Imaging of the Athle/c Knee: injuries associated with ACL disrup/on
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1 Imaging of the Athle/c Knee: injuries associated with ACL disrup/on Brian Petersen, MD Associate Professor of Radiology and Orthopaedics Chief of MSK Radiology University of Colorado CU Sports Medicine Symposium October 4, 2013
2 Learning Objec/ves Allow marrow contusion pa?erns to guide injury evalua/on Recognize common radiographic signs of ACL disrup/on Improve accuracy by increased awareness of injuries associated with ACL tear
3 Injuries Associated with ACL Disrup/on Acute ACL injury- almost never in isola/on Marrow contusion (Fxr) Meniscal tears LMT>MMT MCL injury PCL injury LCL complex injury Posterolateral corner injury Soleus injury
4 Radiographic Signs of ACL Disrup/on Deep sulcus sign (lateral femoral notch sign) Segond fracture Tibial spine avulsion Arcuate avulsion of the fibula
5 Fracture- Deep Sulcus Sign
6 Avulsion Fracture- Segond Avulsion of the lateral capsular ligament Associated injuries ACL (~100%) LMT or MMT (66-70%).
7 Avulsion Fracture: Tibial Spine More common in pediatric popula/on Tibial spine bony inser/on fails before ligament
8 Avulsion Fracture: Arcuate Sign Crescent shaped avulsion fracture of the fibular styloid Associated with injuries to a?achment of ligaments of posterolateral corner Popliteofibular Arcuate Fabellofibular May include the conjoined tendon a?achment if large Juhng, S.-K. et al. Am. J. Roentgenol. 2002;178:
9 Associated Injuries Associated injuries can depend on the mechanism of injury (MOI) Pivot shiv injury- non contact torsional forces Anterior /bial force in knee flexion (dashboard injury) Hyperextension injury Clip injury Marrow contusion pa?ern!!! Hayes, C. W. et al. Radiographics 2000;20: S
10 Pivot ShiV Non- contact or indirect mechanism of injury Valgus load, flexion and external rota/on of /bia or internal rota/on of the femur Skiers, football, soccer players etc.
11 Pivot ShiV Injury: Marrow Contusion Classic bone bruise pa?ern- LFC/LTP Medial /bial plateau contusion less common ( about 25%) Contre- coup injury with contact of FC (MFC?LFC?) and MTP with rela/ve varus forces upon reduc/on Very high incidence of MMT with MTP contusion
12 Dashboard injury: Marrow Contusion Force applied to anterior /bia with knee in flexion Bone bruise pa?ern of anterior /bia, posterior patella Associated with PCL rupture, ACL rupture and posterior capsule injury Sanders, T. G. et al. Radiographics 2000;20: S
13 Hyperextension Injury: Marrow Contusion Kissing contusions anterior femoral condyle and anterior /bial plateau ACL, PCL, menisci, and posterior capsule injuries Can result in disloca/on Disloca/on can risk neurovascular compromise of popliteal artery and /bial nerve in popliteal fossa Sanders, T. G. et al. Radiographics 2000;20: S
14 Clip Injury: Marrow Contusion Contact injury with pure valgus stress on par/ally flexed knee ACL, MCL, meniscal tear O Donaghue s terrible triad= ACL, MCL and MMT More common to have ACL, MCL, LMT Sanders, T. G. et al. Radiographics 2000;20: S
15 MFC Edema Not typically direct blow Variable amounts detected in 56% of acute ACL tears (Eaton, Petersen 2013)
16 MFC Edema Avulsion of the meniscofemoral ligament component of the deep MCL (dmcl) 73% of MFC edema had tears of the dmcl (OR=7.6, p<.0001; Eaton, Petersen 2013) Torn dmcl=7.6or of MFC De Maeseneer M et al. Radiographics 2000;20:S83-S by Radiological Society o North America
17 Meniscal Tears 41-68% of acute ACL injuries in adults Up to 79% in pediatric popula/on Lateral more common than medial in acute semng Bone contusion to the posterior /bial plateau increases likelihood of tear
18 Medial Meniscal Tears Associa/on of medial meniscal tear with medial /bial bone bruise is excep/onally high 96% (24/25) by Kaplan et al. Commonly peripheral and ver/cal at the meniscocapsular junc/on
19 Meniscal Tears O Donoghue s Terrible Triad of ACL, MCL and MMT is unusual ACL, MCL and LMT more common according to Shelbourne and Nitz High incidence of displaced meniscal flap into the intercondylar notch with LMT
20 MCL Injury Injured with valgus stress/torsion MR grading system Grade I: edema without tear Grade II: par/al tear Grade III: complete tear
21 MCL Injury Injured with valgus stress/torsion MR grading system Grade I: edema without tear Grade II: par/al tear Grade III: complete tear Distal MCL injury can be a surgical lesion
22 PCL injury Hyperextension mechanism- first to fail followed by ACL Sanders, T. G. et al. Radiographics 2000;20: S
23 Posterolateral Corner (PLC) Increasing awareness of importance of PLC injury in the surgical literature Persistent PLC instability resul/ng from high grade PLC injury can result in failure of ACL and PCL repair The urgency of PLC assessment and repair is related to the need for early surgical management (less than 2-3 weeks), if primary repair is a?empted
24 Anatomy of the PLC Posterolateral corner stabilizers are both sta/c and dynamic Posterior cruciate ligament Fibular collateral ligament Popliteus muscle and tendon Posterolateral joint capsule Popliteofibular ligament Arcuate ligament- medial and lateral limbs Fabellofibular ligament in the presence of a fabella
25 Imaging of PLC The ligaments of the PLC are small and difficult to assess individually as intact and normal Edema superficial to the posterolateral capsule has been used as a secondary sign of PLC injury, promp/ng scru/ny of these small structures
26 PLC injury 17yo male
27 Soleus, along with hamstrings, act as ACL agonists Soleus prevents anterior /bial transla/on When s/mulated it will translate /bia posterior Gastrocs and quads are ACL antagonists When s/mulated the /bia translates anteriorly Soleus Injury
28 Soleus From la/n root solea, meaning sandal or sole of a shoe Origin at proximal /bia and fibula with confluent inser/on on the calcaneus with Achilles tendon
29 Soleus Contribu/on We have no/ced that a significant number of acute ACL tears have concomitant injury of the soleus fibular origin and can contribute to edema about the PLC
30 Soleus Injury Peel or Strain 91/163 (56%) of subjects had soleus abnormality 33 soleus strain (20%) 58 soleus peels (36%) 72/163 (44%) had normal soleus Edema superficial to the PLC 86% of peels 64% of strains Sta/s/cally greater incidence of PLC injury
31 Conclusion ACL tear is rarely isolated Associated injuries depend on mechanism Being aware of mechanism/contusion pa?ern increases sensi/vity and specificity for associated injuries
32 Thank you!
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