1. MỘT SỐ PHÂN ĐỘ TỔN THƯƠNG
CƠ XƯƠNG KHỚP
CHI TRÊN VÀ CHI DƯỚI
Dr Le Duy Chung

2. • Shoulder
• Elbow
• Wrist and Hand
Upper extremity

3. Type I Type II
Type III Type IV
Type 1: flat undersurface
Type 2: curved undersurface
Type 3: hooked
Type 4: upward or superior
convexity of inferior border
Contemp Orthop. 1995 Mar;30(3):227-9.
Acromion Shape

4. flat lateral tilt low-lying
Acromion Slope

5. Os Acromiale

6. Os Acromiale

8. Crescentic U-shaped L-shaped
Supraspinatus Tear Shape

9. Partial-Thickness Tear
Bursal surface
Partial-thickness tear with
tendon thinning
Articular surface Intrasubstance

10. Ellman’s grade
– Grade 1: < 3mm
– Grade 2: 3-6mm, < 50% of cuff thickness
– Grade 3: > 6mm, > 50% of cuff thickness
Clin Orthop Relat Res. 1990 May;(254):64-74.
Partial-Thickness Tear : Depth

11. Greatest dimension of tear
• Small : < 1 cm
• Medium : 1~3 cm
• Large : 3~5 cm
• Massive : > 5 cm
Full-Thickness Tear

12. Small: < 1cm Medium: 1-3 cm
Large: 3-5 cm Massive : >5cm

13. Tendon Retraction
Stage 1 Stage 2 Stage 3
Irreparable if retracted tendon edge is
medial to glenoid fossa !
Full-Thickness Tear

14. Grade 0
normal
Pfirrmann CWA et al .
Radiology 1999; 213: 709-714
Subscapularis
Tendon Tears
Grading Grade 1
cranial lesion
Grade 2
cranial three-
quarters tears
Grade 3
complete tear

15. Impingement : Classification
• Type 1
– Presence of subacromial bursitis
• Type 2
– Tendinosis (type 2a),
– Partial tear (type 2b)
• Type 3
– Complete tear of RC
AJR Am J Roentgenol. 1988 Feb;150(2):343-7.

16. Impingement : Classification

17. Goutallier classification is used for
the assessment muscle degeneration:
Grade 0: No intramuscular fat
Grade 1: Some fatty streaks
Grade 2: Fat is evident but less fat than muscle tissue
Grade 3: Fat equals muscle tissue
Grade 4: More fat is present than muscle tissue
References
Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and
postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994;78-83
Fuchs B, Weishaupt D, Zanetti M, Hodler J, Gerber C. Fatty degeneration of the muscles of the rotator cuff:
assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elbow Surg. 1999;
8(6):599-605
Goutallier Classification

18. I II
IV
III
V
Goutallier Classification

19. normal atrophy
Tangent Sign
Muscle Atrophy
Oblique sagittal at medial coracoid process
Scapular Ratio
< 50%, atrophy

20. Current SLAP Lesion Classification with Associated
Clinical Findings and Mechanisms of Injury
I Fraying Could be incidental finding; more significant in young people involved in
overhead activities
II Tear with biceps extension Most common type; association with acute traction,
repetitive overhead motion, and microinstability; could be associated with type
IV
III Bucket-handle tear with intact biceps Less severe than type IV; association
with fall on outstretched arm
IV Bucket-handle tear with biceps extension More severe than type III because of
biceps extension; could be associated with type II; association with fall on
outstretched arm.
V Not specified Either a Bankart lesion with superior extension or a SLAP lesion
with anterior inferior extension
VI Anterior or posterior flap tear Probably represents type IV or less likely type III
with tear of the bucket-handle component
VII Not specified Type of middle glenohumeral ligament extension (avulsion or
split) not specified; association with acute trauma with anterior dislocation
VIII Not specified Similar to type IIB but with more extensive abnormalities;
association with acute trauma with posterior dislocation
IX Not specified Global labrum abnormality; probably traumatic event
X Not specified +Rotator interval extension; articular side abnormalities

21. I Fraying
II Tear
III Bucket handle tear
IV Biceps tendon
V Bankart Fraying
VI Flap
VII MGHL
VIII Posterior
IX AnteriorPosterior
X RCI
SLAP lesion

22. SLAP lesion

23. Smith et al. Radiology 201:251–256
Eur Radiol. 2006 Feb;16(2):451-8
Superior sublabral recess : Types

24. Superior sublabral recess.
Drawings representing a coronal
section through the labral-
bicipital complex illustrate type I
(1), type II (2), and type III (3)
labral attachments. In type I, the
labrum (L) is tightly attached to
the glenoid, whereas in types II
and III, a recess is present
between the labrum and glenoid
(arrow). B = biceps tendon,
C = cartilage.
De Maeseneer, M. et al. Radiographics 2000;20:67-81S
Superior sublabral recess : Types

25. Zlatkin MB, et al. AJR;1988: 150: 151-158
From glenoid labrum From glenoid neck, < 1cm
From glenoid neck, > 1cm
Capsular insertion : Types

26. Type IIType I Type III
Zlatkin MB, et al. AJR;1988: 150: 151-158
Capsular insertion : Types

27. Habermyer classification of biceps
pulley lesions
J Shoulder Elbow Surg. 2004 Jan-Feb;13(1):5-12.
Group 1
Group 4Group 3
Group 2

28. • Formation phase
• Resting phase
– No enlargement of deposit
• Resorptive phase
– Inflammation with cells resolving calcium
• Post-calcific phase
– Reconstruction of tendon integrity
Calcific tendinitis : Stages

29. • Shoulder
• Elbow
• Wrist and Hand
Upper extremity

31. • Stage 1
– PLRI of ulna and radius
– Disruption of LUCL ± RCL & post-lat capsule
• Stage 2
– Incomplete dislocation
– Coronoid appears perched on the trochlea
– Lateral ligaments and capsular disruption
• Stage 3
– complete posterior dislocation
– 3A: only posterior bundle of MCL disruption
– 3B: anterior bundle of MCL disruption
Clin Orthop Relat Res 2000(370):34-43
Elbow instability : Stages
(posterolateral rotatory instability PLRI)

32. Clin Orthop Relat Res 2000(370):34-43
Elbow instability : Stages

33. • Shoulder
• Elbow
• Wrist and Hand
Upper extremity

36. Distal radioulnar joint dislocation

38. TFCC lesions by Palmer

39. I: traumatic injury
– A: central perforation
– B: ulnar avulsion ± distal ulnar fracture
– C: distal avulsion (carpal attachment)
– D: radial avulsion ± sigmoid notch fracture
TFCC lesions by Palmer

40. I
A
I
B
TFCC lesions by Palmer
B: ulnar avulsion ± distal ulnar
fracture
A: central perforation

41. I
D
I
C
TFCC lesions by Palmer
C: distal avulsion
(carpal attachment)
D: radial avulsion
± sigmoid notch fracture

42. • II; degenerative injury
– A: TFC complex wear
– B: A + chondromalacia (lunate or ulnar)
– C: TFCC perforation + chondromalacia
– D: C + lunotriquetral ligament perforation
– E: D + ulnocarpal osteoarthritis
TFCC lesions by Palmer

43. IIA IIB
TFCC lesions by Palmer
A: TFC complex wear B: A + chondromalacia
(lunate or ulnar)

44. IIEIIDIIC
TFCC lesions by Palmer
C: TFCC perforation
+ chondromalacia
D: C + lunotriquetral
ligament perforation
E: D + ulnocarpal
osteoarthritis

45. extensor carpi ulnaris tendon

46. • Hip
• Knee
• Ankle and Foot
Lower extremity

47. Ficat RP, JBJS(B) 1985: 67:3-9
Stage Radiographic Appearance RN uptake
0 Normal Normal
I Normal Decrease
II Increased sclerosis Increased
IIIa Increased sclerosis, subchondral fracture without
collapse
Increased
IIIb Increased sclerosis, subchondral fracture with collapse Increased
IV Increased sclerosis, subchondral fracture with collapse
and secondary osteoarthritis
Increased
Osteonecrosis Staging
Ficat stages

48. Osteonecrosis Staging
Association Research Circulation Osseous (ARCO)
0 Normal
I Medullar edema, joint effusion
II Necrosis, demarcation
III Microfracture
IV Flattening head
V Joint space narrowing, acetabular
VI Joint destruction

49. Criteria for staging AVN
______________________________________________________________________________________
Stage
______________________________________________________________________________________
0 Normal or non-diagnostic radiograph, bone scan and MRI
I* Normal radiograph, abnormal bone scan and/or MRI
II* Abnormal radiograph showing `cystic' and sclerotic changes in the femoral head
III* Subchondral collapse producing a crescent sign
IV* Flattening of the femoral head
V* Joint narrowing with or without acetabular involvement
VI Advanced degenerative changes
______________________________________________________________________________________
Quantification of extent of involvement by AVN
__________________________________________________________________________________________
Stage Grade
__________________________________________________________________________________________
I and II A, mild <15% of head involvement as seen on radiograph or MRI
B, moderate 15% to 30%
C, severe >30%
III A, mild subchondral collapse (crescent) beneath <15% of articular surface
B, moderate crescent beneath 15% to 30%
C, severe crescent beneath >30%
IV A, mild <15% of surface has collapsed and depression is <2 mm
B, moderate 15% to 30% collapsed or 2 to 4 mm depression
C, severe >30% collapsed or >4 mm depression
V A, B or C average of femoral head involvement, as determined in stage IV,
and estimated acetabular involvement
__________________________________________________________________________________________
Steinberg ME et al. JBJS(B) 1995: 77 (1);34-41
Steinberg Staging

50. Steinberg ME, Hayken GD, Steinberg DR. A quantitative system for staging avascular necrosis. J Bone
Joint Surg Br 1995;77(1):34–41
RadioGraphics 2007;27:1005-1021
Osteonecrosis staging
University of Pennsylvania System for Staging Avascular
Necrosis of the Hip
Stage Imaging Criteria
0
Normal or nondiagnostic radiographs, bone scans, and MR
images
I Normal radiographs, abnormal bone scans and MR images
II
Abnormal radiograph showing cystic and sclerotic changes in
the femoral head
III Subchondral collapse producing a crescent sign
IV Flattening of the femoral head
V Join narrowing with or without acetabular involvement
VI Advanced degenerative changes

51. % of necrotic lesion =
(A/180)x(B/180)x100

52. Mitchell Staging System

56. Acetabular labral lesions
Czerny classification
Stage 0
Homogeneous low SI, triangular shape, continuous attachment
to lateral margin of acetabulum without notch or sulcus (normal)
1A
Area of increased SI within the center of triangular shaped
labrum
1B 1A + thickened labrum, no labral recess
2A
Extension of contrast material into labrum without detachment
from acetabulum.
Triangular shape and labral recess is present
2B 2A + thickened labrum, no labral recess
3A
Detached labrum from acetabulum.
Triangular shape and labral recess is present
3B 3A + thickened labrum, no labral recess
Czerny C, et al. Lesions of the acetabular labrum: accuracy of MR imaging and MR arthrography in detection and
staging. Radiology 1996;200:225-230

59. • Hip
• Knee
• Ankle and Foot
Lower extremity

60. Medial patellar plica
Sakakibara Arthroscopic Classification
Type A: cordlike elevation
in synovial wall
Type B: shelflike
appearance but not
cover anterior surface of
medial femoral condyle
Type C: large with
shelflike appearance
and cover anterior
surface of medial
femoral condyle
Type D: central defect
(fenestrated plica)
Basis of size
AJR 2001; 177:221-227
Sakakibara J. Arthroscopic study on Iino's band. Nippon Seikeigeka Gakkai Zasshi 1976;50:513 -522

61. Suprapatellar plica
Zidorn classification
Type I (septum completum)
suprapatellar bursa and
knee joint are
completely separated
by septum
Type II (septum perforatum)
one or more openings
of varying size in
septum
Type III (septum residuale)
remaining fold, usually
in medial location
Type IV (septum extinctum)
completely involuted
septum

65. Outerbridge Classification
Grade 0: intact cartilage with normal signal and uniform
thickness
Grade 1 : thickening with abnormal signal
Grade 2 : superficial ulceration or fissuring
Grade 3 : deep ulceration or fissuring
Grade 4 : full-thickness chondral injury with bruising of
subchondral bone
Grade 5 : osteochondral injury with separation of
osteochondral fragment

68. Cartilage lesions
Outerbridge and Yulish Classification
Yulish BS, Montanez J, Goodfellow DB, Bryan PJ, Mulopulos GP, Modic T. Chondromalacia patellae: assessment
with MR imaging. Radiology 1987;156:763-766
Arthroscopic (Outerbridge)
classification
MR (Yulish) classification
Grade 0 Normal Grade 0 Normal
Grade 1
Softening, without
morphologic defect
Grade 1
Normal contour ± abnormal
signal
Grade 2
Superficial blistering or
fraying: erosion or ulceration
of <50%
Grade 2
Superficial fraying: erosion or
ulceration of < 50%
Grade 3
Partial-thickness defect of >
50%, but <100%
Grade 3
Partial-thickness defect of >
50%, but <100%
Grade 4 Ulceration and bone exposure Grade 4 Full-thckness cartilage loss

69. Grade I inhomogeneous signal intensity on
high-spatial-resolution GRE images
grade IIa cartilage defects: less than half of articular
cartilage thickness
grade IIb cartilage defects: more than half of cartilage
but less than full thickness
grade III cartilage defects exposing bone
Cartilage Lesions
Noyes and Stabler Classification
(Modified for MR imaging by Recht et al)

70. Classification of ACL
according to Barry et al.
Type 0: an intact ligament.
Type I to type V describe different ligamentous ruptures.
Type I: a swollen ligament with increased signal in T2, an intraligamentous rupture
Type II: a horizontally orientated ligament
Type III: non visualization of a ligament
Type IV: interruption of a ligament
Type V: a vertically orientated ligament.
M. Munshi, M. Davidson, P.B. MacDonald, W. Froese and K. Sutherland, The efficacy of magnetic resonance
imaging in acute knee injuries, Clin J Sport Med 2000;10:34-39

72. Copyright ©Radiological Society of North America, 2000
Recondo, J. A. et al. Radiographics 2000;20:S91-S102
Lateral collateral ligament tears
Avulsion fracture Complete tear Partial tear

73. Stage I stable lesion in continuity with the host
bone, covered by intact cartilage
Stage II partial discontinuity of the lesion, stable on
probing
Stage III complete discontinuity of the "dead in
situ" lesion, but fragment not dislocated
Stage IV dislocated fragment
AJR 2003; 180:641-645
International Cartilage Repair Society. ICRS cartilage injury evaluation
package. Available at:
http://www.cartilage.org/evaluation_package/ICRS_evaluation.pdf.
Accessed December 23, 2002
Osteochondritis dissecans
International Cartilage Repair Society classification at surgery

74. • Grade I: minimal disruption at M-T junction
• Grade II: partial tear with intact M-T fibers present
• Grade IIIA: complete rupture of M-T unit
• Grade IIIB: avulsion fracture at tendon origin or insertion
Tuit MJ, DeSmet AA. MRI of selected ports injuries: muscle tears, groin pain, and osteochondritis dissecans. Semin
Ultrasound CT MR 1994;15:318-340
Muscle strain

75. Types of tibial spine avulsions
Mayer and Mc Keevers classification

76. Types of tibial tuberosity avulsions
Christie MJ, Dvonch VM. Tibial tuberosity avulsion fracture in adolescents. J Pediatr Orthop 1981; 1:391-394
Radiographics. 1999;19:655-672

77. Tibial tuberosity fractures
Watson-Jones classification
Type I
A small fragment, displaced superiorly
Type II
A larger fragment involving the secondary center of ossification and proximal tibial
epiphysis
Type III
A fracture that passes proximally and posteriorly across the epiphyseal plate and
proximal articular surface of tibia (S-H type III)
Type I Type II Type III

78. • Hip
• Knee
• Ankle and Foot
Lower extremity

79. Osteochondral Lesion of the Talus
MRI Classification
Stage I Subchondral trabecular compression.
Plain raidiograph normal, positive bone scan
Marrow edema on MRI
Stage IIA Formation of subchondral cyst.
Stage IIB Incomplete separation of fragment.
Stage III Unattached, undisplaced fragment with
presence of synovial fluid around fragment.
Stage IV Displaced fragment.
Anderson IF et al. JBJS(A) 1989; 71:1143

80. Stage IIA Formation of subchondral cyst.
Stage I Subchondral trabecular compression. Marrow edema on MRI

81. Stage IIB
Incomplete
separation of
fragment.

82. Stage III Unattached, undisplaced
fragment with presence of synovial fluid
around fragment.

84. Stage IV
Displaced fragment

85. Achilles tendon ruptures
A four-stage classification system has been developed to grade
Achilles tendon ruptures
• Type 1: Partial ruptures affecting 50% or less of the tendon
• Type 2: Complete ruptures with a tendinous gap of 3cm or less
• Type 3: Complete ruptures with a tendinous gap of 3 to 6cm
• Type 4: Complete tendon ruptures with a defect greater than 6cm
Type 4 is associated with neglected ruptures.

86. Focal complete tear of Achilles tendon
with less than 3cm of retraction
Partial Achilles tendon tear

87. Type 3: complete rupture of Achilles
tendon with a tendinous gap of 3 to 6cm

88. Type 4: complete rupture of Achilles tendon with a defect greater than 6cm
Partial overlap
of torn Achilles
tendon ends

89. Symptomatic Type II
Accessory Navicular Bone
• Type I : Os tibiale externum
Sesamoid bone
No cartilage connection with
navicular tuberosity
• Type II accessory navicular
Triangular or heart-shaped
accessory ossification center of
navicular tuberosity
Connected to navicular by 1-2 mm
fibrocartilage or hyaline cartilage
Most commonly symptomatic
• Type III : cornuated navicular
Osseous fusion of accessory
navicular
Australasian Radiol 2004; 48:267