Shoulder manipulation under targeted ultrasound-guided rotator interval block for adhesive capsulitis.

OBJECTIVE: To describe and evaluate the outcome following shoulder manipulation under rotator interval block for the treatment of adhesive capsulitis. MATERIALS AND METHODS: Patients with adhesive capsulitis referred by our local orthopaedic shoulder surgeons consented to targeted ultrasound-guided injection of the glenohumeral joint via the rotator interval. Inclusion criteria included a failure to respond to conservative treatment and the absence of a full-thickness rotator cuff tear. Twelve millilitres of a mixture of local anaesthetic and steroid was injected into the rotator interval using a 21-gauge needle, with a small volume of the same solution instilled into the subacromial bursa. Following injection, under local anaesthetic block, patients were gently manipulated into abduction, external rotation and internal rotation as far as they could comfortably tolerate. Patients were assessed pre-injection with documented pain scores from 0 to 10 on a visual analogue scale (VAS) and the Oxford Shoulder Score (OSS) questionnaire. Initial follow-up comprised a VAS pain score at 1 h, 24 h and 2 weeks. Clinical review by the referring orthopaedic surgeon was performed at 2 months post-injection. Long-term follow-up involved a VAS pain score and the OSS questionnaire at 5 months. RESULTS: Forty patients were suitable for inclusion in the study. Twenty-three were female (57.5%) and 17 were male. The mean age was 52 years (range, 31-73 years). Twelve patients were post-operative. The duration of symptoms ranged from 3 months to 18 months. Mean pre-procedure OSS was recorded as 23.3 (range, 4-36). The mean VAS pain score was 7.7 before the procedure (range, 4 - 10), 3.4 at 1 h (range, 0-8), 2.9 at 24 h (range, 0-8), and 1.8 at 2 weeks (range 1-4). Orthopaedic follow-up at an average of 66 days post-injection was recorded in 18 patients. All patients reported initial improvement of their shoulder pain and return to near full range of movement; however, recurrence of adhesive capsulitis symptoms was recorded in 5 patients. One case of rupture of the long head of the biceps tendon was reported, but the patient remained asymptomatic. Long-term follow-up at 5 months was obtained in 31 patients, with a mean OSS of 42 (range, 21-60) and VAS of 2.3 (range, 0-7). CONCLUSION: Manipulation under general anaesthesia is a well-recognised treatment for adhesive capsulitis. We report that targeted ultrasound-guided injection of the rotator interval and manipulation of the shoulder under local anaesthetic blockade result in good outcomes in reducing shoulder pain and symptoms of adhesive capsulitis with low recurrence and complication rates.

Targeted ultrasound-guided hydrodilatation via the rotator interval for adhesive capsulitis.

OBJECTIVE: To describe and evaluate ultrasound-guided hydrodilatation via the rotator interval for the treatment of adhesive capsulitis. MATERIALS AND METHODS: Patients referred to our department with adhesive capsulitis were consented for hydrodilatation. Inclusion criteria included a failure to respond to conservative treatment and the absence of full thickness rotator cuff tear. Twenty-one milliliters of a mixture of local anesthetic and steroid was injected into the rotator interval using a 21-gauge needle. Patients were followed up at 2 weeks and 4 months, with documented pain scores from 0 to 10 on a visual analogue scale and the Oxford Shoulder Questionnaire. RESULTS: Twenty-two patients were suitable for inclusion in the study. Nineteen were female (86 %) and three were male. The mean age was 55 years (range, 32-71 years). The duration of symptoms ranged from 4 weeks to 20 months. At 4 months, 19/22 (86 %) of patients described either complete (7/22) or good (12/22) improvement in their symptoms. The mean pain score was 8.4 prior to the procedure, 3.1 at 48 h and 1.9 at 4 months, and 20/22 (91 %) had a lower pain score after 4 months. There was a statistically significant (p < 0.05) improvement in the Oxford shoulder score, from a mean of 13.6 pre-procedure to 36.5 at 4 months. CONCLUSIONS: The rotator interval and anterior joint capsule are strongly implicated in the symptomatology of adhesive capsulitis. The novel use of targeted ultrasound-guided hydrodilatation via the rotator interval gives good results in reducing shoulder pain and symptoms in adhesive capsulitis.

The iliotibial band in acute knee trauma: patterns of injury on MR imaging.

OBJECTIVE: To delineate the spectrum of knee injuries associated with sprains and tears of the distal iliotibial band (ITB). MATERIALS AND METHODS: A retrospective review of 200 random MRI scans undertaken for acute knee trauma was performed. Scans were excluded if there was a history of injury over 4 weeks from the time of the scan, septic arthritis, inflammatory arthropathy, previous knee surgery, or significant artefact. In each scan, the ITB was scored as normal, minor sprain (grade 1), severe sprain (grade 2), and torn (grade 3). The menisci, ligaments, and tendons of each knee were also assessed. RESULTS: The mean age was 27.4 years (range, 9-69 years) and 71.5% (n = 143) of the patients were male. The ITB was injured in 115 cases (57.5%). The next most common soft tissue structure injured was the anterior cruciate ligament (ACL) in 53.5% of cases (n = 107). Grade 1 ITB injury was seen in 90 of these 115 cases (45%), grade 2 injury in 20 cases, and grade 3 injury in only five cases. There is a significant association between ITB injury and ACL rupture (p < 0.05), as well as acute patellar dislocation (p < 0.05). There were ten cases of significant posterolateral corner injury, and all were associated with ITB injury, including four ITB tears. Only two cases of isolated ITB injury were seen (1%). CONCLUSIONS: ITB injury is common in acute knee trauma and is associated with significant internal derangement of the knee, especially cruciate ligament rupture, posterolateral corner injury, and patellar dislocation.

Multiple hereditary exostoses and ischiofemoral impingement: a case-control study.

OBJECTIVE: To assess whether there is a significant difference in the ischiofemoral space in patients with multiple hereditary exostoses affecting the proximal femora compared to normal patients. INTRODUCTION: Ischiofemoral impingement is an increasingly recognized cause of hip and buttock pain. This causes narrowing of the ischiofemoral space resulting in an abnormal quadratus femoris muscle. MATERIALS AND METHODS: We performed a retrospective search for individuals with MHE with proximal femoral involvement on pelvic MRI over a 7-year period (2006-2013). Suitable patients were age- and sex-matched with a control group. The minimum ischiofemoral space (MIFS) was recorded in each hip, as was the presence of edema and atrophy of quadratus femoris and concomitant hip osteoarthrosis. MRI features suggestive of ischiofemoral impingement were defined as MIFS less than 10 mm or an abnormal quadratus femoris muscle. RESULTS: Twenty-one hips in 11 individuals with MHE were included in the study. A total of 42 hips were analyzed. The mean age was 37 years (range, 13-72 years) and 55% were male. There was a significant difference (p < 0.05) in the MIHS in individuals with MHE (mean, 10.7 mm, range, 0-21 mm) compared to a control group (mean, 18.1 mm, range, 10.5-26.5 mm). MRI features suggestive of ischiofemoral impingement were seen in 13/21 (62%) hips in the MHE group and 0/21 (0%) in the control group. CONCLUSIONS: The reduced ischiofemoral space and associated quadratus femoris abnormalities in patients with MHE involving the proximal femora may account for hip/buttock symptoms in the absence of significant degenerative change.

Evaluation of ultrasound-guided diagnostic local anaesthetic hip joint injection for osteoarthritis.

PURPOSE: The diagnosis of hip osteoarthritis is often complicated by co-existing pathology in the knee and spine, and mismatch between clinical and radiological signs. Temporary pain relief from a local anaesthetic injection into the hip joint has been reported to help localise symptoms, reducing the risk of unnecessary surgery being performed. We hypothesize that good surgical outcome is predicted by good analgesia following diagnostic injection, and that alternative pathology is present when there is no response to injection. METHODS: Data were analysed from a prospective database of 163 consecutive patients who underwent diagnostic hip injection for possible osteoarthritis. We recorded result of injection and whether hip arthroplasty was performed. A good outcome to surgery was defined as subsequent pain relief without significant residual symptoms. RESULTS: A total of 138 patients were suitable for inclusion in the study. Fifty-eight patients had hip arthroplasty following a good response to diagnostic injection. Of these 54 had a good outcome following surgery (93%). There was also a quantitative improvement in pain and function in these patients as measured by 1 year post-operative and pre-operative Harris hip scores (P < 0.0001). A total of 44/49 patients had no surgery following no response to injection. A clear alternative diagnosis to hip osteoarthritis was made in 40 of these patients (91%). CONCLUSION: Diagnostic ultrasound-guided local anaesthetic injection of the hip joint is a useful test in confirming hip pathology. Complete relief of hip pain following intracapsular injection of local anaesthetic is associated with good surgical outcome following joint replacement.

Polyarticular extension of pigmented villonodular synovitis to contiguous joints via pigmented villonodular tenosynovitis.

Pigmented villonodular synovitis is an uncommon benign neoplastic process that affects synovial-lined joints, bursae and tendon sheaths. We describe polyarticular extension of pigmented villonodular synovitis across joints secondary to pigmented villonodular tenosynovitis. Given that treatment is required to prevent progressive destruction of the involved joint, tendon or bursa, radiologists must be vigilant for diffuse polyarticular or extrasynovial involvement to optimize patient care and initiate appropriate therapy.

Internal derangement of the knee in fibular hemimelia: radiographic and MRI findings.

BACKGROUND: Fibular hemimelia is a rare bone dysplasia with partial or complete absence of the fibula. There are many associated lower limb deformities. METHODS: We describe the commonly associated bone and soft tissue abnormalities in the knee joint in a case series of six knees in five patients with fibular hemimelia who underwent both radiographic and MR imaging. RESULTS: In all knees, there was an elongated conjoint tendon of the lateral collateral ligament and biceps femoris. In five out of six knees, there was trochlear dysplasia. In four out of six, there was complete absence of the anterior cruciate ligament. In four out of six, there was an abnormal lateral meniscus (three were hypoplastic and one absent). CONCLUSION: These associations in fibular hemimelia, although unpredictable, have relevance in the guidance of further orthopaedic management in this complex condition.

The inguinal and femoral canals: A practical step-by-step approach to accurate sonographic assessment.

Ultrasonography (USG) is an accepted and reliable tool for the assessment of groin hernias. However, USG of the groin is operator dependent and challenging. The anatomy of this region is complex and the normal sonographic findings can be difficult to interpret. We describe the relevant normal anatomy of the groin relating to inguinal and femoral hernias, and describe a straightforward, reliable technique for identifying and assessing the integrity of the inguinal and femoral canals. The inferior epigastric vessels are a critical landmark for assessment of the inguinal canal and deep inguinal ring.

Four hand injuries not to miss: avoiding pitfalls in the emergency department.

The clinical and radiological findings in some hand injuries can be subtle and easily misinterpreted, leading to irreversible changes and profound functional loss. The importance of early and accurate diagnosis is clear. This study looks at four such injuries, with reference to pertinent anatomy, typical mechanisms of injury, examination and radiological findings, with emphasis on avoiding pitfalls in the emergency department.