Imaging Anatomy of the Knee Region: Anatomy-CT-NMR Frontal Slices, Sagittal Slices, Horizontal Slices

92 Pages·1988·15.34 MB·English

by  Henri Sick

H. Sick, J.-L. Burguet· Imaging Anatomy ofthe Knee Region
Henri Sick, Jean-Louis Burguet
Imaging Anatomy
of the Knee Region
Anatomy-CT - NMR
Frontal Slices, Sagittal Slices, Horizontal Slices
With 124 Photographs
J. F. Bergmann Verlag Miinchen
Henri Sick
Professeur d'Anatomie
Praticien Hospitalier
lean-Louis Burguet
Chef de Clinique des Universites
Assistant des Hopitaux
Faculte de Medecine
Universite Louis Pasteur
4, rue Kirschleger
F-67085 Strasbourg Cedex
France
ISBN-13:978-3-642-80521-9 e-ISBN-13:978-3-642-80519-6
DOl: 10.1007/978-3-642-80519-6
CIP-Titelaufnahme der Deutschen Bibliothek:
Sick, Henri:
Imaging anatomy of the knee region: anatomy - CT - NMR ;
frontal slices, sagittal slices, horizontal slices / Henri Sick;
Jean-Louis Burguet. [Photogr. by R. Becker]. - Munchen:
Bergmann; New York; Berlin; Heidelberg: Springer, 1988
Franz. Ausg. u.d. T.: Sick, Henri: Atlas de coupes seriees de la region
dugenou
NE: Burguet, Jean-Louis:
French edition: Atlas de Coupes Seriees de 1a Region du Genou. Anatomie - Tomodensitometrie - IRM. ISBN 3-8070-0366-5
This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation,
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and a copyright fee must always be paid. Violations fall under the prosecution act of the German Copyright Law.
© J. F. Bergmann Verlag, Munchen 1988
Softcover reprint of the hardcover 1st edition 1988
Photographs by R. Becker
Reproduction of photographs: Gustav Dreher, Stuttgart
2382/3321-543210
Preface
Introducing the work of Professor H. Sick and Dr. J.-L. Bur As a consequence it is essential to come back to fun
guet is a very happy event for me, for during its production damental science, determinative for picture scanning, de
I had the privilege of being witness to the enthusiasm and scriptive and topographic anatomy, and apply it to new
untiring commitment of both authors. I saw how this valu prospects already open. This coming back must be carried
able atlas of serial sections of the region of the knee - which out with the precision of observation, analysis and synthe
brings together a judicious synthesis of the anatomic, com sis, and requires adequate experience.
puted-tomographic, and magnetic resonance data collected The work presented here is high quality evidence of this
on serial frontal, sagittal, and horizontal sections - was edi new approach. Its iconography, achieved with care of per
fied with rigorous methods and logic. fection, intelligibility, and synthesis offers a rich harvest
This new approach, from descriptive and topographic which significantly takes place in the medical imaging of
anatomy, is henceforth essential in medical imaging; it the region of the knee.
gives a new, particularly determining, trend to anatomical
research applied to clinical investigation. J. G. Koritke
The amount of morphological data collected from the Professeur des Universites
image is much increased and the description and topogra Praticien Hospitalier
phy greatly specified, while their number and comparison Institut d'Anatomie Normale
more easily suggest a functional interpretation. de la Faculte de Medecine de Strasbourg
If my friend H. Sick and my student J.-L. Burguet come to plines: the rates of exploration are very variable; the nature
be recognized for their achievement in producing this pres of information, although very similar, requires analogic
tigious atlas of serial sections of the region of the knee, the support that has to be dealt with within the contingencies of
thanks goes to their master Professor J. G. Koritke, for their digitalization; laboratories are not uniform, their geo
style of publication takes place in the tradition of the fa graphical separation is often excessive (Strasbourg-Paris).
mous "Atlas Strasbourgeois" In spite of the best intentions, there remains an interdis
1.
H. Sick, anatomist, and J.-L. Burguet, radiologist, pos ciplinary obstacle which resembles our European border
sess "occipital" intelligence. They are prompted by a liking lines, which, we are told, will soon disappear. However,
for structure in a "structural" as well as in a "structured" anatomy is such a well-established discipline in occidental
meaning. They must not be surprised by their own success civilization that it looks like a "University Notable" in com
guaranteed to anyone able to study existing structures parison with radiology, which is less than a century old and
(anatomy), their connections, relations, and imminent rules still suffering from the stupendous frolics of youth and its
(structuralism). J.-L. Burguet, brought up in the atmosphere concomitantly fantastic instability (X-rays, IR, US, CT,
of the "Radiologistes, Imagiers de la Medecine" was able, MRI).
2,
despite his youth, to spend time and efforts in the bidis The prosperous calmness of anatomy facilitates to a cer
ciplinary research of radiological anatomy (or anatomical tain degree the effervescence of radiology. H. Sick and J.-L.
radiology?). Burguet represent this modern phenomenological double
Bidisciplinary research brings of course many positive dealing and hereby give us their knowledge and the results
qualities to imaging. It naturally induces confrontation, of their work. They are to me the perfect image of the pro
comparison, opposition, superimposition, correlation, cess of structuralist research spreading beyond oversimple
spatialization, bi- or tridimensional vision - in short, a set of confrontations.
manipulations constituting the intellectual reality of the If J.-L. Burguet now feels some attraction - as do many
disciplinarian centaurs, and easy to be materialized, thanks others - for the University of Paris, he will nevertheless re
to imaging. These advantages are expressed in the reality tain many friends in Strasbourg, as well as the opportunity
underlying the mastery of the interface, which works only to do further research there. Let us not, however, forget the
with difficulty or inadequately, between the different disci- words ofH. Fischgold, who said that we have the possibility
"to change this or that, but not our parents".
J. G. Koritke, H. Sick (1982) Atlas de coupes seriees du corps humain.
1
Coupes [rontales, sagittales et horizon tales. Urban & Schwarzenberg,
A. Wackenheim
Miinchen Wien Baltimore
A. Wackenheim (1986) Les radiologistes, imagiers de la medecine, 2nd Professeur de Radiologie
2
edn. Axone, Montpellier de la Faculte de Medecine de Strasbourg
Acknowledgments
This book was accomplished in a favorable environment. radiology. Thanks to Professor J. Grellet and to Drs. M. F.
We found encouragement and aid from our masters and Bellin and E. Auberton (Hapital de la Pitie, Paris) we ob
colleagues and we are here very much indebted to them. In tained the views in magnetic resonance imaging. The talent
the spirit and tradition of the Institute of Normal Anatomy and availability of Mr. R. Becker, photographer in the Insti
at Strasbourg, brilliantly represented by Professor J. G. tute of Pathological Anatomy of Strasbourg (Professor Y.
Koritke, we began to identifY the anatomical structures. Legal), enabled us to achieve quality iconography. Finally,
Professor A. Wackenheim, Chairman in Radiology, impart the great experience of Professor H. J. Clemens of Berg
ed in us his own dynamism and allowed us free use of the mann Verlag was instrumental in the realization of this
X-ray scanner belonging to the Department of Neuro- work.
Table of Contents
Preface (J. G. Koritke) ............................ V S4 (1.5 cm) ................................. 40,41
Preface (A. Wackenheim) ......................... V S5 (1.0 cm) ................................. 42,43
Acknowledgments ............................... VI S6 (0.5 cm) ................................. 44,45
Introduction .................................... 1 S7 (0) ...................................... 46,47
Material and methods ............................ 3 S8 (0.5 cm) ................................. 48,49
Abbreviations ................................... 4 S9 (1.0 cm) ................................. 50,51
S 10 (1.5 cm) ................................. 52, 53
Frontal slices F 1-F 13 S 11 (2.0 cm) ................................. 54, 55
(referential plane F 12 passing through the anterior tuber S 12 (2.5 cm) ................................. 56, 57
osity of tibia) S 13 (3.0 cm) ................................. 58,59
[Anatomy, CT anatomy, CT in vivo, NMR in vivo] . 6-31
Fl (5.5 cm) ................................. 6, 7
F2 (5.0 cm) ................................. 8, 9 Horizontal slices H 1-H 12
F3 (4.5 cm) ................................. 10, 11 (referential plane H7 passing through the medial femoro
F4 (4.0 cm) ................................. 12,13 tibial articular interspace)
F5 (3.5 cm) ................................. 14,15 [Anatomy, CT anatomy, CT in vivo, NMR in vivo] . 62-85
F6 (3.0 cm) ................................. 16,17 HI (6.0 cm) ................................. 62, 63
F7 (2.5 cm) ................................. 18, 19 H2 (5.0 cm) ................................. 64, 65
F8 (2.0 cm) ................................. 20,21 H3 (4.0 cm) ................................. 66,67
F9 (1.5 cm) ................................. 22,23 H4 (3.0 cm) ................................. 68,69
FlO (1.0 cm) ................................. 24, 25 H5 (2.0 cm) ................................. 70, 71
Fll (0.5 cm) ................................. 26,27 H6 (1.0 cm) ................................. 72, 73
F 12 (0) ...................................... 28,29 H7 (0) ...................................... 74, 75
F 13 (0.5 cm) ................................. 30,31 H8 (1.0 cm) ................................. 76, 77
H9 (2.0 cm) ................................. 78,79
Sagittal slices S 1-S 13 H 10 (3.0 cm) ................................. 80,81
(referential plane S 7 passing through the middle of the in H 11 (4.0 cm) ................................. 82, 83
tercondylar fossa) H 12 (5.0 cm) ................................. 84, 85
[Anatomy, CT anatomy, CT in vivo, NMR in vivo] . 34-59
S 1 (3.0 cm) ................................. 34, 35
S2 (2.5 cm) ................................. 36,37 References ...................................... 86
S3 (2.0 cm) ................................. 38,39 Index .......................................... 87
Introduction
On account of the reduction in volume of the muscular tive as it displays the longitudinal organs already seen on
masses, and of the longitudinal arrangement of the tendons adjacent sections as well as the transversal structures en
and vasculonervous axis, the exploration of the knee ap closed in the articular cavity (menisci and associated liga
pears to be without any difficulty. In fact many problems ments). Within both ends of the horizontally explored re
come up with the interpretation of the images of this joint. gion, the slices show at best the changes in the constitution
Questions arise due to the complexity in shape and struc and relations of the vasculonervous axis.
ture of the walls of the synovial cavity (presence of menisci, Thus within a vertical parallelepipedic volume measur
pads of fat, synovial folds, communicating pathways with ing 6 X 6 X 12 cm and for each fundamental plane, one
serous periarticular bursa); but questions also arise with re dozen slices allows the study of the main structures of the
gard to the partial integration of dynamic structures region of the knee joint.
(muscles and tendons) with articular structures (patellar A four-step analysis reveals the information to be found
folds, oblique popliteal ligament), achieving more or less in each section. These successive steps are: the anticipation
separate and distinct lamellar layers. Still other difficulties of the image, the revelation of the structure, the confronta
relate to the setting in the superior part, to the division in tion of image and structure, and the generalization of the
the inferior portion of the popliteal fossa of the vas Image.
culonervous axis of the knee which gives in addition col First, the anticipation of the image imposes consider
lateral and recurrent branches stemming from the region it ation of the knee as an integral part of the human frame ar
self or from adjacent areas. Finally, these interpretative ranged in euclidean space. This enables the definition of or
problems are increased by the overlapping of the muscles of thogonal planes on the anatomic specimen or on the patient
the thigh with those of the calf which delineate sliding clefts previously placed in anatomical posture. Thus we have
where vessels and nerves come through. been led to choose the terms frontal, sagittal, and horizon
The landmarks we use here are of a skeletal nature. tal. Then for each of these planes a fixed referential land
Some are easily and clinically located (tubercle of adductor mark has to be determined (i.e., anterior tuberosity of tibia
magnus, medial femorotibial articular interspace, anterior for frontal slices, middle of the intercondylar fossa for sagit
tuberosity of tibia), while the last one (middle of the in tal sections, medial femorotibial articular interspace for
tercondylar fossa) has to be determined using roentgeno horizontal slices). The setting of these planes is achieved by
graphic methods. clinical examination and by conventional radiology, on the
The 5-mm interspaced frontal sections, located by refer anatomic specimen as well as on a patient. This preliminary
ence to the anterior tuberosity of the tibia, concern a widely approach allows anticipation of which essential structures
extended segment on both sides of the femorotibial articu are to be found at determined levels. It requires a pre
lar interspace. The transversal contour of the latter em viously acquired knowledge of classical anatomy.
phasizes the contiguous arrangement of the skeletal struc The revelation of an anatomical structure, on both the
tures, divides their image into two distinct levels, femoral scanographic picture and the anatomical section, leads the
and tibial, and calls attention to the precise relations of the observer to the immediately perceptible features. The reali
longitudinally displayed elements, first of all the collateral zation of scanographic sections, before any handling of the
ligaments, with the adjacent osseous structures. anatomical specimen, gives a rapid view of the actual case
The 5-mm incremental sagittal sections, achieved on and allows the eventual correction of mistakes made during
both sides of the middle of the intercondylar fossa, cor the first step of prevision. The key in this procedure re
respond approximately to the same area as the frontal mains, of course, the anatomical section. This reduction of
slices. They make it possible to follow the changes in shape the three-dimensional reality to two dimensions requires an
and direction of longitudinal tracts along a wide portion of adjustment of our understanding: for instance, the superim
their course. Thus the crossing of the articular interspace by position of fibrous layers is best seen on CT rather than on
the musculotendinous structures and its bridging by the anatomical slices; nevertheless, their identification remains
ligaments, first of all the cruciate ligaments. more difficult. In most cases hesitation is removed by the
As to the horizontal sections, the field of investigation examination of the anatomical slices: corroboration or ne
here is limited to the area situated between the tubercle of gation of the initial impressions is found within the depth of
adductor magnus and the anterior tuberosity of tibia. In the anatomical slice or from the piling up of several ana
cremental slices of 10 mm taken from both sides of the tomical slices. We chose to use the international Latin no
medial femorotibial articular interspace are sufficient for menclature to name the information revealed at this step.
listing mainly longitudinally displayed structures (contrarily The confrontation between a structure and its own
to the sagittal and frontal planes which required 5-mm in image is now possible: the same material is taken up by the
cremental sections). The referential section passing through same observers using the same unchanging language. This
the femorotibial articular interspace is particularly informa- confrontation is particularly fruitful when imaging methods
2 Introduction
put stress on anatomical structures, such as a horizontal CT tained with variable techniques applied on any human be
section which displays the oblique popliteal ligament better ing. The absence or modification of the structural image
than the corresponding anatomical slice does! But this con must receive a rational explanation since the idea of refer
frontation may be frustrating, too, when a precise item of ence to the first image has to be kept in mind.
information on the image must be left out because of insuf This procedure, rigorous, but time-consuming, allows us
ficient anatomical corroboration. not only to find a general concept for a plane of section, but
The generalization of the image is the last step and also to reconstitute a region or organs from standardized
opens on medical practice. A structure which has been in planes, or to reduce the data contained in a plane to more
dividualized on the anatomical section and identified on the basic data. This method does not exclude the multifarious
scanographic section in the same place within the same features of reality, but facilitates any statistical work draw
anatomical specimen must be found again on sections ob- ing the norm, variations, and pathological conditions.
Material and Methods
Material After successive trials, the following CT parameters were
finally selected for producing the best results:
This atlas achieves a confrontation between:
- voltage and amperage applied to the X-ray tube: 120 kV,
- anatomical slices of the region of the knee studied in the
80 rnA;
three fundamental spatial planes, i.e., frontal, sagittal,
- acquisition time of data: 6.8 s;
and horizontal;
- field of view: 130 mm and 260 mm (frontal and sagittal
- the corresponding views obtained by computed tomogra
views), 130 mm (horizontal views);
phy (Cl) of the same anatomical specimens;
- slice thickness: 1 mm;
- equivalent horizontal CT views of the region of the knee
- high spatial resolution filtering;
alive;
- 512 X 512 matrix.
- images of magnetic resonance (MR) of the knee alive
studied at the same levels in the same spatial planes.
After completing each CT exploration (frontal, sagittal,
The CT-anatomical confrontation makes use of cadaveric horizontal) the anatomical specimen is automatically trans
knees isolated from corpses previously injected in view of lated so that the light focusing beam falls in with the slice
conservation and frozen to -30°C in the anatomical posi level passing through the corresponding plane of reference.
tion of reference (extended knee). The anatomical material Eight to ten intramuscular needles are then implanted into
for this study comes from 20 adults less than 50 years old, the specimen along the light beam projection. A last scout
free of any articular pathological condition. We have strictly view is performed in order to check up the right alignment
respected the homogeneity of each set of views: for one of the needles with the plane of reference.
plane of section (frontal, sagittal, horizontal) all the ana The anatomical specimen is frozen again, then sliced up
tomical slices presented here come from the same specimen. along the plane represented by the intramuscular needles.
The horizontal in vivo CT slices are obtained from Frontal and sagittal slices have 5 mm thickness, horizontal
young healthy volunteers. slices have 10 mm thickness. Thus slice F 1 passes 5.5 cm be
All the views in MR imaging come from the same pa hind the anterior tibial tuberosity and slice F 13 passes
tient free of any pathological condition. 0.5 cm before this landmark; slice S 1 passes 3 cm laterally
by reference to the middle of the intercondylar fossa and
slice S 13 passes 3 cm medially by reference to this same
datum line; slice HI passes 6 cm proximally by reference to
Methods the medial femorotibial articular interspace and slice H 12
passes 5 cm distally by reference to this same landmark.
All the CT views presented in this work are realized with a During the realization of the anatomical slices, a rapid
total body scanner (CE 10,000, Compagnie Generale de examination allows estimation of the normality of the speci
Radiologie). Each frozen anatomical specimen is placed in men; tiny retouching facilitates bringing to light structures
to the gantry so that its orientation corresponds to the ex included in the slice thickness or trimming of some edges.
plored spatial plane. For each of the three fundamental Each slice is photographed near a centimetric scale allowing
planes of section, two scout-views are performed (front and recognition of the real size of the structures during the
side views) in order to test the right position of the anatom elaboration of the documents.
ical specimen. The different referential planes are chosen as During the phase of interpretation, the anatomical slices
follows: are dissociated. The course of the vessels is followed by
selective injections towards their origin and branches.
- frontal sections: plane passing through the anterior tu
Nerves are followed from slice to slice along their course.
berosity of the tibia;
Each element identified on the anatomical section has its
- sagittal sections: plane passing through the middle of the
image investigated. When additional data are found on the
intercondylar fossa;
photograph, their anatomical substratum is systematically
- horizontal sections: plane passing through the medial
investigated in the thickness ofthe specimen.
femorotibial articular interspace.
The in vivo CT slices are made with the same scano
Sections are performed parallel to and on both sides of graphic equipment using the same parameters. The knee is
these referential planes, with a 5-mm incrementation for extended supine, without any quadricipital contraction;
frontal and sagittal slices, and a lO-mm incrementation for both legs are placed parallel into the gantry; the feet are
horizontal sections. fixed by means of Velcro strips.
4 Material and Methods
The in vivo MR images are realized with total body For the same slice level, the same numbers correspond
equipment (Magniscan, Compagnie Generale de Radio to the same elements. Nevertheless printing these numbers
logie) using a supraconductor magnet working at 0.5 tesla. with the same sequence on corresponding slices has not al
The extended knee is carefully positioned in the middle of ways been possible.
the main magnetic field, placed into a cervical emitting At the bottom of the anatomical specimen, a centimetric
receiving coil, and strictly fixed supine by plastic scale immediately restores the size of the different struc
foam cushions. The field of view thus achieved is 200 mm tures. This scale is only available for the anatomical view.
in diameter. A spin-echo sequence is performed using
TR=450 ms and TE=26 ms. The data acquisition matrix is
256 X 256. The slice thickness is 5 mm with a 5-mm in Abbreviations
crement for sagittal and frontal views and a lO-mm in
crement for horizontal views. The landmarks and referential • Slice identification and orientation:
planes used in the CT confrontation are still employed here.
ANT : anterior
F : frontal
H : horizontal
LAT : lateral
Notice MED : medial
POST: posterior
Each slice level is represented by the photograph of the S : sagittal
anatomical slice and its corresponding CT view, both dis
played on the right-hand page. The CT and MR in vivo • Imaging abbreviations:
views are displayed on the left-hand page.
The frontal views are seen from the front; sagittal ones A : anatomy
are seen from the outside; horizontal views are seen from CTA : computed tomography (anatomy)
the bottom. CT : computed tomography in vivo
Some structures identified on the anatomical section are NMR: nuclear magnetic resonance imaging in vivo
sometimes not mentioned on the scanographic view be
cause their identification is unreliable (inadequate scano • Legends:
graphic resolution). On the contrary, some elements may be
only visible on the scanographic document. () : brings a precision to the preceding term