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PRESENTED BY: Dr. BEN
MRI KNEE OF ORTHOPEDIC IMPORTANCE
MRI is based on the principle of nuclear magnetic resonance (NMR)
Two basic principles of NMR1.Atoms with an odd number of protons or neutrons have spin
2.A moving electric charge, be it positive or negative, produces a magnetic field
Body has many such atoms that can act as good MR nuclei (1H, 13C, 19F, 23Na)
Hydrogen nuclei is one of them which is not only positively charged, but also has magnetic spin
MRI utilizes this magnetic spin property of protons of hydrogen to elicit images
BASICS AND PRINCIPLES OF MRI
Hydrogen nucleus has an unpaired proton which is positively charged
Every hydrogen nucleus is a tiny magnet which produces small but noticeable magnetic field
Hydrogen atom is the only major species in the body that is MR sensitive
Hydrogen is abundant in the body in the form of water and fat
Essentially all MRI is hydrogen (proton) imaging
•In our natural state Hydrogen ions in body are spinning in a haphazard fashion, and cancel all the magnetism.
•When an external magnetic field is applied protons in the body align in one direction. (As the compass aligns in the presence of earth’s magnetic field)
SIGNIFICANCE OF HYDROGEN IN MRI
When RF pulse is stopped higher energy gained by proton is retransmitted and hydrogen nuclei relax by two mechanisms
T1 or spin lattice relaxation- by which original magnetization (Mz) begins to recover.
T2 relaxation or spin spin relaxation - by which magnetization in X-Y plane decays towards zero in an exponential fashion. It is due to incoherence of H nuclei.
T2 values of CNS tissues are shorter than T1 values
CONCEPT OF T1 AND T2 IMAGING
TE (echo time) : time interval in which signals are measured after RF excitation
TR (repetition time) : the time between two excitations is called repetition time
By varying the TR and TE one can obtain T1WI and T2WI
In general a short TR (<1000ms) and short TE (<45 ms) scan is T1WI
Long TR (>2000ms) and long TE (>45ms) scan is T2WI
Long TR (>2000ms) and short TE (<45ms) scan is proton density image
HOW TO OBTAIN T1 AND T2 IMAGES?
Liquids: long T1 and T2 valuesFat: short T1 and T2 values
HYALINE CARTILAGE
ARTICULAR CARTILAGE
SAGITTALCORONAL
AXIAL
SEQUENCE OF EVALUATION
SAGITTAL VIEW
Vastus medialis
Medial gastrocnemius
Sartorius
Vastus medialis
Medial femoral condyle
Medial meniscus
Tibia
Medialgastrocnemius
Gracilis tendon
Sartorius muscle
Vastus medialis
Medial femoral condyle
Medial meniscus
Tibia
Semitendinosus tendon
Medialgastrocnemiusmuscle
Gracilis tendon
Medial gastrocnemiustendon
Posterior horn of medial meniscus
Joint capsule
Anterior horn of medial meniscusSemimembranosustendon
Semitendinosustendon
Semimembranosusmuscle
Shaft of the tibia
Shaft of the femur
Infrapatellar fat pad
Patella
Oblique poplitealligament
Posterior cruciate ligament
Popliteus muscle
Posterior cruciateligament
Popliteal artery
Anterior cruciate ligament
Patellard tendon
Quadriceps tendon
Tibial nerve
Popliteal vein
Anterior cruciate ligament
Popliteal artery
Popliteus muscle
Posterior horn oflateral meniscus
Quadriceps tendon
Patella
Patellar tendon
Tibia
Femur
Popliteus muscle
Popliteus tendon
Posterior horn oflateral meniscus
Head of fibula
Anterior horn of lateral meniscus
Lateral femoral condyle
Commonperoneal nerve
Lateral head ofgastrocnemius muscle
Biceps femoris muscle
Tendon of the lateralhead of gastrocnemius
Common peronealnerve
Lateral meniscus
Vastus lateralis muscle
Superior tibiofibularjoint
Tibialis anterior muscle
CORONAL VIEW
Biceps femoris tendon
Biceps femoris
Popliteal artery
Lateral head of gastrocnemius muscle
Head of fibula
Semimembranosusmuscle
Gracilis tendon
Semimembranosustendon
Medial head ofgastrocnemius muscle
Semitendinosustendon
Lateral superior geniculate artery
Sartoriusmuscle
Medial inferior geniculateartery
Popliteal artery
Popliteus muscle
Biceps femoris tendon
Lateral femoral condyleGreatsaphenousvein
Popliteus muscle
Lateral gastrocnemius tendon
Medial gastrocnemius tendon
Medial femoral condyle
Sartorius tendon
Gracilistendon
Posterior cruciate ligament
Lateral tibial plateau
Semimembranosus tendon
Medial tibial plateau
Great saphenous vein
Lateral meniscus
Head of the fibula
Anterior cruciate ligament
Lateral collateral ligament Medial collateralligament
Medial femoral condyle
Lateral femoral condyle
Popliteus tendon
Lateral intermuscularseptum
Anterior cruciate ligament
Lateral meniscus
Lateral intercondylar tubercleMedial intercondylar tubercle
Posteriorcruciate ligament
Vastus medialis muscle
Anterior cruciate ligament
Iliotibial band
Iliotibial band
Anterior horn ofmedial meniscus
Infrapatellar fat pad
Vastus lateralis tendon
Lateral retinaculum
Patella
Lateral retinaculum
Infrapatellar fat pad
Patellar tendon
Medial retinaculum
Quadriceps tendon
AXIAL VIEWS
Tibial tuberosity
Saphenous nerve
Great saphenous vein
Medial gastrocnemiusLateral gastrocnemius
Soleus
TibiaTibialis anterior
Fibula
Patellar tendon
Lateral tibial condyleIliotibial tract
Medial tibial condyle
Sartorius tendon
Gracilis tendon
Semitendinosus tendonSemimembranosus tendon
Medial femoral condyle
Lateral femoral condyle
Infrapatellar fat pad Patellar tendon
Popliteus tendon
Sartorius muscle
Semimembranosus tendon
Semitendinosus tendon
Tibial nervePopliteal vein
Popliteal artery
Lateral gastrocnemius
Joint capsule
Superior medial geniculate arterySuperior lateral geniculate artery
PatellaSynovial fluid
Quadriceps tendon
Semitendinosus tendonSemimembranosus muscle
Popliteal artery and vein
Biceps femoris
Femur Vastus medialis
Sartorius muscle
Suprapatellar bursa
BASIC SEQUENCES IN MSK MRI
Proton-density-weighted sequences: they produce images with the highest signal-to-noise ratio and, therefore, provide better resolution than T2-weighted FSE images. USEFUL FOR MENISCI, CARTILAGE
T1-weighted images: produce high a signal-to-noise ratio, useful in showing musculoskeletal anatomy. WORKHOUSE FOR ANATOMY. Fat appear bright signal/white.Gadolinium enhanced T1 with STIR determine presence of abscess
T2-weighted sequences: have the poorest signal-to-noise ratio, and therefore the poorest resolution, but they are used primarily for their fluid sensitivity and their ability to detect pathology that has a high fluid content (e.g., tendon or ligament tears, tumors).
SIGNIFICANCE OF THE DIFFERENT SEQUENCES OF MRI
The ability to depict anatomic detail, bone marrow abnormalities (including marrow infiltrating processes and fractures), meniscal pathology, blood products, melanin, and enhancement after the administration of gadolinium are the strengths of T1- weighted SE sequences.For the assessment of tumors or musculoskeletal infection, fat-suppressed T1-weighted imaging after gadolinium contrast administration represents the sequence of choice because the high signal from fat is suppressed, making enhancement of abnormal tissue more conspicuous .Advantages: Short scan times.
excellent spatial resolution and depiction of anatomic detailDisadvantage: lower sensitivity for detecting soft-tissue edema compared with fluid-sensitive sequences such as fat-suppressed T2-weighted and STIR sequences.
T1 WEIGHTED IMAGING
GADOLINIUM ENHANCED T1 IMAGING
Advantages: excellent for detecting edema/fl uid, which appears bright and is often associated with pathologic processes such as tumors, infection, fractures, tenosynovitis, and bone contusions
good for evaluating ligaments and tendons, cartilage and fluid-filled structures such as cysts.Disadvantage:Long imaging time
inability to detect marrow pathology when not combined with fat-suppression techniques
T2 WEIGHTED IMAGING
are excellent for depicting anatomic detail because of the high signal-to-noise ratio of proton-density–weighted images. used to evaluate regions obscured by high signal on T2-weighted images.
Fat-suppressed proton-density imaging is often used for the MRI evaluation of meniscal and articular cartilage.
Disadvantage: not sensitive for the detection of fl uid and marrow pathology.
PROTON-DENSITY SE AND PROTON-DENSITY FSE
like T2-weighted sequences with fat suppression, is excellent for detecting fluid and edema when administered with a long TE.
STIR can be used as an alternative to T2-weighted imaging. Change the appearance of white to black; highlighting liquids.
On fluid-sensitive-images such as STIR, fluid appears bright and makes the edema and fluid associated with certain types of pathology more conspicuous than they are on non–fluid-sensitive sequences.
Such pathology includes osteomyelitis, fasciitis, abscesses, metastases, primary bone tumors, fractures, tenosynovitis, tendon tears, and bone contusions.
STIR(SHORT TAU INVERSION RECOVERY)
Fat remain bright and hence difficult to differentiate it from liquid.
Hence fat suppression is required and can be performed using STIR
CAN REDUCE METAL ARTEFACT
SPIN ECHO
1. determination of pulse sequence for review
2. evaluation of T2 weighted images
3. evaluation of T1 weighted images
4. evaluation of specialised pulse sequenes
5. correlation of imaging findings with clinical history and examination findings
EVALUATION OF MRI
T1-weighted image
T2-weighted image
Intermediate-weighted or proton-density–weighted image
Fluid-sensitive sequence, such as STIR or fat-suppressed T2-weighted image
Gradient-echo image
Postgadolinium T1-weighted image
SEQUENCE OF MRI USED MOSTLY FOR MUSCULOSKELETAL SYSTEM
On T1 image, fluid(as in joint, bladder, CSF) will appear dark.
In T2 image, fluid will appear bright/white
Recognition of the TR and TE values, which are often printed on the film can give idea regarding image sequence.(TR value is usually 300 to 800 ms for T1-weighted images and 2000 to 5000 ms for T2-weighted images)
HOW TO RECOGNISE T1 VS T2 IMAGE?
Suppression of signal from fat.
Images appear darker than conventional T2help accentuate the increase in T2-weighted signal (relative to the adjacent tissues)
In evaluation of bone marrow edema and edema secondary to other pathologic processes.
FAT-SUPPRESSED T2-WEIGHTED IMAGES ORSTIR IMAGES
STIR
STIR
Postgadolinium T1-weighted images and fat-suppressed postgadolinium T1-weighted images are typically obtained for the evaluation of infection, tumor, and postsurgical changes or scar.
fluid seems to be dark, and the pathology seems to be bright,in postgadolinium T1-weighted image
POSTGADOLINIUM T1-WEIGHTED IMAGES
POST GADOLINIUM ENHANCEMENT
Trauma( hemarthrosis, meniscal tears, ACL tear, PCL tear, MCL and LCL tear, quadeiceps and patellar tendon rupture, etc)
Degenerative conditions
Infection
Inflammatory
Tumors
Miscellaneous
MRI FINDINGS IN SOME COMMON KNEE CONDITIONS
T1 VS T2 IMAGES: SAGITTAL(LATERAL TO MEDIAL)
T1 VS T2 IMAGES: CORONAL(ANTERIOR TO POSTERIOR)
T1 VS T2: AXIAL VIEWS(CEPHALO-CAUDAL)
TraumaticDegenerative knee conditionsInflammatory knee conditions
Infective knee conditionsTumors
MRI FINDINGS IN COMMON ORTHOPEDIC KNEE CONDITIONS
MRI is commonly used to discern the etiology of an acute hemarthrosis,especially when the knee is too tender or the patientis too anxious for a thorough physical examination. MRI is especially helpful when conventional radiographs are negative.Typically, acute hemarthrosis appears as fluid within the joint with high signal intensity on T2-weighted imagesand intermediate signal intensity on T1-weighted images
HEMARTHORIS
BONE MARROW CONTUSIONS
MARROW EDEMA
Meniscal tears are graded according to how they appear on MRI and are best seen on T1-weighted, gradient-echo, and proton-density images.
Menisci show low intensity on all sequences.uses MRI findings to categorize tears as follows• Horizontal• Vertical radial• Vertical longitudinal with/without flap displacement• Complex
MENISCAL TEARS
HORIZONTAL TEAR OF POST. HORN OF MED. MENISCUS
GRADING OF MENISCAL TEARS
MENISCAL TEAR WITH CYST
DOUBLE PCL SIGN
ACL TEARS
CHRONIC ACL TEAR
PCL TEARS
PARTIAL PCL TEAR
MCL TEAR
PATELLAR TENDON RUPTURE
PATELLA ALTA
PATELLA BAJA
CHONDROMALACIAE PATALLAE
QUADRICEPS TENDON RUPTURE
LOOSE BODIES
MEDIAL RETINACULUM TEAR
SYNOVIAL CHONDROMATOSIS
OSTEOARTHRITIS
STRESS FRACTURE
JUMPER’S KNEE
OSGOOD’S SCHLATTER DISEASE
DISCOID MENISCUS
PLICAE
SUPRA PATELLAR PLICA
PES ANSERINUS BURSITIS
PRE PATELLAR BURSITIS
OSTEONECROSIS
BAKER CYST
CHONDRAL DELAMINATION
OSTEOCHONDRAL FRACTURE
OSTEOCHONDRITIS DESSICANS
SYNOVIAL CYST
CHONDROBLASTOMA
CHONDROBLASTOMA
ENCHONDROMA
NON OSSIFYING FIBROMA
CHONDROMYXOID FIBROMA
OSTEOCHONDROMA
GIANT CELL TUMOR
ANEURSYMAL BONE CYST
OSTEOSARCOMA
OSTEOSARCOMA
SEPTIC ARTHRITIS
THANK YOU