Search

After a brief review of the pertinent anatomy of joint compartments and main ligaments of the wrist, the authors present the technique of wrist arthrography and CT arthrography. They discuss the normal and pathological patterns. The main indications are the chronic painful wrist and posttraumatic wrist. Imaging can reveal ligament defects (particularly scapholunate ligament, or lunotriquetral ligament), triangular fibrocartilage tears, capsular defects, cartilage thinning, foreign bodies, synovial ganglia or synovitis of the wrist.

Ruptured abdominal aortic aneurysm is the major surgical emergency in the retroperitoneal compartment. Rupture of an abdominal aortic aneurysm is always fatal without urgent operative repair. Computed tomography is the reference standard for the diagnosis of ruptured abdominal aortic aneurysm in hemodynamically stable patients. At CT, the diagnosis is based on the combination of abdominal aortic aneurysm and extraluminal retroperitoneal blood. Retroperitoneal hemorrhage usually demonstrates both isodense and hyperdense areas. In most cases hemorrhage is located in psoas compartments and perirenal space. In the case of ruptured abdominal aortic aneurysm other findings may be demonstrated such as focal interruption of the aortic wall and active extravasation of contrast media in the retroperitoneal compartments. Inflammatory abdominal aortic aneurysm, that may present as acute abdominal pain, should be recognized and differentiated from ruptured abdominal aortic aneurysm. Inflammatory abdominal aortic aneurysm is characterized by a fibrotic process around the abdominal aorta that may entrap adjacent structures such as ureters, duodenum and inferior vena cava. Aortic dissection, mycotic aneurysm, and inferior vena cava thrombosis are less common. Complications occurring after emergency aneurysm replacement are also considered.

The diagnosis of acute pancreatitis is based on clinical examination and basic laboratory tests. The main role of sonography in acute pancreatitis is to evaluate gallstones and small fluid collections. However, sonography is frequently difficult due to intestinal ileus related to pancreatitis. CT is indicated early in the clinical course of acute severe pancreatitis when the diagnosis is uncertain or when complications such as abscess, hemorrhage, or necrosis, are suspected. In addition, CT may be used to assess the prognosis and follow-up of patients.

Interventional radiology used in acute abdominal diseases has demonstrated its efficacy in most emergency cases especially in patients at high risk for surgery. Percutaneous drainage is a reference standard for abscesses located within the abdomen and pelvis with high success rates of up to 80%. The diagnosis and treatment of gastrointestinal hemorrhage have changed over the past two decades, with decreased diagnostic examinations and advances in pharmacologic therapy and improved endoscopic techniques. On the other hand, embolization techniques and new procedures such as trans jugular intra hepatic porto systemic shunt have been developed. Arterial embolisation in many situations such as blunt or direct trauma, obstetric or post operative hemorrhage, can be used as an effective easy and relatively safe technique with high success rates to stop bleeding and save the organ. Percutaneous drainage and angiographic techniques adapted to biliary and urinary tree have also been developed as well as endoscopic procedures, allowing treatment of stenoses by balloon dilatation, or plastic or metal prostheses. Indications, technical aspects, complications and limits of these various procedures are presented.

Radiologic evaluation of abdominal trauma must provide a quick and accurate assessment of the lesions in order to improve the management of the patient. The technique used varies depending on the mechanism of the trauma (blunt trauma or stab wounds) and the hemodynamic status. Radiologic evaluation is usually performed in blunt trauma whereas stab wound trauma is usually explored surgically. The various techniques available are standard radiographs, ultrasonography, computed tomography and arteriography. The role of magnetic resonance imaging in the immediate evaluation is still not well defined. It appears to be a useful method in the delayed evaluation of diaphragmatic trauma. Computed tomography is the method most commonly performed in trauma patients. This technique is accurate and allows correct assessment of the lesions. The disadvantages are the radiation induced and the need for a hemodynamically stable patient. The aim of the radiologic evaluation is to provide the clinicians with an accurate description of the lesions. It can help in the management of the patient usually in association with clinical and laboratory data. It can also guide interventional procedures (drainage, embolization...). Finally, it allows radiographic follow-up when conservative treatment is performed.

Intraperitoneal vascular lesions constitute severe causes of acute abdomen. These disorders include ischemia and infarction of colon and small bowel and abdominal hemorrhage. In case of intestinal ischemia, the radiologic procedures are performed in order to establish the diagnostic, identify the site of ischemia, and detect the etiology of ischemia. Plain radiography of the abdomen, ultrasonography, CT scan and angiography may be performed. In case of intestinal hemorrhage, angiography may be performed when endoscopy fails to establish the diagnosis. Embolization can be performed in selected cases.

Infectious disease is a common cause of acute abdomen. The diagnosis is based on clinical examination and basic laboratory tests. However, medical imaging routinely performed according to the clinical findings is frequently useful. Hepatic and splenic abscesses are correctly demonstrated by ultrasonography and computed tomography. Ultrasonography is the reference standard for the diagnosis of acute cholecystitis. The US examination is also performed for the diagnosis of appendicitis and its complications. Ultrasonography and barium enerna are commonly performed for the evaluation of signoid diverticulitis. Computed tomography is the reference standard to determine medical or surgical procedures.

Emergency pelvic imaging is currently based on transabdominal and transvaginal sonography. Life threatening emergencies such as ectopic pregnancy and annexial torsion can be diagnosed by these technics. Doppler imaging (pulsed Doppler and color encoded) improve the diagnostic efficacy in an emergency context. Evaluation of pelvic inflammatory disease, cyst bleeding and placental disruption in best obtained by US because of its simplicity, safety and low cost.

Acute abdominal disorders are common reasons for consultation at the emergency department. The diagnosis of all acute abdominal disorders begins with a careful history and physical examination. When appropriate, the clinical examination should be supplemented by conventional plain abdominal radiography. Gastrointestinal perforation and obstruction are very commonly encountered in the diagnosis of acute abdomen. Plain abdominal radiographs are the initial diagnostic methods of choice. In some circumstances, ultrasonography and CT may be valuable for the evaluation of the cause of abdominal disorder.

Acute renal disease, in the absence of trauma, consist of acute renal obstruction, renal infection or a combination of the two. The diagnosis of acute renal colic is usually performed with ultrasound or excretory urography whereas parenchymal involvement in renal infection is best demonstrated on computed tomography images. The aim of radiologic investigations is to look for complications in order to guide the treatment, particularly percutaneous procedures. Other less common acute renal diseases include renal vein thrombosis optimally analyzed with contrast injection to demonstrate renal function, and spontaneous renal hemorrhage, which implies careful renal assessment looking for a small tumor. Acute psoas compartment diseases include hematomas and abscesses. Computed tomography is the best diagnostic tool and the examination of choice for the follow-up lesions and to guide percutaneous drainage.

Pubalgia is a painful syndrome of the groin which particularly affects young athletes. Although soccer players are the athletes most often affected, they are not alone. Also included in this group are fencers, tennis players and rugbymen. This ailment is associated with varying degrees of lesions of the muscles of the lower frontal abdomen, pubic symphysis and adductor muscles. The clinical diagnosis is confirmed by standard X-rays which can show radiological anomalies of the pubic symphysis in cases of microtraumatic pubic osteo-arthropathy or insertion tendinitis. Scintigraphic anomalies occur earlier than radiological anomalies and return to normal before them; thus allowing confirmation of healing even when the radiographs are still abnormal. Sonogram and MRI can be advantageous in the detection of a lesion of the abdominal muscles or adductor muscles. MRI can also detect a lesion of the pubic symphysis. The principal differential diagnosis is pubic osteitis. Treatment is medical and combines rest, analgesics and anti-inflammatories. Surgery, namely Nesovic's operation, is reserved for those forms resistant to medical treatment, and must be bilateral.

Wrist injuries are an extremely common occurrence. The origin of these injuries may be due to a fracture of the two bones of the forearm or the wrist bones, which may sometimes require specific X-rays views. They are rarely responsible for a dislocation of the wrist. Strains wrists may be misdiagnosed and may result in instability of the wrist. The initial examination of all wrist injuries should systematically include the following four views: (1) a PAview of the wrist in pronation (with the palm facing downward). (2) a lateral view according to the Meyrueis technique. (3) an oblique view. (4) a scaphoid view. An additional, fifth view with the wrist in supination (with the palm facing upward) may be required. If there is clinical evidence of instability of the wrist or if the initial examination results in a probably strained wrist, a further more complete radiological examination can then be undertaken. This examination, known as "the instability examination" includes stress views, which can allow detection of a discrete instability of the wrist. Finally, it is sometimes necessary to carry out this examination in a bilateral and comparative manner.

Although endoscopy is the fundamental examination for exploration of the esophagus, imaging study (CT scan, barium swallow) retains numerous indications. It completes the endoscopic study in the assessment of space-occupying lesions and investigates functional disorders of the oesophagus. Barium swallow associated with the administration of glucagon has a therapeutic role in food obstruction. Endoscopic ultrasonography allows direct evaluation of the local extension of oesophageal masses. Percutaneous ultrasonography sometimes facilitates the study of the lower oesophagus in children and the cervical oesophagus.

Although endoscopy has replaced radiology for the diagnosis of diseases of the oesophagus, postoperative imaging still remains essential. The radiological investigation depends on the initial disease, and its technique is adapted to the suspected complication and the type of operation performed. Immediately postoperatively, a barium swallow allows verification of the surgery before reintroducing food. The early diagnosis of possible complications is based on the barium swallow and CT scan. At a longer interval after the operation, medical imaging, particularly barium swallow, allows anatomical and functional postoperative surveillance. Relapses of the initial disease, particularly neoplastic recurrences can be distinguished from an intercurrent disease or a mechanical complication due to the operation.

The radiologic imaging of esophageal cysts in adults is described. These rare cysts are often an incidental finding. They can lead to severe airway or digestive obstruction. Rare cases of rupture and haemorrhage are described. The authors report a case of cervical esophageal duplication, investigated by pharyngography, sonography, CT and MRI. A cystic mass located between the esophagus and trachea was depicted. Pharyngography and MRI showed the communication of the superior pole of the mass with the cervico-esophageal junction as a midline vertical tract. The upper extremity of the tract opened at the antero-medical portion of the retro-cricoïd region. The other diagnostic possibilities were excluded, especially fourth branchial pouch fistulae.

The authors report a case of cervical schwannoma with an atypical clinical expression, site and imaging features. The anteromedian lesion lying in the prevertebral and retropharyngeal spaces accounts for its clinical expression in the form of dysphagia. The target appearance on computed tomography and on the T2-weighted MRI sequence was suggestive of a neurofibroma and was due to deposition of fibrin and haemorrhagic exudates in the center of the lesion. The presence of a prevertebral ansa cervicalis in front of the long muscles of the neck, between the longus capitis and longus colli muscles, accounts for the vertical, elongated appearance of this tumour involving the prevertebral space.

Medical imaging defines the local, regional and metastatic spread of cancers of the oesophagus, guiding the therapeutic approach and, in particular, the indication for surgery. CT scan and echoendoscopy are currently the reference examinations. MRI provides complementary elements. After treatment, imaging is performed to detect operative complications and recurrence.

This study of the topographic distribution of tumoral and pseudotumoral lesions of the proximal femur shows that certain lesions have a preferential site, for example osteoid osteoma affects the internal cortex of the neck and diaphysis or the intertrochanteric zone; chondroblastoma occurs in zones of epiphyseal ossification of the head; fibrous dysplasia affects the femoral neck, while sparing the epiphyseal femoral head and trochanters. The island of osteosclerosis is situated, at least partially, in the support fan; so-called physiological cysts are situated on or above the midline of the neck and below the basicapital line. Osteolytic or mixed metastases preferentially involve Ward's triangle in the femoral neck and the intertrochanteric region. The sites of these lesions therefore appears to depend on the bony architecture which, in turn, is dependent on mechanical stresses. However, this purely morphological study fails to demonstrate whether mechanical stresses influence the development of these lesions.

The frequency of life-threatening complications induced by Swan-Ganz catheter is estimated at 2% to 17%. Pseudoaneurysm formation secondary to traumatic injury of the pulmonary artery is rare (0.66% to 2%), but carries a high risk of hemorrhagie. Recognition of possible lesions should be based on clinical data and predisposing factors. Diagnostic and therapeutic investigations should be rapidly performed. Embolization is the best treatment giving very good results. Should acute hemorrhage occur in the operating room, emergency vascular occlusion can be carried out by the use of the Swan-Ganz catheter.

Nuclear magnetic resonance has shed new light on our understanding of osteonecrosis of the femoral head. It is at present the most sensitive and most specific imaging technique for the diagnosis of this condition. Studies involving correlations between MR images and anatomical findings have facilitated the understanding of tissue changes responsible for magnetic appearances. However, all problems are not resolved. At an early stage, fortunately almost always asymptomatic, false negative MRI or MR findings similar to those of algoneurodystrophy of the hip can be encountered. The aim of this article is to pinpoint the current status of these questions on the basis of a review of the recent literature. The contribution of MRI with injection of Gadolinium and future prospects are also discussed.

Olfactory neuroblastoma, a nerve tumour arising in the olfactory mucosa, is a relatively easy diagnosis in the case of a mass centered around the cribriform plate. It is more difficult to diagnose in its exceptional ectopic forms (maxillary sinus) in the absence of any cytological and histochemical arguments (fibrils, olfactory rosettes). Its local malignancy is variable with a 42% 5-year survival for stage C and metastases in 30% of cases (principally cervical nodes, bone and liver). The role of imaging is to define the criteria of a mass syndrome and to perform the preoperative staging in a case of apparently simple sinus obstruction.

Neurofibromatosis is classified into two types. Type 1, NF1 or von Recklinghausen's disease, consists of skin and bone lesions as well as central nervous system tumours arising at the expense of glial tissue: optic tract gliomas, glioblastomas, astrocytomas and "hamartomas". Type 2 consists almost exclusively of CNS tumours arising at the expense of nerve envelopes: Schwannomas, meningiomas.

Osteomyelitis of the skull base is a rare, but serious disease whose incidence is tending to increase. It affects the marrow of the temporal, occipital and sphenoid bones and is generally secondary to Pseudomonas aeruginosa infection of the external auditory meatus. Based on a clinical case, the authors recall the difficulty of establishing the positive diagnosis and the possible confusion with neoplastic disease, hence the fundamental role of biopsies. They also review the literature on this subject.

The recent advances in imaging of the temporomandibular joint (TMJ), especially the introduction of MR imaging and surface colls allowing precise visualization of superficial structures led us to reconsider the different techniques used in this very complex anatomical region, due to both its morphology and function. We also tried to determine their respective role, especially in the study of TMJ dysfunction syndromes, that represent the most frequent pathology of this region. Conventional radiography allows us to appreciate the overall amplitude of the joint movements, and to study bone abnormalities, but CT is much more precise in the study of cortical bone. In TMJ dysfunction, the joint itself is studied by either arthrography or MRI, but both techniques have their limitations and remain complementary in some aspects, which are detailed here, so that the choice between them depends on availability and therapeutic indications.

Ultrasound seems to be the investigation of choice when a testicular tumor is suspected, especially when physical examination appears to be normal. 37 testicular tumors have been diagnosed out of a series of more than one thousand case of scrotal ultrasonography. The most important sonographic patterns are presented and their etiologies are discussed.

Fibrous pseudotumor of the testicular appendices is a rare, benign tumour which, because of its site, frequently simulates a malignant testicular tumour. Ultrasonography establishes the diagnosis of benign extratesticular tumour based on a number of arguments in favour of this entity, allowing local excision instead of unnecessary orchidectomy.