Chapter 11
Musculoskeletal Imaging
John A. Carrino, MD, MPH
William B. Morrison, MD
Available Imaging Modalities
All medical imaging modalities that are available clini-
cally have musculoskeletal applications. There have
been significant technologic advancements in the areas
of radiography, CT, ultrasound, nuclear medicine, and
MRI.
Radiography
Digital radiography exists in the form of computed radi-
ography or direct radiography. Image processing and dis-
tribution is achieved through a picture archiving and com-
munication system. The images can be placed on a
compact disk with an imbedded viewer. The widespread
availability of computers with compact disk readers allows
this method of image processing to be a more portable
mechanism of transporting and managing images. View-
ing the images in the soft copy environment allows for
panning, zooming, windowing, and leveling so that the
viewing experience and diagnostic yield are optimal.
There are certain tradeoffs; the spatial resolution of dig-
ital radiography systems is not as great as that with film
screen radiography. However, as additional experience
and data are accumulated, it has been found that the im-
proved contrast resolution is more important than spatial
resolution for diagnostic efficacy, making less defined spa-
tial resolution a reasonable trade-off (Figure 1).
Computed Tomography
The latest generation of CT scanners uses multiple de-
tector row arrays. Multislice CT represents a major im-
provement in helical CT technology, wherein simulta-
neous activation of multiple detector rows positioned
along the longitudinal or z-axis (direction of table or
gantry) allows acquisition of interweaving helical sec-
tions. The principal difference between multislice CT
and predecessor generations of CT is the improved res-
olution in the z-axis. More of the photons generated by
the x-ray tube are ultimately used to produce imaging
data. With this design, section thickness is determined
by detector size and not by the collimator itself. Rapid
data acquisition times are possible because of short gan-
American Academy of Orthopaedic Surgeons
try rotation intervals combined with multiple detectors
providing increased coverage along the z-axis. Currently
there are configurations with up to 64 channel detectors
available. The data from a multislice CT scanner can be
used to generate images of different thickness from the
same acquisition. The minimum section thickness is re-
duced to approximately 0.5 mm and images can be re-
constructed at this 0.5-mm interval. Isotropic (equal di-
mension) voxels measuring 0.5 mm in x, y, and z
directions greatly improve the spatial resolution and the
quality of reconstructing algorithms, allowing generation
of exquisite multiplanar reformats (Figure 1) and three-
dimensional images. These three-dimensional image
processing and display techniques are particularly useful
for regions of complex anatomy such as the pelvis, or
for bones for which it is difficult to obtain isolated pro-
jections without overlap, such as the scapula or the cer-
vical spine (Figure 2). Multiplanar reformats can be cre-
ated in any plane or using a curved surface to reduce
distortion. Other advantages include increased speed
and increased total volume coverage. Therefore, a single
pass whole body protocol may be feasible, particularly
with 16-detector scanners that can image from the head
vertex to below the hips in less than 1 minute. The abil-
ity to acquire high-quality images in the presence of
hardware/joint implants has improved using multislice
CT. Metal artifacts are caused by photopenic defects in
the back projection and are displayed on CT images as
streak artifact. With multislice CT, the holes in the fil-
tered back projection are not as pronounced, resulting
in a less severe streak artifact. This improvement is at
the expense of excess tissue radiation along the penum-
bra of the beam, which is then picked up by adjacent
detector channels filling in these photopenic defects in
the projection. This technology has forced radiologists
into redefining the image viewing process to a volumet-
ric paradigm rather than a simple tile mode or section-
by-section viewing. In addition, CT protocols have to be
reformulated. There is also an expanded range of CT
applications and indications. The challenges associated
with multislice CT include selection of optimal imaging
sequences, controlling radiation exposure to the patient,
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Musculoskeletal Imaging Orthopaedic Knowledge Update 8

Figure 1 Digital radiography and multi-

slice CT multiplanar reformat image qual-
ity. A, Anteroposterior projection of the
knee performed with a direct radiography
unit shows high-quality contrast. B, Mul-
tidetector CT coronal multiplanar reformat
image shows exquisite trabecular detail
similar to conventional radiography.
Source images were acquired using isotro-
pic 0.75-mm voxels.

Figure 2 Position compensated multiplanar reformat.

Cervical spine multislice CT myelography in a patient
who underwent anterior cervical fusion: Sagittal and
coronal multiplanar reformat images are created from
an axial image (A) while adjusting the planes to cor-
rect for any rotation (double oblique prescriptions).
Similar maneuvers are done for the sagittal (B) and
coronal (C) planes to generate more useful sections
based on true anatomic landmarks. Oblique axial im-
ages (D) are also used to generate sagittal oblique im-
ages (E) through the neural foramen at each level on
each side to compensate for changes in orientation of
the neural canal. Coronal and sagittal oblique multi-
planar reformat images show an osseous ridge com-
pressing the nerve roots (arrow in C and E).

and efficiently managing the large amount of data gen- tons per voxels; because smaller voxels tend to have
erated. Some disadvantages of multislice CT are high fewer photons, increased image noise is the result. To
radiation dose to the tissue and potentially noisy im- keep the noise level reasonable, the exposure (and thus
ages. Noise is inversely related to the number of pho- radiation dose) must be increased.

120 American Academy of Orthopaedic Surgeons

 Orthopaedic Knowledge Update 8
Ultrasound
Ultrasound is the medical imaging modality used to ac-
quire and display the acoustic properties of tissues. A
transducer array (transmitter and receiver of ultrasound
pulses) sends sound waves into the patient and receives
returning echoes that are converted into an image. Sound
is mechanical energy that propagates through continuous,
elastic medium by the compression and rarefaction of the
particles that compose it (such as air). The resolution of
the ultrasound image and attenuation of the ultrasound
beam depend on the wavelength and frequency.A low fre-
quency ultrasound beam has a longer wavelength and less
resolution but greater depth of penetration. For muscu-
loskeletal imaging of more superficial structures such as
tendons and ligaments, a high frequency beam having a
smaller wavelength provides superior spatial resolution
and image detail. Thus, the creation of appropriate trans-
ducers is of critical importance in performing musculo-
skeletal imaging. Higher frequency transducers ranging
from 7.5 MHz up to even 15 MHz are now available. Mod-
ern ultrasound scanners use phased array transducers with
multiple piezoelectric elements to electronically sweep an
ultrasound beam across the volume of interest, thus being
able to create a three-dimensional image.
Applications of ultrasound include evaluation of ten-
don and muscle abnormalities such as rotator cuff tears.
In addition, ultrasound has also been applied to evaluate
the glenoid labrum and knee menisci. High-resolution ul-
trasound has the potential to be used for visualization of
articular cartilage. Synovial effusions and proliferation
can be evaluated using color Doppler imaging to deter-
mine the degree of hypertrophy and inflammation. Ultra-
sound has been used more often for diagnostic and ther-
apeutic procedures because of improved transducer
technology being better able to detect infrastructural de-
tail. In addition, ultrasound is a more economical modal-
ity for assessing a specific clinical concern. Ultrasound is
best used when the clinical question is specific and well
formulated; the condition is dichotomous (is there a full
thickness tear or not?); for characterizing a soft-tissue le-
sion (cystic or vascular); or for guiding particular interven-
tions. Performing percutaneous interventions with ultra-
sound ensures accurate needle tip placement and helps
direct the needle away from other regional soft-tissue
structures and neurovascular bundles.The visualization of
the needle tip in real time allows for reliable placement in
the tendon sheath, bursa, or joint of interest. Intratendi-
nous calcifications, the plantar fascia, and interdigital
(Mortons) neuromas can also be visualized and injected
directly under real-time guidance.
Nuclear Medicine and Positron Emission Tomography
The most significant recent advancement in nuclear
medicine is positron emission tomography (PET) and
the combination of PET CT scanners with important
American Academy of Orthopaedic Surgeons
Chapter 11 Musculoskeletal Imaging
implications for oncology, especially for soft-tissue neo-
plasms or postoperative cancer patients. PET has only
recently been widely used in clinical oncology. Short-
lived positron emitting radioisotopes annihilate to form
two photons with trajectories approximately 180 apart
at a particular energy level (511 kev). The coincidental
detection of these photons by a ring detector is recon-
structed via a filtered backprojection (similar to CT) to
form images of tracer distribution. [18F] 2-deoxy-2-
fluoro-D-glucose (FDG) is a metabolic tracer most
widely used in clinical PET oncology. FDG accumula-
tion reflects the rate of glucose utilization in a tissue be-
cause FDG is transported into a tissue by the same
mechanisms of glucose transport and trapped in a tissue
as FDG-6-phosphate, which is a poor substrate for the
further enzyme systems of glycolysis or glycogen stor-
age. The use of FDG in evaluation of the musculoskele-
tal system is based on increased glycolytic rate in patho-
logic tissues. Thus, PET has proved to be the gold
standard in metabolic imaging. FDG provides a means
of quantitating the glucose metabolism, with the amount
of tracer accumulation reflecting the glucose metabo-
lism. High-grade malignancies tend to have higher rates
of glycolysis than do low-grade malignancies and benign
lesions; therefore, high-grade malignancies have greater
uptake of FDG than that of low-grade or benign lesions.
PET, as a metabolic imaging technique, has advan-
tages over and complements structural imaging methods
and also shows differences from conventional nuclear
medicine. All of these factors have led to its growth in
clinical applications in recent years. PET applications
are evolving, but the technique has been approved for
the diagnosis, staging, and restaging of many common
malignancies and has shown efficacy for the detection of
osseous metastasis from several malignancies, including
lung and breast carcinomas and lymphoma. However,
the significance of FDG PET in the evaluation of pri-
mary bone tumors and tumor-like lesions has not been
extensively elucidated. Several investigators have re-
ported the usefulness of FDG-PET in oncologic applica-
tions for primary musculoskeletal tumors. Preliminary
reports suggest a good correlation between glucose con-
sumption measured by FDG PET and the aggressive-
ness of musculoskeletal tumors. However, a significant
overlap exists between benign and malignant groups;
therefore, PET is not a solo method for differential di-
agnosis of benign and malignant bone lesions. Both neo-
plastic and inflammatory processes can cause an in-
crease in FDG activity; therefore, tissue sampling should
be directed to the most metabolically active regions
identified by PET (Figure 3). Therefore, PET has a role
as a useful adjunct to anatomic imaging techniques be-
cause it can provide an in vivo method for quantifying
functional metabolism in normal and diseased tissues.
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Magnetic Resonance Imaging
Recent MRI technology developments include high
field strength clinical systems for the entire body (3.0
Tesla) and dedicated extremity scanners operating at 1.0
Tesla, with improved gradients and radiofrequency (RF)
coils. Parallel imaging and faster novel pulse sequences
are addressing the time factor involved in obtaining an
MRI scan. High spatial resolution imaging with im-
proved signal-to-noise ratio has generated a new area of
imaging known as magnetic resonance microscopy, used
for the smaller and more complex articulations such as
the hand, wrist, foot, ankle, and elbow. Expanding the
types of three-dimensional pulse sequences available us-
ing fast spin-echo techniques afford the opportunity for
isotropic voxel acquisition and better volumetric data
rendering. Examination time can be reduced by using a
single acquisition and reconstructing the plane of inter-
est (similar to multislice CT). Currently the most useful
sequences are two-dimensional. Because musculoskele-
tal imaging often relies on the depiction of particular
anatomy, several planes are acquired using the same
pulse sequence depending on the articulation, indica-
tion, and specific structure of interest.
Imaging of cartilage has been difficult; however,
some new advances in MRI techniques, such as the use
of biologically relevant elements such as hydrogen,
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Orthopaedic Knowledge Update 8
Figure 3 PET CT coregistration image fusion.
The imaging studies are from a patient who
was referred for evaluation for metastatic
bone disease. Composite image: Coronal and
sagittal maximum intensity projection FDG-PET
images (A and B) show an area with abnormal
FDG uptake in the pelvis that is not localized
with certainty. Coronal, sagittal, and transaxial
PET-CT fused images (C, D, and E) reveal a hy-
permetabolic focus corresponding to an os-
teolytic lesion, which was confirmed histo-
pathologically by percutaneous biopsy to be
adenocarcinoma.
oxygen-16, oxygen-17, fluorine-19, sodium-23, and
phosphorus-31, will help in providing and interpreting
these images. Most clinical MRI is hydrogen imaging;
more recently, sodium and phosphorus images have
been obtained in vivo. Sodium imaging can be used for
estimating the glycosaminoglycan content of articular
cartilage. Because of the low natural abundance of so-
dium in articular tissues, in vivo imaging is limited to
high-field magnets (3.0 Tesla or greater). There are sev-
eral pulse sequences that have been applied to cartilage
imaging. Gradient-recall echo imaging has been used
because of its three-dimensional capability and ability to
provide high-resolution images. Fat-suppressed tech-
niques are combined with gradient-recall echo imaging
to increase the dynamic range and improve the detec-
tion of signal abnormalities in cartilage. However, scan
acquisition time can be substantial (8 to 10 minutes),
thus making the image prone to motion artifact. Magne-
tization transfer contrast creates tissue contrast by the
exchange of magnetization between protons associated
with macromolecules and bulk water protons by means
of cross relaxation or chemical exchange. Magnetization
transfer contrast acts as an off-resonant saturation pulse
and may make cartilage lesions easier to see. Although
this type of contrast is usually used in conjunction with
the gradient echo techniques, some magnetization trans-
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Orthopaedic Knowledge Update 8
fer occurs inherently with fast spin-echo or turbo spin-
echo techniques. The driven equilibrium Fourier trans-
form contrast method is another promising approach for
imaging of cartilage disorders. This method produces
image contrast that is a function of proton density,
T1/T2 and echo time/repetition time (TE/TR). Many tis-
sues have competing T1 and T2 contrast, so the T1 to T2
ratio for driven equilibrium Fourier transform contrast
tends to be synergistic. Driven equilibrium Fourier
transform contrast is well suited to imaging articular
cartilage because synovial fluid is high and articular car-
tilage is intermediate in signal intensity; the osseous
structures are dark and lipids can be suppressed using
spectral fat saturation techniques. This creates an image
in which cartilage is easily distinguishable from all adja-
cent tissues based on signal intensity alone, aiding seg-
mentation and volume calculation.
Magnetic resonance arthrography has also been ap-
plied to the evaluation of cartilage and may be per-
formed directly (a dilute gadolinium-containing solution
is percutaneously placed into the joint via a needle) or
indirectly (intravenous gadolinium is administered and
allowed to diffuse into the joint). Gadolinium-enhanced
imaging has the potential to monitor glycosaminoglycan
(GAG) content within the cartilage. GAGs are funda-
mentally important for several reasons: they play a ma-
jor mechanical support role, they are lost early in the
course of cartilage degeneration, and may need to be re-
plenished during the course of any effective cartilage
treatment regimen. GAGs contribute strong negative
charge to the cartilage matrix and mobile ions will dis-
tribute to reflect local GAG concentration. When
GAGs are lost as part of the degenerative process, the
negative charge conferred to the cartilage also is lost.
Consequently, when a negatively charged contrast agent
is administered (either intravenously or intra-
articularly) it preferentially distributes into the de-
graded cartilage and the T1 effect of this contrast mate-
rial can be qualitatively visualized and quantitatively
measured. With direct magnetic resonance arthrography,
it takes 3 hours for the contrast to sufficiently diffuse
into the cartilage, whereas with indirect magnetic reso-
nance arthrography it only takes approximately 1.5
hours.
Clinical higher field MRI systems, typically 3.0 Tesla
(or 3T) are becoming widely available. The higher in-
trinsic signal-to-noise ratio of high-field strength MRI
can be used to improve imaging speed or resolution but
changes in relaxation time at 3T as well as increased ar-
tifacts must be considered. Nevertheless, 3T MRI offers
the opportunity to explore physiologic imaging of joints
as well as morphologic features. Tissues in a magnetic
field are categorized by two types of relaxation: T1
(spin-lattice relaxation time) and T2 (spin-spin relax-
ation time). Manipulation of imaging parameters of the
TE and the TR produce the various types of contrast
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Chapter 11 Musculoskeletal Imaging
seen in MRI. T2 is fairly constant at different field
strengths, but T1 increases with increasing field strength.
Fat suppression is improved at 3T because the peaks be-
tween water and fat are further separated (greater
chemical shift effect; the nature of the chemical shift
phenomenon is that protons associated with long chain
aliphatic fat molecules have precessional frequencies
slightly lower than protons associated with mobile water
molecules, which is field strength-dependent), providing
more robust spectral fat suppression. The US Food and
Drug Administration and manufacturers have mandated
the use of power monitoring systems for 3T because of
increased danger of RF burns. The more problematic se-
quences are fast spin-echo/turbo spin-echo (unless the
refocusing pulse is reduced to less than 180) and short
TR spin-echo sequences (T1-weighted). Motion artifacts
appear worse at 3T and may be because of the overall
higher signal to noise ratio. Susceptibility artifacts will
be increased, and postoperative imaging may be more
problematic at higher field strengths. Increasing the re-
ceiver bandwidth may also help alleviate these artifacts.
There are improvements in speed because the signal to
noise ratio is proportional to the square of the imaging
time, and therefore it is possible to go up to four times
faster at 3T than 1.5T while maintaining an equal signal
to noise ratio.
Another trend is the use of dedicated extremity
scanners that typically operate at low field to midfield
ranges. Low field open scanners or extremity scanners
have been available for several years. However, recently
a higher field extremity scanner at 1.0 T has become
available (Orthone, ONI, Inc, Wilmington, MA). This
unit can image the elbow, hand, wrist, knee, foot, and an-
kle but cannot acquire images of the shoulder, hip, or
spine. Therefore, it is not considered a stand-alone unit
but may be useful for a high volume site with a backlog
of musculoskeletal patients to supplement a whole body
unit. The site requirements are less than those for a con-
ventional high field strength system, making it a more
economical option. The image quality is much improved
over the typical low field open MRI or very low field
extremity scanners, and this type of device will likely
have a niche role providing high-quality clinical images
for the amenable body parts (Figure 4). It is also a use-
ful option for claustrophobic patients. There are Larger
and smaller diameter RF coils available. Both coils are
quadrature types of volume transmit-receive coils, which
contribute to the improved image quality. There are cer-
tain advantages when this method is compared with tra-
ditional high field closed MRI systems. The images are
of high quality despite the fact that the field strength is
lower. Loss of signal to noise ratio and artifacts from off
isocenter imaging are minimized. The majority of pulse
sequences are available, including spectral fat suppres-
sion.
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Musculoskeletal Imaging Orthopaedic Knowledge Update 8

Figure 4 High-field open dedicated extremity MRI system. Elbow common extensor tendinopathy and partial tear: axial T1-weighted image (A) shows intermediate signal at the
common extensor tendon ulnar attachment (arrowhead), coronal oblique T2-weighted image (B) with spectral fat suppression shows a small fluid gap (arrow) but not complete
discontinuity of the common extensor tendon ulnar attachment reflecting a partial tear. Achilles tendinopathy (insertional tendinitis): axial T1-weighted image (C) through distal
Achilles tendon (subjacent to marker) shows tendinosis manifested by enlargement (loss of the normal comma shape) and intermediate signal, sagittal T2-weighted image with
spectral fat suppression. (Images courtesy of Barbara N. Weissman, MD and Rosemary J. Klecker, MD, Harvard Medical School, Brigham and Womens Hospital.)

Parallel imaging is a relatively new class of tech-
niques capable of significantly increasing the speed of
MRI acquisitions. Although a variety of different tech-
niques have emerged, the common principle is to use
the spatial information inherent in the elements of an
RF coil array to allow a reduction in the number of
time-consuming phase-encode steps required during the
scan. Recent technical advances and increased availabil-
ity to imaging centers place parallel imaging on the
verge of widespread clinical use.
Imaging of Specific Orthopaedic Conditions
Spine
Disk Disease Nomenclature
Spine imaging can exquisitely provide information re-
garding pathoanatomy of degenerative disk disease but
does not define a specific painful clinical syndrome be-
cause of the nonspecific appearance of painful versus
painless degenerative conditions. However, abnormal
imaging findings of the lumbar disks may be degenera-
tive, adaptive, genetic, or a combination of environmen-
tal and determined factors. Many findings may simply
represent senescent changes that are the natural conse-
quences of stress applied during the course of a lifetime.
The imaging appearance of lumbar spine degenerative
disk disease has a similar incidence in symptomatic and
asymptomatic patients. Therefore, the appropriate use of
imaging modalities within a defined clinical context is
paramount. For some patients with complicated or re-
calcitrant symptoms, the most useful aspect for ad-
vanced imaging techniques may be in the exclusion of
more serious causes of axial low back pain such as infec-
tion, neoplasm, or fracture rather than the inclusion of
any specific degenerative findings.
In terms of improving communications between pro-
viders there is a multispecialty, multisociety-endorsed no-
menclature for the lumbar spine disk disease (some ad-
vocate that this system may be used for cervical and
thoracic spine descriptors also). It is important to recog-
nize that the definitions of diagnoses should not define or
imply external etiologic events such as trauma, should not
imply relationship to symptoms and do imply need for
specific treatment. Hence, the following are pathoana-
tomic descriptors that do not imply a specific pathoetiol-
ogy or syndrome. Osteoarthritis or osteoarthrosis is a pro-
cess of synovial joints. Therefore, in the spine it is
appropriately applied to the zygoapophyseal (Z-joint,
facet), atlantoaxial, costovertebral, and sacroiliac joints.
Degenerative disk disease is a term applied specifically to
intervertebral disk degeneration. The term spondylosis is
often used in general as synonymous with degeneration,
which would include both nucleus pulposus and anulus fi-
brosus processes, but such usage is confusing, so it is best
that degeneration be the general term and spondylosis
deformans a specifically defined subclassification of de-
generation characterized by marginal osteophytosis with-
out substantial disk height loss (reflecting predominantly
anulus fibrosis disease). Intervertebral osteochondrosis is
the term applied to the condition of mainly nucleus pul-
posus and the vertebral body end-plates disease including
annular fissuring (tearing).
Normally, the posterior disk margin tends to be con-
cave in the upper lumbosacral spine (Figure 5, A), and is
straight or slightly convex at L4-5 and L5-S1. The poste-
rior margin typically projects no more than 1 mm be-
yond the end plate. An annular bulge is described as a
generalized displacement (greater than 180) of disk
margin beyond the normal margin of the intervertebral

124 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 11 Musculoskeletal Imaging

Figure 5 Lumbar disk contour abnormalities; all are axial T2-weighted images at the level of the intervertebral
disk. A, Normal: the posterior disk margin (arrowhead) should have a slight concavity, with the exception of the
lumbosacral junction, which may have a slight convexity. B, Annular bulge: There is generalized displacement
(arrowheads) of greater than 180 of the disk margin beyond the normal margin of the intervertebral disk space
and is the result of disk degeneration with an intact anulus fibrosus. C, Disk protrusion: The base against the
parent disk margin is broader than any other diameter of the herniation. Extension of nucleus pulposus through a
partial defect in the anulus fibrosus is identified (arrow) but the herniated disk is contained by some intact
annular fibers. D, Disk extrusion: The base against the parent disk margin is narrower than any other diameter of
the herniation (arrowhead). There may be extension of the nucleus pulposus through a complete focal defect in
the anulus fibrosus. Substantial mass effect is present, causing moderate central canal and severe left lateral
recess stenosis.

disk (Figure 5, B). The normal margin is defined by the
vertebral body ring apophysis exclusive of osteophytes.
The annular bulge can be the result of disk degenera-
tion with a grossly intact anulus. Disk margins tend to
be smooth, symmetric, or eccentric and nonfocal, and
may have a level-specific appearance in the lumbar
spine. Disk herniation is a localized displacement (less
than 180 of the circumference) of disk material beyond
the normal margin of the intervertebral disk space (Fig-
ure 5, C). This material may consist of nucleus pulposus,
cartilage, fragmented apophyseal bone, or fragmented
annular tissue. It is often the result of disk degeneration
with some degree of focal annular disruption. The types
of disk herniation are designated as protrusion, extru-
sion, and free fragment (sequestration). Protrusion re-
fers to a herniated disk in which the greatest distance in
any plane between the edges of the disk material be-
yond the disk space is less than the distance between
the edges of the base in the same plane. It is character-
ized by the following: the base against the parent disk
margin is broader than any other diameter of the herni-
ation; extension of nucleus pulposus may occur through
a partial defect in the anulus fibrosus but is contained
by some intact outer annular fibers and the posterior
longitudinal ligament. The types of protrusions may be
broad based (90 to 180 circumference) or focal (less
than 90 circumference). Extrusion refers to a herniated
disk in which, in at least one plane, any one distance be-
tween the edges of the disk material beyond the disk
space is greater than the distance between the edges of
the base in the same plane (Figure 5, D), or when no
continuity exists between the disk material beyond the
disk space and that within the disk space. An extrusion
is characterized by the following: the base against the
parent disk margin tends to be narrower than any other
diameter of the herniation; extension of the nucleus pul-
posus through a complete focal defect in the anulus fi-
brosus. Extruded disks in which all continuity with the
disk of origin is lost may be further characterized as se-
questrated. Disk material displaced away from the site
of extrusion may be characterized as migrated; it may
stay subligamentous, contained by the posterior longitu-
dinal ligament or may migrate widely. Schmorls nodes
are intervertebral disk herniations (transosseous disk
extrusion). Herniation of the nucleus pulposus occurs
through the cartilaginous end plate into the vertebral
body. These herniations often have a characteristic
round or lobulated appearance. They may enhance after
contrast administration with ring-like enhancement be-
ing most common. They are often incidental and likely
to be developmental or posttraumatic rather than
purely degenerative or adaptive. There is now imaging

American Academy of Orthopaedic Surgeons 125

Musculoskeletal Imaging
evidence of a significant genetic association between the
COL9A3 tryptophan allele (Trp3 allele), Scheuermanns
disease, and intervertebral disk degeneration among
symptomatic patients.
There are no formal staging systems for lumbar degen-
erative disk disease and most physicians will commonly
report findings using the designations of mild, moderate,
and severe disease. However, these designations will hold
different meaning among physicians, especially with re-
spect to degree of disk degeneration. The following
scheme is used to define the degree of canal compromise
produced by disk displacement based on the goals of be-
ing practical, objective, reasonably precise, and clinically
relevant. Measurements are typically taken from an axial
section at the site of the most severe compromise. Canal
compromise of less than one third of the canal at that sec-
tion is mild, between one and two thirds is moderate, and
over two thirds represents severe disease. This scheme
may also be applied to foraminal (neural canal) narrow-
ing with the sagittal images also playing a useful role for
defining the degree of narrowing. Observer interpreta-
tions are also made with various degrees of confidence.
Statement of the degree of confidence is an important
component of communication. The interpretation should
be characterized as definite if there is no doubt, prob-
able if there is some doubt but the likelihood is greater
than 50%, and possible if there is reason to consider but
the likelihood is less than 50%.
Positional, Load-Bearing, and Dynamic
(Functional) Imaging
Because imaging in the supine position may not fully re-
veal the anatomic lesions, there has been an interest in
performing functioning, positional, or load-bearing im-
aging of the spine. Spine imaging position options avail-
able are supine, supine with axial loading (simulated
weight bearing), seated, or standing upright position.
Noncompressive lesions on conventional MRI may
show encroachment and neural element impingement
on dynamic load-bearing (seated) scans. Fluctuating po-
sitional foraminal and central spinal canal stenosis has
also been shown in the cervical spine between recum-
bent and upright neutral position. This situation has led
to a concept of fluctuating kinetic central spinal canal
stenosis (fluctuating fluid disk herniation) that can only
be shown with these different positions. Cervical spine
imaging in the recumbent position showing posterior os-
teophytes may only reveal cord compression with
upright-extension positioning. Because of the preva-
lence of back pain that occurs in a nonsupine position
and the inability of routine supine MRI to satisfactorily
reveal clinical syndromes, it is likely that positional im-
aging will have a role in the future but how it exactly
will be implemented is as yet undetermined; the role of
imaging the hip, knee, and ankle under axial load also
warrants further investigation. If the supine simulated
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Orthopaedic Knowledge Update 8
weight-bearing paradigm becomes validated, then the
currently installed base of magnets can be used without
having to deploy new, costly space-occupying devices.
Further studies comparing simulated weight-bearing
versus upright imaging will be needed to show whether
new magnets are required for this purpose.
Sports Medicine: Magnetic Resonance Arthrography
For any joint the placement of intra-articular contrast
whether by direct or indirect means can be used to as-
sist the evaluation of ligaments, cartilage, synovial pro-
liferation, or intra-articular loose bodies. MRI provides
cross-sectional and multiplanar imaging for precise spa-
tial delineation and an additional capability to supply
soft-tissue contrast outside of the joint cavity (tendons,
muscles, and bone marrow) unavailable by any other
modalities. Pertinent issues for optimizing diagnostic
yield include technical considerations in performing
magnetic resonance examinations, properly identifying
structures of interest, and the clinical significance of the
incidental findings. Magnetic resonance arthrography
has been most extensively studied in the shoulder and
to a lesser degree in the hip and the postoperative knee.
Other joints in which it has been applied include the el-
bow and wrist and to a lesser degree the ankle.
Direct magnetic resonance arthrography, most often
done with injection of diluted gadolinium or less often
with saline solution, can be useful for evaluating certain
pathologic conditions in the joints. Gadolinium-based
contrast agents have not been approved by the US Food
and Drug Administration for intra-articular injection
but may be used clinically under the doctrine of the
practice of medicine. These agents are most helpful for
outlining labral-ligamentous abnormalities in the shoul-
der (Figure 6) and distinguishing partial-thickness from
full-thickness tears in the rotator cuff, demonstrating la-
bral tears in the hip, showing partial- and full-thickness
tears of the collateral ligament of the elbow and delin-
eating bands in the elbow, identifying residual or recur-
rent tears in the knee after meniscectomy (Figure 7), in-
creasing the certainty of perforations of the ligaments
and triangular fibrocartilage in the wrist, correctly iden-
tifying ligament tears in the ankle and increasing the
sensitivity for ankle impingement syndromes, assessing
the stability of osteochondral lesions in the articular sur-
face of joints, and delineating loose bodies in joints. Di-
rect magnetic resonance arthrography has become a
well-established method of delineating various joint
structures that otherwise show poor contrast on conven-
tional MRI. However, direct magnetic resonance ar-
thrography is minimally invasive and usually necessi-
tates fluoroscopic guidance for joint injection (some
authors have described doing blind injections or using
other modalities such as ultrasound or MRI).
American Academy of Orthopaedic Surgeons
 Orthopaedic Knowledge Update 8
Figure 6 Direct magnetic resonance arthrography of the shoulder. T1-weighted fat-suppressed images obtained after the intra-articular injection of a dilute gadolinium solution.
A, Buford complex: axial image at the level of the coracoid process shows a deficient anterosuperior labrum (white arrow) with a thick cord-like middle glenohumeral ligament
(black arrowhead) reflecting a normal developmental variant. B, Bankart lesion: axial image caudal to the level of the coracoid process shows contrast intravasation into an
irregular deformed anteroinferior glenoid labrum (arrow) distinct from the middle glenohumeral ligament (arrowhead). C, Superior labral anterior and posterior lesion: coronal
oblique image posterior to the biceps attachment to the glenoid shows an irregular collection of contrast material (arrow) extending into the superior labrum with partial
detachment.
Intravenous gadolinium-based contrast leaks from
the capillary bed into the interstitial space of the syn-
ovium and then diffuses through the synovial lining into
the joint cavity. Because the synovial membrane is
highly vascular, intravenous gadolinium-based contrast
material enhances the joint cavity, causing the arthro-
graphic effect. This technique has developed as an alter-
native to direct magnetic resonance arthrography for
imaging joints. The arthrographic effect is dependent on
the degree of synovial enhancement and volume of syn-
ovial fluid. Synovial enhancement is poorer in nonin-
flamed joints. Well-vascularized and inflamed tissues
will show enhancement with this method. One limita-
tion of indirect magnetic resonance arthrography is a
lack of controlled joint distension compared with that of
direct arthrography. Joint distension facilitates recogni-
tion of certain conditions such as capsular trauma or
soft-tissue injury concealed by a collapsed capsule.
Joints with a large capacity (knee, hip, shoulder) are less
suited to indirect magnetic resonance arthrography be-
cause the larger volume necessitates a longer delay and
leads to less predictable heterogeneous enhancement.
Nonetheless, indirect magnetic resonance arthrography
can provide diagnostic arthrogram-like images of the
shoulder, elbow, wrist, hip, knee, and ankle joint if the
technique is optimized. Fat saturation and joint exercise
before imaging is critical to provide high signal intensity
joint fluid. Diffusion is increased in joints, which are in-
flamed, or after gentle exercise, because of physiologic
hyperemia. Factors affecting passage of contrast mate-
rial between the blood vessels and synovial fluid include
pressure differences between these spaces and the vis-
cosity of the intra-articular fluid. The normal joint space
is a low-pressure space, containing joint fluid of rela-
tively low viscosity. Exercise not only increases vascular
American Academy of Orthopaedic Surgeons
Chapter 11 Musculoskeletal Imaging
Figure 7 Direct magnetic resonance
arthrography of the knee: Sagittal T1-
weighted fat-suppressed spin echo
images show a horizontal increased
intrameniscal signal intensity similar
to the contrast material extending to
the free margin (arrow) of the poste-
rior horn of the medial meniscus, re-
flecting a recurrent meniscal tear. The
posterior horn of the medial meniscus
is truncated from a prior partial me-
niscectomy. Extensive cartilage loss of
the posterior aspect of the lateral
femoral condyle is seen.
perfusion but also increases vascular pressure. Exercise
also leads to motion within the joint fluid, thereby re-
ducing the concentration of contrast adjacent to the syn-
ovial membrane and thus facilitating the diffusional ef-
fect. Increase in signal intensity of joint fluid has been
reported to be four times greater in joints that were ex-
ercised 10 up to 15 minutes before imaging compared
with joints that were not exercised. Without exercise the
signal intensity increases slowly and reaches a maximum
after approximately 60 minutes. In patients with os-
teoarthritis, maximum enhancement may occur as late
as 90 minutes in the absence of joint motion. As con-
trast diffusion is based on the concentration difference
between plasma and joint fluid, increasing the dose of
contrast material administered intravenously may in-
crease the diffusion gradient. However, double- and
triple-dose intravenous injections have been shown to
have a limited positive effect on indirect arthrography.
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Musculoskeletal Imaging
Figure 8 Indirect magnetic resonance arthrography of the wrist: lunotriquetral liga-
ment tear. Coronal T1-weighted fat suppressed spoiled gradient recalled image ob-
tained after the administration of a standard dose of intravenous gadolinium based
contrast material and 10 minutes of exercise shows high signal equal to contrast ma-
terial in the lunotriquetral interval (arrow) reflecting ligament disruption (normally
there should be a low signal band at the base of the proximal carpal bones). Note the
multicompartment enhancement.
Thus, a standard dose of gadolinium-based contrast in-
jected intravenously is usually sufficient to attain a good
signal to noise ratio and good contrast to noise ratio. It
allows simultaneous assessment of both intra-articular
and extra-articular soft tissues but the physician must be
cognizant of the determinants of contrast enhancement
not to be confounded by normally enhancing structures
(Figure 8). Indirect magnetic resonance arthrography is
a useful adjunct to conventional musculoskeletal MRI,
may be preferable to the more invasive direct magnetic
resonance arthrogram in certain applications, and often
can be performed when direct arthrography is inconve-
nient or not logistically feasible (outpatient magnet). Al-
though indirect magnetic resonance arthrography has
some disadvantages, it does not require fluoroscopic
guidance or joint injection and it is often superior to
conventional MRI in delineating structures.
Hand/Upper Extremity: Internal Derangements
of the Wrist
Challenges associated with MRI of the hand and upper
extremity are related to the small compact complex
anatomy and the high special resolution requirement.
High signal-to-noise ratios are desired; however, thin
section, small field of view, and high-resolution images
all detract from signal-to-noise ratios. Off isocenter im-
aging, as is commonly done for the elbow and the wrist,
128
Orthopaedic Knowledge Update 8
can detract from quality because of artifacts related to
reduced field homogeneity. Using a high-field dedicated
extremity magnet can improve overall quality by having
the structure of interest within the isocenter. High-
quality surface RF coils should be used for wrist or el-
bow imaging and can improve the signal-to-noise ratios
threefold to fivefold. Higher field strength with stronger
gradients (increased slew rates) allows for thinner sec-
tion acquisition, smaller field of views, and reduced
scanner time. Conventional MRI systems have a 3-mm
section limitation for two-dimensional pulse sequences
because the amplifier can only deliver a fixed amount of
power to the gradient coil. The addition of volumetric
three-dimensional imaging can also be useful. The elbow
and wrist are joints that contain compact anatomy and
perform complex motions. Frequently, the structures of
interest are not well shown in the standard planes of im-
aging and appropriate positioning at optimal planes
needs to be acquired for each area. A three-dimensional
pulse sequence that can be dynamically manipulated
may be advantageous in this context. Contrast resolu-
tion issues are also extremely important and are related
to determining the optimal pulse sequence. For certain
structures in the wrist and elbow such as the fibrocarti-
lage, ligaments, and capsule, there is a limited inherent
contrast that normally exists. In this respect intra-
articular contrast medium (magnetic resonance arthrog-
raphy) greatly assists the conspicuity of findings. The
contrast-to-noise ratio tends to improve by fat suppres-
sion because this alters the dynamic range by reducing
the contribution of signal from fat with the smaller con-
trast differences rescaled across a broader range of sig-
nal intensity pixel values. The resulting effect is that the
rescaling provides amplified contrast even with nonfat-
containing structures (such as cartilage). Currently, gra-
dient echo sequences can provide high-resolution imag-
ing but there are significant contrast limitations.
Spurious signals are often present in tendons and liga-
ments, particularly when they approach a 55 angle to
the main magnetic field (causing magic angle artifact, a
T2 shortening phenomenon manifested in short TE im-
ages). This is often the case in at least some portion(s)
of some of the tendons given the complex anatomy in
this region.
MRI of the hand, wrist, and elbow is useful for
extra-articular pathology and in this sense is comple-
mentary to diagnostic arthroscopy. The reports for diag-
nostic performance of MRI for ligamentous wrist le-
sions in the literature are variable. Thus, MRI has not
achieved a respected role in defining the biomechani-
cally clinically significant lesions in the wrist. One mech-
anism to improve spatial resolution is to use dedicated
high-resolution coils. Thin and contiguous slices are
needed for adequate MRI of the wrist because many of
the larger ligaments around the wrist are no greater
than 1 to 2 mm thick. Recent magnetic resonance tech-
American Academy of Orthopaedic Surgeons
Orthopaedic Knowledge Update 8
nology allows the use of a microscopy coil, which pro-
vides high-resolution MRI of the hand and wrist. High-
resolution MRI with a microscopy coil is a promising
method to diagnose triangular fibrocartilage complex
and other ligament lesions. The limitation of microscopy
coils is that the depiction of deep structures is inade-
quate. However, this may be resolved by combined posi-
tioning with a larger surface coil or a flexible coil. In ad-
dition, the limited sensitivity of microscopy coils may
sometimes make accurate coil setting difficult over tar-
geted structure or suspected lesions. The availability of
superconducting coils has also been applied to small
joint imaging. Overall, it is likely that advanced coil de-
velopment will lead to improved diagnostic perfor-
mance of MRI because high spatial resolution imaging
is paramount to detect infrastructural features of the
wrist and elbow when evaluating for internal arrange-
ments.
Foot and Ankle: Bone Marrow Edema-Like Lesions
Bone marrow edema (BME)-like lesions are often ob-
served on MRI. Although BME-like signal is not spe-
cific on MRI, additional morphologic findings are often
useful to reveal the etiology of many BME patterns.
Normal marrow constituents have three components:
osseous, myeloid elements, and adipose cells. Hemato-
poietic (red) marrow has approximately 40% fat con-
tent and fatty (yellow) marrow has 80% fat content. The
appendicular skeleton tends to have more fatty marrow
than hematopoietic marrow and this serves as a natural
contrast agent, showing bright T1 signal and suppression
on fat saturation images. MRI to detect BME relies on
fluid-sensitive sequences (short-tau inversion recovery
[STIR] and fat suppressed T2-weighted images). T1-
weighted images can supplement T2-weighted images
and are very specific for the infiltrative process, but are
not as sensitive if there is nonfat marrow or no substan-
tial degree of edema. Gradient echo images are poor for
assessing marrow because of increased susceptibility re-
lated to the interfaces between the trabecula and he-
matopoietic marrow. Gradient echo images can be use-
ful to reveal other diagnoses such as lesions that contain
iron, calcium, or hemosiderin (pigmented villonodular
synovitis). Other novel MRI techniques that have been
variably applied include chemical shift imaging, diffu-
sion weighted imaging, and magnetic resonance spec-
troscopy.
BME lesions can reflect nonspecific response to in-
jury or excess stress. The pathophysiology is related to
the extracellular fluid, which can be affected by hyper-
vascularity and hyperperfusion (hyperemia), an inflam-
matory infiltrate causing resorption, granulation (fi-
brovascular) tissue or an adaptive/reactive phenomena
related to biomechanical alterations (MRI manifesta-
tion of Wolffs Law). The pathoetiologies are legion and
American Academy of Orthopaedic Surgeons
Chapter 11 Musculoskeletal Imaging
the signal intensity is directly proportional to the
amount of extracellular water. Contrast enhancement
occurs in areas of BME irrespective of etiology (benign
or malignant, infectious or noninflammatory). The po-
tential etiologies of BME include diseases in the cate-
gory of trauma, biomechanical, developmental, vascular,
neoplastic, inflammatory, neuropathic, metabolic, degen-
erative, iatrogenic, and potentially idiopathic conditions
(transient BME syndromes).
Occult injuries result from an acute overt episode of
trauma. The physician should suspect a fracture in these
patients. The traditional modality applied to fracture de-
tection has been radiography, which may be negative or
indeterminate for nondisplaced fractures or a fracture
plane that is not tangential to the x-ray beam. In this
context MRI serves as a more sensitive technique for
fracture detection and characterization. Contusions, also
known as bone bruises, are considered microtrabecular
fractures. On MRI there is no fracture line and the pat-
tern may be a clue or secondary sign of ligament or ten-
don injury. These fractures often occur in a subarticular
location from osteochondral impaction injuries.
In terms of developmental conditions the normal
conversion of red marrow to yellow marrow sometimes
has areas of slight T2 or STIR hyperintensity but these
usually are not as bright as pathologic lesions. Areas of
a developmental synchondrosis with failure of segmen-
tation of the primitive mesenchyme may cause symp-
toms via abnormal biomechanics. Symptomatic fibrous
or cartilaginous tarsal coalitions often show reciprocal
areas of BME. Anatomic variants that can present as
painful lesions may be considered a separate but related
category. Those of chronic chondro-osseous disruption
include bipartite patella, dorsal defect of the patella, and
os subfibulare of the ankle. Those in the congenital syn-
chondrosis category include accessory navicular bone
and os trigonum. There are lesions that may predispose
to premature degenerative joint disease; one example is
the os intermetatarsarum, which can contribute to hal-
lux valgus by causing excessive metatarsus varus. When
these variants are symptomatic they often demonstrate
BME-like signal about the abnormality, reflecting al-
tered biomechanics, chronic stress, or sometimes areas
of osteonecrosis. It is thought that MRI can form an ob-
jective basis for management of the lesions, particularly
when surgery is considered.
The well-established vascular causes of BME-like
signal may be related to either hyperemic or ischemic
conditions. Of the hyperemic etiologies, inflammatory
disorders that increase vascularity or disuse may cause
subarticular BME patterns. The disuse pattern is also
partly related to increased blood flow, can be character-
istic and parallels the radiographic appearance of ag-
gressive osteoporosis with diffuse or multiple rounded
areas of fluid-like hyperintensity in a subarticular and
metaphyseal distribution predominantly in the hindfoot
129
Musculoskeletal Imaging Orthopaedic Knowledge Update 8

Figure 9 Osteomyelitis superimposed on neuropathic arthropathy. A, Axial T1-weighted spin-echo image of the midfoot reveals disorganization and dislocation of the Chopart
joint, showing replacement of the normal marrow with diffuse infiltration of hypointense signal (arrowheads) in the tarsal bones. B, Sagittal T2-weighted fast spin-echo image
reveals marrow edema in the midfoot and hindfoot bones, tarsus effusions, a rocker bottom deformity and fluid-like signal in the overlying subcutaneous tissues (arrow). C,
Sagittal T1-weighted spin-echo contrast-enhanced image shows rim enhancement around plantar sinus tracts (small arrows) from the ulcer base and extending into midfoot
reflecting a plantar space abscess (large arrow). The marrow edema is enhancing, which is nonspecific, but there is cortical irregularity of the anterior aspect of the cuboid
adjacent to the soft-issue enhancement (arrowhead). The secondary signs of cutaneous ulcer, sinus tract, and cortical interruption have the highest positive predictive value for
osteomyelitis.

and midfoot. In terms of ischemic lesions, the broad cat-
egory of osteonecrosis (infarct, osteonecrosis) can have
BME early in the course of the disorder associated with
acute, painful symptomatology. Pain improvement usu-
ally parallels the resolution of the BME-like signal. The
MRI pattern shows early BME with loss of subchondral
fat signal intensity. The double line sign is specific and
most often identified as a ring of T1 hypointensity and
T2 hyperintensity. This likely reflects a reactive interface
rather than chemical shift artifact. MRI signal of the ne-
crotic segment may be reconstituted and appear fatty
because of the lipid content (the signal is not signifi-
cantly altered because of the reduced metabolic state).
MRI findings may be seen as early as 10 to 15 days and
for most patients within 30 days after the vascular in-
sult. Transient osteoporosis or the MRI correlate, tran-
sient bone marrow edema syndrome, may occur in nu-
merous other low extremity locations including the hip,
knee, talus, cuboid, navicular, and metatarsals. In addi-
tion, it may be migratory and occur in a ray pattern.
Some believe that these lesions may reflect salvaged os-
teonecrosis but it is likely that many of these lesions
may simply be biomechanical in nature.
In the inflammatory category it is well established
that infectious etiologies cause BME. One difficult dif-
ferential diagnosis in the setting of diabetic neuropathy
is distinguishing osteomyelitis from a Charcot joint.
There are several MRI findings that may help in the dif-
ferentiation. Osteomyelitis is more common in the pha-
langes, distal metatarsals, and calcaneus (secondary to
overlying ulceration) whereas neuropathic disease is
more common in the Lisfranc, Chopart, and ankle joints.
One notable exception is an ulceration that develops
because of poorly fitting footwear, or foot deformity
and altered weight bearing that can cause atypical loca-
tion of osteomyelitis. However, there should be a soft-
tissue defect identified over these areas to diagnose os-
teomyelitis. The epicenters of signal abnormalities can
be useful. Neuropathic disease has an articular epicenter
and usually multiple joints are involved with a regional
instability pattern. Osteomyelitis has a marrow epicen-
ter with focal centripetal spread throughout the bone. It
is important to emphasize that transcutaneous spread is
the route of inoculation in more than 90% of cases of
osteomyelitis of the foot in patients with diabetes.
Therefore, secondary soft-tissue signs are paramount; a
subcutaneous ulcer with interruption of cutaneous sig-
nal, cellulitis, soft-tissue mass effect from a phlegmon,
soft-tissue abscess (well-defined rim enhancing fluid col-
lection) and particularly a sinus tract strongly support
infection (Figure 9).
It has been recently recognized that degenerative
conditions are associated with areas of BME. These de-
generative conditions may occur with either primary or
secondary osteoarthritis. Geodes (subchondral cysts)
are one of the imaging hallmarks of osteoarthritis and
can be identified on MRI. Early during the course of
disease, ill-defined areas of BME appear and later form
discrete cystic structures. Some of these areas with hy-
perintensity have been shown by pathologic studies not
to reflect the fluid. It has been hypothesized that some
of these findings are likely mechanical or adaptive re-
sponses related to the altered mechanics from the joint
failure and may be considered the MRI manifestation

130 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8
of Wolffs Law. In the knee (and possibly in the ankle
and foot) bone marrow findings are strongly associated
with the presence of pain, and moderate or larger fu-
sions in synovial thickening are more frequent among
those with pain than those without pain adjusted for de-
gree of radiographic osteoarthritis. In addition, focal
subchondral BME may be a clue to focal cartilage de-
fects (potential treatable cartilage defects), which pre-
sumably are posttraumatic events. The cartilage abnor-
mality itself may be relatively inconspicuous on MRI
pulse sequence selection or spatial resolution and there-
fore an area of subarticular flame-shaped BME in a
nonarthritic joint can be a helpful secondary sign. An-
other recently described pattern of BME is a subtendi-
nous location. This has been identified as a response to
tendon abnormality and hypothesized to be from me-
chanical friction, hyperemia, or because of biomechani-
cal reasons. A subtendinous location is most common in
the lower extremity, particularly in the foot and ankle,
and is most often seen with posterior tibialis tendon
(PTT) dysfunction (Figure 10, A). The areas of edema
related to PTT dysfunction are the medial tibia (malleo-
lus), navicular tubercle, calcaneous, and talus. This find-
ing is not seen in most people with PTT dysfunction but
may be a sign for a more advanced stage and poorer
tendon quality. Less frequently, BME may also be re-
lated to peroneal tendinopathy (Figure 10, B): typically
in the lateral fibula (lateral malleolus) or lateral calca-
American Academy of Orthopaedic Surgeons
Chapter 11 Musculoskeletal Imaging
Figure 10 Tendinopathy-associated bone
marrow edema. A and B are T2-weighted fat-
suppressed fast spin-echo MRI. Posterior tibi-
alis tendon dysfunction: axial image (A) shows
medial malleolus marrow edema (arrowhead)
immediately subjacent to the posterior tibialis
tendon (arrow). Peroneal tendinopathy: coro-
nal image (B) shows peroneus longus tendon
tenosynovitis (arrow) with underlying subtendi-
nous bone marrow edema in peroneal tuber-
cle of the calcaneus (arrowhead).
neus (along the peroneal tubercle). Noninfectious in-
flammatory enthesopathies such as psoriatic or reactive
arthritis cause prominent flame-shaped BME patterns
at the tendon-bone junction (enthesis) often with an as-
sociated erosion that may be better appreciated with ra-
diography.
There are several miscellaneous but important causes
of lower extremity BME patterns. Hematopoietic (red)
marrow can sometimes be confused for an abnormal
BME pattern. Hematopoietic marrow is most prominent
in the pediatric population and there is a conversion pat-
tern progression from distal to proximal. One important
realization is that once an epiphysis is ossified, it should
contain fatty signal with a couple of important exceptions
(reconversion not infrequently occurs in proximal femo-
ral epiphysis). In general, reconversion related to anemia
or other conditions is in the opposite direction. In terms
of marrow replacement disorders (leukemia and lym-
phoma) the pattern may be a diffuse or focal area of mar-
row signal abnormality.With infiltrative diseases, the mar-
row pattern tends to have some asymmetry and
pathologic processes tend to have more T2 prolongation
and higher signal intensity (brighter BME). Neoplasms of-
ten show lesional or perilesional BME. The signal inten-
sities are unreliable for histology and there is substantial
overlap between benign and malignant conditions. Met-
astatic deposits are hematogenous in origin and are pre-
dominantly located in red marrow areas (axial skeleton)
131
Musculoskeletal Imaging
but can also be present in the appendicular skeleton, es-
pecially for deposits from bronchogenic or breast carci-
noma. For primary neoplasms, the degree of BME does
not correspond to malignancy potential.There are several
well-known benign lesions that are characterized by very
prominent BME: chondroblastoma, osteoid osteoma, and
Langerhans cell histiocytosis. Patients who have under-
gone radiotherapy or chemotherapy, those who are tak-
ing bone marrow recovery agents, and patients who have
recently undergone dbridement may show BME de-
pending on the time course of the treatment.
Pediatrics: Physeal Lesions and Growth Arrest
The growing skeleton is susceptible to injury. Advances
in pediatric musculoskeletal radiology have been made
in imaging the cartilage, epiphysis, and physis. Closure
disturbance of the long bones in children is frequently
posttraumatic but also occurs because of physeal, epi-
physeal, or metaphyseal ischemia. The growth mecha-
nism represented by the cartilage structures at the ends
of growing bones is not directly visible on radiography
but is well visualized by MRI. Improved definition of
cartilaginous abnormality by MRI may permit earlier
detection and treatment of disorders and thus prevent
bone deformity. The formation of physeal bars (bony
bridges across the growth plate) is one active area of pe-
diatric musculoskeletal radiology research. Premature
bony fusion in children is most often posttraumatic and
disproportionately involves the tibia and femur with
bridges tending to develop as the site of earliest physio-
logic closures (anteromedially and centrally). The distal
tibia, proximal femur, and proximal tibia physes are dis-
proportionally at risk because of the complex geometry.
The central undulations in the distal femur and Kumps
bump in the distal tibia are sites of initial physiologic
closure and the most frequently involved in the prema-
ture fusions. Animal studies with physeal and metaphy-
seal injuries have shown MRI can identify persistence of
abnormality in the growth cartilage after physeal inju-
ries and evolution of abnormalities after metaphyseal
injury best seen on T2-weighted images. It has been
shown on MRI in animal models that abnormalities in
the physeal cartilage result in development of a trans-
physeal vascularity that precedes the formation of bony
bridge after trauma. MRI can detect this transphyseal
vascular lesion within the first 2 weeks of injury. In vivo
studies in humans confirm that MRI defect abnormali-
ties in the cartilage are associated with subsequent
growth disturbances and provide accurate mapping of
physeal bridging and associated growth abnormality in
the posttraumatic population (Salter-Harris injuries).
Contrast enhancement can be useful in showing recon-
stitution of metaphyseal vascularity after injury but does
not reliably enable the detection of transphyseal vascu-
larity after physeal injury until a distinct bony bridge is
132
Orthopaedic Knowledge Update 8
formed. Early MRI evaluation in children with lower
extremity fractures can be prognostic. Physeal narrow-
ing or tethering in the absence of growth arrest lines
was found in those patients who subsequently required
late surgical intervention. The MRI in acute phase pro-
vided accurate evaluation of physeal fracture anatomy
and could often augment the staging of the Salter-Harris
classification. The course and level of injury within the
cartilage physeal fracture-separation can be defined
with MRI. Extension into the juxtaepiphyseal region is
another potential risk factor for growth arrest and is de-
tectable by MRI. Early MRI can demonstrate transphy-
seal bridging or altered arrest lines in physeal fracture
before they become manifest on radiographs. Physeal
enhancement decreases with physeal closure as ex-
pected. In the marrow and the extremities, contrast en-
hancement is greater in the metaphyseal metathesis por-
tion than the fatty epiphyseal portion. In both areas
enhancement decreases as the marrow becomes more
fatty. Local physeal widening in a growing bone may
represent the imprint of the previous or ongoing inter-
ference with endochondral ossification. Widening can be
seen on a fluid-sensitive pulse sequences in physeal dys-
function without bridge formation. Physeal widening
with focal palisading morphology, central distribution in
the metaphysis and concomitant epiphyseal signal ab-
normalities are significant predictors of subsequent
growth disturbance. Therefore, MRI should be consid-
ered as part of the evaluation for patients at high risk
for growth disturbance, especially young children with
extensive residual growth potential and those that in-
volve particularly vulnerable growth plates (such as
about the knee) and pediatric patients with severe com-
plex fractures. MRI is now a standard of care and helps
surgical management for these patient populations with
cartilage-sensitive sequences, exquisitely showing the
disturbance and associated abnormality that may follow
physeal injuries.
Orthopaedic Oncology: Metabolic Imaging
Distinguishing benign from malignant soft-tissue lesions
in the extremities is a difficult if not impossible task by
imaging using either signal, morphologic, or enhance-
ment criteria. Follow-up imaging for sarcoma patients is
also complicated by complex prostheses, which can pro-
duce artifacts and limit visualization at the surgical site.
PET scanning, discussed earlier in the chapter, holds
promise in showing metabolically active areas and may
be particularly suitable for monitoring patients after
therapy (resection, chemotherapy, or radiotherapy).
Orthopaedic Traumatology: Multislice
Computed Tomography
One of the most recently evident benefits of multislice CT
is in the setting of appendicular and axial trauma. CT
American Academy of Orthopaedic Surgeons
 Orthopaedic Knowledge Update 8
greatly improves the anatomic depiction of spinal injury
when compared with projectional radiography. Compared
with single detector helical CT scanners, multislice CT
scanners have increased tube heating capacity and run at
a higher table speed, allowing an increased volume of cov-
erage with the same amount of scanning time. This makes
screening examination of part of the spine or the entire
spine feasible, which may eliminate screening radiographs
in certain settings. Examinations of the thorax and the
lumbar spine can be extracted from a CT examination of
the chest abdomen and pelvis.
There are several pitfalls to be aware of but the most
important image artifacts are not unique to multislice CT.
These pitfalls include metal-induced streak artifact and
patient motion. Because of the higher spatial resolution,
vascular channels of the vertebral bodies are better appre-
ciated and may be mistaken for normal structures. Mul-
tislice CT has some risk predominantly related to the ra-
diation dose to the individual patient and to the
population. The radiation dose of the patient increases as
the volume of coverage increases. Multislice CT allows
imaging of very thin sections quickly, much faster than
previously possible, allowing for effective screening of spi-
nal injuries and evaluating extremity injuries. Screening
CT of the entire cervical spine is cost effective if high-risk
criteria, such as focal neurologic deficit referable to the
cervical spine, head injury (skull fracture, intracranial
hemorrhage) or loss of conscious at the time of examina-
tion, and high-energy mechanism (motor vehicle accident
at a speed of greater than 35 mm, pedestrian struck by a
car, or a fall greater than 10 feet).
Diagnostic and Therapeutic Procedures
Spinal Injections
Epidural steroid injections, sacroiliac joint injections,
zygapophyseal (facet) joint injections, diskography, and
vertebral augmentation are image-guided procedures
that are important components of a comprehensive
management approach to spine pain syndromes for es-
tablishing a diagnosis, directing or administering ther-
apy, and facilitating rehabilitation and functional resto-
ration.
Demand for epidural injections is rapidly expanding.
Patient satisfaction elicited from these procedures is of-
ten a direct result of imaging guidance, which can
shorten and simplify procedures, minimize potential for
complications, and verify accurate localization of the
needle to selectively provide the lowest necessary dose
of analgesic to the optimal area. These procedures can
greatly contribute to patient management and surgical
planning by determining sources of pain and treating
pain generators. Participation of an experienced radiolo-
gist in performing these procedures optimizes patient
care, because radiologists are trained in anatomy and
image-guided needle localization procedures. However,
American Academy of Orthopaedic Surgeons
Chapter 11 Musculoskeletal Imaging
use of spinal injections should be considered a team ef-
fort in conjunction with an experienced clinical diagnos-
tician who can accurately diagnose the patients prob-
lem and recommend the appropriate procedure.
Performance of these procedures requires an intimate
knowledge of relevant anatomy, appropriate equipment
and facilities, and apprenticeship with an experienced
practitioner. Selective epidural injections can offer sig-
nificant diagnostic and therapeutic benefit for patients
with radicular pain. Attention to proper technique will
minimize risk of complications from these procedures
while maximizing their benefit.
Controversy and differences in opinion related to
epidural steroid injections often revolve around choice
of trajectory (transforaminal versus transflaval [trans-
laminar, interlaminar]) and whether to use image guid-
ance. Transflaval injections may be done with or without
image guidance (using loss of resistance techniques),
whereas transforaminal injections are done with image
guidance. Studies reviewing the efficacy of epidural ste-
roid injections favor it as a useful treatment overall.
However, controlled clinical trials performed without
fluoroscopic guidance are not unanimous in demonstrat-
ing the benefits of lumbar epidural steroid injections
with a broad range of successful results, ranging from
18% to 90%. This broad range may be related to the ac-
tual location of medication deposition. The incidence of
failure to reach the epidural space using a nonimage-
guided transflaval approach ranges from 13% to 30%
and may target the wrong interlaminar space by one or
more levels. The transforaminal approach demonstrates
superior ventral opacification, whereas the transflaval
method shows predominantly dorsal opacification (us-
ing CT as the reference standard to confirm contrast lo-
cation after fluoroscopically-guided epidurography).
Dorsal deposition may be less effective because the ste-
roid is remote from the source of irritation (for exa-
mple, disk herniation). There is an increased risk of a
dural puncture (intrathecal administration), spinal head-
ache (may require blood patch treatment), intrathecal
administration of steroid or residual preservatives of lo-
cal anesthesia leading to nerve root injury, hypotension,
or dyspnea. For several reasons image-guided epidural
steroid injection is favored; it adds only minimal risk
(radiation) and may not add to the overall costs of spine
injections but may even reduce costs by eliminating re-
peat injections (a nonimage-guided paradigm is to per-
form two to three successive transflaval epidural steroid
injections because the miss rate of the epidural space is
about 33%).
Intra-articular injections have an established role for
identifying zygapophyseal (facet) and sacroiliac joint ar-
ticulations as nociceptors. However, intra-articular injec-
tions with anesthetic or corticosteroid are often not suf-
ficient for a long lasting therapeutic effect. Once a
zygapophyseal joint has been implicated as a substantial
133
Musculoskeletal Imaging
Figure 11 CT characterization after intradiskal contrast injection. Postdiskography transaxial CT images. A, Normal nucleogram characterized by central globule of contrast
material that remains within the expected confines of the nucleus pulposus. B, Annular fissure. Contrast material is noted within the nucleus pulposus, but also extends in a radial
fashion posterolaterally beyond the expected confines of the nucleus pulposus into the region of the anulus fibrosus (arrow). There is also a circumferential component noted in
the anulus fibrosus (arrowhead).
or significant nociceptor then targeted therapy options
exist that may include a neuroablative procedure (me-
dial branch neurotomy) in conjunction with functional
restoration via physical therapy. Sacroiliac joint treat-
ment can be more problematic given the diffuse inner-
vation of the articulation; however, sacroiliac joint fu-
sion is a technique practiced by some orthopaedic
surgeons. For true inflammatory sacroiliitis related to a
spondyloarthropathy, there is good evidence from sev-
eral clinical trials that intra-articular corticosteroid is
proven to be an effective component of treatment.
However, the data on the efficacy of steroid intra-
articular injections for mechanical somatic dysfunction
are conflicting. For an intracanalicular synovial cyst em-
anating from an adjacent zygapophyseal joint that is
causing lateral recess stenosis with radicular symptoms,
intra-articular injection with corticosteroid assists in de-
creasing the perineural inflammation, reducing the size
of the cyst, and alleviating the radicular symptoms.
Diskography
The primary purpose for diskography is for documenta-
tion of the disk as a significant nociceptor. For patients
who have chronic pain that is predominantly axial, non-
myelopathic, and nonradicular, imaging may be insuffi-
cient or equivocal for determining the nature, location,
and extent of symptomatic pathology. A position state-
ment regarding lumbar diskography from the North
American Spine Society was published in 1995. Specific
134
Orthopaedic Knowledge Update 8
indications include patients with persistent pain in
whom noninvasive imaging and other tests have not
provided sufficient diagnostic information. In patients
who are to undergo fusion, diskography can be used to
determine if disks within the proposed fusion segment
are symptomatic and if the adjacent disks are normal.
Surgeons concerned with limiting the extent of fusion
are interested in obtaining more evidence beyond MRI
abnormalities to document what intervertebral disk lev-
els are contributing to the painful syndrome. In postop-
erative patients who continue to experience significant
pain, diskography can be used to assist in differentiating
between postoperative scar and recurrent disk hernia-
tion (when MRI or CT is equivocal); or to evaluate seg-
ments adjacent to the arthrodesis. Postdiskography CT
can also be used to confirm a contained disk herniation
as a prelude to minimally invasive intradiskal therapy
(Figure 11). Diskography is also being used as part of
the selection criteria for many clinical trials assessing
lumbar interbody fusion devices or percutaneous in-
tradiskal treatments.
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American Academy of Orthopaedic Surgeons
 Orthopaedic Knowledge Update 8
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American Academy of Orthopaedic Surgeons
Chapter 11 Musculoskeletal Imaging
Recent reports and experience suggest that FDG-PET
cannot be a screening method for differential diagnosis be-
tween benign and malignant musculoskeletal lesions, including
many neoplasms originating from different tissues. FDG-PET
might not accurately reflect the malignant potential of muscu-
loskeletal tumors, but rather might implicate cellular compo-
nents included in the lesions. A high accumulation of FDG can
be observed in histiocytic, fibroblastic, and some neurogenic
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American Academy of Orthopaedic Surgeons