Evaluation of vertebral fractures on lateral chest radiographs of inner-city postmenopausal women.

We assessed the prevalence of vertebral fractures as a marker for osteoporosis on lateral chest radiographs in inner-city, minority, postmenopausal women. We reviewed outpatient lateral chest radiographs on all women 55 years and older at an inner-city hospital during two randomly selected months, August 2000 and April 2002. There were 106 women with a mean age of 65 (range 55-89) years, 45 were Hispanic, 42 Black, 9 White, 10 of other ethnicity. Deformity was graded on a 0-3 scale with Grades 2 (moderate) and 3 (severe) deformities considered fractures. Interval lateral chest radiographs within 1-2 years were evaluated. Of the group 25% (26/106) had vertebral fractures. The fracture prevalence increased with age: 13% (17/54) of women under 65 years and 37% (19/52) of women 65 years and older had fractures ( P < 0.05). The fracture was described as part of the radiographic report in only 15% (4/26) of the women. Of the group 15% (16/106) had interval lateral chest radiographs. Among those with interval lateral chest radiographs, 19% (3/16) developed new fractures. In this series 29% (31/106) of women were scheduled for bone density studies, but the studies were only completed in 6% (6/106). Lateral chest radiographs showed that vertebral fractures occurred commonly, increased with age, and progressed on follow-up. In a population of underserved minority women, the lateral chest radiograph provides an opportunity to identify women with osteoporosis for possible treatment.

MRI features of confirmed "pre-slip" capital femoral epiphysis: a report of two cases.

We describe the morphologic and signal changes detected about the proximal femoral growth plate in two patients with hip pain preceding the progression to slipped capital femoral epiphysis using magnetic resonance imaging.

The diagnostic role of gadolinium enhanced MRI in distinguishing between acute medullary bone infarct and osteomyelitis.

The objective of the study was to evaluate the diagnostic utility of contrast enhanced magnetic resonance imaging (MRI) for distinguishing between acute medullary bone infarct and osteomyelitis. There were 11 patients (age 6-34 years) presented to our institution between December 1994 and February 1998 with a clinical differential diagnosis of acute bone infarct versus osteomyelitis and inconclusive radiographs were imaged using MRI. All but one received i.v. gadolinium. Nine of the patients had homozygous Sickle Cell disease (SCD) and two had Systemic Lupus Erythematosus (SLE), the latter requiring chronic methylprednisolone. Osteomyelitis was confirmed either by biopsy alone or by the combination of Gallium(67) scan in conjunction with positive blood cultures and clinical resolution following antibiotics. Infarcts without osteomyelitis were confirmed either by biopsy or resolution of symptoms without antibiotic therapy. All patients had at least six months clinical follow-up. The results found that seven of nine patients with SCD had acute infarct only. One patient with SCD had osteomyelitis only. Three patients (two SLE and one SCD) had both acute-on-chronic infarcts and superimposed osteomyelitis, one with an adjacent soft tissue abscess. Accurate distinction between infarct and osteomyelitis was impossible for one patient with SLE who did not receive contrast. All other cases were correctly diagnosed prospectively based on distinct patterns of MRI contrast enhancement. In all adult patients, acute infarcts demonstrated thin, linear rim enhancement on MRI while osteomyelitis revealed more geographic and irregular marrow enhancement. Two of four cases of osteomyelitis also demonstrated subtle cortical defects with abnormal signal traversing marrow and soft tissue. The single pediatric patient demonstrated elongated, serpiginous central medullary enhancement with periostitis. We concluded that the pattern of MR contrast enhancement may allow accurate distinction between acute infarct and osteomyelitis, or recognition of osteomyelitis superimposed on bone infarction.

HIPAA security: compliance in radiology--an academic radiology department's plan contrasted with a small private practice.

In complying with the HIPAA security regulations, the large, multi-site academic radiology department is quite different from the small, private radiology practice. This article compares and contrasts the methods each of these two model organizations use to achieve compliance. In common between the two organizations is that complete documentation of the procedures and processes involved in data management must be prepared and reviewed. Although not required in the regulations, having the documentation conform to the regulation allows for easy monitoring, auditing, and certification of compliance by future independent bodies. The level to which each organization must secure their data, perform threat assessments, and implement security procedures and intrusion detection systems are very different. The regulations do not specify what level of due diligence is required. This must be determined by each organization using their own common-sense dictum. Although the solutions used by these two types of organizations may not be the same as those adopted by other radiology departments and practices, the approaches may still serve as useful templates to guide compliance efforts by others.

PACS and RIS: approaches to integration.

PACS and RIS have traditionally been discrete information systems with separate databases. Maintaining more than one database containing identical data sets creates the potential for outdated information being used in parallel with accurate information. Today, because of increased implementation of PACS and improved Web technology, this problem must be solved. Furthermore, as PACS technology is applied to areas outside radiology such database issues become more critical. Application of XML offers a cost-effective and workable solution to many of the thorniest problems that will likely become more prevalent in the post-Y2K era.

Computerized bone densitometric analysis: operator-dependent errors.

PURPOSE: To determine the nature and relative frequency of operator-dependent data analysis errors in dual x-ray absorptiometry. MATERIALS AND METHODS: Over 40 months, 2,528 dual x-ray absorptiometric examinations of the forearm, femoral neck, and lumbar spine were performed by 11 technologists by using standard techniques and software. Each analysis was reviewed by a radiologist; errors were recorded and corrected. RESULTS: There were no forearm analysis errors. There were 24 (0.9%) femoral neck analysis errors, of which 23 resulted from misplacement of the analysis region. There were 33 (1.3%) spinal analysis errors, of which 24 resulted from misplacement of intervertebral disk space markers. Analysis errors of the femur and spine resulted in six misdiagnoses (0.2%). CONCLUSION: Misdiagnosis due to analysis errors is rare. Femoral neck analysis errors were easily detectable, but accurate spinal analyses depended on accurate identification of vertebral end plates and posterior elements. Nonetheless, these potentially serious errors can be detected and corrected if the analyses are reviewed and interpreted by a supervising physician who is familiar with the relevant anatomy, proper analysis techniques, and factors--such as artifacts--that adversely affect the accuracy of the analysis.

Complications related to osteopenia in the thoracic spine on admission chest radiographs of substance abuse detoxification patients.

OBJECTIVE: To assess the prevalence of complications related to osteopenia in the thoracic spine (anterior wedging and fish vertebrae) of patients admitted for substance abuse detoxification. DESIGN AND PATIENTS: We retrospectively identified 150 sequential patients admitted to our drug and alcohol detoxification ward in whom posteroanterior and lateral admission chest radiographs and clinical charts were available for review. There were 116 men and 34 women with a mean age of 37 years (range 19-67 years). Thirty-eight patients were admitted for drug detoxification, 37 for alcohol detoxification, and 75 for drug and alcohol detoxification. These patients were compared with 66 age- and sex-matched controls from our hospital's employee health service. Two radiologists reviewed all chest radiographs for the presence of anterior wedging and fish vertebrae in the thoracic spine and other nonspinal fractures. Serum calcium and inorganic phosphorus levels were recorded for the substance abuse detoxification patients. RESULTS: Forty-nine percent (n=73) of detoxification patients had complications of osteopenia in the thoracic spine including: anterior wedging (n=47), fish vertebrae (n=21), or both (n=5). Twenty-four percent (n=36) of patients had an elevated serum inorganic phosphorus level and one patient had an elevated serum calcium level. Patients with anterior wedging or fish vertebrae included: 45% (n=45) of patients below age 40 years, 35% (n=12) of women, 41% (n= 15) of drug detoxification patients, 58% (n=22) of alcohol detoxification patients, 48% (n=36) of drug and alcohol detoxification patients, and 47% (n=17) of patients with elevated serum inorganic phosphorus (P=NS). Six percent (n=9) of our study population had nonspinal fractures on their chest radiographs. Twenty-one percent (n=14) of controls had complications of osteopenia in the thoracic spine (all anterior wedging). This prevalence differed significantly (P<0.05, chi-squared) from the study population. CONCLUSION: Osteopenia-related anterior wedging and fish vertebrae in the thoracic spine are common findings on chest radiographs of patients hospitalized for substance abuse detoxification. Serum inorganic phosphorus and calcium levels did not correlate with the presence of anterior wedging or fish vertebrae.

Slipped capital femoral epiphysis: a physeal lesion diagnosed by MRI, with radiographic and CT correlation.

OBJECTIVE: To define and compare early lesions associated with slipped capital femoral epiphysis (SCFE) on magnetic resonance imaging (MRI), computed tomography (CT) and radiography. DESIGN AND PATIENTS: Thirteen patients with 15 symptomatic hips due to SCFE underwent radiography and MRI; CT was performed in 12 patients. SCFE was graded on radiographs, head/neck angles and qualitative changes were evaluated on CT, and morphologic/signal abnormalities were determined on MRI. RESULTS: Physeal widening, apparent on T1-weighted MRI, was evident in every case of SCFE, including one presumed "pre-slip." T2-weighted images demonstrated synovitis and marrow edema but obscured physeal abnormalities. CT head/neck angles ranged from 4-57 degrees for symptomatic to 0-14 degrees for asymptomatic hips. Physeal and metaphyseal changes were variably identified on both radiographs and CT in all cases of SCFE, but not in the pre-slip. CONCLUSION: MRI clearly delineates physeal changes of both pre-slip and SCFE, and demonstrates very early changes at a time when radiographs and CT may appear normal.

Magnetic resonance imaging and computerized tomography of a gravid leopard tortoise (Geochelone pardalis pardalis) with metabolic bone disease.

Secondary nutritional metabolic bone disease was diagnosed in a gravid leopard tortoise (Geochelone pardalis pardalis). Diagnosis was based upon history, physical examination, hematology, plasma biochemistry, and radiography. Despite induced oviposition and treatment of metabolic bone disease for 8 wk, the tortoise's condition deteriorated. Repeat radiographs demonstrated gaseous intestinal distention. Oral administration of metoclopramide and mineral oil failed to stimulate defecation. Persistence of the ileus pattern prompted utilization of magnetic resonance imaging (MRI) and computerized tomography (CT). MRI demonstrated brightly enhanced loops of mineral oil-filled small bowel and preovulatory follicles. CT demonstrated dystrophic calcification of the left hepatic lobe and preovulatory follicles and the typical reticular pattern of chelonian lung. The interstitial septa were caused by pulmonary vasculature or bands of smooth muscle.

HLA-DRB1 and DQB typing of Hispanic American patients with rheumatoid arthritis: the "shared epitope" hypothesis may not apply.

OBJECTIVE: To determine whether the association of particular MHC class II alleles and the DRB1 "shared epitope" with disease susceptibility and severity in rheumatoid arthritis (RA) applies to ethnic groups other than Caucasian Americans. METHODS: 67 Hispanic American patients with RA and a similar number of ethnically matched controls were typed for DRB1 using polymerase chain reaction methods. DR4 subtype and DQB1 type were determined for the subjects positive for DR4. Disease severity in the patients with RA was assessed by clinical, radiographic and laboratory variables. RESULTS: The frequency of DR4 was significantly increased in the subjects with RA compared to the control group. However, the "shared" DRB1 amino acid sequence was relatively infrequent in the Hispanic American patients with RA, and there was no association of specific DR4 or DQ alleles with more severe disease or extraarticular manifestations. CONCLUSION: The HLA markers that predict poor prognosis and suggest that more aggressive clinical management may be appropriate in Caucasian American patients with RA may not be useful in other ethnic groups.

Pulmonary pseudonodules on computed tomography: a common pitfall caused by degenerative arthritis.

This study assessed the prevalence of pseudonodules of the lung on computed tomography (CT) related to degenerative arthritis at the distal first rib and sternum. A total of 250 serial chest CT scans were retrospectively reviewed by a chest and a musculoskeletal radiologist. A pseudonodule was defined as a round or oval opacity identified on lung window surrounded by aerated lung and superimposable on an osseous structure on the immediate cephalad slice. The pseudonodules were classified as originating from one of the following three locations: first costochondral junction, first costosternal junction, or sternoclavicular junction. CT slice thickness was 8 mm or 10 mm. For each side, the presence of a pseudonodule and its classification was noted. The presence or absence of degenerative arthritis was also noted for each side. The median patient age of the 111 men and 139 women was 62 years (range, 2-97). Degenerative arthritis was noted bilaterally in 94 (38%) and unilaterally in two. Pseudonodules were present in 29 patients (12%). Eighteen (62%) were men with a median age of 73 years (range, 50-84), and 11 (38%) were women with a median age of 67 years (range, 52-85). All of the patients with pseudonodules had bilateral degenerative arthritis. Twenty-seven pseudonodules were caused by degenerative arthritis at the first costochondral junction, four at the first costosternal junction, and one at the sternoclavicular junction. Fifteen pseudonodules were right sided and 17 were left sided. Three patients had bilateral pseudonodules. Pulmonary pseudonodules caused by degenerative arthritis, most commonly at the first costochondral junction, were present in 12% of our series. This common finding occasionally may be misinterpreted as a true pulmonary nodule.

Calcification of the ligamentum arteriosum in adults: CT features.

OBJECTIVE: The present study describes the frequency and pattern of ligamentum arteriosum calcification seen on chest CT in adults. MATERIALS AND METHODS: We retrospectively reviewed 402 sequential unenhanced chest CT studies for ligamentum arteriosum calcification, atherosclerotic cardiac or aortic calcification, and granulomatous calcification. The pattern of calcification was characterized as curvilinear, punctate, or clumped. RESULTS: Mean patient age was 60 (+/- 18, range 18-97) years with 214 women (53%) and 188 men (47%). Of these patients 194 (48%) had calcification in the ligamentum arteriosum including 26 (6%) with calcification in the ligamentum arteriosum alone, 108 (27%) with atherosclerotic calcification, 11 (3%) with granulomatous calcification, and 49 (12%) with both. A total of 100 patients (25%) had no calcifications. In the study population 169 patients (42%) had atherosclerotic calcification, 32 (8%) had granulomatous calcification, and 75 (19%) had both. The patterns of calcification for the 26 patients with calcification of the ligamentum arteriosum alone were curvilinear (7 patients, 27%), punctate (17 patients, 65%), and clumped (2 patients, 8%). The pattern of ligamentum arteriosum calcification for the 108 patients with only atherosclerotic and ligamentum arteriosum calcification was curvilinear (28 patients, 26%), punctate (32 patients, 30%), and clumped (48 patients, 44%). The patients without any calcifications and the patients with ligamentum arteriosum calcification formed one group (based on their similarity in age, mean 47 years) with a prevalence of ligamentum arteriosum calcification of 21%. The patients with atherosclerotic and ligamentum arteriosum calcification formed a second group (mean age 71 years) with a prevalence of ligamentum arteriosum calcification of 65%. CONCLUSION: On unenhanced chest CT calcification of the ligamentum arteriosum is a common finding in adults and increases in prevalence with increasing age and atherosclerosis.

MRI of the Stener lesion.

OBJECTIVE: To assess the utility of MR in detecting surgically induced Stener lesions (displaced thumb ulnar collateral ligaments) in cadaveric models. DESIGN: Six cadaver thumbs had ulnar collateral ligament (UCL) tears created surgically. MR examinations (2D STIR and 3D GRASS) were performed identically on all specimens both before displacement (non-Stener) and after displacement (Stener lesion) of the UCL. The MR images were then randomly numbered. Each image was evaluated separately in blinded fashion by four musculoskeletal radiologists for the presence or absence of a Stener lesion. Each radiologist reinterpreted the images after an interval of several days. The interpretation was based on previously published criteria for Stener lesion diagnosis by MR. RESULTS: The sensitivity of GRASS ranged from 0.17 to 0.67 with the most experienced reader scoring the lowest. The specificity of GRASS ranged from 0.33 to 1.0 (most experienced reader 0.67, 0.83). STIR had a sensitivity of 0.00-0.17 and a specificity of 0.53-0.83. The kappa values for inter- and intraobserver agreement were measured. The intraobserver kappa for GRASS was 0.27-0.75 (most experienced reader 0.75). CONCLUSIONS: 2D imaging is probably inadequate for the evaluation of Stener lesions. The most likely reason is that the STIR slice thickness of 3 mm limits resolution of small UCLs. The poor sensitivity and specificity of GRASS as well as poor interobserver agreement suggest that MR may not be sufficiently accurate for Stener lesion evaluation.

Diagnosis of partial tears of the anterior cruciate ligament of the knee: value of MR imaging.

OBJECTIVE: The purpose of our study was to assess the ability of MR imaging to detect partial tears of the anterior cruciate ligament (ACL) as these injuries, if extensive enough, may result in ligamentous insufficiency or predispose to subsequent acquired knee instability. MATERIALS AND METHODS: A review of all arthroscopic reports from two institutions during the periods 1990-1992 and 1992-1993, respectively, revealed 13 patients with partial tears of the ACL. Thirteen cases each of intact and completely ruptured anterior cruciate ligaments on arthroscopy were randomly selected as controls from the same report review. Preoperative MR images for all cases selected were obtained. Criteria for diagnosis included the absence of findings of complete ACL tear in conjunction with abnormal intrasubstance signal, bowing of the ACL, or nonvisualization of the ACL on one MR imaging sequence with visualization of intact fibers on other sequences. Inter- and intraobserver agreement was assessed using the kappa statistic. RESULTS: The sensitivity of MR imaging for detecting partial ACL tears ranged from 0.40 to 0.75, and the specificity ranged from 0.62 to 0.89. Variability of both inter- and intraobserver interpretations was greater than 0.7 kappa in all but one combination, comparing the diagnostic consistency of each of three readers both with himself, using two readings on separate days, and with each separate interpretation by the other two radiologists. CONCLUSION: Our results show that MR evaluation of partial ACL tears is not sufficiently sensitive to establish the diagnosis without arthroscopy. This study was limited, however, by its small size and by the heterogeneity of the MR imaging technique.

CT scans through metal scanning technique versus hardware composition.

OBJECTIVE: Streak artifact on CT scans of metal containing areas has been a long standing problem. Although several artifact reducing methods have been used to improve image quality, most have been limited by requiring specialized equipment or lengthy complex calculations that are not automated. Others have shown that increasing the beam energy results in increased thickness of metal that may be imaged by CT without severe image degradation. We have studied the image quality of bone surrounding metal both with titanium and cobalt-chrome prostheses using various scanning techniques. METHODS: In a double blind fashion, 28 radiology residents and attendings were surveyed as to the best technique for imaging bone detail surrounding metal. A series of images was arranged of an implanted titanium prosthesis, a cobalt-chrome prosthesis and a pelvis repaired with stainless steel pelvic reconstruction plates. Scans were performed using three techniques: 120 kVp, 170 mA, 2 s, 360 degrees rotation, 140 kVp, 140 mA, 3 s, 360 degrees rotation, 140 kVp, 140 mA, 4 s, 420 degrees rotation. RESULTS: Titanium was superior to cobalt-chrome (p < .0001 Wilcoxon Signed Rank Test). No advantage was noted for higher kVp or increased scan arc of 420 degrees compared to the standard 360 degrees. CONCLUSION: Titanium allows improved bone detail surround the metal than CT cobalt-chrome. We have found no advantage to using either high kVp or a 420 degrees scan arc to improve the image quality of bone surrounded by metal.

O'Donoghue's triad: magnetic resonance imaging evidence.

OBJECTIVE: The objective was to search for magnetic resonance imaging evidence of medial collateral ligament (MCL) injury in knees with proven tears of the anterior cruciate ligament (ACL) and medial meniscus; the three abnormalities that make up O'Donoghue's triad. Although the MCL injury can be unapparent clinically, knee joint stability may be compromised. DESIGN: The superficial portion of the MCL was evaluated on 19 MR studies of 16 knees with arthroscopically proven ACL and medial meniscal tears. MCL thicknesses were compared to those on MR images of 19 normal knees. PATIENTS: The injured knees were of 13 men and 3 women, ranging in age from 19 to 56 years; the normal knees were of 10 men and 9 women, ranging in age from 19 to 55 years. RESULTS AND CONCLUSIONS: The medial collateral ligaments of all injured knees were abnormal, and, as a group, they had greater thicknesses and more intraligamentous thickness variability than normal knees. The MR appearance of both ACL and medial meniscal tears served as indirect evidence of MCL injury, with irregular MCL thickening indicative of prior injury.

MR imaging: its role in detecting occult fractures.

Magnetic resonance (MR) studies were performed on 30 consecutive patients who continued to be symptomatic despite negative or inconclusive findings on radiographs and other imaging studies including radionuclide bone scans, computed tomography, and/or polytomography. There were 9 men and 21 women, 20-92 years old (mean age 63 years) whose MR studies were done 3-72 h after frank trauma in 22 cases and in another 8 after 1-4 weeks of increasing pain subsequently attributed to trauma or unaccustomed effort. MR studies were performed using 0.5-T (Phillips) or 1.5-T (Phillips, GE) superconductive magnets. Results indicated that: (1) MR images allowed identification of acute fractures in an emergency room setting, as well as subtle subacute or chronic fractures in the context of strong clinical suspicions despite negative or inconclusive radiographs and other subsequently indecisive imaging studies. (2) MR imaging is the most sensitive way of documenting the earliest changes in traumatized osseous and soft tissue structures simultaneously.

Abnormal geometry of the distal radioulnar joint: MR findings.

Previously developed criteria of normal distal radioulnar joint (DRUJ) axial geometry were applied to routine magnetic resonance (MR) images of 50 wrists. All wrists lacked clinically evident DRUJ instability. An attempt to apply the three geometric criteria to seven of the cases was not possible, since the prescribed landmarks were not visible. The remaining 43 cases were retrospectively divided into a symptomatic group (25 wrists), with clinical abnormalities referable to the ulnar side of the wrist, and an asymptomatic group (18 wrists), with no such abnormalities. Abnormal DRUJ geometry was found in 12 symptomatic and 2 asymptomatic wrists. This difference between the groups is significant (p = 0.02), suggesting that many symptomatic wrists exhibit different DRUJ geometry than is found in most asymptomatic wrists.