(a) Diagram shows a fracture that is creating an osteochondral fragment. This study determined that chondral injuries were more frequently detected compared with meniscal and ACL injuries, and patterns varied depending on stage of physeal closure. Healing juvenile OCD in a 13-year-old boy. SIF in a 64-year-old woman with a complex tear in the medial meniscus with peripheral extrusion (arrow in a). Presumably, when an OCD lesion cannot withstand forces applied to the joint surface, it begins to separate from the “parent” bone. MRI is a valuable diagnostic tool that provides critical information about the composition, stability, and integrity of the OCD fragment. The overall extent of meniscal abnormality and cartilage loss in the joint and decreased knee range of motion at the time of presentation are associated with clinical progression (21). Such force is typically internal, related to the contact of one bone with a neighboring bone during the traumatic event (9). ■ Evaluate MRI findings of each condition and how they pertain to treatment. A bone contusion (* in b) is visible at the posterior aspect of the lateral tibial plateau. In the acute setting, the fracture line is best shown on T1-weighted MR images as a linear hypointensity. Although they are not essential for the diagnosis of SIF, associated cartilage abnormalities are often present (18,21). (a) Initially, a large area of necrosis shows normal marrow signal intensity that represents mummified fat (black *) outlined with a sclerotic rim (arrows) that is convex to the articular surface. Arthroscopic parameters used to evaluate OCD continue to evolve with the recent classification system introduced by the ROCK study group, which showed excellent intra- and interobserver reliability (63). Instead, they are fluid-filled lesions surrounded by bone. Harding described the lateral X-ray as a method to identify the site of an OCD lesion. (b) Coronal MR image in the same patient obtained 2 years earlier shows the normal appearance of the subchondral bone plate (arrow). Osteochondral fracture with a subchondral bone plate depression in an 18-year-old man. SIFs are associated with meniscal tears in the same compartment in 76%–94% of patients (18,20,21). The advent of new procedures for repairing cartilage in knee and ankle joints has increased the need for accurate noninvasive methods to objectively evaluate the success of repair. These criteria were revised for juvenile OCD (62) with the addition of three secondary signs that all showed 100% specificity: (a) a T2-weighted high-signal-intensity rim surrounding a juvenile OCD lesion indicates instability only if it has the same signal intensity as that of joint fluid, (b) a second outer rim of T2-weighted low signal intensity, or (c) multiple breaks in the subchondral bone plate on T2-weighted MR images (Fig 18). MR imaging of epiphyseal lesions of the knee: current concepts, challenges, and controversies, Presumptive subarticular stress reactions of the knee: MRI detection and association with meniscal tear patterns, Femoral condyle insufficiency fractures: associated clinical and morphological findings and impact on outcome, Fat-suppressed T2-weighted MRI appearance of subchondral insufficiency fracture of the femoral head, MRI of subchondral fractures: a review, Subchondral insufficiency fractures of the knee: review of imaging findings, Dynamic contact mechanics of the medial meniscus as a function of radial tear, repair, and partial meniscectomy, Osteonecrosis of the knee after arthroscopic surgery: diagnosis with MR imaging, The importance of early diagnosis in spontaneous osteonecrosis of the knee: a case series with six year follow-up, Imaging of osteonecrosis: radiologic-pathologic correlation, Osteonecrosis and transient osteoporosis of the femoral head, MR imaging of avascular necrosis and transient marrow edema of the femoral head, Subchondral avascular necrosis: a common cause of arthritis, The role of sclerotic changes in the starting mechanisms of collapse: a histomorphometric and FEM study on the femoral head of osteonecrosis, Morphological analysis of collapsed regions in osteonecrosis of the femoral head, MRI evaluation of steroid- or alcohol-related osteonecrosis of the femoral condyle, Correlation between bone marrow edema and collapse of the femoral head in steroid-induced osteonecrosis, Subchondral fractures in osteonecrosis of the femoral head: comparison of radiography, CT, and MR imaging, Diagnostic performance of MR imaging in the assessment of subchondral fractures in avascular necrosis of the femoral head, Osteonecrosis of the femoral head: using CT, MRI and gross specimen to characterize the location, shape and size of the lesion, Osteochondritis dissecans: editorial comment, AAOS appropriate use criteria: management of osteochondritis dissecans of the femoral condyle, A review of knowledge in osteochondritis dissecans: 123 years of minimal evolution from König to the ROCK study group, American Academy of Orthopaedic Surgeons clinical practice guideline on: the diagnosis and treatment of osteochondritis dissecans, Osteochondritis dissecans 1887-1987: a centennial look at König’s memorable phrase, Studies on hereditary, multiple epiphyseal disorder, Hypertrophy and laminar calcification of cartilage in loose bodies as probable evidence of an ossification abnormality. Recipient of a Magna Cum Laude award for an education exhibit at the 2017 RSNA Annual Meeting. Changes in the orientation relative to B0 alter the appearance of the cartilage. Figure 3a. The rim of fluid signal intensity surrounding an OCD lesion most likely represents a fluid-filled cleft between the progeny and parent bone, while an outer rim of low signal intensity may represent organized fibrous tissue or sclerotic bone at the interface (50,51). Osteochondral injury is commonly associated with immediate effusion that represents hemarthrosis or lipohemarthrosis. Subchondral hypointense fracture lines tend to resolve with conservative therapy and can be seen in patients with transient reversible SIF and in 78% of those with clinical SONK. Osteochondritis dissecans (OCD) is a term for a distinct clinical-pathologic entity: a pathologic condition that affects subchondral bone formation and may result in an unstable subchondral fragment, disruption of adjacent articular cartilage, and possible separation of the fragment. Coronal proton-density–weighted fat-suppressed MR image (a) sagittal proton-density–weighted MR image (b), and T2-weighted fat-suppressed MR image (c) show an OCD lesion in a classic location at the lateral aspect of the medial femoral condyle with cysts (curved arrow in a and c) and a high-signal-intensity rim (straight arrow in b) at the interface between the fragment and parent bone associated with breaks in the subchondral bone plate and articular cartilage along the periphery of the lesion (arrowhead in b and c). Note articular surface collapse of the medial femoral condyle (arrowhead in b and c), with depression of the subchondral bone plate (c) and loss of subchondral fatty signal intensity (b). Figure 6b. OCD in the extended classic location in a 19-year-old man, with features of instability applicable to both juvenile and adult OCD. (c) Radiograph obtained 6 months later shows the progression of normal ossification (arrow). (a) Radiograph demonstrates the absence of normal ossification in the subchondral area of the medial femoral condyle (arrow). The compact subchondral bone and calcified cartilage are collectively termed the subchondral plate (4,5). Changes in the orientation relative to B0 alter the appearance of the cartilage. Although there is evidence that both mechanisms may operate together, results of recent studies (71,72) support the bone contusion theory of osteoarthritis by showing that subchondral cysts arise in preexisting regions of subchondral bone marrow edema-like lesions, and their development is predicted much more strongly by bone marrow edema-like lesions than by full-thickness cartilage loss (71,72). Figure 9a. (b–d) Sagittal T2-weighted fat-suppressed MR image (b), proton-density–weighted MR image (c), and CT image (d) show a curvilinear fracture (arrow in b and c) encircling a portion of subchondral bone and overlying cartilage. A localized osteochondral defect can be created acutely or can develop as an end result of several chronic conditions. Figure 14b. (d) MR image obtained 6 months later shows restoration of the subchondral bone plate (arrowhead). Subchondral cystlike lesions are well-defined rounded areas of fluid signal intensity; they may contain necrotic bone debris, myxoid and adipose tissue, fibrous elements, or proteinaceous material and are lined by a nonepithelial fibrous wall (67,68). AVN of the knee in a 59-year-old woman who was undergoing long-term corticosteroid treatment. These are essential findings to acknowledge in patients with acute traumatic injuries and SIF. In vitro T2-weighted spin-echo MR images of the tibial plateau at 7 T in the same specimen oriented perpendicularly to the main magnetic field (B0, gray arrow, top image) and tilted 55° to B0 (bottom image) show the typical layered appearance of the articular cartilage. Figure 3b. (b, c) Coronal T1-weighted (b) and proton-density–weighted fat-suppressed (c) MR images show a progeny (P) fragment separated from the parent bone, with signal intensity equal to that of fluid (white arrow in c) and an additional outer rim of sclerosis (black arrow in c). 3, © 2020 Radiological Society of North America, Evaluation and management of osteochondral lesions of the talus, Acute and stress-related injuries of bone and cartilage: pertinent anatomy, basic biomechanics, and imaging perspective, In vitro MR imaging of hyaline cartilage: correlation with scanning electron microscopy, The tibial subchondral plate. The actual defect may or may not be present on MR images, depending on the stage of the process. Subchondral bone plate collapse, demonstrated by the presence of a frank depression or a fluid-filled cleft, can be seen in advanced stages of both AVN and SIF, indicating irreversibility. It is important to recognize the MRI appearance of this critical complication of AVN that leads to premature osteoarthritis. Subchondral fracture in a 32-year-old man with an acute medial collateral ligament tear (arrow in d) and an anterior cruciate ligament rupture (not shown). This pattern of bone injury should prompt a search for additional findings of hyperextension with a varus or valgus component. MR imaging of epiphyseal lesions of the knee: current concepts, challenges, and controversies, Presumptive subarticular stress reactions of the knee: MRI detection and association with meniscal tear patterns, Femoral condyle insufficiency fractures: associated clinical and morphological findings and impact on outcome, Fat-suppressed T2-weighted MRI appearance of subchondral insufficiency fracture of the femoral head, MRI of subchondral fractures: a review, Subchondral insufficiency fractures of the knee: review of imaging findings, Dynamic contact mechanics of the medial meniscus as a function of radial tear, repair, and partial meniscectomy, Osteonecrosis of the knee after arthroscopic surgery: diagnosis with MR imaging, The importance of early diagnosis in spontaneous osteonecrosis of the knee: a case series with six year follow-up, Imaging of osteonecrosis: radiologic-pathologic correlation, Osteonecrosis and transient osteoporosis of the femoral head, MR imaging of avascular necrosis and transient marrow edema of the femoral head, Subchondral avascular necrosis: a common cause of arthritis, The role of sclerotic changes in the starting mechanisms of collapse: a histomorphometric and FEM study on the femoral head of osteonecrosis, Morphological analysis of collapsed regions in osteonecrosis of the femoral head, MRI evaluation of steroid- or alcohol-related osteonecrosis of the femoral condyle, Correlation between bone marrow edema and collapse of the femoral head in steroid-induced osteonecrosis, Subchondral fractures in osteonecrosis of the femoral head: comparison of radiography, CT, and MR imaging, Diagnostic performance of MR imaging in the assessment of subchondral fractures in avascular necrosis of the femoral head, Osteonecrosis of the femoral head: using CT, MRI and gross specimen to characterize the location, shape and size of the lesion, Osteochondritis dissecans: editorial comment, AAOS appropriate use criteria: management of osteochondritis dissecans of the femoral condyle, A review of knowledge in osteochondritis dissecans: 123 years of minimal evolution from König to the ROCK study group, American Academy of Orthopaedic Surgeons clinical practice guideline on: the diagnosis and treatment of osteochondritis dissecans, Osteochondritis dissecans 1887-1987: a centennial look at König’s memorable phrase, Studies on hereditary, multiple epiphyseal disorder, Hypertrophy and laminar calcification of cartilage in loose bodies as probable evidence of an ossification abnormality. Because of the proven microtraumatic origin of SONK and the histopathologic and MRI features that unite it with SIF, it is currently accepted that a SONK is a SIF that has progressed into collapse, with secondary necrosis found in the collapsed specimens. Full-thickness cartilage loss is present (arrowheads), accompanied by subchondral sclerosis (immediately under the tissue near the arrowhead in a). MRI features of this lesion also have been shown to be profoundly different from those of primary AVN (17,18). This condition remains poorly understood and, despite years of collaborative research, there is no consensus regarding its etiology, natural history, or treatment (41,42). Once SIF progresses to collapse and articular surface destruction, distinguishing it from primary osteoarthritis at imaging may be impossible, and it is likely to be clinically irrelevant. 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