Post-traumatic medial midfoot pain
Tibialis posterior tendon tendinopathy
Os naviculare syndrome
Stress fracture of navicular and Lisfranc ligament injury
Acquired flatfoot
Os naviculare synchondrosis
Anomalous tibialis posterior tendon attachment of Os naviculare.
Reference:
Crisp-padhiar syndrome -- Crisp et al. 45 (2): e1 -- British Journal of Sports Medicine:
Cortical Desmoid
Irregular lucency in medial supraconsylar ridge (posteromedial aspect of the distal femoral metaphysis), secondary to chronic avulsion injury of the adductor magnus aponeurosis.
Common in adolescent
Pain, or asymptomatic
May or may not show periosteal reaction
Mixed sclerosis and lucency in the cortex
Self limiting
Bilateral in 1/3rd
Low signal on T1, increased signal on T2, and may enhance with Gd
A case with good MR images
Another case
Review article: MR features of cortical desmoid
Common in adolescent
Pain, or asymptomatic
May or may not show periosteal reaction
Mixed sclerosis and lucency in the cortex
Self limiting
Bilateral in 1/3rd
Low signal on T1, increased signal on T2, and may enhance with Gd
A case with good MR images
Another case
Review article: MR features of cortical desmoid
Scoliosis Imaging: What Radiologists Should Know — RadioGraphics
Scoliosis = lateral spinal curvature with Cobb angle of 10° or more.
Classification:
A. Idiopathic: 80%; infantile, juvenile and adolescent
B. Associated with
1. Vertebral anomaly
2. Neurological anomaly
3. Skeletal dysplasias
4. Neuromuscular diseases
5. Bone tumours
6. CNS or PNS tumours
Scoliosis Imaging: What Radiologists Should Know — RadioGraphics
Classification:
A. Idiopathic: 80%; infantile, juvenile and adolescent
B. Associated with
1. Vertebral anomaly
2. Neurological anomaly
3. Skeletal dysplasias
4. Neuromuscular diseases
5. Bone tumours
6. CNS or PNS tumours
Scoliosis Imaging: What Radiologists Should Know — RadioGraphics
Ulnar sided impaction syndromes
Ulnocarpal abutment syndrome:
= Ulnar impaction syndrome, Ulnar abutment, Ulnocarpal loading
Most common cause of ulnar sided impaction
Predisposing factors:
Positive ulnar variance, distal radial malunion, unrecognised DRUJ derangement
Imaging:
Positive ulnar variance (pronation and firm grip view can increase ulnar variance by 1-2 mm)
Chondromalacia of ulnar head, lunate and triquetral, subchondral degenerative changes later
Central perforation of TFC
Lunotriquetral ligament tear
End stage: OA of ulnocarpal joint and DRUJ
Distal radioulnar impingement syndrome
= Ulnar impingement syndrome:
Causes: surgery (e.g., Madelung deformity correction), RA, trauma, negative ulnar variance
Shortened distal ulna (proximal to sigmoid notch), impinging on the distal RADIUS (not carpal bones), proximal to sigmoid notch
Erosive changes to scalloping of distal radius
Radioulnar convergence
Ulnocarpal impaction secondary to ulnar styloid non-union:
Fracture ulnar styloid
Type 1: Intact TFC and stable DRUJ
Type 2: Avulsion of ulnar attachement of TFC (Palmer IB) with DRUJ instability
Chondromaclia, subchondral changes in the triquetral bone
Ulnar styloid impaction syndrome:
Excessively long ulnar styloid more than 6 mm
Ulnar styloid process index of more than 0.28 (Length of ulnar styloid – ulnar variance/ transverse diameter of ulnar head)
Chondromaclia, subchondral changes in the triquetral and ulnar styloid
Hamatolunate impingement syndrome:
Type II lunate bone (lunate articulates with hamate)
Chondromlacia, subchondral changes in the proximal pole of hamate
Reference:
1. Cerezal et al. Imaging findings in ulnar sided writst impaction syndromes
= Ulnar impaction syndrome, Ulnar abutment, Ulnocarpal loading
Most common cause of ulnar sided impaction
Predisposing factors:
Positive ulnar variance, distal radial malunion, unrecognised DRUJ derangement
Imaging:
Positive ulnar variance (pronation and firm grip view can increase ulnar variance by 1-2 mm)
Chondromalacia of ulnar head, lunate and triquetral, subchondral degenerative changes later
Central perforation of TFC
Lunotriquetral ligament tear
End stage: OA of ulnocarpal joint and DRUJ
Distal radioulnar impingement syndrome
= Ulnar impingement syndrome:
Causes: surgery (e.g., Madelung deformity correction), RA, trauma, negative ulnar variance
Shortened distal ulna (proximal to sigmoid notch), impinging on the distal RADIUS (not carpal bones), proximal to sigmoid notch
Erosive changes to scalloping of distal radius
Radioulnar convergence
Ulnocarpal impaction secondary to ulnar styloid non-union:
Fracture ulnar styloid
Type 1: Intact TFC and stable DRUJ
Type 2: Avulsion of ulnar attachement of TFC (Palmer IB) with DRUJ instability
Chondromaclia, subchondral changes in the triquetral bone
Ulnar styloid impaction syndrome:
Excessively long ulnar styloid more than 6 mm
Ulnar styloid process index of more than 0.28 (Length of ulnar styloid – ulnar variance/ transverse diameter of ulnar head)
Chondromaclia, subchondral changes in the triquetral and ulnar styloid
Hamatolunate impingement syndrome:
Type II lunate bone (lunate articulates with hamate)
Chondromlacia, subchondral changes in the proximal pole of hamate
Reference:
1. Cerezal et al. Imaging findings in ulnar sided writst impaction syndromes
Ultrsaound of hernias
Inguinal region:
Anterior wall: external oblique aponeurosis; inguinal ligament more anteriorly
Posterior wall: transverse abdominus and part of internal oblique
Deep/internal inguinal ring:
Defect in transversalis fascia
Lateral to inferior epigastric artery
Above inguinal ligament
Superficial/external inguinal ring:
Defect in external oblique aponeurosis and inguinal ligament, immediately superior and lateral to pubic tubercle
Inferior epigastric artery:
Originates from EIA proximal to inguinal ligament
Passes medial to deep inguinal ring
Within the investing fascia of rectus abdominis, deep to rectus abdominis
Inferior epigastric artery and inguinal ligament divide inguinal region into 3 anatomic areas:
1. Hesselbach's triangle or inguinal canal: inferiorly by inguinal ligament, medially by lateral margin of rectus abdominis, and superolaterally by inferior epigastric artery
2. Femoral region: inferior to medial aspect of inguinal ligament
3. Region lateral to inferior epigastric artery and just above the inguinal ligament
Conjoint tendon:
Condensation of internal oblique and transversus abdominis aponeuroses
Lacunar ligament:
Reflection of the inguinal ligament
Four weak areas = 4 hernias:
1. Deep inguinal ring = indirect inguinal hernia
2. Inferior aspect of Hasselbach’s triangle = direct inguinal hernia; situated just lateral to conjoint tendon and medial to the inferior epigastric artery
3. Inferior to inguinal ligament and lateral to lacunar ligament = femoral hernia, medial to femoral vessels
4. Lateral margin of rectus abdominis muscle, superior to inferior epigastric artery as it crosses linea semilunaris = spigelian hernia
Relationship of hernia to inferior epigastric artery:
Hernia arising lateral to inferior epigastric vessel = indirect = passing thru inginal canal
Hernia arising medial to inferior epigastric vessel = direct = bulging thru posterior wall
Technique:
Don’t apply pressure.
Slow valsalva = slow strain. No coughing.
Transverse oblique plane:
Identifying deep inguinal ring:
1. Transverse oblique scan of rectus abdominis – identify inferior epigastric vessels deep to rectus within investing fascia
2. Transverse oblique scan of femoral vessels - move cranially to see origin of inferior epigastric vessels
Deep inguinal ring lies lateral to inferior epigastric vessels.
Medially symphisis pubis and laterally inferior epigastric vessels.
Short axis = sagittal plane:
Identify femoral artery in longitunal plane – move medially to identify inferior epigastric vessel – as they pass superiorly towards rectus abdominis, move more medially.
Inguinal canal is seen as ill-defined oval shaped area with hypoechogenic tubular structures.
In men, spermatic cord (heterogeneous hyperechoic structure with hypoechoic tubules and vascularity) is seen originating from the internal inguinal ring
Valsalva leads to narrowing of inguinal canal, distension of the femoral and inferior epigastric vessels, distension of vessels within the inguinal canal
Indirect inguinal hernia:
Thru inguinal canal
Persistent processus vaginalis seen in 30% adults
Can be extensive and protrude thru external ring
Superior to inguinal ligament
Transverse plane:
Lateral to inferior epigastric vessels
Extends thru the long axis of inguinal canal
Sagittal plane:
Distends canal in valsalva, effacing the contents
Direct inguinal hernia:
Usually in the inferior aspect of Hesselbach's triangle (H)
Protrude from posterior inguinal wall within transverse abdominis fascia
More localized
Transverse plane:
Medial to inferior epigastric vessels
Sagittal plane:
Comes from posterosuperior aspect into the canal
Femoral hernia:
Lateral to lacunar ligament, inferior to inguinal ligament
Transverse scan thru femoral vessels, valsalva leads to distension of femoral vein. Hernia, if any, will be seen, and may prevent normal expansion of the femoral vein
Spigelian hernia:
Along the linea semilunaris, just superior to inferior epigastric artery as it passes deep to lateral border of rectus abdominis muscle
Reference:
1. Jamadar DA et al. Sonography of inguinal region hernias. AJR 2006; 187: 185-190
2. McNally EG. Practical musculoskeletal ultrasound. Elsevier publication. 2005
Anterior wall: external oblique aponeurosis; inguinal ligament more anteriorly
Posterior wall: transverse abdominus and part of internal oblique
Deep/internal inguinal ring:
Defect in transversalis fascia
Lateral to inferior epigastric artery
Above inguinal ligament
Superficial/external inguinal ring:
Defect in external oblique aponeurosis and inguinal ligament, immediately superior and lateral to pubic tubercle
Inferior epigastric artery:
Originates from EIA proximal to inguinal ligament
Passes medial to deep inguinal ring
Within the investing fascia of rectus abdominis, deep to rectus abdominis
Inferior epigastric artery and inguinal ligament divide inguinal region into 3 anatomic areas:
1. Hesselbach's triangle or inguinal canal: inferiorly by inguinal ligament, medially by lateral margin of rectus abdominis, and superolaterally by inferior epigastric artery
2. Femoral region: inferior to medial aspect of inguinal ligament
3. Region lateral to inferior epigastric artery and just above the inguinal ligament
Conjoint tendon:
Condensation of internal oblique and transversus abdominis aponeuroses
Lacunar ligament:
Reflection of the inguinal ligament
Four weak areas = 4 hernias:
1. Deep inguinal ring = indirect inguinal hernia
2. Inferior aspect of Hasselbach’s triangle = direct inguinal hernia; situated just lateral to conjoint tendon and medial to the inferior epigastric artery
3. Inferior to inguinal ligament and lateral to lacunar ligament = femoral hernia, medial to femoral vessels
4. Lateral margin of rectus abdominis muscle, superior to inferior epigastric artery as it crosses linea semilunaris = spigelian hernia
Relationship of hernia to inferior epigastric artery:
Hernia arising lateral to inferior epigastric vessel = indirect = passing thru inginal canal
Hernia arising medial to inferior epigastric vessel = direct = bulging thru posterior wall
Technique:
Don’t apply pressure.
Slow valsalva = slow strain. No coughing.
Transverse oblique plane:
Identifying deep inguinal ring:
1. Transverse oblique scan of rectus abdominis – identify inferior epigastric vessels deep to rectus within investing fascia
2. Transverse oblique scan of femoral vessels - move cranially to see origin of inferior epigastric vessels
Deep inguinal ring lies lateral to inferior epigastric vessels.
Medially symphisis pubis and laterally inferior epigastric vessels.
Short axis = sagittal plane:
Identify femoral artery in longitunal plane – move medially to identify inferior epigastric vessel – as they pass superiorly towards rectus abdominis, move more medially.
Inguinal canal is seen as ill-defined oval shaped area with hypoechogenic tubular structures.
In men, spermatic cord (heterogeneous hyperechoic structure with hypoechoic tubules and vascularity) is seen originating from the internal inguinal ring
Valsalva leads to narrowing of inguinal canal, distension of the femoral and inferior epigastric vessels, distension of vessels within the inguinal canal
Indirect inguinal hernia:
Thru inguinal canal
Persistent processus vaginalis seen in 30% adults
Can be extensive and protrude thru external ring
Superior to inguinal ligament
Transverse plane:
Lateral to inferior epigastric vessels
Extends thru the long axis of inguinal canal
Sagittal plane:
Distends canal in valsalva, effacing the contents
Direct inguinal hernia:
Usually in the inferior aspect of Hesselbach's triangle (H)
Protrude from posterior inguinal wall within transverse abdominis fascia
More localized
Transverse plane:
Medial to inferior epigastric vessels
Sagittal plane:
Comes from posterosuperior aspect into the canal
Femoral hernia:
Lateral to lacunar ligament, inferior to inguinal ligament
Transverse scan thru femoral vessels, valsalva leads to distension of femoral vein. Hernia, if any, will be seen, and may prevent normal expansion of the femoral vein
Spigelian hernia:
Along the linea semilunaris, just superior to inferior epigastric artery as it passes deep to lateral border of rectus abdominis muscle
Reference:
1. Jamadar DA et al. Sonography of inguinal region hernias. AJR 2006; 187: 185-190
2. McNally EG. Practical musculoskeletal ultrasound. Elsevier publication. 2005
ACJ injury
Allam and Tossy:
Grade 1: mild sprain, normal radiograph, increased T2 signal on MR.
Grade 2: moderate sprain, less than 50% on radiograph, fluid outside joint capsule on MR.
Grade 3: complete disruption, widening of joint with more than 50% displacement on radiograph, displacement.
Rockwood:
Type I: mild AC ligament sprain, intact CC ligament, joint capsule, deltoid, trapezius muscle, no clavicle elevation.
Type II: ruptured AC ligament, sprained CC ligament, ruptured joint capsule, minimally detatched deltoid and trapezius, clavicle less than 50% of joint height
Type III: ruptured AC and CC ligament and joint capsule, detached trapezius and deltoid, clavicle elevated more than 50% of joint height
Type IV: III + clavicle displaced posteriorly into trapezius
Type V: III + clavicle elevated superiorly more than 100% of joint height.
Type VI: III + clavicle inferiorly displaced behind coracobrachialis and biceps tendons
Grade 1: mild sprain, normal radiograph, increased T2 signal on MR.
Grade 2: moderate sprain, less than 50% on radiograph, fluid outside joint capsule on MR.
Grade 3: complete disruption, widening of joint with more than 50% displacement on radiograph, displacement.
Rockwood:
Type I: mild AC ligament sprain, intact CC ligament, joint capsule, deltoid, trapezius muscle, no clavicle elevation.
Type II: ruptured AC ligament, sprained CC ligament, ruptured joint capsule, minimally detatched deltoid and trapezius, clavicle less than 50% of joint height
Type III: ruptured AC and CC ligament and joint capsule, detached trapezius and deltoid, clavicle elevated more than 50% of joint height
Type IV: III + clavicle displaced posteriorly into trapezius
Type V: III + clavicle elevated superiorly more than 100% of joint height.
Type VI: III + clavicle inferiorly displaced behind coracobrachialis and biceps tendons
Baastrups's disease
Close approximation of spinous processes = kissing spines
Bursae between the spines on MR
Bursae between the spines on MR
Post arthroscopy fibrosis
Common route of entry in arthroscopy: anterolateral, anteromedial, central
Focal thickening of the patellar tendon
Focal linear low signal on all sequences
Focal thickening of the patellar tendon
Focal linear low signal on all sequences
Localized nodular synovitis
Localised form of PVNS of Hoffa's fat
Similar to giant cell tumor of tendon sheath
localised mass in the synovium or Hoffa's fat
hemosiderin (blooming) and/or fibrosis can give low signal on all sequences
Similar to giant cell tumor of tendon sheath
localised mass in the synovium or Hoffa's fat
hemosiderin (blooming) and/or fibrosis can give low signal on all sequences
Intracapsular chondroma
Also known as extraskeletal ossifying fibroam, intracapsular osteochondroma, soft tissue osteochondroma
Rare
Located inferior to patella
Come consider this as end stage Hoffa's disease
Heterogenous mass
Plain film: chondroid or osseous matrix
Rare
Located inferior to patella
Come consider this as end stage Hoffa's disease
Heterogenous mass
Plain film: chondroid or osseous matrix
Subscribe to:
Posts (Atom)