1. Orthopedics and Magnetic Resonance Imaging
Dr. F. Vanrietvelde
Dept. of medical imaging
AZ Groeninge, Kortrijk

2. Orthopedics and MR How does MR work?
Why MR (comparison with other imaging techniques)?
Overall and regional orthopedic indications?
Contra-indications.

3. MR: how does it work?
Static external magnetic field (Bo), i.e. 1.5 T

4. MR: how does it work?
MR active nuclei (i.c. H) align (anti)-parallel to the magnetic field

5. MR: how does it work? Radio-frequency pulse application
Excitation and flipping of the magnetic vector of the nuclei

6. MR: how does it work?
Stopping the RF pulse leads to energy loss and induces a signal
Signal is transformed to an image

7. MR: how does it work?
Characteristics of the image dependent on the RF pulse parameters T1 T2
Related sequences (STIR) T1 T2

8. Why MR? Conventional RX Sonography Computed Tomography
Poor soft tissue contrast including medullary component of bone
Projection technique
Radiation
Sonography
(Near) absent visualisation beyond cortical bone and air
Poor result for deeper components
Computed Tomography
Poor soft tissue contrast

9. Why not MR? Calcifications: RX and CT Air: CT
Cortical and trabecular bone: RX and CT
(arthrographic cartilage imaging: CT)
Contra-indications: Pace-maker, Ferromagnetic implants intracranial, FI extracranial (<6 weeks), Neuro-stimulation material, Ferromagnetic splinter orbital, pregnancy first trimester.

10. Indications and examples
Sonography will give you the diagnosis in many cases and allows dynamic imaging
Disadvantages:
Operator dependent
Non reproducible
Difficult anatomical display
Poor soft tissue characterisation

11. Knee
Principal indications: menisci, cruciate ligaments, collateral ligaments, (cartilage)
Lateral meniscal tear
PD fs
PD fs

12. Knee PD fs Posterior horn medial meniscal tear Bucket handle tear
Double PCL sign
normal

13. Knee
PD fs
Double PCL sign

14. Knee
PD fs
Normal ACL
ACL tear

15. Knee
PD fs
MCL tear
Normal MCL
MCL tear

16. Knee
PD fs
Jumper’s knee
Normal patellar tendon

17. Shoulder
Principal indications: rotator cuff pathology, biceps , subacromio-deltoid bursa(labrum, cartilage), capsula
Indirekte versus directe MR arthrography
Indirect: RC, SD bursa, capsula
Direct: labrum, cartilage, (RC), gleno-humeral ligaments

18. Indirect versus Direct
Direct articular punction
Ia injection of diluted Gd
Indirect
IV injection of Gd
Active or passive mobilisation 10 min
Synovial stimulation
Gd in articular space
T1 fs
T1 fs

19. Shoulder Full thickness tear Full thickness tear + retraction
T1 fs + iv Gd

20. Shoulder
Normal superior labrum
Arthro T1 fs
SLAP lesion

21. Shoulder
Arthro T1 fs
Bankart lesion

22. Shoulder
T1 fs iv Gd
T1 fs iv Gd
Normal
GH capsulitis

23. Ankle
Principal indications: musculo-tendinous, ligaments, (cartilage), bone
STIR T1
Fasciitis plantaris

24. Ankle
OLT T1
OLT
STIR

25. Ankle T1 T2
STIR T1
Achilles tendinosis
Intratendinous tear
Normal

26. Ankle
STIR
Posterior impingment syndrome T1 T1
Normal os trigonum

27. Wrist
Principal indications: musculo-tendinous, ligaments, nerves, bone
STIR T1
Avascular necrosis proximal navicular bone

28. Wrist
Arthro T1 fs
Normal
scapho-lunate ligament tear

29. Wrist
GE T2 fs
Normal TFCC
TFCC tear
TFCC tear
Arthro-CT

30. Wrist T2 T2
Extensor carpi radialis
peritendonitis
Normal

31. Hip Principal indications: avascular necrosis, labrum, pain e.c.i. T1
(peri)trochanteritis
STIR
STIR

32. Hip
STIR T1
Avascular necrosis T1
STIR

33. Hip
T1Gdfs
Normal
Anterosuperior labrum tear

34. Hip
STIR
STIR
Hamstring injury
Normal

35. Elbow Principal indications: tendinous, ligaments, cartilage, bone
T2 fs
STIR
T2 fs
Normal CET
Epicondylitis radialis

36. Elbow
STIR
STIR
UCL tear
Epicondylitis ulnaris

37. Elbow T1 T2
T1 fs Gd
Bursitis Bicipitalis

38. Elbow T1
STIR
T2 fs
Tear distal biceps humeri

39. Cartilage imaging CT has a higher resolution
MR show grade 1 chondromalacia
Intra-articular contrast with CT (invasive)
MR shows concommitant pathology

40. Cartilage imaging
STIR
Arthro-CT
Artefacts / image distortion

41. Cartilage imaging
Arthro CT
Arthro T1 fs
Resolution difference

42. Soft tissue tumors Sonography at first
X-ray to detect calcifications/relation to bone
MR characterisation
Imaging pre-intervention!!!

43. Soft tissue tumors
aT1
aT2 fs
aT1 Gd
Recidief liposarcoma

44. Soft tissue tumors T1
T2 fs
T1Gd
N.Tibialis Schwannoma

45. Soft tissue tumors
cT2
cT1
cT1 fs Gd
Intramusculair hemangioma

46. Which imaging modality?
Bone: RX, if nessecary CT and/or MR (medullary pathology)
Ligaments: US, RX (bony avulsions), MR (concommitant pathology,detection and characterisation)
Muscles/tendons: US, RX (bony avulsions, calcifications), MR (detection,characterisation)
Cartilage: arthro-CT, MR (concommitant pathology)