mri of the knee - office of continuing medical...
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MRI of the Knee
Jennifer Swart, M.D.Musculoskeletal Radiology
South Texas Radiology Group
Financial Disclosure
• I have no relevant financial relationships with commercial interests to disclose.
Outline
• Coils, Patient Positioning
• Acquisition Parameters, Planes and Pulse Sequences
• Knee Arthrography
• Normal Anatomy
• Abnormal Anatomy (Injury Patterns)
• High Field MRI (3.0T Magnets)
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Imaging Details
• Supine Positioning
• Slight external rotation
• Dedicated knee coil
– 8 channel
• 14 to 16 cm field of view
• 2.5 to 5 mm slice thickness
• Rarely use intravenous gadolinium
• Exam time 15 minutes
MRI Pulse Sequences
• T1 weighted Sequences
– Fat sensitive
– Good anatomic resolution
• Proton Density Sequences
– Fat and fluid sensitive
– Best anatomic resolution
• T2 Fat Saturated Sequences
– Fluid sensitive, all else dark
– Pathology sequence
– Poor anatomic resolution
MRI Acquisition Planes
• Scout Image
– Find the knee in the magnetic field
• Axial Images
– Parallel to tibial plateau
• Coronal Images
– Parallel to posterior margin of femoral condyles
• Sagittal Images
– Perpendicular to sagittal plane
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Axial Images
Axial MPGR Axial T2 FS
Coronal Images
Coronal T1 Coronal T2 FS
Sagittal Images
Sagittal T2 FSSagittal PD
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MR Knee Arthrography
• Infrequently Performed• Allows T1 weighted imaging for best
spatial resolution• Mainly used in cartilage and post-
operative meniscus assessment• Fluoroscopically guided• Anterior approach with 25 g needle• 20-30cc Dilute Gadolinium injected• MR performed within 45 minutes after
exercise
MR Arthrogram Images
• Distended joint, gadolinium fills tears in structures that line the joint
• Sequences: T1 axial, coronal, sagittal with fat saturation
– Only bright structure is gadolinium
• Coronal T1 no fat saturation
• Sagittal T2 with fat saturation
MR Arthrogram Knee Loose Osteochondral Lesion
Coronal T2 Fat Sat Coronal T1 Post Gad Fat Sat Sagittal T1 Post Gad Fat Sat
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Normal Anatomy: Medial Collateral Ligament (MCL)
Coronal T2 Fat SatCoronal T1
Normal Anatomy: Lateral Collateral Ligament (LCL or FCL)
Coronal T2 Fat SatCoronal T1
Normal Anatomy: Anterior Cruciate Ligament (ACL)
Sagittal T2 Fat SatSagittal PD
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Normal Anatomy: Posterior Cruciate Ligament (PCL)
Sagittal T2 Fat SatSagittal PD
Normal Anatomy: Medial Meniscus
Sagittal T2 Fat SatSagittal PD
Normal Anatomy: Lateral Meniscus
Sagittal T2 Fat SatSagittal PD
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Normal Anatomy: Coronal Plane Menisci
Coronal T2 Fat SatCoronal T1
Interpreting Knee MR
• Systematic, disciplined approach is crucial
– Don’t go for the money• Structured Report
– Menisci
– Cruciates
– Extensor Mechanism
– Collaterals
– Cartilage
– Fluid
– Bone Marrow• Look for Injury Patterns
• Address the clinical question
Grade 2 MCL Sprain
Coronal T2 Fat SatCoronal T1
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Grade 3 LCL Sprain
Coronal T2 fat sat
Acute Interstitial ACL Tear
Sagittal T2 Fat SatSagittal PD
Associated ACL injuries
Sagittal T2 Fat SatSagittal T2 Fat Sat
Posterolateral Corner Injury
Segond Fracture
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ACL Avulsion
Coronal T2 Fat SatSagittal T2 Fat Sat
PCL Avulsion
Coronal T1 Coronal T2 fat sat
ACL Graft Tear
Intact ACL GraftSagittal PD
Torn ACL GraftSagittal PD
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Chronic ACL Tear
Sagittal T2 Fat SatSagittal PD
Acute PCL Tear
Sagittal T2 Fat SatSagittal PD
Radial Lateral Meniscus Tear
Sagittal PDAxial MPGR
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Complex Medial Meniscus Tear
Sagittal T2 Fat SatSagittal PD
Bucket Handle Medial Meniscus Tear
Coronal T2 Fat Sat Sagittal PD
Flipped Locked Lateral Meniscus Tear
Sagittal T2 Fat SatSagittal PD
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Discoid Lateral Meniscus Tear
Sagittal T2 Fat SatSagittal PD
Parameniscal Cyst presenting as mass - percutaneous aspiration and
rupture
Medial and Lateral Bucket Handle Tears
Sagittal T2 Fat Sat Axial MPGRCoronal T2 Fat Sat
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Cartilage Defects
Sagittal T2 Fat Sat Sagittal T2 Fat SatCoronal T2 Fat Sat
Post Intervention Cartilage Assessment
Axial T1 Post ArthrogramAxial T1 Post Arthrogram
Pre-Microfracture Post-Microfracture
Baker’s Cysts
Sagittal T2 Fat SatSagittal PD
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Baker’s Cyst Rupture
Sagittal T2 Fat SatSagittal PD
IT Band Friction Syndrome
Coronal T2 Fat SatCoronal T1
Transient Patellar Dislocation
Coronal T2 Fat SatAxial T2 Fat Sat
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Jumper’s Knee (Infrapatellar Tendonopathy)
Sagittal T2 Fat SatSagittal PD
Quadriceps Tendon Rupture
Sagittal T2 Fat SatSagittal PD
Infrapatellar Tendon Rupture
Sagittal T2 Fat SatSagittal PD
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Chronic hemorrhagic bursitis
Recent Advances: High Field MRI3.0 Tesla versus 1.5 Tesla MRI
• Twice the magnetic field strength
• Twice the signal to noise in a given pixel
– Increase matrix / decrease pixel size (increase spatial resolution)
– Decrease slice thickness (increase spatial resolution)
Sagittal T2 Fat Sat 3.0T Sagittal T2 Fat Sat 1.5T
Exostotic Osteochondroma
Sagittal T2 Fat SatCoronal T2 Fat Sat
– Decrease NEX / imaging time (decrease spatial resolution)
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Fractures
Radiograph Coronal T2 Fat Sat
Fractures
Coronal T1Coronal T2 Fat Sat
Cartilage Mapping
• T2 mapping
– Reflects cartilage ultrastructure
– Capable of detecting early cartilage degeneration before surface changes
Axial T2 Fat Sat 3.0T Axial Cartigram 3.0T
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Cartilage Mapping
Sagittal Cartigram 3.0TSagittal T2 Fat Sat 3.0T
MARS (metal artifact reduction sequence)
Axial STIR Sagittal T2
MARS prosthesis imaging
Axial T2
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Summary
• MRI plays an indispensable role in the evaluation of knee injuries.
• Intra-articular and Intravenous gadolinium are not routinely required in the assessment of knee injuries.
• High field MR systems increase diagnostic sensitivity, particularly of cartilage lesions.
• Accept nothing less than the interpretation of a specialized musculoskeletal radiologist.
• Always correlate imaging findings with clinical examination and discuss discrepancies with your radiologist.