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.

Peroneal Fracture Monitoring

about ultrasound monitoring of peroneal fracture

Two months after a peroneal fracture the x-rays show a regular healing but the patient feels pain: why?

Peroneal Fracture Healing

I suggest you to always use both ultrasound and Mri imaging to better evaluate the correct healing of the fracture.

In this professional football player is also evident a gross perilesional edema involving the peroneal muscles togheter with the peroneal neurovascular bundle.

Peroneal Fracture Mri

Axial T2w (left) and Stir (right) mri sequences of the same patient (0.3 Tesla).

Peroneal Fracture Mri2

Sagittal Stir (left) and T2w (right) Mri sequences (0.3 Tesla); the perilesional edema along the course of peroneal neurovascular bundle is evident.

The dynamic ultrasound exam allows to better appreciate all the structures involved in this pathological picture; just a little reminder: high sensibility but 0% specificity of the ultrasound imaging in the study of cortical bone.

 

 

Psoriatic Arthritis of the Elbow

About chronic synovitis of the elbow in a patient with psoriatic arthritis.

Sometimes patients come to our attention without a specific clinical history, referring just joint pain.

In case of this joint swelling and gross chronic synovitis always think to a rheumatic disorder. Remember that on MRI, psoriatic synovitis appears indistinguishable from that of rheumatoid arthritis. According to the EULAR (European League Against Rheumatism) recommendations – “A definitive diagnosis of rheumatic diseases can be made by assessing the medical history, by performing a physical examination or ordering specific laboratory tests and undertaking imaging investigations”.

psoriatic-synovitis2

Coronal Ge Stir (left) and T1W Mri scans (0.3 Tesla).

psoriatic_synovitis_jpg

Coronal GeStir (left) and Sagittal T2w (right) Mri scans (0.3 Tesla). A gross synovitis with pseudonodular distension of the bicipitoradialis bursa is evident.

The Mri examination shows diffuse irregularity of the cortical bone surfaces and entheseal region of tendons and ligaments, with distension of adjacent bursae by fluid collection. All of these findings are well depicted on ultrasound exam.

This patient also suffered for a painful synovial impingement along the course of the posterior interosseous nerve at Frohse’s arcade, best seen with the dynamic ultrasound examination.

With the elastosonography exam you can discriminate the real fluid quote of this chronic synovitis.

Avoid joint aspiration in this kind of situations: it’s like putting a needle into the marmalade! 

Take home message? Keep calm and call a rheumatologist.

Sartorius Tendon Injury

About sartorius tendon injuries in adolescents.

14 years-old male soccer player presents with right hip pain after kicking. The site of referred higher pain is located on the anterior-superior iliac spine.

The dynamic ultrasound exam shows a partial strain of the sartorius tendon bone attachment, togheter with a gross irregularity of the cortical bone surface, a common finding in young patients; power-doppler evaluation defines the typical post-traumatic hypervascularity.

In these cases I always suggest to perform also the Mri exam for the correct diagnosis and clinical management.

Ultrasound imaging is not enough: what’s about the osteochondral involvment?

antero-superior-iliac-spine

Axial (left) and Sagittal Pdw-Spair Mri scans (1.5 Tesla).

The partial tear of sartorius tendon with associated marrow and soft tissue edema is evident. Apophyseal injuries to the hip and pelvis are quite frequent in skeletally immature individuals playing football. Combining ultrasound and Mri imaging modalities is the gold standard, especially beacuse radiographs may be interpreted as negative also in case of non-displaced fractures.

If you are a “pure sonographer” or a physiotherapist don’t forget to talk with a radiologist about these kind of injuries.

The Medial Collateral Ligament Bursa

About the dynamic ultrasound study of the medial collateral ligament bursa.

Three layers can be defined on the medial compartment of the knee: layer I – crural fascia; Layer II – superficial portion of the medial collateral ligament; Layer III – joint capsule and the deep portion of the medial collateral ligament.

Along the course of layer II, the medial collateral ligament bursa may become apparent when filled with fluid; as happened in this patient after an intense session of horse riding.

medial-collateral-ligament-bursa

Coronal Fast Stir (left) and T2 weighted Mri sequences (0.3 tesla).

All of bursae are typically founded  in areas where friction takes place, such as between bony surfaces and ligaments or tendons.

The dynamic ultrasound examination better defines the fluid collection within the bursa;

If necessary, the elastosonography evalutaion allows to monitorate the evolution of fluid collection; in this patient is still evident the typical fluid appearance with three-layer colour pattern.

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).