The diagnostic performance of MRI signs to distinguish Pectoralis major tendon avulsions from Myotendinous injuries.

BACKGROUND: Management of pectoralis major (PM) injuries is largely determined by the anatomic location of the injury, with tendon avulsions from the humerus requiring surgery while myotendinous (MT) injuries are typically managed non-operatively. Because physical examination cannot reliably make this distinction, MRI is often used for staging. However, correct classification can also be difficult with MRI where there is extensive soft tissue edema and distorted anatomy. OBJECTIVE: To determine the diagnostic performance of primary and secondary MRI signs of PM injury for distinguishing tendon avulsions from MT injuries in a selected sample of patients that underwent surgical repair using a practical interpretation algorithm. METHODS: In this retrospective study, 3 blinded observers independently assessed the MRI findings of 17 patients with PM injury (including 12 acute injuries, 4 chronic, and 1 of uncertain age) where subsequent surgery documented tendon avulsion (11) and MT injuries (6) by applying the primary MRI criteria of absent tendon at the humerus, retracted tendon stump, epicenter of edema, and the secondary finding of soft tissue edema contacting the anterior humeral cortex. Operative findings were used as the reference standard. Sensitivity, specificity, and positive and negative predictive value were recorded for each finding. RESULTS: The primary MRI finding of lack of a visible tendon at the insertion (sensitivity 82-100%, specificity 100%) and the secondary finding of edema contacting the anterior humeral cortex (sensitivity 64-91%, specificity 67-100%) were both useful for the distinction of tendon avulsion from MT injury, particularly in acute injuries. The presence of a retracted tendon stump and the epicenter of edema were not reliable findings. The use of a decision tree including the secondary finding of humeral edema increased the sensitivity and specificity for 2 of the 3 observers. CONCLUSION: MRI assessment of PM injury focused on the humeral insertion of the PM tendon allows accurate distinction of tendon avulsion from MT injury. CLINICAL IMPACT: This study describes a practical approach to classifying PM injuries with MRI to distinguish injuries that require surgery from those that can potentially be managed conservatively.

Fluoroscopy-guided intervertebral disc biopsy with a coaxial drill system.

OBJECTIVES: Percutaneous biopsy of discitis-osteomyelitis is performed to isolate the causative microorganism and exclude alternative diagnoses. We compared drill-assisted and manual fluoroscopy-guided intervertebral disc biopsies with respect to conscious sedation requirements and histologic quality of obtained specimens. MATERIALS AND METHODS: Medical records of all single-level, fluoroscopy-guided intervertebral disc biopsies supervised by one of two musculoskeletal radiologists between January 2010 and March 2015 were reviewed. Duration and cumulative medication doses required for each biopsy were recorded. Pathology reports were reviewed to determine whether the obtained specimens were adequate for histopathologic evaluation. Microbiology reports were reviewed to determine whether the causative organism was isolated from the biopsy specimen. RESULTS: During the study period, 21 drill-assisted and 20 manual biopsies were performed. The median duration of conscious sedation for drill-assisted biopsies was 30 min (range, 17-40 min) compared with 39 min (range, 20-90 min) for manual biopsies (p < 0.01). Drill-assisted biopsies also required lower median cumulative doses of intravenous midazolam [2 mg (range, 0-5 mg) vs. 3 mg (range, 0-9 mg); p = 0.02]. All drill-assisted biopsy specimens were adequate for histopathologic evaluation. One manual biopsy specimen (5 %; 1/20) was inadequate for histopathologic evaluation owing to crush artifact. The microbiology yields of drill-assisted and manual biopsies were comparable [14 % (3/21) vs. 20 % (4/20); p = 0.62]. CONCLUSIONS: Fluoroscopically-guided intervertebral disc biopsies performed with drill assistance require less conscious sedation compared with manual biopsies and yield specimens that are adequate for histopathologic evaluation.

Extracranial Giant Cell Arteritis - A Distinctive Subtype.

Giant cell arteritis (GCA) is a chronic vasculitis, characterized by inflammation of large- and medium-sized arteries, primarily affecting the external carotid artery and its branches, especially the superficial temporal artery. We describe a series of three cases of "extracranial GCA" involving the aorta and its branches in the absence of classical cranial arteritis symptoms at the onset. Because of the paucity of disease-specific manifestations and its variability, extracranial GCA can be an overlooked clinical entity. Our clinical series illustrates that early recognition can be challenging but critical in preventing potentially devastating complications.

Tennis leg: mechanism of injury and radiographic presentation.

As summer is upon us, we thought a discussion of tennis leg would be beneficial to our fellow clinicians. Tennis leg is a relatively common clinical condition, classically manifesting as acute, sports-related pain in the mid-calf. First described in 1883, the pathogenesis has been debated--tennis leg was first attributed to rupture of the plantaris tendon, though more recent investigations have implicated rupture of the medial head of the gastrocnemius at its myotendinous junction. For simplicity, many authors use the term tennis leg to describe all such acute muscle injuries in the superficial calf.

Fluoroscopy-Guided Percutaneous Vertebral Body Biopsy Using a Novel Drill-Powered Device: Technical Case Series.

BACKGROUND: A novel coaxial biopsy system powered by a handheld drill has recently been introduced for percutaneous bone biopsy. This technical note describes our initial experience performing fluoroscopy-guided vertebral body biopsies with this system, compares the yield of drill-assisted biopsy specimens with those obtained using a manual technique, and assesses the histologic adequacy of specimens obtained with drill assistance. METHODS: Medical records of all single-level, fluoroscopy-guided vertebral body biopsies were reviewed. Procedural complications were documented according to the Society of Interventional Radiology classification. The total length of bone core obtained from drill-assisted biopsies was compared with that of matched manual biopsies. Pathology reports were reviewed to determine the histologic adequacy of specimens obtained with drill assistance. RESULTS: Twenty eight drill-assisted percutaneous vertebral body biopsies met study inclusion criteria. No acute complications were reported. Of the 86 % (24/28) of patients with clinical follow-up, no delayed complications were reported (median follow-up, 28 weeks; range 5-115 weeks). The median total length of bone core obtained from drill-assisted biopsies was 28 mm (range 8-120 mm). This was longer than that obtained from manual biopsies (median, 20 mm; range 5-45 mm; P = 0.03). Crush artifact was present in 11 % (3/28) of drill-assisted biopsy specimens, which in one case (3.6 %; 1/28) precluded definitive diagnosis. CONCLUSIONS: A drill-assisted, coaxial biopsy system can be used to safely obtain vertebral body core specimens under fluoroscopic guidance. The higher bone core yield obtained with drill assistance may be offset by the presence of crush artifact.