Isolated subacromial bursal fluid on MRI of the shoulder in symptomatic patients: correlation with arthroscopic findings

Fluid in the subacromial bursa (SAB) is a common finding on magnetic resonance (MR) images of the shoulder, and the implications of this finding have not been clarified. We retrospectively reviewed and correlated the MR features with arthroscopic findings in 21 symptomatic patients who had fluid in the SAB on MR imaging without demonstrable rotator cuff tear. Rotator cuff impingement was the most frequent surgical finding (42.9%). Other frequent surgical observations were glenoid labrum abnormality (28.6%), bursitis (19%), and supraspinatus tendinitis (14.3%). Distribution of acromial types was similar to that reported by Bigliani et al., and impingement was evenly distributed among acromial types in our study population. We conclude that in our patient population group the MR finding of isolated SAB fluid in symptomatic patients is highly likely to be associated with the finding of other abnormalities in the shoulder joint at surgery.

Comparison between fast spin-echo and conventional spin-echo imaging of normal and abnormal musculoskeletal structures in children and young adults

RATIONALE AND OBJECTIVES

The differences in imaging characteristics between conventional and fast spin-echo studies of the skeletons of children and young adults were evaluated.

METHODS

Concurrent conventional and fast spin-echo studies of 23 patients were compared by measuring signal intensity, contrast, and, subjectively, conspicuity of normal and abnormal musculoskeletal structures.

RESULTS

Fast proton-density-weighted images had lower signal-to-noise ratios of muscle, fat, and physeal, epiphyseal, and articular cartilage. Using more than three echoes for proton-density images resulted in blurring and decreased lesion conspicuity. On fast T2-weighted images, there was greater conspicuity of normal cortex, ligaments, and muscle; but less contrast between fat and water because of a higher signal-to-noise ratio of fat. When both sequences were obtained with similar image quality, fast spin-echo was 40% faster.

CONCLUSION

Fast spin-echo studies allows faster imaging, but can have blurring on proton-density-weighted images and decreased fat-water contrast on T2-weighted images.

Pseudothrombophlebitis in neuropathic arthropathy of the shoulder

The syndrome of pseudothrombophlebitis is a well-known complication of popliteal cysts. We report the case of a patient with a neuropathic arthropathy of the shoulder in whom pseudothrombophlebitis of the upper extremity subsequently developed. To our knowledge, this is the first such case that has been reported.

Rice bodies in the pleural aspirate of a patient with rheumatoid arthritis

Images

High frequency of specific T cell receptor rearrangements in rheumatoid arthritis: analysis of synovial fluid T lymphocytes

1. We have searched for rearrangements in the beta chain T cell receptor genes to identify clonal T lymphocyte populations in the synovial fluid of 10 patients with well established rheumatoid arthritis, using a T cell population unbiased by preselection. 2. Analysis of the restriction fragments with the beta chain constant region probe C beta 2 disclosed a rearranged band in 50% of cases (5/10). No significant differences in age, duration of the disease, treatment employed and presence of articular deformities or erosion upon X-ray examination were observed when patients with or without rearrangements were compared. 3. The rearranged band observed after BamH I digestion was of the same size in the 5 patients (14 kb). In addition, two patients presented a 10-kb rearranged band upon restriction with Hind III. 3. These data indicate that a significant number of rheumatoid arthritis patients probably present oligoclonal T cell proliferation of their synovial fluid lymphocytes.

Distribution of normal and abnormal fluid collections in the glenohumeral joint: implications for MR arthrography

Although magnetic resonance (MR) images of the glenohumeral joint frequently demonstrate intraarticular fluid, no specific criteria have, to the authors' knowledge, been published that allow accurate assessment of the amount of fluid present. Also, despite the increasing use of MR arthrography of the shoulder, the optimal amount of intraarticular fluid that should be used with this technique has not been determined. The authors progressively distended the glenohumeral joint in six cadaveric shoulder specimens with a dilute gadopentetate dimeglumine solution and obtained MR images after injection of 2, 5, 10, 15, and 20 mL of the solution. The pattern of fluid distribution was evaluated, and these results were then used to estimate the amount of fluid that was present in the glenohumeral joint on MR images of 20 shoulders obtained in 12 asymptomatic volunteers. In 14 of these shoulders, intraarticular fluid was present; however, in none was more than 2 mL evident. Results of the cadaveric study also indicated that 15 mL of intraarticular fluid appears to be the optimal amount for MR arthrography.

[MRI of the knee. Value of delayed sequences after intravenous injection of gadolinium]

A prospective study of delayed sequences after intravenous injection of gadolinium for knee MRI shows the similar results as from the literature: enhancement of synovial fluid after 30 minutes. Sixteen patients were studied mainly with gradient echo. This phenomenon improves the visualisation of the intraarticular structures like meniscus, cruciate ligaments, or cartilage. This study leads to use this technique in case of difficulties like postoperative intraarticular lesions.

[MRI of the knee joint of young soccer players. Are there early changes of the internal structures of the knee due to competitive sports?]

In a prospective study, the right knee of 21 symptom free juvenile footballers was examined by MRT (group I) and the results were compared with 12 juveniles of similar age but who did not take part in any special sporting activities (group II). A 1.5 Tesla Magnetome with an extremity coil was used. There were no abnormal changes in either group in the cruciate ligaments. The hyaline cartilage medially was about 10% thicker than laterally in both groups but in group I it was, on average, 24.8% thicker than in group II. Increased signals in the centre of the menisci were observed in 8 members of group I and two in group II. 5 of the 8 in group I, but none in group II, also showed an increase in the joint fluid.

Fluid in normal and abnormal ankle joints: amount and distribution as seen on MR images

OBJECTIVE

The appearance of fluid in tendon sheaths of the ankle joint and in ankle articulations seems to vary. To determine the degree of this variability and to see if fluid occurs in normal ankles, we evaluated the presence, amount, and distribution of joint fluid as seen on MR images of normal and abnormal ankles.

MATERIALS AND METHODS

The study included 40 normal ankles of volunteers, 15 ankles of patients with disorders of the posterior tibial tendon, 73 ankles of patients with disorders not involving tendons studied (occult fractures, osteochondritis dissecans, and Achilles tendon disorders), and 46 asymptomatic ankles of patients with disorders of the opposite ankle. We analyzed the MR images of these ankles to determine the volume of fluid in the ankle and subtalar joints. We also analyzed the relative volumes of fluid in tendon sheaths. We then compared the results in patients who had symptoms with those in asymptomatic subjects and developed an algorithm of fluid interrelationships.

RESULTS

Most patients had fluid in the ankle (77%) and subtalar joints (72%). Fluid was common around all tendons except the extensor tendons. Large amounts of fluid were particularly common around the flexor hallucis longus tendon (14%). No statistically significant difference in the prevalence or relative volumes of fluid in the subtalar or ankle joints or tendon sheaths was found between normal and abnormal ankles. A close relationship was found between volumes of fluid between tendons, usually those in close proximity to each other. We found no correlation between fluid in the subtalar and ankle joints.

CONCLUSION

Our results show that fluid in the articulations and tendon sheaths of the ankle is common in asymptomatic patients, and the amounts of fluid are not significantly different from the amounts in patients with symptoms. There also appear to be complex interrelationships between fluid seen in the joint and in tendon sheaths.

Acute dislocation of the patella: MR findings

PURPOSE

The authors describe magnetic resonance (MR) imaging findings of acute traumatic dislocation of the patella.

MATERIALS AND METHODS

MR imaging at 0.1 T was performed in 25 patients with an acute patellar dislocation, 24 of whom underwent surgery. All patients were young male conscripts, aged 18-22 years.

RESULTS

Signal intensity abnormalities of bone, seen as areas of decreased signal intensity on T1-weighted images, were found in all 25 patients (100%). The lateral femoral condyle was involved in all cases. Signal intensity changes also appeared in the patella in eight patients and in the lateral tibial plateau in three. Osteochondral fragments seen at plain radiography and cartilage fissuring noted at arthroscopy were not visible at MR imaging. Injury of the medial patellar retinaculum was seen at MR in each case. All patients had a joint effusion. Lateral subluxation of the patella was a common finding.

CONCLUSION

Constant findings at MR imaging were (a) contusion of the lateral femoral condyle, (b) tear of the medial retinaculum, and (c) joint effusion.

Classification in slipped capital femoral epiphysis. Sonographic assessment of stability and remodeling

In a prospective study of 26 hips in 21 patients with slipped capital femoral epiphyses (SCFEs), serial sonography was more sensitive than radiography in showing epiphyseal displacement and reduction. Reductions were associated with grossly visible hip joint effusions. The initial slips were reduced by treatment in seven of 11 hips with effusion. The 15 hips without effusion were unreduced. After stabilization and pinning, the effusion did not recur in any case. Sonography is sensitive and free from projectional errors in the assessment of metaphyseal remodeling. If any remodeling is present, the SCFE is at least three weeks in duration. A new classification into acute, acute-on-chronic, and chronic SCFEs is proposed, based on the objective sonographic data. Joint effusion represents physeal instability or recent progression, and remodeling is a sign of chronicity. An acute SCFE is characterized by effusion, whereas a slip without effusion but with remodeling is designated as chronic. An acute-on-chronic SCFE is associated with both effusion and remodeling. Joint effusion suggests that SCFEs should be operatively fixed and that displacement may diminish with traction or intraoperative positioning of the hip.

Distribution of joint effusion in patients with traumatic knee joint disorders: MRI assessment

One hundred forty-five knee magnetic resonance imaging examinations with joint effusions were reviewed to clarify the usual distribution of joint fluids in patients with traumatic knee joint disorders. Almost all knees (99%) had effusions in the central portion, and most knees (76%) had effusions in the suprapatellar pouch. Effusions were rarely found in the posterior femoral recess (9%) or subpopliteal recess (2%). However, this difference was considered to be only a reflection of anatomic communications. Effusions were occasionally found around posterior cruciate ligaments (36%), but were less frequently seen around anterior cruciate ligaments (18%).

The etiology of focal spinal arachnoiditis. An experimental study

Focal arachnoiditis and back pain have been attributed to potentially irritating substances leaking into the spinal canal from the lumbar intervertebral disc or facet joints. Through experimentation this hypothesis was tested: the nucleus pulposus (escaping from the intervertebral disc), lactic acid (from anaerobic glycolysis in the disc), chondroitin sulfate (a component of glycosaminoglycans in the disc), or synovial fluid (from degenerating facet joints) causes inflammation in the meninges if it contacts the dura mater. The test and control substances were injected into the epidural space of monkeys. Twelve weeks later the animals were killed; the dural sac was exposed by total lumbar laminectomy, grossly inspected, and then removed, fixed, sectioned, stained, and examined microscopically. Nucleus pulposus produced significant fibrosus in the arachnoid and epidural spaces; the other substances did not cause fibrosus or inflammation. The study suggests that leakage of nucleus pulposus into the epidural space causes an inflammatory response in the arachnoid and epidural spaces.

The elbow: MR features of nerve disorders

The authors retrospectively reviewed 15 magnetic resonance (MR) studies of elbows with radiographic evidence of nerve disorders. These 15 cases were selected from 55 MR studies of the elbow in patients referred for various complaints. MR images of the elbow of 10 healthy volunteers were also reviewed. Ulnar nerve disorders were seen in 11 cases. Three patients had median nerve disease, and one patient had a pathologic condition of the radial nerve. The following nerve abnormalities were detected: focal or diffuse nerve thickening, increased signal intensity on T2-weighted images, and course deviation due to either mass effect or spontaneous subluxation. Six of seven patients with nerve thickening, two of two patients with increased nerve signal intensity, and five of eight patients with nerve displacement complained of neurologic symptoms. Four of the patients underwent surgery; in each, surgical results confirmed the findings at MR. These results suggest that MR imaging has a potential role in the detection of nerve disorders at the elbow and in the guidance of treatment.

Avoidable complications of arthroscopic surgery

The incidence of complications from arthroscopic surgery is low. Between 1978 and 1991, 8500 arthroscopies were performed by the two senior authors (J.N. and D.R.A.D.). Several significant complications were recorded, and these are presented to show how they occurred, and how our practice of arthroscopy was subsequently modified. There were four cases of clinically detectable deep vein thrombosis of which three were associated with pulmonary embolus, three cases of haemarthrosis, two deep infections, three compartment syndromes with one case of impending compartment syndrome, six cases of instrument failure and one case of persistent synovial fistula.

Enhancement of joint fluid with intravenously administered gadopentetate dimeglumine: technique, rationale, and implications

This study reports findings on joint fluid enhancement after intravenous administration of gadopentetate dimeglumine. Ten subjects were studied: two asymptomatic volunteers and eight patients with suspected meniscal tears. The subjects underwent imaging at 1.5 T before, immediately after, and 42-60 minutes after intravenous administration of gadopentetate dimeglumine. The rate of fluid enhancement was assessed in three subjects, and the effects of exercise were studied. All subjects exhibited enhancement of joint fluid. Mean fluid enhancement for patients was 137% on initial and 262% on delayed images obtained after exercise. Exercise increased the rate and degree of fluid enhancement and distributed contrast material uniformly throughout the joint. The arthrographic effect of the fluid enhancement increased the number of perceived cartilage defects. This study documents enhancement of joint fluid in healthy subjects and in those with effusions. The arthrographic effect may provide a more convenient alternative to intraarticular injection of gadopentetate dimeglumine for MR arthrography.

[Diagnosis and therapy of coxitis fugax with special reference to the value of ultrasonographY-assisted diagnosis and hip joint puncture]

Between 1984 to 1991 55 children (mean age 7.0 years) were observed with a painful effusion of the hip examined by ultrasound. Children with radiologically diagnosed hip diseases were excluded. In 47 cases we found a transient synovitis of the hip which started at an average interval of 4 days in mean before admission. All children were reexamined 6 weeks after the end of treatment sonographically and clinically, 4 of those revealing incipient Perthes diseases. The primary sonographic right/left difference in amount of effusion (mean) was 4.0 +/- 1.7 mm and after aspiration 1.5 +/- 1.4 mm with a significantly correlation with the amount of aspirated synovial fluid. The radiological findings for a diagnosis of an effusion of the hip were not reliable. Beside the diagnostic signs of the appearance of the aspirated fluid the sonographic assisted aspiration of the hip is an important treatment mode to reduce the intracapsular pressure and the pain of a hip effusion in children.

Hip effusion in nephrotic syndrome mimicking septic arthritis

A case of painful bilateral hip effusions resolving spontaneously in the diuretic phase of steroid responsive nephrotic syndrome in a 6-year-old girl is reported.

Pressurized infusion of sodium hyaluronate for closed lock of the temporomandibular joint. Part I: A case study

Patients with temporomandibular joint disorders (TMD) report a myriad of problems including headaches, facial pain, limited mouth opening capacity, and clicking and/or grating sounds from the temporomandibular joints. Although conservative therapy with an occlusal splint can bring relief for many of these patients, a small number of subjects must be treated by means of surgical procedures. Direct injections of either air or fluids (saline, local anesthetic, corticosteroid, hyaluronate) into the superior and/or inferior temporomandibular joint (TMJ) cavities have gained popularity. The injection of a local anesthetic and hyaluronic acid can provide relief for patients with persistent, painful nontranslatory closed-lock conditions of the TMJs. As documented through objective electronic and computer-enhanced measurements, this case report describes the effect of sodium hyaluronate on a closed lock condition of the TMJ. This case report explains the methodology employed for a larger group of closed lock patients treated and monitored for over one year. The results of that larger group will be reported at a later time after long-term efficacy is confirmed.

The added gradient echo pulse sequence technique: application to imaging of fluid in the temporomandibular joint

PURPOSE

To assess the value of an added gradient echo in the same pulse sequence with a T1-weighted spin echo for determining the presence of an abnormal fluid collection in the temporomandibular joint with no additional imaging time.

MATERIALS AND METHODS

Using a standard T1-weighted sequence used in cine temporomandibular joint imaging, a readout gradient reversal was added and the resulting gradient echo collected. This image was compared with standard T1- and T2-weighted sequences, a short inversion recovery imaging sequence, and a small flip angle fast low-angle shot gradient-echo sequence.

RESULTS

The T1-weighted spin echo preceding the added gradient echo is not affected by the gradient reversal, but the additional gradient echo adds T2* contrast information that displays fluid as bright as and compares favorably with other fluid detection sequences.

CONCLUSION

The added gradient-echo technique adds sensitivity for the detection of an abnormal increase in fluid in the temporomandibular joint without adding to the overall imaging time of a routine T1-weighted sequence.

A prospective and blinded investigation of magnetic resonance imaging of the knee. Abnormal findings in asymptomatic subjects

To evaluate magnetic resonance imaging (MRI) of meniscal, ligamentous, and bony abnormalities in patients without clinical symptoms, scans were performed on 74 asymptomatic volunteers without histories or symptoms of knee injury. Before review by three radiologists in an independent and blinded fashion, the scans were mixed with 26 MRI scans from symptomatic patients. Sixteen percent of the asymptomatic volunteers had meniscal abnormalities consistent with a tear. The prevalence of MRI findings of a meniscal tear increased from 13% in individuals younger than 45 years of age to 36% in those older than 45. An additional 30% of the volunteers showed meniscal abnormalities consisting of a linear area of increased MR signal not communicating with a meniscal edge, which was not interpreted to represent a tear. The high incidence of abnormal MRI findings in asymptomatic subjects underscores the danger of relying on a diagnostic test without careful correlation with clinical signs and symptoms. These findings also emphasize the importance of access to relevant clinical data when interpreting MRI scans of the knee.

Value of unenhanced spin-echo MR imaging in distinguishing between synovitis and effusion of the knee

OBJECTIVE

We performed a study to determine if unenhanced spin-echo MR imaging can be used to differentiate effusion from synovitis of the knee joint.

MATERIALS AND METHODS

Unenhanced spin-echo MR imaging examinations of 1051 consecutive patients referred for evaluation of internal derangement of the knees were reviewed. Twelve of 550 knees with significant joint effusion also had thickened or irregular synovium. Of these, the cause of synovitis was proved in 10 patients. In the other two, the cause was unknown.

RESULTS

Thickened synovium was of intermediate signal intensity on T1-weighted MR images compared with the lower signal intensity of joint effusion. In eight cases, the thickened synovium had an intermediate signal intensity on T2-weighted images relative to the high signal of the joint effusion. MR images in the other four cases showed increased signal intensity indistinguishable from that of joint effusion.

CONCLUSION

Our experience suggests that unenhanced spin-echo MR images can be used to distinguish synovitis from effusion in the knee joint.

Knee effusion: normal distribution of fluid

Although visualization of articular fluid on MR images of the knee is common, no specific MR criteria that enable assessment of the quantity of the effusion have been established. We performed MR of three cadaveric knee specimens after the instillation of increasingly large volumes of fluid and studied the distribution of the fluid. When 4 ml of fluid was injected, the anteroposterior diameter of the suprapatellar recess was 4 mm on midline sagittal MR images and 10.0-12.5 mm on lateral sagittal MR images, corresponding to the usual routine radiographic criteria for a knee effusion.