Diagram of the fluid-sensitive MR image (a) and sagittal T2-weighted fat-suppressed (b), coronal T1-weighted (c), and proton-density–weighted fat-suppressed (d) MR images show a subchondral fracture (arrow in b and c) as a curvilinear hypointensity surrounded by bone marrow edema, without associated contour deformity. (d) MR image obtained 6 months later shows restoration of the subchondral bone plate (arrowhead). Through case scenarios, this article describes and provides images that depict conditions commonly encountered in the pediatric knee. Figure 13. The distal femoral physis is closed (*). (c) Radiograph obtained 6 months later shows the progression of normal ossification (arrow). These osseous injuries are the result of impaction of the lateral femoral condyle against the posterolateral tibial plateau during internal rotation and anterior translation of the tibia accompanying an anterior cruciate ligament rupture (arrow in d). Patient demographics, the clinical presentation, and the role of trauma are critical for differential diagnosis. Figure 11c. Edema is present in the bed of the defect (asterisk). Diagram (a) and coronal proton-density–weighted fat-suppressed MR image (b) show an irregular hypointense line parallel to the subchondral bone plate (a) and curvilinear and open-ended laterally (white arrow in b), amid extensive bone marrow edema–like signal intensity in the subchondral region (*). Subchondral cystlike lesions are well-defined rounded areas of fluid signal intensity; they may contain necrotic bone debris, myxoid and adipose tissue, fibrous elements, or proteinaceous material and are lined by a nonepithelial fibrous wall (67,68). It may be less conspicuous on T2-weighted images when it is hyperintense and surrounded by bone marrow edema, unless there is a component of trabecular impaction that renders the fracture hypointense on both T1- and T2-weighted MR images, similar to the appearance of stress fractures. Coronal proton-density–weighted fat-suppressed MR image (a) sagittal proton-density–weighted MR image (b), and T2-weighted fat-suppressed MR image (c) show an OCD lesion in a classic location at the lateral aspect of the medial femoral condyle with cysts (curved arrow in a and c) and a high-signal-intensity rim (straight arrow in b) at the interface between the fragment and parent bone associated with breaks in the subchondral bone plate and articular cartilage along the periphery of the lesion (arrowhead in b and c). Osteochondral fracture in a 32-year-old man with a hyperextension injury associated with a posterior cruciate ligament tear (not shown). (d) MR image obtained 6 months later shows restoration of the subchondral bone plate (arrowhead). Once a characteristic pattern of osseous injury is recognized on MR images, the radiologist must seek specific additional soft-tissue and osseous injuries. The deepest calcified cartilage layer is located at the interface with the subchondral bone plate, a layer of compact cortical bone that overlies the cancellous marrow-containing trabecular bone. The distal femoral growth plate is open (* in a and b). Figure 18c. If the address matches an existing account you will receive an email with instructions to reset your password. OCD in an 18-year-old man who heard a pop while getting out of bed and was unable to extend his knee. (c) Radiograph obtained 6 months later shows the progression of normal ossification (arrow). Healing juvenile OCD in a 13-year-old boy. Note articular surface collapse of the medial femoral condyle (arrowhead in b and c), with depression of the subchondral bone plate (c) and loss of subchondral fatty signal intensity (b). Authors of many studies have emphasized the role of chronic repetitive trauma in active children, particularly those who are high-level athletes (52,53). Osteochondral defects (OCDs), often used interchangeably with osteochondritis dissecans in the juvenile population, are focal areas of articular cartilage wear/damage resulting in a loss of cartilage and inflammation of the adjacent subchondral bone (Juneau et al., 2016; Modarresi & Jude, 2015; Wheeless, 2012). Figure 2. From the Department of Radiology, Einstein Healthcare Network, 5501 Old York Rd, Philadelphia, PA 19141 (T.G, M.C., B.W.C.) Figure 18a. Figure 8a. In osteoarthritis, such abnormalities include bone sclerosis (referred to as eburnation on radiographs), bone marrow edema-like lesions, and subchondral cystlike lesions (Fig 19). Additional secondary criteria are employed for a juvenile OCD lesion to increase specificity. Figure 3d. (a) Radiograph shows a localized ossification defect of the medial femoral condyle containing linear calcifications (white arrow) and surrounded by sclerosis (black arrow). (d) MR image obtained 6 months later shows restoration of the subchondral bone plate (arrowhead). A bone contusion (* in b) at the lateral tibial plateau can be distinguished from a fracture because of the absence of a contour deformity or fracture line. Diagram of image from a fluid-sensitive sequence (a), coronal T1-weighted MR image (b), and proton-density–weighted fat-suppressed MR image (c) show multiple regions of AVN in the femur and tibia. Histologically, articular cartilage is organized into four layers, each characterized by a different cellular composition and orientation of collagen fibers that produce gradual variations in signal intensity: superficial, transitional, deep (radial), and calcified layers (2). (a) Radiograph demonstrates the absence of normal ossification in the subchondral area of the medial femoral condyle (arrow). Describe the anatomy of the osteochondral junction with MRI correlation. Unlike the appearance in primary osteonecrosis, the line is incomplete, and edema appears on both sides of the line. Figure 18b. Figure 5a. Figure 19a. Coronal proton-density–weighted fat-suppressed MR image (a) sagittal proton-density–weighted MR image (b), and T2-weighted fat-suppressed MR image (c) show an OCD lesion in a classic location at the lateral aspect of the medial femoral condyle with cysts (curved arrow in a and c) and a high-signal-intensity rim (straight arrow in b) at the interface between the fragment and parent bone associated with breaks in the subchondral bone plate and articular cartilage along the periphery of the lesion (arrowhead in b and c). These types of tears dramatically increase contact pressure across the joint (25). The absence of bone marrow edema, morphology and location of the lesion, and the age of the patient should aid in the important differentiation of a developmental variant of ossification from OCD (56,57). Juvenile osteochondritis dissecans: is it a growth disturbance of the secondary physis of the epiphysis? This pattern of bone injury should prompt a search for additional findings of hyperextension with a varus or valgus component. These findings are essential in diagnosis of acute traumatic injuries, subchondral insufficiency fracture, and its potentially irreversible form, spontaneous osteonecrosis of the knee. Figure 5b. ■ Evaluate MRI findings of each condition and how they pertain to treatment. Healing juvenile OCD in a 13-year-old boy. In osteoarthritis, such abnormalities include bone sclerosis (referred to as eburnation on radiographs), bone marrow edema-like lesions, and subchondral cystlike lesions (Fig 19). Figure 19b. Irreversible SIF of the lateral femoral condyle progressing to articular collapse in a 61-year-old man who presented with acute knee pain after a fall. (b–d) Sagittal T2-weighted fat-suppressed MR image (b), proton-density–weighted MR image (c), and CT image (d) show a curvilinear fracture (arrow in b and c) encircling a portion of subchondral bone and overlying cartilage. Healing juvenile OCD in a 13-year-old boy. Note the macerated and extruded medial meniscus (black arrow in b). The distal femoral physis is closed (*). Subchondroplasty, a procedure developed to treat bone marrow edema lesions by injecting a bone substitute, is one of the evolving treatment options for patients with SIF. Cysts surrounding a juvenile OCD lesion indicate instability only if they are multiple or larger than 5 mm (62). For this journal-based SA-CME activity, the authors, editor, and reviewers have disclosed no relevant relationships. Although they are not essential for the diagnosis of SIF, associated cartilage abnormalities are often present (18,21). (b) Coronal MR image in the same patient obtained 2 years earlier shows the normal appearance of the subchondral bone plate (arrow). Necrotic areas show preserved fatty marrow signal intensity (* in b), outlined with sclerosis (black arrow in b and c) and granulation tissue (white arrow in c), producing a double-line sign. These criteria were revised for juvenile OCD (62) with the addition of three secondary signs that all showed 100% specificity: (a) a T2-weighted high-signal-intensity rim surrounding a juvenile OCD lesion indicates instability only if it has the same signal intensity as that of joint fluid, (b) a second outer rim of T2-weighted low signal intensity, or (c) multiple breaks in the subchondral bone plate on T2-weighted MR images (Fig 18). MRI features that aid in diagnosis include the location and extent of bone marrow edema, the presence of a fracture line, a hypointense area immediately subjacent to the subchondral bone plate, and deformity of the subchondral bone plate. Figure 10c. This pattern of bone injury should prompt a search for additional findings of hyperextension with a varus or valgus component. Two misconceptions contributed to a long evolution of the understanding of this disorder: (a) a pre–MRI-era hypothesis that attributed it to a primary AVN, resulting in the misnomer, and (b) an effort to distinguish it fundamentally from SIF, largely impelled by differences in prognosis. The risk of collapse in the femoral condyle seems to be related directly to the size and location of the infarct: Lesions involving more than one-third of the condyle on midcoronal MR images or the middle and posterior one-third of the condyle on midsagittal MR images are at higher risk of collapse (34). Diagram (a), coronal proton-density–weighted fat-suppressed MR image (b), and sagittal T2-weighted fat-suppressed image (c) show a bone marrow edema pattern “painting” the entire medial femoral condyle (* in b). The most common histologic findings in bone marrow edema-like lesions include bone necrosis, fibrosis, hemorrhage, and trabecular abnormalities, while edema is infrequent (64–66). AVN of the knee in a 59-year-old woman who was undergoing long-term corticosteroid treatment. We offer a summary of current concepts for each condition to aid in their differentiation at MRI. Osteochondral fracture with a subchondral bone plate depression in an 18-year-old man. Osteochondral fracture in a 32-year-old man with a hyperextension injury associated with a posterior cruciate ligament tear (not shown). The distal femoral physis is closed (*). and Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (Y.M. The distal femoral growth plate is open (* in a and b). The laminar configuration of the signal intensity in the fragment reflects the presence of calcifications in its deep zone (arrow in b). The location of the abnormality is dictated by the mechanism of injury. Patients typically present with chronic ankle pain and swelling, and some have mechanical symptoms. Subchondral hypointense fracture lines tend to resolve with conservative therapy and can be seen in patients with transient reversible SIF and in 78% of those with clinical SONK. MR imaging of epiphyseal lesions of the knee: current concepts, challenges, and controversies, Presumptive subarticular stress reactions of the knee: MRI detection and association with meniscal tear patterns, Femoral condyle insufficiency fractures: associated clinical and morphological findings and impact on outcome, Fat-suppressed T2-weighted MRI appearance of subchondral insufficiency fracture of the femoral head, MRI of subchondral fractures: a review, Subchondral insufficiency fractures of the knee: review of imaging findings, Dynamic contact mechanics of the medial meniscus as a function of radial tear, repair, and partial meniscectomy, Osteonecrosis of the knee after arthroscopic surgery: diagnosis with MR imaging, The importance of early diagnosis in spontaneous osteonecrosis of the knee: a case series with six year follow-up, Imaging of osteonecrosis: radiologic-pathologic correlation, Osteonecrosis and transient osteoporosis of the femoral head, MR imaging of avascular necrosis and transient marrow edema of the femoral head, Subchondral avascular necrosis: a common cause of arthritis, The role of sclerotic changes in the starting mechanisms of collapse: a histomorphometric and FEM study on the femoral head of osteonecrosis, Morphological analysis of collapsed regions in osteonecrosis of the femoral head, MRI evaluation of steroid- or alcohol-related osteonecrosis of the femoral condyle, Correlation between bone marrow edema and collapse of the femoral head in steroid-induced osteonecrosis, Subchondral fractures in osteonecrosis of the femoral head: comparison of radiography, CT, and MR imaging, Diagnostic performance of MR imaging in the assessment of subchondral fractures in avascular necrosis of the femoral head, Osteonecrosis of the femoral head: using CT, MRI and gross specimen to characterize the location, shape and size of the lesion, Osteochondritis dissecans: editorial comment, AAOS appropriate use criteria: management of osteochondritis dissecans of the femoral condyle, A review of knowledge in osteochondritis dissecans: 123 years of minimal evolution from König to the ROCK study group, American Academy of Orthopaedic Surgeons clinical practice guideline on: the diagnosis and treatment of osteochondritis dissecans, Osteochondritis dissecans 1887-1987: a centennial look at König’s memorable phrase, Studies on hereditary, multiple epiphyseal disorder, Hypertrophy and laminar calcification of cartilage in loose bodies as probable evidence of an ossification abnormality. Second, the subchondral bone marrow and subchondral bone plate must be examined and correlated with the radiographic appearance. His exam is completely normal and symmetric to his left knee. T1 Irreversible SIF of the lateral femoral condyle progressing to articular collapse in a 61-year-old man who presented with acute knee pain after a fall. Figure 11a. SIF in a 64-year-old woman with a complex tear in the medial meniscus with peripheral extrusion (arrow in a). This misnomer was entrenched in the medical lexicon for many years, persisting after recognition of this entity as a SIF (15,16). (d) Sagittal T2-weighted fat-saturated MR image shows disruption of the subchondral bone plate (arrowhead). SIF in a 51-year-old woman with atraumatic sudden onset of knee pain and swelling. Figure 4c. These findings are essential in diagnosis of acute traumatic injuries, subchondral insufficiency fracture, and its potentially irreversible form, spontaneous osteonecrosis of the knee. Figure 7b. (b) Coronal proton-density–weighted fat-suppressed MR image shows an OCD lesion surrounded by a rim of increased signal intensity (thick arrow) that is not as intense as the joint fluid (thin arrow). Figure 3b. OCD is a focal idiopathic alteration of subchondral bone with a risk for instability and disruption of adjacent articular cartilage that may result in premature osteoarthritis (39,40). Because of the proven microtraumatic origin of SONK and the histopathologic and MRI features that unite it with SIF, it is currently accepted that a SONK is a SIF that has progressed into collapse, with secondary necrosis found in the collapsed specimens. A hypothesis that juvenile OCD is produced by a disruption of endochondral ossification of the epiphysis was introduced in early studies (43–45) and was further developed in more recent work on the basis of MRI observations (46) (Fig 13). Several pathologic conditions may manifest as an osteochondral lesion of the knee, which is a localized abnormality of the subchondral marrow, subchondral bone, and articular cartilage. This association and a link between SIF and meniscectomy (26) support the proposed role of mechanical stress in the development of SIF and emphasize the rationale for meniscal conservation. Interpreting pediatric knee MRI studies may be a challenge for those unfamiliar with the evolving patterns of normal development and of the signs of conditions that are more prevalent in children. The articular cartilage imaging group of the International Cartilage Repair Society has issued detailed recommendations with r… Subchondral bone plate collapse, demonstrated by the presence of a depression or a fluid-filled cleft, can be seen in advanced stages of both avascular necrosis and subchondral insufficiency fracture, indicating irreversibility. The advent of new procedures for repairing cartilage in knee and ankle joints has increased the need for accurate noninvasive methods to objectively evaluate the success of repair. A bone contusion (* in b) at the lateral tibial plateau can be distinguished from a fracture because of the absence of a contour deformity or fracture line. An osteochondral defect can be created acutely or, more often, develops as a common final pathway of several chronic conditions. If the lesion consists of a subchondral region demarcated from the surrounding bone, the demarcation should be examined for completeness and the presence of a “double-line sign” that is seen in avascular necrosis or findings of instability, which are important for proper evaluation of osteochondritis dissecans. (b) Coronal proton-density–weighted fat-suppressed MR image shows an OCD lesion surrounded by a rim of increased signal intensity (thick arrow) that is not as intense as the joint fluid (thin arrow). (a) Diagram shows a fracture that is creating an osteochondral fragment. Larger lesions with progressive articular collapse and persistent pain may require surgery (often total knee arthroplasty). (MR images courtesy of Douglas W. Goodwin, MD, Dartmouth Geisel School of Medicine.). This differs from the more localized bone marrow edema lesion subjacent to cartilage loss in osteoarthritis (10). SIF in a 64-year-old woman with a complex tear in the medial meniscus with peripheral extrusion (arrow in a). Both a subchondral hypointense line (white arrow in b and c) and a subchondral area of low signal intensity (arrowhead in b and c) are observed along the weight-bearing aspect of the condyle and are associated with subtle flattening of the articular surface. Histologic core biopsy specimens obtained in juvenile OCD lesions showed that osteonecrosis is either absent (47,50) or infrequent (48,51). (a) Diagram shows a fracture that is creating an osteochondral fragment. Osteochondral fracture with a subchondral bone plate depression in an 18-year-old man. The calcified cartilage layer may be unmasked by using very short echo time (often referred to as “ultrashort” echo time) imaging (2,6); however, it cannot be separated from the subchondral bone during routine clinical pulse sequences. Unlike the appearance in primary osteonecrosis, the line is incomplete, and edema appears on both sides of the line. Sagittal proton-density–weighted (a) and T2-weighted fat-suppressed (b) MR images of the medial femoral condyle show subchondral cystlike lesions (arrow) and bone marrow edema-like lesions (* in b). and Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (Y.M. An osteochondral defect of the femoral condyle (✩) may be the result of several acute and chronic conditions that produce a surface deformity with a localized defect of the articular cartilage and subchondral bone. MR This misnomer was entrenched in the medical lexicon for many years, persisting after recognition of this entity as a SIF (15,16). Sagittal proton-density–weighted (a) and T2-weighted fat-suppressed (b) MR images of the medial femoral condyle show subchondral cystlike lesions (arrow) and bone marrow edema-like lesions (* in b). Magnetic resonance imaging (MRI) and ultrasound. Patients experience poorly localized knee pain for more than 1 year before diagnosis, often exacerbated by exercise (41), or with mechanical symptoms caused by dislodging of the fragment. The literature on osteonecrosis of femoral condyles is often mixed with and sometimes dedicated entirely to spontaneous osteonecrosis of the knee. Art. Osteochondral fracture with a subchondral bone plate depression in an 18-year-old man. Unstable OCD lesion in a 17-year-old boy. (b) Coronal MRimage in the same patient obtained 2 years earlier shows the normal appearance of the subchondral bone plate (arrow). Subchondral hypointense fracture lines tend to resolve with conservative therapy and can be seen in patients with transient reversible SIF and in 78% of those with clinical SONK. Figure 12b. osteochondral defects (lunge lesion), as well as address the mechanism of injury. As demonstrated in studies (36–38) of osteonecrosis of the femoral head, radiography and, in particular, CT are superior to MRI in demonstrating subchondral fracture. This pattern of bone injury should prompt a search for additional findings of hyperextension with a varus or valgus component. Osteonecrosis of the knee can be encountered in epiphyseal or subarticular bone, where it is referred to as an AVN, and in the metadiaphysis, where the term bone infarction is often applied. The exact incidence and prevalence withi… Figure 4c. Unstable OCD lesion in a 17-year-old boy. This condition typically is seen in older patients after the 6th decade of life and more frequently in women. 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