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Hello and welcome to Noon Conference, hosted by MRI Online

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Today we are honored to welcome Dr.

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Jonathan Sam for a case review live entitled Anatomy

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and Pathophysiology of the Forefoot.

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Dr. Sam is an associate professor of radiology

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and orthopedic surgery at Northwestern University Feinberg

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School of Medicine, primarily based at Anne

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and Robert h Lurie Children's Hospital of Chicago, serving

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as the Division Head of Body Imaging

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and section head of MSK Imaging.

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He also works in the adult MSK radiology section at

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Northwestern Memorial Hospital.

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At the end of the lecture, please join Dr.

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Sam in a q and a session

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where he will address questions you may

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have on today's topic.

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Please remember to use the q

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and a feature to submit your questions so we can get to

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as many as we can before our time is up.

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With that, we are ready to begin today's lecture. Dr.

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Samit, please take it from here.

1:18

Thank you very much, John Salmon here.

1:21

And, uh, excited to give you this, uh, talk on the forefoot.

1:26

And let's see here.

1:28

So, um, what we're gonna do today is have

1:32

sort of a two-part session.

1:34

First, we're gonna really dig into the anatomy.

1:37

Um, the first case is just a normal forefoot MRI

1:41

and just wanna go over some of the important things to look

1:43

for structures that I use in my search pattern, um,

1:47

pathologies that I look for.

1:49

And then we'll start going through a few cases

1:51

and, um, see some common pathologies

1:53

that they're gonna see in practice.

1:56

And I have the, uh, chat bar open, um, for questions.

1:59

So please feel free to ask questions as we go along.

2:02

What I'll do is I'll go through a case or so,

2:05

and then I'll try to answer the questions after that.

2:08

So first, um, let's go in here

2:10

and, um, look at this normal foot, uh, MRI.

2:16

So, um, what you can see is that, um, when you, uh,

2:21

image the forefoot, um, first

2:24

of all, what are we talking about?

2:25

We're talking about, um, really from the tips of the toes

2:29

to sort of the midfoot.

2:31

Um, the hind foot

2:32

or ankle would be more the, just the hind foot to the,

2:36

the tarsa metatarsal joints.

2:38

Um, if you, uh, image the entire foot in one field

2:42

of view from the heel all the way to the tips of the toes,

2:46

the only issue with that is that you sort

2:47

of have a very zoomed out view of the whole foot.

2:50

In pediatrics, sometimes we do like that

2:52

because, uh, we can just get a lay of the land.

2:54

Um, but for most, uh, imaging, adult imaging

2:59

and, uh, once you're a teenager,

3:01

so you really wanna have a zoomed in kind of small foot

3:04

of you over just the forefoot alone in order to be able

3:06

to make good diagnoses.

3:08

So when you think of the protocol,

3:10

of course you want three planes.

3:12

Um, you want a short axis, a long axis, and a sagittal.

3:16

Um, there's a variety of ways to do it here.

3:19

Um, in this, uh, particular, uh, example, we're scrolling

3:23

through a long axis, T two, um, turbos echo image.

3:27

So this does not have fat suppression.

3:28

It depends on what region you are practicing, uh, in.

3:32

Um, I do also like to have a fat suppressed image in general

3:35

to assess for bone marrow edema.

3:38

But let's just, uh, go ahead

3:39

and start here looking at the forefoot.

3:42

So first thing is just to kind of get familiarize yourself

3:45

with the, um, bone anatomy.

3:48

So when you look here from the proximal aspect,

3:51

what we're gonna see is the midfoot bones.

3:55

So, um, depending on your exact field of view, um,

3:59

you're gonna see the, um, tarsal bones here.

4:03

So I'm gonna minimize this thing here

4:05

so you guys don't have to see that.

4:07

And I'm also going to, um, rotate this here.

4:12

When you look here, you see the, um, navicular bone, uh,

4:16

and it's gonna have a large kinda articulation

4:18

with three other bones.

4:19

Here you have the medial QA formm, the intermediate

4:23

or middle QA formm, and the lateral QA formm.

4:26

So forming the navicular qa formm articulation,

4:29

you're gonna have the cuboid here in part of the BL to view.

4:35

And so, um, the next layer

4:37

of joints is gonna be the tarsa metatarsal joints.

4:39

So it's a very important joint.

4:41

Um, what we're seeing is the first, second, third,

4:46

fourth, and fifth tarsa metatarsal joints.

4:50

Now, the first metatarsal should line up

4:54

with the first QA formm.

4:55

And when we say line up, we're pretty strict about that

4:58

for the, um, for the TMT joints.

5:00

So think of these four bones as, uh, bones

5:03

that really should be locked together very tight.

5:06

This sort of holds in the hole forefoot.

5:08

Uh, you have two lined up with the second, uh, q and A form.

5:13

So you really wanna be strict.

5:14

You don't wanna see any step offs here.

5:16

And the, of course, the, the main ligament that you want

5:19

to be able to identify

5:21

and they're gonna be asked to, um,

5:23

evaluate is the Liz Frank Li.

5:25

Now, of course, there's ligaments that are going between,

5:27

uh, the, all of the base of the metatarsal,

5:29

but the one that's very important is the Liz Frank Ligament

5:32

proper, which is here shown here.

5:34

And you can see that there's a diagonally shaped hypo

5:37

intense structure going from the base of the second

5:40

to the medial CNA form.

5:43

And yes, it does have different parts, the dorsal part, the

5:48

um, interosseous and the plantar,

5:51

but when you're on the long axis,

5:53

this I think is the best view

5:55

to really get a nice look at the Liz Frank Ligament.

5:58

You should look straight, very taut in appearance.

6:01

Um, can have a little bit of striation, that's okay.

6:05

But in a Liz Frank injury, uh, you might have of course,

6:09

rupture of the ligament.

6:10

You might have edema surrounding the ligament,

6:12

and also look for bone marrow edema

6:14

around this site as well.

6:16

So one of my big search patterns is just looking at these

6:19

four bones, again, making sure that one lines up with one,

6:22

two lines up with two, and the Liz Frank ligament is intact.

6:25

We can also look at the Liz Frank Ligament

6:27

on the short axis.

6:28

So we'll scroll through that. And

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I'm also going to

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Keep the chat option open just to make sure that I can still

6:44

answer questions in a bit.

6:46

What you're seeing here in the short axis is, um,

6:49

as we go all the way to the same area,

6:52

it becomes a little bit more confusing.

6:54

What bones are we actually looking at?

6:56

Um, and what you can do is just remember

6:59

that you have the tus, the calcaneus.

7:01

As you go distally, you're gonna be able

7:05

to see the Liz Frank Ligament here.

7:07

This is an interosseous portion.

7:09

You are gonna have a dorsal band, the planter band also,

7:12

you can sometimes see as well, um, being over here.

7:16

Now the planter band can go to the third metatarsal base.

7:19

But, um, stressing again, I think the,

7:23

the long axis is really your best bet

7:26

to find the Liz Frank Ligament.

7:27

And it's shown right here.

7:29

So, um, remember

7:32

that we do talk about the Liz Frank Ligament a lot,

7:34

but again, there's other things that will keep those bones,

7:38

uh, first on first and second on second as well.

7:40

So, for example, you have the capsule

7:42

of the first TMT joint, so I always wanna check that

7:45

that is intact, as you can see here, right?

7:49

Um, and, um, again, I check for bone marrow edema

7:52

around these sites.

7:54

If you have an X-ray with a possible bone fragment,

7:58

then actually CT might be better to, um, able

8:01

to see those small little avulsion fracture fragments if the

8:04

Liz Frank Ligament pulled off a bit

8:06

of bone from either side.

8:09

So that is, um,

8:11

a little bit about the Liz Frank ligament to start.

8:14

Um, when you come over here to the, uh, oid, you can see

8:19

that the cuboid, uh,

8:21

is a lar larger than than just one metatarsal.

8:24

It actually connects to the fourth

8:25

and the fifth, um, metatarsal.

8:28

So the fourth and fifth

8:30

TMT joint is basically the cuboid to both of those.

8:34

And, um, what you're gonna see is

8:36

that there's actually some important structures

8:37

that will attach to the base of the fifth.

8:40

So the base of the fifth, right?

8:42

The very important thing, we're always looking

8:44

for fractures at the base of the fifth.

8:47

If the fracture is a small little avulsion fracture off the

8:50

tip, um, that would be, um, less

8:52

of a significant than if it's more of a Jones fracture,

8:55

which is sort of just a regular, uh, shaft fracture of the,

8:59

uh, fifth metatarsal.

9:01

If you have a shaft fracture, then of course

9:02

that would be more, uh, more concerning

9:04

and might need to be treated,

9:06

uh, surgically or more aggressively.

9:08

You're gonna see two things

9:09

that are attaching to the base of the fifth.

9:11

Um, so you might be familiar with, um, one of them.

9:15

So this linear structure

9:16

and this hyperintense structure is gonna be the insertion

9:19

for the peroneous brevis.

9:21

Uh, we're used to looking at that more on ankle MRI, um,

9:26

but remember that it does attach to the base of the fifth,

9:28

but it attaches more along the dorsal side.

9:30

So you're seeing that here.

9:32

But when you get to the plantar side, um, you're gonna see

9:35

yet another, uh, linear structure as well,

9:38

a little bit lesser known.

9:40

Um, and this is actually part of the plantar fascia.

9:43

So we just had a case, uh, on the adult side where someone,

9:46

uh, just had what seemed like plantar fascia,

9:48

but it wasn't at the heel.

9:50

And remember that the lateral cord will actually attach

9:53

to the base of the fifth as well.

9:55

So there's, there's a couple of things that attach there.

9:57

And then when we go to the short axis,

10:00

you can sometimes appreciate that.

10:01

So when you're in the short axis,

10:04

you can see coming from dorsal is gonna be

10:05

that peroneous brevis.

10:07

As I scroll down,

10:08

you'll see the peroneous brevis right here attaching

10:11

to the base of the fifth.

10:13

But on the plantar aspect,

10:15

you can see here this little black structure is actually

10:17

attaching to the plantar aspect of the base of the fifth.

10:19

That's your lateral cord of the plantar fascia.

10:23

So base of the fifth, of course,

10:25

is an area that is troublesome.

10:27

You wanna look for bone marrow edema, fractures,

10:29

avulsion fractures, and things like that.

10:34

So that's, um, that's kind of the first part is

10:39

what I look for in the, the back of the midfoot.

10:41

And as we go, um, towards the toes,

10:45

the next big thing I look for, um, is

10:48

stress fracture of the metatarsals.

10:50

Very common, um, to see that.

10:52

And what you're gonna do is you're gonna basically gonna

10:54

look at each metatarsal bone separately, scroll

10:58

through them, and you're gonna want to check

11:00

for any bone marrow edema, any fracture,

11:03

any periosteal edema, or new bone formation.

11:06

When you have a stress fracture,

11:08

there's a spectrum of findings.

11:10

If it's very mild, you might just see a normal x-ray,

11:13

and then you go to MRI,

11:14

and you see bone marrow edema in the shaft

11:16

of the bone will show a picture of that.

11:19

If the patient keeps running, uh,

11:21

you might have an actual crack in the bone,

11:24

and so you're gonna wanna see an actual line

11:26

going through the cortex.

11:27

So there's a variety of findings,

11:29

but usually you're gonna see bone marrow edema kind

11:31

of in the mid shaft of the bone,

11:33

and that is a very important finding to look for.

11:36

Here's the sagittal images,

11:38

and we also can look for bone marrow edema

11:41

in the metatarsal shaft.

11:43

This case is, uh, showing an example

11:45

of relatively normal flemer, I just giving you, um,

11:48

just kind of pointers of what is,

11:50

what is a search pattern you can do

11:51

to make sure you don't miss any important pathology.

11:58

Now I'm going to then move on

12:00

and go more distally into the, um, into the foot.

12:13

And what you're going to start looking for is the shape

12:16

of the metatarsal heads.

12:17

These are called the metatarsal heads.

12:20

So one thing, um, that I always just double check

12:23

for is the second metatarsal head.

12:26

That is a, a bony finding, a bony, uh, landmark

12:30

that can be affected by berg's infraction.

12:33

Free berg's infraction is one of the osteos.

12:37

It is a sort of idiopathic avascular necrosis

12:42

of the second metatarsal head, kind of think of it similar

12:45

to, uh, perthes or a VN and the femoral head.

12:48

You can get it in the, um, second metatarsal head.

12:51

Some people think that, um,

12:52

there's also just a there combination of overuse

12:56

and stress that, uh, that may be at play here as well,

12:59

because people who get it are typically, um,

13:02

very active runners and whatnot.

13:04

Um, but look at the shape of the head.

13:06

If you have it similar to femoral head,

13:08

AV n you might have a sub chondral fracture, you might have

13:11

collapse or depression of the, um, metatarsal head.

13:14

So this is a nice rounded shape for that.

13:18

Then I look at the fifth, uh, MTP joint.

13:22

And again, we're just focusing on

13:23

bony findings to start here.

13:25

Um, for the fifth MTP joint, I always just look, um,

13:29

to make sure that there aren't signs

13:30

of an inflammatory arthritis.

13:32

Uh, as you may know, uh,

13:33

rheumatoid arthritis likes certain areas

13:36

and in the foot, um, we sometimes will see an erosion

13:40

of the fifth metatarsal head neck area here and effusion.

13:43

So I do look in that area.

13:46

And of course, uh, last

13:47

but not least, the first MTP joint, very common joint, uh,

13:52

to be affected by osteoarthritis.

13:55

Um, and so this showing, we do have

13:58

to look at in multiple planes to assess

14:00

for osteoarthritis in the long axis.

14:02

Here you get a really nice view, similar to, um, the, uh,

14:06

AP view of the foot,

14:07

and you're gonna wanna look for joint space narrowing,

14:09

osteophyte formation, subc chondral edema,

14:12

cyst formation and whatnot.

14:14

But remember that the undersurface of the joint

14:18

also can be affected by osteoarthritis.

14:20

And so what we're gonna look

14:22

for here is the hallex sesamoid, um, articulations.

14:31

And so on this view, what you can see is that there are two,

14:36

um, ossicles.

14:38

So this is gonna be the medial Hal Smide,

14:42

and this is the lateral haloid.

14:45

You'll also hear the terms, um, tibial hal smide

14:48

and fibular haces.

14:51

So what you'll notice is this interesting

14:53

shape of the articulation.

14:55

You have the sesamoids, which are gonna articulate

14:57

with the undersurface of the metatarsal head.

15:02

And first thing you want to notice is if they are aligned

15:06

with the metatarsal.

15:08

Sometimes what happens is with, um, foot deformities,

15:11

you'll have kind of a translation

15:14

of the sesamoids that'll might go have a what's called

15:17

peri aal rotation.

15:18

The sesamoids might shift over lateral, for example, um,

15:22

and the head could swing, um, medial.

15:24

So you wanna just first assess, um,

15:26

are they actually articulating in the correct, uh, location,

15:30

similar to sort of a sunrise view.

15:32

When you're looking at the knee, uh,

15:33

you would wanna just make sure

15:34

that they're actually aligned.

15:36

Um, then what you're gonna do is you're gonna go

15:38

to the sagal images.

15:40

And in this case, this is a, a t two kind

15:43

of gradient, uh, sequence.

15:45

And you wanna make sure that the sesamoids are whole,

15:48

that they're not, um, you know, uh,

15:52

uh, fractured or bipartite.

15:53

Actually, here's another one, a long axis view of it.

15:55

So again, here's the lateral and medial holic sesamoid.

15:58

Um, you can see the little SALs here,

16:00

and they're along the under surface.

16:03

Now, the, the sesamoids, um,

16:05

as I'm sure you've seen many times on

16:07

radiographs, uh, can be tricky.

16:09

The medial Hal sesamoid, uh, often has a what's, uh, known

16:13

as a bipartite sesamoid.

16:15

Uh, so it comes in two halves, and that can be confusing

16:19

because it may, uh, look like a fracture.

16:22

Um, but remember that, uh,

16:25

bipartite moid is very common.

16:27

Now you can have a bipartite moid and still have pain.

16:31

So if it comes in two parts,

16:33

it could still have bone marrow edema

16:35

and osteo stress reaction.

16:36

So at first, you just wanna describe what you see

16:39

and don't, don't stress too much about the interpretation

16:41

just yet, but you can see here there's two sesamoids

16:46

and they're whole.

16:48

Um, when we look at the sagittal images,

16:51

you can see again the, um, sesamoids

16:54

and we'll go to the, um, medial haloid.

16:58

Now, in this case, the patient does seem

17:00

to have a little bit of a fragmented, uh, look

17:03

of their medial Hal ssm, um, a bit of bone marrow edema.

17:07

So that could be the sequela, a prior stress reaction.

17:09

This, this moid, uh, tends

17:11

to have these sesamoids have a stress.

17:13

Of course, you're standing on your foot.

17:15

As we go to the lateral side,

17:17

you can see a more normal appearing, um,

17:19

lateral Hal Moid articulating with the under surface.

17:22

So similar to other joints, just look for, uh,

17:25

subc chondral edema, cyst formation osteophytes,

17:28

and comment on the status of the kind of,

17:33

uh, first MTP and haces moid complex.

17:38

So, um, again,

17:40

you also can look at these MTP joints on the sagittal.

17:45

And first, just kind of look for joint effusions, look

17:48

for signs of arthritis.

17:52

You also get, again,

17:53

a nice look at the TMT joints on the sagittal as well.

17:57

So check those, okay, um,

18:02

multiple joints for you to assess.

18:05

So that, um, that covers most of the, um, osseous findings.

18:10

Of course, you do have the, um, the PIP

18:13

and the DIP joints of the toes as well,

18:16

that you wanna just at least scroll through and check.

18:19

Moving on. Um, if you notice,

18:21

and we can stay on this plane here, we

18:23

of course have the flexor and extensor tendons.

18:26

So the flexor and extensor tendons, uh, are going

18:30

to be going to their destinations to the toes.

18:33

Um, what we can see here is that there's an extensor tendon,

18:36

extensor houses tendon going to the base of the first,

18:40

uh, distal failings.

18:43

Remember that in order to extend

18:44

and flex each, um, each joint, you have to have a tendon

18:48

that will go to those joints.

18:49

Uh, so that's kind of how I think about it.

18:51

So you can see here the, uh,

18:53

extensor Hal's previs will then go to the, uh, base

18:56

of the proximal phalanx.

18:57

On the flexor side, you have a flexor tendon

19:00

that's going all the way to the tip of the, uh, not

19:04

to the tip, but to the, uh, distal phalanx.

19:06

So flexor, it's a flexor house as long as,

19:08

and each of the toes are gonna have an extensor tendon

19:12

and a flexor tendon.

19:14

So you wanna make sure that those are intact.

19:15

Usually, uh, you are not gonna find a rupture

19:18

unless there's a good history.

19:20

Occasionally have a patient who's had, uh, who has a more

19:23

of a clinically occult rupture,

19:26

and they may present with a mass,

19:27

and you might see a bald up tendon,

19:30

or you might see teno synovitis.

19:32

So look at those tendons as well.

19:34

Look at them on the short axis,

19:36

which is a really nice view for me.

19:38

I like to look at the fortino synovitis.

19:40

So in the short axis, you can see the extensor tendons

19:44

as these little black dots here and the flexor tendons.

19:47

So you can scroll through. I look for tenitis.

19:50

I look to make sure that they are in the midline,

19:52

that they're attached, uh, that they're, uh, aligned

19:55

with their respective ray here.

19:58

One thing to note for the flexor lysis, uh,

20:01

longest is the flexor for the gray toe, is that it does,

20:04

has an interesting, uh, course.

20:06

So you'll see the flexor haliss here.

20:08

And when you get to that Hal sesame complex,

20:10

which we're gonna go into more detail in a minute,

20:12

you're gonna see that the flexor haliss long is

20:17

the FHL is right in the middle.

20:19

It's in the middle between the two sesame.

20:22

So that's a good landmark.

20:24

So the, the flexor house as long is gonna go right

20:28

between the sesamoids

20:29

and it's actually just superficial to this structure,

20:31

which is the intermodal ligament.

20:35

And, um, you're gonna follow that,

20:38

make sure it's in the midline.

20:39

It's gonna keep going all the way to the distal failings.

20:46

When you look, um, a little bit further back,

20:51

you're gonna see multiple muscle groups.

20:55

Um, when you're reading emr, you do want

20:59

to take a look at those, and you do want

21:00

to comment if there's any atrophy or edema.

21:03

Um, on the extensor side, you have extens digitorum muscles.

21:07

On the flexor side,

21:08

you're gonna have the abductor lysis muscles.

21:12

You're gonna have, um, and we'll go over that in detail.

21:15

You're gonna have brevis and longus.

21:17

You're gonna have the extensor digitorum brevis muscles just

21:21

deep to that quadratus planty.

21:23

And on the outer side, the lateral side,

21:25

you're gonna have the abductor digi MiniMe.

21:28

If you have Baxter's neuropathy, right,

21:30

which is basically kind of an impingement

21:32

of the first branch off the lateral plantar nerve,

21:36

you might have atrophy

21:38

and fatty infiltration of the, um, abductor digi MiniMe.

21:42

So that's one thing you can look

21:43

for like the short axis for that.

21:48

Remember that the plantar fascia keeps going.

21:49

So this is not at the heel,

21:50

but of course you still see the plantar fascia.

21:53

That's type one 10 structure here.

21:55

And the plantar fascia has the three cords.

21:57

We talked about the lateral cord as sort

21:59

of this lesser discussed, uh, part of the plantar fascia

22:02

that will go to the base of the fifth.

22:04

And then we have the central cord

22:06

and the medial cord as well.

22:12

And then scrolling through, again, if you were looking

22:14

for stress fracture, you would look around each

22:17

of the metatarsals here to make sure

22:19

that there wasn't any periosteal edema, muscle edema,

22:22

you can see stress fracture lines if they're there.

22:27

Okay, moving on.

22:30

Um, there's also, um, very important structures of each

22:35

of the MTP joints known as the plantar plate.

22:39

So the plantar plate, um, is basically, uh, think of it

22:43

as analogous to the voor plate, uh,

22:45

in the hands, but not exactly.

22:47

It is a sort of, um, thickening of the capsule, um,

22:52

uh, fibro cartilagenous structure, um,

22:55

along the plantar aspects of the joints.

22:58

And, um, it's gonna be deep to the flexor tendon

23:03

for each of the joints.

23:04

And, um, you need good high resolution images

23:08

to see it well,

23:09

but as I zoom in here,

23:14

what you're gonna see for each of the toes is

23:17

that there's a, a flexor tendon.

23:19

But then if you look just on the bottom part of the,

23:22

of the joint, you're gonna see a black structure.

23:27

Here again, is a plantar plate here of this, uh,

23:32

fourth MTP joint.

23:35

Notice that there's a little bit of a fluid recess here.

23:38

So, um, try not to overcall tears of the plantar plate.

23:43

Um, near the fla, uh, the phal attachment,

23:46

you will see a little thin, um, sliver of fluid.

23:49

That's a normal recess.

23:51

Um, there was a talk, uh, just at the rss NA, uh, and,

23:55

and I've heard in the past where basically if this fluid

23:58

slit, um, is more than two and a half millimeters,

24:02

and that will be more concerning for a tear.

24:04

Uh, so a little tiny bit of fluid is okay,

24:07

but you don't wanna see a bigger fluid, uh, gap

24:09

as you keep going to the bigger joints.

24:11

Again, you can see this plantar plate, sort of think of it

24:13

as a thickening of the under surface of the capsule,

24:16

little tiny, uh, recess of fluid there.

24:19

And then, um, as we get to, um, the, the biggest, uh,

24:23

join you kind of have, we're gonna discuss here the, uh,

24:26

the first MTP.

24:27

So when you talk about the first MTP, there's a lot

24:31

of structures and we,

24:32

we've mentioned a bunch of them so far.

24:34

But to keep going, remember you have the first metatarsal

24:37

head and the proximal phalanx.

24:39

You're gonna have the join here of the MTP,

24:43

and you're gonna have the Hal Smide articulations.

24:46

The planter plate of the first MTP is shown here.

24:50

You can see this kind of, um, hyperintense structure,

24:53

linear structure, and there is the, again, a recess here

24:57

between the phalanx and the plantar plate.

25:00

So try to avoid, um, calling tears,

25:02

unless it's a more of a larger gap for the plantar plate.

25:08

Now, the plantar plate structures, um,

25:10

are really at the midline, so

25:13

that's an important thing to remember.

25:14

So right here, we're at the midline.

25:16

What I'm gonna do is actually go off to the side here.

25:19

This is the lateral part of the joint.

25:23

And if you see here, we have the CSEs moid,

25:25

but then we have a black structure going from the CSS moid

25:28

to the proximal failings.

25:31

This is the sesamoid phalangeal ligament.

25:35

Uh, so it is a ligament, again, a supportive structure

25:38

that you want to check,

25:39

because that can be, um, torn in the setting of turf toe.

25:44

So you have the, uh, ligament going from the cess moid

25:47

to the phalanx on the medial side.

25:51

You, again, are gonna have a ligament going from the medial

25:55

Hal Moid to the proximal failings.

25:57

Again, this is nice and intact.

25:59

You see hypertense, uh, ligament there again,

26:02

we talked about how this sesamoid might have a bit of edema,

26:05

have some stress reaction,

26:06

but the ligament itself is intact.

26:10

You also have, um, ligament stitch that aren't, aren't

26:13

as commonly torn, but you still wanna look, um,

26:15

that go from the sesamoid to the metatarsal,

26:18

the sesamoid metatarsal ligaments.

26:19

So again, you can see here on the proximal side,

26:22

there's a ligament going from the smite to the metatarsal,

26:25

and you're gonna have one on each side.

26:27

So go to the medial side and then the lateral side.

26:34

So, um, going then to the short axis,

26:44

we're gonna see that

26:50

the sesamoids are connected by an intermodal ligament.

26:56

So again, this type one 10 structure

26:58

going between the ligaments.

26:59

So you wanna just check that as well.

27:01

And remember that the FHL, the flexor house

27:04

as long is just superficial to that.

27:08

Also, when you're on the, um, when you're on the long axis,

27:12

remember that every joint is gonna have a medial collateral

27:15

ligament and a lateral collateral ligament.

27:17

So this is totally separate from everything

27:19

we've talked about so far.

27:20

But you also just wanna check that those, um,

27:23

ligaments are intact.

27:26

It's not uncommon to see

27:29

some cyst formation at the sites

27:32

of these ligament attachments.

27:33

I think of them as just sive cyst traction cysts.

27:37

Um, over time, if you have valgus, uh,

27:40

you might have some stress on those ligaments.

27:42

You might have osteophytes.

27:44

So remember the, the collateral ligaments

27:47

of the great toe as well.

27:50

So when I do my search pattern of the great toe, uh,

27:54

Hal Sesamoid complex, I'm looking at all those things.

27:56

So to review, you have your collateral ligaments,

27:59

you have the joint itself, you have the sesamoids.

28:02

You wanna assess the sesamoids.

28:03

Are bipartite, are they fragmented?

28:05

Is there bone marrow edema?

28:08

Um, you want to look at the plantar plate, um,

28:12

for all of the joints, but particularly the, the gray toe.

28:16

Um, you want to look at the sesamoid phlange ligaments,

28:19

one on each side.

28:21

And one last thing I I forgot to mention,

28:24

we talked about the flexor lysis longus, uh,

28:27

but remember that we have these two muscles here

28:30

with their individual tendons, flexor lysis, brevis,

28:34

and those, um, have an interesting attachment.

28:37

Uh, so where unlike the flexor lysis long,

28:39

which goes all the way to the distal failings,

28:42

the flexor lysis, brevis, medial,

28:44

and lateral heads will attach to the back of the sesamoids.

28:48

So the sesamoids have a lot of things attached to them.

28:50

And so you wanna remember that, um, those muscles, uh,

28:55

that you can see are attaching, uh, to the back of the,

29:00

uh, sesamoids show that, um,

29:03

in these cases here, right there as well.

29:09

So you have muscles, tendons, ligaments, um, many things

29:13

to consider, uh, when you're looking at these, uh,

29:16

these four foot MRIs.

29:18

And so, um, but I think go through the anatomy,

29:24

look at the patient's, uh,

29:27

clinical history, it's very important.

29:29

Um, look at the X-ray, look at,

29:30

look at an X-ray, if you have it.

29:32

Um, try to look at the clinical question that's asked

29:35

and focusing on those areas.

29:37

Um, and one thing, um, as well is, well,

29:41

is if there's a part of the anatomy that is, um, difficult

29:45

for you, uh, that you're kind of nervous to get

29:47

that one case, uh, that's evaluating for it.

29:50

Uh, for example, for me, it was always a Liz Frank ligament.

29:53

I was always nervous. I would get a case

29:55

and not know if it was torn or not.

29:56

Um, what you should do, I encourage people,

29:59

is when you get a a foot study for something else,

30:02

so stubb toe

30:03

or something, um, just look at the Liz Frank ligament,

30:06

look at that ligament that you're always kind of afraid

30:08

to miss when you have a real case of, of an injury to it.

30:12

And you get a sense of the normal variability of what

30:14

that ligament will look like

30:16

and try to find these structures when you're not under

30:19

pressure, uh, to, to diagnose, uh,

30:22

something at, at that time.

30:25

Um, so I am going

30:28

to then just make one other comment.

30:30

Um, here. I, I know there's a, um, a couple of things, uh,

30:35

else that are left here.

30:37

Um, before we go into the cases,

30:41

we talked about some of the muscles.

30:43

Um, we talked about the joints.

30:46

One of the thing that you're gonna be asked to look

30:47

for is Morton's neuroma.

30:50

And so Morton's neuroma, um, is basically, um,

30:55

peral scarring and neuroma formation

30:59

of the interdigital nerve.

31:01

So there's a nerve that goes in between the,

31:04

uh, toes, right?

31:06

Uh, and so we talk about the web spaces.

31:09

So you have the first, the second, the third and the fourth.

31:12

And what you're gonna look for is a focal area

31:16

and we'll showcase of, um, kind of T one intermediate

31:20

to low signal rounded, uh, mass like structure going

31:24

between the metatarsal heads.

31:26

And I'm at the level of the MTP joints here.

31:29

So you're gonna wanna scroll back and forth

31:31

through those areas here where my cursor is

31:33

and look for anything that looks like a rounded thing kind

31:35

of hanging down there.

31:37

Um, it's, uh, most commonly in the third, uh, MTP,

31:42

uh, third, um, in third web space.

31:45

Also the second very common.

31:47

So really focus in on the second and the third.

31:50

Uh, the thing that can kind of, um, trip people up is that

31:55

often with just joint pathology,

31:58

you might have peri capsular scarring along the plantar

32:01

aspects of the MTP joints.

32:03

Um, that density or that signal,

32:06

or mass lake area, sorry about that, will be, um, more so

32:11

in the midline, not, not so much, um, in the actual, um,

32:17

inter metatarsal space.

32:19

And so what you wanna do is really focus

32:22

between the metatarsal heads there

32:24

and see if you see any, uh,

32:26

any extra tissue in those locations.

32:28

And I will show an example on the T twos.

32:31

You want to, um, also look for inter metatarsal bursitis.

32:35

And so, um, what you're going to look for is, um,

32:39

too much fluid between the meta in metatarsal spaces in

32:42

that similar area you are.

32:44

Um, you are sort of allowed to have a little bit of fluid,

32:47

um, in those spaces,

32:48

but if you start to see kind of more rounded, um, areas kind

32:52

of going up and down and the patient has a history

32:54

that fits, that's when you can diagnose inter

32:57

metatarsal, uh, bursitis.

33:01

So, um, that is kind of a whirlwind, um, anatomy

33:05

of the forefoot, uh, forefoot midfoot

33:08

for your kind of what to look for.

33:11

Talked about the bones, the ligaments, the tendons.

33:13

Um, I'll pause there, just if anyone has any kind

33:17

of quick questions.

33:18

Um, and then, um, we will then go through, uh, some, uh,

33:22

example cases kind of to show what, um, what we might look

33:26

for in real life, in real, some real cases.

33:28

So if anyone has any kind of burning questions, uh,

33:31

something that I missed, uh, please, uh,

33:33

please put it in the chat, chat and, um,

33:37

and I'll try my best to answer it.

33:38

And then of course, we'll have time at the end

33:40

for more questions, um, as well.

33:45

So, okay, great.

33:53

Um, oh, here, I was looking in the wrong, wrong chat box.

33:57

All right. So, um,

34:01

where does the forefoot begin?

34:04

Um, so good question.

34:07

Um, I kind of think of the forefoot as distal

34:12

to the, uh, distal to the tarsal metatarsal joints.

34:16

Um, I I, I, I don't know if

34:19

that's the most anatomically correct, uh, thing,

34:22

but that's kind of what I think of in most

34:23

forefoot protocols.

34:25

Um, we basically go from the tips of the toes to at least,

34:29

uh, proximal to the tarsal metatarsal joints.

34:32

And so, um, you're gonna cover all of those areas.

34:35

Let's go to, um, one of these cases here that we have.

34:40

This is one that you will, I'm sure, um, commonly be asked

34:45

to, um, look for when you are reading MRI.

34:50

So this was a patient, um, with a, a, um,

34:56

kind of a wound, a large wound, um,

35:00

over the planter aspect of the foot, um,

35:05

and on exam.

35:06

And they were concerned, uh, for underlying osteomyelitis.

35:10

What you can see here is there is a, a very large kind of

35:15

wound and abnormality along the planter aspect

35:18

of the foot here, very thick walled, um,

35:23

kind of collection with central fluid here.

35:27

Um, so, um, if, if you're reading this,

35:30

you're gonna be concerned for a large abscess.

35:33

Um, you can see a central pocket of fluid here.

35:38

Whenever you're doing an osteomyelitis case, you always want

35:41

to, um, find the wound, locate the wound, uh, whether it's,

35:46

um, the media tab and the notes, uh,

35:49

or, um, the clinical history.

35:51

Try to look in that area specifically

35:53

because deep to that is where you might see pathology.

35:56

And then what you do is you're gonna want

35:59

to look at the bones just deep to the, uh, the wound

36:04

and to see for abnormalities.

36:05

So in this case, uh, I might call this a large, uh,

36:08

wound with abscess.

36:10

Um, I'm looking at the underlying bones,

36:13

and what you see is that it kind of tracks to the, um,

36:17

Taylor head here where there's a small amount

36:20

of bone marrow edema.

36:22

And we also wanna look

36:23

to see if we see T one marrow replacement.

36:25

Now in this case, we'll show a more, a more,

36:27

uh, dramatic osteo case.

36:29

This, I would say is probably subtle.

36:30

We have a little bit of loss of the T one signal

36:33

and a little bit of high signal on, uh, on the stir.

36:35

So I would say there's probably mild osteomyelitis here,

36:38

but certainly this large, um, kind of collection.

36:41

So another case of osteo as a companion case,

36:46

see here, um, what we can see here is

36:51

that there is focal bone marrow edema

36:54

of the first toe distal phalanx.

36:58

And on T one

37:02

you see corresponding low signal.

37:04

So for a kind of a confident diagnosis of osteomyelitis,

37:08

you do wanna see low signal on T one,

37:12

high signal on T two.

37:15

Um, I like the T ones and the sagittals.

37:18

Um, as I'm sure you've seen, you can have failure

37:21

of fat suppression on a, uh,

37:23

T two fat set sometimes in the foot.

37:25

And so sort of that stir sequence seems to be more

37:28

of the true, uh, signal that I like to see.

37:31

So here on T one, lots of marrow replacement, uh,

37:35

on the T one low signal,

37:37

and then on the stir image you see high signal,

37:40

it's just deep to a wound.

37:42

And this was a case of acute osteomyelitis

37:45

of the great to distal phx.

37:48

Very good. And then, um, moving on,

37:53

we are going to then, um, this is, uh,

37:57

just one last case of this here.

37:58

Um, first of all,

37:59

before we get to this, uh, first MTP joint

38:02

that looks extremely inflamed, notice how all

38:05

of the muscles are hyperintense on T two.

38:08

Um, that is probably not diffuse infectious myositis.

38:13

Um, that is more likely a patient who is diabetic

38:17

and has diffuse diabe diabetic myopathy.

38:20

Very common to see kind

38:22

of diffuse signal within those muscles.

38:24

But what we're showing you here,

38:25

and of course that's a setup for this patient,

38:27

placed spasm at risk.

38:29

That nice smooth joint surface of the first MTP joint, uh,

38:33

has been kind of destroyed very irregular.

38:35

There's subluxation of the joint.

38:37

We have marked hyper enhancement of the bone marrow

38:40

on both sides of the joint.

38:41

The joint is destroyed.

38:43

And so this being, um, a case of infection septic joint, um,

38:48

of the first toe, um, you see, um, terrible destruction

38:53

of the bone surfaces, hypo 10 signal on t2, not a normal,

38:58

uh, anatomy that we're being able to find.

38:59

And so this was a severe infection there.

39:02

What we're gonna do now is, um, show the next case here,

39:07

just going through number of an examples for you guys.

39:10

Um, one, uh, when we look on this, uh, sagittal sequence,

39:16

we're scrolling through the bones in this T two

39:17

weighted fat suppress sequence.

39:18

You can see that, um, most

39:20

of the metatarsals have a very low signal on the

39:24

T two fat suppressed.

39:25

Um, but when we get to the fifth metatarsal, you can see

39:30

that there's abnormal T two hyperintense signal in the shaft

39:33

of the bone, uh, with surrounding, um, marrow edema.

39:39

When we go to the axial images, um,

39:42

you also can see hyperintense signal in the marrow,

39:45

and this was a stress, uh, fracture of the fifth metatarsal.

39:50

Now, if I don't see a fracture line,

39:53

I'll use the term stress reaction.

39:55

Um, I believe that they treat them often similarly,

39:58

but of course it's a higher degree injury if you have an

40:01

actual fracture line

40:03

and on T one instead

40:08

of seeing the nice fatty marrow, you might, uh,

40:11

see a little bit of darkening of the marrow, um,

40:14

for a stress, uh, fracture.

40:16

So very common to see that as well.

40:19

Um, let's go on to, um,

40:23

some plantar plate injuries.

40:25

So we talked about the normal structure, sort

40:27

of a thickening of the capsule, uh, on the plantar aspect

40:32

of the MTP joints.

40:33

Um, so in this case, they were concerned

40:37

for a plantar plate injury.

40:39

Um, we're gonna go this time to the second, uh, toe.

40:43

And what you can see here

40:49

is that we have the second MTP joint, um,

40:52

we have the flexor tendon below,

40:55

but we have more than

40:57

what we typically would see for a recess.

40:59

You're seeing kind of a big fluid gap edema.

41:04

And so this was a plantar plate tear, um, at the,

41:08

at the second MTP joint, you can see here

41:10

that there's too much fluid here.

41:11

There's a discontinuity.

41:13

I'll show the adjacent, uh, joint here.

41:15

You can see a more normal plantar plate of this other toe.

41:19

It's always important to image at least one

41:21

or two other, um, other toes

41:23

or other, other fingers, uh, if you're evaluating the hand

41:27

to get a sense of normal control within that same patient.

41:30

Very, very helpful. Uh,

41:32

so here you can see a beautiful plantar plate attaching

41:36

to the base of the phalanx,

41:37

but then we go to the affected toe.

41:40

We see that there's obviously a disruption, uh, fluid here,

41:44

and this was a plantar plate tear.

41:47

Save the questions here just for a second here.

41:49

Let just see, see there's some related to that.

41:53

Um, is the normal first MTP plantar

41:56

plate recess that you put in the others?

41:58

Um, so the question is about the, the plantar plate

42:01

of the first toe.

42:03

Is that recess that we see

42:05

a little bit bigger than the other toes?

42:07

Um, I just,

42:11

from just personal experience, I think the whole,

42:14

the great toe is just, has a little bit bigger than all the

42:16

other toes just in general.

42:17

So everything might be a tiny bit bigger.

42:19

Uh, I still kind of use the same rules.

42:21

If it looks like a small little slit, uh, versus something

42:24

that's more than two and a half millimeters in irregular,

42:25

then um, I use that to kind of diagnose tear.

42:28

Um, we'll get to the next question, um, in a minute, uh,

42:32

here, but going on, um, to more cases,

42:38

um, I'd like to show you, um, something else as well.

42:43

So we talked about evaluation of Morton's Aroma

42:49

and, um, in my institution, we, um,

42:53

have more gotten used to, um,

42:55

ultrasound actually for Morton xr.

42:57

Um, I used to feel only comfortable with MRI for Mor Zoma,

43:02

but then when you do ultrasound, it's a little bit,

43:05

I feel like it's a little bit easier, I feel a little bit

43:07

more confident, but it is a hard diagnosis, um, either way.

43:11

So in this case, um,

43:12

what we're doing is we're gonna be scrolling through the,

43:15

um, the forefoot at the MTP level

43:17

and looking at the inter metatarsal areas.

43:20

And what you can see here in the third

43:25

web space, there is this hypo intense, uh, structure

43:30

between the toes that is not really centered

43:34

around the capsular area.

43:36

So that's, um, a good sign that you're not dealing

43:40

with just a kind of a pseudo neuroma

43:42

or the peri capsular scarring.

43:44

And this would be concerning for mourns.

43:46

Now, of course, you would wanna correlate

43:49

with the patient's symptoms.

43:50

So sometimes of course we might see things that

43:53

look like more omas, but the patient's asymptomatic.

43:57

Um, and, and this is, you know, a hard area,

44:02

we might just be seeing the peri cap, the peri, uh,

44:04

neural scar tissue.

44:05

And so you wanna definitely correlate with the, the history.

44:09

One thing that I, I didn't mention, uh, previously,

44:11

and this, this case is, uh, um,

44:14

has something else very abnormal on the medial side,

44:16

but you often see, um, a little bit

44:19

of callous formation at the, uh, basis

44:21

of the plantar aspects of the fifth and first MTP joints.

44:25

So, um, don't be alarmed if you see, uh, some kind

44:29

of scar tissue or even, um, edema signal along the base

44:33

of the, uh, the fifth MTP in the first.

44:36

Now this case, um, has a finding that is, uh,

44:40

not typical of callous.

44:41

So, um, what we're seeing here is way too much, uh,

44:47

rounded mass, like, um, signal, um, than,

44:50

than one might expect for, for callous.

44:53

Um, as we're looking here,

44:55

we can see there's multiple nodular mass like, uh,

44:58

structures along the medial implanter aspect.

45:02

And this, this one picture, I think tells it all.

45:05

So one

45:06

of the mass like structures is actually along this linear,

45:09

um, structure that, that we discussed as part

45:12

of the plantar fascia.

45:14

And if you look carefully, um, at these masses,

45:17

they are hypo intense on T one,

45:19

but they actually have some black streaks in them,

45:22

and that's a sign you're dealing with a fibrous lesion.

45:25

Uh, and so if you have a fibrous lesion, um,

45:29

in the plantar fascia, um, you do want to think about

45:35

plantar fibromatosis.

45:36

Uh, so plantar fibromatosis is multiple

45:40

fibromas along the plantar fascia.

45:42

Not uncommon. Um, often we see like one

45:45

or two, this is kind of a larger one.

45:46

So you do wanna, um, kind of correlate with the history,

45:49

make sure there's not like a rapidly growing sarcoma, uh,

45:53

that, that you could, you know, uh,

45:55

be mistaken to call it a FiberOne.

45:57

But usually if you have like one or two small ones

46:00

and it's, um, kind of has that kind of,

46:01

those black streaks within it, then it's a, a good sign

46:05

that it's a, uh, a, a planter, uh, fibroma case.

46:08

So it's just a nice case of that moving on, um,

46:13

a along that kind of same kind of family of, uh, masses.

46:18

Just wanted to show this case here.

46:21

Um, and then we can open it up for more questions.

46:24

Um, what we're seeing on this T two sequence is a

46:29

kind of nodular large rounded mass,

46:33

and a first glance kind

46:34

of very confusing, like, what is this?

46:36

Where is it coming from? Um, again,

46:39

very dark signal on T two.

46:42

There's not that many things that have such dark signals.

46:46

So we talked about, uh, fibromatosis.

46:49

Um, you can have desmoid tumors,

46:52

which is aggressive fibromatosis,

46:54

but you also want to keep in mind, uh, this entity, um,

46:57

which is another thing that can have dark signal.

47:00

And part of the reason it has dark signal is, uh, due

47:03

to the hemosiderin,

47:04

the old blood products within this lesion, we're used

47:08

to seeing this lesion within a joint.

47:11

Um, and it can be diffuse or focal form,

47:14

but it actually can also be a long tendon sheaths as well.

47:18

Uh, and so, um, you guys probably already know I'm going

47:22

to be talking about, uh, pigmented vi nodular synovitis.

47:26

Um, the newer kind of term is

47:29

tenino synovial giant cell tumor.

47:31

Um, and so, sorry, this is having trouble loading,

47:34

but basically it was a very hypo intense,

47:38

um, mass like structure.

47:40

Um, and this was PVNS of the, uh,

47:44

of the hindfoot there.

47:46

So what I might do now,

47:47

since we only have a few minutes left,

47:49

is open it up for questions.

47:51

Um, and I can kind of, um,

47:55

you know, try to answer some of them.

47:57

Uh, there's a question about any tips on reporting

48:00

tumors such as melanoma.

48:01

What are the key points to include in the report?

48:03

Apart from, apart from the depth of the tumor

48:05

and relationships with the muscles

48:07

and bone, I find it hard to detect acro melanoma lesion.

48:11

Um, I don't have

48:12

that much experience with that, to be honest.

48:13

It's usually the dermatologists who are diagnosing it, uh,

48:16

because they're looking at the skin.

48:18

And that would be more useful when we do image melanoma.

48:21

Um, of course, as you said, we're looking for the depth

48:25

of invasion, um,

48:26

which I think is probably the most important,

48:28

most important thing there.

48:29

So they tell you where the tumor is

48:31

and you wanna look, um, you know, how extensive it is,

48:34

how deep it goes, um, to give them, uh, answers for that.

48:38

Um, thank you for the compliment there.

48:41

Um, follow-up lecture on alignment

48:45

problems would be very interesting.

48:46

Sure, we can, we can work on that.

48:48

Uh, alignment, uh, is is a very difficult topic, um,

48:52

especially when you talk about congenital foot deformities.

48:55

I do pediatric Ms K, so I could try to teach that.

48:57

That's a interesting thing.

48:59

Uh, can contrast help more aroma?

49:01

So, um, very good question.

49:04

Neuromas, um, just in general will enhance on

49:07

post contrast imaging.

49:09

Um, probably because of the scar tissue, um, and whatnot.

49:13

Um, traumatic neuromas will enhance the more,

49:18

most commonly though, um,

49:20

you typically will do these studies without contrast,

49:23

orthopedics will just order them without contrast.

49:25

Um, I, I wouldn't,

49:27

I wouldn't necessarily recommend a foot mar

49:29

with contrast just for Mor Oma.

49:31

I personally would just do an ultrasound.

49:33

I think it's much more helpful because when you're in there,

49:35

you push on the foot

49:36

and if they have a lot of symptoms in that inner space,

49:39

you feel much more confident that you're dealing

49:41

with a Morton syndrome as opposed to just kind of, you know,

49:44

some other structure that you're over calling.

49:47

Uh, question any comments on osteomyelitis when you have

49:49

soft tissue infection?

49:52

Um, is every bone marrow edema already osteomyelitis?

49:55

So, um, no.

49:58

I think, um, when you're dealing with infection, again,

50:01

I think the most important thing is

50:03

to find out if there's a wound and where is the wound.

50:06

Uh, usually you can find that in the note.

50:08

You can ask your clinical provider right where the wound is.

50:12

You wanna look at the bone marrow just deep to that site.

50:13

So if you have, um,

50:15

if you have bone marrow edema at a site on the opposite side

50:18

of the foot, it's unlikely to be, um, osteomyelitis, right?

50:22

Because most of the cases

50:23

that we're gonna see on the adult side are contiguous spread

50:26

of, of, of infection.

50:28

Um, whereas, uh, you know, in pediatrics

50:32

or in sort of like spine disto osteomyelitis, for example,

50:34

it's more hematogenous spread

50:36

and then that any bone could be kind of affected.

50:39

But most cases that, that we're gonna read in the foot, uh,

50:42

are, are only right beneath the ulcer.

50:44

Um, next question. So I would ask about the last case.

50:48

Did you discuss synovial sarcoma?

50:50

So, um, this, uh, this is not a case for my institution, um,

50:54

but synovial sarcoma is a good thought.

50:57

It's a mass that is, uh, it's a misnomer.

50:59

It's not truly within a joint,

51:01

but it's actually around joints.

51:04

Peri articular, um, in my experience,

51:06

Novus sarcoma are usually T two hyperintense.

51:09

They're, they're actually known for being T two hyperintense

51:11

to the point that people, um, actually have been known

51:14

to mistake them for ganglion cyst or baker cysts.

51:17

So I've never seen the novias sarma that's

51:19

that dark on T two.

51:21

Um, and then as far as biopsy, yes, you would definitely,

51:25

uh, at our institution, our orthopedic oncologists, um,

51:28

are very big believers in needle

51:30

biopsy before they do anything.

51:31

Uh, I think that's a good practice.

51:33

And so, um,

51:34

you could do an ultrasound-guided biopsy of that mass.

51:38

Uh, another, uh, thank you, uh, comment. Appreciate that.

51:42

And so, um, yeah, I think, um, you know,

51:46

the anatomy is, is very important,

51:48

but I like a practical approach of just looking for key

51:51

for very common pathology, uh,

51:54

regarding plantar fibromatosis.

51:55

Do we need tissue biopsy? So most cases you might see a

52:00

small plantar fibroma.

52:01

Um, I don't recommend biopsy.

52:03

If you have a case like the last one I showed, um,

52:06

if you have a very large one, you know,

52:10

you can call your provider

52:11

and say, look, this is probably plantar fibromatosis.

52:14

How long have they had the mass?

52:15

If they say they've had it for years,

52:17

maybe you can watch it.

52:19

I don't think you need to do biopsy if it is most likely

52:22

plantar fibromatosis.

52:24

Um, if you are concerned

52:26

for an enlarged rapidly enlarging mass, then yes,

52:29

you should refer to orthopedic oncology

52:31

and consider doing a biopsy.

52:32

But in many of the cases that we see in practicality, uh,

52:35

we don't do biopsy, uh, current preferred treatment.

52:41

Um, good question.

52:43

I don't wanna over, uh, step out of line as a radiologist.

52:46

Um, I know that we diagnose some of 'em.

52:48

I don't think that they necessarily remove them all, uh,

52:51

because they're benign lesions.

52:52

Uh, I think if they cause pain

52:54

and problems, they might do something.

52:55

But I would refer to our, uh, our kind of, um,

53:00

podiatry colleagues on that one.

53:04

Dr. Samit, you have a few questions

53:06

that wound up in the chat box.

53:08

Oh, sorry. If you're able to access

53:10

Yes, yes, yes, yes, yes. Um,

53:12

One of them you answered already,

53:13

the first question that pops up. Yes,

53:15

Thank you. Do you

53:16

hold with T one equals dark being diagnostic?

53:19

So if it's dark on T one and Bright on T two, then yes.

53:23

And, and in the correct clinical setting, I,

53:25

I would say it's compatible with osteomyelitis.

53:27

The tricks, the tricky part becomes when you have bright on

53:30

T two, but the T one is still fatty.

53:32

And for those I think it's controversial, I think for those

53:36

you have to word it carefully.

53:37

So what I tend to do is if it's bright on T two,

53:39

but the T one is still preserved, I will say that, um,

53:42

it could be reactive osteitis,

53:44

however, early osteomyelitis cannot be excluded, uh,

53:48

because, uh, in those cases it's not as certain, um,

53:52

oncolysis and nail bed evaluation.

53:55

Um, you know, again, I think that's more of a clinical,

53:59

uh, clinical evaluation.

54:01

Um, if someone is concerned for osteomyelitis

54:05

of the distal phalanx adjacent to, um,

54:09

a toe on clinical exam, that's concerning,

54:10

we can definitely look for osteomyelitis.

54:12

I just, I don't know how good we are at the nails.

54:14

With, with Mr. Uh, first large abscess case you showed,

54:18

how much involvement of soft tissue tendon

54:21

muscle would you talk about?

54:23

Um, I'm a big, uh, describer.

54:28

I think, uh, in that other case was like very, very,

54:30

it had a very thick wall.

54:31

So, uh, I, I, I didn't mention it,

54:33

but if, if you didn't have a history of of infection,

54:36

you could be concerned for like a

54:37

fungating mass, to be honest.

54:39

Uh, 'cause I had a really thick wall.

54:40

But I do think it's important to describe, you know,

54:43

to some extent where it is, uh, you know, what's,

54:46

what are the surrounding muscles,

54:47

but if it's not really a cancer case, I don't think that

54:51

the RID docs are gonna really need

54:54

to know exactly which tendons and muscles.

54:57

Um, so, so I wouldn't stress about it too

54:59

much, uh, for that.

55:01

Do you give contrast? Ooh, very good question. Hot topic.

55:05

And one of my areas of, of kind of interest, um,

55:08

so it depends if you're talking pediatric or um, adult.

55:12

Uh, I just, uh, work with a group through Society

55:16

of skeletal radiology for last year's white paper.

55:20

Um, and I wrote an article with a bunch of other people on,

55:23

um, um, basically indications for when

55:27

to use contrast in musculoskeletal, um, um, MRI

55:32

and, and we had a whole section discussing this exact

55:35

issue for osteomyelitis.

55:38

Um, short answer,

55:39

I don't think you need contrast for osteomyelitis.

55:42

Um, I think contrast can help reader confidence,

55:45

but for many cases you are just fine without it.

55:49

Uh, because many cases that I save osteomyelitis,

55:52

there's T two edema, which is identical

55:55

to the post contrast enhancement.

55:57

So I don't necessarily think it adds that much.

56:00

I think for complicated cases of osteomyelitis,

56:03

if you have someone that's refractory treatment,

56:05

you're concerned for, uh, you know, sequestering

56:08

or dead, dead tissue

56:09

or whatnot, maybe yes, you can give contrast,

56:11

but I don't think you necessarily have to give contrast.

56:15

Uh, and, um, I think you can be pretty confident without it,

56:18

just based on T2 and T1 is my personal opinion.

56:21

But check out that article if you want, you want.

56:23

So, um, going back and forth. This was super fun, guys.

56:28

Uh, I hope you enjoyed it.

56:30

I hope I wasn't, uh, rambling too much,

56:32

but I was just giving you kind of a practical approach of

56:34

how I look at the foot, uh, some anatomy

56:37

and, um, some common pathologies.

56:40

And, uh, thanks for listening. Really appreciate it.

56:44

Uh, thank you to MRI online for giving this,

56:46

uh, chance to talk to you guys.

56:48

And, uh, that's all I have today.

56:51

Well, thank you so much Dr. Sam.

56:52

As always, it's a pleasure to have you here.

56:54

And thank you so much to everyone for, for participating

56:58

and for your awesome questions.

57:00

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57:02

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57:04

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57:07

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57:11

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57:13

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57:16

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57:20

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57:22

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57:24

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57:28

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