5 sconfienza mcl and pmc injury - lugano 2018...coronal fs pdwi mamoru niitsu. springer 2013 linear...

MCL and posteromedial corner injuries

of the knee

Unit of Diagnostic and Interventional Radiology

IRCCS Istituto Ortopedico Galeazzi, Milano

Department of Biomedical Sciences for Health

Università degli Studi di Milano

ITALY

Luca Maria Sconfienza, MD PhD

5th Musculoskeletal MRI meeting 2018: Knee MRI

Saturday, May 5th 2018

Personal use only

Pedersen RR. Semin Musculoskelet Radiol 2016;20:12

ANATOMY

• Superficial and deep MCL

• Pes anserinus

• POL

• Semimembranosus

• Posteromedial capsule

• Medial patellar retinaculumPersonal use only


ANATOMYMCL

De Maeseneer M. Radiographics 2000;20:S83

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Lundquist RB. RadioGraphics 2015;33:1123

ANATOMYPosteromedial corner

PMCPersonal use only


ANATOMYPOL

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ANATOMYAxial MRI

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ANATOMYCoronal MRI

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ANATOMYSagittal MRI

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BIOMECHANICS Superficial MCL

• The sMCL is the primary valgus stress stabilizer at all degrees of flexion, most effective at 60°and less at full extension

• The sMCL also serves as a secondary stabilizer for sagittal motion

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BIOMECHANICS Deep MCL


The dMCL is a secondary static valgus stabilizer

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BIOMECHANICS Posteromedial corner

Dold AP. J Am Acad Orthop Surg2017;25:752-61

• The SM is an important dynamic stabilizer

preventing valgus in extension and

preventing external rotation in flexion

• POL stabilizes for valgus stress closer to

extension

• If the sMCL is injured, the POL and the PMC

take over as the primary valgus stabilizers

• Valgus stabilizers and stabilizers of anterior

and posterior translation and rotational

stress

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INJURYMCL tear

Mamoru Niitsu. Springer 2013

De Maeseneer M. Radiographics. 2000 Oct;20 Spec No:S83

• Classified in three grades:• Grade 1: sprain or strain, mainly consisting of

elongation of the ligament without any functional loss. Treated conservatively.

• Grade 2: partial tear.• Grade 3: complete tear.

• Differentiating between grade 2 and 3 may be impossible (often written as “grade 2–3 tear”)

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INJURYValgus stress

A direct impact onto the lateral knee with the

foot planted produces a valgus force resulting in

lateral bone bruises and may lead to isolated

injuries to the sMCL and dMCL. Higher valgus

forces, especially when associated with external

rotation, can result in POL and PMC injury.

Antero-Medial Instability

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Mamoru Niitsu. Springer 2013 Coronal FS PDWI

Linear hyperintensity representing edema along the ligament’s fibers due to sprain or strain can be seen.

This imaging finding can alsobe found in medial meniscal tear and knee osteoarthritis.

INJURYGrade 1 MCL tear

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Pedersen RR. Semin Musculoskelet Radiol 2016;20:12Coronal FS PDWI

Grade 2 rupture of the sMCL, where the ligament is thickened and irregular with elevated signal because of partial rupture of the fibers


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Edematous changes can extend into the surrounding medial retinaculum and vastus medialis


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After surgery for valgus instability

INJURYMCL tear – fibrotic changes

Homogeneous thickening related to fibrotic changes

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Discontinuity of the fibers and signal abnormalities

due to edema and hematoma


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Radiology 2016;281:23-40

Complete tear of the proximal sMCLand the meniscofemoral component of the dMCL. The meniscotibialcomponent of the dMCL is intact


Valgus injury

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Avulsion of the sMCL from its expected origin, continuing in a stripped periosteal proximal continuation. Normal meniscotibial ligament and a probable injury to the meniscofemoral ligament because it is poorly defined and edematous

INJURYMCL tear

Personal use only


Avulsion of the proximal attachment of themeniscofemoralligament.. A small bony fragment is attached to the proximal part of the ligament, most obvious on the T1 image

INJURYMCL tear

Personal use only

Radiology 2016;281:23-40

Osseous avulsion of the proximal sMCL

INJURYMCL tear

Multiligamentous

injury

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Radiology 2016;281:23-40

Avulsion of the meniscotibial component of the dMCL with a reverse Segond fracture and a partial tear of the proximal PCL. AP X-ray 5 weeks after MR shows evidence of healing of the reverse Segond fracture

INJURYMCL tear + PCL + reverse Segond fracture

Hyperextension valgus

injury

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More than half of MCL tear occurs at the femoral portion, but it can less commonly occur in the tibial portion

INJURYMCL distal tear

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Radiology 2016;281:23-40

Complete retracted tear of the distal sMCL and a complete tear of the meniscofemoral component of the dMCL. The meniscotibial ligament is intact.


Valgus injury

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Edema in the lateral femoral condyle and total distal rupture of the MCL. The meniscofemoral ligament is identified but poorly defined proximally

Valgus injury

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INJURYMCL distal tear + PMC

Complete retracted tear of the distal sMCL and edematous POL and posteromedial capsule. The meniscotibialligament is intact.

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INJURYClip Injury: O’ Donoghue triad or unhappy triad

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INJURYMCL + POL + PCL + MM

Radiology 2016;281:23-40

Coronal: tear of the POL and partial tear of the PCL and a radial tear of the posterior horn of the medial meniscus. Axial: partial tear of the sMCL and tear of the POL

Hyperextension valgus

injury

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INJURYMCL + POL + MM


Edematous POL and posteromedial capsule. Avulsed fragment of meniscus at the posteromedial superior corner of the meniscus

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INJURYSemimembranosus tear


Axial: edema and distorted SM tendon at the expected insertion

Sagittal: rupture of the distal

semimembranosus tendon

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INJURYChronic Semimembranosus injury


Chronic traction-related changes in the posteromedial tibia, edema, and cysts. Tendinosis and edema appears along the semimembranosus tendon

Chronic posteromedial pain after

valgus injury

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TAKE HOME MESSAGES

• Complex anatomy

• Important medial stabilizers

• Valgus stress and externalrotation

• Antero-medial instability

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ThankYou.

Luca Maria Sconfienza, MD PhD

Chair, Unit of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Galeazzi

Associate Professor of Radiology, University of MilanoMilano, Italy

[email protected]

Personal use only

5 sconfienza mcl and pmc injury - lugano 2018...coronal fs pdwi mamoru niitsu. springer 2013 linear...

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