Fusion of positron emission tomography/computed tomography with magnetic resonance imaging reveals hamstring peritendonitis in polymyalgia rheumatica.

Objectives: To characterize 18F-fluorodeoxyglucose (18F-FDG) uptake on whole-body PET/CT in PMR, and identify its precise anatomic correlate using MRI. Methods: Patients with newly diagnosed PMR according to the 2012 EULAR/ACR classification criteria were prospectively recruited. Participants with GCA were excluded. A whole-body 18F-FDG PET/CT scan was performed in all untreated patients. Qualitative and semiquantitative [standardized uptake value maximum (SUVmax)] scoring of abnormal 18F-FDG uptake was undertaken. MRI of the pelvis, knee and wrist and hand was performed in three representative patients with anatomical correlation of FDG-avid sites carried out using Medview fusion software. Results: Twenty-two patients with PMR were recruited. Their mean age was 68.3 years (s.d. 6.3) and 13/22 were male. On whole-body PET/CT, 18F-FDG uptake adjacent to the ischial tuberosities was observed in 21 participants (95.4%) and recorded the highest mean SUVmax value [3.6 (s.d. 1.7)]. A high frequency of posteromedial knee (61.9%) and wrist and/or hand involvement (66.7%) was also appreciated. MRI of the pelvis revealed high T2 signal surrounding the proximal hamstring tendon origins of both semimembranosus and the conjoint tendon of the semitendinosus and biceps femoris. At the knee, peritendonitis at the distal insertion of the semimembranosus was observed. PET/MRI fusion at the pelvis and knee confirmed semimembranosus peritendonitis as the anatomical correlate of 18F-FDG uptake adjacent to the ischial tuberosities and of posteromedial knee structures. Conclusion: Hamstring peritendonitis is a common and distinctive manifestation of PMR on whole-body PET/CT. Trial registration: Australian New Zealand Clinical Trials Registry, http://www.anzctr.org.au, ACTRN1261400696695.

Characterising polymyalgia rheumatica on whole-body 18F-FDG PET/CT: an atlas.

The impact of modern imaging in uncovering the underlying pathology of PMR cannot be understated. Long dismissed as an inflammatory syndrome with links to the large vessel vasculitis giant cell arteritis (GCA), a pathognomonic pattern of musculotendinous inflammation is now attributed to PMR and may be used to confirm its diagnosis. Among the available modalities, 18F-fluorodeoxyglucose (18F-FDG) PET/CT is increasingly recognized for its high sensitivity and specificity, as well as added ability to detect concomitant large vessel GCA and exclude other relevant differentials like infection and malignancy. This atlas provides a contemporary depiction of PMR's pathology and outlines how this knowledge translates into a pattern of findings on whole body 18F-FDG PET/CT that can reliably confirm its diagnosis.

Patient's assessment of discomfort during ultrasound-guided injection of Morton's neuroma: selecting the optimal approach.

PURPOSE: Assess patient discomfort during two different methods of injection of Morton's neuroma. METHODS: Sixty-eight patients referred for ultrasound-guided injection of Morton's neuroma had punctures performed dorsal or plantar to the interdigital skin crease, with and without preliminary subcutaneous local anesthesia (LA). Patients rated discomfort during skin puncture (SP) and needle advancement (NA) using a visual analog scale. RESULTS: Average pain score was 4.4 ± 2.3 (1 SD) for the plantar approach and 2.9 ± 2.0 for the dorsal approach. This difference was statistically significant during SP (p < 0.01) and NA (p < 0.05). During the plantar approach with LA, mean pain score during SP was 4.4 (± 2.1) and 3.9 (± 2.8) during NA. This plantar approach without LA resulted in a pain score of 4.3 (± 2.6) and 3.8 (± 3.1), respectively. Mean pain scores for patients injected from the dorsal approach with LA during SP were 3.8 (± 2.7) and NA were 2.2 (± 2.0) and without LA were 2.6 (± 1.9) and 3.0 (± 2.1). There was no statistical significance in mean pain score difference during SP and NA, with and without LA for either the plantar (p > 0.05) or the dorsal (p > 0.05) approach. CONCLUSIONS: Injection of Morton's neuroma was better tolerated via a dorsal approach and use of preliminary LA did not confer any benefit.

Use of computed tomography and magnetic resonance imaging for occult neck of femur fractures: A single-centre study.

OBJECTIVE: Neck of femur (NOF) fractures are common and serious injuries in the elderly. When a NOF fracture is suspected but is not clearly visible on radiographs, guidelines recommend magnetic resonance imaging (MRI), or computed tomography (CT) if MRI is not available/contraindicated. The aim of our study was to review the use of CT and subsequent MRI for suspected NOF fractures in patients with negative or equivocal radiographs. METHODS: A retrospective review of adult patients with negative or equivocal plain radiographs with suspected NOF fractures presenting between 1 July 2015 and 30 June 2017 was performed. Review of CT and subsequent MRI studies was performed with documentation of reported findings, time intervals from plain radiographs to CT and MRI and final outcomes. RESULTS: A total of 184 CT studies in 181 patients were reviewed; median age was 82 years (interquartile range 71-89 years) with 110 (60.8%) female patients. CT reported 20 occult fractures; all proceeded to surgery. MRI was performed in 23 patients and revealed additional four NOF fractures missed by CT. An additional fifth fracture missed by CT was confirmed by follow-up radiographs. Median time was approximately 4 h from radiographs to CT and approximately 56 h from radiographs to MRI. CONCLUSION: Access to CT for evaluation of suspected occult NOF fractures is much quicker compared to MRI. When CT results are negative with on-going clinical suspicion of an occult fracture, MRI should be performed in a time efficient manner.

Enlarging left atrial haemangioma in a patient with Cowden syndrome.

A 53-year-old female patient known to have Cowden disease (PTEN mutation positive) was found to have a mass at the left atrium on a CT coronary angiography performed as part of a preoperative workup for an unrelated surgery. Further radiological characterisation of the lesion was achieved using MRI and positron emission tomography. Interval growth prompted surgical excision; however, surgery was expedited after the patient presented with haemopericardium and cardiac tamponade. The patient was discharged home 8 days postoperatively, and no intraoperative or postoperative complications were encountered. A diagnosis of cavernous haemangioma was made on histology.