44. GEOGRAPHIC AREAS WITH NARROW ZONE OF THE TRANSITION. MEDIAL CONDYLE/ TIBIAL PLATEAU- WEIGHT BEARING AREAS INVOLVED. POSITIVE CRESCENT SIGN APPRECIATED AS PARALLEL SUBCHONDRAL HYPERINTENSITY IN TIBIOFEMORAL ARTICULATIONS.
61. MR - ARTHROSCOPY MEDIALLY FLIPPED MENISCUS DISKOID CAN IMPAIR VISION PERIPHERAL TEAR PRONE TO BE MISSED POST ARTHROSCOPY PAIN
62. ANY BODY CAN HAVE THE FACTS,BUT HAVING AN OPINION IS AN ART&MEDICINE IS AN ART
63. CASE REVIEW- ORTHOPAEDICS 25 Yr male with Acute Spontaneous onset of pain and swelling both knee joints (since Feb 2010) – Recurrent symptoms left knee.
64. MR PROTOCOL………. USE BODY COIL FIRST USE SURFACE COIL NEXT OBTAIN CORONAL OR SAGGITAL FIRST AXIALS TO FOLLOW DYNAMIC CONTRAST BETTER THEN CONVENTIONAL
70. THIS CASE CHEST SKIA GRAM ? RADIOGRAPH OF LESION? (NON SPECIFIC) EXTRA COMPARTMENT INTRA CAPSULAR CENTRIFUGAL CODMANS ANGLE LOBULATED LOW SIGNAL/ MODERATE ENHANCEMENT
75. Tears in the red zone of the meniscus may be treated with a variety of meniscus-preserving techniques (eg, suture repair); by contrast, tears in the white zone of the meniscus typically are treated by means of débridement (3,7). It also is important to identify a tear located in the red zone because the prognosis associated with such a tear is superior to that associated with tears in the white zone, regardless of whether white-zone tears are treated surgically (4–6).
76. Post Arthroscopy Appreciate the entry ports Anterior portal ( patellar tendon) – Heterogenoushoffa’s fat pad Recurrent – residual meniscal pathology – consider MR arthrogram Symptomatic post arthroscopy – recurrent / residual pathology – Necrotic changes in the bones. Meniscal morphology Diskoid meniscus ( lateral >Medial). Diskoid meniscus – impairs complete evaluation through single anterior appraocah Radial diametre > 12mm Diagnostic ( Sagittal 5mm thick scans – three section)
78. G ACL Image in external rotation / oblique image Double echo ACL TEAR – ancilliary findings Anterior tibialsubluxation > 5mm with respect to fibula Posterior dislocation to posterior horn of tibia. Kissing contusion – Posterolateraltibial plateau , anterior and middle femoral condyle Chronic ACL tear – Slumping of distal fragment over tibial spine. Intact lateral segment and slumping medial fragment Post ACL repair MR – Both osseous and intraarticular components seen ARTHROSCOPY – Limited to anterior graft surface.
79. PCL GRADE ONE –INTRALIGAMENTOUS HAEMORRHAGE / EDEMA GRADE TWO – PARTIAL TEAR GRADE THREE –COMPLETE TEAR BONY CONTUSIONS – LATERAL FEMORAL CONDYLE , ANTERIOR TIBIAL PLATEAU. MCL SUPERFEICIAL / DEEP PART - 8 TO 10CM LONG SPAN FRON MEDIAL FEMORAL EPICONDYLE TO MEDIAL TIBIAL METAPHYSIS. MCL DEEP TO PES ANSERINUS TENDON AND AWA FROM THE JOINT LINE.J O “DONOGHUE’S TRIAD- TEARS OF ACL /MCL/MEDIAL MENISCUS GRADE ONE – INTTRASUBSTANCE EDEMA/ HAEMORRHAGE GRADE TWO –PARTIAL TEAR GRADE THREE – COMPLETE TEAR
80. LCL ILIOTIBIIAL BAND/ TENDON OF BICEPS FEMORIS/RETINACULUM / ARCUATE LIGAMENT. EXTENDS FROM LATERAL FEMORAL EPICONDYLE EXTENDS INFERIORLY & JOINS TENDON OF BICEPS FEMORIS TO FORM CONJOINT TENDON INSERTING ON FIBULAR HEAD. SEGOND FRACTURE – AVULSION FRACTURE OF LATERAL CAPSULE AT IT’S TIBIAL INSERTION SITE. ASSOCIATION WITH ACL TEAR
81. PATELLAR TENDON CHRONIC STREEE OVER INSERTION SITE – PAIN/ INFLAMMATORY REACTION IN REGION OF TIBIAL TUBEROSITY – OS GOOD-SCHLATTER DISEASE.I LOSS OF NORMAL TONE – DEGENERATION TENDNITIS
82. BONY INJURIES TYPE I – MEDULLARY EDEMA – IGNORED CAN LEAD TO IMPACTIO FRACTURES. TYPE 2 – CORTICAL BREAK/ INTERUPPTION . INDENTATION APPRECIATED IN THE ROUND , SMOOTH , CONTOUR OF THE ARTICULAR SURFACE OF THE BONE . INTRAARTICULAR FAT MAY BE APPRECIATED TYPE THREE – SUBCHONDRAL DEGENERATIVE SCLEROSIS.H OSTEOCHONDRITIS DISSECANS FRAGMENTATION OF THE CORTICAL BONE LATERAL ASPECT OF THE MEDIAL FEMORAL CODYLE USUALLY UNILATERAL , YOUNG INDIVIDUALLS, LOOSE BODIES. DISPLACED / NON DISPLACED CORTICAL FRAGMENT STABLE / UNSTABLE CORTICAL FRAGMENT - >1CM SIZE, FLUID DEEP TO THE FRAGMENT, INCREASED BONY UPTAKE ON BONE SCAN. INTERUPPTED ARTICULAR CARTILAGE REPRESENT UNSTABLE FRAGMENT.
83. OSTEONECROSIS SPONTANEOUS OSTEONECROSIS POST TRAUMATIC OSTEONECROSIS DOUBLE LINE SIGN ON T2W OSTEOCYTE NUTRITION IS COMPROMISED CHONDROMALACIA CARTILAGE AND MENISCI INCRESE THE EFFECTIVE CONTACT BETWEEN THE ARTICULAR SURFACES CARTILAGE CAN TAKE UP 5 TIMES THAN THE NORMAL PRESSURE – ANY THING MORE THAN THAT CAN LEAD TO CHONDROMALACIA
84. MR GRADING OF CHONDROMALACIA 1- SURFACE INTACT ( FOCAL THICKENING/ MR SIGNAL CHANGE <10MM) 2-SURFACE FISSURE ( IRREGULAR SURFACE WITHOUT COMPLETE CARTILAGE LOSS >10MM<25MM) 3- EXPOSED BONE ( FULL THICKNESS LOSS OF CARTILAGE WITH JOINT FLUID CONTACTING BONE). ( >25MM) PATELLAR MALTRACKING / MAL ALIGNMENT Any malalignment/ maltracking occur only during early 5 to 30 degrees of flexion. Kinematic imaging with or without load ( dynamic imaging). Patella alta ( inferior pole of the patella placed high in relation to the trochlear groove) Patella baja / infera (inferior pole of the patella is positioned below the trochlear groove).
85. Patellar shape ( wiberg) Type 1 – Both lateral and medial facet are equal and concave . Type 2 – Medial facet is smaller than the lateral facet . Type 3 – Medial facet is significantly small in comparison to the lateral facet. Normal patellar alignment / tracking Ridge of the patella is placed in the centre of the trochleargoove all thorugh the flexion. Flexion movement – forces act on the patellofemoral joint. ( Retinaculum , quadriceps tendon ) Extension – no forces act of the patella ( any deviation is pseudosubluxation)
86. Excessive lateral patellar syndrome/ lateral patellar tilt . Medial subluxation of the patella ( patelloadentro) Lateral to medial subluxation Pictures Patella alta / baja Vastuslateralis Patellar tracking Forces around patella.
87. Periarticular fluid collections Bursae - Glide planes ( lubricating) Semimemberanous – semitendinosusbursae – popliteal / baker’s bursae. Tendon of pesanserinus / superficial MCL ( Pesanserinusbursae) MCL and semimemberanous tendon Semimemberanous and medial epicondyle of the femur Medial head of the gastrocnemius and posteromedial capsule – often communicating with the joint space.
88. Pesanserinus bursitis – fluid present medial to pes tendons ( sartorius / gracialis/ semitndinosis) MASSES OSTEOCHONDROMA - CARTILAGE CAP. ( <1CM) OSTEOID OSTEOMA - CENTRAL NIDUS WITH CALCIFIED LESION WITH PERILESIONAL EDEMA ( IF TRABECULAR) , PERILESIONAL SCLEROSIS ( IF CORTICAL). BONE ISLAND ENCHONDROMA – MATRIX CALCIFICATION PVNS – MONOARTICULAR , MULTIFOCAL, RARELY CALCIFIED. HAEMOSIDERIN STAIN OF SYNOVIUM SYNOVIAL CHONDROMATOSIS – METAPLASIA OF SYNOVIUM – CHONDRAL ISLANDS – LLOOSE BODIES
89. INFLAMMATION PANNUS – ISOINTENSE TO THE FLUID- CEMR HELPS TO DIFFERENTIATE THE PANNUS FRO JOINT FLUID.
90.
91. SONK (Spontaneous osteonecrosis of the knee joint) Age =40 to 60 years of age. Unknown etiology Steroid Haemoglobinopathy Transplant Fracture. Medial femoral condyle – common Lateral femoral condyle –less frequent Both together – Rare. Cortical flattening Subchondral cyst/ sclerosis. Crescent sign –Linear cleft immediately below and parallel to the involved cortex is visible ( representing subchondral fracture) Loose bodies - later stage.
92. OSTEOCHODRITIS DISSECANS SPONTANEOUS OSTEONECROSIS AGE = 40 to 60 years Medial condyle wt bearing surface Flattening - Present Collapse- Present Sequesteration- Present Loose body- Present Joint degeneration-Present AGE < 20 yrs Medial condyle non wt bearing surface Flattening - absent Collapse- absent Sequesteration- Present Loose body- Present Joint degeneration-absent.
93.
94. Look for step defect ( lucency in the subcortical location) on radiographs especially in wt bearing areas.
95. Crescent sign and flattening of the Cortical contour appreciated on MR .
