Repetitive Strain Injuries of the Upper Extremity: Imaging of Tendon Pathology and Compressive Neuropathies.

Repetitive strain injuries (RSIs) encompass a broad clinicopathologic spectrum which includes discrete patterns of tissue injury involving tendons, bursae and nerves although an element of subjective symptomatology may be contributory. Upper extremity RSIs include De Quervain's tenosynovitis, intersection syndromes, epicondylitis, ulnar, and median neuritis as well as other compressive neuropathies. It is estimated that RSIs cost the US economy over $60 billion annually and while detailed clinical examination remains the diagnostic mainstay, imaging can aid in diagnosis, guide management and reduce costs.

Bursal lipohematoma: a CT sign of full thickness rotator cuff tear in patients with proximal humerus fractures.

PURPOSE: The main purpose of the study is to determine if the presence of a particular computed tomography (CT) imaging finding, a bursal lipohematoma, portends the presence of a concomitant rotator cuff tear (RCT) in patients with proximal humerus fractures by reviewing previous CTs. METHODS: Three hundred eighty-six CT scans were retrospectively reviewed by two board-certified radiologists to determine the presence of a proximal humerus fracture and to assess for the presence of a subacromial/subdeltoid or subcoracoid bursal hematoma. The medical record including operative documentation was then examined in the patients with proximal humerus fractures, with or without a concomitant bursal lipohematoma. RESULTS: Of the surgically managed patients, four had an intraoperative diagnosis of RCT. The preoperative CT scans of all of these patients demonstrated a bursal lipohematoma. Additionally, a non-surgically managed patient with a subacromial/subdeltoid bursal lipohematoma on CT scan was found to have a RCT on subsequent MRI. Of note, a rotator cuff tear was not documented in operative reports of patients with CT scans that were not found to contain a bursal lipohematoma. CONCLUSIONS: Bursal lipohematoma is a potentially useful preoperative CT sign of full thickness rotator cuff tear in patients with proximal humerus fractures, providing the clinician with more information in the optimization of the management approach.

Ulnar focal cortical indentation: a progressive, deforming variant of focal fibrocartilaginous dysplasia.

BACKGROUND: Focal fibrocartilaginous dysplasia is a rare growth disturbance of bone resulting in deformity. In the ulna, focal fibrocartilaginous dysplasia is particularly rare, and the characteristic fibroligamentous tether can result in progressive deformity with progressive dislocation of the radial head. The fibroligamentous tether is similar in appearance and function to the Vickers ligament seen in Madelung deformity. The imaging features of ulnar focal fibrocartilaginous dysplasia include a unilateral angular deformity in the ulna with a radiolucent cortical defect and surrounding sclerosis, with secondary radial bowing or radial head dislocation. Focal fibrocartilaginous dysplasia of the ulna has been described using the term ulnar focal cortical indentation. OBJECTIVE: To review the clinical and radiologic features of four cases of ulnar focal cortical indentation occurring in pediatric patients. MATERIALS AND METHODS: We retrospectively reviewed picture archiving and communication system and electronic medical record imaging findings with surgical correlation of ulnar focal cortical indentation at two large specialty pediatric hospitals. RESULTS: Ulnar focal cortical indentation lesions typically arise in the ulnar metaphysis and result in angular forearm deformities with progressive radial deformity including radial head dislocation. Early surgical intervention prevents progression of the deformity and retains range of motion. CONCLUSION: Ulnar focal cortical indentation, although rare, is likely a progressive form of focal fibrocartilaginous dysplasia resulting in significant deformity and disability. Early recognition of the characteristic imaging features is important for early surgical intervention to preserve range of motion and prevent radial head dislocation.

The 2015 Amtrak Philadelphia Train Derailment: After-Action Review of the Emergency Radiology Response at Temple University Health System.

PURPOSE: The aim of this article is to assess a large tertiary care medical center's emergency radiology response after the 2015 Amtrak Philadelphia train derailment. METHODS AND MATERIALS: A total of 55 patients with 308 total CTs and radiographs ordered within 12 hours of arrival to Temple University Health System (combining Temple University Hospital and Episcopal Hospital) emergency departments on May 12 to 13, 2015, were included in this study. A retrospective PACS and electronic medical record chart review of emergency department imaging turnaround times (TAT) during this event was completed and compared with emergency department radiology operations for the same 12-hour period throughout the preceding year. Wilcoxon's rank-sum test analysis was performed. RESULTS: A total of 308 CTs and radiographs were performed, and 91 radiologically evident injuries were observed in a total of 30 patients, with fractures (n = 51) as the most common type of injury. There were no significant differences in time from patient arrival to beginning of radiological examination (26 min; interquartile range [IQR], 11-58 min) compared with annual median (28 min; IQR, 10-131 min; P = .232). Examination completion TATs were significantly increased (35 min; IQR, 17-112 min) compared with annual median (10 min; IQR, 5-15 min; P < .001), and time required from viewing of the examination by the radiologist to the examination being marked as read was significantly decreased (17 min; IQR, 6-45 min) compared with annual median (248 min; IQR, 126-441 min; P < .001). CONCLUSIONS: The analysis highlights areas of efficiency in our response but also indicates areas for process improvement in future potential mass casualty events.

Imaging Patterns of Injuries After the 2015 Amtrak Philadelphia Train Derailment.

OBJECTIVE: The purpose of this article is to describe the injury patterns observed in the 2015 Philadelphia Amtrak train derailment. CONCLUSION: Fractures accounted for most observed injuries, but uncommon and potentially serious injuries included posterior sternoclavicular dislocation and mesenteric contusion. Imaging plays a critical role in the triage of patients during mass-casualty events, and familiarity with the injury patterns associated with high-velocity unrestrained blunt force trauma will aid diagnosis in any future similar occurrence.

Florid cemento-osseous dysplasia: review of an uncommon fibro-osseous lesion of the jaw with important clinical implications.

Florid cemento-osseous dysplasia (FCOD) is a rare, benign, multifocal fibro-osseous dysplastic process affecting tooth-bearing areas of the jaw, characterized by replacement of normal trabecular bone with osseous tissue and dense acellular cementum in a fibrous stroma. It is one clinicopathologic variant in a spectrum of related non-neoplastic fibro-osseous lesions known as cemento-osseous dysplasias (CODs), thought to arise from elements of the periodontal ligament. Diagnosis primarily relies upon radiographic and clinical findings; unnecessary biopsy should be avoided, as inoculation with oral pathogens may precipitate chronic infection in these hypovascular lesions. Appropriate management of uncomplicated FCOD consists of periodic radiographic follow-up. Accordingly, it is important that both radiologists and clinicians performing endodontic interventions possess familiarity with this entity in order to prevent misdiagnosis and inappropriate intervention, which may result in a protracted clinical course. Lesions are usually asymptomatic in the absence of infection, typically discovered on routine dental radiographs or imaging performed for unrelated indications. Radiographically, the condition typically manifests as widespread non-expansile intraosseous masses of varying internal lucency and sclerosis that surround the root apices of vital teeth or edentulous areas in the posterior jaw. While all CODs share similar microscopic features, FCOD is distinguished by its multifocal distribution, involving two or more quadrants of the maxilla and mandible, often in a bilateral symmetric fashion. The vast majority of cases are sporadic, though few exhibit an autosomal dominant familial inheritance pattern. In this pictorial review, we discuss the radiologic characteristics of this entity, pertinent clinical and histologic features, differential diagnoses, and management options.

Madelung deformity and Madelung-type deformities: a review of the clinical and radiological characteristics.

Madelung deformity of the distal radius results from premature closure of the medial volar aspect of the distal radial physis, leading to increased volar tilt and increased inclination of the radial articular surface, triangulation of the carpus with proximal migration of the lunate and dorsal displacement of the distal ulna. The deformity is particularly common in Leri-Weill dyschondrosteosis, but it may also occur in isolation. True Madelung deformity can be differentiated from Madelung-type deformities by the presence of an anomalous radiolunate ligament (Vickers ligament). In this article, we will review the imaging characteristics of true Madelung deformity, including the common "distal radius" variant, the less common "entire radius" variant and "reverse" Madelung deformity. We will discuss the role of the Vickers ligament in disease pathogenesis and its use in differentiating true Madelung deformity from Madelung-type deformities arising from trauma or multiple hereditary exostoses. Surgical management of these patients will also be addressed.

The effect of reminder systems on patients' adherence to treatment.

BACKGROUND: Patient adherence is an important component of the treatment of chronic disease. An understanding of patient adherence and its modulating factors is necessary to correctly interpret treatment efficacy and barriers to therapeutic success. PURPOSE: This meta-analysis aims to systematically review published randomized controlled trials of reminder interventions to assist patient adherence to prescribed medications. METHODS: A Medline search was performed for randomized controlled trials published between 1968 and June 2011, which studied the effect of reminder-based interventions on adherence to self-administered daily medications. RESULTS: Eleven published randomized controlled trials were found between 1999 and 2009 which measured adherence to a daily medication in a group receiving reminder interventions compared to controls receiving no reminders. Medication adherence was measured as the number of doses taken compared to the number prescribed within a set period of time. Meta- analysis showed a statistically significant increase in adherence in groups receiving a reminder intervention compared to controls (66.61% versus 54.71%, 95% CI for mean: 0.8% to 22.4%). Self-reported and electronically monitored adherence rates did not significantly differ (68.04% versus 63.67%, P = 1.0). Eight of eleven studies showed a statistically significant increase in adherence for at least one of the reminder group arms compared to the control groups receiving no reminder intervention. LIMITATIONS: The data are limited by imperfect measures of adherence due to variability in data collection methods. It is also likely that concomitant educational efforts in the study populations, such as instructions regarding proper administration and importance of correct dosing schedules, contributed to improved patient adherence, both in reminder and control arms. The search strategy could have missed relevant studies which were categorized by disease rather than adherence. CONCLUSIONS: Reminder-based interventions may improve adherence to daily medications. However, the interventions used in these studies, which included reminder phone calls, text messages, pagers, interactive voice response systems, videotelephone calls, and programmed electronic audiovisual reminder devices, are impractical for widespread implementation, and their efficacy may be optimized when combined with alternative adherence-modifying strategies. More practical reminder-based interventions should be assessed to determine their value in improving patient adherence and treatment outcomes.