Knee X-rays

Cite this article as:
Tessa Davis. Knee X-rays, Don't Forget the Bubbles, 2014. Available at:

1.  Know your knee anatomy

See the the anatomical landmarks on the diagrams below.






Remember that the knees of younger children will look different, as the patella forms, and the ossification centres form.




2. Look for an effusion

There are two fat pads in the knee

  • the suprapatellar fat pad
  • the prefemoral fat pad

Make sure they are next to each other. Soft tissue density in between the two fat pads indicates an effusion – this is only reliably seen on the lateral view (see images below).

It is sometimes helpful to rotate the PACS view so you are looking at the knee in the horizontal plane, in the same way the image is taken.  Your eyes are much more adept at picking up an effusion or even a fat/fluid level (lipohaemarthrosis) that way.


Case courtesy of Dr Jeremy Jones,, rID: 29039


Case courtesy of Dr Henry Knipe,, rID: 32559

3. Look at the main bones

Check for fractures in the fibular head, femur and tibia.


4. Check the tibio-femoral alignment

Draw a line along the margin of  the lateral femoral condyle. The tibia should be within 0.5 cm of this line, otherwise it suggests a tibial plateau fracture.

tibiofemoral alignment

Case courtesy of Dr Jeremy Jones,, rID: 29039


5. Looks at the tibial plateaus

These most commonly happen on the lateral tibial plateau.


Check for a tibial plateau avulsion from the lateral edge (Segond fracture)



Tibial plateau fractures in children are exceedingly rare and require a marked degree of axial force. They are more likely to get a Salter-Harris V.

6. Look at the intercondylar eminence

A fracture here is most common in adolescents following hyperextension of the knee. It’s an avulsion fracture at the tibial attachment of the ACL.

tibial eminence

Case courtesy of Gerry Gardner,, rID: 13915



7. Look for patellar tendon disruption

The patellar tendon goes from the inferior pole of the patella to the tibial tuberosity. Its length should be the same as the patellar length +/- 20%. If it’s too long then think of a patellar tendon rupture. This is the Insall-Salvatti ratio and should ideally me measure with the knee flexed at 30 degrees.


Case courtesy of Dr Wael Nemattalla,, rID: 10329


8. Look for a patellar fracture

Bipartite patellas are common. It is a congenital condition that occurs when the patella is made of two bones instead of a single bone. Normally the two bones would fuse together as the child grows but in bipartite patella they remain as two separate bones. The edges appear well corticated as compared to in a fracture. See an example below.


Case courtesy of, rID: 11236

Most patella fractures are transverse, but they can be vertical.



Consider a skyline view. This gives a clearer view of the patella in cases of clinically suspected patella fracture where the AP and laterals look ok. It gives a good view of the space between the patella and the femur. See a normal skyline view below.




9. Remember the fabella…

This is a normal variant and not a floating fracture! It’s normal sesamoid bone that lies in the posterior knee.


Case courtesy of Dr David Cuete,, rID: 27428



Interpreting x-rays of the knee join – YouTube video

Knee radiograph: an approach. Radiopaedia

Trauma x-ray, Radiology Masterclass

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About Tessa Davis

Tessa Davis is a Consultant in Paediatric Emergency Medicine at the Royal London Hospital and a Senior Lecturer at Queen Mary University of London.

Author: Tessa Davis Tessa Davis is a Consultant in Paediatric Emergency Medicine at the Royal London Hospital and a Senior Lecturer at Queen Mary University of London.

17 Responses to "Knee X-rays"

  1. Ellen Harai
    Ellen Harai 5 years ago .Reply

    Dear Tessa,

    Lots of information here. Thanks very much! I just want you to know your public-spirited gift of information is much appreciated.



  2. Dr, S, Venkat Raman
    Dr, S, Venkat Raman 5 years ago .Reply

    Dear Tessa, do you have a similar session of the hip x rays?

    • Andrew Tagg
      Andrew Tagg 5 years ago .Reply

      Not yet, but that’s an excellent idea.

  3. Dr. Niraj Chaturvedi
    Dr. Niraj Chaturvedi 5 years ago .Reply

    Dear Tessa,

    thanks to provide such useful information .

  4. t chigoka
    t chigoka 4 years ago .Reply

    thank you so much

  5. alex
    alex 4 years ago .Reply

    Would you cast a knee fracture

  6. yousef yaseen
    yousef yaseen 4 years ago .Reply

    thank you so much

  7. kavitha
    kavitha 4 years ago .Reply

    Thanks .
    Please S thr special cases r congenital abnormalities upload.

  8. Puia Ralte
    Puia Ralte 4 years ago .Reply

    very helpful…greatly appreciated @ Dr.Tessa.

  9. Dr Vivek Andrews
    Dr Vivek Andrews 3 years ago .Reply

    very much useful information. Thank You.

  10. Tali
    Tali 2 years ago .Reply

    Thank you for the usful information!

  11. hany mammdouh
    hany mammdouh 2 years ago .Reply

    many thanks
    god bless you

  12. Yasmeen Hasnain
    Yasmeen Hasnain 2 years ago .Reply

    for hip X-rays see following link

  13. Venkatesh prabhu
    Venkatesh prabhu 2 years ago .Reply

    Very useful thank you

  14. Carlos Alberto Giglio
    Carlos Alberto Giglio 1 year ago .Reply

    I am professor of Radiology of the physiotherapy course at a Brazilian university and I would like to know if I can use the imaging exams (with the said quote from the site and author) of the site to set up online courses

    Grateful for the attention


    Prof. Dr Carlos Alberto Giglio

  15. Abhishek Mishra
    Abhishek Mishra 11 months ago .Reply

    Very nice and organized presentation. Thank you

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