Don’t Stress about your fractures! Have you tried VIBE-MRI?

VIBE-MRI is a promising tool for the diagnosis of MSK injuries in radiation-sensitive athletes

Keywords: VIBE-MRI, musculoskeletal injuries, radiation exposure

Volumetric interpolated breath-hold examination (VIBE) is an MRI sequence that is increasingly being used by Sports and Exercise Medicine (SEM) clinicians, to evaluate sports injuries in radiation-sensitive populations (1). It offers the promise of evaluating osseous lesions and soft tissue injuries where time, patient comfort and early diagnoses are key to rehabilitation. This blog discusses how VIBE-MRI can be considered to help diagnose sports injuries in adult and adolescent athletes. 

What makes VIBE-MRI different?

VIBE sequence MRI is a relatively new technique that was first developed in 1999. It has the benefit of being fast – producing high resolution images in under 30 seconds, when traditional sequences can take up to 30 minutes. Recently, it has been adapted for the diagnosis of MSK injuries, where reducing ionising radiation exposure and early diagnosis, can help to inform rehabilitation in young athletes. 

Modality Typical effective doses (MsV) Equivalent period of natural background radiation 
CT Head 2 1 year
CT Abdomen / Pelvis 10 4.5 years
Lumbar X-Ray 1.3 7 months
Limbs & Joints X-Ray (except hip) <0.01 <1.5 days
Hip X-Ray 0.3 7 weeks
VIBE MRI 0 0

Table 1: Radiation exposure of common MSK imaging modalities (2)

*2.2 MsV per year = Average natural background radiation in the United Kingdom

VIBE-MRI has the following additional benefits over standard MRI:

  • High cortical resolution enables the identification of intracortical bone pathologies/fractures. 
  • Avoids the need of duplicate/additional scans, such as CT.
  • Obtain high quality, multiplanar and 3D reconstruction images.
  • Rapid scanning time – minimises discomfort in athletes with significant pain following an injury or those that have claustrophobia.

VIBE-MRI – Avoid the need for duplicate imaging.

  • MRI scans have traditionally been more expensive than CT, however, the costs are decreasing.
  • VIBE-MRI can also negate the need for duplicate imaging (MRI followed by CT). This is by providing soft tissue definition and images to detect fractures or osseous lesions in a single scan, where appropriate.

Figure 1: Infographic summarising VIBE-MRI

The following images show typical findings on Standard MRI Sequences:

Figure 2: Pars Fracture. 

Sagittal T2 weighted image of the lumbar spine. Red arrow indicates a pars defect at L5/S1. There is also some grade 1 anterolisthesis.

Figure 3: Osteitis Pubis

Axial STIR image of the pelvis. Red arrow shows the bone marrow oedema present at the pubic symphysis. Green arrow shows the adductor muscle oedema.

Figure 4: Osteitis Pubis 

Coronal STIR image of the pelvis. Red arrow shows the bone marrow oedema present at the pubic symphysis. Green arrow shows the adductor muscle oedema.

Figure 5: Medial Tibial Stress Syndrome. 

Axial STIR sequences of the tibia and fibula. There’s an increased fluid signal adjacent to the tibia, as shown by the red arrow.  This scan shows a slightly atypical appearance, as the oedema is advancing to the posterior aspect of the tibia.

Injury Type Findings
Pars Fracture
  • Assessed with sagittal views at the level of the pedicles.
  • Look for a low signal intensity (fracture line) transversing the pedicle. (Craniocaudal orientation)
  • Anterolisthesis, secondary to a pars defect, may also be seen by assessing alignment of the end plates.
Osteitis Pubis
  • Assessed best with axial/coronal views (T2 fat saturation sequence/STIR sequences) 
  • An increased signal at the pubic symphysis (medial aspect of the inferior and superior pubic rami) indicates fluid/oedema.
  • Cystic change and sclerosis may also be seen here.
Medial Tibial Stress Syndrome
  • Can be assessed using the Fredericson criteria for low grade stress responses (periosteal/bone marrow oedema).
  • Grade 4a/4b lesions should be visible when assessing for stress fractures on VIBE sequence images. 
Bankart Lesion
  • Sagittal views, at the level of the glenoid, are optimal to visualise a Bankart fracture (seen as a linear low signal fracture line).
  • Bony Bankart lesions are also well visualised with VIBE sequence MRI.

 

Table 2: Typical findings on VIBE-MRI Sequences.

How does VIBE-MRI measure up to other imaging modalities?

In the world of elite sport and adolescent injuries, SEM clinicians are increasingly using VIBE-MRI to diagnose injuries. These sequences show good diagnostic accuracy for certain MSK injuries and can help provide key information to plan further interventions and rehabilitation.

Injury Standard MRI3 VIBE-MRI4
Sensitivity Specificity Sensitivity Specificity
Pars Fracture 81 99 97.7 92.3

 

Injury CT Arthrography5 VIBE-MR Arthrography6
Sensitivity Specificity Sensitivity Specificity
Bankart Lesion 89.4 96.4 95.7–100 93.9–97.0
Glenoid Bone Loss 100 100 95 93.8

 

Injury Ultrasound7 VIBE-MR Arthrography8
Sensitivity Specificity Sensitivity Specificity
Rotator Cuff Tears

Full Thickness

Partial Thickness 

 

91

68

 

93

94

 

92

55->92

 

>92

92-94

 

Injury CT arthrography9 VIBE-MRI9
Sensitivity Specificity Sensitivity Specificity
Elbow Loose Bodies

Anterior

Posterior

Either/Both

 

64-91

92-100

88-100

 

33-67

54-69

20-70

 

46-91

92-100

88-100

 

13-73

15-77

20-60

Table 3: VIBE-MRI compared to other imaging modalities.

Figure 5: Infographic summarising when a VIBE MRI scan may be appropriate for sport-related injuries.

In conclusion, how can SEM clinicians utilise VIBE-MRI?

  • VIBE-MRI produces fast sequence images, with good sensitivity for the detection of common sports-related, bone and soft tissue injuries.
  • VIBE-MRI scans can help inform early diagnosis and management, reducing time lost to injury and enabling appropriate return to sport timelines.10 This is key for radiation-sensitive populations (adolescent and young adults).
  • VIBE-MRI can prevent the need for dual scanning, using both CT and MRI, in complex soft tissue pathologies.
  • Further studies are needed to evaluate the sensitivities and specificities of VIBE-MRI in a wider range of sports-related injuries. This could help to inform how and when VIBE-MRI scans can be used as the first line in injury management pathways. 

 

Authors and Affiliations:

Mr Rifat Hassan, Dr Irfan Ahmed, Dr Haseeb Rehman, Dr Imran Lasker 

No competing interest

No relevant disclosures

 

Rifat Hassan 

Final Year Medical Student 

University of Southampton

Twitter @RifatHassan_

 

Dr Irfan Ahmed 

Sports and Exercise Medicine Consultant 

Connect Health, United Kingdom

Twitter @Exerciseirfan

 

Dr Haseeb Rehman 

Junior Doctor

York Hospital

Twitter @Haseeb2502

 

Dr Imran Lasker

Consultant Radiologist with Specialist interest in MSK

Employer: Mid and South Essex Foundation Trust

Twitter @DocLasker

Link to MSK/MRI courses: imranlasker.comradiologyseminars.comemergencyimaging.co.uk

References

  1. Koh E, Walton ERJ, Watson P. VIBE MRI: an alternative to CT in the imaging of sports-related osseous pathology? The British Journal of Radiology [Internet]. 2018 [cited 2022 Aug 4];91(1088). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6209485/
  2. Public Health England. Patient Dose information: guidance [Internet]. 2008 [cited 2022 Oct 22]. Available from: https://www.gov.uk/government/publications/medical-radiation-patient-doses/patient-dose-information-guidance
  3. Dhouib A, Tabard-Fougere A, Hanquinet S, Dayer R. Diagnostic accuracy of MR imaging for direct visualization of lumbar pars defect in children and young adults: a systematic review and meta-analysis. European Spine Journal [Internet]. 2018 May 1 [cited 2022 Sep 10];27(5):1058–66. Available from: https://link.springer.com/article/10.1007/s00586-017-5305-2
  4. Ang EC, Robertson AF, Malara FA, O’Shea T, Roebert JK, Schneider ME, et al. Diagnostic accuracy of 3-T magnetic resonance imaging with 3D T1 VIBE versus computer tomography in pars stress fracture of the lumbar spine. Skeletal radiology [Internet]. 2016 Nov 1 [cited 2022 Aug 4];45(11):1533–40. Available from: https://pubmed.ncbi.nlm.nih.gov/27614965/
  5. Khedr SA, Kassem HM, Azab MA. Comparative study of direct MR arthrography and CT arthrography with arthroscopic correlation in preoperative evaluation of anterior shoulder instability. Egyptian Journal of Radiology and Nuclear Medicine [Internet]. 2013 [cited 2022 Sep 11];44(4):817–27. Available from: https://www.sciencedirect.com/science/article/pii/S0378603X13000831?via%3Dihub
  6. Tian CY, Shang Y, Zheng ZZ. Glenoid bone lesions: Comparison between 3D VIBE images in MR arthrography and nonarthrographic MSCT. Journal of Magnetic Resonance Imaging [Internet]. 2012 Jul 1 [cited 2022 Sep 11];36(1):231–6. Available from: https://onlinelibrary.wiley.com/doi/full/10.1002/jmri.23622
  7. Roy JS, BraÃn C, Leblond J, Desmeules F, Dionne CE, MacDermid JC, et al. Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterisation of rotator cuff disorders: A systematic review and meta-analysis [Internet]. Vol. 49, British Journal of Sports Medicine. 2015. p. 1316–28. Available from: http://dx.doi.org/10.1136/bjsports-2014-094148
  8. Vandevenne JE, Vanhoenacker F, John JMM, Gelin G, Parizel PM. Fast MR arthrography using VIBE sequences to evaluate the rotator cuff. Skeletal Radiology [Internet]. 2009 Jul 18 [cited 2022 Aug 7];38(7):669–74. Available from: https://link.springer.com/article/10.1007/s00256-009-0677-y
  9. Dubberley JH, Faber KJ, Patterson SD, Garvin G, Bennett J, Romano W, et al. The detection of loose bodies in the elbow. The value of MRI and CT arthrography. Journal of Bone and Joint Surgery – Series B [Internet]. 2005 [cited 2022 Aug 24];87(5):684–6. Available from: https://online.boneandjoint.org.uk/doi/full/10.1302/0301-620X.87B5.14851
  10. Beech M, Nagra NS, Wedatilake T, Kluzek S. Symptomatic stress reaction of the humerus in a professional cricketer. BMJ Case Reports [Internet]. 2019 Sep 1 [cited 2022 Aug 4];12(9):e227088. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6754635/

 

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