SHOULDER ( LEFT / RIGHT )    NAME _______________________  DATE_______

MRI Site:______________________

  

History:___________________________  Prior surgery? Type:__________________

Contrast     ____none       ____IV indirect arthro(___cc)        ____IA direct arthro

Prior exam: date________  changes__________________________________________

 

Joint effusion: s/m/l

IA Bodies:________

Synovitis: mild/mod/severe

Subacromial-subdeltoid bursal fluid (yes / no)

 

Rotator Cuff:

Supraspinatus:

            Normal / Tendinosis / Partial tear: undersurface / bursal-sided

            Full-thickness tear (…cm in AP diameter; …cm of proximal retraction)

Infraspinatus

Normal / Tendinosis / Partial tear: undersurface / bursal-sided

            Full-thickness tear (…cm in AP diameter; …cm of proximal retraction)

Subscapularis

Normal / Tendinosis / Partial tear: undersurface / bursal-sided

            Full-thickness tear (…cm in AP diameter; …cm of proximal retraction)

Rotator Cuff Interval

normal/fluid/edema

 

Muscle atrophy (yes / no) (supra / infra / subscap / teres) (edema / fatty atrophy)

 

Acromion shape:Flat / Curved / Hooked / Laterally downsloping

 

Subacromial spur (yes / no) (anterior / lateral) (small / mod / large)

 

Acromioclavicular joint:

            Capsular hypertrophy / OA (mild / mod / marked)

            Subchondral bone marrow edema (yes / no)

            Os acromiale (yes / no)

 

Long head of the biceps tendon:

            Tendinosis / Tenosynovitis / Tear

 

Labrum:

            SLAP (biceps involved? yes / no) (type_____)

            Other tear (location:______________________; type:__________________)

            Paralabral cyst (size:_______________; location______________________)

 

Osseous Bankart (yes / no)      Hill-Sachs (yes / no)

 

Bone marrow edema: location__________________; sugg etiology________________

 

Glenohumeral osteoarthritis (osteophytes / cartilage loss / cysts)

KNEE ( LEFT / RIGHT )    NAME _______________________  DATE_______

 

MRI Site:______________________

                                                                  

History:___________________________ ; Prior surgery? Type:__________________

Contrast     ____none       ____IV indirect arthro(___cc)        ____IA direct arthro

 

Prior exam: date________  changes__________________________________________

 

Fluid

Effusion ( S / M / L )     Bakers ( S / M / L )    Ganglia ( S / M / L )  location________________          

IA body?  Location/size:_________________________________________________________     

Plica? ( medial / supra )  Synovitis?  (mild / mod / marked)                                  

                                                                                                                                               

Menisci

Medial Tear - Location ( AH / body / PH ) ( peripheral? / inner margin?)

            Type ( horiz / oblique / vertical / bucket / radial / flap / complex )

            Parameniscal cyst? (size:_____________  location: AH / body / PH )

            Flipped fragment? ________________________________________

Lateral Tear - Location ( AH / body / PH ) ( peripheral? / inner margin?)

            Type ( horiz / oblique / vertical / bucket / radial / flap / complex )

            Parameniscal cyst? (size:_____________  location: AH / body / PH )

            Flipped fragment? ________________________________________

 

Cruciates

Anterior Tear – acute / subacute / chronic;      proximal / midsubstance / distal (avulsion?)

Posterior Tear – acute / subacute / chronic;     proximal / midsubstance / distal (avulsion?)

Ganglion (size:_________________ location: ACL / PCL )

Graft: Type: BTB / other ;        Path:  impingement / tear / part tear / degen / arthrofibrosis

 

MCL sprain  ( grade 1 / 2 / 3 )   or edema

 

LCL complex ( IT band / FCL / biceps )  Popliteus / Post-lat corner_______________________

 

Extensor mech

Tendinosis ( patellar / quad )  Tear ( partial ___% / complete ) ( patellar / quad )

Position: ( Alta / baja )  ( sublux / lat tilt )  

Bursitis ( prepatellar / pretibial )  or edema                      Hoffa’s fat ( scar / edema )

 

Cartilage

Patella (med / median ridge / lat )

(hetero signal / surface irreg / diffuse / focal: size____________________ partial / full )

Trochlea (M C L )(hetero signal / surface irreg / diffuse / focal: size____________ partial / full )

Medial comp (hetero signal / surface irreg / diffuse / focal: size________________ partial / full )

Lateral comp (hetero signal / surface irreg / diffuse / focal: size________________ partial / full )

Cysts (location:_________________) osteophytes ( PF / med comp / lat comp )

 

Marrow

Bone bruise: location __________________

Edema: location __________________   sugg etiology __________________________________

 

 

 

ANKLE ( LEFT / RIGHT )    NAME _______________________  DATE_______

 

MRI Site:______________________

                                                                  

History:___________________________ ; Prior surgery? Type:__________________

Contrast     ____none       ____IV indirect arthro(___cc)        ____IA direct arthro

 

Prior exam: date________  changes__________________________________________

 

Fluid

Effusion (joint/S/M/L:____________________________________________)

Synovitis

IA bodies (size:__________; location:________________________________)

 

Joints

OA (joints/ mild/mod/marked:______________________________________)

OCD (size:___________; location:_________________________)

Os trigonum (pseudarthrosis?)          Anterior impingement?

Coalition (subtalar / calcaneonav) (cartilagenous / fibrous / osseous)

 

Ligaments

Syndesmosis (ant / post)  (Tear / partial tear / scar)

Anterior talofibular (Tear / partial tear / scar)

Calcaneofibular (Tear / partial tear / scar)

Deltoid

Anterolateral impingement?

 

Tendons

Achilles (peritendinitis / chronic tendinosis (mild/mod/marked): mucoid/hypoxic)

                (tear: location:_________; ____% tendon inv; longitudinal / horiz)

PTT (tenosynovitis / tendinosis / tear: type:_______________________)

FDL (tenosynovitis / tendinosis / tear: type:_______________________)

FHL (tenosynovitis / tendinosis / tear: type:_______________________)

PL  (tenosynovitis / tendinosis / tear: type:_______________________)

PB  (tenosynovitis / tendinosis / tear: type:_______________________; split?)

ATT / EH / ED (tenosynovitis / tendinosis / tear: type:_______________________)

 

Bursitis (retrocalcaneal / retroAchilles)

 

Plantar fascia (fasciitis: acute/chronic; spur; marrow edema)

 

Sinus tarsi

Edema / fat replacement / ganglion

 

Marrow

AVN: location_______________________

Bone bruise: location __________________

Fracture: acute / stress; location:_________________

Edema: location __________________   sugg etiology _________________________

Osteomyelitis: location__________________; extent______________________

                (ulcer location:_____________; abscess:_______________)

 

 

 

 

 

WRIST ( LEFT / RIGHT )    NAME _______________________  DATE_______

 

MRI Site:______________________

                                                                  

History:___________________________ ; Prior surgery? Type:__________________

Contrast     ____none       ____IV indirect arthro(___cc)        ____IA direct arthro

 

Prior exam: date________  changes__________________________________________

 

Joint effusion:

 

Guyon’s canal:

 

Alignment of carpal arcs: normal vs. disrupted of …………………………..(indicate arc)

Bone marrow (patterns of stress vs. osteoarthritis vs. SLAC vs. ulno-lunate abutment)--          

describe bones involved and specific locations within individual bones

 

TFCC:             Intact vs. central thinning vs. central tear vs. peripheral tear

Ulna variance:

            Positive vs. negative vs. neutral

Scapholunate and lunotriquetral ligaments:

            Intact

            Perforation

            Torn (indicate side………………..(e.g. at scaphoid attachment)

Carpal tunnel:

Bowing of the flexor retinaculum

Tenosynovitis

Changes in caliber and signal of median nerve (describe):

………………………………………………………………………………………Space occupying lesions (describe)

……………………………………………………………………………………...

Extensor tendons:

Tenosynovitis…………………………………………………………compartment

Ganglia (mention size, anatomical relationships and joint from where they seem to arise)

 

 

 

 

 

HIP/PELVIS ( LEFT / RIGHT )    NAME _______________________  DATE_______

 

MRI Site:______________________

                                                                  

History:___________________________ ; Prior surgery? Type:__________________

Contrast     ____none       ____IV indirect arthro(___cc)        ____IA direct arthro

 

Prior exam: date________  changes__________________________________________

 

Soft tissues/organs: 

            Muscles________________________________________________

            SQ____________________________________________________

            Intrapelvic______________________________________________

            Bursitis (trochanteric / iliopsoas)

 

Joints:

Hip       Joint effusion (left - S / M / L; right - S / M / L); synovitis______

            IA bodies___________  OA (left - mild/mod/marked; right - mild/mod/marked);

            Labral tear/location________________________________________________

            Paralabral cyst/size/location__________________________________________

            AVN (left - ____% artic surface; collapse?; right - ____% artic surface; collapse?)      

 

SI joints

            OA (L / R)______ Sacroileitis (L / R)/etiology____________________________

Pubic symphysis

            Symphysitis____________etiology_____________________________________

 

Marrow:

            Mets/myeloma: location/size of lesions__________________________________

            Atypical hematopoietic marrow________________________________________

            Edema: location____________________________________________________

Ddx (e.g., stress fx, transient osteoporosis, early AVN, infection, lesion ___________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOOT ( LEFT / RIGHT )    NAME _______________________  DATE_______

 

MRI Site:______________________

                                                                  

History:___________________________ ; Prior surgery? Type:__________________

Contrast     ____none       ____IV indirect arthro(___cc)        ____IA direct arthro

 

Prior exam: date________  changes__________________________________________

 

Joints

OA/location_____________________________________________________________

synovitis/location/etiology_________________________________________________________________________________________________________________________

erosions/location__________________________________________________________

 

Sesamoids (tibial and fibular)

Fracture (T / F)

Bipartite (T / F); pseudarthrosis (T / F)

AVN (T / F)

Sesamoiditis (T / F)

Hallux valgus_____________

Other (T / F)_____________________________________________________________

 

Tendon/ligament

Lisfranc ligament (intact / edema / torn / deformity)

Plantar plate injury/location_________________________________________

Sesamoid ligs____________________________________________________

Tenosynovitis____________________________________________________

Tendon tear______________________________________________________

Plantar fascia (fasciitis, tear, mass)_______________________________________

 

Bursitis

Intermetatarsal (1st / 2nd / 3rd / 4th interspace)

Adventitial/location______________________________________________

 

Morton neuroma (1st / 2nd / 3rd / 4th interspace)

 

Muscle

Atrophy__________________________________________________

Edema/etiology____________________________________________

 

Marrow

Edema

Location / etiology_______________________________________________________

 

 

 

 

 

ELBOW ( LEFT / RIGHT )    NAME _______________________  DATE_______

 

MRI Site:______________________

                                                                  

History:___________________________ ; Prior surgery? Type:__________________

Contrast     ____none       ____IV indirect arthro(___cc)        ____IA direct arthro

 

Prior exam: date________  changes__________________________________________

 

Common flexor tendon:

            Normal

            Tendonitis (medial epicondylitis)

            Partial tear

            Full-thickness tear (…..mm)

Common extensor tendon:

            Normal

            Tendonitis (lateral epicondylitis)

            Partial tear

            Full-thickness tear (…..mm)

Biceps tendon:

            Normal

            Tendonitis

            Partial tear

            Complete tear (……mm proximal retraction)

            Bicipito-radialis bursitis

Brachialis……………………………………………………………………………..

Triceps………………………………………………………………………………..

Lateral collateral ligament (normal vs. sprained vs. torn) (specify fascicle…………)

Medial collateral ligament (normal vs. sprained vs. torn)

Cubital tunnel (changes in caliber or signal in ulnar nerve, osteophytes impinging)

………………………………………………………………………………………..

Bone marrow and cartilage (subchondral edema, osteophyte formation)

 

 

 

 

 

 

MISCELLANEOUS ( LEFT / RIGHT )    NAME ____________________________  BODY PART_____________________________________________DATE_______

 

MRI Site:______________________

                                                                  

History:___________________________ ; Prior surgery? Type:__________________

Contrast     ____none           ____IV gad (_____cc)

 

Prior exam: date________  changes__________________________________________

 

MASS              Location:

 

Size:                                         Signal characteristics:

 

Morphology:

 

Margins:

 

Neurovascular bundle involvement?

 

DDX:_________________________________________________________________________

 

 

RSD

 

Skin thickening: (none / R / L / both)      location________________________       

 

Skin enhancement:                                 Periarticular enhancement:

 

SQ edema:                                            Joint effusion / synovitis:

 

Muscle atrophy

 

RSD stage:_______

 

Other findings:__________________________________________________________________

 

 

INFECTION

 

Cellulitis location/extent:

 

Devitalization / necrosis:

 

Abscess size/location:

 

Ulceration:                                                        Sinus tract:

 

Osteomyelitis location/extent: