361

Pictorial Essay

Knee Effusion: Normal Distribution of Fluid

Mark E. Schweitzer,1 Andreas FaIk,2 Dean Berthoty,2 Michael Mitchell,2 and Donald ReSnick2
American Journal of Roentgenology 1992.159:361-363.

Although visualization of articular fluid on MR images of the Electric Medical Systems, Milwaukee, WI) in the sagittal plane. Images
knee is common, no specific MR criteria that enable assess- were obtained with a 14-cm field of view, a 256 x 192 matrix, and
ment of the quantity of the effusion have been established. We two signal acquisitions. The spin-echo technique, 600/20 (TR/TE),
performed MR of three cadavenc knee specimens after the in- was used with a slice thickness of 4 mm and a 1-mm interslice gap.
stillation of increasingly large volumes of fluid and studied the Two radiologists simultaneously evaluated the MR images and
distribution of the fluid. When 4 ml of fluid was injected, the recorded the precise location of the fluid by consensus. In addition,
anteroposterior diameter of the suprapatellar recess was 4 mm the widest anteroposterior diameter of the suprapatellar recess and
on midline sagittal MR images and 10.0-12.5 mm on lateral the anteroposterior diameter of the suprapatellar recess on a midline
sagittal MR images, corresponding to the usual routine radio- image was recorded. The radiologists knew the amount of fluid
graphic criteria for a knee effusion. injected.

Materials and Methods Results

Knee specimens from three frozen cadavers were obtained by
Distribution of fluid was nearly identical in the three cadav-
sectioning with a band saw at the levels of the midportion of the
femur and the midportions of the tibia and fibula. Routine radiographs
eric specimens. Afterthe introduction of i ml of gadopentetate
were obtained to exclude the presence of significant abnormalities or dimeglumine, MR imaging in each cadavenc knee showed
joint fluid. The specimens subsequently were frozen at-20#{176}Cfor 12 fluid that was barely visible collecting between the femoral
hr. Before MR imaging, the knees were thawed and heated to condyles and Hoffa’s fat pad (Fig. i). In addition, a small
approximately 37#{176}C. triangular collection of fluid was seen in a recess above the
After fluoroscopic localization, a 19-gauge needle was inserted medial meniscus in two of the three knees.
into the suprapatellar recess. While the specimen was being rotated, With 3 ml of gadopentetate dimeglumine, fluid consistently
we tried several times to aspirate any joint fluid that was present in accumulated in the suprapatellar recess. The layer of fluid
order to ensure a “dry” articulation before the instillation of fluid, between the condyles and Hoffa’s fat pad thickened to ap-
although little fluid could be aspirated. The knee was progressively
proximately 2 mm in the sagittal plane. A small amount of
distended by using a dilute solution of gadopentetate dimeglumine
fluid was still noted in the posterior meniscal recesses (greater
(1 :250, gadopentetate dimeglumine to normal saline). In each cadav-
eric specimen, MR images were obtained after volumes of 1 3, 4, ,
medially than laterally), and a small amount of fluid was seen
1 5, and 20 ml had been injected. posterior and medial to the posterior cruciate ligament.
The knees were placed in the supine position with 15#{176}
of external With 4 ml of fluid, the widest aspect of the suprapatellar
rotation. Each specimen was imaged with a 1 .5-T unit (Signa, General recess, the lateral aspect, was 1 0.0-i 2.5 mm (Fig. 2A). On

Received December 27, 1991; accepted after revision February 24, 1992.
This work was supported in part by Veterans Affairs grant SA 306.
1 Department of Radiology, Jefferson Medical College of Thomas Jefferson University, 132 S. 1 0th St., 1096A Main, Philadelphia, PA 191 07. Address reprint
requests to M. E. Schweitzer.
2 Department of Radiology, Department of Veterans Affairs Medical Center, 3350 La Jolla Village Dr., San Diego, CA 92161.

AJR 159:361-363, August 1992 o361-803x/92/1592-0361 5 American Roentgen Ray Society

 362 SCHWEITZER ET AL. AJR:159, August 1992

Fig. 1.-Sagittal MR image (600/20) obtained Fig. 2.-Sagittal MR images (600/20) of lateral aspect of cadavenc knee after instillation of 4 ml
after instillation of I ml of dilute gadopentetate of dilute gadopentetate dimeglumine.
dimeglumine into cadaveric knee shows small A, Anteroposterior measurement of widest aspect of suprapatellar recess is I 1 mm (arrows). Also
amount of fluid adjacent to femoral condyles seen is signal void from injection needle.
(black arrows) and a tiny amount of fluid in supra- B, On midline image, fluid layers about femoral condyles (black arrows), in suprapatellar recess
patellar recess (white arrow). (white arrow), and in recesses about menisci. Midline width of suprapatellar recess is 4 mm in this
American Journal of Roentgenology 1992.159:361-363.

specimen.

Fig. 3.-Sagittal MR images (600/20) obtained

after instillation of 15 ml of dilute gadopentetate
dimeglumine into cadavenc knee.
A, Suprapatellar recess measures 18 mm at its
widest aspect (arrows).
B, On midline image, increased fluid is seen in
suprapatellar recess that is 10 mm in anteropos-
tenor dimension (straight white arrows). Small
amounts of gadopentetate dimeglumine are seen
distending superior vertical cleft in Hoffa’s fat pad
(open arrow), horizontally oriented posterior cleft
(curved black arrow), between femoral condyle
and Hofta’s fat pad (straight solid black arrows),
and posteriorly about cruciate ligaments (curved
- white arrow).

midline images, the anteroposterior diameter of this fluid fluid was just anterior to the lateral condylar notch. The
averaged around 4 mm (Fig. 2B). junction between the fluid and the fat pads was smooth and
With i 5 ml of fluid in thejoint, the anteroposterior dimension well marginated.
of the suprapatellar recess was i 6-20 mm at its widest Two synovial-lined clefts were evident within Hoffa’s fat
aspect (Fig. 3A) and 9.5-i 5.5 mm at the level of the patellar pad. One was located superiorly just posterior to the inferior
tendon (Fig. 3B). Fluid was seen between the cartilage of the portion of the patella and had a vertical orientation. The other
femoral condyles and Hoffa’s fat pad; its dimension averaged cleft was anterior to the anterior horns of the menisci and had
about 3 mm in this region. Fluid also was seen in two clefts a horizontal orientation. With large effusions, these clefts
within this pad. Greater volumes of fluid were seen in the distended with fluid and became cigar shaped but retained
posterior meniscal recesses, and fluid was seen within the their characteristic location and orientation (Figs. 3B and 4B).
popliteal tendon sheath. The vertical posterior cleft distended first and to a greater
The widest aspect of the suprapatellar recess was 18-20 degree. The superior cleft initially distended with i 5 ml of
mm with 20 ml of injected fluid (Fig. 4A). The measurement fluid.
was 1 1 mm at the level of the quadriceps tendon in all
specimens (Fig. 4B). The popliteal tendon sheath was dis-
Discussion
tended and the fluid between the condyles and the fat pad
nearly paralleled the cortex of the femoral condyles, although Although articular fluid is commonly recognized on MR
it was slightly convex anteriorly. The widest portion of this images of the knee [i], to our knowledge, the distribution of
 AJR:159, August 1992 DISTRIBUTION OF KNEE FLUID ON MR 363

Fig. 4.-Sagittal MR images (600/20) of lateral

aspect of knee obtained after injection of 20 ml of
dilute gadopentetate dimeglumine into cadaveric
knee.
A, Suprapatellar recess measures 19 mm at its
widest aspect (arrows).
B, On midline image, suprapatellar recess
measures I I mm (white arrows). Note that Hoffa’s
fat pad Is displaced in anteroinferior direction, and
contour of fluid parallels femoral condyles
(straight solid black arrows). Distension of vertical
superior (open arrow) and horizontal posterior
(curved arrow) clefts in Hoffa’s fat pad is seen.

increasing amounts of joint fluid in the knee has not been the knee joint, we were aware of some limitations in the
previously studied. With MR imaging in the sagittal plane, a design of the study. First, distribution of fluid in cadaveric
volume of 1 ml of fluid generally was visible, lying adjacent to knees may not simulate distribution of fluid in living patients.
American Journal of Roentgenology 1992.159:361-363.

the condyles of the femur. The classic plain film radiographic Second, MR may be more sensitive to dilute gadopentetate
criterion of a joint effusion, a 1 0-mm soft-tissue density in the dimeglumine used to simulate knee effusions than to small
suprapatellar recess [2, 3], was seen lateral of midline on volumes of articularfluid found
in clinical practice. Third, larger
sagittal MR images of supine cadaveric knees after 4 ml of numbers of specimens would
be necessary to account for
fluid had been injected. With this volume of injected fluid, the variability in fluid accumulation. Furthermore, despite our vig-
anteroposterior diameter of the midline suprapatellar recess orous attempts to remove all fluid before the MR study, small
averaged about 4 mm. This measurement closely corre- amounts may have been present. Although only sagittal im-
sponds to the 5-mm fat pad separation sign described by Hall ages were examined, we think this is the most useful plane
[2], which is the distance between prefemoral and quad- for the detection and localization of fluid in the knee.
riceps fat pads as measured on lateral knee radiographs. This
volume of fluid also corresponds to the clinical definition of a
significant effusion [4]. Although the radiographs in the series REFERENCES
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should be noted that fluid distribution in the lateral-most 2. Hall FM. Radiographic diagnosis and accuracy in knee joint effusions.
aspect of the suprapatellar recess will also depend on rota- Radiology 1975;1 15:49-54
3. Engedstad BL, Friedman EM, Murphy WA. Diagnosis of joint effusion on
tion. To closely simulate the conditions of clinical imaging, we
lateral and axial projections of the knee. Invest Radiol 1813:188-190
placed the cadaveric knees in slight external rotation. 4. McCarthy DL. Synovial fluid. In: McCarthy OJ, ed. Arthritis and allied
Because this was a preliminary study of fluid distribution in conditions, 1 lth ed. Philadelphia: Lea & Febiger, 1989:70-71