Johannes Roth, MD PhD FRCPC RhMSUS
The Knee, Foot and Ankle
sonoanatomy & relevant pathology–
Knee - Synovial Spaces
All illustrations in this presentation adapted from C Martinoli
Positioning of the patient:
1) supine position with slight flexion of the knee joint (30 °)
2) maximal flexion 3) prone position
4) vary all positions especially for Doppler – dynamic exam !!!
Suprapatellar longitudinal scan (30 °Flexion)
30 ° Flexion
straight Different
positions might
be necessary for Doppler !!!
Suprapatellar longitudinal scan (30 °Flexion)
30 ° Flexion
Femur Tibia
Patella
Rectus Femoris Vastus lat & med Vastus intermedius
Patella Tendon
Mandl P et al Arthritis Care & Research Vol. 64, No. 5, May 2012, pp 773–779
Suprapatellar longitudinal scan
Schmidt-WA ARD 2004: Sagittal midline 2.4 ± 1.2 mm
Patella Fat pad
Femur Fat pad
Recess
Growth Plate
Femur proximal and distal
Lower Leg
Knee – the pediatric window
Adult Pediatric
Patella - Development
•first few years the patella is completely cartilaginous and radiolucent
•first radiographic evidence of patellar ossification may be present by two to three years, but may not appear until as late as five to six years
•Patellar ossification normally develops from multiple small foci, although this is a very transient phase
•Sometimes there is a distinct division between the inferior and superior portion of the ossification center. This division may be mistaken for a fracture
•Additional ossification centers may develop, particularly in the superolateral half of the bone, the bipartite patella being the most common
Pat Tendon
J.A. Ogden: Radiology of Postnatal Skeletal Development. Skeletal Radiol (1984) 11:24
6 year old 8 year old
Patella –
normal irregular ossification
Patella – Erosion ?
Feeding Vessel ! Possible Patella bip or distinct division
Patella
Knee – the pediatric patella & recess
Suprapatellar long
Recess Cartilage
Knee – the pediatric patella
Suprapatellar long
Recess Cartilage
physiologic blood flow
Effusion suprapatellar recess
Quadriceps tendon
Longitudinal trans
Suprapat Fat
Synovial Hypertrophy Synovial Fluid
Effusion suprapatellar recess
Wakefield R et al Rheumatology 2012;51:921925 Greatest sensitivity in 30 degrees flexion
Syn Tissue
Fat Syn Fluid
Fat Herniation
Effusion suprapatellar recess, pediatric
affected side unaffected side
Patella Patella
Femur Femur
Femur QT
trans
Effusion suprapatellar recess, Doppler
QT
The parapatellar recess
Lateral Medial
PATELLA
FEMUR lateral
retinaculum
medial retinaculum
PATELLA
FEMUR
Illustrations: C Martinoli
Parapatellar Recess
Lateral
Lateral
Medial
Retinaculum lesion
Plica Knee
Paczesny and Kruczynski
Radiology: Volume 251: Number 2—May 2009
Medial Plica – Medial Plica syndrome / Knee pain
Suprapatellar transverse scan in maximal flexion (cartilage)
Schmidt-WA ARD 2004: Cartilage 3.1 ± 0.7 mm
Femur Meniscus Tibia sup
deep
Medial longitudinal scan – medial collateral lig
sup deep
Femur Meniscus Tibia
Cart Cart SC
sup DC
deep
sup deep
supdeep
supdeep
Cart Cart SCDC
Knee –
Ligaments medial
Femur Tibia
Femur Meniscus Tibia
Femur Meniscus Tibia sup
deep
Medial / Anterior Pes Anserinus
MCL Anserine Tendons
Insertion of Anserine Tendons
Genicular artery variation
Lateral longitudinal scan –
Iliotibial Band, lateral collateral ligament, biceps femoris insertion
Lateral longitudinal scan – Iliotibial Band
Lateral longitudinal scan – lateral collateral ligament
Femur Tibia Fibula
popl. groove
Fibula Ligament
Lateral longitudinal scan – Biceps femoris tendon
Fibula Tendon
med and lat synovitis
Infrapatellar longitudinal scan proximal
Patella
Tendon Location of Bursa
Schmidt-WA ARD 2004: Patella tendon 2 cm distal Patella 3.2 ± 0.7 mm Hoffa
Infrapatellar transverse scan
Condyle
Patella Tendon
Infrapatellar longitudinal scan - distal
Tibia Hoffa
Bursa infrapat profunda
Bursa infrapatellaris superficialis
Development of tibial tuberosity (Ogden)
Fibrocartilage
Ossification Centres
Development of tibial tuberosity (Ogden)
8 year old
14 year old
Fibrocartilage
Jumpers Knee /Sindig Larsen Johannsen
Ganglion, Synovial Cyst, Bursitis
Bursitis and Synovial Cyst arise from a synovium lined bursa
The Synovial Cyst would typically occur in relation to intraarticular pathology and often show a
communication with the joint
This is different from a ganglion cyst for example In the wrist which does not have synovial lining and contains mucinous material
Infrapatellar long and trans
Tibia
Deep infrapatellar bursitis
Posterior transverse scan(condylar and tibial)
SM ST Sa
Gr
medial condyle
MHG SM
MHG BC
Posterior transverse
SM
GC ST
Condyle Condyle
Visualisation of Semimembranosus and Gastrocnemius tendon
SM
GC
Baker Cyst
Post aspiration
Doppler
Extended and Ruptured Bakers Cyst
Thrombosis posterior knee
•Reliable diagnosis of thrombosis needs practise
•Absent flow
•Thrombus can sometimes be demonstrated
•Lack of compressibility very important sign
A V Baker Cyst N
Cyst, Blood Vessels and Nerve GC
Vein compressed
Foreign Body Gonarthritis
Tang et al J Clin Ultrasound 42:379–381, 2014
Ankle Sonoanatomy
Lower Leg
distal lower leg
3 months 7 months 3 years
8 years
10 years
distal lower leg – ossification almost complete
12 years
Cave:
Even though ossification may occur early for example In the calcaneus, parts of the bone may ossify more slowly
For example the
Sustentaculum talli may show significant cartilage for a long time
Ankle and Midfoot
Tibiotalar 9 mo & 15 y
Tibia Talus Nav Cun Mett
Talus
Capsule
Tibiotalar long
Anterior (Tibiotalar) transverse
Talus with cartilage on top
Ext dig Ext halluc Tib ant Talus
Patella
Hoffa
Perimalleolar medial transverse
Tendon
PTA PTV
FHL
Peroneal Tubercle
PL PB Lateral Ankle
PL PB
Peroneal Tubercle trans
Malleolus Peroneus
tendons
Talus
Capsule
Tibiotalar
Subtalar medial
palpable
Talus Navic.
Talonavicular
Talus and Calcaneus
Hoffa
Tib post
Flex
Flex hall
Medial Swipe
Subtalar medial
Subtalar lateral
Retromalleolar Swipe
Sinus Tarsi Slide
Tib Talus Calcaneus
Posterior Subtalar
Adjusting Settings
Lower Frequency & Change Focus
Tibia
Deltoid Ligament
tibiotalar è tense tibionavicular è lax tibiotalar è lax
tibionavicular è tense
Courtesy Carlo Martinoli
Ligaments medial
tibiocalcaneal
Tibia post tibtalar lig
Tibio-talo- navicular
Lateral Subtalar Joint Posterior
Calcaneus Talus LM
PL PB
Calcaneus Talus
Lateral Malleolus
Ligaments lateral
Calcaneo Fib Ligament
Peronaeus Tendons
hammock
Ligament
Tibio Fibular Ligament
Fibrillar but variable
echogenicity Bone to Bone !!
Plantar Fascia
< 4mm
Midfoot longitudinal scan
Dorsal Longitudinal & Transverse Scan
MTP and IP
MTP 1
IP 1
Pathology
Pathology Anterior
Injection avoid the artery
?
Talonavicular
Talonavicular Move across !
Navicular Cuneiforme
?
Synovitis Subtalar medial
Talus Calcaneus
* * = Effusion
Synovitis Subtalar lateral
Tenosynovitis Peroneal
Tenosynovitis Peroneal ?
Plantar Fasciitis
Bursitis
Synovitis IP joint
Patient 6: 10 year old with sJIA
Outcome: Complete resolution of findings and symptoms
10 year old sJIA patient coming in for routine Tocilizumab treatment.
Noticed area of swelling of midfoot and forefoot, painful.
Patient 7: Monarthritis of the toe
Keloid in a 9 year old with EF and LS
