1) Demonstrate an understanding of the technical and procedure-related considerations in MR imaging of the elbow. 2) Identify the normal anatomic structures and variants within the four compartments of the elbow. 3) Diagnose common sports injuries of the elbow, using this compartmental approach.

To analyze the relationship between the total innings pitched and MRI findings of the elbow in asymptomatic and symptomatic professional pitchers, and to identify whether any asymptomatic MRI findings predicted a subsequent throwing related elbow injury that required a stay on the disabled list.

Between 2001 to 2010, 25 asymptomatic Major League Baseball pitchers underwent MRI of their pitching arm at the time of a contract signing or a trade. Thirteen additional MRIs were performed on players as a result of new onset elbow symptoms during the course of the season. 2 MR arthrograms and 38 MRIs without intra-articular contrast were performed with a closed 1.5-T magnet at 1 of 4 different centers. The images were reviewed by a musculoskeletal radiologist who was blinded to the original MRI interpretations, the subjects' injury status, and innings pitched. The total innings that the player pitched prior to the MRI was recorded in addition to elbow injuries requiring a stay on the disabled list following the MRI. Statistical analysis was performed to examine association between total career innings pitched and the presence of a particular MRI finding as well as between MRI findings and a subsequent disabled list stay.

When grouped as a whole and analyzed for MRI findings in relation to innings pitched several trends were observed that reached statistical significance. There was a greater number of innings pitched in players with degenerative findings of the UCL, cartilage lesions, olecranon osteophytes, flexor pronator mass tendinosis, and increased signal in the extensor wad.

The major league baseball pitcher's elbow is subject to repetitive valgus torque over the course of their career, leading to adaptive and degenerative changes with the medial elbow and intra-articular structures. Though detected on MRI, these findings do not necessarily correlate with elbow pain or dysfunction. Analysis of a small but significant number of asymptomatic pitchers, who later sustained elbow injuries requiring a stay on the disabled list, revealed that all had degeneration of the UCL with olecranon osteophytes, and most had flexor pronator mass tendinosis.

Degenerative findings along the medial elbow are commonly observed on MRI in professional pitchers. However, these findings are often clinically insignificant and do not correlate with time on the disabled list.

The anconeus epitrochlearis muscle (AEM) is an anomalous accessory muscle in the elbow, coursing from the medial olecranon to the medial epicondyle. Several cases in the literature have suggested the association of this muscle with ulnar compression neuropathy. The purpose of this study is to review the MRI findings of the AEM, assess the relationship between muscle size and ulnar nerve morphology, and investigate the muscle's correlation with ulnar compression neuropathy.

Thirty two cases of elbow MRI studies of patients with an AEM from July 2007 to March 2014 were reviewed retrospectively. All of these patients presented with elbow pain and/or numbness with mean age of 40 years (range 18 to 60 years). The following parameters were evaluated: ulnar nerve diameter proximal, within, and distal to the cubital tunnel (CT); AEM cross sectional area (MA) and volume (MV); and encroachment ratio of the muscle at the superior and inferior aspects of the CT. Changes in ulnar nerve caliber and signal were also assessed.

The mean ulnar nerve diameters proximal, within, and distal to the CT were 3.63, 3.97, and 3.39 mm respectively. The mean MA was 68.47 mm² and mean MV was 6300 mm³. The mean encroachment ratio of the AEM in the CT was 0.58 superiorly and 0.56 inferiorly. There was no statistically significant correlation between the ulnar nerve diameter within the CT and MA (r = 0.05) or MV (r = 0.06). There were positive correlations between the MA and both the superior (r = 0.66) and inferior (r = 0.64) encroachment ratios as well as between the MV and the superior (r = 0.65) and inferior (r = 0.57) encroachment ratios. The most common abnormalities involved the common extensor (n = 17) and biceps (n = 6) tendons. Four of the thirty two cases demonstrated focal T2 hyperintensity and/or thickening of the ulnar nerve consistent with ulnar neuritis, three within the CT and one just proximal to the CT.

Most findings of anconeus epitrochlearis muscle are incidental and asymptomatic without ulnar compression neuropathy. There is no significant correlation between anconeus epitrochlearis muscle size and ulnar nerve caliber in the cubital tunnel.

Anconeus epitrochlearis muscle is usually incidentally found and not associated with symptoms or ulnar compression neuropathy. This knowledge can help the clinician in the management of elbow pain.

1) Describe the normal peripheral nerve anatomy and muscle innervation in the upper extremity with an emphasis on sites of compression. 2) Identify the common sites of nerve entrapment in the upper extremity. 3) Recognize the imaging features of peripheral nerve entrapment in the upper extremity. 4) Recognize the limitations in imaging of upper limb entrapment neuropathies.

The objectives of this study are to implement high-resolution magnetic resonance imaging (MRI) using ultrashort time-to-echo (UTE) techniques to evaluate the triangular fibrocartilage complex (TFCC) and to quantify the MR properties of the TFCC.

Institutional review board approval with exemption of informed consent was obtained. Wrists of subjects and human cadavers were imaged in a 3T Signa TwinSpeed scanner (GE Healthcare) with optimized coils (microscopy and dedicated wrist coils). Morphologic evaluation sequences included high-resolution proton density (PD), 3D spoiled gradient echo (SPGR) and 2D/3D UTE. Quantitative evaluation included conventional (T2 SE), T1rho sequences tailored for long T2 values (2D/3D T1rho) and UTE (UTE T2* and UTE T1rho) sequences and an in-house MatLab analysis algorithm fitting regions of interest (ROIs) to determine average values.

High-resolution MR images demonstrated the different structures of the TFCC as well as pathological findings including perforations, degeneration and calcifications of the fibrocartilage among others. UTE sequences allowed the visualization of structures with short T2 components and subtraction techniques facilitated the identification of these components, such as TFC calcifications, which were better demonstrated in UTE sequences as compared with conventional PD sequences. Quantitative MR analysis of the TFC showed a bi-component decay behavior in normal subjects (short T2* = 0.31 ms, long T2* = 9.68 ms). T2, UTE T2* and T1rho values were increased with degeneration of the TFC. In the presence of calcifications, UTE T2* values were decreased probably due to magnetic susceptibility effects. In some cases, certain areas of the TFC showed increased UTE T2* values despite a normal appearance on standard PD sequences, which may indicate early stages of degeneration.

UTE MRI allows the visualization of short T2 components of the TFCC and improved the demonstration of certain pathologies as compared with the standard clinical sequences. Quantitative MR analysis reflected changes in TFC composition in some pathological cases.

Morphological and quantitative UTE sequences allow visualization of the short T2 components of the TFCC and demonstration of some pathological cases not provided by the standard clinical sequences.

The purposes of this study were to introduce dynamic cine-arthrography (DCA) and compare the diagnostic performance between MR arthrography (MRA) alone and MRA with DCA for evaluating triangular fibrocartilage complex (TFCC) and intrinsic ligament tears.

93 wrists of 88 patients underwent both DCA and MRA from May 2010 to February 2014. Among them, 44 wrists of 42 patients who had undergone arthroscopy were included in this study. DCA was performed during contrast injection for MRA. After puncture of the radio-carpal joint, DCA was taken while slowly injecting contrast under fluoroscopic guidance during passive wrist exercise. We obtained 3.0T MRA with fat-suppressed coronal, sagittal, and axial images. Two radiologist evaluated TFCC, scapho-lunate (S-L) ligament, and luno-triquetral (L-T) ligament tears on MRA and MRA with DCA, respectively. Based on the arthroscophic findings, we compared the diagnostic values between MRA and MRA with DCA by the McNemar test.

The overall sensitivity and specificity of the diagnosis of TFCC tear were the same between MRA and MRA with DCA (reader 1, sensitivity 96.4%/96.4% (MRA/MRA with DCA), specificity 68.8%/68.8%, accuracy 86.4%/86.4%, reader 2, sensitivity 96.4%/96.4%, specificity 93.8%/93.8%, accuracy 95.5%/95.5%). For intrinsic ligaments, all diagnostic values were increased on MRA with DCA as compared with MRA for both readers (S-L ligament: reader 1, sensitivity 77.8%/77.8% (MRA/MRA with DCA), specificity 92.3%/96.2%, accuracy 86.4%/88.6%, reader 2, sensitivity 61.1%/61.1%, specificity 76.9%/88.5%, accuracy 70.5%/77.3%, L-T ligament: reader 1, sensitivity 66.7%/100%, specificity 89.7%/89.7%, accuracy 81.8%/93.2%, reader 2, sensitivity 60.0%/86.7%, specificity 82.8%/86.2%, accuracy 75%/86.4%), without statistical significance (p>0.05). The inter-observer agreement was more increased on MRA with DCA than MRA alone.

Wrist MR arthrography with dynamic cine-arthrography resulted in a higher diagnostic value of intrinsic ligament tear and increased the inter-observer agreement of TFCC and intrinsic ligament tear as compared with wrist MR arthrography alone.

The use of wrist MR arthrography plus dynamic cine-arthrography which was performed during contrast injection for MRA, may help increase diagnostic performance for TFCC and intrinsic ligament tear.

View learning objectives under main course title.

1) Review relevant anatomical structures in the wrist that may be injured during sports. 2) Discuss the biomechanics of various types of wrist injuries. 3) Illustrate the imaging features of common sports injuries demonstrated on different imaging modalities.

Many anatomical structures in the wrist may be injured in a variety of ways during participation in sports. Many of these sporting activities, whether competitive or recreational, are associated with specific injury patterns related to actions and stresses associated with a particular sport. Imaging has an important role in the evaluation of the range of bone and soft tissue injuries sustained. Knowledge of the biomechanics behind a particular sporting activity is useful for understanding the pathophysiology of wrist injury and helps explain the findings seen at imaging. Recognizing the imaging features aids in the early diagnosis, identification and prevention of potential complications, management and follow-up of these injuries. It is particularly important to be aware of wrist injuries affecting the immature skeleton of pre-aldolescent and aldoescent athletes, as continued sporting activity may result in growth arrest and other long-term problems.

http://media.rsna.org/media/abstract/2014/13010800/VSMK21-08 sec.pdf

To evaluate the cost effectiveness of performing 3T MRI in patients with chronic wrist pain

A decision analysis model was designed to compare the following diagnostic algorithms in the patients with chronic wrist pain (> 3 months): (1) 3T MRI followed by diagnostic arthroscopy for positive findings; and (2) Diagnostic arthroscopy. The assumption was the detected injuries were treatable by surgical repair or therapeutic arthroscopy. Short-term and long-term outcome were considered as unnecessary arthroscopy avoided and Quality-Adjusted-Life (QALY), respectively. Costs from societal perspective and incremental cost to effectiveness ratio were calculated. Accuracy of MRI in detection of wrist injuries, utility loss due to wrist pain and costs associated with each strategy were estimated from literature and Medicare reimbursement data for 2013. The willingness-to-pay threshold was considered to be $50000. Sensitivity analysis was conducted to examine the model's stability to variations in the clinically plausible range of the model's variables.

Sensitivity and specificity of MRI was considered as 74% and 84%, respectively. The prevalence of ligamentous injuries in the study population was considered as 25%. The analysis showed that using MRI as the primary indicator of necessity of performing arthroscopy cost average of $1425 per patient, while performing arthroscopy in all patients cost $2500 per patient. The incremental cost of using MRI to avoid one unnecessary arthroscopy was estimated as $793. The incremental costs of performing non-selective arthroscopy in all the patients in comparison to using MRI was $82692 per one QALY gained. Considering a subgroup of patients whose ligamentous injury is not amenable by arthroscopy, this amount decreased to $8035. The sensitivity analysis showed the model was stable to variation in clinically plausible ranges of 3T MRI sensitivity and specificity, providing prevalence of repairable wrist injury between the patients with chronic wrist pain did not exceed 34%.

Performing 3T MRI to determine the necessity of diagnostic arthroscopy in patients with chronic wrist pain may be cost-effective.

In practices where most patients with wrist pain require no arthrosopic repair; MRI may be cost-effective both in avoiding unnecessary diagnostic arthroscopy and long-term societal perspective.

1) Demonstrate understanding of the complex anatomy, kinematics and injury patterns of the wrist and elbow. 2) Become familiar with routine and novel static and dynamic imaging techniques to assess wrist and elbow instability.

Posttraumatic injuries of the scapholunate ligament (SLL) may cause scapholunate dissociation (SLD) which bears a high risk of osteoarthritis. Plain radiographs are used for initial diagnostic work up and MR imaging (MRI) is the preferred imaging modality for the assessment of ligamentous injuries. However, dynamic instability can only be assessed by cineradiography. The aim of the study was to evaluate diagnostic accuracy of cine-MRI for the assessment of SLD in comparison to arthroscopy.

23 Patients with clinically suspected SLD were included. All patients underwent static MRI and cine-MRI of wrist at 3T. We acquired T2-weighted (T2w) images in axial and coronal planes and sagittal T1w images. Cine-MRI was performed from extreme radial to ulnar abduction and during clenching and unclenching of the fist with a temporal resolution of 5 images/s. Cineradiography was performed in all patients with a temporal resolution of 12.5 images/s. Afterwards all patients underwent arthroscopy. Images were evaluated by one hand surgeon and one experienced MSK radiologist blinded for intraoperative finding. Cineradiography and cine-MRI were evaluated for scapholunate (sl) distance, sl alignement, synchronous motion of carpal bones and continuitiy of Gilula lines. Sensitivity, specificity, positive (pLR) and negative (nLR) likelihood ratio for cine-MRI with respect to intraoperative findings were calculated. Differences between cineradiography and cine-MRI were evaluated using t-test. A p-value <0.05 was considered statistically significant.

Cine-MRI was of diagnostic quality in all patients. There was no statistical significant difference between cineradiography and cine-MRI (p=0.081). SLD was correctly diagnosed in 5 patients and excluded in 16 patients. SLD was diagnosed false positive and negative in one case each. Sensitivity and specifity of cine-MRI for SLD was 83% and 94%, respectively. PLR and nLR was 13,83 and 0,18 respectively.

Cine-MRI has a high sensitivity and specificity for the diagnosis of SLD. It can be easily integrated in conventional MR imaging and may eliminate the need for cineradiography.

CINE-MRI is a safe and feasible method to identify scapholunate dissociation and may prevent exposure of the patients to radiation.

This study aimed to identify the frequency of MRI-detected tenosynovitis at the metacarpophalangeal (MCP) and wrist joints in early arthritis, the diagnostic value for RA and the association with severity features within RA.

178 early arthritis patients underwent unilateral 1.5T extremity-MRI at baseline. MRI-scans were made and scored using the RAMRIS-protocol. Tenosynovitis was scored at the wrist and MCP joints by two readers using the method as described by Haavardsholm et al. During the first year 69 patients fulfilled the 2010-classification criteria for RA; patients with and without RA were compared. Within RA-patients comparisons were made for anti-citrullinated-peptide-antibody (ACPA)-positivity and for radiographic progression (increase in Sharp van der Heijde score) during the first year.

65% of the 178 early arthritis patients had MRI-detected tenosynovitis at any of the studied locations. The flexor tendon at MCP-3 and the tendon of the extensor carpi ulnaris were most frequently affected (22% and 34%). Furthermore, tenosynovitis was more often present in RA than non-RA patients (75% versus 59% p 0.023). More commonly affected locations in RA than in non-RA were the tendons of the flexors at MCP-5 (odds ratio (OR) 2.8 95% CI 1.2-7.0), the extensors at MCP-2 (OR 9.1 95% CI 1.9-42.8) and MCP-4 (OR 14.2 95% CI 1.7-115.9) and extensor compartment I at the wrist 4.0 (95% CI 1.4-11.1). The specificity for these locations ranged 92-99% and the positive predictive value between 61-89%. The associations between tenosynovitis at these locations and RA were independent of the presence of local synovitis. Within RA-patients, the tenosynovitis scores were not associated with the presence of ACPA or radiographic progression during the first year.

MRI-detected tenosynovitis is common in early arthritis and is more common in RA patients than in early arthritis patients with other diagnoses. Locations with a high specificity for RA are the tendons of the flexor at MCP-5, the extensor at MCP-2 and MCP-4 and the first extensor compartment of the wrist.

MRI is a sensitive method to detect tenosynovitis. However, the prevalence of MRI-detected tenosynovitis and its diagnostic and prognostic value in early arthritis patients are unclear.

In rheumatoid arthritis, identifying the exact demarcation of erosions on MR images can be difficult because the cortical defect might be obliterated by either synovium or bone marrow edema.. Opposed-phase MR imaging might enhance the visibility of this transition by visualizing it as a clear black line due to the presence of both water and fat protons within the same voxel. The purpose of this study was to determine whether opposed phase gradient-echo imaging improves visualization of erosions when compared to regular T1w TSE sequences.

Unilateral wrist and MCP joints of 14 early arthritis patients were imaged on a 1.5T extremity MRI. T1w TSE and opposed phase T1w gradient-echo sequences were obtained in the coronal plane, both before and after gadolinium contrast administration. T2w TSE images were also obtained and were available to support scoring for both image sets. Images were assessed for image quality on a 0-5 scale and scored according to the OMERACT RAMRIS score for erosions in consensus by two observers blinded to clinical data. A reference score was established using all available images together.

Scanning time was 0:43 for the opposed phase sequence and 3:30 for the TSE sequence. Overall image quality, absence of movement artifacts and sharpness were significantly better using opposed phase images than T1w TSE images. Homogeneity, Signal-to-noise ratio, RAMRIS erosion scores and rater confidence did not differ between sequences. There was a trend towards higher sensitivity of opposed phase images for detection of erosions (85.6%, 95%CI 76.6-91.6% vs 68.0%, 95%CI 57.7-76.9%). Specificity, positive predictive value and negative predictive value were similar between the sequences and all >85%.

Our results demonstrate the feasibility of using a fast out-of-phase T1w spoiled-gradient echo sequence to assess erosions according to OMERACT RAMRIS score. It decreases imaging time while providing better image quality and might increase sensitivity for small erosions.

Shorter scanning time of the opposed phase sequence reduces movement artifacts and patient discomfort, and better delineation of the bone-tissue interface may improve reliability of erosion detection.

1) Discuss the roles of the radiologist in diagnosis and management of arthropathies. 2) Describe the imaging findings of rheumatoid arthritis and spondyloarthritis based on current literature. 3) Identify the various categories of disease modifying therapies (DMOADs and DMARDs).

1) Discuss the roles of the radiologist in diagnosis and management of arthropathies.
2) Describe the imaging findings of rheumatoid arthritis and spondyloarthritis based on current literature.
3) Identify the various categories of disease modifying therapies (DMOADs and DMARDs).