MRI Evaluation of Internal derangement of the Knee Joint - A PICTORIAL REVIEW

Transcription

1 MRI Evaluation of Internal derangement of the Knee Joint - A PICTORIAL REVIEW Poster No.: C-1386 Congress: ECR 2015 Type: Educational Exhibit Authors: V. Nadaraja, F. Abubacker Sulaiman; Chennai/IN Keywords: Anatomy, Musculoskeletal soft tissue, Musculoskeletal joint, MR, Imaging sequences, Diagnostic procedure, elearning, Athletic injuries, Trauma DOI: /ecr2015/C-1386 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 36

2 Learning objectives 1. Radiological evaluation of internal derangement of the knee joint using Magnetic Resonance Imaging 2. To study the pattern of internal derangement in relation to mechanism of injury. Page 2 of 36

3 Background Internal derangement of the knee (IDK) is an inclusive term used to indicate (alone or in combination) certain disorders of the joint including (alone or in combination) torn meniscus, loose bodies in the knee, and damaged collateral or cruciate ligaments. The term does not signify chronic disorders such as chondromalacia patellae, congenital discoid meniscus, meniscal cysts or degenerative processes such as osteoarthritis of the knee. MRI is a considerable advance and may well preserve patients from unnecessary operations. A knee which is producing definite mechanical symptoms will need arthroscopic surgery whatever is shown on MRI. However, if there are no mechanical symptoms MRI may be indicated to [2]. exclude any treatable pathology. Normal MRI Anatomy: Anterior Cruciate Ligament: ACL appears as a solid band or as a striated band diverging slightly distally. Interestingly, while the ACL is known to be composed predominately of anteromedial and posterolateral bands, as many as 4 distinct striations may be visible. The ACL substance shows slightly higher signal than that of the adjacent posterior cruciate ligament (PCL), low-to-intermediate intensity. The distal ACL further demonstrates relatively increased signal intensity owing in part to distal divergence of bands/striations. On coronal/sagittal images, a normal ACL is usually well seen, although the band (or bands) often appears much more attenuated and less bulky than in the sagittal plane. The lateral position of the ACL in the femoral intercondylar [1,2] notch is apparent in the coronal plane; the PCL is seen medially. Page 3 of 36

4 Fig. 1: Sagittal T1W MRI image demonstrates normal appearance of Anterior Crutiate Ligament References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Posterior Cruciate Ligament: The PCL attaches to the posterior intercondylar area and passes anterosuperiorly to insert into the lateral surface of the medial femoral condyle. The PCL is intracapsular but extrasynovial and is approximately 13mm in diameter. It contains two fibre bundles named according to their relative attachments Antero-lateral Postero-medial The normal appearance of the PCL on MR images is a well-defined continuous band of low signal intensity in all pulse sequences.a normal PCL usually measures no more than 6 mm in anteroposterior diameter on sagittal T2-weighted images, with the measurement perpendicular to the fibers of the vertical segment.[1,2,4] Page 4 of 36

5 Fig. 2: Sagittal T1W MRI image demonstrates normal appearance of Posterior Crutiate Ligament References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Meniscus: The anterior horn, body, and posterior horn of the menisci have a triangular crosssectional appearance on both coronal and sagittal MR images. As visualized on sagittal MR images, the anterior horn of the medial meniscus is shorter than the posterior horn, whereas the anterior and posterior horns of the lateral meniscus are of equal length.[3,5] Page 5 of 36

6 Fig. 3: Coronal T1W MRI image demonstrates normal appearance of Medial Meniscus References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 6 of 36

7 Fig. 4: Coronal T1W MRI image demonstrates normal appearance of Lateral Meniscus References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Medial Collateral Ligament: The anterior vertical component and the posterior oblique component of the MCL are depicted consistently on coronal T1-weighted or SE/FSE T2-weighted sequences. The MCL is seen as a thin, taut, well-defined, low T1/T2-signal structure extending from the medial femoral epicondyle to the medial tibial metaphysis.[8,9] Page 7 of 36

8 Fig. 5: Coronal T1W MRI image demonstrates normal appearance of Medial Collateral Ligament References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Lateral collateral ligament: Because of its posterior course, the entire LCL rarely is visualized on a single coronal image. Specialized coronal oblique (parallel to typical course of normal LCL) and sagittal, 1-mm, 3-dimensional, volume-rendered sequences depict the LCL and posterior lateral corner (PLC) structures particularly well. The LCL is seen as a thin, taut, well-defined, low - T1/T2-signal structure extending laterally and posteriorly from the lateral femoral epicondyle to the fibular head.[6,7] Page 8 of 36

9 Fig. 6: Coronal T1W MRI image demonstrates normal appearance of Lateral Collateral Ligament References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 9 of 36

10 Images for this section: Fig. 3: Coronal T1W MRI image demonstrates normal appearance of Medial Meniscus Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 10 of 36

11 Fig. 4: Coronal T1W MRI image demonstrates normal appearance of Lateral Meniscus Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 11 of 36

12 Fig. 5: Coronal T1W MRI image demonstrates normal appearance of Medial Collateral Ligament Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 12 of 36

13 Fig. 6: Coronal T1W MRI image demonstrates normal appearance of Lateral Collateral Ligament Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 13 of 36

14 Fig. 1: Sagittal T1W MRI image demonstrates normal appearance of Anterior Crutiate Ligament Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 14 of 36

15 Fig. 2: Sagittal T1W MRI image demonstrates normal appearance of Posterior Crutiate Ligament Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 15 of 36

16 Findings and procedure details MRI Criteria for ACL rupture: Complete Rupture: DIRECT SIGNS: Complete fiber disruption Abnormal course of cruciate ligament Intracapsular pseudomass in position of ACL INDIRECT SIGNS: Acute angulation of PCL Drawer phenomenon Kissing contusions Incomplete Rupture: Thinning of ACL < 10mm Periligamentous pseudomass in presence of intact fibers Increased intraligamentous signal with remnants of intact fibers Page 16 of 36

17 Fig. 7: Sagittal PD FS MRI image demonstrates normal course but abnormal high internal signal consistent with partial tear of ACL. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 17 of 36

18 Fig. 8: Sagittal PD FS MRI image demonstrates complete tear of ACL. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN MRI Criteria for PCL Rupture: Confined areas of increased signal intensity along course of the ligament (= partial rupture) Continuity disruption (= complete rupture) Page 18 of 36

19 Fig. 9: Sagittal PD FS MRI image demonstrates partial tear of PCL. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 19 of 36

20 Fig. 10: Sagittal PD & T2 FS MRI image demonstrates complete tear of PCL. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN MRI Criteria for MCL/LCL injury: Grade 1: (minor sprain) high signal is seen medial (superficial) to the ligament, which looks normal Grade 2: (severe sprain or partial tear) high signal is seen medial to the ligament, with high signal or partial disruption of the ligament Grade 3: complete disruption of the ligament Page 20 of 36

21 Fig. 15: Coronal STIR MRI image demonstrates Grade I sprain of Medial collateral ligament. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 21 of 36

22 Fig. 16: Coronal PD FS MRI image demonstrates Grade II tear of Lateral collateral ligament. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 22 of 36

23 Fig. 17: Coronal PD FS MRI image demonstrates Grade III tear of Lateral Collateral Ligament. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN MRI Evaluation of Meniscal Damage: Size Configuration of meniscus and signal pattern Page 23 of 36

24 Depth and width of altered signal Location within meniscus Fig. 11: Image demonstrates Gradation of Signal Alteration in Menisci References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Gradation of Signal Alteration in Menisci (Stoller): Meniscal Tear Morphology: Vertical (traumatic or degenerative) Horizontal (usually traumatic, posterior horn) Bucket-Handle Tear (subtype of vertical) Peripheral (within 5mm of periphery) Amputating (truncated free border or tip) Radial (traumatic or degenerative, medial) Page 24 of 36

25 Fig. 12: Sagittal PD FS MRI image demonstrates radial tear of meniscus. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 25 of 36

26 Fig. 13: Sagittal PD FS MRI images demonstrates horizontal tear. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 26 of 36

27 Fig. 14: Sagittal T2W MRI image demonstrates Bucket handle tear of meniscus References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 27 of 36

28 Images for this section: Fig. 13: Sagittal PD FS MRI images demonstrates horizontal tear. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 28 of 36

29 Fig. 7: Sagittal PD FS MRI image demonstrates normal course but abnormal high internal signal consistent with partial tear of ACL. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 29 of 36

30 Fig. 10: Sagittal PD & T2 FS MRI image demonstrates complete tear of PCL. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 30 of 36

31 Fig. 14: Sagittal T2W MRI image demonstrates Bucket handle tear of meniscus Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 31 of 36

32 Fig. 12: Sagittal PD FS MRI image demonstrates radial tear of meniscus. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 32 of 36

33 Fig. 15: Coronal STIR MRI image demonstrates Grade I sprain of Medial collateral ligament. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 33 of 36

34 Conclusion MRI of knee has the potential for rapid, definitive diagnosis with a noninvasive examination in comparison to gold standard arthroscopy. It reduces need for diagnostic arthroscopy. MRI of knee contributes in planning the correct treatment of IDK. Page 34 of 36

35 Personal information Dr.F.Abuabacker Sulaiman, MD.RD Associate Professor Department of Radiology and Imaging Sciences Chettinad Hospital and Research Institute Kelambakkam Kanchipuram District Tamilnadu India Dr.Vasudave Nadaraja 1st year Post graduate student Department of Radiology and Imaging Sciences Chettinad Hospital and Research Institute Kelambakkam Kanchipuram District Tamilnadu India Page 35 of 36

36 References 1. Fritz RC. MR imaging of meniscal and cruciate ligament injuries. Magn Reson Imaging Clin N Am 2003;11: Oei EH, Nikken JJ, Verstijnen AC, Ginai AZ, Myriam Hunink MG. MR imaging of the menisci and cruciate ligaments: a systematic review. Radiology 2003;226: Kowalchuk RM, Kneeland JB, Dalinka MK, Siegelman ES, Dockery WD. MRI of the knee: value of short echo time fast spin-echo using high performance gradients versus conventional spin-echo imaging for the detection of meniscal tears. Skeletal Radiol 2000;29: Robertson PL, Schweitzer ME, Bartolozzi AR, Ugoni A. Anterior cruciate ligament tears: evaluation of multiple signs with MR imaging. Radiology 1994;193: De Smet AA, Norris MA, Yandow DR, Quintana FA, Graf BK, Keene JS. MR diagnosis of meniscal tears of the knee: importance of high signal in the meniscus that extends to the surface. AJR Am J Roentgenol 1993;161: Crues JV, Mink J, Levy TL, Lotysch M, Stoller DW. Meniscal tears of the knee: accuracy of MR imaging. Radiology 1987;164: Seigel DG, Podgor MJ, Remaley NA. Acceptable values of kappa for comparison of two groups. Am J Epidemiol 1992;135: Bergin D, Keogh C, O'Connell M, et al. Atraumatic medial collateral ligament oedema in medial compartment knee osteoarthritis. Skeletal Radiol 2002; 31: Schweitzer ME, Tran D, Deely DM, Hume EL. Medial collateral ligament injuries: evaluation of multiple signs, prevalence and location of associated bone bruises, and assessment with MR imaging. Radiology 1995; 194: Haggar AM, Froelich JW, Hearshen DO, Sadasivan K. Meniscal abnormalities of the knee: 3DFT fast-scan GRASS MR imaging. AJR 1988; 150: Masi JN, Sell CA, Phan C, et al.. Cartilage MR imaging at 3.0 versus that at 1.5 T: preliminary results in a porcine model. Radiology 2005;236: Page 36 of 36