MRI

KNEE JOINT
Patellar , Synovial , miscellaneous
Lesions and quiz cases
Mamdouh Mahfouz MD
Cairo University

ssregypt.com
Patellar and quadriceps
tendons
quadriceps tendon
Patellar tendons
Lateral pressure syndrome

 Thickening of the lateral retinaculum

 Lateral knee pain
 Obese, athletic patients
 May be associated with chondromalacia
Patella alta
 Sequlae of
patellofemoral
dysplasia

 Lengthening of the
infrapatellar tendon

 May be associated
with chondromalacia

 Length of patellar
tendon/ length of
patella > 1.3
 Patella Baja
 Poliomyelitis
 Achondroplasia
 JRA
Hyaline cartilage
Hyaline cartilage
T2* MT

Hyaline cartilage
Articular cartilage
MT STIR
 Chondromalacia patellae

Degeneration of the hyaline cartilage

Anterior knee pain in young adults

Four stages
Signal abnormalities
Ulceration [ fraying , partial or
full thickness defects ]
Reactive bone changes [ edema ,
cyst formation , sclerosis ]
Osteoartheritic changes
Loose bodies
• Read with plain films
• Low signal fragments
Synovial osteochondromatosis
Loose bodies
 Synovial osteochondromatosis

Metaplasia of subsynovial soft tissues cartilage formation

Affects any joint [ knee , hip , elbow ]
Age incidence 40 years M:F=2:1
FINDINGS
Widening of the joint space
Bone erosions
Intra articular loose bodies
Secondary osteoartheritic changes
Synovial chondromatosis
Synovial chondromatosis
 Lipoma arborescens
Rare
Idiopathic
Fatty synovial infiltrations forming
variable sized villous projections within the joint
capsule commonly in the suprapatellar pouch
Associated with joint effusion
Painless swelling
Treatment by synovectomy
Lipoma arborescence
 Pigmented villo-nodular synovitis
 Idiopathic
 Monoarticular disease 1% incidence
 Hypertrophic synovial masses with hemosiderin laden
macrophages bone erosions
 Intermediate signal in T1 and low signal in T2 with
enhancement after contrast injection
 Typical location posterior to Hoffa’s fat pad
 Painless swelling , pain with progressive disease
 Treatment by synovectomy
PIGMENTED VELLONODULAR
SYNOVITIS
PIGMENTED VILLONODULAR SYNOVITIS
PIGMENTED VILLONODULAR SYNOVITIS
VERSUS LIPOMA ARBORESCENS
Pigmented villo-
nodular synovitis
 POPLITEAL CYST

Fluid in the bursa which is usually

communicating with the joint space
Other names
Baker’s cyst
Gastrocnemius/semimembranosus bursa
 Medial plica syndrome
 Inflamed synovial plica causing pain , crepitus
and pseudolocking
 Often in adolescents and athletics
 No measurement for plica thickness
Four types of plica
Suprapatellar 90%
Medial 15 -30%
Infrapatellar
Lateral [ rare]
PLICA SYNDROME
Knee pain with Normal MRI ?!
 Kinematic
MENISCAL CONTUSION
 Meniscal contusion
 Menisco-capsular separation
 Plicae
Medial plica Syndrome
 Osteochonddritis dissecans
 Osteochondral fragment in a typical location
 Young male
 Lateral aspect of the medial femoral condoyle
 Variable sized fragment attached or detached
 Criteria of unstable fragment
Large size more than 1cm
Fluid between the fragment and donor bone
Cystic changes at the donor site
Enhancement of the separation line
Osteochondritis Dissecans
OSTEOCHONDRITIS DISSECANS
Red marrow recon version / marrow lesion
Bone marrow contusion
Migratory osteoporosis
 Bone infarcts
 Serpigenous lesions in the bone marrow
 Variable in size [ Chinese figures ]
 Double line sign is diagnostic [peripheral
hyperintense with hypointense inner border on T2

 CAUSES
POSTTRAUMATIC
STEROIDS
COLLAGEN DISEASES
ALCOHOLISM
PANCREATITIS
SPONTANEOUS
BONE INFARCTS
BONE INFARCTS
THANK YOU

MAMDOUH MAHFOUZ MD
Quiz Cases
Case 1

7
1

2 6 5
3
8
Case 2

2
1
Case 3
Case 4
Case 5
Case 6

1
2

4
Case 7
Case 8
Case 9
Case 10

3
1

2 4
Case 11
Case 12
Case 13
Case 14
Case 15
Case 16
Case 17
Case 17
Case 18
Case 19
Case 20
Case 21

ACL TEAR
Thank
You
Case 19
Synovial chondromatosis
Chondromyxoid fibroma
Lipoma + ACL coronal +retinacula torn
Neoplastic lesions

 Low signal in T1 / high signal in T2

 Calcium low signal in both T1 & T2

 Blood high signal in both T1 & T2

 Plain X ray is very helpful

 Contrast injection may help
Osteochondroma
Chondroblastoma
Non ossifying fibroma
Giant cell tumour
osteosarcoma
osteosarcoma
Ewing sarcoma
Metastatic RCC
Lymphoma
Chondromyxoid fibroma
Malignant fibrous histeocytoma
Osteosarcoma
Giant cell tumour
Enchondroma
PATELLAR TENDINITIS
PATELLAR TENDINITIS
OSGOOD-SCHLATTER DISEASE
ACUTE OSGOOD-SCHLATTER DISEASE
CHONDRMALACIA PATELLAE
OSTEOARTHRITIS
2 CASES
osteosarcoma
 Baker cyst

Lipoma +
MCL INJURY
+ve

PCL LINE SIGN

PCL redundancy as a secondary sign of ACL tear. This is a relatively unreliable
secondary sign of ACL tear.
 Partial ACL tear
 Common about 10-43% of ACL tears
 Suboptimal accuracy of MRI
 Subtle 1ry and 2ry signs
 Focal angulation
 Focal increase T2 signal
[non specific ]
 Single bundle sign

Sagittal MRI shows an abruptly

angulated mid-ACL (arrow) .A wavy or
sharply angulated appearance is
abnormal.
Partial ACL tear ?!
 Chronic ACL Tear
 Fragmented ACL [ common finding ]
 Absent bone edema and contusions
 Empty notch sign
 ACL attached to PCL
 Chronic ACL tear, empty notch sign. T1-weighted coronal
MRI shows fat in the lateral intercondylar notch, ACL is
absent. This is a frequent MRI appearance of a chronic ACL
tear after resolution of acute edema and hemorrhage.
?
TORN ACL
?
Torn ACL at femoral attachment
?
Supportive signs of ACL tear
 ?
Torn ACL at femoral attachment
Normal ACL

Lax ACL
 Posterior cruciate ligament
 The major stabilizer of the knee
 Uniform low signal , no striations
 Twice strong as the ACL
 The menisco-femoral ligaments are intimately
related to PCL. They connect the posterior horn
of the lateral meniscus to the medial femoral
condyle
Ligament of Humphrey anterior to PCL
Ligament of Wrisberg posterior to PCL
 Proton-dense sagittal image demonstrates the normal
tibial insertion of the PCL. The insertion site is a
vertically inclined posterior to the articular surface.
 Posterior cruciate ligament
 PCL injuries represent about 12% of knee injuries
 Combined PCL injuries represent 97%
With ACL 65%
With MCL 50%
With MM 30%

TYPES OF PCL INJURES

Complete tear 40%
Partial tear 55%
Avulsion tear 7%
MR FINDINGS NORMAL PCL

Increased signal due to

hemorrhage and edema
Diffuse enlargement of PCL

TORN PCL
COMPLETE PCL TEAR
An enlarged, intermediate signal
(obviously torn) PCL
 NORMAL PCL
AVULSION TEAR
• Involves the tibial insertion
• Retracted bone fragment
• Bone marrow edema at avulsion site
• The actual PCL may be normal
AVULSION PCL TEAR
AVULSION PCL TEAR
PARTIAL PCL TEAR