Imaging of Sport Injuries with Radiologist Dr. John Crues

MR Imaging of Athletic Trauma John Crues, MD Medical Director, Radnet, Inc. Los Angeles, CA Professor of Radiology, UCSD Imaging for the Anaheim Ducks

Athletic Trauma • Hips • Sports Hernia • Shoulder • Wrist • Hand

Hip Pathology • Bone Injuries • Labral Tears • Femoro-acetabular Impingement

Hip Pathology • Bone Injuries • Labral Tears • Femoro-acetabular Impingement

Normal Arthrogram

Coronal

Axial

Normal Arthrogram Acetabulum

Acetabulum Femoral Head

Femoral Head

Acetabulum Coronal

Axial

Normal Arthrogram Gluteus Muscles

Acetabulum

Acetabulum Femoral Head

Femoral Head

Obturator Muscles

Coronal

Acetabulum Axial

Normal Arthrogram Gluteus Muscles

Acetabulum

Acetabulum Labrum

Femoral Head

Femoral Head

Obturator Muscles

Acetabulum Labrum

Coronal

Axial

Labral Tear

Femoro-Acetabular Impingement - FAI  Repetitive trauma in flexion/internal

rotation in abnormally shaped femoral neck and acetabulum leads to chronic bone reaction, articular cartilage injury, degenerative subchondral bone disease and pain.  Types:  CAM  Pincer

Prevalence of Radiographic Findings in Asymptomatic Subjects (874 males, 1207 females)

 CAM ->  Pistol-grip deformity -> 21.5% M, 3.3% F  Femoral neck bump -> 10.3 %, 2.6 %  Lateral head flattening -> 14.4 %, 6.2 %  Pincer  Posterior wall sign ->

23.4 %, 11.0 %  Increase acetabular cov. -> 14.6 %, 4.9 %  Crossover -> 51.4 %, 45.5 % Laborie LB, et al. Radiology(2011);260(2):494-502

Prevalence of Radiographic Findings in Asymptomatic Subjects (874 males, 1207 females)

 CAM ->  Pistol-grip deformity -> 21.5% M, 3.3% F Especially in males,  Femoral neck bump -> 10.3 %, 2.6 % radiographic findings of FAI  Lateral head flattening -> 14.4 %, 6.2 % are common in asymptomatic  Pincer

young adults.  Posterior wall sign -> 23.4 %, 11.0 %  Increase acetabular cov. -> 14.6 %, 4.9 %  Crossover ->

51.4 %, 45.5 %

Laborie LB, et al. Radiology(2011);260(2):494-502

Femoral Acetabular Impingement - FAI  CAM-Type Impingement  Femoral neck bump - abnormal alpha angle  Anterio-lateral acetabular labral and bone injury  Treatment  Bump resection  Labral tear removal  Microfracture

CAM-Type FAI - Alpha Angle

Notzli, et al. JBJS(Br) 2002;84-B:556-60

CAM-Type FAI - Alpha Angle

Notzli, et al. JBJS(Br) 2002;84-B:556-60

CAM-Type FAI - Alpha Angle Normal less than 55 degrees

Notzli, et al. JBJS(Br) 2002;84-B:556-60

CAM-Type FAI - Alpha Angle Normal less than 55 degrees

Notzli, et al. JBJS(Br) 2002;84-B:556-60

CAM-Type FAI - Alpha Angle Abnormal Normal less greater thanthan 55 degrees 55 degrees

Notzli, et al. JBJS(Br) 2002;84-B:556-60

CAM-Type FAI - Alpha Angle Abnormal Normal less greater thanthan 55 degrees 55 degrees Bump

Notzli, et al. JBJS(Br) 2002;84-B:556-60

31 yo MLB pitcher Chronic hip pain and stiffness

31 yo MLB pitcher Chronic hip pain and stiffness

31 yo MLB pitcher Chronic hip pain and stiffness

31 yo MLB pitcher Chronic hip pain and stiffness

31 yo MLB pitcher Chronic hip pain and stiffness

31 yo MLB pitcher Chronic hip pain and stiffness

FAI with Labral Tear, Cyst and DJD

Femoral Acetabular Impingement - FAI  Pincer-Type Impingement  Overgrowth of acetabulum  Postero-inferior acetabular bone injury  Treatment  Acetabular rim resection

Pincer FAI

Text

Pfirrmann, C. W. A. et al. Radiology 2006;240:778-785

Pincer FAI Inferior Acetabular DJD

Pfirrmann, C. W. A. et al. Radiology 2006;240:778-785

Text

Sports Hernia Athletic Pubalgia  Rectus abdominis insertional injury  Thigh adductor injury  Osteitis pubis  Remote disease

Zoga et al. Radiology(2008);247(3):797-807

Zoga et al. Radiology(2008); 247(3):797-807 Copyright ©Radiological Society of North America, 2008

Rectus Abdominis Insertion Tear

Zoga et al. Radiology(2008); 247(3):797-807 Copyright ©Radiological Society of North America, 2008

Adductor Longus/Pectineus Muscle Tears

16 yo son of orthopedist with chronic right lower abdominal wall pain

Right

Left

16 yo son of orthopedist with chronic right lower abdominal wall pain

Right

Left

16 yo son of orthopedist with chronic right lower abdominal wall pain

Right

Left

16 yo son of orthopedist with chronic right lower abdominal wall pain

Right

Left

Chronic Rectus Abdominus Tendon Tear

Right

Left

31 yo NHL player with groin pain

11-28-11 1-7-12

31 yo NHL player with groin pain

11-28-11

31 yo NHL player with groin pain

11-28-11

31 yo NHL player with groin pain

11-28-11

Partial Tears Adductor Origins

11-28-11

Injury in practice, R/O adductor tear

Injury in practice, R/O adductor tear

1-7-12

Injury in practice, R/O adductor tear

1-7-12

Injury in practice, R/O adductor tear

1-7-12

Adductor Longus Avulsion

1-7-12

12-26-06 All-star hockey player with groin pain

12-26-06 All-star hockey player with groin pain

3/23/07 12-26-06 All-star hockey player with groin pain

3/23/07 12-26-06 All-star hockey player with groin pain

3/23/07 12-26-06 All-star hockey player with3-23-07 groin pain

Secondary Cleft Sign

3/23/07 12-26-06 All-star hockey player with3-23-07 groin pain

Secondary Cleft Sign

3/23/07 12-26-06 All-star hockey player with3-23-07 groin pain 4-2-07

Secondary Cleft Sign

3/23/07 12-26-06 All-star hockey player 4-2-07 with3-23-07 groin pain 4-2-07

Secondary Cleft Sign

3/23/07 12-26-06 All-star hockey player 4-2-07 4-2-07 with3-23-07 groin pain 4-2-07

Adductor Origin Partial Avulsion - AKA Sports Hernia

Secondary Cleft Sign

3/23/07 12-26-06 All-star hockey player 4-2-07 4-2-07 with3-23-07 groin pain 4-2-07

Professional Hockey Player R/O Sports Hernia

Professional Hockey Player R/O Sports Hernia

Professional Hockey Player R/O Sports Hernia

Professional Hockey Player R/O Sports Hernia

Professional Hockey Player R/O Sports Hernia

Professional Hockey Player R/O Sports Hernia

Osteitis Pubis

Hamstring Avulsion

Courtesy Dr. Kyung Suh

Courtesy Dr. Kyung Suh

Courtesy Dr. Kyung Suh

Courtesy Dr. Kyung Suh

Courtesy Dr. Kyung Suh

Hamstring Avulsion with Hematoma

Courtesy Dr. Kyung Suh

69 yo male 9 months after motorcycle accident

69 yo male 9 months after motorcycle accident

Chronic Hamstring Avulsion with Atrophy

Chronic Inferior Tuberosity Avulsion Injury

Treatment of Acute Injuries  Proximal tendon avulsion -> early surgery  Muscle tears -> non-operative

Wood DG, Packham I, Trikha SP, and Linklater J. JBJS(2008);90-A:2365-74

Shoulder Injuries  Rotator Cuff Tears  Calcific Tendonitis  Long Head of Biceps Tendon Injuries

Rotator Cuff Partial Tears Ø Acute

muscle strains/tear Ø Musculotendinous junction Ø Tendon proper - transverse Ø Tendon proper - longitudinal Ø Tendon insertion - footplate

31 yo male with pain after a weight-lifting injury

A-C Joint

Glenoid Humeral Head

T1

PDFS

31 yo male with pain after a weight-lifting injury

A-C Joint

Glenoid Humeral Head

T1

PDFS

31 yo male with pain after a weight-lifting injury

A-C Joint

Glenoid Humeral Head

T1

T2

31 yo male with pain after a weight-lifting injury

A-C Joint

Glenoid Humeral Head

T1

T2

Supraspinatus Muscle Strain A-C Joint

Glenoid Humeral Head

T1

T2

Intact Surface - Tendinosis

27 yo MLB pitcher with increasing posterior axillary pain after pitching -> R/O teres major or latissimus tear

4-22-09

27 yo MLB pitcher with increasing posterior axillary pain after pitching -> R/O teres major or latissimus tear

4-22-09

5-27-09

27 yo MLB pitcher with increasing posterior axillary pain after pitching -> R/O teres major or latissimus tear

4-22-09

5-27-09

27 yo MLB pitcher with increasing posterior axillary pain after pitching -> R/O teres major or latissimus tear

4-22-09

5-27-09

New Partial Tear and Marrow Edema: Muscles Normal

4-22-09

5-27-09

T1

T1

FSPD

T1

FSPD

T2

T2 T1 FSPD Greater than 50% thickness!

High-Grade Partial Tear

T2 T1 FSPD Greater than 50% thickness!

Full-Thickness Tears Ø Subacromial

fluid Ø Subcoracoid fluid Ø Fluid interrupting tendon Ø Proximal retraction MT junct. Ø Repair with scar “in-situ” Ø Muscle atrophy Ø Rotator cuff arthropathy

Joint Fluid Extending Through Tear

Rotator Cuff Tears: What the orthopedist wants to know?*       

Size Quality of tissues Location Fatty infiltration Elevations of humeral head Acromion morphology Status of biceps

*Richard Hawkins, Current Issues of MRI in Orthopaedics And Sports Medicine, San Francisco, August 2003

Rotator Cuff Repair

From Mohana-Borges, et al. Radiographics 2004;24(1), 69-85

Pre-Op

Post-Op

Pre-Op

Post-Op

Pre-Op

Post-Op

Pre-Op

Post-Op

Pre-Op

Post-Op

suture anchor

Recurrent Tear with Displaced Anchor

42 yo with acute onset severe left shoulder pain

42 yo with acute onset severe left shoulder pain

Calcific Tendinitis

Rotator Cuff Tears: What the orthopedist wants to know?*       

Size Quality of tissues Location Fatty infiltration Elevations of humeral head Acromion morphology Status of biceps

*Richard Hawkins, Current Issues of MRI in Orthopaedics And Sports Medicine, San Francisco, August 2003

Biceps Instability - Bennett* Grade 0 - Sling injury without displacement Ø Grade 1 - Perched biceps Ø Grade 2 - Displaced into subscapularis tendon Ø Grade 3 - Displaced into joint Ø Grade 4 - Displaced anterior to subscapularis Ø Grade 5 - Dislocation of biceps with subscap rupture Ø Grade 6 - Posterior dislocation of biceps Ø Grade 7 - Biceps rupture Ø

*Bennett. Arthroscopy 2003

Biceps Tendon

Anterior shoulder pain

Anterior shoulder pain

Biceps

Anterior shoulder pain

Subscapularis Tendon Biceps

Biceps Tendinosis & Instability with Partial Tear Subscap Subscapularis Tendon Biceps

Grade 1 Injury Subscapularis Tendon Biceps

Biceps in Subscap

Grade 2

Biceps in Subscap

Biceps in Joint - Type 3

Hand and Wrist Injuries Ø Bone

Injuries Ø Impingement Syndromes Ø Instability Ø Triangular Fibrocartilage (TFCC) Ø Tendons Ø Ligaments

50 yo, pain after falling roller blading with daughter

X-Ray Occult Fractures are Common

Gilula’s Archs

Kaewlai R, et al. Radiographics(2008);28:1771-84

Gilula’s Archs

Kaewlai R, et al. Radiographics(2008);28:1771-84

Gilula’s Archs

Greater Arch

Kaewlai R, et al. Radiographics(2008);28:1771-84

Gilula’s Archs

Greater Arch

Lesser Arch Kaewlai R, et al. Radiographics(2008);28:1771-84

Acute Trauma - 0.2 T

Acute Trauma - 0.2 T

T1

Acute Trauma - 0.2 T

T1

Acute Trauma - 0.2 T

T1 STIR

Acute Trauma - 0.2 T

T1 STIR

Lunate & Scapholunate Ligament Injuries

T1 STIR

Scaphoid Injury - Mayo Clinic

Kaewlai R, et al. Radiographics(2008);28:1771-84

Scaphoid Injury - Mayo Clinic Articular

Tuberosity Distal Waist

Proximal Kaewlai R, et al. Radiographics(2008);28:1771-84

19 yo female athlete with wrist injury 10/1/08: R/O scaphoid fx

10/17/08

Proximal pole fx with no edema: ? perfusion of proximal pole

10/17/08

12/17/08

12/17/08

2 months later: proximal pole edema

12/17/08

Acute Scaphoid Fracture

Acute Scaphoid Fracture

No DISI

Scaphoid Humpback Deformity

DISI Instability

Early SNAC scaphoid non-union advanced collapse

DISI Instability

Impingement Syndromes § Ulnar Impaction* § Ulnar Impingement* § Non-union ulnar styloid* § Ulnar styloid Impaction* § Hamatolunate* § Radial styloid § Scaphocapitate *Cerezal, et al. Radiographics 2002;22:105-121

Ulnar Impaction

*from Cerezal, et al. Radiographics 2002;22:105-121

Ulnar Impaction

Ulnar Impingement

*from Cerezal, et al. Radiographics 2002;22:105-121

Ulnar Impingement

Ulnar Styloid Avulsions

TYPE 1

*from Cerezal, et al. Radiographics 2002;22:105-121

TYPE 2

Styloid Avulsion - Type 2

Ulnar Styloid Impaction

*from Cerezal, et al. Radiographics 2002;22:105-121

Triquetral Injury

Triquetral Injury Ulnar Styloid Injury

Ulnar Styloid Impaction

Triquetral Injury Ulnar Styloid Injury

Ulnar Styloid Impaction - Chronic

Hamatolunate Impaction

*from Cerezal, et al. Radiographics 2002;22:105-121

Medial Fossa (Type 2)

Impaction

Medial Fossa (Type 2)

Hematolunate Impaction Impaction

Medial Fossa (Type 2)

Instability § Gross stability from extrinsic ligaments § Intermediate stability from intrinsic ligaments § Fine tuning from TFCC

49 yo male fell 6 days ago R/O TFCC tear

49 yo male fell 6 days ago R/O TFCC tear

49 yo male fell 6 days ago R/O TFCC tear

49 yo male fell 6 days ago R/O TFCC tear

Dorsal Carpal Ligament Tear

49 yo male fell 6 days ago R/O TFCC tear

Dorsal Carpal Ligament Tear Standard T2 - 3mm

Standard STIR - 3mm

49 yo male fell 6 days ago R/O TFCC tear

Dorsal Carpal Ligament Tear Standard T2 - 3mm

Standard STIR - 3mm

49 yo male fell 6 days ago R/O TFCC tear

Dorsal Carpal Ligament Tear Standard T2 - 3mm

CUBESTIR T2 - 1.6mm Standard - 3mm

49 yo male fell 6 days ago R/O TFCC tear

Dorsal Carpal Ligament Tear Standard T2 - 3mm

CUBESTIR T2 - 1.6mm Standard - 3mm

49 yo male fell 6 days ago R/O TFCC tear

Dorsal Carpal Ligament Tear CUBE T2T2 - 1.6mm Standard - 3mm

CUBESTIR T2 - 1.6mm Standard - 3mm

49 yo male fell 6 days ago R/O TFCC tear

Proximal Dorsal Ligament Intact

Dorsal Carpal Ligament Tear CUBE T2T2 - 1.6mm Standard - 3mm

CUBESTIR T2 - 1.6mm Standard - 3mm

1.6 mm CUBE better displays soft tissue injury Proximal Dorsal Ligament Intact

Dorsal Carpal Ligament Tear CUBE T2T2 - 1.6mm Standard - 3mm

CUBESTIR T2 - 1.6mm Standard - 3mm

DISI Instability

Normal

DISI

DISI Instability

Normal

DISI

DISI Instability

Normal

DISI

DISI Instability

Normal

DISI

Scaphoid Fx:

Scaphoid Fx:

Scaphoid Fx:

Scaphoid Fx:

Scaphoid Fx:

Scaphoid Fx:

Scaphoid Fx:

Scaphoid Fx: DISI

Classic Causes of DISI

§Scaphoid fracture §Scapho-lunate ligament tear

36 yo professional hockey player with wrist pain for 1 year

T1

PDFS

36 yo professional hockey player with wrist pain for 1 year

T1

PDFS

Scapholunate & Lunotriquetral Ligamant Avusions

T1

PDFS

Luno-triquetral Tear

Luno-triquetral Tear

Luno-triquetral Tear

Luno-triquetral Tear

VISI Instability

Luno-triquetral Tear

0.2 T 3D GRE

0.2 T 3D GRE

Luno-Triquetral Ligament Tear

0.2 T 3D GRE

TFCC Anatomy - Pronation

Resnick,Internal Derangement of Joints,Bone and Joint Disorders,Saunders,2002

TFCC Anatomy

Resnick,Internal Derangement of Joints,Bone and Joint Disorders,Saunders,2002

TFCC Anatomy

Yoshioka, et al. Skeletal Radiology(2003),32(10):575-81

23 yo male with wrist pain

23 yo male with wrist pain

23 yo male with wrist pain

ClassA - Central Perforation

Class B - Peripheral Tear

1.5 Tesla

Luno-triquetral Ligament

1.5 Tesla

Luno-triquetral Ligament

Ulno-triquetral Ligament

1.5 Tesla

Luno- & Ulno-Triquetral Ligament Tears - Class C Luno-triquetral Ligament

Ulno-triquetral Ligament

1.5 Tesla

Radial Attachment Tear

Palmar Class D

Radial Attachment Tear

Anatomy - Zone VII

Extensor Tendons § 1st comp - De Quervain’s

Syndrome § 2nd comp - Intersection Syndrome (oarman’s synd) § 3rd comp - hypertrophy of Lister’s tubercle § 4th and 5th comps § 6th comp - ECU

First Extensor Compartment

Dequervain’s Disease

First Extensor Compartment

Extensor Carpi Ulnaris

Ulnar Head - Axial View

! 1. Extensor Retinaculum ! 2. ECU Subsheath ! 3. ECU tendon ! 4. Ulnar Styloid ! 5. Ulnar Head

ECU Split Tear

ECU Tenosynovitis

ECU Dislocation

80 yo female with long standing RA and inability to extend 4th digit

Courtesy Dr. Phillip Tirman

80 yo female with long standing RA and inability to extend 4th digit

Courtesy Dr. Phillip Tirman

80 yo female with long standing RA and inability to extend 4th digit

Courtesy Dr. Phillip Tirman

80 yo female with long standing RA and inability to extend 4th digit

Courtesy Dr. Phillip Tirman

80 yo female with long standing RA and inability to extend 4th digit

Courtesy Dr. Phillip Tirman

80 yo female with long standing RA and inability to extend 4th digit

Courtesy Dr. Phillip Tirman

4th Extensor Tendon Rupture

Courtesy Dr. Phillip Tirman

Gamekeepers Thumb - Non-displaced

Coronal 1st MCP

Sagittal 1st MCP

Unstable injury

Coronal 1st MCP

Sagittal 1st MCP

Unstable injury

Coronal 1st MCP

Volar Plate injury

Sagittal 1st MCP

Unstable injury

Volar Plate injury

Marrow edema Coronal 1st MCP

Sagittal 1st MCP

Unstable injury

Volar Plate injury

Adductor Pollicis Aponeurosis

Marrow edema Coronal 1st MCP

Sagittal 1st MCP

Stener Lesion Unstable injury

Volar Plate injury

Adductor Pollicis Aponeurosis

Marrow edema Coronal 1st MCP

Sagittal 1st MCP

Hockey player checked against the boards, thumb pain

Hockey player checked against the boards, thumb pain

Hockey player checked against the boards, thumb pain

String

Hockey player checked against the boards, thumb pain

String Yoyo

Stener Lesion

String Yoyo

29 yo professional hockey player with 3 month hx 3rd MCP Injury

29 yo professional hockey player with 3 month hx 3rd MCP Injury

29 yo professional hockey player with 3 month hx 3rd MCP Injury

29 yo professional hockey player with 3 month hx 3rd MCP Injury

29 yo professional hockey player with 3 month hx 3rd MCP Injury

29 yo professional hockey player with 3 month hx 3rd MCP Injury

UCL Avulsion

Athletic Trauma • Hips • Sports Hernia • Shoulder • Wrist • Hand