The Knee: Clinical Evaluation Nick Iannuzzi, MD November 28 th - 2011.
Evaluation Knee
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Transcript of Evaluation Knee
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Radiological Evaluation of Knee Pain
Presented by Rebecca J. Spencer, Ph.D.
Learning Lab by Gillian Lieberman, M.D.
Harvard Medical School
Beth Israel Deaconess Medical Center
6/22/09
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Common Causes of Adult Knee Pain
• Patellofemoral dysfunction
• Past Trauma: ligamentous sprains or meniscal tear • Osteoarthritis
• Baker cyst
• Bursitis• Inflammatory arthritis
• Septic arthritis
• Gout, pseudogout
• Medial plica syndrome
Calmbach WL, American Family Physician. 2003 Sep 1;68(5):917-22.
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Modalities Used to Evaluate Knee Pain
• Plain Film
• MRI
• CT
• Bone Scan
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Plain Films Reveal Bony Abnormalities
• Osteoarthritis
– Joint space narrowing – Sclerosis
– Subchondral cysts
– Spurring of tibial spines
– Osteophytes
• Loose bodies• Chondrocalcinosis
• Fracture
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MRI Provides Definition of Soft Tissue
• Tendonitis or tendon tears
• Articular cartilage• Meniscus tears
• Bone bruise/marrow edema
• Strains
• Cysts
• Bursitis• Tumors
• Osteonecrosis
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CT Provides Cortical Detail
• Occult fractures
• Fracture fragment location
• Tumors – Periosteal reaction
– Small amounts of calcification
• Special uses:
-Fulkerson study (patellar tracking)
-CT arthrogram
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Bone Scan Highlights Physiological
Rather than Anatomic Processes
• Neoplasm
• Occult Fracture
• Osteonecrosis
PACS Imaging, BIDMC
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Plain Film Patient ND: History
• 45 year old man with knee pain
• Knee pain suddenly worsened, notraumatic incident
• No prior work up
• Initial imaging for knee pain is plain film.
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Plain Film: Views
SunriseLateral AP
PACS Imaging, BIDMC
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Plain Film: Anatomy
Bones of the Knee
PACS Imaging, BIDMC
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Plain Film: Anatomy Articular Compartments
Medial compartment
Lateral compartment Patellofemoral compartment
PACS Imaging, BIDMC
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Plain Film Patient ND:Weight bearing AP Demonstrates Degeneration
Normal Patient ND
• Joint space
narrowing• Subchondral
sclerosis• Osteophytes
• Normal Alignment
PACS Imaging, BIDMC, courtesy of Jim WuPACS Imaging, BIDMC
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Plain Film Patient ND:
Lateral View Shows Degeneration
Normal Patient ND: Osteophytes, Loose Bodies
PACS Imaging, BIDMC, courtesy of Jim WuPACS Imaging, BIDMC
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Plain Film Patient ND:
Sunrise View Shows Patellofemoral Compartment
Normal
Patient ND:
Marginal Osteophytes
Relatively preserved joint space
PACS Imaging, BIDMC, courtesy of Jim WuPACS Imaging, BIDMC
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Plain Films Can Show Soft Tissue Abnormalities
Normal Plain Film Companion Patient: Effusion
PACS Imaging, BIDMC, courtesy of Jim Wu
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Plain Film Patient ND: Conclusion
• Plain films showed advanced arthritis in arelatively young man (age 45).
• MRI: Chronic ACL tear, anterior translation ofthe tibia, meniscal tears, cartilage damage,
loose bodies.
• Arthroscopy: Partial meniscectomy and removal
of loose bodies.
• Knee replacement at age 50
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MRI Patient MJ
• 61 year old female
• Mild osteoarthritis by plain film
• Left knee pain, mostly posterior
• Pain has persisted > 4 months
• Takes Tylenol with some relief
• Physical therapy did not help
• Received non-contrast MRI of
the left knee
PACS Imaging, BIDMC
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Knee MRI: Views
Axial Sagittal Coronal
PACS Imaging, BIDMC
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Knee MRI: Sequences
Proton Density Fat Saturation (PD FS)
• Cartilage
• Meniscus
PACS Imaging, BIDMC
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Knee MRI: Sequences
T2 Fat Saturation (T2 FS)
• Highlights fluid
• Edema
• Cysts
• Tendon
• Ligament
PACS Imaging, BIDMC
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Knee MRI: Sequences
Proton Density (PD)
• Cartilage• Meniscus
• Fractures• Fatty structures
PACS Imaging, BIDMC
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Knee MRI: Sequences and Views
Axial PD FS
Sagittal PD
Sagittal T2 FS
Coronal PD FS
PACS Imaging, BIDMC
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MRI Anatomy: Structure of Menisci
William Sutton, Hughston Health Alert: http://www.hughston.com/hha/a.meniscus.htm
PCL
Lateral MeniscusMedial Meniscus
Humphrey Ligament
(anterior meniscofemoral)
Wrisberg Ligament(posterior meniscofemoral)
ACL Transverse Ligament
• Meniscus appears black on MRI.
• Intersection of ligaments and meniscus
may mimic a tear.
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MRI Anatomy: Menisci
William Sutton, Hughston Health Alert: http://www.hughston.com/hha/a.meniscus.htm
PACS Imaging, BIDMC
PCL
Lateral MeniscusMedial Meniscus
Humphrey Ligament
(anterior meniscofemoral)
Wrisberg Ligament
(posterior meniscofemoral)
Transverse Ligament ACL
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MRI Patient MJ: Menisci
• Lateral meniscus tear to the tibial surface
• Lateral meniscus free edge tear
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MRI Anatomy: Location of Articular Cartilage
• Black = Cortex
• Grey = Cartilage
• White = Joint fluid
Patella
PACS Imaging, BIDMC
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MRI Anatomy: Images of Articular Cartilage
• Black = Cortex
• Grey = Cartilage
• White = Joint fluid
Patella
PACS Imaging, BIDMC
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MRI Patient MJ: Loss of Patellar Cartilage
MRI Patient MJ:
Loss of patellar cartilage
MRI Companion Patient #1:
Normal patellar cartilage
PACS Imaging, BIDMC
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MRI Anatomy: Tendons and Ligaments
• Tendons and ligaments appear black.
• Discontinuity: tear
• Increased signal: tendonopathy,
tendonitis, mucinous degeneration, sprain
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MRI Anatomy: Cruciate Ligaments• Anterior Cruciate Ligament (ACL)• Posterior Cruciate Ligament (PCL)
ACL
PCLT2 Fat Saturation
PACS Imaging, BIDMC
MRI Patient MJ: NormalMRI Patient MJ: Normal
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MRI Companion Patient #2:
Increased Signal in Quad
Tendon, ACL detached
T2 Fat Saturation
MRI Patient MJ: Normal
MRI Anatomy: Extensor Mechanism
Quadriceps
Tendon
Patellar
Tendon
PACS Imaging, BIDMC
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MRI Companion Patient #3: TornMRI Patient MJ: Normal
MRI Anatomy: Medial Collateral Ligament
MCL
PACS Imaging, BIDMC
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MRI Anatomy: Ligaments and Tendons
PD Fat Saturation
Lateral View
PACS Imaging, BIDMC
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MRI Anatomy: Baker Cyst
Medial Gastrocnemius
Semimembranosus Tendon
Baker Cyst
Excess synovial fluiddistends synoviumposteriorly between themedial head of thegastrocnemius and the
semimembranosustendon
MRI Companion Patient #4: 48 year
old female with pain and swelling inthe posterior aspect of the left knee
Axial STIRPACS Imaging, BIDMC
Femur
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MRI Patient MJ: Baker Cyst
Baker Cyst
PACS Imaging, BIDMC
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MRI Anatomy: Ganglion
Ganglion
Popliteus
PACS Imaging, BIDMC
MRI Companion Patient #5
PD FS
MRI A t M Ed
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MRI Anatomy: Marrow EdemaInsufficiency Fracture
T2 Fat Saturation
PACS Imaging, BIDMC
Eugene Lin et al, “ Chapter 129 Subchondral Bone Marrow Edema” (Chapter). Practical DifferentialDiagnosis for CT and MRI.
• Marrow Edema – Insufficiency Fracture
– Cartilage Loss
– Contusion (within 3 months)
– Osteonecrosis
– Fracture
– Infection
– Tumor
MRI Companion Patient #6
MRI A t M Ed
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MRI Anatomy: Marrow EdemaCartilage Loss
• Marrow Edema• Insufficiency Fracture
• Cartilage Loss
• Contusion (within 3 months)
• Osteonecrosis
• Fracture
• Infection
• Tumor
MRI Companion Patient #7
T2 Fat Saturation
PACS Imaging, BIDMC
Eugene Lin et al, “ Chapter 129 Subchondral Bone Marrow Edema” (Chapter). Practical DifferentialDiagnosis for CT and MRI.
MRI A t M Ed
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MRI Anatomy: Marrow EdemaKissing Contusions
• Marrow Edema – Insufficiency Fracture
– Cartilage Loss
– Contusion (within 3 months)
– Osteonecrosis
– Fracture
– Infection
– Tumor
MRI Companion Patient #8
T2 Fat Saturation
PACS Imaging, BIDMC
Eugene Lin et al, “ Chapter 129 Subchondral Bone Marrow Edema” (Chapter). Practical DifferentialDiagnosis for CT and MRI.
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MRI Patient MJ: Conclusion
• 61 year old female with posterior left knee pain
• Thinned patellar cartilage
• Meniscal tears
• Small baker cyst
• Posterior knee pain could be due to tears andthe baker cyst, but asymptomatic meniscaltears and cysts are common.
Johnson Carl A, "Chapter 12. Approach to the Patient with Knee Pain" (Chapter). Imboden JB,
Hellmann DB, Stone JH: CURRENT Rheumatology Diagnosis & Treatment, 2e.
F.T. Tschirch et al, AJR Am J Roentgenol. 2003 May;180(5):1431-6.
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CT Scan Patient PW
• 24 year old Female with right knee pain
• History of periodic patellar dislocation, first dislocation atage 18.
• Exam: anterior tenderness, patellar laxity, patellar click, Jsign, and patellar apprehension, and normal alignment.
• Physical therapy has not helped.
• Plain film: good alignment, ossific body at the edge ofthe patella.
• MRI: evidence of a medial retinacular tear andpatellofemoral cartilage loss.
• Received a Fulkerson study to evaluate patellar tracking.
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Anatomy: Stabilizers of the Patella
Vastus medialis
Quadriceps tendon
Patella
Patellar tendon
Medialpatellofemoral
ligament
Retinaculum
Tibial Tubercle
PACS Imaging, BIDMC, courtesy of Jim Wu
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Anatomy: Patellar Tracking
Patellar Facets
PACS Imaging, BIDMC
Trochlear Groove
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Conditions associated with
patellofemoral pain• Laxity
• Joint hypermobility• Weakness of the vastus medialis
• Genu valgus• Internal femoral torsion
• Tight lateral patellar retinaculum
• Patellar or trochlear dysplasia
• Osteoarthritis
CT Companion Patient: Fulkerson Study
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CT Companion Patient: Fulkerson Study
Fulkerson Study Shows Patellar Engagement, Tilt, and Subluxation
Patella not engaged
Patella begins to engage.
Any subluxation becomes apparent.
Patella is engaged
Normal
0°
15°
30°
60°Non Contrast CT
PACS Imaging, BIDMC
CT Patient PW: Fulkerson Study Confirms
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CT Patient PW: Fulkerson Study Confirms
Abnormal Patellar tracking
Patella not engaged
Patella is not engaged. Trochlear grooveis not well defined.
Patella is laterally positioned and tilted.
Normal
0°
15°
30°
60° Patella is engaged.
Abnormal
Non Contrast CT
PACS Imaging, BIDMC
CT Companion Patient: Fulkerson Study Measures
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CT Companion Patient: Fulkerson Study Measures
Tibial Tubercle-Trochlear Groove distance
• Distance between thetibial tubercle and
trochlear groove isshown in orange.
• Normal distance <2 cm
• Longer distance may
contribute to a patellartracking problem
Non Contrast CT
PACS Imaging, BIDMC
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CT Patient PW: Conclusion
• Tibial Tubercle-Trochlear Groove distance wasnormal so tibial tubercle osteotomy was not
offered.
• Fulkerson study revealed lateral displacement of
the patella and late engagement.
• MRI showed a medial retinacular tear.
• Medial patellofemoral ligament reconstructionwas recommended.
Radiological Evaluation of Knee Pain:
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Radiological Evaluation of Knee Pain:
Conclusion• Plain film: Initial imaging
• MRI: – Persistent pain with non-diagnostic films
– Clinical suspicion of soft tissue process
– Pre-operative planning
• CT:
– CT arthrogram if MRI contraindicated
– Fulkerson for suspicion of tracking disorder
• Bone Scan:
– Usually not indicated
– May be used for tumors
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Acknowledgements
Thanks to the following individuals for discussion
of knee imaging:• Jim Wu, M.D.
• Vaibhav Mangrulkar, M.D.
• Perry Horwich, M.D.
• Mike Geary, M.D.
• Colm McMahon, M.D.
Thanks to Gillian Lieberman, M.D. for
presentation feedback and web publishing.
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References
• Images from PACS Imaging, BIDMC unless otherwise noted.
• Calmbach WL, American Family Physician. 2003 Sep 1;68(5):917-22.
• American College of Radiology, ACR Appropriateness Criteria, Reviewed 2008.http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/NonTraumaticKneePainDoc15.aspx
• Johnson Carl A, "Chapter 12. Approach to the Patient with Knee Pain" (Chapter).Imboden JB, Hellmann DB, Stone JH: CURRENT Rheumatology Diagnosis &Treatment, 2e.
• Dempsey Springfield, "Chapter 42. Orthopaedics" (Chapter). Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE, SchwartzSI: Schwartz's Principles of Surgery, 8th Edition.
• Haygood Tamara M, Auringer Sam T, "Chapter 6. Musculoskeletal Imaging"(Chapter). Chen MYM, Pope TL, Jr., Ott DJ: Basic Radiology.
• Frank G. Shellock, “Chapter 13. Kinematic Magnetic Resonance Imaging” (Chapter).Stoller DW: Magnetic Resonance Imaging in Orthopedics and Sports Medicine.
• Eugene Lin et al, “ Chapter 129 Subchondral Bone Marrow Edema” (Chapter).Practical Differential Diagnosis for CT and MRI.
• F.T. Tschirch et al, AJR Am J Roentgenol. 2003 May;180(5):1431-6.