Franz Kainberger 1

Division of Neuro- and MSK Radiology & CIR Lab, Department of Radiology

Imaging of collateral ligaments and posterior corners: combined with cruciate ligament lesions

franz.kainberger@billrothhaus.at

24 ys male, bicycle accident, your diagnosis, please

Download PDF under: http://radiodiagnostik.meduniwien.ac.at/1/and on button Division of Neuroradiology and Musculoskeletal Radiology

indication

interpretation

differential diagnosis

The role of twisting injuries and the mainanatomic stabilizers to prevent them

Objectives

Footprint patterns of kinetic chains

Puzzling the diagnosis by grading andin the context of clinical findings

MRI is not first, but best imaging choice

characteristic clinical findings:

• focal tenderness

• effusion

• inability to bear weight

Fall or twisting injuries of the knee

Pivot shift-injury: a form of twisting with ellipticalmovement line of tibia against femur

male patient after injury during handball

The clinical entity termed the pivot shift was studied in cadaver specimens and its significance was evaluated:It was found to be highly correlated with a tear of the anterior cruciate ligament, and it corresponded to a sudden anterior-internal rotation subluxation-dislocation of the tibia and posterior horn of the lateral meniscus beneath the lateral femoral condyle.

Fetto JF; Marshall JL J Bone Joint Surg Am. 1979 Jul; 61(5): 710-4

“sudden anterior-internal rotation subluxation of the tibia”

Radiographics, 2000

Deep sulcus sign (M. Cobby et al. Radiology 1992)

Anatomy: the main stabilizers of the kneeClassification basing on anatomy and biomechanical forces

Knee extensor system:osseo-musculo-tendinous unit

Lateral aspectof flexor system:

lock and unlock mechanismsof tibial rotation

posterior corners: capsule and tendonsare strong stabilizers

Medial aspect:of hamstring cuff

Semimembranosus tendon: key to understand anatomy

Medial meniscus

Semimembranosus tendon

Medial gastrocnemius head

Medial collateral ligament

Medial retinaculum

• deep portion with

• superficial portion

meniscofemoral extensionmeniscotibial extension

Medial supporting structures

Franz Kainberger 2

VALGUS-EXTERNAL ROTATION STABILIZING SYSTEM

(ordered from superficial to profound location)

• Medial retinaculitis

• MCL insufficiency (breaststroker‘s knee; due to repeated stretching during swimming)

• Pes anserinus bursitis

• Semimembranosus tendinitis or injury

• Plica syndrome

Common overuse syndromes

Garcia-Valtuille R et al, Radiographics Sept 02

mediopatellar plica (Sakakibara Typ B)

Medial collateral ligament (MCL)

• primary valgus stabilizer: proximal division of the superficial MCL

• primary external rotation stabilizer: distal division of the superficial MCL at 30° of knee flexion

• primary internal rotation stabilizers: POL and the distal division of the sMCL with the meniscofemoral and meniscotibial ligaments

Griffith CJ et al., Am J Sports Med, 2009

Combined ACL and MCL lesion

snowboarding 6 days ago:

predominantly valgus injury mechanism

Medial collateral ligament

rupturestrain/partial rupture

Anserine bursa

anserine bursitissuperficial pes anserinus

sartorius tendon

gracilis tendon

semitendinosus

The posteromedial corner: 2 components and 3 layers concepts

• Layer I: the crural fasciaand retinaculum

Pes anserinus (betweenlayers I and II)

• Layer II: superficial MCL and semimembranosus tendon

• Layer III: deep MCL andfibrous knee joint capsule

The 3 layers concept

Warren LF et al. The supporting structures and layers on the medial side of the knee: an anatomical analysis JBJS (Am) 1979

2 components of MCL:

• the straight part

• the fan-like posterior part

posteromedialcorner {

Franz Kainberger 3

Beltran J et al. The semimembranosus complex. Skelet Radiol 2003

Layer II: the semimembranosus complex, i. e. its insertional tendon

24 ys male, bicycle accident, your diagnosis, please

The semimembranosus complex. (Beltran J, Skelet Radiol 2003)

Semimembranosus muscle: the strongest knee flector

• strongest flector of knee• forms pes anserinus profundus

by inserting with three branches:- oblique popliteal ligament within

posterior capsule- medial tibial surface- fascia of popliteus muscle

• protector of medial and lateral meniscus

Kim YC et al. Tendinous insertion of semimembranosus muscle into the lateral meniscus. Surg Radiol Anat 1997; 19: 365

Semimembranosus: abnormal findings

semimembranosus bursitis

avulsion edema atsemimembranosus insertionBeltran J et al., Skeletal Radiol 2003

Meniscocapsular inflammation or separation

Inflammation of meniscal attachment

Menisco-capsular separation. De Maeseneer M et al., EJR, March 2002

Baker‘s cyst: Advanced degenerative rupture: rupture is a severe form of degeneration

associated Baker‘s cyst

Baker‘s cyst

Marti-Bonmati L et al. MR imaging of Baker cysts – prevalence andrelation to internal derangementsof the knee. Magma 2000, 10; 205

• Association with menisceal lesion: 51 %

• Association with cruciate ligament lesion: 15 %

Semimembranosus tendon

communication at proximal joint

Franz Kainberger 4

The lateral supporting structures

Knee extensor system:osseo-musculo-tendinous unit

Lateral aspectof flexor system:

lock and unlock mechanismsof tibial rotation

posterior corners: capsule and tendonsstrong stabilizers

Medial aspect:of hamstring cuff

Lateral collateral ligament (LCL) andpopliteus tendon

LCL – redPopliteus tendon - blue

Kozanek M et al. Am J Sports Med 2009

Lateral supporting structures

Pseudoextrusion of meniscus

lateral retinaculum

Lateral collateral ligament [Winslow]

Lateral meniscus

Common peroneal nerve

Biceps femoris tendon

VARUS-INTERNAL ROTATION STABILIZING SYSTEM

Common overuse syndromes:

Iliotibial bandGerdy‘s tubercle

Iliotibial band:direct contact> in varus

• Iliotibial band friction syndrome(runner‘s knee, cyclist's knee)

• Popliteal tendinitis

• Bicipital tendinitis, peroneal nerve entrapment

Iliotibial band friction (ITBF) syndrome: Runner‘s knee and cyclist‘s knee

Cyclist's knee: insufficient medial musclesupport leads to

• patellofemoal painsyndrome

• ITBF: friction during contactwith 30 degrees of flexion

Farrell KC et al., The Knee, 2003

triathlete

Segond fractureWhite L. et al. Sem Musculoskel Radiol 2004

Posterolateral corner (= the arcuate complex)

fibular collateral ligament

popliteus tendon

stabilizes against varus and external rotation

arcuate ligament

Franz Kainberger 5

Popliteus muscle

Popliteal muscle notch

popliteustendon

lateral femoral condyle

meniscus

Origin: popliteal notchpopliteofibular ligamentpopliteomeniscal ligament

Posterior ligamentousrelationships

Lee BY et al. Incidence and significance of demonstrating themeniscofemoral ligament on MRI. Br J Radiol 2000; 73; 271: visible with MRI in 83 %

posterior cruciate ligament

anterior cruciate ligament

Humphrey ligament

Wrisberg ligament

Popliteus muscle

Posterolateral corner (= the arcuate complex)

Biceps muscle and tendon

Fibular collateral ligament

Popliteus tendon

Popliteofibular ligament

stabilizes against varus and external rotation

Posterior-lateral corner lesions

40 ys patient after skiing accident

a serious problem of capsular instability

Arcuate ligament rupture(White L et al, 2004)

• PCL injury

• Unsharp latero-posterior capsular structures

• Popliteal muscle abnormality

Fibular collateral ligament injury

motor cycling accident

Practice recommendation: the fibular collateralligament – the forgotten ligament in MR reporting

Imaging of collateral ligaments and posterior corners: combined with cruciate ligament lesions

Download PDF under: http://radiodiagnostik.meduniwien.ac.at/1/and on button Division of Neuroradiology and Musculoskeletal Radiology

indication

interpretation

differential diagnosis

Puzzling the diagnosis by grading andin the context of clinical findings

Franz Kainberger 6

Diagnostic concept of kinetic chains

• The musculo-tendino-osseouschains

• The interossous ligamentouschains

due to indirect forces

“Ligaments at risk” • within a narrow anatomic

environment or rubbing against adjacent bones

• with exposure to strong tensile forces

• within a complicated ligament complex

• with weak bony attachments.

Resnick, Chang, Pretterklieber, 2007

„Unhappy triad“: ACL, MCL, medial meniscus

We conclude that the classic O'Donoghue triad is, in fact, an unusual clinical entity among athletes with knee injuries.

Shelbourne KD, Nitz PA. The O'Donoghue triad revisited. Combined knee injuries involving anterior cruciate and medial collateral ligament tears. Am J Sports Med. 1991, 19:474

Hayes CW et al. Radiographics 2000

The Hayes classification system Bone marrow edema patterns

Kissing edema

Radiographics, 2000

Imaging of collateral ligaments and posterior corners: combined with cruciate ligament lesions

Biomechanical forces induce typical anatomicdistributions of injury, mostly „unhappy triad“ typeFoot pints of injury is traumatic type bone marrowedema: compression, avulsion, or stress-induced

Indication

Interpretation

Download PDF under: http://radiodiagnostik.meduniwien.ac.at/1/and on button Division of Neuroradiology and Musculoskeletal Radiology

Images and anatomic support: • Stummvoll G, Pretterklieber M, Kainberger F (eds.): [Motion

and Performance], Facultas-Publishers, Vienna• Lena Hirtler, MD, core unit of antomy and cell biology,

Medical Universitiy of Vienna