Avulsion fracture of the tibial eminence in an adult with a unique mechanism of injury.

Tibial eminence avulsion fractures are not infrequent in the pediatric population; however, they are rare in the adult population. These injuries typically occur in skeletally immature patients between the ages of 8 and 14 years. We report the unique clinical history, imaging findings, and operative results of a 48-year-old female who presented with severe knee pain. Imaging findings revealed an anterior tibial eminence fracture with an intact anterior cruciate ligament tendon attached to the avulsed fragment. The patient underwent knee arthroscopy, with direct repair of the tibial eminence fracture.

Reviewing CT Scout Images: Observations of an Expert Witness.

OBJECTIVE: The purpose of this article is to share the views of an experienced expert witness in medical malpractice cases on the use of CT scout images. CONCLUSION: The medical literature has resurrected issues regarding viewing of CT scout images. Scout images are an integral part of any CT examination and should be carefully reviewed for findings that may or may not be included in the FOV of the study.

CT-guided iliosacral screw placement.

Computed tomography (CT)-guided iliosacral screw placement for posttraumatic instability of that joint is a safe procedure that may be performed in a radiology department. CT guidance allows more accurate screw placement than traditional fluoroscopic imaging in the operating room. This article describes the technique for placing cannulated surgical screws percutaneously across the iliosacral joint in patients with unstable pelvic fractures using CT for guidance. We also discuss the pitfalls of the procedure and the complications.

Cervical spine clearance in the traumatically injured patient: is multidetector CT scanning sufficient alone? Clinical article.

OBJECT: Clearance of the cervical spine in patients who have sustained trauma remains a contentious issue. Clinical examination alone is sufficient in neurologically intact patients without neck pain. Patients with neck pain or those with altered mental status or a depressed level of consciousness require further radiographic evaluation. However, no consensus exists as to the appropriate imaging modality. Some advocate multidetector CT (MDCT) scanning alone, but this has been criticized because MDCT is not sensitive in detecting ligamentous injuries that can often only be identified on MRI. METHODS: Patients were identified retrospectively from a prospectively maintained database at a Level I trauma center. All patients admitted between January 2004 and June 2011 who had a cervical MDCT scan interpreted by a board-certified radiologist as being without evidence of acute traumatic injury and who also had a cervical MRI study obtained during the same hospital admission were included. Data collected included patient demographics, mechanism of injury, Glasgow Coma Scale score at the time of MRI, the indication for and findings on MRI, and the number, type, and indication for cervical spine procedures. RESULTS: A total of 1004 patients were reviewed, of whom 614 were male, with an overall mean age of 47 years. The indication for MRI was neck pain in 662 patients, altered mental status in 467, and neurological signs or symptoms in 157. The MRI studies were interpreted as normal in 645 patients, evidencing ligamentous injury alone in 125, and showing nonspecific degenerative changes in the remaining patients. Of the 125 patients with ligamentous injuries, 66 (52.8%) had documentation of clearance (29 clinical, 37 with flexion-extension radiographs). Another 32 patients were presumed to be self-cleared, bringing the follow-up rate to 82% (98 of 119). Five patients died prior to clearance, and 1 patient was transferred to another facility prior to clearance. Based on these data, the 95% confidence interval for the assertion that clinically irrelevant ligamentous injury in the face of normal MDCT is 97%-100%. No patient with ligamentous injury on MRI was documented to require a surgical procedure or halo orthosis for instability. Thirty-nine patients ultimately underwent cervical surgical procedures (29 anterior and 10 posterior; 5 delayed) for central cord syndrome (21), quadriparesis (9), or discogenic radicular pain (9). None had an unstable spine. CONCLUSIONS: In this study population, MRI did not add any additional information beyond MDCT in identifying unstable cervical spine injuries. Magnetic resonance imaging frequently detected ligamentous injuries, none of which were found to be unstable at the time of detection, during the course of admission, or on follow-up. Magnetic resonance imaging provided beneficial clinical information and guided surgical procedures in patients with neurological deficits or radicular pain. An MDCT study with sagittal and coronal reconstructions negative for acute injury in patients without an abnormal motor examination may be sufficient alone for clearance.

Radiology medical student education: an outcome-based survey of PGY-1 residents.

RATIONALE AND OBJECTIVES: Postgraduate year (PGY)-1 residents are frequently required to order imaging studies and make preliminary interpretations on them. This study determines whether PGY-1 residents feel their radiology education in medical school sufficiently trained them for the clinical responsibilities of internship. MATERIALS AND METHODS: This multicenter, institutional review board-approved survey asked PGY-1 trainees three categories of questions: 1) extent of medical school training for ordering and interpreting imaging studies, 2) confidence levels in ordering appropriate imaging studies and making common/emergent diagnoses, and 3) rating the importance of radiologic interpretation by interns. Respondents also submitted ideas for medical school teaching topics deemed most useful for interns. RESULTS: A total of 175 questionnaires were returned with good representation across specialties. Although 63.7% of interns were frequently asked to independently preview radiology studies, 12.6% received no formal radiology training in medical school. Participants rated chest radiographs as the most important study for interns to competently interpret (93.4% reporting very or extremely important). However, only 60.2% of interns reported high confidence in recognizing common/emergent pulmonary findings, and 56.3% for evaluating line and tube position. With regard to ordering imaging studies, 81.0% had never used or never heard of the American College of Radiology Appropriateness Criteria®. Only 33.1% had high confidence in knowing when to order oral/intravenous contrast. Similar low percentages had high confidence identifying and premedicating contrast allergies (36.4%) and knowing risk factors of nephrogenic systemic fibrosis (13.2%). CONCLUSIONS: PGY-1 residents feel that medical school curriculum emphasizing interpretation of chest radiographs and ordering appropriate imaging studies would better prepare students for the responsibilities of internship.

ACR appropriateness criteria(®) acute trauma to the knee.

There are more than 1 million visits to the ER annually in the United States for acute knee trauma. Many of these are twisting injuries in young patients who can walk and bear weight, and emergent radiography is not required. Several clinical decision rules have been devised that can considerably reduce the number of radiographic studies ordered without missing a clinically significant fracture. Although fractures are seen on only 5% of emergency department knee radiographs, 86% of knee fractures result from blunt trauma. In patients with falls or twisting injuries who have focal tenderness, effusion, or inability to bear weight, radiography should be the first imaging study performed. If radiography shows no fracture, MRI is best for evaluating for a suspected meniscal or ligament tear or patellar dislocation. Patients with knee dislocation should undergo radiography and MRI, as well as fluoroscopic angiography, CT angiography, or MR angiography. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Understanding the US medical school requirements and medical students' attitudes about radiology rotations.

RATIONALE AND OBJECTIVES: To learn what percentage of US medical schools require their students to complete rotations in radiology during the clinical years. A secondary goal was to survey students' opinions about radiology rotations. MATERIALS AND METHODS: Data were collected from 159 US medical schools from the Association of American Medical Colleges (AAMC) for allopathic medical schools, the American Association of Colleges of Osteopathic Medicine (AACOM) for osteopathic medical schools, and by e-mailing curriculum directors at US medical schools with a survey. The secondary goal was achieved by e-mailing curriculum directors for voluntary medical student participation with an institutional review board-approved online survey. RESULTS: Data from the 2009-2010 academic year from AAMC and AACOM showed that 25% of US medical schools required radiology as a clinical rotation. Our survey of curriculum directors corroborated the AAMC and AACOM data. Data from our medical student survey showed that 87% of students from institutions requiring radiology thought radiology should be required. From institutions not requiring radiology, 45% of students thought that radiology should be required as a standalone course. Of students not required to take radiology, 63% planned to take radiology as an elective. CONCLUSIONS: Students, regardless of requirements, think there is value in having radiology as a regular aspect of a medical school curriculum. Medical schools should consider ways of incorporating radiology into their clinical curriculum.

ACR Appropriateness Criteria® on acute shoulder pain.

The shoulder joint is a complex array of muscles, tendons, and capsuloligamentous structures that has the greatest freedom of motion of any joint in the body. Acute (<2 weeks) shoulder pain can be attributable to structures related to the glenohumeral articulation and joint capsule, rotator cuff, acromioclavicular joint, and scapula. The foundation for investigation of acute shoulder pain is radiography. Magnetic resonance imaging is the procedure of choice for the evaluation of occult fractures and the shoulder soft tissues. Ultrasound, with appropriate local expertise, is an excellent evaluation of the rotator cuff, long head of the biceps tendon, and interventional procedures. Fluoroscopy is an excellent modality to guide interventional procedures. Computed tomography is an excellent modality for characterizing complex shoulder fractures. Computed tomographic arthrography or fluoroscopic arthrography may be alternatives in patients for whom MR arthrography is contraindicated. A multimodal approach may be required to accurately assess shoulder pathology. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Radiologic evaluation of chronic neck pain.

For many years, there were no guidelines for evaluating patients with chronic neck pain. However, in the past 15 years, considerable research has led to recommendations regarding whiplash-associated disorders. This article summarizes the American College of Radiology Appropriateness Criteria for chronic neck pain. Imaging plays an important role in evaluating patients with chronic neck pain. Five radiographic views (anteroposterior, lateral, open-mouth, and both oblique views) are recommended for all patients with chronic neck pain with or without a history of trauma. Magnetic resonance imaging should be performed in patients with chronic neurologic signs or symptoms, regardless of radiographic findings. The role of magnetic resonance imaging in evaluating ligamentous and membranous abnormalities in persons with whiplash-associated disorders is controversial. If there is a contraindication to magnetic resonance imaging, computed tomography myelography is recommended. Patients with normal radiographic findings and no neurologic signs or symptoms, or patients with radiographic evidence of spondylosis and no neurologic findings, need no further imaging studies.

ACR appropriateness criteria on metastatic bone disease.

Appropriate imaging modalities for screening, staging, and surveillance of patients with suspected and documented metastatic disease to bone include (99m)Tc bone scanning, MRI, CT, radiography, and 2-[(18)F]fluoro-2-deoxyglucose-PET. Clinical scenarios reviewed include asymptomatic stage 1 breast carcinoma, symptomatic stage 2 breast carcinoma, abnormal bone scan results with breast carcinoma, pathologic fracture with known metastatic breast carcinoma, asymptomatic well-differentiated and poorly differentiated prostate carcinoma, vertebral fracture with history of malignancy, non-small-cell lung carcinoma staging, symptomatic multiple myeloma, osteosarcoma staging and surveillance, and suspected bone metastasis in a pregnant patient. No single imaging modality is consistently best for the assessment of metastatic bone disease across all tumor types and clinical situations. In some cases, no imaging is indicated. The recommendations contained herein are the result of evidence-based consensus by the ACR Appropriateness Criteria((R)) Expert Panel on Musculoskeletal Radiology.

ACR Appropriateness Criteria on suspected osteomyelitis in patients with diabetes mellitus.

Imaging of the diabetic foot is among the most challenging areas of radiology. The authors present a consensus of the suggested tests in several clinical scenarios, such as early neuropathy, soft-tissue swelling, skin ulcer, and suspected osteomyelitis. In most of these situations, magnetic resonance imaging (MRI) with or without contrast is the examination of choice. Most other imaging tests have complementary roles. For soft-tissue swelling or an ulcer, radiography and MRI with or without contrast are suggested. Bone scintigraphy with white blood cell scanning is used when MRI is contraindicated. In patients with diabetes without ulcers, radiography and MRI with or without contrast are suggested; bone scanning may be used when MRI is contraindicated.

ACR Appropriateness Criteria on suspected spine trauma.

The evaluation of patients with suspected spine trauma is controversial. This document addresses several pertinent issues: (1) which patients need imaging, (2) how much imaging is necessary, and (3) exactly what sort of imaging is to be performed. This subject is important, because conservative estimates indicate that more than 1 million blunt trauma patients, who have the potential for sustaining spine injuries, are seen annually in emergency departments in the United States. Adult patients who satisfy any of several "low-risk" criteria for cervical spine injury need no imaging. Patients who do not fall into this category should undergo thin-section computed tomographic examinations that includes sagittal and coronal multiplanar reconstructed images. For those patients who cannot be examined using computed tomography, 3-view radiographic examinations of the cervical vertebrae may be performed to provide preliminary assessments of the likelihood of injury until computed tomography can be performed. Thoracic and lumbar computed tomographic images may be obtained from data collected for thorax-abdomen-pelvis studies. Radiography is recommended for children under 14 years of age. Reconstructed computed tomographic images may be used from thorax-abdomen-pelvis studies of children, if they have been obtained. Magnetic resonance imaging should be the primary modality for evaluating possible spinal cord injury or compression as well as ligamentous injuries in acute cervical spine trauma. Flexion and extension radiography is best reserved for follow-up of symptomatic patients, after neck pain has subsided.

Defining the relationship between rotator cuff injury and proximal humerus fractures.

The purpose of our study was to correlate radiographic characteristics with rotator cuff tendon injury on magnetic resonance imaging after fractures of the proximal humerus. We prospectively obtained magnetic resonance imaging on 30 patients with proximal humerus fractures after classifying each fracture radiographically using Neer and AO systems and determining the displacement of the greater tuberosity. Twelve patients (40.0%) had either complete ruptures or avulsions of at least one of the rotator cuff muscles. No abnormality was identified in the rotator cuff musculature in nine patients (29%). Severity of injury to the rotator cuff tendons increased substantially with respect to increasing AO and Neer classes and 5 mm or greater displacement of the greater tuberosity fragment. Additional study is needed to determine the exact role of rotator cuff tendon injury in the ultimate function attained by patients with proximal humerus fractures.

CT-guided iliosacral screw placement: technique and clinical experience.

OBJECTIVE: The purpose of this study was to describe the technique of and experience in using CT guidance for percutaneous iliosacral screw placement in patients with unstable pelvic fractures. CONCLUSION: CT-guided iliosacral screw placement is a safe and accurate procedure that can be performed by radiologists in a radiology suite.

Detection of cervical spine injuries in alert, asymptomatic geriatric blunt trauma patients: who benefits from radiologic imaging?

There are differing recommendations in the literature regarding cervical spine imaging in alert, asymptomatic geriatric patients. Previous studies also have not used computed tomography routinely. Given that cervical radiographs may miss up to 60 per cent of fractures, the incidence of cervical spine injuries in this population and its implications for clinical management are unclear. We conducted a retrospective study of blunt trauma patients 65 years and older who were alert, asymptomatic, hemodynamically stable, and had normal neurologic examinations. For inclusion, patients were required to have undergone computed tomography and plain radiographs. The presence and anatomic location of potentially distracting injuries or pain were recorded. Two hundred seventy-four patients were included, with a mean age of 76 +/- 10 years. The main mechanisms of injury were falls (51%) and motor vehicle crashes (41%). Nine of 274 (3%) patients had cervical spine injuries. The presence of potentially distracting injuries above the clavicles was associated with cervical injury when compared with patients with distracting injuries in other anatomic locations or no distracting injuries (8/115 vs 1/159, P = 0.03). There was no association of cervical spine injury with age greater or less than 75 years or with mechanism of injury. The overall incidence of cervical spine injury in the alert, asymptomatic geriatric population is low. The risk is increased with a potentially distracting injury above the clavicles. Patients with distracting injuries in other anatomic locations or no distracting injuries may not need routine cervical imaging.

POEMS syndrome: radiographic appearance with MRI correlation.

POEMS syndrome is a rare disorder in which patients present with the hallmark signs of polyneuropathy, organomegaly, endocrinopathy, M protein and skin changes. Many other clinical findings are also often present, most notably osseous lesions. The MRI appearance of the bony lesions in POEMS syndrome has been described in five cases, four of which are in the non-English literature. We report the MRI appearance of the osseous lesions in a patient with POEMS syndrome who presented with sciatic neuropathy.

Controversies in cervical spine imaging in trauma patients.

The subject of cervical spine imaging for trauma patients has generated significant controversy over the past decade and a half. This review considers three aspects of this controversy. The first examines the indications for cervical imaging, focusing on the factors that determine whether trauma patients are at high or low risk for cervical injury. The second discusses the uses of radiography and computed tomography as the main screening diagnostic examination. In addition to the roles of each modality in this evaluation process, other factors such as efficacy of diagnosis, time requirements for study, and cost will be discussed. The final section explores the methods currently used to "clear" the cervical spine in comatose patients.

Electrochemical corrosion of metal implants.

OBJECTIVE: The objective of our study was to show the radiographic changes that result from electrochemical corrosion of implanted metal in the body. CONCLUSION: Corrosion of metal implants is not rare. Radiologists should become familiar with the changes this process produces.

Controversies in cervical spine imaging in trauma patients.

No area of emergency radiology has generated as much discussion in recent years as the subject of cervical spine imaging for trauma patients. This review will be in three parts. The first will examine the indications for cervical imaging and will focus on those factors that make patients at high risk or low risk for cervical injury. The second part will discuss the merits of radiography and computed tomography as the main screening diagnostic examination. In addition to the roles of each modality in the evaluation process, such factors as efficacy of diagnosis, time (duration) of study, and cost will be discussed. Finally, the third part will explore the methods currently employed to "clear" the cervical spine in comatose patients.