle contusion and medial retinacular tear.
Axial FS PD FSE shows osseous contusions (arrows) of the medial facet and lateral aspect of the lateral femoral condyle. Medial retinacular tear and hemorrhagic fluid level are present.
MR Findings Abbreviations and Synonyms Patellar dislocation, patellar subluxation 124
Definitions Dislocation of the patella laterally as the result of twisting injury with valgus stress or as the result of direct trauma
General Features Best diagnostic clue o Bone contusions of the anterior lateral femoral condyle and medial patella are diagnostic Includes osteochondral fracture Location: Patellofemoral joint Size: Osteochondral defects small and nondisplaced to large +/- displaced Morphology: Intact posttraumatic structures to edematous, torn and/or fractured
Radiographic Findings
mHm
Radiography: Fracture of the patella or anterior lateral femoral condyle may be seen
1
TlWI o Bone contusion (hypointense edema) of medial patella + lateral aspect of lateral femoral condyle characteristic o Decreased signal intensity edema o + Hypointense effusion o +/- Hypointense fracture of medial patella (osteochondral fracture) o +/- Fracture of anterior lateral femur (osteochondral fracture) - hypointense o +/- Hypointense chondral fracture anterior femur o +/- Discontinuous medial patellofemoral ligament at femoral origin or attachment to medial facet T2WI o Bone contusion (hyperintense edema) of medial patella + anterior lateral femur (lateral aspect of lateral femoral condyle) o Disruption of the origin of the medial patellofemoral ligament - increased signal intensity at femoral origin or from medial patellar facet Disruption of this ligament is often surgically treated Partial or complete retinacular tear identified on axial FS PD FSE o Hemarthrosis - fluid signal intensity on T2WI (hyperintense) Decreased signal intensity, debris
DDx: Transient Patellar Dislocation
Chondromalaaa
Vastu~H~mangroma
&F Cor FS PD FSE
Ax PD FSE MR
Sa
PD FSE
Ax FS PD FSE
TRANSIENT PATELLAR DlSLOCATlON Key Facts Terminology Dislocation of the patella laterally as the result of twisting injury with valgus stress or as the result of direct trauma
Imaging Findings Bone contusions of the anterior lateral femoral condyle and medial patella are diagnostic +/- Hyperintense fracture of anterior lateral femur (osteochondral fracture)
Top Differential Diagnoses Patellar Osteochondral Injury Lateral Femoral Bone Injury
rn
+/- Fluid-fluid level
o Chondral or osteochondral fragments often free
o o o
o o
floating within an effusion Important to identify intermediate signal chondral fragments or hypointense osteochondral fragments + Hyperintense effusion +/- Hyperintense fracture of medial patella (osteochondral fracture) +/- Hyperintense fracture of anterior lateral femur (osteochondral fracture) +/- Hyperintense chondral fracture anterior femur Edema in muscle stain of vastus medialis obliquus (VMO) muscle Stripping of the VMO away from the adductor magnus tendon
Imaging Recommendations Best imaging tool: MRI Protocol advice o FS PD FSE in the axial and coronal planes o Axial images to define medial retinacular tear at medial patellar facet vs. adductor tubercle
Pathology Secondary to a shallow trochlear groove, ligamentous laxity or both Intrinsic muscle abnormalities and soft tissue damage predispose to dislocation
Clinical Issues Patella often spontaneously reduces into trochlear groove with extension following the injury
Diagnostic Checklist Direct impact injury Consider patellar dislocation in case of injury to lateral aspect of lateral femoral condyle Axial images show typical pattern of bone contusions/fractures, retinacular tear and chondral injuries
+/- ACL tear
Bipartite Patella Normal variant Failure of fusion of secondary ossification center Superolateral pole patella (not medial)
High Signal T2 Mass Hemangioma medially may mimic retinacular damage Rare FS PD FSE most sensitive o Increased venous vascularity
Chondromalacia Patella FS PD FSE sequence for chondral evaluation Axial images to identify patellar facets and sagittal images for the trochlear groove +/- Hyperintense collage; matrix on FS PD FSE +/- Underlying patellar bone edema o Hyperintense T2WI +/- Subchondral cysts o Hyperintense on T2WI +/- Trochlea osteoarthritis +/- Medial plica
1 PATHOLOGY Anterior Cruciate Ligament (ACL) Tear with Hemarthrosis May mimic transient patellar dislocation clinically +/- Valgus injury Posterolateral tibia plateau contusion Lateral femoral condyle (sulcus) contusion
Patellar Osteochondral Injury Direct trauma Sleeve avulsion Sudden quadriceps contraction +/- Chondral displacement
Lateral Femoral Bone Injury Valgus stress Direct trauma
General Features General path comments o Traumatic patellar dislocation occurs laterally o Usually iatrogenic o Secondary to realignment procedures, +/- previous surgery Etiology o Two common mechanisms Noncontact, indirect injury Direct mechanism secondary to a blow to knee o Knee in internal rotation and valgus vs. forced external rotation of the tibia (less common) o Secondary to a shallow trochlear groove, ligamentous laxity or both o Abnormal iliotibial band and vastus lateralis attachment produce a lateral patellar pull
TRANSIENT PATELLAR DISLOCATION o Occurs throughout adulthood secondary to twisting
o Intrinsic muscle abnormalities and soft tissue
damage predispose to dislocation o Variation of patellar shapes (Wiberg types) may predispose to dislocations including type 3 (small and convex medial patellar facet) and type 5 uagerhut or hunter's cap) patella Patella alta with subsequent loss of containment by the lateral femoral condyle predisposes to dislocations Epidemiology: Uncommon injury, 1% of general population Associated abnormalities o Osteochondral injuries of the patella and lateral femoral condyle o +/- Tear of the medial retinaculum o +/- Strain of the vastus medialis obliquus o +/- Disruption of the medial patellofemoral ligament
injury, valgus stress or direct blow
Demographics Age: Younger patient to adult Gender: No predilection
Natural History & Prognosis Patella often spontaneously reduces into trochlear groove with extension following the injury Torn medial patellofemoral ligament (especially from medial femoral epicondylar insertion) predisposes patella to recurrent dislocations Torn medial patellofemoral ligament (MPFL) usually repaired
Treatment Non operative treatment includes o Cast immobilization and rehabilitation with early return of range of motion and strength Arthroscopy is used in o Diagnosis and treatment of osteochondral fragments and associated intraarticular pathology o Selective lateral retinacular release Lateral retinacular release relieves the retinacular pull +/- Medial patellofemoral ligament repair to medial femoral epicondyle and use of adductor magnus tendon for reinforcement
Gross Pathologic & Surgical Features
126
Injury/hemorrhage/edema of medial patella, lateral femoral condyle, medial patellofemoral ligament, VMO Osteochondral fracture o Medial patellar facet o Lateral l i of ~ trochlear o Lateral trkhlear fractures result in patellofemoral instability Rupture of vastus medialis obliquus muscle is usually interstitial (insertional ruvture when vresent can be sutured surgically)
Microscopic Features Fracture, ligamentous disruption, chondral injury
Consider
Staging, Grading or Classification Criteria Classification (Fulkerson) o I: Subluxation o 11: Subluxation and tilt o 111: Tilt o IV: No malalignment Associated with each class o A: Absence of articular lesion o B: Presence of minimal chondromalacia o C: Presence of osteoarthritis Wiberg classification for patella shape; no predisposition for dislocation o Type 1: Concave facets, symmetrical and equal in size (10%) o Type 2: Medial facet is smaller; lateral facet is concave (65%) o Type 3: Medial facet is distinctly smaller with marked lateral predominance (25%)
Presentation Most common signs/symptoms o Anterior and anterolateral knee pain after twisting injury o ACL tear often suspected clinically Clinical profile o Children with congenitally shallow trochlear groove
Direct impact injury Consider patellar dislocation in case of injury to lateral aspect of lateral femoral condyle
Image Interpretation Pearls Axial images show typical pattern of bone contusions/fractures, retinacular tear and chondral injuries Distinguish between medial retinacular tear to medial facet vs. disruption to adductor tubercle attachment (insertion to the medial femoral epicondyle)
1 SELECTED REFERENCES 1. 2. 3.
4. 5.
6.
Arendt EA et al: Current concepts of lateral patella dislocation. Clin Sports Med 21(3):499-519, 2002 Bharam S et al: Knee fractures in the athlete. Orthop Clin North Am 33(3):565-74, 2002 Elias DA et al: Acute lateral patellar dislocation at MR imaging: Injury patterns of medial patellar soft tissue restraints and osteochondral injuries of the inferomedial patella. Radiology 225(3):736-43, 2002 Drez D et al: Results of medial patellofemoral ligament reconstruction in the treatment of patellar dislocation. Arthroscopy 17(3):298-306,2001 Sanders TG et al: Medial patellofemoral ligament injury following acute transient dislocation of the patella: MR findings with surgical correlation in 14 patients. J Comput Assist Tomogr 25(6):957-62, 2001 Pope TL Jr: MR imaging of patellar dislocation and relocation. Semin Ultrasound CT MR 22(4):371-82, 2001
TRANSIENT PATELLAR DISLOCATION
-
(Left)Axial graphic shows an intact patellar attachment of the medial retinaculum after dislocation. The medial patellofemoral ligament is torn at the medial femoral epicondyle. Fragmentation of medial patellar chondral surface is shown. (Right) Axial FS PD FSE MR shows a dislocation osseous injury pattern associated with a disruption of the origin of the medial patellofemoral ligament from the medial femoral epicondyle (arrow).
(Left) Axial FS PD FSE MR shows an impaction fracture of anterior aspect of lateral femoral condyle and a loose osteochondral fragment (arrow) within the medial joint recess. Origin of the medial patellofemoral ligament is disrupted (open arrow). (Right) Sagittal FS PD FSE MR of the same patient shows the large displaced osteochondral fragment within the medial suprapatellar joint recess.
(Left) Coronal FS PD FSE MR shows an osteochondral injury, including a chondral defect (arrow), of the anterior lateral femoral condyle. (Right) Axial FS PD FSE MR shows the typical bone injury pattern (edema of lateral femoral condyle and medial patellar facet) of a recent patellar dislocation. The medial patellofemoral ligament origin, however is intact.
MEDIAL PLICA SYNDROME
Sagittal graphic shows a thickened medial plica (arrow) interposed between the patella and medial femoral condyle.
Sagittal FS PD FSE MR shows a slightly thickened hypointense medial plica (arrow) in medial aspect of the suprapatellar bursa.
o Elongated and thin or thickened
M R Findings
Abbreviations and Synonyms Medial plica syndrome (MPS), medial shelf, mediopatellaris, Iino's band 128
Definitions Inflamed synovial plica leading to pain, crepitus and/or pseudolocking
General Features Best diagnostic clue: Low signal intensity linear structure (usually thickened if symptomatic) on all sequences at expected location in a patient with dull aching medial knee pain Location o Originates on medial side of knee joint adjacent to medial patella o Oblique, course from superior/midpatellar medial capsule towards synovium covering medial aspect of fat pad Size: Varies from 1to several mm in thickness Morphology o Thin in case of normal variant o Thickens and fibrotic when symptomatic
TlWI o Abnormal plica as thickened band of low signal intensity o Subchondral cystic changes of medial patella well-defined, with low signal intensity o Focal synovitis - increased in signal intensity relative to adjacent fluid o Subchondral reactive decreased signal intensity changes in the medial anterior femur (trochlea) (rare) T2WI o Thickened band of low signal intensity 0 Chondromalacia of medial patellar facet Increased signal intensity within hyaline articular cartilage Surface ulceration FS PD FSE (hyperintense erosions) 0 Increased signal intensity synovitis Intermediate signal relative to joint fluid PDIIntermediate o Intermediate signal intensity synovitis adjacent to patella in medial joint o Joint fluid is slightly decreased in signal compared to inflamed synovium T2* GRE o Plica thicker if hemorrhagic
-
DDx: Medial Plica Syndrome
Salg PD FSE M R
D FSE M R
EMR
Ax FS PD FSE M R
MEDlAL PLlCA SYNDROME Key Facts Terminology Inflamed synovial plica leading to pain, crepitus and/or pseudolocking
Imaging Findings Best diagnostic clue: Low signal intensity linear structure (usually thickened if symptomatic) on all sequences at expected location in a patient with dull aching medial knee pain Originates on medial side of knee joint adjacent to medial patella Thin in case of normal variant
Top Differential Diagnoses Patellar Chondromalacia (Chondro Patella) Femoral Trochlear Osteoarthritic Change (Trochlea Chondro) Due to blooming/susceptibility o Sensitivity similar to FS PD FSE for identification of
plica No measurements have been described to define plical thickening o Thickening is a subjective determination in a symptomatic patient Sagittal images show elongated plica as linear hypointense structure anterior to the anterior horn of the medial meniscus
Imaging Recommendations Best imaging tool: MRI Protocol advice o Axial & sagittal FS PD FSE for demonstrating thickened plica FS PD FSE demonstrate associated chondromalacia in medial patella facet
-
Medial Meniscal Tear Positive clinical signs (e.g., Lachman's test) Increased signal abnormality on short TE sequences extending to articular surface o TI, PDIIntermediate, T2* GRE +/- Reactive edema in medial tibia +/- Medial bursitis
Patellar Chondromalacia (Chondro Patella) Tenderness along medial patellar facet Imaging helpful to define chondral erosions Common abnormality often without symptomatic plica +/- Medial plica o Thin plica may be incidental Typically older patient population
Hoffa's Impingement (Excessive Lateral Pressure Syndrome) More often lateral/superior when due to chronic frictional trauma
Suprapatellar Plica
Pathology Incomplete/partial resorption of synovial membrane that divides medial knee during embryologic development = medial plica Thickened, indurated and inflamed often fibrotic synovial membrane
Clinical Issues Most common signs/symptoms: Dull aching medial knee pain sometimes worsened by activity or prolonged sitting Age: Adolescent and athletic population
Diagnostic Checklist Thickened elongated plica especially on axial images
o Excessive lateral pressure syndrome when lateral and
superior
Femoral Trochlear Osteoarthritic Change (Trochlea Chondro) Includes chondromalacia, subchondral reactive edema +/- cystic change, sclerosis and/or osteophyte formation +/- Associated thickened infrapatellar plica Posttraumatic associated with impact of patella on trochlea
Suprapatellar Plica May form complete shelf (suprapatellar septum) and result in fluid build up in suprapatellar pouch o Mimics mass o Child to adolescent Rarely become inflamed and symptomatic One-way valve theory o Trapping of fluid in bursa o Small perforation or porta in plica allows passage of fluid & results in sequestration of loose bodies
lnfrapatellar Plica Extends into intercondylar notch to anterior cruciate ligament (ACL) Associated with trochlear chondromalacia
Patellar Tendinitis (Pat Tendinitis) Jumper's knee Anterior infrapatellar pain Hyperintensity of proximal posterior fibrosis on FS PD FSE or T2* GRE
Patellar Bone Injury (Pat Bone Inj) Direct impact vs. avulsive stress Increased signal on T2WI (esp. FS PD FSE) Stress related (chronic frictional)
1 PATHOLOGY General Features Etiology
MEDlAL PLlCA SYNDROME o Incomplete/partial resorption of synovial membrane
-
that divides medial knee during embryologic development = medial plica o Asymptomatic plica may become symptomatic after injury Effusion and synovitis cause plica to become edematous causing fibrotic reaction Leads to tightening, bowstringing and impingement against medial femoral condyle and/or medial patellar facet Vicious cycle of further thickening and contraction o Intraarticular pathology contributes to symptomatic plica secondary to inflammation and hemorrhage Osteochondritis dissecans Loose bodies Meniscal pathology Epidemiology o Four types of plica Suprapatellar (89% incidence) Medial (18-30% incidence) Infrapatellar (common) Lateral (rare) Associated abnormalities o In association with or in continuity with a suprapatellar plica o Chondromalacia of the medial patellar facet
Gross Pathologic & Surgical Features 1 10
Thickened, indurated and inflamed often fibrotic synovial membrane Loss of elastic properties
Microscopic Features Bland fibrous synovial membrane Fibrous tissue Hyalinization Calcification
Rowing Swimming Cycling o Snap and roll of medial plica with applied pressure to medial femoral condyle o Pop between 60 and 45 degrees of knee flexion (with applied pressure to patella medially)
Demographics Age: Adolescent and athletic population Gender: No predilection
Natural History & Prognosis Symptoms may resolve but are often progressive with fibrosis, especially if repeated injuries occur Best results with treatment in teenagers because of less damage to articular cartilage
Treatment Conservative o Activity reduction, NSAIDs, physical therapy Surgical o Arthroscopic resection for recalcitrant cases o 66-90% success reported
Consider In correct clinical setting Evaluate for different cause of anterior knee pain o Differentiate medial plica from patellofemoral syndrome and meniscal tear
Image Interpretation Pearls Thickened elongated plica especially on axial images Medial sagittal images through suprapatellar bursa helpful
Staging, Grading or Classification Criteria Arthroscopic o Type A: Cord-like elevation of the medial wall o Type B: Shelf-like appearance that does not cover anterior surface of medial condyle o Type C: Shelf-like appearance that covers the anterior surface of medial condyle o Type D: Double insertions onto the medial wall (separation between the shelf and synovial wall, creating a bucket-handle component)
Presentation Most common signs/symptoms: Dull aching medial knee pain sometimes worsened by activity or prolonged sitting Clinical profile o Often adolescent Mechanical symptoms such as crepitus o Pressure erosions of articular cartilage of medial femoral condyle and patella o Exacerbated discomfort/pain with repetitive flexion-extension motions
DeLee J et al: Orthopaedics sports medicine. Knee. vol 1. 2nd ed. Philadelphia PA, Saunders, 1577-2135, 2003 Calpur OU et al: United unresorbed medial and lateral plicae as anterior mesenchymal synovial septa1 remnant. Knee Surg Sports Traumatol Arthrosc 10(6):378-80, 2002 Calpur OU et al: Arthroscopic mediopatellar plicectomy and lateral retinacular release in mechanical patellofemoral disorders. Knee Surg Sports Traumatol Arthrosc 10(3):177-83,2002 Duri ZA et a1:The immature athlete. Clin Sports Med 21(3):461-82, 2002 Kim SJ et al: Pathologic infrapatellar plica. Arthroscopy 18(5):E25, 2002 Garcia-Valtuille R et al: Anatomy and MR imaging appearances of synovial plicae of the knee. Radiographics 22(4):775-84,2002 Rang M et al: The Story of Orthopaedics. Philadelphia PA, WB Saunders, 493-7,2000 Thomee RJ et al: Patellofemoral pain syndrome: A review of current issues. Sports Med 28(4):245-62, 1999 Bae DK et al: The clinical significance of the complete type of suprapatellar membrane. Arthroscopy 14(8):830-5,1998
MEDIAL PLlCA SYNDROME
Variant (Left) Sagittal graphic shows a suprapa tellar plica (arrow) in the superior aspect of the suprapatellar pouch and an infrapatellar plica (open arrow) anterior to the anterior cruciate bgamen t. (Right) Sagittal PD FSE MR shows a thick infrapatellar plica (arrow). This plica has been implicated as a cause of femoral trochlear chondromalacia.
(Left) Axial FS PD FSE MR shows an irregular, elongated medial plica (arrow) with adjacent chondromalacia of the patella and reactive marrow edema within the patella. (Right) Axial FS PO FSE MR shows a thick medial plica (arrow) without associated medial patellar chondromalacia.
(Left) Axial PD FSE MR shows a thickened and frayed medial plica (arrow) and adjacent patellar chondrornalacia. (Right) Axial PD FSE MR shows a mildly thickened medial plica with adjacent patellar chondromalacia (arrow).
I
1
OSTEOARTHRITIS, KNEE
Sagittal graphic shows findings of osteoarthritis including chondral erosions, subchondral sclerosis (eburnation) and fibrinous rice bodies as a result of synovitis.
Sagittal PD FSE MR shows large osteophytes, cartilage loss, rneniscal tear, and synovitis consistent with osteoarthritis.
Radiographic Findings Radiography: Joint space narrowing, subchondral sclerosis/eburnation, subchondral cysts, and osteophyte formation
Abbreviations and Synonyms Osteoarthritis (OA), degenerative joint disease (DJD)
Definitions Primary - gradual process of destruction ST
M R Findings
regeneration as result of chronic microtrauma Secondary - non-inflammatory degenerative joint disease resulting from predisposing events such as previous trauma, congenital deformity, infection or metabolic disorder
1 IMAGING
1
FINDINGS
General Features Best diagnostic clue: Chondromalacia often accompanied by subchondral sclerosis, subchondral cysts, osteophytes and/or edema Location: Hyaline chondral surfaces of the knee Size: Can affect small localized area (typically post trauma), compartment, or whole knee Morphology: Progressive loss of articular cartilage with associated new bone formation and capsular fibrosis
TlWI o Decreased signal intensity - subchondral cysts, marrow fat signal can be seen extending into osteophytes Subchondral decreased signal indicating sclerosis and/or edema T2WI o Variable degree of high signal in hyaline cartilage, subchondral bone marrow edema (bright signal) Decreased signal indicating sclerosis in subchondral bone General thinning of articular (hyaline) cartilage with occasional focal defects o FS PD FSE - increased signal in hyaline cartilage erosions and subchondral bone marrow edema Thinning of hyaline cartilage +/- focal defects and underlying bone change Edema (hyperintense) demonstrated with fat saturation Subchondral decreased signal indicating sclerosis = Associated findings including subchondral cysts (bright signal), and osteophytes
nHHm
-
DDx: Osteoarthritis, Knee SONK
L
Sag STIR M R
:0
Sag FS PD FSE
Cor STIR M R
H
Cor PO FSE M R
OSTEOARTHRITIS, KNEE Key Facts Terminology Primary - gradual process of destruction & regeneration as result of chronic microtrauma Secondary - non-inflammatory degenerative joint disease resulting from predisposing events such as previous Or metabolic disorder
Imaging Findings 1
Variable degree of high signal in hyaline cartilage, subchondral bone marrow edema (bright signal)
Pathology Epidemiology: Affects 90% of patients older than 40 years Degraded cartilage with fissured and/or ulcerated cartilage surface, loss of surface sheen
Clinical Issues
Best diagnostic clue: Chondromalacia often accompanied by subchondral sclerosis, subchondral cysts, osteophytes and/or edema Radiography: Joint space narrowing, subchondral sclerosis/eburnation, subchondral cysts, and osteophyte formation
Pain with utilization of joint and variable joint capsular swelling (effusion)
Diagnostic Checklist Secondary OA in cases of focal findings Utilize FS PD FSE to visualize chondral erosions and subchondral edema
--
o T2 FSE
Edema not as hyperintense compared to FS PD FSE because of the high signal intensity of fat on non fat suppressed FSE images PDIIntermediate o PD FSE - cartilage not as well seen unless resolution is increased Synovial thickening seen well = Sclerosis is difficult to appreciate without T1 contrast Edema difficult to appreciate without fat suppression * T2* GRE o With fat suppression, cartilage abnormalities are visualized as decreased signal areas on T1 weighted GRE images o T2* demonstrates loose bodies as hypointense structures within joint capsule T1 C+ o Synovium enhances in cases of synovitis Irregular free edge of Hoffa's fat pad in inflammatory OA
Nuclear Medicine Findings Bone Scan: Increased tracer uptake with subchondral fractures, cysts, or general sclerosis
Imaging Recommendations Best imaging tool: MRI for cartilage visualization Protocol advice o FS PD FSE o GRE imaging to demonstrate loose bodies
Inflammatory Arthritis 1
Polyarticular systemic disease Serum indicators Synovitis +/- erosions
Crystal Deposition Disease Polyarticular with crystals in joint aspirates Calcium pyrophosphate dihydrate (CPPD), gout
Crystals identified at microscopy
+/- Erosions
Osteochondral Abnormalities History of trauma Underlying edema common Osteoarthritis (OA) as a complication Osteochondritis dissecans (OCD) may mimic or lead to OA Spontaneous osteonecrosis (SONK) may lead to OA
( PATHOLOGY General Features General path comments o Begins as fatigue fracture of the collagen meshwork followed by increased hydration of the articular cartilage (as opposed to desiccated cartilage seen with aging) Fibrillation of the cartilage followed by deep clefts and regeneration/proliferation of chondrocytes Proliferative changes occur at the joint margins with formation of osteophytes Articular cartilage thins and is fissured in areas of maximum mechanical stress, underlying bone becomes sclerotic and subchondral cysts form Compression of weakened bone with variable degrees of collapse Loose bodies are followed by fragmentation of osteochondral surfaces Synovial hypertrophy - joint pain by nerve stimulation Synovial fluid - increased intraarticular pressure "stretching the joint lining," causing pain Increased levels of degrading enzymes including matrix metalloproteinases (MMPs), collagenase, gelatinase, and stromelysin Loss of proteoglycans from the matrix into the synovial fluid o Molecular changes in osteoarthritic cartilage include Increased water m Weakening of type I1 collagen network
OSTEOARTHRITIS, KNEE Shorter collagen chains Alteration of proteoglycans Etiology o Multiple theories - chronic microtrauma (primary) leading to disruption of the articular surface, fibrillation, eburnation, subchondral cysts, and osteophytes Secondary OA results from healing of major trauma or other predisposing events Joint instabilities may be predisposing o Associated injuries with OA Meniscal tears (and partial meniscectomy) Cruciate ligament damage Epidemiology: Affects 90% of patients older than 40 years Associated abnormalities o Deformities o Subluxations o Ankylosis o Loose bodies with catching and locking
Demographics Age: Typically older patients (over 50) unless history of trauma Gender: M > F for knee joint
Natural History & Prognosis Progressively debilitating disease without medical intervention
Treatment Conservative o Protection of knee from overloading including weight loss o Exercise of supporting muscles around joints to increase stability and avoid wasting o Pain management by analgesics or NSAIDs o Hyaluronic acid injections, glucosamine & chondroitin supplements Surgical o Indicated for patients with persistent symptoms and pain o Arthroscopy (debridement) o Arthroplasty o Realignment osteotomies may be performed in younger patients to redistribute weight bearing load to prevent progression o Newer treatments include Soft tissue periosteal and perichondral grafts ~hondrocftet r a n ~ ~ l a n t a ~ imosaicplasty on, Artificial matrix - carbon fiber, collagen, polylactic acid, fresh osteochondral grafts, doxycycline therapy, and transforming growth factor beta (TGF beta)
Gross Pathologic & Surgical Features Degraded cartilage with fissured and/or ulcerated cartilage surface, loss of surface sheen o Subchondral geodes (cysts) containing variable amounts of debris o Buttressing osteophytes to increase surface area o Articular surface collapse 7 34
Microscopic Features
Diminution of chondrocytes in superficial zones with chondrocyte swelling Cartilage matrix loses its ability to stain for proteoglycans with Alcian blue or safranin-0 Matrix chondrocytes demonstrate proliferation in clusters (brood capsules) Neovascularity penetrates layer of calcified cartilage and new chondrocytes extend up from deeper layers Hypertrophied synovium becomes folded into villous folds with variable infiltration of plasma cells, and lymphocytes
I DIAGNOSTIC CHECKLIST Consider Secondary OA in cases of focal findings
Image Interpretation Pearls Utilize FS PD FSE to visualize chondral erosions and subchondral edema Irregular fat pad sign in OA + synovitis on sagittal images
Staging, Grading or Classification Criteria Primary osteoarthritis o Hip, knee, first metacarpophalangeal and interphalangeal articulations Secondary (following a preexisting joint disorder) o Shoulder, elbow, foot and ankle Articular cartilage damage (stages) o I: Edema o 11: Articular fissuring o 111: "Crabmeat"changes o IV: Full thickness defect + subchondral erosions
Presentation Most common signslsymptoms o Pain with utilization of joint and variable joint capsular swelling (effusion) Often with antecedent traumatic history Clinical profile: Catching, locking or grinding in older patient
1.
2.
Saito I et al: Increased cellular infiltrate in inflammatory synovia of osteoarthritic knees. Osteoarthritis Cartilage 10(2):156-62,2002 Hill CL et al: Knee effusions, popliteal cysts, and synovial thickening: Association with knee pain in osteoarthritis. J Rheumatol28(6):1330-7, 2001
I
OSTEOARTHRITIS, KNEE
Typical (Left) Sagittal PD FSE MR shows the typical findings of OA including chondromalacia, osteophytes, and synovitis. (Right) Coronal FS PD FSE MR shows OA of the medial compartment greater than the lateral compartment. Note the synovial cyst extending superiorly from the posterosuperior medial joint as a result of chronic increased joint pressure
(Left) Coronal PD FSE MR shows OA in a post operative setting. Note the displaced bucket-handle tear (arrow) of the medial meniscus. (Right) Coronal FS PD FSE MR demonstrates medial compartment O A after partial meniscectomy.
Tveical (Left) Coronal PD FSE MR shows medial compartment OA including a meniscal tear. (Right) Axial FS PD FSE MR shows very large femoral osteophytes in effect creating a new femoral trochlea (arrows).
RHEUMATOID ARTHRITIS, KNEE
Sagittal graphic shows MRI findings of rheumatoid arthritis including synovitis and cartilage degradation. Periarticular erosions and cysts are characteristic findings as well.
Sagittal PD FSE MR shows synovitis and a hypointense rheumatoid nodule (arrow) within the superficial infrapatellar bursa in a patient with rheumatoid arthritis.
o Thickened edematbus knee synovium in association
Abbreviations and Synonyms Rheumatoid arthritis (RA) 136
Definitions Systemic inflammatory arthritic condition requiring the presence of 4 out of the following 7 criteria for > 6 weeks Classification criteria for rheumatoid arthritis o Morning stiffness o Oligo or polyarthritis in three or more joints or several joint groups o Arthritis of either wrist, metacarpophalangeal joint or proximal interphalangeal joint o Symmetric arthritis o Rheumatoid nodules over bony prominences, extensor surfaces or juxta-articular o Abnormal amounts of serum rheumatoid factor o Radiographic changes including erosions and juxta-articular demineralization
I IMAGING FINDINGS General Features
with effusion in patient with suggestive clinical symptomatology o Erosions common Location o Affects synovium first, then cartilage and bone with destructive changes leading to deformity o +I-Nodules 20% of RA patients Mixed signal intensity masses in the skin, synovium, tendons, sclera, viscera Size: Variable involvement of synovium or tenosynovium Morphology o Thickened irregular synovium usually in the presence of a joint effusion Synovitis followed by erosive/destructive changes
Radiographic Findings Radiography o Osteopenia o Periarticular erosions o Joint space narrowing (symmetric) o Effusion and soft tissue swelling o +/- Cyst formation (cystic rheumatoid) o Destruction (late)
Best diagnostic clue
DDx: Rheumatoid Arthritis, Knee Traumatic Effus
PVNS
Sag FS PD FSE
Sag FS PD FSE
Cor FS PD FSE
Cor FS PD FSE
Sag T2 MR
RHEUMATOID ARTHRITIS, KNEE Key Facts Terminology Systemic inflammatory arthritic condition requiring the presence of 4 out of the following 7 criteria for > 6 weeks
Imaging Findings Thickened edematous knee synovium in association with effusion in patient with suggestive clinical symptomatology Diffuse hyaline articular cartilage loss Erosions: Increased signal intensity defects in the subchondral bone at the joint edges FS PD FSE demonstrates synovium as intermediate signal and hyperintense joint fluid
Top Differential Diagnoses
Pathology Combination of genetic and environmental factors Felty's syndrome characterized by splenomegaly and leukopenia Juvenile chronic arthritis UCA) Still's disease characterized by fever, rash and splenomegaly
Clinical Issues 10% improve after first attack of synovitis and up to 60% can have remissions
Diagnostic Checklist Causes of synovitis: What is the clinical picture, is presentation monoarticular or polyarticular
Synovitis
CT Findings NECT: Joint space narrowing, effusion, occasional cyst formation (cystic rheumatoid) followed by destruction
MR Findings TlWI o Erosions - decreased in signal intensity o Hypointense subchondral edema and effusion o Lateral compartment involvement frequent Valgus deformity T2WI o Joint effusion: Increased signal intensity Popliteal cyst o Diffuse hyaline articular cartilage loss o Erosions: Increased signal intensity defects in the subchondral bone at the joint edges o Hyperintense subchondral edema PDIIntermediate o Inflamed synovium = increased signal intensity in thickened joint lining o PD FSE shows hypointense to intermediate signal in synovium o FS PD FSE demonstrates synovium as intermediate signal and hyperintense joint fluid o Poor contrast visualization of subchondral marrow edema unless fat suppression or STIR sequence used STIR o Generally less effective because of poor signal to noise and blurring o Useful at low and mid field - edema is of increased signal intensity T2* GRE: Shows subchondral erosions although masks subchondral edema T1 C+ o Marked synovium enhancement especially with fat saturation o FS T1 (+ contrast) - enhancement of thickened edematous synovium and subchondral edema
Nuclear Medicine Findings Bone Scan: Bone reactive change will demonstrate increased uptake
Imaging Recommendations Best imaging tool: MR to show thickened synovium, cartilage loss, subchondral edema and early erosions Protocol advice: FS PD FSE
Systemic Lupus Erythematosus Characteristic rash and other symptoms/signs (especially bone involvement) different from RA Erosions uncommon +/- Subluxation
Psoriatic Arthritis Primarily involves wristlhands, feet, sacroiliac joint and spine Asymmetric destructive erosive articular process Sausage digits
Synovitis Thickened increased signal synovium best seen on PDWI Multiple causes, including RA + Enhancement with gadolinium
Trauma Effusion, +I-thickened synovium Soft tissue edema +/- Fracture Asymmetrical
Pigmented Villonodular Synovitis (PVNS) Monoarticular Hemosiderin laden macrophages Decreased signal synovium on all pulse sequences
Synovial Cyst Atypical location May extend from popliteus tendon sheathltibiofibular joint +/- Synovial lining
RHEUMATOID ARTHRITIS, KNEE
1 PATHOLOGY
Staging, Grading or Classification Criteria Fundamental imaging signs o Soft tissue swelling and direct visualization of pannus tissue o Juxta-articular osteoporosis (marrow inhomogeneity) o Loss of subchondral plate o Erosion o Subchondral cysts o Joint space narrowing
General Features
138
General path comments o IgM: Rheumatoid factor (RF) 0 Affects synovium first, then cartilage and bone leading to deformity 0 Lab tests (RF) alone do not confirm diagnosis of RA RF can be present (usually low titers) in normal individuals and other diseases Genetics: HLA-D allele DR4 is associated with RA patients Etiology o Combination of genetic and environmental factors 0 Interaction of antigen presenting macrophages with T cells (helperlinducer) - likely inciting event o Complexes of IgM & IgG rheumatoid factor can deposit in blood vessels and lead to vasculitis o Hepatitis B vaccine may be causative in a small number of patients Epidemiology: 1-2% of general population Associated abnormalities o Felty's syndrome characterized by splenomegaly and leukopenia 0 Juvenile chronic arthritis (JCA) o Still's disease characterized by fever, rash and splenomegaly o Siogren svndrome: Decreased salivary and lacrimal iaGd se&etion and lymphoid prolif&ation o Extraarticular manifestations Nodules, lymphadenopathy, splenomegaly, vasculitis, myopathy, sensory changes from neuropathy or direct compression from synovitis Visceral changes including pericarditis, pulmonary fibrosis, nodules, and pleuritic pain
. .
1 CLINICAL ISSUES Presentation Most common signs/symptoms o See 7 inclusion criteria (described in definition) o Knee stiffness, pain, swelling
Demographics Age: Adult (22 to 55 years) for classical RA, variants (juvenile - JCA) affect younger patients Gender: F:M = 3:l
Natural History & Prognosis 10% improve after first attack of synovitis and up to 60% can have remissions Up to 10% can become disabled Poor prognostic indicators include o Elevation of RF, periarticular erosions, rheumatoid nodules, muscle wasting, joint contractures
Treatment Conservative o Rest, physical therapy o Pyramid pharmaceutical approach including NSAIDs, antimalarials, disease modifying agents (MTX, sulphasalazine, gold, penicillamine), steroids and cytotoxic drugs Surgical o Synovectomy o Arthroplasty, arthrodesis, osteotomy
Gross Pathologic & Surgical Features Pannus (exuberant inflammatory synovium) tissue erodes cartilage & bone o Direct extension of pannus occurs at the margins of the joint o Tendon sheaths also involved with pannus (tendinomuscular involvement) Synovial cysts (popliteal fossa) Sinus tracts ~
~
Microscopic Features ~hickeni&of the synovial membrane ~dematous,villous projections Multilayering of synoviocytes over thickened villous membrane Infiltration of synovia o Macrophages, lymphocytes, plasma cells Fibrin deposition and necrosis within synovia RA cells (neutrophils) o Granular intracytoplasmic inclusions of phagocytized immune complexes Rheumatoid nodules o Central fibrinoid necrosis o Inflammatory infiltrate of palisaded epithelioid cells and surrounding lymphocytes, macrophages, and plasma cells
I DIAGNOSTIC CHECKLIST Consider Causes of synovitis: What is the clinical picture, is presentation monoarticular or polyarticular
Image Interpretation Pearls Evaluate PD & FS PD images for synovial thickening, effusions and erosions o FS PD FSE to detect hyperintense subchondral edema
*
1. 2.
Usatine RP et al: A swollen knee. J Fam Pract 52(1):53-5, 2003 Dabby D et al: Synovial knee pain arising from chronic inflammatory disorders of the knee. J Knee Surg 15(1):53-6, 2002
1
RHEUMATOID ARTHRITIS, KNEE
Tvaical
(Lest) Axial FS PD FSE MR shows erosions, synovitis and reactive edema in a patient with RA. (Right) Coronal PD FSE MR shows an anterior rheumatoid nodule and synovitis in a patient with RA.
(Left)Axial FS PD FSE MR demonstrating a thick rind (arrow) of synovial hypertrophy lining the suprapatellar bursa. (Right) Axial FS PD FSE MR shows hypertrophic synovium (intermediate signal) involving the suprapatellar bursa.
Typical
(Left) Coronal FS PD FSE MR shows edematous synovium/pannus (arrow) extending into the popliteus tendon sheath in a patient with RA. (Right) Sagittal STIR MR shows synovitis, erosions, edema and adenopathy in a patient with RA.
PIGMENTED VILLONODULAR SYNOVITIS, KNEE
Sagittal graphic shows a focal nodular synovitis lesion in a typical location immediately adjacent to the posterior aspect of Hoffa's fat pad.
Sagittal PD/lntermediate MR shows hypointense focal nodular PVNS deforming the posterior margin of Hoffa 's fat pad.
Radiographic Findings --
-
Abbreviations and Synonyms Pigmented villonodular synovitis (PVNS) 140
Definitions Monoarticular synovial proliferative disorder characterized by hemosiderin laden macrophages within hypertrophic synovial masses often associated with sclerotic rimmed bone erosions
IMAGING FINDINGS General Features
1
Best diagnostic clue: Hypertrophic synovium which is of variable intermediate to decreased signal intensity on T1 and T2WI Location: Focal nodular form found posterior to Hoffa's fat pad Size: Thickened synovium masses ranging from a few mms to cms in size Morphology o Diffusely thickened synovium which is of intermediate to decreased signal intensity on all pulse sequences o May be focal especially adjacent to Hoffa's fat pad = focal nodular PVNS (localized PVNS)
Radiography o +/- Effusion o +/- Variable-sized erosions with sclerotic margins Where adjacent synovium is located o Absence of calcification within hyperplastic synovium
CT Findings NECT o No calcification is demonstrated in synovial mass o +/- Effusion o +/- Chronic erosive changes o Involvement of any synovial tissue CT arthrography o Irregular and thickened synovium +/- erosions o Nodular filling defects
M R Findings TlWI o Intermediate to decreased signal intensity masses o +/- Hypointense erosions +/- Surrounding hypointense edema o Erosions well-defined with thin margin o Hypointense effusion T2WI o Hypointense to intermediate signal secondary to paramagnetic effect of iron
DDx: Piemented Villonodular Svnovitis, Knee F k m Svnovttts
'?ae FS PO FSE
L&, -L Sag T2* C R E M R
Ax PO FSE M R
Sag FS PD FSE
Cor PO FSE M R
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PIGMENTED VILLONODULAR SYNOVITIS, KNEE Key Facts Terminology Monoarticular synovial proliferative disorder characterized by hemosiderin laden macrophages within hypertrophic synovial masses often associated with sclerotic rimmed bone erosions
Imaging Findings Best diagnostic clue: Hypertrophic synovium which is of variable intermediate to decreased signal intensity on T1 and T2WI May be focal especially adjacent to Hoffa's fat pad = focal nodular PVNS (localized PVNS)
Top Differential Diagnoses Hemophilic Arthropathy Hemorrhagic Synovitis
o
+/- Intermediate signal erosions rn +/- Surrounding hyperintense edema
FS PD FSE less sensitive to hemosiderin in pannus tissue and synovium than T2* GRE o Hyperintense effusion PDIIntermediate o Decreased signal intensity masses o Hemosiderin deposits in synovium - decreased signal T2* GRE o Decreased signal intensity masses o Condylar erosions associated with synovial mass and fibrous tissue o Foci of hypointensity due to hemosiderin deposits in synovium GRE sensitive to hemosiderin Involved synovium found in all potential joint recesses in diffuse form T1 C+ o Inflamed synovium enhances o Hemosiderin - infiltrated synovial masses show only minimal enhancement Diffuse form: Diffusely thickened synovium with variable degrees of decreased signal intensity on all pulse sequences Focal nodular form o Adjacent to the patella and Hoffa's fat pad Variable but generally decreased signal intensity on all pulse sequences Hemosiderin laden macrophages in synovium
Pathology Found in any recess in communication with joint Diffuse form and focal nodular form
Clinical Issues Monoarticular synovial disorder Nonpainful soft tissue mass
Diagnostic Checklist Monoarticular arthritis characterized by decreased signal intensity synovial thickening is diagnostic Hypointense (intermediate to hypointense) synovial mass posterior to free edge of Hoffa's fat pad T2* GRE identifies hemosiderin components (hypointense)
T2* GRE sensitive
Hemorrhagic Synovitis Posttraumatic o Traumatic history Hypointense synovium on all pulse sequences
Hypertrophic Synovitis Thickened synovium Absence of decreased signal masses unless hemorrhagic Focal or nodular presentation unusual o Inflammatory, posttraumatic, infectious
Rheumatoid Arthritis (RA) Systemic inflammatory disorder Polyarticular + RA factor usually Thick synovium (cause of synovitis)
Synovial Cyst Usually reflects repeated effusions Can extrude from joint at many locations Hyperintense on T2WI Often exits the joint posteriorly
ScarIAdhesions Posttraumatic Post surgical Hypointense cicatricial change on all pulse sequence
Imaging Recommendations Best imaging tool: MRI Protocol advice: GRE images demonstrate hemosiderin component due to susceptibility of hemosiderin
I DIFFERENTIAL DIAGNOSIS Hemophilic Arthropathy Clinical history Diffuse form most common Familial (X-linked) Decreased signal masses on all pulse sequences
General Features General path comments o Monoarticular synovial proliferative disorder o Found in any recess in communication with joint rn Popliteus tendon sheath rn Coronary recess rn Meniscofemoral recess rn Suprapatellar pouch Popliteal cyst rn Intercondylar notch
PIGMENTED VILLONODULAR SYNOVITIS, KNEE Etiology o Idiopathic monoarticular disorder o Hemosiderin laden macrophages Epidemiology: > 1%general population
Gross Pathologic & Surgical Features Localized/nodular type o Well-circumscribed o Lobular o Usually < 4 cm in diameter o Cut surface with white, yellow, gray and brown areas (fat and hemosiderin) o Soft and elastic vs. fibrous scarring in later stages Diffuse type o Multiple, soft, spongy lesions o Brown, yellow, or rust-like (based on hemosiderin content) o No well defined collagenous capsule
Microscopic Features
IJ-:
Localized/nodular type o Dense, collagenous capsule o Fibrous scarring o Multinucleated giant cells o Mononuclear cells o Xanthoma cells o ~istiofibroblastic hyperplasia o Small cystic spaces o Hemosiderin (less than diffuse type of PVNS) Diffuse type o Hemosiderin within histiocytes o Villous hyperplasia of synovial membrane & capillary hyperplasia o Sheets of polymorphic/rounded cells o Cystic clefts o Decreased number of multinucleated giant cells relative to localized type o Collagen in stroma f hyalinized appearance
Staging, Grading or Classification Criteria Diffuse form and focal nodular form o Diffuse form: Throughout joint o Focal nodular form: Adjacent to patellofemoral joint (adherent to posterior surface of Hoffa's fat pad)
CLINICAL ISSUES Presentation Most common signs/symptoms o Monoarticular synovial disorde~ o Nonpainful soft tissue mass
Demographics Age: Typically found in adults (common age range between 20 & 50 years) Gender: Predilection for females
Natural History & Prognosis Progressive synovitis with pain and effusions
Treatment Synovectomy
1
I DIAGNOSTIC CHECKLIST Consider Hemophilia or any cause of hemorrhagic synovitis
Image Interpretation Pearls Monoarticular arthritis characterized by decreased signal intensity synovial thickening is diagnostic Hypointense (intermediate to hypointense) synovial mass posterior to free edge of Hoffa's fat pad TZ* GRE identifies hemosiderin components (hypointense)
1 SELECTEDREFERENCES
I
p~
Calmet J et al: Localized pigmented villonodular synovitis in an unusual location in the knee. Arthroscopy 19(2):144-9,2003 2. Adem C et al: Recurrent and non-recurrent pigmented villonodular synovitis. Ann Pathol 22(6):448-52,2002 3. Abdelwahab Fet al: True bursa1 pigmented villonodular svnovitis. Skeletal Radiol 31(6):354-8, 2002 s .Louis MO, Mosby, 4. &zgerald RH et al: ~ r t h o ~ a e d i cSt 2002 5. Durr HR et al: Pigmented villonodular synovitis. Review of 20 cases. J Rheumatol28(7):1620-30, 2001 6. DiCaprio MR: Pigmented villonodular synovitis of the elbow: A case report and literature review. J Hand Surg Am 24(2): 386-91, 1999 7. Lin J et al: Pigmented villonodular synovitis and related lesions: The spectrum of imaging findings. Am J Roentgen01 172:191-7, 1999 8. Lindenbaum BL et al: An unusual presentation of pigmented villonodular synovitis. Clin Orthop 122:263-7, 1999 9. Lee B et al: Localized pigmented villonodular synovitis of the knee: Arthroscopic treatment. Arthroscopy 14(7):764-8, 1998 10. Mancini GB et al: Localized pigmented villonodular synovitis of the knee. Arthroscopy. 14(5):532-6, 1998 11. Aigner TS et al: Iron deposits, cell populations and proliferative activity in pigmented villonodular synovitis of the knee joint. Verh Dtsch Ges Pathol 82:327-31, 1998 12. Bertoni F et al: Malignant giant cell tumor of the tendon sheaths and joints (malignant pigmented villonodular synovitis). Am J Surg Pathol 21(2):153-63, 1997 13. Stoller DW et al: Magnetic resonance imaging in orthopaedics and sports medicine. vol 1.2nd ed. Philadelphia PA, J.B. Lippincott, 203-442, 1997 14. Aboulafia AJ et al: Neuropathy secondary to pigmented villonodular synovitis of the hip. Clin Orthop 174-80, 1996 15. Bravo SM et al: Pigmented villonodular synovitis. Radiol Clin North Am 34(2):311-26, 1996 16. Gezen F et al: Spinal pigmented villonodular synovitis: A case report. 21(5):642-5, 1996 17. Giannini C et al: Pigmented villonodular synovitis of the spine: A clinical, radiological, and morphological study of 12 cases. J Neurosurg 84(4):592-7,1996 18. Budny PG et al: Localized nodular synovitis: A rare cause of ulnar nerve compression in Guyon's canal. J Hand Surg Am 17(4):663-4,1992 19. Schwartz HS et al: Pigmented villonodular synovitis. A retrospective review of affected large joints. Clin Orthop 247:243-55, 1989 1.
PIGMENTED VILLONODULAR SYNOVITIS, KNEE IMAGE GALLERY Typical
(Lef) Sagittal graphic shows the diffuse form of PVNS.
(Right) Sagittal TZ* CRE MR shows diffuse PVNS predominately in the posterior aspect of the joint.
Variant
(Left) Sagittal PD MR shows focal nodular PVNS adjacent to Hoffa's fat pad. (Right) Coronal F5 PD FSE MR shows the focus of focal nodular PVNS at the anterior aspect of the joint (arrow). The patient had an extension block and was suspected of having a bucket-handle meniscus tear.
(Left) Axial PD FSE MR shows PVNS (arrow) in the popliteus tendon sheath. (Right) Sagittal PD FSE MR shows intermediate signal intensity PVNS (arrow) in the popliteus tendon sheath.
LlPOMA ARBORESCENS, KNEE Key Facts Terminology
Pathology General path comments: Infiltration of fat tissue at synovium and subsynovial tissue forming frond-like masses ~ t i ~idiopathic, l ~ ~ unusual : response to chronic synovial irritation, +/- underlying degenerative joint disease Epidemiology: Rare
Fatty synovial/subsynovial infiltration
Imaging Findings Best diagnostic clue: Increased (fat) signal thickening of the synovium on TlWI, PD FSE & FS PD FSE MR Size: Small fronds of affected synovium to large infiltrated fronds filling the joint Morphology: Usually frond-like until large then globular and rounded masses NECT: Decreased density synovial masses
.
Clinical Issues Most common signs/syrnptoms: Swelling, usually painless
Top Differential Diagnoses Synovial Lipoma Synovitis Normal Fat around the Joint
+/- Marrow fat vs. sclerotic hypointense signal
Diagnostic Checklist Saturation of synovial masses (esp. frond-like) on FS PD FSE is diagnostic
Treatment
Normal Fat around the Joint
Synovectomy
Volume averaged mimicking LA, e.g., normal prefemoral fat (Normal Prefem Fat)
1 PATHOLOGY General Features General path comments: Infiltration of fat tissue at synovium and subsynovial tissue forming frond-like masses Etiology: Idiopathic, unusual response to chronic synovial irritation, +/- underlying degenerative joint disease Epidemiology: Rare Associated abnormalities: Joint effusion
Gross Pathologic & Surgical Features Fatty enlargement of the synovium with frond-like architecture Fatty appearing globules and villous projections seen at arthroscopy
Consider Other causes of synovial proliferation
Image Interpretation Pearls Saturation of synovial masses (esp. frond-like) on FS PD FSE is diagnostic
1 SELECTED REFERENCES 1. 2. 3. 4.
1
Al-Ismail K et al: Bilateral lipoma arborescens associated with early osteoarthritis. Eur Radio1 12(11):2799-802,2002 Ikushima K et al: Lipoma arborescens of the knee as a possible cause of osteoarthrosis. Orthopedics 24(6):603-5, 2001 Kloen P et al: Lipoma arborescens of the knee. J Bone Joint Surg Br 80(2):298-301, 1998 Feller JF et al: Lipoma arborescens of the knee: MR demonstration. AJR 163(1):162-4,1994
Microscopic Features Mature adipocytes within subsynovium and enlarged synovial fronds
Presentation Most common signs/symptoms: Swelling, usually painless Clinical profile: Painless effusion
Demographics Age: Reported in adolescents - adults Gender: No predilection
Natural History & Prognosis Painless swelling usually without complete regression
(Left) Sagittal PD FSE MR shows lipoma arborescens within the suprapatellar pouch at the lateral aspect of the joint in this arthritic knee. (Right) Axial FS PD FSE MR shows fat saturation of the lipomatous masses.
REFLEX SYMPATHETIC DYSTROPHY, KNEE
Sagittal graphic shows patchy edema within the femur, tibia and patella. There is an associated fracture of the patella. Chronic intractable disproportionate pain characterizes RS D.
Sagittal FS PD FSE MR shows patchy bone marrow edema in a patient three months post trauma with a pain syndrome clinically characteristic of reflex sympathetic dystrophy.
o Distinct "major"nerve injury CRPS = injury to a nerve or soft tissue (e.g., osseous fracture) that does not follow the normal healing path
Abbreviations and Synonyms Reflex sympathetic dystrophy (RSD), complex regional pain syndrome (CRPS)
IIMAGING
FINDINGS
I
Definitions Chronic pain disorder of the sympathetic nervous system, usually result of trauma or complication of surgery, infection, casting or splitting o Normal system of pain perception "misfires"leading to abnormal cycle of intractable pain o With progression, effect on other areas of the body can result in varying degrees of disability as recruitment of other systems occurs Complex regional pain syndrome - type I (RSD) = initiating noxious event, or a cause of immobilization o Pain, zlodynia, or hyperalgesia with which the pain is disproportionate to inciting event o Edema, changes in skin blood flow (skin color changes, skin temperature changes more than l.l°C difference from the homologous body part), or abnormal pseudomotor activity in region of the pain o Nerve injury cannot be immediately identified Complex regional pain syndrome - type I1 (causalgia) o Type I + continuing pain, allodynia, or hyperalgesia after nerve injury, not necessarily limited to distribution of the injured nerve
General Features Best diagnostic clue o Clinical: Prolonged, intractable pain more severe than expected with original injury o Patchy areas of bone marrow edema on FS PD FSE Location: Bones of the knee (subarticular in patella, femur, tibia, and fibula) Size: Patchy areas of edema vary in size Morphology: Patchy or smaller diffuse punctate pattern bone changes (edema)
Radiographic Findings Radiography: Osteopenia - not sensitive CT Findings NECT Osteopenia and focal lucencies
MR Findings TlWI o Foci of hypointense bone marrow edema Proper clinical setting
~eflflexSympathetic Dystrophy, . . Knee , .
Normal Marrow
Sap FS PD FSE
arrow
Metastasis
Sag FS PD FSE
Sag FS PD F!
Normal
I
Tibia1 Fracture
Cor FS PD FSE
Cor FS PD FSE
1
REFLEX SYMPATHETIC DYSTROPHY, KNEE Key Facts Terminology Chronic pain disorder of the sympathetic nervous system, usually result of trauma or complication of surgery, infection, casting or splitting
Imaging Findings Clinical: Prolonged, intractable pain more severe than expected with original injury Patchy areas of bone marrow edema on FS PD FSE
Top Differential Diagnoses Normal Marrow Metastasis Bone Infarct FractureIBone Trabecular Injury
+/- Healinglhealed fracture (if posttraumatic) (hypointense) o +I- Healingthealed ligamentous changes (if posttraumatic) +/- Thickeninglfibrosis hypointensity T2WI o FS PD FSE Skin thickening, soft tissue edema = stage I Skin thickeninglthinning without edema = stage I1 Muscle atrophy = stage I11 o Patchy bone marrow edema - hyperintensity Proper clinical setting o +/- Healinglhealed fracture (if posttraumatic) +/- Hyperintensity Proper clinical setting o +I- Healinglhealed ligamentous changes (if posttraumatic) Proper clinical setting PDIIntermediate o Intermediate "sponge painted" bone marrow appearance PD FSE usually insensitive to marrow signal changes relative to TlWI or FS PD FSE and STIR STIR 0 Patchy bone marrow edema - hyperintensity o +I- Healinglhealed fracture (if posttraumatic) (+/hyperintensity) 0 +I- Healinglhealed ligamentous changes if posttraumatic (typically hypointense) 0
.
Nuclear Medicine Findings Bone Scan: +I- Increased uptake
Imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE, STIR, T1
1 DIFFERENTIAL DIAGNOSIS Normal Marrow Red marrow mimicking bone marrow edema Brighter than normal skeletal muscle on TlWI
Pathology Fatty atrophy in later stages
Clinical Issues Most common signslsymptoms: Severe chronic pain out of proportion to trauma Patient with severe pain out of proportion to frequent trivial trauma, skin changes (swelling and redness in the affected area)
Diagnostic Checklist Interpret images in setting of proper clinical history for RSD diagnosis Use T1 and FS PD FSE images to identify changes in subarticular marrow signal intensity
Younger patients Patients on hormonal therapy Seen in proliferative states o Anemia o Perimenopausal hormone therapy o Obesity (occasionally)
Metastasis Older age group Positive history Often multifocal
Bone Infarct Serpiginous region of signal abnormality Result of vascular compromise Predisposing condition o Steroids o Caisson's disease o Pancreatitis Double line sign Location not restricted to metaphyseal areas
FractureIBone Trabecular Injury +/- Decreased signal intensity fracture line Trabecular injury with increased signal intensity on T2WI Focal involvement
1 PATHOLOGY General Features General path comments: Sympathetic nervous system dysfunction Etiology o Result of minor trauma, inflammation following surgery, infection, lacerations, degenerative joint disease, burns and compression such as casting or swelling due to injury that may cause prolonged pressure on peripheral nerves o Sympathetic nervous system dysfunction Nociceptors transmit pain syndrome to spinal cord
1
REFLEX SYMPATHETIC DYSTROPHY, KNEE Atypical sympathetic reflex results in tissue edema, capillary collapse, and ischemia Wide dynamic range neurons stimulated increasing sympathetic activity from the spinal cord to the periphery Release of norepinephrine in the periphery has effect on the blood vessels causing vasoconstriction and pain Recruitment of receptors = allodynia = pain from light touch Vasoconstriction = increased pain + sympathetic nervous system stimulation = Substance P and prostaglandin increase in nociceptor stimulation Other theories for abnormal pain include unregulated sensitivity of a-adrenoreceptors for catecholamines or an exaggeration of the peripheral neural inflammatory response Epidemiology: May follow 5% of all injuries Associated abnormalities: Muscle atrophy, chronic pain
Gross Pathologic & Surgical Features Skin edema, swelling progress to skin thinning, and muscle atrophy
Microscopic Features Fatty atrophy in later stages
Staging, Grading or Classification Criteria 148
RSD stages o Stage I (traumatic): Up to 3 months after injury, swelling and redness of affected area o Stage I1 (dystrophic): 3-9 months after injury, affected area becomes blue and cold + increased pain, stiffness, +/- osteoporosis rn Skin temperature decreases, mottled skin tone, pseudomotor dysfunction, +/- osteoporosis Most difficult stage to treat o Stage I11 (atrophic): 9-18 months after injury, wasting of affected muscles, contraction of tendons, atrophy
Presentation Most common signs/symptoms: Severe chronic pain out of proportion to trauma Clinical profile o Patient with severe pain out of proportion to frequent trivial trauma, skin changes (swelling and redness in the affected area) o Types I and I1 CRPS have similar clinical symptoms and progression of disease No known nerve injury in type I o If regional sympathetic block provides immediate relief, diagnosis can be sympathetically maintained pain (RSD) rn If symptoms remit only after a complete nerve block then diagnosis may be nerve entrapment o Acetone drop test can be done to demonstrate allodynia
Alcohol applied on affected limb then blow on the area - evaporation will stimulate cold hyperalgesia in RSD patient
Demographics Age: Children and adults Gender o Females predominate Lower extremity
Natural History & Prognosis Often improves but may progress to atrophy and chronic dysfunction
Treatment Drug therapy, nerve blocks, physical therapy, transcutaneous electrical stimulator Implantable devices: Spinal cord stimulator, drug delivery infusion pump Sympathectomy
~D~AGNOST~C CHECKLIST Consider Any etiology of bone marrow edema Complex regional pain syndrome (CRPS) is divided into two types o Type I replaces the term reflex sympathetic dystrophy o Type I1 replaces the term causalgia
Image Interpretation Pearls Interpret images in setting of proper clinical history for RSD diagnosis Use TI and FS PD FSE images to identify changes in subarticular marrow signal intensity
ISELECTED REFERENCES
1
Cuckler J.M: The stiff knee: Evaluation and management. Orthopedics 25(9):969-70, 2002 Papadopoulos GS et al: The treatment of reflex sympathetic dystrophy in a 9 year-old boy with long standing symptoms. Minema Anestesiol67(9):659-63,2001 Leitha T: Reflex sympathetic dystrophy after arthroscopy. Clin Nucl Med 25(12):1028-9, 2000 Poncelet C et al: Reflex sympathetic dystrophy in pregnancy: Nine cases and a review of the literature. Eur J Obstet Gynecol Reprod Biol86(1):55-63, 1999 Braverman DL et al: Recurrent spontaneous hemarthrosis associated with reflex sympathetic dystrophy. Arch Phys Med Rehabil 79(3):339-42, 1998 Stanton-HicksM et al: Reflex sympathetic dystrophy: Changing the concepts and taxonomy. Pain 63:127-133, 1995 Merskey H et al: Classification of chronic pain: Descriptions of chronic pain syndromes and definitions of pain terms. 2nd ed. Seattle WA, IASP Press, 1994 Michell SW et al: Gunshot wounds and injuries of nerves. New York NY, JB Lippincott, 1989
1
REFLEX SYMPATHETIC DYSTROPHY, KNEE
Typical
(Left) Axial PD FSE MR shows RSD changes of the patella in a patient s/p trauma. (Right) Axial FS PD FSE MR shows the patchy high signal intensity edema within the patella. This patient had a clinical presentation of RSD.
(Lefl) Sagittal FS PD FSE MR shows RSD hyperintense RSD changes in the femur and tibia in a patient without history of a nerve injury. (Right) Axial FS PD FSE MR image of the same patient shows the hyperintense inhomogeneity of the tibia and fibula.
Typical (IRft) Coronal T I Wl MR shows hypointense areas of marrow involvement with RSD. (Right) Sagittal FS PD FSE MR shows isolated involvement of the patella (hyperintenseedema) in this patient with RSD and no history ofpatellar trauma.
CHONDROCALCINOSIS, KNEE
Coronal oblique graphic shows the typical appearance of chondrocalcinosis at gross pathologic inspection with white calcium deposits within the hyaline and fibrocartilage.
Sagittal T2* GRE MR shows hypointense chondrocalcinosis (arrow) within the hyaline articular cartilage of the posterior lateral femoral condyle.
Symptoms are identical to those of patients with OA + calcium pyrophosphate crystals Common in orthopedic practices o Chondrocalcinosis Asymptomatic
Abbreviations and Synonyms Calcium pyrophosphate dihydrate deposition (CPPD) disease (CPPDD), pseudogout, tophaceous pseudogout I 50
Definitions Chondrocalcinosis = visible calcification within tissues on imaging study * CPPD represents deposition of calcium pyrophosphate crystals in hyaline cartilage, synovial tissue, capsule, meniscus o Chondrocalcinosis not synonymous with CPPD CPPD represents chemical manifestation of separate, yet related diseases o Pseudogout Acute presentation appears very similar to gout + Crystals (no urate as in gout) o Tophaceous pseudogout Produces pseudotumor Rare in knee o Familial calcium pyrophosphate dihydrate deposition Appears at earlier age (as early as third decade of life) More aggressive & poor long-term prognosis o Osteoarthritis (OA) Pyrophosphate arthropathy
1
General Features Best diagnostic clue o Radiography valuable for showing chondrocalcinosis (pathognomonic) o Decreased signal intensity calcium deposition in soft tissues on all sequences Location: Knee - most often affected joint in the body Size: Small to large areas of calcific depositions Morphology: Small to large irregular depositions of calcium crystals
Radiographic Findings Radiography o Foci of increased density (calcification = chondrocalcinosis) o Chondrocalcinosis in hyaline cartilage, menisci, synovium
CT Findings NECT
I
DDx: Chondrocalcinosis, Knee Trochlear Chondro F
Sag FS PD FSE
~
Sag PD FSE MR
Chondromalaaa
Chondromalacra
Ax PD FSE MR
Ax FS PD FSE
O
CHONDROCALCINOSIS, KNEE Key Facts Terminology Calcium pyrophosphate dihydrate deposition (CPPD) disease (CPPDD), pseudogout, tophaceous pseudogout Chondrocalcinosis = visible calcification within tissues on imaging study
Imaging Findings Chondrocalcinosis within hyaline articular cartilage as decreased signal intensity foci (GRE most sensitive technique)
Top Differential Diagnoses Gout Osteoarthritis without CPPD
o Chondrocalcinosis in hyaline cartilage, menisci,
synovium o Changes of OA (in pyrophosphate arthropathy) rn Subchondral sclerosis, cysts, osteophytes CECT Enhancing synovium in case of synovitis
M R Findings TlWI o Chondrocalcinosis: Decreased signal intensity foci within hyaline articular cartilage o Menisci demonstrate punctate irregularities within degenerated foci o TlWI not sensitive to calcium pyrophosphate dihydrate crystals o Synovitis - thickened intermediate signal intensity joint lining compared to hypointense fluid o Association with osteoarthritis Osteophytes, joint space narrowing, subchondral sclerosis, chondral erosions T2WI o Intermediate sensitivity compared to GRE o Difficult to visualize articular cartilage or meniscal crystal deposition even when using FS PD FSE or STIR PDlIntermediate o Synovitis - relatively increased signal intensity thickened joint lining compared to hypointense fluid Sensitive for synovitis o Decreased signal intensity foci within hyaline articular cartilage o Difficult to visualize on either PD or FS PD FSE TZ* GRE o Chondrocalcinosis within hyaline articular cartilage as decreased signal intensity foci (GRE most sensitive technique) o Menisci may demonstrate punctate irregularities within degeneration foci o 3-dimensional fat saturated gradient echo technique superior to radiography for the detection of crystals in articular cartilage Calcium deposition (decreased signal intensity) in soft tissues is characteristic on all sequences
Pathology F'yrophosphate arthropathy resembles osteoarthritis f intermittent attacks of pseudogout
Clinical Issues
Pseudogout - begins in galloping fashion, peak within hours, + pain, swelling, heat, and redness 50% of patients have fever Associated with OA in older patient Spontaneous resolution over several days to weeks
Diagnostic Checklist Evaluate hyaline articular cartilage on MR images TZ* GRE is the most sensitive sequence for the detection of CPPD crystal deposition
o Inflamed synovium will enhance
Imaging Recommendations Best imaging tool: Radiography, MRI Protocol advice o Include GRE if index of suspicion is high, otherwise calcium deposition is poorly visualized on other sequences Findings are often subtle (hypointense deposits within hypointense menisci on T1 and TZWI)
DIFFERENTIAL DIAGNOSIS
1
Gout Monosodium urate monohydrate crystals Needle shaped negatively birefringent crystals o Pseudogout in comparison = rhomboid shaped crystals with weak positive birefringence as seen with calcium pyrophosphate dihydrate crystals Hyaline cartilage calcification not characteristic
Tumoral Calcinosis Mimics tophaceous pseudogout
Osteoarthritis without CPPD Absence of CPPD crystals on TZ* GRE confirms diagnosis Typical changes of subchondral reaction o +/- Cysts, edema, sclerosis, osteophytes
Chondromalacia (Chondro) Desiccation of hyaline cartilage may be associated with decreased signal intensity (FS PD FSE) o Usually early stage before defined defect +/- Associated subchondral bone reactive changes o Subchondral cysts o Edema o Sclerosis Posttraumatic Early OA
Osteochondral Injuries Chondromalacia + underlying bone edema +/- fracture
CHONDROCALCINOSIS, KNEE Posttraumatic Osteochondritis dissecans (OCD) +/- history of trauma Well defined chondral defect rather than foci of chondrocalcinosis
1 PATHOLOGY
Clinical profile o Associated with OA in older patient o After injury or surgery to affected area o Pseudogout identified following parathyroid adenoma excision
1
Demographics Age: Elderly, increases with age Gender: M:F = 1.4:l
General Features General path comments o CPPD crystal 0 Pyrophosphate arthropathy resembles osteoarthritis intermittent attacks of pseudogout 0 Crystals are identified in synovial fluid Genetics o Autosomal dominant mode of inheritance in familial form of CPPD Chromosome 8q Etiology 0 Deposition of calcium pyrophosphate crystals into soft tissue o Chondrocyte and surrounding matrix Noxious event incites cascade - hypertrophy and degeneration of chondrocytes Separation of calcium-binding effect of the matrix Crystals grow adjacent to hypertrophic chondrocytes within affected matrix Collagen cells - probable source of inorganic pyrophosphate Epidemiology 0 4 to 2 25% of the population by age 80 years Half as common as gout in typical practice Associated abnormalities: Hyperparathyroidism, hemochromatosis, hemosiderosis, hypomagnesemia, hypophosphatemia
Natural History & Prognosis Spontaneous resolution over several days to weeks Treatment accelerates recovery
*
Treatment Conservative: Depends on degree of involvement o Treat as OA in most common presentation o Modified activity, physical therapy, NSAIDs Surgical treatment: Recalcitrant cases o Arthrocentesis + intraarticular steroid = prompt relief o Arthroscopic debridement: +/- Helpful o Patients with OA form Surgical debridement Microfracture chondroplasty Radiofrequency chondroplasty Osteochondral transfers Osteotomy Partial or total joint replacement
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.. .. ..
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[
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Gross Pathologic & Surgical Features
Consider In setting of acute arthritis (esp. with findings of OA and radiographic findings of calcium deposition)
Image Interpretation Pearls
White crystal precipitation in various joints +/- OA
Evaluate hyaline articular cartilage on MR images T2* GRE is the most sensitive sequence for the detection of CPPD crystal deposition
Microscopic Features Crystal deposition with adjacent chondroid metaplasia
+/- Synovial hyperplasia with inflammatory changes o Mononuclear cells
Tophaceous pseudogout +/- giant cells CPPD crystals identified from joint fluid by polarized light microscopy
Staging, Grading or Classification Criteria Clinical syndromes of calcium pyrophosphate dihydrate crystal deposition disease o Chondrocalcinosis (asymptomatic) o Pseudogout (acute crystal synovitis) o Pyrophosphate arthropathy Osteoarthritis-like Neuropathic-like
Presentation Most common signs/symptoms o Pseudogout - begins in galloping fashion, peak within hours, + pain, swelling, heat, and redness 50% of patients have fever
.
1 SELECTEDREFERENCES 1.
Al-Arfaj AS: The relationship between chondrocalcinosis and osteoarthritis in Saudi Arabia. Clin Rheumatol 21(6):493-6,2002 2. Canhao H et al: Cross-sectional study of 50 patients with calcium pyrophosphate dihydrate crystal arthropathy. Clin Rheumatol20(2):119-22,2001 3. Sagarin MJ: Pseudogout. J Emerg Med 18(3):373-4,2000 4. Oni 0 0 : Crystal deposition in normal and diseased articular cartilage. An extended report. Afr J Med Med Sci 28(3-4):181,1999 5. Concoff AL et al: What is the relation between crystals and osteoarthritis?Curr Opin Rheumatol 11(5):436-40,1999 6. Gunther KP et al: Reliability of radiographic assessment in hip and knee osteoarthritis. Osteoarthritis Cartilage 7(2):239-46,1999 7. Beltran J et al: Chondrocalcinosis of the hyaline cartilage of the knee: MRI manifestations. Skeletal Radio1 27(7):369-74,1998 8. Baldwin CT et al: Linkage of early-onset osteoarthritis and chondrocalcinosis to human chromosome 8q. Am J Hum Genet 56(3):692-7,1995
I
CHONDROCALCINOSIS, KNEE
(Left) Sagittal T2* CRE MR shows chondrocalcinosis within the hyaline cartilage of the lateral compartment in a patient with CPPD. (Right) Sagittal T2* CRE MR shows the hypointense punctate foci of chondrocalcinosis (arrow) in a patient with CPPD. Gradient echo images often show these calcifications secondary to increased magnetic susceptibility.
Typical (Left) Axial FS PD FSE MR shows subtle chondrocalcinosis within the trochlear hyaline cartilage. (Right) Sagittal T2* CRE (more sensitive technique) MR shows chondrocalcinosis within the patellofemoral hyaline articular cartilage.
Typical (Left) Anteroposterior radiography shows calcification (arrow) within the medial meniscus. (Right) Sagittal T2" CRE MR shows chondrocalcinosis within the meniscus as irregular hypointense heterogeneous signal in addition to meniscal degenerative tearing.
I
Sagittal graphic shows an intercondylar notch cyst associated with proximal fibers of the ACL.
Abbreviations and Synonyms Cruciate cyst 1.54
I
INTERCONDYLAR NOTCH CYST
Definitions Cyst within or extending from the intercondylar notch Cyst containing thick, sticky, clear, colorless, jellylike material (cruciate ganglion) Mucoid degeneration of a cruciate ligament o Contains mucinous material from degeneration of a cruciate ligament Fatty material occasionally expressed at arthroscopy o Often associated with adjacent edema, +/degenerative cysts at origin (femur) or insertion (tibia) of ligament
Sagittal PD FSE MR shows the classical appearance of an intercondylar notch cyst posterior to the proximal PCL.
Location o Intercondylar notch of knee o +/- Within cruciate ligament o More common in anterior cruciate ligament Size: Mild expansion of cruciate ligament to cyst, several centimeters in size Morphology o Simple cyst Oval expansion of ligament to round or multiloculated cyst o Mucoid degeneration "Celery stalk" appearance Fusiform enlargement with preservation of some fibers
Radiographic Findings Radiography: Enlarged notch with large cyst (rare)
CT Findings NECT o Homogeneous decreased attenuation (0-20 HU) mass Degenerative cruciate or small cyst may not be visualized as separate structures CECT +/- Rim enhancement if inflamed
mpJma&
General Features
Best diagnostic clue o Increased signal intensity (T2WI) mass expanding and/or extending from a cruciate ligament Hyperintense on T2WI (FS PD FSE), T2* GRE, and STIR
MR Findings TlWI
-
DDx: Intercondylar Notch Cyst
Ax FS PD FSE
Cor FS PD FSE
Sag FS PD FSE
Cor FS PD FSE
Ax FS PD FSE MR
INTERCONDYLAR NOTCH CYST Key Facts Terminology Cyst within or extending from the intercondylar notch Cyst containing thick, sticky, clear, colorless, jellylike material (cruciate ganglion)
Imaging Findings Increased signal intensity (TZWI) mass expanding and/or extending from a cruciate ligament Size: Mild expansion of cruciate ligament to cyst, several centimeters in size Protocol advice: FS PD FSE
Top Differential Diagnoses Meniscal Cyst Popliteal Cyst
o Homogeneous decreased signal intensity mass
within or extending from intercondylar notch o Mucoid degeneration: Fusiform enlargement of intermediate to hypointense cruciate ligament o Subchondral sclerosis/cysts in adjacent lateral femur or in tibia - hypointense Sclerosis/cysts seen as reactive phenomenon especially with mucoid degeneration T2WI o Homogeneous increased signal intensity mass within or extending from the intercondylar notch simple cyst o FS PD FSE shows hyperintense fluid due to saturation of surrounding fat increasing cyst contrast o Mucoid degeneration appears as fusiform enlargement of intermediate to hyperintense cruciate "Celery stalk" appearance o Subchondral cysts in adjacent lateral femur or in tibia - hyperintense o Surrounding reactive edema - hyperintense STIR o Increased signal intensity cyst within or extending from intercondylar notch o Mucoid degeneration fusiform enlargement of intermediate to hyperintense cruciate o Hyperintense subchondral cysts in adjacent lateral femur or tibia o Surrounding reactive edema - hyperintense o Superior contrast with decreased spatial resolution T1 C+ o +/- Rim enhancement if inflamed o Enhancing synovitis
Ultrasonographic Findings Visualize cystic mass from posterior approach Through transmission (simple cysts) Mucoid degeneration may not be seen
Imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE
Pathology Asymptomatic or variable presentation of pain Related to trauma followed by tissue breakdown of cruciate ligament or adjacent tissue Epidemiology: 1% of MR knee studies
Clinical Issues Usually asymptomatic but may present as dull non-focal pain Pain if associated with erosions
Diagnostic Checklist Visible cyst extending from cruciate ligament on MRI Pitfall - mistaking an ACL cyst for an intraarticular tumor
1 DIFFERENTIAL DIAGNOSIS Meniscal Cyst May extend into notch Associated with meniscal tear Posterior horn medial meniscus Anterior horn lateral meniscus
Cyst within Tibial Tunnel after ACL Surgery & Extension into notch Mass effect causing knee extension difficulty or limitation
Partial Tear of Cruciate Associated with intracruciate hemorrhage Expansion of cruciate may occur with attempted healing
Joint Fluid Loculated in or near notch Associated with synovitis Hemorrhage o Inhomogeneous on T2WI
Popliteal Cyst In association with joint fluid Seen with joint synovitis & Hemorrhagic Often reflects intraarticular pathology Typical (medial) or atypical (lateral) location
1 PATHOLOGY General Features General path comments o One large cyst or several smaller cysts Common stalk connects multiple small cysts Multiloculation common o Asymptomatic or variable presentation of pain o Mucoid degeneration +/- history of trauma Chronic partial tear or in asymptomatic patient with no instability Cyst may develop without history of trauma
INTERCONDYLAR NOTCH CYST Etiology o Related to trauma followed by tissue breakdown of cruciate ligament or adjacent tissue o Defect or weakness of synovial lining of cruciate ligament Epidemiology: 1%of MR knee studies Associated abnormalities o If cyst is large, results in pressure erosion of adjacent bone o +/- Reactive edema o +/- Sclerosis o +/- Subchondral cysts
Gross Pathologic & Surgical Features Cyst contains thick, sticky, clear, colorless, jellylike material seen as bulge or synovial covered mass
Microscopic Features Inflammatory cells contained in cyst Mucoid degeneration contains fatty material
1.
2. 3.
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4.
5. 6.
7. 8.
Presentation
1 5h
Most common signs/symptoms o Usually asymptomatic but may present as dull non-focal pain Pain if associated with erosions Chronic in case of trauma with associated pathology/instability Clinical profile: Usually incidental finding
Demographics Age: Adults Gender: M >/= F
Natural History & Prognosis May regress, remain unchanged, or enlarge causing mass effect
Treatment Conservative o Anti-inflammatory drugs for dull general pain Surgical o Arthroscopic aspiration/resection if Large and seen at arthroscopy Associated with erosions Symptomatic at physical exam
Consider Meniscal tear with associated cyst or partial tear of cruciate with associated hemorrhage
Image Interpretation Pearls Visible cyst extending from cruciate ligament on MRI Pitfall - mistaking an ACL cyst for an intraarticular tumor
Sanders TG et al: Fluid collections in the osseous tunnel during the first year after anterior cruciate ligament repair using an autologous hamstring graft: natural history and clinical correlation. J Comput Assist Tomogr 26(4):617-21. 2002 Fealy S et al: Mucoid degeneration of the anterior cruciate ligament. Arthroscopy 17(9):E37,2001 Kim MG et al: Intra-articular ganglion cysts of the knee: Clinical and MR imaging features. Eur Radio1 11(5):834-40, 2001 McIntyre JS et al: Mucoid degeneration of the anterior cruciate ligament mistaken for ligamentous tears. Skeletal Radiol 30(6):312-5,2001 Sung MS et al: Myxoid liposarcoma: Appearance at MR imaging with histologic correlation. Radiographics 20(4):1007-19,2000 Bui-Mansfield LT et al: Intraarticular ganglia of the knee: prevalence, presentation, etiology, and management. AJR 168(1):123-7,1997 Lepore L et al: Bilateral baker's cyst in a patient with psoriatic arthritis of pediatric onset. Clin Exp Rheumatol 14(1):109-10, 1996 Takano Y et al: Is Baker's cyst a risk factor for pulmonary embolism? Intern Med 35(11):886-9, 1996 Szer IS et al: Ultrasonography in the study of prevalence and clinical evolution of popliteal cysts in children with knee effusions. J Rheumatol 19(3):458-62,1992 Toolanen G et al: Sonography of popliteal masses. Acta Orthop Scand 59(3):294-6,1988 Kattapuram SV et al: Case report 181: Calcified popliteal cyst (Baker cyst). Skeletal Radiol 7(4):279-81, 1982 Goldberg RP et al: Calcified bodies in popliteal cysts: A characteristic radiographic appearance. AJR 131(5):857-9, 1978 Houston CS: Pitfalls to avoid. When is fabella not a fabella not a fabella? J Can Assoc Radiol 29(3):193, 1978
9. 10. 11. 12. 13.
~
INTERCONDYLAR NOTCH CYST
Typical (Left) Sagittal PD FSE MR shows an intercondylar notch cyst communicating with the proximal ACL. (Right) Sagittal FS PD FSE MR shows the hyperintense cyst with septations.
Typical (Left) Sagittal FS PD FSE MR shows expansion of the ACL and a "celery stalk" appearance secondary to mucoid degeneration. There is reactive cystic intraosseous change in the tibia - a common association. (Right) Coronal FS PD FSE MR shows the "celery stalk" appearance of mucoid degeneration of the ACL.
Typical (Left) Axial PD FSE MR shows an intercondylar notch cyst. There is also proximal patellar tendinosis. (Right) Axial FS PD FSE MR shows the expanded appearance of mucoid degeneration of the ACL (arrow).
POPLlTEAL CYST
Coronal graphic shows a large popliteal cyst originating from gastrocnemius sernirnembranosus bursa.
Sagittal FS PD FSE MR shows a medial popliteal cyst in a patient post trauma.
o Soft tissue swelling in posteromedial knee
+/- Displacement of popliteal artery +/- Calcified debris
Abbreviations and Synonyms
M R Findings
Pop cyst = popliteal cyst, Baker's cyst,
gastrocnemius/semimembranosusbursa 158
Definitions Fluid distension of gastrocnemius/semimembranosus bursa which is usually in communication with the knee joint
General Features Best diagnostic clue: Fluid signal intensity mass in typical location (gastrocnemius/semimembranosus bursa) Location: Posterior to the medial femoral condyle between tendons of medial head gastrocnemius and semimembranosus Size o Range from 1-30+cm3 (median 3cm3) o When large may dissect into calf Morphology: Flattened sac to oval shaped cystic mass depending on the amount of fluid
Radiographic Findings Radiography
I
TlWI o Decreased signal intensity mass o +I-Adjacent hypointense edema o Variable size o Gastrocnemius/semimembranosus bursa distension o Extends in multiple different directions (multiple appearances) o Subacute hemorrhage in cyst seen with areas of hyperintensity T2WI o Increased signal intensity mass: Gastrocnemius/semimembranosusbursa +/- Debris +/- Hemorrhage (fluid level/hypointensity foci hemosiderin) Calcification/loose bodies (hypointense) Thick synovial rind o +/- Hyperintense surrounding edema = Leakagetrupture PDlIntermediate: Intermediate signal intensity mass within gastrocnemius/semimembranosus bursa STIR: Increased signal intensity fluid within gastrocnemius/semimembranosus bursa T2* GRE
I
DDx: Po~litealCvst I
Synowat C y a
Sag FS PD FSE
Sag Doppler US
u
Sag ,PD FSE M,R
Sag T I C+ MR
Sag FS PD FSE
POPLlTEAL CYST Key Facts Terminology Fluid distension of gastrocnemius/semimembranosus bursa which is usually in communication with the knee joint
Imaging Findings Best diagnostic clue: Fluid signal intensity mass in typical location (gastrocnemius/semimembranosus bursa) Morphology: Flattened sac to oval shaped cystic mass depending on the amount of fluid Typical findings of fluid-filled mass on ultrasound Best imaging tool: MRI
Top Differential Diagnoses Meniscal Cyst Cystic Adventitial Degeneration of a Popliteal Artery o Increased signal intensity mass in typical location:
Gastrocnemius/semimembranosus bursa Sensitive to hypointense foci of hemosiderin T1 C+ o Rim enhancement Inflamed synovial lining o Recommended to evaluate atypical cyst locations, morphology or matrix
Ultrasonographic Findings Typical findings of fluid-filled mass on ultrasound Pure cystic structure or complex cyst Anechoic mass with posterior acoustic enhancement o +/- Identifiable communication with knee joint
Imaging Recommendations Best imaging tool: MRI Protocol advice: FS PD FSE shows cystic mass intermediate to hyperintense located medial to medial head of the gastrocnemius muscle
Meniscal Cyst Associated with meniscal tear Increased signal extending to articular surface on short TE sequences Posterior horn of medial meniscus (PHMM)
Cystic Adventitial Degeneration of a Popliteal Artery Cystic degeneration of arterial adventitia Color Doppler helpful in differentiating popliteal cyst Rare
Popliteal Artery Aneurysm Color Doppler imaging can confirm the absence of vascular flow within the mass Continuous with artery Pulsatile +/- History of sharp trauma
Popliteal Artery Aneurysm
Pathology Baker's cyst usually communicates with the joint at posteromedial knee Fluid from joint effusion extending into cyst
Clinical Issues Popliteal mass, swelling, dull ache, knee effusion Cyst may regress or enlarge
Diagnostic Checklist Evaluate underlying disorder as a popliteal cyst is common and is frequently associated with intraarticular pathology Follow the course of the popliteal cyst proximally for confirmation of orgin and joint communication
GanglionISynovial Cyst Atypical location compared to popliteal cyst Variable location around knee joint o Tibiofibular joint o Bursa between lateral head gastrocnemius muscle and biceps femoris May extend from popliteus tendon sheath/tibiofibular joint +/- Synovial lining
Deep Venous Thrombosis (DVT) Mimics rupture or leak of popliteal cyst Irritating nature of synovial fluid on the interstitial soft tissues Hyperintense on T2WI in soft tissues Venous collaterals developing in medial head of gastrocnemius
Semimembranosus Tibial Collateral Ligament Bursitis Bursal fluid distention Hyperintense on T2WI Inverted "U" shape +/- Semimembranosus tendinosis
1 PATHOLOGY General Features General path comments o Baker's cyst usually communicates with the joint at posteromedial knee o Cyst represents pressure relief valve for joint effusions o Often acts as ball valve with fibrin in the joint preventing fluid return o Cyst has projections away from tendons that may preferentially become filled with fluid leading to slight change in location Can be followed to bursa Etiology o Fluid from joint effusion extending into cyst
POPLlTEAL CYST o Fluid may communicate freely or be restricted to the
o Nonsteroidal anti-inflammatory agents, ice, assisted
cyst via a ball valve mechanism * Epidemiology o 5-58% of general population 0 Most common with effusion producing disorder such as rheumatoid arthritis (RA), osteoarthritis (OA) or trauma Associated abnormalities o Underlying knee disorders Arthritis (inflammatory or degenerative), trauma, infection, other synovial processes
1 DIAGNOSTIC CHECKLIST
Gross Pathologic & Surgical Features
Consider
Fluid-filled bursal sac in popliteal space Lining may be indurated Sac may contain debris Arise in bursa deep to medial head gastrocnemius Some cysts arise laterally Alternative site of orgin = herniation through posterior joint capsule
weight bearing Surgical o Radioactive synoviorthosis - radionuclide agents instilled at arthrography After documentation of cyst integrity Leakage is contraindication o Cyst excision when other treatment fails
Evaluate underlying disorder as a popliteal cyst is common and is frequently associated with intraarticular pathology
Image Interpretation Pearls Follow the course of the popliteal cyst proximally for confirmation of orgin and joint communication
Microscopic Features Lined by synovium - extension of the knee joint Four histopathologic types of popliteal cyst o Fibrous o Synovial o Inflammatory o Transitional IOU
Staging, Grading or Classification Criteria Primarylidiopathic cyst - valvular connection with joint Secondary/symptomatic cyst communicates freely with joint with normal synovial fluid o + Underlying articular disorder
Presentation Most common signslsymptoms o Popliteal mass, swelling, dull ache, knee effusion o Symptoms from underlying derangement such as meniscal tear, etc. Clinical profile: Adult patient with recurrent knee effusions
Demographics Age o 6.3% of children's knee MRI studies o Popliteal cysts in children may be isolated bursal sac formations without associated intraarticular pathology o Associated with intraarticular pathology in adult population Gender: More common in males
Natural History & Prognosis Cyst may regress or enlarge Good prognosis
Treatment Conservative o Treatment of underlying cause
Zandman-Goddard G et al: Coexisting chondrocalcinosis, osteoarthritis and popliteal cyst. Isr Med Assoc J 5(1):74-5, 2003 Torreggiani WC et al: The imaging spectrum of Baker's (Popliteal) cysts. Clin Radiol 57(8):681-91, 2002 Hsu WH et al: Dissecting popliteal cyst resulting from a fragmented, dislodged metal part of the patellar component after total knee arthroplasty. J Arthroplasty 17(6):792-7,2001 Garcia-Porrua C et al: Atypical Baker's cyst as a presenting sign of osteomyelitis superimposed on avascular necrosis of the knee. Clin Exp Rheumatol20(1):118, 2001 Rupp S et al: Long-term results after excision of a popliteal cyst. Unfallchirurg 104(9):847-51, 2001 Hill CL et al: Knee effusions, popliteal cysts, and synovial thickening: Association with knee pain in osteoarthritis. J Rheumatol28(6):1330-7, 2001 Handy JR: Popliteal cysts in adults: A review. Semin Arthritis Rheum 31(2):108-18, 2001 De Maeseneer M et al: Popliteal cysts in children: Prevalence, appearance and associated findings at MR imaging. Pediatr Radiol 29(8):605-9, 1999 Dunlop D et al: Ruptured baker's cyst causing posterior compartment syndrome. Injury 28(8):561-2, 1997 Krome J et al: Acute compartment syndrome in ruptured Baker's cyst. J South Orthop Assoc 6(2):110-4, 1997 Langsfeld M et al: Baker's cysts mimicking the symptoms of deep vein thrombosis: Diagnosis with venous duplex scanning. J Vasc Surg 25(4):658-62, 1997 Baker WM: On the formation of synovial cysts in the leg in connection with disease of the knee joint. 1887. Clin Orthop (299):2-10, 1994 Fielding JR et al: Popliteal cysts: A reassessment using magnetic resonance imaging. Skeletal Radiol 20(6):433-5, 1991 Fergusson C et al: An unusual loose body in the knee. Clin Orthop (206):233-5, 1986 Fam AG et al: Ultrasound evaluation of popliteal cysts on osteoarthritis of the knee. J Rheumatol9(3):428-34, 1982 Onetti CM et al: Synoviorthesis with 32P-colloidal chromic phosphate in rheumatoid arthritis--clinical, histopathologic and arthrographic changes. J Rheumatol 9(2):229-38,1982
POPLlTEAL CYST
(Left) Sagittal FS PD FSE MR shows a popliteal cyst and tibia1 collateral ligament semimembranosus bursitis. (Right) Axial FS PD FSE MR shows a popliteal cyst expansion of the gastrocnemius semimembranosus bursa. There is a bone trabecular contusion of the lateral femoral condyle.
(Left) Sagittal FS PD FSE MR shows a leaking popliteal cyst with surrounding inflammation (arrow). (Right) Sagittal FS PD FSE MR shows recently ruptured popliteal cyst.
Typical (Left) Sagittal FS PD FSE MR shows a popliteal cyst adjacent to the semimembranosus tendon. (Right) Sagittal FS PD FSE MR shows the medial soft tissue extension of a popliteal cyst.
-
SECTION 6: Ankle and Foot Tendons Achilles Tendinitis Achilles Tendon Tear Tibialis Posterior Tendon Tear Flexor Hallucis Longus Abnormalities Tibialis Anterior Tendon Tear Peroneus Brevis Tendon Tear
6-2 6-6 6-10 6-14 6-18 6-22
Ligaments Anterior Talofibular Ligament Tear Calcaneofibular Ligament Sprain Deltoid Ligament Sprain Syndesmosis Sprain Anterolateral Impingement Anterior Impingement Syndesmotic Impingement Posterior Impingement Sinus Tarsi Syndrome
Osseous Fractures Ankle Fractures Talus Fractures Calcaneal Fractures Navicular Fractures Metatarsal Fractures Lisfranc Fracture-Dislocation Osteochondral Lesion of the Talus Avascular Necrosis (AVN) of the Talus Freiberg's Infraction Medial Tibia1 Stress Syndrome Tarsal Coalition
Overuse Syndromes and Soft Tissue Injury 0 s Trigonum Syndrome Accessory Navicular Sesamoid Dysfunction Compartment Syndrome, Lower Extremity Gastrocnemius Soleus Strain Plantaris Rupture Tarsal Tunnel Syndrome Plantar Fasciitis Plantar Fibromatosis Morton's Neuroma Diabetic Foot
ACHILLES TENDlNlTlS
,
Sagittal graphic shows non-insertional Achilles tendinosis with anterior tendon convexity proximal to the os calcis. Mucoid degeneration shown in yellow.
Abbreviations and Synonyms Tendo Achilles tendinitis; Achilles tendinopathy
Definitions Tendinosis or tendinopathy represents intrasubstance tendon degeneration Paratenon-connective tissue envelope surrounding tendon (also referred to as peritenon) Paratendinitis as generalized inflammation of tissues surrounding the Achilles tendon Paratendinitis with tendinosis as inflammation of surrounding tissues with tendon degeneration Paratenonitis as inflammation of connective tissue envelope Tendinitis as clinical symptoms develop in association with degenerative process of tendinosis
General Features Best diagnostic clue: Focal thickening or diffusely enlarged tendon Location o Non-insertional
Sagittal FS PD FSE MR shows non-insertional Achilles tendinosis with hyperintense mucoid degeneration and anterior tendon convexity.
Hypovascular area 2-6 cm proximal to Achilles insertion o Insertional Distal calcaneal tendon insertion Size: Variable in longitudinal extent + anteroposterior thickening within watershed region of decreased vascular perfusion Morphology o Anterior tendon convexity o Nodular thickening
Radiographic Findings Radiography o Enlarged Achilles tendon o Blurring between anterior tendon margin and pre-Achilles fat on lateral radiograph
MR Findings TlWI o Increased cross sectional diameter on axial images o Increased anteroposterior dimensions o Prominent anterior convexity with focal or diffuse thickening in sagittal plane o Thickening + intermediate signal of peritendinous tissue dorsal, medial, & lateral to Achilles tendon o Assess lesion size, extent of tendinopathy and severity of degeneration o Intermediate signal intensity effacement of peritendinous tissue anterior to Achilles tendon
DDx: Achilles Tendinitis Gout
Xanthoma
Reiterr<Syndrorne
Sag T l Wl MR
Sag T I WI MR
Sag FS PD MR
ACHILLES TENDINITIS Key Facts Imaging Findings Best diagnostic clue: Focal thickening or diffusely enlarged tendon Non-insertional Insertional Anterior tendon convexity
Top Differential Diagnoses Gout Spondyloarthropathies Xanthoma Rheumatoid Arthritis
Pathology I
Hyperpronation
Clinical Issues Most common signs/symptoms: Pain with weight bearing Symptoms proximal to retrocalcaneal bursa Tenderness with deep palpation Tenderness at os calcis tendon insertion in Haglund's deformity Partial tears associated with regions of tendinosis
Diagnostic Checklist MR to identify coexistent partial tears of Achilles tendon on sagittal FS PD FSE images
Hypovascular watershed zone 2-6 cm proximal to calcaneal insertion Eccentric loading of a fatigued muscle-tendon unit T2WI o Hypointense to intermediate signal within enlarged tendon o Hyperintense inflammatory fluid anterior to tendon o Tendinous mucoid degeneration may show increased signal on FS PD FSE or STIR images o Associated partial tears hyperintense on FS PD FSE or STIR images o Haglund's deformity - insertional tendinitis with reactive calcaneal marrow edema, and constellation of thickened tendon, retrocalcaneal/Tendo Achilles bursitis, and calcaneal bony prominence o Effacement + edema of pre-Achilles fat body may exist with normal tendon morphology/signal T1 C+: Soft tissue inflammatory fluid enhancement in paratendinitis
Ultrasonographic Findings Operator dependent Increased fibril thickness Disruption fibrillar bundles Fragmentation Decreased echogenicity associated with extent of disease Nodularity with small hypoechoic focal lesions
Imaging Recommendations Best imaging tool: MR for superior soft tissue contrast Protocol advice: Requires both T1 (or PDWI) and FS PD FSE sagittal & axial images
I DIFFERENTIAL DIAGNOSIS Gout Intermediate signal intensity urate tophi
Spondyloarthropathies Band of reactive marrow edema in calcaneus Inflammatory enthesopathy with insertional tendinitis
Xanthoma Infiltrating mass with large soft tissue component
Rheumatoid Arthritis
Identify intermediate signal rheumatoid nodules + synovitis, reactive osseous marrow edema
1 PATHOLOGY General Features General path comments o Relevant anatomy Achilles tendon has no synovial sheath Retrocalcaneal bursae between Achilles insertion and calcaneus Tendo Achilles bursa located posterior to Achilles tendon Etiology o Direct trauma to Achilles tendon Hematoma Inflammation Fibrosis with restricted tendon sliding o Hypovascular watershed zone 2-6 cm proximal to calcaneal insertion o Eccentric loading of a fatigued muscle-tendon unit Overtraining Runners susceptible in both acceleration (sprinting) and deceleration (eccentric contraction) o Hyperpronation Leg and foot generate opposing forces of rotation Subtalar joint pronates Calcaneus everts Knee extends o Forefoot varus o Cavus foot 0 Equinus deformity Triceps surae contracture o insertional changes Calcaneus bony prominence o Hypertrophic spur or enthesophyte o Systemic arthropathy HLA-B27 antigen Rheumatoid arthritis
I
ACHILLES TENDlNlTlS Epidemiology o 11%incidence in runners o 9% in dancers
Gross Pathologic & Surgical Features Inadequate healing Adhesions Fibrotic changes of peritenon Loss of normal tendon luster Nodular thickening Calcification Inflamed peritenon
Microscopic Features Chronic paratendinitis o Hypertrophic connective tissue o Increased capillary infiltration o Regional blood vessel degeneration o Fibrinogen deposition and fibrinoid necrosis o Round cell infiltrate o Increase in glycosaminoglycans (chondroitin sulfate) and mucoid degeneration o Leakage plasma proteins secondary to disruption of local blood flow o Absence of tendon inflammatory response (separate from inflammatory disease of peritendinous tissues and peritenon)
Presentation Most common signs/symptoms: Pain with weight bearing Clinical profile o Non-insertional Acute pain with altered biomechanics Symptoms proximal to retrocalcaneal bursa Tenderness with deep palpation Palpable tendon nodularity Occurs in higher level athlete o Insertional tendinitis Tenderness at os calcis tendon insertion in Haglund's deformity Older, less athletic or sedentary population
Demographics Age o Adult ages 30-40 most at risk o Also young athletes, sedentary individuals and older population Gender: Pronounced lesions associated with male gender Activity o 6.5-18% incidence of non-insertional Achilles tendinitis in runners
Natural History & Prognosis Chronic tendinopathy o Perfusion insufficiency with vascular proliferation o Abnormal tendon fiber morphology o Hypercellularity o 90% symptomatic o Partial tears associated with regions of tendinosis
o Tendinosis may be precursor lesion to final stage of
partial or complete tendon tear
Treatment Conservative - to decrease symptoms of tendinopathy o Therapeutic rest o Stretching exercises o Cross training or alternative exercise o Antiinflammatory medications o Immobilization o Orthoses to correct hyperpronation o Brisement to lift adherent paratenon Surgical o Release excision paratenon in paratenonitis (improved success relative to cases of intrinsic tendon degeneration) o Excision of calcaneal prominence in insertional tendinopathy o Partial tears repaired o Mucoid degeneration treated with debridement
*
Consider Evaluate paratenon connective tissue envelope and paratendinous tissue for inflammatory change separate from tendon degeneration MR to identify coexistent partial tears of Achilles tendon on sagittal FS PD FSE images
1 SELECTEDREFERENCES --
-
.
Paavola M et al: Achilles tendinopathy. J Bone Joint Surg Am 84-A(11):2062-76,2002 Shalabi A et al: Dynamic contrast-enhanced MR imaging and histopathology in chronic Achilles tendinosis. A longitudinal MR study of 15 patients. Acta Radiol 43(2):198-206, 2002 Banks A et al: McGlamry's comprehensive textbook of foot and ankle surgery. vol 1. Philadelphia PA, Lippincott Williams & Wilkins, (35):1091- 152, 2001 Myerson M: Foot and ankle disorders. vol2. Philadelphia PA, Lippincott Raven, (55):1367-98, 2000 Stoller D: Magnetic resonance Imaging in orthopaedics & sports medicine. 2nd ed. Philadelphia PA, Lippincott Williams & Wilkins, (8):443-595, 1997 Resnick D et al: Internal derangement of joints: Emphasis on MR imaging. Philadelphia PA, Saunders WB, (17):787-925, 1997 Astrom M et al: Chronic Achilles tendinopathy. A survey of surgical & histopathologic findings. Clin Orthop 316:151-64, 1995 Clement DR et al: Achilles tendonitis and peritendonitis: Etiology and treatment. AMJ Sports Med i2(3):197-84, 1984 Neuhold A et al: Degenerative Achilles tendon disease: Assessment by magnetic resonance and ultrasonography. Eur J Radiol 4(4):145-50, 1976
ACHILLES TENDINITIS
I IMAGE GALLERY (Lef)Sagittal T l Wl MR shows non insertional Achilles tendinosis with focal degeneration and paratendinitis. (Right) Sagittal FS PD FSE MR shows hyperintense mucoid degeneration (arrow) and paratendinitis.
Typical
(Left) Sagittal graphic of insertional Achilles tendinitis. (Right) Sagittal FS PD FSE MR shows Haglund's deformity with insertional tendinitis and calcaneal marrow edema plus hyperintense retrocalcaneal (arrow) and retro-Achilles bursa.
Variant
(Left)Sagittal graphic shows xanthoma with infiltrating soft tissue mass in yellow. (Right) Sagittal FS PD FSE MR shows posterior infiltrating intermediate signal xanthomatous soft tissue mass (arrow).
ACHILLES TENDON TEAR
Sagittal graphic shows high grade partial tear of the distal Achilles tendon.
Sagittal FS PD FSE MR shows hyperintense signal in partial tear of the distal Achilles tendon (insertional tear).
o Hemorrhage or edema in intratendinous or
peritendinous soft tissue: Hyperintense (FS PD FSE) o Normal Achilles tendon is of uniform hypointensity o Ruptureltear = disruption with discontinuity f wavy
Abbreviations and Synonyms Achilles tendon rupture
retracted tendon
Definitions
PI
Partial or complete discontinuity Achilles
+ tendinous gap in
General Features Best diagnostic clue: Hyperintense fluid-filled tendinous gap Location: Rupture 2-6 cm superior to the os calcis Size: Variable based on tendon retraction Morphology: Diffuse convexity anterior margin and enlarged tendon ends at tear site
MR Findings TlWI o Effacement of Kager's triangle o Intratendinous degeneration as intermediate signal intensity o Assess morphology of tendon edges o Assess tendon enlargement + retraction T2WI
o Hyperintense fluid-filled gap k interposed fat
Proximal tendon retraction associated with fraying or corkscrewing of tendon edges o Intratendinous fluid: May be seen up to six months post surgical treatment or conservative management (a widened tendon up to 12 months) o Enlarged proximal and distal ends may be associated with an attenuated union bridging the tear site o Surgical repair healing response: Increased size of tendon associated with decreased tendinous signal intensity secondary to scar tissue o Associated edema in peritendon and preachilles fat pad is a common finding T1 C+: FS T1 C+ to enhance tear site and define margins 0
Imaging Recommendations Best imaging tool o MR superior to ultrasound and CT for partial and complete tears especially intratendinous lesions o MR imaging identifies tendinous gap - important for conservative management (retracted tendons are less likely to heal with large diastasis) Protocol advice
DDx: ~ c h i l l e sTendon Tear Post. lrnpin~ement
Planfarik Rnlptur~
Cor FS PD MR
Sag FS PD MR
1 MR
ACHILLES TENDON TEAR Key Facts Imaging Findings Best diagnostic clue: Hyperintense fluid-filled tendinous gap Location: Rupture 2-6 cm superior to the os calcis Assess tendon enlargement + retraction Hemorrhage or edema in intratendinous or peritendinous soft tissue: Hyperintense (FS PD FSE)
Top Differential Diagnoses Partial Tear of the Achilles Tendon Plantaris Tendon Tear Posterior Impingement
Pathology Indirect trauma common Repetitive microtrauma
Forced dorsiflexion of foot against contracting force (triceps surae group) or eccentric loading in a sudden stretch Direct trauma: Rupture at the myotendinous junction Posterior fibers rupture first (partial tearing inay exist in anterior fibers which are under less tension)
Clinical Issues Pain and soft tissue swelling (hemorrhage) Athletic activity in middle-aged males Musculotendinous junction in younger population Surgical repair usually required
Diagnostic Checklist
Identify proximal and distal tendon ends on sagittal images
o MR
T1 and FS PD FSE or STIR sagittal and axial images required
o Acute rupture: Predisposing factors include chronic
tendonitis and partial tears o Use of fluoroquinolone antibiotics
Epidemiology: Third most frequent tendon rupture
1 DIFFERENTIAL DIAGNOSIS Partial Tear of the Achilles Tendon Without tendinous gap
Plantaris Tendon Tear A torn plantaris tendon may mimic an Achilles tendon tear on medial sagittal images (an intact plantaris tendon may also be seen in the presence of an Achilles tendon rupture) Fluid between plantaris and Achilles may mimic a tear
Posterior Impingement Hyperintensity of posterior ligaments or interposed ganglion & synovitis
I PATHOLOGY General Features General path comments o No true synovial sheath o Mesotendon provides blood supply through anterior mesentery o Kager's triangle = triangular fat pad anterior to Achilles tendon Etiology 0 Indirect trauma common o Repetitive microtrauma o Over pronation of foot or heel stress leads to micro tears o Forced dorsiflexion of foot against contracting force (triceps surae group) or eccentric loading in a sudden stretch 0 Direct trauma: Rupture at the myotendinous junction o Atrophy of soleus muscle o Rheumatoid arthritis, systemic lupus, diabetes mellitus and gout
Gross Pathologic & Surgical Features Tear 2-3 cm proximal to calcaneal insertion Reduced anterior mesenteric blood supply with increasing age Posterior fibers rupture first (partial tearing may exist in anterior fibers which are under less tension) Plantaris usually intact secondary to a more anterior calcaneal insertion
Microscopic Features Degeneration with decreased collagen cross-linking o Increased stiffness o Loss of viscoelasticity
Staging, Grading or Classification Criteria Type 1 o Partial ruptures of 50% or less Type 2 o Complete rupture with tendinous gap 3 cm or less Type 3 o Complete rupture with tendinous gap 3 cm to 6 cm Type 4 o Complete rupture with defect of greater than 6 cm o Associated with neglected ruptures
Presentation Most common signs/symptoms o Pain and soft tissue swelling (hemorrhage) o Clinical assessment can be incorrect up to 25% Clinical profile o Athletic activity in middle-aged males o Hyperdorsiflexion sign o O'Brien's needle test to detect proximal tendon motion as a sign of tendon continuity in acute ruptures o Palpable tendon defect
ACHILLES TENDON TEAR 4.
o Thompson test positive if squeezing calf does not
produce plantar flexion response
Demographics
5.
Age o After age 30 (30 to 50 years most common) o Musculotendinous junction in younger population Gender o M:F = 5:l to 6:l for complete rupture secondary to indirect trauma o Concentric loading Basketball Tennis Racquetball
6. 7. 8. 9. 10.
Natural History & Prognosis Non-surgical rate of rerupture 20.8% Surgical rate of rerupture 1.7% Recurrent rupture o 10 to 30% with conservative treatment o 5% with a surgical reinforcement
11.
Treatment
12.
Non-operative o Cast immobilization Above knee cast with equinus for 4 weeks Below knee cast with decreased equinus o Often indicated for acute ruptures < 48 hours Steroid induced ruptures Surgical repair usually required o Type 1 and 2 ruptures repaired with an end-to-end anastomosis o Type 3 rupture requires autogenous tendon graft flap o ~~~e4 requires a free tendon graft or synthetic graft Suture techniques o Bunnell o Kessler o Krackow (locking loop) with four sutures across repair site o Percutaneous repair o Synthetic graft materials Alternative function bracing Plantaris reinforcement
II
13. 14. 15. 16. 17. 18. 19. 20.
[DIAGNOSTIC CHECKLIST Consider Identify proximal and distal tendon ends on sagittal images Use axial FS PD FSE images to confirm complete rupture (an intact plantaris may simulate an intact tendon in sagittal plane) Identify surface contour irregularity to differentiate partial tears vs. nonretracted complete ruptures
(SELECTEDREFERENCES 1.
2. 3.
Dwornik L et al: Radiologic case study. Acute Achilles tendon rupture. Orthopedics 25(11):1239, 1318-20, 2002 Marshall H et al: Contrast enhanced magic-angle MR imaging of the Achilles tendon. AJR 179(1): 187-92, 2002 Schepsis AA et al: Achilles tendon disorders in athletes. Am J Sports Med 30(2): 287-305, 2002
1
Banks A et al: McGlamry's comprehensive textbook of foot and ankle surgery. vol 1. 3rd ed. Philadelphia, Lippincott Williams & Wilkins, 1706-23, 2001 Myerson M et al: Foot and ankle disorders. vol 1. Philadelphia, W.B. Saunders, 1367-98, 2000 Saltzman C et al: Achilles tendon injuries. J Am Acad Orthop Surg 6(5):316-23, 1998 Stoller D et al: Magnetic resonance imaging in orthopaedics & sports medicine. 2nd ed. Philadelphia, Lippincott Williams & Wilkins, 443-595, 1997 Resnick D et al: Internal Derangements of Joints: Emphasis on MR imaging. 1st ed. Philadelphia, W.B. Saunders, 787-925, 1997 Karjalainen PT et al: Magnetic resonance imaging during healing of surgically repaired Achilles tendon ruptures. Am J Sports Med 25:164-71, 1997 Astrom M et al: Imaging in chronic Achilles tendinopathy: A comparison of ultrasonography, magnetic resonance imaging and surgical findings in 27 histologically verified cases. Skeletal Radio1 25:615-20, 1996 Cetti R et al: Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med 21(6):791-9, 1993 Schweitzer ME: Magnetic resonance imaging of the foot and ankle. Magn Reson Q 9(4):214-34, 1993 Kier R et al: MR imaging of the normal ligaments and tendons of the ankle. J Comput Assist Tomogr 15(3):477-82,1991 Mink JH et al: Tendon injuries of the lower extremity: Magnetic resonance assessment. Top Magn Reson Imaging 3(4):23-38, 1991 Keene JS et al: Magnetic resonance imaging of Achilles tendon ruptures. Am J Sports Med 17:333-7, 1989 Hamilton WG: Foot and ankle injuries in dancers. Clin Sports Med 7(1):143-73, 1988 Quinn SF et al: Achilles tendon: MR imaging at 1.5 T. Radiology 164:767-70, 1987 Reinig JW et al: MR imaging of a ruptured Achilles tendon: Case report. J Comput Assist Tomogr 9:1131-4, 1985 Clement P et al: Achilles tendinitis and peritendinitis: Etiology and treatment. Am J Sports Med 12:179-84, 1984 James S et al: Injuries to runners. Am J Sports Med 6:40-50, 1978
ACHI LLES TENDON TEAR
I IMAGE GALLERY (Left) Sagittal graphic shows Achilles tendon rupture with overlapping proximal and distal tendon segments. (Right) Sagittal T l Wl MR shows complete rupture of Achilles tendon with approximation of proximal and distal tendon fibers.
Tvaical
(Left) Sagittal graphic shows Achilles tendon tear with tendinous gap and retraction. (Right) Axial FS PD FSE MR shows hyperintensity at hemorrhagic tear site in a complete tendon rupture.
Tvaical (Left) Sagittal graphic shows anterior tendon deformity with partial Achilles tear. (Right) Sagittal FS PD FSE MR shows hyperintense linear signal in an insertional Achilles partial tear (arrow) with reactive calcaneal marrow edema.
-
TIBIALIS POSTERIOR TENDON TEAR
Sagittal graphic shows tibialis posterior tendon tear type 1 with medial malleolar spur opposite area of interstitial longitudinal split. Abnormal segment of tendon shown in red.
Axial FS PD FSE MR shows type 1 tibialis posterior tendon tear with hyperintense signal (arrow) within an enlarged tendon. Involved tendon is shown posterior to the deltoid ligament.
o Attenuation in a curvilinear orientation o Complete tendinous gap
Abbreviations and Synonyms
M R Findings
Tibialis posterior tendon dysfunction; tibialis posterior tendon insufficiency, tibialis posterior tendon rupture
TlWI o Type 1 tear Intrasubstance vertical split Enlarged tendon diameter & intrasubstance intermediate signal o Type 2 tear Thin or attenuated tendon with variable intratendinous signal change o Type 3 tear Complete tendinous discontinuity with low to intermediate signal intensity fluid-filled gap Presence of sub-tendons in partial tears Associated findings: Hypertrophy medial tubercle of navicular, abnormal talonavicular alignment, accessory navicular, loss of longitudinal arch on sagittal images Normal variant of increased signal intensity + girth at distal tendon insertion to navicular (intrasubstance striations) Osseous spur k fatty marrow signal posteromedial aspect medial malleolus Uncommon to see tendon dislocation, associated with disruption of flexor retinaculum T2WI
Definitions Tendinopathy and progressive tendon tear resulting in collapsed pes valgus deformity
General Features Best diagnostic clue: A change in tendon size, morphology and/or signal intensity Location o Mid portion of tendon involved at level of and immediately distal to medial malleolus o corresponds to relative zone of tendon hypovascularity Size o Normal tibialis posterior 2x size of flexor digitorum longus o Tibialis posterior tendon tear presents as spectrum of tendon hypertrophy, attenuation or disruption Morphology o Bulbous cross sectional enlargement
mmm DDx: Tibialis Posterior Tendon Tear Deltoid Sprain
Medial Arthritis
.,
I
,T
-
' T d
> .
.
>
Ax FS PD FSE MR
Ax FS PD FSE MR
*c.
-
TlBlALlS POSTERlOR TENDON TEAR Key Facts Imaging Findings Best diagnostic clue: A change in tendon size, morphology and/or signal intensity Mid portion of tendon involved at level of and immediately distal to medial malleolus Presence of sub-tendons in partial tears
Top Differential Diagnoses Tenosynovitis Tibialis Posterior Tendon Insertion Deltoid Sprain Medial Tibiotalar Arthritis
Pathology Acute trauma less common than degenerative Degenerative is most frequent etiology of tibialis posterior dysfunction o Tendon hypertrophy with heterogenous signal intensity (FS PD FSE) in type 1 vertical split o Thickening flexor retinaculum
o Tenosynovitis
Hyperintense fluid seen associated with degeneration and tendon tears o Hyperintense fluid-filled gap or diastasis at tendon rupture site o Chronic dysfunction: Spring ligament laxity or rupture Superomedial calcaneal navicular component usually injured STIR o Tenosynovitis: Seen in tears and degeneration as hyperintense fluid o Subchondral marrow edema
Imaging Recommendations Best imaging tool: MR superior to CT for tendon morphology, vertical splits, tenosynovitis and edema Protocol advice o TI or PD FSE and FS PD FSE axial, sagittal and coronal planes o Axial plane key in evaluating changes of tendon morphology o Coronal and sagittal planes used for secondary confirmation of tendon pathology
1 DIFFERENTIAL DIAGNOSIS Tenosynovitis Tendon morphology is maintained without intrinsic tendinopathy
Tibialis Posterior Tendon Insertion Normal broadening of tendon restricted to navicular insertion
Deltoid Sprain Superficial or deep layer hyperintensity on T2WI
Type 1 tear: Tendon hypertrophy with vertical split Type 2 tear: Attenuated section of tendon at level of medial malleolus with sub-tendons Type 3 tear: Complete with tendinous gap
Clinical Issues Most common signs/symptoms: Pain, swelling, tenderness and flattening of medial longitudinal arch Age: Fifth and sixth decades Gender: Two-thirds cases female population Plantar fasciitis Severe pes planus
Diagnostic Checklist
Assess tendon morphology otherwise may overlook type 2 tears
Medial Tibiotalar Arthritis
Sclerosis (hypointense) between medial malleolus + talus
Magic Angle Effect Increased signal where tendon alignment is approximately 55" relative to main magnetic field (e.g., at medial malleolus) Lengthening of T2 relaxation Seen on short echo sequences (typically TE is less than 40 ms) Not present on long TE sequences
1 PATHOLOGY General Features General path comments o Relevant anatomy Tibialis posterior superficial to superomedial calcaneal navicular component of spring ligament Synergistic relationship of tibialis posterior tendon with spring ligament o Insertion Proximal on navicular tuberosity Extensive plantar insertions o Relevant function Supports medial arch Stabilizes foot High inversion moment arm Supination of foot Pulley action with medial malleolus Etiology o Traumatic Acute trauma less common than degenerative Minor trauma Lacerations and puncture Rupture usually associated with indirect trauma (sprains and/or fractures) o Chronic Degenerative is most frequent etiology of tibialis posterior dysfunction
TIBlALlS POSTERIOR TENDON TEAR
. . . .
Clinical profile o Weakness of inversion o Severe pes planus deformity o Heel valgus, talar plantar flexion and forefoot abduction
o Systemic inflammatory disease
Rheumatoid arthritis o Seronegative spondyloarthropathies Psoriasis Ankylosing spondylitis Reiter's Enteropathic arthritis Associated with sites of enthesopathy o Infections Gonococcal Tubercular o Tendon hypovascularity Zone of hypovascularity in mid portion of tendon, at and distal to medial malleolus At risk for rupture Diminished arterial perfusion (age-related)leading to tendon ischemia Acute angulation of tendon posterior to medial malleolus compounds hypovascularity Pronation of hindfoot causes tendon compression o Biomechanical Overuse Pes valgus Equinus Increased stress on tibialis posterior with decreased medial longitudinal arch support o Abnormal insertion Accessory navicular Prominent medial navicular tubercle Associated with tendon degeneration secondary to change in leverage o Iatrogenic tendon dysfunction Medial ankleltarsal tunnel surgery - . Steroid use Epidemiology: Patients > 50 years: 60% associated with hypertension, diabetes + obesity
. .. .
Demographics Age: Fifth and sixth decades Gender: Two-thirds cases female population Distribution o Unilateral (90%) and left sided predominance
Natural History & Prognosis Change in foot shape Decreased exercise tolerance Plantar fasciitis Tarsal tunnel associated with tenosynovitis and tendon hypertrophy Severe pes planus Tenderness sinus tarsi and lateral ankle pain in advanced deformity
Treatment Conservative o Tendon must be intact without significant degeneration o Orthotics, medial heel wedge (support medial longitudinal arch) o Non-steroidal antiinflammatory drugs o Physical therapy Surgical o Primary repair o Excision of segmental defects with reanastomosis or grafting o Reinforcement with flexor digitorum longus or tibialis anterior o Osteotomies + limited fusions
.
.
12
Gross Pathologic & Surgical Features Longitudinal split p end on laxity and elongation Irregular surface Adhesions with sheath and flexor retinaculum Elongated and fibrotic tendon Bone proliferation Atrophic sheath Tendon rupture Scarred and frayed proximal and distal tendon ends
I I
Microscopic Features ~ntrasubstancedegeneration
Staging, Grading or Classification Criteria MR criteria o Type 1 tear: Tendon hypertrophy with vertical split o Type 2 tear: Attenuated section of tendon at level of medial malleolus with sub-tendons o Type 3 tear: Complete with tendinous gap
Presentation Most common signs/symptoms: Pain, swelling, tenderness and flattening of medial longitudinal arch
Consider Assess tendon morphology otherwise may overlook type 2 tears Identify associated sub-tendons Confirm tendon anatomy on coronal and sagittal images
1 SELECTEDREFERENCES 1.
2. 3.
Banks AS et al: McGlamry's comprehensive textbook of foot and ankle surgery. vol 1. 3rd ed. Philadelphia PA, Lippincott Williams & Wilkins, 862-99, 2001 Myerson M: Foot and ankle disorders. vol2. Philadelphia PA, Lippincott Raven: 1017-39, 2000 Karasick D et al: Tear of the posterior tibia1 tendon causing asymmetric flatfoot: Radiologic findings. AJR 161:1237, 1993
I
TIBIALIS POSTERIOR TENDON TEAR
Typical (Left) Axial T 1 Wl MR shows enlarged tibialis posterior tendon in type 1 tear with oosterior medial malleolus spur. The medial spur (arrow) is marrow containing. (Right) Axial FS PD FSE MR shows hyperintense signal (arrow) in partial tear (type 1 ) of the posterior aspect of the tibialis posterior tendon. Adjacent soft tissue edema is hyperintense.
Typical (Left) Sagittal graphic shows longitudinal split of the tibialis posterior tendon into two subtendons. Subtendons and abnormal tendon section shown in red. (Right) Axial FS PD FSE MR shows the anterior and posterior subtendons of a type 2 tibialis posterior tendon tear. Subtendons (arrows) are posterior to the deltoid ligament and anterior to the flexor digitorum longus tendon.
(Left) Sagittal graphic shows complete rupture of the tibialis posterior tendon with retracted tendon stumps. (Right) Axial FS PD FSE MR shows hyperintense fluid (arrow) occupying area of absent tibialis posterior tendon in a type 3 tendon tear. Nuid is anterior to the flexor digitorum longus tendon.
-
FLEXOR HALLUCIS LONCUS ABNORMALITIES
Sagittal graphic shows tenosynovitis in red.
flexor
hallucis longus
Axial FS PD FSE MR shows hemorrhagic tenosynovitis with layering of fluid in the flexor hallucis longus tendon sheath.
o Muscle tendon unit injuries with diffuse edema
Abbreviations and Synonyms Tendinosis; tenosynovitis; muscle-tendon unit (MTU) strain; tethering; tear
Definitions Susceptible to tendinosis + rupture through tarsal tunnel
MR Findings TlWI: Hypointense to intermediate signal intensity fluid T2WI o Hyperintense fluid in tendon sheath on FS PD or T2 FSE images Commonly identified between tibia1 plafond + calcaneus Fluid generally uniform hyperintensity septation Disproportionate fluid in flexor hallucis longus (FHL) tendon sheath relative to tibiotalar joint o Muscle strain: Hyperintense edema or hemorrhage radiating from trauma epicenter Foci of hemosiderin within muscle o Ruptured retracted FHL tendon enlarged in cross sectional area
*
General Features Best diagnostic clue: Hyperintense fluid (FS PD FSE) in synovial sheath disproportionate to quantity of tibiotalar joint fluid Location o Runs posterior to medial malleolus, through tarsal tunnel, to Henry's knot Plantar to base of first metatarsal Size o Muscle - focal or involving entire cross sectional diameter o Tendon sheath - variable Morphology o Restricted to muscle or tendon sheath
Imaging Recommendations Best imaging tool o MR to identify Tendon sheath fluid Muscle signal changes Tendon morphology Protocol advice
DDx: Flexor Hallucis Longus Abnormalities
Sag FS PD MR
+
focal muscle hemorrhage o Tenosynovitis with hyperintense fluid on FS PD/T2 images (circular to elongated fluid collection)
Achillcs Dcgen.
TP Tcnosynovtti~
Sag FS PD MR
Ax T l WI MR
FLEXOR HALLUCIS LONGUS ABNORMALITIES -
Key Facts Imaging Findings Best diagnostic clue: Hyperintense fluid (FS PD FSE) in synovial sheath disproportionate to quantity of tibiotalar joint fluid Muscle tendon unit injuries with diffuse edema & focal muscle hemorrhage Tenosynovitis with hyperintense fluid on FS PD/T2 images (circular to elongated fluid collection) Ruptured retracted FHL tendon enlarged in cross sectional area
Top Differential Diagnoses 0 s Trigonum Syndrome Fluid in Tendon Sheath 2" to Ankle Effusion Achilles Tendonitis Tibialis Posterior (TP) Tenosynovitis
o Routine ankle using FS PD FSE in axial, sagittal, and
coronal planes Coronal images through the foot for distal rupture
I DIFFERENTIAL DIAGNOSIS 0 s Trigonum Syndrome Hypertrophy of the os trigonum
Fluid in Tendon Sheath 2" to Ankle Effusion Fluid may be present in association with tibiotalar effusion (pseudo-tenosynovitis) Communication with ankle joint in 70%
Achilles Tendonitis Thickening Achilles tendon
Tibialis Posterior (TP) Tenosynovitis Fluid in tendon sheath & Associated tendinopathy of tibialis posterior
1 PATHOLOGY General Features General path comments o Relevant anatomy Fibroosseous tunnel deep to flexor retinaculum (between medial + lateral tubercles of posterior talar process) Passes underneath sustentaculum tali Sheaths of FHL and flexor digitorum longus cross at master knot of Henry Plantar insertion base distal phalanx great toe 0 s trigonum - ununited lateral tubercle of posterior talar process Etiology 0 Repetitive plantar flexion and dorsiflexion lead to tenosynovitis o Low-lying FHL muscle creating impingement 0 Partial tearing or thickening with nodule development and hallux triggering (hallux sultans)
Pathology Repetitive plantar flexion and dorsiflexion lead to tenosynovitis Twisting injury ankle Paratendinitis (tenosynovitis) most common abnormality
Clinical Issues Most common signs/symptoms: Pain, swelling and tenderness posterior ankle Repetitive stress may result in chronic muscle strain hemorrhage Release constricting FHL tendon sheath
+
Diagnostic Checklist
Tendon sheath fluid may be a normal finding and should be correlated with ankle joint fluid volume
o Fixed or locked FHL within sheath associated with
severe tenosynovitis Epidemiology o Twisting injury ankle o Calcaneal fracture with involvement of sustentaculum tali o Ballet dancing FHL termed the Achilles tendon of the foot or "dancer's Achilles heel" o Paratendinitis (tenosynovitis) most common abnormality
Gross Pathologic & Surgical Features Tendon thickening with tendinosis and partial tear Fluid proximal to talar fibroosseous tunnel in stenosing tenosynovitis Complete tendon rupture in talar fibroosseous tunnel uncommon Midfoot rupture more frequent at distal insertion Paratenonitis in three anatomic sites o Fibroosseous tunnel between medial and lateral tubercles of posterior talar process o Deep to flexor retinaculum o Level of sesamoids within distal hallux tunnel
Microscopic Features Inflammatory reaction surrounding FHL
VL ISSUES Presentation Most common signs/symptoms: Pain, swelling and tenderness posterior ankle Clinical profile 0 Demipointe to pointe in ballet (balled foot to toe position) 0 Condition exacerbated by hyper plantar flexion
Demographics Age: Young athletes and dancers Gender: More common in female than male dancers
FLEXOR HALLUCIS LONGUS ABNORMALITIES Natural History & Prognosis Repetitive stress may result in chronic muscle strain f hemorrhage Stenosing tenosynovitis Partial or complete tendon tear
Treatment Conservative o Antiinflammatory agents o Rest o Modification of dance or related causative activities o Immobilization Surgical o Release constricting FHL tendon sheath o Excision of an associated symptomatic os trigonum
Consider Chronic muscle changes in dancers at muscle tendon junction Follow distal course of FHL to exclude distal rupture Tendon sheath fluid may be a normal finding and should be correlated with ankle joint fluid volume
1. 2.
16
3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
Sitler DF et al: Posterior ankle arthroscopy: An anatomic study. J Bone Joint Surg AM 84~(5):763:9, 2002 Banks A et al: McGlamry's comprehensive textbook of foot and ankle surgery. vol 1. Philadelphia PA, Lippincott Williams & Wilkins, (35):1091-152, 2001 Myerson M: Foot and ankle disorders. vol2. Philadelphia PA, Lippincott Raven, (39):942-71, 2000 Bureau NJ et al: Posterior ankle impingement syndrome: MR imaging findings in seven patients. Radiology 215(2): 497-503, 2000 Cooper ME et al: 0 s trigonum syndrome with flexor hallucis longus tenosynovitis in a professional football referee. Med Sci Sports Exerc 31:S493-96, 1999 Sammarco GJ et al: Flexor hallucis longus tendon injury in dancers and nondancers. Foot Ankle Int 19(6):356-62,1998 Sammarco GJ et al: Flexor hallucis longus tendon injury in dancers and nondancers. Foot Ankle Int 19:356-63, 1998 Inokuchi S et al: Closed complete rupture of the flexor hallucis longus tendon at the groove of the talus. Foot Ankle Int 18:47-9, 1997 Kolettis GJ et al: Release of the flexor hallucis longus tendon in ballet dancers. J Bone Joint Surg Am 78A:1386-90, 1996 Hamilton WG et al: Pain in the posterior aspect of the ankle in dancers. Differential diagnosis and operative treatment. J Bone Joint Surg Am 78:1491-1500, 1996 Chandnani VP et al: Achilles tendon and miscellaneous tendon lesions. Magn Reson Imaging Clin N Am 2(1):89-96, 1994 Schweitzer ME et al: Fluid in normal and abnormal ankle joints: Amount and distribution as seen on MR images. AJR 162(1):111-4,1994 Coghlan BA et al: Traumatic rupture of the flexor hallucis longus tendon in a marathon runner. AM J Sports Med ASSOC 21:617-18, 1993 Mink JH et al: Tendon injuries of the lower extremity: Magnetic resonance assessment. Top Magn Reson Imaging 3(4):23-38,1991 Floyd DW et a1:Tendon lacerations in the foot. Foot Ankle
453-14, 1983 16. Cowell HR et al: Bilateral tendonitis of the flexor hallucis longus in a ballet dancer. J Pediatr Orthop 2:582-86, 1982 17. Garth WP Jr: Flexor hallucis tendinitis in a ballet dancer. A case report. J Bone Joint Surg Am 63:1489, 1981 18. Krackow KA: Acute, traumatic rupture of a flexor hallucis longus tendon: A case report. Clin Orthop 150:261-2, 1980 19. Frenette JP et al: Lacerations of the flexor hallucis longus in the young athlete. J Bone Joint Surg Am 59:673-76, 1977 20. Hamilton WG: Tendonitis about the ankle joint in classical ballet dancers. Am J Sports Med 5:84-8, 1977
FLEXOR HALLUCIS LONCUS ABNORMALITIES
I IMAGE GALLERY (Lef?) Axial graphrc oiplanlar rupture of ilexor hallucis longus tendon. (Right) Axial FS PD FSE MR of distal rupture (arrow) with retraction o i ilexor hallucis longus tendon. Retracted tendon shows enlarged distal con tour.
(Lef)Coronal FS PD FSE MR showing absence of distal flexor hallucis longus tendon between the sesamoids of the first metatarsal. (Right) Coronal FS PD FSE MR of retracted flexor hallucis longus tendon surrounded by hyperintense fluid at the level of the master knot of Henry (arrow).
(Left) Axial FS PD FSE MR shows hyperintense traumatic tenosynovitis distending the flexor hallucis longus tendon sheath (arrow). (Right) Axial FS PD FSE MR shows chronic flexor hallucis longus muscle tendon unit injury. Hyperintense edema (arrow) and chronic hypointense hemorrhage are present within the belly of the flexor hallucis longus muscle.
1
TIBIALIS ANTERIOR TENDON TEAR
-
Sagittal graphic shows rupture of tibialis anterior with tendinous gap. Frayed tendon ends are shown in red. Tear site is located between slips of the inferior extensor retinaculum.
Coronal FS PD FSE MR shows complete tear (arrow) of the tibialis anterior tendon on image acquired perpendicular to the long axis of the tendon. Hyperintense fluid occupies tear site.
MR Findings TlWI o Enlarged tendon and sheath o Intermediate signal intensity in tendinous gap o Variable increased signal intensity (intermediate) in frayed tendon ends o Partial tendon continuity with preserved hypointense tendon fibers in high grade partial tear o Absence of tendon at tear site o Associated dorsal osteophyte in ruptures at medial tarsometatarsal joint T2WI o Partial tear: Focal enlargement with high grade discontinuity, hyperintense on FS PD or T2 FSE o Complete rupture: Hyperintense fluid filled gap with proximal tendon retraction o Hyperintense fluid within tendon sheath o Absent tendon at tear site (empty sheath) o Inhomogeneity of associated hemorrhage TI C+ o Enhancement of tendon ends o Enhancement of inflamed sheath
Abbreviations and Synonyms Tibialis anterior tendon rupture
Definitions Rupture between extensor retinaculum and insertion onto medial first cuneiform and adjacent base first metatarsal
General Features Best diagnostic clue: Tendinous gap Location o Between superior and inferior extensor retinaculum o 1.5-3 cm proximal to insertion site Size o Variable based on retraction of torn tendon deep to superior slip of inferior extensor retinaculum o Retraction limited to level of ankle joint secondary to inferior extensor retinaculum Morphology o High grade partial to complete tear (normal width 1 cm) o Mass secondary to protrusion of proximal tendon above inferior retinaculum
-
Imaging Recommendations
mm
Best imaging tool: MR imaging provides greater soft tissue resolution and contrast relative to CT Protocol advice o FS PD FSE in axial and sagittal planes required
DDx: Tibialis Anterior Tendon Tear Midfoot Arthritis
T ~ n oynovitis s
"%
Sag T I Wl MR
Synovttis
- -- ,,*
Ax TZ* CRE MR
Sag FS PD MR
-
TlBlALlS ANTERIOR TENDON TEAR Kev Facts I
Imaging Findings Best diagnostic clue: Tendinous gap Bemeen superior and inferior extensor retinaculum Absent tendon at tear site (empty sheath) Supplement with oblique axial images perpendicular to tendon at level of medial malleolus
Top Differential Diagnoses Partial Tear Versus Complete Tear Peroneal Nerve Palsy Midfoot Arthritis Tenosynovitis Tibiotalar Synovitis
Pathology Spontaneous rupture is rare Forceful contraction against forced plantar flexed foot
Inferior edge of extensor retinaculum as abrading surface with diabetes, gout rupture and rheumatoid arthritis exOstOsis
Clinical Issues Most common signs/symptoms: Weakness with attempted dorsiflexion Local tenderness and foot drop Palpable mass and/or defect Age: Spontaneous rupture - over 45 yrs. (usually > 60) Mechanical irritation
Diagnostic Checklist
Differentiate partial vs. complete rupture using axial
and
images
o Supplement with oblique axial images perpendicular
o Repetitive dorsiflexion and plantar flexion
to tendon at level of medial malleolus o Oblique coronal images parallel to long axis
o Forceful contraction against forced plantar flexed
foot o Rupture proximal to insertion however no zone of
I DIFFERENTIAL DIAGNOSIS Partial Tear Versus Complete Tear Axial oblique and coronal oblique images required
Peroneal Nerve Palsy Extensor hallucis longus + extensor digitorum longus innervated by deep peroneal nerve Peroneus longus + brevis innervated by superficial peroneal nerve
Midfoot Arthritis Sclerosis Erosions Osteophytes
Tenosynovitis Hyperintense fluid surrounding tendon
Tibiotalar Synovitis
hypovascularity documented o Inferior edge of extensor retinaculum as abrading
surface o Steroid injections predispose to rupture o Spontaneous rupture associated with diabetes, gout
and rheumatoid arthritis Epidemiology: 1%of muscle + tendon injuries
Gross Pathologic & Surgical Features Tendon retraction Mass effect produced secondary to tendon protrusion relative to inferior extensor retinaculum Secondary inflammation of adjacent tendon sheaths Hemorrhage Empty tendon sheath Dorsal exostosis
Microscopic Features Peritenonitis inflammatory changes Lack of intrinsic tendon degeneration
Intermediate to hyperintense inhomogeneity in anterior joint capsule
Presentation General Features General path comments o Tendon inserts onto medial cuneiform o Dorsiflexor of the ankle o Invertor of subtalar + metatarsal joint o Blood supply exclusively from anterior tibia1 artery at risk for ischemia o Musculotendinous junction at level of mid to distal third of tibia (tendinosis rare finding at surgery) Etiology o Spontaneous rupture is rare o Plantar flexion places eccentric stress on tibialis anterior
Most common signs/symptoms: Weakness with attempted dorsiflexion Clinical profile o Local tenderness and foot drop o Palpable mass and/or defect o Initial symptoms may be minimal
Demographics Age: Spontaneous rupture - over 45 yrs. (usually > 60) Gender: Male athletes: Runners, soccer players, hikers Activity o Related to eccentric contraction during midfoot and forefoot forced plantar flexion o Mechanical irritation Ski boots and hockey skates
TIBIALIS ANTERIOR TENDON TEAR resonance imaging. Can Assoc Radiol J 46:9-18, 1995 10. Ouzounian TJ et al: Anterior tibial tendon rupture. Foot Ankle 16:406, 1995 11. Bernstein RM: Spontaneous rupture of the tibialis anterior tendon. Am J Orthop 24(4):354-6,1995 12. Barnett T et,al: Anterior tibial tendon rupture. Contemp Orthop 23(4):365-7, 1991 13. Mensor MC et al: Traumatic subcutaneous rupture of the tibialis anterior tendon. J Bone Joint Surg Am 35(30):675-80,1953 14. Moberg E: Subcutaneous rupture of the tendon of the tibialis anterior muscle. Acta Chir Scand 95:455-60, 1947 15. Lapidus PW: Indirect subcutaneous rupture of the anterior tibial tendon. Bull Hosp Joint Dis Orthop Inst 2:119-27, 1941 16. Burman MS: Subcutaneous rupture of the tendon of the tibialis anticus. Ann Surg 100:368-72, 1934
Natural History & Prognosis Diagnosis frequently delayed Critical history may be related to minor injury Association with chronic rupture tibialis posterior tendon History of steroid injections Avulsion fracture medial cuneiform Initially patients adapt gait to compensate Foot slapping Dragging toes Inability to heel walk Eversion of foot with active dorsiflexion 0 Engaged extensor hallucis longus and extensor digitorum longus Complications 0 Progressive flat foot deformity in older patients 0 Equinocavus deformity and Achilles tendon contracture in children
Treatment Conservative o Displacement of tendons < 5 mm osseous fragments 0 Less active or older population treated with below knee non-weight bearing cast Surgical o Young and active population within 3 to 4 months of injury o End-to-end repair o Sliding tendon graft + extension hallucis transfer o Tendon grafts if increased tendon gap (use of extensor digitorum longus, free peroneus brevis for tendon lengthening)
*
20
Consider Differentiate partial vs. complete rupture using axial and coronal oblique images
I
Aydingoz U et al: Spontaneous rupture of the tibialis anterior tendon in a patient with psoriasis. Clin Imaging 26(3):209-11,2002 Lohman M et al: MRI abnormalities of foot and ankle in asymptomatic, physically active individuals. Skeletal Radiol 30(2):61-6,2001 Banks AS et al: McGlamry's comprehensive textbook of foot and ankle surgery. vol 1. 3rd ed. Philadelphia, Lippincott Williams & Wilkins, 1683-705, 2001 Maganaris CN: In vivo measurement-based estimations of the moment arm in the human tibialis anterior muscle-tendon unit. J Biomech 33(3):375-9,2000 Myerson M: Foot and ankle disorders. vol2. Philadelphia, W.B. Saunders Company, 942-71, 2000 Jacobson JA: Musculoskeletal sonography and MR imaging. A role for both imaging methods. Radiol Clin North Am 37(4):712-35, 1999 Khoury NJ et al: Rupture of the anterior tibial tendon: Diagnosis by MR imaging. AJR 167:351, 1996 Aerts P et al: Abnormalities of the foot and ankle: MR imaging findings. Am J Roentgen01 (165):119-24, 1995 Brandser EA et al: Tendon injuries: Application of magnetic
TIBIALIS 'ANTERIOR TENDON TEAR
(Lef)Sagittal graphic shows partial tear of the tibialis anterior tendon (posterior surface). (Right) Axial FS PD FSE MR shows partial tear (arrow) of tibialis anterior tendon with enlargement of cross sectional diameter.
Variant (Z.4)Sagittal T 1 Wl MR shows hypointense ganglion associated with tibialis anterior tendon sheath. (Right) Sagittal FS PD FSE MR shows hyperintense ganglion anterior to tibialis anterior tendon in the absence of tendon fiber disruption.
Variant (Left) Axial FS PD FSE MR shows hyperintense tenosynovitis of the more laterally located extensor digitorum longus tendon (arrow). This could be mistaken for clinical symptoms of tibialis anterior dysfunction. (Right) Axial FS PD FSE MR shows tenosynovitis (arrow) of the tibialis anterior as hyperintense signal secondary to a traumatic eccentric overload stress.
PERONEUS BREVE TENDON TEAR
Axial graphic shows split peroneus brevis tendon posterior to the lateral rnalleolus.
Sagittal FS PD FSE MR shows anterolateral subluxation of split (arrow) peroneus brevis tendon immediately distal to the lateral malleolus.
o Decrease in cross sectional diameter o Anteroposterior separation of split components of
tendon
Abbreviations and Synonyms
o Peroneus longus tendon may interpose between two
Peroneus brevis split tear; peroneus brevis split syndrome
subtendons of brevis o Intermediate signal in degenerative tendon
Definitions Longitudinal split tear within tendon substance Division of tendon into two subtendons
I IMAGING FINDINGS General Features Best diagnostic clue: Split of peroneus brevis tendon into two subtendons Location o Centered at retrofibular groove near distal tip lateral malleolus o Tear extends distally or proximally or both directions Size: Longitudinal tears 2.5 to 5 cm in length Morphology: C-shaped split configuration relative to peroneus longus
MR Findings
1
Imaging Recommendations Best imaging tool: MR preferred over ultrasound Protocol advice: FS PD FSE and T1 or PD axial and sagittal images to detect longitudinal splits (secondary visualization on coronal images)
I DIFFERENTIAL DIAGNOSIS Peroneal Tenosynovitis
TlWI o Hypointense subtendons o Irregular contour
1
T2WI o Fluid hyperintense in association with tenosynovitis o Associated sprain with discontinuity or laxity of superior peroneal retinaculum andlor lateral ligamentous complex o Hyperintense fluid between split subtendons o Clefts within tendon o Split brevis tendon wraps around longus tendon o Attenuated tendons without subtendons in partial tears
Hyperintense fluid with tendon cleft (T2WI) May be associated with tendon degeneration
I
DDx: Peroneous Brevis Tendon Tear Calcaneal Fx
PVNS
FSE MR
-
Retinaculum Tear
0 s Peroneum Abn.
I
I
PERONEUS BREVlS TENDON TEAR Key Facts Imaging Findings
Clinical Issues Most common signs/symptoms: Chronic ankle pain Edema within peroneal sheath Popping and clicking with active foot eversion Pain with peroneal compression test (compression of longus against brevis) Peroneal tendon instability with disruption of superior peroneal retinaculum
Best diagnostic clue: Split of peroneus brevis tendon into two subtendons Centered at retrofibular groove near distal tip lateral malleolus Morphology: C-shaped split configuration relative to peroneus longus Peroneus longus tendon may interpose between two subtendons of brevis
Diagnostic Checklist
Top Differential Diagnoses
Split tendon syndrome may be part of lateral ligamentous injury complex Identify any disruption or laxity of superior peroneal retinaculum and associated tendon instability
Peroneal Tenosynovitis Synovitis Anterolateral Ankle Instability Fractures Painful 0 s Peroneum Syndrome
= Superior peroneal retinaculum (restrains tendon
Synovitis
subluxation or dislocation) inserts into medial and lateral ridges of the tendon sulcus Distal to lateral malleolus, brevis tendon is above calcaneal peroneal tubercle in osseoaponeurotic canal formed by inferior peroneal retinaculum Close relationship of calcaneofibular ligament (CFL) + common peroneal tendon sheath Etiology o Overuse syndrome with repetitive trauma o Chronic injury o Mechanical friction and shearing injury induces degeneration o Degenerative changes precede longitudinal splits o Dynamic injury associated with CFL sprain o Shallow fibular groove o Superior peroneal retinacular laxity o Lateral ligament tears and laxity of superior peroneal retinaculum leads to split and tendon subluxation o Anatomic factors Hypertrophic fibular ridge Peroneus quartus Accessory or anomalous peroneal tendon o Calcaneal friction associated with entrapment or tear Epidemiology o Spontaneous ruptures less common than traumatic o Partial tears more common than complete
Hyperintense fluid and intermediate signal intensity synovium (TZWI) Pigmented villonodular synovitis (PVNS)
Anterolateral Ankle Instability Anterior talofibular rt calcaneofibular ligament tear
Fractures Distal fibula Lateral process talus Anterior process calcaneus Fifth metatarsal base Lateral calcaneal fracture
Retinacular Tear Complete brevis rupture may be associated with reactive calcaneal marrow edema at lateral attachment of inferior peroneal retinaculum (peroneal tubercle) Associated subluxation or dislocation of peroneal tendons with brevis displaced anterolaterally o Stripping of periosteum with superior peroneal retinaculum
Painful 0 s Peroneum Syndrome Displacement or fracture of os peroneum may be associated with peroneus longus dysfunction Associated peroneus longus tear
1 PATHOLOGY
I
General Features General path comments o Relevant anatomy and function Peroneal tendons are lateral stabilizers of the ankle joint = Brevis contributes to eversion Brevis and longus share a common synovial sheath posterior to lateral malleolus Brevis located anterior to longus in retrofibular groove
Gross Pathologic & Surgical Features Synovial proliferation Degenerative tendon Longitudinal split Frayed tendon
Microscopic Features Disruption of fibrillar arrangement Inflammation tendon sheath Mucoid tendon degeneration Increased vascular and fibroblastic growth
Staging, Grading or Classification Criteria Grade I: < 50% cross sectional tendon area Grade 11: > 50% cross sectional tendon area
PERONEUS BREVlS TENDON TEAR [CLINICALISSUES
1
8.
Presentation Most common signs/symptoms: Chronic ankle pain Clinical profile o Insidious onset o Edema within peroneal sheath o Popping and clicking with active foot eversion o Subclinical subluxation 0 Crepitus o Pain with peroneal compression test (compression of longus against brevis)
9. 10. 21,
12.
Demographics
13.
Age: Young adults for spontaneous rupture and athletic trauma; older adults for degenerative tendon splits Gender: Soccer players with indirect and direct trauma without sex bias
14. 15.
Natural History & Prognosis Peroneal tendon instability with disruption of superior peroneal retinaculum Progression of tendon fissuring Frank tendon rupture Concomitant involvement of peroneus longus Stenosing tenosynovitis
Treatment Conservative o Limited immobilization o Antiinflammatory medications o Physical therapy o Orthotics Surgical o Primary anastomosis o Tendon debridement o Excision tenosynovial inflammation
24
Consider Split tendon syndrome may be part of lateral ligamentous injury complex Identify any disruption or laxity of superior peroneal retinaculum and associated tendon instability
1
1.
2. 3. 4. 5. 6.
1
Fitzgerald RA et al: Orthopaedics. St Louis MO, Mosby, (39):942-71, 2002 Banks AS et al: McGlamry's comprehensive textbook of foot and ankle surgery. vol 1. 3rd ed. Philadelphia PA, Lippincott Williams and Wilkins, (33):1091-152, 2001 Myerson MS: Foot and ankle disorders. vol2. Philadelphia PA, WB Saunders, (39):942-71, 2000 DIGiovanni BF et al: Associated injuries found in chronic lateral ankle instability. Foot Ankle Int 21(10):809-15, 2000 Major NM et al: The MR imaging appearance of longitudinal split tears of the peroneus brevis tendon. Foot Ankle Int 21(6): 514-9, 2000 Rademaker J et al: Tear of the peroneus longus tendon: MR ~adiology214(3):700-4, imaging features in nine 2000
7.
Rosenberg ZS et al: MR features of longitudinal tears of the peroneus brevis tendon. AJR 168:141-7, 1997 Schweitzer ME et al: Using MR imaging to differentiate peroneal splits from other peroneal disorders. AJR 168:129-33, 1997 Tjin A et al: MR imaging of peroneal tendon disorders. AJR 168:134-40,1997 Khoury NJ et al: Peroneus longus and brevis tendon tears: MR imaging evaluation. Radio1 2002333, 1996 Geppert MJ et al: Lateral ankle instability as a cause of superior peroneal retinacular laxity: An anatomic and biomechanical study of cadaveric feet. Foot Ankle 14:330, 1993 Mink JH et al: MRI of the foot and ankle. New York, Raven Press 160-171, 1993 Link SC et al: MR imaging of the ankle and foot: Normal structures and anatomic variants that simulate disease. AJR 607-12, 1993 Munk RL et al: Longitudinal rupture of the peroneus brevis tendon. J Trauma 803-6, 1976 Eckert WR et al: Acute rupture of the peroneal retinaculum. J Bone Joint Surg 670-3, 1976
PERONEUS BREVlS TENDON TEAR
I IMAGE GALLERY (Lefc) Sagittal graphic shows peroneus brevis tendon tear with frayed tendon posterior to the lateral malleolus. Associated lateral subluxation of peroneus brevis is identified. (Right) Axial FS PD FSE MR shows split peroneus brevis tendon (arrow) anterior to normal hypointense peroneus longus tendon. Fluid signal is hyperintense.
Typical (Left) Sagittal graphic shows complete rupture of peroneus brevis tendon with avulsion of the inferior peroneal retinaculum. Osseous avulsion of calcaneal fragment from the inferior peroneal tubercle is shown attached to the inferior retinaculum. (Right) Axial FS PD FSE MR shows complete rupture (arrow) of the peroneus brevis tendon.
Variant (hj?) Sagittal graphic shows chronic stenosing tenosynovitis of the peroneal tendons. Thickened and chronically inflamed tendon sheath in red. (Right) Axial PD MR shows chronic stenosing tenosynovitis with intermediate signal granulation tissue encasing (arrow) the peroneus brevis and longus tendons.
I
ANTERIOR TALOFlBULAR LIGAMENT TEAR
Axial T I C+ MR (intraarticular contrast) shows complete tear (arrow) and absence of the ATFL.
Sagittal graphic shows tear of the ATFL.
o Ligament laxity o Thickening (acute + chronic) or attenuation
(chronic) of ligament fibers
Abbreviations and Synonyms
o Irregularity of ligament contours
Anterior talofibular ligament (ATFL) tear; anterior talofibular ligament sprain or injury
Radiographic Findings
Definitions Partial to complete disruption of anterior talofibular ligament fibers
I IMAGING FINDINGS General Features Best diagnostic clue: Loss of normal ligament morphology and/or continuity Location o Along course of ligament from anterior border lateral malleolus to its talar insertion anterior to lateral articular facet o Midsubstance rupture or a talar avulsion Size o Interstitial involvement, avulsion to complete ligamentous disruption of both larger upper and smaller lower band o ATFL: 5 mm width + 12 mm length Morphology o Partial or complete ligament interruption
~adiograph~ o Avulsion fracture distal fibula o Stress radiographs Anterior drawer test: Test for ATFL rupture with > 4 mm anterior displacement of talus relative to tibia Stress inversion test: Test for combined ATFL and calcaneofibular ligament injury using talar tilt comparison Stress applied to plantar flexed talus to evaluate ATFL function
MR Findings TlWI o Change from hypointense to intermediate signal intensity o Interruption of a segment or entire ligament o Blurring of anterior + posterior ligament margins on TlWI o Acute injuries with thickening of ligament or absence of ligament on TlWI
DDx: Anterior Talofibular Ligament Tear Ant. Process Fx
Sag T l Wl MR
Peroneal Disloc.
Cor FS PD MR
A x FS PD MR
I
ANTERIOR TALOFIBULAR LIGAMENT TEAR Key Facts Imaging Findings
Pathology
Best diagnostic clue: Loss of normal ligament morphology and/or continuity Interstitial involvement, avulsion to complete ligamentous disruption of both larger upper and smaller lower band Blurring of anterior + posterior ligament margins on TlWI Acute injuries with thickening of ligament or absence of ligament on TlWI
Top Differential Diagnoses
Anterior Process Fracture Calcaneus
hypoplastic ligament with sharper, more defined ligament margins o Reinjury with continued stress may produce ligament hyperplasia o Avulsed ligament distal fibula avulsion fracture T2WI o Hyperintensity of ATFL along its course in a 45" angle from lateral malleolus to talus o Associated capsular rupture o Extension of hyperintense fluid anterolaterally into soft tissues o Acute tears associated with partial to complete absence of ligament o Subacute to chronic tears may be hyperintense with only mild residual thickening o Intermediate to hyperintense inflamed synovium o Inhomogeneity + hypointense hemosiderin associated with hemorrhage o Hyperintense soft tissue edema adjacent to anterolateral gutter o Bone marrow edema distal fibular or talar insertion o Hyperintense fluid in tibiotalar effusion and adjacent tendon sheaths (peroneal tendons)
Identified on lateral sagittal images adjacent to calcaneocuboid joint
Lateral Process Fracture Talus
*
Visualized on coronal images Symptoms similar to grade I1 or 111 lateral sprain Snowboarders fracture
Osteochondral Lesion of the Talus (OLT) Lesion medial or lateral talar dome Associated with ankle instability
Peroneal Tendon Dysfunction Differential for grade I1 and 111 sprain Displacement peroneus brevis (split) and longus over posterior lateral distal fibula
Fibula Fracture May have associated deltoid ligament injury
Calcaneus and Talar Neck Fractures Differential for grade 111 sprain Tenderness over medial and lateral calcaneal tuberosity Talar neck fracture anterior to tibiotalar joint
Imaging Recommendations Best imaging tool: MRI superior for extent of injury, chronicity + acute ligamentous defects Protocol advice o Requires axial TI or PD and FS PD FSE images o Secondary ligament visualization in lateral sagittal images + coronal images
Navicular Metatarsal Mimics grade I injuries clinically
Most common signs/symptoms: Pain + swelling lateral ankle ATFL tenderness Pop followed by pain + swelling in acute grade I11 Use TlWI or PDWI to increase sensitivity for grade I + I1 ankle sprains
o Chronic instability associated with attenuated or
Stress Fracture
Clinical Issues
Diagnostic Checklist
Stress Fracture Anterior Process Fracture Calcaneus Osteochondral Lesion of the Talus (OLT) Peroneal Tendon Dysfunction
DIFFERENTIAL DIAGNOSIS
Inversion + internal rotation & plantar flexion Grade I: ATFL stretching Grade 11: ATFL partial tear with stretching of CFL Grade 111: Complete tear ATFL and CFL
I PATHOLOGY General Features
I
General path comments o Relevant anatomy ATFL separated into two distinct bands Taut in plantar flexion Lateral collateral ligament complex also includes calcaneofibular ligament (CFL) + posterior talofibular ligament Etiology o Inversion + internal rotation & plantar flexion o Loading ball of foot with landing from a jump or fall o Talus moves anteriorly and is unlocked from mortise in ankle plantar flexion
ANTERIOR TALOFIBULAR LlGAMENT TEAR o ATFL tight in plantar flexion + susceptible to injury
o Arthroscopy to address impingement + osteochondral lesions o Evans procedure: Transposition of entire peroneus brevis through distal fibula o Watson-Jones procedure: Tenodesis of peroneus brevis for single ligament replacement to replace the ATFL o Bronstrom procedure: Suturing with end-to-end ligament repair o Modified Bronstrom: Capsular shift o Bronstrom/Evans: Tenodesis peroneus brevis with fibular tunnel o Christman-Snook procedure (modification of Elmslie repair, with split peroneus brevis tendon instead of fascia lata): Tenodesis of peroneus brevis for a double ligament replacement of ATFL and CFL
vs. CFL which is taut in neutral position o ATFL weakest of lateral collateral ligaments Epidemiology o 85% of ankle sprains occur laterally 0 Represents 12% of emergency room trauma 0 25-50% of lateral sprains occur in running + jumping sports
Gross Pathologic & Surgical Features Ligament fiber disruption + hemorrhage Anterior displacement talus Combined ligament injury with CFL = widening of lateral joint space + medial tilt of talus
Microscopic Features Acute injuries with hyperplastic synovial reaction + hemosiderin Chronic injury either fibrous ingrowth with hyperplastic ligament vs. hypoplastic ligament
Staging, Grading or Classification Criteria
Consider
Use TlWI or PDWI to increase sensitivity for grade I + I1 ankle sprains Evaluate for associated impingement, osteochondral lesion and other ligament injuries
Lateral ankle sprains o Grade I: ATFL stretching o Grade 11: ATFL partial tear with stretching of CFL o Grade 111: Complete tear ATFL and CFL
Presentation Most common signs/symptoms: Pain + swelling lateral ankle Clinical profile o Most common among athletes o ATFL tenderness o Pop followed by pain + swelling in acute grade I11 o Difficult to bear weight on affected ankle in acute grade I1 and I11 o Sense of giving way = functional instability o Joint instability
Demographics Age: 15 to 35 years most common Gender o Males predominate in 15 to 35 year group o Females with higher incidence after 40 years
Natural History & Prognosis Scarred ligament with return of biomechanics Anterolateral impingement Chronic lateral ankle instability
Treatment Conservative o Early functional rehabilitation for acute injuries beginning with immobilization + range-of-motion exercises o Functional CAM walker (controlled ankle motion) for stability + protected weight bearing Surgical o Acute grade I11 sprain + chronic lateral ankle instability o Primary repair
1.
2.
3. 4. 5.
6. 7. 8. 9. 10. 11. 12. 13. 14.
Uys HD et al: Clinical association of acute lateral ankle sprain with syndesmotic involvement: A stress radiography and magnetic resonance imaging study. Am J Sports Med 30(6):816-22,2002 Banks A et al: McGlamry's comprehensive textbook of foot and ankle surgery: Chronic ankle conditions. vol 1. 3rd ed. Philadelphia, Lippincott Williams & Wilkins, 1091-152, 2001 Myerson M: Foot and ankle disorders: Injuries about the ankle: Instability of the ankle and subtalar joint. vol 1. Philadelphia, W.B. Saunders, 1399-419, 2000 Jordan LK 3rd et al: Magnetic resonance imaging findings in anterolateral impingement of the ankle. Skeletal Radio1 29(1):34-9,2000 Tochigi Y et al: Acute inversion injury of the ankle: Magnetic resonance imaging and clinical outcomes. Foot Ankle Int 19(11):730-4, 1998 Colville MR: Reconstruction of the lateral ankle ligaments. J Bone Joint Surg (AM) 76.4:1092, 1994 Rijke AM et al: MRI of lateral ankle ligaments injuries. AM J Sports Med 21527, 1994 Erickson SJ et al: MR imaging of the lateral collateral ligament of the ankle. AJR 156:131, 1991 Kier R et al: MR imaging of the normal ligaments and tendons of the ankle. J Comput Assist Tomogr 15:477-82, 1991 Kannus P et al: Treatment for acute tears of the lateral ligaments of the ankle. J Bone Joint Surg 73A:305-12, 1991 Beltran J et al: Ligaments of the lateral aspect of the ankle and sinus tarsi: An MR imaging study. Radiology 177:455-8, 1990 Kneeland JB et al: MR imaging of the normal ankle: Correlation with anatomic sections. AJR 151:117-23, 1988 Hamilton WG: Foot and ankle injuries in dancers. Clin Sports Med 7(1):143-73, 1988 Perlman M et al: Inversion lateral ankle trauma: Differential diagnosis, review of the literature, and prospective study. J Foot Surg 26(2):95-133, 1987
ANTERIOR TALOFIBULAR LIGAMENT TEAR
(Lejl)Axial FS PD FSE MR shows grade I1 tear (arrow) of the ATFL with ligament thickening and hyperintensity. (Right) Sagittal graphic shows chronically thickened ATFL secondary to grade I1 sprain.
(Lef)Axial FS PD FSE MR shows normal morphology of the ATFL with hyperintense fluid in the lateral gutter. (Right) Axial T2WI MR showing intermediate signal intensity with increased sensitivity on the first echo (left image) of a dual echo sequence in a chronic grade I1 ankle sprain. Ligament is hypointense on second echo image (right).
(Left) Sagittal T l Wl MR shows edema without normal morphology of the ATFL. Associated marrow containing avulsion fragment (arrow) is present anterior to the lateral malleolus. (Right) Axial FS PD FSE MR shows osseous avulsion injury (arrow) with the ATFL attached to the displaced osseous fragment.
I
CALCANEOFIBULAR LIGAMENT SPRAIN
Sagittal graphic shows mid substance tear of the CF ligament.
Axial FS PD FSE MR shows attenuated CFL (arrow) with associated hyperintense edema in a grade /I ligament sprain.
o Irregular ligament contour o Attenuated ligament fibers o Edematous soft tissue mass
Abbreviations and Synonyms CFL sprain; calcaneofibular ligament injury
Definitions Stretching, partial to complete tear of calcaneofibular ligament (CFL)
:{I1
General Features Best diagnostic clue: Loss of normal ligament morphology associated with hyperintense fluid signal intensity on T2WI Location o Along course of ligament from distal lateral malleolus to lateral surface of calcaneus o Midsubstance rupture complex of both anterior talofibular ligament (ATFL) + CFL + intervening capsule -. Size o Cordlike structure o 2 cm length14 to 6 mm diameter Morphology o Partial or complete ligament interruption o Ligament laxity
Radiographic Findings Radiography o Stress radiographyltalar tilt test Varus stress applied with neutral dorsiflexion of talus to isolate CFL function Talar tilt > 18 degrees associated with rupture of ATFL and CFL o Arthrography Leakage of contrast into peroneal tendon sheath up to one week post CFL tear
MR Findings TlWI o Hypointense to intermediate signal intensity ligament o Segmental interruption of ligament o Blurring of medial and lateral margins of ligament o Absence of ligament T2WI o Tenosynovitis o Hyperintense edema surrounding ligament between calcaneus and peroneal tendons o Associated tear of peroneal tendon sheath o Attenuated ligament + adjacent edema or hemorrhage - -
-
DDx: Calcaneofibular Ligament Sprain
Ax FS PD FSE MR
Sag TlWl MR
Ax TlWI MR
Sag T l Wl MR
I
CALCANEOFIBULAR LIGAMENT SPRAIN Key Facts Imaging Findings
Pathology
Best diagnostic clue: Loss of normal ligament morphology associated with hyperintense fluid signal intensity on T2WI Midsubstance rupture complex of both anterior talofibular ligament (ATFL) + CFL + intervening capsule Blurring of medial and lateral margins of ligament
Top Differential Diagnoses ATFL Sprain Anterior Process Fracture Calcaneus Lateral Process Fracture Talus Peroneal Tendon Subluxation/Dislocation Osteochondral Lesion of Talar Dome
o Loss of linear or cordlike morphology o Peroneal retinacular thickening o Associated peroneal tendon subluxation
Imaging Recommendations Best imaging tool o MR for acute, subacute and chronic injuries o Associated lesions of talar dome.. ~eronealtendons and subtalar sinus tarsi ligaments visualized on MRI Protocol advice: Axial FS PD FSE to visualize ligament deep to peroneal tendons
CFL partial or complete tear in combination with complete tear ATFL Peroneal retinacular thickening Edematous mass or synovial reaction + influx of fluid associated with hemorrhage
Clinical Issues
Most common signs/symptoms: Pain + swelling lateral ankle Tenderness at both ATFL and CFL Increased varus tilt of talar dome
Diagnostic Checklist CFL sprain as an associated injury with ATFL tear
Bifurcate Ligament Sprain Associated with plantar flexion-inversion mechanism k Anterior process fracture calcaneus
Fibular Fracture Tenderness at osseous fracture site (not over CF ligament)
L
General Features ATFL Sprain Pain and tenderness anterior to CFL
Anterior Process Fracture Calcaneus Pain isolated to anterior process inferior and distal to sinus tarsi
Lateral Process Fracture Talus Snowboarder'sfracture Tender distal to tip of fibula
Peroneal Tendon Subluxation/Dislocation Pain posterior border fibula
Osteochondral Lesion of Talar Dome Tibiotalar pain referred medial or laterally + osteochondral fracture
Lisfranc Sprain Midfoot dorsal tenderness base of first and second metatarsals
Fracture Base of Fifth Metatarsal Pain, swelling and tenderness distal and inferior to ATFL and CFL
Subtalar Coalition Direct visualization with MRI for talocalcaneal or calcaneonavicular coalition (CN coalition)
General path comments o Relevant anatomy and function = CFL crossed superficially by peroneal tendons and their sheaths = CFL is extracapsular and stabilizes both tibiotalar and subtalar joints = Normal CFL/ATFL angle between 70 and 140 degrees Etiology o Twisting injuries o Dorsiflexion and internal rotation o CFL alignment parallel to tibia in neutral dorsiflexion placing CFL at risk for sprain Epidemiology o CFL second most frequently injured ankle ligament o CFL partial or complete tear in combination with complete tear ATFL
Gross Pathologic & Surgical Features Ligament fiber disruption and hemorrhage Combined ligament injury of ATFL and CFL = widening of lateral joint space + varus tilt of talus Peroneal retinacular thickening Peroneal tenosynovitis
Microscopic Features
Edematous mass or synovial reaction + influx of fluid associated with hemorrhage Chronic scarring with hypoplastic ligament
CALCANEOFIBULAR LIGAMENT SPRAIN Staging, Grading or Classification Criteria Lateral ankle sprains o Grade I = ATFL stretching o Grade I1 = ATFL tear with stretching CFL o Grade I11 = complete tear ATFL and CFL
Presentation Most common signs/symptoms: Pain + swelling lateral ankle Clinical profile o Tenderness at both ATFL and CFL o Increased varus tilt of talar dome o Unstable ankle in acute grade I11 injury o Grade 111 sprain associated with pop followed by severe pain + swelling o Inability to continue physical activity in severe lateral ankle sprains o Ecchymosis
Consider CFL sprain as an associated injury with ATFL tear Axial T2WI using FS PD or T2 FSE best to visualize status of ligament morphology and adjacent hyperintense edema
ISELECTED 1.
2. 3.
4.
Demographics Age: 15 to 35 years most common Gender: Males predominate in 15 to 35 year group
Natural History & Prognosis Scarred ligament Chronic instability with persistent laxity History of frequent ankle sprains: Subtalar injury with associated sinus tarsi ligament injury Associated injuries include osteochondral lesion + peroneal tendon instability 32
5. 6. 7. 8.
Treatment Conservative o Rest, ice, compression, elevation (RICE) o Range of motion o Protected weight bearing o Functional Cam walker for stability o Cast immobilization o Early mobilization with improved stability Surgical o Acute grade 111 sprains or chronic instability o Primary repair - acutelsubacute disruption o Ligament reconstruction - chronic instability: Evans, Watson-Jones, Elmslie, Chrisman and Snook Evans: Transposition of entire peroneus brevis through distal fibula Watson-Jones procedure: Reconstruction with peroneus brevis tenodesis to replace ATFL without anatomic replacement of CFL Modified Watson-Jones: Use of split peroneus longus tendon, split peroneus brevis, plantaris tenodesis (or graft) and split Achilles tenodesis Elmslie-fascia lata graft to replace or augment ATFL and CFL (more anatomic than modified Watson-Jones) Chrisman and Snook-modification of Elmslie repair with split peroneus brevis tendon instead of fascia lata to replace the ATFL and CFL (more anatomic than modified Watson-Jones) Modified Brostrom repair - primary tendon repair + augmentation using extensor retinaculum
9. 10. 11. 12. 13. 14. 15. 16.
REFERENCES
DeLee JC et al: Orthopaedic sports medicine. Principles and practice. Ligament injuries of the foot and ankle in the athlete. vol2. 2nd Ed. Philadelphia PA, Saunders, (E):2323-71, 2003 Fitzgerald RH et al: Orthopaedics. Ligament injuries of the foot and ankle. St. Louis, Missouri, Mosby Inc, 1607-21, 2002 Uys HD et al: Clinical association of acute lateral ankle sprain with syndesmotic involvement: A stress radiography and magnetic resonance imaging study. Am J Sports Med 30(6):816-22, 2002 Banks A et al: McGlamry's comprehensive textbook of foot and ankle surgery. Chronic ankle conditions. vol 1. Philadelphia PA, Lippincott Williams & Wilkins (35):1091-152, 2001 Kreitner KF et al: Injuries of the lateral collateral ligaments of the ankle: Assessment with MR imaging. Eur Radiol 9(3):519-24, 1999 Tochigi Y et al: Acute inversion injury of the ankle: Magnetic resonance imaging and clinical outcomes. Foot Ankle Int 19(11):730-4,1998 Zanetti M et al: Magnetic resonance imaging of injuries to the ankle joint: Can it predict clinical outcome? Skeletal Radiol 26(2):82-8,1997 Nishimura G: Trabecular trauma of the talus and medial malleolus concurrent with lateral collateral ligamentous injuries of the ankle: Evaluation with MR imaging. Skeletal Radiol 25(1):49-54, 1996 Chandnani VP et al: Chronic ankle instability: Evaluation with MR arthrography, MR imaging, and stress radiography. Radiology 192(1):189-94,1994 Mink JH et al: MRI of the foot and ankle. Ligaments of the ankle. New York, Raven Press, 173-8, 1992 Schneck CD et al: MR imaging of the most commonly injured ankle ligaments. Part I. Normal anatomy. Radiology 499-506, 1992 Schneck CD et al: MR imaging of the most commonly injured ankle ligaments. Part 11. Ligament injuries. Radiology 507-12, 1992 Kannus et al: Treatment for acute tears of the lateral ligaments of the ankle. J Bone Joint Surg 305-12, 1991 Erickson SJ et al: MR imaging of the lateral collateral ligament of the ankle. AJR 131-6,1991 Kier R et al: MR imaging of the normal ligaments and tendons of the ankle. J Comput Assist Tomogr 477-82, 1991 Beltran J et al: Ligaments of the lateral aspect of the ankle and sinus tarsi: An MR imaging study. Radiology 455-8, 1990
CALCANEOFIBULAR LIGAMENT SPRAIN
(Left) Axial T1 WI MR shows edema associated with CFL sprain deep to the peroneal tendons. (Right) Axial FS PD FSE MR shows intact CFL (arrow) fibers status post grade 1 sprain.
(Left) Axial T2* CRE MR shows absent CFL (arrow) in a severe lateral ligamentous sprain. (Right) Axial T2" CRE MR shows associated lateral ligamentous complex injury with torn ATFL.
Typical
(kft)Coronal TI C+ MR (intraarticular contrast) shows normal oblique orientation of the CFL (arrow) in the coronal plane. (Right) Axial T I C+ MR (intraarticular contrast) shows normal linear morphology of CFL (arrow) deep to the peroneus brevis and longus tendons.
DELTOID LIGAMENT SPRAIN
Coronal graphic shows partial tear of the superficial and deep layers of the deltoid ligament.
Axial FS PD FSE MR shows hyperintensity and inhomogeneity (arrow) of the deltoid ligament fibers.
o Complete disruption of fiber morphology with
absent ligament less common
Abbreviations and Synonyms
Radiographic Findings
Deltoid ligament tear; medial ankle sprain
Definitions Partial or complete disruption of deltoid ligaments fibers
General Features Best diagnostic clue: Interstitial hyperintensity on T2WI Location: Midsubstance close to medial malleolus Size o Superficial component longer than deep with tibiocalcaneal ligament 2 cm length and 1 cm wide at insertion o Deep component shorter with small anterior component + strong posterior talotibial ligament 1.5 cm length, 1.5 cm width and 1.0 cm thickness at origin Morphology o Superficial layer: Wide triangular ligaments o Deep layer: Conical posterior talotibial ligaments
Radiography o Weight bearing o Associated malleolar fracture o Osteochondral lesion o Avulsion fracture o Deltoid ossification o Increased medial clear space o Stress radiograph Valgus stress test with anteroposterior radiograph Valgus tilt greater than 2 degrees with deltoid ligament injury o Arthrography - not commonly used Leakage at level of medial malleolus in partial deltoid rupture
M R Findings TlWI o Interstitial intermediate signal intensity o Loss of fiber striation o Medial malleolus fracture o Hypointense medial malleolus subchondral edema o Marrow containing ligament ossification o Talar displacement laterally or posterolaterally o Coronal images to separate superficial from deep layer sprains
DDx: Deltoid Ligament Sprain Med~alMall. Fx
Synovial lmping.
3-
TP Teno~vnnvrhs
__-'
1 ~ : -= ' I
Sag T1WI MR
Cor FS P D FSE
Ax FS P D FSE
Sag FS P D MR
Ax FS P D FSE MR
DELTOID LIGAMENT SPRAIN Kev Facts I
Imaging Findings Best diagnostic clue: Interstitial hyperintensity on T2WI Loss of fiber striation iffu use amorphous hrperintensity on FS PD and T2 FSE Mass-like morphology in disruption with associated edema, hemorrhage and granulation tissue
Top Differential Diagnoses Normal Deltoid Ligament Fracture Impingement Tibialis Posterior (TP) Tendon Dysfunction
Pathology
End stage of supination external rotation injury Partial tear more common than complete ligamentous disruption
Clinical Issues ~ o scommon t signs/symptoms: Swelling and tenderness over deltoid ligaments + surrounding soft tissue Anteromedial or medial pain Medial sprains more paiiful than lateral sprains Associated lateral ligamentous injury, fibular fracture and/or syndesmosis injuries
Diagnostic Checklist Correlate axial and coronal images to define extent of injury in superficial and deep layers of deltoid
Increased load: Deep deltoid ligament last to fail o Loss of detail in individual ligamentous components
on medial sagittal image through superficial layer o Absence of ligamentous fibers o Osseous degenerative change medial malleolar talar articulation T2WI o Diffuse amorphous hyperintensity on FS PD and T2 FSE o Indistinct margins and loss of fiber striation especially talotibial (tibiotalar) fibers of deep layer o Axial + coronal images to separate superficial from deep layer sprains o Mass-like morphology in disruption with associated edema, hemorrhage and granulation tissue o Axial FS PD FSE to assess associated tendon and neurovascular structures o Fluid-filled gap in complete disruption T1 C+: Useful in peripherally enhancing partial tears, synovi and inflammatory fluid collections
lmaging Recommendations Best imaging tool: MR superior to CT and ultrasound Protocol advice o Axial T1 or PD and FS PD FSE and coronal FS PD FSE image for partial or complete ligament tears o Superficial layer of deltoid seen on coronal images or on a single medial sagittal image with TI, PD or FS PD FSE sequence
I DIFFERENTIAL DIAGNOSIS Normal Deltoid Ligament Interposed fatty tissue Partial volume of periligamentous fatty or fibrocartilaginous tissue
Fracture Medial malleolus fracture may be isolated or associated with deltoid ligament injury Edema and fracture line on coronal and sagittal images
Impingement Anterior or medial soft tissue impingement
Synovial thickening and fluid on FS PD FSE axial images
Tibialis Posterior (TP) Tendon Dysfunction Tenosynovitis, degeneration and tear on axial images
Accessory Ossification Center Accessory navicular medially Hyperintense edema across synchondrosis Degenerative changes across synchondrosis
General Features General path comments o Superficial layer Superficial anterior tibiotalar Tibionavicular Tibioligamentous (tibiospring) Tibiocalcaneal Superficial posterior tibiotalar o Deep layer m Small anterior component: Anterior talotibial (tibiotalar) Strong posterior talotibial (tibiotalar) Etiology o Increased load: Deep deltoid ligament last to fail o Associated with ankle fractures o Abduction (deep deltoid injury) o External rotation (anterior deltoid injury) o Eversion o End stage of supination external rotation injury o Significant ankle trauma Epidemiology o 10 to 15% of all ankle sprains o Less frequent than lateral injury o 10% have associated syndesmosis injury o Isolated injury rare
.. .
Gross Pathologic & Surgical Features Weakest to strongest components o Tibiocalcaneal, tibionavicular, tibiospring and posterior tibiotalar
DELTOID LIGAMENT SPRAIN
*
Disruption of tibiocalcaneal fibers of superficial layer results in talocrural increase contact pressure and decrease contact area Medial malleolus fracture with posterior deep tibiotalar (talotibial) ligament tear Partial tear more common than complete ligamentous disruption Hemorrhage Increased valgus talar tilt
o Delayed primary repair o Ligament reconstruction with tendon transfer or
graft
Consider Associated injury to lateral ligamentous complex Assess medial malleolus Correlate axial and coronal images to define extent of injury in superficial and deep layers of deltoid
Microscopic Features Acute injuries with hyperplastic synovial reaction and hemosiderin Chronic injury with fibrous ingrowth or scar
Staging, Grading or Classification Criteria Grade I - stretch injury
1.
Grade I1 - partial tear Grade 111 - complete ligamentous disruption 2.
Presentation Most common signs/symptoms: Swelling and tenderness over deltoid ligaments + surrounding soft tissue Clinical profile o Anteromedial or medial pain 0 Blister formation o Gross deformity 0 Ecchymosis o Medial sprains more painful than lateral sprains o Tender over deltoid + distal tip medial malleolus o Mechanical instability
Demographics Age: 15 to 35 years most common Gender o Males predominates in 15 to 35 year group o Females with higher incidence after 40 years
Natural History & Prognosis Associated lateral ligamentous injury, fibular fracture and/or syndesmosis injuries Fullness in region of retromalleolar tendons secondary to chronic irritation and inflammation Widened ankle mortise more common with deltoid injuries with preexisting lateral complex injuries Alignment and translation deformity Chronic medial ankle pain + instability Heals in lengthened position Deltoid ossification
Treatment Conservative o Rest, ice, compression and elevation (RICE) o Range of motion o Protected weight bearing o Grade 111 requires complete immobilization with short leg cast Surgical 0 Infrequently used o Debride symptomatic anterior deltoid ossicle 0 Imbrication
3.
4.
5.
6. 7. 8. 9. 10. 11. 12. 13.
DeLee JC et al: Orthopaedic sports medicine. Principles and practice: Ligament injuries of the foot and ankle in the athlete. vol 1. 2nd ed. Philadelphia, Elsevier Science, 2323-91, 2003 Fitzgerald RH et al: Orthopaedics: Ligament injuries of the foot and ankle. 2nd ed. Philadelphia, J.B. Lippincott Company, 1607-21,2002 Banks A et al: McGlamry's comprehensive textbook of foot and ankle surgery: Chronic ankle conditions. vol 1. 3rd ed. Philadelphia Lippincott, Williams & Wilkins,1091-152, 2001 Tochigi Y et al: Acute inversion injury of the ankle: Magnetic resonance imaging and clinical outcomes. Foot Ankle Int 19(11):730-4,1998 Ego1 KA et al: Impingement syndrome of the ankle caused by a medial meniscoid lesion. Arthroscopy 13(4):522-5, 1997 Klein MA: MR imaging of the ankle: Normal and abnormal findings in the medial collateral ligament. AJR 162(2):377-83,1994 Deutsch AL et al: MRI of the foot and ankle: Ligaments of the ankle. New York, Raven Press, 173-8, 1992 Schneck CD et al: MR imaging of the most commonly injured ankle ligaments. Part I. Normal anatomy. Radiology 184:499-506, 1992 Schneck CD et al: MR imaging of the most commonly injured ankle ligaments. Part 11. Ligament injuries. Radiology 184:507-512, 1992 Kier R et al: MR imaging of the normal ligaments and tendons of the ankle. J Comput Assist Tomogr 152477-482, 1991 Kneeland JB et al: MR imaging of the normal ankle: Correlation with anatomic sections. AJR 151:117-123, 1988 Siegler S et al: The mechanical characteristics of the collateral ligaments of the human ankle joint. Foot Ankle 8:234-42, 1988 Perlman M et al: Inversion lateral ankle trauma: Differential diagnosis, review of the literature, and prospective study. J Foot Surg 26(2):95-133,1987
DELTOID LIGAMENT SPRAIN
/ IMAGE GALLERY Tvaical (Lefl) Coronal FS PD FSE MR shows partial tear (arrow) of deep fibers of the deltoid. (Right) Sagittal graphic with partial tearing of the tibiocalcaneal and superficial posterior tibiotalar components of the superficial deltoid.
Typical (Lqfr) Coronal FS PD FSE MR shows osteochondral lesion of the lateral talus in association with a grade 11 deltoid sprain (arrow). Medial malleohr and tahr edema is hyperintense. (Right) Axial FS PD FSE MR shows complete disruption of both the medial (arrow) and lateral ligamentous complexes.
Typical (Left) Axial T 1 Wl MR shows chronic deltoid tear with absent ligament and marrow containing osseous avulsion (arrow). Note lack of deltoid ligament striations deep to the tibialis posterior tendon. (Right) Coronal FS PD FSE MR shows avulsed fracture (arrow) of the medial malleolus with osseous displacement. Superficial component of the deltoid ligament is attached to the displaced medial malleolus.
SYNDESMOSIS S P R A I N
Coronal graphic shows anterior syndesmotic (anterior inferior tibiofibular) ligament tear.
Axial FS PD FSE MR shows syndesmotic ligament disruption (arrow) associated with disruption of medial ankle ligaments.
o PITF
Thick band
= Quadrilateral shape
Abbreviations and Synonyms
Transverse tibiofibular ligament (deep and inferior component) True posterior labrum Interosseous membrane Short fibrous bands
Syndesmotic injury; tibiofibular diastasis, high ankle sprain
Definitions Stretching, partial tear or tear of distal tibiofibular syndesmotic ligaments
General Features Best diagnostic clue: Associated fluid and ligamentous edema of syndesmotic ligaments Location o Anterior inferior tibiofibular (AITF) ligament o Posterior inferior tibiofibular (PITF) ligament o Transverse tibiofibular ligament o Interosseous membrane Size: Diastasis of 2.3 mm to 7.3 mm Morphology o AITF Flat band Two or three bands Multifascicular 20% intraarticular
Radiographic Findings Radiography o Weight-bearing views o Medial clear space on mortise view (normal < 4 mm) o Syndesmotic clear space on anteroposterior (AP) and mortise (normal < 6 mm) o Tibiofibular overlap on AP or mortise (normal > 6 mm) o Stress testing for dysfunction and instability o External rotation stress test = widening of mortise
CT Findings NECT More sensitive for 1 to 3 mm diastasis compared to radiographs
MR Findings TlWI o Intermediate signal intensity and blurring syndesmotic ligaments o Lateral fibular subluxation
-
Ax T I WI MR
Ax FS PD FSE MR
Ax FS PD FSE MR
SYNDESMOSlS SPRAlN Key Facts Imaging Findings Best diagnostic clue: Associated fluid and ligamentous edema of syndesmotic ligaments Size: Diastasis of 2.3 mm to 7.3 mm Contour irregularity of syndesmotic ligaments (AITF or PITF) Fluid hyperintensity and diastasis of AITF and PITF on T2WI
Top Differential Diagnoses Lateral Ankle Instability Fibular Fracture Compartment Syndrome Posterior Impingement
o Calcification interosseous membrane o Fibular shortening
o Tibiofibular diastasis T2WI o Ligament thickening: Increased anteroposterior (AP) dimension of anterior or posterior syndesmotic ligament o Intraligamentous hyperintensity o Contour irregularity of syndesmotic ligaments (AITF or PITF) o Frank discontinuity of ligaments o Fluid hyperintensity and diastasis of AITF and PITF on T2WI o Interosseous membrane linear hyperintensity o Interosseous membrane hemosiderin, fibrosis or calcification
Imaging Recommendations Best imaging tool: MR to identify anterior and posterior syndesmotic ligaments Protocol advice: Axial FS PD FSE
I DIFFERENTIAL DIAGNOSIS Lateral Ankle Instability Positive anterior drawer and talar tilt Tear of ATFL and calcaneofibular ligament (CFL) Synovitis MR documents intact syndesmotic ligaments
Fibular Fracture Point tenderness over lateral malleolus
Compartment Syndrome Pain out of proportion to injury
Posterior Impingement Synovitis of posterior ankle ligaments
Pathology Abduction, external rotation and dorsiflexion of anklellower leg Substantial tearing AITF, PITF and interosseous membrane
Clinical Issues Most common signs/symptoms: Severe pain with external rotation Pain anterolateral leg Palpable tenderness over syndesmosis Age: Young personslhigh-contact athletic injuries
Diagnostic Checklist
Evaluate congruity and diastasis of syndesmosis on axial images
1 PATHOLOGY General Features Etiology o Abduction, external rotation and dorsiflexion of anklellower leg o Relevant causative factors Football Soccer Basketball o Complication of fractures Epidemiology o Syndesmotic injuries: 10% to 20% of ankle sprains o Second most common ankle injury after lateral ligament injury AITF o Oblique from anterior inferior lateral malleolus to anterolateral tubercle tibia o Contacts lateral ridge talar trochlear surface in plantarflexion PITF 0 Posterior lateral malleolus to posterolateral tibial tubercle o Transverse tibiofibular ligament: Deep and inferior to PITF From fibular tubercle + digital fossa to posterior tibial articular surfacelmedial border medial malleolus True posterior labrum: Projects below posterior tibial margin o Tibia1 slip: Posterior talofibular ligament to posterio tibia + transverse tibiofibular ligament o Interosseous membrane Medial distal fibular shaft to lateral distal tibia Vault over tibiofibular synovial recess
Gross Pathologic & Surgical Features Substantial tearing AITF, PITF and interosseous membrane Hemorrhage Associated bi- and tri-malleolar fractures Fibular subluxation Plastic deformation fibula
SYNDESMOSIS SPRAlN Posterior rotation and subluxation fibula Talus dislocated superiorly
Evaluate congruity and diastasis of syndesmosis on axial images
Microscopic Features ~emorrhagiccellular elements Soft tissue hyperplasia Heterotopic calcification
(SELECTED REFERENCES 1.
Staging, Grading or Classification Criteria Clinical o Grade I: Stretch o Grade 11: Partial tear o Grade 111: Complete rupture Frank diastasis: Identified on unstressed radiographs Latent diastasis: Identified on stress radiographs Radiologic types of frank injuries o Type I: Straight lateral fibular subluxation and increased medial clear space o Type 11: Straight lateral fibular subluxation and plastic/angul& deformation fibula o Type 111: Posterior rotation and subluxation distal fibula o Type IV: Talus dislocated superiorly and increased intermalleolar distance
2.
3. 4.
5.
6.
7. 8.
Presentation
40
Most common signs/symptoms: Severe pain with external rotation Clinical profile o Pain anterolateral leg o Palpable tenderness over syndesmosis o pain on squeeze test of fibula and tibia o Swollen leg o Mild pain over ATFL and CFL o Instability o Unable to bear weight o Muscular splintingtreflex spasm
Demographics Age: Young personsthigh-contact athletic injuries Gender: Male predominance
Natural History & Prognosis Chronic instability of distal tibiofibular syndesmosis Reduction of syndesmosis necessary to minimize dysfunction and arthritis Tibiofibular joint snapping Syndesmotic impingement: Inflamed synovium, AITF scarring, talar chondromalacia and osteophytes
Treatment Open reductiontinternal fixation Repair AITF using plantaris or peroneal tendons Arthrodesis for severe pain & degenerative changes
I DIAGNOSTIC CHECKLIST Consider In more severe ankle sprains MRI to document disruption of AITF, PITF or interosseous membrane
9. 10. 11. 12.
1
DeLee JC et al: Orthopaedic sports medicine. Principles and practice: Ligament injuries of the foot and ankle in the athlete. vol 2. 2nd ed. Philadelphia, Saunders, 2323-75, 2003 Uys HD et al: Clinical association of acute lateral ankle sprain with syndesmotic involvement: A stress radiography and magnetic resonance imaging study. Am J Sports Med 30(6):816-22,2002 Banks A et al: McGlamry's comprehensive textbook of foot and ankle surgery. vol 1. Philadelphia, Lippincott Williams & Wilkins, 1091-152, 2001 Ogilvie-Harris DJ et al: Disruption of the ankle syndesmosis: Diagnosis and treatment by arthroscopic surgery. Arthroscopy 10561, 1994 Schneck CD et al: MR imaging of the most commonly injured ankle ligaments. Part I. Normal anatomy. Radiology 184:499, 1992 Mink JH: MRI of the foot and ankle: Ligaments of the ankle. New York, Raven Press, 185-9, 1992 Schneck CD et al: MR imaging of the most commonly injured ankle ligaments. Part 11. Ligament injuries. Radiology 184:499-506, 1992 Erickson SJ et al: MR imaging of the lateral collateral ligament of the ankle. AJR 156:131-6, 1991 Noto A et al: MR imaging of the ankle: Normal variants. Radiology 170:121-4, 1989 Fritschy D: An unusual ankle injury in top skiers. Am J Sports Med 17(2):282, 1989 Sclafini S: Ligamentous injury of the lower tibiofibular syndesmosis: Radiographic evidence. Radiology 56:21-7, 1985 Monk C: Injuries to the tibo-fibular ligaments. J Bone Joint Surg 51B:330-7, 1969
IMAGE GALLERY Typical (I&) Axial FS PD FSE MR shows discontinuity (arrow) of anterior syndesmotic ligament (anterior inferior tibiofibular ligament) with associated hyperintense contusion of the medial malleolus. (Right) Sagittal graphic shows disruption of both the anterior and posterior syndesmotic ligaments.
(Left) Axial FS PD FSE MR shows posttraumatic ganglion cyst (arrow) formation adjacent to anterior syndesmotic ligament tear. (Right) Axial FS PD FSE MR shows linear fluid collection (arrow) anterior to partial tear of the anterior syndesmotic ligament.
(Left) Axial FS PD FSE MR shows normal hypointense anterior inferior tibiofibular ligament (arrow). This ligament may be divided into two or three bands or may be multifascicular. (Right) Surgical pa thology shows location of the oblique course of the anterior syndesmotic ligament (anterior inferior tibiofibular ligament at tip of probe).
I
1
ANTEROLATERAL IMPINGEMENT
Coronal graphic shows anterolateral soft tissue impingement with synovitis (red), fibrosis, and chondromalacia in the anterolateral gutter. Small ossicle is located deep to the ATFL.
Axial FS PD FSE MR shows hypertrophic synovial tissue anterior to and within the lateralgutter.
MR Findings Abbreviations and Synonyms Anterolateral impingement syndrome; anterolateral soft tissue impingement
Definitions Synovitis and fibrosis of anterior inferior tibiofibular ligament (AITF), anterior talofibular ligament (ATFL) and lateral gutter 4:'
I IMAGING FINDINGS
u
General Features
-
~ e sdiagnostic t clue: Soft tissue thickening anterior aspect lateral gutter T
..--L:..-
LULdLlUll
o AITF
o Lateral gutter o ATFL Size: Variable synovitis, fibrosis, chondromalacia relative to lateral gutter Morphology o Thickened adhesive bands and synovium o Osteophytes o Loose bodies o Meniscoid-shaped lesion
II
I
TlWI o Hypointense to intermediate signal intensity in anterolateral gutter o Effacement of fat signal anterior to AITF o Hypointense fluid to intermediate signal synovium deep to AITF o Hypointense ossicle/loose body in soft tissues at tip of fibula T2WI o Intermediate signal intensity hyalinized mass o Associated injury to AITF and ATFL o Hyperintense fluid and intermediate signal seovium anterolateral gutter o Hypointense fibrosislscar band o Talar chondromalacia - denuded intermediate signal chondral surface o Hypointense loose body surrounded by hyperintense fluid TI C+: Enhanced synovium
Imaging Recommendations Best imaging tool o MR superior o Radiographs, bone scan, CT often negative Protocol advice: Axial FS PD FSE and FS T1 C+
DDx: Anterolateral Impingement ATFl T ~ a r
Sinus Tarsi SVR.
AXFSPDFSEMR
Cor FS PD MR
Sag FS PD MR
AX FS PD FSE MR
1
ANTEROLATERAL IMPINGEMENT Key Facts Imaging Findings Best diagnostic clue: Soft tissue thickening anterior aspect lateral gutter Size: Variable synovitis, fibrosis, chondromalacia relative to lateral gutter Thickened adhesive bands and synovium Associated injury to AITF and ATFL
Top Differential Diagnoses Retracted ATFL Tear Sinus Tarsi Syndrome Pigmented Villonodular Synovitis (PVNS) Idiopathic Synovial (Osteo) Chondromatosis Ganglion Cysts Osteochondral Lesion of Talus (OLT)
I DIFFERENTIAL DIAGNOSIS Retracted ATFL Tear Without synovitis/fibrosis
Sinus Tarsi Syndrome Pathology of sinus tarsi ligaments Synovitis/ligament tearing
Pigmented Villonodular Synovitis (PVNS) Hemosiderin/intermediate signal tissue: Diffuse or nodular
Idiopathic Synovial (Osteo) Chondromatosis Multiple loose bodies not restricted to anterolateral gutter
Ganglion Cysts T2WI - focal hyperintense cyst Osteochondral Lesion of Talus (OLT) MR sensitive and specific for talar subchondral sclerosis, edema and cystic change
General Features General path comments 0 Relevant anatomy AITF ATFL Syndesmosis Lateral gutter Etiology o Posttraumatic with plantar flexion inversion most common o Synovial and capsular irritation 0 Infection 0 Rheumatologic 0 Degenerative Epidemiology o Subset of inversion injury population o True meniscoid lesion less common
. ..
Pathology Posttraumatic with plantar flexion inversion most common Partial/complete tear AITF or ATFL Synovial hyperplasia and compression
Clinical Issues Most common signs/symptoms: Vague pain anterolateral ankle Tenderness along syndesmosis + anterior gutter Inflammatory tissue lateral gutter + syndesmosis between tibiatfibula
Diagnostic Checklist Contrast to enhance scarlfibrosis
D
20-40% occur post ankle sprain = chronic ankle pain
Gross Pathologic & Surgical Features Partial/complete tear AITF or ATFL Intraarticular hemorrhage Synovial hyperplasia and compression Entrapment synovial membrane Hyalinized scarlmeniscoid lesions o Hyalinized tissue post lateral sprain o Synovial impingement lesion o Attached to anteroinferior talofibular joint capsule o Extension into lateral gutter o Fibrocartilaginous consistency o 5 mm width o Anterior to fibula o Between lateral talus + distal medial fibula o Associated with synovitis, chondromalacia + osteophytes o Morphology similar to hypertrophic synovitis Chondral erosion lateral talar dome
Microscopic Features Synovial hyperplasia Subsynovial capillary proliferation Hyaline cartilage degenerative change/fibrosis Chronic inflammatory process Absence of ligamentous tissue on histology
Presentation Most common signs/symptoms: Vague pain anterolateral ankle Clinical profile o Pain absent at rest o Pain with activitylcutting + pivoting movement o Tenderness along syndesmosis + anterior gutter o +/- Tenderness posterior subtalar joint + sinus tarsi
Demographics Age: Younger population post inversion injury to lateral ligament
ANTEROLATERAL IMPINGEMENT Gender: Male predominance in athletic population
Natural History & Prognosis Heterotropic bone interosseous space Ossicles at tip of fibula and talar dome Chronic lateral ankle pain Inflammatory tissue lateral gutter + syndesmosis between tibia/fibula
Treatment Conservative o Physical therapy o NSAIDs Surgical o Arthroscopic with shavers, burrs, graspers and baskets o Debridement: Removing inflamed synovium, thickened adhesive bands, osteophytes and loose bodies o Involved tissue excised down to underlying cartilage o Removal synovium and inflamed capsular and ligamentous tissue o ATFL remnant not excised Post surgical splint CAM walker
I DIAGNOSTIC CHECKLIST Image Interpretation Pearls
~ x i aimages l to identify synovitis anterior + posterior to ATFLIAITF Contrast to enhance scarlfibrosis Identify associated talar chondral erosions
1 SELECTED REFERENCES Robinson P et al: Soft-tissue and osseous impingement syndromes of the ankle: Role of imaging in diagnosis and management. Radiographics 6:1457-69, 2002 Banks A et al: McGlamry's comprehensive textbook of foot and ankle surgery. Philadelphia PA, Lippincott Williams & Wilkins, 1091-152, 2001 Robinson P et al: Anterolateral ankle impingement: MR arthrographic assessment of the anterolateral recess. Radiology 221(1):186-90, 2001 Trnka HJ et al: Arthrography of the foot and ankle. Ankle and subtalar joint. Foot Ankle Clin 5(1):49-62,2000 DIGiovanni BF et al: Associated injuries found in chronic lateral ankle instability. Foot Ankle Int 21(10):809-15, 2000 Rosenberg ZS et al: From the RSNA refresher courses, Radiological Society of North America. MR imaging of the ankle and foot. Radiographics 20 (Spec No:S153-79): Review, 2000 Jordan LK 3rd et al: Magnetic resonance imaging findings in anterolateral impingement of the ankle. Skeletal Radio1 29(1):34-9,2000 Akseki D et al: The distal fascicle of the anterior inferior tibio-fibular ligament as a cause of anterolateral ankle impingement: Results of arthroscopic resection. Acta Orthop Scand 70(5):478-82, 1999 Farooki S et al: Anterolateral imuinaement of the ankle: Effectiveness of MR imaging. ~ a d i z 207(2):357-60, o ~ ~ 1998 10. Skib RA: Anterolateral soft tissue impingement of the ankle. Radiology 209(3):855, 1998 11. Resnick D et al: Internal Derangement of Joints. Emphasis
12. 13. 14. 15. 16. 17. 18.
on MR Imaging. Philidelphia PA, WB Saunders. Chap 17, 1997 Rubin DA et al: Anterolateral soft-tissue impingement in the ankle: Diagnosis using MR imaging. AJR 169(3):829-35, 1997 Mink JH: MRI of the foot and ankle. Ligaments of the ankle. New York, Raven Press, 178-185, 1992 Bassett F et al: Talar impingement by the anteroinferior tibiofibular ligament. J Bone Joint Surg 72A:55-59, 1990 Martin D et al: Operative ankle arthroscopy. Long term follow-up. Am J Sports Med 17(1):16-23,1989 Martin D et al: Arthroscopic treatment of chronic synovitis of the ankle. Arthroscopy 5(2):110-14,1989 Ferkel R et al: Progress in ankle arthroscopy. Clin Orthop Re1 Res 210-20, 1988 McCarrol J et al: Meniscoid lesions of the ankle in soccer players. Am J sports Med 15:255-7, 1987
1
ANTEROLATERAL lMPlNCEMENT
I IMAGE GALLERY
7 (L@) Axial FS PD FSE MR shows hyperintense synovitis anterior (arrow) and posterior to the ATFL. (Right) Axial T2WI MR shows synovitis in area of previous ATFL disruption.
Typical (Left) Axial T l Wl MR shows soft tissue thickening (arrow) and scar tissue corresponding to ATFL sprain. (Right) Axial PD FSE MR shows hyperintense edema and thickening in area of previous ATFL sprain.
Typical
(Left) Axial FS PD FSE MR shows scarred ATFL (arrow) with fluid and synovitis anterior and posterior to its fibers. (Right) Coronal surgical pathology shows location for anterolateral impingement at the level of the anterior aspect of the lateral gutter. Absent ATFL is indicated.
ANTERIOR IMPINGEMENT
Sagittal graphic shows anterior spur formation of the anterior tibial plafond and dorsal surface talar neck. ( I ) capsular contraction (2) and Achilles tendon shortening (3) are associated.
Sagittal T l W l MR shows hypointense sclerotic anterior osteophytes of the tibia and talus contributing to anterior tibiotalar impingement.
o Less sensitive for associated effusion, chondral
surfaces and marrow changes
Abbreviations and Synonyms Anterior impingement syndrome; athlete's or football player's ankle
Definitions Spur formation anterior inferior tibial plafond + talar neck
General Features Best diagnostic clue: Distal anterior tibial osteophyte Location: Between anterior surface tibia and superior aspect neck of talus Size: Osteophyte greater than 1 cm in grade 3 and 4 lesions Morphology: Triangular shaped osteophyte - tibia side spur with narrower base than talar spur
Radiographic Findings Radiography: Anterior tibial exostosis on lateral radiograph
CT Findings
MR Findings TlWI o Low signal intensity osteophytes o Fat signal intensity osteophytes o Intermediate signal fluid + synovium between tibial osteophyte and talus at capsular attachment o Hypointense subchondral sclerosis T2WI o Low to intermediate signal osteophytes o Hyperintense tibiotalar effusion o Intermediate to hyperintense fluid + synovium adjacent to anterior talar neck o Hyperintense talar + anterior distal tibial subchondral edema o Discrete cartilaginous defectsltrough of talus = tram track lesion o Hypointense fibrous overgrowth T1 C+: Variable enhancement of inflamed synovium + fibrous tissue
Imaging Recommendations Best imaging tool: MR superior for talar longitudinal chondral defects Protocol advice: Sagittal Tl/PD + FS PD FSE
NECT o Tibia1 and talar osteophyte on sagittal reformations
DDx: Anterior Impingement Arthritis
Loose Body
Talar Fx
IF3 .$9
Sag Tl WI MR
Sag TlWl MR
Sag FS PD MR
Ax Tl Wl MR
Key Facts Imaging Findings Best diagnostic clue: Distal anterior tibial osteophyte Location: Between anterior surface tibia and superior aspect neck of talus Morphology: Triangular shaped osteophyte - tibia side spur with narrower base than talar spur
Top Differential Diagnoses Generalized Tibiotalar Arthritis Talar Fracture (Fx) Synovitis - Tibiotalar Joint Loose Body
Pathology
Clinical Issues Most common signslsymptoms: Generalized anterior ankle pain Pain augmented by dorsiflexion Pain at end-range of motion Restricted dorsiflexion capacity Arthroscopy: Decompression + resection hypertrophic synovitis
Diagnostic Checklist
Osteophytes on distal tibio + talar neck decrease tibio-talar angle to < 60 degrees Direct tibial talar repetitive + forceful microtrauma
Generalized Tibiotalar Arthritis Narrowing of entire articulation Osteochondral defects Subchondral sclerosis anterior tibial plafond
Talar Fracture (Fx)
Edema talar headlneck + linear trabecular fracture segments
Synovitis - Tibiotalar Joint Tibiotalar effusion Anterior capsular distention with intermediate signal intensity hyperplastic synovium (on T2WI)
Loose Body
I
Not secondary to single episode of acute trauma thickness talar chondral defects Synovial hyperplasia
Chondral or osteochondral fragment in anterior joint capsule
1 PATHOLOGY General Features General path comments 0 Relevant anatomy Talar sulcus normally seen superior aspect talar neck Normal tibial-dorsal talar neck angle = 60 degrees Osteophytes on distal tibio + talar neck decrease tibio-talar angle to < 60 degrees Etiology 0 Hyperdorsiflexion o Direct tibial talar repetitive + forceful microtrauma o Spur formation anterior inferior tibial plafond + neck of talus (capsular attachment site) . Synovial impingement + tibia1 spur Osteochondral reaction - exostosis formation Exostosis k fragmentation + secondary dorsal talar spur k fragmentation of secondary osteophytes Pantalocrural arthritic destruction (degenerative) o Not secondary to single episode of acute trauma o Lateral ankle ligament laxity
-
Sagittal MR images to differentiate anterior impingement from generalized tibiotalar arthritis
o Equinus foot Epidemiology o Subset chronic ankle pain population o Activity at risk: Hyperdorsiflexion Runners High jumpers Rock climbers Gymnasts
Gross Pathologic & Surgical Features Superior dorsally projecting talar + anteriorly projecting tibial osteophytes Exuberant bone: Focal or bridging "Door jam" effect between osteophytes Fractureifragmentation of osteophytes Full thickness talar chondral defects
Microscopic Features Inflammatory cellular response Synovial hyperplasia Fibrous ingrowth
Staging, Grading or Classification Criteria Grade 1: Abnormal osseous contour, anteroinferior tibia Grade 2: Sharp interface of hypertrophic bone Grade 3: Tibial exostosis 318 to 112 inch (1-1.3 cm) with sharply defined margins Grade 4: Tibial exostosis > 112 inch ( > 1.3 cm), poorly defined apextbase k fragmentation
Presentation Most common signslsymptoms: Generalized anterior ankle pain Clinical profile O Pain augmented by dOrsiflexion o Pain at end-range of motion o Restricted dorsiflexion capacity o Divot in anterior talar neck in soccer players secondary to tibia1 spur abutment
ANTERIOR IMPINGEMENT o "Tram track" lesions in soccer players - contact by
prominent tibia1 osteophyte with talar dome articular cartilage
Demographics Age: Younger agelathletes (i 40 years) Gender o Present in male and female sport activities Football, dancing, soccer
Natural History & Prognosis Pronounced ankle restriction Progressive hypertrophic bone Inflammation Spur fragmentation Synovitis
Treatment Conservative o Activity modification o Immobilization o Antiinflammatory agents o Steroid compounds Surgical o Arthroscopy: Decompression + resection hypertrophic synovitis o Open surgical: Resection of large exostosis
Consider 48
Sagittal MR images to differentiate anterior impingement from generalized tibiotalar arthritis T ~ Wto I identify effusion, marrow edema, acute fragmentation of osteophytes + associated chondral lesions
DeLee JC et al: Orthopaedic sports medicine. Principles and practice. Ligament Injuries of the foot and ankle in the athlete. Osteochondroses and related problems of the foot and ankle. vol2. 2nd ed. Philadelphia PA, Saunders, 2587-623,2003 Robinson P et al: Soft-tissue and osseous impingement syndromes of the ankle: Role of imaging in diagnosis and management. Radiographics 22(6):1457-69, 2002 Tuite MJ: MR imaging of the tendons of the foot and ankle. Semin Musculoskelet Radiol 6(2):119-31,2002 Robinson P et al: Anteromedial impingement of the ankle: Using MR arthrography to assess the anteromedial recess. AJR 178(3):601-4,2002 Banks A et al: McGlamry's comprehensive textbook of foot and ankle surgery. Philadelphia PA, Lippincott Williams ST Wilkins, 1091-152, 2001 Haverstock BD: Anterior ankle abutment. Clin Podiart Med Surg 18(3):457-65, 2001 Jordon LK 3rd et al: Magnetic resonance imaging findings in anterolateral impingement of the ankle. Skeletal Radiol 29(1):34-9,2000 Farooki S et al: Anterolateral impingement of the ankle: Effectiveness of MR imaging. Radiology 207(2):357-60, 1998 Rubin DA et al: Anterolateral soft-tissue impingement in the ankle: Diagnosis using MR imaging. AJR169(3):829-35, 1997
Khan K et al: Overuse injuries in classical ballet. Sports 19:341, 1995 Cutsuries AM et al: Arthroscopic arthroplasty of the ankle joint. Clin Podiatr Med Surg 11(3):449-67,1994 Vogler HW et al: Anterior ankle impingement arthropathy. The role of anterolateral arthrotomy and arthroscopy. Clin Podiatr Med Surg 11(3):425-47,1994 Ogilvie-HarrisDJ et al: Anterior impingement of the ankle treated by arthroscopic removal of bony spurs. J Bone Joint Surg 75:437, 1993 Ferkel RD et al: Arthroscopy of the ankle and foot. J Bone Joint Surg 75:1233, 1993 Hardaker WT Jr et al: Foot and ankle injuries in theatrical dancers. Foot Ankle 659, 1985 King JW et al: Lesions of the feet in athletes. South Med J 64:45, 1971 Brodelius A et al: Osteoarthritis of the talar joints in footballers and ballet dancers. Acta Orthop Scand 30:309, 1960 O'Donoghue DH et al: Impingement exostoses of the talus and tibia. J Bone Joint Surg 39:835, 1957 McMurray TP et al: Footballer's ankle. J Bone Joint Surg 32:68, 1950 Morris LH et al: Athlete's ankle. J Bone Joint Surg 25:220, 1943
1 DIFFERENTIAL DIAGNOSIS
SYNDESMOTIC IMPINGEMENT Key Facts Imaging Findings Best diagnostic clue: Tissue thickening in syndesmotic space on axial images between tibia and fibula Abnormal fascicle AITF which rubs over talar dome = Bassett's ligament Inflamed synovium envelops AITF Synovial nodules
Top Differential Diagnoses dsteochondral Lesion (OLT) Peroneal Tendon Dysfunction Fracture Base 5th Metatarsal Achilles Tendon Injury Anterior Impingement Posterior Impingement
Fracture Base 5th Metatarsal Edema and hypointense fracture line
Achilles Tendon Injury Tendinosis or partial tear on axiallsagittal images
Pathology Mechanism = external rotation or hyperdorsiflexion Syndesmotic sprains - 10%of ankle injuries
Clinical Issues Most common signs/symptoms: Tenderness along syndesmosis + interosseous membrane Anterior popping sensation Age: Young high-performance athletes Talar dome extrudes anteriorly with dorsiflexion
Diagnostic Checklist Evaluate the entire anteroposterior extent of syndesmosis on axial cross-sectional images
Chondromalacia of talus Osteophytes involving syndesmosis
Microscopic Features Synovial hyperplasia Capillary proliferation
Anterior Impingement Anterior osteophytes tibiotalar joint
Posterior Impingement Posterior talofibular, posterior syndesmotic + tibia1 slip
1 PATHOLOGY General Features General path comments o Relevant anatomy = AITF PITF Inferior transverse tibiofibular ligament (just inferior to PITF) Interosseous membrane 20% AITF is intraarticular Etiology o With sprains + fractures o Collision sports: Hockey, football, soccer o Mechanism = external rotation or hyperdorsiflexion o Tibiofibular joint mechanics Width trochlear surface of talus smaller posteriorlyjlateral malleolus pulled superiorly with fibula medial rotation Epidemiology o Syndesmotic sprains - 10%of ankle injuries o Impingement - 3% of ankle injuries o Syndesmosis injuries underestimated clinically
Gross Pathologic & Surgical Features Inflamed synovium AITF involvement Inferior articulation tibialfibula Synovial nodules Frayed AITF
Presentation Most common signs/symptoms: Tenderness along syndesmosis + interosseous membrane Clinical profile o Syndesmosis palpation elicits symptoms o Squeeze test: Compressing fibula against tibia proximal to mid calf o External rotation test: Pain with external rotation foot Knee 90 degrees flexion o Passive dorsiflexion test o Anterior popping sensation
Demographics Age: Young high-performance athletes Gender: Male predominance: Military cadets, football players
Natural History & Prognosis Laxity lateral ankle Talar dome extrudes anteriorly with dorsiflexion Tibiofibular synostosis Pain with push-off Restricted dorsiflexion Ossification between distal tibia and fibula Talar surface degeneration
Treatment Conservative o Physical therapy 0 NSAIDs Surgery o Arthroscopy
-
-
SYNDESMOTIC IMPINGEMENT
I DIAGNOSTIC CHECKLIST
1
SYNDESMOTIC IMPINGEMEN'
1 IMAGE GALLERY (hj?) Axial FS PD FSE MR shows multilobulated posterior syndesmotic ganglion. (Right) Axial FS PL FSE MR shows abnormal osseous syndesmosis.
Typical
(Left) Axial FS PD FSE MR shows anterior syndesmotic synovitis (arrow). (Right) Sagittal graphic shows inflamed synovium enveloping frayed anterior inferior tibiofibular ligament and joint capsule. There is ligamentous impingement against the talus in dorsiflexion.
(Lefl) Axial FS PD FSE MR shows attenuated anterior syndesmotic ligament (arrow). (Right) Axial T l Wl MR shows chronic thickening (arrow) with scar formation of anterior inferior tibiofibular ligament.
POSTERIOR IMPINGEMENT
Coronal graphic shows synovitis, fibrosis, and capsulitis involving the posterior ligaments (posterior syndesmotic, transverse, posterior talofibular ligaments, tibial slip).
Coronal FS PD FSE MR shows hyperintense syqovitis at level of posterior syndesrnotic (open arrow), transverse (arrow), posterior talofibular ligaments as well as tibial slip (curved arrow).
Intermediate signal capsular thickening Hypointense fibrosis 0 Enlarged labrum (transverse ligament) Hypointense to intermediate signal 0 Periostitis T2WI o Inhomogeneous fluid/synovium combination surrounding posterior ligaments 0 Hyperintense ganglion cysts protruding between posterior ligaments 0 Interstitial hyperintensity posterior ligaments 0 Gross enlargement of tibial slip or labrum (transverse ligament) o Synovial nodule intermediate signal T1 C+: Enhanced synovium 0
0
Abbreviations and Synonyms Posterior soft tissue impingement; posterolateral soft tissue impingement
m
Definitions Soft tissue impingement posterolateral ankle
54
General Features Best diagnostic clue: Edema and fluid associated with posterior talofibular ligament (PTFL), transverse tibiofibular ligament, or tibial slip Location: Lateral side posterior ankle from posterior syndesmosis proximally to PTFL distally Size: Variable relative to synovitis, ganglion formation + combination of ligaments involved Morphology o HypertrophyJtear of posterior ligaments o Posterior labrum enlargement (transverse ligament) o Bucket-handle tear tibial slip
Imaging Recommendations Best imaging tool: MR Protocol advice o FS PD FSE posterior coronal and sagittal images to identifjr individual components of posterior ligament complex o T1 C+ selective enhancement of thickened synovium or synovial nodule
mwmmB
M R Findings
TlWI o Hypointense to intermediate signal fluid and synovium encasing posterior ligaments
DDx: Posterior Impingement
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POSTERlOR lMPlNCEMENT Key Facts Imaging Findings Best diagnostic clue: Edema and fluid associated with posterior talofibular ligament (PTFL), transverse tibiofibular ligament, or tibial slip Intermediate signal capsular thickening Hypointense fibrosis Enlarged labrum (transverse ligament)
Top Differential Diagnoses 0 s Trigonum Syndrome Osteochondral Lesion Talus (OLT) Posterior Talofibular Ligament Sprain
Pathology Isolated or in combination with anterolateral + syndesmosis impingement
0 s Trigonum Syndrome Compression flexor hallucis longus tendon against medial edge ununited lateral tubercle of posterior talar process Osseous form of posterior ankle impingement
Osteochondral Lesion Talus (OLT) Compressed or avulsed talar dome fracture
Posterior Talofibular Ligament Sprain Associated with severe lateral ankle sprain Severe acute trauma + fracture
Peroneal Subluxation Sprain superior peroneal retinaculum/lateral ligament complex
Subtalar Arthrosis Subchondral sclerosis f cystic change posterior facet subtalar joint
Tarsal Coalition Lateral cuneonavicular osseous, fibrocartilaginous or fibrous coalition with restricted motion
Plantar flexion mechanism with traumalrepetitive stress Predisposed with prominent posterior labrum or tibial slip Fibrosis
Clinical Issues Most common signslsyrnptoms: Painltenderness posterior ankle Posterior soft tissue fullness Chronic plantar flexion associated with fibrosis thickened synovium + ganglion
Diagnostic Checklist
Identify posterior ligaments as potential sites of impingement on direct posterior coronal and sagittal images
PTFL: From mediallposterior lateral malleolus to insertion tubercle posterior talus lateral to flexor hallucis longus (FHL) groove Etiology o Isolated or in combination with anterolateral + syndesmosis impingement o Plantar flexion mechanism with traumalrepetitive stress o Athletes: Plantar flexionlinversion o Predisposed with prominent posterior labrum or tibial slip o Pseudomeniscus lesion on tibial slip k displacement into joint o Ballet predisposes: Forced turn out and foot plant Epidemiology: Subset of ballet dancing, gymnastics, football players with plantarflexion activity
Gross Pathologic & Surgical Features Fibrosis Capsulitis Synovial swelling Hypertrophy transverse tibiofibular ligament or tibial slip Pseudomeniscus/tibial slip Synovial nodule
Microscopic Features General Features General path comments o Relevant anatomy Posterior inferior tibiofibular ligament (PITF): From posterior lateral malleolus upward medially to posterolateral tibial tubercle Transverse tibiofibular ligament: Deeplinferior to PITF (deep component of PITF) = Tibia1 slip: Superior border PTFL to posterior tibial margin + transverse tibiofibular ligament (insertion to posterior surface medial malleolus) = posterior intermalleolar ligament
Synovial hyperplasia Subsynovial capillary proliferation Chronic inflammatory process Fibrous ingrowth
Presentation Most common signs/symptoms: Painltenderness posterior ankle Clinical profile o Pain reproduced with passive plantar flexion ankle o Posterior soft tissue fullness
I
POSTERIOR IMPINGEMENT
Demographics Age: Younger population participating in plantar flexion sports Gender o Female predominance in ballet and gymnastics o Male involvement in football
Natural History & Prognosis Improvement with rest Chronic plantar flexion associated with fibrosis thickened synovium + ganglion Chronic ankle pain
Treatment Conservative o NSAIDs o Alteration of foot plantar flexion mechanics o Corticosteroid injection (lateral approach) Surgical o Arthroscopic Debridement: Synovium + fibrosis
Consider
Sh
Identify posterior ligaments as potential sites of impingement on direct posterior coronal and sagittal images Use T2WI (FS PD FSE) to identify hyperintense ganglion between posterior ligaments Normal variations exist in size of tibia1 slip and transverse ligament, evaluate gross hypertrophy of these structures
Robinson P et al: Soft tissue and osseous impingement syndromes of the ankle: Role of imaging in diagnosis and management. Radiographics 1457-69, 2002 Bureau NJ et al: Posterior ankle impingement syndrome: Radiology 497-503, MR imaging findings in seven 2000 Fiorella D et al: The MR imaging features of the posterior intermalleolar ligament in patients with posterior impingement syndrome of the ankle. Skeletal Radiol 573-6, 1999 Steinbach LS: Painful syndromes around the ankle and foot: Magnetic resonance imaging evaluation. Top Magn Reson Imaging 311-26, 1998 Masciocchi C et al: Ankle impingement syndromes. Eur J Radiol Suppl 1:S70-3,1998 Masciocchi C et al: Overload syndromes of the peritalar region. Eur J Radiol 46-53,1997 Rosenberg ZS et al: Posterior intermalleolar ligament of the ankle: Normal anatomy and MR imaging features. AJR Am J Roentgen01 387-90, 1995 Hedrick MR et al: Posterior ankle impingement. Foot Ankle 15:2-8, 1994 Schweitzer ME et al: Magnetic resonance imaging of the foot and ankle. Magn Reson Q 214-34, 1993 Gibson JN et al: Arthroscopic lavage and debridement for osteoarthritis of the knee. J Bone Joint Surg Br 74534-7, 1992 Marotta JJ et al: 0 s trigonum impingement in dancers. Am J Sports Med 20533-6, 1992
12. Glick J et al: Ankle arthroscopy: Instructional course. Presented at the annual meeting of the American academy of orthopaedics surgeons, New Orleans, February 1990 13. Holt K et al: Isolated ruptures of the flexor hallucis longus tendon: A case report. Am J Sports Med 18:645, 1990 14. Martin DF et al: Operative ankle arthroscopy copy. Am J Sports Med 17:16-23, 1989 15. Hamilton WG: Foot and ankle iniuries in dancers. Clin Sports Med 7:160-6, 1988 16. Kleiger B et al: The posterior tibiotalar impingement syndrome in dancers. Bull Hosp Jt Dis Orthop Inst 47:203-10, 1987 17. Brodsky EAE et al: Talar compression syndrome. Am J Sports Med 472-6, 1986 18. Glick JM et al: Ankle and foot fractures in athletics. The lower extremity and spine in sports medicine. St Louis, Mosby, 526-40, 1986 19. Andrews JR et al: Arthroscopy of the ankle: Technique and normal anatomy. Foot Ankle 6:29-33, 1985 20. Paulos LE et al: Posterior compartment fractures of the ankle: A commonly missed athletic injury. Am J Sports Med 11:439-43, 1983 21. Hamilton WG et al: Stenosing tenosynovitis of the flexor hallucis longus tendon and posterior impingement upon the os trigonum in ballet dancers. Foot Ankle 3:74-80, 1982 22. Howse AJG et al: Posterior block of the ankle joint in dancers. Foot Ankle 331-4, 1982
1
POSTERIOR IMPINGEMENT
(Left) Coronal graphic shows partial tear of the posterior talofibular ligament. Frayed ligament fibers are shown in red. Enlargement of the posterior talofibular ligament may represent a potential site for posterior impingement. (Right) Axial FS PD FSE MR shows hyperintense edema (arrow) and synovitis associated with sprain of the posterior talofibular ligament.
Typical
(Left)Axial FS PD FSE MR shows posterior impingement with multilobulated and septated ganglion associated with the posterior talofibular ligament. (Right) Coronal surgical pathology shows normal morphology of the posterior talofibular ligament which courses horizontally to insert on the posterior surface of the talus lateral to the groove for the FHL tendon.
Typical
(Left) Sagittal T I C+ (MR arthrogram) shows posterior inferior tibiofibular ligament and transverse tibiofibular ligament which projects inferior to posterior margin of distal tibia, anterior to posterior capsule. (Right) Sagittal FS PD FSE shows posterior impingement with hyperintense edema, synovitis, fluid involving posterior syndesmotic, transverse, (open arrow) posterior talofibular (arrow) ligaments. Hyperintense tibia1 bone marrow edema is also noted.
SINUS TARSI SYNDROME
Sagittal graphic shows sinus tarsi syndrome with synovitis (in red) and tearing of the sinus tarsi ligaments. There is an associated tear of the ATFL.
Abbreviations and Synonyms Sinus tarsi pathology
Definitions Sinus tarsi + lateral hindfoot pain and instability with injury to the contents of the tarsal canal and sinus
Sagittal FS PD FSE MR shows hyperintense bone marrow edema of the roof of the sinus tarsi with partial tearing (arrow) of the normally hypointense interosseous talocalcaneal ligament.
3 to 5 mm wide 15 to 20 mm long Morphology o Sinus tarsi = funnel-shaped channel o 45 degree angle between long axis sinus tarsi & lateral aspect calcaneus
Radiographic Findings Radiography o Negative for degenerative findings o Normal stress radiography o Arthrography - decreased microrecesses/loss of sinus tarsi filling
5s
General Features Best diagnostic clue: Synovitis and poorly defined sinus tarsi ligaments Location o Anterior to posterior facet subtalar joint o Between inferior surface talus and superior surface calcaneus o Posterior to talocalcaneonavicular joint o Sinus tarsi continuous medially with narrower tarsal canal Size o Sinus tarsi + tarsal canal separates subtalar joint into anterior and posterior articulations o Larger lateral opening of tarsal canal = sinus tarsi o Tarsal canal 10 to 15 mm high
k;l
MR Findings TlWI o Effacement sinus tarsi fat with intermediate signal fluid, synovitis f fibrosis on TlWI o Poorly defined margins of interosseous and cervical ligaments o Secondary sclerosis and subchondral cystic change roof of sinus tarsi o Osseous flattening subchondral hypointense sclerosis posterior facet subtalar joint o Subchondral erosions within critical angle of Gissane T2WI o Hypointense/intermediate synovial fibrosis o Inhomogeneous synovitis
DDx: Sinus Tarsi Syndrome
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SINUS TARSI SYNDROME Key Facts Imaging Findings
,
Best diagnostic clue: Synovitis and poorly defined sinus tarsi ligaments Larger lateral opening of tarsal canal = sinus tarsi Effacement sinus tarsi fat with intermediate signal fluid, synovitis f fibrosis on TlWI Poorly defined margins of interosseous and cervical ligaments Secondary sclerosis and subchondral cystic change roof of sinus tarsi
Top Differential Diagnoses Subtalar Arthrosis Tarsal Coalition Lateral Ankle Ligament Sprain Ganglion
o Tears f absence normally hypointense interosseous
talocalcaneal and cervical ligaments o Increased signal intermediate and medial roots
inferior extensor retinaculum o Synovitis anterior capsule of posterior talocalcaneal joint o Talar + calcaneal subchondral cystic degeneration o Lateral ankle ligament sprain Anterior talofibular Calcaneofibular o Complete rupture interosseous talocalcaneal + cervical ligaments = subtalar joint dislocation o Associated tibialis posterior tendon dysfunction T1 C+ o Enhancement of chronic synovitis inflammation o Peripheral enhancement synovial cysts
Imaging Recommendations Best imaging tool: MRI indicated for nonlocalized symptoms, persistent pain, failed conservative treatment or associated injuries Protocol advice o Sagittal Tl/PD and FS PD FSE o FS TI C+ for selective enhancement hypertrophic synovium
DIFFERENTIAL DIAGNOSIS Subtalar Arthrosis Subchondral sclerosis and degeneration isolated to posterior facet > middle facet without sinus tarsi involvement
Tarsal Coalition Osseous or fibrous talocalcaneal or calcaneonavicular
Lateral Ankle Ligament Sprain Localized to anterior talofibular (ATFL) or calcaneofibular ligaments and not sinus tarsi ligaments
Pathology Initial traumatic event: Decreased venous outflow Fibrosis with vascular engorgement or nerve irritation Interosseous ligament tears
Clinical Issues Most common signs/s~m~toms: Pain lateral aspect sinus tarsi Previous ankle sprain in 70% Tibialis posterior tendon disruption Association of subtalar +_ lateral ankle instability
Diagnostic Checklist Document condition of interosseous talocalcaneal and cervical ligaments in sagittal plane
Bifurcate Ligament Sprain Localized to anterior subtalar and calcaneocuboid articulation (bifurcate ligament connects anterior process calcaneus to navicular and cuboid)
Ganglion Extension through sinus tarsi without sprain of sinus ligaments Hyperintense on T2WI
Lipomas Mass effect secondary to extrinsic compression on sinus tarsi contents Fat signal suppresses on FS PD FSE or STIR
Inflammatory Arthritis Seropositive (reactive synovial hyperplasia) Seronegative Calcium pyrophosphate dihydrate deposition (CPPD)
1 PATHOLOGY General Features General path comments o Relevant anatomy Fat pad Arterial anastomosis (branches of posterior tibia1 and peroneal arteries) Proprioceptive nerves Bursa1 projection Ligaments: Medial and intermediate roots inferior extensor retinaculum; cervical ligaments; talocalcaneal interosseous ligament of tarsal canal Etiology o Initial traumatic event: Decreased venous outflow o Fibrosis with vascular engorgement or nerve irritation o Inversion injury ankle or hindfoot o Ligament injury sequence Calcaneofibular ligament Lateral talocalcaneal ligament Interosseous ligament
SINUS TARSI SYNDROME Subtalar joint sprain Epidemiology: Posttraumatic = 70% of cases
Gross Pathologic & Surgical Features Interosseous ligament tears Osteoarthrosis Arthrofibrosis Partial tears calcaneofibular ligament Synovial hypertrophy
Consider Document condition of interosseous talocalcaneal and cervical ligaments in sagittal plane Evaluate arthrosis of posterior facet of subtalar joint on sagittal images Use of T1 C+ if severe synovial hypertrophy present
Microscopic Features Scarring Synovial hyperplasia Chronic synovitis Hemosiderin
Staging, Grading or Classification Criteria Clinical signs o Tenderness with palpation o Instability on uneven terrain o Pain relief with local anesthetic block o Failure to reproduce instability clinically or radiographically
Presentation
hO
Most common signs/symptoms: Pain lateral aspect sinus tarsi Clinical profile o ~ r e v i o i sankle sprain in 70% o Deep aching o Throbbing o Subtalar &stability o Symptoms exacerbated with weight bearing o Swellingledema in acute setting o Relief of pain with local anesthetic injection o Tibialis posterior tendon disruption
Demographics Age: 20 to 40 years Gender: Slight male predominance as a function of chronic ankle sprain history
Natural History & Prognosis Association of subtalar k lateral ankle instability > 50% respond to conservative treatment
Treatment Conservative o Physical therapy o NSAID's o Steroid injections into sinus tarsi o Orthotics o Castinglaircast splints Surgery o Sinus tarsi evacuation o Subtalar arthroscopy/debridement of posterior subtalar joint and sinus tarsi o Removal hypertrophic synovium and scarred ligamentous tissue o Arthrodesis for posterior facet arthrosis subtalar joint
Banks A et al: McGlamry's comprehensive textbook of foot and ankle surgery. vol 1. Philadelphia PA, Lippincott Williams & Wilkins, 1091-152,2001 Lektrakul N et al: Tarsal sinus: Arthrographic, MR imaging MR arthrographic, and pathologic findings in cadavers and retrospective study data in patients with sinus tarsi syndrome. Radiology 19(3):802-10, 2001 Myerson M: Foot and ankle disorders. vol2. Philadelphia PA, Lippincott Raven, 1399-419,2000 Rosenberg ZS et al: From RSNA refresher courses. Radiologic Society of North America. MR imaging of the ankle and foot. Radiographics 20 S153-79, 2000 Steinbach LS: Painful syndromes around the ankle and foot: Magnetic resonance imaging evaluation. Top Magn Reson Imaging 9(5):311-26,1998 Beltran J: Sinus tarsi syndrome. Magn Reson Imaging Clin N Am 2(1):59-65, 1994 Klein MA et al: MR imaging of the tarsal sinus and canal: Normal anatomy, pathologic findings, and features of the sinus tarsi syndrome. Radiology 186(1):233-40,1993 Keeland JB et al: Magnetic resonance imaging of the foot and ankle. Magn Reson Q8(2):97-115 review, 1992 Regnauld B: The foot: Pathology, etiology, semiology, clinical investigation, and therapy. Sinus tarsi syndrome. New York NY. Springer-Ver-lag,298, 1986 Taillard W et al: The sinus tarsi syndrome. Int Orthop 5:117, 1981 Meyer JM et al: Post-traumatic sinus tarsi syndrome: An anatomical and radiological study. Acta Orthop Scand 48:121, 1977 12. Cahill DR et al: The anatomy and function of the contents of the human tarsal sinus and canal. Anat Rec 153:1, 1965 13. O'Connor D et al: Sinus tarsi syndrome - a clinical entity. J Bone Joint Surg 40A:720, 1958
S I N U S TARSI SYNDROME
Typical
(Left) Sagittal graphic shows intact cervical and interosseous talocalcaneal ligaments of the sinus tarsi. The sinus tarsi and tarsal canal separate the anterior and posterior articulations of the subtalar joints. (Right) Axial graphic shows normal 45 degree angle of the long axis of the sinus tarsi relative to the lateral aspect of the calcaneus. The cervical ligament (open arrow) is anterolateral to the interosseous talocalcaneal ligament (arrow).
(Lef)Coronal T l Wl MR shows subchondral sclerosis (arrow) and cystic change of the roof of sinus tarsi with poorly defined margins of the sinus tarsi ligaments. (Right) Sagittal FS PD FSE MR shows hyperintense cystic changes (arrow) and synovitis within the sinus tarsi ligaments.
Variant (Left) Axial FS PD FSE MR shows synovitis with hypertrophic synovium (arrow) encasing the sinus tarsi and tarsal canal. (Right) Sagittal FS PD FSE MR shows subtalar arthrosis with anteriorly projecting synovium (arrow) mimicking posterior sinus tarsi pathology.
ANKLE FRACTURES
Sagittal graphic shows non-displaced posterior malleolar fracture.
Sagittal FS PD FSE MR shows hyperintense edema involving the posterior tubercle of the distal tibia (fracture of the posterior or third rnalleolus).
o Dupuytren = fibula 2 to 7 cm proximal to distal
tibiofibular syndesmosis o Maisonneuve = proximal fibula at proximallmiddle
Abbreviations and Synonyms Malleolar; distal tibia or pilon; Tillaux (lateral margin tibia); triplanar or Marmor-Lynn (lateral distal tibia epiphysis); distal third fibular or Pott fracture; Du~uvtren or fibular (~roximalto distal tibiofibular a , syndesmosis); Maisonneuve (proximal half fibula)
Definitions 62
Fracture of malleoli, distal tibia and fibula
General Features Best diagnostic clue: Complete cortical fracture malleoli, distal tibia or fibula Location o Medial, lateral and posterior malleoli o Pilon = distal tibia with + intraarticular extension o Tillaux = lateral margin distal tibia to distal articular surface o Juvenile Tillaux = Salter-Harris (S-H) type 111 distal tibial growth plate o Triplanar = S-H type IV, lateral distal tibial epiphysis with sagittal, axial and coronal plane components o Pott = distal third fibula
thirds diaphysis Size: Variable based on location (malleoli vs. tibia vs. fibular) and pathomechanics Morphology o Malleoli - transverse to oblique to vertical (posterior malleolus) o Pilon - comminution distal tibia + extension through tibial plafond o Tillaux - horizontal physeal component + vertical extension to distal tibia articular surface o Triplane = vertical in sagittal plane + horizontal in axial plane + oblique in coronal plane o Fibular fractures - horizontal to oblique
Radiographic Findings Radiography o Routine anteroposterior (AP), lateral & oblique internal rotation (mortise) o Full-length views for proximal tibialfibula o Stress views
* *
CT Findings
MDM
NECT o Extent & position articular fragments o Degree of comminution o Associated osteochondral lesions talus
DDx: Ankle Fractures Deltord Sprarn
ATFI. Spram
Cor FS PD MR
Ax FS; PD FSE AdR
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Ax FS PD MR
ANKLE FRACTURES Key Facts Imaging Findings Best diagnostic clue: Complete cortical fracture malleoli, distal tibia or fibula Pilon = distal tibia with + intraarticular extension l-illaux = lateral margin distal tibia to distal articular surface Triplanar = S-H type IV, lateral distal tibia1 epiphysis with sagittal, axial and coronal plane components
Top Differential Diagnoses Medial Ankle Sprain Lateral Ankle Sprain Syndesmotic Sprain
Pathology Position of foot and direction of force at time of loading = injury type
MR Findings TlWI o Malleoli: Hypointense fracture line & hypointense marrow edema o Pilon Separate comminuted distal tibial fragment Hypointense fracture extension to tibial plafond k Displacement o Tillaux: Vertical hypointense fracture line perpendicular to epiphysis + thick hypointense lateral physis with lateral fracture extension o Triplanar: Separate hypointense fractures oriented anteroposterior in axial plane, proximal to distal in coronal plane, oblique in sagittal plane o Fibular: Hypointense transverse to oblique T2WI o Malleoli: Diffuse marrow edema to localized edema adjacent to fracture site 0 Distal tibia Localized edema adjacent to fracture site vs. more diffuse pattern of edema Variable proximal extension of hyperintense signal Interruption of distal chondral surface with hyperintense fluid signal
lmaging Recommendations Best imaging tool: MR, except CT for complex pilon fractures with displacement of weight-bearing segments Protocol advice o Coronal, sagittal and axial T1 (note PD - poor marrow contrast) o Coronal, sagittal and axial FS PD FSE or STIR
1 DIFFERENTIAL DIAGNOSIS Medial Ankle Sprain Sprained deltoid > complete tear Associated osseous avulsions f Fibular fracture
Eccentric vertical loading = asymmetric compression Torsional loading = helical fracture patterns Combined loading most common = medial, lateral, torsional, axial Epidemiology: Supination - external rotation - most common mechanism = 40 to 75% all malleolar fractures
Clinical Issues Most common signs/symptoms: Localized pain & tenderness over malleoli, distal tibia, fibula Degenerative changes in 85% if not anatomically reduced
Diagnostic Checklist Associated ligamentous injuries - medial, lateral or syndesmotic ligaments
Widened mortise in preexisting lateral complex injuries
Lateral Ankle Sprain Pain & tenderness & swelling anterior to fibular ligament distribution & Calcaneofibular ligament involvement f Anterior displacement talus f Widened mortise
Syndesmotic Sprain Pain over anterior inferior tibiofibular ligament (AITF) most common Diastasis syndesmosis at level of tibial plafond Hemorrhage & fibrosis in syndesmosis f interosseous membrane involvement
1 PATHOLOGY General Features General path comments 0 Relevant anatomy Load-bearing surface = pilon = lower tibial metaphyseal expansion Etiology 0 Eversion fractures Pott Maisonneuve Dupuytren Tillaux 0 Position of foot and direction of force at time of loading = injury type 0 Eccentric vertical loading = asymmetric compression o Torsional loading = helical fracture patterns 0 Combined loading most common = medial, lateral, torsional, axial 0 Pilon: Pronation/dorsiflexion Epidemiology: Supination - external rotation - most common mechanism = 40 to 75% all malleolar fractures
Gross Pathologic & Surgical Features Supination - adduction (Lauge-Hansen)
ANKLE FRACTURES o Stage I = lateral ligamentous failure + lateral
o Ecchymosis
malleolus avulsion (transverse fracture at level of plafond) o Stage I1 = vertical, medially displaced fracture medial malleolus Supination - external rotation o Stage I = tear anterior talofibular ligament (ATFL) o Stage I1 = spiral oblique fracture lateral malleolus from plafond extending proximally o Stage 111 = tear posterior inferior tibiofibular ligamentlfracture posterior malleolus o Stage IV = medial malleolus fracture rupture deep deltoid ligament Pronation - abduction o Stage I = transverse avulsion fracture medial malleolus or deltoid ligament rupture o Stage I1 = rupture anterior and posterior inferior tibiofibular syndesmotic ligaments o Stage I11 = horizontal, oblique fibular fracture above the joint (plafond) Pronation - external rotation o Stage I = rupture deltoid ligament or medial malleolus transverse fracture o Stage I1 = tear anterior inferior tibiofibular ligament o Stage 111 = obliquelspiral fibular fracture above plafond o Stage IV = tear posterior inferior tibiofibular ligament or posterior malleolus fracture Pilon o Type I = fissure fracture undisplaced o Type I1 = displaced + articular incongruity o Type I11 = compression fracture + displacement weight-bearing segments (crushing subchondral cancellous bone) Tillaux: Fracture line from distal tibial articular surface proximally + toward lateral cortex Triplane: Fracture - vertical, horizontal & oblique Maisonneuve: Spiral fracture proximal fibula + unstable ankle injury
o Fibular compression test
+
Microscopic Features Fracture site o Hematoma o Revascularization o Primary heading vs. callus o Collagen separation of ligamentous structures
Staging, Grading or Classification Criteria Danis - Weber type A = Lauge - Hansen supination adduction Danis - Weber type B = Lauge - Hansen supination external rotation or pronation - abduction Danis - Weber type C = Lauge - Hansen pronation external rotation
Presentation Most common signs/symptoms: Localized pain & tenderness over malleoli, distal tibia, fibula Clinical profile o Deformity = dislocation o Swelling
-
Demographics Age o Variable o Tillaux as juvenile Tillaux pattern in children o Pediatric ankle fracture = most common is Salter I physis injury Gender: Non-specific for gender Related activity o High energy (e.g., motorcycle) o Low energy - seen as mechanism for medial malleolar injuries
Natural History & Prognosis Arthritis - based on severity Degenerative changes in 85% if not anatomically reduced
Treatment Conservative: Closed reduction Surgical: Open reduction with internal fixation (ORIF)
Consider Associated ligamentous injuries - medial, lateral or syndesmotic ligaments CT may be useful for displaced distal tibial pilon fractures Evaluate for osteochondral lesions of the talus (OLT)
1 SELECTED REFERENCES Vander Griend et al: Fractures of the ankle and distal parts of the tibia. Inst Course Lect 46:311-21, 1997 Petit P et al: Acute fracture of the distal tibial physis: Role of gradient-echo MR imaging versus plain film examination. AJR 166(5):1203-6, 1996 Michelson JD: Fractures about the ankle. J Bone Joint Surg Am 77:142-52, 1995 Karas EH et al: Displaced pilon fractures: An update. Orthop Clin North Am 25:651, 1994 Schils JP et al: Medial malleolar stress fractures in seven patients: Review of the clinical and imaging features. Radiology 185:219, 1992 Michelson JD et al: Examination of the pathologic anatomy of ankle fractures. J Trauma 32355, 1992 Harper MC et al: Posterior malleolar fractures of the ankle associated with external rotation-abduction injuries: Results with and with-out internal fixation. J Bone Joint Surg Am 70: 1348, 1988 Bauer M et al: Supination-eversion fractures of the ankle joint: Changes in incidence over 30 years. Foot Ankle 8:26-28, 1987 Lindsjo U: Classification of ankle fractures: The Lauge-Hansen or A 0 system? Clin Orthop 199:12, 1985
I
ANKLE FRACTURES IMAGE GALLERY (Left) Coronal FS PD FSE MR s h o w transverse fractures of the distal tibia and fibula with hyperintense edema. Tibiolalar joint instability and medial OLT are prcscnt. (Right) Col-onal g~aphic shows medial mallcolar trac'tore.
(Left) COI-onalgraphic shows Tillaux fracture, with avulsion of the lateral margin o/'~tir distal tibia. (Right) COI-onal graphic thows triplane injury wilh tlarture involving the sagittal, axial, alld coronal planes.
(Left) Coronal graphic shows D u p ~ ~ y t ~fraclure -en of the fibular diaphysis with delloid ligament, interosseous nieml~rane,and syndesmosis disruption. This also represents a Weber type C fracture. (Right) Coronal graphic- shows Ma~sonneuve fiacture involving the proximal libula with disruption of the interosseous niernbrane and 5yndesmotic Iiganienl.
TALUS FRACTURES -
Coronal FS PD FSE MR shows vertical non-displaced fracture of the talar body. Hyperintense edema of the fracture is oriented in the sagittal plane.
Sagittal graphic shows fracture of the talar body.
..
o Lateral process
Comminuted Large fragment (noncomminuted) o Posterior process 0 s trigonum - vertical fracture at synchondrosis o Talar neck: Vertical 0 Body Coronal Sagittal Horizontal
. .. .
Abbreviations and Synonyms Fractures of the talus
Definitions
ta
Fracture of talar head, neck, body, lateral or posterior process
Radiographic Findings
66
Radiography o Head of talus Lateral view: Fracture pattern Sagittal view: Displacement = Oblique views: Extent of fracture o Lateral process AP or mortise o Posterior process Lateral view o Talar neck Lateral view: f Subluxation/dislocation o Talar body Lateral view
General Features
.. . . .
Best diagnostic clue: Linear, usually vertical fracture segments Location o Talar head, neck + body o Lateral + posterior process Size o Variable Nondisplaced = Displaced Open fractures Morphology o Head of talus Avulsion Peripheral Compression
. . .. .
mwu CT Findings
NECT o Direct coronal + axial, sagittal reformations
DDx: Talar Fractures
I
.* Ax FS PD FSE MR
Sag T1WI MR
Cor FS PD MR
I
TALUS FRACTURES Key Facts Imaging Findings Best diagnostic clue: Linear, usually fracture segments Talar head, neck + body Lateral + posterior process Best imaging tool: MR - to appreciate marrow edema, chondral involvement + AVN
Top Differential Diagnoses Ankle Sprains 0 s Trigonum Osteochondral Lesions (OLT)
Pathology
0.5% of all fractures neck = 50% talar talar fracture) + associated with calcaneus + spine + medial malleolus fractures Talar neck = Hawkins classification
Clinical Issues Most common signslsymptoms: Anklelfoot pain 15% talar fractures = open Associated injuries = calcaneus + medial malleolus Arthritis: 40-90%
Diagnostic Checklist Evaluate for AVN with talar neck fractures
Articular cartilage = 60% talar surface High-energy trauma: Falls + motor vehicle accidents (MV.4) o Used in comminuted fractures
MR Findings TlWI o Head of talus = Avulsion usually medially = Intraarticular displacement/dislocation talonavicular joint Single vs. multiple hypointense fracture lines Associated diffuse hypointensity o Lateral process Hypointense edema in comminuted fracture Oblique/vertical single fracture (hypointense) + intraarticular displacement o Posterior process Fracture vs. painful os trigonum difficult on TlWI Irregular separation on sagittal = talus + fragment o Talar neck Posterior to transverse sulcus Vertical hypointense nondisplaced segment (type 1) ~ubluxationldislocationtalus in subtalar joint (type 11) Displacement of talar body (type 111) o Talar body Comminuted Primary fracture in any of three orthogonal planes Hypointense fracture line T2WI o Head of talus Hyperintense talar head ~ d e m a obscures fracture line Chondral extension to talonavicular joint o Lateral process Hyperintense edema on coronallsagittal images Increased hyperintense subtalar fluid + chondral interruption o ~osterior~rocess Complete hyperintense vertical fluid gap between talus/posterior process Adjacent marrow edema Hyperintense soft tissue fluid + edema
+
Hyperintense fluid flexor hallucis longus tendon sheath o Talar neck Hyperintense fluid + inhomogeneity of hemorrhage with separation between head and necklbody Adjacent fragment hyperintense marrow Sagittal plane to document extrusion of talus from subtalar joint (Hawkins type 111 injury) o Talar body Hyperintense edema across fracture plane (coronal, sagittal or axial) Soft tissue hyperintense edemalhemorrhage TZ* GRE o Head of talus T2* gradient reduce edema, define fracture pattern
Imaging Recommendations Best imaging tool: MR - to appreciate marrow edema, chondral involvement + AVN Protocol advice: Coronal, sagittal and axial TI, PD FSE
+ FS PD FSE
1 DIFFERENTIAL DIAGNOSIS Ankle Sprains Fracture of lateral and posterior process mistaken for ligament injury Anterior drawer sign with ligament tear
0 s Trigonum Vs. fracture posterior process 0 s trigonum - smooth cortical border
Osteochondral Lesions (OLT) Subchondral fracture medialllateral talar dome
1 PATHOLOGY General Features General path comments o Relevant anatomy
TALUS FRACTURES Articular cartilage = 60% talar surface Etiology o High-energy trauma: Falls + motor vehicle accidents (MVA) o Head of talus Plantarflexed foot is forcefully dorsiflexed Axial load = shearing force o Lateral process Inversion + dorsiflexion + compressive force Snowboarder'sfracture: ~lexibleboots + increased subtalar motion MVA o Posterior process Forced plantarflexion + compression o Talar neck Forced dorsiflexion - contact between anterior lip tibia + dorsal talar neck sulcus o Talar body Axial compression + plantarflexed talus Epidemiology o 0.5% of all fractures o Talar neck = 50% of talar injuries (most common talar fracture) + associated with calcaneus + spine + medial malleolus fractures
Presentation Most common signslsymptoms: Anklelfoot pain Clinical profile o Swelling o Ecchymosis o 15% talar fractures = open o Associated injuries = calcaneus + medial malleolus
Demographics Age: Talar neck = 30-38 years Gender: Talar neck: M:F = 3:l
Natural History & Prognosis Outcomes related to fracture type Malunion in comminuted fractures Arthritis: 40-90% Complications: AVN
Treatment Conservative: Short cast Surgical: Open reduction with internal fixation (ORIF) o Body fracture, displaced o Lateral process, displaced o Talar neck, type I11
Gross Pathologic & Surgical Features Head of talus o Periphery of head (medially) 0 Subtalar dislocation o Comminution vs compression Lateral process o Comminuted fracture, minimal displacement o Larger fragment displacement Posterior process o Irregular separation from talus Talar neck o Head + neck separated from talar body o + Failure interosseous talocalcaneal ligament o & Disruption vascular supply o k Talar dislocation from mortise Talar body o Comminuted fractures without dislocations o Less comminuted fractures associated with dislocations ankle + subtalar joint o Simple fracture
1 DIAGNOSTIC CHECKLIST Consider Evaluate for AVN with talar neck fractures Coronal, sagittal and axial planes to characterize fracture pattern Associated injuries visualized include medial malleolus and calcaneus
+
68
Microscopic Features Fracture site o Hematoma o Revascularization o Haversian canal formation in primary healing o Callus formation o Lamellar bone - remodeling
Staging, Grading or Classification Criteria Talar neck = Hawkins classification 0 Type I (11 - 21%): No talar displacement o Type 11 (40 - 42%): Subluxation/dislocation talus with respect to subtalar joint (dislocation posterior facet) o Type 111 (23 - 47%): Displacement talar body (ankle and subtalar dislocation) o Type IV (rare): Additional dislocation talonavicular joint
1.
2. 3. 4.
5.
Banks A et al: McGlamry's comprehensive textbook of foot and ankle surgery. Talar fractures. vol 1. 3rd ed. Philadelphia PA, Lippincott Williams & Wilkins, 1865-96, 200 1 Sijbrandij EJ et al: Posttraumatic subchondral bone contusions and fractures of the talotibial joint: Occurrence of "kissing"lesions. AJR 175(6):1707-10,2000 Adellar RS: Complex fractures of the talus. Instr Course Lect. Review (46):323-38, 1997 Thordarson DB et al: Magnetic resonance imaging to detect avascular necrosis after open reduction and internal fixation of talar neck fractures. Foot Ankle Int 17(12):742-7,1996 Nishimura G et al: Trabecular trauma of the talus and medial malleolus concurrent with lateral collateral ligamentous injuries of the ankle: Evaluation with MR imaging. Skeletal Radio1 25(1):49-54, 1996
TALUS FRACTURES
(Left) Sagittal graphic shows talar neck fracture. (Right) Sagittal FS PD FSE MR shows hyperintense non-displaced fracture of the talar neck.
(I@)
Sagittal FS PD FSE MR shows hyperintense marrow edema in talar head fracture. lntraarticular extension to the talonavicular joint is present in the plantar aspect of the fracture. (Right) Sagittal T l Wl MR shows comminuted talar body fracture.
(Lef?)Axial graphic shows lateral process fracture of the talus. (Right) Sagittal FS PD FSE MR shows hyperintense edema in lateral process fracture.
CALCANEAL FRACTURES
Sagittal graphic shows Essex Lopresti type B intraarticular joint depression fracture of the calcaneus.
Abbreviations and Synonyms Fracture of the calcaneus
Definitions Extraarticular or intraarticular fracture of the calcaneus
Sagittal T l Wl MR shows central joint depression pattern with posterior extension to the posterior facet of the subtalar joint.
Morphology o Sanders classification = number of fragments in posterior facet on coronal CT o Intraarticular fracture Y-shaped on lateral perspective Secondary fracture: Tongue-type = horizontal extension to posterior tuberosity; joint depression = vertical to thalamic fragment (lateral articular posterior facet)
Radiographic Findings General Features Best diagnostic clue: Fracture line f extension into subtalar joint Location o Extraarticular o Intraarticular Essex Lopresti type A: Tongue-type Essex Lopresti type B: Joint depression Fracture line vertical from Gissane's crucial angle (anterior lateral aspect tarsal canal) to calcaneal plantar surface Secondary fracture line: Tongue type extends posterior to posterior facets + dorsal calcaneal tuberosity; depression type extends to fractured articular surface posterior facet Size: Varies from localized tuberosity, sustentaculum, process, avulsion, depression to comminution
Radiography o Lateral foot, axial heel (Harris view) o AP + oblique foot - fracture calcaneocuboid joint and lateral wall displacement o Foot dorsiflexed and internal rotation to visualize posterior facet o Normal Bohler's angle = 20 to 40 degrees o Normal Gissane's critical angle = 120 to 145 degrees
CT Findings NECT o Coronal and axial images, sagittal reformations, & three dimensional reconstruction o Sanders classification: Number of posterior facet fragments on coronal CT
M R Findings TlWI
DDx: Calcaneal Fractures
IF->. [h;y Sag T I WI MR
Sag FS PD MR
Sag TlWl MR
A
SE MR
Cor FS PD MR
CALCANEAL FRACTURES Key Facts Imaging Findings Best diagnostic clue: Fracture line f extension into subtalar joint Extraarticular Intraarticular
Top Differential Diagnoses Lateral Ankle Ligament Sprain Sinus Tarsi Syndrome Achilles Tendon Tear Peroneal Tendon (PB, PL) Dysfunction Deltoid Ligament
Pathology
Axial loading of hindfoot + downward talar force Primary fracture line - shears calcaneus obliquely (anteromedial + posterolateral portions)
o Anterior process fracture (Rowe type I)
1 1
Avulsion at origin bifurcate ligament: Hypointense to intermediate edema vs. chronic hypointense sclerosis Compression fracture - hypointense fracture extension to calcaneocuboid joint o Sustentaculum tali (Rowe type I) f Medial displacement o Beak and avulsion fxs (Rowe type 11) Hypointense edema in beak or avulsed tuberosity Attached Achilles tendon to superior tuberosity o Calcaneal body (Rowe type 111) No subtalar joint communication Sagittal images to exclude posterior facet involvement o Intraarticular Coronal images for widening of calcaneus Sagittal images to separate central depression from tongue-like fracture o Stress fractures Hypointense linear lines posterior calcaneus perpendicular to long axis vs. more diffuse posterior calcaneus trabecular microfracture edema T2WI o Anterior process fracture (Rowe type I) Hyperintense edema lateral sagittal images f Bifurcate ligament edema Increase signal extensor digitorum brevis muscle and calcaneocuboid ligament Compression fracture f avulsion navicular tuberosity with hyperintense edema; + calcaneocuboid joint o Sustentaculum tali (Rowe type I) Hyperintense edema, fluid or hemorrhage axiallcoronal o Beak and avulsion fxs (Rowe type 11) = Beak - smaller Avulsion - larger 2" sudden contraction Achilles tendon = Hyperintense fracture line posterior-superior calcaneus o Calcaneal body (Rowe type 111)
Secondary fracture line - divides calcaneus transversely 75% intraarticular in adults (25% in children)
Clinical Issues Most common signslsymptoms: Ankle pain Inability to ambulate Ecchymosis (heel + arch) Limited ankle motion (flattened calcaneus + talar dorsiflexion) Surgical for displaced intraarticular Complications: Compartment syndrome
Diagnostic Checklist
Determine presence of subtalar joint extension
Single hyperintense fracture line posterior to posterior facet vs. comminution o Intraarticular Hyperintense edema - in joint - depression vs. tongue-type fracture Chondral extension Free fragments - hypointense bodies outlined by hyperintense fluid o Stress fracture Posterior calcaneal hyperintensity in linear pattern parallel to posterior tuberosity vs. diffuse hyperintense edema
Imaging Recommendations Best imaging tool o MR for extraarticular and noncomminuted intraarticular o CT superior for multifragment involvement, fracture displacement, loose bodies Protocol advice: Tl/PD + FS PD FSE in all 3 orthogonal planes
I DIFFERENTIAL DIAGNOSIS Lateral Ankle Ligament Sprain Not tender over anterior process Tear of anterior talofibular (ATFL) or calcaneofibular ligament
Sinus Tarsi Syndrome Abnormal sinus tarsi edema + sinus tarsi ligament pathology Sinus tarsi pain in anterior process fracture
Achilles Tendon Tear Severe tendinosis and tear with no associated posterior superior calcaneal avulsion
Peroneal Tendon (PB, PL) Dysfunction Tenosynovitis, tendinosis or splint without fracture of calcaneal body Lateral wall blow-out fracture - impingement of peroneal tendons
CALCANEAL FRACTURES Rowe classification
Medial ankle ligament sprain
Deltoid Ligament Stretch or tear without fractured sustentaculum
Presentation General Features
72
General path comments o Relevant anatomy Middle third calcaneus supports posterior facet Posterior facet separated from anterior + middle facets by tarsal canal + sinus tarsi Anterior = calcaneocuboid joint Thalamic bone = cortical bone supporting posterior facet Angle of Gissane - thick cortex of anterior lateral tarsal canal Etiology o Axial loading of hindfoot + downward talar force o Primary fracture line - shears calcaneus obliquely (anteromedial + posterolateral portions) o Secondary fracture line - divides calcaneus transversely o Posterior facet - impacted into body + rotated anteriorly o Lateral wall = blown out o Direct trauma o Stressloveruse in athletes Epidemiology o 2% of all fractures o 60% of tarsal bone injuries o 5-9% = bilateral o 75% = fall from height o 10%associated with thoracic/lumbar (T12-L2) compression injuries o 25 to 70% associated with lower extremity injuries o 15 to 25% = extraarticular fractures o 75% intraarticular in adults (25% in children)
Most common signs/symptoms: Ankle pain Clinical profile o Inability to ambulate o Swelling, tenderness o Ecchymosis (heel + arch)
Demographics Age: Working age population (30-50 years)/fall from height (3-50 feet) Gender: M:F = 5:l
Natural History & Prognosis Sequelae include widened heel (blown out lateral wall); shortened heel (anterior process split) Limited ankle motion (flattened calcaneus + talar dorsiflexion)
Treatment Conservative for nondisplaced/minimally displaced intraarticular o Early range of motion without reduction o Closed reduction k fixation Surgical for displaced intraarticular o Open reduction + internal fixation o Arthrodesis - comminuted Complications: Compartment syndrome
Consider
MR or CT with coronal + sagittal planes to identify fracture type Determine presence of subtalar joint extension CT superior for severe comminuted + displaced fragments
Gross Pathologic & Surgical Features Rowe classification o Type I (21%): Fracture of tuberosity, sustentaculum tali, anterior process o Type I1 (3.8%): Beak + avulsion fractures/Achilles tendon insertion o Type I11 (19.5%): Oblique fractures (no subtalar involvement) o Type IV (24.7%): Fracture involving subtalar joint o Type V (31%): Central depression comminution
*
Microscopic Features Fracture site o Vascular disruption (hematoma) o Revascularization o Haversian canal - formation in primary healing o Callus formation response to micromotion at fracture (fibrous tissue, cartilage + woven bone) o Lamellar bone - remodeling
Staging, Grading or Classification Criteria Sanders classification: Coronal CT based, number of fragments involving post facet (sustentaculum, medial, central + lateral columns)
1. 2. 3. 4.
5. 6.
Banks A et al: McGlamry's comprehensive textbook of foot and ankle surgery. Calcaneal fractures. vol 1. Philadelphia PA, Lippincott Williams & Wilkins, (57):1819-64, 2001 Karr JC: Magnetic resonance imaging evaluation of heel pain. J Am Podiatr Med Assoc 89(7):364-7, 1999 Robbins MI et al: MR imaging of anterosuperior calcaneal process fractures. AJR 172(2):475-9,1999 Born CT et al: Imaging of calcaneal fractures. Clin Podiatr Med Surg 14(2):337-56,1997 Berger PE et al: MRI demonstration of radiographically occult fractures: What have we been missing? Radiographics 9:407, 1989 Lee YK et al: Stress fractures: MR imaging. Radiology 169:217, 1989
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CALCANEAL FRACTURES IMAGE GALLERY
NAVlCULAR FRACTURES
Sagittal graphic shows non-displaced stress fracture of the navicular. The dorsal fragment is sclerotic.
Abbreviations and Synonyms Fractures of the navicular
Definitions Fractures of the navicular: Tuberosity, body, avulsion or stress
7
4 1
[IMAGING FINDINGS General Features Best diagnostic clue: Linear fracture line usually perpendicular to long axis of navicular Location o Avulsion Dorsal lip At insertion of dorsal tibionavicular ligament (tibialis posterior insertion) o Navicular tuberosity fx o Body fx o Stress fx Middle third Size o Avulsion Cortical avulsion: Part of dorsal cortex o Tuberosity
Sag FS PD MR
Sagittal T l Wl M R shows navicular stress fracture with involvement of the proximal and distal cortices in a world-class sprinter. The dorsal fragment shows hypointense sclerosis.
Variable with size of tuberosity Minimally displaced o Body Nondisplaced most common o Stress Anteroposterior/short axis length of navicular In sagittal planelcentral third navicular 96% are partial fxs Morphology o Avulsion Elongated cortical fragment o Tuberositv Fracture sharpljagged edges o Body Horizontal Crush Displaced o Stress Complete Incomplete
Radiographic Findings Radiography: Conventional radiographs often negative for stress fractures
CT Findings NEC'T o Stress (most useful indication) Direct coronal
Cor FS PD MR
Ax FS PDFSE MR
NAVlCULAR FRACTURES Key Facts Imaging Findings Best diagnostic clue: Linear fracture line usually perpendicular to long axis of navicular Avulsion Navicular tuberosity fx Body fx Stress fx
Top Differential Diagnoses Cuboid Fracture Deltoid Ligament Sprain Tibialis Posterior (TP) Tendon Tear
Pathology
,
Central third navicular avascular (at risk for stress fracture + nonunion) Dorsal avulsion = 47% of navicular fractures Direct axial Confirm diagnosis: CT visualizes central third navicular
MR Findings -
TlWI o Avulsion Elongated hypointense dorsal cortical fragment Adjacent dorsal soft tissue hypointense edema + Hypointensity dorsal tibionavicular component deltoid o Tuberosity Hypointense subchondral edema across tuberosity fracture Irregular edges at fracture site 0 Body Hypointense vertical or horizontal fracture line + edema Hypointense subchondral edema o Stress Hypointense fracture line on direct coronal or axial images ~ypointensemarrow edema + visualized fracture on sagittal T2WI o Avulsion Fragment remains hypointense (corticallybased) Adjacent edemalhyperintensity (soft tissue + navicular) o Tuberosity Variable hyperintensity across fracture site ~ ~ ~ e r i n t efluid~hemorrha~e nse at fracture site Hyperintense fluid involving tibialis posterior tendon o Body Hyperintensity epicentered in coronal plane, from dorsolateral to plantar medial within navicular or comminution in sagittal plane o Stress Hyperintensity diffuse marrow edema in acute injuries
+
Tuberosity = 24% of navicular fractures Body = 29% of navicular fractures
Clinical Issues Most common signs/symptoms: Midfoot pain Avulsion = tenderness + edema at fracture site Tuberosity = tenderness medial navicular Body = pain mid medial arch & local tenderness & swelling Stress = poorly localized dorsum pain + medial longitudinal archtminimal swelling
Diagnostic Checklist Correlate navicular edema with axial or coronal images to confirm a stress fracture
Imaging Recommendations Best imaging tool o MR with improved multiplanar display especially in stress fractures o MR useful for tuberosity fractures vs accessory navicular Protocol advice: Coronal, sagittal + axial T1 or PD FSE + FS PD FSE
1 DIFFERENTIAL DIAGNOSIS Cuboid Fracture
Edema + fracture line in cuboid Associated with navicular tuberosity fracture Associated cuneiform fracture
*
Deltoid Ligament Sprain Vs. dorsal avulsion fracture of navicular Normal dorsal margin navicular on sagittal
Tibialis Posterior (TP) Tendon Tear Intrinsic hypertrophy, attenuated or complete tear Mimics avulsion fracture navicular tuberosity
Bipartite Tarsal Navicular Vs. true fracture of body Bipartite = smooth interface
I PATHOLOGY General Features General path comments o Relevant anatomy Central third navicular avascular (at risk for stress fracture + nonunion) Etiology o Avulsion Plantar displacement foot + inversion or eversion Dorsal tibionavicular ligament taut = dorsal cortex avulsion at insertion o Tuberosity
NAVlCULAR FRACTURES Avulsion - tibialis posterior Forceful eversion - contraction tibialis posterior o Body Direct or indirect mechanism Fall + foot plantarflexion Plantarflexion + abduction metatarsal joint o Stress Excessive pronation Running Epidemiology o 62% of midfoot fractures o 37% of all foot fractures o Dorsal avulsion = 47% of navicular fractures o Tuberosity = 24% of navicular fractures o Body = 29% of navicular fractures
Related causes o Stress fractures in sprints, hurdles and jumps o Body fractures - fall from great height or motor vehicle accident
Natural History & Prognosis Avulsion o If displaced - closed reduction usually unstable Tuberosity o 50% calcaneocuboid joint injury = persistent pain o Edema decreases after 72 hours Body o Remain nondisplaced o Heal without sequelae Stress o Under-diagnosed o Symptoms increased with activity o Failure to treat = delayed or nonunion
Gross Pathologic & Surgical Features Avulsion o Fragment may contain segment of articular cartilage Tuberosity o Nondisplaced most common o Associated injury calcaneocuboid joint Body o Nondisplaced most common o Navicular compressed between talar head & cuneiform Stress o 96% incomplete o Complete fracture f dislocation
Treatment Conservative o Short leg cast Surgical o Avulsion: Open reduction with internal fixation (ORIF) if > 20% articular cartilage o Tuberosity: Reattachment for displacement; resection o Body: Displacement requires ORIF vs. closed reduction vs. K-wires o Stress: Displaced, nonunions, comminuted or cyst formation requires graft vs. excision vs. ORIF Complications o Degenerative arthritis o Nonunion
*
Microscopic Features
7 11
Fracture site o Hemorrhage o Revascularization o Primary healing with haversian canal o Callus formation o Remodeling with lamellar bone
Staging, Grading or Classification Criteria
DIAGNOSTIC CHECKLIST Consider
Body fractures o Type 1: Transverse + dorsal fragment (< 50% body) o Type 2: Transverse from dorsolateral to plantar medial across body (major fragment = dorsomedial; smaller comminuted fracture = plantar lateral ) o Type 3: Central or lateral comminution (major fragment = medial)
Stress fractures associated with running & jumping athletic activity High axial compression related to acute navicular fractures Correlate navicular edema with axial or coronal images to confirm a stress fracture
1.
Presentation Most common signs/symptoms: Midfoot pain Clinical profile o Avulsion = tenderness + edema at fracture site o Tuberosity = tenderness medial navicular o Body = pain mid medial arch & local tenderness & swelling o Stress = poorly localized dorsum pain + medial longitudinal archlminimal swelling
Demographics Age o Stress fractures in athletes + recreational age o Ages 20 to 50 years Gender: Stress fracture in male & female population
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2.
3.
4.
5.
Coris EE et al: Tarsal navicular stress fractures. Am Fam Physician. 67(1)85-90, 2003 Choi CH et al: Occult osteochondral fractures of the subtalar joint: A review of 10 patients. J Foot Ankle Surg 40-3, 2002 Ostlie DK et al: Tarsal navicular stress fracture in a young athlete: Case report with clinical, radiologic, and pathophysiologic correlations. J Am Board Fam Pract 381-5, 2001 Banks A et al: McGlamry's comprehensive textbook of foot and ankle surgery. Midfoot fractures. vol 1. Philadelphia PA, Lippincott Williams & Wilkins (35):1791-818, 2001 Myerson M: Foot and ankle disorders. Fractures of the midfoot and forefoot. vol2. Philadelphia PA, Lippincott Raven (52): 1265-96, 2000
1
NAVlCULAR FRACTURES IMAGE GALLERY Typical (Left) Sagittal FS PD FSE MR shows diffuse hyperintense marrow edema in the plane of the navicular fracture. (Right) Axial T 1Wl MR shows fracture (arrow) of the proximal medial navicular (tuberosity fracture).
Typical (Left) Sagittal T l Wl MR shows diffuse hypointensity without direct visualization of the fracture. (Right) Axial T l Wl MR shows stress fracture (arrow) perpendicular to the long axis of the navicular.
(L@) Sagittal T l Wl MR shows chronic changes of navicular fracture with sclerosis and foreshortening. (Right) Sagittal FS PD FSE MR shows complication of navicular fracture with dorsal subluxation deformity.
METATARSAL FRACTURES
Sagittal graphic shows stress fracture of the proximal metatarsal with associated bone marrow edema.
Abbreviations and Synonyms Fractures of the metatarsals
m
Sagittal T I Wl MR shows second metatarsal stress fracture (arrow) in a ballet dancer.
First - direct f comminution, indirect f avulsion Central - displacement in same direction Fifth - avulsion or transverse Jones fracture Morphology o Stress - transverse angulation k periosteal reactionlexuberant callus o Head - f angulation or rotation o Neck - f plantar + lateral displacement o Mid shaft - oblique, transverse, spiral or comminuted o Base - associated with Lisfranc's fracture-dislocation (alignment usually maintained) o First - direct with comminution vs. indirect with avulsion o Central - usually transverse + parallel relationship of fractured segments o Fifth - transverse pattern in Jones fracture
+
Definitions Metatarsal fracture: Stress, head, neck, mid shaft, base, first, central (2nd, 3rd, 4th), or 5th fracture
78
General Features Best diagnostic clue: Bone marrow edema + fracture line Location 0 Stress - proximal third, common in dancers o Head, neck, shaft, base, central Size 0 Variable Stress - perpendicular to long axis Head - shortening in impaction injuries Neck - k displacement & f multisegment involvement Mid shaft - size related to oblique, transverse, spiral & comminuted patterns Base - usually minimal displacement & good alignment
*
Radiographic Findings Radiography o Confirms fracture location o Three views recommended o + Comparison study uninvolved extremity o Healing = new bone formation
CT Findings NECT o For fracture displacement & dislocation of metatarsals
DDx: Metatarsal Fractures
Ax FS PD FSE MR
-
Sag T l W l MR
Ax FS PD MR
METATARSAL FRACTURES Key Facts Imaging Findings
Best diagnostic clue: Bone marrow edema + fracture line Stress - proximal third, common in dancers Head, neck, shaft, base, central Best imaging tool: MR to identify marrow edema in nondisplaced fractures
Top Differential Diagnoses Lisfranc's Fracture Navicular Fracture Cuboid & Cuneiform Fracture
Pathology Direct - crushing, blunt trauma or penetrating injuries Indirect - axial loading o Documents cortical thickening in stress fractures
Overuse: Running or dancing Fifth metatarsal > 3rd > 2nd > 1st > 4th for gross involvement Stewart classification of fifth metatarsal base fractures
Clinical Issues Most common signslsymptoms: Pain at fracture site Stress - focal tenderness + pain with activity (diaphysis or neck most common) First metatarsal - altered gait Age: Stress fractures: Young runners, dancers, marchers
Diagnostic Checklist Metatarsal marrow edema often indicative of a stress fracture
o Neck
= Hyperintense marrow +- soft tissue edema
MR Findings TlWI o Stress Subchondral hypointensity Asymmetric thickening of hypointense cortex Hypointense fracture line (single or multiple) Usually perpendicular to metatarsal long axis o Head Displacement Hypointense edema metatarsal head & Dislocation 0 Neck Hypointense oblique or transverse fracture & edema k Plantar displacement 0 Mid shaft Oblique or transverse + hypointense marrow edema & Shortening, angulation, displacement 0 Base Hypointense marrow edema Identify multiple metatarsal involvement 0 First Extensive soft tissue effacement with hypointense edemalhemorrhage Comminution in direct injuries Avulsion fragment 0 Central: Displacement as unit o Fifth: Hypointensity of base f extension into proximal diaphysis T2WI o Stress Hyperintense medullary edema f Soft tissue hyperintensity Edema without fracture line visualization in acute stage 0 Head Angulation or rotation of articular surface on sagittal images Chondral fracture with interruption of intermediate signal intensity articular cartilage
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o
o
o
o
o
Tendinous interposition Muscle hyperintensity Mid shaft: Variable proximal/distal diaphysis edema Base Hyperintense base & visualized fracture fragment in Lisfranc injuries Chip fractures - variable marrow hyperintensity First = +_ Association with Lisfranc injuries Marrow hyperintensity Central Multiple metatarsal involvement (second, third + fourth) Displacement with extensive soft tissue + muscular hyperintense edema Fifth Increased fracture gap in nonunion Marrow hyperintensity vs. hypointensity of fibrous tissue or sclerosis
Imaging Recommendations Best imaging tool: MR to identify marrow edema in nondisplaced fractures Protocol advice o Tl/PD FSE + FS PD FSE Direct axial for Lisfranc joint Coronal for displacement & dislocation Sagittal for shortening and angulation
DIFFERENTIAL DIAGNOSIS Lisfranc's Fracture Tarsometatarsal involvement Homolateral vs. divergent displacement Axial plane to diagnose
Navicular Fracture Dorsal avulsion Tuberosity Body
METATARSAL FRACTURES Cuboid & Cuneiform Fracture Cuneiform associated with tarsometatarsal dislocations Cuboid associated with fractures of calcaneus, fifth metatarsal or navicular
/ PATHOLOGY General Features General path comments o Relevant anatomy Metatarsal structure = base, diaphysis, neck & head Base - broad & cancellous with strong plantar ligaments Diaphysis - origin of intrinsic foot muscles Neck - strong intermetatarsal ligaments Metatarsal heads - weightbearing Etiology o Direct vs. indirect force Direct - crushing, blunt trauma or penetrating injuries Indirect - axial loading o Stress Overuse: Running or dancing Decrease bone density: Amenorrhea o Head: Direct trauma o Neck: Shearing force vs. direct trauma o Mid shaft: Direct, blunt vs. torsional o Base: Direct trauma = motor vehicle accident or fall from a height o First metatarsal: Crush vs. twisting o Central metatarsals: Direct impact or crushing o Fifth metatarsal: Plantarflexion + inversion vs. direct impact Epidemiology: 35% of foot fractures
Gross Pathologic & Surgical Features
*
Fifth metatarsal > 3rd > 2nd > 1st > 4th for gross involvement Stress mechanism to complex trauma Malalignment post fracture = displacement, shortening, or angulation
Clinical profile o Stress - focal tenderness + pain with activity (diaphysis or neck most common) o First metatarsal - altered gait
Demographics Age: Stress fractures: Young runners, dancers, marchers Gender o Females more susceptible in military context (thinner cortices) o Level of fitness most important determinant (stress fractures)
Natural History & Prognosis Bridging callus - good prognosis Complications: Non-union, malunion, unresolving pain
Treatment Conservative o Stress fracture - decreasedlaltered activity to immobilization o Head - closed treatment if intact nondisplaced articular surface o Neck, base, central, fifth = immobilization/cast for nondisplaced fractures Surgical: Head, neck, mid shaft, base, lst, central, 5th for displacement o Open reduction with internal fixation (ORIF)
D~ACNOST~C CHECKLIST 1Consider Metatarsal marrow edema often indicative of a stress fracture ,Axial Diane to visualize Lisfranc tarsometatarsal articulations
1 SELECTEDREFERENCES .-
1.
2.
Microscopic Features Fracture site o Hematoma o Revascularization o Primary healing vs. callus
Staging, Grading or Classification Criteria Stewart classification of fifth metatarsal base fractures o Type I: Jones fracture o Type 11: Intraarticular o Type 111: Avulsion o Type IV: Comminuted intraarticular o Type V: Apophysis
(CLINICALISSUES Presentation Most common signs/symptoms: Pain at fracture site
l
3. 4. 5.
Banks A et al: McGlamry's comprehensive textbook of foot and ankle surgery. Metatarsal fractures. vol 1. 3rd ed. Philadelphia PA, Lippincott Williams & Wilkins, (55):1775-90,2001 Ashman CT et al: Forefoot pain involving the metatarsal region: ~ifferentialdiagnosis with MR imaging. Radiographics 21(6):1425-40, 2001 Harmath C et al: Stress fracture of the fifth metatarsal. Orthopedics 24(2):111, 204-8 Review, 2001 Chowchuen P et al: Stress fractures of the metatarsal heads. Skeletal Radio1 27(1):22-5, 1998 Harrington T et al: Overuse ballet injury of the base of the second metatarsal. A diagnostic problem. Am J Sports Med 21(4):591-8, 1993
METATARSAL FRACTURES
I IMAGE GALLERY Tvaical
(Lefr) Axial T I Wl MR shows first distal transverse metatarsal fracture. (Right) Axial FS PD FSE MR shows diaphyseal fracture with hyperintense marrow edema and soft tissue reaction. Asymmetric periosteal reaction is noted.
Typical (IRfr) Axial FS PD FSE MR shows hyperintense marrow edema (arrow) in a fracture of the base of the fifth metatarsal (Jones fracture). (Right) Axial T 1 Wl MR shows diffuse hypointense edema and sclerosis of a proximal second metatarsal fracture.
LISFRANC FRACTURE-DISLOCATION
Axial graphic shows fracture of the base of the 1st metatarsal with disruption of Lisfranc's ligament. Homolateral displacement of the metatarsals is shown.
Abbreviations and Synonyms Tarsometatarsal fracture-dislocation; tarsometatarsal dislocation
Definitions Dorsal dislocation as homolateral or divergent + associated fractures at tarsometatarsal joints
Axial FS PD FSE MR shows fracture with hyperintense edema at the base of 2nd metatarsal and trabecular injury of 1st and intermediate cuneiforms. The Lisfranc ligament (arrow) is intact.
Morphology o Homolateral o Divergent o Fracture base 2nd metatarsal o Pathognomonic flock fracture proximal medial 2nd metatarsal
Radiographic Findings Radiography o Lateral view: Uneven osseous dorsal contour o AP view: Metatarsal cuneiform offset o Stress radiographs
CT Findings
General Features Best diagnostic clue: Lateral offset lateral aspect 1st metatarsal relative to medial cuneiform + medial aspect 2nd metatarsal relative to medial aspect intermediate cuneiform Location o Fractures at bases 2nd and 3rd metatarsals o Dislocation metatarsocuneiform joint o Lateral shift 2nd - 5th metatarsals o Homolateral - 1st to 5th metatarsals dislocated laterally o Divergent - 1st metatarsal medially dislocated Size: Variable based on associated ligament disruption, fractures and static vs. dynamic displacement of metatarsals
NECT
o Direct axial o Superior to standard radiography: Tarsometatarsal joints without overlap o Dislocation detection as subtle as 1 mm o Confirms chip fractures
M R Findings TlWI o Axial: Lateral displacement 1st to 5th homolaterally; 1st metatarsal medially dislocated + lateral dislocation metatarsals 2 through 5 in divergent form
I
DDx: Lisfranc Fracture-Dislocation Ant. Process Fx
Ax FS PD FSE MR
Sag FS PD MR
Sag T l Wl MR
Ax TlWl MR
LISFRANC FRACTURE-DISLOCATION Key Facts Imaging Findings
Pathology Forced plantar flexion of forefoot on rearfoot (e.g., stepping off curb) Direct: Blow/crush (e.g., foot run over by motor vehicle) Osseous avulsion (Lisfranc ligament)
Best diagnostic clue: Lateral offset lateral aspect 1st metatarsal relative to medial cuneiform + medial aspect 2nd metatarsal relative to medial aspect intermediate cuneiform Homolateral - 1st to 5th metatarsals dislocated laterally Divergent - 1st metatarsal medially dislocated
Clinical Issues Most common signs/syrnptoms: Pain tarsometatarsal joint and midfoot Pain with weightbearing
Top Differential Diagnoses Lateral Ligamentous Sprain Jones Fracture Navicular Fracture Subtalar Sprain
Diagnostic Checklist Identify Lisfranc ligament between medial cuneiform
& proximal 2nd metatarsal
Thickened or attenuated scarred ligaments Inversion of plantar flexed ankle
o Fractures hypointense at base 2nd or 3rd
metatarsals, mediallintermediate cuneiform or navicular o Impaction injury cuboid + abduction deformity forefoot = lateral column shortening o Disruption dorsal arch on direct coronal (2nd metatarsal normally at apex of arch) o Intermediate signal or discontinuity Lisfranc ligament medial cuneiform to medial proximal 2nd metatarsal o Hypointense edema at Lisfranc's ligament avulsion fracture, proximal medial aspect 2nd metatarsal T2WI o Hyperintense subchondral marrow edema tarsometatarsal joints = chip or trabecular fractures o Oblique (Lisfranc) ligament frayed or torn & synovitis and hyperintensity o Intramedullary hyperintensity in displaced metatarsals seen in cross section on direct coronal plane o Arterial injury on coronal images o Charcot arthropathy with superimposed neuropathic hyperintensity throughout midfoot + Lisfranc fracture-dislocation o Cuboid marrow hyperintensity with trabecular impaction injury o Widening lst/2nd metatarsal interspace-axial plane
Jones Fracture Fifth metatarsal base fracture Avulsion force + supination of foot
Navicular Fracture May involve naviculocuneiform & calcaneocuboid joints Repetitive stress - running + jumping Body fractures 2" to axial compression Avulsion fracture of tuberosity - pull of tibialis posterior Dorsal avulsion - talonavicular or deltoid + forced plantar flexion
Subtalar Sprain Mild to complete subtalar + talonavicular dislocation Associated with lateral ankle sprain o Superficial layer (lateral root inferior extensor retinaculum, lateral talocalcaneal, calcaneofibular, posterior talocalcaneal + medial talocalcaneal) o Intermediate layer (intermediate root inferior extensor retinaculum + cervical ligament) o Deep layer (medial root inferior extensor retinaculum + interosseous talocalcaneal ligament)
Bifurcate Sprain
Imaging Recommendations
Ligament spans from anterior process calcaneus to navicular and cuboid Midfoot remains stable with this injury Anterior process fracture
Best imaging tool o MR sensitive to nondisplaced fractures with presence of marrow edema o CT delineates cortical detail of chip fractures after initial workup with MR Protocol advice: T1 and FS PD FSE axial images with entire midfoot tarsometatarsal articulation in plane
I DIFFERENTIAL DIAGNOSIS Lateral Ligamentous Sprain
1 PATHOLOGY General Features
1
Partial or complete tear localized to anterior talofibular ligament (ATFL) or calcaneofibular ligament (CFL)
General path comments o Relevant anatomy Recessed second metatarsal base Metatarsals bound by transverse dorsal + stronger plantar ligaments
LISFRANC FRACTURE-DISLOCATION No ligament directly attaching 1st metatarsal base to base of lesser (2nd-5th) metatarsals Dorsal medial ligament (medial cuneiform - 1st metatarsal) Lisfranc ligament medial cuneiform to 2nd metatarsal base (medial aspect 2nd metatarsal base) * Etiology 0 Forced plantar flexion of forefoot on rearfoot (e.g., stepping off curb) o Plantarflexed foot + longitudinal force (e.g., equestrian injury - foot caught in stirrup) 0 Direct: Blow/crush (e.g., foot run over by motor vehicle) 0 Motor vehicle + industrial injuries = majority * Epidemiology 0 1 in 55,000 people per year o 0.2% of all fractures o 67% motor vehicle related; motorcade + crush = high energy injuries o < 1% dislocations
o Shortening foot o Forefoot abductedladducted o Palpation dorsal or plantar displacement 2nd
metatarsal o Plantar ecchymosis sign o Pain with weightbearing o Excessive range of motion (hypermobility)
Demographics Age o High energy trauma not age specific o Athletic injury in younger population (collegiate age): Basketball, running, gymnastics, football 0 Charcot arthropathy in older diabetic population Gender: Increase male predominance in athletic activities and motorcycle accidents
Natural History & Prognosis Initial evaluation - 20% missed diagnosis Delayed treatment - chronic instability Complication - compartment syndrome Long term morbidity high Osteoarthritis - posttraumatic arthritis Fracture-dislocation/instabilityrequires surgical treatment
Gross Pathologic & Surgical Features Osseous avulsion (Lisfranc ligament) Lisfranc ligament disruption Homolateral displacement all rays laterally Divergent displacement - 1st ray medial, 2nd-5th rays laterally Widened intermetatarsal space (between 1st + 2nd) Malalignment metatarsals and cuneiforms Associated fractures
Treatment Conservative 0 Rest, ice, compression, elevation (RICE) o Non-weight bearing o Stretchtpartial tear capsule + ligament use cast boot o Physical therapy + orthotic Surgical o Nondisplaced unstable - percutaneous wire fixation o Displaced or angled - open reduction with internal fixation (ORIF) with cannulated screws 0 Anatomic reduction improves outcome
Microscopic Features 84
Hemorrhagic elements; soft tissue edema Fracture cortical, subchondral + trabecular Ligamentous microtears to complete collagen fiber disruption Chondrolysis Arterial spasm (at risk - branch between dorsalis pedislplantar arterial arch)
Staging, Grading or Classification Criteria Type A 0 Total incongruity 0 Displacement metatarsals 1st-5th lateral or dorsoplantar Type B o Partial incongruity o Medial dislocation 1st metatarsal o Lateral dislocation tarsometatarsal joints (metatarsals 2-5) Type C o Divergent; partial or total displacement o 1st metatarsal medially + lesser metatarsals laterally
Presentation Most common signs/symptoms: Pain tarsometatarsal joint and midfoot Clinical profile o Pop or snap o Edema midfoot
Consider Align metatarsal bases with respective cuneiforms on direct axial images to show tarsometatarsal joints in same plane of section Identify Lisfranc ligament between medial cuneiform & proximal 2nd metatarsal Use direct coronal images to appreciate dorsallplantar displacement
[SELECTEDREFERENCES
I
Peicha G et al: The anatomy of the joint as a risk factor for Lisfranc dislocation and fracture-dislocation. An anatomical and radiological case control study. J Bone Joint Surg Br 84(7):981-5,2002 2. Banks A et al: McGlamry's comprehensive textbook of foot and ankle surgery. Talar fractures. vol 1. 3rd ed. Philadelphia PA, Lippincott Williams & Wilkins, 1091-152, 2001 3. Preidler KW et al: Conventional radiography, CT, and MR imaging in patients with hyperflexion injuries of the foot: Diagnostic accuracy in the detection of bony and ligamentous changes. AJR 173(5):1673-7,1999 1.
1
LISFRANC FRACTURE-DISLOCATlON IMAGE GALLERY (Lef)Axial 71 WI MR shows Lisfranc fracture with lateral displacement of the 1st and 2nd metatarsals relative to the medial and intermediate cuneiforms. (Right) Axial FS PD FSE MR shows extensive trabecular marrow edema pattern in metatarsal bases and distal cuneiforms associated with partial tearing of Lisfranc's ligament.
Typical (Left) Axial FS PD FSE MR shows more extensive pattern of cuneiform fracture involving the medial, intermediate, and lateral cuneiforrns. (Right) Axial FS PD FSE MR shows avulsion fracture with attached Lisfranc ligament. Hyperintense midfoot edema is present.
Typical (LLft) Coronal 71 Wl MR shows fracture at the level I the cuneiforms. (Right) Coronal FS PD FSE MR shows hyperintense edema and fractures of the intermediate and lateral cuneiforms.
I
OSTEOCHONDRAL LESION OF THE TALUS
Coronal graphic shows stage 111 OLT with unattached and nondisplaced chondral fragment. Associated subchondral bone marrow edema in yellow.
Coronal T I C+ MR (intraarticular contrast) shows medial talar dome OLT with attenuated overlying articular cartilage.
Morphology o Lateral: Shelllwafer shaped displaced o Medial rn Deeperlcup-shaped rn Usually not displaced
*
Abbreviations and Synonyms OLT, transchondral fracture, osteochondral fracture, osteochondritis dissecans, talar dome fracture, flake fracture
Definitions Chronic phase of compressed or avulsed talar dome fracture Ilh
I IMAGING FINDINGS General Features Best diagnostic clue: Focal talar dome subchondral hypointensity on TI, hyperintensity on T2WI Location o Medial: Middle/posterior third o Lateral: Middle or anterior o Exceptions Anteromedial corner rn Posterolateral corner Central lesions Multiple sites Size o Variable size from 1mm to > 1 cm o Perilesional edema larger than osteochondral focus
1
DDx: Osteochondral Lesion of Talus
Radiographic Findings Radiography o Conventional radiographs insensitive to occult OLT (stage I) o Unable to assess integrity of hyaline articular cartilage o Difficult to differentiate grades I, 11, 111 o Berndt and Harty's original classification rn Stage I: Subchondral compression Stage 11: Partially detached osteochondral fragment Stage 111: Completely detached fragment without displacement from crater Stage IV: Osteochondral fragment detached + displaced from crater
CT Findings NECT o Stage I Cystic lesion + intact roof o Stage IIA Cystic lesion + communication with talar dome o Stage IIB
1
OSTEOCHONDRAL LESION OF THE TALUS Key Facts Imaging Findings Best diagnostic clue: Focal talar dome subchondral hypointensity on TI, hyperintensity on T2WI Variable size from 1mm to > 1 cm Perilesional edema larger than osteochondral focus Conventional radiographs insensitive to occult OLT
Top Differential Diagnoses Osteochondral Lesion Tibia Osteonecrosis
Compressed/avulsed talar dome fracture Increased joint pressures forces synovial fluid into fracture site - prevents healing
Clinical Issues Most common signslsymptoms: Persistent ankle pain post inversion injury Swelling Catching Giving way Reduced motion
Diagnostic Checklist Coronal FS PD FSE coronal images to define morphology of overlying chondral surface Direct trauma Repetitive microtrauma Open articular surface lesion + nondisplaced fragment o Stage I11 Nondisplaced lesion + lucency o Stage IV 8 Displaced fragment
MR Findings TlWI o Detached cortical fragment: Hypointense o Attenuated or irregular subchondral plate o Subchondral lesion: Hypointense to intermediate (function of fluid and fibrous tissue) o Subchondral edema: Hypointense T2WI o Fluid: Hyperintense o Hypointense reactive bone sclerosis o Adjacent subchondral talar marrow edema rn Extends beyond focus of necrosis Hyperintense on FS PD FSEISTIR o Chondral thinning, bowing, nodularity and disruption (fissures and flap lesions) o Unattached fragment: Complete ring of hyperintense fluid T1 C+ o Intravenous contrast Congruity of chondral surface rn Enhance subchondral edema Enhance synovial tissue o Intraarticular Unstable fragment - free fragmentlloose body Communication with subchondral cyst MR classification (TI + T2WI) o Stage I: Subchondral trabecular compression and marrow edema o Stage IIA: Subchondral cyst o Stage 11: Incomplete separation fragment o Stage 111: Unattached, nondisplaced fragment + synovial fluid surrounding fragment o Stage IV: Displaced fragment
Imaging Recommendations Best imaging tool: MR: Superior for articular cartilage + marrow edema Protocol advice o FS PD FSE all orthogonal planes o 10 cm FOV coronal FS PD FSE to define talar chondral surface o TlWI to correlate lesion subchondral sclerosis
I DIFFERENTIAL DIAGNOSIS Osteochondral Lesion Tibia Similar subchondral
* chondral lesion tibia
Osteonecrosis Sclerosis subchondral bone with infarct like morphology
Fracture Sclerosis or edema in body fractures; discrete linear fracture line identified Talar neck fracture complicated by avascular necrosis (Am)
*
Arthritis Usually posttraumatic Joint space narrowing
Transient Osteoporosis Edema without subchondral lesion Resolution on follow up MR
1 PATHOLOGY General Features General path comments o Relevant anatomy Wider anterior talus Narrower posterior talus Ankle mortise = medial + lateral malleolus Etiology
OSTEOCHONDRAL LESION OF THE TALUS Direct trauma Repetitive microtrauma Compressed/avulsed talar dome fracture Trauma + predisposition to talar dome ischemia Increased joint pressures forces synovial fluid into fracture site - prevents healing o Subchondral fracture susceptible to AVN o Torsional impaction o Lateral lesions Strong inversion force + dorsiflexed foot + internal rotation tibia Lateral talar margin impacted/compressed against medial fibula = shear end compression o Medial lesions Strong inversion force + plantarflexed foot + lateral rotation tibia on talus (external rotation) Posteromedial edge talar dome impacted against posteromedial tibia + shear stress o Shear stress > bone = subchondral fracture + intact articular cartilage o Shear stress > bone + cartilage = complete displaced osteochondral lesion Epidemiology o 0.09% of all fractures o 1% of talar fractures o 4% of cases of osteochondritis o 6.5% of sprained ankles o Lateral lesions (44%):Trauma (94%) o Medial lesions: Trauma (62%) o Bilateral (10 to 30%)
o o o o o
Cross Pathologic & Surgical Features HII
Presentation Most common signs/symptoms: Persistent ankle pain post inversion injury Clinical profile o Chronic ankle painlsprain o Stiffness o Swelling o Ecchymosis o Catching o Clicking o Locking o Giving way o Reduced motion
Demographics Age o Average age = 25 years o Also occurs fifthlsixth decades o Children - not common Gender: Male = 67%; female = 33%
Natural History & Prognosis Joint stiffness Ankle instability Stable fragment = healing Healing + motion = fibrous tissue at fracture + sequestration Degenerative arthritis
Treatment Conservative o Stage I and 11, medial stage I11 lesions o Reduced activity, limited ankle motion - stage I o Casting - acute stage I1 Surgical = stage I11 + IV lesions o Free fragment excision o Curettage o Drilling o Abrasion arthroplasty Complications o Continued pain o Degenerative joint arthrosis
Cartilage o ~oft,k-ayed Subchondral plate defectlcyst Loose bodies Effusion Stable vs. unstable fragment in crater
Microscopic Features Cartilage o Chondrocytes viable o Fibrillation o Fissures o Fracture Fibrous granulation tissue Poor capillary ingrowth Trabecular compression and necrosis subchondral bone Synovial hyperplasia
1 DIAGNOSTIC CHECKLIST I
Consider TlWI most accurate to assess sclerosis Do not overestimate size of lesion by including adjacent marrow edema in lesion dimensions Coronal FS PD FSE coronal images to define morphology of overlying chondral surface
Staging, Grading or Classification Criteria Surgical grade - articular cartilage o Grade A: Smooth, intact + soft o Grade B: Rough surface o Grade C: Fibrillations/fissures o Grade D: Flaplexposed bone
o Grade E: Loose, undisplaced fragment
o Grade F: Displaced fragment
~ C T E REFERENCES D 1. 2.
Banks A et al: McGlamry's comprehensive textbook of foot and ankle surgery. vol 1. Philadelphia PA, Lippincott Williams & Wilkins, (35):1091-152, 2001 Loredo R et al: Imaging of osteochondral injuries. Clin Sports Med 20(2):249-78, 2001
I
OSTEOCHONDRAL LESION OF THE TALUS
Typical
(Left) Coronal FS PD FSE MR shows stage 111 OLT with joint fluid undermining the osteochondral fracture. There is interruption of the subchondral plate with associated bone marrow edema. (Right) Coronal FS PD FSE MR shows hyperintense surgical drilling tract for the treatment of a stage 111 OLT.
(Lef)Coronal graphic shows stage 11 OLT with partial osteochondral fracture. Bone marrow edema in yellow. (Right) Coronal graphic shows stage IV OLT with loss of articular cartilage, interruption of the subchondral plate, and displaced medial fragment. There is a lack of bone marrow edema in this chronic lesion.
Typical
(Left)Axial graphic shows the posteromedial (cup-shaped) and anterolateral (wafer-shaped) appearance of OLT. (Right) Surgical pathology showing the posteromedial OLT location in the talar dome.
AVASCULAR NECROSIS (AVN) OF THE TALUS
Sagittal graphic shows subchondral ischemic focus (dark) of the talus with associated diffuse bone marrow edema pattern.
Sagittal T l Wl MR shows central marrow containing ischemic region outlined by sclerotic periphery
o Dome of talus o Localized subchondral rarefaction = Hawkins sign,
indicative of intact blood supply
Abbreviations and Synonyms Avascular necrosis of the talus (AVN); osteonecrosis of the talus
Definitions Ischemic injury to the talar bone
o Body of talus with increased density relative to
adjacent osseous structures = AVN (osteolysis with well-marginated sclerotic rim)
CT Findings -
I IMAGING
o Subchondral sclerotic region = AVN
-
FINDINGS
General Features Best diagnostic clue: Localized subchondral ischemic focus + bone marrow edema Location o Central subchondral talus (talar dome) o Diffuse infarction pattern entire body of talus Size: Variable from small focus to entire talar volume Morphology o Well-demarcated linear subchondral lesion o Long axis directed from anterior to posterior o Ovoid ischemic area with sharply defined serpiginous perimeter o Diffuse bone infarct pattern with serpiginous sclerotic border
Radiographic Findings
NECT o Subchondral fracture o Collapse of articular surface o Mixed sclerotic pattern o Assess percentage of affected talus
MR Findings TlWI o Small hypointense necrotic focus superior talar dome o Hypointense sclerotic line directly adjacent to subchondral plate o Hypointense sclerotic line marginating central marrow fat signal o Diffuse osteonecrosis: Serpiginous bone infarct pattern o Association with talar neck fractures T2WI o Ischemic focus remains hypointense
Radiography
DDx: Avascular Necrosis of the Talus
Cor FS PD MR
Sag PD FSE MR
Sag FS PD MR
Ax FS PD FSE MR
AVASCULAR NECROSIS (AVN) OF THE TALUS
-
Key Facts Atraumatic
Imaging Findings Best diagnostic clue: Localized subchondral ischemic focus + bone marrow edema Central subchondral talus (talar dome) Diffuse infarction pattern entire body of talus Marrow edema most hyperintense adjacent to ischemic focus (with ischemia, edema commonly seen with focus of AVN) on T2WI
Top Differential Diagnoses Osteochondral Lesion of the Talus (OLT) Osteoarthritis Bone Marrow Edema Syndrome Osteomyelitis
30 Talar neck fracture Subtalarltalar dislocation
70%
Clinical Issues Most common signs/symptoms: Pain with weight bearing Limited range of motion Effusion Bilateral with asynchrony Delayed onset AVN: 3 months or greater post trauma
Diagnostic Checklist Repeat with serial MR to document resolution of edema to help define AVN focus
Pathology Post-traumatic -
-
o Disproportionate hyperintense diffuse marrow
edema o Signal-void secondary to necrosis centrally with hyperintense rim (fat suppressed sequences) o Marrow edema most hyperintense adjacent to ischemic focus (with ischemia, edema commonly seen with focus of AVN) on T2WI o Chronic Resolution of bone marrow edema Persistent well demarcated focus osteonecrosis o Double line sign Hypointense outer line (sclerosis + fibrosis) Hyperintense inner line (granulation tissue) T1 C+: Enhancement - periphery of necrosis
Imaging Recommendations Best imaging tool: MRI - to diagnose and determine extent of talar involvement Protocol advice o Coronal and axial TlWI and FS PD FSE MR o High resolution coronal or sagittal TlWI to identify subtle subchondral fracture o T1 C+/fat suppression to assess reparative process
1 DIFFERENTIAL DIAGNOSIS Osteochondral Lesion of the Talus (OLT) Chronic phase of compressedtavulsed talar dome fracture Cup-shapedtdeep medial lesions Wafer-shapedtthin lateral lesions Less extensive pattern of talar edema
Osteoarthritis Joint space narrowing Osteophytes Sclerosis both sides tibiotalar joint No discrete ischemic focus
Bone Marrow Edema Syndrome Transient + self-limiting No associated subchondral ischemic focus
Edema may be centered in distal 112 of talus (talar head and neck)
Osteomyelitis Erosions Soft tissue involvement including sinus tracts Adjacent joint involvement
Tumors Trabecular destruction Cortical breakthrough Space-occupying Matrix often appreciated
1 PATHOLOGY General Features General path comments o Relevant anatomy Neck of talus - susceptible to fracture Subtalar region - dislocation Posterolateral corner talus = poorest blood supply Etiology o Post-traumatic Talar neck fracture Talar dislocation o Atraumatic = Vasculitis or fattarterial embolism Diabetes mellitus Systemic lupus erythematosus/vasculitis Sickle cell anemia Corticosteroids Epidemiology o Incidence: Less frequent relative to AVN of femoral head, Kienbock's, scaphoid fracture necrosis and Freiberg's 0 40%AVN: Talar neck fracture + subtalar dislocation 0 90%AVN: Complete talar dislocation + subtalar dislocation o 100%AVN: Comminuted fracture body of talus o Bilateral involvement: 30 to 70%
AVASCULAR NECROSIS (AVN) OF THE TALUS Gross Pathologic & Surgical Features Talar neck fracture Subtalarltalar dislocation Disruption tarsal canal artery - a posterior tibia1 artery branch Subchondral collapse + necrotic focus Focal vs. entire body of talus
1 DIAGNOSTIC CHECKLIST Consider Bone marrow edema syndrome without focal necrotic focus Repeat with serial MR to document resolution of edema to help define AVN focus Exclude bilateral involvement if atraumatic etiology
Microscopic Features Arteriallvenous insufficiency Intraluminal capillary obstruction and compression Ischemic marrow edema Increased intraosseous pressure Necrosis (vascular insufficiency) Trabecular insufficiency and subchondral plate fracture
Staging, Grading or Classification Criteria 0: Ischemia
I: Necrotic focus + edema 11: Large defined necrotic area 111: Subchondral fracture (analogous to Ficat 111 in hip) IV: Subchondral collapse + secondary osteoarthrosis
Presentation Most common signslsymptoms: Pain with weight bearing Clinical profile o Inability to walk o Limited range of motion o Effusion o Compensatory weight shift o Bilateral with asynchrony
Demographics Age: Peak = fourth decade Gender: Not specific
Natural History & Prognosis Delayed onset AVN: 3 months or greater post trauma Revascularization of avascular fragment: Up to 24 months Risk of osseous collapse: Dependent on vertical load Collapse and repair = change in talar morphology Osteoarthritis: Degenerative process o Joint space narrowing o Ankylosis
Treatment Conservative o Protection from weight bearing during revascularization phase o Bracing o Nonsteroidal antiinflammatory agents o Orthotic support Surgical o Anatomic reduction of talar fracture: Screw fixation o Decompression (core) of necrosis o Debridement and autogenous grafting o External fixation o Ankle and subtalar arthrodesis
Fitzgerald RH et al: Orthopaedics. Trauma. 2nd ed. St. Louis Missouri, Mosby Inc 250-6, 2002 Banks A et al: McGlamry's comprehensive textbook of foot and ankle surgery. Talar fractures. vol 1. Philadelphia PA, Lippincott Williams & Wilkins 1865-96, 2001 Myerson M: Foot and ankle disorders. Fractures of the Hindfoot. vol2. Philadelphia PA, Lippincott Raven 1297-340,2000 Agnew PS: Avascular necrosis of the talus in a toddler. J Foot Ankle Surg 34(2):132-4, 1995 Mitchell MJ: The foot and ankle. Top Magn Reson Imaging 157-73, 1989 DeLee JC et al: Subtalar dislocation of the foot. J Bone Joint Surg 433-7, 1982 Dunn A: Peritalar dislocation. Orthop Clin North Am 7-18, 1974 Hawkins LG: Fractures of the neck of the talus. J Bone Joint Surg Am 52A:991-1002, 1970 Detenbeck LC et al: Total dislocation of talus. J Bone Joint Surg 283-8,1969
-
AVASCULAR NECROSIS (AVN) OF THE TALUS
(Left) Sagittal graphic shows diffuse pattern of talar osteonecrosis. (Right) Sagittal T l Wl MR shows diffuse infarct pattern involving the entire talus.
(Left) Sagittal FS PD FSE MR shows hyperintense marrow edema of the talar body associated with a subtle ischemic focus. (Right) Sagittal FS PD FSE MR shows hyperintense periphery in localized ischemia of the talus.
Variant (Left) Sagrttal FS PD FSE MR shows regronal mrgratory osteoporosrs wrth hyperrntense signal rnvolving the talar head and neck N o fracture or ischemic focus s rdentrfied (Right) Sagrttal graphrc shows osteomyelrtrs ~nvolvmgthe metaphyseal equrvalent locatrons of the talus (not to be rnrstaken for AVN)
-
FREIBERG'S INFRACTION
Sagittal graphic shows Freiberg's infraction with osteonecrosis of the 2nd metatarsal head.
Axial T l Wl MR shows sclerosis and flattening of the distal subchondral plate with mild hypertrophy of the metatarsal head.
o Advanced changes with more extensive involvement
of distal metatarsal associated with central collapse and articular cartilage separation Morphology o Flattening metatarsal head o Periostitis o Cortical thickening adjacent metaphysis + diaphysis o Cystic lesion metatarsal head o Enlargement metatarsal head
Abbreviations and Synonyms Freiberg disease; Kohler-Freiberg disease
Definitions Articular osteochondrosis metatarsal head
Radiographic Findings
I
94
General Features Best diagnostic clue: Sclerosis and flattening of second metatarsal head Location o Most frequently involves second metatarsal head o Less common involvement of third + fourth metatarsal heads o Rarely first metatarsal heads o Unilateral characteristic o Bilateral involvement and changes in two or more metatarsal heads possible Size o Initially restricted to distal dorsocentral subchondral bone o Focal hypointense sclerosis
Radiography o Initial radiographs normal o Subtle flattening distal subchondral plate o Increased sclerosis o Cystic lucency o Metatarsophalangeal (MTP) joint widening to joint space collapse o Osteochondral fragment o Periostitis o Metatarsal metaphysis + distal diaphysis cortical thickening o Premature physeal closure o MTP joint osseous fragments o Endstage with marked metatarsal head flattening + hypertrophy
CT Findings NECT
DDx: Freiberg's Infraction Midfoot Arthritis
MTP Arthritis
'
A
R
.
Sag T1 WI M R
\x T l Wl M R
Sag T1WI M R
FREIBERG'S INFRACTION Key Facts Single event or repeated microtrauma Vascular damage/compression Long involved second metatarsal: 85%
Imaging Findings Best diagnostic clue: Sclerosis and flattening of second metatarsal head Most frequently involves second metatarsal head Initially restricted to distal dorsocentral subchondral bone Variable degenerative subchondral marrow change with hyperintense edema
Clinical Issues Most common signs/symptoms: Localized pain (metatarsalgia) Focal tenderness Swelling ~ecrea&drange of motion at MTP joint Peak = 11 to 17 years Gender: M:F = 1:3 up to 1:11
Top Differential Diagnoses Osteoarthritis Trauma Rheumatoid Arthritis
Diagnostic Checklist Confirm contour abnormality of metatarsal head
Pathology Long 2nd metatarsal susceptible to increased stresses Trauma is primary event
Hallux valgus o Hyperostosis + cystoid osseous transformation o Bursitis
o Metatarsal head deformity on sagittal reformations
o Sclerosis + osteophytes using bone window
algorithm
Trauma
MR Findings
Stress fractures + osseous contusions o Subchondral marrow edema without metatarsal head flattening
TlWI o Hypointense sclerosis o Subchondral plate flattening metatarsal head on sagittal images o Fragmentation subchondral plate T2WI o Variable degenerative subchondral marrow change with hyperintense edema o Hyperintense joint effusion MTP joint o Intermediate to hypointense loose bodies o Fragmentation of chondral surface metatarsal head on FS PD FSE images
Rheumatoid Arthritis Metatarsal heads commonly involved o Involvement from lateral to medial Forefoot deformities o Hallux valgus o Hammer toe o MTP joint lateral subluxation o Dorsiflexion + lateral deviation of toes o Interphalangeal + intertarsal erosions later in disease
Imaging Recommendations
Calcium Pyrophosphate Dihydrate Crystal Deposition
Best imaging tool: MRI subsequent to conventional radiography Protocol advice o TI axial and sagittal images to assess sclerosis o FS PD FSE axial and sagittal images for chondral surface evaluation o Direct coronal FS PD FSE for MTP joint capsule visualization in cross section
[DIFFERENTIALDIAGNOSIS Midfoot Arthritis
'
Degenerative sclerosis
Productive + erosive process T2* images to identify crystal deposition
Diabetes Mellitus Neuropathic arthropathy o Destructive arthropathy with erosive + productive changes
1
Gout First MTP joint o ~ o u t tbphus y o Normal bone density o Sharply marginated erosions
Metatarsal Phalangeal JointArthritis Joint space narrowing + sclerosis 1st or 2nd digits
Lisfranc Fracture Tarsometatarsal articulation
Neuropathic Joint Erosion, sclerosis, + marrow changes
Osteoarthritis Degenerative changes in malpositioned toes
1 PATHOLOGY General Features General path comments o Relevant anatomy m Long 2nd metatarsal susceptible to increased stresses
FREIBERG'S INFRACTION Second metatarsal head epiphysis unique vascular pattern of penetrating radial arteries to periosteal shaft network Etiology o Trauma is primary event Single event or repeated microtrauma o Vascular damage/compression o Long involved second metatarsal: 85% o Biomechanical stress (e.g., high heel shoes) Distribution o Unilateral involvement predominates
o Dorsal osteophyte o Loose body o Proliferative changes proximal aspect adjacent
proximal phalanx o Complications
Related to fragmentation of cartilage + subchondral bone o Prognosis Decreased symptoms with protecting metatarsal head during remodeling
Treatment
Gross Pathologic & Surgical Features
Nonoperative o Cast immobilization o Non weight bearing o Corticosteroids Surgical o Second metatarsal head debridement + synovectomy o Metatarsal head excision or reshaping o Cheilectomy of osteophytes o Dorsiflexion osteotomy o Joint replacement
Vascular occlusion Subchondral trabecular fracture Secondary compression of chondral surface Cortical thickening
Microscopic Features Necrosis trabecular marrow Revascularization o Vascular invasion from periosteum and metaphyseal regions Necrotic trabeculae resorption Subperiosteal osseous apposition
Staging, Grading or Classification Criteria Bragard classification o Stage I subchondral decreased density plus metatarsal head flattening o Stage I1 with sclerotic and radiolucent areas leading to fragmentation, metatarsal head deformity + enlargement, cortical thickening + physeal fusion o Stage I11 with degenerative osteoarthritis
Consider Confirm contour abnormality of metatarsal head Metatarsal symptoms may be related to a stress fracture Exclude an associated systemic disorder (e.g., rheumatoid arthritis)
1 SELECTEDREFERENCES 1.
Presentation Most common signs/symptoms: Localized pain (metatarsalgia) Clinical profile o Focal tenderness o Swelling o Decreased range of motion at MTP joint o Vague forefoot pain which increases with weight bearing and/or activity o Pain with extreme range of motion
Demographics Age o Peak = 11 to 17 years o Degenerative arthrosis in adulthood Gender: M:F = 1:3 up to 1:11
Natural History & Prognosis Asymptomatic to symptomatic Associated o Periarticular edema o Soft tissue thickening o Localized warmth o Synovitis Antalgic gait to compensate for metatarsalgia Later findings o Enlarged metatarsal head
2.
3.
4.
5. 6. 7.
Banks A et al: McGlamry's comprehensive textbook of foot and ankle surgery. Osteochondroses of the foot and ankle. vol 1. Philadelphia PA, Lippincott Williams & Wilkins, (66):2075-96, 2001 Myerson M: Foot and ankle disorders. Osteochondroses of the foot. vol2. Philadelphia PA, Lippincott Raven, (31):785-99, 2000 Chao KH et al: Surgery for symptomatic Freiberg's disease: Extraarticular dorsal closing-wedge osteotomy in 13 patients followed for 2-4 years. Acta Orthop Scand 70(5):483-6, 1999 Maresca G et al: Arthroscopic treatment of bilateral Freiberg's infraction. Arthroscopy 12(1):103-8, 1996 Kinnard P et al: Freiberg's disease and dorsiflexion osteotomy. J Bone Joint Surg Br. 864-5, 1991 Walsh HPJ et al: Etiology of Freiberg's disease: Trauma. J Foot Surg 27:243-4, 1988 Wiley JJ et al: Freiberg's disease. J Bone Joint Surg Br 63:459. 1981
FREIBERG'S INFRACTION
1
IMAGE GALLERY Typical (Left) Sagittal T I WI MR shows early flattening of the metatarsal head in Freiberg's infraction. Osteonecrosis is hypointense. (Right) Coronal STIR MR shows hyperintense edema in the necrotic focus in the distal metatarsal head.
Typical (Left) Axial T l Wl MR shows focal well marginated sclerosis of 2nd metatarsal head. There is no fragmentation of the subchondral plate. (Right) Sagittal FS PD FSE MR shows dorsocentral flattening of the metatarsal head with adjacent subchondral bone marrow edema.
(Left) Axial T l Wl MR shows advanced changes of Freiberg's infraction with flattening and fragmentation of the 2nd metatarsal head. (Right) Axial FS PD FSE MR shows subchondral cystic changes adjacent to fragmentation of subchondral plate.
I
I
MEDlAL TlBlAL STRESS SYNDROME
Coronal graphic shows grade 11 medial tibial stress syndrome with bone marrow and periosteal edema.
Axial FS PD FSE MR shows hyperintense anteromedial periosteal edema (arrow) in grade I medial tibial stress syndrome.
o Eccentric curvilinear to more diffuse marrow signal
change
Abbreviations and Synonyms
.
Radiographic Findings
Medial tibial stress; shin splint syndrome; shin splints
Definitions
Radiography o Usually negative o i Posteromedial tibial cortex - hypertrophy (remodeling)
Leg pain + discomfort secondary to repetitive overuse in running + hiking
MR Findings TlWI o Intermediate signal within deep subcutaneous tissue overlying medial tibial cortex o Intermediate signal within normally hypointense cortex o Eccentric hypointense marrow in medullary bone of diaphysis T2WI o Linear hyperintense periosteal edemalfluid in direct contact with medial tibial cortex o Anteromedial to posteromedial extension o Hyperintense edemalfluid extends to orgin of soleus posteromedially (soleus bridge) o Marrow hyperintensity (common anterior or posteromedially) o Intermediatethyperintense focus or linearity anterior tibial cortex TI C+ o May enhance medial periosteal interface
General Features Best diagnostic clue: Hyperintense edemalfluid signal (T2WI) medial tibial border Location o Posteromedial to anteromedial tibia o Medial periosteum o Intracortical o Medullary cavity Size o Middle + distal third of leg o 4 cm proximal to medial malleolus k proximal extension up to 12 cm Morphology o Linear edemalfluid applied to medial periosteum o Linear to globular intracortical increased signal
Hmm DDx: Medial Tibia1 Stress Syndrome
-*
Fascia Herniation
Ax FS PO FSE MR
Ax TIWl MR
+$.&-.*. 3~:-
\
Saa T l Wl MR
Cellulitis
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Ax FS PO FSE MR
Ax FS
4R
MEDIAL TIBIAL STRESS SYNDROME -
Key Facts Imaging Findings Best diagnostic clue: Hyperintense edemalfluid signal (T2WI) medial tibia1 border Linear hyperintense periosteal edemalfluid in direct contact with medial tibia1 cortex Anteromedial to posteromedial extension Hyperintense edemalfluid extends to orgin of soleus posteromedially (soleus bridge)
Top Differential Diagnoses Stress Fracture of the Tibia Deep Venous Thrombosis (DVT) Gastrocnemius - Soleus Strain Cellulitis
o Variable marrow enhancement
Nuclear Medicine Findings Bone Scan o Radionuclide activity posteromedial border tibiadelayed images - involves 113 length of tibia o Perfusion and blood pool phases = normal in medial tibial stress o Uptake - soleus muscle origin (posteromedially)
Imaging Recommendations Best imaging tool: MR more specific for staging and morphology of medial tibial stress Protocol advice o Axial FS PD FSE or STIR images required o Sagittal/coronal plane to visualize longitudinal extent of tibial involvement in a single image
1 DIFFERENTIAL DIAGNOSIS Stress Fracture of the Tibia Transverse fracture Posteromedially (compression side of tibia) Continuum from medial tibial stress syndrome to frank fracture Interruption of cortex
Deep Venous Thrombosis (DVT) Perivascular hyperintensity - neurovascular bundle at or distal to popliteal fossa Enlargement and thrombus popliteal vein Muscle infarct Venous Doppler confirmation
Gastrocnemius - Soleus Strain Medial head gastrocnemius strain Hyperintense edema or hemorrhage medial head gastrocnemius
Cellulitis Subcutaneous edema extension beyond anterior/posteromedial tibia
Pathology
Periosteal avulsion + periostitis = medial soleus insertional stress Velocity of pronation = stresslstrain of supporting musculature + soleus bridge
Clinical Issues Most common signslsymptoms: Tenderness posteromedial tibial border - mid to distal third Pain on exertion
Diagnostic Checklist FS PD FSE or STIR to identify subtle periosteal edema requires axial plane of section
Popliteal Artery Entrapment Syndrome Exercise - induced claudication
Anomalies or anatomic variation of popliteal artery fibrous bands, third head of gastrocnemius
Chronic Exertional Compartment Syndrome Increased compartmental pressure in leg with exercise Compartment tightness to palpation
Accessory Soleus k Overuse symptoms with exercise Fullness or bulge medial ankle + lower 113 leg Sensory nerve findings k Calcaneal nerve involvement Less commonly plantar nerve involvement
Fascial Herniation Localized asymmetric bulge or prominence of muscle group contour without muscle strain
/ PATHOLOGY General Features General path comments o Relevant anatomy Soleus bridge = medial origin of investing fascia posteromedially Deep posterior compartment = anterior to soleus muscle Etiology o Periosteal avulsion + periostitis = medial soleus insertional stress o Velocity of pronation = stresslstrain of supporting musculature + soleus bridge o Hyperpronation foot - increase stress medial soleus 0 Not related to tibialis posterior overload o Varus hindfoot o Genu valgum o Excessive femoral anteversion 0 External tibial torsion o Decreased heel cord flexibility 0 Change in activity or intensity of training
MEDIAL TIBIAL STRESS SYNDROME Epidemiology o 13% of injuries in runners o 4.07% in Naval Academy cadets
o Cushion insoles to decrease velocity of foot
pronation on heel strike (decreases eccentric muscle stress) Surgical o Resistant medial tibial stress syndrome o Release soleus investing fascia o Cauterization posteromedial tibial periosteum
Gross Pathologic & Surgical Features Hypertrophy posteromedial tibial cortex Surface scalloping anterior or medial tibia Avulsion periosteum Periostitis + inflammatory response
Microscopic Features Increased erythrocytes - vascular congestion + thrombosis within bone Osteoclastic resorption Periosteal reaction - increase in osteoblasts Osseous remodeling Periosteal callus - cortical hypertrophy Increased mineralization with repetitive stress
Staging, Grading or Classification Criteria Grade I: Periosteal edema (TZWI) Grade 11: Periosteal and marrow edema (TZWI) Grade 111: Marrow edema (TI and TZWI) Grade IV: Fracture line
I DIAGNOSTIC CHECKLIST Consider Advanced grade medial tibial stress syndrome = tibial stress fracture FS PD FSE or STIR to identify subtle periosteal edema requires axial plane of section
1 SELECTED REFERENCES 1.
2. 3.
Presentation
1 00
Most common signs/symptoms: Tenderness vosteromedial tibial border - mid to distal third klinical profile o Pain with active resistance plantar flexion and toe raises o Pain on exertion o Dull ache o Soreness o Mild swelling o Tenderness more diffuse relative to complete stress fracture
4. 5. 6. 7. 8. 9. 10.
Demographics Age: Uncommon < 15 years Gender o Females at increased risk: Smaller bone size + amenorrhea in competitive runners o Female runners up to 12x risk stress fracture vs. male counterparts
Natural History & Prognosis 7-10 days - return to low impact activity Recurrent pain (premature return to training) Development complete fracture line = tibial stress fracture (end stage of medial tibial stress syndrome)
Treatment Conservative o Rest - relative o Antiinflammatory medication o Heel cord stretching o Casting o Evaluate gait mechanics + lower limb alignment o Heel cup for hindfoot valgus o Orthotic for excessive foot pronation
11. 12. 13. 14. 15. 16. 17. 18. 19.
1
DeLee JC et al: Orthopaedic sports medicine. Principles and practice. The Leg. vol 2. 2nd ed, Philadelphia PA, Saunders, (29):2155-82, 2003 Spitz DJ et al: Imaging of stress fractures in the athlete. Radio1 Clin North Am 40(2):313-31, 2002 Magnusson HI et al: Abnormally decreased regional bone density in athletes with medial tibial stress syndrome. Am J Sports Med 29(6):712-5, 2001 Bennett JE et al: Factors contributing to the development of medical tibial stress syndrome in high school runners. J Orthop Sports Phys Ther 31(9):504-10,2001 Gibbon W W Shin splits. Radiology 207(3):826-7, 1998 Beck BR: Tibia1 stress injuries. An etiological review for the purposes of guiding management. Sports Med 26(4):265-79, 1998 Anderson MW et al: Shin splints: MR appearance in a preliminary study. Radiology 204(1):177-80, 1997 Deutsch A et al: Imaging of stress injuries to bone. Clin Sports Med 16:275-90, 1997 Beck BR: Medial tibial stress syndrome. The location of muscles in the leg in relation to symptoms. J Bone Joint Surg Am 76(7):1057-61,1994 Clanton T et al: Chronic leg pain in the athlete. Clin Sports Med 13:743-59, 1994 Detmer DE: Chronic shin splints. Classification and management of medial tibial stress syndrome. Sports Med 3:436-46, 1986 Stafford S et al; MRI in stress fracture. AJR 147:553-6, 1986 Michael RH et al: The soleus syndrome. A cause of medial tibial stress (shin splints). Am J Sports Med 13:87-94, 1985 Milgrom C et al: The long term follow-up of soldiers with stress fractures. Am J Sports Med 13:398-400, 1985 Mubarak SJ et al: The medial tibial stress syndrome. A cause of shin splints. Am J Sports med 10:201-05, 1982 James SL et al: Injuries to runners. Am J Sports Med 6:40-50, 1978 Stanitski C et al: On the nature of stress fractures. Am J Sports Med 6:391-6,1978 Andrish JT et al: A prospective study on the management of shin splints. J Bone Joint Surg Am 56:1697-700, 1974 Darling R et al: Intermittent claudication in young athletes: Popliteal artery entrapment syndrome. J Trauma 14:543-52, 1974
I
MEDIAL TIIBlAL STRESS SYNDRO
1 IMAGE GALLERY (Left) Axial T I Wl MR shows hypointense anteromedial periosteal edema with normal bone marrow signal. (Right) Axial FS PD FSE MR shows hyperintense periosteal edema involving the anteromedial and posteromedial tibial periosteum in a grade I medial tibial stress syndrome.
(Left) Axial FS PD FSE MR shows hyperintense signal within the anterior medullary cavity, intracortical cystic change, and medial periosteal edema. This represents medial tibial stress syndrome in a sprinter. (Right) Axial NECT shows intracortical cystic reaction (arrow) with remodeling of repeated cortical stress fractures.
Typical (Left) Sagittal T2* GRE MR shows edema applied to the periosteum (arrow) of the anterior tibial cortex. (Right) Axial T2WI MR shows hyperintense edema extending from the medial to the lateral aspect of the distal tibia.
TARSAL COALITION
Sagittal graphic shows fibrocartilaginous coalition.
calcaneonavicular
Sagittal FS PD FSE MR shows intermediate signal with mild reactive osseous changes in calcaneonavicular fibrous coalition (arrow).
o Intraarticular = bridges (e.g., talocalcaneal)
Radiographic Findings
Abbreviations and Synonyms Coalitions
Definitions Osseous, cartilaginous or fibrous union of two or more bones involving hindfoot or midfoot
1 02
General Features Best diagnostic clue: Approximation or incorporation of talus + calcaneus through middle facet vs. calcaneus to navicular through anterior facet Location 0 Talocalcaneal 0 Calcaneonavicular o Talonavicular (less common) o Cubonavicular (less common) Size: Variable based on location + synostosis vs. synchondrosis vs. syndesmosis or combination Morphology o Synostosis = complete coalition o Synchondrosis = cartilaginous o Syndesmosis = fibrous o Extraarticular = bars (e.g., calcaneonavicular)
Radiography o Calcaneonavicular coalition 4.5" internal oblique view Comma sign = protrusion of calcaneus toward navicular on oblique view Anterior nose sign = anterior extension of calcaneus on lateral view Connecting bar between anterolateral process calcaneus + dorsal lateral margin navicular = osseous, cartilaginous, fibrous or mixed Sclerosis + osseous marrow irregularity at interface in cartilaginous + fibrous coalitions k Hypoplasia talar head Flattening navicular adjacent to calcaneus o Talocalcaneal coalition Lateral radiograph + axial views (Harris-Beath)for visualization posterior and middle facets Joint space absenttdiminished Middle facet involvement (less frequently anterior + posterior facets) = Narrowing posterior facet subtalar joint Talar beak (limited subtalar joint motion + dorsal subluxation navicular) C sign - prominence inferior border sustentaculum tali + medial outline talar dome on lateral view
DDx: Tarsal Coalition Talar Head Fx
Osteoarthrrtis
Sag FS PD M R
Cor FS PD MR
Sag FS PD MR
Ax T l W l MR
TARSAL COALlTlON Key Facts Imaging Findings Best diagnostic clue: Approximation or incorporation of talus + calcaneus through middle facet vs. calcaneus to navicular through anterior facet Synostosis = complete coalition Synchondrosis = cartilaginous Syndesmosis = fibrous
Top Differential Diagnoses Subtalar Fractures Osteoarthritis Osteochondral Lesion of the Talus (OLT)
Pathology
Congenital = failure of differentiation + segmentation of primitive mesenchyme Acquired = arthritis, infection, trauma + neoplasm rt Ball-and-socket ankle joint - decreased subtalar motion with concavity proximal talar surface + concavity distal tibia1 surface
CT Findings NECT o Requires direct axial + coronal images o Requires sagittal reformations o Section thickness = 1.5 cm or less o Calcaneonavicular coalition Narrowing + sclerosis between calcaneus + navicular on sagittal reformations Medial broadening anterior + dorsal aspects calcaneus at navicular o Talocalcaneal Direct coronal CT to visualize connection between talus + calcaneus through middle facet m Solid osseous continuity Fibrous/fibrocartilaginous coalition with sclerosis + irregular articular interface k cystic subchondral changes Change in sustentaculum tali slope from upward medially to downward or laterally rt Sustentaculum hypoplasia
MR Findings TlWI o Calcaneonavicular coalition Sagittal plane to visualize osseous vs. cartilaginous vs. fibrous rt Hypointense subchondral sclerosis at synchondrosis or syndesmosis Narrowing calcaneal navicular interface o Talocalcaneal Coronal plane Osseous connection with fat signal bone marrow continuity between talus and calcaneus Narrowing with irregular articular interface rt sclerosis across middle facet in cartilaginous, fibrous or fibrocartilaginous unions rt Hypoplastic sustentaculum tali Talar beaking + degenerative dorsal changes calcaneocuboid joint on lateral sagittal images
90% coalition = talocalcaneal + calcaneonavicular
Clinical Issues Most common signs/symptoms: Limitation of subtalar joint motion; pain Talocalcaneal coalition = rearfoot pain with localization to sustentaculum medially + sinus tarsi laterally Limitation of subtalar + mid tarsal joint motion including peroneal muscle spasm Tarsal coalition = most common cause of peroneal spastic flatfoot
Diagnostic Checklist Talocalcaneal coalitions require coronal images
Talar neck concavity on sagittal views T2WI o Calcaneonavicular rt Linear hyperintense calcaneonavicular interface in non-osseous coalition Irregular interface contour rn rt Hyperintense reactive subchondral marrow edema Solid continuous marrow continuity between calcaneus and navicular on lateral sagittal images o Talocalcaneal Continuity of marrow across middle facet on coronal images Variable increased subchondral signal + degenerative changes in fibrous, cartilaginous or fibrocartilaginous coalitions Intermediate signal on fibrocartilaginous interface rn Low to intermediate signal in fibrous tissue syndesmosis
Imaging Recommendations Best imaging tool: MR with direct three plane visualization + identification of subchondral marrow edema and non-osseous cartilaginous + fibrous unions Protocol advice o Coronal Tl/PD + FS PD FSE for talocalcaneal coalition o Sagittal Tl/PD + FS PD FSE for calcaneonavicular coalition o Sagittal plane for secondary osseous changes including talar beaking
I DIFFERENTIAL DIAGNOSIS Subtalar Fractures Head of talus, lateral process, posterior process, talar neck + body Calcaneal extra + intraarticular fractures
Osteoarthritis Subtalar arthrosis middle or posterior facet with sclerosis + subchondral cystic change
1
TARSAL COALlTlON Calcaneocuboid sclerosis
Osteochondral Lesion of the Talus (OLT) Antecedent trauma (e.g. torsional impaction) Chronic phase of compressed or avulsed talar dome fracture
Tumor Bone cyst Secondary osseous invasion (e.g., synovial sarcoma)
Rheumatoid Arthritis Retrocalcaneal bursitis Posterior calcaneal erosion Pannus formation/hypertrophied synovium
Recurrent Ankle Sprains Injured lateral ligament complex with inversion + internal rotation + plantar flexion Complication = anterolateral impingement
Sinus Tarsi
Presentation Most common signs/symptoms: Limitation of subtalar joint motion; pain Clinical profile o Asymptomatic to symptomatic o Talocalcaneal coalition = rearfoot pain with localization to sustentaculum medially + sinus tarsi laterally o Limitation of subtalar + mid tarsal joint motion including peroneal muscle spasm o Tarsal coalition = most common cause of peroneal spastic flatfoot
Demographics Age: Second decade Gender: Slight male predominance
Natural History & Prognosis Coalitions are initially cartilaginous and progress to ossification Decreased rearfoot motion results in increased laxity ankle ligaments (susceptible to sprain) Decreased subtalar & midtarsal joint motion
Lateral foot pain + tenderness Tears of sinus tarsi ligaments Subtalar microinstability
Treatment Conservative o Shoe modification, orthotics Surgical o Resection of coalition o Fusion of involved joint
General Features General path comments o Relevant anatomy Subtalar articulation through anterior, middle + posterior facet Transverse tarsal joint: Calcaneocuboid + talonavicular joints Normal subtalar motion + rotation + gliding Genetics: Genetic mutation autosomal gene, autosomal dominant Etiology o Congenital = failure of differentiation + segmentation of primitive mesenchyme o Acquired = arthritis, infection, trauma + neoplasm Epidemiology o 1%incidence of talocalcaneal coalitions o 90% coalition = talocalcaneal + calcaneonavicular o Talocalcaneal slightly more common than calcaneonavicular o Talonavicular = 3rd most common o 22 - 60% bilateral rate - talocalcaneal o 40 - 68% bilateral rate - calcaneonavicular
Gross Pathologic & Surgical Features OSS~OUS Cartilaginous Fibrous
Microscopic Features Nonosseous coalitions - no neural elements Microfracture = pain generator Osseous remodeling = pain generator Vascular proliferation Osteoblastic + osteoclastic activity Fibrous connective tissue, cellular components
-
* casting
I DIAGNOSTIC CHECKLIST Consider Talocalcaneal coalitions require coronal images Calcaneonavicular coalitions require sagittal images
1 SELECTED REFERENCES 1.
Sijbrandij ES et al: Bone marrow ill-defined hyperintensities with tarsal coalition: MR imaging findings. Eur J Radio1 43(1):61-5, 2002 2. Lee MF et al: Tarsal tunnel syndrome caused by talocalcaneal coalition. Clin Imaging 26(2):140-3, 2002 3. Banks A et al: McGlamry's comprehensive textbook of foot and ankle surgery. Tarsal coalition. vol 1. Philadelphia PA, Lippincott Williams & Wilkins (31):99-1032, 2001 4. Newman JS et al: Congenital tarsal coalition: Multimodality evaluation with emphasis on CT and MR imaging. Radiographics 20(2):321-32, 2000 5. Skellariou A et al: Tarsal coalition. Orthopedics 22(11):1066-73,discussion 1073-4 Review, 1999 6. Emery KH et al: Tarsal coalition: A blinded comparison of MRI and CT. Pediatr Radiol 28(8):612-6,1998
1
TARSAL COALITION IMAGE GALLERY Typical ( L e f ) Sagittal FS PD FSE MR shows hyperintensity (arrow) in calcaneonavicular fibrocartilaginous coalition. (Right) Sagittal FS PD FSE MR shows solid extraarticular synostosis representing a calcaneonavicular bar.
(Left) Coronal FS PD FSE MR shows symptomatic fibrocartilaginous talocalcaneal coalition with hyperintense subchondral bone marrow edema (arrow) on the talar side of the middle facet. (Right) Coronal T l Wl MR shows complete intraarticular bridge representing a talocalcaneal synostosis. There is complete continuity of bone marrow across the sustentaculum tali.
Typical ( L e f ) Sagittal T I WI MR shows solid talocalcaneal coalition involving both the middle and posterior facets of the subtalar joints with obliteration of the sinus tarsi (Right) Coronal FS PD FSE MR shows complete synostosis of the talus and calcaneus in talocalcaneal coalition.
OS TRICONUM SYNDROME
Sagittal graphic shows triangular shaped os trigonurn at the level of the lateral tubercle of the posterior talar process. Surrounding edema is highlighted in yellow.
Sagittal FS PD FSE MR shows hyperintensity of the posterior talus (arrow) with fluid signal and synovitis surrounding the os trigonurn.
o Well-rounded osseous body
o Prominent os trigonum or trigonal process o Irregular gap between talus and os trigonum on
Abbreviations and Synonyms Talar compression syndrome; posterior ankle impingement syndrome; posterior impingement syndrome
Definitions 106
Pain with disruption of cartilaginous synchondrosis between os trigonum + lateral tubercle of posterior talar process
General Features Best diagnostic clue: Hyperintensity across synchondrosis on T2WI Location: Lateral tubercle of posterior talar process Size: Variable size from absence of os trigonum to grossly enlarged Morphology o Round o Oval o Triangular
lateral view
MR Findings TlWI o Enlarged fat marrow containing os trigonum o Hypointense degenerative sclerosislcystic change between os trigonum & talus o Hypointense sclerosis, edema in a trigonal process o Hypointense fluid, effacement of surrounding soft tissues T2WI o 0 s trigonum or trigonal process hyperintensity on PD T2 FSE or STIR o Hyperintensity in synchondrosis or posterior talus o Hyperintense edemalsynovitis posterior to talus + superior to os trigonum o Hyperintense edema/synovitis posterior to os trigonum on sagittal images o Isolated hyperintense tenosynovitis flexor hallucis longus (FHL) tendon sheath (partial tethering FHL tendon) o Hyperintense degenerative cystic changes between os trigonum and talus o + Intraarticular loose bodies
HmHm
Radiographic Findings
Radiography o Smooth edges + dense cortical bone
DDx: Us Trigonurn Sydrome
F k I L Tenosynovitts
Sag FS PD MR
Cor FS
Ax T2WI MR
Sag FS PD MR
OS TRlCONUM SYNDROME
I
Kev Facts I
Imaging Findings Best diagnostic clue: Hyperintensity across synchondrosis on T2WI Location: Lateral tubercle of posterior talar process Size: Variable size from absence of os trigonum to grossly enlarged 0 s trigonurn or trigonal Process hyperintensity On PD T2 FSE or STIR
Top Differential Diagnoses Fracture of Lateral Tubercle (Shepherd's Fracture) Posterior Soft Tissue Impingement Flexor Hallucis Longus - (FHL) Tenosynovitis
Pathology Repetitive microtrauma Forceful repetitive ankle joint plantar flexion
Imaging Recommendations Best imaging tool: MR: Identifies marrow edema, synchondrosis and soft tissue changes Protocol advice o T1 sagittal, coronal + axial to evaluate marrow signal changes (sclerosis vs. edema) o FS PD FSE sagittal, coronal + axial for edema, fluid + synovitis o Sagittal plane required for accurate diagnosis
I DIFFERENTIAL DlAGNOSlS Fracture of Lateral Tubercle (Shepherd's Fracture) Irregular jagged separation between talar body and fragment Progressive wideningldiastasis of fracture site
Posterior Soft Tissue Impingement Posterolateral side of ankle joint Posterior tibiofibular ligament Transverse tibiofibular ligament Tibia1 slip Impingement = fibrosis + capsulitis + synovial swelling
Flexor Hallucis Longus (FHL) Tenosynovitis Fluid in FHL tendon sheath Scar + fibrosis in chronic overuse injury
Dancer's Foot Subchondral sclerosis posterior facet + calcaneocuboid joint Secondary to vertical loading stress Pain posterior subtalar area or laterally
Flexor Hallucis Longus Checkrein Deformity Fixed tethering FHL at or proximal to flexor retinaculum Flexion contracture interphalangeal joint of hallux + claw hallux Posttraumatic adhesions with healing of distal tibia1 fracture
Extreme ankle dorsiflexion = compression of ossicle between FHL + posterior talofibular ligament (PTFL) End-range plantar flexion = compression ossicle between calcaneus + tibia Enlarged os trigonum - not required
Clinical issues ~ o scommon t signslsymptoms: Posterior ankle pain Tenderness posterior ankle soft tissue &elling posterior ankle Pain exaggerated by plantarflexion + weight-bearing activities Decreased subtalar range of motion
Diagnostic Checklist
Identify signal changes across synchondrosis + os trigonum
(PATHOLOGY
I
General Features General path comments o Relevant anatomy = os trigonum Triangular ossicle posterior to lateral tubercle of posterior talar process Articulates with posterolateral process talus + superior aspect calcaneus Ossicle united to posterior process by cartilaginous, fibrous or fibrocartilaginous tissue Stieda's process = posterior extension lateral tubercle talus Etiology o Repetitive microtrauma o Forceful repetitive ankle joint plantar flexion o Ballet associated o Extreme ankle dorsiflexion = compression of ossicle between FHL + posterior talofibular ligament (PTFL) o End-range plantar flexion = compression ossicle between calcaneus + tibia o High-arched or supinated foot = traction force on posterolateral talar process by PTFL o Pronated foot = traction force on posterolateral talar process by posterior talocalcaneal ligament o Calcaneal eversion = impingement between superior surface calcaneus/ossicle + tibia o Plantarflexion + dorsiflexion = irritation of FHL at level of posterior talar process Epidemiology o 0.2% incidence of syndrome in ankle sprain population o 0 s trigonum common bilaterally (50%) o Bipartite morphology is rare o 0 s trigonum bone present in 10%of population L,
Gross Pathologic & Surgical Features FHL tendon sheath thickening Accessory bone = os trigonum Synchondrosis fissuring Arthritic process between talar projection + calcaneus Degenerative changes across synchondrosis Enlarged os trigonum - not required
OS TRlGONUM SYNDROME Microscopic Features
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Chronic inflammation Synovial hyperplasia Tendinosis FHL Periostitis of FHL sulcus
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- .--:-I-.. Lunsluer P
Identify signal changes across synchondrosis + os . . trigonum . Evaluate fluid and morphology of adjacent FHL tendon + sheath Anatomic variations exist in lateral tubercle
Staging, Grading or Classification Criteria Anatomic variations posterolateral talus o Type I = normal tubercle o Type I1 = Steida's processlenlarged tubercle o Type 111 = accessory bone or os trigonum 0 Type IV = fused os trigonum via synchondrosis or syndesmosis with talus
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[SELECTEDREFERENCES 1.
2.
1
Presentation ~
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+
I on
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~
Most common signs/symptoms: Posterior ankle pain Clinical profile o Tenderness posterior ankle o Soft tissue swelling posterior ankle o Pain exaggerated b y plantarflexion + weight-bearing activities o Pain = deep and aching o Decreased subtalar range of motion o Peroneal spasm o Impingement FHL tendon o Ballet dancers: Seen with demipointe, full pointe, tendu, frappe, releve, jump (weight bearing in plantar flexion) o Onset associated with chronic ankle sprain
Demographics
Age o Fusion of os trigonum: 8 to 11 years o Ossification os trigonum: Second decade o Pain syndrome: 20 to 35 years Gender: > Female involvement in dancers
Natural History & Prognosis Symptoms frequently relieved with rest Recalcitrant pain Fracture FHL stenosing tenosynovitis
Treatment
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Conservative o Splinting o Antiinflammatory . agents 0 Steroid iniection o on-weight bearing vs. weight bearing cast Surgical - for recalcitrant pain or fracture 0 Resection of os trigonum o Recontouring of prominences in superior calcaneus + posterolateral talus o Resection of hypertrophic or fibrotic tissue o Resection of hypertrophic or scarred FHL sheath o Arthroscopic technique available Complications o Arthritis o Impingement of soft tissue
'. 4.
-Rnnks --.- 'A ~t - .-nl.-. .M. r-C-l n--m r v1 '-s rnmqrehensive textbook of foot -----I A
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and ankle surgery. Chronic ank le conditions. vol 1. Philadelphia F ~ , ' ~ i ~ ~ i nWilliams c o t t & Wilkins (35):1091-152, 2001 Bureau NJ et al: Posterior ankle impingement syndrome: MR i m a ~ i n afindinas in seven natient? Radiolnw
MaSciocchi et A.nkle impingement syndromes. Eur J Radio1 27 Suppl 1:S710-3, 1998 Wakeley CJ et al: Thcr value of MR imaging i n the diagnosis rmrlrrrmn P L a l o + ~ l ..au,u, D.Irl;nl L 9cI9\.127 L of the os trigonum S~,,UL,L,,C. J,LI,.IJJ-V, 1996 Karasick D et al: The os trigonum syndrome: Imaging features. AJR 166:125-9, 1996 o,LLLLal
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OS TRlGONUM SYNDROME
ACCESSORY NAVlCULAR
Axial graphic shows type I1 accessory navicular.
Axial FS PD FSE MR shows symptomatic accessory (arrow) tarsal navicular with bone marrow edema of the accessory navicular and tuberosity.
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Abbreviations and Synonyms 0 s tibiale externum; navicular secundum; pre hallux; bifurcate navicular; accessory tarsal scaphoid; extrascaphoid + divided navicular
Definitions 110
Congenital development of navicular tuberosity from a secondary center of ossification with synchondrosis to the navicular body
General Features Best diagnostic clue: Unattached accessory bone or synchondrosis within medial navicular Location o Medial navicular o Accessory bonefsesamoid of tibialis posterior (TP) tendon in plantar portion at level of inferior calcaneonavicular ligament o Tuberosity separated from medial part of navicular body Size o Type I accessory navicular = 4 to 6 mm ossicle o Type I1 with non-ossified zone of 1 to 3 mm
o Type I11 cornuate or enlarged navicular tuberosity Morphology o Type I - true sesamoid within TP tendon o Type I1 - triangular or heart shaped o Type I11 - enlarged medial extension of navicular
Radiographic Findings Radiography o Type I = small ossicle proximal to navicular tuberosity on anteroposterior and lateral radiographs o Type I1 = extension of navicular radiographically + connection by a radiolucent zone, produces double density on lateral radiograph with proximal extension of navicular overlapping digital calcaneus o Type 111 = navicular extends medially proximal to talar head
MR Findings TlWI o Type I Small (4 to 6 mm) usually marrow fat containing ossicle proximal to navicular tuberosity Within hypointense to intermediate signal intensity distal tibialis posterior tendon 5 to 7 mm separation from navicular o Type I1
wmH DDx: Accessory Navicular
Sag FS PD MR
T f T~nosvnovitis
Midfoot Arthritrs
Ax FS PD MR
Ax T l Wl MR
ACCESSORY NAVKULAR Key Facts Imaging Findings
Pathology
Best diagnostic clue: Unattached accessory bone or synchondrosis within medial navicular Accessorv bone/sesamoid of tibialis posterior (TP) tendon in plantar portion at level of inferior calcaneonavicular ligament Marrow fat containing triangular or heart-shaped ossicle with direct connection to medial navicular through a synchondrosis Symptomatic = usually hyperintense marrow edema + degenerative hyperemia subchondral bone
*
Top Differential Diagnoses Navicular Tuberosity Fracture Tibialis Posterior (TP) Tendon Tear
Marrow fat containing triangular or heart-shaped ossicle with direct connection to medial navicular through a synchondrosis Non-ossified synchondrosis low to intermediate signal intensity Associated degenerative sclerosis f subchondral cystic degeneration = hypointensity across synchondrosis Medial hypointense to intermediate signal intensity bursitis Distal thickening in tibialis posterior tendinosis Intermediate signal intensity in partial tear of tibialis posterior o Type I11 Enlarged or cornuate marrow fat signal intensity extension of medial navicular proximally No hypointense synchondrosis present T2WI o Type I Suppressed fat signal in ossicle Ossicle may be difficult to differentiate from surrounding hypointense tibialis posterior o Type I1 Asymptomatic = normal fat suppressed marrow signal intensity Symptomatic = usually hyperintense marrow edema + degenerative hyperemia subchondral bone Hyperintense overlying bursitis Hyperintense tibialis posterior tenosynovitis f partial to complete tibialis posterior tendon tear Hyperintensity may involve synchondrosis directly Osseous edema may involve accessory navicular, accessory + navicular tuberosity or tuberosity alone o Type I11 Normal marrow fat characteristics on T2 or fat suppressed PD or T2 or STIR No synchondrosis present - -
*
Type I = small ossicle Type I1 = synchondrosis Type 111 = cornuate or enlarged medial tuberosity
Clinical Issues Most common signs/symptoms: Medial navicular pain Type I = symptoms of tibialis posterior tendinosis f pes valgO planus Type I1 = navicular pain, shoe irritation Type I11 = complaint of shoe irritation + superficial pain
Diagnostic Checklist Evaluate status of tibialis posterior tendon
Imaging Recommendations Best imaging tool: MR to visualize the signal intensity of marrow, bursitis and integrity of the synchondrosis Protocol advice: TI and FS PD FSE or STIR direct axial images required
I DIFFERENTIAL DIAGNOSIS Navicular Tuberosity Fracture Navicular tuberosity = 24% of navicular fractures Avulsion injuries Usually non-displaced If abduction force involved f osseous trauma to calcaneocuboid joint
Tibialis Posterior (TP) Tendon Tear Site of rupture within 6 cm of navicular insertion Spectrum of degeneration and longitudinal splitting Collapse of medial longitudinal arch
Midfoot Arthritis Sclerosis f joint space narrowing between navicular + medial cuneiform
Kohler's Disease Fragmented ossification in skeletally immature patien Tarsal navicular fragmentation in previously documented normal navicular Pain at site of fragmentation
1 PATHOLOGY General Features General path comments o Relevant anatomy = medial osseous prominences Head of talus Tuberosity of navicular Accessory ossicles Combination of above Etiology
ACCESSORY NAVlCULAR o Congenital navicular variations from a secondary
center of ossification 0 Type I f Tibialis posterior tendinosis o Type I1 Chronic stress o Type 111 Irritation of navicular prominence Epidemiology o 2 to 20% incidence of accessory ossicle o 0 s tibiale externum = 2nd most common accessory bone of foot (1st = os peroneum) o Type I = 30% of accessory naviculars o Type I1 & I11 = 70%
Treatment Conservative o Type I, I1 & 111 = orthotic, shielding, shoe modifications Surgical o Kidner operation - to remove accessory navicular prominence & reinsertion of tibialis posterior o Type I - removal of ossicle from tibialis posterior tendon in symptomatic tibialis posterior tendinosis o Type I1 - resection entire non-ossified synchondrosis or bone graft + arthrodesis o Type 111 rn Surgical remodeling Reconstructive procedures for pes valgo planus Complications o Weakness tibialis posterior muscle post excision Type I, I1 or 111 navicular prominences
Gross Pathologic & Surgical Features Synchondrosis o Fibrous 0 Cartilaginous o Fibrocartilaginous 0 Partially osseous
Microscopic Features
I
Consider
Inflammatory chondro-osseous changes Microfracture Cellular proliferationlrepair
Evaluate status of tibialis posterior tendon Need adequate fat suppression - T2WI in axial plane to appreciate hyperintense edema Identify associated bursa of soft tissue inflammatory changes
Staging, Grading or Classification Criteria Type I = small ossicle Type I1 = synchondrosis Type IIa = more superior placement of accessory bone (at risk for avulsion + tension force) Type IIb = more inferior placement of accessory bone (at risk for shearing forces) Type I11 = cornuate or enlarged medial tuberosity Combination prominence
1.
2. 3.
Presentation Most common signs/symptoms: Medial navicular pain Clinical profile o Type I = symptoms of tibialis posterior tendinosis + associated pes valgo planus o Type I1 = navicular pain, shoe irritation o Type I11 = complaint of shoe irritation + superficial pain
Demographics Age o 0 s tibiale externum ossifies age 9 to 11 years o Symptoms after 5 years of age o Symptoms most common during adolescence Gender: More frequent in females
Natural History & Prognosis Symptoms may occur or exacerbate post local trauma to foot and ankle Chronic irritation + bursa development over bony protuberance Degenerative change - progressive at synchondrosis k Height loss medial longitudinal arch Intact range of motion of ankle, subtalar & transverse tarsal joints
J
4. 5. 6.
Banks A et al: McGlamry's comprehensive textbook of foot and ankle surgery. Common Pedal Prominences. vol 1. Philadelphia PA, Lippincott Williams & Wilkins, (11):419-40, 2001 Demeyere N et al: Quiz case. Symptomatic type I1 accessory navicular. Eur J Radiol 37(1):60-3, 2001 Kiter E et al: Tibialis posterior tendon abnormalities in feet with accessory navicular bone and flatfoot. Acta Orthop Scand 70(6):618-21, 1999 Steinbach LS: Painful syndromes around the ankle and foot: Magnetic resonance imaging evaluation. Top Magn Reson Imaging 9(5):311-26, 1998 Bencardino J et al: 0 s sustentaculi: Depiction on MR images. Skeletal Radiol 26(8):505-6, 1997 Miller 'IT The symptomatic accessory tarsal navicular bone: Assessment with MR imaging. Radiology 195(3):949-53,1995
ACCESSORY NAVlCULAR
Typical
(Lef)Axial
T l Wl MR shows type I (arrow) accessory navicular as a true sesamoid. (Right) Axial T l Wl MR shows type 111 accessory navicular with enlarged medial extension (arrow) of the tuberosity (cornuate navicular).
Typical ( L e f ) Axial T1W l MR shows degenerative changes (arrow) with sclerosis and erosions with the type I1 triangular navicular. The non ossified zone is 1-3 mm in thickness. (Right) Axial FS PD FSE MR shows hyperintense bone marrow edema of a type I1 accessory navicubr on both sides of the non ossified synchondrosis.
( L e f ) Axial T l Wl MR shows sclerotic hypointense marrow in a type I1 accessory navicular. (Right) Axial FS PD FSE MR shows intermediate to hyperintense signal in the synchondrosis of the type I1 accessory navicular (arrow). Bone marrow edema is present in both the navicular and accessory navicular.
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SESAMOID DYSFUNCTlO
Axial graphic shows medial tibial sesamoid fracture.
Coronal FS PD FSE MR shows hyperintense medial tibial sesamoid edema (arrow) secondary to fracture.
o Oblique view for fibular sesamoid o Axial view for both sesamoids
Abbreviations and Synonyms
MR Findings
Sesamoid disorders
Definitions Bipartite sesamoids; fractures, turf toe, osteochondritis
+ avascular necrosis; sesamoiditis, arthritis 113
General Features Best diagnostic clue: Altered signal intensity or morphology of sesamoids Location: Within double tendon of flexor hallucis brevis, the two plantar sesamoids articulate with the 1st metatarsal head Size: Medial sesamoid slightly > lateral sesamoid Morphology: Ovoid morphology separated by intersesamoidal ridge or crista to articulate with concave facets of first metatarsal head
Radiographic Findings Radiography o Anteroposterior to show limited (obscured by metatarsal head) view of medial (tibial) and lateral (fibular) sesamoids o Lateral view - overlap of sesamoids
TlWI o Bipartite sesamoids More frequent involvement of medial sesamoid Identical vs. asymmetric division with marrow fat signal intensity Lateral sesamoid rarely separated into > than 2 fragments Smooth margins (rounded edges) o Fracture Sharp or discrete linear hypointense line Replacement of marrow fat with hypointense edema Hypointense adjacent capsularlsoft tissue edema o Turf toe Disruption plantar joint capsule = discontinuity Disruption plantar plate = hypointense to intermediate signal of fluid in sesamoid attachment to base of proximal phalanx o Osteochondritis and avascular necrosis Fragmentation of involved sesamoid Hypointense signal Greater involvement of lateral sesamoid o Sesamoiditis Hypointense effusion 1st metatarsophalangeal (MTP) joint
DDx: Foot Sesamoid Dysfunction
BB AX Fs PD FsE MR
Fibromatosis
Hallux Ridgidus
Cor Fs PD MR
AX Fs PD FsE MR
SESAMOID DYSFUNCTION Key Facts Terminology
Clinical Issues
Sesamoid disorders
Imaging Findings Best diagnostic clue: Altered signal intensity or morphology of sesamoids Morphology: Ovoid morphology separated by intersesamoidal ridge or crista to articulate with concave facets of first metatarsal head
Top Differential Diagnoses Stress Fracture Synovitis
Most common signs/symptoms: Pain over plantar aspect sesamoids Fracture = nonspecific swelling first MTP joint + discomfort on passive range of motion Osteochondritis = tenderness on palpation Turf toe = pain with dorsiflexion + weight bearing Sesamoiditis = pain weight bearing + athletic activity (e.g. running) + localized tenderness + MTP swelling Osteoarthritis - in association with hallux valgus + rigidus
Diagnostic Checklist
Pathology Irregular ossification in medial bipartite sesamoid Sudden loading or repetitive stress Mild subchondral sclerosis (hypointense) between 1st metatarsal facets + dorsal articular surface sesamoids o Arthritis Marrow fat signal maintained Subchondral hypointense sclerosis at articulation with 1st metatarsal head Osteophytic spurring MTP joint hypointense joint fluid T2WI o Bipartite sesamoids No increase in signal intensity on T2 or fat suppressed T2WI Normal surrounding soft tissue + capsular structures o Fracture Hyperintense linear transverse fracture rt displacement of fragment Serrated + irregular edges Variable subchondral hyperintense edema in one or both fragments o Turf toe + Plantar subchondral hyperintense edema 1st metatarsal head Hyperintense edematfluid associated with capsular + plantar plate injury + Discontinuity in intersesamoid ligament associated with sesamoid displacement/dislocation o Osteochondritis and avascular necrosis Chronic phase with hypointensity Acutetsubacute with variable increased signal intensity 0 Sesamoiditis Hyperintense effusion + synovitis 1st MTP joint Dorsal sesamoid chondral degeneration with narrowing relative to metatarsal concave articular facets o Arthritis Osteophytes maintain marrow fat signal intensity + Hyperintense 1st metatarsophalangeal joint effusion Sclerosis hypointense ~
Distinguish between fracture line vs. normal bipartite morphology
Imaging Recommendations Best imaging tool: MR for detection of sesamoid marrow edema + identification of capsular structures Protocol advice o Coronal, axial & sagittal TI + FS PD FSE or STIR o Coronal plane to visualize both sesamoids + flexor hallucis longus in one image
I DIFFERENTIAL DIAGNOSIS Stress Fracture Distal third metatarsal except dancers (proximal third) Bone callus Subchondral marrow edema
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Synovitis Hyperintense fluid (T2WI) Intermediate signal synovium (T2WI) Capsular distention
Metatarsal Fracture Proximal fracture base 1st metatarsal
Plantar Fibromatosis Inhomogeneous mass medial plantar fascia
Morton's Neuroma Localized enlargement interdigital nerve Between third + fourth metatarsal heads Lateral branch medial plantar nerve to third interspace
Hallux Limitus & Hallus Rigidus Painful, acquired, arthritis first MTP joint Inadequate sagittal mobility Limitus = precursor to rigidus Rigidus = ankylosis of sesamoids to plantar surface 1st metatarsal
1 PATHOLOGY General Features General path comments
1
SESAMOID DYSFUNCTION o Turf toe = pain with dorsiflexion + weight bearing o Sesamoiditis = pain weight bearing + athletic activity
o Relevant anatomy
Sesamoid + collateral ligaments = stabilize 1st MTP joint Dorsal surface of sesamoids = cartilaginous to articulate with first metatarsal head Etiology o Bipartite sesamoids Irregular ossification in medial bipartite sesamoid o Fracture Sudden loading or repetitive stress Increase weight bearing function medial Dorsiflexion or hyperflexion o Turf toe Extreme dorsiflexion + valgus/varus strain MTP joint in turf toe injuries Associated with artificial sports surfaces o Sesamoiditis Associated with trauma * Sesamoid chondromalacia is sesamoiditis o Arthritis: + Progression sesamoiditis, chondromalacia or trauma Distribution o 90% bipartite sesamoids = bilateral o Up to 90% bipartite sesamoids = tibia1 or medial o Tibia1 sesamoid divided into two or three fragments
(e.g. running) + localized tenderness + MTP swelling + swelling + restricted range of motion + pain to palpation o Osteoarthritis - in association with hallux valgus + rigidus o Arthritis = warmth
Demographics Age o Ossification hallucal sesamoids - 7 to 10 years o Sesamoiditis - young athletes Gender: Ossification sesamoids in females earlier
Natural History & Prognosis Fracture = bony consolidation vs fibrous union Osteochondritis = fragmentation Sesamoiditis = reduce weight bearing Turf toe = improved recurrent with sprains vs. continued pain with rupture of sesamoid complex
Treatment Conservative o Fracture: Below knee walking cast o Osteochondritis = avascular necrosis: Shoe insertlpad + nonsteroidal anti-inflammatory medication o Turf toe: Below knee cast o Sesamoiditis: Activity modification + reduced weight bearing o Arthritis: Orthotic, stiff insole + padding + nonsteroidal anti-inflammatory medications Surgical: Excision - for failed conservative treatment + chronically painful sesamoid
Gross Pathologic & Surgical Features Bipartite sesamoids o Asymmetrical division bipartite sesamoid o Medial sesamoid o Metatarsophalangeal joint swelling Fracture o Transverse cleft + displacement o Irregular fracture interface Turf toe o Ruptured sesamoid complex o + Proximal vs. distal migration o Sesamoid fracture Osteochondritis and avascular necrosis o Fragmentation o Stress fracture Sesamoiditis o MTP joint swelling o Inflammation plantar sesamoid complex Arthritis o Erosion articular cartilage o Osteophytes
+
(DIAGNOSTIC CHECKLIST Consider Identify sesamoid edema on FS PD FSE or STIR Distinguish between fracture line vs. normal bipartite morphology
ISELECTED REFERENCES 1.
Microscopic Features Bipartite sesamoids = articular cartilage between fragments Osteochondritis - stress fracture + healing = fragmentation
Presentation Most common signs/symptoms: Pain over plantar aspect sesamoids Clinical profile o Fracture = nonspecific swelling first MTP joint + discomfort on passive range of motion o Osteochondritis = tenderness on palpation
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2. 3.
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DeLee JC et al: Orthopaedic sports medicine. Principles and practice. Ligament injuries of the foot and ankle in the athlete. Foot and ankle, conditions of the forefoot. Sesamoid dysfunction. vol2. 2nd ed. Philadelphia PA, Saunders 2510-20, 2003 Ashman CJ et al: Forefoot pain involving the metatarsal region: Differential diagnosis with MR imaging. Radiographics 21(6):1425-40, Review, 2001 Karasick D et al: Disorders of the hallux sesamoid complex: MR features. Skeletal Radio1 27:411-8, 1998
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SESAMOlD DYSFUNCTlON
Typical (Lef)Sagittal graphic shows disruption of the MTP joint capsule. (Right) Sagittal FS PD FSE MR shows hyperintensejoint effusion associated with capsular sprain in turf toe.
Typical (Left) Axial T1Wl MR shows bipartite medial tibial sesamoid. The normal medial sesamoid is larger than the lateral sesamoid. (Right) Sagittal T1 WI MR shows normal marrow fat signal in a bipartite medial tibial sesamoid.
Typical
COMPARTMENT SYNDROME, LOWER EXTREMITY
Coronal graphic muscle edema.
shows
anterior
compartment
Axial FS PD FSE MR shows edema of the tibialis posterior muscle in deep posterior compartment syndrome.
o Combined foot + leg compartment syndromes may
Abbreviations and Synonyms Acute compartment syndrome; chronic (exertional) compartment syndrome
Definitions Circulation + function of tissue within anatomically confined spacelfibro-osseouscompartment are damaged by elevated pressure
occur Morphology: Diffuse along affected muscle group/compartment of leg and/or foot
MR Findings -
TlWI o Intermediate signal intensity within edematous muscle o Loss of normal muscle striations o k Increased signal in subacute hemorrhage o Hypointense hemosiderin foci o Enlargement of affected muscle group peripheral convex bowing o Hypointense calcification in chronic compartment syndrome o Hyperintense fat in muscle atrophy/chronic compartment syndrome o Chronic fibrous replacement = hypointensity o Calcific myonecrosis - intermediate signal liquefied necrotic muscle & hypointense calcific shell o T1 k normal in exertional compartment syndrome T2WI o Hyperintense diffusely within cross sectional anatomic boundaries of affected muscle + proximal/distal extension on T2WI o Hyperintense fluid/hemorrhage/edema also between muscles in fascia1 planes
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I IMAGING FINDINGS General Features Best diagnostic clue: Diffuse hyperintensity on T2WI (FS PD FSE or STIR) within affected compartment muscle or muscles Location o Anterior, lateral, superficial + deep posterior compartments of the leg (tibialis posterior may be classified as its own compartment) o Medial, central, lateral + interosseous + calcaneal compartments of the foot Size o Variable as a function of affected muscle group or groups within a compartment
DDx: Compartment Syndrome, Lower Extremity
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DVT
Castroc. Strain
Infection
AX FS PD FSE MR
AX FS PD FSE MR
Cor FS PD MR
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COMPARTMENT SYNDROME, LOWER EXTREMITY Key Facts Imaging Findings Best diagnostic clue: Diffuse hyperintensity on T2WI (FS PD FSE or STIR) within affected compartment muscle or muscles Hyperintense diffusely within cross sectional anatomic boundaries of affected muscle + proximalldistal extension on T2WI
Top Differential Diagnoses Deep Vein Thrombosis (DVT) Gastrocnemius - Soleus Muscle Strain Cellulitis Tumors
Pathology
Muscle hernias in 40% of chronic compartment syndrome Acute compartment syndrome in leg usually related to tibial fractures
Clinical Issues Most common signslsymptoms: Disproportionate pain relative to injury Palpable swelling (f tense skin), pain, pallor, paralysis + paresthesias Acute = fasciotomylopen procedure
Diagnostic Checklist Use axial images to identify diffuse muscle edema + compartmental bulging
Arteriovenous gradient theory Ischemia - reperfusion theory Hyperintensity associated with both edema + rhabdomyolysis 0 Atrophied muscle suppresses without associated hyperintensity o + Subcutaneous tissue hyperintense edema 0 Intermediate to increased signal of muscle in exertional compartment syndrome (FS PD FSE or STIR) 0 Calcification + fibrosis remain hypointense + Associated muscle herniation on TlWI + T2WI 0
Imaging Recommendations Best imaging tool o MR superior to bone scan, radiography and CT o Edema, fibrosis + fatty infiltration contrast best visualized on MR o Conventional radiography and CT limited to ruling out associated injuries Protocol advice 0 T1 + FS PD FSE or STIR axial, coronal, + sagittal images 0 Axial plane required for cross-sectional muscle compartment + neurovascular relationship
I DIFFERENTIAL DIAGNOSIS Deep Vein Thrombosis (DVT) Neurovascular bundle perivascular edema Edema in watershed distribution f medial head gastrocnemius + soleus f Enlarged popliteal vein with thrombus occlusion f collateral venous structures
Gastrocnemius - Soleus Muscle Strain Grade 1to 2 muscle/muscle tendon unit partial tear Featheryldiffuse edema hyperintense on FS PD FSE or STIR Partial intermuscular septum disruption + Plantaris muscle myotendinous rupture between medial head gastrocnemius + soleus
Cellulitis Reticular to circumscribed subcutaneous (superficial + deep) edema No muscle compartment involvement or fascia1 extension
Tumors Intramuscular lipoma or hemangioma
Myositis Ossificans Localized soft tissue ossifications (circumscripta) Damage to interstitium not muscle directly proximal involvement > distal Soft tissue mass + periosteal reaction to peripheral calcification to circumscribed pattern of bone + Periosteal enhancement or edema
General Features General path comments o Relevant anatomy Anterior compartment (leg) muscles = tibialis anterior, extensor hallucis longus, extensor digitorum longus + peroneus tertius Anterior compartment neurovascular bundle = deep peroneal nerve + anterior tibial artery Posterior compartment divided by deep transverse fascia into superficial and deep sections Superficial posterior compartment muscles = gastrocnemius, plantaris + soleus Deep posterior compartment muscles = popliteus, flexor digitorum longus, flexor hallucis longus + tibialis posterior Neurovascular supply posterior compartment = tibial nerve + posterior tibial artery Anterolateral compartment muscles = peroneus longus + peroneus brevis Neurovascular supply anterolateral compartment = superficial peroneal nerve + branches peroneal artery Etiology
I 1
COMPARTMENT SYNDROME, LOWER EXTREMlTY o Arteriovenous gradient theory Compromised blood flow - arterial, capillary or
venous Reduced blood flow: Hypotension, increased vascular resistance (shock or arterial spasm), increased tissue pressure (extravasated blood) o Ischemia - reperfusion theory Compromised blood flow Ischemia Impaired cellular metabolism Interstitial edema Increased compartmental pressure o Reperfusion: Restore cellular activity vs. worsen preexisting cellular damage o Fractures leading to compartment syndrome Proximal + middle thirds tibia Open tibial fractures o Acute compartment pressure elevation Fractures (tibia) Muscle rupture Crush injuries Burns o Chronic: Exercise induced chronic compartment syndrome o Foot compartment syndrome: Calcaneal fractures Epidemiology o Open tibial fractures = 20% complicated by compartment syndrome o Muscle hernias in 40% of chronic compartment syndrome o 5% calcaneal fractures develop compartment syndrome of the foot o Acute compartment syndrome in leg usually related to tibial fractures o Bivalving a cast = 85% reduction in intracompartmental pressure
Presentation Most common signs/symptoms: Disproportionate pain relative to injury Clinical profile o Palpable swelling (+ tense skin), pain, pallor, paralysis + paresthesias o Distal pedal pulses usually intact o Crush injuries to the foot: Massive swelling + fractures or dislocations o Chronic - exercise related, anterior or deep posterior compartment o cute compartment syndrome uncommon in athletic population o chronic-compartment syndrome - in runners
Demographics Age: Nonspecific Gender: No gender bias
Natural History & Prognosis Nerve + muscle ischemia > 12 hours = permanent injury Muscle necrosis Volkmann's contracture (fibrous contracture + neurologic damage) Complication: Reperfusion injury
Treatment Conservative: Not an option Surgical o Acute = fasciotomylopen procedure o Chronic = surgical decompression - fasciotomy o Techniques for fasciotomies: Fibulectomy, perifibular fasciotomy or double-incision fasciotomy
Gross Pathologic & Surgical Features Fracture f open Hemorrhage Inflammation Decreased compartment size (pressure dressings) Venous obstruction
Consider Use axial images to identify diffuse muscle edema + compartmental bulging T2WI (FS PD FSE or STIR) visualizes fluid in fascia1 boundaries T1 + T2WI to identify loss of normal muscle striations TlWI characterizes the associated atrophy and fibrosis in chronic compartment syndrome
Microscopic Features Tissue - cellular damage (muscle + nerve ischemia) Neutrophils + leukocytes with reestablished flow Interstitial edema Local vasodilation
Staging, Grading or Classification Criteria Acute o Resting intracompartment pressures > 30 mm Hg (Wick catheter measurement) Chronic o Resting intramuscular pressure > 10 mm Hg o Elevated tissue pressure of 15 mm Hg at 15 minutes post exercise
1 SELECTEDREFERENCES 1.
2.
3. 4.
1
DeLee JC et al: Orthopaedic sports medicine. Principles and practice. Ligament injuries of the foot and ankle in the athlete. The Leg. vol 2. 2nd ed. Philadelphia PA, Saunders, (29):2155-82, 2003 Lauder TD et al: Exertional compartment syndrome and the role of magnetic resonance imaging. Am J Phys Med Rehabil 81(4):315-9,2002 Brown RR et al: MR imaging of exercise-induced lower leg pain. Magn Reson Imaging Clin N Am 9(3):533-52,2001 Matsen F et al: Diagnosis and management of compartment syndromes. J Bone Joint Surg Am 62:286-291, 1980
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COMPARTMENT SYNDROME, LOWER EX 'REMITY
Typical (Left) Axial FS PD FSE MR shows hyperintense edema of the posterior fibers of the tibialis anterior muscle. (Right) Coronal graphic shows edema of the tibialis anterior in the anterior compartment.
Typical (Lef)Axial FS PD FSE MR shows compartment syndrome with hyperintense edema of the tibialis posterior muscle. (Right) Axial FS PD FSE MR shows intramuscular hemangioma with central hemosiderin focus and reactive muscle edema of the soleus.
Typical (Lefi) Axial T l WI MR shows lateral herniation of the crural fascia with associated peroneus brevis and longus muscles. (Right) Axial FS PD FSE MR shows hyperintense hemangioma between the posterior fibula and soleus muscle group in a runner presenting with compartment syndrome. Anteromedial periosteal edema in medial tibia1 stress syndrome is also shown.
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GASTROCNEMIUS SOLEUS STRAIN
Axialgraphic shows subtle edema of the medial head of the gastrocnemius in a grade 1 strain.
o Intermediate signal edema medial head o Subacute hemorrhage as hyperintensity o Laxity intermuscular septum between gastrocnemius
Abbreviations and Synonyms Gastrocnemius-soleuscomplex injury; tennis leg (has been used for either injury to medial head gastrocnemius or plantaris tendon rupture)
Definitions Partial to complete tear medial head of gastrocnemius muscle
(IMAGINGFINDINGS General Features Best diagnostic clue: Diffuse hyperintensity within medial head gastrocnemius k soleus muscle * Location: Medial head gastrocnemius at muscle-tendon junction f associated soleus muscle Size: Variable from a portion to entire cross sectional areas of medial gastrocnemius Morphology o Feathery or diffuse edema pattern o Irregularity of intermuscular fascia o i Localized muscle hemorrhage in grade 2 tears o Muscle discontinuity in grade 3 disruption
MR Findings
Axial FS PD FSE MR shows feathery distribution (arrow) of muscle edema in the medial head of the gastrocnemius in a grade 1 injury.
and soleus o Intermediate signal fluid deep to subcutaneous
tissue T2WI o Hyperintensity in edematous muscle fibers o Fascia1 discontinuity o Fluid between gastrocnemius & soleus o Fluid filled gap (hyperintense) in myofascial separation T2* GRE: Hypointense signal in hemosiderin foci especially on T2* gradient echo
Imaging Recommendations Best imaging tool: MR - demonstrates cross sectional muscle morphology and distribution of edemalhemorrhage Protocol advice o Axial T1 and FS PD FSE or STIR o Secondary - coronal and sagittal FS PD FSE or STIR
1 DIFFERENTIAL DIAGNOSIS Plantaris Tendon Rupture Intermuscular hematoma - between medial head gastrocnemius & soleus
TlWI
DDx: Gastrocnemius Soleus Strain
I
A x FS PD FSE MR
A x FS PD FSE MR
A x FS PD FSE MR
I
GASTROCNEMIUS SOLEUS STRAIN Key Facts Terminology Gastrocnemius-soleuscomplex injury; tennis leg (has been used for either injury to medial head gastrocnemius or plantaris tendon rupture)
Imaging Findings Location: Medial head gastrocnemius at muscle-tendon junction & associated soleus muscle + Localized muscle hemorrhage in grade 2 tears Fascia1 discontinuity
Top Differential Diagnoses Plantaris Tendon Rupture Deep Venous Thrombosis (DVT) Posterior Compartment Syndrome
Retracted plantaris tendon & mass effect
Deep Venous Thrombosis (DVT) Calf swelling, tenderness & pain with dorsiflexion Duplex ultrasound vs. venography MR: Peri-neurovascular edema with watershed edema medial head gastrocnemius Prominent venous collaterals extending into gastrocnemius
Posterior Compartment Syndrome Progressive pain, exceeding degree of injury Paresthesias Weakness Requires direct measurement of compartment pressure
General Features General path comments o Relevant anatomy Medial larger than lateral head gastrocnemius Gastrocnemius crosses two joints (knee & ankle) Gastrocnemius = fast twitch fibers Soleus muscle = slow twitch fibers Medial head origin = medial condyle & adjacent femur & capsule of knee joint Medial head insertion = Achilles tendon into calcaneus Etiology o Overstretching - forced dorsiflexion & extended knee o Eccentric action - increased force during muscle fiber lengthening o Jump injury (plyometric muscle activity) o Running Epidemiology o Muscle strains = 30% sports injuries o Gastrocnemius, rectus femoris, hamstring & adductor longus - most susceptible o Passive stretch - causative if too aggressive o Gastroc-soleus activated during stretch
Pathology Overstretching - forced dorsiflexion & extended knee Tear medial head gastrocnemius at muscle-tendon junction Hemorrhage between medial head & soleus without plantaris tear
Clinical Issues Most common signs/symptoms: Acute onset calf pain Calf swelling (pain & swelling develop 1st 24 hours) Gastrocnemius pain with localized tenderness to medial head gastrocnemius soleus
+
Diagnostic Checklist Axial images to identify fascia1 disruption
o Eccentric action - muscle forces high during fiber
lengthening
Gross Pathologic & Surgical Features Tear medial head gastrocnemius at muscle-tendon junction Hemorrhage between medial head & soleus without plantaris tear Partial tear of fascia between medial head gastrocnemius & soleus Partial tear transverse intermuscular septum at border of superficial posterior & deep posterior compartment
Microscopic Features Muscle strain in fast-twitch type I1 fibers of medial head gastrocnemius Muscle-tendon unit (MTU) = weak link Inflammatory cell infiltrate Separation of muscle fibers from tendon or fascia
Staging, Grading or Classification Criteria Grade 1 strain o No myofascial disruption o Edema o Swelling Grade 2 strain o Weakness o Variable separation muscle from tendon or fascia Grade 3 strain o Myofascial separation complete o Lack of muscle function
Presentation Most common signs/symptoms: Acute onset calf pain Clinical profile o Young - middle-aged recreational athlete o History running & sudden stop or change in direction o Calf swelling (pain & swelling develop 1st 24 hours) o Gastrocnemius pain with localized tenderness to medial head gastrocnemius + soleus
CASTROCNEMlUS SOLEUS STRAlN o Difficulty in walking (activity results in stress in
preexisting MTU injury)
Demographics Age: Middle-aged Gender: Based on eccentric muscle activation - non gender specific
Natural History & Prognosis Improvement with non weight-bearing & rest 1st 24 hours = greatest pain & swelling Reinjury common if premature return to activity
Treatment Conservative o Supportive wraps o Ice o Anti-inflammatory medications o Cam walker - ambulation without crutches (no activation of injured MTU) o Early ankle motion o Stretching exercises as pain decreases o Strengthening to follow stretching o Criteria for return to activity - pain free motion & 90% return of gastrocnemius muscle strength Surgical o Compartment syndrome requires fasciotomy Complication o Acute posterior compartment syndrome (deep or superficial) o ~nteriorcompartment syndrome o Lateral compartment syndrome
I
Consider Evaluate soleus muscle in association with medial head gastrocnemius strain DVT if perivascular hyperintensity, watershed distribution of muscle edema or prominent venous collaterals Axial images to identify fascia1 disruption
1 SELECTED REFERENCES 1.
2. 3. 4. 5. 6.
7. 8.
DeLee JC et al: Orthopaedic sports medicine. Principles and practice: Ligament injuries of the foot and ankle in the athlete. vol2. 2nd ed. Philadelphia PA, Saunders, 2323-71, 2003 Clarkson PM et al: Exercise-induced muscle damage in humans. Am J Phys Med RehabilSl(11 Suppl):S52-69, 2002 Boutin RD et al: Imaging of sports-related muscle injuries. Radio1 Clin North Am 40(2):333-62, Review, 2002 Delgado GJ et al: Tennis leg: Clinical US study of 141 patients and anatomic investigation of four cadavers with MR imaging and US. Radiology 224(1):112-9,2002 Bencardino JT et al: Traumatic musculotendinous injuries of the knee: Diagnosis with MR imaging. Radiographics 20 Spec No:S103-20, 2000 Nguyen B et al: Pains, strains and fasciculations: Lower extremity muscle disorders. Magn Reson Imaging Clin N Am 8(2):391-408,2000 Leekham R et al: Using sonography to diagnose injury of plantaris muscles and tendons. AJR 172:185-9, 1999 Bianchi S et al: Sonographic evaluation of tears of the
gastrocnemius medial head ("tennis leg").J Ultrasound Med 17:157-62, 1998 Pomphrey MM Jr: More comments on tennis calf or tennis leg. Orthopedics 19(8):643,1996 Menz MJ et al: Magnetic resonance imaging of a rupture of the medial head of the gastrocnemius muscle. A case report. J Bone Joint Surg 73(8):1260-2, 1991 Gecha S et al: Knee injuries in tennis. Clin Sports Med 7:435-52, 1988 Leach R: Leg and foot injuries in racquet sports. Clin Sports Med 7:359-70, 1988 Anouchi Y et al: Posterior compartment syndrome of the calf resulting from misdiagnosis of a rupture of the medial head of the gastrocnemius.J Trauma 27:678-80, 1987 Straehley D et al: Acute compartment syndrome (anterior lateral, and superficial posterior) following tear of the medial head of the gastrocnemius muscle. Am J Sports Med 14:96-9, 1986 Sutro C et al: The medial head of the gastrocnemius: A review of the basis for partial rupture and for intermittent claudication. Bull Hosp Jt Dis 45:150-7, 1985 Daffner RH: Anterior tibia1 striations. AJR 143:651-3, 1984 Severance H et al: Rupture of the plantaris - does it exist?J Bone Joint Surg Am 64:1387-8, 1982 Miller W: Rupture of the musculotendinous juncture of the medial head of the gastrocnemius muscle. Am J Sports Med 5:191-3, 1977 Froimson A: Tennis leg. JAMA 209:415-6, 1969
GASTROCNEMIUS SOLEUS STRAIN
(Lejl) Axial T1Wl MR shows isointense changes in a grade 1 medial head strain indistinguishable from normal muscle. (Right) Axial FS PD FSE MR shows soleus muscle edema (arrows) involving both medial and lateral aspects.
Typical (Lef)Coronal T2 FSE MR shows retracted medial head of the gastrocnemius muscle. (Right) Axial FS PD FSE MR shows gastrocnemius muscle-tendon-unit (MTU) injury with laxity (arrow) of fascia, edema of the gastrocnemius muscle, and intermuscular fluid.
(Left) Axial FS PO FSE MR shows subtle MTU injury involving the medial aspect of the soleus muscle. (Right) Axial FS PD FSE MR shows diffuse hyperintense edema involving the medial and lateral aspects of the soleus muscle. The intramuscular soleus tendon is perpendicular to the tendo calcaneus tendon posteriorly.
PLANTARIS RUPTURE
Axial graphic shows enlarged retracted plantaris tendon with associated edema of adjacent muscle fibers of the medial head of the gastrocnemius muscle.
Axial FS PD FSE MR shows rupture of plantaris tendon with intermuscular hemorrhage between the soleus and medial head of the gastrocnemius muscle groups. Hemosiderin ring is hypointense.
o Hyperintense subacute hemorrhage o Variable intermediate signal within adjacent medial
head gastrocnemius f soleus
Abbreviations and Synonyms
o Distal tears with absence of distal course of plantaris
Plantaris tendon tear Tennis leg (has been used for both injury to medial head gastrocnemius and plantaris tendon rupture)
less common o Proximal tears associated with anterior cruciate ligament (ACL) injuries (f anterior translation of
Definitions Myotendinous junction rupture
1 IMAGING
I
FINDINGS
General Features Best diagnostic clue: Hemorrhage & mass effect Location: Between medial head gastrocnemius and soleus muscles Size: Variable: Tendon & hemorrhage may extend up to 50% anteroposterior length of fascia1 division between soleus and medial head Morphology o Tubular hemorrhagic fluid collection o Tendon mass & hemorrhage with convex medialllateral margins
M R Findings TlWI
tibia1 relative to femur) T2WI o Hyperintense hemorrhage f hypointense hemosiderin ring & inhomogeneity in restricted tendon o Hyperintense edema within a portion or complete cross sectional area at a specified level o f Hyperintense edema soleus and less commonly lateral head gastrocnemius o Hyperintense hemorrhagic fluid tracks medially deep to subcutaneous tissue o Hyperintense fluid k anterolateral & posteromedial extension between subcutaneous tissue and medial headlsoleus plane o Fluid f extension anteromedial to tibia o Disruption of fascia separating medial head gastrocnemius and soleus o Less commonly associated with strain tibialis posterior
mwm -
o Intermediate signal mass f hypointense hemosiderin between medial head gastrocnemius & soleus
DDx: Plantaris Rupture
Lateral Corner
.-
Ax FS PD MR
Sag FS PD MR
Ax FS PD FSE MR
PLANTARIS RUPTURE Key Facts Imaging Findings Best diagnostic clue: Hemorrhage & mass effect Location: Between medial head gastrocnemius and soleus muscles Tubular hemorrhagic fluid collection Tendon mass & hemorrhage with convex medialllateral margins
Top Differential Diagnoses Gastrocnemius - Soleus Muscle Strain Posterolateral Corner Sprain Deep Venous Thrombosis (DVT)
Pathology Forceful muscle contraction Overstretching - forced dorsiflexion & extended knee Eccentric loading o Proximal injuries at muscle-tendon junction k ACL tears or hyperintense fluid in posterolateral corner sprains o Hyperintense curvilinear "comet sign" of fluid extending along distal course of plantaris adjacent to Achilles tendon 0 Absent plantaris muscle in proximal tears in sagittal plane through knee joint
lmaging Recommendations Best imaging tool: MR - demonstrates retracted tendonlhemorrhage mass in axial plane & localizes proximal vs. distal injury Protocol advice o TI, FS PD FSE or STIR axial images (T2* gradient echo optional for hemosiderin detection) o Additional sagittal images for posterolateral corner complex injury with proximal tears o Coronal images to define lateral to medial course of hemorrhage
I DIFFERENTIAL DIAGNOSIS Gastrocnemius - Soleus Muscle Strain Partial to complete tear medial head gastrocnemius Absence of retracted plantaris tendon
Posterolateral Corner Sprain Fluid posterior to popliteus tendon & disruption arcuate ligament Strain to partial tear popliteus muscle & muscle tendon junction
Deep Venous Thrombosis (DVT) Calf swelling, tenderness & pain with dorsiflexion Duplex ultrasound vs. venography MR findings: Perivascular edema & watershed muscle edema & venous collaterals & popliteal venous obstruction
Posterior Compartment Syndrome Progressive pain, exceeding degree of injury Paresthesias
Less common incidence relative to gastrocnemius muscle strain
Clinical Issues Most common signs/symptoms: Acute onset calf pain Sudden pop followed by calf swelling & tenderness Difficulty in walking Impaired weight bearing Symptoms localized more proximally in association with myotendinous and posterolateral complex injuries Improvement with non weight-bearing & rest
Diagnostic Checklist
Hemorrhage within the gastrocnemius - soleus plane may present without plantaris rupture
Weakness Requires direct measurement of compartment pressure
1 PATHOLOGY General Features General path comments o Relevant anatomy Plantaris anterior to lateral head gastrocnemius at level of knee joint Extends obliquely from lateral to medial Medial to Achilles tendon in distal course Origin = distal lateral supracondylar line femur Myotendinous junction = level of soleus origin from tibia Plantaris plane = between medial head gastrocnemius & soleus Etiology o Forceful muscle contraction o Overstretching - forced dorsiflexion & extended knee o Eccentric loading 0 Plyometric muscle action - jumping 0 Running - uneven terrain Epidemiology o Plantaris normally absent 7-10% population o Less common incidence relative to gastrocnemius muscle strain
Gross Pathologic & Surgical Features Myotendinous junction tear vs. distal tendon avulsion (less common) Myotendinous proximal tear associated with distal retraction
Microscopic Features Muscle-tendon unit (MTU) failure Inflammatory cell infiltrate Hemorrhagic cellular elements
Staging, Grading or Classification Criteria First degree strain 0 No myofascial disruption
PLANTARIS RUPTURE o Edema o Swelling
Second degree strain o Weakness o Variable separation of muscle from tendon or fascia Third degree strain o Myofascial separation complete o Lack of muscle function
Presentation Most common signs/symptoms: Acute onset calf pain Clinical profile o Sudden pop followed by calf swelling & tenderness o Difficulty in walking o Impaired weight bearing o Symptoms localized more proximally in association with myotendinous and posterolateral complex injuries o Tenderness medial to Achilles in cases of distal rupture
Demographics Age: Young - middle aged recreational athlete Gender: Non gender specific
Natural History & Prognosis Improvement with non weight-bearing & rest 1st 24 hours = greatest pain & swelling Recovery also based on associated injuries o Posterolateral corner o Anterior cruciate ligament o Popliteus muscle sprain o Lateral head gastrocnemius sprain
Treatment Conservative o Supportive wraps o Ice o Antiinflammatory medications o Cam walker o Stretching and strengthening of gastrocnemius soleus complex after acute phase Surgical o Not required for plantaris tendon o Compartment syndrome not common unless severe hemorrhage with compartment constriction
1 DIAGNOSTIC CHECKLIST Consider Evaluate plantaris proximally on sagittal and axial images and distally to the calcaneus on axial images Cases of suspected plantaris rupture are usually medial head gastrocnemius partial tears Hemorrhage within the gastrocnemius - soleus plane may present without plantaris rupture
Delgado GJ et al: Tennis leg: Clinical US study of 141 patients and anatomic investigation of four cadavers with MR imaging and US. Radiology 244(1):112-9,2002 Pomphrey MM Jr: More comments on tennis calf or tennis leg. Orthopedics 19(8):643,1996 Brown TR et al: Diagnoses of popliteus injuries with MR imaging. Skel Radio1 24:511-4, 1995 Menz MJ et al: Magnetic resonance imaging of a rupture of the medial head of the gastrocnemius muscle. A case report. J Bone Joint Surg AM 73(8):1260-2, 1991 Leach R: Leg and foot injuries in racquet sports. Clin Sports Med 7:359-70, 1988 Gecha S et al: Knee injuries in tennis. Clin Sports Med 7:435-52, 1988 Sutro C et al: The medial head of the gastrocnemius: A review for the basis for partial rupture and for intermittent claudication. Bull Hosp Jt Dis 45:150-7, 1985 Daffner RH: Anterior tibia1 striations. AJR 143:651-3, 1984 Severance H et al: Rupture of the plantaris - does it exist?J Bone Joint Surg Am 64:1387-8, 1982
PLANTARIS RUPTURE
(Left)Axial FS PD FSE MR shows plantaris rupture with intramuscular hemorrhage with associated edema of the medial head of the gastrocnemius muscle. (Right) Axial T2* GRE MR shows magnetic susceptibility (arrow) effect of hemorrhage within plane of injury.
(Left) Axial FS PD FSE MR shows hemorrhagic mass associated with a plantaris tendon rupture. Plantaris tendon tissue is not visualized. (Right) Axial T2' CRE MR shows well circumscribed hemosiderin ring surrounding hemorrhagic fluid collection associated with an absent plantaris tendon.
Typical (Left) Coronal FS PD FSE MR shows longitudinal distribution of hemorrhage corresponding to the course of the retracted plantaris tendon. (Right) Coronal graphic shows rupture of the plantaris tendon at the muscle-tendonjunction. Tendon retraction is illustrated.
TARSAL TUNNEL SYNDROME
Sagittal graphic shows compression neuropathy of the posterior tibial nerve secondary to a space occupying ganglion deep to the flexor retinaculum.
Sagittal FS PD FSE MR shows hyperintensity (muscle denervation) of the abductor hallucis (arrow) from tarsal tunnel syndrome secondary to varicose veins.
M R Findings Abbreviations and Synonyms Tibia1 neuropathy
Definitions Entrapment or compression neuropathy of posterior tibial nerve
General Features Best diagnostic clue: Space occupying lesion k muscle denervation supplied by posterior tibial nerve or one of its branches Location: Fibroosseous tunnel deep to flexor retinaculum posteriortinferior to medial malleolus Size: Variable based on involvement of posterior tibial nerve or one of its branches + etiology (e.g., trauma vs. space-occupying lesions) Morphology o Morphology based on causative factor (e.g., fracture vs. varicosities, ganglion, lipomas, neurilemomas, thickened flexor retinaculum, accessory muscles) o Distribution of associated muscle denervation supplied by medial or lateral plantar nerves
I
I
TlWI o Fractures Sustentaculum tali Medial tubercle posterior process talus o Serpiginous venous signal (intermediate) varicosities o Hypointense ganglia o Hyperintense lipomas o Intermediate signal neurilemomas o Hypointense thickened flexor retinaculum (lacinate ligament) o Muscle signal in presence of accessory muscle o Intermediate signal proliferative synovitis . o Fat marrow signal in bony vs. low to intermediate signal fibrous coalition o Fat marrow signal in talar exostosis T2WI o Hyperintense edema associated with fractures of talus/calcaneus o Hyperintense tangle of venous varicosities o Hypointense lipomas (FS PD FSE or STIR) o Hyperintense neurilemomas o Intermediate to hyperintense synovitis o Diffuse hyperintense muscle edema in muscle groups supplied by posterior tibial nerve + its branches (abductor hallucistmedial plantar nerve + abductor digiti quintitlateral plantar nerve)
I
DDx: Tarsal Tunnel Syndrome Plantar Fasciitis
TP Tenosvnovitis
Stress Fx
Sag FS PD M R
A x FS PD M R
Sag FS PD MR
Sag ~1 WI MR
I
TARSAL TUNNEL SYNDROME Key Facts Imaging Findings Best diagnostic clue: Space occupying lesion & muscle denervation supplied by posterior tibial nerve or one of its branches Morphology based on causative factor (e.g., fracture vs. varicosities, ganglion, lipomas, neurilemomas, thickened flexor retinaculum, accessory muscles) Distribution of associated muscle denervation supplied by medial or lateral plantar nerves
Top Differential Diagnoses Interdigital Neuroma Plantar Fasciitis Tibialis Posterior (TP) Tenosynovitis Tarsal Coalition
o Tenosynovitis - hyperintense fluid flexor hallucis
sheath T1 C+: To differentiate enhancing neurilemomas vs. nonenhancing synovial cysts
Imaging Recommendations Best imaging tool: MR to identify space-occupying soft tissue lesions + denervation hyperintensity Protocol advice: Axial, coronal and sagittal T1 or PD + FS PD FSE
Pathology Idiopathic - up to 50% Varicosities 13% 34.4%association with systemic disease Inflammation posterior tibia1 nerve
Clinical Issues Most common signs/symptoms: Pain plantar aspect foot Burning Numbness Positive Tinel's sign (percussion of tibia1 nerve over tarsal tunnel) + sensory impediment
Diagnostic Checklist Associated denervation muscle hyperintensity (e.g., abductor hallucis) with space-occupying lesions
Calcaneal Stress Fracture Posterior calcaneal subchondral edema Discrete linear calcaneal fracture lines perpendicular to long axis
0 s Trigonum Syndrome Pain + disruption cartilaginous synchondrosis between os trigonum and lateral tubercle of posterior process talus
) PATHOLOGY Interdigital Neuroma Morton' s neuroma Metatarsalgia + localized enlargement interdigital nerve Between third + fourth metatarsal heads Lateral branch medial plantar nerve to third interspace
Plantar Fasciitis Inflammation plantar aponeurosis Associated calcaneal spur, inflammatory changes + thickening fascia Hyperintense plantar aponeurosis os calcis attachment
Tibialis Posterior (TP) Tenosynovitis Fluid signal hyperintensity in tendon sheath Spectrum of degeneration + longitudinal splitting + tearing
Radiculopathy Disc protrusion lower lumbar discs on sagittal and axial images L5 or S1 radiculopathy
Tarsal Coalition Talocalcaneal coalition between sustentaculum tali + middle facet of subtalar joint Visualized on T1 coronal image
Diabetic Neuropathy Osseous hyperemia Associated chronic stenosing tenosynovitis
General Features General path comments o Relevant anatomy: Tarsal tunnel Distal deep posterior compartment leg forms tarsal tunnel Posterior to medial malleolus Fibroosseous space * Formed by medial talar wall, sustentaculum tali + medial calcaneal wall Flexor retinaculum = lacinate ligament = roof of tarsal tunnel Contents: Tibialis posterior, flexor digitorum longus + flexor hallucis longus tendons; neurovascular (N/V) bundle Posterior tibial nerve terminal branches = medial + lateral plantar nerves Posterior tibial nerve usually bifurcates within tarsal tunnel Third branch of posterior tibial nerve = medial calcaneal nerve (may arise from lateral plantar nerve) Etiology o Idiopathic - up to 50% o Trauma: Fractured sustentaculum tali or medial tubercle posterior talar process o Varicosities o Ganglia o Lipomas o Neurilemomas
TARSAL TUNNEL SYNDROME Thickened flexor retinaculum Accessory muscle Synovitis (inflammatory arthropathies) Tarsal coalition Diabetes o Valgus heel + pronated forefoot Epidemiology o Trauma incidence 17% o Varicosities 13% o Fibrosis 9% o Heel valgus 8% o 34.4% association with systemic disease
o o o o o
o NSAIDs to decrease posterior tibia1 nerve
inflammation Corticosteroid injections Orthotics Physical therapy Compressive stockings Immobilization Surgical o Surgical decompression o Excision of space-occupying lesion o Release flexor retinaculum, abductor fascia + decompress posterior tibia1 nervelbranches Complications o Recurrent tarsal tunnel syndrome o Space-occupying lesions + coalitions = better post surgical result vs. trauma or idiopathic
o o o o o
Gross Pathologic & Surgical Features Accessory flexor digitorum longus muscle Proliferative synovitis Ganglia Varicosities Lipomas Neurilemomas
Microscopic Features
Consider Associated denervation muscle hyperintensity (e.g., abductor hallucis) with space-occupyinglesions Use of T1 C+ to distinguish between cysts and neural tumors TlIPD coronal images to exclude tarsal coalition
Inflammation posterior tibia1 nerve Axonal compression Vascular changes Atrophy innervated muscles
ISELECTEDREFERENCES Presentation Most common signslsymptoms: Pain plantar aspect foot Clinical profile 0 Burning 0 Tingling 0 Numbness o Pain localized to posterior tibia1 nerve or one of its three terminal branches o Pain aggravated with activity + prolonged standing o Nocturnal paresthesias o Valleix's phenomenon = radiation of paresthesias proximally to calf + leg o Positive Tinel's sign (percussion of tibia1 nerve over tarsal tunnel) + sensory impediment o Tenderness to palpation o Motor symptoms = less common o Perthes' tourniquet test for varicosities = test deep venous system/posterior tibial venae comitantes by occluding superficial venous system
Demographics Age: Average = 47 years Gender: Female = 56% predilection
Natural History & Prognosis Varies with etiology Synovitis responds to rest + antiinflammatory medications (NSAIDs) Space-occupying lesions usually require surgical decompression
Treatment Conservative
1. 2. 3. 4. 5.
6.
7. 8. 9. 10. 11. 12. 13.
1
Kinoshita M et al: Tarsal tunnel syndrome associated with an accessory muscle. Foot Ankle Int 24(2):132-6, 2003 Lee MF et al: Tarsal tunnel syndrome caused by talocalcaneal coalition. Clin Imaging 26(2):140-3, 2002 Banks A et al: McGlamry's comprehensive textbook of foot and ankle surgery. vol 1. Philadelphia PA, Lippincott Williams & Wilkins, 1266-78, 2001 Still GP: Neurilemoma of the medial plantar nerve: A case report. J Foot Ankle Surg 40(4):236-9, 2001 Garchar DJ et al: Hypertrophic sustentaculum tali causing a tarsal tunnel syndrome: A case report. J Foot Ankle Surg 40(2):110-2,2001 Rosenberg ZS et al: From the RSNA refresher courses. Radiological Society of North America. MR imaging of the ankle and foot. Radiographics 20 Spec No:s153-79 Review, 2000 Narvaez JA et al: Painful heel: MR imaging findings. Radiographics 20(2):333-52, 2000 Steinbach LS: Painful syndromes around the ankle and foot: Magnetic resonance imaging evaluation. Top Magn Reson Imaging 9(5):311-26, 1998 Turan I et al: Tarsal tunnel syndrome. Outcome of surgery in longstanding cases. Clin Orthop 343:151-6, 1997 Kerr R et al: MR imaging in tarsal tunnel syndrome. J Comput Assist Tomogr 15:280-6, 1991 Zeiss J et al: Normal magnetic resonance anatomy of the tarsal tunnel. Foot Ankle 10:214-18, 1990 Have1 PE et al: Tibial nerve branching in the tarsal tunnel. Foot Ankle 10:214-18, 1990 Dellon AL et al: Tibia1 nerve branching in the tarsal tunnel. Arch Neurol41:645-46, 1984
TARSAL TUNNEL SYNDROME IMAGE GALLERY Tvwical (Left) Axial FS PD FSE MR shows hyperintense varicosities (arrow) within the tarsal tunnel. (Right) Axial FS PD FSE MR shows enlarged varicose veins with associated muscle denervation (arrow) of the abductor hallucis muscle (medial to the veins).
(Left) Coronal T I WI MR shows muscle denervation isointense to adjacent muscle in the acute phase. (Right) Coronal FS PD FSE MR shows hyperintense muscle denervation (arrows) involving the abductor hallucis, flexor digitorum brevis, and abductor digiti minimi. Both the medial and lateral (abductor digiti minimi) plantar nerves are involved.
Typical
(Lef)Coronal T l Wl MR shows chronic changes of compression neuropathy with fatty atrophy developing in the abductor hallucis, flexor digitorum brevis, and abductor digiti minimi. (Right) Coronal FS PD FSE MR shows prominent varicose veins with muscle hyperintensity (arrows) of the abductor hallucis, flexor digitorum brevis, and abductor digiti minimi.
PLANTAR FASCIITIS
Sagittal graphic shows inflamed and thickened plantar fascia (in red). Adjacent plantar calcaneal enthesophyte is attached to the plantar fascia.
Sagittal FS PD FSE MR shows long segment of proximal plantar fascia with hyperintensity and convex dorsal thickening of the aponeurosis.
MR Findings Abbreviations and Synonyms Proximal plantar fasciitis, heel pain syndrome, subcalcaneal pain syndrome
m
Definitions
TlWI o Initial prefascial thickening = hypointense to intermediate effacement of subcutaneous tissue superficial (plantar) to os calcis attachment o Hypointense thickening of plantar fascia o & Enthesophyte o Enthesophyte marrow containing fat signal o Partial detachment of medial or lateral cord o _+ Adjacent calcaneal erosions (tuberosity of calcaneus) T2WI o Intermediate to hyperintense thickening proximal plantar fascia on T2WI o Hyperintense subcutaneous tissue edema o Hyperintense reactive calcaneal marrow edema o Subcutaneous tissue hyperintensity + edema deep to plantar fascia o Rupture both mid portion and at proximal segment o Hyperintense fluid-filled gap in fascia1 rupture
*
Inflammation of plantar aponeurosis
1:
General Features Best diagnostic clue: Hyperintensity (T2WI) of plantar aponeurosis adjacent to os calcis attachment Location o Medialllateral cords or central attachment of plantar fascia to os calcis o Most common site = origin of plantar fascia from medial calcaneal tuberosity Size o Variable in proximal/distal extent (usually posterior third or 1-2 cm plantar fascia) o Increased plantar fascia thickness to 7 or 8 mm (normal thickness 3 or 4 rnm) Morphology: Superior to inferior thickening directed along long axis
Imaging Recommendations Best imaging tool: MR superior for edema in subcutaneous tissue + fascia Protocol advice o TlWI sagittal for enthesophyte and subcutaneous tissue effacement
DDx: Plantar Fasciitis Fibromatosrs
Cor FS PD MR
Cor FS PD MR
Cor FS PD MR
PLANTAR FASCllTlS P
Key Facts Imaging Findings Best diagnostic clue: Hyperintensity (T2WI) of plantar aponeurosis adjacent to os calcis attachment Increased plantar fascia thickness to 7 or 8 mm (normal thickness 3 or 4 mm) Intermediate to hyperintense thickening proximal plantar fascia on T2WI
Top Differential Diagnoses Plantar Fibromatosis Tarsal Tunnel Syndrome Calcaneal Stress Fracture Entrapment of 1st Branch of Lateral Plantar Nerve
Pathology Microtrauma of plantar fascia
o FS PD FSE coronal + sagittal for identifying cords of
involvement (medial, lateral or central)
I DIFFERENTIAL DIAGNOSIS Plantar Fibromatosis
Fibrous proliferation + replacement of plantar aponeurosis Nodules Solitary or multiple
Tarsal Tunnel Syndrome Entrapment or compression neuropathy Affecting posterior tibia1 nerve in fibroosseous tunnel deep to flexor retinaculum Pain + sensory deficit sole + foot Intrinsic muscle weakness
Calcaneal Stress Fracture Trabecular fractures perpendicular to long axis of calcaneus Posterior subchondral bone calcaneus (not plantar) Extensive posterior calcaneal marrow edema
Entrapment of 1st Branch of Lateral Plantar Nerve At level of medial plantar aspect heel Between fascia of abductor hallucis + medial head quadratus plantae
Sarcoidosis Bilateral heel pain occurring with or prior to onset of sarcoid arthritis
General Features General path comments 0 Relevant anatomy = plantar aponeurosis Origin = os calcis Plantar fascia = multilayered fibrous aponeurosis Three segments or cords + distal superficial tracts
* Nerve entrapment or irritation of medial calcaneal
digiti quinti N. Or lateral plantar N. Repetitive tensile overload affecting central band Reparative inflammatory response to traumatic overload Calcaneal spur - within flexor brevis origin
Clinical Issues ~ o scommon t signs/symptoms: Pain medial tuberosity calcaneus Affects medial aspect foot & heel Severe inflammation - unable to weight bear on heel Medial tuberosity enthesophyte
Diagnostic Checklist
Locate involvement in medial, lateral or central portions
Central segment = largest + extends from plantar posteromedial calcaneal tuberosity to proximal phalanges + skin, ball of foot = Lateral cord = from lateral process os calcis tuberosity to base of fifth metatarsal Medial cord = thin + covers plantar aspect abductor hallucis Medial calcaneal nerve (N.) in subcutaneous tissue between plantar fascia + skin Nerve to abductor digiti quinti (from lateral plantar nerve) passes between long plantar ligament & calcaneal plantar enthesophyte Etiology o Microtrauma of plantar fascia o Nerve entrapment or irritation of medial calcaneal N. or lateral plantar N. to abductor digiti quinti o Repetitive tensile overload affecting central band o Reparative inflammatory response to traumatic overload 0 Heel cord contracture o Pes planus association o Pes cavus association o Calcaneal spur - within flexor brevis origin Epidemiology o 50% of adult plantar heel pain patients Calcaneal enthesophyte (enthesophyte actually located in short toe flexor origins and not aponeurosis) r
*
Gross Pathologic & Surgical Features Inflamed proximal plantar fascia Thickened fascia from normal thickness of 3 mm to mean thickness of 7.4 mm Calcaneal enthesophyte Fatigue fractures/periosteitis medial calcaneal tuberosity
Microscopic Features Angiofibroblastic hyperplasia Collagen degenerative/necrosis Chondroid metaplasia Matrix calcification
PLANTAR FASCIITIS Staging, Grading or Classification Criteria
-
Acute plantar fascia rupture less common, with palpable defect distal to medial calcaneal tuberosity Chronic proximal plantar fasciitis
Presentation Most common signsJsymptoms: Pain medial tuberosity calcaneus Clinical profile o Slow gradual onset pain o Pain with dorsiflexion toes o Pain f associated with twisting injury to foot o Affects medial aspect foot & heel o Pain worse i n AM o Severe inflammation - unable to weight bear on heel o Medial tuberosity enthesophyte o k Seronegative spondyloarthritis (HLA-B27 antigen positive) o History increased stress on foot either standing or activity related
*
Demographics Age: Average = 45 years Gender: 2 times more common i n women
Natural History & Prognosis Pain partially resolves during day Exacerbated by prolonged standing or athletic activity 90% patients improve with conservative treatment
Treatment Conservative o Nonsteroidal antiinflammatory medications o Rest o Orthotics o Physical therapy with stretching o ~mmobilizationwith cast o Steroid injection - controversial Surgical o Plantar fasciotomy o Excision calcaneal spur o Release of nerve to abductor digiti quinti o Endoscopic plantar fascia release Complications o Steroid injections associated with rupture of plantar fascia & fat pad atrophy o Endoscopic release: Stress fractures, pseudoaneurysm, recurrence of pain
( DIAGNOSTIC CHECKLIST Consider Identify associated plantar fascial tearing Locate involvement i n medial, lateral or central portions Early diagnosis by visualizing subcutaneous fat effacement by edema on TlWI i n sagittal plane
1 SELECTED REFERENCES
1
McGonagle D et al: The rule of biomechanical factors and HLA-B27 in magnetic resonance imaging-determined bone changes in plantar fascia enthesopathy. Arthritis Rheum 46(2):489-93, 2002 Recht MP et al: Magnetic resonance imaging of the foot and ankle. J Am Acad Orthop Surg 9(3):187-99, 2001 Balen PF et al: Association of posterior tibia1 tendon injury with spring ligament injury, sinus tarsi abnormality, and plantar fasciitis on MR imaging. AJR 176(5):1137-43,2001 Theodorou DJ et al: Disorders of the plantar aponeurosis: A spectrum of MR imaging findings. AJR 176(1):97-104,2001 Theodorou DJ et al: Plantar fasciitis and fascial rupture: MR imaging findings in 26 patients supplemented with anatomic data in cadavers. Radiographics 20 Spec N0:S181-97, 2000 Narvaez JA et al: Painful heel: MR imaging findings. Radiographics 20(2):333-52, 2000 Yu JS et al: Foot pain after a plantar fasciotomy: An MR analysis to determine potential causes. J Comput Assist Tomogr 23(5):707-12, 1999 Yu JS et al: The plantar fasciotomy: MR imaging findings in asymptomatic volunteers. Skeletal Radio1 28(8):447-52, 1999 Grasel RP et al: MR imaging of plantar fasciitis: Edema, tears, and occult marrow abnormalities correlated with outcome. AJR 173(3):699-701, 1999 Schepsis AA et al: Plantar fasciitis. Etiology, treatment, surgical results, and review of the literature. Clin Orthop Re1 Res 266:185-196, 1991 Berkowitz JF et al: Plantar fasciitis: MR imaging. Radiology 179:665-7, 1991 Amis J et al: Painful heel syndrome: Radiographic assessment. Foot Ankle 9:91-5, 1988 Kwong PK et al: Plantar fasciitis: Mechanics and pathomechanics of treatment. Clin Sports Med 7:119-26, 1988 Williams RL et al: Imaging study of the painful heel syndrome. Foot Ankle 7:345-9, 1987 Baxter DE et al: Heel pain operative results. Foot Ankle 5:16-25, 1984 Clancy WG Jr. et al: Tendinitis and plantar fasciitis in runners. Orthopedics 6:217-33, 1983 Graham CE: Painful heel syndrome: Rational of diagnosis and treatment. Foot Ankle 3:261-7, 1983 Snider MP et al: Plantar fascia release for chronic plantar fasciitis in runners. Am J Sports Med 11:215-9, 1983
PLANTAR FASCllTlS
(Left) Sagittal FS PD FSE MR shows partial detachment farrow) of plantar fascia adjacent to plantar enthesophyte and os calcis attachment. Partial retraction of the plantar fascia contributes to the thickening of the proximal aponeurosis. (Right) Sagittal FS PD FSE MR shows high grade tear of the plantar fascia with adjacent inflammatory change, calcaneal subchondral marrow edema, and hyperintensity of the flexor digitorum brevis.
(Lef)Coronal T 1 Wl MR shows preferential involvement of the medial cord (band) of the plantar fascia with convex dorsal and plantar margins and central intermediate signal. (Right) Coronal FS PD FSE MR shows hyperintense inflammatory change of the medial cord (arrow) of the plantar fascia.
Typical (Left) Sagittal T l Wl MR shows large calcaneal enthesophyte adjacent to plantar fascia. Plantar enthesophyte is usually located in the toe flexor origins and not the aponeurosis. (Right) Sagittal FS PD FSE MR shows surgical release (arrow) of the plantar fascia origin.
PLANTAR FIBROMATOSIS
Sagittal graphic shows localized plantar fibromatosis with nodular thickening.
Abbreviations and Synonyms Collagenous fibromatosis, plantar fibromas
T2WI 0 Mild hyperintensity plantar subcutaneous tissue o Convex dorsal (deep) and plantar (superficial) margins o Intermediate signal in adjacent unaffected plantar fascia 0 Infiltrative upper margins o Lesions deep to plantar aponeurosis T1 C+ o Enhancement o Plantar margin more defined vs. infiltrative upper margin 0 Identification of multiple lesions Intermediate central signal intensity on FS PD FSE, STIR or T2* gradient echo imaging
+
Definitions
*
Fibrous and collagenous nodular development in plantar aponeurosis
138
Sagittal FS PD FSE MR shows central hyperintense signal (arrow) in early lesion consisting of proliferating fibroblasts.
I IMAGING FINDINGS
1
+ + +
General Features Best diagnostic clue: Nodular thickening in plantar aponeurosis Location: Plantar fascia + subcutaneous tissue usually medial Size: Usually less than 1 cm diameter Morphology: Nodular single or multiple lesions
MR Findings TlWI o Hypointense nodule o Central region of low to intermediate signal intensity 0 k Low signal intensity effacement of plantar subcutaneous tissue o Long axis of nodule along long axis of plantar fascia o Normal thickness of adjacent plantar fascia
Imaging Recommendations Best imaging tool: MR to identify location, morphology and extension relative to plantar aponeurosis Protocol advice: FS PD or T2 FSE or STIR sagittal images
mnm
IDIFFERENTIAL DIAGNOSIS Plantar Fasciitis
Hyperintensity in thickened plantar fascia1 attachment to os calcis
DDx: Plantar Fibromatosis Plantar Fasci~trs
Sag FS PD MR
Cor FS PD MR
Sag FS PD MR
PLANTAR FlBROMATOSiS Key Facts Imaging Findings Best diagnostic clue: Nodular thickening in plantar aponeurosis Morphology: Nodular single or multiple lesions Convex dorsal (deep) and plantar (superficial) margins Intermediate central signal intensity on FS PD FSE, STIR or T2* gradient echo imaging
Top Differential Diagnoses Plantar Fasciitis Lipoma Ganglion Cyst Pigmented Villonodular Synovitis (PVNS)
Nodular or poorly defined aggregates of fibroblasts + dense collagen Infiltration of surrounding structures without malignant transformation
Clinical Issues Most common signs/symptoms: Mild plantar pain Asymptomatic vs. pain + discomfort with walking or prolonged standing Dupuytren's contracture (palmar) Nodules = firm and fixed to plantar aponeurosis
*
Diagnostic Checklist Use FS PD FSE, STIR or contrast to appreciate increased signal
Pathology Superficial collagenous fibromatoses group No discrete nodular thickening Partial detachment medial or lateral cord
Lipoma Subcutaneous tissue location Fat signal with suppression on STIR or FS PD or T2 Heterotopic lipomas = intramuscular, intermuscular, lipoma of tendon sheath
Ganglion Cyst Common on dorsum of foot Round morphology Hypointense on TlWI Hyperintense on T2WI
Pigmented Villonodular Synovitis (PVNS) Inhomogeneous hyperintensity with hypointense hemosiderin (T2WI)
Hemangioma Dilated, serpiginous vessels Hypointense on Tl WI Hyperintense on FS PD FSE, STIR or T2* gradient echo Extension to skin + subcutaneous tissue
Schwannoma Benign peripheral nerve sheath tumor Grows eccentrically from nerve Painless mass relative to major nerve f Cystic degeneration
Neurofibromas Develop within a peripheral nerve Painless mass Minority of patients develop multiple neurofibromas (syndrome of neurofibromatosis) Target lesions with hypointense center + hyperintense periphery
Synovial Sarcoma Hypointense mass on TlWI Hyperintense mass on T2WI (FS or STIR) f Adjacent osseous invasion Tracking along adjacent tendons
Biphasic histology of epithelioid cells + fibroblastic spindle cells Occur in close proximity to joints
I PATHOLOGY General Features General path comments o ~elevantanatomy = plantar fascia From calcaneus to metatarsal heads and distally Central, lateral + medial parts or cords Central section k contributions from plantaris + Achilles tendon Lateral plantar aponeurosis = plantar to abductor digiti minimi muscle Medial plantar aponeurosis = plantar to abductor hallucis muscle Genetics: Proposed genetic link based on occurrence of plantar + palmar fibromatosis together in some individuals Etiology o Superficial collagenous fibromatoses group o Association with Peyronie's disease + Dupuytren's contracture hand Associated abnormalities: Association with other collagenous fibromatoses (palmar + penile) Distribution o Solitary, multiple, unilateral or bilateral o Less common than palmar fibromatosis
Gross Pathologic & Surgical Features Similar to palmar fibromatosis - except without flexion contractures Single or multiple lesions Firm Thin poorly defined capsule Cut surface gray-white or gray-yellow
Microscopic Features Nodular or poorly defined aggregates of fibroblasts + dense collagen Myofibroblasts
PLANTAR FIBROMATOSIS Infiltration of surrounding structures without malignant transformation Mitotic figures uncommon
Staging, Grading or Classification Criteria * Proliferative phase = fibroblastic activity & cellular proliferation Involutional phase = active phase with nodule formation Residual phase = reduced fibroblastic activity + collagen maturation
6. 7. 8. 9.
10. 11.
Presentation Most common signs/symptoms: Mild plantar pain Clinical profile o Asymptomatic vs. pain + discomfort with walking or prolonged standing 0 + Dupuytren's contracture (palmar) o Nodules = firm and fixed to plantar aponeurosis
12. 13. 14.
Radio1 29(9):491-501,Review, 2000 Llauger J et al: MR imaging of benign soft-tissue masses of the foot and ankle. Radiographics 18(6):1481-98,Review, 1998 -- - Ericson SJ et al: MR imaging of the ankle and foot. Radio1 Clin North Am 35(1):163-92,Review, 1997 Morrison WB et al: Plantar fibromatosis: A benign aggressive neoplasm with a characteristic appearance on MR images. Radiology 193(3):841-5,1994 Pasternack WA et al: Plantar fibromatosis: Staging by magnetic resonance imaging. J Foot Ankle Surg 32(4):390-6, 1993 Berquist TH et al: Value of MR imaging in differentiating benign from malignant soft tissue masses. AJR 1251-55, 1990 Kirby EJ et al: Soft tissue tumors and tumor-like lesions of the foot. An analysis of eighty-three cases. J Bone Joint Surg Am 621-26,1989 Kransdorf MJ et al: Soft tissue masses: Diagnosis using MR imaging. AJR Am J Roentgen01 541-7, 1989 Chang AE et al: Magnetic resonance imaging versus computed tomography in the evaluation of soft tissue tumors of the extremities. Ann Surg 340-8,1987 Simon MA et al: Diagnostic strategy for bone and soft tissue tumors. Instr Course Lect 527-36. ~,1987 Totty WG et al: Soft tissue tumors: MR imaging. Radiology 135-41, 1986 ~
Demographics Age: Fibromatosis usually in ages 65 and older (especially palmar fibromatosis) Gender: Slight predilection for men
Natural History & Prognosis
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Gradual enlargement More extensive distribution Increasing number of nodules No contractures of toes
Treatment Conservative o Orthotics o k Anti-inflammatory agents Surgical o Excision Complications o Local recurrence
I DIAGNOSTIC CHECKLIST Consider Occurs in more distal location compared to plantar fasciitis Use FS PD FSE, STIR or contrast to appreciate increased signal Upper or dorsal margins frequently infiltrative
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I..
2. 3. 4.
5.
Recht MP et al: Magnetic resonance imaging of the foot and ankle. J Am A G Orthop ~ Surg 9(3):<87-99, 2001 Ng A et al: Atypical presentation of plantar fasciitis secondary to soft-tissue mass infiltration. J Am Podiatr Med ASSOC 91(2):89-92,2001 Theodorou DJ et al: Disorders of the plantar aponeurosis: A spectrum of MR imaging findings. AJR 176(1):97-104,2001 Timins ME: MR imaging of the foot and ankle. Foot Ankle Clin 5(1):83-101,Review, 2000 Yu JS: Pathologic and post-operative conditions of the plantar fascia: Review of MR imaging appearances. Skeletal -
15.
PLANTAR FIBROMATOSIS
I IMAGE GALLERY (Left) Sagittal T l Wl MR shows convex margins (arrows) of plantar fibromatosis oriented along the long axis of the plantar fascia. (Right) Sagittal FS PD FSE MR shows convex deep and superficial margins with central hyperintensity (arrow).
(Left) Coronal T I WI MR shows preferential involvement of the medial plantar fascia with large single nodular lesion. (Right) Coronal TZ* GRE MR shows intermediate central SI with inhomogeneity of medial plantar fibromatosis (arrow).
(Lef)Sagittal T 1 WI MR shows plantar subcutaneus tissue extension (arrow) of the plantar fibroma. (Right) Coronal FS PD FSE MR shows well defined plantar margin and more infiltrative upper margins characteristic of plantar fibromatosis.
MORTON'S NEUROMA
Axial graphic shows Morton's neuroma with localized enlargement of the interdigital nerve branch between the 3rd and 4th metatarsal heads.
Coronal FS PD FSE MR shows hyperintense mass (arrow) plantar to the metatarsal heads in the 2nd interspace.
M R Findings Abbreviations and Synonyms Metatarsalgia, interdigital neuralgia
Definitions Metatarsalgia + localized enlargement of the interdigitainerve between 3rd; 4th metatarsal heads
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General Features
Best diagnostic clue: Soft tissue mass between + distal to 3rd + 4th metatarsal heads Location: 3rd common digital branch of medial plantar nerve, plantar to deep transverse intermetatarsal ligament Size: 5 mm or greater in diameter (normal interdigital nerve diameter = 2 mm) Morphology: Fusiform teardrop-shaped enlargement with bulbous plantar extension
Radiographic Findings Radiography o Increased intermetatarsal angle of affected interspace o Neuroma not visible
TlWI o Hypointense to intermediate on coronal TlWI o Teardrop-shaped mass o Plantar to metatarsal heads in third interspace o Fat signal plantar subcutaneous tissue visualized superficial to mass o k Hypointensity extending dorsal to transverse metatarsal ligament in a thickenedlinflamed intermetatarsal bursa T2WI o Intermediate to hyperintense on FS PD FSE + STIR images o Intermediate without areas of hyperintensity on conventional or non-fat suppressed sequences o Effacement of plantar subcutaneous fat by convex border of teardrop-shaped mass o Inhomogeneity modified by degree of fibrosis o Hyperintense intermetatarsal bursa1 fluid T2* GRE: Intermediate to hyperintense T1 C+ o Diffuse hyperintense enhancement o Enhanced lining of inflamed intermetatarsal bursa Epineurium fibrosis intermediate signal on T1+ T2WI
Imaging Recommendations Best imaging tool: MR for direct coronal cross sectional images in initial diagnosis and recurrence
DDx: Morton's Neuroma Metatarsal Fx
Sag T l W l MR
Tarsal Tunnel
Ax T l W l MR
Sag FS PD MR
MORTON'S NEUROMA Key Facts Imaging Findings Best diagnostic clue: Soft tissue mass between f distal to 3rd + 4th metatarsal heads Location: 3rd common digital branch of medial plantar nerve, plantar to deep transverse intermetatarsal ligament Intermediate to hyperintense on FS PD FSE + STIR images Effacement of plantar subcutaneous fat by convex border of teardrop-shaped mass
Top Differential Diagnoses Metatarsal Stress Fracture Osteochondrosis (Freiberg's Infraction) Tarsal Tunnel Syndrome Neurofibroma
Protocol advice: FS PD FSE or STIR or TIC+ direct coronal images
I DIFFERENTIAL DIAGNOSIS Metatarsal Stress Fracture Discrete fracture linelmetatarsal edema Cortical thickening
Osteochondrosis (Freiberg's Infraction) Flattening second metatarsal head Subchondral fracture Sclerosis
Tarsal Tunnel Syndrome Medial tarsal tunnel mass Denervation hyperintensity
Neurofibroma Hyperintense on conventional, non-fat suppressed T2 as well as FS PD FSE images Morton's neuroma requires STIR or FS PD FSE or TIC+
lntermetatarsal Bursitis Hyperintense fluid between metatarsals (on T2WI) No focal soft tissue mass superficial to transverse metatarsal ligament
Rheumatoid Arthritis Inflammation intermetatarsal bursa Rheumatoid nodules Chronic joint involvement = synovitis = pannus Involvement begins at fifth ray metatarsal head + progresses medially
1 PATHOLOGY General Features General path comments o Relevant anatomy Third common digital branch of medial plantar nerve
Intermetatarsal Bursitis
Pathology Entrapment neuropathy secondary to compressive forces against deep transverse intermetatarsal ligament Fibrotic response: Not true tumor Inflammation intermetatarsal bursa Dense fibrosis of axons and sheath (Schwann cells)
Clinical Issues Most common signslsymptoms: Plantar foot pain Paroxysmal burning sensation Neurologic pain in toe f interdigital space
Diagnostic Checklist TIC+ useful especially in post operative recurrence
Communicating branch lateral plantar nerve may contribute to 3rd common digital nerve (also supplies 3rd interspace) Plantar nerve superficial to deep transverse intermetatarsal ligament Third plantar metatarsal artery and veins also superficial (plantar) to transverse metatarsal ligament Tendon of third lumbrical muscle - also superficial to transverse metatarsal ligament Pacinian corpuscles in subcutaneous tissue Fat pad of subcutaneous tissue superficial to plantar nerve Etiology o Entrapment neuropathy secondary to compressive forces against deep transverse intermetatarsal ligament o Localized enlargement third common digital branch medial plantar nerve o Fibrotic response: Not true tumor o Tethering 3rd common digital branch medial plantar nerve by anastomotic or communicating branch between medial + lateral plantar nerves o Traction on 3rd interspace nerve by hindfoot valgus, intermetatarsal bursitis or extreme dorsiflexion of toes (high-heeled shoes) Distribution o 93% of patients with foot pain o 64% to 91% third intermetatarsal space o Bilateral lesions in 0 to 12% o < 4% involvement in two intermetatarsal spaces
Gross Pathologic & Surgical Features Benign fusiform enlargement third common digital nerve Perineural fibroma Shiny + glistening white to yellowish surface Bifurcating digital branches + fusiform enlargement in resected neuroma Nodule attached to intermetatarsal bursa Inflammation intermetatarsal bursa
*
14
MORTON'S NEUROMA Complications
Microscopic Features Neural proliferation Dense fibrosis of axons and sheath (Schwann cells) Degeneration Endoneural + neural edema (early) Perineural + epineural fibrosis + hypertrophy (late stages) Endoneural blood vessel wall hyalinization Perivascular fibrosis Vascular occlusion Endoneural + perineural mucinous change Demyelination + axonal loss Renaut's bodies (hyaline granules) in endoneural tissue in response to compressive nerve trauma Wallerian or fatty degeneration Axon regeneration
o Hematoma o Vascular ischemia o Hammer toes related to division of deep transverse
intermetatarsal ligament o Painful stump neuroma
o Continued pain o Subcutaneous fat pad atrophy with steroid
injections
Consider Use FS PD FSE or STIR in the direct coronal plane to identify Morton's neuroma T2* gradient echo techniques can be used if there is inhomogeneity on fat-suppressed images TIC+ useful especially in post operative recurrence
Staging, Grading or Classification Criteria Early stage = endoneural + neural edema Late stage = perineural, epineural & endoneural fibrosis
1 SELECTED REFERENCES 1.
Presentation Most common signs/symptoms: Plantar foot pain Clinical profile o Pain = sharp, dull or throbbing o Paroxysmal burning sensation o Neurologic pain in toe + interdigital space o Tingling toe or forefoot o Increased pain with walking also + night pain o f Numbness third + fourth toes o Exacerbation with wearing shoes + activity o Relief by rest o Positive Mulder's sign with palpation plantar interspace distal to metatarsal heads
Demographics Age o 40 to 60 years of age o Less common in teenagers Gender: Increased incidence in women
Natural History & Prognosis Tenderness with applied pressure to metatarsophalangeal joints Palpable mass dorsal or plantar Associated inflammation intermetatarsal bursa < 60% success for conservative treatment
Treatment Conservative o Avoid high-heeled shoes o Wider shoes + arch support o Metatarsal of pads o Injection of corticosteroids Surgical o Excision involved interdigital nerve o Epineural neurolysis or decompression o Endoscopic instrumentation o Percutaneous electrocoagulation o Carbon dioxide laser techniques
2. 3. 4. 5. 6, 7. 8. 9. 10. 11. 12.
13.
Weishaupt D et al: Morton neuroma: MR imaging in prone, supine, and upright weight-bearing body positions. Radiology 266(3):849-56, 2003 Gentili A et al: MR imaging of soft tissue masses of the foot. Semin Musculoskelet Radio1 6(2):141-52, 2002 Banks A et al: McGlamry's comprehensive textbook of foot and ankle surgery. Morton's Neuroma. vol 1. Philadelphia PA, Lippincott Williams & Wilkins, (8):231-52, 2001 Still GP: Neurilemoma of the medial plantar nerve: A case report. J Foot Ankle Surg 40(4):236-9, 2001 Ashman CJ et al: Forefoot pain involving the metatarsal region: Differential diagnosis with MR imaging. Radiographics 21(6):1425-40, 2001 Bencardino J et al: Morton's neuroma: Is it always symptomatic? AJR 175(3):649-53,2000 Morscher E et al: Morton's intermetatarsal neuroma: Morphology and histological substrate. Foot Ankle Ing 21(7):558-62, 2000 Zanetti M et al: Morton neuroma: Effect of MR imaging findings on diagnostic thinking and therapeutic decisions. Radiology 213(2):583-8, 1999 Llauger J et al: MR imaging of benign soft-tissue masses of the foot and ankle. Radiographics 18(6):1481-98, 1998 Zanetti M et al: Efficacy of MR imaging in patient suspected of having Morton's neuroma. AJR 529-32, 1997 Terk MR et al: Morton neuroma: Evaluation with MR imaging performed with contrast enhancement and fat suppression. Radiology 516-20, 1997 Williams JW et al: MRI in the investigation of Morton's neuroma: Evaluation with MR imaging performed with contrast enhancement and fat suppression. Radiology 239-41,1989 Sartoris DJ et al: Magnetic resource images: Interdigital or Morton's neuroma. J Foot Surg 78-82, 1989
MORTON'S NEUROMA IMAGE GALLERY (Lef)Coronal T 1 WI MR shows hypointense intermetatarsal bursal fluid associated with epineurium fibrosis. (Right) Coronal FS PD FSE MR shows hyperintense intermetatarsal fluid and inhomogeneity of Morton's neuroma (arrow) modified by the presence of fibrosis.
(Left) Coronal T 1 WI MR shows hypointense teardrop-shaped mass (arrow) projecting plantar to the metatarsal heads of the 3rd interspace. (Right) Coronal T I C+ MR shows recurrence of a Morton's neuroma on a gadolinium-enhanced fat suppressed image. Intermetatarsal bursal enhancement medially is greater than the recurrent neuroma laterally (arrow).
(Left) Coronal T l Wl MR shows isointense Morton's neuroma with adjacent inflammation. (Right) Coronal STIR MR shows contrast differentiation between hyperintense inflammation medially and intermediate to hyperintense reactive connective tissue proliferation and nerve degeneration laterally (arrow).
DIABETIC FOOT
Sagittal graphic shows neuropathic edema (in red) involving the subarticular portions of the talus and adjacent calcaneus.
Sagittal T l Wl MR shows neuropathic hyperemic marrow with hypointense signal changes involving the talus and calcaneus.
Size: Variable, with neuropathic joint involvement over several tarsal bones Morphology o Ulcers - curve of 1st + 5th metatarsal heads o Neuropathic ulcer - under metatarsal head + thick hyperkeratosis o Ischemic ulcer - fibrotic base without hyperkeratosis o Charcot foot - foot collapse, arch flattens + osseous destruction + bone formation and subluxation/dislocation o Osteomyelitis - soft tissue infection +_ skin tract from ulcer to bone
Abbreviations and Synonyms Diabetic foot ulcers and infection; neuropathic arthropathy
Definitions Soft tissue infection, osteomyelitis Neuropathic changes
Radiographic Findings
General Features Best diagnostic clue o Osteomyelitis associated with pressure point ulcers + hyperintense osseous signal on T2WI o Neuropathic arthropathy - involves midfoot joints with intermediate to hyperintense signal on T2WI without overlying ulcer or pressure point Location o Pressure lesions in footlinfection sites Plantar relative to 1st + 5th metatarsal heads Calcaneal tuberosity Malleoli Medial to 1st metatarsal head o Neuropathic: Midfoot or multiple joints without overlying ulcers
Radiography o Limited for acute osteomyelitis o Infection associated with periosteal reaction, lytic lesions or sclerotic sequestra o Osteolysis distal forefoot to mid-metatarsal level + neuropathic process o Charcot process - osteopenia + fractureldislocation or fragmentation
*
MR Findings TlWI o Hypointense to intermediate signal in ulcer o Ulcer k cystic component o Pressure lesion/ulcer with hypointense effacement of subcutaneous fat or fat plane
Bmm DDx: Diabetic Foot Osteoarthrit~s
P
Cor TI WI MR
Sag FS PD MR
L
a
I
Cor FS PD M R
DIABETIC FOOT Key Facts Terminology Neuropathic changes
imaging Findings Osteomyelitis associated with pressure point ulcers + hyperintense osseous signal on T2WI Neuropathic changes common: Metatarsophalangeal, tarsometatarsal, intertarsal joints Neuropathic + osteomyelitis change hyperintense on FS PD FSE or STIR Primary findings in osteomyelitis = hyperintense soft tissue tract from skin ulcer to bone + osseous erosion and marrow edema on T2WI
Top Differential Diagnoses Osteoarthritis Osteonecrosis o Neuropathic arthropathy hypointense replacement
of fat marrow o Neuropathic changes common: Metatarsophalangeal, tarsometatarsal, intertarsal ioints o ~eriostealreaction + cortical destruction in osteomyelitis or neuropathic o Muscle atrophy with fat signal intensity in neurovathic foot T2WI o Pressure lesions/ulcer intermediate signal intensity o Necrotic cystic center of ulcer = hyperintense o Cellulitis = hyperintense soft tissue o Abscesses - thick wall = central hyperintense necrosis o Neuropathic + osteomyelitis change hyperintense on FS PD FSE or STIR o Focal area of greatest hyperintensity = osteomyelitis superimposed over neuropathic change o Primary findings in osteomyelitis = hyperintense soft tissue tract from skin ulcer to bone + osseous erosion and marrow edema on T2WI o Neuropathic changes associated with joint based abnormalities including fragmentation + resorption o Reactive marrow edema in area adjacent to soft tissue inflammation visualized on STIR & FS PD FSE T2* GRE: Osteomyelitis frequently hyperintense on T2* gradient echo vs. neuropathic marrow which is not hyperintense T1 C+ o Abscess enhances along peripheral wall o Enhancement may be present in both neuropathic + osteomyelitis o Cellulitis = larger area of diffuse enhancement
Imaging Recommendations Best imaging tool: MR to identify ulcer, cellulitis, soft tissue tract, osteomyelitis vs. neuropathic marrow signal Protocol advice o T1 - to assess marrow fat replacement and subcutaneous tissue effacement o FS PD FSE or STIR - for marrow edema
Infection
Pathology ~ e u r o ~ Q L- sensory " h ~ type responsible for diabetic foot complications Charcot's neuroarthropathy = motor + autonomic Plantar surface forefoot ulcers in diabetic feet
Clinical Issues Diabetic foot ulcer = non-healed plantar ulcer Charcot's joint = painless swelling + erythema of foot + ankle Charcot's joints = fragmentation or dislocation
Diagnostic Checklist STIR or FS PD or T2 FSE = hyperintense for both osteomyelitis & neuropathic joints
o T2* gradient echo to help differentiate osteomyelitis
from neuropathic change
Osteoarthritis Cartilage destruction; lack of erosions Osteophytes; subchondral sclerosis + cysts
Osteonecrosis Avascular necrosis (AVN) - body of talus Localized ischemia produces diffuse marrow edema vs. diffuse infarction pattern
infection Sinus tracts, multiple abscesses Loss of subcutaneous tissue planes
Calcium Pyrophosphate Dihydrate Crystal Deposition Disease Mixed erosive + productive process Subchondral cysts Intraarticular + paraarticular crystal deposition Uniform cartilage destruction
1 PATHOLOGY General Features General path comments o Relevant anatomy - at risk Metatarsal heads, calcaneal tuberosity Tendo Achilles bursa Soft tissue medial to 1st metatarsal head Malleoli, distal toes Tarsometatarsal joints Etiology o Neuropathy - sensory type responsible for diabetic foot complications o Neuropathy theories - sorbitol accumulation, glycosylation of proteins o Motor neuropathy - intrinsic muscle atrophy, weakness + foot deformity
.. . .
DIABETIC FOOT o Charcot's neuroarthropathy = motor + autonomic o Arteriosclerotic disease - lower extremity ischemia o Biomechanics - decrease range of motion + tightness
gastrocnemius/soleus complex o Posterior heel ulcers = heel pressure; ulcers sides + dorsum related to footwear Epidemiology o Diabetes mellitus = 5.9% population o Foot problems = 20 to 25% of admissions for diabetic population o Diabetic foot ulcers divided into 113 neuropathic; 113 ischemic + 113 mixed o 2-4% diabetic patients = diabetic foot ulcers or deep infections
o Neuroarthropathy associated with alcoholism +
trauma - more frequent in males
Natural History & Prognosis Diabetic foot ulcers o At risk for infection = spontaneous drainage, erythema, cellulitis, f lymphadenitis, osteomyelitis Charcot's neuroarthropathy: Fixed deformity Complications: Infection = polymicrobial
Treatment Conservative o Diabetic foot ulcers = bedrest, orthotics, casting, cast boots, crutches, walker or wheelchair o Charcot's neuroarthropathy = non-weight bearing, cast, orthotic walker (total contact cast) Surgical o Diabetic foot ulcers = debridement + off-loading o Charcot's neuroarthropathy = exostosectomy, arthrodesis, open reduction + internal fixation, reconstruction, + fusion Complications o Surgery in Charcot's joints associated with prolonged healing times o + Amputations for infections
Gross Pathologic & Surgical Features Diabetic foot ulcers o Plantar surface forefoot ulcers in diabetic feet o Associated claw toes and Charcot's midfoot Charcot's joints o Fracture o Subluxation, dislocation o Resorption + new bone formation
Microscopic Features Diabetic foot ulcers o Platelets, cytokines, neutrophils o Chemotactic fractures o Granulocytes + lymphocytes o + Fibroblastic + endothelial cell migration o Failure of wound remodeling Charcot's neuroarthropathy o Osseous resorption + new bone formation in neuropathic joints o Detritic synovitis with cartilaginous + osseous debris
1 DIAGNOSTIC CHECKLIST Consider Osteomyelitis associated with soft tissue ulcers at pressure points Neuropathic joints - usually independent of soft tissue ulcers + typically involve joints Hyperintensity on TZ* gradient echo when present seen in osteomyelitis and not neuropathic marrow STIR or FS PD or T2 FSE = hyperintense for both osteomyelitis & neuropathic joints
Staging, Grading or Classification Criteria Diabetic foot ulcers: Based on depth + ischemia Charcot's joints o Stage I = acute inflammatory process o Stage I1 = reparative process o Stage 111 = consolidation stage of healing
I
1.
2.
Presentation Most common signs/symptoms o Diabetic foot ulcer = non-healed plantar ulcer o Charcot's joint = painless swelling + erythema of foot + ankle Clinical profile o Ulcer = tracks, abscess, bone or joint involvement o Charcot's joints = fragmentation or dislocation
Demographics Age o Diabetic elderly population at risk o Charcot's joint diagnosed in patients with diabetes for 10 years Gender o Neuropathic arthropathy - no sex predilection o Neuroarthropathy associated with connective tissue disorders - more common in females
3. 4. 5.
I
Fitzgerald RH et al: Orthopaedics. Sec 11foot and ankle. The diabetic foot. 2nd ed. St Louis Missouri, Mosby Inc (11-5 ):1665-80,2002 Morrison WB et al: Work-up of the diabetic foot. Radio1 Clin North Am 40(5):1171-92, 2002 Ledermann HP et al: Tendon involvement in pedal infection: MR analysis of frequency, distribution, and spread of infection. AJR 179(4):939-47,2002 Ledermann HP et al: Pedal abscesses in patients suspected of having pedal osteomyelitis: Analysis with MR imaging. Radiology 224(3):649-55, 2002 Ledermann HP et al: MR image analysis of pedal osteomyelitis: Distribution, patterns of spread, and frequency of associated ulceration and septic arthritis. Radiology 223(3):747-55, 2002
DIABETIC FOOT
I IMAGE GALLERY (Left) Sagittal STlR MR shows hyperintense neuropathic changes of the hindfoot associated with soft tissue inflammation. The differentiation between neuropathy and osteomyelitis may be more difficult with STlR imaging. (Right) Axial T2WI MR shows hypointense encasement (arrow) of the peroneal tendons with granulation tissue in a diabetic patient.
(Left)Sagittal FS PD FSE MR shows selective involvement of the cuboid (arrow) with osteomyelitis in a diabetic patient. Erosions are present in the proximal dorsal aspect of the cuboid. (Right) Axial FS PD FSE MR post amputation shows residual chronic soft tissue inflammation without osteomyelitis of the proximal metatarsal stump.
(Left) Sagittal T1WI MR shows osteomyelitis of the distal metatarsal in a diabetic patient. Marrow involvement and loss of distal cortices are best visualized on T I WI MR. (Right) Sagittal graphic shows metatarsal osteomyelitis with medullary and soft tissue extension.
SECTlON 2 Bone Marrow
Round Cell Tumors Langerhans Cell Histiocytosis Ewing Sarcoma Leukemia Lymphoma Multiple Myeloma
Hemoglobinopathies Sickle Cell Anemia Thalassemia
7-22 7-26
Lipid Storage Diseases Gaucher's Disease
7-30
Miscellaneous Marrow Lesions Metastases, Bone Marrow Paget Disease
7-34 7-38
LANGERHANS CELL HlSTlOCYTOSlS
Sagittal graphic shows multiple lytic 'punched-out" lesions of the skull. Note the well-defined beveled margins.
Abbreviations and Synonyms Histiocytosis X, eosinophilic granuloma (EG), Hand-Schiiller-Christian disease, Letterer-Siwe disease
Definitions Group of disorders characterized by proliferation of Langerhans cells
General Features I L .
Best diagnostic clue: Well-defined lytic lesion without sclerotic rim Location o Flat bones: 70% Calvarium Mandible = Pelvis o Long bones: 30% Metadiaphysis o Spine: 9% o Monostotic involvement: 50-75% o Multifocal involvement: 10-20% Osseous lesions appear simultaneously or within 1-2 years
Lateral radiography in a child with disseminated Langerhans cell histiocytosis shows multiple well-defined lytic lesions involving the calvarium.
If new lesions occur four years after initial diagnosis it should be interpreted as localized form Size: 1-15 cm, mean: 4-6 cm Morphology: Lytic and sharply demarcated "~unched-out" lesions
Radiographic Findings Radiography o Skull Well-defined lytic lesion without sclerotic rim Sclerotic rim during healing phase Occasional cortical destruction Coalescence of lesions, geographic skull Hole-within-a-hole appearance Outer table of skull more destroyed than inner table; button sequestrum Beveled edges Soft tissue mass overlying lytic lesion Floating tooth: Lesion in alveolar portion of mandible o Appendicular skeleton Expansile lytic lesion with ill-defined, sclerotic edges Endosteal scalloping, widening of medullary cavity Lesions respect joint spacelgrowth plate Intramedullary in majority, can be intracortical o Ribs
DDx: Langerhans Cell Histiocytosis -
A P Radiography
AP Radiography
Leukemia
Lat Radiography
Cor T I WI MR
Lat Radiography
LANGERHANS CELL HISTIOCYTOSIS Key Facts Fever, elevated sedimentation rate, leukocytosis, peripheral eosinophilia Eosinophilic granuloma: Lung and lymph node involvement common Chronic disseminated form: Christian's triad (lytic skull lesion, exophthalmus, diabetes insipidus) Acute disseminated form: Acute onset of hepatosplenomegaly, rash, lymphadenopathy Benign course with healing of lesions after curettage Eosinophilic granuloma has best prognosis Spontaneous remission of bone lesions within 3 months to 2 years Acute disseminated form often fatal Observation Curettage with bone grafting of large lesions at risk of pathologic fracture
Imaging Findings Best diagnostic clue: Well-defined lytic lesion without sclerotic rim
Top Differential Diagnoses Osteomyelitis Ewing Sarcoma Hemangioma Lymphoma Metastases
Pathology 1% of biopsied primary bone tumors
Clinical Issues Most common signs/symptoms: Local pain, tenderness, swelling -
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Periosteal reaction
Lytic expansile lesion Can have permeative appearance o Spine Vertebra plana: Complete collapse of vertebral body o Pelvis Involved in young children a
a
Ewing Sarcoma Permeative bone destruction Lamellated periosteal reaction Progression of tumor o Langerhans cell histiocytosis: "Tempo phenomenon" rapid progression and disappearance of lesion
CT Findings
Hemangioma
NECT o Helpful to assess extent of disease o Can show periosteal reaction, reactive sclerosis, beveled edges
Calvarium: Radiating thickened trabeculae Greater expansion of outer than inner table
Lymphoma. Older patients Permeative bone destruction
MR Findings TlWI: Low signal intensity TZWI: High signal intensity T1 C+: Marked enhancement Destructive lesion with surrounding edema Can show early bone marrow involvement in absence of radiographic findings
Metastases Metastatic neuroblastoma, rhabdomyosarcoma Permeative bone destruction Multifocal
1 PATHOLOGY
Nuclear Medicine Findings Bone Scan o Increased uptake of radiotracer in majority of cases o Decreased uptake with surrounding halo of increased uptake o Normal uptake in 35%
General Features
Imaging Recommendations Best imaging tool: Radiographs, MRI Protocol advice o Radiographs diagnostic o Bone scan or skeletal survey to look for additional lesions o TI, FS T2 or STIR, T1 C+ MR to evaluate extent of lesion o Chest CT to evaluate for pulmonary involvement
1 DIFFERENTIAL DIAGNOSIS Osteomyelitis Moth eaten appearance
I
General path comments o Letterer-Siwe (acute disseminated form): 10% o Hand-Schiiller-Christian (chronic disseminated form): 20% o Eosinophilic granuloma (only bone involvement): 70% Etiology o Group of disorders involving abnormal proliferation of histiocytes in organs of reticuloendothelial system o Disorder of immune regulation rather than neoplastic process Epidemiology o 1% of biopsied primary bone tumors o Incidence: 0.05-0.5 per 100,000 children per year in the US
7
LANGERHANS CELL HlSTlOCYTOSlS Gross Pathologic & Surgical Features Sharply demarcated yellow, gray, or brown tumor mass with hemorrhagic areas Cortical disruption common Large areas of soft yellow tissue (representing lipid filled histiocytes) in lesions that undergo spontaneous involution
Microscopic Features Proliferation of Langerhans cells: Mononuclear histiocyte-like cells 0 Produce prostaglandin, causes bone resorption o Prominent indentation of nuclear membrane (nuclear groove), coffee bean nuclei o Low phagocytic activity, Birbeck granules (racquet shaped cytoplasmatic organelles) o Immunohistochemistry: Positive for S-100 protein and CDla Infiltrate of histiocytes, eosinophils, lymphocytes, neutrophils, plasma cells Eosinophils may aggregate with necrosis (eosinophilic abscess)
Presentation
3
Most common signslsymptoms: Local pain, tenderness, swelling Clinical profile o Soft tissue mass o Fever, elevated sedimentation rate, leukocytosis, peripheral eosinophilia o Fulminant forms can be associated with lymphoma o Eosinophilic granuloma: Lung and lymph node involvement common Can be isolated to bone or lung o Chronic disseminated form: Christian's triad (lytic skull lesion, exophthalmus, diabetes insipidus) Massive lymph node involvement, hepatosplenomegaly, pulmonary fibrosis, seborrhea o Acute disseminated form: Acute onset of hepatosplenomegaly, rash, lymphadenopathy Skeletal involvement can be absent o Multiple lesions more frequently associated with involvement of parenchymal organs and skin o Mandibular involvement: Floating teeth, fractures o Pathologic fractures o Back pain from compression fractures (vertebra plana)
Demographics
I
Age o 0-30 years, mean age: 5-10 years o 80% < 30 years, 50% < 10 years o Disseminated form can occur during first two years of life Gender: M:F = 2:l Ethnicity: More common in Caucasians
Natural History & Prognosis Benign course with healing of lesions after curettage Eosinophilic granuloma has best prognosis
o Spontaneous remission of bone lesions within 3
months to 2 years Acute disseminated form often fatal
Treatment Observation Curettage with bone grafting of large lesions at risk of pathologic fracture 0 Usually no local recurrence Steroid injections Radiation therapy for inaccessible lesion Neurologic impairment from spinal involvement: Decompression, spinal fusion
I DIAGNOSTIC CHECKLIST Consider Important to differentiate localized from disseminated disease (different prognosis)
Image Interpretation Pearls Langerhans histiocytosis is "great imitator" of various benign and malignant bone lesions
Kilborn TN et al: Paediatric manifestations of Langerhans cell histiocytosis: A review of the clinical and radiological findings. Clin Radiol 58:269-78, 2003 Arico M et al: Clinical aspects of Langerhans cell histiocytosis. Hematol Oncol Clin North Am 12:247-58, 1998 Broadbent V et al: Current therapy for Langerhans cell histiocytosis. Hematol Oncol Clin North Am 12:327-38, 1998 Greenspan A et al: Differential diagnosis of tumors and tumor-like lesions of bones and joints. 1st ed. Philadelphia PA, Lippincott-Raven, 247-55, 1998 Lieberman PH et al: Langerhans cell (eosinophilic) granulomatosis. A clinicopathologic study encompassing 50 years. Am J Surg Path01 20519-52, 1996 Fisher AJ et al: Quantitative analysis of the plain radiographic appearance of eosinophilic granuloma. Invest Radio1 30:466-73, 1995 Kilpatrick SE et al: Langerhans cell histiocytosis (histiocytosis X) of bone. A clinicopathologic analysis of 263 pediatric and adult cases. Cancer 76:2471-84, 1995 Beltran J et al: Eosinophilic granuloma: MRI manifestations. Skeletal Radiol 22:157-61, 1993 David R et al: Radiologic features of eosinophilic granuloma of bone. Am J Roentgen01 153:1021-6, 1989
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LANGERHANS CELL HlSTlOCYTOSlS
(Left) Anteroposterior radiography shows collapse of the T 10 vertebral body, consistent with vertebra plana. (Right) Sagittal FS T2 FSE MR shows vertebra plana in the thoracic spine. Note preservation of intervertebral disk spaces.
(Left)Axial NECT shows lytic lesion in the posterior left calvarium. Sclerotic central focus is consistent with a button sequestrum. (Right) Lateral radiography shows lytic lesions in the femoral diaphysis with sclerotic areas and periosteal reaction. These changes are seen in the healing phase of the disease. In this stage the lesion can be mistaken for osteomyelitis.
(Lef)Coronal T 1 WI MR shows oval diaphyseal lesion of low signal involving the left femur. Surrounding bone marrow edema is hypointense. (Right) Coronal FS T2 FSE MR shows oval hyperintense lesion in the femoral diaphysis. Surrounding hyperintense bone marrow and soft tissue edema is noted.
Sagittal graphic shows tumor involvement of the medullary cavity in the femoral metadiaphysis. Large extraosseous soft tissue component is shown in brown.
Abbreviations and Synonyms Ewing's sarcoma, Ewing tumor
Definitions Round cell sarcoma of bone involving predominately long bones of skeletally immature patients
Anteroposterior radiography shows poorly defined diaphyseal lesion with permeative bone destruction and aggressive periosteal reaction.
o Prominent periosteal reaction of "onion skin" or "sunburst" type, Codman triangle o Cortical erosion, sclerosis, thickening o Saucerization of cortex due to periosteal destruction and extrinsic pressure from soft tissue mass o Penetration into soft tissue with extraosseous, noncalcified, soft tissue mass (50%) 0 No tumor matrix o Can be sclerotic in flat bones
CT Findings
General Features h
Best diagnostic clue: Ill-defined intramedullary lesion with permeative bone destruction Location o Every bone can be affected o Diaphysis of long bones: 70% o Flat bones (sacrum, scapula): 25% o Ribs: 6% o Vertebral body: 5% Size: 3-20 cm long Morphology: Ill-defined lesion in diaphysis of long bones
Radiographic Findings Radiography o Ill-defined, lytic intramedullary lesion with permeativelmoth eaten bone destruction
NECT o Intramedullary mass o Aggressive periosteal reaction o Associated soft tissue mass o Extraosseous (soft tissue) Ewing sarcoma: Rare Nonspecific soft tissue mass CECT: Heterogeneous enhancement
MR Findings TlWI o Intermediate to low signal intensity o Hypointense compared to surrounding bone marrow T2WI o High signal intensity o Hyperintense compared to muscle STIR o High signal intensity o Helpful to show tumor extent and peritumor edema
DDx: Ewing Sarcoma Orteornycirt~s
A P Radiography
Lat Radiography
A P Radiography
Lat Radiography
AP Radiography
Key Facts Imaging Findings Best diagnostic clue: Ill-defined intramedullary lesion with permeative bone destruction
Top Differential Diagnoses Osteomyelitis Langerhans Cell Histiocytosis (LCH) Osteosarcoma Lymphoma Metastatic Neuroblastoma Primitive Neuroectodermal Tumor (PNET)
Pathology 6-8% of all primary malignant bone tumors 6th most common malignant bone tumor
T1 C+ o To differentiate tumor from peritumoral edema o Enhancement of cellular areas To assess intra- and extraosseous extent
Angiographic Findings Hypervascular mass
Nuclear Medicine Findings Bone Scan o Intense radiotracer uptake o For evaluation of skeletal metastases PET o Increased FDG uptake of tumor and metastases o Helpful in assessing response to therapy o To differentiate tumor recurrence from post therapeutic changes
Imaging Recommendations Best imaging tool: MRI Protocol advice o Radiographs to detect aggressive periosteal reaction o MRI to determine extent of tumor o TI, FS T2W MR, STIR, T1 C+
I DIFFERENTIAL DIAGNOSIS Osteomyelitis May look identical Duration of symptoms usually shorter (< 2 weeks)
Langerhans Cell Histiocytosis (LCH) Solid periosteal reaction Less aggressive appearance
Osteosarcoma Usually involves metaphyses Bone formation within destructive lesion and soft tissue
Lymphoma Older age group Late cortical destruction
Clinical Issues Localized pain Soft tissue mass Fever, leukocytosis, elevated ESR in disseminated disease (simulating osteomyelitis) Highly malignant neoplasm, 3rd leading cause of death in children between 10-14 years Metastases to lung, regional lymph nodes, and other bones in 30% at presentation Poor prognostic signs include increased age, large tumor, increased ESR and leucocytosis at presentation Adjuvant and neoadjuvant chemotherapy Surgical resection with wide margins in case of good response to chemotherapy Radiation therapy for surgically inaccessible lesions, stage 111 disease, poor response to chemotherapy
Metastatic Neuroblastoma Patients younger than 5 years Multifocal
Primitive Neuroectodermal Tumor (PNET) Clinically, radiologically, and histologically very similar to Ewing sarcoma Can not be differentiated from Ewing sarcoma by imaging
General Features General path comments: Prototype of non-hematologic small round cell tumor Genetics o Reciprocal translocation of chromosomes 11 and 22 involving bands q24 and q12 in 90% of cases o Expression of new chimeric EWSIFLI-1 protein Etiology o Derived from undifferentiated mesenchymal cells of bone marrow or primitive neuroectodermal cells (small round cell tumor) o Associated with PNET Epidemiology o 6-8% of all primary malignant bone tumors o 6th most common malignant bone tumor
Gross Pathologic & Surgical Features Intraosseous component: Firm, gray-white, moist intramedullary mass Can involve large portion of medullary cavity without cortical disruption Cortex permeated by small nests of tumor, which penetrate cortex and grow subperiosteally Extraosseous component: Softer and more friable, may be considerably larger than intraosseous tumor
Microscopic Features Proliferation of undifferentiated mesenchymal cells Densely packed, small, uniform cells with round nuclei replacing medullary cavity
EWING SARCOMA o If solitary lesion involves expendable bone (long
Clear cytoplasm and nuclei with prominent cytoplasmic glycogen Two cell types o Principal type (light, open intact chromatin) o Secondary type (dark, condensed chromatin) Necrosis common Paucity of stromal elements No microscopic evidence of matrix production
bones of upper and lower extremity, clavicle) o In case of pathologic fracture o In case of recurrence after chemo- and radiation
therapy Radiation therapy for surgically inaccessible lesions, stage I11 disease, poor response to chemotherapy o Try to avoid radiating actively growing physis (risk of growth disturbance) Combination of chemotherapy, surgical resection, and radiation therapy in high-risk patients
Staging, Grading or Classification Criteria Surgical staging system for malignant musculoskeletal tumors o Stage IA: Low grade, intracompartmental o Stage IB: Low grade, extracompartmental o Stage IIA: High grade, intracompartmental o Stage IIB: High grade, extracompartmental o Stage IIIA: Low or high grade, intracompartmental, metastases o Stage IIIB: Low or high grade, extracompartmental, metastases
Consider FDG PET useful to assess response to therapy potentially obviating repeated biopsies
Image Interpretation Pearls Can look and present clinically identical to osteomyelitis
Presentation Most common signslsymptoms o Localized pain o Soft tissue mass Clinical profile o Most patients present with stage IIB lesion o Fever, leukocytosis, elevated ESR in disseminated disease (simulating osteomyelitis) o Pathologic fracture in 5-15%
Demographics
FI
Age o 5-25 years; peak: 15 years o 90% of patients present before 20 years Gender: M:F = 2:l Ethnicity: Caucasians: 96%
Natural History & Prognosis Highly malignant neoplasm, 3rd leading cause of death in children between 10-14 years Metastases to lung, regional lymph nodes, and other bones in 30% at presentation Presence of metastases best prognostic factor o Localized resectable disease treated with resection and chemotherapy: 5-year survival 70% o Disseminated disease: 5-year survival 30% Post-therapy necrosis important prognostic factor o 90-100% of necrosis strong predictor of long-term survival Poor prognostic signs include increased age, la,rge tumor, increased ESR and leucocytosis at presentation
Treatment Adjuvant and neoadjuvant chemotherapy o Chemotherapy at time of diagnosis o If response is satisfactory (decrease of tumor size, pain relief, resolution of systemic symptoms) resection or radiation therapy Surgical resection with wide margins in case of good response to chemotherapy
Rodriguez-Galindo C et al: Treatment of Ewing sarcoma family of tumors: Current status and outlook for the future. Med Pediatr Oncol 40:276-87, 2003 2. Hawkins DS et al: Evaluation of chemotherapy response in pediatric bone sarcomas by -fluorodeoxy-D-glucose positron emission tomography. Cancer 94:3277-84, 2002 3. Devoe K et al: Immunohistochemistry of small round-cell tumors. Semin Diagn Pathol 17:216-24, 2000 4. Dorfman HD et al: Bone tumors. 1st ed. St. Louis MO, Mosby, 607-631, 1998 5. Llombart-Bosch A et al: Histology, immunohistochemistry, and electron microscopy of small round cell tumors of bone. Semin Diagn Pathol 13:153-70,1996 6. Downing JR et al: Detection of the (11;22)(q24;q12) translocation of Ewing's sarcoma and peripheral neuroectodermal tumor by reverse transcription polymerase chain reaction. Am J Pathol 143:1294-300, 1993 7. Eggli KD et al: Ewing's sarcoma. Radiol Clin North Am 31:325-37, 1993 8. Oestreich AE: Imaging of the skeleton and soft tissues in children. Curr Opin Radiol 455-61, 1992 9. Bacci G et al: Long-term results in 144 localized Ewing's sarcoma patients treated with combined therapy. Cancer 36:1477-86, 1989 10. Boyko OB et al: MR imaging of osteogenic and Ewing's sarcoma. Am J Roentgen01 148:317-22, 1987 1.
EWING SARCOMA IMAGE GALLERY Typical (Left) Anteroposterior radiography shows destruction of the left pubic rami with large associated soft tissue mass. lnvolvement of the flat pelvic bones is common in Ewing sarcoma and uncommon in other primary bone tumors in children. (Right) Axial NECT shows destruction of the pubic rami with large associated soft tissue component causing mass effect on the pelvic organs. Areas of calcification within the mass represent residual bone.
(Left) Anteroposterior radiography shows permeative bone destruction and aggressive lamellated periosteal reaction in the proximal femoral diaphysis. (Right) Anteroposterior bone scan shows increased uptake of radiotracer in the proximal femoral diaphysis. There is expansion of the involved bone.
Typical (Left) Coronal T1 C+ MR shows large soft tissue mass with heterogeneous enhancement in the right hemipelvis. Destruction of the pubic rami was seen on additional images. (Right) Coronal FS T2 FSE MR shows abnormal high signal in the distal femoral diaphysis, consistent with tumor involvement. Note associated soft tissue mass and cortical destruction.
Coronal graphic shows leukemic infiltration of red marrow.
.. .
Spine: 14% Tibia: 9% Scapula: 4% o Adults: Axial skeleton Size: 3-10 cm Morphology: Moth eaten bone destruction
Abbreviations and Synonyms Acute lymphocytic leukemia (ALL), chronic lymphocytic leukemia (CLL), acute myelogenous leukemia (AML), chronic myelogenous leukemia (CML) Granulocytic sarcoma, chloroma
Radiographic Findings
Definitions Neoplastic disorder of white blood cells that can be myeloid or lymphoid in origin and acute or chronic Granulocytic sarcoma (chloroma) represents extramedullary tumor of immature granulocytic cells in association with leukemia
0 1 II
General Features Best diagnostic clue: Moth eaten bone destruction +/radiolucent transverse metaphyseal bands (leukemic lines) Location o Children Femur: 24% Humerus: 11% Ilium: 17%
Radiography o Radiographically detectable bone lesions most common in children with acute leukemia o Diffuse osteopenia of spine and long bones Radiographs can look normal Coarse trabeculation of spongiosa Collapsed vertebral bodies (vertebra plana) o "Leukemiclines": 40-53% in ALL Transverse, radiolucent metaphyseal bands (most common in region of knee and humerus) Horizontal bands in vertebral bodies Dense metaphyseal lines post therapy In patients < 2 years radiolucent lines are usually due to malnutrition, severe systemic disease o Focal destruction of flatltubular bones Multiple small well-defined osteolytic lesions Moth eaten appearance Lytic lesions distal to knee or elbow in children suggestive of leukemia Blastic or mixed blastic-lytic lesions (rare)
.. . . . .
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H111188 ..
I
Anteroposterior radiography shows transverse radiolucent lines in the distal femoral and proximal tibia1 and fibular metaphyses (leukemic lines).
DDx: Leukemia Metastases
Lat R a d i o ~ r a ~ h v
Osteon?y~/itis
Lat Radiogra~hv
AP Radiography
Ewing Sarcoma
AP Radiography
AP Radiography
LEUKEMIA Key Facts Imaging Findings
Clinical issues
Best diagnostic clue: Moth eaten bone destruction +/radiolucent transverse metaphyseal bands (leukemic lines)
Top Differential Diagnoses Metastases Langerhans Cell Histiocytosis (LCH) Osteomyelitis Ewing Sarcoma Lymphoma
Pathology Most common malignancy of childhood 20th most common cause of cancer death in all age groups
Sutural widening, prominent convolutional markings of skull o Periostitis of long bones: 12-25% Smooth, lamellated, sunburst pattern of periosteal reaction o Pathologic fractures Occur through abnormal metaphyses Can result in slipped capital femoral epiphysis o Granulocytic sarcoma: Destructive lytic lesion
CT Findings NECT o Permeative bone destruction o Helpful in demonstrating localized mass in case of granulocytic sarcoma
Localized or diffuse bone pain Sharp, localized, recurrent paraarticular arthralgias (75%) Fever, elevated ESR May be confused with acute rheumatic fever, rheumatoid arthritis, osteomyelitis 5-year survival of all leukemias combined: 25-30% Children with ALL: Complete remission in 90% Adults with ALL: Remission in 60-80% Chemotherapy Intrathecal chemotherapy in case of CNS involvement Combined chemo- and radiation therapy Bone marrow transplant
Periosteal reaction Endosteal scalloping Soft tissue mass
Osteomyelitis Can have systemic symptoms similar to leukemia Periosteal reaction, soft tissue extension
Ewing Sarcoma No metaphyseal lucent lines Marked periosteal reaction Associated soft tissue mass
Lymphoma Older patients Large associated soft tissue mass
MR Findings TlWI: Leukemic infiltrate of low signal, replacing high signal marrow fat T2WI: Increased signal intensity of leukemic marrow STIR: Increased signal intensity of leukemic marrow Most sensitive imaging modality, often positive when radiographs show no abnormalities
Nuclear Medicine Findings Bone Scan o Increased radiotracer uptake of involved areas o Often underestimates extent of disease
Imaging Recommendations Best imaging tool: MRI Protocol advice: T1, FS T2, whole body STIR MR
1 DIFFERENTIAL DIAGNOSIS Metastases Metastatic neuroblastoma, rhabdomyosarcoma Bone involvement similar to leukemia o Metaphyseal bands, moth eaten bone destruction Multifocal
Langerhans Cell Histiocytosis (LCH) Lytic lesion
1
I PATHOLOGY General Features General path comments o Arises from primitive stem cell either de novo or from preexisting preleukemic state o Clone of malignant cells can arise at any stage of maturation Genetics o Patients with trisomy 21 and chromosomal translocations are at high risk of developing ALL o Trisomy 12 in patients with CLL o 90% of patients with CML have acquired chromosomal abnormality Philadelphia chromosome, translocation between chromosomes 9 and 22 Etiology o External factors: Alkylating drugs, ionizing radiation, chemicals (benzene) o Internal factors: Chromosomal abnormalities o Predisposing hematological disorders: Aplastic anemia, chronic myeloproliferative disorders Epidemiology o Most common malignancy of childhood ALL: 75%, AML: 15-20%, CML: 5%
I
LEUKEMIA o Induction phase, consolidation phase, maintenance
o 20th most common cause of cancer death in all age
therapy phase o Intrathecal chemotherapy in case of CNS involvement Combined chemo- and radiation therapy Bone marrow transplant
groups
Gross Pathologic & Surgical Features Hyperemic/hemorrhagic bone marrow with destruction of bony trabeculae Areas of bone infarction
Microscopic Features
[DIAGNOSTIC CHECKLIST
Diffuse infiltration of bone marrow by poorly-differentiated blast cells ALL: Infiltrates of small blue cells AML: Auer rods diagnostic o Condensed lysosomal cytoplasmatic rod shaped structures CLL: Mature lymphocytes, < 55% atypical cells CML: Leukocytosis with increase in basophils, eosinophils , neutrophiles o Philadelphia chromosome t(9;22)
Image Interpretation Pearls If leukemia is suspected MRI should be performed in case of negative radiographs or inconclusive laboratory findings
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1. 2.
[CLINICALISSUES Presentation
12
Most common signslsyrnptoms o Localized or diffuse bone pain o Sharp, localized, recurrent paraarticular arthralgias (75%) Clinical profile o Fever, elevated ESR o May be confused with acute rheumatic fever, rheumatoid arthritis, osteomyelitis o Hepatosplenomegaly, lymphadenopathy o Joint effusion o Petechial hemorrhage, retinal hemorrhage o Anemia o Frequent infections o Proptosis, diplopia in orbital involvement o Patients with chronic leukemias can be asymptomatic
Demographics
I
Age o ALL: Most common leukemia of childhood, peak: 2-10 years o AML: 15-20% of childhood leukemias, peak > 65 years o CML: Rare in childhood (< 5%), peak > 40 years o CLL: 50-70 years Gender: M:F = 2:l Ethnicity: More common in Caucasians
Natural History & Prognosis 5-year survival of all leukemias combined: 25-30% Children with ALL: Complete remission in 90% o 80% disease free 5 years after treatment Adults with ALL: Remission in 60-80% o 20-30% disease free 5 years after treatment AML: 5-year survival 45% CLL: Median survival 6 years CML: Median survival 5 years
Treatment Chemotherapy
] 3. 4. 5.
6. 7. 8.
9.
Beckers R et al: Acute lymphoblastic leukaemia presenting with low back pain. Eur J Paediatr Neurol6:285-7, 2002 Barr RD et al: Impact of age and cranial irradiation on radiographic skeletal pathology in children with acute lymphoblastic leukemia. Med Pediatr Oncol 30:347-50, 1998 Greaves MF: Aetiology of acute leukaemia. Lancet 349:344-9, 1997 Gallagher DJ et al: Orthopedic manifestations of acute pediatric leukemia. Orthop Clin North Am 27:635-44, 1996 Heinrich SD et al: The prognostic significance of the skeletal manifestations of acute lymphoblastic leukemia of childhood. J Pediatr Orthop 14:105-11, 1994 Rivera GK et al: Treatment of acute lymphoblastic leukemia. 30 years' experience at St. Jude Children's Research Hospital. N Engl J Med 329:1289-95, 1993 Oestreich AE: Imaging of the skeleton and soft tissues in children. Curr Opin Radio1 4:55-61, 1992 McKinstry CS et al: Bone marrow in leukemic and aplastic anemia: MR imaging before, during, and after treatment. Radiology 162:701-7, 1987 Neiman RS et al: Granulocytic sarcoma: A clinicopathologic study of 61 biopsied cases. Cancer 48:1426-37, 1981
LEUKEMIA -
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IMAGE GALLERY (Left) Axial T2 WI MR shows abnormal hyperintense bone marrow and cortex of the femoral metaphyses. Note the surrounding hyperintense edema. (Right) An teroposterior radiography shows permeative bone destruction and lamellated periosteal reaction.
Typical (Left) Coronal T l Wl MR shows hypointense bone marrow infiltration of the distal femur in a patient with AML. (Right) Coronal T 1 Wl MR shows diffuse hypointense bone marrow infiltration of the femoral metadiaphyses and iliac bones. Note the relative sparing of the epiphyses which contain predominately yellow marrow.
Other (Left) Anteroposterior radiography shows multiple small well-defined osteolytic lesions in the metacarpal and phalangeal bones in a child with ALL. (Right) Clinical photography shows red-violet nodules and plaques involving the lower extremities of a patient with AML. These findings represent leukemic infiltration of the skin and are usually a sign of disseminated disease.
LYMPHOMA
Coronal graphic shows lymphomatous bone marrow infiltration of the iliac crest.
Anteroposterior radiography shows permeative bone destruction with periosteal reaction and large associated soft tissue mass. Note the pathologic fracture of the lesser trochanter.
o Pelvis: 20% o Spine: 14% o Skull: 7%
Abbreviations and Synonyms
o Scapula: 5% o Metadiaphysis o Can involve entire bone with extension to subchondral bone o Multifocal: 10-40% Several foci in one bone, simultaneous involvement of multiple bones Size: 3-25 cm, mean: 5-10 cm Morphology: Permeative bone marrow infiltration with associated soft tissue mass
Primary lymphoma of bone, reticulum cell sarcoma, lymphosarcoma
Definitions
rn
Lymphoma within medullary cavity of single bone without concurrent lymph node or visceral involvement for at least six months following diagnosis Must be distinguished from skeletal involvement in systemic lymphoma
Radiographic Findings Radiography o Often normal o Cancellous bone erosion (earliest sign) o Mottled permeative pattern of bone destruction o Edges of lesion blend imperceptibly with normal bone Radiographs often underestimate tumor extent o Mixed lytic-scleroticlesions in 30% o Bone sequestrum: 11% o Late cortical destruction o Soft tissue component often disproportionally large o Sclerosis ("ivory bone") in vertebrae or flat bones (in secondary involvement from Hodgkin disease)
General Features Best diagnostic clue o Mottled permeative pattern of bone destruction often with disproportionally large soft tissue component o Intact cortex despite soft tissue extension Location o Long tubular bones: 48% Femur: 24% Tibia: 10% Humerus: 10%
.
..
DDx: Lymphoma Leukemia
Ax T1 C+ MR
A P Radiography
Cor T I W I MR
A P Radiography
Ax T l W l MR
LYMPHOMA Key Facts Imaging Findings Mottled permeative pattern of bone destruction often with disproportionally large soft tissue component Intact cortex despite soft tissue extension
Top Differential Diagnoses Ewing Sarcoma Osteomyelitis Osteosarcoma Leukemia Metastases Multiple Myeloma Fibrosarcoma
Pathology
Clinical Issues Localized dulllaching bone pain Few clinical symptoms despite extensive disease Primary osseous lymphoma without soft tissue involvement has best prognosis of all osseous malignancies 5-year survival for combined chemo- and radiation therapy: 60-80% Combined chemo- and radiation therapy
Diagnostic Checklist
Important to distinguish primary lymphoma of bone from secondary involvement, which has worse prognosis and is treated differently
3-4% of all malignant primary bone tumors
CT Findings NECT o To determine bone destruction and soft tissue involvement o Can detect bony sequestrum
MR Findings TlWI: Diffuse infiltration of low signal intensity T2WI o Heterogeneous signal intensity o Can be hyper-, iso- or hypointense o Hypointense areas correspond to fibrosis STIR: High signal intensity T1 C+: Enhancement Helpful to evaluate extent and associated soft tissue component Cortex can be intact despite soft tissue extension
Nuclear Medicine Findings Bone Scan o Increased radiotracer uptake o Central cold areas correspond to necrosis
lmaging Recommendations Best imaging tool: MRI Protocol advice o TI, T2, STIR or FS T2 FSE, TI C+ MR o CT of chest, abdomen, pelvis to evaluate extent and to exclude primary lymphoma
New bone formation Younger patients
Leukemia Diffuse osteopenia, coarse trabeculae Leukemic lines Vertebral compression fractures, vertebra plana
Metastases Multifocal disease Cortical destruction
Multiple Myeloma No surrounding sclerosis or periosteal reaction Endosteal scalloping Cold on bone scan
Fibrosarcoma Well-defined to destructive lytic lesion +I-soft tissue mass No calcified matrix, minimal periosteal reaction Osseous sequestrum
1 PATHOLOGY General Features General path comments o Most primary lymphomas of bone are due to non-Hodgkin lymphoma, 6% are due to Hodgkin lymphoma o Lymphoblastic cells produce osteoclast-stimulating factors that cause bone destruction * Genetics: Translocation of chromosomes 14 and 18 and chromosomes 8 and 14 * Etiology o Unknown, might be due to viral infection or immunosuppression o Can occur as posttransplant lymphoproliferative disease in immunocompromised patients, often occurs in AIDS patients Epidemiology o 3-4%of all malignant primary bone tumors o 1%of all non-Hodgkin lymphomas
FFERENTIAL DIAGNOSIS Ewing Sarcoma Systemic symptoms Younger patients Lamellated/onion skin periosteal reaction
Osteomyelitis Can have similar radiographic picture Systemic symptoms
Osteosarcoma Less medullary extension
1
5-year survival for combined chemo- and radiation therapy: 60-80% 5-year survival in children after aggressive chemotherapy: > 90% Metastases (lung, liver, brain) Local recurrence rare Poor prognostic factors o Advanced stage at diagnosis (lymph node, soft tissue involvement), o Advanced age (> 60 years) 5-year survival for secondary lymphoma is worse
o Secondary involvement of bone in 35-50% of
non-Hodgkin lymphoma and 13% of Hodgkin lymphoma
Gross Pathologic & Surgical Features Gray-white, soft, fleshy, intraosseous component (centered in metaphyses) o Mixture of bone spicules and marrow fat and areas of necrosis Reactive sclerosis: Firm ivory-like areas Cortical disruption and extension into soft tissues common Extraosseous tissue with tanlwhite appearance, resembles lymphomatous lymph nodes
Treatment Radiation therapy o Risk of growth disturbance if used in children, radiation induced sarcoma Chemotherapy Combined chemo- and radiation therapy Allogenic bone marrow transplantation for refractory cases Internal fixation in case of pathologic fractures or to prevent pathologic fracture Surgical resection rarely indicated
Microscopic Features Sheet-like aggregates of malignant, small, round, lymphocytic cells that fill marrow spaces Majority of B cell type o Mixed small-and-large cell type (35%), diffuse large cell type (32%), immunoblastic type (3%) Diffuse growth pattern o Bone marrow permeation by round tumor cells Hodgkin lymphoma: Reed-Sternberg cells
Staging, Grading or Classification Criteria Modified Ann Arbor staging system o Stage I: One bone lesion with or without soft tissue extension o Stage 11: Two bone lesions on the same side of the diaphragm or one bone lesion with regional lymph node involvement o Stage 111: Involvement on both sides of diaphragm o Stage IV: Involvement of central or peripheral nervous system or bone marrow
1 DIAGNOSTIC CHECKLIST Consider Important to distinguish primary lymphoma of bone from secondary involvement, which has worse prognosis and is treated differently
Image Interpretation Pearls Combination of normal radiographs and positive bone scan should suggest possibility of osseous lymphoma
1 SELECTEDREFERENCES Iti
Presentation Most common signslsymptoms o Localized dulllaching bone pain o Diagnostic requirement for primary lymphoma of bone Interval of 4-6 months between skeletal manifestation and development of extraskeletal disease Clinical profile o Few clinical symptoms despite extensive disease o 50% of patients have symptoms for over one year o Occasionally palpable mass o Fever uncommon, no lymphadenopathy, or hepatosplenomegaly o Pathologic fractures in 25% o Hypercalcemia in some pediatric patients (poor prognosis)
Demographics Age: 20-70 years, peak: 35-45 years Gender: M:F = 1.5-2:l
Natural History & Prognosis Primary osseous lymphoma without soft tissue involvement has best prognosis of all osseous malignancies
1. 2. 3. 4.
5. 6. 7. 8. 9.
Gianelli U et al: Lymphomas of the bone: A pathological and clinical study of 54 cases. Int J Surg Path01 10:257-66, 2002 Heyning FH et al: Primary non-Hodgkin's lymphoma of bone: A clinicopathological investigation of 60 cases. Leukemia 13:2094-8, 1999 Greenspan A et al: Differential diagnosis of tumors and tumor-like lesions of bones and joints. 1st ed. Philadelphia PA, Lippincott-Raven, 267-75, 1998 Melamed JW et al: Imaging of primary multifocal osseous lymphoma. Skeletal Radiol 26:35-41, 1997 Hillemanns M et al: Malignant lymphoma. Skeletal Radiol 25:73-5, 1996 Hicks DG et al: Primary lymphoma of bone. Correlation of magnetic resonance imaging features with cytokine production by tumor cells. Cancer 75:973-80, 1995 Mulligan ME at al: Sequestra in primary lymphoma of bone: Prevalence and radiologic features. Am J Roentgenol 160:1245-8, 1993 Malloy PC et al: Lymphoma of bone, muscle, and skin: CT findings. Am J Roentgenol 159:805-9, 1992 Bragg DG: Radiology of the lymphomas. Curr Probl Diagn Radiol 16:177-206, 1987
LYMPHOMA
1 IMAGE GALLERY Typical (Lep) Anteroposterior radiography shows permeative bone destruction of the right superior pubic ramus. (Right) Axial NECT of the same patient shows destruction of the right inferior pubic ramus with associated soft tissue mass which was not visualized on the radiograph. Note the bony sequestrum at the medial aspect.
(Left) Coronal T 1 Wl MR shows hypointense bone marrow infiltration of right proximal femur. Note the large surrounding hypointense soft tissue mass. (Right) Axial FS T2 FSE MR shows abnormal hyperintense bone marrow signal in the right femur with large surrounding hyperintense soft tissue mass. Note the relative lack of cortical destruction with abnormal signal at the posterior cortex.
(Left) Sagittal T l Wl MR shows diffuse, mottled hypointense bone marrow infiltration of the thoraco lumbar spine in a patient with disseminated non-Hodgkin lymphoma. (Right) Anteroposterior radiography shows mottled appearance of the proximal humerus with associated soft tissue mass. Subtle cortical destruction is seen medially.
MULTIPLE MYELOMA
Sagittal graphic shows multiple small lytic "punched-out" lesions in the calvarium. Note scalloping of the inner cortical margin and lack of sclerotic borders.
-
Lateral radiography shows multiple I p c lesions without surroundingsclerosis involving the calvarium.
Morphology: Multifocal, sharply demarcated lytic intramedullary foci
Abbreviations and Synonyms
Radiographic Findings
Myeloma, solitary myeloma, plasmacytoma, extraskeletal myeloma
Definitions Monoclonal, neoplastic proliferation of plasma cells involving bone marrow
General Features Best diagnostic clue: Multiple, well-defined, intramedullary lytic lesions Location o Any bone containing red marrow can be involved o Axial skeleton Spine: 34% Ribs: 20% Femur: 18% Pelvis: 15% Humerus: 12% o Extraskeletal myeloma (rare) Lungs, nasopharynx, oral cavity Size: Range from mms to several cms
. .. .
Radiography o Multiple, well-defined, punched-out lesions o ~lasmacytoma:solitary, large, expansile lesion Represents early stage of multiple myeloma o Endosteal scalloping o Cortical erosions o No periosteal new bone formation o Soft tissue mass adiacent to bone destruction o Diffuse osteoporosis or osteolysis, accentuated trabecular pattern o Expansile osteolytic lesion (ribs, pelvis, long bones) o Spine: Vertebral collapse Sparing of posterior elements Paraspinal soft tissue mass, extradural extension o Sclerosis after therapy
CT Findings NECT: Helpful in evaluating intra- and extraosseous extent, cortical destruction
MR Findings TlWI: Intermediate to low signal intensity compared to surrounding bone marrow T2WI: High signal intensity STIR: High signal intensity
DDx: Multiple Myeloma
I
Metastases
Osteoporosis
Heman~iorna
Leukemia
Gaucher Disease
AP Radiography
Ax NECT
Lat Radrography
Cor T l WI MR
AP Radrography
MULTlPLE MYELOMA Key Facts Imaging Findings Best diagnostic clue: Multiple, well-defined, intramedullary lytic lesions I
Top Differential Diagnoses Metastases Osteoporosis Hemangioma Lymphoma Leukemia Langerhans Cell Histiocytosis Gaucher Disease
Pathology
Clinical Issues Mild transient bone pain, worsened by activity (75%) Fatal disease, death usually 1-5 years after diagnosis Chemotherapy: Transient remission in 50-70% Radiation to control disease locally Osteoclast inhibiting agents: Bisphosphates Internal fixation for pathologic fractures or prevention of pathologic fractures
Diagnostic Checklist If patient presents with single lytic lesion (plasmacytoma) look carefully for additional lesions More than one lesion changes prognosis from stage I to stage III
Most common primary bone tumor 27-40% of all primary bone tumors
TI C+: Enhancement Signal abnormalities can be focal or diffuse Associated soft tissue mass
Nuclear Medicine Findings Bone Scan o Normal scan in majority of cases Due to bone destruction with minimal new bone formation o Increased radiotracer uptake in 10% of lesions o Can be hot due to hyperemia or cold due to replacement of marrow by myeloma cells PET: FDG-PET might be useful to assess extent of disease
.
Imaging Recommendations Best imaging tool: MRI Protocol advice: Skeletal survey and MRI of the spine to evaluate extent
1 DIFFERENTIAL DIAGNOSIS Metastases Pedicles involved first (late involvement in myeloma) Increased activity on bone scan Ill-defined bone destruction
Osteoporosis No endosteal scalloping No cortical destruction or associated soft tissue mass
Hemangioma Vertical striations, honeycomb appearance Areas of high signal intensity on T1 and T2WI MR, corresponding to vascular components No soft tissue mass
Lymphoma "Ivory bone" in vertebrae or flat bones Cancellous bone erosion (earliest sign) Late cortical destruction
Leukemia Multiple small clearly-defined osteolytic lesions
Coarse trabeculation of spongiosa Smooth, lamellated, sunburst pattern of periosteal reaction
Langerhans Cell Histiocytosis Younger patients Self limiting disease
Gaucher Disease Younger patients Generalized osteopenia or honeycombed appearance Erlenmeyer flask deformity No associated soft tissue mass
1 PATHOLOGY General Features General path comments: Malignant hematological disorder characterized by bone marrow infiltration with neoplastic plasma cells Genetics: Translocation of chromosomes 11, 14 Etiology o Uncontrolled proliferation of plasma cells (subset of B cells) within bone marrow o Secretion of nonfunctional monoclonal immunoglobulins that suppress benign polyclonal plasma cells o Myeloma cells produce osteoclast stimulating factor o Suppressed osteoblastic response resulting in demineralization and bone destruction Epidemiology o Most common primary bone tumor o 27-40% of all primary bone tumors o Second most common hematopoietic neoplasm o 1% of all malignant neoplasms Associated abnormalities o POEMS syndrome Polyneuropathy, organomegaly, endocrine disorders, monoclonal gammopathy, skin changes Enthesopathies Sclerotic foci resembling bone islands or ivory vertebral bodies
. ..
MULTDPLE MYELOMA o Amyloidosis: 10-15%
Amyloid deposited in bone marrow, kidneys, heart, GI tract, liver, spleen, muscle, skin, CNS
Gross Pathologic & Surgical Features Red-gray soft tumor replacing bone marrow Growth in discrete nodules, circumscribed or confluent (advanced stage) Extension into surrounding soft tissues
Microscopic Features Aggregates of neoplastic plasma cells o Infiltrate and completely replace normal hematopoietic and fatty marrow Myeloma cells: Eccentric, round, hyperchromatic nucleus with "cartwheel"distribution of chromatin o Expression of plasma cell associated antigen Drug resistant myeloma: Expression of p-170 (P glycoprotein) o Resistance to vincristine-doxorubicin, Adriamycin, dexamethasone (VAD) protocol
Staging, Grading or Classification Criteria Clinical staging system for multiple myeloma (Durie and Salmon) o Stage I: Up to one lytic bone lesion Hemoglobin: > 10 g/dL Serum calcium: < 12 mg/dL Low immunoglobin production: IgG < 5g/dL or IgA < 3 g/dL o Stage 11: Patients in between stage I and stage I11 o Stage 111: More than one lytic bone lesion Hemoglobin: < 8.5 g/dL Serum calcium: > 12 mg/dL H'igh immunoglobulin production: IgG > 7g/dL,
20
Presentation Most common signs/symptoms o Mild transient bone pain, worsened by activity (75%) Predominately in weight bearing sites Duration of pain usually < 6 months Clinical profile o Palpable mass (extraosseousextension, associated hemorrhage) o Anemia, fever, weight loss o Bleeding diathesis o Hypercalcemia o Frequent infections o Bence Jones proteins in urine o Renal failure o Electrophoresis: Monoclonal gammopathy (IgAIIgG peak) o Pathologic fractures o Peripheral neuropathy in sclerotic form (POEMS syndrome)
Demographics Age: 40-80 years, peak: 64 years Gender: M:F = 3:2
Natural History & Prognosis Fatal disease, death usually 1-5 years after diagnosis o Stage I: Median survival 10 years o Stage 11: Median survival 1-5 years o Stage 111: Median survival < 2 years Solitary form (plasmacytoma) usually converts to multiple myeloma
Treatment Chemotherapy: Transient remission in 50-70% o Only used in patients with disseminated disease Radiation to control disease locally o Rapid decompression of vital structures (spinal canal) o For pain relief Osteoclast inhibiting agents: Bisphosphates Internal fixation for pathologic fractures or prevention of pathologic fractures Decompressive laminectomy for symptomatic spine involvement (compressive myelopathy) Vertebroplasty for vertebral compression fractures
I DIAGNOSTIC CHECKLIST Consider If patient presents with single lytic lesion (plasmacytoma) look carefully for additional lesions More than one lesion changes prognosis from stage I to stage I11
Image Interpretation Pearls Punched out lytic lesions in ribs and skull of adults usually due to multiple myeloma
Schirrmeister H et al: Initial results in the assessment of multiple myeloma using 18F-FDG PET. Eur J Nucl Med Mol Imaging 29:361-6, 2002 Dimopoulos MA et al: Solitary plasmocytoma of bone and asymptomatic multiple myeloma. Blood 96:2037-44, 2000 Lecouvet FE et al: Skeletal survey in advanced multiple myeloma: Radiographic versus MR imaging survey. Br J Haematol 106:35-9, 1999 Ludwig H et al: Multiple myeloma: An update on biology and treatment. Ann Oncol6:31-43, 1999 Dorfman HD et al: Bone tumors. 1st ed. St. Louis MO, Mosby, 664-79, 1998 Moulopoulos LA et al: Prognostic significance of magnetic resonance imaging in patients with asymptomatic multiple myeloma. J Clin Oncol 13:251-6, 1995 Libshitz HI et al: Multiple myeloma: Appearance at MR imaging. Radiology 1822333-7, 1992 Moulopoulos LA et al: Multiple myeloma: Spinal MR imaging in patients with untreated newly diagnosed disease. Radiology 185:833-40, 1992 Bataille R et al: Bone scintigraphy in plasma cell myeloma. A prospective study of 70 patients. Radiology 145801-4, 1982
MULTlPLE MYELOMA
Typical (Left) Sagittal T l Wl MR shows heterogeneous bone marrow of the lumbar spine. Radiographs were normal in this patient with multiple myeloma. (Right) Lateral radiography of the femur shows multiple osteolytic lesions with endosteal scalloping of the cortex.
Variant (Lef)Anteroposterior radiography shows large lytic lesion with destruction of the left iliac bone in a patient with plasmacytoma. (Right) Axial CECT shows destruction of the left iliac bone and sacrum. There is heterogeneous replacement of bone marrow of the left hemipelvis with large associated soft tissue mass in a patient with plasmacytoma.
SICKLE CELL 4
Sagittal graphic shows widening of the medullary cavity with thinning of the outer table.
dlA
Lateral radiography shows widening of the medullary cavity and decreased width of the outer table. Vertical hair-on-endstriations are also noted.
o Metaphysis, subchondral bone of long bones
involved in adults o Diaphyses of small tubular bones of hands and feet
Abbreviations and Synonyms Sickle cell disease, hemoglobin HbSS disease, sickle cell trait, HbSA disease, HbSC disease
Definitions * Systemic hereditary disease characterized by anemia due to replacement of fetal hemoglobin by abnormal S hemoglobin Homozygous: HbSS (sickle cell anemia) Heterozygous: HbSA (sickle cell trait), HbSC (less severe form)
7 '? +-
General Features Best diagnostic clue o Hyperplasia of erythropoietic bone marrow o Multiple bone infarcts Location o Any bone can be involved o Long bones Femur: 96%; humerus: 48% o Small tubular bones of hands and feet: 20-50% o Spine: 43-70% o Skull: 25%
involved in children Size: 3-10 cm Morphology o Expanded medullary cavity o Bone infarctions
Radiographic Findings Radiography o Marrow hyperplasia Widened medullary space, thinning of cortex Osteoporosis with thinning of trabeculae Coarsened trabecular pattern Skull: Widening of diploe, decreased width of outer table Hair-on-end appearance of skull (vertical striations) Biconcave "fish"vertebra (bone softening) Pathologic fractures o Bone infarctionJdiminished blood supply Avascular necrosis (AVN) in medullary spaces of long bones, hands, growing epiphyses Osteolysis in acute infarct Dystrophic medullary calcifications Periosteal reaction: Bone-within-bone appearance Juxtacortical sclerosis H-shaped vertebrae
DDx: Sickle Cell Anemia
Lat Radiography
Perthes Disease
Gaucher Disease
Cor T I Wl MR
A P Radiography
SICKLE CELL ANEMIA Key Facts Imaging Findings Hyperplasia of erythropoietic bone marrow Multiple bone infarcts Hair-on-end appearance of skull (vertical striations) Biconcave "fish"vertebra (bone softening) Avascular necrosis (AVN) in medullary spaces of long bones, hands, growing epiphyses
Top Differential Diagnoses Thalassemia Legg-Calvk-Perthes Gaucher Disease
Pathology
Clinical issues Sickle cell crisis: Sudden onset of severe bone, abdominal, chest pain Sickle cell crisis often as result of infection, temperature change, hypoxia (flight) Skeletal pain (bone infarction, osteomyelitis, cellulitis) Osteomyelitis (staphylococcus, salmonella) Repeated episodes lead to progressive bone infarction Death < 48 years in sickle cell disease Sickle cell crisis treatment: Oxygen, hydration, pain management No prophylactic measure to prevent bone infarcts
1%of African Americans 8-13s of African Americans carry sickling factor (HbS) Collapse of femoral head Premature epiphyseal closure resulting in growth defect Epiphyseal deformity, cupped metaphyses Dactylitis (hand-foot syndrome): Bone infarcts of hands and feet Calcaneal erosions (represent microinfarction) o Infections Periostitis; septic arthritis
CT Findings NECT Sclerotic bone infarction
MR Findings TlWI o Low signal intensity of bone marrow (hematopoietic marrow replacing fatty marrow) o Focal areas of low signal intensity (acute marrow infarction) T2WI o Intermediate - low signal intensity of bone marrow (hematopoietic marrow replacing fatty marrow) o Focal areas of increased signal intensity (acute marrow infarction) T1 C+ o Acute infarct: Thin, linear rim enhancement Osteomyelitis: Geographic, irregular marrow enhancement To evaluate extent of disease Helpful in differentiating between infarcts and osteomyelitis
Nuclear Medicine Findings Bone Scan 0 Marked expansion of hematopoietic marrow 0 Increased radiotracer uptake in areas of infarction 0 Bone marrow defects (old infarction) 0 More sensitive than radiographs in detecting early AVN
Imaging Recommendations Best imaging tool: Radiographs diagnostic
* Protocol advice o Radiographs
o TI, T2W MR to evaluate extent of disease o T1 C+ to differentiate between osteomyelitis and
bone marrow infract
I DIFFERENTIAL DIAGNOSIS Thalassemia Expanded bone marrow space AVN less common than in sickle cell anemia Paravertebral masses (extramedullary hematopoiesis)
Legg-Calv6-Perthes Idiopathic AVN of femoral head in children Rare in African Americans Femoral epiphysis of affected hip smaller than normal contralateral side Sclerosis, collapse of femoral epiphysis
Gaucher Disease AVN of hip and shoulder Erlenmeyer flask deformity Marrow expansion Cortical thinning, periostitis Lytic lesions
General Features General path comments: Sickle cell disease HbSS associated with many bone findings, sickle cell trait HbAS occasionally associated with bone infarcts Genetics: Mutation resulting in substituting thymine for adenine in the 6th codon of beta-chain gene GAG to GTG Etiology o Structural defect in hemoglobin HbS: Glutamic acid in position 6 substituted with valine o Altered shape and plasticity of red blood cells under lowered oxygen tension leads to increase of blood viscosity, stasis o Occlusion of small blood vessels leads to infarction, necrosis
SlCKLE CELL ANEMIA Gender: M:F = 1:l Ethnicity o Majority of cases found in African Americans o Less frequently in eastern Mediterranean and Middle Eastern populations
o Children are protected for the first 6 months by
elevated levels of fetal Hb (HbF) o HbS protects from malaria Epidemiology o 1% of African Americans o 8-13% of African Americans carry sickling factor (HbS) o 3% of African Americans are HbC carrier o 1:40 with sickle cell trait will manifest sickle cell anemia (HbSS) o 1:120 with sickle cell trait will manifest HbSC disease Associated abnormalities: Can coexist with thalassemia .
Gross Pathologic & Surgical Features Areas of infarction: Dense, hard, sclerotic bone Yellow marrow replaced by hyperplastic red hematopoietic marrow Infarcted marrow spaces filled with clotted blood
Natural History & Prognosis Sickle cell crisis begins at 2-3 years of life Repeated episodes lead to progressive bone infarction Premature arthritis due to AVN Poor prognostic factors: Dactylitis before 1year, Hb levels < 7 g/dL, leukocytosis in absence of infection Death < 48 years in sickle cell disease Patients with sickle cell trait (HbSA) have normal life expectancy
Treatment Systemic treatment Sickle cell crisis treatment: Oxygen, hydration, pain management High-dose methylprednisolone can reduce duration of pain in children Hydroxyurea possibly helpful in increasing total Hb concentration, reducing vaso-occlusive complications No prophylactic measure to prevent bone infarcts AVN of femoral head: Varus osteotomy, total hip replacement o Transfusion of packed red blood cells to lower percentage of HbS < 45% (pre-operative)
Microscopic Features Areas of infarction: Thickened trabeculae, acellular necrotic bone Trabeculae have multiple concentric cement lines Proliferation of fibrovascular repair tissue No osteoclastic activity Marrow spaced filled with granular basophilic cell debris
1 DIAGNOSTIC CHECKLIST Presentation
24
Most common signs/symptoms o Sickle cell crisis: Sudden onset of severe bone, abdominal, chest pain Sickle cell crisis often as result of infection, temperature change, hypoxia (flight) +I- Fever, leukocytosis May last hours to days Clinical profile o Skeletal pain (bone infarction, osteomyelitis, cellulitis) o Osteomyelitis (staphylococcus, salmonella) o Chronic hemolytic anemia o Jaundice o Abdominal pain o Splenomegaly (in children), later splenic atrophy o Growth retardation o High incidence of infections Pneumococcal septicemia, meningitis are leading causes of death o Chest pain (acute pulmonary crisis, rib infarcts) o CNS involvement: Stroke o Dactylitis: 20-50% of children with with SS disease (between 6 months to 2 years) Swelling of hands and feet Decreased range of motion Self limiting after days to weeks
Demographics Age: Manifests in second half of first year of life; persists lifelong
Consider Patients should be educated about risk factors that precipitate sickle cell crisis
Image Interpretation Pearls Important to distinguish acute infarction from osteomyelitis
[SELECTEDREFERENCES 1.
2. 3. 4. 5.
6.
7.
Steinberg MH: Hydroxyurea treatment for sickle cell disease. ScientificWorldJouma125:1706-28,2002 Lonergan GJ et al: Sickle cell anemia. Radiographics 21:971-94, 2001 States LJ: Imaging of metabolic bone disease and marrow disorders in children. Radio1 Clin North Am 39:749-72, 2001 Jean-Baptiste G et al: Osteoarticular disorders of haematological origin. Baillieres Best Pract Res Clin Rheumatol 14:307-23, 2000 Umans H et al: The diagnostic role of gadolinium enhanced MRI in distinguishing between acute medullary bone infarct and osteomyelitis. Magn Reson Imaging 18:255-62, 2000 Hernigou P et al: Abnormalities of the adult shoulder due to sickle cell osteonecrosis during childhood. Rev Rhum Engl Ed 65:27-32, 1998 Rothschild BM et al: Microfoci of avascular necrosis in sickle cell anemia: Pathophysiology of the dot dash pattern. Clin Exp Rheumatol15:663-6,1997
I
SICKLE CELL ANEMIA
(Left) Anteroposterior radiography shows sclerosis of the humeral head, consistent with AVN. (Right) Sagittal graphic shows step-like endplate depression of the vertebral bodies (H-vertebra) as a result of infarction and bone softening.
(Left) Anteroposterior radiography shows patchy sclerosis involving the entire pelvis and femoral heads, consistent with extensive bone marrow infarction. (Right) Coronal FS T2 FSE MR shows hyperintense bone marrow edema of the distal femur in a patient with acute infarction.
Variant (Left) Anteroposterior radiography in a child with fever & leukocytosis shows lytic lesions with periosteal reaction and cortical destruction of the distal radius & ulna. This was iound to represent osteomyelitis due to salmonella. (Right) An teroposterior radiography shows patchy sclerosis of metatarsals & phalanges, consistent with bone infarcts in a child with hand-foot syndrome. Often impossible to distinguish osteomyelitis from bone infarction
Sagittal graphic shows thickened calvarium. New bone formation in the diploic space is manifested by hair-on-endappearance..
o Humerus o Spine o Skull
Abbreviations and Synonyms Thalassemia major, thalassemia minor, Cooley anemia, thalassemia intermedia, Mediterranean anemia, hereditary leptocytosis, erythroblastic anemia
o Small bones of hands and feet Size: Involvement of entire bone Morphology: Expanded marrow cavity
Radiographic Findings
Definitions Hereditary group of disorders involving hemoglobin synthesis with decreased production of either alpha chains of hemoglobin resulting in varying degrees of anemia
/IMAGING FINDINGS 2b
Lateral radiography shows widening of calvarium with hair-on-end appearance. Note the relative sparing of occipital bone due to lack of hematopoietic marrow
General Features Best diagnostic clue o Expansion of medullary cavity, thinning of cortical bone, resorption of cancellous bone o Extramedullary hematopoiesis Location o Axial and proximal appendicular skeleton (hematopoietic marrow) in adults o Axial and appendicular skeleton in infants and children (equal distribution of hematopoietic marrow) 0 Femur
Radiography o Skull Widened diploic space, coarsened trabeculae, thinning of outer table Hair-on-end appearance Occipital bone usually spared (lacks hematopoietic marrow) Impaired pneumatization of paranasal sinuses Lateral displacement of orbits Rodent facies: Ventral displacement of teeth due to marrow expansion of maxilla o Long bones Widened medullary space, thinning of cortex, resorption of cancellous bone Osteoporosis, coarsened trabeculae Undertubulation of long bones (Erlenmeyer flask deformity) Premature fusion of epiphysis (proximal humerus, distal femur, proximal tibia, proximal femur) Cortical erosions due to subperiosteal proliferation of marrow
HWm DDx: Thalassemia
Gaucher D~sease
AP Radiography
A P Radiography
AP Radiography
THALASSEMIA Key Facts Imaging Findings Expansion of medullary cavity, thinning of cortical bone, resorption of cancellous bone Extramedullary hematopoiesis
Top Differential Diagnoses Sickle Cell Anemia Gaucher Disease Leukemia
Pathology Thalassemia major (homozygote): 10% in high risk areas (Mediterranean islands) Thalassemia minor (heterozygote): 2.5% of Italian Americans, 7-10s of Greek Americans
Arthropathy (due to hemochromatosis, calcium pyrophosphate dihydrate deposition (CPPD)) Deferoxamine induced bone dysplasia 0 Spine Thickened vertebral trabeculae, paucity of horizontal trabeculae (striated appearance) Compression fractures Paravertebral masses (extramedullary hematopoiesis) o Ribs Expanded posterior aspect of ribs, thinned cortex Rib-within-a-ribappearance: Linear density within medullary cavity of middle and anterior aspects of ribs
CT Findings NECT o Expanded medullary cavity o Extramedullary hematopoiesis: Soft tissue masses CECT: Enhancement of areas of extramedullary hematopoiesis To evaluate complex anatomic structures (craniofacial bones) To define extent of extramedullary hematopoiesis
MR Findings TlWI 0 Low-intermediate signal intensity of bone marrow o Extramedullary hematopoiesis: Active lesions intermediate signal Inactive lesions: Low signal due to iron deposition, high signal due to fatty replacement T2WI: Low-intermediate signal intensity of bone marrow T2* GRE: Helpful to diagnose hemochromatosis T1 C+: Marked enhancement of areas of extramedullary hematopoiesis Deferoxamine-induced bone dysplasia: Blurred physeal-metaphyseal junction, physeal widening, metaphyseal signal changes To evaluate complications from extramedullary hematopoiesis (i.e. cord compression)
Clinical Issues Most common signs/symptoms: Hypochromic microcytic anemia Hepatosplenomegaly due to extramedullary hematopoiesis Endocrine abnormalities due to iron overload of pituitary gland Cardiomegaly, congestive heart failure due to hemochromatosis Thalassemia major: Hemolysis and severe anemia Death within 1st decade of life if untreated Thalassemia minor: Normal life expectancy Transfusion of packed red blood cells to maintain physiologic Hb level Chelation therapy to prevent iron accumulation, promote iron excretion
Nuclear Medicine Findings Bone Scan o Marked expansion of hematopoietic marrow o Increased overall skeletal radiotracer activity
Imaging Recommendations Best imaging tool: Radiographs diagnostic Protocol advice: MRI, CT for evaluation of disease and therapy induced complication (hemochromatosis, cord compression)
I DIFFERENTIAL DIAGNOSIS Sickle Cell Anemia Bone infarcts with avascular necrosis (AVN) Extramedullary hematopoiesis less common
Gaucher Disease Erlenmeyer flask deformity AVN of hip and shoulder Lytic lesions Cortical thinning, periostitis No extramedullary hematopoiesis
Leukemia Diffuse osteopenia of spine and long bones Leukemic lines Moth eaten pattern of bone destruction Collapsed vertebral bodies (vertebra plana)
1 PATHOLOGY General Features General path comments o Physiologic hemoglobin in adulthood: HbA (98%, 2 alpha and 2 beta chains) o Physiologic hemoglobin in fetal life: HbF (2 alpha and 2 gamma chains) o Beta chain production starts at 8 weeks of gestation, switch to adult hemoglobin completed at 4 months of age
THALASSEMIA Genetics o Autosomal recessive inheritance o Beta globin chain gene: Chromosome llp15.5 o Type of mutation specific to ethnic group Etiology o Alpha thalassemia: Decreased synthesis of alpha chains leading to excess of beta and gamma chains Disease begins in intrauterine life since no fetal hemoglobin (HbF) is produced Homozygote form is lethal (no oxygen transport) o Beta thalassemia: Decreased synthesis of beta chains leading to excess of alpha and gamma chains (fetal hemoglobin) Disease manifests in early infancy, after 4 months of life Homozygote defect: Thalassemia major (Cooley anemia), early onset, thalassemia intermedia, later onset Heterozygote defect: Thalassemia minor o Decrease of hemoglobin synthesis resulting in hypochromic anemia o Alpha chains precipitate as insoluble inclusion bodies Increased erythrocyte hemolysis Epidemiology o Thalassemia major (homozygote): 10% in high risk areas (Mediterranean islands) o Thalassemia minor (heterozygote): 2.5% of Italian Americans, 7-10% of Greek Americans o Alpha thalassemia (heterozygote): 30% in Southeast Asia and Africa Associated abnormalities: Can coexist with sickle cell anemia
o Thalassemia minor usually asymptomatic except for
periods of stress (infection, pregnancy)
Demographics Age o Alpha thalassemia: Begins in utero o Beta thalassemia: Develops after newborn period, usually after 4-6 months o Persists lifelong Gender: M:F = 1:l Ethnicity o Alpha thalassemia: Southeast Asia and China o Beta thalassemia: People from Mediterranean origin, less frequently in Chinese and other Asians, African Americans
Natural History & Prognosis Thalassemia major: Hemolysis and severe anemia o Death within 1st decade of life if untreated Thalassemia intermedia: Milder clinical form with longer life expectancy Thalassemia minor: Normal life expectancy
Treatment No treatment necessary for heterozygote patients Treatment for homozygote patients Transfusion of packed red blood cells to maintain physiologic Hb level o Complications: Hepatitis B, hemosiderosis, hypersplenism Chelation therapy to prevent iron accumulation, promote iron excretion o Deferoxamine: Iron balance in growing children, negative iron balance in older patients o Complications: Erythema, pruritus, visual impairment (cataracts, poor color vision), sensorineural hearing loss Bone marrow transplant Splenectomy in case of hypersplenism
Gross Pathologic & Surgical Features Hyperplastic hematopoietic bone marrow Marrow spaces filled with clotted blood
Microscopic Features Microcytic anemia, normal low serum iron, decreased haptoglobin, hemopexin Normocellular hematopoiesis, erythroid predominance, megakaryocytosis
1 DIAGNOSTIC CHECKLIST Consider Genetic counseling if both parents have disease or are carriers
Presentation Most common signs/symptoms: Hypochromic microcytic anemia Clinical profile o Growth retardation o Hyperbilirubinemia (gallstones) o Hepatosplenomegaly due to extramedullary hematopoiesis o Skin hyperpigmentation o Endocrine abnormalities due to iron overload of pituitary gland o Cardiomegaly, congestive heart failure due to hemochromatosis o Liver failure, cirrhosis, pancreatic insufficiency, diabetes mellitus due to hemochromatosis o Increased infection rate o Bleeding diathesis
Image Interpretation Pearls Imaging is important to detect serious complications from extramedullary hematopoiesis (cord compression) or frequent transfusions (hemochromatosis)
1.
2. 3.
Ball LM et al: Paediatric allogeneic bone marrow transplantation for homozygous beta-thalassaemia, the Dutch experience. Bone marrow transplant 31:1081-7, 2003 Chaston TB et al: Iron chelators for the treatment of iron overload disease: Relationship between structure, redox activity, and toxicity. Am J Hematol 73:200-10, 2003 Orofino MG et al: Fetal HLA typing in beta thalassaemia: Implications for haemopoietic stem-cell transplantation. Lancet 362:41-2, 2003
I
THALASSEMIA
(Lef)Anteroposterior radiography shows generalized osteopenia, coarsened trabeculae, and cortical thinning of the phalanges. widening of the medullary cavity resulting in squaring of the metacarpals. (Right) Anteroposterior radiography shows widening of the ribs and clavicles. Linear densities overlapping the anterior ribs result in "rib-within-a-rib" appearance.
Typical (Lef) Lateral radiography shows marked expansion of the calvarium and hair-on-end appearance. Note the enlarged impressions of the calvarial vessels. (Right) Anteroposterior radiography shows expansion of the medullary cavity with coarsened trabeculae and cortical thinning.
Typical (Left) Anteroposterior radiography shows coarsening and osteopenia of the pelvis with expansion of the medullary cavity. (Right) Lateral radiography shows thickened vertical trabeculae with paucity of horizontal trabeculae resulting in a striated appearance. Note expansion of the medullary cavity.
CAUCHER'S DISEASE
Sagittal graphic shows expansion of the medullary cavity with coarsened trabeculae and cortical thinning. Note undertubulation of the distal femur resulting in Erlenmeyer flask deformity.
Anteroposterior radiography shows widening of the proximal humerus with osteopenia, coarse trabeculae, andcorticalthinning.
Radiographic Findings ~adiograph~ o Generalized osteopenia o Coarsened trabeculae (honeycombing) o Erosion of inner cortex and widened medullary
Abbreviations and Synonyms Gaucher disease, acid beta-glucocerebrosidase deficiency
Definitions
cavity
Hereditary disease characterized by deposition of glucocerebroside in cells of the reticuloendothelial system (RES) due to deficiency of beta-glucocerebrosidase
o Endosteal scalloping
o Multiple circumscribed lytic lesions o Expansion of metadiaphysis of long bones:
Erlenmeyer flask deformity o Weakened subchondral bone, degenerative arthritis o Spinal compression fractures:' ~ - c h a ~ vertebrae ed
(10%) o Avascular necrosis of femoral head (20%),humeral 30
head (lo%), ankle, wrist
General Features Best diagnostic clue o Expansion of medullary cavity with generalized osteopenia o Erlenmeyer flask deformity Location o Axial skeleton o Long bones o Pelvis o Relative sparing of epiphyses Size: Involvement of entire bone Morphology: Widened medullary cavity with generalized osteopenia
[
o Medullary bone infarcts o Dual-energy X-ray absorptiometry (DEXA) useful in
evaluation of osteopenia
M R Findings TlWI: Bone marrow infiltration of low signal intensity T2WI o Bone marrow infiltration of low signal intensity o Areas of high signal represent acute disease STIR: Increased signal intensity MR helpful to evaluate for complication o Avascular necrosis (AVN), cord compression
1
DDx: Gaucher's Disease
A P Radiography
A P Radiography
Lat Radiography
AP Radiography
Cor T l Wl MR
GAUCHER'S DISEASE Key Facts imaging Findings Expansion of medullary cavity with generalized osteopenia Erlenmeyer flask deformity
Top Differential Diagnoses
'
Multiple Myeloma Hurler Syndrome Morquio Syndrome Thalassemia egg-calve-~erthes Nieman Pick Disease
Pathology
Clinical Issues Most common signs/symptoms: Splenomegaly, bleeding diathesis Pancytopenia (hypersplenism) Bone involvement in 75% Type 1: Longest time of survival Type 2: Death during first 2 years of life Type 3: Death in childhood, early adulthood Enzyme replacement therapy for type 1disease
Diagnostic Checklist
Bone crises with severe swelling and pain are frequently mistaken for synovitis or osteomyelitis
60% of Ashkenazi Jewish population are homozygote for mild mutation
Dixon chemical shift imaging helpful in quantifying bone marrow involvement
Nuclear Medicine Findings Bone Scan: Increased radiotracer uptake in region of proximal humeri, distal femora, proximal tibiae Positive bone scan in 60% of patients
Imaging Recommendations Best imaging tool: Radiographs diagnostic Protocol advice: TI, T2WI MR to evaluate disease extent and complications (AVN, cord compression)
Multiple Myeloma Older age group Soft tissue mass adjacent to bone destruction
Hurler Syndrome Shortened extremity bones Normal/increased vertebral body height Vertebral inferior beak Hypoplastic pelvis
Morquio Syndrome Platyspondyly (vertebra plana) Ovoid vertebral bodies with central anterior beak "Wine glass pelvis"
Thalassemia Extramedullary hematopoiesis "Hair-on-end"appearance of skull AVN less common
Legg-Calvk-Perthes Idiopathic AVN of femoral head in children Femoral epiphysis of affected hip smaller than normal contralateral side Sclerosis, collapse of femoral epiphysis
Nieman Pick Disease Erlenmeyer flask deformity Severe mental retardation
General Features General path comments: Glucosylceramide (accumulated glycolipid) derived from phagocytosis and degeneration of leukocytes and erythrocyte membranes Genetics o Most common genetic lysosomal storage disorder o Autosomal recessive inheritance o Gene for glucocerebrosidase located on chromosome lq21 Etiology o Deficiency of beta-glucocerebrosidase leads to accumulation of glucosylceramide within cells of RES o Glucosylceramide storage in bone marrow, liver, spleen, lungs lead to pancytopenia, hepatosplenomegaly, diffuse pulmonary disease o Type 2 and 3: Neural cell loss due to accumulation of glucosphingosine from severe deficiency of acid beta-glucocerebrosidase Epidemiology o Carrier frequency 1 in 15, disease frequency 1 in 855 in Jewish people from Eastern European descent (type 1) o 60% of Ashkenazi Jewish population are homozygote for mild mutation
Gross Pathologic & Surgical Features Infiltration of cancellous bone with pale yellow tissue distinguishable from fatty marrow Secondary infarction: Dense sclerotic bone
Microscopic Features Infiltration of bone marrow with Gaucher cells (kerasin-laden histiocytes) Gaucher cell: Large, pale, polyhedral cell, eccentric nucleus, weakly eosinophilic cytoplasm containing striations ("wrinkled tissue paper" appearance)
GAUCHER'S DISEASE
1
Staging, Grading or Classification Criteria
I
Type 1:Most common, no central nervous system involvement Type 2: Rare, involves central nervous system Type 3: Rare, involves central nervous system
Presentation Most common signslsymptoms: Splenomegaly, bleeding diathesis Clinical profile o Neurologic symptoms (type 2, 3): Seizures, mental retardation, spasticity o Hepatosplenomegaly due to accumulation of glucosylceramides o Pancytopenia (hypersplenism) o Fatigue, weight loss o Bone involvement in 75% Bone crises: Bone pain from infarction Pathologic fractures, vertebral compression fractures, cord compression AVN of femoral and humeral head, wrist, ankle Osteomyelitis Osteoarthritis = Growth retardation Repeated pulmonary infections
Consider Bone crises with severe swelling and pain are frequently mistaken for synovitis or osteomyelitis
1.
2. 3.
4.
5.
A
Demographics
0 32
Age o Adult form (type 1):May present in childhood or adulthood o Infantile form (type 2): 1-12 months o Juvenile form (type 3j: 2-6 years Gender: M:F = 1:l Ethnicity o Type 1: Most common genetic disorder among Ashkenazi Jewish population o Type 3 frequently found in Sweden
Natural History & Prognosis Type 1: Longest time of survival o Patients of non Ashkenazi Jewish descent have worse prognosis Type 2: Death during first 2 years of life Type 3: Death in childhood, early adulthood
Treatment Enzyme replacement therapy for type 1 disease 0 Recombinant enzyme imiglucerase (Cerezyme) 0 Can reverse visceral and hematologic manifestations Skeletal disease responds slowly Beta-glucosidase mannose substitution 0 Substitution of mannose to the enzyme glucosidase causes destruction of the accumulated glucosylceramide AVN: Bed rest, analgesics, total hip replacement in advanced cases Splenectomy in case of severe splenomegaly
8. 9.
Zhao H et al: Gaucher's disease: Identification of novel mutant alleles and genotype-phenotype relationships. Clin Genet 6457-64, 2003 Cabrera-Salazar MA et al: Gene therapy for the lysosomal storage disorders. Curr Opin Mol Ther 4:349-58, 2002 Maas M et al: Quantification of skeletal involvement in adults with type I Gaucher's disease: Fat fraction measured by Dixon quantitative chemical shift imaging as a valid parameter. Am J Roentgenol 179:961-5, 2002 Weinreb NJ et al: Effectiveness of enzyme replacement therapy in 1028 patients with type 1 Gaucher disease after 2 to 5 years of treatment: A report from the Gaucher Registry. Am J Med 113:112-9, 2002 Poll LW et al: Magnetic resonance imaging of bone marrow changes in Gaucher disease during enzyme replacement therapy: First German long-term results. Skeletal Radiol 30:496-503, 2001 Kelman CG et al: Metaphyseal undertubulation in Gaucher disease: Resolution at MRI in a patient undergoing enzyme replacement therapy. J Comput Assist Tomogr 24:173-5, 2000 Hermann G et al: Gaucher disease: Assessment of skeletal involvement and therapeutic responses to enzyme replacement. Skeletal Radiol 26:687-96, 1997 Terk MR et al: MR imaging of patients with type 1 Gaucher's disease: Relationship between bone and visceral changes. Am J Roentgenol 165599-604, 1995 Oestreich AE: Imaging of the skeleton and soft tissues in children. Curr Opin Radiol 455-61, 1992
GAUCHER'S DISEASE IMAGE GALLERY
-
(Left) Coronal T l Wl MR shows diffuse hypointense bone marrow infiltration of the distal femur. Hypointense signal represents lipid in reticuloendothelial cells. (Right) Anteroposterior radiography shows multiple lytic lesions involving the distal femur with associated pathologic fracture. This lytic appearance may be mistaken for metastatic disease.
Tvpical (Left) Anteroposterior radiography shows classic undertubulation (widening) of the distal femoral metadiaphyses (Erlenmeyer flask deformity). Diffuse osteopenia is noted. (Right) Sag~ttalgraphic shows vertebral compression fracture.
(Left) Anteroposterior radiography shows expansion of the humeral medullary cavity with osteopenia and coarsened trabeculae (honeycombing). (Right) An teroposterior radiography shows avascular necrosis with significant associated osseous deformity involving the right femoral head.
METASTASES, BONE MARROW
Sagittal graphic shows metastatic bone marrow infiltration of a thoracic vertebral body. Note cortical destruction and associated anterior soft tissue mass.
Anteroposterior radiography shows osteoblastic metastases from prostate cancer involving the pelvis.
Morphology: Single/multiple osteolytic or blastic lesions of variable size
Abbreviations and Synonyms
Radiographic Findings
Skeletal metastases, bone metastases
Definitions Spread of cancer from one part of the body to another
General Features
0 4
.+
Best diagnostic clue: Permeative pattern of bone destruction, osteolytic and/or osteoblastic lesions Location o Axial and proximal appendicular skeleton most frequently involved Persistence of red marrow Spine, ribs, pelvis, skull Femur, humerus o Widespread disease in children (more red marrow) Neuroblastoma, leukemia most common o Distal bones rarely affected: Lung, breast, renal cancer Small tubular bones of hands and feet: Can be affected in lung cancer Size: < 5 cm in length
.
Radiography o Insensitive for detecting early metastatic disease At lease 30-50% of normal bone must be lost before metastases are visible o Multiple areas of bone destruction Moth eaten, permeative, geographic pattern o Osteolytic lesions: 70% Primary: Kidney, breast, thyroid, GI tract o Osteoblastic lesions: 15% Primary: Prostate, breast, cervix, ovary, urinary bladder, carcinoid, osteosarcoma o Mixed osteoblastic and osteolytic lesions: 10% Any primary, most common in breast, lung o +/- Cortical destruction, periosteal new bone formation o +/- Extension into soft tissue o Spine: Destruction of pedicles, endplate deformity Joint spaces and intervertebral spaces preserved (cartilage resistant to invasion) o Increased sclerosis and decrease in size with healing
. . .
CT Findings NECT o Lytic or blastic bone marrow infiltration o Cortical destruction
DDx: Metastases, Bone Marrow M bF l
I
AP Radiography
' r
Sag T l WI MR
1
1
Lat Radiography
e
Sag T7 WI MR
Lat Rad~ography
METASTASES, BONE MARROW Key Facts Imaging Findings Best diagnostic clue: Permeative pattern of bone destruction, osteolytic and/or osteoblastic lesions
Top Differential Diagnoses Multiple Myeloma Lymphoma Paget Disease Hemangioma Malignant Fibrous Histiocytoma (MFH)
Pathology -. Bone marrow: Third most common site of metastatic disease Skeletal metastases in 30-70% of patients with malignancy at autopsy
Useful in evaluating radiographically negative areas when metastases are suspected
MR Findings TlWI o Lytic metastases Low signal intensity o Osteoblastic metastases Low signal intensity o Mixed metastases Heterogeneous signal intensity T2WI o Lytic metastases High signal intensity o Osteoblastic metastases Low signal intensity o Mixed metastases Heterogeneous intermediate-high signal intensity STIR o Lytic metastases: High signal intensity o Osteoblastic metastases: Low signal intensity o Mixed metastases: Heterogeneous intermediate-high signal intensity o Whole body STIR to evaluate entire skeleton for metastases DWI: Helpful in differentiating benign osteoporotic from malignant compression fractures T1 C+: Variable enhancement Helpful in evaluating associated soft tissue components, complications (cord compression)
Angiographic Findings Hypervascular Preoperative embolization of hypervascular metastases
Nuclear Medicine Findings Bone Scan o High sensitivity for many metastatic tumors (breast, lung, prostate) Increased radiotracer uptake in > 90% Normal bone scan: 5% Decreased activity in metastases with low metabolic activity or destruction but no new bone formation
Metastases to bone 25 times more common than primary skeletal neoplasms
Clinical Issues ~ o scommon t signs/symptoms: Pain (70%), weight loss, anemia Pathologic fractures Osteoclast inhibiting agents: Bisphosphates (alendronate, etidronate, pamidronate, clodronate) Radiation therapy Internal fixation in case of pathologic - fracture or to prevent pathologic fractureA
checklist Multiple bone lesions in patients over 50 years are usually due to metastases
o Multiple asymmetric areas of increased radiotracer
uptake o Superscan: Widespread bone marrow metastases
produce diffusely increased uptake Absence of normal activity in kidneys and urinary bladder o "Healing flare" phenomenon: Transient increased activity under therapy during healing o False positives: 10%
Imaging Recommendations Best imaging tool: Bone scan, MRI Protocol advice o Bone scan to detect extent of metastatic disease o MRI to evaluate complications
I DIFFERENTIAL DIAGNOSIS Multiple Myeloma Late involvement of pedicles (pedicles involved first in metastases) Cold on bone scan Sclerosis extremely rare Endosteal scalloping
Lymphoma Permeative bone destruction Cortical destruction occurs late in disease Lamellated, sunburst periosteal reaction
Paget Disease Thickened cortex and trabeculae Marrow replacement not mass like No cortical destruction
Hemangioma Multiloculated lytic foci Vertical striations, honeycomb appearance
Malignant Fibrous Histiocytoma (MFH) Permeative bone destruction Solitary lesion
METASTASES, BONE MARROW
1 PATHOLOGY
I
General Features General path comments o Metastases: Late event in process of cancer development o Every malignancy can metastasize to bone Cancers metastasize more common than sarcomas Cancers most likely to metastasize to bone: Breast, lung, prostate, thyroid, kidney Children: Neuroblastoma Etiology o Hematogenous spread through arterial circulation to vascular red marrow o Hematogenous spread through retrograde venous flow (prostate) o Direct extension (uncommon) Epidemiology o Bone marrow: Third most common site of metastatic disease o Skeletal metastases in 30-70% of patients with malignancy at autopsy o Metastases to bone 25 times more common than primary skeletal neoplasms
.
Gross Pathologic & Surgical Features Firm, white tumor with or without necrotic, hemorrhagic areas Cortical disruption Invasion into adjacent soft tissues
Microscopic Features
36
Replacement of bone marrow by carcinoma cells depending on origin of primary tumor Excretion of osteoclast-stimulating factors and necrotic factors with direct lytic activity by metastatic cells Tumor cells with increased levels of laminin and fibronectin surface receptors have high metastatic potential Increased type IV collagenase of tumor cells correlates with increased metastatic potential o Type IV collagenase degrades major component of basement membrane (type IV collagen)
Presentation Most common signs/symptoms: Pain (70%), weight loss, anemia Clinical profile o Swelling in region of affected bone o Pathologic fractures o Hypercalcemia (lo%), elevated alkaline phosphatase o Neurologic impairment with spinal metastases
Demographics Age: > 40 years, unless known primary Gender: Dependent on primary cancer
Natural History & Prognosis Initial metastasis usually occurs within two years after diagnosis of primary malignancy
Patients with lung cancers and bone metastases have median survival of < 6 months
Treatment Osteoclast inhibiting agents: Bisphosphates (alendronate, etidronate, pamidronate, clodronate) Radiation therapy Strontium-89 for bone pain (palliative) Vertebroplasty for spinal compression fractures Internal fixation in case of pathologic fracture or to prevent pathologic fracture Important to determine etiology of malignant lesion prior to fixation o If lesion represents primary mesenchymal sarcoma, increased risk of tumor seeding during internal fixation (may convert limb salvage procedure into amputation) o If lesion is due to metastatic carcinoma, low risk of tumor seeding during internal fixation
[DIAGNOSTIC CHECKLIST Image Interpretation Pearls Multiple bone lesions in patients over 50 years are usually due to metastases
Vane1 D et al: MRI of bone marrow disorders. Eur Radiol 10:224-9, 2000 Trail1 ZC et al: Magnetic resonance imaging versus radionuclide scintigraphy in screening for bone metastases. Clin Radiol 54:448-51, 1999 Vane1 D et al: MRI of bone metastases. Eur Radiol 8:1345-51, 1998 Yamaguchi T et al: Intertrabecular pattern of tumors metastatic to bone. Cancer 78:1388-94, 1996 Papac RJ: Bone marrow metastases. A review. Cancer 74:2403-13, 1994 Scher HI et al: Bone metastases: Improving the therapeutic index. Sem Oncol21:630-56, 1994 Stetler-Stevenson WG et al: Tumor cell interactions with the extracellular matrix during invasion and metastasis. Annu Rev Cell Biol9:541-73, 1993 Asdourian PL et al: The pattern of vertebral involvement in metastatic vertebral breast cancer. Clin Orthop 250:164-70, 1990 Gold RI et al: An integrated approach to the evaluation of metastatic bone disease. Radiol Clin North Am 28:472-83, 1990
METASTASES, BONE MARROW
1 IMAGE GALLERY Typical (teft) Anteroposterior radiography shows large lytic expansile lesion involving the humerus in a patient with renal cell cancer. Metastases from renal cell cancer are hypervascular and can lead to severe hemorrhage during surgery. (Right) Anteroposterior radiography shows destruction of multiple tarsal and metatarsal bones in a patient with lung cancer. Metastases to the feet are uncommon but can be seen with lung cancer.
Typical
(Left) Sagittal T 1 Wl MR shows vertebral collapse with associated soft tissue mass and marked kyphotic angulation causing cord compression in a patient with colon cancer. (Right) Coronal radiography (resected specimen) shows normal thoracic vertebral bodies. Corresponding gross specimen shows multiple bone marrow metastases in a patient with breast cancer. This shows the low sensitivity of radiographs in metastases.
Typical (L@) Anteroposterior radiography shows expansile lytic lesions in the metacarpal bones and phalanges in a patient with thyroid cancer. (Right) Clinical photograph shows expansile masses in the metacarpals and phalanges corresponding to lytic metastases from thyroid cancer.
iGET DISEASE
Sagittal graphic shows osteolytic phase of Paget disease (osteoporosiscircumscripta) involving the frontal bone.
Lateral radiography shows cortical and trabecular thickening, expansion of the femur with multiple transverse stress fractures in the lateral cortex. The lesions extend to the end of bone.
o Polyostotic: 70% o Monostotic: 10-35%
Size 0 2-3 cm in early stage o Involvement of entire bone in late phase Morphology: Expanded bone with thickened trabeculae
Abbreviations and Synonyms Osteitis deformans, Paget's disease
Definitions Chronic skeletal disease characterized by abnormal osteoblastic and osteoclastic activity resulting in abnormal bone remodeling
0 38
Radiographic Findings Radiography o Pelvis Thickening of iliopectineal line Thickened trabeculae, coarse cortex Acetabular protrusion o Skull Diploic widening: Inner and outer table involved Osteoporosis circumscripta: Well-defined lytic lesions (destructive active stage) Usually frontal bone involvement Cotton-wool appearance: Mixed lytic and blastic pattern of thickened calvarium (late stage) Basilar invagination with narrowing of foramen magnum o Long bones "Candle flame" lysis: V-shaped lytic defect originating subarticular and advancing to diaphysis of long bone Banana fractures: Small, horizontal stress fractures in weight bearing bones (on convex surface)
General Features Best diagnostic clue o ~nlargedbone with thickened and coarse trabeculae o Starts at one end of bone and progresses along shaft Location o Pelvis: 73% o Spine: 58% 0 Skull: 42% 0 Proximal long bones: 2 5 - 3 0 s 0 Scapula: 24% o Clavicle: 11% o Long bones: Lesion starts at one end of bone, extends along shaft Usually unilateral involvement, contralateral bone normal or minimally affected
aaAua DDx: Paget Disease
C #
A P Rad~ography
A P Radiography
A P Rad~ography
Lat Radiography
Sag T I WI MR
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PAGET DISEASE Key Facts Imaging Findings Enlarged bone with thickened and coarse trabeculae Starts at one end of bone and progresses along shaft Osteoporosis circumscripta: Well-defined lytic lesions (destructive active stage) Cotton-wool appearance: Mixed lytic and blastic pattern of thickened calvarium (late stage)
Top Differential Diagnoses Osteoblastic Metastases Lymphoma Fibrous Dysplasia Multiple Myeloma Hemangioma Myelofibrosis
Lateral bowing of femur, anterior bowing of tibia Acetabular protrusio o Spine Picture-frame vertebral body: Enlarged, square, vertebral body with thickened, peripheral trabeculae and radiolucent inner portion Ivory vertebra: Increased density Ossification of spinal ligaments o Progression from active osteolytic phase to sclerotic phase Reversion form sclerotic phase to lytic phase possible = However, lytic lesion in previously sclerotic pagetoid bone is suspicious for malignant degeneration o Rarely associated with multiple giant cell tumors
CT Findings NECT: Enlarged sclerotic bone with thickened coarse trabeculae CECT: Dense enhancement in lytic phase Helpful in complex anatomic areas (skull, spine)
MR Findings TlWI o Low signal intensity Yellow marrowlfat Marrow replacement not mass like T2WI o Active phase: High signal intensity o Low signal intensity (sclerosis) Marrow replacement: Parallels signal intensity of fat T1 C+: Enhancement in lytic phase Coarsened appearance of bone marrow Helpful in evaluating spine (cord, nerve root compression) ' For evaluation of sarcomatous degeneration
Angiographic Findings Involved bone is hypervascular
Nuclear Medicine Findings Bone Scan
Pathology Affects 3% of individuals > 40 years Affects 10% of individuals > 80 years
Clinical Issues Insidious onset, asymptomatic for many years Bowed and enlarged femur and tibia Compression fractures (soft bone despite increased density) Peripheral nerve compression, neurological disorders from compression of brainstem Elevated serum alkaline phosphatase and urine hydroxyproline Sarcomatous transformation (< 1%) Bisphosphates: Alendronate, etidronate Calcitonin
o Increased radiotracer uptake in lytic phase o Normal scan in sclerotic, burned-out lesions o Abnormal before radiographs o Helpful to assess distribution
Imaging Recommendations Best imaging tool: Radiographs diagnostic Protocol advice o Radiographs diagnostic, MRI and CT to evaluate for complications o Bone scan useful in determining extent of disease
1 DIFFERENTIAL DIAGNOSIS Osteoblastic Metastases May be indistinguishable Often diffuse, bilateral (Paget usually unilateral)
Lymphoma Cancellous bone erosion Cortical destruction with soft tissue mass High signal on T2W MR of involved areas
Fibrous Dysplasia Ground glass appearance Cranial lesions may be indistinguishable
Multiple Myeloma Multiple well-defined lytic lesions Sclerosis extremely rare Endosteal scalloping Soft tissue mass adjacent to bone destruction
Hemangioma Vertical striations, honeycomb appearance Multiloculated lytic foci No trabecular thickening
Myelofibrosis Sclerosis without bone enlargement Bilateral involvement
1 PATHOLOGY
1
General Features General path comments 0 Increased osteoclastic activity resulting in progressive multifocal bone resorption followed by bone formation o High rate of bone turnover with rapid bone growth can lead to mutations and genomic deletions leading to malignant transformation Genetics: Mutations in gene encoding sequestosome 1 (SQSTM1) in familial and sporadic Paget disease Etiology o Chronic disease of osteoblasts and osteoclasts o Possible viral etiology (parvomyxovims) o Regional difference i n disease prevalence supports environment influence Epidemiology o Affects 3% of individuals > 40 years o Affects 10% of individuals > 80 years
Gross Pathologic & Surgical Features Newly formed bone abnormally soft and deformed Increased vascularity Disorganized trabecular pattern Thickened trabeculae with small marrow cavities
Microscopic Features
40
Active phase (osteolytic phase) o ~ ~ ~ r e s sbone i v e resorption with lytic lesions o Replacement of hematopoietic bone marrow by fibrous connective tissue o Increased vascular channels o Osteoblastic rimming Inactive phase (quiescent phase) o ~ecreaiedboGe turnovk with skeletal sclerosis and coarse trabeculae o Loss of excessive vascularity o Irregular cement lines Mixed pattern o Mixture of lytic and sclerotic phase o Intracytoplasmatic inclusions
Presentation Most common signs/symptoms o Insidious onset, asymptomatic for many years o Full clinical picture with characteristic bone deformities after 20-30 years Clinical profile o Fatigue o Bowed and enlarged femur and tibia o Skin over affected bones warm, erythematous o Secondary arthritis o Compression fractures (soft bone despite increased density) o Peripheral nerve compression, neurological disorders from compression of brainstem Hearing loss, blindness, facial palsies o Enlarged hat size o Elevated serum alkaline phosphatase and urine hydroxyproline
.
o High output congestive heart failure (rare)
Demographics Age: 55-85 years, unusual < 40 years Gender: M:F = 2:l Ethnicity 0 Highest incidence in the United Kingdom, New Zealand, Australia o Uncommon in Asia, Africa (excluding South Africa)
Natural History & Prognosis Sarcomatous transformation (< 1%) o Osteosarcoma (22-90%) o Fibrosarcoma/malignant fibrous histiocytoma (MFH) (29-51%) o Chondrosarcoma (1-15%) o Poor prognosis, 5-year survival for osteosarcoma: 8%
Treatment Bisphosphates: Alendronate, etidronate Calcitonin Mithramycin Joint replacement in case of arthritis Fixation of pathologic fractures Radical resection of sarcomatous transformed bone, amputation often necessary
I DIAGNOSTIC CHECKLIST Consider Delayed diagnosis of sarcomatous degeneration may affect prognosis for prolonged survival
Image Interpretation Pearls In a patient with malignancy, metastases will preferentially involve pagetic bone
Hocking LJ et al: Domain-specificmutations in sequestosome 1 (SQSTM1) cause familial and sporadic Paget's disease. Hum Mol Genet 11:2735-9, 2002 Whitehouse RW: Paget's disease of bone. Semin Musculoskelet Radiol 6:313-22, 2002 Boutin RD et al: Complications in Paget disease at MR imaging. Radiology 209:641-51, 1998 Mirra JM et al: Paget's disease of bone: Review with emphasis on radiologic features. Part 1. Skeletal Radiol 24:163-71, 1995 Gallacher SJ: Paget's disease of bone. Curr Opin Rheumatol 5:351-6, 1993 Roberts MC et al: Paget disease: MR imaging findings. Radiology 173:341-5, 1989 Meunier PJ et al: Skeletal distribution and biochemical parameters of Paget's disease. Clin Orthop 217:37-44, 1987 Frame B et al: Paget disease: A review of current knowledge. Radiology 141:21-4, 1981
PAGET DISEASE
I
IMAGE GALLERY (Left) Lateral radiography shows osteolytic lesion involving the anterior calvarium, consistent with osteoporosis circumscripta (lytic phase). (Right) Anteroposterior radiography shows marked cortical thickening and coarse trabecular pattern of the pelvis in the cold phase of the disease.
(Left) Lateral radiography shows increased density of the C2 and C4 vertebral bodies (ivory vertebral body). (Right) Anteroposterior bone scan shows markedly increased radiotracer uptake extending from the distal femoral epiphysis to the proximal diaphysis. Expansion of the femur is noted.
Other
(Left) Coronal T 1 WI MR shows enlargement of the distal femur with cortical thickening and coarse cancellous trabeculae of low signal. (Right) Coronal gross pathology, section shows involvement of the distal femur with cortical thickening and coarse trabeculae.
SECTlON 8: Bone Tumors
Osteoblastic Tumors Osteoma Osteoid Osteoma Osteoblastoma Osteosarcoma
Cartilaginous Tumors Enchondroma Osteochondroma Chondroblastoma Chondromyxoid Fibroma Chondrosarcoma
Fibrous Tumors Fibrous Dysplasia Fibroxanthoma Malignant Fibrous Histiocytoma, Bone Fibrosarcoma
8-38 8-42 8-46 8-50
Miscellaneous Tumors and Tumor-Like Lesions Giant Cell Tumor Intraosseous Hemangioma Unicameral Bone Cyst Aneurysmal Bone Cyst Intraosseous Lipoma Adamantinoma
OSTEOMA
Coronal graphic show sclerotic ivory-like osteoma arising from the right mandible. The tumor abuts the orbital floor and maxillary sinus. There is no invasion or cortical destruction.
Anteroposterior radiography of the skull shows a round well-defined sclerotic lesion located in the left frontal sinus.
o Lesion attached to bone o Bone mass is arising from surface of bone
Abbreviations and Synonyms
0
Definitions Benign, slow growing hamartomatous lesion consisting of well-differentiated mature bone
Intraparenchymal: No connection to dura or bone Dural: No bony attachment, arise from falx Skull base: Occur in paranasal sinuses, maxilla, mandible, temporal bone Skull vault: Arise from outer table of skull (exostotic) or inner table (enostotic)
General Features Best diagnostic clue: Well-defined round dense sclerotic lesion attached to underlying bone Location o Frontal and ethmoid sinuses: 75% o Sphenoid sinus: 1-4% o Innerlouter table of calvarium o Mandible o Rare in long and flat bones o Parosteal (not intramedullary) o May be multiple Size: 1-5 cm, usually < 2 cm Morphology: Dense sclerotic well-defined mass
CT Findings NECT o Homogeneous calcific hemispheric mass o Lesion is arising from external surface of the cortex o Periosteal reaction can be seen o Helpful in demonstrating lack of cortical invasion and lack of medullary continuity with host bone CECT: No enhancement
MR Findings
Radiographic Findings Radiography o Dense, ivory-like sclerotic mass
Well-defined margins
o No associated osseous destruction o No satellite lesions o Mild periosteal reaction can be seen o Cranial osteomas
Ivory exostosis
Mm
TlWI o Low signal intensity o Attached to underlying bone T2WI o Low signal intensity
DDx: Osteoma
Osteochondroma
Enostosis
-f
Lat Radiography
Lat Radiography
Cor T l W l MR
Lat Radiography
OSTEOMA Key Facts Imaging Findings Best diagnostic clue: Well-defined round dense sclerotic lesion attached to underlying bone
Top Differential Diagnoses Parosteal Osteosarcoma Sessile Osteochondroma Enostosis (Bone Island) Juxtacortical Myositis Ossificans
Pathology Extracranial osteoma: 0.03% of biopsied primary bone lesions Gardner's Syndrome: Autosomal dominant Multiple osteomas, intestinal polyposis, soft tissue desmoid tumors
o Attached to underlying bone o FS T2 FSE
Low signal intensity STIR: Low signal intensity T1 C+: No enhancement
Nuclear Medicine Findings Bone Scan o Increased radiotracer uptake of active lesions o No increased uptake of latent lesions
Imaging Recommendations Best imaging tool: Radiographs, CT Protocol advice: CT to evaluate anatomic complex areas (craniofacial bones)
I DIFFERENTIAL DIAGNOSIS Parosteal Osteosarcoma Zone of decreased density at periphery Less dense and homogeneous than osteoma Incomplete cleft between lesion and adjacent cortex
Sessile Osteochondroma Cortex of lesion merges without interruption with cortex of host bone Cancellous portion continuous with host medullary cavity
Enostosis (Bone Island) Intramedullary location Blends with surrounding trabecular bone Irregular spiculated margins Small: < 1 cm
JuxtacorticalMyositis Ossificans Zonal phenomenon Lucent center, dense ossified periphery
Clinical Issues Small lesions are usually asymptomatic Large paranasal sinus tumors may obstruct nasal ducts Tumors near orbit can cause exophthalmus, double vision, vision loss Benign lesion Asymptomatic lesions require no treatment
Diagnostic Checklist Multiple osteomas or osteomas outside craniofacial bones, think of Gardner's Syndrome Heterogeneous lesion, cortical destruction, consider parosteal osteosarcoma
/ PATHOLOGY General Features General path comments: Dysplastic developmental anomaly Genetics: Gardner's Syndrome (mutations involving adenomatous polyposis coli gene mapped to chromosome 5q21) Etiology o Defect in bone resorption or formation during skeletal maturation o Arises beneath endosteum from inner surface of cortex o Elevation of periosteum form underlying bone causes surrounding reactive bone formation Lesion grows inwards from the periphery Epidemiology o Extracranial osteoma: 0.03% of biopsied primary bone lesions o Paranasal sinus osteomas: Incidence 0.4% Associated abnormalities o Gardner's Syndrome: Autosomal dominant Multiple osteomas, intestinal polyposis, soft tissue desmoid tumors Bone lesions may precede intestinal polyposis Multiple osteomas, solitary osteoma of mandible, or osteomas in appendicular skeleton raise suspicion of Gardner's Syndrome
Gross Pathologic & Surgical Features Circumscribed, juxtacortical bone mass Periosteum easily removed from underlying lesion (serves as capsule) Similar to normal cortical bone Peripheral reactive bone formation
Microscopic Features
an cello us type: Cancellous, trabecular architecture o Active bone formation with transformation to
lamellar bone Lamellar bone: Composed of layers of mature matrix with densely packedcollagen fibers
3
Woven bone: Consists of mature matrix with collagen fibers Compact type: Dense, compact, mature lamellar bone Overlying periosteum: Layer of mature, fibrous, connective tissue and proliferating osteoblasts
3. 4.
Staging, Grading or Classification Criteria
5.
Surgical staging system for benign musculoskeletal tumors o Stage 1: Latent o Stage 2: Active o Stage 3: Aggressive
6. 7. 8. 9.
Presentation Most common signs/symptoms o Small lesions are usually asymptomatic o Palpable enlarging osseous mass Clinical profile o Large paranasal sinus tumors may obstruct nasal ducts Can erode wall of cranial fossa and dura Can cause mucoceles, sinusitis, nasal discharge, headache, pain o Tumors near orbit can cause exophthalmus, double vision, vision loss o Tumors in craniofacial bones can cause enlargement of cheeks ("cherubism")
Demographics Age: 10-79 years, peak: 4th-5th decade Gender: M:F = 1:1 Ethnicity: No racial predilection
Natural History & Prognosis Benign lesion No malignant degeneration Lesion undergoes involution from active stage 2 lesion to latent stage 1 lesion
Treatment Asymptomatic lesions require no treatment Symptomatic lesions: En bloc resection with marginal margins Sinonasal endoscopy
I DIAGNOSTIC CHECKLIST Consider Multiple osteomas or osteomas outside craniofacial bones, think of Gardner's Syndrome
Image Interpretation Pearls Heterogeneous lesion, cortical destruction, consider parosteal osteosarcoma
ISELECTEDREFERENCES 1.
2.
Eppley BL et al: Large osteomas of the cranial vault. J Craniofac Surg 14:97-100, 2003 Haddad FS et al: Cranial osteomas: Their classification and management. Report on a giant osteoma and review of the
10. 11. 12. 13. 14. 15.
literature. Surg Neurol 48:143-7, 1997 Peyser AB et al: Osteoma of the long bones and the spine: A study of eleven patients and a review of the literature. J Bone Joint Surg 78A:1172-80, 1996 Sundaram M et al: Surface osteomas of the appendicular skeleton. Am J Roentgen01 167:1529-33, 1996 Bertoni F et al: Parosteal osteoma of bones other than of the skull and face. Cancer 75:2466-73, 1995 Davies DR et al: Severe Gardner syndrome in families with mutations restricted to a specific region of the APC gene. Am J Hum Genet 57:1151-8, 1995 Greenspan A: Benign bone-forming lesions: Osteoma, osteoid osteoma, and osteoblastoma. Skeletal Radiol 22:485-500. 1993 0'Connell JX et al: Solitary osteoma of a long bone. J Bone Joint Surg 75A:1830-4, 1993 Greenspan A: Sclerosing bone dysplasias - a target-site approach. Skeletal Radio1 20:561-83, 1991 Cervilla V et al: Case report 596. Parosteal osteoma of the acetabulum. Skeletal Radiol 19:135-7, 1990 Sadry F et al: The potential aggressiveness of sinus osteomas. A report of two cases. Skeletal Radiol 17:427-30, 1988 Jacobson HG: Dense bone - too much bone: Radiological considerations and differential diagnosis. Part I. Skeletal Radiol 13:l-20, 1985 Jacobson HG: Dense bone - too much bone: Radiological considerations and differential diagnosis. Part 11. Skeletal Radiol 13:97-113, 1985 Stern PJ et al: Giant metacarpal osteoma. A case report. J Bone Joint Surg 67A:487-9, 1985 Dolan K et al: Gardner's syndrome. A model for correlative radiology. Radium Ther Nucl Med 119:359-64, 1973
OSTEOMA
Typical (Left) An teroposterior radiography shows round sclerotic lesion in the left frontal sinus. (Right) Lateral radiography shows well-defined sclerotic mass in the frontal sinus.
Variant (Left) An teroposterior radiography of the pelvis shows round, circumscribed, sclerotic lesion in the right iliac bone. (Right) Axial NECT shows round, well-defined sclerotic lesion in the right iliac bone, adjacent to the right Sl joint. There is no osseous destruction or periosteal reaction.
Typical (Left) Axial T2WI MR shows a round area of signal void in the right iliac bone, consistent with sclerosis. Note absence of bone marrow edema or cortical disruption. (Right) Coronal graphic shows round ivory mass attached to the cortex of the proximal phalanx.
OSTEOlD OSTEOMA
Coronal graphic shows intracortical osteoid osteoma in the femoral neck. Nidus (in red) and surrounding sclerosis are shown.
Axial NECT shows well-defined radiolucent nidus with surrounding sclerosis involving the subtrochanteric femur.
o Subperiosteal: Rare Size: Nidus: < 1.5-2 cm Morphology: Lucent nidus with marked surrounding periosteal reaction
Abbreviations and Synonyms Osteoid Osteoma ( 0 0 )
Radiographic Findings
Definitions
Radiography o Cortical lesion Radiolucent central nidus < 1.5 cm with surrounding dense sclerosis = Periosteal reaction may be present o Cancellous/intraarticular lesion Mild reactive sclerosis Associated periostitis away from lesion Joint effusion, synovitis o Subperiosteal lesion = Round soft tissue mass adjacent to cortex Surrounding reactive changes usually absent o Limb overgrowth in children if located near growth plate
.
Benign lesion characterized by less than 2 cm nidus of osteoid/woven bone in vascular tissue
. .
General Features
6
Best diagnostic clue: Well-defined lytic to sclerotic lesion with surrounding sclerosis Location o Metaphysis/diaphysis of long bones: 65-80% Femur, tibia: 53-60% o Phalanges of hands and feet: 21% o Spine: 9% Posterior elements: 90% Vertebral body: 10% o Extremely rare in skull and facial bones o Cortical: 70-80% Long bone diaphysis o Cancellous: 25% Femoral neck, hands and feet Often intraarticular
. . . ..
AP Radiography
Cor T l Wl MR
.
CT Findings NECT o Small, well-defined, round/oval nidus surrounded by sclerosis o Use thin sections (1-2 mm)
M R Findings TlWI: Nidus isointense to muscle
Ax NECT
Ax NECT
Ax NECT
OSTEOlD OSTEOMA Key Facts Imaging Findings
Clinical Issues
Best diagnostic clue: Well-defined lytic to sclerotic lesion with surrounding sclerosis
Most common signs/symptoms: Local pain worse at night, decreased by salicylates in less than 30 minutes (75%)
Top Differential Diagnoses
Local swelling and point tenderness Spinal involvement: Painful scoliosis with concavity of curvature toward side of lesion No malignant potential No growth progression Can regress spontaneously Surgical en-block resection of nidus curative if nidus completely removed Percutaneous removal (CT guided) Percutaneous radio-frequency ablation (CT guided) Medical management: Nonsteroidal antiinflammatory drugs
Osteomyelitis (Brodie's Abscess) Enostosis (Bone Island) Stress Fracture Osteoblastoma Osteoma
Pathology Nidus has limited growth potential 4% of primary bone tumors 12% of benign bone tumors
Cortical destruction
T2WI: Radiolucent areas of nidus: Intermediate to high signal intensity T1 C+ o Dynamic imaging: Peak enhancement during arterial phase, early partial washout Slower, progressive enhancement of adjacent bone marrow Low signal on all pulse sequences if nidus is completely mineralized May have extensive bone marrow edema which can obscure nidus Can show synovitis and joint effusion with intraarticular lesion
Enostosis (Bone Island) No increased activity on bone scan Thorny radiations Low signal on T2WI MR
Stress Fracture Radiolucency more linear and perpendicular to cortex (rather than parallel)
Osteoblastoma Larger (> 2-2.5 cm) Progresses, no regression
Ultrasonographic Findings
Osteoma
Color Doppler o Increased vascularity of nidus o Can be used to localize lesion for biopsy
Cold on bone scan No periosteal reaction No nidus
Angiographic Findings Intense blush of nidus during early arterial phase that persists during venous phase
General Features
Nuclear Medicine Findings Bone Scan o Increased uptake o Double density sign: Small focus of increased activity (nidus) surrounded by larger area of less intense activity (reactive sclerosis) PET Can be used to detect osteoid osteoma in anatomic complex areas (posterior elements of spine)
Imaging Recommendations Best imaging tool: CT study of choice for identifying nidus Protocol advice: MRI in difficult cases to evaluate for joint effusion, synovitis
1 DIFFERENTIAL DIAGNOSIS Osteomyelitis (Brodie's Abscess) Linear, serpentine tract, extends away from abscess cavity
1
General path comments o Benign tumor consisting of osteoblastic mass (nidus) surrounded by zone of reactive sclerosis Zone of sclerosis not integral part of tumor, represents secondary reversible change Nidus has limited growth potential o Prostaglandin E2 elevated 100-1000 times within nidus (likely cause of pain and vasodilatation) o Tumor can regress spontaneously, possibly secondary to infarction Etiology o Unknown: May be inflammatory, traumatic, vascular, viral o Benign, highly vascular osteoblastic proliferation Epidemiology o 4% of primary bone tumors o 12% of benign bone tumors
Gross Pathologic & Surgical Features Nidus: Redltan mass of gritty osseous tissue
OSTEOlD OSTEOMA Easily separated from surrounding reactive bone Less than 1 cm in greatest dimension
Microscopic Features Nidus composed of osteoid tissue or mineralized, immature, woven bone Osteoid matrix and bone form trabeculae o Surrounded by highly vascular, fibrous stroma with osteoblastic and osteoclastic activity Sclerosis surrounding lesion composed of dense bone Adjacent synovium may be thickened and infiltrated with inflammatory cells and lymphoid follicles o Lymphofollicular synovitis; can simulate rheumatoid arthritis
o Under general or spinal anesthesia Percutaneous thermocoagulation (CT guided) Medical management: Nonsteroidal antiinflammatory drugs o Can induce permanent relief of symptoms and regression of nidus
Consider Consider medical management as initial treatment since lesions can regress spontaneously Image guided therapy often more successful than surgical resection
Staging, Grading or Classification Criteria Surgical staging system for benign musculoskeletal tumors o Stage 1: Latent o Stage 2: Active o Stage 3: Aggressive
Presentation * Most common signs/symptoms: Local pain worse at night, decreased by salicylates in less than 30 minutes (75%)
n
Clinical profile o Local swelling and point tenderness o Pain exacerbated by alcohol o Average duration of symptoms: 3 years o Spinal involvement: Painful scoliosis with concavity of curvature toward side of lesion Idiopathic scoliosis: Never painful Scoliosis improves/resolves if nidus is resected within 15 months after diagnosis Neurologic abnormalities in 6% of patients with spine involvement o Intraarticular lesion: Symptoms of arthritis o Elevated urinary excretion of major prostacyclin metabolite (2,3-dinor-6-keto-PGF 1 a) Returns to normal after removal of nidus
Demographics Age: 10-35 years Gender: M:F = 2-3:l Ethnicity: Rare in African Americans
Natural History & Prognosis No malignant potential No growth progression Can regress spontaneously Regression of active stage 2 lesion to latent stage 1 lesion: 3 years (average)
Treatment Surgical en-block resection of nidus curative if nidus completely removed o Recurrence due to incomplete resection of nidus o Tetracycline and radionuclide labeling for lesion location at surgery Percutaneous removal (CT guided) Percutaneous radio-frequency ablation (CT guided)
1 SELECTED REFERENCES
1
Liu PT et al: Imaging of osteoid osteoma with dynamic gadolinium-enhanced MR imaging. Radiology 227:691-700, 2003 2. DeFriend DE et al: Percutaneous laser photocoagulation of osteoid osteoma under CT guidance. Clin Radiol 58:222-6, 2003 3. Dorfman HD et al: Bone tumors. 1st ed. St. Louis MO, Mosby, 85-103, 1998 4. Greenspan A et al: Differential diagnosis of tumors and tumor-like lesions of bones and joints. 1st ed. Philadelphia PA, Lippencott-Raven, 36-46, 1998 5. Assoun J et al: Osteoid osteoma: MR imaging versus CT. Radiology 191:217-23, 1994 6. Bilchik T et al: Osteoid osteoma: The role of radionuclide bone imaging, conventional radiography and computed tomography in its management. J Nucl Med 33:269-71, 1992 7. Cassar-Pullicino VN et al: Intra-articular osteoid osteoma. Clin Radiol 45:153-60, 1992 8. Greco F et al: Prostaglandins in osteoid osteoma. Int Orthop 15:35-7, 1991 9. Azouz EM et al: Osteoid osteoma and osteoblastoma of the spine in children. Report of 22 cases with brief literature review. Pediatr Radiol 16:25-31, 1986 10. Cohen MD et al: Osteoid osteoma: 95 cases and a review of the literature. Semin Arthritis Rheum 12:265-81, 1983 1.
OSTEOID OSTEOMA
I IMAGE GALLERY (Left) Anteroposterior radiography shows radiolucent nidus with surrounding sclerosis in the right femoral intertrochanteric region. (Right) Axial NECT shows lucent intracortical nidus with surrounding sclerosis in the proximal femur.
(Left) Axial NECT shows low attenuation nidus with central calcifications in the right pedicle of C4 extending into the lamina. (Right) Axial NECT shows radiolucent nidus with central sclerosis and surrounding periosteal reaction in the femoral cortex.
Other (Left) Lateral radiography shows radiolucent nidus with surrounding periosteal reaction in the proximal femoral metaphysis. (Right) Coronal gross pathology shows round, sharply demarcated, reddish nidus, surrounded by sclerotic bone.
OSTEOBLASTOMA
Axial graphic shows osteoblastoma (in red) involving the posterior elements. Central calcifications are shown in white.
Abbreviations and Synonyms Giant osteoid osteoma, osteogenic fibroma
Definitions Benign osseous tumor, characterized by production of osteoid and woven bone
General Features Best diagnostic clue: Expansile, circumscribed lytic lesion involving extremities and posterior elements of spine Location o Spine: 40% Posterior elements: > 60% Posterior elements with extension into vertebral body: 25% Vertebral body: 15% o Long bones: 30% o Hands and feet: 15% o Skull and face (jaw): 15% o Pelvis: 5% o Diaphysis: 58% o Metaphysis: 42%
.
Axial NECT shows an expansile circumscribed lytic lesion with scalloped margins involving the vertebral body and posterior elements.
o Eccentric: 46% o Intracortical: 42% o Periosteal: Extremely rare Size: Greater than 1.5 - 2 cm Morphology: Expansile lytic lesion
Radiographic Findings Radiography o Expansile, circumscribed, lytic lesion o Reactive sclerosis: 60% 0 Variable central calcification and matrix 0 Can rapidly increase in size o Cortical expansion: 75-94% 0 Cortical destruction: 20-22% 0 Radiolucent nidus > 1.5 - 2 cm o Surrounding sclerosis, periostitis: 50% o Secondary aneurysmal bone cyst (ABC) component: 16% o Can have adjacent soft tissue mass
CT Findings NECT 0 Expansile lytic lesion with or without matrix mineralization 0 Adjacent periosteal reaction, sclerosis, cortical erosions o To evaluate mineralized matrix and nidus o Can show soft tissue mass
mUmm -
DDx: Osteoblastoma Osteoid Osteoma
*
Osteosarcoma
/
:;... Ax NECT
AP Radiography
Cor T 1 Wl MR
A P Rad~ography
-
OSTEOBLASTOMA Key Facts Imaging Findings Best diagnostic clue: Expansile, circumscribed lytic lesion involving extremities and posterior elements of spine
Top Differential Diagnoses Osteoid Osteoma Osteosarcoma Aneurysmal Bone Cyst (ABC) Osteomyelitis (Bone abscess) Chondromyxoid Fibroma
Pathology < 1%of all primary bone tumors 3% of all benign bone tumors Aggressive osteoblastoma: Epithelioid osteoblasts
Clinical Issues Dull, localized pain of insidious onset Localized swelling, tenderness, decreased range of motion Painful scoliosis with vertebral involvement Benign neoplasm, no malignant transformation Recurrence after resection: 10-25% Aggressive osteoblastoma: Recurrence in 50% Marginal en bloc excision of symptomatic lesions Radiation and chemotherapy in cases of aggressive and surgically unresectable lesions
Diagnostic Checklist Look for calcified matrix in spinal osteoblastomas to differentiate from ABC
--
o Aggressive osteoblastoma disrupts cortex and has
soft-tissue component
MR Findings TlWI o Low-intermediate signal intensity o Foci of signal void Corresponding to calcifications T2WI o Intermediate-high signal intensity 0 Foci of signal void Corresponding to calcifications T1 C+: Enhancement of tumor and surrounding inflammatory reaction To evaluate bone and soft tissue extent, adjacent edema May simulate malignant process due to extensive inflammatory response
Angiographic Findings Hypervascularity
Nuclear Medicine Findings Bone Scan: Intense uptake of radiotracer
Imaging Recommendations Best imaging tool: Radiographs, CT Protocol advice: CT imaging modality of choice to demonstrate exact size and areas of ossification within lesion
Aneurysmal Bone Cyst (ABC) Fluid-fluid levels No matrix calcification Osteoblastoma often has secondary ABC component
Osteomyelitis (Bone abscess) Periosteal reaction Serpentine tract Sequestrum
Chondromyxoid Fibroma Expansile lytic lesion with sclerotic margin Matrix calcification rare Rare in spine No periosteal reaction
General Features General path comments o Lesion size > 1.5 cm o Smaller lesions classified as osteoid osteoma Etiology o Unknown o Histologically similar to osteoid osteomas, producing osteoid and primitive woven bone Epidemiology o < 1%of all primary bone tumors o 3% of all benign bone tumors
Gross Pathologic & Surgical Features Osteoid Osteoma Smaller (< 2 cm) Predilection for axial skeleton Can regress spontaneously o Osteoblastoma tends to progress
Osteosarcoma Cortical destruction Mineralized matrix Soft tissue component
Circumscribed mass, often surrounded by shell of cortical bone or periosteum Sharp interface between the lesion and cancellous bone o Often marked by a thin rim of reactive bone Nidus: 2-10 cm, friable, deep red (high vascularity) o Well-demarcated at periphery Prominent cystic spaces may indicate secondary ABC formation
p P
OSTEOBLASTOMA Microscopic Features Similar to osteoid osteoma, greater osteoid production and vascularity Numerous, multinucleated giant cells (osteoclasts) Very vascular connective tissue stroma with interconnecting trabecular bone No cartilage Aggressive osteoblastoma: Epithelioid osteoblasts
Staging, Grading or Classification Criteria Surgical staging system for benign musculoskeletal tumors o Stage 1: Latent o Stage 2: Active o Stage 3: Aggressive
I DIAGNOSTIC CHECKLIST Consider
Consult orthopedic surgeon before biopsy of presumed o~teoblastom~ If histology reveals osteosarcoma, biopsy-induced contaminated needle tract can mandate different surgical approach
Image Interpretation Pearls Look for calcified matrix in spinal osteoblastomas to differentiate from ABC
I
1.
2.
Presentation Most common signs/symptoms o Dull, localized pain of insidious onset o Pain rarely interferes with sleep Clinical profile o Localized swelling, tenderness, decreased range of motion o Response to salicylates in 7% o Painful scoliosis with vertebral involvement o Pathologic fractures rare o Can cause tumor associated osteomalacia o Toxic osteoblastoma: Extremely rare (two cases reported) Severe systemic manifestations: Fever, weight loss, anemia, clubbing, hyperdynamic circulation, systemic periostitis
3. 4. 5. 6. 7. 8. 9.
Demographics Age: 5-45 years, peak: 2nd decade Gender: M:F = 2-3:l Ethnicitv: No racial ~redilection
Natural History & Prognosis 12
Benign neoplasm, no malignant transformation cases of malignant degeneration reported o These lesions likely represented undiagnosed osteosarcoma Presents as active, slow growing stage 2 lesion Can have foci of aggressive stage 3 lesion (prone to ABC formation, pathologic fracture) Recurrence after resection: 10-25% o Aggressive osteoblastoma can recur after excision of conventional osteoblastorna Aggressive osteoblastoma: Recurrence in 50%
Treatment Marginal en bloc excision of symptomatic lesions o Recurrence of stage 3 lesions: 30-50% Curettage with bone graft Radiation and chemotherapy in cases of aggressive and surgically unresectable lesions
-
10.
11. 12. 13. 14.
I
Ozaki T et al: Osteoid osteoma and osteoblastoma of the spine: Experience with 22 patients. Clin Orthop 397:394-402, 2002 Dale S et al: Severe toxic osteoblastoma of the humerus associated with diffuse periostitis of multiple bones. Skeletal Radiol 30:464-8, 2001 Sulzbacher I et al: Periosteal osteoblastoma: A case report and a review of the literature. Pathol Int 50:667-71, 2000 Papagelopoulos PJ etal: Clinicopathologic features, diagnosis, and treatment of osteoblastoma. Orthopedics 22:244-7, 1999 Shaikh MI et al: Spinal osteoblastoma: CT and MR imaging with pathological correlation. Skeletal Radiol 28:33-40, 1999 Dorfman HD et al: Bone tumors. 1st edition. St. Louis MO, Mosby, 103-17, 1998 Greenspan A: Differential diagnosis of tumors and tumor-like lesions of bones and joints. 1st ed. Philadelphia PA, Lippincott-Raven, 46-59, 1998 Della Rocca C et al: Osteoblastoma: Varied histological presentations with a benign clinical course. An analysis of 55 cases. Am J Surg Pathol. 20:841-50, 1996 Crim JR et al: Widespread inflammatory response to osteoblastoma: The flare phenomenon. Radiology 177:835-6, 1990 Kroon HM et al: Osteoblastoma: Clinical and radiologic findings in 98 new cases. Radiology. 175783-90, 1990 Gitelis S et al: Osteoid osteoma and osteoblastoma. Orthop Clin North Am 20:313-25, 1989 Azouz EM et al: Osteoid osteoma and osteoblastoma of the spine in children. Report of 22 cases with brief literature review. Pediatr Radiol 16:25-31, 1986 Kenan S et al: Aggressive osteoblastoma. A case report and review of the literature. Clin Orthop 195294-8, 1985 DeSouza DL et al: Osteoid osteoma - osteoblastoma. Cancer 33:1075-81, 1974
OSTEOBLASTOMA IMAGE GALLERY Typical (Left) Anteroposterior radiography shows a circumscribed lesion with central ossifications involving the inferior pubic ramus. (Right) Axial NECT shows a lytic expansile lesion with central ossification of the right iliac bone. Note cortical thinning at the posterior aspect of the lesion.
Typical (Left) An teropos terior radiography shows radiolucent lesion of the femoral diaphysis surrounded by sclerotic bone. (Right) Axial NECT (same patient) shows a well defined lytic lesion with surrounding sclerosis involving the femoral diaphysis.
Tvoical (Left) Sagittal FS T2 FSE MR shows a lesion of high signal in the femoral diaphysis. Note surrounding bone marrow edema. (Right) Sagittal T l Wl MR shows eccentric lesion of low signal arising from the posterior calcaneus. There is cortical destruction and extension of the tumor into the adjacent soft tissues.
OSTEOSARCOMA
Coronal graphic shows osteosarcoma in the distal femur.
Lateral radiography of the femur shows medullary and cortical bone destruction with associated periosteal reaction of sunburst type. Soft tissue extension with new bone formation is present.
o Conventional osteosarcoma: 85%
Abbreviations and Synonyms Osteogenic sarcoma (OGS)
Definitions Malignant tumor with ability to produce osteoid directly from neoplastic cells
FMAGING FINDINGS General Features
I *I
Best diagnostic clue: Bone destruction with associated tumor bone formation and aggressive periosteal reaction Location o Around knee: 55% o Metaphyses of long tubular bones: 80% o Extension into epiphysis: 75% o Flat bones, vertebral bodies: 20% o In older patients (> 50 years), axial skeleton and flat bones: 40% Size: 5-10 cm Morphology: Destructive lesion with osteoid formation
Poorly-defined, intramedullary mass, extends through cortex Moth-eaten bone destruction Aggressive periosteal reaction: Codman triangle, sunburst pattern Indistinct borders with wide zone of transition Soft tissue mass +I-tumor calcification o Telangiectatic osteosarcoma: < 5% Was thought to have worst prognosis, but prognosis is likely similar to conventional OGS Purely lytic lesion Cystic cavities filled with blood/necrosis Fluid levels (may mimic aneurysmal bone cyst ABC) o Multicentric osteosarcoma: 1% Synchronous osteoblastic osteosarcoma at multiple sites (usually symmetric) Exclusively in children (5-10 years) Extremely poor prognosis o Parosteal osteosarcoma: 3% Low grade osteosarcoma in older age group (20 50 years) Posterior distal femur Attached to underlying cortex at origin o Periosteal osteosarcoma: 1% Intermediate-grade osteosarcoma Most common diaphyseal
unmmr
Radiographic Findings Radiography
DDx: Osteosarcoma
A P Radiography
AP Radiography
AP Rad~ography
Ax T2WI MR
Lat Radiography
OSTEOSARCOMA Key Facts Imaging Findings Best diagnostic clue: Bone destruction with associated tumor bone formation and aggressive periosteal reaction
Top Differential Diagnoses Ewing Sarcoma Osteomyelitis Chondrosarcoma Lymphoma Aneurysmal Bone Cyst (ABC) Myositis Ossificans
-
Pathology Most common malignant primary bone tumor in young adults and children 20% of all primary bone malignancies
No medullary involvement Cortical thickening o Gnathic osteosarcoma: 5-9% Involvement of mandible, maxilla rn Sclerotic, lytic, mixed Periosteal reaction Soft tissue extension o Secondary osteosarcoma: 5% Arises in association with preexisting lesion of bone such as Paget disease, prior radiation, bone infarct
CT Findings NECT o Helpful in imaging surface OGS o Can show complex anatomy in gnathic OGS CECT o Enhancement of solid components Helpful in differentiating telangiectatic OGS from ABC Telangiectatic OGS: Nodular peripheral enhancement
MR Findings TlWI o Low signal intensity: Mineralized tumor o Low-intermediate signal intensity: Solid, nonmineralized tumor T2WI o Low signal intensity: Mineralized tumor o High signal intensity: Nonmineralized tumor, soft tissue mass STIR: Helpful in imaging entire bone to detect skip lesions, multicentric OGS
Nuclear Medicine Findings Bone Scan o Increased uptake 0 For staging, detection of skip lesions, metastases PET o Useful in evaluating tumor recurrence o Helpful in imaging patients with protheses
Clinical Issues Progressive pain Soft tissue mass, swelling Pathologic fracture Pulmonary metastases common, can cause pneumothorax (calcifying) 5-year survival: 41% 5-year survival in patients with resectable tumor and without metastases: 60-70% Surgical resection with wide margins Adjuvant and neoadjuvant chemotherapy
Diagnostic Checklist Always image adjacent joints and use bone scan to detect skip lesions, metastases, multifocal OGS
Imaging Recommendations Best imaging tool: Radiographs first imaging modality to detect bone destruction and periosteal reaction Protocol advice o Radiographs to detect bone destruction and periosteal reaction o MR to determine Extent of tumor within bone marrow and soft tissue Relationship to vessels and nerves 0 Bone scan to detect skip lesions o MRI should be performed prior to biopsy
Ewing Sarcoma Diaphysis of long bone Large soft tissue mass
Osteomyelitis No bone formation Sequestrum
Chondrosarcoma Ring and arc calcifications Thickened cortex, endosteal scalloping
Lymphoma Moth-eaten lytic bone destruction No periosteal new bone formation
Aneurysmal Bone Cyst (ABC) Can look similar to telangiectatic OGS Purely lytic No periosteal reaction
Myositis Ossificans Bone formation in periphery, zonal phenomenon o Surface OGS: Central bone formation Cleft between osseous mass and cortex
OSTEOSARCOMA
1 PATHOLOGY General Features General path comments o Malignant tumor with ability to produce osteoid directly from neoplastic cells o Frequency of tumor occurrence corresponds to greatest growth rate during adolescence Genetics o Overexpression of P-glycogen in OGS cells with propensity for metastases and treatment failure o Alterations of Rb genes in OGS that develops in association with retinoblastoma Etiology o Majority of OGS of unknown etiology = primary OGS o Secondary to predisposing factors (Paget disease, bone infarct, radiation) = secondary OGS Epidemiology o Most common malignant primary bone tumor in young adults and children o 20% of all primary bone malignancies
Gross Pathologic & Surgical Features Heterogeneous mass with ossified and non-ossified components Ossified areas: Yellow-white, firm, may be as hard as cortical bone Less ossified areas: Soft, tan, with foci of hemorrhage and necrosis Penetration of cortex with often large extraosseous tumor mass Periosteal reaction: Lamellae of new bone at periphery of lesion
Microscopic Features Highly pleomorphic, spindle-shaped tumor cells producing different forms of osteoid Three histologic subtypes depending on sarcomatous component o Osteoblastic, chondroblastic, fibroblastic OGS
Staging, Grading or Classification Criteria Surgical staging for malignant musculoskeletal tumors o Stage Ia: Low grade, intracompartmental o Stage Ib: Low grade, extracompartmental o Stage IIa: High grade, intracompartmental o Stage IIb: High grade, extracompartmental o Stage IIIa: Low or high grade, intracompartmental, metastases o Stage IIIb: Low or high grade, extracompartmental, metastases
Presentation Most common signs/symptoms o Progressive pain o Soft tissue mass, swelling Clinical profile o Pathologic fracture o Pulmonary metastases common, can cause pneumothorax (calcifying)
o Increased serum alkaline phosphatase
o Patients with OGS often taller than their peers
Increased levels of somatomedin
Demographics Age o Bimodal age distribution First peak: 2nd-3rd decade, corresponds to peak of skeletal growth Second peak: > 6th decade Gender: M:F = 1.3-1.6:l Ethnicity: Slightly more common in African Americans
Natural History & Prognosis Very aggressive tumor Prognosis depends on OGS type, size, location, resectability, presence of metastases o Central OGS worse prognosis than juxtacortical type 5-year survival: 41% 5-year survival in patients with resectable tumor and without metastases: 60-70%
Treatment Surgical resection with wide margins Adjuvant and neoadjuvant chemotherapy Amputations may be necessary Biopsies must be planned with future tumor excision in mind
Consider Always consult orthopedic surgeon before biopsy of possible OGS
Image Interpretation Pearls Always image adjacent joints and use bone scan to detect skip lesions, metastases, multifocal OGS
I
Goorin AM et al: Presurgical chemotherapy compared with immediate surgery and adjuvant chemotherapy for nonmetastatic osteosarcoma: Pediatric Oncology Group Study POG-8651. J Clin Oncol21:1574-80, 2003 Bredella MA et al: Value of FDG PET in conjunction with MR imaging for evaluating therapy response in patients with musculoskeletal sarcomas. Am J Roentgenol 179:1145-50, 2002 Dorfman HD et al: Bone tumors. 1st ed. St. Louis MO, Mosby, 128-252, 1998 Onikul E et al: Accuracy of MR imaging for estimating intraosseous extent of osteosarcomas. Am J Roentgenol 167:1211-5, 1996 Baldini N et al: Expression of P-glycoprotein in high grade osteosarcoma in relation to clinical outcome. N Engl J Med 333:1380-5, 1995 Dorfman HD et al: Bone cancers. Cancer 75:203-10, 1995 Rosenberg ZS et al: Osteosarcoma: Subtle, rare, and misleading plain film features. Am J Roentgenol 165:1209-14, 1995 Bloem JL et al: Osseous lesions. Radio1 Clin North Am 31:261-78, 1993
OSTEOSARCOMA IMAGE GALLERY Typical ( L e f ) Axial NECT shows densely mineralized tumor in the medullary canal with cortical destruction and mineralized soft tissue component. (Right) Axial T1 WI MR shows low signal intensity in the medullary cavity, corresponding to mineralized portions of osteosarcoma. Cortical disruption and extension into the posterior soft tissues is noted.
Variant ( L e f ) Lateral radiography shows lobulated sclerotic mass arising from the metaphyseal surface of the posterior distal femur, consistent with parosteal osteosarcoma. (Right) Axial FS T2 FSE MR shows abnormal bone marrow SI and large extraosseous soft tissue component with fluid-fluid levels, consistent with telangiectatic osteosarcoma.
Other ( L e f ) Sagittal T l Wl MR shows heterogeneous tumor involving the distal femoral rneta-diaphysis. Areas of low signal correspond to mineralized tumor, nonmineralized areas are of intermediate signal. (Right) Coronal gross pathology, section shows yellow-brown tumor with hemorrhagic areas in the femoral meta-diaphysis with cortical destruction and extraosseous extension.
ENCHONDROMA
Coronal graphic shows enchondroma (in blue) involving the proximal 2nd phalanx.
Lateral radiography shows radiolucent lesion in the distal femoral metaphysis containing chondroid matrix (rings and arcs calcifications).
Morphology: Localized, radiolucent lesion with punctate or stippled calcification
Abbreviations and Synonyms
Radiographic Findings
Chondroma
Definitions Common benign intramedullary neoplasm composed of mature cartilage
General Features
18
Best diagnostic clue: Well-defined lytic lesion with chondroid matrix (rings and arcs calcifications) Location o Any bone formed by enchondral ossification can be involved o Short, tubular bones of hands and feet: 60% Most common tumor of phalanges of the hand o Long tubular bones: 2545% Metaphysis, proximal/distal end of diaphysis Femur: 17% Humerus: 7% o Pelvis: < 3% o Spine, scapula, ribs: rare Size: < 3 cm
Radiography o Short, tubular bones: Radiolucent lesion o Long bones: Chondroid calcification ("rings and arcs," "popcorn" type) o Scalloped inner cortical margins o Expansion of cortex without cortical break o No periosteal reaction or soft tissue mass Cortical break, soft tissue mass suggest malignant transformation o Progressive calcification Focal loss of calcification suggests malignant transformation o Rapid growth suggestive of malignant transformation
CT Findings NECT o Helpful in detecting chondroid matrix o Intact cortex
MR Findings
mllM
TlWI o Low to intermediate signal intensity o Calcification: Signal void T2WI
DDx: Enchondroma Bone Infarct
Chondrosarcoma
Cor T l Wl MR
Lat Radrography
AP Radrography
-++-
Sag T2WI MR
ENCHONDROMA Key Facts Imaging Findings
Clinical Issues
Best diagnostic clue: Well-defined lytic lesion with chondroid matrix (rings and arcs calcifications) Best imaging tool: Radiographs usually diagnostic Protocol advice: CT best imaging modality to detect chondroid matrix
Usually asymptomatic Painless swelling Pain, unexplained by injury or fracture, should raise suspicion of malignancy Heal after curettage and bone grafting Recurrence of incompletely curetted lesions in short bones of hands Recurrence of long bone lesions suggests malignancy Asymptomatic lesions require no treatment Painful or worrisome lesions require curettage and careful microscopic evaluation
Top Differential Diagnoses Bone Infarct Chondrosarcoma Epidermoid Inclusion Cyst Juxtacortical Chondroma
Pathology
Diagnostic Checklist
Second most common benign bone tumor 2-10% of all bone tumors
In absence of a fracture, painful enchondroma is considered malignant until proven otherwise
o High signal intensity o Calcification: Signal void T1 C+: No significant enhancement Helpful in evaluating exact size and extent of lesion
o Develop from abnormal zone of dysplastic
chondrocytes in growth plate Fail to undergo normal enchondral ossification Epidemiology o Second most common benign bone tumor o 12-24% of benign bone tumors o 2-10% of all bone tumors Associated abnormalities o Ollier disease: Non-hereditary rare developmental bone dysplasia Multiple enchondromas Predilection for appendicular skeleton; involvement of trunk bones in severe cases Mostly unilateral monomelic distribution Growth disparity with leglarm shortening: Affected bones grow more slowly Sarcomatous transformation: 25-30% Osteosarcoma (young adults), chondrosarcoma/fibrosarcoma (older patients) o Maffucci syndrome: Non-hereditary rare disorder characterized by enchondromatosis and soft tissue hemangiomas Multiple enchondromas and multiple soft tissue cavernous hemangiomas Unilateral involvement of hands and feet Very large enchondromas, projecting into soft tissue Phleboliths within hemangiomas Malignant transformation of enchondroma into chondrosarcoma: 15-25% Transformation of soft tissue hemangioma into vascular sarcoma: 3-5% Associated ovarian and pancreatic malignancies o Metachondromatosis: Autosomal-dominant Multiple enchondromas and osteochondromas Transformation into chondrosarcomas: 50%
Nuclear Medicine Findings Bone Scan: No increased uptake unless fractured
Imaging Recommendations Best imaging tool: Radiographs usually diagnostic Protocol advice: CT best imaging modality to detect chondroid matrix
Bone Infarct Well-defined, densely sclerotic, serpiginous borders No endosteal scalloping
Chondrosarcoma Clinical findings (primarily pain) better indicator of chondrosarcoma than radiographic findings Periosteal reaction, soft-tissue mass Size: > 4 cm suggests malignancy
Epidermoid Inclusion Cyst Phalangeal tuft History of trauma
JuxtacorticalChondroma Involves surface of bone Can erode underlying cortex Periosteal new bone formation
General Features path Occurs in that enchondral ossification (not skull) Genetics: Mutant parathyroid hormone related protein (PTHIPTHrP) type I receptor in enchondromatosis Etiology
Gross Pathologic & Surgical Features Most enchondromas treated by curettage; resected specimens rare of confluent lobules of mature hyaline cartilage
.
ENCHONDROMA Tumor fragments consist of blue-white, glistering hyaline cartilage, mixed with yellow, calcified foci
Microscopic Features Lobules of mature hyaline cartilage with translucent intercellular matrix (little collagen) Tumor cells located in lacunae Lobules separated by normal bone marrow spaces Calcification common (correspond to matrix calcifications/enchondral ossification) Small bones of hands and feet can contain foci of myxoid tissue o Prominent myxoid changes suspicious of malignancy Immunohistochemistry: Positive for S-100 protein and vimentin
Presentation Most common signs/symptoms o Usually asymptomatic o Painless swelling Clinical profile o May present as pathologic fracture o Patient should be instructed to report symptoms: = Pain, unexplained by injury or fracture, should raise suspicion of malignancy
Demographics Age: 15-40 years; peak: 10-30 years Gender: M:F = 1:l Ethnicity: No racial predilection
Natural History & Prognosis Heal after curettage and bone grafting Recurrence of incompletely curetted lesions in short bones of hands Recurrence of long bone lesions suggests malignancy Malignant transformation of long bone enchondroma into chondrosarcoma rare Malignant transformation in Ollier disease, Mafucci syndrome, metachondromatosis: 15-50%
Treatment Asymptomatic lesions require no treatment Painful or worrisome lesions require curettage and careful microscopic evaluation o Important to evaluate entire lesion o ~ i m i t e dsampling may miss malignant foci Suspicious lesions of trunk and flat bones require wide local excision o Reduces tissue contamination and recurrence if lesion turns out to be malignant Curettage and bone grafting of large lesions
Consider Presencelabsence of pain In absence of a fracture, painful enchondroma is considered malignant until proven otherwise
Image Interpretation Pearls Focal lucency in densely calcified enchondromas requires biopsy to exclude malignant transformation
Hopyan S et al: A mutant M'HIPTHrP type I receptor in enchondromatosis. Nat Genet 30:306-10, 2002 Unni KK: Cartilaginous lesions of bone. J Orthop Sci 6:457-72, 2001 Dorfman HD et al: Bone tumors. 1st ed. St. Louis MO, Mosby, 253-96, 1998 Greenspan A et al: Differential diagnosis of tumors and tumor-like lesions of bones and joints. 1st ed. Philadelphia PA, Lippincott-Raven, 125-46, 1998 Murphey MD et al: Enchondroma versus chondrosarcoma in the appendicular skeleton: Differentiating features. Radiographics 18:1213-37, 1998 Geirnaerdt MJ et al: Usefulness of radiography in differentiating enchondroma from grade 1 chondrosarcoma. Am J Roentgen01 169:1097-104, 1997 Geirnaerdt MJ et al: Cartilaginous tumors: Correlation of gadolinium-enhanced MR imaging and histopathologic findings. Radiology 1865313-7, 1993 Aoki J et al: MR of enchondroma and chondrosarcoma: Rings and arcs of Gd-DTPA enhancement. J Comput Assist Tomogr 15:1011-6, 1991 Greenspan A: Tumors of cartilage origin. Orthop Clin North Am 20:347-66, 1989 Resnik CS et al: Case report 522. Concurrent adjacent osteochondroma and enchondroma. Skeletal Radio1 18:66-9, 1989 Unger EC et al: MR imaging of Maffucci syndrome. Am J Roentgen01 150:351-3, 1988 Liu J e al: Bone sarcomas associated with Ollier's disease. Cancer 59:1376-85, 1987 13. Goodman SB et al: Ollier's disease with multiple sarcomatous transformations. Hum Path01 1591-3, 1984 14. Nakamura Y et al: S-100 protein in tumors of cartilage and bone: An immunohistochemical studv. Cancer 52:1820-4. 1983
ENCHONDROMA IMAGE GALLERY (Left) Axial NECT shows calcified lesion with chondroid matrix involving the proximal humerus. (Right) Anteroposterior radiography show expansile purely lytic lesion at the base of the proximal phalanx of the 4th digit. The radiolucent appearance is typical for enchondromas of the hands.
(Left) Coronal 71Wl MR shows circumscribed, lobulated lesion of intermediate SI in the distal femoral metaphysis. (Right) Coronal FS T2 FSE MR shows circumscribed, lobulated femoral lesion of high signal. Areas of high signal represent cartilaginous matrix.
Variant (Left) Anteroposterior radiography shows multiple large lobulated cartilaginous masses with associated bone deformity in a patient with Ollier disease. (Right) Anteroposterior radiography in a patient with Maffucci syndrome shows multiple enchondromas and associated phleboliths in soft tissue hemangiomas.
OSTEOCHONDROMA -
Coronal graphic shows pedunculated osteochondroma arising from the humeral rnetaphysis. Continuity with host bone is shown.
Lateral radiography shows heavily mineralized pedunculated osteochondroma arising from the distal femoral metaphysis.
Radiographic Findings Abbreviations and Synonyms Exostosis, osteocartilaginous exostosis
Definitions Developmental osseous anomaly resulting in exophytic outgrowth on surface of bone
.
1 IMAGING FINDINGS General Features Best diagnostic clue: Exostosis with continuity of bone cortex and medullary marrow space to host bone Location o Any bone with enchondral ossification can be involved o Metaphysis of long bones: 70% Femur: 30% Tibia: 20% Humerus: 20% o Hands and feet: 10% o Pelvis: 5% o Scapula: 4% Size: 1-15 cm, mean: 3-7 cm Morphology: Pedunculated or sessile
.
Radiography 0 Cartilage covered bony projection (exostosis) on external surface of bone Calcification of hyaline cartilage cap o Pedunculated type: slender pedi61e directed away from joint Lesion grows at right angles to long axis of host bone o Sessile type: Broad-based attachment to cortex o Undertubulation of long bones (Erlenmeyer flask deformity) o ~ a l i ~ n adegeneration nt Development of thick, bulky, cartilaginous cap (thickness > 1 cm by CT, > 2 cm by MRI) Dispersed calcifications within cartilaginous cap Development of soft tissue mass
..
CT Findings NECT o To demonstrate continuity of cortical and medullary portions of lesion with host bone o To demonstrate thickness of cartilaginous cap o Helpful in showing bursa formation
MR Findings TlWI: Intermediate signal intensity T2WI
DDx: Osteochondroma
Ax NECT
Lat Radiography
Lat Radiography
Lat Rad~ography
AP Rad~ography
OSTEOCHONDROMA Key Facts Imaging Findings Best diagnostic clue: Exostosis with continuity of bone cortex and medullary marrow space to host bone
Top Differential Diagnoses Parosteal Osteosarcoma Periosteal Chondroma Chondrosarcoma Juxtacortical Myositis Ossificans Subungual Exostosis
Pathology
,
Most common benign bone tumor 12% of all bone tumors Multiple hereditary osteochondromas (MHE): Autosomal dominant hereditary disorder o Cartilaginous cap: High signal intensity o Band of low signal surrounding cap (represents
perichondrium) To evaluate thickness of cartilaginous cap and overlying bursa formation
Imaging Recommendations Best imaging tool: Radiographs diagnostic Protocol advice o Radiographs for initial diagnosis o CT or MRI to evaluate thickness of cartilaginous cap
I DIFFERENTIAL DIAGNOSIS Parosteal Osteosarcoma Osseous destruction
Periosteal Chondroma Can simulate sessile osteochondroma Intact cortex
Chondrosarcoma Cortical destruction Thick, bulky, cartilaginous cap o > 1 cmbyCT, >2cmbyMRI
Juxtacortical Myositis Ossificans Intact cortex No continuity between abnormal ossification and host bone
Subungual Exostosis Intact cortex No flaring of cortical bone into lesion
/ PATHOLOGY General Features General path comments o Lesions have own growth plate and stop growing with skeletal maturity
Multiple osteochondromas associated with bone deformities of affected sites
Clinical Issues Most common signs/symptoms: Usually painless mass, present for many years Painful with impingement on nerves/blood vessels Bursa can form over cap Pain in absence of fracture, nerve compression, or bursitis considered malignant until proven otherwise Benign lesion with self-limited growth Malignant transformation: 1-2% of solitary lesions Malignant transformation of MHE: 3-5% Surgical resection of symptomatic lesions If entire cartilage cap removed recurrence unlikely (< 5%)
o Bursa formation as response to friction in moving
body parts Genetics o Genetic alterations in patients with multiple hereditary exostoses Point mutation of EXTl gene leading to premature translation stop Alteration of EXT2 gene in families with chromosome 1lpll-13 defect Etiology o Arises from aberrant epiphyseal development with displacement of physeal cartilage through perichondral fibrous ring Displaced peripheral chondroblasts act as ectopic growth plate o Can be induced by implanting epiphyseal tissue into cortex o Can arise after external radiation for non-osseous neoplasm Epidemiology o Most common benign bone tumor o 45% of all benign bone tumors o 12% of all bone tumors Associated abnormalities o Multiple hereditary osteochondromas (MHE): Autosomal dominant hereditary disorder Multiple osteochondromas associated with bone deformities of affected sites Involves knee, hip, ankle, shoulder (usually symmetric involvement) Knees almost always affected: Knee radiographs for initial screening Involvement of multiple sites in severe cases Growth disturbance and bowing deformities of affected bones Can result in pseudo-Madelung deformity of forearm (ulnar shortening, bowing of radius) Sessile form more common Increased risk of malignant transformation into chondrosarcoma
If entire cartilage cap removed recurrence unlikely (< 5%)
Gross Pathologic & Surgical Features Normal cortical bone with cartilaginous cap covered by thin, fibrous membrane (perichondrium) o Perichondrium continuous with periosteum covering stalk o Thickness of cap 1-3 mm, rarely up to 1 cm o Greater thickness may imply malignant transformation Continuity of lesion with marrow and cortex of host bone (hallmark) Zone of provisional calcification of epiphyseal plate at iunction of cap and underlying . - spongiosa -
Consider Pain in absence of fracture, nerve compression, bursitis suspicious of malignancy
Image Interpretation Pearls Cartilage thickness: Best measured on CT, MRI
Microscopic Features Cartilage cap containing a basal surface with enchondral ossification o Represents epiphyseal growth plate Bursa at periphery of some osteochondromas attached to perichondrium of cap o Bursa wall lined by synovium o Can be associated with cartilaginous loose bodies in bursa
Presentation Most common signs/symptoms: Usually painless mass, present for many years Clinical profile o Painful with impingement on nerves/blood vessels o Pathologic fracture, usually at base of stalk, rarely presenting symptom o Bursa can form over cap Can become inflamed, accumulate synovial fluid or loose bodies o Pain in absence of fracture, nerve compression, or bursitis considered malignant until proven otherwise
Demographics Age: 10-35 years Gender: M:F = 1.8-2:l
Natural History & Prognosis Benign lesion with self-limited growth o Growth ceases after skeletal maturation Recurrence: < 5% Malignant transformation: 1-2% of solitary lesions o Suspect if Growth of lesion after skeletal maturation Pain in absence of fracture, bursitis, nerve compression Malignant transformation of MHE: 3-5%
Treatment Surgical resection of symptomatic lesions Marginal excision including cartilaginous cap and overlying perichondrium Cartilaginous cap should not be traumatized during resection Osseous base has minimal activity and may be removed piecemeal
-
Ahmed AR et al: Secondary chondrosarcoma in osteochondroma: Report of 107 patients. Clin Orthop 411:193-206, 2003 2. Trebicz-Geffen M et al: The short-lived exostosis induced surgically versus the lasting genetic hereditary multiple exostoses. Exp Mol Path01 74:40-8, 2003 3. Murphey MD et al: Imaging of osteochondroma: Variants and complications with radiologic-pathologiccorrelation. Radiographics 20:1407-34, 2000 4. Dorfman HD et al: Bone tumors. 1st ed. St. Louis MO, Mosby, 331-52, 1998 5. Greenspan A et al: Differential diagnosis of tumors and tumor-like lesions of bones and joints. 1st ed. Philadelphia PA, Lippincott-Raven, 146-59, 1998 6 . Mehta M et al: MR imaging of symptomatic osteochondromas with pathologic correlation. Skeletal Radio1 27:427-33, 1998 7. Karasick D et al: Symptomatic osteochondromas: Imaging features. AJR 168: 507-12, 1997 8. Le Merrer M et al: A gene for hereditary multiple exostoses maps to chromosome 19p. Human Molecular Genetics 3:717-22, 1994 9. Griffiths HJ et al: Bursitis in association with solitary osteochondromas presenting as mass lesion. Skeletal Radio1 20513-6, 1991 10. Hudson TM et al: Benign exostoses and exostotic chondrosarcomas: Evaluation of cartilage thickness by CT. Radiology 152595-9, 1984 11. ~ i l ~ r JW: a m The origin of osteochondromas and enchondromas. Clin Orthop 174:264-84, 1983 1.
OSTEOCHONDROMA
Typical (Left) Anteroposterior radiography shows pedunculated osteochondroma arising from the distal femoral metaphysis. Note the continuity of cortical and cancellous bone. Peduncula ted osteochondromas usually point away from closest joint. (Right) Anteroposterior radiography shows a large calcified broad based osteochondroma arising from the scapula.
Typical (Left) Anteroposterior radiography show sessile osteochondroma arising from the medial cortex of the proximal humeral diaphysis. Note the continuity of the lesion with the underlying cortex. (Right) Sagittal T 1 W l MR shows sessile osteochondroma arising from the proximal humeral meta-diaphysis. Note similar 51 of medullary cavity of lesion and host bone. Thin hypointense rim surrounding the lesion represents perichondrium.
Variant (Left) Anteroposterior radiography in a patient with MHE shows irregular dense undulations of the proximal femoral metaphyses. (Right) Anteroposterior radiography shows multiple osteochondromas arising from the proximal tibia and fibula in a patient with MHE.
CHONDROBLASTOMA
Coronal graphic shows lytic epiphyseal lesion with chondroid matrix (in white) involving the humeral head. Well-definedsclerotic margin is shown.
Abbreviations and Synonyms Codman tumor
Definitions Benign cartilage neoplasm, characterized by immature cartilage cells and extracellular matrix component
Lateral radiography shows a well-defined lytic lesion in the femoral epiphysis.
Apophyses: Greater trochanter, greater tuberosity, patella (most common tumor affecting patella) Epiphyseal-equivalentsite of flat bones: Acetabulum, iliac crest o Epiphyses and metaphyses: 55% o Metaphyses: 5% Size: 2-6 cm Morphology: Well-defined roundloval lytic defect with thin sclerotic rim
Radiographic Findings General Features
26
Best diagnostic clue: Well-defined lytic lesion centered in epiphyses of skeletally immature patients Location o Long bones: 80% ~rvoximalfemur and greater trochanter: 23% Distal femur: 20% Proximal tibia: 17% Proximal humerus: 18% o Hands and feet: 10% Tubular bones Ankle (talus, calcaneus) o Craniofacial bones (base of skull and temporal fossa): 16% o Spine, clavicle, sternum: Rare o Epiphyseslapophyses: 40%
. ..
Radiography o Well-defined, eccentrically or centrally located lytic lesion o Rarely expansile o Thin sclerotic margin Margins: Smooth (63%~)~ scalloped (27%)) lobulated (10%) 0 Geographic pattern of bone destruction 0 Stippled calcifications in 40-50% o Periosteal reaction away from lesion outside joint capsule: 50% o Bone expansion with secondary aneurysmal bone cyst formation: 15-20% o Stage 3 lesion may extend through growth plate into metaphysis or through cartilage into joint o Usually seen in immature skeleton
.
mmm DDx: Chondroblastoma Chondrosarcoma
Giant Cell Tumor
AP Rad~ography
A P kaa~ography
Cor T2 WI MR
CHONDROBLASTOMA Key Facts Imaging Findings Best diagnostic clue: Well-defined lytic lesion centered in epiphyses of skeletally immature patients Radiographs diagnostic MRI might suggest aggressivelmalignant lesion due to extensive surrounding edema
Top Differential Diagnoses Clear-Cell Chondrosarcoma Giant Cell Tumor Langerhans Cell Histiocytosis (LCH) Intraosseous Ganglion Aneurysmal Bone Cyst (ABC) Avascular Necrosis of the Femoral or Humeral Head Osteomyelitis (Abscess) Pseudotumor of the Greater Humeral Tuberosity
CT Findings NECT o Helpful in evaluating calcified chondroid matrix o Fluid-fluid levels
MR Findings TlWI o Low to intermediate signal intensity o Bone marrow edema: Low signal intensity T2WI o Intermediate to low signal intensity (solid components) o Bone marrow edema: High signal intensity T1 C+: Enhancement of edematous areas Prominent soft tissue and bone marrow edema o Overestimates extent and aggressiveness of lesion Joint effusions: 30-50% Fluid-fluid levels
Imaging Recommendations Best imaging tool: Radiographs Protocol advice o Radiographs diagnostic o MRI might suggest aggressivelmalignant lesion due to extensive surrounding edema
Pathology Less than 1%of all primary bone tumors 9% of benign bone tumors
Clinical Issues Mild joint pain, tenderness, swelling Benign tumor May become locally aggressive Curettage and packing with bone graft, polymethylmethacrylate
Diagnostic Checklist Location (epiphyseslapophyses),age (immature skeleton)
Variable margins, less well-defined Multiple lesion
lntraosseous Ganglion Eccentric location Radiolucent No calcified matrix
Aneurysmal Bone Cyst (ABC) No calcified matrix Thinned cortex
Avascular Necrosis of the Femoral or Humeral Head More irregular Crescent sign
Osteomyelitis (Abscess) Less well-defined Serpentine tract No calcified matrix
Pseudotumor of the Greater Humeral Tuberosity Lucency due to increase amount of cancellous bone Pseudotumor, no sclerotic margin or internal matrix
[DIFFERENTIAL DIAGNOSIS
1 PATHOLOGY
Clear-Cell Chondrosarcoma
General Features
May be indistinguishable Exhibits same benign pattern More heavily calcified Both may be seen in immature skeleton
Giant Cell Tumor Usually larger and less well-demarcated No calcified matrix Older age group with closed growth plate May expand epiphysis and diaphysis
Langerhans Cell Histiocytosis (LCH) No calcified matrix
General path comments: Benign cartilage neoplasm, characterized by proliferation of immature cartilage cells Etiology: Originates from chondroblasts in epiphyseal cartilage plate Epidemiology o Less than 1%of all primary bone tumors o 9% of benign bone tumors
Gross Pathologic & Surgical Features Well-demarcated, gray-tan mass Blue-gray foci represent chondroid matrix Foci of calcification and hemorrhage
CHONDROBLASTOMA Large, blood-filled, multiloculated cyst-like areas: Secondary ABC formation Larger tumors may break into metaphysis or through cortex
Consider Location (epiphyseslapophyses),age (immature
Microscopic Features Nodules of mature cartilage matrix surrounded by undifferentiated tissue of chondroblast-like cells Contains multinucleated giant cells of osteoclast type "Chicken wire" calcification (pericellular deposition of calcification) pathognomonic ABC component: 5-15% Immunohistochemistry: Positive for S-100 protein and vimentin Receptor activator of NF-KBligand (RANKL) involved in osteolytic bone destruction
Staging, Grading or Classification Criteria Surgical staging for benign musculoskeletal tumors o Stage 1: Latent o Stage 2: Active o Stage 3: Aggressive
Presentation Most common signslsymptoms o Mild joint pain, tenderness, swelling Due to involvement of articular cartilage and synovium (epiphyseal lesion) Symptoms can range from months to several years (> 10 years) Clinical profile o Joint effusion: 30% o Pathologic fractures rare o Elevated ESR
Demographics Age 0 5-59 years; peak: 5-25 years 0 Occurs before cessation of enchondral bone growth Gender: M:F = 2:l
Natural History & Prognosis Benign tumor o May become locally aggressive Pulmonary "metastases"(pulmonary implants): Rare o No histologic evidence of malignancy o May be due to hematogenous spread of tumor cells during operative manipulation o Should be resected due to growth potential
Treatment Curettage and packing with bone graft, polymethylmethacrylate o Tumor may seed to adjacent joints or lungs if spilled o Recurrence: 5-10% Stage 3 lesions usually not amenable to curettage (50% recurrence rate) o En-bloc excision Excision of pulmonary nodules
skeleton)
Image Interpretation Pearls MRI can be misleading (suggests aggressive lesion)
1 SELECTED REFERENCES 1.
2.
Huang L et al: Receptor activator of NF-KB ligand (RANKL) is expressed in chondroblastoma: Possible involvement in osteoclastic giant cell recruitment. Mol Pathol 56:116-20, 2003 Masui F et al: Chondroblastoma: A study of 11 cases. Eur J Surg Oncol28:869-74, 2002 Greenspan A et al: Differential diagnosis of tumors and tumor-like lesions of bones and joints. 1st ed. Philadelphia PA, Lippincott-Raven, 158-63, 1998 Weatherall PT et al: Chondroblastoma: Classic and confusing appearance at MR imaging. Radiology 190:467-74, 1994 Turcotte RE et al: Chondroblastoma. Hum Pathol 24:944-9, 1993 Edel G et al: Chondroblastoma of bone: A clinical, radiological, light and immunohistochemical study. Virchows Arch 421:355-66, 1992 Brower AC et al: The frequency and diagnostic significance of periostitis in chondroblastoma. Am J Roentgen01 154:309-14, 1990 Bloem JL: Chondroblastoma: A clinical and radiological study of 104 cases. Skeletal Radio1 14:l-9, 1985 Huvos AG et al: Aggressive chondroblastoma: Review of the literature on aggressive behavior and metastases with report of one new case. Clin Orthop 126:266-72, 1977 Dahlin DC et al: Benign chondroblastoma: A study of 125 cases. Cancer 30:401-13, 1972
1
CHONDROBLASTOMA
Typical .
+,
(Left) Anteroposterlor radiography of the left proximal femur shows a well-defined lytic lesion involving the greater trochanter (ep~physis equrvalent) (Right) Axla1 FS T2 FSE MR shows marked edema surrounding the chondroblastoma in the left greater trochanter
Typical (Left) An teroposterior radiography shows a multilobulated lytic expansile lesion with chondroid matrix in the humeral epiphysis. (Right) Coronal FS 12 FSE MR shows heterogeneous signal in the expansile lesion centered in the humeral epiphysis.
Typical (Left) Axial NECT shows a lytic lesion with chondroid matrix in the distal femoral epiphysis. (Right) Sagittal FS T2 FSE MR shows a high signal lesion in the tibia1 epiphyseal which is crossing the growth plate. Findings are consistent with secondary ABC formation.
CHONDROMYXOID FIBROMA
Sagittal graphic shows lytic, slightly lobulated lesion with thin sclerotic margin involving the tibial metaphysis.
Anteroposterior radiography shows a radiolucent, lobulated lesion in tibial metadiaphysis, exhibiting geographic type of bone destruction, sclerotic scalloped borders, and internal septa.
o Diaphyses: 5% o Apophyses can be involved
Abbreviations and Synonyms CMF, fibromyxoid chondroma, myxofibrous chondroma
Definitions Benign tumor composed of immature myxoid mesenchymal tissue with features of primitive cartilaginous differentiation
General Features Best diagnostic clue o Well-defined expansile lytic metaphyseal lesion with geographic pattern of bone destruction and sclerotic margin o Predilection for proximal tibia Location o Long bones: 60% About knee: 55% Proximal tibia: 30% o Short tubular bones of hands and feet: 25% Involvement of feet more common o Pelvis: 8%) o Metaphyses: 95%
I
I
Size: 1-10 cm, mean: 3-4 cm Morphology o Expansile lytic lesion with well-defined sclerotic margin o ~ a t h calcification x rare
Radiographic Findings Radiography o Round-ovoid eccentric lytic lesion Long axis of lesion parallel to long axis of host bone o Geographic pattern of bone destruction o Septa within lesion occasionally seen o Scalloped, sclerotic margins o Small tumors: Thin sclerotic margins No calcification or trabeculation o Cortical thickening can extend short distance beyond lesion o Partial cortical erosions o No visible periosteal reaction (unless fractured) o Matrix calcification rare o Can break through cortex and infiltrate into surrounding soft tissues (rare)
CT Findings NECT o Well-defined lytic lesion +/- matrix calcification
DDx: Chondromyxoid Fibroma
AP Radiography
A P Radiography
A P Radiography
AP Radiography
I
CHONDROMYXOID FIBROMA Key Facts 2% of all benign bone tumors
Imaging Findings
.
Well-defined expansile lytic metaphyseal lesion with geographic pattern of bone destruction and sclerotic margin Cortical expansion and soft tissue extension covered by thin layer of periosteal new bone
Clinical Issues Most common signs~symptoms:Local swelling and pain Can be asymptomatic, incidental finding in Pathologic fracture: 2-5% Benign tumor Can cause damage by continued growth and extension into soft tissues Malignant degeneration rare Curettage and bone grafting for stage 2 lesions Recurrence (25%) likely due to incomplete curettage En bloc resection with marginal margin for stage 3 lesions
Top Differential Diagnoses Fibroxanthoma Fibrous Dysplasia Aneurysmal Bone Cyst (ABC) Chondroblastoma Chondrosarcoma Adamantinoma
Pathology 0.5% of all primary bone tumors Osteofibrous dysplasia: Limited to anterior cortex of tibia o More sclerotic o Peak age: 1st decade of life
o Cortical expansion and soft tissue extension covered
by thin layer of periosteal new bone o To visualize chondroid matrix calcification o CT most sensitive modality to evaluate chondroid matrix calcifications CECT: Enhancement
Aneurysmal Bone Cyst (ABC) Fluid-fluid levels Periosteal new bone formation No matrix mineralization
MR Findings TlWI: Intermediate to low signal intensity T2WI o High signal intensity o Heterogeneous intermediate to high signal intensity o Hypointense rim STIR: High signal intensity T1 C+: Heterogeneous enhancement Heterogeneous signal due to chondroid, myxoid, fibrous components +/- hemorrhage To demonstrate soft tissue extension
Chondroblastoma Epiphyseal lesion Calcified matrix in 50%
Chondrosarcoma Chondroid matrix Cortical destruction Soft tissue extension
Adamantinoma
Angiographic Findings
Predilection for tibia Cortical destruction Aggressive periosteal reaction Older patients
Minimal neovascularity
Nuclear Medicine Findings Bone Scan: Increased uptake of radiotracer
Imaging Recommendations Best imaging tool: Radiographs diagnostic Protocol advice o CT to demonstrate thin overlying periosteal bone formation, matrix calcification o MRI to demonstrate soft tissue extent
[ DIFFERENTIAL DIAGNOSIS Fibroxanthoma No cortical ballooning or cortical destruction Periosteal reaction only in cases of fracture
Fibrous Dysplasia Central location Internal septations rare No periosteal reaction
General Features
1
General path comments o Benign tumor composed of mixture of chondroid, myxoid, and fibrous tissues o Cases reported as osseous myxomas/myxofibromas probably represent CMF Genetics: Pericentric inversions of chromosome 6 Etiology: Originates from cartilage-forming connective tissue Epidemiology o 0.5% of all primary bone tumors o 2% of all benign bone tumors
Gross Pathologic & Surgical Features Rubbery, bluish-gray, translucent tumor, resembles hyaline cartilage
CHONDROMYXOID FIBROMA Lobulated and well-marginated Surrounding bone shows sclerotic changes Hemorrhagic and cystic foci can be seen
Consider
Microscopic Features Large lobulated areas of spindle-shaped cells within myxoid or chondroid intercellular material Separated by septum-like zones of more cellular tissue that may contain giant cells Matrix: Dense chondroid; matrix stains basophilic o Loose myxoid matrix; stains eosinophilic Large pleomorphic and hyperchromatic cells occasionally seen o Can lead to confusion with diagnosis of chondrosarcoma Immunohistochemistry: Expression of type I1 collagen, SlOOB
Staging, Grading or Classification Criteria Surgical staging for benign musculoskeletal tumors o Stage 1: Latent o Stage 2: Active o Stage 3: Aggressive
VL ISSUES
1
Presentation Most common signs/symptoms: Local swelling and pain Clinical profile o Most cases present as stage 2 lesions o Can be asymptomatic, incidental finding in 10% o Pathologic fracture: 2-5% o Case report of oncogenic osteomalacia (hypophosphatemia, phosphaturia, low 1,25-dihydroxyvitamin D3)
Demographics Age o 5-79 years, peak: 2nd-3rd decade o 75% younger than 30 years Gender: M:F = 1.5 - 2:l Ethnicity: No racial predilection 32
Natural History & Prognosis Benign tumor Can cause damage by continued growth and extension into soft tissues Malignant degeneration rare o After radiation Recurrence in 25% after curettage o Recurrence more frequent in young patients (< 20 years) Rare cases of recurrence as chondrosarcoma reported
Treatment Curettage and bone grafting for stage 2 lesions o Recurrence (25%) likely due to incomplete curettage En bloc resection with marginal margin for stage 3 lesions Radiation therapy contraindicated due to risk of malignant transformation
Location: Metaphysis of lower extremity, proximal tibia Morphology: Expansile, matrix calcification rare
I
Park HR et al: Expression of collagen type 11, S100B, S100A2 and osteocalcin in chondroblastoma and chondromyxoid fibroma. Oncol Rep 9:1087-91, 2002 Park JM et al: Oncogenic osteomalacia associated with soft tissue chondromyxoid fibroma. Europ J Radiol 39:69-72, 2001 Durr HR et al: Chondromyxoid fibroma of bone. Arch Orthop Trauma Surg 120:42-7, 2000 Safar A et al: Recurrent anomalies of 6q25 in chondromyxoid fibroma. Hum Pathol 31:306-11, 2000 Greenspan A et al: Differential diagnosis of tumors and tumor-like lesions of bones and joints. 1st ed. Philadelphia PA, Lippincott-Raven, 164-69, 1998 Wu CT et al: Chondromyxoid fibroma of bone: A clinicopathologic review of 278 cases. Hum Pathol 29:438-46, 1998 Yamaguchi T et al: Radiographic and histologic patterns of calcification in chondromyxoid fibroma. Skeletal Radiol 27:559-64, 1998 O'Connor PJ et al: Chondromyxoid fibroma of the foot. Skeletal Radiol 25:143-8, 1996 White PG et al: Chondromyxoid fibroma. Skeletal Radiol 25:79-81, 1996 Wilson AJ et al: Chondromyxoid fibroma: Radiographic appearance in 38 cases and a review of the literature. Radiology 179513-8, 1991 Zillmer DA et al: Chondromyxoid fibroma of bone: Thirty-six cases with clinicopathologic correlation. Hum Pathol 20:952-64, 1989 Schajowicz F: Chondromyxoid fibroma: Report of three cases with predominant cortical involvement. Radiology 164:783-6, 1987 Beggs IG et al: Chondromyxoid fibroma of bone. Clin Radio1 33:671-9, 1982 Rahimi A et al: Chondromyxoid fibroma: A clinicopathologic study of 76 cases. Cancer 30:726-36, 1972 Feldman F et al: Chondromyxoid fibroma of bone. Radiology 94:249-60, 1970
I
CHONDROMYXOID FIBROMA
Variant (Left) Anteroposterior radiography show a radiolucent, slightly lobulated lesion with thin sclerotic margin in the first metatarsal bone. Note cortical disruption which led to pain and local swelling. (Right) Anteroposterior radiography shows expansive lytic lesion in the metadiaphysis of the first metatarsal bone. Note thinned but intact cortex. This was thought to represent an enchondroma, however, biopsy revealed a CMF.
Other (Left) Coronal intra-operative photograph shows cartilaginous, lobulated, well marginated mass. (Right) Micropa thology, low power, H&E stain shows lobules of chondromyxoid tissue (left) and cellular fibrous tissue (right).
CHONDROSARCOMA
Coronal graphic shows chondrosarcoma in the proximal femur. Ring like calcifications are shown in white. There is cortical destruction and tumor extension through the cortex medially
Anteroposterior radiography shows a destructive lesion in the proximal humerus with areas of ring and arc like calcifications, cortical destruction, and associated soft tissue extension.
.
Humerus: 10%
o Craniofacial bones: 2%, can arise from laryngeal
cartilage
Abbreviations and Synonyms Conventional chondrosarcoma, dedifferentiated chondrosarcoma, mesenchymal chondrosarcoma
Definitions Malignant tumor of connective tissue, characterized by formation of cartilage matrix by tumor cells
General Features
34
Best diagnostic clue: Lytic mass with or without chondroid matrix, cortical disruption and extension into soft tissues Location o Flat bones Pelvis: 25% Ilium: 15% Pubis and ischium: 9% Scapula: 5% o Ribs and sternum: 12% o MetaphysisJdiaphysisof long bones, may extend into epiphysis Femur: 15% Tibia: 5%
.. ..
..
I
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o Spine and sacrum: 5% o Soft tissues (extraskeletal chondrosarcoma)
Size: 1-40 cm, mean: 10 cm Morphology: Ill-defined lytic lesion with or without chondroid matrix
Radiographic Findings Radiography o Lytic mass with or without chondroid matrix o Medullary (central) chondrosarcoma: 85% = Expansion of medullary cavity Thickening of cortex with endosteal scalloping Popcorn-like ring and arc calcification Cortical disruption with extension into soft tissue in advanced stages o Exostotic (peripheral) chondrosarcoma Thickening of cortex and soft tissue mass at site of attachment to bone Chondroid matrix Late destruction of bone o Dedifferentiated chondrosarcoma: 10% Ill-defined, lytic lesion in continuitv with cartilaginous tumor Abrupt transition between cartilaginous tumor and dedifferentiated lytic component o Mesenchymal chondrosarcoma: < 1%
.. . . ..
.
.
DDx: Chondrosarcoma Enchondroma
Chondroblastoma
AP Radiography
AP Radiography
Osteosarcoma
Lat Rad~ography
MFH
Ax NECT
1
CHONDROSARCOMA Key Facts Imaging Findings Best diagnostic clue: Lytic mass with or without chondroid matrix, cortical disruption and extension into soft tissues Chondroid matrix mineralization of "rings and arcs" (characteristic)
Top Differential Diagnoses Enchondroma Chondroblastoma Osteosarcoma (OGS) Malignant Fibrous Histiocytoma (MFH)
Pathology Can occur as primary chondrosarcoma or as malignant degeneration of osteochondroma or enchondroma Aggressive lytic bone destruction Predilection for mandible, femur, ribs o Clear cell chondrosarcoma: 5% Round, sharply-marginated, lytic lesion Involves epiphysis of long bones May contain calcifications Surrounding sclerosis Indistinguishable from chondroblastoma (slow growth over years) o Extraskeletal chondrosarcoma Lobulated soft tissue mass with and without calcification Extremities (thigh) most common
CT Findings NECT 0 Chondroid matrix mineralization of "rings and arcs" (characteristic) 0 Nonmineralized portions of tumor hypodense to muscle High water content of hyaline cartilage
MR Findings TlWI: Low to intermediate signal intensity T2WI: High signal (hyaline cartilage), areas of low signal intensity (mineralization) TI C+ 0 Enhancement of septa with ring and arc pattern o Nonenhancing areas represent hyaline cartilage, cystic mucoid tissue, necrosis To determine intramedullary extent and soft tissue invasion
Nuclear Medicine Findings Bone Scan 0 Increased uptake of radiotracer 0 Overestimates extent of lesion due to surrounding hyperemia and edema
lmaging Recommendations Best imaging tool: Radiographs diagnostic, show calcification, periosteal reaction, endosteal scalloping Protocol advice
Third most common primary malignant bone tumor 10-25% of all primary bone sarcomas Extraskeletal chondrosarcoma: 2% of all soft tissue sarcomas
Clinical Issues Dull aching pain at rest, may be severe at night soft tissue swelling, mass Prognosis depends on location, size, and histologic grade Overall 5-year survival: 48-60% 5-year survival 90% for grade 1,81% for grade 2, 29% for grade 3 tumors Wide surgical excision Biopsies must be planned with future tumor excision in mind
CT to evaluate for chondroid matrix, cortical destruction, intra- and extraosseous extension o MRI to evaluate intramedullary extent and relationship to neurovascular bundle 0
Enchondroma r No periosteal reaction or cortical destruction No soft tissue mass Development of pain and swelling in previously asymptomatic enchondroma suspicious for malignant degeneration
Chondroblastoma May be indistinguishable from clear cell chondrosarcoma Both occur in epiphyses and can occur before skeletal maturity
Osteosarcoma (OGS) Osteoid matrix No chondroid matrix Usually younger patients
Malignant Fibrous Histiocytoma (MFH) Often purely lytic Can have areas of sclerosis, no chondroid matrix No significant periosteal reaction
1 PATHOLOGY General Features General path comments: Malignant tumor in which neoplastic cells form cartilage Genetics o Grade 1 chondrosarcomas: Diploid o Grade 2 and 3 chondrosarcomas: Aneuploid, correlate with aggressive behavior 0 High grade lesions: Complex chromosomal aberration with nonreciprocal translocations and deletions
CHONDROSARCOMA Accumulation of p53 protein, may be indicator of poor prognosis Etiology o Can occur as primary chondrosarcoma or as malignant degeneration of osteochondroma or enchondroma o Exostotic (peripheral) chondrosarcoma Malignant degeneration of hereditary multiple exostoses, Ollier disease Can arise in cartilage cap of a previously benign osteochondroma Epidemiology o Third most common primary malignant bone tumor o 10-25% of all primary bone sarcomas o Extraskeletal chondrosarcoma: 2% of all soft tissue sarcomas
Duration of symptoms - several months to years Clinical profile o Soft tissue swelling, mass o If lesion is close to joint, restricted range of motion
Demographics Age: 20-90 years, peak: 40-60 years Gender: M:F = 2:l
Natural History & Prognosis Prognosis depends on location, size, and histologic grade o Overall 5-year survival: 48-60% o 5-year survival 90% for grade 1, 81% for grade 2, 29% for grade 3 tumors Recurrence 5-10 years after surgery o Recurrence can be associated with increased histologic grade and more aggressive behavior Metastases (lung, lymph nodes, liver, kidneys, brain): 66% (grade 3 chondrosarcomas) Degeneration into fibrosarcoma, malignant fibrous histiocytoma, osteosarcoma in 10% Pelvic chondrosarcoma may invade bladder or colon Pathologic fractures rare
Gross Pathologic & Surgical Features Lobulated tumor composed of translucent hyaline nodules (resemble normal cartilage) o Mineralization at periphery of nodules Focal ivory-like areas represent extensive enchondral ossification Hemorrhagic necrosis, especially in high-grade tumors Central lesions erode and destroy cortex with extension into surrounding soft tissue o Cortical disruption earlier in flat bones due to narrow medullary cavity Extraosseous component grows on outer bone surface o Encircles affected bone
Treatment Wide surgical excision Limited role for chemotherapy or radiation therapy o For high grade chondrosarcomas Biopsies must be planned with future tumor excision in mind
Microscopic Features
-1 A
~rre~ular-s'haped lobules of cartilage May be separated by narrow, fibrous bands Chondrocytes arranged in clusters, can be mononuclear or multinucleated Matrix: Mature hyaline cartilage or myxoid stroma Immunohistochemistry: Positive for S-100 protein and vimentin Dedifferentiated chondrosarcorna: Two components that coexist in one tumor o High grade sarcoma +I-heterologous elements (MFH, OGS) o Low-grade cartilaginous lesion
Consider Enlarging or painful enchondroma or osteochondroma suspicious for sarcomatous transformation Clear cell chondrosarcoma may be indistinguishable from benign chondroid lesions (chondroblastoma, enchondroma) Always consult orthopedic surgeon before biopsy of possible chondrosarcoma
.I,*
Staging, Grading or Classification Criteria Grade 1 chondrosarcoma: Slowly growing, locally aggressive, indolent course o Recurrent growth potential, no metastatic spread o Diagnosis requires supportive evidence from clinical and radiographic data Grade 2 chondrosarcoma: Locally aggressive tumor with great potential for local recurrence o Metastases in 10-15% Grade 3 chondrosarcoma: Highly aggressive, rapidly growing o Metastases in over 50%
SELECTED REFERENCES 1. 2. 3. 4.
5.
6.
Presentation Most common signslsymptoms o Dull aching pain at rest, may be severe at night
Bjornsson J et al: Primary chondrosarcoma of long bones and limb girdles. Cancer 83:2105-19, 1998 Dorfman HD et al: Bone tumors. 1st ed. St. Louis MO, Mosby, 353-440, 1998 Greenspan A et al: Differential diagnosis of tumors and tumor-like lesions of bones and joints. 1st ed. Philadelphia PA, Lippincott-Raven, 169-98, 1998 Swarts SJ et al: Chromosomal abnormalities in low grade chondrosarcoma and a review of the literature. Cancer Genet Cytogenet 98:126-30, 1997 Mercuri M et al: Dedifferentiated chondrosarcorna. Skeletal Radiol. 24:409-16, 1995 Aoki J et al: MR of enchondroma and chondrosarcoma: Rings and arcs of Gd-DTPA enhancement. J Comput Assist Tomogr 15:1011-6, 1991
CHONDROSARCOMA
(Lef)Axial NECT shows a destructive lesion in the right acetabulum with cortical destruction and associated soft tissue mass. Note the calcified matrix. (Right) Axial FS T2 FSE MR shows intramedullary tumor with large associated soft tissue mass displaying high signal corresponding to chondroid matrix. Areas of low signal are consistent with calcifications.
Variant (Lef)Axial NECT shows a large, partially calcified mass adjacent to the right sacrum, consistent with a soft tissue chondrosarcoma. (Right) Lateral radiography shows cortical destruction adjacent to an enchondroma, consistent with sarcomatous transformation.
Other (Left) Anteroposterior radiography shows a lytic lesion with calcification of the femoral epiphysis. Biopsy revealed clear cell chondrosarcoma. (Right) Coronal gross pa thology shows lobulated, cartilaginous tumor with ill defined margins, and soft tissue extension.
FIBROUS DYSPLASlA
Coronal graphic shows polyostotic fibrous dysplasia involving the proximal femur and acetabular roof Cystic changes are shown in red, ground glass appearance in brown.
Abbreviations and Synonyms Definitions Developmental anomaly of bone formation
FINDINGS
General Features Best diagnostic clue: Expansile marrow lesion with "ground glass" appearance Location o Meta-diaphysis of long bones, sparing of epiphysis o Monostotic form: 85% Femur: 35-40% Tibia: 20% Skull and facial bones: 10-25s Ribs: 10% rn Hands, feet, spine: Rare o Polyostotic form: 15% Skull and facial bones: > 50% rn Pelvis, long bones, ribs Unilateral or monomelic o Osteofibrous dysplasia Tibia: > 90%
38
I
Fibula: 15% Size: 1-30 cm Morphology: Expansile lytic medullary lesion
Radiographic Findings
Osteitis fibrosa
IIMAGING
Anteroposterior radiography shows bowing deformity of the proximal femur (shepherd's crook deformity). Note expansion of bone with ground glass appearance.
Radiography o Radiolucent, expansile, medullary lesion o Ground glass appearance rn Due to woven bone in bone marrow cavity o Well-defined sclerotic margins, endosteal scalloping o No periostitis o Bowing deformities of long bones (shepherd's crook deformity) o Growth disturbance (polyostotic form) o Craniofacial involvement: Mixed lytic and sclerotic lesions Sclerosis in lesion involving skull base Expanded calvarium with greater involvement of outer table rn Frontal bossing, facial asymmetry o Osteofibrous dysplasia: Lytic lesion in anterior cortex of tibia1 diaphysis May involve medullary cavity Bowing, pathologic fracture, pseudoarthrosis
CT Findings NECT o No mineralized matrix o 70-400 HU, due to microscopic ossification
I
DDx: Fibrous Dvs~lasia
mbqam I
Lat Radiography ..
t
AP Radrography
I
La t Rad~ography
Lat Radiography
FIBROUS DYSPLASiA Key Facts Imaging Findings Best diagnostic clue: Expansile marrow lesion with "ground glass" appearance
Top Differential Diagnoses Neurofibromatosis Paget Disease Unicameral Bone Cyst (UBC) Chondromyxoid Fibroma (CMF) Aneurysmal Bone Cyst (ABC) Adamantinoma
Pathology 1% of biopsied primary bone tumors Most common benign lesion of the rib McCune Albright syndrome Mazabraud syndrome o No soft tissue mass o Helpful in evaluating skull lesions CECT: Enhancement of active lesions
MR Findings T1WI: Homogeneous low signal, thin rim of low signal TZWI: High signal in 60%, mixed signal, thin rim of low signal T1 C+: Enhancement of active lesions
Clinical Issues Monostotic form: Usually asymptomatic Polyostotic form: 213 symptomatic by age 10 Leg pain, limp, pathologic fracture Endocrine disorders: Hyperthyroidism, hyperparathyroidism, diabetes mellitus, acromegaly No progression of monostotic to polyostotic form Malignant transformation: 0.5% into osteosarcoma (most common), chondrosarcoma, fibrosarcoma No treatment for asymptomatic lesions Curettage and bone grafting of large lesions at risk for pathologic fracture
Diagnostic Checklist Evaluate patient for endocrine abnormalities in polyostotic form
Aneurysmal Bone Cyst (ABC) Marked expansion of affected bone Fluid-fluid levels
Adamantinoma Older patients Eccentrically located (osteofibrous dysplasia involves anterior tibia1 cortex) Destructive features
Nuclear Medicine Findings Bone Scan o To determine activity and extent of involvement o Increased uptake in majority of lesions o Decrease in radiotracer activity implies that lesion has become inactive
Imaging Recommendations Best imaging tool: Radiographs diagnostic Protocol advice: Bone scan to determine if disease is monostotic or polyostotic
Neurofibromatosis Long bone deformities without intramedullary changes Pseudoarthrosis poor prognosis o Pseudoarthrosis has good therapeutic response in fibrous dysplasia
Paget Disease Calvarium: Expansion of inner and outer table o Greater involvement of outer table in fibrous dysplasia
Unicameral Bone Cyst (UBC) Centrally located "Fallen fragment" sign in case of fracture
Chondromyxoid Fibroma (CMF) Geographic pattern of bone destruction Periosteal new bone formation
1 PATHOLOGY General Features General path comments o Inability of bone-forming tissue to produce mature lamellar bone Even if osteoid is produced it cannot mature to lamellar bone Genetics o Predisposition to somatic mutations of skeleton-forming mesenchymal tissue Clonal structural alterations involving chromosomes 3, 8, 10, 12, 15 Heterozygous deactivating GNASl mutations Increased levels of c-fos oncoprotein in lesions of fibrous dysplasia Etiology o Benign developmental abnormality in which medullary cavity is replaced with fibrous tissue Fibrous tissue contains immature woven bone Epidemiology o 1% of biopsied primary bone tumors o Most common benign lesion of the rib Associated abnormalities o McCune Albright syndrome Polyostotic unilateral fibrous dysplasia Endocrine abnormalities (precocious puberty, hyperthyroidism) Cafe-au-lait spots ("coast of Maine") Female predominance o Mazabraud syndrome
Curettage and bone grafting of large lesions at risk for pathologic fracture Surgery with curettage associated with high rate of local recurrence: 20-100% Straightening of angular deformities and grafting with cortical bone Treatment of underlying endocrine abnormalities Bisphosphonates to decrease pain and prevent pathologic fractures o Can lead to partial resolution of lesions
Multiple fibrous and myxomatous soft tissue tumors in association with polyostotic fibrous dysplasia
Gross Pathologic & Surgical Features Centrally located lesion of firm, fibrous, white or red tissue Variable gritty consistency, depending on the amount of mineralized bone Expanded thinned cortex Secondary blood-filled cyst formation common
Microscopic Features Medullary cavity replaced by spindle cells in storiform arrangement and irregular trabeculae of immature woven bone Various levels of bone trabeculae maturation Curved, branching trabeculae without surface osteoblasts: Resemble chinese characters Foci of cartilage in 10%
I DIAGNOSTIC CHECKLIST Consider Evaluate patient for endocrine abnormalities in polyostotic form
I SELECTEDREFERENCES -
Ippolito E et al: Natural history and treatment of fibrous dysplasia of bone: A multicenter clinicopathologic study promoted by the European Pediatric Orthopaedic Society. J Pediatr Orthop B 12:155-77, 2003 2. Rickard SJ et al: Analysis of GNASl and overlapping transcripts identifies the parental origin of mutations in patients with sporadic Albright hereditary osteodystrophy and reveals a model system in which to observe the effects of splicing mutations on translated and untranslated messenger RNA. Am J Hum Genet 72:961-74, 2003 3. Lane JM et al: Bisphosphonate therapy in fibrous dysplasia. Clin Orthop 382:6-12, 2001 4. Dorfman HD et al: Bone tumors. 1st ed. St. Louis MO, Mosby, 441-91, 1998 5. Greenspan A et al: Differential diagnosis of tumors and tumor-like lesions of bones and joints. 1st ed. Philadelphia PA, Lippincott-Raven, 215-30, 1998 6. Choi KH et al: Fibrous dysplasia: MR imaging characteristics with radiopathologic correlation. Am J Roentgen01 167:1523-7, 1996 7 . Ruggieri P et al: Malignancies in fibrous dysplasia. Cancer 73:1411-24, 1994 8. Inamo Y et al: Findings on magnetic resonance imaging of the spine and femur in a case of McCune-Albright syndrome. Pediatr Radio1 23:l.S-8, 1993 9. Utz JA et al: MR appearance of fibrous dysplasia. J Comput Assist Tomogr 13:845-51, 1989 10. Campanacci M et al: Osteofibrous dysplasia of the tibia and fibula. J Bone Joint Surg 63(3):367-75, 1981 1.
Presentation
40
Most common signs/symptoms o Monostotic form: Usually asymptomatic = Can present with pathologic fracture rn Painful stress fractures common in femoral neck rn Dysplastic callus formation after fracture o Polyostotic form: 213 symptomatic by age 10 Leg pain, limp, pathologic fracture rn Abnormal vaginal bleeding (25%) Endocrine disorders: Hyperthyroidism, hyperparathyroidism, diabetes mellitus, acromegaly Hypophosphatemic rickets McCune Albright syndrome (precocious puberty) Clinical profile o Hyperpigmentation of skin (cafe-au-laitspots) -oftencorresponds to sites of skeletal involvement o Soft tissue myxomas o Cherubism: Autosomal dominant Svmmetric involvement of mandible and maxilla o ~eoktiasisossea (craniofacial fibrous dysplasia) Involvement of facial and frontal bones rn Leonine facies (resembling a lion) rn Cranial nerve palsies
Demographics Age: 5-50 years; peak: 10-20 years Gender: M:F = 1:l
Natural History & Prognosis No progression of monostotic to polyostotic form Monostotic form: Growth of lesion usually stabilizes during puberty Enlargement of lesions during pregnancy Polyostotic form: Lesions remain active after puberty Malignant transformation: 0.5% into osteosarcoma (most common), chondrosarcoma, fibrosarcoma
Treatment No treatment for asymptomatic lesions
Typical (Lef)Anteroposterior radiography shows multiple circumscribed expansile lytic lesions involving the right hand in a patient with polyostotic fibrous dysplasia. Normal left hand for comparison. (Right) Anteroposterior radiography shows marked craniofacial involvement in a patient with McCune Albright syndrome. Note obliteration of the left orbit.
Typical (Left) Anteroposteriot radiography shows circumscribed mixed, predominately sclerotic and lytic lesion in the proximal tibia1 metaphysis. (Right) Coronal T l Wl MR shows low signal lesion of the proximal iemoral metaphysis with peripheral spiculation corresponding to areas of sclerosis.
Other (Lef)An teroposterior radiography in a patient with polyostotic fibrous dysplasia shows marked deformity of the tibia and fibula with multiple expansile lytic lesions. (Right) Clinical photograph shows marked deformity o i the lower extremity in a patient with polyostotic fibrous dysplasia.
Coronal graphic shows eccentric lytic lesion with scalloped sclerotic margins in the tibial rnetaphysis.
Anteroposterior radiography shows an eccentric well-defined lytic lesion with sclerotic scalloped borders in the distal tibial metaphysis.
o Less common in upper extremity: 8%
Humerus: 5% o Multifocal: 50%
Abbreviations and Synonyms Metaphyseal fibrous defect, benign fibrous histiocytoma, nonossifying fibroma, fibrous cortical defect
Definitions Benign asymptomatic hamartomatous lesion of children Fibroxanthoma comprises o Nonossifying fibroma (NOF) o Fibrous cortical defect (FCD)
General Features Best diagnostic clue: Well-defined expansile eccentric lytic lesion with scalloped sclerotic margins in metaphyses of long bones Location o Metaphysis of long bones (postero-medial):90% Close to growth plate Distance from growth plate increases with age o Tibia: 43% o Femur: 38% o Fibula: 8%
42
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Size: 0.5-7 cm Morphology: Eccentric cortical based lytic lesion
Radiographic Findings Radiography o Eccentric, cortical lytic lesion with thin or scalloped sclerotic margins o FCD: < 2 cm, within the cortex o NOF: > 2 cm, encroach medullary cavity o Can extend or primarily involve medullary cavity o Expansion of overlying cortex o Cortex may be thinned but intact o No matrix mineralization o Trabeculation in periphery of lesion o Increased mineralization in healing stages Begins at diaphyseal end and progresses to growth plate o Long axis of lesion is parallel to long axis of bone
CT Findings NECT o Well defined lytic lesion with surrounding sclerosis o Helpful in showing medullary involvement and pathologic fractures o If lesion involves > 50% of transverse diameter of bone, increased risk of fracture
DDx: Fibroxanthoma
Sag FS T2 MRI
A P Radiography
A P Radiography
Lat Radiography
FIBROXANTHOMA Key Facts Imaging Findings Best diagnostic clue: Well-defined expansile eccentric lytic lesion with scalloped sclerotic margins in metaphyses of long bones FCD: < 2 cm, within the cortex NOF: > 2 cm, encroach medullary cavity Best imaging tool: Radiographs diagnostic
Top Differential Diagnoses Cortical Desmoid Aneurysmal Bone Cyst (ABC) Unicameral Bone Cyst (UBC) Fibrous Dysplasia Chondromyxoid Fibroma (CMF)
Pathology Most common fibrous lesion of bone o HU slightly higher than normal bone marrow CECT Enhancement
MR Findings TlWI o Low signal intensity o Peripheral hypointense rim (reactive sclerosis) T2WI o Low to intermediate signal intensity o Septations o Peripheral hypointense rim (reactive sclerosis) T1 C+: Enhancement
Nuclear Medicine Findings Bone Scan o Increased radiotracer uptake of active lesions o Decreased uptake corresponds to involution
Imaging Recommendations Best imaging tool: Radiographs diagnostic Protocol advice o Radiographs o CT for preoperative planning o Larger lesions require radiographic follow-up to assess progression and fracture risk Radiographs every 4-6 months
1 DIFFERENTIAL DIAGNOSIS Cortical Desmoid At tendinous insertion Typically posterior distal femur
Aneurysmal Bone Cyst (ABC) Marked expansion of affected bone Fluid-fluid levels Periosteal new bone formation
Unicameral Bone Cyst (UBC) Centrally located "Fallen fragment" sign in case of fracture
Fibrous Dysplasia Expansile medullary lesion
Occurs in 20-30% of normal population during 1st and 2nd decades of life Jaffe-Campanacci syndrome Neurofibromatosis type 1
Clinical Issues Most common signs/syrnptoms: Usually asymptomatic May cause pain, pathologic fracture Benign lesion, no malignant transformation Spontaneous regression Usually does not require treatment Curettage with bone grafting of larger lesions at risk for fracture
Diagnostic Checklist Don't touch lesion
Ground glass appearance
Chondromyxoid Fibroma (CMF) Geographic pattern of bone destruction Periosteal new bone formation
1 PATHOLOGY General Features General path comments o Non-neoplastic process that occurs in the juxtaepiphyseal region of long bones o NOF results from proliferation of FCD that has expanded medullary cavity Etiology o Developmental defect arising in trabeculae of tubular bones Migrates toward diaphysis as bone grows in length o May be result of periosteal injury Epidemiology o Most common fibrous lesion of bone o Occurs in 20-30% of normal population during 1st and 2nd decades of life o FCD: 30-40% of children develop one or more lesions o NOF: 2% of biopsied primary bone tumors Associated abnormalities o Jaffe-Campanacci syndrome Multifocal fibroxanthoma with extraskeletal manifestations in children Cafe-au-lait spots Mental retardation Hypogonadism, cryptorchidism Congenital cardiovascular defects o Neurofibromatosis type 1 Multifocal fibroxanthoma of long bones May be bilateral and symmetric
Gross Pathologic & Surgical Features Eccentric, cortically based lesion with demarcated and scalloped inner boundary Fibrous, fleshy tissue with shades of grey and yellow
FIBROXANTHOMA o Color dependent on relative proportions of fibrous
tissue and foamy histiocytes Cystic changes, hemorrhage, necrosis in larger lesion with pathologic fracture Involuted lesions: Replacement of fibrous component by cholesterol
1 DIAGNOSTIC CHECKLIST Consider If detected on radiographs no further work up required (no biopsy) Don't touch lesion
Microscopic Features NOF and FCD are histologically identical Bundles of spindle-shaped fibroblasts, scattered multinucleated giant cells, and foamy histiocytes Foam cells more common in older lesions Hemosiderin pigment in stromal cells Arranged in storiform pattern
Staging, Grading or Classification Criteria Surgical staging for benign musculoskeletal tumors o Stage 1: Latent o Stage 2: Active o Stage 3: Aggressive
Presentation Most common signs/symptoms: Usually asymptomatic Clinical profile o During adolescence fibroxanthoma represents active stage 2 lesion o May cause pain, pathologic fracture Increased risk of pathologic fracture if lesion is larger than 3.3 cm or involves > 50% of weight bearing bone o Hypophosphatemic vitamin D resistant rickets, osteomalacia Tumor may secrete substance that increases renal tubular resorption of phosphorus
Demographics
01 '1, 4.,
Age: 2-20 years, peak: 10-15 years Gender: M:F = 2:l
Natural History & Prognosis Benign lesion, no malignant transformation presents during childhood, disappears in adolescence Spontaneous regression o Involution over 2-4 years Heal by membranous ossification Bone island in adult may be residue of incompletely involuted fibroxanthoma
Treatment Usually does not require treatment Curettage with bone grafting of larger lesions at risk for fracture o Risk of growth disturbance from injury to growth plate Casting after pathologic fracture to avoid injury to physis during surgery o Lesion may heal after fracture
(SELECTED REFERENCES Yanagawa T et al: The natural history of disappearing bone tumors and tumour like conditions. Clin Radiol 56:877-86, 2001 2. Smith SE et al: Primary musculoskeletal neoplasms of fibrous origin. Semin Musculoskel Radiol 4:73-88, 2000 3. Dorfman HD et al: Bone tumors. 1st ed. St. Louis MO, Mosby, 205-15, 1998 4. Greenspan A et al: Differential diagnosis of tumors and tumor-like lesions of bones and joints. 1st ed. Philadelphia PA, Lippincott-Raven,492-514, 1998 5. Friedland JA et al: Quantitative analysis of the plain radiographic appearance of nonossifying fibroma. Invest Radio1 30:474-9, 1995 6. Araki Y et al: MRI of fibrous cortical defect of the femur. Radiat Med 12:93-8, 1994 7. Sethi A et al: Allograft in the treatment of benign cystic lesions of bone. Arch Orthop Trauma Surg 112:167-70, 1993 8. Hudson TM et al: Fibrous lesions of bone. Radiol Clin North Am 31279-97, 1993 9. Unni KK et al: Fibrous and fibrohistiocytic lesions of bone. Semin Orthop 6:177-86, 1991 10. Kransdorf MJ et al: MR appearance of fibroxanthoma. J Comput Assist Tomogr 12:612-5, 1988 11. Mirra JM et al: Disseminated nonossifying fibromas in association with cafe-au-laitspots Gaffe-Campanacci syndrome). Clin Orthop 168:192-205, 1982 1.
I
IBROXANTHOMA IMAGE GALLERY Typical (Left) Lateral radiography shows predominantly sclerotic lesion in the posterior femur with scalloped sclerotic border! (Right) Coronal T I WI MR shows well-defined, lobulated, eccentric lesion low-intermediate 51 in the distal tibial diaphysis.
Tvpical ( L e f ) Lateral radiography shows well-demarcated expansile lytic lesion with traheculation of the proximal tibia. (Right) Anteroposterior hone scan shows eccentric area of increased uptake in the left femoral metadiaphysis. Normal right side for comparison.
Variant (Left) Anteroposterior radiography of the femur shows fibroxanthoma with pathologic fracture. (Right) Anteroposterior radiography shows fibroxanthoma of the distal tibial metaphysis with pathologic fracture.
MALIGNANT FIBROUS HISTIOCYTOMA, BONE
Sagittal graphic shows permeative tumor involving the distal femoral metaphysis. Cortical destruction is shown posteriorly.
Craniofacial bones: 9-14% Spine: 5% Rare in small bones of hands and feet Metaphyses, central: 90% Diaphyses, eccentric: 10Yo Size: 2-10 cm Morphology: Lytic ill-defined osseous lesion o o o o o
Abbreviations and Synonyms MFH, malignant fibrous xanthoma, malignant histiocytoma
Definitions Malignant neoplasm of bone characterized by mixture of spindle and pleomorphic cells
General Features Best diagnostic clue o Lytic ill-defined metaphyseal lesion with permeative bone destruction and cortical disruption o Frequently occurs as secondary sarcoma in area of abnormal bone Location o Long tubular bones About knee: 50% Femur: 45% rn Tibia: 20% Humerus: 10% o Pelvis rn Ilium: 10% Sacrum: 6%
I
Lateral radiography shows destructive osteolytic lesion with moth-eaten pattern of bone destruction involving the distal femoral meta-diaphysis.
Radiographic Findings Radiography o Lytic, ill-defined intramedullary lesion o Geographic, permeative, moth-eaten patterns of bone destruction o Cortical disruption o Extension into soft tissue o Little periosteal new bone formation o Lamellated periosteal reaction in presence of pathologic fracture o Secondary MFH: Occurs in areas of abnormal bone Paget disease, bone infarct, chronic osteomyelitis o Presence of calcification suggests secondary MFH
CT Findings NECT o Density similar to muscle o Hypodense areas represent necrosis CECT: Variable enhancement
I
DDx: Malignant Fibrous Histiocytoma, Bone v
hbrosarcoma
Osteosarcoma
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MALIGNANT FIBROUS HISTIOCYTOMA, BONE --
Key Facts Imaging Findings Lytic ill-defined metaphyseal lesion with permeative bone destruction and cortical disruption Frequently occurs as secondary sarcoma in area of abnormal bone
Top Differential Diagnoses Fibrosarcoma Osteosarcoma Metastases Giant Cell Tumor (GCT) Lymphoma Multiple Myeloma
Pathology
Clinical Issues Most common signs/symptoms: Pain with or without swelling Pathologic fracture: 23% Aggressive neoplasms with tendency to recur and metastasize Local recurrence: 3 1-44% Metastases: 42% 5 year survival: 52% Surgical resection with wide margins Neoadjuvant and adjuvant chemotherapy
Diagnostic Checklist 20% of all osseous MFH occur in areas of abnormal bone
Epidemiology: 2-10% of primary malignant bone tumors
-
MR Findings TlWI: Intermediate-low signal intensity T2WI o Heterogeneous signal o High signal intensity STIR: High signal intensity T1 C+: Variable enhancement To show intra- and extraosseous extent
Nuclear Medicine Findings Bone Scan: Increased radiotracer uptake, predominately in periphery of tumor
Imaging Recommendations Best imaging tool: Radiographs, MRI Protocol advice o Radiographs to diagnose osseous destruction o MRI to evaluate intra- and extraosseous extent
I DIFFERENTIAL DIAGNOSIS Fibrosarcoma Often indistinguishable Osseous sequestrum
Osteosarcoma Osseous matrix Aggressive periosteal reaction Can occur secondary to Paget disease
Metastases Multifocal Associated soft tissue mass Can be lytic, sclerotic, mixed
Giant Cell Tumor (GCT) Epiphyseal lesion No soft tissue mass Well-defined lytic lesion
Lymphoma Can be sclerotic ("ivoryvertebra") Late cortical destruction
Multiple Myeloma Multifocal Cold on bone scan
General Features General path comments: Resembles high-grade fibrosarcoma Genetics: Loss of chromosome 13 Etiology o Derived from monocyte-macrophage precursors o Controversial if tumor represents specific entity or microscopic pattern common to heterogeneous group of sarcomas o Can occur secondary to preexisting lesion: Paget disease, bone infarct, chronic osteomyelitis o Can arise after radiation therapy for unrelated tumor Epidemiology: 2-10% of primary malignant bone tumors
Gross Pathologic & Surgical Features Gray with fleshy yellow areas Soft-fibrous mass Irregular, ill-defined borders Cortical disruption, infiltration into adjacent soft tissues Areas of necrosis and hemorrhage
Microscopic Features Fibroblast like spindle cells and giant cells resembling histiocytes in pleomorphic-storiform pattern Necrotic foci common Storiform/pleomorphic type: 50-60% Myxoid type: 25% Giant cell type: 5-10% Inflammatory type: 5-10%
Staging, Grading or Classification Criteria Surgical staging system for musculoskeletal tumors o Stage IA: Low grade, intracompartmental o Stage IB: Low grade, extracompartmental
MALIGNANT FIBROUS HISTIOCW'OMA, BONE o Stage IIA: High grade, intracompartmental o Stage IIB: High grade, extracompartmental o Stage IIIA: Low or high grade, intracompartmental,
metastases o Stage IIIB: Low or high grade, extracompartmental,
metastases
Presentation Most common signs/symptoms: Pain with or without swelling Clinical profile o Symptoms usually present for several months o Most patients present with aggressive stage IIB lesion o Pathologic fracture: 23%
Demographics Age o 10-90 years, peak: 50 years o 10% < 20 years Gender: M:F = 1-1.5:l Ethnicity: More frequent in Caucasians
Natural History & Prognosis Aggressive neoplasms with tendency to recur and metastasize Prognosis depends on tumor size, histologic subtype Secondary MFH (arising in preexisting condition) more aggressive than primary MFH Local recurrence: 3 1-44% Metastases: 42% o Lung: 90%, lymph nodes: 4-12%, bone: 8%) liver: 1% 5 year survival: 52% 10 year survival: 41%
Treatment Surgical resection with wide margins Neoadjuvant and adjuvant chemotherapy Radiation and chemotherapy Radiation therapy for inoperable tumors o Risk of radiation-induced sarcoma
I DIAGNOSTIC CHECKLIST Consider 20% of all osseous MFH occur in areas of abnormal bone
I SELECTED REFERENCES 1.
2.
3.
4.
Bielack SS et al: Malignant fibrous histiocytoma of bone: A retrospective EMSOS study of 125 cases. European Musculo-Skeletal Oncology Society. Acta Orthop Scand 70:353-60, 1999 Mairal A et al: Loss of chromosome 13 is the most frequent genomic imbalance in malignant fibrous histiocytomas. A comparative genomic hybridization analysis of a series of 30 cases. Cancer Genet Cytogenet 111:134-8, 1999 Dorfman HD et al: Bone tumors. 1st ed. St. Louis MO, Mosby, 531-52, 1998 Greenspan A: Differential diagnosis of tumors and
tumor-like lesions of bones and joints. 1st ed. Philadelphia PA, Lippincott-Raven,1998 Nishida J et al: Malignant fibrous histiocytoma of bone. A clinicopathologic s&dy of 81 patients. cancer 79:482-93, 1997 Lin WY et al: The role of Tc-99m MDP and Ga-67 imaging in the clinical evaluation of malignant fibrous histiocytoma. Clin Nucl Med 19:996-1000, 1994 Murphey MD et al: From the archives of the AFIP. Musculoskeletal malignant fibrous histiocytoma: Radiologic-pathologic correlation. Radiographics 145307-26, 1994 Yokoyama R et al: Prognostic factors of malignant fibrous histiocytoma of bone: A clinical and histopathologic analysis of 34 cases. Cancer 72:1902-9, 1993 Pezzi CM et al: Prognostic factors in 227 patients with malignant fibrous histiocytoma. Cancer 69:2098-103, 1992 Boland PJ et al: Malignant fibrous histiocytoma of bone. Clin Orthop 204:130-4, 1986 Huvos AG et al: The pathology of malignant fibrous histiocytoma of bone. A study of 130 patients. Am J Surg Path01 9:853-71, 1985 Ros PR et al: Malignant fibrous histiocytoma: Mesenchymal tumor of ubiquitous origin. Am J Roentgenal 142:753-9, 1984 Weiss SW et al: Malignant fibrous histiocytoma: An analysis of 200 cases. Cancer 41:2250-60, 1978 14. ~eldmanF et al: Primary malignant fibrous histiocytoma (fibrous xanthoma) of bone. Skeletal Radio1 1:145-60, 1977 15. Spanier SS et al: Primary malignant fibrous histiocytoma of bone. Cancer 36:2084-98, 1975
MALIGNANT FIBROUS HISTIOCYTOM
BONE
Typical (Left) Sagittal T 1 Wl MR shows heterogeneous intermediate signal with soft tissue extension involving the distal femoral meta-diaphysis. (Right) Sagittal FS 72 FSE MR shows high signal tumor in the distal femoral epiphysis. Note posterior cortical disruption.
(Left) Lateral radiography shows ill-defined lytic lesion with anterior cortical destruction involving the distal femoral metaphysis. (Right) Axial NECT shows permeative osteolytic lesion with anterior cortical disruption and soft tissue extension.
Other (Left) Anteroposterior radiography of the left proximal femur demonstrates pathologic fracture through ill-defined destructive lesion. (Right) Coronal surgical pathology shows hemorrhagic tumor with associated soft tissue mass involving the proximal femur.
Coronal graphic shows eccentric destructive osteolytic lesion in the proximal femur. Note the lack of periosteal reaction.
Lateral radiography shows ill-defined lytic lesion involving the distal femoral meta-diaphysis. Note the permeative pattern of bone destruction and wide zone of transition.
o Rare in small bones of hands and feet o Eccentric in metaphysis: 85% o Extension into diaphysis, epiphysis
Abbreviations and Synonyms Fibroblastic malignancy, mesenchymal sarcoma
Definitions Spindle-cell sarcoma characterized by myofibroblastic differentiation and absence of osteoid production
[IMAGING FINDINGS General Features Best diagnostic clue o Low grade lesion: Circumscribed lytic lesion with irregular lobulated cortex, osseous sequestrum o High-grade lesion: Lytic ill-defined lesion with permeative bone destruction, cortical disruption, soft tissue mass Location o Long tubular bones Femur: 40% Tibia: 15% About knee: 30-50% Humerus: 9% o Pelvis: 15% o Craniofacial bones: 9% o Spine: 5%
. .
o Multifocal lesions: Rare Size: 2-10 cm Morphology: Well-defined to destructive lytic lesion +/- soft tissue mass
Radiographic Findings Radiography o Intramedullary (central) fibrosarcoma Lytic lesion with permeative, moth-eaten, &ographic of bone destruction Low-grade tumors: Circumscribed lytic lesion with sclerotic rim Loculated "soap bubble" appearance High-grade tumors: Large lytic lesion with cortical destruction, soft tissue extension Associated soft tissue mass: 85% Osseous sequestrum Minimal periosteal reaction No calcified matrix Presence of calcification suggests secondary fibrosarcoma o Periosteal fibrosarcoma (rare) Irregular cortex Periosteal reaction o Secondary fibrosarcoma: Occurs in areas of abnormal bone
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DDx: Fibrosarcoma
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FIBROSARCOMA Key Facts Imaging Findings Low grade lesion: Circumscribed lytic lesion with irregular lobulated cortex, osseous sequestrum High-grade lesion: Lytic ill-defined lesion with permeative bone destruction, cortical disruption, soft tissue mass
Top Differential Diagnoses Malignant Fibrous Histiocytoma (MFH) Giant Cell Tumor (GCT) Lymphoma Metastases Multiple Myeloma Aneurysmal Bone Cyst (ABC) Osteosarcoma
Paget disease, bone infarct, chronic osteomyelitis, giant cell tumor After radiation of giant cell tumor, lymphoma, malignancy unrelated to bone Dedifferentiation of chondrosarcoma o Infantile fibrosarcoma: Rare Excellent prognosis
CT Findings NECT o Osseous mass of muscle density o Low density areas correspond to necrosis CECT Variable enhancement
MR Findings TlWI: Intermediate-low signal intensity T2WI o Heterogeneous signal o High signal intensity STIR: High signal intensity T1 C+: Variable enhancement
Nuclear Medicine Findings Bone Scan: Increased radiotracer uptake
Imaging Recommendations Best imaging tool: Radiographs, MRI Protocol advice o RadiographsICT to show bone destruction o MRI to evaluate intra- and extraosseous extent
I DIFFERENTIAL DIAGNOSIS Malignant Fibrous Histiocytoma (MFH) Radiographically indistinguishable from high-grade fibrosarcoma
Giant Cell Tumor (GCT) Epiphyseal lesion Well-defined borders Trabeculation within tumor matrix No marginal sclerosis
Pathology Epidemiology: 4% of all primary bone tumors
Clinical Issues Mass with Or Pathologic fractures: 15-23% Low-grade type: 10-year survival 80% High-grade type: 5-year survival 35-40% Stage Ia lesion: Limb salvage resection with wide surgical margins Stage IIb lesion: Radical resection with wide margins Adjuvant and neoadjuvant chemotherapy
Diagnostic Checklist 30% of all fibrosarcomas occur in areas of abnormal bone
Lymphoma Can be sclerotic Late cortical destruction
Metastases Multifocal Associated soft tissue mass common
Multiple Myeloma Multifocal Cold on bone scan
Aneurysmal Bone Cyst (ABC) Can resemble low-grade fibrosarcoma Fluid-fluid levels No cortical destruction
Osteosarcoma Calcified matrix Aggressive periosteal reaction Associated soft tissue component
1 PATHOLOGY General Features General path comments: Clinically and radiographically resembles MFH Etiology o Comprises low-grade end of spectrum that includes MFH at high-grade end o Can occur secondary to preexisting lesion Paget disease, bone infarct, chronic osteomyelitis o Can be radiation induced o Patients with neurofibromatosis have 10% risk of developing fibrosarcoma Epidemiology: 4% of all primary bone tumors
Gross Pathologic & Surgical Features Fleshy-fibrous tumor Foci of tan-gray soft tissue Myxoid, hemorrhagic areas High grade tumors: Hemorrhagic, friable, necrotic Cortical break
Microscopic Features Interlacing spindle cells arranged in "herringbone" pattern Permeative invasion of bony trabeculae No bone or cartilage matrix Low-grade tumors: Abundant collagen, hypocellular High-grade tumors: More cellular, less collagen production
Staging, Grading or Classification Criteria Surgical staging system for malignant musculoskeletal tumors o Stage Ia: Low grade, intracompartmental o Stage Ib: Low grade, extracompartmental o Stage IIa: High grade, intracompartmental o Stage IIb: High grade, extracompartmental o Stage IIIa: Low or high grade, intracompartmental, metastases o Stage IIIb: Low or high grade, extracompartmental, metastases
Presentation Most common signs/symptoms o Mass with or without swelling o Dull pain Clinical profile o Pathologic fractures: 15-23% o Metastases: 42%
Demographics Age: 10-90 years, peak: 3rd-5th decade Gender: M:F = 1.2:l Ethnicity: No racial predilection
Natural History & Prognosis Prognosis depends on tumor size, histologic subtype Low-grade m e : 10-year survival 80% ~ i ~ h r ~ r&pe: a d e 5-;ear survival 35-40% Local recurrence: 60%
-3 -1
Treatment Stage Ia lesion: Limb salvage resection with wide surgical margins Stage IIb lesion: Radical resection with wide margins o Amputation may be required o Adjuvant and neoadjuvant chemotherapy Radiation therapy for surgically inaccessible lesion o Risk of radiation-induced sarcoma Resection of pulmonary metastases
I DIAGNOSTIC CHECKLIST Consider 30% of all fibrosarcomas occur in areas of abnormal bone
1 SELECTED REFERENCES
I
Saito T et al: Low-grade fibrosarcoma of the proximal humerus. Pathol Int 53:115-20, 2003 2. Papagelopoulos PJ et al: Clinicopathologic features, diagnosis, and treatment of fibrosarcoma of bone. Am J Orthop 31:253-7, 2002 3. Smith SE et al: Primary musculoskeletal tumors of fibrous origin. Semin Musculoskelet Radiol 4:73-88. 2000 4. Dorfman HD et al: Bone tumors. 1st ed. St. Louis MO. Mosby, 552-5, 1998 5. Nashida J et al: Malignant fibrous histiocytoma of bone. A clinicopathologic sGdy of 81 patients. cancer 79:482-93, 1997 Hudson TM et al: Fibrous lesions of bone. Radiol Clin North Am 31:279-97, 1993 Suh CH et al: Fibrosarcoma: Observations on the ultrastructure. Ultrastructural Pathol 17:221-9, 1993 Wiklund TA et al: Postirradiation sarcoma: Analysis of a nationwide cancer registry material. Cancer 68:524-31, 1991 Wetzel LH et al: A comparison of MR imaging and CT in the evaluation of musculoskeletal masses. Radiographics 7:851-74, 1987 Aisen AM et al: MRI and CT evaluation of primary bone and soft-tissue tumors. Am J Roentgen01 146:749-756, 1986 Bertoni F et al: Primary central (medullary) fibrosarcoma of bone. Semin Diagn Pathol 1:185-98, 1984 Taconis WK et al: Fibrosarcoma and malignant fibrous histiocytoma of long bones: Radiographic features and grading. Skeletal Radiol 11:237-45, 1984 Larsson SE et al: Fibrosarcoma of bone: A demographic, clinical and histopathological study of all cases recorded in the Swedish cancer registry from 1958 to 1968. J Bone Joint Surg 588-B:412-17, 1976 Huvos AG et al: Primary fibrosarcoma of bone: A clinicopathologic study of 130 patients. Cancer 35:837-47, 1975 15. Eyre-Brook AL et al: Fibrosarcoma of bone: Review of fifty consecutive cases from the Bristol Bone Tumour Registry. J Bone Joint Surg 51-B:20-37, 1969 I.
FIBROSARCOMA -
-
IMAGE GALLERY ( L e f ) Lateral radiography shows destructive lytic lesion involving the proximal tibia. (Right) Anteroposterior radiography shows large lytic lesion involving the 5th metatarsal bone. Cortical destruction with no periosteal new bone formation is noted.
Variant (Left) Axial T1 Wl MR shows eccentric tumor of low signal in the distal right femur. (Right) Anteroposterior radiography shows pathologic fracture through lytic destructive femoral lesion.
Other (Left) Anteroposterior radiography of resected specimen shows lytic lobulated tumor with cortical destruction. This was found to represent a low-grade fibrosarcoma. (Right) Coronal micropathology, low power shows infiltrating fibrosarcoma with cortical disruption involving the proximal femur.
GlANT CELL TUMOR
Coronal graphic shows expansile lytic lesion with trabeculations extending to subchondral bone. Thinned but intact cortex is shown.
o Pelvis: 4% o Multifocal: 0.5-1% with Paget disease Size: 2-20 cm, mean: 5-7 cm Morphology: Eccentric lytic lesion without matrix extending to subchondral bone
Abbreviations and Synonyms Giant cell tumor (GCT)
Definitions Locally aggressive neoplasm composed of osteoclast like giant cells involving the epiphyses in skeletally mature patients
General Features
54
Anteroposterior radiography shows a large lytic expansile lesion with trabeculation involving the distal radius with extension to subchondral bone.
Best diagnostic clue o Lytic epiphyseal lesion extending to subchondral bone without surrounding" sclerosis o Occurs typically in skeletally mature patients Location o Originates in metaphyseal side of growth plate Centered in meta-epiphysis Subsequent growth to subchondral bone o Long bones: 75-90% About knee: 50-65% Radius: 10% Humerus: 6% o Spine: 7% o Hands and feet: 5%
Radiographic Findings Radiography o Eccentric, lytic bone lesion o Well-defined borders o Expansile remodeling with apparent cortical permeation: 20-50% o Conspicuous peripheral trabeculae without tumor matrix ("soapbubble" appearance) o Septations o No marginal sclerosis o Periosteal reaction: 10-30%
CT Findings NECT o Soft tissue attenuation, foci of low attenuation (hemorrhage/necrosis) o May break through cortex with cortical thinning, soft tissue invasion
wofJm M R Findings
TlWI o Low-intermediate signal intensity o Best to see intramedullary portion of tumor
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DDx: Giant Cell Tumor
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GIANT CELL TUMOR Key Facts Imaging Findings
Clinical Issues Pain and swelling at affected area, relieved by decreased activity Pathologic fracture in 30% Locally aggressive: 12-50% recurrence rate Can undergo sarcomatous transformation, spontaneously or in response to radiation therapy Curettage with cryotherapy, phenol, liquid nitrogen to reduce recurrence rate Surgical resection with filling of resection cavity with bone graft or methylmethacrylate Radiation only for cases of unresectable tumor (risk of sarcomatous degeneration) Resection of pulmonary implants
Lytic epiphyseal lesion extending to subchondral bone without surrounding sclerosis Occurs typically in skeletally mature patients
Top Differential Diagnoses Aneurysmal Bone Cyst (ABC) Intraosseous Ganglion Chondroblastoma Osteosarcoma Giant Cell Reparative Granuloma
Pathology 5% of all primary bone tumors 6th most common primary bone tumor
T2WI o Low-intermediate signal intensity o Fluid-fluid levels o To evaluate extraosseous component of tumor
General Features
Angiographic Findings Neovascularity: 80% Intense, heterogeneous capillary blush
Nuclear Medicine Findings Bone Scan o Doughnut sign: Intense uptake around periphery with little activity in central portion o May help in detection of multicentric giant cell tumor
Imaging Recommendations Best imaging tool: Radiographs diagnostic Protocol advice: MRI to evaluate extraosseous component
1 DIFFERENTIAL DIAGNOSIS Aneurysmal Bone Cyst (ABC) Rarely affects articular end of bone Younger age group May coexist with giant cell tumor
lntraosseous Ganglion Sclerotic borders Eccentric location
Chondroblastoma Calcified Younger age group
Osteosarcoma Aggressive periosteal reaction Osseous matrix
Giant Cell Reparative Granuloma Benign reparative lesions in small bones of hands and feet
1
General path comments: Solitary lesion characterized by osteoclast like giant cells and stroma cells originating at metaphyseal site of growth plate Genetics o Chromosomal aberrations with telomeric fusion may correlate with aggressive features High recurrence rate Metastatic potential Etiology o Unknown o Mononuclear cells from mesenchymal origin fuse to form giant cells Epidemiology o 5% of all primary bone tumors o 6th most common primary bone tumor Associated abnormalities o Goltz syndrome (focal dermal hypoplasia) Rare condition characterized by multiple anomalies of skin, teeth, and bone
Gross Pathologic & Surgical Features Soft, friable, fleshy, red-brown tumor with yellow areas Tumor tissue well-demarcated, can extend to articular cartilage Can be hemorrhagic, ABC-like formation: 10-15% Surrounding bone is expanded with thinning of the cortex Delineated in periphery by thin layer of fibrous and reactive bone tissue
Microscopic Features Multinucleated osteoclastic giant cells intermixed throughout spindle cell stroma Osteoclastic giant cells not apposed to bone surfaces o Do not participate in bone resorption No bone or cartilage matrix production in multiloculated giant cells
Staging, Grading or Classification Criteria Surgical staging of benign musculoskeletal tumors
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GIANT CELL TUMOR o Stage 1: Latent o Stage 2: Active o Stage 3: Aggressive
Presentation Most common signs/symptoms o Pain and swelling at affected area, relieved by decreased activity Can mimic internal derangement of the knee Clinical profile o Pathologic fracture in 30% o Limited range of motion of joint adjacent to affected area o Pulmonary metastases (benign pulmonary implants) in 1-2% Histologically identical to primary tumor
Demographics Age o 20-55 years, occurs after skeletal maturity o Rare in children: 1%
Gender: F:M = 2:l Ethnicity: More common in Chinese population
Natural History & Prognosis
E C.
Clinical behavior cannot be predicted on basis of radiological and histologic features Locally aggressive: 12-50% recurrence rate Can undergo sarcomatous transformation, spontaneously or in response to radiation therapy Pulmonary metastases (pulmonary implants): 1-2% o Occurs in patients with stage 3 disease o Within 3 years after removal of primary GCT, can be seen without prior surgery o Self limited growth potential, histologically benign o May regress spontaneously o Cases of death reported due to progressive growth of non-resected lung lesions (rare) Tumor involving distal radius often more aggressive than in other locations Primary malignant GCT extremely rare
..'I,
Treatment Curettage with cryotherapy, phenol, liquid nitrogen to reduce recurrence rate o Stage 1 and 2 lesions Surgical resection with filling of resection cavity with bone graft or methylmethacrylate o Stage 3 lesions Curettage alone associated with high rate of recurrence Wide excision in case of recurrence Radiation only for cases of unresectable tumor (risk of sarcomatous degeneration) Arterial embolization of GCT involving the sacrum Resection of pulmonary implants
Consider Location: Extends to subchondral bone Age: Fused growth plate
Boons HW et al: Oncologic and functional results after treatment of giant cell tumors of bone. Arch Orthop Trauma Surg 12217-23, 2002 Lackman RD et al: The treatment of sacral giant-cell tumours by serial arterial embolization. J Bone Joint Surg 84(B):873-7, 2002 Dorfman HD et al: Bone tumors. 1st ed. St. Louis MO, Mosby, 559-606, 1998 Meis JM et al: Primary malignant giant cell tumor of bone: "Dedifferentiated giant cell tumor. Mod Path01 2:541-6, 1995 Manaster BJ et al: Giant cell tumor of bone. Radiol Clin North Am 31:299-323, 1993 Schutte HE et al: Giant cell tumor in children and adolescents. Skeletal Radiol 22:173-6, 1993 Tubbs WS et al: Benign giant-cell tumor of bone with pulmonary metastases: Clinical findings and radiologic appearance of metastases in 13 cases. Am J Roentgen01 158:331-4, 1992 Aoki J et al: Giant cell tumors of bone containing large amounts of hemosiderin: MR-pathologic correlation. J Comput Assist Tomogr. 15:1024-7, 1991 Bridge JA et al: Cytogenetic findings and biologic behavior of giant cell tumors of bone. Cancer 65:2697-703, 1990 Tanaka H et al: The Goltz syndrome associated with giant cell tumor of bone: A case report. Int Orthop 14:179-81, 1990 Carrasco CH et al: Giant cell tumors. Orthop Clin North 11. Am 20:395-405, 1989
GIANT CELL TUMOR
Tvnical (Left) Sagittal T I WI MR shows tumor of low-intermediate SI involving the distal femoral meta-epiphysis. The tumor has penetrated the cortex. (Right) Sagittal T2 Wl MR shows high SI tumor with surrounding edema and cortical ~enetration.
Tvnical (Left) Anteroposterior radiography shows a large lytic lesion with cortical destruction involving the left hemipelvis. (Right) Axial NECT shows extensive destruction of the sacrum and ilium with large associated soft tissue mass.
Other ( L e f ) Sagittal T 1 WI MR shows a purely lytic lesion with non sclerotic margin and cortical destruction involving the proximal tibia. The lesion extends to subchondral bone. (Right) Coronal gross pathology shows brown-reddish tumor involving the proximal tibia with extension to subchondral bone and through the cortex. Areas of hemorrhage and cyst formation are noted.
Axial graphic of the vertebral body shows radiating spicules and coarse trabeculations in a polka-dot pattern.
Size: 1-7 cm Morphology: Lytic lesion with radiating trabecular thickening
Abbreviations and Synonyms Hemangioma of bone
Radiographic Findings
Definitions Benign lesion composed of newly formed blood vessels
1 IMAGING FINDINGS
I
General Features Best diagnostic clue o MRI: Areas of high signal on T1 and T2WI MR o Radiographs and CT: VerticalIradial striations, spoke wheellpolka-dot appearance ~ocationo Spine: 28% Vertebral body, may extend into lamina, spinous process (rare) o Calvarium: 20% Occurs in diploic space o Flat bones: Rib, clavicle, mandible o Long bones o Intraosseous, intracortical, periosteal o Intraarticular (synovial) o Can be multifocal - -
iH
Coronal T l Wl MR shows area of high signal involving the L2 vertebral body. Note the prominent trabeculations.
. .
Radiography o Coarse striations 0 Multifocal lytic areas o Periosteal and intracortical type Lytic, cortical erosions, periosteal reaction 0 Vertebral body: Vertical striations, honeycomb appearance Multiloculated lytic foci May have associate soft tissue mass or pathologic fracture o Calvarium: Small, round, circumscribed lytic lesion Diploe: Greater expansion of outer than inner table Radiating thickened trabeculae, spoke wheel pattern Multicentric: 15% o Long bones: Expansile lesion, thinning of cortex m Honeycomb, "hole-within-hole'' appearance Radial trabecular thickening Spiculated periosteal reaction o Flat bones: Radiating thickened trabeculae, spoke wheel pattern Lesions usually larger
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DDx: lntraosseous Hemangioma
Multipl~M y ~ l o m a
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INTRAOSSEOUS HEMANGIOMA Key Facts 1% of biopsied primary bone tumors
Imaging Findings MRI: Areas of high signal on T1 and T2WI MR Radiographs and CT: VerticalIradial striations, spoke wheel/polka-dot appearance
Clinical Issues
,Mostly asymptomatic Local pain and swelling with involvement of skull and ribs Vertebral hemangiomas can extend to spinal canal and cause cord compression Usually stabilizes in growth May undergo spontaneous regression Small asymptomatic lesions require no treatment Curettage and bone grafting for symptomatic lesions
Top Differential Diagnoses Osteopenia Fibrous Dysplasia Paget Disease Multiple Myeloma Metastases Langerhans Cell Histiocytosis (LCH)
Pathology
Diagnostic Checklist
Can look aggressive on radiographs, look for high signal on TlWI MRI
Lesion with high degree of fat will less likely be symptomatic Incidence: 10%
Paget Disease
CT Findings
Enlarged vertebral body Sclerotic endplates Diploic widening Osteoporosis circumscripta
NECT: Vertebral body: Multiple sclerotic dots ("polka dot" appearance) CECT: Enhancement
MR Findings
Multiple Myeloma
TlWI o Areas of high signal intensity, corresponding to vascular components Areas of low signal intensity, corresponding to trabecular thickening T2WI o Areas of high signal intensity, corresponding to vascular components Areas of low signal intensity, corresponding to trabecular thickening T1 C+: Enhancement Helpful in demonstrating possible extension into spinal canal
Destructive lesion Associated soft tissue mass Multiple lesions
Metastases Cortical destruction Often associated soft tissue mass Multifocal
Langerhans Cell Histiocytosis (LCH) Calvarium: Well-defined lytic lesion o Outer table of skull more destroyed than inner table o Button sequestrum Usually multifocal
Nuclear Medicine Findings Bone Scan o Moderate uptake o Photopenia
General Features
Imaging Recommendations Best imaging tool: MRI, CT Protocol advice: MRI to evaluate potential complications (e.g., cord compression)
/DIFFERENTIAL DIAGNOSIS Osteopenia Can be indistinguishable on CT No focal high signal on TI Diffuse, no focal mass
Fibrous Dysplasia Lytic lesion Ground glass appearance Expansile
1
General path comments o Vascular proliferation that may be congenital, developmental, or acquired o Lesion with high degree of fat will less likely be symptomatic Etiology o Vascular malformation o Likely hamartomatous condition rather than true neoplasm Epidemiology o Incidence: 10% o 1%of biopsied primary bone tumors Associated abnormalities o Hemangiomatosis Multiple hemangiomas involving two or more non contiguous sites o Gorham disease
lNTRAOSSEOUS HEMANCIOMA o Risk of radiation induced sarcoma
Progressive bone resorption in association with multiple hemangiomas or lymphangiomas
Gross Pathologic & Surgical Features Well-demarcated soft, friable, brown-red intramedullary lesion Can be intracortical or subperiosteal Bony trabeculae coursing through lesion Variable degree of sclerosis Some lesions composed exclusively of vascular tissue, contain no bone
I DIAGNOSTIC CHECKLIST Consider Can look aggressive on radiographs, look for high signal on TlWI MRI o Malignant lesions are usually low signal on TlWI MRI
Microscopic Features ~ e m a n ~ i o m a t o tissue us spreads between bone trabecuiae without causing bone distortion Capillary type: Small vessels, consist of flat epithelium, surrounded by only basilar membrane o Most common in vertebral body Cavernous type: Composed of dilated, blood-filled spaces lined by flat endothelium and basilar membrane o Most common in calvarium Venous type: Composed of thick-walled spaces with muscle layer, frequently contain phleboliths Arteriovenous type: Abnormal communication between arteries and veins o Rare in bones, common in soft tissues
1. 2. 3. 4. 5. 6.
7.
Presentation Most common signs/symptoms o Mostly asymptomatic o Pathologic fracture rare Clinical profile o Local pain and swelling with involvement of skull and ribs o Vertebral hemangiomas can extend to spinal canal and cause cord compression
Demographics hU
Age o 1-80 vears o 75% diagnosed between 20-60 years Gender: F:M = 1.5-2:l Ethnicity: No racial predilection
Natural History & Prognosis Benign, no malignant degeneration Usually stabilizes in growth Can progress, causing tissue destruction May undergo spontaneous regression
Treatment Small asymptomatic lesions require no treatment Curettage and bone grafting for symptomatic lesions o Can cause severe hemorrhage during surgery o Preoperative arteriography and embolization Symptomatic spinal lesions: Decompression laminectomy CT guided intralesional injection of ethanol Hemangiomas of calvarium and facial bones: En bloc excision Surgically inaccessible lesions: Radiation therapy
8. 9. 10. 11. 12. 13. 14. 15. 16.
Doppman JL et al: Symptomatic vertebral hemangiomas: Treatment by means of direct intralesional injection of ethanol. Radiology 21:341-8, 2000 Wenger DE et al: Benign vascular lesions of bone: Radiologic and pathologic features. Skeletal Radiol 29:63-74, 2000 Greenspan A et al: Differential diagnosis of tumors and tumor-like lesions of bones and joints. 1st ed. Philadelphia PA, Lippincott-Raven,289-96, 1998 Friedman DP: Symptomatic vertebral hemangiomas: MR findings. Am J Roentgen01 167:359-64, 1996 Lomasney LM et al: Multifocal vascular lesions of bone: Imaging characteristics. Skeletal Radiol 25:255-61, 1996 Murphey MD et al: From the archives of the AFIP. Musculoskeletal angiomatous lesions: Radiologic-pathologic correlation. Radiographics 15:893-917, 1995 Assoun J et al: CT and MRI of massive osteolysis of Gorham. J Comput Assist Tomogr 18:981-4, 1994 Suh JS et al: Soft tissue hemangiomas: MR manifestations in 23 patients. Skeletal Radiol 23:621-5, 1994 Conway WF et al: Miscellaneous lesions of bone. Radiol Clin North Am 31:339-58, 1993 Hawnaur JM et al: Musculoskeletal hemangiomas: Comparison of MRI with CT. Skeletal Radiol 19:251-8, 1990 Laredo JD et al: Vertebral hemangiomas: Fat content as a sign of aggressiveness. Radiology 177:467-72, 1990 Makhija M et al: Hemangioma: A rare cause of photopenic lesion on skeletal imaging. Clin Nucl Med 13:661-2, 1988 Moreno AJ et al: Hemangioma of bone. Clin Nucl Med 13:668-9, 1988 Cohen JW et al: Arteriovenous malformations of the extremities: MR imaging. Radiology 158:475-9, 1986 Laredo JD et al: Vertebral hemangiomas: Radiologic evaluation. Radiology 161:183-9, 1986 Faria SL et al: Radiotherapy in the treatment of vertebral hemangiomas. Int J Radiat Oncol Biol Phys 11:387-90, 1985
INTRAOSSEOUS HEMANGIOMA
Typical ( L e f ) Axial NECT shows coarse dots that indicate reinforced trabeculae of cancellou5 bone ("polka-dots"). (Right) Lateral radiography shows increased vertical striations of the L2 vertebral body.
(Left) Anteroposteriot radiography shows a large expansile trabeculated /;tic lesion (honeycomb pattern) involving the proximal humerus. (Right) Lateral radiography shows slight anterior bowing, increased str~ations,and multiple small lucencies involving the tibia1 diaphysis.
Typical (Left) Lateral radiography shows a large lytic lesion with vertical trabeculation involving the calvarium. (Right) Anteroposterior bone scan shows increased radiotracer uptake in the L4 vertebral body.
UNICAMERAL BONE CYST
Sagittal graphic shows a unicameral bone cyst in the calcaneus. Note the lack of periosteal reaction and cortical destruction.
Anteroposterior radiography shows a well-defined lytic lesion in the central humeral metaphysis. Note the cortical thinning and lack of periosteal reaction.
Radiographic Findings Abbreviations and Synonyms Solitary or simple bone cyst
Definitions Tumor-like lesion of unknown etiology, attributed to local disturbance of bone growth
I IMAGING FINDINGS
1
General Features
62
Best diagnostic clue: Well-defined central lytic lesion Location o Humerus and femur: 60-80% o Calcaneus, talus, ilium: 50% (in older patients) o Spine, sacrum, craniofacial bones: Rare o Proximal metaphysis, adjacent to epiphyseal cartilage (during active phase) o Migration into diaphysis with growth (during latent phase) o Does not cross growth plate Size: 2-15 cm, mean: 6-8 cm Morphology o Well-defined lytic lesion o Migrates into diaphysis with bone growth
Radiography o Centrally located, well-defined, expansile, lucent lesion o Long axis parallel to long axis of host bone o Sclerotic margin o Scalloping of underlying cortex o Cortex never completely disrupted o Fluid-filled cavity (fluidtfluid levels) o No periosteal reaction unless fractured o No extension into soft tissues o Fallen fragment sign secondary to pathologic fracture (pathognomonic) Fragment migrates to dependent portions of cyst o Increased density/sclerosis after steroid injection
CT Findings NECT o Fluid-filled cavity HU: 15-20 Can have fluid-fluid levels o Helpful in evaluating anatomic complex areas (pelvis, spine) o To determine extent CECT o No enhancement o Helpful in differentiating cyst from solid lesion
.
7unK, DDx: Unicameral Bone Cyst
L AP Radiography
AP Radiography
AP Radiography
AP Radiography
UNICAMERAL BONE CYST Key Facts Imaging Findings
Clinical Issues Most lesions asymptomatic Pain, swelling, stiffness at closest joint 66% of cysts present with pathologic fractures Spontaneous regression in majority of cases Recurrence rate after injection, curettage: 20-45% Dual needle aspiration and percutaneous injection of corticosteroids (80-200 mg methylprednisolone) Open curettage with bone graft in weight bearing bones
Best diagnostic clue: Well-defined central lytic lesion Fallen fragment sign secondary to pathologic fracture (pathognomonic)
Top Differential Diagnoses Aneurysmal Bone Cyst (ABC) Fibrous Dysplasia Fibroxanthoma Bone Abscess Enchondroma Langerhans Cell Histiocytosis Brown Tumors
Diagnostic Checklist Starts at one end of bone, migrates towards diaphysis with bone growth
Pathology Epidemiology: 3% of primary bone lesions
Cortical destruction Sinus tract
M R Findings TlWI: Low to intermediate signal intensity T2WI o High signal intensity o Heterogeneous signal in case of fracture (blood products) T1 C+ o No enhancement o To differentiate cyst from solid lesions Fluid-fluid levels Septations
Enchondroma Calcified matrix Lytic in hands
Langerhans Cell Histiocytosis Destructive lesion Surrounding bone marrow edema
Brown Tumors Hyperparathyroidism (HPT) Associated with other features of HPT o Subperiosteal resorption, osteopenia
Nuclear Medicine Findings Bone Scan o Increased peripheral radiotracer uptake o Decreased central radiotracer uptake o May be normal
General Features
Imaging Recommendations Best imaging tool: Radiographs diagnostic Protocol advice: CT for anatomic complex areas (spine, pelvis)
I DIFFERENTIAL DIAGNOSIS I
Aneurysmal Bone Cyst (ABC) ~ccentric,expansile lesion Periosteal reaction Geographic type of bone destruction surrounding edema Prominent fluid-fluid levels
Fibrous Dysplasia No trabeculation Ground glass, smoky appearance No "fallen-fragment sign" in case of fracture
Fibroxanthoma Eccentric lesion Thin or scalloped sclerotic margins
Bone Abscess Periosteal reaction
I
General path comments o Fluid containing lesion lined by mesenchymal cells o Only primary true cyst of bone that conforms to pathologic definition of cyst Genetics: Case report of translocation (16;20) (p11.2;q13) Etiology o Unknown o Appears to be reactive or developmental rather than neoplastic o Possibly due to lymphatic or venous obstruction or synovial rests that produce joint fluid 0 Venous obstruction in area of rapidly growing and remodeling bone Epidemiology: 3% of primary bone lesions
Gross Pathologic & Surgical Features Intact specimens rarely seen Intramedullary cavity filled with clear or yellow fluid with low viscosity Fluid under pressure Septation with multiple cavities occasionally seen Spongy component composed of multiple smaller cysts can be present
UNlCAMERAL BONE CYST Wall composed of paper thin (1 mm), tan-yellow fibrous tissue with bony ridges Intact periosteum
Consider Starts at one end of bone, migrates towards diaphysis with bone growth
Microscopic Features Wall of lesion has no epithelial lining o Fibrous and granulaGon tissue, hemosiderin deposits and small lymphocytes within cyst wall o Giant cells of osteoclastic type in cyst wall o Fibrinous debris may undergo calcification simulating cementum Fluid usually shows elevated alkaline phosphatase Fluid contains prostaglandins and interleukins (can cause bone resorption) * Blood products in cyst fluid in case of prior fracture
1 mage 1 nterpretation Pearls Fallen fragment sign is pathognomonic, indicates that lesion is fluid-filled
1.
2.
Presentation Most common signs/symptoms o Most lesions asymptomatic o Pain, swelling, stiffness at closest joint Clinical profile o 66% of cysts present with pathologic fractures Sudden onset of pain, often during exercise (playing tennis, soccer) o Growth arrest in 10% of patients Due to pathologic fracture (+/- surgical curettage), extension to physeal plate o Older patients with involvement of atypical sites (calcaneus, talus, ilium) usually asymptomatic
Demographics
4. 5.
6. 7. 8. 9.
Age: 10-20 years, 3-14 years: 80% Gender: M:F = 2-3:l
10.
Natural History & Prognosis
11.
Benign lesion, no malignant transformation Enlarge during skeletal growth Inactive, latent after skeletal maturity ~ ~ o n t a d e o regression us in majority of cases Recurrence rate after injection, curettage: 20-45% 64
3.
12. 13. 14.
Treatment Trephination: Drilling multiple holes into lesion +/irrigation o Performed in the operating room under general anesthesia Dual needle aspiration and percutaneous injection of corticosteroids (80-200 mg methylprednisolone) o 1-3 injection at 2 months interval Percutaneous injection of demineralized bone matrix and autogenous bone marrow Open curettage with bone graft in weight bearing bones o Recurrence 40-45% o Damage to growth plate may result in growth arrest Subtotal resection, allografting, packing with synthetic materials
15.
Richkind KE et al: Translocation (16;20) (p11.2;q13): Sole cytogenetic abnormality in a unicameral bone cyst. Cancer Genet Cytogenet 137:153-5, 2002 Rougraff BT et al: Treatment of active unicameral bone cyst with percutaneous injection of demineralized bone matrix and autogenous bone marrow. J Bone Joint Surg 84-A:921-9, 2002 Wilkins RM: Unicameral bone cysts. J Am Acad Orthop Surg 8:217-24, 2000 Greenspan A et al: Differential diagnosis of tumors and tumor-like lesions of bones and joints. 1st ed. Philadelphia PA, Lippincott-Raven,322-9, 1998 Lokiec F et al: Simple bone cyst: Etiology, classification, pathology, and treatment modalities. J Pediatr Orthop B 7:262-73, 1998 Capanna R et al: Unicameral and aneurysmal bone cysts. Orthop Clin North Am 27:605-14, 1996 Kransdorf MJ et al: Aneurysmal bone cyst: Concept, controversy, clinical presentation, and imaging. Am J Roentgen01 164573-80, 1995 Conway WF et al: Miscellaneous lesions of bone. Radiol Clin North Am 31:339-58. 1993 Mylle J et al: Simple bone cysts: A review of 59 cases with special reference to their treatment. Arch Orthop Trauma Surg 111:297-300, 1992 Rud B et al: Sim~lebone cvsts in children treated with methylprednisoione acetate. Orthopedics 14:185-7, 1991 Struhl S et al: Solitary (unicameral) bone cyst. The fallen fragment sign revisited. Skeletal Radiol 18:261-5, 1989 Blumberg ML: CT of iliac unicameral bone cysts. Am J Roentgen01 136:1231-2, 1981 McGlynn FJ et al: The fallen fragment sign in unicameral bone cyst. Clin Orthop 156:157-9, 1981 Weisel A et al: Development of a unicameral bone cyst. J Bone Joint Surg 62A:664-6, 1980 Norman A et al: Simple bone cyst: Factors of age dependency. Radiology 124:779-82,1977
UNICAMERAL BONE CYST IMAGE GALLERY Typical (Left) Lateral radiography shows a well-defined lytic lesion in the calcaneus. (Right) Axial FS T2 FSE MR shows a hyperintense lesion in the calcaneus with fluid-fluid levels.
(Left) Axial NECT shows a iytic expansilr lesion in the central iliac bone. Cortical thinning without periosteal reaction is noted. (Right) Anteroposterior hone scan shows expansion of the left iliac wing with decreased radiotracer u ~ t a k e .
Variant (Left) Anteroposterior radiography shows a lytic lesion in the proximal humerus with pathologic fracture. Note the osseous fragment in the dependent portion of the cyst (fallen fragment sign). (Right) Intra-operative photograph shows injection of corticosteroids into an UBC.
I
I
ANEURYSMAL BONE CYST
Coronal graphic shows an expansile, septated lesion in the distal tibia. Thinned but intact cortex is shown.
Axial T2WI MR shows an expansile lesion with fluid-fluid levels involving the proximal tibia. Note the surrounding edema.
Morphology: Eccentric geographic lytic lesion
Radiographic Findings
Abbreviations and Synonyms
Radiography o Multicystic, eccentric expansion of bone with thin
Aneurysmal bone cyst (ABC)
Definitions Expanrile lesion of bone containing thin-walled blood filled cystic cavities
o o
[IMAGING FINDINGS General Features Best diagnostic clue o Radiographs: Expansile lytic lesion with septations o MRI: Fluid-fluid levels Location o Long tubular bones: 70-80% o Pelvis: 5-10% o Spine (posterior elements): 15% May cross intervertebral disk to involve more than one vertebra o Hands: 10-15% o Metaphysis: 80-90% o Diaphysis: 10-20% o Intramedullary (most common) o Intracortical, intraperiosteal (rare) Size: 2-20 cm: mean: 5-8 cm
1
i
DDx: Aneurysmal Bone Cyst
-L
AP Radiography
Lat Radiography
o o
periosteal reaction type of bone with zone of transition Sclerotic margin ~rabeculationwithinlesion Internal calcification rare Phase of rapid growth with marked bone destruction can be mistaken for malignant neoplasm
CT Findings NECT o Helpful in delineating extent, soft tissue involvement o Can show trabeculations o Intact, thin cortex 0 HU: 20-78 o Fluid-fluid levels CECT: No enhancement of cystic components
M R Findings TlWI: Cyst of different signal intensity (different stages of blood products) T2WI
1
Osteosarcoma
Ax FS T2WI MR
AP Radiography
A P Radiography
ANEURYSMAL BONE CYST
-
-
Key Facts Arises in preexisting lesion (benign or malignant neoplasm) Epidemiology: 6% of primary bone lesions
Imaging Findings Radiographs: Expansile lytic lesion with septations MRI: Fluid-fluid levels
Top Differential Diagnoses
Clinical Issues
Most common signs/syrnptoms: Progressive pain and
Unicameral Bone Cyst (UBC) Chondromyxoid Fibroma (CMF) Telangiectatic Osteosarcoma Giant Cell Tumor (GCT) Metastases Osteoblastoma
swelling Locally destructive Recurrence in 10-20% No malignant transformation Curettage, cryosurgery, bone grafting
Pathology
Diagnostic Checklist
In case of recurrence, thorough examination of original radiographs and pathology specimens should be performed to exclude underlying neoplasm
Primary ABC Arises de-novo in bone without recognizable pre-existing lesion Secondary ABC
No surrounding sclerosis/periosteal reaction
o Cysts of different signal intensity (different stages of
blood products) o Surrounding edema: High signal T1 C+ o No enhancement of cystic components o Septa1 components can enhance ("honeycomb" appearance) Well-defined lesion, lobulated contour Cystic cavities with fluid-fluid levels Internal septations Rim of low signal intensity surrounding lesion, represents intact thickened periosteal membrane
Metastases Usually multifocal Destructive
Osteoblastoma Can look identical in the spine Calcified matrix
General Features
Angiographic Findings Hypervascular periphery of lesions
Nuclear Medicine Findings Bone Scan o Doughnut sign Increased peripheral uptake, photopenic center
lmaging Recommendations Best imaging tool: Radiographs diagnostic, MRI to detect fluid-fluid levels
1 DIFFERENTIAL DIAGNOSIS I
Unicameral Bone Cyst (UBC) Central location Little or no expansion Fallen fragment sign in case of fracture
Chondromyxoid Fibroma (CMF) May be indistinguishable Eccentric, expansile Metaphyseal MR: Solid lesion, no fluid-fluid levels
Telangiectatic Osteosarcoma Can be purely lytic Soft tissue extension
Giant Cell Tumor (GCT) Extends to subchondral bone
1 I
General path comments o Benign lesion characterized by cyst-like walls of fibrous tissue filled with blood o Can be easily mistaken for malignant neoplasm (pathologically and radiographically) Genetics: (6:17) (p21;p13) gene translocation reported Etiology o Represents neither cyst nor neoplasm o Represents reparative process triggered by tumor or trauma induced vascular process Osseous arterio-venous malformation, venous obstruction o Primary ABC Arises de-novo in bone without recognizable pre-existing lesion Can be caused by trauma o Secondary ABC Arises in preexisting lesion (benign or malignant neoplasm) Benign tumors: Giant cell tumor, osteoblastoma, chondroblastomas, fibrous dysplasia Malignant tumors: Osteosarcoma, chondrosarcoma, malignant fibrous histiocytoma (MFH) Epidemiology: 6% of primary bone lesions
Gross Pathologic & Surgical Features Cavernous blood-filled spaces lined by fibrous walls "Blood-filledsponge"
ANEURYSMAL BONE CYST Fluid-fluid levels represent sedimentation of red blood cells and serum within cystic cavities
Microscopic Features Blood-filled spaces alternating with more solid areas Lined by single layer of flat undifferentiated cells o Endothelial lining rarely seen Fibrous lining contains giant cells Solid tissue composed of fibrous, highly vascular, connective tissue
Presentation Most common signs/symptoms: Progressive pain and swelling Clinical profile o Rapid increase of pain over 6-12 weeks o Spinal lesions may cause cord compression (radiculopathy, quadriplegia), nerve root impingement 4 Scoliosis: 10% o Pathologic fracture: 20% o Limited range of motion if close to joint o History of trauma
Demographics Age o 10-30 years old o < 20 years in 76% Gender: M:F = 1:1.2
Natural History & Prognosis Benign Locally destructive Recurrence in 10-20% Recurrence increased in young patients with open growth plate No malignant transformation Never metastasizes
Treatment .--
Options, risks, complications o Important to identify underlying lesion which will change treatment o Curettage, cryosurgery, bone grafting o Resection Risk of bleeding during surgery Preoperative embolization o Embolotherapy Complications: Aseptic necrosis o Percutaneous Ethibloc injection o Radiation therapy Risk of sarcomatous degeneration
I DIAGNOSTIC CHECKLIST Consider In case of recurrence, thorough examination of original radiographs and pathology specimens should be performed to exclude underlying neoplasm
Image Interpretation Pearls Only osseous neoplasm named for its radiologic appearance
ELECTED REFERENCES Mahnken AH et al: Aneurysmal bone cyst: Value of MR imaging and conventional radiography. Eur Radio1 13:1118-24, 2003 2. Falappa P et al: Aneurysmal bone cysts: Treatment with direct percutaneous Ethibloc injection: Long term results. Cardiovasc Intervent Radiol 25:282-90, 2002 3. Woertler K et al: Imaging features of subperiosteal aneurysmal bone cyst. Acta Radiol 43:336-9, 2002 4. Greenspan A et al: Differential diagnosis of tumors and tumor-like lesions of bones and joints. 1st ed. Philadelphia PA, Lippincott-Raven, 329-39, 1998 5. Kransdorf MJ et al: Aneurysmal bone cyst: Concept, controversy, clinical presentation, and imaging. Am J Roentgen01 164573430, 1995 6. Freiberg AA et al: Aneurysmal bone cyst in young children. J Pediatr Orthop 14336-91, 1994 7. Wojno KJ et al: Fibro-osseous lesions of the face and skull with aneurysmal bone cyst formation. Skeletal Radiol 23:15-8, 1994 8. Gipple JR et al: Solid aneurysmal bone cyst. Orthopedics 15:1433-6, 1992 9. Murphy WA et al: Transcatheter embolization therapy of an ischial aneurysmal bone cyst. J Bone Joint Surg 64B:166-8, 1992 10. Verge1 de Dios AM et al: Aneurysmal bone cyst. A clinicopathologic study of 238 cases. Cancer 69:2921-31, 1992 11. Martinez V et al: Aneurysmal bone cyst: A review of 123 cases including primary lesions and those secondary to other bone pathology. Cancer 61:2291-304, 1988 1.
I
ANEURYSMAL BONE CYST
Typical (Left) Axial NECT shows a lytic expansile lesion involving the posterior elements o f a thoracic vertebra. There is no mineralized matrix. The lesion is surrounded by a thin shell of bone. (Right) Coronal T l Wl MR shows expansile lesion with fluid-fluid levels involving the right posterior elements of L3.
Variant (Left) Anteroposterior radiography shows a lytic expansile lesion involving the third metatarsal bone. There is a thin shell of periosteal bone surrounding the lesion. (Right) Anteroposterior bone scan shows increased radiotracer uptake in the periphery of the femoral metaphysis and decreased uptake in the central portion (doughnut sign).
Other (Left) Anteroposterior radiography shows a lytic expansile lesion in the proximal femoral metaphysis with pathologic fracture. (Right) Gross pathology shows hemorrhagic and cystic lesion with multiple septations ("blood-filled sponge ").
Coronal graphic shows lipomatous tumor (in yellow) involving the proximal femoral metaphysis. There is no cortical destruction or extraosseous extension.
Sagittal T l Wl MR shows calcaneal lesion almost entirely composed of fat. Central area of low SI is consistent with calcification. This corresponds to a Stage 1 lesion.
Size: 2-15 cm, mean: 3-6 cm Morphology: Expansile lesion containing fat
Abbreviations and Synonyms
Radiographic Findings
Lipoma of bone
Definitions Bone tumor comprised of mature adipose tissue
General Features
YO
Best diagnostic clue o MRI: Follows signal intensity of subcutaneous fat on all pulse sequences o CT: -40 to -100 HU (fat) Location o Metaphysis of long bones: 60% Femur (inter-subtrochanteric area), tibia, fibula, humerus o Calcaneus: 10% o Ribs: 10% o Craniofacial bones: 10% o Pelvis: 6% o Spine: 4% o Solitary lesion o Intramedullary o Parosteal
1
Radiography o Lytic lesion with trabeculation o Bone expansion with thinned, intact cortex o No periosteal reaction o Central calcifications (dystrophic calcification from fat necrosis) o Sclerotic, osseous pedicle in parosteal lipoma Grows from bone surface into adipose tissue
CT Findings NECT 0 -40 to -100 HU o Central cvst formation: 0-20 HU o Peripheral calcification CECT: No enhancement
M R Findings TlWI o Tumor: High signal intensity o Cysts: Intermediate signal intensity o Peripheral rim of low signal intensity (calcification) T2WI o Tumor: Intermediate signal intensity o Cyst: High signal intensity o FS T2 FSE
DDx: lntraosseous Lipoma
Cor FS T2 MR
Lat Radiography
A P Radiography
Lat Radiography
I
P
INTRAOSSEOUS LIPOMA Key Facts Imaging Findings MRI: Follows signal intensity of subcutaneous fat on all pulse sequences CT: -40 to -100 HU (fat)
Top Differential Diagnoses
I
Medullary Bone Infarct Unicameral Bone Cyst (UBC) Aneurysmal Bone Cyst (ABC) Fibroxanthoma Pseudotumor
Pathology Controversial if lesion represents true benign tumor of fat or is end result of involution of other bone lesions Reported incidence: 0.1% of all primary bone tumor Tumor: Dark (fat suppression) Cyst: High signal intensity o T2 FSE Tumor: High signal intensity Cysts: High signal intensity STIR o Tumor: Dark o Cyst: Bright TZ* GRE: Areas of low signal intensity (calcifications) TI C+: No enhancement Follows signal intensity of subcutaneous fat on all pulse sequences Homogeneous in majority of cases o Heterogeneous in cases of hemorrhage, myxomatous degeneration Helpful in demonstrating intraosseous extension
Likely more frequent with the advent of CT and MRI
Clinical Issues Most common signslsyrnptoms: Usually asymptomatic Pain, swelling Slow growing benign tumor Malignant transformation extremely rare Asymptomatic lesions require no treatment Curettage and packing with bone graft in large lesions with risk of fracture
Diagnostic Checklist
and prominent trabeculae may k e a s of osteO~orosis mimic intraosseous lipoma Follows signal intensity of fat on all pulse sequences
Aneurysmal Bone Cyst (ABC) Eccentric, expansile lesion Fluid-fluid levels No fat on CTIMRI
Fibroxanthoma Eccentric location Thin scalloped sclerotic margins No central calcifications No fat on CT/MRI
Pseudotumor Normal zone of porosity in anterior calcaneus, subtrochanteric femur No discrete mass No margins
Nuclear Medicine Findings Bone Scan o Variable o Can be normal o Peripheral increased uptake
Imaging Recommendations Best imaging tool: MRI Protocol advice: MRI with and without fat suppression
Medullary Bone Infarct Dense serpiginous peripheral calcifications o Lipoma: Central calcifications No osseous expansion Can be multifocal
Unicameral Bone Cyst (UBC) Well-defined, central, lucent lesion Scalloping of underlying cortex Fluid-filled Fallen fragment sign in case of fracture (excludes solid lesion) No fat on CT/MRI
General Features General path comments o Tumor composed of mature fat cells Variable small quantities of fat necrosis, cysts formation, and dystrophic calcifications Etiology o Controvgsial if lesion represents true benign tumor of fat or is end result of involution of other bone lesions May be the result of involuting bone infarcts, infection, other inflammatory processes Epidemiology o Reported incidence: 0.1% of all primary bone tumor o Likely more frequent with the advent of CT and MRI Associated abnormalities o Multiple lipomatosis: Fat deposition due to associated endocrine abnormalities (Type IV hyperlipoproteinemia)
Gross Pathologic & Surgical Features Circumscribed lobular mass, composed of yellow, soft adipose tissue Tumor may be encapsulated
Central areas of necrosis and dystrophic calcifications may be present
Microscopic Features Consists of lobules of mature lipocytes o Lipocytes slightly larger than non-neoplastic fat cells Fat necrosis with dystrophic calcifications can be present o Bone cysts may form in calcified regions
Staging, Grading or Classification Criteria Milgram staging system o Stage I: Viable mature lipocytes interspersed with fine bonv trabeculae Fat identical to subcutaneous fat, no cellular atypia Areas of remodeling, intact cortex o Stage 11: Expansion of lipocytes within trabeculae Areas of infarction, necrotic adipose tissue, calcifications o Stage 111: Extension of infarction to involve entire lesion Necrotic fat, calcifications, cyst formation, reactive new bone formation Resembles bone infarct
Presentation Most common signslsymptoms: Usually asymptomatic Clinical profile o Pain, swelling o Micro-trabecular fractures in area of weakened bone
Demographics Age: 5-75 years, mean: 38 years Gender: M:F = 1:l Ethnicity: No racial predilection
Natural History & Prognosis -
Slow growing benign tumor Malignant transformation extremely rare
-r -. 2
Treatment
Asymptomatic lesions require no treatment Curettage and packing with bone graft in large lesions with risk of fracture
Consider Areas of osteoporosis and prominent trabeculae may mimic intraosseous lipoma
Image Interpretation Pearls Follows signal intensity of fat on all pulse sequences
1 SELECTED REFERENCES 1. 2.
Campbell RS et al: Intraosseous lipoma: Report of 35 new cases and a review of the literature. Skeletal Radiol 32:209-22, 2003 Goto T et al: Intraosseous lipoma: A clinical study of 12 patients. J Orthop Sci 7:274-80, 2002
3. Jebson PJ et al: Intraosseous lipoma of the proximal radius 4.
5.
6. 7. 8.
with extraosseous extension and a secondary posterior interosseous nerve palsy. Am J Orthop 31:413-6, 2002 Propeck T et al: Radiologic-pathologic correlation of intraosseous lipomas. Am J Roentgen01 175:673-8, 2000 Greenspan A et al: Differential diagnosis of tumors and tumor-like lesions of bones and joints. 1st ed. Philadelphia PA, Lippincott-Raven, 339-42, 1998 Greenspan A et al: Intraosseous lipoma of the calcaneus. Foot Ankle Int 1853-6, 1997 Levin MF et al: Intraosseous lipoma of the distal femur: MRI appearance. Skeletal Radiol 25532-4, 1996 Blacksin MF et al: Magnetic resonance imaging of intraosseous lipomas: A radiologic-pathologiccorrelation. Skeletal Radiol 24:37-41, 1995 Rhodes RD et al: Intraosseous lipoma of the os calcis. J Am Podiatr Med Assoc 83:288-92, 1993 Williams CE et al: Intraosseous lipomas. Clin Radiol 47:348-50, 1993 Milgram JW: Intraosseous lipoma: Radiologic and pathologic manifestations. Radiology 167:155-60, 1988 Dooms GC et al: Lipomatous tumors and tumors with fatty component: MR imaging potential and comparison of MR and CT results. Radiology 157:479-83, 1985 Ramos A et al: Intraosseous lipoma: CT appearance. Radiology 157:615-9,1985 Milgram JW: Intraosseous lipomas with reactive ossification in the proximal femur. Report of eight cases. Skeletal Radiol 7:l-13, 1981 Freiberg RA et al: Multiple intraosseous lipomas with type-IV hyperlipoproteinemia. A case report. J Bone Joint S U I 56-A:1729-32, ~ 1974 Zorn DT et al: Intraosseous lipoma of bone involving the sacrum. J Bone Joint Surg 53-A:1201-4, 1971
1
I
INTRAOSSEOUS L I P O M A
(Left) Anteroposterior radiography shows a lytic lesion with central calcifications in the humeral diaphysis. (Right) Coronal T l Wl MR shows the humeral diaphyseal lesion to be of heterogeneous SI with areas following SI of fat and calcificat~ons.
(Lef) Lateral radiography shows lytic lesion in the calcaneus of fat density with central calcification. (Right) Axial NECT shows a calcaneal lesion of fat density with central calcifications and cyst formation.
Typical (Left) Sagittal T I WI MR shows a lesion in the tibia1 metaphysis with 51 of fat and central areas of low SI, consistent with calcification. (Right) Sagittal FS 7 2 FSE MR shows saturation of previously noted areas of high 51, corresponding to fat. Central area of intermediate SI with surrounding rim of high 51 corresponds to calcifications and fluid.
ADAMANTINOMA
Coronal graphic shows lobulated expansile tumor in the tibia1 metadiaphysis.
Lateral radiography shows multiple, confluent lytic lesions with areas of sclerosis involving the tibia1 diaphysis.
Radiographic Findings Abbreviations and Synonyms Angioblastoma, malignant angioblastoma, differentiated adamantinoma
Definitions Low-grade malignant tumor with preferential involvement of the tibia
[IMAGING FINDINGS General Features Best diagnostic clue: Large, lobulated, expansile lytic lesion in tibial meta-diaphysis Location o Tibia: 80% o Tibia and fibula: 5% o Femur: 5% o Humerus: 4% o Ulna: 3% o Fibula: 1% o Anterior metadiaphysis Size: 3-16 cm, mean: 11 cm Morphology o Eccentric, expansile, lytic lesion o Can break through cortex, soft tissue extension
Radiography o Well-defined, eccentric lesion in anterior tibial metadiaphysis Can extend to ends of bone o Multiple lytic lesions with sclerotic intervening bone o Additional foci in continuity with dominant lesion o Sclerotic, ground glass appearance in long standing lesions o Can have soap bubble appearance o Expansion and destruction of cortex Saw-toothed pattern of cortical destruction Soft tissue mass o Bowing deformity of tibia o Intracortical or intramedullary involvement o Classic adamantinoma: Destructive growth Older patients (> 20 years) o Differentiated adamantinoma: Intracortical, multicentric Osteofibrous dysplasia-like pattern Younger patients (< 20 years)
CT Findings NECT o Expansile lytic intramedullary lesion Low attenuation lesion o Helpful in demonstrating cortical disruption and associated soft tissue mass
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~ D D X : Adamantinoma
Lat Radiograohv
Lat Radiography
AP Radrography
AP Radiography
Lat Radiography
ADAMANTINOMA Key Facts Best diagnostic clue: Large, lobulated, expansile lytic lesion in tibial meta-diaphysis
Top Differential Diagnoses Osteofibrous Dysplasia Fibroxanthoma Chondromyxoid Fibroma (CMF) Metastases Possibly related to osteofibrous dysplasia Epidemiology: 0.1% of all primary bone tumors
Clinical Issues
Swelling near shin History of trauma in 60% Low grade malignancy Locally aggressive Local recurrence: 31% Metastases: 15-20% 10 year survival: 10-65% En bloc excision with wide surgical margins, bone graft
Diagnostic Checklist Location: Anterior tibia Age: Fused growth plate Important to differentiate adamantinoma from osteofibrous dysplasia (different management, prognosis)
Dull aching pain
MR Findings TlWI: Low signal intensity T2WI: High signal intensity TI C+: Intense enhancement of some foci TO determine extent of osseous and extraosseous involvement
Nuclear Medicine Findings Bone Scan: Increased uptake of radiotracer
Imaging Recommendations Best imaging tool: Radiographs diagnostic Protocol advice: MRI to evaluate intraosseous extent and soft tissue involvement
I DIFFERENTIAL DIAGNOSIS Osteofibrous Dysplasia Younger age Involves anterior tibial cortex o Adamantinoma more eccentric Well-defined Less aggressive No cortical destruction
Fibroxanthoma Lobulated, well-defined lesion with sclerotic borders No cortical invasion Periosteal reaction only in case of fracture
Chondromyxoid Fibroma (CMF) Expansile lytic lesion with sclerotic margins Geographic pattern of bone destruction No cortical invasion Matrix calcification rare
Osteomyelitis Periosteal reaction Sequestrum
Metastases Often multifocal o Use bone scan to look for additional lesions
Isolated metastasis to tibia extremely rare
General Features General ~ a t comments h o Low g;ade malignant tumor characterized by formation of epithelial cells surrounded by spindle cell fibrous tissue o Stromal component with fibrous dysplasia-like features present in many cases o Resembles ameloblastoma (adamantinoma) of jaw Genetics: Translocation in region 13q14 Etiolom o ~ ~ i t h e l iorigin al o Possibly related to osteofibrous dysplasia Epidemiology: 0.1% of all primary bone tumors
Gross Pathologic & Surgical Features Gray-white tumor of firm to soft consistency Smooth or lobulated Circumscribed at periphery Cystic degeneration, areas of hemorrhage May contain spicules of bone, cystic cavities, or straw colored fluid Involvement of cortex and periosteum common Can extent into soft tissues
Microscopic Features Epithelial component admixed with fibrous component Epithelial component: Islands of polyhedral cells 0 Peripheral nuclear palisading o Palisading and columnar arrangement of peripheral cells with stellate central cells Resembles ameloblastoma of the jaw o Prominent keratin staining Hypocellular fibrous connective tissue in spaces between epithelioid islands Epithelial spaces and stroma may be highly vascular o Lesion may resemble vascular neoplasm May have foci of Ewing-like areas (worse prognosis)
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May have osteofibrous dysplasia-like areas
[SELECTEDREFERENCES
Staging, Grading or Classification Criteria Surgical staging system for malignant musculoskeletal tumors o Stage IA: Low grade, intracompartmental o Stage IB: Low grade, extracompartmental o Stage IIA: High grade, intracompartmental o Stage IIB: High grade, extracompartmental o Stage IIIA: Low or high grade, intracompartmental, metastases o Stage IIIB: Low or high grade, extracompartmental, metastases
Presentation Most common signs/symptoms o Dull aching pain o Swelling near shin Clinical profile o Duration of symptoms: Months to years o Firm tender mass o History of trauma in 60% o Two case reports of paraneoplastic hypercalcemia
Demographics
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Age: 11-70 years, mean: 35 years Gender: M:F = 1.7:l Ethnicity: No racial predilection
11.
Natural History & Prognosis 12.
Low grade malignancy Locally aggressive Local recurrence: 31% o Tumor can recur up to 7 years following diagnosis Metastases: 15-20% o Metastasizes to lungs, other bones, lymph nodes, liver o Metastases occur late, 2-5 years after diagnosis 10 year survival: 10-65% Highest mortality rate in young women 7h
13. 14.
Treatment En bloc excision with wide surgical margins, bone graft Simple excision with marginal margins has high recurrence rate Amputation might be necessary in case of recurrence Radiation therapy and chemotherapy not useful
I DIAGNOSTIC CHECKLIST Consider Location: Anterior tibia Age: Fused growth plate
Image Interpretation Pearls Important to differentiate adamantinoma from osteofibrous dysplasia (different management, prognosis)
I
Kahn LB: Adamantinoma, osteofibrous dysplasia and differentiated adamantinoma. Skeletal Radiol 32:245-58, 2003 Torriani M et al: Magnetic resonance imaging of tibia1 classic adamantinoma at 2 tesla. J Comput Assist Tomogr 26:855-9, 2002 Dorfman HD et al: Bone tumors. 1st ed. St. Louis MO, Mosby, 949-73, 1998 Greenspan A et al: Differential diagnosis of tumors and tumor-like lesions of bones and joints. 1st ed. Philadelphia PA, Lippincott-Raven,347-50, 1998 Zehr RJ et al: Adamantinoma. Skeletal Radiol 24:553-5, 1995 Benassi MS et al: Cytokeratin expression and distribution in adamantinoma of the long bones and osteofibrous dysplasia of tibia and fibula. An immunohistochemical study correlated to histogenesis. Histopathology 25:71-6, 1994 Hazelbag HM et al: Adamantinoma of the long bones. A clinicopathological study in thirty-two patients with emphasis on histological subtype, precursor lesion, and biological behavior. J Bone Joint Surg 76A:1482-99, 1994 Sweet DE et al: Cortical osteofibrous dysplasia of long bone and its relationship to adamantinoma. A clinicopathologic study of 30 cases. Am J Surg Pathol 16:282-90, 1992 Adler CP: Case report 587: Adamantinoma of the tibia mimicking osteofibrous dysplasia. Skeletal Radiol 19:55-8, 1990 Sozzi G et al: Involvement of the region 13q14 in a patient with adamantinoma of the long bones. Hum Genet 85:513-5, 1990 Keeney GL et al: Adamantinoma of long bones. A clinicopathologic study of 85 cases. Cancer 64:730-37, 1989 Moon NF et al: Adamantinoma of the appendicular skeleton-updated. Clin Orthop 204:215-37, 1986 Alguacil-Garcia A et al: Osteofibrous dysplasia (ossifying fibroma) of the tibia and fibula and adamantinoma. A case report. Am J Clin Pathol 82:470-4, 1984 Weiss SW et al: Adamantinoma of long bone. An analysis of nine new cases with emphasis on metastasizing lesions and fibrous dysplasia-like changes. Hum Pathol 8:141-53, 1977
ADAMANTINOMA IMAGE GALLERY Typical (Left) Anteroposterior radiography s h o ~ a lytic expansile lesion involving the proximal tibia. (Right) Sagittal T2 WI MR shows expansile lesion with increased T2 signal involving the proximal tibia.
Typical (Left) Lateral radiography shows a mixed sclerotic and lytic lesion with surrounding sclerosis in the mid-tibia1 diaphysis. (Right) Sagittal T l Wl MR shows low signal of the mid-tibia1 diaphyseal lesion. lntraosseous extent is well seen on MRI.
Other (Left) Anteroposterior radiography shows multiple lytic lesions involving the distal tibia1 diaphysis. (Right) Coronal gross pathology shows lobulated hemorrhagic lesion involving the distal tibia.
SECTlON 9: Soft Tissue Tumors
Fibrous Tumors Fibrosarcoma, Soft Tissue Fibromatosis Malignant Fibrous Histiocytoma
Synovial Tumors Pigmented Villonodular Synovitis Synovial Sarcoma
Fatty Tumors Lipoma, Soft Tissue Liposarcoma, Soft Tissue
Neural Tumors Benign Peripheral Nerve Sheath Tumor Malignant Peripheral Nerve Sheath Tumor
Muscular Tumors Rhabdomyosarcoma, Soft Tissue
Vascular Tumors Hemangioma, Soft Tissue
Sagittal graphic shows intramuscular fibrosarcoma in the posterior aspect of the hip. Surrounding pseudocapsule is shown in white.
Coronal T1 C+ MR shows a heterogeneous, enhancing, deep soft tissue mass in the lateral right thigh.
o Poorly defined curvilinear/punctate peripheral
calcifications in 5-20% o Cortical erosions of adjacent bone
Abbreviations and Synonyms Fibroblastic malignancy, mesenchymal sarcoma
CT Findings NECT o Lobulated soft tissue mass with attenuation similar to muscle o Central hypodense areas Correspond to necrosis o High attenuation areas Correspond to hemorrhage CECT O Or hypervascular o Enhancement of solid components
Definitions Malignant mesenchymal tumor composed of fibroblasts
General Features Best diagnostic clue: Heterogeneous hemorrhagic deep soft tissue mass Location o Deep in large muscle groups of extremities: 7S0h Lower extremity: 45% Upper extremity: 28% o Trunk: 17% o Head and neck: 10% o Originates from intra- and intermuscular fibrous tissue, aponeuroses, tendons Size: 3-10 cm Morphology: Heterogeneous, deep soft tissue mass
M R Findings
Dmmm
Radiographic Findings Radiography o Soft tissue mass
I
TlWI o Intermediate signal intensity o Areas of low signal Correspond to calcifications T2WI o High signal intensity o Areas of low signal Correspond to calcifications STIR: High signal intensity T1 C+ o Enhancement of solid components
DDx: Fibrosarcoma, Soft Tissue MFH
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Cor T l W l M R
Cor T I C+ MR
Ax NECT
Sag T l W l MR
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Ax T2WI MR
1
FIBROSARCOMA, SOFT TISSUE
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Key Facts Imaging Findings Best diagnostic clue: Heterogeneous hemorrhagic deep soft tissue mass
Top Differential Diagnoses Malignant Fibrous Histiocytoma (MFH) Fibromatosis Synovial Sarcoma Liposarcoma Malignant Peripheral Nerve Sheath Tumor (MPNST) Hematoma
Pathology Clinically and radiographically Similar to malignant fibrous histiocytoma Epidemiology: 5% of soft tissue sarcomas
Clinical Issues Most common signslsyrnptoms: Enlarging soft tissue mass Pain in 30-50% 5 year survival: 39-79% Local recurrence: 12-42% Metastases (lung, spine, skull, lymph nodes): 34-63% Surgical resection with wide margins Adjuvant radiation therapy Adjuvant chemotherapy for high grade fibrosarcomas
Diagnostic Checklist
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Always consult orthopedic surgeon before biopsy ~ imust be ~ planned ~ with future ~ tumor i excision ~ ~ in mind -
o Helpful in differentiating fibrosarcoma from
hematoma Heterogeneous often well defined soft tissue mass o Pseudocapsule Areas of hemorrhage can obscure underlying tumor
Ultrasonographic Findings Well-defined hypoechoic solid mass
Angiographic Findings Hypervascular soft tissue mass
Nuclear Medicine Findings Bone Scan: Early blood pool images can show mildly increased radiotracer uptake
Imaging Recommendations Best imaging tool: MRI Protocol advice: TI, T2WI MR, T1 C+ MR
1 DIFFERENTIAL DIAGNOSIS Malignant Fibrous Histiocytoma (MFH) Radiographically similar to fibrosarcoma Areas of extensive hemorrhage common
Fibromatosis Predominately low signal on T1 and T2WI MR No metastases
Synovial Sarcoma In proximity to joint Calcifications Cortical erosions Younger patients
Liposarcoma Presence of fat in > 40% Calcifications rare
Malignant Peripheral Nerve Sheath Tumor (MPNST) Related to neurovascular bundle
Hematoma No enhancing solid components Surrounding edema
1 PATHOLOGY General Features General path comments o Clinically and radiographically similar to malignant fibrous histiocytoma o Comprises low-grade end of spectrum that includes malignant fibrous histiocytoma at high-grade end Genetics: Rearrangements of RET oncogene in radiation induced fibrosarcomas Etiology o Possibly related to prior trauma Can arise in scar tissue or at site of prior injury o Can be radiation induced o Can form dedifferentiated portion of dedifferentiated chondrosarcoma Epidemiology: 5% of soft tissue sarcomas Associated abnormalities: Patients with neurofibromatosis have 10% risk of developing fibrosarcoma
Gross Pathologic & Surgical Features Soft-firm, gray-white, yellow, fleshy lobulated mass Pseudocapsule Large tumors infiltrate surrounding tissues
Microscopic Features Anaplastic spindle cells with varying degrees of differentiation Cells arranged in herringbone pattern Well-differentiated type: Marked fibrogenesis, rich in mature collagen, herringbone pattern o Osseous, cartilaginous metaplasia Poorly differentiated fibrosarcoma: Herringbone pattern less distinct o Areas of necrosis, hemorrhage Sclerosing epithelioid type: Rare variant o Hypocellular, densely hyalinized stroma
FIBROSARCOMA, SOFT TlSSUE o Epithelioid tumor cells arranged in nests, strands o Sarcomatous spindle cells
Staging, Grading or Classification Criteria Surgical staging system for malignant musculoskeletal tumors o Stage Ia: Low grade, intracompartmental o Stage Ib: Low grade, extracompartmental o Stage IIa: High grade, intracompartmental o Stage IIb: High grade, extracompartmental o Stage IIIa: Low or high grade, intracompartmental, metastases o Stage IIIb: Low or high grade, extracompartmental, metastases
Presentation Most common signslsymptoms: Enlarging soft tissue mass Clinical profile o Pain in 30-50% o Superficial lesions can cause skin ulcerations o Hypoglycemia due to excretion of insulin-like substances o Infantile fibrosarcoma: Rapidly growing soft tissue mass
Demographics Age o 30-70 years, peak: 35-55 years o Infantile fibrosarcoma: < 10 years Gender: M:F = 1.5:l Ethnicity: More frequent in Caucasians
Natural History & Prognosis Prognosis depends on tumor size, histologic subtype, location, metastases 5 year survival: 39-79% Local recurrence: 12-42% Reduced recurrence rate in case of postoperative radiation therapy Metastases (lung, spine, skull, lymph nodes): 34-63% Secondary fibrosarcomas have worse prognosis Infantile fibrosarcoma: Excellent prognosis, 5-year survival: 80%
Treatment Options, risks, complications o Surgical resection with wide margins o Adjuvant radiation therapy Recurrence: 12-30% o Adjuvant chemotherapy for high grade fibrosarcomas o Amputation may be necessary
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~ D ~ A C N O S TCHECKLIST ~C Consider Always consult orthopedic surgeon before biopsy Biopsies must be planned with future tumor excision in mind
Image Interpretation Pearls Radiologically often indistinguishable from malignant fibrous histiocytoma
1 SELECTEDREFERENCES Fletcher CD et al: Clinicopathologic re-evaluation of 100 malignant fibrous histiocytomas: Prognostic relevance of subclassification. J Clin Oncol 19:3045-50, 2001 Weiss SW et al: Enzinger and Weiss's soft tissue tumors, 4th ed. St.Louis MO, CV Mosby, 409-39, 2001 Pate1 SC et al: Sarcomas of the head and neck. Top Magn Reson Imaging 10:362-75, 1999 Borman H et al: Fibrosarcoma following radiotherapy for breast carcinoma: A case report and review of the literature. Ann Plast Surg 41:201-4, 1998 Delpla PA et al: Soft tissue tumors following traumatic injury: Two observations of interest for the medicolegal causality. Am J Forensic Med Path01 19:152-6, 1998 Ito T et al: In vitro irradiation is able to cause RET oncogene rearrangement. Cancer Res 532940-3, 1993 Wiklund TA et al: Postirradiation sarcoma: Analysis of a nationwide cancer registry material. Cancer 68524-31, 1991 Scott SM et al: Soft tissue fibrosarcoma. A clinicopathologic study of 132 cases. Cancer 64:925-31, 1989 Wetzel LH et al: A comparison of MR imaging and CT in the evaluation of musculoskeletal masses. Radiographics 7:851-874, 1987 Ninane J et al: Congenital fibrosarcoma. Cancer 58:1400-6, 1986 Petasnick JP et al: Soft tissue masses of the locomotor system: Comparison of MR imaging with CT. Radiology 160:125-33, 1986 Lindberg RD et al: Conservative surgery and postoperative radiotherapy in 300 adults with soft tissue sarcomas. Cancer 47:2391-7, 1981 Chung EB et al: Infantile fibrosarcoma. Cancer 38:729-39, 1976 Pritchard DJ et al: Fibrosarcoma - a clinicopathologic and statistical study of 199 tumors of the soft tissues of the extremities and trunk. Cancer 33:888-97, 1974 Exelby PR et al: Soft-tissue fibrosarcoma in children. J Pediatr Surg 8:415-20, 1973
FIBROSARCOMA, SOFT TlSSUE IMAGE GALLERY
(Left) Axial PD FSE MR shows tumor of intermediate to high S1 involving the thigh. (Right) Axial T1 C+ MR shows homogeneous, enhancing soft tissue mass in the right thigh.
Other (LLfi) Coronal gross pathology shows brown fleshy soft tissue mass with small areas of hemorrhage. (Right) micropathology shows fibroblasts arranged in distinct intersecting fascicles ("herringbone" pattern).
FIBROMATOSIS
Sagittal graphic shows fibromatosis (in red) arising from the medial plantar aponeurosis.
Coronal T I C+ MR shows large enhancing soft tissue mass centered in the medial thigh with areas of low signal.
Extremities: 60% Abdominal fibromatosis (abdominal desmoid) rn Mesentericlintraabdominal fibromatosis in Gardner syndrome rn Arises from deep structures (muscles of trunk and extremities) o Infantile fibromatosis Solitary lesion most common rn Multicentric lesions: 5-15% Size o Superficial type: 1-5 cm o Deep type: 5-10 cm, rarely > 20 cm Morphology: Soft tissue mass with invasion of adjacent tissues rn
Abbreviations and Synonyms Non-metastasizing fibrosarcoma, aggressive fibromatosis, desmoid tumor
Definitions Group of benign disorders characterized by fibrous growth, tendency to infiltrate adjacent tissues and to recur
General Features Best diagnostic clue o Soft tissue mass invading soft tissue planes o Predominately low signal on T1 and T2WI M R Location o Superficial fibromatosis: Slowly growing, small, often multiple lesions rn Palmar fibromatosis (Dupuytren contracture) Plantar fibromatosis (Ledderhose disease) rn Penile fibromatosis (Peyronie disease) rn Arises from superficial fasciae, aponeuroses o Deep fibromatosis: Rapidly growing, large rn Extraabdominal fibromatosis (extraabdominal desmoid)
Radiographic Findings Radiography o Soft tissue mass o Osseous involvement: 6-37% "Frondlike"periosteal reaction, erosions, scalloping
CT Findings NECT o Iso-, hypo-, hyperdense to muscle o If close to bone: Erosion, periosteal reaction CECT Enhancement during active phase
DDx: Fibrornatosis Fibrosarcoma
MFH
Cor T7 C+ MR
Ax NECT
Ax T1 C+ MR
Soft tissue mass invading soft tissue planes Predominately low signal on T1 and T2WI MR
Top Differential Diagnoses Malignant Fibrous Histiocytoma (MFH) Synovial Sarcoma Fibrosarcoma
Pathology Dupuytren contracture: Incidence 1-2% in general population, 20%in patients > 65 years Concomitant palmar and plantar fibromatosis: 10-65% Intra-abdominal fibromatosis associated with Gardner syndrome: 15%
MR Findings TlWI o Iso- hypointense to muscle o Dupuytren contracture: Low signal intensity If intermediate signal on TI, higher rate of recurrence Contracture of 4th and 5th metacarpophalangeal joints T2WI o Intermediate - low signal intensity (fibrous components) o Areas of high signal o Dupuytren contracture: Low signal intensity If intermediate signal on T2 higher rate of recurrence STIR: Hyper - isointense compared to surrounding muscle T1 C+ o Intense enhancement during active phase Enhancement of cellular areas o No significant enhancement during latent phase Poorly defined Invasion of fat/muscle Thickening of plantar aponeurosis
Ultrasonographic Findings Soft tissue mass of variable echogenicity Smooth well-defined margins
Imaging Recommendations Best imaging tool: MRI Protocol advice: TI, T2WI MR, T1 C+ MR
Malignant Fibrous Histiocytoma (MFH) Arises in deep soft tissues Calcifications Metastases
Synovial Sarcoma In proximity to joint
Palmar and plantar fibromatosis: Associated with diabetes, epilepsy, alcohol induced liver disease
Clinical Issues ~ o scommon t signs/symptoms: soft tissue mass Biologic behavior intermediate between benign fibrous lesions and fibrosarcoma Local recurrence: 20-77% Self limited disease, no metastases Fatalities from direct invasion of chest wall or neck, and infiltration of vital organs Surgical excision with wide margins Radiation therapy in aggressive recurrent lesions
Diagnostic Checklist Can look very aggressive and may be mistaken for sarcoma
Amorphous calcifications
Fibrosarcoma High signal on T2WI MR Areas of hemorrhage, necrosis Metastases
1 PATHOLOGY General Features General path comments: Soft tissue lesion characterized by proliferation of fibrous tissue, surrounded by abundant collagen Genetics o Superficial fibromatoses: Trisomies of chromosome 7, 8, 14 o Fibromatosis associated with Gardner syndrome: Abnormality of adenomatous polyposis coli (APC) gene Etiology o Superficial fibromatoses: Possibly caused by repetitive microtrauma or microvascular injury o Deep fibromatoses: Posttraumatic, postradiation Abdominal fibromatosis: Endocrine abnormalities (tumor occurs after pregnancy) Epidemiology o Dupuytren contracture: Incidence 1-2% in general population, 20% in patients > 65 years o Concomitant palmar and plantar fibromatosis: 10-65% Associated abnormalities o Intra-abdominal fibromatosis associated with Gardner syndrome: 15% o Palmar and plantar fibromatosis: Associated with diabetes, epilepsy, alcohol induced liver disease
Gross Pathologic & Surgical Features Firm, gray-white mass Streaky, scar like cross section No capsule or pseudocapsule May appear circumscribed, microscopically ill-defined borders
FIBROMATOSIS Interdigitating, infiltrative growth into surrounding muscle or soft tissue
Microscopic Features Proliferation of uniform fibroblastic cells Early proliferative phase: Immature fibroblasts Late mature phase: Fibrocytes with abundant dense collagenous stroma No cellular atypia Myxoid changes, areas of hemorrhage, and focal inflammation Resembling hypertrophic scar tissue
Amputation occasionally necessary Surgical excision with adjuvant radiation therapy o Recurrence: 20-30% Plantar fibromatosis: Well molded and padded shoes o Transference of weight away from nodules
Image Interpretation Pearls Can look very aggressive and may be mistaken for sarcoma
Staging, Grading or Classification Criteria Surgical staging system for benign musculoskeletal tumors o Stage 1: Latent o Stage 2: Active o Stage 3: Aggressive
Presentation Most common signs/symptoms: Soft tissue mass Clinical profile o Subcutaneous nodules o Flexion contracture o Pain in case of nerve compression o Deep lesions usually non tender o Penile fibromatosis: Plaque-like scar tissue o n penile shaft o Abdominal fibromatosis: Occurs after pregnancy, regression with menopause
Demographics Age o 20-40 years, peak: 23 years o Infantile fibromatosis: 0-2 years Gender o M:F = 1:l o Palmar fibromatosis: M:F = 4-7:l o Plantar fibromatosis: M:F = 1:l o Deep fibromatosis: M < F Ethnicity: More common in Caucasians
Natural History & Prognosis Biologic behavior intermediate between benign fibrous lesions and fibrosarcoma o No malignant transformation into fibrosarcoma Local recurrence: 20-77% o Younger patients have higher recurrence rate Self limited disease, n o metastases Fatalities from direct invasion of chest wall or neck, and infiltration of vital organs
Treatment Early surgery should be avoided due to increased risk of recurrence Surgical excision with wide margins o Predisposition for local regrowth if excision is 'incomplete o Recurrence: 40-70% Release of flexion contracture Radiation therapy in aggressive recurrent lesions
Breiner JA et al: Trisomy 8 and trisomy 14 in plantar fibromatosis. Cancer Genet Cytogenet 108:176-7, 1999 Arkkila PE et al: Dupuytren's disease: Association with chronic diabetic complications. J Rhematol24:153-9, 1997 Kransdorf MJ et al: Imaging of soft tissue tumors. 1st ed. Philadelphia PA, W.B. Saunders, 160-75, 1997 Romero JA et al: Different biologic features of desmoid tumors in adults and juvenile patients: MR demonstration. J Comput Assist Tomogr 19:782-7, 1995 Yacoe ME et al: Dupuytren's contracture: MR imaging findings and correlation with MR signal intensity and cellularity of lesions. Am J Roentgenol 160:813-7, 1993 Liu P et al: MRI of fibromatosis: With pathologic correlation. Pediatr Radiol 22:587-9, 1992 Quinn SF et al: MR imaging in fibromatosis:Results in 26 patients with pathologic correlation. Am J Roentgenol 156:539-42,1991 O'Keefe F et al: Magnetic resonance imaging in aggressive fibromatosis. Clin Radiol 42:170-3, 1990 Enneking WF: A system of staging musculoskeletal neoplasms. Clin Orthop 204:9-24, 1986 Hudson TM et al: Aggressive fibromatosis: Evaluation by computed tomography and angiography. Radiology 150:495-501, 1984
FIBROMATOSIS IMAGE GALLERY Typical (Lef)Anteroposterior radiography shows soft tissue mass and osseous destruction of the ulna in a patient with recurrent fibromatosis. (Right) Sagittal T I C+ MR shows infiltrating enhancing soft tissue mass with associated osseous destruction.
(Left) Sagittal T I WI MR shows well-defined soft tissue mass of low SI involving the dorsal aspect of the foot. (Right) Axial T2 WI MR of the foot shows heterogeneous soft tissue mass with areas of intermediate - low signal and foci of high signal.
(Left) Axial T1 WI MR shows well-defined soft tissue mass isointense to muscle in the posterior right thigh. (Right) Cross pathology shows circumscribed white tumor with coarsely trabeculated surface.
MALIGNANT FIBROUS HISTIOCYTOMA
Sagittal graphic shows MFH arising in the deep soft tissues of the posterior thigh. Areas of calcifications are shown in white. Hemorrhage is shown in red.
Coronal TlWl MR shows hemorrhagic deep seated mass in the medial right thigh.
Morphology: Heterogeneous, hemorrhagic, deep soft tissue mass
Abbreviations and Synonyms
Radiographic Findings
MFH, malignant fibrous xanthoma, xanthosarcoma, malignant histiocytoma
Definitions Sarcoma composed of spindle and pleomorphic cells demonstrating myofibroblastic differentiation
Radiography o Deep soft tissue mass o Curvilinear/punctate peripheral calcifications: 5-20% o Cortical erosions of adjacent bone
CT Findings General Features Best diagnostic clue o Heterogeneous hemorrhagic deep soft tissue mass o Any patient with spontaneous musculoskeletal hemorrhage should be evaluated for underlying MFH Location o Extremities: 75%, involves deep large muscle groups Lower extremity: 50% Upper extremity: 25% o Retroperitoneum: 15% o Head and neck: 5% o chest wall o Arises deep to the deep fascia Size: 5-15 cm
IO
I
NECT o Large lobulated soft tissue mass o Isodense to muscle o Central hypodense areas, corresponding to myxoid regions or necrosis o High attenuation areas, corresponding to hemorrhage o Punctate/curvilinear calcifications o Cortical erosions o Retroperitoneal tumor: Heterogeneous mass, invasion of abdominal wall CECT o Hypo- or hypervascular o Enhancement of solid components TlWI: Low to intermediate signal intensity T2WI: High signal intensity, especially myxoid type
DDx: Malignant Fibrous Histiocvtoma V
Fibrosarcoma
mm
M R Findings
ti
Fibromatos~s
sarcoma
;&Cor T I C+ MR
Cor T7 C+ M R
Cor T l W l MR
Sag T l W l MR
Ax T2 Wl M R
MALIGNANT FIBROUS HISTIOCYTOMA Key Facts Imaging Findings Heterogeneous hemorrhagic deep soft tissue mass Any patient with spontaneous musculoskeletal hemorrhage should be evaluated for underlying MFH Extensive areas of hemorrhage can obscure underlying neoplasm
Top Differential Diagnoses Fibrosarcoma Synovial Sarcoma Fibromatosis Hematoma Liposarcoma Malignant Peripheral Nerve Sheath Tumor (MPNST)
T1 C+: Nodular enhancement Heterogeneous often well defined soft tissue mass o Pseudocapsule Areas of calcification, hemorrhage, necrosis Extensive areas of hemorrhage can obscure underlying neoplasm o Fluid-fluid levels in areas of hemorrhage
Ultrasonographic Findings Well-defined heterogeneous solid mass Hypoechoic areas correspond to necrosis
Angiographic Findings Hypervascular soft tissue mass
Nuclear Medicine Findings Bone Scan: Increased radiotracer uptake on blood pool images
Imaging Recommendations Best imaging tool: MRI Protocol advice: TI, T2W1, T1 C+ MR
I DIFFERENTIAL DIAGNOSIS -
Fibrosarcoma Radiographically often indistinguishable
Synovial Sarcoma In proximity to joints Cortical erosions Younger patients
Fibromatosis Predominately low signal on T1 and T2WI MR No metastases
Hematoma Nonenhancing solid components Surrounding soft tissue edema
Liposarcoma Presence of fat in > 40% Calcifications rare
Pathology Most common primary malignant soft-tissue tumor of late adult life 20-30% of all soft tissue sarcomas
Clinical Issues Most common signs/symptoms: Painless soft tissue mass with progressive enlargement over several months Aggressive neoplasms with tendency to recur and metastasize 5-year survival: 65-7096, retroperitoneal tumors: 15-20% Stage I: Surgical resection with wide margins Stage IT: Surgical resection with adjuvant radiation or chemotherapy
Malignant Peripheral Nerve Sheath Tumor (MPNST) Related to neurovascular bundle
1 PATHOLOGY General Features General path comments: Clinically and radiographically similar to fibrosarcoma Genetics: Imbalances in DNA sequence copy number Etiology o Derived from primitive mesenchyme with fibro- or myofibroblastic differentiation o Controversial if tumor represents specific entity with uniform pathogenesis or heterogeneous group of undifferentiated sarcomas o Can be radiation induced Epidemiology o Most common primary malignant soft-tissue tumor of late adult life o 20-30% of all soft tissue sarcomas o Most common radiation induced sarcoma Associated abnormalities: Hematological diseases: Lymphoma, multiple myeloma
Gross Pathologic & Surgical Features Multilobulated, gray-brown fleshy mass, attached to adjacent structures Focal areas of hemorrhage and necrosis Size at diagnosis usually over 5 cm
Microscopic Features Storiform/pleomorphic type: 50-60% o Fibroblast like spindle cells and giant cells resembling histiocytes, arranged in pleomorphic-storiform pattern o Most common in extremities Myxoid type: 25% o More than 50% of tumor must have myxoid stroma o Myxoid tissue: Large amount of mucoid material
MALIGNANT FlBROUS HlSTlOCrCOMA Extracellular mucopolysaccharide and hyaluronic acid o Most common in extremities and retroperitoneum Giant cell type: 5-10% o Osteoclast-like giant cells o Necrotic and hemorrhagic foci common o Osteoid in 50% o Most common in extremities Inflammatory type: 5-10% o Inflammatory and foam cells o Can present with fever and leukocytosis o Most common in retroperitoneum
Staging, Grading or Classification Criteria Surgical staging system for malignant musculoskeletal tumors o Stage Ia: Low grade, intracompartmental o Stage Ib: Low grade, extracompartmental o Stage IIa: High grade, intracompartmental o Stage IIb: High grade, extracompartmental 0 Stage IIIa: Low or high grade, intracompartmental, metastases 0 Stage IIIb: Low or high grade, extracompartmental, metastases -
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Presentation Most common signs/symptoms: Painless soft tissue mass with progressive enlargement over Several months Clinical profile o Any deep-seated invasive intramuscular mass in a patient > 50 years is most likely MFH o Any patient with spontaneous musculoskeletal hemorrhage should be evaluated for underlying MFH o Patients with retroperitoneal MFH: Fever, malaise, weight loss, increased abdominal pressure
Demographics Age: 10-90 years, peak: 50 years Gender: M:F = 2:l Ethnicity: More common in Caucasians
Natural History & Prognosis Aggressive neoplasms with tendency to recur and metastasize Prognosis depends on tumor size, depth, location, histologic subtype Local recurrence: 19-31% Metastases: 35-41% o Lung: 90%, lymph nodes: 4-12%) bone: 8%, liver: 1% 5-year survival: 65-7096, retroperitoneal tumors: 15-20% Tumor < 5 cm: 80% 5-year survival Tumor 5-10 cm: 65% 5-year survival Tumor > 10 cm: 40-50% 5-year survival
Treatment Stage I:Surgical resection with wide margins Stage 11: Surgical resection with adjuvant radiation or chemotherapy
Neoadjuvant and adjuvant chemotherapy Intra-arterial chemotherapy Radiation therapy
..
Consider Always consult orthopedic surgeon before biopsy Biopsies must be planned with future tumor excision in mind
Image Interpretation Pearls Spontaneous intramuscular hemorrhage in adult patient suspect underlying MFH
Mairal A et al: Loss of chromosome 13 is the most frequent genomic imbalance in malignant fibrous histiocytomas. A comparative genomic hybridization analysis of a series of 30 cases. Cancer Genet Cytogenet 111:134-8, 1999 2. Salo JC et al: Malignant fibrous histiocytoma of the extremity. Cancer 85:1765-72, 1999 3. Larramendy ML et al: Comparative genomic hybridization of malignant fibrous histiocytoma reveals a novel prognostic marker. Am J Pathol 151:1153-61, 1997 4. Miller 'IT et al: MRI of malignant fibrous histiocytoma of soft tissue: Analysis of 13 cases with pathologic correlation. Skeletal Radio1 23:271-5, 1994 5. Murphey MD et al: From the archives of the AFIP. Musculoskeletal malignant fibrous histiocytoma: Radiologic-pathologic correlation. Radiographics 142307-26, 1994 6. Fletcher CD: Pleomorphic malignant fibrous histiocytoma: Fact or fiction? A critical reappraisal based on 159 tumors diagnosed as pleomorphic sarcoma. Am J Surg Path01 16:213-28, 1992 7. Iwasaki H et al: Malignant fibrous histiocytoma: A tumor of facultative histiocytes showing mesenchyrnal differentiation in cultured cell lines. Cancer 69;437-47, 1992 8. Pezzi CM et al: Prognostic factors in 227 patients with malignant fibrous histiocytoma. Cancer 69:2098-103, 1992 9. Panicek DM et al: Hemorrhage simulating tumor growth in malignant fibrous histiocytoma at MR imaging. Radiology 181:398-400, 1991 10. Sanchez RB et al: Musculoskeletal neoplasms after intraarterial chemotherapy: Correlation with MR images with pathologic specimens. Radiology 174:237-40, 1990 1.
1
MALIGNANT FIBROUS HISTIOCrrOMA
Typical
(Left) Coronal T l Wl MR shows encapsulated (pseudocapsule)large soft tissue mass in the medial right thigh. Areas of high and low signal correspond to hemorrhage and necrosis, respectively. (Right) Coronal T I C+ MR shows marked enhancement of the soft tissue mass. Nonenhancing areas correspond to necrosis.
Typical (Left) Axial T I C+ MR shows homogeneously enhancing intramuscular mass in the left shoulder. (Right) Sagittal T2Wl MR shows well defined round hyperintense lesion in the superficial soft tissues of the thigh.
Other
(Lef)Anteroposterior radiography shows large soft tissue mass involving the thigh. Note areas of calcification at the inferior aspect of the mass. (Right) Cross pathology shows circumscribed, yellow-white, multilobulated, fleshy mass.
1
PIGMENTED VILLONODULAR SYNOVlTlS
Sagittal graphic shows intraarticular mass hypertrophiedsynoviurn (in brown).
with
Axial T2* CRE MR shows frond-like projections of low S/.
..
Knee: 80% Hip, ankle, shoulder, elbow Usually monoarticular
Abbreviations and Synonyms
Size o GCTTS: 2-4 cm o PVNS: Larger, irregular Morphology: Villonodular frond-like proliferation of synovial membrane
PVNS, giant cell tumor of the tendon sheath (GC'ITS), benign synovioma
Definitions Family of benign proliferative lesions originating in synovium of the joint, bursa, and tendon sheath GC'ITS (nodular tenosynovitis): Localized form, extraarticular PVNS: Diffuse form, intraarticular
Radiographic Findings Radiography o GCTTS: Soft tissue mass Pressure erosions of underlying bone: 15% Calcifications may mimic synovial chondromatosis, calcific tendinitis o PVNS: Noncalcified, dense, soft tissue mass (hemosiderin deposits) Joint effusion Bony erosion: 50% Erosions in joints with tight capsule: Hip (93%), shoulder (75%), knee (26%) Erosions, subchondral cysts on both sides of joint Joint space preserved Secondary degenerative changes with concentric joint space narrowing, osteophytes in chronic disease Normal mineralization Calcifications rare
.
I
IMAGING FINDINGS General Features
14
Best diagnostic clue o MRI: Low signal on all pulse sequences o Radiographs/CT: Dense intra-articular soft tissue mass without calcifications Subchondral erosions with preserved joint space Location o GCTTS Hand and wrist (6589%): Volar aspect of digits Foot and ankle (5-15%): First and second toe Usually solitary lesion o PVNS: Involves large joints
Hammu .
DDx: Pigmented Villonodular Synovitis
rC. 2'
A x FS PD FSE MR
Lat Rad~ography
Sag T2WI MR
Ax FS PD MR
Sag T I WI MR
PIGMENTED VILLONODULAR SYNOVITIS Key Facts Imaging Findings I
MRI: Low signal on all pulse sequences Radiographs/CT: Dense intra-articular soft tissue mass without calcifications Subchondral erosions with preserved joint space
Top Differential Diagnoses Synovial Sarcoma Synovial Chondromatosis Hemophilia Rheumatoid Arthritis (RA) Posttraumatic Synovitis Lipoma Arborescence
Pathology
Clinical Issues Most common signs/symptoms: Limited joint mobility Sudden increase in pain due to torsion of synovial nodules Rapid accumulation of joint fluid after aspiration Benign, locally aggressive lesion Progressive destruction of articular cartilage and subchondral bone results in severe osteoarthritis PVNS: Recurrence 20-50% Complete synovectomy (open): Recurrence 20% Arthroscopic synovectomy (often piecemeal, incomplete): Recurrence 50% Total joint replacement
5% of all primary soft tissue tumors
CT Findings NECT o Soft tissue mass o Sharply defined erosions with sclerotic margins o Increased attenuation, relative to muscle due to hemosiderin o Joint effusion CECT Enhancement of synovium
MR Findings TlWI o GCTTS: Low signal intensity o PVNS: Nodular mass isolhypointense to muscle Foci of high signal represent lipid laden macrophages T2WI o GCTTS: Heterogeneous o Signal intensity equal to or lower than fat o PVNS: Iso/hypointense to muscle, scattered areas of hyperintensity PDIIntermediate: Low signal intensity T1 C+: Intense enhancement GCTTS: Well-defined soft tissue mass adjacent to tendon PVNS: Heterogeneous well-defined synovium-based mass o Margins may be obscured and difficult to separate from adjacent muscle o Extends away from joint space o Septations o Subchondral erosions o Low signal on all pulse sequences characteristic (due to presence of hemosiderin)
Angiographic Findings Hypervascular soft tissue mass
Nuclear Medicine Findings Bone Scan: Increased uptake on blood pool images can be seen
Imaging Recommendations Best imaging tool: MRI
Protocol advice: TI, T2WI MR, T1 C+ MR
1 DIFFERENTIAL DIAGNOSIS Synovial Sarcoma Arises outside joint Areas of calcifications MRI: Shorter T1 and longer T2 than PVNS
Synovial Chondromatosis Multiple intraarticular bodies Can be calcified or noncalcified
Hemophilia Usually affects multiple joints Can cause growth disturbance
Rheumatoid Arthritis (RA) No hemosiderin deposits Periarticular osteoporosis Joint space narrowing
Posttraumatic Synovitis High signal on T2WI MR
Lipoma Arborescence Composed of hypertrophic villi distended with fat Follows signal intensity of fat on all pulse sequences
1 PATHOLOGY General Features General path comments: Locally destructive fibrohistiocytic proliferation and villonodular protrusions of synovial membranes, affecting joints, bursae, tendon sheaths Genetics o Clonal chromosomal aberrations, aneuploidy Trisomies 5 and 7 Etiology o Controversial: Reactive inflammatory process o Low-grade, locally aggressive neoplasm
.
PIGMENTED VILLONODULAR SYNOVlTlS
Epidemiology o 5% of all primary soft tissue tumors o GCTTS: Second most common soft tissue mass of hand
Gross Pathologic & Surgical Features * GCTTS: Small rubbery, encapsulated multinodular mass o Yellow-brown color, due to excessive deposits of lipid and hemosiderin PVNS: Joint filled with unclotted dark blood o Villonodular frond like proliferation of synovial membrane o Cut surface: Yellow-brown due to iron pigment (hemosiderin)
Microscopic Features GCTTS: Synovial proliferation o Multinucleated giant cells, macrophages, fibroblasts, xanthoma cells o Hemosiderin PVNS: Synovial hyperplasia o Multinucleated giant cells, hemosiderin-laden macrophages Intra- and extracellular hemosiderin o Lipid laden histiocytes
Presentation Most common signs/symptoms: Limited joint mobility Clinical profile 0 GCTTS Slowly enlarging, mobile, soft tissue mass Pain increased with activity 0 PVNS Joint swelling, pain of insidious onset Increased skin temperature Pain increased with motion, improved by rest Sudden increase in pain due to torsion of synovial nodules Decreased range of motion, joint locking Joint effusion: Serosanguineous/xanthochromic fluid Recurrent sanguinous effusions without history of trauma Rapid accumulation of joint fluid after aspiration Pathologic fracture secondary to subchondral bone invasion can be seen
Demographics Age o GCTTS: 30-50 years, mean: 32 years o PVNS: 30-40 years, childhood appearance reported Gender o GCTTS: M:F = 1:l o PVNS: F:M = 2:l
Natural History & Prognosis Benign, locally aggressive lesion Progressive destruction of articular cartilage and subchondral bone results in severe osteoarthritis PVNS: Recurrence 20-50%
Treatment Complete synovectomy (open): Recurrence 20% o Knee: Anterior and posterior synovectomy to reduce recurrence rate Arthroscopic synovectomy (often piecemeal, incomplete): Recurrence 50% Intraarticular yttrium-90 radiation synovectomy (experimental) Synovectomy combined with low dose radiation Total joint replacement Joint fusion in patients with advanced disease
1 DIAGNOSTIC CHECKLIST Image Interpretation Pearls Can look like hemophilia but is monoarticular
1 SELECTEDREFERENCES
I
Blanco CE et al: Combined partial arthroscopic synovectomy and radiation therapy for diffuse pigmented villonodular synovitis of the knee. Arthroscopy 17:527-31, 2001 De Beuckeleer L et al: Magnetic resonance imaging of localized giant cell tumour of the tendon sheath (MRI of localized GCTTS). Eur Radiol 7:198-201, 1997 Cotten A et al: Pigmented villonodular synovitis of the hip: Review of radiographic features in 58 patients. Skeletal Radiol 24:l-6, 1995 Hughes TH et al: Pigmented villonodular synovitis: MRI characteristics. Skeletal Radiol 24:7-12, 1995 Abdul-Karim EW et al: Diffuse and localized tenosynovial giant cell tumor and pigmented villonodular synovitis: A clinicopathologic and flow cytometric DNA analysis. Hum Path01 23:729-35, 1992 Besette PR et al: Gadolinium-enhanced MRI of pigmented villonodular synovitis of the knee. J Comput Assist Tomogr 16:992-4, 1992 Fletcher JA et al: Trisomy 5 and trisomy 7 are non random aberrations in pigmented villonodular synovitis: Confirmation of trisomy 7 in uncultured cells. Genes Chromosomes Cancer 4:264-6, 1992 Karasick D et al: Giant cell tumor of tendon sheath: Spectrum of radiologic findings. Skeletal Radiol 21:219-24, 1992 Ogilvie-HarrisDJ et al: Pigmented villonodular synovitis of the knee. The results of total arthroscopic synovectomy, partial, arthroscopic synovectomy, and arthroscopic local excision. J Bone Joint Surg Am 74(1):119-23, 1992 Butt WP et al: Pigmented villonodular synovitis of the knee: Computed tomographic appearances. Skeletal Radiol 19:191-6. 1990
PIGMENTED VILLONODULAR SYNOVlTlS
Typical (Left) Sagittal T l Wl MR of the knee shows lobulated masses of low signal intensity. (Right) Coronal T2WI MR shows heterogeneous lobula ted mass with areas of high and low signal. Osseous erosions are noted.
Typical (Left) Sagittal T 1 Wl MR shows lobulated mass of low signal involving the anterior and posterior aspect of the ankle. (Right) Anteroposterior radiography shows lytic lesions on both sides of the joint. There is joint space narrowing. Residual contrast from prior arthrogram is noted.
Other (Left) Axial T l Wl MR shows large lobulated mass of low signal causing cortical erosions. (Right) Intra-operative photograph shows red-brown villonodular fronds.
SYNOVlAL SARCOMA
Sagittal graphic shows heterogeneous synovial sarcoma posterior to the talus. Cortical invasion is shown in the anterior aspect of the lesion.
o Deep soft tissues Sizei 3-8 cm Morphology: Well-defined round or lobulated soft tissue mass
Abbreviations and Synonyms Synovioma, tendosynovial sarcoma
Radiographic Findings
Definitions
Radiography o Soft tissue mass close to joint o Amorphous calcifications: 25-30% o Bone invasion: 10-20% Periosteal reaction, invasion of cortex, massive bone destruction rare o Juxta-articular osteoporosis
Sarcoma of mesenchymal origin occurring in para-articular regions of extremities
General Features
1D
Anteroposterior radiography shows large soft tissue mass with coarse calcifications eroding the great toe.
Best diagnostic clue o Radiographs, CT: Soft tissue mass with calcifications in proximity to joints o T2WI MR: Heterogeneous mass with triple signal intensity Location o Extremities: 80-95% Lower extremity: 60%, knee and foot Upper extremity: 15% o Head and neck: 10% o Trunk: 5-10% o Tuxta-articular soft tissues, tendon sheaths Within 5 cm of joint o Intraarticular: 5-10% Extension from extraarticular site into joint
CT Findings NECT o Soft tissue mass isodense to muscle o Areas of hemorrhage, necrosis, cysts, calcifications o Useful to identify soft tissue calcification and osseous involvement o To evaluate pulmonary metastases, can be calcified CECT o Marked enhancement o IV contrast helpful to differentiate from adjacent muscle, neurovascular bundle
mmBuM -
MR Findings
TlWI o Heterogeneous septated mass
-
DDX: Synovial Sarcoma
<
4
m'-
Lat Radiography
Sag T l W l MR
Sag T l W I MR
Lat Radiography
Ax NECT
SYNOVlAL SARCOMA Key Facts Imaging Findings
- -
Radiographs, CT: Soft tissue mass with calcifications in proximity to joints
Top Differential Diagnoses Soft Tissue Chondrosarcoma Myositis Ossificans Pigmented Villonodular Synovitis (PVNS) Parosteal Osteosarcoma Malignant Fibrous Histiocytoma (MFH) Juxtacortical Chondroma Fibromatosis
Pathology 8-10% of all soft tissue sarcomas Most common soft tissue sarcoma of hands and feet
Low - intermediate signal o Small lesions have homogeneous intermediate
signal, isointense to muscle T2WI o Heterogeneous mass with hyperintense, isointense, and hypointense areas o Triple signal intensity: 30% = Mixture of cystic and solid elements with hemorrhage and fibrous tissue o Cystic components with fluid-fluid levels: 18% T1 C+: Marked enhancement Infiltrative margins Bone erosion and destruction To differentiate from surrounding muscles and neurovascular bundle
Ultrasonographic Findings Well-defined soft tissue mass Heterogeneous echogenicity +/- cystic components
Angiographic Findings Hypervascular soft tissue mass
Nuclear Medicine Findings Bone Scan: Increased radiotracer uptake around areas of calcification PET: Helpful in differentiating recurrent tumor from post-therapeutic changes
Imaging Recommendations Best imaging tool: MRI Protocol advice o MRI to evaluate extent o CT/radiographs to evaluate for calcification
I DIFFERENTIAL DIAGNOSIS Soft Tissue Chondrosarcoma Arises in proximal part of extremities and buttocks Aggressive appearance with invasion of adjacent skeletal structures
Clinical Issues Slow growing palpable soft tissue mass Progressive pain Metastases in 80% Size less than 5 cm, young age (15 years or younger) have favorable prognosis 5 year survival rate: 27-7696, up to 82% in heavily calcified tumors 10 year survival rate: 20-63% (reflects relative high incidence of late metastases) Surgical resection with wide margins Local recurrence in 20-25% Surgical resection with preoperative radiation therapy Local recurrence: < 10%
Myositis Ossificans Distinctive zoning phenomenon Lucent center, dense ossified periphery
Pigmented Villonodular Synovitis (PVNS) Rarely calcifies Low signal on T1 and T2WI MR
Parosteal Osteosarcoma Periosteal reaction Incomplete cleft between lesion and adjacent cortex
Malignant Fibrous Histiocytoma (MFH) Rarely calcified Older patients
Juxtacortical Chondroma Involves surface of bone Can erode subchondral bone Periosteal new bone formation
Fibromatosis Predominately low signal on T1 and T2WI MR
1 PATHOLOGY General Features General path comments: Tumor of high malignancy but slow growth Genetics: Chromosome translocation t(X;18)(p11.2;q11.2) Etiology o Does NOT arise from synovial tissue o Likely originates from undifferentiated mesenchymal tissue (pluripotent mesenchyme of the limb bud) Epidemiology o 8-10% of all soft tissue sarcomas o 4th most common soft tissue sarcoma o Most common soft tissue sarcoma of hands and feet
SYNOVlAL SARCOMA o Bones: 8-11%
Gross Pathologic & Surgical Features Solid, sharply circumscribed, yellow, grey-white fleshy mass Smooth pseudocapsule Attached to surrounding tendons, tendon sheaths, joint capsule Areas of necrosis or hemorrhage Occasional spotty areas of calcification
Microscopic Features Biphasic type (most common): Spindle cell and epithelial component o Spindle and epithelial cells arranged in glandular or nest-like structure Monophasic type: Interdigitating fascicles formed by spindle cells o Only small number of epithelial cells Poorly differentiated type: Can be superimposed on other subtype o More aggressive, metastasizes earlier o Rich vascular pattern with thin walled vascular spaces, resembles hemangiopericytoma Foci of calcification usually in areas of hyalinization, periphery of tumor Chondroid and osseous metaplasia possible
Lesions with calcification have better prognosis Size less than 5 cm, young age (15 years or younger) have favorable prognosis 5 year survival rate: 27-76%, up to 82% in heavily calcified tumors 10 year survival rate: 20-63% (reflects relative high incidence of late metastases)
Treatment Surgical resection with wide margins o Local recurrence in 20-25% o Occurs in excision scarlamputation stump Surgical resection with preoperative radiation therapy o Local recurrence: < 10% High grade lesions: Radical resection and radiation therapy Chemotherapy in metastatic cases Neoadjuvant chemotherapy successful in some cases
Image Interpretation Pearls Does NOT arise from joint Often misdiagnosed as benign lesion (e.g., ganglion)
Staging, Grading or Classification Criteria Surgical staging system for malignant musculoskeletal tumors o Stage Ia: Low grade, intracompartmental o Stage Ib: Low grade, extracompartmental o Stage IIa: High grade, intracompartmental o Stage IIb: High grade, extracompartmental o Stage IIIa: Low or high grade, intracompartmental, metastases o Stage IIIb: Low or high grade, extracompartmental, metastases
Presentation
20
Most common signs/symptoms o Slow growing palpable soft tissue mass o Mass is firm and fixed to deeper structures Clinical profile o Progressive pain o ~ e n ~ o r ~ l r n odysfunction 'tor distal to lesion o Long duration of symptoms: Average 2-4 years Can be misdiagnosed as arthritis or synovitis o Metastases present at initial diagnosis in 25%
Demographics Age: 10-50, mean: 32 years Gender: M:F = 1.2:l
Natural History & Prognosis Slow growing malignant tumor with invasion of adjacent soft tissues and bone Lesions in hands and feet grow slower than lesions in more proximal extremities or trunk Metastases in 80% o Lungs: 60-90% o Lymph nodes: 5-20%
/SELECTED REFERENCES 1.
Weiss SW et al: Enzinger and Weiss's soft tissue tumors. 4th ed. St. Louis MO, CV Mosby, 1483-509,2001 2. Bergh P et al: Synovial sarcoma: Identification of low and high risk groups. Cancer 85:2596-607, 1999 3. Hirsch RJ et al: Synovial sarcomas of the head and neck: MR findings. Am J Roentgenol 169:1185-8, 1997 4. De Leeuw B et al: Identification of a yeast artificial chromosome (YAC) spanning the synovial sarcoma specific t(x;18)(p11.2;q11.2)breakpoint. Genes Chromosomes Cancer 6:182-9, 1993 5. Jones BC et al: Synovial sarcoma: MR imaging findings in 34 patients. Am J Roentgenol 161:827-30, 1993 6 . Kampe CE et al: Synovial sarcoma: A study of intensive chemotherapy in 14 patients with localized disease. Cancer 72:2161-9, 1993 7. McKinney CD et al: Intraarticular synovial sarcoma. Am J Surg Path01 16:1017-20, 1992 8. Menendez LR et al: Synovial Sarcoma: A clinicopathologic study. Orthop Rev 21:465-71,1992 9. Morton MJ et al: MR imaging of synovial sarcoma. Am J Roentgenol 156: 337-40, 1991 10. Ryan JR et al: The natural history of metastatic synovial sarcoma. The experience of the southwest oncology group. Clin Orthop 164:257-, 1982 11. Varela-DuranJ et al: Calcifying synovial sarcoma. Cancer 50:345-52, 1982
SYNOVIAL SARCOMA IMAGE GALLERY Typical (Left) Axial T I Wl MR shows round well-defined soft tissue mass of intermediate and central low signal in the anterior right thigh. (Right) Anteroposterior radiography shows calcified soft tissue mass in the right shoulder region.
Typical (Lefi) Lateral radiography shows soft tissue mass in the thigh with coarse calcifications. (Right) Axial NECT shows calcified soft tissue mass in the anterior thigh.
Typical
-
(Left)Axial T 1 C+ MR shows :ter eneous enh zing ass the pla otar rface of the foot. ( ~ k h tAxial ) FS T2 FSE MR shows heterogeneous soft tissue ass ?diaibes ignal the ank le. Note areas of low and high signal.
I
LIPOMA, SOFT TISSUE
Coronal graphic shows well defined subcutaneous lipma.
I
Coronal T l Wl MR shows large homogeneous mass of fat 51 involving the left thigh. Thin septations within the mass are noted.
Radiographic Findings Radiography o Hypodense soft tissue mass o Calcifications occasionally seen
Abbreviations and Synonyms Soft tissue lipoma
Definitions Benign soft tissue tumor composed of mature adipose tissue
General Features
12
Best diagnostic clue: Parallels signal intensity of subcutaneous fat on all pulse sequences Location o Can occur anywhere in the body o Superficial/subcutaneous (most common): Posterior trunk, neck, proximal extremities o Deep: Retroperitoneum, chest wall, deep soft tissues of hands and feet o Multifocal: 5-8% Size o < 5 cm: 80% o > 10 cm rare Morphology: Well-defined homogeneous fatty soft tissue mass
CT Findings NECT o Well-defined, homogeneous soft tissue mass: Low attenuation (-65 to 120 HU) Comparison with attenuation of surrounding fat helpful (fat attenuation can vary between different locations) o Occasional ossification within tumor o May cause cortical thickening when close to bone o Bone erosions rare CECT: No significant enhancement
M R Findings TlWI: High signal intensity T2WI: Intermediate signal intensity STIR: Low signal intensity T1 C+: No significant enhancement Parallels signal intensity of subcutaneous fat on all pulse sequences Differentiation from other lesions by fat suppression Well-defined and homogeneous, often with septations Intramuscular lipoma may be poorly marginated and infiltrate muscle planes
DDx: Lipoma, Soft Tissue L~posarcoma
Lipoma Arboresr.
Hematoma
AxT1 C+ MR
Sag T l W l MR
Cor T l W I MR
LIPOMA, SOFT TISSUE Key Facts Imaging Findings Best diagnostic clue: Parallels signal intensity of subcutaneous fat on all pulse sequences Well-defined, homogeneous soft tissue mass: Low attenuation (-65 to 120 HU) Use fat suppression sequences to differentiate from other lesions
Top Differential Diagnoses Liposarcoma Lipoma Arborescence Hematoma
Pathology Fat unavailable for systemic metabolism, does not change in size during starvation Most common soft tissue tumor Fibrolipoma: Contains fibrous tissue o Septations of low signal * Lipoblastoma: Cellular, immature lipoma, occurs in childhood, rare o Mixed lipomatous and nonspecific non-lipomatous components o Resembles liposarcoma Angiolipoma: Composed of fatty and vascular tissue o Can have flow voids, phleboliths Spindle cell lipoma: Contains large amounts of collagen forming spindle cells o Spindle cell elements: Low signal intensity Infiltrating lipoma: Extends between muscle fibers o Associated with muscle atrophy Neural fibrolipoma: Enlargement of nerve by fibrofatty tissue o Longitudinal serpiginous signal voids separated by areas of fat signal
Angiographic Findings Hypovascular soft tissue mass
lmaging Recommendations Best imaging tool: MRI, CT Protocol advice 0 Use fat suppression sequences to differentiate from other lesions o Place marker over subcutaneous lesion o Comparison with contralateral sidelextremity to identify subtle asymmetry
IDIFFERENTIAL DIAGNOSIS Liposarcoma Heterogeneous mass with fat and soft-tissue components Enhancement after IV contrast administration
Lipoma Arborescence Composed of hypertrophic villi distended with fat Likely reactive process to chronic synovitis Monoarticular Villous frondlike mass on MRI
50% of all soft tissue tumors Familial multiple lipomas
Clinical Issues Most common signslsymptoms: Usually asymptomatic Slowly growing mobile soft mass Can produce pain by compression of nerves Benign tumor Marginal en bloc excision of large or symptomatic lesions * Recurrence: 5%
Diagnostic Checklist
If palpable tumor not easily identified on MRI the diagnosis is often subcutaneous lipoma
Signal intensity of fat on all pulse sequences
Hematoma Heterogeneous Surrounding edema
General Features General path comments o Tumor tissue similar to ordinary body fat o Fat unavailable for systemic metabolism, does not change in size during starvation Genetics o Translocation between 12q13-15 o HMGI-C gene part of high morbility group protein gene family, mapped to 12q15 Etiology o Mesenchymal neoplasm o More common in obese patients and diabetics, often increases during weight gain o Blunt trauma or radiation can lead to overgrowth of fat indistinguishable from lipoma o Multiple lipomas reported in diabetic patients at the site of insulin injection Epidemiology o Most common soft tissue tumor o 50% of all soft tissue tumors o Occurs in 1% of population Associated abnormalities o Familial multiple lipomas Autosomal dominant inheritance Multiple subcutaneous lipomas Hypercholesterolemia in some cases o Cowden syndrome: Autosomal dominant Multiple hamartoma syndrome Multiple lipomas, hemangiomas, papillomatous lesions of skin and mucosa Multinodular goiter Gastrointestinal polyps o Proteus syndrome Rare hamartomatous disorder
LIPOMA, SOFT TISSUE Multiple lipomas, venous, lymphatic malformations, nevi Partial gigantism with limb overgrowth
Gross Pathologic & Surgical Features Soft, well-encapsulated, yellow lobulated mass Thin surrounding capsule Consists of yellow, grossly normal-appearing fat Greasy, myxoid cut surface
Microscopic Features Mature, uniform fat cells (adipocytes), slightly larger than non-neoplastic fat cells Fibrous connective tissue, associated with capsule or septations Well vascularized, vessels compressed by distended adipocytes
Staging, Grading or Classification Criteria Surgical staging system for benign musculoskeletal tumors o Stage 1: Latent o Stage 2: Active o Stage 3: Aggressive
Presentation Most common signs/symptoms: Usually asymptomatic Clinical profile o Slowly growing mobile soft mass o Deep intramuscular tumors can have firm consistency o Mass can harden after application of ice o Deep seated tumors can reach large size before diagnosis o Superficial lesions can be differentiated from cystic lesions by inability to transmit light o Can produce pain by compression of nerves
Demographics Age: 5-75 years; peak: 40-60 years Gender: M:F = 1:l
Natural History & Prognosis
24
Benign tumor Commonly presents as active stage 2 lesion, becomes latent over time Deep lesions can become remarkably large Displaces adjacent tissues, no invasion of fascia1 planes Malignant transformation reported in few cases o Subtle features of malignancy in these cases probably missed at initial presentation
Treatment Marginal en bloc excision of large or symptomatic lesions o Recurrence: 5% Liposuction
1 DIAGNOSTIC CHECKLIST Consider Lipoma variants can resemble liposarcoma and may require biopsy for diagnosis
Image Interpretation Pearls If palpable tumor not easily identified on MRI the diagnosis is often subcutaneous lipoma
ISELECTED
REFERENCES
Weiss SW et al: Enzinger and Weiss's soft tissue tumors. 4th ed. St.Louis MO, CV Mosby, 571-639, 2001 2. Willen H et al: Comparison of chromosomal patterns with clinical features in 165 lipomas: A report of CHAMP study group. Cancer Genet Cytogenet 10246-9, 1998 3. Kransdorf MJ et al: Imaging of soft tissue tumors. 1st ed. Philadelphia PA, W.B. Saunders, 57-79, 1997 4. Munk PL et al: Lipoma and liposarcoma: Evaluation using CT and MR imaging. Am J Roentgenol 169589-94, 1997 5. Stoll C et al: Multiple familial lipomatosis with polyneuropathy, an inherited dominant condition. Ann Genet 39:193-6, 1996 6. Schoenmakers EF et al: Recurrent rearrangements in the high mobility group protein gene, HMGI-C, in benign mesenchymal tumors. Nat Genet 10:436-44, 1995 7. Kransdorf MJ: Benign soft tissue tumors in a large referral population: Distribution of diagnoses by, age, sex, and location. Am J Roentgenol 164:395-402, 1995 8. Gelineck J et al: Evaluation of lipomatous soft tissue tumors by MR imaging. Acta Radio1 35:367-70, 1994 9. Mrozek K et al: Chromosome 12 breakpoints are cytogenetically different in benign and malignant lipogenetic tumors: Localization of breakpoints in lipoma to 12q15 and in myxoid liposarcoma to 12q13.3. Cancer Res 53:1670-5, 1993 10. Kransdorf MJ et al: Fat containing soft tissue masses of the extremities. Radiographics 11:81-106, 1991 11. Solvonuk PF et al: Correlation of morphologic and biochemical observations in human lipomas. Lab Invest 51:469-74, 1984 1.
LIPOMA, SOFT TISSUE IMAGE GALLERY (Left) Lateral radiography shows large mass of fat density in the anterior thigh. (Right) Axial T l Wl MR shows hyperintense mass of fat signal in the posterior paraspinous soft tissues.
Variant (Left) Lateral radiography shows soft tissue mass of fat density with areas of calcifications in the posterio~ thigh. (Right) Axial NECT in a patient with lipomatosis shows multiple lipomas replacing almost entire musculature of the left thigh.
Other (Left) Coronal T1 WI MR shows multiple lipomas of the hand in a patient with lipoma tosis. (Right) Intra-operative photograph shows multiple lobulated yellow masses involving the hand.
LIPOSARCOMA, SOFT TISSUE
Coronal graphic shows infiltrating soft tissue mass in the medial thigh. Areas of mature fat are shown in yellow
Axial T I C+ MR show heterogeneous, enhancing soft tissue mass with septations posterior to the proximal tibia. Surgery revealed a high grade liposarcoma.
o 2-30 cm, may be > 30 cm o Retroperitoneal tumors can weigh several pounds Morphology: Heterogeneous soft tissue mass with or without fat
Abbreviations and Synonyms Soft tissue li~osarcoma
Radiographic Findings
Definitions Malignant mesenchymal tumor with microscopic appearance of adipose tissue
Radiography o Nonspecific soft tissue mass o Ossification within tumor: 10%
CT Findings General Features Best diagnostic clue: Large, enhancing, septated mass with fatty and soft tissue components Location o Trunk/retroperitoneum: 42% o Lower extremity: 41% Buttocks Medial thigh rn Popliteal fossa ~ d d u c t o canal r o Upper extremity: 11% Shoulder Upper arms o ~ead-andneck: 6% o Arises along neurovascular bundle, between muscles Size
. .
Lh
NECT o Heterogeneous soft tissue mass o Fatty and soft tissue components o Fat frequently radiologically not detectable o Calcifications CECT Enhancement
M R Findings TlWI o Hypo- hyperintense o Septations: Hypointense T2WI o Hyperintense, near water density (myxoid cells) o Septations: Hyperintense T1 C+: Enhancing components Fat may or may not be present The more differentiated, the more the signal intensity of tumor approaches fat
DDx: Liposarcoma, Soft Tissue Lipoma
MFH
MPNST
Hematoma
Cor T l W l MR
Cor T I C+ MR
Ax T2WI MR
Cor T l W l MR
LBPOSARCOMA, SOFT TISSUE Key Facts Imaging Findings Best diagnostic clue: Large, enhancing, septated mass with fatty and soft tissue components The more differentiated, the more the signal intensity of tumor approaches fat
Top Differential Diagnoses Lipoma Malignant Fibrous Histiocytoma (MFH) Peripheral Nerve Sheath Tumors: Malignant (MPNST), Benign (BPNST) Hematoma Intraabdominal Desmoid
Clinical Issues Most common signs/symptoms: Usually painless mass Can cause symptoms from compression of neurovascular bundle, abdominal organs Weight loss despite large soft tissue mass Biologic behavior and prognosis determined by histologic type and size Metastases in 50% overall 5-year survival: 60% Stage I lesions: Surgical resection with wide margins Stage I1 lesions: Surgical resection with wide margins and radiation therapy
.
Pathology 2nd most common soft tissue sarcoma in adults 16-20% of all malignant soft tissue tumors Irregular thickened septa
Ultrasonographic Findings Hyperechoic heterogeneous soft tissue mass
Angiographic Findings Hypervascular soft tissue mass
Nuclear Medicine Findings PET: Increased FDG uptake
lmaging Recommendations Best imaging tool: MRI Protocol advice: TI, T2WI MR, T1 C+ MR
I DIFFERENTIAL DIAGNOSIS Lipoma Homogeneous soft tissue mass Occurs more commonly in subcutaneous tissues (liposarcoma: Deep soft tissues) No enhancement after IV contrast administration
Malignant Fibrous Histiocytoma (MFH) No fat components Often hemorrhagic
Peripheral Nerve Sheath Tumors: Malignant (MPNST), Benign (BPNST) Related to neurovascular bundle HU less than muscle May mimic fatty tissue (lipid rich Schwann cells) Entrapment of adjacent adipose tissue by plexiform neurofibromas
Hematoma Signal on T1 and T2WI MR longer than fat TlWI MR: Darker than fat T2WI MR: Brighter than fat Surrounding edema
lntraabdominal Desmoid No fat components
1 PATHOLOGY General Features General path comments o Mesenchymal sarcoma with different subtypes that shows wide range of behavior and prognosis Non metastasizing neoplasm to high grade sarcoma with metastatic potential Genetics o Myxoid and round cell type: Reciprocal translocation between chromosome 12 and 16 o Breakpoint 12q13.3 Etiology o Malignant tumor of mesenchymal origin with fat-forming cells (lipoblasts) o Relationship to trauma has been reported Epidemiology o 2nd most common soft tissue sarcoma in adults o 16-20% of all malignant soft tissue tumors
Gross Pathologic & Surgical Features Circumscribed, lobular tumor with smooth surface Color and consistency varies with histologic composition o Soft, bright yellow, fleshy, firm o Can have large areas of necrosis and hemorrhage
Microscopic Features Well-differentiated type: IS%, best prognosis o Large, mature lipocytes with varying degrees of nuclear atypia Myxoid type: 40-50% o Proliferating fibroblasts, plexiform capillary pattern, myxoid matrix, fat amount < 10% o Metastasizes to serosal and pleural surfaces, subcutis, spine Pleomorphic type: 20%, highly anaplastic tumor, pleomorphic cells growing in disorderly fashion o Voluminous cytoplasm filled with lipid vacuoles, displace and distort nuclei ("scalloped"effect) Round cell type: < lo%, poorly differentiated, highly cellular tumor
LIPOSARCOMA, SOFT TISSUE o Primitive, small, round cells with sporadic
lipoblastic differentiation o Areas of hemorrhage and necrosis common Immunohistochemistry: S-100 positive
Staging, Grading or Classification Criteria WHO classification: Well differentiated, dedifferentiated, myxoid, pleomorphic, round cell type Surgical staging system for malignant musculoskeletal tumors o Stage Ia: Low grade, intracompartmental o Stage Ib: Low grade, extracompartmental o Stage IIa: High grade, intracompartmental o Stage IIb: High grade, extracompartmental o Stage IIIa: Low or high grade, intracompartmental, metastases o Stage IIIb: Low or high grade, extracompartmental, metastases
Presentation Most common signs/symptoms: Usually painless mass Clinical profile o Painful in 10-15% o Can cause symptoms from compression of neurovascular bundle, abdominal organs o Patients with involvement of extremities present 5-10 years earlier than patients with retroperitoneal tumors o Weight loss despite large soft tissue mass o Metastases to lung (50%), visceral organs
Demographics Age o 50-60 years o Patients with liposarcomas involving extremities 10-15 years younger than patients with retroperitoneal liposarcomas Gender: M:F = 1:1, M > F
Natural History & Prognosis
2P
Biologic behavior and prognosis determined by histologic type and size Well differentiated type: Best prognosis, can recur locally, does not metastasize o 5-year survival: 80-100% Pleomorphic and round cell type: Poor prognosis, recur, metastasize o 5-year survival: 50% Size > 15 cm poor prognosis Metastases in 50% Overall 5-year survival: 60%
Treatment Stage I lesions: Surgical resection with wide margins o Resection with marginal margins, neoadjuvant radiation therapy o Recurrence in 60% Stage I1 lesions: Surgical resection with wide margins and radiation therapy o Radical resection, possible amputation
Surgical resection with radiation and chemotherapy for high grade stage 111 lesions
1 D~ACNOST~C CHECKLIST
1
Image Interpretation Pearls Liposarcoma often does not contain visible fat
Weiss SW et al: Enzinger and Weiss's soft tissue tumors. 4th ed. St. Louis MO, CV Mosby, 641-43, 2001 Arkun R et al: Liposarcoma of soft tissue: MRI findings with pathologic correlation. Skeletal Radiol 26:167-72, 1997 Kransdorf MJ et al: Imaging of soft tissue tumors. 1st ed. Philadelphia PA, W.B. Saunders, 79-101, 1997 Fletcher CD et al: Correlation between clinicopathological features and karyotype in lipomatous tumors: A report of 178 cases from the chromosomes and morphologic (CHAMP) collaborative study group. Am J Pathol 148:623-630, 1996 Kilpatrick SE et al: The clinicopathologic spectrum of myxoid and round cell liposarcoma: A study of 95 cases. Cancer 77:1450-8, 1996 Kransdorf MJ: Malignant soft tissue tumors in a large referral population: Distribution of diagnoses by age, sex and location. Am J Roentgen01 164:129-34, 1995 Jelinek JS et al: Liposarcoma of the extremities: MR and CT findings in the histologic subtypes. Radiology 186:455-9, 1993 Mrozek K et al: Chromosome 12 breakpoints are cytogenetically different in benign and malignant lipogenetic tumors: Localization of breakpoints in lipoma to 12q15 and in myxoid liposarcoma to 12q13.3. Cancer Res 53:1670-5, 1993 Crim JR et al: Diagnosis of soft-tissue masses with MR imaging: Can benign masses be differentiated from malignant ones? Radiology 185581-6, 1992. Sundaram M et al: Myxoid liposarcoma: Magnetic resonance imaging appearances with clinical and histological correlation. Skeletal Radiol 19:359-62, 1990. Bolen JW et al: Liposarcomas: A histogenetic approach to the classification of adipose tissue neoplasms. Am J Surg Pathol8:3-17, 1984
LIPOSARCOMA, SOFT TISSUE IMAGE GALLERY
I
Typical (Left) Axial T I C+ MR shows heterogeneous, enhancing soft tissue mass in the posterior upper arm, which was found to be a liposarcoma of round-cell type. (Right) Sagittal FS 72 FSE MR shows hyperintense, septated soft tissue mass in the posterior thigh. Surgery revealed a myxoid liposarcoma.
Typical (Left) Sagittal T I Wl MR shows heterogeneous mass with lipomatous components in the posterior thigh. Surgery revealed a high-grade liposarcoma. (Right) Sagittal T2 Wl MR of the high-grade liposarcoma shows marked hyperintensity of the tumor. Septations are better visualized on this T2 WI MR.
Other (Left) Sagittal T I WI MR shows well-defined mass in the posterior thigh with lipomatous components (hyperintense). Surgery revealed a well-differentia ted liposarcoma. (Right) Gross pathology shows lobular tumor with yellow and fleshy areas.
BENIGN PERIPHERAL NERVE SHEATH TUMOR
Coronal graphic shows BPNST in the medial thigh. The lesion is eccentric to the nerve consistent with Schwannoma. Surrounding epineurium is shown in yellow
Sagittal PD FSE MR shows sacral dumbbell-shaped nerve sheath tumor of intermediate signal.
Neural plexus, peripheral, or spinal nerve Cutaneous nerves most commonly involved o Neurofibroma Solitary in 90% o Schwannoma Mostly solitary rn Multiple in 5% Size o<5cm o Deep lesions associated with large nerves: Up to 15 cm Morphology: Soft tissue mass related to neurovascular bundle
Abbreviations and Synonyms Benign peripheral nerve sheath tumors (BPNST) divided into o Schwannoma (neurilemmoma) o Neurofibroma
Definitions Benign lesion of neural origin that may occur in peripheral nerves, soft tissue, skin, or bone
Radiographic Findings General Features
30
Best diagnostic clue o Circumscribed fusiform mass entering and exiting nerve o Best seen on long-axis MRI Location o Schwannoma Cutaneous nerves of head and neck Flexor surfaces of extremities (peroneal and ulnar nerves commonly involved) Posterior mediastinum rn Retroperitoneum o Neurofibroma
Radiography o Deep or superficial soft tissue mass o Mineralization within tumor uncommon o Erosion of adjacent bone
CT Findings NECT o Hypodense (20-30 HU) soft tissue mass, between muscle bundles associated with neurovascular bundle o Isodense to skeletal muscle CECT: Large lesions show marked enhancement
DDx: Benign Peripheral Nerve Sheath Tumor Hematoma
Ax T2WI M R
Cor T 7 W l MR
Ax T I C+ MR
BENIGN PERIPHERAL NERVE SHEATH TUMOR Key Facts Imaging Findings Circumscribed fusiform mass entering and exiting nerve Best seen on long-axis MRI Best imaging tool: MRI
Top Differential Diagnoses l align ant peripheral Nerve Sheath Tumor (MPNST) Hematoma Liposarcoma
Pathology Schwannoma: 5% of all benign soft tissue tumors Neurofibroma: Slightly more than 5% of all benign soft tissue tumors
MR Findings TlWI: Soft tissue mass isointense to muscle T2WI o Soft tissue mass hyperintense compared to surrounding fat o "Target sign": Center of low signal (due to collagen and condensed Schwann cells) T1 C+ o Variable enhancement o Often peripheral enhancement Well-defined fusiform mass Spinal involvement o Intradural extramedullary mass o Well-defined dumbbell shaped mass (extradural component extends through neural foramen) o Widening of intervertebral foramina 4 Erosion of pedicles = Scalloping of vertebral bodies Peripheral nerve involvement o Related to neurovascular bundle, nerve entering and exiting mass o Peripheral rim of fat ("split-fat" sign) o Can cause displacement of associated neurovascular bundle o Large masses can cause venous obstruction and hypertrophy of feeding vessels o Muscle atrophy can be seen Schwannoma o Nerve is eccentric to mass o Fibrous pseudocapsule Neurofibroma o Indistinct margins
Ultrasonographic Findings Hypoechoic well-defined mass
Imaging Recommendations Best imaging tool: MRI Protocol advice: T1, TZWI, TIC+ MR
Clinical Issues Most common signs/symptoms: Slowly growing painless mass Involvement of large nerves often produces neurologic symptoms Associated with NF-1: Neurofibromas, Lisch nodules, cafe-au-lait spots Only 10% of patients with neurofibromas have NF-1 Schwannoma: Recurrence unusual Potential for malignant transformation: 4% in NF-1, rare in solitary tumors Surgical excision of symptomatic lesions
IDIFFERENTIAL DIAGNOSIS Malignant Peripheral Nerve Sheath Tumor (MPNST) Involves major nerve trunks Sudden enlargement of pre-existing neurofibroma in NF-1 Usually > 5 cm
Hematoma Surrounding edema No enhancement of solid components
Liposarcoma Not related to neurovascular bundle BPNST may mimic fatty tissue: Lipid rich Schwann cells o Entrapment of adjacent adipose tissue by plexiform neurofibromas
General Features General path comments: Most important benign soft tissue tumors in which malignant transformation is acknowledged phenomenon Genetics o Neurofibromatosis Type 1 (NF-I), Von Recklinghausen's disease Autosomal dominant, one of most common genetic diseases High rate of penetrance 50% of cases from new mutations Genetic abnormality on chromosome 17 Tumor suppressor gene producing protein neurofibromin Etiology o Arises from tissue of neuroectodermal or neural crest origin o Schwannoma and neurofibroma contain cells that are closely related to normal Schwann cells o Might arise from Schwann cells
r
BENIGN PERIPHERAL NERVE SHEATH TUMOR Epidemiology o Schwannoma: 5% of all benign soft tissue tumors o Neurofibroma: Slightly more than 5% of all benign soft tissue tumors Associated abnormalities o NF-1: Multiple neurofibromas rn Skeletal abnormalities Kyphoscoliosis Lambdoid suture defects Pseudarthrosis (tibia) Rib deformities Meningoceles Optic nerve gliomas, astrocytoma
Gross Pathologic & Surgical Features Schwannorna o True capsule composed of epineurium o Involvement of large nerves: Tumor eccentric to nerve, nerve displaced to periphery of mass o Involvement of small nerves: Nerve often obliterated by mass o Degenerative changes with cyst formation, calcification, hemorrhage Neurofibroma o Firm, gray-white mass often without capsule o Lesion cannot be separated from involved nerve o Nerve may be seen entering and exiting fusiform tumor mass o Extension of tumor outside epineurium of small nerves o Solitary neurofibroma: Well-delineated, firm, white shiny o Plexiform neurofibroma: Multifocal myxoid lesions, "bag of worms", diagnostic of NF-1
Neurofibroma Superficial painless mass Involvement of large nerves often produces neurologic symptoms Associated with NF-1: Neurofibromas, Lisch nodules, cafe-au-lait spots Only 10% of patients with neurofibromas have NF-1
Demographics Age: 20-30 years Gender: M:F = 1:l
Natural History & Prognosis Schwannoma: Recurrence unusual o Malignant degeneration extremely rare Neurofibroma o Potential for malignant transformation: 4% in NF-1, rare in solitary tumors
Treatment Surgical excision of symptomatic lesions Schwannorna o Resection with sparing of associated nerve Neurofibroma o Excision of involved nerve necessary o Incomplete excision of neurologically important nerves to decrease neurological impairment
[DIAGNOSTIC CHECKLIST Consider Malignant transformation in patients with NF-1 with enlarging neurofibroma
Microscopic Features Schwannorna o Intermixed Antoni A cells: Cellular, arranged in short bundles or interlacing fascicles o Antoni B cells: Less cellular and organized, more myxoid component Neurofibroma o Does not contain Antoni A or B cells o Composed of interlacing bundles of Schwann cells, fibroblasts, with involvement of nerve fibers o Immunohistochemistry: Variable S:100 expression
Staging, Grading or Classification Criteria 32
Surgical staging system for benign musculoskeletal tumors o Stage 1: Latent o Stage 2: Active o Stage 3: Aggressive
Presentation Most common signs/symptoms: Slowly growing painless mass Clinical profile o Schwannoma Painless mass No neurologic symptoms
Weiss SW et al: Enzinger and Weiss's soft tissue tumors. 4th ed. St. Louis MO, CV Mosby, 1111-207, 2001 Beggs I: Pictorial review: Imaging of peripheral nerve tumors. Clin Radiol 52%-17, 1997 Gutmann DH et al: The diagnostic evaluation and multidisciplinary management of neurofibromatosis 1 and neurofibromatosis 2. JAMA 278:Sl-7, 1997 Kransdorf MJ et al: Imaging of soft tissue tumors, 1st ed. Philadelphia PA, W.B. Saunders, 238-54, 1997 Pollack IF et al: Neurofibromatosis 1and 2. Brain Pathol 75323-36, 1997 Bass JC et al: Retroperitoneal plexiform neurofibromas: CT findings. Am J Roentgen01 163:617-20, 1994 Suh JS et al: Peripheral (extracranial) nerve tumors: Correlation of MR imaging and histologic findings. Radiology 183:341-6, 1992 Stull M et al: Magnetic resonance appearance of peripheral nerve sheath tumors. Skeletal Radiol 20:9-14,1991 Sundaram M et al: Magnetic resonance imaging of soft tissue masses: An evaluation of fifty-three histologically proven tumors. Magn Reson Imaging 6:237-48, 1988
BENIGN PERIPHERAL NERVE SHEATH TUMOR IMAGE GALLERY Typical (Lef) Sagittal T 1Wl MR shows well-defined round BPNST of intermediate signal involving the ulnar nerve. (Right) Sagittal T1 C+ MR show heterogeneous enhancement of the ulnar nerve sheath tumor.
Variant (Left) Sagittal FS T2 FSE MR shows hyperintense plexiform neurofibroma in a pa tien t with NF 1. (Right) Axial FS T2 FSE MR shows hyperintense plexiform neurofibroma in a patient with N F I .
Other
I
MALIGNANT PERIPHERAL NERVE SHEATH TUMOR
Coronal graphic shows a fusiform mass arising from the sciatic nerve. Areas of hemorrhage and necrosis are shown in the center of the lesion.
1
Axial T2WI MR shows heterogeneous MPNST in the posterior thigh.
Radiographic Findings Radiography o Deep or superficial soft tissue mass o Calcifications common
Abbreviations and Synonyms Malignant peripheral nerve sheath tumors (MPNST) divided into o Malignant schwannoma o Neurofibrosarcoma
CT Findings NECT o Soft tissue mass hypodense to muscle o Heterogeneous areas corresponding to hemorrhage and necrosis o Calcifications CECT: Marked enhancement
Definitions Malignant lesion of neural origin that may occur in peripheral nerves, soft tissue, skin, or bone
MR Findings TlWI: Soft tissue mass isointense to muscle T2WI o Hyperintense compared to surrounding fat o T2 FSE: Hyperintense STIR: Hyperintense T1 C+: Marked enhancement Heterogeneous soft tissue mass with indistinct margins Areas of hemorrhage (fluid-fluid levels) Involves major nerve trunks, related to neurovascular bundle Can cause displacement of associated neurovascular bundle Nerve entering and exiting through mass
General Features
34
Best diagnostic clue o Large infiltrative often hemorrhagic soft tissue mass related to neurovascular bundle o Best seen on long-axis MRI Location o Neural plexus, peripheral, spinal nerves o Posterior mediastinum o Retroperitoneum o Proximal portion of extremities Size: > 5 cm Morphology: Infiltrative soft tissue mass related to neurovascular bundle
Sheath Tumor
Ax T I C+ M R
MFH
Hernatorna
Cor T l Wl MR
Cor T l WI M R
~
MALIGNANT PERIPHERAL NERVE SHEATH TUMOR Key Facts Imaging Findings Large infiltrative often hemorrhagic soft tissue mass related to neurovascular bundle Best seen on long-axis MRI
Top Differential Diagnoses Benign Peripheral Nerve Sheath Tumor (BPNST) Malignant Fibrous Histiocytoma (MFH) Hematoma
Pathology 5-10% of all malignant soft tissue tumors 25-75% occur in association with NF-1 NF-1: 3 4 % of patients develop MPNST
Nutrient vessels connected to proximal and distal poles of the nerve Infiltration of surrounding soft tissues Muscle atrophy can be seen Spinal involvement: Intradural extramedullary mass, dumbbell configuration o Widening of intervertebral foramina Erosion of pedicles Scalloping of vertebral bodies
.
Angiographic Findings Hypervascular soft tissue mass
Nuclear Medicine Findings Bone Scan: Increased radiotracer uptake on blood pool and delayed images PET o Increased FDG uptake o To detect malignant changes in plexiform neurofibroma
Imaging Recommendations Best imaging tool: MRI Protocol advice: TI, T2WI MR, T1 C+ MR
I DIFFERENTIAL DIAGNOSIS Benign Peripheral Nerve Sheath Tumor (BPNST) No invasion of surrounding structures Variable enhancement Sudden enlargement of pre-existing neurofibroma in NF1 suspicious for MPNST
Malignant Fibrous Histiocytoma (MFH) Not related to neurovascular bundle Often hemorrhagic
Hematoma No enhancing solid components Surrounding edema
Clinical Issues Most common signs/symptoms: Enlarging soft tissue mass Involves major nerve trunks, e.g., sciatic nerve, brachial or sacral plexus Pain and neurologic symptoms (motor weakness and sensory paresthesia) Sudden enlargement of preexisting neurofibroma in NF- 1 High grade sarcoma Local recurrence: 40% Metastases: 65% (lung, bone, pleura) Surgical resection Usually presents as stage IIb lesion: Requires radical resection Amputation often necessary
1 PATHOLOGY General Features General path comments: Tumor of nerve sheath, composed of Schwann cells and fibroblasts Genetics o Neurofibromatosis Type 1 (NF-I), Von Recklinghausen's disease Autosomal dominant, one of the most common genetic diseases High rate of penetrance 50% of cases from new mutations Genetic abnormality on chromosome 17 Increased Ras activity due to loss of NF-1 gene product, neurofibromin o Increased expression of CD44 family transaminase glycoproteins Might be responsible for tumor cell invasion and metastatic potential Etiology o Arise from tissue of neuroectodermal or neural crest origin o Occurs in 25-70% in association with NF-1 o Radiation induced in 11% (latency period: 10-20 years) Epidemiology o 5-10% of all malignant soft tissue tumors o 25-75% occur in association with NF-1 Associated abnormalities o NF-1: 3-5% of patients develop MPNST Skeletal abnormalities Kyphoscoliosis Lambdoid suture defects Pseudoarthrosis (tibia) Rib deformities Meningoceles Optic nerve gliomas, astrocytoma
..
. ... .
Gross Pathologic & Surgical Features Large fusiform mass associated with major nerve Often contains areas of hemorrhage and necrosis Infiltrate surrounding soft tissues Spreads along perineurium and epineurium
1
MALIGNANT PERIPHERAL NERVE SHEATH TUMOR Microscopic Features Heterotopic epithelioid or mesenchymal elements (mature foci of bone and cartilage): 10-15% Components of rhabdomyosarcoma may be present (malignant Triton tumor, often seen in NF-1) Resembles fibrosarcoma
Staging, Grading or Classification Criteria Surgical staging system for malignant musculoskeletal tumors o Stage Ia: Low grade, intracompartmental o Stage Ib: Low grade, extracompartmental 0 Stage IIa: High grade, intracompartmental o Stage IIb: High grade, extracompartmental o Stage IIIa: Low or high grade, intracompartmental, metastases o Stage IIIb: Low or high grade, extracompartmental, metastases
Presentation Most common signs/symptoms: Enlarging soft tissue mass Clinical profile o Involves major nerve trunks, e.g., sciatic nerve, brachial or sacral plexus Pain and neurologic symptoms (motor weakness and sensory paresthesia) o Sudden enlargement of preexisting neurofibroma in NF-1 o Associated with NF-1: Neurofibromas, optic nerve gliomas, Lisch nodules, cafe-au-lait spots
Demographics Age o 20-50 years o If associated with NF-1: 10-50 years Gender o M:F = 1:l o InNF-1: M > F
Natural History & Prognosis High grade sarcoma Local recurrence: 40% Metastases: 65% (lung, bone, pleura) 5-year survival: 50% Patient with NF-1 might have worse prognosis
Treatment Surgical resection o Local recurrence: 40°h Usually presents as stage IIb lesion: Requires radical resection o Amputation often necessary Preoperative radiation therapy, resection with wide margins
Consider Malignant transformation when preexisting neurofibroma enlarges
1 SELECTED REFERENCES --
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Lang-Lazdunski L et al: Malignant "Triton"tumor of the posterior mediastinum: Prolonged survival after staged resection. Ann Thorac Surg 751645-8, 2003 2. Su W et al: Malignant peripheral nerve sheath tumor cell invasion is facilitated by Src and aberrant CD44 expression. Glia 42:350-8, 2003 3. Weiss SW et al: Enzinger and Weiss's soft tissue tumors. 4th ed. St.Louis MO, CV Mosby, 1209-63, 2001 4. Ferner RE et al: Evaluation of (18) fluorodeoxyglucose positron emission tomography ((18) FDG PET) in the detection of malignant peripheral nerve sheath tumours arising from within plexiform neurofibromas in neurofibromatosis 1. J Neurol Neurosurg Psychiatry 68:353-7, 2000 5. Beggs I: Pictorial review: Imaging of peripheral nerve tumours. Clin Radiol 52:8-17, 1997 6. Kransdorf MJ et al: Imaging of soft tissue tumors, 1st ed. Philadelphia PA, W.B. Saunders, 240-54, 1997 7. Bass JC et al: Retroperitoneal plexiform neurofibromas: CT findings. Am J Roentgen01 163:617-20, 1994 8. Suh JS et al: Peripheral (extracranial) nerve tumors: Correlation of MR imaging and histologic findings. Radiology 183:341-6, 1992 9. Stull M et al: Magnetic resonance appearance of peripheral nerve sheath tumors. Skeletal Radiol 20:9-14,1991 10. Riccardi VM et al: Neurofibrosarcoma as a complication of von Recklinghausen neurofibromatosis. Neurofibromatosis 2:152-65, 1989 11. Sundaram M et al: Magnetic resonance imaging of soft tissue masses: An evaluation of fifty-three histologically proven tumors. Magn Reson Imaging 6:237-48, 1988 1.
MALlCNANT PERlPHERAL NERVE SHEATH TUMOR
(Lef)Coronal PDNntermediate MR shows large soft tissue mass, hyperintense to muscle, in the region of the femoral nerve in a patient with NF- 1. The mass was rapidly increasing in size and was found to represent a MPNST at surgery. (Right) Coronal T I C+ MR shows enhancing mass in the right medial thigh. Central nonenhancing areas are consistent with necrosis.
(Lefl) Axial FS 12 FSE MR in a patient with NF- 1 shows hyperintense mass associated with the femoral nerve. Note irregular projection into surrounding soft tissues, encasement and displacement of the femoral artery and vein. (Right) Coronal T I C+ MR shows infiltrative enhancing mass in the region of the medial malleolus with involvement of the medial side of the plantar arch, medial flexor tendons, and neurovascular bundle. Nonenhancing necrotic foci are
I
Other (Lef?) Sagittal FS T2 FSE MR show fusiform hyperintense tumor arising from the femoral nerve. This was found to represent a malignant schwannoma at surgery. (Right) Intra-operative photograph shows large fusiform mass arising from the femoral nerve. Note the enlarged nerve entering and exiting the tumor.
7
RHABDOMYOSARCOMA, SOFT TISSUE
Axial graphic shows heterogeneous soft tissue mass anterior to the femoral neck. Areas of hemorrhage are shown in red. Note the osseous metastases (in brown).
Sagittal T I C+ MR shows heterogeneous, enhancing mass in the gluteus musculature.
Radiographic Findings Abbreviations and Synonyms RMS, sarcoma botryoides
Definitions Mesenchyrnal sarcoma occurring in children characterized by rhabdomyoblastic differentiation
Radiography o Nonspecific soft tissue mass o Local bone invasion: 24% o Permeative pattern of bone destruction o Bone metastases: Ill-defined lytic lesions in metaphyses of long bones
CT Findings General Features
38
Best diagnostic clue: Soft tissue mass isointense to muscle Location o Head and neck: 44% Orbit, sinuses, nasopharynx o Genitourinary system: 20-25% Deep pelvic structures in region of pelvic floor, bladder, vulva, vagina, testicle o Extremities: 15% o Retroperitoneum and trunk: 15% Size o 3-4 cm o Pleomorphic type: > 10 cm Morphology: Soft tissue mass resembling muscle
NECT o Isodense to muscle o Orbit: Large soft tissue mass with ill-defined margins Destruction of orbital wall Extension into preseptal space, sinuses, intracranial cavity Associated sclerosis and periosteal reaction CECT: Heterogeneous enhancement
MR Findings TlWI: Isointense to muscle T2WI: Hyperintense, can also be iso-hypointense to muscle STIR: High signal intensity T1 C+: Heterogeneous enhancement Prominent vascularity with serpentine vessels Areas of hemorrhage
DDx: Rhabdomyosarcoma, Soft %sue
Ax T I C+ MR
Ax FS T2 FSE MR
Lat Radiography
RHABDOMYOSARCOMA, SOFT TISSUE Key Facts Imaging Findings Best diagnostic clue: Soft tissue mass isointense to muscle
Top Differential Diagnoses Neuroblastoma Ewing Sarcoma Lymphoma Leukemia
Pathology Most common soft tissue malignancy in children 19% of all childhood soft tissue sarcomas
Clinical Issues Most common signs/symptoms: Soft tissue mass
Rapidly progressive exophthalmos, proptosis with orbital involvement Abdominal pain, distension (from bladder outlet obstruction) Metastases in 20% at presentation High grade malignancy with rapid growth, local recurrence and metastases 5-year survival for patients < 21 years: 30-80% 2-year survival for adults: 20-50% Survival following relapse: 32% at 1 year, 17% at 2 years Tumor of orbit and GU tract: Best prognosis Retroperitoneal tumors: Worst prognosis Resection with wide margins Adjuvant and neoadjuvant chemotherapy
Ultrasonographic Findings Isoechoic to muscle High diastolic flow
Leukemic involvement of bones can look similar to metastases from rhabdomyosarcoma Can have associated soft tissue component
Hypervascular soft tissue mass
1 PATHOLOGY
Nuclear Medicine Findings
General Features
Angiographic Findings
Bone Scan: Increased radiotracer uptake on blood pool images PET o Increased FDG uptake o Helpful in differentiating tumor recurrence from post therapeutic changes
Imaging Recommendations Best imaging tool: MRI Protocol advice o TI, T2WI MR, TI C+ MR o Whole body STIR for staging
I DIFFERENTIAL DIAGNOSIS Neuroblastoma Coarse calcifications within tumor (40-70s) Located along sympathetic neural chain Catecholamine production
Ewing Sarcoma Originates in bone marrow Extension into soft tissues common
Lymphoma Lymphadenopathy Orbital lymphoma often presents without systemic disease Well-defined high density mass Osseous lymphoma can have associated soft tissue component
Leukemia Can infiltrate lacrimal glands, extraocular muscles
General path comments o Mesenchymal sarcoma that can arise anywhere in the body Predominantly involving head and neck, genitourinary tract, retroperitoneum, and extremities Genetics o Abnormalities of short arm of chromosome 11 o Translocation of (2;13) or (1;13) Etiology o Primary mesenchymal tumor with rhabdomyoblastic differentiation Originally thought to arise from striated muscle o Increased incidence in patients with neurofibromatosis Epidemiology o Most common soft tissue malignancy in children o 19% of all childhood soft tissue sarcomas
Gross Pathologic & Surgical Features Firm rubbery gray-white to pink soft tissue mass Infiltration into surrounding tissues Areas of necrosis, cystic degeneration
Microscopic Features Embryonal type: Most common: 49-70%, best prognosis o Small cells with spindle-shaped hyperchromatic nuclei, eosinophilic cytoplasm (rhabdomyoblasts) Alveolar type: 18-4596, worst prognosis, high rate of early regional and distant metastases o Small round cells forming nests separated by fibrous connective tissue Pleomorphic type: Rare o Large tumor cells with eosinophilic cytoplasm
RHABDOMYOSARCOMA, SOFT TlSSUE o Bone (long bones, spine, ribs, skull), bone marrow o Liver
o Resembles malignant fibrous histiocytoma o Myo-Dl antibodies
Staging, Grading or Classification Criteria National cancer institute classification o Embryonal rhabdornyosarcoma (favorable): Conventional, pleomorphic, leiomyomatous o Alveolar rhabdornyosarcoma (unfavorable): Conventional, solid alveolar o Pleomorphic rhabdornyosarcoma o Rhabdomyosarcoma, "other" Surgical staging system for malignant musculoskeletal tumors o Stage la: Low grade, intracompartmental o Stage Ib: Low grade, extracompartmental o Stage IIa: High grade, intracompartmental o Stage IIb: High grade, extracompartmental o Stage IIIa: Low or high grade, intracompartmental, metastases o Stage IIIb: Low or high grade, extracompartmental, metastases
Presentation Most common signs/symptoms: Soft tissue mass Clinical profile o Symptoms depend on tumor location o Most patients present with stage IIb lesion o Rapidly progressive exophthalmos, proptosis with orbital involvement o Abdominal pain, distension (from bladder outlet obstruction) o Metastases in 20% at presentation o Boneljoint pain from osseous metastases o Anemia, thrombocytopenia, neutropenia
Demographics Age o Embryonal type Birth to 15 years, peak: 8 years o Alveolar type: Adolescents and young adults 10-25 years, peak: 16 years o Pleomorphic type: Adults > 45 years Gender 0 M:F = 1.4-1.7:l o GU tract: M:F = 2-3:l o Extremities: M:F = 1:1.2 o Orbit: M:F = 1:1.2 Ethnicity: More common in Caucasians
Natural History & Prognosis * High grade malignancy with rapid growth, local recurrence and metastases 5-year survival for patients < 21 years: 30-80% 2-year survival for adults: 20-50% Survival following relapse: 32% at 1year, 17% at 2 years Tumor of orbit and GU tract: Best prognosis Retroperitoneal tumors: Worst prognosis Hematogenous metastases o Lungs, pleura (most common)
o Lymph nodes
Treatment Resection with wide margins Adjuvant and neoadjuvant chemotherapy Adjuvant radiation therapy o Risk of radiation induced sarcomas Amputation may be necessary
Consider Rhabdomyosarcoma in young adults with soft tissue mass
Bredella MA et al: Value of FDG PET in conjunction with MR imaging for evaluating therapy response in patients with musculoskeletal sarcomas. Am J Roentgenol 179:1145-50, 2002 2. Mazumdar A et al: Whole body fast inversion recovery MR imaging of small cell neoplasms in pediatric patients: A pilot study. Am J Roentgenol 179:1261-6, 2002 3. Weiss SW et al: Enzinger and Weiss's soft tissue tumors, 4th ed. St.Louis MO, CV Mosby, 785-835, 2001 4. Kransdorf MJ et al: Imaging of soft tissue tumors, 1st ed. Philadelphia PA, W.B. Saunders, 226-33, 1997 5. Yang WT et al: Imaging of pediatric head and neck rhabdomyosarcoma with emphasis on magnetic resonance imaging and a review of the literature. Pediatr Hematol Oncol 14243-57, 1997 6. Wesche WA et al: Immunhistochemistry of Myo-Dl in adult pleomorphic soft tissue sarcomas. Am J Surg Pathol 19:261-9, 1995 7. Hays DM: Rhabdomyosarcoma. Clin Orthop 289:36-49, 1993 8. Shapeero LG et al: Bone metastases as the presenting manifestation of rhabdomyosarcoma in childhood. Skeletal Radio1 22433-8, 1993 9. Tsokos M et al: Rhabdomyosarcoma: A new classification scheme related to prognosis. Arch Pathol Lab Med 1162347-55, 1992 10. Dillon E et al: The role of diagnostic radiology in the diagnosis and management of rhabdomyosarcoma in young persons. Clin Radio1 2953-9, 1978 1.
RHABDOMYOSARCOMA, SOFT TISSUE I
I
Typical (Left) Axial
T I WI MR shows soft tissue mass, isointense to muscle, anterior to left gluteus maximus. (Right) Axial T2WI MR shows well defined soft tissue mass with areas of hyperintense and intermediate signal.
Typical (Left) Axial NECT shows rhabdomyosarcoma involving the left orbit and causing deformity of the left globe and left sided exophthalmus. (Right) Axial NECT shows rhabdomyosarcoma arising in the right pterygopalatine fossa.
Variant (Left) Axial NECT shows soft tissue mass involving the ankle. Note the underlying osseous destruction. (Right) Anteroposterior radiography shows mottled appearance of both femurs representing metastases in a patient with alveolar rhabdomyosarcoma of the upper extremity.
1
HEMANCIOMA, SOFT TISSUE
Axialgraphic shows intramuscular mass with phleboliths (white) and vascular elementr (red). Peripheral fat overgrowth is shown in yellow
Anteroposterior radiography shows soft tissue mass in the forearm with multiple phleboliths, consistent with cavernous hemangioma.
o Nonspecific soft tissue mass o Phleboliths: Most common in cavernous
hemangiomas (30-50%)
Abbreviations and Synonyms
o Curvilinear, amorphous calcifications o May extend into bone o Bone overgrowth
Capillary, cavernous hemangioma, soft tissue hemangioma
Definitions
CT Findings
Benign lesion that resembles normal blood vessels
General Features
32
Best diagnostic clue o Soft tissue mass of muscle-fat density on radiographs or CT, phleboliths (diagnostic) o Areas of high signal on T1 and T2WI MR with flow voids Location o Superficial: Skin, subcutaneous tissue Predilection for head and neck o Deep: Intramuscular o Synovial (rare) o Localized or multifocal Size: 1-15 cm Morphology: Soft tissue mass containing blood vessels
Radiographic Findings Radiography
NECT o Poorly defined soft tissue mass, attenuation similar to muscle o Areas of fat attenuation o Phleboliths o Periosteal reaction in lesions adjacent to bone CECT: Serpentine enhancement
MR Findings TlWI o Poorly marginated heterogeneous mass o Isointense to muscle o Areas of high signal intensity (fat, slow flowing blood) T2WI o Well-marginated heterogeneous mass o Areas of intermediate and very high signal intensity o FS PD/T2 FSE: High signal intensity T2* GRE: Helpful to detect high (arterial) flow T1 C+ o Marked enhancement
DDx: Hemangioma, Soft Tissue Hematoma
Cor T l Wl MR
Key Facts Imaging Findings ,
Soft tissue mass of muscle-fat density on radiographs or CT, phleboliths (diagnostic) Areas of high signal on and T2WI MR with flow voids
Top Differential Diagnoses Lipoma Hematoma Hemophilia
Pathology 7% of all benign tumors Most common tumor of infancy and childhood
Superficial lesions: Purple discoloration of overlying skin Intramuscular lesions: Pain after exercise Synovial lesion: Recurrent episodes of joint pain, swelling, effusion Benign lesion, no malignant transformation 90% of juvenile capillary hemangiomas involute by age 7 Cavernous hemangiomas do not involute, can cause local destruction by increased pressure Capillary hemangiomas: Followed clinically Cavernous hemangiomas: Often require surgical resection with wide margins
Clinical Issues Most hemangiomas are asymptomatic
o Prominent draining veins Infiltration of adjacent tissue Joint effusion and hemorrhage in synovial hemangioma
Ultrasonographic Findings Complex mass Acoustic shadowing may be caused by phleboliths High flow on color Doppler
Angiographic Findings Vascular soft tissue mass, may be high or low flow Blood vessels oriented parallel to each other Important for pre-treatment planning if embolization is considered
Nuclear Medicine Findings Bone Scan: Little or no increased uptake of radiotracer
imaging Recommendations Best imaging tool: MRI Protocol advice o TI, T2WI MR, FS PDlT2, T2* GRE, TI C+ o Use radiographs or CT to evaluate for phleboliths
(DIFFERENTIALDIAGNOSIS Lipoma Homogeneous soft tissue mass Fat containing No enhancement
Hematoma Surrounding edema No enhancement
Hemophilia Repetitive bleeding of synovial hemangioma into joint can mimic hemophilia Polyarticular
General Features General path comments o Benign lesion with increased number of normal or abnormal appearing vessels o Can increase in size during pregnancy: Endothelial cells responsive to circulating hormones Genetics o Capillary hemangioma can be familial (rare) o Mutation of chromosome 5 Etiology o Vascular malformation that may be congenital, developmental, or acquired o Likely hamartomatous condition rather than true neoplasm Epidemiology o 7% of all benign tumors o Most common tumor of infancy and childhood Associated abnormalities o Kasabach-Merritt syndrome: Rapidly enlarging cavernous hemangiomas, hemangioendotheliomas, angiosarcomas Usually located in extremity Intravascular coagulation and sequestration of platelets Petechiae and ecchymoses involving skin and internal organs Death from hemorrhage: 30% o Maffucci syndrome: Mesodermal dysplasia with multiple hemangiomas and enchondromas Cavernous hemangiomas o Osler-Weber-Rendusyndrome: Hereditary hemorrhagic telangiectasia Autosomal dominant Systemic vascular dysplasia, resulting in aneurysms, telangiectasia, arteriovenous malformations Involves skin, lung, visceral organs Repeated episodes of hemorrhage o Klippel-Trenaunay-Weber syndrome: Non-hereditary Anomalies of deep venous system
HEMANCIOMA, SOFT TISSUE o Recurrence < 10% o Marginal excision: Recurrence > 25%
Bone and soft tissue hypertrophy, varicose veins, cutaneous hemangiomas Unilateral
Chemotherapy in hemangiomatosis has been tried with variable success
Gross Pathologic & Surgical Features Blue-red soft tissue mass composed of large vessels Nonvascular elements: Fat, smooth muscle, fibrous tissue, bone Fat overgrowth may lead to misdiagnosis of lipoma
Image Interpretation Pearls Obtain radiographs if MRI is non-diagnostic, phleboliths might be missed with MRI
Microscopic Features Resembles normal blood vessels Nonvascular elements: Fat, smooth muscle, fibrous tissue, bone, hemosiderin o Capillary type: Small vessels lined by flattened endothelium Occur in skin and subcutaneous tissues o Cavernous type: Dilated spaces filled with blood, lined by flattened epithelium Involve deep structures o Arterio-venous type: Abnormal communication of arteries and veins, persistence of capillary bed o Venous type: Vessels with thick muscular walls
Presentation Most common signs/symptoms: Painful mass, intermittent change in size Clinical profile o Most hemangiomas are asymptomatic o Superficiallesions: Purple discoloration of overlying skin o Intramuscular lesions: Pain after exercise Relative hypoxia of surrounding muscle o Synovial lesion: Recurrent episodes of joint pain, swelling, effusion o Arterio-venous type: Enlarged extremity Reflex bradycardia after compression (Branham sign) o Can increase in size during pregnancy
Demographics Age: 1 month - 36 years; most hemangiomas involute by age 10 Gender: F:M = 1.5-2:l
Natural History & Prognosis Benign lesion, no malignant transformation 90% of juvenile capillary hemangiomas involute by age 7 Cavernous hemangiomas do not involute, can cause local destruction by increased pressure Limited growth potential Local recurrence: 15-50%
Treatment Capillary hemangiomas: Followed clinically o Symptomatic lesions with compression of critical structures (airways) Systemic glucosteroid, interferon oc Cavernous hemangiomas: Often require surgical resection with wide margins o Preoperative arteriography and embolization
1
Walter JW et al: Genetic mapping of a novel familial form of infantile hemangioma. Am J Genet 82:77-83, 1999 2. Greenspan A et al: Synovial hemangioma: Imaging features in eight histologically proven cases, review of the literature, and differential diagnosis. Skeletal Radiol 24583-590, 1995 3. Murphey MD et al: Musculoskeletal angiomatous lesions: Radiologic-pathologic correlation. Radiographics 15:893-917, 1995 4. Ezekowitz RA et al: Interferon alpha-2a therapy for life-threatening hemangiomas of infancy. N Engl J Med 326:1456-63, 1992 5. Greenspan A et al: Imaging strategies in the evaluation of soft tissue hemangiomas of the extremities: Correlation of the findings of plain radiograohv, CT, MRI, and ultrasonography in 12 histoldgi&illy proven cases. Skeletal Radio1 21:ll-8. 1992 6. Rak KM et al: MR imaging of symptomatic peripheral vascular malformations. Am J Roentgenol 159:107-112, 1992 7. Buetow PC et al: Radiologic appearance of intramuscular hemangioma with emphasis on MR imaging. Am J Roentgen01 154:563-7, 1990 8. Nelson MC et al: Magnetic resonance imaging of peripheral soft-tissue hemangiomas. Skeletal Radiol 19:447-82, 1990 9. Cohen EK et al: MR imaging of soft-tissue hemangiomas: Correlation with pathologic findings. Am J Roentgenol 150:1079-81, 1988 1.
1
HEMANCIOMA, SOFT TISSUE (IMAGE GALLERY
I
Typical (Left) Axial T 1 Wl MR shows soft tissue mass of intermediate signal in the gastrocnemius. Foci of high and low signal are seen within the mass. (Right) Sagittal T2WI MR shows heterogeneous mass in the vastus medialis. Areas of high signal correspond to slow flowing blood, intermediate signal corresponds to fat overgrowth.
Typical (Left) Anteroposterior radiography shows multiple osseous and soft tissue hemangiomas in a patient with hemangiomatosis. (Right) Axial T2Wl MR shows hyperintense soft tissue mass at the plantar aspect of the foot. Serpentine areas of high signal correspond to slow flowing blood in vascular channels.
Typical
(Lef)Lateral radiography of the foot reveals soft tissue mass and multiple phleboliths. Deformity of the first phalanx secondary to the soft tissue mass is noted. (Right) Clinical photograph shows marked enlargement and purple-bluish discoloration of the first phalanx (same patient ).
Accessory navicular, 6-1 10 to 6-1 13 Accessory ossification center, deltoid ligament sprain VS.,6-35 Accessory soleus, medial tibia1 stress syndrome vs., 6-99 Acetabular fractures, 4-54 to 4-57 description, 4-54 to 4-57 femoral head fractures vs., 4-47 hip dislocations vs., 4-59 Acetabular labrum. See Labrum, acetabular. Acetabular tumor, hip dislocations vs., 4-59 Achilles tendinitis, 6-2 to 6-5 description, 6-2 to 6-5 flexor hallucis longus abnormalities vs., 6-15 Achilles tendon tear, 6-6 to 6-9 calcaneal fractures vs., 6-71 description, 6-6 to 6-9 syndesmotic impingement vs., 6-51 ACL. See Anterior cruciate ligament. Acromial fracture, os acromiale vs., 1-1 19 Acromioclavicular joint arthritis, 1-122 to 1-125 description, 1-122 to 1-125 os acromiale vs., 1-119 partial thickness rotator cuff tear vs., 1-15 separation acromioclavicular joint arthritis vs., 1-123 os acromiale vs., 1-1 19 to 1-120 Adamantinoma, 8-74 to 8-77 chondromyxoid fibroma vs., 8-31 description, 8-74 to 8-77 fibrous dysplasia vs., 8-39 Adhesive capsulitis, 1-54 to 1-57 ALPSA lesion vs., 1-68 Bankart lesion vs., 1-60 description, 1-54 to 1-57 full thickness rotator cuff tear vs., 1-15 HAGL lesion vs., 1-75 IGL tears vs., 1-79 partial thickness rotator cuff tear vs., 1-7 Perthes lesion vs., 1-64 rotator interval tears vs., 1-19 secondary, 1-55 subacromial impingement vs., 1-115 subscapularis rupture vs., 1-39 ALPSA (anterior labroligamentous periosteal sleeve avulsion) lesion, 1-66 to 1-69 Bankart lesion vs., 1-59 description, 1-66 to 1-69
GLAD lesion vs., 1-71 HAGL lesion vs., 1-75 Perthes lesion vs., 1-64 Amyloid, osteomyelitis of hip vs., 4-99 Anconeus epitrochlearis, 2-46 to 2-47 Aneurysmal bone cyst, 8-66 to 8-69 chondroblastoma vs., 8-27 description, 8-66 to 8-69 fibrosarcoma vs., 8-5 1 fibrous dysplasia vs., 8-39 fibroxanthoma vs., 8-43 giant cell tumor vs., 8-55 intraosseous lipoma vs., 8-7 1 osteoblastoma vs., 8-1 1 osteosarcoma vs., 8-15 unicameral bone cyst vs., 8-63 Angiography aneurysmal bone cyst, 8-67 bone marrow metastases, 7-35 chondromyxoid fibroma, 8-31 Ewing sarcoma, 7-7 fibrosarcoma, soft tissue, 9-3 giant cell tumor, 8-55 hemangioma, soft tissue, 9-43 lipoma, soft tissue, 9-23 liposarcoma, 9-27 malignant fibrous histiocytoma, soft tissue, 9-1 1 osteoblastoma, 8-1 1 osteoid osteoma, 8-7 Paget disease, 7-39 peripheral nerve sheath tumor, malignant, 9-35 pigmented villonodular synovitis, 9-15 rhabdomyosarcoma, soft tissue, 9-39 synovial sarcoma, 9-19 Ankle and foot. See also Ankle and foot fractures. accessory navicular, 6-1 10 to 6-1 13 Achilles tendinitis, 6-2 to 6-5, 6-15 Achilles tendon tear, 6-6 to 6-9, 6-51, 6-71 ankle sprains. See Ankle sprains. anterior impingement, 6-35, 6-46 to 6-49, 6-51 anterior talofibular ligament sprain or tear, 6-26 to 6-29, 6-31, 6-43 anterolateral impingement, 6-42 to 6-45 avascular necrosis of talus, 6-90 to 6-93 calcaneofibular ligament sprain, 6-30 to 6-33, 6-83 deltoid ligament sprain, 6-11, 6-34 to 6-37, 6-75 diabetic foot, 6-146 to 6-149 flexor hallucis longus abnormalities, 6-14 to 6-17, 6-107 gastrocnemius-soleus strain, 6-99, 6-1 19, 6-122 to 6-125, 6-127
I I
INDEX
instability anterolateral, peroneusbrevis tendon tear vs., 6-23 lateral, syndesmosis sprain vs., 6-39 lower 'extremity compattment syndrome, 6-1 f8 to * t, * 6-121 medial tibial stress syndrome, 6-98 to 6-101 midfoot arthritis, 6-19, 6-95, 6-1 11 Morton's neuroma, 6-115, 6-142 to 6-145 os trigonum syndrome. See 0 s trigonum syndrome. osteochondral lesion. See Talus, osteochondral lesion (OLT). peroneus brevis tendon tear, 6-22 to 6-25. See also Peroneal tendon disorders. plantar fasciitis, 6-131, 6-135 to 6-137 plantar fibromatosis, 6-1 15, 6-135, 6-138 to 6-141 plantaris tendon rupture, 6-122 to 6-123, 6-126 to 6-129 posterior impingement. See Ankle impingement, posterior. sesamoid dysfunction, 6-1 14 to 6-1 17 sinus tarsi syndrome, 6-43, 6-58 to 6-61, 6-71, 6-104 sprains. See Ankle sprains. syndesmotic impingement, 6-50 to 6-53 tarsal coalition, 6-55, 6-59, 6-102 to 6-105, 6-131 tarsal tunnel syndrome, 6-130 to 6-133, 6-135, 6-143 tibialis anterior tendon tear, 6-18 to 6-21 tibialis posterior tendon. See Tibialis posterior tendon. Ankle and foot fractures, 6-62 to 6-65 calcaneal. See Calcaneal fractures. description, 6-62 to 6-65 Freiberg's infraction, 6-94 to 6-97, 6-143 Lisfranc fracture-dislocation, 6-79, 6-82 to 6-85, 6-95 metatarsal. See Metatarsal fractures. navicular, 6-74 to 6-77, 6-79, 6-83, 6-1 11 osteochondral, of talus. See Talus, osteochondral lesion (OLT). stress anterior talofibular ligament tear vs., 6-27 sesamoid dysfunction vs., 6-115 talar. See Talar fractures. Ankle impingement anterior, 6-46 to 6-49 deltoid ligament sprain vs., 6-35 description, 6-46 to 6-49 syndesmotic impingement vs., 6-51 anterolateral, 6-42 to 6-45 medial, deltoid ligament sprain vs., 6-35 posterior, 6-54 to 6-57. See also 0 s trigonum syndrome. Achilles tendon tear vs., 6-7 description, 6-54 to 6-57 os trigonum syndrome vs., 6-107 syndesmosis sprain vs., 6-39 syndesmotic impingement vs., 6-51 syndesmotic, 6-50 to 6-53 Ankle sprains ankle fractures vs., 6-63 lateral ankle fracture vs., 6-63 calcaneal fractures vs., 6-71
.
+
lateral ligament, sinus tarsi syndrome vs., 6-59 medial, ankle fracture vs., 6-63 recurrent, tarsal coalition vs., 6-104 syndesmosis sprain, 6-38 to 6-41 talus fractures vs., 6-67 Annular pulley tears, flexor, 3-98 to 3-101 Anterior cruciate ligament mucoid degeneration, ACL tear vs., 5-43 partial tear, intracondylar notch cyst vs., 5-155 reconstruction, 5-46 to 5-49 description, 5-46 to 5-49 meniscal tear with locking in, 5-47 tibial tunnel pseudo impingement in, 5-47 scarred chronic disruption, meniscal bucket-handle tear vs., 5-31 tears, 5-42 to 5-45 description, 5-42 to 5-45 partial tear vs., 5-43 with hemarthrosis, transient patellar dislocation VS.,5-125 Anterior labroligamentous periosteal sleeve avulsion. See ALPSA (anterior labroligamentous periosteal sleeve avulsion) lesion. Apophysis, normal pediatric fusing, osteochondritis dissecans vs., 5-79 Arthritis. See also Osteoarthritis; Rheumatoid arthritis. acromioclavicular joint, 1-122 to 1-125 description, 1-122 to 1-125 os acromiale vs., 1-119 partial thickness rotator cuff tear vs., 1-15 carpometacarpal carpal tunnel syndrome vs., 3-55 first, De Quervain's tenosynovitis vs., 3-83 infectious developmental dysplasia of hip vs., 4-15 elbow osteomyelitis vs., 2-99 hip osteomyelitis vs., 4-99 rheumatoid arthritis of wrist and hand vs., 3-71 shoulder osteoarthritis vs., 1-139 inflammatory De Quervain's tenosynovitis vs., 3-83 elbow osteoarthritis vs., 2-91 rheumatoid arthritis vs., 2-95 flexor annular pulley tears vs., 3-99 iliopsoas bursitis vs., 4-39 Kienbock's disease vs., 3-51 knee osteoarthritis vs., 5-133 synovitis vs., 5-1 11 shoulder osteoarthritis vs., 1-139 sinus tarsi syndrome vs., 6-59 juvenile chronic Legg-Calve-Perthe disease vs., 4-7 rheumatoid arthritis of wrist and hand vs., 3-71 metatarsal phalangeal, Freiberg's infraction vs., 6-95 midfoot accessory navicular vs., 6-1 11 Freiberg's infraction vs., 6-95 tibialis anterior tendon tear vs., 6-19 neuropathic, osteoarthritis of shoulder vs., 1-139
INDEX osteochondral lesion of talus (OLT) vs., 6-87 psoriatic knee rheumatoid arthritis vs., 5-137 rheumatoid arthritis of shoulder vs., 1-143 wrist and hand rheumatoid arthritis vs., 3-71 rheumatoid arthritis of wrist and hand vs., 3-71 seronegative, rheumatoid arthritis of hip vs., 4-95 tibiotalar generalized, anterior impingement vs., 6-47 medial, tibialis posterior tendon tear vs., 6-1 1 Arthrosis, degenerative, avascular necrosis of femoral head vs., 4-3 Artifacts, hip, loose bodies of hip vs., 4-91 Avascular necrosis (AVN) femoral head description, 4-2 to 4-5 femoral head fractures vs., 4-47 femoral neck fractures vs., 4-51 hip dislocations vs., 4-59 hip chondroblastoma vs., 8-27 femoroacetabular impingement vs., 4-83 hamstring tendinosis vs., 4-31 osteoarthritis of hip vs., 4-87 rheumatoid arthritis of hip vs., 4-95 osteomyelitis of hip vs., 4-99 scaphoid, scapholunate ligament tear vs., 3-3 shoulder, 1-126 to 1-129 description, 1-126 to 1-129 osteoarthritis vs., 1-139 osteochondral injuries vs., 1-131 talar, 6-90 to 6-93 Avulsion hip fractures, 4-62 to 4-65 acetabular fractures vs., 4-55 description, 4-62 to 4-65 Axillary neurapraxia, subscapularis rupture vs., 1-39 to 1-40
Bankart lesion, 1-58 to 1-61 ALPSA lesion vs., 1-67 description, 1-58 to 1-61 GLAD lesion vs., 1-71 greater tuberosity fracture vs., 1-135 HAGL lesion vs., 1-75 IGL tears vs., 1-79 Perthes lesion vs., 1-63 superior dissection, anterosuperior variations of shoulder vs., 1-52 Bennett lesion description, 1-82 to 1-85 posterior labral tear vs., 1-87 Biceps lateral complex (BLC), normal, biceps tendinosis VS.,1-95 Biceps tendon dislocation anterosuperior variations of shoulder vs., 1-52 description, 1-1 10 to 1-1 13 mass (neoplasm), biceps tendon rupture vs., 2-1 1 normal, biceps tendon rupture vs., 2-1 1
partial tear, bicipital radial bursitis vs., 2-83 rupture, 2-10 to 2-13 biceps tendon dislocation vs., 1-111 description, 2-10 to 2-13 hidden lesion vs., 1-92 tear, 1-98 to 1-101 tendinosis, 1-94 to 1-97 biceps tendon dislocation vs., 1-1 11 bicipital radial bursitis vs., 2-83 description, 1-94 to 1-97 hidden lesion vs., 1-91 tenodesis, biceps tendon tear vs., 1-99 Bicipital radial bursitis, 2-82 to 2-85 biceps tendon rupture vs., 2-1 1 description, 2-82 to 2-85 rheumatoid arthritis vs., 2-95 Bifurcate ligament sprain Lisfranc fracture vs., 6-83 sinus tarsi syndrome vs., 6-59 Bipartite patella patellar fracture vs., 5-91 patellar tendon tears vs., 5-1 14 transient patellar dislocation vs., 5-125 Bipartite tarsal navicular, navicular fractures vs., 6-75 Bone abscess, unicameral bone cyst vs., 8-63 Bone cysts aneurysmal. See Aneurysmal bone cyst. unicameral. See Unicameral bone cyst. Bone infarct enchondroma vs., 8-19 knee description, 5-82 to 5-85 reflex sympathetic dystrophy vs., 5-147 medullary, intraosseous lipoma vs., 8-71 Bone island (enostosis) osteoid osteoma vs., 8-7 osteoma vs., 8-3 Bone marrow edema syndrome avascular necrosis of talus vs., 6-91 transient, transient osteoporosis of hip vs., 4-1 1 Ewing sarcoma, 7-6 to 7-9 Gaucher's disease, 7-30 to 7-33 knee tumor, bone infarct vs., 5-83 Langerhans cell histiocytosis, 7-2 to 7-5 leukemia, 7-10 to 7-13 lymphoma, 7-14 to 7-17 metastases, 7-34 to 7-37 multiple myeloma, 7-18 to 7-21 normal bone infarct vs., 5-83 of elbow, coronoid process fracture vs., 2-50 reflex sympathetic dystrophy of knee vs., 5-147 Paget disease, 7-38 to 7-41 sickle cell anemia, 7-22 to 7-25 thalassemia, 7-26 to 7-29 tumors, avascular necrosis of shoulder vs., 1-127 Bone tumors acetabular fractures vs., 4-55 adamantinoma, 8-31, 8-39, 8-74 to 8-77 aneurysmal bone cyst. See Aneurysmal bone cyst.
avascular necrosis of shoulder vs., 1-127 avascular necrosis of talus vs., 6-91 avulsion hip fractures vs., 4-63 chondroblastoma, 8-26 to 8-29, 8-31, 8-35, 8-55 chondromyxoid fibroma. See Chondromyxoid fibroma. chondrosarcoma. See Chondrosarcoma. elbow osteomyelitis vs., 2-99 to 2-100 enchondroma, 5-83, 8-18 to 8-21, 8-35, 8-63 femoral neck fractures vs., 4-51 fibrosarcoma, 7-15,8-47, 8-50 to 8-53 fibrous dysplasia. See Fibrous dysplasia. fibroxanthoma. See Fibroxanthoma. giant cell tumor. See Giant cell tumor. infiltrative, transient osteoporosis of hip vs., 4-1 1 intraosseous hemangioma, 8-58 to 8-61 intraosseous lipoma, 6-59, 8-70 to 8-73 malignant fibrous histiocytoma, 7-35, 8-35, 8-46 to 8-49, 8-51 osteoblastoma, 8-7, 8-10 to 8-13, 8-67 osteochondroma, 3-75,8-3,8-22 to 8-25 osteoid osteoma, 2-99 to 2-100,4-7,8-6 to 8-9,8-11 osteoma, 8-2 to 8-5 osteomyelitis of hip vs., 4-99 osteosarcoma. See Osteosarcoma. tarsal coalition vs., 6-104 unicameral bone cyst. See Unicameral bone cyst. Brachial plexus, carcinomatous or granulomatous infiltration of, Parsonage-Turner syndrome vs., 1-35 Brachial plexus neuritis. See Parsonage-Turner syndrome. Brachialis strain, biceps tendon rupture vs., 2-1 1 Brodie's abscess (osteomyelitis),osteoid osteoma vs., 8-7 Brown tumors, unicameral bone cyst vs., 8-63 Bucket-handle tear, meniscal, 5-30 to 5-33 anterior cruciate ligament tear vs., 5-43 description, 5-30 to 5-33 discoid meniscus vs., 5-3 osteochondral inju~yof knee vs., 5-75 post-operative meniscus change vs., 5-39 with displacement, meniscal flap tear vs., 5-27 Buford complex SLAP lesions I-IV vs., 1-103 SLAP lesions V-IX vs., 1-107 Bursitis bicipital radial, 2-1 1, 2-82 to 2-85, 2-95 greater trochanteric, 4-27, 4-43, 4-51, 4-79 iliopsoas, 4-38 to 4-41, 4-43 infrapatellar, 5-71, 5-103 intermetatarsal, Morton's neuroma vs., 6-143 ischial tuberosity, piriformis syndrome vs., 4-35 medial, of knee, 5-58 to 5-61, 5-87 medial collateral ligament, meniscocapsular separation vs., 5-35 olecranon, 2-15,2-86 to 2-87, 2-95, 2-100 patellar, anterior, 5-106 to 5-109 prepatellar, patellar tendinitis vs., 5-99 sacral insufficiency fractures vs., 4-71 semimembranosus tibial collateral ligament, 5-15, 5-55, 5-159 tibial collateral ligament, 5-55
trochanteric. See Trochanteric bursitis.
Calcaneal fractures, 6-70 to 6-73 anterior process anterior talofibular ligament tear vs., 6-27 calcaneofibular ligament sprain vs., 6-31 description, 6-70 to 6-73 neck, anterior talofibular ligament tear vs., 6-27 stress plantar fasciitis vs., 6-135 tarsal tunnel syndrome vs., 6-131 Calcaneofibular ligament sprain or tear, 6-30 to 6-33 description, 6-30 to 6-33 lateral, Lisfranc fracture vs., 6-83 Calcaneonavicular coalition, calcaneofibular ligament sprain vs., 6-31 Calcific tendinitis. See Rotator cuff, calcific tendinitis. Calcinosis, tumoral, chondrocalcinosis of knee vs., 5-150 Calcium pyrophosphate dihydrate crystal deposition disease. See Chondrocalcinosis. Cancer. See Bone tumors; Metastatic disease; Soft tissue tumors; Tumors. Capitate fractures hamato-lunate impingement vs., 3-67 scaphoid fractures vs., 3-39 Capitellum fracture, 2-72 to 2-73 description, 2-72 to 2-73 lateral epicondylitis vs., 2-3 to 2-4 osteochondritis dissecans vs., 2-53 radial head fracture vs., 2-57 osteochondritis dissecans, 2-52 to 2-55 bicipital radial bursitis vs., 2-83 capitellum fracture vs., 2-72 description, 2-52 to 2-55 lateral collateral ligament injury vs., 2-19 lateral condylar fracture vs., 2-69 Little Leaguer's elbow vs., 2-31 loose bodies and os supratrochleare vs., 2-61 medial condylar fracture vs., 2-79 radial head fracture vs., 2-57 supracondylar fracture vs., 2-75 pseudo defect of capitellum fracture vs., 2-72 osteochondritis dissecans vs., 2-53 Capsulitis. See Adhesive capsulitis. Carpal disorders. See also Carpal tunnel syndrome. carpometacarpal joint arthritis, 3-55, 3-83 fractures/dislocations of, 3-95 extensor carpi ulnaris. See Extensor carpi ulnaris (ECU). flexor carpi radialis tenosynovitis, De Quervain's tenosynovitis vs., 3-83 instability carpal tunnel syndrome vs., 3-55 hamate fractures vs., 3-43 Kienbock's disease vs., 3-5 1 intercarpal pathology
I
INDEX
distal radial ulnar joint instability vs., 3-19 extensor carpi ulnaris tendinitis vs., 3-87 midcarpal instability, 3-10 to 3-13 ulnocarpal abutment, 3-14 to 3-17 Carpal tunnel syndrome, 3-54 to 3-57 De Quervain's tenosynovitis vs., 3-83 description, 3-54 to 3-57 hamate fractures vs., 3-43 ulnar tunnel syndrome vs., 3-58 to 3-59 Carpometacarpal joint arthritis carpal tunnel syndrome vs., 3-55 first, De Quervain's tenosynovitis vs., 3-83 fractures/dislocations of, ulnar collateral ligament tear vs., 3-95 Cellulitis compartment syndrome of lower extremity vs., 6-119 elbow osteomyelitis vs., 2-99 hip osteomyelitis vs., 4-99 medial tibial stress syndrome vs., 6-99 Cervical radiculopathy carpal tunnel syndrome vs., 3-55 median neuropathy vs., 2-43 ulnar tunnel syndrome vs., 3-59 Cervical spine disease adhesive capsulitis vs., 1-55 neuropathy, Parsonage-Turner syndrome vs., 1-35 suprascapular, spinoglenoid notch vs., 1-151 Charcot (neuropathic) joint Freiberg's infraction vs., 6-95 rheumatoid arthritis of shoulder vs., 1-143 Chondroblastoma, 8-26 to 8-29 chondromyxoid fibroma vs., 8-31 chondrosarcoma vs., 8-35 description, 8-26 to 8-29 giant cell tumor vs., 8-55 Chondrocalcinosis diabetic foot vs., 6-147 Freiberg's infraction vs., 6-95 knee, 5-150 to 5-154 osteoarthritis vs. elbow, 2-91 hip, 4-87 knee, 5-133 osteomyelitis vs. elbow, 2-99 hip, 4-99 rheumatoid arthritis vs. hip, 4-95 wrist and hand vs., 3-71 Chondroma juxtacortical enchondroma vs., 8-19 synovial sarcoma vs., 9-19 periosteal, osteochondroma vs., 8-23 Chondromalacia patellar, 5-1 16 to 5-1 19
chondrocalcinosis of knee vs., 5-150 description, 5-1 16 to 5-1 19 medial plica syndrome vs., 5-129 patellar (anterior) bursitis vs., 5-107 patellar fracture vs., 5-91 quadriceps tendon tear vs., 5-121 transient patellar dislocation vs., 5-125 ulnar head, lunotriquetral instability vs., 3-7 Chondromatosis, synovial idiopathic (osteo), anterolateral impingement VS.,6-43 osteoarthritis of hip vs., 4-87 pigmented villonodular synovitis vs., 9-15 rheumatoid arthritis of hip vs., 4-95 snapping hip syndrome vs., 4-43 Chondromyxoid fibroma, 8-30 to 8-33 adamantinoma vs., 8-75 aneurysmal bone cyst vs., 8-67 description, 8-30 to 8-33 fibrous, fibroxanthoma vs., 8-43 fibrous dysplasia vs., 8-39 osteoblastoma vs., 8-1 1 Chondrosarcoma, 8-34 to 8-37 chondromyxoid fibroma vs., 8-31 clear-cell, chondroblastoma vs., 8-27 description, 8-34 to 8-37 enchondroma vs., 8-19 osteochondroma vs., 8-23 osteosarcoma vs., 8-15 soft tissue, synovial sarcoma vs., 9-19 Clavicle fracture, os acromiale vs., 1-119 Clear-cell chondrosarcoma, chondroblastoma vs., 8-2 7 Collateral ligament lateral. See Lateral collateral ligament injuryltear. medial. See Medial collateral ligament injury. ulnar. See Ulnar collateral ligament. Compartment syndrome chronic exertional, medial tibial stress syndrome vs., 6-99 lower extremity, 6-118 to 6-121 posterior gastrocnemius-soleus strain vs., 6-123 plantaris tendon rupture vs., 6-127 syndesmosis sprain vs., 6-39 Computed tomography (CT) acetabular fractures, 4-54 to 4-55 acromioclavicular joint arthritis, 1-123 adamantinoma, 8-74 ALPSA lesion, 1-66 aneurysmal bone cyst, 8-66 ankle fractures, 6-62 anterior cruciate ligament tear, 5-42 anterior impingement, ankle, 6-46 avascular necrosis femoral head, 4-2 shoulder, 1-126 talus, 6-90 avulsion hip fractures, 4-62
vi
I
Bankart lesion, 1-58 Bennett lesion, 1-82 biceps tendinosis, 1-94 biceps tendon dislocation, 1-110 rupture, 2-10 tear, 1-98 bicipital radial bursitis, 2-82 bone infarct, 5-82 bone marrow metastases, 7-34 to 7-35 calcaneal fractures, 6-70 capitellar osteochondritis dissecans, 2-52 capitellum fracture, 2-72 chondroblastoma, 8-27 chondrocalcinosis of knee, 5-150 chondromyxoid fibroma, 8-30 to 8-31 chondrosarcoma, 8-35 condylar fractures lateral condyle, 2-68 medial condyle, 2-78 to 2-79 supracondylar, 2-74 coronoid process fracture, 2-48 De Quervain's tenosynovitis, 3-82 developmental dysplasia of hip, 4-14 distal radial ulnar joint instability, 3-18 distal radius fractures, 3-26 die punch fracture, 3-30 elbow posterior dislocation, 2-22 to 2-23 enchondroma, 8-18 epicondylitis lateral, 2-2 medial, 2-6 to 2-7 Ewing sarcoma, 7-6 femoral head fractures, 4-46 femoral neck fractures, 4-50 fibromatosis, 9-6 fibrosarcoma bone, 8-51 soft tissue, 9-2 fibrous dysplasia, 8-38 to 8-39 fibroxanthoma, 8-42 to 8-43 flexor digitorum profundus avulsions, 3-102 Freiberg's infraction, 6-94 to 6-95 giant cell tumor, 8-54 gluteus medius muscle strain, 4-26 greater tuberosity fracture, 1-134 HAGL lesion, 1-74 hamate fractures, 3-42 hamato-lunate impingement, 3-66 hamstring tendinosis, 4-30 hemangioma intraosseous, 8-59 soft tissue, 9-42 hidden lesion of shoulder, 1-90 hip dislocations, 4-58 iliopsoas bursitis, 4-38 internal shoulder impingement, 1-10 intracondylar notch cyst, 5-154 Kienbock's disease, 3-50 labral tears
acetabular, 4-74 posterior, shoulder, 1-86 Langerhans cell histiocytosis, 7-3 lateral collateral ligament elbow, 2-18 to 2-19 knee, 5-62 lateral tibia1 plateau fracture, 5-94 leukemia, 7-1 1 lipoma intraosseous, 8-70 soft tissue, 9-22 lipoma arborescens of knee, 5-144 liposarcoma, 9-26 Lisfranc fracture, 6-82 Little Leaguer's elbow, 2-30 loose bodies of hip, 4-90 lymphoma, 7-15 malignant fibrous histiocytoma bone, 8-46 soft tissue, 9-10 medial collateral ligament elbow injury, 2-26 tear, 5-54 median neuropathy, 2-42 meniscocapsular separation, 5-34 meniscus bucket-handle tear, 5-30 cysts, 5-14 flap tear, 5-26 horizontal tear, 5-10 longitudinal tear, 5-18 radial tear, 5-22 metatarsal fractures, 6-78 to 6-79 microinstability of shoulder, 1-22 midcarpal instability, 3-10 multiple myeloma, 7-18 navicular fractures, 6-74 to 6-75 olecranon fracture, 2-64 os acromiale, 1-1 18 os supratrochleare, elbow, 2-60 Osgood-Schlatter disease, 5-102 osteoarthritis elbow, 2-90 hip, 4-86 osteoblastoma, 8-10 to 8-11 osteochondral injuries knee, 5-74 shoulder, 1-130 osteochondral lesion of talus (OLT), 6-86 to 6-87 osteochondritis dissecans, 5-78 osteochondroma, 8-22 osteoid osteoma, 8-6 osteoma, 8-2 osteomyelitis elbow, 2-99 hip, 4-98 osteoporosis of hip, transient, 4-10 osteosarcoma, 8-15 Paget disease, 7-39 paralabral cysts, 4-78
Parsonage-Turner syndrome, 1-34 patellar fracture, 5-91 patellar tendinitis, 5-98 pectoralis major tear, 1-42 peripheral nerve sheath tumor benign, 9-30 malignant, 9-34 Perthes lesion, 1-62 pigmented villonodular synovitis, 5-140, 9-14 piriformis syndrome, 4-34 posterior cruciate ligament tear, 5-50 posterolateral complex injury, 5-66 pubic rami stress fractures, 4-66 quadrilateral space syndrome, 1-146 radial head fracture, 2-56 rectus femoris muscle strain, 4-22 reflex sympathetic dystrophy of knee, 5-146 rhabdomyosarcoma, soft tissue, 9-38 rheumatoid arthritis elbow, 2-94 hip, 4-94 knee, 5-137 shoulder, 1-142 wrist and hand, 3-70 rotator cuff calcific tendinitis, 1-30 to 1-31 post-operative repair, 1-23 sacral insufficiency fractures, 4-70 scaphoid fractures, 3-38 scaphoid non-union, 3-46 sickle cell anemia, 7-23 snapping hip syndrome, 4-42 subacromial impingement, 1-114 subscapularis rupture, 1-38 suprascapular, spinoglenoid notch, 1-150 syndesmosis sprain, 6-38 synovial fringe of elbow, 2-88 synovial sarcoma, 9-18 synovitis of knee, 5-1 10 tarsal coalition, 6-103 thalassemia, 7-27 triceps tendon rupture, 2-14 ulnar neuropathy, 2-34 ulnar styloid fractures, 3-34 ulnar tunnel syndrome, 3-58 unicameral bone cyst, 8-62 Condylar fractures epicondylar, 2-19, 2-49 lateral collateral ligament injury vs., 2-19 lateral condyle, 2-68 to 2-71, 2-75 medial condyle, 2-78 to 2-81 supracondylar, 2-23, 2-49, 2-74 to 2-77, 2-79 Congenital coxa vara, developmental dysplasia of hip vs., 4-15 Connective tissue diseases, inflammatory systemic, 4-95 to 4-96 Contusion muscular, muscle strain of hip vs., 4-19 osseous, hip avascular necrosis of femoral head vs., 4-3
femoral neck fractures vs., 4-51 transient osteoporosis of hip vs., 4-1 1 triceps muscle, triceps tendon rupture vs., 2-15 Coronoid process fracture, 2-48 to 2-51 Cortical desmoid, fibroxanthoma vs., 8-43 Coxa vara, congenital, developmental dysplasia of hip vs., 4-15 Cruciate ligaments. See Anterior cruciate ligament; Posterior cruciate ligament. Crystal deposition disease. See Chondrocalcinosis. CT. See Computed tomography (CT). Cubital tunnel syndrome, ulnar tunnel syndrome vs., 3-59 Cuboid fracture metatarsal fractures vs., 6-80 navicular fractures vs., 6-75 Cuneiform fracture, metatarsal fractures vs., 6-80 Cystic mass meniscal cyst vs., 5-15 patellar (anterior) bursitis vs., 5-107 Cysts acetabular fractures vs., 4-55 aneurysmal bone. See Aneurysmal bone cyst. epidermoid inclusion, enchondroma vs., 8-19 femoral neck fractures vs., 4-51 ganglion. See Ganglion cysts. intracondylar notch, 5-154 to 5-157 intratendinous, rotator cuff full thickness tear vs., 1-15 partial thickness tear vs., 1-7 rotator cuff tendinopathy vs., 1-3 labral, shoulder, 1-46 to 1-49 meniscal. See Meniscus. paralabral, 4-78 to 4-81 description, 4-78 to 4-81 iliopsoas bursitis vs., 4-39 popliteal intracondylar notch cyst vs., 5-155 knee, 5-158 to 5-161 synovial knee rheumatoid arthritis vs., 5-137 medial bursitis of knee vs., 5-59 meniscal cyst vs., 5-15 pigmented villonodular synovitis vs., 5-141 popliteal cyst vs., 5-159 tibia1 tunnel anterior cruciate ligament reconstruction VS.,5-48 intracondylar notch cyst vs., 5-155 unicameral bone. See Unicameral bone cyst.
Dancer's foot, os trigonum syndrome vs., 6-107 De Quervain's tenosynovitis, 3-82 to 3-85 carpal tunnel syndrome vs., 3-55 description, 3-82 to 3-85 scaphoid fractures vs., 3-39 scaphoid non-union vs., 3-47
scapholunate ligament tear vs., 3-3 Deep venous thrombosis (DVT). See Thrombosis, deep venous (DVT). Degenerative arthritis. See Osteoarthritis. Degenerative arthrosis, avascular necrosis of femoral head vs., 4-3 Delayed onset muscle soreness (DOMS) muscle strain of hip vs., 4-19 pubic rami stress fractures vs., 4-67 Deltoid ligament dehiscence, post-operative rotator cuff repair VS.,1-27 to 1-28 normal, deltoid ligament sprain vs., 6-35 sprain, 6-34 to 6-37 description, 6-34 to 6-37 navicular fractures vs., 6-75 tibialis posterior tendon tear vs., 6-1 1 stretch or tear of, calcaneal fractures vs., 6-72 Desmoid cortical, fibroxanthoma vs., 8-43 intraabdominal, liposarcoma vs., 9-27 Developmental dysplasia of hip. See Dysplasia. Diabetes mellitus, Freiberg's infraction and, 6-95 Diabetic foot, 6-146 to 6-149 Diabetic neuropathy Parsonage-Turner syndrome vs., 1-35 tarsal tunnel syndrome vs., 6-131 Die punch fracture, distal radius description, 3-30 to 3-33 Madelung's deformity vs., 3-75 Discogenic pain, piriformis syndrome vs., 4-35 Discoid meniscus, 5-2 to 5-5 Distal radial ulnar joint (DRUG). See Radial ulnar joint, distal (DRUJ). Distal radius fractures. See Radial fractures. Dorsal wrist ganglion. See Ganglion cysts, dorsal wrist. DRUJ. See Radial ulnar joint, distal (DRUJ). Dysplasia developmental, of hip, 4-14 to 4-1 7 description, 4-14 to 4-17 femoroacetabular impingement vs., 4-83 labral tears vs., 4-75 osteoarthritis of hip vs., 4-87 paralabral cyst vs., 4-79 rheumatoid arthritis of hip vs., 4-95 fibrous, 8-38 to 8-41 chondromyxoid fibroma vs., 8-31 description, 8-38 to 8-41 fibroxanthoma vs., 8-43 intraosseous hemangioma vs., 8-59 Paget disease vs., 7-39 unicameral bone cyst vs., 8-63 osteochondral injury of knee vs., 5-75 osteofibrous, adamantinoma vs., 8-75 Dystrophy, reflex sympathetic. See Reflex sympathetic dystrophy.
ECU. See Extensor carpi ulnaris (ECU). Elbow anconeus epitrochlearis, 2-46 to 2-47 antecubital mass, bicipital radial bursitis vs., 2-83 biceps tendon rupture, 1-92, 1-111,2-10 to 2-13 bicipital radial bursitis, 2-11,2-82 to 2-85,2-95 capitellar osteochondritis. See Capitellum, osteochondritis dissecans. capitellum fracture, 2-3 to 2-4, 2-53, 2-57, 2-72 to 2-73 coronoid process fracture, 2-48 to 2-5 1 cortical notch, olecranon fracture vs., 2-65 epicondylitis. See Epicondylitis. fractures loose bodies and os supratrochleare vs., 2-61 osteomyelitis vs., 2-99 lateral collateral ligament injury, 2-18 to 2-21 lateral condylar fracture, 2-68 to 2-71, 2-79 Little Leaguer's elbow, 2-27, 2-30 to 2-33 loose bodies, 2-60 to 2-63, 2-88 medial bone injury, medial epicondylitis vs., 2-7 medial collateral ligament injury, 2-7, 2-23, 2-26 to 2-29, 2-31 medial condylar fracture, 2-78 to 2-81, 5-95 median neuropathy, 2-39,2-42 to 2-45 nonspecific myositis/trauma, radial neuropathy vs., 2-39 normal bicipital radial bursitis vs., 2-84 osteoarthritis vs., 2-91 synovial fringe vs., 2-89 normal ossification center, olecranon fracture VS.,2-65 olecranon bursitis, 2-15, 2-86 to 2-87, 2-95, 2-100 olecranon fracture. See Olecranon fracture. os supratrochleare, 2-60 to 2-63 osteoarthritis, 2-90 to 2-93 description, 2-90 to 2-93 radial head fracture vs., 2-57 rheumatoid arthritis vs., 2-95 synovial fringe vs., 2-88 osteomyelitis, 2-98 to 2-101 posterior dislocation, 2-22 to 2-25 bicipital radial bursitis vs., 2-83 capitellar osteochondritis dissecans vs., 2-53 capitellum fracture vs., 2-72 coronoid process fracture vs., 2-49 description, 2-22 to 2-25 lateral condylar fracture vs., 2-69 lateral epicondylitis vs., 2-4 medial condylar fracture vs., 2-79 medial epicondylitis vs., 2-7 olecranon fracture vs., 2-65 radial head fracture vs., 2-57 supracondylar fracture vs., 2-75
INDEX triceps tendon rupture vs., 2-15 posterolateral rotatory instability, capitellar osteochondritis dissecans vs., 2-53 radial head fracture, 2-56 to 2-59, 2-57, 2-83 to 2-84 radial headlneck fractures. See Radial fractures. radial neuropathy, 2-3, 2-38 to 2-41, 2-43 rheumatoid arthritis, 2-94 to 2-97 stress fractures, Little Leaguer's elbow vs., 2-31 supracondylar fracture, 2-23, 2-49, 2-74 to 2-77, 2-79 swollen, tender, lateral collateral ligament injury vs., 2-19 synovial fringe, 2-88 to 2-89 triceps tendon rupture, 2-14 to 2-1 7 ulnar neuropathy, 2-27, 2-34 to 2-37, 2-39, 2-46 to 2-47 Enchondroma, 8-18 to 8-21 chondrosarcoma vs., 8-35 description, 8-18 to 8-21 knee, bone infarct vs., 5-83 unicameral bone cyst vs., 8-63 Enostosis (bone island) osteoid osteoma vs., 8-7 osteoma vs., 8-3 Eosinophilic granuloma elbow osteomyelitis vs., 2-99 hip osteomyelitis vs., 4-99 to 4-100 Epicondylar fracture avulsion, medial, coronoid process fracture vs., 2-49 lateral collateral ligament injury vs., 2-19 Epicondylitis lateral, 2-2 to 2-5 lateral collateral ligament injury vs., 2-19 Little Leaguer's elbow vs., 2-31 posterior dislocation of elbow vs., 2-23 recalcitrant, radial neuropathy vs., 2-39 medial, 2-6 to 2-9 Little Leaguer's elbow vs., 2-31 medial collateral ligament elbow injury vs., 2-2 7 rheumatoid arthritis vs., 2-95 ulnar neuropathy vs., 2-35 Epidermoid inclusion cyst, enchondroma vs., 8-19 Epiphysis, slipped capital femoral. See Femoral epiphysis, slipped capital. Ewing sarcoma, 7-6 to 7-9 description, 7-6 to 7-9 Langerhans cell histiocytosis vs., 7-3 leukemia vs., 7-1 1 lymphoma vs., 7-15 osteosarcoma vs., 8-15 rhabdomyosarcoma of soft tissue vs., 9-39 Exertional compartment syndrome, chronic, medial tibial stress syndrome vs., 6-99 Exostosis, subungual, osteochondroma vs., 8-23 Extensor carpi ulnaris (ECU) subluxation distal radial ulnar joint instability vs., 3-19
lunotriquetral instability vs., 3-7 midcarpal instability vs., 3-1 1 tendinitis, 3-86 to 3-89 description, 3-86 to 3-89 triangular fibrocartilage tear vs., 3-23 ulnar styloid fractures vs., 3-35 Extensor tendinitidtear, patellar fracture vs., 5-91
Facet arthropathy, piriformis syndrome vs., 4-35 Fascia1 herniation, medial tibial stress syndrome VS.,6-99 Fat saturation failure, greater tuberosity fracture VS.,1-135 to 1-136 Femoral bone injury, lateral, transient patellar dislocation vs., 5-125 Femoral deficiency, proximal focal, developmental dysplasia of hip vs., 4-15 Femoral epiphysis, slipped capital developmental dysplasia of hip vs., 4-15 femoral head fractures vs., 4-47 hip dislocations vs., 4-59 Legg-Calve-Perthe disease vs., 4-7 Femoral head avascular necrosis of, 4-2 to 4-5 description, 4-2 to 4-5 femoral head fractures vs., 4-47 femoral neck fractures vs., 4-5 1 hip dislocations vs., 4-59 fractures, 4-46 to 4-49 description, 4-46 to 4-49 hip dislocations vs., 4-59 Femoral neck fractures, 4-50 to 4-53 description, 4-50 to 4-53 femoral head fractures vs., 4-47 hip dislocations vs., 4-59 stress pubic rami stress fractures vs., 4-67 sacral insufficiency fractures vs., 4-71 Femoral trochlea osteoarthritic change of, medial plica syndrome vs., 5-129 osteochondral injury of, chondromalacia patella vs., 5-1 17 Femoroacetabular impingement, 4-82 to 4-85 description, 4-82 to 4-85 labral tears vs., 4-75 osteoarthritis of hip vs., 4-87 paralabral cyst vs., 4-79 rheumatoid arthritis of hip vs., 4-95 snapping hip syndrome vs., 4-43 Fibroma chondromyxoid. See Chondromyxoid fibroma. nonossifying bone infarct vs., 5-83 osteochondral injury of knee vs., 5-75 Fibromatosis plantar, 6-138 to 6-141
description, 6-138 to 6-141 plantar fasciitis vs., 6-135 sesamoid dysfunction vs., 6-1 15 soft tissue, 9-6 to 9-9 description, 9-6 to 9-9 fibrosarcoma of soft tissue vs., 9-3 malignant fibrous histiocytoma of soft tissue vs., 9-11 synovial sarcoma vs., 9-19 Fibrosarcoma bone, 8-50 to 8-53 descrivtion, 8-50 to 8-53 lymphoma vs., 7-15 malignant fibrous histiocytoma vs., 8-47 soft tissue, 9-2 to 9-5 description, 9-2 to 9-5 fibromatosis vs., 9-7 malignant fibrous histiocytoma of soft tissue vs., 9-1 1 Fibrous dysplasia, 8-38 to 8-41 chondromyxoid fibroma vs., 8-31 description, 8-38 to 8-41 fibroxanthoma vs., 8-43 intraosseous hemangioma vs., 8-59 Paget disease vs., 7-39 unicameral bone cyst vs., 8-63 Fibrous histiocytoma, malignant. See Histiocytoma, malignant fibrous. Fibroxanthoma, 8-42 to 8-45 adamantinoma vs., 8-75 chondromyxoid fibroma vs., 8-31 description, 8-42 to 8-45 intraosseous lipoma vs., 8-71 unicameral bone cyst vs., 8-63 Fibular fractures distal, 6-62 to 6-65 syndesmosis sprain vs., 6-39 Flexor annular pulley tears, 3-98 to 3-101 Flexor carpi radialis tenosynovitis, De Quervain's tenosynovitis vs., 3-83 Flexor compartment tenosynovitis, flexor digitorum profundus avulsions vs., 3-103 Flexor digitorum profundus avulsions, 3-102 to 3-105 Flexor hallucis longus, 6-14 to 6-1 7 abnormalities of, 6-14 to 6-17 checkrein deformity of, os trigonum syndrome VS.,6-107 tenosynovitis of, os trigonum syndrome vs., 6-107 Flexor pulley system injury, flexor digitorum profundus avulsions vs., 3-103 Flexor superficialis crossover syndrome, median neuropathy vs., 2-43 Flexor tendon tear, flexor annular pulley tears vs., 3-98 to 3-99 Flexor tenosynovitis/tendinitis, hamate fractures vs., 3-43 Flipped meniscus, discoid meniscus vs., 5-3 Fluid in tendon sheath 2" to ankle effusion, flexor hallucis longus abnormalities vs., 6-15 Foot disorders. See Ankle and foot.
Foot fractures. See Ankle and foot fractures. Football player's ankle. See Ankle impingement, anterior. Foreign bodies, wrist, giant cell tumor of tendon sheath vs., 3-91 Fractures. See specific joint. Freiberg's infraction description, 6-94 to 6-97 Morton's neuroma vs., 6-143
Ganglion cysts, 3-78 to 3-81 anterolateral impingement vs., 6-43 description, 3-78 to 3-81 dorsal wrist De Quervain's tenosynovitis vs., 3-83 scaphoid fractures vs., 3-39 scapholunate ligament tear vs., 3-3 giant cell tumor of tendon sheath vs., 3-91 intraosseous chondroblastoma vs., 8-27 giant cell tumor vs., 8-55 medial bursitis of knee vs., 5-59 meniscal cyst vs., 5-15 patellar (anterior) bursitis vs., 5-107 plantar fibromatosis vs., 6-139 popliteal cyst vs., 5-159 sinus tarsi syndrome vs., 6-59 Gastrocnemius, lateral, insertional tearltendinosis, 5-63 Gastrocnemius-soleus strain, 6-122 to 6-125 compartment syndrome of lower extremity vs., 6-1 19 description, 6-122 to 6-125 medial tibia1 stress syndrome vs., 6-99 plantaris tendon rupture vs., 6-127 Gaucher's disease, 7-30 to 7-33 description, 7-30 to 7-33 multiple myeloma vs., 7-19 sickle cell anemia vs., 7-23 thalassemia vs., 7-27 Geniculate ligament insertion, anterior transverse, 5-19 Giant cell reparative granuloma, giant cell tumor vs., 8-55 Giant cell tumor bone, 8-54 to 8-57 aneurysmal bone cyst vs., 8-67 chondroblastoma vs., 8-27 description, 8-54 to 8-57 fibrosarcoma vs., 8-5 1 malignant fibrous histiocytoma vs., 8-47 tendon sheath, 3-90 to 3-93 description, 3-90 to 3-93 ganglion cysts vs., 3-79 GLAD (glenoid labrum articular disruption) lesion, 1-70 to 1-73 anterosuperior variations of shoulder vs., 1-52
INDEX description, 1-70 to 1-73 Glenohumeral ligament detachment. See Bankart lesion. HAGL (humeral avulsion of glenohumeral ligament) lesion, 1-74 to 1-77 ALPSA lesion vs., 1-67 to 1-68 Bankart lesion vs., 1-59 description, 1-74 to 1-77 IGL tears vs., 1-79 reverse HAGL vs., 1-76 posterior labral tear vs., 1-87 subscapularis rupture vs., 1-39 inferior (IGL), tears of, 1-78 to 1-81 ALPSA lesion vs., 1-68 Bankart lesion vs., 1-59 description, 1-78 to 1-81 HAGL lesion vs., 1-75 pectoralis major tear vs., 1-43 subscapularis-inferior, injury, pectoralis major tear vs., 1-43 Glenoid bare area, osteochondral injuries of shoulder VS.,1-131 fracture, osteochondral injuries vs., 1-131 Glenoid impingement, posterosuperior Bennett lesion vs., 1-83 labral cyst vs., 1-47 osteoarthritis vs., 1-139 rotator cuff tendinopathy vs., 1-3 subacromial impingement vs., 1-1 15 Glenoid labrum articular disruption (GLAD) lesion anterosuperior variations of shoulder vs., 1-52 description, 1-70 to 1-73 Glenoid version (retroversion), posterior labral tear vs., 1-87 Gluteal muscle strains, piriformis syndrome vs., 4-35 Gluteal tendon avulsion, gluteus medius muscle strain vs., 4-27 Gluteus medius muscle strain, 4-26 to 4-29 Gout Achilles tendinitis vs., 6-3 chondrocalcinosis of knee vs., 5-150 Freiberg's infraction vs., 6-95 Granuloma eosinophilic elbow osteomyelitis vs., 2-99 hip osteomyelitis vs., 4-99 to 4-100 giant cell reparative, giant cell tumor vs., 8-55 Greater trochanteric bursitis. See also Trochanteric bursitis. femoral neck fractures vs., 4-51 gluteus medius muscle strain vs., 4-27 paralabral cyst vs., 4-79 snapping hip syndrome vs., 4-43 Greater tuberosity bone trabecular injurylfracture, biceps tendon tear vs., 1-99 fracture description, 1-134 to 1-137
rheumatoid arthritis of shoulder vs., 1-143 humeral, pseudotumor of, chondroblastoma VS.,8-27
HAGL (humeral avulsion of glenohumeral ligament) lesion, 1-74 to 1-77 ALPSA lesion vs., 1-67 to 1-68 Bankart lesion vs., 1-59 description, 1-74 to 1-77 IGL tears vs., 1-79 reverse HAGL vs., 1-76 posterior labral tear vs., 1-87 subscapularis rupture vs., 1-39 Hallucis longus. See Flexor hallucis longus. Hallux limitus, sesamoid dysfunction vs., 6-115 Hallux rigidus, sesamoid dysfunction vs., 6-1 15 Hamate fractures, 3-42 to 3-45 description, 3-42 to 3-45 hamato-lunate impingement vs., 3-67 ulnar tunnel syndrome vs., 3-59 Hamato-lunate impingement, 3-66 to 3-69 Hamstring muscle strainltear hamstring tendinosis vs., 4-31 lateral, iliotibial band syndrome vs., 5-71 piriformis syndrome vs., 4-35 Hamstring tendinosis, 4-30 to 4-33 Hand. See Wrist and hand; Wrist and hand fractures. Heel pain syndrome. See Plantar fasciitis. Hemangioma, 9-42 to 9-45 bone marrow metastases vs., 7-35 giant cell tumor of tendon sheath vs., 3-91 intraosseous, 8-58 to 8-61 Langerhans cell histiocytosis vs., 7-3 multiple myeloma vs., 7-19 muscle strain of hip vs., 4-19 Paget disease vs., 7-39 plantar fibromatosis vs., 6-139 soft tissue, 9-42 to 9-45 Hematoma anconeus epitrochlearis vs., 2-46 to 2-47 benign peripheral nerve sheath tumor vs., 9-31 fibrosarcoma of soft tissue vs., 9-3 hemangioma of soft tissue vs., 9-43 liposarcoma vs., 9-27 malignant fibrous histiocytoma vs., 9-11, 9-35 of non communicating cyst, labral cyst of shoulder vs., 1-47 patellar tendon tears vs., 5-114 prepatellar, patellar tendinitis vs., 5-99 quadrilateral space syndrome vs., 1-147 soft tissue lipoma vs., 9-23 triceps muscle, triceps tendon rupture vs., 2-15 Hemophilia hemangioma of soft tissue vs., 9-43 pigmented villonodular synovitis vs., 5-141, 9-15
I
INDEX Hemorrhage, patellar, patellar (anterior) bursitis VS.,5-107 Hidden lesion. See Shoulder, hidden lesion. Hip. See also Hip fractures. avascular necrosis. See Avascular necrosis (AVN), hip. developmental dysplasia. See Dysplasia. dislocations, 4-58 to 4-61 acetabular fractures vs., 4-55 description, 4-58 to 4-61 developmental dysplasia of hip vs., 4-15 effusions, iliopsoas bursitis vs., 4-39 femoroacetabular impingement. See Femoroacetabular impingement. gluteus medius muscle strain, 4-26 to 4-29 hamstring tendinosis, 4-30 to 4-33 iliopsoas bursitis, 4-38 to 4-41, 4-43, 4-71 intraarticular derangements, acetabular fractures vs., 4-55 intrinsic pathology gluteus medius muscle strain vs., 4-27 hamstring tendinosis vs., 4-31 piriformis syndrome vs., 4-35 pubic rami stress fractures vs., 4-67 rectus femoris muscle strain vs., 4-23 sacral insufficiency fractures vs., 4-71 labral tears. See Labrum, acetabular. Legg-Calve-Perthedisease, 4 6 to 4 9 , 499, 7-23, 7-3 1 loose bodies, 4-43, 4-90 to 4-93 muscle strain, 4-18 to 4-21 avulsion hip fractures vs., 4-63 description, 4-18 to 4-21 iliopsoas bursitis vs., 4-39 pubic rami stress fractures vs., 4-67 sacral insufficiency fractures vs., 4-71 osteoarthritis, 4-86 to 4-89 osteomyelitis, 4-11, 4-67, 4-98 to 4-101, 6-91 paralabral cysts, 4-39, 4-78 to 4-81 piriformis syndrome, 4-27, 4-34 to 4-37, 4-51, 4-63 rectus femoris muscle strain, 4-22 to 4-25 rheumatoid arthritis, 4-94 to 4-97 septic, Legg-Calve-Perthe disease vs., 4-7 snapping hip syndrome. See Snapping hip syndrome. transient osteoporosis, 4-3, 4-10 to 4-13, 4-51, 4-99 Hip fractures acetabular, 4-54 to 4-57 description, 4-54 to 4-57 femoral head fractures vs., 4-47 hip dislocations vs., 4-59 avascular necrosis of femoral head vs., 4-3 avulsion, 4-62 to 4-65 acetabular fractures vs., 4-55 description, 4-62 to 4-65 femoral head, 4-46 to 4-49 description, 4-46 to 4-49 hip dislocations vs., 4-59
femoral neck, 4-50 to 4-53 description, 4-50 to 4-53 femoral head fractures vs., 4-47 hip dislocations vs., 4-59 stress pubic rami stress fractures vs., 4-67 sacral insufficiency fractures vs., 4-71 osteomyelitis of hip vs., 4-99 pubic rami stress fractures, 4-66 to 4-69 description, 4-66 to 4-69 sacralinsuffi~ienc~ fractures vs., 4-71 rectus femoris muscle strain vs., 4-23 sacral insufficiency, 4-70 to 4-73 stress acetabular fractures vs., 4-55 avulsion hip fractures vs., 4-63 femoral head fractures vs., 4-47 femoral neck, sacral insufficiency fractures VS.,4-71 gluteus medius muscle strain vs., 4-27 hamstring tendinosis vs., 4-31 hip dislocations vs., 4-59 piriformis syndrome vs., 4-35 pubic rami, 4-66 to 4-69 transient osteoporosis of hip vs., 4-11 Hip impingement, femoroacetabular, 4-82 to 4-85 description, 4-82 to 4-85 labral tears vs., 4-75 osteoarthritis of hip vs., 4-87 paralabral cyst vs., 4-79 rheumatoid arthritis of hip vs., 4-95 snapping hip syndrome vs., 4-43 Histiocytoma, malignant fibrous bone, 8-46 to 8-49 bone marrow metastases vs., 7-35 chondrosarcoma vs., 8-35 description, 8-46 to 8-49 fibrosarcoma of bone vs., 8-51 soft tissue, 9-10 to 9-13 description, 9-10 to 9-13 fibromatosis vs., 9-7 fibrosarcoma of soft tissue vs., 9-3 liposarcoma vs., 9-27 malignant peripheral nerve sheath tumor vs., 9-35 synovial sarcoma vs., 9-19 Histiocytosis. See Langerhans cell histiocytosis. Hoffa's impingement, medial plica syndrome vs., 5-129 Hoffa's pad, inflammation of, chondromalacia patella vs., 5-1 17 Humeral avulsion of glenohumeral ligament. See HAGL (humeral avulsion of glenohumeral ligament) lesion. Humeral capitellum. See Capitellum. Humeral head osteochondral defect (HHOCD), osteoarthritis VS.,1-139 osteochondral injuries vs., 1-131
Humeral tuberosity, greater, pseudotumor of, chondroblastoma vs., 8-27 Humerus bare area, osteochondral injuries of shoulder VS.,1-131 fractures distal, supracondylar fracture vs., 2-75 posterior labral tear vs., 1-87 proximal greater tuberosity fracture vs., 1-135 quadrilateral space syndrome vs., 1-147 Hurler syndrome, Gaucher's disease vs., 7-3 1
IGL (inferior glenohumeral ligament) tears, 1-78 to 1-81 ALPSA lesion vs., 1-68 Bankart lesion vs., 1-59 description, 1-78 to 1-81 HAGL lesion vs., 1-75 pectoralis major tear vs., 1-43 Iliopsoas bursitis, 4-38 to 4-41 description, 4-38 to 4-41 sacral insufficiency fractures vs., 4-71 snapping hip syndrome vs., 4-43 Iliopsoas tendon, normal, labral tears vs., 4-75 Iliotibial band syndrome, 5-70 to 5-73 description, 5-70 to 5-73 posterolateral complex injury vs., 5-67 Impingement ankle. See Ankle impingement. hamato-lunate, 3-66 to 3-69 hip. See Femoroacetabular impingement. shoulder. See Shoulder impingement. ulnar, 3-15, 3-75 Infarct, bone. See Bone infarct. Infection diabetic foot vs., 6-147 ganglion cyst vs., 3-79 hip avascular necrosis of femoral head vs., 4-3 muscle strain of hip vs., 4-19 indolent, knee synovitis vs., 5-1 11 knee, bone infarct vs., 5-83 Infectious arthritis. See Arthritis, infectious. Inferior glenohumeral ligament (IGL) tears. See Glenohumeral ligament, inferior (IGL), tears of. Inflammatory arthritis. See Arthritis, inflammatory; Osteoarthritis. Infraspinatus tear, suprascapular, spinoglenoid notch vs., 1-151 Intercondylar notch cyst, 5-154 to 5-157 Interdigital neuroma, tarsal tunnel syndrome vs., 6-131 Intermeniscal ligament, oblique, meniscal bucket-handle tear vs., 5-31 Intermetatarsalbursitis, Morton's neuroma vs., 6-143
INDEX Interphalangeal joints distal, dislocation of, flexor annular pulley tears vs., 3-99 proximal, dislocation of flexor annular pulley tears vs., 3-99 flexor digitorum profundus avulsions vs., 3-103 Intersection syndrome, De Quervain's tenosynovitis vs., 3-83 Intracondylar notch cyst, 5-154 to 5-157 Intraosseous hemangioma, 8-58 to 8-61. See also Hemangioma. Ischial tuberosity bursitis, piriformis syndrome vs., 4-35
Jones fracture, Lisfranc fracture vs., 6-83 Juvenile chronic arthritis Legg-Calve-Perthe disease vs., 4-7 rheumatoid arthritis of wrist and hand vs., 3-71 Juvenile osteonecrosis, Legg-Calve-Perthe disease vs., 4-7
Kienbock's disease, 3-50 to 3-53 degenerative arthritis of wrist vs., 3-63 description, 3-50 to 3-53 die punch fracture of distal radius vs., 3-31 distal radial ulnar joint instability vs., 3-19 extensor carpi ulnaris tendinitis vs., 3-87 hamato-lunate impingement vs., 3-67 scapholunate ligament tear vs., 3-3 to 3-4 traumatic abnormalities of, distal radius fractures vs., 3-27 triangular fibrocartilage tear vs., 3-23 ulnar styloid fractures vs., 3-35 ulnocarpal abutment vs., 3-15 Knee. See also Knee fractures; Patella. anterior cruciate ligament. See Anterior cruciate ligament. bone infarct, 5-82 to 5-85, 5-147 bone trabecular injuries lateral collateral ligament tear vs., 5-63 meniscal flap tear vs., 5-27 reflex sympathetic dystrophy of knee vs., 5-147 chondrocalcinosis, 5-150 to 5-154 iliotibial band syndrome, 5-67, 5-70 to 5-73 intercondylar notch cyst, 5-154 to 5-157 intrinsic pathology of, rectus femoris muscle strain vs., 4-23 lateral collateral ligament tear, 5-62 to 5-65, 5-71 lateral tibia1 plateau fracture, 5-63, 5-71, 5-94 to 5-97 lipoma arborescens, 5-144 to 5-145 medial bursitis, 5-58 to 5-61, 5-87 medial collateral ligament injuries, 5-35, 5-54 to 5-57, 5-59, 5-60
INDEX medial plica syndrome, 5-121, 5-128 to 5-131 meniscal disorders. See Meniscal tears; Meniscus. Osgood-Schlatter disease, 5-99, 5-102 to 5-105 osseous injury of, medial collateral ligament tear vs., 5-55 osteoarthritis, 5-132 to 5-135 bone infarct vs., 5-83 chondrocalcinosis of knee vs., 5-150 description, 5-132 to 5-135 knee synovitis vs., 5-1 11 osteochondral injury of knee vs., 5-75 patellar tendinitis vs., 5-99 to 5-100 post-operative meniscus change vs., 5-39 quadriceps tendon tear vs., 5-121 spontaneous osteonecrosis vs., 5-87 osteochondral injuries. See Osteochondral injuries. osteochondritis dissecans, 5-75, 5-78 to 5-81, 5-8 7 patellar disorders. See Patella. pigmented villonodular synovitis, 5-140 to 5-143 popliteal cyst, 5-155, 5-158 to 5-161 posterior cruciate ligament tear, 5-50 to 5-53, 5-63 posterolateral complex injuries, 5-51, 5-66 to 5-69, 5-95 quadriceps tendon tear, 5-120 to 5-123 reflex sympathetic dystrophy, 5-146 to 5-149 rheumatoid arthritis, 5-136 to 5-139 spontaneous osteonecrosis, 5-86 to 5-89 stress responselfracture, spontaneous osteonecrosis of knee vs., 5-87 synovitis, 5-1 10 to 5-1 13, 5-137, 5-141, 5-147 trauma, rheumatoid arthritis vs., 5-137 Knee fractures. See also Patella, fractures. insufficiency, osteochondritis dissecans vs., 5-79 lateral tibial plateau fracture vs., 5-95 reflex sympathetic dystrophy of knee vs., 5-147 stress bone infarct vs., 5-83 osteochondritis dissecans vs., 5-79 spontaneous osteonecrosis of knee vs., 5-87 subchondral, spontaneous osteonecrosis of knee, 5-88 Kohler-Freiberg disease, 6-94 Kohler's disease. accessorv navicular vs.. 6-1 11
xiv
I
Labroligamentous periosteal sleeve avulsion lesion, anterior (ALPSA), 1-66 to 1-69 Bankart lesion vs., 1-59 description, 1-66 to 1-69 GLAD lesion vs., 1-71 HAGL lesion vs., 1-75 Perthes lesion vs., 1-64 Labrum, acetabular degenerative, labral tears vs., 4-75
normal attachment, labral tears vs., 4-75 paralabral cysts, 4-78 to 4-81 tears, 4-74 to 4-77 description, 4-74 to 4-77 femoroacetabular impingement vs., 4-83 loose bodies of hip vs., 4-91 osteoarthritis of hip vs., 4-87 rheumatoid arthritis of hip vs., 4-95 snapping hip syndrome vs., 4-43 Labrum, shoulder anterosuperior variations of shoulder and, 1-50 to 1-53 cyst, 1-46 to 1-49 normal Perthes lesion vs., 1-64 posterior labral tear vs., 1-87 partially torn non-distracted, Bankart lesion VS., 1-59 posterior tears, 1-86 to 1-89 Bennett lesion vs., 1-83 description, 1-86 to 1-89 GLAD lesion vs., 1-71 SLAC lesion, hidden lesion vs., 1-91 SLAP lesions anterosuperior variations of shoulder vs., 1-52 Bankart lesion vs., 1-60 biceps tendinosis vs., 1-95 biceps tendon dislocation vs., 1-1 11 biceps tendon tear vs., 1-99 GLAD lesion vs., 1-71 hidden lesion vs., 1-92 lesions I-IV, 1-102 to 1-105 lesions V-IX, 1-106 to 1-109 microinstability vs., 1-23 Perthes lesion vs., 1-64 without RTC pathology, internal shoulder impingement vs., 1-1 1 torn, detached, biceps tendon dislocation vs., 1-1 11 Langerhans cell histiocytosis, 7-2 to 7-5 chondroblastoma vs., 8-27 description, 7-2 to 7-5 Ewing sarcoma vs., 7-7 intraosseous hemangioma vs., 8-59 leukemia vs., 7-1 1 multiple myeloma vs., 7-19 unicameral bone cyst vs., 8-63 Lateral collateral ligament injuryltear elbow, 2-18 to 2-21 knee description, 5-62 to 5-65 iliotibial band syndrome vs., 5-71 ulnar, posterior dislocation of elbow vs., 2-23 Lateral condylar fracture description, 2-68 to 2-71 medial condylar fracture vs., 2-79 supracondylar fracture vs., 2-75 Lateral tibial plateau fracture, 5-94 to 5-97 iliotibial band syndrome vs., 5-71 lateral collateral ligament tear vs., 5-63
INDEX Lateral tubercle fracture, os trigonum syndrome VS.,6-107 Latissimus dorsi injury, pectoralis major tear vs., 1-43 Legg-Calve-Perthe disease, 4-6 to 4-9 description, 4-6 to 4-9 Gaucher's disease vs., 7-31 osteomyelitis of hip vs., 4-99 sickle cell anemia vs., 7-23 Leprosy, ulnar neuropathy vs., 2-35 Leukemia, 7-10 to 7-13 description, 7-10 to 7-13 lymphoma vs., 7-15 multiple myeloma vs., 7-19 rhabdomyosarcoma of soft tissue vs., 9-39 thalassemia vs., 7-27 Ligament disorders ALPSA. See ALPSA (anterior labroligamentous periosteal sleeve avulsion) lesion. anterior cruciate ligament. See Anterior cruciate ligament. anterior impingement of ankle, 6-46 to 6-49 anterior talofibular ligament tear, 6-26 to 6-29 anterolateral impingement of ankle, 6-42 to 6-45 bifurcate ligament sprain, 6-59, 6-83 calcaneofibular ligament sprain, 6-30 to 6-33, 6-83 deltoid ligament. See Deltoid ligament. glenohumeral. See Glenohumeral ligament. HAGL lesion. See HAGL (humeral avulsion of glenohumeral ligament) lesion. lateral collateral ligament. See Lateral collateral ligament injuryltear. lunotriquetral instability, 3-6 to 3-9 medial collateral ligament. See Medial collateral ligament injury. posterior cruciate ligament, 5-50 to 5-53 posterior impingement of ankle, 6-54 to 6-57 scapholunate ligament tear, 3-2 to 3-5, 3-39, 3-4 7 semimembranosus tibial collateral ligament bursitis, 5-15, 5-55, 5-159 sinus tarsi syndrome, 6-58 to 6-61 sprains, hamate fractures vs., 3-43 syndesmotic impingement of ankle, 6-50 to 6-53 syndesmotic sprain, 6-38 to 6-41 talofibular. See Talofibular ligament sprainltear. tibial collateral ligament bursitis, 5-55 tibiofibular ligament syndesmotic sprain, 6-38 to 6-41 ulnar collateral ligament elbow, 2-27 to 2-28 wrist, 3-94 to 3-97 Lipoma intraosseous, 8-70 to 8-73 description, 8-70 to 8-73 sinus tarsi syndrome vs., 6-59 soft tissue, 9-22 to 9-25 description, 9-22 to 9-25 giant cell tumor of tendon sheath vs., 3-91
hemangioma of soft tissue vs., 9-43 liposarcoma vs., 9-27 plantar fibromatosis vs., 6-139 synovial, lipoma arborescens of knee vs., 5-144 Lipoma arborescens knee, 5-144 to 5-145 pigmented villonodular synovitis vs., 9-15 soft tissue lipoma vs., 9-23 Liposarcoma, soft tissue, 9-26 to 9-29 benign peripheral nerve sheath tumor vs., 9-31 description, 9-26 to 9-29 fibrosarcoma of soft tissue vs., 9-3 malignant fibrous histiocytoma of soft tissue VS.,9-11 soft tissue lipoma vs., 9-23 Lisfranc fracture-dislocation, 6-82 to 6-85 description, 6-82 to 6-85 Freiberg's infraction vs., 6-95 metatarsal fractures vs., 6-79 Lisfranc sprain, calcaneofibular ligament sprain VS.,6-31 Little Leaguer's elbow description, 2-30 to 2-33 medial collateral ligament elbow injury vs., 2-27 Loose bodies ankle, anterior impingement vs., 6-47 elbow description, 2-60 to 2-63 synovial fringe vs., 2-88 hip description, 4-90 to 4-93 snapping hip syndrome vs., 4-43 knee lipoma arborescens of knee vs., 5-144 meniscal flap tear vs., 5-27 shoulder GLAD lesion vs., 1-71 rotator cuff calcific tendinitis vs., 1-31 Lumbar radiculopathy gluteus medius muscle strain vs., 4-27 piriformis syndrome vs., 4-35 rectus femoris muscle strain vs., 4-23 sacral insufficiency fractures vs., 4-71 tarsal tunnel syndrome vs., 6-131 Lunate fracture, acute, Kienbock's disease vs., 3-5 1 Lunotriquetral coalition, partial, lunotriquetral instability vs., 3-7 Lunotriquetral dissociation triangular fibrocartilage tear vs., 3-23 ulnar styloid fractures vs., 3-35 Lunotriquetral instability description, 3-6 to 3-9 midcarpal instability vs., 3-1 1 Lunotriquetral ligament tear, hamato-lunate impingement vs., 3-67 Lupus erythematosus, systemic rheumatoid arthritis of knee vs., 5-137 rheumatoid arthritis of shoulder vs., 1-143 Lymphoma, 7-14 to 7-1 7 bone marrow metastases vs., 7-35
INDEX description, 7-14 to 7-17 Ewing sarcoma vs., 7-7 fibrosarcoma vs., 8-51 Langerhans cell histiocytosis vs., 7-3 leukemia vs., 7-1 1 malignant fibrous histiocytoma vs., 8-47 multiple myeloma vs., 7-19 osteosarcoma vs., 8-15 Paget disease vs., 7-39 rhabdomyosarcoma of soft tissue vs., 9-39
Madelung's deformity of wrist, 3-74 to 3-77 Magic angle effectjartifact biceps tendinosis vs., 1-95 meniscal degeneration, 5-7 osteochondral injury of knee vs., 5-75 patellar tendinitis vs., 5-99 quadriceps tendon tear vs., 5-121 rotator cuff tendinopathy vs., 1-3 tibialis posterior tendon tear vs., 6-1 1 Malignant fibrous histiocytoma. See Histiocytoma, malignant fibrous. Malignant peripheral nerve sheath tumor. See Peripheral nerve sheath tumor, malignant. Malignant tumors. See Tumors, malignant. Malleolus fractures of, 6-62 to 6-65 medial, fracture of, deltoid ligament sprain vs., 6-3 5 Manubrium-sternum dislocation, pectoralis major tear vs., 1-43 Mass(es). See Neoplasms. MCL. See Medial collateral ligament injury. Medial bursitis of knee description, 5-58 to 5-61 spontaneous osteonecrosis of knee vs., 5-87 Medial collateral ligament injury elbow, 2-26 to 2-29 description, 2-26 to 2-29 normal medial collateral ligament vs., 2-28 posterior dislocation of elbow vs., 2-23 sprain, Little Leaguer's elbow vs., 2-31 strain, without tendon disruption, medial epicondylitis vs., 2-7 traction spur vs., 2-27 to 2-28 knee bursitis, meniscocapsular separation vs., 5-35 sprain or stress response, medial bursitis of knee vs., 5-60 superficial tear and joint effusion, meniscocapsular separation vs., 5-35 tear, 5-54 to 5-57 traumatic hemorrhage, medial bursitis vs., 5-59 Medial condylar fracture description, 2-78 to 2-81 lateral tibia1 plateau fracture vs., 5-95
supracondylar fracture vs., 2-75 Medial epicondylar fracture avulsion, coronoid process fracture vs., 2-49 supracondylar fracture vs., 2-75 Medial plica syndrome description, 5-128 to 5-131 quadriceps tendon tear vs., 5-121 Median neuropathy description, 2-42 to 2-45 radial neuropathy vs., 2-39 Meniscal tears anterior, chondromalacia patella vs., 5-1 17 anterior cruciate ligament reconstruction vs., 5-47 bucket-handle, 5-30 to 5-33 anterior cruciate ligament tear vs., 5-43 description, 5-30 to 5-33 discoid meniscus vs., 5-3 osteochondral injury of knee vs., 5-75 post-operative meniscus change vs., 5-39 with displacement, meniscal flap tear vs., 5-2 7 chondrocyte "healing" of, post-operative meniscus change vs., 5-39 flap, 5-26 to 5-29 description, 5-26 to 5-29 displaced discoid meniscus vs., 5-3 post-operative meniscus change vs., 5-39 horizontal tear vs., 5-1 1 meniscal bucket-handle tear vs., 5-31 horizontal, 5-10 to 5-13 description, 5-10 to 5-13 meniscal flap tear vs., 5-27 lateral meniscus iliotibial band syndrome vs., 5-71 lateral collateral ligament tear vs., 5-63 posterolateral complex injury vs., 5-67 longitudinal, 5-18 to 5-21 medial medial collateral ligament tear vs., 5-55 medial plica syndrome vs., 5-129 medial bursitis of knee vs., 5-59 to 5-60 meniscal degeneration vs., 5-7 noncommunicating intrameniscal tear, meniscal degeneration vs., 5-7 oblique tearlflap tear, meniscal radial tear vs., 5-23 radial tear anterior cruciate ligament tear vs., 5-43 description, 5-22 to 5-25 spontaneous osteonecrosis of knee vs., 5-87 Meniscofemoral femoral ligament insertion, meniscal longitudinal tear vs., 5-19 Meniscus. See also Meniscal tears. chondral lesions, meniscal flap tear vs., 5-27 cyst, 5-14 to 5-17 description, 5-14 to 5-17 iliotibial band syndrome vs., 5-71 intracondylar notch cyst vs., 5-155
medial bursitis of knee vs., 5-59 meniscocapsular separation vs., 5-35 patellar (anterior) bursitis vs., 5-107 popliteal cyst vs., 5-159 degeneration, 5-6 to 5-9 description, 5-6 to 5-9 meniscal flap tear vs., 5-27 meniscal radial tear vs., 5-23 discoid meniscus, 5-2 to 5-5 fat planes within meniscotibial attachments, meniscal degeneration vs., 5-7 flipped meniscus, discoid meniscus vs., 5-3 fluid distention of attachment recesses medial bursitis vs., 5-59 meniscocapsular separation vs., 5-35 linear intrameniscal signal abnormality of, horizontal tear vs., 5-1 1 magic angle phenomenon, meniscal degeneration vs., 5-7 meniscocapsular separation, 5-34 to 5-37 ossicle marrow fat-containing, meniscal degeneration vs., 5-7 meniscal cyst vs., 5-15 meniscal radial tear vs., 5-23 post-operative change description, 5-38 to 5-41 meniscal radial tear vs., 5-23 vascularity normal, horizontal tear vs., 5-1 1 prominent or linear, meniscal degeneration vs., 5-7 Metacarpophalangeal joint capsular trauma of, ulnar collateral ligament tear vs., 3-95 dislocations of flexor digitorum profundus avulsions vs., 3-103 ulnar collateral ligament tear vs., 3-95 trauma to, flexor annular pulley tears vs., 3-99 Metastatic disease. See also Bone tumors; Neoplasms; Soft tissue tumors; Tumors. acetabular fractures vs., 4-55 adamantinoma vs., 8-75 aneurysmal bone cyst vs., 8-67 avascular necrosis of femoral head vs., 4-3 avascular necrosis of shoulder vs., 1-127 avulsion hip fractures vs., 4-63 bone marrow, 7-34 to 7-37 femoral neck fractures vs., 4-51 fibrosarcoma vs., 8-5 1 intraosseous hemangioma vs., 8-59 Langerhans cell histiocytosis vs., 7-3 leukemia vs., 7-1 1 lymphoma vs., 7-15 malignant fibrous histiocytoma vs., 8-47 multiple myeloma vs., 7-19 osteoblastic, Paget disease vs., 7-39 pubic rami stress fractures vs., 4-67 reflex sympathetic dystrophy of knee vs., 5-147
sacral insufficiency fractures vs., 4-71 Metastatic neuroblastoma, Ewing sarcoma vs., 7-7 Metatarsal fractures, 6-78 to 6-81 base of fifth metatarsal calcaneofibular ligament sprain vs., 6-31 syndesmotic impingement vs., 6-51 description, 6-78 to 6-81 Freiberg's infraction of, 6-94 to 6-97 sesamoid dysfunction vs., 6-1 15 stress, Morton's neuroma vs., 6-143 Metatarsal phalangeal arthritis, Freiberg's infraction vs., 6-95 Microinstability of shoulder. See Shoulder, microinstability. Midcarpal instability, 3-10 to 3-13 description, 3-10 to 3-13 lunotriquetral instability vs., 3-7 Midfoot arthritis accessory navicular vs., 6-1 11 Freiberg's infraction vs., 6-95 tibialis anterior tendon tear vs., 6-19 Milwaukee shoulder, osteoarthritis of shoulder vs., 1-139 Morton's neuroma description, 6-142 to 6-145 sesamoid dysfunction vs., 6-1 15 Multiple myeloma, 7-18 to 7-21 bone marrow metastases vs., 7-35 description, 7-18 to 7-21 fibrosarcoma vs., 8-5 1 Gaucher's disease vs., 7-31 intraosseous hemangioma vs., 8-59 lymphoma vs., 7-15 malignant fibrous histiocytoma vs., 8-47 Paget disease vs., 7-39 Muscle soreness, delayed onset (DOMS) muscle strain of hip vs., 4-19 pubic rami stress fractures vs., 4-67 Muscle strain gluteus medius, 4-26 to 4-29 hamstring muscle strainltear, 4-31, 4-35, 5-71 hip. See Hip, muscle strain. rectus femoris, 4-22 to 4-25 Myelofibrosis, Paget disease vs., 7-39 Myeloma. See Multiple myeloma. Myositis, nonspecific, Parsonage-Turner syndrome VS.,1-35 Myositis ossificans compartment syndrome of lower extremity vs., 6-119 elbow osteomyelitis vs., 2-100 juxtacortical osteoma vs., 8-3 osteochondroma vs., 8-23 osteosarcoma vs., 8-15 paralabral cyst vs., 4-79 synovial sarcoma vs., 9-19
INDEX P
Navicular, accessory, 6-1 10 to 6-1 13 Navicular fractures, 6-74 to 6-77 description, 6-74 to 6-77 Lisfranc fracture vs., 6-83 metatarsal fractures vs., 6-79 navicular tuberosity, accessory navicular vs., 6-1 11 Necrosis, avascular. See Avascular necrosis (AVN). Neoplasms. See also Bone tumors; Metastatic disease; Soft tissue tumors; Tumors. biceps tendon rupture vs., 2-1 1 cystic, meniscal cyst vs., 5-15 extraarticular, rheumatoid arthritis of shoulder VS.,1-143 knee synovitis vs., 5-1 11 to 5-1 12 labral cyst of shoulder vs., 1-47 olecranon bursitis vs., 2-86 shoulder, quadrilateral space syndrome vs., 1-147 synovial, anconeus epitrochlearis vs., 2-46 to 2-47 triceps tendon rupture vs., 2-15 Neuroblastoma metastatic, Ewing sarcoma vs., 7-7 rhabdomyosarcoma of soft tissue vs., 9-39 Neurofibromatosis, fibrous dysplasia vs., 8-39 Neurofibromas Morton's neuroma vs., 6-143 plantar fibromatosis vs., 6-139 Neuroma anconeus epitrochlearis vs., 2-46 to 2-47 interdigital, tarsal tunnel syndrome vs., 6-131 Morton's. See Morton's neuroma. Neuropathic (Charcot) joint Freiberg's infraction vs., 6-95 rheumatoid arthritis of shoulder vs., 1-143 Nieman Pick disease, Gaucher's disease vs., 7-31 Nuclear medicine acromioclavicular joint arthritis, 1-123 adamantinoma, 8-75 aneurysmal bone cyst, 8-67 avascular necrosis femoral head, 4-2 to 4-3 shoulder, 1-127 Bennett lesion, 1-83 bone marrow metastases, 7-35 chondromyxoid fibroma, 8-3 1 chondrosarcoma, 8-35 enchondroma, 8-19 Ewing sarcoma, 7-7 fibrosarcoma, 8-51 soft tissue, 9-3 fibrous dysplasia, 8-39 fibroxanthoma, 8-43 Gaucher's disease, 7-3 1 giant cell tumor, 8-55 hemangioma of soft tissue, 9-43 intraosseous hemangioma, 8-59 intraosseous lipoma, 8-71
Langerhans cell histiocytosis, 7-3 lateral condylar fracture, 2-69 Legg-Calve-Perthe disease, 4-6 to 4-7 leukemia, 7-1 1 liposarcoma, 9-27 lymphoma, 7-15 malignant fibrous histiocytoma, 8-47 soft tissue, 9-1 1 medial tibia1 stress syndrome, 6-99 multiple myeloma, 7-19 Osgood-Schlatter disease, 5-103 osteoblastoma, 8-1 1 osteoid osteoma, 8-7 osteoma, 8-3 osteosarcoma, 8-15 Paget disease, 7-39 patellar fracture, 5-91 peripheral nerve sheath tumor, malignant, 9-35 pigmented villonodular synovitis, 9-15 pubic rami stress fractures, 4-66 rhabdomyosarcoma, soft tissue, 9-39 rheumatoid arthritis shoulder, 1-143 wrist and hand, 3-71 sacral insufficiency fractures, 4-71 sickle cell anemia, 7-23 spontaneous osteonecrosis of knee, 5-87 synovial sarcoma, 9-19 thalassemia, 7-27 unicameral bone cyst, 8-63
Olecranon bursitis, 2-86 to 2-87 description, 2-86 to 2-87 elbow osteomyelitis vs., 2-100 rheumatoid arthritis vs., 2-95 triceps tendon rupture vs., 2-15 Olecranon fracture, 2-64 to 2-67 coronoid process fracture vs., 2-49 description, 2-64 to 2-67 lateral condylar fracture vs., 2-69 medial condylar fracture vs., 2-79 radial head fracture vs., 2-57 supracondylar fracture vs., 2-75 triceps tendon rupture vs., 2-15 0 s acromiale, 1-118 to 1-121 degenerative changes, acromioclavicular joint arthritis vs., 1-123 description, 1-118 to 1-121 post-operative rotator cuff repair vs., 1-27 to 1-28 subacromial impingement vs., 1-115 0 s peroneum syndrome, painful, peroneus brevis tendon tear vs., 6-23 0 s supratrochleare, 2-60 to 2-63 0 s trigonum syndrome, 6-106 to 6-109 description, 6-106 to 6-109 flexor hallucis longus abnormalities vs., 6-15
posterior impingement vs., 6-55 talus fractures vs., 6-67 tarsal tunnel syndrome vs., 6-131 Osgood-Schlatter disease description, 5-102 to 5-105 patellar tendinitis vs., 5-99 Osseous contusion. See Contusion, osseous, hip. Ossification center accessory, deltoid ligament sprain vs., 6-35 normal elbow, olecranon fracture vs., 2-65 os acromiale vs., 1-1 19 Osteoarthritis. See also Arthritis; Rheumatoid arthritis. avascular necrosis of talus vs., 6-91 diabetic foot vs., 6-147 elbow, 2-90 to 2-93 description, 2-90 to 2-93 radial head fracture vs., 2-57 rheumatoid arthritis vs., 2-95 synovial fringe vs., 2-88 femoral neck fractures vs., 4-51 femoroacetabular impingement vs., 4-83 flexor annular pulley tears vs., 3-99 Freiberg's infraction vs., 6-95 hip, 4-86 to 4-89 iliopsoas bursitis vs., 4-39 inflammatory, transient osteoporosis of hip vs., 4-1 1 knee, 5-132 to 5-135 bone infarct vs., 5-83 chondrocalcinosis of knee vs., 5-150 description, 5-132 to 5-135 knee synovitis vs., 5-1 11 osteochondral injury of knee vs., 5-75 patellar tendinitis vs., 5-99 to 5-100 post-operative meniscus change vs., 5-39 quadriceps tendon tear vs., 5-121 spontaneous osteonecrosis vs., 5-87 labral tears vs., 4-75 loose bodies of hip vs., 4-91 paralabral cyst vs., 4-79 rheumatoid arthritis of wrist and hand vs., 3-71 shoulder, 1-138 to 1-141 adhesive capsulitis vs., 1-55 avascular necrosis vs., 1-127 description, 1-138 to 1-141 osteochondral injuries vs., 1-131 rheumatoid arthritis of shoulder vs., 1-143 tarsal coalition vs., 6-103 to 6-104 ulnar collateral ligament tear vs., 3-95 wrist, 3-62 to 3-65 Osteoblastic metastases, Paget disease vs., 7-39 Osteoblastoma, 8-10 to 8-13 aneurysmal bone cyst vs., 8-67 description, 8-10 to 8-13 osteoid osteoma vs., 8-7 Osteochondral injuries avascular necrosis of shoulder vs., 1-127 elbow, osteoarthritis vs., 2-91
femoral trochlea, chondromalacia patella vs., 5-1 17 knee, 5-74 to 5-77 anterior cruciate ligament reconstruction VS.,5-48 bone infarct vs., 5-83 chondrocalcinosis of knee vs., 5-150 to 5-151 description, 5-74 to 5-77 fracture, osteochondritis dissecans vs., 5-79 osteoarthritis vs., 5-133 posterior cruciate ligament tear vs., 5-51 patellar, transient patellar dislocation vs., 5-125 shoulder, 1-130 to 1-133 Osteochondral lesion of talus (OLT). See Talus. Osteochondritis dissecans, 5-78 to 5-81 capitellum, 2-52 to 2-55 bicipital radial bursitis vs., 2-83 capitellum fracture vs., 2-72 description, 2-52 to 2-55 lateral collateral ligament injury vs., 2-19 lateral condylar fracture vs., 2-69 Little Leaguer's elbow vs., 2-31 loose bodies and os supratrochleare vs., 2-61 medial condylar fracture vs., 2-79 radial head fracture vs., 2-57 knee, 5-78 to 5-81 description, 5-78 to 5-81 osteochondral injury of knee vs., 5-75 spontaneous osteonecrosis of knee vs., 5-87 Osteochondroma, 8-22 to 8-25 description, 8-22 to 8-25 Madelung's deformity vs., 3-75 sessile, osteoma vs., 8-3 Osteochondromatosis rotator cuff calcific tendinitis vs., 1-31 synovial lipoma arborescens of knee vs., 5-144 loose bodies and os supratrochleare vs., 2-61 Osteochondrosis. See Freiberg's infraction; LeggCalve-Perthe disease. Osteofibrous dysplasia, adamantinoma vs., 8-75 Osteoid osteoma. See Osteoma, osteoid. Osteolysis, post-traumatic, acromioclavicular joint arthritis vs., 1-123 Osteoma, 8-2 to 8-5 description, 8-2 to 8-5 osteoid, 8-6 to 8-9 description, 8-6 to 8-9 elbow osteomyelitis vs., 2-99 to 2-100 Legg-Calve-Perthe disease vs., 4-7 osteoblastoma vs., 8-1 1 Osteomyelitis adamantinoma vs., 8-75 chondroblastoma vs., 8-27 elbow, 2-98 to 2-101 Ewing sarcoma vs., 7-7 hip, 4-98 to 4-101 avascular necrosis of talus vs., 6-91 description, 4-98 to 4-101 pubic rami stress fractures vs., 4-67
x
transient osteoporosis of hip vs., 4-11 Langerhans cell histiocytosis vs., 7-3 leukemia vs., 7-1 1 lymphoma vs., 7-15 osteoblastoma vs., 8-1 1 osteoid osteoma vs., 8-7 osteosarcoma vs., 8-15 Osteonecrosis. See also Avascular necrosis (AVN). diabetic foot vs., 6-147 juvenile, Legg-Calve-Perthe disease vs., 4-7 osteochondral lesion of talus (OLT) vs., 6-87 spontaneous, knee, 5-86 to 5-89 transient osteoporosis of hip vs., 4-1 1 Osteopenia, intraosseous hemangioma vs., 8-59 Osteoporosis multiple myeloma vs., 7-19 osteochondral lesion of talus (OLT) vs., 6-87 transient, hip, 4-10 to 4-13 avascular necrosis of femoral head vs., 4-3 description of, 4-10 to 4-13 femoral neck fractures vs., 4-51 osteomyelitis of hip vs., 4-99 regional migratory osteoporosis vs., 4-1 1 Osteosarcoma, 8-14 to 8-1 7 chondrosarcoma vs., 8-35 description, 8-14 to 8-17 Ewing sarcoma vs., 7-7 fibrosarcoma vs., 8-5 1 giant cell tumor vs., 8-55 lymphoma vs., 7-15 malignant fibrous histiocytoma vs., 8-47 osteoblastoma vs., 8-1 1 parosteal osteochondroma vs., 8-23 osteoma vs., 8-3 synovial sarcoma vs., 9-19 telangiectatic, aneurysmal bone cyst vs., 8-67 Overuse syndromes/soft tissue injuries accessory navicular, 6-110 to 6-113 carpal tunnel syndrome, 3-43, 3-54 to 3-57, 3-58,3-83 diabetic foot, 6-146 to 6-149 gastrocnemius-soleus strain, 6-99, 6-1 19, 6-122 to 6-125,6-127 iliotibial band syndrome, 5-70 to 5-73 lower extremity compartment syndrome, 6-1 18 to 6-121 medial tibia1 stress syndrome, 6-98 to 6-101 Morton's neuroma, 6-142 to 6-145 os trigonum syndrome. See 0 s trigonum syndrome. plantar fasciitis, 6-131, 6-135 to 6-137, 6-138 plantar fibromatosis, 6-115, 6-135, 6-138 to 6-141 plantaris tendon rupture, 6-122 to 6-123, 6-126 to 6-129 sesamoid dysfunction, 6-1 14 to 6-1 17 tarsal coalition, 6-55, 6-59, 6-102 to 6-105 tarsal tunnel syndrome, 6-130 to 6-133, 6-135, 6-143
ulnar tunnel syndrome, 3-43, 3-58 to 3-61
Paget disease, 7-38 to 7-41 bone marrow metastases vs., 7-35 description, 7-38 to 7-41 fibrous dysplasia vs., 8-39 intraosseous hemangioma vs., 8-59 Panner's disease capitellar osteochondritis vs., 2-52 elbow osteomyelitis vs., 2-100 loose bodies and os supratrochleare vs., 2-61 Paralabral cysts description, 4-78 to 4-81 iliopsoas bursitis vs., 4-39 Parosteal osteosarcoma osteochondroma vs., 8-23 osteoma vs., 8-3 synovial sarcoma vs., 9-19 Parsonage-Turner syndrome, 1-34 to 1-37 median neuropathy vs., 2 4 3 quadrilateral space syndrome vs., 1-147 suprascapular, spinoglenoid notch vs., 1-151 ulnar neuropathy vs., 2-35 Patella. See also Patellar tendon. bipartite patellar fracture vs., 5-91 patellar tendon tears vs., 5-114 transient patellar dislocation vs., 5-125 bone injury, medial plica syndrome vs., 5-129 bursitis anterior, 5-106 to 5-109 infrapatellar iliotibial band syndrome vs., 5-71 Osgood-Schlatter disease vs., 5-103 prepatellar, patellar tendinitis vs., 5-99 chondromalacia, 5-116 to 5-1 19 chondrocalcinosis of knee vs., 5-150 description, 5-1 16 to 5-1 19 medial plica syndrome vs., 5-129 patellar (anterior) bursitis vs., 5-107 patellar fracture vs., 5-91 quadriceps tendon tear vs., 5-121 transient patellar dislocation vs., 5-125 dorsal defect chondromalacia patella vs., 5-1 17 patellar fracture vs., 5-91 excessive lateral pressure syndrome, iliotibial band syndrome vs., 5-71 fractures, 5-90 to 5-93 description, 5-90 to 5-93 patellar tendinitis vs., 5-99 quadriceps tendon tear vs., 5-121 hemorrhage, patellar (anterior)bursitis vs., 5-107 insufficiency fracture, anterior cruciate ligament reconstruction vs., 5-48 osteochondral injury, transient patellar dislocation vs., 5-125
INDEX prepatellar edema chondromalacia patella vs., 5-1 17 patellar tendinitis vs., 5-99 prepatellar hematoma, patellar tendinitis vs., 5-99 stress response patellar tendinitis vs., 5-99 quadriceps tendon tear vs., 5-121 transient dislocation, 5-124 to 5-127 Patellar tendon tears, 5-114 to 5-115 tendinitis, 5-98 to 5-101 anterior cruciate ligament reconstruction VS.,5-48 chondromalacia patella vs., 5-1 17 description, 5-98 to 5-101 medial plica syndrome vs., 5-129 Osgood-Schlatter disease vs., 5-103 patellar (anterior) bursitis vs., 5-107 patellar tendon tears vs., 5-114 tendinosis quadriceps tendon tear vs., 5-121 without tear, patellar tendon tears vs., 5-114 Pectoralis major tear, 1-42 to 1-45 Pectoralis minor injury, 1-43 Pelvic fractures. See also Hip fractures. acetabular fractures vs., 4-55 femoral head fractures vs., 4-47 hip dislocations vs., 4-59 Periosteal chondroma, osteochondroma vs., 8-23 Peripheral nerve sheath tumor benign, 9-30 to 9-33 malignant, 9-34 to 9-37 benign peripheral nerve sheath tumor vs., 9-31, 9-35 description, 9-34 to 9-37 fibrosarcoma of soft tissue vs., 9-3 liposarcoma vs., 9-27 malignant fibrous histiocytoma of soft tissue vs., 9-1 1 Peroneal nerve palsy, tibialis anterior tendon tear VS.,6-19 Peroneal tendon disorders anterior talofibular ligament tear vs., 6-27 calcaneal fractures vs., 6-71 to 6-72 peroneus brevis tendon tear, 6-22 to 6-25 retinacular tear, peroneus brevis tendon tear vs., 6-23 subluxation/dislocation calcaneofibular ligament sprain vs., 6-31 posterior impingement vs., 6-55 syndesmotic impingement vs., 6-5 1 tenosynovitis, peroneus brevis tendon tear vs., 6-22 Perthes lesion, 1-62 to 1-65 ALPSA lesion vs., 1-67 Bankart lesion vs., 1-59 description, 1-62 to 1-65 GLAD lesion vs., 1-71 greater tuberosity fracture vs., 1-135
HAGL lesion vs., 1-75 Phalanx, distal, fractures of, 3-102 to 3-103 Physeal closure, osteochondral injury of knee vs., 5-75 Pigmented villonodular synovitis, 9-14 to 9-1 7 anterolateral impingement vs., 6-43 description, 9-14 to 9-17 hip osteoarthritis vs., 4-87 hip rheumatoid arthritis vs., 4-95 knee, 5-140 to 5-143 knee rheumatoid arthritis vs., 5-137 plantar fibromatosis vs., 6-139 synovial sarcoma vs., 9-19 Piriformis syndrome, 4-34 to 4-37 avulsion hip fractures vs., 4-63 description, 4-34 to 4-37 femoral neck fractures vs., 4-51 gluteus medius muscle strain vs., 4-27 Plantar fasciitis, 6-135 to 6-137 description, 6-135 to 6-137 plantar fibromatosis vs., 6-138 to 6-139 tarsal tunnel syndrome vs., 6-131 Plantar fibromatosis, 6-138 to 6-141 description, 6-138 to 6-141 plantar fasciitis vs., 6-135 sesamoid dysfunction vs., 6-1 15 Plantar nerve, lateral, entrapment of 1st branch of, 6-135 Plantaris tendon rupture description, 6-126 to 6-129 gastrocnemius-soleus strain vs., 6-122 to 6-123 tear, Achilles tendon tear vs., 6-7 Plica infrapatellar, 5-129 suprapatellar, 5-129 Plica syndrome, medial description, 5-128 to 5-131 quadriceps tendon tear vs., 5-121 Polyarthritis, autoimmune chronic, wrist and hand, 3-71 Popliteal artery adventitial degeneration, popliteal cyst vs., 5-159 aneurysm, popliteal cyst vs., 5-159 entrapment syndrome, medial tibia1 stress syndrome vs., 6-99 Popliteal cyst intracondylar notch cyst vs., 5-155 knee, 5-158 to 5-161 Popliteal muscle/tendon hiatus meniscocapsular separation vs., 5-35 posterolateral complex injury vs., 5-67 insertional tendinosisltear, lateral collateral ligament tear vs., 5-63 meniscal longitudinal tear vs., 5-19 popliteuslbiceps strain, posterolateral complex injury vs., 5-68 tendinosis, iliotibial band syndrome vs., 5-71 tendon sheath, meniscal cyst vs., 5-15
1
INDEX Posterior cruciate ligament graft surgery of, PCL tear vs., 5-51 mucoid degeneration, PCL tear vs., 5-51 tear description, 5-50 to 5-53 lateral collateral ligament tear vs., 5-63 Posterolateral complex injury, 5-66 to 5-69 description, 5-66 to 5-69 lateral tibia1 plateau fracture vs., 5-95 posterior cruciate ligament tear vs., 5-51 Posterolateral corner sprain, plantaris tendon rupture vs., 6-127 Prepatellar disorders bursitis, patellar tendinitis vs., 5-99 edema chondromalacia patella vs., 5-1 17 patellar tendinitis vs., 5-99 hematoma, patellar tendinitis vs., 5-99 Primitive neuroectodermal tumor (PNET), Ewing sarcoma vs., 7-7 Pronator teres syndrome, carpal tunnel syndrome vs., 3-55 Pseudotumor greater humeral tuberosity, chondroblastoma VS.,8-27 intraosseous lipoma vs., 8-71 knee synovitis vs., 5-1 11 to 5-112 Psoriatic arthritis knee rheumatoid arthritis vs., 5-137 rheumatoid arthritis of shoulder vs., 1-143 wrist and hand rheumatoid arthritis vs., 3-71 Pubic rami stress fractures description, 4-66 to 4-69 sacral insufficiency fractures vs., 4-71 Pyrophosphate arthropathy. See Chondrocalcinosis.
Quadriceps tendon tear, 5-120 to 5-123 Quadrilateral space syndrome, shoulder, 1-146 to 1-149
Radial bursitis, bicipital, 2-82 to 2-85 biceps tendon rupture vs., 2-1 1 description, 2-82 to 2-85 rheumatoid arthritis vs., 2-95 Radial fractures distal radius, 3-26 to 3-29 carpal tunnel syndrome vs., 3-55 description, 3-26 to 3-29 die punch fracture, 3-30 to 3-33 Madelung's deformity vs., 3-75 scaphoid fractures vs., 3-39 scaphoid non-union vs., 3-47 radial head, 2-56 to 2-59 bicipital radial bursitis vs., 2-83 to 2-84
description, 2-56 to 2-59 radial neck fracture vs., 2-57 radial headlneck coronoid process fracture vs., 2-49 lateral collateral ligament injury vs., 2-19 lateral condylar fracture vs., 2-69 lateral epicondylitis vs., 2-3 olecranon fracture vs., 2-65 posterior dislocation of elbow vs., 2-23 scapholunate ligament tear vs., 3-3 Radial neuropathy, 2-38 to 2-41 description, 2-38 to 2-41 lateral epicondylitis vs., 2-3 median neuropathy vs., 2-43 Radial ulnar joint, distal (DRUJ) instability, 3-18 to 3-21 description, 3-18 to 3-21 die punch fracture of distal radius vs., 3-31 extensor carpi ulnaris tendinitis vs., 3-87 Madelung's deformity vs., 3-75 midcarpal instability vs., 3-1 1 traumatic abnormalities of, distal radius fractures vs., 3-27 triangular fibrocartilage tear vs., 3-23 ulnar styloid fractures vs., 3-35 ulnocarpal abutment vs., 3-15 subluxation or dislocation, lunotriquetral instability vs., 3-7 Radiculopathy cervical carpal tunnel syndrome vs., 3-55 median neuropathy vs., 2-43 ulnar tunnel syndrome vs., 3-59 lumbar gluteus medius muscle strain vs., 4-27 piriformis syndrome vs., 4-35 rectus femoris muscle strain vs., 4-23 sacral insufficiency fractures vs., 4-71 tarsal tunnel syndrome vs., 6-131 Radiography. See also specific type of imaging. accessory navicular, 6-1 10 acetabular fractures, 4-54 Achilles tendinitis, 6-2 acromioclavicular joint arthritis, 1-122 adamantinoma, 8-74 adhesive capsulitis, 1-54 ALPSA lesion, 1-66 aneurysmal bone cyst, 8-66 ankle fractures, 6-62 anterior cruciate ligament tear, 5-42 anterior impingement, ankle, 6-46 anterior talofibular ligament tear, 6-26 avascular necrosis femoral head, 4-2 shoulder, 1-126 talus, 6-90 avulsion hip fractures, 4-62 Bankart lesion, 1-58 Bennett lesion, 1-82 biceps tendinosis, 1-94
biceps tendon dislocation, 1-1 10 rupture, 2-10 tear, 1-98 bicipital radial bursitis, 2-82 bone infarct, 5-82 bone marrow metastases, 7-34 bursitis (anterior) bursitis, 5-106 calcaneal fractures, 6-70 calcaneofibular ligament sprain, 6-30 capitellar osteochondritis dissecans, 2-52 capitellum fracture, 2-72 carpal tunnel syndrome, 3-54 chondroblastoma, 8-26 chondrocalcinosis of knee, 5-150 chondromalacia patella, 5-1 16 chondromyxoid fibroma, 8-30 chondrosarcoma, 8-34 to 8-35 coronoid process fracture, 2-48 De Quervain's tenosynovitis, 3-82 degenerative arthritis of wrist, 3-62 deltoid ligament sprain, 6-34 developmental dysplasia of hip, 4-14 diabetic foot, 6-146 die punch fracture, distal radius, 3-30 discoid meniscus, 5-2 distal radius, fractures of, 3-26 elbow posterior dislocation, 2-22 enchondroma, 8-18 epicondylitis lateral, 2-2 to 2-3 medial, 2-6 Ewing sarcoma, 7-6 extensor carpi ulnaris tendinitis, 3-86 femoral head fractures, 4-46 femoral neck fractures, 4-50 femoroacetabular impingement, 4-82 fibromatosis, 9-6 fibrosarcoma bone, 8-50 to 8-51 soft tissue, 9-2 fibrous dysplasia, 8-38 fibroxanthoma, 8-42 flexor annular pulley tears, 3-98 flexor digitorum profundus avulsions, 3-102 Freiberg's infraction, 6-94 ganglion cysts, 3-78 Gaucher's disease, 7-30 giant cell tumor, 8-54 tendon sheath, 3-90 glenohumeral ligament disorders HAGL lesion, 1-74 IGL tears, 1-78 gluteus medius muscle strain, 4-26 greater tuberosity fracture, 1-134 HAGL lesion, 1-74 hamate fractures, 3-42 hamato-lunate impingement, 3-66 hamstring tendinosis, 4-30 hemangioma
intraosseous, 8-58 soft tissue, 9-42 hidden lesion of shoulder, 1-90 hip dislocations, 4-58 IGL tears, 1-78 iliopsoas bursitis, 4-38 iliotibial band syndrome, 5-70 internal shoulder impingement, 1-10 intracondylar notch cyst, 5-154 Kienbock's disease, 3-50 labral tears acetabular, 4-74 posterior, shoulder, 1-86 Langerhans cell histiocytosis, 7-2 to 7-3 lateral collateral ligament elbow, 2-18 knee, 5-62 lateral condylar fracture, 2-68 lateral tibia1 plateau fracture, 5-94 Legg-Calve-Perthe disease, 4-6 leukemia, 7-10 to 7-1 1 lipoma intraosseous, 8-70 soft tissue, 9-22 lipoma arborescens of knee, 5-144 liposarcoma, 9-26 Lisfranc fracture, 6-82 Little Leaguer's elbow, 2-30 loose bodies elbow, 2-60 hip, 4-90 lunotriquetral instability, 3-6 lymphoma, 7-14 Madelung's deformity of wrist and hand, 3-74 malignant fibrous histiocytoma bone, 8-46 soft tissue, 9-10 medial bursitis of knee, 5-58 medial collateral ligament elbow injury, 2-26 medial condylar fracture, 2-78 median neuropathy, 2-42 meniscal disorders flap tear, 5-26 longitudinal tear, 5-18 meniscocapsular separation, 5-34 radial tear, 5-22 metatarsal fractures, 6-78 microinstability of shoulder, 1-22 midcarpal instability, 3-10 Morton's neuroma, 6-142 multiple myeloma, 7-18 navicular fractures, 6-74 olecranon bursitis, 2-86 olecranon fracture, 2-64 os acromiale, 1-1 18 os supratrochleare, elbow, 2-60 Osgood-Schlatter disease, 5-102 osteoarthritis elbow, 2-90 hip, 4-86
INDEX
a 1
yxiv
knee, 5-132 shoulder, 1-138 osteoblastoma, 8-10 osteochondral injuries knee, 5-74 shoulder, 1-130 osteochondral lesion of talus (OLT), 6-86 osteochondritis dissecans, 5-78 osteochondroma, 8-22 osteoid osteoma, 8-6 osteoma, 8-2 osteomyelitis elbow, 2-98 hip, 4-98 osteonecrosis of knee, spontaneous, 5-86 osteosarcoma, 8-14 to 8-15 Paget disease, 7-38 to 7-39 paralabral cysts, 4-78 Parsonage-Turner syndrome, 1-34 patellar disorders fracture, 5-91 tendinitis, 5-98 tendon tears, 5-1 14 pectoralis major tear, 1-42 peripheral nerve sheath tumor benign, 9-30 malignant, 9-34 Perthes lesion, 1-62 pigmented villonodular synovitis, 5-140, 9-14 piriformis syndrome, 4-34 popliteal cyst, 5-158 posterior cruciate ligament tear, 5-50 posterolateral complex injury, 5-66 pubic rami stress fractures, 4-66 quadriceps tendon tear, 5-120 quadrilateral space syndrome, 1-146 radial head fracture, 2-56 radial ulnar joint, distal, instability of, 3-18 radius, distal, fractures of, 3-26 rectus femoris muscle strain, 4-22 reflex sympathetic dystrophy of knee, 5-146 rhabdomyosarcoma, soft tissue, 9-38 rheumatoid arthritis elbow, 2-94 hip, 4-94 knee, 5-136 shoulder, 1-142 wrist and hand, 3-70 rotator cuff calcific tendinitis, 1-30 full thickness tear, 1-14 partial thickness tear, 1-6 post-operative repair, 1-23 tendinopathy, 1-2 rotator interval tears, 1-18 sacral insufficiency fractures, 4-70 scaphoid fractures, 3-38 scaphoid non-union, 3-46 scapholunate ligament tear, 3-2 to 3-3 sesamoid dysfunction, 6-1 14
sickle cell anemia, 7-22 to 7-23 sinus tarsi syndrome, 6-58 SLAP lesions V-IX, 1-106 snapping hip syndrome, 4-42 spontaneous osteonecrosis of knee, 5-86 subacromial impingement, 1-114 subscapularis rupture, 1-38 supracondylar fracture, 2-74 suprascapular, spinoglenoid notch, 1-150 syndesmosis sprain, 6-38 synovial fringe of elbow, 2-88 synovial sarcoma, 9-18 talus fractures, 6-66 to 6-67 tarsal coalition, 6-102 to 6-103 thalassemia, 7-26 to 7-27 tibia, medial, stress syndrome of, 6-98 transient osteoporosis of hip, 4-10 transient patellar dislocation, 5-124 triangular fibrocartilage tear, 3-22 triceps tendon rupture, 2-14 ulnar collateral ligament tear, 3-94 ulnar neuropathy, 2-34 ulnar styloid fractures, 3-34 ulnar tunnel syndrome, 3-58 ulnocarpal abutment, 3-14 unicameral bone cyst, 8-62 Radiohumeral meniscus synovial fringe, 2-3 Radionuclide imaging. See Nuclear medicine. Radius fractures. See Radial fractures. Rectus femoris muscle strain, 4-22 to 4-25 Reflex sympathetic dystrophy knee, 5-146 to 5-149 rheumatoid arthritis of wrist and hand vs., 3-71 transient osteoporosis of hip vs., 4-11 Revascularization, in anterior cruciate ligament reconstruction, 5-47 Rhabdomyosarcoma, 9-38 to 9-41 Rheumatoid arthritis Achilles tendinitis vs., 6-3 elbow, 2-94 to 2-97 Freiberg's infraction vs., 6-95 ganglion cysts vs., 3-79 hip, 4-94 to 4-97 iliopsoas bursitis vs., 4-39 Kienbock's disease vs., 3-51 knee, 5-136 to 5-139 Morton's neuroma vs., 6-143 osteoarthritis of hip vs., 4-87 pigmented villonodular synovitis vs., 5-141,9-15 shoulder description, 1-142 to 1-145 full thickness rotator cuff tear vs., 1-15 tarsal coalition vs., 6-104 wrist and hand, 3-70 to 3-73 Rotator cuff. See also Rotator cuff tears; Rotator interval tears. acute trauma, subacromial impingement vs., 1-1 15 calcific tendinitis, 1-30 to 1-33 Bennett lesion vs., 1-84
INDEX
a I
xxv i
tendinosis, 1-91, 1-94 to 1-97, 1-111 calcific tendinitis. See Rotator cuff, calcific tendinitis. capsular strain without disruption, IGL tears VS.,1-79 capsular tear, posterior, Bennett lesion vs., 1-83 capsulorrhaphy arthropathy, osteoarthritis vs., 1-139 extraarticularmass, rheumatoid arthritisvs., 1-143 fractures, pectoralis major tear vs., 1-43 GLAD (glenoid labrum articular disruption) lesion, 1-52, 1-70 to 1-73 greater tuberosity fracture, 1-134 to 1-137, 1-143 HAGL lesion. See HAGL (humeral avulsion of glenohumeral ligament) lesion. hidden lesion, 1-90 to 1-93 biceps tendon tear vs., 1-99 description, 1-90 to 1-93 internal shoulder impingement vs., 1-12 microinstability vs., 1-23 rotator interval tears vs., 1-19 subacromial impingement vs., 1-1 16 IGL tears. See IGL (inferior glenohumeral ligament) tears. impingement. See Shoulder impingement. labral cyst, 1-46 to 1-49 mass lesion, quadrilateral space syndrome vs., 1-147 microinstability, 1-22 to 1-25 description, 1-22 to 1-25 hidden lesion vs., 1-91 internal shoulder impingement vs., 1-11 to 1-12 rotator cuff tendinopathy vs., 1-3 Milwaukee, osteoarthritis of shoulder vs., 1-139 muscle denervation, labral cyst vs., 1-47 neuromuscular dysfunction, adhesive capsulitis vs., 1-55 os acromiale, 1-27,l-115, 1-118 to 1-121,l-123 osteoarthritis, 1-138 to 1-141 adhesive capsulitis vs., 1-55 avascular necrosis vs., 1-127 description, 1-138 to 1-141 osteochondral injuries vs., 1-131 rheumatoid arthritis of shoulder vs., 1-143 osteochondral injuries, 1-130 to 1-133 Parsonage-Turner syndrome. See Parsonage-Turner syndrome. pectoralis major tear, 1-42 to 1-45 Perthes lesion. See Perthes lesion. posterior labral tear, 1-71, 1-86, 1-86 to 1-89 quadrilateral space syndrome, 1-146 to 1-149 reactive edema, osteochondral injuries vs., 1-131 rheumatoid arthritis, 1-142 to 1-145 description, 1-142 to 1-145 full thickness rotator cuff tear vs., 1-15 rotator cuff. See Rotator cuff. SLAP lesions. See SLAP (superior labrum from anterior-to-posterior) lesions.
subacromial impingement. See Shoulder impingement. subcortical degenerative cystic change, greater tuberosity fracture vs., 1-135 subscapularis rupture, 1-38 to 1-41 suprascapular, spinoglenoid notch, 1-150 to 1-153 supraspinatus tear, internal shoulder impingement vs., 1-12 Shoulder impingement adhesive capsulitis vs., 1-55 biceps tendon tear vs., 1-99 classic, microinstability vs., 1-23 glenoid, posterosuperior labral cyst of shoulder vs., 1-47 rotator cuff tendinopathy vs., 1-3 internal, 1-10 to 1-13 os acromiale vs., 1-119 SLAP lesions I-IV vs., 1-103 SLAP lesions V-IX vs., 1-107 subacromial, 1-1 14 to 1-117 acromioclavicular joint arthritis vs., 1-123 description, 1-114 to 1-117 internal impingement vs., 1-11 subcoracoid impingement vs., 1-116 subcoracoid biceps tendon dislocation vs., 1-111 biceps tendon tear vs., 1-99 hidden lesion vs., 1-92 microinstability vs., 1-23 suprascapular, spinoglenoid notch, 1-150 to 1-153 Sickle cell anemia description, 7-22 to 7-25 thalassemia vs., 7-27 Sinding-Larsen-Johansson syndrome Osgood-Schlatter disease vs., 5-103 patellar fracture vs., 5-91 patellar tendinitis vs., 5-99 patellar tendon tears vs., 5-1 14 Sinus tarsi syndrome, 6-58 to 6-61 anterolateral impingement vs., 6-43 calcaneal fractures vs., 6-71 description, 6-58 to 6-61 tarsal coalition vs., 6-104 SLAC (superior labrum anterior cuff lesion), hidden lesion vs., 1-91 SLAP (superior labrum from anterior-to-posterior) lesions anterosuperior variations of shoulder vs., 1-52 Bankart lesion vs., 1-60 biceps tendinosis vs., 1-95 biceps tendon dislocation vs., 1-111 biceps tendon tear vs., 1-99 GLAD lesion vs., 1-71 hidden lesion vs., 1-92 lesions I-IV, 1-102 to 1-105 lesions V-IX, 1-106 to 1-109 microinstability vs., 1-23 Perthes lesion vs., 1-64 without RTC pathology, internal shoulder impingement vs., 1-11
Slipped capital femoral epiphysis developmental dysplasia of hip vs., 4-15 femoral head fractures vs., 4-47 hip dislocations vs., 4-59 Legg-Calve-Perthe disease vs., 4-7 Snapping hip syndrome, 4-42 to 4-45 description, 4-42 to 4-45 femoral head fractures vs., 4-47 femoral neck fractures vs., 4-51 hip dislocations vs., 4-59 iliopsoas bursitis vs., 4-39 Soft tissue injuries. See Overuse syndromes/soft tissue injuries. Soft tissue tumors fibromatosis, 9-3, 9-6 to 9-9, 9-11, 9-19 fibrosarcoma, 9-2 to 9-5, 9-7, 9-11 ganglion cyst vs., 3-79 giant cell tumor of tendon sheath, 3-90 to 3-93 hemangioma. See Hemangioma. hip/pelvis, gluteus medius muscle strain vs., 4 2 7 histiocytoma, malignant fibrous. See Histiocytoma, malignant fibrous. Langerhans cell histiocytosis vs., 7-3 lipoma. See Lipoma, soft tissue. liposarcoma. See Liposarcoma, soft tissue. muscle strain of hip vs., 4-19 paralabral cyst vs., 4-79 peripheral nerve sheath tumor. See Peripheral nerve sheath tumor. pigmented villonodular synovitis. See Pigmented villonodular synovitis. rhabdomyosarcoma, 9-38 to 9-41 synovial sarcoma. See Synovial sarcoma. Soleus muscle. See also Gastrocnemius-soleus strain. accessory, medial tibia1 stress syndrome vs., 6-99 Spondyloarthropathies, Achilles tendinitis vs., 6-3 Spontaneous osteonecrosis, knee, 5-86 to 5-89 Sprains ankle. See Ankle sprains. bifurcate ligament, 6-59, 6-83 calcaneofibular ligament, 6-30 to 6-33, 6-83 sacroiliac, 4-63 syndesmosis, 6-38 to 6-41, 6-63 talofibular ligament anterior, 6-26 to 6-29, 6-31, 6-43 lateral, 6-83 posterior, 6-55 Stress fractures. See specific type of bone fracture. Subacromial impingement, 1-1 1, 1-1 14 to 1-117, 1-116, 1-123 Subacromial vessel, os acromiale vs., 1-119 Subcalcaneal pain syndrome. See Plantar fasciitis. Subchondral fracture, spontaneous osteonecrosis of knee, 5-88 Subcoracoid impingement, 1-23, 1-92, 1-99, 1-1 11 Sublabral foramen labral tears vs., 4-75 SLAP lesions I-IV vs., 1-103 SLAP lesions V-IX vs., 1-107
Sublime tubercle fracture, medial collateral ligament elbow injury vs., 2-28 Subscapularis-inferiorglenohumeral ligament injury, pectoralis major tear vs., 1-43 Subscapularis tendon rupture, 1-38 to 1-41 description, 1-38 to 1-41 greater tuberosity fracture vs., 1-135 Perthes lesion vs., 1-63 tear ALPSA lesion vs., 1-68 anterosuperiorvariations of shoulder vs., 1-52 Bankart lesion vs., 1-59 to 1-60 biceps tendinosis vs., 1-95 HAGL lesion vs., 1-75 IGL tears vs., 1-79 microinstability vs., 1-23 Subtalar joint arthrosis posterior impingement vs., 6-55 sinus tarsi syndrome vs., 6-59 coalition, calcaneofibular ligament sprain vs., 6-3 1 fractures, tarsal coalition vs., 6-103 sprain, Lisfranc fracture vs., 6-83 Superior labrum lesions SLAC (superior labrum anterior cuff lesion), 1-91 SLAP. See SLAP (superior labrum from anteriorto-posterior) lesions. Supracondylar fracture, 2-74 to 2-77 coronoid process fracture vs., 2-49 description, 2-74 to 2-77 medial condylar fracture vs., 2-79 posterior dislocation of elbow vs., 2-23 Suprascapular, spinoglenoid notch, 1-150 to 1-153 Suprascapular denervation, subacromial impingement vs., 1-1 15 Suprascapular nerve, mass compression of, suprascapular, spinoglenoid notch vs., 1-151 Supraspinatus tendinopathy, microinstability vs., 1-23 Supraspinatus tendon tear ALPSA lesion vs., 1-68 Bankart lesion vs., 1-59 greater tuberosity fracture vs., 1-135 internal shoulder impingement vs., 1-12 microinstability vs., 1-23 Perthes lesion vs., 1-64 Syndesmosis sprain ankle fracture vs., 6-63 description, 6-38 to 6-41 Syndesmotic impingement of ankle, 6-50 to 6-53 Synovial chondromatosis idiopathic (osteo), anterolateral impingement VS.,6-43 osteoarthritis of hip vs., 4-87 pigmented villonodular synovitis vs., 9-15 rheumatoid arthritis of hip vs., 4-95 snapping hip syndrome vs., 4-43 Synovial cysts
knee rheumatoid arthritis vs., 5-137 medial bursitis of knee vs., 5-59 meniscal cyst vs., 5-15 pigmented villonodular synovitis vs., 5-141 popliteal cyst vs., 5-159 Synovial disorders, loose bodies of hip vs., 4-91 Synovial fluid iliotibial band syndrome vs., 5-71 intracondylar notch cyst vs., 5-155 Synovial fringe elbow, 2-88 to 2-89 radiohumeral, trauma and fibrosis of, lateral epicondylitis vs., 2-3 Synovial lipoma, lipoma arborescens of knee vs., 5-144 Synovial mass, anconeus epitrochlearis vs., 2-46 to 2-47 Synovial osteochondromatosis lipoma arborescens of knee vs., 5-144 loose bodies and os supratrochleare vs., 2-61 Synovial sarcoma, 9-18 to 9-21 description, 9-18 to 9-21 fibromatosis vs., 9-7 fibrosarcoma of soft tissue vs., 9-3 giant cell tumor of tendon sheath vs., 3-91 malignant fibrous histiocytoma of soft tissue VS.,9-11 pigmented villonodular synovitis vs., 9-15 plantar fibromatosis vs., 6-139 Synovitis ankle peroneus brevis tendon tear vs., 6-23 sesamoid dysfunction vs., 6-1 15 tibiotalar, anterior impingement vs., 6-47 elbow rheumatoid arthritis vs., 2-95 synovial fringe vs., 2-88 hip developmental dysplasia vs., 4-15 toxic, Legg-Calve-Perthe disease vs., 4-7 knee description, 5-1 10 to 5-1 13 hemorrhagic, pigmented villonodular synovitis vs., 5-141 hypertrophic, pigmented villonodular synovitis vs., 5-141 lipoma arborescens vs., 5-144 rheumatoid arthritis vs., 5-137 pigmented villonodular, 9-14 to 9-1 7 anterolateral impingement vs., 6-43 description, 9-14 to 9-17 hip osteoarthritis vs., 4-87 hip rheumatoid arthritis vs., 4-95 knee, 5-140 to 5-143 knee rheumatoid arthritis vs., 5-137 plantar fibromatosis vs., 6-139 synovial sarcoma vs., 9-19 posttraumatic knee synovitis vs., 5-1 11 pigmented villonodular synovitis vs., 9-15
shoulder HAGL lesion vs., 1-75 to 1-76 osteoarthritis vs., 1-139 wrist, ganglion cysts vs., 3-79 Systemic lupus erythematosus knee rheumatoid arthritis vs., 5-137 shoulder rheumatoid arthritis vs., 1-143
Talar compression syndrome. See 0 s trigonum syndrome. Talar fractures, 6-66 to 6-69 anterior impingement vs., 6-47 description, 6-66 to 6-69 lateral process anterior talofibular ligament tear vs., 6-27 calcaneofibular ligament sprain vs., 6-31 neck, anterior talofibular ligament tear vs., 6-27 osteochondral lesion of talus (OLT) vs., 6-87 Talocalcaneal coalition, calcaneofibular ligament sprain vs., 6-31 Talofibular ligament sprainttear anterior, 6-26 to 6-29 anterior calcaneofibular ligament sprain vs., 6-3 1 description, 6-26 to 6-29 retracted tear of, anterolateral impingement VS.,6-43 lateral, Lisfranc fracture vs., 6-83 posterior, posterior impingement vs., 6-55 Talus. See also Subtalar joint. avascular necrosis of, 6-90 to 6-93 fractures. See Talar fractures. osteochondral lesion (OLT), 6-86 to 6-89 anterior talofibular ligament tear vs., 6-27 anterolateral impingement vs., 6-43 avascular necrosis of talus vs., 6-91 description, 6-86 to 6-89 of talar dome, calcaneofibular ligament sprain vs., 6-31 posterior impingement vs., 6-55 syndesmotic impingement vs., 6-51 talus fractures vs., 6-67 tarsal coalition vs., 6-104 Tarsal coalition, 6-102 to 6-105 description, 6-102 to 6-105 posterior impingement vs., 6-55 sinus tarsi syndrome vs., 6-59 tarsal tunnel syndrome vs., 6-131 Tarsal navicular, bipartite, navicular fractures vs., 6-75 Tarsal tunnel syndrome, 6-130 to 6-133 description, 6-130 to 6-133 Morton's neuroma vs., 6-143 plantar fasciitis vs., 6-135 Tarsometatarsal fracture-dislocation. See Lisfranc fracture-dislocation. Tendon disorders. See also Tenosynovitis.
INDEX - -
Achilles tendinitis, 6-2 to 6-5, 6-15 Achilles tendon tear, 6-6 to 6-9, 6-51, 6-71 avulsion hip fractures vs., 4-63 biceps tendon. See Biceps tendon. extensor carpi ulnaris tendinitis. See Extensor carpi ulnaris (ECU). flexor annular pulley tears, 3-98 to 3-101 flexor hallucis longus abnormalities, 6-14 to 6-17 flexor tendon, 3-43,3-98 to 3-99 giant cell tumor of tendon sheath, 3-79, 3-90 to 3-93 gluteal tendon avulsion, gluteus medius muscle strain vs., 4-27 hamstring tendinosis, 4-30 to 4-33 patellar. See Patellar tendon. peroneal tendon. See Peroneal tendon disorders. plantaris tendon rupture, 6-122 to 6-123, 6-126 to 6-129 plantaris tendon tear, 6-7 popliteal. See Popliteal muscle/tendon. quadriceps tendon tear, 5-120 to 5-123 rotator cuff. See Rotator cuff. semimembranosus tendinosis, 5-55, 5-60 subscapularis. See Subscapularis tendon. supraspinatus. See Supraspinatus tendon tear. tibialis anterior tendon tear, 6-18 to 6-21 tibialis posterior tendon. See Tibialis posterior tendon. triceps tendon, 2-14 to 2-17, 2-86 Tenosynovitis De Quervain's. See De Quervain's tenosynovitis. flexor, hamate fractures vs., 3-43 flexor annular pulley tears vs., 3-98 to 3-99 flexor carpi radialis, 3-83 flexor compartments, 3-103 flexor hallucis longus, 6-107 ganglion cysts vs., 3-79 peroneal, peroneus brevis tendon tear vs., 6-22 tibialis anterior tendon tear vs., 6-19 tibialis posterior, 6-11, 6-15, 6-131 Teres minor avulsion, posterior labral tear vs., 1-87 TFCC. See Triangular fibrocartilage complex (TFCC). Thalassemia, 7-26 to 7-29 description, 7-26 to 7-29 Gaucher's disease vs., 7-31 sickle cell anemia vs., 7-23 Thoracic outlet syndrome carpal tunnel syndrome vs., 3-55 ulnar tunnel syndrome vs., 3-59 Thrombosis, deep venous (DVT) compartment syndrome of lower extremity vs., 6-1 19 gastrocnemius-soleus strain vs., 6-123 medial tibial stress syndrome vs., 6-99 muscle strain of hip vs., 4-19 plantaris tendon rupture vs., 6-127 popliteal cyst vs., 5-159
Thumb, ulnar collateral ligament tear, 3-94 to 3-97 Tibia distal, fractures of, 6-62 to 6-65 medial tibial stress syndrome of, 6-98 to 6-101 osteochondral lesion of, osteochondral lesion of talus vs., 6-87 stress fracture of, medial tibial stress syndrome VS., 6-99 Tibial collateral ligament bursitis medial collateral ligament tear vs., 5-55 semimembranous, medial collateral ligament tear vs., 5-55 Tibial neuropathy. See Tarsal tunnel syndrome. Tibial osteotomy, lateral tibial plateau fracture vs., 5-95 Tibial plateau fracture, lateral, 5-94 to 5-97 iliotibial band syndrome vs., 5-71 lateral collateral ligament tear vs., 5-63 Tibial tunnel cysts anterior cruciate ligament reconstruction VS., 5-48 intracondylar notch cyst vs., 5-155 pseudo impingement of, anterior cruciate ligament reconstruction vs., 5-48 Tibialis anterior tendon tear, 6-18 to 6-21 Tibialis posterior tendon dysfunction, deltoid ligament sprain vs., 6-35 insertion, tibialis posterior tendon tear vs., 6-1 1 tear, 6-10 to 6-13 accessory navicular vs., 6-1 11 description, 6-10 to 6-13 navicular fractures vs., 6-75 tenosynovitis flexor hallucis longus abnormalities vs., 6-15 tarsal tunnel syndrome vs., 6-131 tendon tear vs., 6-1 1 Tibiofibular ligament, syndesmotic sprain of, 6-38 to 6 4 1 Tibiotalar joint arthritis generalized, anterior impingement vs., 6-47 medial, tibialis posterior tendon tear vs., 6-1 1 effusion, fluid in tendon sheath 2" to ankle effusion associated with, 6-15 synovitis anterior impingement vs., 6 4 7 tibialis anterior tendon tear vs., 6-19 Toxic synovitis, Legg-Calve-Perthe disease vs., 4-7 Trabeculae, normal weight-bearing, transient osteoporosis of hip vs., 4-1 1 Transchondral fracture. See Talus, osteochondral lesion (OLT). Transient osteoporosis. See Osteoporosis, transient, hip. Triangular fibrocartilage complex (TFCC) tears, 3-22 to 3-25 description, 3-22 to 3-25 hamate fractures vs., 3-43 lunotriquetral instability vs., 3-7
I XX
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midcarpal instability vs., 3-1 1 traumatic abnormalities die punch fracture of distal radius vs., 3-31 distal radial ulnar joint instability vs., 3-19 distal radius fractures vs., 3-27 extensor carpi ulnaris tendinitis vs., 3-87 ulnocarpal abutment vs., 3-15 Triceps muscle contusion/hematoma, triceps tendon rupture VS.,2-15 prominent medial head anconeus epitrochlearis vs., 2-47 ulnar neuropathy vs., 2-35 Triceps tendon partial tear, olecranon bursitis vs., 2-86 rupture, 2-14 to 2-17 tendinosis, olecranon bursitis vs., 2-86 Triquetral fractures. See also Lunotriquetral entries. hamato-lunate impingement vs.,3-67 Trochanteric bursitis femoral neck fractures vs., 4-51 gluteus medius muscle strain vs., 4-27 greater femoral neck fractures vs., 4-51 gluteus medius muscle strain vs., 4-27 paralabral cyst vs., 4-79 snapping hip syndrome vs., 4-43 piriformis syndrome vs., 4-35 sacral insufficiency fractures vs., 4-71 snapping hip syndrome vs., 4-43 Tubercle, lateral, fracture of, os trigonum syndrome vs., 6-107 Tumor-like soft tissue masses, paralabral cyst vs., 4-79 Tumors. See also Neoplasms. bone. See Bone tumors. compartment syndrome of lower extremity vs., 6-1 19 malignant ganglion cyst vs., 3-79 iliopsoas bursitis vs., 4-39 metastatic. See Metastatic disease. plantar fibromatosis vs., 6-139 pseudotumor greater humeral tuberosity, chondroblastoma vs., 8-27 intraosseous lipoma vs., 8-7 1 knee synovitis vs., 5-1 11 to 5-1 12 soft tissue. See Soft tissue tumors.
Ulnar collateral ligament, tear of, 3-94 to 3-97 Ulnar head chondromalacia, lunotriquetral instability vs., 3-7 Ulnar impaction syndrome Kienbock's disease vs., 3-51 lunotriquetral instability vs., 3-7 Ulnar impingement
Madelung's deformity vs., 3-75 ulnocarpal abutment vs., 3-15 Ulnar neuritis Little Leaguer's elbow vs., 2-31 medial epicondylitis vs., 2-7 Ulnar neuropathy, 2-34 to 2-37 anconeus epitrochlearis and, 2-46 to 2-47 description, 2-34 to 2-37 medial collateral ligament elbow injury vs., 2-27 radial neuropathy vs., 2-39 Ulnar stress fracture, olecranon fracture vs., 2-65 Ulnar styloid fractures description, 3-34 to 3-37 hamate fractures vs., 3-43 Ulnar tunnel syndrome description, 3-58 to 3-61 hamate fractures vs., 3-43 Ulnocarpal abutment, 3-14 to 3-17 description, 3-14 to 3-17 die punch fracture of distal radius vs., 3-31 distal radial ulnar joint instability vs., 3-19 extensor carpi ulnaris tendinitis vs., 3-87 traumatic abnormalities of, distal radius fractures vs., 3-27 triangular fibrocartilage tear vs., 3-23 ulnar styloid fractures vs., 3-35 Ulnocarpal impaction degenerative arthritis of wrist vs., 3-63 midcarpal instability vs., 3-1 1 Ultrasonography Achilles tendinitis, 6-3 biceps tendon dislocation, 1-1 11 rupture, 2-1 1 bicipital radial bursitis, 2-83 fibromatosis, 9-7 fibrosarcoma, soft tissue, 9-3 hemangiorna, soft tissue, 9 4 3 iliopsoas bursitis, 4-39 labral cyst, shoulder, 1-47 liposarcoma, 9-27 loose bodies of hip, 4-91 malignant fibrous histiocytoma, soft tissue, 9-1 1 olecranon bursitis, 2-86 osteoid osteoma, 8-7 peripheral nerve sheath tumor, benign, 9-31 popliteal cyst, 5-159 rhabdomyosarcoma, soft tissue, 9-39 rheumatoid arthritis, wrist and hand, 3-71 rotator cuff calcific tendinitis, 1-31 full thickness tear, 1-14 partial thickness tear, 1-7 tendinopathy, 1-3 snapping hip syndrome, 4-43 synovial fringe of elbow, 2-88 synovial sarcoma, 9-19 Unicameral bone cyst, 8-62 to 8-65 aneurysmal bone cyst vs., 8-67 description, 8-62 to 8-65
fibrous dysplasia vs., 8-39 fibroxanthoma vs., 8-43 intraosseous lipoma vs., 8-71
Vacuum phenomenon, discoid meniscus vs., 5-3 Valgus impaction fracture, capitellar osteochondritis dissecans vs., 2-53 Valgus injury medial condylar fracture vs., 2-79 supracondylar fracture vs., 2-75 Valgus stress, coronoid process fracture vs., 2-49 Vascular disorders, ganglion cyst vs., 3-79 Venous thrombosis, deep. See Thrombosis, deep venous (DVT).
Wartenberg's syndrome, De Quervain's tenosynovitis vs., 3-83 to 3-84 Wrist and hand. See also Wrist and hand fractures. carpal tunnel syndrome, 3-43,3-54 to 3-57, 3-58, 3-83 De Quervain's tenosynovitis. See De Quervain's tenosynovitis. degenerative arthritis of wrist, 3-62 to 3-65 distal radial ulnar joint instability. See Radial ulnar joint, distal (DRUJ). extensor carpi ulnaris subluxation, 3-7, 3-1 1, 3-19 tendinitis, 3-23, 3-35, 3-86 to 3-89 flexor annular pulley tears, 3-98 to 3-101 flexor digitorurn profundus avulsions, 3-102 to 3-105 ganglion cysts. See Ganglion cysts. giant cell tumor of tendon sheath, 3-90 to 3-93 hamato-lunate impingement, 3-66 to 3-69 intrinsic ligament pathology die punch fracture of distal radius vs., 3-31 distal radius fractures vs., 3-27 Kienbock's disease. See Kienbock's disease. lunotriquetral instability, 3-6 to 3-9, 3-1 1 Madelung's deformity, 3-74 to 3-77 midcarpal instability, 3-7, 3-10 to 3-13 rheumatoid arthritis, 3-70 to 3-73 scapholunate ligament tear, 3-2 to 3-5, 3-39, 3-47 triangular fibrocartilage complex. See Triangular fibrocartilage complex (TFCC). ulnar disorders. See Ulnar entries. Wrist and hand fractures die punch fracture, distal radius, 3-30 to 3-33, 3-75 hamate, 3-42 to 3-45,3-59, 3-67 radius. See Radial fractures. scaphoid. See Scaphoid fractures. scaphoid non-union, 3-46 to 3-49, 3-63 ulnar styloid, 3-34 to 3-37, 3-43
