0:00

Okay, we're back to the foot.

0:02

To the foot and ankle near and dear to my heart.

0:09

So as before I, I start out right with a sagittal projection.

0:12

If I'm reading by myself, this is where I begin. Unless it's a soft tissue mass,

0:17

it's a soft tissue mass.

0:19

I prefer to go into the short axis view because it's very CT like,

0:24

very anatomic like, and helps me position, uh,

0:27

the lesion a little bit quicker.

0:31

So here's our sagittal fat weighted T1 weighted image on the left

0:36

and our water weighted image on the right.

0:48

So this patient has medial ankle discomfort

0:54

evaluate for posterior tibial tendon tear, tendon tear,

0:57

which is the most commonly torn group in the medial tendon group.

1:01

The flexor group.

1:02

I like to point the toe down that straightens out the posterior tibial tendon

1:07

and allows me to do something like this. All right,

1:11

so I wanna be like this to avoid artifacts like the anti centropic

1:16

artifact or the 54.5 degree, uh, artifact,

1:20

known as the magic angle effect. And we have that in this case,

1:25

we have some axials. That'll of course,

1:27

through that way to evaluate this commonly torn or

1:32

injured tendon. Remember we've got that mnemonic,

1:36

1, 2, 3, 4, 3 on the medial side. To help you remember,

1:41

let's scroll the axial and give you a really high quality look

1:46

at the tendon,

1:47

which is what you need to answer the polling question unless you're a magician.

1:57

We're down low, we're coming up high.

2:01

There's some nice spring lium and anatomy sedl, spring medial oblique,

2:06

spring infra lateral plantar. Spring, three components of the spring, one, two,

2:11

and three. And then we have our friends, Tom Tibi Ellis,

2:15

posterior dick, the flexor digitorum,

2:17

and Harry the flexor sis longest.

2:22

There's some fluid around Harry.

2:26

We're interested in Tom. Now let's put up the polling question.

2:31

Which of the following is false? A, the posterior tibial tendon is torn.

2:36

B, the patient has an US tibial sternum. C.

2:41

The patient has a type two accessory, navicular D.

2:45

The patient manifests os navary syndrome,

2:50

E A and B 13% said the posterior tibial tendon is torn.

2:54

The posterior tibial tendon is not torn, but we're going to drill into that.

2:58

Now, the patient has an OTE ALIX sternum.

3:03

That is a well demarcated corticated obstacle.

3:08

It's circular or oval. You'll see in a moment that is not the case here.

3:14

The patient does have a type two accessory navicular,

3:20

and the patient does manifest ary syndrome.

3:23

So the two false answers are A and B. Therefore,

3:26

the correct answer is E, A and B are false. Now,

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let's start scrolling and look at our posterior tibial tendon.

3:34

Some of you might have thought, okay, when I get down here,

3:38

the tendon looks a little ruffled, a little scuffled, a little scuffed,

3:43

a little frayed. But no, it's fanning out,

3:47

inserting on a very swollen

3:51

bony protuberance.

3:53

That bony protuberance has a cartilaginous interface,

3:58

a PSD arthrosis, if you will, between it and the underlying navicular.

4:04

So this is what's known as a type two accessory navicular.

4:08

You see how serrated and irregular it is. If it was an alley sternum,

4:13

it would be located within the tendon. For instance,

4:16

let's take this tendon right here,

4:18

and it'd be like a little round corticated ossicle.

4:22

That would be an O tibi alley sternum. In the tibialis posterior tendon,

4:27

we don't have that.

4:30

What we have is a tendon that's fanning out that's swollen and inflamed on a

4:34

hyper mobile type two accessory navicular. Now,

4:39

how do we know it's hyper mobile?

4:41

Remember our lesson from us osteo Citis decans with edema.

4:45

Look at how swollen and emis this thing is.

4:50

The t1, maybe not so much. You have to look very carefully.

4:54

It's a little darker than the medial NICUs of the

4:58

tibia,

4:59

but it's certainly emis on the water weighted sensitive image.

5:05

Look at how EMIS that is and the underlying navicular bone.

5:10

And yet the tendon is straight and smooth. Yes,

5:14

it has a little bit of signal in it, but it's not focal. It's not well defined.

5:19

That's simply a swollen tendon inserting on an inflamed

5:24

hyper mobile structure. So yes, there is os Navary syndrome.

5:30

No, there's no posterior tibial tendon tear. Yes,

5:33

there's extensive swelling and peritonitis.

5:38

Some of you are probably asking, is this a surgical case?

5:41

It is a surgical case where they most likely will remove and

5:46

did remove this fragment and reimplanted the posterior tibial

5:51

tendon in what's known as a kidney procedure.

5:55

And the remaining tendons are intrinsically normal.

6:00

On the medial side, even though there is quite a bit of fluid around the fhl,

6:04

the fhl or flexor hales sheath communicates

6:10

with the ankle joint.

6:11

So ankle joint fluid track down along the F hhl to where it

6:16

crosses the flexor digitorum at Henry's master knot

6:21

gravity. Does that,

6:23

don't confuse that with a ganglion or a cyst that needs aspirating.

6:27

What about the rest of attendance? Well, here's our friend Tom.

6:32

The tibials anterior looks fine.

6:35

Here's our friend Harry Extensor Haas looks fine.

6:39

And here is dick. The extensor digitorum and peroneus tertius.

6:44

They look fine. How about the peroneus? Longest and brevis?

6:49

Well, here's the brevis.

6:51

Let's follow that down to the base of the fifth.

6:56

There's a little signal in it, but within the spectrum of normal,

6:59

not very focal, not split. Let's take a look at the longest.

7:04

It's a little juicy and fat. Let's follow it down. It's getting a little grayer.

7:10

A little grayer. Let's keep following it. Keep following it up.

7:14

Starting to get some vocality and right there. Lots of vocality,

7:19

not focal, not focal, focal.

7:24

There's a tear in it. Focal with surface communication.

7:29

This one was intrasubstance. That one is communicating.

7:33

You'll see that if you want to. It's very small.

7:37

So there's a perus longest tear in the plantar

7:41

segment as it leaves the cuboidal arch. Tricky, huh?

7:46

Is it possible to differentiate a syndesmosis from a sinon?

7:53

I'm not sure I understand the nature of your question,

7:58

but I will say this.

7:59

There is a cartilage remnant that is found between

8:04

the type two accessory navicular and the underlying bone when they are fused,

8:09

when there's fusion of the two, which may be what you mean by asci osmosis.

8:14

This is known as a corn it or ate navicular,

8:18

also known as a type three navicular.

8:20

And when it's completely intra tenderness and round and corticated,

8:25

it's an OTE Bali sternum. So those are the three types.

8:28

US Tibi sternum number one. Um,

8:33

OAR number two, and corn navicular or arcuate navicular.

8:37

Number three.