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Dr. P here.

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3 00:00:01,930 --> 00:00:07,960 I've got an 18-year-old female who has a heel

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abnormality, and five years prior to this study

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had an implanted foreign body, which was removed.

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So the question that has been posited

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to us is, what is this thing in the

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heel pad on the sagittal T2 PD image?

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The TE was 60, the TR was about 3,000.

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On your right is the sagittal

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straight-up T1 spin echo.

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And on your left is an axial, just to roll it

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along, an axial T2 nonfat-suppressed image.

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So I gave you a porridge, a soup,

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of different signal intensities.

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Something very heavily water-weighted,

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something somewhat water-weighted,

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and something that is fat-weighted.

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Then you take a look at this

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mass and say, okay, where is it?

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It's in the heel pad.

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That narrows the differential

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diagnosis quite a bit.

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For instance, and you don't get

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ganglion pseudocysts of the heel pad.

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The next thing you do is you look at it and you

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say, well, it's multilobulated or multiloculated.

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Kind of like ganglion cysts might

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be, except it's in an awful location.

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So you have to think about

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another potential diagnosis.

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Then the other factors that play into

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this are, what's the zone of transition?

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Is it pretty tight or is it pretty loose?

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You know, you look at the T1-weighted

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image. There's some ill-defined, wax

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on, wax off signal around it, but it's

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pretty well-concentrated to this area.

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It's not crossing any boundaries.

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It's not invading anything.

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It's not exophytic.

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These are all things you need to think about.

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It is not attached to a tendon or to a joint.

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So that really winnows down

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the differential diagnosis.

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So the types of things that should

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go through your head are epidermoid,

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implantation, and inclusion cysts.

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They tend to be a little bit

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loculated, but not so much like this.

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These almost look like little clusters of grapes.

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And you don't see that very

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often with an epidermoid.

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Granted, it can occur.

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Certainly other cystic lesions

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like a cystic schwannoma.

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There really isn't any nerve there, so a cystic

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tumor would be an unlikely consideration.

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We've already mentioned ganglia don't

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occur in the heel pad, even though

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the signal is not inconsistent.

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But when you go to the axial T2-weighted

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image, some of you are wondering, with

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these lobulated finger-like masses, that,

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by the way, have some internal architecture

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and signal inside them with septa.

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What is this?

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Is that the residua or the remains of

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the so-called five-year-old foreign body?

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And the answer is, no, there's more of them.

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There's another one here.

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And if you keep looking, maybe

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there's another one here.

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And eventually, you arrive at the correct

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diagnosis, which is that of a hemangioma.

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There's a whole classification of hemangiomas.

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Not gonna go through that

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classification right now.

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But, the diagnosis of hemangioma is highly

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likely with the presence of phleboliths.

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This sort of bowl of grapes or cluster of

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little grapes or seedlets within the heel.

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It likes the heel pad.

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Sometimes it'll involve the subcutaneous space.

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As it does, it's gray in signal,

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similar to muscle, and bright on T2.

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It does have some internal signal in it

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because it has debris or blood inside it.

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Not too dissimilar from lymphangioma,

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which, by the way, don't occur here.

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And I'll share one anecdote with you.

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When I was a young attending, a woman was in the

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stirrups delivering, and right after the delivery,

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she had a giant swollen red and purple heel.

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Which she then ascribed to a

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trauma from the OB-GYN surgeon.

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And we went and did an MRI on her to

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visualize this traumatic hematoma.

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And what we saw was nothing more than a giant

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hemangioma that had responded hormonally to

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the delivery and had grown within a matter of

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hours, creating this false red and purple mass.

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It had absolutely nothing to do with the patient.

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Uh, with what the surgeon did,

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it was completely atraumatic.

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And you can confirm, if you have any

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question, the diagnosis of a hemangioma, or

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a venous malformation, or a lymphangioma,

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by going to ultrasound with Doppler analysis

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looking at arterial and venous flow.

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With that, let's move on.

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Dr. P out.