MR Arthrography

8 ■ APPLIED RADIOLOGY© www.appliedradiology.com September 2010

Magnetic resonance (MR)arthrography was first intro-duced to the musculoskeletal

community in 1987 with a cadavericstudy of several joints including theshoulder.1 Several years later, Palmer etal. explored the clinical relevance ofMR arthrography in the diagnosis ofrotator cuff and labral injuries about theshoulder.2,3 The years that followedgave way to numerous studies that fur-ther refined the techniques and indica-tions for MR arthrography. Today, MRarthrography is widely utilized and con-sidered by most musculoskeletal radiol-ogists and orthopedists to be an integralpart of their clinical practice. Practicallyany joint that can be accessed by a nee-dle can be imaged using MR arthrogra-phy. This article will focus on the mostcommonly imaged joints: the shoulder,elbow, wrist, hip, knee and ankle.

Shoulder MR arthrographyMR arthrography of the shoulder

has proven to be the gold standardimaging technique for evaluation ofshoulder joint pathology and can beparticularly useful for evaluation oflabroligamentous abnormalities.4 Theadvantages of MR arthrography areparticularly evident when evaluatingacute pathology in younger, activepatients with relatively little degenera-tive joint disease.

Rotator cuffFull thickness tears of the rotator cuff

are defined as tears with defects extend-ing completely through the tendon. Thisallows communication between theglenohumeral joint and the overlyingsubacromial/subdeltoid bursa (Figure 1).4

Partial thickness tears of the rotator cuffinvolve either the articular or bursal sur-face and do not extend completelythrough the tendon and do not allow com-munication between the glenohumeraljoint and the overlying subacro-mial/subdeltoid bursa (Figure 2).4 MRarthrography can be very helpful forarticular surface tears of the rotator cuffand typically demonstrates linear con-trast, tracking into the substance of thetendon. Bursal surface tears do not com-municate with the joint space and there-fore will not contain contrast. Detectionof bursal surface tears is typically best with conventional fluid-sensitive

sequences and will show fluid signalwithin the defects rather than contrast.

Glenoid labrumMR arthrography is particularly help-

ful in diagnosing tears of the glenoidlabrum. Superior labral tears are oftenreferred to as SLAP (superior labrumanterior to posterior) tears, referring tothe direction from which these tearstend to propagate: anterior to posterior.5

Superior tears are most common anddemonstrate 2 characteristics that areimportant for diagnosis. First, contrastwithin a SLAP tear is directed awayfrom the interface between the fibrocar-tilaginous labrum and the osseous gle-noid (Figure 3). Signal abnormalitiesthat appear parallel to this interfacemore commonly represent a superiorbicipitolabral sulcus, which is a normalanatomic variant (Figure 4).6 Second,abnormal signal and contrast delineat-

MR arthrography

Joshua Yellin, MD, and Jeffrey J. Peterson, MD

Dr. Yellin is a Musculoskeletal Fellowand Dr. Peterson is Professor, in theDepartment of Radiology, Mayo Clinic,Jacksonville, FL

www.appliedradiology.com APPLIED RADIOLOGY©■ 9September 2010

MR ARTHROGRAPHY

ing a labral tear typically has a globularcontour (Figure 5). This is in contrast tothe sharply delineated contour seen withthe superior bicipitolabral sulcus.

MR arthrography can also be criticalwhen evaluating the anterior labrum inthe setting of traumatic anterior shoul-der instability. Common injuriesinclude Bankart lesions (cartilaginousand osseous), Perthes lesions and ante-rior labral periosteal sleeve avulsions(ALPSA). Distinguishing betweenthese entities can be facilitated by theaddition of intra-articular contrast withMR arthrography.

Bankart lesions are caused by the col-lision of the humeral head with theanteroinferior glenoid during forceful

abduction, extension and external rota-tion of the humerus. There are 2 formsof Bankart lesions, cartilaginous andosseous. Cartilaginous Bankart lesionswill involve tears of the glenoid labrumwith an intact osseous glenoid (Fig-ure 6).7 Osseous Bankart lesions includeboth labral and osseous injuries of theanterior inferior glenoid (Figure 7).Bankart lesions are also characterizedby disruption of the anterior scapularperiosteum; a feature that distinguishesthem from Perthes lesions. Pertheslesions are seen as a gap between thelabrum and the glenoid with an intactperiosteal sleeve (Figure 8).8 ALPSAlesions are similar to Perthes lesionsapart from further stripping of the

periosteal sleeve from the glenoid,allowing the labroligamentous complexto fold back medially onto the scapularneck (Figure 9).9

Posterior shoulder instability is muchless common than anterior instability,accounting for only 2% to 4% of allreported shoulder instability.10 Commoncauses include posterior labral tearsrelated to repetitive overhead throwing(baseball pitchers) and posterior gleno-humeral subluxation or dislocation. Pos-terior labral tears and reverse Bankartlesions will demonstrate similar findingsas their anterior counterparts, except theyoccur at the posterior glenoid rim. Aswith anterior Bankart lesions, the scapu-lar periosteum is disrupted, allowing

FIGURE 2. High-grade, partial-thickness tear of the supraspinatus tendon. T1 FS imagesshow contrast tracking into the substance of the tendon (arrow) without extension into the sub-acromial subdeltoid bursa in coronal (A) and sagittal (B) planes.

A B

A B

FIGURE 3. SLAP tear (Superior Labrum Anterior-Posterior) characterized by contrastextending into the superior labrum (arrow) tracking away from the glenolabral interface oncoronal (A) and sagittal (B) T1 FS images.

FIGURE 4. Bicipitolabral sulcus. Normalvariant (arrow) characterized by sharplydelineated contrast tracking parallel to theglenolabral interface.

FIGURE 1. Full-thickness tear of the supra-spinatus tendon. Coronal T1 FS imagedemonstrating contrast spilling out into thesubacromial subdeltoid bursa through adefect in the distal supraspinatus tendon.


MR ARTHROGRAPHY

contrast to spill out of the glenohumeraljoint (Figure 10). POLPSA (posteriorlabral periosteal sleeve avulsion) lesionsare similar to ALPSA lesions and arecharacterized by stripping of the perios-teum attached to the posterior labrum asit is avulsed from the glenoid rim.11

Elbow MR arthrographyElbow arthrography was first

described by Lindblom in 1952 andlater refined by Arvidsson and Johans-son into the technique most commonlyused today.12,13 In 1995, Schwartz et al.suggested that MR arthrography of theelbow provided an advantage in diag-nosing collateral ligament injuries in

throwing athletes.14 Several studiessince then have supported this sugges-tion but failed to identify additionaladvantages of MR arthrography overconventional MR imaging of the elbow.Current indications for elbow MRarthrography include evaluation of theligamentous structures and depiction ofarticular hyaline cartilage defects. MRarthrography can also be useful to delin-eate loose bodies and synovial prolifer-ative processes about the elbow.

Collateral ligament injuriesThe anterior bundle of the medial col-

lateral ligament (MCL) is the primaryconstraint to valgus stress on the elbow.

The insertion is contiguous with the sub-lime tubercle of the coronoid process;any fluid signal or contrast seen betweenthe distal fibers of the anterior band ofthe medial collateral ligament and thesublime tubercle should be consideredabnormal.15 Partial tears of the anteriorband of the MCL are best seen in thecoronal plane and are characterized bylinear contrast extending into the liga-ment or contrast tracking between theligament and sublime tubercle (Figure11). The latter pattern can often demon-strate the “T sign” which has a high sen-sitivity and specificity for MCL injury.16

Complete tears of the MCL will demon-strate discontinuity of the MCL complex

A B

FIGURE 5. SLAP tear. Contrast tracking into the substance of the labrum commonly has aglobular contour (arrow). This can help distinguish SLAP tears from normal anatomic variants.

FIGURE 6. Cartilagenous Bankart lesion.Contrast extends into the substance of theanterior interior glenoid labrum and betweenthe portions of the labrum and the anteriorglenoid (arrow). The patient reported arecent anterior dislocation of the shoulder.

FIGURE 7. Osseous Bankart lesion. AxialT1 FS image demonstrates contrast (blackarrow) tracking between the anterior osteo-chondral fragment (white arrow) and theremainder of the glenoid.

FIGURE 8. Perthes lesion. Linear contrastis seen tracking between the avulsed ante-rior labrum and the glenoid. Contrast mater-ial follows the contour of the anterior glenoidand scapular neck restricted by the intactscapular periosteum (arrow).

FIGURE 9. ALPSA lesion. The anteriorlabrum has avulsed and has folded backmedially onto the glenoid neck (arrow).


MR ARTHROGRAPHY

and extra-articular leakage of contrastinto adjacent soft tissues.

The lateral collateral ligamentouscomplex consists of the radial collat-eral ligament, the lateral ulnar collat-eral ligament, the accessory lateralcollateral ligament, and the annularligament.15 Complete ligament tearsdemonstrate discontinuity of fibers andextracapsular contrast (Figure 12).Complete tears of the lateral ulnar col-lateral ligament are commonly seen inconjunction with tears of the commonextensor tendons in patients withadvanced injuries. Both the radial col-lateral ligament and lateral ulnar col-

lateral ligament play important roles inpreventing posterolateral rotationalinstability and either, or both, may betorn with this clinical presentation.

Wrist MR arthrographySince the initial description by

Kessler and Silberman in 1961, wristarthrography has evolved signifi-cantly.17 Over the years, various manu-scripts have advocated triple-compartment injections, bilateral injec-tions, and have examined potentialadvantages of CT and MR arthrographyover conventional arthrography. In1991, Manaster reported that triple-

compartment injections were moreexpensive, time-consuming and uncom-fortable for the patient, while providing little advantage over single-compartment radiocarpal injections per-formed with adequate distention anddigital subtraction.18 A report bySchweitzer in 1992 concluded thatwhile MR arthrography was the mostaccurate method for diagnosingscapholunate, lunotriquetral, and trian-gular fibrocartilage complex (TFCC)tears, the slight aggregate improvementin accuracy over conventional MRimaging probably did not justify theinvasive technique.19 Today, there

FIGURE 10. Posterior labral tear. Axial T1FS image demonstrates contrast trackingbetween the torn posterior labrum and theposterior glenoid rim (arrow).

FIGURE 11. Partial tear of the anterior bun-dle of the medial collateral ligament. CoronalT1 FS image demonstrates contrast trackinginto the substance of the anterior bundle ofthe medial collateral ligament (arrow).

FIGURE 12. Complete tear of the radial col-lateral ligament. Coronal T1 FS image demon-strates discontinuity of the radial collateralligament (arrow) with abnormal widening ofthe lateral aspect of the radiocapitellar joint.

FIGURE 13. Complete tear of the scapholu-nate ligament. Coronal T1 FS imagedemonstrates a tear involving the scapholu-nate ligament (arrow) with free spill of con-trast from the radiocarpal joint into themidcarpal joint. Also note the complex tearof the triangular fibrocartilage (arrowhead)with contrast extending into the distalradioulnar joint.

FIGURE 14. Complete lunotriquetral ligamenttear. Coronal T1 FS image demonstrates dis-continuity of the lunotriquetral ligament (largearrow) with spillage of contrast into the mid-carpal joint.

FIGURE 15. Complete tear of the TFCC.Contrast identified within the distal radioul-nar (arrow) joint following a radiocarpalinjection indicative of a full thickness tear ofthe TFCC. Close inspection reveals a smallrent in the central portion of the triangularfibrocartilage (arrowhead).


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remains no real consensus on optimaltechnique or indications for wristarthrography.

Intercarpal ligamentsScapholunate injuries are the most

common cause of carpal instability.The scapholunate ligament is typicallywedge-shaped and comprised of a dor-sal component, volar component and amembranous component extendingbetween them. The dorsal component isthe primary stabilizer and completetears are most likely to be symptomatic.MR arthrography has a high sensitivityand specificity for scapholunate liga-ment injury.20 Incomplete tears demon-

strate linear signal within the ligamentand are best seen on coronal images.Complete tears demonstrate communi-cation between the radiocarpal and themidcarpal joints and will allow contrastto extend into the midcarpal joint after asingle compartment radiocarpal injec-tion (Figure 13). Diastasis of thescapholunate joint (>3 mm) is a com-mon associated finding.20

The lunotriquetral ligament is lesssubstantial than the scapholunate liga-ment and, therefore, addition of intra-articular contrast is often quite helpfulto evaluate the integrity of the liga-ment. Commonly, a complete tear willbe seen only as a fluid-filled gap

between the lunate and triquetrum withcontrast communication between theradiocarpal and midcarpal articulations(Figure 14). Ulnolunate impaction is acommon associated finding withlunotriquetral ligament pathology. Sig-nificant diastasis is a relatively rarefinding with injury of the lunotrique-tral ligament, in contrast to tears of thescapholunate ligament.21

Triangular fibrocartilage complexMR arthrography can be very useful

for evaluating the triangular fibrocarti-lage complex (TFCC). Numerous stud-ies have documented the high incidence

FIGURE 16. Avulsion of the acetabularlabrum. Linear contrast is seen trackingbetween the fibrocartilaginous labrum andthe acetabular rim (arrow).

FIGURE 17. CAM type femoroacetabular impingement. Osseous protuberance (arrow) alongthe anterosuperior aspect of the femoral neck is seen on axial (A) and sagittal T1 FS (B)images.

A B

A B

FIGURE 18. Pincer type femoroacetabular impingement. Coronal (A) and sagittal (B) T1 FSimages of the hip demonstrate a deep acetabulum with overcoverage of the acetabular rimassociated with labral tearing (arrow).

FIGURE 19. Re-tear of a postoperativemedial meniscus. Coronal T1 FS imagedemonstrates linear contrast tracking intothe substance of the body of the medialmeniscal remnant (arrow).


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of asymptomatic and congenital perfo-rations of the TFCC, and have calledinto question the significance of fluidcommunication across the TFCCbetween the radiocarpal joint and infe-rior radioulnar compartment.21 MRarthrography provides direct visualiza-tion of the morphology of the TFCCand associated pathology, as well as

demonstration of contrast traversing theTFCC through the tear.

The TFCC is comprised of severalstructures including a biconcave artic-ular disc that is contiguous with thearticular surface of the distal radius.22

Strong ligamentous attachmentsbetween the distal radius, ulnar styloidand carpal bones stabilize the distal

radioulnar and ulnocarpal joints andare prone to both traumatic and degen-erative injuries. Contrast extendingacross the articular disc is a commonfinding and indicative of TFCC tear inthe symptomatic wrist (Figure 15).Tears at the ulnar aspect of the TFCC,as well as the radial attachments, tendto occur in younger patients and aremore often traumatic in nature. Theseinjuries are typically amenable toarthroscopic repair.23 Central perfora-tions of the TFCC tend to be morecommon in older patients and tend tobe degenerative and less amenable tosurgical repair.

Hip MR arthrographyMR arthrography of the hip was first

described by Hodler et al. in 1995 andwas shown to better depict the acetabu-lar labrum than conventional MR imag-ing.24 Subsequent publications con-firmed the advantages of MR arthrogra-phy in patients with chronic hip pain;particularly when labral tears, femoroac-etabular impingement, or articular carti-lage defects were suspected.

Unlike SLAP tears in the shoulder,tears of the acetabular labrum are morecommonly seen as contrast trackingbetween the fibrocartilaginous labrumand the acetabular rim (Figure 16),

FIGURE 20. Grade-4 chondromalacia of theknee. Sagittal T1 FS image shows diffusecartilage loss from both the femoral and tibialarticular surfaces of the medial compartmentwith large areas of grade-4 chondromalaciainvolving the weight bearing surface (arrow).Lateral compartment articular surface showsbetter preservation of the articular hyalinecartilage with only minimal grade-1 and -2chondromalacia (arrowhead).

A B

FIGURE 21. Loose bodies in the knee. Axial T1 FS (B) and sagittal T1 FS (A) images showmultiple laminated, low signal structures in the posterior recess of the knee compatible withloose bodies (arrowheads).

FIGURE 22. Intact anterior talofibular liga-ment. Axial T1 FS image demonstrates anintact anterior talofibular ligament (arrow)accentuated by intra-articular contrast.

FIGURE 23. Complete tear of the ATFL. AxialT1 FS image exhibits lack of visualization of the ATF (arrow). Contrast extends throughthe defect into the surrounding soft tissues.


MR ARTHROGRAPHY

rather than tracking into the substanceof the labrum itself.25 The presence ofnormal clefts in the labrum is some-what controversial. Location and depthof contrast-filled defects are importantconsiderations when distinguishingbetween normal labral clefts andpathologic tears. Full-length defectsthat occur at the anterosuperior portionof the labrum (11 o’clock) are morelikely to represent tears. There is somecontroversy as to the existence ofacetabular labral clefts. Many believethat defects at the posteroinferior por-tion of the labrum (8 o’clock position)which do not extend the full length ofthe labroacetabular interface may rep-resent clefts.26 Associated perilabralpathology, such as paralabral cysts,strongly favors a tear as well.

In younger patients with chronic hippain, femoroacetabular impingement(FAI) is not uncommon and when sus-pected, MR arthrography should beaccompanied by properly obtainedradiographs in order to evaluate for pre-disposing anatomy. FAI results in mac-eration of the acetabular labrumbetween the femoral neck and osseousrim of the superior acetabulum. Thisoften results in labral tears, calcifica-tion, and accelerated arthritis of the hip.Two types of anatomic variations havebeen associated with FAI: cam and pin-cer type.27 Although most cases of FAIinvolve some combination of both,each has their own specific findings onMR arthrography. Cam type is charac-terized by an osseous protuberancealong the femoral neck, with increasedalpha angles, and cartilaginous defectsto the anterosuperior femoral head(Figure 17).27 Pincer type is character-ized by deep acetabulum and posteroin-ferior cartilaginous defects to thefemoral head (Figure 18).27

Knee MR arthrographyThe first reported arthrogram of the

knee was obtained in 1905.28 Since thattime, knee arthrography has had a longand illustrious history, but with theadvent of MR imaging, the applicationsof knee arthrography have become

fairly limited. MR arthrography of theknee is now most commonly used toevaluate for recurrent meniscal tearsafter partial meniscectomy or meniscalrepair.29 In patients with partial menis-cectomy, re-tears may demonstraterecurrent contrast tracking into the sub-stance of the meniscus whereas meniscithat have not re-torn should not depictintrasubstance extension of contrast(Figure 19). MR arthrography can alsobe useful to further evaluate the articu-lar hyaline cartilage about the knee. MRarthrography has been shown to providean advantage over conventional MRimaging when evaluating the stability ofchondral and osseous fragments. Thepresence of intra-articular contrast bet-ter demonstrates the size and depth ofdefects in the articular cartilage and canassist when grading chondromalacia(Figure 20).30 When contrast is seentracking between cartilaginous flaptears and subchondral bone, it stronglysuggests fragment instability. Loosebodies are also better delineated whensurrounded by contrast and can be dif-ferentiated from synovial processeswhen the diagnosis is unclear on con-ventional images (Figure 21).31

Ankle MR arthrographyMR arthrography of the ankle was

first introduced in 1992 by Mayer et al.and has been shown to be superior toconventional MR imaging and stressradiographs for the evaluation of lat-eral ligamentous complex injuries.32

Although most of these injuries areself-limiting, it has been estimated that10% to 20% are not, and chronic insta-bility can ensue.33 For these patients,MR arthrography may prove beneficialfor grading lateral ligamentousinjuries, thereby determining if surgeryis indicated.

The anterior talofibular (ATFL) andcalcaneofibular ligaments are clearlyidentified on axial and coronal images(Figure 22). The ATFL is typically thefirst to tear with inversion injuries andshould be evaluated initially. Injuriesof the remaining lateral ligamentousstructures are unusual in the absence of

a co-existing injury of the ATFL.Lower-grade tears will demonstrateabnormal signal without extra-articularcontrast. Grade-3 and higher tears willdemonstrate ill-defined contrast track-ing into the adjacent soft tissues andeither a wavy or torn ATFL, and/orabsence of visualization of the liga-ment (Figure 23).

Additional indications include eval-uation of osteochondral defects, loosebodies and various ankle impingementsyndromes. Osteochondral defects andloose bodies in the ankle appear simi-lar to those seen in other joints. As withother joints, differentiation of stablefrom unstable chondral fragments isthe primary advantage of MR arthrog-raphy and has important implicationsfor treatment (the latter is typicallytreated surgically). MR arthrographyhas also been proven superior to con-ventional MR imaging in demonstrat-ing synovial and capsular thickeningand may be useful when ankleimpingement is suspected.34

ConclusionMR arthrography has evolved over

the years to become an invaluable toolfor diagnosing a wide variety of patho-logic processes in joints throughout thebody. It continues to prove its superior-ity to conventional MR imaging for agrowing number of indications and, withfurther research and refinement of tech-niques, this trend is likely to continue.

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