0:00

And this was, uh, an adolescent with, uh, left hip pain,

0:05

uh, after sport.

0:06

I forget, I think it was, um, soccer

0:09

or football or something.

0:10

But I love this case.

0:12

Um, just to, uh, highlight again what Dr. Was talking about.

0:16

If you're not getting large field of view, stirs

0:19

or T ones, what have you, I like a nice, uh, stir, um,

0:24

or a fluid sensitive T two fat suppress,

0:26

whatever you're running just to, uh, large field of view,

0:29

getting the entire pelvis

0:31

and obviously the contralateral hip, just

0:33

to give us a flavor of what's going on

0:35

symmetrically or asymmetrically.

0:37

And without, I argue, without this, uh, large field of view,

0:41

uh, we could have potentially missed this case.

0:43

And this, uh, a nice case of a just attraction, uh,

0:47

apophysis of the rectus fous origin, as we know,

0:51

uh, from, uh, Dr.

0:52

Patricks talking, uh, extending upon

0:54

what she had taught us earlier, an hour

0:57

or so ago, the, uh, rectus femes

1:02

timed out, I apologize, lemme pull that back up.

1:05

Uh, the rectus fem origin. Okay.

1:07

The direct head arises from the anterior inferior iliac

1:12

spine while the indirect head, uh,

1:17

arises more posteriorly off of sort of that acetate

1:21

or limbus, uh, sort of back here.

1:24

Okay. The rectus femes is going to be active,

1:27

particularly in, uh, involved in, uh, extension of, of, uh,

1:33

sorry, the, uh, extension of the knee,

1:35

inflection of the hip.

1:36

But in the first, uh, about, uh, 90 degrees or so,

1:40

or, uh, of flexion of the hip at the direct head

1:45

of the rectus femes is gonna be the major player in that.

1:48

When it starts to get, uh, you know, greater than

1:51

that 90 degrees or so, the rec,

1:54

the direct head gets more lax,

1:56

and we're gonna rely more on the firing of the indirect, uh,

1:59

head, which is, uh, this contribution right here, uh,

2:02

with my cross cross hair.

2:05

So, important thing some people will,

2:07

will call this the conjoint, uh, tendon.

2:09

Just be aware, uh, one of the reasons I don't like

2:12

to use the term conjoint ligament

2:14

or conjoin tendon, it's okay to use it if you're using it,

2:17

but just be aware that there are many conjoint ligaments

2:20

and tendons throughout the musculoskeletal system.

2:22

If you're studying the MSK anatomy, including, for instance,

2:26

and we'll talk about it later, the conjoin tendon

2:29

or the origin of the biceps femoral semi, semi semi, uh,

2:33

tendinosis, uh, tendons, uh, arising from the, uh,

2:36

medial facet of the, uh, ischial condylar tuberosity here,

2:40

which we'll talk about in the next case.

2:42

But this, uh, just a nice case, uh,

2:44

and, uh, of traction hypophysitis

2:47

of the rectus femoral origin, uh, involving obviously the,

2:50

uh, anterior inferior iliac spine

2:53

and really brought out, um,

2:55

but to our eyes, at least when we were reading the case,

2:58

Particularly with the large field of view images.

3:01

Notice here the more normal appearing, uh,

3:03

contralateral right anterior inferior iliac spine,

3:06

we can appreciate the edema at this, uh, fsis.

3:10

Okay. Uh, patient obviously has incompletely fused.

3:13

Most vices are gonna fuse at about, uh, 20 years of age.

3:17

That's a nice, uh, round number

3:19

for, for those that are studying.

3:21

Um, but, uh, a, a epiphyses can be involved

3:25

or damaged basically by two main mechanisms.

3:29

Okay. Um, sorry, before we get into that, sorry.

3:31

Um, epiphyses, you can divide them into

3:35

two broad main categories before I get ahead of myself.

3:38

You can divide epiphyses into pressure epiphyses

3:41

and traction epiphyses or AKA physes, right?

3:45

The, the pressure epiphyses, the classic ones

3:47

that we talk about or, uh, that we can invoke or,

3:50

or discuss is take the epiphysis of the knee, okay?

3:53

It's gonna, uh, grow, uh, it's gonna be in involved, uh,

3:58

the majority of, uh, of

4:00

that epiphysis at the knee distal femur that is,

4:03

is gonna be, uh, involved in growth, uh, limb length growth,

4:07

and also circumferential growth of the knee.

4:09

But traction es like here that we have at the origin

4:13

of the rectus femes at the anterior inferior UX spine,

4:16

that's gonna be, uh, uh, damaged by two major methods, okay?

4:20

Typically in older patients,

4:21

you're gonna get the emulsion fractures, right?

4:23

And in younger patients, as in this case, the fiss okay,

4:27

is going to be the weak link in the chain, okay?

4:31

And you can think of, uh, a lot of these, uh,

4:35

bone tendon muscle sort of liga dis units as such, right?

4:39

As muscle, tendon, bone, um, tendon units, uh,

4:43

if you're reading the literature

4:45

and in, in, uh, kids, unfortunately, the bone

4:50

and the feces are the weak links, okay?

4:52

So that's where the failure is gonna happen

4:54

in younger patients.

4:56

In adults, the failure is gonna happen in the soft

4:58

tissue con, uh, connections.

5:00

That is the muscles, tendons,

5:02

and ligaments, not so much bone when it does though in the

5:04

bone, it's gonna be more of that avulsion type of fracture.

5:08

This, uh, probably more, uh, due

5:10

to a chronic repetitive micro motion tort, uh, sort

5:14

of injury or traction,

5:15

chronic traction apophysis, hence its name.

5:18

And we can see here that's reflected by our imaging, uh,

5:22

with this bright T two signal

5:24

or, uh, whatever sequence you're running,

5:26

but basically edema at the SSIS reflecting histologically,

5:31

the osteoblastic increased osteo,

5:33

black osteoblastic activity, vascular, uh, in, in, uh,

5:38

inva or vascular recruitment, uh,

5:40

inflammatory cells and what have you.

5:42

And that's what we, that's what happens histologically.

5:45

And obviously that's gonna be reflected

5:47

and in our images as apophysis

5:49

or basically just inflammation at the FSIS and in and,

5:53

and around the nearby, uh, bone

5:54

and sometimes the soft tissue.

5:56

So this just a nice case of a IIS erectus,

6:00

femoral direct head traction, apophysis.