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Imaging of the Painful Lower Limb Stump¹

¹ From the Department of Radiology, Centre Alexis Vautrin, Ave de Bourgogne, 54511 Vandoeuvre-les-Nancy, France (P.H., J.S.); and the Departments of Physical Medicine and Rehabilitation (N.M., J.P.) and Radiology Guilloz (F.W., A.B.), Hôpital Central University of Nancy 1, France. Recipient of a Cum Laude award for a scientific exhibit at the 1999 RSNA scientific assembly. Received January 31, 2000; revision requested March 9 and received May 1; accepted May 4. Address correspondence to P.H. (e-mail: p.henrot@nancy.fnclcc.fr).

View larger version (30K): [in a new window]   Figure 1. Diagram illustrates a total surface-bearing transtibial prosthesis. a = lower limb, b = stump covering, c = soft insert, d = hard socket, e = joint with prosthetic foot.

View larger version (77K): [in a new window]   Figure 2. Painful aggressive bone edge in a patient who had undergone below-knee amputation for trauma. Anteroposterior radiograph obtained during weight-bearing shows an abnormal edge of the end of the tibia (arrow).

View larger version (91K): [in a new window]   Figure 3a. Aggressive bone edge in a patient with pain and disability who had undergone below-knee amputation for trauma. (a) Lateral radiograph obtained 1 year after surgery shows the edge of the end of the tibia (arrow). (b) On a lateral radiograph obtained during weight-bearing 5 years after surgery, the end of the tibia is blunted (arrow).

View larger version (106K): [in a new window]   Figure 3b. Aggressive bone edge in a patient with pain and disability who had undergone below-knee amputation for trauma. (a) Lateral radiograph obtained 1 year after surgery shows the edge of the end of the tibia (arrow). (b) On a lateral radiograph obtained during weight-bearing 5 years after surgery, the end of the tibia is blunted (arrow).

View larger version (86K): [in a new window]   Figure 4a. Heterotopic ossification in a patient with pain and disability who had undergone below-knee amputation for trauma. (a) Anteroposterior radiograph shows a spikelike heterotopic ossification at the end of the fibula (arrow). (b) Lateral radiograph obtained during weight-bearing shows a fibular, spikelike heterotopic ossification in the soft tissues of the stump (arrow).

View larger version (75K): [in a new window]   Figure 4b. Heterotopic ossification in a patient with pain and disability who had undergone below-knee amputation for trauma. (a) Anteroposterior radiograph shows a spikelike heterotopic ossification at the end of the fibula (arrow). (b) Lateral radiograph obtained during weight-bearing shows a fibular, spikelike heterotopic ossification in the soft tissues of the stump (arrow).

View larger version (137K): [in a new window]   Figure 5a. Heterotopic ossification in a patient with pain and disability who had undergone above-knee amputation. (a) Coronal T1-weighted MR image shows a spur on the lower end of the femur as well as heterotopic ossification associated with soft-tissue inflammation (bottom arrow). Osteonecrosis of the femoral head is also present (top arrow). (b) Axial T1-weighted MR image shows evidence of soft-tissue inflammation around the femoral spur (white arrow). Sciatic neuroma is also depicted (black arrow).

View larger version (147K): [in a new window]   Figure 5b. Heterotopic ossification in a patient with pain and disability who had undergone above-knee amputation. (a) Coronal T1-weighted MR image shows a spur on the lower end of the femur as well as heterotopic ossification associated with soft-tissue inflammation (bottom arrow). Osteonecrosis of the femoral head is also present (top arrow). (b) Axial T1-weighted MR image shows evidence of soft-tissue inflammation around the femoral spur (white arrow). Sciatic neuroma is also depicted (black arrow).

View larger version (94K): [in a new window]   Figure 6a. Osteomyelitis in a patient who had undergone below-knee amputation for trauma. (a) Anteroposterior radiograph shows osseous abnormalities including osteolytic and condensed zones with periosteal reaction. (b) Coronal T1-weighted MR image shows a large, intraosseous area of low signal intensity at the lower end of the tibia (arrow). (c) Axial gadolinium-enhanced fat-saturated T1-weighted MR image shows an intraosseous abscess (white arrow) extending to the skin through a sinus tract (black arrow). (d) Coronal reconstructed CT scan shows periosteal reaction (open arrow), an intramedullar sequestrum (small solid arrow), and an opening in the cortical wall (large solid arrow).

View larger version (141K): [in a new window]   Figure 6b. Osteomyelitis in a patient who had undergone below-knee amputation for trauma. (a) Anteroposterior radiograph shows osseous abnormalities including osteolytic and condensed zones with periosteal reaction. (b) Coronal T1-weighted MR image shows a large, intraosseous area of low signal intensity at the lower end of the tibia (arrow). (c) Axial gadolinium-enhanced fat-saturated T1-weighted MR image shows an intraosseous abscess (white arrow) extending to the skin through a sinus tract (black arrow). (d) Coronal reconstructed CT scan shows periosteal reaction (open arrow), an intramedullar sequestrum (small solid arrow), and an opening in the cortical wall (large solid arrow).

View larger version (106K): [in a new window]   Figure 6c. Osteomyelitis in a patient who had undergone below-knee amputation for trauma. (a) Anteroposterior radiograph shows osseous abnormalities including osteolytic and condensed zones with periosteal reaction. (b) Coronal T1-weighted MR image shows a large, intraosseous area of low signal intensity at the lower end of the tibia (arrow). (c) Axial gadolinium-enhanced fat-saturated T1-weighted MR image shows an intraosseous abscess (white arrow) extending to the skin through a sinus tract (black arrow). (d) Coronal reconstructed CT scan shows periosteal reaction (open arrow), an intramedullar sequestrum (small solid arrow), and an opening in the cortical wall (large solid arrow).

View larger version (118K): [in a new window]   Figure 6d. Osteomyelitis in a patient who had undergone below-knee amputation for trauma. (a) Anteroposterior radiograph shows osseous abnormalities including osteolytic and condensed zones with periosteal reaction. (b) Coronal T1-weighted MR image shows a large, intraosseous area of low signal intensity at the lower end of the tibia (arrow). (c) Axial gadolinium-enhanced fat-saturated T1-weighted MR image shows an intraosseous abscess (white arrow) extending to the skin through a sinus tract (black arrow). (d) Coronal reconstructed CT scan shows periosteal reaction (open arrow), an intramedullar sequestrum (small solid arrow), and an opening in the cortical wall (large solid arrow).

View larger version (109K): [in a new window]   Figure 7a. Inguinal angiosarcoma in a patient who had undergone above-knee amputation for trauma. The tumor developed 10 years after surgery. (a) Anteroposterior radiograph does not show any abnormality. (b) Axial CT scan shows lymphedematous infiltration of the subcutaneous fat (arrows). (c) Axial contrast material-enhanced CT scan shows a right-sided inguinal tumoral mass with high attenuation infiltrating muscle tissue (arrow).

View larger version (68K): [in a new window]   Figure 7b. Inguinal angiosarcoma in a patient who had undergone above-knee amputation for trauma. The tumor developed 10 years after surgery. (a) Anteroposterior radiograph does not show any abnormality. (b) Axial CT scan shows lymphedematous infiltration of the subcutaneous fat (arrows). (c) Axial contrast material-enhanced CT scan shows a right-sided inguinal tumoral mass with high attenuation infiltrating muscle tissue (arrow).

View larger version (82K): [in a new window]   Figure 7c. Inguinal angiosarcoma in a patient who had undergone above-knee amputation for trauma. The tumor developed 10 years after surgery. (a) Anteroposterior radiograph does not show any abnormality. (b) Axial CT scan shows lymphedematous infiltration of the subcutaneous fat (arrows). (c) Axial contrast material-enhanced CT scan shows a right-sided inguinal tumoral mass with high attenuation infiltrating muscle tissue (arrow).

View larger version (134K): [in a new window]   Figure 8a. Sciatic neuroma in a patient who had undergone above-knee amputation and presented with pain in the lower end of the stump. (a) Axial T1-weighted MR image demonstrates a low-signal-intensity mass (arrow). (b) Axial fat-saturated T2-weighted MR image reveals a high-signal-intensity mass in the area of the sciatic nerve (arrow). (c) Coronal contrast-enhanced fat-saturated T1-weighted MR image shows diffuse enhancement of the mass (arrow). (d) Intraoperative photograph depicts the sciatic neuroma before resection.

View larger version (152K): [in a new window]   Figure 8b. Sciatic neuroma in a patient who had undergone above-knee amputation and presented with pain in the lower end of the stump. (a) Axial T1-weighted MR image demonstrates a low-signal-intensity mass (arrow). (b) Axial fat-saturated T2-weighted MR image reveals a high-signal-intensity mass in the area of the sciatic nerve (arrow). (c) Coronal contrast-enhanced fat-saturated T1-weighted MR image shows diffuse enhancement of the mass (arrow). (d) Intraoperative photograph depicts the sciatic neuroma before resection.

View larger version (97K): [in a new window]   Figure 8c. Sciatic neuroma in a patient who had undergone above-knee amputation and presented with pain in the lower end of the stump. (a) Axial T1-weighted MR image demonstrates a low-signal-intensity mass (arrow). (b) Axial fat-saturated T2-weighted MR image reveals a high-signal-intensity mass in the area of the sciatic nerve (arrow). (c) Coronal contrast-enhanced fat-saturated T1-weighted MR image shows diffuse enhancement of the mass (arrow). (d) Intraoperative photograph depicts the sciatic neuroma before resection.

View larger version (100K): [in a new window]   Figure 8d. Sciatic neuroma in a patient who had undergone above-knee amputation and presented with pain in the lower end of the stump. (a) Axial T1-weighted MR image demonstrates a low-signal-intensity mass (arrow). (b) Axial fat-saturated T2-weighted MR image reveals a high-signal-intensity mass in the area of the sciatic nerve (arrow). (c) Coronal contrast-enhanced fat-saturated T1-weighted MR image shows diffuse enhancement of the mass (arrow). (d) Intraoperative photograph depicts the sciatic neuroma before resection.

View larger version (126K): [in a new window]   Figure 9a. Peroneal neuroma in a patient who had undergone below-knee amputation and presented with lateral stump pain. (a) Anteroposterior radiograph does not show any abnormality. (b) Axial T1-weighted MR image shows a low-signal-intensity nodular lesion in the lateral portion of the stump (arrow). (c) Coronal T1-weighted MR image shows a low-signal-intensity nodular lesion in contact with the end of the fibula (arrow). (d) Coronal contrast-enhanced fat-saturated T1-weighted MR image shows the nodular lesion with increased signal intensity associated with soft-tissue inflammation (arrow). (e) Intraoperative photograph depicts the neuroma in the distribution of the peroneal nerve.

View larger version (124K): [in a new window]   Figure 9b. Peroneal neuroma in a patient who had undergone below-knee amputation and presented with lateral stump pain. (a) Anteroposterior radiograph does not show any abnormality. (b) Axial T1-weighted MR image shows a low-signal-intensity nodular lesion in the lateral portion of the stump (arrow). (c) Coronal T1-weighted MR image shows a low-signal-intensity nodular lesion in contact with the end of the fibula (arrow). (d) Coronal contrast-enhanced fat-saturated T1-weighted MR image shows the nodular lesion with increased signal intensity associated with soft-tissue inflammation (arrow). (e) Intraoperative photograph depicts the neuroma in the distribution of the peroneal nerve.

View larger version (160K): [in a new window]   Figure 9c. Peroneal neuroma in a patient who had undergone below-knee amputation and presented with lateral stump pain. (a) Anteroposterior radiograph does not show any abnormality. (b) Axial T1-weighted MR image shows a low-signal-intensity nodular lesion in the lateral portion of the stump (arrow). (c) Coronal T1-weighted MR image shows a low-signal-intensity nodular lesion in contact with the end of the fibula (arrow). (d) Coronal contrast-enhanced fat-saturated T1-weighted MR image shows the nodular lesion with increased signal intensity associated with soft-tissue inflammation (arrow). (e) Intraoperative photograph depicts the neuroma in the distribution of the peroneal nerve.

View larger version (144K): [in a new window]   Figure 9d. Peroneal neuroma in a patient who had undergone below-knee amputation and presented with lateral stump pain. (a) Anteroposterior radiograph does not show any abnormality. (b) Axial T1-weighted MR image shows a low-signal-intensity nodular lesion in the lateral portion of the stump (arrow). (c) Coronal T1-weighted MR image shows a low-signal-intensity nodular lesion in contact with the end of the fibula (arrow). (d) Coronal contrast-enhanced fat-saturated T1-weighted MR image shows the nodular lesion with increased signal intensity associated with soft-tissue inflammation (arrow). (e) Intraoperative photograph depicts the neuroma in the distribution of the peroneal nerve.

View larger version (96K): [in a new window]   Figure 9e. Peroneal neuroma in a patient who had undergone below-knee amputation and presented with lateral stump pain. (a) Anteroposterior radiograph does not show any abnormality. (b) Axial T1-weighted MR image shows a low-signal-intensity nodular lesion in the lateral portion of the stump (arrow). (c) Coronal T1-weighted MR image shows a low-signal-intensity nodular lesion in contact with the end of the fibula (arrow). (d) Coronal contrast-enhanced fat-saturated T1-weighted MR image shows the nodular lesion with increased signal intensity associated with soft-tissue inflammation (arrow). (e) Intraoperative photograph depicts the neuroma in the distribution of the peroneal nerve.

View larger version (129K): [in a new window]   Figure 10a. Bursitis in a patient who had undergone below-knee amputation and presented with lateral stump pain. (a) Coronal T1-weighted MR image shows low-signal-intensity subcutaneous fat at the level of the fibular head in the area of weight-bearing on the socket (arrow). (b) Coronal fat-saturated T2-weighted MR image shows the soft tissue at the level of the fibular head with a high signal intensity similar to that of fluid (arrows). (c) Axial contrast-enhanced fat-saturated T1-weighted MR image shows peripheral enhancement of the inflamed adventitious bursa (arrows).

View larger version (153K): [in a new window]   Figure 10b. Bursitis in a patient who had undergone below-knee amputation and presented with lateral stump pain. (a) Coronal T1-weighted MR image shows low-signal-intensity subcutaneous fat at the level of the fibular head in the area of weight-bearing on the socket (arrow). (b) Coronal fat-saturated T2-weighted MR image shows the soft tissue at the level of the fibular head with a high signal intensity similar to that of fluid (arrows). (c) Axial contrast-enhanced fat-saturated T1-weighted MR image shows peripheral enhancement of the inflamed adventitious bursa (arrows).

View larger version (121K): [in a new window]   Figure 10c. Bursitis in a patient who had undergone below-knee amputation and presented with lateral stump pain. (a) Coronal T1-weighted MR image shows low-signal-intensity subcutaneous fat at the level of the fibular head in the area of weight-bearing on the socket (arrow). (b) Coronal fat-saturated T2-weighted MR image shows the soft tissue at the level of the fibular head with a high signal intensity similar to that of fluid (arrows). (c) Axial contrast-enhanced fat-saturated T1-weighted MR image shows peripheral enhancement of the inflamed adventitious bursa (arrows).

View larger version (74K): [in a new window]   Figure 11a. Bursitis of the lower end of the stump in a patient with pain and inflammation who had undergone below-knee amputation. (a) Lateral radiograph shows a soft-tissue area of increased opacity in the distal part of the stump (arrow). (b) Coronal T1-weighted MR image demonstrates low signal intensity in the soft tissues of the lower end of the stump (arrow). (c) On a coronal T2-weighted MR image, the soft tissues of the lower end of the stump demonstrate a high signal intensity similar to that of fluid (arrow). (d) Axial contrast-enhanced fat-saturated T1-weighted MR image shows a fluid collection in the lower end of the stump (arrow).

View larger version (95K): [in a new window]   Figure 11b. Bursitis of the lower end of the stump in a patient with pain and inflammation who had undergone below-knee amputation. (a) Lateral radiograph shows a soft-tissue area of increased opacity in the distal part of the stump (arrow). (b) Coronal T1-weighted MR image demonstrates low signal intensity in the soft tissues of the lower end of the stump (arrow). (c) On a coronal T2-weighted MR image, the soft tissues of the lower end of the stump demonstrate a high signal intensity similar to that of fluid (arrow). (d) Axial contrast-enhanced fat-saturated T1-weighted MR image shows a fluid collection in the lower end of the stump (arrow).

View larger version (101K): [in a new window]   Figure 11c. Bursitis of the lower end of the stump in a patient with pain and inflammation who had undergone below-knee amputation. (a) Lateral radiograph shows a soft-tissue area of increased opacity in the distal part of the stump (arrow). (b) Coronal T1-weighted MR image demonstrates low signal intensity in the soft tissues of the lower end of the stump (arrow). (c) On a coronal T2-weighted MR image, the soft tissues of the lower end of the stump demonstrate a high signal intensity similar to that of fluid (arrow). (d) Axial contrast-enhanced fat-saturated T1-weighted MR image shows a fluid collection in the lower end of the stump (arrow).

View larger version (132K): [in a new window]   Figure 11d. Bursitis of the lower end of the stump in a patient with pain and inflammation who had undergone below-knee amputation. (a) Lateral radiograph shows a soft-tissue area of increased opacity in the distal part of the stump (arrow). (b) Coronal T1-weighted MR image demonstrates low signal intensity in the soft tissues of the lower end of the stump (arrow). (c) On a coronal T2-weighted MR image, the soft tissues of the lower end of the stump demonstrate a high signal intensity similar to that of fluid (arrow). (d) Axial contrast-enhanced fat-saturated T1-weighted MR image shows a fluid collection in the lower end of the stump (arrow).

View larger version (152K): [in a new window]   Figure 12a. Painful inflammation of the infrapatellar soft tissue in a patient who had undergone below-knee amputation. (a) Sagittal fat-saturated T2-weighted MR image shows a high-signal-intensity area just below the patella in the fat pad in the area of weight-bearing on the socket (arrow). (b) Coronal fat-saturated T2-weighted MR image shows a high-signal-intensity area with no fluid collection (arrow), a finding that is consistent with soft-tissue inflammation. (c) Axial fat-saturated T2-weighted MR image shows the infrapatellar soft tissue with high signal intensity (arrow). No fluid collection is seen.

View larger version (114K): [in a new window]   Figure 12b. Painful inflammation of the infrapatellar soft tissue in a patient who had undergone below-knee amputation. (a) Sagittal fat-saturated T2-weighted MR image shows a high-signal-intensity area just below the patella in the fat pad in the area of weight-bearing on the socket (arrow). (b) Coronal fat-saturated T2-weighted MR image shows a high-signal-intensity area with no fluid collection (arrow), a finding that is consistent with soft-tissue inflammation. (c) Axial fat-saturated T2-weighted MR image shows the infrapatellar soft tissue with high signal intensity (arrow). No fluid collection is seen.

View larger version (144K): [in a new window]   Figure 12c. Painful inflammation of the infrapatellar soft tissue in a patient who had undergone below-knee amputation. (a) Sagittal fat-saturated T2-weighted MR image shows a high-signal-intensity area just below the patella in the fat pad in the area of weight-bearing on the socket (arrow). (b) Coronal fat-saturated T2-weighted MR image shows a high-signal-intensity area with no fluid collection (arrow), a finding that is consistent with soft-tissue inflammation. (c) Axial fat-saturated T2-weighted MR image shows the infrapatellar soft tissue with high signal intensity (arrow). No fluid collection is seen.

View larger version (93K): [in a new window]   Figure 13a. Soft-tissue inflammation in a patient who had undergone above-knee amputation and presented with pain at the anterior stump end. (a) Sagittal T1-weighted MR image shows low-signal-intensity infiltration of the soft tissue between the end of the femur and the socket (arrow). (b) Axial fat-saturated T2-weighted MR image demonstrates high-signal-intensity subcutaneous fat with inflammation in the area of pressure on the socket (arrow). No fluid collection is seen.

View larger version (100K): [in a new window]   Figure 13b. Soft-tissue inflammation in a patient who had undergone above-knee amputation and presented with pain at the anterior stump end. (a) Sagittal T1-weighted MR image shows low-signal-intensity infiltration of the soft tissue between the end of the femur and the socket (arrow). (b) Axial fat-saturated T2-weighted MR image demonstrates high-signal-intensity subcutaneous fat with inflammation in the area of pressure on the socket (arrow). No fluid collection is seen.

View larger version (125K): [in a new window]   Figure 14a. Bone bruise in a patient with pain on the inside of the knee who had undergone below-knee amputation. The bone bruise developed after the patient had participated in a sporting event. (a) Axial T1-weighted MR image depicts the internal tibial plate with low signal intensity (arrow). (b) On a coronal T2-weighted MR image, the proximal tibial marrow demonstrates high signal intensity (arrow). (c) Axial T2-weighted MR image shows bone marrow with high signal intensity (arrow), a finding that indicates edema associated with a bone bruise.

View larger version (140K): [in a new window]   Figure 14b. Bone bruise in a patient with pain on the inside of the knee who had undergone below-knee amputation. The bone bruise developed after the patient had participated in a sporting event. (a) Axial T1-weighted MR image depicts the internal tibial plate with low signal intensity (arrow). (b) On a coronal T2-weighted MR image, the proximal tibial marrow demonstrates high signal intensity (arrow). (c) Axial T2-weighted MR image shows bone marrow with high signal intensity (arrow), a finding that indicates edema associated with a bone bruise.

View larger version (111K): [in a new window]   Figure 14c. Bone bruise in a patient with pain on the inside of the knee who had undergone below-knee amputation. The bone bruise developed after the patient had participated in a sporting event. (a) Axial T1-weighted MR image depicts the internal tibial plate with low signal intensity (arrow). (b) On a coronal T2-weighted MR image, the proximal tibial marrow demonstrates high signal intensity (arrow). (c) Axial T2-weighted MR image shows bone marrow with high signal intensity (arrow), a finding that indicates edema associated with a bone bruise.

View larger version (125K): [in a new window]   Figure 15a. Bone bruise in a patient with pain on the posterior side of the knee and physical disability who had undergone above-knee amputation. (a) Lateral radiograph of the stump does not show any significant abnormality. (b) Sagittal T1-weighted MR image shows low-signal-intensity bone marrow in the lateral femoral condyle accompanied by edema (arrow). (c) Sagittal T2-weighted MR image shows bone marrow with high signal intensity (arrow), a finding that indicates edema associated with a bone bruise (cf Fig 14c).

View larger version (118K): [in a new window]   Figure 15b. Bone bruise in a patient with pain on the posterior side of the knee and physical disability who had undergone above-knee amputation. (a) Lateral radiograph of the stump does not show any significant abnormality. (b) Sagittal T1-weighted MR image shows low-signal-intensity bone marrow in the lateral femoral condyle accompanied by edema (arrow). (c) Sagittal T2-weighted MR image shows bone marrow with high signal intensity (arrow), a finding that indicates edema associated with a bone bruise (cf Fig 14c).

View larger version (114K): [in a new window]   Figure 15c. Bone bruise in a patient with pain on the posterior side of the knee and physical disability who had undergone above-knee amputation. (a) Lateral radiograph of the stump does not show any significant abnormality. (b) Sagittal T1-weighted MR image shows low-signal-intensity bone marrow in the lateral femoral condyle accompanied by edema (arrow). (c) Sagittal T2-weighted MR image shows bone marrow with high signal intensity (arrow), a finding that indicates edema associated with a bone bruise (cf Fig 14c).