PediatricMSKUltrasonography

Thelowerextremity
Johannes Roth, MD, RhMSUS

Disclosures
Dr.Rothhasnothingtodisclose

Femurproximalanddistal/hipjoint

JointCapsuleHipJointandLabrum

Cartilage

Labrum

Epiphysis

Thechildwithalimp oftenhasaproblemwiththehip

Thechildwithalimp
incidence of a limp in children 1.8 in 1000 children
more common in males and has a mean presentation
age of 4-5 years
transient synovitis of the hip is the most common
cause of hip pain in the child, with an incidence of 1.1
cases per 1000 children
Sometimes it is not the pain, but refusal to walk or
weakness

SagittalUSimagedepictstheanteriorrecessinapatientwithtransientsynovitis.

RobbenSGFetal.Radiology1999;210:499507

1999byRadiologicalSocietyofNorthAmerica

MeasurementsintheAnteriorJointCapsuleofbothHipJointsin
105PatientswithUnilateralSynovitis
MeanThx
(mm)

SD

Symptomatichip
Jointcapsule
Anteriorlayer
Posteriorlayer

9.91
2.38
2.14

1.71
0.66
0.44

Asymptomatichip
Jointcapsule
Anteriorlayer
Posteriorlayer

4.90
2.51
2.10

1.02
0.63
0.58

Knee thepediatricpatella&recess
Suprapatellarlong

Recess

Cartilage
physiologicbloodflow

Effusion suprapatellar recess, pediatric

affected side

unaffected side

Patella

Patella

Femur

Femur

QT

Femur
trans

Plica Knee

Knee thepediatricwindow

Adult

Pediatric

Patella
Patella = Sesamoid

Rectus Femoris Fibres

Tendon

Pat Tendon

Patella

Bone

Patella - Development

first few years the patella is completely cartilaginous and radiolucent

Tendon of patellar ossification may be present by two to
first radiographic evidence
three years, but may not appear until as late as five to six years
Pat Tendon
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 portions
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
Bone

PatTendon

6yearold

8yearold
Bone
J.A.Ogden:RadiologyofPostnatalSkeletal
Development.SkeletalRadiol(1984)11:24

Patella
Patella
normalirregular
ossification
Tendon

Patella

Patella
Erosion?

FeedingVessel!
PossiblePatellabip
ordistinctdivision

PatellarRetinacula

QT
Retinaculum

lpflmpfl
Patella

PatTendon
Pat

lptlmptl

Femur

PT

Bone

Knee Ligamentsmedial

sup
deep

sup
deep
Femur

Tibia

SC
FemurMeniscusTibia
DC

CartCart

Infrapatellarlongitudinalscanproximal

LocationofBursa
Tendon

Patella
Hoffa

Infrapatellarlongitudinalscan distal

Bursainfrapatellarissuperficialis

Tibia
Hoffa
Bursainfrapatprofunda

Developmentoftibialtuberosity(Ogden)

Fibrocartilage

OssificationCentres

Developmentoftibialtuberosity(Ogden)

8yearold

Fibrocartilage
14yearold

Enthesis/Apophysis
PatellaTendoninsertionproximaltibia

Location and Position of the Joint

Are all locations the same ?

Does age matter ?
Does the position of the joint matter ?

30
Flexion

neutral

Quadriceps
30 degree

Proximal Patella T: Distal Patella T:

30 degrees
30 degrees

Pat

Pat

Achilles Tendon:

Tuberositas
Calcaneus

Doppler within 2mm

no Doppler

neutral

Doppler at insertion

neutral

Pat

no Doppler

neutral

Pat

Tuberositas
Calcaneus

Doppler within 2m

no Doppler

Doppler at insertion

no Doppler

Location and Position Adolescents

Presence of Doppler signals in Quadriceps tendon and distal
Patella tendon insertion
No signals in proximal patella tendon and achilles tendon
insertion
No consistent effect of joint position but clear difference
between positions in an individual patient
Doppler signals might have to be interpreted according to
location and at various degrees of flexion

Enthesitis
Thickening of the tendon
Tendon

Sub-tendineous bursitis
Patella

Bony erosion

Hoffa

Power Doppler Signal

Calcification and Enthesophyte

Developmentoftheenthesis/apophysis

Chondral
Anlage /
Cartil.
Muscle
Fibrocartilage
Cartila
ge
Apophysis
Muscle
Fibrocartilage
Cartila
ge
Muscle

Avulsion chronicoracute
Weakest Point
Child

Cartilage

Muscle
Weakest Point
Adult

Acute Avulsion typically sports injuries, avulsions of tendon insertions

(cartilage and/or bone), Patella Sleeve Fracture
Chronic Avulsion accessory navicular Osgood Schlatter & Severs (traction
apophysitis)

Traction Apophysitis
Growth spurt, starting in the feet, then legs, then upper body
Increasing forces acting especially on tibial tuberosity and
posterior Calcaneus through Patella Tendon and Achilles
Simultaneously Ossification Process with transformation of
cartilage into bone

Traction Apophysitis, subclinical or clinical (Osgood

Sindig Larssen Johannsen, Severs)

10

Jumpers Knee /Sindig Larsen Johannsen

OsgoodSchlatter

Boy 13 years, unaffected side

OsgoodSchlatter

affected side

11

The differentiation of Apophysitis and JIA-enthesitis

Right

Left

14 year old
with knee pain

his heel used to hurt as well

Right

Right

Left

Enthesitis associated JIA / Spondylarthropathy

10 year old

12

Enthesitis associated JIA / Spondylarthropathy

13 year old with enthesitis related JIA

post treatment

13

LowerLeg

proximallowerleg

3months3years

distallowerleg

3months7months

3years

14

8 year

10 year

distallowerleg ossificationalmostcomplete

12years

Cave:
Eventhoughossification
mayoccurearlyforexample
Inthecalcaneus,partsof
thebonemayossifymore
Slowly
Forexamplethe
Sustentaculumtallimay
showsignificantcartilage

15

AnkleandMidfoot
Tibiotalar9mo&15y

Tibia

Talus

Nav

Cun

Mett

Capsule
TibiotalarJoint intracapsularvsintrasynovial

Calcaneus

SecondaryOssificationCentre(s)/Apophysis

16

CalcaneusOssification

Calcaneusposterior
Healthy

SeversDiseaseorEnthesitis

Severs/Enthesitis Complications

17

AccessoryNavicularBone

also referred to as the os tibiale externum

found in about 10-15% of children
lies within the tibialis posterior tendon

*
CarloMartinoliwithpermission

Sesamoidbone cartilaginous
Sesamoids

MTPplantartrans10yearold

Thatsit!!

18