Long-term functional outcomes (median 10 years) after locked plating for displaced fractures of the proximal humerus.

BACKGROUND: Locked plating has become an accepted treatment for displaced fractures of the proximal humerus. However, to our knowledge, long-term outcomes have not been reported. METHODS: Between February 2002 and March 2004, 121 patients with displaced proximal humeral fractures were treated by open reduction and locking plate fixation. Forty-three patients were available for 10-year (95% confidence interval [CI], 9.8-10.1) follow-up, including Constant score (CS), Disabilities of the Arm, Shoulder and Hand score, and Short Form 36 questionnaire. RESULTS: Of 43 patients (72% women; mean age at time of fracture repair, 58.2 years; 95% CI, 54.2-62.2), the absolute CS 10 years after surgery was 75.3 (95% CI, 69.2-81.4). The normalized CS was 88.4 (95% CI, 81.7-95.1), and the CS in percentage to the contralateral side (%CS) was 83.7 (95% CI, 78.5-88.9). In contrast, at 1 year, the CS was 73.9 (95% CI, 67.8-80.2, P = .774), the normalized CS was 87.2 (95% CI, 80.4-94.0; P = .765), and the %CS was 78.7 (95% CI, 71.5-85.8; P = .355). The CS at 10 years correlated with the CS at 1 year after surgery (r = 0.460; P < .01) and with patient gender (r = -0.424; P < .01), and it strongly correlated with patient age (r = -0.545; P < .001). CONCLUSIONS: Ten years after locked plating of displaced proximal humeral fractures, patients show good to excellent outcomes in the majority of cases with no relevant decline compared with the shoulder function 1 year after surgery. However, poor long-term outcome is seen in 16% of patients and relates to a low CS 1 year after surgery. Thus, patients developing poor long-term outcomes may be identified at an earlier stage.

Male breast disease: pictorial review with radiologic-pathologic correlation.

The male breast is susceptible to many of the same pathologic processes as the female breast. Many of these conditions have mammographic, ultrasonographic (US), and magnetic resonance imaging findings that allow differentiation between clearly benign conditions and those that require biopsy. Gynecomastia is the most common abnormality of the male breast and has characteristic imaging features that usually allow differentiation from malignancy. Mammography is the initial imaging modality for a clinically suspicious mass. A palpable mass that is occult or incompletely imaged at mammography mandates targeted US. Suspicious or indeterminate masses require biopsy, which can usually be performed with US guidance. Approximately 0.7% of breast cancers occur in men. Men with breast cancer often present at a more advanced stage than do women owing to a delay in diagnosis. Benign breast neoplasms that may occur in men include angiolipoma, schwannoma, intraductal papilloma, and lipoma. Benign nonneoplastic entities that may occur in the male breast include intramammary lymph node, sebaceous cyst, diabetic mastopathy, hematoma, fat necrosis, subareolar abscess, breast augmentation, venous malformation, secondary syphilis, and nodular fasciitis. Familiarity with the salient features of the classic benign male breast conditions will allow accurate imaging interpretation and avoid unnecessary and often invasive treatment. © RSNA, 2013.

A feasible high spatiotemporal resolution breast DCE-MRI protocol for clinical settings.

Three dimensional bilateral imaging is the standard for most clinical breast dynamic contrast-enhanced (DCE) MRI protocols. Because of high spatial resolution (sRes) requirement, the typical 1-2 min temporal resolution (tRes) afforded by a conventional full-k-space-sampling gradient echo (GRE) sequence precludes meaningful and accurate pharmacokinetic analysis of DCE time-course data. The commercially available, GRE-based, k-space undersampling and data sharing TWIST (time-resolved angiography with stochastic trajectories) sequence was used in this study to perform DCE-MRI exams on thirty one patients (with 36 suspicious breast lesions) before their biopsies. The TWIST DCE-MRI was immediately followed by a single-frame conventional GRE acquisition. Blinded from each other, three radiologist readers assessed agreements in multiple lesion morphology categories between the last set of TWIST DCE images and the conventional GRE images. Fleiss' κ test was used to evaluate inter-reader agreement. The TWIST DCE time-course data were subjected to quantitative pharmacokinetic analyses. With a four-channel phased-array breast coil, the TWIST sequence produced DCE images with 20 s or less tRes and ~ 1.0×1.0×1.4 mm(3) sRes. There were no significant differences in signal-to-noise (P=.45) and contrast-to-noise (P=.51) ratios between the TWIST and conventional GRE images. The agreements in morphology evaluations between the two image sets were excellent with the intra-reader agreement ranging from 79% for mass margin to 100% for mammographic density and the inter-reader κ value ranging from 0.54 (P<.0001) for lesion size to 1.00 (P<.0001) for background parenchymal enhancement. Quantitative analyses of the DCE time-course data provided higher breast cancer diagnostic accuracy (91% specificity at 100% sensitivity) than the current clinical practice of morphology and qualitative kinetics assessments. The TWIST sequence may be used in clinical settings to acquire high spatiotemporal resolution breast DCE-MRI images for both precise lesion morphology characterization and accurate pharmacokinetic analysis.

Use of clinical history affects accuracy of interpretive performance of screening mammography.

OBJECTIVE: To examine how use of clinical history affects radiologist's interpretation of screening mammography. STUDY DESIGN AND SETTING: Using a self-administered survey and actual interpretive performance, we examined associations between use of clinical history and sensitivity, false-positive rate, recall rate, and positive predictive value, after adjusting for relevant covariates using conditional logistic regression. RESULTS: Of the 216 radiologists surveyed (63.4%), most radiologists reported usually or always using clinical history when interpreting screening mammography. Compared with radiologists who rarely use clinical history, radiologists who usually or always use it had a higher false-positive rate with younger women (10.7 vs. 9.7), denser breast tissue (10.1 for heterogeneously dense to 10.9 for extremely dense vs. 8.9 for fatty tissue), or longer screening intervals (> prior 5 years) (12.5 vs. 10.5). Effect of current hormone therapy (HT) use on false-positive rate was weaker among radiologists who use clinical history compared with those who did not (P=0.01), resulting in fewer false-positive examinations and a nonsignificant lower sensitivity (79.2 vs. 85.2) among HT users. CONCLUSION: Interpretive performance appears to be influenced by patient age, breast density, screening interval, and HT use. This influence does not always result in improved interpretive performance.

Spectrum of disease in the male breast.

OBJECTIVE: The purpose of this article is to review the anatomy of the male breast and to describe the imaging findings of a variety of diseases that affect the male breast to better understand and recognize the imaging findings and underlying pathophysiology of diseases and conditions affecting this emerging subset of patients. CONCLUSION: Understanding the anatomy of the male breast is central to developing a differential diagnosis and delivering optimal care in male patients presenting with breast complaints. Diseases in the male breast can affect the skin and subcutaneous tissues, stroma and glandular elements, and neurovascular and lymphatic structures. Although the most commonly encountered disease entity is gynecomastia, men can develop many other benign and neoplastic diseases, including primary breast cancer. By incorporating clinical presentation with imaging findings on mammography and ultrasound, the breast imager can more effectively establish the correct diagnosis in males.

An assessment of the likelihood, frequency, and content of verbal communication between radiologists and women receiving screening and diagnostic mammography.

RATIONALE AND OBJECTIVES: Research on communication between radiologists and women undergoing screening and diagnostic mammography is limited. We describe community radiologists' communication practices with patients regarding screening and diagnostic mammogram results and factors associated with frequency of communication. MATERIALS AND METHODS: We received surveys from 257 radiologists (70% of those eligible) about the extent to which they talk to women as part of their health care visit for either screening or diagnostic mammograms, whether this occurs if the exam assessment is positive or negative, and how they use estimates of patient risk to convey information about an abnormal exam where the specific finding of cancer is not yet known. We also assessed characteristics of the radiologists to identify associations with more or less frequent communication at the time of the mammogram. RESULTS: Two hundred and forty-three radiologists provided complete data (95%). Very few (<6%) reported routinely communicating with women when screening mammograms were either normal or abnormal. Fewer than half (47%) routinely communicated with women when their diagnostic mammograms were normal, whereas 77% often or always communicated with women when their diagnostic exams were abnormal. For positive diagnostic exams, female radiologists were more likely to be frequent communicators compared to males (87.1%-72.8%; P=.02) and those who spend 40%-79% of their time in breast imaging (94.6%) were more likely to be frequent communicators compared to those who spend less time (67.2%-78.9%; P=.02). Most radiologists convey risk information using general rather than numeric statements (57.7% vs. 28.5%). CONCLUSIONS: Radiologists are most likely to convey information about diagnostic mammographic findings when results are abnormal. Most radiologists convey risk information using general rather than numeric statements.

Do We need to include osteoporosis in today's classification of distal radius fractures?

Although the correlation between decreased bone mineral density and increased incidence of distal radius fractures is widely acknowledged, the effect of osteoporosis on specific fracture types is seldom addressed. No classification system has been established for clinical use that has been validated for osteoporotic fractures or that includes parameters of the bone density or bone quality. So far, only one experimental study could report a clear correlation between bone properties and fracture patterns, and an additional clinical study assesses bone density in relation to displacement in Colles fractures. Further studies are needed to analyze the intra- and interobserver reproducibility of more simplified but nonetheless comprehensive classification systems that recognize the impact of osteoporosis on distal radius fracture and that specifically incorporate bone mineral density.

Flexible intramedullary nailing for stabilization of displaced midshaft clavicle fractures: technique and results in 87 patients.

BACKGROUND: Elastic, stable intramedullary nailing (ESIN) with titanium nails is a promising minimally treatment for displaced midclavicular fractures, which may be an alternative to plate fixation (ORIF) or even nonoperative treatment. We describe the surgical technique and outcome in 87 patients. METHODS: The nail was inserted at the medial inferior end of the clavicle in 83 patients and in the acromial end in 12 patients. An open fracture reduction via an additional small incision was necessary in 53 patients and closed manoeuvre was successful in 42. Implant removal was performed in 82 patients. RESULTS: The functional status of 87 patients after 13 months reached 6.8 (0-43) points on the DASH score and 81 (46-100) points on the self-reported Constant score. The fracture healed in correct anatomical axis in 80 of 87 patients, 2 cases ended in a nonunion. Implant migration of the nail occurred in 4 patients, who required early implant removal. Repeated nailing was necessary in 2 patients in whom the nail missed the lateral medullar canal, and plate fixation was necessary in 2 other patients who had secondary dislocation after early nail removal. INTERPRETATION: Flexible intramedullary nailing, a minimally invasive technique for stabilization of displaced midshaft clavicle fractures, has minor risks and complications.

Failure strengths in distal biceps tendon repair.

BACKGROUND: Surgical repair is the most favored treatment for a rupture of the distal biceps tendon. A variety of techniques have been described for distal biceps tendon reattachment, including transosseous sutures, suture anchors, interference screws, and an EndoButton-based technique. HYPOTHESIS: EndoButton and suture anchor have initially stronger fixation strengths than do transosseous sutures, allowing early postoperative rehabilitation. STUDY DESIGN: Controlled laboratory study. METHODS: Single loads to failure and mode of failure of 13 different fixation techniques were determined using 130 human cadaveric elbows. Quantitative computer tomography was performed to exclude differences in bone mineral density as an affecting factor. Repeated-measures analysis of variance was used to assess differences in failure load between repair techniques. RESULTS: The EndoButton-based technique showed a significantly higher failure load (259 +/- 28 N) than did all other techniques (P < .05). No significant differences were seen between the transosseous suture technique (210 +/- 29 N) and most other techniques (P > .05). Failure loads of the TwinFix-QuickT (57 +/- 29 N) and Biocuff screw (105 +/- 28 N) were significantly lower than those of all other repairs (P < .05). CONCLUSION: Significant differences exist in failure loads and modes of failure for the different repair techniques after rupture of the distal biceps tendon. CLINICAL RELEVANCE: The transosseous technique is still a sufficient and cost-saving procedure for repair of the distal biceps tendon. TwinFix-QuickT 5.0 mm and Biocuff screw 5.7 mm had significantly lower failure loads, which might affect early rehabilitation, particularly in patients with poor bone quality.

Comparison of different radiography systems in an experimental study for detection of forearm fractures and evaluation of the Müller-AO and Frykman classification for distal radius fractures.

OBJECTIVES: We sought to compare the diagnostic performance of screen-film radiography, storage-phosphor radiography, and a flat-panel detector system in detecting forearm fractures and to classify distal radius fractures according to the Müller-AO and Frykman classifications compared with the true extent, depicted by anatomic preparation. MATERIALS AND METHODS: A total of 71 cadaver arms were fractured in a material testing machine creating different fractures of the radius and ulna as well as of the carpal bones. Radiographs of the complete forearm were evaluated by 3 radiologists, and anatomic preparation was used as standard of reference in a receiver operating curve analysis. RESULTS: The highest diagnostic performance was obtained for the detection of distal radius fractures with area under the receiver operating curve (AUC) values of 0.959 for screen-film radiography, 0.966 for storage-phosphor radiography, and 0.971 for the flat-panel detector system (P > 0.05). Exact classification was slightly better for the Frykman (kappa values of 0.457-0.478) compared with the Müller-AO classification (kappa values of 0.404-0.447), but agreement can be considered as moderate for both classifications. CONCLUSIONS: The 3 imaging systems showed a comparable diagnostic performance in detecting forearm fractures. A high diagnostic performance was demonstrated for distal radius fractures and conventional radiography can be routinely performed for fracture detection. However, compared with anatomic preparation, depiction of the true extent of distal radius fractures was limited and the severity of distal radius fractures tends to be underestimated.