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All right, hello and welcome to Noon Conference presented by MRI online.

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In response to the changes happening around the world right now and the

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shutting down of in person events, we have decided to provide free Noon

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Conferences to all radiologists worldwide. Today we are joined by Dr.

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Kumaravel. Dr. Kumaravel is an Assistant Vice President, Professor of Radiology

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and Orthopedics and is Chief of MSK imaging section at UT Houston.

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His clinical training includes a residency in orthopedics and trauma with

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surgical board certifications from Britain. He is also the team doctor for

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the NFL Texans. A reminder that there will be a Q&A session at

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the end of the lecture. So please use the Q&A feature to ask

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your questions and we will get to as many as we can before

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our time is up. That being said, thank you all for joining us

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today. Dr. Kumaravel, I'll let you take it from here.

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Thank you very much indeed. Hello there and thank you for joining and

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thanks for the opportunity to MRI online for letting me present my talk

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today. And I was gonna give you a brief overview about both my

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clinical experience as well as my current radiology experience to try and

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help with imaging of injuries around the ankle and the hindfoot. What we're

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trying to do is to understand what the primary focus of the clinical side

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of the picture is and how would this help in your own practice

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and hopefully give you some pointers to look for things.

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The primary thing that I'm gonna focus on today is gonna be from

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more of an ER perspective, more of a trauma based perspective where with

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just adequate CT scans and X rays, what are the different soft tissue

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injuries that you're gonna be looking at around the ankle and the hindfoot

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region? How would this help you make those subtle diagnostic changes that

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can actually make a huge impact on how a clay case can be

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managed across with these things? Again, as we go through this,

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let me see. I don't have any financial disclosure to present for this

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particular content of the presentation. I do get

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to be a team doctor for the NFL Texans on which I work

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for them as well. So, what are the learning objectives for the next

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40 or 45 minutes or so? We're gonna be reviewing some ankle and

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hindfoot soft tissue anatomy predominantly. We're gonna be looking at those

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structures and thinking about them, how they're gonna help you impact on

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what the pathophysiology of the ankle and hindfoot is gonna be.

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We're gonna look for subtle injury patterns, small things that's gonna happen

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in an ER setting or acute trauma setting that's gonna help you diagnose

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these injuries. We're gonna definitely use cross sectional imaging, particularly

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CT, to augment a lot of these things and definitely MRI to understand

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what the soft tissue underlying components are to try and figure out what

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are the different injuries that can happen in the ankle and the hindfoot

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region. Also, we're gonna identify some pitfalls and complications that

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can happen and hopefully make this more of a useful clinical presentation,

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how things should be managed from an orthopedic perspective as well.

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And thanks for the introduction again. And as I said before,

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I had the privilege of actually going through an orthopedic residency across

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Great Britain and it gave me a lot of insight into how this

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would be handled from an orthopedic perspective as well.

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Let's kick off some. I'm just using a 3D volume rendered image to

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remind you of the anatomy on the medial side of the ankle. We're

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going to start with a couple of tendons. So here's tibialis posterior. An

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important thing about tibialis posterior is the fact that it actually grooves

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the posterior malleolar margin around here, cross here, and also seems to...

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Also attaches to the navicular process, the primary attachment. It also

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gives out multiple small slips that pretty much goes to every single bone

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of the foot and ankle, excluding the talus. The talus does not have

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any muscle attachments, as we know. That's tibialis posterior. The next

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thing we want to understand is about the flexor digitorum. The flexor digitorum

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is a tendon that comes down here next to the Tom... Tom,

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Dick, and Harry, and hangs around here and grooves the Sustentaculum talus

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and supports a straddling structure across to the Sustentaculum talus, so

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it crosses across all of the talus margin around here and such,

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and the calcaneal margin here. So the Sustentaculum talus, as you know,

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belongs to the calcaneus, and that's what's being supported here, and the

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medial aspect of the talus as well. The next structure is the flexor

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hallucis longus, and that's your Tom, Dick, and Harry

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connotation that we all remember from. And that's how it goes by. And

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the flexor hallucis goes all the way across, crossing over, attaching to

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the tip of the great toe. And as you know, the crossover pattern across

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here is the Master Knot of Henry, where the two tendons crisscross across

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here, and that is just important for pectineus and all of components of

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these tendons across the medial side. What else do we need to know

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about the medial side? One of the things we need to think about

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is a structure such as a deep condensation of the fascia, which is

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the retinacular attachment across here. When you look at the retinacular

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attachment, it is a structure that arises from the medial margin of the

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medial malleolus and goes down to the medial process of the calcaneus and

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creates this layer that creates your tarsal tunnel region as well. So that's

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your flexor retinaculum. When we swing around to the lateral side of the

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foot and actually have a look at this, we thankfully have only two

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tendons at that point to worry about. It's the peroneus brevis and the

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peroneus longus. When you look at these tendons, they actually form a single

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tendon sheet up to the retromalleolar groove around this point, and then

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eventually splits into two tendons. And you have the peroneus longus coming

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down and creating a groove in the cuboid called the peroneal groove of

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the cuboid. And then the peroneus longus going down across... Sorry, I beg

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your pardon, the peroneus longus that goes and creates the groove across

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the peroneal of the cuboid, creating the peroneus groove. And the peroneus

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brevis that goes and attaches to the base of the fifth metatarsal.

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And we're gonna be looking at that attachment of the fifth metatarsal in

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a little bit more detail in a few minutes as well.

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The peroneus longus, just to remind everybody, takes a turn and goes all

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the way across and attaches to the base of your first metatarsal. One

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of the things that if you... Every time you want to do an

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ankle MRI, please do make sure that you actually see or include the

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distal attachment of the peroneus longus tendon to the base of the first

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metatarsal. So how are these tendons kept in place?

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We again have a binding structure which is the deep condensation of fascia,

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condensation which creates a sheet on top of the peroneal tendons as such.

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And this is what regulates the function of the peroneal tendons so that

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they actually don't subluxate and move over to the anterior aspect of the

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ankle. So that's a superior peroneal retinaculum. And anytime you have a

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superior peroneal retinaculum, you do have to have an inferior peroneal

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retinaculum. And that comes down across here and attaches down to the calcaneus

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at this margin. And the reason for not including that in most presentations

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is because clinically the chances of actually having an injury to the inferior

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peroneal retinaculum is low. And not only that, but you also don't have

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to...