0:00

I really kind of like these more classic, typical

0:03

cases because there's a lot of teaching besides

0:06

just the main finding that goes with them.

0:09

I am going to do what I always do.

0:11

This is just how I do it.

0:14

I put up the lateral first.

0:16

Um, now sometimes if I'm really speeding

0:18

along, I'll put up whatever's first at the

0:21

top of the screen, but most of the time

0:26

I like to have the lateral view because

0:28

it's a very comfortable view for me.

0:31

And I scroll around and the first thing I'm

0:34

doing, by the way, is I'm looking for swelling.

0:38

I'm not necessarily looking for anatomy. I'm

0:40

looking for swelling, and I have some swelling.

0:42

I got some swelling right there near

0:44

the Achilles, under the Achilles.

0:45

I don't like that.

0:47

It's not necessarily mean

0:49

that's the finding, but it's abnormal.

0:51

This is abnormal.

0:53

There's some swelling around

0:54

the Achilles in the heel pad.

0:56

So these are some subtle findings.

0:59

And then we keep, we keep looking about.

1:01

And as we scroll back and forth, a couple

1:04

of other findings got this sort of very

1:07

strange-looking arthritic appearance.

1:11

Of a joint with some penetrating

1:14

pseudocysts and erosions.

1:16

And then we go to this area

1:18

right here, and we have it again.

1:21

Another weird sort of hard-to-define

1:24

anatomically on this on this STIR

1:28

sequence of pseudocysts and irregularity.

1:31

And then here and there we've got a

1:32

little bit of capsular fluid, which

1:35

is not bothersome to me at all.

1:36

You'll have some trace fluid throughout the

1:39

mid and forefoot in active, uh, individuals.

1:43

Well, this patient is 51, and he's,

1:47

he's been complaining of Achilles pain

1:50

for two weeks with no inciting event.

1:53

I think we have the answer to the Achilles pain.

1:57

You know, he's got a, he's

1:58

got some signal out here.

2:00

He's got a little bit of interstitial tearing.

2:03

He's got swelling of the Achilles

2:06

sheath, which is called the peritendon.

2:10

He's got a little bit of edema of the

2:12

underlying bone, which we might refer to

2:15

as the manifestations of an enthesitis.

2:18

And we look at the footprint, and

2:19

it's nice and flat and attached.

2:22

There's a high footprint reflection.

2:24

There's a mid and a low footprint reflection.

2:27

Those are all intact.

2:29

I don't see a Haglund deformity.

2:31

I do see a little bit of fluid right there,

2:33

but just a tiny amount, probably not even

2:36

worth commenting on because of its small size.

2:39

So, we do have an Achilles problem,

2:42

but it turns out that is not the

2:44

most interesting part of the case.

2:47

And maybe the Achilles problem is because

2:49

he's got abnormal biomechanics of the foot.

2:52

And indeed, when we go to the sagittal

2:54

projection and we look at the anterior

2:58

process of the calcaneus, which is

3:00

going right into this weird, uh, bony

3:03

architecture, it has this snub-nosed look.

3:07

Now normally, the anterior process

3:10

is going to come forward like

3:11

this, and then it's going to taper.

3:16

And then you might see some fibrous

3:17

tissue right here connecting it.

3:20

This fibrous band connecting

3:22

it to, uh, the navicular.

3:25

That is indeed not the case.

3:26

It looks like a snub nose, like

3:28

the end of a gun or a Derringer.

3:31

And then it goes into these

3:32

fragmented areas, which are part of

3:34

the fragmented irregular navicular.

3:37

Now, sometimes with this,

3:41

calcaneonavicular fibrocartilaginous coalition,

3:45

you will get a lot of dorsal spurring

3:48

of the talonevicular articulation.

3:52

This patient surprisingly does not have that.

3:56

Now it is very common.

3:57

In adults, especially women to have asymptomatic

4:01

hypertrophy of this joint, just from constantly

4:05

being in a slightly dorsiflex position.

4:09

So, that part of the list Frank joined.

4:12

I don't really get excited about, except

4:15

just using it as a guide.

4:17

Here you see it's a little

4:18

hypertrophic right there.

4:19

So here it is a little bit abnormal.

4:22

And if it's, you know, a 12-year-old that

4:24

might tip you off to a coalition, you know,

4:26

and a, and a 51-year-old, not so much.

4:29

So, you know, you gotta, cause everybody's got it.

4:32

And, uh, so you, you have to really be

4:35

able to latch onto the anatomic findings.

4:39

And once you have a coalition, it would be

4:41

nice if you can to see how the rest of the

4:45

list Frank joint is doing now, by virtue of the

4:47

fact that this looks so good, it's not perfect.

4:51

Here.

4:51

It's not perfect, but it's pretty darn good.

4:53

And somebody with a big old coalition for

4:55

50 years, that suggests to you that the

4:59

bifurcate ligament is going to be intact.

5:02

And it is, there is the medial

5:05

limb of the bifurcate ligament.

5:07

And here is the lateral limb of

5:08

the bifurcate ligament right there.

5:11

So, it turns out, even though we've

5:13

got a coalition, the bifurcate

5:14

ligaments are still standing.

5:18

And then we have one more issue to address.

5:21

Why do we have this localized arthrosis?

5:27

And, and the reason is we have another

5:31

coalition got two coalitions in one it's

5:34

a breath mint and it's a candy mint.

5:37

We're all the way out to the side, we

5:39

shouldn't really see a joint coming out at us.

5:44

And sometimes if you look at the Corona,

5:46

which we're going to do, you can see that that

5:50

articulation looks a little too fat and too broad.

5:54

There it is.

5:56

It's sticking out like a sore

5:57

thumb, but it's not a thumb.

6:00

Look how much bossing you

6:01

have over there to the side.

6:04

And then here are your erosion.

6:05

So this articulation is way too broad.

6:08

Too fat, way too medial, and of course has

6:13

these arthropathic changes in the next.

6:16

There's one more thing you have to do because

6:18

you have now you've got dysplasia, right?

6:20

You got an adult with two coalitions.

6:25

It'd be nice to see what the status

6:27

of the subtalar ligaments are, and

6:29

they weren't specifically studied.

6:32

Let's see if we can latch

6:33

on to a few of them here.

6:35

Not going to be easy.

6:39

So here is the lateral retinaculum.

6:42

And here is the cervical ligament here,

6:45

and we don't really have much of a

6:47

talocalcaneal interosseous ligament.

6:50

So, not surprising as part of the dysplasia,

6:53

he's got ligamentous agenesis or hypoplasia, and

6:58

I didn't point this out earlier, I should have.

7:01

He's also got a little bit of hypertrophy

7:04

of the posterior, uh, calcaneus as

7:07

a pump bump or Hagelin deformity.

7:09

He's also got a little extra spur here

7:12

that probably broke off from the calcaneus,

7:16

which is not helping matters any and

7:18

may be contributing to his heel pain.

7:20

So what looked like it might be kind of a boring

7:23

case turned out to be An exciting case, right?

7:28

He's got a calcaneonavicular

7:31

fibrocartilaginous coalition.

7:32

He's got a posterior facet

7:35

fibrocartilaginous talocalcaneal coalition.

7:39

He's got some broken spurs.

7:41

He's got arthrosis at the coalition site, and he

7:45

has an Achilles problem with a Haglund deformity.

7:49

distal emphysema, a small interstitial tear,

7:53

and some peritendinous swelling of the Achilles.

7:56

It's all here.

7:57

Dogs and cats living together,

7:59

10 days of darkness, the plague,

8:01

and mass hysteria on this case.