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Hello, everyone and welcome to our event today. We have got the wonderful Pria who is going to talk to us about clinical radiology. MS K. MRI Rea is um she's somebody that med knows very, very well. Pria hosts the BS Sr Grand rounds on the platform. It's bimonthly and there's a link in the chat to those. If you would like to come along to the next one, you can just follow their organization and then they can let you know when the next one is happening, you'll get an invite to that. Ok? So just a quick rundown, we are gonna have as always our questions in the chat box. Er, please do, er, pop your questions in there at the end of the event. You're gonna get your feedback form and then once filled out you'll then get your attendance certificate. Ok. One other thing before I hand you over to Pria, I am just about to, er, action a poll. If you could fill this out, it would be really helpful for Pria. So if you could just click on whichever one is for, you click on that and then Pria can then, er, take it away from there. All right. Thank you, Pria. Over to you. Thank you. Thank you, Sue. Um, uh Sue. You can hear me. I, I uh get it. So, what I'll do is I will start sharing my screen and uh, yes, please. If you can, uh, let me know, uh, you know what your experience is, then I can, um, uh, I mean, get my talk to that. Uh, and then we can take it from there because then I can go through the, you know, the anatomy bit uh faster or, you know, whatever uh you feel, uh I feel that, you know, you know, and uh it will be very helpful. So just, just uh please uh uh answer that call and uh I will share my screen by that time. Ok. Um ok. Oh, ok. Fine. So I think uh the uh answer to the question was like, you know, I think many of them, many of you are learning how to report Mr means. Uh So I'm a, it has uh um uh said um I have different training hats and I love teaching and uh training and um therefore I was involved in, you know, the grand rounds of the PSSR, which is available on me. So please feel free to join that and I love running as well. So, uh uh the other thing that I do is a lot of running and we did uh uh ultra marathon of 100 kilometers continuous running quite recently. So uh you may see, you know, other things that uh uh may come up like, you know, in, in my uh tweets about running because that's my passion as well. OK. So uh we have answered about you. So uh many of your learning how to do Mr Knees and uh what I'm going to focus today is on um the uh non meni injuries. Uh because I think uh I may need to do another talk on just meniscal injuries uh which will be followed at some uh point later. And firstly, um I would like to thank me all because um this is a very good initiative. I know there is a lot of crisis in many countries and Sudan had, you know, had undergone a big crisis and I'm hoping that this session will help the doctors in Sudan to um you know, um help with the progress and with the learning and uh you know, the training there. So, uh and uh med all has made it open to everybody else as well. So thanks to uh medal to soon for putting this uh um session up and I'm hoping it will be helpful for all of you who are attending today. So, firstly, when we talk about um Mr Knee, uh uh the first thing I would say is please have, you know, a look at the pain radiograph, uh do not try and report them in isolation, especially in the context of trauma. Ok. And uh though you know, the um knee uh x-rays, only 6% of the patients may have a fracture that you can see on the x-rays. And uh there are very clear indications why you will do and when you will do the knee x-rays, and those are the owa knee rules or the decision rules. So my main message is, please have a, a look at the plain radiograph um when you look at knee trauma, hey, tomorrow. And uh as we know the Mr Anatomy, uh you know, the knee anatomy is very complex. There are many um uh ligaments, uh intraocular structures uh that you should be uh aware of and we just go through some of them, I'll focus, like I said, more on the uh ligaments today and uh we'll do the menisc inci. So the AC L is one of the main uh uh structures uh that you should be uh able to uh identify clearly. And there are two functional bundles. One is the an medium and uh uh that will be usually very low signal density. And then you have the post lateral bundle which is like a fan shaped structure. So you can have a little bit of high segment in density within these. And uh as you know, I mean, you can remember the acronym lamp um that is uh lateral uh condyle for uh mm anterior cruciate and uh medial condyle for uh post cruciate, you know, that's the attachment to the uh uh femur. Uh and, you know, it's uh in the tibi, it's anterior and posterior. So, you know, the name is self self-explanatory. So that's about AC L and on the um um you know, coronary images, again, it's seen like a fan shaped structure. So that is AC L there. And uh you just have to, you know, uh have a look at them uh regularly to know that you can have a little bit of high segment intensity because of the friendship structure they have, then you come to the PC L and uh this is usually low signal intensity. OK. Much lower than the AC L. And you can see there it's a black uh low sign density structure that you can see. Um then you have the collateral ligaments and uh you have uh the uh middle collateral ligament and the lateral collateral ligament. And uh the medial one has two components that is a superficial and the deep, the deep has the meniscal uh tibial and uh meniscal femoral ligaments. And uh the superficial component is the one that you can see on the side that comes down and attaches. And the most important. One of the most important ones is the anterolateral stabilization. So you also have a postal stabilization that we look at. The an lateral stabilization is provided by the iliotibial tract. And this is one of the favorite things that I keep asking my knee, which is the most anterior structure that comes all the way from the pelvis into the knee. And that is the iliotibial tract. And whereas you also have the capsule that provides further uh stabilization for the anterolateral part, then you have the postal stabilization. And this consists of many different structures. And uh it's quite complex. And uh this uh is also called accurate ligament complex. And uh it compa encompasses of lateral collateral ligament, the bicep ferus, these two together from the conjoined tendon that is attaching to the tip of the fibula. OK. That, that's the head and then you have the popliteus muscle and the tendon and uh then you have the oblique popliteal uh ligament, the arcuate ligament, the uh febrile fibrillar ligaments. These can be seen on the Mr but as knee surgeons when they open it, and there is a lot of uh injury to this area, then they will not be able to identify these structures separately. OK. So the ones that I highlighted in yellow are ones that I would like you to uh know and identify on the Mr scans. And uh I'll just touch upon the meniscus anatomy. We'll be uh looking at it again, but it's divided into the uh in the sagittal plane, into thirds and in the coronal plane, it's uh whether it's vascularized and it's avascular. And uh this uh determines whether the patient can be offered meniscectomy or meniscal repair. So because if it's in the red zone, it'll heal. Whereas if it's completely in the right zone, it's not going to heal. It's no use trying to repair it. Then looking at the uh medial meniscus, just looking at this image, how do you know this is medium because you have the posterior uh third of the meniscus, which is much larger than the anterior third. And uh that is one of the clues. The other clue is the shape of the uh uh tibial plateau at the side. And the fact that you know, you don't have the fibula on this side. OK. Whereas the lateral meniscus, if you look at it, it will have equally sized uh anterior and posterior horns and um look at the uh convexity of the plateau. So look at this, it's concave. So that's why you know, that's under the clue as to where you are on the uh sagittal images. And then you can have what we call a Pes Andis. And that is the uh combination of three of the tendons coming down sartorius gracilis and semi tendinosis. And uh I'm uh particularly highlighting this because it can be an extra articular cause for pain and uh uh post trauma. And um it cannot be seen even by the knee surgeons because even if they do an arthroscopy, they will not be able to see this region and this is seen only on the Mr scan. So uh especially important for you to, you know, recognize that there can be pathology there and uh only you as radiologist may be able to uh uh see that and uh actually uh uh mention or report that. OK. So what are the sequences? There are many combinations that, you know, people do in different areas, the ones that we follow and have been following for now about 15, 20 years is the PD Sagittal uh that is the proton density. And uh that is really good for, you know, looking at the anatomy and then we have the PD, that is the proton density with fat saturation, sagittal axial and coronal images. And uh this will uh uh you know, help you see uh ligamentous injury, help you identify any uh bone bruising and uh also you know, any other uh big effusion. So, uh PDF S is very sensitive for uh showing any kind of edema and especially helpful to see um in the context of trauma. Now, if you're not doing an Mr for trauma that you're doing for non traumatic conditions, say you're suspecting a synovial proliferation of some kind, then sometimes you may need to give a contrast and sometimes you may need to do what we call a T two star gradient echo sequence. Uh That is to look for what we called susceptibility artifact in a condition called PNS. So really depends on uh whether you're doing the Mr for which nontraumatic cause. But if it is trauma and if it's a routine knee, these are the sequences that we do and uh uh many other places may add a T two sequence to this. Uh But we do a PD and a PDF S. So now coming on to the mechanisms of injury, uh many of the uh graphics or you know, the illustrations that I have used uh is from this paper. So I would strongly recommend that uh please have a look at this paper from a GR it is in 2011, but uh it is uh still uh you know, relevant because the mechanism of injury uh doesn't change, you know, the basic principles and they discussed very in detail about the mechanism of injury. So coming into, you know, what kind of things you can have, so you can have direct contact injuries, I'm sure many of you would have scanned order to come across even ed uh patients who have played uh um after rugby match, you know, direct contact and they get burn this injuries or it could be uh due to dashboard injury uh in an RT A um or, you know, somebody being kicked by something else or have, you know, run into something else. So those are the direct contact injuries, many of them however, will be the noncontact injuries. So these are some kind of twisting injuries or, you know, uh hyperflexion or hyperextension. Um There's no, there's no direct, you know, uh uh force that is acting on the knee, but it is due to the body weight itself, which is causing the twisting or, you know, um uh the different motions that can cause the injuries. And most of the things that we see can be the non-direct uh uh noncontact injuries. OK. So then looking at the mechanisms, it can be like we said, hyperextension or it could be due to flexion. If it is hyperextension, it's uh it's extended so much that you know, you get like a locked knee. And uh with these injuries, we get uh Frank, you know, fractures that you can see on brain thumbs and there will be severe distraction injuries on the poster aspect, you know, where you have the capsule, then you have the PC L and you know the posterior structures. And uh it involves the uh posto lateral and postal medial structures. So we already looked at uh the anatomy briefly of especially the posto lateral corners. And uh they are very important for stabilization of the knee. So, you know, when you have severe destruction injuries, these uh knees are very unstable in the hyperextension injuries. Whereas if you have the flexion injuries, uh this will cause um impaction, bone bruising. And uh this is very nicely seen on the PDF S or you know, any fats suppressed images, you will see the uh bone bruising secondary to impaction very clearly. And then you may have what we call smaller avulsion bone bruising. And uh also uh the flexion injuries have great association with meniscal teas. So, knowing the mechanism of injury sometimes can be helpful to know exactly what are the structures that could be disrupted and you know, where the pathology may be. But many times, uh I'm sure you will be um aware of this. Uh you know, when the injury happens, uh the patient is not sure or it was unwitnessed and you will just get um trauma, um, knee pain, uh could cause, you know, that will be usually the uh clinical picture. So, looking at the known contact um AC L injury. So, uh I'm hoping this will uh play the video. So this is if you look at a frontal view of uh simulated noncontact ac L injury, it is very painful. And if you look at that, ah, ok, fine. So you can see that it's quite uh flexed and uh, you know, it twisted as well. So there's loads of things happening and you know, it has taken the bait and uh if indeed the impact is having on the tibia and uh that's why we get the injuries that we will talk about. Yeah, and the findings that we talk about the same thing, um I think we have, um, that's for the view. Let me go to the next slide. So I think it's playing it again and it's just definitely worth seeing that again. So, There you go. Ok. Now, let me try and see if I can make the next slide because that will be the side view. And uh you can again see um how, oh my God, that's painful, isn't it? So you can see the movement especially here. So I just want you to focus and how's the femur? So please. Yeah. Ok. So this is important because uh many of our uh UK trainees are asked about the patterns of bone bruising that occurs in uh in different injuries. And um, they, they, I have a few signs that we see on the MRI. So I will go to the next slide. Yeah. So, um I think my, that, you know, most of the talk that I give will be uh uh interactive. So I just want you to um uh type in what you can see on this radiograph. So remember it is post trauma and uh it has a finding a very important finding that will uh help you in to read the Mr correctly and will also help you think about the mechanism of injury. So, uh can you please uh type into the chat? I think I have um access to the chat. So I should be able to see, you know, if you type in a message. So the question is what um are the findings on this plain radiograph? Uh It's a posttraumatic, you know, uh radiograph. So this is post trauma and uh Thank you. I have a few delegates um um putting in the answers. So they're saying it's joint effusion, it could be a slight uh joint space narrowing. Uh It looks as if the patella has uh moved from its place. We have different things uh coming up. That's good. Like, so, you know, because plain radiograph is the first uh uh investigation that most of the patients with trauma will have. And like I said, I think it's important that we look at the plain radiograph um before you, you know, start looking at the uh um xrays, I mean uh at the Mr scans. Yeah. So, so there's a lot uh of focus on the patella. Um And uh I can see why um because I think there's a big effusion here. It looks as if the, the la is moved. I think it's because of the large effusion. Uh But I can guarantee you the patella was uh you know, within normal limits. Um I would like you to focus on the femoral Condy. So if you uh just check your uh review to the femoral condyle and uh OK, fine. So now we will look at the MRI scan for the same patient. So that is the effusion that you can see. So if you go back here, no occlusion here, you see that and this is the what we call lacto a sign. If I go back here, you can see it here. So there is like a depressed fracture of the left femoral con back. Yeah. So, and again, you may ask that, how do you know it's later in your condyle? You know, we said look at the tibial plateau, but there's also tubular here. So, you know, that's the la from your condyle and this is what we call a lot of bone bruising. So, uh looking at the radio, remember this has gone back, hit this and come. So that's why you have a lot of edema. And uh yes, um uh Douglass is uh right, deep lateral uh femoral notch sign. And uh that is one of the important signs that you look for. So again, just um showing you on the plain radiograph and then showing you an Mr extensive, you know, edema associated with it. So what happens to the AC L in this? Look at this? So it's completely disrupted, completely disrupted this big effusion. Even the posterior structures don't look happy here. The capsule. Yeah. And I'm not focused on the uh meniscus, but you get meniscal tears associated with this as well. OK. So if I just remind you of uh what the AC L looks like, look, it should be, you know, the orientation is completely lost. The low density structure that we had is completely lost. It's basically like a mush, isn't it? There's nothing um uh clear structures that you can see um in this region to say that, you know, there was an ACL. Yeah. So that's what is, uh you know, when you get a noncontact um AC L injury. So this patient, uh 19 year old fell by a sc a friend. So that's painful. Yeah. And uh again on the MRI scan, what you can see is uh so this is a typical of, you know, the hyperextension injury where it's just gone back, you know, completely posteriorly, whereas the other one was a flexion injury where you get the AC L injury. Yeah. So, uh and this shows again, you know, the, we talked about the um collateral ligaments and you know, the collateral ligaments here are completely um ruptured in the sense, like see them at all. And you can imagine why it completely dislocated in this region. And uh this time um yes, you can, you can see AC L complete rupture, OK? But look at the uh PC L or, you know, look at the fact that you cannot see your PCL there, OK. So just reminding ourselves of what the PCL should look like, it should be a black low signal intensity structure like that. You can't see anything like that here. OK. So complete rupture of AC L, complete rupture of PCL. And you also have what looks like, you know, um a meniscal fragment which is displaced, you have the posterior that is completely. So we did talk about, you know, the um mechanism of injury for um hyperextension and you know, it's usually all the posterior structures are completely, you know, uh distorted or strained or tone and very, very uh typical example. It's uh an extreme example, but a good one to show you about disruption of, of the ligaments. And the patient has had surgery, you can see that, you know, they are still in some brace because it's still unstable even, you know, after the surgery it has to heal for it to become stable. Ok. So those were like f uh uh hyperflexion, hyperextension injuries. And uh then we have, you know, two basic loads. So this, I think uh is with some sound effects as well. So just in case, you know, anybody has uh um uh weaned off into uh a sleeping mode or something, it's just to wake you up. So, uh we're talking about, you know, the basic loads that can uh that the knee um joint can undergo. So one is a compression. So in this one, the bones will coli leading to impaction, then there'll be tobacco fractures. That's what we call bone bruising. And they can be depressed, cortical fractures as well. And uh you can have, you know, because of the impaction, the articular cartilage in the meniscus can become uh entrapped whereas uh we can have what we call a tension uh load as well. So basically the bones are pulled apart leading to distraction across the joint. And uh that uh there is a traction on all the stabilizing uh structures like, you know, the postal lateral structures. Um there is ligamentous and tendon tears and uh you could do get fractures but they are small eversion fractures. OK. So, uh so we looked at uh the mechanism that is hyperextension, hyperflexion. And now we are looking at the loads that can cause the different injuries that is compression and tension. So basically, compression is, you know, um fractures and tension is things carrying apart like um ligaments and uh tendons. So, looking at, you know, a va uh a varus um uh injury and in this case, um the compressive load will be on the meal aspect, whereas there will be a tensile load on the lateral aspect. So we said if it's compression, then you can get um bone bruising and you can get fractures. Whereas if it is um pen, you get stretching or, you know, rupture of the ligaments. And in this case, uh it can cause rupture of the iliotibial band, which is the um uh you know, from our anatomy, we learned it's an anterolateral stabilizer. So, looking at now the valgus um you know, um mechanism. So that is virus. I just see, I hope this one plays. Yes, it's been. So again, uh it's all from this article, you know, the AD R from 2011. OK. So that's, that's really bad, isn't it? Because you have, again, uh this side will be the uh uh uh tension. So you'll get disruption of the A PN and the meniscus, but that side will be impact. So just the results of what we saw both. Ok. So just play that again. Uh, because this gives you an idea. OK. What is exactly happening at that time? Yeah, there you go. Ok. So, uh that is a mechanism for valgus, uh injuries. And again, um, you know, trainees are um expecting no, the bone bruising because uh sometimes, you know, looking at the Mr you're not given the mechanism of injury, like I said, and so you are like your lu homes trying to see, oh depending on what bruising pattern, I see what kind of injury it is and what are the structures that can be uh to. Ok. So this is uh valgus stress and uh um you know, a load and it will cause like we said, medial distraction or, you know, uh tear of these things and impaction or compulsive forces on the lateral aspect. And uh we will look at some uh examples uh of what happens when you have these kind of uh bone bruising and fractures. Like, you know, um you know, the pain radiograph, first thing it can show is uh uh lipo hematosis and uh case that we had, you just had a fusion. But you know, if you have um uh intraocular fractures and you have a trabecular fractures, you can get um lipotosis, important takeaway message from this is if lipo hemarthrosis is present, that means there is a trabecular fracture or in trabecular fracture. If it is absent, it does not mean that there is no fracture. OK. So please, I uh uh remember that um it has uh um uh uh it's very sensitive in the sense like you know, if it is there, there will be a fracture. But if it's not, that doesn't mean there's no fracture. Ok. And also the fact that uh it may take up to three hours to appear and uh sometimes can be seen only with horizontal x-ray. And uh if there's a inter uh you know, rupture as well, then, you know, it will just disseminate, you know, the fluid. So you may not see the uh fluid fluid level on that. I'm just uh showing you that in uh you know, um usually it's interpreted in that way because it's a horizontal B beam. And if you're looking at it this way, show you the different lists. So you can see that this is a fat saturated. So you can see this kidneys fat is dark and therefore that's fat floating on top of the fluid. And if you leave it because the Mr takes some time, you know, uh it will take at least um 35 minutes for the Mr to uh sequences to finish. So if you're in that position, the patient is in that position for that long, you can see that um even the uh blood will uh organize itself such that you have the plasma, which is more fluidity and then the hematocrit which has more cells uh layered into it. So that's why sometimes you get three layers. OK. So that is the one that is the plasma and that is the uh fat that you can get. Mhm And uh another example of the same thing and this is uh in the MR in the same way. Uh and this is if you notice it's not a stir image, OK. So it's not to confuse you. But uh this is sorry if I go back. It's a uh key one weighted image because you have fat in the subcutaneous tissue and therefore you have fat which is floating on top of fluid. It's dark. OK. So um just uh you know, I I, depending on what sequence you use, um the uh lipo hemarthrosis will uh uh be layered and will have different signal intensity. But as all of you know, uh fat is high on T one and on PD. And uh food is low on TT one but high on uh T two or on PB OK. This is the one we OK. Fine. So this is uh another example of uh you know, impaction. So because of the impaction of the um uh femoral Condy, there is a large fracture of the uh tibial plateau which is also, you know, uh and uh so this one I just want you to have a look and tell me what's going on. So again, time to get on to the chat and uh please type in what you think is going on with this radiograph. And uh like I said, you know, look at the plain radiograph first before you look at the Mr cause sometimes when you have small uh aversion fractures, they are easier to see on the plain radiograph than on EMR. So the question on these uh images, uh what are the important findings that you can see on the plain radiograph? Is there any lipomatosis? Question mark? OK. Is there fracture? Remember these are post trauma radiographs? So there's no trick. There's no, I'm not showing you any, any nontraumatic uh um manifestation. It's post trauma. So please have a go at what you think is happening with the radiograph. OK. Walk long. Yeah. OK. So I think people are thinking there's no right or wrong answer, you know, we will look at the signs soon. So, and I know I shouldn't, I should have put the horizontal beam as a horizontal beam, isn't it? It's in, in, in this situation? But you, I mean if there is a lipoma, you should be able to see it even if in that, that so any takers on that they stand in silent or am I missing? They're very quiet, aren't they? Samuels answered? Yes. Yes. Yes. Very good. OK, fine. So uh yeah. So there's a small crack on the uh tibia. Very good. We so, so you can actually see there's a density, increased density there. OK. And you can see there's a lucency there and also increased density there. So sometimes a typical example of an intra fracture but no lipo hemarthrosis. Yeah. So there's no lipo hemarthrosis at all, but there's a growing fracture. You can see in this, I will show you the AC T because it is subtle. I'm trying to zoom it as well to show you, you know, so you can see the tibial plateau here, you can see, you know, the two surfaces of the tibial plateau here. But here you can see only one surface because the other surface is depressed. Yeah. So uh that had to be a clue that you can look for on the brain radiograph. But you can see here, same patient quite depressed. OK. And have to have it fixed because um on, on, you know, uh this is just a snapshot of current image. But if you look at more images, there was quite a bit of, you know, depression for the depression. Yeah. So just going back to the plain gra because it's subtle but it's important uh that we uh identify that. And in this case because there's a depressed uh fracture, you're not doing uh Mr we're doing AC T because they're not worried about ligamentous injury. Remember this will be like that compression or the axial loading kind of uh uh mechanism where there is a fracture. So the um when there is like that kind of impaction, then you're gonna get uh uh a depressed fracture or a cortical fracture. And uh those are not as much associated with ligamentous injuries. Therefore, you do ac t to show what the depression is and help the surgeon plan the surgical treatment for it. Yeah. So this is a, a typical example of a tibial plateau fracture which is depressed. OK. Fine. So the uh next one shows a very nice lipo hemarthrosis. OK. And um has anybody seen the fracture? So we said if it's a lipo hemarthrosis, there should be a fracture somewhere. OK. And uh yes, uh we know there are limitations of the pain radiograph. So you may not be able to see but you have to look for it very carefully. Yeah. So if there is a a lipo hemarthrosis that you're looking at, then there will be a fracture. And in this case, you can see the fracture again in the, the plateau and the um yeah, tibial spine very good. OK. So a again, the tibial spine fractures, they can be like aversion fractures. So they will be like anterior or posterior, then you will look at uh whether if it's anterior, it is the footprint of the AC L. You know that structure, it's posterior, it'll be the footprint of the uh PC L that's ruptured. Yeah. So that's what you're looking for to see. Uh is there a fracture of the uh uh tibia? And uh what is happening to the uh tibial spine? Very good. Ok. So the next one is um um you know, a large fracture of the uh patella, it's not displaced, but you can see a big effusion here and it's quite dense. It may be hemarthrosis that you're looking at because it's near soft tissue density or denser than soft tissue density. Yeah. So that's what you're looking at. And you know, this is direct impact, uh this patient had fallen or something like that. So there was direct impact to the knee and it has gone uh the patella, OK, fine. So this one is uh was a very interesting uh um uh case. Uh It was a 13 year old and it was a football tackle. So, like you said, all are, you know, posttraumatic uh radiographs that we're looking at. So, um anybody wants to um you know, try and type in what you, what you're seeing here and then we will look at, you know, some cross sectional imaging here. So um remember when we start looking at pediatric, so you will start off saying that uh this radiograph is in a skeletally immature patient and uh they uh you know, behave um differently in this sense, there is more laxity, the um tendons and the ligaments. So they will get more fractures and less of you know, um ligamentous or uh tendon injuries. Yeah. So, so we have uh uh answers coming up the fibular fracture with fluid and soft tissue swelling. Ok. So what's this for this one here? Yes. Uh So um so we have of the fibular fracture but remember this is a 13 year old, it's a skeletally immature patient. So they will have all the faces that are unfed. Yeah, they will have the faces that are unused. So you should not mistake them for any fracture lines. Yeah, but there is something happening, you know, with the femur. So if you have a look at the femur and then you know you can think about uh what's happening there. OK. So we go to the uh next slide and if you see what has happened, there is fracture through the facial plate. So if you look at this here, so there's slight increased, you know, um um space compared to the other faces, look at that it is much more wider. OK? Uh And uh it looks as if you know this is as true as can be, but it looks as if is moved there. Yeah, and that is because it has actually moved. Yeah. So there is fracture through the faces and that was very traumatic. So can you see that? So it has actually moved there is so, I mean, despite such a big injury, there's no lipo hemarthrosis that you can see. OK. And that can be, like I said, if there is capsular disruption or, you know, it is, it's not uh settled and, you know, it hasn't been given time to actually layer up. Yeah. So another, I mean, again, uh example of no like aros but a big uh fracture that is in. Yeah. So, uh I just want to add in pediatrics. Uh, we must have views from both limbs. Uh, so Sarah, do you mean that you need a right and the left uh that's not our usual practice. We don't get uh you know, um x-rays of both limbs uh because we want to try and uh keep the, you know, radiation dose minimum. Yeah, fine. So, so another good, good example of, you know how uh uh you know, the Mr can be helpful in such situations and in a patient who's having extensive pain, the pain radiograph looks, looks in a sense, but you know, there are uh signs that if you look for them and then the Mr confirms the findings, then you must have come across this uh uh you know, phase saying small flakes, great shakes. Yeah. And uh that is because um like we said, you know, the small aversion fractures may actually uh be the sign of a major intraocular disruption. So, um the, the place that we have seen, we already seen some of these examples, we saw the tibial spine, uh you know, that can be um avulsed uh depending on AC L or PC L and uh you can have uh inferior uh pull of the patella because the patella tendon attaches there and you can have it from the fibular head and you can have it from the lateral, your plateau. And there are uh names for these kind of injuries as well. So we will now look at some of the um you know, uh smaller aversion fractures that can happen. And uh this is a typical example of uh the findings in uh uh typical injury pattern. Ok. So I'll give you um, uh a minute or, I mean, 30 seconds for you to just, uh type in your thoughts as to what kind of injury this is, uh because there are clues on the Mr um, and you can actually see, you know, this segment here on the uh plane geograph. Yeah. So just have a think about what kind of injury this is. This is not something that we have already, you know, done, but we have talked about it because of the uh, bone bruising that you can get. And, uh, actually I think somebody um in the uh chat has, you know, said about this kind of injury. So I'll just give you um 30 seconds. Uh, so, uh, can you kind of? Yeah, yeah. Yeah, it looks like you've got one you've got um, yes, yes. I mean, uh if you have some options that are typed in and if you do agree, just give a thumbs up to that. Then we know that. Ok, many of you agree or disagree with that and if you don't agree with that, then you can type in you answer, please do not rely on me to give an answer because I think most of you who have been on one of the medical education events knows that I am not medical. It, yeah, I haven't shared these slides with uh su so she won't know the answer. That's right. Cause I could just tell just like that. Yeah. Anyone else. OK. So we have one pat dislocation. Anybody else wants to uh second that or you know, uh agree or disagree with that. So there is uh uh this one about medial meniscal uh care in the chat. OK? And Sarah agrees uh with the thumbs up with the patella dislocation. OK? I think uh the others are thinking, I just, I just want you to, you know, think about, oh what are we looking at? So that then you go back and uh look at another case you say ah that's what I learned. That's why. Yeah. So it'll be like quite active learning here. So very good. I mean uh and uh people have said about PC L or lateral patella dislocation. Yes. Yes. Yes. So, so basically, if you look at what is happening to the patella, this has gone and hit this femur and then come back, we looked at how, you know, the AC L reception can happen and you know how the uh femur goes and hits the back of the tibia and comes back here here, the patella dislocates, then it goes and it hits the um uh uh you know, the lateral aspect of the uh um femur and then it comes back. Yeah. In what, what happens with that is you use the lateral ligament. Yeah. And you get bone bruising within the pala and within the femur. So you know, this is uh uh you know uh lateral femoral contact because you can look at the uh meniscus, they are equally size, you can have the fibula here. So you know, it's the lateral femoral contact, so very extensive bone bruising, the left femoral contact, rupture of the um uh pa retinaculum, the medial side. And there is also an osteochondral fragment that has, you know sheared off. OK. So you can see here there is a fragment missing, OK. And it can also be from the side of the femur. So you have an osteochondral fragment. Yeah. And these injuries many times there will not be any clear mechanism given to you and it will just be um post trauma, extensive swelling could cause. That's what, that's what the message will be. Yeah. So like I said again, like you will be like Sherlock Holme detectives, you know, trying to put the uh uh bone bruising patterns together, looking at what is disrupted and say this is what must have happened. OK. So good example of uh osteochondral shear injury. And it's basically the force is shearing force and it's just, you know, taken off a bit of a cartilage and a bit of bone as well showing that with all the arrows uh beds come off. OK. So the next uh uh thing is also a small osteochondral uh injury and that has come out. So if I, if I show you that again, so you can see the fragment there and that has come out from the patella, OK, which has gone and hit, you know, the uh um later femoral condyle and then bounced back. OK. So you can, and you can also see there's a small defect here one. OK. So, and uh but on the Mr, why is it important to see this is because on the Mr trying to find the fragment, we can be very difficult because everything is low, you know, most of the structures are low signal intensity. So if you're trying to find in between that a low signal intensity costochondral uh fragment, it can be difficult. So that's why you look at the plain thumb, look at the Mr and put the 22 things together. So different. Um uh these are different examples of, you know where the fragment could have come from. So you can see the fragment here that's on AC T to show you exactly the size of the uh fragment where it has come from. So that's the defect there and this is on the Mr. So just to again, um you know, point out so if you look at a plain radiograph, you can see a fragment clearly. Look at the CT, you can see that clearly. In this case, the CT was done to actually give the size, you know, of the uh uh osteochondral defect because it will help in surgical planning. But look at the Mr and you can just about see because you know where it is. Otherwise it's very difficult to identify that because it's like, you know, many of the humans and ministers and other things also lose sign in. Yeah. So that's why I was saying you can be really clever by looking at the plain radiograph and identifying this and you know, the Mr to confirm that it is due to, you know what kind of injury it is and also confirm the intra artic structures which you cannot comment on on the plain radiograph. OK. Fine. I think we're nearly there. So uh again, it's showing you the fragments where it's coming from the donor site. And also, you know, the donor site on the Mr scan and the fragment on the CD and the Mr, OK. So this is a fracture that all of you will be familiar with. And uh you can see your small fragment and I have, you know, uh mag it as well. So that's an a fracture. And uh you can see, you know, that you can just about see the fragment on the Mr, like I said, it can be difficult to see uh OIC fragment but, and the AC L you know, is the one that will be um uh ruptured and uh it will be associated with more than 95% of facial tear. Yeah. And this is um if you're looking at it on the cor um we saw a hand shaped structure should be going there, isn't it? So, you know, when we visited the anatomy, but that's not happening yet. OK. There is uh um ill defined, just soft tissue density. That's all. So there's nothing like a ligament that's going in. And uh that's why we know that, you know, there's no, there's no AC L there, OK? And sometimes they call it like a bear sign as well. That means there's nothing it's bear, that's nothing attaching to that area. OK. So those that is um you know, uh ac L rupture with uh sa fracture. Uh And uh it can also have medial meniscal tear associated with it. It can have medial collateral liga. You can see the uh disruption of the later collateral here because there's scapular, you know, uh thicken and there's ill defined um uh low sign in density there. So, second fracture, uh just a few words about it. It's due to extensive internal rotation and uh varus stress as is associated with the tears of the AC L, the meniscal tears and also damage to the Postal Lain corner, which is what is happening in this side where we can see that, you know, there is disruption of the LCL. OK. And uh yeah, so I mean that that is the uh mechanism of injury that we have looked at and uh rever gone is just the opposite the mechanism. What happens. And you can see it on the medial plateau and you will see like a PC L uh injury. And here it's actually uh there's a fragment that has come out from the TV. So it's like an aversion uh injury of the PC L. Yeah. So we have talked about, you know, the fracture fragments, look at that, that is ACL and that is PCL. Do I put the arrows? Yes. So, uh so you can, again, you know, plain radiographs are really helpful to just identify the subtle finding and then go look at the Mr to see and confirm and also look at the meniscal tears and other uh you know, collateral ligaments, which you can't see on the plain negra. So you have to give a complete picture to the uh knee surgeon before he plans his operation. And that's why it's important to um interpret both uh the um plain Negra and the MRI scan. OK. And uh just um again, catching on the post, lateral corner structures. So we know the fibular collateral ligament uh that's the biceps ferus tendon. So you have the conjoined tendon. And um if you start looking at, you know, the parasagittal images, they are really good because they are, they are, they are oblique to, you know, start with when they are obtained and they are very good to look at these uh structures. And then you have the uh um uh you know, the uh fibula, so fi fibular ligament, but these ligaments are the ones that are very difficult, you know, to identify uh when there's a lot of trauma and injury and even the knee surgeons will not be able to identify those. So, what I would suggest is that you uh you please um uh learn to identify the fibular collateral ligament, the biceps femoris, uh that is the uh muscle that is again the fila uh uh po fibular ligament. But again, you know, that's very one, but these will be the main structure that you should focus on. So these are examples of uh uh avulsion fractures uh of the poster lateral corner. So you have the bice femoris. So a big fragment, OK. Come back to the arcuate ligament, which will be usually a very small uh uh slender fragment from the fibular head. OK. So um those are the two different, you know, factors that you can get, but both are indeed if you go back there, it's op post to lateral coral structures and uh other aversion injuries like, you know, we talked about the fibula and uh with that, you know, it's associated with a lot of uh other internal uh um structures and uh uh this disruption of uh the uh uh trabecula because remember it will be infection this side and it will be distracted side. Yeah. So because of distraction, you're losing the, but it's due to impaction, you're getting bone bruising or a fracture. And uh yes, it also shows small fracture fragments in the uh uh tibial plateau area and your spine area. And that is again, as say, showing that there is a version of the uh um cruciate ligaments as well. OK. So um uh plain radiographs are as important as you know, Mr. So recap we did anatomy, we did like um you know, what are the indications, the sense and what is the protocol for uh uh M RNI. We looked at mechanisms quite, quite in detail because uh if you have a very good idea of what the mechanism of injury is, then it will help in your uh interpretation of the plain radiograph and also the Mr and uh also help the clinician exactly know what has happened, you know, in that particular. Then we looked at interpretation and we looked at uh avulsion and osteochondral injuries. You know, what is the significance of small fragments that you can find in different places? And uh what does it actually tell you, you know, a big story behind all this. So thank you for that. I think we are just on time. And uh like I said, I will do the next session on uh uh test and you know, other things that we haven't been able to cover today. Um I'm hoping this was useful to all those who have attended today and uh and stop. Ok, thank you. Thanks a lot. Does anyone have any questions obviously for prayer to answer? Not me? You got any questions, pop them in the chat. So going forward, you will get your feedback form again. Fill it out. Be as honest as you like, Pria loves a bit of feedback. Fill it out. Be as honest as you like, there's a section there as well for further topics you would like in this topic. So um pop your information on there and I will be passing on all the feedback to Pria in about a week. So you've got a little while to feed it to fill it out and then send it back to me and I can pass it on. Alright. Uh sorry. Thank you so much. Thank you, Sarah for joining us. Anyone got any questions or shall we say goodbye? I think, think, think. Ok, I always, I never want to cut off too soon. It's just like, so we're gonna say goodbye to you all and hopefully we'll see you at our next medal education event. And like I said, don't forget to like, er, the BS Sr organization on Medal and then when they create their next event, they can send er, an invitation to all of their followers if you're following them. All right. And you can go along to that and see a bit more of Pria. All right. Take care everyone. Thank you. Thanks.