0:00

We're gonna turn our attention now to osteo dys.

0:04

Hands of the Taylor Dome, typically defined as a subacute

0:09

or chronic osteochondral.

0:11

I hate the word lesion, makes me think of a tumor,

0:14

but that's usually the term

0:16

that is suggested generally occurring in younger people,

0:20

be they a child, an adolescent, or a young adult,

0:24

and often more often related to

0:27

stress, repetitive stress.

0:30

Okay? No acute event

0:32

that's more frequent than a fracture that goes on

0:36

to this particular lesion.

0:38

Alright, now when you think of the term osteo ichan,

0:43

there's certain skeletal sites at which this has been

0:46

certainly emphasized.

0:47

We're talking about the Ali,

0:50

but the femoral condyles, particularly the inner aspect

0:53

of the medial femoral condyles, the back of the patella

0:56

and the capitulate

0:58

or Capella of the distal uh uh, humerus.

1:03

I wanted to show you some of the imaging, uh, findings

1:07

that we can see with this more chronic condition.

1:11

So here are a bunch of pictures

1:13

and these come again from uh, Dr. Griffith here,

1:17

James Griffith, telling you the extensive abnormalities

1:21

you can get collapse of bone, you can get sclerosis,

1:24

increased density of the bone,

1:26

you can get cartilage abnormalities including separation

1:30

defects, delamination.

1:33

And it's interesting that James sent me a lot of images

1:37

where he used traction, particularly during MR imaging.

1:41

So here you're looking at three particular cases

1:45

showing you osteo disc scans

1:47

and the difference between no traction and traction.

1:51

How the traction was very helpful in pointing out more

1:56

of the details of the abnormalities of cartilage and bone.

2:00

Here you can see again the separation of the cartilage.

2:04

So it's not a technique that we are using,

2:07

but it's one that might be helpful.

2:09

Now, one of the classic features of chronic injury

2:13

or osteochondritis disc against of the Taylor dome

2:18

is cyst formation.

2:19

And I've been impressed that as you look at these cysts,

2:22

often they become extremely large either in a horizontal

2:26

direction or in a vertical direction.

2:30

And I've seen examples

2:31

where those cysts have even extended down

2:34

to involve the posterior sub Taylor joint.

2:37

So cyst formation, well recognized.

2:41

Here's another example of osteochondritis disc hands

2:44

of the Taylor dome involving the medial Taylor dome shown

2:48

by conventional radiography.

2:50

And then a T two weighted Mr Coronal image

2:54

with traction placed on the ankle and foot.

2:58

Beautiful example of an intraarticular body

3:01

and you can see here fluid extending

3:05

beneath the slightly separated cartilage and bone fragment.

3:10

Now when we deal with osteo hands of the tailored dome,

3:14

there are some associated conditions that may be present.

3:18

The one that I'm gonna emphasize,

3:20

and I'll talk more about this later in the lecture,

3:23

is tarsal coalition.

3:25

If you are dealing with a developmental tarsal coalition,

3:29

which involves a large number of joints

3:32

or even a single joint, such as the most common region

3:36

of the middle facets as shown here, the fact

3:40

that this occurs early in life,

3:42

what we may see is abnormal development of the Taylor Dome

3:47

and you get what's been called a ball and socket ankle joint

3:52

because the sub Taylor movement is limited

3:55

and the ankle is taking over for some

3:58

of the movement normally occurring in the subtalar joints.

4:03

I want to call your attention also

4:04

to the obliquely oriented abnormal orientation

4:08

of the posterior subtalar joint telling you something is

4:11

wrong and it's often a coalition.

4:14

I'm showing you another example here.

4:16

This is a coronal section in a cadaver in an adult

4:20

who's had a halo calcan coalition involving

4:24

the medial facets.

4:26

And although there isn't a ball and sock

4:28

and ankle joint, you can appreciate in fact

4:31

that there is cartilage abnormalities, okay occurring.

4:36

So you might imagine that in some

4:38

of these persons osteochondral fractures

4:41

or osteo diskin may occur the associated condition,

4:46

a tarsal coalition.

4:48

Now in the differential diagnosis

4:50

of osteochondritis dis hands,

4:53

there are other things that come to mind.

4:56

One of those is osteonecrosis.

4:58

And in a previous lecture I told you,

5:01

whenever I see widespread osteonecrosis as illustrated here

5:06

in a patient and in a cadaver, I always think of lupus

5:10

with corticosteroid therapy, multiple bone infarcts in areas

5:15

of osteonecrosis involving the foot

5:19

and ankle region.

5:22

Another cause of bone fragmentation about the ankle

5:25

that might simulate osteochondritis disc

5:29

and is, is neuropathic osteoarthropathy.

5:33

I show you a beautiful example of congenital insensitivity

5:37

to pain in a patient with minor neurologic deficit

5:41

that has now had a problem in his ankle with an effusion,

5:47

synovial proliferation

5:49

and a subcon fracture characteristic.

5:53

Fragmentation of neuropathic osteoarthropathy

5:57

In terms of the treatment of osteo

5:59

and cystic organs of the Taylor Dome.

6:02

In some cases conservative treatment.

6:04

In other cases, surgery with three particular programs

6:09

that might be suggested stimulant programs such

6:13

as debridement, chondroplasty, and micro fracture.

6:17

And you're seeing the results here.

6:19

Beautiful results, again, a case from James Griffith.

6:23

Regenerative programs with chondrocyte implantation

6:27

and replacement programs with an allograft or autograph.

6:32

Those are the methods of treatment.

6:35

We're gonna move down now to the subtalar joints

6:38

and talk about osteochondral fractures

6:41

of the posterior subtalar joint.

6:44

And here I'm gonna con concentrate on this particular

6:47

region, the lateral process, which is at the anterior aspect

6:51

of the posterior sub subular joint.

6:53

Here is what looks like in the other uh,

6:56

pictures right here.

6:59

This is a well-known site of fracture.

7:02

It's often called snowboarders fracture.

7:05

I show you an example at the top right.

7:08

It is a lateral pros fracture.

7:10

It represents about 25% of all Taylor fractures.

7:15

It also is a common injury up to 15%

7:18

of ankle injuries in snowboarders.

7:22

The mechanism of this debated,

7:25

but probably relates to a combination of axial loading

7:29

dorsiflexion and external rotation of the ankle.

7:32

And in cases at which in which you see this,

7:36

there may be associated abnormalities including problems

7:39

with the calcaneal fibrile ligament, the deltoid ligament,

7:43

and in some cases perineal tendon abnormalities.