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An 81-year-old woman presented to the emergency department because of a recent sharp pain in the left hemithorax and a history of recurrent lower respiratory tract infections. She had been treated with antibiotics twice during the last month before presentation. She was a never-smoker with a previous history of depression and complete thyroidectomy for a nontoxic multinodular goitre., Can you perform a robust histopathological diagnosis for this unusual case? http://ow.ly/40GB30mc5Th

The anatomy of the distal tibia accounts for reduced biomechanical stability and higher complication rates when treating distal tibiofibular fractures with an intramedullary tibia nail (IMTN). The goal of this study was to identify variables that affect the stability of IMTN. We assessed the value of additional fibular fixation, angular stable interlocking screws (ASLS) and multiplanar screw configuration in IMTN.A retrospective cohort study was performed including 184 distal tibial fractures and associated fibula fracture treated with IMTN. Relevant demographic, fracture-related (type and level of the tibia and fibula fracture) and operative variables (depth of the nail, screw type and configuration, use of polar screws, fibular fixation) were studied. Coronal and sagittal alignment was assessed directly and 3-6 months after IMTN. Loss of reduction (LOR) was classified as 5-9° or ≥10°.48.4% of the patients showed ≥5° LOR in one or both planes. Coronal LOR 5°-9° significantly correlated with low tibial fractures (p = 0.034), AO/OTA type 43 distal tibial fractures (p = 0.049), and sagittal LOR 5°-9° (p = 0.015). Although sagittal LOR 5°-9° was associated with fibular fractures (non-fixated suprasyndesmotic, p = 0.011), conversely we could not demonstrate the added value of (suprasyndesmotic) fibula fixation in IMTN. Coronal LOR ≥10° significantly correlated with AO/OTA type 43 distal tibial fractures (p = 0.009). In contrast to multiplanar configuration, we found a clear benefit of ASLS in distal IMTN locking.The level of the tibial fracture (AO/OTA type) and (suprasyndesmotic) fibular fractures were the main determinants of LOR after IMTN. ASLS was found to increase the stability of IMTN. Due to heterogeneity, however, we could not demonstrate the value of fibular fixation in IMTN. Therefore, a future prospective study with uniform treatment strategy for IMTN of distal tibiofibular fractures, with or without fixation of the fibula, is mandatory.

The chapter starts with a short overview of the relevant anatomy of bones and surrounding soft tissues. Most of an imaging part is focused on plain radiography discussing routine views as well as relevant special views, followed by the role of ultrasound, CT, MRI, bone scintigraphy, and SPECT-CT. The main part of the chapter is dedicated to specific overuse trauma, including typical overuse lesions of the immature skeleton. Discussed bony lesions are fractures, the rare stress fractures of scapula and clavicle, stress-related growth plate injury of the coracoid process and medial clavicle, lateral acromial apophysitis, and distal clavicular osteolysis. Joint pathology comprises acromioclavicular and sternoclavicular sprain or dislocation and AC joint osteoarthritis. Typical nerve pathologies of this anatomical area are the suprascapular nerve entrapment and the long thoracic neuropathy.

Background:Controversies remain regarding the preferred treatment strategy for talus fractures. The primary goal of this study was to evaluate the long-term outcome after operative management of talus fractures. Secondarily, we identified those factors that affected the outcome and defined strategies to improve the outcome.Methods:This is a retrospective outcome study of 84 patients with an average follow-up time of 9.1 years. We assessed the functional results, return to daily activities, and general health status using the Foot Function Index-5pt, a numeric rating scale for pain, and the Short Form-36 Health Survey. Furthermore, we conducted a correlation analysis between the outcomes and 14 demographic, clinical, and radiologic variables.Results:We found moderate mean Foot Function Index pain and disability scores of 30.2 and 28.7, respectively. The mean numeric rating scale score was 3.2. Of all responders, 41% (27/66) did not return to their daily activities. We reported low physical, but good mental, Short Form-36 component summary scores of 42.7 and 48.3, respectively. We recorded a complication rate of 56%. Osteoarthritis, articular incongruence and talus body fractures correlated significantly with a poorer functional outcome. Delayed surgery after trauma was associated with better outcome measures.Conclusions:Talus fractures have a major long-term impact on ankle and hindfoot function and on physical health. Success of operative treatment depends on the occurrence of osteoarthritis postoperatively, type of fracture, and quality of fracture reduction. Because only the latter is modifiable, efforts should be made to restore articular congruence in order to improve the outcome. Therefore, we recommend reviewing the quality of the reduction postoperatively on CT. Furthermore, talus fractures should not be considered operative emergencies, but rather treated after recovery of the soft-tissues.Level of Evidence:Level III, comparative study.

ABASTRACT: INTRODUCTION: Although regularly ignored, there is growing evidence that posterior tibial plateau fractures affect the functional outcome. The goal of this study was to assess the incidence of posterior column fractures and its impact on functional outcome and general health status. We aimed to identify all clinical variables that influence the outcome and improve insights in the treatment strategies. METHODS: A retrospective cohort study including 218 intra-articular tibial plateau fractures was conducted. All fractures were reclassified and applied treatment was assessed according to the updated three-column concept. Relevant demographic and clinical variables were studied. The patient reported outcome was assessed using the Knee injury and Osteoarthritis Outcome Score (KOOS). RESULTS: Median follow-up was 45.5 (IQR 24.9-66.2) months. Significant outcome differences between operatively and non-operatively treated patients were found for all KOOS subscales. The incidence of posterior column fractures was 61.9%. Posterior column fractures, sagittal malalignment and an increased complication rate were associated with poor outcome. Patients treated according to the updated three-column concept, showed significantly better outcome scores than those patients who were not. We could not demonstrate the advantage of posterior column fracture fixation, due to a limited patient size. CONCLUSION: Our data indicates that implementation of the updated three-column classification concept may improve the surgical outcome of tibial plateau fractures. Failure to recognize posterior column fractures may lead to inappropriate utilization of treatment techniques. The current concept allows us to further substantiate the importance of reduction and fixation of posterior column fractures with restoration of the sagittal alignment. LEVEL OF EVIDENCE: 3.

Background: In our department, axillary views of the shoulder in trauma patients are not performed on a routine base, but sometimes, they are ordered by the trauma surgeon. We usually perform an anteroposterior view of the shoulder, combined with a posterior and an anterior oblique view of the shoulder in trauma patients. Because the classical described axillary view of the shoulder is sometimes very painful for the patient, especially in patients with humeral fractures, we perform a less painful modified axillary view. Methods: We now perform the axillary view with the patient standing upright and bending forward and we give a craniocaudal tube inclination between 30 and 45°. Doing so, we also have an “axillary” view on the shoulder, but without harm for the patient. We performed a retrospective study in 103 patients with a modified axillary view and the additional value was checked. Conclusion: We conclude that the modified axillary view is useful in 30 patients for detection of Hill–Sachs lesions or evaluation for displacement or angulation in proximal humeral fractures.

Ultrasonography (US) has become an essential tool in the initial evaluation of patients presenting with an acute abdomen, being quick and easy to use. When a patient is referred with acute abdomen of presumed intestinal origin, US can be employed in the diagnosis of acute appendicitis, acute diverticulitis, obstruction, intussusception, Crohn's disease, infectious enteritis, ischemic bowel disease, and even tumors. US does not show findings specific for these disease processes, and frequently only shows nonspecific wall thickening, some infiltration of the adjacent fat, and a small amount of fluid, but nevertheless it is quite sensitive when performed by an experienced examiner, and can therefore be used as a rapid screening tool in patients with an acute abdomen. This paper describes the use of US in the evaluation of the acute abdomen of intestinal origin.

Clearing the cervical spine after blunt trauma remains a challenge. Even in the computed tomography era many emergency departments worldwide still use classical X-rays in first evaluation. Low odontoid fractures are frequently missed, especially in unconscious patients where an open mouth view is not available. Evaluation of the Harris ring in the lateral view can improve identification rate. We studied the diagnostic values of this sign and the educational effect on trainees. Lateral views of 12 computed tomography confirmed low-axis fractures and 13 controls were randomly presented to 17 residents (traumatology, neurosurgery and emergency medicine) and five experienced radiologists. After the residents were taught the use of the axis ring, they had to review the set. Diagnosis was scored with a degree of certitude from 5 to 1. The specificity and sensitivity for the radiologists was 88% (confidence interval 80-96) and 82% (confidence interval 72-91), respectively. The effect of the education on the scores of the residents was evaluated using the Wilcoxon ranking test with a significant effect for the traumatologists (P=0.0008), emergency physicians (P=0.0005) as well for the neurosurgeons (P=0.0087). The axis ring can be a useful diagnostic tool in identifying low odontoid fractures on cross-table cervical spine X-rays. It is easy to teach and should be included in X-ray-based C-spine clearing protocols.

Acute thrombosis of the radial artery in the absence of arteriosclerosis is a rare event. We report on an acute thrombosis after a single blunt (carting) trauma. Since there were only local symptoms and no signs of digital ischemia, a conservative approach was preferred. We describe the clinical presentation and review the literature concerning non-atherosclerotic acute thrombosis of the radial artery.

We present three cases of fracture of the proximal tibia in young children who were jumping on a trampoline. Thetypical radiological findings and the underlying mechanism of trauma are discussed. The key radiological features are: a transverse hairline fracture of the upper tibia often accompanied by a buckle fracture of the lateral or medial tibial cortex, buckling of the anterior upper tibial cortex and anterior tilting of the epiphyseal plate. New types of injuries related to specific recreational activities are recognized. It is often helpful to associate a typical injury with a particular activity. Trampoline related injuries have increased dramatically over the last years. The most common lesions are fractures and ligamentous injuries, in particular a transverse fracture of the proximal tibia. However the radiological findings can be very subtle and easily overlooked. It is therefore important to be aware of the typical history and radiological findings.

Calcific tendonitis of the longus colli muscle is an uncommon cause of sudden onset of neck pain. Differential diagnosis should include retropharyngeal abscess, traumatic injury or even meningitis. Diagnosis can be made radiographically with plain radiograph which reveals an amorphous calcification anteriorly to C1-C2 and severe swelling of the prevertebral soft tissue. Treatment of choice is conservative and consists of administration of nonsteroidal anti-inflammatory drugs. Clinically the complaints disappear after 1-2 weeks. Follow-up radiographs are, in fact, unnecessary but demonstrate complete resolution of the calcific density and normalization of the prevertebral swelling.

We present the case of a 15-year-old boy who underwent shoulder surgery for repair of a Bankart lesion after dislocation of his right shoulder. A compress was left in the surgical wound. This case is presented to highlight an important pitfall in the diagnosis of gossypiboma (foreign body reaction): when the wires of a compress are visualized on X-ray, beware of the fact that it is possibly located inside the body. The diagnosis of an abscess was made by ultrasound. The compress wires were visualized on radiographs.

Mediastinal widening is a frequent radiological finding in the emergency department patient. The causes of mediastinal widening can be divided into traumatic and nontraumatic mediastinal widening. An important association of moderate to high velocity trauma is the mediastinal haematoma. It may be the result of traumatic transsection of the aorta, or it may be due to bleeding from other mediastinal vessels. Before the era of multidetector spiral CT, angiography was the gold standard for the evaluation of patients with a widened mediastinum. Meanwhile, angiography as a risk-carrying invasive examination has widely been replaced by MDCT. However, conventional radiography remains an important diagnostic tool; so does angiography, especially in the context of interventional radiology. Multidetector spiral CT plays an important role (Alkadhi et al., Radiographics 2004; 24:1239-1255), but usually as a second line procedure. This article discusses the radiological signs of traumatic mediastinal widening. Different traumatic lesions resulting in a widened mediastinum are presented, and some nontraumatic causes of a widened mediastinum are shown, in order to facilitate the differentiation between both entities.

The feasibility of a high-spatial-resolution technique for mapping T1 and T2 in articular cartilage in the human knee was evaluated. The technique, turbo mixed magnetic resonance (MR) imaging, is based on a pulse sequence in which inversion-recovery and spin-echo measurements are interleaved. The sequence was first validated in a phantom experiment in which T1 and T2 values obtained with an accepted spectroscopic technique were correlated with those obtained by using a clinical magnetic resonance imager with the turbo mixed technique. T2 maps were obtained with turbo mixed imaging in 25 volunteers (17 men, eight women; mean age, 30.8 years; range, 23-45 years). A high correlation (r = 0.99) was found between T1 and T2 values obtained at spectroscopy and those obtained at turbo mixed imaging. Relative differences in the range of cartilage relaxation times between the two techniques were less than 20%. Turbo mixed imaging in human volunteers showed T2 cartilage relaxation times that corresponded with previously published data. Turbo mixed imaging, thus, is feasible for T2 mapping of cartilage.

The aim of this work was to add to the body of data on the frequency and severity of degenerative radiographic findings at adjacent levels after anterior cervical interbody fusion and on their clinical impact and to contribute to the insights about their pathogenesis. One hundred eighty patients who were treated by anterior cervical interbody fusion and who had a follow-up of >60 months were clinically and radiologically examined by independent investigators. For all patients, the long-term Odom score was compared with the score as obtained 6 weeks after surgery. For myelopathic cases, both the late Nurick and the Odom score were compared with the initial postoperative situation. For the adjacent disc levels, a radiologic "degeneration score" was defined and assessed both initially and at long-term follow-up. At late follow-up after anterior cervical interbody fusion, additional radiologic degeneration at the adjacent disc levels was found in 92% of the cases, often reflecting a clinical deterioration. The severity of this additional degeneration correlated with the time interval since surgery. The similarity of progression to degeneration between younger trauma patients and older nontrauma patients suggests that both the biomechanical impact of the interbody fusion and the natural progression of pre-existing degenerative disease act as triggering factors for adjacent level degeneration. ispartof: JOURNAL OF SPINAL DISORDERS & TECHNIQUES vol:17 issue:2 pages:79-85 ispartof: location:United States status: published

We present the case of a 70-year-old woman with necrotizing fasciitis of the right leg, sepsis and bacteraemia with Escherichia coli. Chest wall emphysema, detected on standard radiograph and the presence of air in the soft-tissue of the foot was the reason for prompt surgical drainage in addition to standard fluid resuscitation and antibiotic therapy. There was no evidence of underlying diabetes mellitus, but unknown chronic renal failure and corticosteroid therapy for rheumatoid arthritis were considered predisposing factors. We present a short overview of this rare life-threatening condition with emphasis on radiological diagnostic modalities.

Lipomatosis of a nerve is a well-known but uncommon entity mostly seen in the median nerve. Magnetic resonance imaging (MRI) has been shown to provide pathognomonic features, obviating the need for diagnostic biopsy. We present a case of lipomatosis of a branch of the medial plantar nerve with an atypical appearance on magnetic resonance imaging.

Ultrasound is a rapid, widely available and inexpensive imaging modality for the evaluation of the ankle and hindfoot. Ultrasonography can be performed in acute, semiacute and chronic conditions. Ankle injuries can be evaluated with ultrasound combined with X-rays. In the emergency room, acute trauma of ankle and hindfoot is an important indication for ultrasound.

Objective: To present our experience of diagnosing fractures of the odontoid process on lateral radiographs of the cervical spine that show the Harris (axis) ring. Design. Retrospective study. Setting: Teaching hospital, Belgium. Subjects: 12 patients with multiple injuries, including cervical spine, 8 of them unconscious or uncooperative. Interventions: Cross table lateral view of the cervical spine. Main outcome measure: Identification of otherwise hidden type 3 axial fractures. Results: Diagnosis of low odontoid fractures in all cases. Conclusion: The Harris ring is disrupted in low odontoid fractures and intact in fractures of the odontoid process. Awareness of this sign will allow diagnosis of otherwise hidden axial fractures.