Challenges in diagnosis of calcaneal fractures: an examination using the WIDI SIM platform.

INTRODUCTION: The calcaneus is the most commonly fractured tarsal bone. Diagnosis is often challenging due to subtle radiographic changes and requires timely identification to prevent complications, including subtalar arthritis, neurovascular injury, malunion, osteomyelitis, and compartment syndrome. Treatment varies based on fracture type, with non-surgical methods for non-displaced stress fractures and surgical interventions for displaced or intra-articular fractures. METHODS: This study utilized the Wisdom in Diagnostic Imaging Simulation (WIDI SIM) platform, an emergency imaging simulation designed to assess radiology resident preparedness for independent call. During an 8-hour simulation, residents were tested on 65 cases across various imaging modalities of varying complexity, including normal studies. A single, unique case of calcaneal fracture was included within the simulation in four separate years of testing. Cases were assessed using a standardized grading rubric by subspecialty radiology faculty, with errors subsequently classified by type. RESULTS: A total of 1279 residents were tested in five separate years on the findings of calcaneal fractures of 5 different patients. Analysis revealed a consistent pattern of missed diagnoses across all training years, primarily attributed to observational errors. There was limited improvement with training progression as all training years exhibited similar average performance levels. CONCLUSIONS: Calcaneal fractures pose a diagnostic challenge due to their frequent subtle radiographic findings, especially in stress fractures. Simulation-based evaluations using WIDI SIM highlighted challenges in radiology residents' proficiency in diagnosing calcaneal fractures. Addressing these challenges through targeted education and exposure to diverse cases is essential to improve diagnostic accuracy and reduce complications with calcaneal fractures.

Comparison of metal artifact reduction using single-energy CT and dual-energy CT with various metallic implants in cadavers.

OBJECTIVES: The purpose of this study was to compare the effectiveness of metal artifact reduction using Single Energy Metal Artifact Reduction (SEMAR) and Dual Energy CT (DECT). MATERIALS AND METHODS: Six cadavers containing metal implants in the head, neck, abdomen, pelvis, and extremities were scanned with Standard, SEMAR, and DECT protocols on a 320-slice CT scanner. Four specialized radiologists blinded to acquisition methods rated severity of metal artifacts, visualization of anatomic structures, diagnostic interpretation, and image preference with a 5-point grading scale. RESULTS: Scores were significantly better for SEMAR than Standard images in the hip, knee, pelvis, abdomen, and maxillofacial scans (3.25 ±â€¯0.88 versus 2.14 ±â€¯0.93, p < 0.001). However, new reconstruction artifacts developed in SEMAR images that were not present in Standard images. Scores for severity of metal artifacts and visualization of smooth structures were significantly better for DECT than Standard images in the cervical spine (3.50±0.50 versus 2.0±0.58, p < 0.001) and was preferred over Standard images by one radiologist. In all other cases, radiologists preferred the Standard image over the DECT image due to increased image noise and reduced low-contrast resolution with DECT. In all cases, SEMAR was preferred over Standard and DECT images. CONCLUSION: SEMAR was more effective at reducing metal artifacts than DECT. Radiologists should be aware of new artifacts and review both the original and SEMAR images. When the anatomy or implant is relatively small, DECT may be superior to SEMAR without additional artifacts. However, radiologist should be aware of a reduction in soft tissue contrast.

Fluoroscopically-guided therapeutic injection of the proximal tibiofibular joint in a patient with lateral knee pain.

Proximal tibiofibular joint (PTFJ) pathology is an uncommon but perhaps underappreciated cause of lateral knee pain. While imaging guided therapeutic injections for diagnosis and management of joint related symptoms are now commonplace and numerous techniques for accessing most joints in the body have been documented, a technique for fluoroscopically guided injection of the PTFJ has not been yet described in the literature. We present a case of an adult patient who presented with lateral knee pain refractory to conservative management who opted for a fluoroscopically-guided therapeutic injection of her PTFJ.

Current Concepts of Femoroacetabular Impingement.

Femoroacetabular impingement (FAI) is a prevalent clinical syndrome and likely a primary contributor to idiopathic hip osteoarthritis. It is characterized by osseous pathomorphology in the hip that alters normal biomechanics, causing accelerated joint degeneration and characteristic patterns of chondral and labral injuries. Early intervention in well-selected patients can provide symptomatic relief and delay progression to osteoarthritis. Because imaging findings of FAI are subtle, a checklist approach based on current concepts is necessary to efficiently generate imaging reports that advance clinical decision-making. This article details an approach to the imaging assessment of FAI.

Computed tomography-guided renal tumor biopsies: tumor imaging features affecting sample adequacy.

OBJECTIVE: The aim of this study was to derive a model that predicts when a computed tomography (CT)-guided renal tumor biopsy will be diagnostic based on the tumor's unenhanced imaging characteristics. METHODS: The CT images used to guide percutaneous biopsy and the pathology reports of 276 consecutive patients undergoing renal tumor biopsy were retrospectively reviewed. The effect of tumor size, growth pattern, location, and CT attenuation on the diagnostic biopsy rate was assessed using univariate and multivariate techniques. A model was derived using logistic regression, and its discrimination was evaluated using receiver operator characteristic curves. RESULTS: The diagnostic rate for all masses was 76.8% (212/276). Univariate and multivariate analyses revealed that increasing size and solid tumor attenuation were associated with diagnostic biopsies. The model demonstrates a discrimination of 0.71. CONCLUSIONS: The likelihood of a diagnostic biopsy of a solid tumor smaller than 1 cm and of any cystic tumor is significantly less than for larger solid renal tumors. The predictive model demonstrates moderate discrimination.

Treatment of infolding related to the gore TAG thoracic endoprosthesis.

The present report describes three cases of thoracic aortic endograft infolding or collapse involving the Gore TAG system. The cases include a penetrating aortic injury, a blunt aortic injury, and a symptomatic type B dissection. In the first case, infolding occurred in a delayed fashion after a normal-appearing 3-month follow-up computed tomographic angiogram. In the other two cases, infolding occurred during the immediate postoperative phase. One of the patients underwent explantation and surgical repair. The other two underwent endovascular repair of the infolded endograft by placement of a balloon-expandable stent in one case and a self-expanding stent in the other.

Computed tomographic angiography for the diagnosis of blunt carotid/vertebral artery injury: a note of caution.

OBJECTIVE: Computed tomographic angiography (CTA) by 16-channel multidetector scanner is increasingly replacing conventional digital subtraction angiography (DSA) for diagnosing or excluding blunt carotid/vertebral injuries (BCVI). To date there has been only 1 study in which all patients received both examinations. That study reported a high accuracy for 16-detector CTA. The current prospective parallel comparative study aims at validating this high accuracy and examining the rates of evaluability of CTA performed with a 16-detector scanner with image reconstruction by modern imaging software. METHODS: Patients at risk for BCVI (facial/cervical-spinal fractures; unexplained neurologic deficit; anisocoria; lateral neck soft tissue injury; clinical suspicion) underwent both CTA (16-channel multidetector scanner) and DSA. Results of the 2 studies and the clinical course were prospectively recorded. RESULTS: During the 40-month study period ending March 2007, approximately 7000 blunt trauma patients were evaluated and of these 119 (1.7%) consecutive patients meeting inclusion criteria were screened by CTA. Ninety-two patients underwent confirmatory DSA. Twenty-three (22%) DSA identified 26 BCVI (vertebral, 13; carotid, 13). Among these 23 CTAs, 17 identified 19 BCVIs (vertebral, 10; carotid, 9) (true positives), and 6 failed to identify 7 BCVIs (vertebral, 3; carotid, 4) (false negatives). Sixty-nine of the 92 DSA were normal. Of these 69 CTAs, 10 were falsely suspicious for 11 BCVIs (vertebral, 7; carotid, 4) (false positives), and 56 were normal (true negatives). The remaining 3 CTAs were nonevaluable (mistimed contrast, 1; streak artifact, 2). Sixteen of 89 (18%) evaluable CTAs, were suboptimal (mistimed contrast, 9; streak artifacts, 4; motion artifact, 2; body habitus, 1). Excluding the 3 nonevaluable CTAs, the sensitivity, specificity, positive and negative predictive values of CTA for diagnosing or excluding BCVI were 74%, 86%, 65%, and 90% respectively. One patient with grade II carotid artery injuries (by CTA and DSA) on antiplatelet agent developed stroke related to carotid artery injuries. CONCLUSIONS: Current CTA technology cannot reliably diagnose or exclude BCVI. Twenty percent of CTAs are either nonevaluable or suboptimal. Until more data are available and the technique is standardized, the current trend towards using CTA to screen for and/or diagnose these rare but potentially devastating injuries is dangerous.

Placement of intracranial pressure monitors: are "normal" coagulation parameters necessary?

INTRODUCTION: Patients with head injuries frequently have abnormal coagulation studies. Monitoring intracranial pressure (ICP) in head injured patients is common practice, but no best practice guidelines exist for coagulation parameters for ICP monitor placement. PURPOSE: To test the hypothesis that hemorrhagic complication rates from ICP monitor placement are low and that the use of FFP to correct coagulation parameters to "normal" is not indicated. METHODS: Retrospective review of all patients admitted to a Level I trauma center over a 3 year period, who underwent fiberoptic intraparenchymal ICP monitoring was undertaken. Inclusion criteria were coagulation studies (prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR), platelet count) before ICP monitor placement and head CT scans to assess for hemorrhage before and after monitor placement. Data collected included age, Glasgow coma score (GCS), head region abbreviated injury score (H_AIS), time to ICP monitor placement, complications and outcomes. RESULTS: From 8/1/00 through 7/31/03, 5163 trauma patients were admitted, and 157 met inclusion criteria. Patients were stratified by INR, at the time of ICP placement as normal (0.8-1.2, 103 patients), borderline (1.3-1.6, 42 patients) and increased (>/=1.7, 12 patients). There was no difference between the groups in age, gender or H_AIS. Twenty two patients had component therapy to correct coagulopathy before ICP insertion, but 10 had INRs in the borderline group and 12 remained with INRs >/=1.7. Eleven patients had platelet counts 50,000-100,000 at ICP monitor placement, despite platelet transfusions. Time from admission to ICP monitor placement was significantly longer in patients who received component therapy (19.2 +/- 19.7 hours versus 8.8 +/- 13.9 hours, p < 0.002). Three patients had clinically insignificant, petechial hemorrhages (1.9%); one in each group, with INRs of 1.2, 1.3, and 2.5, respectively. CONCLUSIONS: In patients with INR

Are automated blood pressure measurements accurate in trauma patients?

BACKGROUND: Automated blood pressure (BP) determinations by oscillometry are reported to be as accurate as invasive monitoring for systolic pressures as low as 80 mm Hg. Automated BP devices are widely used by prehospital providers and in hospital operating rooms, emergency departments, and intensive care units, although the accuracy of automated BP has not been demonstrated in trauma patients. We hypothesized that automated BP is less accurate than manual BP in trauma patients. The purpose of this study was to determine the accuracy of automated BP versus manual BP in trauma patients. METHODS: A retrospective review of patients who met trauma activation criteria admitted to a Level I trauma center over a 30-month period was conducted. Patients were included if both manual BP and automated BP were measured within 5 minutes of admission. Additional data collected included Injury Severity Score, base deficit, and emergency department resuscitation volume. Statistical analysis was performed using paired t test, chi2, and linear regression analysis. Significance was attributed to a value of p < 0.05. RESULTS: From January 2000 through June 2002, 388 patients met inclusion criteria. Patients were grouped by manual BP levels: group 1, BP < or = 90 mm Hg (n = 92); group 2, BP 91-110 mm Hg (n = 119); and group 3, BP > or = 110 mm Hg (n = 177). The mean automated BP measurements were significantly higher than the manual measurements in groups 1 and 2 (26 and 16 mm Hg, respectively; p < 0.001). Of the 92 patients with manual BP < or = 90, 45 (49%) had automated BP > or = 100. The base deficit (-5, -3, and -2 for groups 1, 2, and 3, respectively; p < 0.01), Injury Severity Score (30, 25, and 18; p < 0.01), and volume of resuscitative fluid and blood (p < 0.001) all decreased with higher BP group. CONCLUSION: Injury severity, degree of acidosis, and resuscitation volume were more accurately reflected by manual BP. Automated BP determinations were consistently higher than manual BP, particularly in hypotensive patients. Automated BP devices should not be used for field or hospital triage decisions. Manual BP determinations should be used until systolic blood pressure is consistently > or = 110 mm Hg.