Search

The use of ionising radiation for plain film radiography and computerised tomography is fundamental in both diagnostics and treatment for orthopaedics. However, radiation is not without risk as high exposure can increase the risk of cancer. Little time is spent educating doctors about the relative risks of radiation, both to patients and themselves. In addition, there are common misunderstandings about the best ways to mitigate such risk. We aim to provide an overview of the fundamental principles of the use of ionising radiation and its risks within the context of orthopaedic surgery. While providing a narrative review of the current literature, we discuss the basic physics, standards of good practice and relevant UK and European regulations. We discuss the risks to patients and surgeons and suggest ways that these can be mitigated in the operating theatre. A thorough understanding of the risks, and appropriate procedural rules, with respect to the use of ionising radiation is essential for those in orthopaedic practice.

Objective To evaluate the findings of magnetic resonance imaging (MRI) of the ipsilateral hip(s) as part of the workup of men with chronic orchialgia (CO). Methods Following IRB approval, a retrospective chart review was performed from a single surgeon database of all men with a diagnosis of CO from June 2018 to October 2019 who underwent subsequent hip MRI evaluation. Results Ten men were identified. Median age was 51 years and median duration of pain was 10 months. MRI was obtained after testis pathology was ruled out. Pain was noted in the groin (100%) and hip (50%). Hip MRI identified overt labral tears in 8 men (10/12 hips evaluated, 83%) and labral fraying in the remaining 2 (16.7%). Standard plain film radiography was performed in 6 men prior to MRI, all of which were negative. Following MRI, 5 men underwent hip injection with steroid and local analgesic with lasting resolution (2 men) or significant improvement in pain (2 men; 80%, follow-up 3-15 months). Two men had complete resolution of pain with 8 weeks of physical therapy. Conclusion Hip MRI has a high rate of diagnosis of labral tear in appropriately selected men referred to the urologist for CO. Identification of orthopedic pathology may avoid unnecessary antibiotics, opiates, or urological surgery. Referrals to orthopedics and/or physical therapy for intervention may lead to resolution of pain.

Highlights • Osteochondral patella fractures commonly associated with soft tissue injuries. • We report a rare case of a child with isolated osteochondral patella fracture. • Open reduction and internal fixation of the dicplaced fragment was successful with good outcome., Introduction Osteochondral fracture of the patella is a fairly common pathology, but almost always associated with a spectrum of soft tissue injuries including anterior cruciate ligament (ACL) rupture. We present a rare case of an osteochondral fracture of the patella in the absence of ligament or soft tissue injuries and with no dislocation of the patella in a pediatric patient. Presentation of case An 11-year-old male presented to the orthopedic clinic on crutches following a football injury. The patient had pain in his left knee with flexion deformity. Plain film radiography of the left knee was taken, and an osteochondral fracture of the patella was suspected. Further imaging studies were conducted including computed tomography (CT) and magnetic resonance imaging (MRI) which revealed an isolated osteochondral fracture of the patella with no other associated injuries. Open reduction and internal fixation of the displaced fragment was successfully preformed with favorable outcomes. During follow-up, almost full range of motion was regained, and plain film radiography revealed healed fracture with a normal appearance of the patella. Discussion Traumatic osteochondral fracture of the patella is a common injury and most of these injuries are commonly accompanied by an acute dislocation of the patella or soft tissue injuries such as rupture of the anterior cruciate ligament (ACL) and almost half of all patellar dislocations incidence are associated with osteochondral fractures of the patella. This case had an isolated osteochondral fracture of patella. Conclusion As demonstrated in this case, osteochondral fractures are common among younger population and patients need to be thoroughly evaluated. Advanced Imaging such as MRI and CT are essential to exclude soft tissue injuries. Although management is highly variable, the importance of open reduction and early fixation should be emphasized for optimal outcomes.

Study Design: Efficacy study. Objectives: To elucidate the limitations of radiography in patients with spinal ankylosing disorders (SAD) with an emphasis on thoracolumbar injuries, which have been less focused upon. Methods: We searched our hospital’s emergency room database for patients who underwent a total spine computed tomography (CT) following a diagnosis of SAD on radiographs following a minor fall. A high-quality presentation containing 50 randomly situated anteroposterior + lateral radiographs was created. Of these, 24 contained a hyperextension type fracture diagnosed by CT. Twelve physicians—4 spine surgeons, 4 senior orthopedic residents and 4 junior orthopedic residents were requested to identify the pathologic radiographs and note the fracture level. Results: Fracture diagnosis stood at 65% for the best reader. When examining the different subgroups, the mean rate of diagnosis for spine surgeons was 55% and for orthopedic residents 32%. Mean diagnosis of thoracic fractures was 26%, of lumbar fractures was 55%, and for the entire thoracolumbar spine was 40%. The interobserver agreement (kappa coefficient) was found to be 0.37 for the entire group and 0.39 for spine surgeons. This finding was statistically significant. Conclusions: The simple radiograph is an inefficient modality for diagnosis of hyperextension type thoracolumbar fractures in patients with SAD. The poor interobserver agreement rate further amplifies this finding. Advanced imaging is recommended in these patients.

Pachydermodactyly is an uncommon, progressive, nontender thickening of the fingers with prominent involvement of the proximal interphalangeal joints. Pachydermodactyly mimics inflammatory arthritis but plain film radiography is normal in this condition. Pachydermodactyly has been previously described in workers performing manual labor. Mechanical stimulation has been identified as a predisposing factor in the majority of cases. We present three cases in adolescent males arising in association with excessive computer gaming.

Background We present a case of a 83-year-old man with a prior history of coronary artery bypass who presented to his family physician with progressive symptoms that raised concern for heart failure exacerbation. A chest X-ray was performed, which showed a fractured topmost sternal wire in the lateral projection and indicated that the sternal wire had migrated into the anterior mediastinum. An emergent electrocardiogram-gated flash computed tomography angiography confirmed the location of the fractured wire to be in close proximity to the main pulmonary artery. A discussion of migrated sternal wires with a literature review of cases is provided as well. Aims To present a case of a migrated sternal wire and a literature review. Methods An extensive literature review using pubmed and medline with relevant keywords was preformed. Results 11 known cases of migrated sternal wires with various complications, as detailed in the review table. The mortality rate is low but can be associated with significant morbidity. Discussion Fractured wires are quite common and are usually a benign radiographic finding. However, migration of sternal wires is an extremely rare phenomenon. Only a few reported cases in the literature were sternal wires have migrated beyond the sternum, leading to catastrophic clinical consequences, as detailed in the review table. Conclusion Sternal wire complications secondary to migration beyond the sternum are rare but potentially fatal. Precise wire location and risk assessment with CT are more appropriate when wire location cannot be clearly delineated by plain film radiography.

Oral lesions of myxomatous origin are relatively rare and include nerve sheath myxomas, soft tissue myxomas, oral focal mucinosis, and odontogenic myxomas. These lesions have a common histologic appearance of abundant myxoid ground substance. A 61-year-old edentulous female presented with nasal stuffiness since the past 4 months. Clinical examination revealed an asymptomatic intraoral swelling in the edentulous maxillary ridge which had ulcerated. Plain film radiography and CT showed an expansile osteolytic lesion involving the right maxillary sinus. A partial maxillectomy was performed and direct microscopy showed a predominant embryonic mesenchymal stroma with fibroblasts and calcifications suggestive of a myxoma. The central myxoma is hypothesized to originate from the odontogenic apparatus due to its almost exclusivity to the jaw bones. However, when a central myxoma occurs in an edentulous jaw at an age when the odontogenic apparatus is apparently nonfunctional, explaining the genesis of this unique tumor based on present understanding becomes difficult. We present one such case while reviewing the existing literature on the present concepts of pathogenesis.

Objective Bone impaction (BI) is a common cause for emergency room visits. Among foreign bodies, fish bone is considered the most common. The sensitivity of symptoms in predicting BI is relatively low, making imaging a central tool to aid diagnosis. Current imaging practices include both neck plain film radiography and none-contrast CT scans of the neck. We evaluated the accuracy of neck plain film radiography and CT scans of the neck for the diagnosis of BI. Methods Retrospective review of all patients who presented to the emergency room between 2009 and 2016 with a suspicious history of BI whom underwent plain film neck radiography or CT. All Images were reviewed by two neuro-radiologist blinded to the clinical symptoms and findings. Symptoms, clinical findings and images results were compared to the final diagnosis. Results 89 patients (30.7%), out of 290 patients who presented with complaints of BI, were diagnosed with BI. Mean age was 44.7 years old. Plain film neck radiography failed to predict BI (sen. 14.4%, spe 89.8% accuracy 63.2%), neck CT has an improved accuracy and sensitivity in locating BI (sen. 83.3%, spe. 94.1% accuracy 92.5%). Interobserver agreement between the two neuro-radiologists was moderate (0.46) and substantial (0.77) in neck radiography and CT images, respectively. Neck radiography missed 60 (out of 61) oropharyngeal BI's. Conclusion Neck radiography has high inter-observer variability and low sensitivity for the diagnosis of BI. Neck CT should be the first imaging modality in patients with suspicious complaints for BI and negative physical exam.

Low back pain (LBP) is a common health issue worldwide with a huge economic burden on healthcare systems. In the United States alone, the cost is estimated to be $100 billion each year. Intervertebral disc degeneration is considered one of the primary causes of LBP. Moreover, the critical role of the vertebral endplates in disc degeneration and LBP is becoming apparent. Endplate abnormalities are closely correlated with disc degeneration and pain in the lumbar spine. Imaging modalities such as plain film radiography, computed tomography, and fluoroscopy are helpful but not very effective in detecting the causes behind LBP. Magnetic resonance imaging (MRI) can be used to acquire high-quality three-dimensional images of the lumbar spine without using ionizing radiation. Therefore, it is increasingly being used to diagnose spinal disorders. However, according to the American College of Radiology, current referral and justification guidelines for MRI are not sufficiently clear to guide clinical practice. This review aimed to evaluate the role of MRI in diagnosing LBP by considering the correlative contributions of vertebral endplates. The findings of the review indicate that MRI allows for fine evaluations of endplate morphology, endplate defects, diffusion and perfusion properties of the endplate, and Modic changes. Changes in these characteristics of the endplate were found to be closely correlated with disc degeneration and LBP. The collective evidence from the literature suggests that MRI may be the imaging modality of choice for patients suffering from LBP. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY STAGE: 3.

Objectives: To prevent aesthetic and functional deformities, precisely closed reduction is crucial in the management of nasal fractures. Plain film radiography (PF), ultrasonography (USG), and computed tomography can help confirm the diagnosis and classification of fractures and assist in performing closed reduction. However, no study in the literature reports on precisely closed reduction assisted with PF measurements under the picture archiving and communication system (PACS). Methods: We retrospectively evaluated 153 patients with nasal bone fracture between January 2013 and December 2017. Surgeons conducted precisely closed reduction assisted with PF measurement of the distance between the fracture site and nasal tip under PACS on 34 patients (group A). Another group on 119 patients were reduced under surgeon’s experience (group B). Results: No significant differences in age, gender, Arbeitsgemeinschaft fur Osteosynthesefragen (AO) classification, and reduction outcome were observed between group A and group B ( P > .05). The operative time of the group A was significantly lower (12.50 ± 4.64 minutes) compared to group B (23.78 ± 11.20 minutes; P < .001). After adjusted age, gender, and AO classification, patients in group A scored 10.46 minutes less on the operative time than those in group B ( P < .001). In addition, the severity of nasal bone fracture (AO classification, β = 3.37, P = .002) was positive associated with the operative time. Conclusions: In this study, closed reduction in nasal bone fracture assisted with PF measurements under PACS was performed precisely, thereby effectively decreasing operative time and the occurrence of complications. This procedure requires neither the use of new instruments or C-arm nor USG or navigation experience. Moreover, reduction can be easily performed using this method, and it requires short operative time, helps achieve great reduction, less radiation exposures, and is cost-effective.

This is the case of a 9-month-old female infant who presented to the emergency department with a history of several episodes of nonbilious and nonbloody emesis. The patient was found to be afebrile with normal vital signs and an otherwise normal physical examination. Initial plain film radiography was concern for possible obstruction. Imaging studies with ultrasonogram demonstrated intussusception. This was an unusual case of intussusception because children are typically more ill-appearing with vomiting, diarrhea, fevers, lethargy, and blood in stool. Management options included surgery, pneumatic enema reduction, and barium enema reduction. Pneumatic enema reduction was performed. This procedure has been shown to have superior outcomes in infants with intussusception. Advanced practice providers need to provide a detailed history, complete a thorough physical examination, order the appropriate diagnostics, and be vigilant of the clinical manifestation of intussusception.

Missed fractures are common in pediatric trauma patients. Pediatric bone differs from adult bone in its composition and response to injury, leading to fracture patterns that may be subtle, radiographically unfamiliar, and challenging to distinguish from normal variation. Familiarity with the unique fracture types of the pediatric skeleton and site-specific injury patterns is critical, because prompt diagnosis can significantly alter clinical management and outcome. This article examines the unique features of pediatric bone contributing to missed fractures, the incidence of missed fractures, common injury types of the pediatric skeleton, and frequently missed site-specific fracture patterns, highlighting problem-solving techniques for challenging cases.

A male infant is born at 30 weeks’ gestation via cesarean section to a 36-year-old gravida 4, para 4 woman. The antenatal course had been significant for in vitro fertilization and dichorionic-diamniotic twin pregnancy and gestational diabetes. Prenatal screening laboratory findings are normal. The patient has a birthweight of 1,635 g, with initial Apgar scores of 4 and 8. He has increased respiratory effort in the delivery room requiring resuscitation with continuous positive airway pressure (CPAP), 30 seconds of positive pressure ventilation, and supplemental oxygen. He is admitted to the NICU with the administration of CPAP but because of persistent work of breathing and respiratory acidosis, with a pH of 7.04 and Pco2 of 93 mm Hg (12.4 kPa), he undergoes intubation and receives surfactant for presumed respiratory distress syndrome. During intubation, it is noted that the infant has a tight airway with difficulty inserting a 3.0 endotracheal tube. It is also noticed that while cricoid pressure is being applied there are popping sounds as the tube is advanced. Chest radiography (Fig 1) shows calcifications extending proximal from the thoracic inlet to the mainstem bronchi and fading off at the level of the segmental airway. Subsequent computed tomography (Figs 2 and 3) shows long-segment tracheal, mainstem bronchi, and intermediate bronchus stenosis matching all sites of cartilage ring calcification. Plain film radiography shows abnormal stippling and calcification in the spine, hip, knee, and pelvis. Stippling of the femoral head is displayed in Fig 4. Figure 1. Chest radiograph. Figure 2. Computed tomography scan with 3-dimensional reconstruction. Figure 3. Lateral computed tomography scan. Figure 4. Left femur radiograph. Physical examination findings are unremarkable. He is …

This article summarises the clinical decision tools available to help decide when acute lower limb joint injuries should be referred for plain film radiography. The Ottawa foot and ankle rules are a tool for deciding whether to refer a patient for X-ray or not. The rules are highly sensitive, gaining National Institute for Health and Care Excellence recommendation in the UK, although they have limited benefit in some patient groups, such as those with peripheral neuropathy. The Ottawa knee rules are highly sensitive but less specific than the Pittsburgh decision rules. Although the Pittsburgh rules are more specific, they have been less extensively investigated and, unlike the Ottawa rules, are not National Institute for Health and Care Excellence recommended. A major barrier to use of these rules in clinical practice is the concern of litigation, although National Institute for Health and Care Excellence recommendation should reassure clinicians and thus reduce the amount of unnecessary radiation exposure.

This case report presents a lipofibromatous hamartoma of the median nerve in a 31-year-old man who presents local deformity and a sensory deficit in the nerve territory. The tumor was evaluated with magnetic resonance, computed tomography, and plain film radiography, studying the pathognomonic findings of this tumor. The patient did not want surgical treatment because of prior surgical sequelae. A prior surgical biopsy was reported as a peripheral nerve with normal axonal fascicles surrounded by abundant fibroadipose tissue. This tumor has a low incidence with less than 180 cases reported in the literature., {"references":["Al-Jabri T, Garg S, Mani GV. Lipofibromatous hamartoma of the median nerve. J Orthop Surg Res. 2010;5:71. doi: 10.1186/1749-799X-5-71.","Toms AP, Anastakis D, Bleakney RR, Marshall TJ. Lipofibromatous hamartoma of the upper extremity: a review of the radiologic findings for 15 patients. AJR Am J Roentgenol. 2006;186: 805-11. doi: 10.2214/AJR.04.1717.","Tahiri Y, Xu L, Kanevsky J, Luc M. Lipofibromatous hamartoma of the median nerve: a comprehensive review and systematic approach to evaluation, diagnosis, and treatment. J Hand Surg Am. 2013;38:2055-67. doi: 10.1016/j.jhsa.2013.03.022.","Nilsson J, Sandberg K, Søe Nielsen N, Dahlin LB. Magnetic resonance imaging of peripheral nerve tumours in the upper extremity. Scand J Plast Reconstr Surg Hand Surg. 2009;43:153-9. doi: 10.1080/02844310902734572.","Nardella D, Sohawon S, Carlier A. Lipofibromatous hamartoma of the median nerve. Three case reports. J Plast Reconstr Aesthet Surg. 2009;62 :e314-7. doi: 10.1016/j.bjps.2007.11.061.","Cavallaro MC, Taylor JA, Gorman JD, Haghighi P, Resnick D. Imaging findings in a patient with fibrolipomatous hamartoma of the median nerve. AJR Am J Roentgenol. 1993;161:837-8. doi: 10.2214/ajr.161.4.8372770.","Kara M, Ozcakar L, Ekiz T, Yalçın E, Tiftik T, Akyüz M. Fibrolipomatous hamartoma of the median nerve: comparison of magnetic resonance imaging and ultrasound. PM R 2013;5:805-6. doi: 10.1016/j.pmrj.2013.03.026.","Okechi H, Dimostheni A, Kerscher SR, Gugel I, Bevot A, Schaefer JF, et al. Fibrolipomatous hamartomas of the median nerve in infancy and early childhood-imaging hallmarks, symptomatology, and treatment. Eur J Pediatr. 2018; 177 :567-73. doi: 10.1007/s00431-018-3100-7.","Giuliano V, Outwater EK, Mitchell DG, Burke MA. Median nerve hamartoma: MR imaging using chemical shift techniques. Magn Reson Imaging. 1997;15:1091-4. doi: 10.1016/s0730-725x(97)00155-0."]}

Introduction: At present, there exists no standardized curriculum for the interpretation of plain film radiography for emergency medicine (EM) training programs that have been adopted by an accrediting body. Education geared towards plain film interpretation is highly variable and institutionally specific. This highly variable education is dependent upon institutional resources, availability of real-time radiology interpretations, formalized radiology instruction, in addition to self-directed study. Furthermore, it is unclear whether the presence of a radiology residency program at the same institution will positively or negatively impact the radiographic education of the EM resident. In a community practice setting, EM providers may encounter several scenarios in which they must rely on their own independent interpretations during radiology coverage gaps. The goal of this study was to assess whether the amount of formal radiology training correlates with the confidence in the interpretation of radiographs following residency graduation early in a junior attending’s career. Methods: A survey study with 14 questions was distributed to EM attendings utilizing social media. Over a two-month period, 218 responses were obtained and statistical analysis was performed utilizing a chi-square test. Three survey questions with multi-variable answers were compressed into two variables for statistical analysis. Results: Only 30% of survey participants indicated universal radiology coverage; 30% also responded that they did not feel prepared to interpret plain film radiographs upon residency completion. There were four statistically significant factors associated with higher confidence in interpreting radiographs upon residency graduation. Physicians were more likely to feel confident in reading radiographs if they (1) graduated from a program with no radiology residency present, (2) if their residency was located in a non-tertiary training facility, (3) if most of their radiograph learning occurred on shift and (4) if they made clinical decisions based on their own interpretations frequently. 40% of physicians reported they were more confident currently in interpreting radiographs than when they first completed residency. Conclusion: Steps should be taken to ensure that graduating residents are being prepared to interpret plain film radiographs as many providers will be required to do so independently in future practice. Emphasis should be focused towards on-shift teaching of these skills. Graduates at greatest risk of lower confidence train at large tertiary care centers with concomitant training of radiology residents. By emphasizing on off-shift strategies for the interpretation of plain film radiographs, residents will build confidence and develop the ability to perform these necessary skills early in one's career.

Over the past 125 years, medical imaging has advanced from simple plain film radiography to advanced, multi-modality functional imaging. Throughout that time researchers have leveraged the technology to gain new insights into chest diseases and identify findings correlated with specific patient phenotypes, thereby enabling the ever more precise application of medical care. In this chapter we detail this history and focus on how chest imaging in particular has expanded on the “signs and symptoms” approach to medicine and provides detailed information that enables the personalization of care for chest diseases.

Cilj: Istaknuti nedostatke standardnog radiograma pri obradi ozljede vratne kralježnice, posebice u visokorizičnih pacijenata u kojih je zbog patoanatomskih promjena ova dijagnostička pretraga otežana (ankilozantni spondilitis, stenoza spinalnog kanala i osteoporoza). Prikaz slučaja: Prikazali smo obradu ozljede vratne kralježnice u dva visokorizična pacijenta (osteoporotičnog te pacijenta s ankilozantnim spondilitisom). Prijelomi vratne kralježnice češći su u te dvije skupine i mogu nastati blažim padom. Mehanizam ozljede je u oba slučaja bio pad sa svoje visine. Inicijalni neurološki pregled kod oba pacijenta bio je uredan, tek je odgođeni pregled ukazao na neurološki deficit: u prvom slučaju nekoliko sati nakon ozljede, a u drugom slučaju devet dana nakon ozljede. U oba slučaja ozljeda vratne kralježnice bila je dijagnosticirana naknadno učinjenim MSCT-om vratne kralježnice. Zaključak: S obzirom na potencijalno opasne posljedice neprepoznate i neliječene ozljede vratne kralježnice, htjeli smo naglasiti potrebu za daljnjim istraživanjem i kreiranjem adekvatnog algoritma za visokorizične pacijente. Zbog svoje visoke specifičnosti i senzitivnosti, MSCT bi trebao biti metoda izbora pri dijagnosticiranju ozlijede vratne kralježnice u toj grupi pacijenata., Aim: to emphasize the deficiencies of plain film radiographs in the evaluation of cervical spine injuries especially in high-risk patients in which this diagnostic procedure is inadequate due to pathoanatomical changes (ankylosing spondilytis, spinal canal stenosis and osteoporosis). Case report: We presented the evaluation of cervical spine injury in two high risk groups (osteoporotic patient and patient with ankylosing spondilytis). Spinal fractures are more common in those two groups and can result from a simple fall. The mechanism of injury in both cases was falling from its height. Initial neurological status was normal, only secondary approach revealed neurological deficit; in 1. case couple of hours after injury and in 2. case nine days after injury. In both cases, MSCT revealed cervical spine fracture. Conclusion: Considering the potential severe consequences of unrecognized and untreated injuries, we wanted to emphasise the need for further research and implementation of appropriate evaluation algorithm in high-risk patients. Due to its high specificity and sensitivity, MSCT should be the method of choice in diagnosing cervical spine fracture in this group of patients.

The type of injury in ankle joint depends on force levels as it receives. Internal rotational forces can bring about medial and lateral malleolus fracture and osteochondral fractions of the talus (Fig. 19.1) [1]. Plain film radiography and CT reveal significant diagnostic values in fracture diagnosis and location (Fig. 19.2) and MRI in ankle ligament damage (Fig. 19.3) [2, 3].

Pediatric osteochondral fracture dislocation of the patella is sometimes difficult to diagnose on the basis of physical examination or plain film radiography. Magnetic resonance imaging plays an important role in its early diagnosis, and early treatment can prevent damage to the articular cartilage as well as decrease the dislocation rate. Currently, many treatment choices have been reported with good results, but there is no consensus on which treatment option may lead to the best outcome. Herein, we describe the case of a 14-year-old girl with neglected osteochondral fracture dislocation of the patella. The outcome was optimal on the basis of a 2-year postoperative follow-up; thus, we believe that fixation with headless screws is a simple and effective method if the fracture fragment is large enough.

BACKGROUND Early diagnosis and treatment of rheumatoid synovitis can reduce the progression of rheumatoid arthritis (RA). However, in the early stages of rheumatoid synovitis, patients may only have non-specific musculoskeletal symptoms, and plain film radiographs may not detect early synovial changes. The aim of this study was to compare the sensitivity and specificity of ultrasound with radiography, and clinical investigations in the detection of rheumatoid synovitis in patients presenting with nonspecific musculoskeletal symptoms. MATERIAL AND METHODS This was a non-randomized, cross-sectional, clinical study that included 189 patients who had nonspecific musculoskeletal symptoms. All patients underwent clinical investigations, postero-anterior and dorsal radiographic imaging, and bilateral grey-scale ultrasound examinations of the third and second metacarpophalangeal (MCP) joints, the third and the second proximal interphalangeal (PIP) joints, the second and the fifth metatarsophalangeal (MTP) joints, and the wrist. RESULTS There was no clear predictive value for detection of early synovitis by clinical investigations alone. Plain film radiography of patients only provided accurate information of joint erosions but less information for synovitis. Grey-scale ultrasound was more effective at detecting early synovitis compared with clinical investigations (p=0.00015; q=4.548) and compared with plain film radiography (p=0.0002; q=4.537), and quantified the synovial changes. The predictive values of plain film radiography and clinical investigations had 0.43 and 0.24 sensitivity and 0 specificity compared with ultrasound. CONCLUSIONS The findings of this study support the use of grey-scale ultrasound in the detection of early rheumatoid synovitis of the fingers and the wrist.

Radiological imaging plays a central and invaluable role in the assessment and management of patients with suspected shoulder pathology. Whilst conventional plain film radiography remains the first-line investigation of choice, limitations with its ability to evaluate the soft tissue structures means that it is usually supplemented with ultrasound and/or MRI. The following article reviews common and uncommonly encountered shoulder pathologies and their respective imaging findings, with a specific focus on their ultrasound and MRI appearances.

Imaging plays a vital role in the diagnosis and management of rheumatological disorders. Traditionally, plain film radiography was widely used in arthropathies to assess periarticular bony changes; these often reflect established changes in the late stage of disease and thus have limited value in early diagnosis and disease monitoring. Magnetic resonance imaging (MRI) has become an important imaging modality in rheumatological disorders because it can assess both morphological and functional changes. It plays a substantial role in early diagnosis, monitoring of disease evolution, assessment of treatment responses and prognostication. More recently, advances in hardware and novel imaging sequences have aided the development of new MRI techniques: whole-body MRI, for example, is gaining in popularity and allows an assessment of overall inflammatory status in arthritis. Quantitative MRI shows promise in allowing more objective evaluation and standardization of imaging-based assessment of inflammatory arthritis. This article also discusses other emerging imaging techniques. These include high-resolution peripheral quantitative computed tomography in early detection and monitoring of periarticular bone damage, fluorescence optical imaging in visualizing active inflammation, and molecular imaging in investigating pathogenesis and disease evaluation on a cellular level.

Objectives: The purpose of this pilot study was to obtain an Australian perspective on evaluating the utility of plain film radiography and computed tomography (CT) to rule out fish bone impaction in the upper aerodigestive tract in the emergency department (ED) setting. Methods: A retrospective multicentre cohort study was conducted. A total of 73 patients met the inclusion criteria. A subgroup of patients underwent CT. We studied the sensitivity and specificity of x-ray and CT along with other demographic variables to determine the likelihood of true fish bone impaction. Results: Out of the 73 patients, 28 patients had true bone impaction. The sensitivity for x-ray was 42.9% and specificity was 73.3%. The sensitivity of CT was 87.5% and specificity was 71.4%. We found a significant difference in the mean age of presentation for true bone and false bone impaction, P = 0.02. Conclusion: Due to the low sensitivity of x-ray we do not recommend the utilisation of plain film radiography to rule out bone impaction Advances in low dose radiation multidetector CT scanners may replace plain film radiography as a screening tool.

Tonsilloliths are infrequent calcified concretions that develop in tonsillar crypts within the parenchyma of the tonsils or surrounding it. They are typically single and unilateral, but rarely may be numerous or bilateral. Large tonsilloliths can mimic many conditions including abscesses or neoplasms. It is difficult to diagnose tonsilloliths unless there is a considered emphasis on thorough history taking, careful inspection, and a detailed characterization of the lesion through digital palpation. This may be further supplemented with investigations such as plain film radiography and/or 3D imaging. Here, we present a case of asymptomatic tonsillolith where the patient presented for a painful tooth in mandibular anterior region and was incidentally diagnosed as having with a large tonsillolith on right side of posterior mandible.

Objective This study aims to define a reliable protocol for radiographic identification of placement and tip foldover of newly designed precurved and straight electrodes. Study Design Prospective imaging study. Setting Academic institution. Methods Three models of cochlear implants (Cochlear, MED-EL, and Advanced Bionics) were inserted into fresh cadaveric specimens (n = 2) in 3 configurations (normal positioning in the scala tympani, intracochlear tip foldover, and placement into the vestibular system) for a total of 9 implant scenarios. Specimens were imaged with plain radiography in Stenvers projection, as well as by high-resolution computed tomography. Results Electrode placement and presence or absence of electrode tip foldover were easily identified in all 9 scenarios on plain radiography based on the described technique. Each was confirmed with high-resolution computed tomography. Plain film temporal bone images of new electrode designs with proper and improper placement are provided for reference. Conclusion A defined protocol for intraoperative plain film radiography allowed for reliable imaging of 3 newly designed cochlear implant electrodes and immediate identification of extracochlear placement and tip foldover. Findings may be used for intraoperative confirmation of electrode array placement.

Background A 65-year-old woman presented to the oral maxillofacial department with a nonhealing oral antral fistula. Radiographic examination revealed opacification of the left maxillary antrum and an ill-defined radiolucency in the maxilla. The patient continued to develop further osteolytic lesions in the skull and mandible, leading to anesthesia of the third division of the trigeminal nerve. Objective To discuss the clinicopathological correlation, differential diagnosis, and pathway to achieving a definitive diagnosis in this challenging case. Results Clinical symptoms included a history of fatigue, painful joints, and chest pain. Multiple biopsies taken from the osteolytic lesions of the mandible, maxilla, and a supraclavicular lymph node revealed naked noncaseating granulomas. Computed tomography (CT) of the head and neck revealed an irregular, diffuse, mottled appearance of the bone in the left maxillary alveolus, right mandible, and left temporal bone. Angiotensin-converting enzyme and serum calcium levels were normal. CT scans showed hilar lymphadenopathy, which was not visible on plain film radiography. Exclusion of other causes of granulomatous inflammation eventually led to a diagnosis of sarcoidosis. The patient has been discussed at a multiple disciplinary team meeting and referred to a specialist team. Conclusions Sarcoidosis is a chronic multisystem granulomatous disease characterized histologically by naked noncaseating granulomas. It has an unknown etiology and no pathognomonic diagnostic test, making definitive diagnosis difficult. This patient presented with rare and aggressive features appearing initially to be from the maxillary antrum, eventually affecting the jaws and skull with only subtle symptoms of the more cardinal features of the disease.

The health care system is becoming more technological, and at the same time, it is verbalized that the patient should be in the center. The purpose of this study was to illucidate how radiography with the patient in the center is performed and what patients and radiographers understand about center in radiography. Qualitative methods was used; observations of three MR scans and interviews with three patients and three radiographers are discussed. In the description of an MR scan, it appeared that more elements are involved and that each element has a center of equal importance to complete the MR scan. Several of these elements have a technical focus. There are relations in an MR scan affecting which actions are included in the scan pathway. However, it is the radiographers who decide which actions to include. Patients and radiographers in this study agreed that center in radiography is about directing focus and attention to the patient. Problems arise when more elements in the MR scan have a technical focus demanding attention and action; the humanistic element can be included and centered but not be in the center.

Lesions involving the outer cortical surface of the bone occur quite often among children. Broadly, these include benign cortical, juxtacortical and periarticular lesions, dysplasias affecting the cortical bone, regional and diffuse periosteal pathology and malignant tumours. Some of these lesions are unique to the paediatric population; others are more frequently seen among children than adults — yet others have an adult predilection but can occasionally be seen in children. A complete list of differential considerations for lesions involving the outer cortical surface of the bone in children is presented. Imaging characteristics on plain film radiography and MR are described in association with multiple examples and illustrations. A pictorial review detailing the imaging features of surface lesions of the bone in children will be a useful aide for both radiologists and their clinical colleagues, and will help them sort their way through the maze of differential diagnoses for these abnormalities. Teaching Points • Surface lesions of bones in children comprise a distinct entity and differ from those in adults. • Imaging plays an important role towards classifying surface lesions of bones in children. • MRI features may be characteristic and aid precise diagnosis, thus guiding further management.

Diagnostic imaging of the TMJ has evolved rapidly since the early days of plain film radiography. This chapter is devoted to soft tissue imaging techniques that do not involve ionizing radiation, MR, and ultrasound.

Endotracheal and tracheostomy tubes are defined and discussed in detail, including the nuances of each device, including atypical tubes, such as dual-lumen endotracheal tubes. Optimal positioning is emphasized, as is the evaluation for such on plain film radiography. Complications of malpositioned tubes are discussed, as well as the remediation and treatment for such sequela, including bronchial intubation and tracheal erosion.

We examined scapula glenoids (n = 14) and proximal articular humeri (n = 14) of seven gray wolves that were maintained in a sanctuary park setting. Immediately after death, observations were made visually in situ and by radiography. Further observations were made in a museum laboratory setting, prior to and following clearing of soft tissues. Selected dry bone specimens were evaluated using computed tomography. Significant cartilage erosion and osteoarthropathy were identified in all shoulder joints. No single evaluation method yielded maximal information. Plain film radiography revealed only more severe changes. Computed tomography yielded more detail and clarity than standard radiography. Direct examination of articular cartilage informed about joint soft tissue, and dry bone informed about externally visible bone pathology. These data provide a basis for biological, biomedical, ecological, and archaeological scientists to improve retrospective interpretations of bone lesions. They further support developing plausible differential diagnoses for features of ancient and modern animal bones. We noted a dog-like capacity for wolf longevity in a non-free-roaming environment. However, aged wolves' life spans far exceeded those of similar-sized domestic dogs and breeds, suggesting the possibility of an important species difference that should be explored. We suggest also a hypothesis that the driving force for joint pathology in sheltered non-domestic species may relate significantly to achieving the longevity that is possible biologically, but is uncommon in the wild because of differential stochastic influences. Anat Rec, 299:1338-1347, 2016. © 2016 Wiley Periodicals, Inc.

Carpal instability is a complex and heterogeneous clinical condition. Management requires accurate identification of structural injury with an understanding of the resultant movement (kinematic) and load transfer (kinetic) failure. Static imaging techniques, such as plain film radiography, stress views, ultrasound, magnetic resonance, MR arthrography and computerized tomography arthrography, may accurately depict major wrist ligamentous injury. Dynamic ultrasound and videofluoroscopy may demonstrate dynamic instability and kinematic dysfunction. There is a growing evidence base for the diagnostic accuracy of these techniques in detecting intrinsic ligament tears, but there are limitations. Evidence of their efficacy and relevance in detection of non-dissociative carpal instability and extrinsic ligament tears is weak. Further research into the accuracy of existing imaging modalities is still required. Novel techniques, including four-dimensional computerized tomography and magnetic resonance, can evaluate both cross-sectional and functional carpal anatomy. This is a narrative review of level-III studies evaluating the role of imaging in carpal instability.

Orthopedic surgeons frequently encounter short statured patients. A systematic approach is needed for proper evaluation of these children. The differential diagnosis includes both proportionate and disproportionate short stature types. A proper history and physical examination and judicious use of plain film radiography will establish the diagnosis in most cases. In addition to the orthopedic surgeon, most of these patients will also be evaluated by other specialists, including endocrinologists and geneticists. This article provides an overview of the evaluation of the child with short stature and offers several illustrative examples.

Rationale: Coracoid processes (CPs) fracture with acromioclavicular (AC) joint dislocation are extremely rare. This combined injury has brought many challenges to surgeons, and the mechanism underlying the injury is still not fully understood. There is no clear consensus on its treatment. Patient concerns: Here, we describe a CP fracture with AC joint dislocation in a middle-aged manual worker. Diagnosis: Radiographs showed a fracture of the base of the CP and a third-degree AC joint separation. Interventions: The patient was treated surgically with open reduction and internal fixation of the AC joint by LCP clavicle hook plate, and the CP was fixed with a 3.5 mm diameter cannulated screw. Outcomes: Three months after the operation, shoulder function was completely restored, and the affected shoulder had full mobility with no tenderness. Plain film radiography showed anatomical indications of the healing of these combined injuries. Lessons: Although AC joint dislocation with CP fractures is extremely rare in adults, it is important to remind and remember that this possibility exists. In unclear cases, special radiographic films and CT are necessary. Surgical treatment of AC joint dislocation with CP fractures can provide solid stability and restore normal shoulder function with an excellent prognosis.

Genial tubercle fracture (GTF) is rare and represents a diagnostic challenge as plain film radiography often fails to identify the fractured segment. Traumatic avulsion of the genial tubercle in conjunction with mandibular symphysis fracture may lead to posterior displacement of the tongue with the potential for airway compromise and difficulty in speech and swallowing due to loss of tongue anterior suspension. Fine cut computed tomography (CT) scan is required to confirm the diagnosis and assist further management. To our knowledge, all published cases of surgical intervention in the management of avulsed genial tubercle combined with fracture of the mandibular symphysis used an extraoral approach via submental skin incision to expose the fractured segment. To the authors’ knowledge, this is the first report to describe a transoral approach in the surgical management of GTF associated with a mandibular fracture.

A 22-year-old G1P1 Caucasian female had hysteroscopic removal of a perforated intrauterine device during which the steroid reservoir of the intrauterine device was lost. Isolated steroid reservoirs are radiolucent on plain film radiography. We located the reservoir in the peritoneal cavity with magnetic resonance imaging and removed it via laparoscopy.

Background Magnetic resonance imaging (MRI) is well established as the preferred noninvasive tool for meniscal evaluation. To our knowledge, there has been no study examining the utility of diagnosing meniscal extrusion from radiography alone. We hypothesize that with appropriate window settings, meniscal extrusion may be diagnosed on radiography with high sensitivity and specificity. Materials and methods We included 190 patients with MRI of the knee performed within three months of knee radiography. As defined within the literature, we utilized theMRI criteria of meniscal extrusion as meniscal tissue extending 3 mm or greater beyond the tibial plateau, excluding osteophytes. Two attending radiologists blindly and independently identified the absence or presence, in millimeters, of medial meniscal extrusion on plain film radiography. Kappa test and Pearson correlation coefficient were calculated to assess the extent of inter-reader agreement and correlation. Sensitivity and specificity were calculated for each reader, assuming the concurrent MRI served as the gold standard. Results Ninety-sixpatients had medial meniscal extrusion and 94 had no medial extrusion by MRI. Kappa test for inter-reader agreement = 0.61. Pearson coefficient for inter-reader measurement correlation = 0.69. Reader A had sensitivity of 0.59 (95% CI 0.49-0.69) and specificity of 0.88 (95% CI 0.79-0.94). Reader B had sensitivity of 0.61 (95% CI 0.51-0.71) and specificity of 0.85 (95% CI 0.76-0.91). Conclusion There is substantial inter-reader agreement and high correlation of meniscal extrusion measurement between readers. Our results suggest that while radiographs have low sensitivity for evaluation of meniscal extrusion, their high specificity may be of clinical utility.

Eagle syndrome is group of symptoms caused by an elongated ossified styloid process, the cause of which remains unclear. This is a rare finding that often goes undetected in the absence of radiographic studies. Eagle syndrome can occur unilaterally or bilaterally and most frequently results in symptoms of dysphagia, headache, pain on rotation of the neck, pain on extension of the tongue, change in voice, and a sensation of hypersalivation. In this case, we present the diagnostic CT and lateral view plain film radiography findings of a 42-year-old woman with clinical evidence of Eagle syndrome.

Cone beam computed tomography (CBCT) can be a useful adjunct to conventional plain film radiography, but its use must be carefully justified as the radiation dose is generally higher. Factors affecting the dose include the field of view (FOV) size, the exposure factors, the angle of rotation and voxel size. Once justified, the exposure should be fully optimised to ensure the dose to the patient is kept as low as possible while ensuring there is no reduction in the diagnostic yield. The European Commission (EC) and the Faculty of General Dental Practice (FGDP)(UK) have published selection criteria on the use of CBCT in dentistry. This article provides an overview of CBCT and summarises the latest guidance on selection criteria relevant to the general dental practitioner.

Glenohumeral bone loss and articular defects are often treated by using osseous or osteoarticular allografts. These aid in glenohumeral joint stability and in reconstruction of the native articular surface. Grafts include those such as iliac crest, coracoid, distal tibia, femoral head, or humeral head, depending on the specific surgical pathology. Articular grafts can be further subdivided into viable or nonviable sources. The outcome of grafts that are implemented for stability could be subject to osteolysis, which may portend a poor clinical outcome and recurrent instability. Similarly, grafts required for reconstruction of the articular surface may undergo avascular necrosis, nonunion, and collapse, rendering them useless. The status of these grafts is best assessed with postoperative imaging modalities, which range from plain film radiography to 3-dimensional computed tomography reconstructions. The purpose of this article is to review the current literature regarding the rate of graft resorption, integration, collapse, and union for each of the grafts mentioned using postoperative imaging.

The role of Australian rural radiographers in radiographic interpretation, communication and disclosure of their radiographic opinion with a specific focus on plain film radiography was examined in a two phase, exploratory interpretive study. Data were collected using questionnaires and interviews and analysed thematically. This reports one of the key themes identified in the thematic data analysis. ‘Disclosure of Radiographic Opinion to Patients’ comprises the three interrelated sub-themes Acting Ethically, Selective Disclosure and Filtered Truth. It is wholly concerned with the ways in which rural radiographers choose to disclose their radiographic opinion to patients. Without a clear picture of where they stand medico-legally, rural radiographers draw on experience and a strong ethical framework as the basis for these complex decisions. Rural radiographers frame their disclosures to patients in a manner that is governed by the diagnostic, therapeutic and emotional impact the information disclosed may have on the patient. Disclosure to patients was found to be selective, often diagnostically vague and ethically filtered.

Background Chest X-rays are performed daily in the neonatal intensive care and high care units. The skill of the radiographer is critical for obtaining the best image quality and limiting the patient's radiation exposure. The literature states that indirect flat panel detectors produce images of superior quality in comparison to computed radiography systems. At Steve Biko Academic Hospital a decision was made to revert from the direct digital radiography (DR) system to the computed radiography (CR) system, due to poor image quality experienced. Method The case study objective was to conduct a comparative analysis describing key technical factors contributing to image quality. The analysis entailed retrospectively comparing the images obtained during 2010 and 2011. An image analysis form was utilised in evaluating the technical aspects of the image. A total of 160 images were viewed by 16 participants sampled from the radiography, radiology and paediatric departments. The participants were asked to re-evaluate two of their allotted images after five days to determine their reliability. Results Findings were that the DR system provides significantly better image quality than the CR system (p Conclusion This case study demonstrated that DR images were considered to be superior to CR images. Recommendations include: a standardised technique for imaging the neonates; optimisation of the imaging software for the digital detectors, improved feedback systems in terms of exposure index values, and the training of radiographers and referring physicians in technical image analysis.