T1-VIBE and STIR MRI of lumbar pars interarticularis injuries in elite athletes: fracture characterisation and potential prognostic indicators.

OBJECTIVES: To assess how pars interarticularis fracture characteristics on T1-VIBE and STIR MRI relate to healing and identify anatomical parameters that may impact healing. MATERIALS AND METHODS: A retrospective review of an MRI series of lumbar pars interarticularis injuries in elite athletes over a 3-year period. Fracture configurations, signal intensities and anatomical parameters were recorded by two radiologists. Statistical analysis employed multilevel mixed-effects linear regressions, adjusted for repeated measures and baseline covariates. RESULTS: Forty-seven lumbar pars interarticularis injuries among 31 athletes were assessed. On final scans for each athlete, 15% (7/47) injuries had worsened, 23% (11/47) remained stable, 43% (20/47) partially healed and 19% (9/47) healed completely. Healing times varied, quickest was 49 days for a chronic fracture in a footballer. Bone marrow oedema signal was highest in worsened fractures, followed by improved, and lowest in stable fractures. As healing progressed, T1-VIBE signal at the fracture line decreased. Bone marrow oedema and fracture line signal peaked at 90-120 days before decreasing until 210-240 days. Fractures with smaller dimensions, more vertical orientation and a longer superior articular facet beneath were significantly associated with better healing (p < 0.05). CONCLUSION: Most diagnosed athletic pars interarticularis injuries improve. Normalising T1-VIBE signal at the fracture line is a novel measurable indicator of bony healing. Contrastingly, bone marrow oedema signal is higher in active fractures irrespective of healing or deterioration. Injuries initially perceived as worsening may be exhibiting the normal osteoclastic phase of healing. Better outcomes favour smaller, vertical fractures with a longer superior articular facet beneath.

The association of bone bruising and grade of MCL injury in patients sustaining isolated MCL injuries.

OBJECTIVES: To investigate the incidence of bone bruising with isolated medial collateral ligament injury and to assess whether the presence of bone bruising is related to the injury grade. MATERIALS AND METHODS: Patients who sustained an acute isolated medial collateral ligament injury demonstrated on knee MRI between 2016 and 2020 were included in this study. Patient's characteristics and injury classification (clinical and radiological) were reviewed from clinical notes and imaging. The patients were divided into two groups, based on the presence of bone bruising. Fisher's exact test was used for dichotomous variables and odds ratios were computed in areas of clinical significance. RESULTS: Sixty patients with a median age of 37.6 ± 13.8 were included. Twenty-eight (46.7%) had bone bruising demonstrated on MRI scan. The bone bruising group were 7 times (95% CI [1.4;36.5]) more likely to have a complete disruption of the superficial medial collateral ligament and MRI grade III injury. Injury to the deep medial collateral ligament was more often observed in this group (p < 0.05). The most common location of bone bruising was the lateral femoral condyle (57.1%, 16/28) and/or the medial femoral condyle (57.1%, 16/28). CONCLUSIONS: The incidence of bone bruising with isolated medial collateral ligament injury is significant and is more common with radiologically higher grade injuries. There was no statistically significant difference between the anatomical location of bone bruise and the grade of MCL injury. Bone bruising patterns can help determine the mechanism of injury, with a valgus impact or avulsion type injury most commonly seen.

Medial collateral ligament injury of the knee: correlations between MRI features and clinical gradings.

OBJECTIVE: To evaluate the degree of correlation between MRI and clinical gradings of medial collateral ligament (MCL) injuries and assess for associated structures on MRI which may influence the clinical perception of MCL laxity. MATERIALS AND METHODS: All knee MRIs with acute MCL injuries between 2016 and 2020 at our centre were retrospectively reviewed by two blinded musculoskeletal radiologists. The clinic notes were reviewed for clinical gradings. RESULTS: One hundred and nineteen MRIs included. Forty-eight percent (57/119) agreement between MRI and clinical gradings (κ = 0.21, standard error (SE) 0.07). MRI grades: I 29% (34/119), II 50% (60/119), III 21% (25/119). Clinical grades: I 67% (80/119), II 26% (31/119), III 7% (8/119). In patients with clinical grade III MCL injury, there was waviness of the superficial MCL on MRI in 100% (8/8), deep meniscofemoral ligament tear in 75% (6/8), anterior cruciate ligament (ACL) partial or complete tear in 75% (6/8) and posteromedial corner (PMC) injury in 100% (8/8); compared with 0% (0/111), 34% (38/111), 44% (49/111) and 41% (46/111) respectively in clinical grade I or II injuries (p < 0.05). CONCLUSION: Agreement between MRI and clinical gradings of MCL injuries was only 'fair', with MRI almost always overestimating the grade of the injury when there was a mismatch. Waviness of the superficial MCL and injuries to the deep MCL, ACL and PMC correlate with clinical instability.

Direct Access and Skill Mix Can Reduce Telephone Interruptions and Imaging Wait Times: Improving Radiology Service Effectiveness, Safety and Sustainability.

Unnecessary telephone calls to reporting radiologists impede organizations' workflow and may be associated with a higher chance of errors in reports. We conducted a prospective study in two cycles, which identified vetting plain CT heads as the most common reason for these calls and vetting CT urinary tracts (KUB) was also frequent. Clear vetting and protocolling guidelines exist for both of these scans, which do not routinely require discussion with a radiologist. Therefore, our approach was to create new flow diagrams to allow radiographers to directly accept routine requests for plain CT head and CT KUB scans in- and out-of-hours. After this intervention, incoming calls to radiology for vetting CT heads decreased by 30% and for vetting CT KUBs by 100%. The average wait time between CT head request and scan completion was reduced by 40%. The number of CT head and CT KUB scans performed remained stable. In future, maximizing the benefit of direct access in-patient imaging pathways will rely on effective and sustained communication of the protocols to the junior clinical staff rotating through the organization, as they were responsible for requesting the vast majority of tests.

Missed posterior shoulder fracture dislocations: a new protocol from a London major trauma centre.

BACKGROUND: A high incidence of missed posterior shoulder dislocations is widely recognised in the literature. Concern was raised by the upper limb multidisciplinary team at a London major trauma centre that these missed injuries were causing serious consequences due to the need for surgical intervention and poor functional outcome. OBJECTIVE: To identify factors contributing to missed diagnosis and propose solutions. METHODS: A local quality improvement report was performed investigating time from admission to diagnosis of simple posterior dislocations and fracture dislocations over a 5-year period. Factors contributing to a delayed diagnosis were analysed. RESULTS: The findings supported current evidence: a posterior shoulder dislocation was more often missed if there was concurrent fracture of the proximal humerus. Anteroposterior and scapular Y view radiographs were not always diagnostic for dislocation. Axial views were more reliable in assessment of the congruency of the joint and were associated with early diagnosis and appropriate treatment of the injury. DISCUSSION: As a result of these findings a new protocol was produced by the orthopaedic and radiology departments and distributed to our emergency department practitioners and radiography team. The protocol included routine axial or modified trauma axial view radiographs for all patients attending the emergency department with a shoulder injury, low clinical suspicion for dislocation and a low threshold for CT scan. Reaudit and ongoing data collection have shown significant increase in axial view radiographs and improved diagnosis.

Radiology report alerts - are emailed 'Fail-Safe' alerts acknowledged and acted upon?

BACKGROUND: Guidelines from the Royal College of Radiologists and National Patient Safety Agency highlight the crucial importance of "fail-safe" alert systems for the communication of critical and significant clinically unexpected results between imaging departments and referring clinicians. Electronic alert systems are preferred, to minimise errors, increase workflow efficiency and improve auditability. To date there is a paucity of evidence on the utility of such systems. We investigated i) how often emailed radiology alerts were acknowledged by referring clinicians, ii) how frequently follow-up imaging was requested when indicated and iii) whether practise improved after an educational intervention. METHODS: 100 cases were randomly selected before and after an educational intervention at a tertiary referral centre in London, where the email-based 'RadAlert' system (Rivendale Systems, UK) has been in operation since May 2017. RESULTS: Following educational intervention, 'accepted' alerts increased from 39% to 56%, 'abandoned' alerts reduced from 55% to 37% and 'declined' alerts decreased from 5% to 3%. There was evidence to confirm that, when indicated, further imaging had been requested for 78% of all alerts, 78% of 'accepted' alerts and 76% of 'abandoned' alerts both before and after educational intervention. CONCLUSIONS: Acknowledgment of report alerts by referring clinicians increased after departmental education / governance meetings. However, a proportion of email alerts remained unacknowledged. It is incumbent on reporting radiologists to be aware that electronic alert systems cannot be solely relied upon and to take the necessary steps to ensure significant and clinically unsuspected findings are relayed to referring clinical teams in a timely manner.

Ring Ring Ring! Characterising Telephone Interruptions During Radiology Reporting and How to Reduce These.

BACKGROUND: Telephone calls remain one of the most frequent interruptions in radiology reporting rooms, despite modern electronic order communication systems. A call received by a radiology trainee during the hour before completing a report may increase the chance of a discrepancy by 12%. AIM: To characterise telephone calls to radiology reporting rooms and identify ways to reduce these interruptions. METHODS AND MATERIALS: An observational study over five working days (10 programmed activity reporting sessions equivalent) was conducted across 2 large teaching hospital reporting rooms. Radiologists were requested to record all calls between 9a.m and 5p.m on a preprepared Excel proforma and indicate their initial rating of call appropriateness. RESULTS: A total of 288 calls recorded, 92% (266/288) interrupted reporting. Reasons for calls were 48% (139/288) ask for a request to be vetted, 17% (50/288) ask for a study to be reported, 17% (45/288) "other," 7% (19/288) discuss choice of study, 6% (16/288) review a report, 3% (9/288) wrong number, 2% (7/288) returning a bleep, and 1% (3/288) provide further explanation in addition to the electronic request form. CONCLUSION: Radiologists and referrers remain over reliant on telephone interruptions for their workflow. Attempts to educate referrers previously reduced calls to a computed tomography reporting room by 28%. Our recommendations include (1) defining protected activities, (2) adhering to fully electronic requesting and vetting processes, other than in time critical or exceptional circumstances, (3) electronic critical report alerts and review of report priority triaging to reduce calls for reports, (4) revising duty radiologist timetables to tackle nonreporting responsibilities, and (5) improving new doctor induction in the organization to improve radiology request practice.

Popeye sign of the semimembranosus.

A 23-year-old amateur football player presented 9 months after acute onset of severe pain and a lump in the posterior right knee whilst lifting a heavy box. He had been unable to return to playing football or climbing the stairs. Clinically, a Baker's cyst was suspected. MRI scan, the imaging modality of choice, was essentially normal. A subsequent ultrasound (US) scan demonstrated abnormal dynamic bunching of the muscle fibres at the distal semimembranosus myotendinous junction on resisted isometric contraction, most likely due to a previous tear isolated to the distal myotendinous junction. The proximal biceps femoris tendon is the most commonly injured part of the hamstring. Distal semimembranosus tears are far less common. Semimembranosus tendinopathy is an uncommon cause of chronic knee pain that is probably underdiagnosed and inadequately treated. In this case, the distal semimembranosus injury was occult on MRI because the features were only apparent with dynamic imaging, something that is not routinely part of musculoskeletal MRI protocols, whereas real-time imaging is easily performed with US. MRI is thought to be more sensitive than US for follow-up imaging of healing hamstring injuries; however, this case highlights the usefulness of dynamic imaging of muscle injuries with US. We propose that the abnormal dynamic muscle bulge on the US image would be aptly described as a "Popeye sign," which, to our knowledge, has not previously been reported in any other anatomical location than the long head of the biceps brachii in the published literature.

Audit of foot and ankle surgeons' management of acute peroneal tendon tears and review of management protocols.

INTRODUCTION: The aim of this audit was to identify whether there is consistent and successful management of acute peroneal tendon tears within orthopaedic foot and ankle consultants in the Wessex area of the UK. It was suspected that there was an absence of consistency between surgeons' practices and a more evidenced based management protocol could be developed. MATERIALS AND METHODS: A questionnaire of the orthopaedic surgeons in Wessex investigated whether there was consistency in surgical management of peroneal tears. RESULTS: Our results demonstrate that each of the nine surgeons' management of acute peroneal tendon tears varied greatly. CONCLUSION: The evidence in the literature was examined in an attempt to produce a protocol to aid surgical decision-making. A randomised controlled trial is required for consistent evidenced based surgical management of peroneal tendon tears.

Tophaceous calcium pyrophosphate dihydrate deposition disease of the knee mimicking an aggressive soft tissue tumour.

Calcium pyrophosphate crystal deposition disease (CPPD), previously pseudogout, is the second most common crystal arthropathy after gout. There is increased radiographic prevalence associated with age, trauma and several metabolic disorders. Tophaceous CPPD (T-CPPD) is a rare form of CPPD which, though non-neoplastic, mimics a bone or soft tissue malignancy. T-CPPD usually presents as a mass in the temporomandibular joint and occasionally in the paraspinal tissues, but rarely in the joints of the extremities. We present an exceptionally rare case of T-CPPD that was subtle on plain radiography, presenting as a soft tissue mass in the knee joint.

Osteochondroma mimicking deep vein thrombosis in a young cricketer.

Osteochondromas are bony outgrowths covered by thin cartilaginous caps, accounting for 35% of all benign bone tumours. The majorities are solitary and usually arise at the metaphysis of long bones. They may be associated with bursa formation, while vascular complications are rare. We report a 34-year-old man who presented with a 2-week history of pain, stiffness and swelling of the left lower leg following a cricket match. Clinically, a deep vein thrombosis (DVT) was suspected but D-dimer test was negative. Initial Doppler ultrasound scan (USS) was reported as showing a haematoma and possible DVT. A repeat Doppler USS did not detect a DVT, however the popliteal vein appeared collapsed and a pedunculated osteochondroma of the proximal tibia was found. An MRI confirmed this and also showed an extensive oedema around the calf muscles tracking distally in all compartments, most likely the result of a ruptured bursa.

Biceps femoris tendon injuries sustained while playing hockey.

A 42-year-old female nurse presented in March 2008 with a left proximal hamstring tendon injury sustained while playing hockey. At surgery, the proximal biceps femoris tendon and semitendonosus were found to be ruptured and were repaired. The patient made a good recovery but sustained a further hockey injury in January 2010 involving a complete tear and rupture of the biceps femoris tendon distally. This was managed conservatively and the patient was able to return to playing hockey 10 months later. Biceps femoris tendon injuries have been reported in sport but this is the first documented case of the injury occurring while playing hockey and is also the first reported case of a biceps tendon rupture proximally (hamstring tendon) followed by distal biceps femoris rupture at the knee in the same leg.

Isolated partial tear and partial avulsion of the medial head of gastrocnemius tendon presenting as posterior medial knee pain.

We present a case of medial head of gastrocnemius tendon tear. The type of injury widely reported in the literature is tear of the medial head of gastrocnemius muscle or 'tennis leg'. We previously reported an isolated partial tear and longitudinal split of the tendon to the medial head of gastrocnemius at its musculotendinous junction. The case we now present has notable differences; the tear was interstitial and at the proximal (femoral attachment) part of the tendon, the patient's symptoms and clinical examination suggested a medial meniscus tear, and magnetic resonance imaging demonstrated bone oedema at the tendon insertion site indicating a traction injury. Both cases suggest that isolated tear of the medial head of the gastrocnemius tendon may have a variety of presentations and appearances and should be considered in the differential diagnosis of tennis leg as well as medial meniscus tear.

Isolated tear of the tendon to the medial head of gastrocnemius presenting as a painless lump in the calf.

We report on a case of isolated tear of the medial head of gastrocnemius tendon. The patient presented with a painless lump in the right calf and denied any prior history of trauma or strain to the leg. A longitudinal split of the tendon was demonstrated at ultrasound and magnetic resonance imaging (MRI). There were no other abnormalities and the gastrocnemius muscle was normal. There are no reports in the literature of isolated gastrocnemius tendon tear. To date the calf muscle complex injury described in this area is tearing of the medial head of gastrocnemius muscle, sometimes referred to as "tennis leg". We conclude that an isolated tear of the tendon to the medial head of gastrocnemius should be considered in the differential diagnosis of a lump or swelling in the upper medial area of the calf and we recommend ultrasound or MRI as the investigations of choice.