Paraneoplastic musculoskeletal disorders: review and update for radiologists.

Rheumatic paraneoplastic syndromes are rare syndromes that occur at distant sites from the underlying tumor and may involve the bones, joints, fasciae, muscles, or vessels. In the absence of a known tumor, early recognition of a rheumatic syndrome as paraneoplastic permits dedicated work-up for, and potentially early treatment of an occult malignancy. Although there is a continuously growing list of paraneoplastic rheumatic disorders, not all of these disorders have a well-established association with a neoplastic process. The goals of this article are to review the clinical characteristics, diagnostic work-up, and imaging findings of well-documented rheumatic paraneoplastic disorders.

Meniscal Allograft Transplantation: A Pictorial Review.

Meniscal allograft transplantation may be indicated in a subset of patients with high-grade meniscectomy or irreparable meniscal injury and persistent knee pain that is resistant to conservative management. Meniscal allograft transplantation has demonstrated good to excellent results in short-term to midterm follow-up studies and satisfactory outcomes in long-term studies. The goals of this article are to review the indications, preoperative imaging assessment, surgical techniques, and postoperative assessment of uncomplicated and complicated meniscal allograft transplants.

Low-velocity, civilian firearm extremity injuries-review and update for radiologists.

Firearm injuries are a preventable epidemic in the USA. Extremities are commonly affected in gunshot injuries. Such injuries may be complex with concomitant osseous, soft tissue, and neurovascular components. The maximum wounding potential of a projectile is determined by its kinetic energy and the proportion of the kinetic energy that is transmitted to the target. Accurate assessment of ballistic injuries is dependent on utilizing the principles of wound ballistics, accurate bullet count, and ballistic trajectory analysis. The goals of this article are to review wound ballistics and the imaging evaluation of extremity civilian firearm injuries in the adult population, with emphasis on ballistic trajectory analysis, specific ballistic fracture patterns, and diffuse, secondary soft tissue ballistic injuries.

Non-interventional Radiology Fellowship Programs: What Is Out There?

OBJECTIVE: To determine the spectrum of non-interventional radiology fellowship programs in institutions that offer both a radiology residency program and one or more non-interventional radiology fellowship programs. METHODS: Institutions offering both radiology residency and non-interventional radiology fellowship programs were identified using publicly available websites. The non-interventional radiology fellowship programs were categorized into "traditional" (neuroradiology, breast imaging, abdominal imaging, musculoskeletal imaging, thoracic imaging, pediatric radiology, and nuclear medicine) and "nontraditional" fellowship programs. The nontraditional programs were stratified into four categories: a) Combinations of traditional fellowships; b) Focused nontraditional fellowships; c) Combinations of traditional and focused nontraditional fellowships (excluding traditional-traditional combinations); and d) Mandatory two-year fellowships. The distributions of the different types of traditional and nontraditional fellowship programs were evaluated. RESULTS: 555 fellowship programs were identified in 113 institutions that offered both radiology residency and non-interventional radiology fellowship programs. 73.33% (407/555) of the programs were traditional fellowships, and 26.66% (148/555) were nontraditional fellowships. The 148 nontraditional fellowship programs were comprised of 41 different types of programs, 23 types of which were unique to and offered exclusively at specific institutions. 38.08% of the traditional fellowship programs were Accreditation Council for Graduate Medical Education (ACGME) accredited, while only 16.21% (24/148) of the nontraditional fellowship programs were ACGME-accredited. CONCLUSIONS: The nontraditional non-interventional radiology fellowship programs are formed by a heterogeneous group of programs, some of which are offered exclusively at a single institution. Awareness of the types of existing programs would help radiology residents in making a more informed decision regarding their fellowship training.

Surgical techniques for management of acromioclavicular joint separations: review and update for radiologists.

Imaging plays a central role in the postoperative management of acromioclavicular (AC) joint separations. There are more than 150 described techniques for the surgical management of AC joint injuries. These procedures can be categorized as varying combinations of the following basic techniques: a) soft-tissue repair, b) trans-articular AC joint fixation, c) coracoclavicular (CC) fixation, d) non-anatomic reconstruction of the CC ligaments, e) anatomic reconstruction of the CC ligaments, f) distal clavicle resection, and g) dynamic muscle transfer. The goals of this article are to describe the basic techniques for the surgical management of AC joint separations with an emphasis on technique-specific complications and postoperative imaging assessment.

External fixators: looking beyond the hardware maze.

External fixation has a wide variety of orthopedic applications. Although external fixator frames may have a complex appearance, these constructs are formed from several basic components and can be broadly categorized into unilateral, circular, or hybrid designs. The introduction of computer-aided circular external fixation devices (hexapod frames) has simplified the treatment of multiaxial and especially rotational deformities. Serial radiography plays a central role in the evaluation of callus formation (at the level of treated fracture or nonunion as well as the regenerate and docking site with distraction osteogenesis), tailoring the rate and rhythm of distraction during distraction osteogenesis, evaluation of frame complications, and determination of the timing of frame removal. The goals of this article are to review: the components, types, and relevant terminology of external fixator constructs with special emphasis on the Taylor spatial frame, the principles and techniques of distraction osteogenesis, and complications of external fixation.

Clavicle fixation screw impingement causing subclavian artery pseudoaneurysm.

Vascular injuries are an extremely rare complication of clavicle osteosynthesis, though several cases are reported in the literature. Cadaver studies have established recommended safe lengths for clavicle screws based on precise measurements of bone thickness and distance from subjacent neurovascular structures. We present the case of a 27-year-old female who underwent orthopedic plate and screw fixation of a clavicle fracture and subsequently sustained iatrogenic vascular injury from one of the screws. This necessitated endovascular repair and orthopedic revision. This case underscores the importance of selecting appropriate screws based on available imaging.

Ankle medial flexor retinaculum avulsion fracture.

Medial flexor retinaculum injuries are not uncommon, but medial flexor retinaculum periosteal avulsion injuries are rare. This patient sustained a medial flexor retinaculum tear readily characterized at computed tomography by an associated proximal retinacular avulsion fracture from the posteromedial tibia. Medial flexor retinaculum injury is often also associated with superficial deltoid pathology and/or medial malleolar fracture. An additional significant complication of medial flexor retinaculum tear is anterior dislocation of the tibialis posterior tendon, which heralds a tibialis posterior fibro-osseous tunnel injury.

Incidental discovery of isolated talonavicular coalition: Report of two cases.

Tarsal coalitions may cause altered foot biomechanics leading to patient disability from osteoarthritis and other sequelae. While some types of coalition are common, isolated talonavicular coalitions are relatively rare. We present two cases of osseous talonavicular coalition that were incidentally discovered in adults and were most likely asymptomatic. Talonavicular coalition may have a hereditary component and may be associated with other anomalies, but many seem isolated, asymptomatic, and incidental.

Scapulothoracic dissociation.

Scapulothoracic dissociation is a rare and potentially limb- and life-threatening injury, that results from high-energy trauma. Scapulothoracic dissociation has the potential to be overlooked in the acute setting, especially in the setting of polytrauma. Therefore, a careful search for this condition should be performed in all patients with high-energy shoulder girdle injuries. The goals of this article are to review the anatomy of the scapulothoracic articulation as well as the spectrum, imaging evaluation, differential diagnosis and management of scapulothoracic dissociations.

Multiple open wrist fractures and dislocation of the distal radioulnar joint from a dog bite injury.

Dogs are commonly kept as household pets, but sometimes pet dogs bite people. We report the case of a 69-year-old man who was bitten by his pet pit bull terrier. The dog bite resulted in multiple open wrist fractures and dislocation of the distal radioulnar joint, requiring surgical debridement, open reduction and internal fixation, and bone grafting. CT of the fractures showed that the dog's maxillary canine teeth had been deeply embedded in the hamate and second metacarpal bones, requiring that the dog's mouth be opened and the teeth disengaged in order to remove the injured limb from the dog.

The floating shoulder.

The floating shoulder refers to a subset of complex shoulder injuries that typically occur in the setting of high-energy trauma. Identification of the full extent of complex shoulder injuries with computed tomography may have critical implications in patient management. The goals of this article are to review the anatomy, definition, imaging evaluation, and treatment of floating shoulder injuries.

Thoracic cage injuries.

Rib fractures are the most common form of blunt thoracic injury. Multiple rib fractures are an important indicator of trauma severity, with increased morbidity and mortality occurring with increasing numbers of rib fractures, especially in the elderly. Thoracic cage injuries may be associated with concomitant and potentially life-threating injuries. In the acute setting, correct recognition of the pattern, extent and severity of thoracic cage injuries, may aid in more accurate delineation of concomitant injuries.

The Relevance of Ulnar-Sided Contrast Extravasation During Radiocarpal Joint Wrist Arthrography.

OBJECTIVE: Contrast material often extends from the radiocarpal joint into the proximal soft tissues adjacent to the ulnar aspect of the ulnar styloid during single-compartment radiocarpal joint MR arthrography of the wrist. The hypothesis of this study was that this is a common finding unrelated to symptoms or examination technique. MATERIALS AND METHODS: Wrist MR arthrograms were retrospectively reviewed in consensus by two radiologists. The presence or absence of ulnar-sided contrast extravasation was documented, whether this extravasation appeared contained or dispersed, as was the overall degree of proximal extension of the extravasated contrast material. Patient age, sex, wrist sidedness, volume of contrast material administered, location of symptoms reported clinically, and aberrant contrast material also apparent within the midcarpal space or distal radioulnar joint on the MR images reviewed were documented to determine potential association with ulnar-sided contrast extravasation. RESULTS: Ninety-nine examinations met the inclusion criteria. Ulnar-sided contrast extravasation after single-compartment radiocarpal joint injection was present in 56 of the 99 wrists (57%). This finding was statistically more common in right versus left wrists. No other statistically significant associations were identified. CONCLUSION: Contrast extravasation along the ulnar aspect of the distal ulna after single-compartment radiocarpal joint injection is common. In this study it had no statistically significant association with the location of a patient's wrist pain or abnormal findings evaluated at MR arthrography.

Terrible triad injuries of the elbow.

Terrible triad injury of the elbow is a complex injury that is classically defined as elbow dislocation along with fractures of the coronoid process of the ulna and the radial head. The injury is usually associated with typical soft-tissue disruptions (with common involvement of the lateral collateral ligament complex, elbow joint capsule, as well as the common extensor and flexor-pronator tendons) that are best understood in the context of injury mechanism as well as the role and relevance of the various elbow stabilizers. The goals of this article are to review the pertinent anatomy, mechanism of injury, classification and imaging of terrible triad injuries of the elbow with brief descriptions of treatment, and complications of this complex injury.

Fragility fractures of the proximal femur: review and update for radiologists.

Proximal femoral fragility fractures are common and result in significant morbidity and mortality along with a considerable socioeconomic burden. The goals of this article are to review relevant proximal femoral anatomy together with imaging, classification, and management of proximal femoral fragility fractures, and their most common complications. Imaging plays an integral role in classification, management and follow-up of proximal femoral fragility fractures. Classification of proximal femoral fragility fractures is primarily based on anteroposterior hip radiographs. Pertinent imaging features for each category of proximal femoral fractures that would guide management are: differentiating nondisplaced from displaced femoral neck fractures, distinguishing stable from unstable intertrochanteric fractures, and determining the morphology and comminution of subtrochanteric fractures. Treatment of proximal femoral fragility fractures is primarily surgical with either arthroplasty or internal fixation. Intramedullary nailing is used in the treatment of some types of proximal femoral fragility fractures and may be associated with unique complications that become evident on postoperative follow-up radiographs.

Disengagement and intrapelvic migration of a dynamic helical hip screw.

Some proximal femur fractures may be treated surgically with the use of fracture fixation hardware such as the sliding hip screw and its variants. These devices allow the femoral head and neck fragment to compress against the trochanteric or shaft fragment as the hip screw telescopes into the barrel of the side plate. We describe an unusual complication in which the hip screw disengaged in the opposite direction, migrated through the hip joint, and came to rest inside the pelvic cavity. The separated components of the device were surgically removed without further complication.