0:00

This is a 14-year-old girl.

0:02

This case is dramatically different from

0:05

the one I showed you, which was extremely

0:07

subtle, in which the diagnosis of complex

0:10

regional pain syndrome was raised as

0:12

a possibility along with apophysitis.

0:15

It turned out not to be the case.

0:18

There's another patient with a, with a

0:20

dysplastic calcaneonavicular articulation.

0:23

The snout is too broad, and that might

0:28

be something that you would latch onto.

0:31

this person, the interpreter of

0:33

this case did and also said that the

0:36

patient had multiple stress injuries.

0:43

Let's scroll it.

0:46

It's a case I never want you to forget.

0:48

It's the most important case in the deck.

0:51

Now, children run around a lot.

0:54

And so I don't mind if they have this

0:56

sort of patchy dotted pattern of edema.

1:00

What do I call that?

1:02

I call that overused syndrome or high

1:04

bone turnover syndrome of the juvenile.

1:08

A lot of them complain of vague amorphous pain.

1:14

And I dismiss them 99 percent of the time.

1:16

But when don't I dismiss them?

1:19

When I see a focal area of linearity.

1:23

Like this that looks a little bit like atrial

1:25

fibrillation, then I start to, you know, then then

1:29

I call it a stress fraction or it's coalesced in

1:33

one spot, but I start to get really nervous when

1:39

I see a demon and a child that borders the cortex.

1:45

That favors the cortex and if you zoom out, look

1:50

at how marbly looking the marrow is and look at

1:53

where, why would you get a stress injury here?

1:56

You don't put any stress on the dorsal navicular.

2:01

That would be a really crazy odd place.

2:04

So you have to use good old

2:05

fashioned Aussie common sense.

2:08

Why would you get a stress injury here?

2:12

Very bizarre.

2:14

Oh, this is complex regional

2:15

pain syndrome in a child.

2:18

And the T1 findings are usually

2:21

nondescript or nonexistent.

2:23

They're very minimal.

2:25

Uh, we've got a coronal T1, you

2:27

can see it, it almost looks normal.

2:32

You can barely see the pattern of

2:34

maroedema, and most of the time

2:37

they don't have soft tissue changes.

2:40

There is a soft tissue Pseudoect form

2:43

of neurogenic reaction or neurovascular

2:47

reaction, um, but that is uncommon.

2:51

Most of the time, it starts out in

2:54

the skeleton, and this patient has it.

2:58

The T2 is also unimpressive.

3:00

So without the proton density fat suppression,

3:04

suppression image, TE50, you would, you

3:08

would miss the diagnosis completely.

3:11

Look at this subcortical edema

3:12

here in the back of the calcaneus.

3:14

That is a really weird

3:16

pattern for stress phenomenon.

3:18

Doesn't make any sense.

3:20

She's also got an effusion.

3:23

Now, what are some other causes of juxta

3:26

articular juxtacortical edema was one

3:30

major one that is inflammatory arthritis,

3:35

but we can totally rule that out.

3:39

One reason why we can partially rule

3:40

it out is there's no sign of itis.

3:42

But the reason we can totally

3:44

rule it out is right here.

3:46

There's no synovium on the

3:48

dorsum of the navicular.

3:51

That would be a weird place to have a

3:53

synovial inflammatory skeletal reaction.

3:56

You get it here where the joint is.

3:59

It's non-articular.

4:02

You know, you can even look

4:03

here, not articular or here.

4:08

So the fact that you have nonarticular peripheral

4:12

window framing subcortical subperiosteal edema

4:17

in a juvenile with an effusion, the diagnosis

4:21

of complex regional pain syndrome is clinched

4:25

and the patient needs a lumbar block and

4:29

physical therapy, moving the extremity, right?

4:31

As much as possible and Children who

4:33

have this are frequently hospitalized so

4:36

that they can get this movement returned.

4:39

Uh, and they don't end up with a frozen

4:40

foot again in the axial projection.

4:43

Look at the peripheral nature

4:44

of the edema right there.

4:46

That's real.

4:48

That's real.

4:49

So is that.

4:49

So is that.

4:50

So is that there isn't a great

4:52

correlation between the MRI and the

4:55

and and the improvement of the patient.

4:58

I know this well because someone in my family

5:01

suffered from this condition for over a year.

5:06

So I studied it extensively.

5:09

And there is not a good correlation between the

5:11

regression of edema and how the patient feels.

5:15

But I'll tell you this, when they're treated

5:17

and they get a lumbar block, their pain

5:20

instantly decreases and the vasculature to

5:24

the extremity changes within 20 seconds.

5:28

You can see the foot actually

5:29

go from blue to pink.

5:31

So the patient knows that they're getting

5:34

better and they'll be able to tell you the

5:36

clinician, you know, my, my symptoms are

5:39

coming back or my symptoms are improving.

5:42

So we manage them in terms of symptoms.

5:44

We don't typically use radiography unless the

5:48

patient has taken a negative turn clinically.

5:51

to decide whether they're getting better or not.

5:54

You will know, and so will the clinician.

5:56

What non-contrast features do you

5:59

look for to diagnose synovitis?

6:02

Um, one, juxta-articular edema.

6:06

Not juxta-cortical, juxta-articular.

6:09

Two, joint space narrowing.

6:13

Three, if it's inflammatory,

6:16

auto-digestion of cartilage.

6:17

The cartilage is too thin.

6:20

Four, Erosions.

6:22

Those erosions could be, let's pull up a coronal.

6:26

If we have one, we do.

6:28

Those erosions could be central,

6:30

marginal, or peripheral and para-articular.

6:36

You might see such a weird erosion in gout.

6:40

Number five, the capsule.

6:43

It's not just distended.

6:45

It's floppy.

6:46

It's redundant.

6:48

It doesn't look like it's just filled with fluid.

6:51

It looks like it's elastic.

6:53

You'll get capsules that look like this next.

6:58

Within the capsule, you see synovial

7:01

hypertrophy, which some people have

7:04

described as little rice bodies.

7:06

If those bodies get too big,

7:08

you got to worry about synovial

7:10

chondromatosis or osteochondromatosis.

7:13

If they get really big, you got

7:15

to worry about PVNS or localized

7:17

giant cell tumor of tendon sheath.

7:22

Pannus in the soft tissues, rheumatoid

7:25

nodules, polyarticular involvement.

7:29

symmetry where both extremities

7:32

are involved, soft tissue swelling.

7:37

Those are the features I look

7:38

for to diagnose synovitis.