When one projection just isn’t enough

This 53-year-old male patient presents with pain and catching of the right shoulder when lifting the arm above the head. You are shown proton density fat suppression sequences using STIR short T1 inversion recovery in the coronal and sagittal projections. The patient has a rotator cuff tear.

Q1 – Is the tear full thickness? Look at the blue arrow on image 1 before you make your decision.

Coronal STIR

 

Q2 – When you have made your decision in question 1, check out images 2 and 3. Note the additional pink arrow on image 2, as well. What do you think the blue arrow represents?

Coronal STIR

Sagittal STIR

 

A1 – The tear is not full thickness. It appears ominous and perhaps full thickness in the coronal projection (image 2, pink arrow), but that is because the outer shell fibers are curved and “en face” to the coronal image. However, in the sagittal projection (image 3), a clear hypointense outer shell (pink arrow) covers a partial thickness tear (yellow arrows).

This is a terribly important teaching point, namely that full thickness tears should appear to communicate with the bursal space in two projections. The outer low signal shell (image 3, pink arrow) confirms this in the sagittal projection. Additionally, the patient had surgery affirming the presence of a partial, not full thickness communicating, tear.

A2 – The blue arrow (images 1 and 2) points to the hypertrophied markedly thickened coracoacromial ligament which is often responsible for outlet related stenosis and clinical impingement syndrome. When the patient abducts, the rotator cuff comes in contact with the acromion and thickened coracoacromial ligament where it is repetitively “pinched” or impinged, especially in internal rotation.

 

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It’s hip, it’s obscure, it’s the case of the day

This 39-year-old female presents with hip pain that has continued for four months. Neither a cortisone shot, nor physical therapy could relieve the pain. Have a look at coronal images 1 and 2.

Q1 – What is the most likely diagnosis?
Q2 – Is this entity more common in males or females?

Coronal STIR

Coronal STIR

 

A1 – The most likely diagnosis is proximal iliotibial band (ITB) syndrome.
A2 – Proximal ITB is more common in females.

Proximal ITB syndrome is related to a strain or injury of the iliotibial band enthesis where the ITB attaches to the iliac tubercle. This entity is newly described by Sher et al. in 2011*, with few reports currently existing in literature. As such, little is known about the cause or treatment options.

To date, most results suggest there is a strong female predisposition; some of which are active runners. Others are non-athletic, some of which have a prior traumatic injury. Most commonly, patients are middle aged.

In magnetic resonance imaging, proximal ITB syndrome presents as areas of increased signal intensity adjacent to the iliac tubercle. Partial or complete disruption of the ITB may occur. The appropriate therapy is unknown. It is likely conservative for most patients.

*Reference: Sher I, Umans H, Downie SA, Tobin K, Arora R, Olson TR. Proximal iliotibial band syndrome: what is it and where is it? Skeletal radiology. 2011;40(12):1553-6.

 

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He tried to straighten his elbow, but it proved to be a “sloppy” mess

This 58-year-old male physical therapist, and world-class athletic trainer, now finds himself in need of rehabilitation. Have a look at the following GIF, and see if you can figure out why he cannot completely straighten his elbow.

Coronal STIR

 

Q1 (Advanced) – There are two clinical syndromes that are manifested on imaging in this case. Can you name them?

Coronal T1 FSE

Axial STIR

Sagittal PD FSE Fat Sat

Sagittal PD FSE Fat Sat

Coronal STIR

 

A1 (Advanced) – Image 1, a T1-weighted image, demonstrates a penetrating erosion at the corono-trochlear bump (pink arrow). A subtle fragment of bone or cartilage is indicated by the yellow arrow.

Now have a look at image 2. The blue arrow demonstrates an area of radial chondromalacia that is impacted by an osteochondral defect directly adjacent, and a body that lies between the radius and the humerus.

In image 3, a penetrating defect has produced signal alteration in the radius (pink arrow).

Turn your attention to image 4, and you will see a subtle osteochondral erosion on the humerus (green arrow).

Finally, observe image 5. The pink arrow shows an articular body. The yellow arrow highlights the impaction effect on the radius and its cartilage surface. The green arrows demonstrate inflammation of the common extensor tendon unit, and the adjacent purple arrow shows synovial hypertrophy of the lateral capsule consistent with capsulitis and lateral epicondylitis.

The two syndromes that one might observe on MR that can be translated clinically are:

(a) Lateral epicondylitis syndrome
(b) Sloppy hinge syndrome

The patient has clinical lateral epicondylitis syndrome due to inflammation and microtears of the common extensor mechanism. Go back and review the GIF to see the extensive lateral-sided inflammation both in tendon and soft tissues. This is not the cause for restricted range of motion, though.

The second syndrome is “sloppy hinge syndrome” associated with a loss of the normal smooth undulation of the humerus. Normally the humerus exhibits (a) two depressions, and (b) three bumps which are now interrupted by an osteochondral area of irregularity, and the body that has secondarily damaged the radius preventing full extension of the elbow.

 

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Have you ever measured the alpha angle in a knee?

This 50-year-old female presents with knee pain. There is no known injury, but the patient did have anterior cruciate ligament (ACL) repair 15 years earlier.

Q1 – How would you measure the alpha angle in this case? You may think I have lost my mind, and the wrong case is displayed, but I assure you it is correct.

Q2 – How would you measure the intercondylar notch distance?

Q3 – What is the significance of the alpha angle in the knee?

Q4 – What is the significance of the intercondylar notch distance?

Coronal T1

Sagittal T2 FS (60 TE)

Axial PD FS

 

A1 – A coronal T1 (image 4, pink arrow) shows a spur encroaching on the base of the femoral notch. A sagittal T2 (image 5), at the level of the posterior cruciate ligament, shows how you would measure the alpha angle. The green line is parallel to the long axis of the femur, and the yellow line is parallel to Blumensaat’s line of the femoral roof. In this patient, the angle is 29 degrees. Increasing alpha angles with a more horizontal femoral tunnel roof elevates the risk of notch impingement.

A2 – Have a look at the orange line in axial image 6. At this level, the trochlea is deep, and the insertion of the anterior cruciate ligament along the medial side wall of the lateral femoral condyle is the one to be evaluated (red arrow). The widest transverse dimension of the notch is measured as 1.56cm.

A3 – Alpha angles approaching 55-60 degrees or greater lay out the ACL in a more horizontal position in the native ungrafted knee, and place the ACL at greater risk for stress forces in flexion and extension. On the other hand, several authors have commented that a very vertical roof, and a very narrow alpha angle in ACL grafted knees, may result in an “unforgiving knee”. This would place grafted knees at greater risk for graft failure (American Journal of Sports Medicine, 1995).

A4 – The more narrow the distance, the more at risk the anterior cruciate ligament. A typical distance is 20mm measured at the right level. Patients with distances of approximately 15mm or less are at high risk for ACL deficiency or rupture. Most patients that have intercondylar notch distances of 12mm or less have ACLs that are absent or torn.

NOTES:

  • The alpha angle is similar in normal women and men.
  • The width of the intercondylar distance is more narrow in normal women than men.

Coronal T1

Sagittal T2 FS (60 TE)

Axial PD FS

 

Summary:
Individuals with large alpha angles approaching 55-60 degrees, and narrow intercondylar distances measured where the ACL attaches to the lateral condylar wall of less than 15mm, are at high risk for ACL stressors and subsequent rupture.

 

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Let’s start with the pinky, and see where it takes us

This 20-year-old male fell while skiing. Two weeks after the fall, the patient presented with pain, numbness, and tingling in the left pinky finger.

Can you identify the anatomic correlate of the patient’s symptoms? Have a look at images 1 and 2, and see if you can put the story together.

Axial T1

Axial T2

 

In images 3 and 4, the green arrows point to a mass that is hyperintense on T1 and on T2. This is compatible with a chronic hematoma and consistent with the patient’s history of a fall. The red arrows on image 3 also demonstrate a posteromedial superficial hematoma with T1 hyperintense blood related methemoglobin staining.

The anatomic correlate of the patient’s symptoms is the ulnar nerve. A pink arrow identifies the ulnar nerve as a slightly hyperintense structure on the T2 fat-suppressed image. While the signal of a nerve can be hyperintense to muscle on proton density fat-suppression (PD SPIR or PD STIR), it should be isointense or only slightly hyperintense to muscle on T2 imaging. This nerve is swollen and edematous. In addition, the blue arrow (image 4) identifies an area of cystic injury to the nerve which may be seen with blunt trauma, and is a common sequela in the peroneal nerve after a patient is struck by a car bumper, laterally. This is an analogous type of injury in the ulnar nerve as there was a direct impact. There should be no cystic high signal within a nerve.

Axial T1

Axial T2

 

Diagnosis:
Ulnar nerve contusion and interstitial injury without transection or total failure accompanied by a compressive hematoma.

 

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His ankle went one way, and he went another

This 24-year-old male performance athlete presents with inversion injury. The following axial images are in plantar flexion, 30 degrees.

Q1 – What is the pink arrow pointing to in images 2 and 3?

Q2 – To what is the blue arrow pointing in images 1 through 3?

Q3 – Given the findings highlighted with the pink and blue arrows, what is your imaging checklist?

Axial T1

Axial PD-SPIR

Axial T2

Axial FSE

Axial T1

 

A1 – Torn anterior talofibular ligament.

A2 – Torn calcaneofibular ligament.

A3 – The fact that the patient has a two-part ankle rupture involving the anterior talofibular ligament and calcaneofibular ligament, you should consider evaluating the following structures:

(a) The anterolateral soft tissues for hematoma (image 4, yellow arrow).

(b) The high ankle was normal. High ankle assessment should include the anterior tibiofibular ligament, interosseous ligament, and posterior tibiofibular ligament.

(c) The superior peroneal retinaculum is torn (image 5, green arrow), and peroneus brevis tendon demonstrates a split tear (image 5, red arrow).

(d) The talar dome, which was normal.

(e) Occult fractures; none of which were present.

(f) The subtalar space, and ligaments including the talocalcaneal interosseous ligament, cervical ligament, and lateral extensor retinacular / stem / frondiform ligament were all normal.

 

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There is pain and swelling, but where is the source?

This 27-year-old male presents with pain and swelling in the anterior left knee. The symptoms began eight months prior. There was no known injury or previous surgery.

Have a look at images 1 through 3, and see if anything stands out. Do not be distracted by the obvious finding.

Sagittal PD FSE Fat Sat

Sagittal T2

Axial T2 FSE

 

The images show normal menisci, ligaments, and tendons. There is a large joint effusion. A normal plica is visible, which is not thickened.

If you look closely in the posterior aspect of the suprapatellar joint capsule, there is frond-like synovitis or pannus (images 4 through 6, green arrows). Therefore, the most likely diagnosis is rheumatoid arthritis or seronegative arthropathy. In certain continents, Lyme disease would be a differential. Gout is more common in older patients.

It is important to correlate the findings, and not be distracted by prominent plica, which would not cause the degree of joint effusion.

Sagittal PD FSE Fat Sat

Sagittal T2

Axial T2 FSE

 

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After reading her palm, what do you believe her fortune to be?

This 33-year-old female presents with a mass in the palmar area associated with index finger stiffness.

Q1 – Based on the short-axis T1 fat-weighted images 1 and 2, what is your diagnosis?

Q2 – What are the small dots highlighted by pink arrows in image 1?

Q3 (Advanced) – The blue arrow in image 2 is pointing to what structure in the index finger?

Q4 – What is the signal characteristic, and proper description, of the tissue indicated by the orange arrow on image 2?

Axial T1 FSE

Axial T1 FSE

Coronal PD FSE Fat Sat

Axial T1 FSE

 

A1 – Lipofibromatous hamartoma of the median nerve.

A2 – Bundles of the median nerve.

A3 – Digital nerve surrounded by perineural fat and fibrosis.

A4 – Fat and fatty hypertrophy. Lipofibromatous hamartoma is a rare tumor of peripheral nerves which is characterized by excessive infiltration of the epineurium and perineurium by fiber adipose tissue. Since it is considered a hamartoma, some categorize it as a dysplasia. The median nerve is the most common nerve affected in the body, and often, the abnormality arises in the carpal tunnel. Average age of presentation is often the mid-20s. Lipofibromatous hamartoma of the median nerve has been described rarely in the sciatic, ulnar, and radial nerves.

Because the architecture of the tumor is so infiltrative and intertwined with the nerves, excision is almost never possible. On magnetic resonance imaging, long-axis views have described a spaghetti or cable-like appearance. This is displayed on image 3 (purple arrow).

The disorder is congenital in origin, and is commonly associated with macrodactyly and other conditions at birth.

Several cases of lipofibromatous hamartoma have been associated with exostoses and ectopic calcification. This patient demonstrates an ectopic calcification or ossification (image 4, red arrow). Several references have suggested an association with dysgenetic disorder such as neurofibromatosis. This author and observer has collected over 20 cases of lipofibromatous hamartoma of the median nerve, and none have been associated with neurofibromatosis.

Finally, lipomas and vascular tumors have been associated with this entity. A lipoma or lipomatous hypertrophy is present and was highlighted on image 2 (orange arrow).

Dysplasia’s with macrodactyly and / or extremity enlargement, may be seen in neurofibromatosis type I, Beckwith-Wiedemann syndrome, Proteus syndrome, Klippel-Trenaunay-Weber syndrome, and macrodystrophia lipomatosa.

 

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He didn’t like what was on his plate, but couldn’t return it

This 55-year-old male presents with right knee pain, and his history indicates no known knee injury, surgery, or cancer.

Q1 – You are shown a sagittal T1 (image 1) and axial T2 (image 2) of the patella. What is wrong with the plate?

Q2 – What is the name of the plate indicated in question 1? The axial is key!

Sagittal T1

Axial T2

 

A1 – The plate is delaminating or separating anteriorly from a deformed patella (image 4, pink arrow).

A2 – The prepatellar plate. The prepatellar plate is analogous to the prepubic plate in the pelvis. The quadriceps descends composed of its four layers namely (a) the anterior rectus femoris, (b) the vastus medialis, (c) the vastus lateralis, and (d) the deep vastus intermedius.

The superficial rectus component continues along the anterior surface of the patella where it rejoins the patellar tendon, inferiorly. This is analogous to the rectus abdominis coursing over the prepubic surface, and joining the adductors below it.

When this separation of plate from pubis occurs in the pelvis, it leads to athletic pubalgia syndrome with, potentially, a sports hernia. In other words, pubic plate detachment is one of the causes of sports hernia syndrome.

In the knee, the prepatellar plate is overlooked. This patient has a patellar deformity that includes the following:

  • Post-traumatic, post-fracture scar and remodeling (image 3, purple arrow)
  • Separated inferior patellar tubercle buried within the patellar tendon (image 3, yellow arrow)
  • Innumerable spurs (image 3, orange arrows)

Yet, despite all of this, it is the delamination or “peel” of the prepatellar plate from the undulating irregular anterior surface of the patella (image 4, blue arrows) that are causing the patient’s symptoms. Focal high signal deep to the plate is a helpful sign (image 4, pink arrow) of plate delamination.

Sagittal T1

Axial FSE T2

 

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It’s as if her shoulder was “frozen”

This 40-year-old female presents with right shoulder pain that started two weeks prior. There is no known source of injury. Movement has limited range, and there have been no injections or physical therapy.

Q1 – What are the primary abnormal features of this case?

Q2 – Which common diagnosis could be easily misdiagnosed in this case?

Q3 – What is the significance of an os acromiale?

Coronal PD FSE Fat Sat

Coronal T1 FSE

Axial

Coronal T1 FSE

Coronal PD FSE Fat Sat

Coronal PD FSE Fat Sat

Coronal PD FSE Fat Sat

Sagittal T2 FSE Fat Sat

Axial

 

A1 – Thickening of the inferior glenohumeral ligament and anterior rotator interval.

A2 – Primary rotator cuff abnormality / tendinopathy.

A3 – It predisposes to microinstability.

This is a case of adhesive capsulitis masquerading as rotator cuff tear. On initial inspection, it appears as though the supraspinatus tendon demonstrates abnormal signal due to tendinopathy (images 1 and 5, blue arrows). This would be a commonly “overcalled” diagnosis, but on closer inspection, there is capsular thickening and infiltration / inflammation at the inferior glenohumeral ligament (IGHL) (images 1 and 2, green arrows).

There is also capsular thickening and diffuse intermediate signal on the T1-weighted sequences at the anterior rotator interval (images 3 and 4, yellow arrows) between the subscapularis and the supraspinatus. This abnormal signal at the anterior rotator interval does extend to involve and infiltrate the supraspinatus, and to a lesser extent, the subscapularis, which is a common feature of moderate to marked adhesive capsulitis.

The other features of adhesive capsulitis in this case are thickening of the coracohumeral ligament (CHL) (image 8, pink arrow), and eccentrically displaced joint fluid (images 6 and 7, red arrows) with the fluid tracking along the long head of the biceps tendon and the subscapularis tendon.

Therefore, the diagnosis of fibroinflammatory “dry” capsulitis, which is consistent with the clinical entity of adhesive capsulitis, is made rather than primary rotator cuff / supraspinatus tendinopathy. In other words, the cuff is infiltrated secondarily rather than torn.

Unrelated, but an interesting feature of this case is the presence of an os acromiale (image 9, orange arrow).

 

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