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Knee ultrasound in pediatric patients - anatomy, diagnostic

pitfalls, common pathologies.

Poster No.: C-2434


Congress: ECR 2015
Type: Educational Exhibit
Authors: 1 1 1 2
C. M. Olchowy , M. Lasecki , M. Inglot , D. Holownia , K. Moron ,
1

1 1 2
U. Zaleska-Dorobisz ; Wroclaw/PL, Olesnica/PL
Keywords: Pediatric, Musculoskeletal joint, Anatomy, Ultrasound,
Elastography, Ultrasound-Power Doppler, Education, Education
and training, Trauma
DOI: 10.1594/ecr2015/C-2434

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Learning objectives

The purpose of this educational exhibit is:

1. to illustrate the normal anatomy and normal apperance of knee compartments


depending on age of a patient,

2. to describe a systematic technique (easy to follow check-list protocol) for evaluation


of anatomical structures,

3. to present anatomical schemes, x-ray and corresponding sonography images,

4. to present cases of traumatic and oncologic patients as well as Osgood-Schlatter


disease

Background

Ultrasound is well-established as safe, efficient and cost-effective method to evaluate


superficial structures of the knee. It also has got it's well known limitations, but because
of many advantages it is still one of the most frequently ordered musculoskeletal
procedures in diagnosing traumatic and non-traumatic pediatric patients with knee pain
(often interpreted together with x-ray).

Findings and procedure details

Ultrasound examination od knee joint should consist of assesment of:

1: anterior compartment (patella, suprapatellar recess, patellar ligament and it's insertion,
quadriceps tendon, cartilage structure)

2: lateral compartment ( lateral colateral ligament, ossification centres, cartilage, lateral


meniscus)

3: medial compartment ( medial colateral ligament, ossification centres, cartilage, medial


meniscus)

4: posterior compartment (popliteal fossa, vessels)

Normal images differ among age groups. It is important to be familiar with ultrasound
characteristics od ossification centers.

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Fig. 5: 5-month-old child. Longitudinal view of anterior knee compartment. Note the
ossification center in distal femur and hypoechoic cartilage.
References: Department of Radiology . Wroclaw University Hospital

Hypoechoic cartilage is often misdiagnosed as fluid.

On next images we present normal eppearance of cartilage in knee joint:

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Fig. 2: Longitudial view. Patellar ligament. Normal ultrasound anatomy in 7-year-old
child.
References: Department of Radiology . Wroclaw University Hospital

Fig. 1: Longitudial view. Suprapatellar recess. Normal ultrasound anatomy in 7-year-


old child.

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References: Department of Radiology . Wroclaw University Hospital

Fig. 3: Longitudial view. Medial aspect of knee joint . Normal ultrasound anatomy in 7-
year-old child.
References: Department of Radiology . Wroclaw University Hospital

In pediatric trauma patients ultrasound plays an important role in diagnosing fractures.


Typical image presented below:

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Fig. 4: Ultrasonografic findings - fracture. Discontinuity of periosteum is visible.
Adjacent soft tissues are hypoechoic - hemartoma. Increased vascularity of this area in
PowerDoppler.
References: Department of Radiology . Wroclaw University Hospital

Osgood Schlatter disease typically occurs in patients between 9 and 16 years old . Male
to female ratio - 3:1.

Location : ligament-bone junction of the patellar ligament and the tibial tuberosity.

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Fig. 6: Osgood Schlatter disease - typical ultrasound findings . Arrows show
fragmentation of the apophysis (tibial tuberosity) and cartilage swelling (green arrows).
References: Department of Radiology . Wroclaw University Hospital

Images for this section:

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Fig. 1: Longitudial view. Suprapatellar recess. Normal ultrasound anatomy in 7-year-old
child.

Fig. 2: Longitudial view. Patellar ligament. Normal ultrasound anatomy in 7-year-old child.

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Fig. 3: Longitudial view. Medial aspect of knee joint . Normal ultrasound anatomy in 7-
year-old child.

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Fig. 4: Ultrasonografic findings - fracture. Discontinuity of periosteum is visible.
Adjacent soft tissues are hypoechoic - hemartoma. Increased vascularity of this area in
PowerDoppler.

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Fig. 5: 5-month-old child. Longitudinal view of anterior knee compartment. Note the
ossification center in distal femur and hypoechoic cartilage.

Fig. 6: Osgood Schlatter disease - typical ultrasound findings . Arrows show


fragmentation of the apophysis (tibial tuberosity) and cartilage swelling (green arrows).

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Fig. 7: Sinding Larsen Johansen disease. Arrow shows fragmentation od of lowerpole of
the patella. Cartilage swelling is also visible. Stars - tendinosis of patellar ligemnt.

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Conclusion

Knowledge of anatomy landmarks is essential for scanning the knee accurately and
efficiently. In pediatric patients also the appearance of bony parts differs depending on
age: occification centers, articular cartilage, epiphysis.

Easy to follow ultrasound examination protocol can be a useful tool in everyday practice
of pediatric radiologists.

Personal information

References

1. Callahan, M. J. (2013). Musculoskeletal ultrasonography of the lower


extremities in infants and children. Pediatric radiology, 43(1), 8-22.
2. Navarro, O. M., & Parra, D. A. (2009). Pediatric musculoskeletal ultrasound.
Ultrasound Clinics, 4(4), 457-470.
3. Allen, G., & Wilson, D. (2011). Current role for ultrasonography. In Sports
Injuries in Children and Adolescents (pp. 83-93). Springer Berlin Heidelberg.
4. Seol, J. G., & Callahan, M. J. (2013). Pediatric Musculoskeletal Ultrasound.
Ultrasound Clinics, 8(3), 459-475.
5. Bellah, R. (2001). Ultrasound in pediatric musculoskeletal disease:
techniques and applications. Radiologic Clinics of North America, 39(4),
597-618.
6. Harcke, H. T., & Grissom, L. E. (1998). Musculoskeletal ultrasound in
pediatrics. In Seminars in musculoskeletal radiology (Vol. 2, No. 03, pp.
321-329). © 1998 by Thieme Medical Publishers, Inc..
7. Mayr, J. M., Grechenig, W., & Höllwarth, M. E. (2004). Musculoskeletal
ultrasound in pediatric trauma. European Journal of Trauma, 30(3), 150-160.

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