HOW TO TAKE AND INTERPRET RADIOGRAPHS OF THE YOUNG PERFORMANCE HORSE

How to Take and Interpret Radiographs of the

Equine Stifle

David A. Wilson, DVM, MS, Diplomate ACVS

Author’s address: University of Missouri, College of Veterinary Medicine, Columbia, MO 65211;

e-mail: wilsonda@missouri.edu. © 2013 AAEP.

1. Introduction opacity that must be differentiated from a suspected

Stifle radiography in the young performance horse is septic joint. This irregularity generally resolves by
a fairly routine procedure for most equine practitio- 3 to 5 months of age.
ners. The primary reasons for taking radiographs The distal femoral physis generally closes by 24 to
of the stifle include radiographic evaluations for pur- 30 months of age. The physis between the tibial
chase, stifle joint effusion, lameness associated with tuberosity and the tibial epiphysis tends to close by
the stifle, evaluation after a traumatic event associ- 9 to 12 months, and the physis between the tibial
ated with the stifle, and comparison of the perceived tuberosity and the tibial metaphysis closes at 30 to
normal stifle to the affected stifle. Acquisition of 36 months. The proximal tibial physis, between
stifle radiographs is not always intuitive for the the proximal tibial epiphysis and the tibial metaph-
beginner. A thorough knowledge of the 3D anat- ysis, closes at 24 to 30 months of age.
omy of the stifle as well as the anticipated patholo-
gies of the stifle are necessary to properly position 3. Stifle Joint Pathology
the x-ray generator and detector plate. Proper po-
sitioning results in acquisition of radiographs with Osteochondrosis is reportedly the most common ab-
sufficient quality to allow the veterinarian to make normality in the young performance horse stifle,
an informed diagnosis.1– 4 affecting the trochlear ridges of the femur, the fem-
oral condyles and the patella, and less frequently,
2. Immature Horse the proximal tibia. Osteochondritis dissecans
From birth until ⬃36 months of age, the stifle ma- (OCD) of the trochlear ridges involves primarily the
tures from a structure with six ossification centers: lateral trochlear ridge with the medial trochlear
metaphysis and distal epiphysis of the femur, prox- ridge less commonly affected. The articular surface
imal epiphysis and metaphysis of the tibia, tibial of the patella also is a common site for OCD. Sub-
tuberosity (apophysis), and patella. The lateral chondral bone cysts are primarily observed in the
and medial trochlear ridges of the femur are initially medial femoral condyle, with much less frequency in
fairly equal in size and the proximal portions of the patella and even less frequently in the lateral
these ridges often have an irregular contour and femoral condyle.

NOTES

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Fig. 1. (A) Positioning for lateromedial view. (B) Apparently normal lateromedial radiographic view of a mature Thoroughbred
gelding highlighting the medial trochlear ridge (MTR), the lateral trochlear ridge (LTR), and the intertrochlear groove (ITG).

Other abnormalities include osteoarthritis, tu-

moral calcinosis (calcinosis circumscripta), collat-
eral and patellar ligament desmititis, meniscal
injuries, injuries to bone and soft tissues from acute

Fig. 3. Lateromedial radiographic map of ligament and tendon

attachments to the stifle. Structures attaching within the inter-
condylar area of the tibia and the femur are indicated with dotted
lines. From Maulet et al.4 LP indicates lateral patellar liga-
Fig. 2. Line drawing of lateromedial radiographic view identi- ment; IP, middle patellar ligament; MP, medial patellar liga-
fying anatomical structures of importance. (1) Base of patella; ment; LFP, lateral femoropatellar ligament; MFP, medial
(2) periarticular and subchondral areas of the patella*; (3) apex; femoropatellar ligament; LC, lateral collateral ligament; MC, me-
(4) medial ridge of femoral trochlea*; (5) lateral ridge of femoral dial collateral ligament; CraLatM, cranial ligament of the lateral
trochlea*; (6) area of extensor fossa*; (7) distal femoral physeal meniscus; CraMedM, cranial ligament of the medial meniscus;
scar; (8) femoral condyles*; (9) tibial spine (medial intercondylar MF, meniscofemoral ligament of the lateral meniscus; CrCr, cra-
eminence); (10) tibial condyle; (11) area of attachment for the nial cruciate ligament; CauCr, caudal cruciate ligament; Po, ori-
cranial ligaments of the menisci; (12) fibula; (13) tibial tuberosity; gin popliteus muscle; PT, origin of peroneus tertius; LDET, origin
(14) tibial crest*; (15) areas of attachment for the tendon of of long digital extensor; FP, femoropatellar joint capsule; LatFP,
semitendinosus muscle. *Common sites of pathology noted on lateral femorotibial joint capsule; MedFT, medial femorotibial
lateromedial view. Adapted from O’Brien.3 joint capsule.

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Fig. 4. A and B, Typical poor positioning for lateromedial view. Beam is directed at a proximal to distal angle instead of horizontal.

Fig. 5. (A) Positioning for caudocranial view. (B) Apparently normal caudal-cranial radiographic view of a mature Thoroughbred
gelding.

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Fig 6. Line drawing of caudocranial radiographic view identify-

ing anatomical structures of importance. (1) Medial femoral con-
dyle; (2) lateral femoral condyle; (3) medial tibial condyle; (4)
lateral tibial condyle; (5) intercondylar fossa of the femur; (6)
areas of attachment of the cranial cruciate ligament; (7) area of
Fig. 7. Caudocranial radiographic map of ligament and tendon
attachment of the caudal cruciate ligament; (8) areas of attach-
attachments to the stifle. Structures associated with the caudal
ment for the cranial ligaments of the menisci; (9) tibial tuberosity;
half of the femur or tibia are indicated with dotted lines. From
(10) fibula; (11) tibial crest; (12) attachment site for the semiten-
Maulet et al.4 LP indicates lateral patellar ligament; IP, middle
dinosus tendon; (13) patella; (14) lateral ridge of the trochlea of
patellar ligament; MP, medial patellar ligament; LFP, lateral
the femur; (15) intercondylar eminences: medial (spine) and
femoropatellar ligament; MFP, medial femoropatellar ligament;
lateral. Adapted from O’Brien.3
LC, lateral collateral ligament; MC, medial collateral ligament;
CraLatM, cranial ligament of the lateral meniscus muscle; Cra-
MedM, cranial ligament of the medial meniscus; MF, menis-
cofemoral ligament of the lateral meniscus; CrCr, cranial cruciate
traumatic events, and other miscellaneous sclerosis
ligament; CauCr, caudial cruciate ligament; Po, origin popliteus
and lucencies of the trochlear ridges and proximal muscle; PT origin of peroneus tertius; LDET, origin of long digital
tibia). extensor; FP, femoropatellar joint capsule; LatFP, lateral femo-
rotibial joint capsule; MedFT, medial femorotibial joint capsule.
4. Radiographic Views
There are three standard radiographic views that
are commonly acquired for most stifle evaluations,
including the lateromedial, caudal to cranial (10 –
hind limb anatomy of most horses. As a rule of
20° proximodistal), and 30o caudolateral-craniome-
thumb, align the beam parallel to the heel bulbs of
dial oblique. Optional views that are not acquired
the limb to be imaged.
routinely, but are necessary views to highlight spe-
The lateromedial view highlights the medial and
cific anatomic structures, include the patellar sky-
lateral ridges of the femoral trochlea, the intertroch-
line, flexed lateromedial, and 30° to 45°
lear groove, the periarticular and subchondral areas
caudomedial-craniolateral oblique views. In addi-
of the patella, the tibial crest, the tibial plateau and
tion, special oblique projections can be very useful
areas of attachment of the cranial cruciate ligament
for specific joint abnormalities when the standard
and the cranial ligaments of the menisci, the exten-
radiographic views do not sufficiently demonstrate
sor fossa, and the femoral condyles.
the abnormality.
Caudal to Cranial View (10 –20° Proximodistal)
Lateromedial View
The horse should be positioned with both hind limbs
The horse should be positioned with both hind limbs fully weight-bearing. The center of the beam
fully weight-bearing with the limb to be imaged should be directed at the soft tissue indentation at
slightly caudal to the contralateral limb (Figs. 1– 4). midline and the angle of the beam directed 10 –20°
The x-ray beam should be directed horizontally, cen- proximodistally (Figs. 5– 8).
tered on the femorotibial joint, caudal and distal to
the apex of the patella. The beam will most com- 30° Caudolateral-Craniomedial Oblique
monly be directed ⬃10° to 20° caudal to cranial to The horse should be positioned with both hind limbs
the frontal plane to accommodate for the typical fully weight-bearing. The center of the beam
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 HOW TO TAKE AND INTERPRET RADIOGRAPHS OF THE YOUNG PERFORMANCE HORSE

Fig. 8. A and B, Typical poor positioning for caudocranial view.

Beam is directed horizontal rather than proximal to distal result-
ing in failure to achieve separation to evaluate femorotibial joint
spaces. Fig. 10. Line drawing of a 30° caudolateral-craniomedial oblique
view. The view is taken primarily to evaluate (1) site of typical
subchondral cyst in medial femoral condyle; (2) typical area for
OCD of the lateral trochlear ridge of the femur; (3) medial ridge
should be directed on the femorotibial joint, ⬃10 of the femoral trochlea; (4) area of the extensor fossa; (5) tibial
cm caudal to the cranial aspect of the limb. The tuberosity; (6) medial femoral condyle; (7) lateral femoral condyle;
x-ray beam should be directed horizontal to the (8) spine of the tibia; (9) medial condyle of the tibia; (10) attach-
ground or slightly proximal to distal 10°–15° ment site for the biceps femoris and lateral patellar ligament.
Adapted from O’Brien.3
(Figs. 9 –13).
Patellar Skyline (Cranioproximal-Craniodistal Oblique View)
The patellar skyline view is taken with the stifle and to better assess a known patellar fracture or
flexed and the tarsus either flexed or extended. suspected osteochondrosis of the patella or lateral
The cassette is held approximately horizontal with trochlear ridge of the femur (Figs. 14 and 15).
its caudal edge against the cranial aspect of the
tibia, centered just proximal to the tibial crest. Flexed Lateromedial View
Depending on the horse, the beam angle may range Positioning is similar to the lateromedial view.
from a proximal 10° lateral-distal medial oblique The degree of flexion of the stifle can vary from just
direction to a 30°– 40° proximocranial-distocaudal slightly flexed with the horse resting the toe on the
direction. Adducting the flexed limb may facilitate ground to moderate flexion. The beam is directed
positioning by rotating the stifle outwards. horizontal, centered on the patella (Figs. 16 and 17).
The indications for the patellar skyline view in- The indications for the flexed lateromedial view in-
clude assessment of a suspected patellar fracture, clude a better assessment of the apex of the patella, to

Fig. 9. (A) Positioning for 30° caudolateral-craniomedial oblique view. (B) Apparently normal 30° caudolateral-craniomedial oblique
radiographic view of a mature Thoroughbred gelding.

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Fig. 11. (A) Lateromedial view and (B) 30° caudolateral-craniomedial oblique view of mild osteochondral defect (arrow) in the lateral
trochlear ridge in an 18-year-old Warmblood gelding.

Fig. 12. (A) Lateromedial view and (B) 30° caudolateral-craniomedial oblique view of a large osteochondral fragment of the lateral
trochlear ridge of the femur in a 15-month-old Standardbred filly.

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Fig. 13. (A) Caudo-cranial and (B) 30° caudolateral-craniomedial oblique view of small subchondral bone cyst of the medial femoral
condyle with secondary mild osteophyte on medial tibial condyle in a mature Quarter Horse gelding.

Fig. 14. (A) Positioning for patellar skyline view. (B) Apparently normal patellar skyline radiographic view of a mature Thorough-
bred gelding.

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Fig. 15. Patellar skyline (cranioproximal-craniodistal oblique view). Shaded areas are common sites of subchondral lucency with/
without sclerosis. Adapted from O’Brien.3

separate and better assess the articular surfaces of the ment sites of the cranial ligaments of the menisci and
patella and the proximal aspects of the trochlear cranial cruciate ligament in the region of the cranial
ridges of the femur, and to better as-sess the attach- aspect of the intercondylar eminences.

Fig. 16. (A) Positioning for flexed lateromedial view. (B) Apparently normal flexed lateromedial radiographic view of a mature
Thoroughbred gelding.

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Fig. 17. (A) Lateromedial and (B) flexed lateromedial view of calcification (arrow) of the cranial attachment of the medial meniscus
in a 3-year-old Standardbred filly.

References 3. O’Brien TR. Radiographic interpretation of the stifle and

proximal tibia. In: O’Brien’s Radiology for the Ambulatory
1. Morgan JP, Neves J, Baker, T. Equine Radiography. Ames, Equine Practitioner. Jackson, Wyoming: Teton NewMedia;
Iowa: Iowa State University Press; 1991:253–269. 2005:227–247.
2. Butler JA, Colles CM, Dyson SJ, et al. Clinical Radiology of 4. Maulet BEB, Mayhew IG, Jones E, et al. Radiographic anat-
the Horse. 2nd edition. Oxford, United Kingdom: Blackwell omy of the soft tissue attachments of the equine sti-
Science Ltd; 2000:285–326. fle. Equine Vet J 2005;37:530 –35.

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