Ultrasound of the distal biceps brachii tendon using four approaches: reproducibility and reader preference.

OBJECTIVES: To determine which sonographic appearance of the distal biceps brachii tendon (DBBT) is preferred by readers, and if images obtained by two different operators are reproducible. METHODS: We performed an IRB-approved prospective sonographic evaluation of the DBBT in 50 healthy elbows using four different approaches (anterior, lateral, medial, posterior) performed by two operators. Five musculoskeletal radiologists independently reviewed the images, and ranked the four approaches based on overall appearance of echogenicity of the tendon, visualized length, and visualization of the insertion. RESULTS: The medial approach was preferred in 79.6% of elbows, anterior in 17.6%, lateral in 2.8%, and the posterior approach was never preferred. The difference was statistically significant (P < 0.001). Kappa values for the five readers were 0.61 to 0.8 for choosing the images produced by the medial approach. CONCLUSION: The appearance of the DBBT using the medial approach is preferred by readers and is reproducible between different operators.

The Clinical Severity of Patients Diagnosed With an In-Hospital Pulmonary Embolism Following Modern, Elective Joint Arthroplasty Is Unrelated to the Location of Emboli in the Pulmonary Vasculature.

BACKGROUND: In the event of a postoperative pulmonary embolism (PE), it is generally believed that patients with centrally located emboli will have worse clinical symptoms than those with segmental or subsegmental ones. We studied if a relationship exists between the clinical severity at the time of PE diagnosis and the location of the emboli within the pulmonary vasculature. METHODS: All 269 patients who developed an in-hospital, computed tomography pulmonary angiography-proved, PE following elective total hip arthroplasty or total knee arthroplasty in our institution were studied. The clinical severity of the PE was calculated using the Pulmonary Embolism Severity Index (PESI) that classifies patients in 5 classes (class 5: most severe). All computed tomography pulmonary angiographies were re-reviewed to determine the location of the emboli within the pulmonary vasculature (central, segmental, or subsegmental-unilateral or bilateral). The association between PESI and the PE location was examined. RESULTS: The most proximal location of the emboli was central in 62, segmental in 139, and subsegmental in 68. There were 180 unilateral and 89 bilateral PE patients. There was no association between the PESI and the location of the emboli within the pulmonary vasculature (P = .32). Patients with bilateral or unilateral lung involvement had similar PESI (P = .78). CONCLUSION: The PESI, a recognized, validated predictor of mortality after PE was similar in patients with central, segmental, or subsegmental PE; and in patients with unilateral or bilateral lung involvement. The present study may aid clinicians while assessing and discussing the severity of PE symptoms with patients at the time of diagnosis.

Ultrasound-guided perineural injection for nerve blockade: Does a single-sided injection produce circumferential nerve coverage?

PURPOSE: Our current clinical technique for sonographic-guided perineural injection consists of two-sided perineural needle placement to obtain circumferential distribution of the injectate. This study aimed to determine if a single-side needle position will produce circumferential nerve coverage. METHODS: Fresh-frozen cadaveric specimens were used for this study. In six upper extremities, a needle was positioned along the deep surface of median, radial, and ulnar nerves in the carpal tunnel, radial tunnel, and cubital tunnel, respectively, and 2 ml of contrast was injected for each nerve. In three pelvic specimens, a needle was positioned deep to the sciatic nerves bilaterally, and 5 ml of contrast was injected. An additional four median nerve injections were performed using superficial surface needle position. The specimens then underwent CT scanning to assess the distribution of the perineural contrast medium. RESULTS: One hundred percent of the radial, ulnar, and sciatic nerves demonstrated circumferential distribution on CT. Only 50% of the median nerve injections with the needle placed deep to the nerve produced circumferential coverage, whereas 100% of median nerves injected with the needle between the nerve and retinaculum demonstrated circumferential coverage. The average length of spread of perineural injectate was 11.6 cm in the upper extremity and 10.3 cm for the sciatic nerves. CONCLUSIONS: Using clinical volumes of fluid, needle positioning at the deep surface of upper extremity and sciatic nerves was sufficient to produce circumferential coating of the nerve, except in the carpal tunnel, where placement of the needle between the nerve and flexor retinaculum is recommended. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:465-469, 2016.

Volume and Movement Affecting Flow of Injectate Between the Biceps Tendon Sheath and Glenohumeral Joint: A Cadaveric Study.

OBJECTIVE: The objective of our study was to determine if flow of injectate between the biceps tendon sheath and the glenohumeral joint is a function of injectate volume or of motion of the upper extremity. MATERIALS AND METHODS: Sixteen upper-extremity fresh-frozen cadaveric specimens were used. Initially, three ultrasound-guided biceps tendon sheath injections were performed using 2, 5, and 10 mL of contrast material. Immediately after the injections, the specimens were imaged using CT. If contrast material was not visualized within the glenohumeral joint, the specimen was manipulated for 5 minutes and reimaged using CT to assess for contrast material within the joint. Five separate ultrasound-guided glenohumeral joint injections were also performed using 5 mL (three specimens), 10 mL (one specimen), and 15 mL (one specimen) of contrast material. The specimens underwent CT, and the presence or absence of contrast material in the biceps tendon sheath was documented before and after manipulation. Next, eight additional ultrasound-guided biceps tendon sheath injections were performed using 2 mL (six specimens) and 5 mL (two specimens) of contrast material. RESULTS: The 5- and 10-mL biceps tendon sheath injection specimens and the 5-, 10-, and 15-mL glenohumeral joint specimens showed communicating contrast flow on the initial CT study. Only two of the seven 2-mL biceps tendon sheath injection specimens showed flow of contrast material into the glenohumeral joint from the biceps tendon sheath on the initial CT study; the remaining five specimens showed no communication even after manipulation. CONCLUSION: Communication between the biceps tendon sheath and the glenohumeral joint may be a function of injectate volume rather than patient movement.

Ultrasound diagnosis and evaluation of plantar heel pain.

BACKGROUND: One of the most common causes of heel pain is plantar fasciitis; however, there are other pathologic disorders that can mimic the symptoms and clinical presentation of this disorder. The purpose of this study was to retrospectively review the prevalence of various pathologic disorders on ultrasound in patients with proximal plantar heel pain. METHODS: The medical records and diagnostic ultrasound reports of patients presenting with plantar heel pain between March 1, 2006, and March 31, 2007, were reviewed retrospectively, and the prevalence of various etiologies was collected. The inclusion criteria were based on their clinical presentation of plantar fasciitis or previous diagnosis of plantar fasciitis from an unknown source. Ultrasound evaluation was then performed to confirm the clinical diagnosis. RESULTS: We examined 175 feet of 143 patients (62 males and 81 females; age range, 16-79 years). Plantar fibromas were present in 90 feet (51%). Plantar fasciitis was diagnosed in 128 feet (73%). Coexistent plantar fibroma and plantar fascial thickening was found in 63 feet (36%). Of the 47 feet that were negative for plantar fasciitis on ultrasound, 27 (57%) revealed the presence of plantar fibroma. CONCLUSIONS: Diagnostic ultrasound can effectively and safely identify the prevalence of various etiologies of heel pain. The high prevalence of plantar fibromas and plantar fascial tears cannot be determined by clinical examination alone, and, therefore, ultrasound evaluation should be performed for confirmation of diagnosis.

Lumbar discal cyst: Diagnostic discography followed by therapeutic computed tomography-guided aspiration and injection.

Discal cysts are extradural masses that communicate with the intervertebral disk and are a rare cause of lower back pain and lumbar radiculopathy. This case report describes a lumbar discal cyst, the diagnosis of which was confirmed on conventional discography, and which was treated with computed tomography-guided aspiration and steroid injection. Several reports have described this procedure, but only one in the radiology literature, and thus the purpose of this report is to remind the radiology community of the existence of this entity and propose a minimally invasive means of treatment.

Magnetic resonance angiography in the management of recurrent hemarthrosis after total knee arthroplasty.

Spontaneous hemarthrosis is an infrequent but disabling complication after total knee arthroplasty. The purpose of this case series is to demonstrate the utility of magnetic resonance angiography (MRA) in the evaluation of hemarthrosis after total knee arthroplasty. Patients presenting with hemarthrosis unexplained by trauma, anticoagulation, or a bleeding diathesis were retrospectively identified. Eighteen patients were referred for MRA to evaluate recurrent hemarthrosis after failing conservative therapy (n = 16) or synovectomy (n = 2). Despite artifact caused by the metallic components, diagnostic evaluation of regional vessels was made. In 12 of 13 cases that underwent embolization or synovectomy, a hypertrophic feeding artery (or arteries) was visualized on MRA. One case of negative MRA did not have subsequent surgery, and we are unable to comment on the rate of false-positives because all patients in this case series had evidence of bleeding. By characterizing the vascular anatomy and identifying a dominant artery (or arteries) supplying the hypervascular synovium, MRA can serve as a guide for subsequent embolization or synovectomy, as indicated.

Sonographic evaluation and sonographic-guided therapeutic options of lateral ankle pain: peroneal tendon pathology associated with the presence of an os peroneum.

Clinical implications of acute injuries of the os peroneum have been described, with the recommendation in some cases being the excision of the bone fragments. We describe the spectrum of sonographic appearances associated with pain in the region of the os peroneum, document associated peroneal tendon pathology, and describe the use of sonography to direct and guide therapeutic and/or diagnostic injections. All sonographic examinations in our ultrasound database from Jan 1, 2001-Jan 30, 2007 with the words "os peroneum" were reviewed. Patients were cross-referenced in our radiology database to find relevant foot or ankle radiographs for correlation. There were 47 patients (18 men and 29 women, age range 16 to 83) referred for sonographic evaluation of lateral foot and/or ankle pain who had an os peroneum identified during the sonographic evaluation. Eighteen patients were referred specifically for targeted injection of the lateral ankle, including peroneal tendon sheath injections (N = 10), calcaneocuboid joint injections (N = 1), and injections around symptomatic os peroneum (N = 7). All 47 patients had tendinosis of the peroneus longus, in varying degrees of severity. Radiographs were available for correlation in 28 patients. The causes of lateral ankle pain with a co-existent os peroneum are multifactorial and may not directly relate to the presence of an os peroneum. Ultrasound can be of value in separating out the specific etiology for pain, as well as provide a method for problem solving by the performance of targeted diagnostic or therapeutic injections in the lateral ankle.

Lumbar discography.

Lumbar discography has generally proven to be a safe diagnostic tool for the evaluation and potential treatment planning of presumed discogenic pain, but it has not been wholeheartedly embraced by the radiologic and surgical community because of doubts as to its safety, accuracy, and relevance to patient outcome. There have been some conflicting reports on the relative merits and limitations of the procedure in the diagnosis and treatment planning of low back pain and radiculopathy; further studies are needed to determine with certainty whether discography is in fact able to localize the precise discs of clinical significance and accurately predict those patients who will respond well to surgery and those who will not.