1/9/2013

Imaging anterior cruciate ligament tear helpful tips

James F Griffith

Anatomy ACL
AM PL

Anterior tibia lateral femoral condyle Anteromedial and posterolateral bundles Intermediate bundle
Department of Imaging and Interventional Oncology The Chinese University of Hong Kong Prince of Wales Hospital

Encased in synovial envelope Intra-articular but extra-synovial in location Limited blood supply from medial geniculate a.

Anatomy
Bundles act synergistically to prevent anterior tibial translation in flexion and extension Contributes to screw home movement. Femur rotates medially at end of extension

Normal ACL obl sagittal plane

450

Oldrini GetalSkel Radiol 2012

Normal ACL coronal & axial plane

Normal ACL oblique coronal plane

LFC

* *

LFC C
LFC

HongSHetalJCompTom2003

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Normal ACL oblique axial plane

Oblique axial imaging ACL

MFC

anteromedial

anteromedial

posterolateral

posterolateral

LTC

Tibial insertion

NgAWetalSkel Radiol 2011

NgAW,GriffithJFetalSkel Radiol 2011

Oblique axial imaging ACL

LFC
anteromedial

Oblique axial imaging ACL

LFC
anteromedial

anteromedial

anteromedial

posterolateral

posterolateral posterolateral

LTC

posterolateral

Mid-substance

Femoral attachment

NgAW,GriffithJFetalSkel Radiol 2011

NgAW,GriffithJFetalSkel Radiol 2011

Oblique axial intermediate bundle

ACL tear
Most commonly torn ligament in the knee Typical mechanism : knee rotation with ankle flexed Only a few fibres complete tear Majority (~85%) are complete tears Usually occur close to femoral attachment

NgAWetalSkel Radiol 2011

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Clinical tests
Anterior drawer Lachmann Pivot shift

ACL tear complete

Anterior drawer / Lachmann test anterior instability Pivot shift tests anterolateral instability Pivot shift best most reliable indicator of ACL injury
Oedematous mass Discontinuity Mal-alignment

ACL tear complete

Anterior translation

>5mm

Mal-alignment with re-attachment

Mal-alignment with attenuation

Complete attrition

Do mention in report as is associated with clinical instability

NgA,GriffithJFetalClin Imaging2012

MRI imaging scenarios

Unequivocal ACL tear stop

Knee flexion

Probable complete tear i.e. there is a severe t tear but b t is i it complete l t flexion fl i view i

Probable partial tear i.e. there may be a tear but how bad is it oblique axial view

Extension

Extension

Flexion

Anterior synovial thickening

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Knee flexion

Knee flexion

Extension

Flexion

Extension

Flexion

Complete ACL tear

High grade partial ACL tear

Partial ACL tear

<15% of all ACL tears. One bundle or both bundles to variable degree. May heal or may progress Full assessment difficult at arthroscopy. Recognition g and q quantification on MRI relevant High grade (>50%) functionally unstable Low grade (<50%) functionally stable Single bundle rather than complete graft reconstruction with biomechanical, vascular, and proprioceptive advantages

Partial ACL tear

Extension

Flexion

Arthroscopy confirmed complete PL bundle tear

Suspected ACL tear

Partial tear ACL oblique axial view

Low grade partial tear, PL > AM

NgAW,GriffithJFetalSkel Radiol 2012

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Partial ACL tear oblique axial view

ACL avulsion fracture

Partial AM with complete PL

NgAW,GriffithJFetalSkel Radiol 2012

ACL avulsion fracture very variable

ACL avulsion fracture

GriffithJFetal,Arthroscopy2002

Mucoid degeneration & ganglion cyst

Conclusion
ACL = still not an uncommon cause of contention

Mucoid degenn

Mucoid degenn

Ganglion cyst

If unsure about complete ACL tear flexion view If unsure about partial ACL tear axial oblique view

Preservation of linear striations Celery stick sign Frequently with mucoid degeneration PCL

Thank you!