Dialysis crystalline arthropathy: an entity underrecognized pathologically.
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Arthritis↗
Biomedical subjects
J R Crim
Publications and source records attributed to J R Crim.
Clearance of the cervical spine in multitrauma patients: the role of advanced imaging.
The cervical spine is injured in 3% of major trauma patients. Radiographic clearance for injury must be provided efficiently and accurately. There are numerous choices for clearance that are now in clinical practice: lateral radiograph only, 3-view or 5-view cervical-spine (c-spine) series, flexion-extension radiographs, computed tomography (CT) with multiplanar reformations, and magnetic resonance imaging (MRI). This article reviews the literature on methods of c-spine clearance, and emphasizes the pitfalls of each modality. Although lateral radiographs detect 60% to 80% of c-spine fractures, a significant number of fractures are not visible, even when three views of the spine are obtained. The sensitivity of plain radiographs can be improved by attention to several subtle features, which are discussed. Flexion-extension radiographs in the acute setting have an unacceptably high false-negative and false-positive rate. CT detects 97% to 100% of fractures, but its accuracy in detection of purely ligamentous injuries has not been documented. Furthermore, CT is limited in patients with severe degenerative disease. MRI is highly sensitive in the detection of ligamentous injury, but not all cases of injury may cause instability. MRI is also much less sensitive than CT to fractures of the posterior elements of the spine, and to injuries of the craniocervical junction. The causes of missed cervical spine injury and delayed instability are discussed and shown in this article. An algorithm for the use of advanced imaging is proposed.
Algorithms↗
Radiographic imaging for treatment and follow-up of developmental dysplasia of the hip.
Developmental dysplasia of the hip (DDH) is a spectrum of abnormalities that can range from a very mild disturbance to a very severe process that is incapacitating later in life. This article considers the causative factors and natural history of DDH, as well as anatomic abnormalities, physical examination findings, and both surgical and nonsurgical treatment options. The goal of this article is to place in perspective the use of advanced imaging techniques in the diagnosis and follow-up of patients with DDH. Ultrasound, computed tomography (CT), and magnetic resonance (MR) findings are reviewed with respect to the diagnosis of DDH, treatment complications, and long-term problems that may occur in treated and untreated patients.
Acetabulum↗
Osteochondral injuries.
Osteochondral injuries are an important type of musculoskeletal trauma that can lead to disabling arthritis if not recognized and treated appropriately in the early stages. The anatomic configuration and biomechanical function of a joint are important for understanding its particular pattern of osteochondral injury and the resultant imaging appearance. The imaging of osteochondral fractures and osteochondrosis dissecans (OCD) is reviewed in this article, with particular attention to differentiating surgical and nonsurgical lesions on the basis of their appearance with advanced imaging modalities. Computed tomography (CT) and magnetic resonance imaging (MRI) have improved both the sensitivity and specificity for detection and characterization of osteochondral injuries. MRI is currently the modality of choice for the detection and staging of osteochondral injuries. It has the greatest sensitivity owing to its ability to depict marrow edema and directly assess the fracture clefts of stage 3 lesions, as well as the morphology of articular cartilage. Newer strategies for differentiating stable from unstable osteochondral fragments include MR arthrography and intravenous contrast-enhanced MRI.
Bone and Bones↗
Imaging the diabetic foot.
Early and accurate diagnosis of infection or neuropathy of the diabetic foot is the key to successful management. Angiopathy leads to ischemia which, in combination with peripheral neuropathy, predisposes to pedal skin ulceration, the precursor of osteomyelitis. Chronic hyperglycemia promotes production of glycosylated end products which accumulate on endothelial proteins, causing ischemia of the vasa nervorum. When combined with axonal degeneration of the sensory nerves, the result is hypertrophic neuroarthropathy. Should the sympathetic nerve fibers also be damaged, the resultant loss of vasoconstrictive impulses leads to hyperemia and atrophic neuroarthropathy. Plain radiography, although less sensitive than radionuclide, magnetic resonance (MR), and computed tomographic examinations, should be the initial procedure for imaging suspected osteomyelitis in the diabetic patient. If the radiographs are normal but the clinical suspicion of osteomyelitis is strong, a three-phase 99mTc-MDP scan or MR imaging is recommended. An equivocal 99mTc-MDP scan should be followed by MR imaging. To exclude osteomyelitis at a site of neuroarthropathy, a 111In white blood cell scan is preferable. To obtain a specimen of bone for bacteriological studies, percutaneous core biopsy is the procedure of choice, with the entrance of the needle well beyond the edge of the subjacent ulcer.
Biopsy, Needle↗
Imaging evaluation of osteomyelitis.
Bone infection, or osteomyelitis, is a common medical problem that is often difficult to diagnose. Osteomyelitis is not unusual in diabetic patients with foot ulcers and bedridden patients with decubitus ulcers--populations where diagnosis is especially difficult. Spinal osteomyelitis and septic arthritis require early diagnosis in order to avoid permanent debilitating consequences. Regardless of the clinical setting, imaging plays an important role in establishing the diagnosis and directing treatment. A variety of imaging modalities may be used, including plain radiography, radionuclide imaging, computed tomography (CT), and magnetic resonance imaging (MRI). Decisions regarding the best imaging modality can be challenging and should reflect the location of the suspected infection and associated illness or bony disorders.
Adult↗
Diagnosis of low-grade chondrosarcoma.
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Adult↗
Case report 748: Chondroblastoma of the femur with an aneurysmal bone cyst.
A case of chondroblastoma associated with an aneurysmal bone cyst has been described. The radiographic appearance of the lesion understandably reflects the combined features of both tumors. Up to one-half of all cases of aneurysmal bone cysts are found in association with other tumors, benign or malignant, and up to 15% of chondroblastomas are combined with an aneurysmal bone cyst (4).
Adolescent↗
Diagnosis of soft-tissue masses with MR imaging: can benign masses be differentiated from malignant ones?
A blinded, retrospective review of 83 soft-tissue masses (49 benign and 34 malignant) was performed to evaluate the ability to distinguish benign from malignant soft-tissue masses with magnetic resonance (MR) imaging. The correct histologic diagnosis was reached in 31% of cases by one reader and in 16% of cases by the second reader. Mean sensitivity was 50% for benign masses and 80% for malignant masses. The majority of both benign and malignant masses had inhomogeneous signal intensity and at least partially irregular borders. Malignant masses uncommonly had smooth borders and homogeneous signal intensity. MR imaging can be used to evaluate the extent of soft-tissue masses, but most masses will require biopsy to determine if they are benign or malignant.
Adult↗
Enchondroma protuberans. Report of a case and its distinction from chondrosarcoma and osteochondroma adjacent to an enchondroma.
Enchondroma protuberans has been defined as an exophytic enchondroma of a long bone. We contrast a case of enchondroma protuberans with two cases of coincident enchondroma and osteochondroma. Our cases and the previously published ones lead us to believe that enchondroma protuberans is probably an enchondroma variant and that its unusual growth pattern may be related to the oblique orientation of the proximal humeral epiphysis. Unlike osteochondroma, which may be treated surgically by removing the cartilage cap and, in some cases, the stalk, enchondroma protuberans requires intralesional curettage. Enchondroma protuberans must be distinguished radiographically from chondrosarcoma.
Adult↗
Widespread inflammatory response to osteoblastoma: the flare phenomenon.
A case of vertebral osteoblastoma caused a diffuse, reactive inflammatory infiltrate in two vertebrae, adjacent ribs, and the paraspinous soft tissues. The authors call this the flare phenomenon. On magnetic resonance images the diffuse inflammatory response caused a misleading appearance that simulated a malignant process (lymphoma or Ewing sarcoma). A computed tomographic myelogram was diagnostic.
Adult↗
Extracranial lesions of the head and neck: preliminary experience with Gd-DTPA-enhanced MR imaging.
The authors report initial experience with magnetic resonance imaging enhanced with gadolinium diethylenetriaminepentaacetic acid (DTPA) in 27 patients with various extracranial lesions of the head and neck. Unenhanced T1- and T2-weighted images were compared with T1-weighted images obtained 3-30 minutes after Gd-DTPA administration. Overall, compared with precontrast T1- and T2-weighted images, Gd-DTPA improved the visibility of lesions in 11 and five of 27 patients, respectively. Gd-DTPA particularly improved the conspicuity of tumors of the nasal cavity and paranasal sinuses and tumors having perineural or intracranial extension. Gd-DTPA-enhanced images were equivalent to precontrast T1- and T2-weighted images in five and 13 patients, respectively, and inferior to them in nine and eight patients, respectively. Mixed results were obtained in two patients and one patient when Gd-DTPA-enhanced images were compared with T1- and T2-weighted images, respectively. The authors conclude that Gd-DTPA has definite but limited uses in extracranial head and neck pathologic conditions and that more research is needed to evaluate particular applications.
Adolescent↗
Desmoplastic fibroma of bone: radiographic analysis.
Desmoplastic fibroma (DF) of bone is a rare, nonmetastasizing but locally aggressive tumor that has been discussed infrequently in the radiology literature. The radiographs from 107 previously published cases of DF and seven cases from the authors' institution were analyzed to better understand and define its radiographic characteristics. DF was most common in the mandible, pelvis, and femur. A geographic pattern of bone destruction, with a narrow zone of transition and nonsclerotic margins, was seen in 80 (96%) patients with intraosseous DF for whom radiographs were available (83 patients). Internal pseudotrabeculation was seen in 76 (91%). Although widening of the host bone due to gradual apposition of periosteal new bone was common, occurring in 74 (89%) patients, distinct periosteal new bone occurred in only two (2%) patients with DF of intraosseous origin. The cortex was breached in 23 (28%) patients. Three cases of DF arising in the periosteum were identified and were differentiated radiographically from desmoid tumors of intraosseous or soft-tissue origin.
Adult↗
Magnetic resonance imaging of the hindfoot.
This article demonstrates normal anatomy of the foot and ankle as visualized with magnetic resonance imaging (MRI) in the sagittal, axial, and coronal planes. Additionally, selected cases chosen from our experience with more than 100 clinical scans are shown to highlight the primary areas in which we have found MRI to be clinically useful: bone marrow abnormalities, especially osteomyelitis and osteonecrosis, soft tissue injuries and masses, and cases in which metallic fixators make CT evaluation problematic.
Adult↗
Use of vertebral levels to measure presumed internal rotation at the shoulder: a radiographic analysis.
Internal rotation of the shoulder is frequently measured by noting the maximal vertebral level reached by the patient's thumb, but it is not at all certain that this maneuver is strictly measuring internal rotation. We analyzed this maneuver with computed tomographic scans of the shoulder in differing positions. We also analyzed extension of the glenohumeral joint and scapulothoracic articulation with scapular lateral radiographs. Finally, we used posteroanterior radiographs to analyze elbow flexion at the limits of internal rotation behind the back. We found that maximal internal rotation behind the back occurs in approximately a 2 : 1 ratio between the glenohumeral joint and the scapulothoracic articulation. However, the scapulothoracic articulation was more significant in placing the arm behind the back, whereas the glenohumeral joint performed most of the internal rotation in front of the body. The scapulothoracic articulation assists in this motion by both extension and internal rotation of the scapula on the thorax. The limits of internal rotation behind the back are reached with a significant contribution from elbow flexion. We conclude that measuring shoulder internal rotation by the maximal vertebral level reached by the patient's thumb greatly oversimplifies the concept of internal rotation and that limitations in this motion may not be strictly due to a loss of internal rotation at the glenohumeral joint.
Adult↗
Bone tumor radiograph review by pathologists prior to pathologic diagnosis: a receiver operator curve analysis of diagnostic utility.
Radiologic-pathologic correlation has long been considered a prerequisite for the accurate diagnosis of bone lesions. We investigated using receiver-operating characteristic analysis the accuracy of histopathologic diagnoses with and without pathologist review of radiographs. While accuracy of diagnosis did improve when the radiographs were reviewed by the pathologist, this increase did not reach statistical significance (P=0.1311). Potential reasons for this finding including case selection and reviewer expertise are discussed. Based on our study, the review of radiographs did not result in a statistically significant difference in accuracy of the pathologic diagnosis of bone tumors. However, our data suggest that there may be a difference particularly in selected cases and among certain observers.
Bone Neoplasms↗
Spinal neuroarthropathy after traumatic paraplegia.
Spinal neuroarthropathy is a little-known complication of traumatic paraplegia. Four cases of this syndrome are described, with emphasis on the characteristic radiographic findings of severe juxta-articular bone destruction, dense appositional new bone formation, large osteophytosis, and soft-tissue bony debris. The factors predisposing patients to develop a neuropathic joint are diminished pain and proprioceptive sensations with maintained mobility. When a paraplegic patient transfers in or out of a wheelchair or moves his upper torso, he exerts force on an insensate spine. Repeated trauma increases joint mobility beyond the normal limits, and this leads to further damage, with the process culminating in severe instability and bone destruction. The other causes of neuropathic joints in the spine--tertiary syphilis, syringomyelia, and diabetes--must be ruled out on clinical grounds. Neuropathic changes in the spine are often silent, delaying treatment, or may be mistaken for infection or degenerative disease. Their true prevalence is difficult to determine, but the possibility should be considered in paraplegic patients with the characteristic radiographic findings.
Adult↗