Diz çevresi osteonekroz ve kemik enfarktı

Özet

Atravmatik diz ağrısı olan erişkinde subkondral yetersizlik kırığı (SIF) ve osteonekrozla komplike SIF (SIF-ON); sistemik riskleri olan hastada ise epifiz osteonekrozu veya distal femur/proksimal tibia medüller kemik enfarktı ayrıştırılmalıdır. Erken subkondral kemik iliği değişikliklerinin değerlendirilmesinde MR öne çıkar; osteonekrozla komplike SIF eklem yüzü çökmesine ilerleyebilir. Medüller kemik enfarktı çoğu kez serpijinöz sklerotik kenarlı, merkezinde yağlı medüller yoğunluğu koruyan bir odak olarak görünür.

Faz ve pencere

Kontrastsız tanısal

SIF’te subkondral kırık çizgisi görülebilir; SIF-ON eklem yüzünde geri dönüşümsüz çökme ile ilerleyebilir. Erken SIF ve SIF-ON’da kemik iliği ödemi-benzeri sinyal MR’da değerlendirilir; tek başına özgül değildir.

Kemik algoritması tanısal

Erken SIF ve SIF-ON’da kemik iliği ödemi-benzeri sinyal MR’da görülebilir; SIF’in saptanması ve izleminde MR en iyi yöntemdir.

Önerilen pencereler: Kemik (G 1800 / M 400), Yumuşak doku (G 400 / M 40).

BT bulguları

• Subkondral skleroz — femoral kondillerde belirgin skleroz görülebilir.
• Serpijinöz medüller sınır — metafiz/şaft medullasında kıvrımlı sklerotik kenarın çevrelediği, merkezinde medüller yağ yoğunluğunu koruyabilen enfarkt odağı.
• Subkondral yarımay kırığı — MR’da subkondral hipointens kırık çizgisi SIF ile uyumludur; SIF-ON eklem yüzünde geri dönüşümsüz çökme ile ilerleyebilir.
• Eklem yüzü çökmesi — SIF-ON, eklem yüzünde geri dönüşümsüz çökme ile ilerleyebilir.
• İkincil eklem değişikliği — subkondral çökme sonrası osteoartrit gelişebilir.
• Birden fazla kemikte benzer medüller serpijinöz odaklar çok odaklı kemik enfarktı örüntüsünü düşündürür; dağılım klinik bağlamla birlikte yorumlanır.
• Eşlik eden kırık veya serbest osteokondral parça — subkondral kemik plağı kesintisi ve eklem içi fragman ayrıca kaydedilir.

Normalde

Normal femoral kondil ve tibial platoda subkondral kemik plağı düzgün ve kesintisizdir; eklem yüzü olağan konturunu korur. SIF-ON'da subkondral alanda, değişmiş kemik iliğine bağlı sıvıya duyarlı MR sekanslarında düşük sinyal görülebilir.

Ayırıcı tanı

Subkondral yetersizlik kırığı (SIF), subkondral kırık çizgisiyle ilişkilidir; MR'da kemik iliği ödemi-benzeri sinyal eşlik edebilir. SIF osteonekroz ile komplike olduğunda SIF-ON olarak adlandırılır. Medüller kemik enfarktı metafiz/şaft medullasında, sistemik kökenli osteonekroz ise epifizde yerleşebilir; klinik bağlamla birlikte değerlendirilir.

Osteokondritis dissekans

subkondral kemik ve eklem kıkırdağını içeren fokal osteokondral lezyondur; juvenil olgularda en sık femoral kondilin posterolateral bölümünde görülür.

Kronik osteomiyelit

sekestr, kortikal kloaka, periostal yeni kemik veya yumuşak doku sinüs yolu eşlik edebilir.

Osteoartrit

yaygın kompartman daralması, osteofit ve subkondral skleroz oluşturur; tek başına serpijinöz medüller sınır beklenmez.

Tuzaklar

• Erken SIF'te MR'da kemik iliği ödemi-benzeri sinyal ve subkondral kırık çizgisi görülebilir; erken tanı ve değerlendirmede MR en uygun yöntemdir. Tarihsel “SONK” terimi yerine bulgu uygunsa SIF veya SIF-ON kullanın.
• SIF'te subkondral kırık çizgisi MR'da görülebilir; değerlendirmede eşlik eden kemik iliği ödemi de dikkate alınır.
• Medüller enfarktın çevresel sklerozu agresif lezyon sanılabilir; merkezde korunmuş medüller yağ ve düzgün serpijinöz sınır, kortikal yıkım olmamasıyla birlikte benign enfarkt lehinedir.
• Subkondral yetersizlik kırığı ilerleyerek eklem yüzü çökmesine ve ikincil osteoartrite yol açabilir.
• SIF’te MR’da subkondral hipointens kırık çizgisi ve kemik iliği ödemi-benzeri sinyal görülebilir; menisküs arka kök yırtıkları ve ekstrüzyon birçok hastada bildirilmiştir.

Kendini dene

1. Diz MR'ında kondil altında hipointens kırık çizgisi ve kemik iliğinde ödem-benzeri sinyal görülüyor. Bu bulgular en çok hangi lezyonla uyumludur?

   • Subkondral stres kaynaklı kırık
   • Epifiz osteonekrozu
   • Osteokondral disekan lezyon
   • Kronik kemik enfeksiyonu
   Cevabı göster

   Subkondral stres kaynaklı kırık. Subkondral hipointens kırık çizgisi ve kemik iliği ödemi-benzeri sinyal SIF için tipik MR bulgularıdır.

2. Distal femur medullasında iyi sınırlı, serpentinöz kenarlı bir odak görülüyor. Tanı nedir?

   • Kemik enfarktı
   • Osteosarkom
   • Brodie apsesi
   • Kemik adacığı
   Cevabı göster

   Kemik enfarktı. Serpentin biçimli, iyi sınırlı medüller odak kemik enfarktını destekler; kemik iliği ödemi-benzeri sinyal MR’da değerlendirilir. Brodie apsesi kemikte litik, sklerotik kenarlı bir kavite olarak görülebilir.

İlgili konular

• Diz lipohemartrozu
• Tibia platosu posterior shear/kolon kırığı
• Segond avulsiyon kırığı

Kaynaklar

Bu sayfadaki 39 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla otomatik olarak karşılaştırıldı; 18 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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Eğitim amaçlıdır; hasta başında tanı ve tedavi kararının yerine geçmez, tıbbi tavsiye değildir. Metinler yapay zekâ desteğiyle yazıldı ve otomatik bir adımda kaynak alıntılarıyla karşılaştırıldı; bu bir tıbbi doğrulama değildir ve içerik uzman radyolog incelemesinden geçmedi. Klinik kararlarda güncel kılavuzları, kurum protokollerini ve radyoloji raporunu esas alın.