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Acute Imaging of the Knee

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Monica Khanna

on 17 March 2015

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Transcript of Acute Imaging of the Knee

Flexion, Valgus, Tibial Rotation

Lateral Meniscus
Meniscofemoral ligament junction
Flexion, Varus, IR
1% of injuries
Bone contusions
Lateral femoral condyle
Posterolateral tibia
Segond fracture
Arcuate fracture
Ligamentous injuries
ACL
Posterolateral corner
Lateral and medial menisci at risk
Knee Dislocations
ACL tears in all
PCL in 90-100%
MCL in 50%
Posterolateral corner injury 60%
Arcuate fracture
Popliteus tear in 50%

Large number of A&E visits
60% are sports related
40% ages 20-29
70% men
Football 35%
Skiing 26%
Predictable patterns
Early MRI in acute knee injury facilitates faster diagnosis and management
Flexion, Valgus, Tibial Rotation
Bone contusions
Lateral femoral condyle
Posterolateral tibia
Posteromedial tibia
Flexion / Hyperflexion Injuries
8% of injuries
Dashboard injury
Fall on flexed knee
Bone contusions
Anterior tibia
Ligamentous injuries
Isolated PCL
Knee dislocation
Flexion / Hyperflexion Injuries
Force acting on anterior tibia
Posterior tibia displacement
Posterior bone bruising
Hyperextension injury
Injuries
ACL
PCL
Posterior capsule
posterolateral corner injury (varus)
posteromedial corner injury (valgus)
Hyperextension injury
Injuries
ACL
PCL
Posterior capsule
posterolateral corner injury (varus)
posteromedial corner injury (valgus)
Patellar Dislocation
Effusion or lipohaemarthrosis
Bone Contusions
Inferomedial patella
Lateral femoral condyle
Patellar Dislocation
Osteochondral injuries
Medial facet patella
Lateral trochlea
Intraarticular bodies
Flexion, Valgus, Tibial Rotation
Bone contusions
Lateral femoral condyle
Posterolateral tibia
Posteromedial tibia
Flexion, Valgus, Tibial Rotation
Medial meniscus
Peripheral tears
Meniscocapsular

Lateral Meniscus
Meniscofemoral ligament junction

Popliteus tears
Hyperextension injury
Injuries
ACL
PCL
Posterior capsule
posterolateral corner injury (varus)
posteromedial corner injury (valgus)
Monica Khanna
Imperial College Healthcare NHS Trust
London, UK

Sports
Imaging
2015

Valgus Injury
Clip injury
Typically mild flexion
More common than varus injuries
Valgus Injury
Bone contusions
Lateral femoral condyle
Lateral tibial plateau
Ligamentous injury
MCL
ACL or PCL
Flexion, Valgus, Tibial Rotation
ACL
Typically complete or high grade
Within 6 months most completely ruptured
Low grade tears typically no contusive injury
Flexion, Valgus, Tibial Rotation
MCL
Deep component
Superficial MCL
Bone bruising less common with isolated MCL injuries

Popliteus tears
Flexion, Valgus, Tibial Rotation
Hyperextension injury
Bone contusions
Anterior central tibia
Anterior femoral condyle
Arcuate fracture (varus)
Hyperextension injury
Bone contusions
Anterior central tibia
Anterior femoral condyle
Hyperextension injury
Bone contusion
Anterior femoral condyle
Hyperextension injury
Injuries
ACL
PCL
Posterior capsule
posterolateral corner injury (varus)
posteromedial corner injury (valgus)
Flexion, varus, IR
Hyperextension varus
<1% knee MRIs
Avulsion conjoined tendon insertion
Biceps femoris
FCL
Posterolateral corner injury
Arcuate Fracture
Knee Dislocation
High energy trauma
MVA/Pedestrian
Sports
Fall from height
Orthopaedic emergency
vascular / peroneal injury
Patellar dislocation
Flexion, Valgus, IR
Direct blow
Often reduces spontaneously
Clinically mistaken for meniscal or MCL tears
Patellar Dislocation
Ligamentous injuries
Medial retinaculum
MPFL
MCL
ACL
Forces and Restraints
Mechanisms of Knee Injury
Pure valgus (6%)
Pure varus (1%)

Flexion, valgus, tibial rotation (ER) 46%
(IR)
Flexion, varus, IR (1%)

Flexion with posterior translation (8%)
Hyperflexion
Hyperextension injuries (2%)
With varus (8%)
With valgus (2%)

Knee dislocations
Patellar dislocations (6%)
The Pivot Shift: Flexion, Valgus, Tibial Rotation
Anterior shear force

Rotational component
Tibial IR (femoral ER)
Tibial ER (Femoral IR)
Mild flexion: 5-40 degrees

Planted foot
Contact sports
Non-contact sports
Flexion, Valgus, Tibial Rotation
The Pivot Shift
Hyperextension injury
Mechanisms:
Anterior blow
Fall with hyperextension
Planted foot
Hyperextension injury
Mechanisms:
Anterior blow
Fall with hyperextension
Planted foot
Hyperextension injury
Injuries
ACL
PCL
Posterior capsule
posterolateral corner injury (varus)
posteromedial corner injury (valgus)
Knee Dislocation
Knee Dislocation
High energy trauma
MVA/Pedestrian
Sports
Fall from height
Orthopaedic emergency
vascular / peroneal injury
Knee Dislocations
Fractures 50%
Meniscal tears 50-70%
Posterior capsule 65%
Peroneal nerve injury 25%
Posterolateral dislocations
Popliteus tear
Case 1
Case 3
Arcuate Fracture
>90% have cruciate injury
>50% injuries to ACL and PCL
ACL tear typically distal as opposed to usual proximal-mid
2/3 posterior capsular injury
Popliteus injury 30%
Early Rx better results
Knee Dislocations - Classification
Posterior, anterior, medial, lateral, posterolateral
Schenck classification
KDI: ACL or PCL + collateral ligaments
KDII: ACL + PCL, intact collaterals
KDIII: ACL + PCL + one collateral
KDIV: 4 ligaments +/- neurovascular
KDV: Dislocation with condylar fracture
Conclusion
Contusive injury clue to the mechanism of injury

Mechanism of injury predicts pattern of injury

May help to identify more subtle injuries
Case 2
Case 3
Pivot shift:
Flexion,valgus,
Tibial rotation

Flexion/hyperflexion Injury
Hyperextension Injury
Knee
Dislocation

Patella
Dislocation

Cases
Introduction
Acute Knee Injury:
Mechanism Based Approach
to Knee Injury Interpretation

Osseous anatomy
Menisci
Capsulo-ligamentous structures
Hamstrings and extensor mechanism
Knee Stabilizers
Forces acting on the knee:
direction and magnitude
Rotation
Position of the knee
Position of the foot
1.
2.
4.
monica.khanna@imperial.nhs.uk
What are the xray findings?
What is the mechanism of injury?
What structures are potentially injured?

What are the xray findings?
Deepened lateral sulcus terminalis
Posterolateral tibial plateau impaction
What is the mechanism of injury?
Pivot shift

(flexion, valgus , tibial R)
What structures are potentially injured
ACL
MM -peripheral tears, meniscocapsular separation
LM tears-junction meniscofemoral ligament
Popliteus injury
What are the xray findings?
Segond fracture
What is the mechanism of injury?
Flexion, varus, internal rotation
What structures are potentially injured
ACL
Meniscal tear
Arcuate fracture
Avulsion of conjoined tendon
FCL and Biceps femoris
What are the xray findings?
Arcuate fracture
What is the mechanism of injury?
Flexion, varus, internal rotation
Hyperextension varus

What structures are potentially injured
Posterolateral corner
cruciate injury 90%, both 50%
posterior capsular injury 2/3
popliteus injuries 30%
35 year old footballer sustained a twisting injury
25 year old lady injured knee skiing
Less time of work
Improved pain
Reduced activity limitation
Better satisfaction scores
N.K. Patel et al.Knee Surgery, Sports Traumatology, Arthroscopy (March 2012)
Valgus Injury
Compression
Tension
Bones collide - impaction
Bone marrow contusion/fracture
Damage to interposed soft tissues
Distraction
Traction on stabilising structures
Joint capsule
Retinacula
ligaments
Tendons
3.
Pattern of bone contusion reflects the mechanism of injury
Predictable patterns of internal derangement
Sudden direction change
Cutting
Catching a ski edge
Landing from jump
Flexion, Valgus, Tibial Rotation
Medial meniscus
Peripheral tears
Meniscocapsular
Flexion varus
Internal Rotation

ACL Avulsion
Segond Fracture
ACL tear related impactions
Segond Fracture ACL Avulsion fracture
ACL avulsion fracture
Medial meniscal tear
Post op
Anteromedial tibia, femoral condyle
(impactions)
Posterolateral corner injury
FCL, biceps femoris tendon
Bone marrow oedema Anterolateral tibia
and femoral condyle (impactions)
PCL tear at femoral attachment
Grade II MCL tear at femoral attachment
Grade II MCL tear at femoral attachment
28 year old male playing football, sliding tackle
!
10 catergories
complex knee injury
Posterolateral Corner
Primary restraint
External rotation tibia

Lateral collateral complex

FCL & Biceps Tendon
Popliteus
Pop-fib ligament
Lateral head gastroc
Capsule
Arcuate ligament
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Grade II MCL
Grade III MCL
FCL
PFL
Popliteus
Full transcript