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MRI OF THE

KNEE
MARIA THERESA M. NAVARRO, MD
Fourth Year Radiology Resident
Department of Medical Imaging
Quirino Memorial Medical Center
MRI OF THE KNEE

most frequently requested MRI joint


study
comprehensive examination of the

knee
road map for surgeons in arthroscopy

or open surgery
sensitivity & specificity of 90% to

95% for the menisci and close to


100% in cruciate ligaments
MRI OF THE KNEE

SAGITTAL IMAGES

 meniscus
 cruciate ligaments
 T1W images, proton density, gradient
echo sequences
 T2W image with fat suppression
(cruciate ligaments, cartilage, and
bones)
CORONAL PLANE

 collateral ligament
 cruciate ligaments

MRI OF THE KNEE

AXIAL PLANE

 patellar cartilage
 trochlear cartilage
 medial patellar plica
 T2 sequences
ANATOMY OF THE
KNEE
Anterior Supporting Structures: Central Supporting Structures:
•Quadriceps muscles •ACL
•Patellar tendon •PCL
•Medial Retinacular & Vastus Medialis
•Lateral Retinacular & Vastus Lateralis

Lateral Supporting Structures:


Medial Supporting Structures: •Illiotibial band
•Superficial MCL •Biceps femoris
•Deep MCL •Lateral retinaculum
•Joint capsule •LCL
•Medial Retinaculum •Joint capsule

Posteromedial Corner: Posterolateral Corner:


•Semimembranous Tendon •Popliteus Muscle & Tendon
•Joint capsule •Arcuate ligament
•Posterior Oblique Ligament Posterior Supporting Structures: •Joint capsule
•Posterior Capsule
•Gastrocnemius Muscles
•PCL
By Hayes et al
MENISCAL TEARS
MENISCI
Functions

 shock
absorption
 stabilization
 lubrication
 proprioception
Normal Menisci

Medial
 •L a te ra l m e n iscu s
meniscus
Meniscal Tear
GRADE 1 GRADE 2 GRADE 3
Abnormal Menisci
According to Kaplan, et al., the only
abnormal signal that has any real
signficance is that which disrupts
the articular surface of the
meniscus  tear
Any signal that does not disrupt an

articular surface  intrasubstance


or myxoid degeneration
Meniscal Tear

 Abnormal morphology
 Irregular margin of
meniscus
 Focal defect on articular
surface
 Abnormally small
Meniscal Tear

Vertical tear

 Longitudinal tear
 Radial tear

Horizontal tear

Complex tear

HORIZONTAL TEAR
horizontal tear, cleavage tear,
fishmouth tear
meniscal tear that occurs in

horizontal plane, dissecting through


the circumferential collagen fibers
Best Diagnostic Clue: linear

horizontally oriented, increased


signal intensity on short TE
sequences
 within meniscus from free edge
inward
Stoller et al.2004. Diagnostic Imaging: Orthopaedics
Horizontal Tear
Most Common Location: posterior

horn of the medial meniscus

Stoller et al.2004. Diagnostic Imaging: Orthopaedics


Most
common
Horizontal Tear
RADIAL TEAR
Vertical tear oriented perpendicular

to the free edge of the meniscus


 Best Diagnostic Clue
 GHOST MENISCUS – when in plane of
acquisition in root tears
includes root tear at meniscotibial
attachement
Location :

 junction of the anterior horn and body


of the lateral meniscus
 meniscotibial attachment posterior
horn of the meniscus (root tear),
M e n isca lR a d ia lTe a r

Absent bowtie
sign
Parrot beak tear

Free-edge
tear

Sagittal PD FSE MR shows a radial


Axial oblique graphic shows a radial tear of posterior horn of the medial
tear involving the posterior horn of the meniscus at the root attachment giving
lateral mensicus at the meniscotibial a “ghost meniscus” appearance.
attachment
Radial Tear
MENISCAL CYST
 Cyst extending from meniscal tear
 horizontal tear most common
Best Diagnostic Clue : cystic mass
extending from a meniscal tear
Location :

 anterior horn of the lateral meniscus


 posterior horn of the medial meniscus
 Clinical Sign : Pisani’s sign (palpable
mass that disappears with flexion)
• Sagittal FS PD
FSE MR shows
a moderate
sized meniscal
cyst projecting
anteriorly from
an anterior
lateral
§Coronal PD FSE MR
meniscus tear
shows a small meniscal
cyst (arrow) adjacent to a
lateral meniscal tear of
the body
Meniscal Cyst

 Fluid extrusion
thru meniscal
tear
 MR evaluation
 Presence of
cyst
 Presence or
absence of
Meniscal Tear

Special types

 Bucket-handle tear
 Flipped meniscus
 Inferior flap tear
 Meniscocapsular
separation
 Meniscal root tear
BUCKET-HANDLE TEAR
Vertical peripheral tear with
displaced mesial portion to the
notch of knee
Best Diagnostic Clue:

 coronal images show small meniscus


body and meniscal fragments at the
notch resulting in 2 meniscal
fragments
 “double posterior cruciate ligament
(PCL) sign” on sagittal images
 “double delta sign”

Bucket Handle Tear
MENISCAL FLAP TEAR
Meniscus oblique tear
Tear of the meniscus with both

longitudinal and radial components


forming a flap of meniscal tissue
that may become displaced
Best Diagnostic Clue: obliquely

oriented tear of the meniscus


containing
 longitudinal component
 radial component
 Location : posterior horn and
posterior aspect of body of medial
Meniscal Flap Tear

Sagittal PD FSE MR shows a slightly


displaced flap tear of the medial
Vertical and horizontal component
meniscus with characteristic vertical
of a flap tear
signal intensity involving the inner 3rd
of the meniscus fibrocartilage
Flipped Meniscus

Too much meniscal tissue


Lateral meniscus
Inferior flap tear

 Flap of meniscus
 flip into medial
gutter
Meniscal Root Tear
Medial meniscus posterior root
Disruption of posterior horn near

PCL
DISCOID MENISCUS

• Large congenitally dysplastic


meniscus with loss of normal
semilunar shape
• Result of failure of resorption of the
central portion
• Best Diagnostic Clue : loss of normal
semilunar shape filling lateral or
medial compartment
• Location : lateral discoid meniscus
is more common
Stoller than Imaging:
et al., 2004 Diagnostic the medial
Orthopedics
Discoid Meniscus
Pitfalls
•M e n isco fe m o ra l  Transverse
lig a m e n t ligament
Transverse Ligament
MRI OF KNEE
LIGAMENTS
Lig a m e n t in ju rie s a re u su a lly
g ra d e d in te rm s o f th e ir se ve rity:

Grade I sprain – some micro-tearing or


slight stretching occurs, however the
overall integrity of the ligament is
preserved. The ligament hurts if stressed
but is stable.
Lig a m e n t in ju rie s a re u su a lly
g ra d e d in te rm s o f th e ir se ve rity:

Grade II sprain – partial disruption of the


ligament. Painful to stress, there is
detectable laxity but the ligament has an
eventual endpoint.
Lig a m e n t in ju rie s a re u su a lly
g ra d e d in te rm s o f th e ir se ve rity:

Grade III tear – complete ligament tear


and laxity with no endpoint or stability to
testing. As the nerves in the ligament are
torn too, there is often minimal pain with
stressing the joint
Direction of Injury-Producing Forces
Acting on the Knee
Hyperextension
Hyperextention, Hyperextension,
Varus Valgus

Pure Valgus
Pure Varus

Flexion, Varus, Flexion, Valgus,


Int. Rotation Ext. Rotation
Flexion,
Anterior Tibial
Translation
By Hayes et al
Anterior Cruciate
Ligament
Anterior Cruciate Ligament Tear
Best Diagnostic Clue : disruption of
normal continuous low signal
intensity ACL with irregularity and
increased signal on T2WI
Location : ACL in the intercondylar

notch of knee
most commonly caused

 by forward translation of tibia,


 external rotation of the femur with
respect to the tibia,
 valgus stress
Direct MR Signs of ACL Tear
• Discontinuity of
fibers
• Abnormal slope of
ACL
• Nonvisualization
of the ACL
fibers on both
sagital and
coronal planes
• Avulsion of the
anterior tibial
spine
Indirect MR Signs of ACL
Tear
Bone contusion sign: Lateral femoral
condyle and posterior tibial plateau (pivot-
shift injury)
Deep sulcus sign: Lateral femoral condyle

Segond fracture: Capsular avulsion fracture

of the lateral tibial plateau


Kissing contusions: Anterior tibia and

femur (hyperextension injury)


Anterior drawer sign: Anterior translation of

tibia relative to femur


Sagittal PD FSE MR
shows the typical
appearance of a proximal
ACL tear

Coronal FS PD FSE MR
shows an “empty lateral
intercondylar notch wall”
representing a grade III
ACL tear
Associated bone contusions
after an internal rotation valgus
mechanism of injury involving
the lateral femoral condyle and
the posterolateral tibia

Sagittal FS PD FSE MR shows


lateral bone injuries associated
with an ACL tear including the
posterolateral tibia and sulcus
terminalis of the lateral femoral
condyle. Proximal fibula is also
injured.
Posterior Cruciate
Ligament
PCL Tear
disruption of the PCL usually after forced
posterior displacement of the tibia
Best Diagnostic Clue: discontinuous and/or

thickened PCL fibers of increased signal


intensity on all pulse sequences
Location: Posterior tibia insertion site

avulsion fracture
Clinical : positive posterior drawer sign

(excessive mobility of the tibia


posteriorly)
caused by direct trauma impacting the

anterior knee in a posterior direction


(dashboard injury with the knee in
PC L TEA R

Sagittal FS PD FSE MR
Sagittal FS PD FSE MR
shows a complete tear of
shows a complete tear of
the PCL mid portion
the PCL
PC L TEA R

Sagittal graphic shows the Sagittal STIR MR shows a partial


typical anterior bone PCL tear and an anterior
contusion pattern of subchondral contusion of tibia in a
hypertension often seen with patient who suffered a dashboard
PCL tears injury
Contusion Patterns in PCL Tears
Direct Sign of PCL Injury

Complete tear
Partial tear

Peel-off injury: An avulsion injury of

the femoral insertion of the ligament.


Indirect Signs of PCL Injury

Bone marrow edema involving the


anterior proximal tibia
Avulsion of the posterior tibia at the

PCL insertion site


LCL TEAR
fibular collateral ligament tear
tear of the LCL after varus +/-

external rotation stress


Best Diagnostic Clue: Discontinuous

LCL fibers +/- thickening,


hyperintense on FS PD FSE or T2WI
Location: extends from lateral

femoral condyle to insertion with


the biceps femoris on the fibular
head
 usually at the proximal region

La te ra lC o lla te ra lLig a m e n t ( LC L ) Te a r

Tear at distal aspect of the lateral


Sagittal FS PD FSE MR shows a
collateral ligament with mild
tear of the lateral collateral
retraction of the ligament
ligament
proximally
Sagittal PD FSE MR shows a Coronal PD FSE MR shows a
normal LCL normal LCL
La te ra lC o lla te ra lLig a m e n t Te a r

Coronal PD FSE MR shows a Sagittal FS PD FSE MR shows


grade III sprain of the proximal a mid and distal aspect LCL
aspect of the LCL tear
Medial Collateral Ligament Tear
tibial collateral ligament tear
secondary to valgus stress

Best Diagnostic Clue: discontinuous MCL

with thickening and increased signal


intensity on all sequences within the
ligament remnant
Location : superficial and deep layers

(medial capsular ligament)


 superficial component – medial (tibial)
collateral ligament proper
 deep layer : meniscofemoral and
meniscotibial attachments
M e d ia lC o lla te ra lLig a m e n t Te a r

Coronal oblique graphic shows


a grade III tear of the proximal Coronal FS PD FSE shows a
aspect of the medial collateral grade III MCL tear after valgus
ligament injury
Take Home Point

MRI is a good imaging modality to detect


the ligament injuries.
Certain combination of forces cause

specific injury patterns.


Understanding the mechanism of injury is

important to improve the diagnosis.


Direct signs and Indirect signs are

important for diagnosis of ligament injury.



Thank you
po!