Thenar lumps: a review of differentials.

Most soft-tissue lumps in the hand are benign, with ganglions being the commonest, but in the thenar region, solid soft-tissue masses are more common than a ganglion. In this review, we focus on soft-tissue lesions (neoplastic and non-neoplastic) presenting as a palpable lump in this region. A specific diagnosis can often be reached using ultrasonography and/or magnetic resonance imaging. Most of these lesions are managed in local hospitals or primary care, whereas some are referred to specialist centres. This review article will help both general and musculoskeletal radiologists to diagnose and characterise these lesions, provide a guide for further imaging, and provide an insight into imaging features that may need specific investigations such as core biopsy, tertiary referral, and further review at multidisciplinary meetings.

Comparison of referrals for lumbar spine magnetic resonance imaging from physiotherapists, primary care and secondary care: how should referral pathways be optimised?

OBJECTIVE: To compare sensitivity of pathology on imaging between referrals from primary care, physiotherapists, spinal surgeons and other secondary care providers. DESIGN AND SETTING: A retrospective review of 200 consecutive magnetic resonance imaging (MRI) scans of patients' first presentations to radiology for MR lumbar scanning at a tertiary orthopaedic centre. A scan report was defined as positive if there was any evidence of neural compromise. Fisher's exact 2×2 contingency analyses were performed. RESULTS: Eighty-seven (44%) scans were positive and 113 (57%) were negative. Forty-four percent of scans requested by general practitioners (GPs) were reported as positive compared with 57% of scans requested by physiotherapists. Only 40% and 20% of scans requested by specialist spinal surgeons and non-spinal team secondary care providers were positive, respectively. Physiotherapist referrals for MRI lumbar spine scans were significantly more likely to be positive compared with GPs (P=0.05), spinal surgeons (P=0.03) and others (P=0.004). CONCLUSION: When appropriate, referrals via the extended physiotherapy service should be encouraged, rather than referrals directly from GPs. With appropriate training and in the appropriate clinical context, extended physiotherapy services could include inpatients and could accept outpatient referrals from other secondary care providers and not just from GPs; this would improve efficiency and reduce the workload of the radiology department and the spinal surgical unit.

Musculoskeletal manifestations of sickle cell anaemia: a pictorial review.

Sickle cell anaemia is an autosomal recessive genetic condition producing abnormal haemoglobin HbS molecules that result in stiff and sticky red blood cells leading to unpredictable episodes of microvascular occlusions. The clinical and radiological manifestations of sickle cell anaemia result from small vessel occlusion, leading to tissue ischemia/infarction and progressive end-organ damage. In this paper we discuss and illustrate the various musculoskeletal manifestations of sickle cell disease focusing primarily on marrow hyperplasia, osteomyelitis and septic arthritis, medullary and epiphyseal bone infarcts, growth defects, and soft tissue changes.

Diagnostic value of MR arthrogram in SLAP lesions of the shoulder.

BACKGROUND: Superior labrum anterior to posterior (SLAP) lesions are important cause of shoulder pain and instability. MR Arthrogram is key investigation for assessment of these lesions. We aimed this study to evaluate the diagnostic performance of MR Arthrogram in SLAP tears. MATERIALS AND METHODS: This was a retrospective study of 124 clinically diagnosed SLAP cases who had MR Arthrogram performed. Clinical, radiological and operative records were reviewed. MR Arthrogram findings were compared with arthroscopy. Those patients who did not undergo arthroscopy were not included in the final sensitivity analysis. RESULTS: Out of 124 cases, 54(43.54%) had normal MR Arthrogram, 32 (25.8%) had impingement or cuff related problems, 2 (1.61%) had Bankart lesions, and in 36 (29%) cases SLAP lesions were identified. Out of 54 patients with normal MR Arthrogram, 44 were discharged to physiotherapy and 10 underwent arthroscopy, showing SLAP lesion in one patient. Out of 32 patients with impingement or cuff problems, 19 were discharged to rehabilitation and 13 underwent surgery. Out of 36 patients with SLAP lesions, 5 recovered spontaneously, 5 were awaiting outpatient review and 26 underwent arthroscopy showing SLAP lesions in 22 cases. Overall, only 51 patients underwent arthroscopy. The MR Arthrogram was falsely positive in 4 cases (15.38%) and falsely negative in one case (3.84%). The sensitivity of MR Arthrogram was 95.6% (22/23), specificity 85.7% (24/28), positive predictive value 84.6% (22/26) and the negative predictive value was 96% (24/25). CONCLUSION: MR Arthrogram is a useful technique for the diagnosis and preoperative planning of suspected SLAP lesions. It may also save patients from unnecessary diagnostic arthroscopy.

Hibernoma--correlation of histopathology and magnetic-resonance-imaging features in 10 cases.

UNLABELLED: OBJECTIVE, DESIGN AND PATIENTS: Hibernoma is an uncommon, slow-growing, benign soft-tissue tumour resembling brown adipose tissue. The histological appearances are well-documented, but there are relatively few descriptions of the magnetic resonance (MR) imaging features. We report a retrospective comparison of the histological and MR appearances of ten hibernomas of the extremities, classified histologically into lipoma-like [<70% multivacuolated adipocytes (MVAs)] and non-lipoma-like hibernomas (>70% MVAs). RESULTS: The lipoma-like hibernomas measured 4-27 cm in maximum size. All were well-defined on MR imaging and histology except for one subcutaneous lesion that blended in with surrounding fat histologically. All lesions were isointense with subcutaneous fat on T1- and T2-weighting apart from one lesion that was predominantly slightly hypointense on T1-weighting and predominantly slightly hyperintense on T2-weighting and STIR. Two slightly inhomogeneous lesions contained thin (<5 mm thickness) tortuous vessels. One patient received intravenous contrast, but the lesion did not enhance. The six non-lipoma-like hibernomas measured 2.5-15.5 cm in maximum size and all were unencapsulated. Three were well-defined and three partly ill-defined on MR imaging. There were no significant differences in the MR characteristics of the non-lipoma-like variants. On T1-weighting, the non-lipoma-like hibernomas that contained >90% MVAs were predominantly slightly hypointense to subcutaneous fat. One lesion was isointense with subcutaneous fat, but this lesion only contained from 80-90% MVAs. All non-lipoma-like lesions were slightly hyperintense on STIR but so too were two of the four lipoma-like lesions. Four of the six non-lipoma-like lesions showed marked or moderate inhomogeneity due to thick septa and prominent vessels. Of the two cases that received intravenous contrast, both showed enhancement corresponding to regions of >90% MVAs or prominent vessels within fibrous septa. CONCLUSIONS: MR imaging has shown some distinguishing features between lipoma-like and non-lipoma-like hibernomas. Lipoma-like hibernomas are usually isointense with subcutaneous fat on T1-weighting, are either homogeneous or slightly inhomogeneous and may contain thin tortuous vascular structures. Non-lipoma-like hibernomas are pre-dominantly slightly hypointense to subcutaneous fat on T1-weighting, often display marked or moderate inhomogeneity with prominent septa and vessels and enhancement is typical. The appearances of non-lipoma-like hibernomas are not diagnostic and may be mimicked by lipoma variants and by well-differentiated liposarcoma or atypical lipoma.