Hey, hey, one, two, check, check. All right. Good morning, everybody. Thank you, guys, for showing up bright and early to talk about imaging. I'm Rob Gray. I'm a hand surgeon from Chicago. Tate Greditzer is a radiologist at HSS in St. Louis, and Jean-Jose from University of Miami is a radiologist who will be joining us via recorded video since the hurricane kind of got in the way of travel plans. So basically the format of this is, you know, I'm kind of the idiot surgeon. I'm going to tell you my idiot surgery way of thinking about this imaging, and then we'll listen to the smart people tell us the right way to think about the imaging. All right, so these are my disclosures, none are relevant, all right, very cool, all right. So I'm going to start with MRI, basically kind of like why I get it and why I don't, and then I want to focus more on ultrasound because I think as hand surgeons, that's something we don't know anything about, we're not really taught about it in training very much, and for me that is by far more valuable than MRI. So why do I ever get an MRI? I think occult scaphoid is by far in a way like the best diagnosis that an MRI is important for, you can indicate surgery, you can indicate get out of my office, you're doing fine, solve a lot of problems really fast with that. Gamekeeper's thumb and the other ligaments, it's good for that, I think an exam in history are probably just as good as anything else, sagittal band rupture, sure, jersey finger, I mean a good story is as good as an MRI for a jersey finger. Pulley injuries, I do like MRI for pulley better than I like ultrasound for it. If I've got any mass proximal to the carpus, I get an MRI. Every once in a while you get a spooky thing and you know, you just don't want to be surprised if it's distal to the carpus, if it's bad, we know where that's going anyway. Distal biceps, again the story and the history and the physical are the best things. The reason I get an MRI is to figure out how likely I am to need an allograft and so I'll get it for that reason. I always have one in the room anyway. Rotator cuff, so I don't do rotator cuff repairs, I do tenotomies with ultrasound. But after I've sent someone to therapy and given them a shot, if they're not better, I get an MRI to make sure it's not, you know, massively retracted. Early keen box, I do think there's some use for it for that. You have kind of a ganglion story, but it's not quite a ganglion. I will diagnose that with an MRI. The most important reason is I don't know what to do and the clinic is busy and so I need to stall. So I send them out of my office and they get an MRI and it buys me a week or two to kind of think. Jersey finger, I do think that ultrasound is better than MRI, but you can pick these up on MRI. You know, when you're looking at these on the axials, you just see the absence of the FTP as you're going distally, and that's a really good indicator of what you got. I use the ultrasound to figure out the level in pre-op holding to know where I need to make any cuts to go fissure tendon. Pulley injuries, same thing. I think that MRI is better than ultrasound for these. These fortunately are pretty rare. Sagittal band, I do think MRI is good for those, for those patients that don't get better. Obviously, if you have subluxation, you don't really need it, you can figure it out on exam. But these, you know, you figure them out, you do your little wrap or repair, reconstruction or whatever it is you're going to do. Why don't I get an MRI? For avian of the scaphoid, I think it's kind of worthless. We'll talk about that in a second. Tendinopathies, tendinitis in golfer's elbow, everyone over 30 has it on MRI. I think it's a waste of everyone's time and money. SL injuries, I'm not really going to talk about those because I kind of don't believe in them. We'll talk about it later if you want to. PC injuries, basically braces and shots are going to cure most of these. So if braces and shots don't, then I get an MRI. If someone comes with ulnar pain, I don't image them first because, you know, you're going to see something. Ganglion cysts, you know, I can figure that out on exam. Ultrasound is actually better if I can't figure it out on exam. So why don't I MRI scaphoids looking for vascularity? So this is a study that Bishop did, basically trying to prove that vascularized bone grafting works as advertised. It's a very elegant study. He used a canine carpus. He took the scaphoid analog out, freeze-dried in liquid nitrogen, coated it in Krazy Glue to make sure the bone was dead, dead, dead as a negative control. As an MRI is one of the things of the study, those dead, freeze-dried, methacrylated bones, they showed up as normal on the MRI. So it's just, after that, I was just not really sold that that was a reliable test to see the vascularity of the proximal pole. Why do I do ultrasounds? Injections is the main indication. Gamekeeper's thumb, I won't indicate the surgery based on it, but I can figure out the problem based on that. Sagittal band injuries, Jersey fingers, mass evaluation, you can figure out if it's a cyst or not. Foreign bodies, it's really good for finding splinters. And a save time. Ultrasounds, I can do it right there immediately, have an answer for the patient, which is very helpful. So we're uncomfortable, typically, as surgeons doing ultrasound. We need to get over it. It will help you, it'll help your patients. I'd say probably my favorite indication for them diagnostically is to evaluate hardware. A lot of times you can figure it out, you look at the x-ray, person hurts, I reach out to grab a can of Coke and kind of, I've got de Quervain's now. You can look at those implants and kind of figure out on x-ray what's going on, but the ultrasound can tell you for sure, oh yeah, the tendon's rubbing on the plate. Here you've got a bowl or plate, one of these kind of over the top rim plates. You can see the flexors rubbing over top of the plate, so you can show the patient, yeah, I got to pull this out, this is not going to work. Dorsal screw penetrations, this is one of my favorite indications for early ultrasound before you're very comfortable. That screw lights up like a Christmas tree. You don't have to know anything about anything, I mean, you see all the threads on that screw very clearly, you know what's going on here. This is a little bit more subtle one, so that other screw is out a mile. This one's just barely out a little bit, but you can still see the same thing. I also recommend in the OR, if you're not sure, you're doing your plate, there's an ultrasound in the room, they did a block, throw an ultrasound on the back of the wrist to see if the screws are out, it's very helpful. Here's a patient, you know, I fixed her wrist, we had this sort of EPL-ish rupture thing, but you can still, she can extend the IP, it's like not out out, but it's definitely not in, it's a little weird. On the ultrasound, if you look real closely, there's like a spicule of bone, and I can see some fibers of EPL intact going by listers, but you know, something's obviously wrong. So this is EPL down here, on top of the freezer, and there's a little bony spike, still never saw any hardware, you can see EPL's mostly gone, got a couple of fibers intact, and it's scarred down to the bone, and this looks like the proximal part of EPL, so that's why on the ultrasound it looked intact, because the ends were in continuity, they were just ruptured. So one of the advantages we have as surgeons is not only can we do the imaging, but we get to look right at it, so you will get better faster at this stuff. So this is her after I fixed her, and you can evaluate the repair in the office and make sure that the repair is still working. So when they're not moving quite well, because they're swollen, they're scarred, you can make sure your work is good. I do a lot of PERC screws for fractures, one of the pitfalls of PERC screws is you can have prominence, especially around the thumb, so this is a kid I fixed, and he came back a year later and he had like some tendon irritation, so you can kind of see on the ultrasound, you see that screw head coming out, so I was like, oh yeah, I got to take this out, so I took it out. My ultrasound injection setup is very simple, I use a Tegaderm as a probe cover, I use a couple chloropreps to clean the site, the fluid from the chloroprep is all you need to actually get the image, you don't really need gel, this is good enough, and then I got my shot. So ganglion cysts are a really good one, they're very obvious, it's a big black water balloon, you can inject them, like obviously I didn't need ultrasound to figure out where the cyst was on this one, but it just kind of shows the concept. Cubital tunnel, a lot of us are nervous about injecting the cubital tunnel, because we can't see it, we're worried about poking the nerve, I will tell you, you're much more likely to poke the median nerve in the carpal tunnel than you are for the cubital tunnel. I typically do this, I do this transverse, you can see the nerve kind of there in the groove, and I usually do what we call out of plane, so I don't bring the needle in, you can come in in plane, so you watch the needle come in long axis, this is an out of plane, so you'll see as I bounce through in a second, and you'll feel, you can feel yourself bouncing through Osborne's, and then the fluid should come in a second, there's a little bit, so I'm not deep enough, so I keep advancing, not deep enough, and there you go, and you know, you can see exactly what you're doing, you can make sure you're not in the nerve, and not hurting folks. This is a cubital tunnel, or ulnar nerve instability, ultrasound could be a very good method for diagnosing that, if you can't figure it out on exam, but you can see that nerve shooting over the medial epicondyle. Cubital tunnel injections, it is very easy to hit the nerve, this is again one I do in short axis, out of plane, and we should see the video didn't shorten up, but you watch that fluid fill around the nerve, and it's very comforting, you know, so if the shot didn't work, it's not because I missed, right, it just didn't work. ECU injections, similar thing, you can figure out instability, you can diagnose a split tear, a split torn ECU on this, it'll look like Pac-Man, it should be like a white dot, but if it looks like a Pac-Man, there's a split tear there, you gotta fix it, that's not gonna work otherwise. I don't know why the video's so jumpy. I know. I'm looking at my screen, it looks okay, this is seizure mode. All right let's keep going. CMC injections, this is very valuable. This is a small joint, it's hard to hit. You know you're going to be kind of in the midline of the thumb but how far up and how far down it can sometimes be hard to tell. With a transducer you can line up right at that CMC joint and then you know that's where you're going. I come in the dorsal radial corner, put some fluid around first because it can be very painful. No, just the Tegaderm on the probe. Now, they'll tell you, the probe manufacturers, that that's no bueno, and they can mess up the probes. I've done it for years and years and years and years without a problem. I think it's technically like an off-label probe use for Tegaderm, but it works. It will ruin the probes. It will ruin the probes? Yes. Okay, fine, this is, I mean, you know, all right, fair. Do you do gel on them, or, I mean, you do the real thing. Yeah, well, yeah, but I'll put, I just use sterile gel. Yeah. Because they have sterile gel, and you can just use that. Yeah. Wrist injection, same thing. Sometimes in, you know, really bad snack wrists, slack wrists, the joint can be actually harder to hit than you think. I kind of aim for the capitate, that little neck at the capitate, and that's an easy place to get the shot in. This is terrible. Yeah. Longhead biceps tendon. This is a way to make people very happy very fast. You can do it in-plane or out-of-plane. And this other video is in-plane, which is fantastic. But this is something, the fluid will go around that tendon in the sheath, and it's very satisfying. They'll be able to tell right away that they're better. I would just comment, when you're doing a longhead of the biceps tendon injection, do not inject more than 1.5 cc's of fluid, because otherwise it goes in the joint. Ah. Little study we did at HSS. Yeah, I usually do two cc injections for everything, one cc of Lido and one cc of Dex for absolutely everything. That's fine. Yeah. But all right. Subacromial injection, same sort of thing. The important point on this one is the position to get the shoulder in. I have them act like they're taking their iPhone out of their back pocket. That kind of pulls the shoulder out, so it shows the rotator cuff, gets it out from underneath the abdomen. And so when you see the needle come in right over top the tendon, the fluid will fill up and distend that bursa, showing you you're in the right spot. You want to see that black stripe fill up when you get there. All right. You know, you got to have your coach help you. Tennis elbow. So I don't inject steroid in tennis elbow. I think it's no good. I do perctinotomies typically, but that spike on the ultrasound is pathognomonic. These people will get better when you get that tendon off of that spike. They absolutely get better after perctinotomy. It's very reliable finding. Trigger finger. Same thing. I mean, obviously we can all inject the trigger finger blind, but it's the patients like to see it. I think it also helps with anxiety quite a bit. They don't want to look at the needle, but a lot of times when they look at the screen, it kind of depersonalizes things just a little bit. So some of these very needle phobic people, when they watch the ultrasound screen, calm down substantially. It's really been a miraculous thing in my practice. So I do these long acts in plane. So you can see the needle coming in underneath the pulley and get the fluid in. Perctrigger finger release. Same thing. I can numb them up, use an 18 gauge needle and come in and just kind of poke and divide the pulley that way. You kind of come underneath and cut up. I like an open release better to be honest with you, but every once in a while for patients who can't or don't want to go to the OR, this is a way to take care of them. So sorry for the technical issues. Thank you guys so much for your attention. I'll jump to Tate. Uh, or left click, yeah, try that. It was working this morning. To do the files. All right, so I'm Tate Greditzer, I'm an assistant professor at the Hospital for Special Surgery and I'm going to talk to you guys about MRI technique and one of the points of my talk is you guys go to these meetings and you're hand surgeons and you see this radiologist get up here and they show you all these amazing pictures and then you go back to your practice and you're like, well my images look like shit, like why, like why can't I get my images to look like this guy's. So I want to give you guys the tools when you go back to your practice to be able to talk to your radiologist, if you guys have your own magnets, I don't know, your practice that you own or talk to your technologist and say this is what I want or this is what I need. So I'm going to, so it's kind of, the talk should be orthopedic MRI, how we do it at HSS and then how you guys can kind of take it to your practice as well. You got some news from the doctor recently that you were going to share with us, is that correct? Oh well I have a labral tear in my hip, which is, yeah, I believe I have a bit of my, the full Hospital for Special Surgery's report on my hip and pelvis, yeah, I did not read that on that, that, that radio. What every man wants to hear. It's not, it's, it's unremarkable. Typical radiologist, right? So hand, wrist and elbow imaging, what do you guys need to get started? So you, obviously we're talking about MRI, you're going to need a magnet, but then the question is open magnet, do you use an open magnet? What about coils? Do you need coils? And then sequences, T1s, T2s, so there's a lot that goes into kind of what you need for an MRI. So I see this crap all the time, it's terrible, five reasons to choose an open MRI, just stay away from open MRIs, especially for extremities. You guys are hand surgeons, wrists, fingers, elbows, it's total crap and I'm not even sure it's totally reimbursable anymore for radiologists, so if you own your magnet, you're not even going to get paid. So when is low field strength like, I'm talking less than 1.5 Tesla field strength, like there have been studies where they've looked at rheumatoid arthritis, just seeing like a little bit of bony erosions. I'm not totally sure that a radiograph isn't going to be totally more helpful than this. So that's really the only way I've, I've kind of seen it used. So you're going to need 1.5 Tesla field strength or stronger, I'll talk to you guys a little bit about 3T, everybody's like crazy about the 3Ts right now. But this is probably, if you take nothing out of this talk, you need to take this away, is you need a receiver coil and you need a dedicated wrist coil or a dedicated hand coil. I work, I help consult at an orthopedic practice in St. Louis, Missouri and there was a hand surgeon that came on and he was like, these images look like crap. And I had the head of the group buy a receiver coil and he was like, oh my God, they're amazing. I can see everything now. So this is really important. So you need a really good receiver coil. You guys want to talk to me afterwards, I can, I can kind of help you. It shortens the examination time, decrease signal to noise, and I'll just show you examples of that. So it allows, this is a really nice receiver coil here. What I'm doing is I'm putting the patient's hand in based on where I want the ISO center of the signal to hit. So if it's a hand, a finger, or a thumb, I use this coil right here and it's a really nice coil. So here's just an example. This is an MRI of the wrist at 1.5 tesla field strength. On the left is a T1, which really should have no part in your imaging sequences. T1s are terrible unless you're doing a whole lot of trauma. But even then you want to use proton densities rather than a T1. And then on the right is a, is an inversion recovery sequence. But this is when I use a wrist coil. This is without a wrist coil. It's okay. It's not bad. Probably maybe a lot of what you're seeing back in your practice, use a wrist coil and look at that. I mean, look at the detail in the articular cartilage. You can see the left sequence is a gradient, which is really nice for looking at ligaments. Rob doesn't believe in scapula ligament tears. I do. You can see them really well with a gradient sequence here. So this is just showing you which image do you guys like better. How many people like number one better? How many people like number two better, right? Number two is money, right? So that's a proton density. On the left is a T1. A T1 blurs out the cartilage. It's terrible. If you're using them in your practice, stop and tell your technologist, be like, I wasn't to take Reditzer at the ASSH and I'm moving to proton densities. Proton densities are great. You can see ligaments better and you can see cartilage better. So I think everyone agrees that that's a much better one. Okay. So for a wrist coil, so this is like the traditional wrist coil that we have here. This is an eight channel GE coil. Again, it's going to give you improved signal to noise. You have to put the patient in the scanner, kind of like in the Superman position. This is a huge problem with our NFL players because they don't fit when they injure their wrists. This is like the only position that you can use. You can image them by their side if they're too big. But this will really get that wrist in the isocenter, the sweet spot of the magnet where there's all that field strength, and you're going to really get nice sequences. But the thing you guys want to remember and also take away is a lot of radiologists will do three planes of IR or inversion recovery, and then like three planes of a proton density. You want to shorten your sequences. You probably only need one or two planes of an IR. And if you're noticing on your MRI images that there's a lot of motion, and there's always motion, then the sequences are too long and the patients are getting tired holding it there and they're going to start moving their wrists. So another thing you want to do to improve your images is shorten your sequences. You don't need like seven different sequences for an MRI of the wrist, okay? So that's a big thing. So motion artifact, I talked about that. So shorter exam times is like a typical motion degraded wrist, so it looks terrible. You want to talk to your technologist, make sure the patient's comfortable, repeat the sequences. And then parallel imaging is another thing that's out on the market. So parallel imaging shortens the sequence. It's called propeller on GE. I think it's called blade on Siemens. But parallel imaging acquires the sequence in half the time and it kind of, the computer kind of uses AI and uses time points to where a proton should be and then acquires the image. The image doesn't quite look as sharp as a normal, but it's good and it looks a lot, a hell of a lot better than that one right there. So that's parallel imaging right there. So it looks way better than a motion degraded sequence. So field strength, 3T versus 1.5T. So everyone's talking about 3T, 3T, 3T. I'm one of the team docs for the Mets and the trainers are always like, no doc, we need it on a 3T. I'm like, that's not necessarily better. A 3T is faster. So if you guys have a busy practice, you own your own magnet and you want to get a lot of patients in and out and you want to do like 25 patients a day, a 3T will, it's half the time of a 1.5. Also if you want to image around metal, if you guys are doing any like metal suppression kind of imaging, which I'll show in a little bit, 1.5, the higher Tesla field strength, you're going to get way more metal artifacts. So you need a 1.5 if you want to image around metal. And the other thing is if you own your magnet, you're going to get paid the same for three versus a 1.5. But a 3.5 can give you slightly better imaging if you know what sequences to use. But the main thing is this, it's not exactly like way better, just really faster. So this is one of the new flex coils that GE has. There are these new cool coils that they're like, are almost like drapes. They had a GE imaging, like wore it as a suit coat at a meeting one time, but you can kind of just drape it over the patient and it's the new flex coil. But this is really nice for the elbow. Looks good. And you're going to get images that look like this. So this is just using a coil is going to really improve how the MRI of the elbow looks. I like to do one coronal fluid sequence. So one fluid sensitive sequence, and then I do a gradient because I, again, I like, we do a lot of baseball players. I think it's good for looking at the UCL. And then I do three planes of proton density, and that's really all you need. So this is just an, just a sagittal and axial, again, using a proton density, not a T1. So you want, this is my chairman, Dr. Potters, who kind of came up with the proton density sequence. And you just want to make sure you have small fields of view, high resolution sequences. This is the proton density that I was talking about before. I gave that shirt to all the sports fellows. And so it's the proton density, it's not a T1, it's not a T2, but it gives you, like I said before, excellent signal detection of fluid, hyaline cartilage, fibrocartilage, and it's really ideal in the assessment of joints. You know you're doing well when your co-speaker takes a picture. So again, this is a T1, this is a PD. So we'll just go through some quick cases. How much time do I have? Am I doing okay? I think we're a little long. A little long? No, you're good. I was long. Okay. This is a 32-year-old male with a finger injury after a dino. Does anybody know here what a dino is? I don't. I don't either. So it's where you're a rock climber and you use your hands to jump. So this is just like a nice MRI right here of an A2 pulley injury, and you can really see it nicely when you use these high-resolution imaging. I know Rob was talking about pulley injuries before, but using those dedicated coils will really give you a good... So again, let's see here, I wanted to show you guys something else. So this is just an example of how we can image around metal. This is a 45-year-old male with a biceps repair one year ago. He had paresthesias in the hands and fingers. And here you can see really nicely when you use metal suppression, that screw coming out and it's impinging on the median nerve right there, what's really, really nice here. As radiologists, we get really excited when we see these things and you just hear the surgeon swearing on the other end of the line. But with metal suppression, you can really get good images. This is a 1.5 tesla field strength, it's not a 3T. So I was talking about imaging around metal, there's another thing totally available, it should be available on almost every MRI unit, it's called Maverick, that's the GE. For Siemens, I can't remember what it's called, maybe it's Mars, I can't remember what it's called on Siemens. But anyway, this allows you to image around metal, it's available on all MRI magnets. If you don't have it, just talk to your technologist, if they don't know about it, talk to the vendor and they'll get it put on there. But it really works very, very well. So this is just an example of a T1 and a Maverick. Here you can see this is a really nice case. So this is a patient with an elbow arthroplasty, had pain, here's the radiograph. You know, we couldn't really see much on the radiograph here, but when we use the Maverick, you can see the implant really well and you can see just extensive osteolysis surrounding that implant right here and right here, right there, which you couldn't see on the radiograph at all. So the Maverick works really, really nicely and it's really, really easy to use. We scanned along here axially and we also used the Maverick and here you can just see all the osteolysis eroding the bone. Really nice case. This is a nice example, 42-year-old male with a stainless steel radial head replacement. So this is what the MRI looks like that we had on the outside. Like right? Radiograph's way more helpful, right? You can't see anything. So the patient came to HSS and we used our good friend, Pete Mitchell here. And although it's stainless steel, there is an artifact. You can see that there's a really bad stress reaction right there within the radial shaft. So it did eliminate a lot and we could kind of tell the patient why they were having pain. So really nice example of that. This is just something else that's cool that's out there. This is a patient with a Bennett fracture. You can see that easily on the MRI. Does anybody know what this sequence is on the left? This is coming down the pipe. Not FDA approved, but look out for it. Is that a CT? Looks like one. That's actually a ZTE. So that's an MRI. So the MRI can now change the image to a CT. So we're starting to use that. So that's ZTE. So we're able to look at kind of the fracture healing. It's not FDA approved yet. This is a shoulder. We're starting to use it in hips as well. But this is coming down the pipe and it's going to be really, really nice for your patients, young patients. You don't want them to be exposed to radiation or anything like that. So I think I'll stop there. Do we want to show a little of John Jose's? Any questions? You guys have? No? Hello, I'm Dr. Gene Jose from the University of Miami, and we'll be discussing ultrasound and MR imaging of traumatic peripheral nerve injuries. I have no relevant disclosures, and the use of copyrighted material in this presentation is done for the purpose of teaching. The normal peripheral nerve anatomy is easily depicted on both ultrasound and MRI. We can see the outer epineurium containing fibrofatty connective tissues and endovascular structures. These endovascular structures may enhance following IV contrast administration on high-resolution MRI. Within it, we also see fascicles, which are a group of nerve fibers, which are contained within the perineurium. These fascicles should not demonstrate enhancement following IV contrast. And the reason why is because the perineurium contains a nerve blood barrier with tight junctions, which will prevent the migration of contrast from the epineurial vessels and into the endoneurium. Within the perineurium, we see myelinated and unmyelinated axons contained within the endoneurium, and that collagenous connective tissue layer, which invests the individual nerve fibers, has a rich capillary network and some fluid. Therefore, normal peripheral nerves will be slightly T2 hyper-intense in relation to skeletal muscle on fluid-sensitive MR sequences. However, the T2 hyper-intensity of the fascicles within the endoneurium should never exceed that of surrounding vessels. On long-axis coronal and sagittal MR images, we should identify the normal continuous striations of peripheral nerves with preserved surrounding fat planes. On axial images, we'll see the classic fascicular honeycomb pattern. The size and shape of the fascicles will vary depending on the type of nerve you're looking at, but they should be uniform throughout the individual nerve. The contour of the nerve should be smooth. Again, the fat plane should be preserved. The nerve should be uniform in size, T1 and T2 hyper-intensity, and signal intensity, and should travel in normal course. Here's an example of a non-fat-suppressed image of the median nerve at the level of the carpal tunnel. Notice that the fascicles are of uniform size. They're not compressed or otherwise distorted. The epineurium is easily identified, and the surrounding soft tissues are maintained. On this fluid-sensitive fat-suppressed image, the normal nerve, again, is slightly hyper-intense to normal skeletal muscle, but it should not exceed that of surrounding major blood vessels. Again, this is afforded by those connective tissues within the endoneurium. The blood nerve barrier is important as it separates the endoneurium from the endovascular spaces and the epineurial connective tissue. Disruption of this blood nerve barrier leads to functional and structural impairment of peripheral nerves and plays an important role in many disorders, including nerve injury resulting in malaria degeneration, nerve inflammation, and demyelination. So the images on the top are pre- and post-contrast, high-resolution MRI showing enhancement of blood vessels within the epineurium, but outside of the endoneurium. The orange arrows show, on the image on the right, the enhancement of these blood vessels, which is normal. So this is normal appearance of a larger nerve. Again, notice that the fascicles are not enhancing. This is abnormal. So if you look, the image in the middle shows diffused fascicular enlargement with enhancement following IV contrast. This is indicative of disruption of that blood nerve barrier with migration of contrast from the endovascular spaces within the epineurium through the perineurium and into the endoneurium causing the fascicular enhancement. So we see this in many different types of nerve injuries and lesions, including nerve degeneration, inflammation, demyelination, and also tumors. When evaluating peripheral nerves on MRI, we have to be aware of magic angle. Again, as these nerves course at directions away from the static magnetic field on short TE sequences, the nerve will become fictitiously hyper-intense. So how can we identify this? Well, we know that the nerve will be hyper-intense in these sequences, but that they should have preserved fascicle anatomy and the surrounding soft tissue should be maintained as in this case. So we will also overcome magic angle as we increase the TE on MR sequences. So normal magic angle seen in peripheral nerves. Under ultrasound, the fascicular anatomy of nerves should be maintained. The epineurium should be thin and smooth and echogenic. You should see the striations of the fascicles and the surrounding soft tissues will be maintained. We have to be careful with anisotropy. If we interrogate the nerves at anything other than 90 degrees, they will become hypoechoic. Again, this is an artifact. So here's an example of a peripheral nerve in long axis interrogation where the ultrasound transducer is placed at 90 degrees to the course of the nerve. And so you can nicely see the nerve fascicular alignment. But when you incinate the nerve away from 90 degrees, the nerve becomes hypoechoic mimicking pathology. Again, just be aware of anisotropy in the setting of ultrasound and always be adjusting the transducer along the course of the nerve to avoid this artifact. So peripheral nerve injury is classically described by the Sedan and Sutherland classification schemes. And we can see this on MRI. And let me show you some classic findings of these nerve injuries. So in the grade one, the neuropraxia, the nerve will be T2 hyper intense, but continuous. There'll be no neuroma formation, no nerve discontinuity, and the surrounding soft tissues should be preserved. In grade two, axonofmesis, you start seeing some axonal injury, but you'll have preservation of the endoneurium, perineurium, and epineurium. On MRI, the nerve will be diffusely enlarged. The fascicles may start becoming enlarged and you may start developing a little bit of perineurofibrosis, but not significantly. Furthermore, on dynamic imaging, you should have preservation of nerve gliding. In grade three, neurotmesis, you'll have axonal injury plus endoneurial injury. So on high resolution imaging, you're going to see fascicular disruption. This will result in more enlarged and asymmetric appearance of fascicles, T2 hyper intensity, and you'll start seeing more significant perineurofibrosis. In the grade four neurotmesis, you'll have axonal loss with endoneurial and perineurial injury, and these are usually accompanied by neuromas in continuity. So the presence of a neuroma in continuity is usually indicative of at least a grade four injury. Finally, the grade five injury, the classic finding is complete nerve interruption involving the endoneurium, perineurium, and epineurium. And usually you'll have a gap between the nerve and the formation of stump neuromas over both sides. So let me show you what this looks like. This is the classic grade one. So normal on the left, abnormal on the right. Notice that there is diffuse T2 hyper intensity of the nerve. However, the fascicles remain of uniform size. There is no architectural distortion. The perineurofibromas are preserved. This is the classic finding for grade one neuroprax. Grade two exonotmesis, we start seeing more fascicular distortion. The fascicles are now enlarged. You still have preservation of striations within the nerve without interruption. And most of the surrounding soft tissues are maintained. We don't see a neuroma. This is classic for grade two. As grade two injuries progress into grade three, we'll see progression of the fascicular distortion. You'll have asymmetric enlargement of some of the fascicles. There'll be also more T2 hyper intense than the other surrounding fascicles. You may start seeing the development of more perineurofibrosis, but still there is no appreciable endoneurial discontinuity. So this is progression of exonotmesis. As the nerve fascicles become enlarged, you may get a dominant fascicle within the epineurial spaces, compress adjacent normal fascicles. And this may give a dominant hypoechoic appearance to the nerve on ultrasound. So this is progression of fascicular enlargement and distortion as we're migrating between a grade two and a grade three injury. Remember that different nerves will have different fascicular anatomy. So this is a paper looking at the normal, ondor, median, and perineal nerves. Notice that the shape of the fascicles and the number of fascicles are different. But as the nerve becomes enlarged, you're gonna have accentuation of fascicular size discrepancy and hypoechoic pattern or hypoechogenicity. And then as this progresses, you'll see fewer visible fascicles within it because the enlarged fascicles will start compressing the adjacent fascicles. And at the end, the entire nerve will be enlarged with distension or expansion of the epineurial space. So assessment of the perineural fat planes is very important as it, when there is disruption of the perineural fat planes, it usually indicates a higher degree of injury. And the clinical significance is the decreased nerve gliding. So on MRI, we wanna see those preserved fat planes, nice fat layer around these peripheral nerves and normal muscle architecture around it, both on MR and on ultrasound. So normal images on the top, abnormal on the bottom. Notice that at the bottom, there is marked architectural distortion and the formation of scar tissue. The scar tissue may either be echogenic or hypoechoic, depending on the evolution of the fibrosis. So a lot of architectural distortion on the bottom involving the epineurium of the nerve. Here's more architectural distortion on the ultrasound on the bottom. Notice the extensive hypoechoic scar formation around these nerves. And again, this will significantly restrict blood flow to the nerve and it will impede nerve regeneration and it will also impede nerve gliding. So this idea of nerve gliding is very, very important. The nerves glide with regards to the surrounding soft tissues and it will also glide intranurally, the fascicles slide against each other. So the brachial plexus can glide up to five centimeters, the ulnar and median nerves can glide up to eight centimeters and the median nerve at the carpal tunnel can glide normally up to 10 centimeters. So we can easily assess this by ultrasound. Here is the normal median nerve at the level of the forearm with arm movement. You can see the preserved fascicular architecture and that median nerve is nicely gliding with regards to the surrounding soft tissues. And if you pay close attention, you will also see that the fascicles glide with regards to one another. So this is normal nerve gliding. So anything that entraps or impedes this, whether it's an intraneural problem or an extraneural problem or both, will have significant future problems to the nerve because it restricts vascularity, again, impeding nerve regeneration, causing mechanical compression. So here's an example of a nerve that is markedly abnormal. It's enlarged, it's hypoechoic. And notice that there is decreased nerve gliding with regards to the surrounding soft tissues. You can see that the epineurium is being tethered to the surrounding soft tissues and this results in decreased nerve gliding. This is very clinically significant. When you see this, usually patients will have a poor outcome and they may benefit from surgical neurolysis. On static images, this is again demonstrated by these irregular soft tissues around the nerve with extensive perineural scarring. This happens to be a median nerve in the carpal tunnel. When you look at long axis ultrasound and longitudinal coronal and sagittal MR images, you'll see the irregularity of the epineurium. The nerve can become kinked and will give this appearance of enlargement and constriction. And as you can surmise on the static images, when the patient tries to move, there'll be decreased nerve gliding. So always pay attention to the epineurium. Okay, we're short on time. So I'm just gonna give the last talk here. But that was a really nice review of nerves. Any questions you guys have from that? I would just say that last point about nerve gliding on ultrasound is super important. When you start doing these injections in the office and then you take the patients to the OR, those are the patients that when you open the carpal tunnel and the nerve is like plastered to the ligament, you gotta do that kind of neural lysis to get it going, you'll definitely see it. And those are patients that when you do that neural lysis in the OR, they get better faster. I still can't believe you're injecting your carpal tunnels short. Yeah. So you go in like that? I go in short. It's so easy to do it from the side. I'm not as good as you. I'm not as good as you. Try it in long view. Okay, so I'm gonna just kind of, this is kind of gonna be a little case-based. We're gonna discuss MRI and ultrasound above the wrist. I think you guys kind of have the tools now so you know what kind of MRI sequences you should use. This is an axial proton density. So muscle disorders, you know, on an MRI, you're gonna see, it's kind of like, you kind of already know this. Abnormal anatomy with normal signal intensity. You can see edema or inflammation related to increased water content, obviously an intramuscular mass or atrophy resulting in tissue loss. And then, you know, early atrophy, you can see denervation edema and then denervation edema, you're eventually going to see fatty atrophy. So this is, you know, talking about accessory muscles. This is a nice example of an anchoneous epiturchal aris, an anomalous muscle that runs between the medial aspect of the olecranon and the medial epicondyle, found in up to 28% of cadavers. And you can just see a nice example of that right there, compressing the ulnar nerve. This is a nice ultrasound case that I had. A patient came into our ultrasound clinic, a 50-year-old female with a mass. This is an outside MRI that we saw, and we saw that little piece of, I don't know what it is, maybe a little muscle there. We put an ultrasound probe on it because it's so superficial. And you can see nicely there, here, this was a muscle herniation. And when you had the patient just move their arm, you can see that muscle kind of coming out right there. So this was just a nice example where ultrasound can kind of be helpful in diagnosing problems. This is an MRI of a 28-year-old female with relapsing forearm pain. Here you can see diffuse intramuscular high T2 signal intensity. Not sure what that is. That could be, usually it doesn't look like a muscle strain, right? It's just so diffused. The patient didn't have any history of trauma, accessory exercise. So this is an example of inflammatory myopathy. And the muscle involvement is most common in scleroderma. Up to 28% of patients with rheumatoid arthritis or SLE can demonstrate myositis with muscle necrosis and inflammation. And at MR imaging, the myositis related to collagen vascular disorders is actually indistinguishable from a polymyositis. So these people usually get a biopsy. This is an example of chronic compartment syndrome. Again, you can see diffuse muscle atrophy. There's scar tethering right here related to atrophy. And then as Dr. Jose was talking about the nerve right there, you can see that that nerve is vastly abnormal. Like that normal honeycomb appearance, all those fascicles are swollen and enlarged. Nerves at MR imaging are usually very hard to see. And when you can see, when you can obviously see the nerve on your MRI when you're looking at it, you should be thinking something might be wrong here. This is a 45 year old female with a mass in her arm. This is just a nice example of how ultrasound can be helpful. Here you can see that massive high T2 signal intensity mass. So what we did was we, the patient came to our ultrasound clinic and we did a panoramic view. Are any of you guys using these panoramics? These are really nice with ultrasound. Rob, do you use those at all now? So you can just take the probe, you just put it on panoramic view and you just run the probe along and you'll get a nice long picture like we see there, kind of almost similar to the sagittal MRI that I'm showing above. And then we just use ultrasound to go in and aspirate that mass. You can see it really nicely. That's the way we did it. And this was an abscess in an immunosuppressed patient. So nice example. This is one of my favorite cases. This is a patient that came in with unilateral forearm swelling after biking across America. I can't even imagine doing that. But they had unilateral forearm swelling. So the orthopedic surgeon came to me. He's like, oh, it's TOS. So we did a vascular ultrasound and that was negative. And then he's like, oh, no, no, no, it's his biceps. It's his biceps. And I was like, okay. So we took an ultrasound of the biceps. There it is in short axis. There it is at its insertion in kind of like the equivalent of an MR sagittal. Biceps look totally normal. So I was looking at this guy's forearm and I was like, what the hell is going on? Why does this look so weird? So all those, so you see the brachioradialis is bright. ECRB is bright and the ECRL looks pretty normal. So this was rhabdomyolysis. And that's just diffuse edema within the muscles right there. So, and you can just see it by marked hypoecogenicity and all those. And thankfully, I don't know, maybe it would have been hard for me to diagnose. The ECRL was normal in appearance. So I was looking at the muscles and being like, why do these look so weird? So rhabdomyolysis, you know, obviously you guys all know what it is and you just get diffuse edema. The problem with rhabdomyolysis on MRI or ultrasound is it's indistinguishable from delayed muscle onset soreness. So you're gonna need to get a creatinine on these patients. Because, so this is a patient that I was a fellow, I was reading it with my chairman, Dr. Potter, and this girl had just done SoulCycle and it was her first time doing SoulCycle. And she had just sheet-like edema. And she was like, oh my God, this is rhabdo. And it was actually ended up being dom. So it's indistinguishable from that. But unfortunately there's just no way to know. So living in New York, did we see some interesting things? This was a new phenomenon that people were doing during the pandemic. Rather than riding inside, they like to ride outside the subway. There weren't many people around. I love the guy with the Mets fan, just doesn't know how that's normal. So this was not my patient, but a patient doing a similar thing came in. And when he was riding up there, he said he got something caught in his hand and his hands was swollen. So here we see the MRI. There's diffuse edema right there. But what, like, I was like, what is that thing on the left right there? Like, what is that like low signal intensity object? And, you know, you have to kind of look at everything satisfaction to search and make sure you look at the whole MRI and not just the point that you're concerned. And it was, that's a little piece of rubber from the top of the subway that got lodged in his hand from riding like that. And you can see that nicely. So IV contrast was helpful in this sense because you can see the little abscess outlining right here with, where there's no enhancement in the fluid and hyper enhancement around it. So IV contrast was helpful in that setting. This is a really interesting case I had of a patient with hand swelling, rule out foreign body. They were on vacation in the beach. Anybody know what movie this is? I'm probably showing my age here. Naked Gun, right? Yeah, I play this with my sports fellows and no one knows the movies anymore. And I realized I'm getting really old. But anyway, so we got, there was a radiograph. The radiograph was normal. Nice, where Rob was kind of talking about foreign bodies, where ultrasound's really helpful. So we said, let's put an ultrasound on it. You can see the foreign body there. The surgeon took it out. It was a sea urchin. So really nice how ultrasound can be used for evaluation of foreign bodies. This is just unfortunate case of, you can see that large T2 hyper intense mass in the elbow. That was a myxofibrosarcoma. And this is another example of a nice pin case. So you've got some atrophy right there in the supinator that we can see right there. And we can see like an abnormal poster neurosis nerve. Look how swollen it was. Kind of what John Jose was talking about. It's really nice and easy to do these with ultrasound. I like injecting these. So that's the nerve right there. As you can see, you know, we were talking about the honeycomb appearance. There's no honeycomb there. That's just all swollen nerve fascicles. So no honeycomb comb for that guy. These are really easy to inject on ultrasound. Once you find them, you just put the needle down. A little trick that I have when I do these is, I think Rob showed this really nicely. I think that cubital tunnel injection that you had, you want it to be like a moat. Like you want your nerve, so you don't want to obviously inject into the nerve, but you want to inject your lidocaine. You want the lidocaine to circle around the nerve. And when you see that, you're like, oh, great. It's all surrounding the nerve. And then once I, so I put my needle in, start injecting lidocaine. I start to see it circle the nerve, and then I put the steroid in, and the steroid's going to follow where the lidocaine is. So you kind of want that moat kind of appearance. So I always tell my fellows like, make the nerve look like a moat. I want it to completely encircle the nerve. We've all kind of seen this before. This is the unfortunate case of probably why Rob was saying he does not inject lateral epicondylitis. This was a patient with an unfortunate case where the side of their elbow actually fell off. This is actually a very famous rock and roll drummer. I'm not going to say who, but then this patient had posterolateral rotatory instability. I use the sagittal MRI. When I see that radial head going posteriorly, it's PLRI until proven otherwise. And with the whole lateral side of this guy's elbow off, obvious to that. So the problem is, is like, I see a lot of people injecting, and I've actually got this from like YouTube or Google, and people inject the elbow this way. Like they're putting the needle right into the tendon with ultrasound. So I actually do inject lateral epicondylitis, but I don't inject it that way. So you can see the ECRB there and the needle there. It shouldn't be there, right? So where you want the needle is right here. So I injected on the top of the tendon and I just let the steroid coat that. Now I'm not saying that if I do that in a patient, like, you know, every four months, the side of their elbow is not going to fall off, but you're not injecting it right into the tendon. And when you inject it, and I watch my fellows, if they inject into the tendon, it's like, there's such resistance, but you do that, you get a nice coating over the tendon. So if you're going to inject lateral epicondylitis, I would do it this way. Last thing, I do a lot of baseball players. So I think this is really helpful if you guys are looking at athletes for UCL, the ultrasound can be really helpful. So that's Lindsey, one of my favorite ultrasound techs, and I'm just showing how to do a moving valgus stress test, probably incorrectly because I'm a radiologist, but you can see the ulnar collateral ligament very, very nicely here with ultrasound right there. And there's people that have done some talks on that or some research, the head team doctor for the Phillies looked at gapping at the joint and found that that was predictive of ulnar collateral ligament tears when he combined that with MR arthrography. All right, as usual, I talked way too much. So it's 8.57. So I'm going to end and open the floor for questions if you guys have any. Yeah. Yeah. So we're, yeah. I think that, yeah, it's very easy to see tears of the ECRB with ultrasound. I'm doing a study right now where we're, we're looking at ultrasound of ECRB tears and, and just, we're doing different treatments that I really don't understand, but I'm just reading the ultrasounds, but I think you can see them well, Rob. Yeah. I mean, basically, you know, when you put the probe on, the fibers should come right up to the mountain peak. The tear or the degeneration looks like a black kind of sail. It's almost like a sail sign and an elbow swelling for an occult fracture. That kind of shape, black hypoechoic sign in the origin, and you see it right away. You'll, you'll see it. And then you see that spike. When you see the spike, that's what they got and you can definitely make them better. Yeah. And also I like going in short axis. So long. And then if you turn short, you can see the tears that like right underneath the bone because those tears always go from the undersurface. Also you can turn on power dappler, look for hyperemia, elbows inflamed. We're also doing a study with that at HSS for lateral epicondylitis. I personally haven't found the power, I'm probably doing it wrong, but I can't because I'll use it to try to figure out like if someone's getting better and so you're supposed to be able to follow it to see, you know, more or less blood flow indicating that their, their tendon is healing. I can't tell the difference to be honest. Do you use power or color? Color. So you want to use power? So power is sensitive to the blood flow. Okay. So like hyperemia where, where color is just like, you know, the speed of flow. So that might help. So would you get an MRI or an ultrasound then for lateral epicondylitis? In New York, we're doing a lot of ultrasounds for lateral epicondylitis, um, honestly, um, kind of, I don't know. Yeah. I mean, the only reason to get an MRI for a tennis elbow kind of case is you're worried that the collateral ligament is torn and you got to go in and you got to repair that part of it. And, or you think there might be like a plica, some intraarticular thing that you have to address at the time of surgery for standard tennis elbow, they get a screening x-ray to make sure I want patient come in. Why am I getting this x-ray? When did you last get acupuncture? How'd you know I got acupuncture? Cause the needle's sitting there in your elbow. So I always get an x-ray, right? And then, and then I do an ultrasound cause I do ultrasound perctinotomy, uh, to treat them. Anybody else? Clear as mud. All right. Thank you guys. Thank you guys for coming so early in the morning.

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