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<v ->This second case,

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we have a

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13 year old male

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amateur soccer player

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with chronic pain, the left knee.

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He has been playing,

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he has been practicing soccer for five years

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and here in his

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MRI, this is the first MRI, okay?

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For this case, we have the first MRI.

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That is the case two B.

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After that, we have two way

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after that we have the second MRI.

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That is the case two B.

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And we have one CT that is the case two C,

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because you you find that online.

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If you, when you go to review your material

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you find the name of the case this way.

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So this is the first MRI.

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And in this first MRI

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you can see this high signal intensity

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in the physio plate off the distal femur.

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And you can see the irregularity of the physio plate here.

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And like

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Dr. Resnick also

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have showed

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in his experience.

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He has a lot of

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cases of throwers.

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And here in Brazil,

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we have a lot of experience with soccer players.

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And this is it's

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a chronic stress reaction of the physio plate.

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This chronic, it it's caused

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by chronic and repetitive trauma.

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It damaged the micro avascularization around the physics

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and the capacity of the physics to transform

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cartilaginous tissue in bone

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in calcified the cartilage, it's

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compromised.

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So that's why we can see a lot

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of cartilage tissue, you can see the thickening

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of the physio plate.

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And we cannot see the

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provisional classifications on that.

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We normally see, for example, here,

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we can see beautifully the margins of the plate

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and here we can, we can't see these margins.

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They become blurred because of this chronic collision.

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And if this lesion it is diagnosed earlier,

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the conservative treatment is sufficient

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and it involves time off from sports, of course.

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And if the patient does not stop, does not stop training

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or if the condition is not diagnosed earlier,

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complications may occur such as growth arrest

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and a pathological fracture.

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And in this case, we have one of these complications.

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So here we have another MRI of the same patient

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one year later

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and in this MRI

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we can see a fracture of the physics and this fracture.

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They, it goes to the meet that physio bone here

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in this intermediate portion of the femur.

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So it is Salter-Harris type II fracture.

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It's a complication of stress reaction

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of the distal femur and

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we can, we also have the CT of this case.

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And when we see the CT of the case, let me put here

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like in the sagittal plate

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here, the sagittal plate, you can see the fracture.

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We can see the fracture

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in this region and notice that in this case, actually

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the MRI is much better to see the

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physio plate,

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the complication than the CT of the femur.

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And by the way, we also can see on the MRI

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in the osteo hematoma here in this region.

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Let me put the coronal plane for you.

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Look, that was very similar to the case that Don just showed

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about the

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dissection of the periosteal

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by the lesions,

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by the physio fractures that we can see.

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So that's our second case.

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Okay?

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And let me see if I have some,

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some more comments about this case.

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Well, now the treatment should be more,

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it will be more aggressive.

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The return to play will take a much longer

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time than it was before

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Don, any comments about the case?

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<v ->Yeah.

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I just wanna ask in your experience,

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if you are asked about premature fusion of a physes,

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what imaging method would you recommend?

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<v ->Yeah, it's like, we start, generally

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we start with the MRI to see

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how the...

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But for first methods, I think I, it would be CT.

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We use CT to make the, to calculate the area

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of the fusion

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and the literature, they give some number.

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I've not, I can't remind the numbers now,

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but I don't know if it's 50%, but there is a number

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that if it's number is reached orthopedic surgeons,

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they tend to

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operate the patient.

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But, the first method would be CT.

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<v ->Yeah. I agree with that.

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<v ->Yep.

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<v ->Okay. Let's go to the second case, third case.