Age / Sex : 55 / M

Chief complaint: Right lateral elbow pain during extension

What is your impression?

Two weeks later, you can see the final diagnosis with a brief discussion of this case.

(Please submit only one answer)

Courtesy: Seon Jeong Kim, Myongji Hospital, Seonam

University College of Medicine

Synovial fringe (plica or fold) syndrome (posterolateral impingement)

Discussion

Findings:

Triangular shape dark signal intensity lesion in the radiocapitellar joint

-size: 9.9x7.5x3.2mm (AP x W x H)

Differential Diagnosis:

Loose body

Diagnosis:  

Synovial fringe (plica or fold) syndrome (posterolateral impingement)

Discussion:

Synovial plicae are folds of synovial tissue, remnants of embryonic septa of the normal articular

development. Plicae have no known function and are usually asymptomatic. Plicae may cause clinical symptoms in the elbow joint, especially when they become hypertrophied or inflamed.

Elbow synovial fold syndrome can be clinically confused with epicondylitis, frequently delaying appropriate diagnosis.

Imaging findings

n  Ultrasound

•       Normal synovial fold : hypoechoic triangular shaped structure surrounded by a thin hypoechoic ring

•       Pathologic synovial folds : thickened, irregular echogenicity and margins

n  MRI

•       Hypointense bands surrounded by synovial fluid

•       3mm or 2.6mm cutoff for thickened versus normal folds

•       Nodular or irregular appearance (not specific, can be seen in both symptomatic and asymptomatic patients)

•       Existence of focal posterolateral synovitis and chondromalacia in the anterolateral aspect of radial head, capitellum

•       T1CE : detection of associated synovitis

•       MR Arthrography : excellent visualization of plicae

References:

1.     Awaya H, Schweitzer ME, Feng SA et al. Elbow synovial fold syndrome : MR imaging findings. AJR Am J Roentgenol. 2001;177 (6): 1377-81.

2.     Cerezal L, Rodriguez-Sammartino M, Canga A et al. Elbow synovial fold syndrome. AJR Am J Roentgenol. 2013;201 (1): W788-96.

3.     Ruiz de Luzuriaga BC1, Helms CA, Kosinski AS, Vinson EN. Elbow MR imaging findings in patients with synovial fringe Syndrome Skeletal Radiol 2013; 42:675–680.