Rapid Magnetic Resonance Imaging Evaluation of Femoral Neck Stress Fractures in a U.S. Active Duty Military Population.

OBJECTIVES: Timely diagnosis of femoral neck stress fractures is important to prevent fracture completion and displacement. We hypothesize that an abbreviated magnetic resonance imaging (MRI) hip examination can diagnose femoral neck stress fractures and that femoral neck stress fractures are common in U.S. military recruits. METHODS: We retrospectively reviewed abbreviated hip MRI examinations performed on active duty patients from November 1, 2013, to August 5, 2014. Patients were referred by primary care providers on the basis of high clinical suspicion. Study variables included presence and grade of femoral neck stress fractures. RESULTS: 229 patients were evaluated with an abbreviated hip MRI. 43 patients (18.8%) were diagnosed with femoral neck stress fractures and 12 patients (5.2%) had bilateral femoral neck stress fractures. All femoral neck stress fractures were on the compressive side. Grading of stress fractures was as follows: 0 Grade I (0%), 8 Grade II (14.5%), 32 Grade III (58.2%), and 15 Grade IV (27.2%). CONCLUSIONS: An abbreviated MR hip examination can diagnose femoral neck stress fractures as well as additional pathologies that explain the patient's symptoms. Femoral neck stress fractures are common in U.S. military personnel.

Suprascapular neuropathy after distal clavicle resection and coracoclavicular ligament reconstruction: a resident's case problem.

STUDY DESIGN: Resident's case problem. BACKGROUND: Acromioclavicular joint pathology is reported to be present in up to 30% of all patients complaining of shoulder dysfunction. The operative approach to treating acromioclavicular joint disease often includes a distal clavicle excision and, in circumstances of acromioclavicular joint instability, reconstruction of the coracoclavicular and/or the acromioclavicular ligament. Surgical complications for these procedures are rare, but potentially include suprascapular neuropathy secondary to the course of the suprascapular nerve posterior to the clavicle prior to entering the supraspinatus fossa. DIAGNOSIS: A 28-year-old Caucasian woman reported directly to an outpatient physical therapy clinic with a complaint of right shoulder weakness. Three years prior, the patient underwent a distal clavicle excision and coracoclavicular ligament reconstruction. A detailed examination, including diagnostic imaging, identified infraspinatus atrophy and weakness, increasing the suspicion for suprascapular nerve injury. Electromyography was ordered to confirm the clinical and imaging diagnosis of suprascapular neuropathy and to rule out other nerve lesions, especially considering the selective atrophy of the infraspinatus muscle without mechanical explanation. DISCUSSION: The clinical decision making and systematic use of diagnostic testing resulted in identifying a rare case of suprascapular neuropathy, selective to the infraspinatus, in a patient who previously underwent a distal clavicle excision and coracoclavicular ligament reconstruction. Without a spinoglenoid cyst or other suprascapular nerve lesion identified on advanced imaging, it is likely that the suprascapular neuropathy identified in this case was related to the surgical procedure. LEVEL OF EVIDENCE: Differential diagnosis, level 4.

Surgical management of retrorectal lesions: what the radiologist needs to know.

OBJECTIVE. The purpose of this article is to highlight the most salient imaging features of retrorectal masses with regard to surgical planning, preoperative biopsy, and identification of nonneoplastic mimickers of malignancy. CONCLUSION. Retrorectal tumors are associated with high morbidity. CT and MRI aid in preoperative planning because surgical resection is the treatment of choice for both benign and malignant entities. Radiologists need to understand the operative techniques currently used for retrorectal tumors because the first attempt at excision is the best chance for complete resection and optimal outcome.

Subtrochanteric femur fractures: review of the complete pathologic spectrum with emphasis on distinguishing imaging features.

Subtrochanteric femur fractures result from a variety of mechanisms of injury and underlying pathologies. Radiologists can play a pivotal role by differentiating the etiology of a subtrochanteric femur fracture, which assists the orthopedic surgeon in choosing the correct method of treatment. To provide this valuable service, one must be familiar with the characteristic radiologic features of the numerous causative etiologies, ranging from Paget disease to underlying bone lesions to iatrogenic fractures.

Sonography of musculoskeletal soft-tissue masses: techniques, pearls, and pitfalls.

OBJECTIVE: The purpose of this article is to review the appropriate use of ultrasound in the workup of soft-tissue masses of the extremities. The normal sonographic appearance of superficial soft tissues, the importance of proper technique in image acquisition, and the characteristic sonographic appearance of certain masses and potential pitfalls are discussed. CONCLUSION: Ultrasound is increasingly being used for the initial evaluation of soft-tissue masses of the extremities. Certain clinical and imaging findings allow diagnosis of selected soft-tissue masses; however, most imaging findings are nonspecific, and further evaluation is necessary. The many potential pitfalls can lead to adverse patient outcomes.

Greater trochanteric fracture with occult intertrochanteric extension.

Proximal femoral fractures are frequently encountered in the emergency department (ED). Prompt diagnosis is paramount as delay will exacerbate the already poor outcomes associated with these injuries. In cases where radiography is negative but clinical suspicion remains high, magnetic resonance imaging (MRI) is the study of choice as it has the capability to depict fractures which are occult on other imaging modalities. Awareness of a particular subset of proximal femoral fractures, namely greater trochanteric fractures, is vital for both radiologists and clinicians since it has been well documented that they invariably have an intertrochanteric component which may require surgical management. The detection of intertrochanteric or cervical extension of greater trochanteric fractures has been described utilizing MRI but is underestimated with both computed tomography (CT) and bone scan. Therefore, if MRI is unavailable or contraindicated, the diagnosis of an isolated greater trochanteric fracture should be met with caution. The importance of avoiding this potential pitfall is demonstrated in the following case of an elderly woman with hip pain and CT demonstrating an isolated greater trochanteric fracture who subsequently returned to the ED with a displaced intertrochanteric fracture.

Disruption of a patellar tendon repair.

The patient was a 38-year-old man evaluated by a physical therapist 14 weeks after repair of the left patellar tendon. The physical therapist requested radiographs, which revealed findings consistent with a patellar tendon retear. The radiologist recommended further evaluation with magnetic resonance imaging, which showed a left patellar tendon tear.

Imaging of hemorrhagic fever with renal syndrome: a potential bioterrorism agent of military significance.

Hemorrhagic fever with renal syndrome (HFRS) is a potentially fatal infectious disease with worldwide distribution. Its etiologic agents are viruses of the genus Hantavirus of the virus family Bunyaviridae. Hypothetical ease of production and distribution of these agents, with their propensity to incapacitate victims and overwhelm health care resources, lend themselves as significant potential biological agents of terrorism. HFRS has protean clinical manifestations, which may mimic upper respiratory tract infection, nephrolithiasis, and Hantavirus pulmonary syndrome and may delay proper treatment. Sequelae of HFRS, such as hemorrhage, acute renal failure, retroperitoneal edema, pancreatitis, pulmonary edema, and neurologic symptoms, can be detected by different imaging modalities. Medical providers caring for HFRS patients must be aware of its radiologic features, which may help to confirm its clinical diagnosis. In this article, the authors review the epidemiology, pathophysiology, clinical presentation, diagnosis, treatment, and complications of HFRS.

Isolated bone infarct of the calcaneus after fracture.

The calcaneus has a rich vascular supply; therefore, avascular necrosis of the calcaneus is extremely rare. We report the first case of bone infarct of the calcaneus 9 months after a fracture. We also review the literature on osteonecrosis of the calcaneus to offer potential mechanisms for bone infarction in the calcaneus after a fracture.

Magnetic resonance diagnosis of tarsal tunnel syndrome due to flexor digitorum accessorius longus and peroneocalcaneus internus muscles.

Anomalous muscles of the ankle are common. Although they are often asymptomatic, they can sometimes cause tarsal tunnel syndrome. We report a case of tarsal tunnel syndrome due to flexor digitorum accessorius longus and peroneocalcaneus internus muscles diagnosed on magnetic resonance imaging. Recognition of the most common accessory muscles of the ankle on magnetic resonance imaging and tarsal tunnel syndrome are also reviewed.

Costovertebral fracture dislocations: important radiographically difficult diagnosis.

The authors' aim is to report the appearance of fracture dislocations of the costovertebral joint. We will review the pertinent anatomy of the costovertebral articulation, summarize the current literature, report our experience and the imaging appearance of costovertebral joint fracture dislocations, and discuss important concepts of the costovertebral joint, as it relates to thoracic spine fractures.

Magnetic resonance imaging of stress injury of the cuneiform bones in patients with plantar fasciitis.

OBJECTIVE: The authors reported the magnetic resonance (MR) appearance of stress fractures of the cuneiform bones in patients with plantar fasciitis and performed a review of the literature on stress fractures associated with plantar fasciitis. MATERIALS AND METHODS: The authors performed a retrospective review of their experience with 5 cases of cuneiform stress fractures and associated plantar fasciitis. The medical records and MR examinations were reviewed. A literature search was performed on the PubMed search engine. RESULTS: There were 5 patients (1 man and 4 women) with stress fractures of at least 1 cuneiform bone. Patients' age ranged from 41 to 77 years, and their average weight was 212 lb. All patients had heel pain and either midfoot or lateral foot pain. There were 2 intermediate, 1 medial, and 3 lateral cuneiform stress fractures seen on MR imaging in these 5 patients. Two of these patients had undergone plantar fasciotomy, and all 5 had been treated with steroid injections. CONCLUSION: Plantar fascia injury, changes in gait, large body habitus, and excessive or new onset of exercise regimens are all potential causes of cuneiform stress fractures. Although the incidence of cuneiform stress fractures is extremely rare, they may occur in patients with plantar fasciitis.

Radiology pathology conference of Brooke Army Medical Center: trichoblastoma of breast.

The differential diagnosis of a superficial breast lesion detected on mammography typically includes seborrheic keratosis, dermal nevus, epidermal inclusion cyst, and basal cell carcinoma with subcutaneous invasion [Kopans DB. Breast Imaging. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2007; pp. 481-2]. The case presented is of a trichoblastoma of the superficial breast. Trichoblastoma is a benign skin neoplasm that is rarely found in the breast. It has not previously been described in the radiologic literature. This case describes and correlates the findings of trichoblastoma of the breast on mammography, sonography, and histology.

Comparison of planar scintigraphy alone and with SPECT for the initial evaluation of femoral neck stress fracture.

OBJECTIVE: The objective of our study was to compare the accuracy of planar scintigraphy alone versus planar scintigraphy with SPECT for the initial evaluation of femoral neck stress fractures in a young military population. MATERIALS AND METHODS: We retrospectively identified 38 patients who had undergone planar scintigraphy and 33 patients who had undergone planar scintigraphy and SPECT before MRI of the hips over a 6-month period for evaluation of suspected femoral neck fracture. Data were analyzed regarding the sensitivity and specificity of bone scanning alone and with SPECT for detecting femoral neck stress fracture and grading fractures as low grade (grades I and II) or high grade (grades III and IV). RESULTS: Twelve fractures were identified in the group who underwent planar scintigraphy alone and 13 in the group who underwent planar scintigraphy with SPECT. The sensitivities of planar scintigraphy alone and with SPECT were 50% and 92.3%, respectively (p = 0.03). The accuracy of each technique for the detection of high-grade fractures was 12.5% and 70%, respectively (p = 0.025). CONCLUSION: Planar scintigraphy with SPECT had a higher sensitivity and accuracy in assessing the grade of femoral neck stress fractures than planar scintigraphy alone. The results of this study suggest that SPECT should be performed with planar bone scintigraphy for the evaluation of patients with suspected femoral neck stress fractures.

Magnetic resonance appearance of intra-articular synovial sarcoma: case reports and review of the literature.

Intra-articular synovial sarcoma is extremely rare. The authors report the magnetic resonance appearance of 2 cases of intra-articular synovial sarcoma and review the current medical literature on this subject. Intra-articular synovial sarcoma must be considered in the differential diagnosis of a heterogeneously enhancing multiloculated intra-articular mass, especially in the knee joint, that does not have the typical radiological features of either synovial osteochondromatosis, pigmented villonodular synovitis, or synovial hemangiomas.

MRI of quadratus femoris muscle tear: another cause of hip pain.

OBJECTIVE: The objective of this study is to report the MR appearance of quadratus femoris muscle tear, another cause of hip pain. We will review the pertinent anatomy of the quadratus femoris muscle, summarize the current literature on quadratus femoris muscle tear, and report our experience in the diagnosis of quadratus femoris muscle tear on MRI. CONCLUSION: MRI is an important tool in assisting clinicians to make a correct diagnosis for the patient who presents with hip pain. Although quadratus femoris muscle tear is an uncommon injury, radiologists should be aware of this entity to assist with making a diagnosis that is usually unsuspected clinically.