Patella Skyline View

10.123. Radiographs (5): Note any joint space narrowing (indicating cartilage loss) (N), lipping (L), marginal sclerosis (S). cysts (C), loose bodies (H), varus or valgus (these are all common in osteoarthritis). Do not mistake a bipartite patella (B) for fracture; bipartite patella, if present, affects the outer quadrant). Note any abnormal calcification, as in Pellegrini-Steida disease (J), calcified meniscus (K), and pseudogout.

10.124. Radiographs (6): Look for alterations in bone texture (e.g. in Paget's disease, rheumatoid arthritis, osteomalacia, infections). Note any bone defects (D) suggestive of tumour or infection, or areas of periosteal reaction (P). perhaps indicative of tumour or infection. Do not mistake epiphyseal lines (E) for hairline or other fractures.

10.125. Radiographs (7): Intercondylar (tunnel ) radiographs are often of help in confirming the diagnosis of osteochondritis dissecans, as they show the common sites more clearly, especially in the medial femoral condyle. They are also of value in locating loose bodies.

Osteochondritis Superior Pole PatellaSkyline View PatellaPatella Osteomalacia

10.126. Radiographs (8): Where the patella is suspect, a tangential (skyline) view should he obtained. This may show (1) a marginal (medial) osteochondral fracture, common in recurrent dislocation of the patella, (2) other fractures, (3) occasionally, evidence of chondromalacia patellae. (4) bipartite patella.

10.129. Aspiration (1): Aspirate the knee

(a) in the presence of a tense haemarthrosis or

(b) to obtain specimens for bacteriology in suspected infections. Taking full aseptic precautions, begin by raising a skin weal with local anaesthetic just above and lateral to the patella.

projection may help in assessing patellar instability. Draw tangents to show the lateral patellofemoral angle. This is positive in 97% of normal subjects (A). In those suffering from recurrent dislocation of the patella it is zero in 80% (B), or negative in 20% (C). This angle may also be defined by CT scans. Note also whether the sulcus is shallow (> 170°).

Normal Skyline View Adult Patella

10.130. Aspiration (2): Now infiltrate the tissues more deeply down to the level of the synovial membrane of the suprapatellar pouch.

10.128. Radiographs (10): Again, in suspected recurrent dislocation of the patella the lateral projection should be taken with the knee weightbearing and held in full extension. This may confirm the presence of a highly placed and susceptible patella (patella alta).

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10.131. Aspiration (3): Unless the knee is very tense, squeeze fluid from the upper limits of the suprapatellar pouch to float the patella forwards before inserting the aspiration needle.

Suprapatellar PouchWoc Osteoporosis
10.132. Aspiration (4): Squeeze the superior aspect and sides of the joint during the terminal stages of aspiration to empty the joint. After withdrawal of the needle, apply a sterile dressing over the aspiration site.

10.133. Aspiration (5): Unless other treatment is contemplated, apply a Jones compression bandage. This consists of several layers (2-4) of wool in the form of wool roll, gamgee or cottonwool sheets, each held in place with firmly (but not tightly) applied calico, domette or crepe bandaging. Alternatively, a double layer of a circularly woven bandage (e.g. Tubigrip) may be used.

10.134. Examples of pathology (1): The radiographs show both femora] and fibular exostoses affecting the metaphyses of these bones. Clinically corresponding swellings were obvious on inspection and palpation. Diagnosis: diaphyseal aclasis (sometimes also referred to as metaphyseal aclasis).

Bipartite Patella TreatmentSkyline Projection Retro Patellar Joint

10.136. Pathology (3): Tangential (skyline) projection of the previous case showing the lateral irregularity (to the right of the picture).

10.135. Pathology (2): The superolateral quadrant of the patella has a separate centre of ossification, and despite not showing clearly on the radiographs the edges were well rounded and not typical of fracture. Clinically there was no local tenderness. Diagnosis: bipartite patella. The constancy of the site may often help differentiate it from fracture.

10.136. Pathology (3): Tangential (skyline) projection of the previous case showing the lateral irregularity (to the right of the picture).

10.137. Pathology (4): This is a weightbearing lateral projection of the knee in an adolescent girl. The patella is in contact with the femur proximal to its articular surface, and the joint is hyperextended. Diagnosis: genu recurvatum and patella alta deformities.

Skyline View KneeRetro Patellar Arthritis

10.138 Pathology (5): This radiograph is of an acute injury to the knee in an adolescent girl. Although the shadows of the femur and tibia show that the joint has been correctly positioned for the lateral projection, the patella is superimposed on the femur. Diagnosis: lateral dislocation of the patella.

10.139. Pathology (6): There is a well defined irregularity involving the proximal two-thirds of the articular surface of the patella in a young woman. Diagnosis: this illustrates a marked degree of chondromalacia patellae.

10.140. Pathology (7): This localized view of the knee shows marked narrowing of the joint space between the femur and the patella, with patellar lipping. Diagnosis: severe retropatellar osteoarthritis.

Patella Skyline View Method

10.141. Pathology (8): Note the separation and fragmentation of the tonguelike downward-projecting proximal tibial epiphysis. This was associated with chronic, localized knee pain.

Diagnosis: Osgood-Schlatter's disease.

10.142. Pathology (9): This radiograph is an anteroposterior view of the knee which has been positioned to show the intercondylar notch (the so-called 'tunnel projection'). Note the punched-out area in the medial femoral condyle, indicated with the arrow. Diagnosis: osteochondritis dissecans, typically affecting the lateral side of the medial femoral condyle.

10.143. Pathology (10): These radiographs of a young man (note the degree of epiphyseal fusion) show separation of a large fragment of bone (and articular cartilage) from the medial femoral condyle. Diagnosis: long-standing osteochondritis dissecans.

Loose Body Knee PathologyOsteochondritis Dissecans PatellaOsteochondritis Dissecans Patella

10.144. Pathology (11): This is the radiograph of a middle-aged man. The arrow points to a small spherical loose body lying in the lateral compartment of the joint. There is some unilateral joint space narrowing, and irregularity of the articular surface of the lateral femoral condyle. Diagnosis: osteoarthritis of the knee, with the loose body probably secondary to that process.

10.145. Pathology (12): The arrows point to three opacities related to the knee. Diagnosis: the upper arrow points to a normal fabella. The lower arrow indicates two loose bodies, lying in the posterior part of the joint. These are secondary to osteoarthritis.

10.146. Pathology (13): There are sclerotic changes involving the posterior articular surface of the patella, and to a lesser extent the related condylar surfaces of the femur. There is a little irregularity of the tibial spines, and there is a large opacity lying proximal to the upper pole of the patella. Diagnosis: osteoarthritis of the knee, with a large loose body in the suprapatellar pouch.

Knee Pathology ChondromatosisPellegrini Stieda

10.147. Pathology (14): There are multiple loose bodies in the knee joint. Diagnosis: synovial chondromatosis.

10.148. Pathology (15): There is gross disorganization of the knee, with much new bone formation. Diagnosis: Charcot's disease.

10.149. Pathology (16): This radiograph, taken following acute trauma, show widening of the medial joint line. Diagnosis: rupture of the medial ligament of the knee. It is uncommon to see such a degree of deformity without stress being applied to the joint while the films are being exposed. The gross nature of the deformity indicates that the posterior ligament and probably both cruciate ligaments are also torn. There is no evidence of an associated fracture of the lateral tibial plateau.

Arthritis The Lateral Plateau

10.151. Pathology (18): There is gross narrowing of the joint space with a degree of osteoporosis.

Diagnosis: rheumatoid arthritis.

10.150. Pathology (17): There is a history of chronic pain on the medial side of the knee, and the radiographs shows calcification in the region of the upper attachment of the medial ligament.

Diagnosis: Pellegrini-Stieda disease.

10.151. Pathology (18): There is gross narrowing of the joint space with a degree of osteoporosis.

Diagnosis: rheumatoid arthritis.

10.152. Pathology (19): There is destruction of the medial joint compartment, with some horizontal bone striations (Looser's zones) indicative of repeated incidents of temporary growth arrest. Diagnosis: chronic joint infection typical of tuberculosis of the knee.

Pseudogout KneePellegrini Stieda Syndrome

10.154. Pathology (21): There is calcification in the lateral meniscus. Diagnosis: this is a common finding in pseudogout.

10.153. Pathology (20): There is narrowing of the medial joint compartment, with a degree of marginal sclerosis of bone. There is a little residual disturbance of the lateral tibial plateau, where there has been an old fracture.

Diagnosis: osteoarthritis of the knee, probably secondary to an old valgus injury where there has been a tibial plateau fracture (and possibly an associated medial ligament injury).

10.154. Pathology (21): There is calcification in the lateral meniscus. Diagnosis: this is a common finding in pseudogout.

10.155. Pathology (22): There is a fusiform swelling of the femoral shaft encroaching on the knee joint. Note the radial spiculation.

Diagnosis: the appearances are typical of osteogenic sarcoma.

Sarcoma Osteogenic

10.156. Pathology (23): The proximal part of the tibial metaphysis on its medial side is beaked, and clinically there was marked bowing of this child's legs. Diagnosis: tibia vara.

10.157. Pathology (24): Clinically there was a marked bow-leg deformity. The radiographs confirm the tibial bowing and show widening of the metaphyses of the tibia, with characteristic irregularity and cupping. Diagnosis: rickets associated with vitamin D deficiency.

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