Imaging Posterior Instability of the Shoulder.

Posterior instability of the shoulder is much less common than anterior instability with a clinical presentation that is often less obvious, making the diagnosis more challenging and more easily missed. We describe the imaging findings of posterior instability so the radiologist can make the diagnosis and provide a detailed description, enabling the surgeon to make more informed decisions regarding management and surgery.

Rupture of the peroneus quartus tendon in a professional rugby player.

The peroneus quartus is one of a variety of described accessory peroneal muscles, most commonly an incidental finding on MRI or ultrasound of the ankle. We present the only described case in the literature of a peroneus quartus tendon rupture in a professional rugby player as well as the MRI findings.

Percutaneous Release Procedures: Trigger Finger and Carpal Tunnel.

Trigger digit and carpal tunnel syndrome are both conditions traditionally treated with open surgery but are potentially amenable to curative treatment using percutaneous techniques. The advantages of minimally invasive techniques are lower risk of wound breakdown and infection, quicker healing, reduced postprocedural pain, reduced complications, and a quicker return to normal activity. The advent of high-resolution ultrasound has allowed percutaneous release procedures for these conditions to be developed and performed with a potential for a reduced risk of complications and an increased likelihood of success. This article reviews the literature as well as our institutional experience in performing ultrasound-guided percutaneous release for trigger digit and carpal tunnel syndrome.

Imaging and management of greater trochanteric pain syndrome.

Greater trochanteric pain syndrome (GTPS) is a commonly diagnosed regional pain syndrome with a wide spectrum of aetiologies, reflecting the anatomy of the structures outside the hip joint capsule. There are five muscle tendons that insert on to the greater trochanter and three bursae in the region of the greater trochanter. The term GTPS includes tendinopathies, tendinous tears, bursal inflammation and effusion. There are a range of treatments and therapies depending on the specific diagnosis and severity of the condition. Many patients with GTPS can be successfully managed conservatively with weight loss and non-steroidal anti-inflammatory drugs. Patients suffering from more chronic pain can receive varying degrees of symptomatic relief with lateral hip corticosteroid and local anaesthetic injections. More severe refractory cases of GTPS can be treated with surgical intervention. It is therefore important to make the correct diagnosis to ensure that appropriate management can be implemented. The clinical features of GTPS however are often non-specific because common conditions such as lumbar radicular pain and hip joint osteoarthritis can present with an almost identical form of lateral hip pain. The various diagnostic imaging modalities have particular strengths and weaknesses with ultrasound being the best first-line investigation due to its availability, low cost, dynamic nature and ability to guide treatments such as steroid injections. MRI can be very helpful in the further investigation of patients in whom there is diagnostic uncertainty as to the cause of lateral hip pain and in whom specialist orthopaedic referral is being considered.

Image-guided percutaneous spinal biopsy.

The purpose of this article is to discuss the role of imaging in the diagnosis and management of spinal disorders, with particular attention to that of image-guided percutaneous spinal biopsy. We discuss the indications, general principles, pre-procedural steps and specific techniques used for image-guided percutaneous spinal biopsy in the context of our experience and the wider literature. Percutaneous spinal biopsy is a safe and diagnostically accurate procedure when appropriately selected for further evaluation in the multidisciplinary team setting.

Contemporary imaging of inguinal hernia and pain.

Inguinal hernias are the commonest type of hernia, and are frequently encountered by general, abdominal and musculoskeletal radiologists. Such hernias may cause discomfort or pain; but many other conditions may cause pain in a similar location, meaning it is not always straightforward to determine the underlying cause of a particular patient's symptoms. Although surgical fixation of hernia has high success rates with low recurrence, ongoing symptoms are common after apparently uncomplicated surgery. In particular, post-surgical chronic groin pain can be highly problematic in some patients. In this review, we highlight the relevant surgical and imaging anatomy, common modes of clinical presentation, contemporary surgical approaches to the repair of inguinal hernia, imaging techniques to diagnose such hernias in both unoperated and operated groins and mimics of hernia-related pain.

Lumbar spine MRI findings in asymptomatic elite male academy footballers: a case series.

BACKGROUND: Understanding common MRI findings may allow clinicians to appreciate the sport-specific effects on the lumbar spine, and to discern clinically significant pathology. Prevalence data regarding radiological abnormalities seen during the surveillance of asymptomatic elite footballers is, therefore, important to help understand injury mechanisms and to prevent associated injuries. The purpose of this study was to evaluate the magnetic resonance imaging (MRI) findings in the lumbar spines of asymptomatic elite male adolescent footballers. METHODS: A prospective case-series study was carried out. MRI was performed using a 3T Siemens Prisma scanner including a 3D VIBE sequence in 18 asymptomatic male elite adolescent footballers recruited from a professional academy in England (mean age 17.8, range 16.9-18.6 years). The images were independently reported by two consultant musculoskeletal radiologists to achieve consensus opinion. Standardised classification criteria were used to assess and report abnormalities descriptively. RESULTS: Fifteen players (15/18, 83%) showed ≥1 abnormalities, included facet degeneration, synovial cysts, disc degeneration, disc herniation, and pars injury. One player (1/18, 6%) had mild (Grade 1) facet joint arthropathy at L4/L5 and 3/18 (16.7%) showing evidence of bilateral facet joint effusions. Three synovial cysts were identified in 2/18 players (11%), 4/18 players (22%) presented asymptomatic pars injuries, with 4 showing a grade 2 subtotal stress fracture and 1 player a grade 4 chronic stress fracture seen on 3D VIBE sequencing. Disc degeneration at one or more levels was demonstrated in 7/18 players (38%). Disc herniation was present in 5/18 players (27%). CONCLUSION: A range of unsuspected findings on MRI of the lumbar spine are common in elite adolescent footballers.

Radiology and management of multiligament injuries of the knee.

Multiligament injury of the knee, which may include joint dislocation, is a severe injury that can devastate knee function. It usually results in rupture of three of the four major stabilizing ligaments of the knee, but occasionally only two of the ligaments are torn. Evaluation and management is made more complex due to associated articular and meniscal cartilage injury, bony fractures, and neurovascular injury. What is considered best treatment is often varied and controversial. This article discusses the diagnosis and management of multiligament knee injury and the role of imaging in the context of the published literature and our own experience.

Internal herniation of the caecum into the lesser sac: an unusual cause of an acute abdomen (2009: 10b).

Internal hernias are rare, occurring in 0.2-0.9% of autopsy cases. Hernias through the foramen of Winslow are even rarer, occurring in up to 8% of internal hernias. The clinical presentation is variable, making diagnosis difficult, and a delay in diagnosis can result in significant morbidity. As such, early radiological diagnosis is paramount. We report a rare case of caecal herniation through the foramen of Winslow in a 49-year-old female patient in whom the diagnosis was made radiologically and allowed appropriate and prompt management.

Ultrasound-guided percutaneous release of the annular pulley in trigger digit.

The purpose of this study was to describe and evaluate a new technique for ultrasound-guided percutaneous release of the annular pulley in trigger digit using a modified hypodermic needle. A total of 35 ultrasound-guided percutaneous releases were performed on 25 patients diagnosed and referred by hand surgeons in our institution over 16 months from October 2006. Inclusion criteria were as follows: adulthood, triggering present for at least 4 months, failure to respond to conservative management or steroid injections, no previous history of pulley release in the affected digit. Under ultrasound guidance, the affected pulley was released using a standard 19-gauge hypodermic needle bent at two points as the cutting device. Follow-up took place at 12 weeks and 6 months with improvement in triggering and clinically graded pain. At follow-up, no complications had occurred and all patients demonstrated improvement in their triggering, with complete resolution in 32 digits (91%), good improvement in 2 digits (6%) and some improvement in 1 digit (3%). This new technique uses a widely available and safe cutting device and is safe and can be used to provide definitive management for trigger finger, allowing the procedure to be performed in a variety of clinical settings.

Pars interarticularis injury in elite athletes - The role of imaging in diagnosis and management.

Injuries of the lumbar neural arch, in particular the pars interarticularis, are widely considered to be due to abnormal bone stress secondary to repetitive loading/shearing, and are a common pathology and a main cause of lower back pain in elite athletes across a range of sports. Medical imaging plays a pivotal role in the diagnosis, monitoring and prognostication of neural arch injury. Early detection is highly desirable in the young elite athlete, as early injuries have been shown to require shorter recovery time and have a higher potential of full healing, whilst accurate grading of injury allows appropriate rehabilitation planning. Various imaging modalities are used in the diagnosis and management of pars stress injury, each with their strengths and weaknesses. There is currently a lack of general consensus over the most appropriate imaging pathway for neural arch injury in this specific group of patients. In this review article, we present an overview of neural arch injury, the various imaging modalities used and their imaging appearances with a brief pictorial review, and a proposed imaging algorithm with special considerations in the young elite athletes.

The imaging of osteomyelitis.

Osteomyelitis is an important cause of morbidity and mortality in children and adults. Imaging plays a crucial role in establishing a timely diagnosis and guiding early management, with the aim of reducing long-term complications. Recognition of the imaging features of osteomyelitis requires a good understanding of its pathogenesis. In this review, the key imaging findings in osteomyelitis are correlated with the underlying pathological processes. There is a particular emphasis on magnetic resonance imaging (MRI), which is the best available imaging modality owing to its high sensitivity for detecting early osteomyelitis, excellent anatomical detail and superior soft tissue resolution. However, other modalities such as nuclear medicine and computed tomography (CT) are also useful in many clinical contexts, and will also be described in this review.

Desmoplastic small round cell tumour: the radiological, pathological and clinical features.

OBJECTIVES: Desmoplastic small round cell tumours (DSRCTs) are rare aggressive tumours of young adults that present late and have poor prognosis. This review discusses distinctive radiological features, histopathology and clinical course of this soft-tissue sarcoma. METHODS: From 1991 to 2012, the radiology of 20 patients with pathologically proven DSRCT was independently reviewed by two experienced radiologists. The clinical presentation, treatment and outcome were recorded. PATIENTS: 16 men, four women; mean age 28.3 years. Computed tomography (CT) demonstrated peritoneal/omental masses without an organ of origin (94 %), with the majority of cases demonstrating large (>5 cm) dominant soft-tissue deposit (80 %) with multiple smaller foci. CT and magnetic resonance imaging (MRI) typically demonstrated heterogeneous soft-tissue enhancement with cystic degeneration. A minority (20 %) demonstrated calcification. Lymph node enlargement occurred in 50 % of cases. Distant metastatic disease occurred in 25 %. Painful abdominal masses were clinically predominant. Treatment strategies include combination chemotherapy with debulking surgery and/or radiotherapy. Median survival from diagnosis was 22.8 months. CONCLUSION: Features of multifocal peritoneal/omental masses, usually in combination with a dominant soft tissue deposit, are distinctive in this rare sarcoma. CT/MRI defines the extent of disease and characterises supporting imaging findings. Prolific desmoplastic reaction histologically separates DSRCT from similar subtypes. Combination treatment strategies can infer a survival benefit but prognosis remains poor. TEACHING POINTS : • DSRCTs are rare tumours of young adults (mean age 28.3 years) with a male predominance (4:1). • Painful abdominal masses clinically predominate. Non-specific features of malignancy can be present. • Multifocal peritoneal masses with a dominant soft tissue lesion is a distinctive imaging finding. • A large desmoplastic reaction differentiates DSRCTs from histologically similar round cell subtypes. • Despite debulking surgery with adjuvant chemotherapy, median survival from diagnosis is 22.3 months.