1. DEPARTMENT OF RADIOLOGY
Lower Limb Imaging
Gerald R. Aben, MD, FACR
Associate Professor Radiology
College of Osteopathic Medicine
In this series of images were going to discussed various objectives associated with the lower limb evaluation.
9/18/2018
DEPARTMENT OF RADIOLOGY

2. DEPARTMENT OF RADIOLOGY
Starting at the top in the pelvis we are able to identify the sacroiliac joints, the radiolucencies between the adjoining iliac wing and sacrum, the iliac crest and the anterior inferior iliac spine. The anterosuperior and anteroinferior iliac spines can be demonstrated. The pubic symphysis as represented by a radiolucency between the two pubic bones. The superior inferior pubic rami are demonstrable as well as relative location of the issue tuberosity. Note the appearance of the acetabulum in relationship to the femoral head.
9/18/2018
DEPARTMENT OF RADIOLOGY

3. DEPARTMENT OF RADIOLOGY
More detailed images of the hip demonstrate the acetabulum, the joint, the femoral head and the fovea of the femoral head. The greater and lesser trochanters can be demonstrated as well as the intertrochanteric line which on some individuals will be quite evident. The femoral neck is defined as well on this examination.
9/18/2018
DEPARTMENT OF RADIOLOGY

4. DEPARTMENT OF RADIOLOGY
Another projection showing the relative relationship of the greater and lesser trochanter as well as the femoral head. This in a younger individual where the apohysis that cause the formation of the greater and lesser trochanter have not yet totally fused.
9/18/2018
DEPARTMENT OF RADIOLOGY

5. DEPARTMENT OF RADIOLOGY
At the distal femur the lateral and medial femoral condyles are defined. The relationships of the condyle to the tibial plateau and the proximal portions of the tibia demonstrated. Two separate frontal projections one referred to as a tunnel view which allows better evaluation of the intercondylar notch.
9/18/2018
DEPARTMENT OF RADIOLOGY

6. DEPARTMENT OF RADIOLOGY
Our lateral knee projection allows us to evaluate the distal portion of femur and its two articulating surfaces the medial and lateral femoral condyle. The relationship of the distal femur to the patella anteriorly and to the tibia and fibula distally is noted. Note also the fact that the fibula sits relatively posterior to the tibia. The detailed view of the patella demonstrates a differing appearances to the lateral and medial facets of the patella. There is as well variation in the contours of the medial and lateral condyles of the femur to be utilized to assist in identifying the site of abnormality.
9/18/2018
DEPARTMENT OF RADIOLOGY

7. DEPARTMENT OF RADIOLOGY
Continuing to the lower portion leg using standard radiography. The tibia and fibula are demonstrated. Note the relative posterior and lateral location of the fibula with respect to the tibia. The fibular head and the proximal tibiofibular joint can be defined. The distal portion of the fibula sometimes referred to as a lateral malleolus. The distal portion of the medial tibia referred to as the medial malleolus at the ankle joint
9/18/2018
DEPARTMENT OF RADIOLOGY

8. DEPARTMENT OF RADIOLOGY
Detailed imaging of the ankle joint. A straight on frontal view and a slightly oblique view demonstrating ankle joint, the ankle mortise, the medial and lateral malleolus the distal most aspect of the tibia and fibula respectively and as well as the distal tibiofibular joint.
9/18/2018
DEPARTMENT OF RADIOLOGY

9. DEPARTMENT OF RADIOLOGY
Lateral evaluation of the foot allows demonstration of the variety of tarsal bones including the talus and calcaneus. The talus being divided up into the body, neck and head. The tarsonavicular and cuboid bone are seen as well as the tuberosity at the base of the fifth metatarsal. In this view the cuneiforms are superimposed upon each other and difficult to separate.
9/18/2018
DEPARTMENT OF RADIOLOGY

10. DEPARTMENT OF RADIOLOGY
The frontal and oblique films of the foot allow evaluation of the relationship of the various bones in the foot. More proximally the talar head and neck and calcaneus are demonstrated. The interaction or the joint between the talar head and navicular the calcaneus and cuboid are clearly defined. The lateral, medial and intermediate cuneiforms can be seen. The relationships between the tarsals and metatarsals including their joints are clearly defined. Metatarsals and phalanges are clearly seen as are the metatarsophalangeal joints and interphalangeal joints. Please note that the development of the mid and distal phalanges can be variable with many individuals having fusion of several of these joints.
9/18/2018
DEPARTMENT OF RADIOLOGY

11. DEPARTMENT OF RADIOLOGY
The lateral T1 allows exquisite evaluation of the anatomy about the knee. the relatively high signal present within fat helps us to define fatty marrow within the bony structures, the subcutaneous fat and fat within Hoffa's fossa. Note that our articular surfaces and tendinous structures are dark in signal including the tendon of the quadriceps femoris the patellar tendon, the lateral menisci where we see both the anterior and posterior horn as well as portions of the articular surface. Muscle signal is somewhat intermediate to that of the fat and the tendons. Cortical bone will always be the lowest signal.
9/18/2018
DEPARTMENT OF RADIOLOGY

12. DEPARTMENT OF RADIOLOGY
Frontal T1 evaluation gives us looks at both the medial and lateral menisci. These somewhat triangularly shape structures as noted in their mid body portions. We also see portions of the fibers of both the posterior and anterior cruciate ligament as indicated by the titles and lines.
9/18/2018
DEPARTMENT OF RADIOLOGY

13. DEPARTMENT OF RADIOLOGY
A lateral midline section through the knee demonstrate anterior cruciate ligament as a curvilinear low signal structure going from the anterior aspect of the tibia to the posterior aspect of the distal femur. Again note high signal on T1 associated with fatty structures including bone marrow, subcutaneous fat and Hoffa's fossa.
9/18/2018
DEPARTMENT OF RADIOLOGY

14. DEPARTMENT OF RADIOLOGY
Slightly off center from the previously described lateral projection, the posterior cruciate ligament is noted to extend from the posterior-most aspect of the tibia to a more curvilinear anterior approach to the posterior aspect of the distal femur
9/18/2018
DEPARTMENT OF RADIOLOGY

15. DEPARTMENT OF RADIOLOGY
This frontal aortogram demonstrates some contrast material within the kidneys with an early nephrogram effect. We see contrast within the aorta and common iliac, external and internal iliac arteries. The external iliac arteries forming the common femoral and ultimately the arteries of the upper portions of the thigh.
9/18/2018
DEPARTMENT OF RADIOLOGY

16. DEPARTMENT OF RADIOLOGY
On this direct angiogram we are able to identify contrast material within the superficial and the deep femoral arteries. Note the small high attenuating flecks of structures within the thigh region representing fragments from recent bullet injury. This particular study done to evaluate for vascular damage. Also note a small vessel circumferentially related to the proximal femur representing the lateral femoral circumflex artery.
9/18/2018
DEPARTMENT OF RADIOLOGY

17. DEPARTMENT OF RADIOLOGY
Additional imaging of the lower extremity demonstrating the distal portions of femoral artery as it exits the abductor canal also note the presence of the popliteal artery the anterior, posterior and fibular branches of the popliteal artery at the trifurcation and distally anterior and posterior tibial arteries as they approach the foot.
9/18/2018
DEPARTMENT OF RADIOLOGY

18. DEPARTMENT OF RADIOLOGY
Venous structures of the lower extremity can also be evaluated contrast material introduced into veins in the lower portion of the leg can be followed proximally. In this case we identify the superficial and deep femoral veins at their confluence at the common femoral vein and ultimately their extent to the iliac vein as the contrast material proceeds towards the heart.
9/18/2018
DEPARTMENT OF RADIOLOGY

19. DEPARTMENT OF RADIOLOGY
More distally deep and superficial femoral veins are more clearly seen as is the popliteal vein. Note the slight bulbous appearance of this vein at intervals as reflects the location of the valves within the veins.
9/18/2018
DEPARTMENT OF RADIOLOGY

20. DEPARTMENT OF RADIOLOGY
Finally in the distal most portion leg, the anterior tibial vein, the fibular veins, the posterior tibial veins are demonstrated. Most of these veins being paired veins with there being two veins for each accompanying artery in this distal region. Again slight swelling noted along the course of the veins at the site of the various venous valves. These studies are important for evaluation for deep vein thrombosis, a clinical condition.
9/18/2018
DEPARTMENT OF RADIOLOGY