Marc A.

Karpo , DPM
Assistant Professor Department of Medicine
Temple University School of Podiatric Medicine

MRI AND CT
Cross Sectional Imaging

 These are studies that are used in areas that

require visualizing complex areas
 There is usually irregular bones or
superimposition on standard x ray views
 These cross sectional techniques allow a
single plane of interest to be examined by
eliminating or blurring the other structures
that would otherwise be superimposed and
decrease visualization
Modalities Utilized

 Conventional Tomography

 Computed Tomography

 Magnetic Resonance Imaging

Conventional Tomography

 Variation of plain film technique

 Uses an x ray tube and film
 The x ray tube and film move in opposite
directions around a fulcrum but in the same
plane
 The fulcrum is the plane of the focal area of
interest
 Foot sections at 0.5 cm sections
Conventional Tomography

 Pick view based on anatomic lesion of

interest
 Limited role in soft tissue injuries
 Planes:
 Coronal (frontal)
 Axial (transverse)
 Sagittal
Conventional Tomography
Indications
 Tarsal Coalition
 Tarsal Fracture
 Subtalar joint arthritis
 Oteocartilagenous lesions, loose bodies
 Fracture Healing
 Scanning patients who are contraindicated
For Computed Tomography or MRI
Contraindications to
Computed Tomography or MRI

 Patients on life support

 Aneurysm clips or metallic devices,
pacemakers, implanted medication pumps
 In addition with MRI any history of working
with metal . (metal debris in the eyes), which
can be ruled out with a frontal orbital x ray.
Conventional Tomography
Computed Tomography (CT)

 Direct multiplanar image acquisition

 High contrast resolution (can distinguish
between two tissue types with only slightly
different attenuation characteristics)
 Xray tube rotates 360 degrees around
extremity, detectors measure Xray beam,
attenuation values determined (Housefield
units HU)
 Can make soft tissue or bone more visible
by computer adjusting image
Computed Tomography -
Indications
 Images obtained in axial and coronal planes
 Sagittal and 3D images obtained by
readjusting computer images
 Useful for calcaneal fractures, STJ
pathology as well as 3 d reconstruction
 Slice thickness can be obtained between 1.5
and 12 mm , 1.5 to 2.0 mm slices are
recommended for foot pathology
Additional Indications CT

 Lisfrac Injuries – used in addition to

conventional x rays to evaluate metatarsal
disloctions, navicular dislocations.
 Overlapping between metatarsal and tarsal
bones
 Cortical margins and articular surfaces Axial
views
CT- coronal plane bone window
Ankle/Rear Foot
CT- coronal plane soft tissue
window
Tarsal Synostosis
Cuboid Navicular Coalition
Contrast and Computed
Tomography
 Iodinated Contrast Agents
 Intravenous Agents
 Osteomyelitis-to enhanced soft tissue.
 Primary soft tissue abcess
 Soft tissue components of bone tumors
 Intra-articular Contrast
 Osteochondritis Dessicans
 Loose Bodies
 Synovial Chondromatosis
 Pigmented Villonodular Synovitis
 MRI

 Best diagnostic tool for non-bony

abnormalities
 MRI is superior to CT for soft tissue
 Does not use ionizing radiation
 Radiofrequency pulses are absorbed by body
then re-emitted from the body while in a
magnetic field
 Can obtain images in any plane
Terminology of MRI

 Spin Echo – Utilizes a 90 * excitation pulse

followed by a 180 * of refocusing pulse
 Time to Echo TE – Time between the 90*
excitation pulse and spin echo production
 Time to Repetition TR – Time elapsed
between 90* excitation pulses
Magic Angle

 The magic angle is an MRI artefact which occurs

on sequences with a short TE (less than 32ms;
T1W sequences, PD sequences and gradient
echo sequences).
 It is confined to regions of tightly bound collagen
at 54.74° from the main magnetic field (Bo), and
appears hyperintense, thus potentially being
mistaken for tendonopathy.
 Normally
 In tightly bound collagens, water molecules are
restricted usually causing very short T2 times,
accounting for the lack of signal.
Magic Angle Indications

 Typical sites include:

 proximal part of the posterior cruciate ligament
(PCL)
 peroneal tendons as they hook around the
lateral malleolus.
 cartilage can also be affected, e.g. femoral
condyles
 supraspinatus tendon
 triangular fibrocartilage complex (if the patient is
imaged with the arm elevated)
 infrapatellar tendon at the tibial insertion
MRI Views

 Coronal

 Sagital (reconstruction)

 Axial

 Slice thickness 4 mm to 2 mm can increase

definition to an MRI especially for 3 D
reconstruction
MRI T 1

 T1-weighted image
 Anatomic image
 Fat , bone marrow and cancellous bone
demonstrates highest signal intensity
 TE short 20 – 30 msec
 TR short 300 – 800 msec
MRI T1-weighted image
MRI T 2

 T2-weighted image
 Water has strongest signal intensity
 Reflects areas of inflammation, cystic fluid,
hemorrhage and tumors.
 Used to assess pathology
 TE long – 60 – 120 msec
 TR long – 1500 – 300 msec
MRI T 2 Weighted Image
Stir View

 Increased signal with infectious process or malignancy

 STIR (Short TI or T 2 Inversion Recovery) is an inversion

recovery pulse sequence with specific timing so as to
suppress the signal from fat.

 An inversion recovery pulse sequence is a spin echo pulse

sequence preceded by a 180° RF pulse.

 Also can be termed as a recovery sequence

MRI T1-weighted image
MRI Cross Section Midfoot T1
MRI Mid foot Coronal l view
MRI T 1 Frontal Plane
Forefoot
MRI T 1 Corona View
T 1 Lateral View
MRI Indications

 Soft tissue and osseous abnormalities

 Tendon and ligament injuries
 Osteomyelitis
 Neuroma
 Stress fracture
 Physis fracture
 Osteonecrosis
 Tarsal tunnel syndrome
 Plantar fasciitis
 Tumors
MRI - Ligaments

 ATFL and CFL most commonly injured

 Normal ligaments appear black (low water
content), low signal on T1 and T2
 Injured ligaments with increased signal on T2
due to hemorhage and edema
 Ligament s are hard to visualize due to small
size
T 2 Image Mid Foot
MRI T 2 – ATFL tear
MRI - Tendons

 Low water content therefore very low signal

intensity (black)
 Injury shows increased T2 signal within
substance of tendon
 13 tendons cross ankle, most commonly injured
are: Achilles, TP, PL, PB, TA
 Achilles: normally crescentic in axial view
 TP: most commonly injured posterior to medial
malleolus
 PL and PB: most commonly injured posterior
to lateral malleolus
MRI T 2– Achilles Rupture
MRI T 2 – Achilles Rupture
MRI – Tendonitis TP Tendon
MRI - Fractures

 While CT is useful for gross fractures, MRI is

superior for occult fractures, stress fractures
and osteochondral fractures
 Fracture lines show decreased signal intensity
(black) in medullary space and cortex
 Signal intensity increases next to the
fracture line due to edema
Occult Cortical Fracture

 Useful in all views especially involving the

talus and the calcaneus
 Fracture lines are usually well defined
 T 1 images show well defined high contrast
between fracture line and marrow fat
 T 2 images show soft tissue changes such as
edema or bone bruises
Stress Fractures

 Occur as a result of repeated cyclic loading of

the bone
 Insufficiency Fractures result from normal
stress on abnormal bone
 Fatigue Fractures result from abnormal
stress on normal bone – common in active
people
 Pain and tenderness common symptoms
MRI T 1– Stress fracture
MRI T 2– Stress Fracture
Stress Fractures T 1 and T 2
Osteochondral Fractures

 Most commonly after the talar dome as the

result of trauma
 Also termed Osteochondritis Dessicans and
Transchondral Fractures
Lateral - result of dorsiflexion/eversion
 Medial - result of plantarflexion/inversion
 Middle – result of compression
 Osteochondral Fractures

 Stage l Compression

 Stage ll Incomplete separate fragment

 Stage lll Complete separation fragment

 Stage lV Complete separation with free

floating fragment
MRI – Osteochondral Fracture
MRI – Osteochondral Fracture
Nonunions

 Fracture or an osteotomy to have a delay in

healing
 Delay of 6 to 9 months in healing
 Can be avascular or hyper vascular
 Can have local causes bone apposition
infection, blood supply
 systemic causes, anemia, diabetes, and
growth hormones
 Can use CT and MRI for evaluation
Bone Bruise

 Defined as bruising confined to medullary

bone, the cortex and cartilage are usually
intact
 Acute trauma
 Show as decreased signal poorly defined T 1
 Show as increased signal
nonhomogeneousT 2
 Affect epiphyseal region primarily and the
metaphyseal region secondarily
Break.....
Foreign Body CT and MRI

 The most common foreign objects found in the

foot are wood or glass
 Can be detected by conventional x ray
 CT scans can show excellent contrast between
foreign bodies (glass) and soft tissues,
depends on differences of attenuation
 MRI uses T 1 and T2 relies on differences of
proton density which gives excellent multiplanar
soft tissue contrast of adjacent structures such
as neurovascular structures
Plantar Fascial Diseases

 Plantar Fascitis and Heel Pain Syndrome

 Plantar Fascial Tears and Ruptures

 Plantar Fibromatosis
Plantar Fascitis and Heel
Pain Syndrome
 Inflammation of the plantar fascia with
microtears
 True plantar fascitis shows thickening of the
plantar fascial band to 7.4 mm in sagittal
view ( normal 3.22) and 7.56 in the coronal
plane ( normal 3.44)
 T 2 shows increased signal
Plantar Fascitis
Plantar Fascial Tears and
Ruptures
 Plantar Fascial tears and thickness are
relatively uncommon except in runners and
athletes
 Symptoms are pain and palpable mass at site
of rupture
 Inflammation present at the area of rupture
Plantar Fibromatosis

 Soft tissue lesion called fibromatosis aspect

 Primarily unilateral bilateral in 25 % of cases
 Superficial lesion of the plantar aponeurosis,
medial also called Ledderhoses Disease
 Nodular growth with a low intensity with
collagen in the lesion on T 2
 More aggressive lesions may have a mixed
signal
Plantar Fibromatosis
MRI – Plantar Fasciitis

 Normal plantar fascia: homogenous low

signal intensity, uniform thickness
 Plantar fasciitis: significantly thickened, T2
with increased signal intensity, subcutaneous
edema with increased signal on T2
MRI – Plantar fasciitis (Fig
17-25)
Contrast and MRI

 The use of Gadolinium used to enhance areas of

fluid
 Changes a hypo intense signal to a hyper intense
signal.
 Indications Infection delineation
 Tumor chracteristics
 Joint Effusion
 Tendon and capsule injuries
 Fracture healing
 Osteonecrosis revascularization
MRI with Contrast
MRI – Soft Tissue Infection

 Cellulitis can disguise an abscess or

osteomyelitis
 MRI superior for abscesses
 Abscesses appear as high signal well-
marginated collections
 Gas appears as focal areas of low signal
intensity within an abscess
 T 2 and stir, signal noted increase signal
MRI – Abscess (Fig 17-27)
MRI – Osteomyelitis`

 Acute : decreased signal on T1, increased

signal on T2 (decrease in fat and increase in
water in the marrow)
 Subacute: low signal T1, high signal
centrally in T2, with low intensity rim
outlining both
 Chronic: sequestra are low signal, sinus
tracts are high signal on T2
Acute Osteomyelitis

 Symptoms increased temp, pain swelling,

pain on palpation
 Most common cause Staphyloccocus
Aureus
 Inflammatory process
 CT show an increase attenuation medullary
canal 66 % sensitive
 MRI decrease in T 1 , increase in T2 97 %
sensitive increase in fat and water in marrow
Subacute Osteomyelitis

 This presents as a low grade infection of bone

 It will present in its quiescent phase as a
Brodies abcess in the bone
 Occurs more commonly in males
 On CT will show a well defined sclerotic
margin possible fluid levels
 On MRI T 1 T 2 low homogenous signal
Chronic Osteomyelitis

 Chronic infection that is present over a long

period of time
 Can be present over months to years
 Commonly in middle aged men
 CT may show sequestra in the medullary
cavity with cortical gaps present
 MRI will show an increase signal extending
from the skin with cortical disruption with a
band of low signal surrounding the area on
T2
MRI – Osteomyelitis
MRI – Osteomyelitis
Deep Plantar Space Infection

 Potentially life threatening

 Common in diabetics
 Central area most serious, anaerobic bacteria
 CT scans will indicate area with fat pad
obliteration, but has limitations as can not
show distinction between edema, fibrosis and
granulation tissue
 MRI shows high density homogeneous signal
on T 2 and STIR views.
Deep Plantar Space Infection
MRI – Other Indications
 Arthritic conditions: order if necessary, increased
visualization of cartilage, marrow edema
 Neuropathic arthropathy (Charcot): decreased marrow
signal on T1, effusions with high signal on T2 (CT can be
useful for operative planning as well)
 Coalitions
 Avascular necrosis
 Early: low signal T1, high signal T2
 Late: both T1 and T2 low signal
 Neoplasms

 Morton’s neuroma: T1 low signal intensity mass, possible high

signal on T2
 Ganglion cyst: low T1 intensity, very high T2 intensity
Arthritic Conditions

 Increase visualization of cartilage

 Increased visualization marrow edema

 T 1 and T 2
Rheumatoid Arthritis
Rheumatoid Arthritis

 T2
Osteoarthritis
Gout-First MPJ-Tophi-Bone-
Erosion Metabolic Disease
Neuropathic Arthropathy
(Charcot):

 decreased marrow signal on T1

 effusions with high signal on T2

Neuropathic Arthropathy
Tarsal Coalitions-Congenital

 Can use standard x ray, Ct scan or MRI which

also shows soft tissue definition
 Calcaneonavicular Coalition most common
of the tarsal coalitions occurs 50 % of all
coalitions
 Talocalaneal Coalitions involves the middle
facet of the talus occurs 35 % of the time
 Other coalaitions can be osseus , fibrous or
cartilagenous
MRI – Coalition (Fig 17-34)
Avascular Necrosis
 Bone destruction due to loss of the blood supply
to the bone in question

 Early: low signal T1, high signal T2

 Late: both T1 and T2 low signal

MRI – Avascular Necrosis (Fig
17-35A)
MRI – Avascular Necrosis (Fig
17-35B)
Mortons Neuroma

 Common in the third interspace

 Female predominance

 Most common is the mortons neuroma

 T ! Signal with a hypointense area due to

fibrous composition of the lesion
MRI – Morton’s neuroma (Fig 17-
31)
Ganglion Cyst

 Fibrous capsule with fluid filled center

 Can be tendon sheath, joint capsule, tendon

 Hypointense T 1 signal Fibrous outer area

 Hyperintense T 2 signal fluid in center

MRI – Ganglion cyst (Fig 17-33)
Ganglion Cyst
Benign Neoplasms

 Unicameral Bone Cyst

 Aneurysmal Bone Cyst
 Osteochondroma
 Chondroblastoma
 Enchondroma
 Synovial Chondromatosis
Unicameral Bone Cyst
T 1 shows low intensity
signal

T 2 shows a high
intensity signal
Aneurysmal Bone Cyst
T 1 reveals
intermediate signal
intensity with high and
low foci

T 2 reveals high signal

intensity with multi
lobular appearance
Osteochondroma
T 2 weighted images
the top area of the
lesion reveals an
intense signal
Perichondral area is a
low signal intensity on T
1
Chondroblastoma
Heavily calcified shows
a low intensity T 1 and T
2 signal
Enchondroma
T 1 signal is low
intensity
T 2 has a high intensity
with heterogenius
pattern
With GD DTPA can
show ring and arc
pattern
Synovial Chondromatosis
T 1 signal low intesity
T 2 signal is high
intensity
Malignant Tumors

 Osteosarcoma
 Ewings Sarcoma
 Chondrosarcoma
 Fibrosarcoma
 Adamantinoma
Osteosarcoma
Uncalcified lesions
T 1 signal can high intensity have
high and low signal intensity
T 2 signal has a
No real cortical borders

T
Fibrosarcoma
T1 and T 2 both show a
non homogenous mass
Low or intermediate
signal
Osseus soft tissue and
intrarticular
involvement
 Ewings Sarcoma
T 1 has a low intensity
signal
T 2 high intensity signal
or intensity signal with
fatty cortical marrow
Adamantinoma
Similar to Ewings
sarcoma
T 1 and T 2 signal are
mixed low and variable
signal involvement
Can involve soft tissue
and articular tissue,
References

 https://www.google.com/search?q=aneurysmal+bon
e+cyst+mri
 Podiatricresidency.com
 Orthoinfoaas.com
 Bryanmri.com
 Amerothopaedic.combonetumor.org
 Revisemri.com
 McGlamrys ComprehensiveTextbook of Foot and
Ankle Surgery, Fourth Edition, Joe T Sutherland et al,
Wolter Kluwer/Lippincott,Williams ans Wilkins,vol 2,
Philadlephia, New Y ork, Baltimore ,LondonChapter
45 NRI,CT, Tarsal Coaltion, Page 610
References

 The Foundation Board Certification , Review

Study Guide, Editor in Chief, John
Marty,MS,DPM,2012 William L. Goldfarb,chapter
38,Radiographic Pathology,MRI,CT, page 570
 Foot and Ankle Radiology,ed, Robert
A.Christman, DPM, Chapter 23 Bone Tumors and
Tumor like lesions,pages 508-538, Lesions Pages
508-538, Churchill Livingston, St Louis Missiouri
copywrite 1989
 Radioortopedia.org/articles/magicangleeffect-
mri-artefact
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