Ebook Diagnostic imaging orthopaedics: Part 1

IAGNOSTIC IMAGING



David W. Stoller, MD, FACR
Director, California Advanced Imaging and MRI
California Pacific Medical Center
Director, National Orthopaedic Imaging Associates
San Francisco, California
Director, Musculoskeletal MRI
California Pacific Medical Center

Phillip F. J.Tirman, MD
Director, California Advanced Imaging
California Pacific Medical Center
Director, National Orthopaedic Imaging Associates
San Francisco, California
Director, Musculoskeletal MRI
California Pacific Medical Center

Miriam A. Bredella, MD
Department of Radiology
University of California San Francisco
San Francisco, California

Salvador Beltran, MD
Medical Illustrator

Robert M. Branstetter Ill, MD
Diversified Radiology of Colorado

Denver, Colorado

Simon C. P. Blease, MD, FRCR
Honorary Senior Clinical Lecturer
University of Bristol
United Kingdom

AM1 RSYS"
A medical reference publishing company


AM I RSYS"
A medical r e f e r e n c e

publishing

company

First Edition
Second Printing -June2004

Text - Copyright David W

Stoller

MD 2004

Drawings - Copyright A m i r s y s Inc 2004
Compilation - Copyright Amirsys Inc 2004

rights reserved. No part o f this publication may be reproduced, stored in a retrieval system, or transmitted, in any f o r m or media
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Printed by F r i e s e n s , Altona, Manitoba, Canada
ISBN:

0-7216-2920-2

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Library of

Stoller,

Congress Cataloging-in-Publication Data

David W.

Diagnostic imaging, orthopaedics / David W. Stoller, Phillip F.J.
Tirman, Miriam A. B r e d e l l a ;S a l v a d o r Beltran, medical illustrator.1st ed.
p. ;cm.
I n c l u d e s bibliographical r e f e r e n c e s and index.
I S B N 0-7216-2920-2
1. Musculoskeletal s y s t e m - R a d i o g r a p h y - A t l a s e s .

2. Diagnostic
imaging-Atlases.
[ D N L M : 1. Musculoskeletal S y s t e m - r a d i o g r a p h y - A t l a s e s .
2.
Diagnostic I m a g i n g - m e t h o d s - A t l a s e s .
3. Orthopedic
Procedures-methods-Atlases.
WE 17 S875d 20041 I. Title:
Orthopaedics. 11. Tirman, Phillip F. J. 111. B r e d e l l a , Miriam A. IV.
Title.


To m y cherished son, GrifFn, and m y lovely wife, Marcia
for their extraordinary love and support
&

to the exceptional team of Phillip F. J. Tirman, MD,

Miriam A. Bredella, MD, Salvador Beltran, MD, Robert M.
Branstetter III, MD and Simon C. P. Blease, MD, FRCR
whose cohesive partnership on the production of this book
truly represented a force of nature.

D. WS.

To m y father, the late Robert M. Tirman, MD who was
an inspiration. To Collin and Skye, m y children and
Linda whose patience and understanding was truly
appreciated.

To m y parents, Erika and Lothar, and to Harold, for
their love and encouragement.

M.A.B.



CONTRIBUTORS
David W. Stoller, MD, FACR
Director, California Advanced Imaging and MRI
California Pacific Medical Center
Director, National Orthopaedic Imaging Associates
San Francisco, California
Director, Musculoskeletal MRI
California Pacific Medical Center

Phillip F. J. Tirman, M D
Director, California Advanced Imaging

California Pacific Medical Center
Director, National Orthopaedic Imaging Associates
San Francisco, California
Director, Musculoskeletal MRI
California Pacific Medical Center

Miriam A. Bredella, M D
Department of Radiology
University of California San Francisco
San Francisco, California

Salvador Beltran, M D
Medical Illustrator

Robert M. Branstetter Ill, M D
Diversified Radiology of Colorado
Denver, Colorado

Simon C. F! Blease, MD, FRCR
Consultant Musculoskeletal Radiologist
Med-Tel International Corporation
McLean, Virginia
Honorary Senior Clinical Lecturer
University of Bristol
United Kingdom

Jana M. Crain, M D
Medical Director
National Orthopaedic Imaging Associates

Niku F! Wasudev, M D
Musculoskeletal MRI
National Orthopaedic Imaging Associates

James 0.Johnston, M D
Professor Orthopaedic Oncology
University of California, San Francisco
Director Orthopaedic Oncology
Kaiser South San Francisco

vii



DIAGNOSTIC IMAGING: ORTHOPAEDICS

The imaging, orthopedics and sports medicine communities have been waiting a long time
for a new "Stoller". We at Amirsys and Elsevier are proud to present a precedent-setting,
image- and graphics-packed series that debuts with a brand-new work by David Stoller and
colleagues. This splendid work represents the textbook of the twenty-first century: Not your
old-fashioned, dense prose exposition with comparatively few images. The unique bulleted
format of the Diagnostic Imaging books allow our authors t o present approximately twice the
information and four times the images per diagnosis, compared to the old-fashioned traditional
prose textbook.
These richly illustrated books will cover all major body areas and follow a similar format.
The same information is in the same place: Every time! A welcome innovation is the new visual
differential diagnosis "thumbnail" that provides at-a-glance looks at entities that can mimic the
diagnosis in question. "Key Facts" boxes provide a succinct summary for quick, easy review. In
short, this is a product designed with you, the reader, in mind. Today's typical practice settings
demand efficiency i n both image interpretation and learning. We think you'll find the

Diagnostic Imaging format a highly efficient and wonderfully rich resource. Enjoy!

Anne G. Osborn, MD
Executive Vice-President and Editor-in-Chief, Amirsys
H. Ric Harnsberger, MD
Chairman and CEO, Amirsys Inc

David W. Stoller, MD, FACR
Editor Diagnostic Imaging Orthopaedics



FOREWORD

Over the last 20 years, MR imaging has become a significant diagnostic test performed in
orthopaedic and sports medicine. Surgeons have come to depend on this modality to provide
crucial information, which assists not only in understanding the underlying pathology, but also
in making the critical decision regarding surgical intervention. With the rapid growth and
sophistication of MR technology, MR imaging is an indispensable step in the workup of patients
with joint disorders and sports injuries. It has especially become important in the evaluation
and treatment of professional athletes who often depend on quick and accurate diagnosis in
order that they can resume their activities.

Diagnostic Imaging i n Orthopaedics is an invaluable text to orthopedists and radiologists alike.
This thousand-page text contains over 550 color illustration plates and over 1000 radiographic
images. Each radiographic diagnosis is discussed in outline format with thumbnail images of
other differential considerations. While the unique correlative color illustrations for each
diagnosis allow the reader to better understand anatomy and mechanism of disease, the concise
yet complete format of the textbook allows for quick reference in the clinical setting.
Dr. Stoller has successfully expanded the collaboration between orthopedic surgeons and

radiologists with Diagnostic Imaging in Orthopaedics as exemplified by the representative images
and correlative discussions of topics including pathophysiology, anatomy, and patient
management. Not only does this text focus on orthopaedic diagnosis involving the
appendicular skeleton, but he also covers bone, soft tissue, and marrow tumors. Many of the
techniques and applications described in this text were either originated or improved by Dr.
Stoller and his co-authors. This comprehensive text is the first of its kind in encompassing an
understanding of orthopaedics with correlative color illustrations and therefore will become an
invaluable reference and establish a higher standard of imaging for orthopaedists and
radiologists.

W. Dilworth Cannon Jr., MD
Professor of Clinical Orthopaedic Surgery
UCSF Sports Medicine Center
University of California
San Francisco, California


xii


PREFACE

Joint efforts from the fields of radiology and orthopaedics have continued to define the growing
indications and current issues for the use of MR in orthopaedics and sports medicine. Since the mid19801s,skeletal radiology has undergone an accelerated transformation with the infusion of MR
technology and applications. Credit is acknowledged to my early contemporaries including Jerrold H.
Mink, M.D. and John V. Crues 111, M.D. Our collaborative research in 1984-5 helped contribute to the
initial MR applications for the meniscus; and thus, hastened the integration of MR in routine
musculoskeletal imaging.

Diagnostic Imaging Orthopaedics represents the culmination of a collaborative vision I share with Anne

Osborn, M.D. and Ric Harnsberger, M.D. to further and improve the landscape of education of residents,
fellows, academic institutions, and private practice centers of excellence. This text reflects the manner in
which the authors presently utilize MR in clinical imaging and explains the reliance of MR applications
over CT and US in the appendicular joints. Each diagnosis consists of a classic color illustration and MR
image. Differential diagnosis thumbnails are provided as a reference guide to help address related topics
without competing or distracting the reader from the image galleries for each diagnosis. The outline style
of writing not only provides more information than a comparable prose format, but also allows the reader
to rapidly scan information in selected subsections or within the key facts box.
Our team has performed an excellent job in organizing the orthopaedic topics into nine categories:
six chapters concerning the appendicular joints and three chapters addressing marrow, bone and soft
tissue tumors. Salvador Beltran, M.D. has provided one of the largest correlative collections of superbly
illustrated orthopaedic pathology in color found in a single text.

Diagnostic Imaging Orthopaedics is a comprehensive and current reference that addresses the growing
need of radiologists, orthopedists, and sports medicine physicians to understand and incorporate new
clinical applications of bone and joint imaging into their practices.
David W Stoller, MD
Director, California Advanced Imaging and MRI
California Pacific Medical Center
Director, National Orthopaedic Imaging Associates
San Francisco, California
Director, Musculoskeletal MRI
California Pacific Medical Center

...

Xlll

ACKNOWLEDGMENTS
Illustrations
Salvador Beltran, MD

Art Direction and Design
Richard Coombs, MS
Lane R. Bennion, MS
James A. Cooper, MD

ImageIText Editing
Mingqian Huang, MD
Melissa Morris
Cassie Dearth
Kaerli Main

Medical Text Editing
Mingqian Huang, MD
Richard H. Wiggins 111, MD
Karen L. Salzman, MD
Bernard Chow, MD
Janaki N. Ramanathan, MD

Research Contributors
Lesley J. Anderson, MD
Frank M. Cmkovich, MD
David M. Lichtman, MD
Richard D. Ferkel, MD
Wesley M. Nottage, MD

Technological Assistance

Christopher Govea, MD
Philip Tran, MD
Margie Garbarino, CRT, ARRT, (R,MR)
Peter R. Osuna

Manuscript Preparation
Mingqian Huang, MD
Susan Bybee, CRT, ARRT, (R,MR)

Image Contribution
Me1 Senac, MD
Rob Campbell, MD
Andrew Grainger, MD
John Feller, MD
Oliver Cuitanic, MD
Britta Gooding, MD

Production Director
Pattie R. Dawson



SECTIONS

Shoulder
Elbow
Wrist and Hand
Hip
Knee

151

Ankle and Foot
Bone Marrow

Soft Tissue Tumors
index

xvii


TABLE OF CONTENTS
ECTiON I:Shoul
Rotator Cuff
Rotator Cuff Tendinopathy
Rotator Cuff Partial Thickness Tear
Internal Impingement, Shoulder
Rotator Cuff Full Thickness Tear
Rotator Interval Tears
Microinstability, Shoulder
Rotator Cuff Post-Operative Repair
Rotator Cuff Calcific Tendinitis
Parsonage-Turner Syndrome
Subscapularis Rupture
Pectoralis Major Tear

Labral Cyst, Shoulder
Anterosuperior Variations, Shoulder
Adhesive Capsulitis, Shoulder
Bankart Lesion

Perthes Lesion
ALPSA Lesion
GLAD Lesion
HAGL Lesion
IGL Tears
Bennett Lesion
Posterior Labral Tear, Shoulder
Hidden Lesion, Shoulder

Biceps TendonIAnchor
Biceps Tendinosis
Biceps Tendon Tear
SLAP Lesions I-IV
SLAP Lesions V-IX
Biceps Tendon Dislocation

Osseous Structures
Subacromial Impingement
0 s Acromiale
Acromioclavicular Joint Arthritis
AVN, Shoulder
Osteochondral Injuries, Shoulder
Greater Tuberosity Fracture

Arthritis
Osteoarthritis, Shoulder
Rheumatoid Arthritis, Shoulder

xviii

Neural Impingement
Quadrilateral Space Syndrome
Suprascapular, Spinoglenoid Notch

SECTiON 2: Elbow
Tendinopathy
Lateral Epicondylitis
Medial Epicondylitis
Biceps Tendon Rupture
Triceps Tendon Rupture

Instability
Lateral Collateral Ligament Injury
Posterior Dislocation, Elbow
MCL Elbow Injury
Little Leaguer's Elbow

Neuropathy
Ulnar Neuropathy
Radial Neuropathy
Median Neuropathy
Anconeus Epitrochlearis

Osseous Trauma
Coronoid Process Fracture
Capitellar Osteochondritis
Radial Head Fracture
Loose Bodies and 0 s Supratrochleare
Olecranon Fracture
Lateral Condylar Fracture

Capitellum Fracture
Supracondylar Fracture
Medial Condylar Fracture

Inflammation
Bicipital Radial Bursitis
Olecranon Bursitis
Synovial Fringe, Elbow

Arthritis
Osteoarthritis, Elbow
Rheumatoid Arthritis, Elbow

Infection
Osteomyelitis, Elbow

1-146
1-150


I

1

SECTION 3: Wrist and Hand

I

SECTION 4: Hip
Osteonecrosis

Ligaments
Scapholunate Ligament Tear
Lunotriquetral Instability

3-2
3-6

Avascular Necrosis, Femoral Head
Legg-Calve-Perthes

Marrow

Carpal Instabilities
Mid Carpal Instability

3-10

Transient Osteoporosis of the Hip

Dysplasia

Distal Radioulnar Joint
Ulnocarpal Abutment
Distal Radioulnar Joint Instability

3-14
3-18

Triangular Fibrocartilage Complex

Triangular Fibrocartilage Tear

3-22

Fractures, Distal Radius and Ulna
Distal Radius Fractures
Die Punch Fracture, Distal Radius
Ulnar Styloid Fracture

3-26
3-30
3-34

3-38
3-42

Avascular Necrosis
Scaphoid Non-Union
Kienbock's Disease

Developmental Dysplasia of the Hip

Overuse Syndromes and Muscle Trauma
Muscle Strain, Hip
Rectus Femoris Muscle Strain
Gluteus Medius Muscle Strain
Hamstring Tendinosis
Piriformis Syndrome
Iliopsoas Bursitis
Snapping Hip Syndrome

3-46
3-50

Femoral Head Fractures
Femoral Neck Fractures
Acetabular Fractures
Hip Dislocations
Avulsion Fracture
Pubic Rami Stress Fractures
Sacral Insufficiency Fractures

Carpal Tunnel
Carpal Tunnel Syndrome

3-54

Labral Tear, Hip
Paralabral Cysts, Hip

Arthritis

3-58

Arthritis
Degenerative Arthritis, Wrist
Hamato-Lunate Impingement
Rheumatoid Arthritis, Wrist and Hand
Madelung's Deformity

3-62
3-66
3-70
3-74

Femoroacetabular Impingement
Osteoarthritis, Hip
Loose Bodies, Hip
Rheumatoid Arthritis, Hip

Infection
Osteomyelitis, Hip

Cysts
Ganglion Cyst, Wrist

4-46
4-50
4-54
4-58
4-62
4-66
4-70

Labrum

Guyon's Canal Syndrome
Ulnar Tunnel Syndrome

4-18

4-22
4-26
4-30
4-34
4-38
4-42

Osseous Trauma

Carpal Fractures
Scaphoid Fractures
Hamate Fractures

4-10

3-78

SECTION 5: Knee

3-82
3-86
3-90

Menisci

Tendons
De Quervain's Tenosynovitis
Extensor Carpi Ulnaris Tendinitis
Giant Cell Tumor Tendon Sheath

Finger
Ulnar Collateral Ligament Tear, Thumb
Flexor Annular Pulley Tears
Flexor Digitorum Profundus Avulsions

3-94
3-98
3-102

Discoid Meniscus
Meniscal Degeneration
Meniscal Horizontal Tear
Meniscal Cyst
Meniscal Longitudinal Tear
Meniscal Radial Tear
Meniscal Flap Tear
Meniscal Bucket-Handle Tear
Meniscocapsular Separation
Post-Operative Meniscus Change

xix


Anterior Cruciate Ligament
Anterior Cruciate Ligament (ACL) Tear
ACL Reconstruction

5-42
5-46

Posterior Cruciate Ligament
Posterior Cruciate Ligament Tear

5-50

Deltoid Ligament Sprain
Syndesmosis Sprain
Anterolateral Impingement
Anterior Impingement
Syndesmotic Impingement
Posterior Impingement
Sinus Tarsi Syndrome

Osseous Fractures

Medial Collateral Ligament
Medial Collateral Ligament Tear
Medial Bursitis, Knee

Lateral Collateral Ligament Complex
Lateral Collateral Ligament (LCL) Tear
Posterolateral Complex Injuries
Iliotibial Band Syndrome

5-62
5-66
5-70

Osseous/Cartilagenous Structures
Osteochondral Injuries, Knee

Osteochondritis Dissecans, Knee
Bone Infarct, Knee
Spontaneous Osteonecrosis, Knee
Patellar Fracture
Lateral Tibial Plateau Fracture

Ankle Fractures
Talus Fractures
Calcaneal Fractures
Navicular Fractures
Metatarsal Fractures
Lisfranc Fracture-Dislocation
Osteochondral Lesion of the Talus
Avascular Necrosis (AVN) of the Talus
Freiberg's Infraction
Medial Tibial Stress Syndrome
Tarsal Coalition

Overuse Syndromes and Soft Tissue
Injury
0 s Trigonum Syndrome
Accessory Navicular
Sesamoid Dysfunction
Compartment Syndrome, Lower Extremity
Gastrocnemius Soleus Strain
Plantaris Rupture
Tarsal Tunnel Syndrome
Plantar Fasciitis
Plantar Fibromatosis
Morton's Neuroma

Diabetic Foot

Extensor Mechanism
Patellar Tendinitis
Osgood-Schlatter Disease
Patellar (Anterior) Bursitis
Synovitis, Knee
Patellar Tendon Tears
Chondromalacia Patella
Quadriceps Tendon Tear
Transient Patellar Dislocation
Medial Plica Syndrome

SECTION 2 Bone Marrow
Osteoarthritis, Knee
Rheumatoid Arthritis, Knee
Pigmented Villonodular Synovitis, Knee
Lipoma Arborescens, Knee
Reflex Sympathetic Dystrophy, Knee
Chondrocalcinosis, Knee

5-132
5-136
5-140
5-144
5-146
5-150

SynovialIDegenerative Cysts
Intercondylar Notch Cyst

Popliteal Cyst

SECTION 6: Ankle and Foot

Round Cell Tumors
Langerhans Cell Histiocytosis
Ewing Sarcoma
Leukemia
Lymphoma
Multiple Myeloma

Hemoglobinopathies
Sickle Cell Anemia
Thalassemia

Lipid Storage Diseases
Gaucher's Disease

Tendons
Achilles Tendinitis
Achilles Tendon Tear
Tibialis Posterior Tendon Tear
Flexor Hallucis Longus Abnormalities
Tibialis Anterior Tendon Tear
Peroneus Brevis Tendon Tear

Ligaments
Anterior Talofibular Ligament Tear
Calcaneofibular Ligament Sprain

7-22
7-26

7-30

Miscellaneous Marrow Lesions
Metastases, Bone Marrow
Paget Disease

SECTION 8: Bone Tumors
Osteoblastic Tumors
Osteoma
Osteoid Osteoma

8-2
8-6


Osteoblastoma
Osteosarcoma

Cartilaginous Tumors
Enchondroma
Osteochondroma
Chondroblastoma
Chondromyxoid Fibroma
Chondrosarcoma

8-18
8-22

8-26
8-30
8-34

Fibrous Tumors
Fibrous Dysplasia
Fibroxanthoma
Malignant Fibrous Histiocytoma, Bone
Fibrosarcoma

8-38
8-42
8-46
8-50

Miscellaneous Tumors and Tumor-Like
Lesions
Giant Cell Tumor
Intraosseous Hemangioma
Unicameral Bone Cyst
Aneurysmal Bone Cyst
Intraosseous Lipoma
Adamantinoma

I

8-54
8-58
8-62
8-66

8-70
8-74

SECTION 9: Soft Tissue Tumors

1

Fibrous Tumors
Fibrosarcoma, Soft Tissue
Fibromatosis
Malignant Fibrous Histiocytoma

Synovial Tumors
Pigmented Villonodular Synovitis
Synovial Sarcoma

Fatty Tumors
Lipoma, Soft Tissue
Liposarcoma, Soft Tissue

Neural Tumors
Benign Peripheral Nerve Sheath Tumor
Malignant Peripheral Nerve Sheath Tumor

Muscular Tumors
Rhabdomyosarcoma, Soft Tissue

Vascular Tumors
Hemangioma, Soft Tissue

xxi



DEFlNlTlON OF TERMS
Also used when fat suppression fails with FSE sequences
Sensitive t o magnetic field inhomogeneties,
paramagnetics and ferromagnetic micrometallic artifacts
compared to SE and FSE (secondary to gradient
rephrasing)

T I Wl

-

.

T1 Weighted Image
Includes spin echo (SE), fast spin echo (FSE) and gradient
echo (GRE)
Used to show hypointense signal in sclerosis and
subchondral edema
Marrow fat signal is hyperintense on T1 weighted images

-

T2WI
4

T2 Weighted Image

Includes SE and FSE sequences
T2 FSE used to evaluate the rotator cuff (complementing
FS PD FSE images) by differentiating tendinosis and tears
T2 FSE application limited because of hyperintense fat
signal, (FS PD FSE used more commonly for this reason)
FS T2 FSE produces an image with poor SNR (signal-tonoise) with TE values of greater than 60 msec

PDWl

.
.

Proton Density Weighted or Intermediate Weighted
Image
Long TR and short TE images
High SNR
Useful for articular cartilage evaluation as an alternative
to FS PD FSE
May obscure sclerosis or marrow edema due to poor
marrow fat contrast compared to TlWI or FS PD FSE

STIR (SHORT TI INVERSION RECOVERY)

-

.
.

.

GRE
Gradient Echo

Inversion Recovery Fat Suppressed Spin Echo Pulse
Sequence
Initial 180 degree inversion pulse prior to 90 degree pulse
STIR has more uniform fat suppression because IR is less
sensitive to magnetic field inhomegeneties and off center
field-of-view (FOV) effects
Used when FS PD FSE not available or when fat
suppression inadequate in FSE images
T1 & T2 contrast additive in STIR however SNR is low
secondruy to reduced transverse magnetization
Limited by prolonged scan times

T I C+

.

FS PD FSE
Fat Suppressed Proton Density Weighted Fast Spin Echo
Evaluates marrow edema, articular cartilage, ligaments,
tendons, synovium, and meniscal morphology
Commonly used sequence for all appendicular joint
imaging
Often referred to as FS T2 FSE although TE values are
typically less than 60 msec
TR values greater than or equal to 3000 msec
TE values of 40-50 msec to optimize image quality

ZIP
Zero-fill Interpolation Processing
Reconstruction technique to enhance apparent image
resolution without actually creating resolution

Intravenous contrast administration in conjunction with
fat suppression to increase the conspicuity of synovium
vascularity, inflammation and tumors
Also used to improve visualization of intraarticular
structures by delayed enhancement of joint fluid without
the benefit of capsular distension

ABER
Abduction External Rotation position of the shoulder to
optimize visualization of the inferior glenohumeral
ligament labral complex (IGLLC), biceps labral complex
(BLC) and articular surface of the rotator cuff

MR ARTHRO

-

- echoes
Reverse gradient polarity to rephrase protons and form
.
Usually used to create images with T2* contrast
.
- T2*
contrast used t o evaluate TFC (triangular
fibrocartilage), patellar tendon, intrameniscal signal,

MR arthrography
Dilute intraarticular MR contrast agent and saline or nonionic contrast
Distend joint capsule to improve visualization of
intraarticular and capsular structures
Used in selective applications for the shoulder, wrist, hip,
elbow and knee
Used in conjunction with T1 fat suppression and FS PD
FSE sequences

subscapularis tendon and chondrocalcinosis

xxiii


xxiv