Imaging of TFCC Injury of the Wrist

about dynamic cone-beam ct imaging of TFCC wrist injury

It’s always difficult to combine clinical aspects and diagnostic imaging, approaching wrist joint pathology; in many circumstances the orthopaedic surgeon needs to directly visualize what’s happened during the joint motion, especially in a complex region such as the wrist.

I show you an example in which a complex tear of the triangular fibrocartilage complex (TFCC) is evident, togheter with a positive ulnar variance. TFCC is a complex of a fibrocartilaginous disk in association with several ligamentous structures, acting as a  stabilizers of the distal radioulnar joint, and transmitting axial loading from carpus to the ulna.

TFC Injury

Coronal T1w (left) and 3D SHARC (right) Mri scans (0.3 Tesla).

The dedicated Mri examination (0.3 Tesla), depicts the pathologic picture; the ulnar plus defines the reduction of the quadrilateral ulno-carpal space, and the consequent complex tear of the TFCC at its ulnar attachment; but what happens during the active movements? I usually perform also the dynamic evaluation, both with ultrasound and Mri exams. In this case the Cone-beam CT (CBCT) dynamic acquisitions give the answer.

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Dynamic MSK Imaging of Metacarpal Fracture

About dynamic msk imaging modalities in the study of post-traumatic metacarpal fracture

4th metacarpal fracture

Acute 4th metacarpal spiroid fracture of a professional football goalkeeper; first diagnosis was made directly on pitch with an ultrasound examination. Plain radiographs and Mri exam were performed just one hour after trauma.

One month after surgical fixation the fracture is studied with dynamic US, Mri and Cone-Beam CT imaging. The US and MR dynamic evaluations, show a regular tendon sliding over the fixation devices.

No metal-induced artifacts were seen, allowing a perfect visualization of the implanted devices.

CBCT Reconstruction

Cone-Beam CT Sagittal (left) and Coronal (right) reconstructions.

The study was completed with dynamic Mri (0.3 Tesla) and Cone-Beam CT scans, performed with active flexion-extension of carpal-metacarpal joint structures.

Ulnar Nerve Synovial Impingement

about dynamic ultrasound findings of ulnar nerve synovial impingement

This is the case of a patient suffering for a post-traumatic olecranon bursitis with ulnar nerve entrapment symptoms, one month after an elbow contusion.

A standard plain radiograph was made immediatly after trauma, showing a small bony fragment of the olecranon cortical surface.

Elbow

Olecranon Bursitis

Sagittal T2w (left) and Axial T2w (right) Mri scans (0.3 Tesla).

The Mri exam shows a gross olecranon bursitis, but the inflammatory process involving the ulnar nerve is better appreciated with the dynamic ultrasound examination.

My suggestion is always tha same… Mri and Ultrasound exams complement each other succesfully, so use both togheter in your daily practice.

Calcaneofibular Ligament Injury

There is usually a predictable kinematic pattern of injury involving the anterior talofibular ligament followed by the calcaneofibular ligament; don’t forget that finding a complete rupture of the calcaneofibular ligament means that also the anterior talofibular ligament must be injured.

pierarrow

Coronal (left) and Axial (right) T2 weighted Mri scans (0.3 Tesla) demonstrate a complete rupture of the calcaneofibular ligament.

The ultrasound imaging needs an accurate dynamic evaluation to demonstrate the injured ligament.

In this young professional football player both the anterior talofibular and calcaneofibular ligaments are completely torn.

pierarrow2

Coronal (left) and Axial (right) T2 weighted Mri scans of the same patient: a complete rupture of the ATFL is evident.

The ultrasound dynamic investigation well defines the high degree injury of the ligament.

1 Month After…. Anterior Talo-Fibular Ligament (ATFL) Injury

Have you seen my recent post Anterior Talo-Fibular Ligament (ATFL) Injury? In this new post you can see the changes of Mri and Ultrasound imaging after one month; it’s very important the monitoring with both modalities but…. don’t forget to consider also the evolution of clinical presentation and if possible, go on the playing field to directly see the real situation.

Pellebis

Axial T2 weighted an Fast Stir Mri scans (0.3 Tesla) 1 month after a complete rupture of the ATFL

It Depends

If someone asks me what’s best between Mri and Ultrasound imaging in the study of muscles? I usually give the same answer: always use both modalities! It depends on what kind of informations you need to know from them. Take a look at the following images.

This is the case of an high degree strain of the biceps femoris, in a 17 years old professional football player. One month after injury a fibrotic scar is evident along the course of the proximal tendon-aponeurosis. Great panoramicity of Mri scan but with ultrasound exam you can best appreciate the real extent and morphology of the calcifications.

compara zecca

Coronal and axial Mri scans: comparison between T1w and Pdw Spair acquisitions

 Sagittal dynamic ultrasound exam of the same patient

zecca

The elastosonography evaluation well depicts the calcification hardness but stable scarring evolution; irregular thermoregulation is evident in the injured left thigh after one month.

I always use the thermographic camera during the recovery period, morover when the athletes come back to specific sport activity.

Are Muscle Strains Hot?

As consultant radiologist for the U.S. Palermo football team, I had a collaboration with the Medical Staff directed by DrCristian Francavilla; Stefano Gari is one of the physiotherapists. He’s working on an interesting project: to study muscular activity with a thermographic camera. 

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Me and Stefano Gari together with Dr. Francavilla and the goalkeeper Stefano Sorrentino during Sassuolo-Palermo match of last year “Serie A”season.

From Wikipedia, the free encyclopedia: “A thermographic camera (also called an infrared camera or thermal imaging camera) is a device that forms an image using infrared radiation, similar to a common camera that forms an image using visible light. Instead of the 400–700 nanometer range of the visible light camera, infrared cameras operate in wavelengths as long as 14,000 nm (14 µm). Their use is called thermography.

Stefano started from a physiological consideration: the inflammatory process increases local temperature; the classical signs of acute inflammation are pain, heat, redness, swelling and loss of function. In the first 24 hours after an injury, a great difference of temperature occurs between the site of injury and the peripheral tissues. Before making the standard radiological examinations, he began to take several thermographic pictures of the injured muscle and then tried to correlate with Mri imaging. The results? In such cases the comparison is incredible. 

thermo1

2nd degree strain of gastrocnemius medial head – coronal stir mri study and thermography correlation

Thermographic camera never can be considered an alternative to others radiological examinations but a complementary study, especially during physiotherapy treatment follow-up of muscular strains, to better evaluate the progression to healing.

thermobiceps

Thermographic pictures taken 24 hours (A) and 48 hours (B) after a strain injury of the right biceps femoris in a professional football player.

sorre

Coronal – Sagittal – Axial Stir Mri scans of the same patient performed two days after trauma.

Many colleagues often ask me what I think about the use of ultrasound exams immediately after a muscle trauma on the playground: is it useful? In my opinion the answer is no; too high the risk of underestimate a muscular lesion immediately after an injury. The perfect timing for a good ultrasound examination is about 48-72 hours after the trauma. Can the thermographic camera cover this time interval to have a pre-evaluation of the possible damages? I hope so; at this moment I find very interesting the possibility of monitoring the tissue changes during the physiotherapy treatments.

Come on Stefano, get down to it! I’m waiting for further studies!