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Imaging of Ankle joint and foot (II) (DRE) Prof. Mamdouh Mahfouz — Transcript

by Prof. Mamdouh Mahfouz - Radiology in English (DRE) · 6,961 words · 1,044 segments · language en · Watch on YouTube

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0:22now we'll discuss the uh second part of
0:26the topic uh dealing with imaging of the
0:32ankle and foot by MRI and we have
0:38finished with the ankle joint and we'll
0:41start now the evaluation of the
0:45foot we'll have uh some words about the
0:49vascular necrosis in the ankle and fot
0:52ankle impingement syndromes fractures of
0:56the ankle and foot and miscellaneous
0:58issues
1:00including Morton neuroma blanter fitis
1:04th to pigmented vular sinovitis diabetic
1:08food sharot neuropathy gout arthropathy
1:12and finally uh some words about
1:17osteoarthritis starting by the vascular
1:20necrosis which is um disease affects a
1:24lot of the bones in the ankle and foot
1:27particularly the tails and this is known
1:31as colar disease affection of the uh
1:35sorry the affection of the navicular is
1:38known as colar disease affection of the
1:41calanus is severe disease and affection
1:44of the head of the second metal bone is
1:47known as fryberg disease the causes of a
1:51vascular necrosis is idiopathic or
1:54secondary to trauma or secondary to the
1:56use of
1:58corticosteroids or secondary to Bone
2:01Maru infiltrative
2:04lesions the tailor of vascular necrosis
2:07is graded into four grades grade one is
2:12just diffuse B Mar edema of the tailor
2:16bone grade two is Cystic changes in the
2:19area of the Dead uh bone grade three is
2:24separation of the dead bone without
2:26displacement and grade four is
2:29displacement of the separated
2:32bone of course the stage of bone Maru
2:34edema is seen by MRI more better than
2:38any Imaging technique where you can see
2:41that the TS is of low signal in the T1
2:44and high signal and the t2 weighted
2:47image if you uh have a bonus scan it
2:52will show positive uh positive findings
2:55and this stage can be mistaken for a lot
2:58of diseases like the just bone Maro
3:02edema
3:03of transient osteoporosis or bone Maro
3:07edema secondary to trauma or contusion
3:12then this stage is is not bonic of a
3:17vascular neosis unless it is followed by
3:21the second stage or the stage to where
3:24you can see that the the dead bone is
3:28transformed into to cystic area with low
3:32signal in the T1 and high signal in the
3:35t2 damage and this is also an example of
3:39stage two a vascular necrosis of the
3:41taus and you see there is a low signal
3:45in the T1 and high signal in the stair
3:48with no uh separation of the bone when
3:52the dead bone is separated then you are
3:54dealing with stage three and this is an
3:58example by Mr I and this is also an
4:01example by uh CT coronal reformated
4:05damage when the uh separated bone has
4:09been displaced from its side then you
4:12got a defect in in the bone which is
4:16appreciated by MRI and also by CT and
4:19then you you are diagnosing stage four a
4:23vascular necrosis of the
4:26Tails and coer disease is a vascular NE
4:29proess of the navicular bone this is a
4:32self-limiting
4:33disorder and it affects the uh children
4:39or boys between the age of 3 to 10 years
4:43and is commonly unilateral but bilateral
4:47disease can be seen in about 25% of the
4:51of the
4:52cases uh as in any of the vascular
4:56necrosis of uh anywhere in the body and
5:00you got some sclerosis of the dead bone
5:02flattening
5:04fragmentation and maybe secondary
5:07ostearthritis of the related
5:10joints then U you know that the blood
5:14supply of the navicular bone is Rich
5:17from the periphery but is Bor in the
5:20central part so the navicular is PR to
5:25uh develop this type of a vascular
5:28necrosis which as I have mentioned is
5:31self-limiting and it it resolves by
5:35itself considering the
5:37uh the conservative measures on MRI and
5:42you got flattening of the bone and
5:45before flattening you got born
5:47Maroa as similar to the stage
5:51one vascular croses of the Tails which
5:54is of low signal in the T1 and high
5:57signal in the t2 then
6:01uh uh in order to differentiate the
6:04avascular necrosis from uh let's say
6:09infection of the uh tarsal bones in
6:12cases of infection and you got erosion
6:14of the CeX you got soft tissue Abes and
6:17you got uh overlying
6:20cellulitis but in a vascular necrosis
6:23and you got just bonaro edema of the uh
6:28navicular with is of course partial or
6:32complete collapse of the of the
6:35bone then the fryberg disease which is
6:39an osteonecrosis of the metatarsal head
6:42commonly affects the second metatarsal
6:44bone and is bilateral in about 10% of
6:48the cases seen more commonly in in girls
6:53in between the age of 10 and 18 years
6:57and the high heel is one of the uh
7:01direct causes of this particular uh
7:04disease the complaint is uh pain on
7:08weight bearing with swelling and
7:11tenderness localized to aect to the
7:13affected metatarsal bone which is
7:16commonly the second one then byan xray
7:20and he got some flattening and cystic
7:22changes in the head of the second
7:25metatarsal bone first you got widening
7:29of the metatarso Fingal joint and later
7:32on you got fragmentation Bon sclerosis
7:35and maybe
7:38osteoarthritic uh it's worth to know
7:40that some metal head flattening can be
7:44seen in about 10% of asymptomatic
7:48pulation before the stage of fishering
7:53and the fragmentation bone marrow is
7:56bone marrow edema can be displayed by
7:59MRI and here you can see in the second
8:03metors head localized area of bone Mara
8:07later on there Will there will be
8:10collapse fragmentation and Bone
8:13sclerosis this is the classification
8:15provided in the literature for the
8:18fryberg disease considering stage one as
8:23Metal Head flattening with a decreased
8:27the subcortical bone density stage two
8:30metatarsal head sclerosis
8:32fragmentation and cortical thickening
8:35stage three is development of Osteo
8:38arthritic changes of this metatarso
8:42fenial joint then before as I have
8:45mentioned the changes has appeared in
8:48have appeared in the uh Blaine x-ray you
8:51can see the changes by MRI in the form
8:55of Bone mareda which is not a specific
8:59for this particular disease B Mara can
9:02be secondary to trauma can be secondary
9:04to oul or stress fractures and can be
9:07secondary to infection but um in order
9:11to diagnose Friberg disease there should
9:14be some flattening and IR regularity of
9:17the metatarsal land and here you see
9:20classic appearance of briber disease
9:23with uh cortical depression Bon
9:26sclerosis of the uh second metors
9:32B then uh severe disease is a affection
9:37of the uh calcan apices and um many of
9:43the legions are not seen by the Blain
9:46x-ray they are better appreciated by MRI
9:50this occurs in the children and young
9:52adolescents
9:53especially who are um uh performing
9:58jumping and run running uh Sports and um
10:03uh severe disease is usually
10:05diagnosed uh clinically the radiographs
10:09may show normal findings sometimes they
10:12may show the changes of a vascular
10:14neosis like bone sclerosis fragmentation
10:17and collapse then here you see relative
10:21Bon sclerosis of the calcan hesis with
10:25some fragmentation and according to the
10:28lit
10:29this corresponds to O disease of the
10:33tial toity and the little leg elbow of
10:36the
10:38medialine by MRI you can see Bor Maru
10:41edema which will appear as a low signal
10:45in the T1 and high signal in the stair
10:49images also you may appreciate bone Maro
10:52Eda in the adjacent part of the
10:56calanus then we came to the ankling
10:59impingement syndromes and we have
11:01posterior impingement anterior
11:03impingement and the this rare one which
11:06is the ccino fibular
11:09impingement the posterior impingement is
11:13uh thought to be the cause of repetitive
11:16ankle
11:17blunter uh flexion and is classically
11:21described in ballet
11:23dancers then there are many causes for
11:26impingement and a posterior inment of
11:29the ankle one of these causes and is a
11:33common one is
11:34oston which is separated bone behind the
11:38calanus or elongation of the styal
11:41process the lateral process of the Tas
11:44is long uh than enough or is appreciably
11:50long and this will interfere interfere
11:53with the uh mechanics of the posterior
11:56aspect of the ankle uh third cause is
12:00elongation of the posterior tibial
12:02process as you can see here or fractures
12:06of the lateral process of the Tais or
12:08inflammation posterior to the talanian
12:12joint or this bony SP spare in the
12:16superior aspect of the calcinus there
12:18are six causes the first two are the
12:21most commonly seen in the clinical
12:25practice then associated with impingment
12:29there may be retr calcan capsular
12:31thickening and
12:33sinovitis you got some inflammation
12:35around this elongated the ster process
12:39of the of the taus and you got some
12:42fluid around and also you may see Bor
12:45Maro edema of the process
12:49itself sometimes you got ositis of the
12:52flex
12:53oralis longest tendon
12:56and you may got soft tissue edema
13:00posterior to the Tails and this is a
13:04good example of posterior ankle
13:07impingement where there is elongation of
13:09the lateral process of the tails with
13:12the surrounding soft tissue edema there
13:15is no fractures there is no OST trionum
13:18and there is no bone Maro edema of the
13:22Tor process and this is also elongation
13:26of the uh uh of the lateral process of
13:30the taus known as the ca process with
13:34the surrounding soft tissue edema of the
13:37uh related uh soft tissues and also you
13:43may see in the aial image that the
13:47flexor longest tendon is surrounded by
13:50fluid denoting the presence of
13:54tenosinovitis the aill tendon is intact
13:57as you can see here then an anterior
14:01ankle ement is also caused by repetitive
14:05trauma with ement of the anterior tibia
14:09against the tus and those who have uh
14:13some um dorsy flection of the
14:18ankle then painful and limited dorsy
14:22flection of the anterior joint line of
14:25the ankle
14:26with anterior an
14:29swelling and you may got some Bon Mar
14:32edema and sinovial thickening of the
14:35related soft tissues along the anterior
14:39aspect of the joint then here and you
14:42see this small process uh projecting
14:46anteriorly from the inferior aspect of
14:48the tibia and another protrusion here
14:53together with uh thickening of the
14:55capsule of the joint and some soft
14:58tissue edema related to the to the
15:01legion also you can see that the
15:05anterior tular ligament is considerably
15:07taken maintaining its normal signal
15:10denoting chronic strain or chronic
15:14injury and here an anterior ankle ement
15:18is usually diagnosed by the presence of
15:21a small bony process in the anro
15:23inferior aspect of the tibia and also a
15:26bony process in the superior aspect of
15:28the taus
15:29together with the soft tissue edema of
15:32and cap capsular thickening of the area
15:36in
15:36between and this is a case of severe
15:39osteoarthritis of the uh ankle joint
15:43that has resulted in very prominent uh
15:47and osteophytic liing this will also
15:50lead to anterior ankle impingement but
15:53this is and the ankle ement here is
15:56secondary so this Osteo arth IC
15:59changes now we came to the calcino
16:02fibular impingement and normally you can
16:04see that the tus is interposed between
16:08the fibula and the calanus and in normal
16:13conditions there is no direct contact
16:17between the fibula and the calanus but
16:23if there is
16:26osteoarthritic uh changes here here uh
16:29in the talanian joint there will be some
16:34vulgus deformity of the calanus then the
16:38taus will go medial and the calcinus
16:41will go lateral then there should there
16:44will be a direct contact between the
16:47fibula and the TS resulting in this
16:51caleno fibular uh
16:54impingement and this is the
16:56demonstration and you can see that there
16:59is marked narrowing of the T calcan
17:04joint with uh vulgus deformity of the
17:09calanus and displacement of the tus
17:12medially now the fibula is facing the
17:15calanus and this will result in severe
17:19stress injury here where as you can see
17:22narrowing of the joint spaces B Maro
17:24edema and osteoarthritic changes
17:28normally if you draw a line from the
17:31axis of the tibia and a line along the
17:34medial border of the ganus it will form
17:37an angle less than
17:396° but in cases of osteoarthritic
17:43changes of the talanian joint with
17:46narrowing of the joint space there will
17:49be vulgus deformity and the angle will
17:52be so much increased and this will allow
17:56direct contact between the TS between
18:00the ganus and the fibula resulting in
18:03this Gano fibular impingement and the
18:06osteoarthritic changes of the Talan
18:09joint are evident here in the T1 and the
18:13stair with subarticular pseudocystic
18:15changes and degenerative bone Mara in
18:19the coronal image you can appreciate
18:22that the Tas has displayed medially and
18:25now the fibula is facing the calcinus
18:28with severe degenerative changes
18:30subarticular pseudocystic changes in the
18:34uh joint interfering between both and
18:38this is another example of uh displaced
18:41the fracture with a high food vulgus
18:43deformity and twoyear history of diffuse
18:46ankle pain and uh if you look here the
18:50same situation there is vus deformity of
18:53the calanus facing the fibula with tr
18:58compartmental osteoarthritic changes
19:00between the fibula and the Tais as well
19:03as
19:05theales and this is 2D uh surgal and
19:10coronal reformatted CT images after
19:15ankle joint arthrography showing the
19:18classic appearances of Elin fibular
19:22ement you see severe osteoarthritic
19:25changes of the subtor joint with most
19:28total obliteration of the joint space
19:31prominent osteophytic living of the
19:33articular surfaces then you can see that
19:36there is direct almost direct contact
19:39between the calanus and the fibula with
19:42this articulation developing secondary
19:46osteoarthritic changes now we came to
19:49the fractures around the ankle and the
19:51foot the ankle fractures are classified
19:54by weaper into three types A B and C and
19:58the fracture uh the fracture type is
20:04detected according to its position in
20:08relation to the syndesmotic complex you
20:11remember that we have two uh ligaments
20:15on the lateral aspect of the ankle the
20:19uh hopular ligaments and the syndesmotic
20:23complex the syndesmotic complex can be
20:27appreciated in the Blain
20:29x-ray at the uh point where the fibula
20:34is almost in contact with the tiia this
20:38is the site of the cnis mosis if the
20:40fracture is below the cnis mosis this is
20:43type A if it is at the level of the cnis
20:46mosis this is type B if it is above the
20:50synes mosis this is Type C and this film
20:55will show the three types of fractures
20:59and also the mechanism of inury in each
21:03type of these
21:08[Music]
21:14[Music]
21:27fractures
21:32[Music]
21:41[Music]
21:55[Music]
22:05okay then uh these are once more the the
22:09three types of fractures and the type A
22:13is below the syis mosis and this is the
22:16side of the cnis Moses and then if you
22:18can see from the video that frequently
22:21the medial malus is fractured as well
22:24during the three types of throne but
22:28uh you have to to decide or to see the
22:31fracture type and this is the site of
22:34the synes mosis the fracture is below
22:36and this is type A look carefully for
22:40the uh medial malus if it is fractured
22:43or not and also look behind the ankle
22:47for fracture of the posterior aspect of
22:50the tiia if this is fractured and this
22:55one and this one the fracture is known
22:57as Tri mular fracture type B will
23:01involve the fibula at the level of the
23:04cnis mosis and the syndesmotic complex
23:08will be ruptured in uh more than 50% of
23:12the cases and it may be also associated
23:15with uh rupture of the deltoid ligament
23:18and medial uh mular uh fracture this is
23:23an example and you see the fracture it
23:25at the level of the CIS mosis with the
23:28fracture of the medial malus as well and
23:31this is type B and here is a type B
23:34fracture you can see the fracture at the
23:36level of cmosis the nearest point
23:39between the fibula and the tibia and the
23:42medial malus is intact and this is an
23:45accessory Ole at the medial malus type
23:50type c is the fracture above the CES
23:53mosis the CES mosis will be injured the
23:56medial collateral ligament will be
23:58injured as well with possible fractures
24:00of the medial malas then here is the
24:05fracture above the level of the cmosis
24:08the medial mulus is intact and also the
24:11posterior mulus is intact this is what I
24:15mean by Tri mular uh fracture it is a
24:19fracture of the lateral mulus medial
24:22malus and the posterior aspect of the
24:24tibia this is known as Tri mular uh
24:29fracture and here is another example and
24:32you see the fracture of the fibula the
24:34fracture of the medial malus and if you
24:37look carefully here and you can see the
24:39fracture of the posterior aspect of the
24:42TB then complications of fractures
24:45around the ankle include uh dislocation
24:48or sublation of the ankle joint
24:51stiffness osteoarthritis ankin stability
24:55nonunion and Mal Union of the uh of the
24:59fractures then we came to the fractur of
25:02the foot and we would like to have some
25:04words about less France injury Sher
25:07injury aulion fractures snowboarder
25:10fracture Jones fracture calcan and
25:13stress fractures the Les France ligament
25:16is the ligament between the second and
25:19the first metatarsal bones and this
25:23ligament is ruptured
25:25during or by a crush injury on or aial
25:30load to the planter flexed foot then if
25:33the ligament is ruptured then you got
25:35separation between the first and the
25:39second metatarsal bones which is easily
25:42appreciated on the uh plane x-rays
25:46normally if you draw a line along the
25:49medial border of the second metor bone
25:52it will form a gentle curve with the
25:55medial with the middle uniform bone but
25:59in cases of lis France uh ligament
26:03injury you got widening of this space
26:06and if you draw a line there will be a
26:08step deformity like this one diagnostic
26:12of L France engine and this is L franch
26:15injury and you can see the wide
26:18separation between the second and first
26:20metal bone and if you draw a line then
26:23you will got the step deformity between
26:26the metal and the middle uniform or the
26:29inter intermediate uniform bone this is
26:32diagnostic of Les France injury and then
26:36the short Port injury is the fracture
26:39dislocation of the mid torsal joints of
26:42the foot it affects mainly The Tao
26:46navicular and the Calia CID joints
26:50actually this fracture is well
26:52appreciated in the uh lateral x-ray of
26:56the ankle or the sagittal images of the
26:59CT or MRI the foot is usually dislocated
27:03medially and superiorly as it is blunter
27:08flexed and inverted frequently
27:12associated with fractures of the related
27:15Bones the calcinus the cuboid and the
27:17navicular but the tus usually remains
27:21intact and its relation with the tabia
27:25is preserved
27:28then if you have the frontal X-ray and
27:31the oblique X-rays of the foot this is
27:33the normal uh frontal and oblique
27:36X-rays and this is the Sher injury you
27:40cannot appreciate the injury uh all you
27:44can see that there is this disturbance
27:47of the relation of the uh torsal bones
27:50with loss of the clear joint definition
27:53between the bones
27:56itself themselves
27:58then uh if you have the lateral x-ray
28:01this is the normal relation between the
28:04calcinus and the CID the taus and and
28:08navicular but you can appreciate easily
28:11here that the foot is dislocated
28:13superiorly with disruption of the
28:16related joints and if you have the CT
28:19scan you can also see this is the normal
28:22appearance of the tus and the navicular
28:25and the tiia the tus will remain will
28:28remain or may maintain its relation to
28:31the to the tibia but there is disruption
28:35of the taon navicular and calcan CUO
28:38joints with Superior dislocation of the
28:42uh mid foot then uh the fractures of the
28:47fifth metatarsal bone include aulion
28:50fracture Jones stress and shaft
28:52fractures these are this the four types
28:56of the uh fractures then in young
28:59persons you have to uh uh to
29:03discriminate between the line separating
29:08the Abes from the fracture line the the
29:14aices uh before uh being united to the
29:18shaft where the line separating will be
29:22more vertical or oblique but the
29:25fracture line will pass
29:27horizontal like this one then if you
29:30look to this foot and you see that there
29:34is aulion fracture of the TP of the
29:37fifth metad doal bone and 90% of uh the
29:43base of the fifth
29:45metatarsal uh fractures affect this this
29:49type of the avulsion fracture and it is
29:54usually uh seen in uh
29:58tennis players because of the frequent
30:01inversion injuries of the ankle and foot
30:04and this fracture has an excellent uh
30:08prognosis and if you uh draw a line
30:13separating this part of the uh of the
30:17metatarsal bone from the shaft this is
30:19the actual side of the aversion fracture
30:23if the fracture is above here like this
30:27and this will be Johan's fracture and
30:30this is an evulsion fracture of the base
30:32of the fifth C tors bone and this is
30:36what I mean by Jan's fraction if you
30:39draw a line here the the this line will
30:43indicate the sight of the aulion
30:46fracture but if the fracture is above
30:49then this is Jones fracture which has a
30:53high risk of
30:55nonunion and this is the joint fracture
30:58It is Well above the site of the
31:02evulsion fracture of the base of the
31:04fifth metatarsal
31:06bone the lateral teral process fracture
31:10also known as snowboarder fracture
31:14because it affects usually those who are
31:18playing on the snow and uh this is the
31:22appearance of the fracture by coronal uh
31:26reformated City the image of the ankle
31:29this is the fibula and this is the tibia
31:31this is the tus and you again got the
31:33fracture of the lateral process of the
31:36Tails this fracture may be missed on the
31:39plane x-ray but it can be easily
31:42appreciated on the C scan this is the
31:46sustentaculum which looks medially then
31:48this is the lateral process of the TS
31:51which is fractured then we came to the
31:54calcan fractures and the Cal canus is
31:58the most commonly fractured dorsal bone
32:01it accounts for about 2% of the
32:04fractures and 60% of all torsal bone
32:09fractures sometimes it is known as the
32:13lover fracture or kazanova uh fracture
32:17because in the old days uh some of the
32:21lovers used to climb the tree or the
32:26bbes reaching the um the girl who are
32:32loving then many times he is discovered
32:36by the parents and they try to jump from
32:38a high uh from a height and fall in his
32:43uh ankles with commonly fractured
32:49calcinus and the fracture is usually
32:51bilateral and may also be associated
32:54with spinal fractures there are many
32:58angles to judge the calcan fracture but
33:01usually the fracture is evident in the
33:03plan xray and then the CT as well if you
33:06draw a line tangential to the superior
33:09surface of the calanus and another line
33:12tangential to the posterior surface of
33:14the calanus then you measure the angle
33:17between these two
33:18lines this angle should be in the range
33:21between 20 to 40° if the calcinus is
33:26fractured it will be flattened and the
33:28angle will be decreased and it become
33:30less more than
33:3220° then if you uh draw two lines along
33:37the uh Superior surface of the calcinus
33:40and they measure the angle in between
33:42this
33:43angle normally ranges between 95 and
33:48105° if the calanus is fractured the
33:52angle will be more wide and it may be
33:55greater than
33:5830° or even there is no an angle at all
34:02the surface will be uh
34:05flattened then uh this is the
34:08normal calcan angle and this is the
34:12angle uh of fractured calcinus you can
34:15see the flatten the calcinus and the
34:18angle is decreased and this is
34:22bilateral uh calcan fracture for for a
34:26male 25 years old jumped from a height
34:30and landed on his feet then you got
34:33commuted fracture of both
34:36calanus uh bones and
34:39here you can see that the calcinus is
34:42flattened and the angle is almost
34:46lost uh sometimes minor trauma may
34:49result in stress fractures and MRI is
34:53one of the uh best modalities to see the
34:56fractures of the stress fractures of the
34:59calanus by demonstrating bone Maro edema
35:03around the fracture line and if you have
35:06the blin xray you can miss the fracture
35:09side but this also can be easily
35:12identified by the uh strong uptake on
35:17bone scan
35:19images there are a lot of
35:21classifications for calcan
35:24fracture affecting the um the lateral
35:28part or the medial part the articular
35:31surface or not but all what we can
35:35provide as radiologist is to mention the
35:39site and the type of the fracture and
35:41very importantly to to to to indicate if
35:46it has disrupted the articular surface
35:49or not then stress fractures are uh seen
35:54commonly in Runners and then the third
35:57metatarsal shaft is the commonest side
36:01for this type of the fracture many times
36:04you cannot see the fracture itself or
36:06you may see prominent colors formation
36:10at the fracture site or just you can
36:13identify uh localized boster reaction
36:17meaning that the fracture has uh being U
36:22healed and the residual changes are only
36:26seen it's also important to knowe that
36:29stress fractures are not always visible
36:31on the initial x-rays if suspected the
36:35x-rays may may be repeated or you may
36:38have MRI to uh better see the fracture
36:43site and the surrounding bone
36:46marm and we came to the Morton neuroma
36:50which is known as inter metatarsal
36:52neuroma and it this is not a neuroma by
36:57uh the mere word this is just a very
37:00neural fibrosis around the blanter
37:03digital nerve and these are the the
37:06blunter digital nerves and the the site
37:10of the neuroma is commonly seen in the
37:14third metatarsal space and less
37:18frequently it can be seen in the second
37:21space but the rest of the spaces are
37:24rarely affected by this disease
37:27and uh it is uh
37:30frequently uh the result
37:33of irritation of this uh Space by uh
37:38let's say minor traa or something like
37:41this then you got very neural fibrosis
37:44forming a mass which is painful and this
37:48Legion may be bilateral in about 10% of
37:51the cases then here is the MRI of a
37:56patient with Morton neuroma you got a
37:59dumble shaped leion insinuated between
38:03the
38:04metatarsal uh heads in the third
38:08commonly in the third space and um this
38:11Legion being a fibrous tissue will
38:14appear uh black or of blue signal and
38:18the T1 uh relative minimal increase
38:22signal in the t2 image but if you inject
38:25contrast it will show significant
38:28enhancement then we came to the blunter
38:31fasciitis which means inflammation of
38:33the blunter fascia and is considered the
38:35most common cause of heel pain this uh
38:40pain is usually uh felt on
38:46weightbearing the causes include the
38:48stress or repetitive trauma like in
38:51Runners for example degenerative or in
38:56uh some of the um arthroses like Ser
39:00negative Bly spilo arthropy and closing
39:04spondilitis rer and psorisis
39:07and in the Blain xray you can just see
39:11only kcan spare but this is not diagnos
39:15diag diagnostic of blunter fasciitis
39:18since the calcan SP can be seen in
39:24asymptomatic uh
39:27and is not an indication of planter
39:30fitis but in order to diagnose planter
39:33fasciitis it should have MRI looking at
39:37the blunter fascia which is uh in in
39:41these in those patients will be
39:43thickened and will show abnormal signal
39:47it may be ruptured and also may show uh
39:50soft tissue edema in the heel bad of fat
39:54in the form of low signal in the T1 and
39:58high signal in the t2 and the stair
40:00images you can compare these appearances
40:04by the normal blunter fascia the normal
40:07thickness and the normal soft tissues
40:11around the fascia
40:13itself then here you can see by the BL
40:16film calan spare and this is not enough
40:19for diagnosis of plant
40:21fasciitis MRI you can see the fascia is
40:25thin and you got some fluid signal at
40:29its anatomic site and also you can see
40:32uh edema of the subcutanous soft tissues
40:35if you have a bone scan or isotop scan
40:39and you got evident uptake related to
40:42the site of inflammation this is the
40:45normal lunter fascia and this is the
40:48fascia which is affected by
40:52inflammation we came to the torf two and
40:55this this is in stress injury due to
41:00extreme uh dorsy flexion and
41:03hyperextension injury of the toe as you
41:05can see here and this is frequently
41:09referred to as sand toe as it is common
41:13in sand volleyball uh players and um
41:17this uh pattern of injury will put too
41:22much stress on the uh ligaments and tend
41:26related to the big two will result in
41:31this in this particular disease which is
41:35known as for to this is seen in
41:39professional athletes but not specific
41:43for a particular type of sport any sport
41:47which is associated with this position
41:50can lead to this injury and you know
41:54that the big two and at the metu fenial
41:58Joint there are two cisoid bones that
42:01are connected by a ligament known as the
42:04inter cisoid ligament and each cisoid
42:07bone is connected to the phic by a
42:09ligament which is known as the lateral
42:13and the medial cisoid ligaments any
42:16injury of this ligamentous complex or
42:19any strain and soft tissue uh damage
42:23will result in this uh tor two and here
42:27is a drawing after removal of the head
42:32of the metatarsal bone you see the two
42:35cids medial and lateral the inter cisoid
42:39ligament the ligament connecting the
42:42cisoid bone to the uh fings
42:46and this should be uh this Integrity
42:49should be maintained in order uh uh to
42:53maintain the function of the uh BTO
42:56then here is the uh coronal image of the
43:01foot at the level of the
43:04first metatarso Fingal joint and you can
43:08see that there is capsular stretching
43:11and some soft tissue edema here and
43:14there which is diagnostic of turf to
43:18then you can compare the normal
43:20appearance of the uh of the ligaments
43:24and the rupture of the ligament with uh
43:27uh bone soft tissue edema at the side of
43:31the uh of the ligament and you should
43:34have the coronal images in order to see
43:39the which is which is Sid ligament has
43:43ruptured to differentiate between the
43:45medial and lateral one like this here
43:48and you can see this is the normal
43:50appearance of the of the ligament and
43:53this is rupture of the medial uh system
43:56oid Fingal Fingal
43:59ligament then we have some of the issues
44:02that has been discussed previously uh in
44:06many topics in the topic of vol
44:08arthropathy and in the in the knee and
44:12uh maybe uh in different joints and this
44:16is uh the pigmented villonodular cites
44:20this is an idiopathic disease of unknown
44:24ethology it is a articular disease
44:27results in binless swelling of the joint
44:31and Bin will develop after progression
44:34of the disease with affection of the
44:37bones and articular surfaces it is the
44:40squally of deposition of uh pigments in
44:45hypertrophied cium resulting in big
44:49sinovial uh masses interfering with the
44:53uh mechanical uh joint MO movement and
44:57these pigments will uh produce uh masses
45:01of low signal in the T1 and the low
45:04signal in the t2 withed images uh but if
45:07you inject contrast material they will
45:10enhance after contrast injection these
45:14lesions are treated by removal of the
45:17covi and in this image you can see big
45:21low signal masses in the T1 weighted
45:23image in the back of the ankle joint and
45:26some smaller lesions in the anterior
45:28aspect of the joint and here you can see
45:32low signal lesions in the anterior
45:34aspect of the ankle in both T1 and T2
45:37withed image if you inject to contrast
45:39material and the lesion will enhance and
45:43this is also pigmented volod sinovitis
45:47big Mass posterior to the ankle a
45:49smaller one anterior to the ankle low
45:52signal in the T1 low signal in the
45:54gradient image if you in to contrast
45:56material the lesions will
45:59enhance and this is also another example
46:02of pigmented vular sinovitis of the
46:06ankle a bigger Mass anterior and a
46:09smaller one posterior but you remember
46:12in order to diagnose this as pigmented V
46:15cobitis the lesions will be will appear
46:18dark in the T1 and dark in the t2 images
46:21and they will enhance after contrast
46:24injection then we came to the uh issue
46:27of diabetic foot and you know the
46:29changes in the foot of diabetics are
46:33secondary to the combination of reduced
46:35the blood supply due to arterial
46:37sclerosis reduced sensation due to
46:40pereral neuritis and the the super added
46:42infection the changes will start by the
46:45formation of what is known as colus and
46:49this colus is like you can see it's an
46:52indurated skin which is related to the
46:55pressure point Point especially under
46:57the heads of the first and the fifth
47:00metatarsal bones in amary amary
47:04diabetics those who are walking uh here
47:08and there but in bed readen patients the
47:11uh this colus will develop and over uh
47:16under the heel or over the heel and the
47:19lateral
47:20mules then uh uh this colors will is is
47:25made of indurated soft tissue it will
47:28show low signal in all B sequences by
47:31MRI and it will enhance if you inject
47:34the contrast material later on the
47:37neuropathy will result in skin dryness
47:40and fissures and this will result in uh
47:44ulceration which is aggravated by uh
47:47minor trauma and this ulcers uh if they
47:52reach the size of 2 cm they will
47:54penetrate the underlying soft tissues
47:57resulting in sinus tracts and these
48:00sinus tracts will uh be an provide an
48:05access for the infection to go deep in
48:08the soft tissues and this may result in
48:10soft tissue abses and also may affect
48:14the bone resulting in
48:16osteomyelitis and the de penetration of
48:20the skin in and the subcutaneous tissues
48:25by
48:26this inflammatory process is known as
48:29cellulitis and cellulitis is confined to
48:32the skin and subus tissue later on the
48:36infection will affect the muscles and
48:38the facial blaines will result in a mass
48:42of
48:42inflammatory uh granulation tissue known
48:45as the Fon when this Mass liquefies and
48:50curates it will result in an absis
48:53formation and this absis formation being
48:57intimately related to the tendons of the
49:00uh of the food may lead to
49:03tenosinovitis and this tenosinovitis may
49:07result finally in tear of the related
49:11tender then uh diabetic motor neuropathy
49:17will result in acute muscle denervation
49:20which will uh present by muscle swelling
49:23and edma an m and later on you got
49:27severe muscle atrophic changes and fatty
49:31infiltration the role of different
49:34Imaging modalities in evaluation of
49:36diabetic food the x-rays are can uh show
49:42soft tissue swelling due to inflammation
49:44can show vascular and soft tissue
49:46calcification due to arterial
49:50sclerosis can show radio foreign bodies
49:53and you know that foreign bodies
49:55penetration is common in diabetics due
49:57to Associated uh neuropathy and foreign
50:01body if it is opaque it will appear on
50:03the Blain film if not it will appear as
50:07signal void structure in all B sequences
50:09by MRI surrounded by inflammatory
50:13granulation tissue which will enhance if
50:15you inject contrast material also the
50:18Blain xray may may show gas Shadows due
50:21to gas forming organism or necrotizing
50:23fasciitis can show bone erosions and
50:26Bone sclerosis and this is an example of
50:29diabetic food with necrotizing fasciitis
50:33and you can appreciate the extensive
50:35gases in the uh in the soft tissues also
50:39by by Blain film in you can see
50:42destructive changes in the bone
50:44secondary to osteomylitis Bone
50:46resorption fragmentation and Bone
50:50sclerosis by MRI you can see the colous
50:53legion which appears black in all B
50:56sequences you can see the ulcers and the
50:58sinus tracts you can see cellulitis Fons
51:02and abses and you can see foreign bodies
51:05as I have mentioned and also you can see
51:08bone Maru edema of the uh food bones
51:12osteomyelitis bone erosion bone
51:15sclerosis and muscle atrophy with fatty
51:18changes you can see here there is uh
51:22soft tissue swelling uh
51:25the big two with low signal in the T1
51:29High signal in the t2 and post contrast
51:32enhancement denoting the Fon of uh which
51:36is a mass of inflammatory granulation
51:39tissue also MRI can see destructive bony
51:43changes can see uh deep soft tissue
51:48inflammatory uh masses can see skin
51:51ulcerations and can see uh bone
51:54sclerosis
51:55if you
51:57got areas of low signal in all bu
52:00sequences you can see Bor Maro edema
52:02which will appear of low signal in the
52:05T1 and high signal in the t2 and this is
52:09also diabetic osteitis with septic
52:13arthritis the delion affects here the
52:16middle caniform bone which is black in
52:19the T1 bright in in the t2 withed image
52:23you may not appreciate these changes in
52:25the Blaine x-ray because of the
52:27sensitivity of MRI uh for bone Maru
52:31edema this is the effected bone in the
52:34t2 if you inject uh bone Maro edema of
52:38whatever ethology will enhance wi
52:40contrast by MRI and this image showed
52:43that also the third metatarsal bone is
52:47involved as
52:48well then you came to what's known as
52:51ghost sign and ghost sign is an indicat
52:56of the presence of neuro
52:58osteoarthropathy with super added Osteo
53:01myit the signs means that you cannot uh
53:05uh see the the margins of the Bony
53:08lesions in T1 weighted image but you can
53:12see the margins clear after injection of
53:16contrast material and in this patient
53:19with diabetic foot and you see an ulcer
53:21here and also you can see both soft is
53:25edema and extensive bone Maro edema of
53:28the ganus if you inject contrast
53:30material the bone Maro edema will
53:32enhance and you got the
53:35osteomyelitis clear and this is known as
53:39the ghost sign then one of the major
53:43complications of di diabetic food is the
53:46development of neuropathic uh
53:48arthropathy or the shal joint which has
53:52also many uh other underlying causes
53:56like spinal uh diseases brain injury and
53:59so on
54:01and charot uh neuro
54:05osteoarthropathy there is a
54:08degenerative uh Progressive destructive
54:12changes of the bones and joints of the
54:15of the foot and um this is uh secondary
54:19to uh the absence of sens sensation due
54:23to the associated neurological disorder
54:26and the super added uh infection as well
54:30as the uh traumatic insults today
54:35diabetes is the most common ethology of
54:38uh sharot neuro
54:41osteoarthropathy then um if you uh look
54:44by the Blain x-ray the affected joint
54:48will appear as if it has been HED by
54:52this very strong Hummer then you got the
54:56destructive changes disorganization and
54:59fragmentation with bone sclerosis
55:02fractures and fragmentations narrowing
55:04or widening of the joint space Market
55:07bony sclerosis large amount of bony and
55:11soft tissue debras per hostal NE neone
55:14formation and this are summarized in
55:17what is known as the five D this
55:20organization the structive changes deas
55:24density in incase and deformity and this
55:27is the the
55:31shood neuro arthropy of the ankle and
55:35and foot diabetes is the most common
55:38cause of this appearance and in the
55:42early stages and you can see this as a
55:45clinical inflammation of the foot itself
55:48but later on and you got a change in the
55:50axis of the foot uh this this is the
55:53normal appearance and this is the uh let
55:58us say flattening of the foot arches
56:01with bon deis in the superior aspect of
56:03the joint also you can use MRI and CT
56:07for uh the diagnosis of charal joint you
56:11will I think they will not add uh too
56:14much information to the Blan xray you
56:16see bone sclerosis bone debris uh the
56:21structive changes in the joints and the
56:23derangement of the
56:25uh articulation between the affected
56:30joints and G is also one of the lesions
56:34that can one of the diseases that cause
56:37lesions in the food and the gout may be
56:41primary due to over production of uric
56:43acid or failure of its renal excretion
56:47or may be secondary to many of the
56:50diseases the hyperuricemia will result
56:53in deposition of uric acid crystals in J
56:57articular uh position and this is
57:01commonly seen at the metatarsal joint of
57:04the big to but it also can affect the
57:07rest of the foot joints and also the
57:10hands the the erosions are classically
57:13sharp punched out erosions and they
57:17start adjacent to the Joint line and
57:20later on they will affected the joint
57:23line and may cross to affected the
57:25opposite bone as well then you got
57:28severe destructive changes and big soft
57:32tissue Mass which is known as uh tofi or
57:36uh the the
57:38inflammatory uh granulation tissue uh
57:42that has resulted from uh this
57:45deposition of uric acid crystals and you
57:48see affection of the interial joint and
57:51the metop Fingal joint of the
57:53foot finally osteoarthritis can affect
57:58uh any of the joints in the in the hand
58:00and in the foot and ankle and um the the
58:05usual manifestations are similar to any
58:07ostearthritis anywhere in the body
58:10meaning that there is narrowing of the
58:12joint space subarticular Bon sclerosis
58:15osteophytic libing of the articular
58:18surfaces maybe subarticular pseudocystic
58:20changes maybe intraarticular gas and
58:23maybe lose bodies especially in in large
58:29joints thank you very much
58:34ald

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