RADIOLOGIC EVALUATION OF

KNEE and
◤
TIBIA/FIBULA
 ◤
KNEE JOINT

-the complex arthrokinematics of the knee allows for great

stability combined with great mobility.

-the knee’s unique anatomy, combined with its exposed

location between the two longest bones of the body, does,
however, predispose it to various injuries, trauma, and other
pathologies.
 ◤

ANATOMY
REVIEW
◤
◤
 ◤
JOINT MOBILITY

▪ The knee functions as a specialized hinge joint, permitting a

wide range of flexion and extension movement in the sagittal
plane.

▪ Accessory rotation mobility is present in the transverse

plane.
◤
Q ANGLE

▪ determined by the intersection of

the line of pull of the quadriceps
with the line connecting the center
of the patella to the center of the
tibial tuberosity.

▪ The normal Q angle is

approximately 10 degrees
 ◤
GROWTH AND DEVELOPMENT
▪ At birth, the secondary epiphyseal centers for the distal femur and the
proximal tibia are present and can be identified as ossified structures on
radiograph.

▪ The secondary epiphyseal center for the head of the fibula does not
appear until approximately 3 years of age.

▪ The patella is not visible on radiographs until it begins ossification at

approximately 4 years of age.

▪ The physis of each long bone continues to grow progressively, and the
physeal plates finally fuse postpuberty at approximately 16 to 18 years of
age.

▪ Women generally show earlier skeletal maturity than men.

◤
GROWTH AND DEVELOPMENT
◤
 Practice
◤ Guidelines for Knee Radiography in
Children and Adults
Goal
- identify or exclude anatomic abnormalities or disease processes

▪ Indications

▪ trauma (including suspected physical abuse); osseous changes secondary to

metabolic disease, systemic disease, or nutritional deficiencies; neoplasms;
infections; non neoplastic bone pathology; arthropathies; pre-operative, post-
operative, and follow-up studies; congenital syndromes and developmental
disorders; vascular lesions; evaluation of soft tissue (such as for a suspected foreign
body); pain; and correlation of abnormal skeletal findings on other imaging studies.

▪ The minimum recommended projections are an anteroposterior (AP) and lateral

projection of the knee and patella and a tangential view of the patella.
◤
ROUTINE RADIOLOGIC EVALUATION
OF THE KNEE
BASIC PROJECTIONS

- Anteroposterior (AP)

- Lateral

- Posteroanterior (PA) axial “tunnel” view of

the intercondylar fossa

- Tangential view of the patellofemoral joint

 ◤

This view demonstrates the distal femur, proximal tibia, the

femorotibial articulation, and head of the fibula
◤ ANTEROPOSTERIOR VIEW
 ◤
LATERAL VIEW

- demonstrates the patellofemoral joint in profile, the

suprapatellar bursa, the quadriceps tendon, and the patellar
tendon.

- patient is normally in a lateral recumbent position, lying on

the side that is being examined.
◤
LATERAL VIEW
 ◤
PA axial “tunnel” view of the
intercondylar fossa

- demonstrates the intercondylar fossa, the posterior aspects of the

femoral and tibial condyles, the intercondylar eminence of the
tibia, and the tibial plateaus.

- often done with the patient in a standing position for evaluation of

osteoarthritis.
◤
PA axial “tunnel” view of the
intercondylar fossa
 ◤
Tangential view of the patellofemoral
joint

- demonstrates an axial view of the

patellofemoral joint space and the articular
surfaces of the patella and the femur.
◤ Tangential view of the patellofemoral joint

a. Sulcus angle
b. Congruence angle
◤
Additional Views

(A) Internal oblique view

(B) External oblique view

 ◤
Advanced Imaging Evaluation

▪ The most frequently requested MRI exams are for the knee and the shoulder.

▪ This makes sense due to the frequency of soft tissue injuries at these joints,
which are best defined by MRI

▪ Remember that radiographs will continue to be the first imaging test

performed for most suspected bone and soft tissue abnormalities of the knee,
and will often suffice to either (1) diagnose the problem and initiate treatment
or (2) exclude an abnormality and direct further imaging.
 ◤
Practice Guidelines for CT of the Knee

Indications

● Severe trauma
● Assessment of alignment and displacement of fracture fragments
● Identifying loose bodies in the joint
● Evaluation of tibial plateau depression fractures
● Evaluation of any condition typically seen by MRI if MRI is
contraindicated; this includes the use of intra- articular contrast for
a CT arthrogram, if MR arthrogram is contraindicated
 ◤
BASIC CT PROTOCOL

▪ A CT exam of the knee extends from the suprapatellar region to the

proximal tibia.

▪ The scanning plane is aligned with the tibial plateau.

▪ The scanning plane and reference slices can be seen on the preliminary
scout view.

▪ Most current CT scanners obtain very thin (<1 mm) slices in the axial
plane.
◤
CT of the KNEE

▪ Parameters:

● Scanning plane is parallel to tibial plateau

● Field of view extends from supra - patellar

region to the proximal tibia, including the
proximal tibiofibula joint.

● Slices are <1 mm thick, and recon- structed to

2-3 mm thick. 40-100 are reviewed in each plane.
◤
CT of the KNEE
◤
CT of the KNEE
 ◤
MRI of the KNEE
INDICATIONS

▪ ● Meniscal disorders: tears, discoid menisci, meniscal cysts; complications of

meniscal surgery
● Ligament abnormalities: cruciate and collateral sprains and tears; complications
following repair

▪ ● Extensor mechanism abnormalities: quadriceps and patellar tendon degeneration,

partial, and complete tears; patellar fractures and periosteal sleeve avulsions; and
retinacular sprains and tears

▪ ● Osteochondral abnormalities: osteochondral fractures, osteochondritis dissecans,

treated osteochondral defects
◤ AXIAL PLANE
 ◤

SAGITTAL PLANE
◤
CORONAL PLANE
◤
MR Arthrogram
 ◤
TRAUMA at the KNEE

▪ Radiographs should be ordered after trauma if there are any

of the following present: joint effusion after a direct blow or
fall, inability to walk without limping, palpable tenderness
over the patella or fibular head, or inability
to flex the knee to 90 degrees.

▪ Radiographs should not be ordered if a patient had a twisting

injury but is able to walk and no effusion is present.
◤ FRACTURES OF THE DISTAL FEMUR

Mechanism

▪ Fractures of the distal femur occur when great

force is applied, as in motor vehicle accidents or
falls from great heights. Low-level forces or minor
falls can cause fracture if the bone is weakened
by preexisting osteoporosis or other pathology.
 ◤
FRACTURES OF THE DISTAL FEMUR

▪ TREATMENT

▪ The objective of treatment in femoral fractures is not perfect anatomic reduction of the
fracture site but restoration of the knee axis to a normal relationship with the hip and ankle.

NON OPERATIVE

- Nonoperative treatment of distal femoral fractures may involve continuous skeletal traction
via pinning through the tibial shaft, followed by casting at 3 to 6 weeks after injury

SURGICAL

Surgical reduction with internal fixation is usually necessary with open fractures
◤
SUPRACONDYLAR FRACTURE OF
DISTAL FEMUR
Rehabilitation begins early to maintain joint range of
motion.

Ambulation with partial weight-bearing is progressed as

radiographic evidence demonstrates healing.

Patients are generally ambulating well with a device 4

weeks after injury and can expect return to normal
activity within 3 to 4 months.

Complications include malunion, which may result in a

rotated or shortened limb; joint and soft tissue
adhesions; an posttraumatic degenerative joint disease.
◤
FRACTURES of THE PROXIMAL TIBIA

- occur most frequently at the medial and lateral

tibial plateaus, when varus or valgus forces
combined with axial compression cause the hard
femoral condyle to impact and depress the softer
tibia plateau.

A common mechanism of injury is a car–

pedestrian accident in which the car’s bumper
strikes the pedestrian’s knee.

Elderly patients with osteoporosis are more likely

to sustain a tibial plateau fracture than a soft
tissue in jury after a twisting injury to the knee.

AP, lateral, and both oblique radiographs of the

knee are usually obtained.
◤
◤
 TIBIAL◤ PLATEAU FRACTURES
TREATMENT

▪ NONOPERATIVE TREATMENT for minimally displaced fractures and, especially, in elderly

patients with osteoporosis. The patient is non–weight bearing for 4 to 6 weeks, then partially
weight-bearing until solid bony union is radiographically evident, as should occur in another
4 to 6 weeks.

▪ OPERATIVE TREATMENT for patients with significant articular surface depression or

displacement, open fractures, or ruptured ligaments. Internal fixation utilizes plate or screws
and can involve elevating and internally fixating the depressed plateau and filling the
underlying defect wit bone grafts

COMPLICATIONS

▪ Possible complications include peroneal nerve injury; popliteal artery injury; avascular
necrosis of small articular fragments, which may result in loose bodies in the joint
◤
LIPOHEMARTHROSIS

▪ Fat and blood escapes from the marrow space

through the fracture and mixes with synovial
fluid in the joint.
◤ FRACTURES OF THE PATELLA
Falls or dashboard impactions
fracture the patella as it is
compressed against the femur.

Avulsion fractures occur when

the patella is pulled apart by
forceful contraction of the
quadriceps coupled with passive
resistance of the patellar
ligament.

- seen when a person attempts to

keep from falling after tripping.
◤
PATELLAR FRACTURES

Radiographic assessment of
patellar fractures is generally
complete on routine tangential,
lateral, and oblique views.
 PATELLAR FRACTURES
◤
TREATMENT

▪ NONOPERATIVE for nondisplaced or minimally displaced fractures. Immobilization in a long

leg cast for 4 to 6 weeks with full weight-bearing, crutch- assisted ambulation is typical and is
often followed with a hinged knee brace for protected progressive return of knee motion.

▪ OPERATIVE TREATMENT for significant fragment displacement, articular incongruity, or

open fractures. Multiple methods of fixation exist, including tension banding with wires or
cancellous screws. Range-of-motion exercises are initiated a few days after surgery, and
ambulation is progressive to partial and then full weight-bearing by 6 weeks.

▪ COMPLICATIONS

▪ If the patella is present, complications include posttraumatic degenerative joint disease of the
patellofemoral joint.
PATELLOFEMORAL
◤
SUBLUXATION
 ◤
PATELLOFEMORAL SUBLUXATION
TREATMENT
CONSERVATIVE TREATMENT focuses on minimizing the abnormal
biomechanics that predispose the patellofemoral joint to subluxation.
Strengthening and stretching exercises, or- thotics, patellar taping, and muscle
reeducation are part of rehabilitation.

Surgical release of the lateral patellar retinaculum may be indicated for

correction of patellar malalignment.

Distal repositioning of the patellar ligament insertion is indicated for the

correction of extensor mechanism malalignment or to reduce an excessive
patellar Q angle.
 ◤ Injury to the Articular Cartilage

-OSTEOCHONDRAL FRACTURE
 ◤ OSTEOCHONDRAL FRACTURE

▪ It is most often sports-related injuries involving combinations of shear,

rotation, and impaction forces at the knee that damage the articular
cartilage ( chondral fracture) or the articular cartilage and underlying
subchondral bone ( osteochondral fracture).
 ◤
Osteochondritis Dissecans (OCD)

▪ seen in older children, teenagers, and young adults, particularly those active in
sports.

▪ Dull pain and chronic joint effusions are exacerbated with weightbearin activity

▪ a chronic form of osteochondral fracture.

▪ The non–weight-bearing medial femoral condyle is involved 85% of the time.

▪ MECHANISM

▪ As in the case of osteochondral fracture, shearing and rota tional forces act to detach
a fragment of articular cartilage and subchondral bone.
 ◤
SPONTANEOUS OSTEONECROSIS

▪ affects older adults and has a predilection for the weight-bearing area of the medial
femoral condyle.

▪ MECHANISM

- presents in older adults, usually female, as an acute pain without a history of trauma.

▪ ETIOLOGY

- associated with steroids, administered either parenterally or by intra-articular

injection

- associated with preexisting meniscal tears that may cause a concentrated area of
stress between the femoral condyle and meniscal fragment.
 ◤
MENISCAL TEARS

▪ common sports-related and age-related injuries

▪ isolated tears present with intermittent clicking and eventually

chronic blocking or locking of knee joint motion, accompanied
by episodes of effusion and pain
 ◤
MENISCAL TEARS
◤
MENISCAL TEARS
 ◤ MENISCAL TEARS TREATMENT

▪ surgical intervention because the torn fragment will disrupt normal knee
functioning.

▪ Partial meniscectomies excise the torn portion of the meniscus and preserve
as much of the meniscus as possible.

▪ Rehabilitation generally involves an early phase of protected joint motion,

isometric exercise, and partial weight-bearing; an intermediate phase of
progressive isotonic and isokinetic exercise and progressive ambulation;
and a return to function phase involving full restoration of normal range of
motion and plyometrics to prepare for joint-loading situations.

▪ Generally, the patient returns to full function in 4 to 5 months.

 ◤
INJURY TO THE LIGAMENTS
TEAR OF COLLATERAL LIGAMENTS

▪ The patient presents after an acute episode with pain, joint

effusion, and instability upon physical examination via
ligamentous stress testing.

▪ MECHANISM OF INJURY

▪ The lateral collateral ligament is injured from a varus force.

◤
 ◤
TEARS OF CRUCIATE LIGAMENTS

▪ Sports-related anterior cruciate ligament injuries occur at a rate

of about 200,000 per year in the United States.

▪ Women are affected up to eight times more often than men

participating in the same sports; factors implicated in this
disparity include hormones, anatomic differences, and more
uprigh posture during athletic activity.

▪ The true incidence of the less common posterior cruciate

ligament injury is not known.
◤
◤
◤
Anterior dislocation of the knee with
Rupture of Ligaments
 ◤ TRAUMA TO THE PATELLAR
LIGAMENT
Sinding–Larsen–Johansson disease- the disorder at the proximal patellar attachment
Osgood–Schlatter disease - the disorder at the distal patellar attachment

MECHANISM OF INJURY

▪ mechanical in etiology, possibly initiated by trauma such as a fall, and as such are not
true disease processes.

▪ the repetitive irritation from tension force generated by quadriceps activity postinjury is
theorized to be a factor in the development of these traction apophysitis conditions.

▪ chronic irritation from activities such as jumping and running on hard surfaces
exacerbates these conditions.
◤
TREATMENT

▪ limited activity, modalities to control

inflammation and pain, and protective
padding to prevent further impact to
the knee.

▪ surgical excision of large calcified

areas may be necessary.
◤
 ◤
DEJENERATIVE JOINT DISEASE

▪ CAUSES:

▪ Repetitive mechanical and compressive stresses from

occupational, recreational, athletic, and normal activities of daily
living over many decades typically result in degenerative changes
in the joints.

▪ Also, secondary degenerative changes are long-term sequelae of

previous fracture, meniscal, or ligamentous injury.
◤
KNEE DJD

Radiographic signs:

1.Decreased radiographic joint space

2. Sclerosis of subchondral bone

3. Osteophyte formation at joint margins

4. Subchondral cyst formation

5. Varus or valgus joint deformity
 ◤
KNEE ANOMALIES

▪ GENU VALGUM/”knock-knees”- the distal ends o the tibia are

spaced widely apart when the knees are approximated

▪ GENU VARUM/“bow legs- the knees are spaced wide apart

when the ankle malleoli are in contact

▪ GENU RECURVATUM - excessive hyperextension of the knee

◤
GENU VALGUM

The condition becomes most obvious when a child

begins to ambulate.

Etiology: may be familial, related to hip or foot

positioning, associated with trauma to the physeal
plate, fractures, or neurological deficits, or it may
be idiopathic.

The AP radiograph of the entire lower extremity

adequately demonstrates this deformity.
◤
GENU VARUM

▪ It is common for a certain amount of apparent

bowing to be present in infants and toddlers; this
physiological bowing will be symmetrical and is
usually outgrown during childhood, decreasing
progressively as the child ages

▪ Etiology: maybe related to renal or dietary rickets,

epiphyseal injury, osteogenesis imperfecta, or
medial tibial osteochondritis, known as Blount’s
disease.
◤
GENU RECURVATUM

▪ Etiologies: may be familial, idiopathic, or related

to neurological and muscular deficits.

▪ Treatment : usually conservative, using bracing

and exercise to restore alignment and muscular
balance.

▪ The lateral radiograph demonstrates this

deformity.
◤

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