Upper Extremity Page Lower Extremity Special Cases

Transcription

1 MSK MRI PROTOCOLS

2 Contents Upper Extremity Shoulder Elbow Wrist Finger Thumb Lower Extremity Hip Pelvis Thigh Knee Lower Extremity/Shin Ankle Foot Special Cases Soft Tissue Mass Metal Protocol Page

3 MSK CHEST

4 MR MSK Chest Indications: Pectoralis Major Indications: PecPec tear Sternum Sternum / SC joints Indications: Tumor, Tumor, infection, arthritis, trauma Chest Chest wall Indications: Trauma, Trauma, tumor

5 Use Use large FOV Pectoralis Major Medial-lateral: lateral: cover to midline chest Superior-inferior: inferior: cover down to mid-humeral shaft FOV

6 Pectoralis Major Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex T x / min FSTIR x 19 4/0.5 > T: T: T T: 70 - T FSE x 56 4/0.5 > Cor Obl FSTIR x 19 4/0.5 > T: T: T T: 70 - Sag Oblique T FSE Fat Sat x 19 >

7 Sternum Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex T x / min FSTIR 4 56 x 19 4/0.5 > T: T: T T: 70 - Sag T x 56 4/ min Sag FSTIR x 19 4/0.5 > T: T: T T: 70 - Cor oblique T FSE x 19 >

8 Coronal: Coronal: oblique along sternum Planned from sagittal images

9 Sternoclavicular joints Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex T x / min FSTIR x 19 4/0.5 > T: T: T T: 70 Sag T x 56 4/ min Sag FSTIR x 19 4/0.5 > T: T: T T: 70 Cor T FSE x 19 >

10 Smaller FOV for SC joints Otherwise protocol is similar to Sternum

11 MSK - Chest Wall

12 UPPER EXTREMITY

13 MR Shoulder Indications: Routine Shoulder Indications: Rotator Cuff Pathology/Evaluation MR Arthrogram Indications: Labrum Pathology/Tear Post Gadolinium Shoulder (Indirect MR Arthrogram) Indications: Labral Pathology/Instability without ability to do a direct arthrogram

14 Shoulder-Routine Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex PD FSE x 56 4/ Cor Oblique FSTIR x 19 4/0.5 > T: T: T T: 70 - Cor Oblique T1 SE Non x / minimum - - Sag Oblique T FSE Non Fat Sat x 19 1 >

15 MR Arthrogram Shoulder Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex T1 SE x 19 3/ minimum Cor Oblique T1 SE x 19 3/ minimum Cor Oblique PD FSE x 19 3/0.5 > Sag Oblique T1 SE Non x minimum ABER T1 SE Fat Sat x 19 3/ minimum

16 Shoulder-Post Gadolinium (Indirect MR Arthrogram) **Inject standard dose of IV contrast and wait 0 minutes before scanning** Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex T1 SE x 19 3/ minimum PD FSE x 19 3/ Cor Oblique T1 SE x 19 3/ minimum Sagittal PD FSE x Cor Oblique FSTIR x 19 4/0.5 > T: T: T T: 70 -

17 Shoulder- Imaging Plane Relevant Anatomy Imaging Plane Prescribe plane parallel to humeral shaft. Cover from top of AC joint through proximal humeral diaphysis. Clavicle Humeral Head AC Joint (Not shown on MR) Bony Glenoid

18 Shoulder-Coronal Imaging Plane Relevant Anatomy Coronal Imaging Plane Prescribe coronal plane off of axial images parallel to supraspinatus muscle Supraspinatus

19 Shoulder-Sagittal Sagittal Imaging Plane Relevant Anatomy Sagittal Imaging Plane Prescribe sagittal plane off axial images with line parallel to bony glenoid. Image from mid-scapula through deltoid muscle. Deltoid Muscle Cartilaginous Labrum Ant. and Post. Humeral Head Bony Glenoid Labrum

20 MR Elbow Indications: Routine Elbow Indications: Biceps/Triceps tear Medial/Lateral collateral ligament tear Common Flexor/Common extensor tendon pathology MR Arthrogram Elbow Indications: Intra articular body evaluation Medial/Lateral Collateral Ligament Evaluation Osteochondral defect (OCD) Post Gadolinium Elbow (Indirect MR arthrogram) Indications: IA body OCD

21 Elbow-Routine* Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex T x minimum FSTIR x 19 > T: T: T T: 70 Coronal T x / minimum Coronal PD FSE x 56 3/0.5 > Sag PD FSE x 56 3/ *for Biceps pathology perform FABS sequence; follow this link.

22 MR Arthrogram Elbow Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex T1 Non PD FSE x x >1500 minimum Coronal T x 56 3/ minimum Coronal PD FSE x 56 3/0.5 > Sag T1 SE x 56 3/ minimum

23 Elbow- Imaging Plane Relevant Anatomy Imaging Plane *Prescribe plane perpendicular to coronal plane ( ). Scan from humeral metaphysis through radial tuberosity. Lateral and Medial Humeral Condyles * Radial Tuberosity (bump on medial radius) Radius Ulna Radial tuberosity *

24 Elbow-Coronal Imaging Plane Relevant Anatomy Coronal Imaging Plane *Prescribe plane parallel to medial and lateral epicondyles. Lateral Epicondyle * Humerus Olecranon process of Ulna Medial Epicondyle *

25 Elbow-Sagittal Imaging Plane Relevant Anatomy Sagittal Imaging Plane *Prescribe plane perpendicular to coronal plane ( ). Scan through entire elbow. Lateral Humeral Condyle * Humerus Medial Humeral Condyle * Olecranon process of Ulna

26 For Biceps pathology FABS Sequence Acquire T1 and T FS

27 Wrist Indications: Routine Wrist Indications: TFCC, Lunotriquetral, Scapholunate tear Flexor Tendon/Carpal Tunnel/ Extensor Tendon Pathology Evaluation for Occult fracture MR Wrist Arthrogram Indications: TFCC/LT/SL ligament tears Dynamic Enhanced Wrist (Post Gad Images) Indications: Evaluation of Scaphoid Nonunion/Avascular Necrosis Exam: IMPORTANT: **Perform routine wrist PLUS Pre/Post Gadolinium images through carpal bones in coronal plane**

28 Wrist-Routine Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex Coronal T x / minimum Coronal PD FSE x 56 3/0.5 > Coronal D or 3D GRE x 19 1/0 60 minimum 0-40 PD FSE Fat Sat x 56 3/ Sag FSTIR x 19 3/1 > T: T: T T: 70

29 MR Arthrogram Wrist (direct or indirect) Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex Coronal T1 SE x 56 3/ minimum Coronal PD FSE x 56 3/0.5 > Coronal D or 3D GRE x 19 1/0 60 minimum PD FSE x 56 3/1 > T1 Non x / minimum Sag PD FSE /1 >

30 Wrist- Imaging Plane ***IMAGE WRIST IN PRONATED POSITION! SUPINATED PRONATED Relevant Anatomy Imaging Plane Prescribe plane parallel to distal radius. Scan from proximal metacarpals through distal radial/ulnar metaphysis. trapm trapz cap ham triq scaph lun Dist radius Distal ulna

31 Wrist-Coronal Imaging Plane Remember to pronate the wrist! Relevant Anatomy Coronal Imaging Plane *Prescribe plane parallel to line drawn from ulnar styloid through radial styloid. Scan through entire wrist. Ulnar Styloid Radial Styloid * *

32 Wrist-Sagittal Imaging Plane Relevant Anatomy Sagittal Imaging Plane *Prescribe plane perpendicular to coronal plane ( ). Scan through entire wrist. Ulnar Styloid Radial Styloid * *

33 Hint: if the ulnar styloid is poking out to the side, the wrist is in pronated position

34 Thumb Indications: Routine Routine Thumb Indications: Gamekeeper s s thumb (Ulnar( Collateral Ligament tear) Flexor/Extensor Tendon Tear R/O R/O Occult Fracture

35 Thumb Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex Coronal PD FSE x 56 3/0.3 > Coronal T FSE Fat Sat x 19 3/ Sag FSE STIR x 19 3/0.3 > T: T: T T: 70 T1 SE x / minimal T FSE Fat Sat x 19 3/

36 Thumb- Imaging Plane Relevant Anatomy Imaging Plane Prescribe plane perpendicular to midshaft of proximal 1 st phalanx. Scan from CMC joint through thumb. IP Joint Proximal Phalanx MCP Joint Metacarpal CMC Joint

37 Thumb-Coronal Imaging Plane Coronal Imaging Plane *Prescribe plane with line bisecting sesamoid bones. Scan through entire thumb. Relevant Anatomy * Sesamoids Thumb

38 Thumb-Sagittal Imaging Plane Relevant Anatomy Sagittal Imaging Plane *Prescribe plane perpendicular to coronal imaging plane ( ). Scan through entire thumb. Sesamoids * Thumb

39 Finger Indications: Routine Finger Indications: Pulley rupture/flexor or Extensor Tendon Injury Post Gadolinium Finger Indications: Mass **Perform routine finger plus and either Coronal or Sagittal (whichever plane mass best seen) pre/post gadolinium fast GRE or T1 SE images. See mass protocol and adjust FOV and other parameters as needed.

40 Finger-Routine Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex Sag T1 SE x / minimum Sag T FSE x 19 3/ T1 SE x 19 3/ minimum PD FSE x56 3/ Coronal STIR x56 3/0.3 > T: T: T T: 70

41 Finger- Imaging Plane Relevant Anatomy Distal Phalanx Mid Phalanx Proximal Phalanx Imaging Plane Prescribe best fit line. Scan from proximal metacarpal through entire finger. Metacarpal

42 Finger-Coronal Imaging Plane Relevant Anatomy Extensor Tendon Coronal Imaging Plane *Prescribe plane parallel to anterior metacarpal head. Scan through entire finger. Include adjacent fingers. * Thumb

43 Finger-Sagittal Imaging Plane Relevant Anatomy Extensor Tendon Sagittal Imaging Plane *Prescribe plane perpendicular to coronal plane ( ). Scan through entire finger. Include adjacent fingers. Thumb *

44 LOWER EXTREMITY

45 Bony pelvis Indication: AVN, Mets, transient osteoporosis, bursitis, arthritis, tis, tendonitis, hip pain over age 50 PA Torso Coil is 1 st choice Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex Coronal FSE-STIR STIR x19-3 > T FSE x 56 5/ Coronal T1 SE Non x Minimum Sag T FSE (Hip to Hip) 1-56 x /1 > Coronal in/out of phase T1 GRE

46 ER Hip (Hip fracture screening) Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex Coronal FSE-STIR STIR x19 > T: T: T T: 70 Coronal T1 SE Non x Minimum T FSE x 56 >

47 Direct arthrogram hip Indication: hip labrum tear, FAI or dysplasia, hip pain under age a 50 PA Torso coil is 1 st choice Prescribe obliques along femoral neck from coronal localizer Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex Coronal (PELVIS) T1 SE Non x Minimum Coronal (PELVIS) FSE-STIR STIR x19 > T: T: T T: 70 (PELVIS) T FSE x 56 > Ax oblique (HIP) T x 56 4/ Minimum Coronal (HIP) T x 56 4/ Minimum Sag (HIP) T x 56 4/ Minimum

48 Noncontrast hip Indication: Unilateral hip pain PA Torso coil is 1 st choice Prescribe ax obliques along femoral neck from coronal localizer Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex Coronal (PELVIS) T1 SE Non x Minimum Coronal (PELVIS) FSE-STIR STIR x19 > T: T: T T: 70 (PELVIS) T FSE x 56 > Ax oblique (HIP) PD FSE x 56 > Coronal (HIP) PD FSE x 56 > Sag (HIP) PD FSE x 56 >

49 MARS (Metal Artifact Reduction Sequences) Hip Exam Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex Coronal FSE-STIR STIR x19 > T: T: T T: Coronal T1 SE Non x Minimum 64 T FSE x 56 > (HIP) PD FSE x 56 > Coronal (HIP) PD FSE x 56 > Sag (HIP) PD FSE x 56 >

50 Hip- Imaging Plane Relevant Anatomy Imaging Plane Prescribe plane parallel line bisecting lesser trochanters and/or acetabular roofs. Scan from iliac crests through lesser trochanter. Ilium Acetabular Roof Greater Trochanter Lesser Trochanter

51 Hip-Coronal Imaging Plane Relevant Anatomy Coronal Imaging Plane *Prescribe plane parallel femoral heads. Scan from ischium through pubic symphyses. Femoral Neck Superior Pubic Ramus * Femoral Head Ischium Greater Trochanter

52 Hip-Sagittal Imaging Plane Relevant Anatomy Sagittal Imaging Plane *Prescribe plane perpendicular to coronal plane. Scan from acetabulum through greater trochanter. Femoral Neck Superior Pubic Ramus * Femoral Head Ischium Greater Trochanter

53 Oblique Imaging Plane (For Femoracetabular Impingement Patients Only) Relevant Anatomy Oblique Plane Prescribe plane parallel to femoral neck. Scan through entire femoral neck. Femoral Neck Femoral Head

54 TJUH Athletic Pubalgia MR Protocol Indication: Athletic Pubalgia, Sports Hernia, Sportsman s s Hernia, Adductor tear/strain, Rectus Abdominis Injury PA Torso coil is 1 st choice Prescribe obliques along anterior iliac crest from sagittal localizer Seq. FOV Matrix/NEX Slice TR TE TI ETL BW Coronal STIR Coronal T1 SE T FSE Fat Sat Obl PD FSE Nonfatsat Obl T FSE Fat Sat Sag T FSE Fat Sat Sag PD FSE Nonfatsat (optional) -36 (Both hips) (Both hips) (Both hips) x x x x x x x56-3 > minimum 5/1 > / (max) 4/.5 4/.5 4/.5 >000 >000 >

55 Oblique Imaging Plane (Adductor unfolding plane) Relevant Anatomy Oblique Imaging Plane *Prescribe plane to line paralleling anterior Iliac crest*. Be sure to scan across pubic symphysis at midline Iliac crest * Hip joint *

56 Oblique Imaging Plane (Adductor unfolding plane)

57 Post Gadolinium Pelvis Indications: Osteomylitis IMPORTANT: Bony Pelvis (Special Cases) *Follow Hip Planes* Same as Routine Hip Protocol but perform axial and coronal images on both sides. In addition, perform FMPSPGR fat saturated images pre/post in both axial and coronal planes. In/Out of Phase Pelvis Indications: Possible Bony Metastases IMPORTANT: Perform In/Out of Phase images in Coronal Plane

58 Bony Pelvis Osteo pre/post option Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex Coronal T1 Non Coronal STIR x x >000 minimal 0-40 T1 Non x minimal T FSE x Sag T FSE 0 56 x ? (60-70) /Cor FMPSPGR Pre/Post 1 56 x 19 3/

59 Coronal STIR Indications: Sacrum Sacroiliac joints Possible Sacroileitis (Septic/Rheumatoid or Rheumatoid Variant Seq. Arthritis) FOV Matrix/ Slice TR TE TI Flip ETL BW Nex x 19 > T FSE x 56 > Cor Oblique T1 SE Non 1-56 x 56 3/ minimal Cor Oblique T FSE 1-56 x 56 3/.5 > Sag T FSE 1-56 x 56 3/.5 > T1 SE Non 1-56 x 56 3/ minimal

60 Sacrum Sacroiliac joints Prescribing the coronal oblique plane: parallel the sacrum on a sagittal localizer

61 Routine Thigh (Follow Hip Imaging Planes) Routine Routine Thigh Indications: Polymyositis/Diabetic Myonecrosis

62 Thigh-Routine Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex Coronal T1 SE Non x minimal Coronal T FSE x 56 > Sag STIR 6 56 x 19 > SE T1 Non 6 56 x minimal T FSE 6 56 x 56 >

63 Knee Indications Routine Knee Indications: Meniscal Tear/Medial or Lateral Ligament Tear/ACL/PCL Direct Arthrogram Indications: Meniscal Re-tear Intra articular Body Post Gadolinium Knee Indications Meniscal Re-tear IMPORTANT: Image 0 minutes post gadolinium

64 Knee-Routine Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex Sag PD FSE Non x 56 4/ Sag T FSE x 56 4/ Cor T1 SE Non x / Minimal Coronal T FSE Fat Sat x 56 3/0.5 > T FSE x 56 3/0.5 >

65 MR Arthrogram Knee (dir or ind) Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex Sag T1 Se x Minimal Sag PD FSE Non x 56 4/ Coronal T FSE x 56 > Coronal T1 SE x Minimal T FSE x 56 > T1 SE x Minimal

66 Knee- Imaging Plane Relevant Anatomy Imaging Plane Image from distal quad tendon through patellar tendon insertion Distal Quadriceps tendon P A T Femur Patellar Tendon Insertion Tibia

67 Knee-Coronal Imaging Relevant Anatomy Coronal Imaging Plane Prescribe plane with line parallel to femoral condyles. Image entire knee. Patella Med Fem Condyle Lat Fem Condyle

68 Knee-Sagittal Imaging Plane Relevant Anatomy Sagittal Imaging Plane *Prescribe plane perpendicular to coronal plane ( ). Scan from the medial to the lateral femoral condyle. Patella Med Fem Condyle Lat Fem Condyle * *

69 Lower Extremity/Shin Indication: Shin Splints IMPORTANT: Acquire coronal and axial (STIR) sequences covering both shins, but sagittal and axial (t only of side in question Place a marker on pain / tenderness

70 Lower Extremity/Shin Area Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex Coronal T1 SE Non x minimal Coronal STIR x 19 > STIR x 19 > T FSE (through marker region) x 56 > Sag T FSE 56 x 56 >

71 Ankle Indications Routine Routine Ankle Ligament Sprain/Tendon pathology/tarsal Tunnel/Sinus Tarsi/Occult fracture, PTT, Plantar fasciitis Ankle Ankle Arthrogram Indications: Intra-articular articular Body Post Post Gadolinium Ankle

72 Ankle-Routine Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex Sag T1 SE Non x / Minimal Sag STIR x /1 > PD FSE Non x T FSE x 56 > Coronal T FSE x /1 >

73 MR Arthrogram Ankle (dir or ind) Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex Sag T1 SE 56 x minimal Sag STIR 1 56 x 19 > T1 SE x min PD FSE Non x Coronal T1 SE x minimal Coronal T FSE x 56 >

74 Ankle-Post Contrast Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex FMPSPGR Pre/Post x XX 00? 4? Sag T1 SE Non 56 x minimal T1 SE 1 56 x 56?00 Minimal PD FSE x 56 > Cor T1 SE x minimal

75 Ankle- Imaging Plane Relevant Anatomy Imaging Plane Prescribe plane parallel to axis of calcaneus. Scan ankle from distal tibia through subcutaneous soft tissues (include plantar fascia). Tibia Talus Calcaneus Black band is plantar fascia

76 Ankle-Coronal Imaging Plane Relevant Anatomy Coronal Imaging Plane Prescribe plane perpendicular to axial imaging plane. Scan ankle from calcaneus through metatarsal bases. Talus M E T A T A R Cuboid Calcaneus S A L S

77 Ankle-Sagittal Imaging Plane Relevant Anatomy Sagittal Imaging Plane Prescribe plane with line parallel to talus. Cover ankle from medial through lateral malleolus. Talus Med Mal Lat Mal Ach

78 Midfoot

79 Forefoot

80 Foot-Indications Routine Foot Indications Plantar Plate Injury, R/O fracture, Lisfranc injury, tarsal/metatarsal fracture Post Gadolinium Foot Indications: Morton s Neuroma Osteomyelitis IMPORTANT: Perform routine foot plus coronal FMPSPGR fat saturated pre and post gad images and axial POST gad FMPSPGR fat saturated images.

81 Foot-Routine Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex Coronal (short axis) T1 Non Coronal (short axis) T FSE Sag STIR x x x /0.5 3/0.5 3/ >000 >1500 minimal Sag T1 Non x / minimal (long axis) PD FSE Non x 56 3/0.5 > (long axis) T FSE x 56 3/0.5 >000 90

82 Foot-Mass/Osteomyelitis Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex Coronal T1 SE Non Coronal T FSE Sag STIR x x x 19 3/0.5 3/0.5 3/ >000 >1500 minimal Sag T1 Non x / minimal Coronal FMPSPGR Pre/Post x 19 3/ FMPSPGR Post x 19 3/

83 Foot- Imaging Plane Relevant Anatomy Imaging Plane Prescribe plane parallel to rd or 3rd metatarsal. Scan foot from navicular through phalanges. Phalanges nd metatarsal C U N N A V

84 Foot-Coronal Imaging Plane Relevant Anatomy Coronal Plane *Prescribe plane parallel to 1 st and 5th metatarsal Shafts. Scan through entire foot. Metatarsals 1 3 * 4 5

85 Foot-Sagittal Imaging Plane Relevant Anatomy Sagittal Plane *Prescribe plane perpendicular to coronal Plane ( ). Scan through entire foot. Metatarsals * 1 3 * 4 5 *

86 Soft Tissue Mass Protocol General Recommendations Place Place Vitamin E capsule LIGHTLY on skin (do not depress skin with capsule) If post-operative: operative: place markers at each end of surgical scar FOV FOV determined by mass size / location Try to include adjacent joint for reference always; Sag or Cor depending on location of mass (speak with radiologist)

87 Soft Tissue Mass Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex T1 SE Non 56 x 19 5/ minimum T FSE 56 x 19 5/1 > Sag or Cor T1 SE Non 56 x 19 5/ minimum Sag or Cor STIR 56 x 19 5/1 > T1 GRE or SE Pre/Post Gd 56 x 19 5/ minimum Sag or Cor T1 GRE or SE Pre/Post Gd 56 x 19 5/ minimum

88 Metal Protocol general recommendations Assess Assess severity of artifact on scout discuss with MSK radiologist Maximize Maximize BW (bandwidth) Lower Lower TE (T and STIR) Remove Remove fat suppression (call MSK rad first) Avoid Avoid GRE Use Use STIR instead of Tw fat sat

89 MR Neurography Pelvis Seq. FOV Matrix/ Slice TR TE TI Flip ETL BW Nex Coronal (PELVIS) T1 SE Non x Minimum Coronal (PELVIS) FSE-STIR STIR x19 > T: T: 150 (PELVIS) T FSE 4 (hip to hip) 56 x /1 > > Coronal T vista (or equivalent) x345 1 / T1 3D FFE 4 76 x76 1 3/ M FFE 4 40x0 1 3/ Sagittal PD SPAIR 4- x 1 3.5/1 Max >

90 Marrow Survey

91 ER / Inpatient Protocols Hip / pelvis fracture Joint: Joint: survey exam Non-contrast R/O osteomyelitis Chest Chest wall / Abdominal wall Spine Spine survey