 Hello everyone, I'm Dr. Chaitali Parekh, Consultant, Musculoskeletal Interventional Radiologist, practicing in Mumbai. Sonopas, one of the most awaited ultrasound conference, is going to happen from 6th to 8th January 2023 in Mumbai. And in this conference is one of a kind workshop which is on ultrasound guided interventions. The main highlight of the workshop is that it's a hands-on workshop. That is, all the delegates will get a chance to perform all the interventions on a phantom under the guidance of a tutor. This workshop is going to include all the interventions ranging from FNAC to radius, visceral and soft tissue biopsies, synovial biopsies and musculoskeletal interventions like injections, ganglion cyst fenestrations and calcific parbo-touch. So I hope all of you register for this workshop, learn all the interventions and perform these interventions with confidence in your day-to-day-to-team practice. Thank you. Thank you so much Dr. Mithusha and thank you Malini Ma'am for inviting me for this wonderful session. So with this I'll just begin with the quiz directly. So first let's begin with the lower limb. So this is the first quiz. So most of you have got it right. About 60 to 70% of them have answered this as a ACL tear and this is a injury pattern of the ACL tear. So this is a classical pivot shift injury pattern where you get an antrilateral femoral edema and a postrolateral tbl marrow edema. And along with that on the medial side what you get is a peripheral medial marrow edema along with a posterior medial tbl marrow edema. So just to give you a quick revision, this is a full thickness anterior cruciate ligament tear. This is a partial thickness ACL tear and this is also a partial thickness ACL tear. Now the catch in this is in this particular patient if you look at the edge here you'll find that these are the two bundles. This is your anterior medial bundle and the postrolateral bundle. This is a partial thickness tear which is involving both the bundles. Whereas in this particular patient it is only the postrolateral bundle which is torn. The anterior medial bundle is intact. So the take home point don't just look at only one image that is on one plane. Please look at the injuries on all the three planes to get a better idea of the type of injury. And over here you can see this is a Osias evalsion fracture at the tbl attachment of the ACL with a low grade injury towards the tbl attachment. And plus these injuries are also well picked up on an x-ray where you can see that this is the evalsed Osias fragment over here. And don't forget whenever you see an ACL injury there will be a lot many injuries associated with it. Most of them are obvious like a meniscal tear or a medial collateral ligament injury. The thing that you often miss would be a Segon's fracture because it's a very small fracture. So you can see that this is a tiny antrilateral tbl fracture which is at the attachment of antrilateral ligament. And again these fractures are better picked up on an x-ray. Similarly you can have small fractures at the postulateral corner. So again these fractures will be better picked up on an x-ray. So make sure to look at the radiographs along with an MRI. Next question which of the following is correct whether it is a medial meniscal tear there is no meniscal tear maybe there is a tear I don't know next question please. So you have 10 seconds. So yes there is a medial meniscal tear. So let's just look at it now. So this is nothing but a ramp lesion. Now ramp lesion is nothing but it is a tear at the posterior medial meniscal capsule junction. So you can see a discrete fluid signal that is extending up to the articular surface. When you correlate this on the axial images you can find that this is the tear over here. So you can see that there is a fluid signal which is going in a shape of a crescent. So this is nothing but a ramp lesion or a posterior medial meniscal capsule junction tear. Just a quick revision on the tears. So here you can see this is your horizontal tear. This is a longitudinal tear which is nothing but a peripheral longitudinal tear commonly seen with and cruciate ligament injuries and the third type of the basic tear is a radial tear. So this is nothing but the ghost meniscus sign. You can appreciate the anterior horn of the medial meniscus but you cannot see the posterior horn. I'm going to look at the axial images. If you have an axial image that is cutting exactly through the level of the meniscus you'll find that this is the tear in this region. So you can see the posterior root. You can see the posterior horn and then there is a discrete gap between the two and this gap corresponds to this section. So this is a radial tear. So you've got three basic types of tears. A horizontal tear, a longitudinal tear and a radial tear. Next question. What is the diagnosis? Whether it's a bucket handle tear, horizontal tear, horizontal tear with a displaced flap or a radial tear? The answer is it's a horizontal tear with a displaced flap. So here you'll see this is a normal appearing lateral meniscus. Here you will see that the upper portion of the medial meniscus is well seen whereas in the lower portion you'll see that the meniscal fragment is missing and when you scroll back and forth you realize that at the level of the body you can see that the meniscal flap is going into the superior medial gutter. So whenever you see such a tear please keep an eye and look out for meniscal flaps which can be displaced either in the gutter. Common sites are in the superior or inferior gutter adjacent to the posterior root attachment or adjacent to the posterior cruciate ligaments. So these are the common sites where the meniscus flap tends to be displaced. Now again another patient where you can see the anterior horn is very small. There is a oblique tear in the posterior horn of the medial meniscus but the horn is somewhat maintained in size but the anterior horn is very much attenuated. So again when you see such a case look out for a displaced meniscal flap. Often in chronic tears you won't be able to see a flap but in acute tears you will see a flap. So here you can see in this is the coronal image of the same patient at the level of the body and you can see that there is a large flap which is going into the superior medial gutter. Same patient on the axial section you can appreciate the flap. Now about 35% of you mentioned it as a bucket handle tear. Bucket handle tear is a kind of a displaced flap tear but it's a particular type of a flap tear. So what happens is there is a tear it's actually a longitudinal tear and not a horizontal tear to begin with. It's a large longitudinal tear. So if you imagine there is a tear at this level and the inner part of the meniscus is going to just shift inside like a bucket. So it's something like this and it just flips over like this. So that's a bucket handle tear. How to identify an MR? You will see a very small peripheral remnant at the level of the body and posterior horn as well as anterior horn and a meniscal fragment which is displaced in the intercondylar notch. So that is important the fragment should be in the intercondylar notch and the fragment will be communicating with the anterior and posterior root attachments. So this is what is a bucket handle tear. Next question. What is the diagnosis? Is there a medial meniscal tear, lateral femoral osteopondrial defect, lateral femoral osteomyelitis and lateral femoral subcondrial fracture? Wow. So 65% of you have actually answered it as a lateral femoral subcondrial fracture and it is that. So you can see a lot of marrow edema in the femoral contile but the important finding is this thin linear hypo intense signal which is there in the subcondrial region. The overlying articular cartilage is intact. So this could be more like a fatigue fracture or a stress fracture but you can see this hypo intense signal is something that you need to pick up. It can happen in osteoarthrosis as well where there is a cartilage loss. Because of the cartilage loss the underlying bone becomes weak and the patient tends to develop a subcondrial fracture. Even with an intact articular cartilage if the bone is weak because of osteopenia and other reasons patient can develop these subcondrial fractures. So just don't label this as a marrow edema. It needs to be labeled as a subcondrial fracture. Sometimes the subcondrial fractures are very obvious. As you can see there is a high grade at least an intermediate grade control loss in this patient. Some of the cartilage is still there and the patient is developing a medial femoral subcondrial fracture and there is a lot of marrow edema. Sometimes these subcondrial fractures are very subtle. As you can see in this patient again there is a condrial wear in the medial femoral trivial compartment and you can see a subtle hypo intense signal which is very much in continuity with the cortex. So how to identify such subtle subcondrial fractures is when you see a lot of marrow edema which is out of proportion to just an osteoarthrosis and those conditions you need to look if there is any subcondrial fracture. Sometimes it may not be seen but often you'll find one. So you need to look for such subtle subcondrial fractures as well and the third is this patient where you can see this is more like a proximal tbl stress fracture. So it is not in the subcondrial region. Yes there is a high grade osteoarthrosis. The lateral compartment is good. You cannot appreciate any medial compartment cartilage. There is extrusion of the meniscus but again this fracture is not in the subcondrial region. It is more like a proximal medial tbl stress fracture. Next question again what is the diagnosis? Medial femoral AVN, medial femoral subcondrial insufficiency fracture, osteocondritis desiccants or osteomyelitis. Okay most of you have got it right which is osteocondritis desiccants. I'm very happy that none of you have mentioned it as a nerve ocular neck process because that's a very obvious finding and you don't see a geographic area of AVN and none of you have mentioned it as an osteomyelitis. So that's really good. Some of you have labelled it as a subcondrial insufficiency fracture. Please remember usually when you're labelling a subcondrial insufficiency fracture there should be a lot of marrow edema at least mild to moderate marrow edema otherwise you don't label it as a subcondrial insufficiency fracture. So here what you can see this is the same patient. So you can see that there is a proper osteocondrial defect. The other the cartilage in the rest of the medial femur is good. The medial tibial cartilage is good and when you come anteriorly you actually see a osteocondrial fragment. So again on an x-ray these such osteocondrial fragments if they are sizable ones they'll be easily picked up on a radiograph. So often when you have difficulty finding for an osteocondrial fragment on an MR because sometimes it's difficult to pick up bone on MR such small osteocondrial fragments. Please look at the x-rays they will really help you to locate such osteocondrial fragments. So this is obviously an unstable OCD with a displaced osteocondrial fragment. This is the second patient where you can see that there is a proper OCD. So you can see this jet black line is the cortex above it there's the cartilage and there is a fragmentation of this osteocondrial fragment. There is a proper fluid signal that is going between the osteocondrial fragment and the underlying parent bone with subconversistic changes in the underlying parent bone. So this is an unstable OCD because there is a fluid signal that is going between it but it is not displaced. So this is an unstable displaced OCD. This is an unstable but a non-displaced OCD and this is a third patient where you don't see you can see that there are changes of OCD which have begun but there is no fluid signal so this is still a stable OCD. So that's how you differentiate between the three. Next question, what is the likely injury in this patient? Is this edema pattern of a ACL tear or a PCL tear, patellar dislocation or MCL tear? Okay, at least 70% of you have got it right. So this is a patellar dislocation pattern. Some of you have mentioned the ACL and a PCL tear. Just remember I know this is anterolateral femur. Yes but the difference between the two is in case of a ACL injury this is the region of sulcus terminalis which is just anterior to the anterior horn of lateral meniscus. You will see edema pattern in the region of sulcus terminalis whereas in case of patellar dislocation the edema is mainly located on the anterior trochlea because what happens is when the patellar dislocates when it tries to come back it hits against this anterior trochlea and comes back and the second thing why it is not an ACL or a PCL tear is you can obviously see the edema in the inferior patellar. So when you put these two together you know that this is a patellar dislocation. Now the things that you need to look out for besides diagnosing it as a patellar dislocation, one is obviously you need to look for the medial patellar femur and ligament because what happens is your patellar dislocates laterally and so the medial patellar femur and ligament is stretched and gets injured. So here you can see there is a high grade injury at the femoral attachment or as well as there is a intermediate grade injury at the patellar attachment and along with that you can see there is a small osteoscis fracture. So there is a evulgent fracture at the patellar attachment of the MPFN. The second thing that you need to look out for is the if you see any inferior medial ponderal loss or a proper osteopondrial defect. So this person if you see the cortex here is good the cortex here is good. In this region the cortex is missing and the overline cartilage is missing. So in such cases you need to keep an eye for an osteopondrial defect. Why this is important if it's a acute injury a young patient if you find the osteopondrial fragment and it's a sizable one the surgeon is going to put it back. Second thing even if it's a small osteopondrial fragment if it's left inside in the joint it will form a loose body which can result into locking of the knee as well as early osteoarthrosis. So it needs to be taken out for that it is important that you need to tell the orthoport where exactly is the osteopondrial fragment. So whenever you see these cases such particular picture please look at all the planes and try to find that osteopondrial fragment. So here you can see this is the same patient coronal image and this osteopondrial fragment was actually lying in the inferior medial gutter. So you need to look out for such things. Easier way look at the radiographs they will really help you if provided it is not just a contral flap sometimes we can get only a contral flap for that you have to rely only on an MRI but if it's an osteopondrial fragment you can pick it up on an x-ray as well and obviously your CT scans will also help you. So here you had a very smaller osteopondrial fragment this is a patient who had a sizable osteopondrial fragment which was easily picked up even on an x-ray right. So whenever you see such x-ray you know that one of the conditions in a young patient if they give you a history of patella dislocation or a patella instability you know that this is an osteopondrial fragment which has been chipped off from either medial patella or lateral femur. Another thing that you need to look out in these patients is you need to calculate your TTG ratio and the second thing is you need to look at for the chocolate dysglasia. So if you can see this particular patient actually has a chocolate dysglasia. So all of these stuff need to go into your report.