Practical Reporting of Musculoskeletal Imaging Studies: MRI Elbow

Transcription

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

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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