0:02

Let's take a look at this

0:03

78-year-old man who's got pretty severe

0:06

hip pain and multiple findings.

0:08

And as we wind down here, we have covered

0:12

labral abnormalities, hyaline cartilage

0:15

abnormalities, and capsular abnormalities.

0:16

And now we're going to show you a

0:17

bone abnormality, which initially was

0:20

missed by a very experienced observer.

0:23

Now what the reader didn't miss

0:25

were all these erosions on the

0:27

femoral side of the articulation.

0:29

It's a little strange that there aren't a

0:31

lot of erosions on the acetabular side.

0:33

But let's give credit where credit is due.

0:36

Those are probably erosive

0:38

changes from an arthropathy.

0:40

But it's very hard to justify these erosions

0:43

causing this much marrow edema so far

0:47

away from the home base of the erosions.

0:50

Generally, the swelling or edema in the

0:52

bone is going to be around the erosions and

0:54

not extending all the way down the femoral

0:56

cervical neck to the intertrochanteric area.

1:00

So you have to change your thinking here.

1:02

You can't write off the edema to

1:04

simple swelling from arthropathy.

1:06

It's too extensive,

1:08

it's too broad, it's too distant.

1:10

So then you gotta go goodwill hunting.

1:12

And when you do, you very subtly see some

1:16

wavy signal in the femoral cervical neck.

1:21

Now I admit that this is a challenge

1:24

to see on the water-weighted image.

1:26

It's a little easier in retrospect,

1:27

but if I really tightly window it, you can

1:29

see kind of a little almost like a spider

1:31

like crack that's going up and down.

1:34

It's a little more apparent here on the T1.

1:36

There it is, right there.

1:38

That's a crack.

1:40

So is that.

1:41

It's squiggly.

1:42

It's wiggly.

1:43

It's irregular.

1:44

In fact, it's so irregular that the femoral

1:47

cervical neck is actually a crumble bunny.

1:50

It's crumbling right beneath our very eyes.

1:53

But the findings are so delicate

1:55

that you could easily miss the crack.

1:58

Here's the crack right in

1:59

the femoral cervical neck.

2:00

Let me blow it up and make it as obvious

2:02

as I can even though it's still subtle.

2:04

There it is.

2:05

Now another critical point about this crack

2:09

is that it's located within the capsule.

2:12

So how do we tell that?

2:14

We look at the effusion and if we draw a line

2:17

from the capsular edge to the capsular edge,

2:19

everything above this line is intra-articular.

2:22

Everything below this line is extra-articular.

2:25

So let's, let's draw it again

2:27

capsule to capsule, so let's put up the line.

2:31

Here we are, capsule to capsule.

2:33

Everything above this line is

2:34

going to be intra-articular.

2:36

Everything below that line is

2:37

going to be extra-articular.

2:40

So this has an intra-articular component.

2:42

It's above that line, right here.

2:45

Therefore, it places the femoral head at very

2:48

high risk for ischemia and avascular necrosis.

2:51

Finally, let me scroll the T2.

2:54

Now the T2 is not a very useful,

2:57

medullary, spongy, and chondral bone sequence.

3:00

But even the T2 still shows the squiggly,

3:04

wiggly, thin, irregular line of an

3:08

intra-articular, femoral, cervical neck

3:11

fracture, which it's critical not to

3:13

miss because the patient must get off

3:15

this hip, otherwise the fracture will

3:17

complete and they'll surely go on to AVN.

3:20

Now granted, this patient needs a hip

3:21

replacement anyway, but you don't want somebody

3:24

going on to a displaced fracture because that

3:27

would produce somewhat of a catastrophic pain

3:29

syndrome and would be extremely awkward to

3:33

have a patient walking around on a hip like

3:35

this and then complete the fracture without

3:37

bringing it to the clinician's attention.

3:39

Thanks, and I've enjoyed going

3:42

through bone, cartilage, labrum,

3:45

and capsule with you in the hip.

3:47

A most difficult joint.