Practical Reporting of Musculoskeletal Imaging Studies: MRI Knee. James F Griffith

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1 Practical Reporting of Musculoskeletal Imaging Studies: MRI Knee James F Griffith

2 Lecture series Practical reporting Everyday clinical scenarios Informal, my opinion Interactive

3 We re not going to talk about Imaging protocols Didactic discussion on specific abnormalities

4 Knee Get a history Don t rely on request form Ask radiographers to request history

5 Report Should be commensurate with the clinical status Must address and concentrate on answering clinical question

6 Grade. Don t mention any feature without grading it Qualitative measure : Minimal, mild, moderate, severe Quantitative measure: Small, medium, large (mm long x mm deep x mm wide)

7 This talk : outline Effusion Cartilage injury Meniscal injury ACL injury PCL injury

8 Effusion Normally the knee contains a very small amount of fluid No knee joint effusion

9 Effusion If slightly more than this: Slight increase in knee joint fluid

10 If see more than this: small, medium-sized or large joint effusion Small Effusion

11 Medium-sized effusion

12 Synovial proliferation Mild reactive-type synovial proliferation

13 Synovial proliferation Moderate or severe synovitis : think of inflammatory synovitis or low grade infection.

14 Descriptive subregions lateral patellar facet medial patellar ridge medial patellar facet lateral trochear ridge trochlear apex medial trochear ridge

15 Descriptive subregions femoral trochlea posterior central weightbearing ant mid- post medial tibial condyle lateral tibial condyle

16 Normal articular cartilage

17 Normal articular cartilage

18 Cartilage injury fibrillation

19 Cartilage injury fibrillation

20 Cartilage injury mild OA Mild osteoarthritis with mild (20-25%) irregular diffuse cartilage thinning, particularly over the lateral patellar facet and median patellar ridge

21 Cartilage injury moderate OA Moderate osteoarthritis with moderate (35-60%) irregular cartilage thinning, most pronounced over the lateral patellar facet and median patellar ridge

22 Cartilage injury severe OA Severe (80- >95%) cartilage thinning, mainly affecting the median patellar ridge and lateral patellar facet

23 Severe patellofemoral OA severe patellofemoral osteoarthritis with severe (>95%) thinning of articular cartilage mainly at the lateral patellar facet

24 Cartilage injury Mild OA Mild (10-25% ) cartilage thinning is present on the weightbearing areas of the medial femorotibial compartment

25 Cartilage injury Moderate OA Moderate (30-55% ) cartilage thinning is present on the weightbearing areas of the medial femorotibial compartment

26 Cartilage injury Severe OA Severe (> 90% ) cartilage thinning is present on the weightbearing areas of the medial femorotibial compartment

27 Focal cartilage injury - location

28 Focal cartilage injury - location

29 Focal cartilage defect (mild)

30 Focal cartilage defect (moderate)

31 Focal cartilage defect (severe)

32 Focal cartilage defect There is a localized (mm wide x mm long). partial thickness (%) near full-thickness (80-90%) full-thickness chondral defect on the...

33 Subchondral bone marrow oedema Minimal, mild, moderate, severe Localised or diffuse

34 Subacute chondral defect

35 Focal cartilage defect This seems like an acute injury with fluid filling the defect This defect seems partially healed with the defect partially filled by reparative fibrocartilage This lesion seems to have largely healed with reparative fibrocartilage completely filling the chondral defect

36 Healing of chondral defects Not healed Partially healed Largely healed

37 Largely healed chondral defect localised (mm x mm) area of chondral thinning on the more lateral aspect of the lateral patellar facet. The cartilage is thinned by 30%. This cartilage defect is partially healed and filled mainly with fibrocartilage. Mild subchondral bone marrow oedema is present

38 Chronic osteochondral injury

39 Chronic osteochondral injury

40 Chronic osteochondral injury

41 Chronic osteochondral injury

42 Chronic osteochondral injury mild localised bone marrow oedema quite severe ill-defined bone marrow oedema reflecting disease activity

43 Delamination

44 Delamination localised (mm x mm) area of chondral injury with delamination, moderate chondral swelling and mild subchondral bone marrow oedema

45 Chondromalacia

46 Chondromalacia localised (mm x mm) area of chondral injury with chondral oedema and swelling consistent with moderate-severity chondromalacia. No focal chondral defect present

47 Cartilage fracture

48 Cartilage fracture full thickness cartilage fracture extending over a mm length. No osteochondral separation or cartilage defect

49 Chondral separation

50 Cartilage abnormality Osteoarthritis Focal chondral defect Delamination injury Chondromalacia Chondral fracture Chondral seperation

51 Menisci Degeneration Tear Anchorage

52 Meniscal degeneration Flattening Deformation Extrusion

53 Meniscal Flattening Normal Mild Moderate Severe

54 Meniscal deformation Normal Minimal Mild Moderate Severe

55 No undue meniscal extrusion

56 No undue meniscal extrusion

57 Meniscal extrusion

58 Meniscal extrsuion

59 Meniscal extrsuion

60 Sample report There is mild to moderate meniscal degeneration with mild meniscal flattening, and moderate (4mm) peripheral extrusion of the meniscal body. No meniscal deformation

61 Sample

62 Sample

63 Post root

64 Post root tear There is a complete tear of posterior root of the medial meniscus. This is retracted by mm from its insertional area. (There is a mm wide x mm long area of micro-cystic change deep to the insertional area).

65 Post root tear

66 Meniscal tears Horizontal Longitudinal / bucket handle Radial

67 Meniscal tears Length (mm) Location : body, anterior horn, posterior horn Degree of displacement Inner, mid-, peripheral one-third Horizontal tear - parameniscal cyst Bucket handle tear how much is displaced and whether attached at ant or posterior ends

68 ACL tear Complete intrasubstance Acute or chronic Bone bruising (grade) Tibiofemoral translation (mm) Associated findings (meniscal tear)

69 ACL tear complete Oedematous mass Discontinuity Mal-alignment

70 ACL tear complete Mal-alignment with re-attachment Mal-alignment with attenuation Complete attrition

71 Tibiofemoral translation Associated with clinical instability >5mm

72 Tibiofemoral translation Anterior tibial translation >5mm

73 Associated injuries * * * * Bone bruising Anterocentral aspects femoral condyles Posterior aspects tibial condyles

74 Associated injuries Peripheral meniscal tear Corner tear at posteromedial medial meniscus

75 Corner meniscal tears at PM corner

76 ACL tear Partial Anteromedial or posterolateral bundle % tear of each bundle Overall % torn

77 Different scenarios 1. Unequivocal ACL tear stop 2. Probable complete tear 3. Possible partial tear

78 Knee flexion Extensio n Complete ACL tear Flexion

79 Knee flexion Extensio n Complete ACL tear Flexion

80 Knee flexion Extensio n High grade partial ACL tear Flexion

81 Different scenarios 1. Unequivocal ACL tear stop 2. Probable complete tear flexion 3. Possible partial tear

82 Suspected ACL tear

83 Partial tear ACL oblique axial view Low grade partial tear, PL > AM

84 Partial ACL tear oblique axial view Partial AM with complete PL tear

85 Mucoid degeneration & ganglion cyst Mucoid degen n Mucoid degen n Ganglion cyst Preservation of linear striations Celery stick sign

86 How do you know it is mucoid degeneration? Typical appearances Intraosseous ganglion cysts or fluid leakage PCL also shows mucoid degeneration

87 PCL tear Complete or partial - intrasubstance Acute or chronic Bone bruising (grade) Associated injury (posterolateral corner)

88 PCL tear complete 2 Discontinuity Diffuse oedema & discontinuity Diffuse oedema & discontinuity Swelling & discontinuity main signs of complete PCL tear

89 PCL partial tear Partial Partial Partial Swelling without discontinuity partial PCL tear

90 PCL tear vs double PCL sign 12 Longitudinal split Double PCL sign Some partial tears may manifest as longitudinal split Don t confuse with double PCL sign

91 PCL tear & PL corner injury G LCL SMR FFL PT AL PFL

92 PCL tear & LCL tear

93 Popliteofibular ligament Intact Torn

94 Popliteus tendon partial tear

95 Arcuate ligament injury Posterolateral corner capsular injury

96 PCL has propensity for healing 1 3 Healed PCL Healed PCL In healed PCL tears, the ligament may elongate Remains clinically lax

97 Thank you

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