Anatomy

Image Evaluation
Fractures and Pathology
Pitfalls and Variants
Images
Case Study



Made up of 3 bones - femur,
the tibia and the patella
2 ligaments - medial and
lateral collateral ligaments,
(stabilize the knee from side-
to-side), ACL and PCL
(stabilize the knee from front-
to-back)
AP Knee
Lateral Knee
Skyline View
Source: Wikiradiography
Ligament Origin Insertion Function
Medial Collateral
Ligament (MCL)
Medial Epicondyle
of Femur
Superior Tibia
The MCL protects the medial
side from a valgus force.
Lateral Collateral
Ligament (LCL)
Lateral Epicondyle
of Femur
Head of Fibula
The LCL protects the lateral
side from a varus force
Anterior Cruciate
Ligament (ACL)
Lateral Condyle of
Femur
Tibia Plateau (anterior
intercondylar area)
The ACL prevents anterior
displacement of the tibia
relative to the femur.
Posterior Cruciate
Ligament (PCL)
Medial Condyle of
Femur
Tibia Plateau (posterior
intercondylar area)
The PCL prevents posterior
displacment of the tibia
relative to the femur.
Arcuate Ligament
Lateral Epicondyle &
Condyle of Femur
Medial Fibular head
Strengthens the joint capsule
posteriorlaterally.
Oblique Popliteal
Ligament
Medial Tibial
Condyle
Lateral Femoral Condlye
A recurrent expansion of the
tendon of the
semimembranosus that
reinforces the joint capsule
posteriorly.
Patellar Ligament Apex of the Patella Tibial Tuberosity
A very strong, thick fibrous
band that helps maintain
alignment of the patella and
the way it articulates on the
surface of the femur.
A bursa is a fluid-filled structure that is present between
the skin and tendon or tendon and bone to reduce
friction between adjacent moving structures.
Methode 1:
The lateral
condylopatellar
sulcus(arrowed) @ lateral
femoral notch,
distinguishes the lateral
femoral condyle from the
medial femoral condyle.
Methode 2:
The most reliable method
for identifying the medial
condyle is to locate the
rounded bony tubercle
(black arrow) known as
the adductor tubercle.

On AP, a
perpendicular line
drawn at the most
lateral margin of
femoral condyle
should not have
more than 5 mm of
the lateral margin of
tibia condyle outside
of it
>5mm
Tibia plateau
fracture
1. Lateral split.
2. Split with depression.
3. Pure lateral depression.
4. Pure medial depression.
5. Bicondylar.
6. Split extends to
metadiaphyseal region


The patellar tilt angle is
formed by a line drawn
across the anterior limits of
the femoral condyle and a
line connecting the apex of
the patellar articular surface
(lateral)
+ve angle = normal
0
0
or ve angle = abnormal
- PL = length of the
patella
- TL = length of the
patellar tendon
patella alta : > 1.2
(>1.5)
patella baja : < 0.8
(<0.74

Alta Baja
Alternative to Insall-Salvati ratio
A horizontal line at the level of the tibial
plateau is drawn. Perpendicular to this
line vertically and a measurement (B)
made of the distance between the
horizontal line and the inferior aspect of
the patellar articular surface. A second
measurement (A) is made along the
patellar articular surface.
B/A is a measure of patellar height
Normal value = ratio of 0.8.
Patella alta = ratio >1.0
Identified by
significant patella alta
blurring of the posterior
margin of the patellar
tendon in to Hoffas fat
pad
presence of an avulsion
fracture
This patient has had an unknown injury to the knee causing
rupture of the quadriceps femoris tendon.
Note the unusual low position and forward tilting of the patella.
The quadriceps tendon which is usually visualised contrasted
by the suprapatellar fat body is not demonstrated(arrow)
Lines drawn along the lateral patellar facet and the
anterior margins of the femoral trochlea.
The lateral patellofemoral angle should be open laterally.
Measured by the difference between the angles formed by the
bisector of the sulcus angle (T0) and a line from the apex of the
sulcus angle to the central ridge (TR).
The more lateral the angle, the greater the malalignment.
Line BD should be equal or medial to the bisector line BD.
If it is lateral (as in this case), patellar subluxation can be
confirmed.
Yellow = Hoffa's fat pad
[largest]

Blue = Posterior
suprapatellar fat pad

Red = Anterior
suprapatellar fat pad
If suprapatellar
pouch (bursa)
> 5mm joint
effusion
Normal appearance
Appears as well-defined rounded homogeneous soft tissue density
within the suprapatella recess.
Will displace the quadraceps tendon and patella anteriorly.
Can result from inflammation, infection or trauma and may be an
exudate, transudate, blood or fat.
A particular type of effusion that occurs in
intra-articular fracture.
A fat-fluid level is seen due to marrow fat
leaking into the joint space via the fracture.
There is no evidence of knee joint effusion.
Hoffa's fat pad appears normal.
There is no evidence of fracture or dislocation.
The swelling corresponds with the pre-patellar bursa.
(a) Transverse (usually in
central or distal third of
the patella)
(b) Vertical
(c) Marginal
(d) Comminuted
(e) Osteochondral
(f) Sleeve

Transverse fracture
Vertical fracture
Marginal fracture
fracture of edge of the
patella, do not extend across
patella
Comminuted fracture
Osteochondral fracture:
An immediate fracture around the point of contact, separating a single
fragment that includes articular cartilage, subchondral bone, and
supporting trabecular bone.
Sleeve fracture
Chondral or osteochondral avulsion injury at the inferior pole of the patella.
Occur in the pediatric population, typically between 8 - 12 years old.
Result from sudden and forceful contraction of quadriceps.
(A)An avulsion fracture between ligament and bone and
(B) An osteochondral fracture between the articular cartilages;
(C)Following patellar relocation, the osteochondral fragment
resulting from the fracture is located between the lateral facet of
the patella and the lateral femoral condyle.

- Fracture at the superior pole of the patella
May involve one or both condyles.
Usually associated with high impaction.
Usually associated soft tissue injury due to disruption
of ligamentous attachments.
Mechanism of injury: axial loading with varus/
valgus force

Type A: extra-articular fracture
Type B: partial articular fracture
Type C: complete articular fracture
Often associates with soft tissue injury
Caused by varus/valgus load with/without axial
load
Frequency :
lateral (60%)> bicondylar (25%)> medial(15%)
Partial or complete ligamentous ruptures occur in
about 15-45% & meniscal lesions in about 5-37% of
all tibia plateau fracture.
http://www.wheelessonline.com/ortho/tibial_plateau_fractures
1. Lateral split.
2. Split with depression.
3. Pure lateral
depression.
4. Pure medial
depression.
5. Bicondylar.
6. Split extends to
metadiaphyseal region


60% of plateau fracture
involve lateral plateau.
This probably is result of
valgus alignment of lower
extremity and fact that
most injuring forces are
directed laterally to
medially.
Segond fracture
Reverse Segond fracture
Anterior cruciate ligament avulsion fracture
Posterior cruciate ligament avulsion fracture
Arcuate complex avulsion fracture
Biceps femoris avulsion fracture
Pellegrini Stieda disease (MCL tear)


http://radiopaedia.org/articles/avulsion-fractures-of-the-knee
Avulsion fracture of the
lateral tibial plateau
75% associated with
disruption of ACL
Occurs as a result of internal
rotation and varus stress
http://radiopaedia.org/articles/segond-fracture
Involves a fragment similar to that of the Segond
fracture except that it is located on the medial
aspect of the proximal tibia.
Represents an avulsion of the deep capsular
component of the medial collateral ligament
Mechanism of injury: external rotation and a valgus
stress applied to the knee

http://radiopaedia.org/cases/diagram-classification-of-acl-avulsion-fractures-1
Type 1 - minimally/non-
displaced fragment
Type 2 - anterior
elevation of the fragment
Type 3 - complete
separation of the
fragment. 3b - Involves
the majority of the
eminence.
Type 4 - comminuted
avulsion or a rotation of
the fragment.
Most common in children between ages of
8-14 years
Usually result from avulsions of anterior
intercondylar eminence from pull of ACL
Caused by hyperflexion of the knee with
tibial internal rotation, or hyperextension of
the knee.

White arrow - capsular
avulsion fracture,
termed a Segond #.
Segond # are highly
associated with ACL
tears.
Black arrow - avulsion #
of the tibial spines,
indicates ACL injury.
Fracture of the posterior tibia
eminence
Less common
Caused by sudden
hyperextension of the knee or
a violent posterior
displacement of the tibia
while the knee is in flexion.
The arcuate sign describes an avulsed bone fragment related
to the insertion of the arcuate complex at the fibular styloid
process.
The avulsed bone fragment appears as an elliptic piece of bone
arising from the fibular styloid process with its long axis oriented
horizontally on the AP knee
Difficult to distinguish an avulsion fracture of the fibular head from
that of the arcuate sign
Compare to appearance of arcuate sign, avulsion fracture of
the biceps femoris tendon appears simply as an irregular bone
fragment arising from the fibular head
Uncommon
Calcification of MLC may occur after
MLC tear, known as Pellegrini Stieda
disease
Post traumatic ossification in or near the medial collateral ligament near
the margin of the medial femoral condyle
Osgood-Schlatter disease
Sinding-Larsen-Johanson Syndrome
Osteochondritis Dissecans
Synovial Osteochondromatosis
Diaphyseal Aclasia
Jumpers knee
Chronic avulsion injury related to
repetitive microtrauma and traction on
the tibial tubercle by the patellar tendon
Always occurs in adolescent athletes
performing activities that require jumping
& kicking
X-ray: reveal fragmentation anterior to
the tibial tubercle, soft-tissue swelling, and
obliteration of the inferior angle of the
infrapatellar fat pad
Mainly a clinical diagnosis rather than a
radiographic one

Osteochondrosis involving the apex of
patella
Usually seen in active adolescents between
10-14 years old
Calcification and ossification seen at inferior
pole of patella
X ray: small bony fragments adjacent to the
distal surface of patella with overlying soft
tissue swelling
Further evaluation with MRI is necessary to
distinguish this from patella sleeve fracture

http://www.pedsradiology.com/Historyanswer.aspx?qid=140&fid=1
Sub-articular, post traumatic
necrosis
Result of aseptic separation of an
osteochondral fragment with
gradual fragmentation of the
articular surface
Commonly caused by direct blow
85% seen at medial condyle, 15%
at lateral condyle

http://radiopaedia.org/articles/osteochondritis_dissecans
An uncommon disease in which there is metaplasia
of the synovial lining of joints, bursae or tendons
into cartilaginous nodules
The nodules may detach and become loose
bodies in the joint
As the loose bodies receive their nourishment from
the synovial fluid, they may continue to grow even
though floating in the joint

http://www.learningradiology.com/archives06/COW%20209-
Synovial%20Chondromatosis/synchondromatosiscorrect.htm
Multiple exostoses / osteochondromas which
arise from the metaphyseal region and point
away from the joint.
Usually asymptomatic, but can become large
and may fracture.
May become malignant, particularly if located
axially rather than from a long bone.

Most common benign tumour in pediatric
A benign lytic lesion often seen at the distal femur
and proximal tibia.
Large fibrous cortical defect (>2cm) located within
the diametaphyseal region of a long bone.
Appears as metaphyseal eccentric "bubbly" lytic
lesion surrounded by sclerotic rim.

http://radiopaedia.org/articles/non-ossifying_fibroma
A trochlear groove which has formed abnormally, generally
with the sides being too flat or too steep. Might cause recurrent
dislocation of patella.
Crossing sign" is a line represented by deepest part of trochlear
groove, crossing the anterior aspect of condyles
Double contour sign" is a double line at anterior aspect of
condyles, and seen if medial condyle is hypoplastic
The fragment margins appear
smooth
The fragment will not fit back
(like a broken biscuit) to make
a normal smooth contoured
patella
Differential diagnosis:
Sinding-Larsen-Johansson
disease
patellar sleeve fracture
osteochondral fracture.
Bipartite patella
Tripartite patella
A common sesamoid
bone in the lateral head
of the gastrocnemius
muscle
DDx: avulsion fracture
Single
Double
Tripartite
Bifid
Os Cyamella
(Embedded in the
popliteus tendon)
Adjacent to Fibular Head
Meniscal Ossicles
(occur usually in the
medial aspect)

May be mistaken as detached bone fragment
An accentuated groove for the
patellar tendon
Differential diagnosis: erosion
The epiphyseal region of the tibial head forms a beak-shaped
process that extends downward anteriorly over the tibia at its
distal end.
There is an isolated ossification center which forms the tuberosity.
DDx: Osgood-Schlatter disease
May be mistaken as avulsion fracture of the tibial tuberosity
or Osgood Schlatter disease
An old injury (or injuries) to
the medial collateral
ligament(MCL).
A form of myosotis
ossificans soft tissue
calcification.
Located within the
superior attachment of
the medial collateral
ligament
Mimics #
1. pedestrian struck by car head injury ? left humerus fracture
1. pedestrian struck by car head injury ? left humerus fracture
Mildly displaced fractures of the (L) distal femur, lateral tibial condyle of the
(L) proximal tibia and (L) proximal fibula are seen. A sizeable (L) suprapatellar
effusion is noted, associated with soft tissue swelling.
Fracture, (L) patella. Bony density along the medial tibial plateau is
noted, with lucency in the medial tibial spine, suspicious for another
fracture. A (L) suprapatellar joint effusion is noted, along with soft tissue
swelling of the (L) knee.
2. No clinical diagnosis
3.
Cortical irregularity seen involving the posterior lip of the left tibial
plateau may represent a minimally displaced fracture in this
location. Kindly correlate clinically to confirm any tenderness over
this site. A small joint effusion is detected.
3.
There is a minimally depressed (0.2 cm) fracture
of the medial tibial plateau with condensation
of the trabeculae extending from the
metaphyseal region to the intercondylar region.
Non-depressed fracture of the medial tibial
plateau extending to its articular surface is also
present.
Conclusion
Schatzker Type V fracture
4. rt knee pain and swelling
Prominent anterior tibial tubercle is commonly seen in patient with Osgood
Schlatter's disease.
No evident cortical break or fracture line seen.
There is obliteration of the suprapatellar fat space suggestive of joint space
effusion.
4. rt knee pain and swelling
6. JUMPED AND LANDED IN FULL EXTENSION ON LEFT LL, NOW WITH LEFT KNEE
PAIN AND SWELLING
6. JUMPED AND LANDED IN FULL EXTENSION ON LEFT LL, NOW WITH LEFT KNEE
PAIN AND SWELLING
Lateral tibial plateau fracture suspected. Repeat AP view suggested.
A joint effusion/ haemoarthrosis associated.
Overall CT findings
are in in keeping
with a Schatzker
type 1 lateral tibial
plateau fracture with
less than 4 mm
articular surface
depression.

7. left knee pain with bruised
(L) suprapatellar effusion is noted.
No fracture or dislocation is seen; the lucency across the lateral aspect of the
patella which appears well corticated is likely related to a bipartite patella.
7. left knee pain with bruised
8. left shin pain after fell into drain
8. left shin pain after fell into drain
There is deformity of the lateral tibial plateau with widening of the joint
space in keeping with with a depression fracture. On the lateral view there
is a vertical lucent line seen which is suspicious and could represent an
acute fracture. Please correlate clinically. No fracture or dislocation is
seen involving the shaft of the tibia or fibula.
9. Right knee pain
9. Right knee pain
Cortical irregularity seen at the anterior aspect of the intercondylar
eminence suggests an avulsion fracture at the tibial insertion of the anterior
cruciate ligament. A small joint effusion is demonstrated.
10. slipped and fel into drain. rt knee pain, limited rom
10. slipped and fel into drain. rt knee pain, limited rom
There is suggestion of a fluid--fluid level seen in the supra-patellar pouch and
this may represent a lipo-haemarthrosis.
11. left knee
11. left knee
A radiolucent cortical lesion measuring 2.7 x 1.8cm in posterolateral
metaphyseal region of distal tibia, associated with narrow zone of
transition and sclerotic margin, likely to represent fibrous cortical defect
(FCD).

12. laceration rt knee
12. laceration rt knee
No opaque foreign body or bony injury seen.
Lucencies in the suprapatellar pouch and tibiofemoral joint are suspicious
for intra-articular air from penetrating injury.
Report: Cortical irregularity suggests subtle cortical fracture of lateral tibial
condyle.

-1.0x 0.4cm recent subchondral # w submeniscal chondral fissure of lat tibial
plateau.
- Mild chondromalacia noted at posterior aspect of lateral femoral condyle &
inf patellar surface.

Report: No fracture or dislocation is detected.
# of the medial
tibial plateau