0:00

This, uh, next case, uh, was a football player, um,

0:04

collegiate, middle linebacker.

0:06

He had an injury several weeks earlier.

0:10

On physical exam, he had an effusion, positive lockman.

0:13

It wasn't graded. Uh, his pivot shift was deferred due to,

0:16

uh, um, due to guarding

0:18

and a negative dial test again

0:21

for poster lateral corner injury.

0:24

Here are his, uh, images

0:29

and so as expected, um, this patient had

0:34

given his lockman exam a complete tear

0:36

of the superior fibers

0:38

of the anterior cruciate

0:39

ligament near the femoral attachment.

0:40

He can see the redundancy and waviness of the tibial stump.

0:44

So a fairly straightforward injury.

0:47

Um, his PCL isn't entirely normal.

0:51

Um, you can see that there is some thickening

0:53

and some intra ligament to signal,

0:55

so at least some partial intrasubstance tearing.

0:59

Although, um, his exam

1:01

and his arthroscopic exam, uh, indicated

1:04

that there was no gross abnormality of the poster

1:07

ship ligament medially.

1:10

He does have a little bit of perlin edema about his MCL,

1:13

but no gross fiber discontinuity.

1:16

So if anything, the, uh, we might be dealing

1:18

with a low, low-grade sprain.

1:20

It does have a little bit

1:21

of edema at the meniscocapsular junction

1:24

of the posterior horn, the medial meniscus,

1:25

but at, uh, arthroscopy

1:27

that all they found was some edema and erythema.

1:30

There wasn't much in the way of a clear separation.

1:33

So no ramp lesion.

1:35

And as we move to the lateral part of the knee, this is

1:37

where we start to run into, um, some issues too.

1:41

So although we can see that his, uh, antola ligament, um,

1:46

we can follow it from the femur to the tibia in some places.

1:50

Indeed, it is thickened and emus.

1:52

There's some places where it looks a little bit thinner.

1:54

There have a lot of peri lius edema around it.

1:57

So although this is not a, a complete tear

1:59

of the ant lateral ligament, we have at least, uh,

2:01

some degree of sprain of the ant lateral ligament.

2:05

As we move more posteriorly, we can also see

2:07

that he has an injury to his femoral attachment.

2:10

Uh, if of his fibular collateral ligament,

2:12

we can see thickening an increased intra sub signal

2:16

reflecting partial tear.

2:18

Again, as we scroll back

2:19

and forth, we can see that there are indeed some

2:21

fibers that remain intact.

2:23

So maybe a low

2:24

or moderate rate partial tear

2:26

of the fibrillar collateral liga, but not a complete tear.

2:29

Let's make sure we round out our valuation

2:31

by looking at the pope tendon.

2:34

A little bit thickened indem, but otherwise intact.

2:38

And then finally, as we look at the biceps femes,

2:41

he did have a little defect that was picked up

2:44

by the radiologist, um, of the distal tendon

2:47

that was actually repaired primarily.

2:49

And this was open via an open approach.

2:53

If we wanna kind of look at some

2:55

of those smaller lateral supporting structures,

2:57

we can sure give it a try.

2:59

As we center on the sagal images over the fibular tile

3:03

styloid, we can see the popal fibular ligament in this case

3:07

mostly intact.

3:08

Maybe you could call a little bit of edema, uh,

3:11

within the ligament and some, certainly some per liga edema.

3:14

So most we'd be dealing with the sprain.

3:16

Uh, but remember the poppit fibular and the arcuate

3:20

and, uh, fabelo fibular ligaments are not as critical to try

3:24

to identify, nor is they critical in conferring stability

3:28

to the poster lateral corner of the knee.

3:33

Certainly we can see that this, uh,

3:34

patient also has some ACEs contusions

3:37

that are expected for an ACL.

3:39

We've, uh, learned, um,

3:41

in the past few days about the deep sulcus sign.

3:44

Uh, and you've also learned at about the presence

3:46

of a double sulcus sign.

3:48

And we're still trying to figure out if there's a,

3:50

a measurement that is for a too long sulcus, I guess

3:54

that remains to be, um, studied.

3:57

And we have the corresponding, um, co uh,

4:00

bone contusion at the posterior aspect

4:02

of the lateral tibial plateau

4:04

and also the bone contusion at the posterior aspect

4:07

of the medial tibial plateau.

4:08

Sometimes these are thought to be related

4:10

to contra coup type injuries.

4:15

I do believe I have the scope images in here.

4:19

What is, uh, interesting about this case?

4:23

So here's the torn anterior cruciate ligament

4:26

within the intercondylar notch.

4:27

Remember, this had kind of a long tibial stump, so empty,

4:30

uh, it's a, there's it's torn more proximally

4:34

and yeah, this is why it's interesting.

4:36

So in, in this case, this patient

4:38

actually had a little radial tear.

4:40

This is the lateral meniscus, sort of the junction

4:43

of the body

4:44

and posterior horn segment that wasn't called, uh,

4:47

prospectively on the MRI.

4:49

And, uh, even if you kind of go back

4:50

and forth, it is, I think it's incredibly tough

4:55

to call anything that would be right around here.

4:58

Certainly sometimes we like to look at our axial images,

5:01

but well, as I look at this image,

5:03

this looks like a radial tear.

5:04

And why does it look like a radial tear?

5:06

Because the surgeon gave us another image

5:08

where you could see that he's done some debridement.

5:11

But interestingly enough, none

5:13

of this was mentioned in the operative note.

5:15

You know, I think, uh, radiologists we're,

5:18

we're also probably guilty as charged.

5:20

We see things and sometimes we

5:22

forget to put them in the report.

5:23

Um, so that's why it's important

5:25

to be very systematic when you go through your knee MRIs,

5:27

um, and make sure that you have everything

5:29

compartmentalized, whether you use, um, you know,

5:33

templated reports, uh, systemized, uh,

5:35

reports for your reporting.

5:38

Um, but the reason why I bring this up too,

5:41

and I don't think I uploaded these images,

5:45

but this is the follow up.

5:47

Um, after the patient had obviously undergone an anter

5:51

cruciate ligament reconstruction, and there was a little

5:57

Divot, a little defect here, let me see right here.

6:01

Now you can see at that junction of the mid-body

6:03

and posterior horn segment that was called a tear.

6:07

And unfortunately, if you read the operative note

6:09

and they didn't mention it, yes, this looks like a tear,

6:12

but going to those scope images, you can indeed see that,

6:15

uh, the surgeon had been in there

6:17

and done some arthroscopic debridement.

6:20

So, uh, kind of interesting from this standpoint.

6:26

Okay, so I think I have one more case

6:30

and then we'll have time for question and answer.

6:34

And so these, this is what the, um, patient had done.

6:36

Uh, bone tendon, bone anterior cruciate liga reconstruction

6:39

and repair of that torn biceps fems tendon.