MR ANATOMY OF WRIST AND ELBOW RV

MRI ANATOMY OF WRIST AND ELBOW ; special emphasis on TFCC, planning of wrist and elbow mri, intrinsic and extrinsic ligaments, compartments of wrist, neurovascular anatomy of elbow and wrist,

1. MR ANATOMY OF WRIST AND ELBOW DR ROSHAN VALENTINE PG RESIDENT DEPT OF RADIODIAGNOSIS ST JOHNS HOSPITAL BANGALORE

2. HOW TO IMAGE COILS AND PATIENT POSITION IMAGE ORIENTATION PULSE SEQUENCE AND ROI Slice thickness of 3mm Interslice gap 0.3mm CONTRAST

3. HOW TO IMAGE -PLANNING

4. NORMAL STRUCTURES - BONES BONES Three articulations Radius-capitulum(pronation and supination) Ulna – trochlea Proximal RU joint(pronation and supination) Radial head rotates in sigmoid notch of ulna

5. NORMAL STRUCTURES - LIGAMENTS Thickening of the medial and lateral portions of collateral ligaments 2 types – Radial(Lateral ) and ulnar(medial ) collateral ligaments

6. NORMAL STRUCTURES - LIGAMENTS RADIAL COLLATERAL LIGAMENT COMPLEX Provide varus stability 4 ligaments Radial collateral ligament Annular ligament Accessory collateral ligament Lateral ulnar collateral ligament Posterior to common extensor tendons Posterolateral elbow stabilizer- maintain support of radial head and radio-ulnar articulation

7. NORMAL STRUCTURES - LIGAMENTS ANNULAR LIGAMENT Origin – Radial head Insertion – sigmoid notch of ulna Function: Stabilize the proximal RU joint BSI : Axial

8. NORMAL STRUCTURES - LIGAMENTS RADIAL COLLATERAL LIGAMENT Origin- Anterior part of lateral condyle Insertion- Annular ligament and supinator muscle fascia Funxn ; Resistant to varus stress

9. NORMAL STRUCTURES - LIGAMENTS LATERAL ULNAR COLLATERAL LIGAMENT Origin: Lat epicondyle Insertion : Ulna – crista supinatoris Funx : Varus stress Posterior continuation of radial coll ligament

10. NORMAL STRUCTURES - LIGAMENTS ULNAR COLLATERAL LIGAMENT Anterior Posterior Transverse bundles

11. NORMAL STRUCTURES - LIGAMENTS ANTERIOR BUNDLE Origin : medial epicondyle Ins : medial coronoid process Funxn : Valgus stress restraint BSI : Coronal Flared SHAPE

12. NORMAL STRUCTURES - LIGAMENTS POSTERIOR BUNDLE Origin : medial epicondyle Ins : Outer part of coronoid process Funxn : Valgus stress restraint BSI : axial

13. NORMAL STRUCTURES - LIGAMENTS TRANSVERSE BUNDLE Joins inferior margin of anterior and posterior bundles Tip of olecranon and coronoid Not well seen in MRI Limited importance

14. NORMAL STRUCTURES – MUSCLES AND TENDONS 4 compartments Anterior Posterior Medial Lateral

15. NORMAL STRUCTURES – MUSCLES AND TENDONS ANTERIOR COMPARTMENT Biceps and brachialis BSI : Axial and sagittal Brachialis Origin: 2.5cm below humeral articular surface Insert : ulnar tuberosity Shorter tendon compared to biceps

16. NORMAL STRUCTURES – MUSCLES AND TENDONS ANTERIOR COMPARTMENT – BICEPS BRACHII Superficial to brachialis Long tendon – prone to injury Insert: Radial tuberosity Distal tendon – bicipital radial bursa

17. NORMAL STRUCTURES – MUSCLES AND TENDONS POSTERIOR COMPARTMENT Triceps and anconeus muscle BSI: axial and sagittal

18. NORMAL STRUCTURES – MUSCLES AND TENDONS POSTERIOR COMPARTMENT Triceps Proximal portion of olecranon At site of insertion – high signal onT1 and T2

19. NORMAL STRUCTURES – MUSCLES AND TENDONS POSTERIOR COMPARTMENT Anconeus Origin: Posterior aspect of lateral epicondyle Ins: olecranon Funxn : provide dynamic support to RCL

20. NORMAL STRUCTURES – MUSCLES AND TENDONS MEDIAL COMPARTMENT Pronator Teres Flexors of hand and wrist BSI: Axial and coronal CFT: dynamic support to underlying ulnar collateral ligament to valgus stress

21. NORMAL STRUCTURES – MUSCLES AND TENDONS LATERAL COMPARTMENT Supinator Brachioradialis Common extensors tendon BSI : Axial and coronal images

22. NORMAL STRUCTURES – NERVES Ulnar,median and radial nerve Subjected to various entrapment syndromes Surrounded by fat

23. NORMAL STRUCTURES – NERVES ULNAR NERVE Most superficial BSI: Axial Located in cubital tunnel formed by FCU and cubital tunnel retinaculum distally.

24. NORMAL STRUCTURES – NERVES MEDIAN NERVE BSI: Prone arm axial Between brachialis and lacertus fibrosus (bicipital apponeurosis ) Ant interosseous nerve between ulnar and humeral head of pronator teres .

25. NORMAL STRUCTURES – NERVES RADIAL NERVE B/W brachialis and brachioradialis Divides in to PIN at the region of capitulum Imaiois

26. NORMAL STRUCTURES – BURSA Two bursa at biceps tendon insertion Bicipitoradial Interosseous bursa Significant: T1 iso mass with T2 hyperintense signal, anterior to biceps tendon.

27. HOW TO IMAGE

28. NORMAL STRUCTURES

29. NORMAL STRUCTURES – LIGAMENTS LIGAMENTS Intrinsic – connect carpal bones together Extrinsic – carpal to forearm bones

30. NORMAL STRUCTURES – LIGAMENTS INTRINSIC LIGAMENT Scapholunate and Lunotriquetral ligaments Disruption of these causes instability and pain 3 shapes – horse-shoe, bandlike, triangle shaped

31. NORMAL STRUCTURES – LIGAMENTS (SLL)

32. NORMAL STRUCTURES – LIGAMENTS (SLL) Volar – Intermediate SI Attaches to cortical bone Low density of collagen and high loose connective tissue (hence Inc SI) Middle – Lower SI Dorsal- Low SI Both attach to the hyaline cartilage

33. NORMAL STRUCTURES – LIGAMENTS -LTL LUNOTRIQUETRAL LIGAMENT Smaller and taut than SLL Heterogenous SI May attach to hyaline cartilage/cortical bone Volar part blends with TFCC

34. NORMAL STRUCTURES – LIGAMENTS EXTRINSIC LIGAMENTS Thickening of the joint capsule Volar ligament Dorsal ligament

35. NORMAL STRUCTURES – LIGAMENTS VOLAR LIGAMENT Stronger and thicker Major stabilizer of wrist Radioscaphocapitate and radiolunotriquetral ligament

36. NORMAL STRUCTURES – VOLAR LIGAMENT RADIOSCAPHOCAPITATE LIGAMENT Origin : volar surface of radial styloid Course over scaphoid like seatbelt Insert: center of capitate

37. NORMAL STRUCTURES – VOLAR LIGAMENT RADIOLUNOTRIQUETRAL LIGAMENT Aka Radiolunate /long radiolunate Largest ligament of the wrist Seen ulnar side of RSC ligament Attach to volar surface of lunate and triquetrum

38. NORMAL STRUCTURES – DORSAL LIGAMENT Run obliquely between distal radius and proximal carpal bones Dorsal intercarpal, dorsal radiotriquetral , radiolulnar ligament. MRI ability to detect abnormality of these are unknown

39. NORMAL STRUCTURES – DORSAL LIGAMENTS

40. NORMAL STRUCTURES – TFCC Triangular fibrocartilage complexes Primary stabilizer of the distal radioulnar joint TFC Volar radioulnar ligament Dorsal radioulnar ligament Meniscus homologue Ulnar collateral ligament ECU tendon sheath

41. NORMAL STRUCTURES – TFCC Primary stabilizer of DRUJ Absorbs axial loading forces Stabilizes ulnar side of wrist and distal radioulnar joint

42. NORMAL STRUCTURES – TFCC Fibrocartilaginous biconcave disk Medial side: attached to styloid process and foveal part. Lateral : hyaline cartilage over the radial attachment BSI : coronal gradient SI: Low to intermediate(if myxoid tissue present)

43. NORMAL STRUCTURES – TFCC

44. NORMAL STRUCTURES – RADIOULNAR LIGAMENTS Broad striated bands Origin : Volar and dorsal cortex of sigmoid notch Course: pass over and below TFC and blend with it. Insertion: Ulnar styloid process medially and distal radius laterally. Diff from TFC by flat superior and inferior margins

45. NORMAL STRUCTURES – MENISCUS HOMOLOGUE Thickening of the ulnar side of joint capsule Infrequently present Triangle shaped BSI: Coronal(low SI)

46. NORMAL STRUCTURES – ECU Extensor carpi Ulnaris BSI : Axial > Coronal Normal position : Groove of the dorsum of ulna(neutral and prone) On Supination: Subluxation Tendon sheath seen only when fluid noted around it

47. NORMAL STRUCTURES – UCL ULNAR COLLATERAL LIGAMENT BSI : Coronal Thickening of the wrist joint capsule Origin: Ulnar styloid process Ins: Triquetrum

48. NORMAL STRUCTURES – TENDONS

49. NORMAL STRUCTURES – TENDONS Oval to round Low SI ECU – inherently has high SI APL- Striations and heterogeneity- due ot fat between the fascicles

50. NORMAL STRUCTURES – CARPAL TUNNEL Fibro-osseous space Concave volar aspect of carpal bones on dorsal surface Flexor retinaculum on volar surface CONTENTS: Flexor tendons and Median Nerve Fat normally on the dorsal aspect

51. NORMAL STRUCTURES – NERVES MEDIAN NERVE Seen in volar and radial aspect of carpal tunnel Nerve SI > tendons Tunnel size decrease as we progress further similar to the nerve Narrowest at the level of hook of hamate

52. NORMAL STRUCTURES – NERVES ULNAR NERVE Pass through Guyons canal – ulnar side of wrist

53. NORMAL STRUCTURES – OSSEOUS STRUCTURES