Interesting case

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Alex Brenner PT MPT OCS -> Interesting case (February 1, 2005 6:49:00 PM)
I will slightly modify the history. 32 year old male was in Europe visiting friends. When he lifted his packed suitcase to place it into the trunk of his car he felt his right knee pop and give out under the weight of his body and the suitcase. He was unable to put any weight on the leg and was brought to our clinic in a wheelchair. He complains of 6/10 right knee pain. He has odd visual swelling over the lateral aspect of the knee, over the fibular head and just below the lateral joint line of the knee. Radiographs of the knee were ordered. These were the first we looked at. (all images obtained and used with permission) [IMG]http://img.photobucket.com/albums/v85/brennerak/kneeap.jpg[/IMG] [IMG]http://img.photobucket.com/albums/v85/brennerak/kneelat.jpg[/IMG]

Synergy -> Re: Interesting case (February 1, 2005 7:29:00 PM)
I'm definitely not a pro at this, but I'll give it my best. I believe I see a lateral non-displaced tibial condyle fracture running obliquely. Could be me, but it appears that the patellar position is pathological...maybe an avulsed patellar tendon? I also think I see a fracture of some kind running down the shaft of the tibia in the lateral view.

SJBird55 -> Re: Interesting case (February 2, 2005 1:23:00 AM)
Looks like he's got problems in the right lateral compartment - for a 32 year old, the spacing isn't normal. I'm not skilled enough looking at films to determine if the compartment issue is bony in nature or meniscal in nature. A tibial fracture doesn't seem to make sense if that's what that is. 1) tibias don't commonly just fracture 2) your reported mechanism would not be a mechanism for a fracture of the tibia 3) I would also think that if the suitcase thing wasn't the mechanism of injury, then that means if there is a fracture, then the fracture existed prior to the suitcase deal and if that was the case, he'd have a decent amount of hurt going on which would leave me to believe that he wouldn't be walking around to get a suitcase out of the trunk.

Sebastian Asselbergs -> Re: Interesting case (February 2, 2005 1:38:00 AM)
Almost looks like a compound fracture - non displaced - of the lateral tibial condyle. That IS an odd long "crack" in the shaft in the lateral view. SJ, I no longer think significant trauma in the history is necessary to suspect fractures: in 1991, at the training centre across the road, a 17 year old skating coach stood at centre ice in her shoes (!), turned to see her skater - fell over in excruciating pain. X-rays showed spiral fracture of the tibia - mid-shaft- with no osteopenia or other bone pathologies.... Did not make sense from a biomechanical point of view (still doesn't), but there it was - plain as day! This x-ray story seems a bit like that...

Bournephysio -> Re: Interesting case (February 2, 2005 3:40:00 AM)
Is that a tumour in the tibia just under the lateral tibial plateau? That would explain the ease with which he fractured his leg. It is just above the "crack" in the lateral view. Doug

jma -> Re: Interesting case (February 2, 2005 4:19:00 AM)
Hello, Looks like a fracture along the lateral tibia in the lateral view. The lateral edge of the femur does not look smooth to me, unless that is how it is supposed to look. Not sure about what the whiteness is near the beginning of the fracture, just below the lateral tibia. If this fracture was due a tumor, then I would have to call this an longitudinal nondisplaced pathological fracture of the lateral tibia. Of course, I could be wrong on this. JMA

UTDC -> Re: Interesting case (February 2, 2005 1:13:00 PM)
pathological fracture secondary to lytic lesion (giant cell tumor?) described by Doug. Much like the previous case, benign in appearance but needs follow-up. Thanks, Jeff

pablo w -> Re: Interesting case (February 2, 2005 9:36:00 PM)
The femur looks OK to me. I think the apparent decrease in lateral compartment space is due to the fracture of the lateral tibial plateau. This seems slightly displaced posterolaterally. I also see the longitudinal crack along the tibia. SJBird55 is right, the tibia is not supposed to fracture just like that. I would class this as a pathological fracture. At the proximal end of the "crack" along the tibia, I see an opacity about 15mm in diameter. This is also visible on the AP view where it appears a lot larger. The appearance of a fracture line through the lateral tibial condyle seems to mark the proximal end of this. You already hinted that these were the first radiographs you looked at, which suggets to me some more were ordered (I think with good reason). I think MRI would be the modality of choice here. Just curious, what causes the strange appearance of the soft tissues of the thigh? It loks as if there are circumferential rings as if he has something wrapped around the thigh and compressing the soft tissues. Was his thigh bandaged when the radiographs were taken? Can you tell us anything else about his history? Pablo

chiroortho -> Re: Interesting case (February 3, 2005 3:48:00 AM)
I'm surprised that nobody has mentioned the effusion inferior to the patella. Look again on the lateral view. You can see it outlining the capsule at it's inferior aspect.

Synergy -> Re: Interesting case (February 3, 2005 5:09:00 AM)
Pablo, I think the circumferential rings are eveidence of bunched up clothing...maybe wind pants because I see a zipper (could be wrong). I agree with Chiro in regards to the patellar pathology, mentioned in my previous post. Interesting case here!

chiroortho -> Re: Interesting case (February 3, 2005 5:42:00 AM)
Hi Chris, the patella's fine, no dislocation. The effusion would be due to bleeding or other fluid entering the joint capsule as a result of the 'pop'. As you know and are well aware, when somebody tears an ACL, for example, the knee will blow up like a balloon. This is one way that we differentiate between a ACL tear and anything else on the field. Almost instant balloon knee. Fractures will make the knee bleed too when the fx is intracapsular.

Alex Brenner PT MPT OCS -> Re: Interesting case (February 3, 2005 8:12:00 AM)
Pablo, The history is very similar to what I mentioned above, no previous history of trauma, no previous history of leg or knee pain, no family hx of cancer, no red flags. I was unable to perform a good physical exam (i.e. ligamentous tests due to pain). He had a very bizaare swelling over the lateral portion of his leg outside the knee capsule and just inferior to the patella. The circumferential rings noted on the films are his blue jeans push up above the knee.

jbeneciuk -> Re: Interesting case (February 3, 2005 5:40:00 PM)
Does the contour of the Lateral femoral condyle look right?

Synergy -> Re: Interesting case (February 3, 2005 6:20:00 PM)
Greg, thanks for the correction! :)

nari -> Re: Interesting case (February 3, 2005 9:01:00 PM)
Pathological fracture within the tibial condyle. Bizarre fractures do occur with relatively slight impact trauma, eg jumping off a 80 cm log - but usually spiral, and this seems different. Why on earth did they take XRs with the jeans on??? Contributing to oedema... He's too old for sarcoma, I think, but there are other sorts. Nari On the other hand, there is a tendency to look for zebras in XRs..

Alex Brenner PT MPT OCS -> Re: Interesting case (February 4, 2005 2:01:00 AM)
Follow on films same day. (all images obtained and used with permission) [IMG]http://img.photobucket.com/albums/v85/brennerak/tibpathfx2.jpg[/IMG] [IMG]http://img.photobucket.com/albums/v85/brennerak/tibpathfx.jpg[/IMG]

chiroortho -> Re: Interesting case (February 4, 2005 3:26:00 AM)
Maybe it's my monitor but these films look underpenetrated. Would sure like better visualization of the knee proper.

Alex Brenner PT MPT OCS -> Re: Interesting case (February 4, 2005 4:09:00 AM)
Greg, You are right. The Army uses a digital system for the radiographs so there are no longer "hard" copies of the films. The radiographs are taken and then sent electronically to my desk computer. I utilize an online program that allows you to change brightness, contrast, size and other attributes to allow for better visualization. I have not figured out how to change the contrast and then save the images to my hard drive.

chiroortho -> Re: Interesting case (February 4, 2005 5:49:00 AM)
That's fantastic news that you have access to digital radiography. Sure cuts down on retakes, doesn't it? I'm linked via MedWeb and MagicWeb to two local imaging centers, which allows me to view MR scans and other studies within an hour of when they were performed. The system allows me to modify contrast, use a 'magnifying glass', add comments with a red arrow, etc. I can save the films just by modifying them and closing the window. I get a prompt that asks 'Save changes?' or something like that. Again, great news that the Army is using digital radiography.

Bournephysio -> Re: Interesting case (February 4, 2005 6:22:00 AM)
Army, you could try a program like imagej to change the settings. It is a free program designed for scientific applications so if the file format is proprietory you might still be able to change it. It appears that you are able to convert to jpg so you may be able to edit the jpg. jpg is a lossy format so it may not work as well. If you could output to a tiff file it may work better. tiff could be the native format anyway. Doug

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