Large Joint Imaging

Imaging of Large Joints: Knee Shoulder and Hip Monica Khanna Division of Musculoskeletal Radiology Department of Medical Imaging University Health Network, Mount Sinai Hospital, Women’s College Hospital

Shoulder
Knee
Hip

Shoulder

Shoulder
plain film
computed tomography
ultrasound
magnetic resonance imaging

Plain Film
mainstay of bone and joint imaging, particularly in trauma
advantages
fast
inexpensive
readily available
good for assessing bones and joints

Plain Film
mainstay of bone and joint imaging, particularly in trauma
disadvantages
uses ionising radiation (x rays)
limited information regarding soft tissues

Plain Film frontal / AP transcapular / lateral / Y axillary / axial

frontal / AP transcapular / lateral / Y axillary / axial Plain Film

frontal / AP transcapular / lateral / Y view axillary / axial Plain Film

Plain Film

luxatio erecta (eager student sign) with associated fracture greater tuberosity inferior shoulder dislocation

calcific tendinitis supraspinatus ultrasound guided barbotage

30 year female 6 weeks of shoulder pain. MRI done to r/o rotator cuff pathology

Computed Tomography (CT)
x ray tube rotated around the patient
cross sectional imaging capability
reformatting in other planes and 3D
best for bony cortex and calcification
good at evaluation of comminuted fractures to complex structures

disadvantages
radiation dose to patient
metal artefact
poor soft tissue characterization
Computed Tomography (CT)

bony Bankart fracture anteroinferior glenoid labrum

Hill Sach’s defect

bony Bankart

Ultrasound
increased demand and growth of MSK ultrasonography
becoming more frequently utilized
continual improvement in technology
wide availability
relatively lower cost

Musculoskeletal Ultrasound
Advantages
ready accessibility
portability
relatively quick scan time
better patient tolerability
contralateral comparison

Advantages
personal interaction with the patient
directed / targeted examination
clinical history
dynamic imaging
compression of structures
movement of a joint

Disadvantages
highly operator dependant
long learning curve
physician time-intensive examination
proper training and experience required (most N. American training programs do not perform a significant number of MSK ultrasound)

normal supraspinatus tendon longitudinal transverse

normal supraspinatus tendon longitudinal transverse full thickness supraspinatus tear

Clinical scenarios when MRI > US in shoulder imaging
Large RCT (>3cm retraction)
US may underestimate retraction, miss atrophy / OA
Young patients / elite athletes with shoulder pain
High incidence of labral / other pathology
Mechanism suggests bony pathology
e.g. dislocation

routine sequences for MRI shoulder
AC joint
rotator cuff
biceps
labrum
bone
bursae

Rotator Cuff
Supraspinatus
Infraspinatus
Teres minor
Subscapularis

MRI Arthrography of the Shoulder
Evaluation of
Patients with clinically suspected shoulder instability
Glenoid labrum
Ligaments
Joint capsule

Why?
MR Arthrography is more accurate in evaluation of:
capsule and ligaments
glenoid labrum
intracapsular portion of the long head of biceps tendon
rotator cuff tears (small articular sided tears and small full thickness perforations)

superior labral tear

Prior anterior dislocation
Hill Sachs impaction fracture
Bony and fibrocartilagenous Bankart

Remember
Get a plain film
N.B. posterior dislocation
Ultrasound is a great test to evaluate the cuff in the right hands
MRI if
large tear for surgery
young patient / elite athlete
mechanism suggest bony pathology
MRI arthrogram if instability / ? labral path

Knee
plain film
computed tomography
ultrasound

Anterior Lateral Posterior

A-P View of the Knee

Lateral view

Skyline View of the Knee patella medial femoral condyle lateral femoral condyle

Arcuate Fracture

Deepened lateral sulcus terminalis

Complete tear ACL

Patellar fracture

Effusion Large effusion

Osteoarthritis

Normal Dislocated patella

MR Patella dislocation
Bone contusion
Medial facet of patella
Lateral trochlea
Ligamentous injuries
Medial retianaculum
MPFL
ACL
MCL

Dislocation

Dislocation – risk of popliteal artery injury

routine sequences for MRI knee
menisci
ligaments
muscles
tendons
cartilage
bone
effusion
loose bodies
bursae

normal meniscus meniscal tear intrasubstance signal extending to an articular surface

normal meniscus meniscal tear abnormality of meniscal contour

Displaced fragment
Displaced meniscal fragment, anterior

Displaced fragment
Displaced meniscal fragment, central

Displaced fragment - Bucket Handle Tear

normal sagittal complete tear ACL

Bilateral knee pain, recent running

Knee US
Common pathologies amenable to US
Joint effusion/synovitis
Bursitis:
Suprapatellar
Prepatellar
Pes anserinus
Politeal cysts
Extensor mechanism tears tendinopathy
Collateral ligament injury

Extensor mechanism

Baker’s cyst

Remember
Get a plain film
Ultrasound is a great test to evaluate
Extensor mechanism
Collateral ligaments
Baker’s cyst
MRI for
Menisci / ligaments
Cartilage
Bone

Hip
plain film
computed tomography
ultrasound

Anteroposterior View of the Hips

greater trochanter lesser trochanter intertrochanteric crest femoral neck fovea femoral head iliac crest anterior superior Iliac spine anterior inferior iliac spine

Subcapital Mid cervical Basicervical Intertrochanteric Subtrochanteric Proximal Femoral Fractures

Avascular Necrosis (AVN) flattening fragmentation collapse

Intertrochanteric fracture fixed by dynamic hip screw

Trauma Normal

Subcapital fracture - high risk of AVN

Subcapital fracture - high risk of AVN Treated with a hemiarthroplasty

Occult fractures
18-85% hip / pelvis fractures missed by initial radiographs
MR imaging supplanted scintigraphy as next imaging test of choice
elderly patients
osteoporosis
pain with minimal trauma
equivocal or “normal” radiographs

Osteoarthritis

osteoarthritis
cardinal features
commonly affected joints

osteoarthritis
cardinal features
narrowing of joint space
subchondral sclerosis
osteophyte formation
subchondral cysts
commonly affected joints
large joints hip and knee
small joints interphalyngeal joints of the hand and thumb carpometacarpal joint

osteoarthritis
common causes of secondary OA

osteoarthritis
common causes of secondary OA
trauma
avascular necrosis
inflammatory arthritis (RA, gout etc.)
septic arthritis
Paget’s
neuroarthropathy / Charcot’s

normal

Crescent sign Subchondral collapse

50 y.o. male in ER with right hip pain

T1 septic arthritis hip T2 fat sat

T1 post gadolinium septic arthritis hip T1

Routine Sequences for MRI hips
Bone
Tendons
Effusion
Labrum
Cartilage
Muscles
Intrarticular bodies
Bursae

Indications for Routine Hip MR
Nonspecific hip pain
Fracture (stress/insufficiency)
Pubalgia (osteitis pubis/sports hernia)
Muscle tendon injuries
Osteonecrosis
Tumour

US Hip
Joint effusion/synovitis
Bursitis: Greater trochanteric Ischial Iliopsoas
Tendinopathy/tears: Hamstrings Adductors Rectus Femoris
Snapping tendons: Iliopsoas
Iliotibial Band

Hip US

Indications for Hip MR arthrography
Assess the intra-articular structures
Labrum
Cartilage
Intra-articular loose bodies
Ligaments
Capsule

MR Hip arthrogram

Remember
Get a plain film
Ultrasound is a great test to evaluate effusion, bursitis, tendinosis in the right hands
MRI if
Bone marrow – AVN, stress fracture
Muscle tendon injuries
Non specific hip pain
MRI arthrogram if ? labral pathology

Thank you

Large Joint Imaging

by Nurse Practitioners' Association of Ontario on Aug 02, 2011

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Large Joint Imaging — Presentation Transcript