Tibial Tunnel Cyst

About diagnostic imaging of postoperative complication of anterior cruciate ligament (ACL) reconstruction.

This is the case of a patient the came to my observation for a palpable mass into the anterior-medial pretibial region, two years after ACL reconstruction.

Tunnel cyst formation is a rare complication after ACL reconstruction, usually occurring 1-5 years post-operatively, which may occasionally be symptomatic. The ultrasound exam in this case is not enough. The study is completed with MRI and Cone-Beam CT examination.

Tibial Tunnel Cyst MRI

MRI-Cone-Beam CT

Why Cone-Beam CT? Same diagnostic capability of total-body CT but low radiation dose!

Low Radiation Dose

The computed tomography dose index (CTDI) is a commonly used radiation exposure index in X-ray computed tomography (CT); in this case 4,74 mGy was the value detected. 16.98 mGy is the estimated absorbed dose by using a total-body CT scan for the same examination.

Total-Body CT

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Dorsal Scapholunate Ligament Tear

about dynamic mri and ultrasound examination of carpal instability

In my previous post Dynamic Evaluation of Dorsal Scapholunate Ligament I showed the usefulness of both ultrasound and Mri dynamic evaluation in the study of this important ligament structure. Today I want to show you the dorsal scapholunate ligament (SL) tear in a patient that came to my observation after a regular healing of post-traumatic scaphoid fracture.

SL Tear

Coronal Stir (left) and T1w (right)  Mri scans (0.3 Tesla): correct visualization with no artifacts of post-surgical treatment with scaphoid screw. Tear of the dorsal scapholunate ligament is evident (red arrow).

For the appropriate treatment is crucial to see also the dynamic behaviour of this kind of injuries. I always perform both ultrasound and Mri dynamic evaluation in these cases.

The dynamic ultrasound exam shows the post-traumatic carpal instability; dorsal SL tear is evident, togheter with the scapholunate dissociation and DISI picture.

For the correct ultrasound scanning please see my previous post Dynamic Evaluation of Dorsal Scapholunate Ligament.

The Dynamic Mri evaluation (0.3 Tesla) during flexion-extension and ulnar-radial deviation confirms the clinical picture, better defining all the pathologic findings. The radiology technician plays a crucial role for this kind of examination, explaining to the patient the correct wrist movement during the Mri acquisitions.

Dupuytren Disease

About Mri and Ultrasound study of palmar fibromatosis of the hand.

This fibrosing hand disorder often leads to progressive and debilitating flexion contractures of the fingers. The diagnosis is made clinically but defining how much a fibrous nodule infiltrates a tendon is a keyelement in the diagnosis and treatment strategy, especially because recurrence after surgery is common.
For this reason I always perform both Mri and ultrasound examinations in my daily practice. Always.

dupuytren

Sagittal (left) and Axial (right) T2w Mri scans (0.3 Tesla); red arrows indicate the fibrous nodule and flexor tendons.

The video below demonstrates the nodule traction on the underlying flexor tendons, resulting in flexion contractures of the digits (Dupuytren contractures).

 

Third Metacarpal Fracture

about fracture ultrasound visualization

This is the case of a non-displaced third metacarpal fracture of a professional football player after a contusion at football match. The ultrasound dynamic exam shows a gross irregularity of the cortical bone surface, with perilesional soft-tissue swelling.

It’s very important to be familiar with the ultrasound appearance of fractures, because in a large number of cases the ultrasound exam allows to appreciate the early bone damages that can be as a result of overuse injuries often seen in athlete with stress fractures.

Several tudies showed that minor fractures which are not radiologically diagnosed, can be seen in the ultrasound examination, togheter with the surrounding soft tissue structures.

The x-ray evaluation still remains essential.

xray

Plain radiographs of the same patient.

My Mri and ultrasound devices are separated only by a wall, so I usually perform both imagine modalities to give a complete description of the pathologic findings.

ge_stir__2__and_se_t1__3_

Coronal Ge-Stir (left) and T1w Mri scans (0.3 Tesla).

The 3D Sharc Mri acquisition allowed to better discriminate the real extent of the metacarpal fracture and its relationship with the articular plane.

 

Patellar Tendon Degeneration part II

about patellar tendon degeneration

In a previous post I showed you my daily routine in studying patellar tendon degeneration and how crucial is to combine all the imaging modalities for a better treatment strategies.

It’s not easy to study post-surgical outcomes of a tendon with the Mri evaluation; lots of artifacts and calcfications doesn’t allow a clear visualization of tendon’s fibres.

patellar-tendon-degeneration

Sagittal T1w (left) and GeStir (right) of patellar tendon degeneration 10 years after surgery reconstruction; red arrows indicate the site of pain.

This is the case of a patient that ten years after surgical reconstruction of the patellar tendon, starts to feel pain. Is it possible to “see” the pain? Gross tendon degeneration is evident but, only with ultrasound examination I can better depict the hypervascularity of the tendon in the site of referred pain and the relationship between patellar tendon and Hoffa’s fat pad, its well known “biomechanical attenuator”.

But I also asked to myself: what’s behind this tendon degeneration? Dynamic Mri study gave me the answer: a scarce patellar mobility during active flexion-extension movements was evident.

Less patellar mobility means more stress for the tendon. Isn’t it?

0.3 and 1.5 Tesla Mri

Sometimes, if my daily agenda allows to spread my curiosity (time is never enough!), I make a comparison between 0.3 and 1.5 Tesla Mri imaging studying the same patient.

These are the pictures of a sprained medial collateral ligament of a professional football player, quite similar to what is shown in my recent post medial collateral ligament tear.

collateral-tear

Coronal T2w (left) and Sagittal T2w (right) Mri scan (0.3 tesla)

I always complete my study with a dynamic ultrasound exam; in this patient the presence of a calcification is noted, not visible on Mri scans.

mri-comparison

Comparison between Axial and Coronal Mri scans of the same patient.

sagittal-comparison

Sagittal Pd Tse Fs (1.5 tesla) and Fast Stir (0.3 Tesla).

Proximal Rectus Femoris Tendon Tear

Soccer player. Suffering of acute right hip pain after kicking at football match. The Mri exam shows a proximal tendon tear at its insertion on the anterior-inferior iliac spine.

complete_anatomy

t2_tse_rst_cor_fil__4__and_t2_tirm_fs_cor_fil__2_

Coronal T2 weighted (left) and T2 tirm-fs (right) Mri scans (1.5 Tesla).

I always perform a dynamic ultrasound evaluation, monitoring the tendon healing during rest period and  rehabilitation program. In this case the tendon structure is best appreciated with the dynamic exam.

Normal anatomy of the proximal rectus femoris tendon; two tendinous origins: the direct head and the indirect or reflected head are evident. The two heads form a conjoined tendon about 2 cm distal to their origin.

Never forget: normal anatomy before and then pathology.