0:00

Okay.

0:01

This is a 12-year-old with heel pain and

0:03

swelling after landing on her heel 10 weeks ago.

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So I said, I like to, I like to put up my, my

0:12

sequences in threes of three are available.

0:16

And I've got a series of three sagittal.

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So let's put all three of them up together.

0:23

We have a gradient echo.

0:26

We have a PD fat set in which the T

0:30

that was chosen is a little too long.

0:33

Not thrilled about that, but we'll have to live

0:35

with it because that's what we've been given.

0:37

And I've got a T1-weighted image.

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So

0:43

let's start out with our T1-weighted image.

0:47

I am looking at the patient's age.

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The patient is 12.

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I know that the calcaneus is ossified by age 12.

0:56

And there is ossification on the.

0:59

the T1-weighted image.

1:00

But there's also some cartilage within.

1:03

So that makes it a little tricky because

1:06

the cartilaginous component can get a little

1:09

bit bright on the water-weighted image.

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While the osseous component should not,

1:13

the osseous component should fat-suppress.

1:16

So how do you know, how do you

1:19

know when the edema is too much?

1:22

How do you know whether this

1:23

edema is cartilaginous or not?

1:25

And the only way to know that is to

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go to the areas that are more ossified

1:30

and see if there's edema there.

1:32

For instance, this area is more

1:33

ossified, more marrow-like.

1:36

And it's a little bit heterogeneous right there.

1:39

And even the cartilaginous component is a little

1:41

bit brighter than I otherwise might have expected.

1:44

Now, I would really like to see a little

1:46

more swelling in the soft tissues, but the

1:49

patient has heel pain and there is no other

1:55

living, breathing explanation for heel pain.

1:58

She's got no fracture.

2:00

She's 12 years old.

2:02

She has plantar.

2:03

She has a normal plantar fascia.

2:06

She has a normal Achilles.

2:09

She has a perfect superior calcaneal protuberance.

2:13

She has a perfect foot plate or footprint.

2:16

She has a perfect kegger space.

2:18

So we have no other explanation for the

2:20

patient's clinical syndrome with one exception.

2:27

This case is billed as Sever's disease, and

2:31

that's because this is the only finding.

2:39

I don't want to scroll this case for you.

2:43

There's one other finding that I find disturbing,

2:50

and here's the finding.

2:52

I don't like the fact that I see subcortical,

2:58

very scant edema in the navicular.

3:03

I also see it in the calcaneus.

3:08

I see it.

3:09

I see these shiny edges.

3:12

I also see it in the cuboid.

3:13

So there's only one other diagnostic

3:18

consideration here other than, um, apophysitis.

3:24

And of course the history isn't great for

3:26

apophysitis right the patient fell you

3:28

would think the patient had a fracture,

3:30

and that is complex regional pain

3:32

syndrome type two, which is also known as

3:38

apophysitis.

3:39

Reflect sympathetic dystrophy.

3:41

This could be one of the earliest

3:43

manifestations of this, this syndrome.

3:47

And in this case, that diagnosis required ruling

3:49

out, uh, the child was followed for a period

3:52

of time, did not have, um, pillow motor signs.

3:58

And so I had to take the podiatrist

3:59

and the foot surgeon who was taking

4:01

care of this patient at their word.

4:04

So, by process of elimination, we came up

4:07

with a diagnosis of of Sever's disease or an

4:10

apophysitis, even though the history did not

4:13

fit swimmingly well, but I want you to keep

4:17

these findings in mind as we look at the follow

4:20

up case that's going to be coming up in a few

4:22

moments because ruling out CRPS in a child.

4:28

is essential.

4:30

It's one of those diagnoses that cannot

4:32

be missed for a child can lose their foot.

4:35

If this diagnosis is missed,

4:37

you miss a meniscus tear.

4:39

You're doing a child a favor in many

4:40

cases, unless it's a bucket handle tear.

4:43

But if you miss CRPS,

4:44

It can be a disaster.