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Inflammatory back pain is a hallmark feature of axial spondyloarthritis, a heterogeneous group of inflammatory disorders which affects the sacroiliac joints and spine. Imaging plays a key role in diagnosis of this disease and in facilitating appropriate treatment. This document provides evidence-based recommendations on the appropriate use of imaging studies during multiple stages of the clinical evaluation of patients with suspected or known axial spondyloarthritis. 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.

Management of pectoralis major (PM) injuries is largely determined by the anatomic location of the injury, with tendon avulsions from the humerus requiring surgery while myotendinous (MT) injuries are typically managed non-operatively. Because physical examination cannot reliably make this distinction, MRI is often used for staging. However, correct classification can also be difficult with MRI where there is extensive soft tissue edema and distorted anatomy. To determine the diagnostic performance of primary and secondary MRI signs of PM injury for distinguishing tendon avulsions from MT injuries in a selected sample of patients that underwent surgical repair using a practical interpretation algorithm. In this retrospective study, 3 blinded observers independently assessed the MRI findings of 17 patients with PM injury (including 12 acute injuries, 4 chronic, and 1 of uncertain age) where subsequent surgery documented tendon avulsion (11) and MT injuries (6) by applying the primary MRI criteria of absent tendon at the humerus, retracted tendon stump, epicenter of edema, and the secondary finding of soft tissue edema contacting the anterior humeral cortex. Operative findings were used as the reference standard. Sensitivity, specificity, and positive and negative predictive value were recorded for each finding. The primary MRI finding of lack of a visible tendon at the insertion (sensitivity 82–100%, specificity 100%) and the secondary finding of edema contacting the anterior humeral cortex (sensitivity 64–91%, specificity 67–100%) were both useful for the distinction of tendon avulsion from MT injury, particularly in acute injuries. The presence of a retracted tendon stump and the epicenter of edema were not reliable findings. The use of a decision tree including the secondary finding of humeral edema increased the sensitivity and specificity for 2 of the 3 observers. MRI assessment of PM injury focused on the humeral insertion of the PM tendon allows accurate distinction of tendon avulsion from MT injury. This study describes a practical approach to classifying PM injuries with MRI to distinguish injuries that require surgery from those that can potentially be managed conservatively.

Recent orthopedic surgical literature emphasizes a three-column approach to understand and guide the treatment of tibial plateau fractures. This three-column classification system published in 2010 relies on preoperative CT images to depict injuries to the medial, lateral, and posterior columns of the tibial plateau and improves surgical outcomes in complex tibial plateau fractures with coronal fracture planes and posterior plateau fracture fragments requiring dorsal plating. Tibial plateau fracture classification systems traditionally used by radiologists and orthopedic surgeons, including the Schatzker and the Arbeitsgemeinschaft für Osteosynthesefragen-Orthopedic Trauma Association (AO-OTA) classification systems, rely on findings at anteroposterior radiography and lack the terminology to accurately characterize fractures in the coronal plane involving the posterior tibial plateau. Incorporating elements from the contemporary three-column classification system into radiology reports will enhance radiologists' descriptions of these injuries. It is essential for radiologists to understand the role of clinical assessment and the pertinent imaging findings taken into consideration by orthopedic surgeons in their management of these injuries. This understanding includes familiarity with injury patterns and how they relate to mechanism of injury, patient demographics, and underlying pertinent comorbidities. Evaluating findings on initial radiographs is the basis of tibial plateau fracture diagnosis. Additional information provided by preoperative cross-sectional imaging, including two-dimensional and three-dimensional CT and MRI in specific circumstances, aids in the identification of specific soft-tissue injuries and fracture morphologies that influence surgical management. These specific fracture morphologies and soft-tissue injuries should be identified and communicated to orthopedic surgeons for optimal patient management.

Background Diabetes mellitus (DM) with peripheral neuropathy (PN) results in foot deformity increasing ulceration, joint dislocation, and amputation risk. This study describes the frequency and severity of foot and ankle musculoskeletal abnormalities and their relationship to radiographic alignment in people with DMPN with (DMPN + MCD) and without (DMPN − MCD) medial column deformity (MCD) compared to age- and body mass index-matched controls without DMPN or MDC. Methods DMPN + MCD (n = 11), DMPN − MCD (n = 12), and controls (n = 12) were studied. A radiologist scored foot and ankle magnetic resonance images (MRI) for abnormalities in tendons/fascia, ligaments, muscles, joints, and bones. Higher scores represent greater abnormalities. Foot alignment was measured from lateral weightbearing radiographs. Frequency of abnormalities between groups and relationships between abnormalities and foot alignment in the combined group (n = 35) were examined. Results DMPN + MCD had higher total muscle, joint, and bone scores compared to controls and higher total joint scores than DMPN − MCD. DMPN − MCD had higher total muscle scores than controls. DMPN + MCD higher bone and joint scores were driven by increased frequency of osteophytes, cartilage damage, focal bone marrow edema, new bone formation, and subchondral cysts. Significant correlations included cuboid height and total bone and joint scores (ρ = −0.37 and ρ = −0.40, respectively) and talar declination angle and total joint score (ρ = 0.38). Conclusion High contrast resolution MRI allowed identification of structural lesions of the foot affecting the cartilage surfaces, bone marrow, and soft tissue supports in patients with DMPN + MCD. As expected, the presence of bone and joint lesions on MRI were strongly associated with DMPN + MCD; surprisingly, although the sample is small, lesions of the soft tissue supports were not associated with MCD. While MRI is not done routinely to investigate MCD, opportunistic use of the information from MRI done for the common clinical indications may allow early identification of the structural lesions associated with MCD and facilitate early, aggressive therapy. Level of evidence III.

Nitrogen-containing bisphosphonates (N-BPs), such as alendronate, are the most widely prescribed medications for diseases involving bone, with nearly 200 million prescriptions written annually. Recently, widespread use of N-BPs has been challenged due to the risk of rare but traumatic side effects such as atypical femoral fracture (AFFs) and osteonecrosis of the jaw (ONJ). N-BPs bind to and inhibit farnesyl diphosphate synthase (FDPS), resulting in defects in protein prenylation. Yet it remains poorly understood what other cellular factors might allow N-BPs to exert their pharmacological effects. Here, we performed genome-wide studies in cells and patients to identify the poorly characterized gene, ATRAID. Loss of ATRAID function results in selective resistance to N-BP-mediated loss of cell viability and the prevention of alendronate-mediated inhibition of prenylation. ATRAID is required for alendronate inhibition of osteoclast function, and ATRAID-deficient mice have impaired therapeutic responses to alendronate in both postmenopausal and senile (old age) osteoporosis models. Lastly, we performed exome sequencing on patients taking N-BPs that suffered ONJ or an AFF. ATRAID is one of three genes that contain rare non-synonymous coding variants in patients with ONJ or AFF that is also differentially expressed in poor outcome groups of patients treated with N-BPs. We functionally validated this patient variation in ATRAID as conferring cellular hypersensitivity to N-BPs. Our work adds key insight into the mechanistic action of N-BPs and the processes that might underlie differential responsiveness to N-BPs in people.One Sentence SummaryATRAID is essential for responses to the commonly prescribed osteoporosis drugs nitrogen-containing bisphosphonates.OverlineBONE

Neoplasms of the sacrum are rare. Given the non-specific imaging findings in sacral lesions, the imaging-based differential diagnosis is always difficult. This case is about an adult with primary sacral neuroblastoma and we have discussed imaging and histopathological findings of this rare tumor.

Study design A retrospective review. Objective The aim of this study was to demonstrate proof-of-concept of preoperative percutaneous intraosseous fiducial marker placement before thoracic spine surgery. Summary of background data Wrong-level spine surgery is defined as a never event by Center for Medicare Services, yet the strength of data supporting the implementation of Universal Protocol to limit wrong level surgery is weak. The thoracic spine is especially prone to intraoperative mislocalization, particularly in cases of morbid obesity and anatomic variations. Methods We retrospectively reviewed all cases of preoperative percutaneous image-guided intraosseous placement of a metallic marker in the thoracic spine. Indications for surgery included degenerative disc disease (16/19), osteochondroma resection, spinal metastasis, and ligation of dural arteriovenous malformation. All metallic markers were placed from a percutaneous transpedicular approach under imaging guidance [fluoroscopy and computed tomography (CT) or CT alone]. Patient body mass index (BMI) was recorded. Overweight and obese BMI was defined greater than 25 and 30 kg/m, respectively. Results All 19 patients underwent fiducial marker placement and intraoperative localization successfully without complication. Twenty-two thoracic spine levels were localized. The T7, T9, T10, and T11 levels were the most often localized at rate of 18.1% for each level (4/22). The most cranial and caudal levels localized were T4 and T11. About 84.2% (16/19) of the cohort was overweight (57.9%; 11/19) or obese (26.3%; 5/19). The median BMI was 30.2 kg/m (range, 23.9-54.3 kg/m). Conclusion Preoperative percutaneous thoracic fiducial marker placement under imaging guidance is a safe method for facilitating intraoperative localization of the target spinal level, especially in obese patients. Further studies are needed to quantify changes in operative time and radiation exposure. Level of evidence 4.

The purpose of this article is to provide tactics for the behavior analyst to effectively evaluate the evidence base for an unfamiliar nonbehavioral intervention when expanding services. Just as behavior analysts must be aware of fad treatments in autism likely to be encountered, so, too, should practitioners become familiar with potential fad treatments in any expanded area of practice. The present article extends previous work by considering challenges surrounding contact with nonbehavioral literature in the context of an expanded consumer base. The article also considers ethical interactions with nonbehavioral professionals following appraisal of the intervention, and how adopting the strategies listed here can aid in establishing oneself as a resource. Associated barriers and solutions are presented around four tactics: (a) searching the literature, (b) recognizing and evaluating the common properties of fad treatments, (c) distinguishing quality of evidence, and (d) ascertaining behavioral mechanisms of action. Examples from gerontology will be provided to illustrate the use of the proposed tactics.

In contrast to widely-reported sternal insufficiency fractures, stress fractures of the sternum from overuse are extremely rare. Of the 5 cases of sternal stress fracture published in the English-language medical literature, 3 were in the sternal body and only 2 were in the manubrium. We describe two cases of manubrial stress fracture related to golf and weightlifting, and present the first report of the MR findings of this injury. In each of these cases, the onset of pain was atraumatic, insidious, and associated with increased frequency of athletic activity. Imaging was obtained because of clinical diagnostic uncertainty. On MRI, each patient had a sagittally oriented stress fracture of the lateral manubrium adjacent to the first rib synchondrosis. Both patients had resolution of pain after a period of rest, with subsequent successful return to their respective activities. One patient had a follow-up MRI, which showed resolution of the manubrial marrow edema and fracture line. Based on the sternal anatomy and MR findings, we hypothesize that this rare injury might be caused by repetitive torque of the muscle forces on the first costal cartilage and manubrium, and propose that MRI might be an effective means of diagnosing manubrial stress fracture.

Background: In ice hockey players, serious bone injuries in the foot and ankle, especially those attributed to impact from the moving puck, may be radiographically occult and underrecognized. Purpose/Hypothesis: The purpose of this research was to study foot and ankle bone injuries detected with magnetic resonance imaging (MRI) that occurred in elite hockey players. The hypothesis was that these injuries predominate medially, especially when caused by the impact from the puck, and are associated with prolonged lost playing time. Study Design: Case series; Level of evidence, 4. Methods: Three independent observers, blinded to the mechanism of injury, retrospectively reviewed foot and ankle MRI examinations acquired after 31 acute injuries that occurred in 27 elite ice hockey players who had no radiographically visible fractures. Bone abnormalities were classified as fractures or varying degrees of contusion based on predetermined definitions. Interobserver agreement was analyzed with kappa statistics. The association between the injury mechanism and the bones involved was examined with the Fisher exact test. A t test was applied to determine if MRI evidence of a severe bone injury (defined as either a fracture or a high-grade bone contusion) was associated with longer recovery times, when return-to-play information was available. Results: The observers identified at least 1 bone injury in 27 of the 31 MRI examinations, including 10 with radiographically occult fractures. Agreement among the 3 observers for injury categorization was substantial (κ = 0.76). Seventeen injuries were caused by a direct blow (15 from a moving puck, 2 from an uncertain source), resulting in 6 fractures and 6 high-grade bone contusions, with 14 of the 17 involving a medial bone (medial malleolus, navicular, or first metatarsal base). Compared with other mechanisms, direct impaction was statistically more likely to result in a severe bone injury and to involve the medial foot and ankle. In 20 injuries where return-to-play information was available, players with severe bone injuries missed a mean of 10.6 games compared with 2.4 games for other players ( P = .05). Conclusion: MRI can show severe bone injuries that are not visible radiographically in ice hockey players. Most fractures and high-grade contusions involve the medial ankle and midfoot bones, can be caused by direct blows from the puck, and are associated with prolonged recovery times.

Musculoskeletal disorders are a common presenting reason for emergency department patients. A wide range of musculoskeletal pathologies are commonly encountered by emergency physicians and related clinicians, and by radiologists, including traumatic, infectious, inflammatory, and tumor-related emergencies. This chapter will review common potential errors in trauma radiology, including frequently missed fractures, as well as conditions which are radiographically occult, for which the radiologist should recommend a complementary imaging examination to confirm or refute a diagnosis.

Unenhanced MRI, indirect MR arthrography, direct MR arthrography, and CT arthrography are each currently used to evaluate patients with recurrent knee pain after meniscus surgery. The purpose of this study is to review the evidence for the use of these examinations in patients with suspected recurrent meniscus tear.Direct and indirect MR arthrography are superior to conventional MRI for the assessment of the postoperative meniscus after meniscus repair or partial meniscectomy involving more than 25% of the meniscus.

The lateral abdominal wall is comprised of three muscles, each with a different function and orientation. The transversus abdominus, internal oblique, and external oblique muscles span the abdominal cavity between the iliocostalis lumborum and quadratus lumborum posteriorly and the rectus abdominis anteriorly. The lateral abdominal wall is bound superiorly by the lower ribs and costal cartilages and inferiorly by the iliac crest and inguinal ligament. The lateral abdominal wall may be acutely or chronically injured in a variety of athletic endeavors, with occasional acute injuries in the setting of high-energy trauma such as motor vehicle collisions. Injuries to the lateral abdominal wall may result in lumbar hernia formation, unique for its high incarceration rate, and also Spigelian hernias. This article will review the anatomy, the magnetic resonance (MR) imaging approach, and the features and complications of lateral abdominal wall injuries.

THE PROBLEM A common cause of fraud and abuse in the medical system is the assignment of services with incorrect Current Procedural Terminology (CPT) codes, leading to billing for services that were not performed or misrepresentation of the actual services that were provided [1-3]. Additionally, incorrect CPT coding has been shown to result in “undercoding” of the service provided, ultimately resulting in a loss of potential revenue [3,4]. Only a few studies have evaluated the accuracy of CPT coding for imaging-related interventions, demonstrating that CPT coding errors are commonplace [3,5]. Application of correct CPT codes is essential for physicians, regardless of experience or the coding arrangements within their practices. A general review of our coding compliance found a surprising number of monthly coding errors involving our musculoskeletal interventional service. As a section, we believed that it was important to improve our coding accuracy and chose to initiate a project with the goal of decreasing our CPT coding errors. Additionally, because the ultimate responsibility for coding accuracy rests on the radiologist, this initiative also further educated our

The purpose of this study is to evaluate the histopathologic diagnostic yield, sample size, procedural time, and dose-length product (DLP) for the biopsy of CT-occult lesions found at MRI or PET or both.A retrospective review of our radiology information system for biopsies of CT-occult lesions using CT guidance from January 1, 2010, through December 31, 2014, was performed and compared with a selection of CT-guided biopsies of CT-evident bone lesions during the same period. The data were then evaluated for diagnostic yield of histopathologic diagnosis, procedural time, use of sedation medication, DLP, and size of specimens obtained.A total of 30 CT-occult biopsies met the inclusion criteria. Twenty-seven of those biopsies had results that were concordant with the patient's primary histopathologic diagnosis, imaging findings, and clinical course. In the CT-evident lesion group, concordant histopathologic abnormalities were identified in 27 of 30 patients. There was a statistically significant increase in number of samples obtained for the CT-evident lesions compared with CT-occult lesions. There was no statistically significant difference in total specimen length, DLP, number of CT scans, procedural time, or use of sedation medication between the CT-occult and CT-evident biopsy groups.Biopsy of CT-occult lesions using anatomic landmarks achieves diagnostic yields similar to those for CT-guided biopsy of CT-evident lesions.

This article is a case-based review of the broad spectrum of tumors with musculoskeletal histology that can arise in the abdomen or pelvis and involve the soft tissues, muscle, and bone. In this article, pathology-proven cases are presented with a focus on radiographic, computed tomography, magnetic resonance imaging, and positron emission tomography-computed tomography findings. The imaging features that differentiate tumors with musculoskeletal histology from more common abdominal tumors are discussed. Representative cases include malignant fibrous histiocytoma, chondrosarcoma, Ewing sarcoma, hemangiopericytoma, desmoplastic fibroma, neurofibrosarcoma, osteosarcoma, intimal sarcoma, liposarcoma, leiomyosarcoma, synovial sarcoma, teratoma, and chordoma. A variety of tumors with musculoskeletal histology can arise in the abdomen and pelvis. In some cases, unique imaging characteristics allow a confident diagnosis, whereas other cases have a more nonspecific appearance. Recognition of imaging features that suggest a musculoskeletal tumor including direct extension from a bone or neural foramen, the presence of cartilaginous or osseous matrix, or macroscopic fat would allow the radiologist to suggest the proper diagnosis. Recognizing imaging characteristics of tumors with musculoskeletal histology is important clinically as management and prognosis differ from that of more common abdominal tumors.

This article reviews the basics of image-guided intervention of musculoskeletal neoplasms. Image-guided procedures are playing an ever-increasing role in the diagnosis, staging, and treatment of musculoskeletal tumors. The successful handling of these lesions necessitates a multidisciplinary approach, with the radiologist working closely with the orthopedic oncologic surgeon, medical oncologist, radiation oncologist, and pathologist to ensure that the procedure is performed in a way that maximizes the chance of definitive diagnosis and/or the treatment effect while minimizing potential complications. To accomplish these goals, the radiologist must be familiar with the indications and contraindications for any biopsy or treatment, effective procedure planning (e.g., selection of biopsy path, type of imaging guidance and biopsy needle, etc.), proper specimen handling, and potential treatment options such as thermal ablation or cement augmentation. Continued involvement after the procedure-including follow-up to ensure that pathology is concordant with imaging-is also crucial.

Objective: To compare accuracy of ultrasound and MRI for detecting focal peripheral nerve pathology, excluding idiopathic carpal or cubital tunnel syndromes. Methods: We performed a retrospective review of patients referred for neuromuscular ultrasound to identify patients who had ultrasound and MRI of the same limb for suspected brachial plexopathy or mononeuropathies, excluding carpal/cubital tunnel syndromes. Ultrasound and MRI results were compared to diagnoses determined by surgical or, if not performed, clinical/electrodiagnostic evaluation. Results: We identified 53 patients who had both ultrasound and MRI of whom 46 (87%) had nerve pathology diagnosed by surgical (n = 39) or clinical/electrodiagnostic (n = 14) evaluation. Ultrasound detected the diagnosed nerve pathology (true positive) more often than MRI (43/46 vs 31/46, p 2 cm) and only occasionally (2/13) outside the MRI field of view. MRI missed multifocal pathology identified with ultrasound in 6 of 7 patients, often (5/7) because pathology was outside the MRI field of view. Conclusions: Imaging frequently detects peripheral nerve pathology and contributes to the differential diagnosis in patients with mononeuropathies and brachial plexopathies. Ultrasound is more sensitive than MRI (93% vs 67%), has equivalent specificity (86%), and better identifies multifocal lesions than MRI. In sonographically accessible regions ultrasound is the preferred initial imaging modality for anatomic evaluation of suspected peripheral nervous system lesions.

We report a 19-year-old man with the rare occurrence of primary osseous Rosai-Dorfman disease (RDD). The patient presented with a painful, solitary, bone marrow-replacing lesion in the distal femur. A diagnosis of chronic osteomyelitis was initially made on tissue from a CT-guided needle biopsy of the lesion; however, the diagnosis of RDD was eventually made after histological and immunohistochemical analysis of material from a subsequent curettage. No lymphadenopathy or other sites of involvement were found on clinical evaluation and PET-CT. To our knowledge, this is the first report of solitary osseous RDD based on systemic staging with PET-CT. We review the clinical, imaging, and histological features of primary osseous RDD, including pitfalls in diagnosis.

Diabetes mellitus is increasingly prevalent and results in various clinically important musculoskeletal disorders affecting the limbs, feet, and spine as well as in widely recognized end-organ complications such as neuropathy, nephropathy, and retinopathy. Diabetic muscle ischemia-a self-limited disorder-may be confused with infectious or inflammatory myositis, venous thrombosis, or compartment syndrome. The absence of fever and leukocytosis, combined with the presence of bilaterally distributed lesions in multiple and often noncontiguous muscles in the legs, including the thighs, is suggestive of ischemia; by contrast, the presence of well-defined intramuscular abscesses with rimlike enhancement favors a diagnosis of infectious pyomyositis. In the diabetic foot, an ulcer, sinus tract, or abscess with an adjacent region of abnormal signal intensity in bone marrow favors the diagnosis of pedal osteomyelitis over that of neuropathic arthropathy. Contrast material-enhanced magnetic resonance imaging is important when planning the treatment of foot infections in diabetic patients because it allows the differentiation of viable tissue from necrotic regions that require surgical débridement in addition to antibiotic therapy. Subtraction images are particularly useful for visualizing nonviable tissue. Dialysis-associated spondyloarthropathy characteristically occurs in diabetic patients with a long history of hemodialysis. Intervertebral disk space narrowing without T2 signal hyperintensity, extensive endplate erosions without endplate remodeling, and facet joint involvement are suggestive of spondyloarthropathy instead of infectious diskitis or degenerative disk disease. Although the clinical features of these conditions may overlap, knowledge of the patient's medical history, coupled with recognition of key imaging characteristics, allows the radiologist to make a prompt and correct diagnosis that leads to appropriate management.

Heterotopic mesenteric ossification is an unusual but important complication in patients who sustain blunt and penetrating abdominal trauma. In this condition, bone formation occurs in the mesenteric and omental fat in response to injury and may result in serious complications such as bowel obstruction and fistula formation. Although a few case reports exist, the radiology literature on this topic is scant. Based on our experience, this entity is under-recognized on imaging studies and often results in diagnostic confusion due to its resemblance to other pathologies such as barium leak and extraskeletal bone-forming neoplasms. This review highlights the imaging features of heterotopic mesenteric ossification with an emphasis on computed tomographic findings. Radiologist awareness of this condition is crucial to avoid misdiagnosis as well as to direct appropriate and timely management.

The standard radiographic series is not always sufficient to diagnose and characterize subtle musculoskeletal injuries. Missed or delayed diagnoses can negatively affect patient acute morbidity and long-term outcomes. Similarly, management based on erroneous diagnoses may lead to unnecessary treatment and restrictions. Body-part- or joint-specific supplemental radiographic views and stress radiography offer an alternative for further evaluation of subtle injuries in specific clinical situations and may obviate the need for the added cost and potential ionizing radiation exposure of further cross-sectional imaging. Familiarity with these complementary exams allows radiologists to play an important role in patient care, as their utilization can improve diagnostic accuracy, clarify subtle or uncertain findings, and direct timely patient management. This review highlights important supplemental views and stress radiographic examinations useful in the evaluation of emergent lower extremity musculoskeletal trauma.

Many diseases result in polyostotic bone lesions including benign entities, benign entities with malignant potential, intermediate entities, and malignant entities. Imaging plays a key role in identifying complications of these disorders, most importantly malignant transformation of a benign lesion. The most common polyostotic bone lesions are reviewed and examples of malignant transformation are highlighted.

Open Fractures Open fractures are potentially devastating injuries. Even with optimal orthopedic management, contamination of the fracture site and devitalized soft tissues result in increased risk of infection, nonunion, and wound complications that can threaten limb salvage and cause long-term morbidity. The Gustilo classification for open fractures, initially published in 1976 and modified in 1984 to its current form, is the most commonly used system for characterizing these injuries, communicating injury severity among the trauma team, and predicting outcomes based on fracture type (Table 1). Immediate treatment goals for an open fracture involve determining the type and extent of injury so that urgent antibiotic therapy, irrigation, debridement, and fracture fixation can be performed. In general, the higher the Gustilo grade, the higher the risk of subsequent infection and adverse outcome. Although ultimate Gustilo grading occurs in the operating room, radiology plays an important role in the initial evaluation of patients with open fractures and planning for surgical intervention. One of the most important branch points in the open fracture treatment algorithm is determining whether an arterial injury is present (Gustilo grade IIIC). If present, and depending on the type of injury, an immediate decision must be made

Cognitive impairment represents a common mental health problem in community-dwelling and institutionalized older adults, and the prevalence increases with age. Multidisciplinary teams are often asked to assess cognitive and functional impairment in this population. The Cognitive Assessment of Minnesota was created by occupational therapists for this purpose and is frequently used, but has not been extensively validated. This study examined the performance of the CAM and compared it to the MMSE with 113 outpatient clinic patients over the age of 60. Subgroups were established based on scores on a depression inventory to determine if the presence of depressed mood altered the relationship between the measures. Both measures demonstrated good internal consistency. The overall correlation between the two measures was high, statistically significant and remained high regardless of depression status. We offer recommendations about the utility of each measure in screening cognitive functioning for older adults.

Wandering is a difficult-to-manage behavior problem for individuals with cognitive impairments that can jeopardize safety if an individual enters a hazardous area or becomes lost. This study investigated the effects of a cloth barrier on entry into an unsafe area. The cloth barrier reduced entry into the restricted area and had high treatment acceptability.

10585 Background: Metastatic spinal lesions can be debilitating with significant impact on patients quality of life. Concern for damage to adjacent neural elements during treatment exist due to high radiation doses required to treat certain radioresistant spinal lesions such as soft tissue sarcoma. Radiofrequency ablation (RFA) of metastatic lesions has been shown to be effective in bone. Spine anatomy presents challenges for minimally invasive (MI) treatment of posterior vertebral body lesions. Targeted RFA (t-RFA) using a novel tumor ablation system, designed for spinal anatomy is evaluated in patients with symptomatic posterior vertebral wall spinal lesions. Methods: Five patients with metastatic leiomyosarcoma or liposarcoma and posterior vertebral body spine lesions, treated by prior radiation with continued progression of lesion size and pain received t-RFA, using a novel spinal tumor ablation system (STAR, DFINE), which contains an articulating bipolar, extensible electrode for navigation. Device thermocouples (TC) permit real time monitoring of the ablation zones to determine size. Sequential post-procedural pain scores, PET and contrast enhanced magnetic resonance imaging, and histopathology of treated area was performed. Results: No complications or thermal injury occurred. Intra-procedural imaging demonstrated the articulated, bipolar instrument was able to navigate to posterior lesions. Post-ablation MRI demonstrated lesion necrosis within a discrete ablation zone. No evidence of malignancy by PET or histopathology was noted through 10 months. All patients reported post procedural pain relief. Systemic therapy was not interrupted. Conclusions: Navigational t-RFA proved a safe and effective, non-ionizing palliative therapy alternative for radio-resistant lesions . Post-ablation imaging and histology confirmed metastatic lesions were necrotic and included in ablation zone with tumor control 10 mos post treatment. Ablation zone was very consistent with real time temperature readings. t-RFA permitted MI targeted treatment of lesions within close proximity of spinal cord, not controlled by systemic therapy. Prospective clinical trial is under preparation.