0:00

All right.

0:01

So, we come to this patient who is

0:03

a football player, 17 years old,

0:06

sustains an injury while playing in the field.

0:10

And he immediately has sharp pain

0:13

and inability to move his knee.

0:17

We can see at the level of

0:19

the intercondylar notch,

0:20

so we are right here going through

0:22

the anterior cruciate ligament,

0:25

the roof of the intercondylar notch,

0:28

also named Blumensaat line,

0:31

and we move medially towards the PCL,

0:35

and there is complete discontinuity

0:37

of the posterior cruciate ligament fibers

0:41

tthrough the genu of the ligament.

0:43

The ligament has a horizontal component,

0:46

a vertical component.

0:48

Right at the mid portion,

0:50

there is discontinuity of the fibers

0:53

related to a full thickness tear.

0:55

We can see the loss of the laxity

0:58

of the torn fibers proximally.

1:01

That's an indication also that there

1:04

has been a high grade tear.

1:06

High grade tears classified as greater

1:09

than 50% of the ligament substance.

1:12

Here we see it going all the way across.

1:15

If we look at the axial images,

1:17

we can scroll through these 3D reformats,

1:20

very, very thin slices.

1:23

And as we go through the genome of the PCL,

1:27

we have just very high signal intensity

1:31

in keeping with that area of full thickness discontinuity.

1:36

One element that can help us here is that

1:40

this patient has a Wrisberg ligament.

1:42

So coming from the posterior horn

1:45

of the lateral meniscus,

1:46

going towards the medial femoral condyle,

1:50

we see this low signal intensity structure.

1:53

That is the meniscofemoral ligament of Wrisberg.

1:56

And if we go just anterior to it,

1:59

we see that there is complete discontinuity of the

2:02

fibers of the PCL in a patient with full thickness

2:06

posterior crucial ligament here.

2:09

Very important to mention that we don't want to

2:12

miss an injury to the posterior cruciate ligament.

2:15

Always, always, it should be part of your search pattern

2:18

when you are in the intercondylar notch,

2:21

the two main players are

2:22

the anterior cruciate ligament

2:24

and the posterior cruciate ligament.

2:25

So, this patient has a full thickness tear

2:28

in the mid substance.

2:29

And those are the findings.

Wk 3, Case 2 - Review

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0:00

All right.

0:01

So, we come to this patient who is

0:03

a football player, 17 years old,

0:06

sustains an injury while playing in the field.

0:10

And he immediately has sharp pain

0:13

and inability to move his knee.

0:17

We can see at the level of

0:19

the intercondylar notch,

0:20

so we are right here going through

0:22

the anterior cruciate ligament,

0:25

the roof of the intercondylar notch,

0:28

also named Blumensaat line,

0:31

and we move medially towards the PCL,

0:35

and there is complete discontinuity

0:37

of the posterior cruciate ligament fibers

0:41

tthrough the genu of the ligament.

0:43

The ligament has a horizontal component,

0:46

a vertical component.

0:48

Right at the mid portion,

0:50

there is discontinuity of the fibers

0:53

related to a full thickness tear.

0:55

We can see the loss of the laxity

0:58

of the torn fibers proximally.

1:01

That's an indication also that there

1:04

has been a high grade tear.

1:06

High grade tears classified as greater

1:09

than 50% of the ligament substance.

1:12

Here we see it going all the way across.

1:15

If we look at the axial images,

1:17

we can scroll through these 3D reformats,

1:20

very, very thin slices.

1:23

And as we go through the genome of the PCL,

1:27

we have just very high signal intensity

1:31

in keeping with that area of full thickness discontinuity.

1:36

One element that can help us here is that

1:40

this patient has a Wrisberg ligament.

1:42

So coming from the posterior horn

1:45

of the lateral meniscus,

1:46

going towards the medial femoral condyle,

1:50

we see this low signal intensity structure.

1:53

That is the meniscofemoral ligament of Wrisberg.

1:56

And if we go just anterior to it,

1:59

we see that there is complete discontinuity of the

2:02

fibers of the PCL in a patient with full thickness

2:06

posterior crucial ligament here.

2:09

Very important to mention that we don't want to

2:12

miss an injury to the posterior cruciate ligament.

2:15

Always, always, it should be part of your search pattern

2:18

when you are in the intercondylar notch,

2:21

the two main players are

2:22

the anterior cruciate ligament

2:24

and the posterior cruciate ligament.

2:25

So, this patient has a full thickness tear

2:28

in the mid substance.

2:29

And those are the findings.

Report

Patient History
17-year-old male with constant moderate left knee pain, difficulty walking, weakness and swelling following an injury playing football 3 days prior.

Findings
Menisci:

Medial Meniscus: Intact.

Lateral Meniscus: Intact.

Ligaments:

Anterior Cruciate Ligament: Intact.

Posterior Cruciate Ligament: Complete full-thickness midsubstance to proximal PCL tear, with associated ligamentous laxity, fiber discontinuity and marked increased intrasubstance signal.

Medial Collateral Ligament: Extensive periligamentous edema involving layer I or the “crus layer” surrounding an intact tibial collateral ligament, consistent with low-grade/grade 1 sprain.

Lateral Collateral Ligament: Intact.

Posterolateral Corner Structures: Posterolateral corner injury with swollen sprained popliteofibular ligament and arcuate ligament. Diffuse periligamentous edema. Low to intermediate grade strain at the popliteus myotendinous junction with diffuse edema involving at least 50 percent of the cross-section and extending approximately 5 cm in length. Posterior capsule thickened and swollen.

Posteromedial Corner Structures: Intact.

Extensor Mechanism:

Patellar Tendon: Intact.

Distal Quadriceps Tendon: Intact.

Medial Patellofemoral Ligament: Intact.

Medial and Lateral Patellar Retinacula: Intact.

Hoffa’s Fat Pad: Unremarkable.

Articulations:

Patellofemoral Compartment: Unremarkable.

Medial Compartment: Unremarkable.

Lateral Compartment: Unremarkable.

General:

Bones: Minimally impacted fracture of the anterolateral tibial plateau, with high-grade osteoedema. Small microtrabecular injury of the anterior aspect of the medial tibial plateau. Otherwise unremarkable.

Effusion: Moderate-sized suprapatellar effusion.

Baker’s Cyst: None.

Loose Bodies: None.

Soft tissue and neurovascular structures: Unremarkable.

Conclusion
Combination of findings consistent with a hyperextension injury, including:

1.High grade, full thickness mid substance PCL tear (PCL transection).
2.Grade 1-2 sprain medial collateral ligament.
3.Minimally impacted fracture of anterior medial tibial plateau and mictotrabecular fracture of the lateral tibial plateau. Hyperextension injury.
4.Injured posterolateral corner with sprained popliteofibular and arcuate ligaments and strained popliteus myotendinous junction sprain. Capsular injury.

Case Discussion

Faculty

Omer Awan, MD, MPH, CIIP

Associate Professor of Radiology

University of Maryland School of Medicine

Stephen J Pomeranz, MD

Chief Medical Officer, ProScan Imaging. Founder, MRI Online

ProScan Imaging

Jenny T Bencardino, MD

Vice-Chair, Academic Affairs Department of Radiology

Montefiore Radiology

Edward Smitaman, MD

Clinical Associate Professor

University of California San Diego

Practice Cases

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Wk 3, Case 2 - Review