The utility of standing knee radiographs for detection of lipohemarthrosis: comparison with supine horizontal beam radiographs

Objectives Lipohemarthrosis is a key finding in acute trauma patients and indicates an intra-articular fracture. The horizontal beam lateral radiography with supine position is known to be the best technique to demonstrate knee lipohemarthrosis. Our main purpose was to compare the sensitivity of supine and standing lateral knee radiographs to detect lipohemarthrosis. Methods In our retrospective study, consecutive patients with lipohemarthrosis on computed tomography of the knee between October 2019 and September 2021 were included. Fractured bone, the presence of lipohemarthrosis, and image quality in both standing and supine anteroposterior and lateral knee radiographs were evaluated. Interobserver reliability of the three observers was calculated. Fisher exact chi-square and z -proportion tests were used to compare lateral and anteroposterior knee radiographs. Krippendorff’s Alpha and Kappa coefficients were used for inter-observer agreement. Results A total of 61 patients (38 men [62.3%], 23 women [37.7%]; mean age, 43 years ± 17 [standard deviation]) were included. The most common type of fracture was isolated tibial fractures ( n = 32; 52.5%). The sensitivity of showing lipohemarthrosis of standing lateral knee radiographs (95.5%) was higher than supine lateral radiographs (38.5%) ( p < 0.001). While non-optimal image quality did not affect lipohemarthrosis detection on lateral radiographs ( p > 0.99), it caused a significant decrease in the diagnosis of lipohemarthrosis on anteroposterior radiographs ( p = 0.036). We found a good–excellent interobserver agreement in lipohemarthrosis detection. Conclusions Standing lateral radiographs have higher sensitivity than supine lateral radiographs in detecting lipohemarthrosis and are beneficial for detecting lipohemarthrosis which indicates the presence of occult-evident intraarticular fracture in patients with knee trauma. Clinical relevance statement Standing lateral knee radiographs offer a useful method for reducing the misdiagnosis of the occult intra-articular fractures by showing the fat-fluid leveling more clearly. Its advantages may be more prominent when the advanced imaging modalities are limited. Key Points • Fat-fluid level (lipohemarthrosis) is an important radiographic sign to assess patients with acute trauma. It almost always indicates an intra-articular fracture. • Our retrospective study results support that lipohemarthrosis sign could be observed more frequently in standing lateral knee radiographs than in supine lateral radiographs. • Knee trauma patients, when available, should be evaluated with standing lateral radiographs for the diagnosis of lipohemarthrosis.