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Introduction

According to (Thawait et al.2012) Lipohaemarthrosis is a joint effusion comprised of synovial fluid with fat and blood. As fat is less dense than synovial fluid the fat floats on the top, which in X-ray images, is detected as fluid-fluid level. pursuant to (Tahara et al.2011) the first visualisation of lipohaemarthrosis was made a number of decades ago by horizontal beam technology. The condition arises from trauma, such as an intra-articular fracture that extends from the surface to the bone marrow, allowing fat and blood from the marrow to seep into the joint space, because of the differences in X-ray attenuation of blood components, fat and synovial fluid, cross-sectional imaging techniques. When blood enters synovial fluid, it separates with serum floating over haemoglobin- and iron rich- erythrocytes. With the serum’s density being comparable to that of water, it forms the first fluid-fluid level. In lipohaemarthrosis, being less dense than serum fat floats at the top of the effusion, creating another fluid-fluid level (Thawait et al.2012). Thus, lipohaemarthrosis is characterised by two fluid-fluid levels; the top-most fluid layer lies between the fat and serum layers, whilst the second fluid-fluid layer occurs between the serum layer and that of the concentration of erythrocytes (Thawait et al.2012). The following is an overview of a typical case of lipohaemarthosis of the knee, including a background overview of the issue and typical radiologic features.

Background

As noted above, the characteristic of lipohaemarthosis is the transfer of fat and blood into the joint from the marrow space as the result of a fracture (Griffith, 2015). Munstonen (2009) suggests that 1.6% of all knee injuries may show this feature. Around 40% of intra-articular fractures show lipohaemarthosis, and almost all intra-articular fractures of the tibial plateau show this feature (Blin et al., 2007). In lipohaemarthosis of the knee, the two most common fractures are tibial plateau fractures or distal femoral fracture. In the case of tibial plateau fracture, the most common mechanism of injury is axial loading, such as through a fall (Ha et al., 2014). Both types of fractures can also occur with impact from automobile bumpers: around 25% of tibial plateau fractures have this mechanism of injury (Ha et al., 2014). Other significant causes are laterally directed or through twisting-style injuries (Hegenscheid et al., 2012). The type of fracture presentation is largely dependent on age, with older patients showing depression fractures and younger patients showing splitting: both of these can lead to lipohaemarthosis of the knee joint (Kim et al., 2007).

The clinical presentation of lipohaemarthosis is usually seen through radiologic imaging, although swelling of the knee joint indicates the presence of a serious injury (Kim et al., 2007). Joint effusion can be seen on a standard x-ray, but diagnostically CT scans are more useful (Rajeswaran et al., 2011). On a CT scan, three layers will appear that are indicative of lipohaemarthosis. These are: fat, which settles at the top of the collection of fluid due to its lighter weight; serous joint effusion as the middle layer; and the inferior layer is composed of the cellular components of blood (Rajeswaran et al., 2011). Not only are these results indicative of lipohaemarthosis, they can also be used to confirm intra-articular fracture of the tibial plateau (Mustonen, 2009). It may take up to three hours following the injury for lipohaemarthosis to appear in the joint, and gravity and rest are needed to make a radiologic diagnosis. Figure one shows the typical radiologic presentation of lipohaemarthosis. Figure two shows a subtle case.

Mechanisms of injury

This condition may result from a two part mechanism which is of significant energy. One is a case where there is an axial load applied with a concurrent varus or valgus force applied at the knee. Lateral plateau fractures are most common with fractures on medial plateau being 10-23% and bicondylar fractures representing 10-30%. Attention must also be paid to the joint distraction force on the opposite condyle which might show as soft tissue injury. High energy injuries are common to young patients while the elderly show tibial plateau fractures due to mechanisms of lesser force due to osteoporotic degeneration. (Rytter et al, 2009, pp. 19)

Clinical presentations

In an erect lateral knee that is represented in the fig.1, there is a demonstration of the lipohaemarthrosis condition. The view is useful especially for the subtle lipohaemarthrosis because in this case, there is no superimposed quadriceps tendon. Here, there is a limitation to its use and that is the likelihood of the patient with the fracture on the knee not being able to mobilize. There is a common presentation of the condition that is now termed as the snow globe effect. A snow globe is a toy that a person, either an adult or a child, shakes in order to produce an effect like that of the falling snow. This phenomena can also be observed during the presentation of the condition. In some patients, the initial plain film image of the lipohaemarthrosis of the knee may demonstrate a very indistinct fat-blood interface (Hall, 1990, pp. 54).

It was found out that this presentation could be due to the mixing of the blood and the fat that is usually associated with the movements that the patient makes when moving onto the X-ray table or that of the stretcher during the transportation of the patient to the scan department. This movement can be associated with the shaking of the snow globe which mixes the fluid inside the glob to produce the snowing effect, almost the same effect with the indistinct fat-blood interface that is seen during the initial observation (Hall, 1990, pp. 54). The snow glob effect is a theory that holds weight when the imaging is repeated when the patient has been stationery for a while (Hall, 1990, pp. 54). The same patient will show a fat and blood interface that is very sharply defined when the test is done several minutes later. These representations are shown on figure 2 and figure three consecutively after the discussion (Hall, 1990, pp. 54).

Radiographic features

It is common knowledge that fat floats on water because of the density. In this case, the marrow is fatty and hence it separates from water that is based in the blood. In the plain radiograph, the fat fluid level can be seen on any horizontal beam radiograph because the beam is tangential to the blood fat interface. When it comes to the knee, the view is best achieved with the cross-table horizontal lateral view. Here, a long horizontal line can be seen in the cavity or the suprapatellar pouch an effect achieved when the patient has been lying in the position for more than five minutes to allow adequate separation of the blood and the fat.

The fat should not be confused with suprapatellar fat pad that lies anterior to the pouch and posterior to the quadriceps tendon. A distinction between these two can be done by the massaging of the suprapatellar pouch that will cause the fat-fluid level to disappear due to the mixing.

Effects, treatment and complications

In this condition, the patient will be seen to experience a lot of pain from the knee region. There is also the swelling of the knee because of the accumulation of the fluid. The management of the conditions is through surgery by an orthopedic surgeon(Campbell, 2012, pp. 6). These procedure will depend on many factors such as the fracture pattern, joint displacement, extend of soft tissue injury and also the comorbidities and the functional demands of that patient. The indication for the operative management are not absolute but has been suggested for fractures with articular step of 3mm or more, a valgus tilt of over 50 or condylar widening of over 5mm(Campbell, 2012, pp. 6). Complications that may arise include the proximity of veins to both the bony and the soft tissues are disrupted. The most common long term complication is secondary osteoarthritis from the damage of chondral at the time of injury, residual articular discontinuity or the disruption of the mechanical axis post-operatively. (Campbell, 2012, pp. 6).

Case Report

A male 35-year-old male suffering with pain and swelling in his left knee came to the emergency department. He did not have any previous medical history, but he had fallen from a height of three metres the day before. . Upon physical examination, his vital signs were found to be normal, as were the neurological and vascular systems in his left leg, but there was swelling with effusion in the bursa above the knee (Aponte, Novik,2013). There was tenderness when palpating medial and lateral joint lines, as well as at the proximal tibia. Motion of the knee was painful and was limited to zero to forty-five degrees. There was mild laxity with valgus stress compared to the right leg. Anterior-posterior, lateral, and oblique radiographs of the knee were requested (Aponte, Novik,2013). was checked the request card (ID, PPE) and the patient's history on the hospital information system (HIS) system to check for any previous history and corresponding images, radial image was taken (Figure 2). This revealed an intra-articular fracture of the tibia plateau coupled with a fractured fibula head. more than two pieces, which were impacted. The fracture was classified as grade 5 (Figure 3). The knee was wrapped in a compressive bandage and immobilised. The patient was told not to bear weight on the leg and was given an orthopaedic follow-up appointment. Later in the week, the patient underwent surgery to repair the fracture (Aponte, Novik,2013).

Conclusion

Lipohaemarthrosis is caused by just a fracture to the knee but can cause a lot of pain to the patient. The condition can be differently diagnosed as hematocrit effect which is a separation of serum from red cells or suprapatellar fat pad which does not change when the joint fluid is agitated. The associated fracture should be studied so as to investigate more about the fat fluid level found at the knee. Besides, extracapsular free fat in the body may also be assessed in rare forms. The acute trauma of bones found at the knee can be evaluated with the aid of knowledge of the imaging patterns that belong to the floating fat. The most important fact is that the condition is treatable especially if medical assistance is found immediately.

References

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