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Our next patient is a 17-year-old boy.

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17-year-old boy complaining of the knee

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giving out with medial, lateral,

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and posterior knee pain after playing basketball.

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Query Meniscal tear.

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So, let's get that one cooking here.

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All right, so let's do what we did before.

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We're going for the axial first,

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because that's what comes up first.

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Let's go through our quick search pattern,

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just to get a general feel for what's going on.

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The patella, weird.

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Really strange, right?

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Like American politics.

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Very strange.

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Look at this weird bump.

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Look at how you don't really have a medial facet.

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You don't have a lateral facet.

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You've got a fissure right there.

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You've got intrasubstance tearing

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of the patellar apex.

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You've got very gentle,

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superficial crab meat fissuring of

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the superficial patella.

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And yes, the surgeon will see that

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you've got patellar dysplasia.

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You have trochlear dysplasia.

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Well, you certainly have a pretty deep trochlear groove.

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When the groove gets a little shallow,

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we call that a Dejour A.

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When the groove is very flat, like,

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straight across, we call that trochlear dysplasia,

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Dejour B.

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When the groove has a bump in the middle of it,

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we call that a Dejour C.

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If you can't remember that,

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you can google Dejour or take some notes.

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How about our anterior cruciate?

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Now this time, looking good.

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Nice and straight and linear, and black.

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How about our posterior cruciate ligament?

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Looking also excellent.

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How about our medial collateral ligament?

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Looking excellent.

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Remember in our last case,

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we had some swelling right there?

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Not this time.

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Looking quite good so far.

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How about our lateral collateral ligament?

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Also looking good.

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How about our effusion?

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Much smaller than the last case.

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So we're not thinking violent,

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high grade injury.

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I would call the effusion 1+.

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Trace effusion would be just slightly

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more than 1 by 1 cm fluid.

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If the fluid is in the front and in the

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back but not distending the capsule,

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I'll call that 1+.

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So now, let's go right to our

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water-weighted images.

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We already know we have patellofemoral dysplasia.

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We know we have varying degrees of chondromalasia.

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One deep fissure, grade 3.

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One intrasubstance area of fissuring,

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and then some superficial fraying,

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grade 1,

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superficial grade 3, chondromalatia patella.

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So, the patella is not gliding very nicely

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through the trochlear groove.

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Let's get our water-weighted images up now.

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We'll go right to the mid-coronal plane

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and check out our collaterals.

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And we'll go right to the midline

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and check out our cruciates.

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Anterior cruciate intact.

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Posterior cruciate intact.

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Humphrey in the front.

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Wrisberg in the back.

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Posterior capsule and oblique popliteal ligament.

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Let's go over to the posteromedial meniscus.

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Looks fine.

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Meniscocapsular reflection, fine.

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No swelling.

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There is the posterior oblique ligament

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of the knee right there,

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which has a fiber that goes towards

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the posterior superior meniscus,

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anterior horn, body, posterior horn, all fine.

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Cartilage, all fine.

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Should be.

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It's a kid.

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Let's go to the other side.

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Quickly.

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Quickly, we see popliteus tendon.

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Pop fib ligament, not stretched.

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Posterior capsule and arcuit, nice and straight.

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How about our attachments?

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There's one.

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Meniscopopliteal fascicle looks good.

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Bottom one, looks good.

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Remember the last case?

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They were ruptured.

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This time, we don't have a pivot shift.

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We don't have translation, by the way,

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while you're on the lateral side,

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you can look at the tib fib ligament.

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Now, when I dictate,

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I'll occasionally use templates,

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but not very often.

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I either free dictate or I'll go by compartment.

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Anterior, posterior, medial, lateral, tib fib,

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intraarticular,

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other, and also central.

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I left that one out.

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So, central.

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So, those are usually my dictation styles.

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When do I use a template?

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When there's only one or two things wrong and

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everything else is normal. Otherwise,

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I stay away from templates because the clinicians

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recognize that you're just parroting and they're

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afraid you're not really looking at the case.

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So, here is the coronal.

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We got the MCL with its three layers.

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The superficial crus layer right there.

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I'll put an arrow on it so you can see it a little better,

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layer one.

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The tibial collateral ligament, layer two.

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And then, it's hard to see layer three

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because there isn't much fluid in there.

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It's the meniscocapsular attachments and the capsule.

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All looking good.

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Collaterals look good.

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Center of the knee looks good.

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Spines look good.

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Central cartilage looks good.

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Medial compartment, cartilage normal.

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Lateral compartment, cartilage normal.

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Shape and conformity, normal on the lateral side.

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A little bit abnormal on the medial side.

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What's abnormal about the shape and conformity?

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Look at it for 5 seconds, see if you can spot it.

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Wasn't in the report.

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Right there.

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See how there's this funny little dippity do

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in the femoral condylar cartilage?

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And the cartilage is a little swollen

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and has a slight signal alteration.

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Let's call up the sagittal T1.

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No bone abnormalities.

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Menisci, we've covered.

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Growth plate, open on the femur,

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just about closed on the tibia.

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And look at the prefemoral fat pad.

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Indurated.

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Look at all stuff right here.

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How about the infrapatellar fat pad?

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Indurated.

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That means this child is having friction on

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patellar glide, and look at the sclerosis of the patella.

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So, this child has patellar dysplasia,

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patellofemoral maltracking

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fat pad impingement and fibrosis or cicatrisation

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chondromalasia patella.

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And that is the case.

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Are there any questions about this one?

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There is an effusion, obviously,

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and that effusion is all generated

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by patellofemoral maltracking,

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the most common cause of knee pain in an

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atraumatic knee in somebody under age 20,

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Patellofemoral maltracking.