MRI Anatomy of the Knee and Shoulder
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1 November 2002 MRI Anatomy of the Knee and Shoulder James Y. Song, UC San Francisco MSIV Gillian Lieberman MD
2 Agenda Knee Sagittal, Coronal FSE PD Ligamentous (ACL, PCL, MCL, LCL) and meniscal injury Shoulder Sagittal, Coronal T2WI Shoulder impingement classification 2
3 Anatomy: Knee Sagittal patellar articular cartilage plantaris gastroc (m) lateral meniscus (ant.horn) infrapatellar fat pad tibialis posterior P S G (l) BIDMC 2002 lateral meniscus (post.horn) tibia, articular cartilage 3
4 Anatomy: Knee Coronal vastus lateralis biceps femoris iliotibial tract gastroc. (lateral) popliteal a + v. gastroc. (medial) ACL peroneus longus PCL MCL tendon of sartorious BIDMC
5 Anterior Cruciate Ligament Functional Anatomy Intra-articular, extra-synovial, extends from anterior tibia to to inner portion of lateral femoral condyle Limits anterior translation of tibia, hyperextension, internal rotation Mechanism of Injury External rotation and abduction w/ hyperextension, direct forward displacement of tibia, internal rotation w/ fully extended knee Can occur in conjunction w/ meniscal tears (41-68%), injury of other collateral ligaments, osteochondral or compression fractures 5
6 MRI Criteria for ACL rupture Complete Rupture DIRECT SIGNS: -complete fiber disruption -abnormal course of cruciate ligament -intracapsular pseudomass in position of ACL INDIRECT SIGNS: -acute angulation of PCL -drawer phenomenon - kissing contusions 6
7 MRI Criteria for ACL Rupture Incomplete Rupture -thinning of ACL < 10mm -periligamentous pseudomass in presence of intact fibers -increased intraligamentous signal with remnants of intact fibers 7
8 ACL Tear Sagittal PD Sagittal T2WI Graf et al. Am. J. Sports. Med. 1993; 21(2):
9 Post Cruciate Ligament Functional Anatomy Extends from posterior tibia to inner aspect of medial femoral condyle Limits anterior translation of femur, stabilizes knee in extension Mechanism of Injury Isolated tear secondary to fall on flexed knee, assoc. w/ osseous avulsion fracture at tibial insertion site 9
10 MRI Criteria for PCL Rupture - confined areas of increased signal intensity along course of the ligament (= partial rupture) - continuity disruption (= complete rupture) 10
11 Medial Cruciate Ligament and Lateral Cruciate Ligament Functional Anatomy MCL: 8-10 cm, from medial epicondylar region to 4-5cm inferior to tibial plateau LCL: 5-7 cm, extracapsular, from lateral femoral epicondyle to conjoined insertion w/ biceps femoris tendon on fibular head Mechanisms of Injury MCL: valgus stress without rotation, and direct trauma with valgus stress PCL: varus stress with out without rotation 11
12 MRI Criteria for MCL/LCL rupture 12 Bohndorf et al. Musculoskeletal Imaging: A concise multimodality approach. Thieme 2001: 112.
13 Meniscus Anatomy each meniscus can be divided into 3 zones lateral meniscus is more C-shaped, with a shorter radius Anterior horn Anterior meniscus body Intermediate zone (pars intermedia) Peripheral meniscus body Anterior horn Posterior horn Posterior horn Three Units Posterior meniscus body Rule 13
14 MRI Evaluation of Meniscal Damage Size Configuration of meniscus and signal pattern Depth and width of altered signal Location within meniscus 14
15 Gradation of Signal Alteration in Menisci (Stoller) A 3B 15
16 Meniscal Tear Morphology Vertical (traumatic or degenerative) Horizontal (usually traumatic, posterior horn) Bucket-Handle Tear (subtype of vertical) Peripheral (within 5mm of periphery) Amputating (truncated free border or tip) Radial (traumatic or degenerative, medial) 16
17 Bucket-Handle Tear Weiss KL et al. AJR. 1991: 156(1):
18 Shoulder Anatomy Bones (shoulder girdle, humerus) Joints (glenohumeral, scapulothoracic, acromioclavicular; all synovial) Muscles (attachments at ant/post scapula, ant/post humerus, ant/inf clavicle) Nerves and arteries 18
19 Shoulder Anatomy: Coronal 1 supraspinatus (+tendon) subscapularis serratus anterior clavicle coracoid process tendon of biceps brachii (short head) coracobrachialis brachial plexus BIDMC 2002
20 Shoulder Anatomy: Coronal 2 suprascapular a. + n. tendon of biceps brachii m. (long head) glenohumeral ligament biceps brachii m. (short and long head) BIDMC
21 Shoulder Anatomy: Coronal 3 trapezius spine of scapula glenoid cavity scapula clavicle acromion superior glenoid labrum inferior glenoid labrum BIDMC
22 Glenohumeral Joint 1. Anterior labrum 2. Subscapularis 3. Infraspinatus 4. Posterior labrum 5. Humerus 6. Glenoid cavity CyberAnatomy Tutorials, University of Newcastle upon Tyne. 22
23 Shoulder Anatomy: Sagittal 1 coracromial lig. glenohumeral and coracohumeral lig. biceps t. deltoid acromion supraspinatus infraspinatus teres minor anterior circumflex humeral a. + v. triceps brachii BIDMC
24 Shoulder Anatomy: Sagittal 2 clavicle supraspinatus coracoid tendon of biceps brachii m. (long) tendon of biceps brachii m. (short) scapula infraspinatus teres minor latissimus dorsi teres major BIDMC
25 Shoulder impingement syndrome Stage I: <25 yrs., w/ edema and hemorrhage Stage II: yrs., w/ tendinitis and fibrosis of rotator cuff, thickening of subacromial bursa Stage III: > 40 yrs., = tear 25
26 References Bohndorf K., Imhof H., Pope TL. Musculoskeletal Imaging: A concise multimodality approach. Thieme 2001: 112. Slide 12. Graf et al. Bone bruises on MRI evaluation of ACL injuries. Am. J. Sports. Med. 1993; 21(2): Weiss KL, Morehouse HT, Levy IM. Sagittal MR images of the knee: a low-signal band parallel to the posterior cruciate ligament caused by a displaced bucket-handle tear. AJR Am J Roentgenol. 1991; 56(1): Slide 17. Shanahan D. Cyberanatomy Tutorials: Anatomy and Clinical Skills Centre, University of Newcastle Upon Tyne Slide
27 Acknowledgements Steve Reddy, MD Larry Barbaras and Cara Lyn D amour Pamela Lepkowski 27
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