Accuracy of Preoperative Ultrasonography for Cubital Tunnel Syndrome: A Comparison with Intraoperative Findings

BACKGROUND: The aim of this study was to assess the consistency between preoperative ultrasonographic and intraoperative measurements of the ulnar nerve in patients with cubital tunnel syndrome. METHODS: Twenty-six cases who underwent anterior transposition of the ulnar nerve for cubital tunnel syndrome were enrolled prospectively. On preoperative ultrasonography, largest cross-sectional diameters of the ulnar nerve were measured at the level of medial epicondyle (ME) and 3 cm proximal (PME) and distal (DME) to the ME on the transverse scan by a single experienced radiologist. Intraoperative direct measurements of the largest diameter at the same locations were performed by a single surgeon without knowledge of the preoperative values. The consistency between ultrasonographic and intraoperative values including the largest diameter and swelling ratio were assessed. RESULTS: Significant differences between ultrasonographic and intraoperative values of the largest diameter were found at all levels. The mean difference was 1.29 mm for PME, 1.38 mm for ME, and 1.12 mm for DME. The mean ME-PME swelling ratio for ultrasonographic and intraoperative measurements was 1.50 and 1.39, respectively, showing significant difference. The mean ME-DME swelling ratio for ultrasonographic and intraoperative measurements was 1.53 and 1.43, respectively, showing no significant difference. CONCLUSIONS: Ultrasonographically measured largest diameters of the ulnar nerve at any levels were smaller than the real values determined intraoperatively. The ME-DME swelling ratio of the ulnar nerve measured by ultrasonography was consistent with the intraoperative measurement.

Ultrasound and MRI Findings of Intraneural Capillary Hemangioma of the Median Nerve Mimicking Traumatic Neuroma: A Case Report

Intraneural hemangioma of the median nerve is extremely rare. Only a few cases have been reported in literature. The researchers present ultrasound (US) and MRI findings of a case of 38-year-old-man with intraneural capillary hemangioma of the median nerve. The patient had a small, palpable mass in the volar aspect of the wrist and symptoms of carpal tunnel syndrome. US showed an infiltrative intraneural mass, without significant blood flow despite a compression test. The researchers initially misdiagnosed this mass as an in-continuity neuroma. The mass showed heterogeneous, but predominantly high signal intensity on T2-weighted image, as well as heterogeneous enhancement. The MRI findings were helpful for correct diagnosis on the retrospective review.

Ultrasonography of the ankle joint

Ankle disorders are a relatively common pathological condition, and ankle injuries account for approximately 14% of sports-related orthopedic emergency visits. Various imaging modalities can be used to make a diagnosis in cases of ankle pain; however, ultrasound (US) has several benefits for the evaluation of ankle pain, especially in the tendons, ligaments, and nerves of the ankle. The purpose of this article is to review the common causes of ankle pathology, with particular reference to US features. In addition, the importance of a dynamic evaluation and a stress test with US is emphasized.

Pudendal Nerve Entrapment Syndrome due to a Ganglion Cyst: A Case Report

Pudendal nerve entrapment syndrome is an unusual cause of chronic pelvic pain. We experienced a case of pudendal neuralgia associated with a ganglion cyst. A 60-year-old male patient with a tingling sensation and burning pain in the right buttock and perineal area visited our outpatient rehabilitation center. Pelvis magnetic resonance imaging showed the presence of multiple ganglion cysts around the right ischial spine and sacrospinous ligament, and the pudendal nerve and vessel bundle were located between the ischial spine and ganglion cyst at the entrance of Alcock's canal. We aspirated the lesions under ultrasound guidance, and consequently his symptoms subsided during a 6-month follow-up. This is the first report of pudendal neuralgia caused by compression from a ganglion cyst around the sacrospinous ligament.

Ultrasound-Guided Percutaneous Removal of Wooden Foreign Bodies in the Extremities with Hydro-Dissection Technique

OBJECTIVE: We described the technique of ultrasound (US)-guided percutaneous removal of the foreign bodies (FB) with hydro-dissection in the radiologic department and presented video files of several cases. MATERIALS AND METHODS: Four patients referred to the radiology department for US evaluation and US-guided percutaneous removal of the FBs in the upper and lower extremities between November, 2006 and November, 2013 were included in this study. The procedures started with US evaluation for the exact location and shape of the FB. A 5 mm-sized skin incision was made at the site of the nearest point from the FB where no passing arteries or tendons were present. We adopted a hydrodissection technique to separate the FB from adjacent tissue using a 2% lidocaine solution. Injected anesthetics detached the FBs from surrounding tissue and thereby facilitated removal. After the tip of the mosquito forceps reached the FB, the wooden FBs were removed. RESULTS: The mean time required for the entire procedure was approximately 20 minutes. There were no significant complications during the US-guided removal or long-term complications after the procedure. All 4 FBs were successfully removed from the soft tissue under US guidance. CONCLUSION: Ultrasound-guided percutaneous removal of the FBs with hydro-dissection in the radiology department is a less invasive and safe method over surgical removal in the operating room. Additionally, the use of a guide wire and serial dilator may help minimize soft tissue injury and facilitate the introduction of forceps.

Mini-Open Suture Bridge Repair with Porcine Dermal Patch Augmentation for Massive Rotator Cuff Tear: Surgical Technique and Preliminary Results

BACKGROUND: The aim of this study was to describe the mini-open suture bridge technique with porcine dermal patch augmentation for massive rotator cuff tear and to assess preliminary clinical and radiological results. METHODS: Five patients with massive rotator cuff tear for which it was not possible to restore the anatomical footprint underwent mini-open suture bridge repair using a porcine dermal patch. The patients' average age was 53.4 years (range, 45 to 57 years), and the average duration of follow-up was 20.6 months (range, 14 to 26 months). Patients were evaluated with preoperative and postoperative outcome measures, including a visual analog scale (VAS) for pain, the University of California Los Angeles (UCLA) score, and the American Shoulder and Elbow Surgeons (ASES) score. The structural integrity of repaired rotator cuffs was assessed by magnetic resonance imaging 6 months postoperatively. RESULTS: The average VAS pain score, UCLA score, and ASES score improved from 6.8, 15.4, and 39.4 preoperatively to 0.8, 31.2, and 86.4 postoperatively (p = 0.041, 0.042, and 0.043, respectively). Magnetic resonance images obtained at an average of 8 months after surgery showed that four patients had intact repair integrity with graft incorporation. One patient had a re-tear with partial healing but still had a satisfactory clinical outcome. There was no intraoperative or postoperative complication in any patient. CONCLUSIONS: Mini-open suture bridge repair with porcine dermal patch augmentation can be an option in young patients with high physical demands and massive rotator cuff tears for which it is not possible to restore the anatomical footprint.

Soft Tissue Masses Showing Low Signal Intensity on T2-weighted Images: Correlation with Pathologic Findings

OBJECTIVE: The aims of this article are to differentiate soft tissue masses showing low signal intensity on T2-weighted images (T2WIs) according to the histopathologic findings. CONCLUSION: To know relatively small numbered soft tissue masses with low signal intensities on T2WIs adding characteristic location, morphology, signal intensities on other sequences might be helpful for differential diagnosis of mostly nonspecific soft tissue tumors on MRI.

The Usefulness of Ultrasonography in Painful Hip

The causes of hip pain are variable, and, due to its size and deep position, complete physical examination is often difficult. In the past, ultrasonography (US) for the hip was mainly performed in order to rule out developmental hip dysplasia in infants or for evaluation of joint effusion. Now, however, US of the hip has been widely accepted as a useful modality in patients with hip pain and is commonly used in both adults and children. Joint effusion, bursitis, tendinosis or tendon tear, and acetabular labral tear can be main targets. Dynamic study for snapping hip is another unique advantage of US. In addition, US is very useful for guided procedures - aspiration, biopsy, or injection. In this review, the authors will discuss US findings of these common lesions with a brief review of anatomy.

Ischiofemoral Impingement Syndrome

Ischiofemoral impingement syndrome is known as one of the causes of hip pain due to impingement of ischium and femur, and usually correlated with trauma or operation. We report a rare case of ischiofemoral impingement syndrome that has no history of trauma or surgery. A 48-year-old female patient was referred for 2 months history of the left hip pain, radiating to lower extremity with a hip snapping sensation. She had no history of trauma or surgery at or around the hip joint and femur. The magnetic resonance imaging (MRI) of the lumbar spine showed no abnormality, except diffuse bulging disc without cord compression at the lumbosacral area. Electrophysiologic study was normal, and there were no neurologic abnormalities compatible with the lumbosacral radiculopathy or spinal stenosis. Hip MRI revealed quadratus femoris muscle edema with concurrent narrowing of the ischiofemoral space. The distance of ischiofemoral space and quadratus femoris space were narrow. It was compatible with ischiofemoral impingement syndrome. After treatment with nonsteroidal anti-inflammatory drugs, physical therapy, and exercise program, the patient's pain was relieved and the snapping was improved. To our knowledge, this is the first reported case of a nontraumatic, noniatrogenic ischiofemoral impingement syndrome, and also the first case to be treated by a nonsurgical method in the Republic of Korea.

Ultrasound-Guided Percutaneous Removal of Foreign Body Using Hydrodissection and Serial Dilators / 대한정형외과학회잡지

High-resolution ultrasound of the painful, swollen left heel of a 54-year-old man, who reported that his symptoms had lasted 4 months, showed retention of a wooden foreign body in the heel. After administering local anesthesia and making a 5-mm skin incision, we performed hydrodissection of the foreign body from the adjacent soft tissue under real-time ultrasound guidance, using a 1% lidocaine solution. Then, we introduced an 18-gauge spinal needle and inserted a guide-wire through the needle. After we removed the needle, we introduced serial dilators in sizes ranging from 7 French to 12 French along the guide-wire to create a tract for mosquito forceps. Then, we introduced the mosquito forceps and removed the wooden foreign body. Ultrasound-guided percutaneous removal of foreign bodies is quick and safe. We believe that hydrodissection makes removal easier and that use of serial dilators minimizes soft-tissue injury and makes it easier to introduce mosquito forceps.

Physical Examination and Computed Tomography in Children with Toe in Gait

OBJECTIVE: To determine the correlation between the physical examination and the computed tomography of femoral anteversion and tibial internal torsion. METHOD: The angle of internal and external rotation of hip for femoral anteversion and thigh-foot angle for tibial internal torsion were measured by a rehabilitation physician for 116 young children with toe in gait. Within a week after the physical examination, the angle of femoral anteversion and tibial internal torsion were measured by computed tomography for comparison. RESULTS: Two-hundred thirty-two lower limbs of 116 children (64 girls and 52 boys) included in this study whose mean age was 6.4+/-2.7 years for girls and 6.8+/-2.8 years for boys. The Pearson correlation coefficient between the angle of internal rotation of the hip and the femoral anteversion measured by computed tomography showed 0.62 in right side and 0.55 in left side, an indication of significant correlation (p<0.01). The Pearson correlation coefficient between the thigh-foot angle and the tibial internal torsion measured by computed tomography showed 0.50 in right side, 0.42 in left side, an indication of significant correlation (p<0.01). CONCLUSION: Children with toe-in gauts showed a significant correlation between finding of physical exam (i.e. TFA and femoral internal torsion angle) and those of CT omages (i.e. tibial torsion angle and femoral torsion angle).

Synovial Lesions with Low Signal Intensities on T2-Weighted MR Image

Pigmented villonodular synovitis, synovial chondromatosis, long-standing rheumatoid arthritis, hemophilic arthropathy, chronic tophaceous gout, amyloid arthropathy, tuberculous arthritis, and hemangioma are the synovial diseases showing low signal intensity on T2-weighted image. Synovial deposition of hemosiderin, urate, and amyloid and fibrosis or caseous necrosis of hypertrophied synovium are known as the pathologic causes of T2 signal intensity. Because of the low incidence of the synovial lesions showing T2 low signal intensity, recognition of these diseases would be helpful for the exact diagnosis.

Synovial Lesions with Low Signal Intensities on T2-Weighted MR Image

Pigmented villonodular synovitis, synovial chondromatosis, long-standing rheumatoid arthritis, hemophilic arthropathy, chronic tophaceous gout, amyloid arthropathy, tuberculous arthritis, and hemangioma are the synovial diseases showing low signal intensity on T2-weighted image. Synovial deposition of hemosiderin, urate, and amyloid and fibrosis or caseous necrosis of hypertrophied synovium are known as the pathologic causes of T2 signal intensity. Because of the low incidence of the synovial lesions showing T2 low signal intensity, recognition of these diseases would be helpful for the exact diagnosis.

Ultrasound Diagnosis of Either an Occult or Missed Fracture of an Extremity in Pediatric-Aged Children

OBJECTIVE: To report and assess the usefulness of ultrasound (US) findings for occult fractures of growing bones. MATERIALS AND METHODS: For six years, US scans were performed in children younger than 15 years who were referred with trauma-related local pain and swelling of the extremities. As a routine US examination, the soft tissue, bones, and adjacent joints were examined in the area of discomfort, in addition to the asymptomatic contralateral extremity for comparison. Twenty-five occult fractures in 25 children (age range, five months-15 years; average age, 7.7 years) were confirmed by initial and follow-up radiograms, additional imaging studies, and clinical observation longer than three weeks. RESULTS: The most common site of occult fractures was the elbow (n = 9, 36%), followed by the knee (n = 7, 28%), ischium (n = 4, 16%), distal fibula (n = 3, 12%), proximal femur (n = 1, 4%), and humeral shaft (n = 1, 4%). On the retrograde review of the routine radiographs, 13 out of the 25 cases showed no bone abnormalities except for various soft tissue swelling. For the US findings, cortical discontinuity (direct sign of a fracture) was clearly visualized in 23 cases (92%) and was questionable in two (8%). As auxiliary US findings (indirect signs of a fracture), step-off deformities, tiny avulsed bone fragments, double-line appearance of cortical margins, and diffuse irregularity of the bone surfaces were identified. CONCLUSION: Performing US for soft tissue and bone surfaces with pain and swelling, with or without trauma history in the extremities, is important for diagnosing occult or missed fractures of immature bones in pediatric-aged children.

Ultrasonography of Morton's Neuroma Accompanied with Interdigital Bursitis

OBJECTIVE: To investigate clinical and ultrasonographic findings of Morton's neuroma with or without interdigital bursitis. METHOD: Eighty patients who were diagnosed as Morton's neuroma were included. The diagnostic criterion of Morton's neuroma at ultrasonography was hypoechoic mass was 5 mm in sagittal view. When the hypoechoic mass was molded by compression of the probe, Morton's neuroma accompanied with interdigital bursitis was diagnosed. The mean difference of symptom duration from onset to the hospital visit and the size of Morton's neuroma was evaluated. RESULTS: In eigthy patients, total 117 feet, 210 Morton's neuromas were detected. Of the 117 feet, 66% revealed more than one Morton's neuroma per one foot. Mostly Morton's neuroma was at the second (46.7%) and the third interdigital space (43.8%). Mean duration was 19.1+/-16.9 months. Comorbidity of interdigital bursitis was 23.3% of all Morton's neuroma. Mean size of Morton's neuroma with interdigital bursitis was significantly larger (10.3+/-3.0 mm) than single neuroma (8.5+/-2.5 mm). The symptom duration from onset to the hospital visit was significantly shorter in neuroma with interdigital bursitis (14.1+/-16.8 months) than single Morton's neuroma (21.2+/-16.6 months). CONCLUSION: Morton's neuroma had multiple propensity, mostly at the second and the third web space with comparable rate. Comorbidity of interdigital bursitis with Morton's neuroma was 23.3%. When interdigital bursitis was accompanied, the size of hypoechoic mass was larger and symptom duration from onset to the hospital visit was shorter than single Morton's neuroma.

Effect of the Tibia Counter Rotator Orthosis for Tibial Internal Torsion Children: A Preliminary Study

OBJECTIVE: To evaluate the therapeutic effect of the tibia counter rotator orthosis for tibial internal torsion children. METHOD: The 16 limbs included in this study were both lower extremities of 6 subjects and unilateral ones of 4 subjects (7 female and 3 male), ranging in age from less than 3 year to 11 years. These subjects were diagnosed as in-toeing gait with tibial internal torsion and had no history of forefoot adductus or other musculoskeletal abnormality. Tibial torsion was evaluated by thigh-foot angle and computed tomography before and after applying the Tibia Internal Brace(R) (TIB(R)). RESULTS: Thigh-foot angle and computed tomography showed significant improvement of tibial internal torsion before and after applying the TIB(R) (p0.05). And there was no significant correlation between age and improvement of tibial internal torsion (p>0.05). CONCLUSION: TIB(R) was effective for in-toeing gait children with tibial internal torsion.

The Ultrasonographic Findings of Bifid Median Nerve

PURPOSE: We wanted to evaluate the ultrasonographic findings of bifid median nerve and its clinical significance. MATERIALS AND METHODS: We retrospectively reviewed five cases (three men and two women, mean age: 54 years) of incidentally found bifid median nerve from 264 cases of clinically suspected carpal-tunnel syndrome that were seen at our hospital during last 6 years. Doppler sonography was performed in all five cases and MR angiography was done in one case for detecting a persistent median artery. The difference (deltaCSA) between the sum of the cross-sectional areas of the bifid median nerve at the pisiform level (CSA2) and the cross-sectional area proximal to the bifurcation(CSA1) was calculated. RESULTS: The incidence of a bifid median nerve was 1.9%. All the patients presented with a tingling sensation on a hand and two patients had nocturnal pain. All the cases showed bifurcation of the nerve bundle proximal to the carpal tunnel. The margins appeared relatively smooth and each bundle showed a characteristic fascicular pattern. A persistent median artery was noted between the bundles in four cases. deltaCSA was more than 2 mm2 in four cases. CONCLUSIONS: Bifid median nerve with a persistent median artery is a relatively rare normal variance and these are very important findings before performing surgical intervention to avoid potential nerve injury and massive bleeding. We highly suggest that radiologists should understand the anatomical characteristics of this anomaly and make efforts to detect it.

Dynamic Ultrasonography in Musculoskeletal System: Upper Extremity

With technical advances, ultrasonography of musculoskeletal system has been an important imaging modality in variable disorders and has been popular. Real-time imaging and possible dynamic motion study are special advantages of ultrasonography, and particularly helpful in evaluation of tendon or ligament injury. The purpose of this article is to review the basic technique and disorders that dynamic ultrasonography is helpful or essential in diagnosis in upper extremity.

Dynamic Ultrasonography in Musculoskeletal System-Lower Extremity and Miscellaneous disorders

Performing dynamic ultrasonography in the lower extremity is not so popular as performing dynamic ultrasonography in the upper extremity. However, performing this modality is essential for some diseases and it is very helpful for various other disorders too. The purpose of this article is to describe the basic technique and disorders that dynamic ultrasonography is helpful for or essential for making a diagnosis in the lower extremity and for diagnosing other miscellaneous diseases as well. We also include a review of the relevant medical literature.

Comparison of Ultrasonographic and Arthrographic Findings according to the Severity of the Rotator Cuff Tear

OBJECTIVE: To determine the diagnostic value of ultrasonography in detection of the partial and full-thickness rotator cuff tear compared with arthrography. METHOD: One hundred twenty one cases were diagnosed as the patients with rotator cuff tear. Patients with full-thickness tear were divided into subgroups based on the size of small (3 cm) tear. With arthrography as the standard of comparison for diagnosis of rotator cuff tear, full-thickness tear was confirmed by leakage of contrast extending into the subacromial-subdeltoid bursa. RESULTS: Ultrasonography detected full-thickness tear in 90 cases, partial-thickness tear in 24 cases and no tear in 7 cases. A comparison of the results from ultrasonography and arthrography demonstrated a sensitivity of 83.8%, a specificity of 43.9% and an accuracy of 70.2% for detection of full-thickness tear. The size of supraspinatus full-thickness tear in inconsistent group of ultrasonographic and arthrographic findings was significantly smaller than that of consistent group. CONCLUSION: Ultrasonography may be used as the primary screening test for patients who may have suspected rotator cuff tears. However, other diagnostic techniques are recommended to confirm in patients who show small full-thickness tear on ultrasonography.