Sunday, September 26, 2010
Sunday, March 21, 2010
X-ray of the day
History: Six-year-old girl with pain after falling.
Diagnosis: Lateral condyle fracture
Findings: There is a left lateral condylar fracture, with anterior fat pad sign. Fragment is less than 2 mm displaced. Radial head is in place.
The lateral condyle typically ossifies at the age of ten years. At age six, as with this case, a lateral condylar fragment that looks like an ossification center (articulating with the radial head) cannot be an ossification center.
This type of fracture is considered a Salter-Harris type IV fracture.
Here are the follow-up x-rays both 3 and 6 weeks later
Followup imaging reveals bony bridging compatible with healing.Key points about lateral condyle fracture:
- Second most common pediatric elbow fracture (15%).
- Seen most often from age 4 to 10, peak incidence at age 6.
- Usually related fall on an outstretched hand with the elbow extended and the forearm abducted.
- Considered to be a Salter-Harris 4 injury.
- Stage or type 1 fractures with less than 2 mm displacement can be treated with immobilization.
- Open reduction recommended for all type 2 or 3 fractures.
- Easily missed if thought to represent a normal ossification center. The lateral condyle does NOT ossify until age 10.
X-ray of te day: Osteopetrosis
Findings: There is diffuse sclerosis throughout the bones. Additionally, there is a bone within bone appearance involving multiple bones, as well as metaphyseal banding, with alternating bands of lucency and sclerosis.Differential diagnosis for diffuse bony sclerosis:
- Osteopetrosis
- Sickle cell disease with bone infarcts
- Metastatic blastic disease
- Mastocytosis
- Fluorosis
- Metabolic diseases such as renal osteodystrophy
Diagnosis: Osteopetrosis.
- Failure of bony resorption by osteoclasts.
- Numerous possible genetic causes. May present as adult onset or infantile onset.
- Infantile onset typically leads to death in childhood secondary to anemia, bleeding or infection.
- Adult onset can be relatively asymptomatic.
- Typically, bones appear markedly sclerotic.
- Bones may have a "bone within bone" appearance (aka "endobone" appearance).
- Alternating sclerotic and lucent bands may be seen at the ends of long bones. This is known as metaphyseal banding.
- Vertebrae may be diffusely sclerotic, or show alternating bands (rugger jersey spine); this sign can also be seen in hyperparathyroidism.
- Fracture risk is high.
X-ray of the day
What is your diagnosis?
a) Metaphyseal dysplasia.
b) Osteogenesis Imperfecta Type II
c) Achondrogenesis Type I
d) Thanatophoric dwarfism
e) Osteogenesis Imperfecta Type I
Answer:
b. Osteogenesis Imperfecta Type II
MCQs
1. Regarding achondroplasia:
a) Achondroplasia is the most common type of short limb skeletal dysplasia which shortens stature
b) Achondroplasia is an autosomal recessive defect.
c) The short pedicles of achondroplasia lead to spinal stenosis and paraplegia more than 15% of patients
d) Hydrocephalus is an uncommon complication in patients with achondroplasia
e) About 90% of the cases of achondroplasia occur from a spontaneous mutation in patients with normal parents
.
2. Which is the most severe form of short-limbed dwarfism? Please pick the BEST answer.
a) Hypochondroplasia
b) Achondroplasia
c) Thanatophoric dwarfism
d) Homozygous achondroplasia
Answers:
1. a, c, e
Achondroplasia is the most common type of short limb skeletal dysplasia which shortens stature. It is an autosomal dominant defect in endochondral bone formation (osteochondrodysplasia) which causes skeletal growth derived from cartilage to be shortened. The most significant shortening occurs in long tubular bones, cranial base, and spinal pedicles. The short pedicles of achondroplasia lead to spinal stenosis and paraplegia more than 15% of patients. Hydrocephalus is a concern in 60% of patients with achondroplasia. About 90% of the cases of achondroplasia occur from a spontaneous mutation in patients with normal parents. However, it's mode of inheritance is autosomal dominant.
2. c
Thanatophoric dwarfism is the most common cause of fatal neonatal dwarfism. Features include cloverleaf skull, short ribs with small thoracic volume, small pedicles, and square iliac bones
a) Achondroplasia is the most common type of short limb skeletal dysplasia which shortens stature
b) Achondroplasia is an autosomal recessive defect.
c) The short pedicles of achondroplasia lead to spinal stenosis and paraplegia more than 15% of patients
d) Hydrocephalus is an uncommon complication in patients with achondroplasia
e) About 90% of the cases of achondroplasia occur from a spontaneous mutation in patients with normal parents
.
2. Which is the most severe form of short-limbed dwarfism? Please pick the BEST answer.
a) Hypochondroplasia
b) Achondroplasia
c) Thanatophoric dwarfism
d) Homozygous achondroplasia
Answers:
1. a, c, e
Achondroplasia is the most common type of short limb skeletal dysplasia which shortens stature. It is an autosomal dominant defect in endochondral bone formation (osteochondrodysplasia) which causes skeletal growth derived from cartilage to be shortened. The most significant shortening occurs in long tubular bones, cranial base, and spinal pedicles. The short pedicles of achondroplasia lead to spinal stenosis and paraplegia more than 15% of patients. Hydrocephalus is a concern in 60% of patients with achondroplasia. About 90% of the cases of achondroplasia occur from a spontaneous mutation in patients with normal parents. However, it's mode of inheritance is autosomal dominant.
2. c
Thanatophoric dwarfism is the most common cause of fatal neonatal dwarfism. Features include cloverleaf skull, short ribs with small thoracic volume, small pedicles, and square iliac bones
MCQs: Ortopaedic Oncology
1. Regarding desmoplastic fibroma (Choose a single answer):
a) Desmoplastic fibroma is a malignant neoplasm.
b) The most common site of occurence is the ilium.
c) Curretage is the treatment of choice.
d) "Pseudo-trabeculae" are a classic feature of desmoplastic fibroma
2. Regarding Ewings sarcoma (Choose a single answer):
a) Ewings sarcoma is typically a tumor of middle-age and beyond.
b) Tubular bones are most commonly affected in Ewings sarcoma in patients under 20 years old, with flat bones most commonly affected in those older than 20.
c) In Ewings sarcoma, bone metastases are uncommon and unlike the primary tumor, are usually blastic when they do occur.
d) The vast majority of occurrences of Ewings sarcoma in the long bones are of the central diaphyseal type.
3. Regarding osteochondroma
a) An osteochondroma is a bony projection with a cartilaginous cap arising from a bone preformed in cartilage
b) Malignant degeneration of osteochondroma to chondrosarcoma occurs in up to 20% of patients with hereditary multiple exostoses.
c) The cortex and medullary cavity of the host bone are not continuous with the osteochondroma.
d) The most common sites for osteochondroma are the hands and feet.
e) Almost all pseudoanerysms complicating osteochondromas arise from the popliteal artery
f) Benign osteochondromas generally do not demonstrate continued growth after skeletal maturity
Answers:
1. d
Desmoplastic fibroma is a locally aggressive, benign neoplasm of bone. It can be considered the intraosseous counterpart of the soft tissue desmoid tumor. The most common site of occurence is the mandible. Broad local resection is the treatment of choice. The lesion is prone to recur with curretage. "Pseudo-trabeculae" are a classic feature of desmoplastic fibroma.
2. b
Ewings sarcoma is a tumor of young people, with the peak age of incidence being 15 years old. Tubular bones are most commonly affected in Ewings sarcoma in patients under 20 years old, with flat bones most commonly affected in those older than 20. This is thought to reflect the red marrow distribution of the two age groups. In Ewings sarcoma, bone metastases are common, and usually ARE a lytic destructive process similar in appearance to the primary tumor. The vast majority of occurrences of Ewings sarcoma in the long bones are of the central diaphyseal type.
3. a, b, e, f
An osteochondroma is a bony projection with a cartilaginous cap arising from a bone preformed in cartilage. Malignant degeneration of osteochondroma to chondrosarcoma occurs in up to 20% of patients with hereditary multiple exostoses. The cortex and medullary cavity of the host bone ARE continuous with the osteochondroma. The most common sites of involvement include the distal femur, the proximal tibia, and the humerus. Almost all pseudoanerysms complicating osteochondromas arise from the popliteal artery. Benign osteochondromas generally do not demonstrate continued growth after skeletal maturity. In the presence of a large soft tissue mass or enlargement of a previously stable lesion chondrosarcomatous transformation must be considered.
a) Desmoplastic fibroma is a malignant neoplasm.
b) The most common site of occurence is the ilium.
c) Curretage is the treatment of choice.
d) "Pseudo-trabeculae" are a classic feature of desmoplastic fibroma
2. Regarding Ewings sarcoma (Choose a single answer):
a) Ewings sarcoma is typically a tumor of middle-age and beyond.
b) Tubular bones are most commonly affected in Ewings sarcoma in patients under 20 years old, with flat bones most commonly affected in those older than 20.
c) In Ewings sarcoma, bone metastases are uncommon and unlike the primary tumor, are usually blastic when they do occur.
d) The vast majority of occurrences of Ewings sarcoma in the long bones are of the central diaphyseal type.
3. Regarding osteochondroma
a) An osteochondroma is a bony projection with a cartilaginous cap arising from a bone preformed in cartilage
b) Malignant degeneration of osteochondroma to chondrosarcoma occurs in up to 20% of patients with hereditary multiple exostoses.
c) The cortex and medullary cavity of the host bone are not continuous with the osteochondroma.
d) The most common sites for osteochondroma are the hands and feet.
e) Almost all pseudoanerysms complicating osteochondromas arise from the popliteal artery
f) Benign osteochondromas generally do not demonstrate continued growth after skeletal maturity
Answers:
1. d
Desmoplastic fibroma is a locally aggressive, benign neoplasm of bone. It can be considered the intraosseous counterpart of the soft tissue desmoid tumor. The most common site of occurence is the mandible. Broad local resection is the treatment of choice. The lesion is prone to recur with curretage. "Pseudo-trabeculae" are a classic feature of desmoplastic fibroma.
2. b
Ewings sarcoma is a tumor of young people, with the peak age of incidence being 15 years old. Tubular bones are most commonly affected in Ewings sarcoma in patients under 20 years old, with flat bones most commonly affected in those older than 20. This is thought to reflect the red marrow distribution of the two age groups. In Ewings sarcoma, bone metastases are common, and usually ARE a lytic destructive process similar in appearance to the primary tumor. The vast majority of occurrences of Ewings sarcoma in the long bones are of the central diaphyseal type.
3. a, b, e, f
An osteochondroma is a bony projection with a cartilaginous cap arising from a bone preformed in cartilage. Malignant degeneration of osteochondroma to chondrosarcoma occurs in up to 20% of patients with hereditary multiple exostoses. The cortex and medullary cavity of the host bone ARE continuous with the osteochondroma. The most common sites of involvement include the distal femur, the proximal tibia, and the humerus. Almost all pseudoanerysms complicating osteochondromas arise from the popliteal artery. Benign osteochondromas generally do not demonstrate continued growth after skeletal maturity. In the presence of a large soft tissue mass or enlargement of a previously stable lesion chondrosarcomatous transformation must be considered.
Friday, September 25, 2009
Answer to x-ray quiz of the day - 2
The correct answer is d: Osteochondroma
Explanation: Osteochondromas have a characteristic radiographic appearance. The lesion is a surface tumor and the medullary cavity of the normal bone flows into the osteochondroma. Some authors call this "cortical sharing." Osteochondromas may have a well defined stalk (pedunculated osteochondroma) or they may have a broad base as in this case (sessile osteochondroma). This diagnosis can be made with the plain radiographs without histologic confirmation.
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X-ray quiz of the day - 2
A 16-year-old girl has a painless bump behind her knee. However, she does have pain if she her leg is hit while playing soccer. On physical examination there is a firm lump behind the knee. A plain radiograph of the knee is shown.
The most likely diagnosis based on the history, physical examination and plain radiograph is:
a) High-grade intramedullary osteosarcoma
b) Parosteal osteosarcoma
c) Periosteal osteosarcoma
d) Osteochondroma
e) Periosteal chondroma
The most likely diagnosis based on the history, physical examination and plain radiograph is:
a) High-grade intramedullary osteosarcoma
b) Parosteal osteosarcoma
c) Periosteal osteosarcoma
d) Osteochondroma
e) Periosteal chondroma
For answer, click here.
Answer to X-ray quiz of the day - 1
The correct answer is b
The patient has an L5/S1 spondylysis with a grade 1 spondylolisthesis. This patient has undergone a sufficient attempt at conservative management with continued unrelenting low back pain. The next most appropriate step in the management of this condition is a posterolateral fusion at the L5/S1 level with autologous bone graft.
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X-ray quiz of the day - 1
A 22-year-old woman sustained an injury to her low back 1 year ago while playing rugby. She now complains of excruciating low back pain with numbness and tingling into her left buttock. This pain is affecting her daily living activities. The patient underwent 6 months of conservative management consisting of restriction of activities, physical therapy, and anti-inflammatory medication with little relief. Based on the image below, the next appropriate step in the management of this patient is:
a) Continued conservative management
b) Posterolateral fusion at the L5/S1 level with bone graft
c) Laminectomy at the L2/L3 level
d) Laminectomy at the L3/L4 level
e) Diskectomy at the L3/L4 level
Click here for the answer
MCQs: Spine Trauma - General
1. The American Spinal Injury Association (ASIA) has developed a classification of spinal cord injuries. Using this classification system, an Asia C injury is best described as:
a) Complete motor loss with incomplete sensation
b) Complete motor loss with complete sensation loss
c) Incomplete motor loss with some preservation of motor function with groups with less then grade 3 strength
d) Incomplete motor loss with normal bladder function
e) Incomplete motor loss with 4+ strength and patchy sensation
2. Which of the following statements is true regarding neurogenic shock:
a) Neurogenic shock is due to severe blood loss associated with a spinal cord injury.
b) Neurogenic shock can be diagnosed when there is hypotension and tachycardia.
c) Neurogenic shock is due to increased parasympathetic tone.
d) Neurogenic shock is best treated with judicious use of fluids and vasopressors.
e) Neurogenic shock is a sign of an incomplete spinal cord injury.
1. C
a) Complete motor loss with incomplete sensation
b) Complete motor loss with complete sensation loss
c) Incomplete motor loss with some preservation of motor function with groups with less then grade 3 strength
d) Incomplete motor loss with normal bladder function
e) Incomplete motor loss with 4+ strength and patchy sensation
2. Which of the following statements is true regarding neurogenic shock:
a) Neurogenic shock is due to severe blood loss associated with a spinal cord injury.
b) Neurogenic shock can be diagnosed when there is hypotension and tachycardia.
c) Neurogenic shock is due to increased parasympathetic tone.
d) Neurogenic shock is best treated with judicious use of fluids and vasopressors.
e) Neurogenic shock is a sign of an incomplete spinal cord injury.
Answers
1. C
Asia C is an incomplete spinal cord injury with reservation of motor function with <>
2. d
Neurogenic shock is present when there is a spinal cord injury interrupting sympathetic tone to the heart and blood vessels, and it is heralded by bradycardia and hypotension. It is important to maintain a reasonable blood pressure to prevent further damage to the spinal cord due to ischemia. In the absence of significant blood loss from another source, neurogenic shock must be treated with vasopressor medication and atropine. Severe neurogenic shock may require cardiac pacing. Fluids must be used carefully as overzealous use of fluid resuscitation can result in pulmonary edema.
MCQ: Diseases of the Back
1. Weakness of the extensor hallucis longus is evidence of nerve root compression at what level?
a. L2
b. L3
c. L4
d. L5
e. S1
2. Spondylolysis (pars defect) is most widely believed to be caused by what?
a. A congenital defect in the pars
b. An acute traumatic defect in the pars
c. A stress fracture of the pars
d. A benign neoplasm involving the pars
e. None of the above
3. Cauda equina compression (CEC) syndrome is most typically manifested by:
a. Foot-drop
b. Severe back pain
c. Parasthesias in a nonanatomic distribution
d. Urinary retention
e. Priapism
4. A sequestered disk herniation refers to:
a) Bulging of the nucleus through a weakened annulus
b) Rupture of the nucleus through the annulus
c) Rupture of the nucleus through the annulus and the posterior longitudinal ligament
d) Rupture of the nucleus through the posterior longitudinal ligament
e) Separation of a herniated fragment from the disk
5. A 30-year-old man underwent an anterior lumbar discectomy and fusion at L4-L5 and L5-S1 through an anterior retroperitoneal approach 1 month ago. He now reports that he is unable to obtain and maintain an erection. The most likely cause of this condition is:
a) Disruption of the sympathetic nerves during anterior lumbar exposure
b) Traction on the parasympathetic nerve at the L4-L5 level
c) Not related to the surgical dissection
d) Injury to the pudendal nerves in the anterior sacral region during dissection at the L5-S1 level
e) Sexual dysfunction secondary to retrograde ejaculation
6. Which of the following antibiotics would not be useful in staphylococcal vertebral osteomyelitis:
a. Cefuroxime
b. Nafcillin
c. Cefazolin
d. Ciprofloxicin
e. Tobramycin
7. Which of the following is the most common source of infection in vertebral osteomyelitis:
a. Trauma
b. Iatrogenic
c. Hematogenous spread
d. Spontaneous
e. Unknown mechanism
1. d
The extensor hallucis longus is innervated by L5; weakness of this muscle would be evidence of an L5 radiculopathy.
2. c
Spondylolysis is believed to be a stress or fatigue fracture of the pars interarticularis occurring because of repetitive shear stresses from repetitive hyperextension in individuals with a hereditary predisposition. It occurs most commonly at L5, is more common in boys than in girls and in athletes, particularly gymnasts.
3. d
Urinary retention results from lower motor neuron bladder dysfunction seen in cauda equina compression (CEC) syndrome. Patients with CEC syndrome may also present with severe back pain, saddle anesthesia, pain down the back of lower extremities, or even foot drop, but the most typical and most important manifestation is bladder dysfunction.
4. e
A sequestered herniation is a separation of a herniated fragment from the disk from which it came.
5. c
7. c
Hematogenous seeding from another primary source is the most common causative agent. Hematogenous spread of infections is believed to affect the spine via septic emboli in the endarteriolar circulation of segmental spinal arteries at the vertebral endplates. The majority of cases of pyogenic spondylitis begin in the subchondral, metaphyseal region of the anterior subligamentous portion of the vertebral body — the portion with the greatest arterial supply and the most anastomoses.
a. L2
b. L3
c. L4
d. L5
e. S1
2. Spondylolysis (pars defect) is most widely believed to be caused by what?
a. A congenital defect in the pars
b. An acute traumatic defect in the pars
c. A stress fracture of the pars
d. A benign neoplasm involving the pars
e. None of the above
3. Cauda equina compression (CEC) syndrome is most typically manifested by:
a. Foot-drop
b. Severe back pain
c. Parasthesias in a nonanatomic distribution
d. Urinary retention
e. Priapism
4. A sequestered disk herniation refers to:
a) Bulging of the nucleus through a weakened annulus
b) Rupture of the nucleus through the annulus
c) Rupture of the nucleus through the annulus and the posterior longitudinal ligament
d) Rupture of the nucleus through the posterior longitudinal ligament
e) Separation of a herniated fragment from the disk
5. A 30-year-old man underwent an anterior lumbar discectomy and fusion at L4-L5 and L5-S1 through an anterior retroperitoneal approach 1 month ago. He now reports that he is unable to obtain and maintain an erection. The most likely cause of this condition is:
a) Disruption of the sympathetic nerves during anterior lumbar exposure
b) Traction on the parasympathetic nerve at the L4-L5 level
c) Not related to the surgical dissection
d) Injury to the pudendal nerves in the anterior sacral region during dissection at the L5-S1 level
e) Sexual dysfunction secondary to retrograde ejaculation
6. Which of the following antibiotics would not be useful in staphylococcal vertebral osteomyelitis:
a. Cefuroxime
b. Nafcillin
c. Cefazolin
d. Ciprofloxicin
e. Tobramycin
7. Which of the following is the most common source of infection in vertebral osteomyelitis:
a. Trauma
b. Iatrogenic
c. Hematogenous spread
d. Spontaneous
e. Unknown mechanism
Answers
1. d
The extensor hallucis longus is innervated by L5; weakness of this muscle would be evidence of an L5 radiculopathy.
2. c
Spondylolysis is believed to be a stress or fatigue fracture of the pars interarticularis occurring because of repetitive shear stresses from repetitive hyperextension in individuals with a hereditary predisposition. It occurs most commonly at L5, is more common in boys than in girls and in athletes, particularly gymnasts.
3. d
Urinary retention results from lower motor neuron bladder dysfunction seen in cauda equina compression (CEC) syndrome. Patients with CEC syndrome may also present with severe back pain, saddle anesthesia, pain down the back of lower extremities, or even foot drop, but the most typical and most important manifestation is bladder dysfunction.
4. e
A sequestered herniation is a separation of a herniated fragment from the disk from which it came.
5. c
Sexual dysfunction is a common condition after extensive anterior lumbar surgical dissection. Erectile dysfunction is often nonorganic but may be related to parasympathetic injury. The parasympathetic nerves are deep in the pelvis at the level of S2-S3 and S3-S4 and are not usually involved in the surgical field for anterior L4-L5 and L5-S1 procedures. Retrograde ejaculation is the result of injury to the sympathetic chain on the anterior surface of the major vessels crossing the L4-L5 level and at the L5-S1 interspace. Erectile function and orgasm are not affected by sympathetic injury. The pudendal nerve is primarily a somatic nerve and is not located in the surgical field.
6. e
Aminoglycosides, such as tobramycin, are active against gram-negative organisms. First- and second-generation cephalosporins are alternatives to semisynthetic penicillins that may be useful if the organism is not resistant. Ciprofloxicin has also been considered a possible alternative to penicillins against gram-positive vertebral osteomyelitis.7. c
Hematogenous seeding from another primary source is the most common causative agent. Hematogenous spread of infections is believed to affect the spine via septic emboli in the endarteriolar circulation of segmental spinal arteries at the vertebral endplates. The majority of cases of pyogenic spondylitis begin in the subchondral, metaphyseal region of the anterior subligamentous portion of the vertebral body — the portion with the greatest arterial supply and the most anastomoses.
Tuesday, September 22, 2009
X-ray of the day: Knee lesion
Osteoehondritis dissecans (OCD) of the lateral femoral condyle.AP radiograph of the knee showing a typical osteochondral lesion with a defect containing a fragment, located centrally in the femoral condyle.
Aetiology of OCD: Unknown; most commonly accepted thories are trauma, abnormal ossification within the epiphysis, ischaemia, or some combination of these.
The medial condyle is involved 85% of the time vs. 15% of the lateral condyle.
50% of loose bodies in the knee are associated with OCD.
X-ray of the day: Foot lesion
Fracture-dislocation of the Lisfranc joint after fall during jogging.AP and oblique radiographs show small avulsion fractures between the bases of the metatarsal bones (arrows) and a slight increase in distance between the bases of the first and second metatarsal bones.
CT sections of the tarsometatarsal joints confirm the extension of the injury throughout the Lisfranc joint (ventral arrows) with multiple avulsion fractures, including one at the lateral aspect of the cuboid (horizontally oriented white arrow).
X-ray of the day: Foot lesion
Displaced fracture-dislocation of the first through fourth tarsometatarsal joints, the Lisfranc joint (arrows), and avulsion fractures between the base of second and third metatarsal bones (short arrow).
MRI of the day: Talus lesion
Osteochondral fracture of the dame of the talus, osteochondritis dissecans. T2-weighted caranal, gradient echo MR image of an ankle in a young woman one month after injury to the ankle. The cartilage has high signal intensity. The osteochondral lesion appears at the medial aspect of the dame of the talus (arrow). The lesion is covered by cartilage.
X-ray of the day: Traumatic lesion of the ankle
AP and lateral radiographs reveal a fracture of the fibula at a high level and a small avulsion fracture of the posterior lip of the tibia (arrow). According to the staging, the injury includes complete tear of the deltoid ligament of the medial malleolus.
X-ray of the day: Traumatic lesion of the ankle
Supination-external rotation injury of the ankle stage IV: AP and lateral radiographs demonstrate a fracture of the distal end of the fibula and the medial malleolus as well as an avulsion fracture of the posterior lip of the tibia (arrowheads).
Postoperative radiograph after fracture reduction and fixation of this stage IV injury.
MRI of the day: Knee lesion
Tear of the medial meniscus. T2-weighted sagittal MR image of the medial portion of the femur and tibia using gradient echo technique. There is a normal low signal intensity in the anterior horn of the medial meniscus (black arrow). In the posterior horn of the meniscus a tear is seen (white arrow). V = joint effusion, B = Baker cyst.
X-ray of the day: Fracture of the lateral tibial condyle
Fracture of the lateral tibial condyle after a fall from a height. The radiograph shows displacement of fragments of a lateral condyle, but the severity of displacement cannot be assessed.
T1-weighted sagittal MRI scan of the lateral femoral and tibial condyle. Advanced displacement of osteochondral fragment (white arrows) is present. The tibiofibular joint is indicated (black arrow).
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