Search

Copyright of Praxis (16618157) is the property of Aerzteverlag medinfo AG and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

A century and a half after its first description, adhesive capsulitis (frozen shoulder) has revealed only part of its secrets. Its definition remains clinical since the imaging technology we have at our dis-posal is insufficiently sensitive and specific. Next to its idiopathic form, the most frequent and the most characteristic, there are numerous situations inducing a functional limitation of the glenohumeral joint and of its environment. The clinical course inexorably takes place in one to two years, and develops in 3 phases where successively pain, retraction, and then recovery, as a rule complete recovery, dominate. No treatment is likely to shorten it. In the absence of clearly established proof, our therapeutic approach must be prudent and conservative., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Pregnancy-associated osteoporosis usually appears during the first pregnancy and does not affect the followings. We report two cases where non-traumatic fractures have been diagnosed shortly after delivery of second pregnancies. Wide investigations could not find a cause of secondary osteoporosis. In the first case we came to the diagnosis of pregnancy-associated osteoporosis and an intravenous treatment of ibandronate has been prescribed. In the second case the bone mineral density (BMD) being almost normal and the localisation of the fracture being atypical, we concluded to a fracture of non-osteoporotic origin, probably due to mechanical stress during pregnancy. No therapy against osteoporosis has been prescribed.

Vertebral osteoporotic fracture (VOF) is a major problem of public health. Surgical treatments such as vertebroplasty and kyphoplasty are interesting adjuvant treatments for the management of osteoporosis. A consensus proposed by the principal contributors of this management is important. Regarding the actual data, we propose a vertebroplasty or a kyphoplasty for all patients suffering of an acute VOF. If a previous kyphosis or an important local kyphosis exists, secondary to the acute VOF or others, we propose a kyphoplasty. If the VOF is older and the conservative treatment is inefficient, we propose a vertebroplasty. In all cases, a specific management and treatment of osteoporosis is proposed.

Plain radiography remains useful for the diagnosis of osteoarthritis, even if it is not always essential. It is moreover poorly correlated with symptoms, as it reflects rather the accumulation of damage then active processes. Similarly, it is a poor indicator of the progression of osteoarthritis. Modem imaging, particularly MRI, has allowed us to understand better the evolving processes, demonstrating a good correlation with symptoms and a better predictive value of clinical course. It has gradually replaced standard radiography in the study because it directly demonstrates sequelae and the active processes in all the structures of the joint. It remains clinically indicated only to exclude an alternative diagnosis or to determine a possible complication of osteoarthritis.

Direct MR arthrography has a better diagnostic accuracy than MR imaging alone. However, contrast material is not always homogeneously distributed in the articular space. Lesions of cartilage surfaces or intra-articular soft tissues can thus be misdiagnosed. Concomitant application of axial traction during MR arthrography leads to articular distraction. This enables better distribution of contrast material in the joint and better delineation of intra-articular structures. Therefore, this technique improves detection of cartilage lesions. Moreover, the axial stress applied on articular structures may reveal lesions invisible on MR images without traction. Based on our clinical experience, we believe that this relatively unknown technique is promising and should be further developed.

Percutaneous vertebro-plasty is an efficient treatment of the symptomatic vertebral compression fracture refractory to optimal medical therapy. The procedure is used for neoplastic lesions, aggressive angioma, but also osteoporotic compression fractures. In order to adequately advice our patients, it is essential to know its indications and possible complications. However, to practice a vertebro-plasty for an osteoporotic compression fracture without any long term management of the osteoporotic disease is useless. Unfortunately, it still happens too often and it is essential that orthopedic surgeons, general practitioner, radiologist, rheumatologist, and any practitioners work together to guarantee the optimal management of our patients.

There is a mean delay of 5 to 8 years between the onset of symptoms and the diagnosis of ankylosing spondylitis. This is due to the fact that radiographic sacroiliitis is delayed. The purpose of an earlier diagnosis is emphasized by the need for better management, the new diagnostic method including magnetic resonance imaging and by the efficacy of anti-TNF therapy. The current criteria are classification but not diagnostic criteria. Their sensitivity is insufficient for an early diagnosis of ankylosing spondylitis. MRI criteria allow to differentiate inflammatory signs from degenerative signs in patients sent for aspecific low back pain. The aims of this article are to illustrate the different stages of the disease from early inflammatory involvement to ankylosis and to discuss the role of imaging in the management of affected patients.

Pelvic trauma A great variety of very polymorphous lesions of pelvic trauma are deffering from each other by their context, their anatomical aspect and therapeutic implication. In the isolated acetabular fractures, function is mainly at stake. The management consists mainly of re-establishing a joint congruence to prevent early coxarthrosis. Pelvic fractures often occur in violent trauma and are associated with visceral lesions, putting vital prognosis at stake. In case of hemodynamic shock, external fracture stabilization when it is indicated associated to embolisation of pelvic bleeding if necessary and after external fixation are preponderant.

Groin pain is frequent but often problematic as it covers a very broad differential diagnosis. The localisation of pain in one of the five anterior hip regions helps to establish a precise diagnosis and an adapted treatment. We review the differential diagnosis and treatment of anterior hip pain.

Pain of the inguinal region is a frequent but difficult diagnostic problem. It may be induced by accidents, overload due to sports or profession as well as daily life activities. Numerous anatomic structures of the inguinal or hip region may be injured, but one should also think about adjacent structures as the bowel, uro-genital system, spine and nerves. The goal of this article is to describe which clinical and imaging parameters allow to establish a correct diagnosis for each patient.

Femur-acetabular impingement is a recently discovered etiology of early hip osteoarthritis. Patient history and clinical examination allow to make the diagnosis, whereas the radiological exams allow to find the etiology of impingement. Impingement is related to morphological alterations of the acetabular rim and/or proximal femur, leading to an abnormal contact between the articular components. The localisation of the abnormal morphology determines the type of impingement and the resulting articular damages. Because of the increasing risk of chondral lesions, only an early treatment may eventually improve the prognosis of the hip joint. If primary conservative treatment is unsuccessful in confirmed impingement cases, open or arthroscopic surgical treatment is indicated.

Plain Xrays should stay in pole position for the evaluation of shoulder's pathologies. They allow frequently to make a diagnosis of the lesion. Indications to complementary exams are well established. CT-scan and MRI have to give responses to precise questions, which then will permit to manage the treatment. CT-scan allows to evaluate accurately bone structures. It is very useful for analysing complex fractures of the proximal humerus. It allows also to evaluate the amount of glenoid wear to correct before implanting a prosthesis. Arthro-MRI is used to study soft tissues, cartilage and bone. Therefore, it is the first choice exam to evaluate the rotator cuff tendons, as well as the labrum and ligaments in case of shoulder instability.

Femoro-acetabular impingement is an etiology of early osteoarthritis. It is a dynamic theory of development of arthritis due to bony deformations of the acetabulum or the proximal femur. The impingement is diagnosed clinically by the impingement and apprehension tests. The realisation of reproducible and technically irreproachable standard X-Rays is of first importance to detect the subtle but present signs of impingement. The MR arthrography is the best exam for detection of intra-articular pathologies with radial sequences allowing to establish a precise topography of the lesions. The treatment is most of the time surgical to avoid progression of cartilage lesions, either by an open surgical dislocation or arthroscopically for selected cases.

Sacral insufficiency fracture is a debilitating injury for which no active treatment is currently available. It frequently causes significant pain and limits activities of daily living in patients with osteoporosis. Percutaneous vertebroplasty is a common procedure to alleviate the pain associated with thoracic and lumbar vertebral compression fractures. The sacral percutaneous cimentoplasty procedure (sacroplasty) has recently been introduced as an alternative to medical management of osteoporotic sacral insufficiency fractures. The purpose of this article is to illustrate the effectiveness and the utility of percutaneous sacroplasty in this kind of pathology and to show how this procedure can provide symptom relief without having major complications.

Osteoid osteoma and radiofrequency Osteoid osteoma relates to a benign skeletal neoplasm, smaller than 2 cm in diameter, composed of osteoid, highly vascularized connective tissue and surrounded by a ring of bone sclerosis. Its aetiology remains unknown. It affects twice more males than female patients and occurs usually between 5 and 40 years old. Long bones and spine are the most involved areas but the whole skeleton can be involved. Clinical manifestations can include local pain (increased at night and decreased by activity) and relief with salicylates administration. CT guided radiofrequency ablation of osteoid osteoma is in comparison to surgery less invasive, time saving and economic technique with excellent long term results.

Surgical indications in spinal trauma remain a controversial topic. In general, unstable cervical injuries such as displaced odontoid fractures, burst fractures or tear drop fractures require surgical intervention. Thoracolumbar compression injuries without posterior wall involvement or significant kyphosis can be treated conservatively. Surgery is indicated in fractures-dislocations and burst fractures with significant canal narrowing and/or major kyphosis. The role of emergency decompression as well as that of steroids remain uncertain since no study to date has convincingly proven their efficacy.

Tumors and tumor-like lesions of the hand are more frequently benign lesions. Plain film X-rays must be obtained in all patients since they are extensive and panoramic. Ultrasound can accurately assess the internal structure of the mass and its relation with adjacent nerves and vessels. MRI is particularly sensitive to bone marrow and is highly effective in characterizing a wide variety of soft tissue conditions. However, CT remains the method of choice for evaluating bone involvement of soft tissue tumors and small bone tumors such as osteoid oteoma. Where a malignant tumor is considered, thoraco-abdominal and/or bone scintigraphy are essential to evaluate the presence of metastatic lesions.

Although vertebroplasty was initially a treatment of vertebral haemangioma or metastases, this procedure is now frequent option to the treatment of osteoporotic vertebral fractures. In this review article, we will discuss the indication, the techniques and the follow-up of the vertebroplasty. This is a risky procedure, which should be performed by experimented physicians working with high-resolution fluoroscopic equipments, by biplane fluoroscopy, to reduce the risk and irradiation to the patient. According to the available follow-up studies, there is clear evidence of a strong improvement of quality of life after vertebroplasty by rapid decreasing of back pain at least during the first six months. Other new studies will analyze the long-term follow-up after vertebroplasty.

Intracranial aneurysms, cervical carotid stenosis and acute cerebral ischemia constitute the three main and more frequent diseases in which the endovascular approach is considered a valuable alternative to the surgical or pharmacologic treatment. With the introduction of balloon assistance techniques, even intracranial large neck aneurysms can be currently suitable to endovascular treatment. Stent angioplasty is widely used in whole Europe in the treatment of cervical carotid artery stenosis. Mechanical endovascular embolectomy techniques are actually available to be used alone or in combination with pharmacologic thrombolysis in the treatment of acute cerebral ischemia. This article discuss on the new technical possibilities concerning the endovascular approach in these aforementioned diseases.

Rheumatoid arthritis occurs frequently in women in childbearing years. With the improvement of the treatments, more patients with rheumatoid arthritis consider a pregnancy. Close co-operation between the physician and the obstetrician caring for the mother and the foetus is necessary. The disease should be well controlled at the time of the conception, although an amelioration of rheumatoid arthritis occurs in about 75% of pregnancies, in the first trimester. Some medications can be used during pregnancy and lactation. There is no indication of any adverse effects of rheumatoid arthritis on pregnancy outcome. The mother needs to be followed up regularly after delivery because of the high risk of post-partum flare.

Magnetic Resonance Imaging (MRI) is the best imaging method in early detection and management of rheumatoid arthritis (RA). There are other imaging methods available as ultrasound, scintigraphy, computed tomography and plain radiography for imaging RA but MRI provides the best sensitivity in detecting inflammatory changes in the joints. MRI shows the best intra and interobserver reliability and low variation between repetitive examinations. MRI has shown the best visualisation and the greater sensitivity to detect erosion in early RA, compared to standard radiography. The use of a contrast agent further increases the sensitivity in detecting erosions and differentiate synovial proliferation from fluid collections. Otherwise, intraossous cyst, tenosynovitis, bone marrow edema, that are concomitant manifestations of the disease, are best imaged by MRI. MRI assists in the early detection of rheumatoid arthritis, which allows earlier initiation of treatment.

Clinical evaluation is an integral part of medical practice. However, recent data have demonstrated that a systematic and standardized evaluation modifies the prognosis of our rheumatoid arthritis patients. The systematic use of activity indexes allows us to better appreciate the needs of our patients and the necessity to optimize and intensifie treatment. Likewise, auto-evaluations tools bring useful information to patient management.

We report the case of a 58 year old male who presented with acute meningoencephalitis and pneumocephalus (intracranial air) visualized on head CT scan. Despite the lack of typical clinical signs such as retroauricular tenderness, red tympanic membrane or otorrhea, mastoiditis was suggested by head CT scan. The patient made a full recovery after mastoidectomy and six weeks of antibiotic therapy. Streptococcus pneumoniae grew from a surgical purulent mastoid tissue sample. Mastoiditis and its complications are rare in adults. A high level of clinical suspicion is needed when a patient presents with encephalitis of unclear origin.

A radiologist should be included in the multidisciplinary approach which will allow optimal diagnostic evaluation and treatment of sarcoma. The appropriate use of ultrasound, computed tomography and magnetic resonance imaging plays a significant role in the evaluation of these tumors and their recurrences. The potential role of dynamic magnetic resonance imaging has also been evaluated. A review of diagnostic imaging and their clinical utility is discussed.

When a soft tissue tumor is initially misdiagnosed as a simple trauma or a mass, treatment may be adversely affected by the delay in diagnosis or an inappropriate invasive procedure that results in extension of a probable malignant tumor. Patients with soft tissue tumors present a diagnostic challenge to the clinician. A systematic approach to the evaluation and biopsy is necessary in order to minimize diagnostic errors and biopsy complications. With a multidisciplinary approach and adequate surgical management, the prognosis with a five-year survival rate can be excellent.

Heterotopic ossification, mostly of the hip, is a frequent complication after reconstructive surgery. Most common prophylactic therapies are non-steroidal anti-inflammatory medication (AINS) applied post-operatively and external radiotherapy (RT) administered in the pre- or post-operative setting. Both treatments proved to be efficient in several randomised clinical trials. Prevailing trend regarding RT is a treatment prior to surgery. It is appreciated by both physician and the patient because it is simple and comfortable. In this article, we present the literature linked to the subject together with the benefit and the inconvenience of both therapeutic methods.