Paediatric Knee Radiographs: Normal Appearances of the

Knee Joint in the Growing Patient

Poster No.: P-0124

Congress: ESSR 2015
Type: Educational Poster
Authors: C. Chisholm, D. Mak, M. Thyagarajan; Birmingham/UK
Keywords: Education and training, Education, Plain radiographic studies,
Pediatric, Musculoskeletal joint
DOI: 10.1594/essr2015/P-0124

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Page 1 of 25
Learning objectives

Knowledge of the plain radiograph appearances of the paediatric knee joint at different
stages of development.

Background

Ossification in the knee joint in particular the patella in children can lead to confusing
appearacnes on plain radiograph. This poster will outline the normal ossification pattern
in the knee joint through childhood and adolescence and highlight any normal variants
that can mimic pathology.

Imaging findings OR Procedure Details

Ossification of the femur, tibia, fibula and patella is a process that starts in utero and
continues through to the age of 18.

Fig. 1: AP and lateral knee radiographs of a 6 month old child demonstrating

ossification centres of the distal femur and proximal tibia. Note that there is also

Page 2 of 25
metaphyseal beaking of the medial aspect of the tibia which may be confused with a
metaphyseal corner fracture. The patella has not yet ossified at this age.
References: - Birmingham/UK

The femoral shaft begins ossification at 8 weeks in utero. The distal femur then begins
to ossify at 3-6 months (Fig. 1 on page 13). At birth the distal femoral epiphysis is in
a transverse plane and as children start to walk it is exposed to shearing forces which
cause the physis to develop an undulating appearance. The femur continues to grow until
1
the distal femoral physis fuses at 14-16 years in girls and 16-18 years in boys . Fractures
through the epiphysis or physis are described using the Salter Harris classification (Fig.
2 on page 13), and any fracture through the physis can cause growth disturbances.

Page 3 of 25
Page 4 of 25
Fig. 2: AP knee radiograph demonstrating a Salter Harris type 4 with a fracture of both
the epiphysis and metaphysis crossing the growth plate.
References: - Birmingham/UK

The patella begins to ossify at the age of 3-5 years which can lead to confusing
appearances (Fig. 3 on page 15). The patella has between 1-3 ossification centres,
which enlarge rapidly. As the ossification centres enlarge they often have irregular
borders and accessory ossification centres are most common in the superolateral aspect
of the patella (Fig. 7 on page 18). These accesory ossfication centres are the cause
of bipartite patella and may easily be confused for fractures or actual bipartitie patella
2
in both the adult and paediatric patient (Fig. 8 on page 20). The patella finally fuses
in late adolescence. Figures 3 - 6 demonstrate normal paediatric knee radiographs at
varying ages.

Fig. 3: AP and lateral knee radiograph of a 3 year old child demonstrating early
appearance of an ossifying patella.
References: - Birmingham/UK

Page 5 of 25
Fig. 4: AP and Lateral knee radiographs of a 6 year old demonstrating further
ossification of the patella, and undulating distal femoral epiphysis.
References: - Birmingham/UK

Page 6 of 25
Fig. 5: AP and Lateral radiographs of a 12 year old child demonstrating further
ossification of the patella. The proximal tibial ossification centre can also be seen on
the lateral view which develops as the tibial tuberosity.
References: - Birmingham/UK

Page 7 of 25
Fig. 6: Lateral and AP radiographs of a 15 year old child - the physes can be seen to
have started fusing. Also note the presence of the fabella, an accessory ossicle which,
is usually found in the lateral head of the gastrocnemius muscle.
References: - Birmingham/UK

Sindig Larsen-Johansson disease is a chronic traction injury of the osteotendinous

junction affecting the inferior pole of the patella and proximal aspect of the patella tendon
in children (Fig. 9 on page 20). Patella sleeve avulsion fractures also affect the inferior
pole of the patella (Fig. 10 on page 21), and typically affects patients between the
ages of 8 and 12. Both Sindig Larsen-Johansson and patella sleeve avulsion may be
seen as a small bony fragment at the inferior pole of the patella.

Page 8 of 25
Fig. 9: Lateral knee radiograph of a 12 year old child demonstrating Sindig-Larsen-
Johansson syndrome - there is a beaked appearance of the inferior pole of the patella.
The proximal tibial ossification centre is also seen.
References: - Birmingham/UK

Page 9 of 25
Fig. 10: Lateral radiograph of a patella sleeve avulsion fracture, with overlying plaster
of paris.
References: - Birmingham/UK

Page 10 of 25
 th
Ossification of the tibia begins about the 7 week of fetal life and starts at a central
ossification centre and gradually extends towards the extremities each of which have their
own ossification centre. The centre for the upper epiphysis appears around 34 weeks
nd
gestation and the lower epiphysis appears in the 2 year of life. The medial malleolus
forms from its own ossification centre. Later at around the age of 8 a second proximal
ossification centre appears which goes on to form the tibial tuberostiy and fuses around
the age of 17 (Fig. 11 on page 22). Both of these secondary ossification centres can
be mistaken for fractures (Fig. 12 on page 23). The distal physis becomes fully fused
1
around the age of 18 and the proximal physis slightly later at 20 .

Fig. 11: Horizontal beam lateral knee radiograph of an 11 year old showing the
ossification centre for the tibial tuberosity.
References: - Birmingham/UK

Page 11 of 25
Fig. 12: Lateral knee radiograph demonstrating Osgood Schlatters disease.
References: - Birmingham/UK

Page 12 of 25
 th
As with the femur and tibia the fibula begins ossification in the 8 gestational week with 3
growth centres, one central and on at either end of the bone. The distal epiphysis begins
to calcify at the end of the second year and the proximal epiphysis calcifies slightly later
1
around 4 years of age . Closure of both the growth plates occurs in the early 20s and
should not be mistaken for avulsion fractures.

Images for this section:

Fig. 1: AP and lateral knee radiographs of a 6 month old child demonstrating ossification
centres of the distal femur and proximal tibia. Note that there is also metaphyseal beaking
of the medial aspect of the tibia which may be confused with a metaphyseal corner
fracture. The patella has not yet ossified at this age.

Page 13 of 25
Page 14 of 25
Fig. 2: AP knee radiograph demonstrating a Salter Harris type 4 with a fracture of both
the epiphysis and metaphysis crossing the growth plate.

Fig. 3: AP and lateral knee radiograph of a 3 year old child demonstrating early
appearance of an ossifying patella.

Page 15 of 25
Fig. 4: AP and Lateral knee radiographs of a 6 year old demonstrating further ossification
of the patella, and undulating distal femoral epiphysis.

Page 16 of 25
Fig. 5: AP and Lateral radiographs of a 12 year old child demonstrating further ossification
of the patella. The proximal tibial ossification centre can also be seen on the lateral view
which develops as the tibial tuberosity.

Page 17 of 25
Fig. 6: Lateral and AP radiographs of a 15 year old child - the physes can be seen to
have started fusing. Also note the presence of the fabella, an accessory ossicle which,
is usually found in the lateral head of the gastrocnemius muscle.

Page 18 of 25
Page 19 of 25
Fig. 7: AP knee radiograph of a 12 year old demonstrating a bipartite patella; the
secondary ossification centres can be seen in the superolateral aspect of the patellae.

Fig. 8: AP radiograph of an adult patient demonstrating a fractured patella.

Page 20 of 25
Fig. 9: Lateral knee radiograph of a 12 year old child demonstrating Sindig-Larsen-
Johansson syndrome - there is a beaked appearance of the inferior pole of the patella.
The proximal tibial ossification centre is also seen.

Page 21 of 25
Fig. 10: Lateral radiograph of a patella sleeve avulsion fracture, with overlying plaster
of paris.

Page 22 of 25
Fig. 11: Horizontal beam lateral knee radiograph of an 11 year old showing the
ossification centre for the tibial tuberosity.

Page 23 of 25
Fig. 12: Lateral knee radiograph demonstrating Osgood Schlatters disease.

Page 24 of 25
Conclusion

Knowledge of the order and ages of ossification is important in accurate interpretation of

the paediatric knee radiograph to prevent misdiagnosis and inappropriate intervention.

References

1. Ryan S, McNicholas M, Eustace S. Anatomy for Diagnostic Imaging.

rd
Saunders Ltd. 3 Edition. 2010
2. Ogden JA. Radiology of postnatal skeletal development. X. Patella and tibial
tuberosity. Skeletal Radiol. 1984;11(4):246-57.

Personal Information

Dr Cass Chisholm, Radiology ST3, West Midlands Deanery.

Dr Davina Mak, Radiology ST3 West Midlands Deanery.

Dr Manigandan Thyagarajan, Radiology Consultant, Birmingham Childrens Hospital.

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