Paediatric musculoskeletal MRI
RAD Magazine, 42, 489, 24-25 ening of the echo time, there is an increase in the signal
Dr Saira Haque
Consultant paediatric radiologist
Dr David Elias
Consultant radiologist
King’s College Hospital NHS Foundation Trust, London
Introduction
This review will highlight practical aspects of
paediatric musculoskeletal MR imaging.
Awareness of age-specific adaptations in MR
imaging technique, including coil selection and
field of view, is essential. Fat suppression and
intravenous contrast media administration fur-
ther aids the detection of abnormalities. Changes
in vascularity, marrow and cartilage of the pae-
diatric population influence the imaging appear-
ances of developmental disorders, infection,
rheumatic diseases, avascular necrosis, tumours
and soft tissue masses.
Normal MR appearances
Bone marrow
At birth, the majority of marrow is hematopoietically active
(red) marrow. It tends towards slightly higher or equal sig-
nal to muscle on both T1- and T2-weighted sequences.
Haematopoietic marrow is highly vascularised and its signal
increases following intravenous contrast. Fatty (yellow) mar-
row demonstrates signal characteristics similar to fat and
appears hyperintense on T1-weighted sequences and
hypointense on T2-weighted sequences.
Marrow conversion from haematopoietic to fatty marrow
begins in the first year of life.1 It begins in the appendicular
skeleton and proceeds in a centripetal manner from the
periphery (fingers and toes) to the centre (humeri and
femora). The epiphyses convert first, followed by the diaph-
ysis and then the metaphyses; the last parts to convert are
the proximal humeral and femoral metaphyses.
Conversion of the axial skeleton occurs at a slower rate.
Haematopoietic marrow persists throughout adolescence in
the vertebrae, thorax and pelvis. A combination of
haematopoietic and fatty marrow is present in the spine
beyond infancy with progressive increase in fatty marrow
with age. On T1-weighted images, the vertebral bodies
appear hypointense relative to the intervertebral disc before
one year of age, isointense between one and five years, and
hyperintense after five years.
It is normal to have foci of residual metaphyseal
haematopoietic marrow that have a flame shaped appear-
ance, located at the base of the physis. These foci should
demonstrate increased signal relative to muscle on T1-
weighted images. Patchy T2 hyperintense and T1
hypointense marrow signal of the tarsal bones is also a nor-
mal finding in the immature skeleton. This is often accen-
tuated by altered weight bearing following trauma.
Cartilage
Hyaline cartilage demonstrates intermediate signal on T1-
weighted images.2,3 The signal intensity of the epiphyseal
cartilage is low, and can be differentiated from the higher
signal of the physeal cartilage on T2-weighted images and
short tau inversion recovery (STIR) images.
On proton density (PD) images, with progressive short-
from the epiphyseal cartilage with a subsequent reduction
in contrast between epiphyseal and physeal cartilage. On
gradient recalled echo (GRE) imaging, all forms of hyaline
cartilage demonstrate intermediate or high signal.
The physis is located between the epiphysis and metaph-
ysis and is the essential mechanism of endochondral ossifi-
cation. It is of intermediate signal on T1-weighted images
and high signal on other pulse sequences. In very young
children, the physis is flat and smooth, but with growth its
contour begins to undulate. It should have uniform thickness
and the physis becomes thinner and eventually fuses with
advancing skeletal maturation. A thin low signal band, rep-
resenting the zone of provisional calcification, can be seen
parallel to the metaphyseal side of the physis on all pulse
sequences.
Imaging protocol
Overview
Paediatric MSK MR imaging can be generally divided into:
(a) sport related injuries, predominantly standardised stud-
ies, and (b) suspected tumour, inflammatory or infectious
pathology, which are usually tailored to a specific clinical
question and closely supervised by a radiologist to determine
if the field of view (FOV) is adequate and whether contrast
is necessary.
The protocol should contain sequences which (a) identify
normal anatomy and (b) identify abnormal fluid, bone mar-
row oedema or enhancement. It should include T1- or PD-
weighted sequences to evaluate cartilage, internal
derangement and bone marrow, tailored to the body part
being imaged. A susceptibility sequence should be considered
to evaluate for blood products.
Correct positioning of the child is imperative, especially
when imaging small body parts. The study should be per-
formed as quickly as possible before the child starts moving.
Useful adjuncts to make the child comfortable include Velcro
restraints and pillows. Even if a child is sedated or under
general anaesthetic, the patient should be scanned quickly
as these procedures carry their own risks.
The size of the anatomic structures under consideration
and the suspected pathology determine the necessary FOV.
If the FOV is large, signal-to-noise ratio (SNR) will be
higher. A small FOV leads to increased noise, which
degrades image quality, and prevents complete coverage of
the anatomical part. A large FOV can lead to a reduction
in spatial resolution. Small surface coils have a high sensi-
tivity and see a smaller noise volume, yielding relatively
high SNR. However, the imaging coil should be large enough
to include the region of interest.
Pulse sequences
The PD sequence is often the most useful because of its high
SNR which depicts ligamentous and meniscal derangements.
Fast/turbo spin-echo PD imaging can provide similar infor-
mation to conventional spin-echo imaging in less time.
However, this can lead to blurry images and reduce the sen-
sitivity of detecting meniscal injuries and subtle articular
cartilage injuries.
T1-weighted images have the greatest specificity for mar-
row disorders. These images are also useful for detecting
fractures which appear as low signal. Tumour margins are
also clearly delineated on these sequences. Internal T1 het-
erogeneity or septations in a soft tissue lesion suggest fur-
ther evaluation with contrast enhancement is warranted.
T1-weighted images can be obtained using spin echo,
fast/turbo spin echo or GRE. The spin echo sequences delin-
eate fat better than GRE sequences.
GRE sequences are particularly effective in assessing car-
tilage due to their ability to obtain thin sections. Cartilage
is well delineated, with high signal intensity, on fat-sup- giomas, lymphatic malformations, lipomas, haematomas,
pressed T1-weighted GRE images. Fat suppression elimi- periarticular cysts, benign neural tumours and abscesses.
nates chemical shift artifact that can distort the MR imaging is particularly useful in clearly delineating the
cartilage-bone interface. It also narrows the greyscale range lesions for surgical planning and defining the extent of soft
and provides greater contrast. T1-weighted GRE images pro- tissue masses (figure 4). It also determines involvement of
vide poor detail of ligaments and menisci. MR is the imaging the neurovascular bundle and invasion of adjacent joints or
method of choice for evaluation of premature closure of the bones.
epiphyseal plate. Definition of bone bridges across the physis
can be obtained with 3D modelling with the GRE images. Trauma
The major disadvantage is the relatively long acquisition MR is not performed in the acute setting. It is useful in
time. assessing ligamentous disruption, meniscal injury, growth
Fat suppressed fast/turbo spin-echo T2-weighted imaging plate injury and bone marrow oedema. It should always be
and STIR are the most commonly used water sensitive performed after radiographic assessment as an avulsion
sequences. The fat suppression possible by STIR is generally injury is more likely than a ligamentous injury in the pae-
uniform and relatively independent of magnetic field inho- diatric population. MR is useful to assess the physis (figure
mogeneities. It is useful in obtaining a large FOV. This is 5) in order to identify subtle cartilaginous injuries. There is
often necessary in young children who are unable to clearly a high incidence of growth arrest in the distal femoral (40%)
localise musculoskeletal symptoms. Fat suppressed fast/turbo and distal tibial physeal fractures (20%) in the paediatric
T2-weighted imaging allows greater slice acquisition com- population.
pared to the STIR sequence in a similar timeframe. STIR
should not be used as a fat suppression technique post con- Summary
trast. STIR only suppresses tissues with T1 values in the MR imaging has improved diagnostic accuracy of muscu-
range of fat (200-300ms). Tissues enhancing following con- loskeletal disorders. The superficial nature of musculoskele-
trast with similar relaxation times will also be suppressed. tal structures in children is ideal for the application of
localised radiofrequency coils with improved SNR and spatial
Overview of common pathologies resolution. MRI of the musculoskeletal system is ensured of
Infection a significant role in the paediatric population, which will
An early feature of acute osteomyelitis is bone marrow continue to evolve in the future with the development of
oedema, best depicted on fluid sensitive sequences. It is dif- new sequences and contrast agents.
ficult to differentiate reactive bone marrow oedema of septic References
arthritis from associated osteomyelitis. The use of gadolin-
1, Laor et al. MR imaging insights into skeletal maturation: What is normal?
ium in children is useful in the identification of an associ- Radiology. 2009;250(1):28-38.
ated abscess. Synovial enhancement and joint effusions have 2, Jaramillo et al. Pediatric musculoskeletal MRI: Basic principles to optimize
the highest correlation with the clinical diagnosis of a septic success. Pediatr Radiol 2008;38:379-91.
joint (figure 1). Dynamic contrast enhanced MR may sepa- 3, Shapiro et al. Advances in musculoskeletal MRI – technical considerations.
J Magn Reson Imaging 2012;36(4):775-87.
rate the fast enhancing synovium from the slower enhancing 4, Bhargava et al. Contrast-enhanced magnetic resonance imaging in pedi-
fluid.4 atric patients: Review and recommendations for current practice. Magn
Reson Insights 2013;6:95-111.
Juvenile idiopathic arthritis
T1-weighted images are used to assess bone marrow and
erosions. Water sensitive sequences are used to evaluate
joint and tenosynovial fluid, cartilage, marrow oedema and
tendons (figure 2). The use of gadolinium is essential for
distinguishing active synovial inflammation from non-
enhancing joint effusions or fibrotic pannus. Normal
synovium demonstrates minimal enhancement. Contrast-
enhanced fat suppressed T1-weighted images should be
obtained within 10 minutes of injection; diffusion of contrast
material into the joint after 10 minutes limits differentiation
between enhancing synovium and adjacent joint fluid.
Avascular necrosis (AVN)
Numerous studies have demonstrated that MR imaging is
highly sensitive, specific and accurate in the detection of
avascular necrosis. It most often presents with a crescentic
band of low signal in the subchondral bone marrow on
T1-weighted images. This band is thought to represent the
reactive interface between the necrotic and reparative zones;
it typically extends to the subchondral plate.
The ‘double-line sign’ on T2-weighted images is considered
highly specific for AVN. With prolonged ischaemia, the
necrotic bone demonstrates low signal intensity on T1-
weighted images and high signal intensity on T2-weighted
images. Finally, when fibrosis and sclerosis of the involved
bone occurs, it demonstrates low signal intensity on both
T1- and T2-weighted images (figure 3).
Soft tissue lesions
The role of MR imaging in the characterisation of soft tissue
tumours remains limited. Characterisation of lesions with
MR is feasible in the typical manifestations of some pseudo-
tumours and benign neoplastic lesions, such as haeman-
 A B C

Figures 1A-C
This 18-month-old child presented with left knee swelling and pain associated with a fever. (A) Coronal
STIR image shows periosteal oedema tracking around the lower femoral diametaphysis. (B) Sagittal T1 and
(C) axial T1 post-contrast images with fat saturation show a moderate joint effusion with peripheral rim
enhancement and a subperiosteal collection tracking around the lower femoral diametaphysis, predomi-
nantly medially. The final diagnosis was septic arthritis requiring antibiotic treatment and synovial fluid
drainage.

A B C

Figures 2A-C
(A) Sagittal proton density image with fat saturation demonstrates several erosions in this 10-year-old
patient with localised pain. The largest erosion is at the inferior aspect of the talus. Normal synovium is at
most 2mm thick and is hypointense on T1 and T2. Abnormal synovium appears as a thick, irregular wavy
layer that is hypo/isointense on T1 and hyperintense on T2. (B) Coronal T1 and (C) axial T2 images demon-
strate synovial proliferation surrounding the talus consistent with juvenile idiopathic arthritis.

A B C

Figures 3A-C
This 11-year-old patient needed bone marrow transplantation for acute lymphoblastic leukaemia. High
dose methylprednisolone was given. (A) Sagittal proton density image demonstrates a moderate joint effu-
sion and bone infarcts in both femoral condyles. (B) Coronal T1 image shows a subchondral fracture of the
lateral femoral condyle with collapse of the subchondral bone. These features are established and sec-
ondary to avascular necrosis. (C) Proton density coronal image shows cartilaginous thinning in the mid-
portion of the lateral femoral condyle.
A B Figures 4A-B
This six-year-old patient pre-
sented with unilateral painless
enlargement of the third digit of
the hand. (A) Coronal T1 and (B)
sagittal T1 with fat saturation
demonstrates accumulation of fat
in the subcutaneous tissues
without a discernable capsule.
The patient was diagnosed with
macrodystrophia lipomatosa and
MRI was helpful in differentiating
from other causes of macro-
dactyly in this case.

A B C

D Figures 5A-D
This adolescent presented with acute pain after a fall with forced
external rotation. (A) Lateral plain radiograph demonstrates a tripla-
nar fracture of the distal tibia with a vertical fracture through the
epiphysis, horizontal fracture through the physis and oblique fracture
through the metaphysis. (B) Sagittal proton density image with fat
saturation and (C) coronal T1 demonstrate the fracture. MRI was use-
ful to exclude displaced chondral fragments. (D) shows disruption of
the anterior talofibular ligament on the axial proton density image.