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Musculoskeletal ting where radiation exposure is a strong concern or where

there is a contraindication to MRI in patients with pace-


MRI Part II: makers, cochlear implants, intraocular ferrous foreign
bodies, or cerebral aneurysm clips. Many in the field may
Bony Pelvis, Knee, have the impression that newer techniques have rendered
previously used studies such as conventional arthrography

Shoulder & Elbow obsolete. However, combined fluoroscopic/ radiographic


arthrography is still a very viable and sensitive method
for evaluating joint structures. These proven procedures
Andy Trovinger, RT (R) (MR) (CT) (CV); Andrew Sonin, MD; are now combined with newer CT and MRI techniques
Michael Otte, MD; Paul Hsieh, MD to provide added sensitivity to these multiplanar imaging
techniques. Conventional arthrography is also used for
INTRODUCTION patients who are unable to undergo MRI.
MRI is now the gold standard for most types of mus-
Imaging of the bones, joints, muscles, and cartilage culoskeletal imaging. The strength of MRI in imaging
represents the radiologic subspecialty of musculoskeletal physiologic processes is due to its combined strengths of
imaging. Musculoskeletal imaging can be performed high detail, multiplanar imaging capability, lack of ion-
using a number of modalities, including magnetic res- izing radiation, and sensitivity to physiologic changes.
onance imaging (MRI), computed tomography (CT), MRI also excels in the ability to distinguish various types
ultrasonography, nuclear medicine, radiography, and of tissues as a result of their water and fat content. Because
f luoroscopy. Radiography is predominantly used for MRI provides a wide range of choices for imaging in the
bony imaging due to the extremely high detail achiev- form of various pulse sequences and options, it allows for
able with this technique and also because of its com- a very comprehensive evaluation of an injury in a fairly
paratively lower cost. However, bony injuries are often short period of time.
accompanied by injuries to the joint cartilage and mus-
cles, tendons, and ligaments. A bone bruise, or contusion,
is difficult or impossible to detect using radiography,
OVERVIEW OF JOINT MRI
even though radiography excels at demonstrating struc- From a technologists perspective, it is very important to
tural and anatomical detail such as fractures, tumors, or subdivide and differentiate the two primary components
arthritic changes. of musculoskeletal MRI. Joint survey MRI is by far the
Other modalities have different strengths. Because most common type of musculoskeletal MRI performed.
physiologic reactions such as bone marrow edema are not Joint MRI can be performed on almost any articula-
seen radiographically, these other modalities can be used tion in the body. The joints most typically evaluated by
for greater understanding of injuries. Nuclear medicine MRI that fall clearly into the category of musculoskeletal
bone scans are highly sensitive to physiologic changes of imaging are the knee, shoulder, wrist, ankle, hip, elbow,
this type, but the lack of resolution with scinitigraphy and the joints of the hand and foot. On occasion, sterno-
limits its ability to demonstrate fine detail. CT scanning, clavicular or sacroiliac joints may also be imaged. When
although capable of extraordinary spatial resolution, is performing joint MRI, it is important to evaluate all the
similar to radiography in its limitations because these structures of the articulation. This includes the articu-
two modalities rely on the same basic principles of image lating bones and surrounding cartilaginous, synovial, lig-
generation. Sonography has demonstrated utility in a few amentous, tendinous, and muscular structures. Careful
limited areas of musculoskeletal imaging, such as con- attention should be paid to appropriate anatomical cov-
genital hip dislocations in infants, evaluation of tendons, erage, plane angulation, technical parameter selection,
or characterization of some masses, especially ganglion and patient positioning, because errors in any of these
cysts. The lack of ionizing radiation makes sonography areas can adversely affect the sensitivity or specificity of
an ideal method for evaluation of abnormalities in a set- the examination.

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When evaluating any joint, it is incumbent upon the this installment will cover only the
technologist to obtain as much clinically relevant infor-
mation as possible about why the exam was requested. Bony pelvis
For traumatic injury, determine the type or mechanism Knee
of injury and its time of occurrence. If no trauma was
involved, determine where the pain is localized and if the Shoulder
patient has any history of malignancy, acute or chronic Elbow
diseases, long-term medication use, or arthritis. Also
important is whether or not the patient has any systemic Each joint examination will be discussed by presenting
symptoms such as fever, weight loss, or abnormal blood an overview, listing indications for a typical examination
counts. This information is not only important to the of the specific joint, reviewing anatomy, listing frequently
radiologist interpreting the study, but will also aid the seen pathology and, where applicable, the common mech-
technologist in making decisions as to whether or not anisms of injury. Imaging protocols for each examination
additional imaging sequences may be of value. are also discussed. However, it is important to realize
that there is no universally accepted consensus regarding
OVERVIEW OF EXTREMITY MRI the techniques for performing musculoskeletal MRI.
Therefore, these protocols reflect the specific preferences
MR extremity imaging, the second type of muscu- of a small number of fellowship-trained musculoskeletal
loskeletal MRI, is a very different concept than that of imaging specialists, not the entirety of the musculosk-
joint MRI. In joint MRI there are a generally predict- eletal imaging community. The protocols included in
able set of injuries, depending on the joint, or a typical this article are provided for the purpose of reference and
set of disease patterns that appear in the joints. But in should in no way be construed as the only means of eval-
MR extremity imaging, a much wider variety of pro- uating the joints discussed herein. Within our practice,
cesses are likely to be seen. These processes may include musculoskeletal imaging is performed at field strengths
muscle injuries, soft tissue tumors, cellulitis, and osteo- ranging from 0.7 Tesla (T) to 1.5 T.
myelitis. The anatomical structure of the extremities
themselves allows for these processes to spread along The Bony Pelvis
numerous pathways.
Typically, extremity MRI is performed to evaluate The bony pelvis is composed of the iliac bones, the
for a discrete mass, abscess, fluid accumulation, unilat- sacrum and coccyx, the pubis and ischium, and the
eral localized swelling, unexplained pain, or to assess the proximal femurs. These bony structures are connected
extent of a wound infection. It is of paramount impor- by a very complex network of muscles and cartilagi-
tance when performing extremity MRI to include in at nous structures. This assembly provides a fairly rigid
least one plane of imaging the joint closest to the area of support structure that allows the upper body to be car-
abnormality; if surgical intervention is required, the sur- ried by the legs during ambulation and sitting. The
geons will then have an anatomical landmark in terms bony pelvis also provides structural support and pro-
of distance. The abnormality must be thoroughly evalu- tection for the organs of the pelvis-the bladder, bowel,
ated relative to both its extent and involvement with sur- and organs of reproduction.
rounding structures such as muscles, vessels, nerves, and Indications for MRI of the Bony Pelvis
bony structures. Depending on the clinical situation, it
may also be necessary to scan the entire length of the There are a number of indications for MRI evaluation of
extremity in question. Certain bone tumors have a pre- the bony pelvis. Often, the primary area of interest is the
dilection for so-called skip lesions; thus a lesion at one end hip or acetabulum. Due to the weight-bearing mechanics
of the femur might be associated with a second lesion at and range of motion of this joint, many types of injuries
the opposite end of the same bone. Gadolinium intra- or degenerative processes can occur. Cartilage injuries are
venous contrast injection should also be considered for not uncommon; bony and cartilaginous degeneration of
many extremity MRI examinations because this method the articular surfaces occurs frequently in such settings as
can assist greatly in the differentiation of inflammatory osteoarthritis (whether primary or post-traumatic). Hip
processes from malignant ones; this modality also has the traumaespecially femoral neck fracturescan cer-
ability to determine tissue viability. tainly be imaged well; MRI has proved extremely useful
in diagnosing occult fractures. Osteonecrosis (ON) of the
MRI OF SPECIFIC JOINTS AND EXTREMITIES femoral heads is a frequent reason for evaluation of the
hips with MRI, especially in patients undergoing steroid
The scope of this article is to provide the technologist therapy. Sacroiliac pain is also a frequent reason for MRI
with realistic and easily applicable guidelines for MRI to be performed. Trauma can be well evaluated using
imaging of joints and extremities. Due to the complexity MRI, although for complex fractures of the acetabulum,
of many of these procedures and the number of joints, CT scanning with three-dimensional (3-D) surface ren-
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dering is often the preferred examination to demonstrate


to the surgeons the anatomical relationship of the frac-
ture fragments. It is important to bear in mind that when
undertaking an examination of the pelvis, it is possible to
miss pathology if the entire bony pelvis is not evaluated
on at least one series. For this reason, in our practice we
have chosen a rather comprehensive approach to MRI of
the bony pelvis.
Anatomy of the Bony Pelvis
In addition to the bony structures and organs in the
pelvis, there are numerous complex muscle groups.
These include the muscles of the buttock (gluteus max-
imus, medius, and minimus); muscles of the anterior
abdomen (rectus and transversus abdomimus, pyrami-
dalis, and external and internal oblique muscles); mus- FIGURE 1.3 Proton density-weighted sagittal
cles of the lower back (quadratus lumborum, latissimus image through the acetabulum.A- Femoral head,
dorsi, and iliopsoas muscles); muscles of the pelvis and B- acetabulum
pelvic floor (iliacus, quadratus femoris, pectineus, obtu-
rator internus and externus, levator ani, piriformis, and
gemellus groups); and muscles of the superior thigh
(adductor magnus, brevis, and longus; gracilis; sartorius;
and quadriceps and hamstring groups [to be discussed in
greater detail later]).

FIGURE 1.4 Proton density-weighted axial image


through the acetabulum. A- Acetabular labrum,
B- Femoral head
FIGURE 1.1 T1-weighted coronal image through
the pelvis at the level of the femoral heads. Pathology
A- Femoral Head, B-Greater Trochanter of femur,
C- Femoral Neck, D- Iliac Crest Traumatic injury such as those suffered by athletes
often affects the muscles, tendons, ligaments, or cartilage.
Bony involvement is seen as well, but often manifests as
bone contusion or marrow edema as a result of impact or
abnormal movement, especially that related to hyperex-
tension injuries. Evaluation of the acetabular labrum can
be achieved using conventional MRI, but a more defini-
tive diagnosis is often made using MR arthrography. In
this setting it is important to include some high-resolution
scans that are limited to the affected area to adequately
image this smaller structure. ON occurs in the femoral
heads, frequently bilaterally. This process is well docu-
FIGURE 1.2 T1-weighted axial image through the mented using MRI. Although it does not require high
pelvis at the level of the femoral heads.A- Femoral resolution to make the diagnosis of ON, assessment of
neck, B- Femoral Head, C- Greater trochanter of the degree of ON involvement along the articular surface
femur, D- Pubic bone, E- Ischium of the femoral head does require high resolution. This
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can generally be achieved with a single additional series. * T1-weighted SE or FSE high resolution (TE: 11-20 ms)
Pain in the pelvic region can also be referred from soft Coronal plane
tissue injuries or processes. What begins as a musculosk-
eletal examination can ultimately turn into a diagnosis of Coverage from posterior coccyx through ante-
a soft-tissue tumor or a deep hematoma within the pelvic rior ubic symphysis
cavity. Circumstances like this are why we believe it is 5.0- to 6.0-mm thickness with 1.0-mm gap
important not to limit the examination to only the region
of the acetabula. FOV to include lateral skin surfaces (typically
420-480 mm)
Techniques
Matrix 512 F x 320 P (512 interpolated)
For hip/pelvic imaging in the majority of our patients, a
pelvic or torso surface array coil is used. For patients too Phase oversampling at operator discretion
large to be effectively accommodated with this type of
* Fast STIR (FSE-IR) (TE: 45-55 ms)
coil, the integrated body coil is used.
Coronal plane
* Localizer-Three Plane
Inversion time (TI) is field strength-dependent:
Gradient echo: Scan time < 60 sec 130 ms at 1.5 T, 110 ms at 1.0 T, 90 ms at 0.7 T
5-9 slices per plane Coverage from posterior coccyx through ante-
rior pubic symphysis-matched to T1 coronal
10.0-mm thickness with 5.0-mm gap
5.0- to 6.0-mm thickness with 1.0-mm gap
FOV (field-of-view) 480 mm
FOV to include lateral skin surfaces (typically
Matrix 256 F (frequency) x 128 P (phase) 420-480 mm)
* T1-weighted spin echo (SE) or fast spin echo (FSE) Matrix 320 F x 192 P (512 interpolated)
(TE: 11-20 mm)
Axial plane Phase oversampling at operator discretion

Whole-pelvis coverage * Proton density (PD)-weighted (TE: 36 ms) FSE


with spectral fat suppression
6.0- to 8.0-mm thickness with 1.0-mm gap Coronal plane
FOV to fit L-R dimension of pelvis (typically Not scanned if ON seen on previous series-only
320-440 mm) for labral evaluation
Matrix 320 F x 192 P (512 interpolated) Affected side(s) only-centered over acetabulum
Phase axis R-L Coverage through acetabulum with additional
100% phase oversampling 10 mm anterior and posterior

Spatial presaturation slabs superior and inferior 4.0-to 5.0-mm thickness contiguous
to slice volume FOV 200-220 mm
* T2-weighted FSE (TE: 70-80 ms) with spectral fat Matrix 256 F x 192 P (512 interpolated)
suppression
Axial plane 100% phase oversampling

Whole-pelvis coverage-matched to T1 axial Phase axis R-L

6.0- to 8.0-mm thickness with 1.0-mm gap * PD-weighted (TE: 18 ms) FSE
Sagittal plane
FOV to fit L-R dimension of pelvis (typically
320-440 mm) Only scanned if ON is seen or suspected
Matrix 320 F x 192 P (512 interpolated) Affected side(s) only-centered over femoral head
Phase axis R-L Coverage through femoral head with additional
5 mm medial and lateral
100% phase oversampling
4.0-to 5.0-mm thickness contiguous
Spatial presaturation slabs superior and inferior
to slice volume FOV 200-220 mm
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Matrix 256 F x 224 P (512 interpolated)


100% phase oversampling
Phase axis A-P

Additional sequences are occasionally added after the


radiologists review, such as oblique thin section coronal
and axial to evaluate the sacroiliac joints, or thin section
axials for acetabular irregularities. Generally, the exam-
ination can be completed comfortably in a 30-minute
time slot.

The Knee

The knee joint is a hinge joint and consists, in the


broadest sense, of four bones articulating in different
ways. Normal motion is f lexion and extension. The
distal femur articulates with both the proximal tibia and
patella; the tibia articulates with the patella, distal femur,
and proximal fibula.
Soft Tissues and Cartilage
Soft-tissue structures in the knee include the medial FIGURE 2.1 Proton density-weighted fat-sup-
and lateral menisci, the anterior and posterior cruciate lig- pressed axial image through the knee at the level of
aments; medial (MCL) and fibular (FCL) collateral liga- the femoral condyles. A- Patella, B- Patellar artic-
ments; patellar ligament and quadriceps tendon; patellar, ular cartilage, C- Femur
tibial, and femoral articular cartilage; and the muscles
of the thigh and calf. The articular surfaces of the fem-
oral condyles, the tibial plateau, and the posterior patella
are lined with a layer of hyaline cartilage. The muscles
of the mid- and distal thigh involved in knee movement
consist of the quadriceps group anteriorly (rectus fem-
oris and vastus lateralis, intermedius, and medialis); the
hamstring group posteriorly (long and short heads of the
biceps femoris, semitendinosus, and semimembranosus);
and the gracilis and sartorius muscles medially. The
muscles of the proximal and mid-calf involved in knee
movement include the gastrocnemius, popliteus, and per-
oneus longus muscles. There are also several fluid-filled
sacs called bursae that act as cushions between tendons
during movement.
Bony Structures
As previously mentioned, the knee joint is comprised
of the femur, patella, tibia, and fibula. In some patients,
a variant sesamoid bone called the fabella is also seen in
the lateral gastrocnemius tendon. The primary articula-
tions of the knee are between the posterior surfaces of
the patella and the anterior/inferior surfaces of the femur,
and the superior surfaces of the tibia and the inferior/
posterior surfaces of the femur. The proximal tibio-fib- FIGURE 2.2 Proton density-weighted sagittal
ular articulation is a fibrous articulation that does not image through the knee at the level of the inter-
permit very much movement. condylar fossa. A- Quadriceps tendon, B- Patella,
C- Patellar ligament, D- Femur, E- Tibia,
F- Anterior cruciate ligament (ACL), G- Posterior
cruciate ligament (PCL)
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FIGURE 2.5 T2-weighted sagittal image through


FIGURE 2.3 Proton density-weighted sagittal the knee at the level of the intercondylar fossa.
image through the knee at the level of the lateral A- Patella, B- Femur, C- ACL, D- Tibia,
tibia/lateral femoral condyle. A- Lateral femoral E- Quadriceps tendon
condyle, B-Anterior horn of lateral meniscus,
C- posterior horn of lateral meniscus, D- Fibula, Pathology
E- Lateral portion of tibial plateau
The most common traumatic injuries seen in the knee
are tears of the menisci, tears of the anterior cruciate liga-
ment (ACL), chondral injuries, tears of the medial collat-
eral ligament (MCL), and transient patellar dislocations.
Degenerative changes in the knee unrelated to trauma
are also very common and include articular cartilage loss
(chondromalacia), meniscal degeneration, and patellar
cartilage degeneration as well as bony changes related to
asymmetric weight bearing and repetitive motion injury.
Another frequently seen injury, particularly in athletes,
is stress fracture. This can often involve the tibial plateau,
but frequently extends distally along the metaphysis. In
this setting, a complete evaluation for a stress fracture
should include interrogation of the entire portion of the
tibia if there is marrow edema extending beyond the field
of view of the knee examination.
Bakers cysts are another phenomenon seen on an MRI
examination of the knee. These cystic structures com-
monly result from abnormally enlarged bursa between
the medial head of the gastrocnemius muscle and semi-
membranosus tendons. On occasion, Bakers cysts can
rupture, causing the synovial fluid contained within to
be released into the area surrounding the muscles. This
can be quite painful because the fluid dissects along the
FIGURE 2.4 T1-weighted coronal image through intermuscular spaces and gives a MR appearance of high
the knee at the level of the tibial spines. A- Femur, T2 signal intensity surrounding the muscles and ten-
B- Tibial spine, C- Tibia dons in the area of the ruptured cyst. Abnormal accu-
mulations of fluid in various compartments of the knee
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are frequently seen with traumatic injury to ligaments FOV 160 mm


such as the ACL, PCL, and MCL as well as tears of the Matrix 288 F x 192 P (512 interpolated)
menisci or ruptures of the patellar ligament and quadri-
ceps tendon. These fluid collections are generally indica- Phase axis R-L
tions of the injuries that produced them. Spatial presaturation slabs superior and inferior
A wide variety of less common pathologies are also to slice volume
seen on an MR knee examination, including bony
lesions such as benign and malignant neoplasms, osteo- This series allows for a sensitive evaluation of
necrosis, bone cysts, bony changes resulting from reflex the patellar articular cartilage and retinacular
structures and gives a secondary view of the
sympathetic dystrophy (RSD) and processes involving ACL and menisci; the series also allows for
the soft tissues such as rhabdomyosarcoma, tenosyno- evaluation of structures in the popliteal fossa.
vitis, and a rare disorder called pigmented villonodular
synovitis. Metabolic processes can also be visualized on * PD-weighted (TE: 26 ms) FSE
MRI, including yellow-red marrow reconversion, osteo- Sagittal plane
penia, and osteoporosis. In addition, aneurysms of the
popliteal artery can be well visualized with MRI. Coverage from MCL medially through FCL
laterally (inclusive)
Common Mechanisms of Injury
Angulation is perpendicular to the plane inter-
Most traumatic injuries of the knee are related to secting the posterior margins of the femoral
atypical motion (twisting, lateral flexion, or extension) condyles
or exceeding the normal range of motion (hyperexten- 3.0-mm with 1.0-mm gap
sion). These injuries are very common in sports such as
basketball, football, soccer, and tennis and often result FOV 160 mm
in cartilaginous and ligamentous injury. Impact inju-
Matrix 320-384 F x 192-224 P (512 interpolated)
ries such as those sustained from a fall or an automobile
accident, frequently result in fractures of the patella or Phase axis S-I
tibial plateau. However, these two injury types are not
mutually exclusive. With certain specific injuries such as 100% phase oversampling
ACL tears, there are often associated bony injuries in the Spatial presaturation slabs superior and inferior
form of contusions directly related to the mechanics of to slice volume
the motion that occurs as the ligament is torn. This can
present a classic appearance on MRI in the form of a This series allows for a comprehensive evalu-
ation of the patellar ligament and quadriceps
concomitant meniscal injury and bone bruise. tendon, ACL and PCL, and also the menisci.
Technique
* T2-weighted (TE: 115-120 ms) FSE
Our protocol for knee MRI consists of a localizer and Sagittal plane
five sequences. Care is taken when positioning the patient
to ensure that the area of the menisci is centered to the Coverage from MCL medially through FCL
center of the coil. We use a transmit-receive surface coil laterally (inclusive)
for imaging the knee. Matched to PD sagittal
* Localizer-Three Plane Angulation is perpendicular to the plane intersecting
Gradient echo: Scan time < 60 sec the posterior margins of the femoral condyles

5-7 slices per plane 3.0-mm with 1.0-mm gap

8.0-mm thickness with 2.0-mm gap FOV 160 mm

FOV 260 mm Matrix 320 F x 192 P (512 interpolated)

Matrix 256 F x 128 P Phase axis S-I

* PD-weighted (TE: 36 ms) FSE with spectral fat 100% phase oversampling
suppression Spatial presaturation slabs superior and inferior
Axial plane to slice volume
Coverage from above patella through superior This series allows for evaluation of the joint
tibial tuberosity capsule and comparison of fluid and tissue
intensities based on T2 values.
4.0-mm thickness with 0.4- to 1.0-mm gap
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* T2-weighted (TE: 70-80 ms) FSE with spectral fat tional motion of the humerus is a result of the complex
suppression interaction of four muscles-the supraspinatus, infraspi-
Coronal plane natus, subscapularis and teres minor-that together form
Coverage from popliteal artery posteriorly the tendons of the rotator cuff. Other muscles that par-
through patella anteriorly ticipate in movement of the shoulder include the deltoid
group, pectoralis major, latissimus dorsi, biceps brachii,
Angulation is parallel to the plane intersecting triceps brachii, teres major, and coracobrachialis.
the posterior margins of the femoral condyles
4.0-mm thickness with 1.0-mm gap Bony Structures
The bones of the shoulder girdle are the scapula,
FOV 160 mm humerus, and clavicle. The primary mobile articula-
Matrix 320 F x 192 P (512 interpolated) tion is at the glenoid fossa involving the scapula and the
humeral head.
Phase axis R-L
Spatial presaturation slabs superior and inferior
to slice volume
We use this series to evaluate the bony struc-
tures for contusion and also to visualize the
femoral and tibial articular cartilage and eval-
uate for subchondral injury. It also provides
another second look at the ACL and menisci.
* T1-weighted SE (TE: 17 ms) high resolution
Coronal plane
Coverage from popliteal artery posteriorly
through patella anteriorly
Angulation is parallel to a line intersecting pos-
terior margins of femoral condyles
4.0-mm thickness with 1.0-mm gap FIGURE 3.1 Proton density-weighted fat-sup-
FOV 160 mm pressed axial image through the shoulder at the level
of the mid-glenoid. A- Humeral head, B- Glenoid
Matrix 448 F x 224 P (512 interpolated) process of the scapula, C- Posterior glenoid labrum,
Phase axis R-L D- Anterior glenoid labrum
This series gives us a good means of evaluating
the menisci, bony structures, articular surfaces,
MCL, and FCL.
The Shoulder

The shoulder is a complex joint in that it is the sole


attachment of the upper extremity to the torso. The artic-
ulation between the humeral head and the glenoid pro-
cess of the scapula is the joint responsible for abduction,
adduction, and rotation of the upper extremity. The acro-
mial extremity of the clavicle articulates with the acro-
mion process of the scapula to form a fibrous joint known
as the acromioclavicular (AC) joint.
Soft Tissues, Muscles, and Cartilage
The cartilaginous, ligamentous, and myotendinous
structures of the shoulder interact in a complex manner to FIGURE 3.2 T1- weighted oblique coronal image
allow for the range and variety of movements possible at through the shoulder past the level of the mid-
the shoulder. The glenohumeral joint itself is a ball-and- glenoid. A- Humeral head, B- Glenoid process of the
socket joint. The rim of the glenoid fossa is lined with a scapula, C- Superior glenoid labrum, D- Inferior
cartilaginous lip known as the glenoid labrum. The rota- glenoid labrum
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athy of the rotator cuff tendons are often the result of


impingement (rubbing or squeezing of the tendon(s)
against or between adjacent bony structures) and are
oftenbut not alwaysaccompanied by inf lamma-
tion of bursae (bursitis). Fractures of the glenoid and
humeral head are also seen, and the frequency increases
with the degree of trauma. In elderly and osteoporotic
patients, humeral head fractures are often seen and can
be severe enough to require prosthetic replacement.
Separation of the fibrous joint between the distal clav-
icle and scapular acromion are also frequently seen as
a result of trauma.
Non-traumatic abnormalities include osteonecrosis,
neoplastic lesions (either primary or metastatic) and
marrow reconversion.
Common Mechanisms of Injury
The most common shoulder injuries are a result of
FIGURE 3.3 T2-weighted fat-suppressed oblique either a chronic, repetitive nature (impingement) or an
sagittal image through the shoulder at the level of acute, traumatic nature (instability and dislocation or frac-
the mid humerus. A- Humeral head, B- Rotator cuff ture). These injuries are very frequently seen in athletes
tendons, C- Biceps tendon participating in sports that require significant shoulder
use, such as baseball, tennis, football, swimming, weight
Pathology lifting, rowing, and track and field events (e.g., shot put,
javelin throw).
Due to the range and complexity of motion in the Technique
shoulder and the stresses it is subjected to, traumatic
injuries to both the bony and soft tissue structures of Our approach to shoulder imaging is comprehensive
this area are common. The glenoid labrum is a fre- while only requiring four sequences as routine. We use
quent site of injury due to the inherent instability of a four-channel unilateral phased array coil centered over
the articulation between the humeral head and the rel- the affected shoulder. The patient is ideally positioned
atively shallow glenoid fossa. Dislocations commonly with the arm next to the body (adducted) and in as much
result. Cartilaginous tears occur in many classic pat- external rotation as the patient will tolerate.
terns. SLAP lesions (superior labrum anterior to poste-
rior), which occur at the insertion of the biceps tendon * Localizer-Three Plane
into the labrum, and Bankart lesions, which occur at Gradient echo: Scan time < 60 sec
the attachment of the inferior glenohumeral ligament 5-7 slices per plane
to the labrum anteroinferiorly, are among the more
common. Included in the category of Bankart lesions 8.0-mm thickness with 2.0-mm gap
are Perthes lesions and ALPSA (anterior labroligamen-
tous periosteal sleeve avulsions). FOV 260 mm
Another type of injury involving the articular sur- Matrix 256 F x 128 P
face of the glenoid labral cartilage rather than the rim
is a GLAD lesion (glenohumeral articular disruption). * PD-weighted (TE: 36 ms) FSE with spectral fat
Labral and articular surface tears are very common suppression
sequelae of shoulder dislocations. Additionally, dis- Axial plane
locationseither acute and isolated, or chroniccan
result in indentations or grooves in the articular surface Coverage from AC joint superiorly to 10 mm
below inferior margin of glenoid labrum
of the humeral head. Specifically in the case of anterior
dislocations, these lesions are termed Hill-Sachs lesions 4.0-mm thickness with 1.0-mm gap
or deformities. Tears of the rotator cuff tendons are
also among the more common injuries seen, partic- FOV 160 mm
ularly among athletes. Rotator cuff tears can involve Matrix 256 F x 256 P (512 interpolated)
any single tendon of the cuff or a combination of the
four tendons; these tears can be partial or complete 100% phase oversampling
and often involve the inferior surface of the tendons Phase axis A-P
(as in partial undersurface tears). Tears and tendinop-
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This series provides us with good visualization of 3.5- to 4.0-mm thickness with 1.0-mm gap
the anterior and posterior labrum, as well as the
muscles of the shoulder and the humeral head FOV 140-160 mm
* T1-weighted (TE: 11-20 ms) SE or FSE Matrix 320 F x 192 P (512 interpolated)
Oblique coronal plane 100% phase oversampling
Coverage 10 mm posterior-lateral to humeral Phase axis A-P
head through 10 mm anteromedial to humeral
head This series provides exceptional cross-sectional
evaluation of the rotator cuff tendons, the biceps
Angulation parallel to plane of supraspinatus tendon, the subacromial subdeltoid bursa, and
tendon the superior surface of the humeral head.
3.0- to 3.5-mm thickness with 0.5- to 1.0-mm * Fast STIR (FSE-IR) (TE: 45-55 ms) optional
gap
Used as a substitute for T2 with spectral Fat Sat
FOV 140-160 mm if off-isocenter fat suppression is unreliable
Matrix 448 F x 224 P (512 interpolated) Oblique coronal or oblique sagittal plane
100% phase oversampling TI is field strength-dependent: 130 ms at 1.5 T,
110 ms at 1.0 T, 90 ms at 0.7 T
Phase axis A-P
Other parameters identical to T2 fat suppressed
This series provides excellent visualization of series
the superior and inferior glenoid labrum and
articular cartilage of both the glenoid fossa and If the supraspinatus tendon is not well visualized on the
humeral head. initial localizer, an additional axial localizer is performed
* T2-weighted (TE: 70-80 ms) FSE with spectral fat using either a gradient echo sequence or a PD-weighted
suppression FSE sequence. Either of these scans is less than 90 sec-
onds in duration. For the specific evaluation of labral inju-
Oblique coronal plane
ries, we often perform MR arthrography. In that setting,
Coverage 10 mm posterior-lateral to humeral we acquire two planes of T1-weighted FSE with spectral
head through 10 mm anteromedial to humeral Fat Sat (oblique coronal and oblique sagittal), axial T1-
head weighted FSE without Fat Sat, and an oblique coronal
Angulation parallel to plane of supraspinatus T2-weighted series with spectral Fat Sat. These scans are
tendon all performed with the arm in adduction and external
rotation. To facilitate evaluation of the inferior glenohu-
3.0- to 3.5-mm thickness with 0.5- to 1.0-mm meral ligament, we reposition the patient with the arm
gap in abduction and external rotation (ABER) and (after a
FOV 140-160 mm localizer) acquire oblique sagittal spectral fat-suppressed
T1-weighted FSE scans. The slices are planned off of
Matrix 320 F x 192 P (512 interpolated) a coronal slice through the mid-glenohumeral articula-
100% phase oversampling tion and are aligned with the long axis of the humeral
metaphysis. Due to the position of the patients arm for
Phase axis A-P this scan, it is often not possible to use the array coil. In
this case, we use either a linear flex coil or a 5-inch cir-
This series provides excellent visualization of
the rotator cuff tendons and is sensitive to acute cular surface coil.
bony changes resulting from trauma, as well as
providing visualization of the superior and infe- The Elbow
rior glenoid labrum.
The elbow is a combination hinge and condyloid joint.
* T2-weighted (TE: 70-80 ms) FSE with spectral fat
suppression The motion of the elbow includes supination and prona-
tion (of the forearm) as well as flexion and extension of
Oblique sagittal plane the elbow joint. The flexion-extension is a result of the
Coverage from neck of glenoid posteromedially ulnohumeral articulation (hinge) and the supination-pro-
into deltoid muscle anterolaterally nation is a result of the radiohumeral articulation (con-
dyloid). As with the knee, hyperextension injuries are
Angulation perpendicular to plane of supraspi- not uncommon, but because the elbow is not a weight-
natus tendon
bearing joint, twist injuries are less common.
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Soft Tissue, Muscles, and Cartilage


Muscles involved with elbow movement include the
biceps brachii, triceps brachii, brachialis, brachioradi-
alis, anconeus, pronator teres, and supinator muscles.
Articular cartilage lines the articulating surfaces of the
radial head, ulnar olecranon and trochlea, and capitellum
of the humerus. The radial collateral and ulnar collateral
ligaments provide stability to the lateral and medial sides
of the joint, respectively.
Bony Structures
The bones that form the elbow joint are the distal
humerus and the proximal radius and ulna. The olec-
ranon process of the ulna articulates with the trochlear
portion of the humerus medially. The radial head articu-
lates with the capitellar portion of the humerus laterally.
Additionally, the radial head and the radial notch of the
ulna articulate during supination and pronation motion
of the forearm.
Pathology
The most common traumatic injuries of the elbow are
ruptures of the biceps tendon, tears of the ulnar collateral
ligament, and fractures of the radial head and humeral FIGURE 4.2 T1-weighted coronal image through
epicondyles. Overuse or repetitive use injuries, such as the elbow at the level of the humeral epicondyles.
tennis elbow and extensor tendinopathy are common. A- Lateral humeral epicondyle, B- Olecranon Fossa,
Flexor tendinopathy is often seen in unskilled golfers C- Medial humeral epicondyle, D- Ulnohumeral
due to the motion associated with forceful swinging of articulation at trochlea of humerus
the golf club and hitting the ground, resulting in sudden
deceleration. Also, masses in the cubital tunnel can cause
compression of the ulnar nerve that result in pain and
paresthesias distally.

FIGURE 4.3 T2-weighted sagittal image


FIGURE 4.1 Proton density-weighted axial scan through the elbow at the level of the capitellum.
through the elbow at the level of the humeral epicon- A- Capitellum of humerus, B- Radial head,
dyles. A- Olecranon fossa, B-Coronoid fossa, C- Radial tuberosity
C- Medial humeral epicondyle, D- Lateral humeral
epicondyle, E- Triceps tendon
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Common Mechanisms of Injury Coverage from 15-20 mm proximal to humeral


The most common mechanisms of injury to the elbow epicondyles to 15 mm distal to radial tuberosity
are hyperextension injuries, repetitive motion injuries, 4.0-mm thickness with 1.0-mm gap
rapid deceleration injuries, resistance- related injuries,
and so-called valgus stress injuries. Hyperextension FOV 140 mm
injuries most frequently result in biceps tendon tears but Matrix 288 F x 192 P (512 interpolated)
can also be associated with fractures of the olecranon
and radial head, depending on the degree of hyper- Spatial presaturation slabs superior and inferior
extension. Repetitive motion injuries are common in to slice volume
sports where specific motions under force are repeated. Phase axis A-P
Classic examples of this are racquet sports, golf, and
baseball; in the specific case of baseball pitchers, over- * T2-weighted (TE: 117 ms) FSE
hand pitching commonly results in the aforemen- Axial plane
tioned valgus stress injury. Resistance- related injuries
are frequent with weightlifting and often manifest in Coverage from 15-20 mm proximal to humeral
the form of tendon ruptures and tears due to the con- epicondyles to 15 mm distal to radial tuberosity
traction of the muscle under resistance. Injuries to 4.0-mm thickness with 1.0-mm gap
tendons are also associated with courses of systemic
antibiotic therapy, particularly with f luoroquinolone FOV 140 mm
antibiotics such as ciprof loxacin, which can cause tran- Matrix 288 F x 192 P (512 interpolated)
sient changes in the tendons that result in structural
weakening. Although f luoroquinolone-related tendi- Spatial presaturation slabs superior and inferior
nous injuries most frequently occur with the Achilles to slice volume
tendon, they are possible anywhere in the body, espe- Phase axis A-P
cially with muscles under resistance.
Technique * T1-weighted (TE: 13-20 ms) FSE
Oblique coronal plane
Our preference is to use a transmit-receive surface
coil or multichannel surface array such as a knee/ Coverage from posterior to triceps tendon inser-
extremity coil for elbow imaging. This assumes that the tion to 15 to 20 mm anterior to radial tuberosity
patient can extend his or her arm above the head from Angulation parallel to plane intersecting medial
the shoulder and maintain that position for roughly and lateral humeral epicondyles
the 15 minutes required for imaging. Patients unable
to assume and maintain this position are imaged on 3.0-mm thickness with 1.0-mm gap
our open MRI. We have found that far off-isocenter FOV 140 mm
imaging of the elbow on our high-f ield cylindrical
magnets does not provide satisfactory results. For this Matrix 320 F x 224 P (512 interpolated)
reason, imaging the elbow with the patients arm by Phase axis R-L
the side is only used as a last resort. Ideally, we try to
have the patient positioned with the hand supinated * T2-weighted (TE: 70-80 ms) FSE with spectral fat
relative to the antecubitus. Care is taken to assure that suppression
we have localizers that allow us to align our sagittal Oblique coronal plane
and coronal series along the long axes of the humerus
and radius/ulna. Coverage from posterior to triceps tendon
insertion to 15 to 20 mm anterior to radial
* Localizer-Three Plane tuberosity
Gradient echo: Scan time < 60 sec Angulation parallel to plane intersecting medial
and lateral humeral epicondyles
5-7 slices per plane
3.0-mm thickness with 1.0-mm gap
8.0-mm thickness with 2.0-mm gap
FOV 140 mm
FOV 260 mm
Matrix 256 F x 192 P (512 interpolated)
Matrix 256 F x 128 P
Phase axis R-L
* PD-weighted (TE: 30 ms) FSE
Axial plane Spatial presaturation slabs superior and inferior
to slice volume
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* T2-weighted (TE: 117 ms) FSE Musculoskeletal MRI Part II:


Oblique sagittal plane
Bony Pelvis, Knee, Shoulder &
Coverage from 12 mm medial to medial
humeral epicondyle to 12 mm lateral to lateral
Elbow Post Test
humeral epicondyle Expires August 15, 2013 Approved for 1.5 ARRT Category A Credits.
Angulation perpendicular to plane intersecting 1. Imaging of the bones, joints, muscles, and ______
medial and lateral humeral epicondyles represents the radiologic subspecialty of musculo-
4.0-mm thickness with 1.0-mm gap skeletal imaging.
a. epidermis
FOV 140 mm b. nerves
Matrix 320 F x 192 P (512 interpolated) c. cartilage
d. blood vessels
Spatial presaturation slabs superior and inferior 2. In which situations has sonography been shown to
to slice volume be useful?
Phase axis A-P a. Torn cartilage, muscle injury
b. Congenital hip dislocations in infants, ganglion
* T2*-weighted gradient echo (TE: 20 ms/Flip angle cysts
15 degrees) optional c. Bone bruise or contusion
Used for visualization of articular cartilage d. Fractures, arthritic changes
3. Which of the following are advantages in using
Oblique coronal plane MRI in musculoskeletal imaging?
Coverage from triceps tendon insertion to radial 1. Ability to produce high-detail imaging
tuberosity 2. Multiplanar imaging capacity
3. Lack of ionizing radiation
Angulation parallel to plane intersecting medial 4. Sensitivity to physiologic changes
and lateral humeral epicondyles
a. 1 and 2
3.0-mm thickness contiguous b. 1 and 3
c. 2 and 3
FOV 140 mm d. 1, 2, 3, and 4
Matrix 288 F x 192 P 4. The primary objects of musculoskeletal MRI are
imaging of
Phase axis R-L a. joints and extremities.
b. fractures and congenital bone deformities.
SUMMARY c. the hip and ankle.
d. bone and cartilage.
Musculoskeletal imaging can be accomplished with a 5. When performing joint MRI, it is important to
number of different modalities, including radiography, include
fluoroscopic arthrography, sonography, nuclear medicine a. the extremity distal to the joint.
scinitigraphy, CT, and MRI. Musculoskeletal imaging is b. the extremity proximal to the joint.
unequivocally one of the core competencies of MRI due c. all structures of the articulations.
to the f lexibility of imaging planes and sequences and d. only one imaging plane.
the high spatial detail possible. Musculoskeletal MRI is 6. For evaluation of a joint, the patients clinical
not limited solely to the imaging of sports-related inju- history
ries. MRI excels at depicting any processeswhether a. is seldom helpful.
traumatic, neoplastic, or metabolicthat affect the b. will aid both the radiologist and the
bones or soft tissues of the body. MRI is also not lim- technologist.
ited to imaging only the joints. MRI is highly sensitive c. is only necessary in the case of a recent injury.
to injuries and processes involving the bones and mus- d. will not affect the imaging protocol.
cles of the extremities themselves and can be made even 7. In MRI imaging, a much wider variety of injuries
more sensitive and specific with respect to inf lamma- or disease processes are seen in
tory and neoplastic processes through the use of gado- a. pediatric studies compared to adult studies.
linium contrast agents. b. extremities compared to joints.
c. joints compared to the extremities.
d. ultrasonography of the joints compared to MRI
studies of the joints.
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8. When performing extremity MRI to evaluate a 16. What joint is responsible for abduction, adduc-
tumor, it may be necessary to tion, and rotation of the upper extremity?
a. include the joint closest to the area of the a. The articulation between the humeral head and
abnormality in at least one imaging plane. the glenoid process
b. never use intravenous contrast, because this will b. The articulation between the acromion process
mask abnormalities. of the scapula and the clavicle
c. image the entirety of the extremity to assure c. The sternoclavicular joint
that possible skip lesions are seen. d. The articulation between the olecranon process
d. have the patients bone scan from the nuclear and the trochlear portion of the humerus
medicine department available. 17. Which of the following is not part of the rotator
9. Imaging the joint closest to the area of cuff?
abnormality a. Infraspinatus
a. provides no additional information and is there- b. Subscapularis
fore unnecessary. c. Popliteus
b. will ensure that a skip lesion is found. d. Teres minor
c. can provide information for the surgeon, if sur- 18. Common shoulder injuries include
gical intervention is required. a. traumatic injury to ACL, PCL and MCL.
d. is only necessary if the patient has a history of b. SLAP lesions, Bankart lesions and GLAD
cancer. lesions.
10. Which of the following is NOT part of the bony c. stress fractures.
pelvis? d. all of the above.
a. Distal femur 19. The elbow is a combination _____ and _____
b. Iliac bones joint.
c. Sacrum and coccyx a. ball, socket
d. Pubis and ischia b. gliding, saddle
11. What joint is affected by many types of injuries or c. hinge, condyloid
degenerative processes, due to its weight-bearing d. synarthrodial, pivot
mechanics and range of motion? 20. Flexor tendinopathy of the elbow is often seen in
a. Sacroiliac a. basketball players.
b. Hip b. unskilled golfers.
c. Sternoclavicular c. tennis players.
d. Shoulder d. volleyball players.
12. It is not uncommon for patients undergoing ste- 21. Hyperextension injuries of the elbow most fre-
roid therapy to have scans of the hip to rule out quently result in
a. osteoarthritis. a. flexor tendinopathy.
b. degenerative processes. b. osteoarthritis.
c. osteonecrosis. c. osteonecrosis.
d. metastatic disease. d. biceps tendon tears.
13. What type of joint is the knee? 22. Resistance-related injuries of the elbow occur
a. Hinge frequently with
b. Ball and socket a. weight lifting.
c. Synarthrodial b. baseball pitchers.
d. Condyloid, pivot c. racquet sports.
14. Which of the following is NOT a common trau- d. golf.
matic injury of the knee? 23. The preferred method of imaging the elbow is
a. Menisci tear with a trasnmit-receive surface coil or multi-
b. Medial collateral ligament tear channel surface array. The patient must
c. Synovial sarcoma a. hold their arm by their side.
d. Transient patellar dislocation b. hold their arm extended out from the shoulder.
15. Stress fractures are most common in c. extend their arm above their head.
a. children. d. place their arm across their abdomen.
b. athletes.
c. African-Americans.
d. diabetics.
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24. Musculoskeletal MRI is ideally used for


a. imaging sports-related injuries.
b. imaging processes that affect the bones or soft
tissues.
c. imaging joints and extremities.
d. all of the above.
25. Which is statement is TRUE concerning the use
of gadolinium contrast agents in musculoskel-
etal MRI?
a. Gadolinium contrast agents can improve the
sensitivity of musculoskeletal MRI with respect
to inflammatory and neoplastic processes.
b. Gadolinium contrast agents are never used in
musculoskeletal MRI because they may disguise
many disease processes.
c. The use of gadolinium contrast agents in mus-
culoskeletal MRI is limited to investigations of
malignant bone tumors.
d. Gadolinium is contraindicated in patients with
allergies to seafood or iodine.
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Article Title: Musculoskeletal MRI II: Bony Pelvis, Knee, Shoulder & Elbow Office Use: MR68/1.5

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