Practical Reporting of Musculoskeletal Imaging …€™t mention any feature without grading it...
Transcript of Practical Reporting of Musculoskeletal Imaging …€™t mention any feature without grading it...
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Practical Reporting of
Musculoskeletal Imaging
Studies:
MRI Elbow
James F Griffith
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History
Where is pain located?
For how long?
Trauma – if so, what and when
Radiographers can get this info
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Don’t mention any feature without grading it
Qualitative measure :
Minimal, mild, moderate, severe
Quantitative measure:
Small, medium, large (mm long x mm deep x mm wide)
Grade ……….
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Epicondylitis
Cubital tunnel syndrome
Trauma inc biceps insertion
This talk : outline
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Tendinosis of
common extensor
tendon origin
(CETO)
Tendinosis of
common flexor
tendon origin
(CFTO)
Epicondylitis
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Cumulative microtrauma
Inadequate repair
Epicondylitis : Pathophysiology
Tendinosis (collagen disruption, proteoglycan deposition,
vascular ingrowth, fibroblast proliferation, hyaline degeneration)
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Firm up diagnosis
Establish severity
Identify tear
Check for associated abnormalities
Peritendinitis
Collateral ligament injury
Bone oedema, cortical irregularity
Epicondylitis : Why imaging
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Common extensor tendon origin
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Common extensor tendon origin (CETO)
ECRL
ECRBr
ED
ECU
Possibly due to impingement against capitellum
** *
**
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Lateral collateral ligament complex
Radial collateral ligament
Lateral ulnar collateral ligament
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MR imaging protocol
PD cor
T2 SPIR obl cor T2-SPAIR axial
PD axial
+ sagittal images
CETO
CFTO
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CETO normal
Some mild heterogeneity is normal
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CETO tendinosis: moderate
Normal Moderate severity
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CETO tendinosis: moderate
Moderate ….with tear
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Lateral collateral ligament complex
Radial collateral lig (RCL)
Lateral ulnar collateral lig (LUCL)
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Lateral collateral ligament complex
RCL
LUCL
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CETO tendinosis : moderate
Intact RCL Tear CETO Intact LUCL
“There is moderate CETO tendinosis with a medium-sized
(??mm wide x ?? mm long) mainly involving the ECRBr
Insertional area. The RCL and LUCL are intact”
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Avulsion ECRBr > ECRL >>> ED & ECU
ECRBr avulsion ECRL and ECRBr avulsion
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Avulsion ECRBr > ECRL >>> ED & ECU
ECRBr avulsion ECRL and ECRBr avulsion
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Complete tear CETO and RCL
“There is moderate CETO tendinosis with a complete avulsive-
type tear of the CETO as was as the RC and LUC ligaments”
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Complete tear CETO, RCL and LUCL
RCL LUCL
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Ultrasound protocol : lateral
(1) Put finger on lateral epicondyle
(3) Place transducer along this line
(2) Imagine line of extensor tendons
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Ultrasound protocol: CETO
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CETO tendinosis
Thickening
Hypoechogenicity
Calcification
Tear
Cortical irregularity
Hyperaemia
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CETO tendinosis
Thickening
Hypoechogenicity
Calcification
Tear
Cortical irregularity
Hyperaemia
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CETO tendinosis
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CETO tendinosis
‘Lift‘ the transducer
off skin
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CETO tendinosis
Normal < 32mm2 Tendinosis >32mm2
Baumer P et al 2011
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Radial synovial fold syndrome
No fold Thickened
synovial fold
but not impacted
Impacted
synovial fold
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Common flexor tendon origin (CFTO)
PT
FCR
PL
FCU
FDS
* *
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Medial collateral ligament
Anterior band
Transverse band
Posterior band
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Medial collateral ligaments
Anterior band
Transverse band
Posterior band
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CFTO normal
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CFTO normal and moderate tendinosis
Normal Moderate tendinosis
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CETO tendinosis and tear
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Ultrasound protocol : medial
(1) Put finger on medial epicondyle
(3) Place transducer along this line
(2) Imagine line of flexor tendons
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Ultrasound protocol: CFTO
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Ultrasound protocol: CFTO
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US or MR examination?
US MRI
Tendinosis severity
Tear depiction
Hyperaemia
Associated abnormality
Operator independent
3rd party review
++ ++
+ ++
++ -
- +
- +
- +
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1/6 have a normal US
Represents early non-established disease
Epicondylitis : US and MR examination
Proceed to MRI
50% of these will still have normal MRI examination
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Rest, bracing and physiotherapy
Don’t use steroids
Dry needling
Platelet Rich Plasma (PRP)
Autologous blood injection
Botox
Treatment (i)
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Extracorporal shock wave therapy
Low level laser therapy
Treatment (ii)
Surgery
Debridement, drilling
Release (percutaneous, arthroscopic, open)
Suture fixation
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Both US and MRI extremely helpful at assessing
lateral & medial epicondylitis
Epicondylitis : summary
Report on:
Tendinosis severity (mild, moderate, severe)
Presence, size and location of tears
Vascularity (ultrasound)
Collateral ligament integrity
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Clinical Presentation
2nd most common nerve entrapment, > left side (3:1)
Paresthesia
Hypoesthesia
Anaesthesia
Muscle weakness
Muscle wasting
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Cubital Tunnel Anatomy
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Cubital Tunnel Anatomy
FCU
heads
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PRIMARY (Younger):
Excessive leaning on or flexing of elbow
Repeated subluxation/dislocation of ulnar nerve
Aetiology
Husarik DB et al. 2009
SECONDARY (Older):
Osteophytes, loose bodies, synovial proliferation, ganglia,
anconeus epitrochlearis m., hypertrophied medial triceps
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Anconeus epitrochlearis muscle
20% of normal subjects
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Why image cubital tunnel syndrome?
Confirm diagnosis
Assess severity
Look for secondary cause
Look for nerve subluxation
Image with ………….. or
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MR protocol
Axial T2 SPAIR Axial PD ±DWI
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Ulnar Nerve Calibre
Mild UNE : 12.7mm2 ± 0.5
Severe UNE : 19.4mm2 ± 2.5
Normal
11.4mm2 ± 0.5
Diagnostic criterion: > 12mm2 at cubital tunnel
Baumer P et al 2011
10.1mm2 21.3mm2
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T2-hyperintensity (contrast:noise ratio)
Neural SI – Muscle SI
Standard deviation Air CNR =
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T2-hyperintensity (contrast:noise ratio)
Cubitial tunnel if CNR > 50 at cubital tunnel
Baumer P et al 2011
1849 - 711
8.3
= 137 742 - 377
23.2
= 15.7
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DWI (b value 500s/mm2)
10 patients with cubital tunnel syndrome compared to controls
All ten showed +ve findings with DWI
No controls showed +ve findings
No quantitative analysis
Iba K et al 2010
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Diagnostic MR criteria
> 12mm2 CSA ulnar nerve
CNR > 50 at cubital tunnel
DWI positive signal ulnar nerve
Excessive hyperintensity without swelling ?? neuritis
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Ultrasound Cubital Examination
Supine Prone Sitting
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Cubital Tunnel Examination
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Measurements
Proximal
At
Distal
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Criteria for cubital tunnel syndrome
Absolute criteria (CSA ulnar nerve) :
Normal < 9mm2
Symptomatic > 12mm2
Relative criteria (CSA ulnar nerve) :
2.8: 1 (proximal : at cubital tunnel)
Kyoon SJ et al 2008
Thoirs K et al 2007
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Ulnar nerve swelling
Normal Mild
Moderate Severe
9mm2 14mm2
19mm2 23mm2
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Ulnar nerve subluxation (20% normal nerves)
Olecranon Medial epicondyle
Yang SM et al. J Ultrasound Med 2013
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Ulnar nerve subluxation
Due to absence of arcuate ligament
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2o cause: Osteophytes
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2o cause : Loose bodies
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2o cause: Ganglion
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2o cause: synovial proliferation
Severe rhematoid arthritis
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2o cause: Anconeus epitrochlearis m.
Medial head
triceps slip
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Diagnostic criteria (ultrasound or MRI)
CSA> 12mm2 CNR > 50 DWI positive
or 2.8: 1 (prox : at)
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Readily assessed with ultrasound or MRI
Ultrasound more efficient and can assess subluxation
MRI possibly more accurate, especially for mild
disease if CNR measured ± DWI obtained
Cubital Tunnel Syndrome : summary
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CSA > 12mm2 CNR > 50 DWI positive
CONCLUSION
or 2.8: 1 (prox : at)
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Biceps tendon
FABS view: Flexion Abduction Supination
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Biceps tendon
FABS view: Flexion Abduction Supination view
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Biceps and brachialis tendon insertions
Muscular
brachialis
insertion
Muscular
brachialis
insertion
Tendinous
brachialis
insertion
Biceps
tendinous
insertion
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Biceps and brachialis tendon insertions
Muscular
brachialis
insertion
Muscular
brachialis
insertion
Tendinous
brachialis
insertion
Biceps
tendinous
insertion
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Mild tendinosis biceps tendon
Mild tendinosis Mild tendinosis
“Mild distal biceps tendinosis without tear”
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Severe tendinosis biceps tendons
“Severe distal biceps tendinosis with moderate-severity tear”
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Severe tendinosis biceps tendons
“Complete tear distal biceps with retraction by 3cm ”
Operation: short head torn
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Epicondylitis
Cubital tunnel syndrome
Biceps insertion
Conclusion
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Thank you