0:01

Here is a case that modern-day pediatric

0:06

radiologists even miss quite frequently.

0:09

So why do I say modern-day?

0:11

Because typically in the old days, a child

0:14

would come in with foot pain, they would get X

0:17

rays, X-rays would be called negative, and the

0:20

next step would be getting a bone scan, right?

0:23

And when you get a bone scan for this

0:25

condition, it lights up like crazy.

0:29

Nowadays, we don't do very

0:30

many bone scans anymore.

0:31

So oftentimes, we call this radiograph

0:33

negative, the kid goes home, continues to have

0:36

bone pain or foot pain, and later will come

0:38

in, uh, get repeat X-rays or, or get an MRI.

0:43

So an MRI will reveal the abnormality,

0:45

will reveal the abnormality, but you

0:46

can, you can capture what's going

0:49

on actually in the plain films.

0:50

So here are two views of a toddler's

0:55

lower extremity, particularly the foot.

0:57

Here is an AP view and here is an oblique view.

1:01

What's the abnormality?

1:03

I'm going to point it out to you

1:04

and hopefully I can convince you.

1:07

If you look at your tarsal

1:08

bones, here is your cuboid,

1:12

here is one of your cuneiforms,

1:14

here is your talus, sorry, your

1:17

calcaneus, and here is your talus.

1:20

Look at the density of those bones, right?

1:23

The density of this bone pretty much matches

1:25

the density of this bone, of this bone.

1:28

And this part of the cuboid bone, if you

1:32

look very, very carefully, you notice

1:34

that this part right here is a little

1:37

brighter, a little bit more sclerotic.

1:40

Look on the oblique view, again, look at the

1:42

density here, look at the density on this part

1:44

of the bone, but look at the density over here.

1:47

It's a little bit too bright, okay?

1:50

So what has happened?

1:52

And I'll give you the typical history

1:55

on this kid and any kid who has

1:56

this particular type of process.

1:59

This child had a fracture of

2:02

the tibia several months ago.

2:06

That fracture was treated with a

2:08

cast, and the patient was immobilized.

2:11

The fracture healed and the kid was

2:14

allowed to go play again, run around.

2:16

Well, during that time when

2:17

the kid was immobilized,

2:20

he was not using his lower extremity, so

2:22

that meant the bones became very osteopenic.

2:24

They became weak because the

2:26

calcifications were being leached.

2:28

As soon as he started playing again,

2:32

this bone right here, which is your

2:35

calcaneus, banged up against the talus.

2:39

And because he was predisposed

2:41

by that osteopenia, it caused an

2:43

impaction fracture of the cuboid.

2:45

So this is what an impaction

2:47

fracture of a cuboid looks like.

2:49

Now, you may say, well, it looks

2:51

like it's subacute or not acute.

2:54

I agree with you.

2:54

It's not completely acute because you

2:56

already see a little bit of sclerosis.

2:58

That's the healing process.

3:00

Well, then you go, why don't

3:01

I see a periosteal reaction?

3:02

Because that's how bony fractures should heal.

3:06

You remember that tarsal and carpal bones

3:09

don't undergo ossification by periosteal

3:12

formation because they don't have a periosteum.

3:14

They undergo ossification endochondrally.

3:17

So in other words, calcification

3:19

happens from the inside out.

3:21

It's the cartilage itself that becomes ossified.

3:24

The periosteum doesn't cause

3:25

any cortical formation.

3:27

So that's why when you have

3:28

healing of bones that don't have a

3:30

periosteum, all you see is sclerosis.

3:33

You don't see, quote,

3:34

unquote, periosteal reaction.

3:36

So this is a great example of a cuboid impaction

3:40

fracture, and the history is so important.

3:43

Oftentimes, like I said, these kids

3:45

have an injury that happened a few weeks

3:46

ago that caused them to be immobilized.

3:49

Something very similar can actually also

3:51

happen in the carpal bones of the hands if

3:55

they've had a fracture in the radius or ulna.

3:57

They won't use it for a while, and

3:59

then, and then they will use it

4:01

after the cast has been taken off.

4:03

Maybe they're doing handstands, maybe

4:04

they're a gymnast, and you'll develop

4:06

these impaction-type fractures.

4:08

In the carpal bones also.