Ebook Imaging anatomy musculoskeletal (2nd edition): Part 1

SECOND EDITION

MANASTER | CRIM


ii


SECOND EDITION

B.J. Manaster, MD, PhD, FACR
Emeritus Professor
Department of Radiology
University of Utah School of Medicine
Salt Lake City, Utah

Julia Crim, MD
Chief of Musculoskeletal Radiology
Department of Radiology
University of Missouri
Columbia, Missouri

iii


1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

IMAGING ANATOMY: MUSCULOSKELETAL, SECOND EDITION

ISBN: 978-0-323-37756-0

Copyright © 2016 by Elsevier. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including
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This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be
noted herein).

Notices
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional practices,
or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described
herein. In using such information or methods they should be mindful of their own safety
and the safety of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check
the most current information provided (i) on procedures featured or (ii) by the manufacturer
of each product to be administered, to verify the recommended dose or formula, the
method and duration of administration, and contraindications. It is the responsibility of
practitioners, relying on their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each individual patient, and to
take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or
editors, assume any liability for any injury and/or damage to persons or property as a matter
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Publisher Cataloging-in-Publication Data
Imaging anatomy. Musculoskeletal / [edited by] B.J. Manaster and Julia Crim.
2nd edition.
pages ; cm
Musculoskeletal
Includes bibliographical references and index.
ISBN 978-0-323-37756-0 (hardback)
1. Musculoskeletal system--Imaging--Handbooks, manuals, etc.
I. Manaster, B. J. II. Crim, Julia. III. Title: Musculoskeletal.
[DNLM: 1. Musculoskeletal Diseases--diagnosis--Atlases. 2. Musculoskeletal
System--injuries--Atlases. 3. Musculoskeletal System--radiography--Atlases.
WE 141]
RC925.7 .I434 2015
616.7/0754--dc23
International Standard Book Number: 978-0-323-37756-0
Cover Designer: Tom M. Olson, BA
Cover Art: Richard Coombs, MS
Printed in Canada by Friesens, Altona, Manitoba, Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1

iv


Dedications

This book is dedicated to the residents and fellows with
whom we have worked over the past many years. It is
a joy to have been your teachers, mentors, and friends.
As we wrote the second edition of Imaging Anatomy:

Musculoskeletal, we thought about you and tried to clearly
answer all the anatomy questions you have asked; we hope
the book is useful to you and to all scholars studying the
musculoskeletal system.

BJM and JRC

v


vi


Contributing Authors
Catherine C. Roberts, MD
Professor of Radiology
Mayo Clinic
Scottsdale, Arizona

Theodore T. Miller, MD, FACR
Chief, Division of Ultrasound
Hospital for Special Surgery
Professor of Radiology
Weill Medical College of Cornell University
New York, New York

Cheryl Petersilge, MD, MBA
Clinical Professor of Radiology
Cleveland Clinic Lerner College of Medicine
Case Western Reserve University

Cleveland, Ohio

William B. Morrison, MD
Professor of Radiology
Director, Division of Musculoskeletal Imaging and
Intervention
Department of Radiology
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Philadelphia, Pennsylvania

Carol L. Andrews, MD
Associate Professor
Division Chief, Musculoskeletal Radiology
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania

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Owner/Manager
Bonehead Radiology, PLLC
Eagle, Idaho

Zehava Sadka Rosenberg, MD
Professor of Radiology and Orthopedic Surgery
NYU School of Medicine
NYU Langone Medical Center
New York, New York

vii

viii


Preface
This second edition of Imaging Anatomy: Musculoskeletal retains features that made
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B.J. Manaster, MD, PhD, FACR
Emeritus Professor
Department of Radiology
University of Utah School of Medicine

Salt Lake City, Utah

Julia Crim, MD
Chief of Musculoskeletal Radiology
Department of Radiology
University of Missouri
Columbia, Missouri

ix


x


Acknowledgements
Text Editors
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xi


xii


Sections

SECTION 1: SHOULDER
SECTION 2: ARM
SECTION 3: ELBOW
SECTION 4: FOREARM
SECTION 5: WRIST

SECTION 6: HAND
SECTION 7: PELVIS AND HIP
6(&7,21  7+,*+
SECTION 9: KNEE
6(&7,21  /(*
SECTION 11: ANKLE
SECTION 12: FOOT

xiii


TABLE OF CONTENTS

4

14
36

86

94

102

112

126

138

154

SECTION 1: SHOULDER

280

Shoulder Overview
B.J. Manaster, MD, PhD, FACR and Catherine C. Roberts,
MD
Shoulder Radiographic and Arthrographic Anatomy
B.J. Manaster, MD, PhD, FACR and Julia Crim, MD
Shoulder MR Atlas
B.J. Manaster, MD, PhD, FACR and Catherine C. Roberts,
MD
Shoulder Abduction-External Rotation (ABER) Plane
B.J. Manaster, MD, PhD, FACR and Catherine C. Roberts,
MD
Shoulder: Rotator Cuff and Biceps Tendon
B.J. Manaster, MD, PhD, FACR and Catherine C. Roberts,
MD
Shoulder: Rotator Interval
B.J. Manaster, MD, PhD, FACR and Catherine C. Roberts,
MD
Shoulder Ligaments
B.J. Manaster, MD, PhD, FACR and Catherine C. Roberts,
MD
Shoulder Labrum
B.J. Manaster, MD, PhD, FACR and Catherine C. Roberts,
MD
Shoulder Normal Variants and Imaging Pitfalls

B.J. Manaster, MD, PhD, FACR

292

SECTION 2: ARM

436

Arm Radiographic Anatomy and MR Atlas
B.J. Manaster, MD, PhD, FACR and Catherine C. Roberts,
MD

SECTION 3: ELBOW
194

200
214

248

270

xiv

Elbow Overview
B.J. Manaster, MD, PhD, FACR and Theodore T. Miller,
MD, FACR
Elbow Radiographic and Arthrographic Anatomy
B.J. Manaster, MD, PhD, FACR and Julia Crim, MD
Elbow MR Atlas

B.J. Manaster, MD, PhD, FACR and Theodore T. Miller,
MD, FACR
Elbow Muscles and Tendons
B.J. Manaster, MD, PhD, FACR and Theodore T. Miller,
MD, FACR
Elbow Ligaments
B.J. Manaster, MD, PhD, FACR and Theodore T. Miller,
MD, FACR

Elbow Normal Variants and Imaging Pitfalls
B.J. Manaster, MD, PhD, FACR
Elbow Measurements and Lines
B.J. Manaster, MD, PhD, FACR

SECTION 4: FOREARM
298

Forearm Radiographic Anatomy and MR Atlas
B.J. Manaster, MD, PhD, FACR and Theodore T. Miller,
MD, FACR

SECTION 5: WRIST
326
334
342
388
398
418
428

Wrist Overview
Julia Crim, MD and Carol L. Andrews, MD
Wrist Radiographic and Arthrographic Anatomy
Julia Crim, MD
Wrist MR Atlas
Julia Crim, MD and Carol L. Andrews, MD
Wrist Ligaments
Julia Crim, MD and Carol L. Andrews, MD
Wrist Tendons
Julia Crim, MD and Carol L. Andrews, MD
Wrist and Hand Normal Variants and Imaging Pitfalls
Julia Crim, MD
Wrist Measurements and Lines
Julia Crim, MD and Carol L. Andrews, MD

SECTION 6: HAND
444
452
456
472

Hand Overview
Julia Crim, MD and Jeffrey W. Grossman, MD
Thumb Anatomy
Julia Crim, MD
Hand Radiographic Anatomy
Julia Crim, MD and Jeffrey W. Grossman, MD
Hand MR Atlas
Julia Crim, MD and Jeffrey W. Grossman, MD
Flexor and Extensor Mechanisms of Hand

Julia Crim, MD

SECTION 7: PELVIS AND HIP
486
494
528
554
558

Pelvis Overview
Julia Crim, MD and Cheryl A. Petersilge, MD, MBA
Pelvis MR Atlas
Julia Crim, MD and Cheryl A. Petersilge, MD, MBA
Anterior Pelvis
Julia Crim, MD and Cheryl A. Petersilge, MD, MBA
Hip Overview
Julia Crim, MD
Hip MR Anatomy
Julia Crim, MD and Cheryl A. Petersilge, MD, MBA


TABLE OF CONTENTS
574

590
598

Pelvis and Hip Radiographic and Arthrographic
Anatomy
Julia Crim, MD

Pelvis and Hip Normal Variants and Imaging Pitfalls
Julia Crim, MD
Pelvis and Hip Measurements and Lines
Julia Crim, MD and Cheryl A. Petersilge, MD, MBA

SECTION 8: THIGH
606

Thigh Radiographic Anatomy and MR Atlas
Julia Crim, MD and Cheryl A. Petersilge, MD, MBA

1084 Intrinsic Muscles of Foot
Julia Crim, MD
1090 Tarsometatarsal Joint
Julia Crim, MD
1096 Metatarsophalangeal Joints
Julia Crim, MD
1100 Foot and Ankle Normal Variants and Imaging Pitfalls
Julia Crim, MD and Zehava Sadka Rosenberg, MD
1128 Foot and Ankle Measurements and Lines
Julia Crim, MD

SECTION 9: KNEE
662
670

686
734
742
768

786
796
812
858

Knee Overview
B.J. Manaster, MD, PhD, FACR
Knee Radiographic and Arthrographic Anatomy
B.J. Manaster, MD, PhD, FACR and William B. Morrison,
MD
Knee MR Atlas
B.J. Manaster, MD, PhD, FACR
Knee Extensor Mechanism and Retinacula
B.J. Manaster, MD, PhD, FACR
Menisci
B.J. Manaster, MD, PhD, FACR
Cruciate Ligaments/Posterior Capsule
B.J. Manaster, MD, PhD, FACR
Knee Medial Supporting Structures
B.J. Manaster, MD, PhD, FACR
Knee Lateral Supporting Structures
B.J. Manaster, MD, PhD, FACR
Knee and Leg Normal Variants and Imaging Pitfalls
B.J. Manaster, MD, PhD, FACR
Knee and Leg Measurements and Lines
B.J. Manaster, MD, PhD, FACR

SECTION 10: LEG
878

Leg Radiographic Anatomy and MR Atlas
B.J. Manaster, MD, PhD, FACR

SECTION 11: ANKLE
918

Ankle Overview
Julia Crim, MD and Zehava Sadka Rosenberg, MD
934 Ankle Radiographic and Arthrographic Anatomy
Julia Crim, MD
946 Ankle MR Atlas
Julia Crim, MD and Zehava Sadka Rosenberg, MD
980 Ankle Tendons
Julia Crim, MD and Zehava Sadka Rosenberg, MD
1004 Ankle Ligaments
Julia Crim, MD and Zehava Sadka Rosenberg, MD

SECTION 12: FOOT
1034 Foot Overview
Julia Crim, MD
1042 Foot Radiographic and Arthrographic Anatomy
Julia Crim, MD
1054 Foot MR Atlas
Julia Crim, MD

xv


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SECOND EDITION

MANASTER | CRIM


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SECTION 1

Shoulder

Shoulder Overview
Shoulder Radiographic and Arthrographic Anatomy
Shoulder MR Atlas
Shoulder Abduction-External Rotation (ABER) Plane
6KRXOGHU 5RWDWRU &Xƪ DQG %LFHSV 7HQGRQ
Shoulder: Rotator Interval
Shoulder Ligaments
Shoulder Labrum
Shoulder Normal Variants and Imaging Pitfalls

4
14
36
86
94
102
112

126
138


Shoulder

Shoulder Overview

GROSS ANATOMY
Overview
• Multiaxial ball-and-socket joint
• Hemispheric humeral head articulates with shallow pearshaped glenoid fossa
○ Joint surrounded by synovial-lined fibrous capsule
○ Glenoid deepened by labrum, a fibrocartilage rim of
tissue
○ Cartilage thins in central glenoid and in periphery of
humeral head
• Range of motion: Flexion, extension, abduction, adduction,
circumduction, medial rotation, and lateral rotation
○ Flexion: Pectoralis major, deltoid, coracobrachialis, &
biceps muscles
○ Extension: Deltoid & teres major muscles
– If against resistance, also latissimus dorsi & pectoralis
major
○ Abduction: Deltoid & supraspinatus muscles
– Subscapularis, infraspinatus, & teres minor exert
downward traction
– Supraspinatus contribution controversial
○ Medial rotation: Pectoralis major, deltoid, latissimus
dorsi, & teres major muscles

– Subscapularis when arm at side
○ Lateral rotation: Infraspinatus, deltoid, & teres minor
muscles
• Joint stabilizers
○ Skeletally unstable joint
○ Superior support by coracoacromial arch
○ Anterior support by subscapularis tendon, anterior
capsule, synovial membrane, anterior labrum and
superior, middle, & inferior glenohumeral ligaments
○ Posterior support by infraspinatus and teres minor
tendons, posterior capsule, synovial membrane,
posterior labrum, & inferior glenohumeral ligament
• Vascular supply
○ Articular branches of anterior and posterior humeral
circumflex arteries and transverse scapular artery
• Innervation
○ Axillary and suprascapular nerves

•

•

•

IMAGING ANATOMY
Overview
• Humerus
○ 8 ossification centers: Shaft, head, greater tuberosity,
lesser tuberosity, capitulum, trochlea, medial, & lateral
epicondyles

○ Anatomic neck located along base of articular surface,
region of fused epiphyseal plate, and attachment of joint
capsule
○ Surgical neck located 2 cm distal to anatomic neck,
below greater and lesser tuberosities, extracapsular,
most common site of fracture
○ Greater tuberosity anterolateral on humeral head
– Attachment of supraspinatus, infraspinatus, & teres
minor tendons
○ Lesser tuberosity located along proximal anterior
humeral head, medial to greater tuberosity
– Attachment of subscapularis tendon
4

•

•

•

○ Intertubercular or bicipital groove
– Between greater and lesser tuberosities
– Transverse ligament, an extension of subscapularis
tendon, forms roof of groove
– Contains long head of biceps tendon & anterolateral
branch of anterior circumflex humeral artery and vein
Scapula
○ Acromion
– Acromion orientation ranges from flat to sloping,
mediolaterally

– Roughly classified into 4 types based on posterior to
anterior shape
– Type I: Flat
– Type II: Curved, paralleling humeral head
– Type III: Anterior hooked
– Type IV: Convex undersurface
– Low-lying, anterior downsloping or inferolateral tilt
decreases volume of coracoacromial outlet
○ Os acromiale
– Ununited acromial ossification center
– Should fuse by 25 years of age
– Incidence of persistent ossicle: 2-10%
– 60% bilateral
– Four types: Mesoacromion, metaacromion,
preacromion, basiacromion
○ Glenoid
– Shallow, oval recess
– Fibrocartilage labrum increases depth
○ Coracoid process
– May extend lateral to plane of glenoid
– Normal distance between coracoid and lesser
tuberosity > 11 mm with arm in internal rotation
Clavicle
○ Acromioclavicular joint between distal clavicle &
acromion
– 20° range of motion
○ Synovial-lined joint capsule
○ Fibrocartilage-covered ends of bone & central
fibrocartilage disk
Bone marrow

○ Predominantly yellow marrow in adults with residual
hematopoietic red marrow in glenoid and proximal
humeral metaphysis
○ Often strikingly heterogeneous in distribution
Glenohumeral joint space
○ 1-2 ml synovial fluid
○ Normal communication with biceps tendon sheath
○ Normal communication with subscapular recess
○ Posterior joint capsule typically inserts on base of labrum
○ Anterior joint capsule has variable insertion
Anterior joint capsule insertion
○ Type 1: Inserts at tip or base of labrum
○ Type 2: Inserts scapular neck < 1 cm from labrum
○ Type 3: Inserts scapular neck > 1 cm from labrum
Subscapular recess
○ Between scapula & subscapularis muscle and tendon
○ Joint communication via foramen of Weitbrecht:
Between superior and middle glenohumeral ligaments
○ Joint communication via foramen of Rouvière: Between
middle and inferior glenohumeral ligaments


Shoulder Overview

– Additional heads are rarely present and arise from
brachialis muscle, intertubercular groove or greater
tubercle
• Bursae
○ Subacromial-subdeltoid bursa
– Normally contains a minimal amount of fluid

– Adherent to undersurface of acromion
– Lies superficial to rotator cuff
○ Subcoracoid bursa
– Separate from normal subscapular recess of joint
– Between subscapularis tendon and
coracobrachialis/short head of biceps tendon
– Can communicate with subacromial-subdeltoid bursa
– Does not normally communicate with joint
○ Infraspinatus bursa
– Between infraspinatus tendon and joint capsule
– Can rarely communicate with joint
○ Other less common bursae
– Deep to coracobrachialis muscle
– Between teres major & long head of triceps
– Anterior & posterior to latissimus dorsi tendon
– Superior to acromion
• Additional muscles of upper arm
○ Deltoid, biceps, coracobrachialis, triceps
• Extrinsic shoulder muscles
○ Trapezius, latissimus dorsi, levator scapulae, major &
minor rhomboids, serratus anterior, subclavius,
omohyoid, pectoralis major, pectoralis minor

Shoulder

○ Normally opacified during arthrography
• Rotator cuff
○ Supraspinatus, infraspinatus, subscapularis, and teres
minor
○ Tendons interdigitate forming continuous band at

attachment to humerus
○ Origins
– Supraspinatus: Supraspinatus fossa of scapula
– Infraspinatus: Infraspinatus fossa of scapula
– Teres minor: Lateral scapular border
– Subscapularis: Anterior scapular surface (subscapular
fossa)
○ Insertions
– Supraspinatus, infraspinatus, and teres minor insert on
the greater tuberosity
– Supraspinatus has a direct component that inserts on
anterior portion of tuberosity and posterior oblique
component that undercuts the infraspinatus at
posterior portion of tuberosity
– Subscapularis inserts on lesser tuberosity
• Ligaments
○ Coracoacromial ligament
– Anterior 2/3 of coracoid to tip of acromion
○ Coracoclavicular ligament
– Stabilizes acromioclavicular joint
– Base of coracoid process to clavicle
– Conoid (medial) & trapezoid (lateral) bands have
common origin on coracoid, diverge to clavicle
○ Coracohumeral ligament
– Lateral base of coracoid to lesser & greater
tuberosities
– Blends with subscapularis tendon, supraspinatus
tendon, joint capsule, & superior glenohumeral
ligament
○ Superior & inferior acromioclavicular ligaments

○ Superior, middle, & inferior glenohumeral ligaments
– Superior and middle glenohumeral ligaments extend
from superior glenoid region to lesser tuberosity
– Congenitally absent or diminutive middle
glenohumeral ligament in 30% of population
– Inferior glenohumeral ligament (anterior band,
posterior band, & axillary pouch) extends from inferior
labrum to humeral anatomic neck
• Capsulolabral complex
○ Labrum
– Oval fibrocartilage tissue along glenoid rim
– Hyaline cartilage may lie between labrum & bone
(undercutting labrum)
– Varies in shape, size, and appearance
– Anatomic variants, most common in anterosuperior
region, include sublabral foramen & Buford complex
○ Biceps tendon
– Long head arises from supraglenoid tubercle or
superior labrum
– Long head may be congenitally absent
– Long head may arise from intertubercular groove or
joint capsule
– Short head originates at coracoid process as conjoined
tendon with coracobrachialis

Internal Contents
• Quadrilateral or quadrangular space
○ Teres minor, superior border
○ Teres major, inferior border
○ Humerus, lateral border

○ Long head triceps, medial border
○ Contains axillary nerve and posterior circumflex humeral
artery
• Coracoacromial arch
○ Acromion, superior border
○ Humeral head, posterior border
○ Coracoid process and coracoacromial ligament, anterior
border
○ Contains subacromial-subdeltoid bursa, supraspinatus
muscle/tendon, long head of biceps
• Rotator interval
○ Triangular space between inferior border of
supraspinatus muscle/tendon and superior border of
subscapularis muscle/tendon
○ Medially bordered by coracoid process
○ Laterally bordered by transverse humeral ligament
○ Anterior border formed by coracohumeral ligament,
superior glenohumeral ligament, & joint capsule

5


Shoulder

Shoulder Overview

3D CT RECONSTRUCTION, MUSCLE ORIGINS & INSERTIONS

Deltoid muscle

Serratus anterior muscle

Biceps muscle, long head
Trapezius muscle
Supraspinatus muscle

Pectoralis minor muscle

Coracobrachialis & short head
biceps m.

Pectoralis major muscle

Subscapularis muscle

Subscapularis muscle

Pectoralis major muscle
Latissimus dorsi muscle

Serratus anterior muscle

Teres major muscle
Deltoid muscle

Pectoralis major muscle
Coracobrachialis muscle

Brachialis muscle

Deltoid muscle
Biceps muscle, long head
Supraspinatus muscle
Coracobrachialis & short head
biceps m.

Trapezius muscle

Pectoralis minor m.
Pectoralis major muscle

Subscapularis muscle
Pectoralis major muscle

Subscapularis muscle

Latissimus dorsi muscle
Deltoid muscle

Teres major muscle
Coracobrachialis muscle

Brachialis muscle

(Top) Anterior view of the right shoulder from a 3D CT reconstruction is shown. Muscle origins are shown in red. Muscle insertions are
shown in blue. (Bottom) Anterior oblique view of the shoulder is shown.

6

Shoulder Overview
Shoulder

3D CT RECONSTRUCTION, MUSCLE ORIGINS & INSERTIONS

Levator scapulae muscle
Supraspinatus muscle
Rhomboideus minor muscle

Trapezius muscle
Deltoid muscle
Supraspinatus muscle
Infraspinatus muscle

Infraspinatus muscle
Rhomboideus major muscle
Teres minor muscle

Teres minor muscle
Triceps muscle, long head
Triceps muscle, lateral head

Teres major muscle
Latissimus dorsi muscle
Deltoid muscle
Brachialis muscle
Triceps muscle, medial head

Levator scapulae muscle
Supraspinatus muscle

Rhomboideus minor m.
Infraspinatus muscle
Rhomboideus major muscle
Teres minor muscle
Teres major muscle
Latissimus dorsi muscle

Trapezius muscle
Deltoid muscle
Supraspinatus muscle
Infraspinatus muscle
Teres minor muscle
Triceps muscle, long head
Triceps muscle, lateral head

Deltoid muscle
Brachialis muscle

Triceps muscle, medial head

(Top) Posterior oblique view of the shoulder from a 3D CT reconstruction is shown. Muscle origins are shown in red. Muscle insertions
are shown in blue. (Bottom) Posterior view of the shoulder is shown.

7


Shoulder

Shoulder Overview

GRAPHICS: ANTERIOR, POSTERIOR SHOULDER MUSCULATURE
Acromion process
Posterior belly deltoid muscle

Coracoid process
Musculocutaneous nerve

Supraspinatus tendon
Transverse humeral ligament
Subscapularis muscle
Anterior circumflex humeral
artery
Biceps muscle & tendon, long
head
Biceps muscle & tendon, short
head

Circumflex scapular artery

Teres major muscle

Latissimus dorsi muscle

Coracobrachialis muscle
Brachial artery
Median nerve

Supraspinatus muscle

Acromion process

Anterior belly deltoid muscle

Scapular spine
Infraspinatus muscle
Teres minor muscle

Supraspinatus tendon
Infraspinatus tendon
Teres minor tendon

Teres major muscle
Triceps muscle & tendon,
lateral head

Latissimus dorsi muscle

Triceps muscle & tendon, long
head

(Top) Anterior graphic of the shoulder shows a superficial scapulohumeral dissection. (Bottom) Posterior graphic of the shoulder shows
superficial scapulohumeral dissection demonstrating the musculature.

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