Venous thrombosis: a mimic of musculoskeletal injury on MR imaging.

Clinical signs and symptoms of venous thrombosis and musculoskeletal pathologies frequently overlap. Sometimes, patients with venous thrombosis undergo MR examinations under an equivocal suspicion of muscle, tendon or articular injury. A low pretest clinical suspicion and lack of familiarity with the conventional MR imaging signs of venous thrombosis may result in failure to diagnose venous thrombosis, delaying treatment and raising morbimortality. In MR imaging, thrombosis presents as venous ectasia with intraluminal heterogeneous content. Small vein thrombosis is often identified as having a branching aspect. Perivenous edema and inflammatory soft tissue changes may be the most prominent findings. The purpose of this paper is to illustrate MR findings of venous thrombosis in patients who underwent MR examinations due to suspected musculoskeletal pathologies. Cases of venous thrombosis in different sites of the body diagnosed through MR are presented.

Anterolateral ligament MRI of the knee in ACL injuries: MRI abnormalities association with instability.

OBJECTIVE: To evaluate anterolateral ligament abnormalities (ALL) at MRI scans and correlate with data from clinical instability tests (Lachman and pivot shift) performed under anesthesia in patients with acute anterior cruciate ligament (ACL) tears. Furthermore, perform multivariate analysis with other variables to isolate the ALL contribution to instability from other abnormalities. METHODS: Retrospective analysis of MRI and instability tests of 95 patients with ACL tears. The ALL was classified as no abnormality, abnormality without discontinuity, and discontinuity. Injuries in other knee ligament structures and menisci were also assessed. Results of instability tests (pivot shift and Lachman) with the patient anesthetized for arthroscopic ACL reconstruction were obtained from the patient database. Statistical analysis was performed using the IBM SPSS 22. RESULTS: ALL abnormalities and iliotibial band (ITB), lateral (LCL), and medial (MCL) collateral ligament injuries showed a statistically significant correlation with the pivot shift test. The ALL MRI abnormalities were associated with the high-grade pivot shift results (p < 0.0005), with an odds ratio of 55.9 for high degrees of pivot shift in patients with abnormal ALL. The logistic model for all variables analyzed with the results of the pivot shift test demonstrated that the ALL was the only variable with a statistically significant correlation in the model (p < 0.0005). CONCLUSION: MRI ALL abnormalities in patients with ACL injuries have a significant association with pivot shift test results in patients under anesthesia. The logistic model for high - grade pivot shift test results demonstrated that ALL abnormalities were the only variable with significant correlation. KEY POINTS: • Evaluating the anterolateral ligament with MRI in acute anterior cruciate ligament injuries is useful to predict higher grades of pivot shift test in the moment of the arthroscopic reconstruction. • An abnormal anterolateral ligament presented an odds ratio of 55 for high degrees of pivot shift. • ALL MRI abnormalities association with knee instability is independent from other internal knee injuries.

Patient demographic and magnetic resonance imaging evaluation of isolated posterolateral corner knee injuries.

Background: Posterolateral stability of the knee is maintained by capsular, ligamentous and tendinous structures, which collectively are known as the posterolateral corner (PLC). Injuries to the PLC of the knee rarely occur without associated anterior (ACL) or posterior cruciate (PCL) ligament tears. The main objectives of our study were to report patient demographics and magnetic resonance imaging (MRI) findings of patients with isolated PLC injuries. Methods: This study consists of a retrospective analysis of knee MRI from January 2011 to June 2016, in two hospitals in São Paulo, Brazil, where PLC injuries without associated ACL and PCL injuries were identified in MRI by two radiologists specialized in musculoskeletal injuries. Relative and absolute frequencies were used to describe the injuries of each of the PLC structures in the study cases. Results: A total of 23 cases of PLC injuries without associated cruciate ligament injuries were identified. The mean age of patients was 32.0±8.1 years and 91% patients were male. The main sport associated with isolated PLC injury was Brazilian Jiu-Jitsu (48%), followed by soccer (35%). MRI evaluations of the knees showed lateral collateral ligament (LCL) injuries in 70% of cases, popliteus tendon injuries in 26% of cases and distal biceps tendon injuries in 30% of cases. The popliteofibular ligament (PFL) was damaged in 83% of cases. An associated ALL injury was observed in 43% of cases. Conclusions: Isolated PLC injuries occurred mainly in young men when practicing Brazilian Jiu-Jitsu and soccer. The LCL was the most frequently injured larger structure in association, and the capsuloligamentous structures (PFL) were the most frequently injured structures overall. ALL injuries occurred in approximately half of the cases, most often concomitantly with LCL injuries.

Magnetic resonance imaging findings in patients with polymyalgia rheumatica.

Objective: To describe the prevalence of magnetic resonance imaging (MRI) findings in patients with the clinical diagnosis of polymyalgia rheumatica (PMR). Materials and Methods: Sixteen consecutive patients with untreated PMR, meeting the American College of Rheumatology criteria, underwent MRI examinations of the shoulder(s), hip(s), or both, depending on clinical complaints. Six patients also underwent MRI of the spine. Results: We evaluated 24 shoulders, among which we identified subacromial-subdeltoid bursitis in 21 (87.5%), glenohumeral joint effusion in 17 (70.8%), and fluid distention of the long head of the biceps tendon sheath in 15 (62.5%). Peritendinitis and capsular edema were observed in 21 (87.5%) and 17 (70.8%) shoulders, respectively. We also evaluated 17 hips, identifying hip joint effusion in 12 (70.6%), trochanteric bursitis in 11 (64.7%), peritendinitis in 17 (100%), and capsular edema in 14 (82.4%). All six of the patients who underwent MRI of the spine were found to have interspinous bursitis. Conclusion: Subacromial-subdeltoid bursitis, glenohumeral joint effusion, and hip joint effusion are common findings in patients with PMR. In addition, such patients appear to be highly susceptible to peritendinitis and capsular edema. There is a need for case-control studies to validate our data and to determine the real impact that these findings have on the diagnosis of PMR by MRI.

Objetivo: Descrever os achados de ressonância magnética (RM) mais prevalentes em pacientes com diagnóstico clínico de polimialgia reumática (PMR). Materiais e Métodos: Dezesseis pacientes com PMR não tratada, classificados pelos critérios do American College of Rheumatology, foram submetidos a RM do ombro e/ou quadril, segundo suas queixas clínicas. Seis pacientes também foram submetidos a RM da coluna. Resultados: Foram avaliados 24 ombros, identificando-se bursite subacromial-subdeltoide em 21 (87,5%), sinovite glenoumeral em 17 (70,8%) e distensão líquida da bainha do tendão da cabeça longa do bíceps em 15 (62,5%). Peritendinite e edema capsular foram observados em 21 (87,5%) e 17 (70,8%) ombros, respectivamente. Dezessete quadris foram analisados, identificando-se sinovite em 12 (70,6%), bursite trocantérica em 11 (64,7%), peritendinite em 17 (100%) e edema capsular em 14 (82,4%). Os seis pacientes que realizaram RM da coluna apresentavam bursite interespinhosa. Conclusão: Bursite subacromial-subdeltoide, sinovite glenoumeral e do quadril são achados de imagem prevalentes em pacientes com PMR. Além disso, achados como peritendinite e edema capsular tiveram alta prevalência nesses pacientes. Estudos de casocontrole devem ser realizados para validar esses dados e estabelecer o real impacto desses achados no diagnóstico de PMR.

Magnetic resonance imaging findings in patients with polymyalgia rheumatica / Achados de ressonância magnética em pacientes com polimialgia reumática

Abstract Objective: To describe the prevalence of magnetic resonance imaging (MRI) findings in patients with the clinical diagnosis of polymyalgia rheumatica (PMR). Materials and Methods: Sixteen consecutive patients with untreated PMR, meeting the American College of Rheumatology criteria, underwent MRI examinations of the shoulder(s), hip(s), or both, depending on clinical complaints. Six patients also underwent MRI of the spine. Results: We evaluated 24 shoulders, among which we identified subacromial-subdeltoid bursitis in 21 (87.5%), glenohumeral joint effusion in 17 (70.8%), and fluid distention of the long head of the biceps tendon sheath in 15 (62.5%). Peritendinitis and capsular edema were observed in 21 (87.5%) and 17 (70.8%) shoulders, respectively. We also evaluated 17 hips, identifying hip joint effusion in 12 (70.6%), trochanteric bursitis in 11 (64.7%), peritendinitis in 17 (100%), and capsular edema in 14 (82.4%). All six of the patients who underwent MRI of the spine were found to have interspinous bursitis. Conclusion: Subacromial-subdeltoid bursitis, glenohumeral joint effusion, and hip joint effusion are common findings in patients with PMR. In addition, such patients appear to be highly susceptible to peritendinitis and capsular edema. There is a need for case-control studies to validate our data and to determine the real impact that these findings have on the diagnosis of PMR by MRI.

Resumo Objetivo: Descrever os achados de ressonância magnética (RM) mais prevalentes em pacientes com diagnóstico clínico de polimialgia reumática (PMR). Materiais e Métodos: Dezesseis pacientes com PMR não tratada, classificados pelos critérios do American College of Rheumatology, foram submetidos a RM do ombro e/ou quadril, segundo suas queixas clínicas. Seis pacientes também foram submetidos a RM da coluna. Resultados: Foram avaliados 24 ombros, identificando-se bursite subacromial-subdeltoide em 21 (87,5%), sinovite glenoumeral em 17 (70,8%) e distensão líquida da bainha do tendão da cabeça longa do bíceps em 15 (62,5%). Peritendinite e edema capsular foram observados em 21 (87,5%) e 17 (70,8%) ombros, respectivamente. Dezessete quadris foram analisados, identificando-se sinovite em 12 (70,6%), bursite trocantérica em 11 (64,7%), peritendinite em 17 (100%) e edema capsular em 14 (82,4%). Os seis pacientes que realizaram RM da coluna apresentavam bursite interespinhosa. Conclusão: Bursite subacromial-subdeltoide, sinovite glenoumeral e do quadril são achados de imagem prevalentes em pacientes com PMR. Além disso, achados como peritendinite e edema capsular tiveram alta prevalência nesses pacientes. Estudos de caso- controle devem ser realizados para validar esses dados e estabelecer o real impacto desses achados no diagnóstico de PMR.

Biomechanical evaluation in runners with Achilles tendinopathy.

OBJECTIVES: To evaluate the clinical characteristics, ground reaction force (GRF), and function of the plantar muscles and dorsiflexors of the ankle in runners with and without Achilles tendinopathy (AT) and in non-runners. METHODS: Seventy-two participants (42 men, 30 women; mean age: 37.3±9.9 years) were enrolled in this cross-sectional study and divided into three groups: AT group (ATG, n=24), healthy runners' group (HRG, n=24), and non-runners' group (NRG, n=24). Both ankles were evaluated in each group. The American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale was used for clinical and functional evaluation. GRF was evaluated using force plates and muscle strength was evaluated using an isokinetic dynamometer. RESULTS: The AOFAS scores were lower in the ATG. The strike impulse was higher in the ATG than in the HRG and NRG. However, GRF was similar among the groups. The ATG exhibited lower total work at 120°/s speed than the HRG. The peak torque in concentric dorsiflexion was lower in the NRG than in the ATG and HRG. The peak torque and total work in concentric plantar flexion were lower in the NRG than in the ATG. The peak torque and total work in eccentric plantar flexion were lower in the NRG than in the ATG and HRG. CONCLUSION: Runners with AT showed higher strike impulse, lower muscle strength of the plantar flexors, and higher clinical and functional damage.

Degenerative Medial Meniscus Tear With a Displaced Flap Into the Meniscotibial Recess and Tibial Peripheral Reactive Bone Edema Presents Good Results With Arthroscopic Surgical Treatment.

PURPOSE: To report the arthroscopic treatment results of a degenerative medial meniscus tear with a displaced flap into the meniscotibial recess, tibial peripheral reactive bone edema, and focal knee medial pain. As a secondary objective, we propose to identify possible factors associated with a good or poor prognosis of the surgical treatment of this lesion. METHODS: From 2012 to 2018, patients who had this specific meniscus pathology and underwent arthroscopic surgical treatment were retrospectively evaluated. Patients with Kellgren-Lawrence (KL) classification greater than 2 were excluded. KL classification, the presence of an Outerbridge grade III/V chondral lesion of the medial compartment, limb alignment, body mass index, and smoking were evaluated. The subjective outcomes included the International Knee Documentation Committee score, improvement in the pain reported by patients, and the Global Perceived Effect (GPE) scale score. RESULTS: A total of 69 patients were evaluated. The mean age was 58.6 ± 7.1 years. The follow-up time was 48.7 ± 20.8 months. Fifty-five (79.7%) patients reported pain improvement. The postoperative International Knee Documentation Committee was 62.6 ± 15.4, and the mean GPE was 2.3 ± 2.6. Fourteen patients (20.3%) showed no improvement in pain, and 7 patients (10.2%) presented complications. Groups that improved (GPE > 0) and did not improve (GPE < 0) did not present differences regarding age, sex, follow-up time, chondral lesions, or body mass index. Patients without improvement had a greater incidence of smoking (P = .001), varus alignment (P = .008), and more advanced KL classification (P < .001). In the multivariate analysis based on the GPE score, KL classification (P = .038) and smoking (P = .003) were significant. CONCLUSIONS: Arthroscopic surgical treatment of degenerative medial meniscal tears with a meniscal flap displaced into the meniscotibial recess and adjacent focal bone edema in the tibia shows good results in approximately 80% of cases. Smoking and KL grade 2 were factors associated with poor prognosis of surgical treatment. LEVEL OF EVIDENCE: Level IV (case series).

Biomechanical evaluation in runners with Achilles tendinopathy

OBJECTIVES: To evaluate the clinical characteristics, ground reaction force (GRF), and function of the plantar muscles and dorsiflexors of the ankle in runners with and without Achilles tendinopathy (AT) and in non-runners. METHODS: Seventy-two participants (42 men, 30 women; mean age: 37.3±9.9 years) were enrolled in this cross-sectional study and divided into three groups: AT group (ATG, n=24), healthy runners' group (HRG, n=24), and non-runners' group (NRG, n=24). Both ankles were evaluated in each group. The American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale was used for clinical and functional evaluation. GRF was evaluated using force plates and muscle strength was evaluated using an isokinetic dynamometer. RESULTS: The AOFAS scores were lower in the ATG. The strike impulse was higher in the ATG than in the HRG and NRG. However, GRF was similar among the groups. The ATG exhibited lower total work at 120°/s speed than the HRG. The peak torque in concentric dorsiflexion was lower in the NRG than in the ATG and HRG. The peak torque and total work in concentric plantar flexion were lower in the NRG than in the ATG. The peak torque and total work in eccentric plantar flexion were lower in the NRG than in the ATG and HRG. CONCLUSION: Runners with AT showed higher strike impulse, lower muscle strength of the plantar flexors, and higher clinical and functional damage.

Is there something new regarding triceps brachii muscle insertion?

PURPOSE: Previous studies have questioned whether the triceps brachii muscle tendon (TBMT) has a double or single insertion on the ulna. Aiming to provide an answer, we describe the anatomy of the TBMT and review a magnetic resonance imaging (MRI) series of the elbow. METHODS: Forty-one elbows were dissected to assess the details of the triceps brachii insertion. Elbow plastination slices were analyzed to determine whether there was a space on the TBMT. Magnetic resonance imaging from the records of the authors were also obtained to demonstrate the appearance of the pre-tricipital space on MRI. RESULTS: A virtual space on the medial aspect near the TBTM insertion site in the olecranon was consistently found on anatomic dissections. It was a distal pre-tricipital space. Magnetic resonance imaging demonstrated the appearance of the pre-tricipital space on MRI, and its extension was measured longitudinally either in elbow flexion or extension. There was no statistically significant difference between the measurements of this space in the right and left elbows or between flexion and extension (p > 0.05). The coefficient of variation was <10% for all measurements. CONCLUSION: Knowledge of this structure may be essential to avoid incorrect diagnosis and unnecessary therapeutic interventions.

Accuracy of magnetic resonance imaging for diagnosing hallux valgus.

OBJECTIVE: To assess the accuracy of magnetic resonance imaging (MRI) for the diagnosis of hallux valgus using radiography during weight bearing as the gold standard. MATERIALS AND METHODS: This was a retrospective analysis of all patients undergoing MRI of the foot and radiography of the foot during weight bearing at our institution between January and June of 2015. The hallux valgus angle (HVA) was measured on MRI and radiography. The Wilcoxon signed-rank test and simple linear regression were used in order to compare measurements. Patients were divided into two groups according to the HVA determined on radiography: > 15° (hallux valgus) and ≤ 15° (control). Qualitative and quantitative assessments of MRI scans were performed. For quantitative assessment, receiver operating characteristic curves were used in order to determine the HVA cutoff with the highest accuracy. RESULTS: A total of 66 MRI scans were included, 22 in the hallux valgus group and 44 in the control group. Wilcoxon signed-rank tests indicated a significant difference between the radiography and MRI measurements. Simple linear regression showed a nonlinear relationship between the measurements and values did not present a strong correlation. In comparison with the radiography measurements, MRI with an HVA cutoff of 16.4° exhibited the highest accuracy (86%). The accuracy of the subjective (qualitative) assessment was inferior to the objective assessment (measurement of the HVA). CONCLUSION: Hallux valgus can be diagnosed by measuring the HVA on MRI, satisfactory accuracy being achieved with an HVA cutoff of 16.4°.

OBJETIVO: Avaliar a acurácia da ressonância magnética (RM) para o diagnóstico de hálux valgo usando radiografias com carga como padrão ouro. MATERIAIS E MÉTODOS: Análise retrospectiva de pacientes que realizaram RM do antepé e radiografias com carga, de janeiro a junho de 2015. O ângulo metatarsofalangiano (AMF) foi medido nas RMs e nas radiografias. O teste de Wilcoxon e regressão linear foram utilizados para comparar as mensurações. Pacientes foram divididos de acordo com os valores do AMF nas radiografias: > 15° (hálux valgo) e ≤ 15° (grupo controle). Avaliações qualitativa e quantitativa foram realizadas por RM. Para análise quantitativa, uma curva ROC foi utilizada para definir o ponto de corte com maior acurácia. RESULTADOS: Foram incluídas 66 RMs, 22 no grupo com hálux valgo e 44 no grupo controle. O teste de Wilcoxon indicou diferença significativa entre os métodos. Avaliação de regressão demonstrou relação não linear entre as medidas e e os valores não apresentaram boa correlação. Considerando os grupos hálux valgo e controle, um valor de corte 16,4° na RM demonstrou maior acurácia (86%). A avaliação subjetiva foi inferior à avaliação objetiva. CONCLUSÃO: A medida do AMF na RM pode ser utilizada para diagnóstico de hálux valgo, com um valor de corte de 16,4°.

Accuracy of magnetic resonance imaging for diagnosing hallux valgus / Acurácia da ressonância magnética para o diagnóstico de hálux valgo

Abstract Objective: To assess the accuracy of magnetic resonance imaging (MRI) for the diagnosis of hallux valgus using radiography during weight bearing as the gold standard. Materials and Methods: This was a retrospective analysis of all patients undergoing MRI of the foot and radiography of the foot during weight bearing at our institution between January and June of 2015. The hallux valgus angle (HVA) was measured on MRI and radiography. The Wilcoxon signed-rank test and simple linear regression were used in order to compare measurements. Patients were divided into two groups according to the HVA determined on radiography: > 15° (hallux valgus) and ≤ 15° (control). Qualitative and quantitative assessments of MRI scans were performed. For quantitative assessment, receiver operating characteristic curves were used in order to determine the HVA cutoff with the highest accuracy. Results: A total of 66 MRI scans were included, 22 in the hallux valgus group and 44 in the control group. Wilcoxon signed-rank tests indicated a significant difference between the radiography and MRI measurements. Simple linear regression showed a nonlinear relationship between the measurements and values did not present a strong correlation. In comparison with the radiography measurements, MRI with an HVA cutoff of 16.4° exhibited the highest accuracy (86%). The accuracy of the subjective (qualitative) assessment was inferior to the objective assessment (measurement of the HVA). Conclusion: Hallux valgus can be diagnosed by measuring the HVA on MRI, satisfactory accuracy being achieved with an HVA cutoff of 16.4°.

Resumo Objetivo: Avaliar a acurácia da ressonância magnética (RM) para o diagnóstico de hálux valgo usando radiografias com carga como padrão ouro. Materiais e Métodos: Análise retrospectiva de pacientes que realizaram RM do antepé e radiografias com carga, de janeiro a junho de 2015. O ângulo metatarsofalangiano (AMF) foi medido nas RMs e nas radiografias. O teste de Wilcoxon e regressão linear foram utilizados para comparar as mensurações. Pacientes foram divididos de acordo com os valores do AMF nas radiografias: > 15° (hálux valgo) e ≤ 15° (grupo controle). Avaliações qualitativa e quantitativa foram realizadas por RM. Para análise quantitativa, uma curva ROC foi utilizada para definir o ponto de corte com maior acurácia. Resultados: Foram incluídas 66 RMs, 22 no grupo com hálux valgo e 44 no grupo controle. O teste de Wilcoxon indicou diferença significativa entre os métodos. Avaliação de regressão demonstrou relação não linear entre as medidas e e os valores não apresentaram boa correlação. Considerando os grupos hálux valgo e controle, um valor de corte 16,4° na RM demonstrou maior acurácia (86%). A avaliação subjetiva foi inferior à avaliação objetiva. Conclusão: A medida do AMF na RM pode ser utilizada para diagnóstico de hálux valgo, com um valor de corte de 16,4°.

Magnetic Resonance Imaging Evaluation of the Anterolateral Ligament and the Iliotibial Band in Acute Anterior Cruciate Ligament Injuries Associated With Segond Fractures.

PURPOSE: To evaluate the magnetic resonance imaging (MRI) characteristics of Segond fractures, including the structures attached to the avulsed fragment, the integrity of anterolateral ligament (ALL) and iliotibial band (ITB), and fragment size and location. METHODS: This was a retrospective, cross-sectional study with MRI scans from 2016 to 2019 with the term "Segond" in the reports, signs of acute trauma, and a bony anterolateral tibial avulsion (Segond) fracture. Two experienced observers accessed images to evaluate fragment dimensions (anteroposterior, mediolateral, and craniocaudal) and distances from anatomic landmarks (Gerdy's tubercle, articular surface, and posterolateral tibial corner). ALLs and ITBs also were evaluated, both for integrity and for attachment to the avulsed bony fragment. Data were statistically evaluated for significant correlations. RESULTS: Forty-eight knee MRIs of patients suffering from a combined anterior cruciate ligament and Segond injury were evaluated. The ALL presented with edema in 28 cases (58.3%) and was torn in 3 cases (6.3%). The ALL was attached to the bone fragment in all cases and the ITB also was attached in 25 cases (52.1%). Receiver operating characteristic curves also demonstrated that the larger each of the dimensions and the volume of the fragment, the greater the probability of ITB fibers being inserted. Also, the narrower the distance from the fragment to the center of Gerdy's tubercle, the greater the probability of iliotibial band fibers being attached. Interobserver correlation varied from 0.87 to 0.97 for all measurements. CONCLUSIONS: In all combined ACL injuries and Segond fracture MRI cases, the complete ALL inserted on the avulsed bony fragment, whereas the posterior part of the ITB was only attached in 52.1% of the cases. Segond fracture fragment size was predictive for the structures attached to it. The ALL was abnormal in 64.5% of cases and presented a clear discontinuity in 6.3%. LEVEL OF EVIDENCE: Case Series, Level IV.

Value of ultrasound in the anatomical evaluation of the brachial plexus: correlation with magnetic resonance imaging.

OBJECTIVE: To assess the accuracy of ultrasound in the visualization of the brachial plexus and to determine the value of the method in comparison with that of magnetic resonance imaging (MRI). MATERIALS AND METHODS: This was an anatomical study of the brachial plexuses of 20 asymptomatic adults (40 plexuses), comparing ultrasound and MRI in terms of their accuracy. In the ultrasound study, a high-frequency linear transducer was used, and a neurovascular coil was used in the MRI study. To estimate the frequency of visualization, the brachial plexus was divided into segments. RESULTS: The cervical nerve roots, the upper trunk, and the middle trunk were the segments that were best visualized on ultrasound. On MRI, the degree of visualization was excellent for most of the segments. In the comparison between ultrasound and MRI, the C6, C7, upper trunk, and middle trunk segments showed equivalent degrees of visualization, with a high level of agreement between the two methods. CONCLUSION: In the brachial plexus, ultrasound can be used in the assessment of the cervical nerve roots, as well as of the upper and middle trunks, although it provides limited visualization of the remaining segments. Ultrasound and MRI showed a high level of agreement for the visualization of the C6, C7, and middle trunk segments.

Value of ultrasound in the anatomical evaluation of the brachial plexus: correlation with magnetic resonance imaging / Valor da ultrassonografia na avaliação anatômica do plexo braquial por meio da correlação com estudo por ressonância magnética

Abstract Objective: To assess the accuracy of ultrasound in the visualization of the brachial plexus and to determine the value of the method in comparison with that of magnetic resonance imaging (MRI). Materials and Methods: This was an anatomical study of the brachial plexuses of 20 asymptomatic adults (40 plexuses), comparing ultrasound and MRI in terms of their accuracy. In the ultrasound study, a high-frequency linear transducer was used, and a neurovascular coil was used in the MRI study. To estimate the frequency of visualization, the brachial plexus was divided into segments. Results: The cervical nerve roots, the upper trunk, and the middle trunk were the segments that were best visualized on ultrasound. On MRI, the degree of visualization was excellent for most of the segments. In the comparison between ultrasound and MRI, the C6, C7, upper trunk, and middle trunk segments showed equivalent degrees of visualization, with a high level of agreement between the two methods. Conclusion: In the brachial plexus, ultrasound can be used in the assessment of the cervical nerve roots, as well as of the upper and middle trunks, although it provides limited visualization of the remaining segments. Ultrasound and MRI showed a high level of agreement for the visualization of the C6, C7, and middle trunk segments.

Resumo Objetivo: Avaliar a eficácia do exame de ultrassonografia (US) na visualização do plexo braquial e avaliar o método comparativamente à ressonância magnética (RM). Materiais e Métodos: Estudo da anatomia do plexo braquial pela US e RM (40 plexos braquiais) em 20 adultos assintomáticos. No estudo por US foi utilizado transdutor linear de alta frequência e na RM de alto campo magnético foi utilizada bobina neurovascular. O plexo braquial foi dividido em segmentos para estimar a frequência da visualização entre a US e a RM. Resultados: As raízes cervicais e os troncos superior e médio foram as estruturas que apresentaram maior grau de visualização pela US. Na RM, a maioria dos segmentos do plexo apresentou excelente grau de visualização. Na análise da equivalência entre a US e a RM, as raízes de C5, C6, tronco superior e médio apresentaram graus de visualização equivalentes, com alta concordância. Conclusão: O método de US consegue avaliar de forma eficaz o segmento proximal do plexo braquial que compreende as saídas das raízes cervicais de C5, C6 e C7, assim como os troncos superior e médio na região lateral do pescoço. O exame de US mostrou ter alta concordância com a RM nos ramos ventrais cervicais de C6, C7 e o tronco médio bilateral.

USE OF MAGNETIC RESONANCE IMAGING TO DIAGNOSE BRACHIAL PLEXUS INJURIES.

OBJECTIVE: To compare magnetic resonance imaging and intraoperative findings in patients diagnosed with traumatic injury to the brachial plexus. METHODS: Patients with a diagnosis of traumatic injury to the brachial plexus admitted to the hand and microsurgery outpatient consult of the Hospital das Clínicas at the University of São Paulo were selected during December 2016. A total of three adult patients with up to six months of injury who underwent surgical treatment were included in the study. A diffusion-weighted sequence magnetic resonance protocol and fluid-sensitive volumetric reformatting sequence were applied. The magnetic resonance results were compared with the diagnoses obtained from the injuries observed during the surgery. The study was double-blind (surgeon and radiologist). RESULTS: A descriptive correlation was found between the magnetic resonance imaging results and the diagnostic findings from the surgeries, for both pre- and post-ganglionic injuries. CONCLUSION: Magnetic resonance imaging has shown to be a promising diagnostic method in preoperative assessment of brachial plexus lesions; it is less invasive than other common methods, showing not only avulsion lesions but also localized postganglionic lesions in the supra- and infraclavicular region. Level of Evidence III; Diagnostic studies - Investigating a diagnostic test.

OBJETIVO: Comparar resultados de ressonância magnética e achados intraoperatórios de pacientes com diagnóstico de lesão traumática do plexo braquial. MÉTODOS: Foram selecionados pacientes com diagnóstico de lesão traumática do plexo braquial admitidos no ambulatório de mão e microcirurgia do Hospital das Clínicas de São Paulo no mês de dezembro de 2016. Foram incluídos pacientes adultos com até seis meses de lesão que seriam submetidos a tratamento cirúrgico, totalizando três para o estudo. Foi aplicado um protocolo de ressonância magnética com sequência ponderada em difusão e sequência com reformatação volumétrica fluido-sensível. Os resultados da ressonância magnética foram comparados com os diagnósticos das lesões obtidos na cirurgia. O estudo foi duplo-cego (cirurgião e radiologista). RESULTADOS: Houve correlação em termos descritivos entre os laudos das ressonâncias magnéticas e os achados diagnósticos das cirurgias, tanto para as lesões pré como pós-ganglionares. CONCLUSÃO: A ressonância magnética mostrou ser um método diagnóstico promissor na avaliação pré-operatória das lesões do plexo braquial, sendo menos invasiva que os outros métodos mais utilizados, permitindo o estudo não somente das lesões por avulsão, mas também das lesões pós-ganglionares localizadas na região supra e infraclavicular. Nível de Evidência III; Estudos diagnósticos - Investigação de um exame para diagnóstico.

MENISCAL REPAIR RESULTS COMPARING MRI, ARTHRO-MRI, AND ARTHRO-CT.

OBJECTIVE: To clinically and radiologically evaluate patients who received meniscal suture using the outside-in technique, comparing magnetic resonance imaging (MRI), arthro-magnetic resonance imaging (arthro-MRI), and arthro-computed tomography (arthro-CT) to evaluate the healing of meniscal sutures. METHODS: We evaluated eight patients with an average follow-up of 15 months. The evaluation analyzed clinical parameters using the Lysholm and IKDC scores as well as MRI, arthro-MRI, and arthro-CT imaging. RESULTS: At the end of the follow-up period, mean Lysholm score was 89.5 and mean IKDC score was 78.6. In the MRI, signs of meniscal healing were observed in 50% of the cases. The arthro-MRI and arthro-CT showed signs of healing in 75% of cases. There was a positive correlation between arthro-MRI and arthro-CT results in all the cases studied (kappa correlation index=1). CONCLUSION: Meniscal suture using the outside-in technique presented good or excellent results in 87.5% of our patients. The arthro-CT and arthro-MRI showed the same level of accuracy in detecting healing of the sutured region of the meniscus. Level of Evidence IV; Case series.

OBJETIVO: Avaliar clinicamente e radiologicamente pacientes submetidos a sutura-meniscal pela técnica outside-in, comparando a Ressonância Magnética (RM), Artro-Ressonância Magnética (Artro-RM) e Artro-Tomografia Computadorizada (Artro-CT), quanto a cicatrização da sutura meniscal. MÉTODO: Avaliamos oito pacientes com um seguimento médio de 15 meses, clinicamente e por meio de score de Lisholm e IKDC, e realizamos RM, Artro-RM e Artro-CT. RESULTADOS: A média do score de Lysholm foi de 89.5 e o score médio do IKDC foi de 78,6. A RNM observou sinais de cicatrização meniscal em 50% dos casos, enquanto a artro-RNM e artro-CT evidenciaram sinais de cicatrização em 75% dos casos. Houve uma correlação entre a artro-RNM e a artro-CT em todos os casos. CONCLUSÃO: A sutura meniscal pela técnica outside-in apresentou bons e excelentes resultados em 87,5% dos nossos pacientes. A artro-CT e a artro-RNM têm acurácia equivalente na detecção da cicatrização da região suturada do menisco. Nível de Evidência IV; Série de casos.

Meniscal repair results comparing mri, arthro-mri, and arthro-ct / Resultados da sutura meniscal comparando rm, artro-rm e artro-ct

ABSTRACT Objective To clinically and radiologically evaluate patients who received meniscal suture using the outside-in technique, comparing magnetic resonance imaging (MRI), arthro-magnetic resonance imaging (arthro-MRI), and arthro-computed tomography (arthro-CT) to evaluate the healing of meniscal sutures. Methods We evaluated eight patients with an average follow-up of 15 months. The evaluation analyzed clinical parameters using the Lysholm and IKDC scores as well as MRI, arthro-MRI, and arthro-CT imaging. Results At the end of the follow-up period, mean Lysholm score was 89.5 and mean IKDC score was 78.6. In the MRI, signs of meniscal healing were observed in 50% of the cases. The arthro-MRI and arthro-CT showed signs of healing in 75% of cases. There was a positive correlation between arthro-MRI and arthro-CT results in all the cases studied (kappa correlation index=1). Conclusion Meniscal suture using the outside-in technique presented good or excellent results in 87.5% of our patients. The arthro-CT and arthro-MRI showed the same level of accuracy in detecting healing of the sutured region of the meniscus. Level of Evidence IV; Case series.

RESUMO Objetivo Avaliar clinicamente e radiologicamente pacientes submetidos a sutura-meniscal pela técnica outside-in, comparando a Ressonância Magnética (RM), Artro-Ressonância Magnética (Artro-RM) e Artro-Tomografia Computadorizada (Artro-CT), quanto a cicatrização da sutura meniscal. Método Avaliamos oito pacientes com um seguimento médio de 15 meses, clinicamente e por meio de score de Lisholm e IKDC, e realizamos RM, Artro-RM e Artro-CT. Resultados A média do score de Lysholm foi de 89.5 e o score médio do IKDC foi de 78,6. A RNM observou sinais de cicatrização meniscal em 50% dos casos, enquanto a artro-RNM e artro-CT evidenciaram sinais de cicatrização em 75% dos casos. Houve uma correlação entre a artro-RNM e a artro-CT em todos os casos. Conclusão A sutura meniscal pela técnica outside-in apresentou bons e excelentes resultados em 87,5% dos nossos pacientes. A artro-CT e a artro-RNM têm acurácia equivalente na detecção da cicatrização da região suturada do menisco. Nível de Evidência IV; Série de casos.

Use of magnetic resonance imaging to diagnose brachial plexus injuries / Uso da ressonância magnética para o diagnóstico das lesões do plexo braquial

ABSTRACT Objective: To compare magnetic resonance imaging and intraoperative findings in patients diagnosed with traumatic injury to the brachial plexus. Methods: Patients with a diagnosis of traumatic injury to the brachial plexus admitted to the hand and microsurgery outpatient consult of the Hospital das Clínicas at the University of São Paulo were selected during December 2016. A total of three adult patients with up to six months of injury who underwent surgical treatment were included in the study. A diffusion-weighted sequence magnetic resonance protocol and fluid-sensitive volumetric reformatting sequence were applied. The magnetic resonance results were compared with the diagnoses obtained from the injuries observed during the surgery. The study was double-blind (surgeon and radiologist). Results: A descriptive correlation was found between the magnetic resonance imaging results and the diagnostic findings from the surgeries, for both pre- and post-ganglionic injuries. Conclusion: Magnetic resonance imaging has shown to be a promising diagnostic method in preoperative assessment of brachial plexus lesions; it is less invasive than other common methods, showing not only avulsion lesions but also localized postganglionic lesions in the supra- and infraclavicular region. Level of Evidence III; Diagnostic studies - Investigating a diagnostic test.

RESUMO Objetivo: Comparar resultados de ressonância magnética e achados intraoperatórios de pacientes com diagnóstico de lesão traumática do plexo braquial. Métodos: Foram selecionados pacientes com diagnóstico de lesão traumática do plexo braquial admitidos no ambulatório de mão e microcirurgia do Hospital das Clínicas de São Paulo no mês de dezembro de 2016. Foram incluídos pacientes adultos com até seis meses de lesão que seriam submetidos a tratamento cirúrgico, totalizando três para o estudo. Foi aplicado um protocolo de ressonância magnética com sequência ponderada em difusão e sequência com reformatação volumétrica fluido-sensível. Os resultados da ressonância magnética foram comparados com os diagnósticos das lesões obtidos na cirurgia. O estudo foi duplo-cego (cirurgião e radiologista). Resultados: Houve correlação em termos descritivos entre os laudos das ressonâncias magnéticas e os achados diagnósticos das cirurgias, tanto para as lesões pré como pós-ganglionares. Conclusão: A ressonância magnética mostrou ser um método diagnóstico promissor na avaliação pré-operatória das lesões do plexo braquial, sendo menos invasiva que os outros métodos mais utilizados, permitindo o estudo não somente das lesões por avulsão, mas também das lesões pós-ganglionares localizadas na região supra e infraclavicular. Nível de Evidência III; Estudos diagnósticos - Investigação de um exame para diagnóstico.

Evaluation of the anterolateral ligament of the knee by means of magnetic resonance examination.

OBJECTIVE: To evaluate the presence of the anterolateral ligament (ALL) of the knee in magnetic resonance imaging (MRI) examinations. METHODS: Thirty-three MRI examinations on patients' knees that were done because of indications unrelated to ligament instability or trauma were evaluated. T1-weighted images in the sagittal plane and T2-weighted images with fat saturation in the axial, sagittal and coronal planes were obtained. The images were evaluated by two radiologists with experience of musculoskeletal pathological conditions. In assessing ligament visibility, we divided the analysis into three portions of the ligament: from its origin in the femur to its point of bifurcation; from the bifurcation to the meniscal insertion; and from the bifurcation to the tibial insertion. The capacity to view the ligament in each of its portions and overall was taken to be a dichotomous categorical variable (yes or no). RESULTS: The ALL was viewed with signal characteristics similar to those of the other ligament structures of the knee, with T2 hyposignal with fat saturation. The main plane in which the ligament was viewed was the coronal plane. Some portion of the ligament was viewed clearly in 27 knees (81.8%). The meniscal portion was evident in 25 knees (75.7%), the femoral portion in 23 (69.6%) and the tibial portion in 13 (39.3%). The three portions were viewed together in 11 knees (33.3%). CONCLUSION: The anterolateral ligament of the knee is best viewed in sequences in the coronal plane. The ligament was completely characterized in 33.3% of the cases. The meniscal portion was the part most easily identified and the tibial portion was the part least encountered.

OBJETIVO: Avaliar a presença do ligamento anterolateral (LAL) do joelho em exames de ressonância magnética (RM). MÉTODOS: Foram avaliadas 33 RM de joelho de pacientes feitas por indicações não relacionadas a instabilidade ligamentar ou trauma. Foram obtidas imagens no plano sagital ponderadas em T1 e imagens nos planos axial, sagital e coronal ponderadas em T2 com saturação de gordura. As imagens foram avaliadas por dois radiologistas experientes em patologias musculoesqueléticas. Na avaliação da visualização, dividimos a análise do ligamento em três porções: origem femoral até o seu ponto de bifurcação, da bifurcação até a inserção meniscal e da bifurcação até a inserção tibial. Considerou-se com variável categórica dicotômica (sim ou não) a capacidade de visualizar o ligamento em cada uma das porções e no seu todo. RESULTADOS: O LAL foi visualizado com característica de sinal semelhante às demais estruturas ligamentares do joelho, com hipossinal em T2 com saturação de gordura. O principal plano em que o ligamento foi identificado foi o coronal. Alguma porção do ligamento foi visualizada com clareza em 27 (81,8%) joelhos. A porção meniscal ficou evidente em 25 (75,7%) dos joelhos, a porção femoral em 23 (69,6%) e a tibial em 13 (39,3%). As três porções foram visualizadas em conjunto em 11 (33,3%) joelhos. CONCLUSÃO: O ligamento anterolateral do joelho é mais bem visualizado em sequências no plano coronal. O ligamento foi caracterizado por completo em 33,3% dos casos. A porção meniscal foi a mais facilmente identificada e a tibial a menos encontrada.