Case 1 7 yo male Right elbow injury 3 months ago Medial elbow pain and tenderness over medial epicondyle Long arm cast given but off himself 1 month a
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1 Case presentations
2 Case 1 7 yo male Right elbow injury 3 months ago Medial elbow pain and tenderness over medial epicondyle Long arm cast given but off himself 1 month after Progressive limited elbow flexion XR? Displaced epiphysis of radial head/malunited #
3 Case 1
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6 Discussion Dx: brachialis muscle tendon insertion avulsion fracture Rarely reported in literature Only 1 case report available (6 y o child) Caused by sudden unexpected movement at elbow joint Brachialis : deep and superficial head, inserting on ulna tuberosity and coronoid process Commonly due to deep head avulsion Radiograph : calcification at anterior aspect of coronoid process Conservative management
7 Case 2 35 y o male Gymnastic athlete/trainer Attended competition Use of anabolic steriod Developed severe cramp over anterior compartment of leg 1 day after competition Foot drop : dorsiflexion of big toe and ankle power 0/5 Private MRI performed 1 week later (Aug 2013)
8 Private MRI Aug 2013
9 Follow up Residual but less severe pain and tenderness Persistent foot drop MRI was performed May 2015
10 PWH MRI May 2015
11 PWH MRI May 2015
12 Discussion Diagnosis : exertional compartment syndrome from acute to chronic Acute exertional (atraumatic) compartment syndrome : rare Chronic exertional compartment syndrome (CECS) : less uncommon Exertional pain or swelling during exercise Risk factor : steriod use (rapid increase in muscle bulk) Clinical diagnosis!!!
13 Diagnosis MRI occassionally helpful, particularly exertional MRI MRI DTI recently studied 99Tcm-MIBI scintigraphy for regional perfusion USG muscle size USG Doppler not studied before
14 Isometric muscle contraction -> intramuscular pressure increased -> blood flow comprised -> muscle ischemia Anterior and lateral compartments most common Gold standard: intra-compartmental pressure measurement (ICPs) Treatment : conservative vs fasciotomy Case report of bilateral foot drop related to compartment syndrome after steriod use
15 MRI of flat foot
16 Flat foot Acquired : PTT dysfunction, spring ligament tear Congenital : Tarsal coalition, congenital vertical talus, Down s syndrome, cerebral palsy Flexible (normal in non-weight bearing) Rigid (abnormal in non-weight bearing) Congenital anomalies! Adult Childhood
17 Flat foot Loss of medial plantar arch Talus head directed medially and inferiorly Hindfoot valgus (heel/calcaneovalgus): tibiocalcaneal angle Hindfoot plantar flexion : talonavicular fault (talar tilt) Forefoot/Midfoot (talonavicular) abduction : talonavicular unroofing / navicular lateral shifting
18
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20 Calcaneal inclination angle > 20 degree
21
22
23
24 MRI of flat foot 1 ) Alignment 2 ) Associated abnormalities
25 1) Alignment A. Heel valgus B. Inferomedial migration of talus head C. Uncovering of talus head by navicular D. Talus plantar flexion : talonavicular fault
26 A. Heel valgus (tibiocalcaneal angle : 0-6 degree)
27 Flat foot
28
29 B. Inferomedial migration of talus head (medial rotation and adduction)
30
31 Normal Normal
32 Mild Mild to moderate
33 Moderate Moderate to severe
34 Severe Severe to very severe
35 Very severe Very severe
36 C. Navicular coverage of talus head (normal >85%)
37 Uncovering of talar head
38 Uncovering of talar head
39 D. Talus plantar flexion At the cut of base of 1 st metatarsal bone
40 Mild Mild to moderate Moderate Severe
41 2. Associated abnormalities Posterior tibialis tendon Spring ligament Triad of key structures Sinus tarsi ligaments Plantar fascia Deltoid ligaments Short & long plantar ligaments Other plantar ligaments (naviculocuneiform and tarsometarsal ligaments) Talocalcaneal impingement Caneofibular impingement Coalition Degeneration
42 A. Posterior tibial tendon
43 Mild tendinosis Mild tendinosis
44 Mild to moderate tendinosis Mild to moderate tendinosis
45 Moderate tendinosis Moderate tendinosis
46 Severe tendinosis Severe tendinosis with tears
47 Mild tendinosis with tears Moderate tendinosis with tears
48 Moderate tendinosis with tears Severe tendinosis with tears
49 PTT tears partial thickness PTT tears full thickness
50 Four tendon signs Four tendon signs
51 Tenosynovitis Tenosynovitis
52 Accesssory navicular I II III
53 Type 1 accessory navicular bone
54 Type 2 accessory navicular bone with fibrous connection
55 Type 3 accessory navicular bone = cornuate navicular bone
56 Type 2 accessory navicular bone with fibrous connection and edema
57 Type 2 accessory navicular bone with edema at PTT insertion
58 B. Spring ligament Also called calcaneonavicular ligament (CNL) Superomedial CNL and inferoplantar longitudinal CNL (past : superomedial and inferomedial CNLs) Medioplantar oblique CNL Superomedial ligament mostly involved in flat foot
59
60
61
62 Coronoid fossa
63
64
65 Mild Mild
66 Moderate Moderate
67 Moderate to severe severe
68 Moderate Severe
69 Attenuation of fibers : superomedial CNL
70 Attenuation of fibers :superomedial CNL Attenuation of fibers : medioplantar oblique CNL
71 Superomedial CNL : axial plane Medioplantar oblique CNL : coronal plane Inferoplantar longitudinal CNL : coronal plane
72 Spring ligament ganglion cysts
73 C. Sinus tarsi
74 Normal cervical ligament Normal interosseous ligament
75 Sinus tarsi edema
76 Sinus tarsi ligament thickening
77 Sinus tarsi ligament attenuation
78 Sinus tarsi edema Sinus tarsi fibrosis
79 D. Deltoid ligament and osteochondral lesion
80
81
82
83 E. Plantar fasciitis
84 Mild Moderate Severe Severe
85 F. Long and short ligaments
86
87
88 G. Talocalcaneal impingement
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91 H. Subfibular impingement
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93
94
95 I. Tarsal coalition
96 normal Calcaneonavicular coalition
97 Anterior Middle Posterior Normal
98 Normal middle subtalar facet
99 Talocalcaneal coalition
100 Talar ridge Talar osteophyte Talar beak Talar beak
101 J.Osteoarthritis Tibiotalar Subtalar Talonavicular Naviculocuneiform Metatarsocuneiform
102 Talonavicular articulation
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