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.

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.

 

 

Soleus Myotendinous Junction Injury

About aponeurotic medial insertion injury of the soleus muscle.

Knowing the anatomy and biomechanics of the gastrocnemius-soleus complex – or triceps surae – is crucial for an understanding of the etiology and treatment of all its possible injuries. Today I want to show you a painful partial lesion at the aponeurotic medial insertion of the soleus muscle in a professional soccer player.

One month after a soleus injury, a patient suffered for pain and discomfort at the distal soleus myotendinous junction; first examination was made with an ultraportable device directly on the pitch during a daily training session. A partial injury of the aponeurotic medial insertion was evident, togheter with muscle perilesional edema.

soleus-injury

Sagittal Ultrasound comparative examination of the medial soleus myotendinous junction; normal findings on the right side.

soleus-medial-insertion

Sagittal GeStir (left) and Coronal T2w Mri scans of the same patient (0.3 Tesla).

fse_t2__2__and_fse_t2__4_

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

With the dynamic ultrasound examination is better appreciated also an inflammation along the course of the posterior tibial nerve.

Also in this case the elastosonography evaluation works like a “contrast agent” well depicting the lesional area.

You can find further information about the complex anatomy of the triceps surae in this interesting scientific paper: Anatomy of the Triceps Surae: A Pictorial Essay

 

Ultrasound Muscle Injuries Monitoring

About using Ultrasound and Elastosonography imaging in the muscle injuries monitoring.

Deciding when the injured muscle can be remobilized is probably the most crucial decision in the recovery period after a trauma. The process of scar formation begins almost immediately following injury; immature scar tissue is susceptible to reinjury and the formation of granulation tissue at the site of injury needs to be monitored during the rehabilitation program.

2nd-degree-strain

2nd degree strain of biceps femoris: ultrasound monitoring in a professional athlete; the two images appear quite similar.

The rehabilitation program is usually regulated with reduced activity until the scar reaches sufficient strength to bear the muscle contraction.

How to differentiate the tissue structural changes in the site of injury?

In my daily practice the elastosonography examination allows to distinguish normal from inadequate healing, working as a “contrast agent” in the site of scar formation.

Looking at the referral colour scale I remind you that red colour means softness and blue colour means hardness.

elasto

Same patient studied with elastosonography examination.

15 days after the injury an immature granulation tissue is present (red color in the site of injury), while after 1 month  the scar seems to be progressing favorably (blue color is dominant).

In this case the difference between scar tissues elements is more evident with elastosonography than with standard B-mode ultrasound  examination. Power-doppler exam demonstrates the revascularization by ingrowing capillaries in the site of injury.

 As I showed in my previous post “Are Muscle Strains Hot?” a difference of temperature occurs between the site of injury and the peripheral tissues.

img_2368

Also in this patient the thermographic evaluation shows an altered temperature diffusion in the left injured tigh; this is another useful information about the progression of the injurious event.

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).

Medial Collateral Ligament Tear

This is the case of a professional football player with a  grade 2 injury of the medial collateral ligament; high signal and partial disruption of the ligament is seen on Mri exam. The study is completed by dynamic ultrasound and elastosonography evaluation;  in this picture the elastosonography signal works like a “contrast agent”, with the red color that depicts the real extent of the ligament tear.

Have you ever tried to change the point of view of your ultrasound images? Takea look at the picture below, in which both Mri and ultrasound images have the same angle orientation.

medial-collateral

Coronal T2w mri scan (0.3 Tesla) and ultrasound exam of the same patient.

collateral-ligament-grading-injury

Medial collateral ligament tear: from grade 1 to grade 3. T2w coronal Mri scans (0.3 Tesla).