(Plain) Radiographic Evaluation of the Knee

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(Plain) Radiographic Evaluation of the Knee

• Garry W. K. Ho, M.D.
• Sports Medicine Fellow - VCU / Fairfax Family
  Practice
• May 2007

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Anatomy - Osteology
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Anatomy - Osteology

• Femur
• Medial lateral
• Condyles
• Epicondyles
• Trochlear groove
• Intercondylar notch
• Patella
• Superior pole (base)
• Inferior pole (apex)
• Medial lateral facets

• Tibia
• Medial lateral
• Condyles
• Gerdys tubercle
• Pes anserine area
• Tibial tuberosity
• Tibial plateau
• Tibial spines
• Fibula
• Head
• Neck

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Anatomy Major Ligaments Tendons

• Quadriceps tendon
• Patellar tendon
• Medial lateral patellar retinaculum
• Medial collateral ligament (MCL)
• Lateral collateral ligament (LCL)
• Iliotibial tract (IT band)
• Anterior cruciate ligament (ACL)
• Posterior cruciate ligament (PCL)

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Anatomy Joint Capsule

• Bones

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AP View of the Knee

• AP View
• Femur
• Medial lateral epicondyles condyles
• Patella
• Tibia
• Medial lateral condyles plateaus
• Spines
• Fibula
• Head
• Neck
• Joint space
• Soft tissues

Femur
Lateral epicondyle
Medial epicondyle
Tibial spines
Tibia
Fibula
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Lateral View of the Knee

• Lateral View
• Femur
• Medial lateral condyles
• Patella
• Tibia
• Tibial tuberosity
• Plateaus
• Spines
• Fibula
• Apex (styloid)
• Head
• Neck
• Joint space
• Soft tissues

Tibial plateau
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Tunnel (Notch) View of the Knee

• Tunnel (Notch) View
• Femur
• Medial lateral epicondyles condyles
• Intercondylar notch
• Osteochondral lesions
• Patella
• Tibia
• Medial lateral condyles
• Medial lateral plateaus
• Spines
• Fibula
• Head neck

Lateral femoral condyle
Intercondylar notch
Lateral tibial plateau
Medial femoral condyle
Tibial spines
Fibular head
Medial tibial plateau
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Sunrise (Merchant) Views of the Knee

• Sunrise (Merchant, Skyline) Views
• Femur
• Medial lateral condyles
• Trochlear groove
• Patella
• Articular facets
• Patellofemoral joint
• Tibia
• Plateau
• Fibula
• Head
• Apex (styloid)

Patellofemoral joint
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Pediatric Knee Radiographs
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Other Views of the Knee
So many views... So little time
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Indications Ottawa Knee Rules

• Stiell et al. - Ann Emerg Med 1995
• Ottawa Knee Rules
• Age 55 or older
• Isolated tenderness at patella (no bony
  tenderness of knee other than patella)
• Tenderness at head of fibula
• Inability to flex knee to 90 degrees
• Patient unable to bear weight for four steps
  immediately and in the emergency department or
  office
• Sensitivity 100 ? 97
• NPV 100
• Specificity 49 ? 27

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Indications Pittsburgh Decision Rules

• Bauer et al. - J Emerg Med 1995
• Pittsburgh Decision Rules
• Blunt trauma or a fall as mechanism of injury
  plus either
• Age younger than 12 years or older than 50 years
• Inability to walk four weight-bearing steps in
  the emergency department
• Sensitivity 100 ? 99
• Specificity 79 ? 60

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Indications American College of Radiology

• American College of Radiology (ACR)
  Appropriateness Criteria for Musculoskeletal
  Imaging
• Acute Trauma to the Knee
• Developed in 1998 ? last revised 2005
• Plain film x-rays indicated
• Focal bony TTP, effusion, or inability to
• bear weight - s/p fall or twisting injury
• Focal TTP over patella or fibular head regardless
  of MOI
• Inability to flex knee beyond 90 degrees
• Hx of significant trauma
• (esp MVC suspicious for dashboard injury)
• Parameters to not order x-rays
• Able to ambulate without a limp
• Twisting injury with no effusion
• Lateral view may suffice to rule out fracture

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Indications American College of Radiology

• American College of Radiology (ACR)
  Appropriateness Criteria for Musculoskeletal
  Imaging
• Nontraumatic Knee Pain
• Developed in 1995
• Last revised 2005
• Plain film x-rays indicated
• Child or adolescent with non-patellofemoral
  (non-anterior) symptoms (AP lateral views)
• Suspicion for OCD
• Patellofemoral (anterior) symptoms (AP, lateral,
  axial views)
• ??? - Rationale unclear
• Adult with nontraumatic knee pain (AP, lateral
  views)
• Suspicion for osteoarthritis

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Indications

• Other indications
• Knee pain with Hx of joint
• replacements or prostheses
• Activity-related swelling
• Suspicion of bony neoplastic
• or osteolytic lesion
• Suspicion of instability
• The patient cannot communicate
• (altered mental status, alcohol intoxication, or
  other)
• Persistent pain and decreased ROM
• Anytime your history and physical dont give you
  enough information

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• 23 y/o female marathoner with anterior R knee
  pain with climbing up lt down stairs
• AP lateral views of R knee
• Skeletally mature
• Normal appearing bone quality
• Normal X-rays
• Dx Patellofemoral syndrome
• Tx Conservative measures

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57 y/o male firefighter with 6 month h/o
intermittent R knee pain stiffness AP
lateral views of R knee Skeletally
mature Underpenetrated Joint space
narrowing Osteophytes Subchondral sclerosis
cysts Degenerative subluxation Dx
Osteoarthritis / DJD Tx depends on symptoms
functional impairment ? shared decision making
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12 y/o male year-round, multi-sport athlete (per
parents by proxy) with 1 month hx of L anterior
knee pain Lateral view of L knee Skeletally
immature Normal appearing bone quality Fragmentat
ion of apophysis at tibial tuberosity Associated
soft tissue swelling Dx Osgood-Schlatter
Disease Tx Conservative
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11 y/o female basketball player with 3 week hx of
L anterior knee pain Lateral view of L
knee Skeletally immature Normal appearing bone
quality Fragmentation of apophysis at inferior
pole of patella Dx Sinding-Larsen Johansson
Disease Tx Conservative
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19 y/o male x-treme sports athlete, s/p fall
during downhill mountain bike race AP
lateral views of R knee Skeletally mature Normal
appearing bone quality Posterior knee
dislocation Dx knee dislocation with
multi-directional instability Tx Operative
reduction fixation reconstruction as needed
neurovascular eval surgical repair as needed
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21 y/o female collegiate soccer player, s/p land,
plant, twist ? R knee pain swelling AP,
lateral, tunnel views of R knee Skeletally
mature Normal appearing bone quality Lateral
tibial spine fracture Dx Lateral tibial spine
fracture Tx Operative fixation reconstruction
of cruciate ligaments prn
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22 y/o male s/p fall onto anterior aspect of R
knee ? pain swelling AP lateral views of R
knee Skeletally mature Normal appearing bone
quality Patellar fracture Dx Patellar
fracture Tx Operative fixation
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16 y/o male cross-country runner with grinding
sensation in L knee Lateral view of L
knee Are you kidding? ?
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58 y/o male CIA agent with 3 year h/o
intermittent R knee pain stiffness ? now
significantly worse over past 2 months AP
lateral views of R knee Skeletally
mature Underpenetrated Joint space
narrowing Osteophytes Subchondral sclerosis
cysts Dx Osteoarthritis / DJD Tx depends on
symptoms functional impairment ? shared
decision making
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18 y/o male football, lacrosse, ice hockey
player with 3-4 yr h/o R knee pain occasional
locking initially cleared to RTP by
orthopaedist medial joint line tenderness
Oblique, tunnel, sunrise views of R
knee Skeletally mature Normal appearing bone
quality Subchondral bone defect on lateral
articular surface of medial femoral condyle, with
1 cm loose body Dx Stage 4 osteochondral
defect Tx Surgerize !
AP lateral views of R knee Skeletally
mature Normal appearing bone quality Subchondr
al bone defect on articular surface of medial
femoral condyle
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34 y/o female ultra-endurance athlete training
for upcoming marathon with 2 month h/o
episodic, insidious onset L knee pain with
running ( 6 miles into run) ? resolving after 1
hour of rest AP view of L knee Skeletally
mature Underpenetrated Subtle sclerotic line in
proximal tibial metaphysis Dx Stress
fracture Tx conservative therapy
biomechanical evaluation risk factor assessment
? address as indicated
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33 y/o female soccer player plant twist ? pop,
pain, immediate swelling in L knee
AP, sunrise, lateral views of L
knee Skeletally mature Normal appearing bone
quality Small bony fragment c/w avulsion
fracture off of lateral tibial condyle 1 medial
patellar tilt Eponym? Segond Fracture Dx ACL
tear Tx Operative reconstruction
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43 y/o male with 6 month h/o intermittent
episodes of poorly localized R knee pain
stiffness AP view of R knee Skeletally
mature Underpenetrated Linear radio-opacity in
medial and lateral joint spaces Dx
Chondrocalcinosis (Calcium pyrophosphate
dihydrate deposition disease) Tx Trial of
conservative therapy for osteoarthrits / or
pseudogout
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14 y/o male track field athlete with gnawing
L knee pain Lateral view of L knee Im on a
roll. ?
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17 y/o female cheerleader with L knee pain s/p
fall onto anterior aspect of L knee
AP, oblique, lateral views of L
knee Skeletally mature Normal appearing bone
quality Bipartite patella Dx Contusion
sprain of fibrous bipartite synchondrosis Tx
Trial of conservative therapy
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57 y/o female with L knee pain swelling s/p
fall while skiing
AP cross-table lateral views of L
knee Skeletally mature Normal appearing bone
quality Minimally displaced lateral unicondylar
fracture Lipoarthrosis Tx Non-weight
bearing conservative management vs. surgerize
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47 y/o male with R knee pain s/p stabbed in the
knee by my wife during domestic discord
incident earlier that day
AP cross-table lateral views of R
knee Skeletally mature Normal appearing bone
quality Vague, anterior, infrapatellar soft
tissue opacity Pneumoarthrosis SQ
emphysema Tx Surgerize !
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34 y/o female motorcycle police officer, with R
knee pain swelling s/p MVC
Tunnel view of R knee hi-res CT Skeletally
mature Normal appearing bone quality Comminuted
type VI tibial plateau fracture Tx
Surgerize !
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58 y/o male with long-standing h/o poorly
controlled diabetes mellitus Bilateral
knee Charcot arthropathy
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67 y/o female with long-standing h/o of bilateral
hand, wrist, and knee pain ? presents for initial
work-up Advanced untreated
bilateral knee rheumatoid arthritis ?
auto-arthrodesis
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Chronic medial knee pain with history of multiple
knee sprains Pellegrini-Stieda
Disease
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Recent immigrant from Latin America
Bilateral cysticercosis
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Conclusion

• Read as many of your own films as possible
• Know what views to order when
• AP, Lateral, Sunrise, Tunnel
• Weight-bearing views
• Know your anatomy
• Know how to describe
• what you see
• Share with your patients
• Share with your colleagues

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Questions?
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Thank you