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Shoulder girdle trauma is one of the most common injuries encountered in emergency centers. These injuries can be easily overlooked due to the complex osteology of the shoulder. Although radiographs are usually sufficient for assessing traumatic shoulder injuries, cross-sectional imaging is sometimes indicated to assess portions of the shoulder not well visualized by radiographs. In this article, the authors review the spectrum of shoulder girdle injuries: sternoclavicular dislocations, clavicle fractures, acromioclavicular separations, shoulder dislocations, scapula fractures, and scapulothoracic dissociation. They also discuss the presentation, imaging evaluation, and classification of these injuries with emphasis on pitfalls in imaging diagnosis and indications for computed tomography/magnetic resonance.

Injuries to the cervical and thoracolumbar spine are commonly encountered in trauma patients presenting for treatment. Cervical spine injuries occur in 3% to 4% and thoracolumbar fractures in 4% to 7% of blunt trauma patients presenting to the emergency department. Clear, validated criteria exist for screening the cervical spine in blunt trauma. Screening criteria for cervical vascular injury and thoracolumbar spine injury have less validation and widespread acceptance compared with cervical spine screening. No validated criteria exist for screening of neurologic injuries in the setting of spine trauma. CT is preferred to radiographs for initial assessment of spine trauma. CT angiography and MR angiography are both acceptable in assessment for cervical vascular injury. MRI is preferred to CT myelography for assessing neurologic injury in the setting of spine trauma. MRI is usually appropriate when there is concern for ligament injury or in screening obtunded patients for cervical spine instability. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Shoulder pain is one of the most common reasons for musculoskeletal-related physician visits. Imaging plays an important role in identifying the specific cause of atraumatic shoulder pain. This review is divided into two parts. The first part provides a general discussion of various imaging modalities (radiographs, arthrography, nuclear medicine, ultrasound, CT, and MRI) and their usefulness in evaluating atraumatic shoulder pain. The second part focuses on the most appropriate imaging algorithms for specific shoulder conditions including: rotator cuff disorders, labral tear/instability, bursitis, adhesive capsulitis, biceps tendon abnormalities, postoperative rotator cuff tears, and neurogenic pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Background The number of revision hip arthroplasty procedures has been increasing substantially, with the acetabular component requiring component revision in over half of the cases. New porous implant designs attempt to improve outcomes due to improved osseointegration; however, sufficient primary stability is paramount for good osseointegration. Methods We compared 2 revision cups of the same geometry, yet different surface properties in an in vitro scenario: a porous titanium surface and a conventional sintered-bead titanium surface. These were tested in 10 cadaveric pelvises under a physiologic cyclic partial weight-bearing scenario. Each side was randomly implanted with one of the implants. Relative motion between the bone and cup was measured using an optical measuring device. Statistical evaluation was carried out descriptively using a covariance analysis with repeated measures and a test of fixed effects, with significance determined as P Results The conventional cup displayed an average relative motion of 28.02 μm; and the porous implant displayed an average relative motion of 33.42 μm. There was no statistically significant difference between the two with regard to the resultant relative motion ( P = .2649). The bone mineral density does have a significant influence on resultant relative motion ( P = .0406), with higher bone mineral density correlating with less relative motion in both implants. Conclusion The porous implant provides similar primary stability to the conventional implant in the tested scenario; the motion of both implants relative to the bone was within safe limits for osseointegration. Bone stock must be considered when choosing implant type and postoperative care.

Objective Bony ingrowth of short stems is under investigation. Method Over one year bony reactions around the Metha ® stem were investigated using the DXA method in a standardized zonal system (19 ROIs). Clinical results were documented using the HHS. Results HHS significantly improved from 46 points to 97 points. After one year bone marrow density (BMD) increased in the lateral distal and lateral proximal areas as well as in the mid medial area. BMD decreased in the proximal medial and mid lateral areas. Conclusion The concept of metaphyseal ingrowth was confirmed, but distal bony reactions need further investigation.

Neonatal Salter-Harris I fractures of the distal humerus are a rare injury. This injury can be easily mistaken for a posterior elbow dislocation, creating a delay in diagnosis. We present a case of a neonate with a distal humerus Salter-Harris I fracture secondary to trauma during delivery. The patient presented with pseudoparesis of the left arm following birth. Posterior displacement of the elbow was identified on radiographs. Ultrasound of the elbow was performed after a gentle closed reduction of the left elbow was unsuccessful. A transphyseal supracondylar distal humerus fracture was identified on ultrasound. The patient subsequently had an intraoperative left elbow arthrogram to assist in visualization of the supracondylar fracture during closed reduction and percutaneous pinning. At 2-month follow-up, the patient was neurologically intact with full passive range of motion and had normal alignment of the capitellar ossification center and distal humerus on follow-up radiographs.

Acanthamoeba spp. are pathogenic protozoa that are uncommonly encountered. They tend to infect immunocompromised patients, most often causing cutaneous lesions and in some instances granulomatous amebic encephalitis, as well as rare instances of dissemination to other organs. We present a case of amebic osteomyelitis of the fibula in a patient with rejection of a transplanted kidney who was chronically immune-suppressed.

Objectives/purpose 1. Understand three different techniques for embolization of juvenile nasal angiofibroma (JNA) and assess their combined efficacy. 2. Perform successful endoscopic intralesional embolization of highly vascular sinonasal neoplasms. Methods In this study, we present the case of a 10-year-old male patient diagnosed with juvenile nasal angiofibroma (JNA) who successfully underwent trimodal embolization and resection at a tertiary academic medical center after failed coil embolization in his home country. We examine the clinical details of the case and a review of pertinent literature. Results Preoperative embolization is common in the treatment of JNA, but there is little consensus as to the proper timeframe and techniques utilized. In our case, preoperative imaging revealed a vascular tumor with intracranial extension consistent with UPMC Stage V JNA. Diagnostic angiogram revealed significant arborization from the internal and external carotid systems. A trimodal embolization technique, utilizing transarterial, percutaneous, and direct endoscopic intralesional injection of n-Butyl Cyanoacrylate (n-BCA) was performed. A two-staged endoscopic and open resection was subsequently performed one week later with minimal blood loss. In our case, combining intralesional embolization with traditional transarterial techniques resulted in an improved operative field and a successful clinical result. Conclusion Embolization of highly vascular sinonasal tumors with n-BCA is not limited to endovascular techniques, but can be safely combined with percutaneous and endoscopic intralesional embolization up to one week prior to surgical resection.

Aseptic loosening and focal osteolysis are the most common reasons for knee arthroplasty failure. The best treatment remains unclear. We reviewed the literature on the treatment of revision knee arthroplasty using bony structural allografts (476 cases) and porous metal cones (223 cases) to determine if a difference in the revision failure rates was discernable. The failure rates were compared using a logistic regression model with adjustment for discrepancies in FU time and number of grafts used (femoral, tibial, or both). In this analysis, the porous implant shows a significantly decreased loosening rate in AORI 2 and 3 defects. The overall failure rate was also substantially lower in the porous metal group than the structural allograft group; little difference in the infection rates was noted.

Background Thoracic or thoracoabdominal aortic stent-graft repair has shown a reduction in morbidity and mortality rates due to the procedure's advantages (no aortic cross-clamping, continuous distal aortic perfusion, no reperfusion injury). However, 3% to 12% of the patients are at risk of spinal cord ischemia. We investigated spinal cord protective measures with evoked potentials, cerebrospinal fluid drainage, and prevention of hypotension to minimize postoperative neurologic deficit. Methods Between November 2000 and July 2005, vital parameters and spinal cord function were monitored, including cerebrospinal fluid pressure and transcranial motor-evoked and somatosensory-evoked potentials in 36 stent-graft procedures (31 patients) on the thoracic or thoracoabdominal aorta. Results Stent-graft placement was technically successful in all patients. We achieved a survival rate of 100% without neurologic deficit after fast-track extubation. Eleven of 31 patients exhibited changes in evoked potentials during stent-graft deployment. In 12 of 31 patients (including the 11 with evoked potential alterations), cerebrospinal fluid pressure exceeded 15 mm Hg. Cerebrospinal fluid drainage and vital parameter adjustment were executed in those instances. We observed intraoperative evoked potential total recovery in 10 of 11 patients after these interventions. Conclusions Interventions to improve spinal cord perfusion led to total recovery of spinal function in most patients (10/11). Therefore, spinal cord protective measures with motor- and somatosensory-evoked potential monitoring, cerebrospinal fluid drainage, and prevention of hypotension can reduce the incidence of spinal cord ischemia and improve the neurologic outcome of patients undergoing endovascular thoracic or thoracoabdominal aortic repair.