Sacral insufficiency fractures.

PURPOSE: To highlight difficulties in the diagnostic process and the validity of imaging techniques for sacral insufficiency fractures. METHODS: Records of 25 women aged 68 to 95 years with sacral insufficiency fractures were reviewed. Baseline blood biochemistry and haematology test results were obtained. Pelvic anterior/posterior radiography was undertaken for all patients; additional computed tomography, technetium bone scanning, and magnetic resonance imaging were used in some. Treatments were based on the severity of the injury and the patient's mobility and cooperativeness. RESULTS: Among the 25 women, 11 had bilateral and 14 had unilateral vertical sacral fractures. Associated fractures included horizontal sacral fracture, fractures of the os pubis and ilium. Symptoms included lower back or buttock pain, abdominal pain, and those emulating radiculopathy and myelopathy, including leg weakness, sciatica, and urinary retention. The mean delay in diagnosis was 9 (range, 1-28) days. The mean recovery time between bilateral and unilateral fractures was significantly different (22 [range, 12-33] vs 14 [range, 8-36] weeks, p=0.01). No patient with bilateral fractures regained her pre-injury mobility, compared to 43% among those with unilateral fractures (p=0.02, Fisher's exact test). Computed tomography was the most reliable imaging technique; technetium bone scanning was highly sensitive but non-specific; magnetic resonance images of the fractures may mimic metastatic disease. CONCLUSION: With the increase in the elderly population, sacral insufficiency fractures may become epidemic in future. Primary and secondary osteoporoses are common causes. Once a diagnosis is established, in most cases treatment is simple but recovery may be protracted and full mobility curtailed.

Multislice CT in imaging of trauma of the spine, pelvis and complex foot injuries.

Multislice CT (MSCT) has greatly enhanced the performance of CT scanners and has vastly improved imaging of musculoskeletal trauma. Fast, high resolution scanning is now possible. In our institution, MSCT is an essential part of the imaging of the traumatized patient. The advantages of volume imaging, such as multiplanar reconstructions (MPRs) with near isotropic viewing, three-dimensional imaging and thick slice (wedge) MPRs (mimicking conventional radiographs), enable more accurate assessment of complex anatomical areas such as the spine, pelvis and foot. We discuss the general principles of scanning for musculoskeletal trauma and describe our experience of MSCT of the traumatized spine, pelvis and foot.

Chronic contained leak of abdominal aortic aneurysm presenting as lumbar neuropathy.

Chronic contained rupture of aortic aneurysm is a rare event which can cause diagnostic difficulties. It can present as high lumbar neuropathy, hence, chronic contained rupture should be borne in mind while examining patients with back pain. Delayed diagnosis and delayed surgical repair of the ruptured aneurysm can compromise the final results. The outcome of urgent repair of a chronic contained leak is equivalent to that of elective aneurysm repairs.

Ultrasound imaging of forearm fractures in children: a viable alternative?

OBJECTIVE: A pilot study to investigate whether ultrasonography can be reliably used to demonstrate uncomplicated greenstick and torus fractures in children. METHOD: Children between the ages of 2 and 14 years with a high clinical suspicion of a non-articular, undisplaced forearm fracture were included. Ultrasound imaging of the injury was performed by a consultant radiologist who gave an immediate report. Standard radiographs of the forearm were then obtained and the patient treated in the normal way. The radiograph was formally reported on at a later date. RESULTS: 26 patients were included. There was an absolute correlation between the ultrasound and radiographic findings. The procedure was well tolerated. CONCLUSION: Ultrasound seems effective for detecting uncomplicated forearm fractures in children. The procedure is easy to perform and the images easy to interpret. A larger study will now be undertaken to confirm these initial findings.

A comparison of barium swallow and erect esophageal transit scintigraphy following balloon dilatation for achalasia.

We evaluated the relationship between radionuclide esophageal transit studies and barium swallow appearances in a group of patients following forceful balloon dilatation for the treatment of achalasia of the cardia. Paired erect radionuclide esophageal transit studies and erect barium swallows of a group of patients who had undergone pneumatic balloon dilatation for the treatment of achalasia were analyzed. Indices derived from the radionuclide transit study were the percentage of maximum activity remaining in the esophagus 30 s after swallowing a dilute volume of tracer (A30 s) and the percentage of retained activity remaining at 100 s after washout with a bolus of water (A100 s). Indices derived from the barium swallow were a subjective grading of the degree of esophageal dilatation on a 4-point scale and a similar grading of the maximum distensibility of the gastroesophageal channel. Twenty five pairs of radionuclide and barium studies in 18 patients were analyzed. There was statistically significant correlation between the amount of retained activity on the radionuclide studies and degree of esophageal dilatation on the barium studies (r = 0.69 for A30 s, r = 0.56 for A100 s, P = < 0.01). There was no correlation between the amount of retained activity on the radionuclide studies and the degree of distension of the gastroesophageal channel on barium studies. The relationship between the radionuclide esophageal transit curve and barium appearances of the esophagus following pneumatic balloon dilatation for the treatment of achalasia is complex. The transit study provides unreliable information about the distensibility of the gastroesophageal channel and should not be relied upon in isolation for assessment of the efficacy of treatment.

Magnetic resonance imaging of the lumbar spine: direct access for general practitioners.

At the Cardiff Royal Infirmary we have offered general practitioners (GPs) direct access for magnetic resonance imaging (MRI) of the lumbar spine for sciatica or suspected spinal claudication since January 1993. We compared referrals for MRI from GPs and hospital outpatient doctors, and assessed GP patient management following the scan report. No difference in the diagnostic rates for disc herniation and spinal stenosis were found. GP direct access shortens investigation time, potentially reduces waiting lists, and allows GPs to make more informed management decisions.

Impact of MRI on a knee arthroscopy waiting list.

As part of a waiting list initiative, magnetic resonance imaging (MRI) scans were arranged for 69 patients waiting for knee arthroscopy. All patients had a clinical diagnosis of a meniscal tear. With 11 non-attenders, 58 scans were performed. Of the patients scanned, 35 had demonstrable meniscal tears, and five patients had other pathology on their scans. All patients were reviewed clinically after their scans, and 24 patients were removed from the waiting list. After a further 9 months, only one of the 24 patients removed had been re-listed for therapeutic arthroscopy. This initiative proved a cost-effective method of reducing waiting times for knee arthroscopy.

Bile duct stenting: a comparison of the One-Action Stent introduction system with the conventional delivery system.

BACKGROUND AND STUDY AIMS: A "One-Action Stent Insertion System" (OASIS) for use with biliary stents has been produced, which is said to be easier to use than conventional insertion systems. The aim of this study was to assess whether there was any measurable difference in the technique in a comparison between the two methods. PATIENTS AND METHODS: A prospective study was carried out. Twenty consecutive patients requiring stents for biliary obstructing lesions were randomly allocated to have the stent inserted either using the OASIS system or the conventional system. All the sent insertions were performed by two experienced endoscopists. The actual time of the insertion procedure and the screening time were recorded. RESULTS: Patients' tolerance for the procedure was similar in the two groups. In nine out of ten OASIS stent insertions, the endoscopist considered the procedure to be easy, compared with five out of ten conventional stent placements. Both techniques resulted in satisfactory positioning of the stent in nine out of ten patients. Although there was no statistically significant difference in the screening times for the two methods (p = 0.16), the actual time taken using the conventional method was significantly longer than with the OASIS method (p < 0.001). CONCLUSION: The One-Action Stent Insertion Set (OASIS) allows easier insertion of biliary stents. The system decreases the number of exchanges that need to be undertaken, precluding inadvertent wire displacement and the need to reinitiate cannulation and guide wire insertion. The actual time required for insertion is significantly less using this method, and this may also reduce the radiation exposure.

Percutaneous transluminal angioplasty of an innominate artery occlusion.

A middle-aged woman presented with recent-onset left hemiparesis and right subclavian steal syndrome. She was found to have an obstructed innominate artery. We successfully performed balloon angioplasty of the occluded innominate artery and encountered no complications during follow-up of currently 8 months.

Tuberculosis contact tracing: are the British Thoracic Society guidelines still appropriate?

The value of contact tracing in South Glamorgan for the period May 1987 to December 1989 was assessed. Tuberculosis was diagnosed in six (3.5%) of 170 close contacts. All were young and were detected in the initial screening. Tuberculosis was not found among 441 casual contacts. The value of follow up of contacts after the initial screening and of screening casual contacts in districts with a low prevalence of tuberculosis is questioned.

Audit of a tuberculosis contact tracing clinic.

OBJECTIVE: To determine the efficiency of tuberculosis contact tracing in South Glamorgan 1987-9. DESIGN: Review of records of contact tracing clinic and of data from the Mycobacterium Reference Unit. The clinic's practice was compared with 1983 British Thoracic Society's recommendations. SETTING: Health authority tuberculosis control programme. MAIN OUTCOME MEASURES: Proportion of contacts screened, follow up attendance rates, number of secondary cases detected, and quality of record keeping. RESULTS: 101 index patients and 611 contacts were identified. 596 (97.5%) contacts were screened, of whom 139 should not have been. Of 356 contacts requiring a Heaf test, 237 were tested, seven refused the test, and 112 had chest radiography without a Heaf test. 95 contacts were unnecessarily tested. 87 contacts had chest radiography unnecessarily and seven should have had radiography but did not. 34 contacts were given follow up appointments inappropriately and seven were overlooked for follow up. Tuberculosis was diagnosed in five asymptomatic contacts, all at initial screening and all close contacts of index patients with pulmonary disease. CONCLUSION: Inadequacy of data, non-adherence to contact tracing guidelines, and failure to define the term highly infectious index case resulted in many contacts being unnecessarily screened or followed up. IMPLICATIONS: The efficiency of tracing contacts would be improved by specifying smear results and ethnic origin of the index case on the notification form, clearly classifying contacts as close or causal, and clearly defining the term highly infectious.