0:01

This is a 30 5-year-old woman.

0:03

She fell on some loose wooden steps

0:06

while wearing high heels.

0:08

So once again, let's start with the bones.

0:11

Um, here I confess I had the advantage

0:14

that I looked at the radiographs first

0:15

and I didn't upload those or, or um, share those with you.

0:20

But if we look, um, for our bone marrow edema

0:23

to clue us into the areas of importance, you'll see

0:27

that there's marrow edema at

0:29

that second metatarsal proximal shaft, um,

0:32

extending to the base.

0:34

And then if we look very carefully here, medial base

0:37

of the second metatarsal looks like there's a little

0:40

avulsion fracture in this location.

0:44

If we come further laterally, there's also a little bit

0:47

of edema at that base of the third metatarsal.

0:51

Um, even further laterally, additional edema base

0:55

of the fourth metatarsal

0:57

with another non-displaced fracture here at the medial base

1:00

of the fourth metatarsal.

1:02

Um, some more edema at the middle

1:06

and lateral QA forms as well as at the cuboid.

1:10

I don't really see fractures here,

1:12

but it's gonna be challenging to identify those really small

1:16

fractures of the torso bones at the torso.

1:18

Metatarsal joints on mr.

1:20

So if you really wanna identify them all probably would have

1:24

to confirm with a ct,

1:25

but we know there's at least bone contusions

1:28

possible fractures here.

1:30

Um, thinking about the structures

1:33

and the ligamentous structures that attach to them, we know

1:36

that they're at the expected attachments

1:38

of important components of the lis Frank Ligament complex.

1:42

So let's talk a little bit about those ligaments.

1:46

So on our long axis images, um, we know that

1:51

the lis Frank Interosseous ligament is gonna attach

1:54

to the base of the second metatarsal

1:57

where we have our fracture.

1:59

And actually we can see that the ligament itself

2:02

a little bit too bright, too much fluid signal,

2:05

um, a little bit irregular.

2:07

Normally the interosseous ligament should be either striated

2:11

or homogeneous, and it should be a low in signal intensity.

2:16

So here I think that ligament is injured.

2:19

Um, as we kind of move to the more plantar aspect

2:22

of the foot, you're getting into the

2:24

plantar li FRA ligament.

2:27

So this should arise from the um,

2:33

medial kof form.

2:35

Um, its attachment is actually going

2:37

to be a little bit proximal

2:38

and deep to the attachment

2:40

of the peroneous longest tendon, which we're seeing here.

2:44

So here's our more proximally,

2:46

our plantar li frank ligament.

2:48

It's gonna divide into deeper

2:50

and more superficial components.

2:52

That deeper component attaching at the base

2:55

of the second metatarsal,

2:57

the more superficial component going further laterally

3:00

to attach at the base of the third metatarsal.

3:03

Here, again, I think too much, um,

3:06

signal in those ligaments.

3:08

So, um, also injured, um,

3:12

or plantar less frank ligament.

3:17

Um, there are additional ligaments that contribute

3:20

to the stability of the Lis Frank joint complex.

3:23

Um, we can ask Dr. Chung and Dr.

3:25

Resnick if they specifically identify these ligaments on

3:28

their routine analysis of these images.

3:31

Um, lis Frank injuries, um, of their assessing foot

3:35

and ankle MRI.

3:36

But for the purposes of, um, reviewing them, um,

3:41

there are additional ligaments.

3:43

There are second and third, uh, interosseous ligaments.

3:47

The second going from that lateral aspect

3:50

of the middle kidney of form to the base

3:52

of the third metatarsal.

3:55

Um, the third going from the lateral aspect

3:58

of the lateral keya form to the base

4:00

of the fourth metatarsal near the location

4:02

of our fourth metatarsal base fracture.

4:06

There are int tarsal ligaments, for example, here

4:09

between the middle and lateral keya forms.

4:13

And then you're also going

4:14

to have inter metatarsal ligaments, um, for example here

4:19

between the base of the second metatarsal

4:21

and the base of the third metatarsal.

4:24

And then also our tarsal metatarsal joint, um, capsule

4:28

and dorsal tarsal metatarsal ligaments are gonna contribute

4:31

to the stability of the Lis Frank complex as well.

4:34

But I think most of those other structures that, um,

4:37

we've just discussed, other than

4:39

that Lis Frank Interosseous ligament

4:42

and that plantar lisfranc ligament are thought

4:44

to be less important to the stability

4:46

of the lis Frank joint.