Percutaneous Release Procedures: Trigger Finger and Carpal Tunnel.

Trigger digit and carpal tunnel syndrome are both conditions traditionally treated with open surgery but are potentially amenable to curative treatment using percutaneous techniques. The advantages of minimally invasive techniques are lower risk of wound breakdown and infection, quicker healing, reduced postprocedural pain, reduced complications, and a quicker return to normal activity. The advent of high-resolution ultrasound has allowed percutaneous release procedures for these conditions to be developed and performed with a potential for a reduced risk of complications and an increased likelihood of success. This article reviews the literature as well as our institutional experience in performing ultrasound-guided percutaneous release for trigger digit and carpal tunnel syndrome.

MRI findings and return to play in football: a prospective analysis of 255 hamstring injuries in the UEFA Elite Club Injury Study.

AIM: The present study evaluated whether the MRI parameters of hamstring injuries in male professional football players correlate with time to return to play (RTP). METHODS: 46 elite European football teams were followed prospectively for hamstring injuries between 2007 and 2014. Club medical staff recorded individual player exposure and time-loss after hamstring injury. MRI parameters were evaluated by two independent radiologists and correlated with the RTP data. RESULTS: A total of 255 grade 1 and 2 injuries were evaluated in this study. RTP was longer for grade 2 than grade 1 injuries (24±13, 95% CI 21 to 26 days vs 18±15, 95% CI 16 to 20 days; mean difference: 6, 95% CI 2 to 9 days, p=0.004, d=0.39). 84% of injuries affected the biceps femoris (BF) muscle, whereas 12% and 4% affected the semimembranosus (SM) and semitendinosus (ST), respectively. No difference in lay-off time was found for injuries to the three different muscles (BF 20±15 days, SM 18±11 days, ST 23±14 days; p=0.83). The recurrence rate was higher for BF injuries than for SM and ST injuries combined (18% vs 2%, p=0.009). The size of the oedema weakly correlated with time to RTP (r(2)=6-12%). No correlation was found between location of injury and time to RTP. The majority of the intramuscular injuries affected the MT junction (56% in grade 1 and 2 injuries), but no difference in lay-off time was found between the different types of injuries. CONCLUSIONS: The radiological grade and size of the oedema correlate with time to RTP for both, grade 1 and 2 injuries. No correlations were found between time to RTP and the location and type of injury.

Hamstring muscle injuries in professional football: the correlation of MRI findings with return to play.

BACKGROUND: Hamstring injury is the single most common injury in professional football. MRI is commonly used to confirm the diagnosis and provide a prognosis of lay-off time. OBJECTIVE: To evaluate the use of MRI as a prognostic tool for lay-off after hamstring injuries in professional football players and to study the association between MRI findings and injury circumstances. METHODS: Prospective cohort study where 23 European professional teams, were followed between 2007 and 2011. Team medical staffs recorded individual player exposure and time-loss injuries. Radiological grading was performed using a modified Peetrons classification into four grades where grades 2 and 3 represent fibre disruption. RESULTS: In total, 516 hamstring injuries occurred and 58% of these were examined by MRI. Thirteen per cent were grade 0 injuries, 57% grade 1, 27% of grade 2 and 3% of grade 3. Grade 0 and 1 injuries accounted for 56% (2141/3830 days) of the total lay-off. The lay-off time differed between all four radiological grades of injury (8±3, 17±10, 22±11 and 73±60 days, p<0.0001). Eighty-three per cent of injuries affected the biceps femoris while 11% and 5% occurred to the semimembranosus and semitendinosus, respectively. Re-injuries (N=34/207) constituted 16% of injuries. All re-injuries occurred to the biceps femoris. CONCLUSION: MRI can be helpful in verifying the diagnosis of a hamstring injury and to prognosticate lay-off time. Radiological grading is associated with lay-off times after injury. Seventy per cent of hamstring injuries seen in professional football are of radiological grade 0 or 1, meaning no signs of fibre disruption on MRI, but still cause the majority of absence days.

Groin pain: clinical assessment and the role of MR imaging.

Groin pain is a common problem in the elite athlete and may lead to prolonged inactivity if inadequately treated. Groin pain, arising from injuries to the hip and pelvis, accounts for 5 to 6% of athletic injuries in adults and 10 to 24% of these injuries in children. Lower limb-dominated athletic activities such as football, rugby, ice hockey, running, and ballet are particularly at risk. Comprehensive evaluation of all the anatomical locations prone to injury including the hip joint, sacrum, ilium and proximal femora, pelvic tendon attachments, and pelvic musculature is required. Magnetic resonance (MR) imaging provides superb soft tissue contrast resolution, multiplanar capabilities, and a wide field of view to evaluate many potential causes of groin pain. Careful clinical examination allows the optimal use of MR imaging and MR arthrography to evaluate the articular, osseous, tendinous, and muscular structures, which may be the source of groin pain. Accurate diagnosis is essential for appropriate management and rehabilitation plans. This article reviews the role of clinical assessment in guiding diagnostic imaging and also describes the relevant MR imaging findings in athletes presenting with groin pain.

Ultrasound-guided treatments for chronic Achilles tendinopathy: an update and current status.

Minimally-invasive treatments for chronic Achilles tendinopathy may prevent the need for surgery when conservative methods have failed. Whilst injections have traditionally been used to manage symptoms, recently described therapies may also have disease-modifying potential. Ultrasound provides the ability to guide therapeutic interventions, ensuring that treatment is delivered to the exact site of pathology. Treatments can be broadly categorised according to their intended therapeutic targets, although some may act through several possible mechanisms. In this article, we review the ultrasound-guided techniques currently used to treat chronic Achilles tendinopathy, with reference to the available literature. There is strong pilot-level evidence supporting the use of many of these techniques, although large definitive trials are lacking. An approach towards the management of chronic Achilles tendinopathy is suggested.

Ultrasound-guided percutaneous release of the annular pulley in trigger digit.

The purpose of this study was to describe and evaluate a new technique for ultrasound-guided percutaneous release of the annular pulley in trigger digit using a modified hypodermic needle. A total of 35 ultrasound-guided percutaneous releases were performed on 25 patients diagnosed and referred by hand surgeons in our institution over 16 months from October 2006. Inclusion criteria were as follows: adulthood, triggering present for at least 4 months, failure to respond to conservative management or steroid injections, no previous history of pulley release in the affected digit. Under ultrasound guidance, the affected pulley was released using a standard 19-gauge hypodermic needle bent at two points as the cutting device. Follow-up took place at 12 weeks and 6 months with improvement in triggering and clinically graded pain. At follow-up, no complications had occurred and all patients demonstrated improvement in their triggering, with complete resolution in 32 digits (91%), good improvement in 2 digits (6%) and some improvement in 1 digit (3%). This new technique uses a widely available and safe cutting device and is safe and can be used to provide definitive management for trigger finger, allowing the procedure to be performed in a variety of clinical settings.

Normal sonographic anatomy of the posterolateral corner of the knee.

OBJECTIVE: The posterolateral corner of the knee comprises a group of structures that are important to knee stability. MRI is currently the standard imaging technique, but visualization of individual structures is often incomplete. Sonography allows rapid real-time assessment of these superficial structures, but knowledge of the anatomy is essential to allow accurate examination. CONCLUSION: We present an illustrated review of the sonographic anatomy of the posterolateral corner of the knee with MRI correlation.

Ultrasound findings of the locked metacarpophalangeal joint.

The radiographs and sonographic findings of two cases of locked metacarpophalangeal joint secondary to tethering of the volar plate are described. The presence of osteophytes and the dynamic ultrasound assessment of the volar plate have provided confirmation of the clinical diagnosis prior to surgery.

Posterior impingement syndromes of the ankle.

Acute, or repetitive, compression of the posterior structures of the ankle may lead to posterior ankle impingement (PAI) syndrome, posteromedial ankle impingement (PoMI) syndrome, or Haglund's syndrome. The etiology of each of these conditions is quite different. Variations in posterior ankle osseous and soft tissue anatomy contribute to the etiology of PAI and Haglund's syndromes. The presence of an os trigonum or Stieda process is classically associated with PAI syndrome, whereas a prominent posterosuperior tubercle of the os calcis or Haglund's deformity is the osseous predisposing factor in Haglund's syndrome. PoMI has no defined predisposing anatomical variants but typically follows an inversion-supination injury of the ankle joint. This article discusses the biomechanics, clinical features, imaging, and management of each of these conditions. Magnetic resonance imaging (MRI) provides the optimal tool in posterior ankle assessment, and this review focuses on the MRI findings of each of the conditions just listed.

Normal sonographic anatomy of the wrist and hand.

The advent of ultra-high-frequency sonographic transducers has significantly enhanced our ability to image superficial structures. As a result, sonography now can be used to assess injuries of the tendons in the wrist and hand. A clear understanding of normal sonographic anatomy is required to prevent misdiagnosis and ensure optimal patient care. The anatomy of the wrist and hand is best described by considering the extensor and flexor surfaces separately. The carpal extensor retinaculum divides the dorsal extensor tendons into six separate synovial compartments, which are demarcated by the points of its attachment to the radius and ulna. The course of these tendons from the wrist to the sites of their insertion can be traced by using sonography. The intrinsic wrist ligaments, triangular fibrocartilage, and dorsal finger extensor hood also can be assessed sonographically. The anatomy of the flexor surface of the wrist is defined principally by the flexor retinaculum. The median nerve, which is located deep to the retinaculum in the carpal tunnel, and the ulnar nerve, which is superficial to the retinaculum in the Guyon canal, can be easily detected. The long flexor tendons in the wrist and hand are also clearly depicted at sonography. The flexor annular pulley system is formed by five foci of thickening along the long flexor finger tendon synovial sheath, and the second and fourth annular pulleys can be identified sonographically in most patients. Sonography provides a rapid, cheap, noninvasive, and dynamic method for examination of the soft-tissue structures of the wrist and hand. Familiarity with the appearance of normal anatomic structures is a prerequisite for reliable interpretation of the resultant sonograms.

Abdominal computed tomographic findings of Mycobacterium tuberculosis and Mycobacterium avium intracellulare infection in HIV seropositive patients.

OBJECTIVE: To compare the computed tomographic (CT) findings of abdominal Mycobacterium tuberculosis (MTB) infection and Mycobacterium avium intracellulare (MAI) infection in patients with human immunodeficiency virus (HIV) infection. METHODS: A retrospective review of the CT findings of 30 patients with HIV and proven MTB (n = 9) or MAI (n = 21) infection was conducted. Images were reviewed by a radiologist blinded to the diagnosis, and the radiologic findings involving the abdominal viscera, peritoneum and lymph nodes were compared. RESULTS: The following were more frequent in patients with MAI infection: hepatomegaly (MAI 71% v. MTB 44%, p < 0.05), uniform attenuation of lymph nodes (MAI 90% v. MTB 55%, p < 0.05) and clustered pattern of lymph nodes (MAI 57% v. MTB 22%, p < 0.05). In patients with MTB infection, lymph nodes with low attenuation centrally were more common (MAI 10% v. MTB 44%, p < 0.05), and mesenteric lymph nodes were significantly larger (MAI mean = 20 mm v. MTB mean = 40 mm, p < 0.05). CONCLUSION: Although nonspecific, CT may be useful in the early diagnosis of MTB and MAI infection, allowing for presumptive treatment before microbiologic confirmation.

Dynamic magnetic resonance imaging evaluation of the structural and functional results of postanal repair for neuropathic fecal incontinence.

PURPOSE: The aim of this study was to determine whether dynamic magnetic resonance imaging of the pelvic floor can discriminate between patients who improve after postanal repair for neurogenic fecal incontinence and those who remain symptomatic. METHODS: Pelvic floor measurements obtained during dynamic magnetic resonance imaging in eight females whose anal incontinence had improved after postanal repair were compared with those from nine females who remained symptomatic. All subjects also underwent standard anorectal physiology testing. RESULTS: There was no significant difference between groups with respect to any measurement of anterior or middle pelvic floor compartments. Additionally, there was no difference in posterior pelvic floor configuration when symptomatic patients were compared with those who had improved. However, dynamic magnetic resonance measurements revealed patients who remained symptomatic had significantly greater posterior pelvic floor weakness. Anorectal physiology was unable to differentiate between groups. CONCLUSIONS: There is no difference in static pelvic floor measurements when subjects remaining symptomatic after postanal repair are compared with those who have improved. In contrast, dynamic measurements may be able to predict failure in those who demonstrate excessive posterior pelvic floor mobility.

The use of a D-dimer assay in patients undergoing CT pulmonary angiography for suspected pulmonary embolus.

PURPOSE: To assess the ability of a semi-quantitative latex agglutination D-dimer test Accuclot with bedside measurements of arterial oxygen saturation, respiratory and cardiac rates to exclude pulmonary embolism (PE) on computed tomographic pulmonary angiography (CTPA). MATERIALS AND METHODS: All patients referred to our CT unit for investigation of suspected acute pulmonary embolism were enrolled. Pulse oximetery, respiratory rate, heart rate and blood sampling for D-dimer testing were carried out just before CT. A high resolution CT (HRCT) of the chest was followed by a CT pulmonary angiogram (CTPA). The images were independently interpreted at a workstation with cine-paging and 2D reformation facilities by three consultant radiologists blinded to the clinical and laboratory data. If positive, the level of the most proximal embolus was recorded. Discordant imaging results were re-read collectively and consensus achieved. RESULTS: A total of 101 patients were enrolled. The CTPA was positive for PE in 28/101 (28%). The D-dimer was positive in 65/101 (65%). Twenty-six patients had a positive CT and positive D-dimer, two a positive CT but negative D-dimer, 39 a negative CT and positive D-dimer, and 34 a negative CT and negative D-dimer. The negative predictive value of the Accuclot D-dimer test for excluding a pulmonary embolus on spiral CT was 0.94. Combining the D-dimer result with pulse oximetry (normal SaO2 > or = 90%) improved the negative predictive value to 0.97. CONCLUSION: A negative Accuclot D-dimer assay proved highly predictive for a negative CT pulmonary angiogram in suspected acute pulmonary embolus. If this D-dimer assay were included in the diagnostic algorithm of these patients a negative D-dimer would have unnecessary CTPA rendered in 36% of patients.