Lesser Metatarsophalangeal Joint Plantar Plate Degeneration and Tear and Acute First Metatarsophalangeal Joint Capsuloligamentous Injury: What the Surgeon Wants to Know.

Injuries to the plantar plate complex of the first toe and the lesser toes, although closely related anatomically, differ significantly in their pathogenesis. Lesser metatarsophalangeal joint plantar plate degeneration and tear typically presents as an attritional pattern of capsuloligamentous deficiency in middle-aged patients, whereas first metatarsophalangeal joint capsuloligamentous injury is typically acute and occurs in younger adult athletes engaged in sports involving repetitive running and jumping. Consequently, considerations regarding surgical decision-making also differ. Knowledge of the anatomy, pathophysiological basis, common patterns, grading and classification of these injuries, and indications for surgery, will aid imaging interpretation in the preoperative setting. The acuity and extent of injury, tissue quality and functional requirements of the patient (such as timely return to sport) influence clinical decision-making with respect to conservative versus surgical management and are informed by the use of optimized multimodal imaging. This section will provide an overview of these injuries in 2 parts, separated into those affecting the first toe and the lesser toes, and will highlight imaging findings relevant to surgical decision-making.

Traumatic irreducible anterior dislocation of the radio-capitellar joint due to entrapment of the brachialis tendon lateral to the radial head: A case report.

Elbow dislocation is the second most common type of joint dislocation in adults and the most common joint dislocation in children. These dislocations are commonly associated with significant soft tissue injury and/or fractures. Anterior dislocation of the radio-capitellar articulation is uncommon. Failure of relocation of the radial head due to soft tissue imposition requiring open reduction is rare, however, is extremely important to recognise clinically and radiologically. This case report describes a case of anterior dislocation of the radio-capitellar joint due to entrapment of the brachialis tendon lateral to the radial head and discusses the radiological assessment and the spectrum of causes of a clinically irreducible radio-capitellar joint. Misdiagnosis of a dislocation or failed reduction may result in long-term functional sequelae for the patient.

Acute calcific periarthritis-a commonly misdiagnosed pathology.

Acute calcific periarthritis (ACP) is a self-limiting, monoarticular, peri-articular process of dystrophic mineral deposition and adjacent inflammation. Patients present with a sudden onset of pain, localised swelling, erythema, tenderness and restricted range of motion. Symptoms reduce in severity within 4-7 days and self resolve in 3-4 weeks. ACP is commonly misdiagnosed, in particular, as infective or inflammatory pathologies such as septic arthritis and gout. This condition has specific imaging findings which allows differentiation from other disorders when combined with the clinical presentation. Prompt diagnosis results in appropriate management and reduces the likelihood of unnecessary diagnostic and therapeutic procedures.

Presurgical Perspective and Postsurgical Evaluation of Plantar Plate and Turf Toe.

Capsuloligamentous injury of the first metatarsophalangeal (MTP) joint (eponymously called "turf toe") mostly occurs in athletes and involves acute trauma, whereas tears of the lesser MTP joint plantar plate typically are an attritional-degenerative condition. This article reviews the anatomy, pathophysiology, mechanism and patterns of injury, grading and classification of injury, imaging appearances (pre- and postoperative), and management of first MTP joint capsuloligamentous injuries and lesser MTP joint plantar plate tears. These two distinct pathologies are discussed in separate sections.

Retroperitoneal sarcomas: a review of disease spectrum, radiological features, characterisation and management.

Retroperitoneal sarcomas are a rare disease. The overall 5-year survival rate for these lesions remains low, and surgical management offers the only option for effective treatment and potential for cure. Radiotherapy is increasingly being employed in addition to standard surgical treatment. Improvements in cross-sectional imaging have also facilitated better characterisation of lesions, preoperative planning and long-term follow-up. This article reviews the current literature and documents the various types of retroperitoneal sarcomas with a particular approach to their imaging features. We also highlight the pathology, diagnostic methods and most current management of these tumours.

Femoroacetabular impingement.

Femoroacetabular impingement (FAI) of the hip is a well-recognized entity that can cause hip pain and limit range of motion. Although there are 2 types of FAI (cam and pincer), these 2 entities most commonly coexist. Plain radiographs and magnetic resonance imaging are commonly used to assess FAI, and play an integral role in diagnosis in conjunction with patient symptoms and clinical examination. Treatment of FAI is also evolving, with arthroscopic management becoming increasingly more popular. This review provides an overview of the proposed etiology, mechanisms, clinical history, imaging, and treatment of FAI.

Ankle impingement syndromes.

Impingement is a clinical syndrome of end-range joint pain or motion restriction caused by the direct mechanical abutment of bone or soft tissues. Impingement syndromes at the ankle may occur after acute macrotrauma or repetitive microtrauma. Modern imaging modalities can show underlying diseases and anatomic variations and assist with patient management. Implicit in the definition of impingement as a clinical syndrome is that the diagnosis remains clinical, because imaging changes alone do not reliably predict symptoms or clinical relevance. This article reviews the anatomy, pathogenesis, clinical features, differential diagnosis, imaging, and management of various impingement syndromes around the ankle.

Injuries of the spine sustained whilst surfboard riding.

Surfboard riding is a popular sport worldwide. Although surfing is considered a 'safe' pastime, significant injuries do occur, particularly to the head and cervical spine. Spinal injuries most commonly occur when the surfer's head strikes the seafloor. This case series identifies the spectrum of spinal pathologies sustained whilst surfing and their imaging appearances. No similar study has previously been published.

Acquired flat foot deformity: postoperative imaging.

Flat foot (pes planus) is a progressive and disabling pathology that is treated initially with conservative measures and often followed by a variety of surgeries. This article briefly reviews the pathology in acquired flat foot deformity, the classification of posterior tibial tendon dysfunction, discusses surgical techniques for the management of adult flat foot deformity, and reviews potential complications and their relevant imaging appearances.

Pearls and pitfalls of magnetic resonance imaging of the upper extremity.

Magnetic resonance imaging (MRI) is capable of producing images in any anatomical plane, visualizing and analyzing a variety of tissue characteristics, as well as quantifying blood flow and metabolic functions. Although MRI details of compact bone and calcium are poor when compared to those taken with plain radiography or computed tomography, its high soft tissue contrast discrimination and multiplanar imaging capabilities are significant advantages. Musculoskeletal anatomy and neurovascular bundles are well delineated. The advent of MRI has revolutionized the clinician's ability to confirm a proper diagnosis for musculoskeletal problems, which has led to more directed, specific rehabilitative protocols. However, the value of MRI to rehabilitative professionals has been even greater in its ability to identify serious, more uncommon pathologies, such as in those with underlying infection, fracture, or tumor, that require immediate care and are considered to be beyond their scope of practice. Furthermore, MRI, with its precise delineation of fat, muscle, and bone, is an ideal candidate for imaging of muscle disease or injury and has emerged as the method of choice for the detection of early cartilage wear in young patients, such as osteoarthritis. Finally, this imaging modality can avoid radiation exposure in a predominantly younger patient cohort commonly affected by musculoskeletal diseases. The aim of this paper is to consider how physical therapists may take advantage of the diagnostic value of MRI of the upper limb, while avoiding the pitfalls of misinterpretation of images as a result of technical issues, pathological changes, or normal variants.

Normal variants of the cerebral circulation at multidetector CT angiography.

Multidetector computed tomographic (CT) angiography is used in many institutions for initial evaluation of the cerebral circulation for acute stroke and subarachnoid hemorrhage as well as in various preoperative settings. A comprehensive CT examination that includes a review of three-dimensional and maximum intensity projection images of the intra- and extracranial arteries and axial images of the skull base (obtained with bone window settings) allows identification of most abnormalities and normal variants. Knowledge of the presence and clinical relevance of normal variants such as fenestrations, duplications, and persistent fetal arteries plays a crucial role in the diagnosis and management of acute stroke and subarachnoid hemorrhage and may aid in surgical planning. For example, the preoperative detection of a medial or intrasellar persistent trigeminal artery may help surgeons avoid a potentially life-threatening hemorrhage in a patient undergoing transsphenoidal surgery for pituitary adenoma. However, the significance of normal variants diverges widely: A clinically important association has been observed between fenestration and intracranial aneurysm formation, whereas early branching of the middle cerebral artery is not associated with an increased risk of aneurysm formation and has little clinical significance. Supplemental material available at http://radiographics.rsnajnls.org/cgi/content/full/29/4/1027/DC1.

The accuracy of magnetic resonance imaging scanning and its influence on management decisions in knee surgery.

PURPOSE: The purpose of our study was to evaluate the impact of preoperative magnetic resonance imaging (MRI) assessment of articular knee pathology on the clinical management of patients presenting with joint line pain. METHODS: A preliminary study on 100 patients was performed to assess the accuracy of specific MRI sequences, using arthroscopy as a gold standard. Six hundred and eighteen consecutive patients with knee symptoms presenting to 2 specialist knee surgeons were then recruited. A clinical diagnosis of an arthroscopically treatable lesion was made in all cases. Clinical assessment data were correlated to subsequent MRI findings, recording any discrepancy and in particular whether or not MRI findings influenced management decisions. RESULTS: In the preliminary study, MRI sequences had an overall sensitivity of 83.2% and a specificity of 94.3% for the detection of chondral lesions. However, when considering arthroscopic grade III and IV lesions, MRI sensitivity and specificity were improved to 84.5% and 97.1%. In the second phase of the study, 141 (22.8%) of the 618 patients presenting with knee symptoms had an altered clinical management subsequent to MRI. The presence of unexpected chondral lesions was found in 77 of these patients. Conversely, 22 patients with clinical symptoms suspicious for simple chondral degeneration had unstable meniscal tears. CONCLUSIONS: We suggest that preoperative MRI scanning identifies a group of patients who have more advanced degenerative joint disease than the clinical assessment and the plain radiographs suggest. This would expedite definitive surgery in patients with advanced osteoarthritis on MRI scans. LEVEL OF EVIDENCE: Level II, development of diagnostic criteria on basis of consecutive patients with universally applied gold standard.

Outcomes following surgery for congenital heart disease in low-birthweight infants.

AIM: To describe cardiac surgery, survival and outcomes for low-birthweight (< or = 2500 g) infants undergoing surgery for congenital heart disease. METHODS: Using data from a prospectively collected population-based database of admissions to neonatal intensive care units in New South Wales and the Australian Capital Territory, we identified all low-birthweight infants undergoing cardiac surgery between 1992 and 2001. Infants with only a persistent ductus arteriosus were excluded. Two-year cardiac and neurodevelopmental outcome data were sought from hospital medical records. RESULTS: A total of 121 low-birthweight infants underwent cardiac surgery, of whom 34% had a congenital syndrome or non-cardiac birth defect. Most (81%) underwent a palliative surgical procedure in the neonatal period. There were 19 early (15.7%) and 19 late deaths giving a 2-year mortality of 31%. Factors associated with mortality included birthweight below 1500 g (P = 0.006), low weight at surgery (P = 0.028) and Apgar score at 1 min (P = 0.019). No single factor predicted 30-day mortality. By 2 years of age, 27 (33% of survivors) were known to have neurodevelopmental delay. Although 22 children are known to be developing normally, the neurodevelopmental status of 34 children was not known. CONCLUSIONS: These surgical data were comparable to previous single-institution studies. This group had a high risk of disability due to prematurity, low birthweight and associated conditions. There is a need to prospectively assess and manage neurodevelopmental outcomes in this group.