Persistent bilateral atypical femoral fractures in an antiresorptive-naïve Singaporean Chinese patient with Graves’ Disease / Journal of the ASEAN Federation of Endocrine Societies

@#Atypical femoral fractures (AFFs) are rare adverse effects of bisphosphonate therapy. We report an unusual case of bilateral diaphyseal AFFs in an antiresorptive-naïve Singaporean Chinese female with Graves’ disease. She presented with complete right AFF requiring surgical fixation, and persistent left incomplete AFF for over four years. Femoral bowing, varus femoral geometry, and ethnic influence likely contributed to the AFFs’ formation. This case may provide insights into the pathogenesis of AFFs in high-risk Asian populations.

Do Radiology Residents Perform Well in Preliminary Reporting of Emergency MRIs of Spine?

PURPOSE: To evaluate interpretation errors involving spine MRIs by residents in their second to fourth year of training, classified as minor, intermediate and major discrepancies, as well as the types of commonly discordant lesions with or without clinical significance. MATERIALS AND METHODS: A staff radiologist evaluated both preliminary and final reports of 582 spine MRIs performed in the emergency room from March 2011 to February 2013, involving (1) the incidence of report discrepancy, classified as minor if there was sufficient description of the main MR findings without ancillary or incidental lesions not influencing the main diagnosis, treatment, or patients' clinical course; intermediate if the correct diagnosis was made with insufficient or inadequate explanation, potentially influencing treatment or clinical course; and major if the discrepancy affected the main diagnosis; and (2) the common causes of discrepancy. We analyzed the differences in the incidence of discrepancy with respect to the training years of residents, age and sex of patients. RESULTS: Interpretation discrepancy occurred in 229 of the 582 cases (229/582, 39.3%), including 146 minor (146/582, 25.1%), 40 intermediate (40/582, 6.9%), and 43 major cases (43/582, 7.4%). The common causes of major discrepancy were: over-diagnosis of fracture (n = 10), missed cord lesion (n = 9), missed signal abnormalities associated with diffuse marrow (n = 5), and failure to provide differential diagnosis of focal abnormal marrow signal intensity (n = 5). No significant difference was found in the incidence of minor, intermediate, and major discrepancies according to the levels of residency, patients' age or sex. CONCLUSION: A 7.4% rate of major discrepancies was found in preliminary reporting of emergency MRIs of spine interpreted by radiology residents, probably related to a relative lack of clinical experience, indicating the need for additional training, especially involving spine trauma, spinal cord and bone marrow lesions.

Computed Tomography Urography: Comparison of Image Quality and Radiation Dose between Single- and Split-Bolus Techniques

<p><b>INTRODUCTION</b>In this study, we aimed to compare the split-bolus and single-bolus computerised tomography (CT) urography and determine if this offers a reduction in radiation dose without compromising image quality.</p><p><b>MATERIALS AND METHODS</b>A retrospective evaluation was performed on 88 patients undergoing split-bolus CT urography and this was compared to a control group of 101 consecutive patients undergoing single-bolus CT urography. A radiation dose analysis was performed on each subject. Subjects with urinary bladder lesions, hydronephrosis, renal masses or cysts >3 cm in diameter were excluded. All images were classified according to image quality by 2 consultant radiologists.</p><p><b>RESULTS</b>Opacification of  the renal parenchyma, pelvicalyceal system, proximal ureters and urinary bladder were comparable between the 2 techniques, whilst image quality of the middle and distal third of the ureters was better using the split-bolus technique. The mean dose length product (DLP) for the single-bolus technique was 1324.1 mGy-cm, whilst that of  the split-bolus technique was 885.7 mGy-cm. The mean effective dose reduction was calculated to be 31.1% between the 2 groups.</p><p><b>CONCLUSION</b>The split-bolus technique gives a reduced radiation dose without compromising image quality. The associated reduction in images is beneficial for data storage and reporting efficiency. As such, our department will adopt the split-bolus technique for young, low-risk patients.</p>

Anatomical Variants of Lister's Tubercle: A New Morphological Classification Based on Magnetic Resonance Imaging

OBJECTIVE: Lister's tubercle is used as a standard anatomical landmark in hand surgery and arthroscopy procedures. In this study, we aimed to evaluate and propose a classification for anatomical variants of Lister's tubercle. MATERIALS AND METHODS: Between September 2011 and July 2014, 360 MRI examinations for wrists performed using 1.5T scanners in a single institution were retrospectively evaluated. The prevalence of anatomical variants of Lister's tubercle based on the heights and morphology of its radial and ulnar peaks was assessed. These were classified into three distinct types: radial peak larger than ulnar peak (Type 1), similar radial and ulnar peaks (Type 2) and ulnar peak larger than radial peak (Type 3). Each type was further divided into 2 subtypes (A and B) based on the morphology of the peaks. RESULTS: The proportions of Type 1, Type 2, and Type 3 variants in the study population were 69.2, 21.4, and 9.5%, respectively. For the subtypes, the Type 1A variant was the most common (41.4%) and conformed to the classical appearance of Lister's tubercle; whereas, Type 3A and 3B variants were rare configurations (6.4% and 3.1%, respectively) wherein the extensor pollicis longus tendon coursed along the radial aspect of Lister's tubercle. CONCLUSION: Anatomical variations of Lister's tubercle have potential clinical implications for certain pathological conditions and pre-procedural planning. The proposed classification system facilitates a better understanding of these anatomical variations and easier identification of at-risk and rare variants.