Lower Limb
Radiology Rotating Exhibit
Post-Session Version
2021
Scott Lehto, MD
Steven Ostrow, M.D.
Lee Eisner, Ph.D.
A 14 year old basketball player presents to his physician
complaining of intermittent worsening right knee pain.
Set A Case 1
Question 1
Identify the numbered bones.
14 year old with right knee pain
2
1
3 3
4 4
PA Lateral
Set A Case 1
Question 2
dentify the labeled regions of the bones.
Question 3
What structures are the 14 year old with right knee pain
arrows pointing to?
C C
B B B B
A A A A
A A A
A
B
B B B
C
C PA Lateral
Set A Case 1
Question 4
What is the abnormal lucency indicated by the arrow which is causing the patient’s pain?
14 year old with right knee pain
PA Lateral
Set A Case 1
A 13 year old obese male complains of worsening pain in his left hip which
sometimes extends to his medial thigh and knee. His left limb looks a little shorter
and externally rotated compared to the right. His ROM for internal rotation is
reduced. His mother says that sometimes he walks with a limp.
Set A Case 2
AP and Lateral projection images of our 14 year old patient’s hip are displayed.
Question 1
Why are the radiographs presented with the right side of the patient on the left of the
screen and the left side of the
patient on the right of the RT AP LT AP
screen?
3
Question 2 1
4
Identify the numbered parts
of the femur and the structures
that the arrows point to. 2
RT FROG LEG LAT LT FROG LEG LAT
RT FROG LEG LAT
1
Thigh is abducted, externally
rotated and flexed at hip
2
Set A Case 2
AP and Lateral projection images of our 14 year old patient’s hip are displayed.
Question 3
Why do you think the left
proximal femoral physis
is widened relative
to the normal right physis?
Set A Case 2
A 45 year old female crossing the street was hit by the fender of a
car that went through a red light. She presents with marked swelling,
pain and limited range of motion in the right knee.
She is unable to bear weight on the injured limb.
Set B Case 1
Question 1
Match the numbers with the appropriate x-ray density listed below to the right.
45 year old female patient
X-RAY DENSITIES
Metal
2 Air
Fat
5 1
Bone
Soft Tissue
44
2 3
AP view Cross table lateral view
(obtained using vertical x-ray beam) (obtained using horizontal x-ray beam)
Set B Case 1
Question 2
The arrows point to abnormal radiolucencies. Describe their location. Be as
specific as possible . Find the corresponding radiolucency on the AP projection.
45 year old female patient
What pathology do these
radiolucencies represent?
What is the relationship
of these radiolucencies
to the articular surface of
the knee joint?
AP view Cross table lateral view
(obtained using vertical x-ray beam) (obtained using horizontal x-ray beam)
Set B Case 1
Question 3
Name the potential space outlined by the white lines.
Describe the contents of this space and the interface between them.
Does this interface allow you to be more specific about the composition of substance 2?
Do you have enough information to determine how the patient is positioned for
this image?
1
2
Cross table lateral view (same as previous image)
(obtained using horizontal x-ray beam)
Set B Case 1
Question 4
What does the abnormal presence of these substances in the bursa tell you about the
knee joint? (Hint : Remember the nature of the patient’s tibial abnormality.)
1
2
Set B Case 1
10 year old male falls down stairs and presents with
pain and an inability to bear weight.
Set B Case 2
Question 1
Identify the numbered bones.
10 year old male patient
44
44
33
2b
2b 33
2a
2a
11 55
88
66 2b
2b 77
Lateral
Lateral AP
Set B Case 2
Question 2
Find the abnormality. Describe its appearance and location as specifically as possible.
What is its relationship to the structure indicated by the arrows?
10 year old male patient
Lateral
Lateral AP
Set B Case 2
A 50 year old foreign correspondent was assigned to cover a breaking
story overseas. She began taking an antibiotic as a prophylaxis against
developing traveler’s diarrhea. One week after her arrival she developed
severe pain, tenderness, and swelling in the posterior aspect of her
left ankle.
Set C Case 1
Question 1
What is the plane of imaging?
Question 2
Match the numbers to some of these structures. 5 3
(Not all are visualized in this plane.)
Tibia
Fibula
Calcaneus 6
4
Talus 1
Navicular
Achilles tendon
Soleus muscle 2
Flexor hallucis longus
Fat
Normal Ankle MRI
Set C Case 1
Our patient was unable to ambulate and had to return home from her trip. After
arriving she had an MRI exam. Here is an image taken in the same plane as the
normal MR image in the previous slides.
Question 3
Find and describe the abnormality imaged on the MR.
Question 4
Predict what her functional
impairment must have
been.
Set C Case 1
A wide receiver was tackled during an attempted interception.
Subsequently he complained of pain and swelling in his right knee,
which was exacerbated by weight-bearing. He also experienced
intermittent inability to straighten his leg.
Set C Case 2
Injured football player
1
Question 1
Identify the numbered structures. *
Give two clues for identifying 2 & 3.
2 3
5
Question 2 *
What is the composition and 7
4
location of the substance marked
by the asterisks? 6
Right knee axial T2 weighted MR
2 3
*
Coronal
Set C Case 2
uestion 3
entify the labeled structures. Injured football player
uestion 4
hich of these structures is
bnormal, and why?
Normal Knee
2 3
Right knee sagittal Right knee sagittal
T1 weighted MR medial aspect
Set C Case 2
This is a midsagittal MR image of the knee from another patient who
experienced an injury similar to that of the first patient.
Question 5
Identify the following structures:
Quadriceps tendon
Patellar ligament
Infrapatellar fat pad
Anterior cruciate ligament
Posterior cruciate ligament
Question 6
Which of these structures is
abnormal, and why?
Right knee sagittal T1 weighted MR
medial aspect
Set C Case 2
A 24 year old ballet dancer reported pain on the dorsum
of the right foot that was exacerbated by the demi pointe position.
The pain began two months ago without any history of trauma.
Set D Case 1
24 year old ballet dancer
Question 1
Identify the numbered bones, structures and
labeled joints.
&
Question 2
Can you find an osseous abnormality?
4
6 *
3
1
#
2
AP
Set D Case 1
This is a normal T1 –weighted MR image.
Question 3
Identify the numbered
structures.
Question 4
Name the structure, not
visualized here, that bridges
the space marked by the
1
asterisk * to maintain the height *
2
of the
head of the talus in the medial 3 55
arch of the foot.
4 5 6
Question 5 6
Could this be an image of the
left foot of the ballet dancer?
Set D Case 1
Question 6
The black arrows on both MR images indicate
regions of abnormal signal intensity in the marrow
space of this second metatarsal. On the T1 T1 weighted MR 24 year old ballet dancer
weighted image this region has an abnormally low
signal as compared to the adjacent normal proximal
phalanx. On the STIR image this region of the
metatarsal emits an abnormally high signal MT2
compared to the adjacent normal proximal phalanx.
The fatty marrow in the MT2 is abnormal because it
contains an abnormally high amount of fluid.
STIR MR 24 year old ballet dancer
Similarly, the arrowhead on the STIR image
indicates a thin strip of increased signal in the MT2
periosteal region just superficial to the dorsal cortex
of this metatarsal, also caused by excess fluid in
this region.
Knowing this patient’s history, what do you STIR is an MR pulse
think is the explanation for the excess fluid in sequence used to suppress
the signal arising from normal
these regions?
fat.
Set D Case 1
The patient was advised to cease all dancing activities after the diagnosis
was made based on the history, physical exam and the MR images seen
in the previous slide. A follow-up x-ray of his right foot was obtained 2 weeks
after his initial presentation. 24 year old dancer AP Rt foot
Question 7 at time of initial
two weeks later
presentation
How does this new image differ from
the initial radiograph taken when the
patient presented?
Set D Case 1
A 50 year old man presents to the Emergency Room with
sudden onset shortness of breath and severe chest pain,
accompanied by painful swelling of the right lower limb. One week
earlier he was returning from a business trip on a 17 ½ hour airline
flight from Sydney to Dallas.
With contributions by John Henning,
SUNY Downstate COM Class of 2017
Set D Case 2
In the ER the patient had a CT scan of the chest following administration of
intravenous (IV) contrast. This study revealed blood clots in the pulmonary
arterial vasculature called pulmonary emboli (PE). Additional axial images
were obtained through the proximal lower limbs.
Question 1
9 10
Identify the numbered
structures on the normal 3
left side. 5
4
Question 2
Describe the appearance 2
7
of the contralateral 7 1
vascular structures
(indicated by the white 8
arrow).
50 year old patient
Set D Case 2
Here are two additional axial CT
50 year old patient
images of our patient’s lower
limbs.
A
Question 3
Which image was acquired
more inferiorly, A or B? What
specific clues did you use to
determine this?
Question 4
Name the structure indicated by
the arrow in each image. Contrast
The appearance of these vascular
structures with their contralateral B
counterparts.
Set D Case 2
A new patient, a 26 year old bodybuilder, presents to his primary care physician with
intermittent left lower leg pain that occurs during exercise and is relieved by rest. Here
is a Magnetic Resonance Angiogram (MRA) showing the arterial flow of this patient's
non-symptomatic right leg.
Question 5 1
Identify labeled structures. What
muscular-fascial structure does
the green curve represent?
6
Question 6 2
Trace the arterial path on the
drawing of the skeleton with the
correct anatomical relationship.
The drawing correlates in scale
and level with the MRA. 3
5 4
Set D Case 2
Suspecting a vascular abnormality, the physician Patient’s left lower limb
ordered a conventional angiogram of the
patient’s legs. The angiogram on the right is our
patient's symptomatic left knee taken
immediately after exercise while he was still
experiencing symptoms.
Question 7
Describe the pathology indicated by the black
arrow. Describe the specific location(s) of the
abnormality(ies).
Question 8
Describe in general terms the possible
symptoms of a patient with this pathology.
Set D Case 2
Question 8 Patient’s left lower limb
Describe in general terms the possible
symptoms of a patient with this pathology.
Set D Case 2
Question 9
Contrast the clinical presentation of this patient with the presentation of the previous
patient.
Set D Case 2 Answer
