0:00

Now I'd like to progress to the second case.

0:05

And for the second case, uh,

0:09

let me put the case here first.

0:13

Let's see the x-ray of the case.

0:18

So here we can see the case.

0:24

So the left ankle,

0:26

the second case is a 16-year-old female

0:30

with anterior ankle pain for three months.

0:33

Um, in the x-ray, I think

0:36

that everybody can see this lid lesion right here

0:41

at the meta, uh, meta epi area of the t

0:45

of the distal tibia.

0:47

We can see that the lesion is well-defined.

0:51

We can see a small sclerotic, uh, margin, uh,

0:56

uh, in this lesion.

0:57

Uh, we can see also this lesion here

1:00

at the enter posterior view, uh,

1:03

and we can, uh, repair the de lesion.

1:06

It's not, uh, well-rounded.

1:10

It's more, it's a kind of elongated,

1:13

and maybe there is some communication with their,

1:17

with their articular space right here.

1:20

Look, that the image is kind of elong elongated,

1:23

and there is somewhat here some, the lead lesion goes

1:28

to this area here.

1:29

And so this is important to our diagnosis.

1:32

In this case, when we see a lesion like that, uh,

1:36

in the MET Epi Physio region, we can, uh,

1:41

think about, uh, tumoral lesions and non-tumor lesions

1:45

and about the tumoral lesions.

1:47

Let's talk about like chondroblast stomach,

1:50

giant cell tumors.

1:52

Uh, maybe a subc chondral cyst, but it's not the age

1:55

and there is no osteoarthritis in this ankle.

1:58

And the about the norm tumor

2:01

or lesion, we should, we must think about infection.

2:06

And this is a classic finding,

2:08

and this is a classic image of a broad abscess of, uh,

2:13

infection osteomyelitis of the, of this area right here,

2:18

uh, uh, subacute slash chronic osteomyelitis.

2:21

That is the body's abscess.

2:24

So let's go to the, uh, to the, uh,

2:29

computer tomography of this case.

2:31

So in the computer tomography,

2:32

you can see the lesion right here.

2:35

We can see that the lesion, it has, uh, elongated aspect.

2:39

We can see the, this sclerotic margin right here

2:44

and thiss sclerosis around the, the area.

2:47

Also, not just the margins of the lesions, uh, sclerotic.

2:52

And here we can see maybe this is like,

2:55

probably this is sequestrum inside the lesion

2:59

In this area. And

3:00

here at the central plane, we can see that this lesion

3:05

communicates with the articular region.

3:07

And that's a problem, right?

3:09

We are talking about probably this is a, uh, infection,

3:12

and it's infection that is getting the metaphyseal region,

3:16

and it's going to the epiphysis

3:18

and it's going to the, uh, to the articular joint.

3:22

And, um, this, uh, this woman,

3:27

uh, it's 16 years old, and the metaphysic plate

3:31

or the growth plate is closed.

3:34

So the body is abscess in this patient.

3:37

It works as a broad, is abscess in an adult, okay?

3:41

Because if this was in a child, in a child

3:45

with the growth plate, uh, open, probably the,

3:49

the growth plate will, uh, contain the lesion

3:52

and will stop the lesion.

3:54

But here as an adult bone, uh, that this, uh, woman,

3:59

woman, woman has, uh, what happens is

4:03

that the blood is abscess, it goes to the epiphysis

4:06

and it communicates with the articulation.

4:09

So let's see that better on our, on, on the MRI.

4:14

So here on the MRI,

4:16

this is the T two weighted image here.

4:21

It's also, uh, T two weighted images, a PD weighted image.

4:25

We can see the le the, the lesion right here.

4:28

We can see the, uh, edema in all the inflammation,

4:33

uh, all the, the sep arthritis

4:36

that comes along in this case right here.

4:39

Look, look, that aspect of the onion, uh,

4:43

onion, uh, it's a onion.

4:46

I, I forgot the other name,

4:47

but this laminated aspect of the,

4:51

of the synovial, uh, membrane right here.

4:55

It's also very character risk of, uh, septic arthritis.

4:59

So this is an broad is abscess

5:01

with sep uh, septic arthritis.

5:04

Uh, this is, uh, common, uh, pattern related

5:09

in adult patients, okay?

5:11

In the childhood, it's not like that

5:13

because the growth plate protects the, the epiphysis

5:18

and protects the, the articulation.

5:22

But in the adulthood

5:23

and in the infant, when it very young children, uh,

5:28

the, the VAs of the metaphysis, they communicate

5:31

with the VAs of the epiphysis

5:33

and this pattern of lesion can occur.

5:36

So this is the pd, this is the T two showing the lesion.

5:40

And now I'd like to show you the T one,

5:42

because here in T one we can see the classic finding

5:48

of the penumbra sign.

5:50

Okay? So look here, look at this.

5:53

Uh, broad is abscess in this area here. It's not dark

5:57

On one. It's

5:58

somewhat bright. Okay?

6:00

So this is, uh, what we expect for an infection.

6:05

Uh, this is what we expect when we see, uh, an infection.

6:09

This is the penumbra sign. Uh, let me see here.

6:13

In this other plane, we can see.

6:15

Look, the difference here is our, it's our broadest abscess.

6:19

We see a high signal, not, not, it's not a low signal,

6:23

it's a intermediate signal here in this area,

6:25

different from a low signal

6:27

that we can see on the free fluid.

6:30

I, I'm gonna show you a free fluid right here, ah,

6:33

in this area here.

6:34

Let me get the post construct e composed

6:37

contrast image right here.

6:38

So this is post contrast image showing all the,

6:42

all the enhancement of the broad abscess

6:45

and the septic arthritis.

6:48

Look that in this area right here, we have some

6:51

somewhat some, uh, free fluid right here.

6:53

So the free, free fluid have right here. It's dark sign.

6:57

But look, all the rest, all the rest, we have this

7:02

lighter, uh, sign.

7:04

That is the penumbra sign.

7:05

So this is a classic finding, uh, that I like to show

7:09

with some good stuff to take from this case.