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Training Collections
Library Memberships
On-demand course library with video lectures, expert case reviews, and more
Fellowship Certificate™ Programs
Practice-focused training programs designed to help you gain experience in a specific subspecialty area.
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Unlock access to our full Course Library and all self-paced Fellowships.
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Get access to free live lectures, every week, from top radiologists.
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Dr. Resnick's MSK Conference
Learn directly from the MSK Master himself.
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Musculoskeletal Imaging
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For Training Programs
Supplement your training program with case-based learning for residents, registrars, fellows, and more.
For Private Practices
Upskill in high growth, advanced imaging areas.
Emergency Call Prep
Prepare trainees to be on call for the emergency department with this specialized training series.
Practice Cases
Worklist 1
10 topics, 17 min.
Practice Cases
Worklist 2
10 topics, 21 min.
Practice Cases
Worklist 3
10 topics, 28 min.
Practice Cases
Worklist 4
10 topics, 19 min.
Practice Cases
Worklist 5
10 topics, 43 min.
0:00
So this patient is 48 years old, man.
0:04
He has anterior knee pain and he has also an area
0:09
of palpable abnormality located in the proximal
0:13
most aspect of the patellar tendon.
0:17
On T2 weighted images without fat saturation,
0:20
we can see that this mice is rioted
0:23
intermediate signal intensity, has these lobulated
0:27
components that are emanating from the fibers of
0:32
the patellar tendon and extending
0:34
into the infrapatellar fat pad.
0:37
The quality of these pseudomass is nodular and
0:43
it's causing this lumpy bumpy appearance that
0:47
is very typical of tophaceous gout.
0:51
This patient has clinical history of gout and we
0:55
can see how, because this is an inflammatory
0:58
condition surrounding the areas of intermediate
1:02
signal intensity that correspond
1:04
to the deposits of gouty tophi,
1:08
there are areas of inflammatory reaction
1:11
in the infrapatellar fat pad.
1:13
On T1-weighted images,
1:16
the dominant signal intensity that we see here is
1:20
intermediate signal with some areas of low signal
1:24
intensity corresponding to where we are seeing the
1:28
tophi deposits within the patellar tendon fibers.
1:33
Important also to note that the
1:35
patient has a joint effusion.
1:38
There is some thickening of the synovial
1:40
lining indicative of synovitis,
1:43
and there is also injury to
1:45
the articular cartilage.
1:47
All that can be seen in the setting
1:50
of gouty arthritis.
1:52
If I were at the workstation and
1:54
the patient has radiographs,
1:56
I want to pull those radiographs to search for the
2:00
presence of chondrocalcinosis.
2:02
Sometimes on MRI,
2:04
patients with chondrocalcinosis may have some
2:08
intermediate signal intensity similar to what we
2:11
are seeing here in the posterior horn of the
2:15
medial meniscus given the presence of calcium
2:18
within the fibrocartilage.
2:20
So to summarize,
2:22
lumpy bumpy focus of deposits tophi within the
2:27
patellar tendon, in a patient
2:29
with gout in this setting.
Wk 4, Case 1 - Review
HIDEInteractive Transcript
0:00
So this patient is 48 years old, man.
0:04
He has anterior knee pain and he has also an area
0:09
of palpable abnormality located in the proximal
0:13
most aspect of the patellar tendon.
0:17
On T2 weighted images without fat saturation,
0:20
we can see that this mice is rioted
0:23
intermediate signal intensity, has these lobulated
0:27
components that are emanating from the fibers of
0:32
the patellar tendon and extending
0:34
into the infrapatellar fat pad.
0:37
The quality of these pseudomass is nodular and
0:43
it's causing this lumpy bumpy appearance that
0:47
is very typical of tophaceous gout.
0:51
This patient has clinical history of gout and we
0:55
can see how, because this is an inflammatory
0:58
condition surrounding the areas of intermediate
1:02
signal intensity that correspond
1:04
to the deposits of gouty tophi,
1:08
there are areas of inflammatory reaction
1:11
in the infrapatellar fat pad.
1:13
On T1-weighted images,
1:16
the dominant signal intensity that we see here is
1:20
intermediate signal with some areas of low signal
1:24
intensity corresponding to where we are seeing the
1:28
tophi deposits within the patellar tendon fibers.
1:33
Important also to note that the
1:35
patient has a joint effusion.
1:38
There is some thickening of the synovial
1:40
lining indicative of synovitis,
1:43
and there is also injury to
1:45
the articular cartilage.
1:47
All that can be seen in the setting
1:50
of gouty arthritis.
1:52
If I were at the workstation and
1:54
the patient has radiographs,
1:56
I want to pull those radiographs to search for the
2:00
presence of chondrocalcinosis.
2:02
Sometimes on MRI,
2:04
patients with chondrocalcinosis may have some
2:08
intermediate signal intensity similar to what we
2:11
are seeing here in the posterior horn of the
2:15
medial meniscus given the presence of calcium
2:18
within the fibrocartilage.
2:20
So to summarize,
2:22
lumpy bumpy focus of deposits tophi within the
2:27
patellar tendon, in a patient
2:29
with gout in this setting.
Report
Patient History
48-year-old male complaining of anterior knee pain, weakness and swelling for 3 weeks. Evaluate for meniscus tear or loose body.
Findings
Menisci:
Medial Meniscus: Intact.
Lateral Meniscus: Intact.
Ligaments:
Anterior Cruciate Ligament: ACL intact. Prominent notch synovitis noted.
Posterior Cruciate Ligament: Intact.
Medial Collateral Ligament: Intact.
Lateral Collateral Ligament: Intact.
Posterolateral Corner Structures:Mild capsulitis throughout the popliteus hiatus. Otherwise unremarkable.
Posteromedial Corner Structures: Intact.
Extensor Mechanism:
Patellar Tendon: Complex multiloculated cystic lesion insinuating throughout the the majority of the medial aspect of the patellar tendon, measuring approximately 4.0 cm craniocaudal, 2.0 cm AP and 2.3 cm transversely. Lesion expands the patellar tendon and extends superiorly along the prepatellar plate into the distal quadriceps tendon. The lesion has areas of intermediate and high signal on T2-weighted imaging and contains areas that are cystic, nodular or papillary in appearance, suggesting extensive synovitis. Deep infrapatellar bursal thickening with a small effusion, consistent with bursitis.
Distal Quadriceps Tendon: Synovitic complex multiloculated process described above extends into the superficial distal insertional quadriceps tendon. Remainder of the quadriceps tendon is intact and unremarkable in appearance. Mild enthesophyte formation at the upper pole of the patella.
Medial Patellofemoral Ligament: Intact.
Medial and Lateral Patellar Retinacula: Intact.
Hoffa’s Fat Pad: Multiloculated synovitis process described above protrudes into the superficial aspect of Hoffa’s fat pad superiorly.
Articulations:
Patellofemoral Compartment: No patellofemoral dysplasia. Grade 2-3 chondromalacia involving the patellar ridge and medial facet as evidenced by chondral fissuring. Grade 2-3 chondromalacia involving the trochlear sulcus. No penetrating high-grade chondromalacia.
Medial Compartment: Grade 2-3 chondromalacia involving the lateral aspect of the medial femoral condyle. Smooth intermediate to high-grade chondromalacia involving the medial tibial plateau. No penetrating high-grade osteochondral erosion.
Lateral Compartment: Grade 2-3 chondromalacia involving the mid weight-bearing surface of the lateral femoral condyle and lateral tibial plateau. No penetrating high-grade osteochondral erosion.
General:
Bones: Normal.
Effusion: Moderate to large sized suprapatellar effusion with florid diffuse reactive synovitis.
Baker’s Cyst: Moderate-sized Baker cyst without evidence for dehiscence or rupture. Baker cyst extends medially. No extension into the popliteal fossa or involvement of the popliteal neurovascular bundle.
Loose Bodies: None.
Soft tissue and Neurovascular: Diffuse prepatellar and superficial infrapatellar bursal edema and thickening, consistent with bursitis. No bursal collection.
Conclusion
1.Multiloculated complex cystic lesion insinuating into and expanding the patellar tendon, extending along the prepatellar plate and into the distal superficial insertional quadriceps tendon. Components of florid multifocal synovitis are noted within the lesion. The constellation of findings favor gout. Other less likely differential diagnoses include CPPD, amyloid or focal nodular synovitis.
2.Grade 2-3 patellofemoral, lateral compartment and medial compartment chondromalacia as described above.
3.No meniscus tear.
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
Tags
Musculoskeletal (MSK)
MRI
Knee
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