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Imaging of Synovium and Cartilage of the Knee

Synovium Introduction It is important for the surgeon to understand the principles for imaging the synovial compartments and articular cartilage of the knee. This chapter summarizes the anatomy, normal variations, pathologic conditions, and the strengths and weaknesses of the available imaging modalities. Synovial Anatomy The synovium surrounding a joint has an outer fibrous capsule and an inner thinner synovial membrane. The inner vascular synovial membrane lines…

Cruciate Ligaments

Noncontrast magnetic resonance imaging (MRI) is standard of care imaging in the posttraumatic knee with clinical findings suggestive of ligamentous injury. MRI readily delineates injuries of the cruciate ligaments and offers a distinct advantage in preventing unnecessary arthroscopy by assessing the severity of the anterior cruciate ligament/posterior cruciate ligament (ACL/PCL) tear and other coexisting injuries. In addition, MRI is ideally suited for the evaluation of pain…

Imaging of the Meniscus

Introduction Meniscal tears are among the most common knee injuries. Abnormal biomechanics after a meniscal injury expose the underlying articular cartilage to increased axial and sheer stress, leading to articular cartilage lesions and early osteoarthritis (OA). The choice of treatment and ultimate prognosis associated with meniscal tears are influenced by such factors as tear orientation, extent, and location. In the United States arthroscopic partial meniscectomy is…

Fractures

Diagnosis and Imaging Protocols Radiography Trauma to the knee is a relatively common injury, accounting for a significant number of visits to emergency rooms, urgicenters, and orthopedic offices. However, not all of these knee injuries will present as fractures. When evaluating trauma to the knee and potential fractures about the knee, conventional radiographs have been, and should continue to be, the first approach. Rules have been…

Knee Imaging Techniques and Normal Anatomy

Radiography Applications Radiographs are the workhorse of knee imaging. Almost any symptom or sign may be initially evaluated with an x-ray. Radiographs provide useful information across the entire spectrum of knee pathology, including congenital deformities, arthritis, trauma, oncology, sports injuries, metabolic disease, and arthroplasty evaluation. Technique A brief orientation to x-ray technology enhances an understanding of knee imaging. An x-ray tube converts electricity into a beam…

Gene Therapy for the Treatment of Knee Disorders

* The authors are grateful for the editorial assistance of Ryan J. Warth, MD (Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston), Jorge Chahla, MD (Steadman Philippon Research Institute, Vail, CO), and Lavanya Rajagopalan, PhD. Introduction The treatment of knee disorders has improved over the years as a consequence of new minimally invasive operative techniques, novel instruments, modern rehabilitation, medications, and increasing…

Clinical Examination of the Knee

History Despite improvements in advanced imaging techniques, clinical examination of the knee remains an essential step in evaluating the knee patient. Evaluation of every patient should begin with a complete history of the symptoms and a full description of the mechanism of injury. Often, the history will direct the examiner to the area of knee involvement. This will sharpen the physical examination, result in a more…

Anatomic Aberrations

* The authors thank John N. Insall for his thoughtful guidance and contributions to previous editions of this chapter. Variations of normal anatomy and frankly abnormal structures are occasionally encountered by the physician. Without a fundamental understanding of the more common abnormalities, it may be difficult to identify and interpret the significance of these structures. The goal of this chapter is to provide an overview of…

Anatomy

* The authors thank John N. Insall for his thoughtful guidance and contributions to previous editions of this chapter and Kevin R. Math, Vincent J. Vigorita, and Fred D. Cushner for their prior work. The anatomy of the knee can be examined on a number of levels from microscopic to gross and with a variety of techniques, including physical examination, anatomic dissection, radiographic and cross-sectional imaging,…

Bariatric Surgical Procedures in Adolescence

Childhood obesity is a prevalent and progressive disease with few successful treatment options. Not only have increasing numbers of children and adolescents been affected over the years, but the average weight achieved by obese individuals has soared as well. Pediatric specialists are increasingly considering effective and sustainable measures to combat the serious and immediate health complications of this chronic disease. Evidence from clinical trials shows that…

Endocrine Disorders and Tumors

Thyroid Gland The thyroid gland is one of the largest endocrine organs in the body. Despite this, surgical diseases of the thyroid gland in children are uncommon. In one study, thyroid disease requiring operative intervention was found to occur in 37 of 1000 school-aged children in the United States. Also, the incidence of thyroid cancer in children is increasing at a rate of 1.1% per year.…

Breast Diseases

Development, Anatomy, and Physiology At the end of week 4 of human embryonic development, paired thickenings appear in the ectoderm on the ventral aspect of the torso. Extending from the axilla to the inguinal region, they form the mammary ridges or “milk lines.” Subsequently they regress and leave a pair of primary mammary buds at the level of the fourth and fifth intercostal spaces. The primary…

Pediatric and Adolescent Gynecology

Surgeons who care for girls and young women must be equipped to recognize and treat a variety of developmental and acquired disorders of the female genital tract spanning from neonatal life through adulthood. Most of the gynecologic surgical problems facing this group have distinct characteristics distinguishing them from adult disorders and require a specialized approach. An understanding of the normal and developing genital anatomy, examination techniques,…

Head and Neck Sinuses and Masses

Lesions of the head and neck in children can be subdivided by etiology as those resulting from infection, trauma, neoplasm, or those of congenital origin. The more common benign neoplasms including hemangiomas, lymphangiomas, and cystic hygromas are discussed in Chapter 71 . Malignant neoplasms of childhood (e.g., neuroblastoma, lymphoma, and rhabdomyosarcoma), which occur as primary or metastatic masses in the head and neck, lesions of the…

Vascular Anomalies

Vascular anomalies are broadly divided into two groups based on biologic and clinical behavior: vascular tumors and vascular malformations. Vascular tumors are true neoplasms that arise from cellular hyperplasia. In contrast, vascular malformations are congenital lesions originating from errors of embryonic development and exhibit normal endothelial cell turnover. Historically, the field of vascular anomalies has been hindered by a myriad of confusing and misused terminology and…

Nevus and Melanoma

Melanocytic nevi are a common finding in children. By age 10 years, the mean nevus count among white children is 10–30 and 5–10 among African, Asian, and Native American children. These lesions are frequently encountered by pediatricians and can be a source of concern among parents, especially new or changing pigmented lesions. Fortunately, childhood melanoma is a rare disease, especially among children <10 years. However, the…

Rhabdomyosarcoma

Rhabdomyosarcoma (RMS) is the most common form of soft tissue sarcoma, accounting for 5% of all childhood cancers. It is the third most common pediatric extracranial solid tumor after Wilms tumor and neuroblastoma. RMS is a malignant tumor of mesenchymal origin and along with neuroblastoma, primitive neuroectodermal tumors (PNETs), and lymphoma form the group of small, round blue cell tumors of childhood. Its incidence is estimated…

Lymphomas

Lymphomas are a result of chromosomal alterations resulting in the uncontrolled growth of cells of lymphoid origin. In children, lymphomas are the third most common type of cancer, accounting for 11% of new diagnoses under the age of 15 and increasing to 21% in adolescents between the ages of 15 and 19. Combined, Hodgkin and non-Hodgkin lymphoma are the second most common childhood solid tumor (behind…

Teratomas, Dermoids, and Other Soft Tissue Tumors

Teratomas Teratomas are generally divided into gonadal and extragonadal types. This chapter focuses on those in extragonadal locations, the most common being sacrococcygeal teratomas (SCT). Embryology and Pathology Teratoma, from the Greek teratos (“of the monster”) and onkoma (“swelling”), is a term first applied by Virchow in 1869 to “sacrococcygeal growths.” Teratomas are composed of multiple tissues foreign to the organ or site from which they…

Lesions of the Liver

Hepatic tumors in children are relatively rare. The most common malignant hepatic neoplasms are not primary tumors but rather metastatic lesions such as Wilms tumor, lymphoma, and neuroblastoma (NB). Primary liver tumors make up 1–4% of all solid tumors in children. Malignant hepatic tumors occur at a rate of about 1 to 1.5 per million children per year. Ten primary liver masses occur with some frequency…