MRI and arthroscopy correlations of the elbow: a case-based approach.

The number of elbow arthroscopies and indications for the procedure have increased significantly since the advent of modern elbow arthroscopy in the 1980s. In addition to the patient history, physical examination, and plain radiography, MRI is an important tool for the clinician in diagnosing several pathologies within and around the elbow. Understanding the pathophysiology and clinical presentation and being familiar with the MRI characteristics of a variety of elbow conditions will assist the physician in making an accurate diagnosis and help guide appropriate treatment.

MR imaging of femoroacetabular impingement.

FAI is a common cause of OA of the hip. It can be caused by decreased offset of the femoral head and neck, resulting in abutment of the femoral neck against the acetabular rim (cam impingement) and abutment of this area into the well-constrained socket (pincer impingement)within normal range of motion [15]. This repetitive mechanical trauma to the hip joint causes mechanical wear of the labrum and articular cartilage; left untreated, it causes pain, labral tears, and chondral injuries leading to progressive OA of the hip. The identification of FAI as a cause of OA allows appropriate therapy early and thus delays or prevents end-stage arthritis.MR imaging and MR arthrography are accurate noninvasive imaging modalities able to demonstrate acetabular labral disease and adjacent cartilage damage as well as the subchondral cysts and synovial herniation pits associated with impingement. In addition, MR imaging is able to detect underlying subtle anatomic variations of the femoral head-neck junction and acetabulum associated with FAI.

Femoroacetabular impingement.

Femoroacetabular impingement (FAI) is a common cause of early-onset osteoarthritis of the hip. It can be caused by morphologic abnormalities involving the proximal femur or acetabulum, leading to abnormal abutment of the femoral head-neck against the acetabular rim. This repetitive trauma causes mechanical wear of the labrum and articular cartilage, leading to osteoarthritis of the hip. Magnetic resonance imaging is an accurate noninvasive imaging modality that can detect acetabular labral lesions and adjacent cartilage damage, and is able to detect underlying subtle anatomic variations of the femoral head-neck junction and acetabulum associated with FAI.

ACR appropriateness criteria(®) acute trauma to the knee.

There are more than 1 million visits to the ER annually in the United States for acute knee trauma. Many of these are twisting injuries in young patients who can walk and bear weight, and emergent radiography is not required. Several clinical decision rules have been devised that can considerably reduce the number of radiographic studies ordered without missing a clinically significant fracture. Although fractures are seen on only 5% of emergency department knee radiographs, 86% of knee fractures result from blunt trauma. In patients with falls or twisting injuries who have focal tenderness, effusion, or inability to bear weight, radiography should be the first imaging study performed. If radiography shows no fracture, MRI is best for evaluating for a suspected meniscal or ligament tear or patellar dislocation. Patients with knee dislocation should undergo radiography and MRI, as well as fluoroscopic angiography, CT angiography, or MR angiography. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

ACR Appropriateness Criteria® on acute shoulder pain.

The shoulder joint is a complex array of muscles, tendons, and capsuloligamentous structures that has the greatest freedom of motion of any joint in the body. Acute (<2 weeks) shoulder pain can be attributable to structures related to the glenohumeral articulation and joint capsule, rotator cuff, acromioclavicular joint, and scapula. The foundation for investigation of acute shoulder pain is radiography. Magnetic resonance imaging is the procedure of choice for the evaluation of occult fractures and the shoulder soft tissues. Ultrasound, with appropriate local expertise, is an excellent evaluation of the rotator cuff, long head of the biceps tendon, and interventional procedures. Fluoroscopy is an excellent modality to guide interventional procedures. Computed tomography is an excellent modality for characterizing complex shoulder fractures. Computed tomographic arthrography or fluoroscopic arthrography may be alternatives in patients for whom MR arthrography is contraindicated. A multimodal approach may be required to accurately assess shoulder pathology. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Shoulder imaging in athletes.

Shoulder pain and injuries are common in athletes. Overhead athletes, in particular, place great demands on the shoulder and supporting structures. Magnetic resonance (MR) imaging is well suited to evaluation of the osseous structures and soft tissues of the shoulder and plays an important role in evaluation of shoulder pain in athletes. Primary extrinsic impingement is well evaluated on MR imaging as are the less common posterior superior glenoid impingement and subcoracoid impingement. Rotator cuff tendinosis as well as partial- and full-thickness tears are frequently encountered in the athletic shoulder. The biceps tendon and rotator interval capsular structures are important sources of shoulder pain. Glenohumeral instability that results from a traumatic event or atraumatic multidirectional recurrent instability is assessed. The biceps labral complex is a source of considerable anatomic variability and pathology.

Impingement syndrome of the ankle following supination external rotation trauma: MR imaging findings with arthroscopic correlation.

Our objective was to identify MR imaging findings in patients with syndesmotic soft tissue impingement of the ankle and to investigate the reliability of these imaging characteristics to predict syndesmotic soft tissue impingement syndromes of the ankle. Twenty-one ankles with chronic pain ultimately proven to have anterior soft tissue impingement syndrome were examined by MR imaging during January 1996 to June 2001. The MR imaging protocol included sagittal and coronal short tau inversion recovery (STIR), sagittal T1-weighted spin echo, axial and coronal proton-density, and T2-weighted spin-echo sequences. Nineteen ankles that underwent MR imaging during the same period of time and that had arthroscopically proven diagnosis different than impingement syndrome served as a control group. Fibrovascular scar formations distinct from the syndesmotic ligaments possibly related to syndesmotic soft tissue impingement were recorded. Arthroscopy was performed subsequently in all patients and was considered the gold standard. The statistical analysis revealed an overall frequency of scarred syndesmotic ligaments of 70% in the group with ankle impingement. Fibrovascular scar formations distinct from the syndesmotic ligaments presented with low signal intensity on T1-weighted images and remained low to intermediate in signal intensity on T2-weighted MR imaging. Compared with arthroscopy, MR imaging revealed a sensitivity of 89%, a specificity of 100%, and a diagnostic accuracy of 93% for scarred syndesmotic ligaments. The frequency of scar formation distinct from the syndesmotic ligaments in patients with impingement syndrome of the ankle was not statistically significantly higher than in the control group. In contrast to that, anterior tibial osteophytes and talar osteophytes were statistically significantly higher in the group with anterior impingement than in the control group. Conventional MR imaging was found to be insensitive for the diagnosis of syndesmotic soft tissue impingement of the ankle. Fibrovascular scar tissue distinct from syndesmotic ligaments is suggestive for the diagnosis of soft tissue impingement, but the reliability of these findings is still questionable.

Perthes lesion (a variant of the Bankart lesion): MR imaging and MR arthrographic findings with surgical correlation.

OBJECTIVE: The aim of this study was to evaluate the use of MR imaging in the characterization of the Perthes lesion by correlating MR findings with findings at arthroscopy. CONCLUSION: The use of a combination of axial and abduction-external rotation position sequences on MR images can be helpful in the diagnosis of a Perthes lesion. A fluid-filled joint with capsular distension, caused by either a large amount of effusion or MR arthrography, was found to be helpful in outlining Perthes lesions. Adding the abduction-external rotation position to the protocol in patients in whom Perthes lesion is suspected will increase diagnostic accuracy and may reveal a Perthes lesion not visible on axial images, as was the case in 50% of the patients in our series.