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Chang EY, Bencardino JT, French CN, Fritz J, Hanrahan CJ, Jibri Z, Kassarjian A, Motamedi K, Ringler MD, Strickland CD, Tiegs-Heiden CA, Walker REA. SSR white paper: guidelines for utilization and performance of direct MR arthrography. Skeletal Radiol 2024; 53:209-244. [PMID: 37566148 PMCID: PMC10730654 DOI: 10.1007/s00256-023-04420-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/23/2023] [Accepted: 07/29/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVE Direct magnetic resonance arthrography (dMRA) is often considered the most accurate imaging modality for the evaluation of intra-articular structures, but utilization and performance vary widely without consensus. The purpose of this white paper is to develop consensus recommendations on behalf of the Society of Skeletal Radiology (SSR) based on published literature and expert opinion. MATERIALS AND METHODS The Standards and Guidelines Committee of the SSR identified guidelines for utilization and performance of dMRA as an important topic for study and invited all SSR members with expertise and interest to volunteer for the white paper panel. This panel was tasked with determining an outline, reviewing the relevant literature, preparing a written document summarizing the issues and controversies, and providing recommendations. RESULTS Twelve SSR members with expertise in dMRA formed the ad hoc white paper authorship committee. The published literature on dMRA was reviewed and summarized, focusing on clinical indications, technical considerations, safety, imaging protocols, complications, controversies, and gaps in knowledge. Recommendations for the utilization and performance of dMRA in the shoulder, elbow, wrist, hip, knee, and ankle/foot regions were developed in group consensus. CONCLUSION Although direct MR arthrography has been previously used for a wide variety of clinical indications, the authorship panel recommends more selective application of this minimally invasive procedure. At present, direct MR arthrography remains an important procedure in the armamentarium of the musculoskeletal radiologist and is especially valuable when conventional MRI is indeterminant or results are discrepant with clinical evaluation.
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Affiliation(s)
- Eric Y Chang
- Radiology Service, VA San Diego Healthcare System, San Diego, CA, USA
- Department of Radiology, University of California, San Diego Medical Center, San Diego, CA, USA
| | - Jenny T Bencardino
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Cristy N French
- Department of Radiology, Penn State Hershey Medical Center, Hummelstown, PA, USA
| | - Jan Fritz
- Department of Radiology, New York University Grossman School of Medicine, New York, NY, USA
| | | | - Zaid Jibri
- GNMI in Mississauga, Greater Toronto Area, Toronto, ON, Canada
| | - Ara Kassarjian
- Department of Radiology, Division of Musculoskeletal Imaging, Olympia Medical Center, Elite Sports Imaging, Madrid, Spain
| | - Kambiz Motamedi
- Department of Radiology, University of California, Los Angeles Medical Center, Los Angeles, CA, USA
| | | | - Colin D Strickland
- Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Richard E A Walker
- McCaig Institute for Bone and Joint Health, Calgary, Canada.
- Cumming School of Medicine, University of Calgary, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada.
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Bonazza NA, Saltzman EB, Wittstein JR, Richard MJ, Kramer W, Riboh JC. Overuse Elbow Injuries in Youth Gymnasts. Am J Sports Med 2022; 50:576-585. [PMID: 33780632 DOI: 10.1177/03635465211000776] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Gymnastics is a unique sport that places significant loads across the growing elbow, resulting in unique overuse injuries, some of which are poorly described in the current literature. PURPOSE To provide a comprehensive review of the unique overuse elbow injuries seen in youth gymnasts and to provide an up-to-date synthesis of the available literature and clinical expertise guiding treatment decisions in this population. STUDY DESIGN Narrative review. METHODS A review of the PubMed database was performed to include all studies describing elbow biomechanics during gymnastics, clinical entities of the elbow in gymnasts, and outcomes of operative and/or nonoperative treatment of elbow pathology in gymnasts. RESULTS Participation in gymnastics among youth athletes is high, being the sixth most common sport in children. Early specialization is the norm in this sport, and gymnastics also has the highest number of participation hours of all youth sports. As a result, unique overuse elbow injuries are common, primarily on the lateral side of the elbow. Beyond common diagnoses of radiocapitellar plica and osteochondritis dissecans of the capitellum, we describe a pathology unique to gymnasts involving stress fracture of the radial head. Additionally, we synthesized our clinical experience and expertise in gymnastics to provide a sport-specific rehabilitation program that can be used by providers treating surgical and nonsurgical conditions of the elbow and wishing to provide detailed activity instructions to their athletes. CONCLUSION Overuse injuries of the elbow are common in gymnastics and include osteochondritis dissecans of the capitellum, radiocapitellar plica syndrome, and newly described radial head stress fractures. A thorough understanding of the psychological, cultural, and biomechanical aspects of gymnastics are necessary to care for these athletes.
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Affiliation(s)
| | - Eliana B Saltzman
- Department of Orthopaedic Surgery, Duke University Health System, Durham, North Carolina, USA
| | | | - Marc J Richard
- Department of Orthopaedic Surgery, Duke University Health System, Durham, North Carolina, USA
| | - Whitney Kramer
- Department of Physical and Occupational Therapy, Duke University Health System, Durham, North Carolina, USA
| | - Jonathan C Riboh
- OrthoCarolina, Charlotte, North Carolina, USA.,Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
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Colozza A, Martini I, Cavaciocchi M, Menozzi M, Padovani S, Belluati A. Radiocapitellar plica: a narrative review. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 93:e2022029. [PMID: 35315424 PMCID: PMC8972889 DOI: 10.23750/abm.v93i1.10950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 11/18/2020] [Indexed: 11/23/2022]
Abstract
Radiocapitellar plica is a vestigial lateral portion of elbow synovial fold which may cause pain and snap in some cases. Plica is a difficult and misleading diagnosis and it could be easily confused with a common lateral epicondylitis however, they are different conditions. Pathology full understanding and proper diagnosis is essential to achieve patient's pain relief and functional recovery therefore, we reviewed the most relevant literature about radiocapitaller plica. The aim of this study is to provide the best and current concepts about: clinical evaluation, imaging findings and surgical treatments of radiocapitellar plica.
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Affiliation(s)
- Alessandra Colozza
- Orthopaedic and Traumatology Unit, Azienda Ospedaliera di Faenza, Faenza, RA, Italy
| | - Ilaria Martini
- Department of Orthopaedic and Traumatology, University of Ferrara, Ferrara, Italy
| | - Michele Cavaciocchi
- Orthopaedic and Traumatology Unit, Azienda Ospedaliera di Faenza, Faenza, RA, Italy
| | - Marcherita Menozzi
- Department of Surgery, Orthopaedic Clinic, Parma University Hospital, Parma, Italy
| | - Sara Padovani
- Orthopaedic and Traumatology Unit, Azienda Ospedaliera di Faenza, Faenza, RA, Italy
| | - Alberto Belluati
- Orthopaedic and Traumatology Department, Hospital Santa Maria delle Croci, Ravenna, Italy
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Looney AM, Rigor PD, Bodendorfer BM. Evaluation and management of elbow injuries in the adolescent overhead athlete. SAGE Open Med 2021; 9:20503121211003362. [PMID: 33996078 PMCID: PMC8072106 DOI: 10.1177/20503121211003362] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 02/24/2021] [Indexed: 11/22/2022] Open
Abstract
With an increased interest in youth sports, the burden of overhead throwing elbow injuries accompanying early single-sport focus has steadily risen. During the overhead throwing motion, valgus torque can reach and surpass Newton meters (N m) during the late cocking and early acceleration phases, which exceeds the tensile strength (22.7–33 N m) of the ulnar collateral ligament. While the ulnar collateral ligament serves as the primary valgus stabilizer between and degrees of elbow flexion, other structures about the elbow must contribute to stability during throwing. Depending on an athlete’s stage of skeletal maturity, certain patterns of injury are observed with mechanical failures resulting from increased medial laxity, lateral-sided compression, and posterior extension shearing forces. Together, these injury patterns represent a wide range of conditions that arise from valgus extension overload. The purpose of this article is to review common pathologies observed in the adolescent overhead throwing athlete in the context of functional anatomy, osseous development, and throwing mechanics. Operative and non-operative management and their associated outcomes will be discussed for these injuries.
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Affiliation(s)
- Austin M Looney
- Department of Orthopaedic Surgery, Georgetown University Medical Center, Washington, DC, USA
| | - Paolo D Rigor
- School of Medicine, Georgetown University, Washington, DC, USA
| | - Blake M Bodendorfer
- Midwest Orthopaedics at Rush, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Jeon IH, Liu H, Nanda A, Kim H, Kim DM, Park D, Shin MJ, Koh KH, Kholinne E. Systematic Review of the Surgical Outcomes of Elbow Plicae. Orthop J Sports Med 2020; 8:2325967120955162. [PMID: 33195708 PMCID: PMC7607772 DOI: 10.1177/2325967120955162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/21/2020] [Indexed: 11/17/2022] Open
Abstract
Background: Surgical resection is usually required for symptomatic elbow plicae that have failed nonoperative therapy. However, evidence of surgical outcomes has not been presented. Purpose: To review the surgical outcomes for the treatment of synovial plicae in the radiocapitellar joint. Study Design: Systematic review; Level of evidence, 4. Methods: We searched the PubMed, Ovid/MEDLINE, Cochrane Library, Google Scholar, and Embase databases using keywords as well as Medical Subject Headings terms and Emtree ([(elbow OR humeroradial joint OR radiohumeral joint) AND (meniscus OR plica)] OR snapping elbow OR snapping triceps OR synovial fold syndrome OR synovial fringe) for English-language studies. We conducted a systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: A total of 14 articles comprising four level 5 and ten level 4 studies were identified, including 279 patients (284 elbows). The triggering factors reported for 58 patients were heavy labor (29 patients; 50.0%), sporting activities (17 patients; 29.3%), and nonspecific trauma (12 patients; 20.7%). Overall, 92 patients (33.0%) were administered a steroid injection before surgery. Arthroscopic plica resection was performed in 266 patients (95.3%). Intraoperatively, plicae were mostly found in the posterior (44.0%) and posterolateral (28.6%) sites, and chondromalacia of the radial head was observed in 25 patients (9.2%). Of the reported surgical outcomes, 67.7% showed a resolution of symptoms. However, 9.3% of patients had residual symptoms, which were likely associated with pre-existing radial head chondromalacia. The complication rate was reported as 1.8%. Conclusion: Symptomatic elbow plicae were mostly treated arthroscopically, with most of the results being favorable. Pre-existing chondromalacia and the underestimation of concomitant intra-articular abnormalities may yield an inferior outcome.
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Affiliation(s)
- In-Ho Jeon
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
| | - Hua Liu
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, China
| | - Akriti Nanda
- Medical Sciences Division, John Radcliffe Hospital, Oxford, UK
| | - Hyojune Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
| | - Dong Min Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
| | - Dongjun Park
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
| | - Myung Jin Shin
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
| | - Kyoung Hwan Koh
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
| | - Erica Kholinne
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea.,Department of Orthopedic Surgery, St Carolus Hospital, Jakarta, Indonesia.,Faculty of Medicine, Trisakti University, Jakarta, Indonesia
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Lubiatowski P, Wałecka J, Dzianach M, Stefaniak J, Romanowski L. Synovial plica of the elbow and its clinical relevance. EFORT Open Rev 2020; 5:549-557. [PMID: 33072407 PMCID: PMC7528666 DOI: 10.1302/2058-5241.5.200027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
A synovial plica (fold) is normal anatomic finding, and occurs in 86–100% of cases; however, symptomatic plica is much less common (7.2–8.7% of all elbow arthroscopies). Synovial plica syndrome is a painful elbow condition related to symptomatic synovial plica. Synovial plica syndrome is diagnosed by clinical examination (lateral elbow pain) commonly accompanied by local tenderness, pain at terminal extension and/or painful snapping. Synovial plica syndrome may be mimicked by other elbow conditions, commonly tennis elbow, loose bodies, and degenerative arthritis. Magnetic resonance imaging or ultrasound scan may support diagnosis in correlation with clinical findings, but symptomatic plica may also be diagnosed as unexpected during elbow arthroscopy. The arthroscopic resection is effective and safe if conservative treatment fails.
Cite this article: EFORT Open Rev 2020;5:549-557. DOI: 10.1302/2058-5241.5.200027
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Affiliation(s)
- Przemysław Lubiatowski
- Sport Trauma and Biomechanics Unit, University of Medical Sciences, Poznań, Poland.,Rehasport Clinic, Poznań, Poland.,Department of Traumatology, Orthopaedics and Hand Surgery, University of Medical Sciences, Poznań, Poland
| | - Joanna Wałecka
- Sport Trauma and Biomechanics Unit, University of Medical Sciences, Poznań, Poland.,Rehasport Clinic, Poznań, Poland.,Department of Traumatology, Orthopaedics and Hand Surgery, University of Medical Sciences, Poznań, Poland
| | | | - Jakub Stefaniak
- Sport Trauma and Biomechanics Unit, University of Medical Sciences, Poznań, Poland.,Rehasport Clinic, Poznań, Poland.,Department of Traumatology, Orthopaedics and Hand Surgery, University of Medical Sciences, Poznań, Poland
| | - Leszek Romanowski
- Department of Traumatology, Orthopaedics and Hand Surgery, University of Medical Sciences, Poznań, Poland
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A Comprehensive Review of Radiohumeral Synovial Plicae for a Correct Clinical Interpretation in Intractable Lateral Epicondylitis. Curr Rev Musculoskelet Med 2020; 13:385-390. [PMID: 32458355 DOI: 10.1007/s12178-020-09636-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Radiohumeral synovial plicae (RHSP) have been studied by different authors in different ways; in spite of this, the evidence is poor and the results are controversial and inconclusive even when it comes to referring to this elbow structure. The aim of this article is to review the embryologic development, anatomy and histology, pathophysiologic features, clinical manifestations, physical examination, imaging findings, and treatment of radiohumeral synovial plicae, for their correct clinical interpretation in patients with intractable lateral epicondylitis. RECENT FINDINGS Radiohumeral synovial plicae syndrome (RHSPS) can cause intractable lateral epicondylitis and can be easily confused with other clinical conditions affecting the elbow. Many clinicians are not familiar with radiohumeral synovial plica syndrome since there are not many studies about it and previous reports do not seem to reach a consensus. Although its role in elbow injuries and epicondylitis is accepted and its surgical treatment is effective, there is no clear consensus about clinically relevant aspects. RHSP are remnants of normal embryo development of the articular synovial membrane with different anatomical locations, size and shape. Traumatism or overuse can turn RHSP into symptomatic structures at any age and can be compressed between the radial and humeral heads during movement. This compression can cause pain and other symptoms such as snapping, catching, mobility restriction, pitching, clicking, locking, blockage, popping and swelling. Radiohumeral synovial plica syndrome (RHSPS) may be an isolated condition or it can be associated with other elbow abnormalities. The findings on physical examination and imaging diagnosis are multiple and variable. Nowadays, RHSPS are quite unknown and previous reports do not seem to agree, leading to misdiagnoses as epicondylitis and making this structure the main cause of some cases of "intractable lateral epicondylitis". The outcomes of surgical treatments are quite promising although more, higher quality research is needed. Taking this into account, this review is meant to be a starting point for new anatomical and clinical studies.
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