Mentorship in academic musculoskeletal radiology: perspectives from a junior faculty member.

The first years of an academic musculoskeletal (MSK) faculty position are a time of transition for the junior faculty member, who must rapidly adjust to new clinical, academic, operational, and professional responsibilities. Mentoring has a critical role in helping the faculty member to thrive in these early years. Establishing clear communication, trust, and expectations can set the foundation for an effective mentoring relationship. Junior faculty members ideally would have multiple mentors with different areas of expertise, including mentors of all roles in MSK radiology but also in other radiology divisions and other departments. Private practice MSK radiologists can also benefit from mentorship. Barriers to mentoring in MSK radiology include overall smaller division sizes, a newer and smaller field on a national level, and the increase in clinical volume and remote work that results in less face-to-face interaction. Despite the challenges, both junior MSK faculty members and their mentors can benefit greatly from strong mentoring connections.

Imaging of soccer injuries in adolescent female athletes.

Soccer participation is increasing among female adolescents with a concomitant rise of injuries in this group. Age- and sex-related factors, such as the transition from skeletal immaturity to skeletal maturity as well as anatomic, physiologic, neuromuscular, and behavioral differences between females and males, all play a role in injury patterns for these athletes. Anterior cruciate ligament (ACL) tears in this group have received a great deal of attention in the medical literature and the media in recent years with increasing knowledge about causative factors, surgical management, and injury prevention. There have been fewer studies specifically focused on female adolescent soccer players in relation to other types of injuries, such as patellar dislocation/instability; other knee and ankle ligament tears; hip labral tears; muscle strains and tears; and overuse injuries such as apophysitis, patellofemoral pain syndrome, and bone stress injuries. Because imaging plays a critical role in diagnosis of soccer-related injuries in female adolescents, knowledge of the mechanisms of injury, imaging findings, and clinical considerations are essential for radiologists involved in the care of these patients.

Musculoskeletal findings on MRI among postpartum women with persistent pelvic pain.

INTRODUCTION AND HYPOTHESIS: Persistent postpartum pelvic pain affects one in six women, and its source is often unexplained in the absence of obvious clinical findings. Musculoskeletal injuries during childbirth are common and can be detected using MRI or US; however, pelvic imaging is not standard of care in evaluating women with persistent pain. We hypothesize that clinical symptoms in women with unexplained persistent postpartum pelvic pain will correlate with musculoskeletal abnormalities identified on MRI in > 50% of cases. METHODS: Retrospective cohort study of women with persistent postpartum pelvic pain who underwent a pelvic MRI for this indication. Chart review was performed. MRI findings were classified as major (bone fracture, levator ani avulsion) or minor (edema, inflammation or partial levator ani defect). Descriptive statistics were used to describe the study population. RESULTS: Of the 252 women seen for postpartum pelvic pain, 18 patients met our study criteria. Half of women were primiparous (55.6%, n = 10). Operative delivery occurred in 27.8% (n = 5), 22.2% (n = 4) had anal sphincter lacerations, and 38.9% (n = 7) had prolonged second stage of labor. Median time from delivery to MRI was 4.5 ± 5.13 (IQR) months. Musculoskeletal abnormalities were found in 94.4% (n = 17) of cases; 38.8% (n = 7) were major and 55.6% (n = 10) were minor abnormalities. All findings correlated with presenting symptoms. CONCLUSION: Of women with persistent postpartum pelvic pain, 94.4% had musculoskeletal abnormalities supporting their clinical symptoms. Pelvic floor imaging should be considered in women with unexplained persistent postpartum pelvic pain to accurately manage the source of their pain.

Advanced Quality Training in Radiology: Inaugural Report of a 2-Year Program.

OBJECTIVE. The purpose of this study is to describe and analyze the outcomes of a 2-year advanced quality training program for radiology residents. MATERIALS AND METHODS. In 2016, the radiology quality committee of a quaternary health system created a hands-on 2-year advanced quality training curriculum for diagnostic and interventional radiology residents. Internal candidates with the following prerequisites submitted competitive applications: registration for a 2-day lean health care management course, completion of four or more Radiological Society of North America (RSNA) quality essentials certificates, identification of faculty mentor(s), selection of one quality improvement project to champion, and completion of a two-page essay summarizing interest in quality improvement, the proposed project, and its potential impact. Residents were required to attend monthly quality meetings, pursue their project and its derivatives, submit completed work for consideration to a national meeting and for publication, and present at departmental grand rounds. Outcomes were summarized using descriptive statistics. RESULTS. Five residents submitted four projects for consideration, and all five were selected. In addition to the four submitted projects, seven additional projects were pursued. Participants worked on nine local and three multicenter process improvements, gave one to two grand rounds each, presented three oral and five poster presentations, generated eight publications, received three awards, formed 14 mentor-mentee relationships, and influenced local and multisite practice patterns. Participants reported gaining firsthand experience in quality improvement principles and developing real-world leadership skills. CONCLUSION. A targeted 2-year curriculum emphasizing hands-on quality improvement experience with rich mentor-mentee relationships can produce meaningful results.

Comparison of measurement systems for posterior vaginal wall prolapse on magnetic resonance imaging.

INTRODUCTION AND HYPOTHESIS: A wide variety of reference lines and landmarks have been used in imaging studies to diagnose and quantify posterior vaginal wall prolapse without consensus. We sought to determine which is the best system to (1) identify posterior vaginal wall prolapse and its appropriate cutoff values and (2) assess the prolapse size. METHODS: This was a secondary analysis of sagittal maximal Valsalva dynamic MRI scans from 52 posterior-predominant prolapse cases and 60 comparable controls from ongoing research. All eight existing measurement lines and a new parameter, the exposed vaginal length, were measured. Expert opinions were used to score the prolapse sizes. Simple linear regressions, effect sizes, area under the curve, and classification and regression tree analyses were used to compare these reference systems and determine cutoff values. Linear and ordinal logistic regressions were used to assess the effectiveness of the prolapse size. RESULTS: Among existing parameters, "the perineal line-internal pubis," a reference line from the inside of the pubic symphysis to the front tip of the perineal body (cutoff value 0.9 cm), had the largest effect size (1.61), showed the highest sensitivity and specificity to discriminate prolapse with area under the curve (0.91), and explained the most variation (68%) in prolapse size scores. The exposed vaginal length (cutoff value 2.9) outperformed all the existing lines, with the largest effect size (2.09), area under the curve (0.95), and R-squared value (0.77). CONCLUSIONS: The exposed vaginal length performs slightly better than the best of the existing systems, for both diagnosing and quantifying posterior prolapse size. Performance characteristics and evidence-based cutoffs might be useful in clinical practice.

Fractures Around the Shoulder: Radiologic Update on Surgical Fixation Techniques.

Although radiologists are likely familiar with basic fracture patterns around the shoulder, certain fracture types in this area have particularly relevant and controversial clinical management issues. These include proximal humeral fractures, in which conservative management is favored but some patients receive surgical treatment; glenoid fractures and Hill-Sachs lesions, in which surgery may be performed depending on the amount of bone loss; and distal clavicular fractures, in which certain displaced fractures have high rates of nonunion, but there is no clearly favored surgical technique. Knowledge of the different clinical issues and surgical options can aid the radiologist in identifying key imaging findings and creating a useful report.

Ultrasound Features of Palmar Fibromatosis or Dupuytren Contracture.

OBJECTIVES: To retrospectively characterize the ultrasound appearance of palmar fibromatosis in patients with a surgical or clinical diagnosis of palmar fibromatosis. METHODS: A search of ultrasound reports from 2005 to 2015 and a subsequent search of medical records were performed to identify patients with a surgical or clinical diagnosis of palmar fibromatosis. The ultrasound images were retrospectively reviewed to record the lesion location, size, echogenicity, compressibility, hyperemia, and calcification. RESULTS: A total of 36 patients were identified (average age, 60 years; 61% male), yielding a total of 55 palmar fibromatosis lesions, of which 2%, 7%, 29%, 36%, 20%, and 5% were located at the first, second, third, fourth, and fifth digits and between the fourth and fifth digits, respectively. The lesions were located directly superficial to the flexor tendons in 93% with their epicenters at the distal metacarpal in 89%. Average lesion dimensions were 13.1 mm in length, 6.8 mm in width, and 2.5 mm in depth. On ultrasound images, the lesions were characteristically hypoechoic (98%) and noncompressible (95%). Atypical features included calcification (2%), compressibility (5%), hyperemia on color Doppler images (6%), epicenters at the metacarpophalangeal joint (7%) or proximal phalanx (4%), and location superficial but lateral to the flexor tendons (7%). CONCLUSIONS: Palmar fibromatosis most commonly appears hypoechoic and is located directly superficial to the flexor tendons with an epicenter at the distal metacarpal, most commonly the fourth digit. However, the epicenter location may be at the distal metacarpal and proximal phalanx of other digits, adjacent to the flexor tendons, with possible hyperemia and calcification.

Sonography of Wrist Ganglion Cysts: Which Location Is Most Common?

OBJECTIVES: The literature states that wrist ganglion cysts are most commonly dorsal; however, our experience suggests a volar location is more common. The purpose of this study was to identify the locations of ganglion cysts of the wrist as imaged with sonography. METHODS: After Institutional Review Board approval with informed consent waived, retrospective review of wrist sonography reports from January to April 2016 was completed. Only patients who had a comprehensive evaluation that included the dorsal and volar wrist were included. Ultrasound images were reviewed to characterize wrist ganglion cysts. RESULTS: The study group consisted of 98 subjects (78% female, 22% male) (median age, 51 years; range 13-79) with 124 wrist ganglion cysts, where 69% (86 of 124) were volar and 31% (38 of 124) were dorsal. Ganglion cysts were located between the radial artery and flexor carpi radialis in 63% (78 of 124), followed by a dorsal location superficial to the scapholunate ligament in 20% (25 of 124), other dorsal locations in 11% (13 of 124), and other volar locations in 6% (8 of 124). With dorsal ganglion cysts, the scapholunate ligament when imaged appeared normal in 91% (20 of 22). Ganglion cysts were multilocular/multilobular in all subjects. CONCLUSIONS: The most common location for wrist ganglion cysts is in the volar wrist, particularly between the radial artery and flexor carpi radialis tendon, appearing multilocular or multilobular with a mean largest dimension of 1.0 cm. Given the propensity of ganglion cysts to occur at this site, attention to this area when imaging the wrist with sonography or magnetic resonance imaging should be considered.

Injuries of the adolescent girl athlete: a review of imaging findings.

With the rising participation of girls in sports at both the recreational and elite levels, there has also been increased awareness of injuries common in this athlete population. Anatomic differences between boys and girls cause girl athletes to be predisposed to certain injuries. Certain behavioral patterns, such as eating disorders, also cause problems specific to girl athletes that may result in injury. Imaging plays a large role in diagnosis and ongoing management, but there has been only scant literature dedicated to the specific topic of imaging in girl athletes. The purpose of this article is to review the imaging findings and recommendations for injuries and other conditions affecting the adolescent girl athlete. This article first provides an overview of the key anatomic differences between boys and girls, including both static and dynamic factors, as well as non-anatomic differences, such as hormonal factors, and discusses how these differences contribute to the injury patterns that are seen more typically in girls. The article then reviews the imaging findings in injuries that are commonly seen in girl athletes. There is also a discussion of the "female athlete triad," which consists of osteoporosis, disordered eating, and amenorrhea, and the role of imaging in this condition.

A Women in Radiology Group Fosters Career Development for Faculty and Trainees.

OBJECTIVE: The objective of our study was to evaluate the outcomes of a women in radiology (WIR) group during the first 6 years of its existence, including members' satisfaction, activities, and differences based on seniority. MATERIALS AND METHODS: An anonymous questionnaire was distributed to group members. Survey questions were related to the usefulness of sessions, mentoring, professional opportunities, and camaraderie. Comparisons were made on the basis of training status and seniority. Continuous variables were compared using means, t tests, and correlations, and categoric variables were compared using counts, percentages, and chi-square tests or Mantel-Haenszel tests. RESULTS: Surveys were sent to 61 women, including trainees and faculty; the response rate was 49% (38% of trainees and 53% of faculty). Overall satisfaction score for WIR sessions was high (mean summary score, 1.42 ± 0.37 [SD], with 1 meaning very satisfied and 4 meaning very unsatisfied). Trainees and junior faculty were more likely than senior faculty to report expanded internal networking opportunities (94% vs 69%; p = 0.07), to have gained a mentor (67% vs 8%; p = 0.001), and to have increased research involvement (33% vs 0%; p = 0.02). Both groups were equally likely to have become mentors. Almost all respondents (93%) reported increased camaraderie among women in the department. CONCLUSION: A WIR group can provide career development tools for its members. In this study, trainees and junior faculty reported increased networking and research involvement and gaining a mentor but were equally likely as senior faculty to have become mentors. Most members reported increased camaraderie among women in the department. A WIR group may help to accelerate professional development among trainees and junior faculty, thereby contributing to a more diverse and enabled workforce.

Creating Three-dimensional Printed Models of Acetabular Fractures for Use as Educational Tools.

Acetabular fractures are frequently encountered in some clinical practices, and the precise classification of these fractures greatly influences treatments and outcomes. The authors identified the need for an educational aid when teaching acetabular fracture classifications, given the complex spatial anatomy and the nonintuitive classification system that is commonly used. Three-dimensional ( 3D three-dimensional ) printing is an evolving technique that has applications as an educational aid, providing the student with a tangible object to interact with and learn from. In this article, the authors review their experience creating 3D three-dimensional printed models of the hip for educational purposes. Their goal was to create 3D three-dimensional printed models for use as educational aids when teaching acetabular fracture classifications. Complex cases involving a combination of fracture types, subtle nondisplaced fractures, and/or fractures with associated osteopenia or artifacts were excluded. The selected computed tomographic (CT) scans were loaded into a medical 3D three-dimensional volume-rendering program, and a 3D three-dimensional volumetric model was created. Standard Tessellation Language ( STL Standard Tessellation Language ) files were then exported to STL Standard Tessellation Language model-editing software and edited to retain only the involved hemipelvis. In some cases, the proximal femur and ipsilateral hemisacrum may be included to emphasize hip alignment or disruption of the force transfer. Displaced fracture fragments can be printed as separate segments or a single unit after the addition of struts. Printing was performed by using an additive manufacturing principle, with approximately 36-48 hours needed for printing, postprocessing, and drying. The cost to print a 1:1 scale model was approximately $100-$200, depending on the amount of plastic material used. These models can then be painted according to the two-column theory regarding acetabular fractures. ©RSNA, 2017.

Ultrasound evaluation of bursae: anatomy and pathological appearances.

A bursa is an extra-articular sac that may communicate with a joint and functions to decrease friction between tendons and either bone or skin. Bursae can be classified as native and non-native (adventitious) bursae. The native bursae are lined with a synovial membrane and occur at predictable anatomical sites; knowledge of these normal structures can help distinguish them from other pathological entities. An adventitious bursa can form at sites of friction rather than at predictable anatomical sites, but otherwise have imaging features similar to native bursae. Bursal distention can occur from many pathological processes, most commonly resulting from chronic overuse injury. When imaging bursal pathological conditions, there is often an overlap of imaging findings, regardless of the cause. In general, ultrasound of a distended bursa reveals a fluid collection with either simple anechoic or more complex hypoechoic fluid. Bursal distention is characteristically unilocular and compressible, unlike other structures such as ganglion cysts, which are usually multilocular and non-compressible. This article reviews the anatomical locations of common bursae and shows pathological examples using ultrasound. Knowledge of typical locations and imaging appearances of bursae can aid in narrowing the differential diagnosis and guiding further management and treatment decisions.

Ultrasound of the Gruberi Bursa With Cadaveric and MRI Correlation.

OBJECTIVE: The purpose of this study was to describe the appearance and ultrasound characteristics of the Gruberi bursa using a cadaveric model and retrospective ultrasound imaging review. MATERIALS AND METHODS: For the cadaveric study, ultrasound of the dorsolateral ankle of a foot-ankle specimen was performed and was followed by injection of latex between the extensor digitorum longus (EDL) tendons and the talus and dissection. For the ultrasound imaging review, the radiology database was searched for ultrasound studies performed from September 15, 2000, through April 1, 2015, to identify subjects with a dorsolateral foot or ankle fluid collection detected on ultrasound. Images were retrospectively reviewed to characterize the location and size of the fluid collection, assess for the number of locules, and evaluate the compressibility of the fluid collection. It was determined whether the ultrasound findings were significantly different from chance: CI and p values were obtained from performing a test for one proportion. RESULTS: Dissection of a cadaveric specimen revealed latex within a well-defined region between the EDL tendons and the dorsolateral talus; this location is consistent with a Gruberi bursa. For the image review, the imaging examinations of 162 subjects (age range, 16-88 years; 31 male subjects and 131 female subjects) were reviewed. On the ultrasound images, a fluid collection with its epicenter between the dorsolateral talus and EDL was found in 93% of ankles. Of the fluid collections identified on ultrasound, 98% were unilocular and 94% were anechoic. Of these fluid collections, 133 were assessed for compressibility, and 89% were compressible. The positive findings for a Gruberi bursa that were different from chance (p < 0.0001) were a fluid collection being located between the EDL tendons and the dorsolateral talus and being unilocular, anechoic, and compressible. CONCLUSION: The Gruberi bursa characteristically is located between the EDL and the talus; on ultrasound, the Gruberi bursa is most commonly unilocular, anechoic, and compressible.

Myxoinflammatory fibroblastic sarcoma: spectrum of disease and imaging presentation.

OBJECTIVES: To describe the imaging findings of a series of myxoinflammatory fibroblastic sarcomas (MFSs) from our institution, including a case of dedifferentiated MFS and two cases with areas of high-grade tumor, in addition to typical cases of low-grade tumor. To correlate the imaging findings with the pathologic features of these tumors. SUBJECTS AND METHODS: IRB approval was obtained. Retrospective search of the pathology database at our institution from 2000 to 2015 identified seven cases of MFS with available imaging. Imaging, pathology, and clinical data were reviewed. RESULTS: Unlike the majority of well-differentiated tumors in our series (four cases), one tumor showed dedifferentiation and two cases had areas of high-grade tumor. The dedifferentiated tumor showed peripheral post-contrast enhancement. One case with a substantial high-grade component showed osseous destruction and peripheral enhancement in the high-grade area, while the low-grade component enhanced diffusely. The second case had a small high-grade area and showed diffuse enhancement. All three of these cases had non-acral locations and lacked association with a tendon. The four cases of low-grade MFS demonstrated diffuse enhancement, were located in the distal extremities, and were associated with a tendon. CONCLUSION: The imaging findings of dedifferentiated and high-grade MFS differ from the more typical low-grade tumors in that they have nonenhancing areas, a non-acral location, lack association with a tendon, and may involve bone. The radiologist should be aware that MFS represents a spectrum that includes low-grade tumors, tumors with high-grade areas, and tumors with dedifferentiation and that this spectrum presents with differing imaging features.

Long-term clinical outcomes in women with breast pain in the absence of additional clinical findings: mammography remains indicated.

The purpose of the study was to determine the long-term clinical outcomes of women with breast pain in the absence of additional symptoms or signs (isolated breast pain), and the utility of mammography in their work-up. IRB approved, HIPAA compliant study retrospectively reviewed 1,386 patients referred for breast imaging with ICD-9 code for breast pain between 1/1/2006 and 12/31/2007. Of these, 617 consecutive women (mean age, 49 years) with isolated breast pain, mammogram, and follow-up (mean, 51 months) constituted the study group. Clinical data, mammographic and sonographic BI-RADS assessments, and geographic relationship between the site of cancer and pain were evaluated. The frequency of malignancies and of specific benign outcomes, both at and subsequent to the time of presentation, was determined. Breast cancer and specific benign outcomes were diagnosed in the painful breast of 11/617 (1.8 %) and 63/617 (10.2 %) women, respectively. Majority of the cancers (9/11, 81.8 %) were diagnosed subsequent (5-52 months) to initial imaging evaluation, whereas the majority of benign outcomes (52/63, 82.5 %) were diagnosed at initial presentation. Diagnostic mammography at initial presentation had a negative predictive value of 99.8 % (95 % CI 99.1 %, 100 %), specificity of 98.5 % (95 % CI 97.2 %, 99.3 %), and sensitivity of 66.7 % (95 % CI 11.6 %, 94.5 %). Three cancers were subsequently diagnosed in the contralateral (non-painful) breast. Eleven of 14 (78.6 %) cancers were in the symptomatic breast, of which 9 (81.8 %) geographically corresponded to the same area of focal pain. Thus, infrequently, breast cancer may clinically present as or be preceded by isolated breast pain and diagnostic mammography is useful for assessment.

Medical education research for radiologists: a road map for developing a project.

OBJECTIVE: Medical education research is challenging to do well, but researchers can develop a robust project with knowledge of basic principles. Thoughtful creation of a study question, development of a conceptual framework, and attention to study design are crucial to developing a successful project. CONCLUSION: A thorough understanding of research methods and elements of survey design is necessary. Projects that result in changes to behavior, clinical practice, and patient outcomes have the most potential for success.

Knee MRI: Vascular Pathology.

OBJECTIVE: Patients who undergo knee MRI for presumed musculoskeletal disease can have unexpected vascular findings or pathology in the imaged field. Some vascular processes are limb threatening and affect treatment planning and patient outcome. CONCLUSION: Unexpected vascular findings on knee MRI can range from incidental to symptomatic and can include such processes as variant anatomy, aneurysm, traumatic injury, and neoplasm. The assessment for vascular pathology should be a key component of every radiologist's search pattern when evaluating knee MRI.

MR imaging of the pelvis: a guide to incidental musculoskeletal findings for abdominal radiologists.

Occasionally patients who undergo magnetic resonance imaging for presumed pelvic disease demonstrate unexpected musculoskeletal imaging findings in the imaged field. Such incidental findings can be challenging to the abdominal radiologist, who may not be familiar with their appearance or know the appropriate diagnostic considerations. Findings can include both normal and abnormal bone marrow, osseous abnormalities such as Paget's disease, avascular necrosis, osteomyelitis, stress and insufficiency fractures, and athletic pubalgia, benign neoplasms such as enchondroma and bone island, malignant processes such as metastasis and chondrosarcoma, soft tissue processes such as abscess, nerve-related tumors, and chordoma, joint- and bursal-related processes such as sacroiliitis, iliopsoas bursitis, greater trochanteric pain syndrome, and labral tears, and iatrogenic processes such as bone graft or bone biopsy. Though not all-encompassing, this essay will help abdominal radiologists to identify and describe this variety of pelvic musculoskeletal conditions, understand key radiologic findings, and synthesize a differential diagnosis when appropriate.