ANATOMICAL VARIANTS ON

KNEE MRI

ASIF SAIFUDDIN
Consultant Radiologist
RNOHT Stanmore
INTRODUCTION

 the knee is the commonest joint to be

imaged with MRI
 complex anatomy
– bones
– ligaments
– menisci
– tendons
– muscles

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INTRODUCTION

 anatomical variants are considered

present when
– there is variable appearance of a structure
that is always identified
– a normal anatomical structure may or may
not be routinely identified

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BONES
 BIPARTITE PATELLA

– separate patellar
fragment
» most commonly arises
from superolateral
margin

– prevalence of 2%
– bilateral in 40% of cases

– may occasionally be
tripartite or multipartite

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BONES
 SYMPTOMATIC
BIPARTITE PATELLA

– may be associated with

anterior knee pain
– MRI
» oedema on bipartite
fragment
» fluid at interface

– traumatic avulsion rare

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BONES
 DORSAL DEFECT
PATELLA

– defect in deep aspect of

superolateral patella
– prevalence ~1%
– MRI
» overlying cartilage intact
and fills defect

– rarely associated with

anterior knee pain

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BONES
I  PATELLAR SHAPE

– Wiberg types
» depend upon relative
II sizes of medial (M) and
lateral (L) facets

– 1 M=L (10%)
– 2 M<L (65%)
III – 3 M very small (25%)
» associated with trochlear
dysplasia

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BONES
 FABELLA

– sesamoid bone
» located at lateral head
gastrocnemius MT
junction
– prevalence 13-20%

– fabella syndrome
» posterolateral knee pain
over fabella
» OA/CM/fracture

Absent
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BONES
 DISTAL FEMUR

– distal femoral grooves

» anterior metaphysis
 vascular channels

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BONES
 DISTAL FEMUR

– distal femoral grooves

» lateral condyle
 condylopatellar sulcus
» medial condyle

– do not mistake as OCD

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BONES
Accessory  DISTAL FEMUR
ossification
centre
– anomalous ossification
lateral femoral condyle
– may mimic Stage 1 OCD
– differentiation
» asymptomatic
» location
» absence of oedema
» intact overlying cartilage

Spiculated
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MENISCUS
 MENISCAL FLOUNCE

– buckled meniscus
» wavy/folded
appearance of inner
meniscal margin

– 0.2-6% of knee MRI

» commoner medially

– associated with
ligamentous laxity
» transient
 absent at extremes of
flexion/extension

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MENISCUS
 MENISCAL
EXTRUSION

– extension of margin of
meniscus beyond tibial
plateau
– most commonly seen on
coronal images
– normal/asymptomatic
individuals
» medial (15%)
» lateral (13%)

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MENISCUS
 DISCOID MENISCUS

– normal meniscus
» semilunar
– discoid meniscus
» thickened ‘disc-like’
Normal
– Watanabe classification
» partial
» complete
» Wrisberg
 absent posterior capsular
attachment

Absent ‘bow-tie’
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MENISCUS
 DISCOID MENISCUS

– partial
» does not reach
intercondylar notch
– criteria
» minimal width in coronal
plane 15 mm.
» meniscal width >25% of
tibial plateau width

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MENISCUS
 DISCOID MENISCUS

– complete
» reaches intercondylar
notch
– much commoner laterally
» prevalence 3%
» asymptomatic unless torn
» Wrisberg type
 hypermobile
 can sublux causing
locking

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MENISCUS
 LATERAL MENISCUS

– speckled anterior horn

– common finding due to
fibres of ACL inserting
into meniscus
– do not mistake as
anterior horn tear
» 2% of all meniscal tears
» 6% of lateral meniscal
tears

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MENISCUS
 MENISCAL OSSICLE

– commonest
» young males
» posterior third medial
meniscus
– aetiology
» developmental
» post-traumatic

– occasionally symptomatic

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MENISCUS

 other meniscal malformations

– 0.3% (excluding discoid)
– more common laterally

 ring-like meniscus
– may mimic bucket handle fragment in
intercondylar notch
 double layered
 abnormal lateral band

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SYNOVIAL PLICAE
 intra-articular folds of vascularised
synovial tissue
 remnants of synovial membrane
– medial, superior, inferior
» lateral very rare
 incidence of 50-90%
– 11% of knees have all 3
 MRI
– optimally identified in presence of
effusion
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SYNOVIAL PLICAE
 INFRA-PATELLAR

– commonest plica
– curved course running
from
» intercondylar notch
anterior to ACL
» inferior pole of patella

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SYNOVIAL PLICAE
 MEDIO-PATELLAR

– most likely to be
symptomatic
– runs from
» medial wall of knee joint
» synovium overlying
Hoffa’s fat pad

– 4 Types described
» A small ridge
» B shelf-like
Type B
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SYNOVIAL PLICAE
 MEDIO-PATELLAR

– 4 Types described
» C extends across MFC
» D central fenestration
Type C
– Types 3 and 4 more
likely symptomatic
» impingement between
MFC and patella

Type D
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SYNOVIAL PLICAE
 SUPRA-PATELLAR

– oblique membrane
located just above
patella

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SYNOVIAL PLICAE
 SUPRA-PATELLAR

– complete
– results in separation of
supra-patellar bursa
– inflammation
» mimics ST tumour

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LIGAMENTS
 OBLIQUE MENISCO-
MENISCAL
– runs obliquely through
intercondylar notch
between ACL and PCL
– anterior horn to
contralateral posterior
horn
» medial>lateral
– prevalence 2-4%
– may mimic free meniscal
fragment

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LIGAMENTS
 MENISCO-FIBULAR

– capsular ligament
extending from posterior
third of lateral meniscus
to fibular head
– always present in
dissection specimens
– seen on 16-63% of knee
MRI
» slice thickness
» presence of effusion

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LIGAMENTS
 FABELLO-FIBULAR

– extends from fabella to

styloid process of fibular
head
– identified in
» 24-80% of dissection
specimens
» 48% of coronal oblique
MRI studies

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LIGAMENTS
 POPLITEO-FIBULAR

– major stabiliser of PLC

– extends from popliteus
musculotendinous
junction to fibular head
– almost always present in
dissection specimens
– seen in ~50% of coronal
oblique MRI studies
» also commonly identified
on sagittal MR images

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LIGAMENTS
 MENISCO-FEMORAL
– extend from posterior
horn of lateral meniscus
to
» medial wall of
intercondylar notch
» PCL
– present in 93% of
population
– on MRI
» Humphrey (12%)
» Wrisberg (42%)

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LIGAMENTS
 MENISCO-FEMORAL

– prominent Ligament of
Humphrey may mimic
‘double PCL’ sign

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LIGAMENTS
 MENISCO-FEMORAL

– anteromedial MFL
– rare
– runs anterior and parallel
to ACL
– arises from anterior horn
of medial meniscus

– may mimic ligamentum

mucosum

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LIGAMENTS
 TRANSVERSE INTER-
MENISCAL

– extends through Hoffa’s

fat pad between anterior
horns of the menisci
– prevalence
» 93% at arthroscopy
» 58% on MRI

– if >3mm thickness
» ‘cord-like’

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LIGAMENTS
 POSTERIOR
CRUCIATE

– usually smoothly curved

– may be kinked at genu

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LIGAMENTS
 POSTERIOR
CRUCIATE

– has two bundles

» anterolateral
» posteromedial

– when seen separately on

MRI
» ‘double-barrelled’ PCL

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LIGAMENTS
 POSTERIOR
CRUCIATE

– posterior oblique fibres

also exist
– oblique insertion into
medial femoral condyle
» commonly seen on MRI
» may be mistaken for
meniscofemoral
ligament

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TENDONS
 POPLITEUS

– constant component of
the PLC
– extends from popliteus
musculotendinous
junction to lateral femoral
condyle
– bifurcate popliteus
tendon reported in 0.4%
of knees at arthroscopy

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TENDONS
Lateral  QUADRICEPS

– formed from combination

of
» rectus femoris
» vastus lateralis,
intermedius and
medialis
– multi-layered structure
» single (8%)
» double (30%)
» triple (56%)
» quadruple (6%)
Medial
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TENDONS
 PATELLAR

– buckled
» relatively common
» especially when imaged
erect

– more commonly seen with

Erect
» joint effusion
» ACL rupture

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TENDONS
 BICEPS FEMORIS

– distal insertion typically

into fibular head as part
of conjoined tendon

– separate insertion into

lateral tibial condyle is
commonly seen

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TENDONS
 BICEPS FEMORIS

– predominant/exclusive
tibial insertion

– may be associated with

painful snapping knee

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TENDONS
 SEMIMEMBRANOSUS

– multiple distal insertions

into proximal tibia and
posterior capsule

– intra-tendinous fat
» may mimic partial tear

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MUSCLES
 ARTICULAR MUSCLE

– almost always present

– originates
» anterior shaft distal femur
– inserts
» supra-patellar pouch
– variable size
» single/multiple bundles
– function
» retracts SP pouch in knee
extension

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MUSCLES
 SARTORIUS

– distal insertion may be

predominantly
» tendinous
» muscular

– distal tendon may

bifurcate

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MUSCLES
 ACCESSORY
GASTROCNEMIUS

– typically has medial and

lateral heads arising from
posterior femoral
metaphysis
– third head commonest
variant
» 2.9-5.5% of population
Posterior distal
» may cause popliteal
femur to lateral
entrapment syndrome
head

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MUSCLES
 accessory popliteus
– arises from fabella end inserts into posterior
proximal tibia
– separately or with main muscle

 plantaris
– absent I 10%
– multiple origins and insertions
– thin and fibrous to bulky muscle belly

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CONCLUSIONS

 a large variety of anatomical

variants are seen on knee MRI

 need to be recognised

 some may be symptomatic

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