What’s the Diagnosis – Case 163
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Findings On the initial radiographs, on the PA flexed view there is a faint area of mineralization around the notch which is nonspecific and frankly was only appreciated in retrospect. The initial MRI demonstrates a large osteochondral defect of the lateral trochlea with remodeling of the underlying bone. Insinuated between the ACL and PCL in the notch is a vague, otherwise difficult to characterize structure. On subsequent MRI, a large osteochondral fragment is now seen adjacent to the trochlear defect with the vague structure between the ACL and PCL in the notch no longer being present.
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Diagnosis: Osteochondral Fragment Much more of an “eye test” than many of the cases we have presented and one frankly that I missed initially and only on re-review was able to perceive. Previously, cases have been shown of menisco-meniscal ligaments and oblique meniscofemoral ligaments which are normal variants that traverse the notch. Otherwise, only two structures, the ACL and PCL, should be seen in the notch. In this case, the clinician based on history and physical was certain there was a body in the joint precipitating the intermittent locking. This case highlights the need for careful inspection in all planes and how a close working relationship with clinical colleagues can make all the difference. Given the age of the patient and the already remodeled bone the decision was made to resect this fragment. Note that low signal is attached to the cartilage indicating attached subchodral bone and in a different clinical scenario may be amenable to fixation. My most sincere thanks to Tom Wickiewicz, MD on his assistance on this case and many other cases throughout the years.
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