0:01

This case is another youngin, 15 years old.

0:05

And this is something I alluded to earlier

0:09

and I was discussing with Don offline

0:13

and I've seen numerous cases of young radiologists,

0:16

even some, you know, at esteemed academic institutions

0:21

who have looked at some of these giant, uh,

0:25

impingement related troughs

0:27

and what I call internal impingers,

0:29

who really can abduct their, their elbow gets

0:32

behind the mid horizontal plane, their arm is cocked way,

0:35

way back, and they get basically friction

0:38

and abutment of the superior skeletal structures.

0:43

These trough troughs can be massive in size.

0:45

I've seen them two to three times this, this size.

0:49

It's a child. So this is not a dislocate.

0:51

And that was my prime reason for wanting to share this case.

0:55

Now the child came in for a an MRI,

0:59

so it was obviously symptomatic.

1:01

And when I see something like that, you know,

1:03

I look at the infraspinatus

1:06

and there is some in infraspinatus signal

1:09

and I also look at the posterior superior labrum.

1:11

So he may be nothing more than an internal impinger,

1:14

but he also has another finding, an interesting finding.

1:17

And it is not, uh, the bear area

1:19

or the central NA of Ozaki, it's

1:22

eccentrically positioned in the inferior

1:24

aspect of the glenoid.

1:26

So he's got an osteocondral lesion

1:28

that's probably longstanding

1:30

because it's, there's no swelling there of any kind.

1:33

Um, and that's our last case. Don, any comments on that?

1:36

Well, well a couple things.

1:37

That's why it's cases like this

1:39

and the known findings that occur in the proximal humerus

1:43

with postal superior internal impingement

1:45

that I made the statement that prior to CT

1:49

and Mr I was always confident in diagnosing

1:51

hill sax lesions.

1:53

But once we got the cross-sectional ENG imaging

1:56

and we became aware of other things that could produce

2:00

cystic changes, uh, in the humerus, like a case like this

2:05

that I find more difficulty trying to, to differentiate

2:09

among several causes that can involve this area in terms

2:12

of the osteo disc again, yeah, I do think it's, it's common

2:16

and I think, you know, the idea if you can, if it's not

2:20

where the bear spot is,

2:22

usually it doesn't produce a diagnostic dilemma

2:25

if it, it occurs.

2:26

And I have a couple that occurred right where the bear spot,

2:29

but as long as it's not in the center of the circle

2:33

that occupies the lower two thirds of the glenoid, I, yeah,

2:37

I think this is an osteochondral injury

2:39

and what, you know, as I said,

2:41

the term osteochondritis disc against is

2:43

a very difficult term.

2:44

Um, but it's a term I might apply to a subacute

2:49

or chronic phase of an,

2:51

of a acute osteochondral injury.

2:54

So this might be a place

2:56

where you could call this osteo again, I dunno,

2:59

I will say for the bear area lesions

3:01

that aren't bear area, you know, I look for edema.

3:04

If it's there, it helps me.

3:05

'cause, you know, bear areas are not emus, you know,

3:07

in the underlying skeleton.

3:10

And in looking at

3:11

so much Mr over the years when I have really stretched

3:14

myself to look at

3:16

and analyze the bony architecture in cases

3:18

of osteochondritis dessicans,

3:20

I almost invariably find dysplasia.

3:23

So it's my personal belief that this is a friction induced

3:27

phenomenon where the capsular blood supply is revitalized.

3:30

I would say 90% of the knees

3:32

where I have osteochondritis tes may be more, uh,

3:36

have variability in the size of the condyles that it,

3:38

that suggest dysplasia.

3:41

And one, one other thought with regard to these troughs.

3:44

Um, one nice thing about the hills sax lesions is they tend

3:47

to be a little closer to the apex.

3:49

So when I get off to the, if I'm lucky enough to get one off

3:51

to the side like this, uh,

3:53

and it's very etched looking, I feel confident that I'm,

3:57

I'm not in the realm of a hills sack lesion.

3:59

Yeah. And I'd just like to, one thing I would add to

4:02

what you said, and that was the bare spot classically,

4:06

is the area of cartilage thinning,

4:07

but bone proliferation was described at that site, so

4:11

that's the tubercle vasa that you were,

4:14

uh, referencing. Yeah.

4:16

And, and one other comment

4:17

before we break, I, I have a radiologist

4:19

that sent me his three sons.

4:20

They were all pitchers and they all had O osteo, andr,

4:23

dessicans, and they all had Capella dysplasia.

4:25

One was an active pitcher, one had to be shut down

4:28

and the other had to be completely taken out out baseball.

4:31

And it was from, from that point on

4:33

that I started really honing in on bone shape.