Post on 21-Jun-2020
Franz Kainberger 1
Division of Neuro- and MSK Radiology & CIR Lab, Department of Radiology
Imaging of collateral ligaments and posterior corners: combined with cruciate ligament lesions
franz.kainberger@billrothhaus.at
24 ys male, bicycle accident, your diagnosis, please
Download PDF under: http://radiodiagnostik.meduniwien.ac.at/1/and on button Division of Neuroradiology and Musculoskeletal Radiology
indication
interpretation
differential diagnosis
The role of twisting injuries and the mainanatomic stabilizers to prevent them
Objectives
Footprint patterns of kinetic chains
Puzzling the diagnosis by grading andin the context of clinical findings
MRI is not first, but best imaging choice
characteristic clinical findings:
• focal tenderness
• effusion
• inability to bear weight
Fall or twisting injuries of the knee
Pivot shift-injury: a form of twisting with ellipticalmovement line of tibia against femur
male patient after injury during handball
The clinical entity termed the pivot shift was studied in cadaver specimens and its significance was evaluated:It was found to be highly correlated with a tear of the anterior cruciate ligament, and it corresponded to a sudden anterior-internal rotation subluxation-dislocation of the tibia and posterior horn of the lateral meniscus beneath the lateral femoral condyle.
Fetto JF; Marshall JL J Bone Joint Surg Am. 1979 Jul; 61(5): 710-4
“sudden anterior-internal rotation subluxation of the tibia”
Radiographics, 2000
Deep sulcus sign (M. Cobby et al. Radiology 1992)
Anatomy: the main stabilizers of the kneeClassification basing on anatomy and biomechanical forces
Knee extensor system:osseo-musculo-tendinous unit
Lateral aspectof flexor system:
lock and unlock mechanismsof tibial rotation
posterior corners: capsule and tendonsare strong stabilizers
Medial aspect:of hamstring cuff
Semimembranosus tendon: key to understand anatomy
Medial meniscus
Semimembranosus tendon
Medial gastrocnemius head
Medial collateral ligament
Medial retinaculum
• deep portion with
• superficial portion
meniscofemoral extensionmeniscotibial extension
Medial supporting structures
Franz Kainberger 2
VALGUS-EXTERNAL ROTATION STABILIZING SYSTEM
(ordered from superficial to profound location)
• Medial retinaculitis
• MCL insufficiency (breaststroker‘s knee; due to repeated stretching during swimming)
• Pes anserinus bursitis
• Semimembranosus tendinitis or injury
• Plica syndrome
Common overuse syndromes
Garcia-Valtuille R et al, Radiographics Sept 02
mediopatellar plica (Sakakibara Typ B)
Medial collateral ligament (MCL)
• primary valgus stabilizer: proximal division of the superficial MCL
• primary external rotation stabilizer: distal division of the superficial MCL at 30° of knee flexion
• primary internal rotation stabilizers: POL and the distal division of the sMCL with the meniscofemoral and meniscotibial ligaments
Griffith CJ et al., Am J Sports Med, 2009
Combined ACL and MCL lesion
snowboarding 6 days ago:
predominantly valgus injury mechanism
Medial collateral ligament
rupturestrain/partial rupture
Anserine bursa
anserine bursitissuperficial pes anserinus
sartorius tendon
gracilis tendon
semitendinosus
The posteromedial corner: 2 components and 3 layers concepts
• Layer I: the crural fasciaand retinaculum
Pes anserinus (betweenlayers I and II)
• Layer II: superficial MCL and semimembranosus tendon
• Layer III: deep MCL andfibrous knee joint capsule
The 3 layers concept
Warren LF et al. The supporting structures and layers on the medial side of the knee: an anatomical analysis JBJS (Am) 1979
2 components of MCL:
• the straight part
• the fan-like posterior part
posteromedialcorner {
Franz Kainberger 3
Beltran J et al. The semimembranosus complex. Skelet Radiol 2003
Layer II: the semimembranosus complex, i. e. its insertional tendon
24 ys male, bicycle accident, your diagnosis, please
The semimembranosus complex. (Beltran J, Skelet Radiol 2003)
Semimembranosus muscle: the strongest knee flector
• strongest flector of knee• forms pes anserinus profundus
by inserting with three branches:- oblique popliteal ligament within
posterior capsule- medial tibial surface- fascia of popliteus muscle
• protector of medial and lateral meniscus
Kim YC et al. Tendinous insertion of semimembranosus muscle into the lateral meniscus. Surg Radiol Anat 1997; 19: 365
Semimembranosus: abnormal findings
semimembranosus bursitis
avulsion edema atsemimembranosus insertionBeltran J et al., Skeletal Radiol 2003
Meniscocapsular inflammation or separation
Inflammation of meniscal attachment
Menisco-capsular separation. De Maeseneer M et al., EJR, March 2002
Baker‘s cyst: Advanced degenerative rupture: rupture is a severe form of degeneration
associated Baker‘s cyst
Baker‘s cyst
Marti-Bonmati L et al. MR imaging of Baker cysts – prevalence andrelation to internal derangementsof the knee. Magma 2000, 10; 205
• Association with menisceal lesion: 51 %
• Association with cruciate ligament lesion: 15 %
Semimembranosus tendon
communication at proximal joint
Franz Kainberger 4
The lateral supporting structures
Knee extensor system:osseo-musculo-tendinous unit
Lateral aspectof flexor system:
lock and unlock mechanismsof tibial rotation
posterior corners: capsule and tendonsstrong stabilizers
Medial aspect:of hamstring cuff
Lateral collateral ligament (LCL) andpopliteus tendon
LCL – redPopliteus tendon - blue
Kozanek M et al. Am J Sports Med 2009
Lateral supporting structures
Pseudoextrusion of meniscus
lateral retinaculum
Lateral collateral ligament [Winslow]
Lateral meniscus
Common peroneal nerve
Biceps femoris tendon
VARUS-INTERNAL ROTATION STABILIZING SYSTEM
Common overuse syndromes:
Iliotibial bandGerdy‘s tubercle
Iliotibial band:direct contact> in varus
• Iliotibial band friction syndrome(runner‘s knee, cyclist's knee)
• Popliteal tendinitis
• Bicipital tendinitis, peroneal nerve entrapment
Iliotibial band friction (ITBF) syndrome: Runner‘s knee and cyclist‘s knee
Cyclist's knee: insufficient medial musclesupport leads to
• patellofemoal painsyndrome
• ITBF: friction during contactwith 30 degrees of flexion
Farrell KC et al., The Knee, 2003
triathlete
Segond fractureWhite L. et al. Sem Musculoskel Radiol 2004
Posterolateral corner (= the arcuate complex)
fibular collateral ligament
popliteus tendon
stabilizes against varus and external rotation
arcuate ligament
Franz Kainberger 5
Popliteus muscle
Popliteal muscle notch
popliteustendon
lateral femoral condyle
meniscus
Origin: popliteal notchpopliteofibular ligamentpopliteomeniscal ligament
Posterior ligamentousrelationships
Lee BY et al. Incidence and significance of demonstrating themeniscofemoral ligament on MRI. Br J Radiol 2000; 73; 271: visible with MRI in 83 %
posterior cruciate ligament
anterior cruciate ligament
Humphrey ligament
Wrisberg ligament
Popliteus muscle
Posterolateral corner (= the arcuate complex)
Biceps muscle and tendon
Fibular collateral ligament
Popliteus tendon
Popliteofibular ligament
stabilizes against varus and external rotation
Posterior-lateral corner lesions
40 ys patient after skiing accident
a serious problem of capsular instability
Arcuate ligament rupture(White L et al, 2004)
• PCL injury
• Unsharp latero-posterior capsular structures
• Popliteal muscle abnormality
Fibular collateral ligament injury
motor cycling accident
Practice recommendation: the fibular collateralligament – the forgotten ligament in MR reporting
Imaging of collateral ligaments and posterior corners: combined with cruciate ligament lesions
Download PDF under: http://radiodiagnostik.meduniwien.ac.at/1/and on button Division of Neuroradiology and Musculoskeletal Radiology
indication
interpretation
differential diagnosis
Puzzling the diagnosis by grading andin the context of clinical findings
Franz Kainberger 6
Diagnostic concept of kinetic chains
• The musculo-tendino-osseouschains
• The interossous ligamentouschains
due to indirect forces
“Ligaments at risk” • within a narrow anatomic
environment or rubbing against adjacent bones
• with exposure to strong tensile forces
• within a complicated ligament complex
• with weak bony attachments.
Resnick, Chang, Pretterklieber, 2007
„Unhappy triad“: ACL, MCL, medial meniscus
We conclude that the classic O'Donoghue triad is, in fact, an unusual clinical entity among athletes with knee injuries.
Shelbourne KD, Nitz PA. The O'Donoghue triad revisited. Combined knee injuries involving anterior cruciate and medial collateral ligament tears. Am J Sports Med. 1991, 19:474
Hayes CW et al. Radiographics 2000
The Hayes classification system Bone marrow edema patterns
Kissing edema
Radiographics, 2000
Imaging of collateral ligaments and posterior corners: combined with cruciate ligament lesions
Biomechanical forces induce typical anatomicdistributions of injury, mostly „unhappy triad“ typeFoot pints of injury is traumatic type bone marrowedema: compression, avulsion, or stress-induced
Indication
Interpretation
Download PDF under: http://radiodiagnostik.meduniwien.ac.at/1/and on button Division of Neuroradiology and Musculoskeletal Radiology
Images and anatomic support: • Stummvoll G, Pretterklieber M, Kainberger F (eds.): [Motion
and Performance], Facultas-Publishers, Vienna• Lena Hirtler, MD, core unit of antomy and cell biology,
Medical Universitiy of Vienna