Learning Muscoloskeletal Imaging

Learning Imaging
Series Editors:
R. Ribes A. Luna P. Ros
R. Ribes J. C. Vilanova (Eds.)
Learning
Musculoskeletal
Imaging
Ramn Ribes MD, JD, PhD
Platero Martinez 19
14012 Crdoba
Spain
ribesb@gmail.com
Joan C. Vilanova , MD, PhD

University of Girona
Chief MRI Unit
Clnica Girona
Lorenzana, 36
17002 Girona
Spain
kvilanova@comg.cat
ISBN: 978-3-540-87999-2 e-ISBN: 978-3-540-88000-4

DOI: 10.1007/978-3-540-88000-4
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To Manuel Snchez Glvez, my first

hero.
Ramn Ribes
To my wife Cris and my children

Cristina and Eduard for their love
and for accommodating the sacrifices of
personal time.
Joan C. Vilanova
Preface
Musculoskeletal (MSK) radiology is a radiological subspecialty that has expanded its

knowledge base and imaging capabilities with the advent of MRI, multi/detector CT, ultra-
sound, and PET. Prior to the advent of MRI, MSK radiologists used plain film X-rays and
arthrograms as their primary tools. The subspecialty has progressed from primary imag-
ing of osseous structures and indirect imaging of joint spaces, to direct imaging of soft
tissue structures with direct visualization and fine definition of MSK structures.
A specialized MSK radiologist requires a sound knowledge of anatomy, pathophysiol-
ogy, orthopedic surgical techniques, and advancements in imaging modalities. MSK imag-
ing involves all aspects about anatomy, function, disease states, and aspects of interventional
radiology appertaining to the MSK system including imaging in orthopedics, trauma,
rheumatology, metabolic and endocrine diseases, as well as aspects of pediatrics, oncology,
and sports imaging.
Subspecialty training in MSK radiology must ensure competence to obtain experience
in the following techniques: plain radiography, ultrasonography, CT, MRI, nuclear medi-
cine, bone densitometry, and fluoroscopic procedures including arthrography. MSK radi-
ologists must be aware of the strengths and weaknesses of the different imaging methods
in each pathological condition and choose the appropriate imaging technique and/or the
appropriate sequence in the investigation of specific clinical problems.
A MSK radiologist should be prepared to assure an in-depth understanding of disease
of the MSK system and understand the role of imaging in the diagnosis and treatment of
MSK disease. Moreover, because of innovation and new medical imaging modalities, there
are increasingly demanding requirements by clinical specialists. If radiologists do not or
cannot keep up with increasing demands for MSK interpretations, clinicians will be forced
to compete with radiologists in providing interpretations.
From the beginning of the subspecialty in the 1970s with the foundation of the
International Skeletal Society, multiple multidisciplinary or dedicated skeletal radiology
societies have been founded and organized from international or national societies.
We will try to expand the development of MSK radiology through complete prepared
radiologists, in order to develop the ability to transmit the knowledge and assume the con-
tinuity and evolution of radiological diagnosis in the field of MSK radiology.
Crdoba, Spain Ramon Ribes

Girona, Spain Joan C. Vilanova
Contents
1 Infection and Arthritis

Jos A. Narvez, Matias De Albert, and Joan C. Vilanova . . . . . . . . . . . . . . . . . . . . . . . 1
Case 1.1 Femur Osteomyelitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Case 1.2 Rheumatoid Arthritis of the Cervical Spine. . . . . . . . . . . . . . . . . 4
Case 1.3 Ankylosing Spondylitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Case 1.4 Enthesitis in Psoriatic Arthritis. . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Case 1.5 Calcium Pyrophosphate Crystal Deposition Disease. . . . . . . . . 10
Case 1.6 Muscular Abscess. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Case 1.7 Septic Arthritis of the Pubic Symphysis. . . . . . . . . . . . . . . . . . . . 14
Case 1.8 Facet Joint Arthritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Case 1.9 Cellulitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Case 1.10 Pyogenic Spondylodiscitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2 Tumors
Guadalupe Garrido-Ruiz, Antoino Luna-Alcal, and Joan C. Vilanova . . . . . . . . . . . 23
Case 2.1 Osteoblastoma of the Rib. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Case 2.2 Ewings Sarcoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Case 2.3 Intraosseous Lipoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Case 2.4 Giant Cell Tumor of Bone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Case 2.5 Skeletal Muscle Metastases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Case 2.6 Synovial Sarcoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Case 2.7 Synovial Hemangioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Case 2.8 Brown Tumor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Case 2.9 Intramuscular Myxoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Case 2.10 Soft-Tissue Liposarcoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
3 Tendons and Muscles

Rosa Mnica Rodrigo, Mario Padrn, and Eugenia Sanchez-Lacalle . . . . . . . . . . . . 45
Case 3.1 Tennis Leg Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Case 3.2 Hamstring Muscle Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Case 3.3 Indirect Rectus Femoris StrainInjury . . . . . . . . . . . . . . . . . . . . . 50
Case 3.4 Adductor Muscle Strain Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Case 3.5 External Hip Rotator Muscle Injury . . . . . . . . . . . . . . . . . . . . . . . 54
Case 3.6 Chronic Avulsion of the Ischial Tuberosity . . . . . . . . . . . . . . . . . 56
Case 3.7 Acute Avulsion of the Anteroinferior Iliac Spine. . . . . . . . . . . . . 58
Case 3.8 Patellar Tendinopathy: Partial Tear. . . . . . . . . . . . . . . . . . . . . . . . 60
Case 3.9 Posterior Tibial Tendon Dysfunction. . . . . . . . . . . . . . . . . . . . . . 62
Case 3.10 Partial Rupture of the Aquilles Tendon with Tendinosis. . . . . . 64
Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
X Contents
4 Bone Marrow
Joan C. Vilanova, Mercedes Roca, and Sandra Baleato . . . . . . . . . . . . . . . . . . . . . . . . 67
Case 4.1 Bone Metastasis of Melanoma in the Femoral Head
Mimicking Avascular Necrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Case 4.2 Bone Marrow Necrosis Due to Nonhodgkins Lymphoma. . . . . 70
Case 4.3 Systemic Mastocytosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Case 4.4 Bone Crisis in Gauchers Disease. . . . . . . . . . . . . . . . . . . . . . . . . . 74
Case 4.5 Non-Hodgkins (Diffuse Large B-Cell) Lymphoma. . . . . . . . . . . 76
Case 4.6 Shoulder Arthropathy Secondary to Gauchers Disease. . . . . . . 78
Case 4.7 Multifocal Osteonecrosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Case 4.8 Multiple Myeloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Case 4.9 Bone Metastases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Case 4.10 Regional Migratory Osteoporosis. . . . . . . . . . . . . . . . . . . . . . . . . 86
Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
5 Spine
Eva Llopis, Victoria Higueras, Elena Belloch, and Mara Va . . . . . . . . . . . . . . . . . 89
Case 5.1 Congenital Scoliosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Case 5.2 Herniated Disc Migration with Spontaneous Regression . . . . . 92
Case 5.3 Ligamentum Flavum Cyst. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Case 5.4 Primary Vertebral and Epidural Lymphoma. . . . . . . . . . . . . . . . 96
Case 5.5 Osteoid Osteoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Case 5.6 Meningioma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Case 5.7 Myeloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Case 5.8 Fracture Dislocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Case 5.9 Spondylodiscitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Case 5.10 Sacral Chordoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
6 Shoulder
Fernando Idoate-Saralegui, and Joan C. Vilanova. . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Case 6.1 Adhesive Capsulitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Case 6.2 Parsonage: Turner Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Case 6.3 Bankart Lesion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Case 6.4 Perthes Lesion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Case 6.5 Alpsa + HillSachs Lesion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Case 6.6 Glad Lesion and Calcified Loose Body. . . . . . . . . . . . . . . . . . . . . 122
Case 6.7 Slap Lesion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Case 6.8 Posterior Labral Tear + Paraglenoid Labral Cyst . . . . . . . . . . . . 126
Case 6.9 Ambrii + Bilateral Labral Tears. . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Case 6.10 Posterosuperior Impingement (Throwing Shoulder + GIRD) . 130
Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
7 Elbow, Hand, and Wrist

Juan de Dios Bern, Ana Canga, and Luis Cerezal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Case 7.1 Slac Wrist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Case 7.2 Scaphoid Avascular Necrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Contents XI
Case 7.3 Intraosseous Ganglia of the Lunate

(Pseudo-Kienbck Disease). . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Case 7.4 Glomus Tumor in the Thumb. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Case 7.5 Carpal Boss. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Case 7.6 De Quervain Tenosynovitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Case 7.7 Distal Biceps Tendon Rupture . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Case 7.8 Posterior Dislocation of the Elbow. . . . . . . . . . . . . . . . . . . . . . . . 150
Case 7.9 Occult Fracture of the Radial Head. . . . . . . . . . . . . . . . . . . . . . . . 152
Case 7.10 Pigmented Villonodular Synovitis of the Elbow. . . . . . . . . . . . . 154
Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
8 Hip and Pelvis

Ara Kassarjian, Jos Martel-Villagrn, and ngel Bueno-Horcajadas . . . . . . . . . . 157
Case 8.1 Postpartum Sacral Fracture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Case 8.2 Acute Avulsion Fracture of the Ischial Apophysis. . . . . . . . . . . . 160
Case 8.3 Transient Osteoporosis of the Hip. . . . . . . . . . . . . . . . . . . . . . . . . 162
Case 8.4 Osteolysis Associated with Total Hip Arthroplasty. . . . . . . . . . . 164
Case 8.5 Osteomalacia with Looser Zones. . . . . . . . . . . . . . . . . . . . . . . . . . 166
Case 8.6 Femoroacetabular Impingement (Predominantly Cam Type) . 168
Case 8.7 Pubalgia Due to Common Adductor Tendon Microavulsion . . 170
Case 8.8 Osteopoikilosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Case 8.9 Rapidly Destructive Osteoarthritis. . . . . . . . . . . . . . . . . . . . . . . . 174
Case 8.10 Osteonecrosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
9 Knee
Joan C. Vilanova, Sandra Baleato, and Joaquim Barcel . . . . . . . . . . . . . . . . . . . . . . . 179
Case 9.1 Lipoma Arborescens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Case 9.2 Pigmented Villonodular Synovitis. . . . . . . . . . . . . . . . . . . . . . . . . 182
Case 9.3 Spontaneous Osteonecrosis of the Knee. . . . . . . . . . . . . . . . . . . . 184
Case 9.4 Discoid Meniscus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
Case 9.5 Osgood-Schlatter Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
Case 9.6 Chondromalacia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
Case 9.7 Meniscal Tear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
Case 9.8 Osteochondritis Dissecans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Case 9.9 Mucoid Degeneration of the Anterior Cruciate
Ligament with Ganglion Bone Cyst. . . . . . . . . . . . . . . . . . . . . . . . 196
Case 9.10 Acute Meniscal and Ligament Tears of the Knee. . . . . . . . . . . . . 198
Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
10 Ankle and Foot

Xavier Tomas and Ana Isabel Garcia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Case 10.1 Osteochondral Talar Lesion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Case 10.2 Calcaneal Fracture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Case 10.3 Complete Achilles Tendon Tear. . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Case 10.4 Lateral Collateral Ligament Sprain. . . . . . . . . . . . . . . . . . . . . . . . 208
Case 10.5 Syndesmotic Ankle Sprain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
XII Contents
Case 10.6 Plantar Fasciitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212

Case 10.7 Plantar Fibromatosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
Case 10.8 Tarsal Tunnel Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
Case 10.9 Diabetic Foot. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Case 10.10 Intermetatarsal Bursitis and Mortons Neuroma. . . . . . . . . . . . 220
Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Contributing Authors
Sandra Baleato Luis Cerezal

Department of Radiology Diagnstico Mdico Cantabria (DMC)
CHOP Complexo Hospitalario de Pontevedra Manuel Cacicedo 91
Pontevedra 39012 Santander
Spain Spain
Joaquim Barcel Matias de Albert

Department of Radiology Department of Radiology
Clnica Girona-Hospital Sta. Caterina Hospital Universitario de Bellvitge
Girona Hospitalet de Llobregat
Spain Barcelona
Spain
Elena Belloch
Ana Isabel Garca
Department of Radiology
Radiology Department
Hospital de la Ribera
Muscle-Skeletal Unit
Carretera de Corbera km1
Hospital Clnic
46600 Valencia
Barcelona
Spain
Spain
ngel Bueno-Horcajadas Guadalupe Garrido-Ruiz

Hospital Universitario Fundacin Alcorcn Hospital Vall dHebron
Alcorcn (Madrid) Barcelona
Spain Spain
Juan de Dios Bern-Mestre Victoria Higueras

Department of Radiology Department of Radiology
Virgen de la Arrixaca University Hospital Hospital de la Ribera
30120 El Palmar (Murcia) Carretera de Corbera km1
Spain 46600 Valencia
Spain
Ana Canga
Department of Radiology Fernando Idoate-Saralegui
Marqus de Valdecilla University Hospital Department of Radiology
Radiologic Anatomy Clnica San Miguel
39008 Santander Pamplona
Spain Spain
XIV Contributing Authors
Ara Kassarjian Mercedes Roca

Massachusetts General Hospital Ciberer. Instituto Aragons de Ciencias
Boston, MA de la Salud I+D+I
USA Zaragoza
Spain
Eva Llopis
Department of Radiology Eugenia Sanchez-Lacalle
Hospital de la Ribera Radiology Department
Carretera de Corbera km1 Clnica Cemtro
46600 Valencia Madrid
Spain Spain
Antonio Luna-Alcal Xavier Tomas

Clnica Las Nieves Sercosa Radiology Department
23007 Jan Muscle-Skeletal Unit
Spain Hospital Clnic
Barcelona
Spain
Jos Martel-Villagrn
Corades, S.L.
Majadahonda (Madrid) Maria Va
Spain Department of Radiology
Hospital de la Ribera
Carretera de Corbera km1
Rosa Mnica Rodrigo
46600 Valencia
Resonancia Bilbao
Spain,
Bilbao
Spain
Joan C. Vilanova
University of Girona
Jos A. Narvez
Chief MRI Unit
Department of Radiology
Clnica Girona
Hospital Universitario de Bellvitge
Lorenzana, 36
Hospitalet de Llobregat
17002 Girona
Barcelona
Spain
Spain
Mario Padrn
Radiology Department
Clnica Cemtro
Madrid
Spain
Infection and Arthritis 1
Jos A. Narvez, Matias De Albert, and Joan C. Vilanova
2 J. A. Narvez, M. De Albert, and J. C. Vilanova
Case 1.1
Femur Osteomyelitis
Fig. 1.1.1 Fig. 1.1.2
Fig. 1.1.3
Fig. 1.1.4
Fig. 1.1.5
A 9-year-old boy presented with a 3-week history of left hip pain. Four weeks prior, the patient
had suffered a superficial injury to his abdomen, which required a subcutaneous suture.
At admission, he had intermittent fever. He was reluctant to bear weight on his left limb
and had gait disturbances. Plain-film pelvic radiographs performed in the emergency
room were suspicious for a bone tumor of the left ischium. CT, bone scintigraphy, and MRI
examinations were requested to rule out bone tumor.
Acute hematogenous osteomyelitis usually occurs during skeletal growth when the growth Comments
plate is open. Early detection of osteomyelitis is essential to enable therapy to be started
before bone devitalization.
Hematogenous osteomyelitis may not be evident on plain films until at least 10 days
after the onset of symptoms. The evolution of the infection can manifest radiographically
as soft-tissue swelling with obliteration of adjacent muscle planes, subperiosteal calcifica-
tion, and resorption of bony trabeculae.
Bone scintigraphy is highly sensitive for the diagnosis of osteomyelitis. Bone scintigra-
phy scans are sensitive indicators of altered osteoblastic activity, but local disturbances in
vascular perfusion, clearance rate, permeability, and chemical binding also affect imaging.
CT should be used only as a third-line technique for visualizing bony destruction, gas
within the bone, or bony sequestration.
MRI is highly sensitive as an indicator of disease because pathological findings are evi-
dent much earlier in the course of the disease. The MRI diagnosis of osteomyelitis is based
on its capability to detect bone marrow abnormalities within the physis.
Active osteomyelitis foci appear as low signal intensity areas on T1-weighted images and
high signal intensity areas on T2-weighted images, fat-suppression, or STIR sequences.
MRI is an excellent technique for the detection of osteomyelitis and the depiction of its
extent.
It is important to understand the limitations of each imaging technique to avoid delays
in the diagnosis and management of osteomyelitis and prevent possible complications.
The differential diagnosis of pelvic osteomyelitis in children should include septic
arthritis, Legg-Calve-Perthes disease, toxic synovitis, and less commonly, collagen-vascular
diseases, neoplasms involving bone, and retroperitoneal abscess.
Plain film of the pelvis (Fig. 1.1.1) shows no pathologic findings for bone infection in the Imaging Findings
left femur. A swollen left ischiopubic synchondrosis was found incidentally (open arrow)
and was at first interpreted as the reason for the patients complaint. Bone scintigraphy
(Fig. 1.1.2) scan shows increased uptake within the left femoral head (arrow) and slight
uptake in the left ischiopubic synchondrosis (open arrowhead).
CT (Fig. 1.1.3) shows a round annular area in the left femoral head corresponding to the
focal site of infection.
Axial T1-weighted MRI (Fig. 1.1.4) shows diffuse low signal intensity within the proxi-
mal metaphysis of the left femur. Coronal STIR MRI (Fig. 1.1.5) reveals high signal inten-
sity in the bone marrow of the proximal femoral growth plate, with edema in the surrounding
soft-tissues. Note the hypertrophy of the ischiopubic synchondrosis (arrowhead).
A 58-year-old woman with a 10-year history of rheumatoid arthritis (RA) pre-

Case 1.2 sented hyperreflexia and neck pain unresponsive to conventional treatment. No
sensory or motor deficits were found at neurologic examination. Radiographs and
Rheumatoid Arthritis MRI of the neck were requested to rule out cervical spinal canal compromise.
of the Cervical Spine
Comments The cervical spine, particularly the craniocervical junction, is one of the most
common sites of RA involvement. The prevalence of cervical spine lesions of any
kind among RA patients ranges from 43 to 86%.
Cervical spine involvement can lead to severe pain and disability, as well as a
variety of neurological complications.
RA attacks the synovium; the atlantoaxial joint, where most of the synovial
tissue in the cervical spine is located, is where the disease is most prevalent and
Fig. 1.2.2
Fig. 1.2.1
Fig. 1.2.3 Fig. 1.2.4

where characteristic changes are most evident at imaging. Atlantoaxial joint synovitis
erodes the transverse ligament that holds the odontoid process to the atlas and causes lax-
ity, resulting in anterior atlantoaxial subluxation. This is the most common pattern of
atlantoaxial instability.
Radiographs are the initial imaging method in these cases. The normal anterior atlanto-
odontoid interval is less than 3mm. Anterior atlantoaxial subluxation may be not detected
in radiographs obtained in a neutral position, and lateral views with the neck flexed should
be obtained. When the anterior atlanto-odontoid interval is greater than 9mm, the risk of
cord compression increases.
A more severe manifestation of atlantoaxial rheumatoid disease is vertical subluxation,
in which the odontoid process migrates upward, protruding into the foramen magnum.
This condition results from destruction of the lateral atlantoaxial joints or of bone around
the foramen magnum.
Subaxial (below C2 level) involvement is less common in RA. In this cervical spine segment,
the most common rheumatoid manifestation is anterior subluxation, caused by apophyseal
joint destruction. An anterior vertebral body displacement greater than 3mm is diagnostic of
anterior subaxial subluxation. End-plate erosions, sclerosis, and destructive changes are
apparently due to extension of the inflammatory process from adjacent neurocentral joints
(the joints of Luschka, which are lined by synovium) into the discovertebral area
Magnetic resonance imaging (MRI) is the imaging modality of choice for assessing
involvement of the cervical spine in RA. It permits evaluation of the anatomical relation-
ships of the occiput, atlas, and axis, and it is therefore useful to define the extent of sublux-
ation of this spinal segment. It also permits direct visualization of periodontoid synovitis
formation, spinal cord, and brainstem.
MRI of the cervical spine is mandatory when spinal cord compression is clinically suspected.
In asymptomatic patients, MRI of the cervical spine should be considered when radiographs
show vertical subluxation, an anterior atlanto-odontoid interval greater than 9mm, a posterior
atlanto-odontoid interval of 14mm or less, or a subaxial canal diameter of 14mm or less.
Lateral view of the cervical spine in neutral position (Fig. 1.2.1) shows a normal anterior Imaging Findings
atlanto-odontoid interval (open arrow). Disc space narrowing, end-plate erosions, and sub-
chondral erosions are seen in the anterior region of C3C4; the rest of the disc space is
spared and no associated osteophytes, which correspond to discovertebral rheumatoid
involvement, are present.
Lateral view of the cervical spine with the neck in flexion (Fig. 1.2.2) reveals anterior
atlantoaxial subluxation (anterior atlanto-odontoid interval of more than 3mm) (arrows).
Sagittal T1-weighted (Fig. 1.2.3) and T2-weighted (Fig. 1.2.4) MRIs show periodontoid
synovitis, which presents low signal intensity on T1-weighted and high signal intensity on
T2-weighted images (open arrows). Periodontoid synovitis causes a mild mass effect on the
anterior thecal sac (arrowheads), but there is no cord compression. MRI was performed in
the neutral position, so the anterior atlantoaxial subluxation is not evident.
Note the small erosions and subchondral low signal intensity changes (open arrow-
heads) in the anterior region of the C3C4 disc space.
A 47-year-old man presented with long-standing low back pain and stiffness.
Case 1.3 Several years earlier, he was diagnosed with probable degenerative disc disease.
Radiographs of the lumbar and cervical spine and pelvis were obtained.
Ankylosing Spondylitis
Comments Ankylosing spondylitis is a chronic inflammatory disorder that mainly affects

the axial skeleton. It is more common in males, with a male-to-female ratio of
5:1. It is seen predominantly between the ages of 15 and 35 years.
Fig. 1.3.1 Fig. 1.3.2
Fig. 1.3.3 Fig. 1.3.4

The most common and characteristic initial symptoms are chronic, inflammatory low back
pain, and stiffness. Occasionally, back pain is too mild to impel the patient to seek medical care,
or it is misdiagnosed as sciatica due to degenerative disc disease, as occurred in our case.
Ankylosis spondylitis is characterized by bilateral sacroiliac and spinal involvement.
The sacroiliac joint is the first joint involved. The disease initial involves the spine in the
thoracolumbar junction and progresses to the lumbar and thoracic spine. Cervical spine
involvement is less frequent.
Radiographs are the initial imaging technique in these patients.
Radiographic signs of sacroiliitis are included in the diagnostic criteria of ankylosing
spondylitis. Small erosions are the initial radiographic abnormality, initially on the iliac
side and then on the sacral side. Usually, erosions are surrounded by subchondral sclerosis.
The anterior, synovial aspect of the joint ankyloses relatively early, but ankylosing of the
posterior, ligamentous aspect of the joint is common.
When radiographic findings are normal or inconclusive, CT can demonstrate these
destructive and reparative changes better.
Initially, radiographs of the spine show erosion of the anterior corners of the vertebral
body with secondary reactive sclerosis and a squared appearance of the vertebral body.
Ossification of the longitudinal ligaments is called syndesmophyte and involves the spine
in a symmetrical fashion. Spine ankylosis is associated to disc calcification. Ankylosing of
the apophyseal joints and ossification of the interspinous ligaments may be present. The
resulting appearance is called bamboo spine.
The axial distribution and the bone reparative changes with progression to ankylosis in
a short period of time allow a confident diagnosis in most cases.
In the last decade, MRI has been increasing used to study the inflammatory process in
ankylosing spondylitis and the other spondyloarthropathies. In contrast to radiographs
and CT, which detect destructive and reparative changes as mentioned above, MRI can
detect inflammatory changes at joints before these destructive-reparative changes take
place. MRI signs of early sacroiliitis are subchondral bone marrow edema and increased
signal on T2-weighted images and increased contrast-enhancement of the joint cavity, cor-
responding to synovitis. Bone marrow edematous changes at the ligamentous insertions
(entheses) in the spine are the hallmark of early disease.
Radiograph of the pelvis (Fig. 1.3.1) reveals complete ankylosis of both sacroiliac joints. Imaging Findings
Ossification of the ligaments in the posterior superior portion of the joints is called the
star sign (open arrows).
Radiographs (AP and lateral views) of the lumbar spine (Figs. 1.3.2 and 1.3.3) demon-
strate bilateral, succinct syndesmophytes. Note also disk calcification and partial ankylosis
of the apophyseal joints.
Radiograph (lateral view) of the cervical spine (Fig. 1.3.4) shows anterior syndesmo-
phytes at some disc spaces (closed arrows), disc space calcification, and partial ankylosis of
the apophyseal joints.
Case 1.4
Enthesitis in Psoriatic Arthritis
Fig. 1.4.2
Fig. 1.4.1
Fig. 1.4.3
A 26-year-old man complained of a painful left heel for several months. Pain did not sub-
side with rest. Conservative treatment with relative rest, nonsteroidal antiinflammatory
drugs, and a soft rubber heel pad was ineffective.
Initially, radiographs were obtained. MR imaging study was requested to better evaluate
the soft-tissue structures of the heel.
The enthesis is the point where a tendon, ligament, or joint capsule attaches to bone. Comments
Inflammation at the enthesis, or enthesitis, is considered the hallmark of the spondyloar-
thropathies, which are a group of inflammatory arthropathies that share some common
genetic, pathologic, and clinical features. This group includes ankylosing spondylitis, pso-
riatic arthritis, reactive arthritis (e.g., Reiter syndrome), arthritis associated with inflam-
matory bowel disease (e.g., Crohn disease or ulcerative colitis), and undifferentiated
spondyloarthritis.
Psoriatic arthritis has been defined as an inflammatory arthritis associated with psoria-
sis. Peripheral enthesitis is a common manifestation of psoriatic arthritis. The most com-
mon locations are at the enthesis of the Achilles tendon and plantar fascia in the calcaneus.
Enthesitis is usually bilateral and may be the initial manifestation of the disease.
Radiographs show erosions and bone proliferations at the enthesis of the Achilles ten-
don and plantar fascia, creating irregular and ill-defined spurs. The spurs tend to point
upward toward the calcaneus rather than downward along the course of the plantar aponeu-
rosis as occurs in normal heel spurs.
MRI not only identifies the destructive and reparative changes, but it also reveals the
inflammatory changes at the entheses. MRI signs of enthesitis include edematous changes
in the bone marrow adjacent to the insertion of the tendon or fascia and in the Achilles
tendon and plantar fascia themselves, which show increased signal intensity and variable
thickening. Edematous changes are also seen in the adjacent soft-tissues.
Erosions are seen as irregularity and defects of the bony margins, and sclerosis shows
low signal intensity on all pulse sequences. Precisely the aim of the MRI study is to identify
enthesitis before erosions and reparative sclerosis appear, making it possible to start effec-
tive treatment as early as possible.
Lateral view plain-film radiograph of the ankle (Fig. 1.4.1) shows erosion and bone forma- Imaging Findings
tion at the attachment of the Achilles tendon (open arrow). There is also sclerosis and for-
mation of a calcaneus spur (closed arrow), which points upward toward the calcaneus.
T1-weighted (Fig. 1.4.2) and STIR (Fig. 1.4.3) MRI demonstrates extensive edematous
changes in bone marrow at the insertions of the Achilles tendon and plantar fascia (open
arrowheads). Note also the edematous changes in the adjacent soft-tissues, with small ret-
rocalcaneal bursitis (closed arrowheads).
Case 1.5
Calcium Pyrophosphate Crystal Deposition Disease
Fig. 1.5.1
Fig. 1.5.2
Fig. 1.5.3 Fig. 1.5.4
Fig. 1.5.5
Infection and Arthritis11
A 73-year-old man complained of inflammatory cervical pain for 1 month. Cervical pain
increased progressively and required fentanyl treatment. After radiographs of the cervical
spine were inconclusive, a CT study of the cervical spine was requested.
Calcium pyrophosphate dehydrate (CPPD) crystal deposition is characterized by a constel- Comments

lation of clinical manifestations, which can be grouped in five discrete patterns: pseudogout,
pseudoosteoarthritis with synovitis, pseudoosteoarthritis without synovitis, monoarthrop-
athy, and pseudorheumatoid arthritis.
CPPD crystals may be deposited as soft-tissue masses, a condition known as tophaceous
pseudogout. Commonly affected sites of deposition include the temporomandibular and
atlantoaxial joints, ligamentum flavum, and the finger joints.
Involvement of the atlantoaxial joint is primary related to ligamentous CPPD crystal
deposition, which is associated with periodontoid synovitis and bony erosions and cysts,
mainly in the odontoid process. Erosion of the odontoid process can produce a pathologic
fracture. Retrodental synovial masses with calcification can cause cervical cord compres-
sion. This syndrome of acute neck pain associated with calcification surrounding the
odontoid process has been described as crowned dens syndrome.
Symptomatic spinal involvement of the ligamentum flavum of the cervical and lumbar
spine has been reported.
Ligamentous calcification can be detected by radiographs, but CT is usually necessary to
identify calcifications in the periodontoid synovial masses, allowing a correct diagnosis.
MRI is useful to assess the relationships between these periodontoid masses and the
cervical cord.
Lateral view radiograph of the cervical spine (Fig. 1.5.1) shows small calcifications located Imaging Findings
below the anterior rim of the atlas (open arrow), with ill-defined erosions of the odontoid
process.
Axial CT scans (Figs. 1.5.2 and 1.5.3) demonstrate calcified deposits (closed arrow) and
odontoid erosions (open arrowhead).
Coronal multidetector CT reconstruction of the cervical spine (Fig. 1.5.4) shows the
periodontoid calcifications.
Coronal multidetector CT reconstruction of the pelvis (Fig. 1.5.5) demonstrates a linear
calcification of the symphysis pubis as well as irregular calcifications at the adductor mus-
cle insertions (closed arrowheads).
Case 1.6
Muscular Abscess
Fig. 1.6.2
Fig. 1.6.1
Fig. 1.6.3 Fig. 1.6.4

A 52-year-old alcoholic man presented at the emergency department with disorientation

and depressed level of consciousness. Signs of malnutrition, hypotension, and generalized
edema were detected. Laboratory tests showed pancytopenia. Blood cultures were positive
for Streptococcus equisimilis, though no clear source of infection was identified. Five days
after admission, a cellulitic plaque appeared on his right thigh. He underwent ultrasonog-
raphy and CT.
Although most bacterial infections in the soft-tissues remain localized, depending on the Comments
immunologic status of the patient, these infections can extend and may form an abscess.
The most commonly isolated pathogen in soft-tissue abscesses is S aureus, especially
methicillin-resistant S aureus.
Ultrasonography plays a major role in the detection and management of superficial
abscesses, but deeper fluid collections usually require MRI or CT. MRI and CT are the ideal
techniques to display the soft-tissue abnormalities and can be quite specific and helpful in
detecting the presence and extent of infection, which generally is suspected clinically on
the basis of physical and laboratory findings.
At ultrasonography, soft-tissue abscesses are demonstrated as an irregular fluid-filled
anechoic or diffusely hypoechoic area with posterior acoustic enhancement containing a
variable amount of echogenic debris. Color Doppler imaging may be used to demonstrate
hyperemia at the periphery of the mass and absence of flow in its center.
CT shows a well-demarcated fluid collection, with a peripheral pseudocapsule showing
rim enhancement.
MRI shows a well-demarcated fluid collection that is hypointense on T1-weighted
images and hyperintense on T2-weighted and STIR images, surrounded by a pseudocap-
sule with low signal intensity in all sequences and peripheral rim enhancement after intra-
venous administration of gadolinium-based contrast material.
Needle aspiration biopsy is mandatory if an abscess is suspected. Abscesses are treated
with antibiotics and percutaneous drainage.
Ultrasonographic image of the posterior compartment of the right thigh (Fig. 1.6.1) shows Imaging Findings
a well-circumscribed hypoechoic subcutaneous cavity (open arrow) with internal echoes
(arrow) displacing the fat lobules (open arrowhead). The echogenic material filling the
abscess fluctuated on compression.
Power Doppler ultrasound image (Fig. 1.6.2) shows hyperemic blood flow within the
abscess wall (open arrow). No flow was seen in the center.
CT (Fig. 1.6.3) shows septations of the subcutaneous fat (open arrow), skin thickening
(arrow), and a small rim-enhancing, well-demarcated fluid collection adjacent to the biceps
femoris muscle (open arrowhead).
Coronal MPR CT (Fig. 1.6.4) shows the intramuscular location of the abscess, inside the
biceps femoral muscular fibers (open arrow).
Case 1.7
Septic Arthritis of the Pubic Symphysis
Fig. 1.7.1
Fig. 1.7.2
Fig. 1.7.3 Fig. 1.7.4

An 82-year-old man, who had undergone prostatectomy 2 months before, presented at the
emergency department with a temperature of 38C and history of two days of nausea, and
vomiting. He reported lower abdominal pain centered on the suprapubic region. The white
blood cell count was 20,100 cell/mm3. An exploratory CT examination was performed.
Septic arthritis of the pubic symphysis is a rare and painful condition that may become Introduction
apparent 1 month or longer after a pelvic procedure or surgery, especially after surgery to
correct incontinence in women, prostate surgery, and surgery on pelvic malignancies.
Plain films are relatively insensitive, especially early in the course of disease. The radio-
graphic appearance includes mild to severe pubic symphysis thickening and subchondral
bony irregularity, usually in both pubic bones. In advanced stage disease, bone sclerosis
can also be observed.
CT scans show the classical findings of septic arthritis and include joint effusion with
synovial enhancement and bone erosions around the joint.
An MRI is more sensitive in the detection of early changes in septic arthritis, revealing
signal intensity abnormalities in the bone narrow and soft-tissues, both of which have
edema-like signal intensity (i.e., are hypointense on T1-weighted images and hyperintense
on fat-suppressed T2-weighted images and STIR images).
Extension of infection from the joint space into surrounding tissue is also easily recog-
nized on both CT and MRI.
This rare disease must not be confused with the more common osteitis pubis, a sterile,
inflammatory condition of the pubis occurring after pregnancy, trauma, or gynecologic or
urologic surgery and also seen in athletes, characterized by pubic pain radiating to the
groin, waddling gait with adductor spasm, sclerosis, and rarefaction of the pubic symphysis
on imaging studies. Osteitis pubis in athletes is usually a noninfectious, chronic pubic
periostitis that appears with overuse injuries of muscles inserting on the symphysis.
Plain film of the pelvis (Fig. 1.7.1) shows doubtful thickening of the pubic symphysis (open Imaging Findings
arrow).
CT of the pelvis at the level of the pubic symphysis (Fig. 1.7.2) in soft-tissue window
shows a small collection (open arrow) with peripheral rim enhancement, (arrow) corre-
sponding to an abscess.
CT at the same level with bone window (Fig. 1.7.3) shows cortical thinning (open arrow)
and erosion of the anterior portion of the symphysis.
Sagital MPR CT (Fig.1.7.4) shows, in a more clear view, cortical thinning (open arrow)
with some small erosion (arrow) in the anterior portion of the symphysis.
A 47-year-old female patient with a past history of

Case 1.8 moderate alcoholism and cutaneous discoid lupus ery-
thematosus treated with chloroquine presented 16 days
Facet Joint Arthritis after the onset of acute back pain not relieved with non-
steroidal antiinflammatory treatment. Blood and urine
Fig. 1.8.3
Fig. 1.8.1
Fig. 1.8.4
Fig. 1.8.2 Fig. 1.8.5

cultures were positive for S. aureus. Radiographs of the lumbar spine were obtained and
Technetium-99 bone scintigraphy, CT, and MRI of the lumbar spine were requested.
Pyogenic facet joint infection is a rare and underrecognized clinical entity that is poorly Imaging Findings
documented to date. Clinically, it is characterized by inflammatory low back pain and fever;
neurologic impairment is seen in nearly half the cases. Patients often present systemic pre-
disposing factors, including diabetes mellitus, malignancies, or alcoholism. In one third of
cases, one or more concomitant infectious processes due to the same microorganism are
found, mainly arthritis, skin and soft-tissue infections, endocarditis, and urinary tract
infections. Staphylococcus aureus is the most common etiologic microorganism.
Radiographs are usually of no value in the first stages of the disease. Technetium-99 scin-
tigraphy shows increased tracer uptake at the level of the affected vertebra. Unlike spondylo-
discitis, tracer uptake is usually oriented more vertically than horizontally, although it is
difficult to distinguish between the two conditions based only on the scintigraphic findings.
CT abnormalities include loss of subchondral bone associated with the facet joint, loss
of ligamentum flavum density, and obliteration of fat planes. Contrast-enhanced CT can
also detect phlegmonous changes and/or fluid collections in paraspinal soft-tissue; how-
ever, MRI depicts soft-tissue structures better than CT. CT is also useful for image-guided
biopsy in selected cases.
MRI is the modality of choice for diagnosing pyogenic facet infection. MRI is both sensi-
tive and specific in diagnosing pyogenic facet joint infection as early as 2 days after the
onset of symptoms, and it can rule out involvement of the disc space and vertebral body.
Moreover, it is especially effective for evaluating the neural structures of the spine (i.e., the
spinal cord and nerve roots) and the spread of infection to the epidural space and/or
paraspinal soft-tissues. Paraspinal and/or epidural extension is a frequent finding, and the
use of gadolinium contrast is required to better delineate the extent of the process and to
differentiate nonenhancing abscesses from phlegmonous changes.
It is important to understand the limitations of each imaging technique to avoid delays
in the diagnosis and management of pyogenic facet joint infection and prevent possible
complications.
Bone scintigraphy (Fig. 1.8.1) shows increased tracer uptake at the right L5 level. Imaging Findings
CT (Fig. 1.8.2) shows erosions of the right L5-S1 facet joint. Note the juxta-articular
enhancing phlegmonous reaction in the posterior paraspinal muscles as well as in the spi-
nal canal (open arrows).
Axial T2-weighted (Fig. 1.8.3) and axial contrast-enhanced T1-weighted (Figs. 1.8.4 and
1.8.5) MRI show edematous bone marrow changes and loss of the low signal intensity of
the joint abscess. Note posterior paraspinal (closed arrows) and epidural (open arrowheads)
abscesses, which present high signal intensity on the T2-weighted image and appear as a
nonenhancing collection surrounded by thick enhancing walls.
A 46-year-old man presented at the emergency department with pain, swelling, and func-
Case 1.9 tional impotence of the right lower limb from the thigh to the foot. He was morbidly obese
and had hypertension.
Cellulitis He had a fever (up to 40C) with shivering in the 3 days before admission but no other
symptoms. At physical examination, his temperature was 37.3C and a large area of cellulitis
Fig. 1.9.1
Fig. 1.9.2
Fig. 1.9.3 Fig. 1.9.4

occupied nearly the entire limb; he had skin ulcers in the first and second toes of the right
foot and adjacent to the peroneal malleolus. After emergency ultrasound examination and
suspicion of necrotizing fasciitis, we performed a CT study.
Cellulitis or superficial nonnecrotizing fasciitis is an acute infection of the dermis and Comments
superficial subcutaneous tissue that does not involve the epidermis or the deep fascia. It is
commonly found in clinical practice and, in most cases, the causative agents are group A
Streptococcus pyogenes or S. aureus. It causes pain, erythema, edema, and warmth.
Its origin may be cutaneous, by contiguity, or bacteremic. The cutaneous type occurs
more frequently (bites, sores, cracks, trauma, previous surgery, etc.). Patients with periph-
eral vascular disease or diabetes are especially susceptible to this type of infection since
minor skin injuries facilitate infection.
It is usually managed clinically and does not normally require radiological studies.
Imaging studies are required when necrotizing fasciitis is suspected and to assess the depth
of the infection or the presence of bone infection or abscess formation.
Ultrasound may have an important role, especially for differentiating cellulitis from an
abscess and distinguishing the latter from other soft-tissue masses. Ultrasound shows an
irregular ill-defined hyperechoic appearance of fat and blurring of tissue planes, progress-
ing to hypoechoic strands reflecting edema. Color and power Doppler imaging may help
clinical diagnosis by depicting a hypervascular pattern.
CT may demonstrate skin thickening, septation of the subcutaneous fat, and thickening
of the underlying superficial fascia. If the infection spreads to deeper tissues, deep cellulitis,
myositis, necrotizing fasciitis, or osteomyelitis can occur, all of which can be ruled out with
CT. After injection of intravenous contrast material, diffuse increased enhancement is pres-
ent in the same areas that are abnormal on unenhanced CT.
Lack of involvement of the deep fascia allows fasciitis to be differentiated from necrotiz-
ing cellulitis.
MRI shows skin thickening with low signal on T1-weighted images and high signal on
T2-weighted images, with a reticular (lace-like) pattern in the subcutaneous fat.Additionally,
MRI may show fluid collections and other complications. The main limitation of MRI is its
limited availability in emergency departments.
Ultrasound image over the pretibial region (Fig. 1.9.1) shows enlargement and fluid disten- Imaging Findings
sion of all septa (open arrows) of the subcutaneous tissue. Note the fat lobules, which appear
as individual structures (arrow) separated by the intervening fluid.
Axial CT scan (Fig. 1.9.2) shows skin thickening (open arrow) and septation of the sub-
cutaneous fat with thickening of the superficial fascia (arrow). Note the severe fatty atrophy
of muscle due to the patients extremely sedentary lifestyle (open arrowhead).
Coronal 3D volume-rendered CT images (Fig. 1.9.3) show a noticeable increase in the
diameter of the right lower limb compared with the contralateral side (open arrows).
Coronal CT multiplanar reconstruction (Fig. 1.9.4) shows the extension of the process
and how it affects practically the entire right leg and ankle (open arrows).
A 66-year-old man presented with insidious nonmechanical back pain

Case 1.10 of 3 weeks evolution. He reported an episode of fever and night chills
2 weeks prior. No neurologic signs were evident at physical examination.
Pyogenic Spondylodiscitis Laboratory tests showed mild leukocytosis (white blood cell count of
13,100 cell/mm3.) and elevated eryt\spine.
Fig. 1.10.1 Fig. 1.10.2
Fig. 1.10.3 Fig. 1.10.4

Infectious spondylitis appears in 24% of cases of skeletal infection. A spinal infection may Comments
become established by hematogenous spread from distant septic foci, direct inoculation, or
direct extension from septic foci in adjacent soft-tissue. The lumbar region is most often
affected, followed by the thoracic spine and the cervical spine.
MRI is currently the modality of choice for the evaluation of potential spinal infection.
Advantages of MRI include its capabilities for multiplanar imaging, direct evaluation of the
bone marrow, and simultaneous visualization of the neural structures. Imaging patterns
indicative of spinal infection include decreased disk height with fluid-like signal intensity
and low signal intensity on T1-weighted images, with a loss of definition and erosion of the
vertebral endplate and of the adjacent vertebral bodies and high signal intensity on
T2-weighted and STIR images.
After administration of gadolinium, enhancement is evident in the disc and in infected
bone marrow. However, early stages of spondylodiscitis may be difficult to differentiate
from degenerative abnormalities (especially Modic 1 abnormalities), fractures in seroneg-
ative spondyloarthropathy (Andersson lesion), and less frequently encountered diseases
such as amyloidosis.
Because of the difficulties of noninvasive imaging techniques in diagnosing or excluding
spondylodiscitis, some authors recommend CT-guided core biopsy of intervertebral discs
and adjacent endplantes prior to treatment.
CT allows definition of the extent of bone and disc destruction and of paravertebral and
intraspinal involvement. Gas may be identified in the infected soft-tissue. MRI provides
better definition of epidural extension of the inflammatory process and compression of the
spinal cord and dural sac than CT does.
Most cases are successfully managed with conservative measures, including an
appropriate antibiotic and spinal bracing. Surgical intervention is warranted in only a few
specific circumstances (neurologic signs, spinal instability, vertebral collapse, etc.)
Axial T1-weighted MRI (Fig. 1.10.1) at the level of the infected area shows decreased signal Imaging Findings
intensity in the T6T7 disk (open arrow) and a hypointense mass surrounding it, corre-
sponding to paravertebral inflammatory extension (arrow).
Axial contrast-enhanced fat-suppressed T1-weighted (Fig. 1.10.2) image at the same
level as in Fig. 1.10.1 shows enhancement in paravertebral and epidural tissue (open arrow),
corresponding to a phlegmon.
Sagittal contrast-enhanced fat-suppressed T1-weighted (Fig. 1.10.3) image shows
marked enhancement of all the infected areas, i.e., both vertebral bodies (open arrow) and
the intervertebral space, whose height is diminished (arrow). Note the epidural phlegmon
encompassing all of T6 and T7 (open arrowhead).
Sagittal CT multiplanar reconstruction (Fig. 1.10.4) 3 months later shows changes in the
bony ankylosis between the two vertebral bodies (open arrow).
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msk Narvaez JA, Narvaez J, Roca Y, Aguilera C. MR imaging assess-
http://www.learningradiology.com/ ment of clinical problems in rheumatoid arthritis. Eur Radiol
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Restrepo S, Vargas D, Riascos R, Cuellar H. Musculoskeletal
infection imaging: past, present, and future. Curr Infect Dis
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Salaffi F, Carotti M, Guglielmi G, Passarini G, Grassi W. The
Aliabadi P, Nikpoor N, Alparslan L. Imaging of neuropathic crowned dens syndrome as a cause of neck pain: clinical and
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Azer NM, Winalski CS, Minas T. MR imaging for surgical plan- phosphate dihydrate deposition disease. Clin Exp Rheumatol
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Bennett DL, Ohashi K, El Khoury GY. Spondyloarthropathies: masses. Radiographics 2005; 25:105119
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North Am 2004; 42:121134 StiskalM. Rheumatoid arthritis: a practical guide to state-of-
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rheumatoid arthritis: a review of MRI and sonographic find- tions. Radiographics 2005; 25:381398
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Braun J, Sieper J, Bollow M. Imaging of sacroiliitis. Clin hydroxyapatite crystal deposition diseases: imaging perspec-
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role of CT in the emergency department. Radiographics early rheumatoid arthritis. Radiol Clin North Am 2004;
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patients with spondyloarthritis: comparison of MR imaging 14(suppl 3):E64E71
Tumors 2
Guadalupe Garrido-Ruiz, Antoino Luna-Alcal, and Joan C. Vilanova
24 G. Garrido-Ruiz, A. Luna-Alcal, and J. C. Vilanova
Case 2.1
Osteoblastoma of the Rib
Fig. 2.1.2
Fig. 2.1.1
Fig. 2.1.3 Fig. 2.1.4

Tumors25
An 18-year-old man consulted for recurrent attacks of left back pain during the previous
year. The episodes were occasionally associated with abdominal pain, mainly localized in
the left hypochondrium. At physical examination, tender swelling was noted below the left
scapula. After chest X-ray, a bone tumor was suspected at the level of the left fifth rib and
CT and MRI studies were requested.
Osteoblastoma is a rare benign osteoid-producing bone neoplasm accounting for approxi- Comments
mately 1% of primary bone tumors. Conventional and aggressive types of osteoblastoma
have been described. Osteoblastomas are commonly located in the posterior elements of
the spine (34%) and long bones (30%). The ribs are only affected in 4% of cases. Most
lesions are intramedullary; however, intracortical and periosteal tumors can occur. The
lesion is observed most frequently in individuals younger than 30 years of age. Local pain
is a common manifestation. Worsening of pain at night and amelioration with salicylates
are inconstant clinical features.
The diagnosis of osteoblastoma may be suggested by direct visualization on X-ray or CT
studies of an expansile, circumscribed lytic lesion with variable reactive sclerosis and cen-
tral calcification. Cortical expansion, cortical destruction, and periosteal reaction can
occur.
MRI provides information on the extent of the lesion, but the MRI appearance of low
signal intensity on T1- and mixed to high signal intensity on T2-weighted images is also
nonspecific. MRI is the most accurate technique in evaluating the surrounding edema,
which may be prominent.
Scintigraphic bone scans show intense focal radiotracer accumulation.
Other diagnoses that share similar clinical and radiographic features with conventional
osteoblastoma include osteoid osteoma, giant cell tumor, and fibrous dysplasia. Osteoid
osteoma and osteoblastoma are thought to be variant manifestations of the same osteo-
blastic process. The tendency of osteoblastoma to form a less sclerotic, more expansile
mass and its size (by definition greater than 2cm) are the two major differences between
these two entities. Aggressive osteoblastomas may disrupt cortex and have a soft-tissue
component, mimicking malignant tumors, such as osteosarcoma.
Chest X-ray shows an expansile lytic lesion with well-demarcated margins and some corti- Imaging Findings
cal erosion involving the posterior shaft of the left fifth rib (Fig. 2.1.1). On each side of the
tumor, the rib is broadened and sclerosed. Internal calcifications are seen within the lesion
(open arrow) (Fig. 2.1.2).
CT scan (Fig. 2.1.3) confirms the presence of a well-circumscribed osteolytic lesion with
surrounding sclerosis. Central ossification is prominent. The posterior cortex of the rib is
diffusely thinned with an expanded contour and focal disruption, but no soft-tissue mass
is observed.
Axial STIR MR image (Fig. 2.1.4) demonstrates a well-demarcated intermediate signal
intensity lesion with central calcifications. Prominent reactive marrow edema (open arrow),
solid anterior periosteal reaction (arrow), and mild surrounding soft-tissue edema (open
arrowhead) are also observed.
Case 2.2
Ewings Sarcoma
Fig. 2.2.1 Fig. 2.2.3
Fig. 2.2.2 Fig. 2.2.4

Tumors27
A 22-year-old man presented with pain in his right knee 1 year after anterior cruciate liga-
ment reconstruction with a patellar tendon autograft.
Ewings sarcoma is the sixth most common malignant tumor, accounting for approximately Comments
1112% of all malignant bone tumors. The tumor is derived from red bone marrow.
Ewings sarcoma usually occurs in young people (425 years) and the mean age of pre-
sentation is 13 years. The tumor has a decisively male predominance. Patients typically
present systemic symptoms (fever, anemia, and leukocytosis) and a painful mass.
Ewings sarcoma can occur in both long (60%) and flat (40%) bones. The long bones are
more commonly affected in younger patients. The most common sites are the femur, tibia,
and humerus. The most commonly affected flat bones (typically in older patients) are the
pelvis and the ribs. In the long bones, the tumor almost always affects the metaphysis or the
diaphysis.
Although Ewings sarcoma presents multiple radiological appearances, it is typically
based within the medullary cavity, metadiaphyseal in location, and poorly delineated, with
aggressive periosteal reaction and a large associated soft-tissue mass. Commonly, there is
a permeative lytic pattern.
MRI is essential to evaluate the bone marrow and soft-tissue extent of the tumor. The
typical MRI appearance of Ewings sarcoma includes low signal on T1-weighted sequences,
high signal on T2-weighted sequences, and heterogeneous contrast enhancement.
MRI provides useful information for preoperative planning and posttreatment
follow-up.
The differential diagnosis should include osteomyelitis, lymphoma, chondrosarcoma,
Langerhans cell granuloma, and osteosarcoma. It is important to remember that age is the
most important factor for narrowing the differential diagnosis for bone tumors.
Lateral plain-film radiograph of the distal femur (Fig. 2.2.1) shows a permeative lytic pat- Imaging Findings
tern of bone destruction.
Sagittal T1-weighted MRI demonstrates the intraosseous and extraosseous extent of the
tumor and the disruption of the cortex (open arrow) (Fig. 2.2.2). The tumor has lower sig-
nal intensity than normal marrow fat in this pulse sequence. Notice the hyperintensity of
the patellar tendon from which the ACL graft was taken.
Coronal fat-suppressed T2-weighted MRI shows a heterogeneous high signal intensity
lesion within the medullar cavity and a soft-tissue mass (arrow) (Fig. 2.2.3).
Axial fat-suppressed T2-weighted MRI (Fig. 2.2.4) shows the intramedullary lesion and
the soft-tissue mass extending to the cortex.
Case 2.3
Intraosseous Lipoma
Fig. 2.3.2
Fig. 2.3.1
Fig. 2.3.3 Fig. 2.3.4

Tumors29
A 51-year-old man presented with a 6-month history of intermittent localized right heel
pain, sometimes exacerbated by activity. Physical examination revealed tenderness at the
medial aspect of the right heel, but no swelling. Plain-film radiographs of the right heel
showed a lytic lesion in the calcaneus and a CT scan was done to characterize the lesion.
Intraosseous lipoma is a rare benign primary bone tumor. Lipomas are categorized by their Comments
relation to bone as either intraosseous, intracortical, or parosteal. Intracortical lipoma is
extremely rare. Multiple osseous lipomas have been described in patients with type IV
hyperlipoproteinemia.
Intraosseous lipomas may be diagnosed at any age, but they are most common in the
fourth through sixth decades. No significant sex predominance has been noted. While these
tumors may be asymptomatic, localized pain and/or soft-tissue swelling is reported in up
to two-thirds of patients. The long tubular bones are most commonly affected. The fibula
(20% of cases), femur (15%), and tibia (13%) are frequently involved. Another common site
of involvement is the calcaneus, which accounts for 15% of cases. Other reported sites
include the ilium, skull, mandible, maxilla, ribs, spine, sacrum, coccyx, and the bones of the
hands and feet.
Plain films can suggest the diagnosis of intraosseous lipoma when a well-circumscribed
radiolucent lesion with a thin sclerotic border is visualized in the calcaneus. A central ossi-
fied nidus may be present and lobulation or internal osseous ridges can often be seen.
Cortical bone and periosteum are preserved.
CT scans confirm the fat density of the mass and may demonstrate the central ossified
component, if present.
MRI can also be used to confirm the fatty nature of the mass, which displays fat signal
intensity on all pulse sequences. Chemical shift imaging may be helpful.
The diagnosis of an intraosseous lipoma in the calcaneus can be suggested by the plain-
films. However, its radiographic appearance may be similar to unicameral bone cysts,
which usually appear in the same location as lipomas, in the anteroinferior portion of the
calcaneus, an area free from the main stress lines. The differential diagnosis may also
include normal variations of the trabecular pattern of the calcaneus, which may produce
the appearance of pseudotumor of the calcaneus, secondary to atrophic bone trabeculae.
Other, less frequent, entities that should be considered in the differential diagnosis include
posttraumatic cyst, chondroblastoma, fibrous dysplasia, giant cell tumor, osteoblastoma,
and desmoplastic fibroma.
Plain-film radiographs of the right heel (Figs. 2.3.1 and 2.3.2) show a well-circumscribed Radiological
lytic lesion with a thin, sclerotic border and a lobulated appearance in the calcaneus. No Findings
cortical destruction or periosteal reaction is present. Lateral projection shows the location
of the lesion in the triangular region of the calcaneus, between the major trabecular stress
lines (Fig. 2.3.2).
CT scan (Fig. 2.3.3) confirms the well-circumscribed hypodense mass, with negative
Hounsfield unit values (Fig. 2.3.4), suggesting a fatty lesion.
Case 2.4
Giant Cell Tumor of Bone
Fig. 2.4.2
Fig. 2.4.1
Fig. 2.4.3 Fig. 2.4.4

Tumors31
A 43-year-old man presented with localized pain in his left knee that was exacerbated with
movement. He had no history of trauma. At clinical examination, local swelling and tender-
ness were noted.
Radiographs, CT, and MRI of the left knee were performed.
Giant cell tumor of bone (GCT) accounts for approximately 59% of primary bone tumors Comments
and 20% of benign bone tumors. GCT occurs only after the epiphyseal plates have closed.
It most commonly presents in patients between the ages of 25 and 40 and has a slight
female predominance. GCT can arise in any bone of the skeleton, but is most frequently
detected around the knee (50%); it involves the epiphyseal regions of the distal femur and
proximal tibia, although it originates in the metaphysis. GCT is a locally aggressive, gener-
ally benign lesion; however, 10% are malignant with local spread or metastases, generally
to the lungs.
On radiologic study, typical GCT is usually easily distinguished from other bone tumors.
GCT is lytic, subarticular, and eccentric, and often lacks a sclerotic rim. Prominent trabecu-
lation may be seen. No internal mineralization is present.
CT usually adds little diagnostic information to the radiographic findings, although it is
useful in regions with complex anatomy, such as the vertebrae or pelvic bones. Marginal
sclerosis, cortical destruction, and soft-tissue masses are better assessed with CT scans
than with radiographs. Fluid-fluid levels are seen occasionally, but are nonspecific.
MRI characteristics include low to intermediate signal intensity on T1-weighted images
and heterogeneous high signal intensity on T2-weighted images. Fluid levels may be dem-
onstrated within the tumor. Peritumoral edema is uncommon in the absence of a fracture.
The tumor usually enhances heterogeneously with intravenous administration of contrast
medium. MRI is sensitive for the detection of soft-tissue changes, intraarticular extension,
and marrow changes. MRI is the best method for assessing subchondral breakthrough and
extension of tumor into an adjacent joint. The diagnostic accuracy of MRI is high, espe-
cially when it is interpreted in conjunction with plain radiographs.
Bone scintigraphy is not usually required, except for the evaluation of suspected multi-
centric GCT.
Some conditions such as aneurysmal bone cyst, intraosseous ganglion, chondroblas-
toma, osteosarcoma, and giant cell reparative granuloma may resemble GCT on plain-film
radiographs and should be considered in the differential diagnosis.
Plain-film radiographs of the left knee (Figs. 2.4.1 and 2.4.2) show a well-defined expansile Radiological
eccentric radiolucent lesion in the proximal lateral tibia condyle. No sclerotic margins or Findings
periosteal reaction is present.
CT scanning (Fig. 2.4.3) demonstrates a large osteolytic lesion with marked thinning of
the cortex. MRI shows a well-circumscribed lobulated lesion of low to intermediate signal
intensity on T1-weighted images (not shown) and high signal intensity on T2-weighted
images (Fig. 2.4.4).
Case 2.5
Skeletal Muscle Metastases
Fig. 2.5.1 Fig. 2.5.2
Fig. 2.5.3 Fig. 2.5.4
Fig. 2.5.5
Tumors33
A 56-year-old man diagnosed with stage IV cholangiocarcinoma 2 months before pre-

sented with a palpable mass in the posterior aspect of his left thigh. The mass was painful
at palpation and surrounding soft-tissue inflammation was noted. Plain-film radiographs
of the thigh showed no abnormalities. Axial T1- and T2-weighted, axial and coronal STIR,
and dynamic contrast-enhanced MRI sequences were obtained. Subsequently, contrast-
enhanced thoracoabdominal CT scanning was carried out to evaluate and restage the pri-
mary tumor.
Skeletal muscle is a rare site of metastasis. Most muscle metastases occur in the abdominal, Comments
pectoral, deltoid, psoas, and thigh muscles. The neoplasms with the highest incidence of
metastasis to muscle are carcinoma, leukemia, and lymphoma. Muscle metastases are often
considered a sign of generalized tumor spread; the number and the location of the lesions
are important for the patients clinical outcome. An intramuscular mass is first suspected to
be a primary tumor rather than a metastasis. In oncologic patients with pain in large mus-
cles and no radiographic or scintigraphic evidence of bone metastasis, soft-tissue metasta-
ses are suspected.
The imaging approach to a suspected soft-tissue mass begins with a plain-film radio-
graph to exclude a bone lesion or deformity that could simulate a soft-tissue tumor.
On unenhanced CT, muscle metastases can appear hypodense or isodense with the sur-
rounding muscle and may only be noticed as a muscle asymmetry when compared with
the opposite side. After intravenous contrast administration, muscle metastases usually
present rim enhancement with central hypodensity.
The advantages of MRI over CT for evaluating soft-tissue masses include multiplanar
acquisition and better soft-tissue contrast resolution. MRI findings of multiple muscle
lesions displaying low to intermediate signal intensity on T1-weighted images and high
signal intensity on T2-weighted images can suggest the diagnosis of skeletal muscle metas-
tases, but are not pathognomonic. The use of intravenous gadolinium facilitates differen-
tiation between tumor, muscle, and edematous tissue, and provides information on tumor
vascularity.
The differential diagnosis includes soft-tissue sarcomas, hematomas, and abscesses.
MRI findings, together with the clinical history, should point to the correct diagnosis.
Axial T2-weighted MRI (Fig. 2.5.1) shows two soft-tissue masses, one intramuscular mass Radiological
located between the vastus lateralis muscle fibers in the anterolateral aspect of the left Findings
thigh (open arrow) and the other penetrating the superficial fascia of the posterolateral
aspect of the left thigh (arrow). Both lesions are surrounded by extensive edema, high-
lighted in the STIR image (Fig. 2.5.2). Dynamic contrast-enhanced MRI (Figs. 2.5.3 and
2.5.4) shows strong, early rim enhancement (open arrows).
Contrast-enhanced abdominal CT (Fig. 2.5.5) shows a nodular lesion with rim enhance-
ment and central hypoattenuation in the left psoas muscle (open arrow). Other nodular
lesions were depicted in the right psoas and in the abdominal wall muscles (not shown);
these findings supported the initial diagnosis.
Case 2.6
Synovial Sarcoma
Fig. 2.6.2
Fig. 2.6.1
Fig. 2.6.3 Fig. 2.6.4

Tumors35
A 39-year-old man presenting with a tender, palpable mass in the anterior aspect of the
right leg and ankle that had gradually increased in size over 1012 months and moderate
weight loss over the same time period underwent MRI on a 1.5-T unit.
Synovial sarcoma is a malignant neoplasm of mesenchymal origin that accounts for 810% Comments
of all soft-tissue sarcomas. It is the fourth most common type of soft-tissue sarcoma and
usually occurs in adolescents and young adults. It predominantly affects the extremities (80
95% of cases), usually the lower limbs, and particularly the popliteal fossa in the knee. Despite
its name, the lesion occurs primarily in the para-articular regions, usually close to tendon
sheaths, bursal structures, and joint capsules. Patients usually present with a slow-growing
palpable soft-tissue mass or swelling. Pain and/or neurogenic dysfunctions can occur. The
duration of symptoms before diagnosis varies widely, with an average of 24 years.
Radiographic findings of a soft-tissue mass near, but not within, a joint in a young
patient are very suggestive of synovial sarcoma, particularly if calcification is present.
Typical cross-sectional imaging features of synovial sarcoma include multilobulated
morphology and marked heterogeneity. The most common CT appearance is a soft-tissue
mass isodense or slightly hypodense to muscle. CT is especially useful for detecting soft-
tissue calcifications and cortical bone involvement.
MRI findings of synovial sarcoma often include a well-defined juxta-articular mass with
mainly intermediate signal intensity on T1-weighted images and intermediate to high sig-
nal intensity on T2-weighted images. Marked heterogeneity, consisting of hyperintense,
hypointense, and isointense intermixed areas (the triple signal sign), with presence of
fluid levels, hemorrhage, and septa (the bowl of grapes sign) on T2-weighted images is
the rule in large lesions. Intense but heterogeneous enhancement is seen after intravenous
gadolinium injection. Although it is not possible to make a specific diagnosis with MRI,
this technique is the optimal imaging modality for assessing the extent and intrinsic char-
acteristics of synovial sarcomas.
Scintigraphic evaluation of synovial sarcomas may show increased radiotracer uptake,
revealing their hypervascularization.
The differential diagnosis of synovial sarcoma should mainly include other sarcomas such
as soft-tissue chondrosarcoma, parosteal osteosarcoma, and malignant fibrous histiocytoma.
Other disorders such as myositis ossificans, pigmented villonodular synovitis, or juxtacorti-
cal chondroma should also be considered. It is important to remember that smaller, well-
defined, homogeneous lesions are more prone to mimicking cystic or solid benign lesions.
Axial (Fig. 2.6.1) and sagittal T1-weighted images (Fig. 2.6.2) show a heterogeneous multi- Radiological
lobulated mass isointense to muscle tissue with areas of high signal intensity consistent Findings
with hemorrhage (open arrows). A pseudocapsular appearance is seen at the superior mar-
gin of the lesion (arrow). On T2-weighted images (Fig. 2.6.3), the lesion appears heteroge-
neous, with hyper-, hypo- and isointense areas relative to fat, creating the triple signal sign.
Hemorrhagic components and fluid-fluid levels are also detected.
MRI sequence acquired after intravenous injection of contrast material (Fig. 2.6.4)
shows heterogeneous enhancement of the mass.
Case 2.7
Synovial Hemangioma
Fig. 2.7.3
Fig. 2.7.1 Fig. 2.7.4
Fig. 2.7.2 Fig. 2.7.5

Tumors37
A 23-year-old woman underwent MRI to investigate longstanding pain in the medial com-
partment of her right knee.
Synovial hemangiomas are rare. As in this case, the clinical history usually includes pain or Comments
other longstanding joint symptoms. Synovial hemangiomas typically present during early
childhood, adolescence, or young adulthood. They most commonly involve the knee, fol-
lowed by the elbow and wrist. They may appear in bursa adjacent to a joint, although
hemangiomas not confined by a synovial structure should be excluded from this group, as
should those arising from tendon sheaths or the intramedullary compartments of bone or
skeletal muscle. The origin and pathogenesis of synovial hemangiomas are related to those
of true neoplastic vascular proliferations or to the late stages of a posttraumatic lesion. The
most common histological subtype is cavernous. Synovial hemangiomas are a common
cause of intraarticular bleeding, which can lead to an appearance similar to pigmented
villonodular synovitis or hemophilia-related arthropathy. Preoperative assessment with
MRI and arthroscopy allows accurate classification and appropriate management. Well-
circumscribed masses can be excised arthroscopically, but a wide, open excision is neces-
sary in cases of diffuse synovial hemangioma.
Like hemangiomas in other locations, synovial hemangiomas typically show serpentine
vascular spaces, intratumoral fat content, and increased vascularization. Focal limb enlarge-
ment due to increased vascularization has been reported in some cases of synovial heman-
gioma. Plain films may be unremarkable or show subtle changes like capsular thickening,
phleboliths, soft-tissue density, or bone erosion. Angiography has proven useful in the
evaluation of this vascular lesion, allowing the identification of fine-caliber vessels with
contrast pooling in dilated vascular spaces and early visualization of venous structures.
Embolotherapy has proven effective in treating synovial hemangioma.
Although CT is able to detect intratumoral fat, calcifications, and enhancement, MRIs
superior soft-tissue contrast makes it the preferred imaging modality for the detection and
characterization of synovial hemangiomas. Histological analysis remains necessary to
confirm the diagnosis. The imaging differential diagnosis of synovial hemangioma includes
pigmented villonodular synovitis, nonspecific synovitis, and lipoma arborescens. MRI is
able to differentiate between these entities in most cases.
MRI shows a 50-mm intrasynovial anteromedial mass with well-defined borders and mul- Radiological
tiple internal septa. On T2-weighted sequences (Fig. 2.7.1), the mass is hyperintense with Findings
low signal septa; on fat-suppressed T1-weighted TSE sequences (Fig. 2.7.2), it showed inter-
mediate signal intensity. After contrast administration (Fig. 2.7.3), the mass shows intense
heterogeneous enhancement. In the high b-value diffusion-weighted MRI (Fig. 2.7.4) and
apparent diffusion coefficient map (Fig. 2.7.5), the mass shows moderate restriction of free
water movement. No hemorrhage, fat content, or infiltration of adjacent structures was
demonstrated. Intraarticular fluid and enhancing synovial hypertrophy were additional
features. Histological analysis confirmed the imaging suspicion of synovial hemangioma.
Case 2.8
Brown Tumor
Fig. 2.8.1 Fig. 2.8.2
Fig. 2.8.4
Fig. 2.8.3
Fig. 2.8.5 Fig. 2.8.6

Tumors39
A 47-year-old man with a history of giant cell reparative granuloma in his left patella
resected 2 years before presented progressive pain at the symphysis pubis.
Brown tumors are expansile bone lesions typically associated to hyperparathyroidism. Comments
Their most frequent locations are the mandible, pelvis, ribs, and femora, although poten-
tially any bone may be involved. Intratumoral hemorrhage, necrosis, and cyst formation
are the hallmarks of these tumors. Brown hemorrhage stroma and giant cell formation are
also common pathological findings. Recently, a progressive increase in echo time on
T1-weighted sequences has been used to detect magnetic susceptibility artifacts secondary
to the hemorrhagic content of brown tumors. Brown tumors appear as expansile lytic
lesions with slight trabeculation, uncommon periosteal reaction, and increased activity on
scintigraphic bone scans. Nowadays, it is uncommon for brown tumors to be detected as
the first sign of hyperparathyroidism, as in the case presented. These tumors are destruc-
tive and may be associated to pathological fractures. They usually heal with new formation
of dense bone after removal of the cause of hyperparathyroidism.
Brown tumors cannot be differentiated from reparative giant cell granuloma on the
basis of histological and imaging findings. In this clinical setting, correlation with analyti-
cal and clinical features to rule out hyperparathyroidism is critical for correct diagnosis
and therapeutic management. This is not uncommon when dealing with bone tumors or
even soft-tissue tumors, as histological analysis does not always ensure the correct diagno-
sis. Radiologists should be aware of this fact and integrate imaging findings with clinical
and analytical data. In this case, the presence of several lytic lesions is the differentiating
feature, as reparative giant cell granulomas are rarely multiple and they have not been
reported in pelvic bones.
An expansive lytic lesion was detected in the right superior pubic ramus at plain-film (not Radiological
shown). CT (Fig. 2.8.1.) confirmed a multiseptated expansive lytic lesion with cortical rup- Findings
ture and detected another lytic lesion in the posterior aspect of the contralateral superior
pubic ramus. MRI showed hypointensity on both T2-weighted sequences (Fig. 2.8.2) and
T1-weighted (Fig. 2.8.3) sequences, with moderate enhancement after contrast administra-
tion (Fig. 2.8.4). Additional features seen on MRI were absence of soft-tissue extension and
another lytic lesion in the right femoral head. The presence of multiple lytic lesions and the
personal history of reparative giant cell granuloma raised the suspicion of brown tumors.
Laboratory tests showed hypercalcemia; later, primary hyperparathyroidism and the
diagnosis of multiple brown tumors were confirmed. Review of the pathological specimen
from the previously resected patellar tumor concluded that it also corresponded to a
brown tumor. After resection of a parathyroid gland adenoma, the brown tumors par-
tially regressed and showed a more fibrotic appearance, as seen in the 5-year follow-up
MRI (Figs. 2.8.5 and 2.8.6, axial pre- and postcontrast T1-weighted TSE sequences,
respectively).
Case 2.9
Intramuscular Myxoma
Fig. 2.9.1 Fig. 2.9.2
Fig. 2.9.3 Fig. 2.9.4

Tumors41
A 47-year-old man presented nonspecific progressive posterior thoracic pain during the
nine months prior to consultation.
Intramuscular myxoma (IM) is a benign intramuscular neoplasm composed of fibroblasts Comments

and abundant myxoid stroma. This tumor usually arises in the proximal large muscles of
the extremities. It is more prevalent in women and most commonly presents in the fourth
and fifth decades. Clinically, it usually presents as a nonpainful palpable mass. At histologi-
cal examination, it appears macroscopically as a well-circumscribed, loculated, gelatinous
mass; most lesions are less than 10cm in diameter. The classic histological description is a
hypocellular, hypovascular tumor with no mitoses, composed of bland spindle cells embed-
ded in a rich myxoid extracellular matrix. This tumor lacks a true capsule. An excisional
biopsy is necessary for definitive diagnosis, since it is difficult to make an accurate evalua-
tion with fine-needle aspiration due to its scant cellularity and nonspecific cytologic fea-
tures. The association between IM and fibrous dysplasia is known as Mazabrauds
syndrome.
MRI features for IM include intramuscular location, well-circumscribed margins, homo-
geneous hypointense signal compared to muscle on T1-weighted images, homogeneous
hyperintense signal on T2-weighted images, and inhomogeneous enhancement. This
tumor usually shows fine linear stranding within the tumor, representing thin fibrous septa.
It is also common to find perilesional edema, which represents portions of the tumor
merged into the adjacent muscle separating the fibers, which become atrophic. Another
frequent finding is the presence of fat around both poles of the lesion; this finding corre-
lates with histological findings of fatty muscle atrophy due to the infiltrative pattern of slow
growth of IM.
Postcontrast images commonly show a rim of peripheral enhancement, although most
reported cases evaluated with contrast media had either heterogeneous internal enhance-
ment or peripheral enhancement with occasional fine internal septa. Areas without any
internal enhancement are present in about 50% of cases, corresponding to cystic areas. A
complete absence of internal enhancement is possible but rare.
CT (Fig. 2.9.1) shows a well-defined hypodense mass (open arrow) located in the left tho- Radiological
racic paravertebral soft-tissue. MRI confirms the presence of the mass (arrow), which is Findings
hyperintense on T2-weighted sequences (Fig. 2.9.2) and homogeneously hypointense (open
arrowhead) on T1-weighted sequences (Fig. 2.9.3). After contrast administration, heteroge-
neous internal enhancement indicates its solid nature (Fig. 2.9.4). Additional detectable
features were peritumoral edema in the adjacent soft-tissue and fat around the lesion.
Histological examination after resection confirmed the diagnosis of IM.
Case 2.10
Soft-Tissue Liposarcoma
Fig. 2.10.1
Fig. 2.10.2
Fig. 2.10.3 Fig. 2.10.4

Tumors43
A 22-year-old man presented with a painless tender mass in the upper left supraclavicular
region.
Liposarcoma is a malignant tumor of mesenchymal origin. The term liposarcoma does not Comments
imply that the tumor is derived from fat, but rather that the tumor contains differentiated
adipose tissue. Liposarcoma is the second most common soft-tissue sarcoma seen in adults
(1018%) after malignant fibrous histiocytoma. Liposarcomas are classified into four his-
tologic subtypes: well-differentiated, myxoid, round cell, and pleomorphic.
Well-differentiated liposarcoma is synonymous with atypical lipoma. Between 40 and
65% of liposarcomas of the extremities occur in the thigh. Other common sites, in order of
descending frequency, are the upper arm and shoulder, popliteal fossa and lower leg, but-
tocks, and forearm. Clinically, these tumors manifest as painless masses.
The radiological features of a liposarcoma depend on its histologic type and tend to
reflect its degree of differentiation. CT or MRI findings for well-differentiated liposarco-
mas closely resemble those of subcutaneous fat or a simple lipoma. They are frequently
composed of more than 75% fat, while the other types usually have less than 25%.
On CT, a well-differentiated liposarcoma may appear as a well-delineated mass, with
attenuation values equal to those of simple fat, mimicking a benign lipomatous tumor.
On MRI, a well-differentiated liposarcoma shows some thickened linear or nodular soft-
tissue septa that enhance after intravenous administration of contrast material.
These small nonlipomatous components have low signal intensity on T1-weighted
images and increased signal intensity on fat-suppressed T2-weighted images.
Features for discriminating a well-differentiated liposarcoma from a simple lipoma
include a deep (intramuscular) rather than subcutaneous location, a size of more than
10cm in maximum diameter, the presence of nodular nonadipose components or thick
septa, high signal intensity of septa or nodular soft-tissue areas on T2-weighted fat sup-
pression or STIR images, and contrast enhancement of nonadipose components (best seen
on fat-suppressed T1-weighted images).
MRI is the most specific modality for diagnosing liposarcoma. Figure 2.10.1 shows an axial Imaging Findings
T1-weighted image of a large mass located in the left supraclavicular region, posterior to
the sternocleidomastoideus muscle and medial to the scalene muscles and brachial plexus.
The tumor is predominantly isointense to subcutaneous fat. Multiple thickened septa
extend throughout the tumor (open arrow).
Axial T2-weighted MRI (Fig. 2.10.2) shows the tumor with signal intensity similar to
that of subcutaneous fat and the presence of thick, low signal intensity septa (arrow).
Coronal STIR MRI (Fig. 2.10.3) shows the nonadipose areas with increased signal inten-
sity relative to fat (open arrowhead).
Axial fat-suppressed T1-weighted MRI (Fig. 2.10.4) obtained after contrast administra-
tion shows moderate heterogeneous enhancement of the nonadipose areas (arrowhead).
Further Reading Hayes CW, Conway WF, Sundaram M. Misleading aggressive

MR imaging appearance of some benign musculoskeletal
lesions. RadioGraphics 1992; 12:11191136
Books Kransdorf MJ. Benign soft-tissue tumors in a large referral pop-
Bone and Joint Imaging. 2nd ed. Resnick D (1998) W.B. Saunders, ulation: distribution of specific diagnoses by age, sex, and
Philadelphia, PA location. AJR Am J Roentgenol 1995; 164:395402
Imaging of Bone Tumors and Tumor-Like Lesions. Techniques Kransdorf MJ. Malignant soft-tissue tumors in a large referral
and Applications. Davies AM, Sundaram M, James SLJ (2009) population: distribution of diagnoses by age, sex, and loca-
Springer, Berlin tion. AJR Am J Roentgenol 1995; 164:129134
Imaging of Soft Tissue Tumors. 2nd ed. De Schepper AM, Kransdorf MJ, Murphey MD. Radiologic evaluation of soft-tissue
Parizel PM, De Beuckeleer L, Vanhoenacker F (eds) (2001) masses: a current perspective. AJR Am J Roentgenol 2000;
Springer, Berlin 175:575587
Radiology Review Manual. 6th ed. Dhnert W (2007) Lippincott Llauger J, Palmer J, Monill JM, Franquet T, Bague S, Roson N.
Williams & Wilkins, Philadelphia, PA MR imaging of benign soft-tissue masses of the foot and
Soft Tissue Tumors. 3rd ed. Enzinger FM, Weiss SW (eds) (1995) ankle. RadioGraphics 1998; 18:14811498
Mosby St Louis, Mo Ma LD, Frassica FJ, Scott WW, Fishman EK, Zerhouni EA.
Differentiation of benign and malignant musculoskeletal
tumors: potential pitfalls with MR imaging. RadioGraphics
Web-Links 1995; 15:349366
May DA, Good RB, Smith DK, Parsons TW. MR imaging of mus-
http://www.auntminnie.com// culoskeletal tumors and tumor mimickers with intravenous
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http://www.bonetumor.org// 1997; 26:215
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http://www.umdnj.edu/tutorweb conventional radiography. Radiology 2008; 246:662674
Murphey MD, Robbin MR, McRae GA, Flemming DJ, Temple HT,
Kransdorf MJ. The many faces of osteosarcoma. RadioGraphics
Articles 1997; 17:12051231
Narvaez JA, Narvaez J, Aguilera C, De Lama E, Portabella F. MR
Alyas F, James SL, Davies AM, Saifuddin A. The role of MR imag- imaging of synovial tumors and tumor-like lesions. Eur
ing in the diagnostic characterisation of appendicular bone Radiol 2001; 11:25492560
tumours and tumour-like conditions. Eur Radiol 2007; Nomikos GC, Murphey MD, Kransdorf MJ, Bancroft LW,
17:26752686 Peterson JJ. Primary bone tumors of the lower extremities.
Berquist TH, Ehman RL, King BF, Hodgman CG, Ilstrup DM. Radiol Clin North Am 2002; 40:971990
Value of MR imaging in differentiating benign from malig- Panicek DM, Gatsonis C, Rosenthal DI etal. CT and MR imaging
nant soft-tissue masses: study of 95 lesions. AJR Am J in the local staging of primary malignant musculoskeletal
Roentgenol 1990; 155:12511255 neoplasms: report of the Radiology Diagnostic Oncology
Binkovitz LA, Berquist TH, McLeod RA. Masses of the hand and Group. Radiology 1997; 202:237246
wrist: detection and characterization with MR imaging. AJR Salamipour H, Jimenez RM, Brec SL, Chapman VM, Kalra MK,
Am J Roentgenol 1990; 154:323326 Jaramillo D. Multidetector row CT in pediatric musculoskel-
Bodner G, Schocke MFH, Rachbauer F etal. Differentiation of etal imaging. Pediatr Radiol 2005; 35:555564
malignant and benign musculoskeletal tumors: combined Schoenberg NY, Beltran J. Contrast enhancement in musculosk-
color and power doppler US and spectral wave analysis. eletal imaging. Radiol Clin North Am 1994; 32:337352
Radiology 2002; 223:410 Stacy GS, Mahal RS, Peabody TD. Staging of bone tumors: a
Brown KT, Kattapuram SV, Rosenthal DI. Computed tomogra- review with illustrative examples. AJR Am J Roentgenol 2006;
phy analysis of bone tumors: patterns of cortical destruction 186:967976
and soft tissue extension. Skeletal Radiol 1986; 15:448451 Sundaram M, McLeod RA. MR imaging of tumor and tumor-like
Crim JR, Seeger LL, Yao L, Chandnani V, Eckardt JJ. Diagnosis of lesions of bone and soft tissue. AJR Am J Roentgenol 1990;
soft-tissue masses with MR imaging: can benign masses be 155:817824
differentiated from malignant ones? Radiology 1992; Vilanova JC, Woertler K, Narvez JA et al. Soft-tissue tumors
185:581586 update: MR imaging features according to the WHO classifi-
Dalinka MK, Zlatkin MD, Chao P, Kricum ME, Kressel HY. The use cation. Eur Radiol 2007; 17:125138
of magnetic resonance imaging in the evaluation of bone and Zimmer WD, Berquist TH, McLeod RA etal. Bone tumors: magnetic
soft-tissue tumors. Radiol Clin North Am 1990; 28:461470 resonance imaging versus CT. Radiology 1985; 155:709718
Tendons and Muscles 3
Rosa Mnica Rodrigo, Mario Padrn, and Eugenia Sanchez-Lacalle
46 R. M. Rodrigo, M. Padrn, and E. Sanchez-Lacalle
Case 3.1
Tennis Leg Injury
Fig. 3.1.1 Fig. 3.1.2
Fig. 3.1.3 Fig. 3.1.4

Tendons and Muscles47
A 22-year-old male professional basketball player felt a sharp burning pain in the mid-calf,
associated with a snapping sensation during training.
Tennis leg is a common injury in tennis, basketball, and soccer players, but it can also occur Comments
in middle-aged people during daily activities such as hurried running, walking, or climb-
ing stairs. It is often related to an indirect mechanism (extension of the knee and forced
dorsiflexion of the ankle).
The medial (MG) and lateral (LG) heads of the gastrocnemius converge in the middle of
the calf through a myotendinous junction (MTJ) into a broad flat tendon. The tendon of the
gastrocnemius becomes the attachment of the underlying aponeurosis of the soleus muscle.
The tendons of both muscles (gastrocnemius and soleus) are parallel to each other for a
distance until they narrow and form the Achilles tendon about 15cm above the heel. The
plantaris muscle (absent in 720% of limbs) consists of a small muscle that originates from
the lateral supracondylar line just superior and medial to the lateral head of the gastrocne-
mius muscle and a long slender tendon that follows an oblique course between the medial
head of the gastrocnemius and soleus muscle and is inserted into the calcaneus, just anter-
omedial to the Achilles tendon.
The pathogenesis of tennis leg is more commonly related to the distal MTJ rupture of
the medial gastrocnemius (complete or partial) and is less commonly related to soleus or
plantaris muscle ruptures. These muscle tears in the calf involving the MG and soleus typi-
cally occur along their attachment to the aponeuroses and are also known as muscle-
aponeurosis avulsion.
Magnetic resonance imaging (MRI) and ultrasonography are both good tools to diag-
nose this entity. MRI is also useful in differentiating between other serious causes of calf
pain, such as deep vein thrombosis, compartment syndrome, and Achilles tendon rupture.
The most common finding is a serous-sanguineous fluid collection between the aponeu-
roses of the MG and soleus muscles. The amount of fluid can inexplicably increase with
time. The fluid often surrounds the gastrocnemius bellies (MG more frequently) and edema
is usually seen in the ruptured muscle. A capsulated hematoma sometimes develops and a
laminar fibrous scar is often seen as the result of this rupture, which can be symptomatic
on occasions.
Axial inversion recovery-weighted FSE MRI (Fig. 3.1.1) shows fluid (open arrow) separat- Imaging Findings
ing the fascial planes between the medial gastrocnemius (MG) and soleus, as well as edema
(arrow) in the MG muscle (as a result of a complete distal myotendinous tear). At a more
caudal level (Fig. 3.1.2), note the fluid surrounding the MG muscle (empty arrow) and
edema within the muscle itself (arrow).
Sagittal T2-weighted fat-suppressed FSE MR image at the MTJ of the MG (Fig. 3.1.3)
reveals a total tear surrounded by fluid (open arrow) and an elevated GM muscle (arrow).
MRI acquired in the same sequence and plane after 1 month of inadequate treatment
(Fig. 3.1.4) shows that the lesion has developed into a capsulated fluid collection (open
arrow) that needs to be drained.
A 30-year-old male professional basketball player consulted for acute posterior thigh pain
Case 3.2 (10cm below the gluteal fold) that started when trying to make a catch during a game; the
lesion swelled and he was forced to abandon the game immediately.
Hamstring
Muscle Injury
Comments The hamstring muscle (HM) complex is one of the most frequently injured muscles in the
general population (as they increase their level of fitness) and in athletes (especially soccer
and basketball players). HM strains and tears typically occur during running. Risk factors
for this strain include, among others, increasing age and a prior history of posterior thigh
pain (hamstring strain or back pain).
Thorough knowledge of the relevant anatomy is essential to enable accurate diagnosis.
The HM complex consists of the semimembranosus (SM), semitendinosus (ST), and biceps
femoris (BF) muscles. At MR, two different rounded areas of low signal intensity can be
seen at the ischial tuberosity (IT); these represent the conjoined tendon (ST/BF) arising
Fig. 3.2.1 Fig. 3.2.2
Fig. 3.2.3 Fig. 3.2.4

from the inferomedial aspect of the IT and the SM tendon arising from its superomedial
aspect (anterior to the conjoined tendon). The bulbous ST muscle is the first muscle seen
(just below the IT), with the SM tendon (the largest of the HM complex) lying anterior to
it. The SM muscle originates beneath the proximal half of the ST muscle, and its distal ten-
don is attached to the posteromedial tibia in several locations. The BF muscle (long head)
occupies the most lateral compartment in the posterior thigh, beside the ST muscle, and its
main distal attachment is inserted in the head of the fibula. The ST muscle continues to the
anteromedial aspect of the proximal tibia, joining the gracilis and sartorius, to be inserted
as the pens anserine complex.
It is important to note that the MTJ, which is the weakest link in the HM complex and
the most frequently overstretched component, is a very extensive area in these muscles
(aseachHM has a tendon extending, completely or almost completely, down the length of
the muscle); thus, injuries can occur not only in the proximal or distal MTJ, but also in the
intramuscular MTJ. The proximal MTJ and BF are the most frequently injured and it is
even more common to have more than one HM injured.
MRI provides excellent visualization of HMC injuries, and an accurate diagnosis is easily
obtained, even of low grade strain injuries (which can be missed at US). A feathery pattern
of intramuscular edema is seen in grade 1 strains. Grade 2 injuries are partial tears of the
MTJ without retraction, with intramuscular edema, distortion of the well-defined black
tendon, perifascial fluid beyond the muscle margin, and frequent hematomas (the appear-
ance of which varies according to its age) within the muscle or outside the epimysial cover-
ing (fascia) between the muscles. Grade 3 represents a complete disruption with retraction
of the musculotendinous elements.
Axial fat-suppressed T2-weighted FSE MR images at different levels show this grade 2 BF Imaging Findings
strain injury in the proximal MTJ. At the IT level (Fig. 3.2.1), the proximal SM tendon remains
attached to the anterior IT (empty arrow), the conjoined ST/BF tendon remains normal at its
posterior attachment (full arrow), and perifascial edema (empty arrowhead) is seen between
muscular planes. An image obtained below the IT level, at the proximal MTJ of the HM com-
plex (Fig. 3.2.2), shows a blurred and ruptured conjoined BF/ST tendon with intramuscular
edema in the BF and ST (open arrow) muscles, a normal SM tendon (empty arrowhead), and
perifascial fluid surrounding the HMC and the normal sciatic nerve (arrowhead).
Intramuscular edema is also seen in the adductor magnus and gluteus maximus.
An image acquired at a more caudal level (Fig. 3.2.3) shows a hypointense hematoma
(empty arrow) between the SM tendon (arrow) and the sciatic nerve (empty arrowhead), a
thicker defined conjoined BF/ST tendon (arrowhead), intramuscular edema, and a fluid col-
lection surrounding the HMC. An image acquired using the same sequence and plane (at the
same level as in the previous figure) 1 month later (Fig. 3.2.4) shows that the hematoma
(open arrow) has become smaller and isointense to fluid; the perifascial fluid has disap-
peared (although some intramuscular edema remains), and some high signal intensity areas
have been replaced by areas of low signal intensity (arrow). The low signal areas correspond
to fibrosis and blood products, which partially envelop the sciatic nerve (open arrowhead)
and alter its morphology. This player complained of temporary sciatic pain for some time.
A 20-year-old male professional soccer player (Figs. 3.3.1 and 3.3.2)

Case 3.3 complained of progressive pain when kicking and sprinting while
training.
Indirect Rectus Femoris
StrainInjury
Comments Rectus femoris (RF) muscle injuries are common in soccer players.
Unlike hamstring and tennis leg injuries, RF muscle injuries are not
related to age. They occur due to an indirect mechanism during
Fig. 3.3.2
Fig. 3.3.1
Fig. 3.3.3 Fig. 3.3.4

activities with eccentric contraction, such as sprinting and kicking. Predisposing factors
include muscle fatigue, insufficient warm-up exercises, and a previous tear, among others.
Thorough knowledge of the anatomy of the MTJ of the RF is essential to understand the
different injuries to this muscle. The RF is a long, fusiform muscle on the anterior superficial
portion of the quadriceps muscle group. It has two proximal tendinous insertions above the
hip: the direct (straight) head, arising from the anterior inferior iliac spine (AIIS) and the
indirect (reflected) head, arising more inferiorly and posteriorly from the superior acetabular
ridge and hip joint capsule. Both heads form a conjoined tendon a few centimeters below their
origins. The direct head, forming most of the anterior part of the conjoined tendon, blends
more distally with the anterior fascia of the RF. The indirect head, which forms most of the
posterior component of the conjoined tendon, becomes intrasubstance and forms a long
intramuscular MTJ, extending approximately along two thirds of the length of the muscle.
Indirect (reflected) tendon injuries are usually clinically classified as a contracture because
the pain is usually progressive and players usually complain of a sharp pain when kicking
and sprinting. A hard cord is usually palpated along the length of the intramuscular MTJ.
MRI is extremely useful in the diagnosis of an indirect tendon injury. Different degrees
of edema are seen surrounding the central indirect tendon on fat-suppressed T2-weighted
images. A bulls eye pattern of injury is commonly seen in axial images and a feather-
like pattern is usually seen in coronal images. As the degree of injury increases, a different
amount of hemorrhage and fluid are usually seen surrounding the muscle below the fascia
or through the fascia, even between intermuscular planes. A muscle into a muscle tear
pattern has also been described, as the hemorrhage surrounds the indirect head tendon
and separates it from the rest of the RF muscle.
These indirect injuries usually respond to conservative therapy; afterwards, an irregular
focal scar of the indirect tendon is frequently seen where the rupture was more evident.
Axial fat-suppressed T2-weighted FSE MR image of a professional soccer player (Fig. 3.3.1) Imaging Findings
shows a grade 1 injury with increased signal intensity (open arrow) surrounding the indi-
rect MTJ of the left RF (described as an acute bulls eye pattern) and a tiny focal disconti-
nuity in the tendon (full arrow) with no fascial hemorrhage. Coronal fat-suppressed
T2-weighted FSE MR image (Fig. 3.3.2) shows increased signal intensity surrounding part
of the long length of the indirect MTJ (open arrow) of the RF in a feather-like pattern.
Axial fat-suppressed T2-weighted FSE MR image of a different 20-year-old professional
basketball player (Fig. 3.3.3) shows a more serious lesion (grade 2) in a swollen left RF, with
huge muscular edema surrounding the indirect MTJ and hemorrhage separating this indi-
rect MTJ (open arrow) from the rest of the muscle, in a muscle into a muscle lesion pat-
tern. Hemorrhage is seen beyond the fasciae of the rectus and vastus lateralis (on the
anterior border of these muscles) and between the intermuscular plane with the sartorious
(arrow). The same sequence and plane 40 days later (Fig. 3.3.4) shows no fascial hemor-
rhage and a dark line (empty arrow) of hemosiderin and fibrous tissue (surrounding the
indirect MTJ) with faint residual edema.
Case 3.4
Adductor Muscle Strain Injury
Fig. 3.4.2
Fig. 3.4.1
Fig. 3.4.3 Fig. 3.4.4

A 25-year-old male professional soccer player complained of a stabbing inner thigh pain
during a match, which later became more diffuse with swelling and bruising.
Adductor strain injuries are most frequently seen in hockey, tennis, and soccer players. The Comments
injury usually occurs when a strong eccentric contraction of the adductor musculature is
required, such as during rapid acceleration (sprinting), side to side movements, sudden
stops and changes of direction, and rapid movements of the leg against resistance (such as
kicking a ball). Risk factors include periods of prolonged overuse, a sudden increase in the
amount or intensity of activity, and insufficient adductor muscle strength, among others.
The adductor musculature is divided into short adductors, which go from the pubis to
the femur (the pectineus, adductor brevis, and adductor longus), and long adductors, which
go from the pelvis to the knee (gracilis and adductor magnus). The most commonly injured
muscle is the adductor longus (ABL) muscle, which connects the anterior pubic ramus to
the linea aspera of the femur. ABL injury usually occurs at the MTJ or at the junction
between the tendon and pelvic bone, with acute adductor strain commonly occurring at
the MTJ and chronic injuries being more frequent in the junction between the tendon and
pubic ramus.
MRI enables accurate diagnosis and classification of ABL strain MTJ injuries. In Grade1,
intramuscular edema is found. In grade 2 (partial rupture), blurring of the MTJ, intramus-
cular edema, intermuscular fluid, and sometimes hematoma are seen. In grade 3 strain
injuries, total discontinuity of the MTJ is present together with all the above signs.
Axial fast gradient-recalled (FGR) MR image at the MTJ of the adductor longus (just below Imaging Findings
its insertion) (Fig. 3.4.1) shows a left adductor MTJ (open arrow) (clearly seen in the inner
part of the ABL muscle) and a blurred and partial torn right ABL MTJ (arrow) with edema
surrounding it. Below the previous slice (Fig. 3.4.2), a small hematoma (empty arrow)
between the ABL muscle and the fascia defines this as a grade 2 lesion; a better-defined
tendon remains with edema surrounding it, and extramuscular perifascial fluid is seen sur-
rounding the MTJ medially (arrow).
A closer view (FOV 24) of axial fat-suppressed T2-weighted FSE MR image at the same
level (Fig. 3.4.3) shows the MTJ edema, the blurred tendon, and a less clearly defined hema-
toma (open arrow) than in the previous FGR MR image, which is more sensitive for blood.
Perifascial edema surrounds the ABL muscle below the fascial plane, which is seen as a fine
black line (arrow), and outside the fascia. The same sequence and plane (at the same level)
44 days later (Fig. 3.4.4) shows the fascia joined to the muscle (as the hematoma and peri-
fascial liquid have disappeared), less intramuscular edema, and some fibrosis and blood
products (arrow) surrounding the MTJ. It is interesting to note that although some edema
was still seen at this time, the player was ready for the first match and full training the day
after this MRI.
A 23-year-old male professional soccer player complained of

Case 3.5 acute pain in the groin (without ecchymosis or swelling in the
area) that caused him to withdraw from the match.
External Hip Rotator Muscle Injury
Fig. 3.5.2
Fig. 3.5.1
Fig. 3.5.3 Fig. 3.5.4

External hip rotator muscle strain injuries are an uncommon sports injury, seen mostly in Comments
soccer players. Although these lesions are uncommon, it is important to have knowledge of
them, as they can be serious and require a long recovery period for soccer players. These
injuries usually occur with the adduction and rotation of the hip, which occur frequently
during training in soccer players. The pain is usually first diagnosed as an adductor strain
injury. However, although the adductor stress test provokes vague pain, unlike adductor
strain injuries, external hip rotator muscle strain causes pain in the gluteal area and occa-
sionally in the groin area (as the external hip rotator muscles are in tension) on the internal
rotator hip test. A more careful physical examination and an MRI study are needed if these
lesions are suspected.
The external hip rotator muscles are the quadratus femoris muscle, obturator externus
and internus muscles, piriformis muscle, and inferior and superior gemellus muscles. The
most frequently injured are the quadratus femoris and obturator externus muscles. The
quadratus femoris extends from the lateral border of the IT and inserts in the intertro-
chanteric crest on the posterior surface of the femur between the trochanters. The obtura-
tor externus extends from the medial side of the obturator foramen and the obturator
membrane and inserts distally as a tendon in the trochanteric fossa, where the greater tro-
chanter joins the neck on the posterior surface of the femur.
MRI is an excellent tool for the evaluation of injuries to the external hip rotator muscles.
Ultrasonography can miss lesions to these muscles because they are located deep within
the hip. Grade 1 injuries are seen as diffuse intramuscular edema and grade 2 injuries are
seen as intramuscular edema, perifascial fluid beyond the muscle margin, and hematomas.
Grade 3 injuries are uncommon in this group of muscles.
Axial fat-suppressed T2-weighted FSE MR image (Fig. 3.5.1) shows a grade 1 injury of the Imaging Findings
right obturator externus muscle, with intramuscular edema in the obturator foramen and
obturator membrane insertion (open arrow), with no edema in the distal portion of the
muscle (arrow). Coronal fat-suppressed T2-weighted FSE MR image (Fig. 3.5.2) shows dif-
fuse edema within the medial aspect of the belly of the right obturator externus muscle
(open arrow) without hematoma.
Coronal fat-suppressed T2-weighted FSE MR image of both thighs in a different
20-year-old professional soccer player who complained of right groin pain during training
(Fig. 3.5.3) shows intramuscular edema in the right obturator externus muscle near the
trochanteric fossa (open arrow) with some perifascial fluid (arrow) surrounding it.
Axial fat-suppressed T2-weighted FSE MR image in a different 17-year-old semiprofes-
sional soccer player who complained of acute subgluteal posterior thigh pain during a
match (Fig. 3.5.4) shows edema in the belly of the right quadratus femoris (open arrow)
without hematoma and with a large amount of perifascial edema in the intermuscular
plane. This sequence also shows lesions of the obturator internus and adductor magnus
muscles (arrow) and a partial avulsion of the right ischial apophysis as a disruption in the
cortex of the IT (open arrowhead) with edema and hemorrhage in the surrounding soft-
tissue. The ischiotibial tendons are free of lesions, and the sciatic nerve, running immedi-
ately posterior to the quadratus femoris muscle (arrowhead), appears normal.
Case 3.6
Chronic Avulsion of the Ischial Tuberosity
Fig. 3.6.1
Fig. 3.6.2
Fig. 3.6.3 Fig. 3.6.4

A 17-year-old male soccer player presented with pelvic pain several months after experi-
encing repeated pain in the gluteal fold region.
Avulsion injuries occur at several sites in the pelvis, the most common of which is the Comments
ischial tuberosity (IT), where the hamstrings (HMs) insert. Avulsions occur before closure
of the apophysis. Acute injuries are caused by extremely active contraction of the ham-
strings during sprinting. Patients typically present with pain in the buttock region and
inability to walk. Chronic avulsion injuries are the result of repetitive microtrauma or over-
use and usually occur during sporting activities. At radiography, healing avulsions may
have an aggressive appearance resulting from new bone formation and may resemble neo-
plastic or infectious processes. CT may be helpful in diagnosis and in planning treatment.
Surgical excision of malunited or hypertrophic fragments may relieve pain.
Anteroposterior radiograph of the pelvis shows overgrowth and widening of the right Findings
ischium with new bone formation together with lytic and sclerotic areas with no periosteal
reaction and adjacent soft-tissue calcification (Fig. 3.6.1). Coronal T1-weighted MR image
shows a left ischium bony protuberance with broad insertion of the right HMs (Fig. 3.6.2).
Coronal fat-suppressed proton density-weighted images show a bony irregularity at the
tendon insertion with fluid-filled signal intensity surrounding the new bone formation
(Figs. 3.6.3. and 3.6.4). The hamstring insertion is intact and no changes in signal intensity
are evident in the adjacent bone.
Case 3.7
Acute Avulsion of the Anteroinferior Iliac Spine
Fig. 3.7.1
Fig. 3.7.2
Fig. 3.7.3 Fig. 3.7.4

An 18-year-old male soccer player presented with sudden groin pain and gait dysfunction
after an air kick.
Avulsion injuries are common lesions among adolescents participating in organized sports. Comments
Acute injuries result from extreme, unbalanced, and often eccentric muscular contraction
and may be associated with avulsed bone fragments. Most often, the injury is abrupt and a
clear history is available. The patient presents with severe pain and loss of function.
Avulsion fracture of the anteroinperior iliac spine (AIIS) is common in young soccer play-
ers; it results from forceful extension at the hip and is very common after a failed kick at
the ball. The AIIS is the origin of the straight head of the RF muscle. The proximal RF has
two tendinous origins: the direct (straight) head arising from the AIIS and the indirect
(reflected) head arising slightly more inferiorly and posteriorly from the superior acetabu-
lar ridge and hip joint capsule. The two heads form a conjoined tendon a few centimeters
below their origins. Injured patients typically present with groin pain, an antalgic gait, or
inability to walk. A nondisplaced avulsion of the AIIS appears as a curved, sharply mar-
gined piece of bone adjacent to its origin. Patients with injuries of this type tend to respond
well to conservative treatment such as several days of bed rest and restricted activity over
the next 6 weeks. If the fragment is displaced more than two centimeters, however, fibrous
union may occur resulting in extended disability.
Coronal fat-suppressed proton density-weighted MR image shows a fracture line with high Findings
signal intensity at the insertion of the direct head of the RF with preserved tendon integrity
and slight displacement of the bony attachment (Fig. 3.7.1). Contiguous sagittal fat-
suppressed proton density-weighted MR images show the fracture line, tendon integrity,
and adjacent soft-tissue damage (Figs. 3.7.2 and 3.7.3). Axial fat-suppressed proton den-
sity-weighted image shows mild displacement of the AIIS with fluid signal intensity in
surrounding soft tissues due to edema and hemorrhage (Fig. 3.7.4)
Case 3.8
Patellar Tendinopathy: Partial Tear
Fig. 3.8.1
Fig. 3.8.2
Fig. 3.8.3 Fig. 3.8.4

A 20-year-old male athlete complained of anterior knee pain and tenderness at palpation
with the knee at full extension and relaxed patellar tendon (Basset sign).
The patellar tendon is vulnerable to overuse-type injuries. In adolescents, Osgood Schlatter Comments
disease and Sinding-Larsen-Johansson syndrome are traction-type injuries affecting the
tibial tubercle and proximal end of the patellar tendon, respectively. These two conditions
have a good prognosis and resolve with conservative management. Patellar tendinopathy
was first related to jumping and was commonly referred to as jumpers knee. The term
tendinopathy has been accepted by most orthopedic and sports-related physicians and can
be used to describe both acute and conditions and those resulting from overuse. Histological
study reveals mucoid and myxomatous degeneration and regeneration with increased cel-
lularity and neovascularization of the proximal tendon. The probable mechanism of injury
is impingement of the tendon by the inferior pole of the patella. The pathogenesis of patel-
lar tendinopathy is complex, and exactly how extrinsic (repetitive mechanical overload)
and intrinsic (malalignment, impingement of the inferior pole) factors combine to trigger
the degeneration of the patellar tendon has yet to be established. Patellar tendinopathy can
be assessed with US and MRI. Characteristic sonographic features include focal or diffuse
hypoechogenicity, tendon thickening, irregularity of the tendon envelope, swelling of sur-
rounding structures, and increased vascularity on color Doppler. Calcifications are not
uncommon. On MRI, the tendon shows increased signal intensity on T1-weighted images
and on fluid-sensitive pulse sequences. Focal or fusiform thickening of the tendon is
another typical finding. Focal discontinuity with the signal intensity of fluid has been asso-
ciated with partial tears. The injury usually affects the osteotendinous junction. Findings
typically occur in the deep posterior portion of the patellar tendon adjacent to the lower
pole of the patella. Imaging techniques still have some limitations in the evaluation of ten-
dinopathy, so further research is needed.
Sagittal proton density-weighted and gradient-echo MR images show marked thickening Findings
of the patellar tendon with increased signal intensity in the proximal third of the tendon
due to tendinopathy and partial tear in the midsubstance of the tendon (Figs. 3.8.1 and
3.8.2). US correlation shows decreased echogenicity along the tendon substance and a focal
area of hypoechogenicity with increased neovascularization that corresponds to the par-
tial tear (Figs. 3.8.3 and 3.8.4).
Case 3.9
Posterior Tibial Tendon Dysfunction
Fig. 3.9.1 Fig. 3.9.2
Fig. 3.9.3 Fig. 3.9.4

A 76-year-old woman diagnosed with sprain after a fall presented 2 months later because
her ankle was still swollen; physical examination showed selective pain and tenderness on
palpation of the posterior tibial tendon.
Partial or complete rupture of the posterior tibial tendon is a relatively frequent syndrome Comments
in women in their fifth or sixth decades; the left side is affected more often. Posterior tibial
tendon rupture has also been reported in young athletes (soccer, tennis, ice-hockey, and
gymnastics). It may present as a painful mass in the medial aspect of the foot, swelling, or
tenderness, associated with progressive flat-foot deformity.
Posterior tibial tendon rupture can be caused by trauma, degenerative changes, inflam-
matory arthritis, seronegative spondyloarthropathies, infections, or abnormal insertion in
an accessory navicular.
Typically, the mid-portion of the tendon is affected at the level of or immediately distal
to the medial malleolus; this area corresponds to a zone of relative hypovascularity.
Three types of posterior tibial rupture have been described:
Type I: the tendon is thickened, with longitudinal tears producing a striated appearance
on MR images.
Type II: the tendon is markedly attenuated with variable intratendinous signal intensity
changes on MR images.
Type III: a complete tear seen as discontinuity with a low to intermediate signal intensity
fluid-filled gap on MR images; subtendons are present in partial tears.
Associated peritendinous inflammatory changes can be present in all three types.
In cases with associated tenosynovitis, hyperintense fluid with degeneration and tendon
tears are seen.
Other findings associated include hypertrophy of the medial navicular tubercle, abnor-
mal talonavicular alignment, accessory navicular, loss of the longitudinal arch, and, less
commonly, dislocation associated with disruption of the flexor retinaculum.
Sagittal T1-weighted MRI (Fig. 3.9.1) shows a thickened tendon, with an intermediate sig- Radiological
nal intrasubstance; fat-suppressed proton density-weighted image shows a longitudinal Findings
split (Fig. 3.9.2). Axial fat-suppressed proton density-weighted image (Fig. 3.9.3) shows sev-
eral subtendons and hyperintense fluid within the tendon in a type II posterior tibial ten-
don tear; a hyperintense signal within the peritendinous fat is also present. On axial
T1-weighted images (Fig. 3.9.4), the tendon is enlarged and attenuated at the level of the
medial malleolus.
A 32-year-old male professional soccer player complained of acute Achilles ten-

Case 3.10 don pain that forced him to withdraw from training. Although he had been previ-
ously asymptomatic during that season, he had complained of discomfort and
Partial Rupture of the stiffness in the Achilles region in previous seasons (3 years before).
Aquilles Tendon with
Tendinosis
Comments Achilles tendon injuries are commonly associated with strenuous physical activi-
ties such as running and jumping. Achilles tendon injuries are classified as either
noninsertional or insertional. Noninsertional tendinopathy (located 26cm from
the tendon insertion within the hypovascular watershed zone) ranges from tendi-
nosis (noninflammatory pathology) to partial and full-thickness tears. Insertional
tendinopathy includes insertional tendinosis and retrocalcanear bursitis, which
often coexist. It is interesting to point out that terms like tendinitis, tendonitis,
Fig. 3.10.1 Fig. 3.10.2
Fig. 3.10.3 Fig. 3.10.4

degenerative changes, chronic tendinopathy, and achillodynia all involve changes in

the Achilles tendon that can be defined as tendinosis.
Although most patients who sustain a spontaneous rupture have never had any symp-
toms in the Achilles tendon before the rupture, histopathologic studies on ruptured ten-
dons have shown that almost all subjects have clear degenerative changes. The terms
tendinosis and partial rupture are difficult to distinguish, especially in patients with
longstanding symptoms, where the clinical and imaging findings are frequently identical.
Partial rupture is most often associated with a sudden onset of pain, whereas in tendinosis
pain increases gradually. However, a condition in which tendon pain increases gradually
might have started with a minor partial rupture; therefore, tendinosis and partial rupture
may in fact be coexisting or may possibly be regarded as the same condition.
The Achilles tendon is the strongest, largest, and thickest tendon in the human body; it
is formed by collagen fibers running from the two heads of the gastrocnemius and deeper
soleus muscles. The tendon is enclosed in a paratendon (fibrous tissue with blood vessels),
which provides nutrition to the tendon, allows it to stretch up to several centimeters in
length, and provides some degree of tendon gliding.
The insertion site of the Achilles onto the calcaneus is an enthesis and is intimately
related to the only true anatomic bursa in the ankle, the retrocalcaneal bursa.
Although the patients history and a careful clinical examination will verify the diagnosis of
Achilles tendon injury, both ultrasound (US) and MRI help in defining the condition and in
monitoring clinical progress. US is also useful for administering platelet-rich therapies like the
infiltration of preparation rich growth factors (PRGF) to stimulate tissue healing; this treat-
ment has been used for tendinosis and more commonly for partial Achilles tendon tears.
Tendon imaging abnormalities usually persist even after patients have recovered func-
tion; consequently, imaging appearance should not be used to guide whether or not an
athlete is fit to return to competition after Achilles tendinopathy.
Sagittal T1-weighted MR image 1 month after the onset of acute pain (Fig. 3.10.1) shows a Imaging Findings
dark, homogeneous, thickened Achilles tendon with increased signal intensity (open
arrow); the parallel anterior and posterior margins of the tendon have been obliterated.
Sagittal fat-saturated T2-weighted image (Fig. 3.10.2) is more sensitive to detect the mucoid
degeneration combined with interstitial tear (open arrow) inside this tendon. Findings of
paratendonitis are also seen, such as minimal edema in Kagers fat pad (arrow) and posterior
to the tendon (empty arrowhead). Axial image in the same sequence (Fig. 3.10.3) also shows
the loss of the normal anterior concave margin (open arrow) and the external location of the
injury. This tendon lesion was treated with rest, massotherapy, and finally US-guided PRGF
infiltration in the external part of the tendon in the first session and in the perilesional zone
in the second session a week later.
Sagittal fat-saturated T2-weighted image in a different 22-year-old male professional
soccer player (Fig. 3.10.4) who complained of tenderness in the Achilles region 5 days after
an excessive training session with inappropriate training shoes, shows peritendinosis with
a huge edema in the anterior Achilles tendon fat (open arrow) and a smaller edema poste-
rior to the tendon (arrow). The tendon itself remains unchanged. The same injury devel-
oped in the contralateral Achilles tendon 4 days later (not shown).
Further Reading features. AJR Am J Roentgenol 2008; 190:w182w186 (web

exclusive article)
Hasselman CT, Best TM, Hughes C, Martinez S, Garret W. An
Books explanation for various rectus femoris strain injuries using
Atlas of Imaging in Sports Medicine. 2nd ed.Anderson A, Read J previously undescribed muscle architecture. Am J Sports
(2007) Mc Graw/Hill, New York Med 1995; 23:493499
Diagnostic Imaging Orthopaedics. 1st ed. Stoller D, Tirman P, Hsu JM, Fischer DA, Wright RW. Proximal rectus femoris avul-
Bredella M, Beltran S, Branstetter R, Blease S (2008) Amirsys, sions in national football league kickers. A report of 2 cases.
Salt Lake City Am J Sports Med 2005; 33(7):10851087
Magnetic Resonance Imaging in Orthopaedics and Sports Hutchinson PH, Stieber J, Flynn J, Ganley T. Complete and
Medicine. Stoller DW (2006) Lippincott Williams and Wilkins, incomplete femoral stress fractures in the adolescent athlete.
Philadelphia Orthopedics 2008; 31:604
Orthopaedic Pathology. 2nd ed. Vincent J, Vigorita MD (2007) Jansen JA, Mens JM, Backx FJ, Stam HJ. Diagnostics in athletes
Lippincott Williams & Wilkins, Philadelphia with long-standing groin pain. Scand J Med Sci Sports 2008;
Patologia muscular en el deporte. Diagnostico, tratamiento y 18:679690
recuperacin funcional. 1st ed. Ramn B (2004) Masson, Jrvinen TAH, Kannus P, Paavola M, Jrvinen TLN, Jzsa L,
Elsevier, Paris Jrvinen M. Achilles tendon injuries. Curr Opin Rheumatol
2001; 13:150155
Khan KM, Forster BB, Robinson J, Cheong Y, Louis L, Maclean L,
Web-Links Taunton JE. Are ultrasound and magnetic resonance imaging
of value in assessment of Achilles tendon disorders? A two-
www.radsource.us year prospective study. Br J Sports Med 2003; 37:149153
www.wheelessonline.com. Wheeless Textbook of Orthopaedics Koulouris G and Connel D. Evaluation of the hamstring muscle
www.cmeinfo.com/store_temp/Sports_Medicine_Imaging__296. complex following acute injury. Skeletal Radiol 2003; 32:
asp 582589
http://books.google.es/books?id = 1FSLoxkWe7YC&printsec = Koulouris G, Connel D. Hamstring muscle complex: an imaging
frontcover#PPP1,M1 Magnetic resonance imaging in ortho- review. Radiographics 2005; 25:571586
pedic sports medicine. Pedowitz PD, Resnick R, Chung CB. Lovell M. The management of sports-related concussion: current
2008 status and future trends. Clin Sports Med 2009; 28:95111
www.essr.org Matt M. Biomechanics of muscle strain injury. Lecture 2002.
Sports Medicine and Scine NZ Conference
Montalvan B, Parier J, Brasseur JL, Le VD, Drape JL. Extensor
Articles carpi ulnaris injuries in tennis players: a study of 28 cases.
BrJ Sports Med 2006; 40:424429
Alfredson H, Lorentzon R. Chronic achilles tendinosis: recom- Ouellete H, Thomas BJ, Nelson E, Torriani M. MR imaging of rec-
mendations for treatment and prevention. Sports Med 2000; tus femoris origin injuries. Skeletal Radiol 2006; 35:665672
29(2):135146 Peltola K, Heinonen OJ, Orava S, Mattila K. Quadratus femoris
Brien SD, Bui-Mansfield LT. MRI of cuadratus femoris muscle muscle tear: an uncommon cause for radiating gluteal pain.
tear: another cause of hip pain. AJR Am J Roentgenol 2007; Clinical J Sport Med 1999; 9:228230
189:11851189 Schweitzer ME, Karasick D. MR imaging of disorders of the
Connel DA, Scheneider-Kolsky ME, Hoving M, Hoving JL, achilles tendon. AJR Am J Roentgenol 2000; 175:613625
Malara F, Buchbinder R, Koulouris G, Burke F, Bass C. Silva RT, De BA, Laurino CF, Abdalla RJ, Cohen M. Sacral stress
Longitudinal study comparing sonographic and MRI asses- fracture: an unusual cause of low back pain in an amateur
ments of acute and healing hamstring injuries. AJR Am J tennis player. Br J Sports Med 2006; 40:460461
Radiol 2004; 183:975984 Smet AA, Best TM. Best MR imaging of the distribution and
Cross TM, Gibbs N, Houang MT, Cameron M. Acute cuadriceps location of acute hamstring injuries in athletes. ARJ Am J
muscle strains. Magnetic resonance imaging features and Roentgenol 2000; 174:393399
prognosis. Am J Sports Med 2004; 32(3):710719 Smigielsky R. Management of parcial tears of the Gastro-Soleus
Delgado GJ, Chung CB, Lektrakul MD etal. Tennis leg: clinical US complex. Clin Sports Med 2008; 27:219229
study of 141 patients and anatomic investigation of four cadav- Weishaupt D, Schweitzer ME, Morrison WB. Injuries to the distal
ers with MR imaging and US. Radiology 2002; 224:112119 gastrocnemius muscle: MR findings. J Comput Assist Tomogr
Gyftopoulos S, Rosenberg ZS, Schweitzer ME, Bordalo- 2001; 25(5):677682
RodriguezM etal. Normal anatomy and strains in deep mus- Willick SE, Lazarus M, Press JM. Quadratus femoris strain. Clini
culotendinous junction of the proximal rectus femoris: MRI J Sport Med 2002; 12:130131
Bone Marrow 4
Joan C. Vilanova, Mercedes Roca, and Sandra Baleato
68 J. C. Vilanova, M. Roca, and S. Baleato
Case 4.1
Bone Metastasis of Melanoma in the Femoral Head Mimicking Avascular Necrosis
Fig. 4.1.1 Fig. 4.1.2
Fig. 4.1.3 Fig. 4.1.4

Bone Marrow69
A 43-year-old white man presented right hip pain for approximately 10 months related to
nonspecific trauma. Findings at physical examination were normal.
Ten years earlier, a pigmented skin lesion resected from his shoulder was diagnosed as
melanoma (Level I on Clarks classification and 2.5mm on Breslows classification).
The incidence of malignant melanoma is increasing faster than any other cancer in humans. Comments
The incidence of melanoma peaks in the fourth decade of life, and the head, neck, and
lower limbs are most frequently affected. Although the prognosis for lesions less than
0.76mm thick is excellent, metastases occur in 28%.
Skeletal metastases are found in 17% of melanoma patients at computed tomography
and in 2357% during autopsy.
The appearance of melanoma on CT is nonspecific, but on magnetic resonance imaging
(MRI), amelanotic cells can produce a different pattern than the common melanin-
containing tumors. Metastasis from malignant melanoma should be included in the
differential diagnosis even when the depth of the primitive tumor is low.
Plain-film radiograph (Fig. 4.1.1) of the right hip shows a sharply lytic lesion on the right Imaging Findings
femoral head surrounded by a sclerotic rim (open arrow), raising suspicion of avascular
necrosis. MRI shows a lesion with low signal intensity on T1-weighted images (Fig. 4.1.2)
and mixed signal on T2-weighted images (Fig. 4.1.3). The patient underwent hip replace-
ment surgery and chemotherapy. MRI follow-up 1 year later (Fig. 4.1.4) shows a polylobu-
lated pseudoencapsulated (arrow) soft-tissue mass with high signal intensity on
T2-weighted images within the gluteus muscles near the prosthesis. At histological exami-
nation, the femoral head and soft-tissue lesions were both consistent with infiltration by
amelanotic epithelioid malignant melanoma.
Case 4.2
Bone Marrow Necrosis Due to Nonhodgkins Lymphoma
Fig. 4.2.1 Fig. 4.2.2
Fig. 4.2.3 Fig. 4.2.4

Bone Marrow71
A 53-year-old woman presented with a mass in her right underarm 2 months after it
appeared. She had no general symptoms or history of illness.
Physical exam found a 60-mm axillary mass and a second 12 mm mass in the groin.
Blood tests, including LDH, were normal.
Bone marrow necrosis (BMN) is a rare entity characterized by fever and bone pain; hyper- Comments
calcemia and increased LDH are usually found in blood tests.
Bone marrow aspirate contains amorphous eosinophilic material, with isolated cells in
different degrees of necrobiosis. These findings appear in up to 19.8% of all autopsies,
mostly after hematological malignancies with proliferative features (acute leukemia,
lymphoma).
BMN is generally regarded as a sign of poor prognosis. Magnetic resonance imaging
(MRI) is useful for evaluating bone marrow involvement in this condition.
Histological examination of bone marrow aspirate shows poor cellularity, with different
degrees of necrobiosis on a stippled background. The clinical picture in this case was inter-
preted as BMN secondary to non-Hodgkins lymphoma.
MRI showed diffuse spongy marrow involvement in the lower spine, sacrum, and pelvic Imaging Findings
bones.
A nonhomogeneous variegated pattern of infiltration was detected in all vertebral bod-
ies (Figs. 4.2.1 and 4.2.2), pelvic bones, and femoral head (Figs. 4.2.3 and 4.2.4). Multiple
foci of low signal on T1-weighted images and high signal on T2-weighted images are char-
acteristic of nonhomogeneous mottled or variegated pattern.
Case 4.3
Systemic Mastocytosis
Fig. 4.3.1 Fig. 4.3.2
Fig. 4.3.3 Fig. 4.3.4

Bone Marrow73
A 29-year-old woman with bone pain, fever, diarrhea, and sweating underwent plain-film
radiography of the pelvis and humerus.
Systemic mastocytosis (SM) is a rare disorder (less than 10% of mastocytoses) that usually Comments
affects adults. The clinical symptoms resemble those of lymphoma or leukemia. Many
organs are involved, including the liver, spleen, lymph nodes, skin, and bone marrow. SM
follows a malignant course and can lead to death within a few years.
Skeletal abnormalities are seen in 70% of cases. There is a special tropism for the axial
skeleton. This proliferation is commonly silent, although 28% of patients complain of pain.
Mast cell proliferation into bone marrow stimulates fibroblastic activity and a granuloma-
tous reaction, which leads to trabecular destruction and replacement with adjacent new
bone formation.
MRI features related to medullary infiltration by mast cells in SM are nonspecific.
However, MRI is an excellent technique for assessing the degree of medullary infiltration in
these patients.
Changes are depicted on plain-film radiographs as a sclerotic lesion with diffuse distribu- Imaging Findings
tion (Figs. 4.3.1 and 4.3.2). MRI shows hypointense signal on T1-weighted images (Fig.4.3.3),
similar to that of other sclerotic bone lesions, such as metastases (from breast or prostate
cancer) or end-stage Pagets disease; infiltration is shown as a nonhomogeneous diffuse
pattern including the epiphysis. Microscopic examination of biopsy specimens (Fig. 4.3.4)
shows mast cell infiltrates in bone marrow as focal cell aggregates with granuloma-like
shape and paratrabecular distribution.
Case 4.4
Bone Crisis in Gauchers Disease
Fig. 4.4.2
Fig. 4.4.1
Fig. 4.4.3 Fig. 4.4.4

Bone Marrow75
A 31-year-old white woman first diagnosed with type 1 Gauchers disease at the age of 4
(genotype N370S/W-4X) and receiving enzyme replacement since 1992 presented with
mild pancytopenia, liver and spleen enlargement, and acute severe pain in her right hip
and knee of several weeks evolution. Her right knee was swollen. She improved after 1
month of treatment with NSAIDs, steroids, and opioids. Skeletal MRI diagnosed a new
bone crisis.
Gauchers disease is the most common lysosomal storage disorder. Type 1 is characterized Comments
by splenomegaly, hepatomegaly, pancytopenia, and osteolytic and osteopenic changes in
the skeleton. Clinical symptoms of the disease are variable and can be apparent during the
first weeks of life or can remain undetected until the eighth decade of life. Type 1 affects all
races, but is especially common among Ashkenazi Jews.
The pathogenesis of bone crisis is not clear, but the process appears to cause acute
infarction of a large segment of bone. This event, also called pseudo-osteomyelitis or asep-
tic osteomyelitis occurs in 2337% of patients with Gauchers disease. Laboratory tests
usually find marked leukocytosis, but findings at plain-film radiography are usually nor-
mal. Osteonecrosis is probably the most disabling bone complication of Gauchers disease;
it can appear at any age and the femoral head is involved in 50% of patients.
Bone marrow infiltration by Gaucher cells is thought to be a critical step in the develop-
ment of focal and local disease, with the increase in intraosseous pressure leading to isch-
emia and necrosis.
Bone marrow infiltration may induce the release of inflammatory mediators such as
cytokines from osteocytes and macrophages into the stromal microenvironment, leading
to the dysregulation of osteoblastic/osteoclastic (formation/resorption) activity and path-
ological bone turnover.
Plain-film radiography is useful for the diagnosis of long-bone and spinal infarction as
well as focal lesions such as osteolysis and osteosclerosis, but has a poor sensitivity for
overall patterns of focal disease. It is therefore not an optimal monitoring method.
MRI is the method of choice for assessing bone marrow burden; it is also very sensitive
for the detection of bone crisis, acute bone infarction, infection, and avascular necrosis.
Focal hyperintense signal in both femoral heads and extended marrow edema in both dis- Imaging Findings
tal diaphyses are shown (Figs. 4.4.1 and 4.4.2). Some sclerotic foci corresponding to old
lesions are also seen on T1-weighted images (Fig. 4.4.3). The vertebral bodies have an
entirely normal signal with no changes suggestive of marrow infiltration by Gaucher cells
(Fig. 4.4.4).
Case 4.5
Non-Hodgkins (Diffuse Large B-Cell) Lymphoma
Fig. 4.5.1 Fig. 4.5.3
Fig. 4.5.2 Fig. 4.5.4

Bone Marrow77
A 55-year-old white woman underwent MRI for left groin pain. She had traveled around a
tropical country in the previous month. Findings at clinical examination and blood tests
were normal. After MRI and bone biopsy, she was diagnosed with non-Hodgkins lym-
phoma (diffuse large B-cell lymphoma, DLBCL).
The incidence and mortality of all the major lymphomas except Hodgkins lymphoma is Comments
rising in all European regions; this trend is more accentuated in the Western and Northern
European countries than in Eastern European countries.
New technology to study gene expression offers new opportunities to identify different
clinical subsets; for example, DLBCLs, the most common lymphoid malignancies, are clini-
cally and genetically heterogeneous disorders. Although DLBCL is a chemo-responsive
tumor, many patients will not be cured with conventional empiric treatment regimens.
Gene expression profiles by microarray analysis of specific genetic abnormalities and func-
tional assays have been used to develop comprehensive molecular signatures of tumors
that share similar features and rely upon common survival pathways. These studies are
leading to the identification of subtype-specific rational therapeutic targets and associated
inhibitors for clinical investigation.
Related to different subtypes according to the REAL-WHO classification, the morpholo-
gies with the highest survival were cutaneous lymphoma and other specified lymphomas,
followed by small lymphocytic leukemia/chronic lymphocytic leukemia (SLL/CLL), follic-
ular lymphoma, and lymphoplasmacytic lymphoma. Morphologies with low survival were
lymphoblastic, diffuse B, other T cell, Burkitts, and mantle cell/centrocytic.
Three geographical areas were compared: EUROCARE west (France, Germany, Italy, the
Netherlands, Spain, Switzerland, Iceland, Malta), EUROCARE east (Czech Republic, Estonia,
Slovakia, and Slovenia), and SEER (US registries). For each morphological group, survival
does not usually differ significantly between the three geographic areas. Exceptions are
cutaneous lymphoma, follicular lymphoma, small lymphocytic NHL together with SLL/
CLL, and mantle cell/centrocytic lymphoma, for which 5-year survival in EUROCARE east
(EU) is significantly lower than in SEER (USA); for follicular lymphoma, survival is also
significantly lower in EUROCARE west than SEER.
Plain-film radiograph (Fig. 4.5.1) fails to show the bone marrow infiltration; trabecular Imaging Findings
bone is preserved on both the femoral head and neck. Pelvic MRI showed a low signal area
in the left femoral neck on T1-weighted images (Fig. 4.5.2). After gadolinium administra-
tion, the peripheral margins enhanced (Fig. 4.5.3). Multiple foci were detected in pelvic
bones (open arrows) on fat-suppressed images (Fig. 4.5.4).
A 49-year-old white man diagnosed with type 1 Gauchers disease at the age
Case 4.6 of 10 years (and prior splenectomy) and receiving enzyme replacement
therapy (ERT) for 18 months, presented with diffuse bone pain of several
Shoulder Arthropathy weeks evolution. After plain-film X-ray and MRI examinations, severe
Secondary to Gauchers shoulder arthropathy was diagnosed.
Disease
Fig. 4.6.1 Fig. 4.6.2
Fig. 4.6.3 Fig. 4.6.4

Bone Marrow79
Bone abnormalities affect the vast majority of untreated patients with Gauchers disease; Comments
these abnormalities often lead to progressive skeletal manifestations like osteonecrosis,
osteosclerosis, focal cortical thinning and long-bone deformity, and generalized osteope-
nia and osteoporosis. These symptoms can arise alone or in combination in both children
and adults at any time during the course of disease, and they are consistently reported as
the most disabling and debilitating complication of type 1 Gauchers disease. Patients who
have undergone splenectomy, particularly at a younger age, may be more susceptible to the
most severe bone changes.
Gaucher bone manifestations are very often associated with a significant degree of pain,
pathological bone fractures, and a risk of bone crises, where patients suffer episodes of
excruciating bone pain. The effects of Gauchers disease on the skeleton therefore have a
heavy impact on patients quality of life. Between 15 and 20% of patients have limited
mobility as a result of Gaucher bone manifestations.
The following diagram shows a protocol for the diagnosis and monitoring of Gaucher
bone manifestations related to bone tissue and bone marrow:
Two therapeutic options are available for patients with mild-to-moderate type 1
Gauchers disease: ERT with imiglucerase (Cerezyme; Genzyme Corporation) and sub-
strate reduction therapy (SRT) with miglustat (Zavesca; Actelion Pharmaceuticals).
ERT, which is based on the replacement of the deficient enzyme, b-glucocerebrosidase,
in Gaucher patients was first introduced in 1991 in the form of a modified human placental-
derived product (alglucerase). This was later replaced by imiglucerase, a recombinant DNA
analogue of the human enzyme, which is indicated for the long-term treatment of symp-
tomatic children and adults with type 1 Gauchers disease. Both enzyme preparations must
be administered by intravenous infusion.
SRT is a relatively new treatment aimed at reducing the accumulation of glucosylcer
amide to a level that allows the residual activity of deficient glucocerebrosidase in Gaucher
patients to act more effectively. Miglustat is a glucose analogue that competitively inhibits
glucosylceramide synthase, the enzyme that catalyses the first committed step in glycos
phingolipid synthesis. It is indicated for the treatment of adults with type 1 Gauchers
disease for whom ERT is not a therapeutic option (e.g., due to constraints such as allergy,
hypersensitivity, or poor venous access).
Plain-film radiographs (Figs. 4.6.1 and 4.6.2) show complete destruction of the humeral Imaging Findings
head. The distal clavicle appears intact, and the scapula shows osteoporosis and changes in
the trabecular bone architecture.
Coronal T2-weighted (Fig. 4.6.3) and axial T1-weighted (Fig. 4.6.4) MRI can detect asso-
ciated bone infarcts and bone marrow infiltration secondary to type 1 Gauchers disease.
T1-weighted images show decreased marrow signal secondary to marrow infiltration by
Gaucher cells. T2-weighted images are used to assess ischemia or vascular obstruction dur-
ing episodes of acute bone pain as well as osteomyelitis or intraosseous/subperiosteal
hemorrhage.
Case 4.7
Multifocal Osteonecrosis
Fig. 4.7.1 Fig. 4.7.2 Fig. 4.7.3 Fig. 4.7.4

Bone Marrow81
A 26-year-old woman presented with bilateral knee pain.
Multifocal osteonecrosis is uncommon; it is usually found in the following clinical settings: Comments
corticosteroid administration, connective tissue disorders (e.g., rheumatoid arthritis and
systemic lupus erythematosus), dysbarism, hemoglobinopathies, Gauchers disease, preg-
nancy, inflammatory bowel disease, and alcohol abuse. Other rarer contexts are HIV infec-
tion, transplantation (kidney, heart, or bone marrow), and cancer treatment. In these
patients it is often difficult to isolate a single causative agent, because the underlying dis-
ease process, corticosteroids, chemotherapy, or radiation therapy may be responsible,
either alone or in combination with one another.
Corticosteroids are the single most frequent cause of osteonecrosis. Alcohol abuse has
rarely been reported as a secondary cause of multifocal osteonecrosis, although it is not
uncommon as a cause of osteonecrosis of the femoral head. A high index of suspicion is
required, and treatment remains expectant and symptomatic. Early recognition of this
condition can significantly prevent morbidity. It is necessary to detect involvement of other
areas like the knee or elbow in alcohol-induced osteonecrosis.
T1-weighted whole-body MRI (Fig. 4.7.1) shows necrotic lesions on both femoral heads Imaging Findings
(open arrows) and within the knee joint (arrows). STIR sequence whole-body MRI
(Fig.4.7.2) shows a low signal intensity lesion from the sclerotic subchondral necrosis of
the hip and high signal intensity from the necrosis of the femur and tibia of both lower
limbs. Multifocal necrosis extends to both elbows (open arrowheads) on coronal
T1-weighted image (Fig. 4.7.3). Bone scintigraphy (Fig. 4.7.4) confirms the osteonecrosis in
both legs and elbows, although the necrosis in both hips is not depicted due to lack of cur-
rent osteogenic activity.
A 51-year-old male complained of lumbar back pain.

Case 4.8
Multiple Comments Multiple myeloma is a generalized bone marrow disease caused by an infiltration
Myeloma of plasma cells. It is characterized by expansive growth of malignant plasma cell
clones with consecutive destruction of the bony architecture. It accounts for
1015% of all hematological malignancies and 12% of all cancers. The incidence
of multiple myeloma varies by race and age. Clinically, approximately 1040% of
patients are asymptomatic at diagnosis, although bone pain is the most common
symptom.
Predilection sites are the axial skeleton (spine and pelvis), but also the ribs, the
shoulder region, skull, and proximal femurs thus, the need for whole-body
imaging to adequately assess the extent of disease.
Fig. 4.8.1 Fig. 4.8.2 Fig. 4.8.3 Fig. 4.8.4

Bone Marrow83
In patients with myeloma, the basic diagnostic work-up in many institutions includes
radiographic examinations of the skull (two planes), the rib cage, the upper arms, the spine
(two planes), the pelvis, and the upper legs. Typical radiographic findings include punched-
out lytic lesions without any reactive sclerosis in the flat bones of the skull and pelvis. In
the long bones, there is a range of appearances from endosteal scalloping, to discrete small
lytic lesions, to larger destructive lesions. This diagnostic approach is still represented in
the classic Salmon and Durie staging system of the disease, which assesses radiographic,
immunohistochemical, and serological factors of the disease to determine the best therapy.
Plain-film radiographs are routinely used for skeletal surveys; however, they are not sensi-
tive enough to detect early osteolytic lesions. Newer imaging techniques like multislice CT,
MRI, and whole-body PET offer improved diagnostic accuracy, enabling more precise stag-
ing and better management of this disease.
Modified diagnostic criteria published in 2006, the Durie-Salmon Plus Staging System,
integrate whole-body MRI, FDG-PET, and CT into routine staging. The role of imaging in
the management of myeloma is to assess the extent of intramedullary bone disease, to
detect extramedullary foci, to evaluate the severity of disease at presentation; to identify
and characterize complications, and to evaluate the response to treatment.
MRI has proven valuable for initial screening and follow-up in almost all types of
myeloma patients. MRI has the advantage of enabling bone marrow involvement to be
evaluated and therefore plays an important role in clinical decision making for patients
with myeloma.
Whole-body MRI has the potential to visualize the bone marrow directly and to deter-
mine abnormalities in bone marrow cell composition with high anatomic resolution.
Whole-body MRI is performed using sagittal T1-weighted spin-echo sequences of the
entire spine, coronal fat-suppressed T2-weighted short tau inversionrecovery (STIR) and
diffusion-weighted imaging of the head, thorax including the upper limps, abdomen, pel-
vis, and thighs. Abnormalities in the bone marrow due to myeloma typically show low
signal intensity on T1-weighted sequences and high signal intensity on STIR or T2-weighted
sequences. Diffuse involvement is best detected on unenhanced T1-weighted SE sequences,
where it manifests as homogeneous signal reduction. Myeloma lesions on diffusion-
weighted images present restricted diffusion.
The differential diagnosis includes metastases, lymphomas, myeloproliferative disease,
or atypical hemangiomas.
Treatment of multiple myeloma is complex and can include chemotherapy, radiation,
and transplant.
Sagittal T1-weighted FSE MRI (Fig. 4.8.1) shows diffuse low signal from the vertebral bod- Imaging Findings
ies with some expansion at the T12 level (open arrow). Bone scintigraphy shows no abnor-
mal uptake (Fig. 4.8.2). Diffusion-weighted whole-body MRI (Fig. 4.8.3) with inverted gray
scale shows multiple lesions in the ribs, spine, pelvis, and femurs (arrows). The correspond-
ing STIR sequence (Fig. 4.8.4) from the whole-body MRI study shows the same lesions and
the extension to both femurs (open arrows).
A 31-year-old woman underwent plain-film radiography

Case 4.9 and MRI for left hip pain of 1 months evolution.
Bone Metastases
Comments Bone is a common site of metastasis for many primary
malignant tumors; indeed, it is the third location after
the liver and lungs. Metastases are the most frequent
cause of bone tumors, accounting for 25% of cases.
Furthermore, the spine represents the most frequent
site of skeletal metastasis. Most metastatic lesions in the
skeleton are encountered in middle-aged and elderly
patients. Malignant cells can disseminate to the spine
by various mechanisms: through the arterial system,
through venous drainage, by cerebrospinal fluid, or by
direct extension. With the vertebraes rich blood supply,
the hematogenous route is the most common of these
pathways.
Back pain is the most frequent initial complaint in
patients with spinal metastatic disease. Pain, pathologi-
cal fractures, and hypercalcemia are the major sources
of morbidity of patients with bone metastases.
The diagnosis of bone metastasis is crucial to deter-
mine the prognosis and to optimize therapy. Imaging of
Fig. 4.9.1
Fig. 4.9.2 Fig. 4.9.3 Fig. 4.9.4

Bone Marrow85
spinal metastatic disease may include radiography, myelography, bone scintigraphy, CT,
and MRI.99mTc-phosphonate-based skeletal scintigraphy is the standard method for the ini-
tial staging of bone tumors; its sensitivity ranges from 62 to 89%. MRI and PET can identify
bone metastases. MRI is the only imaging technique that allows direct visualization of the
bone marrow and its components.
Technical advances have enabled whole-body MRI examination using fast gradient-
echo, T1-weighted, STIR, and diffusion-weighted sequences in less than an hour.
Metastatic bone lesions can be described as osteolytic, osteoblastic, or mixed. On
T1-weighted sequences, tumor spread is identified by replacement of normal marrow,
resulting in an isointense or hypointense signal compared to muscle tissue. On STIR
sequences, increased water content within tumor cells readily reveals bone tumors as
lesions hyperintense to the surrounding normal marrow. In osteoblastic metastases, areas
of low signal intensity on T1-weighted turbo SE images correspond to areas of low signal
intensity on T2-weighted turbo SE images. On STIR sequences, the appearance of osteo-
blastic metastases ranges from no signal in very dense sclerotic metastases to hyperintense
signal in cases where more cellular components are present.
Unfortunately, T2-weighted and STIR sequences do not differentiate intracellular water
signal intensity due to malignant disease from the interstitial water signal due to fracture
edema. In diffusion-weighted sequences, these differences can be used to characterize tis-
sue pathology. Diffusion-weighted MRI highlights areas with restricted diffusion, such as
occurs in many malignant primary and metastatic tumors, and provides outstanding visu-
alization of lymph nodes. Diffusion-weighted MRI also provides functional information
and can be used to detect and characterize bone metastases. Diffusion-weighted sequences
typically demonstrate increased signal intensity for tumor areas, edema, infections, highly
cellular lymph nodes, as well as for lytic metastases. Complete osteoblastic metastases are
not shown on diffusion-weighted images.
Whole-body MRI allows the diagnosis of spinal metastasis and appears to be a powerful
tool for differentiating posttherapeutic changes from tumor recurrence. Treatment for
bone metastases is normally palliative. The indications for surgical treatment of spinal
metastases are intractable pain, the onset of neurological deficit (caused by compression of
the myeloradicular structures by the tumor mass or by pathological fracture of the verte-
bra), and instability of the affected spinal segment that causes ingravescent mechanical
pain and/or neurological deficit.
Plain-film radiograph of the pelvis (Fig. 4.9.1) shows a radiolucent lesion in the left acetab- Imaging Findings
ulum and another lytic bone lesion in the right femur (open arrows). These lesions appear
as greatly increased signal on coronal fat-suppressed T2-weighted MRI (Fig. 4.9.2). Coronal
diffusion-weighted whole-body MRI with inverse grayscale intensity scale (Fig. 4.9.3) dem-
onstrates a large apical right pulmonary mass as a low intensity area (open arrow), left
pulmonary metastases (arrow), and bone metastases from the pelvis (open arrowheads).
Corresponding coronal T1-weighted image (Fig. 9.4.4) depicts the primary neoplasm in
the right lung (open arrow).
Case 4.10
Regional Migratory Osteoporosis
Fig. 4.10.2
Fig. 4.10.1
Fig. 4.10.3 Fig. 4.10.4

Bone Marrow87
A 49-year-old woman with a history of lateral meniscectomy in her left knee 1 year earlier,
complained of pain in the lateral compartment of her left knee. Four months later, she had
pain in her left hip. After conservative treatment, she reported pain in her right hip. Six
months later, she had pain in her left foot.
Regional migratory osteoporosis (RMO) is a feature of bone marrow edema syndrome Comments
(BMES). BMES also includes various transient clinical conditions, such as transient osteo-
porosis of the hip (TOH) and reflex sympathetic dystrophy (RSD). The pathogenic mecha-
nism of BMES is unknown. Typical MRI features include ill-defined hyperintensities on
fat-suppressed T2-weighted images and on STIR images and areas of decreased signals on
T1-weighted images. The bone marrow edema pattern seen on MRI is a nonspecific finding
that has been described in several conditions; thus, it is necessary to distinguish between
reversible and irreversible lesions. BMES is a transient condition that usually requires no
active intervention: TOH, RMO, and RDD are self-limiting, and surgical treatment is not
necessary.
RMO is an uncommon condition characterized by migrating arthralgia involving the
weight-bearing joints of the lower limb. RMO may occur in patients of either sex and at all
ages from late adolescence onwards. The hips are the most commonly affected primary
joint; involvement of secondary joints typically occurs within 6 months of presentation. It
regresses spontaneously, with restoration of normal function and bone density over a
period of 612 months.
Plain-film radiographs may initially be normal but eventually demonstrate demineral-
ization in the affected joint with preservation of the joint space after 36 weeks. Bone scin-
tigraphy shows increased uptake in the affected joints; bone scintigraphy usually shows
abnormal findings before changes are detected on plain-film radiographs and may also
precede the onset of arthralgia at other sites.
MRI shows diffuse bone marrow edema involving the epiphysis of the affected joints,
with high signal intensity on T2-weighted and STIR sequences and low signal intensity on
T1-weighted sequences. Joint effusion may also be present. MRI findings are seen within
48h after the onset of symptoms and resolve 411 months after presentation.
Conservative treatment with limited weight-bearing and analgesia is thought to be
effective.
Coronal STIR MRI (Fig. 4.10.1) demonstrates an ill-defined area of high signal intensity Imaging Findings
compatible with bone marrow edema in the lateral femoral condyle of the left knee. Four
months later, the patient developed pain in her left hip. Coronal T1-weighted FSE MRI
(Fig.4.10.2) shows bone marrow edema in the left femoral head and neck. Six months later,
new onset symptoms developed in the right hip. Coronal T1-weighted FSE MRI (Fig. 4.10.3)
demonstrates complete resolution of the left femoral edema with low signal intensity in the
right femoral head, neck, and intertrochanteric region on T1-weighted sequences. Seven
months later, the patient complained of right ankle pain. Sagittal T2-weighted fat-saturated
MRI (Fig. 4.10.4) demonstrates bone marrow edema in the talus.
Further Reading Jones DN. Multifocal osteonecrosis following chemotherapy and

short-term corticosteroid therapy in a patient with small-cell
bronchogenic carcinoma. J Nucl Med 1994; 35:1347
Books Karantanas AH, Nikolakopoulos I, Korompilias AV, Apostolaki E,
Gaucher disease: molecular, genetic and enzymological aspects. Skoulikaris N, Eracleous E. Regional migratory osteoporosis
Grabowski GA, Horowitz M (1997) In: Gauchers Disease, in the knee: MRI findings in 22 patients and review of the
Zimran A (ed). Balliere Tindall, London, 635636 literature. Eur J Radiol 2008; 67:3441
Musculoskeletal MRI. Phoebe K, Clyde H, Mark WA, Robert D, Korompilias AV, Karantanas AH, Lykissas MG, Beris AE. Bone
Nancy M (2001) Elsevier, Amsterdam marrow edema syndrome. Skeletal Radiol. 2009; 38(5):
Myeloproliferative disorders. Resnick: Diagnosis of Bone and 425436
Joint Disorders 2ed, vol 4. Resnick D, Haghighi P (1996) LaPorte DM, Mont MA, Mohan V, Jones LC, Hungerford DS.
WBSaunders, Philadelphia, 633 Multifocal osteonecrosis. J Rheumatol 1998; 25:19681974
IRM Osto-articulaire et musculaire.Imagerie Mdicale Diagnostic Moon JG, Shetty GM, Biswal S, Shyam AK, Shon WY. Alcohol-
Railhac JJ, Sans N. (2004) Masson, Paris induced multifocal osteonecrosis: a case report with 14-year
Resonancia Magntica en Enfermedades Hematolgicas. follow-up. Arch Orthop Trauma Surg 2008; 128:1149
Giraldo P, Roca M, Rubio-Felix D (2001) Aula Mdica Pastores GM, Einhorn TA. Skeletal complications of Gaucher
Ediciones, Madrid disease: pathophysiology, evaluation, and treatment. Semin
Hematol 1995; 32(3 suppl 1):2027
Patten RM, Shuman WP, Teefey S. Metastases from malignant
Web-Links melanoma to the axial skeleton: A CT study of frequency and
appearance. AJR Am J Roentgenol 1990;155:109112
www.skeletalrad.org. The Society of Skeletal Radiology Roach R, Miller D, Griffiths D. Multifocal osteonecrosis predomi-
www.internationalskeletalsociety.com. International Skeletal nantly affecting the knees secondary to chronic alcohol inges-
Society tion: a case report and review. Acta Orthop Belg 2006; 72:234
www.sfr-radiologie.asso.fr. Societ Francaise de Radiologie Roca M, Mota J, Alfonso P, Pocov M, Giraldo P. S-MRI Store: a
www.mrrc.yale.edu. Magnetic Resonance Research Center simple method for assessing bone marrow involvement in
www.em-consulte.com. Elsevier Massom EM/consulte Gaucher disease. Eur J Radiol. 2006;62:132137
Schmidt GP, Schoenber SO, Schmid R, Stahl R, Tiling R, Becker
CR et al. Screening for bone metastases: whole-body MRI
Articles using a 32-chanel system versus dual modality PET-CT. Eur
Radiol 2007; 17:939949
Barcel J, Vilanova JC, Riera E, Balliu E, Pelaez I, Mart J etal. RM Sevinc A, Kalender ME, Pehlivan Y, Sari I, Camci C. Thrombotic
de todo el cuerpo con tcnica de difusin (PET virtual) para thrombocytopenic purpura and bone marrow necrosis as
el cribaje de metstasis seas. Radiologa 2007; 49(6):407415 the initial presentation of lung cancer. Clin Appl Thromb
Charrow J, Andersson HC, Kaplan P etal. The Gaucher registry: Hemost 2007; 13(4):449452
demographics and disease characteristics of 1698 patients Sidransky E. Gaucher disease: complexity in a simple disorder.
with Gaucher disease. Arch Intern Med 2000; 160:28352843 Mol Genet Metab 2004; 83:615
Cox TM, Schofield JP. Gauchers disease: clinical features and Tall MA, Thompson AK, Vertinsky T, Palka PS. MR imaging of
natural history. Baillieres Clin Haematol 1997; 10:657689 the spinal bone marrow. Magn Reson Imaging Clin N Am
Delgado P, Giraldo P, Roca M, Alvarez R. [Magnetic resonance 2007; 15(2):175198
imaging in the early diagnosis of bone marrow necrosis]. Tang MY, Jeavons S, Stuckey Smiddleton H, Gill D. MRI features
Sangre (Barc) 1999; 44(1):6569 of bone marrow necrosis. Am J Roentgenol 2007; 188(2):
Garca Erce JA, Giraldo Castellano MP, Roca Espaiu M. Alteraciones 509514
radiolgicas en la mastocitosis sistmica. Radiologa 1998; Toms AP, Marshall TJ, Becker E, Donell ST, Lobo-Mueller EM,
40:424425 Bar`ker T. Regional migratory osteoporosis: a review illus-
Glockner JF, Sundaram M, Pierron RL. Radiologic case study. trated by five cases. Clin Radiol 2005; 60:425438
Transient migratory osteoporosis of the hip and knee. Vilanova JC, Barcel J. Diffusion-weighted whole-body MR
Orthopedics 1998; 21(5): 600, 594596 screening. Eur J Radiol 2008; 67(3):440447
Hermann G, Pastores GM. Abdelwahab IF. Gaucher disease: Weinreb N, Barranger J, Packman S etal. Imiglucerase (Cerezyme)
assessment of skeletal involvement and therapeutic responses improves quality of life in patients with skeletal manifesta-
to enzyme replacement. Skeletal Radiol 1997; 26:687696 tions of Gaucher disease. Clin Genet 2007; 71:576588
Spine 5
Eva Llopis, Victoria Higueras, Elena Belloch, and Mara Va
90 E. Llopis, V. Higueras, E. Belloch, and M. Va
A 5-year-old child born with craniosynostosis and

Case 5.1 multiple congenital vertebral abnormalities was evaluated
for spinal deformity. Full spine plain-film radiographs
Congenital Scoliosis showed a complex deformity with double-fixed left
thoracic and right lumbar curves. MDCT was performed
to evaluate bone congenital abnormalities and full spine
MRI was performed to rule out cord abnormalities.
Fig. 5.1.2
Fig. 5.1.1
Fig. 5.1.3 Fig. 5.1.4

Spine91
Congenital scoliosis is defined as scoliosis due to bony abnormalities of the spine present Comments
at birth.
Patients with congenital scoliosis must be monitored clinically and radiographically
with full spine films.
The embryonic development of the vertebra is closely related with that of the spinal
cord; these two structures develop at the same time, so MRI is necessary to rule out neural
axis lesions. Spinal MRI should look for cord abnormalities such as Chiari malformation
(cerebellar tonsil extension below the foramen magnum), syringomyelia (cavity within the
spinal cord extending for more than two vertebral body segments), tethered cord syndrome
with or without associated lipoma (includes thick filum terminale, dorsal and caudal posi-
tion of the conus of the conus medullaris), and diastematomyelia (cord split over a portion
of its length). The cleft that divides the cord in diastematomyelia might be associated with
a fibrous or osteocartilaginous spur or septum. The cleft is located below T8 in 85% of
cases and involves only the lumbar spine in 60% of cases. Usually, the cord reunites after the
cord. In diastematomyelia, the gray matter of each hemicord usually forms a dorsal and a
ventral horn.
MDCT should be used as a complementary technique to evaluate bone deformities,
especially complex ones in which there are a jumble of abnormalities that are difficult to
depict and understand on conventional plain-film radiographs. Reformatted images
provide a more complete picture of the patients deformity. Congenital deformities can be
divided into two basic groups based on the embryologic development: segmentation
defects and formation defects. Segmentation defects can be symmetric or asymmetric;
asymmetric defects take the form of unilateral, unsegmented, solid bars with bone fusing
on two or more segments. This defect closely correlates with progressive spinal curvatures.
Formation defects occur secondary to a lack of embryonic material for normal vertebral
development. Hemivertebra, one of the most common formation defects, is defined as the
complete failure of a vertebra to form one side. The severity of the resultant scoliosis is
related to the degree of segmentation associated.
Figure 5.1.1 Plain-film radiographs of the entire spine show a complex deformity with mul- Radiological
tilevel deformities and double-fixed kyphoscoliosis (left thoracic, right lumbar). Findings
Figure 5.1.2 MRI shows a double neural tube separated by a bony spur (open arrow). The
complex kyphoscoliosis has caused the spur to rotate and cross the spinal canal. The spur
inserts into an externally rotated lamina and creates significant asymmetry in the two
hemicanals. Low cerebellar amygdala, diagnostic of Chiari malformation, and low conus
medullaris completed the spectrum of pathologic conditions affecting the neuroaxis.
Figure 5.1.3 Axial volume-rendered MDCT clearly shows the lateral bone spur dividing
the spinal canal into two hemicanals (open arrow).
Figure 5.1.4 Volume-rendered MDCT reconstruction shows the complex vertebral
abnormalities with a segmentation defect of the anterior arch of C1 (open arrow), a com-
plex formation defect, unilateral bars at the cervicothoracic junction (C6-C7-T1) (solid
arrow), a large unilateral left bar segmentation defect on T4T9, and complex associated
rib alterations (arrowhead).
Case 5.2
Herniated Disc Migration with Spontaneous Regression
Fig. 5.2.1
Fig. 5.2.2
Fig. 5.2.3 Fig. 5.2.4

Spine93
A 25-year-old woman presented with acute sciatic pain. MRI showed a herniated disc with
cranial extrusion. She was provided conservative treatment, and a follow-up MRI 3 months
later showed a marked decrease in the size of the hernia.
Herniated disc migrates either superiorly or inferiorly but remains confined to the left or Comments
right anterior epidural space by a midline septum adjacent to the posterior longitudinal
ligament.
A standardized nomenclature and classification system now classifies disc herniations
as protrusions, extrusions, and sequestrations. Disc herniation is classified as protrusion
when the protruding portion involves the majority of the disc; as extrusion when the pro-
truding portion is wider than the neck connecting the cap to the bulk of the disc in the
interspace; and as sequestration when a fragment of the disc becomes separated from the
remaining parent disc. Differentiation between protrusion and extrusion might be of clini-
cal significance because 52% of asymptomatic patients have a bulging disc, 27% have a
protruded disc, and only 1% has an extruded disc.
Spontaneous disc herniation reduction is well known clinically and was also demon-
strated on CT and also on MRI by Bozzao etal. About 70% of herniated discs reduce their
size spontaneously in patients treated conservatively. Pain relief is thought to be due to
subsidence of root sleeve edema and of inflammatory and fibrotic changes around the disc
material. Although the exact mechanism is unknown, dehydration and shrinkage of the
disc material, probably related to the inflammatory response, are thought to be the main
factors involved. The only imaging findings associated with the amount of regression are
the size of the herniation and rim enhancement.
Thoracic disc and cervical disc herniation have been studied less and their rate of
regression is lower. One of the reasons for lower regression rates in thoracic herniation is
the presence of calcification within the disk.
Figure 5.2.1 Sagittal T1-weighted FSE MRI shows obliteration of the normal epidural fat in Radiological
the left lumbar recess by an oval soft-tissue mass connected with the L5-S1 intervertebral Findings
disc, consistent with superiorly migrated herniated material (solid arrow). The lesion is
slightly hyperintense compared to fluid and normal intervertebral disc (open arrow), and
this is associated with a subacute process.
Figure 5.2.2 Sagittal T2-weighted FSE MRI shows the migrated herniated disc (open
arrow) with irregularity and edema in the adjacent endplates (arrow).
Figures 5.2.3 and 5.2.4 Three-month follow-up MRI study: Sagittal T1-weighted FSE
MRI and T2-weighted FSE MRI show the marked regression in the size of the herniated
disc (open arrow).
A 70-year-old man presented with posterior right lower limb pain of 2 months evolution;
Case 5.3 pain become persistent and severe about 2 weeks before the MRI exam. The diagnosis was
confirmed at spinal surgery.
Ligamentum
Flavum Cyst
Introduction Facet and juxtafacet cysts are cystic lesions originating in the facet joint or its surrounding
structures. Synovial cysts and ganglia are distinguished by the presence or absence of syn-
ovial lining, which cannot be differentiated on MRI. Synovial cysts originating in the facet
joint are called facet cysts and those originating in the ligamentum flavum are called
Fig. 5.3.1 Fig. 5.3.2
Fig. 5.3.3
Spine95
ligamentum flavum cysts. These cysts are usually located in the lumbar spine and L2-L3 is
the most common site.
Juxtafacet cysts of the lumbar spine are associated with degenerative facet and ligamen-
tum flavum process due to degenerative disc disease together with facet microinstability
and hypermobility. Up to 5070% have spondylolisthesis.
Clinically, these lesions are a well-recognized cause of lumbar radicular pain and neuro-
genic claudication. Symptoms are related to acute compression or the inflammatory pro-
cess surrounding the cyst.
Diagnosis of a juxtafacet cyst of the lumbar spine is relatively easy with MRI because of
its high contrast resolution. The diagnosis can also be suggested on CT, where calcium and
vacuum phenomena are better depicted.
At MRI, they appear as posterior epidural lesions with low to intermediate signal inten-
sity on T1-weighted MRI. On T2-weighted MRI, the cyst capsule appears as a hypointense
line, well demarcated from the high-signal-intensity intrathecal CSF, representing a fibrous
capsule with hemosiderin deposits or thin calcification. The content of the cyst varies;
therefore, it usually has the signal intensity of fluid, but it can be heterogeneous with low
signal intensity on T2-weighted images due to the presence of proteinaceous material,
hemorrhage (causing acute symptoms), calcification, and the vacuum phenomenon. Rim
enhancement is seen after gadolinium injection. The location of the cyst and its relations
to other structures are the key to differentiating between facet cyst and ligamentum flavum
cyst. The connection between the lesion and the facet or ligamentum flavum can be dem-
onstrated by tailoring the study. Medially located lesions (from 2 to 5 oclock on the right
and from 7 to 10 oclock on the left) adjacent to the ligamentum flavum with less degenera-
tive changes of the facet are diagnostic of ligamentum flavum cysts, whereas laterally
located, more inferior lesions with degenerative changes and fluid within the facet joint are
characteristic of facet cysts. Hemorrhage within the cyst is slightly more common in liga-
mentum flavum cysts than in facet cysts.
These imaging findings, especially the anatomical location, can suggest the diagnosis.
The differential diagnosis includes other processes that can affect the facet, such as septic
arthritis (when hemorrhagic deposits are seen with high signal intensity on T1-weighted
images), pigmented villonodular synovitis of the facet joint, posterior migration of a
sequestrum from a herniated disc (although these very rarely extend the ligamentum
flavum), perineural cyst (these are usually associated with the nerve root sleeve in the
neural foramen and are separate from the facet), or cystic schwannoma (these are usually
intradural and lack a hypointense rim).
Figure 5.3.1 Sagittal T1-weighted FSE MRI shows a hyperintense posterior epidural lesion Imaging
located in the mid-lateral canal at the L2-L3 level. Findings
Figure 5.3.2 Sagittal T2-weighted FSE MRI shows a hyperintense heterogeneous lesion
with a hypointense rim (solid arrow).
Figure 5.3.3 Axial T1-weighted MRI after gadolinium injection shows the right centrally
located posterior epidural lesion, connected with the ligamentum flavum and moderate
rim enhancement (solid arrow).
A 75-year-old woman presenting with intermittent and progressive

Case 5.4 pain in the upper thoracic spine associated with weakness and par-
esthesias in both arms underwent spinal CT and MRI. The diagnosis
Primary Vertebral and Epidural was confirmed by CT-guided biopsy.
Lymphoma
Introduction Primary bone lymphoma is an uncommon malignancy that accounts

for less than 5% of all primary bone tumors. Primary lymphoma is
defined as lymphoma with no evidence of systemic disease at the
time of the presentation. The radiological appearance of primary
bone lymphoma is variable and without reliable characteristics for
a firm diagnosis; however, several features together might suggest
the diagnosis.
Fig. 5.4.1
Fig. 5.4.2
Fig. 5.4.3
Fig. 5.4.4 Fig. 5.4.5

Spine97
Primary bone lymphoma has also been called reticulum cell sarcoma, malignant lym-
phoma of the bone, and more recently osteolymphoma. The vast majority of cases are of
the non-Hodgkins type.
There are three main types of lymphoma: B cell, T cell, and Hodgkins disease. The dif-
ferential diagnosis is readily resolved by immunohistochemical analysis.
Primary bone lymphoma occurs in a broad range of patients and is most prevalent
among patients in the sixth to seventh decades.
The femur is the most common site, followed by pelvis, humerus, and tibia. Vertebral
involvement is not unusual, and the thoracic spine is the most common site in the spine.
It is important to obtain a specific diagnosis for bone lymphoma because this tumor has
a better response to therapy and a better prognosis than other lymphomas.
The radiological appearance is variable; the most frequent appearance is an aggressive
lytic lesion with permeative bone destruction or more rarely osteosclerosis, and bone lym-
phoma forms part of the differential diagnosis of ivory vertebra. Typically, bone lymphoma
shows permeated cortical bone without significant gross destruction, limited periosteal new
bone formation, and a very large soft-tissue mass. Lymphoma does not have a bone or carti-
lage matrix. Expansion of the involved bone is unusual. The disc spaces are usually preserved,
but can become widened in rare cases. Extension into the spinal canal is frequent, as are
paraspinal soft-tissue masses; the extraosseous component is often homogeneous. Epidural
masses cause cord compression more often than vertebral collapse in spine lymphoma.
On plain-film radiographs and CT, primary lymphoma of the spine may be lytic, scle-
rotic, or mixed with associated partial or complete vertebral compression. MRI not only
permits early identification but also depicts the extent of soft-tissue involvement and can
be used to assess the outcome of treatment.
Figure 5.4.1 Unenhanced CT shows a coarse permeative and trabecular pattern in the body Radiological
of T3, with periosteal preservation (open arrow) without significant cortical destruction. A Findings
large soft-tissue mass extends to the prevertebral space and spinal canal (solid arrow).
Findings at chest CT were normal, without pulmonary nodules or adenopathies.
Figure 5.4.2 Axial T1-weighted FSE MRI shows a low signal intensity mass in the T3
vertebral body, with preservation of the cortical periosteal bone (open arrow) and a large
hypointense soft-tissue mass extending into the prevertebral and epidural spaces, as well as
into the vertebral foramen, where it involves the spinal cord (solid arrow).
Figure 5.4.3 Sagittal T2-weighted FSE MRI shows the mass isointense to the T3 vertebral
body and posterior elements; the spinal cord is compressed by the epidural anterior and
posterior soft-tissue mass (open arrow). The soft-tissue mass is slightly hyperintense com-
pared to the spinal cord and extends posteriorly.
Figure 5.4.4 Coronal T1-weighted FSE MRI clearly shows the right paravertebral soft-
tissue extension (open arrow) as well as the preserved cortical bone and intervertebral
space (solid arrow).
Figure 5.4.5 Sagittal fat-saturated T1-weighted FSE MRI after gadolinium injection
reveals the highly intense homogenous enhancement of the vertebral body, posterior ele-
ments, and soft-tissue mass.
A 13-year-old boy presented with low back pain of 2

Case 5.5 months evolution; the pain was predominately noctur-
nal and accompanied by right radicular pain. Plain-film
Osteoid Osteoma radiographs and MRI of the lumbar spine showed scle-
rosis and bone marrow edema in the sacrum, so a dedi-
cated study of the sacrum was performed.
Fig. 5.5.2
Fig. 5.5.1
Fig. 5.5.3 Fig. 5.5.4

Spine99
Osteoid osteoma of the spine accounts for 10% of all osteoid osteomas, but only 2% of Introduction
spinal osteoid osteomas are found in the sacrum.
Osteoid osteomas affect men two to three times more often than women, usually between
the ages of 10 and 20 years.
Most axial osteoid osteomas are located in the posterior elements of the vertebra (pedi-
cles, articular facets, and laminae), and only 7% are located in the vertebral body. The
remaining cases involve the transverse and spinous processes. The lumbar spine is most
commonly affected, followed by the cervical, thoracic, and sacral segments.
These benign osteoblastic lesions contain a central nidus characterized by osteoid and
highly vascular fibrous tissue. Histologically, the nidus of an osteoid osteoma is a small
(<1.52.0cm in diameter), round mass of pink-to-red tissue; the color of the lesion reflects
its vascularity. The nidus is usually less than 1cm in size and is surrounded by a zone of
reactive sclerosis.
On plain-film radiographs, a central radiolucent lesion less than 2cm in diameter repre-
sents the nidus and is surrounded by marked perifocal sclerosis. Central calcification may
be observed within the osteolytic nidus. CT is highly specific for the diagnosis.
The usefulness of MRI in detecting the nidus is unclear; when an osteoma is detected,
signal intensity is generally low with an isointense central nidus on T1-weighted images
and intermediate to high signal intensity on T2-weighted images. Bone-marrow edema and
soft-tissue edema are conspicuous on T2-weighted fat saturation images. In some patients,
the nidus is undetectable as a result of marrow edema, soft-tissue edema, or surrounding
sclerosis.
The enlarged transverse process together with soft-tissue edema might be responsible
for radicular pain.
The differential diagnosis for a dense pedicle includes osteoblastoma (which is larger
than 1.52 cm), osteoblastic metastasis, enostosis (bone island), unusual infection,
lymphoma, and reactive sclerosis caused by abnormalities of the facets.
Figure 5.5.1 Coronal MDCT MPR reconstructions show enlarged and markedly sclerotic Radiological
right S3 process; the central nidus is clearly shown as a small central radiolucent lesion Findings
measuring 7 mm (less than 2 cm) without central calcification (open arrow).
Figure 5.5.2 Axial T1-weighted FSE MRI shows hypointensity in the sclerotic area (open
arrow) and a central area that is isointense-slightly hyperintense to the muscle nidus (solid
arrow).
Figure 5.5.3 Axial STIR MRI shows hyperintensity in the central nidus (open arrow), a
slightly hypointense sclerotic area surrounding it, and marked soft-tissue edema extending
to the right piriformis muscle (solid arrow) and into the right foramen, where it involves
the right neural root.
Figure 5.5.4 Coronal T1-weighted fat saturation FSE MRI after gadolinium injection
shows strikingly high arterial phase uptake in the nidus due to its high vascularity and
enhancement of the surrounding tissue (open arrow).
Radiofrequency ablation of this lesion achieved a good outcome.
Case 5.6
Meningioma
Fig. 5.6.1 Fig. 5.6.2
Fig. 5.6.3 Fig. 5.6.4

101
Spine
A 67-year-old woman presented with low back pain, left radicular pain, weakness of the
lower limbs, instability, and paresthesias. MRI performed to rule out spinal compression
suggested the diagnosis of meningioma, which was confirmed at surgery.
Meningioma is the second most common tumor of the spine, accounting for approximately Introduction
25% of spinal canal tumors. There is a strong female preponderance (80%), with peak age
in the fifth and sixth decades. The most common location is the thoracic spine, followed by
the cervical spine; meningiomas in the lumbosacral spine are rare. Meningiomas are
extramedullary lesions. Because they have a dural attachment, most spinal meningiomas
(approximately 90%) are intradural, only 5% are extradural, and another 5% have combined
intradural and extradural components.
The typical clinical scenario is a middle-aged woman with signs and symptoms of cord
or nerve root compression. The radiological diagnosis is often suggested by its intraspinal
extramedullary location and association with the nerve root sleeve.
CT might show calcification, although this finding is uncommon. At MRI, the tumor
typically appears as a well-circumscribed lesion isointense or slightly hypointense to the
spinal cord on T1- and T2-weighted sequences, with homogeneous gadolinium enhance-
ment. However, in meningiomas with an extradural component, the extradural component
only enhances minimally.
The dural tail sign, consisting of dural enhancement adjacent to the dural attachment,
can be detected, although is not specific and might also be present in some metastases,
lymphoma, or sarcoidosis.
The differential diagnosis should include neurinomas, which are the most common
intraspinal intradural extramedullary tumors. Neurinomas are usually more hypointense
on T1-weighted images and hyperintense on T2-weighted images, and they are more likely
to widen the neural foramen than meningiomas. Other, less frequent, entities in the dif-
ferential diagnosis are filum terminale ependymoma, drop metastasis, sarcoidosis, and
lymphoma.
Surgical excision is the treatment of choice in most cases, and recurrence is
uncommon.
Figure 5.6.1 Sagittal T2-weighted FSE MRI shows a well-defined solid mass at the T11T12 Radiological
level, isointense with the spinal cord (open arrow). Findings
Figure 5.6.2 Sagittal T1-weighted FSE MRI shows the extramedullary lesion isointense
to the cord.
Figure 5.6.3 Coronal T1-weighted FSE MRI after gadolinium injection shows homoge-
neous enhancement with a broad dural attachment (open arrow) and normal-sized neural
foramen; the spinal cord is displaced to the right (solid arrow).
Figure 5.6.4 Sagittal fat-saturated T1-weighted MRI after gadolinium injection demon-
strates strong and homogeneous enhancement.
A 57-year-old patient presented after 2 years chronic progressive lumbar pain refractive to
Case 5.7 conservative treatment and 2 weeks lower limb weakness. Plain-film radiographs of the
lumbar spine revealed multiple lytic lesions, and the diagnosis was reached with spinal MRI,
Myeloma CT-guided biopsy, and bone marrow biopsy. He was treated with radiotherapy, chemotherapy,
and steroids; the response to treatment was good (decreased size of the soft-tissue mass and
of the lytic lesions). Eighteen months later, the patient developed progressive paresthesias and
bilateral motor deficit. MRI showed myelopathy and a lesion with ring enhancement; on the
basis of these findings and clinical and laboratory analyses, the diagnosis of late post-
radiotherapy progressive myelopathy was reached.
Comments Myeloma is the most common primary bone malignancy and one of the most common hema-
tologic malignancies. The diagnosis is based on laboratory tests (monoclonal paraprotein in
serum or urine), bone marrow aspiration, biopsy (greater than 10% of atypical plasma cells),
and the typical radiological appearance of lesions.
There are multiple classification systems, but the most widely used is Durie-Salmon clas-
sification, which includes plain-film findings in addition to laboratory analyses. An update
incorporated MRI or PET/CT in the Durie-Salmon PLUS classification to determine the num-
ber of focal lesions and extent of the diffuse infiltration.
Stage IA: Normal skeletal or a single lesion.
Stage IB: Less than five focal lesions or mild diffuse disease.
Stage IIA/B: 520 focal lesions or moderate diffuse disease.
Stage IIIA/B: More than 20 focal lesions or severe diffuse disease.
Subclasses A and B: (A normal renal function and B abnormal).
Fig. 5.7.1 Fig. 5.7.2 Fig. 5.7.3 Fig. 5.7.4

103
Spine
Solitary plasmocytoma is uncommon and occurs in only approximately 5% of patients

with plasma cell myeloma; by strict definition, the diagnosis requires histologic confirma-
tion of a monoclonal plasma cell infiltrate in one lesion, absence of other bone lesions, and
a lack of marrow plasmacytosis. Often plasmocytoma is present for a year or more as an
isolated lesion before the laboratory evidence of multiple myeloma manifests. Multiple
myeloma develops in most patients in a few years.
Plain-film radiography shows focal osteolytic lesions and diffuse inhomogeneous
osteopenia. Sclerotic lesions are rarely seen, though they are more frequent after treatment.
Several MRI patterns have been described, including from normal bone marrow signal to
focal involvement, diffuse bone marrow infiltration, or combined focal and diffuse (salt and
pepper) pattern. MRI studies should combine T1-weighted FSE sequences with fat-sup-
pressed T2-weighted or STIR sequences. Focal lytic lesions can be large and there may be a
soft-tissue mass with cord compression. On MRI, the soft-tissue mass appears as an expan-
sile lesion that is hypointense on T1-weighted images and hyperintense on T2-weighted
images. Recently, a pattern on axial MRI referred to as a mini brain was reported to be
characteristic of vertebral plasmocytoma. In this pattern, curvilinear structures with low
signal intensity on all imaging sequences extend partially through the vertebral body; these
curvilinear structures result from the compensatory hypertrophy of the residual trabecular
bone in the lytic vertebra that is responding to weight-bearing stress.
The differential diagnosis includes metastasis, lymphoma, myeloproliferative disease, or
atypical hemangiomas.
Treatment includes biphosphonates to reduce fractures, chemotherapy, radiotherapy,
and transplantation. Evaluation of the response to treatment should include the following
parameters: serum or urine monoclonal gammopathy, reduction of plasma cell infiltration,
reduction of the soft-tissue mass, and no increase in the size or number of lytic lesions.
Progressive myelopathy is an uncommon complication of radiotherapy. The following
three criteria must be fulfilled for the diagnosis: (1) inclusion of the spinal cord in the area
irradiated; (2) location of the main lesion in the irradiated segments of the cord; (3) exclusion
of other causes of compression. Radiation myelopathy normally becomes evident 6 months
to 2 or 3 years after radiation therapy. Spinal MRI shows hyperintensity along the irradiated
cord on T2-weighted FSE images and variable enhancement after gadolinium injection.
Figure 5.7.1 Sagittal T1-weighted FSE MRI shows an expansile lytic lesion in T8 with a soft- Radiological
tissue mass (open arrow) extending toward the posterior elements and the superior and Findings
inferior vertebral bodies; the soft-tissue mass involves the epidural space and compresses
the spinal cord, which is posteriorly displaced. Other small lytic lesions are also depicted.
Figure 5.7.2 Corresponding sagittal STIR sequence shows a large hyperintense soft-
tissue mass with pathological fracture on T8.
Figure 5.7.3 Follow-up sagittal STIR image obtained 3 months later shows marked
reduction in the size of the soft-tissue spinal mass (open arrow) and of the rest of lytic
lesions. The bone marrow signal is diffusely lower due to fat infiltration.
Figure 5.7.4 One year later, sagittal T2-weighted FSE image shows progressive reduction
in the size of the lytic mass in T8 (open arrow) and ill-defined hyperintensity within the
spinal cord, indicative of progressive myelopathy (solid arrow).
A 41-year-old patient presented at the emergency department after falling from a height of 4m.
Case 5.8 Neurological exam revealed complete paraplegia of the lower extremities. Plain-film radio-
graphs of the spine showed L1L2 fracture dislocation with associated bilateral facet fracture.
Fracture MDCT and MRI were performed to depict the relationships among the structures and the spi-
Dislocation nal canal and to evaluate injuries to the spinal cord and organs of the chest and abdomen.
Fig. 5.8.1
Fig. 5.8.2 Fig. 5.8.3 Fig. 5.8.4

105
Spine
Vertebral bodies are joined by the intervertebral disc, and the posterior portions of adja- Introduction
cent vertebrae are connected by a ligament complex (supraspinous and interspinous liga-
ments, posterolateral joints, and ligamentum flavum). This ligament complex ensures
spinal stability and avoids luxations. Sagittal-translation fractures are rare, occurring in
approximately 3% of vertebral fractures. These complex fractures result from combined
flexion and rotation forces: the posterior complex ruptures and the upper vertebrae swing
on the lower. In the cervical region, pure dislocation occurs because of the horizontal ori-
entation of its articular processes. In the lumbar region, the articular processes are ori-
ented more vertically; thus, it is more common for them to undergo fracture and subsequent
dislocation rather than pure luxation.
On plain-film radiographs, bony anatomy may be obscured by overlying structures.
Nevertheless, lateral views can demonstrate wedge deformity of the vertebral body, sagittal
translations, and separation of the spinous processes. The AP view may identify lateral
shift of the articular processes. Radiographic indicators of instability of vertebral fractures
include the presence of translational components, compression greater than 50% of verte-
bral body height, fracture of the posterior elements, and increased interpeduncular dis-
tance. Fracture dislocations are therefore unstable by definition.
MDCT, with its capability for multiplanar reconstructions in the coronal and sagittal
planes, has changed the diagnostic approach to vertebral fractures. MDCT can precisely
depict all the elements involved in the fracture and the status of spinal canal.
MRI evaluation provides information about the integrity of soft tissues: posterior
ligaments, discs, and spinal cord and extra-axial collections (epidural hematomas). Fat
saturation T2-weighted images and STIR sequences may also reveal soft-tissue and bone
edema, as well as spinal cord damage. Proton density-weighted images are best for assessing
ligamentous integrity.
Figure 5.8.1 Axial CT at L2 level demonstrates vertebral body fracture with retropulsion of Radiological
the cortex of the posterior vertebral body and narrowing of the spinal canal. Note the frac- Findings
ture of right pedicle (arrow).
Figure 5.8.2 MDCT with sagittal volume rendering reconstruction of the thoracolumbar
spine confirms the fracture of the superior endplate of L2, with loss of vertebral body height
anteriorly, and anterior luxation of L1 on L2. Reformatted images demonstrate widening of
the spinous processes between L1 and L2, with associated fracture of the spinous process of
L1 (open arrow). There is a small fracture of T12 superior endplate (solid arrow).
Figure 5.8.3 Sagittal T1-weighted MRI of the lumbar spine shows L1L2 luxation, frac-
ture of the anterosuperior endplate of L2 (open arrow), and increased distance between the
spinous processes with disruption of the interspinous ligament. Anterior and posterior
(solid arrow) longitudinal ligaments are elongated without rupture. There is a small hyper-
intense epidural collection related to hematoma (arrowhead) as well as compression of the
conus medullaris and cauda equina nerve roots.
Figure 5.8.4 Sagittal STIR MRI shows marked high signal in the soft tissues (open arrow)
and anterior disruption of the interspinous ligament (solid arrow). Bone-marrow edema is
seen in the T12, L1, and L2 vertebral bodies, related to trabecular fractures.
Case 5.9
Spondylodiscitis
a b
Fig. 5.9.1 Fig. 5.9.2
Fig. 5.9.3 Fig. 5.9.4 Fig. 5.9.5

107
Spine
A 76-year-old woman presented with an 8-week history of persistent low back pain despite Clinical History
analgesic treatment and constitutional symptoms. She had a previous history of recurrent
urinary tract infections and diabetes. At physical examination, her temperature was 37.5
and tenderness over lumbar vertebrae was noted. Laboratory tests revealed increased
C-reactive protein without leukocytosis. Comparing plain-film radiographs obtained in
the emergency room with those obtained 1 month before suggested discitis; MRI and
CT-guided biopsy confirmed the diagnosis.
Infectious discitis is an infl ammatory process of the intervertebral disc that usually involves Introduction
the discovertebral junction and may extend into the epidural space, posterior vertebral ele-
ments, and paraspinal soft tissues. Spondylodiscitis accounts for 24% of all osteomyelitis.
It may occur spontaneously, by hematogenous spread from distant septic foci, direct inocu-
lation from spinal surgery or penetrating trauma, or direct extension. The most common
causative organism is Staphylococcus aureus. Most patients present with back pain. Other
symptoms, such as fever, anorexia, and weight loss may be present. Laboratory tests might
reveal leukocytosis, but can be normal in tuberculous infection and in immunocompro-
mised or older patients. C-reactive protein is the most reliable test because erythrocyte
sedimentation rate (ESR) is variable, especially in older patients.
Plain-fi lm radiographs of the spine are normal in the early stages of infection, and
alterations are rarely seen before 24 weeks. MRI is the noninvasive method of choice for
the diagnosis in the early stages space. Imaging fi ndings include decreased signal intensity
of the intervertebral disk and adjacent vertebral body marrow on T1-weighted images, and
high signal intensity on T2-weighted images. After intravenous administration of gado-
linium, discs can show homogeneous, patchy, or peripheral enhancement. Adjacent bone
marrow also enhances diffusely.
The differential diagnosis of infectious discitis includes degenerative changes, ankylosing
spondylitis, SAPHO syndrome (combination of synovitis, acne, pustulosis, hyperostosis,
and osteitis), and neuropathic spine.
Figure 5.9.1 Plain-film radiographs acquired in the emergency department (b) and 1 month Radiological
before (a) show progressive destruction of the T12L1 endplate, with erosion and kyphosis Findings
(open arrow in (a) and solid arrow in (b)). Marked degenerative changes in the rest of the
spine are also evident.
Figure 5.9.2 Sagittal MDCT multiplanar reconstructions clearly show the erosions and per-
meative pattern of the superior and inferior vertebral bodies adjacent to the T12L1 disc space.
Figure 5.9.3 Sagittal T1-weighted MRI shows decreased signal intensity of the subchon-
dral bone marrow and marked erosion of the endplates adjacent to the T12L1 interverte-
bral disc (open arrow). Degenerative L4-L5 spondylolisthesis (solid arrow) and small disc
herniation in L3L4 are also shown (arrowhead).
Figure 5.9.4 Sagittal STIR MRI shows increased signal intensity with erosion of the ver-
tebral bodies and fluid signal intensity in the T12L1 intervertebral disc (open arrow).
Figure 5.9.5 Contrast-enhanced sagittal fat-suppressed T1-weighted image reveals dif-
fuse enhancement of the vertebral bodies without abscess (open arrow).
Case 5.10
Sacral Chordoma
Fig. 5.10.2
Fig. 5.10.1
Fig. 5.10.3 Fig. 5.10.4

109
Spine
A 54-year-old man had severe low back pain of several weeks duration that radiated to
both legs. His medical history and physical examination were unremarkable.
Chordoma is the most common primary malignant sacral tumor; it accounts for 24% of Comments
malignant osseous neoplasms. Chordomas arise from the notochord, which is normally
replaced by mesodermal tissue by the 7th week of development. Scattered vestiges of noto-
chord may be found in the nucleus pulposus and can be present at any level from the base
of the skull to the coccyx. Fifty to sixty percent of chordomas develop in the sacrococcygeal
region. These tumors are found at all ages. The mean age at diagnosis is the sixth decade.
Chordoma affects males twice as often as females.
The classic appearance of chordoma is a destructive, lytic lesion, commonly with inter-
nal calcifications (30%). A large presacral soft-tissue component is usually present. These
tumors are capable of extending across the adjacent disk space and the sacroiliac joint.
Chordoma shows heterogeneous low signal intensity on T1-weighted images and prom-
inent heterogeneously increased signal intensity on T2-weighted images, reflecting the
high water content of the lesions. Contrast enhancement at MRI is common.
The differential diagnosis includes other primary tumors (sarcoma, giant-cell tumor,
and, rarely, ependymoma). Metastases are the most common sacral neoplasm.
Total surgical resection provides the best hope for cure. MRI has proven highly accurate
for evaluating the extent of disease. Most patients succumb to locally recurrent tumor
because chordoma is relatively radioresistant, although patients with chordoma often
survive many years after surgery. The 5-year survival in patients treated with radiation
therapy is 50%.
Figure 5.10.1 Plain-film radiography of the sacrum is nonspecific and might reveal a lytic Imaging
lesion, with obliteration of the cortex (open arrow). Findings
Figure 5.10.2 CT is useful to detect the internal calcifications (arrow) and the extent of
the destructive soft-tissue mass within the sacrum. In this case, the mass extends across the
sacral canal and the anterior neuronal foramina.
Figure 5.10.3 MRI is the best imaging technique, showing low signal intensity on sagittal
T1-weighted images and marked enhancement with a peripheral septal pattern after con-
trast administration (open arrowhead).
Figure 5.10.4 T2-weighted MRI shows a heterogeneously (due to the presence of septa)
hyperintense sacral mass with a presacral and soft-tissue component within the canal.
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Lippincott Williams and Wilkins, Philadelphia ence treatment decision for symptomatic spinal stenosis.
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MZ, Moore KR (2005). Elsevier, Philadelphia Imhof H, Fuchsjager M. Traumatic injuries: imaging of spinal
Imaging of the Musculoskeletal System. Pope TL, Bloem HL, injuries. Eur Radiol 2002; 12(6):12621272
Beltran J, Morrison W, Wilson D (2008). Saunders, Jackson RP, Cain JE Jr., Jacobs RR, Cooper BR, McManus GE. The
Philadelphia neuroradiographic diagnosis of lumbar herniated nucleus
Moes Textbook of scoliosis and other spinal deformities. Moe pulposus: II. A comparison of computed tomography (CT),
JH, Bradford DS (1995). WB Saunders, Philadelphia myelography, CT-myelography, and magnetic resonance
MR Imaging of the Spine and Spinal Cord. Uhlenbrock D (2004). imaging. Spine 1989; 14:13621367
Thieme, Stuttgart, NY Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with
emphasis on imaging. Ann Intern Med 2002; 137:586597
Jensen MC, Brant-Zawadzki MN etal. Magnetic resonance imag-
ing of the lumbar spine in people without back pain. N Engl
Web-Links J Med 1994; 331(2):6973
Keynan O, Smorgick Y et al. Spontaneous ligamentum flavum
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http://www.asnr.org/spine_nomenclature/ 687689
http://myeloma.org/main.jsp?type = article&id = 889 Koeller KK, Rosenblum RS etal. Neoplasms of the spinal cord
http://www.essr.org and filum terminale: radiologic-pathologic correlation.
http://www.serme.org/ Radiographics 2000; 20(6):17211749
Krishnan A, Shirkhoda A etal. Primary bone lymphoma: radio-
graphic-MR imaging correlation. Radiographics 2003; 23(6):
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Shoulder 6
Fernando Idoate-Saralegui, and Joan C. Vilanova
112 F. Idoate-Saralegui, and J. C. Vilanova
A 44-year-old right-hand-dominant woman presented shoulder pain and dysfunction for

Case 6.1 20 weeks. Pain started insidiously in the cervical spine 1 year previously and progressed to
the right shoulder. Pain and stiffness were aggravated by all movements of the shoulder,
Adhesive but were most severe at rest. The intensity of pain and stiffness increased over time, and
Capsulitis she complained of not being able to move her left arm and having difficulties in dressing
and washing herself. At physical examination, both active and passive ranges of motion
were severely restricted. She had no history of acute trauma, dislocation, previous shoul-
der surgery, or arthritis. No abnormalities were found at cervical MRI 2 months before.
Previous physical therapy and antiinflammatory medication failed to improve her symp-
toms. We performed shoulder MR arthrography.
Comments Adhesive capsulitis is a poorly defined entity. Codman coined the term frozen shoulder
in 1934 to describe an entity characterized by slow onset of shoulder pain, inability to
sleep on the affected arm, restriction of both active and passive elevation, and external
rotation. In 1945, Neviaser described characteristic synovial changes in the glenohumeral
joint in patients with frozen shoulder and suggested the term adhesive capsulitis.
The estimated prevalence of adhesive capsulitis is 26%; it commonly affects women
between the ages of 40 and 70 years. The pathogenesis of adhesive capsulitis is still
unknown. It may be idiopathic, or it may occur after trauma or in association with diabe-
tes mellitus or conditions such as Dupuytrens disease or heart surgery. The course of
Fig. 6.1.1 Fig. 6.1.2
Fig. 6.1.3 Fig. 6.1.4

113
Shoulder
idiopathic frozen shoulder syndrome is considered benign. Most authors state that symp-
toms resolve from 6 weeks to 10 years after presentation. Contralateral shoulder involve-
ment occurs in up to 2030% of patients.
Nevasier described the three arthroscopic stages of adhesive capsulitis, supporting the
hypothesis that the underlying pathological change is synovial inflammation with subse-
quent reactive capsular fibrosis.
The most common diagnostic criteria are clinical; these include painful stiff shoulder for
at least 4 weeks, severe shoulder pain that interferes with daily living activities or work activ-
ities, night pain, and painful restriction of both active and passive elevation to less than 100%
and of external rotation (at the side) to less than 50%. Other causes must be excluded.
Findings at plain-film radiography are usually normal, except for some decreases in
bone mineral density during acute and secondary adhesive capsulitis.
Arthrography has been the examination of choice for years and has even been proposed as a
therapeutic alternative. Decreased joint capacity, obliteration of the axillary recess, and variable
filling of the biceps tendon sheath have been considered essential for the correct diagnosis.
Conventional MRI has been proposed as a noninvasive method of evaluation. MRI may
show abnormal signal and thickness of the synovial membrane of the shoulder joint.
However, MR arthrography is more reliable for visualizing capsular thickness and locating
the anatomical region of inflammation associated with frozen shoulder, i.e., the rotator cuff
interval and the coracohumeral ligaments. In 2004, Mengiardi etal. described thickening of
the coracohumeral ligament and the capsule at the rotator cuff interval and complete oblit-
eration of the fat triangle under the coracoid process (subcoracoid triangle sign) as char-
acteristic MR arthrographic findings for frozen shoulder. MRI and MR arthrography also
make it possible to rule out other causes of shoulder pain.
Therapeutic options include physical therapy, mobilization and stretching, intraarticu-
lar corticosteroid injection, closed mobilization with anesthesia, and capsulotomy.
We performed shoulder MR arthrography, discontinuing the injection when the patient com- Imaging Findings
plained of pain and we felt a strong resistance through the syringe; we were able to inject 10mL
of 1mmol/L diluted gadopentate dimeglumine (Magnevist; Schering, Berlin, Germany).
Oblique coronal T1-weighted MR arthrogram (Fig. 6.1.1) shows considerable thickening
of the joint capsule and synovium at the axillary pouch (open arrows); note the normal
appearance of the supraspinatus tendon. Axial T1-weighted MR arthrogram (Fig.6.1.2)
shows a marked decrease in the volumes of the axillary recess and posterior joint cavity
(open arrow). The images reflect capsular retraction. Some contrast solution is seen outside
the capsule (solid arrows); extracapsular contrast solution may be secondary to capsular
rupture due to overdistension.
Sagittal (Fig. 6.1.3) and axial (Fig. 6.1.4) T1-weighted MR arthrograms show a synovitis-
like lesion of intermediate signal intensity (open arrows) located at the subcoracoid fat
triangle, obliterating the fat. The limits of the triangle are defined anterosuperiorly by the
coracoid process (arrow), superiorly by the coracohumeral ligament (open arrowhead),
and posteroinferiorly by the joint capsule (arrowhead). This obliteration of subcoracoid fat
is a characteristic sign of adhesive capsulitis.
A 30-year-old right-hand-dominant woman complained of sudden onset of severe pain

Case 6.2 and progressive weakness affecting her right shoulder and upper arm. Clinical exami-
nation revealed impaired shoulder abduction. There was some sensory disturbance
Parsonage: along her lateral arm. Acute rotator cuff tendon rupture was suspected. Plain-film radi-
Turner ography showed no subacromial calcification. Shoulder ultrasonography excluded
Syndrome rotator cuff tear and subacromial bursitis. Findings at dedicated MRI of the shoulder
were consistent with isolated involvement of the suprascapular nerve without com-
pression of the structures at the suprascapular notch, as opposed to at the supraglenoid
fossa. Electromyography found selective axonal neuropathy.
SS
IS
SE TM
Fig. 6.2.3
Fig. 6.2.1
Fig. 6.2.4
Fig. 6.2.2 Fig. 6.2.5

115
Shoulder
Parsonage-Turner syndrome (PTS), also known as acute brachial neuritis and neuralgic Comments
amyotrophy, is an uncommon clinical problem consisting of an idiopathic self-limiting
neuropathy involving the brachial plexus that causes intense acute pain and progressive
neuromuscular weakness. The exact cause of PTS is unknown. Many factors have been
proposed to cause the neuritis, including trauma, infection, viral disease, heavy exercise,
recent surgery, immunization, and autoimmune conditions.
PTS is relatively rare, with a reported incidence of 1.64 cases per 100,000. It appears to
affect males more often than females, with a peak in incidence in patients in their third and
seventh decades. There does not seem to be any relationship to hand dominance. Bilateral
involvement occurs in up to 30% of patients. The clinical presentation can be confusing,
and there is considerable overlap of the typical signs and symptoms with a broad range of
alternative diagnoses such as cervical spondylosis, rotator cuff tear, shoulder impingement
syndrome, and acute calcific tendonitis.
The classic clinical presentation is described as the sudden onset of severe shoulder pain
followed by profound weakness with no known cause. The pain subsides over a few weeks,
but weakness increases. No specific diagnostic test has been established, but a characteris-
tic pattern of muscle signal change has been reported on MRI.
The MRI findings of PTS are thought to reflect denervation injury, mainly diffuse high signal
intensity involving one or more muscles innervated by the brachial plexus depicted on
T2-weighted images. T1-weighted MR images may also show atrophy of the affected muscle(s).
The pattern of muscular involvement should match the distribution of one or more
peripheral nerves originating from the brachial plexus. Muscles innervated by the supras-
capular nerve (supraspinatus (SS) and infraspinatus (IS) muscles) are most commonly
affected, although other muscles around the shoulder may be involved.
These findings are also nonspecific and may be seen in other myopathies or compression
neuropathies. MRI allows the presence of ganglion cyst and masses or other compressive
structures at the supraglenoid notch to be excluded. These are important distinctions to
make, because treatment of PTS is conservative, whereas suprascapular nerve compression
caused by a ganglion located at this fibro-osseous tunnel warrants surgical exploration.
The diagnosis must be confirmed by electromyography showing denervation affecting
muscles innervated by brachial plexus. Recovery generally occurs over the course of a few
months but may take several years.
Sagittal T1-weighted depicts shoulder anatomy (Fig. 6.2.1). Sagittal STIR (Figs. 6.2.2 and Imaging Findings
6.2.3) images show diffusely increased signal intensity (arrows) involving the IS and SS
muscles; note the normal signal intensity of the subscapular (SE) and teres minor muscles
(TM). Neither muscle atrophy nor fatty changes are noted on T1-weighted images.
Oblique coronal T2-weighted fast spin-echo MRI (Fig. 6.2.4) shows diffuse high signal
intensity throughout the SS muscle. Axial T2-weighted GRE image (Fig. 6.2.5) shows diffuse
high signal intensity in the IS muscle (arrows). Note the absence of compressive structures
at the suprascapular notch (solid arrows in Fig. 6.2.4) and spinoglenoid notch (solid arrows
in Figs. 6.2.5). Rotator cuff tendons show no abnormalities and there are no signs of subac-
romial impingement. These MRI findings reveal what is probably neurogenic edema.
A 27-year-old left-hand-dominant male soccer player presented 7 days after an ini-

Case 6.3 tial anterior dislocation of his left shoulder successfully was reduced by the team
physician at the field. He was treated with physical therapy and NSAIDs; 3 months
Bankart Lesion later, he referred recurrent left shoulder pain and a painful popping. At physical
examination, the range of motion was normal but with great apprehension,
Fig. 6.3.1 Fig. 6.3.2
Fig. 6.3.3 Fig. 6.3.4

117
Shoulder
particularly in abduction and external rotation. He referred two other previous episodes 4
years before and provided a shoulder MRI done 2 years earlier. MR arthrography was done
to evaluate the glenoid labrum, glenohumeral capsule, and rotator cuff. Arthroscopic evalu-
ation showed an extensive detachment of the anterior, superior, and posterior labrum,
which were repaired arthroscopically.
The classic labral injury described by Bankart is a complete detachment of the anterior- Comments
inferior labrum from the glenoid associated with a rupture of the scapular periosteum,
without tear of the anterior band of glenohumeral ligament. The Bankart lesion represents
the most common form of labroligamentous injury in patients with first-time traumatic
dislocations of the shoulder. Due to the lost contact with the periosteum, the lesion shows
no tendency to heal, and commonly a Bankart lesion will lead to recurrent subluxation,
dislocation, or multidirectional instability. Surgical treatment (Bankart repair) consists of
reattachment of the labro-ligamentous complex to the glenoid, either arthroscopically or
during an open procedure. Although MRI may depict labral abnormalities, its accuracy is
low. MR arthrography typically shows a deformed anteroinferior labrum, which is com-
pletely separated from the glenoid and therefore is floating in the anterior capsular recess
adherent to the anterior band of the inferior glenohumeral ligament. In many cases, the
torn periosteum can be visualized on axial MR arthrograms.
The HillSachs lesion is a posterosuperolateral notch defect in the humeral head created
by a compression injury of the posterolateral humeral head against the anteroinferior
aspect of the glenoid rim that develops during anteroinferior dislocation. The incidence of
this lesion at arthroscopy varies considerably (from 47 to 100%) among different series of
patients with first-time traumatic dislocations. The initial defect may become larger with
repeated subluxations or dislocations. The Hill-Sachs lesion can be well seen in all routine
imaging planes and is accurately depicted on MRI. On axial sequences, it is seen on the first
three to four slices, at or above the level of the coracoid. Below this, there is a normal flat-
tening of the posterior aspect of the humeral head.
Axial fat-saturated T1-weighted GRE (Fig. 6.3.1) performed 2 years before the current Imaging Findings
injury shows an irregular focus of high signal intensity in the anterior labrum (open arrow),
interpreted as a probable labral tear. However, it was not possible to evaluate the degree of
labral attachment to the glenoid.
MR arthrography revealed severe detachment of the labrum. Axial T1-weighted SE
(Fig. 6.3.2) MR arthrogram shows contrast medium between the glenoid rim and the
detached labrum (open arrow) consistent with complete detachment of the anteroinferior
labrum (Bankart lesion) and posterior labral tear (solid arrow); oblique sagittal fat-satu-
rated T1-weighted image (Fig. 6.3.3) shows the extent of the anteroinferior labral injury
(open arrows). Coronal fat-saturated T1-weighted MR arthrogram (Fig. 6.3.4) demon-
strated a longitudinal tear posterior to the base of the attachment of the long head of the
biceps tendon (SLAP) (open arrow). A mild Hill-Sachs deformity is observed (open arrow-
heads in Figs. 6.3.2 and 6.3.4).
Case 6.4
Perthes Lesion
Fig. 6.4.1 Fig. 6.4.2
Fig. 6.4.3 Fig. 6.4.4

119
Shoulder
A 25-year-old left-hand-dominant female competitive water polo player presented right

shoulder pain since a traumatic injury 3 years earlier in a bike accident; she also referred
two later episodes of anteroinferior shoulder luxations that she reduced by herself. She
showed full active and passive range of motion and normal strength. At physical examina-
tion, the orthopedic surgeon observed pain during the apprehension test and positive Jobe
and ODriscoll tests. MR arthrography was performed to evaluate structural anomalies
associated to instability.
The Perthes lesion is a variant of the Bankart lesion, which also occurs due to anteroinfe- Comments
rior glenohumeral luxation and is associated to anterior instability. In the Perthes lesion,
first described by the German surgeon Perthes in 1905, the anteroinferior labroligamen-
tous complex is detached from the glenoid, but unlike in the Bankart injury, the scapular
periosteum remains intact and stripped medially, resulting in an incomplete avulsion of
the labrum from the glenoid margin. Therefore, unless only loosely attached, the labrum
may remain in its normal anatomic position. The integrity of the periosteum allows partial
healing of the labrum, which might also become resynovialized and may appear indistin-
guishable from a normal labrum on arthroscopic inspection.
On conventional MRI, Perthes lesions can look normal and may be impossible to dif-
ferentiate from a normal labrum. MR arthrography may reveal contrast medium extending
between the glenoid and the base of the anteroinferior labrum, indicating a loose labrum
and the loss of the stabilizing function. Nondisplaced Perthes lesions can also be difficult
to detect at MR arthrography because scar tissue can prevent contrast material from enter-
ing the labral tear. Additional imaging with the arm in abduction and external rotation
(ABER position) can at times help to visualize nondisplaced Perthes lesions by separating
the base of the anteroinferior labrum from the glenoid and allowing the contrast media to
enter. In the case presented, although the tear is still demarcated by contrast media in the
ABER position, it is more conspicuous on the conventional axial section.
Therefore, the surgeon should be aware of MRI findings that indicate the possibility of a
Perthes lesion, because they may alter treatment planning.
Oblique sagittal T1-weighted MR arthrogram (Fig. 6.4.1) shows a labral tear that involves the Imaging Findings
anterior labrum (open arrows). Axial fat-suppressed T1-weighted MR arthrogram (Fig. 6.4.2)
depicts detachment and slight displacement of the anterior labrum from the glenoid (open
arrow); the labrum remains attached to the intact scapular periosteum (arrow). These find-
ings are consistent with a Perthes lesion. Axial T1-weighted spin-echo MR arthrogram
located inferior to the previous image (Fig. 6.4.3) shows a thin line of increased signal inten-
sity (open arrow) under the attachment of the anterior labrum to the bony glenoid, consis-
tent with a nondisplaced labral tear. Note the prominent Hill-Sachs defect (arrows).
T1-weighted spin-echo MR arthrogram with fat saturation obtained in the ABER position
(Fig. 6.4.4) shows partial detachment of the anterior labrum from the glenoid. Note the
increased signal (open arrow) at the labral insertion to the glenoid.
Case 6.5
Alpsa + HillSachs Lesion
Fig. 6.5.2
Fig. 6.5.1
Fig. 6.5.4
Fig. 6.5.3
Fig. 6.5.6
Fig. 6.5.5 Fig. 6.5.7

121
Shoulder
A 27-year-old left-hand-dominant male amateur handball player had his left shoulder dis-
located by downward traction. When reduction on the field was unsuccessful, plain-film
radiographs were acquired and the shoulder was reduced under conscious sedation. Seven
days later, MRI to evaluate the capsulolabral complex showed hemarthros and anteroinfe-
rior labral tear. He declined to undergo surgery and opted for conservative therapy. Six
months later, he suffered an anteroinferior reluxation of the shoulder. MR arthrography
was performed to reevaluate the labrum.
ALPSA (anterior labroligamentous periosteal sleeve avulsion) lesion is an avulsion of the Comments
anteroinferior labrum from the glenoid with periosteal stripping, which leads to medial
displacement and inferior rotation of the labroligamentous complex together with the
intact periosteum in a sleeve-like fashion, thereby causing incompetence of the inferior
glenohumeral ligament and anterior instability. As a result, the labrum is displaced medi-
ally near the scapular neck. ALPSA lesions were described by Neviaser as a variant of the
Bankart lesion. In chronic ALPSA, the lesion may heal and resynovialize in this abnormal
position and be covered by fibrous tissue formation and adjacent synovial proliferation.
This may produce a pseudo-normal anterior labrum, which can be missed at arthroscopy.
ALPSA is more common in patients with recurrent traumatic dislocations of the shoul-
der than with first-time dislocations.
MR arthrography shows the medial and inferior displacement of the deformed labroliga-
mentous complex; this is best seen on axial and coronal oblique images. The glenoid edge
typically lacks a normal labrum; contrast medium often outlines a crease or cleft between
the glenoid and the nodular-shaped fibrous tissue located medially on the glenoid neck.
Transformation of the ALPSA lesion into a Bankart lesion by dissection of the complex
from the glenoid followed by anatomic refixation (Bankart repair) is the treatment of
choice. ALPSA lesion is often associated to HillSachs defects.
The initial radiologic evaluation (Fig. 6.5.1) shows an anteroinferior luxation of the humeral Imaging Findings
head; the humeral head (open arrow) is not in the glenoid fossa (solid arrow).
Axial T2-weighted (Fig. 6.5.2) and sagittal T1-weighted (Fig. 6.5.3) GRE images show
hemorrhagic articular distension (note the isointense SI of articular fluid in the
T1-weighted image). Sagittal image shows the absence of labrum at the anterior glenoid
(arrow in Fig. 6.5.3); the anterior labrum is medially displaced (arrow in Fig. 6.5.2). These
findings were consistent with labral disruption and possible ALPSA lesion.
MR arthrography was performed after relaxation of the shoulder. Axial T1-weighted MR
arthrogram (Fig. 6.5.4) shows the anterior-inferior labrum partly avulsed from the glenoid
and located medial to the glenoid (open arrows); it remains attached to an intact scapular
periosteum. Oblique coronal MR arthrogram (Fig. 6.5.5) shows inferior displacement of
the labroligamentous complex (open arrow). A HillSachs fracture with subjacent bone
sclerosis and marrow edema in the posterolateral humeral head is demonstrated (open
arrowheads at Figs. 6.5.6 and 6.5.7).
An elite male rugby player with a previous history of shoulder injuries

Case 6.6 (two clinically reported anteroinferior subluxations) and no complete
shoulder dislocations reported a resubluxation (he fell onto his out-
Glad Lesion and Calcified stretched arm with the ball underneath his forearm and a player
Loose Body landed on top of his shoulder). The athlete described global and per-
sistent shoulder pain without relief of symptoms after physiotherapy.
Fig. 6.6.1 Fig. 6.6.2
Fig. 6.6.3 Fig. 6.6.4

123
Shoulder
Physical examination showed a marked reduction in the range of movement of the affected
shoulder, mainly due to pain, and some impingement but no shoulder instability. A supe-
rior labral anterior-to-posterior tear (SLAP) was initially suspected and shoulder MR
arthrography showed a nondisplaced superficial tear of the anteroinferior labrum adjacent
to an area of articular cartilage erosion. After the MR arthrogram, a shoulder CT was
performed.
The GLAD (glenolabral articular disruption) lesion as described by Neviaser is a superfi- Comments
cial tear of the anteroinferior labrum that is held in place by an intact periosteum, in com-
bination with an articular cartilage lesion (fibrillation and erosion) of the anterior inferior
quadrant of the glenoid. The injury is thought to result from impaction of the humeral
head onto the glenoid caused by forced adduction injury to the shoulder with the arm in
abduction and external rotation.
The labral component of the abnormality typically represents an inferior-based flap tear
without evidence of capsuloperiosteal stripping; it is important to note that the anterior
labroligamentous structures and the periosteum remain intact, so there is no displacement
of the labrum and usually no anterior instability.
The degree of articular cartilage damage is variable and ranges from softening and
fibrillation to deep surface defects. When a GLAD lesion is seen at MRI, loose bodies should
be sought and should not be misinterpreted as air bubbles (which appear at nondependent
locations).
MRA allows the labral flap tear to be seen by distending the joint and filling it with con-
trast material. The chondral defect also allows the integrity of the anteroinferior paralabral
periosteum and IGHL to be evaluated.
In a patient with a typical injury and no signs of instability, the GLAD lesion should be
considered the cause of persistent pain.
Identification of the lesion facilitates appropriate treatment, usually arthroscopic debri-
dement of the labrum and adjacent chondral injury.
Fat-saturated T1-weighted GRE arthrogram (Fig. 6.6.1) reveals a nondisplaced labral tear; Imaging Findings
high signal gadolinium is tracked into the labrum (open arrow) showing a full-thickness
defect of the adjacent glenoid cartilage (solid arrow). Axial T1-weighted SE MR arthrogram
(Fig. 6.6.2) slightly caudal to Fig. 6.6.1 shows a full-thickness chondral defect of the anterior
glenoid associated to subchondral sclerosis (open arrow). These findings correspond to a
GLAD lesion.
Fat-saturated T1-weighted GRE arthrogram (Fig. 6.6.3) shows a rounded intraarticular
low signal intensity structure located in dependent regions of the anterior articular space
near the glenoid insertion of the capsule, consistent with a loose body (open arrow).
Inadvertently injected air bubbles are visualized in nondependent regions (solid arrow);
note the blooming artifact, characteristic of air on GRE images. Corresponding shoulder
CT (Fig. 6.6.4) confirms the presence of calcified loose bodies (open arrow) adjacent to the
coracoid process (solid arrow).
A 21-year-old professional soccer goalkeeper presented with nonspecific shoulder pain

Case 6.7 that was particularly intense with overhead motions. He also complained of popping, click-
ing, and catching sensations, some weakness, and some pain on throwing. The patient
Slap Lesion referred a fall onto his outstretched arm with the shoulder in abduction during a match. He
had undergone physiotherapy without improvement.
On clinical examination, he had a full range of active and passive movements, but he
referred pain in full abduction. Cuff examination was normal. The palm-up test was positive
but he had no pain on palpation of the long head of the biceps tendon. Findings at examina-
tion of the acromioclavicular joint were normal. MR arthrography was performed.
Comments SLAP tears, first described in 1990 by Snyder, are an abnormality of the superior labrum
usually centered on the attachment of the long head of the biceps tendon. SLAP lesions
occur at and posterior to the bicipital long head insertion into the superior labrum and
Fig. 6.7.1 Fig. 6.7.2
Fig. 6.7.3 Fig. 6.7.4

125
Shoulder
usually affect athletes. Repetitive overhead motion or falling on an outstretched arm is the
most frequent mechanism of injury. Recently, a study in cadavers confirmed the peel-back
theory of SLAP lesions; in the abducted and externally rotated shoulder, the biceps tendon
assumes a more vertical and posteriorly directed orientation, which transmits a force to
the superior labrum, causing it to peel off the glenoid.
The clinical diagnosis of a SLAP lesion is difficult. Nonspecific shoulder pain, particu-
larly with overhead or cross-body motion, is the most common clinical presentation.
Several examinations can be performed, including the anterior slide test, the OBrien test,
the Crank test, and the Speed test, although their accuracy is limited. SLAP lesions can lead
to shoulder instability or be consequence of it.
Imaging plays a key role in the diagnosis. MR arthrography has proven superior to con-
ventional MRI at identifying SLAP lesions; MR arthrography is reliable in assessing the
stability of the biceps anchor and detecting associated injuries. Distending the gle-
nohumeral joint outlines the intraarticular and synovial surfaces and shows leakage of
contrast through the labral tears, making the pathology more conspicuous and depicting
the superior labrum and its relationship with the long head of the biceps tendon attach-
ment to the glenoid.
Four different types of SLAP lesions were described in Snyders original classification:
Type I is degenerative fraying of the superior labrum with no instability of tendon; Type II
is avulsion of the superior labrum and biceps anchor from the glenoid, causing an instable
anchor; Type III is a bucket-handle tear of the superior labrum with preserved biceps
anchor; and Type IV is similar to type III with extension of the tear into the long head of
the biceps tendon.
Several additional types of lesions have been described; these mainly represent combina-
tions of the most common forms: the type II SLAP lesion with other injuries of the labrum,
medial glenohumeral ligament, or rotator cuff. In practical terms, a description of the extent
of the abnormality is sufficient, and the original Snyder classification is widely accepted.
One of the major challenges of MR arthrography is the differentiation of SLAP lesions
from capsulolabral anatomic variants such as sublabral recess and sublabral foramen.
Numerous concurrent pathologies may be seen in association with SLAP lesions; these
include tears of the glenohumeral ligaments, partial tears of the rotator cuff, Hill-Sachs
defects, Bankart lesions, chondral loose bodies, and paralabral cysts.
Oblique coronal T1-weighted MR arthrograms (Figs. 6.7.1 and 6.7.2) show high signals through- Imaging Findings
out the superior labrum, extending anteriorly and posteriorly due to a tear (open arrows).
The tear has a vertical and an additional horizontal contrast interface, which separate
the avulsed superior labrum as a triangular-shaped fragment from the intact biceps ten-
don; these findings are consistent with a type III SLAP tear (bucket-handle tear). Most
SLAP lesions are best depicted on MR arthrograms oriented in the oblique coronal plane.
Oblique sagittal (Fig. 6.7.3) and axial (Fig. 6.7.4) planes show extensively high signals
throughout the superior labrum, extending anteriorly and posteriorly (arrowheads) to the
biceps anchor (solid arrow).
A 35-year-old male amateur tennis player complained of pain localized in the pos-
Case 6.8 terior aspect of the right shoulder of 3 years evolution. The patient also referred
shoulder fatigue and clicking with activity, and these symptoms increased during
Posterior Labral the previous year. No pervious history of traumatic shoulder dislocation was
Tear + Paraglenoid referred. At physical examination, external rotation of the arm was significantly
Labral Cyst limited, while flexion and internal rotation were remarkably normal. Pain and sense
of instability were elicited when the arm was held in the position of forward flexion,
Fig. 6.8.1 Fig. 6.8.2
Fig. 6.8.3 Fig. 6.8.4

127
Shoulder
adduction, and internal rotation. The posterior drawer/relocation test showed posterior
translation of the humeral head onto the glenolabral rim (clunking without locking).
Preliminary X-rays were normal. MR arthrography was done.
Posterior instability is less frequent than anterior instability, accounting for only 25% of Comments
all cases of shoulder instability patterns. Its etiology is generally threefold, consisting of a
major injury, a repetitive minor trauma, and a virtually atraumatic process. Common
causes of posterior instability include traumatic posterior dislocation (usually during vio-
lent muscle contraction resulting from seizures or electrical shock), a redundant posterior
capsule, and microinstability associated with overhead arm sports involving abduction,
flexion, and internal rotation (weightlifters, baseball pitchers, racket sport athletes, foot-
ballers, and swimmers).The lesions associated with posterior instability can be identified
in detail with MRI, particularly MR arthrography, allowing proper treatment planning.
Findings at MR arthrography include an excessively retroverted or hypoplastic glenoid,
a detached posterior capsule, posterior labral tear, and reverse Hill-Sachs lesion. Similar to
anterior labral tears, posterior tears at MR arthrography are seen as fluid extending into
the substance of the labrum.
Paralabral cysts are associated with glenoid labral tear; a paralabral cyst is diagnosed
when MRI shows a well-defined focal fluid collection within 1cm of the glenoid labrum.
The mechanism involved in paralabral cyst formation is similar to that of meniscal cyst
formation, with extrusion of joint fluid through labrocapsular tears into adjacent tissue
planes. Extraarticular extension of a labral cyst into the spinoglenoid notch or suprascapu-
lar notch can produce suprascapular nerve entrapment, which is a cause of shoulder pain
that can be evaluated with MRI. Paralabral cysts may be difficult to identify on MR arthrog-
raphy unless a T2-weighted sequence is performed. Cyst aspiration may result in tempo-
rary relief of symptoms, but an untreated labral tear should be suspected if cysts recur.
Axial T1-weighted MR arthrogram (Fig. 6.8.1) shows a posterior labral tear (open arrow); Imaging Findings
note the normal shape and signal intensity of the anterior labrum (solid arrow). A round
structure of intermediate signal intensity is seen at the spinoglenoid notch (arrowheads)
adjacent to the posterior labrum; this structure is also visualized on the coronal fat-
saturated T1-weighted MR arthrogram (arrows in Fig. 6.8.2); it is not filled with gadolinium
contrast material.
After the usual arthrographic T1-weighted sequences, oblique coronal T2-weighted
(Fig. 6.8.3) and sagittal STIR (Fig. 6.8.4) sequences performed to evaluate the posterior
paralabral mass demonstrate the cystic characteristic of the mass (high signal intensity
content) and enable the diagnosis of paralabral cyst. The cyst is located between the supras-
capular and spinoglenoid notches near the 9 oclock position of the posterior labrum
(arrowheads), but no indirect signs of neural compression are seen (normal signal inten-
sity of deltoid and rotator cuff muscles on STIR images).
A 15-year-old girl, a competitive kayaker, presented with recurrent bilateral shoulder

Case 6.9 pain, which was more intense in the right shoulder, where she referred a painful pop-
ping sensation. The patient had no history of acute trauma or dislocation but noted
Ambrii + Bilateral exacerbation of symptoms (mainly pain) while kayaking. Physiotherapy had failed to
Labral Tears improve her symptoms. Pain disappeared after she stopped kayaking, but recurred
after she started again. On physical examination of the right shoulder, no atrophy or
tenderness to palpation was noted. She had markedly laxity in both shoulders with a
positive sulcus sign in both shoulders. The patient had full active and passive range
of motion. Cuff examination was normal. Biceps signs were negative. Findings at
examination of the acromioclavicular joint were normal. Apprehension test was pos-
itive. MR arthrogram showed an anterior labral tear and a voluminous glenohumeral
capsule. One year later, an MR arthrogram of the left shoulder for exacerbation of
pain during training showed findings equivalent to the contralateral side.
Fig. 6.9.2
Fig. 6.9.1
Fig. 6.9.3 Fig. 6.9.4

129
Shoulder
The term instability constitutes a spectrum of disorders, which includes hyperlaxity, sub- Comments
luxation, and dislocation. Instability of the shoulder is defined as abnormal or symptom-
atic motion, usually translocation of the humeral head with respect to the glenoid. Laxity,
however, describes the passive motion characteristics of the joint. Shoulder instabilities
can be divided into traumatic (TUBS from traumatic, unidirectional, bankart lesion, sur-
gery), atraumatic glenohumeral instability (AMBRII from atraumatic multidirectional,
bilateral, rehabilitation, inferior capsular shift, interval closure), and microtraumatic gle-
nohumeral instabilities. Congenital or acquired hyperlaxity, microinstability, and trau-
matic instability can overlap, particularly in athletes engaged in overhead sports. Atraumatic
glenohumeral instability is typically multidirectional and usually evident in individuals
with congenital hypermobility syndrome. This instability permits abnormal motion in two
or three planes, generally, anterior-inferior and posterior-inferior. The incidence of multi-
directional instability peaks in the second and third decades of life, and most patients are
younger than 35 years old. On clinical examination, these athletes exhibit bilateral, sym-
metric increases in shoulder laxity in association with generalized hyperlaxity of ligaments
and joints. The increased baseline level of laxity can be advantageous for several types of
sports, but also harbors a high risk of long-term injury with damage to intra- and periar-
ticular structures.
The two anatomic lesions associated with multidirectional instability are deficiency of
the rotator interval and a redundant inferior capsular pouch. A voluminous inferior capsu-
lar pouch can lead to instability in all three directions. MR arthrographys ability to distend
the glenohumeral joint and its improved soft-tissue contrast makes it the procedure of
choice to evaluate the capsular volume, labroligamentous complex, and articular surface of
the rotator cuff.
In most nonathletic AMBRII patients, MR arthrography shows increased capsular vol-
ume; in symptomatic athletes, laxity of the capsule is frequently associated with secondary
damage to the labrum (which may be hypoplastic or torn, but can also appear swollen and
show increased signal intensity due to more or less extensive degenerative change), the
rotator cuff, the labrum, and the biceps anchor.
MR arthrography can help with therapeutic decisions by identifying or ruling out signifi-
cant intraarticular pathology that might represent an indication for surgical repair in addi-
tion to capsular reduction. If conservative management fails, multidirectional instability is
usually treated surgically by inferior capsular shift and closure of the rotator interval.
Postarthrogram sagittal (Fig. 6.9.1) and axial (Fig. 6.9.2) T1-weighted images of the right Radiological
shoulder show capsular laxity. There is a patulous anterior, inferior, and posterior joint Findings
capsule distended by the intraarticular contrast (open arrows); note the prominent capsule
at the rotator interval (solid arrow). A small labral tear is shown (open arrowhead).
MR arthrogram of the left shoulder 1 year later shows a voluminous anterior, posterior,
and inferior capsular pouch attached to the capsule medially (arrows in Fig. 6.9.3). Axial
(Fig. 6.9.3) and sagittal (Fig. 6.9.4) MR images show an anterior labral tear extending from
2 oclock to 4 oclock (arrowheads). These findings are consistent with atraumatic gle-
nohumeral instability associated to bilateral labral tears.
Case 6.10
Posterosuperior Impingement (Throwing Shoulder + GIRD)
Fig. 6.10.1
Fig. 6.10.2
Fig. 6.10.4
Fig. 6.10.3
Fig. 6.10.5 Fig. 6.10.6

131
Shoulder
A 24-year-old right-hand-dominant elite professional handball player was referred for pain
in his right shoulder. After his shoulder was caught down by a defender, he experienced
severe pain during throwing.
He referred mild chronic shoulder pain prior to the episode when throwing (mainly late
cocking-acceleration phase) and a progressive decrease in throwing velocity over the previ-
ous 4 months. At clinical examination, he had almost full range of active and passive move-
ment, with pain at 160 flexion and abduction. The Jobe test was positive. The palm-up test
was also positive. Positive posterior translation was found. The Napoleon sign and lift-off
test were negative. The acromioclavicular joint was normal.
Shoulder ultrasound, MRI, and MR arthrography were performed.
Internal shoulder impingement syndromes result from the impingement of the soft tissues Comments
of the rotator cuff and joint capsule between the glenoid and the humerus. Posterosuperior
glenoid impingement (PSI) was first described in 1993 by Walch etal in normal shoulders
in the ABER (abduction external rotation) position when the posterosuperior rotator cuff
comes into contact with the posterosuperior labrum. This shoulder entrapment may
become pathologic in throwers and overhead athletes, such as baseball pitchers, tennis
players, swimmers, javelin throwers, and handball players, in whom it usually affects the
dominant shoulder. Posterosuperior impingement presents with acute or chronic posterior
shoulder pain. It is thought to result from repetitive microtrauma during the late cocking
and acceleration phases of the throw. A typical pattern of injuries develops (the so-called
kissing lesions), which includes corresponding lesions of the undersurface of the rotator
cuff, the posterosuperior labrum, the greater tuberosity, and the superior bony glenoid.
Two etiologic theories have been postulated to explain this syndrome. Jobe etal postulated
that chronic microtrauma of the anterior capsule (repetitive stretching) can provoke ante-
rior microinstability, which causes anterior subluxation of the humeral head in abduction
and external rotation during overhead movements and thus allows excessive contact
between the rotator cuff and the posterosuperior glenoid. Burkhart and Morgan first devel-
oped a model of posterior-inferior capsule contracture, which changes the glenohumeral
contact point in the late cocking position and leads to progressive stretching of the anterior
capsule. These changes intensify what would otherwise be gentle pinching of the labrum,
cuff, and joint capsule between the greater tuberosity and glenoid rim, as well as cause
twisting shear stress tears of the posterior cuff and labrum. The evidence for this second
theory is that many athletes with pathologic internal impingement have a clinically signifi-
cant glenohumeral internal rotation deficit (GIRD) compared with the contralateral shoul-
der, presumably due to a tight posterior-inferior capsule.
Although ultrasonography can depict rotator cuff tears, MRI, and especially MR arthrog-
raphy are the techniquesof choice to depict intraarticular injuries to guide therapeutic deci-
sions. MRI findings of posterior impingement in the throwing shoulder reflect the structural
abnormalities after microtraumatic glenohumeral instability; these changes are best
depicted by MR arthrography and include cortical irregularities, sclerosis and subchondral
cyst formation in the posterior humeral head, laxity of the anterior capsule, labral injuries
ranging from degeneration and fraying to tearing and detachment, SLAP (superior labral
anterior to posterior) lesions, and articular surface tears of the rotator cuff. Unlike in patients
with subacromial impingement, the supraspinatus lesion usually involves the posterior
part of the tendon.
Conservative treatment is usually called for in athletes with minor structural abnor-
malities, whereas surgical debridement and repair (eventually in combination with capsu-
lar plication) are indicated in the presence of relevant rotator cuff and labral lesions.
Imaging Findings Coronal ultrasound scan (Fig. 6.10.1) of the supraspinatus shows an intrasubstance focus of
hypoechogenicity (fiber defect) consistent with partial tear (open arrows) affecting the mid-
dle and articular thirds of the tendon. Coronal T2-weighted image (Fig. 6.10.2) shows subac-
romial-subdeltoid bursal thickening and fluid; the preinsertional fibers of the posterior
supraspinatus tendon show a linear hyperintensity on the articular side of the tendon, sug-
gesting a partial tear (rim rent tear) (open arrow).
Oblique coronal T1-weighted MR arthrogram (Fig. 6.10.3) shows a tear in the articular sur-
face and contrast accumulation in the undersurface of the substance of the tendon (open arrow);
the arthrogram shows extension of the intraarticular gadolinium to the subacromial-subdel-
toid bursa, consistent with complete tear; axial projection demonstrated a small gap consis-
tent with a full-thickness supraspinatus tendon tear (open arrow in Fig. 6.10.4). A SLAP lesion
with involvement of anterior labrum is also shown (solid arrows in Figs. 6.10.4 and 6.10.5).
There are cortical irregularities in the posterior corner of the humeral head (open arrowheads
in Fig. 6.10.6). Note the prominent axillary and anterior recesses of the glenohumeral capsule
(solid arrowheads) in contrast to the thickened posterior capsule at the posterior capsular labral
junction (open arrow at Fig. 6.10.6), which are associated with GIRD.
133
Shoulder
Further Reading Grainger AJ. Internal impingement syndromes of the shoulder.

Semin Musculoskelet Radiol 2008; 12(2):127135
Harish S, Nagar A, Moro J, Pugh D, Rebello R, ONeill J. Imaging
Books findings in posterior instability of the shoulder. Skeletal
Imaging of the Shoulder; Techniques and Applications. 1 ed. Radiol 2008; 37(8):693707
Baert AL (2006). Springer, Berlin Hodler J. Technical errors in MR arthrography. Skeletal Radiol
Internal Derangements of Joint. 2 ed. Resnick D (2007). Saunders, 2008; 37(1):918
Philadelphia Jost B, Gerber C. What the shoulder surgeon would like to know
Magnetic Resonance Imaging in Orthopedics and Sports from MR imaging. Magn Reson Imaging Clin N Am. 2004;
Medicine. 3 ed. Stoller DW (2007). Lippincott Williams & 12(1):161168
Wilkinson, Philadelphia Mengiardi B, Pfirrmann CW, Gerber C, Hodler J, Zanetti M.
Magnetic Resonance Imaging in Orthopedic Sports Medicine. Frozen shoulder: MR arthrographic findings. Radiology
1ed. Pedowitz R, Chung CB, Resnick D (2008). Springer, Berlin 2004; 233(2):486492
The shoulder. 4 ed. Rockwood C (2009). Saunders, Philadelphia Moosikasuwan JB, Miller TT, Burke B. Rotator cuff tears: clinical,
radiographic, and US findings. Radiographics 2005; 25(6):
15911607
Web-Links Moosikasuwan JB, Miller TT, Dines DM. Imaging of the painful
shoulder in throwing athletes. Clin Sports Med 2006;
http://www.wheelessonline.com/ 25(3):433443
http://www.radiolopolis.com/ Ouellette H, Kassarjian A, Ttreault P, Palmer W. Imaging of the
http://chorus.rad.mcw.edu/ overhead throwing athlete. Semin Musculoskelet Radiol
http://www.secec.org/ 2005; 9(4):316333
http://www.jshoulderelbow.org/ Robinson G, Ho Y, Finlay K, Friedman L, Harish S. Normal anat-
omy and common labral lesions at MR arthrography of the
shoulder. Clin Radiol 2006; 61(10):805821
Articles Rudez J, Zanetti M. Normal anatomy, variants and pitfalls on
shoulder MRI. Eur J Radiol 2008; 68(1):2535
Armfield DR, Stickle RL, Robertson DD, Towers JD, Debski RE. Sahin G, Demirta M An overview of MR arthrography with
Biomechanical basis of common shoulder problems. Semin emphasis on the current technique and applicational hints
Musculoskelet Radiol 2003; 7(1):518 and tips. Eur J Radiol 2006; 58(3):416430
Carroll KW, Helms CA. Magnetic resonance imaging of the Sanders TG, Tirman PF, Linares R, Feller JF, Richardson R. The
shoulder: a review of potential sources of diagnostic errors. glenolabral articular disruption lesion: MR arthrography
Skeletal Radiol 2002; 31(7):373383 with arthroscopic correlation. AJR Am J Roentgenol 1999;
Chang D, Mohana-Borges A, Borso M, Chung CB. SLAP lesions: 172(1):171175
anatomy, clinical presentation, MR imaging diagnosis and Tuite MJ, Petersen BD, Wise SM, Fine JP, Kaplan LD, Orwin JF.
characterization. Eur J Radiol 2008; 68(1):7287 Shoulder MR arthrography of the posterior labrocapsular
Chung CB, Corrente L, Resnick D. MR arthrography of the shoul- complex in overhead throwers with pathologic internal
der. Magn Reson Imaging Clin N Am. 2004; 12(1):2538 impingement and internal rotation deficit. Skeletal Radiol
Connell D, Padmanabhan R, Buchbinder R. Adhesive capsulitis: 2007;36(6):495502
role of MR imaging in differential diagnosis. Eur Radiol 2002; Vanderbeck J, Fenlin J. Shoulder: what the orthopaedic doctor
12(8):21002106 needs to know. Semin Musculoskelet Radiol 2007; 11(1):
De Maeseneer M, Van Roy P, Shahabpour M. Normal MR imag- 5765
ing anatomy of the rotator cuff tendons, glenoid fossa, Waldt S, Burkart A, Imhoff AB, Bruegel M, Rummeny EJ,
labrum, and ligaments of the shoulder. Magn Reson Imaging Woertler K. Anterior shoulder instability: accuracy of MR
Clin N Am 2004; 12(1):110 arthrography in the classification of anteroinferior labroliga-
Elsayes KM, Shariff A, Staveteig PT, Mukundan G, Khosla A, mentous injuries. Radiology 2005; 237(2):578583
Rubin DA. Value of magnetic resonance imaging for muscle Wischer TK, Bredella MA, Genant HK, Stoller DW, Bost FW,
denervation syndromes of the shoulder girdle. J Comput Tirman PF. Perthes lesion (a variant of the Bankart lesion):
Assist Tomogr 2005; 29(3):326329 MR imaging and MR arthrographic findings with surgical
Gaskin CM, Helms CA. Parsonage-Turner syndrome: MR imag- correlation. AJR Am J Roentgenol 2002; 178(1):233237
ing findings and clinical information of 27 patients. Radiology Woertler K, Waldt S. MR imaging in sports-related glenohumeral
2006; 240(2):501507 instability. Eur Radiol 2006; 16(12):26222636
Elbow, Hand, and Wrist 7
Juan de Dios Bern, Ana Canga, and Luis Cerezal
136 J. De Dios Bern, A. Canga, and L. Cerezal
A 34-year-old male manual worker presented with chronic wrist pain that had increased over
Case 7.1 the last 6 months. He had a history of a fall on an outstretched hand more than 10 years ago.
An MRI performed without prior radiographic study showed a complete rupture of the sca-
Slac Wrist pholunate interosseous ligament, the dorsal intercalated segment instability (DISI) pattern of
wrist instability, extensive radioscaphoid chondral denudation, and marked bone remodeling
of the distal radius. Additionally, a type 2 lunate of Viegas (presence of a facet joint between
the hamate and lunate), with advanced chondromalacia in the proximal pole of the hamate
bone, and a small central rupture of the triangular fibrocartilage (Palmer class 1A lesion)
were observed. Scaphoid resection and carpal arthrodesis resulted in complete pain relief and
good functional result.
Fig. 7.1.1
>10
Fig. 7.1.2
Fig. 7.1.3 Fig. 7.1.4

137
Elbow, Hand, and Wrist
Scapholunate advanced collapse (SLAC) of the wrist refers to a specific pattern of osteoar- Comments
thritis and subluxation secondary to scaphoid or scapholunate ligament injury with col-
lapse on the radial side of the wrist. SLAC of the wrist is the most common pattern of
degenerative arthritis in the wrist. It is more common in men than in women and typically
affects manual workers in their dominant wrist.
SLAC wrist pattern is the result of many radial-sided wrist entities. The most frequent
cause of SLAC is untreated chronic scapholunate dissociation. Scaphoid nonunion advanced
collapse (SNAC) is another common cause. Other etiologies include Preisers disease (idio-
pathic avascular necrosis of the scaphoid), midcarpal instability, intraarticular fractures
involving the radioscaphoid or capitate-lunate joints, Kienbck disease, capitolunate
degeneration, and inflammatory arthritis, such as seen in the crystalline deposition disor-
ders of gout and calcium pyrophosphate dihydrate deposition disease (CPPD).
SLAC degeneration follows a specific pattern, starting with narrowing of the radiosca-
phoid joint at the radial styloid aspect (stage 1A), which on radiographs appears as a sharp
elongation of the radial styloid. As the disease progresses, the entire scaphoid fossa is
involved (stage 1B). Complete collapse of the radioscaphoid joint changes the normal load-
bearing ability of the midcarpal capitolunate joint. Shear stress destroys cartilage in the
capitolunate joint and produces joint narrowing and sclerotic changes (stage 2).
Characteristically, the radiolunate joint is preserved at all stages of SLAC wrist.
Long-standing and untreated SLAC wrist might lead to chronic wrist pain, deterioration of
range of motion, and decreased grip strength. Direct palpation of the scapholunate joint or
radiocarpal joint generally elicits pain. Pain with resistance against active finger extension,
while the wrist is held in passive flexion, is common. The scaphoid shift test also elicits pain.
Differential clinical diagnoses of SLAC wrist arthritis include essentially any condition
that causes dorsal radial wrist pain, including scaphoid fractures, de Quervain tenosynovi-
tis, scapholunate dissociation, Kienbck disease, distal radial fracture, Preisers disease,
and scaphotrapezoid-trapezial joint arthritis.
Asymptomatic and mild symptomatic SLAC can often be managed with conservative
treatment. When the condition becomes more symptomatic, surgery is recommended. In
stage 1 SLAC, where the capitolunate joint is spared, proximal row carpectomy preserves
partial wrist motion. In stage 2 SLAC, total wrist fusion often is more effective at relieving
wrist pain.
Axial fat-suppressed T2-weighted MRI (Fig. 7.1.1) shows a complete rupture of the scaphol- Imaging
unate ligament, involving both dorsal (open arrow) and volar (solid arrow) components. Findings
Sagittal T1-weighted MRI (Fig. 7.1.2) shows an increase in the capitolunate angle with
lunate dorsiflexion (dorsal intercalated segment instability DISI deformity).
Coronal fat-suppressed T1- and T2-weighted MRI (Figs. 7.1.3 and 7.1.4) reveal chronic
rupture of the scapholunate ligament (open arrow) with osseous misalignment and diffuse
degenerative changes in the radioscaphoid joint and capitolunate joint (stage 2 SLAC), with
chondral denudation, subchondral sclerosis, and marked focal remodeling of the distal
radius scaphoid fossa. Note the existence of a type 2 lunate of Viegas and degenerative
changes in the hamatolunate joint (hamatolunate impaction syndrome) (solid arrow).
A 32-year-old man with a history of a fall on his right wrist while playing soccer 5 years before,
Case 7.2 diagnosed with wrist sprain without radiographs, presented with pain and swelling in the ana-
tomical snuff box and restriction of mobility by pain after a recent minor injury acquired while
Scaphoid practicing karate. Radiographs showed scaphoid nonunion with a sclerotic proximal fragment;
Avascular gadolinium-enhanced MRI showed nonenhancement of the proximal pole related to necrosis of
Necrosis the proximal fragment. At surgery, the complete absence of bleeding points confirmed necrosis of
the proximal fragment, so vascularized bone grafting was performed. Two years after surgery, the
patient remains free of pain and has the full range of motion in his wrist.
Fig. 7.2.2
Fig. 7.2.1
Fig. 7.2.3 Fig. 7.2.4

139
The scaphoid is the most commonly fractured bone of the carpus. Scaphoid fracture usu- Comments
ally results from a fall on a dorsiflexed hand in young active individuals. Wrist disability is
a relatively common problem after scaphoid fractures because of the frequency of compli-
cations such as delayed union, nonunion, avascular necrosis, deformity or carpal instabil-
ity, and secondary osteoarthritis. The significant number of scaphoid fracture complications
can be attributed to the peculiar vascular anatomy of this bone, with precarious blood sup-
ply, especially to the proximal pole, which makes it vulnerable to posttraumatic ischemia
and avascular necrosis. The scaphoid bone receives its blood supply mainly from the radial
artery, with the dorsal and volar branches entering through the distal portion of the bone.
The presence of avascular necrosis of the proximal fragment is the main prognostic fac-
tor for outcome after the surgical treatment of scaphoid nonunion. Unfortunately, avascular
necrosis has been difficult to diagnose accurately. Physical examination reveals tenderness
in the anatomic snuffbox, decreased range of motion, swelling, and pain with dorsiflexion.
Sclerotic changes in the proximal fragment on conventional radiographs and CT scans cor-
relate poorly with vascular state. Bone scintigraphy is sensitive and can reveal early avascu-
lar necrosis, but has a low specificity because areas of minor damage or synovitis may give
a positive result; furthermore, the spatial resolution of bone scintigrams is low.
Gross inspection of the bone surface during surgery and the presence of punctate bleed-
ing points are usually the most important tests for surgeons assessing the vascular state of
the proximal pole in scaphoid nonunion. Signal intensity on conventional MRI is frequently
patchy and variable on T1- and T2-weighted sequences in both necrotic and viable bone.
Unenhanced MRI does not allow the degree of ischemia or viability of the proximal frag-
ment to be reliably determined. Gadolinium-enhanced MRI is useful to accurately assess
the vascular status of the proximal pole in scaphoid nonunions: gadolinium enhancement
represents viable bone and the absence of enhancement indicates necrosis.
The treatment of scaphoid nonunion with viable proximal pole is bone grafting and
internal fixation. Vascularized bone grafting is the recommended therapeutic option in
cases of scaphoid nonunion with avascular necrosis in the absence of periscaphoid arthritic
changes or established carpal collapse. In long-standing scaphoid nonunion with advanced
degenerative changes of the wrist, a salvage procedure is indicated, usually proximal row
carpectomy or total wrist fusion.
Anteroposterior plain-film radiograph (Fig. 7.2.1) shows nonunion of the proximal third of Imaging
the scaphoid with a sclerotic proximal fragment (open arrow). Coronal fat-suppressed T1- Findings
and T2-weighted images (Figs. 7.2.2 and 7.2.3) show a proximal fragment that is hypoin-
tense on T1-weighted images and hyperintense on T2-weighted images. Oblique sagittal
fat-suppressed T1-weighted image (long axis of the scaphoid) after administration of intra-
venous gadolinium (Fig. 7.2.4) shows the absence of enhancement the proximal fragment
(solid arrow), indicating complete necrosis.
A 35-year-old woman presented with an 18-month history of right wrist pain and a radio-
Case 7.3 lucent lesion of the lunate on plain-film radiographs. On presentation, tenderness was
detected on the dorsal side of the lunate with pain at extreme degrees of motion and with-
Intraosseous out focal swelling. A previous MRI study had misdiagnosed Kienbocks disease. A new MRI
Ganglia of the study showed an intraosseous ganglion in the lunate bone with cortical rupture and exten-
Lunate sion into the scapholunate joint and diffuse lunate bone edema. The lesion was successfully
(Pseudo- treated surgically with curettage and bone grafting. Three years after surgery, the patient is
Kienbck asymptomatic and the radiographic appearance of the lunate has returned to normal.
Disease)
Comments Cyst-like lesions in the carpal bones are generally asymptomatic and are often detected
incidentally on plain-film radiographs after injuries to the wrist and hand. Intraosseous
ganglia are benign cystic lesions located in the subchondral bone adjacent to a joint. They
Fig. 7.3.1 Fig. 7.3.2
Fig. 7.3.3 Fig. 7.3.4

141
are often multiloculated lesions filled with fibrous tissue and show mucoid changes. The
scaphoid and lunate are most commonly involved. The nature of intraosseous ganglia is
still unclear. It is generally believed that there are two types: the primary or idiopathic
intraosseous lesion and the secondary lesion caused by the cortical penetration of a previ-
ously existing soft-tissue ganglion. The primary type is more frequent. In most cases, corti-
cal defects are demonstrated at surgery.
Clinically, intraosseous ganglion always presents as wrist pain. On plain-film radio-
graphs, it appears as a well-defined osteolytic lesion with a surrounding sclerotic area.
Bone scintigraphy can differentiate cysts with increased osteoblastic activity from inactive
unchanging cysts that should be followed radiographically. CT scans are extremely helpful
in locating the cortical defect of the cyst. In most cases of lunate cortical erosions, the
defect is located in the lateral (scapholunate) articular surface of the bone. MRI helps
delineate the tissues surrounding the bony lesion.
The differential diagnosis of painful lytic lesions of the lunate includes enchondroma,
chondroblastoma, osteoblastoma, fibrous dysplasia, giant cell tumor, osteoid osteoma,
chondromyxoid fibroma, unicameral bone cyst, Kienbcks disease, rheumatoid arthritis,
osteoarthritis, and intraosseous ganglion.
Signal change in the lunate bone is often misdiagnosed as Kienbcks disease. This
occurs with particular frequency in ulnar impaction syndrome and intraosseous ganglion
of the lunate. In ulnar impaction syndrome, chondromalacia, sclerosis, cysts, and subchon-
dral edema occur on the radial side of the lunate. The distribution of radiographic changes
within the lunate bone is the key to distinguishing these conditions from Kienbcks dis-
ease. Intraosseous ganglia appear on plain-film radiographs as an area of hyperlucency,
which is frequently radial-sided in communication with the scapholunate joint space.
Intraosseous ganglia have low-signal intensity on T1-weighted MRI and high-signal inten-
sity on T2-weighted images, similar to the signal intensity of water. Sharper margins on
radiographs and a lack of changes in MRI signal intensity in the triquetral bone or ulnar
head help in the diagnosis. The signal intensity pattern in Kienbcks disease may mimic
ulnar impaction syndrome; however, Kienbcks disease lesions are more diffuse or involve
the radial side of the lunate bone compared to involvement of only the ulnar aspect in ulnar
impaction syndrome. Furthermore, the triquetral bone and the ulnar head are not affected
in Kienbcks disease.
Indications for surgery on intraosseous ganglia include progression of the cyst and
continued pain. Most symptomatic intraosseous ganglia can be treated successfully with
curettage and bone grafting. Recurrence has been reported, but is unusual.
Anteroposterior plain-film radiograph of the right wrist (Fig. 7.3.1) showing a well-defined Imaging
cystic lesion in the radial side of the lunate bone with a peripheral sclerotic ring (open Findings
arrow).
CT (Fig. 7.3.2) shows the cystic lesion of the lunate and fracture of the lunate radial cor-
tex (solid arrow).
Fat-suppressed T1- and T2-weighted images (Figs. 7.3.3 and 7.3.4) show a well-defined
cystic lesion with cortical breakage and diffuse edema in the lunate bone (arrowheads).
Case 7.4
Glomus Tumor in the Thumb
Fig. 7.4.1 Fig. 7.4.2
Fig. 7.4.3 Fig. 7.4.4

143
A 51-year-old male presented with a 2-year history of pain in the nail bed of his right thumb,
which was exacerbated by local pressure and cold. Physical examination revealed a blue
focus of discoloration beneath the nail and deformity of the nail plate. Plain-film radio-
graphs of the thumb showed subtle dorsal bone erosion in the distal phalanx. Ultrasound
revealed a 5-mm solid hypoechoic nodule beneath the nail, with marked vasculature within
the tumor at color Doppler. Thumb MRI demonstrated a well-circumscribed oval nodule
that was hypointense on T1-weighted images and enhanced after intravenous administra-
tion of contrast material. On T2-weighted images, the tumor was homogeneously hyperin-
tense with a thin hypointense rim. The tumor was surgically excised and the diagnosis of a
glomus tumor was established histologically.
Glomus tumors in the fingers are rare benign tumors that arise from the neuromyoarterial Comments
glomus, which is an end-organ apparatus with arteriovenous anastomoses (without a
capillary bed), located either beneath the nail or over the palmar aspect of the fingertip.
The mean age at presentation ranges from 30 to 50 years, and there is a three-to-one female
predominance. Clinically, glomus tumors present as a classic triad of paroxysmal pain,
hypersensitivity to cold, and point tenderness. Ultrasound can usually visualize the
subungual tumor, showing a hypoechoic nodule that appears hypervascular at color
Doppler due to the high-velocity flow of intratumor shunt vessels. MRI shows a nodule that
is hypo/isointense on T1-weighted images and hyperintense on T2-weighted images, with
marked contrast enhancement. When the tumor measures less than 2mm, both ultrasound
and MRI are usually negative. The differential diagnosis includes benign and malignant
subungual tumors, such as chondroma and metastasis from lung cancer. The treatment is
surgical removal. To avoid nail deformity, it is better to use a periungual approach for
tumors in the peripheral region and a transungual approach followed by meticulous repair
of the nail bed for tumors in the central region. Recurrent tumors are common. Ultrasound
seems less efficient than MRI for differentiating residual tumor tissue from postoperative
scar.
Photograph of the thumb (Fig. 7.4.1) shows a focal deformity of the nail plate (open Imaging
arrow). Findings
Axial and sagittal fat-suppressed T2-weighted images (Figs. 7.4.2 and 7.4.3) show an
oval, well-circumscribed, homogeneously hyperintense nodule with a thin hypointense
rim (solid arrows) beneath the right thumb nail.
Photograph of the thumb after nail avulsion (Fig. 7.4.4) shows the typical macroscopic
appearance of the glomus tumor (arrowhead).
Case 7.5
Carpal Boss
Fig. 7.5.1
Fig. 7.5.2
Fig. 7.5.3 Fig. 7.5.4

145
A 24-year-old male presented with a 1-month history of a painful, hard, nonmobile bump
at the base of the third metacarpal on the dorsum of his right hand. Palmar flexion of the
wrist increased pain and showed the bump more clearly. The patient reported a minor
trauma while playing basketball. Lateral plainfilm radiographs of the wrist showed an
accessory ossicle: os styloideum. MRI revealed bone marrow edema in the accessory ossi-
cle and in the adjacent metacarpal. In light of the absence of clinical improvement, the
patient was treated with simple resection of the os styloideum.
Carpal boss could be defined as a bony prominence on the dorsal aspect of the second or Comments
third carpometacarpal joint; it may represent degenerative osteophyte formation and/or
an accessory ossification center (os styloideum), which is frequently fused to the metacar-
pal. Its relationship with incomplete dorsal osseous coalition and the absense of the nor-
mal dorsal ligament in the carpometacarpal joint has recently been reported. Carpal boss
is more common in women (2:1) and in the right hand; its incidence peaks between the
third and fourth decades. Although generally asymptomatic, it can occasionally cause pain
and limitation of hand motion because of trauma, degenerative changes, or slippage of the
extensor carpi radialis longus and brevis tendons. Lateral plainfilm radiographs of the
wrist with 30 of both supination and ulnar deviation (carpal boss view) are usually suf-
ficient to show the bony prominence, so MRI generally is not required to make a specific
diagnosis. Nevertheless, MRI provides complementary information, showing bone marrow
edema, osteoarthritic changes, joint effusion, and anomalies of extensor tendons. The
symptoms have also been attributed to the formation of a small ganglion or inflamed bursa
that may develop over the abnormal bone, making the differential diagnosis between car-
pal boss and dorsal wrist ganglion more challenging. Surgical removal is indicated when
conservative treatment does not relieve symptoms. A wedge-shaped carpometacarpal joint
resection is usually performed. Care must be taken to remove less than 35% of the joint to
prevent carpometacarpal instability.
Lateral plain-film radiograph of the wrist (carpal boss view) (Fig. 7.5.1) shows a small Imaging
accessory ossicle (os styloideum) over the base of the third metacarpal (open arrow). Findings
Sagittal T1-weighted (Fig. 7.5.2), fat-suppressed T2-weighted (Fig. 7.5.3), and axial fat-
suppressed T2-weighted (Fig. 7.5.4) images show bone marrow edema in the os styloideum
and in the adjacent metacarpal bone (solid arrows).
Case 7.6
De Quervain Tenosynovitis
Fig. 7.6.2
Fig. 7.6.1
Fig. 7.6.3 Fig. 7.6.4

147
A 47-year-old right-handed woman presented with a 6-month history of pain over the
radial styloid of her right wrist that was exacerbated by grasping heavy objects. She had no
history of trauma. Physical examination indicated tenderness and swelling in the first
extensor compartment. Pain increased with thumb and wrist motion, and the Finkelstein
test was positive. Ultrasound and MRI confirmed the diagnosis of de Quervain tenosyno-
vitis, and multiple accessory tendons in the first extensor compartment were observed. The
patient underwent surgical decompression.
De Quervain disease is a typical example of overuse tenosynovitis of the wrist. This condition Comments
usually affects patients who perform repetitive movements of the thumb such as typists and
piano players. Low-grade chronic microtrauma at the level of the radial styloid can lead to local-
ized thickening of the extensor retinaculum and subsequent impingement of the extensor pol-
licis brevis (EPB) and abductor pollicis longus (APL) tendons within the narrow osteofibrous
tunnel of the first extensor compartment (stenosing tenovaginitis), which usually entails ten-
don sheath inflammation (tenosynovitis). The mean age at presentation ranges from 35 to 55
years, and there is a female predominance (8:1). A useful diagnostic maneuver is the Finkelstein
test: the patient holds his or her thumb inside the clenched fist while the examiner tilts the wrist
in an ulnar direction to stretch the tendons of the first extensor compartment (the test is posi-
tive if pain or tenderness is present over the radial styloid). Plain-film radiographs may show
focal cortical erosion, sclerosis, or periosteal bone apposition of the radial styloid, and the dif-
ferential diagnosis should be made with rhizarthrosis and scaphoid fracture. Ultrasound can
usually confirm the diagnosis of de Quervains tenosynovitis; the ultrasound findings include
thickening of the EPB and APL tendons with thickening of the synovial sheath, which usually
appears hypervascular at color Doppler due to inflammatory hyperemia. In addition, a thick-
ened and hypoechoic extensor retinaculum is usually observed. In acute phases, a hypoechoic
sheath effusion can be demonstrated caudal to the distal edge of the retinaculum. MRI shows
enlargement of the EPB and APL tendons and peritendinous edema. There may be high-signal
fluid within the tendon sheath on T2-weighted images, and contrast enhancement of the syn-
ovial sheath is usually observed. Two main anatomic variants may be encountered in the first
compartment: a septum between the EPB and APL and accessory tendons. The intertendinous
septum is a vertically oriented band that divides the first compartment into two distinct spaces.
It appears hypoechoic on ultrasound and hypointense on both T1- and T2-weighted MRI
sequences. Accessory tendons are usually associated with the APL. Axial images (both ultra-
sound and MRI) give a better view of the retinaculum, intertendinous septum, and accessory
tendons. Injection of corticosteroids into the tendon sheath cures this disease in most patients,
but surgical release of the first extensor compartment is occasionally required.
Axial sonogram (Fig. 7.6.1) and longitudinal color Doppler sonogram (Fig. 7.6.2) show a Imaging
thickened tendon with synovial hypertrophy (hypervascular pattern) and effusion in the Findings
tendon sheath (open arrows), just caudal to the distal edge of the extensor retinaculum
(which appears hypoechoic and thickened) (solid arrow). Axial T2- and coronal T1-weighted
images (Figs. 7.6.3 and 7.6.4) show first extensor compartment tendinosis and surrounding
tenosynovitis (arrowheads).
Case 7.7
Distal Biceps Tendon Rupture
Fig. 7.7.2
Fig. 7.7.1
Fig. 7.7.3 Fig. 7.7.4

149
A 24-year-old male manual laborer presented with a sudden painful left elbow after
attempting to lift a heavy object. He reported hearing and feeling a pop directly in front of
the elbow. Pain, swelling, bruising, and a palpable defect with a proximal lump in the
anterior aspect of the arm were perceived on physical examination of the elbow. Complete
distal biceps tendon avulsion was confirmed by ultrasound and MRI. The tendon was
reattached to the radial tuberosity using a single anterior incision and suture anchors.
Distal biceps tendon rupture is an uncommon injury, representing less than 5% of all Comments
biceps ruptures. Conversely, it is the most commonly (completely) torn tendon of the elbow.
The distal biceps tendon is approximately 7 cm long and it curves laterally and deeply
before inserting into the medial aspect of the radial tuberosity. An aponeurotic expansion
(bicipital aponeurosis, also known as lacertus fibrosus) connects the biceps tendon to the
medial deep fascia overlying the flexor muscles, covering the median nerve and brachial
artery. Rupture usually occurs in the dominant extremity of 4060-year-old males during
heavy weightlifting or vigorous eccentric contraction against resistance with a flexed
forearm. The tendon typically tears from the radial tuberosity. A complete tear of the
tendon with proximally retracted muscle (Popeye sign) is a straightforward clinical
diagnosis, but in cases of an intact lacertus fibrosus and consequent absence of significant
muscle retraction, the clinical differential diagnosis with partial tears and bicipitoradial
bursitis is difficult. In such cases, ultrasound and/or MRI play a key role. Ultrasound is
performed with the elbow extended and the patients forearm in maximal supination to
bring the radial tendon insertion into view; dynamic imaging (with slight supination-
pronation or flexion-extension) is especially useful for differentiating complete from
partial tears. Traditionally, optimal MRI of the distal biceps tendon is performed in the
axial plane with the patients arm extended; longitudinal views are difficult to obtain
because of the oblique course of the tendon. The FABS (Flexed elbow, ABducted shoulder,
forearm Supinated) view with the patient in superman position creates tension in the
tendon and minimizes its obliquity and rotation, resulting in a true longitudinal view of
the tendon. The treatment of choice for complete rupture is early surgical repair. Several
different techniques to secure the distal end of the biceps tendon back to the radial
tuberosity have been described; the two most common techniques are a two-incision
technique using a bone tunnel and single-incision technique with suture anchors or
endobutton.
Longitudinal gray-scale sonogram through the anterior elbow (Fig. 7.7.1) shows hypoechoic Imaging
fluid filling the distal bed of the retracted distal biceps tendon and surrounding its myoten- Findings
dinous junction (open arrows). Sagittal T2-weighted image (Fig. 7.7.2) shows complete dis-
tal biceps tendon avulsion, which appears thickened and retracted (solid arrow). Axial
T1-weighted image (Fig. 7.7.3) and fat-suppressed T2-weighted image (Fig. 7.7.4) show
fluid surrounding the myotendinous junction (arrowheads) that crosses medially over the
median nerve and brachial artery (indicating lacertus fibrosus rupture).
Case 7.8
Posterior Dislocation of the Elbow
Fig. 7.8.2
Fig. 7.8.1
Fig. 7.8.3 Fig. 7.8.4

151
A 32-year-old male manual laborer presented with a shortened left forearm held in flexion.
A prominent mass (olecranon) was noted behind the elbow. He reported falling from a
2-meter height onto his outstretched left hand. Plain-film radiographs confirmed the diag-
nosis of posterior dislocation. After manipulative reduction, plain-film radiographs showed
good alignment of bones and no fractures. MRI showed humeral avulsion of both medial
and lateral ligament complexes, disruption of anterior and posterior joint capsule, and
bone contusion involving the capitellum. The ligaments were reattached surgically and the
patient underwent physical therapy.
Elbow dislocation is the most common joint dislocation in children and is second only to Comments
shoulder dislocation in adults. The most common type is posterior elbow dislocation (both
ulna and radius) and the mechanism of injury is typically a fall onto an outstretched hand.
Elbow dislocations can be divided into two categories: simple (without fracture) or com-
plex (with fracture). The ipsilateral upper extremity should be examined for other injuries
as well, particularly shoulder and wrist fractures and disruption of the distal radioulnar
joint. It is important to note that the ulnar nerve, median nerve, and brachial artery can be
compromised. Anteroposterior and lateral plain-film radiographs of the elbow should be
obtained to both confirm the diagnosis and detect fractures. After closed reduction, CT is
very useful to evaluate intraarticular fractures (i.e., radial head, capitellum, coronoid pro-
cess), which is important for deciding the appropriate management of the injury. MRI is
indicated to assess bone marrow, capsuloligamentous, and soft-tissue injuries. The medial
collateral ligament and lateral collateral ligament are responsible for the ligamentous sta-
bility of the elbow. These ligaments are well seen on coronal images. The medial (or ulnar)
complex consists of three bands: anterior, posterior, and transverse; the anterior band pro-
vides most of the resistance to valgus stress. The lateral complex has four bands: the radial
collateral ligament, the annular ligament, the accessory collateral ligament, and the ulnar
collateral ligament, which courses posteromedially behind the radial neck to insert in the
proximal ulna and its oblique orientation allows for lateral and posterior stabilization of
the elbow. During elbow instability, capsuloligamentous injury progresses from lateral to
medial (stages 13), and the elbow might dislocate completely while the anterior band of
the medial collateral ligament remains intact (stage 3A), although both medial and lateral
complexes are usually avulsed (stage 3B). There is also a variable degree of injury to the
common flexor and extensor musculature.
Lateral plain-film radiograph of the left elbow (Fig. 7.8.1) shows posterior dislocation of Imaging
the ulna and radius in relation to the distal humerus (open arrow). Coronal T2-weighted Findings
gradient-echo images (Figs. 7.8.2 and 7.8.3) show diffuse edema (bone contusion) in the
posterior capitellum and complete avulsion of both the medial and lateral collateral liga-
ments (solid arrows). Sagittal T2-weighted gradient-echo image (Fig. 7.8.4) shows disrup-
tion of the anterior and posterior joint capsule (arrowheads).
Case 7.9
Occult Fracture of the Radial Head
Fig. 7.9.2
Fig. 7.9.1
Fig. 7.9.3 Fig. 7.9.4

153
A 32-year-old man with a history of a motorcycle accident 2 months earlier presented with
persistent of elbow pain and severe functional impairment. Plain-film radiographs showed
no pathological findings. MRI showed an occult fracture of the radial head. CT study was
performed to better define the three-dimensional anatomy of the articular fracture and
plan the therapeutic approach. The joint was immobilized with a cast and the patient made
a complete functional recovery after physical therapy.
The elbow fractures most commonly seen involve the head of the radius (60%), followed by Comments
fractures of the distal humerus (30%) and of the coronoid process (5%). Plain-film radio-
graphs usually reveal the abnormality. In some cases, however, particularly if a radial head
or coronoid process fracture is nondisplaced or minimally displaced, it may not be appar-
ent on routine examination. In the management of fractures of the elbow, especially of the
head of the radius and the capitellum, the correct diagnosis is fundamental not only to
decide whether or not to operate, but also to determine the type of surgical procedure that
may be indicated.
Radiographically occult or equivocal fractures of the elbow may be assessed with MRI.
MRI is useful for detecting and characterizing radial head fractures; it is also helpful in
ruling out associated collateral ligament injury that may contribute to instability. The
integrity of the medial collateral ligament is especially important if excision of the radial
head is being considered. When there is ligamentous disruption and instability, displaced
fractures of the radial head are best treated with internal fixation.
On MRI, radial head fractures are indicated by linear decreased signal intensity within
the radial head surrounded by edema.
Coronal T1-weighted SE MRI shows the intraarticular fracture with cortical disruption
(arrowhead) and mild compression of the radial surface.
Coronal fat-suppressed T1- and T2-weighted MRI (Figs. 7.9.1 and 7.9.2) show a nondis- Imaging
placed fracture (open arrows) of the radial head surrounded by bone marrow edema. Findings
Coronal and axial CT images (Figs. 7.9.3 and 7.9.4) reveal an intraarticular fracture with
cortical disruption (solid arrows) and mild compression of the radial surface.
Case 7.10
Pigmented Villonodular Synovitis of the Elbow
Fig. 7.10.1 Fig. 7.10.2
Fig. 7.10.3 Fig. 7.10.4

155
A 31-year-old man presented with a 6-month history of occasional pain and stiffness in his
right elbow. He had no history of trauma. On physical examination, no local heat or tender-
ness was observed, but discrete swelling and limited range of movement was noted. Plain-
film radiographs were normal. MRI did not show any obvious abnormality, but small
effusion and heterogeneous contrast enhancement of the synovium were observed. MR
arthrography showed hypertrophied synovium in both the anterior and posterior recesses
of the elbow joint with inner hypointense foci on gradient-echo images. The patient under-
went a complete arthroscopic synovectomy, and the diagnosis of diffuse pigmented vil-
lonodular synovitis (PVNS) was confirmed histologically.
PVNS is a rare benign disorder of an uncertain nature that can affect any synovial joint, Comments
bursa, or tendon sheath (also known as giant cell tumor of tendon sheath). Although PVNS
was initially considered an inflammatory reactive process, recent observations have shown
that this disease may actually be a benign neoplastic process with specific genetic altera-
tions. Most patients range from young to middle-aged adults, and there is a slight male
predominance. PVNS almost always involves only one articulation and has a predilection
for the lower extremities, particularly the knee. It results in synovial hypertrophy with dif-
fuse hemosiderin deposits within the joint, which virtually never calcifies. The usual clini-
cal presentation includes progressive swelling, stiffness, and locking of the joint. Plain-film
radiographs may show a dense effusion and, in tight joints, extrinsic pressure bone ero-
sions. MRI shows synovial thickening and enhancement after intravenous administration
of contrast material. Hemosiderin is a magnetic material, its deposit on proliferative syn-
ovial tissue results in a spotty low-signal or extensive low-signal area on T1-weighted and
T2-weighted images, best visualized on gradient-echo images. Fat-suppressed sequences
obscure these deposits. Therefore, foci of low-signal intensity lining and within hypertro-
phied synovium on gradient-echo images are pathognomonic of PVNS, and the differen-
tial diagnosis with noncalcified synovial chondromatosis and rheumatoid pannus is easier
to make. PVNS has two presentations in joints: diffuse and focal. If focal, simple surgical
excision is appropriate. If diffuse, it is associated with a high risk of local recurrence, so
complete synovectomy is indicated. Adjuvant treatment modalities such as medication
(imatinib), radiotherapy, or radiosynoviorthesis are sometimes used after synovectomy.
Sagittal and axial fat-suppressed MR arthrography images (Figs. 7.10.1 and 7.10.2) show Imaging
filling defects in both the anterior and posterior recesses of the elbow joint due to hyper- Findings
trophied synovium (open arrows), which contains foci of low-signal intensity that are bet-
ter depicted on sagittal T2-weighted gradient-echo images (Fig. 7.10.3) (solid arrows).
Arthroscopic image (Figs. 7.10.4) shows a lobulated red and brown mass (arrowheads).
Further Reading Cheng XG, You YH, Liu W, Zhao T, Qu H. MRI features of pigmented
villonodular synovitis (PVNS). Clin Rheumatol 2004; 23:3134
Chew ML, Giuffre BM. Disorders of the distal biceps brachii ten-
Books don. Radiographics 2005; 25:12271237
Atlas de diseccin anatomoquirrgica del codo. Llusa M, Forcada Cunningham PM. MR imaging of trauma: elbow and wrist.
P, Ballesteros JR, Carrera A (2009). Elsevier, Amsterdam Semin Musculoskelet Radiol 2006; 10:284292
Greens Operative Hand Surgery. Green D, Hotchkiss R, Pederson Dailiana ZH, Zachos V, Varitimidis S, Papanagiotou P, Karantanas
W, Wolfe S (2005). Churchill Livingstone, Philadelphia A, Malizos KN. Scaphoid nonunions treated with vascularized
Imaging of the Musculoskeletal System. Pope T, Morrison B, bone grafts: MRI assessment. Eur J Radiol 2004; 50:217224
Bloem H, Beltran J, Wilson D (2007). Elsevier, Amsterdam Diop AN, Ba-Diop S, Sane JC etal. [Role of US in the manage-
MRI of Upper Extremity: Shoulder, Elbow, Wrist, and Hand. ment of de Quervains tenosynovitis: review of 22 cases].
Steinbach L, Chung CB (2009). Lippincott Williams & Wilkins, JRadiol 2008; 89:10811084
Philadelphia Drape JL. Imaging of tumors of the nail unit. Clin Podiatr Med
Mueca-Mano Diagnstico por la imagen. Enfasis en la RM. Surg 2004; 21:493511
Recondo JA (2007). Osatek. Vitoria. Duckworth AD, Ring D, Kulijdian A, McKee MD. Unstable elbow
dislocations. J Shoulder Elbow Surg 2008; 17:281286
Giuffre BM, Moss MJ. Optimal positioning for MRI of the distal
biceps brachii tendon: flexed abducted supinated view. AJR
Web-Links Am J Roentgenol 2004; 182:944946
Glajchen N, Schweitzer M. MRI features in de Quervains teno-
http://www.eatonhand.com/ synovitis of the wrist. Skeletal Radiol 1996; 25:6365
http://emedicine.medscape.com/radiology#musculoskeletal Ilyas AM, Ast M, Schaffer AA, Thoder J. De quervain tenosynovi-
http://www.mskcases.com/ tis of the wrist. J Am Acad Orthop Surg 2007; 15:757764
http://www.uhrad.com/ Kaplan LJ, Potter HG. MR imaging of ligament injuries to the
http://www.orthopaedicweblinks.com/Teaching_Resources/ elbow. Radiol Clin North Am 2006; 44:583594
index.html Murphey MD, Rhee JH, Lewis RB, Fanburg-Smith JC, Flemming
DJ, Walker EA. Pigmented villonodular synovitis: radiologic-
pathologic correlation. Radiographics 2008; 28:14931518
Articles ODwyer H, OSullivan P, Fitzgerald D, Lee MJ, McGrath F, Logan
PM. The fat pad sign following elbow trauma in adults: its
Al-Qattan MM, Al-Namla A, Al-Thunayan A, Al-Subhi F, usefulness and reliability in suspecting occult fracture.
El-Shayeb AF. Magnetic resonance imaging in the diagnosis JComput Assist Tomogr 2004; 28:562565
of glomus tumors of the hand. J Hand Surg [Br] 2005; Oka Y, Umeda K, Ikeda M. Cyst-like lesions of the lunate resem-
30:535540 bling Kienbocks disease: a case report. J Hand Surg [Am]
Alemohammad AM, Nakamura K, El-Sheneway M, Viegas SF. 2001; 26:130134
Incidence of carpal boss and osseous coalition: an anatomic Park MJ, Namdari S, Weiss AP. The carpal boss: review of diag-
study. J Hand Surg [Am] 2009; 34:16 nosis and treatment. J Hand Surg [Am] 2008; 33:446449
Bain GI, Turner PC, Ashwood N. Arthroscopically assisted treat- Waitayawinyu T, McCallister WV, Katolik LI, Schlenker JD,
ment of intraosseous ganglions of the lunate. Tech Hand Up Trumble TE. Outcome after vascularized bone grafting of
Extrem Surg 2008; 12:202207 scaphoid nonunions with avascular necrosis. J Hand Surg
Bennett DC, Hauck RM. Intraosseous ganglion of the lunate. [Am] 2009; 34:387394
Ann Plast Surg 2002; 48:439442 Waitayawinyu T, Pfaeffle HJ, McCallister WV, Nemechek NM,
Cerezal L, Abascal F, Canga A, Garcia-Valtuille R, Bustamante M, Trumble TE. Management of scaphoid nonunions. Orthop
del Pinal F. Usefulness of gadolinium-enhanced MR imaging Clin North Am 2007; 38:237249
in the evaluation of the vascularity of scaphoid nonunions. Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced
AJR Am J Roentgenol 2000; 174:141149 collapse pattern of degenerative arthritis. J Hand Surg [Am]
Cerezal L, Abascal F, Garcia-Valtuille R, Del Pinal F. Wrist MR 1984; 9:358365
arthrography: how, why, when. Radiol Clin North Am 2005; Weiss KE, Rodner CM. Osteoarthritis of the wrist. J Hand Surg
43:709731 [Am] 2007;32:725746
Hip and Pelvis 8
Ara Kassarjian, Jos Martel-Villagrn, and ngel Bueno-Horcajadas
158 A. Kassarjian, J. Martel-Villagrn, and . Bueno-Horcajadas
Case 8.1
Postpartum Sacral Fracture
Fig. 8.1.1 Fig. 8.1.2
Fig. 8.1.3
159
Hip and Pelvis
A 35-year-old woman presented with right-sided sciatica one week after an uncomplicated
vaginal delivery.
There is a wide variety of causes of postpartum pelvic pain, some of which are mechanical Comments
in nature. Peripartum sacral fractures, although relatively uncommon, are a recognized
cause of postpartum low-back, sacral, or pelvic pain. The exact cause of these fractures is
not clear. Pregnancy-related metabolic bone disease, such as osteoporosis, might be a con-
tributing factor. However, it is not entirely clear whether these fractures are fatigue or insuf-
ficiency fractures. Clinicians should remember to include sacral fractures within the possible
etiologies of postpartum low back and pelvic pain. As demonstrated in this case, MRI can be
useful in diagnosing osseous, ligamentous, or muscular etiologies of such pain.
Postpartum sacral fractures are typically not visible on radiographs. However, MRI
clearly shows the classic appearance of a fracture, which may be unilateral, as in this case,
or bilateral. On T1-weighted imaging, a hypointense vertical linear line is seen along the
lateral margin of the sacrum. A similar line is often also visible on T2-weighted imaging. In
addition, the typical bone marrow edema pattern is seen adjacent to the line, resulting in
diffuse low signal adjacent to the fracture line on T1-weighted images and high signal on
T2-weighted images.
Coronal T1-weighted MRI (Fig. 8.1.1) shows a low signal intensity fracture line (open Radiological
arrow) paralleling the sacroiliac joint with adjacent low signal marrow edema (solid arrow). Findings
Coronal T2-weighted MRI (Fig. 8.1.2) shows a low-signal intensity fracture line (open
arrow) paralleling the sacroiliac joint with adjacent high signal marrow edema (solid
arrow). Oblique fat-suppressed T2-weighted images (Fig. 8.1.3) clearly demonstrate the
fracture line with extensive associated bone marrow edema (open arrows).
Case 8.2
Acute Avulsion Fracture of the Ischial Apophysis
Fig. 8.2.1
Fig. 8.2.2
Fig. 8.2.3 Fig. 8.2.4

161
Hip and Pelvis
A 13-year-old girl presented initially with fever and right gluteal pain. She had recurring
pain following exercise and while sitting, since an injury to her right pelvic region 1 year
earlier. Fifteen days before admission, she had a new injury in the same region. The pain
persisted to the point that the night before admission she had acute pain in the right gluteal
region requiring analgesics every 3 hours.
Physical examination showed right hip pain on internal rotation and right gluteal tender- Comments
ness on palpation. Her laboratory tests were all within normal limits.
Apophyseal avulsion fractures of the pelvis are common among skeletally immature
patients. One of the most common fractures involves the apophysis of the ischial tuberosity,
where the hamstrings insert. Ischial apophyseal avulsions are common in children partici-
pating in sports that require rapid and forceful hamstring contraction such as sprinting, soc-
cer, and even cheerleading. The injury typically results in acute pain in the gluteal region with
loss of strength of the ipsilateral hamstrings and either inability to walk or an antalgic gait.
On radiographs, ischial apophyseal avulsions typically appear as a small curved frag-
ment of bone separated from the ischial tuberosity. Occasionally, the separation may be
subtle and only noticeable as a mild widening of the physis when compared to the contral-
ateral normal side.
At MRI, acute apophyseal avulsions are typically seen as periosteal stripping, hemorrhage,
edema, and a fluid-filled cleft between the apophysis and the ischial tuberosity. Significant
edema of surrounding soft tissues may be present. In severe cases, significant displacement
of the fragment and resultant laxity of the hamstring tendons can give them a wavy
appearance. The apophysis itself may be difficult to see depending on the amount of
hemorrhage as well as the degree of mineralization of the fragment. In subacute to chronic
cases, the MRI appearance can be confusing and may even mimic a neoplastic process.
Thus, it is imperative to know the common sites of avulsion injuries in the pelvis to avoid
misdiagnosis and subsequent unwarranted biopsies.
Plain-film radiograph (Fig. 8.2.1) shows a curvilinear bone fragment (open arrow) adjacent Radiological
to the lateral margin of the right ischial tuberosity (arrow), which is somewhat flattened Findings
and irregular compared to the contralateral side.
Coronal T1-weighted MRI (Fig. 8.2.2) shows enlargement and ill-definition of the proxi-
mal hamstring tendons (open arrow) with some loss of the adjacent fat planes. A thin
hypointense curvilinear structure (arrow) represents the avulsed mineralized apophysis.
Coronal STIR image (Fig. 8.2.3) shows a hyperintense cleft (open arrow) between the
osseous fragment and the ischial tuberosity. The avulsed hamstring tendons (arrow) are
expanded, ill-defined, and surrounded by hyperintense edema and hemorrhage.
Axial STIR image (Fig. 8.2.4) again shows a hyperintense cleft (open arrow) between the
osseous fragment and the ischial tuberosity. The avulsed hamstring tendons (arrow) are
expanded and show edema and hemorrhage between the tendon fibers. The sciatic nerve
(arrowhead) is surrounded by hemorrhage and edema.
Case 8.3
Transient Osteoporosis of the Hip
Fig. 8.3.2
Fig. 8.3.1
Fig. 8.3.3 Fig. 8.3.4

163
Hip and Pelvis
A 38-year-old man with a 15-day history of progressive mechanical left hip pain presented
with increasingly intense pain radiating from the left lumbar region to the left ankle. His
pain was so intense that he was unable to walk.
On physical examination, he had no spinal or paraspinal tenderness or tenderness over
the sacroiliac joints. He had tenderness over the left inguinal region. He had the full range
of motion of his left hip, although movements were painful. Neuromuscular exam showed
loss of sensation over the lateral thigh but was otherwise normal.
Transient osteoporosis of the hip is a self-limiting syndrome of unknown etiology. Although Comments
this idiopathic entity was first described in pregnant women, it is currently seen more com-
monly in males in their third to fourth decades. Apart from a possible elevation in the
erythrocyte sedimentation rate, laboratory findings are typically normal.
Initially, plain-film radiographs may be normal whereas bone scintigraphy shows homo-
geneous increased uptake in the affected femoral head and neck. Subsequent radiographs
typically show unilateral demineralization of the femoral head and neck. At MRI, there is a
bone marrow edema pattern involving the femoral head and neck, characterized by loss of
signal intensity on T1-weighted sequences and high signal intensity on fluid-sensitive
sequences (T2, STIR). Associated effusions are common. The pattern of edema must be
differentiated from the two other common causes of femoral head and neck edema:
osteonecrosis and fractures. One discriminating feature of transient osteoporosis (also
called transient bone marrow edema) is the absence of a hypointense line in the femoral
head or neck. Following gadolinium administration, homogeneous diffuse enhancement
of the marrow in the edematous areas (without unenhanced areas) differentiates this entity
from osteonecrosis. Although other diseases, such as neoplasms, can result in marrow
edema, they are typically accompanied by other features that help differentiate them from
transient osteoporosis. It may be difficult to differentiate transient osteoporosis from infec-
tion based, solely on imaging findings.
Although transient osteoporosis of the hip is typically a self-limiting disease, the clinical
course may be somewhat protracted, with resolution requiring 610 months.
Coronal T1-weighted MRI (Fig. 8.3.1) demonstrates decreased signal in the femoral head Radiological
and neck (arrow). There is no linear component to the signal abnormality. Findings
Axial T1-weighted MRI (Fig. 8.3.2) demonstrates decreased signal in the femoral head
(open arrow). There is no linear component to the signal abnormality. Fullness and low
signal along the anterior capsule (arrow) represents an effusion.
Coronal STIR image (Fig. 8.3.3) shows increased marrow signal in the femoral head and
neck (open arrow), consistent with edema. A small effusion is present (arrow).
Axial STIR image (Fig. 8.3.4) shows increased marrow signal in the femoral head (open
arrow), consistent with edema. A small effusion is present (arrow).
Case 8.4
Osteolysis Associated with Total Hip Arthroplasty
Fig. 8.4.2
Fig. 8.4.1
Fig. 8.4.3 Fig. 8.4.4

165
Hip and Pelvis
A 65-year-old man presented with a 1-month history of atraumatic inguinal and greater
trochanteric pain 18 months after total hip replacement for hip fracture. His pain was
greater than in the immediate postoperative period and worse in the mornings and when
starting to walk. At physical examination, he had nearly full range of hip motion, although
painful, and tenderness over the greater trochanter. Loosening of the prosthesis was seen,
but the patient declined surgery.
Three years later, he developed progressive coxalgia and lumbalgia. He now walks with
crutches and has painful limitations of hip flexion, abduction, and adduction but no tro-
chanteric pain.
Although initially called cement disease, periprosthetic osteolysis can be seen with both Comments
cemented and noncemented prostheses. Although motion in and of itself can cause radio-
graphic lucencies, the lucencies of osteolysis are typically more focal, can be larger, and are
more lobular with endosteal scalloping. There may be associated osseous expansion. With
larger lesions, the findings may mimic a neoplastic process. Periprosthetic lucencies may
be related to loosening, foreign body granulomatous reaction, or infection; however, these
entities are not mutually exclusive. For instance, it is not uncommon for loosening to be
present in cases of extensive foreign body granulomatous reaction. In fact, some theorize
that the granulomatous reaction is actually related to loosening.
CT has proven more sensitive than plain-film radiographs to osteolysis associated with
prostheses. Serial radiographs do, however, play an important role in the follow-up of hip
prostheses, since subtle areas of osteolysis may only be apparent on comparison with prior
radiographs.
Initial postoperative frontal radiograph of the left hip (Fig. 8.4.1) shows a noncemented Radiological
total hip prosthesis. There is no evidence of hardware-related complications. Findings
Frontal radiograph of the left hip 1 year after total hip replacement (Fig. 8.4.2) shows
new radiolucencies greater than 2mm along the superior margin of the acetabular compo-
nent (open arrow) and along the proximal lateral margin of the femoral component (solid
arrow). These findings are suspicious for loosening.
Radiograph 2 years after hip replacement (Fig. 8.4.3) demonstrates marked progression
of the radiolucencies, particularly along the acetabular component (open arrow). The
acetabular component has moved into a more horizontal orientation and is causing remod-
eling and sclerosis along the medial wall of the acetabulum (arrowhead). More small linear
lucencies are also more prominent along the proximal femoral stem (solid arrows).
Radiograph 4 years after hip replacement (Fig. 8.4.4) shows extensive acetabular oste-
olysis with marked protrusio acetabuli and cranial migration of the acetabular component
(open arrow). Only a very thin portion of the medial acetabular wall remains intact (solid
arrow). Areas of osteolysis along the proximal femoral stem are seen both along its medial
(open arrowhead) and lateral aspects. There may be insipient ankylosis between the supe-
rior margin of the greater trochanter and the adjacent ilium (closed arrowhead).
Case 8.5
Osteomalacia with Looser Zones
Fig. 8.5.1
Fig. 8.5.2
Fig. 8.5.3 Fig. 8.5.4

167
Hip and Pelvis
A 42-year-old man presented with left knee pain. MRI showed a nondisplaced fracture
along the inferior pole of the patella, despite the absence of a history of trauma. Three
months later, he had right ankle pain, clinically diagnosed as a sprain. Since the pain did
not resolve, MRI was performed and showed a distal fibular fracture. Seven months later,
he had right inguinal pain, right ulnar pain, and left hand pain. MRI showed bilateral femo-
ral neck stress fractures, right ulnar fracture, and left third metacarpal fracture. Given the
multiple atraumatic fractures, the possibility of myeloma was investigated, even though
there was no evidence for myeloma.
Further laboratory tests showed a mildly elevated parathyroid hormone level, normal
vitamin D levels, and evidence of decreased renal tubular absorption of phosphates.
The clinical diagnosis was hypophosphatemic osteomalacia.
Osteomalacia refers to an abnormality of bone due to inadequate or delayed osteoid min- Comments
eralization. This affects mature cortical and cancellous (spongy) bone. X-linked inherited
renal tubular deficiency or phosphate absorption is the most common cause of hypophos-
phatemic osteomalacia.
Adult skeletal manifestations of X-linked hypophosphatemic osteomalacia include
diffuse sclerosis, well-defined osteophytes, and Looser zones or Milkmans pseudofractures.
Looser zones are radiolucencies that typically run perpendicular to the cortex of bone and
appear similar to fatigue or other insufficiency fractures. In long bones, they may be seen
on the convex (tensile) side of the bone. These lucencies represent unmineralized osteoid
and can be painful. Given the abnormal bone, these may progress to complete fractures. As
these are areas of abnormal bone, these fractures can be considered insufficiency fractures
because they occur under normal loading. Treatment for osteomalacia can be monitored
by assessing the response/regression of these Looser zones.
Frontal radiograph of the pelvis (Fig. 8.5.1) shows bilateral inferomedial femoral neck Radiological
lucencies (open arrows), consistent with insufficiency fractures. Findings
Coronal T1-weighted MRI of the pelvis (Fig. 8.5.2) shows hypointense lines on both
femoral necks involving the marrow and extending to the cortex (open arrows).
Coronal STIR image (Fig. 8.5.3) of the pelvis shows bilateral femoral neck marrow edema
(open arrows) and bilateral periosteal and soft-tissue edema (solid arrows).
Axial STIR image (Fig. 8.5.4) shows bilateral femoral neck marrow edema (open arrows)
due to the bilateral femoral neck insufficiency fractures.
Coronal STIR image of the pelvis shows bilateral femoral neck marrow edema (open
arrows) and bilateral periosteal and soft-tissue edema (solid arrows).
Case 8.6
Femoroacetabular Impingement (Predominantly Cam Type)
Fig. 8.6.1
Fig. 8.6.2
Fig. 8.6.3 Fig. 8.6.4

169
Hip and Pelvis
A 23-year-old athlete presented with worsening of chronic right hip pain over the past year.
He had no history of acute hip injury. Physical examination revealed pain on flexion and
internal rotation and a slightly decreased range of motion compared to the left hip.
Femoroacetabular impingement (FAI) is a well-recognized cause of hip pain in athletes of all Comments
ages. In essence, FAI implies abnormal contact between the femur and the acetabulum. In
cam-type FAI, which appears more frequently in young athletic males, the dominant abnor-
mality is a loss of the normal offset or concavity along the anterosuperior head-neck junc-
tion with a relatively normal acetabulum. There are many methods of quantifying the
head-neck morphological abnormalities, including measuring the alpha angle, degree of epi-
physeal extension, and head-neck offset. In cam-type FAI, damage to the anterosuperior car-
tilage of the acetabulum occurs initially and is then followed by damage to the anterosuperior
acetabular labrum. The triad of an increased alpha angle, anterosuperior cartilage lesions,
and anterosuperior labral lesions as seen on MR arthrography is typical of cam-type FAI.
In pincer-type FAI, which is more common in middle-aged women, the predominant
abnormality involves the acetabulum. Some causes of pincer-type FAI include acetabular
retroversion (focal or diffuse), acetabular overcoverage, and coxa profunda. In pincer-type
FAI, initially there is damage to the anterosuperior labrum with cartilage damage appear-
ing afterwards. There is also a possible contrecoup lesion, which appears as cartilage dam-
age and bony changes along the posteroinferior acetabular rim and femoral head.
Although FAI has classically been divided into cam and pincer types, most patients have
a mixed type of FAI with one form predominating.
There is some evidence that femoral neck synovial herniation pits or fibrocystic change may
be associated with FAI, although it is not clear whether these lesions are more common with
cam-type FAI, pincer-type FAI, or occur in equal frequency in the two types. Fibrocystic change
or edema along the femoral neck warrants close attention to the subtle changes of FAI.
Treatment of FAI involves restoring the normal osseous anatomy and treating associated
lesions of the cartilage and labrum. For the femoral contour, osteochondroplasty is often
performed to restore the normal concavity of the anterosuperior femoral head-neck
junction. Acetabular overcoverage can be treated with acetabular rim trimming or, in severe
cases, acetabular reorientation using a periacetabular osteotomy. Labral lesions are repaired
if possible and cartilage lesions are typically debrided, although cartilage repair techniques
such as microfracture may be attempted.
Oblique fat-suppressed T1-weighted MR arthrogram (Fig. 8.6.1) demonstrates a subtle loss Radiological
of the normal concavity/offsetalong the anterior head-neck junction (open arrow). Findings
Coronal fat-suppressed T1-weighted MR arthrogram (Fig. 8.6.2) demonstrates subtle
epiphyseal extension along the superolateral head-neck junction (open arrow).
Sagittal fat-suppressed T1-weighted MR arthrogram (Fig. 8.6.3) demonstrates an antero-
superior labral tear (open arrow).
Axial fat-suppressed T2-weighted image from another patient (Fig. 8.6.4) shows subtle
marrow edema along the anterior head-neck junction (open arrow).
Case 8.7
Pubalgia Due to Common Adductor Tendon Microavulsion
Fig. 8.7.2
Fig. 8.7.1
Fig. 8.7.3 Fig. 8.7.4

171
Hip and Pelvis
A 17-year-old male soccer player presented with left groin pain of subacute onset. Physical
examination demonstrated tenderness near the symphysis pubis but focal localization of
pain was difficult. There was no significant weakness or loss of range of motion, although
there was some tenderness on active adduction of the left hip.
Pubalgia is a nonspecific term used to describe groin pain or pain near the symphysis Comments
pubis. In athletes, particularly those involved in sports that require rapid acceleration,
deceleration, and changes of direction, groin pain can be extremely debilitating and cause
a significant decrease in performance. It is often difficult to determine the cause of pain
based on clinical examination.
MRI elegantly demonstrates the complex anatomy of the symphysis pubis. One major
cause of athletic pubalgia is injury to the rectus abdominus-adductor complex and/or to
the symphysis pubis. Due to the intimate relationship between the distal rectus abdominus
tendon, the symphysis pubis, and the common adductor tendons, injuries of these struc-
tures are interrelated. Injuries to these structures can be subtle and easily missed on MRI.
Therefore, close attention to imaging technique and meticulous analysis of the images is
needed to accurately diagnose these injuries.
It is important to differentiate osteitis pubis and adductor tendon or rectus abdominus
tendon injury from muscle strains, as the treatment for these entities differs. Tendon tears
that do not respond to conservative therapy may require surgical repair; however, osteitis
pubis is much more likely to require surgical repair. In recalcitrant cases, osteitis pubis may
occasionally be treated with internal stabilization of the symphysis. Muscle strains are
treated conservatively.
Coronal STIR image (Fig. 8.7.1) shows focal high signal along the left inferior aspect of the Radiological
symphysis pubis, consistent with focal partial adductor tendon avulsion (open arrow). This Findings
unilateral extension of high signal is referred to as the secondary cleft sign.
Coronal STIR image (Fig. 8.7.2) just posterior to image 1 shows posterior extension of
the partial adductor tendon avulsion (open arrow).
Axial fat-suppressed T2-weighted image (Fig. 8.7.3) shows focal partial adductor tendon
avulsion along the anteroinferior margin of the symphysis pubis (open arrow).
Axial fat-suppressed T2-weighted image (Fig. 8.7.4) shows a myotendinous strain of the
adductors on the right (open arrow) in a different patient.
Case 8.8
Osteopoikilosis
Fig. 8.8.1
Fig. 8.8.2
Fig. 8.8.3 Fig. 8.8.4

173
Hip and Pelvis
A 21-year-old woman with a history of juvenile chronic arthritis was being followed for
positive antinuclear antibodies, thalassemia minor, and iron-deficiency anemia, but had no
evidence of associated systemic disease. Abdominal ultrasonography performed to
investigate her anemia showed splenomegaly, so CT examination of the abdomen and
pelvis was ordered.
Osteopoikilosis is a benign hereditary condition characterized by multiple sclerotic bone Comments

lesions composed of compact lamellar bone. Typically, these are small, bilateral, and concen-
trated around articulations. However, these sclerotic bone lesions can occur anywhere and be
of any size. Ovoid lesions in long bones are typically oriented along the long axis of the bone.
The lesions are asymptomatic but can resemble osteoblastic metastases. However, unlike
osteoblastic metastases, these lesions do not take up radionuclide on bone scintigraphy.
Frontal radiograph of the pelvis (Fig. 8.8.1) shows increased bone density with multiple Radiological
small rounded sclerotic lesions (arrows) and more coalescent areas of sclerosis in the pos- Findings
terior ilium near the sacroiliac joints (open arrows).
Bone scintigraphy (Fig. 8.8.2) shows no evidence of abnormal radionuclide uptake in
areas of sclerotic bone lesions.
Axial CT at S2S3 (Fig. 8.8.3) shows diffuse increased bone density in the iliac bones
(open arrows) adjacent to the sacroiliac joints. Multiple small rounded sclerotic bone
lesions are seen in both iliac bones and the sacrum (solid arrows).
Axial CT scan (Fig. 8.8.4) just inferior to Fig. 8.8.3 shows similar findings with areas of
more confluent sclerosis (open arrow) and multiple small rounded sclerotic nodules (solid
arrows).
Case 8.9
Rapidly Destructive Osteoarthritis
Fig. 8.9.2
Fig. 8.9.1
Fig. 8.9.3 Fig. 8.9.4

175
Hip and Pelvis
A 78-year-old woman presented with a 10-month history of progressive mechanical pain in

the left inguinal region with radiation to the left leg. Physical examination was difficult due
to rigidity from Parkinsons disease. She had 80 degrees of flexion and essentially no inter-
nal or external rotation. Laboratory results were normal.
Rapidly destructive osteoarthritis of the hip (Postels osteoarthritis) is an uncommon form Comments
of osteoarthritis of the hip characterized by severe rapid cartilage loss and bone remodel-
ing/loss over the course of weeks to months. This entity is typically seen in older women
and is most commonly a painful unilateral process. The clinical picture can resemble that
of a septic joint, and joint aspiration may sometimes be required to rule out infection.
However, laboratory parameters typically show no evidence of an infectious process, such
as an elevated white blood count or erythrocyte sedimentation rate.
In rapidly destructive osteoarthritis, cartilage is lost much faster than in typical osteoar-
thritis: radiographs show 2mm or more of joint space lost per year compared to less than
0.8 mm per year in conventional osteoarthritis. Moreover, unlike typical osteoarthritis,
rapidly destructive osteoarthritis shows marked bone loss in the acetabulum and femoral
head without any significant osteophyte formation. Although neuropathic joints may man-
ifest similar radiographic features, a neuropathic joint is typically painless whereas rapidly
destructive osteoarthritis is a painful condition.
Frontal radiograph of the hip (Fig. 8.9.1) shows moderate degenerative changes with supe- Radiological
rior joint space loss (open arrow) as well as mild sclerosis and buttressing of the medial Findings
aspect of the femoral neck (solid arrow).
Frontal radiograph of the pelvis (Fig. 8.9.2) taken 8 months after Fig. 8.9.1 shows oblit-
eration of the superior joint space and ill-definition of the cortex of the acetabular roof
with small erosions (open arrow). There is superior subluxation of the femur with flatten-
ing and sclerosis of the femoral head (solid arrow) and mild widening of the femoral neck
(arrowhead).
Coronal STIR MRI of the pelvis (Fig. 8.9.3) on the same date as Fig. 8.9.2 shows defor-
mity and increased signal in the acetabular roof and femoral head (open arrow) with small
subchondral cysts in the acetabulum. There is marrow edema in the femoral neck and
proximal femoral diaphysis (solid arrow) and edema in the iliacus muscle (open arrow-
head). A joint effusion is also present (solid arrowhead).
Frontal radiograph of the left hip (Fig. 8.9.4) 15 months after Fig. 8.9.1 shows complete
destruction of the femoral head and acetabular roof and superior dislocation of the
femur.
Case 8.10
Osteonecrosis
Fig. 8.10.1
Fig. 8.10.2
Fig. 8.10.3 Fig. 8.10.4

177
Hip and Pelvis
A 41-year-old man on chronic steroid therapy presented with right hip pain and functional
joint disability.
Avascular necrosis of the femoral head appears in a wide spectrum of clinical conditions: Introduction
corticoid steroid therapy, alcohol abuse, Gaucher disease, lupus, coagulopathies, hyperlipi-
demia, organ transplantation, and thyroid disorders; it may also be idiopathic. Osteonecrosis
may be caused by emboli or increased bone marrow pressure, with subsequent decreased
blood flow, anoxia, and eventual death of trabecular bone.
Avascular necrosis is bilateral in 40% of hips; therefore, it is essential to image both
hips.
In the early stages of osteonecrosis, it is difficult to reach the diagnosis on plain-film
radiographs.
MRI is the most sensitive method to detect early femoral head osteonecrosis; it also
provides information about articular cartilage, marrow conversion, joint fluid, and associ-
ated insufficiency fractures. On MRI, ischemic necrosis shows abnormal areas of low signal
intensity with different patterns: homogeneous or inhomogeneous areas, a marginal line of
low signal intensity with higher signal intensity centrally, subchondral fractures, and corti-
cal collapse.
The Ficat grading system classifies the radiographic findings as: grade 0, no pain and no
radiological findings; grade I, pain, negative plain films and positive MRI and bone scintig-
raphy; grade II, positive plain films (sclerosis-lucency), without subchondral fracture on
MRI; grade III, crescent sign on plain films and subchondral collapse on MRI; and IV, joint
space narrowing and osteoarthritis.
Early diagnosis and treatment of the femoral head osteonecrosis improves the prognosis,
often preventing significant disability.
Positive findings on plain-film radiograph (open arrow) indicate at least stage II osteone- Radiological
crosis (Fig. 8.10.1). MRI is the most specific and sensitive technique to evaluate osteonecro- Findings
sis. Oblique coronal T1-weighted MRI of the right hip shows a mixed signal intensity
subchondral lesion (arrow) involving approximately 45% of the femoral head (Fig. 8.10.2).
Oblique sagittal STIR MRI reveals an area of low signal intensity with a marginal hypoin-
tense line (open arrowhead). High signal intensity edema is seen under the cartilage
(arrowhead) and also bordering the marginal low signal intensity line; no subchondral
fracture is present (Fig. 8.10.3).
Oblique coronal T2-weighted GRE MRI demonstrates stage II osteonecrosis and a small
hip joint effusion (Fig. 8.10.4).
Further Reading Karata M, Baaran C, Ozgl E, Tarhan C, Aildere AM.

Postpartum sacral stress fracture: an unusual case of low-
back and buttock pain. Am J Phys Med Rehabil 2008; 87(5):
Books 418422
Bone and Joint Imaging. 3rd ed. Resnick D, Kransdorf M (2006). Kassarjian A, Belzile E. Femoroacetabular impingement: presen-
Elsevier, Saunders, Amsterdam, Philadelphia tation, diagnosis, and management. Semin Musculoskelet
Diagnosis of Bone and Joint Disorders. 4th ed. Resnick D (ed) Radiol 2008; 12(2):136145
(2002). Saunders, Philadelphia, PA Kassarjian A, Yoon LS, Belzile E, Connolly SA, Millis MB, Palmer
Imaging of the Musculoskeletal System. Pope T, Bloem J, Beltran J, WE. Triad of MR arthrographic findings in patients with
Morrison W, Wilson D (2008). Saunders, Elservier, femoroacetabular impingement (cam type). Radiology 2005;
Philadelphia, Amsterdam 236(2):588592
Magnetic Resonance Imaging in Orthopaedics and Sports Keogh CF, Munk PL, Gee R, Chan LP, Marchinkow LO. Imaging
Medicine. 3rd ed. Stoller DW (2007). Lippincott Williams & of the painful hip arthroplasty. AJR Am J Roentgenol 2003;
Wilkins, Philadelphia 180:115120
Musculoskeletal Imaging: The Requisites. 2nd ed. Manaster BJ, Korompilias AV, Karantanas AH, Lykissas MG, Beris AE.
Disler DG, May DA (2002). Elsevier, Amsterdam Transient Osteoporosis. J Am Acad Ortho Surg 2008; 16(8):
480489
Lagier R, Mbakop A, Bigler A. Osteopoikilosis: a radiological
Web-Links and pathological study. Skeletal Radiol 1984; 1(1):161168
Lin JT, Lutz GE. Postpartum sacral fracture presenting as lumbar
http://www.wheelessonline.com/ radiculopathy: a case report. Arch Phys Med Rehabil 2004;
http://www.rad.washington.edu/academics/academic-sections/ 85(8):13581361
msk/teaching-materials/online-musculoskeletal-radiology- Major NM, Helms CA. Sacral stress fractures in long-distance
book/ runners. Am J Roentgenol 2000; 174:727729
http://emedicine.medscape.com/article/398669-overview Nelson EN, Kassarjian A, Palmer WE. MR imaging of sports-
http://emedicine.medscape.com/article/386808-overview related groin pain. Magn Reson Imaging Clin N Am 2005;
http://www.orthosupersite.com/view.asp?rID=25278#ans 13(4):727742
Rosenberg ZS, Shankman S, Steiner GC, Kastenbaum DK,
Articles Norman A, Lazansky MG. Rapid destructive osteoarthritis:
clinical, radiographic, and pathologic features. Radiology
Benli T, Akalin S, Boysan E, Mumcu EF, Kis M, Turkoglu D. 1992; 182(1):213216
Epidemiological, clinical and radiological aspects of osteo- Stevens MA, El-Khoury GY, Kathol MH, Brandser EA, Chow S.
poikilosis. J Bone Joint Surg Br 1992; 74-B:504506 Imaging features of avulsion injuries. Radiographics 1999;
Bloem JL. Transient osteoporosis of the hip: MR imaging. 19(3):655672
Radiology 1988; 167(3):753755 Vande Berg BC, Malghem JJ, Lecouvet FE etal. Idiopathic bone
Brittenden J, Robinson P. Imaging of pelvic injuries in athletes. marrow edema lesions of the femoral head: predictive value
Br J Radiol 2005; 78(929):457468 of MR imaging findings. Radiology 1999; 212(2):527535
Guerra JJ, Steinberg ME. Current concepts review: distinguish- Watanabe W, Itoi E, Yamada S. Early MRI findings of rapidly
ing transient osteoporosis from avascular necrosis of the hip. destructive coxarthrosis. Skeletal Radiol 2002; 31(1):3538
J Bone Joint Surg [Am] 1995;77:616 Wootton JR, Cross MJ, Holt KWG. Avulsion of the ischial apo-
Gupta KB, Duryea J, Weissman BN. Radiographic evaluation of physis. J Bone Joint Surg [Br] 1990; 72:625627
osteoarthritis. Radiol Clin N Am 2004; 42:1141 Wurdinger S, Humbsch K, Reichenbach JR, Peiker G, Seewald HJ,
Hardy DC, Murphy WA, Siegel BA, Reid IR, Whyte MP. X-linked Kaiser WA. MRI of the pelvic ring joints postpartum: normal
hypophosphatemia in adults: prevalence of skeletal radio- and pathological findings. J Magn Reson Imaging 2002; 15(3):
graphic and scintigraphic features. Radiology 1989; 171:403 324329
Ito H, Matsuno T, Minami A. Relationship between bone marrow Zajick DC, Zoga AC, Omar IM, Meyers WC. Spectrum of MRI
edema and development of symptoms in patients with findings in clinical athletic pubalgia. Semin Musculoskelet
osteonecrosis of the femoral head. AJR Am J Roentgenol Radiol 2008; 12(1):312 (review)
2006; 186(6):17611770 Zoga AC, Kavanagh EC, Omar IM, Morrison WB, Koulouris G,
Jacobson JA, Kalume-Brigido M. Case 97: X-linked hypophos- Lopez H, Chaabra A, Domesek J, Meyers WC. Athletic pubal-
phatemic osteomalacia with insufficiency fracture. Radiology gia and the sports hernia: MR imaging findings. Radiology
2006; 240(2):607610 2008; 247(3):797807
Knee 9
Joan C. Vilanova, Sandra Baleato, and Joaquim Barcel
180 J. C. Vilanova, S. Baleato, and J. Barcel
A 74-year-old woman presented with a 6-month history of pain and swelling in

Case 9.1 her right knee.
Lipoma Arborescens
Fig. 9.1.1
Fig. 9.1.2
Fig. 9.1.3 Fig. 9.1.4

181
Knee
Lipoma arborescens is a rare benign intraarticular lesion characterized by the replacement Comments
of subsynovial tissue by mature fat cells giving rise to a villous proliferation. It usually
involves the suprapatellar pouch of the knee, although it has also been reported in other
locations, including the shoulder, subdeltoid bursa, hip, elbow, hand, and ankle. Bilateral
involvement of the knees, wrists, ankles, and hips, as well as multiple joint involvement has
also been observed. Clinically, the most common finding is a slow increase in painless
swelling, accompanied by intermittent joint effusion. Most affected patients are in the fifth
to seventh decades of life. Lipoma arborescens can be similar to other proliferations of the
synovial membrane, but its characteristic feature is the macroscopic hypertrophic lipoma-
tous synovial tissue. The term arborescens, from the Latin word arbor meaning tree, defines
the characteristic morphology of this lipomatous villous synovial proliferation that resem-
bles a tree. Magnetic resonance images (MRI) of lipoma arborescens correspond to and
correlate with the fatty proliferation of the synovial lesion, which makes it possible to reach
a specific diagnosis. MRI characterizes soft-tissues better than other imaging techniques
and also enables fat suppression (STIR sequences). For these reasons, the histological
appearance of lipoma arborescens within the synovial tissue can be perfectly correlated on
MRI.
Lipoma arborescens must be differentiated from other synovial lesions. The differential
diagnosis should include other diffuse pathology of the synovium: villonodular pigmented
synovitis, synovial chondromatosis, synovial hemangioma, and rheumatoid arthritis.
Villonodular pigmented synovitis typically shows a diffuse low signal associated to
hemosiderin. Synovial chondromatosis shows an intermediate-low signal on T1- and
T2-weighted images related to the cartilaginous nature of the lesion. An association
between lipoma arborescens and osteochondromatosis has been suggested, as there is a
differentiation of the synovial tissue in both pathologies: to adipocytes in lipoma arbore-
scens and to osteochondral tissue in osteochondromatosis. The differential diagnosis
should also be done with synovial hemangiomas, which show intermediate signal intensity
on T1- and T2-weighted images with areas of low-signal intensity due to phleboliths or
fluid void within a linear punctate lesion of high-signal intensity, corresponding to fibrous
fatty septa between the vascular channels. Chronic rheumatoid arthritis shows intermedi-
ate-low signal on T1- and T2-weighted images, associated with the formation of fibrous
pannus.
Although it has been suggested that lipoma arborescens might be associated with
osteoarthritis, rheumatoid arthritis, or trauma, its exact etiology remains unknown.
Parasagittal T1-weighted image (Fig. 9.1.1) of the suprapatellar pouch of the knee shows Radiological
the villous lipomatous proliferation of the synovium from a lipoma arborescens (open Findings
arrows). A midsagittal T1-weighted image (Fig. 9.1.2) from the same series shows an ossi-
fied body (arrow) from synovial osteochondromatosis as a coincidence in the same patient:
an association between the two pathologies has been suggested. Coronal STIR sequence
(Fig. 9.1.3) demonstrates the low-signal intensity of the lipoma arborescens similar to fat
(open arrowhead). Axial T2-weighted image (Fig. 9.1.4) shows the diffuse villous prolifera-
tion of the synovium from the suprapatellar pouch (arrowhead).
A 57-year-old woman presented with intermittent pain and swelling of the

Case 9.2 knee.
Pigmented Villonodular
Synovitis Pigmented villonodular synovitis (PVNS) is a rare disease characterized by
Comments idiopathic proliferation of synovial tissue in the joint, tendon sheath, and
bursa of unknown cause. It may occur in two forms: diffuse or localized.
Localized forms appear as a single intraarticular nodule, clinically mimicking
a loose body or a torn meniscus. Diffuse forms present clinically as chronic
Fig. 9.2.1 Fig. 9.2.2
Fig. 9.2.3 Fig. 9.2.4

183
Knee
monoarthritis. PVNS usually affects patients in the second and third decades of life, with no
sex predominance.
PVNS is a locally aggressive lesion that may invade and destroy surrounding soft-tissue
and bone, resulting in functional deterioration of the joint and extremity. The most com-
mon location is the knee, followed by the hip, shoulder, and other joints. Spinal PVNS, fre-
quently involving the posterior elements, is a rare condition.
The clinical findings depend on the location and extent of the disease. In the diffuse form,
mild pain and limitation of range of motion are the main symptoms. These symptoms are
commonly related to joint effusions that occur in episodes: the patient may have completely
symptom-free periods between exacerbations. In superficial joints, the swelling and local
warmth due to effusion are easily noted. Hemarthrosis is a common finding in diffuse PVNS.
Plain-film radiographs may be normal or may reveal nonspecific changes, depending on
the severity of the disease. Calcification is rarely seen on plain-film radiographs. Bony
changes, including marginal erosion and cysts, occur in one third of the diffuse lesions,
particularly in a chronic setting with preservation of joint spaces. The MRI features of
PVNS are highly suggestive but not pathognomonic. In addition to its role in diagnosing
PVNS, MRI provides detailed information regarding the extent of the disease. MRI is the
method of choice since the hemosiderin deposition leads to signal loss on both the T1- and
T2-weighted images, particularly on gradient-echo sequences. PVNS manifests on MRI as
a stalked mass growing from the synovium with heterogeneous signal intensity in all the
imaging sequences manifesting as a combination of low-signal intensity areas (created by
the paramagnetic effects of hemosiderin deposits and fibrous tissue) and high-signal
intensity areas (representing congested synovium and fat content). Joint effusion is shown
as low-intermediate signal on T1-weighted sequences and high signal on T2-weighted
sequences. Bone erosions are well demonstrated on MRI, appearing as cortical discontinu-
ity caused by low and high-signal tissue on both T1- and T2-weighted images. Gadolinium
enhancement depends on the amount of inflammation and vascularity; PVNS lesions dem-
onstrate intense gadolinium enhancement, which may be useful to differentiate the syn-
ovium from nonenhancing fluid and to help define the extent of the lesion.
The differential diagnosis includes hemophilic arthropathy, rheumatoid arthritis, amy-
loid arthropathy, arborescens lipoma, and synovial osteochondromatosis.
PVNS is treated with complete synovectomy, which can be done using arthroscopic or
open techniques. Incomplete synovectomy is associated with a high incidence of recurrence.
Postoperative radiotherapy using low to moderate doses may be beneficial if there is
residual tumor or recurrence.
Sagittal T1-weighted FSE image (Fig. 9.2.1) shows lobulated low-signal intensity soft tissue Imaging Findings
in the suprapatellar pouch and in the popliteal fossa with extracapsular extension. MRI
shows bony changes: a high-signal hemorrhagic cyst (open arrow) in the tibial attachment
and a complex cyst in the tibial plateau (arrow). On the corresponding sagittal T2-weighted
FSE image (Fig. 9.2.2), the synovial proliferation shows low-signal intensity due to hemo-
siderin deposits. The complex and hemorrhagic bone cysts are well depicted. The most
useful sequence to demonstrate the presence of hemosiderin is the T2-weighted gradient-
echo sequence (Figs. 9.2.3 and 9.2.4) due to the susceptibility artifact from the blood.
Case 9.3
Spontaneous Osteonecrosis of the Knee
Fig. 9.3.1 Fig. 9.3.2
Fig. 9.3.3 Fig. 9.3.4

185
Knee
A 58-year-old woman presented with sudden onset of medial knee pain with no prior
trauma.
Idiopathic or spontaneous osteonecrosis of the knee (SONK) is a distinct form of epiphy- Comments
seal osteonecrosis; its clinical, histologic, and imaging features completely separate SONK
from avascular necrosis of the knee. Although the pathogenesis of SONK remains contro-
versial, a mechanical or microtraumatic origin has progressively emerged as the most
likely underlying mechanism of SONK. SONK is more common in middle-aged to elderly
people and in females. No association with metabolic disorders or therapeutic agents has
been found. However, a significant association with meniscal lesions (especially radial tear
or prior meniscal resection) has been reported. SONK is usually unilateral and has a strong
predilection for the medial femoral condyle (90% of cases).
Clinically, patients present severe knee pain of sudden onset in the absence of significant
trauma. SONK can be classified into four stages based on symptoms and radiologic criteria.
In general, stages I and II, the early stages, are potentially reversible or show no progres-
sion, whereas stages III and IV are end stages in the course of the disease and are associated
with irreversible destruction of subchondral bone and articular cartilage that requires
some form of reconstructive surgery.
The most prominent MRI characteristics of SONK are the poorly delimited bone mar-
row edema pattern and the lack of a peripheral rim as seen in avascular necrosis. Bone
marrow edema is not specific to SONK and may also be observed in transient epiphyseal
conditions (transient osteoporosis, trauma, infection, transient bone marrow edema,
algodystrophy).
SONK is seen on MRI as a focal or diffuse hypointense signal abnormality on T1-weighted
images; it predominantly involves the weight-bearing, subarticular portion of the medial
femoral condyle. On T2-weighted sequences, the signal pattern is usually varied. The insuf-
ficiency fracture can be seen as a linear, dark signal focus along the subarticular bone on
both T1- and T2-weighted images. Marrow edema and subsequent necrosis replace the
normal fat signal of the marrow and appear hypointense on T1-weighted sequences and
hyperintense on T2-weighted sequences.
Although, the clinical picture of SONK seems similar to several other disorders, certain
distinct features, including its typical location, clinical symptoms, relative lack of loose
bodies, and late onset of cartilaginous erosion, help distinguish it from other disorders and
facilitate the differential diagnosis.
Sagittal T1-weighted FSE image (Fig. 9.3.1) shows a subchondral low-signal intensity in the Imaging Findings
medial femoral condyle. The corresponding sagittal T2-weighted GE image (Fig. 9.3.2) shows
the focal subchondral area with a low-signal intensity rim due to sclerosis and high-signal
due to necrosis. Coronal fat-suppressed proton density-weighted FSE image (Fig. 9.3.3)
shows the necrotic lesion with edema surrounding the lesion. Axial fat-suppressed proton
density-weighted FSE image (Fig. 9.3.4) depicts the necrotic area.
Case 9.4
Discoid Meniscus
Fig. 9.4.1 Fig. 9.4.2
Fig. 9.4.3 Fig. 9.4.4

187
Knee
A 31-year-old woman was referred for knee pain. At physical examination, she had the full
range of motion. Plain-film radiographs of the knee were normal.
Many types of meniscal anomalies have been reported: discoid meniscus, meniscal ossicles, Comments
and the meniscal flounce. Discoid meniscus is the most common of these.
Discoid lateral meniscus (DLM) is an uncommon normal variant seen in 16% of
patients undergoing arthroscopic studies. Its congenital or acquired origin remains a ques-
tion of debate. It is associated with pain, snapping, locking, and instability of the knee but
can be entirely asymptomatic. The three types of DLM are complete, incomplete, and the
Wrisberg variant. Discoid medial meniscus is much less common, with a reported inci-
dence of 0.120.6%.
MRI can easily diagnose these entities. On MRI, a discoid meniscus is identified on three
or more contiguous 5-mm-thick sagittal images or a meniscal body greater than 15mm
wide or extending into the intercondylar notch is seen on coronal images. The classic con-
figuration is a diffusely thick wafer or slab meniscus with continuity between the anterior
and posterior horns. On sagittal MRI, the typical bow-tie configuration of the normal
meniscus is not identified.
DLM is more susceptible than a normal meniscus to mechanical forces. As a result, indi-
viduals with DLM have a higher incidence of meniscal tear and cystic degeneration. In
arthroscopic series, meniscal tears in patients with DLM are found in approximately
3888% of patients.
A symptomatic discoid meniscus usually leads to diffusely high-signal that may extend
to the joint surface.
The treatment of a discoid meniscus depends on its type and whether it is associated
with a tear. The complete and incomplete types have a firm, normal posterior tibial attach-
ment and are stable. If a discoid meniscus is discovered with no evidence of a tear, then its
presence should be considered incidental and it should be left intact.
If a tear is associated with a complete or incomplete discoid meniscus, then partial
meniscectomy should be performed. In contrast, the Wrisberg variant has no capsular
attachments and the traditional treatment has been total meniscectomy; however, some
investigators have recommended partial meniscectomy with repair.
Consecutive coronal proton density-weighted images (Figs. 9.4.1 and 9.4.2) demonstrate Imaging Findings
the abnormal width of the lateral meniscus. There is a rupture of the medial meniscus
(open arrow). Contiguous sagittal T2-weighted GE MRI (Figs. 9.4.3 and 9.4.4) through the
lateral compartment of the knee reveal a lateral discoid meniscus, extending into the inter-
condylar notch.
Case 9.5
Osgood-Schlatter Disease
Fig. 9.5.1 Fig. 9.5.2
Fig. 9.5.3
189
Knee
A 14-year-old boy presented with tenderness around the right tibial tuberosity.
OsgoodSchlatter disease (OS) is a typical sport-related complaint that occurs in active ado- Comments
lescents. This lesion frequently affects boys between 10 and 15 years of age and is bilateral in
about 2550% of cases. Many theories have been advanced to explain the etiology of the
disease; these include trauma, avascular necrosis, infection, and endocrine abnormalities,
among others. The most widely accepted explanation is Odgens theory that OS is due to an
avulsion of the secondary ossification center. OS results from repeated tensile extension
forces applied by the quadriceps on the tubercle via the patellar tendon resulting in avulsion
of segments of anterior cartilage and/or anterior bone. At physical examination, swelling
and prominence of the tibial tubercle are accompanied by extreme local tenderness.
The diagnosis of OS is almost always established clinically. Imaging, including radio-
graphs, MRI, and skeletal scintigraphy are mainly useful for excluding other pathology.
Findings on plain-film radiographs in OS disease include soft-tissue swelling anterior to
the tibial tubercle, blurring of the margins of the patellar tendon and inhomogeneity of the
infrapatellar fat pad. The tibial tubercle may be irregularly ossified and fragmented,
although in the absence of symptoms, this appearance can appropriately be considered a
normal variant.
MRI shows enlargement and increased T2-weighted signal intensity of the tendon at its
insertion on the tibial tubercle, in the surrounding soft tissues, and in adjacent bone mar-
row. Skeletal scintigraphy may show asymmetrically increased tracer uptake in or around
the patellar tendon.
Treatment includes suspension of sporting activity and a variety of conservative
therapies: infrapatellar strap, ice, massage, and local injection of steroids or lidocaine. OS
is often self-limiting and most patients respond to conservative treatment. Surgery can be
an alternative treatment in cases where symptoms persist.
Sagittal T1-weighted MRI (Fig. 9.5.1) reveals an ossicle of the tendon associated with a Imaging Findings
defect in the anterior cortex of the tibial tubercle (open arrow). The corresponding sagittal
T2-weighted GRE image (Fig. 9.5.2) demonstrates the marrow fat-containing fragment
(arrow). Axial T1-weighted MRI (Fig. 9.5.3) of the knee at the level of the patellar tendon
insertion on the tibial tubercle shows the ossification (open arrowhead).
Case 9.6
Chondromalacia
Fig. 9.6.2
Fig. 9.6.1
Fig. 9.6.3
191
Knee
A 29-year-old woman presented with a 1-month history of anterior knee pain. MRI was
performed after findings on plain-film radiographs were normal.
Chondromalacia of the patellae is pathologic softening of the patellar cartilage. It is one of Comments
the most common causes of knee pain in adolescents and young adults.
Multiple causes have been reported; trauma and mechanical tracking abnormalities are
the most common. Identifying and staging cartilaginous lesions are therefore crucial to estab-
lish the correct treatment and halt the progression of the degenerative process.
MRI can show signal and morphologic changes in the cartilage and can detect cartilage
surface fraying, fissuring, and varying degrees of cartilage thinning. The two most easily
implemented techniques for articular cartilage evaluation are the fat-suppressed three-
dimensional spoiled gradient-echo technique (3D GRE), which produces T1-weighted
images and a fast spin-echo technique, which produces T2-weighted images.
New MRI methods to evaluate physiological parameters in cartilage include: T2 mapping of
articular cartilage, based on the water content of the tissue; sodium imaging, which can depict
regions of glycosaminoglycan depletion; and diffusion-weighted imaging and diffusion tensor
imaging, which provide information about the architecture and matrix of the cartilage.
Cartilage is considered abnormal when focal areas of altered signal are present, as well as
irregularities, defects, or swelling of the articular surface and areas of edema or sclerosis of
subchondral bone.
Several classifications of patellar chondromalacia have been proposed.The International
Cartilage Repair Society (ICRS) classification defines five grades:
Grade 0: Normal. Homogeneous signal intensity without superficial irregularities.
Grade 1: Nearly Normal. Superficial lesions, soft indentation and/or superficial fissures
and cracks.
Grade II: Abnormal. Lesions extending down to <50% of cartilage depth.
Grade III: Severely abnormal. Cartilage defects extending down >50% of cartilage depth
as well as down to the calcified layer and down to but not through the subchondral bone.
Grade IV: Severely abnormal. Defects include the subchondral plate and also the adja-
cent cancellous bone.
Different surgical procedures are currently available: bone marrow stimulation,
osteochondral autografts, autologous chondrocyte transplantation (ACT), and matrix-
assisted ACT. The main advantage of bone marrow stimulating techniques is their minimally
invasive approach. Osteochondral autografting (mosaicplasty) affects the subchondral
plate and shows fibrous tissue between the single hyaline plugs, basically leading to a mixed
repair tissue. To perform autologous chondrocyte transplantation, a small sample of
cartilage is taken in an arthroscopic biopsy and cultivated. The propagated cells are injected
beneath a periosteal graft and the defect is closed with watertight sutures.
Axial T2-weighted FSE images (Figs. 9.6.1 and 9.6.2) reveal increased signal intensity within Radiological
the cartilage perpendicular to the surface and extending through the cortex (open arrows), Findings
making this grade III chondromalacia without subchondral edema. Sagittal T1-weighted
FSE image (Fig. 9.6.3) reveals mild subchondral sclerosis (open arrowhead).
A 46-year-old woman presented with pain 5 days after acute injury to the knee.
Case 9.7
Meniscal Tear The meniscus is made up of fibrocartilage and provides shock absorption and lubrica-
Comments tion. Its circumferential fibers are organized as parallel bundles and serve to resist hoop
stresses. Its radially oriented fibers serve to resist shear stress. The periphery of the
meniscus (red zone arthroscopically) has greater vascularity and greater healing poten-
tial than the avascular portion (white zone).
The menisci are wedge-shaped, semilunar (C-shaped) structures with a concave supe-
rior surface and a flat inferior surface, allowing maximal congruency between the femur
and tibia. Typically, the medial meniscus is larger than the lateral meniscus and has a
greater radius of curvature.
Fig. 9.7.2
Fig. 9.7.1
Fig. 9.7.3
193
Knee
The normal meniscus has low-signal on all MRI sequences. On sagittal slices, both menisci
have a bow-tie configuration on the most peripheral sections. The more central slices dem-
onstrate separate anterior and posterior horns with a triangular configuration showing sharp
margins. On coronal slices, the anterior and posterior horns span across the tibial plateau,
whereas the body has a triangular configuration, reflecting the C-shaped configuration.
There are two major criteria routinely applied for the diagnosis of meniscal tear: abnor-
mal signal intensity and abnormal morphology. Increased signal within the meniscus is
considered to be a tear when it unequivocally extends to the articular surface. If the abnor-
mal signal intensity comes into contact with the articular surface on a single slice in a sin-
gle plane, the sensitivity for a meniscal tear is 55% medially and 30% laterally.
A three-level grading system characterizes meniscal signal intensity. In grade 1, irregu-
lar increased intrameniscal signal does not extend to the articular surface; this is believed
to reflect early degenerative findings. In grade 2, the signal is linear and may connect to the
capsular margin; these features are believed to reflect more severe degenerative findings. In
grade 3, a linear or complex signal extends to the articular surface on more than one slice;
this is unequivocally a tear. Meniscal tears are classified as horizontal, vertical (longitudi-
nal, radial, or oblique), or complex. A horizontal tear is parallel to the tibial plateau and
separates the meniscus into upper and lower parts. A longitudinal vertical tear is perpen-
dicular to the tibial plateau and propagates parallel to the main (circumferential) axis of
the meniscus. A radial vertical tear propagates perpendicular to the main axis. An oblique
or parrot-beak vertical tear propagates obliquely to the main axis of the meniscus. A com-
plex tear comprises two or more tear configurations.
The second major criterion for meniscal tear is morphology. Meniscal shape is impor-
tant and subtle findings of amputation may be the only sign of a tear. A bucket-handle tear
is a specific type of displaced meniscus that results when the inner meniscal segments of a
longitudinal or oblique tear is displaced, most commonly into the intercondylar notch.
MRI is also useful and accurate for predicting whether meniscal tears can be repaired.
The configuration, location, and size of meniscal tears are important in determining the
type of treatment. Four alternatives exist for treatment of meniscal tears: no meniscal sur-
gery, meniscal repair, partial meniscectomy, and complete meniscectomy. Longitudinal and
oblique configurations are usually reparable, whereas horizontal, radial, and complex con-
figurations are usually not reparable and require partial meniscectomy.
The report of an MRI examination of the meniscus should describe its location (anterior
horn, body, posterior horn), plane, shape, completeness, length, and the number of tears.
The tear should be described as horizontal, vertical, complex, displaced flap, bucket-handle,
or meniscocapsular separation.
Sagittal T2-weighted GRE image (Fig. 9.7.1) shows a horizontal tear of the posterior horn Radiological
of the medial meniscus extending to the inferior articular surface (open arrow). Coronal Findings
fat-saturated proton density-weighted image (Fig. 9.7.2) demonstrates the rupture of the
medial meniscus (open arrow). The consecutive image (Fig. 9.7.3) shows inflammatory
edema from the medial condyle.
Case 9.8
Osteochondritis Dissecans
Fig. 9.8.1 Fig. 9.8.2
Fig. 9.8.3 Fig. 9.8.4

195
Knee
A 16-year-old athlete presented with a history of vague knee pain over several months that
limited his physical training.
There are two main types of OCD: the adult form, which occurs after the physis closes, and Comments
the juvenile form, which occurs in patients with an open epiphyseal plate. Although adult
osteochondritis dissecans may arise de novo, it is usually the result of an incompletely healed
and previously asymptomatic lesion from juvenile osteochondritis dissecans. Adult osteo-
chondritis dissecans usually presents between the ages of 17 and 36 years, but it can be seen
at any adult age. The separation of OCD of the knee into juvenile and adult forms is clinically
relevant, as the two pathologic conditions have distinctly different clinical courses.
OCD of the knee most commonly involves, in order of decreasing frequency, the medial
femoral condyle, the lateral femoral condyle, the femoral trochlea, and the patella.
Juvenile osteochondritis dissecans occurs in adolescent athletes, more frequently in boys;
the average age of the patients at the time of the diagnosis ranges from 11.3 to 13.4 years.
About a third of all cases of juvenile OCD are bilateral. The lateral aspect of the medial
femoral condyle is the most commonly affected location in the knee. A focal area of sub-
chondral bone and articular cartilage becomes avascular and may detach to form a loose
body. The mechanism of this injury is uncertain although both repetitive microtrauma and
a single acute trauma event have been implicated.
Findings on plain-film radiographs may initially be normal. MRI demonstrates sub-
chondral edema. In later stages, radiographs may show a lucent crescent-shaped defect in
the subchondral area with or without loose bodies.
MRI can be used for precise staging and postoperative follow-up after chondral trans-
plantation. Stability is the single most important prognostic factor for determining the
likelihood of an OCD lesion to heal with conservative therapy. T2-weighted MRI is able to
demonstrate the grade of the lesion and the degree of stability as well as to visualize the
cartilage; thus, it plays an important role in treatment planning. Fluid between the frag-
ment and adjacent bone indicates disruption of the overlying cartilage and a likelihood
that the fragment will separate and become a loose body within the joint. Based on the MRI
findings, joints with OCD can be classified into the following stages:
Stage I: Thickening of articular cartilage and low signal changes (stable). Stage II: Articular
cartilage breached, low-signal rim behind the fragment indicating fibrous attachment (sta-
ble). Stage III: Articular cartilage breached, high-signal changes behind the fragment and
underlying subchondral bone (unstable). Stage IV: Loose body (unstable). Stages I and II are
stable lesions, while stages III and IV describe unstable lesions in which not only is the car-
tilage breached, but synovial fluid exists between the fragment and underlying bone.
Sagittal T1-weighted image (Fig. 9.8.1) shows classic osteochondritis with low-signal of Radiological
the fragment. Corresponding T2-weighted GRE image (Fig. 9.8.2) demonstrates hyperintensity Findings
between the lesion (open arrow) and the adjacent bone, representing an unstable lesion.
Coronal fat-suppressed proton density-weighted FSE image (Fig. 9.8.3) depicts high signal of
the necrotic fragment from the nonweight-bearing lateral aspect of the medial condyle. Axial
fat-suppressed proton density-weighted FSE image (Fig. 9.8.4) displays the eccentric lesion.
Case 9.9
Mucoid Degeneration of the Anterior Cruciate Ligament with Ganglion Bone Cyst
Fig. 9.9.1
Fig. 9.9.2
Fig. 9.9.3
197
Knee
A 48-year-old man presented with a 2-year history of increasing pain on motion and
difficulty extending the left knee. At physical examination, no swelling, ballottement of the
patella, or instability was seen. The range of motion was limited. Plain-film radiographs
showed slight degenerative change in the medial side of the knee.
Mucoid degeneration of the anterior cruciate ligament (ACL) is a rare cause of knee dys- Comments
function. Mucoid degeneration of the ACL and ganglia represent different manifestations
of the same pathologic condition. Bergin etal. found 76% patients had discrete intraliga-
mentous ganglia, 24% had features consistent with ACL mucoid degeneration only, and
35% had MRI features of both entities. The mean age of patients with ACL mucoid degen-
eration was 43 years (range 2266 years).
The clinical presentation of mucoid degeneration of the ACL is variable; most cases are
discovered incidentally in asymptomatic patients. In some cases, symptoms are varied but
nonspecific, including knee pain, locking, clicking or popping sensations, and decreased
range of motion. Ganglia anterior to the ACL tend to limit knee extension and posterior
cruciate ligament ganglia limit knee flexion.
The pathogenesis of cruciate ganglion cysts remains unclear. Two theories have been
postulated: the first attributes the presence of a ganglion to mucinous degeneration of the
connective tissue, and the second attributes it to herniation of synovial tissue through a
defect in the joint capsule of the tendon sheath, similar to those occurring in the wrist.
MRI is recognized as the gold standard in characterizing cystic knee lesions and is the
only imaging method that can depict mucoid degeneration of the ACL.
MRI findings for mucoid degeneration of the ACL are similar to those for intraligamen-
tous ganglion of the ACL. The characteristic MRI features of intraligamentous ganglion
include sharply demarcated, homogenous, hyperintense signal intensity on T2-weighted
and proton density-weighted images. MRI in mucoid degeneration demonstrates normal
orientation of the ligament, thickened and ill-defined ACL fibers, and increased intraliga-
mentous signal intensity on T2-weighted and proton density-weighted images. Mucoid
degeneration of the ACL was described as a potential pitfall for the diagnosis of a ligament
tear.
ACL ganglion cysts commonly occur in association with MRI features of mucoid
degeneration and these entities are typically not associated with ligament insufficiency.
Intraosseous ganglia at the femoral and tibial attachments have a high association with
these entities.
Sagittal T2-weighted FSE image (Fig. 9.9.1) shows an ill-defined enlarged ligament with Radiological
increased signal intensity in the normal orientation and two intraosseous cysts at the tibial Findings
insertion. Coronal STIR image (Fig. 9.9.2) shows a ganglion cyst in the tibia. Coronal
T2-weighted FSE image (Fig. 9.9.3) reveals an intraosseous cyst at the femoral insertion of
the ACL.
Case 9.10
Acute Meniscal and Ligament Tears of the Knee
Fig. 9.10.1 Fig. 9.10.2
Fig. 9.10.3 Fig. 9.10.4

199
Knee
A 15-year-old boy presented with pain in his left knee 6 weeks after an acute traumatic
injury.
Complex injuries of the knee are common after accidents or sports-related injuries.
MRI is the preferred imaging technique to assess joint injuries. These lesions occur as a Comments
result of multiple forces (varus, valgus, rotation, and hyperextension) applied to the joint.
Depending on the mechanism of injury, different patterns can be recognized. The nor-
mal ACL is a straight, taut structure that runs parallel to the roof of the intercondylar
notch. ACL tears occur more frequently (70%) in the middle aspect of the ligament. Sagittal
T2-weighted images are recommended to depict the ACL. Different signs reveal ACL inju-
ries. Primary signs involve the absence of the normal dark band of the ACL. Secondary
signs are bone-related injuries due to the indirect mechanism of the traumatic event
(microfracture of the posterolateral aspect of the tibial plateau and lateral femoral con-
dyle) and soft-tissue signs secondary to the anterior translation of the tibia. These indirect
signs have a low sensitivity but a high specificity.
The posterior cruciate ligament (PCL) appears as a low-signal structure in the intercon-
dylar notch, gently curving between the posterior aspect of the proximal tibia and the dis-
tal femur. Most PCL tears are incomplete and intrasubstance and are best seen on sagittal
images. Isolated PCL injuries make up only 30% of cases.
The medial collateral ligament (MCL) originates on the medial aspect of the distal femur
and inserts on the medial aspect of the proximal tibia. MRI shows the MCL as a thin dark
band. MCL injuries are revealed on fluid-sensitive coronal sequences and their treatment
with either immobilization or surgery depends on the presence or absence of meniscal tear
or ACL injuries.
The menisci are fibrocartilaginous structures attached to the superior aspect of the tib-
ial plateau. MRI is the best imaging modality for the evaluation of meniscal trauma.
The normal meniscus is devoid of signal on all sequences, but linear images are seen
within the menisci when they are torn. Medial meniscus tears are associated with MCL
rupture in nearly 70% of cases. Meniscal tears are described as horizontal, vertical, radial,
and longitudinal. A different type of meniscal tear is the bucket-handle tear (BHT), which
tends to involve the medial meniscus. BHT is a longitudinal vertical tear with unstable
displaced inner fragment that can usually be found in the intercondylar notch.
The presence of the displaced fragment within the intercondylar notch is known as the
double PCL sign and can be seen on sagittal images.
Coronal fat-suppressed T2-weighted FSE MRI (Figs. 9.10.1 and 9.10.2) reveals increased Imaging Findings
signal in the distal insertion of the MCL (open arrow) and a BHT of the medial meniscus
with a fragment displaced into the notch (arrow). Edema on the lateral condyle of the femur
is an indirect sign of ACL rupture (Fig. 9.10.1).
Sagittal T2-weighted FSE (Fig. 9.10.3) and GRE (Fig. 9.10.4) MRI through the intercon-
dylar notch shows the absence of the ACL (open arrowhead) without clearly identifiable
fibers. The PCL shows increased signal with surface disruption on its proximal insertion
(arrowhead). A small joint effusion is present.
Further Reading Hirano A, Fukubayashi T, Ishii T, Ochiai N. Magnetic resonance

imaging of Osgood-Schlatter disease: the course of the dis-
ease. Skeletal Radiol 2002; 31(6):334342
Books Hofmann S, Kramer J, Vakil-Adli A, Aigner N, Breitenseher M.
Diagnosis of Bone and Joint Disordes. Vol 15. Resnik D, Painful bone marrow edema of the knee: differential diagnosis
Niwayama G (2002). Saunders, Philadelphia and therapeutic concepts. Orthop Clin North Am 2004; 35(3):
Fundamentals of Skeletal Radiology. Helms CA (2005). WB 321333
Saunders, Philadelphia Jee WH, McCauley TR, Kim JM et al. Meniscal tear configura-
Magnetic Resonance Imaging in Orthopaedics and Sports tions: categorization with MR imaging. AJR Am J Roentgenol
Medicine. Stoller DW (2006). Lippincott Williams & Wilkins, 2003; 180(1):9397
Philadelphia Kijowski R, Blankenbaker DG, Shinki K, Fine JP, Graf BK, De
Musculoskeletal Imaging: The Requisites (Requisites in Radiology). Smet AA. Juvenile versus adult osteochondritis dissecans of
Manaster BJ, May DA, Disler DG (2006). Mosby-Yearbook, St the knee: appropriate MR imaging criteria for instability.
Louis Radiology 2008; 248(2):571578
Musculoskeletal MRI. Kaplan P, Helms CA, Dussault R, Anderson Kocher MS, Tucker R, Ganley TJ, Flynn JM. Management of
M (2001). WB Saunders, Philadelphia osteochondritis dissecans of the knee: current concepts
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Lang P, Noorbakhsh F, Yoshioka H. MR imaging of articular car-
tilage: current state and recent developments. Radiol Clin
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Ankle and Foot 10
Xavier Tomas and Ana Isabel Garcia
202 X. Tomas and A. I. Garcia
A 63-year-old woman presented with a 3-month history of left ankle

Case 10.1 pain. She recalled a traumatic ankle sprain 6 months before. Plain-
film radiographs and MRI were obtained.
Osteochondral Talar Lesion
Introduction The name osteochondral lesion mainly describes a posttraumatic

lesion involving an area of hyaline cartilage at an articular surface
and its underlying subchondral bone. This process can precipitate to
loss of continuity at the talar articular surface, with decreased range
of ankle motion and eventually osteoarthritis.
Findings at plain-film radiography can be normal in the earliest
stage (Stage I of the Berndt and Harty classification), when no
detached fragment is present. Many patients report a previous ankle
sprain with normal radiographs and atypically prolonged pain.
Fig. 10.1.1
Fig. 10.1.2 Fig. 10.1.3
Fig. 10.1.4 Fig. 10.1.5

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Ankle and Foot
MRI is the gold standard for diagnosing and staging osteochondral lesions. A subtle
poorly delimited subchondral focus that is hypointense on T1-weighted and hyperintense
on T2-weighted images reveals focal marrow edema due to subchondral trabecular com-
pression without detachment (Stage I). A well-delimited, nondisplaced subchondral lesion
that is hypointense on T1-weighted and hyperintense on T2-weighted sequences, sur-
rounded by an incomplete ring (Stage II) or fluid cysts (Stage IIA on Anderson etal.s clas-
sification) that are hyperintense on T2-weighted sequences, suggests a partially detached
osteochondral fragment. A well-delimited, nondisplaced subchondral lesion that is hypoin-
tense on T1-weighted and hyperintense on T2-weighted sequences, surrounded by a com-
plete ring of fluid that is hyperintense on T2-weighted sequences, suggests a partially
detached osteochondral fragment that is not displaced from its talar dome bed (Stage III).
If the subchondral lesion is completely detached and displaced (loose body), a Stage IV
osteochondral lesion is diagnosed.
It is critical to report whether the osteochondral lesion is stable or unstable, as unstable
lesions may require surgical repair. If unenhanced MRI cannot establish this difference, post-
contrast images can give additional information such as congruity of the chondral articular
surface or vascular continuity of the lesion with the donor site (viability). Indirect MR arthrog-
raphy of the ankle can be useful to improve lesion enhancement. In cases where it is difficult
to evaluate whether the subchondral fragment is detached from the talar dome, direct MR
arthrography of the ankle can determine whether the contrast material completely undercuts
the osteochondral fragment from the donor site. Furthermore, direct MR arthrography of the
ankle can clearly depict focal articular cartilage defects and intra-articular loose bodies.
CT cannot depict bone marrow edema; thus, it cannot detect early osteochondral lesions. For
this reason, CT should be used as an additional technique for visualizing subchondral detach-
ment (Stages IIIII) and bony fragmentation, which are pathognomonic of a Stage IV lesion.
The differential diagnosis must be done with talar fracture (linear morphology of the
fracture line), avascular necrosis (bone infarct with sclerotic margins due to talar neck
fracture or predisposing entities such sickle-cell anemia or steroid treatment), and transient
osteoporosis (homogeneous, reversible edema without a focal subchondral lesion). If both
sides of the ankle joint are affected, arthritis (posttraumatic, crystal-deposition, septic,
etc.) should also be considered.
Axial proton density-weighted MRI (Fig. 10.1.1) shows a well-delimited, heterogeneous adiological
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osteochondral lesion in the medial talar dome (arrow). Findings
Pre- and postcontrast sagittal fat-suppressed T1-weighted MRI (Figs. 10.1.2 and 10.1.3)
show intense osteochondral contrast uptake (arrow), suggesting a stable lesion with pre-
served vascular continuity with the parent bone (Stage II).
In another patient, sagittal fat-suppressed T2-weighted MRI (Fig. 10.1.4) shows a subtle
hyperintense osteochondral area (arrow) without signs of detachment; a stage I osteo-
chondral lesion due to subchondral trabecular compression was diagnosed.
In another patient, a sagittal reformatted MDCT image (Fig. 10.1.5) confirms a subchon-
dral talar dome lesion with osteochondral fragmentation at the articular surface (arrow); a
stage IV osteochondral lesion was diagnosed and confirmed at surgery.
A 21-year-old woman presented with right foot deformity and ecchymosis after a
Case 10.2 fall from a height of 6m.
Calcaneal Fracture
Introduction The calcaneus has four articulating surfaces: three that articulate superiorly with
the talus and one that articulates anteroinferiorly with the cuboid. Of the three
superior, the anterior is supported by the calcaneal beak and the middle is
Fig. 10.2.1 Fig. 10.2.2
Fig. 10.2.3 Fig. 10.2.4

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Ankle and Foot
supported by the sustentaculum tali. Both the anterior and middle facets are separated
from the posterior facet by a groove, the calcaneal sulcus. The canal formed between this
sulcus and the talus is the sinus tarsi.
The calcaneus is the most commonly fractured tarsal bone and accounts for about 2% of
all fractures. Calcaneal fractures have characteristic appearances based on the mechanism
of injury and are divided into two major groups: intra-articular and extra-articular. Most
calcaneal fractures (7075%) are intra-articular and result from axial loading that pro-
duces shear and compression fracture lines. Sanders system is the most used for classify-
ing intra-articular fractures. Extra-articular fractures account for about 2530% of
calcaneal fractures and include all fractures that do not involve the posterior facet. Thus,
the first step in staging these fractures is to rule out posterior facet involvement to deter-
mine whether the fracture is intra- or extra-articular.
Plain-film radiographs of the ankle and foot are among the most frequently requested
imaging tests in the emergency room. The American College of Radiologists (ACR) has
established some guidelines for obtaining ankle radiographs in patients with the following
clinical findings: (1) inability to bear weight immediately after the injury, or (2) point tender-
ness over the medial malleolus, or on the posterior edge or inferior tip of the lateral malleo-
lus or talus or calcaneus, or (3) inability to ambulate for four steps in the emergency room.
Bone scintigraphy is a highly sensitive imaging procedure for diagnosing hidden or
stress fractures of the ankle and foot, but this technique has poor spatial resolution and
specificity compared to CT or MRI.
The ACR recommends MDCT for patients with high energy polytrauma and in those
with complex foot and ankle fractures. The complexity of this anatomic area makes the use
of cross-sectional imaging very useful in the detection and accurate description of each of
these fractures. For instance, it is essential to evaluate the integrity of joint surfaces and the
presence of loose intra-articular fragments; furthermore, reconstructed 3-D images can
aid in planning surgery.
MRI is considered the best imaging tool for evaluating ankle lesions, because it can show
extra-articular and noncomminuted intra-articular fractures as well as associated soft-
tissue lesions (tendon tears, ligament sprains, etc.).
Lateral plain-film radiograph of the left calcaneus (Fig. 10.2.1) shows calcaneal fracture Radiological
lines with an abnormal calcaneal or Bhlers angle (5; normal 2040) and Gissanes criti- Findings
cal angle (75; normal 120145). Both diminished pathologic angles confirm calcaneal
posterior facet collapse.
Axial MDCT image (Fig. 10.2.2) shows a severe comminuted intra-articular fracture of
the calcaneus (Type IV on the Sanders Classification).
Sagittal MDCT reformatted image (Fig. 10.2.3) clearly shows a central joint depression
pattern; the posterior facet of the subtalar joint (arrow) is affected. This sign classifies this
fracture as intra-articular.
Coronal MDCT reformatted image (Fig. 10.2.4) of the calcaneus depicts two shear frac-
ture lines (arrows) that separate the sustentacular (S), middle (M), and tuberosity (T) frag-
ments (double split), with widening of the calcaneus.
A 45-year-old man presented with abrupt onset of pain over the posterior aspect of
Case 10.3 the leg, difficulty in walking, and inability to tiptoe on the injured side. Thompsons
test, carried out by squeezing the calf, was positive. Ultrasound and MRI were
Complete Achilles requested to confirm or rule out a full-thickness Achilles tendon tear and to evaluate
Tendon Tear the gap and the plantaris tendon to decide on the most appropriate treatment.
Introduction The Achilles tendon is the most commonly injured ankle tendon. Achilles tendon
tears tend to occur 26cm superior to the calcaneal insertion, which corresponds
Fig. 10.3.1
Fig. 10.3.2
Fig. 10.3.3
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Ankle and Foot
to a zone of relative avascularity; moreover, the particular disposition of the fibers in this
zone results in an area of increased internal stress on tendon contraction.
Achilles tendon rupture is most common in patients between the ages of 30 and 50 years,
and it often occurs in tendons with previous degeneration. Partial ruptures usually occur
in well-trained athletes secondary to trauma, often lateral in location with longitudinal or
transverse splits. In contrast, complete ruptures tend to occur in middle-aged and poorly
conditioned men.
Partial tears without a tendinous gap can mimic chronic Achilles tendinosis, which presents
heterogeneity, thickening, or waviness of the tendon on MRI and ultrasonography. The clinical
history may differentiate the two pathologies; MRI can help to distinguish between them
because partial tears are often associated with subcutaneous edema or hemorrhage within
Kagers fat pad and intratendinous hemorrhage with high signal intensity on T1-weighted
images. However, this distinction may not be of great clinical importance since both partial-
thickness tears and tendinosis are usually initially treated by conservative measures.
It is important to determine whether there is a large tendinous gap in partial tears or a
complete discontinuity in the Achilles tendon, because these conditions are often treated
by casting the ankle in the equinus position or by surgical repair. Clinical examination in
complete tears is sometimes equivocal because the flexor, peroneal, and plantaris tendons
also contribute to plantar flexion and can compensate for an injured Achilles tendon, and
imaging can help in the diagnosis.
Ultrasonography has proven accurate in differentiating partial-thickness tears or tendi-
nosis from full-thickness tears of the Achilles tendon: an undetectable tendon at the site of
injury, tendon retraction, and posterior acoustic shadowing at the ends of the torn tendon
are characteristics of full-thickness tears.
MRI is better for differentiating acute and chronic ruptures, showing edema and bleed-
ing (intermediate signal intensity on T1- and high signal intensity on T2-weighted images)
in cases of acute ruptures and scar or fat in chronic ruptures. Sagittal and axial T1-weighted
and fat-suppressed proton density-weighted or STIR images are required. MRI is also bet-
ter for evaluating a torn plantaris tendon, which may mimic an Achilles tendon tear or an
intact plantaris tendon in a complete Achilles tendon tear simulating a large partial tear.
Assessment of the status of the plantaris tendon is also important for planning surgical
repair of the Achilles using the plantaris as an anatomical reference.
Imaging techniques should assess the site of the tear, its extent, and the degree of retraction
and fraying of the tendon edges. Some large partial ruptures or complete ruptures with a
tendinous gap of 3cm or less may be repaired with an end-to-end anastomosis. Complete
ruptures with a tendinous gap greater than three require a flap graft.
Sagittal T1-weighted SE MRI (Fig. 10.3.1) shows a complete Achilles tendon rupture with a adiological
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gap less than 3cm (open arrow). Note the fat herniation into the tendon defect (arrow). Findings
Sagittal fat-saturated T2-weighted FSE MRI (Fig. 10.3.2) shows the edema and hemor-
rhage in the gap and in the adjacent soft-tissues (open arrow heads).
In the axial proton density-weighted FSE MR image (Fig. 10.3.3), the plantaris tendon is
intact and is displaced posteriorly into the defect created by the tear (arrowhead); this find-
ing can be mistaken for residual intact fibers of the Achilles tendon.
Two men, one 38-years-old and the other 30-years-old, fell during a sporting activity. At
Case 10.4 admission, the first patient presented significant pain, swelling, and tenderness over the
lateral aspect of the ankle joint; the second patient presented only lateral ankle pain. A
Lateral lateral collateral ligament sprain was suspected in both, and findings on plain-film
Collateral radiographs obtained to rule out associated bone fracture were normal. Due to the
Ligament significant swelling, the first patient underwent MRI at admission to evaluate the ligaments
Sprain involved and to exclude other associated lesions. The second patient underwent MRI 1 year
later for chronic lateral ankle pain.
Fig. 10.4.1 Fig. 10.4.2 Fig. 10.4.3
Fig. 10.4.4 Fig. 10.4.5

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Ankle and Foot
The lateral collateral ligament is one of the most frequently injured ligaments in ankle Introduction
sprains; it is commonly due to inversion with internal rotation of the foot combined with
ankle plantar flexion. This ligament comprises the anterior talofibular ligament (ATFL), the
calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL), correspond-
ing to the inferior group of the lateral stabilizing ligaments of the ankle joint below the
syndesmotic ligaments. The weak ATFL is the most commonly torn ankle ligament, and it is
usually injured alone (approximately 70% of all ankle ligament ruptures). With more severe
inversion stress, the rest of the ligaments rupture in the following order: after the ATFL, the
CFL can be involved (a combined rupture in 2040% of cases), followed by the stronger
PTFL, whose rupture is uncommon except in severe ankle trauma with dislocation.
Imaging evaluation of the injured ankle often begins with anteroposterior plain-film
radiography, which, like CT, can detect bony impairment, i.e., fractures, avulsion fractures
at the insertion, and bone diastases. Stress radiographs are of questionable value: pain,
edema, and muscle spasm hinder image acquisition, and differences in radiographic tech-
nique and in the amount of force applied to the joint make reliable interpretation difficult.
Although sonography is rarely used in this context and requires a confident examiner, it
can be used to examine the soft-tissue structures around the ankle joint, including the liga-
ments and associated peroneal tendon tears.
MRI clearly demonstrates the torn ligament, especially on axial images, as a discontinu-
ous or enlarged ligament with adjacent edema or hemorrhage in the acute phase, evenly
involving the capsular structure. In chronic tears, MRI shows a discontinuous ligament or
often an intact but irregular ligament with thickening, thinning, or detachment. MRI is also
indicated for evaluating associated features like syndesmotic injuries, bone contusion,
osteochondral fractures, and tendon tears.
Most acute ankle sprains have a good prognosis, and conservative treatment is commonly
proposed. However, in severe ruptures in which the ligament fails to heal after conservative
treatment or in competitive athletes, surgical repair may be the treatment of choice.
Some patients can develop chronic ankle pain due to instability, anterior impingement
syndrome, or sinus tarsi syndrome. MRI can demonstrate synovitis and fibrosis in the
anterolateral gutter in patients with impingement syndrome, and obliteration of sinus tarsi
fat in those with sinus tarsi syndrome.
First patient at admission: Axial proton density-weighted (Fig. 10.4.1) and axial fat-sup- adiological
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pressed T2-weighted (Fig. 10.4.2) FSE MR images of the ankle joint. The ATFL cannot be Findings
seen in the anterior aspect of the talofibular joint (open arrows); this corresponds to a com-
plete tear. A hematoma is seen in the adjacent soft-tissues (arrows). Axial proton density-
weighted FSE MR image at a lower level (Fig. 10.4.3) shows a signal change in the CFL,
consistent with sprain (open arrow head).
Second patient with chronic pain 1 year after the sprain: Axial proton density-weighted
(Fig. 10.4.4) and axial T2-weighted (Fig. 10.4.5) FSE MR images showed a soft-tissue lesion
in the anterior aspect of the talofibular joint (arrow heads), causing impingement
syndrome.
Case 10.5
Syndesmotic Ankle Sprain
Fig. 10.5.1 Fig. 10.5.2
Fig. 10.5.3 Fig. 10.5.4

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Ankle and Foot
After being injured in a match, a 27-year-old male soccer player presented with severe
ankle pain that increased with external rotation. Plain-film radiographs of the ankle per-
formed in the emergency room ruled out a fracture. MRI was requested to evaluate the
condition.
Ankle sprains are among the most common athletic injuries and represent a significant Comments
source of persistent pain and disability. Despite the high incidence of ankle sprains in
athletes, syndesmotic injuries have historically been misdiagnosed. The four syndesmotic
ligaments are the anterior (AITFL) and posterior (PITFL) inferior tibiofibular ligaments,
the transverse inferior tibiofibular ligament, and the interosseous ligament, which is a
thickening of the distal portion of interosseous membrane. A common variant (Basset or
Duke Ligament) can be found, forming the distal fascicle of the AITFL. Syndesmotic sprain
can occur alone or in conjunction with ankle fractures or other ligamentous injuries. The
AITFL is the most frequently injured ligament. Syndesmotic sprains account for 18% of all
ankle sprains in professional soccer players, and they take substantially longer to heal
than the more common isolated collateral ligament injuries. When clear tibiofibular dia-
stasis is absent, the acute injury calls for conservative management.
Anteroposterior and mortise weight-bearing plain-film radiographs of syndesmotic
sprain can show syndesmotic clear space due to tibiofibular diastasis (normal <6mm) if
the syndesmotic sprain is complete, and they can rule out associated ankle fractures.
However, because most syndesmotic sprains are incomplete, findings on plain-film radio-
graphs are often normal.
CT should be used as a complementary technique to rule out fractures; joint surfaces
and loose bone fragments must be carefully evaluated.
MRI is the technique of choice. MRI findings are best seen on axial images, where high
signal intensity on T2-weighted images due to fluid within the tibiofibular space is consid-
ered an important secondary sign of acute syndesmotic tear. Contour irregularity or frank
discontinuity of ligaments and tibiofibular space diastasis can be found. Chronic syndes-
motic injury manifests as a thickened hypointense AITFL or as an ossification of the
interosseous membrane.
The differential diagnosis of syndesmotic sprain should include lateral ankle instability
(collateral ligament tear), fibular fracture, compartment syndrome, and posterior
impingement.
Axial proton density-weighted FSE MRI (Fig. 10.5.1) shows syndesmotic ligament (AITFL) adiological
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disruption (arrow). The PITFL is preserved (arrowhead). Axial fat-suppressed T2-weighted Findings
FSE (Fig. 10.5.2) at the same level as in Fig. 10.5.1 shows hyperintense fluid and disconti-
nuity of the AITFL (arrow) as well as a posterior tibial bone bruise (arrowhead).
Axial proton density-weighted FSE (Fig. 10.5.3) and axial fat-suppressed T2-weighted
FSE MRI (Fig. 10.5.4), both obtained caudal to Figs. 10.5.1 and 10.5.2, show an anterior
tibiofibular fascicle of the lateral ligament complex preserving its disposition (arrow).
Case 10.6
Plantar Fasciitis
Fig. 10.6.1
Fig. 10.6.2
Fig. 10.6.3 Fig. 10.6.4

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Ankle and Foot
A 50-year-old male surgeon presented progressive heel pain in his right foot that increased
after playing squash.
Most abnormalities of the plantar fascia are found near the calcaneal insertion and usually Introduction
involve the medial bundle. Plantar fasciitis is the most common cause of heel pain; it can
be found in young athletes (exceptionally, an acute plantar fascia rupture can be seen in
this group) as well as in overweight patients. It is commonly associated with long periods
of weight bearing or sudden changes in weight bearing or activity.
The main clinical symptom is pain that begins with the first steps in the morning,
decreasing after that and then increasing again after long weight bearing.
US is useful in diagnosing plantar fasciitis; it is less expensive than MRI and its reported
sensitivity and specificity are 80 and 89%, respectively, compared with MRI. The thickness
of normal fascia measures 34mm; in plantar fasciitis, the plantar fascia appears hypoechoic
and measures greater than 5 mm at the calcaneal insertion. Furthermore, US-guided
percutaneous treatment is effective in the management of plantar fasciitis, and US can
objectively measure the response to treatment.
MRI may show thickening (greater than 5mm) and heterogeneous signal of the plantar
fascia, with T2 hyperintensity, surrounding soft-tissue edema, calcaneal enthesophytosis
(bone spur), and subcortical calcaneal edema.
The differential diagnosis of plantar fasciitis must include plantar fibromatosis, which is
generally located more distally and presents single or multiple nodules, and other entities
that can affect the plantar heel, such as systemic enthesopathic processes like seronegative
arthritides or sarcoidosis, calcaneal stress fracture (related to the posterior calcaneal area
rather than the plantar area), and tarsal tunnel syndrome (plantar muscles affected with
diffuse edema in the acute phase or atrophy in the chronic phase).
Sagittal STIR MRI (Fig. 10.6.1) shows a subtle thickening of the lateral cord of proximal adiological
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plantar fascia (arrow) with a high signal area of edema in the adjacent subcutaneous fat. Findings
Sagittal STIR MRI (Fig. 10.6.2) depicts greater thickening of the medial cord of the prox-
imal plantar fascia (arrow).
Coronal T2*-weighted MRI (Fig. 10.6.3) shows heterogeneous signal and thickening of
the plantar fascia (arrow).
Sagittal STIR MRI (Fig. 10.6.4) in another patient with plantar fasciitis shows a thick-
ened proximal area of plantar fascia (arrow) without marked edema in adjacent subcuta-
neous fat. In the chronic stage of plantar fasciitis, plantar thickness may increase and
soft-tissue edema may decrease.
Case 10.7
Plantar Fibromatosis
Fig. 10.7.2
Fig. 10.7.1
Fig. 10.7.3 Fig. 10.7.4

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A 55-year-old woman complained of mild plantar pain and a subcutaneous nodule in her
left foot. Her orthopaedist confirmed a soft-tissue nodule along the medial plantar surface
measuring nearly 1cm and fixed to plantar aponeurosis. MRI was requested to characterize
nodule type and extension. Histological study after surgical excision showed the nodule
was surrounded by plantar aponeurosis; microscopically, it was composed of a nodular
mixture of fibroblasts and collagen fibbers without malignant transformation.
Plantar fibromatosis (Ledderhoses disease) is a type of superficial fibromatosis characterized Introduction

by nodular thickening (single or multiple) arising from the plantar fascia of the foot, often
in nonweight-bearing lesions. In some patients, it can be associated to Dupuytrens
contracture. Clinical symptoms include a solid, fixed subcutaneous nodule, which can be
softly painful.
US is an excellent technique to diagnose plantar fibromatosis: it shows a hypoechoic,
heterogeneous nodule arising from the anterior part of the plantar fascia.
MRI is highly accurate in detecting soft-tissue tumors. Plantar fibromatosis is seen as a
nodule growing along the long axis of the plantar fascia; it has heterogeneous signal inten-
sity equal to or less than that of skeletal muscle on both T1- and T2-weighted spin-echo
MRI, although it may be slightly hyperintense if the cellular component is increased. About
50% of these nodules present significant solid contrast enhancement.
The differential diagnosis of plantar fibromatosis should first include plantar fasciitis,
which is located close to the calcaneus, without nodules. Plantar fibromatosis should also
be distinguished from other soft-tissue tumors that can affect the plantar area: ganglion
cyst (hypointense on T1-weighted and hyperintense on T2-weighted images), lipoma
(hyperintense on T1-weighted images; fat signal that ceases on fat-suppressed T2-weighted
or STIR images), neurogenic tumors (arising from nerves, generally painful), giant cell
tumor of tendon sheath (hypointense foci on T2-weighted images due to hemosiderin),
synovial sarcoma (heterogeneous mass arising and growing along tendon sheaths; bone
destruction may be present), and finally soft-tissue chondroma, a very rare tumor (coarse
calcifications within the tumor on plain films, MRI signal voids).
Sagittal T1-weighted MRI (Fig. 10.7.1) shows a single isointense nodule (arrow) through adiological
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the long axis of the plantar fascia (anterior part of the medial cord) extending to the plan- Findings
tar subcutaneous tissue.
Sagittal T2*-weighted MRI (Fig. 10.7.2) at same plane as in Fig. 10.7.1 shows intermedi-
ate signal without hypointense foci (arrow).
Coronal fat suppressed T1-weighted MRI (Fig. 10.7.3) depicts an isointense plantar
nodule (arrow) arising from the medial margin of the medial cord of the plantar fascia. A
skin marker was attached to localize the lesion.
Coronal postcontrast FS T1-weighted MRI (Fig. 10.7.4) at the same level as in Fig. 10.7.3
reveals intense nodular enhancement (arrow), with subtle hypointense linear areas due to
plantar fibers inside the nodule.
Case 10.8
Tarsal Tunnel Syndrome
Fig. 10.8.1
Fig. 10.8.2
Fig. 10.8.3 Fig. 10.8.4

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Ankle and Foot
A 68-year-old woman presented with an 8-week history of nocturnal paresthesias and pain
in the plantar aspect of her right foot that worsened with activity. Physical examination
showed tenderness to palpation and positive percussion of the tibial nerve over the tarsal
tunnel (Tinels sign). MRI was requested to evaluate tarsal tunnel syndrome.
Tarsal tunnel syndrome refers to neuropathy due to entrapment or compression of the Introduction
posterior tibial nerve or one of its branches located in the fibrous-osseous tunnel beneath
the flexor retinaculum and caudal to the tibial malleolus. This tunnel contains other
anatomic structures, including the tibialis posterior, flexor digitorum longus, and flexor
hallucis longus tendons. The syndrome can arise from trauma or occupation of the space
by varicosities, ganglia, or anomalous muscles (flexor digitorum accessorius longus), but
up to 50% of cases are idiopathic.
Plain-film radiographs should rule out talocalcaneal coalition and fractures of the sus-
tentaculum tali or medial tubercle.
CT should be used as a complementary technique to visualize hidden bone fractures.
Ultrasonography can be extremely useful for identifying space-occupying lesions in tar-
sal tunnel syndrome.
MRI is considered the technique of choice because it is highly sensitive in detecting
lesions such as varicosities, ganglia, lipomas, neurogenic tumors, thickened flexor retinac-
ulum as well as talar coalition, exostosis, or fracture. Furthermore, MRI can detect abnor-
mal signal in denervated muscle (hyperintense edema on T2-weighted images in the acute
stage or hyperintense fatty atrophy on T1-weighted images in chronic stages), which could
be a key finding to diagnose tunnel tarsal syndrome.
The differential diagnosis of tunnel tarsal syndrome must include local pathology, such
as tarsal coalition, calcaneal stress fracture, tibialis posterior tenosynovitis, plantar fasciitis,
diabetic foot neuroarthropathy, osteoarthritis, as well as distant pathology such as L5 or S1
radiculopathy.
Coronal T1-weighted MRI (Figs. 10.8.1 and 10.8.2) shows severe fatty atrophy of dener- adiological
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vated abductor hallucis muscle (arrow) and osteoarthritic sustentacular and subtalar Findings
changes with a beak-shaped bony process (arrowhead) occupying the space of the medial
plantar nerve, the larger of the two terminal divisions of the tibial nerve. Other nearby
plantar muscles, such as the quadratus plantae, flexor digitorum brevis, and abductor digiti
quinti, are preserved.
Axial FS T2-weighted FSE MRI (Fig. 10.8.3.) shows no hyperintensity in the abductor
hallucis muscle (arrow) due to edema; an acute phase of compression neuropathy can be
excluded. Other etiologies of tunnel tarsal syndrome, such as varicosities, or different eti-
ologies of local pain, such as stress fractures, can be ruled out.
Coronal T1-weighted MRI in a normal patient without tunnel tarsal syndrome (Fig.
10.8.4) shows the absence of compression neuropathy of the medial plantar nerve and the
normal morphology of the abductor hallucis muscle (arrow).
Case 10.9
Diabetic Foot
Fig. 10.9.2
Fig. 10.9.1
Fig. 10.9.3 Fig. 10.9.4

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Ankle and Foot
A 34-year-old woman diagnosed several years earlier with type II diabetes mellitus
complicated with chronic renal failure presented with a 2-week history of foot disturbances.
Physical examination found foot deformity and skin erythema. Electromyography revealed
severe mixed neuropathy. \Plain-film radiography of the foot showed osteopenia and
several bone erosions. Bone scintigraphy, CT, and MRI were requested to evaluate diabetic
foot pathology.
Diabetic foot is a frequent complication in both type I and type II diabetes mellitus. In Introduction
patients with diabetic foot disorders, it is crucial to differentiate between neuropathic
arthropathy (Charcots joint), which usually occurs in patients with long-standing diabetes,
and osteomyelitis, which is frequently associated with foot ulcers with deep tracks and
soft-tissue abscesses.
Plain-film radiographs of neuropathic arthropathy can show osteopenia, forefoot oste-
olysis, fractures, and fragmentation.
Bone scintigraphy is highly sensitive in diagnosing osteomyelitis in the diabetic foot. In
a recent study, 99mTc-HMPAO leukocyte scintigraphy combined with a 99mTc-MDP bone
scintigraphy scan showed a sensitivity of 92.6% and a specificity of 97.6%; moreover, neu-
roarthropathy did not affect the accuracy of the scintigraphic techniques. The high spatial
resolution of this test is very helpful to differentiate bone infection from soft-tissue infec-
tion, especially in cases of neuroarthropathy.
CT should be used as a complementary technique to visualize bony destruction, gas
bubbles in the bone, or bony sequestration. Reconstructed 3-D images can aid in planning
surgery.
Currently, MRI is the best imaging technique because it is highly sensitive in detecting
both soft-tissue lesions (skin ulcers and tracts, cellulitis, and abscesses) and bone lesions
(hypointense replacement of bone marrow on T1-weighted images). MRI can also stage
diabetic foot lesions accurately. Postcontrast images can provide additional information
(rim abscess enhancement, diffuse cellulitis enhancement), but coexistent renal failure in
those patients must be kept in mind.
The differential diagnosis of diabetic foot neuroarthropathy must include diabetic foot
osteomyelitis, osteoarthritis, talus or navicular osteonecrosis, and crystal deposition arthritis.
Plain-film radiographs of both feet (Fig. 10.9.1) show extensive erosions and bone destruc- adiological
R
tion in the tarsometatarsal and intermetatarsal joints, periosteal reaction in metatarsal Findings
bones, and soft-tissue edema in the right foot (arrow).
Leukocyte bone marrow scintigraphy with a 99mTc-HMPAO scan (Fig. 10.9.2) does not
show increased uptake within the bones right foot and thus rules out osteomyelitis. Only a
subtle focus of uptake due to a skin ulcer is noted (arrow).
CT (Fig. 10.9.3) confirms extensive bone destruction with fragmentation in the tarsal
area (arrow).
Sagittal T1-weighted MRI (Fig. 10.9.4) shows diffuse low signal intensity affecting the
talus, cuboids, and metatarsals with bone erosions and periosteal reaction in the proximal
fifth MTT.
A 56-year-old man presented with right forefoot disturbances of

Case 10.10 several weeks evolution; his plantar foot pain increased with activity.
Physical examination found pain and tenderness in the spaces
Intermetatarsal Bursitis between the first and third metatarsal heads when compression was
and Mortons Neuroma applied. Plain-film radiographs of the foot showed no pathological
findings. MRI was requested to evaluate forefoot pathology.
Fig. 10.10.1
Fig. 10.10.2
Fig. 10.10.3 Fig. 10.10.4

221
Ankle and Foot
Intermetatarsal or Mortons neuromas and intermetatarsal bursitis are two common Introduction
causes of forefoot pain. Mechanically induced chronic microtrauma due to excessive
weight-bearing stress on the forefoot predisposes to these pathologies. The intermetatar-
sal bursa can grow around the intermetatarsal nerve, making manifestations of bursitis
and Mortons neuroma indistinguishable. Mortons neuroma is not a true tumor; its repre-
sents perineural fibrosis, which occurs mainly in the second or third intermetatarsal
spaces, in the third common digital branch of medial plantar nerve, and rarely in the first
or fourth. A transition from intermetatarsal bursitis (acute stage) to fibrosis (chronic
stage), with both entities often coexisting at presentation, has been adduced. Histological
examination shows endoneural edema in early stages and perineural, epineural, and
endoneural fibrosis in late stages.
On US, intermetatarsal bursitis is seen as a compressible, well-defined anechoic or
hypoechoic collection of variable size surrounding metatarsal heads; in contrast, Mortons
neuroma shows a noncompressible nodular morphology, which varies from hypo- to
hyperechoic, with a diameter greater than 3mm in dorsoplantar thickness.
MRI is the technique of choice for evaluating the forefoot because it is highly sensitive
in the detection of both soft-tissue lesions (bursitis, neuromas, tumors) and bone lesions
(metatarsal fractures, Freibergs disease). Intermetatarsal bursitis appears as a well-defined
collection that is hypointense on T1-weighted images and hyperintense on T2-weighted
images; contrast-uptake is limited to the peripheral area (ring-like enhancement). Small
fluid collections with a transverse diameter of 3mm or less in the first three intermetatar-
sal bursas may be physiologic.
Fibrotic changes in Mortons neuroma can lead to hypointense to isointense T1-weighted
signal and isointense to hyperintense signal on FS T2-weighted and STIR sequences; con-
trast uptake varies depending on the maturity of the lesion and associated inflammation.
The differential diagnosis of intermetatarsal bursitis and Mortons neuroma should
include other causes of forefoot pain such as metatarsal fracture (metatarsal bone marrow
edema and cortical-periosteal reaction), osteochondrosis of the second metatarsal head
(also known as Freibergs disease, with flattening and edema), and soft-tissue tumors
(neurogenic, synovial sarcoma..; mainly hyperintense on T2-weighted images with intense
contrast uptake).
Coronal T1-weighted MRI (Fig. 10.10.1) shows an isointense single nodule (arrow) in the adiological
R
third intermetatarsal space, and another larger isointense mass in the first intermetatarsal Findings
space (arrowhead) extending to the plantar subcutaneous tissue.
Coronal T2-weighted MRI (Fig. 10.10.2) shows hypointense signal in the third inter-
metatarsal space nodule (arrow), suggesting a fibrous composition, and a markedly hyper-
intense signal in the well-demarcated mass in the first intermetatarsal space (arrowhead),
suggesting a fluid component.
Axial FS T1-weighted MRI (Fig. 10.10.3) and axial postcontrast FS T1-weighted MRI
(Fig. 10.10.4) at the same level as in Fig. 10.10.3 reveal subtle nodular enhancement (arrow)
of the third intermetatarsal lesion (Mortons neuroma) and intense ring-enhancement due
to intermetatarsal bursitis (arrowhead) of the first intermetatarsal space.
Further Reading Daftary A, Haims AH, Baumgaertner MR. Fractures of the calca-
neus: a review with emphasis on CT. Radiographics 2005;
25(5):12151226 (review)
Books Hartgerink P, Fessell DP, Jacobson JA, van Holsbeeck MT. Full-
Diagnostic Imaging: Orthopaedics. Stoller DW, Tirman PFJ, versus partial-thickness Achilles tendon tears: sonographic
Miriam A, Bredella M (2004). Elsevier, Philadelphia, PA. ISBN accuracy and characterization in 26 cases with surgical cor-
0-7216-2920-2 relation. Radiology 2001; 220(2):406412
Imaging of the Musculoskeletal System. 2-volume set. Thomas Hilary U. Foot and ankle imaging. Radiol Clin North Am 2008;
Pope, MD, Hans Bloem, MD, Javier Beltran, MD, William 46(6):9571130
Morrison, MD, David Wilson, MD (2008). Saunders, Elsevier, Kane D, Greaney T, Shanahan M, Duffy G, Bresnihan B, Gibney
Philadelphia, Amsterdam. ISBN 978-1-4160-2963-2 R, FitzGerald O. The role of ultrasonography in the diagnosis
Problem Solving in Musculoskeletal Imaging. William BM, and management of idiopathic plantar fasciitis.Rheumatology
Timothy GS (2008). Mosby, Elsevier, London, Philadelphia, (Oxford) 2001; 40(9):10021008
PA. ISBN 978-0-323-04034-1 Kreitner KF, Ferber A, Grebe P, Runkel M, Berger S, Thelen M.
Injuries of the lateral collateral ligaments of the ankle: assess-
ment with MR imaging. Eur Radiol 1999; 9:519524
Loredo R, Sanders TG. Imaging of osteochondral injuries. Clin
Web-Links Sports Med. 2001; 20(2):249278 (review)
Masciocchi C, Catalucci A, Barile A. Ankle impingement syn-
http://www.acr.org/. American College of Radiology dromes. Eur J Radiol. 1998; 27(suppl 1):S70S73
http://www.rsna.org/. RSNA Society Morrison WB, Schweitzer ME, Wapner KL, Lackman RD. Plantar
http://www.yottalook.com/. Medical Imaging Search Engine fibromatosis: a benign aggressive neoplasm with a characteris-
http://www.i-fab.org/. International Foot and Ankle tic appearance on MR images. Radiology 1994; 193(3): 841845
Biomechanics Nagaoka M, Matsuzaki H. Ultrasonography in tarsal tunnel syn-
http://www.arrs.org/. ARRS Society drome. J Ultrasound Med 2005; 24(8):10351040
Poirier JY, Garin E, Derrien C, Devillers A, Moisan A, Bourguet P,
Maugendre D. Diagnosis of osteomyelitis in the diabetic foot
with a 99mTc-HMPAO leucocyte scintigraphy combined
Articles with a 99mTc-MDP bone scintigraphy. Diabetes Metab 2002;
28(6 pt 1):485490
Anderson IF, Crichton KJ, Grattan-Smith T, Cooper RA, Brazier Quinn SF, Murray WT, Clark RA, Cochran CF. Achilles tendon:
D. Osteochondral fractures of the dome of the talus. J Bone MR imaging at 1.5 T. Radiology 1987; 164(3):767770
Joint Surg Am. 1989; 71(8):11431152 Robbin MR, Murphey MD, Temple HT, Kransdorf MJ, Choi JJ.
Ashman CJ, Klecker RJ, Yu JS. Forefoot pain involving the meta- Imaging of musculoskeletal fibromatosis. Radiographics
tarsal region: differential diagnosis with MR imaging. 2001; 21(3):585600 (review)
Radiographics 2001; 21(6):14251440 Russell JM, Peterson JJ, Bancroft LW. MR imaging of the diabetic
Berndt AL, Harty M. Transchondral fractures (osteochondritis foot. Magn Reson Imaging Clin N Am 2008; 16(1):5970, vi
dissecans) of the talus. J Bone Joint Surg Am 1959; 41-A:988 Sabir N, Demirlenk S, Yagci B, Karabulut N, Cubukcu S. Clinical
1020 (no abstract available) utility of sonography in diagnosing plantar fasciitis. J Ultra
Bowers CA, Mendicino RW, Catanzariti AR, Kernick ET. The sound Med 2005; 24(8):10411048
flexor digitorum accessorius longus-a cadaveric study. J Foot Sanders R, Fortin P, DiPasquale T, Walling A. Operative treat-
Ankle Surg 2009; 48(2):111115. Epub 2009 Jan 9 ment in 120 displaced intraarticular calcaneal fractures.
Boytim MJ, Fischer DA, Neumann L. Syndesmotic ankle sprains. Results using a prognostic computed tomography scan clas-
Am J Sports Med 1991; 19(3):294298 sification. Clin Orthop Relat Res 1993; 290:8795
Campbell SE, Warner M. MR imaging of ankle inversion inju- Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in
ries. Magn Reson Imaging Clin N Am 2008; 16(1):118 patients with diabetes. JAMA 2005; 293(2):217228 (review)
Coughlin MJ. Common causes of pain in the forefoot in adults. Williams GN, Jones MH, Amendola A. Syndesmotic ankle
JBone Joint Surg Br 2000; 82(6):781790 sprains in athletes. Am J Sports Med 2007; 35(7):11971207.
Dalinka MK, Alazraki NP, Daffner RH, DeSmet AA, El-Khoury Epub 2007 May 22 (review)
GY, Kneeland JB, Manaster BJ, Morrison WB, Pavlov H, Rubin Zanetti M, Strehle JK, Zollinger H, Hodler J. Morton neuroma
DA, Steinbach LS, Weissman BN, Haralson RH III. Expert and fluid in the intermetatarsal bursae on MR images of 70
Panel on Musculoskeletal Imaging. Suspected ankle frac- asymptomatic volunteers. J Radiol 1997; 203(2):516520
tures. [online publication]. Reston (VA): American College of Zehava SR. Update on the ankle and foot. MRI Clin North Am
Radiology (ACR); 2005; 4 2001; 9(3):413671

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Learning Imaging

Joan C. Vilanova , MD, PhD

ISBN: 978-3-540-87999-2 e-ISBN: 978-3-540-88000-4

Springer Heidelberg Dordrecht London New York

Library of Congress Control Number: 2010921306

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

To Manuel Snchez Glvez, my first

To my wife Cris and my children

Musculoskeletal (MSK) radiology is a radiological subspecialty that has expanded its

Crdoba, Spain Ramon Ribes

1 Infection and Arthritis

3 Tendons and Muscles

7 Elbow, Hand, and Wrist

Case 7.3 Intraosseous Ganglia of the Lunate

8 Hip and Pelvis

10 Ankle and Foot

Case 10.6 Plantar Fasciitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212

Sandra Baleato Luis Cerezal

Joaquim Barcel Matias de Albert

ngel Bueno-Horcajadas Guadalupe Garrido-Ruiz

Juan de Dios Bern-Mestre Victoria Higueras

Ara Kassarjian Mercedes Roca

Antonio Luna-Alcal Xavier Tomas

Fig. 1.1.1 Fig. 1.1.2

A 58-year-old woman with a 10-year history of rheumatoid arthritis (RA) pre-

Fig. 1.2.3 Fig. 1.2.4

Comments Ankylosing spondylitis is a chronic inflammatory disorder that mainly affects

Fig. 1.3.1 Fig. 1.3.2

Fig. 1.3.3 Fig. 1.3.4

Enthesitis in Psoriatic Arthritis

Calcium Pyrophosphate Crystal Deposition Disease

Fig. 1.5.3 Fig. 1.5.4

Calcium pyrophosphate dehydrate (CPPD) crystal deposition is characterized by a constel- Comments

Fig. 1.6.3 Fig. 1.6.4

A 52-year-old alcoholic man presented at the emergency department with disorientation

Septic Arthritis of the Pubic Symphysis

Fig. 1.7.3 Fig. 1.7.4

A 47-year-old female patient with a past history of

Fig. 1.8.2 Fig. 1.8.5

Fig. 1.9.3 Fig. 1.9.4

A 66-year-old man presented with insidious nonmechanical back pain

Fig. 1.10.1 Fig. 1.10.2

Fig. 1.10.3 Fig. 1.10.4

Further Reading and radiographic appearances. Radiographics 2005; 25:

Osteoblastoma of the Rib

Fig. 2.1.3 Fig. 2.1.4

Fig. 2.2.1 Fig. 2.2.3

Fig. 2.2.2 Fig. 2.2.4

Fig. 2.3.3 Fig. 2.3.4

Giant Cell Tumor of Bone

Fig. 2.4.3 Fig. 2.4.4

Skeletal Muscle Metastases

Fig. 2.5.1 Fig. 2.5.2

Fig. 2.5.3 Fig. 2.5.4

A 56-year-old man diagnosed with stage IV cholangiocarcinoma 2 months before pre-

Fig. 2.6.3 Fig. 2.6.4

Fig. 2.7.1 Fig. 2.7.4

Fig. 2.7.2 Fig. 2.7.5

Fig. 2.8.1 Fig. 2.8.2

Fig. 2.8.5 Fig. 2.8.6

Fig. 2.9.1 Fig. 2.9.2

Fig. 2.9.3 Fig. 2.9.4

Intramuscular myxoma (IM) is a benign intramuscular neoplasm composed of fibroblasts Comments

Crdoba, Spain Ramon Ribes

Case 10.6 Plantar Fasciitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212