M.R. IMAGING OF THE EXTENSOR MECHANISM

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1 M.R. IMAGING OF THE EXTENSOR MECHANISM Wilfred CG Peh Khoo Teck Puat Hospital, Singapore & National University of Singapore

2 LECTURE OUTLINE Introduction Imaging anatomy Lesions affecting the extensor mechanism Summary

3 INTRODUCTION Extensor mechanism of knee Essential to ambulation Subject to various disorders e.g. traumatic, congenital, inflammatory May result in anterior knee symptoms

4 INTRODUCTION Extensor mechanism of knee Imaging may help define lesions Radiographs acute bony trauma MR imaging comprehensive assessment of joint, bone and soft tissues

5 IMAGING ANATOMY Structures Quadriceps muscles & tendon Patellar retinacula Patella Patellar tendon Others- Hoffa s fat pad

6 Anatomy of the extensor mechanism Sonin AH et al. Radiographics 1995;15:367-82

7 IMAGING ANATOMY Quadriceps muscle/tendon 4 quadriceps muscles rectus femoris, vastus lateralis, v. medialis & v. intermedius join as the quadriceps tendon inserts into superior patella

8 Anatomy of the extensor mechanism Sonin AH et al. Radiographics 1995;15:367-82

9 IMAGING ANATOMY Quadriceps tendon Tendon: hypointense MR signal separated by linear bands of fat anterior lamina: rectus femoris middle: v. medialis & lateralis posterior lamina: v. intermedius trilaminar

10 Anatomy of the distal quadriceps tendon Laminar appearance due to interspersed fat

11 IMAGING ANATOMY Patellar retinacula Formed by tendinous fibers from medial and lateral vastus muscles Extend from medial and lateral collateral ligament complexes to margins of patella Mediolateral stability

12 Anatomy of the extensor mechanism Sonin AH et al. Radiographics 1995;15:367-82

13 IMAGING ANATOMY Patellar retinacula Best seen on axial MR images Well-defined linear bands of hypointense signal on all sequences

14 Anatomy of the patellar retinacula

15 IMAGING ANATOMY Patella Triangular sesamoid bone Articular surface divided by vertical ridge into small medial & large lateral facet cartilage up to 7 mm thick

16 Anatomy of the patella

17 IMAGING ANATOMY Patellar tendon Composed of fibers of the rectus femoris (quads: anterior lamina) Extends from inferior pole of patella to the tibial tuberosity Normally 5cm = patella length

18 IMAGING ANATOMY Patellar tendon Best seen on sagittal images well-defined band of hypointense signal Axial images flattened ovoid shape

19 Anatomy of the patellar tendon

20 IMAGING ANATOMY Other structures Intrapatellar fat pad of Hoffa Pre- and infrapatellar bursae

21 Anatomy of the fat pad of Hoffa Jacobson JA et al. Radiographics 1997;17;

22 EXTENSOR MECHANISM Acute injuries May be due to direct force More often secondary to indirect injury violent deceleration force predisposing conditions: gout, diabetes, collagen vascular disease

23 EXTENSOR MECHANISM Acute injuries Dislocation Fractures Tendon ruptures

24 Distracted patellar fracture and subsequent repair

25 EXTENSOR MECHANISM Chronic injuries Usually due to repetitive trauma Patellar tendon injury Transient patellar dislocation Patellar chondral lesions Bursitis

26 EXTENSOR MECHANISM Patellar tendon injury Proximal patellar tendon common (jumper s knee) tendon thickening and increased signal on PD/T2 tendinous junction with patella - relatively avascular

27 35/M. Proximal patellar tendinosis

28 40/M. Chronic patellar tendinosis

29 EXTENSOR MECHANISM Patellar tendon injury Osgood-Schlatter disease chronic inflammation of tendon insertion at tibial tuberosity tuberosity irregularity heterotopic bone formation marrow and soft tissue edema

30 19/M. Osgood- Schlatter disease

31 EXTENSOR MECHANISM Patellar tendon injury Sinding-Larsen-Johansson disease also seen in juveniles chronic repetitive microtrauma attachment of superior patellar tendon to patella

32 20/M. Sinding- Larsen disease

33 EXTENSOR MECHANISM Transient patellar dislocation Often clinically missed Patellar and trochlea groove dysplasia: predisposes Results from extreme valgus stress forced internal femoral rotation on fixed foot

34 EXTENSOR MECHANISM Transient patellar dislocation MRI findings are characteristic medial retinacular tear marrow edema medial patella and lateral margin of lateral femoral condyle osteochondral defect/ loose body

35 kissing lesions Kirsch MD et al. AJR 1993;161:

36 21/M. Patellar dislocation post-reduction

37 SGPR Ax T1 Ax T1 SGPR Patellar dislocation with osteocartilaginous fragment SGPR SGPR

38 EXTENSOR MECHANISM Patellar chondral lesions Various classifications?term: chondromalacia Descriptions cartilage intact: signal change defect: size, location, depth, extent

39 22/M. Focal chondral lesion with subchondral edema & cyst

40 30/M. Small medial facet chondral defect

41 51/M. Large medial facet chondral defect with subchondral cysts

42 37/M. Severe medial facet chondral loss

43 39/M. Osteoarthritis with cartilage irregularity and defects

44 EXTENSOR MECHANISM Bursitis Not uncommon especially in occupations that require kneeling Inflammation Well-defined fluid collection in known bursal location prepatellar, infrapatellar

45 Sag T1 Sag T2 Sag T1+c FS Ax T1 Ax T2 51/M. Preacher s knee: infrapatellar bursitis

46 EXTENSOR MECHANISM Other lesions Bipartite patella Hoffa s fat pad disorders

47 EXTENSOR MECHANISM Bipartite patella Normal variant small separate ossification center at superolateral patella Symptomatic cases very rare may be due to chronic stress

48 36/M. Bipartite patella

49 Cor T1 Cor T2 39/M. Bipartite patella with stress changes

50 EXTENSOR MECHANISM Hoffa s fat pad disorders Hoffa disease infrapatellar fat pad impingement Injury Synovial lesions Tumors

51 30/M. Shear injury of Hoffa s infrapatellar fat pad. Linear fluid collection. Associated with ACL injury.

52 Sag T1 Sag T2 Sag GRE 24/M. PVNS of Hoffa s fat pad Sag T1 Sag T2 Follow-up MRI postexcision

53 SUMMARY Many conditions can affect the extensor mechanism of the knee Be familiar with anatomy MR imaging is useful in evaluating injuries and other disorders

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