0:01

This was the kiddo that is a young teenager,

0:05

maybe with knee pain after twisting injury, uh,

0:09

a week or so ago. And here, all right,

0:13

so looking at my localizers, okay. A little fuzzy, right?

0:17

But we can tell, you know, maybe there's some action going on about the knee.

0:21

Okay? So pulling up our, uh, fluid sensitive sequence, right?

0:27

We see a lot of action going on here,

0:30

but it looks like the majority of the action is gonna be within bone. Okay?

0:34

With that in mind, okay?

0:36

I am gonna pull up right ATA nice T one 'cause I like

0:41

my T ones for marrow anatomy. But that being said, in kids,

0:45

it can be difficult, right?

0:47

And this is where knowing how marrow reconvert converts, um,

0:52

in the early skeleton,

0:54

that is right from a Paxil initially to ail

0:59

to distal meta ail to proximal, uh, uh,

1:03

meta ail in that order, if you know that order,

1:05

that's gonna help you read your peds cases, right? So, but in this case, the,

1:10

the money okay,

1:12

was probably that sagittal and this coronal and what we see here, okay,

1:18

is the irregularity of the distal FSIS robust edema

1:23

about the FSIS on both sides of the fsis, okay?

1:27

And here too, we have this stripping, okay? Okay.

1:32

Or this detachment, if you will, of the periosteum. Okay?

1:37

Other things that we can sort of see,

1:39

and I forget which sequence it was probably better on.

1:43

We see this sort of incomplete fracture, okay?

1:47

All right. And if we sort of hallucinate, okay, this,

1:50

this fracture cutting through the epiphysis, so that makes this,

1:53

because it's below or extent the ocil, if we look it up,

1:58

this would be qualified for assaulter Harris type three injury,

2:02

the Salter Harris type two injuries obviously are gonna be more common.

2:06

But honestly too, uh, I recently, uh,

2:10

reviewed a paper and I was surprised to learn that there are last I

2:14

checked about nine, 10, or 11 salted hair type injuries.

2:19

So I have slowly forgotten the first four. So I actually look it up now.

2:24

Okay? So for those that repeat something to be aware of, okay?

2:29

But the nice thing that,

2:31

the thing I love about this case is notice here that we have some sort of either

2:36

perusal or some sort of, uh, injury back here.

2:40

And the important thing that I wanna highlight with this case, okay, in kids,

2:45

right, the bone, the bone interface, okay,

2:50

the, the bone or the periosteum is gonna be be the weakest part of the

2:55

bone tendon muscle or bone ligament bone

3:00

interface. So that's why in kids,

3:04

you're gonna wanna pay more attention closer to the bone periosteum,

3:09

what have you, and that's where they will fail.

3:11

And as you can see here with periosteal avulsion injuries, okay? Or,

3:16

or, uh, these injuries, it's gonna be the periosteum is typically gonna be dark,

3:21

right? So our eyes don't pick it up as well.

3:25

And the other problem is too, is because mostly it's soft tissue still,

3:29

it hasn't really occupied or healed and laid down that periosteum new bone.

3:34

If you grab a early acute, uh, I radiographic image,

3:38

we may not see it. So you may have to ask for an imaging study,

3:42

a radiographics, uh, radiograph or a CT later on to help since this diagnosis.

3:48

The, the additional, uh, pearl that I can give you is notice here,

3:53

right? The periosteum, it's, it's lax in kids.

3:57

And this also explains why we get periosteal hematomas and

4:02

lucrum in kids readily. Remember, especially with infection,

4:06

that periosteum is trying to wall off the infection and try to get rid of it.

4:10

The periosteum is not held tightly to the bone by the sharpies

4:15

fibers, which are typically gonna be here. So in this case,

4:18

this is probably a periosteal hematoma with some stripping and emulsion, right?

4:23

But the important thing with this is if you have a fracture,

4:26

especially these bile fractures, arguably maybe I, I,

4:30

I don't know how the gold standards read, but read, right?

4:34

But you can maybe argue that a,

4:37

a wisp of periosteum or maybe ligament or something is cutting

4:42

into that bone. And why is this important?

4:45

Because this will prevent fracture healing.

4:47

So anytime you have a dislocation or fracture that, you know,

4:52

the surgeon comes back to you and says, Hey Eddie, I can't seem to relocate it.

4:57

I can't seem to reduce it. That's something to think about.

5:00

Something relating leading to a reduction block. Okay?

5:05

So this is just a nice case of assaulter Harris injury with some periosteal

5:10

injury, okay?

5:11

And we could even see here how that periosteum has been violated

5:17

and sort of stripped off and pulled off the posterior aspect

5:21

and the medial aspect of that distal femoral metastasis. Okay?

5:26

So a nice case of that here.

5:29

Questions on our salter hairs and our, our kids are,

5:33

are this young kids, uh, MRI study.

5:37

So, uh, just looking that, uh, peral lifting and perusal hematoma,

5:42

how do you differentiate that from a healing process? Like a callous,

5:46

can it be part of a spectrum of, uh, healing or callous formation?

5:50

If, if, so, this is where I would like to get a radiograph, right? So, or,

5:55

or perhaps a CT later on. Um, if there's a small fleck of bone,

6:00

then you know that it's pulled off some of that, you know, that, that, uh,

6:03

cortex with it, right? Um,

6:06

and that's also important for some of my surgeons because,

6:10

and if you extrapolate that out to like other fractures or evulsion injuries of

6:14

kiddos, right? Comminuted avulsion fractures, right? Um,

6:19

are harder to fix, right?

6:21

But larger intact avulsion fracture fragments,

6:25

surgeons wanna know about that because they will go in and tack that down with

6:29

the screw, right? Take for instance, right? The more classic, uh, um,

6:34

you know, evulsion fractures that we see in the knee of kids. Um,

6:38

ACL evulsion fractures, right? If it's in situ, right? Large fragment,

6:43

not comminuted ability to tack it down with one screw, that's,

6:48

that's a meatball. That's, that's a, that's a dinner waiting for the,

6:51

for my surgeon to eat. He's, he, and he and she,

6:55

they're gonna want to go in there and fix that to maintain that, uh, ACL. Uh,

7:00

and, and that knee stability, if it's more comminuted, then that's,

7:04

that's gonna be more problematic and that's gonna be a problem. But one thing,

7:08

you know, when you see these larger flex, uh, good to mention them,

7:13

and especially good to think about these little evulsion of these fracture

7:16

fragments, particularly in kids. And for those that are interested,

7:19

I think I wrote actually about a rare semimembranosus evulsion fracture,

7:24

uh, probably a 10 years ago now for those that are interested, just Google, uh,

7:29

semimembranosus AV bul and fracture, and I was a co-author on that patient,

7:34

and we kind of talk about, uh, periosteum and, and what have you in, in that,

7:39

uh, in that literature.

7:41

So on the, also on the kernel, um, views, especially on T one, uh,

7:46

in the flu sensitive sequences,

7:48

you get this rounded appearance of the marrow just above the FIS l plate.

7:52

So I was just concerned whether it could be some form of, um,

7:56

escaping process that's going on there.

7:58

So with that weird configuration that rounded focus above the fsis, uh,

8:03

how would you describe, uh, how do you describe that?

8:06

Uh, I would be worried about one of two things. A physeal injury. And,

8:11

and again, this is where history with the twisting injury would really help,

8:15

right? Because without any history, you show me just this one image,

8:20

I would worry about infection, right? That's,

8:22

that's just sort of brewing at the metaphysis, right?

8:26

And maybe extending towards VICIS and whatnot. But yeah, I, I, that's,

8:31

that's where, you know, reading in a vacuum could be, uh, problematic.

8:35

But with the history of twisting injury, I would read, I would favor this.

8:39

I would read this as a fi seal injury and start looking for other fractures.

8:43

But mind you too, right? If people start to think, you know,

8:47

MRI is the, you know, the magic bullet of, of imaging, uh,

8:52

the more expensive one is gonna give you the answer, but sometimes, right.

8:56

A good radiograph could have just answered this,

8:58

especially if there was a small fleck, right? Uh, with that periosteum, right?

9:03

The other thing too that I always recommend, especially in foot rate, foot MRIs,

9:08

um, you know, someone that comes in with an inversion or a twisting injury,

9:12

there can be a lot of fractures in there that are vol vol subtypes with very

9:16

little mar edema, and they're just gonna be occult. So I just sort of mention,

9:21

you know, where I see edema, and I, I oftentimes will say, you know what?

9:27

Go to ct, you know, and I, and if it's a friend, uh, orthopedic colleague,

9:31

I will personally pick up the cell phone and I'll say, Hey, you know,

9:35

I think you really need a, a CT rather than an MR in this case. Um,

9:40

you know, uh, to evaluate for possible fractures that are Mr. Occult, but happy,

9:45

you know, for giving me the MR work, you know, and we have this case for a,

9:49

for a teaching file and, and as a teaching point to learn from now.

9:54

So, so that, that low signal border is probably just hemosiderin.

9:58

It's more of a hematoma,

10:00

Probably, I would say. Yeah. You know, some sort of gunk, hematoma, fluid,

10:04

something. Yeah. All right. And, and just as a side too,

10:08

if I remember correctly, there was like a small little fracture here. Another,

10:13

so this arguably is like another salter maybe,

10:16

if you believe it's cutting into the vicis, those, this would be, uh,

10:19

another type three of the, uh, of the proximal, uh, fibular, uh,

10:23

epiphysis here. Okay?