Traumatic Knee Lipohemarthrosis

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Traumatic Knee Lipohemarthrosis

Authors, Editors, Case Information Author: Emily Hudspeth, DO Affiliation: Womack Army Medical Center, Fort Bragg, NC Co Author(s): Peter Wikoff, MD Alex Houser, DO, CAQSM, FAAFP Senior Editor: William Denq, MD Clinical Vignette: A 77-year-old female presents to the Emergency Department after sustaining a mechanical ground-level fall with subsequent right knee pain. She is unable to stand or extend her right knee due to pain. Physical exam shows a right knee effusion, inability to perform straight leg raise, limited knee extension due to pain, and tenderness of the patellar tendon and medial and lateral joint lines. Type of Probe Used: 15-4 MHz linear transducer #1 - Video View Video Long axis cine view of the suprapatellar recess, scanning lateral to medial, shows a triple-layer complex joint effusion involving hyperechoic fat superficial to intra-articular hemorrhage and a gravity-dependent hematocrit level. Left is proximal, and right is distal. #2 - Video View Video Short axis cine view of the suprapatellar recess shows a triple-layer complex joint effusion involving hyperechoic fat lateral to intra-articular hemorrhage and a gravity-dependent hematocrit level. Left is lateral, and right is medial. Labeled Short Axis View of the Suprapatellar Recess Labeled short axis view of the suprapatellar recess shows a triple-layer complex joint effusion involving hyperechoic fat (F) lateral to intra-articular hemorrhage (arrows) and a gravity-dependent hematocrit level (H). Q, Quadriceps tendon. Unlabeled Short Axis View of the Suprapatellar Recess Unlabeled short axis view of the suprapatellar recess. Labeled Long Axis View of the Suprapatellar Recess Labeled long axis view of the suprapatellar recess shows a triple-layer complex joint effusion involving hyperechoic fat (F) superficial to intra-articular hemorrhage (arrows) and a gravity-dependent hematocrit level (H). Q, Quadriceps tendon. Unlabeled Long Axis View of the Suprapatellar Recess Unlabeled long axis view of the suprapatellar recess. Interpretation Image Interpretation: There is a moderate-to-large, complex joint effusion with triple-layering of superficial hyperechoic fat, an intermediate anechoic layer, and a gravity-dependent heterogeneous red blood cell layer consistent with a lipohemarthrosis. The extensor mechanism, including the quadriceps tendon, patella, and patellar tendon, appears normal without bursal abnormalities. The pre-femoral and quadriceps fat pads are both normal in appearance. Teaching Pearl: A subsequent MRI of the right knee, reveals a complex tibial plateau fracture with lipohemarthrosis that was not apparent on radiographs. Lipohemarthrosis occurs when fat and blood from bone marrow leak into the joint space, most commonly due to an intra-articular fracture. In the case of lipohemarthrosis, there will be a multi-layer appearance known as a fat-fluid level in the joint space, with hyperechoic fat above and hypoechoic blood and synovial fluid below. Often, you will also see red blood cells separate from the synovial fluid and blood serum, forming a gravity-dependent, heterogeneous appearing deep layer. Even if a fracture is not visible on ultrasound, the presence of fat-fluid levels is highly suggestive of occult intra-articular fracture (e.g., tibial plateau, patella, distal femur). When evaluating the suprapatellar recess, the patient should be supine with the knee slightly flexed to 30 degrees to best visualize joint-space fluid. A high-frequency linear transducer should be utilized to best visualize joint space fluid. Disclosures: No financial disclosures. The views expressed herein are those of the authors and do not reflect the official policy of the Department of the Army, Defense Health Agency, Department of War, or the U.S. Government.
NOTE: For more information, please contact the AMSSM, 4000 W. 114th Street, Suite 100, Leawood, KS 66211 (913) 327-1415.

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Authors, Editors, Case Information

#1 - Video

#2 - Video

Labeled Short Axis View of the Suprapatellar Recess

Unlabeled Short Axis View of the Suprapatellar Recess

Labeled Long Axis View of the Suprapatellar Recess

Unlabeled Long Axis View of the Suprapatellar Recess

Interpretation

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