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In this article, we review the preoperative imaging features used for planning shoulder arthroplasty as well as review the various shoulder arthroplasty component types, discussing the expected normal imaging features and specific complications to look for with each.Given the increasing use of shoulder arthroplasty, it is important to understand the imaging features of the various shoulder arthroplasty complications.

OBJECTIVE. This article discusses the strengths and weaknesses of the various anatomic and molecular imaging techniques in the evaluation of unexpected bone lesions. CONCLUSION. An approach to the imaging evaluation of chondroid, osteoblastic, and osteolytic lesions as well as focal marrow abnormalities is reviewed.

Evaluate anatomic and imaging features of epitrochlear regional adenopathy secondary to cat scratch disease (CSD) to assist differentiation of CSD from other soft tissue masses at the elbow. Retrospective review of 24 confirmed cases of CSD. Patient demographics, clinical presentation and radiographic (R; n = 10), CT (n = 3), ultrasound (US; n = 5), and MR (n = 21) images were reviewed. Lesion location, size, number of masses, and intrinsic characteristics on R/CT/US/MR and presence of soft tissue inflammatory changes or adjacent bone or joint involvement were established through the consensus interpretation by four musculoskeletal radiologists. The average patient age was 18.6 years. Mass location was anterior and superficial to the medial intermuscular septum (100 %) with the masses posterior or posteromedial to the basilic vein (92 %). Three or fewer lymph nodes were involved in 92 %. Masses were noncalcified with adjacent inflammatory change (R = 90 %, CT = 100 %). US showed hypoechoic soft tissue echogenicity masses with defined to minimally irregular margins (80 %) and preserved central hilar hypervascularity on Doppler (100 % of cases). On MR, masses were T1 isointense (62 %), T2 isointense (54 %), intermediate signal on T2 images with fat suppression (55 %), and had perilesional inflammatory changes (95 %), perilesional fluid collections (38 %), adjacent muscle edema (81 %), hyperintense cental hilar vascular enhancement (65 %) and occasional preserved central hilar fat (14 %). Cat scratch disease is suggested by the characteristic location of a medial epitrochlear mass superficial to the brachial fascia and posterior to the basilic vein with surrounding inflammatory changes and preservation of hilar vascular architecture, hilar enhancement and occasional hilar fat.

Traumatic shoulder pain is pain directly attributed to a traumatic event, either acute or chronic. This pain may be the result of either fracture (the clavicle, scapula, or proximal humerus) or soft-tissue injury (most commonly of the rotator cuff, acromioclavicular ligaments, or labroligamentous complex). Imaging assessment of traumatic shoulder pain begins with conventional radiography and, depending on physical examination findings, will require MRI or MR arthrography for assessment of soft-tissue injuries and CT for delineation of fracture planes. Ultrasound excels in assessment of rotator cuff injuries but has limited usefulness for assessment of the deep soft-tissues. CT angiography and conventional arteriography are helpful for assessment of vascular injury, and bone scintigraphy can be used in assessment of complex regional pain syndrome after traumatic shoulder injury. 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.

Chronic knee pain is a condition that is frequently encountered. Imaging often plays an important role in narrowing down the potential causes and determining the most effective next steps. The ACR Appropriateness Criteria for Chronic Knee Pain provides clinicians with the best practices for ordering imaging examinations. The following narrative and accompanying tables should serve as useful guides to any clinician. 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.

Adiposis dolorosa (Dercum’s disease) is a condition of benign, painful subcutaneous lipomatous lesions associated with weakness, endocrine and lipid abnormalities, and mental disturbances. There is little information documenting the cross-sectional imaging findings that differentiate it from lipomatous and neoplastic soft tissue masses, or massive localized lymphedema. The purpose of this study was to provide a radiological case series of adiposis dolorosa. A 10-year retrospective review of the picture archiving and communications system was performed. Two musculoskeletal radiologists reviewed images to confirm and document imaging features, location, size, and patient demographics. Medical records were reviewed to characterize patients into three groups: one group met at least three of the four criteria of Dercum’s syndrome, the second group met less than three criteria, and the third group had clinical diagnosis of cellulitis of the lower extremity. Seventeen cases (25 masses) of adiposis dolorosa were found, nine cases of which met at least three criteria of Dercum’s syndrome. All cases in the first two groups demonstrated skin thickening and lymphedema of subcutaneous fat, which was fluid attenuation on CT and low or intermediate T1-weighted and high STIR/T2-weighted MR signal. Two cases with pathology showed mild fatty infiltration with fibrous septa, and the third case showed massive localized lymphedema. The third group of ten cellulitis patients demonstrated non-mass-like subcutaneous edema with similar CT attenuation and MR signal characteristics to the first two groups, but differed by the presence of post-contrast enhancement and non-mass-like appearance in 90 %. Imaging findings of adiposis dolorosa and massive localized lymphedema overlap, as do the symptoms and pathological features. Due to the mass-like engorgement of the soft tissues and pain, patients will often undergo imaging to exclude neoplasm or infection. Knowledge of these conditions and the characteristic imaging findings is important to prevent unnecessary biopsy and misdiagnosis.

Background Self-reported pain scales are commonly used in emergency departments (EDs). The 11-point (0–10) numerical rating scale is a commonly used scale for adults visiting EDs in the United States. Despite their widespread use, little is known about whether distribution of pain scores has remained consistent over time. Objectives The objective of this study is to determine if there were upwards or downwards (monotonic) trends in pain scores over time at a single hospital. Methods Retrospective chart review for the years 2003–2011. All pain scores for May 1 st and 2 nd of those years were collected. Multinomial logistic regression was used to model the probability of a patient rating their pain in each of 11 categories (scores 0 to 10) as a function of the calendar year. Additional analysis was carried out with pain scores grouped into four categories. Results Data were collected from 2934 patient charts. Pain scores were recorded in 2136 charts, and 1637 of these pain scores were above zero (i.e., 1–10). The pain score distribution differed significantly over time ( p = 0.001); however, there was no monotonic (single-direction) trend. Conclusion Although there were significant shifts in pain scores over time, there is not a significant monotonic trend. At this hospital, there was no “inflation” or “deflation” in pain scores over time. Shifts in distribution, even when not in a single direction, may be important for researchers examining pain scores in the ED.

To evaluate the variability of clinical treatment and outcomes based on reporting of diabetic foot ulcer MRI findings of adjacent marrow T2 hyperintensity with normal T1 signal. A retrospective review was conducted of 46 MRI examinations evaluating diabetic foot ulcers that demonstrated normal T1 marrow signal, but T2 marrow hyperintensity deep to the ulcer. The cohort was divided based on MRI report impressions into three groups; “osteitis without osteomyelitis” (OW), “osteitis but cannot exclude early osteomyelitis” (OCEO) and “early osteomyelitis” (EO). Patient demographics (age, gender) and accessory MRI findings of ulcer and sinus tract depth were recorded. Initial clinical assessment and medical treatment (route and duration of antibiotics), healing versus disease progression and histology or microbiology results were recorded. The isolated marrow T2 signal hyperintensity was reported as OW in 12 patients, OCEO in 18, and EO in 16. No statistical difference in clinical assessment was demonstrated between the OW, OCEO, and EO groups. Pathological condition was available in 15 patients within 0–7 days (mean 2.4 days) of the MRI examination, with 14 (93%) of these positive for osteomyelitis by histopathology or positive cultures. Initial diagnosis of or progression to osteomyelitis was shown in 28 patients (61%). Treatment of suspected osteomyelitis is heavily determined by clinical factors. Patients who initially demonstrate only T2 marrow signal abnormality under a diabetic ulcer are eventually diagnosed as osteomyelitis in 61% of cases and deserve aggressive treatment as early osteomyelitis when meeting clinical parameters.

Infection of the musculoskeletal system is a common clinical problem. Differentiating soft tissue from osseous infection often determines the appropriate clinical therapeutic course. Radiographs are the recommend initial imaging examination, and although often not diagnostic in acute osteomyelitis, can provide anatomic evaluation and alternative diagnoses influencing subsequent imaging selection and interpretation. MRI with contrast is the examination of choice for the evaluation of suspected osteomyelitis, and MRI, CT, and ultrasound can all be useful in the diagnosis of soft tissue infection. CT or a labeled leukocyte scan and sulfur colloid marrow scan combination are alternative options if MRI is contraindicated or extensive artifact from metal is present. 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.

Objectives Evaluate the impact of wrist MRI in children on clinical diagnosis and management. Materials and methods Four year retrospective analysis including demographics, MRI diagnoses, and effect on diagnoses and management were determined. Results 101 patients were included. Wrist MRI altered management in 86% (95% CI: 77–92%) and diagnosis in 46% (36–56%) of patients. MRI changed both diagnosis and management in 41% (31–51%), changed management only in 46% (35–56%), changed diagnosis only in 5% (2–12%), and had no change in diagnosis or management in 9% (95% CI: 4–17%). Conclusion Wrist MRI in children changes clinical diagnosis and management in a substantial proportion of cases.

Appropriate imaging modalities for the follow-up of malignant or aggressive musculoskeletal tumors include radiography, MRI, CT, (18)F-2-fluoro-2-deoxy-D-glucose PET/CT, (99m)Tc bone scan, and ultrasound. Clinical scenarios reviewed include evaluation for metastatic disease to the lung in low- and high-risk patients, for osseous metastatic disease in asymptomatic and symptomatic patients, for local recurrence of osseous tumors with and without significant hardware present, and for local recurrence of soft tissue tumors. The timing for follow-up of pulmonary metastasis surveillance is also reviewed. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

More than 500,000 visits to the emergency room occur annually in the United States, for acute knee trauma. Many of these are twisting injuries in young patients who can walk and bear weight, and emergent radiographs are not required. Several clinical decision rules have been devised that can considerably reduce the number of radiographs ordered without missing a clinically significant fracture. Although a fracture is seen on only 5% of emergency department knee radiographs, 86% of knee fractures result from blunt trauma. In patients with a fall or twisting injury who have focal tenderness, effusion, or inability to bear weight, radiographs should be the first imaging study obtained. If the radiograph shows no fracture, MRI is best for evaluating for a suspected meniscus or ligament tear, or the injuries from a reduced patellar dislocation. Patients with a knee dislocation should undergo radiographs and an MRI, as well as an angiographic study such as a fluoroscopic, CT, or MR angiogram. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures, by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

This ACR Appropriateness Criteria article offers imaging triage guidance for several variants of patients presenting with acute foot trauma. Patients meeting inclusion criteria for the Ottawa Rules should undergo a 3-view radiographic series. Diabetic patients with peripheral neuropathy should undergo radiography, even though they do not meet the Ottawa Rules inclusion criteria. Patients with suspected midfoot and/or Lisfranc injury should undergo 3-view radiographs with weight bearing on at least the anterior-posterior view. Patients with suspected Lisfranc injury and normal radiographs should be considered for MRI and CT on a case-by-case basis. MRI or ultrasound could confirm cases of suspected acute tendon rupture. Radiography is the initial imaging modality for suspected plantar plate injury after metatarsal-phalangeal joint injury. Weight-bearing anterior-posterior, lateral, and sesamoid axial views may detect proximal migration of the hallux sesamoids. Ultrasound or MRI can directly evaluate the capsuloligamentous complex, specifically the plantar plate. Radiography can detect radiopaque penetrating foreign bodies, and ultrasound can be helpful in detecting those that are nonradiopaque. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures, by the panel. In instances in which evidence is lacking or is not definitive, expert opinion may be used to recommend imaging and treatment.

The magnetic resonance (MR) imaging presentations of arthritis of the knee are important for radiologists to recognize because these disorders are often clinically unsuspected. When they are known or clinically suspected, knowledge of imaging features allows for the confirmation and characterization of the extent of disease. This article reviews the fundamental MR imaging manifestations of rheumatologic disorders of the knee and their presentation in specific arthropathies.

Acute ankle injuries are frequently diagnosed and treated in emergency departments and outpatient clinics. Recent evidence-based clinical treatment guidelines and systematic review of economic analyses support the use of 3-view (anteroposterior, lateral, and mortise) radiographic evaluation of patients meeting the criteria of the Ottawa ankle rules. Cross-sectional imaging has a limited secondary role primarily as a tool for preoperative planning and as a problem-solving technique in patients with persistent symptoms and suspected of having occult fractures. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Primary osseous tumors of the spine are rare lesions and much less frequently encountered than metastases, multiple myeloma, and lymphoma. The interpreting radiologist must be aware of the typical radiographic appearance of the most common nonmyeloproliferative tumors of the spine because these tumors must be considered when a solitary spinal lesion is encountered. The purpose of this article is to describe the radiologic appearance and radiologic staging of the most common benign (hemangioma, enostosis, osteoid osteoma, osteoblastoma, giant cell tumor, aneurysmal bone cyst, and osteochondroma) and malignant (chordoma, chondrosarcoma, Ewing tumor, and osteosarcoma) osseous spine tumors.

Substantial cost, morbidity, and mortality are associated with acute proximal femoral fracture and may be reduced through an optimized diagnostic imaging workup. Radiography represents the primary diagnostic test of choice for the evaluation of acute hip pain. In middle aged and elderly patients with negative radiographs, the evidence indicates MRI to be the next diagnostic imaging study to exclude a proximal femoral fracture. CT, because of its relative decreased sensitivity, is only indicated in patients with MRI contraindications. Bone densitometry (DXA) should be obtained in patients with fragility fractures. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Arthritis, including inflammatory, crystal deposition, and synovial proliferative disorders, may mimic sports injury. The purpose of this article is to review the clinical and radiologic findings of arthropathies that can present in athletes and be confused with internal derangement.

Primary osseous spinal tumors are relatively rare in comparison with metastatic disease, myeloma, and lymphoma. Despite their rarity, the interpreting radiologist must be aware of the typical imaging features to provide appropriate diagnosis for guidance of clinical management. The age of occurrence, distribution longitudinally in the spine, and distribution axially within the vertebra combined with typical imaging appearances can help indicate the correct diagnosis. This article reviews the diagnostic features of benign and malignant primary bone spinal tumors.

Femoroacetabular impingement (FAI) is a recently described entity that occurs when there is impaction of the femoralheadorneckonthelabrumandacetabularrimofthe pelvis secondary to either acquired or developmental abnormality of the femoral head and or acetabulum. 1,2 This abnormal osseous morphology leads to chronic impaction at the extremes of range of motion and subsequent damage of the labrum and articular cartilage. It is critical for the radiologist to have a thorough understanding of this entity because FAI is currently believed to be an important contributor to the early development of osteoarthritis in young patients. However, the natural history of this disorder has not been established, and there is some controversy about the significance of radiologic manifestations of FAI because they can be seen in asymptomatic individuals. The role of the radiologist in the assessment of FAI is 2-fold, screening and definitive evaluation. Screening is usually performed through plain radiography but the findings of FAI may also be recognized on wide field-of-view (FOV) magnetic resonance (MR) imaging (MRI) of the pelvis that is frequently performed for the general evaluation of hip pain. The interpreting radiologist must be sensitive to often subtle findings that may indicate that FAI is responsible or contributing to pain in young patients. Definitive evaluation is usually performed with dedicated imaging of the symptomatic hip by MRI arthrography although noncontrast imaging and, to a lesser extent, computed tomography (CT) have roles in the assessment of suspected FAI.

This study examines interpreter accuracy and interobserver agreement in evaluating conventional radiographs for scaphoid waist fracture displacement.Six fresh-frozen cadaver arms were obtained transected above the elbow. A waist fracture was created in each scaphoid. In a random fashion, three of the fractures were displaced 1 mm in the radial-ulnar plane, whereas the other three were reapproximated to anatomic position before all fractures were stabilized with radiolucent adhesive glue. A three-view conventional radiography series consisting of a posterior-anterior, lateral, and ulnar-deviated elongated scaphoid view was obtained for each wrist. Each radiograph was then presented in the same sequence for interpretation to six independent observers: two hand surgeons, two musculoskeletal radiologists, and two senior orthopaedic surgery residents who were all blinded to the actual fracture pattern.In 14 of the 18 (78%) displaced fracture radiographic series, the interpreters correctly recognized displacement being present. However, displacement was also reported in six of the 18 (33%) nondisplaced fracture series. The estimated overall accuracy of all readings for distinguishing between displaced and nondisplaced fractures was 72%. Of the 90 total possible pairwise agreements between interpreters regarding fracture displacement, there were 54 actual agreements (60%), and kappa was estimated to be 0.31. Taken together, these two measures of agreement can be interpreted as indicating poor to moderate agreement.Our results suggest that conventional radiography is not reliable in determining 1-mm scaphoid waist fracture displacement in the radioulnar plane and also indicated a lack of strong interobserver agreement.

To validate a technique for reproducible measurement of the osteochondroma cartilage cap with computed tomography (CT) and magnetic resonance (MR) imaging and to reevaluate the correlation of the thickness of the cartilage cap with pathologic findings to improve noninvasive differentiation of benign osteochondromas from secondary chondrosarcomas.The institutional review board approved the study and waived the need for informed consent. HIPAA compliance was maintained. After validation of the measurement technique, 101 pathologically confirmed osteochondromas were retrospectively reviewed. Patient demographic data, histologic diagnosis, and chondrosarcoma grade were recorded. Two musculoskeletal radiologists used a standardized technique to independently measure the thicknesses of the cartilage caps on CT and MR images; these measurements were compared for interobserver agreement. Agreement between measurements with CT and MR imaging was also evaluated, as were the sensitivity and specificity of both modalities for differentiation of osteochondromas from chondrosarcomas.Evaluated were 67 benign osteochondromas (from 49 male patients and 18 female patients; mean age, 23.4 years) and 34 secondary chondrosarcomas (from 27 male patients and seven female patients; mean age, 33.2 years). On the basis of the proposed measuring technique, there was 88% interobserver measurement agreement with MR imaging (95% confidence interval [CI]: 80%, 94%) and 93% with CT (95% CI: 84%, 98%). The median difference between measurements of cap thickness at CT and MR imaging was 0 cm (25th and 75th percentiles, -3 mm and 1 mm, respectively). With 2 cm used as a cutoff for distinguishing benign osteochondromas from chondrosarcomas, the sensitivities and specificities were 100% and 98% for MR imaging and 100% and 95% for CT, respectively.The proposed measuring technique allows accurate and reproducible measurement of cartilage cap thickness with both CT and MR imaging. Cap thickness of 2 cm or greater strongly indicated secondary chondrosarcomas.

In the United States, unintentional injury, homicide, and suicide are the first, second, and fourth leading causes of death among persons aged 1-19 years, respectively; the highest rates have occurred among minority populations. The effects of age on the difference in rates between white and minority children and the mechanisms of injury that contribute most to that difference have not been previously reported.Data are presented for fatal injuries among children in the United States by race/ethnicity and mechanism of injury during 1999-2002. Trends in injury mortality by race/ethnicity are provided for 1982-2002.Fatal injury data were derived from death certificates reported through CDC's National Vital Statistics System.During 1999-2002, among infants aged1 year, American Indian/Alaska Natives (AI/ANs) and blacks had consistently higher total injury death rates than other racial/ethnic populations. Both populations had more than twice the rate of injury death compared with white infants. Black infants had the highest rates of unintentional suffocation and homicide, whereas AI/AN infants had the highest rate of motor-vehicle (MV)-traffic death. Among children aged 1-9 years, AI/ANs and blacks had the highest injury death rates. AI/ANs aged 1-9 years had the highest rates of MV-traffic death and drowning; in contrast, blacks aged 1-9 years had the highest rates of homicide and fire/burn death. Among children aged 10-19 years, AI/ANs and blacks consistently had higher total injury death rates than whites. AI/ANs aged 10-19 years had the highest rates of suicide and MV-traffic death, and blacks aged 10-19 years had the highest rates of homicide. The disparity in injury mortality rates by race/ethnicity during 1982-1985 had not declined by 1999-2002.Significant disparities in injury rates still exist between white and minority children. Disparities varied by age and mechanism of injury. Hispanics and Asian/Pacific Islanders consistently had lower risk, whereas AI/ANs and blacks consistently had higher risk for fatal injuries than other racial/ethnic populations.Educational, regulatory, and environmental modification strategies (e.g., home visitation programs, safety-belt laws, and swimming pool fencing) have been developed for each type of injury for use by health-care providers and government agencies.