0:00

<v ->And this second one, it's a case.

0:04

Let me just put the...

0:07

Yeah, yeah, here you have the case.

0:10

And the second one,

0:12

it's a case of a 27 year old female patient

0:16

with history of trauma six months ago,

0:19

presenting pain under the first toe,

0:22

so sesamoiditis, (laughing)

0:26

because it's a clinical term,

0:29

it's pain around the sesamoids of the halluxes,

0:35

and the pain is on the right sesamoid.

0:38

And right out of the gate, I'd like to emphasize,

0:42

so that sesamoiditis is a clinical definition

0:45

of a painful sesamoid.

0:47

And now we have to discover what is the real cause

0:51

of the disease of this patient?

0:53

So look in the images we can see

0:57

in this coronal plane here, we can see this area here

1:03

when we can see the middle sesamoid,

1:06

it's not the lateral sesamoid, the lateral sesamoid's here.

1:09

Let me put the axial plane for you.

1:13

So here I can see the lateral sesamoid,

1:16

and here you can see the middle sesamoid,

1:18

and, by the way, almost all the lesions,

1:21

they tend to concentrate on the middle sesamoid,

1:24

and that's a drawback, right?

1:26

Because we know that the

1:28

middle sesamoid is the bone that has

1:31

all the developmental changes.

1:35

They occur more in the middle sesamoid,

1:38

and so the lateral sesamoid it's like,

1:41

it's not the main target of the disease as well,

1:46

so it's a drawback for us.

1:48

Actually, the lateral sesamoid

1:52

has kind of a escape route for this region here.

1:57

So, for example,

1:59

if you have some stress in in the first toe,

2:02

it goes mainly to the medial sesamoid,

2:05

because the lateral sesamoid

2:07

it can slides down to the lateral region,

2:11

and it is described

2:13

under the pitch literature as well.

2:17

So here we can see this high-signal intensity

2:20

on the middle sesamoid.

2:21

We can see that the bone is divided in two parts, okay?

2:27

Let me put the two, one here again.

2:30

So the bone is divided in two parts,

2:33

and we must differentiate between

2:36

a sesamoid fracture or a bipartite sesamoid.

2:40

So that is the next step that we have to go further here,

2:45

and the easiest way to do that would be

2:48

if you had a previous exam

2:50

showing the sesamoid before the trauma,

2:53

but we don't have this previous exam.

2:56

The sesamoid, the fragments of the sesamoid,

2:59

they are not far away from each other.

3:03

So we don't have also this imaging finding,

3:08

and we don't have also bone reaction around the sesamoid

3:15

like a asus reaction from a previous fracture.

3:20

So we're still in doubt about

3:22

if it is a fracture or a or a bipartite sesamoid.

3:27

So we have to deal with the morphology of the gap

3:33

and the morphology of the two fragments.

3:36

And here we can see that the morphology of the gap,

3:39

it's very linear.

3:41

It seems that one piece of the bone

3:43

it's completing the other piece of the bone.

3:46

And we don't see a lot of sclerotic bone

3:50

or in the margins of the fragments are not well rounded.

3:56

If the margins were well rounded,

3:59

and there were sclerotic bone here,

4:02

it would favor developmental change,

4:07

bipartite sesamoid, but we can't see that here.

4:10

So for these reasons, this should be

4:14

a fracture of the medial sesamoid bone.

4:18

And when we go to the post contrast image here,

4:25

look this image here, (speaking in Spanish)

4:30

here, we can see that post contrast,

4:33

the enhancement is just on the distal fragment.

4:38

The proximal fragment there is no enhancement

4:41

in the proximal fragment.

4:42

So this could represent a vascular insufficiency.

4:47

It can be a beginning of a vascular necrosis,

4:52

compromising the proximal fragment of the medial sesamoid.

4:56

And this is very important to report this area

5:01

of low signal intensity without enhancement,

5:05

because this is a terrible complication.

5:08

Sometimes it can evolve to a complete vascular necrosis

5:13

and fragmentation of the bone.

5:15

And sometimes it must be treated surgically

5:20

to take out this piece of bone, if it's really avascular.

5:26

So that's the second case.

5:28

Don, your thoughts.

5:31

and I don't know the answer to it,

5:33

so I'm just gonna throw that out.

5:35

I don't know when there's developmental partition,

5:38

is it typically that

5:39

the two sizes of the bones are about the same,

5:43

and, you know, with traumatic fractures

5:46

maybe one can be a lot smaller than the other?

5:50

I think it would be interesting to look that up.

5:52

Maybe someone who is listening to us today

5:54

knows the answer to that question.

5:56

I don't know that.

5:57

<v ->Yeah, that's a great question.

5:59

I've never heard or read anything about that.

6:06

Okay. So let's go to the third case.