Lumbar facet joint synovial cyst: percutaneous treatment with steroid injections and distention--clinical and imaging follow-up in 12 patients.

PURPOSE: To determine the imaging characteristics of lumbar facet joint synovial cysts after percutaneous treatment with steroid injections and distention of the cyst and to correlate these findings with the clinical outcome. MATERIALS AND METHODS: Clinical outcome and imaging findings were retrospectively studied in 12 patients (four men, eight women) aged 45-79 years (mean, 60 years) with a symptomatic lumbar facet joint synovial cyst treated with percutaneous steroid injections. At varying times after the procedure, patients were contacted for clinical follow-up, and repeat imaging was performed to verify the status of the cyst. RESULTS: Excellent pain relief was achieved in nine (75%) of 12 patients. At follow-up imaging, the cyst completely regressed in six (67%) of these nine patients, partially regressed in two (22%) patients, and was unchanged in one (11%) patient. One (8%) of the 12 patients had transient pain relief, with recurrence of symptoms at short intervals after each of three injections. No pain relief was achieved in two (17%) of 12 patients. CONCLUSION: Image-guided percutaneous steroid injections are often effective in the treatment of lumbar facet joint synovial cysts and may result in complete regression of the cyst.

Adductor insertion avulsion syndrome (thigh splints): spectrum of MR imaging features.

OBJECTIVE: "Thigh splints," also known as the adductor insertion avulsion syndrome, is a painful condition affecting the proximal to mid femur at the insertion of the adductor muscles of the thigh. Scintigraphic findings in this syndrome have been described; we report a spectrum of MR imaging abnormalities involving this portion of the femur in a group of patients presenting with hip, groin, or thigh pain. CONCLUSION: Symptoms of vague hip, groin, or thigh pain may be associated with stress-related changes in the proximal to mid femoral shaft (thigh splints). When interpreting MR imaging studies of the pelvis in patients presenting with these symptoms, careful attention should be directed to this portion of the femur. This is especially important because the findings may be subtle, and this region is often at the distal edge of most MR imaging studies of the pelvis and hip.

Association of posterior tibial tendon abnormalities with abnormal signal intensity in the sinus tarsi on MR imaging.

OBJECTIVE: To evaluate the association of abnormal signal intensity within the sinus tarsi with abnormalities of the posterior tibial tendon (PTT) on MR imaging. DESIGN AND PATIENTS: Sinus tarsi abnormalities were identified on 30 ankle MR examinations in 29 patients. The PTT and anterior talofibular ligament were retrospectively analyzed for abnormalities in these same patients. RESULTS AND CONCLUSIONS: Tears of the anterior talofibular ligament were found in 13 of 30 (43%) ankles. PTT abnormalities (complete tear, partial tear or dislocation) were seen in 14 of 30 (47%) studies, and were distributed relatively equally between those patients with and without lateral ligament tears. Our results provide evidence of an association between abnormalities of the PTT and the sinus tarsi. The finding of abnormal signal intensity within the sinus tarsi on MR imaging should alert the radiologist to potential abnormalities of the PTT.

Identification of tibial stress fractures using therapeutic continuous ultrasound.

STUDY DESIGN: One-group discriminant analysis. OBJECTIVE: To determine whether 1 MHz of continuous ultrasound can identify tibial stress fractures in subjects. BACKGROUND: Stress fractures can lead to loss of function or to more serious nonunion fractures. Early diagnosis is important to reduce the risk of further injury and to assure a safe return to activity. Therapeutic ultrasound has been reported to be an accessible, less expensive alternative in diagnosing stress fractures compared with other diagnostic techniques. METHODS AND MEASURES: Twenty-six subjects (12 men, 20.33 +/- 1.37 years; 14 women, 20.78 +/- 3.8 years) with unilateral tibia pain for less than 2 weeks volunteered to participate in the study. Continuous, 1 MHz ultrasound was applied to the uninvolved and involved tibias at 7 increasing intensities for 30 seconds each. Subjects completed a visual analog scale after the application of each intensity to assess the pain response to ultrasound. Results from the visual analog scale were compared to magnetic resonance imaging (MRI) findings to determine if continuous ultrasound could predict whether subjects had a normal MRI, increased bone remodeling, or advanced bone remodeling consistent with a stress fracture. RESULTS: Discriminant analysis on the visual analog scale correctly classified subjects into 1 of 3 clinical classification groups in 42.31% of the cases. None of the subjects found to have a stress fracture by MRI were correctly identified by continuous ultrasound. This resulted in a predicted sensitivity of 0% and a predicted specificity of 100%. CONCLUSIONS: A protocol using visual analog scores after the application of 1 MHz continuous ultrasound is not sensitive for identifying subjects with tibial stress fractures.

Avulsion fracture of the base of the fifth metatarsal not seen on conventional radiography of the foot: the need for an additional projection.

OBJECTIVE: To our knowledge, this article is the first to describe a series of patients with avulsion fractures of the base of the fifth metatarsal that were not seen on conventional radiography using the standard three views of the foot but that were seen on radiography of the ankle. CONCLUSION: Because routine radiographs of the foot may fail to reveal an avulsion fracture of the base of the fifth metatarsal, an additional projection should be obtained to better assess this region in the symptomatic patient. The additional view should be an anteroposterior radiograph of the ankle that includes the base of the fifth metatarsal because this projection has been shown to help in the diagnosis of this avulsion fracture.

Fluoroscopy-guided sacroiliac joint injections.

The authors performed fluoroscopy-guided sacroiliac (SI) joint injections. With the patient prone and the x-ray tube perpendicular to the fluoroscopic table, the skin was marked over the distal 1 cm of the SI joint. With the tube angled 20 degrees - 25 degrees cephalad, a 22-gauge needle was inserted at the skin mark and advanced perpendicular to the fluoroscopic table toward the posterior joint. Nonionic contrast material was injected to confirm the intraarticular position of the needle. Of 31 SI joint injections, 30 (97%) were intraarticular. Mean procedure time was 108 seconds. This technique is safe, rapid, and reproducible.

Pedicle marrow signal intensity changes in the lumbar spine: a manifestation of facet degenerative joint disease.

OBJECTIVE: Signal intensity changes in lumbar pedicles, similar to those described in vertebral body endplates adjacent to degenerated discs, have been described as an ancillary sign of spondylolysis on MRI. The purpose of this study was to determine whether pedicle marrow signal intensity changes also occur in association with facet degenerative joint disease. DESIGN: Eighty-nine lumbar spine MRI examinations without spondylolysis were reviewed for marrow signal intensity changes in pedicles and vertebral bodies as well as for facet degenerative joint disease. RESULTS: Five percent (46/890) of lumbar pedicles in 23 patients had marrow signal intensity changes. Ninety-one percent (42/46) of the abnormal pedicles had adjacent degenerative joint disease of the facets, while only 21% (189/890) of normal pedicles had adjacent facet degenerative joint disease (p<0.001). Eighty-nine percent (41/46) of the pedicles with marrow signal intensity changes had adjacent degenerative disc disease. CONCLUSIONS: Pedicle marrow signal intensity changes are not a specific sign of spondylolysis; they are commonly seen with adjacent facet degenerative joint disease in the absence of spondylolysis. Pedicle marrow signal intensity changes are probably a response to abnormal stresses related to abnormal motion or loading caused by the degenerative changes in the spinal segment.

Compartmental anatomy: relevance to staging and biopsy of musculoskeletal tumors.

A thorough understanding of compartmental anatomy is essential for accurate staging of a suspected musculoskeletal tumor with MR imaging and for avoiding potentially devastating biopsy-related complications. Imaging-guided, percutaneous needle biopsy is a safe and cost-effective technique but requires careful planning in conjunction with the surgeon who will perform the definitive surgery because it constitutes the final step in the staging process and the first step in surgical therapy.

Bone contusions of the posterior lip of the medial tibial plateau (contrecoup injury) and associated internal derangements of the knee at MR imaging.

PURPOSE: To determine if there are any predictable patterns of internal derangement associated with a bone contusion of the posterior lip of the medial tibial plateau at magnetic resonance (MR) imaging and to offer a biomechanical explanation for the findings. MATERIALS AND METHODS: A retrospective review of 215 consecutive MR examinations for knee trauma was conducted to identify contusions of the posterior lip of the medial tibial plateau. Any additional contusions and internal derangements were documented in the cases with these contusions. Medical charts and arthroscopic results, when available, were reviewed for mechanisms of injury. RESULTS: The specific medial tibial contusion was demonstrated in 25 of 215 (12%) knee MR examinations. Associated anterior cruciate ligament (ACL) tears were found in 25 of the 25 (100%) examinations. Injury to the meniscocapsular junction (14 of 25) or a peripheral tear of the posterior horn of the medial meniscus (10 of 25) occurred in a combined 96% of the cases. Lateral compartment contusions were noted in 24 (96%) cases. Pivot, twisting, or valgus forces were reported mechanisms of injury. CONCLUSION: Contusions involving the posterior lip of the medial tibial plateau may result from a contrecoup impaction injury directly following an ACL tear, as the knee reduces. These contusions are almost always associated with a far peripheral meniscal tear or with a meniscocapsular junction injury affecting the posterior horn of the medial meniscus.

Fatty marrow conversion of the proximal femoral metaphysis in osteonecrotic hips.

To determine whether fatty marrow conversion of the proximal femoral metaphysis is related to osteonecrosis of the femoral head using a marrow conversion index ([signal intensity of the proximal femoral metaphysis/signal intensity of the greater trochanter] x 100 in T1 weighted magnetic resonance images), a case control study was conducted on 42 osteonecrotic hips in 28 patients. The 28 patients (42 osteonecrotic hips) were matched with 84 control patients (84 normal hips) for gender, age (5-year range), and time of presentation (1-year range). The marrow conversion index was measured in each hip studied. The index was 90.2% (standard deviation, 8.2%) in osteonecrotic hips and 75.1% (standard deviation, 9.1%) in matched controls. By conditional logistic regression, a 5% increase in the index was associated with 3.6 times increase of the odds ratio of osteonecrosis and a 10% increase with a 12.9 times increase of the odds ratio. The marrow conversion index, which reflects the ratio of fatty marrow conversion of the proximal femoral metaphysis to that of the greater trochanter measured on T1 weighted magnetic resonance images, is increased in osteonecrotic hips.

Muscle infarction in patients with diabetes mellitus: MR imaging findings.

PURPOSE: To describe the magnetic resonance (MR) imaging findings in diabetic patients with muscle infarction and to describe commonly associated clinical features. MATERIALS AND METHODS: The MR imaging studies of 21 patients with diabetic muscle infarction were reviewed retrospectively. Of the 21 patients, 12 were women, and nine were men; the mean age was 48 years (range, 30-77 years). RESULTS: Eight patients had bilateral lower-extremity involvement; six had involvement confined to the right lower extremity and seven to the left. The thigh was involved in 17 patients (81%). One or more of the musculi vastus, the most frequently affected muscle group, were affected in 16 patients (76%). Four patients (19%) had isolated calf involvement. MR imaging studies showed diffuse enlargement of involved muscle groups and partial loss of normal fatty intermuscular septa. MR imaging also allowed identification of areas of subfascial fluid in 16 patients (76%) and subcutaneous edema in 19 patients (90%). MR imaging showed involved muscle groups best with T2-weighted, inversion-recovery, and gadolinium-enhanced sequences, where the infarcted muscles appeared diffusely hyperintense compared with adjacent muscles. Comparison of T2-weighted and gadolinium-enhanced MR images of nine patients showed enlarged, enhancing muscles in all patients and small, focal, rim-enhancing fluid collections in six of nine patients (66%). CONCLUSION: Diabetic muscle infarction is suggested in diabetic patients with sudden onset of severe pain in the thigh or calf muscles who have MR imaging findings of diffuse edema and swelling of multiple thigh and calf muscles (often in more than one compartment).

Magnetic resonance imaging of the wrist.

MR imaging of the wrist has the unique capability of simultaneously demonstrating bone and soft tissue structures. Its exquisite sensitivity for detecting bone marrow edema makes it and ideal screening tool for diagnosing radiographically occult osseous injuries and areas of AVN. This, together with its ability to provide a comprehensive, non-invasive assessment of the ligaments, tendons, nerves, and components of the TFC make MRI a very powerful tool for evaluating patients with wrist pain of uncertain etiology. Its exact role in the work-up of these patients has not been entirely established, but with further advances in technology and the radiologist's understanding of wrist anatomy and pathology, MRI is assuming a more central role in this clinical setting.

Anatomy and clinical significance of the horizontal cleft in the infrapatellar fat pad of the knee: MR imaging.

OBJECTIVE: The purpose of this study was to determine the prevalence and nature of a horizontal cleft in the posterior aspect of Hoffa's infrapatellar fat pad and to show pathologic processes involving this cleft. MATERIALS AND METHODS: Fifty consecutive MR imaging examinations of the knee were evaluated for the presence and appearance of a cleft in the infrapatellar fat pad. Examples of abnormalities involving the cleft were collected from additional MR studies. MR imaging, gross dissection, and histologic examination of a cadaveric knee were also performed to evaluate the anatomy and histology of the cleft. RESULTS: The cleft in the infrapatellar fat pad was revealed on MR imaging in 45 of 50 knees and had a variable shape, either linear (82%), pipe-shaped (7%), or globular-shaped (11%). Joint effusion or anterior cruciate ligament tear did not affect the appearance of the cleft. The cleft was located anterior to the distal insertion of the anterior cruciate ligament on the tibia. At gross dissection of the cadaveric knee, the roof of the cleft was formed by the ligamentum mucosum (infrapatellar plica), and the cleft was lined with synovium. The prospective evaluation of additional MR imaging examinations of the knee revealed pathologic entities of the cleft such as ganglion cysts, loose bodies, nodular synovitis, and amyloid. CONCLUSION: A horizontal cleft located in the posterior aspect of the infrapatellar fat pad is a common and normal MR imaging finding with a prevalence of 90%. The horizontal cleft is lined with synovium and its roof is formed by the ligamentum mucosum (infrapatellar plica). This cleft communicates with the knee joint. A distended cleft can form a prominent recess mimicking pathologic processes; conversely, disorders can arise in the cleft.

Imaging of the knee. Current status.

This article reviews the variety of imaging modalities that are currently being used to evaluate the knee. Nuclear scintigraphy is discussed with emphasis on prosthesis abnormalities. Sonography is discussed with regard to the evaluation of popliteal masses. The uses of computed tomography, especially in the evaluation of the tibial plateau fracture, are discussed, and the role of fluoroscopy, computed tomography, and sonography in image-guided needle procedures are reviewed. Emphasis is placed on the role of MR imaging in knee imaging, with attention to internal derangements, bursal and capsular pathology, and other assorted intra- and extra-articular disorders. The focus of this article is to review the wealth of information that may be obtained by using these imaging modalities.

Acutely injured knee: effect of MR imaging on diagnostic and therapeutic decisions.

PURPOSE: To assess the effect of knee magnetic resonance (MR) imaging on the diagnosis and management of acute knee injury. MATERIALS AND METHODS: Two orthopedic knee surgeons prospectively completed pre- and post-MR imaging questionnaires on 84 of 91 consecutive patients with acute knee injury. The pre- and post-MR imaging clinical diagnoses, certainty regarding these diagnoses, other diagnostic tests, and subjective impression of the usefulness of MR imaging were determined. RESULTS: Seven hundred thirty-one of 840 pre- and post-MR imaging diagnoses agreed. Agreement was lowest for medial meniscal injuries (54 of 84). Significantly fewer meniscal injuries were suspected after MR imaging (P < .05). In 60 patients, the orthopedist changed at least one of the 10 potential diagnoses after MR imaging. Clinical diagnostic certainty increased by a mean of 14% for all diagnoses. The increase in diagnostic certainty was greatest for medial meniscal injuries (30%), followed by lateral meniscal injuries (21%). The proposed management changed in 41 patients, resulting in significantly fewer arthroscopic procedures (P < .01). The post-MR imaging management plans included 37% (27 of 73) fewer arthroscopic procedures. CONCLUSION: MR imaging affects the diagnosis and management of acute knee injury by decreasing the number of arthroscopic procedures, improving clinician diagnostic certainty, and assisting in management decisions.

Fluoroscopically guided injections into the foot and ankle: localization of the source of pain as a guide to treatment--prospective study.

PURPOSE: To determine the value of injections of local anesthetic and steroids in the foot and ankle in localizing the source of pain and their effect on clinical confidence and decision making. MATERIALS AND METHODS: In 47 patients, fluoroscopically guided injections of local anesthetic and steroid into the foot and ankle were performed in 106 intra- and extraarticular sites. Questionnaires were completed by the referring surgeon before and after injections to evaluate the level of confidence with regard to the source of pain for each site injected and the proposed treatment plan. RESULTS: Forty-three (91%) patients reported pain relief after injections. The level of confidence that the site injected was the source of pain increased in 68 (64%) sites, decreased in 19 (18%) sites, and remained unaltered in 19 (18%) sites (P < .01). The treatment plan was changed from nonsurgical initially to surgical in three (8%) of 36 patients and was changed from surgical to nonsurgical in three (27%) of 11 patients after injections. Of the remaining eight patients, treatment was altered in three (37%) as a result of pain relief after the injections. CONCLUSION: Fluoroscopically guided injections of local anesthetic and steroid in the foot and ankle can improve clinical confidence with regard to the site of pain and may be valuable in clinical decision making and patient treatment.

MR imaging of ligamentous abnormalities of the elbow.

With high-resolution MR imaging, the collateral ligament of the elbow can be directly evaluated; thus ligamentous injuries can be detected, localized, and graded. The functional anatomy of the ligaments of the elbow is reviewed. The normal appearance of the ligaments on MR images as well as the clinical and MR imaging findings of medial and lateral collateral ligament injury are presented.

Acute knee trauma: how many plain film views are necessary for the initial examination?

OBJECTIVE: To determine whether anteroposterior (AP) and lateral views of the knee are equivalent to four views in acute fracture detection. DESIGN: Three musculoskeletal radiologists retrospectively interpreted the plain film knee examinations of each patient, establishing ground truth for the presence or absence of a fracture. Cases were presented to four masked senior radiology residents twice--once as a two-view study and again as a four-view study--with 4 weeks separating the two reading sessions to minimize recall bias. Sensitivity, specificity, and diagnostic performance were calculated. PATIENTS: Ninety-two patients presenting to the emergency department with acute knee trauma were evaluated with at least a four-view plain film examination. RESULTS AND CONCLUSIONS: Mean sensitivity for fracture detection using four views (85%) was significantly higher than that using two views (79%). Mean specificity and receiver operating characteristic curve areas were not significantly different using two or four views. Four views are more sensitive than AP and lateral views alone in detection of acute knee fracture.

Plain film evaluation of degenerative disk disease at the lumbosacral junction.

OBJECTIVE: Diagnosing degenerative disk disease (DDD) at the lumbosacral junction (LSJ) on plain films is often difficult, compared with other disk levels. The purpose of this study was to determine whether criteria for diagnosis of DDD at the LSJ can be established for plain films. DESIGN AND PATIENTS: We retrospectively reviewed 100 lumbar MRI scans of patients who also had lumbar plain films. Using MRI as the reference standard, the LSJ was classified as normal (n=35) or exhibiting mild (n=45) or severe (n=20) DDD by two radiologists using accepted criteria. Measurements were performed on the plain films by two other radiologists and the average measurements were tabulated according to the three categories of DDD defined by MRI. Plain film measurements included the anterior and posterior disk heights (ADH, PDH), Farfan's ratio, determined by adding ADH to PDH and dividing that number by the measured anteroposterior (AP) length of the inferior end plate of L5 [(ADH+PDH)/AP length of L5], and lumbosacral angle (LSA). Subsequently, five additional radiologists interpreted the radiographs by visual inspection only, for DDD at the LSJ, both before and, several weeks later, after being provided with the quantitative data for normal versus DDD. RESULTS AND CONCLUSION: There was a statistically significant difference between normal disk and increasing severity of DDD on radiographs using the parameters of PDH and Farfan's ratio. There was no statistically significant difference regarding ADH or LSA. Diagnostic accuracy by visual inspection was not significantly altered using the quantitative data for interpretation of DDD (68% correct before, 69.5% correct after). Analysis of results indicates that PDH is the most reliable and easily used criterion for detection of DDD at the LSJ. A PDH < or =5.4 mm on plain lateral film indicates DDD; PDH > or =7.7 mm indicates the absence of DDD on plain film.

Radiographic measurements of dysplastic adult hips.

Hip dysplasia is a not uncommon feature in adults and can vary from subtle acetabular dysplasia to complex sequelae of developmental dysplasia of the hip. This review article describes the most useful radiographic measurements used to evaluate the adult hip. The frontal projection of the pelvis permits measurement of the center-edge angle (CE angle) and "horizontal toit externe" angle (HTE angle), both of which assess the superior coverage of the acetabulum. The femoral neck-shaft angle (NSA) is also measured on this view. The false profile radiograph of the pelvis is described. It allows measurement of the vertical-center-anterior angle (VCA angle), which determines the anterior acetabular coverage and detects early degenerative hip joint disease. When surgery is contemplated, computed tomography (CT) is useful to better determine the anterior acetabular coverage by use of the anterior acetabular sector angle (AASA), and the posterior acetabular coverage by use of the posterior acetabular sector angle (PASA). CT also permits measurement of femoral anteversion. These measurements are particularly useful in the evaluation of acetabular dysplasia and for the preoperative assessment of the dysplastic hip.