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Medanta Bone & Joint Institute
Presented By:-
Dr Himanshu Bansal
Anatomy
BASIC MRI
Tools in MSK imaging
 T1W1
T2W1
FAT SAT T1
STIR
FAT SAT T2
Gadolinium studies
MR arthrography
T1
T2
PD
Fat
Suppression
STIR
MRI Rules
T1 T2
Fat Hyperintense Hyperintense
Water Hypointense hyperintense
Cortical bone Hypointense Hypointense
Fibrous...
Indications of MRI
Occult fracture
Marrow abnormality
Ligament pathology
Tendon pathology
Muscular injury
Infection
...
Sections
Coronal- Ant. To Post.
Saggital- Lateral to Medial
Axial- From above downward
Position for knee MRI-
Knee in full...
Meniscal Tear
 Imaging Criteria
1. Presence of linear signal intensity weather reaching
superior or inferior articular su...
Meniscal Tear
 Grade
Grade 1- Globular signal within the meniscus
Grade 2- Linear signal within the meniscus
not reaching...
Grade I
Grade II
Grade III
Radial tear- Tear perpendicular to free
edge of meniscus
Longitudinal tear
 Bucket Handle Tear- Longitudinal tear
along the length of the meniscus and the
inner rim flips into the intercondylar no...
Bucket Handle tear
Anterior flipped horn
Meniscal cyst
 Joint fluid is expressed
into adjacent soft
tissue through the tear
 Mostly occur in
medial compartment
...
Discoid Meniscus-
 More common on lateral side
 High incidence of tear than normal meniscus
 Complete- Meniscus is a la...
Complete discoid menscus
Meniscocapsular separation
 Fluid signal between
posterior portion of
medial meniscus and
joint capsule
Anterior Cruciate Ligament
 Straight, parallel to Blumensaat line
 Linear striated appearance with
intermediate signal i...
ACL Tear
Acute-
 Replacement of normal striated appearance by cloud
like high signal intensity
 Discontinuity of ligamen...
Normal Acute tear
Discontinuous fibres non visible fibres
Chronic tear
Empty notch sign
 Seen in complete ACL
tear
ACL cystic mucoid degeneration
 Ligaments appear
thickened and ill defined
 MRI- Increased signal on
all sequences
 Mim...
Deep lateral femoral notch sign
 Indicator of chronic ACL
insufficiency but may also
be seen in acute tear
Associated injuries with ACL
 O’Donoghue’s triad-
 ACL rupture
 MCL injury
 Medial meniscal tear
O’Donoghue’s triad
Segond Fracture
Other bony injuries with ACL tear
 Bruise in weight bearing
portion of lateral femoral
condyle and posterior
aspect of la...
Uncovered Meniscus
7mm
Posterior Cruciate Ligament
 Normal- Uniform low
signal intensity on all
MR sequences
Tear- Generalised
thickening of ligament with
intermediate signal
intensity on T1 weighed
sequence and heterogenous
high s...
Medial Collateral Ligament
 Grade I- Mild partial interstitial tear ,appears as edema
along superficial aspect
 Grade II...
Grade I Grade II Grade III
Lateral Collateral Ligament tear
Iliotibial Band Injury
 Overuse injury usually
seen in runners and
bicyclists
 Iliotibial band Friction
syndrome- Due to...
Quadriceps rupture
 Appears as balled up
and mildly retracted
tendon edge with
edema in surrounding
soft tissue and tendo...
Jumper knee/Patellar tendinitis
 Overuse injury to proximal
aspect of patellar tendon
 Usually seen in basket/volleyball...
Osgood Schlatter disease
 Degeneration of distal
aspect of patellar
tendon
 Triad- Pain, soft tissue
swelling, ossificat...
Lateral dislocation of patella
 Bony bruise in medial
aspect of patella and lateral
aspect of lateral femoral
condyle
 T...
Baker cyst
 Fluid collection in
semimembranosus-
medial gastrocnemius
bursa
 Axial MRI- comma shaped
with neck extending...
Baker cyst
Pes Anserinus Bursitis
 Pes anserinus bursa is
located between tendon of
pes anserinus and medial
collateral ligament
 M...
Superficial infrapatellar bursitis/Preacher’s knee
 Present anterior to tibial
tubercle and distal aspect
of patellar ten...
Synovitis
 Fat suppressed T1
weighed image after iv
contrast shows thickened
synovium
Osteochondral injury
 Can be a focal cartilage contusion or loose
osteochondral fragment
 Instability- On T2 weighed ima...
High signal at interface Cyst
Osteochondral injury
Chondromalacia patella
 Inflammation of underside of patella and
softening of cartilage.
 Common in young adults, can mi...
Grade MRI finding
I Focal signal intensity changes without contour deformity
(difficult to assess on MRI)
II Focal signal ...
Normal GradeII Grade II
Grade IVGrade III
Osteochondritis dissecans
 Occur due to blood
deprivation
Cracks forms in cartilage
and subchondral bone
Fragmentation ...
Osteochondritis dissecans - Staging
Stage I : lesion 1-3cm ; intact cartilage
Stage II : Cartilage defect ; no loose body
...
Complete medial plica
 Plicae are remnants of fetal
synovial tissue
 Symptomatic only if
complete
 Forms a shelf from m...
Complete medial plica
Avascular Necrosis
 Initial ischemia- Large area of ill defined marrow
edema
 If ischemia persists- avascular necrosis o...
Initial ischemia Avascular necrosis
(demarcated zone )
Spontaneous Osteonecrosis of knee(SONK)/
Subchondral insufficiency fracture of knee(SIFK)
 Subchondral fracture
followed ...
Mri of knee
Mri of knee
Mri of knee
Mri of knee
Mri of knee
Mri of knee
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Mri of knee

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Mri of knee

  1. 1. Medanta Bone & Joint Institute Presented By:- Dr Himanshu Bansal
  2. 2. Anatomy
  3. 3. BASIC MRI
  4. 4. Tools in MSK imaging  T1W1 T2W1 FAT SAT T1 STIR FAT SAT T2 Gadolinium studies MR arthrography
  5. 5. T1
  6. 6. T2
  7. 7. PD Fat Suppression STIR
  8. 8. MRI Rules T1 T2 Fat Hyperintense Hyperintense Water Hypointense hyperintense Cortical bone Hypointense Hypointense Fibrous tissue Hypointense Hypointense Cartilage Isointense Isointense
  9. 9. Indications of MRI Occult fracture Marrow abnormality Ligament pathology Tendon pathology Muscular injury Infection Bone and soft tissue tumour
  10. 10. Sections Coronal- Ant. To Post. Saggital- Lateral to Medial Axial- From above downward Position for knee MRI- Knee in full extension and 5 degree of internal rotation
  11. 11. Meniscal Tear  Imaging Criteria 1. Presence of linear signal intensity weather reaching superior or inferior articular surface or not 2. Abnormal meniscal morphology
  12. 12. Meniscal Tear  Grade Grade 1- Globular signal within the meniscus Grade 2- Linear signal within the meniscus not reaching the articular surface Grade 3- Linear signal within the meniscus reaching the articular surface
  13. 13. Grade I Grade II Grade III
  14. 14. Radial tear- Tear perpendicular to free edge of meniscus
  15. 15. Longitudinal tear
  16. 16.  Bucket Handle Tear- Longitudinal tear along the length of the meniscus and the inner rim flips into the intercondylar notch while remaining attached to the anterior and posterior horns.  Double-PCL sign -The flipped fragment lies inferior and anterior to the PCL
  17. 17. Bucket Handle tear
  18. 18. Anterior flipped horn
  19. 19. Meniscal cyst  Joint fluid is expressed into adjacent soft tissue through the tear  Mostly occur in medial compartment  Most common associated tear is horizontal cleavage tear
  20. 20. Discoid Meniscus-  More common on lateral side  High incidence of tear than normal meniscus  Complete- Meniscus is a large slab of fibrocartilage instead of a crescent shaped wedge  Incomplete- If lateral meniscus has wedge shaped but wedging is larger than that of medial meniscus  Instability is more in complete discoid meniscus
  21. 21. Complete discoid menscus
  22. 22. Meniscocapsular separation  Fluid signal between posterior portion of medial meniscus and joint capsule
  23. 23. Anterior Cruciate Ligament  Straight, parallel to Blumensaat line  Linear striated appearance with intermediate signal intensity on T2 weighed image
  24. 24. ACL Tear Acute-  Replacement of normal striated appearance by cloud like high signal intensity  Discontinuity of ligament and fibres don’t go parallel to intercondylar roof Chronic- Nonvisualisation of ligament or Angulation of ligament because of scarring Shallow orientation not parallel to intercondylar roof
  25. 25. Normal Acute tear
  26. 26. Discontinuous fibres non visible fibres
  27. 27. Chronic tear
  28. 28. Empty notch sign  Seen in complete ACL tear
  29. 29. ACL cystic mucoid degeneration  Ligaments appear thickened and ill defined  MRI- Increased signal on all sequences  Mimic ACL tear
  30. 30. Deep lateral femoral notch sign  Indicator of chronic ACL insufficiency but may also be seen in acute tear
  31. 31. Associated injuries with ACL  O’Donoghue’s triad-  ACL rupture  MCL injury  Medial meniscal tear
  32. 32. O’Donoghue’s triad
  33. 33. Segond Fracture
  34. 34. Other bony injuries with ACL tear  Bruise in weight bearing portion of lateral femoral condyle and posterior aspect of lateral tibial plateu due to internal rotation of tibia and valgus angulation of knee
  35. 35. Uncovered Meniscus 7mm
  36. 36. Posterior Cruciate Ligament  Normal- Uniform low signal intensity on all MR sequences
  37. 37. Tear- Generalised thickening of ligament with intermediate signal intensity on T1 weighed sequence and heterogenous high signal intensity on T2 weighed sequence
  38. 38. Medial Collateral Ligament  Grade I- Mild partial interstitial tear ,appears as edema along superficial aspect  Grade II- Extensive interstitial partial tear ,appears as thickening of ligament with internal signal abnormality or frank thining due to extensive partial tear  Grade III- Complete rupture of ligament
  39. 39. Grade I Grade II Grade III
  40. 40. Lateral Collateral Ligament tear
  41. 41. Iliotibial Band Injury  Overuse injury usually seen in runners and bicyclists  Iliotibial band Friction syndrome- Due to rubbing of ITB against lateral femoral condyle
  42. 42. Quadriceps rupture  Appears as balled up and mildly retracted tendon edge with edema in surrounding soft tissue and tendon gap
  43. 43. Jumper knee/Patellar tendinitis  Overuse injury to proximal aspect of patellar tendon  Usually seen in basket/volleyball players  Misnomer, mucoid degeneration of collagen fibres of tendon  MRI- Swelling of proximal aspect of tendon with internal high signal intensity. Fusiform swelling Edema in Hoffas fat pad
  44. 44. Osgood Schlatter disease  Degeneration of distal aspect of patellar tendon  Triad- Pain, soft tissue swelling, ossification in distal aspect of patellar tendon  MRI- Enlarged distal tendon with low signal intensity foci of heterotopic ossification
  45. 45. Lateral dislocation of patella  Bony bruise in medial aspect of patella and lateral aspect of lateral femoral condyle  Tear of medial retinaculum appears as thickening and internal high signal intensity on T2 weighed image  Tear of vastus medialis oblique muscle appear as high signal intensity on T2 weighed image
  46. 46. Baker cyst  Fluid collection in semimembranosus- medial gastrocnemius bursa  Axial MRI- comma shaped with neck extending between tendon of medial gastrocnemius and semimembranosus tendon
  47. 47. Baker cyst
  48. 48. Pes Anserinus Bursitis  Pes anserinus bursa is located between tendon of pes anserinus and medial collateral ligament  MRI- High signal intensity fluid filled bursa with low signal intensity internal debris
  49. 49. Superficial infrapatellar bursitis/Preacher’s knee  Present anterior to tibial tubercle and distal aspect of patellar tendon  Named so because it gets compressed between tibial tubercle and wooden bench on which a preacher sit  MRI- Low signal intensity on T1 sequence and high intensity on T2 sequence
  50. 50. Synovitis  Fat suppressed T1 weighed image after iv contrast shows thickened synovium
  51. 51. Osteochondral injury  Can be a focal cartilage contusion or loose osteochondral fragment  Instability- On T2 weighed image fluid signal intensity in the interface between fragment and donor pit and cystic change adjacent to donor pit
  52. 52. High signal at interface Cyst Osteochondral injury
  53. 53. Chondromalacia patella  Inflammation of underside of patella and softening of cartilage.  Common in young adults, can mimic meniscal tear
  54. 54. Grade MRI finding I Focal signal intensity changes without contour deformity (difficult to assess on MRI) II Focal signal intensity change and contour bulge (partial thickness) III Focal signal intensity change, contour irregularities, cartilage thinning and fluid extension into cartilage (full thickness) IV Similar to stage III with defects extending to the cortical bone (with subchondral bony changes)
  55. 55. Normal GradeII Grade II
  56. 56. Grade IVGrade III
  57. 57. Osteochondritis dissecans  Occur due to blood deprivation Cracks forms in cartilage and subchondral bone Fragmentation of cartilage and bone in the joint
  58. 58. Osteochondritis dissecans - Staging Stage I : lesion 1-3cm ; intact cartilage Stage II : Cartilage defect ; no loose body Stage III : Partially detached ost.chond fragment Stage IV : Complete separation ; loose body +
  59. 59. Complete medial plica  Plicae are remnants of fetal synovial tissue  Symptomatic only if complete  Forms a shelf from medial side of joint capsule to infrapatella fat pad  Overuse injury in sports like running,bicycling  MRI- Thickened low signal intensity on T2 weighed image
  60. 60. Complete medial plica
  61. 61. Avascular Necrosis  Initial ischemia- Large area of ill defined marrow edema  If ischemia persists- avascular necrosis of bone occur in subchondral portion manifested as single or double rim of demarcation and may have appearance of fat, edema,blood or sclerosis
  62. 62. Initial ischemia Avascular necrosis (demarcated zone )
  63. 63. Spontaneous Osteonecrosis of knee(SONK)/ Subchondral insufficiency fracture of knee(SIFK)  Subchondral fracture followed by osteonecrosis  MRI- Subchondral linear component representing fracture with low signal intensity and surrounding marrow edema with high signal intensity

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