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1 11.1 Musculoskeletal Imaging Musculoskeketal Sectional Anatomy & Clinical Imaging Slide # 1 Carolyn Kaut Roth, RT (R)(MR)(CT)(M)(CV) FSMRT CEO Imaging Education Associates www.imaginged.com [email protected] 11.1 Musculoskeletal Imaging Part I Planes of the Musculoskeletal system S ti lA t f th t it Outline Slide # 2 Sectional Anatomy of the upper extremity Sectional Anatomy of the lower extremity 11.1 Musculoskeletal Imaging Patient Preparation for MSK Imaging Patient Screening Check for contraindications Remove ALL metal Change into gown Coil Selection For routine For vascular For Arthrography Patient set-up & Positioning Slide # 3 Patient set up & Positioning – Supine Coil on joint Hearing Protection Patient Intercom Landmark Per joint – Other Isocenter 11.1 Musculoskeletal Imaging TMJ TMJ Anatomy Musculoskeletal System Slide # 4 11.1 Musculoskeletal Imaging Median Line Mid-sagittal Plane Parasagittal Planes Axial Mid Frontal Coronal Plane Transverse Plane Imaging Planes - TMJ Slide # 5 Sagittal Coronal MRI Images Sagittal Axial Coronal CT Images 11.1 Musculoskeletal Imaging Localizer for sagittal oblique sections Localizer for coronal oblique sections Overview musculoskeletal Anatomy - TMJ Slide # 6 Sagittal Oblique TMJ Coronal Oblique TMJ Temporal bone Fossa (meniscus within) Mandibular condyle Mandible

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1

11.1 Musculoskeletal Imaging

Musculoskeketal Sectional Anatomy & Clinical Imaging

Slide # 1

Carolyn Kaut Roth, RT (R)(MR)(CT)(M)(CV) FSMRTCEO Imaging Education Associates

www.imaginged.com [email protected]

11.1 Musculoskeletal Imaging

Part I• Planes of the Musculoskeletal system

S ti l A t f th t it

Outline

Slide # 2

• Sectional Anatomy of the upper extremity• Sectional Anatomy of the lower extremity

11.1 Musculoskeletal Imaging

Patient Preparation for MSK Imaging

• Patient Screening– Check for contraindications– Remove ALL metal– Change into gown

• Coil Selection– For routine– For vascular– For Arthrography

• Patient set-up & Positioning

Slide # 3

Patient set up & Positioning– Supine– Coil on joint– Hearing Protection– Patient Intercom

• Landmark– Per joint– Other

• Isocenter

11.1 Musculoskeletal ImagingTMJ TMJ

Anatomy Musculoskeletal System

Slide # 4

11.1 Musculoskeletal Imaging

Median Line

Mid-sagittal Plane

Parasagittal Planes

Axial

Mid FrontalCoronal Plane

TransversePlane

Imaging Planes - TMJ

Slide # 5

Sagittal

Coronal

MRI Images

Sagittal Axial Coronal

CT Images

11.1 Musculoskeletal Imaging

Localizer for sagittal oblique sections Localizer for coronal oblique sections

Overview musculoskeletal Anatomy - TMJ

Slide # 6

Sagittal Oblique TMJ Coronal Oblique TMJ

Temporal boneFossa(meniscus within)Mandibular

condyleMandible

2

11.1 Musculoskeletal Imaging

Shoulder radiograph

Corocoid vs coronoid… “There’s a sea (C) between two Nations”

Slide # 7CoroNoid CoroCoid CoroNoid

Sagittal reformatted CT Lateral radiography (Elbow)

Shoulder radiograph

TMJ 3D CT reformatted image

Shoulder CT

Sagittal MR Elbow

11.1 Musculoskeletal Imaging

Patient Preparation for TMJ MRI

• Patient Screening– Check for contraindications– Remove ALL metal– Change into gown

• Coil Selection– For routine TMJ

• Transmit/receive• Receive only

• Patient set up &

Slide # 8

• Patient set-up & Positioning– Supine - COIL ON TMJ– Pad under knees - elbows– Hearing Protection– Patient Intercom

• Landmark– CENTER EAM

• Isocenter

11.1 Musculoskeletal Imaging

Basic “Vanilla” TMJ Protocol

• Localizer T1 – plane best3 plane loc

• Sagittal Oblique T2 & PD – CLOSED Generally TSE (aka FSE or RARE)

12 ish to fit anatomy3 or 4 mm / 1192 x 256TR = 4000 msTE = 30 ms 100 ms ETL= 8

• Coronal oblique T1closedGenerally TSE (aka FSE or RARE)

CO IL

Sensitivity profile of the RF coil

radius

diameter

Slide # 9

y ( )12 ish to fit anatomy3 or 4 mm / 1192 x 256TR =500-700msTE = min

• Sagittal oblique T1closed/openGenerally TSE (aka FSE or RARE)12 ish to fit anatomy3 or 4 mm / 1192 x 256TR =500-700msTE = min

11.1 Musculoskeletal Imaging

Sag T2

Left

Sagittal Oblique T2Generally TSE (aka FSE)12 ish to fit anatomy3 or 4 mm / 1192 x 256TR 4000

Slide # 10

Right

TR = 4000 msTE = 100 ms ETL= 8

11.1 Musculoskeletal Imaging

Sag T1

Left

Sagittal oblique T1…closedGenerally TSE (aka FSE)12 ish to fit anatomy3 or 4 mm / 1192 x 256

Slide # 11

Right

192 x 256TR =500-700msTE = min

11.1 Musculoskeletal Imaging

Sag T1 “open”

Left

Sagittal oblique T1…openGenerally TSE (aka FSE)12 ish to fit anatomy3 or 4 mm / 1192 x 256

Slide # 12

Right

192 x 256TR =500-700msTE = min

3

11.1 Musculoskeletal Imaging

Open vs. Closed

Closed

Sagittal oblique T1closed/openGenerally TSE (aka FSE)12 ish to fit anatomy3 or 4 mm / 1192 x 256

Slide # 13

Open

192 x 256TR =500-700msTE = min

To evaluate meniscus

11.1 Musculoskeletal Imaging

Anatomy Musculoskeletal System

Shoulder

Shoulder

Slide # 14

11.1 Musculoskeletal Imaging

• Shoulder– Scapula

• Spine of the scapula• Coracoid process

The lumps and bumps of the shoulder

Slide # 15

p• Acromion process

– Clavicle– Humerus

• Head of the humerus• Greater tubercle• Lesster tubercle Reformatted CT Image shoulder

11.1 Musculoskeletal Imaging

Surgical Fixation

AC Joint

Clavicle

Ribs

Slide # 16

11.1 Musculoskeletal Imaging

Median LineMidline Sagittal Plane

Parasagittal Planes

Frontal orCoronal Plane

TransverseOr AxialPlane

Axial

The sagittal oblique plane is acquired along this f

Overview musculoskeletal Anatomy - Shoulder

Slide # 17

Sagittal

Coronal obliqueThe coronal oblique plane is acquired along this dotted red line

on the axial shoulder image. Parallel to the supraspinatus muscle & tendon or perpendicular to the glenoid fossa

dotted red line, parallel to the glenoid fossa

11.1 Musculoskeletal Imaging

Reformatted CT Image

TrapeziusDeltoid

Structures of the rotator cuff …(SITS)

Axial Shoulder CT

Spine of the scapula

Slide # 18

Axial MR Image Coronal oblique MR Image

DeltoidRC (S.I.T.S.)Supraspinatus Infraspinatus Teres Minor Subscapularis

4

11.1 Musculoskeletal ImagingSupraspinatus tendon.Infraspinatus tendonTeres minor tendonSubscapularis tendonBicepts muscle

Reformatted CT Image

Shoulder Structures

Sagittal Oblique Shoulder

Deltoid

Spine of the scapula

Slide # 19

Axial MR Image

TrapeziusDeltoid

Supraspinatus tendonRotator cuff

Glenoid fossa Glenoid labrum

Coronal oblique MR Image

11.1 Musculoskeletal ImagingAcromionA/C joint

(acromio-clavicular joint)ClavicleHumeral HeadHumerusCorocoid process

Reformatted CT Image

Bony Structures of the shoulder

Sagittal Oblique Shoulder

Spine of the scapula

Slide # 20

Axial MR Image Coronal oblique MR Image

AcromionRotator cuffHumeral HeadGlenoid fossaGlenoid rimScapulaHumerus

11.1 Musculoskeletal Imaging

Anatomy Musculoskeletal System

Elbow

Elbow

Slide # 21

11.1 Musculoskeletal ImagingHumerusOlecranon processJoint spaceTrochleaCapetellumCoronoid processUlna

Bones of the Elbow Joint

Slide # 22

Axial MR Image

HumerusOlecranon fossaCapetellumHumero-radial jointCapetellum

TrochleaHumero-ulnar jointRadio-ulnar joint

“Cap on Head”(Capetellum on the head of the radius)

Coronal oblique MR Image

Sagittal Oblique Elbow

11.1 Musculoskeletal ImagingTricepts musclesBicepts MusclesExtensor tendons

Brachoiadialis muscle

Muscles, Tendons & Ligaments of the Elbow Joint

Slide # 23

Axial MR ImageSagittal Oblique Elbow

Coronal oblique MR Image

Tricepts musclesUlnar collateral ligamentBrachoiadialis muscle

Radial collateral ligament

11.1 Musculoskeletal Imaging

Corocoid vs coronoidThere’s a sea (C) between two Nations…

Shoulder radiographTMJ radiograph

Slide # 24

CoroNoid CoroCoid CoroNoidSagittal reformatted CT

Lateral radiography (Elbow)

Shoulder CT

5

11.1 Musculoskeletal Imaging

Anatomy Musculoskeletal System

WristWrist

Slide # 25

11.1 Musculoskeletal Imaging

NavicularLunateTriquetruim

Never Lower Tillie’s Pants…Grandmother Might Come Home

Overview musculoskeletal Anatomy – Wrist

Slide # 26

TriquetruimPisiformGreater MutlangularLesser MultangularCapatateHammate

Coronal reformatted CT

Coronal MRI

11.1 Musculoskeletal Imaging

Overview musculoskeletal Anatomy – Wrist

ScaphoidLunateTriquetruim

Some Lovers Try Positions….That They Can’t Handle

Slide # 27

Coronal reformatted CTCoronal MRI

TrapeziumTrapezoidCapetateHammate

TriquetruimPisiformTrapeziumTrapezoidCapetateHammateAneurysm Raidal arteruUlnar artery

11.1 Musculoskeletal ImagingTrapeziumTrapezoidCapetateHammateHook of the

HammateTFCC (triangulo-fibrocartilege complex)

Overview musculoskeletal Anatomy – Wrist

Slide # 28

fibrocartilege complex)Carpal TunnellFlexor tendonsMedian Nerve

Axial MRI

Coronal MRI

Distal RadiusDistal UlnaRadio-ulnar joint

11.1 Musculoskeletal Imaging

Wrist Pathology

Aneurysm

Slide # 29

Fracture

11.1 Musculoskeletal Imaging

Ultra-Fast MR Angiography

Slide # 30

Images courtesy of Edison Imaging, Edison NJ, Lawrence Tanenbaum, MD

6

11.1 Musculoskeletal Imaging

Anatomy Musculoskeletal System

Slide # 31

HipHip

11.1 Musculoskeletal ImagingAcetabulim

IliumIshiumPubis

Bony anatomy of the HIP

Femoral HeadFemoral Neck

Greater TrocanterLesser trocanter

Femoral Shaft

Slide # 32

Obturator foramen

Reformatted CT Image Hip

Femoral Shaft

11.1 Musculoskeletal Imaging

BONE METS

Compressed vertebral body

Met to the pelvic

Slide # 33

Reformatted Coronal CT Image pelvis

Reformatted Sagittal CT Image Spine

bone

11.1 Musculoskeletal ImagingIlumIliac arteries

Psoas MusclesObturator foramen

Gleuteal MusclesCoronal reformatted CT

Hips & Pelvis

Slide # 34

Obturator Internus musclesObturator Externus

Coronal CT

Mass

Axial pelvis CT

11.1 Musculoskeletal Imaging

Femoral HeadFemoral Neck

Greater TrocanterLesser trocanter

Femoral Shaft

Structures of the HIP

(ASIS) Ilium Acetabulim

Obturator foramen Ishium

Pubis

Slide # 35

Reformatted CT Image Hip

Coronal MRI of the Hips

Ilium Acetabulim Glenoid LabrumFemoral Neck Femur

Obturator Internus musclesObturator Externus

11.1 Musculoskeletal Imaging

NAVELNerve, Artery, Vein, Empty space, Lymph node

Psoas MuscleIliacus MuscleGleuteus MaximusGleuteus minimusQuadracepts MuscleHamstrings

Slide # 36

Coronal MRI of the Hips

Axial MRI of the Hips

NerveArteryVeinEmpty spaceLymph nodesQuadracepts Muscle Gleuteus MaximusRectum

bladder

7

11.1 Musculoskeletal Imaging

Muscular Abcess

Muscular abscess

Pelvic area

Slide # 37

Muscular abscess

Shoulder area

11.1 Musculoskeletal Imaging

Anatomy Musculoskeletal System

Slide # 38

KneeKnee

11.1 Musculoskeletal Imaging

Bones of the Knee

Coronal knee MRI Axial knee

i Condyle

ndylebeal plateaubial spine

Slide # 39

FemurPatellaPatello-femoral jointKnee JointTibiaFibula

Sagittal knee MRI

Coronal reformatted CT

11.1 Musculoskeletal ImagingAnterior cruciate ligament (ACL)

Posterior cruciate ligament (PCL)

Quadracepts musclesFemurHamstrings muscles

Quadcepts tendonMid sagittal slice (MRI)

Lower Extremity Anatomy

Axial pelvis CT

Axial femur CT

Slide # 40Coronal reformatted CT

Para sagittal slice (MRI)

Patello- Femoral JointPatellar ligament

Locations of the lateral collateral ligaments

Femoral coldylesMeniscus ([posterior horn, lateral meniscus)Patella

TibiaFibula

Mid sagittal slice (MRI) Axial femur CT

Axial femur CT

Axial knee CT

11.1 Musculoskeletal Imaging

Muscles of the Knee

Hamstring musclesQuadracepts TendonAttaches the quatracepts musclesGastrocnemius muscles

Slide # 41

Para Sagittal knee MRI

Quatracepts musclesHamstring Muscles

Axial Femur MRI Axial CT

11.1 Musculoskeletal Imaging

Meniscus and other structures of the knee

Anterior horn of the meniscus

Posterior horn of

Lateral aspect of the patello-femoral jointLateral retinaculum

Medial retinaculum

Slide # 42

Para Sagittal knee MRI

Coronal knee MRI

Posterior horn of the meniscus

Axial knee MRI

Medial collateral ligament Medial meniscusLateral collateral ligament

Lateral meniscus

8

11.1 Musculoskeletal Imaging

Patient Preparation for Lone Bone MRI

• Patient Screening– Check for contraindications– Remove ALL metal– Change into gown

• Coil Selection– For routine LONG BONES

• BODY COIL ?• Transmit/receive

Slide # 43

Transmit/receive• Receive only

• Patient set-up & Positioning– Supine– COIL AROUND AREA?– Hearing Protection– Patient Intercom

• Landmark– MID SHAFT

• Isocenter

11.1 Musculoskeletal Imaging

• Mets• Scan only the bone• Scan all the bones

Long Bone Pathology & Views

Slide # 44

11.1 Musculoskeletal Imaging

Lower Leg FractureLower Leg FractureLower Leg FractureLower Leg Fracture

Fracture

Fracture

Slide # 45

AP Scout

Lat Scout

11.1 Musculoskeletal Imaging

Anatomy Musculoskeletal System

Slide # 46

Foot and ankle Foot and ankle

11.1 Musculoskeletal Imaging

Come… (calcaneus)To … (talus)Cuba (cuboid)Next… NavicularCh i t (3 if !)

TibiaFibula

Foot & ankle bones - Come To Cuba Next Christmas

Slide # 47

Christmas … (3 cuneiforms!)

11.1 Musculoskeletal ImagingTibiaFibula

Mortise jointMedial collateral ligamentsLateral collateral ligaments

Ankle Ligaments and Tendons

Tibio-talar joint

Slide # 48

jPosterior longitudinal ligamentAchilles tendon

9

11.1 Musculoskeletal Imaging

Ankle Arthrogram

scar or hypertrophied synovium

Slide # 49

11.1 Musculoskeletal Imaging

Review, Peripheral Vascular Anatomy

Abdominal Aorta(AAA- abdominal aortic aneurysm)

Iliac Arteries

Femoral Arteries

Slide # 50Coronal reformatted CTACoronal MRA

Popliteal Arteries

Trifurcation…(anterior tibial)

(posterior Tibial)(Pernoeus Brevis)

Coronal reformatted CT

11.1 Musculoskeletal Imaging

Patient Preparation for Foot MRI• Patient Screening

– Check for contraindications– Remove ALL metal– Change into gown

• Coil Selection– For routine FOOT

• Transmit/receive• Receive only

Slide # 51

• Patient set-up & Positioning– Supine– FOOT IN COIL- TOES DOWN– Hearing Protection– Patient Intercom

• Landmark– Mid tarsals– Isocenter

11.1 Musculoskeletal Imaging• Localizer (3-plane)• Axial T2 & PD Axial FSE Pd

FOV = 20 ish to fit anatomy3 or 4 mm / 1

• Coronal Oblique T2 & PdFOV =16 ish to fit anatomy3 or 4 mm / 1

Basic “Vanilla” Foot Protocol

Axial

Slide # 52

• Sagittal oblique PD & T2FOV = 16 ish to fit anatomy 3 or 4 mm / 1192 x 256

• STIR plane of interest

Coronal

Sagittal

11.1 Musculoskeletal Imaging

Bone marrow Adema

Slide # 53

• 5th metatarsal

11.1 Musculoskeletal Imaging

Bone Tumor

Slide # 54

10

11.1 Musculoskeletal Imaging

Epidermal Cyst

Slide # 55

11.1 Musculoskeletal Imaging

Osteomyelitis

Slide # 56

11.1 Musculoskeletal Imaging

Foot Pathology & Views• Tarsal Tunell - axial• Plantar Fascitis –

axial & sagittal• Diabetic foot - MRA

Slide # 57

Left ankleHigh res PDW TSEMatrix 1024, Thk 3.0 mmScan time 02:56 min

11.1 Musculoskeletal ImagingPart I – Sectional anatomy of the Musculoskeletal system

Thank you for your attention!

Slide # 58

Carolyn Kaut Roth, RT (R)(MR)(CT)(M)(CV) FSMRTCEO Imaging Education Associates

www.imaginged.com [email protected]

y yClick to take your post test and get your credits