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Musculoskeletal Lesions With Fluid-Fluid Level: A Pictorial Essay

Keenan, Sean MD*; Bui-Mansfield, Liem T. MD*†‡

Journal of Computer Assisted Tomography: May-June 2006 - Volume 30 - Issue 3 - p 517-524
Musculoskeletal Imaging: Pictorial Essay

Abstract: A fluid-fluid level was identified in 11.2% of focal lesions of bone.1 Fluid-fluid levels are observed on cross-sectional imaging with either computed tomography (CT) or magnetic resonance (MR) imaging. They become apparent when a fluid collection containing substances of different density is allowed to settle, and when the plane of imaging is perpendicular to the fluid level. For instance, within a collection of blood, the cellular components will settle dependently, with the lower density plasma forming a layer superiorly. The difference in the density of these layers can be observed on CT imaging. With MR imaging, these layers will have different signal characteristics, allowing for visualization of the fluid-fluid level.

The presence of fluid-fluid levels within a musculoskeletal lesion is an important finding, which can significantly aid in the differential diagnosis. This finding can be observed in a wide variety of lesions: osseous and soft tissue masses, neoplastic or nonneoplastic lesions, malignant or benign neoplasms, and primary or metastatic malignancies.2 When a fluid-fluid level is detected, in conjunction with clinical history, the differential diagnosis for a lesion can often be limited to a few choices. For this reason, it is important to be aware of the multiple lesions that can produce fluid-fluid levels, as well as their differentiating characteristics and typical presentations. We will review both osseous and soft tissue lesions, focusing on their imaging characteristics and other important findings.

From the *Department of Radiology, MCHE-DR, Brooke Army Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston, TX 78234; †Department of Radiology, Division of Radiologic Sciences, Wake Forest University School of Medicine, Medical Center Blvd., Winston-Salem, NC 27157-1088; ‡Department of Radiology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814-4799.

Received for publication December 2, 2005: accepted February 9, 2006.

Presented at the 104th annual meeting of the American Roentgen Ray Society, May 2-7, 2004, Miami Beach, FL and 90th Scientific Assembly and Annual Meeting of the Radiological Society of North America, November 27-December 5, 2004 in Chicago, Illinois as an educational exhibit.

The opinions and assertions contained herein are those of the authors and should not be construed as official or as representing the opinions of the Department of the Air Force or the Department of Defense.

Reprints: Liem T. Bui-Mansfield (e-mail:

© 2006 Lippincott Williams & Wilkins, Inc.