Imaging of Knee Ligaments Injury

(with MRI)

Paulus Rahardjo
Musculoskeletal Consultant Radiologist

Medical Faculty Airlangga University/ Dr. Soetomo General

Hospital Surabaya-Indonesia
 Ligaments of the knee

are major contributor to knee stability.

 Outline:
• MR characteristic of normal knee ligaments
• MRI of ACL tear (Primary + Secondary Signs)
• MRI of PCL tear (Primary + Secondary Signs)
• MRI of MCL tear
• MRI of LCL tear

ILLUSTRATED
 Normal ligaments in MRI
• They are usually show “dark” signal on all
pulse sequences (because of so few mobile
protons in ligaments).

• Exception; the striated appearance at part of

ACL (caused by the longitudinal arrangement
of fasciculi)
Normal ACL and PCL
 NORMAL striated ACLs

1/3 Anterior
DARK

2/3 Posterior
STRIATED

Patient 1 Patient 2 Patient 3 – zoomed in

Normal Ligaments of the knee

ACL PCL

LCL MCL
ACL Rupture
 Primary Signs of ACL Rupture
• Discontinuity of fibers
• Abnormal slope of ACL (“depression”)
• Scarring of ACL
• Non-visualization of the ACL fibers (in
chronic rupture)
• Avulsion of the anterior tibial spine
• Hyperintensity (bright signal)  should be
differentiated with partial rupture  look
for Secondry Signs
ILLUSTRATED
Primary Sign of ACL tear

Normal ACL TEAR

Discontinuity
Primary Sign of ACL tear

Normal ACL TEAR

Depression
Primary Sign of ACL tear
Intercondylar roof line
(Blumensaat line)

Normal ACL:
Parallel or forming
a slight angle
Normal ACL TEAR
Depression
Primary Sign of ACL tear

Normal ACL TEAR

Scar
Primary Sign of ACL tear

Normal ACL TEAR

Non_visualized
Primary Sign of ACL tear

ACL TEAR

Avulsion
Primary Sign of ACL tear

Avulsion
Primary Sign of ACL tear

Normal ACL TEAR?

Increased signal intensity

(+ increased thickness}
 ACL PARTIAL TEAR

Focal hyperintensity =
Tear AM Bundle- Intact
partial tear ACL
PL Bundle 0f ACL

TIPS: CHECK AXIAL AND CORONAL SLICES

http://www.radsource.us/clinic/0603
 ACL PARTIAL TEAR

Tear AM Bundle- Intact

PL Bundle 0f ACL

NORMAL TIPS: CHECK AXIAL AND CORONAL SLICES

http://www.radsource.us/clinic/0603
 ACL PARTIAL TEAR

CORONAL OBLIQUE SLICES

The AM bundle are disrupted at the femoral origin

(arrowhead) and the PM bundle is lax (arrow).

http://www.radsource.us/clinic/0603
 Secondary MR Signs of ACL Rupture
• Bone (“kissing”) contusion sign: Lateral femoral
condyle and posterior tibial plateau (pivot-shift
injury)
• Condylar notch sign
• Anterior drawer sign: Anterior translation of
tibia relative to femur
• Buckling PCL sign
• Joint hemorrhage
• Segond fracture: Capsular avulsion fracture of
the lateral tibial plateau ILLUSTRATED
Secondary Sign of ACL tear

Kissing
Contusions
Secondary Sign of ACL tear

Kissing
Contusions
Secondary Sign of ACL tear

Kissing
Contusions
Secondary Sign of ACL tear

Kissing
Contusions
Secondary Sign of ACL tear

Lateral Condylar Notch

Sign (if > 2mm deep)
Secondary Sign of ACL tear
Through Lat Condyle

> 7mm

Anterior
Draw
Sign
Secondary Sign of ACL tear
Through Lat Condyle

Exposed Post HornSign

Secondary Sign of ACL tear
Buckling PCL
Secondary Sign of ACL tear

Joint Hemorrhage
Secondary Sign of ACL tear

Joint Hemorrhage
 Segond Fracture
.. small avulsion fracture of lateral tibial plateau margins

MR imaging should be performed in all cases of Segond fracture due to the

extensively documented association of this injury with disruption of the
anterior cruciate ligament (ACL) and meniscal tear
GoldmanAB, Pavlov H, Rubenstein D. The Segond fracture of the proximal tibia: a small avulsion that reflects major ligamentous
damage. AJR Am J Roentgenol1988; 151: 1163–1167
“Unhappy triad”
(O'Donoghue in 1950)
Originally the "unhappy triad"
included a complete or partial tear of
2
the anterior cruciate ligament,
medial collateral ligament, and 1
the medial meniscus

Later (1990s), analysis indicated that

the 'classic' O'Donoghue triad is
actually an unusual clinical entity 3
among athletes with knee injuries.

The lateral meniscus tears are far

more common than medial meniscus
tears in sprains of the ACL.

Shelbourne KD. Am J Sports Med September 1991 vol. 19 no. 5 474-477

Barber FA. What is the terrible triad? Arthroscopy. 1992;8(1):19-22.
“Unhappy triad”
(O'Donoghue in 1950)
Originally the "unhappy triad"
included a complete or partial tear of
2
the anterior cruciate ligament,
medial collateral ligament, and 1
the medial meniscus

Later (1990s), analysis indicated that

the 'classic' O'Donoghue triad is
actually an unusual clinical entity ?
among athletes with knee injuries.

The lateral meniscus tears are far

more common than medial meniscus
tears in sprains of the ACL.

Shelbourne KD. Am J Sports Med September 1991 vol. 19 no. 5 474-477

Barber FA. What is the terrible triad? Arthroscopy. 1992;8(1):19-22.
PCL Rupture

ILLUSTRATED
Primary Sign of PCL rupture

NORMAL PCL DISCONTIUITY

Primary Sign of PCL rupture

NORMAL PCL PCL TEAR DISCONTIUITY

Primary Sign of PCL rupture

AVULSION
Primary Sign of PCL rupture

AVULSION
Primary Sign of PCL rupture
Increased AP DIAMETER
`
• On the basis of a
sensitivity of 94% and
specificity of 92%,
• 6 mm as the upper limit
of normal PCL thickness
• Thicknesses of 7 mm and
greater being suggestive
of a tear.

http://www.ajronline.org/doi/full/10.2
214/AJR.07.2921
Primary Sign of PCL rupture

NORMAL
> 6MMPCL PCL TEAR INCREASED INTENSITY
AND THICKNESS
Primary Sign of PCL rupture
` Elogation of PCL
• The PCL is usually injured
as the result of
stretching deformation;
on MRI, the ligament
maintains continuity as a
single structure with
apparent thickening

• >41 mm in length
indicate stretching

Total length: 48,4mm

Primary Sign of PCL rupture

NORMAL PCL PCL TEAR

Secondary Sign of PCL rupture

BONE CONTUSSION (EDEMA)

PATTERN 1: DASHBOARD INJURY
Secondary Sign of PCL rupture

PCL TEAR
Secondary Sign of PCL rupture
BONE CONTUSSION AT BOTH
FEMUR AND TIBIAL CONDYLES

RadioGraphics October 2000 vol. 20 no. suppl 1 S121-S134

PATTERN 2: HYPEREXTENSION
 Reverse Segond Fracture
. . elliptic bone fragment arising from the medial aspect of the proximal tibia

This fracture is known to be associated with both midsubstance tears of the

posterior cruciate ligament (PCL) and avulsions of the PCL from the posterior
tibial plateau, as well as tears of the medial meniscus.
EscobedoEM, Mills WJ, Hunter JC. The “reverse Segond” fracture: association with a tear of the posterior cruciate ligament and medial meniscus. AJR
Am J Roentgenol2002; 178: 979–983
Associated Injury of PCL tear
• Demonstrates
hemorrhage and edema
of the posterolateral
capsule and ligamentous
structures, suggesting a
posterolateral corner
injury.
MCL Rupture

ILLUSTRATED
Normal MCL
 Sprain
“Grade I tear”

Normal MCL with

bright signal at superficial side
Deep Fibers Tear + Partial MCL tear

Brighter MCL
with bright signal at
the deeper site (and superficial sites}
 Discontinuity

Discontinuity at proximal segment with surrounding

bright signal at adjacent soft tissue
 Chronic Partial Tear

Intact + thick MCL

 Chronic MCL tear + ossification
Pellegrini-Stieda disease.

Calcification of the proximal portion of the medial collateral ligament

(arrow) consistent with a chronic medial collateral ligament tear and
Pellegrini-Stieda disease.
LCL Rupture

ILLUSTRATED
LCL partial Rupture
LCL Total Rupture
LCL (chronic) tear/ scar
 Summary:
• MRI is the examination of choice in suspected
knee ligaments tear after plain radiograph is done.
• Bright signal means pathology of the ligaments
• MRI of ACL and PCL tear has primary and
secondary signs. The secondary signs are helpful
to differentiate between total and partial tear (or
mucoid degenerative changes especially for ACL)
• MRI of MCL and LCL tear has been covered.
Th a n k y ou