10/10/13

1

Imaging Musculoskeletal Injuries- Strengths and Weaknesses of Different Modalities

Samuel R. Ward, PT, PhD

Associate Professor Muscle Physiology Lab

Departments of Radiology, Orthopaedic Surgery, and Bioengineering University of California San Diego

VA Medical Center San Diego

MuscleTech Network, Barcelona, Oct 14, 2013

Imaging Modalities

Ultrasound Plain film x-ray

Computed tomography Bone Scan (scintigraphy)

Magnetic resonance imaging Positron emission tomography C

ost /

Com

plex

ity

Saf

ety

/ eas

y of

use

10/10/13

2

Ultrasound

www.terason.com

From Strobel et al, Radiology, 2005

Healthy

Fatty Atrophy

Sag Obl Ultrasound Cor Obl Ultrasound Sag Obl MRI

10/10/13

3

Plain film x-ray

http://www.umphysicians.org

Film/detector

Ionizing radiation source Density contrast

Computed tomography

http://www.cogneuro-lab.org

Density = contrast

Can use iodine-based contrast

10/10/13

4

Bone Scan (Scintigraphy)

http://www.saintlukeshealthsystem.org

Detector (2D or 3D)

Patient = radiation source Metabolic/Remodeling activity contrast

Fracture, tumor- 99mTC-MDP- Osteoblasts Infection- Induim-111 or Galium-neutrophils

Magnetic resonance imaging

http://www.magnet.fsu.edu

Proton imaging (H2O)

Contrast = intrinsic properties of soft tissues Very good at imaging water

Very flexible imaging technique

Gadolinium or Iron- based contrast agents

10/10/13

5

Positron emission tomography

Patient is the radiation source Radiopharmaceuticals-

15O-H2O- blood flow and tissue perfusion FDG- glucose transport/action

Shinozaki, JSES 2013

Rotator Cuff + Nerve Injury

Thieme, Atlas of Anatomy 2007 Sagittal Oblique T1 MRI

Supraspinatus

Infraspinatus Image Plane

10/10/13

6

MRI Spine Stress Films

Standing Sitting

Kne

es to

che

st

Pron

e on

elb

ows

MRI Stress Films

10/10/13

7

High-Res Structure

High-Res DTI

IDEAL

MRI Physiology and Microarchitecture

Skiing Injury with Epimysial Hematoma

Gas

Gas Gas

Sol

Sol Sol

Sag US Ax T1 MRI Ax T2 MRI

Tib Tib

Isointense = acute

10/10/13

8

Intramuscular Hematoma from a Kick

Sag US Ax T2 MRI

Heterogeneous intensity = Subacute

Chronic Subperiosteal Hematoma

Ax T2 MRI Fat Sup Ax T2 MRI Ax CT

RF RF RF

VL VL VL

10/10/13

9

Rhabdomyolysis from Fall

Ax CT Ax MRI

G Max

G Med

Professional Soccer Player Kick Injury after 5-6 weeks

Ax CT Myositis Ossificans

Ax T1 MRI Differential diagnosis- neoplasm?

10/10/13

10

Grade 1- Stress Fracture

Bone Scan Fat Sup T2 Ax MRI X-Ray

Fracture

CC

Cor Fat Sup T2 MRI Cor T1 MRI X-Ray

10/10/13

11

ACL Tear with Bone Bruise

Sag T1 MRI Sag Fat Sup T2 MRI

Quadriceps Tendon Tear

Sag T1 MRI Sag Fat Sup T2 MRI

10/10/13

12

Achilles Tendon MRI UTE T2* Quantification

TE 100 µs

TE 300 µs

TE 500 µs

TE 1 ms

TE 10 ms

TE 2 ms

TE 3 ms

TE 5 ms

UCSD MSK Imaging Research Group cbchung@ucsd.edu

Case 1 •  A young talented player

with symptoms in the patella tendon (on and off pain during warm up or after training, better during activity) during the preseason training

•  what to do? •  continue training? adjust

training? add treatment?

10/10/13

13

Case 2 •  A very important player

during season experience increasing symptoms (pain and stiffness in the morning) in the Patellar Tendon weeks before an important match

•  What to do ??

Case 3

•  One of you players experiences sudden unset of pain in the Insertional Achilles tendon during training but only during high loading.

•  What to do ?

10/10/13

14

Thank You

Mini Pathria, MD Christine Chung, MD

10/10/13

15

Grade Radiography Scintigraphy MR Imaging

0 Normal Normal Normal

I Gray cortex sign; margin is indistinct, density lower

Linear increased cortical activity

Mild to moderate periosteal edema on T2-w images with normal marrow

II Acute periosteal reaction, density differs from rest of cortex showing incomplete mineralization

Small focus of increased activity

Periosteal edema and bone marrow edema on only T2-w images

III Lucent areas in cortex, ill-defined foci at site of pain

Larger focal lesion with highly increased activity in cortical region

Marrow edema on T1-w and T2-w images with/without periostitis and loss of cortical signal void, intracortical increased intensity and intracortical linear hyperintensity

IV Fracture line present Very large focal region of highly increased activity

Low signal intensity fracture line on all sequences, periosteal and marrow edema, may show muscle edema

Beck BR, Bergman G, Miner M et al, Radiology 263:811, 2012