Practical Reporting of Musculoskeletal Imaging Studies: MRI Elbow
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1 Practical Reporting of Musculoskeletal Imaging Studies: MRI Elbow James F Griffith
2 History Where is pain located? For how long? Trauma if so, what and when Radiographers can get this info
3 Grade. 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)
4 This talk : outline Epicondylitis Cubital tunnel syndrome Trauma inc biceps insertion
5 Epicondylitis Tendinosis of common extensor tendon origin (CETO) Tendinosis of common flexor tendon origin (CFTO)
6 Epicondylitis : Pathophysiology Cumulative microtrauma Inadequate repair Tendinosis (collagen disruption, proteoglycan deposition, vascular ingrowth, fibroblast proliferation, hyaline degeneration)
7 Epicondylitis : Why imaging Firm up diagnosis Establish severity Identify tear Check for associated abnormalities Peritendinitis Collateral ligament injury Bone oedema, cortical irregularity
8 Common extensor tendon origin
9 Common extensor tendon origin (CETO) ECRL ECRBr ** ED * ECU ** Possibly due to impingement against capitellum
10 Lateral collateral ligament complex Radial collateral ligament Lateral ulnar collateral ligament
11
12 MR imaging protocol CETO PD axial PD cor CFTO T2-SPAIR axial T2 SPIR obl cor + sagittal images
13 CETO normal Some mild heterogeneity is normal
14 CETO tendinosis: moderate Normal Moderate severity
15 CETO tendinosis: moderate Moderate.with tear
16 Lateral collateral ligament complex Radial collateral lig (RCL) Lateral ulnar collateral lig (LUCL)
17 Lateral collateral ligament complex RCL LUCL
18 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
19 Avulsion ECRBr > ECRL >>> ED & ECU ECRBr avulsion ECRL and ECRBr avulsion
20 Avulsion ECRBr > ECRL >>> ED & ECU ECRBr avulsion ECRL and ECRBr avulsion
21 Complete tear CETO and RCL There is moderate CETO tendinosis with a complete avulsivetype tear of the CETO as was as the RC and LUC ligaments
22 Complete tear CETO, RCL and LUCL RCL LUCL
23 Ultrasound protocol : lateral (1) Put finger on lateral epicondyle (2) Imagine line of extensor tendons (3) Place transducer along this line
24 Ultrasound protocol: CETO
25 Thickening Hypoechogenicity Calcification Tear Cortical irregularity Hyperaemia CETO tendinosis
26 Thickening Hypoechogenicity Calcification Tear Cortical irregularity Hyperaemia CETO tendinosis
27 CETO tendinosis
28 CETO tendinosis Lift the transducer off skin
29 CETO tendinosis Normal < 32mm 2 Tendinosis >32mm 2 Baumer P et al 2011
30 Radial synovial fold syndrome No fold Thickened synovial fold but not impacted Impacted synovial fold
31 Common flexor tendon origin (CFTO) PT * FCR * PL FCU FDS
32 Anterior band Transverse band Posterior band Medial collateral ligament
33 Medial collateral ligaments Anterior band Transverse band Posterior band
34 CFTO normal
35 CFTO normal and moderate tendinosis Normal Moderate tendinosis
36 CETO tendinosis and tear
37 Ultrasound protocol : medial (1) Put finger on medial epicondyle (2) Imagine line of flexor tendons (3) Place transducer along this line
38 Ultrasound protocol: CFTO
39 Ultrasound protocol: CFTO
40 US or MR examination? Tendinosis severity Tear depiction Hyperaemia Associated abnormality Operator independent 3rd party review US MRI
41 Epicondylitis : US and MR examination 1/6 have a normal US Represents early non-established disease Proceed to MRI 50% of these will still have normal MRI examination
42 Treatment (i) Rest, bracing and physiotherapy Don t use steroids Dry needling Platelet Rich Plasma (PRP) Autologous blood injection Botox
43 Treatment (ii) Extracorporal shock wave therapy Low level laser therapy Surgery Debridement, drilling Release (percutaneous, arthroscopic, open) Suture fixation
44 Epicondylitis : summary Both US and MRI extremely helpful at assessing lateral & medial epicondylitis Report on: Tendinosis severity (mild, moderate, severe) Presence, size and location of tears Vascularity (ultrasound) Collateral ligament integrity
45 Clinical Presentation 2 nd most common nerve entrapment, > left side (3:1) Paresthesia Hypoesthesia Anaesthesia Muscle weakness Muscle wasting
46 Cubital Tunnel Anatomy
47 Cubital Tunnel Anatomy FCU heads
48 Aetiology PRIMARY (Younger): Excessive leaning on or flexing of elbow Repeated subluxation/dislocation of ulnar nerve SECONDARY (Older): Osteophytes, loose bodies, synovial proliferation, ganglia, anconeus epitrochlearis m., hypertrophied medial triceps Husarik DB et al. 2009
49 Anconeus epitrochlearis muscle 20% of normal subjects
50 Why image cubital tunnel syndrome? Confirm diagnosis Assess severity Look for secondary cause Look for nerve subluxation Image with.. or
51 MR protocol Axial PD Axial T2 SPAIR ±DWI
52 Ulnar Nerve Calibre 10.1mm mm 2 Normal 11.4mm 2 ± 0.5 Mild UNE : 12.7mm 2 ± 0.5 Severe UNE : 19.4mm 2 ± 2.5 Diagnostic criterion: > 12mm 2 at cubital tunnel Baumer P et al 2011
53 T2-hyperintensity (contrast:noise ratio) CNR = Neural SI Muscle SI Standard deviation Air
54 T2-hyperintensity (contrast:noise ratio) = = 15.7 Cubitial tunnel if CNR > 50 at cubital tunnel Baumer P et al 2011
55 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
56 Diagnostic MR criteria > 12mm 2 CSA ulnar nerve CNR > 50 at cubital tunnel DWI positive signal ulnar nerve Excessive hyperintensity without swelling?? neuritis
57 Ultrasound Cubital Examination Supine Prone Sitting
58 Cubital Tunnel Examination
59 Measurements Proximal At Distal
60 Criteria for cubital tunnel syndrome Absolute criteria (CSA ulnar nerve) : Normal < 9mm 2 Symptomatic > 12mm 2 Thoirs K et al 2007 Relative criteria (CSA ulnar nerve) : 2.8: 1 (proximal : at cubital tunnel) Kyoon SJ et al 2008
61 Ulnar nerve swelling 9mm 2 14mm 2 Normal Mild 19mm 2 23mm 2 Moderate Severe
62 Ulnar nerve subluxation (20% normal nerves) Olecranon Medial epicondyle Yang SM et al. J Ultrasound Med 2013
63 Ulnar nerve subluxation Due to absence of arcuate ligament
64 2 o cause: Osteophytes
65 2 o cause : Loose bodies
66 2 o cause: Ganglion
67 2 o cause: synovial proliferation Severe rhematoid arthritis
68 2 o cause: Anconeus epitrochlearis m. Medial head triceps slip
69 Diagnostic criteria (ultrasound or MRI) CSA> 12mm 2 CNR > 50 DWI positive or 2.8: 1 (prox : at)
70 Cubital Tunnel Syndrome : summary 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
71 CONCLUSION CSA > 12mm 2 CNR > 50 DWI positive or 2.8: 1 (prox : at)
72 Biceps tendon FABS view: Flexion Abduction Supination
73 Biceps tendon FABS view: Flexion Abduction Supination view
74 Biceps and brachialis tendon insertions Muscular brachialis insertion Muscular brachialis insertion Tendinous brachialis insertion Biceps tendinous insertion
75 Biceps and brachialis tendon insertions Muscular brachialis insertion Muscular brachialis insertion Tendinous brachialis insertion Biceps tendinous insertion
76 Mild tendinosis biceps tendon Mild tendinosis Mild tendinosis Mild distal biceps tendinosis without tear
77 Severe tendinosis biceps tendons Severe distal biceps tendinosis with moderate-severity tear
78 Severe tendinosis biceps tendons Complete tear distal biceps with retraction by 3cm Operation: short head torn
79 Conclusion Epicondylitis Cubital tunnel syndrome Biceps insertion
80 Thank you
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