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Training Collections
Library Memberships
On-demand course library with video lectures, expert case reviews, and more
Fellowship Certificate™ Programs
Practice-focused training programs designed to help you gain experience in a specific subspecialty area.
Ultimate Learning Pass
Unlock access to our full Course Library and all self-paced Fellowships.
Noon Conference (Free)
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Dr. Resnick's MSK Conference
Learn directly from the MSK Master himself.
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Musculoskeletal Imaging
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For Training Programs
Supplement your training program with case-based learning for residents, registrars, fellows, and more.
For Private Practices
Upskill in high growth, advanced imaging areas.
Emergency Call Prep
Prepare trainees to be on call for the emergency department with this specialized training series.
Practice Cases
Worklist 1
10 topics, 11 min.
Practice Cases
Worklist 2
10 topics, 18 min.
Practice Cases
Worklist 3
10 topics, 37 min.
Practice Cases
Worklist 4
10 topics, 7 min.
Practice Cases
Worklist 5
10 topics, 46 min.
0:00
These are MRI images of a 45-year-old woman who
0:05
has a history of leukemia in remission, treated
0:10
with steroids during the course of the disease.
0:15
On sagittal T1 and fluid-sensitive sequences,
0:20
what immediately catches our eye is the
0:23
abnormal bone marrow pattern with a geographic
0:28
area of abnormal T1 and T2 signal intensity in
0:34
the posterior talar dome, associated with a very
0:38
prominent reactive marrow extending from the
0:42
talar dome into the neck and the head area.
0:47
In the posterior calcaneus, we also observe the
0:50
presence of a focal area of geographic marrow
0:55
abnormality corresponding to a bone infarct.
0:59
The diagnosis here is avascular necrosis of
1:04
the talar dome in the setting of steroid
1:08
treatment in a patient with leukemia in remission.
1:13
Notice made of the presence of associated ankle
1:17
and posterior subtalar joint effusion,
1:21
which prompts us to assess the subchondral plate
1:24
for focal areas of subchondral plate collapse.
1:28
There is no evidence of subchondral plate
1:32
collapse on T1 and STED images in this patient.
1:38
But this should be followed up closely.
1:42
To prevent the development of
1:45
subchondral plate collapse in the
1:47
setting of underlying osteonecrosis.
Wk 4, Case 4 - Review
HIDEInteractive Transcript
0:00
These are MRI images of a 45-year-old woman who
0:05
has a history of leukemia in remission, treated
0:10
with steroids during the course of the disease.
0:15
On sagittal T1 and fluid-sensitive sequences,
0:20
what immediately catches our eye is the
0:23
abnormal bone marrow pattern with a geographic
0:28
area of abnormal T1 and T2 signal intensity in
0:34
the posterior talar dome, associated with a very
0:38
prominent reactive marrow extending from the
0:42
talar dome into the neck and the head area.
0:47
In the posterior calcaneus, we also observe the
0:50
presence of a focal area of geographic marrow
0:55
abnormality corresponding to a bone infarct.
0:59
The diagnosis here is avascular necrosis of
1:04
the talar dome in the setting of steroid
1:08
treatment in a patient with leukemia in remission.
1:13
Notice made of the presence of associated ankle
1:17
and posterior subtalar joint effusion,
1:21
which prompts us to assess the subchondral plate
1:24
for focal areas of subchondral plate collapse.
1:28
There is no evidence of subchondral plate
1:32
collapse on T1 and STED images in this patient.
1:38
But this should be followed up closely.
1:42
To prevent the development of
1:45
subchondral plate collapse in the
1:47
setting of underlying osteonecrosis.
Report
Patient History
45-year-old woman with a history of leukemia (in remission), complaining of anterolateral ankle pain for 2 weeks with no inciting event.
Findings
SKELETAL/BONES:
Serpiginous area of alternating T1 hypointensity and T2 hyperintensity throughout the mid to posterior talar dome, consistent with avascular necrosis (double line sign). Greater than 75% of the articular surface is involved. Extensive reactive osteoedema throughout the talar dome, extending down the talar neck. No subchondral collapse. No T2 hyperintense subchondral fluid cleft to suggest instability. No displaced fragment.
Additional focal, round, 1.3 cm intraosseous abnormality within the dorsal calcaneus, consistent with a bone infarct. No surrounding reactive osteoedema.
Further separate small subarticular area of avascular necrosis at the talar head, at the talonavicular articulation. No articular/subchondral collapse. No unstable fragment.
No further focal osseous lesion. Bone marrow has normal signal. No permeative or marrow replacing osseous abnormality.
ARTICULATIONS:
Tibiotalar joint/talar dome: No subchondral articular surface collapse at this stage. No unstable or displaced fragment. Moderate tibiotalar capsulitis with a small to moderate-sized effusion. No talar shift.
Ankle mortise/syndesmosis: The ankle mortise is in anatomic alignment. No syndesmosis widening.
Chopart joint: Unremarkable.
Midfoot/hindfoot: No fracture or injury of the anterior calcaneal process. No prominent midfoot or hindfoot arthrosis.
LIGAMENTS:
High ankle: Intact.
Low ankle: Intact.
Subtalar/Chopart: Intact.
TENDONS:
Intact.
GENERAL:
Sinus tarsi: Mild diffuse reactive capsulitis. Otherwise unremarkable.
Muscles: No traumatic muscle injury. No volumetric muscle atrophy.
Soft tissue: Unremarkable.
Plantar fascia: Intact.
Neurovascular complex/tarsal tunnel: Unremarkable. No evidence of entrapment neuropathy.
Intra-articular/loose bodies: None.
Impressions
Multifocal avascular necrosis/osteonecrosis as follows:
1. Extensive talar dome avascular necrosis (greater than 75 % articular surface involvement). No subchondral or articular surface collapse. No unstable or displaced fragment.
2. Small focus of subarticular avascular necrosis at the talar head.
3. Focal calcaneal osteonecrosis.
4. Multifocality consistent with history of leukemia.
Case Discussion
Faculty
Stephen J Pomeranz, MD
Chief Medical Officer, ProScan Imaging. Founder, MRI Online
ProScan Imaging
Jenny T Bencardino, MD
Vice-Chair, Academic Affairs Department of Radiology
Montefiore Radiology
Edward Smitaman, MD
Clinical Associate Professor
University of California San Diego
Tags
Musculoskeletal (MSK)
MRI
Foot & Ankle
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