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Musculoskeletal MRI Part II: Bony Pelvis, Knee, Shoulder & Elbow
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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-
Musculoskeletal MRI Part II: Bony Pelvis, Knee, Shoulder & Elbow
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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
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
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
Musculoskeletal MRI Part II: Bony Pelvis, Knee, Shoulder & Elbow
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The Knee
* 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
Musculoskeletal MRI Part II: Bony Pelvis, Knee, Shoulder & Elbow
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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
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.
Musculoskeletal MRI Part II: Bony Pelvis, Knee, Shoulder & Elbow
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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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Article Title: Musculoskeletal MRI II: Bony Pelvis, Knee, Shoulder & Elbow Office Use: MR68/1.5
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