Pathologies of the patella and normal variants

Poster No.: C-1107

Congress: ECR 2017
Type: Educational Exhibit
Authors: R. Kumar, T. Fernandes; London/UK
Keywords: Musculoskeletal joint, MR, Conventional radiography, Education,
Trauma, Education and training, Arthritides
DOI: 10.1594/ecr2017/C-1107

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Learning objectives

• To understand the anatomy of the patella.

• To raise awareness of normal variants related to the patella.
• To recognise the role of the patella in biomechanics.
• To recognise common pathologies of the patella particularly related to
trauma and age related disease.

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Background

The patella is the largest sesamoid bone with an important biomechanical role.
Awareness of common patella pathologies and recognition of the common normal
variants is vital to ensure accurate reporting. This will improve patient management and
hence improve patient mobility and reduce discomfort.

Anatomy:

The patella is a sesamoid bone which begins ossification at 3-6 years of age. There are
several normal anatomical variants, however it normally forms as a single bone which
attaches to the quadriceps tendon superiorly and patellar tendon inferiorly, which in turn
attaches to the tibial tuberosity. Femoral articulation is via the medial and lateral facets,
both covered in hyaline cartilage, with the medial and lateral femoral condyles. The lateral
facet is larger which aids in identification of the lateral side of the patella-femoral joint on
imaging. The patellar retinaculum allows attachment with the surrounding fascia.

Imaging:

Patella fractures are well seen on plain film radiographs and hence this is first line in the
trauma setting. CT can sometimes be helpful in surgical planning, particularly if there are
also fractures of the femur, tibia or fibula. MRI is crucial for cartilage, tendon and bone
marrow assessment and hence has a role in assessing cartilage damage secondary to
trauma, degenerative disease, inflammatory joint disease and bone tumour assessment.

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Findings and procedure details

Normal variants:

There are several normal patella variants which must be recognised. During ossification,
there may be failure of fusion of the ossification centres of the patella leading to the
common findings of a bipartite or less commonly a multipartite patella. These appear well
corticated and hence must not be misinterpreted as fractures. Rarely the patella can be
completely absent.

The position of the patella can also vary. It can be incidentally high riding (patella alta)
which can be idiopathic but can also be related to a previous patella tendon rupture. It
can be associated with pain, effusions, patella dislocation or chondromalacia patellae.
An abnormally low lying patella (patella baja) can be related to fractures, knee surgery or
previous polio infection and is commonly associated with pain and restricted movement.

The patella can sometimes demonstrate a subchondral defect posteriorly, known as a

dorsal defect of the patella (Figure 1) which is a normal variant and must not be mistaken
for osteochondritis dissecans or infection. It is commonly associated with biparite or
multipartite patellae.

Fractures and dislocations:

Patella fractures are frequent injuries, most commonly related to sports activities due
to forceful, sudden contraction of the quadriceps or direct trauma. They are usually
transverse fractures (Figure 2) and can be communited, and most not be mistaken for a bi
or multipartitie patella. They are usually confidently diagnosed on plain film radiography
but MRI can be helpful is assessing associated soft tissue damage. The patella should
also be assessed for osteochondral defects. This is related to a focal area of damage to
the hyaline cartilage and subchondral bone of the patella. It can be related to repeated
microtrauma or a single injury. Plain film radiography can usually identify the lesion,
however MRI is required to assess for chondral damage, extent of bony damage and for
any loose bodies.

Another common injury to the patella are avulsion injuries (Figure 3). Avulsion of the
inferior pole (which can be chondral/osteochondral) is more common in children and is
also known as a patella sleeve fracture. This is more clearly seen on MRI. Small patella
avulsion fractures can also be associated with patella tendon ruptures and confirmed

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on ultrasound but more accurately demonstrated on MRI. In a chronic setting, there can
be dysfunction at the tendinous junction between the patella and the patella tendon with
thickening and increased signal in the proximal patella tendon and abnormal signal in the
inferior pole of the patella. This is also known as Sinding Larsen disease in children or
Jumper's knee in adults.

Patellar dislocations are a common knee injury related to sporting activities. They are
usually laterally displaced and can be related to patellar instability. A skyline plain film
view can demonstrate the dislocation and there is often a joint effusion. Even after
patella relocation which may be spontaneous, the MRI demonstrates medial retinaculum
disruption, medial patella and/or lateral femoral condyle bone oedema and an associated
joint effusion (Figure 4).

Degenerative and inflammatory disease:

Chondromalacia patella is an age related disease and a common finding related to

hyaline cartilage degeneration resulting in patellofemoral joint osteoarthritis. Patient's
present with knee pain particularly on climbing stairs. The knee may become stiff,
patients may notice crepitus and there is clinically often a joint effusion. Plain films can
usually identify joint space narrowing, osteophyte formation and an associated effusion.
MRI confirms the associated chondral changes related to chondromalacia patella. This
demonstrates abnormal cartilage signal due cartilage loss, underlying bone marrow
oedema and the extent of an associated effusion.

The patellofemoral joint can also be affected by inflammatory diseases. This can include
rheumatoid arthritis which usually involves the whole knee joint and demonstrates
synovial and cartilage inflammation and destruction with bony erosions and eventual
ankylosis. Gout can also be observed in the patellafemoral joint. Plain film can
demonstrate a joint effusion, punched out erosions,lytic bone lesions and soft tissue tophi
which can calcify. The latter is pathognomonic. This can be further characterised on MRI
(Figure 6).

Tumours of the patella:

Patellar tumours are very rare but must be considered with bony lesions of the
patella. The majority are benign, and most commonly due to a giant cell tumour or
a chondroblastoma. Giant cells tumours occur in adults and demonstrate a narrow
zone of transition usually with cortical thinning or expansion on plain film. There
is no cortical destruction or periosteal reaction. On MRI they will also demonstrate

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heteregenous T2 signal (Figure 7). Chondroblastomas occurs in childhood and appear
as well defined lucent, expansile lesions which can have lobulated margins, thin sclerotic
rims, associated calcification and endosteal scalloping. MRI demonstrates high T2 signal
and often surrounding bone marrow and soft tissue oedema (Figure 8 & 9). Aneurysmal
bone cysts can also occur in the patella, and are again most common in children. They
appear as expansile, lytic lesions and can have fluid-fluid levels which are more easily
identified on MRI (Figure 10).

A lytic lesion in the patella on plain film can also be related to a malignant primary
bone tumour such as an osteosarcoma or a metastatic deposit (Figure 11) such as from
breast cancer. These lesions usually demonstrate wide zones of transition, periosteal
reactions and can have a soft tissue mass. Clinical history is important for correlation
and further imaging usually including an MRI and a biopsy are required for confirmation
of the diagnosis.

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Images for this section:

Fig. 1: MRI demonstrating a dorsal defect of the patella - a normal variant.

© Dr Ian Pressney, Consultant Radiologist and Department of Radiology, Royal National

Orthopaedic Hospital, Stanmore, UK

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Fig. 2: Plain radiographs demonstrating transverse fractures through the patella.

© Radiology, Northwick Park Hospital - London/UK

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Fig. 3: MRI demonstrating an avulsion fracture of the inferior pole of the patella.

© Dr Ian Pressney, Consultant Radiologist and Department of Radiology, Royal National

Orthopaedic Hospital, Stanmore, UK

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Fig. 4: MRI image demonstrating a patellar dislocation with an osteochondral fragment.

© Radiology, Northwick Park Hospital - London/UK

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Fig. 5: Plain radiograph demonstrating osteoarthritis and MRI images demonstrating
chondromalacia patellae.

© Radiology, Northwick Park Hospital - London/UK

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Fig. 6: Plain radiograph and MRI images demonstrating gout.

© Dr Ian Pressney, Consultant Radiologist and Department of Radiology, Royal National

Orthopaedic Hospital, Stanmore, UK

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Fig. 7: MRI images demonstrate a giant cell tumour of the patella.

© Dr Ian Pressney, Consultant Radiologist and Department of Radiology, Royal National

Orthopaedic Hospital, Stanmore, UK

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Fig. 8: Plain radiograph demonstrating a lytic lesion within the patella - subsequent
imaging and biopsy confirmed a chondroblastoma.

© Dr Ian Pressney, Consultant Radiologist and Department of Radiology, Royal National

Orthopaedic Hospital, Stanmore, UK

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Fig. 9: MRI images demonstrating a chondroblastoma of the patella.

© Dr Ian Pressney, Consultant Radiologist and Department of Radiology, Royal National

Orthopaedic Hospital, Stanmore, UK

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Fig. 10: MRI images demonstrating an aneurysmal bone cyst of the patella.

© Dr Ian Pressney, Consultant Radiologist and Department of Radiology, Royal National

Orthopaedic Hospital, Stanmore, UK

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Fig. 11: Plain radiograph and MRI images demonstrating a metastatic deposit in the
patella.

© Dr Ian Pressney, Consultant Radiologist and Department of Radiology, Royal National

Orthopaedic Hospital, Stanmore, UK

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Conclusion

Common pathologies of the patella are important to recognise for appropriate and
timely treatment, whilst identifying normal patellar variants to prevent misinterpretation
of imaging. The indications and limitations of plain film radiography, CT and MRI must
also be considered for optimal assessment. This will help with accurate diagnosis and
improve patient management.

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References

Elias, D.A et al. Imaging of patellofemoral disorders. Clinical Radiology 2004 Jul, Volume
59. ,Issue 7 , 543 - 557

Singh, J., James, S.L., Kroon, H.M. et al. Tumour and tumour-like lesions of the patella
- a multicentre Eur Radiol (2009) 19; 701.

Jarraya, M., Diaz, L.E., Arndt, W.F., Roemer, F.W., Guermazi, A. Imaging of patellar
fractures. Insights Imaging. 2016. Nov 30

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