Pediatric Wrist.

Pediatric wrist injuries pose unique diagnostic challenges due to distinct bone characteristics in children and their diverse injury patterns. The dynamic development of the wrist, marked by changes in bone age and emerging ossification centers, is crucial to evaluate growth and identify potential pathologies. The skeletal composition, rich in cartilage, renders bones relatively weaker yet more elastic, impacting their susceptibility to fracture. Forearm fractures display diverse patterns influenced by torsional forces. Scaphoid fractures, less common in children, differ from those in adults. Conditions like Madelung's deformity and ulnar variance are more common wrist disorders in the pediatric population. In addition, the scarcity and nonspecificity of symptoms in those with tendon injuries and triangular fibrocartilage complex lesions can be diagnostically challenging. This article reviews pediatric wrist injuries, emphasizing ossification patterns, common fracture types, and developmental variants. Grasping these complexities in pediatric wrist development and associated pathologies is essential for precise diagnosis and treatment.

Surgical treatment of patients with chronic rupture of the pectoralis major muscle tendon. Prospective comparative study with 2 years of follow-up.

To compare outcomes between autologous fascia lata and autologous hamstring grafts for chronic pectoralis major muscle (PMM) rupture repair, and perform histological, and imaging analyses. Forty male patients with chronic PMM ruptures (time since injury ranging from >3 months to 5 years) and a mean age of 37.3 years (SD = 9.7 years) were evaluated. One group (20 patients) received an autologous semitendinosus graft, and another group (20 patients) received an autologous fascia lata graft for PMM reconstruction. These patients with fascia lata grafts by Bak 2criterium 60% of the patients presented excellent results, 20% presented good results, 15% presented fair results, and 5% presented poor results. In the hamstring group 65% of the patients presented excellent results, 30% presented good results, and 5% presented fair results. In this comparative study, no difference was observed regarding the functional result, image, and histology between groups.

Anabolic steroids and the evaluation of patients with acute PM tendon rupture using microscopy and MRI.

This study presented a pioneering investigation of the changes in the magnetic resonance imaging images of pectoralis major muscle (PMM) tendon rupture. In all, 26 men were evaluated with acute total PMM rupture (<3 months since injury) with a mean age of 37.3 years (SD = 9.7 years) and 10 control patients with a mean age of 32.6 years (SD = 4.2 years). The evaluation of the tendon PMM injuries was based on the magnetic resonance imaging exam and the histological analysis. The magnetic resonance imaging of the surgically showed two (7.1%) contralateral sides were normal, 16 (57.1%) showed superior tendinopathy, and 10 (35.7%) had total tendinopathy. Inferior tendinopathy was not observed. The tendon histology revealed degenerative changes in 16 (66.7%) fragments, with 12 (50.0%) considered as mild (<25%), and four considered as (16.7%) high (>50.0%) tendinopathy. Total acute rupture of the PMM tendon among weightlifters might be associated with tendinous degeneration prior to injury.

MRI findings of closed hand injuries in adolescent goalkeepers: a case-based review.

Soccer-related injuries in youth goalkeepers are underrepresented in epidemiological studies, despite goalkeepers experiencing distinct types of upper limb injuries and training loads compared to outfield players. Digit injuries are particularly prevalent, with up to five times more upper extremity injuries reported in this position. Such injuries can lead to interphalangeal joint instability and an increased risk of reinjury. Mechanisms of injury include falls, axial loading of digits, and rotational force due to grasping activities. The proximal interphalangeal joint is the most frequently injured in sports, followed by the metacarpophalangeal joint of the thumb. Achieving precise diagnosis can be challenging due to the complex soft-tissue anatomy of the hand. Radiologists play a crucial role in accurate diagnosis through imaging studies, enabling timely treatment. This article focuses on closed traumatic finger and thumb injuries in adolescent goalkeepers, describing injury mechanisms and outlining relevant MRI features to facilitate proper clinical approaches for diagnosis based on imaging findings.

Upper extremity infection: imaging features with focus on magnetic resonance imaging.

Upper extremity infections are frequently seen, especially in individuals with weakened immune system, posttraumatic events, and after surgery procedures. If not properly treated, such conditions can lead to serious consequences, such as movement impairment, amputation, and even mortality. These infections have the potential to spread extensively from their initial site of entry, traversing interconnected spaces either intra or extra-compartmental. Understanding the relevant anatomy is crucial to assess location and stage of infection, since surgical intervention and intravenous antibiotics are usually required. In this article, the authors provide a comprehensive review of the imaging findings of upper extremity infection, focusing on magnetic resonance imaging (MRI). Furthermore, this article sheds light on the pivotal role of radiology in managing hand, elbow, and shoulder infections offering an overview of available treatment options. KEY FINDINGS: Various types of infections affecting the upper extremity will be discussed, including infectious tenosynovitis, deep space infections, septic arthritis, and osteomyelitis. Authors also highlight anatomical spaces, common pathogens, spread routes, and key radiological features of these conditions.

Análisis de las Variaciones Anatómicas y Dimensionales del Canal Nasopalatino Mediante Tomografía Computarizada de Haz Cónico / Analysis of the Anatomical and Dimensional Variations of the Nasopalatine Canal by Cone Beam Computed Tomography

El conocimiento anatómico del canal nasopalatino (CNP) es fundamental para la realización de cirugías en el sector anterior del maxilar y así prever posibles complicaciones. El objetivo de este trabajo es evaluar y determinar las variaciones anatómicas y dimensionales del CNP según sexo, edad y estado dental. Este estudio transversal analizó un total de 251 imágenes de TCHC obtenidas de la base de datos del Servicio de Imagenología Oral y Maxilofacial de la Facultad de Odontología de la Universidad Andrés Bello, Viña del Mar, Chile. Para evaluar la asociación estadística entre variaciones del CNP con sexo, edad y estado dentario se realizó la prueba T de Student, chi-cuadrado y ANOVA (p0,05). Además, se detectó diferencia significativa entre el estado dentario y la dimensión de la tabla vestibular en relación con el CNP (p<0,01). Se deben considerar las variaciones de CNP para evitar posibles complicaciones durante los procedimientos quirúrgicos.

SUMMARY: Anatomical knowledge of the nasopalatine canal (PNC) is essential for performing surgeries in the anterior sector of the maxilla and thus anticipating possible complications. The objective of this work is to evaluate and determine the anatomical and dimensional variations of the CNP according to sex, age and dental status. This cross-sectional study analyzed a total of 251 CBCT images obtained from the database of the Oral and Maxillofacial Imaging Service of the Faculty of Dentistry of the Andrés Bello University, Viña del Mar, Chile. To evaluate the statistical association between CNP variations with sex, age and dental status, the Student's T test, chi-square and ANOVA (p0.05). In addition, a significant difference was detected between the dental state and the dimension of the vestibular table in relation to the CNP (p<0.01). CNP variations should be considered to avoid potential complications during surgical procedures.

Imaging findings of lower limb involvement following COVID-19.

Coronavirus disease 2019 (COVID-19) is known mainly by the severe acute respiratory syndrome, with myalgia as a common clinical symptom. Recent reports described musculoskeletal complications related to COVID-19 such as myositis, neuropathy and arthropathy. Radiologists and ordering physicians should be aware of lower limb complications following severe COVID-19 for optimal patient care.

Bilateral upper extremity myositis after COVID-19 vaccination.

Vaccination adverse reactions are common and usually are represented by transitory pain and edema. We present a case of bilateral muscle edema involving shoulders and arms due to myositis following COVID-19 vaccination, and focus on the imaging findings to differentiate with other diagnosis such as infection and tumors.

Automatic MRI segmentation of pectoralis major muscle using deep learning.

To develop and validate a deep convolutional neural network (CNN) method capable of selecting the greatest Pectoralis Major Cross-Sectional Area (PMM-CSA) and automatically segmenting PMM on an axial Magnetic Resonance Imaging (MRI). We hypothesized a CNN technique can accurately perform both tasks compared with manual reference standards. Our method is based on two steps: (A) segmentation model, (B) PMM-CSA selection. In step A, we manually segmented the PMM on 134 axial T1-weighted PM MRIs. The segmentation model was trained from scratch (MONAI/Pytorch SegResNet, 4 mini-batch, 1000 epochs, dropout 0.20, Adam, learning rate 0.0005, cosine annealing, softmax). Mean-dice score determined the segmentation score on 8 internal axial T1-weighted PM MRIs. In step B, we used the OpenCV2 (version 4.5.1, https://opencv.org ) framework to calculate the PMM-CSA of the model predictions and ground truth. Then, we selected the top-3 slices with the largest cross-sectional area and compared them with the ground truth. If one of the selected was in the top-3 from the ground truth, then we considered it to be a success. A top-3 accuracy evaluated this method on 8 axial T1-weighted PM MRIs internal test cases. The segmentation model (Step A) produced an accurate pectoralis muscle segmentation with a Mean Dice score of 0.94 ± 0.01. The results of Step B showed top-3 accuracy > 98% to select an appropriate axial image with the greatest PMM-CSA. Our results show an overall accurate selection of PMM-CSA and automated PM muscle segmentation using a combination of deep CNN algorithms.

Bilateral pectoralis major MRI in weightlifters: findings of the non-injured side versus age-matched asymptomatic athletes.

OBJECTIVE: To evaluate magnetic resonance imaging (MRI) features of the contralateral side in weightlifting athletes with pectoralis major (PM) tears. We hypothesized that MRI of the non-injured side may present increased pectoralis major tendon (PMT) length and thickness and greater pectoralis major muscle (PMM) volume and cross-sectional area when compared with the control group. METHODS: We retrospectively identified MRI cases with unilateral PM injury and reviewed imaging findings of the contralateral side. Also, we evaluated MRI from ten asymptomatic control weightlifting athletes, with PM imaging from both sides. Two musculoskeletal radiologists independently reviewed MRI and measured PMT length, PMT thickness, PMM volume (PMM-vol) and PMM cross-sectional area (PMM-CSA), as well as humeral shaft cross-sectional area (Hum-CSA) and the ratio between PMM-CSA and Hum-CSA (PMM-CSA/Hum-CSA). Data were compared between the non-injured side and controls. The MRI protocol from both groups was the same and included T1 FSE and T2 FATSAT axial, coronal, and sagittal images, one side at a time. RESULTS: We identified 36 male subjects with unilateral PM injury with mean age 35.7 ± 8 years and 10 age- and gender-matched controls (p = 0.45). A total of 36 PM MRI with non-injured PM and 20 PM MRI studies were included in this study. PMT length and PMT thickness were significantly higher in contralateral PM injury versus control subjects (both P < 0.001). Also, PM-CSA and Hum-CSA were greater in the contralateral PM injury group (P = 0.032 and P < 0.001, respectively). PMT thickness > 2.95 mm had 80.6% sensitivity and 90.0% specificity to differentiate the non-injured PM group from controls. CONCLUSION: Non-injured side MR imaging of patients with previous contralateral PM lesion demonstrates greater PMT thickness and length as well as PM-CSA and Hum-CSA than controls.

Audiovisual Content for a Radiology Fellowship Selection Process During the COVID-19 Pandemic: Pilot Web-Based Questionnaire Study.

BACKGROUND: Traditional radiology fellowships are usually 1- or 2-year clinical training programs in a specific area after completion of a 4-year residency program. OBJECTIVE: This study aimed to investigate the experience of fellowship applicants in answering radiology questions in an audiovisual format using their own smartphones after answering radiology questions in a traditional printed text format as part of the application process during the COVID-19 pandemic. We hypothesized that fellowship applicants would find that recorded audiovisual radiology content adds value to the conventional selection process, may increase engagement by using their own smartphone device, and facilitate the understanding of imaging findings of radiology-based questions, while maintaining social distancing. METHODS: One senior staff radiologist of each subspecialty prepared 4 audiovisual radiology questions for each subspecialty. We conducted a survey using web-based questionnaires for 123 fellowship applications for musculoskeletal (n=39), internal medicine (n=61), and neuroradiology (n=23) programs to evaluate the experience of using audiovisual radiology content as a substitute for the conventional text evaluation. RESULTS: Most of the applicants (n=122, 99%) answered positively (with responses of "agree" or "strongly agree") that images in digital forms are of superior quality to those printed on paper. In total, 101 (82%) applicants agreed with the statement that the presentation of cases in audiovisual format facilitates the understanding of the findings. Furthermore, 81 (65%) candidates agreed or strongly agreed that answering digital forms is more practical than conventional paper forms. CONCLUSIONS: The use of audiovisual content as part of the selection process for radiology fellowships is a new approach to evaluate the potential to enhance the applicant's experience during this process. This technology also allows for the evaluation of candidates without the need for in-person interaction. Further studies could streamline these methods to minimize work redundancy with traditional text assessments or even evaluate the acceptance of using only audiovisual content on smartphones.

Rho kinase cascade activation in circulating leukocytes in patients with diabetes mellitus type 2.

BACKGROUND: The intracellular ROCK signaling pathway is an important modulator of blood pressure and of cardiovascular and renal remodeling when Rho-kinase activity is increased. Besides, in preclinical models of diabetes, ROCK activation has also a role in abnormal glucose metabolism as well as in subsequent vascular and myocardial dysfunction. In humans, there are a few data assessing ROCK activation in patients with type 2 diabetes mellitus (T2D) and no studies assessing upstream/downstream components of the ROCK pathway. We assessed here levels of ROCK activation and some of the RhoA/ROCK cascade molecules in peripheral blood mononuclear cells (PBMCs) in T2D patients under current treatment. METHODS: Cross-sectional observational study comparing 28 T2D patients under current antidiabetic treatment with 31 consecutive healthy subjects, matched by age and gender. Circulating levels of malondialdehyde, angiotensin II and inflammatory cytokines IL-6 and IL-8 were determined in all subjects. ROCK activation in PMBCs, upstream and downstream cascade proteins, and levels of the proinflammatory molecules VCAM, ICAM-1 and IL-8 were determined in their PMBCs by Western blot. RESULTS: Compared to healthy controls, ROCK activation in T2D patients measured by 2 direct ROCK targets in PBMCs was increased by 420 and 570% (p < 0001) and it correlated significantly with serum glucose levels. p38 MAPK phosphorylation (downstream from ROCK) and JAK-2 (upstream from ROCK) were significantly higher in the T2D patients by 580% and 220%, respectively. In T2D patients, significantly increased PBMC levels of the proinflammatory molecules VCAM-1, ICAM-1 and IL-8 were observed compared to control subjects (by 180%, 360% and 260%, respectively). Circulating levels of Ang II and MDA were significantly higher in T2D patients by 29 and 63%, respectively. CONCLUSIONS: T2D patients under treatment with glucose-lowering drugs, antihypertensive treatment as well as with statins have significantly increased ROCK activation in their circulating leukocytes along with higher phosphorylation of downstream cascade proteins despite pharmacologic treatment, along with increased plasma angiotensin II and MDA levels. ROCK inhibition might have an additional role in the prevention and treatment of T2D.

MRI findings of intermediate cuneiform osteochondrosis as a rare cause of foot pain in a child.

Few cases of intermediate cuneiform osteochondrosis have been described in the literature. In this report we present a case of a 9-year-old boy with a 2-month history of right foot pain and edema, especially near the third metatarsal, without previous trauma. Also, there were no signs of inflammation, erythema, or fever. Magnetic resonance imaging (MRI) showed bone edema, mild sclerosis, and volumetric reduction of the intermediate cuneiform. Nonsteroidal anti-inflammatory medication was prescribed as treatment. Symptoms remitted spontaneously after 2 weeks. The pain did not return, and the patient was asymptomatic after 3 months. Imaging studies such as X-ray, CT, and MRI are important to identify this condition and may avoid unnecessary tests and treatments such as laboratory exams, scintigraphy, and bone biopsies. Due to the benign nature as well as the possibility of it presenting with no symptoms, we believe that it may be considered as a variant of bone maturation or a self-limited condition.

Rho-kinase pathway activation and apoptosis in circulating leucocytes in patients with heart failure with reduced ejection fraction.

BACKGROUND: Increased Rho-kinase activity in circulating leucocytes is observed in heart failure with reduced ejection fraction (HFrEF). However, there is little information in HFrEF regarding other Rho-kinase pathway components an on the relationship between Rho-kinase and apoptosis. Here, Rho-kinase activation levels and phosphorylation of major downstream molecules and apoptosis levels were measured for the first time both in HFrEF patients and healthy individuals. METHODS: Cross-sectional study comparing HFrEF patients (n = 20) and healthy controls (n = 19). Rho-kinase activity in circulating leucocytes (peripheral blood mononuclear cells, PBMCs) was determined by myosin light chain phosphatase 1 (MYPT1) and ezrin-radixin-moesin (ERM) phosphorylation. Rho-kinase cascade proteins phosphorylation p38-MAPK, myosin light chain-2, JAK and JNK were also analysed along with apoptosis. RESULTS: MYPT1 and ERM phosphorylation were significantly elevated in HFrEF patients, (3.9- and 4.8-fold higher than in controls, respectively). JAK phosphorylation was significantly increased by 300% over controls. Phosphorylation of downstream molecules p38-MAPK and myosin light chain-2 was significantly higher by 360% and 490%, respectively, while JNK phosphorylation was reduced by 60%. Catecholamine and angiotensin II levels were significantly higher in HFrEF patients, while angiotensin-(1-9) levels were lower. Apoptosis in circulating leucocytes was significantly increased in HFrEF patients by 2.8-fold compared with controls and significantly correlated with Rho-kinase activation. CONCLUSION: Rho-kinase pathway is activated in PMBCs from HFrEF patients despite optimal treatment, and it is closely associated with neurohormonal activation and with apoptosis. ROCK cascade inhibition might induce clinical benefits in HFrEF patients, and its assessment in PMBCs could be useful to evaluate reverse remodelling and disease regression.

Sonographically guided botulinum toxin injections in patients with neurogenic thoracic outlet syndrome: correlation with surgical outcomes.

OBJECTIVE: We examined the role of botulinum toxin (BTX) injections of anterior scalene (AS) and pectoralis minor (PM) muscles in patients undergoing surgery for neurogenic thoracic outlet syndrome (NTOS). We hypothesized that symptomatic improvement from BTX injections correlates with favorable long-term response to surgery for NTOS. MATERIALS AND METHODS: This Health Insurance Portability and Accountability Act compliant study was approved by the institutional review board and prior informed consent requirement was waived. We retrospectively analyzed prospectively acquired data in NTOS patients who underwent sonographically guided chemodenervation of AS and PM using BTX type A followed by scalenectomy and first rib resection. Overall responses to BTX injections and surgery were recorded after each procedure. Statistical analyses were performed to determine correlation between responses to BTX injections and surgery. RESULTS: In 157 patients, 178 BTX injections followed by surgery were identified (114 females; mean age 38 ± 13 years). Responders and non-responders to BTX injections and surgery had similar preoperative symptom duration and age (P > 0.14). Better response to BTX injections correlated positively with better response to surgery (P = 0.003), persisting after adjustment for age, gender, and symptom duration (P = 0.03). A high proportion of responders to BTX injections also responded to surgery (positive predictive value of 99%), and BTX injections showed high specificity (90%). BTX injections were moderately sensitive (66%) and accurate (67%) to determine surgical response and had low negative predictive value (14%). CONCLUSION: Response to BTX injections correlates positively with long-term surgical outcome in subjects with NTOS, potentially playing an important role in patient management.

Effect of Early Normotension with Olmesartan on Rho-kinase Activity in Hypertensive Patients.

BACKGROUND: Angiotensin II is a potent activator of the Rho-kinase (ROCK) pathway, through which it exerts some of its adverse vasoconstrictor effects. Clinical evidence on the effects of blocking the angiotensin II receptor 1 on ROCK activity in hypertensive patients is scarce. OBJECTIVE: To demonstrate that ROCK activity in peripheral blood mononuclear cells (PMBCs) in patients with essential hypertension is reduced earlier than previously observed, along with blood pressure (BP) lowering on treatment with olmesartan. METHODS: Prospective pilot open study; 17 hypertensive patients were treated with progressive olmesartan doses starting with 20 mg qd. BP was measured at 3, 6 and 9 weeks after treatment initiation. If treatment failed to normalize BP after 3 weeks, olmesartan dose was increased to 40 mg qd, and if still hypertensive after 6 weeks, 12.5 mg of hydrochlorothiazide qd was added. ROCK activity was measured at baseline and 9 weeks after treatment as myosin phosphatase target subunit 1 phosphorylation (MYPT1-p/T ratio) in PBMC. RESULTS: Mean baseline BP was 162 ± 4.9/101 ± 2.4 mmHg. After 9 weeks of treatment, both systolic and diastolic BP were reduced by 41 and 22 mmHg, respectively (p<0.05). Mean pretreatment MYPT1- p/T ratio in PMBCs was significantly reduced by 80% after 9 weeks with olmesartan (p<0.01). CONCLUSION: Normotension achieved after 9 weeks in 82% of the patients treated with olmesartan was associated with a significant reduction of ROCK activity in PBMC.

Evaluation of Audiovisual Reports to Enhance Traditional Emergency Musculoskeletal Radiology Reports.

Traditional radiology reports are narrative texts that include a description of imaging findings. Recent implementation of advanced reporting software allows for incorporation of annotated key images and hyperlinks directly into text reports, but these tools usually do not substitute in-person consultations with radiologists, especially in challenging cases. Use of on-demand audio/visual reports with screen capture software is an emerging technology, providing a more engaged imaging service. Our study evaluates a video reporting tool that utilizes PACS integrated screen capture software for musculoskeletal imaging studies in the emergency department. Our hypothesis is that referring orthopedic surgeons would find that recorded audio/video reports add value to conventional reports, may increase engagement with radiology staff, and also facilitate understanding of imaging findings from urgent musculoskeletal cases. Seven radiologists prepared a total of 47 audiovisual reports for 9 attending orthopedic surgeons from the emergency department. We applied two surveys to evaluate the experience of the referring physicians using audio/visual reports as a complementary material from the conventional text report. Positive responses were statistically significant in most questions including: if the clinical suspicion was answered in the video; willingness to use such technology in other cases; if the audiovisual report made the imaging findings more understandable than the traditional report; and if the audiovisual report is faster to understand than the traditional text report. Use of audiovisual reports in emergency musculoskeletal cases is a new approach to evaluate potentially challenging cases. These results support the potential of this technology to re-establish the radiologist's role as an essential member of patient care and also provide more engaging, precise, and personalized reports. Further studies could streamline these methods in order to minimize work redundancy with traditional text reporting or even evaluate acceptance of using only audiovisual radiology reports. Additionally, widespread adoption would require integration with the entire radiology workflow including non-urgent cases and other medical specialties.

Correction to: Humeral stress fracture in a female CrossFit athlete: a case report.

It has been brought to our attention that the article [1] in reference [7] Smith MM, Sommer AJ, Starkoff BE, Devor ST. Crossfit-based high-intensity power training improves maximal aerobic fitness and body composition. J Strength Cond Res. 2013;27(11):3159-72 was retracted in October 2017. At the time of the submission of the manuscript the authors were not aware of the retraction and legal implications related to this reference. Therefore, the authors do not support the findings of the retracted article such as that CrossFit has "an apparent disproportionate musculoskeletal injury risk, especially for novice participants". The overall conclusions of the case report are not affected by this erratum.

Humeral stress fracture in a female CrossFit athlete: a case report.

BACKGROUND: Humeral stress fractures are rare injuries usually related to sports practice and joint overload without a direct trauma. A proximal humeral stress fracture has never been reported in a CrossFit athlete. CASE PRESENTATION: We report a stress fracture in the humerus of a 22-year-old woman after intense CrossFit training. Patient's previous medical history included amenorrhea and reduced Vitamin D levels. The patient was treated conservatively and resumed CrossFit training after she was advised not to until follow up imaging. CONCLUSIONS: We present the MRI features of the case and emphasize the difficulties in diagnosis due to multiple possible causes of shoulder pain in a CrossFit athlete and by negative findings on early radiographs. Hormonal variations, Vitamin D insufficiency and the patient's attitude towards exercise were important factors that contributed for the stress injury after weight-lifting in CrossFit.