Knee AP View
Pt supine with knee fully extended and leg in neutral
Beam directed vertically 5-7 degrees slightly cephalic
Limitation: superimposed patella
Knee Lateral View
Pt lays on involved side with 25-30 degrees of knee flexion
Beam directed at medial knee joint 5-7 degrees cephalad
Best for patella femoral relationship
Relationship of patellar ligament length (PL) to patella length (L)
PL=L +/- 20%
Tunnel (Notch) View (Knee)
Pt prone with knee flexed to 40 degrees
Beam projected caudally at 40 degrees from vertical
Demonstrates posterior aspect of femoral condyles, intercondylar notch, intercondylar eminence, medial and lateral tibial spine
Potential increased risk of ACL tear
Females have more of an ‘A’ intercondylar notch while males have more of an ‘H’ notch
Sunrise View (Knee)
Pt. prone with knee flexed 115 degrees
Beam directed at patella 15 degrees cephalad
Demonstrates femoropatellar joint compartment well
What is the purpose of deep knee flexion with sunrise view?
to depress the patella deeply within the intercondylar fossa
Disadvantages of Sunrise View
Articular surfaces of femoropatellar joint not well viewed
Subtle subluxations may not be detected
Position tolerance
Axial (Merchant) View (Knee)
Pt supine with knee flexed 45 degrees
Beam directed caudally through patella at 60 degrees from vertical
Demonstrates Articular facets of the patella and femur, sulcus and congruence angle
Congruence angle
Normal: -6 degrees
Greater than 16 degrees associated with patellofemoral disorders
Bisect sulcus angle, draw 2nd line from lowest point of articular ridge of patella to deepest point of sulcus
Sulcus Angle
Normal: 138 degrees
Formed by lines extending from deepest point of intercondylar sulcus to the top of the femoral condyles
AP Demonstration (Knee)
Medial and lateral joint compartments Varus and valgus deformities Fx of femoral condyles, tibial plateus, tibial spines, proximal fibula, Osteochondral fx Osteochondral dissecans (late stage) Spntaneous osteonecrosis Pellegrinini-Stieda lesion
FBI Sign
Fat Blood Interface aka Lipohemarthrosis: Blood and bone marrow fat enter the joint creating layering on radiograph
Indicates: Intraarticular Fx
Sinding-Larsen-Johansson Disease
Fragmentation of lower pole of the patella and significant soft tissue swelling associated with calcification and ossifications of the patellar ligament
Osgood-Schlatter Disease
Avulsed tibial tuberosity
Soft tissue swelling
Tx: activity modification lower impact and counterforce braces, will heal itself with maturation and time
Osteochondral Fx
Shearing/ rotary forces applied to the articular surface of the femur result in detachment fragment of articular cartilage
Types of meniscus tears
Peripheral detachment Peripheral Tear Cleavage Tear Simple Vertical Tear Bucket-Handle Tear Oblique Tear
Ankle AP View
Pt supine with foot in neutral
Beam directed vertically at midpoint between malleoli
Identifies distal tibia and fibula
Fibular Malleolus Longer than Tibial Malleolus
Ankle AP View Limitations
Overlap of distal fibula and lateral tibia obstructs view of tibiofibular syndesmosis
Mortise View (Ankle)
10 degrees of IR of the ankle eliminates overlap of medial distal fibula for better view of syndesmotic space
Ankle Lateral View
Pt lays on involved side
Beam directed vertically to the medial malleolus
Demonstrates anterior aspect of the distal tibia and posterior lip (3rd malleolus) and Fx oriented in the coronal plane
What imaging modality will demonstrate meniscal injury
MRI?
Ottawa Knee Rules
Age 55+ Tenderness at head of fibula or isolated tenderness of patella Inability to flex knee to 90 degrees Inability to weight bear 4 steps ARE valid under the age of 18 Sensitivity: 98-100% Specificity: Low
Segond Fx and what is typically injured with it
Article
Internal Oblique View (Ankle)
Pt in supine with leg and foot in 35 degrees of IR. Neutral PF/DF (90 degrees to leg).
Beam Directed at lateral malleolus
Demonstrates: Medial and lateral malleoli
Tibial Plafond
*Dome of the Talus
Tibiotalar joint
Tibiofibular syndesmosis
Inversion Stress View (Ankle)
Pt in supine with foot fixed in device. Pressure plate is positoned 2 cm above ankle joint and applies varus stress adducting the heel
Degree of talar tilt is measures by tibial plafond and dome of the talus. (bilateral comparison)
Normal is 20 degrees
Anterior-Draw Stress (Ankle)
Pt on involved side with foot in device. Pressure plate positioned anteriorly 2 cm above ankle and applies posterior stress to shin with heel fixed.
Measure separation btwn Talus and Distal Tibia
0-5 mm Normal
5-10 mm Normal/Abnormal
>10 Abnormal
Foot AP View (Dorsoplantar)
Pt in supine with knee flexed and foot flat on film.
Beam directed vertically to the base of the *first metatarsal bone
Demonstrates metatarsal bones and phalanges
1st metatarsal angle
1st Metatarsal Angle
Quantifies the amount of metatarsus primus varus associated with hallux valgus
Normal angle 5-10 degrees
Foot Lateral View
Pt on involved side Beam directed vertically to midtarsus Demonstrates: Bursal projection Posterior, Medial, Anterior Tuberosities Anterosuperior spine of calcaneous Posterior facet of subtalar joint Sustenaculum tali Talonavicular Calcaneocuboid Boehler Angle Calcaneal pitch
Boehler Angle
Relationship of talus and calcaneous
Intersection of line drawn from posterosuperior margin of the calcaneal tuberosity (bursal projection) through the posterior facet of the subtalar joint
Line drawn from the tip of the posterior facet through the superior margin of the anterior process of the calcaneous
Normal 20-40 degrees
Calcaneal Pitch
Intersection of line drawn tangentially to inferior surface of the calcaneus and one drawn along the plantar surface of the foot
Normal 20-30 Degrees
Foot Oblique View
Pt supine with lateral border of the foot elevated 40-45 degrees
Beam Directed vertically to base of the 3rd metatarsal
Demonstrates Phalanges, Metatarsals, Anterior Subtalar joint
Talonavicular Joint
Naviculocuneiform Joint
Calcaneocuboid Joint
Harris-Beath View (foot)
Pt stands on film
Beam directed at 45 degree angle toward midline of heel
Posterior-Tangential View
Demonstrates: Middle facet of subtalar joint
Posterior facet of subtalar joint
Sustentaculum tali
Body of the calcaneous
Tangential View (foot)
Pt seated with foot and toes DF with gauze
Beam directed vertiacally to head of the 1st metatarsal
Demonstrates: Metatarsal heads
Sesmoid bones of the 1st metatarsal
Pilon Fx
From fall or imact to bottom of foot
Triangular Fx of tibia
Unimalleolar Fx
Come on… kinda self explanatory kid
Avulsion Fx
Commonly separates base of the 5th metatarsal at attachment of tendon of fibularis brevis due to inversion stress
Some overlap as Jones Fx
Jones Fx
Fx of the base of the shaft of the 5th metatarsal
Maisonneuve Fx
Commonly occurs at the junction of the middle and distal thirds of the fibula.
Disrupted tibfib syndesmosis and interosseus membrane is torn up to the level of fx.
Tibiotalar joint compartment is widened because of lateral subluxation of the talus
Ottawa Ankle Rules
Point tenderness on the medial or lateral malleolus, navicular or base of the 5th
Inability to weight bear immediately and in emergency (4 steps)
Rules ARE valid in under 18
Lauge-Hansen
Type A ?
Type B ?
Type C ?
If the broken tibia causes anterior compartment syndrome, what motor and sensory loss would you suspect?
Anterior Compartment Syndrome:
Muscles involved are TA, EHL, EDL, and Fib tertius.
Nerves are the deep peroneal nerve and a branch of the common peroneal nerve.
Deep fibular nerve would innervate the sensory portion between the 1st and second toes. Motor function of this nerve you would lose the DF so foot drop would occur as well as great toe extension and digits 2-5 extension.
Slipped Capital Femoral Epiphysis
Typically occurs anteriorly with excessive ER?
Hip AP View
Patient in supine with both feet in 15 degrees of IR
Beam directed at Midpelvis or Femoral Head
Demonstrates: Iliac, Sacrum, Pubic, Ischium, Femoral Head and Neck, Greater and Lesser Trochanters
Limitations: Acetabulum partially obscured by overlying femoral heads
Not adequate for eval of sacral bone, SI joint or acetabulum
Ferguson View (Hip)
Angled AP view
Pt in supine w/ 15 degrees of IR
Beam at 15 degrees cephalic angle at midpelvis
Demonstrates injury to the SI joints and pubic and ischial rami
Anterior Oblique (Judet) View (hip)
Patient in supine with involved hip elevated to 45 degrees
Central been vertically at hip
Demonstrates iliopubic column and posterior lip of the acetabulum
Posterior Obliqu (Judet) View (hip)
Pt. positioned in supine and the UNaffected hip is elevated to 45 degrees
Beam directed vertically at affected hip
Demonstrates Ilioishial column (posterior) and posterior lip of the acetabulum and the anterior acetabular rim
Frog-Lateral View (hip)
Pt in supine with knees flexed, soles of feet together and thighs maximally abducted
Beam directed vertically 10-15 degrees cephalad to just above pubic rami
Selective - beam directed toward affected hip
Demonstrated lateral aspect of the femoral head and both trochanters
Groin Lateral View (hip)
Pt in supine with affected extremity extended and opposite leg elevated and abducted (out of way)
Cassette on lateral hip
Beam directed horizontally toward the groin with 20 degree cephalad angle
Demonstrates anterior and posterior aspects of femoral head, and anterior rim of acetabulum to identify displacement of Fxs
Angle of femoral anteversion
Normal Femoral anteversion
25-30 Degrees
Common sites of Avulsion Fx and muscles attached (Hip)
Iliac crest -abs
Body of pubis and inferior pubic ramus -adductors and gracillis
Ishial Tub - hamstrings
Lesser Troch - iliopsoas
Greater Troch -glut, obterator internus, gemellus, piriformis
AIIS - Rectus Fem
ASIS -Sartorius and TFL
Malgaigne Fx
Unstable hemipelvic Fx
Unlateral fx of superior or inferior pubic rami
Disruption of ipsilateral SI
Recognized clinically by shortening of LE
Sprung Pelvis
Bilateral Pelvic Dislocation
Disruption of both SI joints
Associated with separation of the pubic symphysis
Proximal Femur Fxs
Intracapsular: Capital - femoral head Subcapital (common) - proximal femoral neck Tans or midcervical - distal femoral neck Basicervical- Distal to the femoral neck Extracapsular: Intertrochanteric - through trochanters Subtrochanteric -proximal femoral shaft
Trabeculae of Hip
..See image in slides
Vascular supply of proximal femur
Branches of Femoral artery… See image in slides
