Practical Reporting of

Musculoskeletal Imaging

Studies:

MRI Elbow

James F Griffith

History

Where is pain located?

For how long?

Trauma – if so, what and when

Radiographers can get this info

Don’t mention any feature without grading it

Qualitative measure :

Minimal, mild, moderate, severe

Quantitative measure:

Small, medium, large (mm long x mm deep x mm wide)

Grade ……….

Epicondylitis

Cubital tunnel syndrome

Trauma inc biceps insertion

This talk : outline

Tendinosis of

common extensor

tendon origin

(CETO)

Tendinosis of

common flexor

tendon origin

(CFTO)

Epicondylitis

Cumulative microtrauma

Inadequate repair

Epicondylitis : Pathophysiology

Tendinosis (collagen disruption, proteoglycan deposition,

vascular ingrowth, fibroblast proliferation, hyaline degeneration)

Firm up diagnosis

Establish severity

Identify tear

Check for associated abnormalities

Peritendinitis

Collateral ligament injury

Bone oedema, cortical irregularity

Epicondylitis : Why imaging

Common extensor tendon origin

Common extensor tendon origin (CETO)

ECRL

ECRBr

ED

ECU

Possibly due to impingement against capitellum

** *

**

Lateral collateral ligament complex

Radial collateral ligament

Lateral ulnar collateral ligament

MR imaging protocol

PD cor

T2 SPIR obl cor T2-SPAIR axial

PD axial

+ sagittal images

CETO

CFTO

CETO normal

Some mild heterogeneity is normal

CETO tendinosis: moderate

Normal Moderate severity

CETO tendinosis: moderate

Moderate ….with tear

Lateral collateral ligament complex

Radial collateral lig (RCL)

Lateral ulnar collateral lig (LUCL)

Lateral collateral ligament complex

RCL

LUCL

CETO tendinosis : moderate

Intact RCL Tear CETO Intact LUCL

“There is moderate CETO tendinosis with a medium-sized

(??mm wide x ?? mm long) mainly involving the ECRBr

Insertional area. The RCL and LUCL are intact”

Avulsion ECRBr > ECRL >>> ED & ECU

ECRBr avulsion ECRL and ECRBr avulsion

Avulsion ECRBr > ECRL >>> ED & ECU

ECRBr avulsion ECRL and ECRBr avulsion

Complete tear CETO and RCL

“There is moderate CETO tendinosis with a complete avulsive-

type tear of the CETO as was as the RC and LUC ligaments”

Complete tear CETO, RCL and LUCL

RCL LUCL

Ultrasound protocol : lateral

(1) Put finger on lateral epicondyle

(3) Place transducer along this line

(2) Imagine line of extensor tendons

Ultrasound protocol: CETO

CETO tendinosis

Thickening

Hypoechogenicity

Calcification

Tear

Cortical irregularity

Hyperaemia

CETO tendinosis

Thickening

Hypoechogenicity

Calcification

Tear

Cortical irregularity

Hyperaemia

CETO tendinosis

CETO tendinosis

‘Lift‘ the transducer

off skin

CETO tendinosis

Normal < 32mm2 Tendinosis >32mm2

Baumer P et al 2011

Radial synovial fold syndrome

No fold Thickened

synovial fold

but not impacted

Impacted

synovial fold

Common flexor tendon origin (CFTO)

PT

FCR

PL

FCU

FDS

* *

Medial collateral ligament

Anterior band

Transverse band

Posterior band

Medial collateral ligaments

Anterior band

Transverse band

Posterior band

CFTO normal

CFTO normal and moderate tendinosis

Normal Moderate tendinosis

CETO tendinosis and tear

Ultrasound protocol : medial

(1) Put finger on medial epicondyle

(3) Place transducer along this line

(2) Imagine line of flexor tendons

Ultrasound protocol: CFTO

Ultrasound protocol: CFTO

US or MR examination?

US MRI

Tendinosis severity

Tear depiction

Hyperaemia

Associated abnormality

Operator independent

3rd party review

++ ++

+ ++

++ -

- +

- +

- +

1/6 have a normal US

Represents early non-established disease

Epicondylitis : US and MR examination

Proceed to MRI

50% of these will still have normal MRI examination

Rest, bracing and physiotherapy

Don’t use steroids

Dry needling

Platelet Rich Plasma (PRP)

Autologous blood injection

Botox

Treatment (i)

Extracorporal shock wave therapy

Low level laser therapy

Treatment (ii)

Surgery

Debridement, drilling

Release (percutaneous, arthroscopic, open)

Suture fixation

Both US and MRI extremely helpful at assessing

lateral & medial epicondylitis

Epicondylitis : summary

Report on:

Tendinosis severity (mild, moderate, severe)

Presence, size and location of tears

Vascularity (ultrasound)

Collateral ligament integrity

Clinical Presentation

2nd most common nerve entrapment, > left side (3:1)

Paresthesia

Hypoesthesia

Anaesthesia

Muscle weakness

Muscle wasting

Cubital Tunnel Anatomy

Cubital Tunnel Anatomy

FCU

heads

PRIMARY (Younger):

Excessive leaning on or flexing of elbow

Repeated subluxation/dislocation of ulnar nerve

Aetiology

Husarik DB et al. 2009

SECONDARY (Older):

Osteophytes, loose bodies, synovial proliferation, ganglia,

anconeus epitrochlearis m., hypertrophied medial triceps

Anconeus epitrochlearis muscle

20% of normal subjects

Why image cubital tunnel syndrome?

Confirm diagnosis

Assess severity

Look for secondary cause

Look for nerve subluxation

Image with ………….. or

MR protocol

Axial T2 SPAIR Axial PD ±DWI

Ulnar Nerve Calibre

Mild UNE : 12.7mm2 ± 0.5

Severe UNE : 19.4mm2 ± 2.5

Normal

11.4mm2 ± 0.5

Diagnostic criterion: > 12mm2 at cubital tunnel

Baumer P et al 2011

10.1mm2 21.3mm2

T2-hyperintensity (contrast:noise ratio)

Neural SI – Muscle SI

Standard deviation Air CNR =

T2-hyperintensity (contrast:noise ratio)

Cubitial tunnel if CNR > 50 at cubital tunnel

Baumer P et al 2011

1849 - 711

8.3

= 137 742 - 377

23.2

= 15.7

DWI (b value 500s/mm2)

10 patients with cubital tunnel syndrome compared to controls

All ten showed +ve findings with DWI

No controls showed +ve findings

No quantitative analysis

Iba K et al 2010

Diagnostic MR criteria

> 12mm2 CSA ulnar nerve

CNR > 50 at cubital tunnel

DWI positive signal ulnar nerve

Excessive hyperintensity without swelling ?? neuritis

Ultrasound Cubital Examination

Supine Prone Sitting

Cubital Tunnel Examination

Measurements

Proximal

At

Distal

Criteria for cubital tunnel syndrome

Absolute criteria (CSA ulnar nerve) :

Normal < 9mm2

Symptomatic > 12mm2

Relative criteria (CSA ulnar nerve) :

2.8: 1 (proximal : at cubital tunnel)

Kyoon SJ et al 2008

Thoirs K et al 2007

Ulnar nerve swelling

Normal Mild

Moderate Severe

9mm2 14mm2

19mm2 23mm2

Ulnar nerve subluxation (20% normal nerves)

Olecranon Medial epicondyle

Yang SM et al. J Ultrasound Med 2013

Ulnar nerve subluxation

Due to absence of arcuate ligament

2o cause: Osteophytes

2o cause : Loose bodies

2o cause: Ganglion

2o cause: synovial proliferation

Severe rhematoid arthritis

2o cause: Anconeus epitrochlearis m.

Medial head

triceps slip

Diagnostic criteria (ultrasound or MRI)

CSA> 12mm2 CNR > 50 DWI positive

or 2.8: 1 (prox : at)

Readily assessed with ultrasound or MRI

Ultrasound more efficient and can assess subluxation

MRI possibly more accurate, especially for mild

disease if CNR measured ± DWI obtained

Cubital Tunnel Syndrome : summary

CSA > 12mm2 CNR > 50 DWI positive

CONCLUSION

or 2.8: 1 (prox : at)

Biceps tendon

FABS view: Flexion Abduction Supination

Biceps tendon

FABS view: Flexion Abduction Supination view

Biceps and brachialis tendon insertions

Muscular

brachialis

insertion

Muscular

brachialis

insertion

Tendinous

brachialis

insertion

Biceps

tendinous

insertion

Biceps and brachialis tendon insertions

Muscular

brachialis

insertion

Muscular

brachialis

insertion

Tendinous

brachialis

insertion

Biceps

tendinous

insertion

Mild tendinosis biceps tendon

Mild tendinosis Mild tendinosis

“Mild distal biceps tendinosis without tear”

Severe tendinosis biceps tendons

“Severe distal biceps tendinosis with moderate-severity tear”

Severe tendinosis biceps tendons

“Complete tear distal biceps with retraction by 3cm ”

Operation: short head torn

Epicondylitis

Cubital tunnel syndrome

Biceps insertion

Conclusion

Thank you