Radiology Workshop Extremities

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Radiology WorkshopExtremities

• Andrew Haims

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Case 1

• This is a 35 year old male who fell off a roof
  and is now complaining of knee pain

How would you describe this injury?
This is a knee dislocation, click to see the
normal orientation of the tibia and the femur
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What types of injuries do you worry about with
knee dislocations?
What is wrong with this angiogram?
Hint, bony, vascular or ligamentous or meniscal?
Vascular is the most concerning and there is
almost always ligamentous and meniscal injuries
What would you do to evaluate the artery?
First examine for a pulse, then possibly an
angiogram
The popliteal artery is disrupted
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Lets take a look at some ligaments, can you
point out the normal anterior and posterior
cruciate ligaments on these sagittal sequences?
Click for arrows
PCL
ACL
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Lets take a look at some more ligaments, can you
point out the normal lateral and medial
collateral ligaments on these coronal sequences?
How about the medial and lateral menisci? Click
for arrows
Lateral Meniscus
Medial Meniscus
LCL
MCL
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Lets now take a look at the anterior and
posterior cruciate ligaments in our trauma
patient on these consecutive sagittal images.
Click for another look at the normals.
These are both torn off their femoral attachments
PCL stump
ACL stump
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Take a look at our patients medial and lateral
collateral ligaments. Do you think they look
normal? Click for normals
The LCL is torn off the fibula and the MCL is
torn proximally, click for arrows.
MCL disrupted fibers
LCL stump
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Case 2

• 65 year old female with a recent history of fall,
  now presents with difficulty abducting the arm

Humerus
Clavicle
Can you identify the humerus, glenoid, coracoid
process, acromion and clavicle? (click for
answers)
Acromion
Glenoid
Coracoid
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The patients physician did not see any
abnormalities on her plain radiographs and she
did not improve with conservative treatment so
she was sent for an MRI to evaluate her rotator
cuff.
These are coronal images from an MR arthrogram
(we put contrast into the shoulder joint). These
are consecutive images which image is the most
posterior?
Hint, where are the AC joint and the long head of
the biceps tendon?
The left image is the most posterior as the AC
joint and bicps are anterior
biceps
AC
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Now take a look at the rotator cuff tendons,
which one do we see on the posterior image and
which one do we see on the most anterior 2 images?
Contrast above the cuff tendons
Infraspinatus tendon
Supraspinatus tendon
These are the most common rotator cuff tendons to
tear. There is no tear in this patient. Where
would you expect to see contrast if there was a
tear? Click to see a tear
contrast
tear
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What are the other 2 rotator cuff tendons (we
already discussed the supraspinatus and
infraspinatus tendons?
Teres minor and subscapularis tendons, Can you
find them on the provided axial images?
Teres Minor
Subscapularis
Subscapinternal rotation Teres minorexternal
rotation
By the attachment of these muscles to the humerus
can you determine their function
Can you identify the anterior and posterior labrum
ANTERIOR
Anterior labrum
Posterior labrum
POSTERIOR
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Now for the diagnosis on this is a coronal
fat-suppressed T2 weighted image do you see an
abnormality?
There is extensive edema in the greater
tuberosity of the humerus consistent with a
nondisplaced fracture.
Try and think why this would cause supra and
infraspinatus symptoms without a rotator cuff tear
The supra and infraspinatus tendons attach to the
greater tuberosity
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Case 3
This is a 27 year old man who fell and has wrist
pain.
Do you seen an abnormality?
There views look normal
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Can you name the carpal bones?
Scaphoid
?
Lunate
?
Triquetrum
?
Pisiform
?
Hamate, do you see the hook
?
Capitate
?
?
Trapazoid
?
Trapezium
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This patient subsequently underwent an MRI of the
wrist to evaluate the etiology of his pain. Can
you identify the radial and ulnar arteries on
these axial sequences.
Hint, palpate your own pulses to determine where
to look
Can you find the median nerve
Ulnar artery
Radial artery
DORSAL
Radius
Ulna
VOLAR
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A common cause of post-traumatic wrist pain is a
tear of the TFCC (triangular fibrocartilage
complex). Can you identify the normal TFCC in
this patient on this coronal image and anatomic
drawing.
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Now for the diagnosis in this case. This is a
coronal fat suppressed T2 weighted sequence. Do
you see an abnormality?
Hint, look for marrow edema in one of the carpal
bones.
Which bone is this?
This a nondisplaced fracture of the scaphoid
This is the most common carpal bone fractured.
Click to see a more obvious fracture of the
scaphoid on a plain radiograph
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The End