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...
Practical Reporting of
Musculoskeletal Imaging
Studies:
MRI Elbow
James F Griffith
History
Where is pain located?
For how long?
Trauma – if so, what and when
Radiographers can get this info
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 ……….
Epicondylitis
Cubital tunnel syndrome
Trauma inc biceps insertion
This talk : outline
Tendinosis of
common extensor
tendon origin
(CETO)
Tendinosis of
common flexor
tendon origin
(CFTO)
Epicondylitis
Cumulative microtrauma
Inadequate repair
Epicondylitis : Pathophysiology
Tendinosis (collagen disruption, proteoglycan deposition,
vascular ingrowth, fibroblast proliferation, hyaline degeneration)
Firm up diagnosis
Establish severity
Identify tear
Check for associated abnormalities
Peritendinitis
Collateral ligament injury
Bone oedema, cortical irregularity
Epicondylitis : Why imaging
Common extensor tendon origin
Common extensor tendon origin (CETO)
ECRL
ECRBr
ED
ECU
Possibly due to impingement against capitellum
** *
**
Lateral collateral ligament complex
Radial collateral ligament
Lateral ulnar collateral ligament
MR imaging protocol
PD cor
T2 SPIR obl cor T2-SPAIR axial
PD axial
+ sagittal images
CETO
CFTO
CETO normal
Some mild heterogeneity is normal
CETO tendinosis: moderate
Normal Moderate severity
CETO tendinosis: moderate
Moderate ….with tear
Lateral collateral ligament complex
Radial collateral lig (RCL)
Lateral ulnar collateral lig (LUCL)
Lateral collateral ligament complex
RCL
LUCL
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”
Avulsion ECRBr > ECRL >>> ED & ECU
ECRBr avulsion ECRL and ECRBr avulsion
Avulsion ECRBr > ECRL >>> ED & ECU
ECRBr avulsion ECRL and ECRBr avulsion
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”
Complete tear CETO, RCL and LUCL
RCL LUCL
Ultrasound protocol : lateral
(1) Put finger on lateral epicondyle
(3) Place transducer along this line
(2) Imagine line of extensor tendons
Ultrasound protocol: CETO
CETO tendinosis
Thickening
Hypoechogenicity
Calcification
Tear
Cortical irregularity
Hyperaemia
CETO tendinosis
Thickening
Hypoechogenicity
Calcification
Tear
Cortical irregularity
Hyperaemia
CETO tendinosis
CETO tendinosis
‘Lift‘ the transducer
off skin
CETO tendinosis
Normal < 32mm2 Tendinosis >32mm2
Baumer P et al 2011
Radial synovial fold syndrome
No fold Thickened
synovial fold
but not impacted
Impacted
synovial fold
Common flexor tendon origin (CFTO)
PT
FCR
PL
FCU
FDS
* *
Medial collateral ligament
Anterior band
Transverse band
Posterior band
Medial collateral ligaments
Anterior band
Transverse band
Posterior band
CFTO normal
CFTO normal and moderate tendinosis
Normal Moderate tendinosis
CETO tendinosis and tear
Ultrasound protocol : medial
(1) Put finger on medial epicondyle
(3) Place transducer along this line
(2) Imagine line of flexor tendons
Ultrasound protocol: CFTO
Ultrasound protocol: CFTO
US or MR examination?
US MRI
Tendinosis severity
Tear depiction
Hyperaemia
Associated abnormality
Operator independent
3rd party review
++ ++
+ ++
++ -
- +
- +
- +
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
Rest, bracing and physiotherapy
Don’t use steroids
Dry needling
Platelet Rich Plasma (PRP)
Autologous blood injection
Botox
Treatment (i)
Extracorporal shock wave therapy
Low level laser therapy
Treatment (ii)
Surgery
Debridement, drilling
Release (percutaneous, arthroscopic, open)
Suture fixation
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
Clinical Presentation
2nd most common nerve entrapment, > left side (3:1)
Paresthesia
Hypoesthesia
Anaesthesia
Muscle weakness
Muscle wasting
Cubital Tunnel Anatomy
Cubital Tunnel Anatomy
FCU
heads
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
Anconeus epitrochlearis muscle
20% of normal subjects
Why image cubital tunnel syndrome?
Confirm diagnosis
Assess severity
Look for secondary cause
Look for nerve subluxation
Image with ………….. or
MR protocol
Axial T2 SPAIR Axial PD ±DWI
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
T2-hyperintensity (contrast:noise ratio)
Neural SI – Muscle SI
Standard deviation Air CNR =
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
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
Diagnostic MR criteria
> 12mm2 CSA ulnar nerve
CNR > 50 at cubital tunnel
DWI positive signal ulnar nerve
Excessive hyperintensity without swelling ?? neuritis
Ultrasound Cubital Examination
Supine Prone Sitting
Cubital Tunnel Examination
Measurements
Proximal
At
Distal
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
Ulnar nerve swelling
Normal Mild
Moderate Severe
9mm2 14mm2
19mm2 23mm2
Ulnar nerve subluxation (20% normal nerves)
Olecranon Medial epicondyle
Yang SM et al. J Ultrasound Med 2013
Ulnar nerve subluxation
Due to absence of arcuate ligament
2o cause: Osteophytes
2o cause : Loose bodies
2o cause: Ganglion
2o cause: synovial proliferation
Severe rhematoid arthritis
2o cause: Anconeus epitrochlearis m.
Medial head
triceps slip
Diagnostic criteria (ultrasound or MRI)
CSA> 12mm2 CNR > 50 DWI positive
or 2.8: 1 (prox : at)
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
CSA > 12mm2 CNR > 50 DWI positive
CONCLUSION
or 2.8: 1 (prox : at)
Biceps tendon
FABS view: Flexion Abduction Supination
Biceps tendon
FABS view: Flexion Abduction Supination view
Biceps and brachialis tendon insertions
Muscular
brachialis
insertion
Muscular
brachialis
insertion
Tendinous
brachialis
insertion
Biceps
tendinous
insertion
Biceps and brachialis tendon insertions
Muscular
brachialis
insertion
Muscular
brachialis
insertion
Tendinous
brachialis
insertion
Biceps
tendinous
insertion
Mild tendinosis biceps tendon
Mild tendinosis Mild tendinosis
“Mild distal biceps tendinosis without tear”
Severe tendinosis biceps tendons
“Severe distal biceps tendinosis with moderate-severity tear”
Severe tendinosis biceps tendons
“Complete tear distal biceps with retraction by 3cm ”
Operation: short head torn
Epicondylitis
Cubital tunnel syndrome
Biceps insertion
Conclusion
Thank you