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The hand and wrist are commonly involved in rheumatic conditions, particularly rheumatoid arthritis and other systemic connective tissue diseases. With spondyloarthritis, hand and wrist involvement frequently occurs in psoriatic arthritis but generally does not occur in the remaining subtypes. The hand and wrist may also be affected in various metabolic and endocrine diseases, but these lie beyond the scope of this review.Radiographs may demonstrate the presence of joint space narrowing, bone loss, cysts and erosions, malalignments, and osteolysis. They may also show regions of soft tissue swelling or thinning, and detect calcifications. Ultrasonography and magnetic resonance imaging (MRI) enable evaluation of the soft tissues, particularly the synovium, tenosynovium, and tendons. Furthermore, erosions are better demonstrated than on radiographs. MRI allows evaluation of periarticular bone marrow edema.This article discusses typical imaging features of the hand and wrist in rheumatologic conditions including the advantages and limitations of the various methods.

Dermatomyositis is a rare autoimmune disorder in which an abnormal immune reaction against vascular endothelial antigens and endomysium leads to obstructive inflammatory changes of blood vessels within muscles, skin and other tissues. The disease is characterized by involvement of muscles, and less frequently of other systems, including the gastrointestinal tract, heart and lungs. Dermatomyositis may be diagnosed based on a detailed patient history, through clinical examination, detection of characteristic physical findings and certain specialized tests. Additional imaging studies may be performed to aid in the diagnosis. These include magnetic resonance imaging and ultrasound of the affected muscles. Magnetic resonance imaging is the modality of choice in the diagnostic work-up and monitoring of dermatomyositis affecting muscles, fasciae, and the subcutis. It may recognize acute inflammatory edematous changes in the affected muscles as well fatty replacement and atrophy. The role of ultrasound to diagnose and follow up muscle echogenicity, vascularity, elasticity and volume during treatment has increased over the last years in both adults and children. Ultrasound is used to discriminate between high and low disease activity, may show features of subclinical disease and may be used to confirm remission. Dermatomyositis is a rare autoimmune disorder in which an abnormal immune reaction against vascular endothelial antigens and endomysium leads to obstructive inflammatory changes of blood vessels within muscles, skin and other tissues. The disease is characterized by involvement of muscles, and less frequently of other systems, including the gastrointestinal tract, heart and lungs. Dermatomyositis may be diagnosed based on a detailed patient history, through clinical examination, detection of characteristic physical findings and certain specialized tests. Additional imaging studies may be performed to aid in the diagnosis. These include magnetic resonance imaging and ultrasound of the affected muscles. Magnetic resonance imaging is the modality of choice in the diagnostic work-up and monitoring of dermatomyositis affecting muscles, fasciae, and the subcutis. It may recognize acute inflammatory edematous changes in the affected muscles as well fatty replacement and atrophy. The role of ultrasound to diagnose and follow up muscle echogenicity, vascularity, elasticity and volume during treatment has increased over the last years in both adults and children. Ultrasound is used to discriminate between high and low disease activity, may show features of subclinical disease and may be used to confirm remission.

Numerous publications have studied the regional anatomy of the carpal tunnel to define a “safe zone” to reduce the risk of perioperative neurovascular complications. This zone, located between the ulnar neurovascular bundle and the median nerve, is considered to be safe mainly because of the absence of vascular structures. This study aims to assess the presence of arterioles within this area using superb microvascular imaging (SMI). The images from patients who underwent a bilateral routine wrist ultrasound with SMI, between January 28 and February 28, 2019, were retrospectively reviewed by two radiologists to evaluate the presence and location of arterioles in the safe zone. In addition, cadaveric wrists injected with intra-arterial red latex underwent dissection of the carpal tunnel. The images from 27 patients (54 wrists) were reviewed. In the safe zone, arterioles were seen superficial to the retinaculum in 36 wrists (36/54; 66.7%) and deep to the retinaculum in 21 wrists (21/54; 38.9%). The arterioles located deep to the retinaculum were more frequently found close to the median nerve (21/54; 38.9%) than to the ulnar artery (9/54; 16.7%). In five cadaveric wrists, arterioles were detected superficial to the retinaculum in 3 wrists (3/5; 60%) and deep to the retinaculum in 2 wrists (2/5; 40%). Arterioles can be seen in the safe zone both superficial and deep to the flexor retinaculum. Deep to the retinaculum, they are mainly observed in the proximal aspect of the carpal tunnel and more frequently close to the median nerve. • Superb microvascular imaging (SMI) enables the visualization of arterioles within the “safe zone” of the carpal tunnel (visible both superficial and deep to the flexor retinaculum). • Arterioles were more frequently observed in the proximal aspect of the carpal tunnel. • Deep to the retinaculum, arterioles were more frequently seen in proximity to the median nerve.

To describe the appearance of the anatomical variations of the sacroiliac joints (SIJ) on MR images and to highlight the potential MR features that might be misleading. Consecutive MRI examinations of SIJs performed at our department from January 2015 to December 2016 were retrospectively analyzed. As one of our goals was to describe potential misleading edematous or structural changes associated with SIJ anatomical variations, patients fulfilling the ASAS criteria were excluded from this study to ensure that signal intensity changes would not be related to sacroiliitis. Five anatomical variations and a dysmorphic appearance of the SIJ were detected. The final group consisted of 157 patients. Unilateral or bilateral anatomical variations of the SIJ were found in 50 patients (accessory SIJ, iliosacral complex and sacral defect in 17, 18 and 21 patients, respectively, and synostosis in one patient). A dysmorphic appearance of the SIJ was found in 26 patients. No case of an unfused ossification centers was depicted. Structural and/or edematous changes of the facing bones were quite frequently observed in accessory and dysmorphic SIJ. Iliosacral complex and sacral defects could be associated with prominent vessels running along their bony surfaces. Several anatomical variations of the SIJs are relatively commonly seen on MR images, particularly in females. These variations may be associated with signal intensity changes, which may be mechanical and not necessarily inflammatory in nature. • Anatomical variations of SIJ may involve the cartilaginous or ligamentous part of the joint • Anatomical variations of SIJ are sometimes associated with edematous and/or structural changes of the adjacent bone • Anatomical variations of the SIJ can be misleading on MR imaging

The most common systemic rheumatologic conditions are connective tissue diseases (including rheumatoid arthritis [RA]) followed by spondyloarthropathy. With the advent of biotherapies and imaging biomarkers, development in the imaging of RA and spondyloarthropathies has received substantial attention in the literature. This article details the various musculoskeletal imaging features of the other connective tissue diseases such as scleroderma and progressive systemic sclerosis, systemic lupus erythematosus, Still's disease, dermatomyositis and polymyositis, Sjögren's syndrome, and mixed connective tissue disease.

This article reviews the main radiographic features of crystal deposition diseases. Gout is linked to monosodium urate crystals. Classic radiographic features include subcutaneous tophi, large and well-circumscribed paraarticular bone erosions, and exuberant bone hyperostosis. Calcium pyrophosphate deposition (CPPD) can involve numerous structures, such as hyaline cartilages, fibrocartilages, or tendons. CPPD arthropathy involves joints usually spared by osteoarthritis. Basic calcium phosphate deposits are periarticular or intraarticular. Periarticular calcifications are amorphous, dense, and round or oval with well-limited borders, and most are asymptomatic. When resorbing, they become cloudy and less dense with an ill-defined shape and can migrate into adjacent structures.

Chronic kidney disease (CKD) is a complex systemic disease that induces mineral metabolic dysfunction leading to bone fragility and tissue calcifications. Bone abnormalities in CKD can include increased bone turnover and resorption due to secondary hyperparathyroidism, decreased bone turnover and bone formation, defective bone mineralization, or a mixed pattern of these abnormalities. Other features of musculoskeletal involvement include synovial, tendon, and ligament thickening due to β2-microglobulin amyloidosis, soft tissue masses, or axial and peripheral arthropathies. The accurate assessment of bone involvement in early-stage CKD is crucial for the success of therapeutic interventions. We summarize the key semiologic features of bone abnormalities in CKD and review musculoskeletal complications as depicted by conventional radiography, computed tomography, magnetic resonance, and ultrasound imaging. We also discuss different experimental diagnostic approaches developed for the purpose of identifying changes in bone quality and structure in early-stage CKD.

Purpose To investigate the current role of WB-MRI for rheumatic inflammatory diseases in clinical practice using a survey addressed to musculoskeletal radiologists. Methods A survey composed of 61 questions, subdivided in three sections, demographics (five questions), application of WB-MRI for inflammatory musculoskeletal diseases in adults and children (28 questions: 7 open and 21 multiple choice for each subgroup) was distributed via the European Society of Musculoskeletal Radiology (ESSR) from July 2 to December 31, 2018 to radiologists working in academic, private, and public workplaces. Comparisons among the different workplaces were performed using the Chi-squared and the Kruskal-Wallis test for nominal and ordinal data, respectively (p Results Seventy-two participants out of the 1779 (4%) members of the ESSR with 10.4 ± 7.9 years of experience in musculoskeletal imaging, replied to at least one question. 30.6% and 12.3% of the respondents performed at least 50 WB-MRI examinations per year in adults and children, respectively. The most frequent indications were myositis in adults and chronic recurrent multifocal osteomyelitis (CRMO) in children, the latter mostly in academic centers (p = 0.013). The ESSR Arthrits Subcommitte's protocol was applied by half of the participants and especially radiologists working in private practice used it for adults (p = 0.025). Contrast medium was rarely used for adults particularly by academics (p = 0.04). Diffusion Weighted Imaging was applied for children mostly in private practice (p = 0.01) although, overall, it plays a marginal role. Scoring systems were rarely used. Ongoing research is limited. Conclusion WB-MRI is not routinely applied for musculoskeletal inflammatory diseases. The most frequent indications are myositis and CRMO.

International audience; Objective: To evaluate the feasibility and potential clinical applicability of speckle-tracking sonography for the dynamic evaluation of the scapholunate diastasis during stress manoeuvres.Material and methods: Two readers used speckle tracking sonography to evaluate scapholunate diastasis during a clenching fist manoeuver in 30 normal wrists. Scapholunate peak strain, mean scapholunate diastasis and the diastasis variation coefficient were analysed. IRB exemption was granted for this study. Conventional and stress wrist radiographs of 26 patients with and without a scapholunate ligament tear were retrospectively analysed to ascertain the range of variation in scapholunate diastasis.Results: Speckle-tracking parameters in normal wrists were similar between the two readers (p > 0.2061). The maximal scapholunate peak strain during stress was relatively low (

Introduction Two previous single-center studies in a university hospital rheumatology department suggested an increase in the incidence of spinal tuberculosis in France in the 1990s. Our objective in this study was to obtain incidence data on spinal tuberculosis since 1995 in the same department and to describe changes over the entire study period from 1966 to 2010. We also compared patients seen between 1966 and 1995 to those seen between 1995 and 2010. Methods We conducted a retrospective review of all cases of spinal tuberculosis seen in our rheumatology department between 1966 and June 1995 and between July 1995 and 2010. We collected the annual incidence, clinical and radiological features, and diagnostic and therapeutic strategies. Results One hundred and thirty patients were managed between 1966 and 2010. The number of cases declined in the 1970s and 1980s then increased over the next two decades. None of the patients had HIV infection. Over 70% of patients were from continental France. Compared to patients seen during the earlier period, those seen after June 1995 were older (62.8 ± 17.2 vs. 53 ± 14.3 years, P = 0.0006), had more comorbidities, and more often exhibited severe radiological findings (including multilevel involvement, epidural involvement, and abscesses). No changes occurred in time to diagnosis or management strategies. Conclusion The incidence of spinal tuberculosis in a university hospital rheumatology department has increased over the last two decades, chiefly as a result of reactivation of past tuberculosis, as opposed to origin from endemic countries or HIV infection.

Langerhans cell histiocytosis (LCH) represents a disorder characterised by an abnormal accumulation of histiocytes in miscellaneous tissues. The bone is commonly affected, especially the flat bones, the spine and the long bones. Some lesions in children such as a “vertebra plana” or a solitary lytic lesion of the skull may be suggestive for LCH, whereas others can be confused with a malignant tumour or osteomyelitis. This pictorial essay presents the main usual and unusual skeletal manifestations observed in LCH. • Osseous involvement in children with LCH is very similar to that seen in multiple myeloma. • A solitary lytic lesion of the cranial vault is a typical radiographic finding of LCH. • A vertebra plana appearance in the spine is another typical radiographic finding. • Extensive signal intensity changes within bone marrow on MRI are a helpful sign for the diagnosis. • In long bones, endosteal scalloping may be responsible for a “budding appearance”.

Imaging of early and subtle signs of the inflammatory arthritides exposes the radiologist to diagnostic pitfalls and, in particular, to false positives. The aim of this chapter is to present the main imaging pitfalls and mimics that may be encountered in daily practice when faced with a clinical suspicion of spondyloarthritis or rheumatoid arthritis.

Neoplasms of neurogenic origin account for about 12% of all benign and 8% of all malignant soft tissue neoplasms. Traumatic neuroma, Morton neuroma, lipomatosis of a nerve, nerve sheath ganglion, perineurioma, benign and malignant peripheral nerve sheath tumors (PNST) are included in this group of pathologies. Clinical and radiologic evaluation of patients with neurogenic tumors and pseudotumors often reveals distinctive features. In this context, advanced imaging techniques, especially ultrasound (US) and magnetic resonance (MR) play an important role in the characterization of these lesions. Imaging findings such as location of a soft tissue mass in the region of a major nerve, nerve entering or exiting the mass, fusiform shape, abnormalities of the muscle supplied by the nerve, split-fat sign, target sign and fascicular appearance should always evoke a peripheric nerve sheath neoplasm. Although no single imaging finding or combination of findings allows definitive differentiation between benign from malign peripheric neurogenic tumors, both US and MR imaging may show useful features that can lead us to a correct diagnosis and improve patient treatment. Traumatic neuromas and Morton neuromas are commonly associated to an amputation stump or are located in the intermetatarsal space. Lipomatosis of a nerve usually appears as a nerve enlargement, with thickened nerve fascicles, embedded in evenly distributed fat. Nerve sheath ganglion has a cystic appearance and commonly occurs at the level of the knee. Intraneural perineuroma usually affects young people and manifests as a focal and fusiform nerve enlargement. In this article, we review clinical characteristics and radiologic appearances of these neurogenic lesions, observing pathologic correlation, when possible.

Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory disorder that is currently diagnosed based on clinical, radiologic, pathological and longitudinal findings.To provide detailed descriptions of CRMO lesion patterns seen on radiographs and MRI and to suggest clinical use of whole-body MRI and propose noninvasive diagnostic strategy.Retrospective longitudinal study (1989-2010) of 31 children (22 girls, 9 boys) diagnosed with CRMO. Imaging data were evaluated by two pediatric radiologists.Mean age at diagnosis was 11 years (3-17). A total of 108 lesions were investigated. The most common sites were the long bone metaphyses (56 lesions in 24 children) especially femoral and tibial (20/24); pelvis (10/31); spine (9/31); clavicle (6/31) and mandible (3/31). In long bones, the radiologic appearance was normal (22/56), mixed lytic and sclerotic (20/56), sclerotic (8/56) or lytic (6/56) often juxtaphyseal (36/56), with hyperostosis or periosteal thickening (10/56). Vertebral involvement was often multifocal (6/9). Medullary edema was seen on MRI (42) with epiphyseal (23/42) or soft-tissue (22/42) inflammation and juxtaphyseal nodule-like appearance (7/42). Whole-body MRI (15/31) was key in detecting subclinical lesions.CRMO is a polymorphous disorder in which whole-body MRI is extremely useful for showing subclinical edema. Vertebral collapse requires long-term monitoring.

Diagnostic tests in patients complaining of carpal tunnel syndrome (CTS) are based on physical examination, electrodiagnostic tests (EDTs), and diagnostic imaging. Timely diagnosis helps prevent permanent nerve damage and its sequelae in terms of functional impairment. Imaging provides additional information to that obtained from clinical tests and EDTs. By allowing direct visualization of the compressed median nerve (MN), ultrasound (US) and magnetic resonance imaging can depict the causes for secondary CTS and describe anatomical variants, such as a bifid MN or a persistent median artery of the forearm, as well as space-occupying lesions including tenosynovitis and ganglion cysts. In addition, diagnostic imaging is of value for postoperative patients presenting with persistent symptoms. Finally, US is able to add information for EDT-negative symptomatic patients. Over time, US has increased in its sensitivity and specificity so it can be used as the initial test in patients presenting with clinical symptoms of CTS because it is now equivalent to EDT. The use of US as a screening test may reduce the number of EDT examinations in patients with suspected CTS, providing additional valuable anatomical information.

While the imaging features of established spondylodiscitis are well known, other presentations may be misleading. The purpose of this article is to review the typical imaging features of spondylodiscitis as well as some more atypical and unusual imaging features (early spondylodiscitis, sceptic spondylitis, septic arthritis of facet joints, primary epidural abscess, unusual germs, neonate).

Superficial soft-tissue sarcomas are malignant mesenchymal tumors located within the cutaneous and/or subcutaneous layers. Most superficial soft-tissue sarcomas are low-grade tumors; yet, the risk of local recurrence is high, and initial wide surgery is the main prognostic factor. Some of these superficial sarcomas may grow, following an infiltrative pattern, and their real extent may be underestimated clinically. Imaging techniques are useful to determine precisely the real margins of the tumor, especially in cases of clinically doubtful or recurrent or large superficial lesions. Imaging tools enable one to determine the relationship with the superficial fascia separating the subcutaneous layer from the underlying muscle. In our institution ultrasonographic examination is followed by magnetic resonance (MR) imaging when the size of the lesion exceeds 3-5 cm. Imaging assessment is performed prior to biopsy, enabling optimal surgical management. Imaging features of the main superficial sarcomas are detailed in the following article, according to their major locations: those arising in the epidermis and/or dermis, which are most often diagnosed by dermatologists, and the subcutaneous sarcomas.

To retrospectively evaluate the magnetic resonance (MR) imaging findings of vertebral involvement in patients with synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome.Ethics committee approval and informed patient consent were not required for this retrospective study. MR images obtained in 12 patients (seven female, five male; mean age, 42 years; range, 16-65 years) with SAPHO syndrome involving the spine were reviewed. One vertebral lesion separated by one or more normal vertebrae was analyzed as a distinct lesion. For each lesion, the number of associated vertebrae with abnormal signal intensity (SI) (ie, single vertebra, two adjacent vertebrae, or more than two adjacent vertebrae) was noted. The following MR imaging findings were evaluated: cortical bone erosion, abnormal vertebral body SI compared with normal vertebral body SI, increased anteroposterior diameter of the vertebral body, soft-tissue involvement, vertebral body height loss of more than 30%, and abnormal SI of the adjacent intervertebral disk compared with the SI of the other disks.Of 24 vertebral lesions found, 17 involved a single vertebra, four involved two adjacent vertebrae, and three involved three or four adjacent vertebrae. Vertebral corner cortical erosion was present in all lesions, and 23 (96%) lesions had anterior vertebral corner involvement. The erosion was confined to a vertebral corner in five (21%) lesions and included the adjacent endplate and/or the anterior cortex of the vertebral body in the remaining 19 (79%) lesions. In four (17%) lesions, involvement of two adjacent vertebral corners on either side of an intervertebral disk mimicked to some extent early disk space infection. An adjacent disk space was narrowed in six (25%) lesions and exhibited abnormal SI in two (8%). Prevertebral tissue thickening was observed in eight (33%) lesions.Erosion of a vertebral body corner is consistently seen on MR images of SAPHO vertebral lesions and may support the diagnosis of SAPHO syndrome in the appropriate clinical context.

Background The objective of this study was to assess clinical and computed-tomography (CT) outcomes at least 2 years after humeral head resurfacing to treat concentric gleno-humeral osteoarthritis. Hypothesis Humeral head resurfacing provides similar outcomes to those achieved with stemmed humeral head implants. Materials and methods This single-centre retrospective study included 40 Copeland™ and 65 Aequalis™ humeral resurfacing heads implanted between 2004 and 2012. Mean patient age at diagnosis was 64 years. The diagnoses were osteoarthritis with an intact (68%) or torn (21%) rotator cuff, avascular necrosis (5%), osteoarthritis complicating chronic instability (3%), post-traumatic osteoarthritis (2%), and chronic inflammatory joint disease (1%). Validated clinical scores, radiographs, and CT before surgery and at last follow-up were compared. Results During the mean follow-up of 56 months, complications occurred in 24 implants. Revision surgery with reverse shoulder replacement was required in 18 cases, after a mean of 43.6 months, to treat glenoid wear or a rotator cuff tear. At last follow-up, for the implants that did not require revision surgery, the mean Constant score was 64/100. The implants had a mean varus of 5° and mean retroversion of −13.3°. The mean increase in glenoid cavity depth was 2.4 mm. Mean increases in medial and lateral humeral offset were 1.9 mm and 2.7 mm, respectively. Pre-operative factors significantly associated with failure were rotator cuff tear (P = 0.017) and glenoid erosion (P = 0.001). Discussion We found a high failure rate related to glenoid wear or progressive rotator-cuff impairment, although CT showed no evidence of implant malposition or overstuffing. Previous studies of stemmed humeral head implants showed better outcomes. Given the low medium-term prosthesis survival rate, we now reserve humeral head resurfacing for concentric osteoarthritis without glenoid erosions or rotator cuff damage. Level of evidence IV, retrospective study.

This article presents the recommendations of the European Society of Musculoskeletal Radiology Arthritis Subcommittee regarding the standards of the use of MRI in the diagnosis of musculoskeletal rheumatic diseases. The recommendations discuss (1) the role of MRI in current classification criteria of musculoskeletal rheumatic diseases (including early diagnosis of inflammation, disease follow-up, and identification of disease complications); (2) the impact of MRI on the diagnosis of axial and peripheral spondyloarthritis, rheumatoid arthritis, and juvenile spondyloarthritis; (3) MRI protocols for the axial and peripheral joints; (4) MRI interpretation and reporting for axial and peripheral joints; and finally, (5) methods for assessing MR images including quantitative, semiquantitative, and dynamic contrast-enhanced MRI studies.

Context: There is growing interest in the relationship between bone marrow fat (BMF), bone mineral density (BMD), and fractures. Moreover, BMF might be influenced by metabolic diseases associated with bone loss and fractures, such as type 2 diabetes mellitus (T2DM), anorexia nervosa (AN), and obesity. Methods: The primary-source literature for this review was acquired using a PubMed search for articles published between January 2000 and April 2015. Search terms included BMF, BMD, fractures, T2DM, AN, and obesity. The titles and abstracts of all articles were reviewed for relevant subjects. Results: Magnetic resonance imaging, with or without spectroscopy, was used to noninvasively quantify BMF in humans. A negative relationship was found between BMD and BMF in both healthy and osteopenic/osteoporotic populations. Data are lacking on the relationship between BMF and fractures. Studies in populations of individuals with metabolic diseases such as T2DM, AN, and obesity have shown BMF abnormalities. Conclusions: We conclude that most human data demonstrate an inverse relationship between BMF and BMD, but data on the relationship with fractures are inconsistent and need further study. In daily practice, the usefulness for clinicians of assessing BMF using magnetic resonance imaging is still limited. However, the perspectives are exciting, particularly in terms of improving the diagnosis and management of osteoporosis.

The thoracic outlet includes three compartments (the interscalene triangle, costoclavicular space, and retropectoralis minor space), which extend from the cervical spine and mediastinum to the lower border of the pectoralis minor muscle. Dynamically induced compression of the neural, arterial, or venous structures crossing these compartments leads to thoracic outlet syndrome (TOS). The diagnosis is based on the results of clinical evaluation, particularly if symptoms can be reproduced when various dynamic maneuvers, including elevation of the arm, are undertaken. However, clinical diagnosis is often difficult; thus, the use of imaging is required to demonstrate neurovascular compression and to determine the nature and location of the structure undergoing compression and the structure producing the compression. Cervical plain radiography should be performed first to assess for bone abnormalities and to narrow the differential diagnosis. Computed tomographic (CT) angiography or magnetic resonance (MR) imaging performed in association with postural maneuvers is helpful in analyzing the dynamically induced compression. B-mode and color duplex ultrasonography (US) are good supplementary tools for assessment of vessel compression in association with postural maneuvers, especially in cases with positive clinical features of TOS but negative features of TOS at CT and MR imaging. US may also allow analysis of the brachial plexus. However, MR imaging remains the method of choice when searching for neurologic compression.

OBJECTIVE The purpose of this study was to evaluate the feasibility and potential usefulness of power Doppler ultrasonography (PDU) in the assessment of changes in arterial cross-sectional area in the thoracic outlet during upper limb elevation. METHODS Forty-four volunteers and 28 patients with a clinical diagnosis of arterial thoracic outlet syndrome were evaluated by B-mode imaging and PDU. Arterial cross-sectional area was assessed in the 3 compartments of the thoracic outlet with the arm alongside the body and at 90 degrees, 130 degrees, and 170 degrees of abduction. The percentage of arterial stenosis was calculated for each of these arm positions. Nineteen of the 28 patients were also assessed by magnetic resonance (MR) imaging. RESULTS No significant arterial stenosis was shown in the interscalene triangle and in the retropectoralis minor space of the volunteers and patients. A significant difference (P < .01) in stenosis between volunteers and patients was seen for all degrees of abduction in the costoclavicular space. The 130 degrees hyperabduction maneuver appeared to be the most discriminating postural maneuver. Seven patients assessed with MR imaging did not have any arterial stenosis on MR images, whereas an appreciable degree of arterial stenosis was shown with ultrasonography. CONCLUSIONS Arterial compression inside the thoracic outlet can be detected and quantified with B-mode imaging in association with PDU.

Neuroblastic tumors cause spinal cord compression when they arise primarily in the spinal canal or invade it through the radicular foramen. Whereas neuroblastomas (NB) are relatively common and are generally treated with chemotherapy, mature neuroblastic tumors (MNT), which include intermixed ganglioneuroblastomas (iGNB) and ganglioneuromas (GN), are less common and the role of surgery is more prominent. Because MNT are rare and have been separated only recently from NB, their clinical and radiological features as well as the role of surgery are poorly defined.In order to increase our knowledge on MNT, we reviewed our database for cases operated for spinal cord compression in our department since the introduction of magnetic resonance imaging (MRI). We treated four cases of NB and one case of iGNB presenting primarily with spinal cord compression.MNT represented 10% of spinal tumors and 1.6% of all tumors of the nervous system in our pediatric neurosurgical practice. The neurological and oncological outcomes were generally favorable after surgical resection, followed by orthotic treatment. In one case with neurofibromatosis type 1, the tumor was inoperable and the child died of tumor progression several years later.GN, and some iGNB, are chemo-insensitive and can only be cured by surgical removal. Surgery is an emergency in case of rapidly progressing paraplegia and can be challenging because the tumor is often hard and hemorrhagic. In case of subtotal removal, tumor remnants can stay stable without oncological treatment.

Although conventional radiographs remain the initial mainstay for imaging of the foot in patients with rheumatoid arthritis (RA), magnetic resonance (MR) imaging has afforded the ability to detect early signs of the disease (i.e., synovitis, tenosynovitis, bone lesions, and bursitis), especially at the forefoot. In addition, the relatively symmetric distribution of the imaging abnormalities depicted in the metatarsophalangeal joints and the frequent involvement of the retro-calcaneal bursitis are almost specific for RA. In more advanced stages of the disease, MR imaging is well suited to evaluation of the hindfoot joints and tendons as well as the musculoskeletal complications of RA (e.g., tendon disruption, rheumatoid nodules, sinus tarsi syndrome).

To evaluate prospectively the use of magnetic resonance (MR) imaging for differentiating true rheumatoid arthritis (RA) from systemic lupus erythematosus (SLE) or primary Sjögren syndrome in patients who have inflammatory polyarthralgia of the hands but no radiographic evidence of RA.This study had institutional review board approval, and patient informed consent was obtained. Twenty-eight patients (16 female and 12 male patients; mean age, 42 years) with early RA and 19 patients (18 female and one male patient; mean age, 46 years) with SLE (n = 14) or primary Sjögren syndrome (n = 5) underwent MR imaging of both hands. All patients had inflammatory polyarthralgia of the hands and no evidence of erosive changes on radiographs. Coronal T2-weighted short inversion time inversion-recovery, transverse T1-weighted spin-echo, transverse fat-suppressed gadolinium-enhanced T1-weighted spin-echo, and transverse gadolinium-enhanced three-dimensional gradient-echo MR images were obtained. The following MR imaging variables were assessed in the wrist and nonthumb metacarpophalangeal joints: synovitis, bone lesions (erosion, defect, and edema), and tenosynovitis. Synovitis and bone lesions were scored with the OMERACT RA-MRI scoring system. Findings in patients with RA and those without RA were compared by means of Mann-Whitney, chi2, and Fisher exact tests.The only significant difference between the two groups in terms of individual scores for synovitis, bone lesions, and tenosynovitis was the more frequent presence of tenosynovitis of the right fourth extensor tendon in patients without RA (P = .04). There were no significant differences between patients with RA and those without RA in terms of global scores for synovitis, bone lesions, and tenosynovitis. However, bone marrow edema in the metacarpophalangeal joints was seen more frequently in patients with RA (P.001).It may be impossible to distinguish between patients with early RA and those without RA (ie, those with SLE or primary Sjögren syndrome) by means of MR imaging.

Objectives. – Percutaneous biopsy is widely used for the diagnosis of primary and secondary bone malignancies. The primary objective of this study was to evaluate the contribution of percutaneous biopsy to the definite diagnosis in patients with suspected bone tumor. The secondary objective was to assess the potential diagnostic benefits of a second percutaneous biopsy when the first failed to provide the diagnosis. Methods. – We retrospectively reviewed 108 percutaneous biopsies of bone lesions in 89 patients admitted to our rheumatology department from January 1994 to December 2001. There were 61 men and 28 women with a mean age of 59 years. The biopsies were done under computed tomography guidance in 68 patients and fluoroscopy in 21 patients. Results. – The diagnostic yield of percutaneous biopsies was 68.5% overall and was significantly higher in patients with metastatic bone disease (100%) than in patients with primary tumors (83%) or hematological malignancies (58%) (P = 0.0004 and P

Resume Des lesions osteocondensantes sont rarement observees au cours des gammapathies monoclonales mais sont parfois presentes au cours du POEMS syndrome (c’est-a-dire : Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal gammopathy and Skin changes ). Dans ce syndrome, l’atteinte osseuse se caracterise par des lesions isolees condensantes ou bien par des lesions mixtes, lytiques et condensantes. Une osteosclerose diffuse est une circonstance extremement rare de decouverte du myelome multiple, habituellement responsable de lyse osseuse avec ou sans osteoporose associee. Nous decrivons le cas d’une patiente de 72 ans presentant une osteosclerose diffuse et intense associee a un myelome a IgA lambda, sans aucun autre critere pour un POEMS syndrome et qui se compliquera tres rapidement d’un tableau de compression medullaire. Une bonne connaissance des aspects radiographiques du myelome permet au clinicien d’evoquer ce diagnostic devant tout aspect de condensation osseuse. Bien qu’exceptionnel, le myelome multiple doit etre evoque devant une condensation osseuse diffuse.

Sclerotic lesions are rare in malignant monoclonal gammopathies, although they are occasionally associated with POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes). In most cases, osseous lesions in POEMS syndrome present as an isolated sclerotic deposit or a combination of both lytic and sclerotic lesions. Diffuse osteosclerosis is extremely rare and may lead to the diagnosis of multiple myeloma, classically known to present as lytic lesions in the skeleton, with or without diffuse osteoporosis. We report a 74-year-old woman with widespread and substantial osteosclerotic lesions, associated with IgA-lambda myeloma, and with no other criteria for POEMS syndrome, and who was rapidly diagnosed with compression of the spinal cord. Detailed knowledge of imaging features in myeloma emphasises the need to consider plasma cell neoplasm in the differential diagnosis of any pattern of bone sclerosis. Although exceptional, multiple myeloma must be borne in mind in the presence of diffuse bone sclerosis.

To use magnetic resonance (MR) imaging to evaluate potential differences in bone structure between men with and men without osteoporosis.Sagittal MR images of the calcaneus were obtained in 50 men (26 patients with osteoporosis and 24 age-matched healthy control subjects). Osteoporosis was defined as a low bone mineral density (at least 2.5 SDs below the normal value for young adults at either the lumbar spine or proximal femur) as measured with dual-energy x-ray absorptiometry. Seventeen patients had a history of osteoporotic fractures. For each participant, 10 consecutive sagittal three-dimensional gradient-echo MR sections were analyzed by using a rectangular region of interest. Twenty structural measurements were obtained from these images. Additionally, density measurements at the calcaneus were obtained in 46 participants. The significance of differences between the two groups was calculated by using the unpaired Student t test. The odds ratios for fracture per 1 SD decrease in the control group were calculated with logistic regression analysis. Adjustment for participant weight and height was performed if necessary.Thirteen of 20 structural parameters, especially connectivity parameters, showed significant differences between control subjects and patients (P.05). Differences between the two groups were more significant (P.001) for apparent bone marrow skeleton length, apparent node count, apparent node-to-node strut count, and apparent terminus-to-terminus strut count. Odds ratios for 11 of 13 structural parameters but not for calcaneus density were significant (P.05). After adjustment for calcaneus density, these parameters were still significant predictors of osteoporotic fracture.Structural measurements derived from MR images of the calcaneus may be used in vivo to characterize trabecular bone architecture in men with osteoporosis.

OBJECTIVE. The aim of our study was to describe the MR imaging findings in patients with rapidly destructive osteoarthritis of the hip.CONCLUSION. The key MR imaging features of rapidly destructive hip osteoarthritis include joint effusion (100%), bone marrow edemalike pattern in the femoral head and neck (100%) or acetabulum (83%) or both, femoral head flattening (92%), and cystlike subchondral defects (83%). Additional findings are low-signal-intensity lines (33%) in the femoral epiphysis, bandlike areas of low signal intensity in the upper pole of the femoral head (8%), and focal signal abnormalities in the adjacent soft tissues (33%) on short tau inversion recovery MR images, fat-suppressed T2-weighted MR images, and fat-suppressed gadolinium-enhanced T1-weighted MR images.

The burial of a child of two years of age from the 4th century site of Lisieux-Michelet (Calvados, France) was examined for bone hyperplasia and a variety of mechanical deformations recognized in association with skeletal trauma. Results of DNA analysis of bone using the PCR method identified this child as female. Microscopic features of the teeth (interglobular dentine) and a sample taken from the tibia conclusively determined that this child suffered from vitamin D-resistant rickets and possibly X-linked hypophosphataemic rickets as its most common form of occurrence. In addition, evidence for child abuse is suspected based on the presence of cranial and tooth fractures and the appearance of successive plaque-like endocranial (meningeal) appositions. This is the first palaeopathological report of child abuse in antiquity. Copyright © 2002 John Wiley & Sons, Ltd. Language: en

The present study aimed to characterize bone microarchitecture assessed by computed tomography (CT) at the calcaneus in male subjects suffering from osteoporosis. Seventy-nine subjects were assessed (45 with osteoporosis and 34 control subjects matched for age). Osteoporosis was defined according to the World Health Organization classification either at the lumbar spine or at the femoral neck. Thirty-three subjects (73%) had a past history of low-energy fracture mainly represented by vertebral fractures (24/33). Nine axial sections (1 mm in width and 2 mm apart) were selected for each subject. Bone microarchitecture analysis was performed using structural (binary and skeletonized images but also skeletonization from gray levels) and fractal analyses. Bone densitometry by dual-energy X-ray absorptiometry (DXA) at the calcaneus was also performed in 73 cases. Bone mineral density (BMD) was decreased in osteoporotic patients compared with controls both at the lumbar spine and hip and also at the calcaneus (p

Diffusion tensor (DT) imaging is an emerging magnetic resonance (MR) imaging technique for evaluating the microstructure of well-organized biologic tissues such as muscles and nerves. DT imaging provides information about tissue microstructure by producing three-dimensional maps of water molecule movements. The two main parameters of measurement at DT imaging, fractional anisotropy and the apparent diffusion coefficient, allow quantitation of architectural changes occurring in tissue. These parameters are modified in the presence of cervical spondylotic myelopathy, cervical spine trauma, carpal tunnel syndrome, lumbar nerve compression, peripheral nerve tumors, and muscle ischemia. Their alteration may be observed at DT imaging even when no abnormality is seen at conventional MR imaging, a fact that suggests that DT imaging allows the detection of abnormalities at an earlier stage of injury. Experimental studies in animals have shown that DT imaging consistently allows identification of pathophysiologic alterations in tissue that correlate with histologic findings. Tractographic images accurately depict both normal and abnormal diffusion in anatomic structures such as the thigh and pelvic muscles, cervical spine, and lumbar nerves. Patients with chronic diseases also may benefit from follow-up evaluation with DT imaging, although DT imaging sequences must be further adapted to improve the evaluation of specific anatomic regions by reducing artifacts, optimizing spatial resolution, and minimizing acquisition time. Given its proven potential for use in identifying abnormalities that are otherwise identifiable only with electrophysiologic and histopathologic studies, and with future technical improvements, DT imaging could soon become a standard method for early diagnosis, management, and follow-up of disease in the spine, muscles, and peripheral nerves.

Acrylic cement vertebroplasty is being increasingly used to treat osteoporotic vertebral compression fractures (VCFs), although no controlled studies supporting this trend have been published. Vertebroplasty remains controversial as a treatment for osteoporotic fractures because it is a local response to a systemic disease and because the pain caused by osteoporotic fractures usually subsides within a few days or weeks. Current data suggest that pain severity may decrease by half, on average, in 90–100% of patients. Although vertebroplasty is usually well tolerated, serious neurological complications have been reported in a few patients. The most common adverse event is nerve root pain, usually caused by leakage of the cement into the intervertebral foramen. Whether vertebroplasty is followed by an increased risk of osteoporotic fractures in the adjacent vertebras remains unclear. Resorbable cements are being developed and may provide better results than the acrylic cements used today. At present, acrylic cement vertebroplasty to treat osteoporotic VCFs is appropriate in only a minority of patients selected carefully by a multidisciplinary team including a rheumatologist.

Vertebroplasty is an effective new radiologic procedure consisting of the percutaneous injection of a biomaterial, usually methyl methacrylate, into a lesion of a vertebral body. This technique allows marked or complete pain relief and bone strengthening in most cases. The principal indications for vertebroplasty are osteolytic metastasis and myeloma, painful or aggressive hemangioma, and osteoporotic vertebral collapse with debilitating pain that persists despite correct medical treatment. Radiography and computed tomography must be performed in the days preceding vertebroplasty to assess the extent of vertebral collapse, the location and extent of the lytic process, the visibility and degree of involvement of the pedicles, the presence of cortical destruction or fracture, and the presence of epidural or foraminal stenosis caused by tumor extension or bone fragment retropulsion. Leakage of methyl methacrylate during vertebroplasty may cause compression of adjacent structures and necessitate emergency decompressive surgery; thus, the procedure should be performed only in a surgical center. The decision to perform vertebroplasty should be made by a multidisciplinary team because the choice between vertebroplasty, surgery, radiation therapy, medical treatment, or a combination thereof depends on a number of factors. Radiologists need to be aware of the various indications for vertebroplasty and of potential future developments and applications of the procedure.

With continued archaeological discoveries of skeletal remains in the USA and Europe, discussion of the possible aetiology for recognized cases of symmetrical erosive polyarthropathy include the spondylarthropathies and rheumatoid arthritis. One skeleton from the fourth century site of Lisieux and a second from the eleventh century site of Rouen are characterized by numerous symmetrical marginal erosions, primarily involving the metacarpophalangeal and proximal interphalangeal joints. Results of maroscopic, microscopic and radiological examination are highly suggestive of a modern-day diagnosis of rheumatoid arthritis. These data are consistent with the presence of rheumatoid arthritis before the onset of the fourteenth century. © 1997 John Wiley & Sons, Ltd.

This review outlines the skin, vascular and musculoskeletal symptoms affecting the hand during systemic inflammatory diseases other than rheumatoid arthritis. Skin lesions are diagnosed clinically and their symptomatology is documented through an extensive series of photographs. These conditions may require specific care before a surgical procedure can be performed. Vascular lesions are also diagnosed clinically and their symptomatology is described in detail. It is important to recognize that acrocyanosis is always benign. The surgeon should be able to distinguish between primary, but benign Raynaud's disease and secondary Raynaud's syndrome, which has a high risk of finger necrosis. Current preventative and curative treatments for finger necrosis are described. The clinical, radiological, progressive and therapeutic features of musculoskeletal lesions are reviewed, namely those associated with psoriatic arthritis, systemic sclerosis and lupus.

Primary vertebral osteosarcoma is a rare type of osteosarcoma, differing from the appendicular forms by an incidence peak occurring at a higher age and a poorer prognosis, due to the difficulties of the surgical treatment. We present five cases of histologically proven primary vertebral osteosarcomas followed in our institution between 2004 and 2012. They allow to illustrate some essential radiologic features, useful to evoke this rare entity.

Closed injuries affecting the metacarpophalangeal and interphalangeal joints and their stabilizers in the thumb and fingers occur very commonly in athletes, possibly leading to finger joint instability and long-standing or permanent disability. This article reviews the spectrum of joint injuries of the thumb and fingers that are common in the athletic population with a main focus on the ultrasound features of collateral ligament tears, palmar plate injuries, and thumb sesamoid fractures. A thorough understanding of the complex anatomy, mechanism of injury, soft tissue abnormalities, and imaging findings is critical in the diagnostic work-up of closed finger joint trauma and may help improve outcomes.

Osteoporotic vertebral crush fractures with neurologic complications are rarely reported in the literature. We report six new cases particularly severe in which death occurred in two cases. The study group included four women and two men with a mean age of 75 years (range: 72-79). Vertebral collapse causing neurological deficit was T5, T9, T11 in two cases, L1 and L3. The mean number of vertebral collapses was three per patient (range: 1-9). Back pain appeared without traumatism 6 weeks before admission (range: 1-24). Neurological complications appeared 2.5 weeks after back pain (range: 1-8). One patient suffered from a paraplegia, three from a paraparesia with bladder dysfunction (n = 1). In one case there was a severe weakness of the levator muscles of the foot and in another a L3 femoral neuralgia with severe bowel and bladder dysfunction. X-rays demonstrated backwards displacement of the posterior cortex in three cases, an intravertebral vacuum phenomenon in two cases and a heterogeneous appearance suggesting a malignancy in two cases. Computed tomography, performed in four patients and tomography in one patient, demonstrated fragmentation of the vertebral body in all the cases and vacuum phenomenon in four cases. Magnetic resonance imaging performed in four cases has confirmed the absence of epiduritis and a compression due to bony structures in two cases. A vertebral biopsy was performed in three cases. Osteoporosis was observed in all the cases and in two cases there was also an osteonecrosis. Surgical treatment was performed in three cases and conservative medical treatment in the other cases. After surgical treatment we have observed an absence of improvement of neurological complications in one case, an improvement in another and finally a full recovery in the last case. After conservative treatment we have noted in two cases an absence of improvement of neurological complications and in one case an improvement of neurological deficit. Two patients died (one after medical treatment and another after surgical treatment).

Percutaneous osteoplasty with acrylic bone cement was performed in 12 acetabular osteolytic lesions in 11 patients with inoperable metastases (n = 8) and myeloma (n = 3). Complementary radiation therapy was started 15-30 days after injection in each case. Pain diminished within hours to 4 days in nine patients, and walking improved in each patient within 1-5 days. Five patients died during the follow-up period. Clinical improvement was maintained in all but two patients.

To evaluate the low-dose biplanar (LDB) skeletal survey (SS) for the assessment of focal bone involvement in patients with multiple myeloma (MM) as compared with digital SS and to compare the two techniques in terms of image quality, patient comfort and radiation exposure. Fifty-six consecutive patients with newly diagnosed or first relapsed MM underwent LDB and digital SS on the same day. These were assessed by two radiologists for the detection of focal bone lesions. In the case of discordance, whole-body MR imaging was performed. Image quality, patient comfort and radiation dose were also assessed. Fifty-six patients (M:30, F:26, mean age, 62 years) with newly diagnosed (n = 21) or first relapse MM (n = 35) were enrolled. A total of 473 bone lesions in 46 patients (82 %) were detected. Out of that total, digital SS detected significantly more lesions than LDB SS (451 [95.35 %] versus 467 [98.73 %]), especially in osteopenic and obese patients. Overall patient satisfaction was greater with LDB SS (48.6 %) compared with digital SS (2.7 %). The radiation dose was significantly reduced (by a factor of 7.8) with the LDB X-ray device. Low-dose biplanar skeletal surveys cannot replace digital SS in all patients suffering from multiple myeloma. • Low-dose biplanar skeletal surveys can readily assess bone lesions in multiple myeloma. • In marked radiographic osteopenia and obesity, LDB SS diagnostic performance is reduced. • Low-dose biplanar skeletal surveys cannot yet replace digital SS in all MM patients.

Congenital upper limb malformations represent complex pathologies because of their varied clinical presentations, imaging features, and etiologies. They can be divided into (1) failure of formation with transverse, intercalary, and longitudinal (preaxial, postaxial, and mesoaxial) deficiencies, (2) failure of differentiation with synostoses, carpal coalitions, syndactylies, and symphalangism, (3) duplication with ulnar dimelia and polydactylies, and (4) brachydactylies. Congenital Madelung's deformity, clinodactyly, camptodactyly, and Kirner's deformity are usually included in these malformations. Despite advances in molecular diagnosis, a good knowledge of clinical and imaging features as well as special consideration of other skeletal or nonskeletal abnormalities are essential to eventually diagnose an embryo fetopathy (maternal valproate treatment, constriction band syndrome), a genetic disorder (trisomy 21 or Down syndrome, Turner's syndrome, Holt-Oram syndrome), or a nongenetic syndrome (vertebral, anal, cardiac, tracheal, esophageal, renal, limb association, Poland's syndrome). Genetic counseling for a child presenting with a congenital upper limb malformation is of great value, both for the treating team and the parents, and imaging is often required. The latter is still largely supported by conventional radiography, both for diagnosis and functional prognosis, but ultrasound and magnetic resonance imaging will be great tools in the near future to better evaluate these conditions.

One of the most important roles of magnetic resonance (MR) in imaging of the diabetic foot is to differentiate between the common and often comorbid pathologies that present with abnormal bone marrow signal. The primary diagnostic challenges in this setting are to distinguish osteomyelitis from reactive bone marrow edema, neuroarthropathy from osteomyelitis, and the sterile from the superinfected neuropathic joint. Whereas both osteomyelitis and reactive marrow edema share increased T2 signal, osteomyelitis is confirmed by T1 hypointensity in the bone marrow and reactive edema demonstrates isolated T2 signal hyperintensity. In distinguishing osteomyelitis from neuroarthropathy, a localized or contiguously spreading forefoot focus of abnormal bone marrow away from the subchondral surface and adjacent to a skin ulcer, cellulitis, abscess, or sinus tract would be indicative of osteomyelitis. A midfoot, subchondral, periarticular, or polyarticular distribution of findings in the absence of a contiguous focus of skin disruption would strongly support neuroarthropathy. Parameters that have been successfully correlated with acute infection superimposed on neuroarthropathy include diffuse bone marrow signal abnormality, progressive subarticular enhancement, loss of subchondral cysts, and the presence of the MRI "ghost sign."

To compare tomosynthesis with radiography for the detection of hand and wrist bone erosions in patients with rheumatoid arthritis (RA), using multidetector computed tomography (CT) as the reference method.The study was approved by the local ethics committee, and written consent was obtained from all patients. From December 2008 to April 2009, 30 consecutive patients with RA were included in this prospective study. They underwent radiography, tomosynthesis, and CT of the most symptomatic hand and wrist on the same day. Two radiologists and one rheumatologist independently read images from the three imaging modalities.A total of 232 erosions were detected with CT, while 199 and 140 erosions, respectively, were detected with tomosynthesis and radiography. More erosions were revealed with CT than with tomosynthesis and radiography (P.0001); significantly more erosions were shown with tomosynthesis than with radiography (P.0001). With CT as the reference method for bone erosions, the overall sensitivity, specificity, and accuracy of tomosynthesis were, respectively, 77.6%, 89.9%, and 83.1%. The corresponding values for radiography were 53.9%, 92%, and 70.9%. The sensitivity of each reader increased by roughly 20% with use of tomosynthesis.The depiction of bone erosions of the hands and wrists is significantly greater with tomosynthesis than with radiography.