0:01

Here we have an elbow of a young child who

0:05

has started pitching and has elbow pain.

0:08

Let's pay close attention

0:09

to our plain films first.

0:11

Looking at the plain film, I think it's a

0:14

subtle finding, but it can be appreciated.

0:17

There is a subtle lucency

0:19

here at the radial head.

0:21

So this is not normal.

0:22

It should be nice and bright throughout.

0:24

So this indicates to me that there's some kind

0:27

of an injury, probably an osteochondral lesion.

0:30

If you remember from the prior vignettes,

0:32

the most common location for an

0:34

osteochondral lesion is at the capitellum.

0:37

However, this person happened

0:38

to get it at the radial head.

0:41

We then did an MRI without

0:45

contrast, and you see it over here.

0:48

Actually, the first MRI we did was with contrast.

0:50

Let's go over here.

0:52

In the April 11th study, I'm

0:53

going to bring it down from here.

0:56

With the contrast, we see that now, the

1:01

osteochondral lesion on a coronal T1

1:03

weighted sequence is very difficult to see.

1:06

If we bring up a fat-suppressed

1:08

fluid-sensitive sequence, this also

1:10

is relatively difficult to see.

1:12

It all depends on what plane you get it at.

1:14

So you may have to look at it at various

1:17

planes to see the osteochondral lesion.

1:20

Let's now bring up a DES sequence,

1:23

which is our very thin slices.

1:26

And you can notice, indeed, yes.

1:29

There is an abnormality in the radial head.

1:32

So that is our osteochondral lesion.

1:35

Why do we give contrast for something like this?

1:38

Well remember, this is a problem

1:41

that's developed because the patient

1:43

is actively putting pressure or

1:46

movements, different movements in the

1:48

shoulder—I'm sorry, in the elbow joint.

1:50

Oftentimes you have concurrent injuries.

1:52

Just because you have a radial

1:54

head or a capitellar injury doesn't

1:56

mean you don't have other injuries.

1:58

One of the most frequently affected areas in a

2:01

picture is on the medial side or the ulnar side.

2:06

So we typically look at the ulnar

2:08

collateral ligament complex.

2:11

So I want to pay a little more attention to

2:13

that detail in this coronal T1 Fatsat image.

2:16

So this here, the structure,

2:21

is the anterior bundle of the ulnar

2:23

collateral ligament, the most important

2:26

component of the ulnar collateral ligament.

2:28

There are other components such as the posterior

2:30

bundle and transverse bundle, not as important.

2:33

The anterior bundle is very, very important

2:35

and that anterior bundle in a young

2:37

patient should be intimately associated

2:40

with this bony structure over here.

2:43

And that is called the sublime

2:44

tubercle of the coronoid process.

2:47

The fact that you have contrast

2:49

interdigitating between the anterior

2:51

bundle and your sublime tubercle means

2:54

that there is an undersurface tear.

2:57

So this will need to get fixed,

2:59

specifically or particularly if this

3:02

patient is a high-performance athlete.

3:05

And I want to show you that same area on

3:07

the same patient when the examination was

3:10

done without intra-articular contrast.

3:13

So here is the test.

3:14

A coronal STIR image, and it could be any

3:17

coronal image; you could get T1, whatever,

3:19

DES, and look how difficult—I would even

3:22

say impossible—to see the separation between

3:26

your sublime tubercle and your anterior

3:28

bundle of your ulnar collateral ligament.

3:31

Here you would never pick up that undersurface

3:34

tear, which could be very important depending

3:36

on the activity level of that patient.

3:38

In fact, just to prove to you that this

3:40

is the same patient, you can see that

3:42

here is the osteochondral lesion that has

3:46

undergone interval healing or interval

3:48

progression since the last examination.64 00:02:43,014 --> 00:02:44,665 And that is called the sublime

2:44

tubercle of the coronoid process.

2:47

The fact that you have contrast

2:49

interdigitating between the anterior

2:51

bundle and your sublime tubercle means

2:54

that there is an undersurface tear.

2:57

So this will need to get fixed,

2:59

specifically or particularly if this

3:02

patient is a high-performance athlete.

3:05

And I want to show you that same area on

3:07

the same patient when the examination was

3:10

done without intra-articular contrast.

3:13

So here is the test.

3:14

A coronal STIR image, and it could be any

3:17

coronal image; you could get T1, whatever,

3:19

DES, and look how difficult—I would even

3:22

say impossible—to see the separation between

3:26

your sublime tubercle and your anterior

3:28

bundle of your ulnar collateral ligament.

3:31

Here you would never pick up that undersurface

3:34

tear, which could be very important depending

3:36

on the activity level of that patient.

3:38

In fact, just to prove to you that this

3:40

is the same patient, you can see that

3:42

here is the osteochondral lesion that has 91 00:03:51,689 --> 00:03:54,180 So here is an extra finding in a patient where

3:54

we only suspected an osteochondral lesion,

3:56

but they happen to have a concurrent lesion on

3:58

the other side of the elbow, the medial side,

4:01

showing an undersurface tear of the anterior

4:05

bundle of the ulnar collateral ligament. 89 00:03:46,180 --> 00:03:48,580 undergone interval healing or interval

3:48

progression since the last examination.

3:51

So here is an extra finding in a patient where

3:54

we only suspected an osteochondral lesion,

3:56

but happens to have a concurrent lesion on

3:58

the other side of the elbow, the medial side,

4:01

showing an undersurface tear of the anterior

4:05

bundle of the ulnar collateral ligament.