Imaging of sports injuries in adolescents.

Musculoskeletal injuries in adolescents tend to occur in particular locations and have distinct characteristics, as they affect an immature skeleton. Increased engagement in sports, extended training and competition periods, and early specialization in specific sports, among other factors, have contributed significantly to the rise in musculoskeletal sports injuries in adolescents. Furthermore, females show a particularly pronounced increase in sports participation, where anatomical and hormonal factors play crucial roles in the development and increased frequency of sports-related injuries. Consequently, there is a growing demand for diagnostic imaging techniques. Musculoskeletal and pediatric radiologists require a comprehensive understanding of intrinsic and extrinsic risk factors and the successive stages of skeletal development that can influence the specific characteristics of sports injuries in adolescents. These aspects are crucial for the diagnostic, prognostic, and therapeutic management of these injuries and for mitigating chronic conditions that could compromise future sports participation. This review analyzes the primary musculoskeletal injuries in adolescent athletes and highlights the pivotal role of different imaging methods in their diagnosis and management.

Prevalence of hip femoroacetabular impingement deformities in high-level (La Liga) male professional football players.

BACKGROUND: Femoroacetabular impingement (FAI) is considered one of the main causes of hip osteoarthritis in young adults, especially in athletes. In recent years, morphological changes in FAI in the hip have been linked to early and intense sports participation, but studying top-level athlete samples is not easy. This paper presents the prevalence of FAI radiological markers in 120 active white male professional football players in the Spanish First Division League (La Liga) and compares the morphological changes with those of a control group of healthy individuals without significant sport activity. METHODS: The precontract medical evaluation hip X-rays of 120 white male professional football players from four different First Division Spanish football teams were prospectively filed and retrospectively reviewed by a dedicated skeletal radiologist. The footballers' hip X-rays were compared with those of a control group of 80 healthy individuals (age-sex matched) without significant sport activity (obtained from routine work medical checks). RESULTS: The femoral head-neck deformity associated with the Cam type of femoroacetabular impingement was observed in 61.6% of professional football players and only in 11.6% of the control group (p <0.01). The presence of "herniation pit" (11.6%) and os acetabuli (13.3%) also reached statistical significance in the professional football players group. In the other analyzed parameters, no statistically significant differences between the groups were observed. CONCLUSIONS: White professional top-level football players have an increased incidence of abnormal lateral epiphyseal extension ("pistol grip deformity"), os acetabuli and herniation pits.

Ultrasound guided ultra-minimally invasive long head of the biceps tendon release: Anatomic and cadaver study.

PURPOSE: The aim of this study was to describe in volunteers and cadavers the location of the vascular structures at risk for performing a new safe and effective ultra-minimally invasive ultrasound guided long head of the biceps tendon (LHBT) release. METHODS: First, with Doppler ultrasound, we defined the position of the acromial artery from our distal cutting point, on the posterior margin of the LHBT. Second, we performed an ultra-minimally invasive ultrasound guided LHBT release in cadavers. We described the stump and reported safety (no rotator cuff, vascular, or articular damages) and efficacy (tendon release rate). RESULTS: In 20 volunteers, the mean distance from the distal cutting point to the acromial artery was 0.9 ± 0.1 cm (range, 0.3-1.6). Ultra-minimally invasive LHBT release was safe and fully effective in the eight specimens. The proximal stump measured a mean of 2.8 cm (range, 1.9-4). There were no complications. CONCLUSIONS: A safe and effective ultra-minimally invasive ultrasound guided LHBT release in cadavers is feasible through an anterior approach.

Interdisciplinary consensus statements on imaging of DRUJ instability and TFCC injuries.

OBJECTIVES: The purpose of this agreement was to establish evidence-based consensus statements on imaging of distal radioulnar joint (DRUJ) instability and triangular fibrocartilage complex (TFCC) injuries by an expert group using the Delphi technique. METHODS: Nineteen hand surgeons developed a preliminary list of questions on DRUJ instability and TFCC injuries. Radiologists created statements based on the literature and the authors' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panelists consisted of twenty-seven musculoskeletal radiologists. The panelists scored their degree of agreement to each statement on an 11-item numeric scale. Scores of "0," "5," and "10" reflected complete disagreement, indeterminate agreement, and complete agreement, respectively. Group consensus was defined as a score of "8" or higher for 80% or more of the panelists. RESULTS: Three of fourteen statements achieved group consensus in the first Delphi round and ten statements achieved group consensus in the second Delphi round. The third and final Delphi round was limited to the one question that did not achieve group consensus in the previous rounds. CONCLUSIONS: Delphi-based agreements suggest that CT with static axial slices in neutral rotation, pronation, and supination is the most useful and accurate imaging technique for the work-up of DRUJ instability. MRI is the most valuable technique in the diagnosis of TFCC lesions. The main indication for MR arthrography and CT arthrography are Palmer 1B foveal lesions of the TFCC. CLINICAL RELEVANCE STATEMENT: MRI is the method of choice for assessing TFCC lesions, with higher accuracy for central than peripheral abnormalities. The main indication for MR arthrography is the evaluation of TFCC foveal insertion lesions and peripheral non-Palmer injuries. KEY POINTS: • Conventional radiography should be the initial imaging technique in the assessment of DRUJ instability. CT with static axial slices in neutral rotation, pronation, and supination is the most accurate method for evaluating DRUJ instability. • MRI is the most useful technique in diagnosing soft-tissue injuries causing DRUJ instability, especially TFCC lesions. • The main indications for MR arthrography and CT arthrography are foveal lesions of the TFCC.

Ankle Instability Update.

Sprains are the most frequent injuries of the ankle, especially in sports. Up to 85% of cases affect the lateral ligament complex. Multi-ligament injuries with associated lesions of the external complex, deltoid, syndesmosis, and sinus tarsi ligaments are also common. Most ankle sprains respond to conservative treatment. However, up to 20 to 30% of patients can develop chronic ankle pain and instability.New concepts have been recently developed, based on arthroscopic advances, such as microinstability and rotatory ankle instability. These entities could be precursors of mechanical ankle instability and at the origin of frequently associated ankle injuries, such as peroneus tendon lesions, impingement syndromes, or osteochondral lesions.Imaging methods, especially magnetic resonance (MR) imaging and MR arthrography, are key in precisely diagnosing ligament lesions and associated injuries, facilitating an adequate therapeutic approach.

Collapse after Carpal Bone Tunneling. An Underreported Complication?

PURPOSE: To report the complication of carpal bone tunnel collapse in scapholunate reconstruction. METHODS: The authors present six cases of carpal collapse or bone necrosis after bone tunneling for ligamentous reconstruction, three in the scaphoid bone and three in the lunate. RESULTS: All six cases were secondary to ligament reconstruction for chronic scapholunate dissociations, none of which had preoperative structural scaphoid or lunate deformities. CONCLUSIONS: Although the incidence of this occurrence is unknown, the consequences could be substantial; therefore, patients should be warned of this possibility when discussing complications of ligament reconstruction for chronic scapholunate instability requiring the creation of a bone tunnel. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Presurgical Perspective and Postsurgical Evaluation of Instability and Microinstability Secondary to Ankle Ligaments Injury.

Injuries of the ankle ligaments complexes are very common, and ∼ 20 to 40% of patients can develop chronic ankle instability (CAI). Current concepts in CAI allow a better understanding of the ankle biomechanics needed to repair it. The surgical treatment of CAI has evolved in the last decade, and ankle arthroscopy has become an essential tool in the treatment of instability with promising results. We review the different surgical techniques to treat CAI, both those frequently used and the new approaches, as well as the normal postsurgical appearance of ankle ligaments repair and the most common complications.

Interdisciplinary consensus statements on imaging of scapholunate joint instability.

OBJECTIVES: The purpose of this agreement was to establish evidence-based consensus statements on imaging of scapholunate joint (SLJ) instability by an expert group using the Delphi technique. METHODS: Nineteen hand surgeons developed a preliminary list of questions on SLJ instability. Radiologists created statements based on the literature and the authors' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panellists consisted of twenty-seven musculoskeletal radiologists. The panellists scored their degree of agreement to each statement on an eleven-item numeric scale. Scores of '0', '5' and '10' reflected complete disagreement, indeterminate agreement and complete agreement, respectively. Group consensus was defined as a score of '8' or higher for 80% or more of the panellists. RESULTS: Ten of fifteen statements achieved group consensus in the second Delphi round. The remaining five statements achieved group consensus in the third Delphi round. It was agreed that dorsopalmar and lateral radiographs should be acquired as routine imaging work-up in patients with suspected SLJ instability. Radiographic stress views and dynamic fluoroscopy allow accurate diagnosis of dynamic SLJ instability. MR arthrography and CT arthrography are accurate for detecting scapholunate interosseous ligament tears and articular cartilage defects. Ultrasonography and MRI can delineate most extrinsic carpal ligaments, although validated scientific evidence on accurate differentiation between partially or completely torn or incompetent ligaments is not available. CONCLUSIONS: Delphi-based agreements suggest that standardized radiographs, radiographic stress views, dynamic fluoroscopy, MR arthrography and CT arthrography are the most useful and accurate imaging techniques for the work-up of SLJ instability. KEY POINTS: • Dorsopalmar and lateral wrist radiographs remain the basic imaging modality for routine imaging work-up in patients with suspected scapholunate joint instability. • Radiographic stress views and dynamic fluoroscopy of the wrist allow accurate diagnosis of dynamic scapholunate joint instability. • Wrist MR arthrography and CT arthrography are accurate for determination of scapholunate interosseous ligament tears and cartilage defects.

Postoperative Imaging of Ulnar Wrist Pain.

Ulnar wrist pain, caused by a broad spectrum of bone and soft tissue injuries, is the most common clinical condition of the wrist. Multiple surgical techniques and their variants in the treatment of these injuries are constantly evolving. Postoperative evaluation of the wrist for many surgeons is limited to serial clinical and radiographic monitoring. However, imaging methods such as ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and arthrographic techniques (arthrographic CT and arthrographic MRI) play a fundamental role in diagnosing and managing postsurgical complications.The several critical aspects in evaluating the postsurgical wrist imaging spectrum are familiarity with the surgical techniques, knowledge of the original clinical problem, understanding the strength and limitations of the different radiologic modalities, and effective communication between surgeon and radiologist.

Sports Imaging of Team Handball Injuries.

Team handball is a fast high-scoring indoor contact sport with > 20 million registered players who are organized in > 150 federations worldwide. The combination of complex and unique biomechanics of handball throwing, permitted body tackles and blocks, and illegal fouls contribute to team handball ranging among the four athletic sports that carry the highest risks of injury. The categories include a broad range of acute and overuse injuries that most commonly occur in the shoulder, knee, and ankle. In concert with sports medicine, physicians, surgeons, physical therapists, and radiologists consult in the care of handball players through the appropriate use and expert interpretations of radiography, ultrasonography, CT, and MRI studies to facilitate diagnosis, characterization, and healing of a broad spectrum of acute, complex, concomitant, chronic, and overuse injuries. This article is based on published data and the author team's cumulative experience in playing and caring for handball players in Denmark, Sweden, Norway, Germany, Switzerland, and Spain. The article reviews and illustrates the spectrum of common handball injuries and highlights the contributions of sports imaging for diagnosis and management.

Conventional and Arthrographic Magnetic Resonance Techniques for Hip Evaluation: What the Radiologist Should Know.

Over the last 2 decades, the definition of pathomechanical concepts that link osseous deformities to chondrolabral damage and expose young and active patients to the risk of early osteoarthritis has led to a tremendous increase in the number of joint-preserving surgeries performed. The rise in arthroscopic procedures has led to an increasing demand for comprehensive preoperative magnetic resonance imaging (MRI) assessment of the hip joint. This includes conventional MRI for the assessment of extra-articular and periarticular pathologies such as greater trochanteric pain, deep gluteal pain syndrome, and sports injuries. Magnetic resonance arthrography with or without traction is reserved for the accurate evaluation of deformities associated with impingement and hip instability and for detecting the resulting intra-articular lesions. This article summarizes the current standard imaging techniques that the radiologist should know. It also explores the potential of computer-assisted analysis of three-dimensional MRI for virtual impingement simulation and volumetric analysis of cartilage composition and geometry.

Sonographic landmarks in hamstring muscles.

The ultrasound examination of hamstrings inspires respect due to the connective complexity of their structures, particularly for sonographers who are not used to this kind of study. Therefore, it is important to know the specific ultrasound reference points that facilitate the location of the hamstring structures, dividing them into four areas of interest: (a) tendinous origin of the hamstring, (b) the proximal half, (c) distal and medial half, and (d) distal and lateral half. The origin of the hamstrings is found at the level of the ischial tuberosity. Here, the connective structures under study are the common tendon and the semimembranosus tendon, together with the muscle fibers more proximal to the semitendinosus, which can also be assessed through ultrasound locating the ischial tuberosity. The proximal half of the thigh consists of a characteristic structure made up by the common tendon, the sciatic nerve and the semimembranosus tendon, enabling to define the biceps femoris and the semitendinosus, respectively. To identify the distal and medial section, the volumetric relationship between the ST and SM muscle masses is used, where it is also possible to identify the three muscles in the knee that make up the pes anserine. To identify the distal and lateral sections, the sciatic nerve pathway is followed until identifying both heads of the biceps femoris. These four areas of interest, with their specific landmarks, show a tuning fork that enables the comprehensive study of hamstrings through ultrasound.

Current perspectives in conventional and advanced imaging of the distal radioulnar joint dysfunction: review for the musculoskeletal radiologist.

Distal radioulnar joint (DRUJ) dysfunction is a common cause of ulnar sided wrist pain. Physical examination yields only subtle clues towards the underlying etiology. Thus, imaging is commonly obtained towards an improved characterization of DRUJ pathology, especially multimodality imaging, which is frequently resorted to arrive at an accurate diagnosis. With increasing use of advanced MRI and CT techniques, DRUJ imaging has become an important part of a musculoskeletal radiologist's practice. This article discusses the normal anatomy and biomechanics of the DRUJ, illustrates common clinical abnormalities, and provides a comprehensive overview of the imaging evaluation with an insight into the role of advanced cross-sectional modalities in this domain.

Lisfranc Injury Imaging and Surgical Management.

The Lisfranc joint is composed of the cuneiform bones and the cuboid and metatarsal bases, united by a synovial capsule and ligamentous complex. Familiarity with the anatomy is essential for image planning and for understanding injury patterns. The more important structures are the Lisfranc ligament and the plantar ligaments that can be visualized with MR, although careful attention to technique and orientation of scan planes is required for accuracy. A combination of conventional radiographs, computed tomography, and MR allow precise diagnosis of Lisfranc fractures, fracture dislocation, and subtle Lisfranc injuries to guide clinical management and surgical planning.

Evaluation and management of ischiofemoral impingement: a pathophysiologic, radiologic, and therapeutic approach to a complex diagnosis.

Ischiofemoral impingement syndrome (IFI) is an underrecognized form of atypical, extra-articular hip impingement defined by hip pain related to narrowing of the space between the ischial tuberosity and the femur. The etiology of IFI is multifactorial and potential sources of ischiofemoral engagement include anatomic variants of the proximal femur or pelvis, functional disorders as hip instability, pelvic/spinal instability, or abductor/adductor imbalance, ischial tuberosity enthesopathies, trauma/overuse or extreme hip motion, iatrogenic conditions, tumors and other pathologies. Magnetic resonance imaging (MRI) is the diagnostic procedure of choice for assessing IFI and may substantially influence patient management. The injection test of the ischiofemoral space (IFS) has both a diagnostic and therapeutic function. Endoscopic decompression of the IFS appears useful in improving function and diminishing hip pain in patients with IFI but conservative treatment is always the first step in the treatment algorithm. Because of the ever-increasing use of advanced MRI techniques, the frequent response to conservative treatment, and the excellent outcomes of new endoscopic treatment, radiologists must be aware of factors that predispose or cause IFI. In addition, focused treatment in these conditions is often more important than in secondary impingement. In this article, we briefly describe the anatomy of the IFS, review the clinical examination and symptoms, assess the diagnostic imaging criteria and pathophysiological mechanisms, and develop an understandable classification of IFI, with particular focus on its etiology, predisposing factors, and associated musculoskeletal abnormalities. We also assess the role of the radiologist in the diagnosis, treatment, and preoperative evaluation of both primary and secondary IFI.

Normal Shoulder MRI and MR Arthrography: Anatomy and Technique.

The use of MR for the diagnosis of shoulder lesions is well established, as well as MR arthrography for the diagnosis for shoulder instability and microinstability. For an accurate evaluation is essential to know the normal anatomy and variants to avoid the misdiagnosis of a pitfall as pathological condition. In addition we will discuss which variants might be clinically relevant. We will review the classical frequent variants such as intraarticular structures, especially glenohumeral ligaments and labrum but also bone, cartilage and rotator cuff variants and pitfalls. Both static and dynamic structures play an important role providing stability at different positions and with different range of motion.

Deep gluteal syndrome: anatomy, imaging, and management of sciatic nerve entrapments in the subgluteal space.

Deep gluteal syndrome (DGS) is an underdiagnosed entity characterized by pain and/or dysesthesias in the buttock area, hip or posterior thigh and/or radicular pain due to a non-discogenic sciatic nerve entrapment in the subgluteal space. Multiple pathologies have been incorporated in this all-included "piriformis syndrome," a term that has nothing to do with the presence of fibrous bands, obturator internus/gemellus syndrome, quadratus femoris/ischiofemoral pathology, hamstring conditions, gluteal disorders and orthopedic causes. The concept of fibrous bands playing a role in causing symptoms related to sciatic nerve mobility and entrapment represents a radical change in the current diagnosis of and therapeutic approach to DGS. The development of periarticular hip endoscopy has led to an understanding of the pathophysiological mechanisms underlying piriformis syndrome, which has supported its further classification. A broad spectrum of known pathologies may be located nonspecifically in the subgluteal space and can therefore also trigger DGS. These can be classified as traumatic, iatrogenic, inflammatory/infectious, vascular, gynecologic and tumors/pseudo-tumors. Because of the ever-increasing use of advanced magnetic resonance neurography (MRN) techniques and the excellent outcomes of the new endoscopic treatment, radiologists must be aware of the anatomy and pathologic conditions of this space. MR imaging is the diagnostic procedure of choice for assessing DGS and may substantially influence the management of these patients. The infiltration test not only has a high diagnostic but also a therapeutic value. This article describes the subgluteal space anatomy, reviews known and new etiologies of DGS, and assesses the role of the radiologist in the diagnosis, treatment and postoperative evaluation of sciatic nerve entrapments, with emphasis on MR imaging and endoscopic correlation.

Usefulness of MR arthrography of the hip with leg traction in the evaluation of ligamentum teres injuries.

PURPOSE: To retrospectively evaluate the diagnostic accuracy of magnetic resonance (MR) arthrography of the hip with leg traction in the evaluation of ligamentum teres lesions and to evaluate whether there is increased articular distraction, possibly indicating secondary instability, in hips with ligamentum teres injuries. MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained for this retrospective study. MR arthrograms of the hip with leg traction of 184 consecutive patients, including 108 men (mean age, 32.6 years; range, 19-53 years) and 76 women (mean age, 38.5 years; range, 18-56 years), who underwent hip arthroscopy were assessed for the presence of ligamentum teres lesions. The MR arthrographic findings were independently assessed by two radiologists who were blinded to the arthroscopic results. The inclusion criteria stipulated no previous surgery, arthroscopy within 1 month after MR arthrography, and availability of a detailed surgical report with ligamentum teres findings. The arthroscopy findings served as the reference standard. Sensitivity, specificity, accuracy, and K statistics for interobserver and intraobserver agreement were calculated. RESULTS: At arthroscopy, 32 ligamentum teres injuries were found. The ligamentum teres was normal in 152 (82.6%) patients and had suffered low-grade partial tears in 15 (8.1%) patients, high-grade partial tears in 10 (5.4%) patients, and complete ruptures in 7 (3.8%) patients. MR arthrography with axial traction demonstrated moderate sensitivity and high specificity for both low-grade (62/93%) and high-grade (66/96%) partial tears. Grouping low- and high-grade partial tears increased the diagnostic performance of MR arthrography, yielding a sensitivity of 87% and a specificity of 95%. For complete ligamentum teres tears, MR arthrography with leg traction demonstrated high sensitivity (92%) and specificity (98%). Articular distraction was significantly increased in patients with complete ruptures of the ligamentum teres (p = 0.001). CONCLUSION: MR arthrography with leg traction offers accurate diagnosis of ligamentum teres injuries. Patients with complete tears of the ligamentum teres exhibit increased articular distraction that may indicate secondary hip instability.