0:00

Fourth case is, again, a young person who had injury, uh,

0:04

while they were in a football game. So again, you're,

0:08

we carefully look at the bones and ligaments here. The,

0:13

um, the planes look much better, the ankle, like the patient's, um,

0:18

ankle position looks more, um, what's recommended.

0:22

So hopefully we'll be able to see all the structures properly on this one.

0:26

So at least tendon looks okay that a fascia looks okay.

0:31

A lot of soft tissue edema that we can see coming on to our axial images.

0:37

Um, trying to bring up the Corona.

0:40

Let's move Corona here and bring on here.

0:45

Okay.

0:46

And then let's link these images so that we can look at both the axial stacks

0:50

simultaneously. Oh, some of they're not linking. No. Okay. We can just,

0:55

uh, keep focusing on if we have AT two image.

1:01

Okay. So this is, this is the area of the,

1:05

this posterior tibial fibrile ligament. I see.

1:07

But I don't see the anterior talo fibrile ligament.

1:10

The syndesmosis is slightly widened. There's a lot of, uh, fluid signal here.

1:15

Let's look at the coronal images for the same. So, see,

1:18

this is where I was asking to look for, uh,

1:20

the anterior distal tibial fibular ligaments. And, and there's a,

1:24

there's a tear of that ligament there. It's a complete tear, um,

1:29

increased signal in the syndesmosis sprain of the interros membrane.

1:32

That's where it is. And, and the posterior tip fib ligament looks.

1:37

Okay.

1:38

So this would be a high ankle sprain where we have injury to the anterior distil

1:42

fibular ligament. Again, as I said, this is, um, um, this,

1:46

the significance of this injury is it's, it, it, uh,

1:50

it can clinically, uh, can get missed, uh, because of like non-specific, um,

1:56

examination findings. Um,

1:58

so since it's important for a radiologist to detect this on imaging, uh,

2:02

if they decide to do imaging and are not able to clinically diagnose, and,

2:07

and as I said, this is a longer recovery time, so if it's in an athlete,

2:10

they need more, uh, the, the return to play will be longer with such injuries.

2:15

So it definitely impacts them, um, quite a bit. And, uh, if not,

2:19

as I said earlier, also if not treated well, it can be to ankle instability. So,

2:23

so really, um, uh, important, uh, a clinically important, um,

2:28

injury here. And then as we go down.

2:31

Now this my anterior taal fibrile ligament, really very thickened.

2:35

The posterior talo fibrillary looks thickened. Let's look at the cal fibula.

2:39

That looks thickened as well. So again, it,

2:42

it is common to see thickening of these, uh,

2:44

ligaments that imply that there has been an old injury with old injury.

2:49

These ligaments,

2:49

if even if they were like completely torn or partly hydrate

2:54

partial tears,

2:55

they can heal with a lot of scar tissue formation and they will look really

2:59

thickened on, on, on follow-up MR imaging.

3:02

And sometimes this thickening would be so much that it,

3:04

it'll cause impingement and then it's known as central lateral impingement. And,

3:08

uh, if it's more g lobular, uh,

3:10

form of thickening of the ligament that's known as your men lesion. So here, um,

3:15

uh, it suggests some old lateral ligament injury.

3:17

I don't see any bright signals.

3:19

I wouldn't think of an acute injury to the lateral ligaments.

3:22

Now coming to the deltoid ligament,

3:26

very nicely seen deep deltoid. Uh, deep deltoid is often like a fan, uh,

3:31

arising from the tails and spreads out as it, uh, attaches onto the tails.

3:38

And then this would be, this is my spring. This is my TBIs posterior,

3:42

this is the SMO band of the spring. So this is my tibio spring, which is again,

3:46

slight a little thick and bright signal, no disruption.

3:49

So there's a little bit of sprain there.

3:54

And I'm trying to find the other band. So this is towards the, no,

3:57

this is still towards the spring. Oh, so this is,

4:01

this is calcaneus, right? So this is the ulu tails of the calcaneus.

4:06

So this would be your tibial calcan bin. So that's how you identify.

4:09

You just take the, the name of the ligament and see if you can see, uh,

4:13

a structure causing towards it. Now,

4:18

and this one, the nib navicular is harder to see.

4:21

I don't get to get in the plane of tib navicular.

4:24

So that's oid looks. Okay. Now moving on to the, the tendons.

4:32

So a little bit of fluid, but no real tend, no cys,

4:35

like little bit of reactive teno synovitis, but no tendon there.

4:39

Peronial tendons look fine. The extensor tendons look okay,

4:46

structures in the tarsal tunnel looked okay. Then the,

4:50

the joint looks okay in osteochondral lesion,

4:54

the posterior SubT joint looks okay,

5:00

the middle SubT joint, all of the joints are okay, this is my sinus tar side.

5:04

It will always, whenever there is, uh, ligament injury,

5:07

all that reactive edema extends into the sinus starci.

5:13

The bone marrow signal is spine.

5:15

I didn't see any fractures or areas of marrow contusion

5:20

microtrabecular injury. Okay, so the main,

5:23

main finding here is or tear of the anterior, um,

5:26

a distant tibia fibular ligament. And that will constitute a high ankle sprain

5:32

and old injury to the lateral ligaments. Okay,

5:36

I think that was all on this one. Any any questions?

5:40

Yeah, a question.

5:41

I think this was a case that was described as showing vernacular stripping

5:44

relating to a peroneous, um, perineal injury. Okay.

5:48

Yes, yes, yes. Um, I think there might be a,

5:52

so I think it was because of there was so much of, uh,

5:55

like thickening of the aaf that goes and bulges out.

5:59

So this is where your peroneal tulu is. So if you see this, uh, black band

6:05

overline, the lateral MEUs and it goes posteriorly.

6:09

So all these reac are keep, they keep these tendons in place. So this is your,

6:12

this is your peroneal tulu right here.

6:15

So I think it's slightly stripped off anteriorly. And, uh,

6:18

since it's attached posteriorly,

6:20

that's why it has kept the peroneal tendons in place and it has not allowed. Uh,

6:24

so if it was com in some cases you see complete stripping off it,

6:27

completely stripped off, and then the peroneal tendons,

6:30

they are either overlying the lateral MEUs or they can come anterior to the

6:34

lateral malus. So that would be a significant vernacular injury. Similar,

6:38

same thing can happen on the medial side. This is your,

6:41

if you see this is your flexor reac, as we already talked about,

6:44

that forms the roof of the tarsal tunnel.

6:46

And if there is stripping injury of that, again,

6:49

you can have subluxation of the tibial as peri tendon.

6:52

They can be seen on coronal images too. So this is,

6:57

this is your tulu, maybe that's what they're calling it,

7:00

this little stripping off. But it's, it's not a, like,

7:03

it's not a complete strip, like, um,

7:06

it's not a completely stripped off tulu. So, um,

7:10

the clinically significant ones are when there are completely stripped off. And,

7:14

um, another important thing about, about,

7:16

about these as far as imaging is concerned is, um,

7:19

when these ret macular injuries become, um, sub acute to chronic, um,

7:24

they will have calcification or ossification,

7:27

like how you have egrin steroidal lesion with MCL injury.

7:30

Very similar thing happens. So if you see a curve, uh,

7:33

curve linear your calcification overlying the medial or the lateral ula,

7:38

that's your radiographic sign of old Rett macular injury.

7:43

Thank you. There's, there's also a question in the chat. Um,

7:47

it says web B stage four.

7:49

Is it common easy to see if it's not complete disruption?

7:54

Uh, so, uh, yeah, this, um, we don't, um, um, uh,

7:58

get into the detailed staging of Webber.

8:01

At least our clinicians don't demand us to put those stages. It's hard to keep.

8:06

So I will just, um, like normally if, uh,

8:09

will pull out a detailed classification, um,

8:11

mentioned and try to see what kind of injuries.

8:14

But for most ankle injuries we just describe, uh, like, okay,

8:17

I see a medial media nerve fracture, um, which is a,

8:20

a virgin type fracture or it's an impaction type fracture.

8:24

We would just be descriptive. So we did, don't get into these stages,

8:27

so I apologize. I would not know what will be parts of, um,

8:33

stage four of Weber BI know that the terminal stages in each weber,

8:37

especially B and C, are when they have posterior macular fracture.

8:40

So those are the unstable injuries. Um, again,

8:43

you'll have more widening of syndesmosis and they're often, uh, not just, uh,

8:48

simple fracture. There's often a fracture, dislocation of the ankle joint.

8:52

But yeah, don't know the detailed,

8:57

um, classification on these ankle fractures because we don't do them routinely.

9:04

So if the maulus is not fractured, but the ligament disrupts,

9:09

yeah, that, that's, those are the cases which are best diagnosed on MR imaging.

9:13

And you can talk about, uh, uh, and see the ligaments very well and tell,

9:18

uh, if that, if there's an injury or not. So I'm not,

9:22

not sure if I answered that question correct or not.

9:24

Is that what you were trying to ask? Maybe this question,

9:27

I'm sorry if I didn't give a detailed answer, but, um, if you all can, um,

9:31

reach out to the other instructors of the courts and if any of them have

9:35

personal experience with these we injuries, but we just go by just A, B,

9:39

and C and really don't get into the, the further staging, uh,

9:44

if we just describe what all injuries we see. So, um,

9:48

that would be my limitation.